In 1970 a ruling of the United States Food and Drug Administration was sufficient to limit severely the use of a group of chemicals known as the cyclamates, many tons of which had been marketed annually in the country's favorite soft drinks and in many other food products. No cyclamates were smuggled into the United States following the new regulation; no black market in cyclamates was established; no midnight raids on clandestine cyclamate pushers were organized-indeed, cyclamates were curtailed without (so far as is known) a single sentence of imprisonment being invoked.

Why could not the opiates be calmly and sensibly removed from the market as effortlessly as the cyclamates were? The glib answer, of course, is that the opiates are addicting. But 'addicting" is a slippery word, often misused. Let us examine a few of its multitudinous meanings.

In Roman law, to be addicted meant to be bound over or delivered over to someone by a judicial sentence; thus a prisoner of war might be addicted to some nobleman or large landowner. In sixteenth-century England, the word had the same meaning; thus a serf might be addicted to a master. But Shakespeare and others of his era perceived the marked similarity between this legal form of addiction and a man's bondage to alcoholic beverages; they therefore spoke of being addicted to alcohol. Poets also spoke of men "addicted to vice," and of young women "addicted to virginity." Dr. Johnson wrote of "addiction to tobacco" and John Stuart Mill of "addiction to bad habits." The concepts of addiction to opium, morphine, and heroin followed quite naturally.

Following the passage of the Harrison Narcotic Act in 1914, however, the meaning of the word "addicting" underwent a subtle change. The original meaning - a drug to which one becomes enslaved-was lost sight of. Many people assumed that any addict could stop taking an addicting drug if he wanted to and if he tried hard enough. The imprisonment of addicts was based on this confusion; addicts were expected to stop taking heroin for fear of imprisonment, or of repeated reimprisonment. We have shown in the previous chapter how that view fell victim to the facts.

Along with these popular views of addiction, various medical theories of addiction have arisen. Physicians noted centuries ago that when alcoholics were abruptly deprived of alcohol, they often developed a very serious, indeed life-threatening, condition known as delirium tremens. When opium, morphine, and heroin addicts were deprived of their drug, they similarly developed a withdrawal syndrome that could be devastating, even fatal.

Dr. Jerome H. Jaffe describes the withdrawal syndrome in Goodman and Gilman's textbook:  

The character and the severity of the withdrawal symptoms ... depend upon many factors, including the particular drug, the total daily dose used, the interval between doses, the duration of use, and the health and personality of the addict.... In the case of morphine or heroin ... lacrimation [excessive tearing], rhinorrhea [running nose], yawning, and perspiration appear ... the addict may fall into a tossing, restless sleep known as the "yen," which may last several hours but from which he awakens more restless and more miserable than before . . . additional signs and symptoms appear . . . dilated pupils, anorexia [loss of appetite], gooseflesh, restlessness, irritability, and tremor . . . symptoms reach their peak at 48 to 72 hours . . . increasing irritability, insomnia, marked anorexia, violent yawning, severe sneezing, lacrimation, and coryza [cold-like nasal symptoms]. Weakness and depression . . . nausea and vomiting . . . intestinal spasm and diarrhea. Heart rate and blood pressure are elevated. Marked chilliness, alternating with flushing and excessive sweating . . . waves of gooseflesh ... the skin resembles that of a plucked turkey . . . the basis of the expression "cold turkey" to signify abrupt withdrawal without treatment. Abdominal cramps and pains in the bones and muscles of the back and extremities are also characteristic, as are the muscle spasms and kicking movements that may be the basis for the expression "kicking the habit." Other signs . . . include ejaculations in men and orgasm in women.... The failure to take foods and fluids, combined with vomiting, sweating, and diarrhea, results in marked weight loss, dehydration. . . . Occasionally there is cardiovascular collapse. At any point in the course of withdrawal, the administration of a suitable narcotic will completely and dramatically suppress the symptoms of withdrawal.1

Physicians thus concluded that drugs such as alcohol and heroin produce a phenomenon known as physical dependence. An addicting drug came to mean a drug that produces physical dependence-that is, withdrawal symptoms-when the drug is abruptly discontinued.

Drugs that produce withdrawal symptoms usually also produce, as noted earlier, a phenomenon known as tolerance. This means that if the same dose is taken day after day, the effects gradually disappear. Thus a new definition was evolved: an addicting drug is one that produces both withdrawal symptoms and tolerance.

The association of addiction with withdrawal symptoms led naturally to the earliest theory of how addiction could be cured: all that was necessary was to help an addict through his withdrawal crisis. Once withdrawn from the drug, it was widely believed, he could live happily ever after as an ex-addict. This theory goes back at least to 1856, when an American pharmacologist, Dr. George B. Wood, wrote in his Treatise on Therapeutics and Pharmacology: 

It is satisfactory to know that this evil habit may be corrected, without great difficulty, if the patient is in earnest; and as the disorders induced by it are mainly functional, that a good degree of health may be restored.... The proper method of correcting the evil is by gradually reducing the cause; a diminution of the dose being made every day, so small as to be quite imperceptible in its effects. Supposing, for example, that a fluid ounce of laudanum [opium in alcohol] is taken daily, the abstraction of a minim [one drop] every day would lead to a cure in somewhat more than a year; and the process might be much more rapid than this.2

In practice, however, the gradual withdrawal method had difficulties. Few addicts stayed with the withdrawal to the end; for while the first portion of the dose-lowering process was quite easy, suffering eventually set in-and it was thereafter prolonged rather than eased by the inadequate daily doses. As early as 1967, accordingly, a writer in the British Medical Journal expressed a contrary view: "Absolute and immediate suspension [of all opiates] is for efficacy the far more reliable plan, being less tedious, less exhausting, less the occasion of hard sufferings." 3

The debate between these two points of view-abrupt versus gradual withdrawal-continued for decades. But both sides agreed that for either type of treatment to succeed, an addict had to be "in earnest" and strongly motivated," and to have "will power"; moral weaklings failed.

The major problem with these early "cures" was that patients-whether abruptly or gradually withdrawn from their opiate-promptly relapsed and became addicted again. Nineteenth-century physicians, however, were not discouraged by this tendency to relapse: the patients, they complained, didn't really want to give up opiates. Or alternatively, they were weaklings lacking in will power. The fault was not in the treatment but in the patient. This is still a widely held view.

The next step forward in the "cure" of drug addiction was prolonged treatment. Patients might be kept in a sanitarium for a month, or six months, or even a year. After enforced abstinence for that long a period, it was universally agreed, opiate addiction must of necessity be entirely cured. After the Harrison Narcotic Act of 1914, this theory was pushed to even further extremes. Addicts were imprisoned for two years, five years, or even longer. When they thereafter promptly returned to their drugs, the same explanations were offered-lack of a desire to give up opiates, and lack of will power.

At the turn of the century the cure of opiate addiction was attempted on a scale that dwarfs even today's efforts. In 1908, for example, Hugh C. Weir reported in Putnam's Magazine: "There are forty institutions in this country advertising a cure for the drug habit, and all of them are largely patronized. One such institution at Atlanta, Georgia, has the names of over 100,000 patients whom it has treated, and there are several others that can show 50,000." 4

There is no evidence, however, that any addicts were ever actually cured at these "sanitariums." Indeed, the enormous success of the sanitariums depended on the fact that they were "revolving-door institutions." Some addicts came back to the same sanitarium again and again; others drifted from one sanitarium to another. Cases of men and women still addicted after ten or twenty "cures" were matters of common knowledge.

With the rise of the behavioral sciences in the twentieth century especially psychology, psychiatry, and sociology-the old theories of "poor motivation" and "weak will power" to explain addiction and relapse were not abandoned but simply rephrased. The newer theories fell into three main categories.

Psychological theories. Theories in this group are in general the heirs to the old "weakness of will" approach. Some of them hold that there exists an "addictive personality." The unfortunate possessors of this personality pattern are prone to become addicted, and are also prone to become readdicted after they have been "cured." A restructuring of the personality is therefore needed. There are many variations on this theme -including Freudian views which trace addiction-proneness to factors in early childhood, existential views which associate addiction-proneness with psychological pressures and conflicts in adult life, and so on. What the views have in common is the belief that the secret of addiction lies in the psyche of the addict.

Sociological views. These views hold in general that society creates addicts and causes ex-addicts to relapse into addiction again. The sense of hopelessness and defeat among dwellers in our city slums, the sense, among young people today, of impotence to affect change, the needs of young people to belong to a group and their consequent drift into groups of heroin users-countless sociological factors such as these are cited to explain both addiction and relapse following "cure." An addict relapses, according to some sociological theories, because he returns to the same neighborhood where he became addicted and associates with addicts once more. What these theories have in common is the belief that the secret of addiction lies in the social context.

There are also, of course, combinations of psychological and sociological theories. The best-known of these is the theory underlying Synanon, Daytop, Odyssey House, Phoenix House, and numerous other "therapeutic communities." In such communities, the addict spends months or even years in a milieu designed to restructure his psyche from immature and addiction-prone into strong, self-reliant, no longer in need of a drug "crutch." Simultaneously, the therapeutic-community milieu provides the ex-addict with a drug-free social setting in which all the social pressures are directed toward abstinence rather than relapse. The degree of success achieved by these communities, combining the best in both the psychological and the sociological tradition, will be reviewed below.

Biochemical theories. These theories are of recent origin, and are held by only a few experts. They have arisen largely as a result of disenchantment with the practical failure of the psychological and sociological theories. These theories begin with the unchallengeable fact-on which all schools of thought are agreed-that the acute withdrawal symptoms suffered after an addict is deprived of his drug are genuinely biochemical in origin. The cause of these immediate withdrawal symptoms is in the structure of the chemical molecule and its effect on cells of the nervous system. Exposed regularly to opiate molecules the human nervous system adjusts to their presence-that is, becomes dependent upon them. If they are withdrawn, the nervous system becomes very seriously disturbed. The nervous system can readjust only gradually to the absence of an opiate in the way in which it initially adjusted to the presence of the opiate.

The controversial additional point urged by proponents of the biochemical theory is their conviction that the long-term outcome of opium, morphine, or heroin addiction-the craving and the tendency of addicts to resume drug-seeking behavior and to become readdicted months or even years after withdrawal has been successfully achieved-is also a direct effect of the opiate molecule on the nervous system.

Holders of the biochemical view are not absolutists. They concede, for example, that some people are more likely to become addicted and readdicted than others (though they tend to explain these differences in terms of differences in the nervous system as well as childhood upbringing or current psychic stresses). They also concede that some ex-addicts can go without drugs, and that psychological and social factors can increase or decrease the likelihood (or the promptness) of relapse and readdiction. But they focus primary attention on the drug itself, and on its effects on the cells of the nervous system. The secret of addiction, they stress, lies primarily in the chemical molecule.

The vast bulk of the evidence to date, it must be pointed out, favors the psychological and sociological theories. But this may be because the vast bulk of scientific studies throughout the past century has been devoted to a search for psychological and sociological factors. The search for biochemical factors has barely begun (see below). We are hopeful that it will prove rewarding.

Fortunately, one need not here decide among these theories. Perhaps all three are true in part-or perhaps there is a fourth explanation of addiction as yet undiscovered. What can and must be done here, however, is to consider the consequences of these theories in the real, nontheoretical world. This can be done by reviewing the success (or failure) of the various treatment programs based on each theory.

The first official United States government theory following passage of the Harrison Narcotic Act of 1914 was a compromise; addicts must be deterred from using drugs by incarceration in an institution and helped to give up drugs by receiving therapy while incarcerated. Hence as early as 1919, the Narcotics Unit of the United States Treasury urged Congress to set up a chain of federal "narcotics farms" where addicts could be incarcerated and treated for their addiction. The request was often renewed; but such institutions cost money. Until 1929, Congress preferred to pass punitive rather than therapeutic legislation. Not until 1935 did the first United States Public Health Service hospital for narcotics addicts actually open its doors, in Lexington, Kentucky. It had 1,000 beds and 500 employees. Tens of thousands of addicts have been treated there, some many times over. A second hospital, at Fort Worth, followed a few years later. 

Federal Narcotics Commissioner Harry J. Anslinger and United States Attorney William F. Tompkins, in The Traffic in Narcotics (1953), reported on the success of the Lexington hospital: 

The bright side ... is the Lexington story. From 1935 to 1952, 18,000 addicts were admitted for treatment. Of these 64 percent never returned for treatment, 21 percent returned a second time, 6 percent a third time, and 9 percent four or more times. These figures should give everyone confidence that the U.S. Public Health Service Hospitals can secure good results in one of medicine's most tremendously difficult tasks.5 

The flaw in Commissioner Anslinger's figures, obviously, is that they refer only to patients who returned to Lexington up to 1952. Addicts released from Lexington who returned to other hospitals, or went to prisons, or who merely continued their addiction at home, or who were to return to Lexington after 1952, were included among the 64 percent who "never returned for treatment."

When we turn from official claims to actual follow-up studies, the figures are very different. One study traced 1,912 Lexington alumni for periods of from one to four and a half years. Only 6.6 percent remained abstinent throughout the follow-up period.6 

A second study checked on 453 Lexington alumni six months, two years, and five years after release. Only 12 of the 453 (less than 3 percent) were abstinent on all three follow-ups. The failure rate was thus in excess of 97 percent.7

 The most recent follow-up of Lexington alumni was published in 1965 by Dr. George E. Vaillant, staff psychiatrist at Lexington and later on the Harvard Medical School faculty. Dr. Vaillant reviewed the records of 100 Lexington alumni-fifty white and fifty black-who had been released from the hospital between August 1, 1952, and January 31, 1953. (The outcomes for blacks and whites did not differ significantly.) The follow-up continued for nearly twelve years, through the end of 1964. Unlike most Lexington alumni, moreover, these ex-addicts were provided with aftercare. "For several years after discharge," Dr. Vaillant explained, "virtually all the patients or their families were regularly contacted by a social agency about once every three months. . . . 

In spite of these relatively favorable conditions, within two years all but ten of the 100 patients again became addicted-at least temporarily. Of the ten who did not, three died in less than four years after discharge, two turned to alcohol, three had never used narcotics more than once a day and one used drugs intermittently after discharge. In other words, virtually all patients who had been physically addicted and did not die, relapsed.8 

Two of the three patients who were not addicted when they entered Lexington became addicted after discharge. "Subsequent to Lexington the 100 patients served over 350 prison terms and underwent over 200 known voluntary hospitalizations for addiction's Only 11 of the more than 200 voluntary hospitalizations were followed by apparent abstinence from narcotics for periods of one year or longer.

Despite these woeful facts, which are here quoted directly from Dr. Vaillant's own report, the Vaillant study has been cited as evidence that narcotics addiction is readily curable. This curious conclusion arose out of the fact that Dr. Vaillant also published a chart showing only 20 of his 100 addicts still addicted in 1964, twelve years after discharge from Lexington.

What happened to the other 80? Some were dead, some were now addicted to alcohol instead of heroin, some were in prisons, some were in hospitals, some had simply disappeared, and the current status of others remained in doubt.

Twenty-three were classified in the Vaillant chart as doing well in 1964-stably employed and not at the moment addicted, so far as could be determined. In this as in other studies, however, the figures at any given moment of time are misleading. For just as some of the "successes" had become readdicted after leaving Lexington, so some could be expected to become readdicted yet again after completion of the follow-up. The evidence for absence of addiction, moreover, depended on "statements from potentially fallible patients, relatives and parole officers," "' as Dr. Vaillant himself modestly noted; perhaps at least a few of those classified as ex-addicts were still taking heroin after all. 

Citing the Vaillant report as evidence that narcotics addiction is readily curable is an example of how far some people will go to delude themselves and others. A fair summary of the findings, both positive and negative, would go something like this. 

At any given time after being "cured" at Lexington, from 10 to 25 percent of graduates may appear to be abstinent, nonalcoholic, employed, and law-abiding. But only a handful at most can maintain this level of functioning throughout the ten-year period after "cure." Almost all become readdicted and reimprisoned early in the decade, and for most the process is repeated over and over again.

 The above figures are not to the discredit of Lexington; satisfactory research of several kinds has been done there since 1935. But no cure for narcotics addiction, and no effective deterrent, was found there-or anywhere else.

The high rate of relapse even after prolonged incarceration and treatment can readi1v be explained in terms of the postwithdrawal syndrome -anxiety, depression, and craving-described in Chapter 2. Prolonged incarceration may postpone the drug-seeking behavior but it does not alleviate that underlying syndrome. Release from prison and from treatment may thereafter trigger an intense new wave of anxiety, depressions and craving-followed by drug-seeking behavior and relapse.

In 1961, California launched its large-scale civil commitment program for narcotics addicts. This program permits addicts to be locked tip without first being convicted of a crime. Instead of being called "prisoners" or "prison inmates," the addicts are called "residents" not of prisons but of "rehabilitation centers." Instead of being tinder the jurisdiction of prison authorities, the "residents" are held by the California Rehabilitation Center (CRC), to which they are committed for periods of up to seven years. Part of the time is spent "in residence," that is, locked up, and the rest on "outpatient status," that is, on parole. Release is supposed to follow three years of successful parole. (The constitutionality of this program of incarceration without criminal trial and conviction-and of similar New York State and federal "civil commitment" programs-has been repeatedly challenged in the courts. The challenges are from time to time successful in individual cases, but the system as a whole has to date remained impervious to constitutional attacks.)

Between September 1961 and the spring of 1968, Dr. John C. Kramer and Richard A. Bass reported in the Journal of the American Medical Association, more than 8,000 addicts or alleged addicts were Committed under the CRC program. Of these, 5,200 were still in the program in the spring of 1968. Up to that point, 3,300 had departed. Only 300, however, had been released because of successful completion of three years on parole. The remaining 3,000 who left had gone from the program to prison, or had disappeared, or died, or gotten out on writs of Habeas corpus or in other ways.11

The CRC program, moreover, locked up persons "in imminent danger of becoming addicted" as well as actual addicts. The Kramer-Bass study cited data indicating that a remarkably high proportion of the 300 alleged " successes" were not in fact heroin addicts and never had been. In a sample of the 300 "successes" selected at random for intensive study, more than 40 percent were "atypical." Some denied ever having used opiates. Some were primarily users of nonopiate drugs. Some had used heroin only occasionally, or on1v briefly, and so on.12 The Kramer-Bass study also cited reasons for anticipating that the relatively small proportion of "successes" emerging from the program--300 out of 3,300 departures was unlikely to improve as the program matured. Instead, more and more "residents" were likely to pile up inside the CRC as the years rolled by. Indeed, the 2,600 "residents" locked up in the institution in the spring of 1968 were already overcrowding it, and it became necessary soon thereafter to reduce the residence period in order to make room for more addicts. Meanwhile, narcotics addiction in California continues to be a major problem.*

* Dr. John C. Kramer wrote (1969): "Though the [California] program has been useful for a small proportion of those committed, for the majority it has proved to be merely an alternative to prison. The majority have entered a revolving system of admission-release-admission-release, and spend a majority of their commitment incarcerated in an institution which resembles a prison more Alan it does a hospital." 13

The figures above, moreover, should not be taken to mean that the California system "cured" 300 out of 3,300 addicts. The 300 were merely released front parole; whether or not any of them would live free of heroin after release remained problematic. Many of the 300 have in fact been returned to CRC or imprisoned. 

New York City and New York State have the most intense narcotics problem in the United States; it has been estimated that more than half of all American addicts reside there. For this and other reasons, which will become apparent below, several New York efforts to rehabilitate addicts deserve detailed attention.

One widely publicized New York program was launched in 1952 at Riverside Hospital on North Brother Island in the East River. Riverside's 140 beds, it was announced, were to be "devoted exclusively to the treatment, aftercare, and rehabilitation of adolescent narcotics addicts." It was to be very generously staffed-"14 full-time and 9 part-time physicians, 6 psychologists, 9 social workers, and 13 rehabilitation and educational personnel" 14-a total of 51 professionals plus guards and other employees for 141 addicts. It was realized, of course, that all the addicts in New York could not be as lavishly provided with care, including rehabilitation services and aftercare following release; but it was hoped that techniques could be devised at Riverside which might prove generally applicable. Some patients were admitted voluntarily; others were committed to Riverside by the courts. New York State put up a million dollars a year to fund the program. 

After five years of Riverside, however, the New York City adolescent narcotics problem remained as acute as ever. Accordingly, in 1957, New York State Health Commissioner Herman Hilleboe, wishing to determine whether the state funds for Riverside were being wisely spent, asked Dr. Ray E. Trussell-then director of the Columbia University School of Public Health-to conduct an evaluation, in which all of the 247 adolescent addicts admitted to Riverside during the calendar year 1955 would be traced and their status determined.

Tracing addicts in the world's largest city proved remarkably easy. "It turned out," Dr. Trussell explained, "that the best way to find these people was to keep an eye on hospital admissions and the admissions to penal institutions." 15 Eighty-six percent of the 247 addicts admitted to Riverside in 1955 were found again in prisons or hospitals-including Riverside Hospital-in 1958. 

Dr. Trussell described the end results of the evaluation as "discouraging." Eleven of the 247 addicts were dead-a high death rate for an adolescent population. An additional 228 had been reimprisoned, or rehospitalized, or both, one or more times, following release from Riverside. Of the 247 addicts admitted in 1955, only eight remained alive, unaddicted, Linimprisoned, and unhospitalized three years later.

Nor was that the worst of it. New York law, like California law and the law of several other states, provides for the incarceration not only of addicts but of persons in imminent danger of becoming addicted. What was most startling, Dr. Trussell reported, was the fact that all eight of the Riverside alumni who remained drug-free in 1958 "to a man swore that they had never been addicted; they had been caught in possession, they had been committed, they had put in their time and gone home, and that was the end of that episode so far as they were concerned." 16 Riverside Hospital records confirmed their nonaddict status in seven of the eight cases. For patients actually addicted, the "success rate [was] zero." 17

In other words, heroin really is an addicting drug.

Having established with precision that the Riverside Hospital program had failed to rehabilitate even one out of 239 addicts, Dr. Trussell and his associates "had a behind-the-scenes meeting with city and state officials and various public leaders interested in the problem of addiction." 18 Those present agreed that "Riverside Hospital should be closed as an absolute failure." But now a phenomenon common in drug-addiction treatment programs appeared. just as Lexington continued to go through the motions of rehabilitating addicts for three decades despite mounting evidence that the failure rate exceeded 90 percent, so Riverside went right on functioning with a 100 percent failure rate. Eminent political figures who had taken credit for establishing Riverside, Dr. Trussell learned, were unwilling to face public responsibility for its collapse. Abandonment proved politically impossible. Riverside thus became, like a number of other rehabilitation programs, a kind of false front-assuaging public demand that "something be done about drug addicts" without actually accomplishing anything.

In 1961, Dr. Trussell became New York City's commissioner of hospitals, with direct responsibility for Riverside. "By this time," he later recalled, "the personnel were smuggling drugs in to the patients or the patients were going home on passes and bringing drugs back. We had some unwanted, unplanned pregnancies; the guards were taking advantage of the patients and it was a situation which was certainly highly undesirable from the patients' point of view and as a public investment of tax funds." 19 Such deterioration in morale is not uncommon in closed institutions devoted to the treatment of drug addicts-especially when it is known that the treatment is accomplishing nothing. Competent staff evaporates from such institutions. Following public airing of the scandalous conditions, Dr. Trussell was able to close Riverside Hospital-which was, he said, "one of the most pleasant things I have ever undertaken as an administrator." 20

What was to take its place? A survey of all known programs, here and in other countries, turned up nothing that really made sense. The most immediate need was, quite simply, for a low-cost "detoxification unit," where addicts could voluntarily go for a few days or weeks to "kick the habit." Most patients who go through a detoxification unit promptly relapse, of course; but at least they experience a few drug-free weeks or months, and after they do relapse, the daily cost of their drugs is lower for a time. In the course of detoxification their numerous other health needs can be met, including the special needs of pregnant addicts. To Dr. Trussell's amazement, he discovered that New York City, despite chronic demands that something be done about the horrors of drug addiction, had failed to set up a single center where addicts could voluntarily go for detoxification. (Most other cities also lacked such centers.)

To provide a detoxification service for women addicts who were pregnant and who wanted to be detoxified, "I got together all the administrators and directors of medicine in my 15 municipal hospitals," Dr. Trussell recalled, "and I said, 'You know, gentlemen, you've got 16,000 beds between you and let's find twenty-five beds for pregnant addicts.' And to my utter amazement I was flatly told where I could go by people who were on my payroll! Further, they formed a committee and sent me a letter saying [in effect], 'Drug addiction is not a medical problem, it's a social and criminal problem, and keep it away from us.' " Thus Dr. Trussell "became aware of the really entrenched negative attitude on the part of the medical leadership in this city toward drug addiction." 21 It was an attitude common in other cities as well-an attitude deeply entrenched ever since federal narcotics officials had begun arresting physicians under the Harrison Narcotic Act of 1914, half a century earlier.

Eventually Dr. Trussell was able to find, on Eighteenth Street in Manhattan, a private proprietary hospital, then known as Manhattan General, which was in financial difficulties and therefore willing to contract with the city to supply detoxification services at the city's expenses. Patients "went in a side door which was used for the delivery of supplies," Dr. Trussell recalled. "They were carefully sequestered from other patients in the hospital and they were treated in a very secretive way." 22 For several years, this remained New York City's only detoxification service.

Two more New York State programs require consideration. In 1956, the New York State Parole Division announced a new plan of intensive follow-up service and parole supervision for selected addicts released from the state's prisons. The publicized central feature of this program was "intensive supervision, using the casework approach in an authoritative setting." 23 The parole officers assigned to the project were specially selected and trained for the job. They were assigned only 30 parolees each instead of the customary 85 or more. In other ways, too, the parolees assigned to this program received more intensive care than is customary.

The head of the project, Meyer H. Diskind, considered the abstinence rates attained by this program "rather favorable"-better, for example, than the rates obtained after hospitalization. A study he published in 1960 reported that of the 344 parolees assigned to the program between November 1, 1956, and October 31, 1959, "119 offenders, or 35 percent, had never been declared delinquent for any reason whatsoever, drugs or otherwise." Another 36 parolees had violated parole but had not, so far as was known, returned to narcotics. "If we were to add these 36 delinquents to the 119 who made a fully satisfactory adjustment," Mr. Diskind and an associate, George Klonsky, announced, "then 45 percent abstained from drugs while under supervision ." 24

Alas, there were several things wrong with that claim. To cite one example, some of the 119 "successes" had only been out of prison a month or two when their status was determined and their success pronounced. To cite another example, use of narcotics was determined primarily by an "arm check"-examining the addict's arms periodically for needle marks. Addicts on the program knew, of course, that their arms would be checked. How many injected narcotics into their legs, or other portions of their anatomy, or took drugs without injecting them, is not known.

In 1964, Diskind and Klonsky published a further report on the same 344 addicts. It was based in part on the project's own records, and in part on a social-work thesis by Robert F. Hallinan and his associates at the Fordham University School of Social Service. Diskind and Klonsky reported that of 66 successful parolees followed up by Hallinan, "36, or 55 percent, had completely abstained from drug usage since their discharge from parole." Seven others had abstained for periods ranging from three to thirty-six months. "If we were to add the 7 who terminated the babit to the 36 complete abstainers, then 43, or 65 percent, were in an abstention status at the time of the study." 25 Statements such as these, enthusiastically reported in the press decade after decade, have given the public a firm belief that heroin addiction is curable.

A closer look at the figures, however, leads to less optimistic conclusions.

Of the 344 addicts admitted to the program prior to October 31, 1959, only 83 were still in good standing on December 31, 1962. Of these 83, moreover, 17 were either still on parole or had been released from parole after less than seven months of supervision. Thus only 66 parolees (19 percent) were believed (on the basis of arm checks) to have remained free of parole violations or narcotics and to have completed seven months or more of parole .26

The 65 percent and 55 percent success figures cited by Diskind and Klonsky in the quotations above applied only to these 66 parolees! When the Fordham University group followed up the 66 "successes" who had been released after seven months or more of parole, they found only 30 still living apparently drug-free and without known legal offendes. 27, Thus, the true success rate for the original 344 addicts was 30 out of 344, or less than 9 percent.

Doubts can be raised, of course, concerning even these 30 alleged " successes." How many of them, for example, had in fact been narcotics addicts? The original sample of 344 consisted of a selected group of addicts with sufficiently modest criminal records to persuade a parole board to release them. It is not unlikely that in this program, as in the Vaillant study, the California Rehabilitation Center program, and the Riverside Hospital program described above, a significant proportion of the 30 "successes" had never in fact been addicted to heroin.

By 1966, the federal program at Lexington, the California Rehabilitation Center program, the Riverside Hospital program, and the New York State "Special Narcotic Project Program" bad firmly demonstrated that neither incarceration alone nor incarceration plus treatment nor incarceration followed by intensive parole supervision accomplishes much of value for more than a handful of addicts, and that costs per addict are very high. Despite these demonstrations, New York State in 1966 announced a mammoth new program-the largest and costliest in history-based on precisely the principles that had so often proved a failure before. A total of 4,500 addicts and alleged addicts were to be immured in twenty-six new institutions. These institutions, as in California, were called rehabilitation centers rather than hospitals or prisons. Aftercare was also provided for, and the official in charge of New York State's "Special Narcotic Project Program," described above, was placed in charge of this aspect of the new program. The cost for the first three years was pegged at $200,000,000-most of it for the purchase of old buildings and the construction of new ones in which addicts could be locked up.28

At the beginning of 1971, the gargantuan New York State program was still spending money at the rate of $150,000,000 a year .29 It had failed to publish any statistics from which its success rate could be calculated. Two outside reports on results did become available, however, in February 1971. One was a staff report to New York City Mayor John Lindsay; the other was a report by New York District Attorney Frank S. Hogan.

The state's Narcotic Addiction Control Commission, it was learned, had 5,800 addicts under treatment, out of an estimated 100,000 addicts in the state.30 To provide similar treatment for the other 94,000 would raise the cost from $150,000,000 a year into the billions. 

The Lindsay report further noted that 526 persons had left the program between April and September 1970. But only 97 of these, or 18.4 percent "had completed the aftercare phase of the program without relapsing or absconding." 31 

This did not mean, of course, that 18.4 percent were cured. It meant only that 18.4 percent were now on the street without supervision. The other 81.6 percent had already relapsed or absconded.

Meanwhile, addicts convicted of narcotics law violations were piling up in New York City jails, under intolerable conditions, and prisoners were rioting in protest at the overcrowding. The New York State "civil commitment program" played a curious role in this overcrowding. Addicts, the Hogan report indicated, much preferred a short sentence in prison to three years in a state "rehabilitation" institution .32 Hence prosecutors were able to persuade them to plead guilty in criminal court, and overcrowd the jails still further, under threat that if they did not plead guilty, they would be committed without a trial to a state "treatment center."

By 1970 even New York Governor Nelson A. Rockefeller, who had launched this mammoth program amid high hopes in 1966, was ready to concede that it had failed. "It is a god-damn serious situation," he told a meeting of clergymen. "I cannot say that we have achieved success. We have not found answers that go to the heart of the problem ." 33 Yet the state continued to pour money into the program.

In 1966, the federal government also established an incarceration-plus aftercare program patterned on the California model. Preliminary evaluation studies of this National Addiction Rehabilitation Administration (NARA) program, made public in 1971, indicated that the NARA program was approximately as successful as the California and New York State programs described above .34 

What about Synanon, Daytop, Phoenix House, Odyssey House, and other widely publicized private and semiprivate agencies for the rehabilitation of heroin addicts in a " therapeutic community" setting?

In 1958 Charles E. Dederich established Synanon in California as a treatment center for drug addicts. The center combined the best features of the psychological and sociological theories of addiction. Addicts entering Synanon went through a rigorous psychic restructuring process designed to change their personalities from addiction-prone to stalwart and self-reliant. Simultaneously the Synanon community was structured so as to encourage total abstinence and discourage drug use. Many could not "take it" and withdrew. Others remained in the Synanon community for years-until the rehabilitation process was presumably complete and the likelihood of relapse negligible.

By the mid-1960s, however, even Synanon itself conceded that its program had with few exceptions failed to turn out abstinent alumni. Members apparently cured beyond any possibility of relapse promptly relapsed when they left the sheltering confines of Synanon or of other therapeutic communities to which they had transferred. Dederich himself estimated in 1971 that the relapse rate among Synanon graduates was in the neighborhood of 90 percent.

"We once had the idea of 'graduates,' " he told a reporter. "This was a sop to social workers and professionals who wanted me to say that we were producing 'graduates.' I always wanted to say to them, 'A person with this fatal disease will have to live here all his life.'

I know damn well if they go out of Synanon they are dead. A few, but very few, have gone out and made it. When they ask me, 'If an addict goes to Synanon, how long will it take?' my answer is, 'If he's lucky, it will take forever.'

"We have had 10,000 to 12,000 persons go through Synanon. Only a small handful who left became ex-drug addicts. Roughly one in ten has stayed clean outside for as much as two years." 35

Even this one-in-ten success rate, moreover, must be viewed with caution. For Synanon accepted in the first place only highly motivated addicts who were willing to go through the rigorous Synanon procedures, including "cold turkey" withdrawal. Many "split" within a few days or weeks after entering Synanon-before they were formally enrolled or included in the statistics. Synanon procedures applied to an unselected cross section of addicts rather than to this very select group would no doubt yield a far lower success rate.

Despite this record of failure, Synanon was widely hailed throughout the 1960s as evidence that heroin addiction is curable; and many other similar centers were modeled more or less closely on Synanon principles. Reasonably precise figures are available for one such project-Liberty Park Village in New Jersey-for the period prior to 1971. It was founded by a Daytop alumnus, with federal and state financing; its budget totaled $1,670,800 for the year beginning August 1, 1970 .3 1;

The area served by Liberty Park Village contained an estimated 4,000 heroin addicts. The program ran six "outreach centers," and an estimated one thousand addicts made contact with these centers during the first twenty-two months. Not all of them, however, were accepted for admission to the Village therapeutic community. During the period from January 1969 through October 1970 only 272 of the more promising applicants were selected.

A basic principle of the therapeutic community is its voluntary nature. Addicts are free to leave at any time. Most Liberty Park Village addicts took advantage of this freedom. By the end of 1970, only 22 had "graduated" and only 67 were left in the program. The others had all "split" (absconded), some of them more than once.

Again, this did not mean that Liberty Park Village had "cured" 22 addicts on its $1,670,800-a-year budget. It only meant that 22 had completed the program and returned to the streets, where they might or might not relapse. At the beginning of 1971, it was known that 4 of the 22 "alumni" were back on heroin or in jail. Nothing was known about the other 18-and no effort was being made to find out. Despite the $1,670,800per-year budget, and despite an additional federal grant for the specific purpose of "evaluating" the program, no funds were available to find out how many of the 18 were back on heroin or in jail.

Yet the most astonishing part of the Liberty Park Village story remains to be told. The New Jersey state officials responsible for supervision of the program, and many ordinary citizens as well, were firmly convinced for a time that it was a success.

Here an explanation is necessary. Despite its woeful overall failure to solve the problems of the 4,000 heroin addicts in its area, Liberty Park Village on any given day has (like other therapeutic communities) a cadre of twenty or thirty bright, alert "ex-addicts" in residence who are doing very well at the moment. Visitors to the project met this core group and were impressed with its progress. So were state officials. "Ex-addict" members of the core group lectured local civic organizations on the good work Liberty Park Village was doing. They also spoke at high schools and other educational institutions. And the message they carried was a very simple one: heroin addiction is curable. Indeed, one need only look at them to see that a young man or woman with enough will power could convert himself from a heroin addict to an upright, healthy, personable ex-addict in a year or so. (Late in 1971, the Liberty Park Village program, philosophy, and leadership were altered and a new program was instituted. It is still too early to evaluate this new program.)

Each of the other "therapeutic communities" differs from Synanon and Liberty Park Village in one respect or another. One difference is that even the rudimentary statistics available for Liberty Park Village are not available for many of the others.* Dr. Vincent P. Dole's comment is, "Agencies seldom conceal success."38

* An unpublished report by George Nash, a sociologist (and currently consultant for program planning and evaluation to the Division of Narcotic and Drug Abuse Control, New Jersey Department of Health), and three associates provides data on Phoenix House programs.37 Of 157 residents in two Phoenix House units, in August and September 1968, the Nash group reported:

40 were still affiliated with the Phoenix House program two years later, of whom 17 were employees, living on the outside,

12 were in treatment,

10 were "elders,"

I was the wife of a program director;

117 had left the program, of whom

100 had "split" (absconded without graduating) and

17 had graduated, of whom

7 were employed in other narcotics programs, and were known to have returned to heroin within a year after graduation. This left

8 graduates who were living on the outside and who, so far as could be determined, were living drug-free.

The 8 graduates believed to be living drug-free on the outside, and not working in the field of narcotics treatment, had been out for less than two years-some of them for much less. It would therefore have been too early to have much confidence in their status as "ex-addicts."

Moreover, at least 19 of the original 157 Phoenix House residents in the study had never been addicted to heroin: they had used heroin only occasionally before admission.

Thus, Phoenix House returns only a trickle of ex-addicts to drug-free life on the outside.

In general, the outline of all the therapeutic communities follows substantially the following pattern.

Out of the estimated 250,000 to 315,000 heroin addicts in the United States, each therapeutic community selects a handful-perhaps 100 or 200 per year-who are the most highly motivated for cure and who seem to be the "best bets." During their first few months on the program, these most promising recruits are made to work very hard and are subjected to severe stresses by those who joined the program earlier. These stresses are an essential part of the program, and are often dubbed "encounter therapy." The purpose is psychological restructuring, combined with sociological adaptation to a drug-free environment. Most addicts cannot take it, and promptly walk out. Their departure is an essential part of the program; for if some do not leave, there is no room for newcomers.

The many who drop out early, however, are not counted as "failures." Indeed, they are not counted at all. The count does not begin until an addict has survived the difficult first few months. Only then is he "admitted" to the therapeutic community-and to the success-failure statistics.

Like Liberty Park Village, the other therapeutic communities have in residence on any given day a cadre of impressive "ex-addicts" who have survived these preliminary months and who arouse the admiration and awe of visitors. What happens to them, however, after they graduate?

Significant proportions of them stay on in the therapeutic community as staff members, or leave to found or help found other therapeutic communities. In either case, they remain in a sort of vise which enables them to stay abstinent. Day and night they are surrounded by the community; their motivation is high, their opportunities for relapsing few. They continue to "make it" (though many of them report they still crave heroin on occasion).

The success claims made by therapeutic communities refer almost entirely to these continuing community members. Those who apply but are not accepted are forgotten, along with those who do not even apply. Those who drop out during the first months are similarly forgotten. Thus a therapeutic community can (and often does) claim a success rate of 50 percent, or 60 percent, or even higher, despite the fact that only a handful of addicts ever "graduate."

Nor is that the whole of the story. In the entire history of therapeutic communities, no study has ever been published of what happens to alumni who complete the treatment program and leave the therapeutic community setting. Their success rate remains unknown. The only statistic we have is Charles Dederich's statement (see above) that about 90 percent of the few who successfully graduate from Synanon return to heroin within two years.

One advantage of therapeutic communities sometimes cited is that they accept young addicts who otherwise would have to serve time in prison, with all of the psychological and social deterioration that the prison experience entails. This is no doubt true in many cases-but not in all. A therapeutic community housed in Fairfield Hills Hospital (a state mental institution) in Newtown, Connecticut, accepts addicts who choose hospitalization in lieu of imprisonment. These patients cannot leave except to go to prison. Yet some of them "decide, after they enter the treatment program, that they can 'do easier time' in jail and thus choose to return there. It is estimated that about sixty percent of such patients stay in the program while about forty percent decide they would rather be in jail."39

The temporary success of therapeutic communities while addicts remain in residence, followed by a high failure rate when they return to the open community, focuses attention once more on the postaddiction syndrome described earlier. Therapeutic communities have developed quite effective techniques for assuaging these mood disturbances anxiety, depression, craving-and preventing them from triggering drugseeking behavior and relapse; but they do not cure the syndrome. Thus, leaving a therapeutic community, like leaving prison or a "treatment center," may be followed by a recurrence of anxiety, depression, and drug craving-and, all too often, by relapse to heroin.

None of these comments should be taken as a criticism of the dedicated men and women who are devoting their lives to Synanon, Daytop, Phoenix House, and some other therapeutic communities. They represent a high flowering of the human spirit. So does the minuscule cadre of exaddicts who continue to live drug-free in the open community after graduation. The failure of the programs is not due to the shortcomings of the staffs or members of therapeutic communities. It results from the fact that heroin is an addicting drug.

Synanon, to its credit, now recognizes its inability to graduate "cured" heroin addicts. It no longer presents itself as solely or even primarily a treatment center for heroin addicts, and it no longer claims that it can graduate successful ex-addicts. Rather, it presents itself as a way of life, admits nonaddicts, and states that the goal is to remain in Synanon forever. Other therapeutic communities, too, are increasingly presenting themselves as a way of life rather than a cure for heroin addiction.

Viewed as a way of life, the therapeutic community may have a role to play in American society. It may also have some merit for drug users who use drugs that are not addicting. Its merits in that context, however, fall outside the scope of this discussion.

From the narrow point of view of heroin addiction, the therapeutic communities, without a single known exception, represent a major disaster, for they have helped persuade the public that heroin addiction is curable, without curing more than a trivial number of addicts.

The message brought to the nation's schools by the therapeutic community "ex-addicts" is also subject to grave question. Their message is that heroin addiction is curable. ("So why be afraid of heroin?" is the natural and obvious corollary.)

The ex-addicts who speak in schools and at civic meetings, it is true, do not portray the cure as easy. They describe it as requiring a heroic effort of will and the ability to endure grave hardships-like climbing a mountain, or like crossing a desert. Young people, of course, are attracted to precisely such challenges.

Let us summarize. No effective cure for heroin addiction has been found-neither rapid withdrawal nor gradual withdrawal, neither the drug sanitariums of the 1900s, nor long terms of imprisonment since 1914, nor Lexington since 1935, nor the California program since 1962, nor the New York State program launched in 1966, nor the National Addiction Rehabilitation Administration program, nor Synanon since 1958, nor the other therapeutic communities. Nor should this uninterrupted series of failures surprise us. For heroin really is an addicting drug. 

Against the background of this tragic century-long record of failure to cure heroin addiction, let us return briefly to the issue with which this chapter began-the dispute among proponents of psychological, sociological, and biochemical theories of heroin addiction.

The failure of the psychological and sociological approaches, reviewed above at such length, certainly does not disprove the psychological and sociological theories of addiction. Perhaps an effective psychological or sociological cure for addiction will be discovered next year. (Certainly some new "cures" will be announced.) But the failure to date of the psychological and social approaches helps to explain why a still small yet growing segment of those concerned with addiction problems in the United States is beginning to take more seriously the biochemical theory.* 

* Many centers are currently at work on biochemical research designed to establish the precise ways in which the heroin molecule achieves its remarkable effects. While all of them are not directly concerned with the "postaddiction syndrome," their findings are likely to prove relevant to an understanding of that syndrome. Workers concerned with the biochemistry of addiction include Dr. Dole at the Rockefeller University, Dr. Avram Goldstein at the Stanford Medical School, Dr. Peter Lomax at the University of California at Los Angeles, researchers at the Addiction Research Center in Lexington, Kentucky, Dr. E. Leong Way at the University of California San Francisco Medical Center, Dr. Naim Khazan at the Mt. Sinai School of Medicine in New York City, Dr. Doris H. Clouet of the Narcotic Addiction Control Commission's Testing and Research Laboratory in Brooklyn, New York, Dr. Thomas R. Castles of the Midwest Research Institute in Kansas City, Missouri, Dr. Louis Shuster at Tufts University School of Medicine in Boston, Drs. Conan Kornetsky and Joseph Cochin at Boston University, Dr. Martin W. Adler at Temple University School of Medicine in Philadelphia, Dr. Philip L. Gildenberg at the Cleveland Clinic Foundation, Drs. Frederick W. L. Kerr and Jose Pozuelo of the Mayo Clinic, and no doubt others. To summarize the complex body of data already assembled would exceed the capacity of the authors of this Report and tax the patience of readers. The most that can be said with confidence is that the next few years-perhaps even the coming year-should see the publication of a substantial volume of experimental data throwing additional light on the biochemistry of addiction.

 A study at the Addiction Research Center in Lexington, Kentucky, by Dr. William R. Martin and his associates (Drs. Eades, Sloan, Jasinski, Jones, and Wikler) is concerned with long-lasting physiological effects of opiate addiction. "We have shown," Dr. Martin reports, "that following withdrawal of patients dependent on morphine and methadone, there is a long-lasting syndrome of physiological abnormalities which has been called protracted abstinence, which appears to be characterized by hyperresponsivity to stressful stimuli and which is associated with relapse to the drug of dependence." 40 The Lexington group's "protracted abstinence syndrome" is no doubt the physiological substrate of the anxiety depression-craving phenomenon, which we have here called the "postaddiction syndrome."

In other countries, too, the biochemical theory is winning new support. In England, for example, Dr. M. A. Hamilton Russell of the Addiction Research Unit, Institute of Psychiatry, London, has recently urged acceptance of the heart of the biochemical approach: the doctrine that the cravings that ex-addicts experience months or even years after their last "fix," and that lead to drug-seeking behavior and to relapse, are as physiological in nature as the early withdrawal symptoms. "Psychological processes are mediated by physiological events. Intense subjective craving, so long regarded by the unsympathetic as 'merely psychological,' may well be governed by physiological adaptive mechanisms in the hypothalamic reward system which are no less 'physical' than the similar mechanisms responsible for the classical phenomena of opiate withdrawal. " 41

The uninterrupted failure of narcotic addiction "cures" from 1856 to date suggests an altogether new definition of an addicting drug-an operational definition. Let us here formulate such a fresh definition, at least roughly.

An addicting drug is one that most users continue to take even though they want to stop, decide to stop, try to stop, and actually succeed in stopping for days, weeks, months, or even years. It is a drug for which men and women will prostitute themselves. It is a drug to which most users return after treatment at Lexington, at the California Rehabilitation Center, at the New York State and City centers, and at Synanon, Daytop, Phoenix House, or Liberty Park Village. It is a drug which most users continue to use despite the threat of long term imprisonment for its use and to which they promptly return after experiencing long-term imprisonment.

The reasons why opiates produce this curious behavior need not be specified; they may be psychological, sociological, or biochemical. But this is the kind of behavior these drugs evoke.

One major virtue of our operational definition is that it specifies precisely what young people should be concerned about, and what parents and public officials should be concerned about. The major reason for not taking opiates is that they are addicting-enslaving-in the ways specified in the definition. If society belittles this enslavement by falsely stressing the curability of heroin addiction, as it was doing throughout the 1960s and as it continues to do, then it should not be surprised that more and more young people turn to heroin. It is society, after all, that has told them that addiction is only temporary.

Readers of this Consumers Union Report need not accept our operational definition of addiction. Nothing that follows depends upon it. But readers are urged to keep the operational definition in mind when reading about "new approaches to drug addiction" or new "cures" or new "rehabilitation programs." The question is not whether a new program is theoretically sound, or honestly motivated, or competently staffed, or adequately financed. The question is whether it can in fact turn out ex-addicts who do not, promptly or after a modest delay, become narcotics addicts again.

But what of the tiny minority of addicts who do succeed in "kicking the habit" permanently? Even if there are only a handful of them, and even if it costs a million dollars apiece to cure them of their addiction, is not the effort worthwhile'? Unfortunately, studies of ex-heroin addicts indicate that a substantial proportion of them are at least as badly off following cure as they were during their addiction.

In their 1956 study of heroin addiction in British Columbia, Dr. Stevenson and his associates sought the names and whereabouts of former addicts currently living there drug-free. There turned out to be very few of them. With great diligence, the Stevenson group managed to interview 14 ex-addicts at length, and made full psychological studies of 7-three men and four women. In addition, they talked with a number of others, and secured anecdotal descriptions of a number whom they did not actually meet.

The most striking finding in this study concerned the very close relationship between alcoholism and abstinence from narcotics. In about half of the cases studied, the ex-addicts "merely changed their status from that of drug addicts to alcohol addicts. Many of these were alcoholic before they began the use of narcotics, and have merely returned to their first love."* 42

* Nineteenth-century physicians were well aware of the tendency of ex-opiate addicts to become alcoholics. Dr. J. B. Mattison, medical director of the Brooklyn Home for Narcotic inebriants, wrote in 1902, after thirty years of experience with addiction treatment: ". . . Unless care be taken, a drunkard results. The shore of the post-poppy land is strewn with wrecks of those who, after escape from narcotic peril, have taken to rum." 43

The reports on these alcoholic ex-addicts make sorry reading indeed:

Male, 46: "Has become an end-stage alcoholic, substituting alcohol for heroin."

Male, 30: "Although [he] has discontinued the use of narcotics he has become heavily alcoholic, which endangers his other home and work adjustments and increases the likelihood of subsequent return to the use of narcotics."

Male, 58: "This man has merely exchanged his addiction from narcotic drugs to alcohol, and has made no satisfactory social adjustment. Does no work, repeatedly in gaol for intoxication and petty theft."

Female, 34: "It is obvious that this is not a successful abstention from narcotics, but merely a change in the chemical substance. Has continued in skid road alcoholism, interrupted only by repeated gaol sentences."

Female, 46: "Because of her dependence on alcohol, the child's father left her.... Has become a skid road alcoholic and prostitute."

Some of the other British Columbia ex-addicts looked at first glance much more promising. For example:

Male, 52: "Has worked steadily for past twelve years, not using narcotics and rarely using alcohol to excess. Has a good job which provides adequately for wife and himself."

Male, 53: "Since joining A.A. has lived a useful and relatively happy life, and is an asset to the community, working steadily and being helpful to others."

Male, 27: "Has worked steadily, is proud of his home and ownership of its contents, and lives contentedly with his wife and child."

Female, 24: "Has continued to abstain from drugs, in spite of husband's relapse and return to gaol. Takes good care of children and home."

Female, 23: "Has found a new life with her second husband and realizes she is living happily on an entirely different level. Gave birth to first baby. Is an excellent wife, home-maker and mother." 44

When we examine these nonalcoholic cases more closely, however, two factors appear which should give us pause. First, those who successfully stopped were in some cases far from being long-term or hard-core addicts. The twenty-four-year-old female ex-addict cited above, for example, first used narcotics at seventeen and stopped at twenty, having served a jail sentence in between. Second, only a handful of nonalcoholic exaddicts could be found in a province with 900 current addicts. Third, the period of abstinence was in some cases still too short to warrant confidence in its permanence.

This third point is illustrated by another portion of the British Columbia study. Of 100 consecutive addict admissions to a penal institution, Dr. Stevenson and his associates reported, 69 had voluntarily discontinued drug use once or several times. An additional 14 had discontinued use of drugs involuntarily during imprisonment-but had continued to abstain voluntarily following release. Of the total of 83 who abstained, the majority bad relapsed in less than a year. But 19 had remained abstinent for two years or longer-a few for as long as five years. Then they had relapsed and had been imprisoned again .45 If studied during the period of abstinence, of course, these 19 addicts would also have looked like successes. Other studies have similarly reported a high percentage of relapse, even after periods of abstinence measured in years. The exaddict, in short, is commonly also a pre-addict. A "cure" is rarely more than temporary.

Turning from opiates to alcohol, as noted above, is almost universally the fate of those who turned initially from alcohol to opiates. All 33 of the drunkards who turned to morphine in Dr. Lawrence Kolb's study "resumed drinking when, by cure of their addiction, they abstained from narcotics for varying periods ." 46

Dr. John A. O'Donnell's classic 1969 study, Narcotic Addicts in Kentucky (see Page 9), not only confirms the British Columbia and the Kolb addict-alcoholic findings but expands them in significant respects. Dr. O'Donnell and his associates actually interviewed 47 male addicts residing in Kentucky, all former patients at the federal hospital in Lexington, who appeared to be abstaining from narcotics at the time of the interview. Of the 47, however, 16 were now alcoholics and 4 were barbiturate addicts. 47

Dr. O'Donnell also prepared data on the number of years the 212 male addicts in his study spent on narcotics, on alcohol or barbiturates, and abstinent following discharge from Lexington. Of the years spent out of institutions and free of narcotics, more than half were spent on alcohol or barbiturates.*48

* The difference between alcoholism and barbiturate addiction is negligible. As we shall demonstrate in Part IV, alcohol is, in many of its effects, a "liquid barbiturate" and the barbiturates are very much like "solid alcohol."

Female addicts showed a considerably better record than male addicts did of abstinence from narcotics, and much less of a tendency to substitute alcohol or barbiturates for narcotics. Even with women included, however, the overall figures were hardly optimistic. Ninety percent of all the addicts in the study, male and female together, spent at least a part of the time following their discharge from Lexington addicted to narcotics, to alcohol, or to barbiturates.

Among the 10 percent who remained abstinent, moreover, several could hardly be defined as "voluntarily" abstinent. Here are three O'Donnell examples:

Case 035 "had used narcotics from about 1907 to 1949.... In 1949 he began to lose his sight, and by 1950 he could not leave the house without [his wife]. He could not go to physicians, and she would not get narcotics for him." 49

Case 177 "was abstinent in the latter years of his life because, due to arthritis, he was bedridden. All medications were controlled by his family, and they could make sure that no narcotics were used."

Case 193 "claimed abstinence for 10 years up to the time of followup, attributing it to an exercise of will power. His wife, however, stated that he still begged for drugs constantly. For the first 5 of these 10 years he had been a traveling salesman, and would visit physicians in the towns he passed through to get [morphine] prescriptions. . . . For the last 5 years, however, he was confined to a wheel chair in his home, and during that time she kept him completely abstinent until the last 6 months, during which the family physician prescribed occasional narcotics for him. This was confirmed in detail by the physician." -111

An example of an "ex-addict" who successfully refrained from narcotics for twelve years following release from Lexington is Dr. O'Donnell's Case Number 088. "Two physicians in his community described him as a chronic alcoholic, and as having been one for years. His local police record showed four arrests between 1957 and 1959, of which one was for driving while intoxicated. . . . State hospital records showed treatment in 1947, 1957, twice in 1959, and again in 1960, always for alcoholism." 51 Finally, let us consider the very small minority of ex-addicts who manage to refrain permanently from both narcotics and alcohol. Dr. O'Donnell's Kentucky report suggests that even these few may not be quite so fortunate as we would hope.

One of Dr. O'Donnell's "successes," for example, became a compulsive eater after discontinuing narcotics. Though only 5 feet 7 inches tall, he weighed 260 pounds.52

Another "success," Case 002, was insane. He was described as

a man who was floridly psychotic, with many religious delusions, during most of the 5-year sentence imposed in 1938 for sale of narcotics. His complete abstinence for more than 20 years after discharge was one of the best documented in the study, with almost every informant in his community spontaneously mentioning him as one addict who was certainly cured. Among the facts mentioned was that he had attended church and Sunday School for over 300 consecutive Sundays, with several informants suggesting he had "too much religion," that his interest in it was abnormal. The taped interview with him reads like a disjointed revival sermon, and the interviewer saw the subject as a schizophrenic in not quite complete remission. But, however a psychiatrist might diagnose him, the facts indicate that it was an act of choice, even though psychotic rather than rational, which explains his abstinence.53

Yet another "success" was Case 183, a formerly addicted physician who at the age of sixty-five was confined to a wheelchair. "His widow stated that be was abstinent from his discharge [from Lexington] to his death. His daughter confirmed this story, adding that . . . his last words were a request for morphine." 54

These case histories, and the other evidence concerning the sorry plight of so many ex-addicts, should serve to remind us once again that the addict seeking to "kick the habit" has far more to contend with than just the short-term withdrawal syndrome. Through the months and years which follow withdrawal, he must also continue to contend with the postaddiction syndrome--the wavering composite of anxiety, depression, and craving that so often leads to drug-seeking behavior and to relapse. When opiates are not available, the syndrome leads to alcoholism or to barbiturate addiction, and when even alcohol is not available, as in the case of closely guarded blind or bedridden patients, the postaddiction syndrome continues to mold their lives, even to their dying words.

Toward the end of the 1960s, heroin use spread increasingly into the middle-class, white drug scene. I I'he -youthful new addicts differed from the traditional addicts in many ways-socioeconomic class, educational level, life-style, length of addiction, motivation for the use of heroin, and so on. Hopes therefore rose that the new-style addicts might be more readily curable than their predecessors.

The first controlled study of these new-style addicts, however, gives little cause for hope. Among 62 old-style addicts admitted to the Haight Ashbury Medical Clinic in San Francisco and detoxified after November 1969, 94.8 percent were using heroin again in 1971. Among 115 new style addicts, 93.3 percent were back on heroin. The difference was not statistically, significant. In addition, 9.4 percent of the old-style addicts and 8.3 percent of the new-style addicts were rated as "markedly improved"; they reported that although they were still using heroin, they were using it only once a week or less.55 Once again, the difference between old-style and new-style addicts was not significant. (For a further discussion of new-style heroin addiction in the "youth drug scene," see Chapter 20.)