A Report to the Ford Foundation
THE DRUG ABUSE SURVEY PROJECT
by Patricia M. Wald and Peter Barton Hutt
The Present Problem and Efforts to Control It
A More Promising Approach to Drug Abuse
The Drug Abuse Council
This report, which summarizes the results of the Drug Abuse Survey Project, is based upon extensive reading and numerous interviews with workers in the field throughout the country.
Part I describes the present drug-abuse problem in this country and what is currently being done to control it. Part 11 summarizes the project's views on a more promising approach to drug-abuse problems. Part III sets forth the project's recommendations for private foundation activity in this field.
Two preliminary observations are essential to this discussion. First, in many aspects of this field, important basic facts have not yet been determined and perhaps cannot be determined in the near future; conclusions, therefore, depend on fragmentary information and primarily on judgment. Because of the emotional and moral attitudes involved in drug issues, conclusions differ widely among individuals and are strongly and deeply held. Secondly, even where facts exist, experts in the field often disagree on their meaning and significance. We have found few areas in which there is not widespread disagreement.
As a result, in arriving at the project's conclusions and recommendations, we have relied strongly on the judgment of the Cochairmen and the Executive Director. It should be understood that at least one recognized expert could readily be found to challenge, perhaps vehemently, virtually any statement we make or might make. It appears that there can be no such thing as consensus or a noncontroversial report on drug abuse.
THE PRESENT PROBLEM AND EFFORTS TO CONTROL IT
THE NATURE AND EXTENT OF DRUG ABUSE
Staff Report I describes the characteristics of the most common drugs of abuse. For purposes of this report, such socially accepted and legal drugs as alcohol and nicotine have been excluded, and "drug abuse" has been limited primarily to heroin, marijuana, stimulant and depressant drugs, and hallucinogens.
The effects of a drug, the pattern of drug use, the prognosis for the user, and the bases of social concern all vary widely depending on the drug used, the age and class of the user, and the circumstances. No categorization, therefore, is totally satisfactory. The four core problems, however, have been broadly delineated by many commentators as: (1) the use of heroin in urban poverty areas, (2) experimentation with a wide variety of drugs by the young, (3) the use of drugs by middle-aged and older persons as a form of quasi-self-medication, and (4) the use of drugs as a behavior-control device.
Heroin in Urban Poverty Areas. According to our best estimates, there were, as of November, 1970, approximately 150,000 to 250,000 active heroin addicts in the United States.' (Some estimates run as high as 300,000 heroin addicts in New York City and 600,000 nationally, but these figures have little support.) The addicts are heavily concentrated in the poorest areas of large metropolitan areas. Probably half live in New York, and 60 to 70 per cent of them are black, Puerto Rican, or Mexican-American. Almost 85 per cent are male.
These figures represent people who use heroin on a daily basis, injecting a dose every six to eight hours as the effect of the previous dose wears off. They may spend anywhere from $10 to $100 per day on heroin, depending on their dosage and tolerance, their economic ability to sustain the habit, the purity of the drug bought, and the price level of the city in which they live.
There is an additional, though unknown, population that uses heroin only occasionally, either alone or as part of a pattern of multiple drug use. The size of this group is a matter of conjecture and debate. Some experts believe that repetitive use of heroin leads inexorably to addiction, whereas others believe that there is a substantial number of intermittent users who do not become addicted.
It is not possible to resolve this issue definitively. It seems probable, however, that a large number of persons have experimented with heroin a few times without becoming addicted. Heroin is easily available in the slum areas of most major cities. Although a large habit is expensive, a single dose is cheap ($1 or less for a capsule containing about I mg. of heroin in Washington, D.C.), and the unit of sale in many places is so small that a neophyte can take it without much fear of an overdose. It seems likely that a large percentage of the young black males in any large urban lower-class area have tried heroin. The majority who have experimented with it have not become addicted. And, although the potency of heroin makes it difficult to believe that large numbers of intermittent users never become addicted, this possibility cannot be ruled out on the basis of present information.
Although heroin is a primary drug for the addict, multiple drug use is exceedingly common. According to some studies, between 40 and 60 per cent of the addicts use one of the amphetamines or barbiturates as a secondary drug on a regular basis. Cocaine, a strong nonaddictive stimulant, is also used widely.
The tremendous wave of concern about heroin that has swept the country appears to be caused primarily by the fear of crime associated with addiction. Heroin itself does not cause criminal behavior in any physiological or psychological sense, but the need to maintain an expensive habit often does. A heroin addict will do almost anything to obtain money to buy the drug. There is virtually no way in which a poor, black, unskilled youth can earn legally the $30 per day that is required for the average habit. To maintain his addiction, he can deal in drugs, engage in consensual crime, or steal. It is reasonable to estimate that addicts steal between $1 billion and $2 billion in merchandise per year. Estimates of thefts in New York City alone range from a low of $.25 billion to a high of $1.9 billion. There is some evidence that up to 50 per cent of property crimes in the major metropolitan areas with a serious heroin addiction problem are committed by addicts. On the other hand, there is evidence that most addicts engaged in crime before they became addicted. Addiction, therefore, cannot necessarily be regarded as the cause of a criminal life-style, although it unquestionably intensifies criminal activity.
A secondary cause of the current concern about heroin is the fear that it has, or will, spread throughout society. While heroin is undoubtedly now available in the suburbs, there is little evidence that it represents a substantial problem there. It remains largely a lower-class drug.
A third cause commonly cited for the concern about heroin is fear of the effects of the drug on the user. Actually, there is no proof that heroin itself causes any organic damage to the body or brain similar, for example, to the extensive damage caused by alcohol. Death through overdose has been attributed by medical experts to the fact that heroin is a powerful nervous-system suppressant that may cause respiration to cease when the dosage exceeds the individual's tolerance, or to the fact that some individuals may experience a severe allergic reaction to heroin.
It seems possible that many addicts would function normally if given a steady supply of good-quality drugs. The real harm to users is that they presently tend to become social dropouts, in that the illegal status of the drug causes them to spend all their time obtaining and using it. There seems little doubt that, if it were not for the fear of crime and the spread of heroin to the suburbs, most of society would not be seriously worried about heroin addiction.
Youthful Drug Experimentation. Within the last five years there has been a substantial increase in the use of illicit nonopiate drugs by the young, particularly among middle-class college and high school students and young military personnel. The prevalent drugs of abuse for this group are marijuana (and, to some extent, the more potent cannabis product, hashish), oral amphetamines and barbiturates, LSD, and other hallucinogens. During 1971 the use of heroin by GI's in Vietnam became, for the first time, a matter of grave public concern.
As of November, 1971, the best estimates are that 15 million people in this country have experimented with marijuana. Possibly 30 per cent of these go on to become occasional users, and 5 per cent become frequent users. While these estimates are very uncertain, survey research supports the conclusion that marijuana use has spread fantastically in the last few years. One survey of 200 colleges found that 47 per cent of those interviewed had smoked it 34 per cent occasionally and 13 per cent frequently. There are major differences among colleges, of course. Other surveys found that 70 per cent of the student body at one medical school were current users of marijuana, as compared with 44 per cent and 5 per cent at two other medical schools. Extrapolating from available statistics, it is likely that 20 per cent of all Americans between the ages of. 15 and 35 have used marijuana at least once -a crime for which they could have been imprisoned by the federal government for up to ten years.'
There is currently little evidence that marijuana causes physical harm. The federal government is now engaged in a crash research program to find out the short- and long-term effects of marijuana. Critics of this research program argue that it is intended simply to justify current federal policy and is not a sound independent scientific investigation. Even persons who are sympathetic to marijuana use will be surprised, however, if it is discovered that marijuana use in large amounts over a long period of time is totally harmless. The real issue over marijuana appears to be not whether it causes mild physical damage but whether its use has already spread so widely that, as is true of alcohol, the social costs of efforts to prohibit it exceed the physical costs that would be incurred by eliminating criminal penalties for, or even legalizing, its use.'
Experimentation with oral amphetamines and barbiturate drugs, all of which have recognized medical uses and are therefore often easily obtainable, is probably second only to the use of marijuana. Some 18 per cent of the students in the 200-campus survey had tried amphetamines, and 15 per cent had tried barbiturates, but only 2 per cent and 1 per cent, respectively, had used them frequently. There are no more reliable estimates available.
A quite dangerous pattern of middle-class youthful amphetamine drug use is the injectable methamphetamine ("speed") Culture. Intravenous injections of methamphetamine usually take the form of continuous use of massive doses for several days. Users may become psychotic while under its influence, and it is probably the drug most likely to lead directly to violence. There is some evidence that it causes serious organic damage. Speed also tends to make the user lose interest in food, sleep, and hygiene. Because of these extreme effects, a speed "run" is hard to sustain over any length of time, and the end of a period of heavy speed use-the "crash"-produces serious depression. Users have learned over time that they can make the crash smoother by taking barbiturates or heroin. Reports from San Francisco, the first city to have a sizable speed culture, are that heroin is becoming the drug of choice for a large proportion of former speed users because it is a more pleasant "down" than the barbiturates.
The use of LSD originally peaked in about 1967, declined briefly, and then started to increase again as the early reports about genetic damage caused by the drug were discredited and as use spread downward into the high schools. The survey that found marijuana use among 47 per cent of college students on 200 campuses found that 11 per cent had used LSD, but only I per cent used it frequently. The National Institute of Mental Health had earlier reported surveys showing a 2 to 9 per cent range of LSD use among college students, with an over-all average of 5 per cent. While a ratio of one LSD experimenter to every five triers of marijuana seems too high for the population at large, or even for most colleges and high schools, it does illustrate a higher rate of current usage than has been suspected.
There is general agreement that LSD is a powerful drug that should be used with care. In clinical use, severe reactions are rare. One study found that 25,000 administrations of LSD or mescaline to 5,000 people resulted in serious complications in only 0.08 per cent of experimental subjects and 0.34 per cent of subjects who were undergoing therapy. There is no scientific certainty concerning other types of reaction that have been alleged, but not proved, to result from LSD use, such as flashbacks and birth defects. The long-term effects are not known.
Youthful . experimentation may also involve heroin, especially in the ghetto. A recent survey of juvenile addicts in Washington, D.C., showed that over half started directly by mainlining heroin rather than first using other drugs. Among middle-class youth, however, experimentation with marijuana predominates, and heroin is probably the least used drug.
Youthful middle-class experimentation with heroin as part of a pattern of multidrug use does appear to be increasing. This phenomenon is too new, and information is too fragmentary, to judge whether it represents the beginnings of significant growth in middle-class addiction. Preliminary reports indicate that people who become involved with heroin in this non-ghetto context have less tendency toward heavy involvement.
The extent of penetration of drugs other than marijuana is difficult to assess. Considerably fewer young people seem to have tried oral doses of amphetamines and barbiturates than have tried marijuana, but more appear to have tried them than have tried LSD. The number of young people who become heavily involved with amphetamines (especially injectable methamphetamine) and barbiturates is unknown but is probably of about the same magnitude as those heavily involved with LSD.
Society's current concern about youthful drug experimentation is often attributed to the possible detrimental effect on the health of drug users. Certainly, concern about the potential harm from heroin experimentation in the ghetto is far more justified than concern about marijuana experimentation in the suburbs. It is our judgment, however, that physical harm is actually only a partial cause of this public concern. There are, after all, up to 9 million alcoholics, whose alcohol abuse affects a total of well over 30 million people in this country, a far larger number than are affected by drug abuse; yet, this enormous health problem has created relatively little public concern.
Rather, the principal force behind the present public concern about youthful middle-class experimentation seems to relate to differences in perceptions and life-styles between older and younger generations. Older persons tend to accept the use of drugs only for therapeutic purposes. They do not regard alcohol and nicotine as "drugs" and believe that the substances can be properly used for social and personal pleasure. But the older generation regards the use of drugs, such as marijuana and LSD, for social and personal pleasure as symptomatic of disrespect for law and authority and as an attempt to escape responsibility. In contrast, many in the younger generation tend to regard the use of drugs for social and personal pleasure as entirely proper. Use of such drugs as marijuana and LSD is therefore viewed by them as an opportunity for enhancement of personal experience, an act of social custom within a peer group, or a mark of youthful rebellion and independence similar to smoking weeds or sipping beer behind the barn fifty years ago.
Drug Use among the Middle-aged and Elderly. Millions of people use psychoactive drugs as a way of coping with the tensions and problems of everyday living. Current estimates are vague, but in a 1967 survey 25 per cent of all persons over 18 reported use of a psychoactive drug during the preceding year. The number of persons reporting use of a tranquilizer at some time in their lives rose from 7 per cent in 1957 to 27 per cent in 1967. American industry apparently produces about 4 billion dosage units of barbiturates (not including other major and minor tranquilizers) and 8 billion dosage units of amphetamines each year. It is charged that half of these are diverted to the illegal market at some point, and an unknown proportion of the rest are prescribed carelessly. Some of these drugs are used by heroin addicts and youthful experimenters. Most are not so used, however, and the problem of self-prescribed use of these drugs is one that pervades all strata of society. (In addition, about 10 per cent of the 80 million people who use alcohol have a serious problem of dependence.)
The National Institute of Mental Health (NIMH) is now conducting a series of comprehensive drug-use surveys, which should provide an accurate picture of the extent of middle-age and elderly drug abuse with legal as well as illegal drugs. The project includes research into the frequency and situational aspects of this problem.
Why certain persons become dependent on these drugs is not clear. As in the case of heroin addiction, there is considerable debate as to what physiological and psychological factors are involved.
The personal costs of this type of drug abuse can be very high. Of all the potential drugs of abuse, alcohol is one of the most damaging, since even relatively light consumption clearly causes some damage to such organs as the brain and liver, and heavy consumption causes serious damage and sometimes death. Barbiturates cause damage very similar to that caused by alcohol, and, in the formal literature, these two drugs are regarded as essentially additive and interchangeable in chronic intoxication. With barbiturates, as well as alcohol, there is a serious risk of lethal overdose. The personal costs of steady amphetamine use are not clear. Experts believe that large doses entail a high risk of organic damage. There appears to be no clear evidence concerning smaller doses.
The social costs of alcoholism are now fairly well known and need not be detailed here, but the social costs of the abuse of barbiturates and amphetamines are still largely unknown. The social benefits attributable to these drugs are equally uncertain. There is clearly a widely felt need for the particular effects of the various drugs. It is far from clear that elimination of this form of drug abuse would result in net benefits to the society, because one cannot be sure that other possible responses to life situations would be less harmful. It is possible that reducing the use of tranquilizers would result in a rise of the violent crime rate, or in the divorce rate, or in child beating. It almost certainly would require greater institutionalization of persons with borderline emotional problems.
Drugs in Behavior Control. A fourth emerging problem is the overprescription of drugs to control the behavior of captive populations, such as overactive school children and nursing-home residents, where other, nondrug methods of control should properly be used instead. Recent information has revealed significant use of amphetamines to calm down behavior in the classrooms of urban public schools. At the other end of the age spectrum, tranquilizers are reportedly being used far too extensively on elderly patients in nursing homes to keep them from clamoring for the attention of overworked attendants.
These drugs are properly used, within limits of sound medical practice approved by the Food and Drug Administration, for hyper-kinetic children and elderly patients with emotional problems. There is a serious danger, however, that they may be used as a simple method of managing school children, institutionalized patients, and correctional inmates as a substitute for a competent staff and the other resources needed in dealing with those not able to care for themselves. And, as the range of behavior-controlling drugs becomes wider, we can anticipate even greater problems in their use in unwarranted situations.
BASIC RESEARCH ON DRUG ABUSE
Existing Research. Most of the basic research now being done on drugs of abuse is conducted by the NIMH Addiction Research Center (ARC) at Lexington, Kentucky, or conducted or financed by grant or contract through the NIMH Division of Narcotic Addiction and Drug Abuse and the NIMH Division of Psycbopharmacology.
ARC is an interdisciplinary group doing basic research on the physiological effects of a number of drugs of abuse, and one of the very few to our knowledge that has recently conducted any research with heroin. Its 1970 budget is about $.8 million. Its principal functions are research on the abuse potential of drugs and on opiate antagonists. ARC would need far more personnel, ranging from senior research scientists to technicians and paraprofessionals, and far more funds if it were to expand its activities broadly to include basic research on the cause and nature of all drug abuse and drug dependence.
NIMH funds for intramural and extramural research relating to drug abuse have increased threefold in five years.' The figures below include research in pharmacology, sociology, psychology,
Year Budget Authority
and many other areas. They also apparently include at least some of the research on psychoactive drugs sponsored by the NIMH Division of Psychopharmacology, which is interested primarily in the use of drugs in the treatment of mental disorders.
The research funds are dispersed among the various drugs of abuse, not concentrated on one or two. For 1970, the only year for which we now have information, the division by drugs was as follows:
NIMH is unable to provide either a dollar breakdown on the types of research represented (pharmacology, sociology, etc.) or a breakdown by drug for previous years. In 1970, $1.3 million of the money spent on marijuana research was dispersed through special contracts. ARC received $.8 million of the money designated for opiate research to operate its program. An undeterminable amount is spent by the Division of Psychopharmacology and other parts of NIMH.' The balance of research expenditures represents about 50 grants to specific individuals and institutions given on application.
The allocation of grant resources is determined primarily by an advisory committee of physical and social scientists that reviews all applications for funding and assigns them a priority ranking on the basis of scientific merit. While NIMH administrators have some authority to overrule the committee (they can fund a low priority project instead of a high-priority one, but they cannot fund a project if the committee refuses to assign it any priority at all), we have been informed that this happens rarely.
We have also been informed that little or no effort is made to create a program of research. Applications are reviewed in a vacuum. Consideration is not given to the importance or relevance of the research to policy issues or to major scientific and medical questions, or to alternative uses of the research budget. The results of prior projects are reportedly not made available to the committee for its consideration in reviewing current grant applications. No significant effort is made to encourage grant applications in areas of particular interest to scientists, physicians, and the government.
The Justice Department's Bureau of Narcotics and Dangerous Drugs (BNDD) has engaged in some research in the past and still has some ongoing efforts on the abuse potential of drugs, the sociology of drug use, the characteristics of dealers, and the market structure of the drug traffic. The decision has recently been made, however, that BNDD's research role is to be limited to subjects related to law enforcement.
A major problem with basic research conducted or funded by the federal government is that it is necessarily limited by governmental policy. Thus, as might be expected, there are large gaps in our basic knowledge about drugs of abuse. In particular, basic experimentation with the effects of heroin on chronic heroin addicts has been virtually ignored in view of the strong federal policy against any such research. Until very recently, federal policy also virtually precluded marijuana research in humans. Federal regulations single out LSD and a handful of other hallucinogens, from among all known drugs, as requiring specific Food and Drug Administration (FDA) approval of an Investigational New Drug Plan (rather than just filing the plan, as is true for all other drugs) before clinical investigation may begin. Under the 1970 federal drug-abuse law, research with heroin, marijuana, and LSD may be conducted only after the Secretary of HEW has approved the researcher and the protocol. In short, current governmental policy is a critical factor in determining the type of research that may be done under federal auspices or approval.
Other possible sources of funding for basic research on drugs of abuse are the states, the universities, and the pharmaceutical industry. Thus far, the states have concentrated on applied research, primarily in the area of treatment. The universities appear to have no significant source of funds for basic research other than the federal government. And the pharmaceutical industry concentrates primarily on product-oriented applied research. As a practical matter, therefore, most basic research depends on federal funds.
The pharmaceutical industry's research efforts are not only product-oriented but, indeed, have the goals of increasing the number of psychoactive drugs, enhancing their effect, or improving their activity in some other fashion. From the standpoint of drug abuse, the pharmaceutical industry is working night and day to create products that will intensify the problem. Many of these drugs, of course, have enormous medical value that far outweighs their abuse potential.
The Need for Additional Basic Research. It is apparent that there is a serious lack of basic information about how drugs of abuse work and their long-term effects on the body. Many examples could be given, but a few will make the point:
Since World War 11, there have been over 3,000 technical papers on LSD. But scientists still do not know why LSD causes a psychoactive effect, or whether it is toxic, or whether it causes birth defects, or whether the widely reported "flashback" effect is real or imagined and, if real, has an organic basis. In short, many of the most important questions remain unanswered.
Morphine was first isolated in the early 1800's, and heroin was synthesized in the late 1800's. Among the things we still do not know about these drugs are the mechanisms by which tolerance develops, or whether an addict can be stabilized on a given dose, or whether the drugs cause any organic damage, or the mechanism by which they alleviate pain, or even whether withdrawal can be psychologically as well as physically induced.
While it is common knowledge that many drug users, including those on methadone, use combinations of drugs, little is known about the effects of these combinations. For example, mixtures of heroin and cocaine, or of amphetamines and barbiturates, are often taken, but we do not know how they interact.
We have been unable to discern agreement among researchers on what is and is not known, or on the priority needs for research, with respect to the drugs of abuse.
Basic research questions concerning psychoactive drugs can be divided roughly into two groups: (1) toxicological and pharmacological effects, and (2) psychological and perceptual effects.
Scientists probably know most about the toxicology (organic damage done to the human body) of drugs of abuse, yet even here there are many unanswered questions. It is known, for example, that excessive use of alcohol and barbiturates causes extreme damage to the brain and liver. It is suspected that amphetamines in massive doses also cause organic damage, but scientists are not yet sure. There is insufficient toxicological information on the opiates (e.g., heroin, morphine), the cannabinols (e.g., marijuana, hashish), and the hallucinogens (e.g., LSD, mescaline), the three categories of drugs with which the country is most concerned.
The organic damage caused by drugs is, of course, only one aspect of the more general study of pharmacological effects that is, on what cells does a drug operate, how does it operate, what metabolites are triggered, and so forth. Nor are such questions unique to drugs of abuse. There appears to be no general theory of drug action based on the chemical structure of drugs into which discrete studies of the pharmacology of the drugs of abuse can be fitted. And there is a question whether psychoactive drugs do or do not represent a separate class of pharmacological compounds that can be studied at a theoretical level, independent of the study of pharmacology generally.
Basic pharmacological research would undoubtedly provide useful knowledge for basic researchers, from which they may some day construct a general theory of psychoactive drug action. The central-nervous-system effect of drugs is, however, a particularly difficult area of study. Many of the drugs with which we are concerned have effects that are apparently quite subtle and difficult to delineate. Some of the major tranquilizers, which exert immensely potent effects on the brain, have been studied intensively by NIMH for almost twenty years, and we still do not really know how they work. It is uncertain whether more could be learned faster by studying LSD, marijuana, or even heroin. In short, the road to a general understanding of the pharmacological effects of psychoactive drugs is difficult, and basic research in this area is not guaranteed to be productive.
Brain functioning is, of course, one of the current frontiers of science, and the complexities of studying the central nervous system make it likely that this area will remain a frontier for years, if not decades. Although drugs are simply one type of instrument for the study of the broader questions, the drugs of abuse may be a particularly interesting input because they clearly have large effects on the brain.
There is a great deal of work to be done here, and much of it will be important. As the pharmacologists study the physiological correlates of drugs and the psychopharmacologists and experimental psychologists study the psychic correlates, at some point in time linkages will be made leading to a unified view of the entire process.
The second category of potential research concerns the general interaction between drug taking and psychological and perceptual awareness. Such psychological variables as anxiety levels, attitudes toward self, perceptions, attention span, and mental ability are all affected by drug taking. Conversely, pre-existing states of mind and attitude have a significant impact on whether an individual will seek drugs in the first place and on the actual effects of a drug once it is taken.
Historically, because drug abuse has been looked at primarily from the standpoint of deviant behavior, the study of its psychological and perceptual effects has been placed largely under the heading of psychopathology. Interest in the role of external stimuli, of which drugs are but one example, in altering the individual's perception and awareness of his surroundings has increased in recent years. There is, for example, greater scientific interest in the subjective experiences and descriptions, rather than simply objective phenomena, connected with drug taking. As with basic pharmacology, there is much important information yet to be obtained in this developing area, all of which is fundamental to a better understanding of human functioning; but the progress of such research will likely be slow and uncertain.
This area of interest, also, is not discrete. There are clearly physical correlates for different states of perception and awareness, although the links have yet to be forged.
DRUG EDUCATION AND PREVENTION
There is substantial uncertainty and confusion in the area of drug education and prevention. Although nearly all workers in the field believe strongly that sensitive and accurate drug education programs can play an important role in preventing harmful drug experiences among youth, there is no real evidence that such educational efforts are successful. Educators are cautious about new programs because of concern in some quarters that too much discussion about drugs of abuse could glamorize them and lead to experimentation. There is also increasing concern about the use of ex-addicts in schools. Although they are popular with students for "telling it like it is," there is justifiable fear that providing them with an aura of prestige may lead significant numbers of students to believe that they can and should try drugs themselves.
Past efforts have generally been of the "scare" type, emphasizing the moral and physical degradation of drug abuse and generously sprinkled with blatant misinformation, especially about marijuana. In schools, such lectures are usually delivered by gym teachers or visiting law-enforcement officials. Their aim has been one-dimensional-to stop young people from trying any illegal drugs.
It is now widely recognized that drug education, to succeed with increasingly sophisticated young audiences, must be accurate, factual, and consistent with the listener's own experiences or observations. Although a truly candid educational program may reduce involvement with the more dangerous drugs, such as heroin, it may also increase experimentation with the less dangerous drugs, such as marijuana, and many educators are reluctant to be drawn into an approach with such potentially controversial consequences. The federal government spent $3.5 million during the summer of 1970 in an attempt to train 350 schoolteachers, administrators, and student leaders to conduct workshops in their home communities dispensing information about drugs. The ability to withstand attitudinal confrontations of skeptical students was stressed. We have no indication whether this program was successful.
Virtually none of the myriad drug-education programs swamping the market from private companies, civic organizations, and even the government itself has been evaluated. The only detailed evaluation we have seen, involving a model-education program in a high school, showed that students improved not only in their factual knowledge but in their cautionary attitude toward drug use. That evaluation showed that the students liked the personal accounts of ex-addicts best but chose doctors to tell the facts. The students wanted more emphasis on the particular drugs in common use in their school and an approach that took the drugs up one by one rather than all grouped together.
The current emphasis among educators is on a continuous spectrum of education about drugs generally (legal and illegal), from kindergarten through high school, and on the integration of drug education into other social-problems curricula, which would include alcohol, smoking, sex, family living, and so forth. Dr. Norman Zinberg of Harvard has been evaluating such an experimental course for senior and junior high schools outside of Boston and expects to produce an effective and exportable curriculum. Dr. William Soskin in California has a different kind of program, for which school credit is given, that creates a third force besides family and school in the youth's life-a primary group with which he shares experiences all week, including a heavy emphasis on inner exploration.
One intrinsic problem with any kind of school-based education is that a large portion of serious student drug users have already rejected school. The motivational exploration that educators stress can be carried on only in a spirit of trust, and too many schools still require teachers and counselors to report all known or suspected users to the police. Only a few schools have had the courage to experiment with the designation of one or more teachers or counselors as official confidants to whom students can turn for help without fear of exposure. Few schools have close working alliances with treatment resources to which they can refer students. Parental permission for such treatment poses another legal obstacle to such desirable arrangements. It is doubtful that the federal government's crash summer teacher-training program can surmount these basic problems without a more fundamental change in community attitudes.
The National Coordinating Council on Drug Abuse Education and Information, composed of nearly one hundred government and private agency members, has recently entered the drug education field.' It conducts evaluations of the explosion of anti drug films and literature and stresses rational, coordinated efforts by city leaders to explore the basis and true extent of a community's drug problems and how the community can best utilize its resources for dealing with them. NCC's approach is that drug education should not aim at suppression of all illicit drug use but should teach children to make rational decisions based on reliable information about which drugs they will use and how much they will use them.
It can reasonably be expected that more federal money will be channeled to the states and cities for drug education, with little direction on how it should be spent. There are only the most primitive notions of how to determine whether a drug-education program has been successful. Even the goals of such programs are hotly contested. And there is little emphasis on evaluation techniques by the federal government.
At least in the immediate future, most schools will probably be unable to alter their basic authoritarian structure to the kind of open-minded approach to drug education that will help early experimenters or drug-prone students. The mere presentation of basic facts,, even if honestly set forth, can be expected to have limited value in stopping the spread of youthful experimentation, and a law-enforcement orientation that requires school personnel to report all users will totally undermine education efforts.
It is probably also true that adults, more than school children, need accurate drug information to counter long-held myths. An appalling number of well-educated parents, as well as their children, still fail to understand the real differences among drugs of abuse. This misunderstanding is perpetuated in the 1970 federal drug-abuse law, which provides a one-year maximum prison sentence for possession of any illegal drug, regardless of whether it is quite dangerous (like heroin) or less harmful (like marijuana).
With respect to treatment, two basic problems exist. First, relatively few drug-dependent persons are currently in treatment programs, largely because the programs do not have sufficient facilities or staff. Second, existing treatment for drug abuse and drug dependence has not produced impressive results (except for some methadone programs), and, even if all drug abusers and drug-dependent persons had treatment available to them, the outcome would be uncertain.
There are three general types of treatment modalities for users of drugs other than heroin. In many urban centers where drug use flourishes, crisis clinics have been set up to offer immediate emergency services to drug users and other troubled youths. They are typically staffed by youths under volunteer professional direction. They give out drug information, analyze street samples, "talk down" people with bad reactions, and see that those in genuine medical danger get to hospitals. Some also refer persons to long term treatment programs or themselves offer individual or group therapy to drug users. San Francisco's Haight-Ashbury Free Medical Clinic is the best-known example of such clinics now found in many cities.
Therapeutic communities, which operate on the basic assumption that a character defect causes drug use, treat all drug users with encounter-group therapy or a more gentle form of "rap session" therapy.
Users of speed and LSD, and even heavy marijuana users, may well have underlying psychiatric problems. The only treatment available for them thus far is the kind of individual or group therapy used with other mental-health patients. Its success remains largely unevaluated.
Because heroin is regarded as the most serious drug threat to society, there has been a much more concentrated effort at treatment for heroin addicts. In New York City, where probably 50 to 60 per cent of the nation's heroin addicts reside, an estimated 10 per cent are in some form of treatment. Washington, D.C., has perhaps 15 per cent of its estimated 15,000 addicts under treatment. As of October, 1970, there were about fifty methadone projects throughout the United States serving a total of about 9,00010,000 persons.' Nationally, it is safe to say that well over 90 per cent of all heroin addicts are not in any treatment program at all.
The two main treatment modalities for heroin addicts are (1) abstinence, bolstered by outpatient or inpatient group therapy, and (2) methadone maintenance, with or without supportive services. (A possible third approach is longer-term "detoxification" with methadone, which is given in decreasing dosages until the subject is entirely drug-free.) In New York City, nearly 4,000 heroin users are currently in fifty residential therapeutic communities, and 5,000-7,000 are reportedly on methadone. In Washington and Chicago, about half of all persons in treatment programs are on methadone and half on abstinence programs. There were, until recently, only a handful of addicts on methadone in California because of a legal restriction on its use outside institutions. Some legal restrictions still exist today. Many other large cities still have no methadone program at all.
Most methadone programs have long waiting lists. Almost all treatment programs have selective admission criteria and thus are probably skimming off the cream of the addict population. They do not appear to handle the most criminally active and hard-core addicts.
As compared to abstinence, methadone is clearly showing better results. Depending upon the degree of prescreening and the amount of supportive services built into the program, between 45 and 80 per cent of those admitted to methadone programs are successfully treated, as measured by continuation in the program, decreased arrests, job stability, and other social indicators. Experimentation is being tried in a few places with "barebones" methadone (without supportive services) to see what portion of the addict population can make it on the substitute drug alone, without concomitant social-adjustment help. The most promising approach we have seen is putting both methadone and nondrug treatment programs under the same administrative roof. From a research standpoint, this permits accumulation of a body of data from which a typology may be developed to show which kind of addict succeeds in which kind of program. There is some concern, however, that a multimodality program, combining maintenance and abstinence alternatives, may confuse patients and reduce the effectiveness of both approaches.
The more comprehensive the methadone program, and the more complete the data collection and evaluation, the more costly the program will be and the fewer patients it will be able to serve. Costs per patient per year may vary from a high of over $2,000 for a full service program to a low of $500 for a "barebones" program.
Methadone has thus far been used primarily with older addicts who have volunteered for treatment. Except in Washington, the average age of persons in methadone programs has been over thirty, close to the age when statistics indicate that a sizable portion of both addicts and criminals tend to "mature out" of their deviance. Whether methadone will do as well with an involuntary population of younger age remains to be seen.
There is a sizable problem of methadone acceptance, especially in the black community, because of opposition from groups who view it as a crutch indistinguishable from heroin and a source of white enslavement of blacks. Detoxification from methadone maintenance is being tried with a small number of patients. If this proves successful, the cloud of lifelong dependence now hanging over methadone will be removed and methadone should prove more acceptable among blacks.
Another problem is the possibility of "leakage" in the control system. Diversion of methadone poses a danger, as is indicated by the death of several non-opiate users who had not built up a tolerance and who ingested large doses. On the other hand, methadone appears to be safe for use by addicts in controlled maintenance programs.
Although all available evidence indicates that methadone is a safe and effective method of treatment, the federal government has nevertheless concluded, apparently for policy reasons, to inhibit its use by giving it only investigational status. This raises costs and staff requirements and limits the number of addicts who can be treated. It is unclear what additional information, if any, would persuade the Food and Drug Administration to alter this decision.'
Until methadone leaves the research context in which it now legally resides, its potential parameters will remain unclear. And just how much federal money will be available in the future to encourage methadone or multimodality programs in all major cities is unknown.
Some work is also being done on the nonnarcotic antagonists, primarily cyclazocine and naloxone, which block the euphoric effect of heroin. Several hundred people have now used these antagonist drugs. The chief problems in their use have been the short duration of action of both drugs-four to eight hours for naloxone, about the same as heroin, and 22 to 26 hours for cyclazocine, about the same as methadone-and, until recently, unpleasant side effects from cyclazocine. Work has been undertaken on longer-acting antagonists and on an implant that could discharge the drugs over a period of weeks. The antagonists, however, apparently do not satisfy the drug craving as methadone is said to do and have not proved as popular with addicts.
Other, more conventional methods of treating heroin addiction appear to have a substantially lower success rate than methadone, although comparison is difficult because of the differences in the types of drug users treated, the criteria for success, the statistics kept, and so forth.
Therapeutic communities like Daytop Village, Odyssey House, and Phoenix House purport to have up to a 75 per cent success rate with those who stay in the program, but they do not include in their figures the large number of addicts (estimated as high as 50 per cent) who drop out within the first month or two. Dr. Jerome Jaffee's work in Chicago, which to our knowledge constitutes one of the few attempts to compare the effectiveness of methadone and therapeutic communities with the same population, shows a startlingly greater success with methadone than with the therapeutic community. Of the 2,500 addicts who have been treated in the New York City Addiction Services Agency's Phoenix Houses since 1967, only 130 have graduated back into community life (and 90 per cent of these work in addiction programs). An inpatient in such a facility costs $3,000 to $5,000 per year compared to a cost of $500 to $2,000 for a methadone patient, but methadone may require a longer, or even a permanent, period of treatment. It seems highly unlikely, in any event, that there could ever be a sufficient number of residential therapeutic communities to have a major impact on the problem.
Black community organizations, such as Colonel Hassan's Blackman's Development Fund and the Bonabond Agency in Washington, also claim a special ability to keep black addicts off heroin by abstinence therapy following detoxification with methadone and appeal to racial pride. But thus far their claims of success have received no objective evaluation.
NIMH is still committed to comprehensive community mental health centers as the answer to the drug-treatment problem, but recent federal legislation for the first time permits support of drug-treatment programs unaffiliated with these centers. We have been able to find only a few examples of success with the community-mental-health-center approach and an equal number of outright failures. The successful community-mental-health-center, drug-treatment programs would appear to be just as successful if they were not affiliated with the centers, and even in theory there is reason to question the inclusion of drug treatment under the umbrella of the centers. In any event, we are unable to find statistics on the effectiveness of this approach.
Virtually everyone agrees that individual psychiatric therapy not only is impractical because of the large number of addicts but generally produces poor results with addicts.
There is one method of treatment that has not been attempted in this country since the Bureau of Narcotics, with the support of the American Medical Association, stamped it out in the early 1920's-heroin maintenance. At one time, there were some forty heroin-maintenance clinics in several areas of the country, unfortunately under rather loose procedures. The Bureau succeeded in banning them by 1923 and has since done everything possible to discredit this method of treatment. The suggestion by a prestigious joint American Bar Association-American Medical Association Committee in the late 1950's that experimentation with a heroin clinic program again be undertaken was met with a vicious attack by the Bureau of Narcotics. During the past five years, the Bureau of Narcotics (now the Bureau of Narcotics and Dangerous Drugs) and NIMH have argued that the British system of narcotics maintenance has utterly failed and could not reasonably be considered for use in this country. (Staff Paper 7 of this report, prepared for the Project after an extensive on-site inspection and investigation, concludes that the British system of narcotics maintenance appears to have succeeded in containing the narcotics problem there.)
One outstanding deficiency in the treatment field involves evaluation. Several treatment programs, mostly methadone-maintenance programs, have data-collection and evaluation components. The Dole-Nyswander program in New York has been intensively evaluated by a prestigious medical committee, and indeed the evaluation of methadone in various programs throughout the country has now reached the point where there can no longer be serious question about the general usefulness of this treatment approach. The vast majority of the treatment programs, however, and particularly the non-methadone programs, have relatively narrow or quite inadequate data-collection and evaluation components, or no such components whatever. Moreover, data collection and evaluation are not standardized, with the result that comparison of programs or techniques for different patients, taking into account the many possible variables, is simply not possible at this time.
The Illinois Drug Abuse Rehabilitation Program, under Dr. Jerome Jaffe, has an unusually sophisticated system of data collection and analysis combined with a multimodality treatment program, thus permitting direct comparison of the effectiveness of different techniques. Similar programs with useful research components include the Washington, D.C., Narcotics Treatment Agency, under Dr. Robert Dupont, and the Connecticut Mental Health Center in New Haven, under Dr. Herbert Kleber. But no such program has the funds or time to standardize data collection for all other programs or to persuade others to adopt a uniform system, much less to attempt to standardize and persuade others to adopt uniform evaluation criteria.
Without sufficient detailed data collected on a standardized basis by a substantial number of different projects, there can be no satisfactory comparative evaluation of various treatment approaches for different types of drug users. Largely unsubstantiated and disputed claims of success and failure will continue to dominate the field until adequate evaluation is accomplished.
A second deficiency apparent throughout the country is the lack of enough trained administrators to run treatment programs. The few outstanding treatment projects emphasize the need for scholar-administrators with a medical and drug-abuse background but also with management skills. The most able project directors do not fall into the typical civil-servant mold but, rather, are men willing to take gambles and basically to let themselves be "burned out" in a few years. How to create a reserve of people equipped with this unique combination of talents and bow to provide incentives for them to enter the field are critical questions in the future of treatment.
Law enforcement has, of course, been the primary means by which society has attempted to control drug abuse in the past and at present appears to represent the principal effort for the future also. Arrests for drug offenses have increased dramatically during the past few years, from 31,752 in 1960 to 134,006 in 1968 and over 230,000 in 1969. Such arrests of persons under eighteen rose from 1,688 in 1960 to 33,091 in 1968 and over 57,000 in 1969.
There is, however, an acknowledged lack of direction and of trained manpower in state and city efforts, which results in scant disruption of illicit traffic above the street level. Most arrests are of users. The principal sellers arrested are amateurish young softdrug peddlers and addict street dealers. Studies show that almost all heroin addicts get arrested at least once every two years of active addiction and spend an average of 15 per cent of their addicted life in jail. In New York City in June, 1970, there were 4,000 drug arrests compared with 1,800 in June, 1969. About 60 to 70 per cent of those arrests involved heroin. In Washington, D.C., arrests doubled in the first six months of 1970 and now run about four hundred per month; over 50 per cent involved heroin. California reportedly made 150,000 drug arrests for use and possession in 1969, a 300-per-cent increase over 1967, and it is unclear whether all of these are reflected in the national statistics.
BNDD has recently announced that it will provide no more than consultative services to local police in use, possession or small trafficking cases, and it is increasingly shifting its resources to the apprehension of large traffickers. In 1969, its agents made or instigated 4,000 arrests; for 1971, this figure is expected to fall to about 1,875. Basically, however, the criminal-law approach appears to have had little impact on the growth of the problem, as is demonstrated by the fact that illegal drug use, by everyone's calculation, is increasing and shows no signs of leveling off.
The federal government formerly took the position that illegal drugs that are imported, such as heroin and marijuana, could be stopped at the border if sufficient resources were allocated to this effort. In spite of recent large increases in budget and manpower, however, no significant impact has been made. Border seizures of heroin amounted to less than 5 per cent of the estimated imports in 1970. Indeed, the price of heroin has been falling steadily and the quality increasing, which indicates a failure to stem the supply. There is strong evidence that Operation Intercept, the attempt to impede the flow of marijuana from Mexico into the United States, has resulted in significant substitution of other drugs for marijuana.
The illegality of heroin is, of course, the sole reason for its high cost in this country. In England, the pharmacy cost of heroin is $.04 per grain (60 mg.), or $.00067 per mg. In the United States, the recent street price is $30-$90 per grain, or $.50-$1.50 per mg., depending on the time and place of sale and the quantity and quality of the drug.
As a result of the failure to stop heroin at the border, recent federal government 'policy has concentrated on cooperation with foreign governments, primarily Turkey, to reduce their opium production. Since it is estimated that the United States requires only 50,000 to 60,000 pounds of opium each year for illicit heroin use, since this amount is about 1.5 per cent of the total world production of opium, and since the entire U.S. demand could probably be met by cultivation of about five square miles of opium,' and since opium could readily be grown in other parts of the world, a program based upon suppression of opium production seems no more likely to succeed than the program based upon prevention of importation.
Finally, the initial hypothesis that drugs were not interchangeable-that, for example, a heroin addict would not be likely to switch to a different drug (e.g., the barbiturates or amphetamines) if heroin were unavailable-does not appear to be true. There is evidence that users will freely substitute even less potent drugs if their drug of choice is not immediately available. There is a far greater pattern of multiple drug use than was previously thought to exist. Suppression of one drug for a period of time, whether long or short, appears, therefore, to have a limited effect on drug abuse generally.
The law-enforcement approach to drug-abuse problems has been ameliorated by legislation permitting civil commitment in lieu of criminal punishment. Under present legislation, however, such treatment is largely illusory, since it is almost wholly institutionalized and often results in greater punishment than would be imposed by a criminal sentence. It is doubtful that institutionalization under these programs has been markedly more successful in rehabilitation than criminal sentencing.
New York, California, and the federal government have civil commitment treatment programs that take a relatively restricted class of criminal defendants in lieu of prosecution or sentencing (as well as persons committed voluntarily or by relatives and others). The New York and California civil-commitment programs have proved very expensive-$4,000 to $5,000 per patient per year for care and treatment in New York, and a total of $12,000 for all costs. About $250 million was spent by New York State in 1967-70, the major share for capital construction and custodial salaries. Only one out of five patients successfully survives the parole period in the California program, and less than 25 per cent the New York program. The federal Narcotic Addict Rehabilitation Act (NARA) program currently has under 1,000 persons in an outpatient status and 800 in an inpatient status. Many addicts are ineligible for treatment because of the restrictive admission criteria contained in the Act, and almost half of the cases referred for evaluation are rejected because they are found "not likely to be rehabilitated." In general, civil commitment programs have suffered from cumbersome legal machinery, restrictive admission requirements, inflexible terms of inpatient residence, expensive security consciousness, lack of dynamic programs, and active resentment among inmates because of the prison like climate and poor treatment efforts.
juvenile courts appear to offer one of the most flexible ways of channeling youthful users into early treatment, yet they are rarely used for this purpose. Almost all addicts are arrested first while in their teens. Most juvenile courts already have the power to divert drug users rapidly to a treatment agency, even without a formal finding of law violation, and they can keep all records confidential. Speedy urinalysis and a closer working relationship between juvenile courts and community treatment programs might have an impact on the problem. Ordinary juvenile institutions are less useful. They are experiencing an increasing problem with contraband drugs (we have been told that many youths get their first drug experiences there), and few, if any, have drug education or therapy programs, or indeed any urinalysis surveillance, after inmates leave the institution.
The federal government (as well as local and state police agencies) has been severely criticized for devoting its law-enforcement efforts to drug users and addict pushers and failing to prosecute large drug wholesalers. In New York and Washington, and probably elsewhere as well, grassroots organizations claim to know the identity of the larger wholesalers and in some instances state that they have turned information over to law-enforcement officials without results.
The short working life of undercover agents, the large amounts of cash necessary to make substantial "buys," and the structure of the heroin market, which is designed to insulate higher figures from contact with the drug, are the reasons most commonly cited by law-enforcement and community officials for the paucity of results in disrupting the heroin traffic. But the factor more commonly cited by ghetto groups, and increasingly also by such respected citizens as former Chief justice Earl Warren, is corruption of narcotics agents. More than thirty federal agents were reportedly indicted on bribery and narcotics-sale charges during 1969 and 1970. The view is endemic in ghetto areas-and apparently it is justified at least in part-that the federal, state, and local police are not doing their job, and that they should be able to arrest more dealers and distributors than they do. Although it may be partly a question of better training, direction at the top, and placement of a higher priority in the area, there may also be widespread corruption involving pay-offs at the lower levels between police and pushers.
Both previous and present federal drug statutes make possession of an illegal drug of abuse a crime. When the Drug Abuse Control Amendments of 1965 were enacted to cover nonopiate drugs, possession for personal use was not made a crime, but this was changed in 1968 because of the LSD scare. The legislation enacted by Congress in 1970 to recodify and modernize all the federal drug-abuse laws continues the policy of making possession a criminal offense, with a one-year maximum sentence for possession of any illegal drug and twice this term for second and subsequent offenses. Neither prior law nor new legislation provides that an addict is not criminally liable for possession of a drug to support his habit. Test cases are being litigated to develop this defense as a matter of constitutional or common law, and the staff of the National Commission on Reform of Federal Criminal Laws has proposed that this should in any event be a statutory defense. Congressional support for such a defense would, however, appear difficult to obtain.
Regardless of judicial or legislative reform, it appears that the law-enforcement process will remain a significant, and probably by far the most important, intake unit for drug-dependent people for many years to come. At present only a few, crude attempts are being made to utilize this intake path to channeling addicts into useful treatment programs outside the civil commitment procedures.
Drug users are generally processed as ordinary criminals, and, conversely, a large percentage of ordinary criminals, when tested by urinalysis, are found to be drug users. Urinalysis tests in the criminal courts and detention facilities of major urban centers show that one-third to one-half of all criminal defendants, including juveniles, are currently using drugs, and some estimate that 80 per cent of the serious property crime in Washington, D.C., is committed by drug users. The likelihood that a criminally processed drug user will be given any specific treatment during his incarceration is slight. But even more basic, attempts at treatment programs in the prison setting have been markedly unsuccessful. Indeed, there is evidence that many nonusers or experimenters are first introduced to drug use or have their habits reinforced while in prison. One survey showed that 90 to 95 per cent of the heroin addicts who leave prison without treatment follow-up lapse almost immediately into drug use. Many of the major urban areas now have parole programs that test for drug use through urinalysis, and a few offer parolees methadone, group-therapy, and/or halfway-house programs. Nonmethadone programs with probationers and parolees, however, have not proved very successful. The majority of such probationers and parolees have had to be returned to prisons or court for drug violations.
It is our belief that a major reason for the confusion and division within the drug-abuse field and the country in general is the lack of effective leadership, on both a governmental and a nongovernmental level. Effective leadership, by our definition, includes such functions as keeping the country informed about drug abuse and the latest drug research and arranging an open climate for medical and social research and for reasonable experimentation with different models of control. Effective leadership should, further, avoid eliciting emotional public reaction to isolated incidents and attempt to remove the drug problem from national politics.
Within the federal government, there are three organizations substantially concerned with drug abuse: BNDD, NIMH, and the Department of Defense."
BNDD has for years pursued a national approach to drug abuse characterized by suppression of illegal drugs and the enforcement of criminal penalties for drug abusers. Although Bureau officials now emphasize the need for rehabilitation, the basic policy position of BNDD has not been significantly altered. The legislation recodifying federal drug-abuse laws, drafted by BNDD and passed by Congress in October, 1970, represents little change in fundamental narcotics policy and only reinforces and codifies existing law (except for some modification of penalties). The reason for the recodification, indeed, was not a desire for reform but a need to repair legislative provisions voided by the Supreme Court on constitutional grounds.
The new law still includes marijuana and heroin in the same classification, provides a uniform penalty for possession of any illegal drug, and contains such harsh sanctions as a thirty-year maximum prison sentence for an eighteen-year-old with a prior offense who sells marijuana to a twenty-year-old friend if there is any profit involved in the transaction. Any change in the basic BNDD approach of penalizing drug abuse seems highly unlikely in the near future.
During the past two crucial years of public-policy development, NIMH has been singularly impotent as an independent voice in policy decisions and has seemingly been forced to accede to the BNDD approach of relying almost exclusively upon law enforcement. There is no reason to believe that NIMH will be given substantially more leeway in putting forward policy alternatives in the immediate future. Although there are a number of NIMH personnel working on drug abuse who do favor a more flexible and health-oriented approach toward drug users and who would promote such an approach if allowed and encouraged to do so, a significant change in federal policy is required before they can be expected to speak out publicly on these matters.
Until mid-1970, the Department of Defense denied that there was any drug-abuse problem at all in the military. It has now admitted that drug abuse does indeed exist in the armed services and is initiating a program for treating users as an alternative to punishment and dishonorable discharge.
Legislation has been introduced in the U.S. Senate to liberalize treatment under the Narcotic Addict Rehabilitation Act, to revitalize the narcotics work of NIMH, and to authorize a far more comprehensive health, welfare, and rehabilitation approach to the problems of drug abuse by the federal government. But even if such legislation is enacted, the present administration's emphasis on the law-enforcement approach could undermine its effective implementation.
The state government picture varies, of course, from state to state. Suffice it to say that, thus far, few states have refused to follow the lead of BNDD with respect to narcotics policy and that of the U.S. Congress with respect to narcotics legislation. As an example of the current climate, the August, 1970, Conference of Uniform State Law Commissioners approved a draft of a uniform state drug-abuse law, prepared by a BNDD attorney, with the understanding that it could be revised before final publication to reflect any appropriate changes in light of federal legislation then pending in Congress. An earlier draft, based upon what BNDD had hoped to have passed by Congress, was enacted by two states before the final version was available.
The nongovernmental organizations interested in the field of drug abuse have not exerted significant leadership during the past two years. During this critical time of public-policy determination, professional, medical, and scientific organizations such as the American Bar Association, the American Medical Association, the American Public Health Association, and the National Academy of Sciences-National Research Council have spoken out only on specific issues of interest to them and only on isolated occasions. Because all these organizations deal only tangentially with drug abuse and must rely for their efforts primarily on busy professionals who have full-time jobs outside the organization, none of them could be expected to exert the effective leadership that is needed in this field.
There is no national voluntary citizens' organization in the field of drug abuse comparable to the National Council of Alcoholism (NCA), and NCA has recently decided that it will enter this field only to consider problems in which drug abuse and alcoholism interact. Both the North American Association of Alcoholism Programs and the National Association of State Mental Health Program Directors, which are organizations representing state tax-supported agencies, also deal only tangentially with drug abuse and have made no serious effort to become concerned with the field in detail.
Largely because of this void, a paper organization, the Committee for Effective Drug Abuse Legislation, was created to represent the medical-scientific viewpoint before Congress during the hearings on the new drug-abuse legislation. Since this organization has been concerned almost exclusively with the freedom to conduct research and is poorly funded, it has had to ignore many other important public-policy issues.
Another new organization is the previously mentioned National Coordinating Council on Drug Abuse Education and Information, created in 1969 to bring together virtually all national organizations, from the drug industry to consumer groups, and from the PTA to the National Student Association, for the purpose of developing an effective drug-abuse education program. Although the Coordinating Council is financed to a significant extent by the federal government and has governmental representatives on its board of directors, it has shown independence and a reasoned approach to education and community planning in the drug field. The Coordinating Council's achievements are largely the work of a very few people, however, and, because of its precarious financial underpinnings, it is uncertain how long and how vigorously it can continue its efforts.
A MORE PROMISING APPROACH TO DRUG ABUSE
The foregoing summary discloses a lack of leadership in the field of drug abuse, a law-enforcement approach that is often ineffective and even harmful, and a country deeply and even bitterly divided over the proper approach to drug abuse. We believe that an effective attack on drug abuse can be launched only in a climate of reason and tolerance, allowing us to discern the real evils of drug abuse while rejecting policies based on confusion, misinformation, and emotion.
Before we can begin to cope adequately with drug-abuse problems, therefore, we must begin to refine and clarify our thinking about them. The world is full of drugs, large numbers of which are psychoactive. The majority of adult Americans take alcohol as a tension reliever or to facilitate social intercourse, and the use of nonprescription and prescription drugs for similar purposes is endemic. The availability and variety of these drugs will probably not only continue but increase.
Many of the drugs used have profound therapeutic benefits that allow people to offset physical or mental pathology and function more normally. Few of us would be willing to forego these therapeutic benefits, and no one perceives the use of drugs to achieve normal functioning as abuse. An increasingly large number of people, however, are not willing to limit their drug taking to medically supervised attempts to offset pathology. Some engage in self-medication with drugs they have become acquainted with through legitimate medical use. This pattern often occurs in the case of tranquilizers. Some wish to escape an unwelcome reality with heroin or barbiturates. Others desire the very acute functioning associated with the amphetamines. Still others, especially the young, seek the pleasurable effects of hallucinogens or marijuana.
The basic philosophy underlying our present drug-control laws is that all of these self-induced effects are to be shunned, or at least are not to be sought through drugs other than alcohol. This is a decision based partly on the fear of actual physical damage caused by the drugs, but primarily on the belief that drugs damage society because they contribute to crime and alienation.
It seems inevitable to us that all segments of society will continue to be exposed to a myriad of drugs in the future, and that society must learn to cope with these chemicals as part of everyday life. It is not possible at present to foresee exactly how the necessary adjustments in social attitudes and policies will be made.
We do feel, however, that current national policy-which singles out particular drugs and makes their possession or use a crime-should be changed for very important empirical reasons. We believe that the individual and social harm caused by imposing criminal sanctions on drug users far outstrips the benefits of this approach. Handling drug users as criminals has created widespread disrespect for the drug laws, has resulted in selective enforcement, has possibly done more to encourage than to discourage illegal drug use, has undercut bona fide efforts to explain the important differences among various drugs in the physical and mental damage they cause, and has deterred drug abusers from seeking necessary help. We feel that, as a first step in bringing the problem back into perspective, criminal penalties for possession of illegal drugs for personal use only should be abandoned in many jurisdictions. If this were done, drug users but not drug traffickers-could then be handled on a public health and social-welfare basis. Like the Canadian LeDain Commission on Non-Medical Use of Drugs, which in its April, 1970, Interim Report recommended retention of only a perfunctory $100 fine for illegal possession of drugs as an interim measure pending issuance of its final report, we have seen no evidence that eliminating the criminal penalties for possession of illegal drugs for personal use would materially impede the effectiveness of law-enforcement efforts against trafficking or remove an incentive for drug users to seek treatment or have other unfortunate consequences.
This conclusion in no way depends on a belief that chemicals should be freely used to induce pleasure. Nor do we believe that it is necessary to await final resolution of the currently popular debate about whether alcohol or marijuana is the more dangerous drug, a debate that has succeeded only in provoking further generational confrontation about hypocrisy, permissiveness, and life styles. Most of those who advocate a public-health approach disapprove strongly of the unsupervised use of dangerous drugs, especially by young people. Our conclusion is based, rather, on a recognition that our present methods of handling the drug abuser are at best ineffective and at worst counterproductive, and that other approaches must be tried. Eliminating criminal penalties for possession for personal use would neither legalize a particular drug nor permit its use. Law-enforcement efforts would, and in our opinion should, continue, but they would be directed at illegal distribution. And illegal drugs would remain subject to confiscation wherever found.
If the confrontation over the role of the criminal law in enforcing private moral judgments or choices of drugs were eliminated, the country might be able to unite behind an intensified approach to research, prevention, treatment, and law enforcement directed against the upper echelons of the illegal drug traffic. Restrictions on scientific research inquiries into particular drugs might then be lifted and substantial public and private funds more easily directed toward the understanding of how drugs work on the mind and body and what effects, both short and long term, they produce. Education of young people against the reckless use of powerful substances that affect the mind could proceed in a free and open climate more calculated to influence their behavior.
As research discloses more about specific drugs, some might eventually become candidates for limited legalization, in the pattern now used for alcohol. In other cases, disclosure of severe or permanent damage to the mind or body would require that distribution controls remain under criminal penalty. With such potentially harmful drugs, the user who refuses to accept treatment, and who can be shown to constitute a danger to others, might be committed civilly for appropriate treatment.
Voluntary treatment for harmful effects of drugs could similarly be made more flexible and accessible under such a system. Restrictions against any experimentation with heroin maintenance and unjustified limitations on the use of methadone maintenance could be reviewed and possibly removed. More public funds would be devoted to current treatment efforts and to searching out new treatment methods, to permit adequate handling of all voluntary and involuntary patients.
Finally, law enforcement could continue to act as an intake unit for treatment programs for those drug abusers accused of minor trafficking or other crimes. Where the drug taking results in dangerous antisocial acts, it is not unjust to require the offender to undergo treatment as a condition of liberty or even to offer it to him within the confines of the institution. But law enforcement's main focus would be directed at illegal drug wholesalers. In this endeavor, it would have the wholehearted backing of vast numbers of Americans, young and old alike.
THE DRUG ABUSE COUNCIL
In the previous section, we outlined an alternative approach to drug abuse that we believe is more promising than the present national approach. Private foundations do not have the means fully to implement such an alternative approach, nor could they legally do all that would be required to bring it about. A foundation cannot, for example, properly engage in efforts to change legislation. On the other hand, pursuit of the public welfare is a well-recognized task of all private foundations, and an important aspect of the approach described above involves education, research, and related activities that have long concerned private foundations. The basic goal might be summarized as one intended to make national drug-abuse policy responsive to facts rather than emotion. This is clearly an area where foundations could properly play a very large role.
Our primary recommendation is that an independent, nonprofit Drug Abuse Council be established to fill the leadership void that now exists in all areas of the drug-abuse field. This would preferably be undertaken as a joint project by a number of private foundations and organizations. The Council would strive to become a vitally needed center of excellence for drug-abuse information, basic research, education, and prevention, evaluation of treatment and education programs, and related activities.
The federal government is not equipped to perform this function. Its activities in the drug-abuse field are fairly narrowly circumscribed by political necessities, it relies largely on recruitment of civil-service personnel even at the top leadership levels, and its financial commitments are short term and subject to the vagaries of Congressional and administration decisions. Federal activities in the drug-abuse field tend to be ad hoc reactions to current crises, such as the 1970 crash drug-education program in response to the well-publicized death of a twelve-year-old heroin addict, rather than well-considered, long-term programs.
Assuming that drug abuse will exist for years to come, and that the country's policies should be grounded on fact and reason rather than on emotion and politics, a long-range investment in education, research, and treatment is necessary. The Drug Abuse Council would be a long-term (ten years at a minimum) effort to obtain the factual information needed to provide a basis for sound policy and to disseminate to the public and to persons in key policy positions the best knowledge available in the field and the best analysis of this knowledge as it pertains to current programs.
The Council would have a board of 10 to 15 trustees. Working under the board's direction would be an interdisciplinary staff responsible for performing the Council's daily work, headed by a full-time president. The president would be a member of the Board of Trustees, but not its chairman.
The majority of the Board of Trustees should be professionals knowledgeable in the field of drug abuse. A few might be prestigious figures in the national scene, but persons who would commit themselves to a heavy working schedule consisting at a minimum of one formal meeting a month and substantial contact with the staff between meetings.
The Board of Trustees should include representatives of medicine, psychiatry, pharmacology, education, community leadership, law, and sociology. Board members would be appropriately compensated for their time and efforts. The chairman of the board should probably be located in, or accessible to, the city where the Council's headquarters are located-preferably Washington, D.C.-and he should be appropriately compensated for his additional work.
The president would initially work out with the board the direction for the Council's first efforts. He would then recruit his staff and proceed to implement those directives by drawing up a detailed set of proposals for Council action.
The initial core of the Council staff might consist of a medically trained person (probably a psychiatrist), a basic researcher in the biochemical field, a social scientist, a lawyer, and an editor writer schooled in simplifying technical writing. This small nucleus could, of course, be expanded as the Council's president and board define priorities and activities.
It is obvious that the President must be a key personality, with proved administrative ability, and soundly grounded in the drug abuse field, its politics, personalities, and peculiar history. He would be responsible for proposing projects to the board, arranging for their financing or administration, preparing draft reports for board consideration, and so forth. Successful implementation of the Council's objectives would depend to a degree on the president's capabilities.
The relationship of the staff to the Board of Trustees also deserves comment. Basically, there seem to be three types of staff-board working relationships. First, a board of trustees may operate as a figurehead, exercising minimal influence over the activities of the staff. Secondly, it may have broad policy- and priority-setting powers but leave most operating decisions to the working group. This requires a far greater commitment of time by the members of the board than the first relationship. Finally, the board may directly run the organization through a staff having little or no independent decision-making capabilities. In essence, this third type of relationship would require the melding of the board of trustees with the working group.
In the case of the Council, it appears that the most productive staff-board relationship would be the second type-a Board of Trustees with policy authority over the working group but not actively involved in the actual day-to-day operations of the group. Such a board would have an important role. Because of the controversial nature of the drug field, board members must be prepared personally to back Council projects and policy statements and to withstand the inevitable attacks almost from the day they convene. If the Council's pronouncements and work are to carry weight in professional and governmental circles and among the general public, the board must stand solidly behind them.
Once under way, the Council should explore the potential for action in many different areas. The following representative list, which reflects areas of current immediate concern, is not intended to exhaust the possibilities. Additional matters will be uncovered, and priorities will change, as developments occur in the field that cannot be predicted at this time.
Finally, it should be noted that the Council may carry out its objectives either by persuading others to undertake and finance the work or by underwriting the work itself. Whenever possible, the Council should encourage federal, state, and local governments to increase their roles in drug-abuse programs. In this respect, the Council should act as a watchdog, to make certain that public agencies fulfill their intended responsibilities. In many instances, however, private action, either funded or undertaken directly by the Council, will also be necessary and appropriate.
SPONSORSHIP OF BASIC RESEARCH
Although not nearly enough is known about the effects of drugs on the mind and body, the investment of new research funds must be carefully directed toward specific objectives, rather than merely toward supplementing federal funds. Some knowledgeable people are dubious about what could be accomplished by the contribution of a few million dollars in private research funds. Nevertheless, we believe that there are finite areas of basic research that the Council could profitably explore.
Encouragement of Interdisciplinary Research. Universities, where most basic research is done, tend to be structured along departmental lines. The incentive structures for researchers and, even more important, for graduate students tend to force the researcher to stay within his area and not become part of an interdisciplinary group. The Council might usefully promote centers of interdisciplinarianism in this field.
There are cogent reasons for encouraging interdisciplinary research. The question of why the same amount of drug ingested by the same person produces dramatically different effects in different settings puzzles scientists and must be studied outside the laboratory as well as within, by psychologists and social scientists as well as by pharmacologists. Many of the basic pharmacological studies on the effects of heroin or methadone should be attached to treatment programs, so that the subjects could be studied and tested in the environment and under the conditions in which they become and remain drug-dependent. Some of the most creative hypotheses for basic research come from the cross-fertilization of different disciplines thinking about the same problem from different approaches. This is the kind of innovative exposure that the federal government's research program, based on the funding of finite projects to explore already articulated hypotheses, does not at present have the capacity to encourage.
One way of supporting this type of work would be to establish a new in-house center for the scientific study of drug abuse on an interdisciplinary basis. Another would be to put money into the best existing university centers, on the condition that they make some effort to study drugs of abuse in the context of their over-all work.
Of these two courses, the second seems preferable. A number of first-class researchers in a relevant field may not regard drug abuse as their primary area of interest or as an area on which they would wish to concentrate their full time, and in any event they might not wish to move. The best researchers in the field might be more willing to study drug abuse, either separately or along with other matters of interest to them scientifically, if permitted to remain at their present location. To a large extent, this means funding interdisciplinary efforts in universities, because that is where the best researchers are currently found.
In addition to multidisciplinary research in universities, it might also be productive to fund a narcotics-research section in an existing institution or simply to fund individual projects wherever the best researchers exist. Finally, the Council might wish to participate in an ongoing treatment program for the unique information that the program might provide with a reasonable additional investment in a research component. Such questions as why heroin addicts stabilize at different levels of methadone dosage and whether long-term tissue changes are caused by a variety of drugs are often researched best with a large treatment population at hand. Each of these possibilities must be explored in greater detail by the Council staff before final recommendations can be made.
Detection of Drugs in the Body. Pharmacologists have informed us that the basic problem of drug detection in the body where drugs go, how long they stay, what metabolites they produce, and what happens to them-is not being studied in the way present methodology would permit if research funds were available to perfect it. The technology of drug detection is an area that is very important to research but is not a high-priority item for any single researcher or university because the benefits are largely external to any particular project. This type of technological development would be of value to all researchers working in basic pharmacology. It would also enable the accurate identification of drugs in cases of acute toxic reaction and thus the development of better methods of treating or preventing such toxic reaction.
Research in this area could also be directed toward development of more accurate, rapid, and inexpensive equipment for a variety of purposes. Of particular importance for both law-enforcement and treatment programs is the chemical analysis of urine specimens to detect heroin and other illegal drugs. Urinalysis is used in broad surveillance programs in determining whether bail should be set for criminals, in probation and parole surveillance, in methadone-maintenance programs, and indeed in virtually all types of drug-treatment programs. It is essential to any evaluation of the success of these programs. Yet, in many burgeoning methadone programs, such as that in Minneapolis, no prompt and cheap urine testing is available, and samples must be mailed hundreds of miles for analysis.
There is substantial doubt whether surveillance programs are in all instances lawful, and even whether their use is productive or counterproductive with respect to treatment results. It will be some time before final answers can be obtained to these questions. Meanwhile, it is clear that urinalysis surveillance is increasing and will continue to increase (particularly if it is made mandatory for all methadone programs, as has been proposed). The problem is that urinalysis detection techniques can be costly, inaccurate, and very time-consuming. They may therefore limit the number of patients who can be admitted to treatment programs because of the cost involved in continuous urinalysis surveillance, wrong decisions may be made because of the erroneous results obtained, and persons may be deprived of liberty, placed under suspicion, or not given adequate treatment for long periods of time while awaiting results.
BNDD and a few private companies reportedly are interested in improving technology and methodology in this area, and there are some indications of progress. One company has apparently produced a marketable electronic device that would improve the speed and reliability of urinalysis but not reduce the cost. We have been assured that the technology for cheaper, reliable urinalysis is available but requires an initial investment to produce the models. Reducing the cost per unit from $1 to $2 to $.50 or less could mean a savings of $.25 million for large-scale projects and more for a city offering centralized urinalysis for all its programs. Hopefully, the Council could persuade the federal government to make the initial investment of a few hundred thousand dollars to conduct this work, if the need is not otherwise met in the near future.
Interaction of Different Drugs Taken in Combination. Large numbers of drug abusers use several drugs, some legal and some illegal, together or in substitution for another. The net effect of their interaction may be quite different from that of either one used alone. (There is some indication, for example, that heavy barbiturate use may neutralize the effect of birth-control pills used simultaneously.) Research on drug interaction could lead to knowledge that might prevent toxic fatalities.
Research with Heroin and Heroin Maintenance. We are unaware of any significant experimentation with heroin in this country, either in animals or in humans. Such research would be potentially very valuable in determining such questions as how an addict stabilizes on any given dose of heroin, how well he functions in society when consistently maintained on his drug, how wide a range of variation in dosage can be given without withdrawal, whether some people can use heroin indefinitely without becoming addicted, and how long a person must use a given dosage of heroin in order to become addicted. The usage patterns of different types of heroin addict also remain a mystery and have important research implications for treatment and education. Research on such issues as these might well have to combine field investigation and medical diagnosis.
One of the first problems the Council would face if it decided such research was desirable would be obtaining the necessary federal and state government permission, setting up the research in a way that would satisfy medical ethics, and justifying the need for the work to the public.
Miscellaneous. Another vital area not now being adequately researched is the effect of drugs, including marijuana and methadone, taken by pregnant women on the behavior and physical characteristics of the child.
A high-priority question is whether there is either an inborn physiological predilection to opiate addiction (as Dr. Dole suggests) or a drug-induced physiological readdiction vulnerability (as Dr. Martin suggests) or a learned response to external stimuli (as Dr. Wickler suggests) or none of these. Although we are not certain how this can be made the subject of a directed research project, it is a question of the greatest importance to the direction of treatment efforts, drug education, and even legal responsibility for addictive behavior. An attempt should be made to devise a series of experiments to advance this kind of research.
FUNDING PROGRAMS RELATING TO TREATMENT AND RESEARCH WITH RESPECT TO TREATMENT
We recommend that the Council should not, as a general rule, fund ongoing treatment programs, except insofar as they make possible unique research efforts not otherwise available. The Council's efforts in this area should instead be directed primarily toward providing the public climate necessary to assure appropriate public financing of any drug-abuse or drug-dependence treatment programs that are found worthy of support. As a practical matter, Council funds could not begin to match the amount of funding available from federal and state sources, if those sources could be persuaded to allocate appropriate amounts for treatment.
The failure of the Council to support ongoing treatment programs will undoubtedly subject it to criticism from community action leaders. We feel, however, that the Council should have the more fundamental role of generating public support for drug abuse programs and supporting and conducting research and evaluation that will begin to establish criteria by which the effectiveness of these programs can be measured. The Council should, further, disseminate information throughout the country with respect to programs that have proved to be worthwhile and that, therefore, will have a broad and long-range national impact.
The Council should, however, be on the lookout for truly experimental and research-oriented treatment programs that, absent nongovernmental support, will not be undertaken. Areas that deserve careful consideration include the following:
Basic Field Work in Programs for juveniles and Hard-Core Addicts. The populations least successfully treated are juvenile drug abusers and hard-core addicts for whom all known treatment methods have repeatedly failed. In our present state of almost total ignorance as to what kind of prevention or treatment programs will work with these populations, it may be necessary to send people out into the field to study the problem for six months to a year and then to come back and design operational program models. There is to our knowledge no present source of funding for any such basic field approach in new prevention or treatment techniques. Prototype projects designed to test specific hypotheses resulting from such field investigations might then be recommended for operation by federal, state, or local governments.
Heroin Maintenance. A related area that definitely seems worth exploring would be an experiment with heroin maintenance. A detailed study of heroin maintenance in the United States before it was stamped out by the Bureau of Narcotics and of the heroin-maintenance techniques that have been utilized in England should undoubtedly precede initiation of such experimentation in this country.
Research with respect to heroin maintenance-its possible use as a bait to get young addicts into other forms of treatment, its possible use as long-term maintenance for addicts who have repeatedly failed with other treatment methods, and other potential uses-might be a high-priority item for the Council.
As already noted, a substantial driving force behind the present public concern about heroin addiction is the fear of drug-related crime. Assuming that not all addicts can be rehabilitated, and indeed that the addiction problem will remain at least as great for some years to come, the hypothesis that drug addiction leads to crime and that a major portion of our crime wave is attributable to the high price of heroin must be put to the test. Such a controlled experiment could determine whether, using a heroin maintenance system, crime is indeed reduced. The superiority of methadone over heroin, or vice versa, in maintenance programs could also be explored for the first time.
Management Assistance to Ongoing Programs. The Council might also consider providing ongoing or nascent treatment programs with desperately needed managerial assistance. A team of management consultants who could look at local programs and persuade their administrators to adopt proven techniques and perhaps to create a data-acquisition and digestion system where appropriate would be a major contribution to good treatment. The few successful project administrators we have seen are working full time in their own projects and cannot spend the necessary months advising other projects. Many methadone programs are subject to justified criticism, and a resultant loss of money, because of sloppy or uninformed management practices or failure to keep and record their data accurately. The kind of service we propose could reduce such needless problems.
Regional Networks. Finally, the Council might work with states and cities to help treatment centers from regional networks to share knowledge and experience, and even to cross-refer patients for specialized attention. This kind of regional network could also make cross-comparisons of variable techniques easier and allow interchange of personnel and pooling of funds for urinalysis, data collection, and training programs for personnel.
EVALUATION OF TREATMENT APPROACHES
Several different treatment approaches are in use today. There is also massive distrust among these programs, misinformation as to what is and is not being done, and a lack of any reliable means to separate truth from fiction. Evaluation approaches and criteria for the various programs are not standardized, and basic data often are not kept. Even when it exists, useful material is often not organized or published. It is therefore virtually impossible at this time to compare the effectiveness of any one approach with any other, or to study the effectiveness of a given approach for different types of patients. Because of lack of evaluative data, we do not know, for example, whether and to what degree the concurrent use of social services increases the effectiveness of methadone, or the per them cost of patient treatment under different programs correlated with the rate of rehabilitation, or the dropout rate under various treatment programs, or the type of person (age, pattern of drug use, race, economic background) who volunteers for and is best handled under various treatment programs. There is a great need for an impartial body to attempt standardization of evaluation criteria and techniques nationally and to disseminate the results of objective evaluation of ongoing programs in order to promote the most useful components of these approaches and discourage ineffective and unproductive efforts.
One approach that the Council might consider in attacking the information gap is to develop a uniform data-processing system for drug-abuse projects and to provide several of the programs with the necessary software and consultative services to install such a system. Local treatment programs must participate actively in working out a good data-evaluation system if they are to be persuaded to cooperate. The results of the data collection might be fed to a central receiving station where Council experts could analyze it and interpret its meaning to the individual programs as well as to other interested parties.
The decision as to what criteria should be used to evaluate any treatment program, however, involves not merely data analysis but basic value judgments based on experience. The Council should be involved in setting these criteria. Major methadone programs, for example, have been attacked because some of the participants continue to use drugs intermittently. This raises the question of whether eschewing all illegal drugs should be the sole or even the primary goal for a treatment program, or whether enhanced social functioning and cessation of antisocial acts, such as stealing, are sufficient criteria for success. If the Council could contribute toward formulating uniform criteria that reflect a realistic and flexible perspective on what treatment programs can be expected to accomplish and in what period of time, and on the immediate and long-term nature of some of the goals of treatment, it would be doing a tremendously worthwhile job.
Technical Information. Technical personnel in the field, researchers, treatment project personnel, and educators need a comprehensive and accessible service that they can tap for complete, accurate, and up-to-date information on specific aspects of drug abuse, such as treatment proj ects, ongoing or past research, model school curricula, or film listings. There are at present several fragmented attempts to provide this kind of informational coverage. On request, NIMH will supply, through its National Clearinghouse for Drug Abuse Information, selected material on drug-abuse problems. Within about six months, it is hoped that the Clearinghouse will be able to provide a computer printout of abstracts of all publications on any subject requested, concentrating on publications appearing within the last decade, and without evaluation of content. Because the NIMH Clearinghouse is a government service, it feels that it cannot exercise any discrimination in the articles it abstracts, and hence it often abstracts worthless material or several virtually identical publications of the same author in different periodicals. NIMH also sends periodically, to certain persons, the protocols of research grants in progress. The National Coordinating Council on Drug Abuse Education and Information is planning a looseleaf service to include information on treatment projects, legislation, films, and what is known about the nature and effect of individual drugs of abuse, but is not sure how complete it can be because of budget problems.
Ideally, there should be one comprehensive index and digest of all this material, perhaps in several looseleaf volumes, and preferably one that is not prepared by the federal government. It should encompass virtually all information pertinent to the field, including a reasonably selective cross-indexed review or abstract of past and present books, articles, reports, and scientific papers, reprints from nineteenth- and early twentieth-century literature on experiences with drug abuse that are otherwise not generally available, descriptions of current treatment and research projects, public-opinion polls and drug surveys, evaluated lists of educational materials, digests of laws, court decisions, and legislative proposals, and other material. The compilation of such a digest and its periodic updating would be an enormous undertaking, and one that might be best accomplished by subsidizing another organization to do the actual work. The relationship between the Council and the editorial board of such a publication would have to be resolved.
Another important way of disseminating and highlighting the best of current research findings is through a technical journal, circulated largely to physicians, scientists, and other specialists in the field. The Institute for the Study of Drug Addiction, in New York, currently publishes the International journal of the Addictions, which covers both alcoholism and drug abuse. We have found this journal a very useful source of basic information. The publishers state that the very limited number of papers and abstracts, and the very small circulation, are due to a lack of funds.
There seems to be no reason to set up a second journal of this type. Subject to further exploration of this matter, we believe that the Council should give serious consideration to working with the Institute for the Study of Drug Addiction to expand the articles and abstracts in their journal in order to cover the field adequately (excluding alcoholism, which is covered well enough in a separate journal), to make the journal a monthly publication, and to increase its circulation. This would provide the field with the detailed results of all significant research on a current basis.
School Drug-Education Programs. The role of the Council in the race to the schoolhouse must be approached with care. The consensus is that private and public organizations are now generating too many drug-education programs without sufficient knowledge of basic educational techniques, pretesting, or evaluation of results.
There are not enough professional educators sufficiently schooled in drug abuse to teach teachers about drugs. Very often we have found that those who teach counselors and others responsible for drug education in the schools have themselves had no training except for a few lectures. It may be that the Council can affect this vacuum through support of university interdisciplinary research that can train a cadre of experts to teach the teachers in the universities and surrounding communities.
Another contribution of the Council might be to help subsidize the evaluation of drug films, literature, and curricula offered to the schools. It might also design or commission methods of evaluation by which school programs would be able to assess their own results.
Perhaps the most critical problem of most school drug-education programs is their passivity. The Council might support and disseminate information about some less traditional approaches, such as active engagement using drugs in behavior experiments with animals, discussion of nondrug inducement of altered states of consciousness, or extended discussions of values and what youngsters hope to get out of drugs. These represent a few of the more promising (but scarce) approaches we have encountered.
The attraction of television for the young child makes it a logical educational device on drugs. Consideration should be given to working with a group skilled in educational motivational techniques, such as Children's Television Workshop, on films for use in elementary school or over national television.
General Public Information. Perhaps the single most important service of the Council would be to act as an independent source of relevant information for the public about drug-abuse problems. There is a need for a new and wholly independent perspective on such fundamental issues as the nature and scope of the drug problem, the effects of present law-enforcement policies at all levels, the real dangers of youthful marijuana use, the treatment or recovery potential of different kinds of drug abusers, how much crime can really be accounted for by drug abusers, how the English system of heroin maintenance works and with what results, the federal government's activity in terms of dollars, and the allocation of those dollars among enforcement, treatment, research, and education, the foreign experience with marijuana users, and how a school-or a parent-should best react to the presence of drugs.
These are the issues that are troubling Americans. Two New York State public-opinion surveys showed that drug use was considered a major neighborhood problem by 23 per cent of those interviewed, surpassed only by burglary, vandalism, and unsafe streets. A New York Times survey of 463 New York voters, reported on October 4, 1970, placed drugs as the fourth most prominent problem facing the nation and the foremost problem facing the voter's immediate community. At present, the public receives its information on these matters primarily from government sources.
Many methods must be used to inform the public of key developments in the field and explore key policy issues in drug abuse control. The Council could commission its own public opinion surveys on key issues to guide the direction of its information efforts. State-of-the-art papers might be published, containing accurate but readable technical material on the nature and effects of drugs. Accounts of comparative experiences of different jurisdictions with varying law-enforcement, treatment, and education approaches could be prepared and disseminated.
Whether such material is widely read will depend in large part on its readability and press coverage. The Council will need a good editor, with a sound basic understanding of the sciences and able to write simply but accurately. It will also need a library capacity to collect and analyze information of all kinds; it may in time want to become a national information center, publishing attractively packaged periodicals for the lay audience containing such analyses. It may use radio and TV for forums in which outstanding experts in the field can discuss key concepts and thus dispel some of the myths that abound. Different media, of course, would be targeted to different audiences-parents, youths, inner-city residents, and the suburban middle class.
Consultative Services for Key Officials and Organizations. The Council might wish to provide counseling services on a selective basis for key figures and organizations in the drug-abuse field, such as major professional organizations and leagues of city or state officials. Such persons might wish to utilize the expertise of Council staff in many areas before undertaking major policy commitments or advising their members. Meetings and symposia could be designed by the Council staff to facilitate communication between key professionals and policy-making officials and to disseminate its own findings.
Basic law enforcement is, of course, a federal, state, and local governmental function, and we would recommend that the Council not enter this field in any substantial way.
Although the federal government is now engaged in international negotiations to reduce the supply of opium and its foreign manufacture into heroin, as well as to increase border surveillance to reduce its importation, we cannot be optimistic about their efforts. Previous attempts by the United States to stop foreign cultivation and manufacture have proved frustratingly unsuccessful, and the number of world sources of opium and the ease with which foreign production quotas can be circumvented give no cause for belief that future efforts will be any more successful. There is also a widely held belief among experts in the drug field that, if any one drug of abuse were eliminated, a new one would almost certainly be available to displace it. Thus, even assuming that all heroin and marijuana were stopped at the border, marijuana could be grown in this country, synthetic hallucinogens (probably more toxic) could readily displace marijuana, and synthetic opiates and other drugs could readily be available for use in place of heroin. Although better border control or reduction of supply might tighten the market somewhat, thus forcing the price up, it seems unlikely that it would have a substantial long-range impact on the underlying causes and effects of drug abuse, or even on its prevalence. In sum, this appears to be an area of limited potential, wishful thinking to the contrary, and one in which the federal government is already investing heavily.
We do recommend, however, that some exploration be made into the reasons that law-enforcement officials at present seem unable to prosecute more of the high-volume drug pushers once the drugs get into the country, even though they profess to know who the pushers are, where they engage in their operations, and a great deal of other information about them. Prosecution of important nonaddict drug pushers can have a temporary effect on total drug availability at the street level and force some addicts into treatment. It would, in addition, have a substantial psychological effect in many ghetto communities, where it is often thought that the police purposely do not prosecute drug pushers because they have made deals with the illicit trader or because they wish minority groups to remain enslaved to drugs. We believe that exerting pressure on the commercial sellers of illegal drugs is a desirable objective and should be done in the most efficient way possible. For that reason, we recommend the exploration with federal and local authorities of ways to increase arrests at the top levels of the drug traffic. If the Council enters this area at all, it should work closely with the staff of the Police Foundation to encourage innovative strategies by state or local police departments. The active utilization of antidrug community groups to help in policing and exerting formal sanctions in their own neighborhoods against pushers is one area of potential.
The Council might also want to study the effect of various laws and law-enforcement policies on the actual use of drugs and the treatment of drug abusers. This area is badly in need of careful study. The results of such a study might then become the subject of a "white paper" by the Council for consideration by local officials, budgetmakers, and the public at large. It might also help to create a more open climate for experimentation in different control strategies. The current push from the federal government is for all the states to commit themselves legislatively to a single model of law enforcement. It would seem, however, that states should be as laboratories to try out different approaches and to evaluate the results stemming from those variations.
There also appears to be a real need for educational programs specifically aimed at law-enforcement and court personnel, who will probably continue to be the largest intake process for illegal drug users. Although BNDD runs a law-enforcement training program for state and local police officers with respect to narcotics laws, it does not appear to emphasize the medical and social aspects of drug abuse, its causes and effects, the community resources that can be utilized in combating it from a public-health and social standpoint rather than from a law enforcement standpoint, the importance of not ruining the lives of young children as a result of unfortunate experimentation with drug abuse, and similar aspects of this problem. The Council might fruitfully direct its efforts to helping police and court personnel, both juvenile and adults, to develop informal mechanisms for rapidly screening and diverting serious drug users into treatment programs in lieu of legal processing. Conferences might be sponsored for law-enforcement and judicial personnel to focus on the best of these diversion programs. An effective juvenile court treatment project along these lines is, in our opinion, one of the greatest unmet needs in the entire field.
Finally, many improvements in the present law-enforcement approach toward drug abuse may have to come from the courts. There will be increasing attacks upon the irrationality of present drug laws, centering upon the right to privacy involved in the personal use of drugs, and the extension of the ruling in Robinson v. California that a person may not be criminally punished for addiction to include possession, use, and presence in illegal establishments or association with other addicts. The question of the right to treatment for an addict can be expected to be raised not only in civil commitment programs, where treatment is minimal, but also in communities without methadone programs, or where methadone dispensation is severely restricted by law, or even ultimately where doctors are not allowed to prescribe it for addict patients.
In the juvenile field, a long-standing and perhaps legally vulnerable impediment to treatment is the legal requirement for paternal permission. Addicts can also be expected to raise their eligibility for welfare as "disabled persons" or as "medically needy" under Medicaid laws. Treatment programs all over the country have encountered difficulties in locating facilities in highaddiction areas because of outmoded zoning laws. The right of "gatekeepers," such as teachers and nurses, to withhold from law-enforcement authorities confidential information received from students may have to be tested in the courts. Limitations of treatment programs to selected kinds of addicts will probably also be legally attacked. The adjustment of our now-primitive body of drug-abuse laws to new medical developments in research and treatment may well have to come about through a series of court cases as well as, and even in the absence of, legislative changes. The Council staff should keep abreast of such legal developments and, where appropriate, lend financial assistance to legal groups seeking such adjustments. The D.C. Lawyers Committee project on training a corps of addict specialists and the comments filed on the methadone regulations by the Center for Law and Social Policy are examples of such worthy efforts.
THE LEADERSHIP ROLE
We have suggested that the most critical reason for establishing a Drug Abuse Council is to create independent leadership in the field. That leadership must inevitably be earned through professional and public credibility, and through excellence of staff and product. The Council must lead in formulating and disseminating sound ways of thinking and acting toward drug use. It must, in short, become a center for policy study in the drug field, to which researchers, legislators, educators, policy-making officials, and the lay public will turn for nonpartisan analysis and information.
This role can be accomplished primarily by using the best thinkers in many different fields to find out what is actually happening to drug users-not just the young experimenters or mainliners, but the older pill-takers as well-why they are taking drugs, and what other ways can be found to satisfy their underlying urges and needs. The "drug-abuse problem" needs to be perceived in a less rigid and emotional way by the public at large. The nation has to understand how our present system of drug controls really operates, and with what consequences to what people. It must be given a realistic notion, rather than palliatives, of what we can expect to accomplish through education, treatment, and law enforcement, and what part of the problem must be approached in even more complex and subtle ways.
At the same time, there must be a sense of urgency about the Council's work. As soon as it is organized, the Council must consider such matters of immediate importance as
The work of the Commission on Marijuana and Drug Abuse established under the 1970 federal drug-abuse law
The authority of the Secretary of HEW to authorize researchers to protect the privacy of research subjects under the 1970 federal law
The obligation of the Secretary of HEW under the 1970 federal law to report to Congress on the proper methods of medical treatment of narcotic addiction
The authority of the Department of justice to establish quotas for drugs, like heroin, that have no accepted medical use but are needed for research purposes
The proposed new International Protocol on Psychotropic Substances being considered by the U.N. Commission on Narcotic Drugs
Implementation of the proposed new methadone regulations The proposals to conform state law to the 1970 federal law and the proposed new Uniform State Act
The proposed new federal Rules of Evidence that affect the confidentiality of the doctor-patient relationship
Of equal importance, priorities must be established with respect to the broad work of the Council and work begun on its long range objectives. The projects that should be given prompt . consideration include the following information:
Research and Field Investigation
It is not possible to lay down a step-by-step program for changing the present climate surrounding drug abuse in the country. How to get the country to focus on the real evils of drug abuse and to attack them rationally without contributing to the creation of even greater ones is a monumental task. Hopefully, the Council will not be alone in working toward such an end and will be able to enlist the support of state and city governments, such branches of the federal government as NIMH, and other private and professional organizations. Hopefully, too, much of its work will affect the related problem of alcoholism and will help to end the fragmented approach toward different kinds of drug-taking. The pace of the work and the priorities must obviously be decided by the Council board and staff itself, guided by a realistic notion of the magnitude of the tasks facing them and the opportunity to do something constructive about them.
It is of fundamental importance that man has and. will inevitably continue to have potentially dangerous drugs at his disposal, which he may either use properly or abuse, and that neither the availability of these drugs nor the temptation to abuse them can be eliminated. Therefore, the fundamental objective of a modern drug-abuse program must be to help the public learn to understand these drugs and how to cope with their use in the context of everyday life. An approach emphasizing suppression of all drugs or repression of all drug users will only contribute to national problems.
There is an urgent need for effective nongovernmental leadership toward a more reasoned approach to drug abuse in this country. A void exists that we believe can be filled by the creation of a new Drug Abuse Council. In our best judgment, the Council could successfully exert this leadership and could have a substantial and beneficial impact on drug abuse in this country.
1. Evidence obtained during 1971 indicates that the number of active heroin addicts as of December, 1971, was probably between 250,000 and 300,000. 2. The Comprehensive Drug Abuse Prevention and Control Act of 1970 reduced these penalties to imprisonment for up to one year for a first offense and two years for each subsequent offense.
3. The 1970 Act established a Commission on Marijuana and Drug Abuse to review existing laws and policy and recommend necessary legislation and administrative action.
4. See Staff Paper 5 for the most recent figures.
5. This information has become available and is presented in Staff Paper 5.
6. In 1971 this organization changed its name to the National Coordinating Council on Drug Use Education.
7. By December, 1971, there were over 300 methadone projects and a large number of persons receiving methadone by prescription outside of these projects. An estimated 50,000 patients are now using this drug for maintenance. See Staff Paper 3.
8. In November, 1971, the Food and Drug Administration announced it intention to propose broader approval of methadone under a closely con trolled distribution system.
9. These estimates are based on an addict population of about 100,000 During 1971, official estimates of the number of addicts were raised. It i now estimated that 100,000 to 120,000 pounds of opium are needed annually to supply the U.S. market.
10. In June, 1971, the President proposed a Special Action Office for Drug Abuse Prevention to coordinate federal drug-abuse efforts in treatment, education, and research. Regulation and law enforcement, and military and veterans' problems are not included.
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