DOCUNE112 REMO CG 010 071 ED 112 298 AUTHOR TITLE INSTITUTION Ferguson, Patricia, Ed.; And Others Drugs and Addict Lifestyles. National Institute on Drug Abuse Research Issues 7. Documentation Associates, Los Angeles, Calif.; National Inst. on Drug Abuse (DHEW/PHS), Rockville, Md. REPORT NO PUB DATE DHEW-ADM-75-189 Nov 74 NOTE 272p. AVAILABLE FROM Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 EDRS PRICE DESCRIPTORS MF-$0.76 HC-$13.32 Plus Postage *Drug Abuse; *Drug Addiction; Government Publications; *Life Style; Psychological Patterns; Reference Materials; *Research Reviews (Publications); *Sociocultural Patterns ABSTRACT This report is the seventh in a series intended to summarize the empirical research findings and major theoretical approaches relating to the issues of drug use and abuse. This volume reviews the research undertaken to describe the lifestyle histories of heroin users. These research findings are formulated and detailed to provide the reader with the purpose, methodology, findings and conclusions of each study reviewed. The first set of research reviews describes the life styles of heroin users by typologies and careers. The second section of the book traces the history of addiction from occasional use to initiation, abstinence/relapse and maturing out. This section concludes with summaries of followup studies of narcotic addicts. Part 3 reviews research on the characteristics of heroin addicts described under the topics of psychological patterns, female addicts, and ethnic and special groups. The remaining two sections include research reviews concerning drug use patterns and theories of addiction. (Author/SJL) *********************************************************************** Documents acquired by ERIC include many informal unpublished * materials not available from other sources. ERIC makes every effort * * to obtain the best copy available. Nevertheless, items of marginal. * * reproducibility are often encountered and this affects the quality * * * of the microfiche and hardcopy reproductions ERIC makes available * via the ERIC Document Reproduction Service (EDRS). EDRS is not * responsible for the quality of the original document. Reproductions * * supplied by EDRS are the best that can be made from the original. *********************************************************************** I1 Research Issues 7 DRUGS AND ADDICT LIFESTYLES U S DEPARTMENT OF HEALTH, EDUCATION &WELFARE NATIONAL INSTITUTE OF EDUCt TION THIS DOCUMENT HAS SEEN REPRO DUCED EXACTLY AS RECEIVED FROM THE PERSON OR ORGANIZATION ORIGIN ATING IT POINTS OF VIEW OR OPINIONS STATED DO NOT NECESSARILY REPRE SENT OFFICIAL NATIONAL INSTITUTE OF EDUCATION POSITION OR POLICY o- Y A 1 NATIONAL INSTITUTE ON DRUG ABUSE RESEARCH ISSUES SERIES 1. Drugs and Employment 2. Drugs and Sex 3. Drugs and Attitude Change 4. Drugs and Family/Peer Influence 5. Drugs and Pregnancy 6. Drugs and Death 7. Drugs and Addict Lifestyles 8. A Cocaine Bibliography Nonannotated 9. Drug Themes in Science Fiction 10. Drug Themes in Fiction Cover Illustration William Blake. The figure of Urizen or the Ancient of Days. Frontispiece from Europe. Illuminated printing. DRUGS AND ADDICT LIFESTYLES Lifestyle Histories of Heroin Users Edited by Patricia Ferguson, M.L.S. Documentation Associates Thomas Lennox, M.L.S. Documentation Associates and Dan J. Lettieri, Ph.D. Division of Research Behavioral and Social Sciences Branch National Institute on Drug Abuse November 1974 National Institute on Drug Abuse 11400 Rockville Pike Rockville, Maryland 20852 For sal* by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 i This volume, part of a Research Issues Series, was prepared for the National Institute on Drug Abuse by Documentation Associates, Box 25892, Los Angeles, California, under Contract Number HSM-42-73-222. DHEW Publication No. (ADM) 75-189 Printed 1975 FOREWORD The issues of drug use and abuse have generated many volumes of words, all written in an attempt to explain the "problem" and suggest the "solution." Data have been generated by researchers from many disciplines, each looking at a particular aspect of an issue. The present booklet is one of a new series intended to aid researchers who find it difficult to find the time to scan, let alone read all the information which exists and which continues to be published daily in their area of interest. An attempt has been made to focus predominantly on empirical research findings and major theoretical approaches. Included in volumes 1 through 7 of the series are summaries of the major research findings of the last 15 years, formulated and detailed to provide the reader with the purpose, methodology, findings and conclusions of previous studies done in the topic area. Each topic was chosen because it represented a challenging issue of current interest to the research community. As additional issues are identified, the relevant research will be published as part of this series. Several of the volumes in the series represent a departure from the above description. These also represent challenging issues, and issues of current interest; they are, however, virtually unexplored areas which have received little attention from the research world. For example, the subjects of drugs and the visual arts, science fiction, and fiction--aspects of contemporary life which impact on all of us--are explored here by writers who have been deeply involved in those fields. Their content is perhaps provocative, and certainly stimulating. The Research Issues series is a group project of staff members of the National Institute on Drug Abuse, Division of Research, Behavioral and Social Sciences Bran,h. Special thanks are due to the continued guidance and support of Dr, Louise Richards and Dr. Norman Krasnegor. Selection of articles for inclusion was greatly aided by the suggestions of a peer review group, researchers themselves, each of whom reviewed a topic of particular interest. It is my pleasure to acknowledge their contribution to the project here. Dan J. Lettieri, Ph. D. Project Officer National Institute on Drug Abuse iii k) ACKNOWLEDGMENTS A bibliographic project such as this necessarily involved a great number of people, all of whom contributed their own particular talent. Many worked on more than one phase of the project. Many more are not named here--their help and advice was instrumental in shaping and defining the series and the It is important, however, to distinguish individual topics. between the members of the peer review group who were instrumental in the initial selection of the articles to be included and abstracted, and the members of the abstracting team who bear sole responsibility for the final format and content of the abstract of each research paper included in this volume. Peer Review Group Irving Lukoff, Ph.D. William McGlothlin, Ph.D. David Nurco, D.S.W. Stephen Pittel, Ph.D. Louise Richards, Ph.D. Alex Richman, M.D. Charles Rohrs, M.D. Elaine Schwartz, Ph.D. Saul Sells, Ph.D. Irving Soloway, Ph.D. Forrest Tennant, M.D. Dan Waldorf, M.A. Michael Baden, M.D. John Ball, Ph.D. Richard Blum, Ph.D. Carl Chambers, Ph.D. Joel Fort, Ph.D. George Gay, M.D. Gilbert Geis, Ph.D. Louis Gottschalk, M.D. Raymond Harbison, Ph.D. Richard Jessor, Ph.D. Denise Kandel, Ph.D. Gerald Kline, Ph.D. Norman Krasnegor, Ph.D. The Abstracting Team consisted of: Greg Austin; David Harris; Susan Hope; Diane Kovacs; Cynthia Lundquist; Marianne Moerman; Roger Owens and Carolee Rosser. iv PREFACE An extensive and comprehensive literature search was carried out to identify materials for inclusion in the Research Issues series. Major clearinghouses, data bases, library collections, and previous bibliographies were searched, either through an automated system or manually. Special efforts were made to correspond with organizations, institutions and individuals who might have relevant materials. Current issues of newsletters and journals were canned throughout the project. A selective list of the sources accessed includes: National Clearinghouse for Drug Abuse Information (NCDAI) NCDAI: Report Series, Selected Reference Series Drug Abuse Current Awareness System (DACAS) SPEED: The Current Index to Drug Abuse Literature Grassroots Addiction Research Foundation, Bibliographies Drug Dependence Psychological Abstracts (PASAR) Sociological Abstracts Dissertation Abstracts Index Medicus (MEDLINE) Addiction: Bioresearch Today Research in Education (ERIC: RIE) Public Affairs Information Service (PAIS) Monthly Catalog of U. S. Government Documents Music Index Art Index Guide to the Performing Arts Reader's Guide to Periodical Literature The criteria for selection of documents were drawn up by a consultant group of drug researchers working with the contractor and representatives of the National Institute on Drug Abuse. For inclusion a study had to meet the following general criteria: (1) (2) (3) empirical research studies with findings pertinent to the particular topic, or major theoretical approaches to the study of that topic published between January 1958 and January 1974, preferably in the professional literature, with the exception of certain older "classics" which merited inclusion and unpublished dissertations English language; however, since the focus was on American drug issues, those English language materials which dealt with aspects of drug use encountered largely in other countries were excluded. After a first review of citations and annotations, to weed out, obviously irrelevant materials, the body of collected literature was subjected to two reviews: one to ensure that materials met the selection criteria, and a second by a peer review group to ensure that studies representative of the universe were included. vi .1 TABLE OF CONTENTS Page I. II. LIFE STYLES 1 I.01 Typologies 2 I. 13 Careers 38 NATURAL HISTORY OF ADDICTION 59 II. 01 Occasional Users 60 II. 02 Initiation 65 II. 03 Abstinence /Relapse 69 II. 07 Maturing Out 81 II. 10 Follow Up Studies 89 CHARACTERISTICS OF HEROIN ADDICTS 121 III. 01 Psycho social Patterns 122 III. 12 Females 154 III. 18 Ethnic Groups 171 Special Groups 194 25 IV. DRUG USE PATTERNS 211 V. THEORIES OF ADDICTION 239 vii I. LIFE STYLES I. 01 Fiddle, Seymour. Notes on the heroin addict and his culture. In: Fiddle, S. Portraits from a Shooting Gallery. New York: Harper and Row, 19?)7. pp. 21- 54. SUMMARY Initially the author provided a description of 6 lifestyles characteristic of addicts. He then pointed out the ways in which the addict's life and feelings parallel much expressed in the writings of existentialists, particularly feelings of alienation, disgust, anguish, uncertainty, ambiguity, and anxiety. THEORY The author presented 6 characteristic lifestyles of addicts that he regarded as theoretically significant: (1) pseudo life, (2) passive life, (3) obsessional, (4) paranoid, (5) depressed, (6) retreatist. The pseudo life feels like real life, but is counterfeit. It is lived out most dramatically by the con man. Rewards are received by exploitation of others, and at length the person can experience gratification only from the mistakes he has caused others to make. Because he continually lives on thin ice he must continually be anxious. The person who lives the pseudo life wants to be punished. The taking of drugs gives him a sense of reality in a fake life. The man who lives the paranoid life is overly conscious of the impact of what he feels to be hostile reality. He needs drugs to still the anxiety and rage he feels when he considers his misfortune. He must be vigilant in the face of what he sees as a dangerous world. He is suspicious, and therefore is lonely. He attempts to recover a lost period of innocence through the use of drugs. There are 3 variants of the passive life: indifferent, dependent, and aggressive. The indifference stems from weariness or apathy, a sense of defeat even though one may not even have fought and lost. The dependent person, faced with the complexity and cruelty of reality, tries to find a strong figure to lean on in order to make life easier. 2 The passive person despairs about his impotence and passivity, and turns this mood into irritation with anger at those around him. He will sometimes attack physically. The depressed person finds the present empty, and boring, and is pessimistic about the future. Drugs provide an exciting break in this otherwise grey, colorless life. The obsessional life is oriented around rituals and codes, and the practitioner is compulsively obedient to both. The obsessed individual seeks in drugs the way of extinguishing the need for tender emotions. The retreatist is filled with anxiety about the world; he particularly fears falling apart, and uses drugs to provide him with a sense of illusory integration. A person who is addicted to heroin often acts as though he has been changed fundamentally. He then feels that he is only normal if he has the added dimension of the drug within himself. He submerges other needs and feeds off of the alien chemical within himself. The author suggested a process called dechemicalization which would wean a man away from the need for the added dimension of drug commitment. This would involve reconditioning the person to enjoy life in a new way without the added dimension of a chemical. Anguish is seen to be very much at the heart of addiction. "The nod" is the high that represents the end of striving, the cessation of troubled thought and the quest for euphoria. It is only a temporary state, and it becomes harder and harder to achieve. The nod also corresponds to Sartre's concept of "nothingness." The life of the addict contains existential anguish in other ways. The addict is very aware of being dispensable; that his presence or absence is of limited importance. He experiences the anguisl-; of being incomplete. The addict also feels anguish at the slowness of legislation supposedly designed to aid him, and the added slowness of society in putting the legislation into practice. This anguish is expressed in the form of cynicism. Anguish lies at the .heart of addiction. Far from being a purely hedonistic creature, the addict leads a life of complex pain and pleasure. The author noted a striking resemblance between the problems of the addicted and the problems of modern man as described by existentialist thinkers. A profound uncertainty dulls the life of the addict, and this uncertainty is hooked into anxiety, which is one of the forces that perpetuate the use of drugs. Also, a loss of the sacred in an existentialist world may cause man to attempt to replace the sacred with a synthetic equivalent. Alienation is an important feeling both for the existentialist and for the addict. The addict experiences bitter loneliness, and is a stranger among strangers. Sartre's concept of disgust, or "nausea," was seen as a feeling shared by addicts because of the conditions of impermanence and provisionality that permeate their lives. Both in Sartre's characters and in addicts can be seen the anxiety, anguish, despair and the nausea connected with one's failure to live up to one's own highest aspirations. An unmasking process goes on frequently among the addicted, and its particular target is conventional society. Addicts accomplish this by confronting members of conventional society with their own addictions to alcohol, cigarettes, or pills. Addicts resist the unmasking process when it is applied to themselves; a rehabilitation process should assist an addict to direct his unmasking powers toward himself. The addict continually complains about time; it is a dreadful foe. He feels burdened with the necessity to find something to do in a boring world. Drugs may be used to attempt to alleviate future boredom. CONCLUSIONS There are 2 divergent tendencies among the addicted, one looking toward a kind of authentic existence and the other toward a synthetic personality and a synthetic life. Many of the addicted feel frustrated at not being able to achieve authenticity, and they continually look for a variety of drugs wherein they may discover the true self. This search may derange or damage the self. I. 02 Rubington, Earl. Drug addiction as a deviant career. The International Journal of the Addictions, 2(1):3-20, Spring 1967. (18 references). SUMMARY This paper discussed the drug addict in terms of careers, seeking to examine him as a believable and understandable person. The author noted that the word "career" evokes symbols of a society's work order. Males are processed in accordance with social production rules to assume roles at work. The adjustment adults make to institutionE, formal organizations, informal relations, the sequence of roles they follow, the identities they assume and shed - all this constitutes having a career. A person must also quite literally work at becoming and being a drug addict. He must make adjustments to institutions, formal organizations, informal relations, and must follow a sequence of roles in confirming and sustaining his identity as a drug addict. The author argued that the order of this career is on the one hand imparted by the adaptation to drug use, and on the other hand by the imposition of social definitions. Five essential characteristics define a state of addiction (Mauer and Vogel, 1954): (1) loss of control, (2) injury to self or others, (3) tolerance, (4) physical dependence, and (5) habituation or emotional dependence. Changes in any of these variables lead to something like a chain reaction effecting changes in the system as a whole. The end result is that addicts become habituated to drug use, become physically dependent on drugs, and finally find that they require drugs in order to function in everyday life. In respect to the social definitions of drug addiction, in no other area of social deviance does the legal system loom so large in the definition of a person. The juridical construction, interpretation, and enforcement of the Harrison Narcotic Law of 1914 has made drug addiction the social problem that it is in this country, as it is in no other country in the world. Virtually overnight addicts became criminals, and following the new law and enforcement apparatus there came necessarily the "dope fiend" mythology asserting that (1) drugs wreck the body, (2) drugs destroy morality, (3) addicts are sexual menaces, (4) drugs make users weak and ineffective members of society, (5) addiction is contagious, and (6) once an addict, always 5 an addict. These are each systematically discussed and dismissed by the author. It is the presence of a drug culture in this country that makes possible one's continued existence as drug user. Societal definitions and reactions to deviance affect the identity, role, and selfimage of the F-2rsons so categorized. Evidence has suggested that legal repression generated visible social deviants, and that both legal repression and visibility produce a deviant subculture. The subculture performs the function of mitigating legal repression while making it possible to carry on one's career as social deviant. As the street addict becomes involved in narcotics use in the United States, he takes on a new and deviant identity simply as a condition of surviving as a drug addict. Through association with other addicts while using as well as during incarceration, the addict comes to view himself through the eyes of his peers. The most general function of this subculture is to make it possible for addicts to exist as social deviants, to pursue their deviant careers, and to evade stigma. In the areas of self-image, skills, norms, and ideology the addict culture performs a set of functions and suggests a lifestyle for addict participants. Self-Image The subculture defines the symbolic meaning and behavior which attend the definition, "junkie". Not only does it make plain what it means to be hooked, but it makes clear how people who meet the criteria cope with a dilemma which it defines as drug-induced. Along with this goes an additional set of ideas about one's self as junkie and how to sustain that image. Skills Addict culture endorses skills for procuring drugs, administering them, obtaining one's high, and simultaneously avoiding exposure. Norms Addict culture also prescribes a casual set of norms for governing interaction between junkies as well as interactions with the various kinds of "squares" who make up the world of those who are not "hip". Ideology Minimal conformity to these casual and drug-centered norms guarantees a fairly stable and orderly world view. Outsiders are square and meant to be worked, no set of obligations must take 6 precedence over supporting one's habit, and, insiders alone can be counted on to understand the drug mystique. The author concluded that the punitive reaction to addicts, arising from definitions of drug use as criminal rather than as symptomatic of disturbances in living, thrusts addicts into contact with other persons whose lives center around drug use. The contingencies of supporting an illegal habit diversify the addict's entire experience so that it includes several varieties of social deviance in addition to illegal drug use. Most, though not all, addicts become misdemeanants to get drugs. Diversification in procurement roles broadens their social contacts with the half-world and the underworld. Unless drug use can become lesS visible, the deviant career of addicts must be simply a long drawn-out degradation ceremony. 7 I. 03 Gregory, Robert J. The eye of the beholder: An important variable in addiction typologies. The International Journal of the Addictions, 6(1):161-166, March 1971. (7 references). SUMMARY Many investigators have developed models, classifications, and dimensions to help cope with the vast quantities and diverse qualities of data about drugs and drug users. One of the most relevant variables in such abstractions is the background, education, and experience of the individual doing the analysis. Different viewpoints regarding drugs and their use come from different personal and professional backgrounds. Some approaches to drug use have arisen from the following backgrounds: (1) chemical or pharmacological, (2) medical or biological, (3) psychological, (4) social or cultural, (5) legal, (6) religious, (7) economic, and (8) "fun and games. " Each approach is valid, but each is a limited scope used to examine an extremely complex phenomenon. Another dimension of drug-use classification considers the person using the drugs. An individual may be involved with drugs in several ways: the drug-free, the normal, the experimenter, the abuser, and the addict. These categories cut across the physiological, social and other disciplinary frameworks. To these frameworks, presenting synchronic frames.of reference may be added a further dimension, through a diachronic perspective. The ages from 5 to 15 represent the time in which all young people undergo standard socialization experiences. Applying Maslow's hierarchy of needs in an historical perspective, people who grew up during the depression were influenced by physical needs, as were people who grew up in poverty during the 1950's and 1960's. People who grew up during World War II were heavily influenced by safety needs, and their values and transactions reflect this. Some people now in their 20's and 30's have grown up without physical and safety need problems and have been more concerned about love and esteem. Young people have gone beyond the boundaries established as appropriate by older generations, not only in drug use and abuse, but in rebelling against conformity, in developing new fashions in art and music, and in a search for meaningful experiences. Drug use and abuse must be seen as one small part of a cultural revolution. 8 The viewpoint adopted toward drugs frequently stems from, and is certainly influenced by, the cultural background. This can be further specified by the age and psychological/social need level attained by individuals, groups, or even the entire society as affected by significant historical events. Other dimensions are undoubtedly possible. Individuals vary in the substances they use, the degree of use, and the reasons for drug use. In order to see clearly the nature of specific drugs, and the meaning and consequences of drug use, the individual must have a perspective unblocked by his own discipline, needs, or chronological age. Only when this caution ,has been observed does it make sense to proceed with a study of the "drug scene. " The table included in this paper arrays Maslow's hierarchy vertically with age groupings displayed horizontally to present information about the psychological/social needs for each generation. 9 ILO I. 04 Stephens, Richard, and Levine, Stephen. The "street addict role": Implications for treatment. Psychiatry, 34(4):351-357, November 1971. (10 references) SUMMARY This study seeks to describe the charaderistic roles of the street addict and the types of behavior to be expected when an addict from the street subculture enters treatment. The viewpoint that drug addiction must not be viewed independent of the context from which it occurs is stressed. The subculture described is composed of heroin-using, slum-dwelling, minority group members. The addict role is determined through subculture literature and observations, and three characteristic interrelated roles are described: "the cool cat" pattern, "conning" behavior, and an antisocial attitude. The "cool cat" is an addict who seeks sensory experiences, lives for the moment, conspicuously displays wealth, and exhibits a sophisticated boredom of "emotional neutrality." In "conning" behavior life is seen as a "game" where shrewdness in deluding people, often for money to purchase drugs, typifies the addict's interactions with others. The antisocial viewpoint is part of the street addict role, manifesting a desire to retaliate against the society that holds the addict down. The world of the street addict is one which provides its own rewards, identities and careers. Therapists are urged to understand the street subculture with its deviant values, norms, languages and life style in order to deal with these patterns in a treatment setting. THEORY No matter what the form of treatment, whether individual, group, or milieu therapy, whether dynamically or behaviorally oriented, or whether voluntary or involuntary, the phenomenon of drug addiction must not be viewed independent of the context in which it occurs. An alteration in an addict's drug-taking behavior will have farreaching ramifications on his social, economic, and interpersonal behavior, and thus must be considered in any formulation of therapeutic objectives. The problem of drug addiction is much broader than a physical need for a specific chemical, or even than a specific psychopathological dynamic, and if therapy is to be effective these sociocultural aspects must be understood. Even though there is overlap among the three main characteristics of the street addict role, implications for treatment regarding the "cool cat" pattern, "conning" behavior, and an antisocial viewpoint are examined as separate entities. 10 The "cool cat" pattern consists of eight definable elements: 1. 2. 3. 4. 5. Lack of social concern. The addict believes that he cannot trust anyone and must always "look out for number one." Not only does the addict have an absence of guilt regarding criminal activities to support a habit, but the addict subculture actually admires success in crime. The lack of social conscience is not seen as a pathological state but rather is part of the addict role. Thus, the therapist is cautioned to expect distrust and an absence of guilt feelings on the part of the addict. Importance of outward appearances. The "cool cat" displays the idea that he has "made it" through outward appearances such as jewelry or clothing. An understanding of the addict's need for status symbols is important for the therapist. The argot. As the street language of the "cool cat" is constantly changing, therapists are cautioned about using "hip" words unless they are both comfortable and confident in their communicative ability. The importance of the addict image. The addict's emphasis on thinking of himself as "cool" means that he is often unwilling to "open up" to others as that is "uncool." Therapists must be willing to expend an extraordinary amount of time and energy with the street addict to form a "therapeutic alliance." The search for excitement. Part of the "cool cat's" role is often seeking a more difficult and even illegal road to an objective simply because the forbidden course is more exciting. 6. "Short run hedonism." Since the addict tends to be on a schedule which only sees him to the next "fix," there is little formation of long-term plans. Therapists have engaged in making long range plans with addicts under treatment, but are warned that this may only be an intellectual exercise on the part of the addict, and thus the therapist should not be surprised if the addict deviates from these plans. 7. The code of the "cool cat." The self-protective cod" of street addicts, where the addict does not inform on other addicts or reveal his sources, may be a major obstacle in therapy. Gaining trust of the patient is the therapist's main tool to combat this. 8. The "passive cool cat." Observations indicate that the stereotypical passive, non-violent addict role may be largely a myth. Observed treatment sessions were often characterized by violent language and attitude if not outright physical violence. It was theorized that the use of heroin may provide the addict with a buffer from violence, and that as long as an addict has an adequate supply he is able to remain detached. A 11 subcategory, the "stand-up cat," is noted where the addict is admired for his brutality, physical strength, and aggressiveness. Such an addict may continue to see himself in this role in a treatment situation. The "conning" or "gaming" activities of the street addict most often enter the therapy setting in two ways. First, addicts often see therapy as a "hustle" and will engage in various "therapy games" to gain a desired end. Second, "conning" can be used in "testing the therapist" where the addict seeks to determine "where the therapist is at.* The addict may attempt to accomplish several goals through "conning": (1) to ascertain the therapist's values, (2) to probe through verbal interaction for the therapist's weaknesses, (3) to find the limits of permissible behavior (especially if the therapist has legal authority over the addict), and (4) to see if the therapist can be "conned.* Two means of dealing with "testing" are suggested. The therapist must be honest with the addict and with himself, for a contradiction or hypocritical situation will be turned against him. Second, the therapist must continually display his trust in the addict's ability to move toward establishing a mutually honest relationship. The antisocial attitude of the street addict can be seen in his viewpoint that "everybody's got a game" and that he was simply one of the unlucky ones who got caught. Therapists are urged to realize that they are seen by the addict as part of the "establishment" which is suppressing him, and that the therapist must react to assertions and accusations of an antisocially thinking addict. CONCLUSIONS The addict life provides for the street addict the kind of rewards we all seek: an identity, a place in a subsociety, acceptance as a peer and a career. Few addicts will display all the behaviors and attitudes described, but most street addicts will behave in many of the ways specified. 12 I. 05 Nurco, David. Transferability of addict life styles into socially acceptable occupations. In: Nurco, David, Project Director, Occupational Skills of Narcotic Addicts. Sponsored by the U.S. Department of Health, Education and Welfare, Social and Rehabilitation Services and the Maryland Psychiatric Research Center. Baltimore, Maryland, 1972. pp. 58-76 SUMMARY A preliminary conceptual model is proposed to deal with the problem of occupations for addicts by moving the addict into occupations related to his life style and personality. Life style or central life interest refers to the single activity ai which dominant emphasis is placed in the life of the individual. For a deviant individual, the central life interest or major social role constitutes both the deviancy itself and the pursuit of the means necessary to sustain that deviance. The addict develops a life style permitting him to exist as an addict. Further, the life style of the addict indicates a way of meeting needs under stress and provides learning experiences which may be transferable to legitimate means of "making it." The proposed conceptual model translates the addict's life style, central life interest, and ways of existing in a deviant culture to socially acceptable occupational and career pursuits. Traditional approaches to job training have been found to have serious limitations when applied to an addict population. Addicts often lack skills, motivation and a general education. In addition, many employers will screen out addicts. Jobs are often closed to the addict because of his addiction history; the unemployment rate is much higher than that of the regular population. Emphasis should be placed on the former life style of the addict in approaching the problem of job training or vocational rehabilitation. Three Life Stiles Three life styles are presented as examples taken from the author's enumeration of 14 life styles in the total population of addicts. Suggestions for possible legitimate occupations for each type are included. 13 (1) The Street Addict. A heroin addict , usually unemployed, supporting his addiction through the commission of illegal acts; he generally has had many experiences with the police, the courts, and the jails. He begins his day with a "fix" or with attempts to get money or drugs. He is very familiar with the addict subculture, and has a tremendous need to be on the street, mingling with other addicts. He has learned certain skills such as how to survive, take risks, how to relate to peers and sources for drugs. Some suggested legitimate jobs are messenger, salesman, or jobs working with people in the street, I. e. , survey taking. (2) The Dealer Addict. The most deeply involved in the addict subculture, he sells and distributes drugs to maintain himself and his addiction. He is likely to be a hard-core heroin user, and is in constant possession of large quantities of heroin. Other addicts envy the dealer because of the potential profits and the advantages of a steady supply. He is a very popular person to all the buyers. He usually sells in only 1 or 2 particular areas and lives in considerable secrecy. Often he needs to keep accounts for the drugs sold. He sees himself as knowing a good deal about the law. Suggested legitimate jobs are door-to-door salesman, bookkeeping, driving a cab, managing a small business. (3) The Shooting-Gallery Addict. He makes available a place where other addicts may come to administer their heroin in relative safety. There is always someone available at the shooting gallery who will assist in administering the drug. His fee is usually $1 or a small amount of drugs. He rarely leaves the house, and often lives there with his peers. He has knowledge of drug reactions, needs to handle funds, provides paraphernalia and sets up a customer network. Suggested jobs are running amusement booths, nurse's aide, medical emergency worker, teacher's aide. CONCLUSIONS The author feels that alternative avenues to the solutions of the addict employment problem must be investigated. Incorporation of skills learned in addict life styles into legitimate job situations is recommended. 14 X I. 06 Feldman, Harvey W. Ideological supports to becoming and remaining a heroin addict. Journal of Health and Social Behavior, 9(2):131-139, 1968. DRUG Heroin SAMPLE SIZE Not Specified SAMPLE TYPE Addicts in Slums AGE Not Specified SEX Male Black Puerto Rican Mexican-American White ETHNICITY GEOGRAPHICAL AREA New York City METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Observations DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 20 SUMMARY It is the premise of this study that ideological principles are directly related to the introduction and use of narcotics in slum areas. Among several ethnic groups, heroes may be identified by behavioral characteristics associated with love of excitement and action. The possessor of certain highly esteemed qualities is thought to hold the key to escape from a life of poverty and despair. A hero is a natural conduit for the introduction of drugs; he may inspire successive waves of new experimenters. 15 THEORY The author believes that studies of drug addiction suffer from failure to explore social features of slum neighborhoods. Investigators may be overly concerned with the treatment of addiction; they may have a tendency to seek explanations from individual pathology; their viewpoint is often restricted by the environment of the large institutions. The author suggests that medical models fail to explain the spread of drug use in epidemic proportions. While such models may recognize general predisposition to emotional pathology among slum dwellers, they do not explain the choice of drug addiction as opposed to another form of deviant behavior. The author speaks on the basis of his experience during six years of service as a settlement worker on the Lower East Side of New York City. He suggests that Puerto Rican, Black, Mexican and other ethnic groups have been found to recognize and admire the so-called stand-up cat" type of individual. After serving as the instrument for introduction of drugs into a neighborhood, the stand-up cat himself may or may not 1hooked on drugs. If so, the author suggests he will adopt a new set of ideological principles, more comfortable for the life of a drug addict. Regardless of the fate of individual members, the author contends new stand-up cats will always be present in slum society. Each will consider his courage and strength superior to those of his predecessor. The nature of his ideals will be sufficient to ensure acceptance of the challenge. Along with ideology, the paper stresses the importance of monetary considerations to the spread of drug addiction in underprivileged areas. Older drug pushers may be able to reap enormous financial success from their efforts, and the earnings of the young recruit compare favorably to those he might attain from another source. CONCLUSIONS The author suggests that because ideology has kept him constantly prepared for some kind of battle, the young slum dweller may be especially susceptible to the temporary benefits of drugs. The first shot may provide a relief from tension and a relaxation he has never before experienced. He further suggests that drug experimentation need not result from failure within a. social structure. Conversely, the drug user may 16 play an active role in starting to use drugs as part of an effort to attain high social status among his peers. The drive to attain social status may be an explanation for the speed with which drug use spreads in a given community. 17 I. 07 Newmeyer, John A. "The Watergate-Era Junkie: Observations on the Changing Face of Heroin Addiction in San Francisco." Unpublished paper. Haight-Ashbury Medical Clinic, San Francisco, California. 9 pp. DRUG Opiate S SAMPLE SIZE 561 SAMPLE TYPE Treatment (outpatient) AGE Adults (18-64) SEX Both Male and Female ETHNICITY Cross - cultural GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Questionnaires DATEIS) CONDUCTED April-Sept. 1972; May-July 1973 NO. OF REFERENCES 2 SUMMARY This is a follow-up study to the author's 1972 report "The Traditional Junkie, the Aquarian Age Junkie, and the Nixon Era Junkie." The present study extends the analysis of trends relating to the "year first hooked" variable, dividing the subjects into three categories: those addicted before December 1968 were placed in the "Old Style Junkie" (OSJ) group, those addicted between January 1969 and December 1970 in the "Transition Era Junkie" (TJ) group, and those addicted after January 1971 were grouped as "Watergate Era Junkies" (WJ). The findings indicated that the type of person becoming addicted to heroin in the Bay Area during the present Watergate era, was female 18 nearly as often as male, was considerably older when first; involved with opiates and was also older at the time of first running-afoul of the law. WJ addicts were generally of working-class origins as the addict of 10 or 20 years ago, and appeared to be experiencing rather less downward mobility than previous addiction-cohorts. They were not any more frequently "poly-drug abusers" than earlier-addicted counterparts, and seemed to be lighter users of alcohol. METHODOLOGY Interview protocols from 116 clients of the Haight-Ashbury Free Medical Clinic Drug Detoxification Project between May and July 1973 were examined in detail. Similar, but less extensive data on an additional 445 clients first seen between April and September 1972 were examined as a check on the findings of the first set of data. Most of the conclusions about changes in the type of person becoming addicted were noted first in the 1973 sample, then co..).firmed in the larger 1972 client sample. FINDINGS Sex Both groups showed a clear trend toward an increasing proportion of females. The proportion of females leaped from about 20 percent to about 38 percent around 1968, but did not increase further during the next few years. The small number of 1973-cohort addicts, however, was fully 50 percent female, possibly the result of a greater tendency for women to seek Clinic help in the very early stages of their addiction. Race Both groups showed a sharp change toward an increased proportion of whites between the OSJ and the TJ-WJ eras: from 54 percent for 19001963 to 75 percent for 1967-1968, 80 percent for 1969-1970, 73 percent for 1971-1973. The proportion of non-whites might be rather strougiy affected by the ship" nature of the Haight Clinic and by the increasing availability of comparable services for Blacks and Latinos in San Francisco. Nevertheless, non-white Clinic clients spoke of being addicted at a significantly earlier time than the white clients. Apparently whites represent a much greater proportion of San Francisco's "new" junkies than its "old" junkies. Socioeconomic Status The TJ's were sharply more middle class than the OSJ's with most of the difference due to an increase in the upper-middle class representation. However, if the clients first addicted in 1969 and 1970 showed a higher proportion of middle class backgrounds than those addicted before or since, the downward mobility of this group was found to be stronger than that of either of the other groups. The WJ's seemed to be as predominantly working-class, or more so, than their OSJ counterparts. The authors noted that as the Haight Clinic is known to 19 attract selectively the more "hip," white, middle-class type of addict, it was clear that the new junkie in San Francisco cannot at all be described as "middle class." What middle class influx there was into the junkie population reached a peak in the late 1960's and has been on the ebb since. Drug Use i7r11,,,i; A There were very few differences between the three cohort-groups, either in their "past two months" or in their "lifetime" use of the major types of drugs. Alcohol use appeared to be heavier among older addicts. There were indications of slightly greater past use of cocaine on the part of the older junkies, and of slightly greater past use of psychedelics on the part of the post-1968 addicts. There was also an indication of greater heroin use among the newer cohorts. This was considered puzzling as heroin habits are expected to be bigger the longer one is addicted. Age at First Use of Opiates The clear trent was seen that the more newly-addicted junkies were becoming involved in opiates at ever later points in their life histories. In the 1973 sample; the median age of first use of opiates was 18.0 for the OSJ's, 18.5 for the TJ's, and 20.3 for the WJ's. The 1972 sample confirmed these results. Similar results were obtained when asked show old were you when you first used opiates on a daily basis?" The new junkie-cohorts were also seen as a "softer" drug problem in terms of the difficulty of their "cure." The WJ's and TJ's reported a much larger median time than the OSJ's between the point they first used opiates and the point at which they were first addicted. The Transition Junkies Data from this study added some revealing peculiarities about the TJ group. The T2* was less often employed when seen at the Haight Clinic; had less financial resources; was less often of big-city origins and more suicide-prone. The TJ group was distinguished by having relatively high socioeconomic-status backgrounds, with subsequent sharp downward mobility and poor employment history. There was evidence that tie TJ had suffered more psychological instability than OSJ and WJ counterparts, and to have become a heavier user of opiates. 1 ) CONCLUSION The author noted that in his political attitudes the WJ junkie was little affected by the political storms of the Watergate era. If anything, the Nixon Administration merely confirmed his apathetic and cynical world-view. This could make work with the Watergate Era Junkie more difficult, but the evidence suggests that the new addict of the 1971-1973 period will prove much easier to rehabilitate than his older fellows. 20 I. 08 Gay, George R.; Winkler, John J.; and Newmeyer, John A. Emerging trends of heroin abuse in the San Francisco Bay area. Journal of Psychedelic Drugs, 4(1): 53-64, Fall, 1971. DRUG Heroin SAMPLE SIZE 1, 539 SAMPLE TYPE Treatment (outpatient) AGE SEX Not Specified Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Clinic Statistics DATE(S) CONDUCTED November 1969 to July 1971 NO. OF REFERENCES 14 SUMMARY This paper discussed both the rise in heroin patients seen at the Haight-Ashbury Free Medical Clinic in San Francisco, and a recent study done by the Heroin Section of the Clinic. The data in this paper were based upon a review of the medical charts of 1,539 patients from the heroin-abusing population, who were seen at the Clinic between November of 1969 and July of 1971. The study attempted to classify users as a means of predicting trends in future heroin abuse elsewhere. 21 METHODOLOGY The addict population seen at the Clinic had been arbitrarily divided in a previous study into 3 subsegments: (a) the "New Junkie" (NJ), who first used heroin after January, 1967; (b) the "Transition Junkie" (TJ), who first used heroin between January, 1964 and January, 1967; and (c) the "Old Style Junkie" (OSJ), who first used heroin prior to January, 1964. This subdivision was used again in the present study. Although inexact in many ways, it enabled the staff to compare and to understand the heroin abusers of the population who may have environmental, psychological and personal problems of a common background, but who are individually unique. For this study, the medical charts of 1, 539 patients seen at the Heroin Section of the Clinic between November of 1969 and July of 1971 were reviewed. The three subsegments.of users were compared according to drugs used heavily prior to heroin, size of habit, method used to withdraw, family status, number of dependent children, race, therapeutic status, number of clinic visits, number of addicts "hooked" in the military service and elsewhere, relative percentage of subsegments seen during "different" time periods, and sex. FINDINGS All three subsegments were found to have experienced a wide range of drug experimentation prior to heroin usage. The "Transition Junkie, " who comprised the smallest addict subsegment (301 patients studied), showed little in common with the "Old Style Jtu kie" (356 patients) Differences blurred between the TJ and the "New Junkie" (882 patients), whc both exhibited a significantly greater history of heavy daily multiple drug use than did the OSJ. The OSJ classically maintained a long-term heavy habit. Whereas the TJ generally experienced a more lengthy "experimental" phase with many drugs prior to heroin, the NJ appeared to find his way to heroin more directly--"smack" being more available and acceptable. The NJ, as well as the TJ, had seen the paranoia and violence of speed, and the "freak-out" of indiscriminate LSD use, and so in many cases he switched to the euphoria of heroin. However, it was found that NJ-TJ demarcations began to blur during the period of increasing multiple drug abuse: Reared inan era of multiple medication, many patients wander from one drug treatment facility to the next, preparing for the next "dry spell" of heroin, or using the medications to supplement directly the very low-potency heroin available on the streets. Several trends were evident, which progress from the OSJ through the TJ to the NJ. One of these was an increasing percentage of female addicts, probably reflecting the increasing involvement of women 22 in many aspects of society previously dominated by the male. Trends also noted at the Clinic were: (1) the "G.I. Junkie" -the returning U.S. serviceman, especially from Vietnam, who reveals a marked increase in contact with, and heavy use of, heroin and cocaine, with the reported "smoking" of heroin; (2) an increase in multiple concurrent drug abuse - especially alcohol, barbiturates, and other "downers" taken with heroin; (3) a "lax phase" 6f from 1 to 3 years between' initial use of heroli. and the time a patient seeks help; and (4) the "Ripple effect" - the pattern of heroin usage spreading in waves through society CONC LUSIONS The authors point out that perhaps such arbitrary divisions of a heroin-abusing population as they have chosen for the review of data in this paper would not hold up statistically. It was felt, however, that if this could provide a starting point for the bases of detoxification, rehabilitation, and aftercare, it would serve a valid purpose. The charting of trends of drug abuse within the patient population serves a useful predictive purpose as heroin abuse appears in other areas; the therapeutic experience and demographic data of the Haight-Ashbury Free Medical Clinic may be of help with future public mental health problems. 23 I. 09 Gay , George R.; Smith, David E. ; and Sheppard, Charles W. Yesterday's Flower Child is Today's Junkie: The Changing Pattern of Heroin Addiction. New York: Insight Publishing Co. , March, 1972. 3 pp. (A Medical Insight Reprint). DRUG SAMPLE SIZE Opiates 1, 254 SAMPLE TYPE Treatment (outpatient) AGE Not Specified SEX Not Specified ETHNICITY Cross-Cultural GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Exploratory/Descriptive, Longitudinal DATA COLLECTION INSTRUMENT Questionnaires DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 12 SUMMARY Changing types of drug addicts in Haight-Ashbury were observed and classified as: the "Old Style Junkie" (OSJ), who first used heroin prior to January 1964; the "Transition Junkie" (TJ), who began using heroin between January 1964, and January 1967; and the "New Junkie" (NJ), who began using the drug after January 1967. The authors noted that because of its excellent tranquilizing and analgesic properties, heroin had traditionally been used as a drug of escape by those whose environment had become too painful to be handled by normal psychological defenses. The Transition Junkie 24 and the New Junkie are middle-class addicts who are distinguished from the ghetto-bred Old Style Junkie by many factors other than background: prior use of drugs, duration of habit, number of withdrawals, therapeutic response, family status, and race. METHODOLOGY In November 1969, the Haight-Ashbury Medical Clinic opened up a special section devoted exclusively to drug detoxification on an outpatient basis. Each patient, on his initial visit, was asked a. series of questions by a Clinic staff member regarding his social situation and drug usage, especially the use of drugs other than heroin, and also simultaneous and sequential drug patterns. The answers were recorded and became a permanent part of the patient's medical. record. This study was based on an evaluation of 1,254 such questionnaires from heroin addicts. FINDINGS The authors noted that two things were immediately apparent from the evaluation of the questionnaires: the large number of patients with a history of relatively recent addiction, and the emergence of three distinct, although overlapping, addict groups. In all groups only 1 to 2% of the habits were greater than $200/ day. The Old Style Junkie The OSJ was more likely to be non-white than the NJ, and his habit was considerably larger. He averaged 2. 77 withdrawals during the course of his addiction. He had a lower cure rate than the other groups, but a higher percentage remained in treatment and did not become lost to follow-up. He made a larger number of visits, was a more faithful patient, and gave therapy a longer trial before rejecting it. Seventeen percent had a habit over $100/day. The OSJ was more likely to be divorced and less likely to be single. He was significantly less involved with heavy use of marijuana, LSD and other psychedelics, and amphetamines, and also indicated a lower degree of prior heavy involvement with alcohol. Several of the OSJ group felt that alcohol increased their feelings of depression. The New Junkie The largest segment, the NJ, comprised 704 out of the sample of 1,254. They had a mean age of 23. 5; 91. 5% had habits of less than $100/day, and they were in general moderatelyinvolved with other drugs prior to using heroin. Sixty-seven percent reported heavy prior use of marihuana, 51. 1% had used amphetamines heavily and 30% had used barbiturates heavily. They averaged only 1. 20 withdrawals each, 50% of which were "cold" and 18.1 . were self-treated. 25 They were young people of predominantly middle-class backgrounds who entered the world of drugs at a time of deep sociological and political disillusionment, who suffered from frustration and de spair, and whose drug use was based on the desire to escape. Since heroin then had widespread Availability, they tended to begin heroin use with comparatively less prior involvement in the heavy use of other drugs. The NJ was more aware of the dangers of the street drugs and less of a self-medicator than the TJ. The Transition Junkie The TJ comprised the smallest, and in many ways the most ambiguous segment of the population. They first used heroin between 1964 and 1967 and entered the drug world at a time of transition between optimism and despair. They had very little in common with the OSJ. Their families and social backgrounds were very much closer to those of the NJ, but at the time they became involved with drugs the social attitude of their subculture was still optimistic, very much involved with drug experimentation and "mind expansion. " When compared with the OSJ they had significantly greater use of all the common street drugs -- marijuana, LSD, amphetamines, and barbiturates -- and seemed to have a slightly greater prior drug use than did the NJ, but this was statistically clear only in the case of amphetamines. In many cases, the TJ first tried heroin as a comparative experiment which later became an escape mechanism. The authors typified them as self-treaters who medicate their mental state with heroin in much the same way that the dominant culture treats colds and digestive troubles. A recurrent story was the regular use of heroin to treat depression following a long amphetamine run or a bad LSD trip. This attitude toward self-Lreatment applied to withdrawal. history also. The TJ self-treated 25 percent of his withdrawals, which is almost twice the percentage treated by the OSJ and almost one and a half times the percentage treated by the NJ. Their attitude is compounded by their distrust of the medical profession in general. CONCLUSIONS The authors hoped that this classification would be useful in program therapy designs as a useful predictive function in patient selection of various follow-up therapies, which would allow for better medical care for the long-neglected and ignored patient population of the TJ and NJ. 26 I. 10 Brotman, Richard, and Freedman, Alfred. A Community Mental Health Approach to Drug Addiction. Washington, D.C.: U.S. Government Printing Office, 1968. DRUG Multi-Drug SAMPLE SIZE 253 SAMPLE TYPE Treatment (inpatient) Adults (age 14 to 74) AGE SEX Male ETHNICITY 36% Black, 39% Puerto Rican, 24% White GEOGRAPHICAL AREA New York City METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED Summer, 1962 to Spring , 1965 NO. OF REFERENCES So SUMMARY This report describes the use of innovative methods of research used to learn more about effective methods for prevention and control of drug addiction. In 1962 the Health Research Council of the City of New York granted funds to the Department of Psychiatry of New York Medical College to study staff and patients of the narcotics addiction wards at Metropolitan Hospital. A major portion of the study emphasized life style adaptation and included standard demographic measures. A typology was established to separate the entrance of a drug addict into one of four types of 27 life styles: (1) conformists, (2) hustlers, (3) two worlders, and (4) uninvolved. These typologies were established on the basis of answers to interview questions and construction of composite indexes of conventionality and criminality based on these answers. This report contains many of the results from that study in addition to discussion of: (1) the American reaction to narcotics use; (2) physical, psychological, and social aspects of addiction; and (3) targets, goals and methods for intervention. Appendices to the report include a glossary of dependence-producing drugs, the screening instrument used in the research study, and a bibliography. It is noted that the report should be of interest to those wishing to keep informed about new developments in the broad field of juvenile delinquency prevention and control. METHODOLOGY Chapter III and Appendix D of this report give detailed information on the methodology used to construct the four life style patterns determined during the study at Metropolitan Hospital in New York. The research design included a longitudinal study of a sample of drug users as they went into, through, and out of the Metropolitan Hospital program. A 50% sample of all admissions to the two 25-bed narcotics wards was used to comprise the 250 patients. This sample was stratified on the basis of order of admission (even admissions one day, odd the next) and by season, approximately one-quarter of the sample being drawn from each season from the summer of 1962 through the spring of 1963. A sample of 253 male, voluntary patients were selected for the patient sample, and in addition 33 staff members, 61% of the total, were studied. Patients and staff were interviewed using one or more of 6 instruments similar to the screening instrument described in Appendix B. The major instrument, a composite index of criminality and conventionality, was designed as a two-dimensional measurement. With the instrument the four life styles were ranked: (1) conformistthe individual highly involved in conventional life and not significantly involved in criminal life, (2) hustler - the individual highly involved in criminal life and not significantly involved in conventional life, (3) two-worlder - the individual highly involved in both areas of life, and (4) uninvolved - the individual not significantly involved in either area. 28 FINDINGS With regard to the four life style adaptations, the results of using stringent cutting points were: (1) conformist 3%, (2) uninvolved 12%, (3) two-worlders 4%, and (4) hustlers 81%. Using median split points between high and low values, results were: (1) conformists 23%, (2)uninvolved 21%, (3) two-worlders 25%, and (4) hustlers 30%. sto, Other findings mentioned in this report were: (1) the average addict in the sample first heard of drugs at 16 (many had heard of drugs at a younger age, of course), first tried drugs at 17, and became addicted at 18; (2) addicts in the Metropolitan sample were 39% Puerto Rican, 36% Negro, and 24% White; conformists were most likely to be found not among the Whites but among Negroes; (3) 58% were Catholic, 35% Protestant, 4% Jewish, 1% Greek Orthodox, and 2% grew up without any religious affiliation; (4) the median age of the sample was 25 years, with a range from 14 to 74; (5) just over half of the sample were siregle at time of admission; (6) over a fifth of the sample were diagnosed by the intake psychiatrist at the hospital as having no personality disturbance other than "drug addiction." Of all cases 83% were diagnosed as having personality disorders, and 13% as schizophrenic reactions; (7) all but 7 addicts reported that heroin was the drug they used most often; (8) the median length of addiction of patients was just over 5 years; (9) conformists tend to show up among the youngest and the oldest addicts; (10) half the conformists had never been in reform school or jail, but only 12% of the hustlers had managed to stay out; (11) three-quarters of the conformists and half the hustlers think that heroin hurts the body more than alcohol (in fact it does not); (12) 26% of the conformists say they are ashamed of using drugs, none of the uninvolved are ashamed; in all, fewer than 10% of the addicts say they are ashamed of drug use; and (13) of the total sample, 70% mentioned getting off drugs as a major goal, and 20% mentioned staying off as a major goal; the remaining 10% said they wanted social and/or psychiatric change only. CONCLUSIONS Through the results of this research study it appeared clear that habit reduction can be sought as a means of achieving a desirable change in adaptation. It was also pointed out in the report from the Metropolitan Hospital study that, "exclusive and obsessive concern with abstinence is not only frustrating for both staff and patient alike but it militates against the possibility of helping the addict with the very real problems he has in coping with his 29 environment ... As with heart, cancer, and other chronically afflicted patients, the content of the therapeutic interchange with addicts should not be diverted and defeated by an underlying obsession with complete remission or cure." 30 Sutter, Alan G. The world of the righteous dope fiend. Issues in Criminology, 2(2):177-222, Fall 1966. DRUG Multi-Drug SAMPLE SIZE Over 140 SAMPLE TYPE Addicts; Non-addicts AGE Adolescents; Adults (15-60) SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Exploratory-Descriptive DATA COLLECTION INSTRUMENT Interviews, Observations OATE(S) CONOUCTEO 1963-1966 NO. OF REFERENCES 53 SUMMARY The essential features of the life of the "righteous dope fiend" are delineated. The term "righteous dope fiend" is used in social interaction by a special type of addict who wants to indicate that (1) he prefers heroin to any other drug and ranks himself above other drug users, (2) he has greater knowledge of hustles and rackets, (3) he can be trusted never to disclose information about a colleague, (4) he is a lifelong member of an elite social world of opiate users. The author stands in opposition to most of the research that has been done on "street addicts," especially those researchers who have labeled the addict subculture as retreatist. 31 The "righteous dope fiend" has mastered the art of hustling; his world is fused with the same success symbols prevalent in conventional society. If he retreats it is only when he quits using drugs, not when he starts. METHODOLOGY For 3 years, informal conversations were held with over 40 heroin users, and over 100 adolescents in a world of non-opiate drugs in the San Francisco Bay area. Heroin users ranged in age from 15 to 6Q years; average age was 24. Additional information was gained by participation in an experimental project designed to organize an but-patient self-help program for addicts. FINDINGS A portrait of the "righteous dope fiend" is formed from a careful analysis of language and social patterns of drug use essential to understanding the dope fiend's existence. The following statements characterize the type of addict who proclaims himself in public as a "righteous dope fiend." Fixing holds a fascination for the dope fiend and becomes integral to the symbolism of his lifestyle. Dope fiends have an overriding fear of being sick which is associated with the experience of "kicking." The dope fiend always knows where a "connection" can be found, and has little trouble reorienting himself to market condi- tions after relapse. It is paradoxical in a dope fiend's life that he desires to be free from drugs when he is using and desires to be using drugs when he is clean. Prestige in the hierarchy of a dope fiend's world is allocated by the size of his habit and his success as a hustler. The regular use of "crystal" (methamphetamine), "pills," or "acid" will change the identity of the righteous dope fiend to "freak." 32 Alcoholics and "garbage junkies" constitute the lowest level of drug user in the eyes of the dope fiend. Garbage junkies rent hotel rooms and loan out outfits in exchange for a few drops or will use any substance available. "Hustlers" work at specialized schemes for making money and they are ranked on a fixed hierarchy of prestige on their "money- making" power, ingenuity, and versatility. Anyone who sells dope is called a dealer, rarely a pusher in dope fiend circles. Dealing is extremely lucrative and a preferred activity among hustlers. A "mackman" is a righteous pimp whose business is dangerous and competitive. Nearly all young "players" aspire to reach this position. There are various hustles in the world of the dope fiend, none of which are mutually exclusive. The scene is often viewed as one big rat race. Throughout the career of the dope fiend, his condition alternates between striking success and sorrow-torn misery, but not abject poverty as it is usually portrayed by other writers. Part of a dope fiend's natural ability is an acute sensitivity to the presence of a narcotics officer. However, the police alone hardly constitute a severe threat. If the dope fiend gets caught, he often uses the prison facilities to learn new and better hustles, new methods of mixing drugs and generally prepares himself to go back on the job when he gets out. Counseling programs simply sharpen the person's ability to fake. Parole supervision and Nal line testing are probably the most agonizing experiences in a dope fiend's life. Relapse is not inevitable for all addicts, but the impulse to relapse is powerful for a righteous dope fiend. Winich has suggested that addiction may be a self-limiting process for perhaps 2/3 of the addicts. Nothing is known about those addicts who actually give up the use of drugs without relapse. 33 The structure of the illicit marketplace and the accessibility of narcotics defines the terms and conditions of a righteous dope fiend's existence. People come to the market with a set of background experiences which allow them the freedom to deal or use narcotics. Heroin addicts use different terms than non-opiate users to describe how a person is first introduced to the drug experience. One "chippies" for a period before getting "hooked. " Most are firmly convinced that they can control the drug rather than being controlled by it. A person defines himself as an addict when he realizes he is "hooked. " CONCLUSIONS Crucial problems remain unanswered, centering on the typical experiences which lead young people to experiment with different drugs which others in the same setting do not use. Why do some relapse and others remain abstinent? These problems cannot be understood from a clinical setting but must be grasped by illuminating group and individual experiences. 34 I. 12 Brotman, Richard; Meyer, Alan S.; and Freedman, Alfred M. An approach to treating narcotic addicts based on a community mental health diagnosis. Comprehensive Psychiatry, 6(2):104-118, April, 1965. DRUG Opiates SAMPLE SIZE 253 SAMPLE TYPE Treatment (inpatient) AGE Not Specified SEX Not Specified ETHNICITY 75% Black and Puerto Rican GEOGRAPHICAL AREA New York, New York METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Not Specified DATE(S) CONDUCTED Not Specified NO. OF REFERENCES SUMMARY Treatment of addiction and the negative effects of community attitudes towards the addict are discussed. Four types of life style adaptations are presented to identify the kinds of social dysfunctions that characterize the addict's efforts to adapt to the environment. The community's attitudes, public policies, and treatment programs are seen as representing much more serious and basic factors to be corrected than the behavior of the addict. 35 4. Cr METHODOLOGY The life style adaptations of 253 randomly selected addict patients at Metropolitan Hospital in New York were studied. Three-quarters of the sample was Negro or Puerto Rican, 3/4 had fathers in blue collar occupations, and 3/4 never graduated from high school. Physician addicts and other more advantaged groups were not represented. Members of the sample were classified according to their level of conventionality and their level of criminality. A classification of life style adaptation was developed which identified the kinds of social dysfunctions which characterized the addicts' efforts to adapt to their environment. FINDINGS Four types of adaptation were delineated: (1) the "conformist" --an addict who showed high conventionality and low criminality; (2) the "two-worlder"--an addict characterized by high conventionality and high criminality; (3) the "uninvolved"--the addict who showed low conventionality and low criminality; and (4) the "hustler"--an addict with low conventionality and high criminality. Four-fifths of the group was found to fall into the "hustler" category when stringent criminality and conventionality criteria were applied. The variability within the "hustler" group was great enough to necessitate further differentiation within that category. The sample was then dichotomized on conventionality and criminality into high and low groups as nearly equal in size as possible. From 20 to 30% fell within each of the 4 adaptation types. The life style classification served to break down the stereotype of addicts into theoretically relevant empirical types. It also defined 3 distinct kinds of adaptation which were dysfunctional for the addict and/or the community: the "hustler, " the "two-worlder, " and the "uninvolved. " In terms of social adaptation the "conformist" was most likely of all the types to be free of major social dysfunction. It appeared that the key definitions associated with addiction were primarily social and, except to a limited degree, did not include physical or mental causes or consequences of opiate use. By using life style classification specific areas of social behavior that society and/or the individual considered to be dysfunctional were pinpointed. These dysfunctions were connected with the community's refusal to accept the possibility that the addict could become a contributing member. Specific goals for treatment were identified as: (1) improved health and prevention of illness; (2) increased participation in conventional activities; (3) decreased participation in criminal activities; and (4) complete cure and maximal social functioning. 36 t CONCLUSIONS A new approach to treatment would mean concentrating on the addict's adaptation and increased ability to function, hopefully without drugs, but with drugs if and when abstinence is impossible. This was counter to the general philosophy of patients and staff who see staying off drugs as the most important thing for addicts when they leave the hospital. To implement a new approach requires education and training for both patients and staff. 37 'r t I. 13 Finestone, Harold. Cats, kicks, and color. In: O'Brien, R. W. , ed., Readings in. General Sociology. 4th ed. Boston: Houghton Mifflin, 1964. pp. 255-260. (Excerpt from original article in Social Problems, 5:3-13, July 1957.) DRUG Heroin SAMPLE SIZE Over 50 SAMPLE TYPE Volunteer AGE Adolescents; Adults SEX Male ETHNICITY Black GEOGRAPHICAL AREA Chicago, Illinois METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED 1951-1953 NO. OF REFERENCES 2 SUMMARY This paper depicts a social type of heroin addiction and presents a hypothetical formulation to account for it. Over 50 Black male heroin users in their late teens and early twenties, selected from the areas of highest incidence of drug use in Chicago, were intensively interviewed. Many common attitudes, values, schemes of behavior, and general social orientation were elicited. It appeared that they had been unusually receptive to the spread of opiate use. Methodologically, their common patterns of behavior suggested the heuristic value of the construction of a social type. 38 fi THEORY The delineation of the generic characteristics of young Black drug users in this study constituted an ideal type. No single drug addict exemplified all of the following traits, but all of them revealed several to a marked degree: (a) An air of superiority, derived from identification with an elite group, the society of "cats" (b) Strict eschewing of the use of force or violence as a technique, but rather achieving goals by indirection, persuasion, and manipulative techniques, and settling problematic situations by use of wits and conversational ability (c) A self image as a cool "operator, " with complete scepticism as to other people's motives, relating to them by outsmarting them or by open-handed and often ruinous generosity, but always looking for a "scheme" or an "angle" (d) A large, colorful, and discriminating vocabulary , which dealt with all phases of the drug experience and used concrete, earthy words for commonplace objects, revealing an attitude of subtle ridicule toward conventional usage (e) An aristocratic disdain for work and for the subordination of self to superiors and the repetitive daily routine entailed by work, which is only for "squares" (f) Having a "hustle, " or non-violent means of "making some bread, " involving a variety of illegal activities of the "conning" variety, acting as a petty thief, pickpocket or pool shark, or possibly playing the enviable role of a pimp (g) Experiencing the ''kick" as the main purpose of life, whether unconventional sex, alc ohol, marijuana, or heroin, with heroin the "ultimate kick" to provide a sense of maximum social differentiation from the "square" (h) Setting great store on the enjoyment of popular music (i) Exercising much sartorial talent on proper dress The cat seeks to make his life a gracious work of art, through a harmonious combination of charm, ingratiating speech, dress, music, the proper dedication to his "kick, " and unrestrained generosity, and feels himself any man's equal. The cat as a social type is a manifestation of social change in which a new type of self-concept has been emerging among Black adolescents of the lower socio-economic levels in large urban centers. The cat as a social type is the personal counterpart of an expressive social 39 movement. The context for such a movement includes the broader community with its policies of social segregation and discrimination, which isolate the cat in a world where he attempts to give form and purpose to dispositions derived from, but denied an outlet within the dominant social order. Two themes are central in the life of the cat: the "hustle" and the "kick, " which conflict and indirectly attack the central conventional values of occupation for the male and the regulation of conduct in terms of future consequences. It is speculated that a type such as the cat has emerged, instead of a social movement with the objective of changing the social order, because of the long tradition of Negro accommodation to a subordinate status as well as to the social climate since World War II, which does not seem to have been favorable to the formation of specific social movements. Stable family and community organization is lacking in those areas of the city where drug use is concentrated. Such a social milieu does not encourage planning for the future and the subordination and disciplining of present behavior for future rewards. It tends by default to enhance the present,and the "kick" appears to be a logical culmination of this. The cat is "free" in the sense he is a pre-eminent candidate for new forms of social organization and novel social practice, attempting to escape from the historical traditions of the Negro which he regards as humiliating. He is not fully assimilated into social institutions available to him, and excluded from the socializing experiences of adolescents in more advantaged sectors. There are few effective controls on his conduct but those exercised by his peer group. It is implicit in the notion of an expressive social movement that, since direct collective action to modify the sources of dissatisfaction and restlessness is not possible, all such movements should appear as forms of "escape. " From the perspective of the young drug user himself, it is a gross over-simplification to view the problem of addiction from the perspective of the established social structure in this way. The emergence of the self-concept of the cat is an attempt to deal with the problems of status and identity in a situation where participation in the life of the broader community is denied, but where the adolescent is becoming increasingly sensitive to the values, goals, and notions of success which are obtained in the dominant social order. Exclusion from the "serious" concerns of the broader community will result in adaptations manifesting a strong element of "play. " It is suggested that the function performed by the emergence of this social type among Negro lower class adolescents is analogous to that performed by "The World of Make-Believe" in the Negro middle class. CONCLUSIONS The development of a social type such as that of the cat is only possible in a situation where there is isolation from the broader community but great sensitivity to its goals, where the peer group pressures are extremely powerful, where institutional structures are weak, where models of success in the illegitimate world have strong 40 rlt) appeals, where specific social movements are not possible, and where novel forms of behavior have great prestige. But the cat cannot escape completely from the perspective, the judgments and the sanctions of the dominant social order. He must eventually confront his role as fantasy. With the realization he is addicted, he becomes fully aware of the conventional attitudes towards addicts as well as of the counter-rationalizations of his peers. This study pointed out that the cat's vacillation with regard to seeking a cure for addiction may be due to a conflict of perspectives. As a heroin user, he has the exhilarating feeling that he belongs to an elite and is participating in a conspiracy. Most drug users wished to keep their knowledge of drug use secret, as a highly prized practice and set of attitudes. The social orientation of the cat contrasted with a smaller group of young White drug users interviewed in this study, who placed a heavy stress on violence and expressed their social orientation by a direct rather than indirect attack on the dominant values of society. 41 I. 14 Preble, Edward, and Casey, John J. , Jr. Taking care of business -- The heroin user's life on the street, The International Journal of the Addictions, 4(1): 1-24, March, 1969. DRUG Heroin SAMPLE SIZE 150 SAMPLE TYPE Volunteer AGE Not Specified Not Specified SEX ETHNICITY Irish, Italian, Negro, Puerto Rican GEOGRAPHICAL AREA New York City METHODOLOGY DATA COLLECTION INSTRUMENT DATE(S) CONDUCTED NO. OF REFERENCES Descriptive/Exploratory Interviews, Observations Not Specified 8 SUMMARY This report is a description of the life and activities of lower-class heroin users in New York City, in the context of their street environment. This report examines the history of heroin addiction since the end of the first world war to the present, and describes the process of heroin distribution and the life of addicts. The report contradicts the widely held belief that heroin users are seeking escape from responsibility and psychological problems, and finds that addicts are engaged in meaningful activities and 42 relationships seven days a week which are challenging, adventurous and rewarding. METHODOLOGY Data on which this report is based came from interviews with patients at the Manhattan State Hospital Drug Addiction Unit and from participant-observation and interviews with individuals and groups in 4 lower-class communities in New York City - East Harlem, lower East Side, Yorkville, Claremont (Bronx). These communities represented the neighborhoods of approximately 85% of the addict patients at Manhattan State Hospital. The anthropologist's approach to the heroin-using study informants was in the tradition of Malinowsky (1922) and Whyte (1955), which in Whyte's words, consisted of the "observation of interpersonal events. " An additional dimension was added with the modified use of research techniques introduced by Kardiner (1939) in his psychosocial studies of primitive and modern cultures. The main feature of this methodology is the life-history interview with individual subjects. All interviews with research informants occurred with their voluntary consent and cooperation. The anthropologist had the advantage of 12 years experience of street work and research in study neighborhoods. Four major ethnic groups were represented among the approximately 150 informants: Irish, Italian, Negro, and Puerto Rican. FINDINGS This study is prefaced with an account of the recent history of heroin use in New York City and is broken down into 6 time periods: 1. Between World War I and World War II Prior to World War U the use of heroin was mainly limited to show people, entertainers, musicians, and racketeers and gangsters. The major ethnic groups represented among these users were Italian, Irish, Jewish and Negro. There were also heroin users among the Chinese, who had a history of opium use. 2. During World War II World War II interrupted the trade routes and distributorships for illicit heroin supplies, which resulted in a 5 year hiatus in heroin use. 3. 1947 to 1951 Use mainly by Negroes and Puerto Ricans and among other lower class, slum-dwelling people. Increase in use was slow and confined mainly to young adults in their 20's and 30's. 43 4. 1951 to 1957 Around 1951 heroin use started to become popular among younger people and its use invariably began with the tough, sophisticated and respected boy, typically a street gang leader. The price of hercin began to rise2and as many teenagers earned nothing or little, crime increased in order to support the habit. 5. 1957 to 1961 In 1957 the criminal organization, or syndicate, which had been mainly responsible for heroin distribution, officially withdrew from the market, resulting in the creation of opportunities for independent operators, which led to a relatively free market. 6. 1961 to the Pri:sent In November, 1961, there was a critical shortage of heroin. Although this shortage only lasted a few weeks, dealers learned that inferior heroin at inflated prices found a ready market. Today (1969) an average heroin habit costs the user about $20 per day, as compared to $2 twenty years ago. This fact is responsible for major social disorder in the city today. The remainder of the report may be summarized under the following headings: The Distribution of Heroin in New York City Opium produced in Turkey, India and Iran is processed into heroin in Lebanon, France, and Italy, and is shipped to the East Coast of the United States. It is eventually sold in $5 bags on the street after having passed through at least six levels of distribution. Adulterants are usually added to the original kilo of heroin to double its size, and profits are made by a succession of dealers as the heroin proceeds along the distribution line. The Street Bag of Heroin The amount of heroin in the street bag is very small. A generous estimate of the aggregate weight of a $5 bag is 90 milligrams, including adulterants. Despite the small amount of heroin, users are never discouraged in their efforts to get it, and are always searching for the best quality. Economic Careers of Heroin TJsers Virtually all heroin users in slum neighborhoods regularly commit crime in order to support their heroin use, for it is impossible to support even a modest habit for less than $20 a day. It is a conservative estimate that heroin users in New York City steal $1 million a day in money, goods, and property. The highest percentage of criminal occupation is "flat-footed hustling" - a term used on the street for one who will commit almo... any crime for money. Hustling has the advantage over other crimes in that it usually yields money, which does not have to be sold at a discount, as does stolen property; money can be easily concealed and can be exchanged directly for heroin. The heroin user is an important figure in the economic life of the slums. In order to support his $20 a day habit he has to steal goods and property worth from $50 to $100. Usually he steals outside his neighborhood, not out .of community loyalty but because the opportunities are better in the wealthier neighborhoods, and he brings his merchandise back to the neighborhood for sale at high discounts. He may eventually build up a tolerance to heroin, which raises the amount of heroin, and money, he needs. He may then enter a hospital for detoxification. If he stays for about 3 weeks he can qualify for Department of Welfare assistance. More often than not, however, he will leave the hospital when his tolerance has been significantly lowered, which occurs in about a week. The heroin user is an active, busy person, preoccupied primarily with the economic necessities of maintaining his real income heroin. CONCLUSIONS Heroin use today by the lower class, primarily the minorities, does not provide them a euphoric escape from the psychological and social problems which derive from ghetto life. On the con- trary, it provides a motivation and rationale for the pursuit of a meaningful life, albeit a socially deviant one. Given the social conditions of the slums and their effects on family and individual development, the odds are strongly against the development of a legitimate, non-deviant career that is challenging and rewarding. If anyene can be called passive in the slums it is not the heroin user, but the one who accepts and submits to the conditions. The ultimate solution to the problem of heroin addiction lies in the creation of legitimate opportunities for a meaningful life for those who want it. While waiting for the ultimate solution, there are 4 major recommended approaches to the treatment and rehabilitation 45 of heroin users: (1) drug treatment (opiate substitutes or antagonists), (2) psychotherapy, (3) existentialist oriented group self-help (Synanon prototype), and (4) educational and vocational training and placement. At the Manhattan State Hospital Drug Addiction Unit an intensive educational and vocational program supported by psychological and social treatment methods has been created in an effort to prepare the patient for a legitimate career which has a future and is rewarding and satisfying. 46 I. 15 Hughes, Patrick H. , et. al. The social structure of a heroin copping community. American Journal of Psychiatry, 128(5):551-558, 1971. DRUG Heroin SAMPLE SIZE 127 (125Addicts) SAMPLE TYPE General Community AGE Adults SEX Both Male and Female ETHNICITY Not Specified GEOGRAPHICAL South side Chicago, Illinois AREA METHODOLOGY DATA COLLECTION INSTRUMENT Exploratory/De scriptive Interviews, Observations, Questionnaires DATE(S) CONDUCTED 1969 NO. OF REFERENCES 5 SUMMARY The article is one product of the author's study of heroin addicts in their natural setting in an effort to understand some of the factors contributing to the spread and maintenance of addiction. The focus is on the social, geographical, and demographic characteristics of drug distribution networks and locations ("copping areas"), and the psychosocial funct ioning of the addicts of one particular area. That there are characteristic features shared by all these networks is accounted for by 2 aspects of heroin addiction. First, an addict's drug supply must be continual to prevent withdrawal; thus he or she 47 , must leoace in or close to source of supply. Secondly there must be a complex distribution system to protect individual community members from police pressure and arrest. Four major "copping areas" were selected and one chosen for intensive study because of a very competent field worker in that area. All of the community members were observed and a majority filled out a card distributed to elicit demographic and drug use information. Sixtyfive percent were studied further through home visits after they volunteered for a treatment program. After observing the dealers and consumers who visited the copping area, the researchers delineated 7 different roles and described their interaction. For each role-group the study presents and compares demographic, drug-use and psychosocial data_ Treatment results are described and suggestions are made for other ways in which the dynamics of drug distribution networks could be utilized or manipulated in treatment attempts. METHODOLOGY An ex-addict field worker studied 127 different heroin dealers and consumers who were regular visitors to a "copping area" in South-side Chicago. The site was monitored and a log kept of the status of all members of the community. A member-was defined as a heroin distributor or consumer who frequented the copping area for at least 4 weeks of the study period. Demographic and drug use data were obtained by administering a card in the field. Thirty-four of the total participated in a home-visit study. Each subject was rated on the Adult Psychosocial Functioning Scale, which assesses the subject's level of social, psychological and occupational functioning on 8 subscales. Ratings were arrived at by the concensus of a psychiatrist and 2 psychologists, 1 of whom conducted a clinical interview during the house visit. FINDINGS Roles It was found that the heroin community dealers and users consisted of a more elaborate system of roles thanis generally supposed. Seven primary roles were identified: big dealer, street dealer, part-time dealer, bag follower, tout, hustler, and workers. The function of each role is described. Three tables show the community's: (1) composition by role, (2) age and drug use, and (3) treatability. Demographic and Drug Use Characteristics Men's roles in the distribution structure were not related to age or formal education. Women were most frequently hustlers and bag followers. Touts had been heroin users longer than others, lending support to the addict belief that chronic heroin use and repeated arrests cause some to lose their nerve and avoid dealing and hustling. 48 Standard of Living It was found that for this sample the standard of living Of big dealers was merely average, not luxurious as is the stereotype. Hustling addicts had the lowest living standard; most hustlers did not support themselves by crime, but lived with and were supported by others. Living standards of the other role members fell between these two extremes. Psychosocial Functioning and Treatability Big dealers had high ratings on the Addict Psychosocial Functioning Scale, but, along with street dealers, bag followers and touts, did poorly in treatment. Part-time dealers had poor functioning rates but were most likely of all to enter treatment and theirs was the second highest percentage to remain in treatment after 6 months. Workers rated relatively well on all sub-scales, suggesting that they might be good treatment prospects. The workers were found to be the most successful in the treatment program--44% entered and 81% remained after 6 months. CONCLUSIONS The authors conclude that neighborhood heroin distribution systems are possibly amenable to study and manipulation by treatment programs. Several different operational models are suggested for the strategy of further study and treatment involving the roles within a distribution network. The findings on the Addict Psychosocial Functioning Scale suggest that all occupants of a role in the community share characteristics that may relate to their choice of role and their ability to maintain their roles. The findings suggest that although all heroin addicts share the same physical withdrawal symptoms, they do not share the same psychological 'disturbance. The approach of this study permitted examination of how differences in psychopathology might relate to the functional requirements of various distribution roles. 49 I. 16 Hughes, Patrick H. , and Jaffe, Jerome H. The heroin copping area: A location for epidemiological study and intervention activity. Archives of General Psychiatry, 24(5):394-400, May 1971. DRUG Heroin SAMPLE SIZE 17 SAMPLE TYPE Known Addicts AGE Adults (Mean Age: 35.7) SEX 86% Male; 14% Female ETHNICITY Black GEOGRAPHICAL AREA Chicago, Illinois METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews; Observations DATE(S) CONDUCTED 1969 NO. OF REFERENCES 10 Copping Areas; 63 Addicts SUMMARY The premises on which the researchers based their approach to the epidemiologic study of heroin addiction are presented, and the results obtained from pilot studies of a specific urban area using this approach are described. A field concept for defining the actively addicted population of the community was needed before systematic epidemiologic studies and intervention projects could be effected. Most heroin users in an urban community are already members of a natural group structure, Le., they participate daily in the operations of a neighborhood heroin-distribution system. To explore the possibility of organizing epidemiologic activities around this drug-distribution system, a field team was assigned to the intensive study of one such 50 "copping area." The team observed and gathered information from all addicts who regularly obtained or distributed heroin at this site for a period of 6 months. This experience suggested that it is possible to obtain epidemiologic data on addicts who frequent a copping area, and that it might be possible to study the impact of treatment, law enforcement, and other competing social factors on the prevalence of active heroin use at such sites. METHODOLOGY During the spring of 1969, 17 street copping areas in the city of Chicago were identified and visited. These were optimal locations for epidemiologic field studies concerned with measuring incidence and prevalence trends. The specific approach was to employ 4 methadone-maintained patients as part-time field workers. The competence of one field worker led to an intensive study of one of the 4 areas. Demographic and epidemiologic data were collected on the majority of addicts frequenting this copping area; weekly records were kept of the current addiction status of all regular visitors to the area and key events affecting the copping community. By the end of 6 months, 72 regular addict visitors had been identified. Survey-card data were obtained on 63 members. Only observational data were available for the remaining 9. Twenty-six were involved in an outreach project offering immediate treatment with methadone, which eventually permitted the assessment of the reliability of their surveycard data. A graduate student of the same ethnic background was assigned to "hang out" in the copping area; this together with field visits and interviews with the sample involved in the out-reach project allowed the observations and judgments of the exaddict field worker to be evaluated. FINDINGS Copping areas were usually located in the most economically deprived neighborhoods. The data suggested that the majority of active heroin addicts could be reached by a field-method locating staff at copping areas, and that, despite many unstable features of the situation, the regular visitors to these areas might be viewed as tnembers of a copping community. The copping area concept for locating addicts a community appeared preferable to a residency concept as a basis for epidemiologic study. Although the majority of the copping area members lived in the immediate neighborhood the total residency of this group of addicts was spread over a large area, which suggested the advantages of visiting one functional area in contrast to the use of more traditional survey methods, such as a house-to-house or a snowball sampling approach. The copping community which was intensively studied might be characterized as a group of adult,Black,long-term,heroin addicts. Data were collected on demographic characteristics, incidence trends and prevalence of active heroin addiction. Of the 63 copping area members who completed survey cards, all were Black and 86% were male. Forty-one percent indicated some form of legitimate occupation at 51 the time they completed the card. Twenty-seven percent reported they first used heroin during the period from 1947-1949 and 51% first used heroin from 1947-1954. Fifty-seven percent lived within a one-mile radius of the copping site and 67% within a two-mile radius. Fifty-four percent had first used heroin within one mile of the copping area. The average duration of heroin use was 15.2 years, suggesting little residential mobility. CONCLUSIONS The data collected indicated that a field team located at neighborhoodlevel heroin-distribution sites can define the membership of these local drug-using networks and obtain the survey and observational data necessary to monitor incidence and prevalence trends among addicts frequenting these sites. The extent to which the field approach can reach the total heroin-addict population of an urban area, however, is not settled. The repetitive drug-seeking behavior of the heroin addict combined with the need for a stable drug source argues for an epidemiologic field approach organized around the drug-distribution structure. The use of arrest, court, and hospital statistics as the primary sources of casefinding data has two major limitations: (1) the process used to identify the active narcotic addict (admission to hospital or jail) frequently removes him from the population of active users, and (2) these sources do not tend to be sensitive barometers of current incidence because they are dependent upon the ability of enforcement agencies to arrest, and treatment agencies to admit, new drug users. Such data may not be representative of the total population of narcotic users, but may deal with only the least successful members of the total addict community. The tentative nature of these pilot findings, current field methods, and conceptual framework is pointed out by the authors. The specific terms "copping area and "copping community" may be limited in their usefulness to the large urban areas of the United States and to the current period in history. The concept of copping community may eventually be abandoned because this term implies a degree of group stability that may not be warranted. New legal definitions and enforcement and drug-using patterns may change the specific geographical and structural characteristics of the heroin-distribution system this paper described. The concepts will require extensive modification to be of use in different cultural settings. The framework is also not applicable to the epidemiologic study of marihuana-using and psychedelic-drug-using-populations; its applicability for epidemiologic study of amphe.tamine users is being explored. 52 I. 17 Agar, Michael. Ripping and Running: A Formal Ethnography Heroin Addicts. New York: Seminar Press, 1973. 173 pp. DRUG Heroin SAMPLE SIZE Not Specified SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Male ETHNICITY Cross- Cultural GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Ethnography DATA COLLECTION INSTRUMENT Observations DATE(S) CONDUCTED 1968-197C NO. OF REFERENCES 65 of SUMMARY Information for this study of the urban heroin addict was obtained by using systematic ethnographic methods as well as by informal communication with addicts at the Lexington, Kentucky, Drug Treatment Center. The techniques used to obtain data are described and central events in the addict's day-to-day existence are analyzed. Many examples are given of the addict's terminology and decision-making techniques for obtaining and using heroin with a minimum of risk. A glossary is included to cover lexical items that occur in the book. 53 .J t) METHODOLOGY Participant observation with addicts in the street was not possible mainly because of the illegality of most of the addicts' daily behavior. It was necessary to develop other methods that could be used in an institutional setting. These included: "simulated situation. " A patient, at the request of the (1) author, organized a group of friends for a taping. The usual group varied from 3 - 5 males; all were racially homogeneous. The group was asked to simulate copping and getting off. They selected the home city of at least one of them as the location and outlined the circumstances of being together. The "realness" of the behavior was checked in at least 3 ways. Four tapes were collected using these methods. (2) "f rame - elicitation." This method was used to study decisionmaking, with the focus on the selection among prerequisites and the estimation of an undesired event's occurrence. (3) "constructed hypothetical situations. " A hypothetical situation (a stated set of conditions) was used to further understand decision making. These three methods plus information from informal sources provided the data for the content of this book. FINDINGS The terminology of heroin addicts is difficult to analyze systematically. While subgroup differences and lexical polysemy are found in any culture, perhaps they are more accentuated in the addict culture. Terms were used in senses that addicts indicated were widely known. Three central categories of addict street life were introduced: hustling, copping and getting off. Hustling skills were not found to be restricted to street junkie culture. Hustles provided an alternative source of financial support. Numerous hustles were used by street junkies. The most common were stealing, dealing, pimping, and confidence games. Copping, as defined by the author, referred to a category of events where the desired outcome is the exchange of money or goods for heroin. The individual from whom one cops is called a dealer. A table of samples of heroin packaging from 3 cities was presented. The final event category was labelled getting off (taking-off, shooting-up, fixing). The desired outcome in all of these was the injection of the dissolved heroin into a vein. Addict vocabulary was used to describe the process of injecting the dissolved heroin. 54 This included a description of all the necessary paraphernalia . Physical effects of the drug were given: initially the rush, then the high, the nod, the feeling of being straight (not sick). Almost all of the junkies' waking hours were spent engaged in or preparing for these activities. The author reproduced simulated situations by the group in which copping and getting-off were illustrated. Three categories of experience which the junkie tries to prevent were discussed. They were: the bust (arrest), the burn (where the target of the hustle is another junkie, not a square), and the rip-off (a kind of a hustle). In the simulated situations these experiences were played out. Some selected decision-making processes related to the event structure were isolated and analyzed. Decisions were: selecting a dealer, selecting a place, selecting a strategy to obtain works, the bust, the burn, and the rip-off. The verbal interaction suggested 2 areas - prerequisites and negative events - as important areas for further understanding. CONCLUSIONS The existence of an addict culture was found to have implications for treatment programs. Erroneous assumptions regarding the addicts' social environment allow the psychiatrist to diagnose the addict as psychologically maladapted. Often the distrust and fearfulness that a psychiatrist may count as pathological responses to a benign environment are more realistically considered adaptive responses to real and accurately perceived danger. The study of events, using approaches developed in other lexical domains, is a fruitful approach to larger behavioral units. The ethnographer can work to learn the knowledge necessary to understand the communicated messages in that community. The description of that knowledge is a description of a culture. The cognitive approach to ethnography can be useful in the study of urban cultures. 55 I. 18 Proctor, Mac. The habit. The International Journal of the Addictions, 6(1):5-18, March, 1971. DRUG Heroin SAMPLE SIZE Not Specified SAMPLE TYPE Addicts at Exodus House AGE Not Specified SEX ETHNICITY Not Specified Not Specified GEOGRAPHICAL AREA New York City METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews DATEIS) CONDUCTED Not Specified NO. OF REFERENCES 3 SUMMARY The article attempted to explain the nature of the heroin habit through excerpts from interviews with a random sample of addicts in New York City's Exodus Douse. It also dealt with the nature of the culture of addiction. The persons interviewed described the habit in their own language, and a glossary of addicts' language was included in the article. Further research, using interviews as a clinical tool, was suggested. The use of methadone was seen as interfering with the addicts' need to work out their problems. 56 METHODOLOGY The author, in an attempt to explain "the habit" which all heroin addicts have in common, used a tape recorder to record interviews with addicts from Exodus House. This agency was originally the Narcotics Committee of the East Harlem Protestant Parish, in New York. The interviews were presented in their entirety. The interviews were conducted on a question and answer basis. All interviews in the article, which represent only a sample of many, followed much the same pattern. FINDINGS After he leaves prison, the individual addict returns to the habit and culture that he knows. The Great Earth-mother of the addict culture reminds the addict of a sense of belonging to something. He has never gotten this feeling from square society. Most of the addicts interviewed had their first experience with drugs around 14 years of age. Most of them were from a ghetto. The drug gave them a positive self-image, something they could not get from the ghetto. Addict culture also provided a place where the person could belong to a chemical elite. Wealth, in the addict culture, was found to be equated with the amount of white powder the person could purchase or possess. People were judged on ability, and amount of risk taken, not on credentials or advantages of birth. The drug culture was seen as a society in which the projection of an image was most important. The addict culture was depicted as providing a scale of stratification which was unique because individuals did not move up and remain stationary at the various levels. Depending upon availability of heroin, an individual could move rapidly up or down the scale of stratification. The addict internalized the junkie image. The addict culture provided a place where the adolescent could work out frustrations and problems which he might not be allowed to work out in normal society. Everyone interviewed saw the habit as female. All, except 3, stated that the habit was still in their heads, and that the habit had a color. Only a few could tell the interviewer what the habit itself looked like, 57 CONCLUSIONS As a result of these interviews the author felt that the nature of the habit and the desire to take heroin might be further researched, especially using interviews as a clinical tool. He also saw the use of methadone as detrimental to solving addicts' problems. The focus should not be on the individual's current inability to remain free of drugs. Methadone serves to perpetuate that inability and to cause further enslavement to drugs. 58 II. NATURAL HISTORY OF ADDICTION E) 59 11.01 Powell, Douglas H. A pilot study of occasional heroin users. Archives of General Psychiatry, 28: 586-594, April 1973. DRUG Opiates SAMPLE SIZE 12 SAMPLE TYPE Volunteer AGE 12 Adults SEX 8 Male, 4 Female ETHNICITY Not Specified GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT Boston, Massachusetts Case Studies Interviews, Psychological Tests DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 8 SUMMARY A pilot study was carried out to learn more about occasional heroin users. Subjects were 12 largely middle-class young adults from intact families with no history of addiction. Extensive interviewing and testing was carried out. Test data showed them to be of above average intelligence and highly anxious. They scored below the mean of college students on well-being, socialization, maturity, responsibility, and achievement via conformance, and were above average on achievement via independence and flexibility. Interview data suggested reasons for occasional heroin use were self-medication, facilitation of emotional expression, and to enhance the sense 60 of competence. Other data indicated many individuals seem to be able to maintain intermittent use without becoming addicted. Two factors that may militate against addiction are their environment and friends. METHODOLOGY A pilot study of 12 occasional heroin users (OHU's) was carried out, drawing subjects from the Boston, Massachusetts area. An OHU (also called chipper) was defined as an individual who (1) had used heroin occasionally for three or more years, and (2) had never had a habit or sought treatment for heroin dependence. Since neither medical services, community drop-in centers, nor researchers were able to refer OHU's who met the criteria, the 12 subjects were obtained through responses to advertisements in 2 Boston papers. Subjects were not paid; most participated because of the opportunity to discuss the results with a psychologist. Each subject was given the following: Structured, open-ended oral interview--focused on drug history, setting for heroin use, the place of drugs in the subjects' past and present life, planning for the future, relationships with parents and others, emotional problems, attitudes and interests, academic and work experiences Written interview Drug-history form Harvard Speed Alphas--general ability verbal and mathematical test School and College Ability Tests (SCAT)--multiple choice test which measures school learning California Psychological Inventorypersonality inventory designed for normal individuals State-Trait Anxiety Indicatorself-report of anxiety Visual Impressions Test--written projective test Rorschach Inkblot Testprojective test FINDINGS Response to procedures - -The subjects were willing to come in immediately, with most interviews scheduled within 24-48 hours of 61 s. their initial phone call. All enjoyed responding orally; most disliked the written segment, with 6 asking if the written tests could be taken orally. Seven subjects returned to discuss the results. Background notes--Most subjects came from upper middle-class intact families in suburban or small urban communities. Although of the families, the no significant abnormalities were found in any during their early lives, majority of the subjects suffered problems irregular school performance, a including conflicts with parents, Half had received psychohistory of poor academic achievement. therapy but none felt helped by the process. All had left home by the time they graduated from high school. The OHU's life-styles were easy-going. They were less intense than others in their age range about achievement of specific goals. There was a lack of long-range planning. Some planned only hours ahead. Patterns of occasional heroin use--On the average the subjects used heroin for one period of time every four weeks, but the use patterns ranged from once a week to once every three months. Only one subject had a predictable pattern of occasional heroin use. Use was more a function of chance than planning; none sought heroin because of an inner need. There was no association between mood or psychological condition and use of heroin. Reasons for using heroin occasionally - -A wide variety of reasons was given for using heroin. The occasional use of heroin produced the following feelings: feelings of strength and competency, masculinity a sense of daring expression of anger and depression ability to express bottled-up feelings, less shy relief of boredom, different experience, getting high Context of occasional heroin use--Nine of the 12 subjects used heroin with one or more friends; three used it alone. Few had their own works. The ritual of use was important to all. Some liked the excitement of doing something illegal. All disliked the drug scene and abhorred heroin addicts. They did not view themselves as being part of the drug scene. On the possibility of becoming addicted - -With two (or possibly three) exceptions, the subjects did not see any serious possibility free of heroin when of addiction. The subjects were relatively involved in something that interested them. Most felt that occasional heroin use was largely determined by friends and the events deterrent was the image of of life. All said that a major addiction using heroin was to change friends the junkie and that the way to stop and environments. 62 4.4 Clinical testing results--A table presents the scores of the objective tests in percentiles for each subject. The results are summarized here. SCAT scores: when there was a significant difference between verbal and quantitative aptitude, the difference was always in the direction of verbal skills. Harvard Speed Alphas: converted to the Wechsler Adult Intelligence Scale,. the mean score was 123; subjects performed better under the demanding time stress of the Speed Alphas than the SCAT. CPI scores: subjects scored significantly below the mean of college students on well-being, socialization, maturity, responsibility and achievement via conformance; they scored above average on self-acceptance, achievement via independence, and flexibility. STAI scores: for both state and trait anxiety, subjects scored higher than mean college population; only 2 scored below 50th percentile in-current anxiety state; 2/3 scored beyond 75th percentile in trait anxiety. Projective Tests: suppo"rted the general picture of high anxiety. CONCLUSIONS The author makes three general observations about occasional heroin use and presents four general impressions about OHU's, emphasizing that this was a pilot study, there was no control group and the data from 12 subjects could not be generalized. Occasional Heroin Use (1) It has been easy for adolescents in the Northeast to obtain heroin. (2) It seems possible for young people from a variety of backgrounds, with a variety of educational abilities to use heroin without becoming addicted. Individuals in the study seemed not to become addicted because of their friends (mostly straight), their environment (not part of the drug scene), and their own self-monitoring of use. (3) Occasional Heroin Users (1) The OHU's in the sample were not very different from other "street people" in their age group, but were more anxious, less responsible, less well socialized, more rebellious, and more concerned with their own personal pleasure than college people in their age group. 63 (2) The OHU's lived at the time of the study in a loose community structure, were generally involved with one member of the opposite sex, and used heroin in groups. (3) The OHU's were uncommitted, unconcerned about the future and had very short time-planning frames. (4) No generalizations could be made about why heroin was used; use was situational for some, accidental for some, personal for some. In general, the study showed that OHU's do exist. The author feels they should be included in future studies, that psychological testing is probably not necessary. He points out that future studies of OHU's may wish to consider the fact that older people or people in stable careers were not found in this study. 64 11.02 Brown, Barry S.; Gauvey, Susan K.; Meyers, Mary lin B.; and Stark, Steven D. In their own words: Addicts' reasons for initiating and withdrawing from heroin The International Journal of the Addictions, 6(4): 635-645, December, 1971. DRUG Heroin SAMPLE SIZE 218 SAMPLE TYPE AGE Volunteer and Treatment (inpatient) 77 Adolescents and 141 Adults sot 182 Male and 36 Female ETHNICITY Cross Cultural GEOGRAPHICAL AREA District of Columbia METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT DATES) CONDUCTED NO. OF REFERENCES Interviews and Questionnaires Not Specified 5 SUMMARY The purpose of this study was to : (1) learn the addicts' reasons for initial and continued heroin use; (2) compare the thinking of adult and juvenile addicts with a view toward exploring the changing role of heroin in the lives of its users; and (3) explore the extent to which the addict has placed himself outside the law before his first use of heroin. Other investigators have contended that most addicts do not become involved in criminal activity until after becoming addicted to heroin. This study proposed therefore, to learn not only about initial use 65 and withdrawal from heroin, but to learn also about the ages at which the street-visible addicts under study first began using heroin and first became involved in criminal activity. METHODOLOGY Accidental samples were drawn from 3 treatment facilities of the Narcotics Treatment Administration of the District of Columbia. Three sample groups were obtained: One-hundred five male addict-clients, age 21 or older; average 1. age 28.6 years; average education 10.3 years; 89% Black; 33% married; 44% single; the remainder formerly married. Ten addicts came to the treatment program through the District of Columbia criminal justice system; all of the remainder were voluntary clients. Thirty-six female adult-clients, age 21 or older; average age 2. 27.4; average education 10.4 years; 95% Black., 22% married; 44% single; the remainder formerly married; all were voluntary clients. 3. Seventy-seven male addict-clients, age 18 or younger; average age 17.2 years; average education 9.58 years; 96% Black; 4% married; 96% single. Seven addicts came to the treatment program through the juvenile court system all of the remainder were voluntary clients. Subjects were given a structured questionnaire, making use of the critical-incident technique. The subjects were asked to describe, through this series of questions, the incidents relating to the situation in which heroin was first used, then withdrawn from, then resumed after voluntary withdrawal,and finally the decision to withdraw voluntarily at the time of the questionnaire. The addict-clients were also asked to describe their commission of the first act that they knew to be illegal, their age at the time of commission, and their first arrest. This data was compared to determine the length of time between initial use and first arrest. FINDINGS First Heroin Use Comparison was made between adult male, adult female, and juvenile male addicts in terms of their descriptions of the critical ircidents involved in their first heroin use. Responses were categorized into 6 groups: curiosity, influence of friends, influence of relatives, relief of personal disturbance, seeking a high, and other. 66 (.1 When the categories "influence of friends" and "influence of relatives" were combined into a single "influence of others" category to permit statistical analysis, the three groups were found to differ significantly in terms of the reasons given for the first use of heroin. As compared with juveniles, adult males more often cited curiosity as a major reason for the first use of heroin. Juveniles placed disproportionately large emphasis on the influence of friends. For all groups, the influence of others, and curiosity about the effects of heroin, were the major reasons given for the first use of heroin. Initial Withdrawal From Heroin The two male groups resembled each other closely in their responses to the question about initial effort at withdrawal. Both groups placed greatest stress on their intentions to change the overall patterns of their lives. Female clients gave drug related physical problems as the reason for their decisions to make an effort to withdraw from heroin. For all groups, neither the threat of punishment for illegal activities, nor the influence of friends, were important factors in the decision to attempt withdrawal. Failure of First Withdrawal Effort There was general agreement among addict-clients that the major reason for the failure of their first efforts at withdrawal was that they had given up drugs only physically, and that a psychological need remained. Among juveniles, the influence of friends was the next most cited reason for returning to heroin. For females, the relief of personal problems was the second most frequently cited reason. For adult males, the easy availability of heroin and the use of heroin to relieve personal problems were of consequence in resuming heroin use. Current Withdrawal From Heroin For all groups of addicts, a major reason cited for attempting withdrawal at the present time of the questionnaire was once again the addicts' concern with changing their overall functioning and life patterns. For women, family problems came to be of particular significance in their decisions to attempt withdrawal. For all, the threat of punishment and the influence of friends were of relatively small importance to the decision to attempt withdrawal. 67 Initial Illegal Act A third of the female addicts who became involved in criminal acts cited the effort to obtaiin drugs as the reason for their first illegal act. By comparison 18% of the men and 14% of the juveniles first committed criminal acts in an effort to obtain drugs. Seventy-four percent of the male addicts and 78% of the juvenile addicts committed illegal acts before their first use of heroin. However, only 40% of the female addicts committed illegal acts prior to the first use of heroin. CONCLUSIONS This study lends support to findings reported elsewhere suggesting that the addict, particularly the male, is drawn from a culture or subculture already engaged in illegal activity. This means that treatment programs must be organized to deal with the problems of the addict-criminal. Any treatment program intended to serve effectively the inner-city addict population must provide an alternative not only to the addict's life style, but to the criminal life style as well. The community, as seen by the addict, acts to produce and maintain addiction. It now becomes necessary to organize treatment programs that place themselves more significantly between the addict and his community. Possibilities in this vein include: heroin replacement programs (e.g., methadone maintenance in which the treatment source becomes the "connection" and is thereby better able to make real demands on the addicts' functioning and behavior); regular counseling in the addict's community; isolation from the community to provide a viable living alternative, such as Synanon. 68 II. 03 Waldorf, Dan. Life without heroin: Some social adjustments during long-term periods of voluntary abstention. Social Problems, 18(2): 228-242, Fall, 1970. DRUG Heroin SAMPLE SIZE 422 SAMPLE TYPE Treatment (inpatient) AGE SEX ETHNICITY Adults Male 45% Black. 30% Puerto Rican. 25% White GEOGRAPHICAL AREA New York METHODOLOGY Exploratory/Descriptive DATA COLLECTION Interview nterviews DATEIS) CONDUCTED August and September 1968 NO. OF REFERENCES 11 SUMMARY This report attempts a preliminary and exploratory description of certain kinds of adjustments of heroin users during a period of voluntary abstention from the drug. A survey of 422 male addicts in 6 treatment facilities showed that many addicts do have long periods of voluntary abstention outside of jails and treatment programs, and that the majority during these abstentions make reasonable adjustments to the working world and the square life. Long-term abstention is associated with both age and length of heroin use. Education, 69 family compatability, and criminality prior to heroin use are associated with social adjustments. The better the social adjustment, the longer the period of voluntary abstention. The ability to deal with one's family and society before the use of heroin assists a person to make an adjustment after he is off heroin. In order to document some of the processes of abstention, the question, "What was the longest period you have abstained voluntarily since you started using heroin?" was asked of all persons from stratified random samples. This report focuses on this single, longest period of abstention. METHODOLOGY Addicts themselves documented the street life of the heroin addict. Four-hundred twenty-two male heroin users were interviewed in 6 different treatment facilities in New York State during August and September, 1968. Comparison of findings with other studies were made, such as the Bellevue Hospital study, 193G, and the Lexington Hospital study, of voluntary patients, 1936-1937. The primary focus of the investigation of abstinence was self-reported behavior in 4 areaswork, substitution of other drugs and alcohol, family relationships and association with addicts, and general adjustment. Questions in these areas were asked of the 163 men who reported that they had at one time abstained from heroin for 3 months or longer. FINDINGS The use of heroin by most addicts was not a steady, uninterrupted process, but was a periodic or episodic one. Use was interrupted by periodic detoxifications, involuntary and voluntary periods of abstention in and out of jails and treatment facilities. One 42-year old man who had been addicted for 25 years said that he had lost count of the number of times he had "kicked his habit and been off heroin for a week or more," but it was at least 100 times. In addition he had served 10 years (8 different times) in jails, during which he was usually abstinent. He had been voluntarily off heroin for one period of 3 years. Of the 422 men interviewed, 40% abstained 3 months or longer, 21% 8 months or longer; 16%, 2 years or longer; 8%, 3 years or longer; 3%, 5 years or longer. Compared with the results of the Lexington and Bellevue studies, the abstention rate was greater than at Lexington Hospital and less than at Bellevue Hospital. The Lexington and 70 c )1 Bellevue population were mostly white Caucasians. In this study there was a high percentage of minority groups: 45% were Black, 30% were Puerto Rican. This study found that the length of heroin use is a stronger predictor of long-term voluntary abstention than is age. Drug Substitutions Among addicts who voluntarily abstained from heroin for 3 months or more, roughly 1/2 used some substitute. Alcohol was used slightly more than other drugs. Puerto Ricans and Whites reported they "drank heavily" and "used other drugs to excess" more than Blacks did. Length of heroin use was also associated with the extent of drug substitution. Persons using heroin for more than 5 years substituted more than short-term users. Family Life and Peer Associations Nearly 62% of the sample had made positive adjustments. Positive social adjustment was strongly associated with length of heroin use. Educational level was found not to be related to a person's overall adjustment score. General compatibility before heroin use seemed to be critical to adjustment. Persons with high adjustment scores had longer periods of abstention than those with low scores. Reasons for Voluntary Abstention It appeared that few persons ever gave up use of heroin of their own volition. They usually came into treatment because of, the pressures of the courts, parole officers, social workers, and family members. CONCLUSIONS It may be that persons "burn out" of heroin use and addiction after an extended period of use. The addict may reach a saturation level, a "rockbottom" state when an all-out effort is made to stay off of opiates. The cause and effect relationships in abstention and overall adjustment are not clear. Adjustment is aided by positive response from others. A principal resource for long abstention is education. Persons who dropped out of school were less likely to sustain a long abstention. The principal resource for overall adjustment is Compatibility with one's family before heroin use. Those 71 who did not commit criminal acts before their initiation to heroin made better adjustments than those who had committed criminal acts. Implications for Treatment of Addiction Older persons, and those with long histories of drug use, are more likely to sustain long abstentions. The young, and those with short drug use histories, are still caught up in the positive, reinforcing aspects of heroin use. Special programs should be devised to treat both groups in effective ways. These programs should not preclude the possibility of maintenance programs. Most persons, when they abstain, make reasonable adjustments. This suggests that relapse to heroin is a result of some emergency or crisis situation. Programs should be prepared to meet these emergencies. Any treatment or rehabilitation program should recognize that there are different types of addicts that need to be treated in different ways. Age, length of heroin use, psycho-pharmacological functions of drug use, and criminality should be given consideration. Neither of the 2 largest programs in the United States recognizes these distinctions. More often than not, the availability of bed space becomes the sole criterion for placement of a resident. This failure to recognize types of addicts reduces the effectiveness of the treatment programs. 72 U. 04 Ray, Marsh B. The cycle of abstinence and relapse among heroin addicts. Social Problems, 9:132-140, 1961. (11 references). SUMMARY This paper reported on the cycle of abstinence and relapse among addicts. Attention was focused on the way addicts or abstainers order and make meaningful the objects of their experience, including themselves as objects, during the critical periods of cure and of relapse, and the related sense of iidentity or of social isolation during interaction with significant others. It was especially concerned with describing and analyzing the characteristic ways the addict or abstainer defines the social situations encountered during these periods and responds to the status dilemmas experienced in them. METHOD Case histories were collected in repeated depth interviews with 17 addicts and abstainers over a two year period. During this time several of the active addicts became abstainers and vice-versa. Additional Material was gathered while the author worked for a year as a social worker in a rehabilitation program for addicts. The author presents his interpretation of the reasons for the high rate of recidivism among heroin addicts and their continual and repeated attempts to seek cures. THEORY The social world of addiction contains a loose system of organizational and cultural elements, including a special language or argot, certain artifacts, a commodity market and pricing system, a system of stratification, and ethical codes. The addict's commitment In addition to these to these values gives a status and identity. direct links to the world of addiction, becoming an addict means that one assumes a number of secondary status characteristics in accordance with the definitions society has of this activity. These various secondary social definitions are the medium of exchange in social transactions with the addict and non-addict world in which the addict identifies as an object and judges himself in relation to addict and non-addict values. 73 An episode of cure begins in the private thoughts of the addict rather than in his overt behavior. These deliberations develop as a result of experience in interactions with important others that cause the addict to experience social stress, to develop some feeling of alienation from or dissatisfaction with his present identity. In these situations the addict engages in private self-debate in which he juxtaposes the values and social relationships which have become immediate and concrete through his addiction, with those that are sometimes only half remembered or only imperfectly perceived. Once the addict has successfully completed withdrawal he enters the period which might best be characterized as a "running struggle" with his problems of social identity. He could not have taken such a drastic step had he not developed some series of expectations concerning the nature of his future relationships with social others. His anticipations concerning these situations may or may not be realistic; what matters is that he has them and that the imagery he holds regarding himself and his potentialities is a strong motivating force in his continued abstinence. Above all, he appears to desire ratification by significant others of his newly developing identity, and in his interactions during an episode of abstinence he expects to secure it. The tendency toward relapse develops out of the meanings of the abstainer's experience in social situations when he develops an image of himself as socially different from non-addicts, and relapse occurs when he redefines himself as an addict. When his social expectations and the expectations of others with whom he interacts are not met, social stress develops and he is required to re-examine the meaningfulness of his experience in a non-addict society and in so doing question his identity as an abstainer. Re-addiction most frequently occurs during the period immediately following the physical withdrawal of the drug. It is at this point, when the old values and old meanings he experienced as an addict are still immediate and the new ordering of his experience without narcotics is not well established, that the ex-addict seems most vulnerable to relapse. The ex-addict's interaction with addict groups is often a source of experiences which cause him to question the value to him of an abstainer identity; experiences with nonaddict groups also play a vital role, when he finds social difficulties in the conduct of such groups toward him, based on the stereotypic thinking of non-addict society concerning addiction. The ex-addict's re-entrance into the social world of addiction requires a recommitment to the norms of addiction and limits the degree to which he may relate to non-addict groups in terms of the latter's values and standards. It demands participation in the 74 old ways of organizing conduct and experience, and, as a consequence, the readoption of the secondary status characteristics of addiction. Every relapse has within it the germ of another cure. The relapsed addict carries back with him an image of himself as one who has done the impossible. He recalls his identification of himself as an abstainer, no matter how tentatively or imperfectly this may have been accomplished. Reflections on this provide the relapsed addict with a rich body of material for self-recrimination and he again evaluates his own conduct in terms of what he believes are the larger society's attitudes toward addicts and addiction. It is then that he may again speculate about his own potential for meaningful experiences and relationships in a non-addict world and thus set into motion a new atter apt at cure. II. 05 O'Donnell, John A. The relapse rate in narcotic addiction: A critique of follow-up studies. In: Wilner, Daniel M. and Kassebaum, Gene G., eds. Narcotics. New York: McGrawHill, 1965. pp. 226-246. (20 references). SUMMARY This paper considered the 11 follow-up studies of American narcotic addicts which, as far as the authors could determine, were all the studies which had been reported. Its purpose was to summarize what has been learned from these studies, with some attention given to the limitations of the studies and the generalizations which may be inferred from them, and to suggest improvements in the design of future followup studies. Factors relating to relapse and abstinence were discussed with emphasis on suggestions for a different method of looking at the relapse-abstinence dichotomy. The author called for new definitions of relapse to render further studies more useful. METHODOLOGY Studies considered in this paper were, by author: Senate, Pescor, Knight, Kuznesof, Gerard, Jones, Trussell, Diskind, Hunt, Lieberman, and Duvall. The author constructed a table of follow-up studies specifying sample size, source of sample, follow-up period, and findings in terms of relapse, irregular use, death and abstinence. FINDINGS Possible predictors of abstinence suggested by the 11 studies, and considered by the author to be worth investigation in the future, were: (1) sex--no difference in relapse rate by sex was reported by either Hunt or Duvall; (2) age--studies suggested that age may play some part in explaining differences in relapse rate, (3) voluntary status- Hunt found that, among patients 30 years or older, nonvoluntary patients had lower relapse rates than voluntary patients, (4) race- Hunt reported that, among nonvoluntary patients under 30, whites had a lower relapse rate than Negroes, (5) length of hospitalization -findings varied. On the basis of his findings, Pescor recommended a comparatively short period of hospitalization, from 2 to 5 months, and (6) social class--the lowest relapse rates were reported,by Jones, for 76 a group of physicians, and by Knight, for an upper-middle class group which included many professionals. The author found that 6 of the studies were done in New York City, which suggested to him that perhaps relapse is more probable in New York than elsewhere. Not only was there variation among the studies in definitions of relapse and abstinence, but few formal definitions were given. The author stated that addiction can be seen as a long and complex process, often involving alternating periods of use and abstinence. It was suggested that the ratio of drug-free months to the months during which the subject could have been using drugs would be the meaningful variable in future follow-up studies. Findings indicated that more attention should be paid to the problem of what evidence is sufficient to classify subjects as abstinent or relapsed. The need for a useful tool, such as Nal line testing, as an objective index of use at the time contact is made with the subject, was noted. It was also suggested that repeated contacts with subjects would greatly increase the validity of findings. The author F#res sed the importance of reducing the number in the "unknown" category to the absolute minimum. The hardest to locate may, in fact, be a large part of the abstinent group. CONCLUSIONS The author concluded that none of the 11 studies proved that most addicts relapse to drugs after a period of forced abstinence or treatment. These studies indicated differences in relapse for different subgroups of addicts. The author felt instead that far more knowledge of relapse, and the factors associated with it, is needed than has been obtained from studies done to date. 77 II. 06 . Schasre, Robert. Cessation patterns among neophyte heroin-users. International Journal of the Addictions, 1(2):23-32, June 1966. DRUG Heroin SAMPLE SIZE 80 SAMPLE TYPE Addicts; Ex-Addicts AGE Not Specified SEX Male ETHNICITY Mexican-American GEOGRAPHICAL AREA Los Angeles, California METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews DATEIS) CONDUCTED Not Specified NO, OF REFERENCES 4 . SUMMARY made to gain information and insight reA preliminary effort was why some individuals garding social factors which might explain involvement, while others cease using heroin after an early juvenile adult less throughout their seem to continue heroin usage more or regarding persons with lives. A group of heroin addicts was queried time, but who no longer whom they had used heroin for a period of identified and subsequently engaged in such usage. The individuals so for periods extendinterviewed related that they had not used heroinResearch tracing the ing from 8 to 16 years prior to the interviews. 78 careers of persistent addicts has established early patterns of use and suggested a wide range of explanations for initial use and for continued recourse to narcotic drugs to alleviate real or imagined personal probi. -ns. This paper attempted to establish that such factors also exist for individuals who do not continue to use drugs to the point of exhibiting the typical addict syndrome. In addition, it presented data concerning the user who abandons his habit relatively early, providing insight into personal and social factors of importance in negating narcotics addiction. METHODOLOGY Addicts and ex-users were informally interviewed together for 2 or 3 sessions each lasting from 3 to 6 hours. Forty of these dual serial interviews were held over a period of 2 years. The major problem was determining the extent to which social factors might have had significant bearing on the differential experience of the participating addicts versus the participating ex-users. The interview procedure involved 3 sequential objectives: (1) to note significant factors (incidents or situations) from the conversation which might explain the divergent careers of the addict and the ex-user; (2) to seek either consensus or disagreement from the 2 interviewees on the actual occurrence or existence of such factors; and (3) to test the factors upon which consensus was reached regarding occurrence, to determine their actual significance in the influer,cing of subsequent divergent careers. All of the interviewees were of Mexican-American origin. They had all experienced their initial involvement with narcotics in east Los Angeles, a predominantly Mexican-American neighborhood. They defined their heroin usage as resulting in a "pleasant experience. " The age at initial involvement ranged from 13 through 17. Slightly more than 50% of the cases were 15 or 16 years of age when first introduced to heroin. FINDINGS The assumption of a clear-cut decision on the part of the ex-user to stop using heroin was found to be not always warranted. In 22 cases the decision was ex post facto to the incidents that initially led to cessation. The remaining 18 cases did involve decision-making which led directly to cessation. The decision-group and the nodecision group data were analyzed separately, as well as some relevant aspects of the addict interviewees' experience. Of the 18 ex-users in the decision-group, 9 cited some sort of direct social influence as the factor in their decision to stop (negative experiences by male peers, strong pressure by girl friends, or social stigma). The remaining 9 cases identified the experience of physical addiction as the significant factor leading to their decision to quit, and also cited a factor reducible to social influence: fear and surprise at the realization that they were "hooked" because they only had "little habits, " leading to a resolve to "quit before it gets out of control." Among the 22 ex-users in the no-decision group, 9 of the cessation factors recounted were geographical in nature and 13 involved the 79 suppliers who had been furnishing the narcotics. Geographical separation of the individual from the neighborhood in which narcotics involvement was begun or an interruption in source; of supply appeared significant in the cessation of heroin usage. CONCLUSIONS In a large percentage of cases the reasons given by both the addict and the former user for the termination of heroin usage were very often non-volitional in nature, representing the intervention of social circumstances which the individual saw as beyond his ability to control or overcome. This seems to underscore strongly the fact that continuance of usage, following early experience with heroin, depends heavily on social opportunity. An important supplementary issue remains: to determine with more precision which individuals will abandon heroin usage in the face of adverse social conditions and which ones will persist and surmount by a the intervening barriers. That the barriers are not overcome considerable number of individuals appears to represent a finding not adequately stressed. The interviews also demonstrated that symptoms of physical withdrawal will not inevitably lead to a search for a narcotic supply. The authors noted some striking personality variations between the addicts and ex-users, but felt these variations could have been the product of different life experiences since the time of initial narcotic involvement. If their personality patterns were more similar in the past, or the men by virtue of their joint initial narcotics usage have been defined as "addict-prone," then the findings suggest rather strongly that social circumstances can and do play an important role in determining whether or not such "addict-prone" neophyte narcotics users will persist in usage into their adult lives. 80 II. 07 Winick, Charles. The 35 to 40 age dropoff. In: Proceedings of the White House Conference on Narcotic and Drug Abuse. Washington, D. C.: U. S. Government Printing Office, 1962. pp. 153-160. DRUG Opiates SAMPLE SIZE 16,725 SAMPLE TYPE Not Specified AGE Adults (18-76) SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA Not Specified METHODOLOGY Longitudinal DA7,1 COLLECTION INSTRUMENT Statistics DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 0 SUMMARY The author studied the 35 to 40 age dropoff in drug addicts, or the maturing out hypothesis of cessation of drug use. Maturing out is the name given to the process by which there is decreasing use of drugs as the user grows older, with ultimate cessation of drug use. METHODOLOGY The author analyzed the data from the Federal Bureau of Narcotics which has maintained since 1953 a master file of all addicts in the U.S. , counting as addicts only regular users of opium derivatives, like heroin and synthetic opiates, The Bureau made a special 81 tabulation of all the addicts in its files who had originally been reported during the calendar year 1955, but who had not been reported again as of December 31, 1959. FINDINGS A statistical survey of the number of addicts put in the inactive file (inactivity defined as not being reported as a drug user for 5 years) at each age, of a total of 7, 234 who became inactive, showed clearly that there was a major concentration of addicts becoming inactive during their thirties. A large concentration of addicts became inactive in the first decade after their addiction began. There was also a considerable number of addicts becoming inactive after varying periods of years, ranging to over a half century. Additional confirmation of the maturing out hypothesis was provided by the Bureau's tabulation of all the addicts originally reported to it during 1953 and 1954. Of the 16, 725 addicts originally reported during this period, there were 10,804 addicts, or 65%, who were not reported again between 1953-54 and 1959. The average length of addiction was 8.6 years. CONCLUSIONS Maturing out appears to be a homeostatic-like process that permits the former user to function with less and less reliance on drugs. Whether this is a psychological process, or a physiological one, or a function of addiction itself, or some combination of these, is not known. The process of maturing out, whether-it is a reflection of the addict's life cycle or a reflection of the-number of years that the addiction process itself continues, is not universal and inevitable but rather a tendency or trend that appears to help the explanation and understanding of the behavior of a substantial number, and even perhaps a majority of adults. It seems possible to speculate that addiction may be a self-limiting process for perhaps two-thirds of adults. The difference between those who mature out of addiction and those who do not may mirror many differences; geographic and other external factors may affect the extent to which a particular group either matures out of or reverts to narcotics use. Older patients may be more likely than younger patients to respond to therapeutic interventions, which may have implications in terms of the thrust of community resources to combat addiction. Additional research is being undertaken by the author to determine if the law of mass action applies to the data. Tentative conclusions suggest that this law applies, suggesting that the underlying phenomena is regular and can be expressed fairly precisely, perhaps in mathematical terms. 82 II. 08 Winick, Charles. The life cycle of the narcotic addict and of addiction. Bulletin on Narcotics, 16(1):1-11, 1964. DRUG Opiate s SAMPLE SIZE 7,234 Addicts recorded by the Federal Bureau of Narcotics SAMPLE TYPE AGE 18-71 SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA National Statistics METHODOLOGY Statistical Study DATA COLLECTION INSTRUMENT N/A DATE(S) CONDUCTED 1960 NO. OF REFERENCES 12 SUMMARY This study reviewed the contributions that have been made towards an understanding of narcotic addiction and of the regularities that may underlie the phenomenon. Age is one of the very few continuous variables that it is possible to examine in the study of narcotic addiction. Interest in the phenomena of the length of addiction and age of the addict when he ceases to use narcotic drugs led to a review of data on former narcotic users obtained from the Federal Bureau of Narcotics, which made a cross-tabulation of the age and number of years of addiction of those persons who had not used narcotics for 5 years, as of 31 December 1960. This data is analyzed statistically in this paper in a series of tables, and the results interpreted in the light of the statistical findings. 83 METHODOLOGY The Federal Bureau of Narcotics prepared a cross-tabulation of the number of years of addiction of each age group in the population of 7,234 former drug users that had become inactive as of 1960. For this study, computations were made to obtain the number of persons beginning drug use at each age, the mean number of years of duration of addiction at each age of onset, the percentage of addicts at each age of onset who had used narcotics for 16 or more years, the mean number of years of drug use, the average length of addiction for those addicted 15 or less years. Correlation and regression analyses were carried out. FINDINGS Figures from the Bureau of Narcotics clearly suggest that there are fewer drug addicts who cease drug use in the later years of life, but a considerable concentration of persons ceasing drug use in the years of prime adulthood. This phenomenon has been identified as maturing out of narcotic addiction. The majority of the dropouts from narcotics use clearly are clustered in the years of mid-adulthood and have an addiction history of less than a decade. There is a heavy concentration of commencement of drug use in the years of late ad.)lescence and early adulthood, probably as one way of coping with the problems and decisions of these stressful years. The mean number of years that the persons in the sample used drugs suggests that the younger a person starts on narcotics, the longer the period of drug use will last. The length of addiction will be between one-eighth and one-ninth of a year less for each year onset of addiction is delayed. There are essentially three different groups in the population of former drug users: the group starting drug use at ages up to 30, the group starting from 38 to 60, and an intermediate group starting between 30 and 38. A regression equation was established for each of the two major age groups. The equation for the 19-30 group allows prediction of length of drug use of the average person starting drug use at any age in this range. The regression equation for the age group from 38-60 enables the prediction of how long a person commencing drug use within this age group will continue. Two regression lines which are almost exactly parallel and with essentially the same slope suggest the operation of some profound underlying principle. The 32-36 age group was considered separately because the data departed from both of the regression formulae. Though this group did not seem to cease drug use with the predictable regularity of the other ages, it appeared to be similar to them if a symmetrically varying proportion of each of the two established age groups at each step of the continuum is assumed. . 84 CONCLUSIONS Strong evidence for the operation of some kind of inherent mechanism in the life cycle of addiction is provided by the evidence. The data appear to lend themselves to interpretation in terms of the law of mass action. To apply this law, it would have been desirable to have more than the single measurement of length of addiction. It is possible, however, to assume the existence of some kind of counterpressure of the kind that characterizes the mass action phenomenon. The existence of two age groups in the population of former drug users is logical where mass action is operating: one that is self-accelerating and the other self-inhibiting. The phenomenon of successive decrement of length of addiction as age at onset increases is in line with other manifestations of the mass-action phenomenon in nature. The regularity of the mass-action phenomenon and the apparent illustration of the maturing out hypothesis are demonstrated by the data. The Weber-Fechner law, derived from physiological psychology, on the principle of diminishing increments as the physical intensity of a stimulus is increased at a constant ratio, also relates these data to larger principles of behavior. As the age of the users increases, the extent of the addiction decreases at a constant ratio. The law of mass action and the Weber-Fechner law provide additional dimensions of understanding which help clarify the phenomenon of successive decrement of length of addiction as age at onset increases. The life cycle of the narcotic addict, including the phenomenon of maturing out explored in this study, suggest that there is an *average" or modal addict who is representative of perhaps three-fifths to twothirds of the total number of persons who begin to use narcotic drugs on any kind of regular basis. The fairly predictable relationship between age at onset and length of addiction suggests the possibility of a specific age range within which an addict is most likely to be able to stop drug use and be most responsive to therapeutic intervention. Rehabilitation of addicts may be most successful if it is introduced when the addict is at that point in his cycle of addiction at which the modal addicts who started drug use when he did are likely to be ceasing it. Programs for probation or parole under civil commitment provide an opportunity for intensive study of special populations with respect to the life cycle of their addiction. Physiological studies should be able to determine whether this peculiarly regular relationship of attenuation of drug use with age is a function of motivation, intensity of need, or strength of resistence. The parameter of age and length of addiction appears to be suggestive and heuristic enough to warrant further study; it suggests some of the regularities that underlie narcotic addiction and make prediction possible. 85 II. 09 I Winick, Charles. Maturing out of narcotic addiction. Bulletin on Narcotics, 14:1-7, 1972. DRUG Opiates SAMPLE SIZE 7, 234 SAMPLE TYPE Addicts recorded by the Federal Bureau of Narcotics AGE 18-76 SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA National Statistics' METHODOLOGY Statistical Survey DATA COLLECTION INSTRUMENT N/A DATE(S) CONDUCTED 1960 NO. OF REFERENCES 12 SUMMARY This study, based on a special tabulation of the records of the Federal Bureau of Narcotics, discusses the age at which a large sample of known users of narcotic drugs appear to have ceased taking drugs and the length of time their addiction covered. The Bureau tabulated all the addicts in its files who had originally been reported as addicts to during the calendar year 1955, but had not been reported againofup opium It counted as addicts only regular users 31 December 1959. such as meperiderivatives such as heroin, and of synthetic opiates reported as a Inactivity was defined as not being dine (Demerol). 86 ' 4.4 1 .1 drug user for 5 years. The data studied indicated that many narcotic addicts seem to cease taking drugs in their thirties, by what may be called a process of maturing out of narcotic addiction. THEORY If the hypothesis suggested of "maturing out" is correct, it appears the substantial concentration of addicts becoming inactive in their thirties may be due to the fact that the problems for which the addict originally began taking drugs, the challenges and problems of early adulthood, become less salient and less urgent. As a result of some process of emotional homeostatis, the stresses and strains of life become sufficiently stabilizing for the typical addict in his thirties so that he can face them without the support provided by narcotics. The process of maturing out of addiction may be entirely a function of the age at which the addict begins taking drugs; it is possible, however, that maturing out of addiction is at least partially a function of the cycle of the disease of addiction itself; the statistical results reported may be measuring the number of years that the addiction process itself takes, from beginning through middle to end. This variable may possibly be independent of the life cycle of the addict. There is a large concentration of addicts becoming inactive in the first decade after addiction began; there is also a considerable number becoming inactive after varying periods of years, ranging to over half a century. Whether the process is one of maturing out as a reflection of the addict's life cycle, or is a reflection of the number of years that the addiction process itself continues, it is a tendency or trend that gives some understanding of the behavior of a substantial majority of addicts. The results of the study suggest that maturing out of addiction accounts for approximately two-thirds of the sample, whether in accordance with the life cycle or length of addiction hypothesis. It is possible to speculate that addiction may be a self-limiting process for perhaps two-thirds of addicts: a function either of the addict's life cycle or of the number of years that he is addicted, or of some combination of the two processes. Insight, or particular life experiences, or other variables, may be relevant to whether an addict will differ from the norm in terms of maturing out. Geographic and other external factors may affect the extent to which a particular group of addicts either matures out of or reverts to narcotic use. CONCLUSION For future study of the phenomenon of maturing out, an attempt should be made to establish whether it is a life-cycle phenomenon, a reflection of the number of years of the addiction process itself, or of some combination of the two, and the extent to which the addict's desire to leave addiction is reflected in the process of maturing out, in contrast to it being a relatively passive process. 87 the From the public health and law enforcement points of view, addict in procedures for coping with the relative effect of various inhibition of the process of terms of possible acceleration or maturing out must be evaluated. What happens to addicts after they mature out, their life span, their susceptibility to disease and their general level of adjustment can be clarified by research. 88 11.10 Vaillant, George E. The natural history of narcotic drug addiction. Seminars in Psychiatry, 2(4):486-498, November, 1970. DRUG SAMPLE SIZE Heroin O'Donnell: 266 Vaillant: 100 SAMPLE TYPE Treatment - discharged AGE SEX Adults ( over 20 years of age) 212 Male and 54 Female ETHNICITY '50% GEOGRAPHICAL AREA New York State and Kentucky METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Not Specified DATE(S) CONDUCTED O'Donnell: 1936-1959 Vaillant: 19 52 -19 64 NO. OF REFERENCES 27 Black, 30% Puerto Rican, and 50% White SUMMARY Findings are reported from 2 long-term follow-ups of patients admqted to the U.S. Public Health Hospital at Lexington, Kentucky. The article provides an over-view of the eventual fate of American adults addicted to narcotics. Findings indicated that addiction patterns and underlying personalities of the disparate types of narcotic addicts are more similar than dissimilar. 89 The natural history of drug addiction is seen as constantly changing, depending on the changes within the culture. As a result or the findings from the two studies, strong recommendations were made for three types of treatment programs. The author suggests further scientific comparison of the treatment programs. METHODOLOGY O'Donnell followed up a stratified sample of all addicts from Kentucky admitted to the Federal narcotics hospital in Kentucky during the period 1936-1959. His sample included 212 males and 54 females. They were of "old American stock, " and most had been originally addicted by a physician's prescription or became addicted in an effort to alleviate alcoholism. The average addict was 41 at time of admission, had been addicted for 10 years prior to admission and was followed for an average of 11 years after first hospital discharge. Only 1 of the 266 persons selected for study was not located for follow-up, either in person or by tangible evidence of death. In terms of education and father's occupation the sample had equal or superior socioeconomic status to that of the state as a whole. The study included 14 physicians. Vaillant followed up 100 addicts from New York City who in 1952 were first admitted to the Lexington Hospital. Nine percent had a college education, but most were high school dropouts. Seventyfive percent sought admission to Lexington voluntarily. Fifty percent were Black, 50% White, 30% of Puerto Rican ancestry. Average age of first illegal drug use, 19; first addiction, 23; first admission to Lexington, 25. No addict in the sample was under 20. Ninety-eight percent were followed for 10 years after their first hospital admission. Ninety-six of the 100 addicts were followed until 15 years after start of addiction. FINDINGS It The author points out that in O'Donnell's sample the decade-long lag between start of addiction and admission to hospital must have served to exclude addicts who rapidly remitted. In Vaillant's sample the long distance of the Lexington hospital from New York probably served to exclude all but the seriously addicted. Although 22% of Vaillant's sample were first addicted in adolescence, no addict in the sample was under 20. Thus, both the adolescent addicts who died and the large proportion of addicts who flirt briefly with heroin were not represented in the study. 90 The detailed findings reported in the study are summarized here. (1) At least in part, narcotics addiction stems from a lack of adequate identification with the adult role. In both studies parental loss before 6 was more frequent than in a similar but nonaddicted segment of society. (2) In both studies, addicts seemed intellectually superior to appropriate control populations. (3) O'Donnell's sample contained more medical addicts than did Vail lant's. But at time of follow-up, only 2% of the medical addicts had medical justification for their addiction. (4) Narcotic addicts have much in common with delinquents. Most individuals who use narcotics have a greater tendency than their socioeconomic peers to be delinquent. Forty percent of O'Donnell's sample had been discharged as unfit from the military. Twenty-four percent had supported themselves with illegal professions prior to addiction. (5) Prior to addiction, addicts encountered gi eat difficulty in sustaining employment. Fifteen percent of O'Donnell's sample were chronically unemployed; 50% of Vaillant's sample were regularly unemployed prior to addiction. (6) At an average of 11 years after treatment in Lexington, O'Donnell found 65% of the living subjects not using drugs. Twelve years after treatment Vaillant found 57% not using drugs. Roughly 50% of addicts who achieve abstinence for a year will subsequently relapse. In Vaillant's sample there appeared to be a trend during the 18 years after Lexington for 2% of addicts at risk to become permanently abstinent each year. (7) A dramatic finding from both studies was that addicts rarely became voluntarily abstinent. For the Kentucky addicts the principal reason for abstinence was unavailability of narcotics. For New York addicts the illegality of narcotics provided motivation for abstinence. (8) A stable pattern of employment prior to addiction was the most important single factor predicting eventual abstinence. Moving out of areas where addiction was endemic did not powerfully affect long-term abstinence. It seemed more important to provide a substitute for addiction. (9) Compulsory community supervision seemed an important "therapeutic" variable. This was documented by the fact that 11 of the 30 men who achieved permanent abstinences began that abstinence while under at least a year of parole. 91 . (10) Abstinent addicts resembled personality disorders who have improved. There was no evidence that addicts were ever worse off while abstinent. (11) Addicts tended to contract frequent marriages, but as a group did not reproduce. (12) In Vail 'antis sample, for every 2 urban addicts who died as a result of addiction, 5 remained more or less constantly addicted for 15 years. CONCLUSIONS The author concluded that perhaps no mental illness is more a product of its social setting than addiction to narcotics. Since drugs depend both for desirability and effect on the milieu in which they are taken, the natural history of addiction changes as the society and subculture change. Long-term follow-ups suggest that people are not just addicted to heroin, but that the addict is a person who lacks employment, is lonely, depressed, and has a paucity of gratifying alternatives. The likelihood of recovery improves with time. The addict needs specific help to achieve independence, i.e., employment and alternatives to solitary gratification. Three treatment methods that appear to effectively raise the recovery rate are parole, methadone, maintenance, and Synanon-like therapeutic communities. All provide some substitutes for narcotics. L., 92 a O'Donnell, John A. A follow-up of narcotic* addicts: Mortality, relapse, and abstinence. American Journal of Orthopsychiatry, 34:948-954, 1964. DRUG Narcotics SAMPLE SIZE 266 SAMPLE TYPE Former Narcotics Patients AGE Adults SEX Both Male and Female ETHNICITY White GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT DATEIS) CONDUCTED NO. OF REFERENCES Lexington, Kentucky Longitudinal Interviews; Program/Clinic Statistics March 1961 - October 1963 1 SUMMARY A follow-up study was conducted to determine what happened to 266 subjects after they were released from Lexington Hospital in Kentucky. All the subjects were White, males and females, and were randomly selected. Only those currently residing in Kentucky were chosen. Of the 266 subjects, 144 had died. Of living subjects, more than half were abstinent from narcotics when located. 93 Although the percentages for relapse among men and women were high, the author stressed that 38% of the men and 79% of the women had some period of complete abstinence during the follow-up period. METHODOLOGY A follow-up study was conducted on Kentucky residents who were treated for narcotic addiction between 1935 and 1959 at the U.S. Public Health Service Hospital in Lexington, Kentucky, to determine what had happened to them after discharge. A sample group of 266 subjects was randomly selected among White Kentucky residents who had been treated. Both males and females were in the sample. Information was obtained from interviews, laboratory tests and clinical records. Only those findings related to mortality and addiction status of living subjects were included in the final report. FINDINGS -One hundred forty-four of the 266 subjects had died. Six more died before the study was completed. Ninety-four males and 19 females died of natural causes (heart disease, tuberculosis, ailments of other organs). Thirty-six males and 1 female died of non-natural causes (accidents, suicides, etc.). The frequency of non-natural causes of death among male subjects, when compared to males in the state of Kentucky, was much higher than was expected. Many of these deaths also occurred at earlier ages than in the general population. Of those living subjects, only 21 (out of 122) were addicted to narcotics. Addiction to narcotics is defined by the author as "regular use of narcotics once a day or more. " Fourteen were institutionalized, most in Lexington Hospital. Another 21 were addicted to barbiturates occasionally; and 50 subjects were completely abstinent. There were clear differences between men and women in the study. Although both groups were equally addicted to narcotics, 2/3 of the women were completely abstinent, whereas only 1/3 of the men were abstinent. This current addiction status was compared to addiction status from the time of first admission. The findings generally paralleled those on current addiction status, with the same major differences between men and women. It was found that women tended to be either addicted to narcotics or abstinent from all drugs, with less probability than males of being institutionalized or becoming 94 A addicted to barbiturates or alcohol. 1. Of those subjects who were addicted, 2/3 were receiving narcotics by prescription from physicians. Some of the usage was deemed legitimate by the author, while some usage was deemed questionable. CONCLUSIONS The author concluded that the major reason for the abstinence from narcotics was that the drugs were not available. It was found that there was no regular illicit source of narcotics for Whites in any of the parts of Kentucky included in the sample. The author also suggested that the findings not be compared with other studies until the drug usage pattern of the deceased subjects was determined. Although 73% of the men and 62% of the women relapsed to narcotics, the author argued that 38% of the men and 79% of the women had some period of complete abstinence during the follow-up period. The author stated that other studies tended to use the most negative of measurements in regard to relapse, and that efforts should be made to look at addiction status in a more positive manner. L 95 II. 12 Vaillant, George E. A twelve-year follow-up of New York narcotic addicts: I. The relation of treatment to outcome. American Journal of Psychiatry, 122(7): 729-740, January, 1966. DRUG Not Specified SAMPLE SIZE 100 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Male ETHNICITY 50 Black and 50 White GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT DATE (S) CONDUCTED New York City addicts in Lexington, Kentucky. Longitudinal Interviews, Program/Clinic Statistics August 1, 1952-1965 NO. OF REFERENCES SUMMARY This study followed 100 male New York City addicts admitted to U.S. P. H.S. Hospital at Lexington, Kentucky, between August, 1952, and January, 1953. Ninety-four percent were successfully followed for at least 10 years. After Lexington, 90% of the sample relapsed to use of narcotics, and over 90% received jail sentences. At last contact, 46% were off drugs and in the community. The most significant variable in determining abstinence in the addict appeared to be the presence or absence of enforced compulsory supervision. 96 METHODOLOGY First-admission male New York City addicts who came to the U. S. P. H.S. Hospital in Lexington, Kentucky, between August 1, 1952, and January 31, 1953, were initially considered. Their names were then arranged in arbitrary order, based on the last digit of their hospital number. The first 50 Negro and the first 50 White patients were then chosen for follow-up. Complete background information was obtained on each patient. Follow-up was pursued by 2 methods: (1) Institutional records on each patient were abstracted and recorded chronologically. Drug, hospital, prison and abstinence history were recorded from 1940 to 1965; (2) In 1964 and 1965 attempts were made to contact relatives of all patients and to interview all patients who were known to have done well. Bad outcomes could be followed through the many institutionalizations of the patients. Data were obtained at a minimum of 5 different points in time on every patient who lived beyond 1955. Patients were defined according to the following terms: addicted, addicted?, well, well?, marginal, institutionalized, and good outcome. FINDINGS The results were divided into 3 parts: The over-all characteristics of the sample, the relation of outcome to treatment, and certain characteristics of the addict's family background. Ninety-four percent of the patients were followed until their death or until 10 years after Lexington discharge. The average patient in the study first used illegal drugs at age 19, was first addicted at 23, and was admitted to Lexington at 25. Thirty patients were considered good outcomes. But in spite of expert treatment by qualified personnel from this hospital, within 2 years all but 10 out of 100 patients again become addicted--at least temporarily. Prior to coming to Lexington, 46% of the patients had been imprisoned. After leaving Lexington, 92% of the patients were imprisoned. Frequent hospitalization was associated with an apparent reduction in criminal convictions. The length of hospitalization at Lexington was positively correlated with the length of short-term abstinence. The data from this study and that of Hunt and Odoroff suggested that length of stay at Lexington was not significantly correlated with long-term abstinence. Straight prison terms of 9 months or more produced abstinence 3 times as frequently as did shorter periods of 97 hospitalization or imprisonment. Imprisonment of 9 months or more, followed by a year of parole, produced a year's abstinence in 20 out of 30 cases. Age was not correlated with the success of a particular treatment. The success of parole could not be attributed simply to maturation of.the addict. Ninety-six percent of the patients in the sample had at least one of the following in their background: a broken home, a parent from a different culture, or residence with a female relative at age 30 or afterwards. The findings underscored the fact that adult addicts remain unusually dependent on their family. CONCLUSIONS The writer felt that the most important finding that came out of this study was the fact that within 10 years of their first Lexington admission, at least 30% of N. Y, addicts achieved good social adjustment. Abstinence was clearly correlated with compulsory supervision. The combination of imprisonment and parole was far more effective tti.vzi long imprisonment alone. At least 2 other studies supported the value of enforced parole supervision in addiction. The findings suggested that addicts may differ from most psychiatric patients and that treatment may need to be more authoritarian. Because addicts often do not acknowledge a strong need to change, they may require more involuntary supervision than the average patient. Both prison sentences without provision for parole and purely voluntary programs are often contraindicated in the treatment of urban addiction. 98 II. 13 Vaillant, George E. A twelve-year follow-up of New York narcotic addicts: III. Some social and psychiatric characteristics. Archives of General Psychiatry, 15(6):599-609, December 1966. DRUG Heroin SAMPLE SIZE 100 SAMPLE TYPE Treatment (inpatient) & Treatment (outpatient) AGE 18-64 SEX Male ETHNICITY 50 Black and 50 White GEOGRAPHICAL AREA New York Addicts in Lexington, Kentucky METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Questionnaires & Program/Clinic Statistics DATE IS) CONDUCTED 1952-1964 NO. OF REFERENCES 43 SUMMARY This paper was based on a 12-year follow-up of 100 New York addicts (50 White and 50 Negro men) who were first admitted to the U. S. Public Health Service Hospital, Lexington, Kentucky, between August 1, 1952 and January 31, 1953. Those characteristics that may differentiate addiction from other psychiatric syndromes were illustrated. The use of longitudinally gathered data permitted the conceptualization of the addict simultaneously as a delinquent and as a psychologically disturbed individual. Different patterns of drug usage were not found to be connected with ethnicity. There 99 seemed to be less difference between the urban heroin addict and the chronically delinquent nonaddict than is generally appreciated. METHODOLOGY The sample used consisted of 50 Negro and 50 White men admitted to the U. S. Public Health Service Hospital, Lexington, Kentucky between August 1, 1952 and January 31, 1953. In 1952 a social worker had completed a 55 item questionnaire on 90% of the men in the sample. This questionnaire contained routine demographic data and also elicited information about family history of addiction, early history of delinquency, arrest record, military and occupational history and drug experience. Demographic data, and that concerning criminal history, was in most cases confirmed by official sources and considered complete. Data on childhood delinquency, deprivation, and family psychopathology represented minimal values. FINDINGS Many of the addicts had been deprived, either by virtue of minority group membership, or because of physical loss of parents or the fact that they had been born into a culture different from that of their parents. Ethnic differences appeared not to lead to different patterns of drug use. Delinquency often preceded drug use, and poor academic and occupational performance often occurred despite adequate or superior intellect. Use of drugs did not appear to conceal latent psychotic conditions. The adult addict seemed less schizoid than has been previously suggested in studies of adolescent addicts. Even when drugs are removed, it appears that latent depression does not become manifest. CONCLUSIONS There appears to be less difference between the urban heroin addict and the chronically delinquent nonaddict than has been generally appreciated. An investigation of the roots of urban addiction may serve to aid understanding of the dynamics of repetitive delinquent behavior in general. 100 II. 14 Valliant, George E. A twelve-year follow up of New York narcotic addicts: IV. Some characteristics and determinants of abstinence. American Journal of Psychiatry, 123(5): 573-585, 1966. DRUG Heroin SAMPLE SIZE 60 SAMPLE TYPE 30 Ex-Addicts and 30 Chronic Addicts AGE Not Specified SEX ETHNICITY __Male Not Specified GEOGRAPHICAL AREA New York City METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews DATEIS) CONDUCTED 1953-1965 NO. OF REFERENCES 18 SUMMARY In a 12 year follow-up of 100 New York City addicts admitted to the Lexington U.S.P.H.S. Hospital, an attempt was made to study intensively the 30 best outcomes. These men had achieved and maintained until the time of this study stable abstinences of at least 3 years duration. Correlated with eventual abstinence were prior ability to hold down a job, intact home until the age of 6, and a late onset of addiction. Establishment of a stable non-parental relationship, a substitute addiction, and compulsory supervision all helped to facilitate abstinence. The addicts' movement from addiction to abstinence was likened to the progression through adoles cence. 101 A, A. METHODOLOGY In 1965, one hundred young male New York City addicts first admitted to Lexington Hospital between August 1, 1952, and January 31, 1953, were chosen for follow-up interviews to determine their status. Thirty "best" outcomes, called "Ex-addicts, " were chosen. They all shared the following characteristics: (a) residence in the community for a minimum of 3 years without the use of narcotic drugs; (L) maintenance of such abstinence until the present time or until death; and (c) no conviction for a narcotic or property offense for at least 4 years. This group of 30 ex-addicts was compared to the 30 "worst, " or "chronic addicts, " who (a) had spent less than 20% of the time since Lexington abstinent in the community; (b) had been actively addicted in the community for at least 5 years; and (c) 10 years after admission to Lexington were still alive. Direct face-to-face interviews could be obtained with only 17 of the 30 ex-addicts. Others were contacted by phone or mail, or relatives were interviewed by the author. In 87% of the cases, corroboration of abstinence was obtained from at least 4 independent sources. Two of the ex-addicts had died, and death certificates were obtained that supported alleged abstinence. FINDINGS Of all addicts in the study, the average duration of abstinence was 7.7 years, and average employment was 6. 0 years. In general, after having left Lexington, the ex-addicts were more likely to have created families, to have achieved independence from home, and to have held down jobs. The differences between ex-addicts and chronic addicts became more apparent with the passage of time. Type of criminality did :,ot distinguish the 2 groups. Seventy-. seven percent of the ex-addicts had at least 1 conviction after Lexington. The two groups were also similar in terms of broken homes, mental illness, and delinquency prior to addiction. The most important difference appeared to be the chronic addict's inability, prior to admission, to find or to keep gainful mployment. Absence of a stable work history seemed the best predictor of subsequent chronicity of addiction. A late onset of addiction correlated with eventual abstinence, as did an intact home until age 6. Compulsory supervision, a substitute addiction, and the establishment of a stable non-parental relationship appeared to facilitate abstinence. . 102 No evidence was found that addicts, as a group developed other incapacitating mental illness when they became abstinent. Psychiatric interviews indicated that, as a group, the ex-addicts had achieved relative psychiatric and social health. Few of the exaddicts interviewed appeared mentally ill in the conventional use of the term. Few of the addicts, however, seemed to know who they were or where they were going. Findings from other studies were also discussed. In a study done by Glueck and Glueck, a poor prior work history was the most powerful predictor of chronic recidivism. They also noted that as adult or adolescent criminal offenders matured past 30, an increasing number of them turned to alcohol. This was true of ex-addicts, but not of chronic addicts. CONCLUSIONS Vaillant likened addiction to problems of adolescence. Therefore, like the adolescent, the addict strives to achieve independence from the familial matrix. Both need to find substitute channels for aggressive and sexual instincts, and must sustain independent responsibility. Like the early adolescent, the addict handles conflicts through rebellion, withdrawal, and solitary self gratification. The goal of treatment must be to assist the addict to pass into late adolescence. 103 II. 15 Richman, Alex, et al. Entry into methadone maintenance programs. A follow-up study of New York City heroin users detoxified in 1961-1963. American Journal of Public Health, 62(7):1002-1007, July 1972. DRUG Methadone; Heroin SAMPLE SIZE 500 SAMPLE TYPE Treatment (inpatient - follow-up) AGE Not Specified SEX Both Male and Female ETHNICITY Black; White; Hispanic GEOGRAPHICAL AREA New York , New York METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Program/Clinic Statistics DATE(S) CONDUCTED 1971 NO. OF REFERENCES 19 SUMMARY This follow-up study of 500 addicts, admitted for detoxification 8-10 years ago, dealt with their later participation in a variety of New York City Methadone Maintenance Programs. The 500 patients followed were a 10% representative sample of the first 5,000 individuals admitted for detoxification between January, 1961, and June, 1963 at the Morris J. Bernstein Institute (MJBI - formerly Manhattan General Hospital) of the Beth Israel Medical Center, New York. Striking differences in methadone program participation were found in terms of sex, ethnicity, and severity of addiction. 104 1 METHODOLOGY Patient charts, MMTP (Methadone Maintenance Treatment Program) registers, and lists of MJBI were examined; the Methadone Data System (Warner, 1971) was used in determining which patients had been admitted to a variety of methadone maintenance programs in New York up to July 1, 1971. The sample was compared with other groups. The study cited data which supported the belief that patients seen at MJBI represent a substantial portion of the known addicts in New York City; the group followed appeared to be fairly representative of the population of addicts in the community. FINDINGS Of the 500 patients, 115 (23%) were found to have entered methadone programs. The proportion of the original group potentially in need of treatment in June, 1971 was estimated as from 28-55%, based on follow-up data of a subgroup of the 500. It was not possible to differentiate whether low rates of MMTP participation were associated with: (a) psychological or attitudinal characteristics of patients; (b) differentials in availability or accessibility of the methadone program; (c) reduced need for treatment (cure or substitution of problems); or (d) nonacceptability of the program to the patients' peers. The most striking differences in MMTP entrance were in sex, ethnicity, and indices of the severity of addiction. Male patients in the follow-up group were more likely than females to participate in a methadone program. By mid-1971, 26% of the men and 14% of the women had entered. There were also ethnic differences in the percentage of each sex entering MMTP. Among the women, more of the Blacks (17%) entered MMTP than did Hispanics (12%) or Whites (6%). Within the ethnic groups, Black women were as likely to enter MMTP as Black men. First admissions to MJBI, with previous inpatient detoxification elsewhere, were more likely (34%) to later enter MMTP than those without such prior detoxification (18%). Patients who had used heroin for more than 5 years were more likely (26%) than others (16%) to enter a methadone program later regardless of age at admission or ethnicity. Almost half (47%) of the patients reported using only heroin prior to their first admission. Of these patients, 19% entered MMTP. Of those who used drugs in addition to heroin, 27% later entered MMTP. At the end of the third year of MMTP (1967), 8% each of the Black and Hispanic men and 4% of the White men had been admitted. By the end of 1969, 14% of the men in each ethnic group were in the program. By mid-1971, 35% of the White men, 30% of the Hispanic men and only 17% of the Black men had entered MMTP. 105 No differences were found for the following factors:'''age group at time of first admission, prognosis of referral agency, amount of schooling, or borough of residence. CONCLUSIONS It was evident from the data in this study that narcotics addicts detoxified some 8-10 years ago are still continuing to enter the Methadone Maintenance Program, v ith the proportion entering MMTP increasing. There is definite confirmation of marked ethnic and sex differences in the rate of entrance. The entrance of Black patients has not continued to accelerate in the same way as for other patients. Patients with indices of more severe addiction seem more likely to enter MMTP. It is estimated that the number of entrants to MMTP from the group being followed could potentially double or triple. 106 Cl II. 16 Richman, Alex. Follow-up of criminal narcotic addicts. Canadian Psychiatric Association Journal, 112:107-115, April 1966. DRUG SAMPLE SIZE SAMPLE TYPE Not Specified IlatSpacifiad Narcotic Addicts AGE Adults SEX Both Male and Female Not Specified ETHNICITY GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT DATEIS) CONDUCTED NO. OF REFERENCES British Columbia, Canada Longitudinal Government Statistics 1955-1964 7 SUMMARY In this paper national statistics on criminal narcotic addiction prepared by the Narcotic Control Division, Department of National Health and Welfare of Canada are reviewed. The author sought to ascertain changes in the number or characteristics of criminal narcotic addicts over a seven-year, follow-up period. Duration of addiction was also studied. Nationally, the number of criminal addicts has not increased between 1955 and 1964, and in fact it seems to be decreasing. Prospect for abstention increases with the age of the addict. Abstention is not less likely in adults who 107 I have long histories of police contact, or who have had previously attempted many times to quit drugs voluntarily. It was clear from this study that abstention does occur without special forms of treatment. METHODOLOGY Reports of previous studies were used as a basis for this study. Addicted prisoners had been studied during 1954-56 in British Columbia. This paper followed up a representative 50% sample of British Columbian criminal addicts who were previously studied during a 12-month period in 1954-55. Information was obtained up to 1964. Individuals were classified as 1) abstinent 2) active users 3) miscellaneous. FINDINGS At least 1/2 of the total sample had remained addicted to narcotics during 1960-64. Twenty-one percent were considered abstinent from narcotic usage for at least the last 3 years. Abstinence was less for males (19%) than for females (25%). There appeared to be little difference for either sex between persons born in British Columbia and persons who arrived there before 18 years of age. The proportion of males judged to be abstinent increased progressively with advancing age. Females aged 35 and over formed the group with the highest percentage considered to be abstinent. Females who began taking narcotics before 1945 formed the largest percentage of presumed abstainers, and males who began addiction in 1950 and later had the smallest percentage. Abstinence did not decrease with increasing duration of narcotic usage. Prolonged duration of police contact did not affect the abstention rate significantly. The differences between men who had attempted to quit several times and men who had never stopped were small. CONCLUSION Some evidence exists to support Winik's concept that the addict matures out of addiction. There is a process, the end result of a combination of forces, that enables the addict in his late twenties or thirties to modify his behavior to adapt to a larger society. 108 II. 17 Duvall, Henrietta J. ; Locke, Ben Z.; and Brill, Leon. Follow-up study of narcotic drug addicts five years after hospitalization. Public Health Reports, 78(3):185-193, March, 1963. DRUG SAMPLE SIZE SAMPLE TYPE Not Specified 453 II 9 - - o AGE 453 Adults SEX Not Specified ETHNICITY Black, White, Puerto-Rican GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT . New York, New York Longitudinal Observations DATE1S) CONDUCTED July, 1952 - 1956 NO. OF REFERENCES 5 SUMMARY Four hundred and fifty-three patients were selected from 1, 359 who were discharged from the Public Health Service Hospital in Lexington, Kentucky between July, 1952, and December, 1955. They were followed for 5 years. The findings indicated a high relapse, unemployment, and arrest records after treatment. The discharged addict was found to be an antisocial individual who did not make use of after-care services. The authors concluded that these findings would support the need for a systematic community after-care program for such persons. 109 METHODOLOGY A stratified sample of 453 discharges was studied. This sample was chosen from a larger group of 1,359 that had undergone follow-up procedures after their discharge from the Public Health Service Hospital at Lexington, Kentucky. They had been discharged during the period from July, 1952, to December, 1955. This study followed them until their readdiction to narcotics or until December 31, 1956. These patients all lived in the New York City area at the time of admission to Lexington. Data covered a 5-year period from time of discharge for each of the 453 discharges in the sample. The study was undertaken to ascertain what happened to the treated narcotic drug addicts over a period of years, in contrast to previous studies which discontinued follow-up after readdiction. Addiction status was determined by the use of habit-forriling narcotic drugs as specified under the Federal Narcotic Act. FINDINGS There were 52 deaths among the 453 patients in the sample. Although more than 97% became readdicted during the 5 years after treatment at Lexington, by the 5th year after discharge only an estimated 46% of the study population were readdicted, and 49% were abstinent, either voluntarily or involuntarily. An important factor in voluntary abstinence was age. Discharges over 30 years of age showed a significantly higher rate than their younger counterparts. They also showed a significantly greater ability to remain drug-free. Abstinence increased with the passage of time, while readdiction rates decreased. An estimated 40% of the study population had been voluntarily abstinent at some time during the follow-up period. Forty-one percent returned to the Public Health Service Hospital at Lexington, Kentucky, or Fort Worth, Texas, during the 5-year period. Approximately 70% of the study population had 1 or more arrests. Higher arrest rates were reported for the under-30 age group than for those over 30. Two-thirds of all the arrests reported were for narcotics violations, and the overwhelming majority of the remaining violations concerned illegal means resorted to by addicts to support their habits. Almost all instances of arrests in the voluntarily abstinent group occurred at times of addiction. 110 1,0 It was estimated that 41% of the male addicts were unemployed 5 years after discharge . Fifty-nine percent were employed full-time. Constantly addicted discharges showed a full-time employment rate of only 13%. During the 5-year follow-up period, few of the patients received psychiatric after-care. CONCLUSION After treatment the drug addict is generally an antisocial individual who has difficulty readjusting to the community. The findings of this study, such as high relapse, arrest, and unemployment rates, plus minimal use of psychiatric after-care services lend support to the view that there should be systematic community after-care for such persons. 111 II. 18 Trussell, R. E, ; Alksne, H. ; Elincon, J. ; and Patrick, S. A Follow-Up Study of Treated Adolescent Narcotic Users. New York: Columbia University School of Public Health, May, 1959. 17 pp. DRUG Not S eslfiesi SAMPLE SIZE 247 SAMPLE TYPE Treatment (outpatient) AGE Adolescents (12-20 years) SEX ETHNICITY 8350 Male, 175, female -;',.% Puerto Rican. 425, White 26% Black GEOGRAPHICAL AREA New York City METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews, Questionnaires, Program/Clinic DATE (S) CONDUCTED 1957 Records NO. OF REFERENCES SUMMARY This report summarized the final report of a follow-up study of treated adolescent narcotics users admitted to the Riverside Hospital (New York City) during 1955. The Riverside Hospital program, devoted to the treatment and rehabilitation of adolescent drug users, and to research, is a unique social as well as medical experiment. The purpose of this report was to assist in an objective appraisal of the program, including both its services and research results, in order to cast light on its effectiveness. 112 isj METHODOLOGY The study was conducted by the Columbia University School of Public Health and Administrative Medicine under contract with the Interdepartmental Health Resources Board of New York, and the research work was initiated in August, 1957. More extensive and systematically collected data was needed regarding what happens tc the young drug user after his or her first Riverside Hospital experience. Information on 247 patients was collected by a records search at the Riverside Hospital, the State Departments of Correction and Mental Hygiene, the City Departments of Correction and Health, the City Youth Board, the Federal Narcotics Bureau and the Social Service Exchange. All available records pertaining to narcotics use and criminal behavior both before and after the patient's first hospitalization were analyzed, since data obtained would be indicative of a negative social adjustment and would also provide some measure of the extent of recidivism. In addition to the records search, a detailed interview schedule was developed for tape-recorded interviews which took between 1 1/2 and 3 hours to complete. Although information was obtained from only 147 patients, the scope, depth, and detail made the interview phase the most informative. Registered letters and short questionnaires were sent to all patients who could not be found for interviews; 97 of these were mailed, 47 were accepted and 15 were returned. Data was obtained from the records on characteristics of the study population, recorded drug use, pre-hospitalization arrests, hospitalization age, time in hospital on first admission, recorded posthospitalization difficulties, nature of criminal behavior, and prehospitalization compared with post-hospitalization. Data was obtained through the interviews of the number of patients 'successful in abstaining from the use of narcotics, maximum frequency of re-use, original reason for use, need for re-use after leaving the Hospital, when first dose was taken after release from Hospital, re-addiction, voluntary withdrawals, techniques for withdrawal, reasons for attempt to withdraw, type of drug most often used and method of use, maximum daily costs, pushers, group relationships while taking narcotics, attitude toward return to narcotics use after treatment, total time in community and institutions, costs of narcotics for patients returning to use, attitudes of parents, siblings and friends, use of alcohol, employment, social factors, leisure time relationships and activities, assistance given to patient, presence of a father in the home, family attitudes, patient's support of family and family 113 activities. FINDINGS Of the 247 patients, 42% were recorded as White, 26% Negro and 32% Puerto Rican; 83% were males; 80% were born in the Continental United States, 17% in Puerto Rico and 3% elsewhere. Of the group born outside the United States 29% had spent 10 or more years in New York City prior to first hospitalization and 75% of the entire group had lived all of their lives in New York; 71% were Roman Catholic, 24% Protestant, and 5% were Jewish or of other faiths-, 27 patients, or 11%, were married at the time of first hospitaliza- tion. Only 6% of the total group completed high school, and 79% had not attended school at all during the entire year prior to hospital entrance. Psychiatric diagnoses were recorded for 96% of the group; 42% were labeled as personality pattern disorder problems, 21% as psychotic. During the 3 years of follow-up time, during any 6-month period, more than 1/2 of the patients spent some time in an institution. The records showed that 85% of the study group were re-hospitalized for treatment of narcotics use or were re-arrested, or both. Of the patients interviewed, 139 admitted returning to the use of narcotics; 124, or 91%, returned to regular daily use; 11% reported no absti- nence at any time; 20% abstained up to one month; 24% managed at least one period of 6 months or more while not on drugs in the community. Those interviewed were somewhat more likely to be younger, male, Negro or Puerto Rican and unmarried. There was little or no difference in nativity, religion, education, and length of residence in New York City. CONCLUSIONS At best the picture presented by the data in this report is grim. Any organized program dealing with the problem of drug addiction is faced with the historical fact that no therapeutic success of any significance has ever been recorded. In the light of this reality the question as to what should be done in organizing a program can only be resolved on the basis of expert opinion, plus research, plus periodic appraisal of results. There is a great need for continued and expanded basic and clinical research, adequate provision for medical supervision, improved therapeutic services and work in the community, judging from the extent of recidivism among young drug users. 114 The frustration inherent in the current Riverside Hospital program should be recognized. It was intended to provide agreed upon services and research, but the Hospital has had difficulty in both respects. The physical plant is inadequate and the facility is understaffed; the under-staffing and lack of funds have precluded research by the Riverside Staff as such. Thus the most important long range objective of establishing a treatment facility exclusively for juvenile drug users which would serve as a research center has not yet been attained. II. 19 Perkins, Marvin E., and Bloch, Harriet I. A study of some failures in methadone treatment. American Journal of Psychiatry, 128(1):47-51, July 1971. DRUG Methadone SAMPLE SIZE 53 SAMPLE TYPE Treatment (outpatient) AGE Adults SEX 46 Male; 7 Female ETHNICITY 33 White; 20 Black/Brown GEOGRAPHICAL AREA New York, New York METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews; Questionnaires OATEN) CONDUCTED 1969 NO. OF REFERENCES 1 S UMMARY A follow-up study was conducted of 66 patients who were discharged from a methadon = maintenance program, at the Morris E. Bernstein Institute, New York (MJBI). The purpose of the survey was to ascertain whether a diligent follow-up effort would result in the location of the majority of unsuccessful former patients and whether the located discharged patients would cooperate in an assessment by interview of their current situation and adjustment. The follow-up resulted in the location of 90 percent of those discharged live during the first three years of operation. Of the 53 116. individuals located and interviewed, 34 had been hospitalized for physical or mental conditions or for detoxification. Although 25 percent (13) had not been arrested, 28 percent had not been jailed, and 36 percent had not been convicted since discharge, the others accounted for more than 110 arrests, 78 incarcerations, and 63 convictions. Abstinence was enforced for 15 of the "institutionalized group," but for the others, use of heroin continued to be a dominant activity. Only two had been abstinent for any length of time at the follow-up interview. The post-discharge course of the located addicts who failed to continue in the methadone project appeared to be in contrast to those persons who were reported as successfully maintained. The authors believe there should a more substantial effort to retain addicts in methadone programs in order to improve their chances of rehabilitation. METHODOLOGY A systematic pre-coded questionnaire was designed to obtain four categories of information: operational data, background characteristics, objective follow-up, and subjective follow-up. Essential identification characteristics were obtained from records at MJBI and letters were sent to respondents at the last known address explaining the project survey and seeking individuals' cooperation. When this technique failed to locate the target population, other locating procedures were employed, e. g., writing and telephoning persons known to be significantly related to patients, daily questioning of the Drug Addiction Service at MJBI. Other methods included listing patients' names in methadone outpatient clinics throughout the city, sending letters to various drug addiction rehabilitation agencies throughout the city and state, and engaging an informal network among addict patients by the employment of a methadone maintenance patient on the research team. Interviews were conducted under various circumstances. Twentyfive patients were interviewed at MJBI, 14 were interviewed in hospitals or penal institutions. In several instances, a staff member of the institution conducted the interview and returned it to the authors by mail. Still others were interviewed wherever located. Of the target population interviewed, 46 were men and 7 were women; 33 were White and 20 were Black or Brown. At the time of the interview the mean age of the men was 34 and of the women, 37; the age ranges were from 31 to 46. Religious and ethnic background were also questioned. At intake, 27 had stated they had never married, on follow-up 19 still maintained this status. Five individuals married in the period between intake and follow-up, while 9 were divorced and 7 separated. Employment status changed between intake and follow-up with 6 more individuals finding employment, one person attending school and 13 117 doing nothing (a decrease from 20). Ten were in jail and 14 were engaged in illegal pursuits. At intake nearly half claimed some high school education (25), 18 were high school graduates, 3 attended college, and one was a college graduate. FINDINGS For 88 percent of the respondents, problems had stayed at the same level or become worse, or new ones were present. At follow-up, 31 (59 percent) considered their most serious problem to be drugs; others selected work, the law, health, family, or other matters. Since discharge, the criminal-legal involvement of the group was particular1 extensive. Forty respondents (75 percent) had been arrested and in total the group accounted for more than 110 arrests, 63 convictions, and 78 incarcerations. Physical and mental health status dropped after discharge. Hospitalization was denied by 19 (36 percent) and of the others, 22 claimed hospitalization for physical disease, 25 for detoxification, and 4 for mental health. Thirty-six of the 38 respondents not in institutions were currently using some drug or alcohol; 29 admitted using heroin and 21 used alcohol. Thirty-one of those interviewed were under the influence of some substance during that interview. The 2 "clean" respondents were in successful abstinence programs. Periods of voluntary abstinence ranged from none to 8 with 19 persons admitting no voluntary abstinence and 17 only one such abstinence. Attempts at rehabilitation had been made one or more times by 31 (58 percent) of the respondents. Patients perceived a decline in mental and physical health from the period o. intake to time of follow-up interview. At intake, 35 (65 percent) rated mental health as excellent or good; at follow-up, only 55 percent rAted as well. Physical health rating dropped from 75 percent to 62 1.1.i.L.ent; however, the decline of respondents' perception of life in general was negligible. Eighty percent rated their life as fair to poor at both intake and follow-up. CONCLUSIONS The post-discharge course appeared to be in striking contrast to those individuals successfully maintained in methadone programs. Death, criminal-legal involvement, incarcerations, hospitalizations and drug abuse patterns seem to be great risks. The authors believe this evidence suggests that intensified efforts to retain addicts may be needed in methadone programs. An alternative suggestion is to redesign a new program for those who "fail." Measures that would make current programs more stringently regulated might have a harmful effect and release more addicts to the street with little chance for rehabilitation. However, these addicts present enormous social problems and the authors doubt that administration without adjunct services will lead to successful treatment. 118 II. 20 Nurco, David N. , Principal Investigator. Analysis of a communitywide population of narcotic addicts. (Description of an on-going research project; abstract supplied by the principal investigator.) ABSTRACT The long-range goal of the present research project is to learn more about the deviancy drug abuse in order to develop programs and facilities that can effectively treat and eventually prevent its occurrence. This project is currently in "the field" (December 1973). Final analysis is planned for September 1975. METHODOLOGY The specific aims of this proposal are as follows: 1. To describe and compare selected personal and social Characteristics of males entering the addict population in Baltimore City in various calendar years (periods) from 1952 through 1971. Analysis of these data should reveal shifts and possible trends in the nature of the target population over time and enlarge our understanding of the recruitment process as it relates to demography and overt changes in the resident populations. 2. To gather developmental data on the addictive process as reflected in these individuals from onset through time periods up to 20 years. Relatively little is known today about the developmental patterns of the narcotic addiction process in relatively unselected community populations. Is there a common developmental pattern (drug career) which is rather typical of the addictive process or are there a number of distinctive patterns associated with demography, pre-addiction history, incarceration, criminality, and the like? The present study is designed to provide answers to these questions and generate data on related medical and social events, on remissions, and mortality. 3. To determine (and verify) the current status of survivors with respect to addiction, drug usage and other forms of social deviancy and describe existing patterns of social functioning. RATIONALE An unduplicated roster of narcotic addicts in the Baltimore area known to the police during the period 1952 through 1971 has been compiled by the present research staff. The Baltimore narcotic addict data will serve as the base of the present research effort. While the roster 119 contains a considerable amount of information about the addicts, far more than is usually available from the rosters of deviants in a population community, it does not contain as much information as would be desirable to conduct social-psychological and developmental research on narcotic addiction. We will, therefore, supplement the roster data with information obtained: (1) from agency records, and (2) directly from the addicts themselves. Questionnaires are being administered in structured interviews that cover such major aspects of their life cycle as developmental patterns of addiction, marital history, job history, history of major illness, recidivism, arrests and other contacts with the police, incarceration, contacts and sup i.:1-vision by various health and welfare agencies, and service in the armed forces. We are also attempting to clearly define transition points, i.e. , points at which the narcotic addict moves from one stage of his life to the next and whether these points can be related to specific "critical incidents, " i.e. , external events which impinge directly on the addict. The methodological problems to be encountered and studied here relate mainly to how many of the addicts can be found at the various stages of their drug career and how much useful data can be obtained from them. However, if all else fails, a by-product of this endeavor will be the procurement of information on mortality and survivorship of addicts. This will be done by using the addicts listed on the roster as a population cohort, i.e., one consisting of various strata defined by differing dates of entry into the cohort. This cohort will be traced and the various sources of attrition or decrement will be identified. From these data, a first approximation to a multiple-decrement life table of narcotic addiction will be developed. Although at any given time there will be some addicts who do not appear on the police roster, it is our contention that the number of urban residents who are truly addicted to heroin and do not eventually come under arrest or investigation for narcotics is small. Thus, in a 20-year file covering over 4, 000 records, persons representing the various patterns of heroin addiction should be present in sufficient numbers to establish the identity of the more common sub-types. We do not have a completely satisfactory solution to the problem of the addict who is not known to police, a specific case of the more general problem of representativeness that plagues all population research on narcotic addiction, but we have reason to believe that our sample will be fairly characteristic of the bonafide addict population of Baltimore City. In prior studies of unselected samples of prisoners and persons identified as addicts on the Psychiatric Register in the State of Maryland, we have, for example, found that the proportions of White male and Negro male opiate addicts from Baltimore City who were known and not known to police were very similar. In short, the police roster, although limited in certain respects, is adequate for the purposes of the study and in terms of community populations represents a significant improvement over institutional samples that reflect treated prevalence. 126'.-J CHARACTERISTICS OF HEROIN ADDICTS 121 J. 111.01 Berzins, Juris I., and Ross, Wesley F. Locus of control among opiate addicts. Journal of Consulting and Clinical Psychology, 40(1):84-91, February 1973. DRUG Opiates SAMPLE SIZE 600 Addicts; 800 Controls SAMPLE TYPE Students; Treatment (inpatient) ETHNICITY Not Specified 400 Male Addicts; 200 Female Addicts; 400 Male Controls; 400 Female Controls 300 Black Addicts; 300 White Addicts GEOGRAPHICAL AREA Kentucky METHODOLOGY Controlled/Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATE(S) CONDUCTED 1968-1970 NO. OF REFERENCES 21 AGE SEX SUMMARY The present investigation resulted from clinical observations at the Lexington Clinical Research Center, which suggested that the opiate addicts admitted for treatment did not fit the customary generalizations regarding locus of control among "powerless" groups. The phenotypic passivity, dependency and maladjustment of many addicts suggested that their mean scores should deviate from the general norms in the external direction. However, addicts certainly displayed a sort of behavioral "independence" that seemed to bespeak an underlying belief in a variant of internal control. Because the use of opiates enables the user to exert direct control over 122 reinforcements, opiate addicts were predicted to show strongly internal expectancies on the locus of control scale, especially on items referring directly to "personal control." This prediction was supported by the study. METHODOLOGY To examine the hypotheses that (a) addicts' mean scores on the locus of control scale would be more internal than those of collegiate subjects, and (b) the predicted differences between the groups would be particularly salient on items that concerned beliefs in "personal control, " addicts' locus of control scale data. was randomly drawn from consecutively accumulated protocols obtained during regular admissions testing. Addict samples of 200 White males, 100 White females, 200 Black males and 100 Black females were selected, which reflected the incidence of these variables at the Center. Collegiate comparison groups of 400 males and 400 females, almost all White, were randomly formed from data gathered in laboratory sections in Introductory Psychology at the University of Kentucky. The addict data were accumulated over a 2-year period (1968-1970); the students were all tested within a 2-week period in 1970. The standard version of the Rotter Internal-External Locus of Control scale was administered to all subjects. Details of the statistical analyses used to test the hypotheses are contained in the article. .> FINDINGS The item and total score differences between the hospitalized group and the comparison group of college subjects strikingly supported the prediction that the addicts would show strongly internal expectancies on the locus of control scale, particularly on "personal control" items. Each addict group exceeded each student group in internality (p < . 025 or better for all comparisons); the student groups did not differ from one another. The multivariate analyses of addict subgroups that were performed disclosed greater internality for culturally favored subgroups (males, Whites) than for less favored ones (females, Blacks). All 23 locus of control scale items are presented in the study, with the content of the internal alternative of each item pair indicated, and the endorsement proportions characterizing the entire addict and student groups. The seven personal control items were endorsed in the internal direction by 82% of the addicts versus 67% of the students, suggesting a strong tendency on the part of addicts to attribute personal control to themselves rather than to external forces. 123 J CONCLUSIONS The addicts' beliefs in personal control seemed worthy of further research to the researchers, especially if it can be demonstrated that such beliefs are drug engendered and, once established, function to counteract the attempts of mental health professionals to facilitate the addict's rehabilitation. The same beliefs in internal control that most treatment regimes hope to engender in the patient may, because of their origins in drug effects rather than in social learning, pose a hindrance to the successful treatment of the opiate addict. 124 III. 02 Gilbert, Jeanne G. , and Lombardi, Donald N. Personality characistics of young male narcotic addicts. Journal of Consulting Psychology, 31(5):536-538, 1967. DRUG Opiates; Multi-Drug SAMPLE SIZE 90 AGE Volunteer 45 (Between 17-34); 45 (Between 16-23) SEX 90 ETHNICITY 38 Black; 52 White GEOGRAPHICAL AREA Newark, New Jersey METHODOLOGY Controlled/Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 16 SAMPLE TYPE Male SUMMARY This study investigated the personality characteristics of young male narcotic addicts. There have been many statements concerning the personality characteristics of narcotic addicts, most of which agree that they have either weak or disturbed personalities. However, most of these evaluations have been based on case histories or personal interviews with apparently no use of any standardized tests of personality. This study compared the personality characteristics of a group of young non-institutionalized narcotic addicts with those of a young nonaddicted group of similar socioeconomic level, using such a test. Results suggested deep-seated and widespread pathology among the addicts. 125 METHODOLOGY Forty-five male narcotic addicts between the ages of 17 and 34 years (average age 22. 7 years) were compared on the MMPI (Minnesota Multiphasic Personality Inventory) with 45 non-addicted males between the ages of 16 and 23 years (average age 18.6 years). The addicts were voluntary participants in the narcotic program of the Mount Carmel Guild in Newark, New Jersey; the control group was identified from the Neighborhood Youth Corps on a voluntary basis. The two groups came from similar below-average socioeconomic levels, most members with less than a high school education. There were unequal numbers of Negroes and whites, but as the scores were practically identical, the two races were treated as one group. Members of the experimental group included persons using a wide variety of narcotic and stimulant drugs. FINDINGS Table 1 of the study, comparing scores of control and addict groups on the MMPI, presents the means, standard deviations and t-test scores for the experimental and control groups. The experimental group as a whole scored higher (indicating greater maladjustment) than the control group on all but one of the diagnostic scales, and the scores on this one scale were quite similar. Figure 1 of the study gives composite 'MMPI profiles of control and addict groups. Only 4% of the addicts showed normal profiles, versus 27% of the control group. Eighty percent of the addicts and 46.7% of the controls gave 2 or more scores above the cutting line. The small percentage of normal personality profiles among the narcotic addicts might have been expected, as well as the relatively large number of "abnormal" profiles in the control group, since most of the controls were school dropouts of a relatively low socioeconomic level. However, it was quite evident that, as a whole, the controls did not show the pathology that was common among the addicts. The test results indicated that individuals in both groups recognized problems within themselves, but that the addicts were somewhat more willing to admit to socially undesirable characteristics. Some individuals in both groups tended to have disturbed personalities, but there seemed to be deeper and more widespread pathology among addicts than among non-addicts. Both groups tended to be overly sensitive and inclined to act out in the face of difficulties or if subjected to too much pressure, but these traits seemed to be more prevalent among addicts than among non-addicts. CONCLUSIONS Although some maladjustment existed in both the experimental and control groups, results suggested deep-seated and widespread pathology among the addicts. Outstanding were the addicts' psychopathic traits, depression, tension, insecurity and feelings of inadequacy, and difficulty in forming warm and lasting interpersonal relationships. 126 I.;.1 - Most addicts seemed to be suffering from a basic character disorder, although many also had associated psycho-neurotic or psychotic traits. It is suggested that the use of drugs may seem to be the only realistic solution to problems, offering temporary relief from the pain of living. £ 127 III. 03 Sutker, P . B. , and Allain, A. M. Incarcerated and street heroin addicts: A personality comparison. Psychological Reports, 32(1):243-246, February 1973. DRUG Opiate s SAMPLE SIZE 204 SAMPLE TYPE Incarcerated; Treatment (outpatient) AGE Adults SEX Male ETHNICITY Not Specified GEOGRAPHICAL AREA New Orleans, Louisiana METHODOLOGY Controlled/Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATE (S) CONDUCTED Not Specified NO. OF REFERENCES 6 SUMMARY between hard-core heroin Earlier studies of personality differencesheroin addicts even more addicts and non-addict prisoners showed prisoners as measured by Scale 4 of socially deviant than non-addict MMPI. These data were collected using an unincarcerated sample of heroin addicts who were physiologically dependent on the drug. The present study evaluated the possibility that the dramatic differences in part related to situaobserved in previous studies may have been This study explored the life. tional pressures inherent in the street functioning of a male addict effects of incarceration upon personality influence of Findings pointed to the modifying prison sample. situational pressures and environmental forces upon current personality functioning, especially among heroin addicts. METHODOLOGY Male volunteers were members of 1 of 3 groups; applicants to the Narcotic Addict Rehabilitation Act Program (NARA), inmates housed in 1 of 2 adult correctional institutions in the State of Louisiana, and inmates serving shorter sentences in the Orleans Parish Prison, New Orleans. A sample of 204 was selected, comprised of 82 NARA applicants, 35 prisoners with a history of heroin addiction and 87 inmates with no history of narcotic abuse. Individuals producing invalid MMPI profiles, showing a history of sporadic heroin or other drug abuse, and/or evidencing signs of mental retardation were excluded from the sample. FINDINGS Comparison of the 3 groups on such descriptive variables as age, education, and intellectual level yielded no significant differences. Although addicts in both groups tended to accumulate more addict convictions than non-addict prisoners, street addicts seemed to have avoided long periods of incarceration better than their prison addict counterparts. Mean MMPI group profile patterns showed that incarcerated individuals, addicts or non-addicts, were more similar in terms of measured personality characteristics than they were different. Street addicts differed significantly from both incarcerated groups on a variety of dimensions. Results suggest that unincarcerated addicts, preoccupied with their addiction,are psychologically more uncomfortable and socially more deviant than either non-addict prisoners or addicts who have been imprisoned and drug free for at least 2 years. Findings pointed to the modifying influences of situational pressures and environmental forces upon current personality functioning, especially among heroin addicts. CONCLUSIONS Pressuresof the drug-oriented life exert a significant effect upon the constellation of personality features so typical of heroin-addicted individuals. Incarceration or hospitalization represent periods of psychological stabilization and relative calm in contrast to their street life and consequently provide the greatest opportunity for initiation of social retraining and self-help efforts toward behavior change. Gains achieved during incarceration may be difficult to sustain because, after release, behavior may reflect the familiar pressures and stimuli suggestive of the old life of addiction. 129 :41 I) III. 04 Gendreau, Paul, and Gendreau, L. P. The "addiction-prone" personality: A study of Canadian heroin addicts. Canadian Journal of Behavioural Science, 2(1):18-25, 1970. DRUG Heroin SAMPLE SIZE 133 SAMPLE TYPE Incarcerated AGE Adults SEX Male ETHNICITY Not Specified GEOGRAPHICAL AREA Kingston Penitentiary, Ontario, Canada METHODOLOGY Controlled /Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATEIS) CONDUCTED January 1962 - January 1965 NO. OF REFERENCES 28 SUMMARY The study tested the evidence supporting the "addiction-prone" personality theory of narcotic addiction through the use of a nonaddict control sample that incorporated several parameters found to be lacking in previous studies comparing addicts and nonaddicts. The results on the Minnesota Multiphasic Personality Inventory (MMPI) of the nonaddict sample were compared to those of an addict group. Contrary to the "addiction-prone" theory, the authors 1laJJ found that the results of the addict and nonaddict groups were not reliably different, and suggested that Lindesmith's alternative to the addiction-prone theory may prove more useful in examining the etiology of addiction. METHODOLOGY The authors argued that in order to measure the differences between addicts and nonaddicts, an adequate control group compared to drug addicts had to meet the following criteria: (1) subjects would come not only from the same socioeconomic level, but also would have had opportunities to obtain narcotics, but failed to become addicted; (2) the control group would have had a criminal record; and (3) age and IQ differences would be minimized between the two groups. To test the "addiction-prone" theory they used as subjects 51 addicts and 81 nonaddicts from Kingston Federal Penitentiary, Ontario, Canada. All had received penitentiary sentences of two years or more and were from the Toronto area. All control subjects' case histories indicated that they had had opportunities to come into contact with narcotics. Ten of these inmates were narcotics pushers. Ages of both groups ranged from 17 to 63 years, and intelligence scores ranged from Beta classification of dull normal to very superior. The mean age and IQ scores of addicts were 30.5 and 104.0, respectively. The mean age and IQ scores of nonaddicts were 29.5 and 103.3, respectively. The testing battery was formed by the Beta IQ test and the Minnesota Multiphasic Personality Inventory (MMPI). The assessment of addicts by means of the MMPI, the authors felt, avoided the subjectivity involved in interpreting projective tests and afforded comparisons with those studies that had found specific differences between addicts and nonaddicts on the MMPI scales. The MMPI and IQ testing of subjects took place at Kingston from January, 1962, to January, 1965. All subjects were tested by trained clerks or the senior author within two weeks after arrival at the penitentiary. A total of 51 addict profiles and 1,500 nonaddict profiles were completed. From the 1,500 nonaddict profiles, 200 nonaddict test profiles were selected at randcr,-.. From this sr aller sample, 82 nonaddict profiles were found to fit the nonaddict criteria. 131 A. A FINDINGS All MMPI scales were scored except the Si scale. No significant differences were found using two-tailed-t-test comparisons. Only two scales, the Mf (t =1. 34, df=131) and Hy (t =1. 46, df=131) were slightly elevated in favor of the addict group. Contrary to previous studies the MMPI scores on the F, HS, Pd, Pa, Pt, and Ma scales were almost identical for the two groups (all t values less than one). CONCLUSIONS The authors had argued that the major emphasis to date on research on narcotic addiction has supported the addiction-prone personality theory that persons who have taken narcotics have specific psychological weaknesses which are satisfied by heroin. However, the evidence that has suggested an "addiction-prone" personality may have been due in part to inadequate control-group samples, at least in those cases where controls were used. The authors concluded that the results of MMPI testing suggested that significant differences between addicts and nonaddicts reported in previous studies may have been due in part to failure in sampling techniques. If the control subjects come from a similar socioeconomic level as addicts and have a prior criminal record, they produce a personality profile markedly similar to addicts. The authors did not deny the importance of psychological factors in the addiction process. However, they discouraged ascribing distinct traits to addicts. Finally they suggested that the Lindesmith alternative to the addiction-prone theory, which argues that opiate addiction is due to the addict's cognitive connection (in terms of linguistic symbols and cultural patterns) between withdrawal stress and the absence of opiates, might prove more useful in examining the etiology of addiction than the "addiction-prone" theory. 132 III. 05 Stewart, Gordon T., and Waddell, Kathleen. Attitudes and behavior of heroin addicts and patients on methadone. In: Proceedings of the Fourth National Conference on Methadone Treatment, National Association for the Prevention of Addiction to Narcotics, (NAPAN), San Francisco, California, January 8-10, 1972. New York: The Association, 1972. pp. 141-144. DRUG Methadone SAMPLE SIZE 147 SAMPLE TYPE Volunteer, Peers, Treatment (outpatient) AGE Not Specified SEX 122 Male, 25 Female ETHNICITY Black and White GEOGRAPHICAL AREA New Orleans, Louisiana METHODOLOGY Controlled/Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATEIS) CONDUCTED Not Specified NO. OF REFERENCES 6 SUMMARY The authors disagree with the general attitude that addiction to heroin is a sickness comparable to chronic deficiency diseases which require both systematic and specific maintenance therapy. They feel the sickness differs from most others in that it is self-engendered through the use of drugs on a scale that leads to a differentiation of the population into two groups: those who become dependent on drugs and those who do not. The authors ask whether behavior with drugs is determined mainly by group characteristics and influences, or by individual characteristics and attitudes of perso.as whose grouping as drug users 133 is accidental. If the former is true, some uniformity in personalities and attitudes among heroin addicts would be expected; if the latter, no difference between addicts and their peer groups should arise except in the use of drugs. The document presents findings concerning patients enrolled in a voluntary methadone program, as contrasted with street addicts and peer controls. Patients stabilized on methadone showed improved patterns of employment and home life. They mostly abandoned crime as a way of life, but this surprisingly was not always shown in arrest rates. Street addicts and methadone program drop-outs showed trends toward psychopathic deviance and confusion. Street addicts as a group also exhibited psychotic responses to the interviews. Variance of these characteristics was greater between groups than within groups. METHODOLOGY Authors obtained demographic and background information from subjects, and used questionnaires and inventories: (1) IPAT, (2) SIV, (3) EPI, (4) Osgood, (5) General Attitude Survey (DART-New Orleans), (6) Drug Experience Check List (DART), and (7) MMPI. Data from these instuments were punched on standard IBM cards as scores. Means, standard deviations, and differences were calculated. A correlation matrix was used to compose mean scores of groups with each other and with background data. The first 6 tests were administered to 218 subjects; the seventh to 147 subjects. Information about charges, arrests, and convictions was obtained and checked in the files of the police departments of greater New Orleans. Information about drop-outs was obtained from the records of methadone clinics, and by tracing individuals. FINDINGS Tests with the IPAT, SIV, EPI and Osgood, the psychological scales, showed an appreciable degree of internal consistency in a correlation matrix. Sociability and leadership correlated significantly with responsibility, and benevolence with conformity (PC.01). Activity on the Osgood scale correlated positively with educational level and number of siblings. Extroversion on the Eysencks (EPI) scale correlated positively with conformity in interpersonal values. Heroin addicts and patients on methadone exhibited high regard for traditional mores, as tested by General Attitude Survey (GAS), except in 134 their use of drugs. None of these scales nor series of psychiatric evaluations gave a clear indication of prognosis, nor did they establish any kind of "addict profile." Differences in personality profiles of Black subjects were revealed by the MMPI. Ex-addicts who were stabilized on methadone did not differ significantly from male and female controls. There were excesses of high scores on the L-F-K scales in male noncollege controls, males on methadone, male dropouts and male street addicts refusing admission to any rehabilitation programs. Profiles of the remaining male and female patients on methadone were strikingly similar to those of the corresponding nonaddict peer groups, indicating an absence of any definite neurotic or psychotic symptom-pattern in subjects completing valid tests. However, high proportions (39%) of male methadone subjects and peer controls could not be tested because of high L-F-K scores. The proportions with invalid tests were also high among male street addicts and males who had returned to the street after dropping out of a methadone program. Subjects completing valid tests showed significant elevations of mean T-scores on Scale 4 (psychopathic deviance). Street addicts showed abnormally high scores on neurotic and psychotic scales, especially Scale 8 (schizophrenia). A discriminant function analysis showed a clear separation of street addicts from all others in T-scores. In overt behavior, methadone-stabilized patients showed improved patterns of employment and home life characteristic of successful methadone programs. They mostly abandoned crime as a way of life, but this was not always shi)wc. in arrest rates. CONCLUSIONS Interpretation of psychological tests, attitudes and behavior in drug users must be pursued cautiously because (1) responses to questions are often deliberately or involuntarily misleading, (2) attitudes vary throughout the day because of drug effects, and (3) adequate "norms" for peer populations are not well-established. Significant deviations in anxiety scales and interpersonal value were absent concerning the various addict groups. The psychological instruments used were insufficiently sensitive to register differences apparent in overt behavior. There was no characteristic "addict profile." The MMPI can serve as a guide to rehabilitation potential and to an additional need for psychiatric treatment in persons whose addiction is associated with confusion, neurosis, and psychosis. For this purpose, interviews are of value only when linked to attendance record, employment, crime record and other aspects of behavior. 135 .A.1) III. 06 Sheppard, Charles et al. Indications of psychopathology in male narcotic abusers, their effects and relation to treatment effectiveness. Journal of Psychology, 81(2):351-360, July 1972. DRUG Heroin SAMPLE SIZE 336 Treatment (inpatient) SAMPLE TYPE c. AGE Adults (Mean Age: 30 Years) SEX 336 Male ETHNICITY Not Specified GEOGRAPHICAL AREA New York, New York METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Psychological Tests DATES) CONDUCTED Not Specified NO. OF REFERENCES 15 SUMMARY This study focused on the incidence, type and degree of psychopathology in a large sample of male narcotic addicts. The MMPI (Minnesota Multiphasic Personality Inventory) was administered to provide data indicating the broad variations in pathology seen in a large sample of addicts. Ninety-four percent of the patients had measurable pathology as reflected in T scores of 70 or above. The data supported the hypothesis that addicts form a heterogenous psychopathological sample. The author believes that quantities of detailed data will help in the design of evaluation studies of treatment effectiveness for each addict subgroup. 136 i A. METHODOLOGY Data were gathered on 336 male narcotic users who were committed to a special treatment unit at Central Islip State Hospital for a 90-day treatment period. To ensure validity of response to a short social history form and the MMPI,participation was voluntary. There were no deviations from the standard instructions for administering the MMPI. All MMPI data were machine scored, and the resulting profiles typed according to the Dahlstrom and Welsh coding system. MMPI self-report was utilized to define personality and psychopathological type because it offered a standardized, objective way to document data of this kind. Standard references defining actuarial rules for assigning tentative diagnostic considerations to MMPI selfreport were employed. This empirical approach reduced certain subjective influences and provided for direct comparison of batches of data collected at varying institutions at different times. Certain differences in reporting MMPI code types were exercised in this report. When L, K, 5, and 0 scales were elevated (above T of 70), this scale was included in profile typing but not in diagnostic considerations. FINDINGS Ninety-four percent of the patients had measurable pathology as reflected in T scores of 70 or above. The data supported the hypothesis that addicts form a heterogeneous psychopathological sample. Thirtythree percent indicated sociopathic personality types, with definite subgroups: patients who had spiked four (4') codes which have been shown to be similar to the MMPI profiles of convicted criminals; patients whose protocols indicated primary sociopathic personality characteristics; patients whose protocols suggested some variant of the 49' primary sociopath, but reflected some defensive operations to contain feelings of anxiety; and a group of secondary sociopathic personality types. Thirty-six percent of the sample had elevations on the psychotic portion of the MMPI. Thirty-two percent of these suggested consideration of underlying schizotypic, incipient schizophrenic, or overt schizophrenic behavior. The remaining 4% indicated possible affective psychotic trends; MMPI profile codes representative of paranoia, paranoid state, or paranoid schizophrenia equaled 24% of this group. Sixteen percent of the sample indicated neurotic disturbance; within this neurotic subgroup, 32 patients had 274' profile types. Two percent of the sample had protocols indicative of organic damage. The data clearly showed that these heroin addicts represented a diverse group in terms of type and degree of psychopathology. Evidence from the study, however, failed to support an addictionprone personality type. 137 CONCLUSIONS In the heterogeneous psychopathological sample of addicts, the specified diagnostic subgroups which can be identified require different treatment modalities. In general, traditional therapeutic methods are ineffective with sociopathic personalities and it may be expected they are equally ineffective with sociopathic heroin addicts. Treatment methods, initial treatment plans and expectations, and total therapeutic goals must differ from those for other patient groups to be realistic. The 3 subgroups of sociopathic heroin addicts differ in counseling readiness, attrition rates, and prognosis; evaluation of treatment effectiveness must be made with regard to specific end points tailored to the characteristics of each group. For the schizotypic, incipient schizophrenic, overt schizophrenic, or psychotic heroin addicts, representing a generally refractory treatment group, focusing on the drug addiction of the group will not be sufficient. This is especially true if the choice of heroin abuse was developed as a means of coping with a basic withdrawal, defensive operation, or protection from sadistic urges or feelings. Methadone maintenance programs for this group will probably have less success than chemotherapeutic programs. The addicts without measurable pathology may show greater readiness for counseling and be reached more effectively by traditional therapeutic approaches. Each of these diagnostic groups have base-rate expectations of treatment effectiveness when addiction is not an attended difficulty. Comparisons of treatment effectiveness of addict subgroups should be made with regard to these base-rate data, rather than to some more global criteria for a total addict sample. 138 i III. 07 Pittel, Stephen M. Psychological aspects of heroin and other drug dependence. Journal of Psychedelic Drugs, 4(1):40-45, Fall, 1971. DRUG Hallucinogens and Opiates SAMPLE SIZE 235 SAMPLE TYPE AGE SEX ETHNICITY Treatment (outpatient) Adults Both Male and Female Not Specified GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Controlled /Ex. erimental DATA COLLECTION INSTRUMENT Psychological Tests DATEIS) CONDUCTED Not Specified NO. OF REFERENCES 11 SUMMARY The primary data for this study were MMPI group profiles obtained from 37 male and 25 female heroin addicts seen at the Haight-Ashbury Free Medical Clinic Detoxification Unit compared with profiles obtained from 100 males and 73 females who have served as volunteer subjects for the Haight-Ashbury Research Project. Findings suggested strong similarities between heroin addicts who seek treatment and users of psychedelic drugs who seek treatment. Both are comparable in basic personality organization to volunteer subjects who are deeply involved in the psychedelic drug culture. 139 ,0 Difficulties in locating a representative sampling of volunteers were discussed. Theoretical implications were set forth by the author as well as suggestions for the handling of persons who are addicted. METHODOLOGY The author compared MMPI group profiles obtained from 37 male and 27 female heroin addicts seen at the Haight-Ashbury Free Medical Clinic Detoxification Unit with those of 100 males and 73 females who served as volunteer, subjects for the Haight-. Ashbury Research Project, The latter subjects were classified as psychedelic drug users on the basis of their primary drug choice. The Detoxification sample included patients classified as New Junkies, Transitional Junkies, and Old Style Junkies on the basis of the date of their initial involvement with heroin. FINDINGS There was a higher overall elevation of the addict profile which might have suggested a greater degree of psychopathology for this group, but the bi-modal profile configuration indicative of character pathology was common to both the addict and psychedelic groups. Despite significant differences between groups on some MMPI scales, the overall similarity of profile configurations suggested that heroin addicts who seek treatment closely resemble psychedelic drug users who seek treatment. Both of these groups are comparable in basic personality organization to volunteer subjects who are deeply involved in the psychedelic drug culture. The author further suggested that there are differences among users of different drugs, and that unique personality constellations, and/or social factors, are associated with the use of each. These two findings have been contrasted in recent drug literature. However, the author feels that the arguments have done little to resolve the question. CONCLUSIONS The author hypothesized that drug dependence is most likely to occur among individuals who lack the psychological resources needed to deal adequately with inner conflicts and/or environmen- tal frustrations. Some individuals appear to become drug dependent in spite of having previously achieved a reasonable degree of personality organization, or when they are subjected to unusually severe situational stress, chronic pain, or anxiety. 140 Attention should be focused on the processes of personality rather than on fixed trait structure when studying drug users. Therapy for drug users would be geared to their need for structure and stability, and to the gradual building of ego functions. 141 III. 08 Sutker, Patricia B. Personality differences and sociopathy in heroin addicts and nonaddict prisoners. Journal of Abnormal Psychology, 78(3):247-251, December 1971. DRUG Heroin SAMPLE SIZE 40 Addicts; 40 Nonaddicts SAMPLE TYPE Treatment (outpatient): Addicts Incarcerated: Nonaddicts AGE Adults SEX 80 Male ETHNICITY Not Specified GEOGRAPHICAL AREA New Orleans, Louisiana METHODOLOGY Controlled/Experimental DATA COLLECTION INSTRUMENT Psychological Tests DATEIS) CONDUCTED 1968( ? ) Na OF REFERENCES 16 SUMMARY The study was designed to investigate personality differences, especially with regard to social deviance or sociopathy as reflected by Minnesota Multiphasic Personality Inventory (MMPI) scores on Scale 4 and profile configurations between a group of hard-core heroin addicts and a control group of nonaddict prisoners. It was hypothesized that although the groups would appear basically similar, heroin addicts would evidence significantly higher elevations on Scale 4 of the MMPI than would nonaddict prisoner's, reflecting greater sociopathy on this dimension. Results suggested that there are measurable personality differences with respect to the incidence and extent of sociopathy. 142 METHODOLOGY A total of 80 adult men was selected: 40 unincarcerated heroin addicts and 40 nonaddict inmates serving sentences in the Orleans Parish Prison. The 2 samples did not differ in terms of age, educational level, intellectual level, or chronicity of antisocial behavior as indicated by time served in prison. In order to screen heroin addicts from the nonaddict control group, the records of all prisoners tested were carefully reviewed, interviews held, and all known addicts excluded from the sample. The subjects in both groups were administered the group form of the MMPI and the Shipley Institute of Living Scale. For the most part, tests were completed in a group situation. Composite MMPI profiles were compared for statistical differences between groups, and individual MMPI profiles were classified using a system of differential diagnosis reported by Meehl in 1956. FINDINGS Although heroin addicts and prisoners evidenced a number of common personality characteristics, heroin addicts reported more neurotic symptoms than did nonaddict prisoners, with more depression, pessimism, anxiety, and concern for bodily ailments. High elevations on these scales could not be attributed to a tendency to endorse deviant items more frequently, as indicated by similar scores on the F scale for the 2 groups. Comparison of unincarcerated heroin addicts and prisoners with no history of heroin addiction on the Cavior He scale showed a significant difference in the predicted direction. Such findings clearly pointed to the possibility of differentiating addicts from nonaddicts using such a scale; however, the problem of overlapping items and similarity between groups would make such comparisons difficult. Classification of MMPI profiles for addict and nonaddict groups showed that at least one-half of the addict sample could be described diagnostically as socially deviant or sociopathic-, while only 30% of the prisoners met the criteria for this category. Twenty-three percent of both addicts and prisoners were classified as psychotic; the percentage of purely neurotic individuals was low in both groups. Even though addicts scored higher than the nonaddicts on the neurotic triad, in the overall classification, only 15% were classified as neurotic. This indicated that although there was evident in the addict group a greater tendency toward social nonconformity and a rejection of traditional values and restrictions, at least some of these sociopathic individuals were also experiencing depression and anxiety. Heroin addicts displayed primarily 2 types of psychopathology, with 50% classified as ccnduct disorder and 23% classified as psychotic. In contrast, almost half the prisoner sample was classified as normal. 143 CONCLUSIONS Results of this investigation suggested that there are measurable personality differences between heroin addicts and nonaddict prisoners, especially with respect to the incidence and extent of sociopathy. There is a need for greater refinement of the concept of sociopathy as well as refinement of sociopathic samples used in research investigations. Preoccupation with physical complaints and concern for bodily functioning are likely to be the result of an addiction which has to be maintained under the pressures of legal surveillance and threat of drug deprivation. It may be hypothesized that anxiety is a recurring state in many unincarcerated addicts, present regardless of personality type. The striking exaggeration of Scale 4 in the mean addict profile suggested that addicts have at least a tendency to be more socially deviant than nonaddict prisoners. Whether their sociopathy is the result of years of struggling to acquire daily illicit drugs or a precipitating factor in their becoming heroin dependent is a problem for further research. Isolating similar types of individuals within the framework of sociopathy offers one avenue of approach for investigating causal factors in the development of various types of antisocial behavior. That differential exposure to criminal or drug-using behavior influences the direction of asocial activities, given the characteristics of social deviance, is not entirely explanatory, however, in that both prisoners and addicts came from predominantly the same low socioeconomic classes in which heroin is often available on the street. Most nonaddict prisoners reported easy access to heroin and other drugs and even drug experimentation. Perhaps there is not yet sufficient justification to abandon the search for specific predisposing characteristics or needs which might be related to the formation of a drug habit. 144 111.09 Gay, George R., et al. The Psychotic Junkie. New York: Insight Publishing Company, October 1972. 4 pp. (A Medical Insight Reprint). DRUG SAMPLE SIZE Opiates 1 SAMPLE TYPE Treatment (inpatient) AGE Adult SEX Male ETHNICITY White GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Case Study DATA COLLECTION INSTRUMENT Not Specified DATEIS) CONDUCTED 1969 NO. OF REFERENCES 11 SUMMARY This is a case study of a psychotic heroin addict, exploring the usage of heroin as an antipsychotic drug, the multiple difficulties associated with treating a psychotic addict, and the methods used in this patient's treatment. The authors observed that between October 1969 and March 1972. Over 2, 000 patients had been seen and treated at the heroin section of the Haight-Ashbury Free Medical Clinic. Among them were numerous individuals who were using heroin for its tranquilizing and antipsychotic properties. The antipsychotic effects of the opiates have long been recognized. Prior to the introduction of the phenothiazine 145 1.4 tranquilizers, opiates were used in Europe to treat severe manicdepressive psychosis and melancholia. In many of the cases the authors observed, covertly psychotic in- dividuals remained ambulatory and functional on self-maintained dosages of heroin, only to have their psychosis become overt during or shortly after withdrawal. However, with some patients the psychotic diagnosis was all too obvious, as they came to the clinic only after their resources for obtaining heroin had failed and a life crisis was well underway. Therefore, establishing a diagnosis of psychosis while the patient is adequately supplied with heroin can be extremely difficult. In this case study, Ed, a 31-year-old white male heroin addict, first came to the Clinic in December 1969. Profoundly depressed and physically unkempt, he was unable to look directly at his interviewer. He mumbled that he wanted to be hospitalized for the rest of his life because, he said, "I quit. " Prior to coming to the Clinic, Ed used not only heroin but barbiturates, alcohol, and occasionally psychedelics. Ed was diagnosed as a hopeless schizophrenic with feelings of utter worthlessness that are common occurrences in the psychotic addict and one of the first hurdles to be overcome in therapy. He agreed to try therapy at the Clinic and was quite faithful to his schedule of five 30-minute sessions a week. His treatment consisted of active, psychodynamically-oriented therapy. Ed discussed his feeling that people wanted to attack him in buses and in stores. He had difficulty remembering what had been said in previous sessions, had no memory of a marriage which lasted from the time he was 16 until he was 25, and only sketchy memories of several hospitalizations during the previous 5 years. A point of crisis occurred during the sixth month of therapy when the sexual atlyd.nces of a woman caused such a panic that Ed consequently overdosed on heroin in an attempt to quell his anxiety. In therapy he was beginning to become aware of his extreme dependency on heroin to manage such situational fear. Subsequently, it was decided to start Ed on chlorpromazine (Thorazine) as a specific antipsychotic medication. Ed then decreased his heroin habit to about one fix every 7 to 10 days. At the end of 6 months, Ed began to have homosexual fantasies concerning the psychologist. During the seventh month, he began to explore his more painful life fears. He recalled his first association with heroin which occurred at the age of 14 when he witnessed his elder brother shoot and kill his mother in her bed while Ed was hiding under it. After leaving the house, the brother went to his own home where he killed his wife and then himself. A week later his father attempted to kill one of his sisters. The father was subsequently hospitalized and Ed was left, along with a younger brother, in the care of an older 146 sister who allowed the boys to run free, often unfed and uncared for. The memory of this family tragedy reduced Ed to such a depressed state that he was barely able to climb the Clinic stairs for his daily therapy sessions. As his depression began to improve, Ed went back to hustling heroin and stopped therapy. The next contact with him occurred when he was brought back to the Clinic in a rigid, catatonic state and was hospitalized for 10 days. After further therapy, Ed saw his psychotic breakdown and hospitalization as the culmination of many life pressures. The first and major pressure was the burden of reactivated memories of his family. Another major fear was the necessity for employment and timestructuring, particularly the associations with strangers which looking for a job involved, and his fear of potential rejection. Ed then became a successful patient on the city's methadone maintenance program for 9 months, and in addition to methadone, received 400 mg. of Thorazine daily. CONCLUFTON The authors felt that Ed's presenting difficulties were extremely complex and required close multiprofessional involvement and medication supervision. Involving Ed immediately in a group confrontation or group encounter experience, a common approach by many nonmedically-oriented programs, would have frightened him to panic proportions and perhaps accelerated psychotic decompensation. In most cases, psychotic addicts voluntarily reject such groups because the intense confrontation is too threatening. As methadone, unlike morphine and heroin, possess little if any antipsychotic effect, they recommended that psychotic addicts who are maintained on methadone should therefore probably also receive antipsychotic medications. With the rapid growth of methadone maintenance as a treatment modality, more clinical research on this issue was urged. 147 1 ' I11.10 Monroe, Jack J. The attribution by opiate addicts of characteristics to addict subgroups and to self. The Journal of Social Psychology, 85(2):239-249, December, 1971. 1 DRUG Opiates SAMPLE SIZE "about" 150 SAMPLE TYPE Treatment (inpatient) AGE Not Specified Male SEX ETHNICITY GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT Black Lexington, Kentucky Controlled/Experimental Addict Identification Scale DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 15 SUMMARY The purpose of this paper was to investigate the applicability of perceived similarity and social favorability scales to the assessment of reference group valences in opiate addicts. Renewed interest in the Addict Identification method as a research tool had been engendered by the clinical assumption that perceived similarity with, and favorable evaluation of, designated others account for the orienting effects of the alternative reference groups upon attitudes and values of institutionalized drug addicts. The investigation demonstrated the applicability of the Addict Identification method 148, for the assessment of alternative reference groups, providing empirical support for theoretical formulations relating addict identification with the values of these groups. METHODOLOGY Subjects were male Negro prisoners from the North Central and North East regions of the United States, resident in a facility at Lexington, Kentucky. About 150 potential subjects agreed to participate. The initial task was to modify and refine the testing materials used in previous studies. Favorability content for each of the 52 items of the original Addict Identification Scale was determined from the responses of 50 addicts drawn at random from the inmate population of male prisoners. The 10 most favorable and the 10 most unfavorable items were selected for a revised favorability scale, to counterbalance the potential effects of yeasaying vs. nay-saying tendencies. Six parallel scales were constructed to collect Favorable Group Evaluations of specific subgroups of addicts. The parallel sets of questionnaire items were designed to elicit favorable and unfavorable self-presentations and group assessments on 3 status dimensions. In each dimension one pole represented a specified membership presumed to be a positive reference group, while the other pole symbolized a contrasting, and presumably negative one. An item by item scoring of congruent responses to pairs of items describing self and designated subgroups yielded measures of addict identification or psychological closeness with reference groups. Configurally scored scales were not superior to single response scales in differentiating the valence levels of reference groups. Quasi-experimental conditions were achieved in this study (a) by controlling and varying the valence content in test items, (b) through the utilization of respondent pools which were carefully matched on pretest self-concept and life history variables, and (c) by random assignment of subjects to test groups. FINDINGS Controlled variation in stimulus materials consisting of positive vs. negative reference group symbols produced different rates of favorable response in the attributions by addicts of characteristics to addict subgroups. Greater favorability was ascribed to membership groups. Subjects tended to attribute unfavorable qualities (and in some cases tended to neutralize their responses) to nonmembership groups. To the extent that psychomeLlically defined perceptions of similarity between self and generalized others and the attribution of characteristics to groups meet conceptual requirements of the social comparison process, this study provided empirical support for linking addict identification with perceived valences of addict groups. 149 CONCLUSIONS The results of this study and of previous investigations with the AddiA Identification method are potentially applicable to the the formation of response hierarchies in a single individual or to development of classes of responders defined in terms of the most favored membership or reference group. Repeated measures may prowith the same subjects on a series of favorability scales of a vide a useful method for measuring the perceived valences practical and variety of social groups. Such scales may have both intervening variables and testtheoretical value in defining crucial and refering underlying assumptions in research on membership inence group selection, and on the role of group attraction and of values and the facilitation fluence in the learning of social attitude change. A'/150 Nurco, David N. An ecological analysis of narcotic addicts in Baltimore. The International Journal of the Addictions, 7(2):341-353, Summer, 1972. DRUG SAMPLE SIZE Not Specified 833 SAMPLE TYPE Narcotic Addicts AGE Not Specified SEX ETHNICITY GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT DATE (S) CONDUCTED NO. OF REFERENCES Not Specified Not Specified Baltimore City, Maryland Statistical Study Government Statistics Not Specified 0 SUMMARY This study examined whether or not narcotic addiction has any relationship to other forms of social pathology. It was based on the records of persons classified as narcotic addicts by the Baltimore City Police Department's Narcotic Unit, from December 1, 1966, to November 30, 1968. Rates per 100, 000 for the current narcotic addict population by census tract in Baltimore City were modified with 1965 population estimates (tabulated by the Baltimore City Health Department). The rate of addiction was then compared to rates computed in the same manner for financial dependency, adult 151 arrests, and juvenile delinquency for Baltimore City. It was concluded that narcotic addiction does not follow as closely the pattern of "residence" as do other forms of social deprivation. METHODOLOGY The analysis of the ecological data was carried out by 3 tests: (Test I) The Pearson r correlation between census tract rates for narcotic addiction and rates for each of the 3 additional measures of social pathology; (Test II) Rank ordering of all census tracts by rates on each of the 4 social pathology variables, and calculation of rank-order overlap within quartiles based on narcotic addiction; (Test III) Computing correlation coefficients within each quartile which takes account of the exact ordering of the tract within quartiles. FINDINGS Test I. The correlation coefficients relating narcotic addiction to each of the 3 other forms of social pathology were: financial dependency (0. 59); adult arrests (0. 44); and juvenile delinquency (0. 52). Test IL The percentage of overlap for those census tracts within each of the 4 quartiles was computed on a percentage basis, in order to make comparisons between narcotic addiction rates and the rates for each of the other forms of social pathology. The relationship between narcotic addiction and the 3 forms of social pathology was fairly high in the first and fourth quartiles; however, it was comparatively low for quartiles 2 and 3. When comparing the social problems of financial dependency with adult arrests, the percentage "overlap" was quite high. Thus, financial dependency and adult arrests were more closely associated within given geographic areas than were either of these with narcotic addiction. Juvenile delinquency was likewise more closely related to financial dependency and adult arrests than to narcotic addiction, though these relations were weaker than those between financial dependency and adult arrests. Test III. Computing correlation coefficients within each quartile was the most rigorous of the 3 tests of relationship among the variables (all 4 forms of social pathology). The statistical tests were presented in order from the least to the most exacting. As the data was broken down into finer units there was less variation, and the overall comparisons (Tests I and II) were more useful than internal comparisons (Test III). 152 CONCLUSIONS It was concluded that narcotic addiction as it is known to the police in Baltimore City is more often found in those areas where there is extreme deprivation, crime, and juvenile delinquency; it is found less often in those areas where these 3 social problems appear less often. In addition, these same 3 problems, when compared with narcotic addiction were more often found in the same degree of intensity in their respective quartiles (i.e., were more highly correlated with each other than they were with narcotic addiction). Therefore, narcotic addiction did not follow as closely the same pattern of "residence" as did the other forms of social deprivation: being a poor person, a criminal, or a juvenile delinquent. The implication of these data for agencies which currently provide services to narcotic addicts is that addicts are not to be found in precisely the same census tracts as persons with other forms of social pathology, although the overlap is substantial. Because there is some difference, these agencies will have to provide services for addicts from among the populations which they do not now serve, which will be particularly important for early case-f inding and other preventive activities. 153 III. 12 Williams, Joyce E., and Bates, William M. Some characteristics of female narcotic addicts. The International Journal of the Addictions, 5(2):245-256, June 1970. DRUG Opiates SAMPLE SIZE 172 AGE Treatment (inpatient) Adults (17-70; Mean Age 34.9) SEX Female ETHNICITY 58 Black, 114 White GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Program/Clinic Statistics DATE(S) CONDUCTED Not Specified SAMPLE TYPE NO. OF REFERENCES 11 SUMMARY The group studied comprised all female addicts admitted to the Public Health Service Hospital in Lexington, Kentucky during the last 6 months of 1965. The study paralleled an earlier study onof males done by Bates in 1966, providing data for a comparison male and female addicts in terms of oPrtain social and geographic characteristics. Two major patterns of drug use emerged: (1) heavily Negro, metropolitan area users of illegal drugs, and (2) nonmetropolitan 154 L .1t Southern, older addicts, users of legal or quasi-legal drugs. Female addicts were found to have characteristics similar to males. They were slightly older as a group when admitted to Lexington. METHODOLOGY From June through December 1965, 172 female patients were admitted to the U.S. Public Health Service Hospital in Lexington, Kentucky. Fifty-eight patients (33. 7%) were Negro, 114 (66. 3%) were White. The female hospital population had an overrepresentation of Negro women by a factor of 3. To study geographical distribution, patients were grouped into 4 residential categories: (1) Metropolitan areas of New York City, Chicago, and Washington, D.C. , (2) South: metropolitan and nonmetropolitan, (3) non-South: metropolitan and nonmetropolitan, and (4) Puerto Rico. FINDINGS New York City produced the largest absolute number of addicts. Over half (63. 8 %) of all Negro women patients came from New York, Chicago, and Washington, D.C. The South contributed 33. 7% of the total population but no Negroes. Negroes were found to be overrepresented in the total patient population, but underrepresented in the Southern admissions. Southern Negro females were less represented than Negro males in hospital admissions. The population studied did not include a single Negro from a nonmetropolitan area. A higher percent of Negro female patients in the group had moved from their state of birth than White patients. Female patients had a mean age of 34. 9 years. Negroes were approximately 7 years younger than Whites; addicts from metropolitan areas were younger than those from nonmetropolitan areas. Sources of narcotics were more likely to be legal in nonmetropolitan areas. Less than 1/2 of all females had a legal source of drugs. The findings paralleled Bates' earlier findings on male addict patients. Two patterns of drug use emerged: a heavily Negro metropolitan pattern of illegal drug use, and a nonmetropolitan Southern pattern comprised of addicts about 10 years older who used legal or quasi-legal drugs. 155 III. 13 Cuskey, Walter R. ; Moffett, Arthur D. ; and Clifford, Happa B. Comparison of female opiate addicts admitted to Lexington hospital in 1961 and 1967. HSMHA Health Reports, 86(4):332 -40, April, 1971. DRUG Opiate s SAMPLE SIZE 457 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Female ETHNICITY 239 White; 218 Black GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT Lexington, Kentucky Comparative Clinical Statistics ()ATM) CONDUCTED 1961 NO. OF REFERENCES 23 and 1967 SUMMARY adThis study was a comparative analysis..of female opiate addicts mitted to Lexington Hospital, Kentucky, in 1961 and 1967. The examined the economic, social, geographic and educational background on characteristics of White and Negro female addicts and commented The study periods of admission. significant changes between the two also suggested various treatment programs and the cost of their ope ration. 156 METHODOLOGY This study was concerned with seeking evidence of changes within the female addict population between 1961 and 1967. Race, having already been demonstrated as- a significant control variable, was incorporated with time, thereby producing a frame of reference to measure changes within the racial composition of the female addict group. From January through June, 1961, 284 women had been admitted the clinical research center at Lexington Hospital for treatment ofto narcotic addiction. The racial distribution of the addicts was 52. 8 %, or 150, Whites and 47. 2%, or 134, Negroes. During the same months of 1967, there were 173 women admitted for treatment, with the racial distribution of the addict patients almost identical to that of 1961: 51.4%, or 89, were White and 48.6%, or 84, were Negroes. The study was designed to ascertain any time-race differences through 3 separate statistical comparisons: (a) White women admitted in 1961 and their 1967 counterparts; (b) Negro women admitted in 1961 and their 1967 counterparts; and (c) all women admitted in 1961 compared with all women admitted in 1967. The variables selected for these comparative analyses were grouped into 3 categories: (a) Pretreatment background characteristics (i. e., level of formal education; marital status (civil) immediately before entering treatment; primary means of support); (b) geographic distribution, and (c) characteristics at admission for treatment. FINDINGS The distribution of attained formal education did not change significantly between 1961 and 1967, regardless of the addict's race. In 1961, a total of 8. 8% of all women had pursued higher educations; by 1967, a total of 13. 3% had gone beyond high school. The number of women who dropped out before completing high school significantly decreased between 1961 (64. 8% school dropouts) and 1967 (55. 5%) dropouts. With regard to marital status, in 1961, a broken marriage was reported by 33.4%; in 1967, however, 42. 2% reported broken marriages. Of all the pretreatment background characteristics, the most significant changes occured in how the female addicts supported themselves. Generally, both the number of those legally employed, and those who were dependents, decreased. The number of those resorting to illegal activities as a primary means of support increased--from slightly more than 10% in 1961 to more than 30% in 1967 among the White addicts, and from a little more than 36% in 1961 to almost 67% in 1967 among the Negro addicts. Regardless of rase, illegal activities increased as a primary means of securing money for drugs. 157 ''he demographic study of the female patients of Lexington would seem to indicate the existence of 3 major life styles: White heroin addict: often a young woman supporting herself by illegal means, with probably one or more broken marriages. White medical addict: an older woman, dependent on others for support, using drugs other than heroin. Negro heroin addicts: younger persons deriving support from illegal means, and having a high rate of broken marriage s. CONCLUSIONS The emerging pattern of the life situations of the women included in the studies shows an interwoven history of social, economic, and psychological problems, with recurrent relapses requiring hospitalization. These findings imply the need for a preventive mental health program directed to the addict population. Particular attention would seem to be required in child psychiatry, and in meeting the socialization needs of children living in pathogenic or pathologic situations. This would be most urgent for female children, especially Negro, whose life alternatives are generally limited to their immediate family and its social network. The findings also imply the need to study the social support systems available to addicts returning to their family environment after hospital treatment and a need to develop possible alternatives. 158 III. 14 Chambers, Carl D.; Hinesley, R. Kent; and Moldestad, Mary. Narcotic addiction in females: A race comparison. International Journal of the Addictions, 5(2):257-278, June 1970. DRUG Opiates SAMPLE SIZE 168 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Female ETHNICITY 57 Black; 107 White; 4 Puerto Rican GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews; Program/Clinic Statistics DATEISI CONDUCTED June-December 1965 NO. OF REFERENCES 5 SUMMARY This study is an analysis of addicted women admitted to a Public Health Service hospital. Differences in social, addiction, and deviancy characteristics were found to be associated with race, Negro versus white. Significant differences in family history, type and source of drugs, and involvement in other illegal activities have led to the description of two main types of abusers. The older, white "medicine" addicts and the young, urban, predominantly Negro group must be dealt with as separate patterns requiring independent treatment modalities. 159 METHODOLOGY A statistical analysis of the records of the 168 female addict patients admitted to the U.S. Public Health Service hospital at Lexington, Kentucky from June-December 1965 was performed. Data were obtained from official hospital records and patient interviews. The study was designed to ascertain any significant differences between the white and Negro addicts using Chi-square comparisons. Investigation was made of social, addiction, and other deviancy characteristics. FINDINGS Social Characteristics The racial distribution of the subjects was 66. 1% white, 33. 9% Negro. The mean age of the white females was 37.0 years and of the Negroes 30,4 years. The white addicts tended to be from the South, while more Negroes came from the North Central region of the U.S. All of the Negroes, but only 78% of the whites, were from a Standard Metropolitan Statistical Area. White addicts more frequently reported their fathers had been white collar workers. Negro addicts had more often been reared in broken homes (72% vs. 46%) and had more often been reared in a situation where the mother worked outside the home. The amount of completed formal education was not associated with race. About 63% of the sample had not completed high school. Negro addicts more frequently reported intact marriages (82% vs. 55%). There were significant race differences in occupational status. Negroes were almost twice as likely to be in the category "illegally employed" and only half as likely to have been "dependent. " Addiction Characteristics The mean age of first drug use for whites was 27.4 years and a medical or quasi-medical rationale was reported. Negro addicts had a mean onset age of 21.3 years and reported first use in a social context. Heroin was overwhelmingly the most popular opiate, although its prevalency was significantly lower for whites. Marijuana use was associated with heroin use, with Negro addicts more frequently reporting marijuana use. Negroes were also more likely to have secured their drugs from an illegal source, a consequence of the greater degree of heroin use by that group. White subjects were more likely to be volunteer patients, with 91% in that category vs. 68% of the Negroes. 160 Other Deviancy Characteristics Negroes, more than whites, reported they had been "pushers. " Most "pushers" reported supporting themselves primarily by this means. More Negroes (68. 4%) than whites (36. 0%) had histories of prostitution. Most who engaged in this activity did so for primary rather than supplementary financial support. Having an arrest record was also associated with race; 91% of the Negro addicts vs. 59% of the whites reported this history. Ninety-one of the patients received a psychiatric evaluation at the hospital. White addicts were most frequently labeled as having personality pattern disorders; Negroes were more frequently diagnosed as having personality trait disorders or sociopathic disturbances. CONCLUSIONS Significant race differences were found between Negro and white opiate addicts. Race, age, specific drug abused, and geographic region may be clustered to differentiate separate patterns of female narcotic addiction. One group would consist of older whites residing in small cities and towns in the South who are abusers of legal narcotics. Health professionals of both races may also be included in this group of "medicine" addicts. A second group would consist of the younger whites and. the Negroes of the larger metropolitan cities, the stereotypic street heroin addict. Race as an independent identifier of a specific type of addict becomes less important in the non-Southern areas where Negroes are allowed greater participation in the drug-taking subcultures. Most social scientists would attribute these subcultural phenomena to theories of alienation, blocked-access, accessibility, etc. The clinician who treats female addicts must have several modalities available. For example, older white addicts will probably not conceive of themselves as addicts, and thus not respond to nonmedical treatment of their "problem. " Their drug use is tied to real or imagined physical illness. The younger white and Negro addicts, who have used drugs for the euphoric effects, will not tie their use to physicial illnesses. They will have histories of arrest and will probably have undergone previous "cures. " Character or behavior modification becomes the major components in any treatment modality with the street addict. The differences in personal and social attributes of female addicts can thus be predictive of their abusing behavior. 161 III. 15 female Glaser, Frederick B. Narcotic addiction in the pain-prone International patient. I. A comparison with addict controls. The Journal of the Addictions, 1(2):47-59, June 1, 1966. ORUG Opiates SAMPLE SIZE 55 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX 55 Females ETHNICITY 13 Black; 39 White; 3 Other GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Controlled/Experimental OATA COLLECTION INSTRUMENT Interviews; Program/Clinic Statistics OATE(S) CONOUCTEO Not Specified NO. OF REFERENCES 24 SUMMARY female The social and demographic differences between pain-prone inand other female addicts were patients addicted to narcotics, of the pain-prone patient was applied: vestigated. Engel's definition whom psychic factors play the primary "certain individuals... among well as the presence of role in the genesis of pain, in the absence as to differ peripheral lesions. " The pain-prone addicts were found Painvariables. addicts on a number of significantly from the control preferred codeine, came prone addicts as opposed to control addicts, identify from a higher social class, were primarily White, did not 162 themselves as addicts, had never spent time in prison, and had never engaged in prostitution to support their habit. METHODOLOGY A group of 25 female pain-prone addicts was identified and compared with a control group of 30 randomly selected female addicts among the patients at the United States Public Health Services Hospital at Lexington, Kentucky. For the purpose of this paper, 3 criteria were applied to identify a pain-prone addict: (1) she had to appear at the Lexington Hospital for a treatment of narcotic addiction, but need not show symptoms of withdrawal severe enough to necessitate substitution medication; (2) her history must indicate she had used narcotics as a result of the experience of pain and (at a conscious level) primarily for the relief of pain; and (3) psychological factors had to be shown to be primary in the genesis of her pain. Hypotheses were formulated as to differences between the study and control groups. The charts of the pain-prone patients were searched for retrospective data bearing on these hypotheses. The 30 control gio up patients were interviewed on a schedule with relatively unstructured periods included. In this sense the approach to the control group was prospective and differed somewhat but not significantly from the study group approach. Patients in both groups were most frequently interviewed during the orientation phase of their hospitalization, subsequent to drug withdrawal. Psychiatric evaluations of all 55 patients were either performed by the author or presented to him at a weekly conference, during which he interviewed the patients. For both groups the data were first tabulated and then tested for statistical significance. FINDINGS All of the pain-prone patients had begun to use narcotics for a medical reason (relief of pain) and this differentiated them from the controls at the start to a highly significant degree. Not one of the painprone patients had ever obtained narcotics from an illegal dealer. The pain-prone patients were older when they came to Lexington and they also had begun using drugs much later in life. All bin one of the painprone patients was White; they were more apt to be Protestant and divorced. There were many similarities between the drug usage patterns of pain-prone patients as a group and what has been called the "Southern pattern" of addiction to narcotics; more pain-prone patients came from the South than controls. A higher degree of education characterized the pain-prone patient; 64% were high-school graduates or better and many were in the nursing profession. The p'a'in -prone patients had undergone major surgical operations to a highly significant degree. None of the pain-prone patients had ever used heroin, whereas it was the drug of choice in the control group. Conversely, none of the control patients preferred codeine, while 28% of the pain-prone patients did. None of the pain-prone patients had used marijuana. Although 76. 7% of the control cases preferred to inject their drugs intravenously, none of the pain-prone patients 163 preferred this. Although the diagnosis of personality disorder was the most prominent one in both groups, the pain-prone patients were given a primary diagnosis of personality disorder in all cases. Only 66.7% of the control cases were so diagnosed. The pain-prone patients more frequently belonged to a higher social class than the controls. Much of the data also appeared to suggest that the painprone patients did not feel themselves to belong to the so-called addict subculture, and their behavioral characteristics did not identify them with it. CONCLUSIONS The study group was selected on the basis of a psychological variable, that of pain-proneness, yet it was found to vary from the control group to a highly significant degree, on a large number of social and demographic variables as well, although the design of-the study favored similarities between the groups. The data demonstrated fairly conclusively that narcotic addiction with the pain-prone patient is an iatrogenic disorder, at least for females. The patient, tending to be from the middle-class, is self-defined neither as a narcotic addict nor as a psychiatric patient; her chosen identity is that of the medical patient. Prevention is the only feasible method of dealing with the problem of addiction in the pain-prone patient. The physician must recognize psychogenic pain and appreciate the potential for addiction in such patients. 164 III. 16 Ellinwood, E.H.; Smith, W. G. ; and Vaillant, G. E, Narcotic addiction in males and females: A comparison. The International Journal of the Addictions, 1(2):33-45, June, 1966. DRUG Multi-Drug SAMPLE SIZE I 11 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Both Male and Female ETHNICITY GEOGRAPHICAL AREA Black and White Lexington, Kentucky METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED October 1964 to March 1965 NO. OF REFERENCES 0 SUMMARY Eighty-one men and 30 women from the U.S. P. H.S. Narcotics Hospital at Lexington, Kentucky, who were admitted from October, 1964 to March, 1965, were selected for study. Comparisons between males and females were made in a variety of categories. Salient similarities and differences were demonstrated. The data revealed much more uniformity between male and female addicts than earlier clinical impressions had led the authors to believe. 165 Results indicated various combinations of cultural, family, and personal dynamics, some sex-specific, which underlie addiction. METHODOLOGY A representative sample of 100 patients selected from the total number of admissions to the U.S. P. H. S. Hospital in Lexington, Kentucky, from October, 1964, to March, 1965, were interviewed extensively by 1 of 5 psychiatrists. The sample, comprised of every tenth admission, with the total admissions for the 6 months' period,found that the sample was in fact representative. The ratio of men to women was 4 to 1. Eighty-one men were selected, and every fifth female was selected from the total admissions until there was a total of thirty women. The design of this study was to provide a broad general description of male and female addicts, and to elicit areas in which women might differ from men. Because of the multiple breakdown in each category, the sex differences were not often statistically significant. FINDINGS The chief difference noted between males and females was in the absolute difference in members. There were 4 times as many males in treatment. Seventy-five percent of the patients were reared in urban or metropolitan areas of the U.S. Similarities were apparent in age, race, and religion. Reasons for starting drugs were similar for both sexes, with about 2/3 having revealed subcultural motivation. Both procured their drugs from similar sources - mainly from fellow addicts. Men and women started drug use at about the same age, but women became addicted more quickly after starting. Women more often resorted to prostitution to support their habit, while men resorted to property crimes. The majority of both sexes were high school drop-outs. Most women (70%) had not had a job in the last year. Men worked more often. Women tended to have fewer convictions and sentences, and were employed for shorter periods of time. The family backgrounds of men and women were similar in many ways, one exception being that men tended to come from larger families. Most patient's parents were immigrants or black rrigrants from the south. Seventy-five percent of the patients were reared in urban or metropolitan areas. One fourth of all fathers were alcoholics. Mothers of women were noted to be frequently antisocial, criminal, and alcoholic. Siblings of women, especially brothers, had histories of psychiatric treatment. About 40% of the 166 sample came from broken families, but in the case of the women there was an earlier separation of parents, both from each other and from the child. There was not only marked competition with rebellion from the mother, but also identification with the behavior of the parent. CONCLUSION Various combinations of cultural, family, and personal dynamics, some sex-spec ific,underlie addiction. Patterns of drug addiction should receive more detailed and controlled analysis. Drug use itself is a great leveler, which may produce much of the uniformity noted in addicts. 167 Wellisch, David K.; Gay, George R.; and McEntee, Roseann. The easy rider syndrome: A pattern of hetero- and homosexual relationships in a heroin addict population. Family Process, 9(4): 425-430, 1970. r DRUG Opiates SAMPLE SIZE Not Specified SAMPLE TYPE Treatment ( outpatient) AGE Adults SEX Male and Female ETHNICITY Not Specified GEOGRAPHICAL AREA San Francisco, California METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Observations DATEIS) CONDUCTED 1970 NO. OF REFERENCES 7 SUMMARY Drawing on experience gained at the Haight-Ashbury Free Medical Clinic, the authors present an analysis of a pattern of dyadic relationship in the heroin addict subculture. The "Easy Rider Syndrome, " a pattern characterized by the male figure of a couple being supported by the female, is analyzed in terms of its familial antecedents, current dynamics, and treatment implications. THEORY The "Easy Rider Syndrome" is a phenomenon noted repeatedly in addict couples, married, unmarried, and homosexual. It denotes a 168 ) sociological dyad in which one partner is supported by the other and becomes an "easy rider" throughout the relationship. The dynamic structure of this lifestyle evolves after at least one year of heavy heroin usage. MMPI profiles indicate that both members of the couple have high psychopathic deviate scales. The "supporters" have high mania scales, the "easy riders" have high depression scales. The female half of the syndrome adopts the role of pseudo-mother figure for her partner. The female's family configuration typically reveals an inept and/or alcoholic father who is alternately physically abusive or immobilized with depression and guilt. Sexual activity between father and daughter are common. Physical abuse can be dynamically interpreted as the father's defense to deal with his sense of panic over loss of sexual impulse control. The mother of the female partner is typically a silent figure. Her role is defined in terms of masochistic caretaker for the husband. She may also manipulate the husband into violent expressions of anger toward the seductive daughter. The daughter uses the dynamics of this family configuration as the genesis for her role-playing in the "Easy Rider Syndrome. " For her father, the girl substitutes a passive-aggressive, inwardly raging young man (who is, incidentally, a heroin addict). Though ostensibly an "easy rider," the male inwardly feels such guilt he often commits foolish errors, spends time in jail, and through this punishment expiates his subconscious guilt. He is a true pas siveaggressive figure. He may exhibit explosive anger and violently beat his "chick" should she have intercourse "for free" (as opposed to her normal prostitution). Classically, the male describes an overprotective but highly dependent mother who seemed, to him, to be able to keep the family together against overwhelming odds. His newfound addict mate similarly keeps the family together by keeping up the heroin supply. The fathers are usually described as emotionally distant figures. The apparently strongly developed sexual relationship does not make couples amenable to social therapy or psychotherapy. The problems are rather compounded by mutual undercutting of their partner's progress. Female partners tend to dominate therapy sessions. When dealing with anxiety-provoking questions, the major defense is sexual seductivity. Another common occurrence is covert competition for the therapists' interest. With the resolution of withdrawal symptoms, the "easy rider" may model himself after the therapist and assume some degree of control over the female. The crucial point in the couple's rehabilitation is the redirection of the male's high energy level, a result of his new "clean" state. This allows the female to settle into a more dependent role. Often, those who have "kicked" unconsciously manipulate their partners to keep them addicted and thus dependent. 169 CONCLUSIONS The suppression of overt heroin dependence must be recognized as only the beginning step in the rehabilitation process. The patterns noted may serve as a realistic therapeutic model for other community health workers. The problems which led any couple to heroin are ever-present, and if not fully dealt with will push one or both back to the familiar heroin lifestyle. 170 1 ) 1 III. 18 De Fleur, Lois B.; Ball, John C.; and Snarr, Richard W. The long-term social correlates of opiate addiction. Social Problems, 17(2):225-234, Fall 1969. DRUG Heroin, Opiates SAMPLE SIZE 53 SAMPLE TYPE Formerly Incarcerated AGE Cross-Age SEX Male ETHNICITY Puerto Rican Puerto Ricans at U.S. Public Health Service Hospital, Lexington, Kentucky GEOGRAPHICAL AREA METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews, Medical Records, Urinalyses, Police Records DATEIS) CONDUCTED 1962-64 NO. OF REFERENCES 10 SUMMARY The problem of comprehending the long-range correlates of opiate addiction and the life patterns of addicts was addressed by this study. Several factors were described which play a role in the long-term social adjustment of addicts. Personal characteristics, social position previous to addiction, the type of drug abused, the social setting in which it is used, and the sociocultural milieu following the onset of addiction were important influences. It is possible to view these various processes in longitudinal terms, that is, variables which were present prior to, during, and after the onset of addiction. 171 This study examined one such progression with subjects from a particular culture who were heroin addicts, and who returned to this culture after time in a penal institution. The data presented covered 53 male Puerto Ricans who had been discharged from the U. S. Public Health Service Hospital in Lexington, Kentucky, between 1935 and 1962. The time lapse since the onset of opiate abuse ranged from 5 to 37 years, and the time from onset to interview averaged 16 years. The focus of the study was to describe patterns of criminality, arrest, incarceration, drug use, and legitimate employment, and the relation of these characteristics to the subjcs-cts' characteristics previous to addiction. Of particular interest were those aspects which indicated the degree to which a subject had either remained a social problem or had made a reasonable social adjustment. Data concerning arrests, further institutionalization, and involvement in illicit activities indicated the former; while records of legitimate employment and abstinence from continued drug abuse indicated the latter. METHODOLOGY Extensive field interviews were conducted in Puerto Rico during 1962-1964 to follow up on 242 former patients at the USPHS Hospital in Lexington. Many had died or left Puerto Rico, but 53 former federal prisoners were interviewed. Voluntary admission patients were not used due to the confidential protection of the cases, and because prisoner patients had supporting data. The background characteristics of the sample showed the following characteristics: above average educational level, often bilingual, generally quite sophisticated in manner of speech, and tended to regard work as either boring or not worth their time. For each subject the following data were obtained: (1) medical reports from the time of first admission, (2) a field interview which focused on addiction history, employment and criminality, (3) urinalysis of a specimen obtained at the time of the interview, and (4) a current (to October 31, 1964) FBI record of arrests and incarcerations. Collateral material was obtained through interviews of friends, employees and physicians in Puerto Rico, as well as local hospital and arrest records. Subsequent admissions to Lexington (or Fort Worth) provided comparable longitudinal information on drug use, employment history, and criminality as well as family stability, psychiatric diagnosis, social mobility, and physical condition at the time of each hospitalization. The following measures were used in the analysis: For each year from the onset of opiate use, each subject was classified as addicted, 172 incarcerated, or voluntarily abstinent, based on which condition prevailed in that year. In addition, arrests while addicted were recorded. Thus, life patterns of addicts could be traced in two ways: first, each condition was traced separately to gain a broad picture of long-term adjustment; secondly, configurations of these factors could be examined which would reveal prevailing life patterns. Such configurations were seen to bring together pre-addiction and post-addiction characteristics which indicated the presence of several types of career patterns. FINDINGS Drug Use It was determined that the common sequence for drug use was marijuana smoking, heroin addiction, arrest for narcotics violation, and incarceration. Two patterns were seen for narcotics usage during the years following the onset of addiction (the "risk years"): (1) continuous opiate addiction, or (2) less commonly, abstinence for three or more consecutive years and presumed cured. Of the subjects, more than half had their only drug-free experiences while in prison and were considered as essentially confirmed addicts, incapable of ending their addiction. Arrests Although only about one-third of the sample group had arrests prior to opiate use, all had records after use, with about three arrests per subject as the mean. The extent of incarceration of the group was considerable. The use of opiates was seen as a definite factor in increasing the frequency of arrests. Occupational Careers The interviews revealed that nearly one-half the patient population had engaged in illegal activities as their main means of support. The types of permanent criminal careers were most commonly drug traffic and theft. Another group of 18 addicts were classified as sporadic criminals who sometimes took jobs in service, trade and labor, but supplemented their income through illicit activities. Only 9 subjects were steadily employed, including four who were in high status occupations. Finally, three addicts were seen as basi cally dependent upon relatives for support. The fact that more than three-fourths the sample group had been in criminal activities indicates the consistent involvement of the subjects in a variety of deviant activities, not just drug use. 173 A.A Life Patterns In examining the configurations of variables along the longitudinal progression (pre-onset, onset, addiction, post-addiction), it was seen that those subjects who were steadily employed were ranked above others in socioeconomic status, educational attainment, and employment prior to addiction. None of these patients had been arrested prior to opiate addiction, and the onset of addiction occurred at a relatively older age than the others. However, most often the steadily employed subject was arrested several years after he began his habit. The criminal group had begun addiction at an earlier age and often had arrests before addiction. Following the onset of opiate use, those who were employed used less uougs (based on cost). A significant number of this group eventu.Ally stopped using drugs. In contrast, the criminal group became increasingly involved in illegal activities, During the three years prior to the interview, all of those in the criminal group had been arrested or were in jail. Those who were classified as sporadic criminals had careers between the two other groups. Most had been employed before onset, but one-third had been arrested. This group was seen as in a transitional stage, with some moving away from drugs while others moved deeper into the drug-crime culture. CONCLUSIONS Long-term social adjustments of the Puerto Rican subjects are seen clearly related to where they were located in the social structure prior to addiction. Two main hypotheses are advanced. First, that there appear to be important differences in the processes of becoming addicted between those who are steadily employed and those who are pursuing criminal careers. The earlier involvement with deviant behavior on the part of the criminal group may be significant. Secondly, post-addiction adjustment may be handled better by those with previous employment and higher educational achievement. In this study, those with less favorable pre-addiction histories were clearly seen to be poor risks for adjustment following their release from incarceration. The data touched upon the issue of marijuana and its relationship to heroin addiction. It was suggested that, because of the clear position of marijuana in the sequence of drugs, the drug may have served as either a facilitating or even a precipitating condition leading towards more serious narcotic abuse for some individuals who had personal or social characteristics which made them susceptible to addiction. 174 The relationship between criminality and heroin addiction is a complex one, and the understanding of variables which lead to one deviancy may be important in understanding the others. 1751 ' ,..) 111.19 Preble, Edward. Social and cultural factors related to narcotic use among Puerto Ricans in New York City. Internationzl Journal of the Addictions, 1(1): 30-41, 1966. DRUG Opiates (heroin predominantly) SAMPLE SIZE About 400 AGE Volunteers Adole$cents (15-19) SEX About 400 Males ETHNICITY Puerto Rican GEOGRAPHICAL AREA New York, New York METHODOLOGY Exploratory /Descriptive DATA COLLECTION INSTRUMENT Interviews; Observations DATEIS) CONDUCTED Not Specified NO. OF REFERENCES 18 SAMPLE TYPE SUMMARY This study reported on an attempt to describe and understand some of the social and cultural factors related to narcotic use among Puerto Ricans in New York City, who comprise along with Negroes the majority of the street addicts, especially in the younger age brackets. Downgrading of the traditionally dominant Puerto Rican male was thought to be the most significant factor leading to narcotic use among adolescents. 176 METHODOLOGY A methodology was formulated based on participant-observation techniques, with the addition of techniques to provide the dimension of psychodynamics. The central feature of this methodology was the psycho-diagnostic life history interview with individual subjects. The four sources of information utilized in the study were: histories, ethnographies, participant-observer field journal records, and lifehistory interviews. The study area selected was an economically and socially deprived neighborhood in New York City less than one half mile square, with Puerto Ricans constituting approximately 60% of the total population. The author obtained the research cooperation of individuals representing the major non-Puerto Rican cultural groups of the area (Jewish, Irish, Elack, Russian and Italian) to provide life history data, observations about the neighborhood (past and present) and impressions of Puerto Rican people. The Puerto Rican research subjects centered around a large extended Puerto Rican family and the block where they lived. FINDINGS As the most recent significantly large minority group, the Puerto Ricans were found to be objects of suspicion and hostility. They spoke an unfamiliar language; they were relatively eager competitors in the labor market, working fast and for minimum wages. Racial identification, the color stigma, was a major problem for them. The defensive reactions of the Puerto Rican to hostility included ingratiation, withdrawal, and aggression. For adolescents, especially sensitive to social discomfort, the main adaptive alternative was to join the "hips" or the "hicks": to adopt the current street style and behavior of delinquent-prone Americanos or to maintain a strict cultural integrity incongruous in many ways with their new environment. The adolescent who could withstand the social pressure, without withdrawing, was known as "'quiet. " In the study area there were about 400 male Puerto Rican youths between the ages of 15 and 19. Approximately 70% were inclined to the "hip" (not necessarily delinquent), about 15% were "hicks" and the remaining 15% could be considered "quiet. " About 15% of these young males were in school, 35% working, and the remaining 50% were idle, running a high risk of narcotic addiction. Perhaps the most significant social factor affecting the Puerto Rican family in New York was the downgrading of the male. The disadvantages with regard to employment and general social acceptance had important family consequences: the females also worked to support the family and the children were left with others or unsupervised after school. There were also more subtle consequences of male downgrading, especially significant in the psychosocial integration of young Puerto-Rican males, which can be related to delinquency and other symptomatic behavior such as narcotic addiction. The traditional respect for male authority among Puerto Ricans and the concomitants of structure and controls in social, familial, and 177 e individual behavior, were destroyed in those cases where the male head of the family succumbed to the social and psychological pressures of New York life. Disruption in patterned, socially inherited cultural imperatives resulted in uncertainty, confusion and conflict within the individual. CONCLUSIONS The most important delinquency problems among New York City street youths, especially Puerto Ricans and Blacks, are narcotic addiction and the crimes committed in support of it. Narcotic use, particularly heroin, has been one solution to the social and psycho- logical problems of Puerto Ricans, which result, in part, from the social burdens imposed on a recent immigrant group. Although the solution itself entails the problem of the daily acquisition of an illegal and expensive commodity, it is preferred by a significant number of Puerto Rican men and male adolescents as a method of coping with social pressures. 178 1., III. 20 Ball, John C. , and Lau, M. P. The Chinese narcotic addict in the United States. Social Forces, 45(1):68-72, September 1966. DRUG Opiate s SAMPLE SIZE 137 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX Male ETHNICITY Chinese GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Program/Clinic Statistics DATEiS) CONDUCTED 1957-1962 NO. OF REFERENCES 13 SUMMARY This study examined the records of Chinese narcotic patients hospitalized at the U.S. Public Health Service hospital at Lexington, Kentucky between 1957 and 1962. It was found that these patients exemplified the sojourner way of life; but they were unsuccessful sojourners. Migrants to America in search of wealth, they lived in metropolitan Chinatowns, worked in laundries and restaurants, and were separated from their families. Evidence of the high incidence of opiate addiction among Chinese-Americans during the first half of the century is considered; reasons why addiction within this minority group has virtually ceased by the 1960's are discussed. 179 METHODOLOGY The data for this study were obtained by an analysis of the medical records of the 137 Chinese male patients discharged from the U. S. Public Health Service hospital in Lexington, Kentucky between July 1957 and June 1962. Statistics regarding occupation, age, opiate use habits, and family history were compiled. Using this information, a composite case history for a typical Chinese addict was synthesized to depict the "addict sojourner" way of life. FINDINGS From 1935 through 1964, about 3% of the male addicts treated at the Lexington hospital were Chinese. This minority group was markedly overrepresented inasmuch as they constituted less than 0. 2% of the United States male population. The subjects of this study exemplified the sojourner way of life, coming to America to seek fortune with the intent of returning to their homeland. Of the 137 subjects, 99 (72%) were born in China, 37 born in the U. S. In 94% of the cases one or both parents were born in China. At the time of their last admission to the hospital, 102 of the patients were from New York City, 19 from Chicago, and the remaining 16 from other U. S. cities. The common occupations followed by the Chinese addicts were laundry (54. 7 %) and restaurant (38. 7 %) work. None were unemployed or engaged in full-time illegal occupations. Their mean age of 53 years was more than 20 years older than that of the hospital population. Although 55% of the men were married, 88% were not living with family members; only 10% were living with their wives. Of the 137 patients, 124 used heroin, 7 morphine, 4 opium, and 2 dolophine. The onset of opiate addiction usually occurred before age 30. Use of barbiturates was not common, and no use of marijuana was recorded. A composite case history revealed that a typical Chinese addict was 53 years old, born in southern China, and came to the U. S. at age 20 to join his father. He carried on a tradition of resisting acculturation, spoke poor English, and was obedient though suspicious of whites. An industrious worker who tended to withdraw into the Chinese community, he knew only the trades of laundry,or restaurant work. Earning $36$50 per week, he lived in shabby rooms near his working place, and had little recreation, social life, or spiritual life. Typically, the addicts returned to China to be married, but then re-entered the U. S. leaving wife and children behind. At the time of his last admission to the Lexington hospital, the typical Chinese addict was injecting about $10 worth of heroin per day. He admitted criminal narcotics offenses, but denied criminal history before addiction. No violent crime or other antisocial behavior was on record. Having volunteered for treatment because of financial distress or deterioration of health, the addicts typically left the 180 .1, institution, after uneventful withdrawal, within four weeks, against medical advice. CONCLUSIONS The". Chinese addict of this study was clearly differentiated from other addict groups in the United States. Markedly alienated from American culture, American goals and values were not a part of his way of life. In his later years, his life goal of financial success was beyond attainment. The high incidence of hospitalization of Chinese-American addicts at Lexington helped substantiate other reports of extensive opiate use by Chinese in the U.S. Some possible reasons for this high rate were given. First, opiate use among Chinese populations outside the U.S. has been part of contemporary Chinese culture and has been transmitted from generation to generation. The use of opiates among Chinese-Americans was associated both with an existing cultural pattern and restricted access to alternative modes of behavior. Narcotic drug abuse among the Chinese in the U.S. has markedly decreased during the last decade. This phenomenon was viewed by the authors as a reflection of an ongoing process of modernization of the Chinatown communities. The process has been furthered by the severance of cultural ties with the homeland since the Communists' take-over in 1949. 181 III. 21 Bates, William M. Narcotics, negroes and the south. Social Forces,. 45(1):61 -67, September 1966. DRUG Opiates SAMPLE SIZE 93, 600 SAMPLE TYPE Incarcerated; Treatment (inpatient) AGE Adults SEX Male ETHNICITY 20, 300 Black; 73, 300 White GEOGRAPHICAL AREA Cross-Sectional U. S. METHODOLOGY Statistical Survey DATA COLLECTION INSTRUMENT Program/Clinic Statistics DATE(S) CONDUCTED 1964 NO. OF REFERENCES 8 SUMMARY To investigate North-South differences in narcotic addiction, an analysis was conducted of the records of patients admitted to the United States Public Health Service hospitals at Fort Worth and Lexington. The analysis revealed that the Negro addicts varied markedly from the white addicts in their regional and age distribution. Negroes were grossly overrepresented in urban metropolitan areas, and underrepresented in the southern areas. Although for the past 30 years they have been markedly younger than the white addicts in the South, Negroes and Whites have had almost identical mean ages in the North. The 182 differences between narcotic addicts from the North vs. the South were shown to be chiefly a function of the urban nature of heroin addiction. METHODOLOGY Records of adult male heroin addict admissions to 2 U.S. Public Health Service hospitals were analyzed to show trends of Negro vs. White admissions. Summaries of records from 1935-1964 were analyzed; during this time 42,160 first admissions were recorded. Tables containing the following data were analyzed and are included in the article: (1) White admissions and Negro admissions for each year, 1935-1964; (2) number and age of Negro and White addicts from each of 17 southern states for 4 selected years; (3) Negro-White male addiction rates per 100,000 population for 9 southern states in 1950 and 1960; (4) number of Negro male addicts from 10 cities of largest population for 4 selected years; (5) proportions by race of admissions from New York City for 8 selected years; and (6) ages ofpersons admitted during selected years. FINDINGS It was found that the greatest increase in Negro admissions was between 1940 and 1950 when admissions almost doubled. In 1948 there were 206 Negro male first admissions, 438 in 1949 and 1, 068 in 1950. The highest percentage of Negroes admitted was in 1957 (43.8 percent). Southern Negroes were much underrepresented. The South contained 59. 9% of the Negro population of the country in 1960, but less than 5% of the Negro addicts came from this area. In 1964 this number rose to 15%, much of the increase from Washington, D.C. In 1960, 20.6% of the southern population was Negro, but only 7. 9% of the southern admissions were Negro. This underrepresentation can be seen as far back as 1940. Negroes were overrepresented in the general addict population but underrepresented from the South. The four areas--Washington, D. C. , Texas, Louisiana, and Maryland- sending the largest numbers of Negro addicts sent them from their largest cities exclusively; this did not hold crue for White addicts. White narcotic use was not nearly so concentrated in the large.cities as Negro narcotic use. The 10 most populous cities of the U. S. accounted for more than 70% of the Negro addicts, though they accounted for less than 40% of the Negro population. In 1940 the mean age of addict admissions was 41.4 years. By 1964 the mean age had dropped to 31.9 years. For White southerners, however, the mean age was around 40 years between 1940-1964, while Negro addicts' mean age was 10 years younger. In northern states the mean age of Negro addicts dropped from 38.2 years to 25.0 years between 1940 and 1950, rising again to 30.6 years by 1964. The major drop in mean age of White addicts occurred a decade later, dropping from 39.9 years in 1950 to 29.9 in 1964, when Negro and White median ages were essentially equal. 183 1:,; CONCLUSIONS Because these data were only for hospitalized addicts, those in the early stages of addiction may have been underrepresented. Also, state and local programs for addicts caused a disproportionality in the sample for these states. The data showed a very large difference in the regional distribution of Negro addicts. Hospitalized southern White addicts were 10 years older than northern White addicts and 8 years older than southern Negro addicts. Two major problems are pointed out. First, why are urban Negroes and not rural Negroes so highly represented in the drug-using group? Secondly, why are rural drug users chiefly White? 184 III. 22 Chambers, Carl D. ; Moffett, Arthur D. ; and Jones, Judith P. Demographic factors associated with Negro opiate addiction. International Journal of the Addictions, 3(2), Fall, 1968. DRUG Opiates SAMPLE SIZE 155 SAMPLE TYPE Treatment (inpatient) AGE Adults SEX 98 Male and 57 Female Black ETHNICITY GEOGRAPHICAL AREA Lexington, Kentucky METHODOLOGY Case Study DATA COLLECTION INSTRUgENT Interviews, Laboratory/Clinic Statistics DATEIS) CONDUCTED Not Specified NO. OF REFERENCES 17 SUMMARY This study attemptcd to ascertain any significant differences between the known Negro addict-patient and the Negro in the general population, and to detect differences between new Negro admissions to Lexington Public Health Service Hospital and Negro readmissions. 185 Interviews were conducted with 155 Negro addicts admitted to the hospital. No consistent significant differences between first time patients and recidivists, or male and female subjects, were revealed, but differences were indicated between addicted Negroes and normal Negro groups. Disrupted family life, illegal activities, and marijuana use patterns were the main characteristics differentiating the addicted group from the normal Negro population. METHODOLOGY Individual interviews were conducted with 98 consecutive male Negro admissions, and 57 consecutive female Negro admissions, to a U.S. Public Health Service hospital at Lexington, Kentucky. All of the males and 82.4% of the females came from New York City or Chicago. Personal history, drug use history, including use of marijuana, and criminal history were the major areas inve stigated. An analysis of the results in categories of male versus female, and first hospital admissions versus recidivists, was made. FINDINGS Of the 155 Negro opiate addicts interviewed in this study 67. 7% had experienced a broken home situation. The education levels of the male addicts were slightly higher than those of the females, 40. 8% and 33. 3 %, respectively, having finished high school. The majority (84. 5 %) had experienced a marital situation, but only 48% of the male, versus 90.4% of the female, addict marriages were intact at the time of hospital admission. Only 25. 2% of the sample had been legally employed, while 61.3% had been supporting themselves by illegal means, and 13. 5% were dependent. In most cases (89%), the subjects had been initiated to opiates by a peer. Heroin was overwhelmingly the drug of abuse, was generally obtained from a pusher, and was taken intravenously. Marijuana was associated with opiate use, 84% of the addict-patients having used the drug. Males were more likely to have used marijuana than females (93% to'68%), though continued use after opiate use was low (14%). Extensive marijuana use was correlated with early termination of education, early opiate use, having been arrested, and barbiturate experimentation. Sixty and six-tenths percent of the subjects reported a history of barbiturate use. Most of the addicts (94. 8 %) reported having been arrested. The mean age of first arrest was lower than the mean age of first opiate use, particularly in the male cohort. At the time of admission 31.6% of the subjects were federal prisoners. Males, more than females (52% versus 40.4%) reported they had sold narcotics, 186 1 4 but 72. 7% of the female sellers derived their major support from selling, compared to 31.4% of the males. CONCLUSIONS This research demonstrated the homogeneity of a Negro opiate addict cohort. do mpa r e d to normal Negro groups the addicts were more likely to have come from broken homes, to have been school dropouts, to have been married, to have been separated from their, spouses, and to have been illegally employed. The extent of marijuana use by an addict may prove to be a valuable independent variable, as many addiction characteristics correlate with marijuana use. The risk potential of graduating to more dangerous drugs should not be understated. Thus, analysts could assume opiate addicts had experienced the physiological and psychological risks of smoking marijuana when adolescents, and had also experienced the potentially more dangerous risk of becoming involved in a subculture in which such deviant behavior was an accepted norm. The data indicated that optimum intervention into the addiction process would have to occur duriiig the earls school years and should focus on the liabilities attendant to marijuana use. That such intervention may be effective or desirable, rather than to increase opiate addiction because access to marijuana would be denied, must be ascertained by further research. 187 III. 23 Chambers, Carl D. ; Cuskey, Walter R. ; and Moffett, Arthur D. Demographic factors in opiate addiction among Mexican-Americans. Public Health Reports, 85(6):523-531, June 1970. DRUG Opiates SAMPLE SIZE 271 SAMPLE TYPE Treatment (inpatient) SEX Adults: median age 25-29 years 247 Male; 24 Female ETHNICITY Mexican-American GEOGRAPHICAL AREA California; Texas METHODOLOGY Statistical Survey DATA COLLECTION INSTRUMENT Program/Clinic Statistics DATElS) CONDUCTED Not Specified NO. OF REFERENCES 16 AGE SUMMARY Empirical data were gathered to provide a definitive description of the contemporary Mexican-American opiate addict. To determine whether demographic characteristics had changed, a sample of Mexican-American addicts first admitted for treatment in 1961 was compared to a sample first admitted in 1967. It was found that the incidence of male MexicanAmerican addicts among the total addicts admitted to the same hospitals had doubled but there were less than half the number of female MexicanAmerican addicts in 1967 as in 1961. .188 : METHODOLOGY Histories of the Mexican-American addicts admitted to the federal hospitals at Lexington, Kentucky and Fort Worth, Texas, during the first 6 months of 1961 were compared statistically with the histories o the Mexican-Americans admitted during the same period in 1967. During the 1961 sampling period, out of a total of 1,745 addicts admitted, 102 or 5. 8% were Mexican-Americans. During the 1967 sampling period, out of a total of 1,438 addicts admitted, 169 or 11. 8% were Mexican-Americans. All statistical comparisons and descriptions were accomplished with these 2 populations. The attributes available for analysis were grouped into 3 categories: (a) social characteristics; (b) characteristics associated with addiction and related deviancies; and (c) characteristics associated with hospital admission. Wherever possible and whenever appropriate, sex was treated as an independent variable. FINDINGS The incidence of Mexican-American addicts among the total addicts admitted to the hospitals doubled between 1961 and 1967, even though the total number of hospital admissions decreased by almost 20%. The increase was only among male addicts. Female representation in 1967 was less than half that of 1961. The majority of Mexican-American addicts in 1967 resided in Texas; in 1961, California had been the largest contributor. An overwhelming majority of the MexicanAmerican addicts, regardless of sex, were school dropouts. Although the addicts averaged 28.1 years of age in 1967, almost one-third had never been married. More than 40% of those who had attempted a marriage had been unable to sustain the relationship. A large majority of the Mexican-American opiate addicts in 1967 had histories of smoking marihuana prior to their use of opiates. Opiate use most often began during the adolescent years. The Mexican-American addicts were most frequently found to be young adults; their mean age decreased between 1961 and 1967. Almost all were addicted to heroin and used it intravenously. Even though the Mexican-American addicts supplemented their incomes from illegal sources, a majority maintained some legal occupational role while addicted. All had been arrested; the first arrest most frequently had preceded the use of opiates. While, by 1967, recidivism was increasing, readmissions were more likely to be voluntary than enforced. CONCLUSIONS The data generated several questions: (1) Why is the sex ratio so out of balance? Mexican-American females seem somehow buffered or insulated from the illicit drug subculture; (2) Why does a minority group representing only 2% of the U.S. population contribute 10% of the opiate addict population?; (3) Why has the incidence of addiction shifted geographically? Data should be collected which would 189 answer these questions and permit a full range of comparisons beand Mexican addicts, between tween Mexican-American addictsMexican-Americans who do not use Mexican-American addicts and addicts and other addicts. drugs, and between Mexican-American 190 III. 24 Maddux, James F.; Berliner, Arthur K.; and Bates, William F. Addiction careers. In: Maddux, James F., et. al. Engaging Opioid Addicts in a Continuum of Services. A Community-based Study in San Antonio Area. Fort Worth, Texas: Texas Christian University Press, January 1971, pp. 64-71 DRUG Opiates SAMPLE SIZE 100 SAMPLE TYPE T.reatment (outpatient) AGE Not Specified SEX Male ETHNICITY Mexican-American GEOGRAPHICAL San Antonio, Texas AREA METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews; Observations DATEIS) CONDUCTED 1966-1968 NO. OF REFERENCES 55 SUMMARY The authors used the term "addiction career" to describe the natural history of addiction. This would involve the pathological sequence regulated by internal biological processes. The typical opioid addict in this study was born in Texas in a Spanishspeaking home. His neig.thorhood in San Antonio was predominantly Mexican-American, poor, and undereducated. Neither he nor his parents were immigrants. About 1/3 had one or both parents born in Mexico. 191 The mothers seemed especially protective of their grown sons. They indulged them, made excuses for their failure and sometimes overtly contributed to continued opioid use by study subjects; at times they directly helped them to obtain drugs. Some of the parents were divorced. The authors estimated that 10% of the fathers of the subjects were alcoholics. Three fathers were heroin addicts. The fathers that the staff had contact with seemed passive and naive in their relations with their sons. Although they disapproved of their sons' addiction, they tolerated it and also the illegal behavior. The subjects adopted the values of the informal neighborhood peer groups during adolescence. Most of the subjects dropped out of school at about the 9th grade, and the group generally had a negative attitude towards school, police, and other legitin ate social organizations. Machismo was reflected in acts of bravery, sexual conquests, and loyalty to the group. Machismo also included getting "high." The authors estimated that practically all the subjects had used alcohol before they had used marijuana or heroin. About 70% said they used marijuana before heroin. While the adolescent group facilitated the approach to heroin use, it was not clear that initial heroin use typically occurred as an activity of the group. The authors felt that most of the subjects actively sought the initial heroin injection. They sought it out of curiosity about the nature of the "high" they would get. Initial use appeared, to some extent, to have been a family, as well as a peer group, affair. Although initially prompted to try heroin out of curiosity, the subjects continued heroin use because they liked it. With compulsive daily use the opioid user began an addiction career. This meant a progressive dropping out of legitimate social activity to devote time and energy to maintain drug dependence. A good many tried to cease opioid use and addiction careers. With the onset of regular use, the addict usually joined an informal "tecato" (addict) group which served as a medium for communication and sociability. In San Antonio the tecato groups created and transmitted the values and language of the addict subculture. Most members of the tecato group spoke a variant of Spanish called "Tex-Mex." Within this dialect, heroin users have a special argot not intelligible to the nonaddict Tex-Mex. Subjects who attempted to remain abstinent said they felt prompted to resume heroin use partly out of a desire for interaction with their tecato group. 192 The subjects appeared to progressively drop out, although the extent of dropping out varied widely, and never seemed permanent. Hardly any subjects seemed to continue indefinitely at heroin use without periods of voluntary or involuntary abstinence. Some seemed to prefer the addiction career. Information about addiction careers of subjects became very meager for the middle and later portions of their careers. This may have been because most of the men in the study were young. CONCLUSIONS The authors felt that their information on addiction careers was partial and incomplete. They did feel that adolescent peer groups set the stage for entry into addiction careers, and later the tecato group helped to perpetuate this career. 193 III. 25 Vaillant, George E. Parent-child cultural disparity and drug addiction. The Journal of Nervous and Mental Disease, 142 (6): 534-539, 1966. DRUG Not Specified SAMPLE SIZE 488 SAMPLE TYPE Discharged Addict Patients AGE Adults SEX Male ETHNICITY Black, White, Puerto Rican GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT New York, New York Exploratory/Descriptive Prograrn/Clinic statistics DATE(S) CONDUCTED Not Specified NO. OF REFERENCES 8 SUMMARY This study examined the writer's hypothesis that the highest addiction risk in New York City occurs not among urban immigrants but among first-generation adults with membership in an established minority. The study compared the nativity of New York City addicts admitted to U. S P,,H.S Hospital in Lexington, Kentucky, with that of non-addict New York City residents of similar age, sex, and ethnic origin. It found that 3 times as many first generation New Yorkers (native born or foreign born) as immigrants were admitted to Lexington. 194 Findings suggested that minority status and cultural mobility of the parents are correlated positively with incidence of drug addiction. This is true among individuals from low socio-economic groups. METHODOLOGY The study group consisted of all addict patients discharged from Lexington between April 1 and December 31, 1961, who were 1) male, 2) born between 1931 and 1940, and 3) residents of New York City when admitted to Lexington. The writer assumed that Southern-born Blacks in New York encounter problems analogous to those of immigrants from foreign countries. Young New York Black adults, 50% of whom are immigrants from the South would then form an intermediate group, based on their immigrant status. The two other groups were adult Puerto Ricans, and adult White non-Puerto Ricans. There were 171 non-Puerto Rican Black addicts in the sample, grouped according to their birthplace and their parent's birthplace. There were 130 Puerto Rican patients grouped according to birthplace, either New York City or Puerto Rico. There were 187 non-Puerto Rican Whites grouped according to birthplace and parent's birthplace. FINDINGS In all instances, individuals born in New York City whose parents were not born in the Northern U. S. , were most likely to be admitted to Lexington. First-generation city dwellers had the highest rate of addiction. Relatively few Black immigrants from the South, or from outside the U.S., were admitted to Lexington. Puerto Rican immigrants exceeded first-generation New York Puerto Ricans in numbers of Lexington admissions. The likelihdod of Lexington hospitalization was also strongly correlated with minority-group membership. When ethnic origin was accounted for, the incidence of a nonimmigrant New Yorker receiving a discharge from Lexington was 3 times that of an immigrant to New York City. The findings, it was warned, apply with certainty only to those New York addicts who came to Lexington as prisoners or as voluntary admissions. Rate of addiction was 20 times as high among New York Puerto Rican and Black populations as among the rest of the New York City population. 1,95 kve CONCLUSIONS Evidence suggested that both minority status and parental, rather than individual, cultural mobility are positively correlated with the incidence of drug addiction among individuals from lower socio-economic groups. At least some of the multiple roots of addiction ought to be found in differences between the lives of the immigrants and the first generation city dwellers. One hypothetical explanation would be, in part, that the roots of addiction are formed before adolescence, and that the addict's alienation comes first from parent influence and secondly from society. 196 III. 26 Glaser, Daniel; Lander, Bernard; and Abbott, William. Opiate addicted and non-addicted siblings in a slum area. Social Problems, 18(4):510-521, Spring 1971. DRUG Opiates SAMPLE SIZE 74 (37 pairs) SAMPLE TYPE Volunteer; Siblings AGE Adults SEX 68 Male; 6 Female ETHNICITY 10 Black; 54 Puerto Rican; 6 Other GEOGRAPHICAL AREA New York, New York METHODOLOGY Exploratory /Descriptive DATA COLLECTION INSTRUMENT Interviews; Psychological Tests DATE(S) CONDUCTED 1969-1970 NO. OF REFERENCES 24 SUMMARY This study compared addicted and non-addicted siblings residing in a slum neighborhood in New York City. Subjects were interviewed in an attempt to gain awareness of sibling differences in family relations, education, delinquent behavior, employment, and personality. The study showed addicts to be more involved in illegitimate activities as youths, and as a result, less successful in education and employment, turning to opiate use as more gratifying behavior. The data contradict the image of uniformly enculturating high delinquency neighborhoods, and point rather to reinforcement, opportunity, and stigmatization theories. 197 METHODOLOGY From an inventory of 138 families in a slum block of New York, 40 pairs of addict and non-addict siblings were identified. Ages varied from 18 to 42 years when interviewed. Non-addicts had never used heroin. Interviews with 37 of the pairs were conducted in various neighborhood settings by interviewers who were local residents. Subjects were interviewed individually and asked about both themselves and their siblings. Results on amount of agreement between siblings on valrious questions are presented. For 34 of the pairs, a Srole Anomia Scale and an alienation scale were determined. FINDINGS The following significant differences between addict and non-addict responses were found. Addicts born outside New York averaged 8, 3 years old on coming to the city, non-addicts 10.4 years. Only 30% of the addicts, compared to 46% of the non-addicts, had never left home for 3 months or more. The departure was for a jail or institution for 70% of the addicts, 8% of the non-addicts. To the question: "Which kid stayed at home most when he was a teenager?", 43% agreed in naming the addict, 19% the non-addict. No significant differences in the siblings' attitudes toward parents were found. Non-addicts were significantly more successful in school; 62% were high school graduates, versus 32% of the addicts. All the addicts, but only 30% of the non-addicts, had used marijuana. Mean age of first heroin use by addicts was 17. 8 years. Gang activity was higher for addicts, 59% having been gang members. Eighty-one' percent of the addicts had been arrested, only 5% of the non-addicts. Addicts tended to start sexual activity younger and 22% reported homosexual experience. Subjects were asked, "When you were a teenager, what did you think you would be when you grew up?" Of the addicts, 24% responded skilled tradesmen, 30% "artist, athlete, adventurer or criminal, " and 14% professional. Non-addicts responded 43% skilled craft, 14% "artist, athlete, etc." and 24% professional. Non-addicts were 95% employed at the time of interview, addicts 19%. In attempting to explain the sibling difference in addiction, addicts tended to cite their own stupidity or ignorance, while non addicts tended to cite peer associates as the major factor. On the Anomia Scale, the mean score for addicts was 2. 9, for nonaddicts 1. 5. The mean score on the alienation scale was 4.1 for addicts and 3;0 for non-addicts. The authors point out these differences may well reflect consequences rather than causes of addiction. CONCLUSIONS Results were interpreted as supporting the "relative deprivationdifferential anticipation" theory since the typical addict differed most from his non-addict sibling in the extent of his involvement in 198 delinquency and marijuana use at an early age, and in consequent arrest, incarceration, deficiencies of schooling, and limited employment. Most clearly indicated is a difference in reference group orientation. The addicts were involved in activities that would be long-run barriers to mobility in legitimate careers. Findings suggest the validity of a deviance polarization paradigm, that motivational stress from ambivalence about norms is relieved by either compulsive conformity or compulsive alienation. Social consequences of early deviance make later efforts for conformity less gratifying, and further deviance more immediately reinforced by peers. The authors feel the data highlight dramatically the errors in conceptions of slum life as monolithic and uniform; it is diverse and mixed, with sharp contrasts even within single households. 199 III. 27 Nurco, David.N., and Lerner, Monroe. Characteristics of drug abusers in a correctional system. Journal of Drug Issues, 2(2):49-56, 1972. DRUG Multi-Drug SAMPLE SIZE 669 Incarcerated 19 percent under 20; 33 percent aged 20-24; 25 percent aged 25-29; 5 percent over 40 SAMPLE TYPE AGE SEX Male ETHNICITY 70 percent Black, 29 percent White; 1 percent' Other GEOGRAPHICAL AREA Maryland METHODOLOGY Statistical Survey DATA COLLECTION INSTRUMENT Interviews; Program/Clinic Statistics DATE(S) CONDUCTED November 1967 - November 1968 NO. OF REFERENCES 1 None SUMMARY This study of drug abusers in the Maryland State Department of Corrections was conducted a::: part of a larger study which assessed the feasibility of collecting data from community agencies other than the police. Part one discusses problems associated with the collection of the data; Part two describes demographic and socio-economic characteristics of the study group, the criminal offenses involved, their drug of cnoice, the location of court sentencing, and whether or not they were known to authorities as drug abusers; Part three deals with the drug history of the inmates, with special' reference to first thug use. Statistical tables are not included in this article. 200 Approximately three-fourths of the inmate population abused heroin, opiates or synthetics as their drug of choice. Most were relatively young, Black, and low achievers in education. They also tended to be Protestant, single, and born within the metropolitan Baltimore area. Three-quarters of the study sample population had been incarcerated for non-violent crimes. This was found to be more closely associated with heroin abusers than with those who abused opiates and synthetics or "all other" drugs. Four-fifths of the group were commitments from the city courts of Baltimore, and there was a stronger association of heroin abusers from that city as opposed to commitments from elsewhere in the state. Most of the study population wera not known to be drug abusers by authorities, although those who abused heroin were more often known. Most of the inmates had begun to use drugs before the age of 20; heroin was the first drug abused in about one-fourth of the cases. Among those who began with marijuana or barbiturates, most had later shifted to heroin use. Amphetamines, LSD and other hallucinogenic drugs were not the initial abuse drugs of those who later abused heroin. METHODOLOGY Data were collected from admission records of the Maryland State Department of Corrections. In addition, a member of the study staff interviewed most of the individuals identified as drug abusers. This separate interview was important because inmates were unwilling to deal with correction personnel for fear of jeopardizing parole and because of anti-authority feelings. The fact that the interviewer was familiar with drug abuse situations was also helpful. Stressing confidentiality yielded a greater expression of emotions on drug problems by the inmates. FlNDINGS The population of 699 inmates was found to be predominantly young and Black, lacking a high school diploma, most often Protestant, single, and born in the Baltimore area. The dominant occupational category of the group was the structural and (building) contracting trade. Almost three-quarters of the inmates abused heroin as their drug of choice, with most of the rest abusing "other drugs," i.e., barbiturates, marijuana and other psychotropics, cocaine, amphetamines, LSD, hallucinogens, and glue. Within the sample group, those who abused heroin tended to be older, more often married, and usually abusing heroin on a daily basis. They were generally still abusing that drug at the time of the survey. Those abusing other opiates and synthetics were younger and better educated than heroin abusers. Only half abused these drugs on a daily basis, but most were still abusing them at the time of the survey. The abusers of "other drugs" were more similar to the opiate and synthetic abusers than to heroin abusers. All three groups were similar in occupational distribution and in age/abuse patterns. 201 6 i. About three-quarters of the inmates had been jailed for non-violent crimes. This was especially true in the case of heroin abusers. Baltimore City courts were responsible for the vast majority of commitments, and most of those were involving heroin abusers. Abusers of "other drugs" were most often committed from outside the Baltimore courts. The majority of the drug abusers in the sample were not known to authorities as drug abusers, but most of those who were known were heroin abusers. Those who were known were generally familiar to the Baltimore City Police with the exception of a few who were knovvii only to the Federal Bureau of Narcotics and Dangerous Drugs. Almost three-fourths of the study group had begun to abuse drugs prior to their twentieth birthday, with a substantial number having begun abuse before age 15. About one-fourth of the study population began drug abuse with heroin, and those who did tended to stay with that drug. Seventy-six percent of those who began abusing marijuana and other psychotropics or barbiturates later shifted to heroin as their drug of choice. However, most of those who began abusing amphetamines or LSD and other hallucinogens had not moved to addictive drugs. In terms of drugs first used, of the 513 inmates identified as heroin abusers, about one-third began with heroin and over half began with "other drugs," especially marijuana and other psychotropics or barbiturates. Only a small number of the 153 inmates who preferred non-addictive drugs had begun use with addictive drugs. 202 III. 28 Capel, W. C. ; Goldsmith, B. M. ; Waddell, K. J. ; and Stewart, G. T. The aging narcotic addict: An increasing problem for the next decades. Journal of Gerontology, 27(1):102-106, January 1972. DRUG Opiate S SAMPLE SIZE 38 SAMPLE TYPE Volunteer AGE Mean Age 58.97 SEX 38 Male ETHNICITY White GEOGRAPHICAL AREA New Orleans, Louisiana METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED 197 1 NO. OF REFERENCES 11 SUMMARY This study examined the situation of the older narcotics addict in New Orleans. Thirty-eight white male addicts between the ages of 48 and 73 were located and interviewed as to their age of addiction, years of addiction, drugs of choice and of abuse, marital status, work habits, arrest, imprisonments, and life style. Results indicated that opiate abuse among older inhabitants of New Orleans was greater than expected, but differed in pattern from abuse by younger age groups and did not appear amenable to any presently conceived treatment modality. 203 Findings did not support the maturing out hypothesis advanced by Winick to account for the disappearance of addicts from public and statistical view after age 45. Older individuals in this study had not stopped using opiates but had developed a protective lifestyle that diverted attention from their addiction. METHODOLOGY The age distribution of heroin addicts on methadone maintenance programs in New Orleans in 1970 showed a marked decrease in persons aged 45 years or more. By using program addicts as leads, a number of addicts over 45 who were not in the clinics were located. Tape recorded open-ended question and answer interviews were conducted with 38 of these addicts. Data were collected on use habits, age of addiction, drug preference, work habits, marital status, manner in which drugs were obtained, primary reason for addiction, and first drug used. FINDINGS The 38 male opiate users studied had a mean age of 58. 9 years with a mean length of use of 35.4 years, the range being from 13 to 55 years. None were on any rehabilitation or maintenance programs. All had lived in New Orleans since an early age; 35 were born there. All but 6 had served jail terms, with time since last arrest ranging from a few months to 9 years. Eighteen of the subjects "fixed" at least once daily, while 2 reported that they took drugs only once or twice a week. Dilaudid was the drug most often used by 62% of the sample; heroin was the next most often used. Older addicts, well aware of the danger of street heroin, preferred Dilaudid because it was cheaper, had a constant dosage, and was pure. As their source of drugs, 79 percent reported a pusher as primary source, 13 percent a doctor, and 8 percent a friend. Half of the subjects were employed full time, 5 part-time, 3 were on pensions, 3 on welfare, 5 on Social Security, while 2 still depended on their "hustle" as a primary income source. Few of the subjects were married. Fifteen had never married, 10 were divorced and 11 separated from their wives. All but 4 said they had smoked marijuana at one time or another, most when they were younger. Some used barbiturates when opiates were not available. Peer influence was the most common reason given for starting drug use. The median age for first drug use other than marijuana was 22. 5 years. CONCLUSIONS The elderly male subjects of this study clearly fit the typology of withdrawn, anomic loners in society; only one was living with his wife. Most 204 began opiate use between the age of 15 and 30 years; peer influence and availability were the major reasons for first use. The fact that some of the addicts had spent as many as 9 "bits" in prison while others had never been arrested seemed to question the theory that the addict is always a sociopath. These people tend to use drugs as "people substitutes" and addiction provides motivation and rationale for a meaningful, thougi socially deviant existence. The treatment of drug abuse as a heinous criminal offense could be in itself a contributor to the occurrence of the anomic and disengaged addict. Treating narcotic addiction as a legal problem has encouraged self-protective camouflage by the addict who becomes shut off from influences that might lead to an end to addiction. To date there are no treatment modalities for older addicts other than methadone maintenance or total abstinence, neither of which appears to be attractive to men of this age group. The tremendous increase in drug abuse by younger persons indicates that the problem of aging addicts will become increasingly important, and new rehabilitative programs applicable to this age group should be developed now. 205 III. 29 Ramer, Barry S.; Smith, David E. ; and Gay, George A. Adolescent heroin abuse in San Francisco. International Journal of the Addictions, 7(3):461-465, 1972. (11 references) SUMMARY San Francisco is described as a center for drug patterns which start in that city's drug subculture and spread throughout the country. Increases of heroin abuse are especially prevalent in adolescents. The Center for Special Problems and the Haight-Ashbury Free Medical Clinic both report about 250 new cases monthly; about 20 percent of these are youths under 18 years of age. The young addicts of today are seen as pessimistic compared to the psychedelic drug users of 10 years before. Depressed and disturbed over various social and ecological problems, they seek heroin as the ultimate pharmacological escape. Demographically, the addict population treated at the clinic is younger, increasingly female, and from a middle class background. Most have an average daily habit of $75 and have been using heroin for less than 3 years. Most are unemployed. A far smaller percentage of Orientals are involved than might be expected from the city's substantial Asian population, perhaps due to that ethnic group's rejection of Caucasian-directed programs. There is difficulty in reaching the Latino and Chicano populations; it is speculated that this is due to a cultural preference to "kick cold" as a more masculine or "machismo" choice. The "street wise" youth often looks for a way to withdraw through "legitimate" medication. Addicted minors, however, have not been eligible for methadone maintenance treatment, which led to many seeking relief through self-medication with combinations of alcohol, barbiturates, marijuana, cocaine, speed, etc. Some success was reported for non-methadone rehabilitation programs, especially in cases of short-term addiction. The Mendocino Family, Phoenix House, Daytop, and Reality House all report that success in such treatment is limited, mostly because the problem of craving cannot be eliminated. CONCLUSIONS Based on the experiences with heroin detoxification at the Center for Special Problems and the Haight-Ashbury Free Medical Clinic, and upon rehabilitation treatment programs of both the methadone and non-methadone types, the authors recommend that treatment for adolescent heroin addicts be a combination of methadone maintenance and rehabilitation. A modification or removal of the legal restraints on treating minors, especially in regard to methadone, is seen as essential to deter the addict from the street cures and to seek help through available medical centers. 206 Methadone maintenance has proven to be an efiective device in rehabilitation of narcotic addicts, and should be made available as a treatment modality for adolescents. Once the destructive life style can be Eatered through rehabilitation efforts, methadone maintenance can be slowly discontinued over time. 207 III. 30 Siegel, Arthur J. The heroin crisis among U.S. forces in Southeast Asia: An overview. Journal of the American Medical Association, 223(11):1258-1261, March 12, 1973. (7 references). SUMMARY This article deals with the occurrence of heroin addiction among U.S. forces in Southeast Asia. This heroin abuse was described as having many features in common with an epidemic: A specific population at risk, a unique setting in which spread occurred, and a single offending agent. The S outheast Asia setting, the psychological and cultural condition of soldiers in this setting, and the manner in which drug abuse generally occurred were described and analyzed. Therapeutic objectives and methods used by the military hospitals were described, and implications of the findings in terms of possible long-term addiction of patients was discussed. The author drew on his persona' -xperience as the Drug Control Officer for the U.S. Army Hospital in Bangkok, Thailand, where ZOO cases of heroin abuse were evaluated during his two year stay. Observations made in this direct combat support area were stated to be generally valid for patients in the military theater as a whole. The principal factor identified in generating the heroin crisis was the availability of drugs. In Southeast Asia, drugs of all varieties were plentiful and cheap. Marijuana, barbiturates, and amphetamines circulated freely. Opiates were plentiful in several forms. Partially processed "rock" heroin, containing from 5% to 15% pure drug, was commonly smoked or snorted. Irritative effects of this type of drug often led to chronic rhinitis or bronchitis, and such symptoms were often the cause of addicts' initial medical treatment. Purified heroin was the most commonly used opiate. This drug, which was 90% to 96% pure, was used chiefly by smoking and prod :ced equivalent effects to injected heroin used in the United States, which is only 1% to 3% pure. Drug-taking among troops began as an extension of similar habits at home. Questionnaires confirmed that 70% of the soldiers arrived with some drug experience, although less than 1% arrived having previously used heroin. 208 In addition to common reasons of curiosity, pleasure seeking, and social pressure, the soldier found himself exposed to such pressures as culture shock, and the threat to personal stability arising from rapid environmental change. Anxiety over separation from family, friends, and home was intensified by a sense of personal danger. Drug-taking assumed an even stronger appeal in this setting, less for recreation than as a refuge from unpleasant reality. Soldiers may have tried heroin for the first time simply because it was there. Preconceived fears of addiction were tempered by seeing peers use it without obvious ill effects. The oral-respiratory route removed the fear of needles and hepatitis, and reduced the risk of overdose. With experience many users continued to function under its influence and remained inconspicuous. Although other drugs were commonly used, serious morbidity from drug use as measured by hospitalization was virtually confined to chronic heroin use. Treatment b..gan with a close screening for current or related disease. Medical complications proved infrequent. The benign nature of the abstinence syndrome among these patients was striking and consistent. Withdrawal states were largely confined to insomnia, mild agitation and transient muscle cramps. Prognosis beyond detoxification hinged upon each patient's psychological resources. Patients detected during early phases of their habits were sometimes convinced by the short term withdrawal that they were not addicted and could incorporate the drug safely into their life style. Significant numbers of patients showed high frequency of family strife and personal failures. Many had failed to finish school or to hold a job in civilian life, and heroin was but the latest in a series of poor adjustment responses., A high rate of recidivism in rehabilitation programs was a rule among this group. Reasons for the attenuation of withdrawal in these subjects remain unclear, and the author feels they deserve further investigation. Also, the heroin outbreak has immediate implications for physicians in the United States. Patients may have atypical symptoms, the genesis of which is related to drugs. Simple questioning about heroin may allow the patient to open the issue for which he is really seeking help. The task of follow-up on these patients returning to civilian life falls upon the medical community at large. e:sf 209 -.a kJ IV. DRUG USE PATTERNS 211 N. 01 Robins, Lee N., and Murphy, George E. Drug use in a normal population of young Negro men. American Journal of Public Health, 57(9): 1580-1596, September, 1967. DRUG SAMPLE SIZE Multi-Drug 235 SAMPLE TYPE Young Black men AGE Cross-age SEX Male ETHNICITY Black GEOGRAPHICAL AREA St. Louis, Missouri METHODOLOGY Longitudinal DATA COLLECTION INSTRUMENT Interviews DATEIS) CONDUCTED 1961 NO. OF RFFERENCES 10 SUMMARY This study investigated drug use in a normal population of young Negro men. The methods used provided an approximation of the lifetime prevalence of drug use and drug addiction for the sample. Childhood variables that predict drug use and addiction were presented. A higher rate of addiction to heroin than expected was found in the sample. A wide variety of drugs were found to be used by heroin addicts. Findings also indicated that heroin addiction is a remitting illness. It was suggested that a particularly vulnerable group might be identified for preventive treatment. 212 METHODOLOGY Records were searched so as to evaluate adult adjustment of 235 young Negro men whose names had been selected from public elementary school records beginning 26 to 30 years earlier. The men were then interviewed as adults between the ages of 30 and 35. The sample was not selected according to particular drug use. Records were sought for all the sample, and personal interviews were obtained with 94%. Criteria for eligibility for this study were: being male, born in St. Louis between 1930 and 1934, having attended Negro St. Louis public elementary school for 6 years or more, having an IQ score of at least 85 in elementary school, and guardian's name and occupation appearing on the school record. There were 30 men in each of the 8 categories created by taking all permutations of 3 dichotomized variables: father's presence or absence, guardian's occupation at the lowest level versus a higher level, and moderate or severe school problems versus mild problems or none. Interviews were obtained for 95% between June, 1965, and August, 1966. Most interviews were conducted in St. Louis, 12% were conducted in other towns and cities, and several took place in prison. FINDINGS The findings of this study applied only to the eligible population: Negro men of normal IQ, born and reared in St. Louis. The authors were surprised to find that 1 out of every 10 of their sample had been addicted to heroin. Four percent had been treated in a U.S. Public Health Service Hospital, a higher figure than had been anticipated. No regular heroin user in the present population had escaped official attention; 86% had records as addicts with the Federal Bureau of Narcotics. Findings substantiated arrest records. Very few men who denied drug use had had narcotics arrests. Cumulative lists of men arrested for drug violations were seen as providing fairly reliable lifetime prevalence figures for heroin addiction. Fourteen percent of the addicts reported having used heroin in the last year. Among men in the sample who had been in a U.S. P. H.S. Hospital, 22% reported current heroin use, and 44% reported use of other drugs only. These figures were similar to results of an earlier study by O'Donnell and Vaillant. In addition to the fact that 10% of the sample had been heroin addicts, 1/2 had used some drug illegally. Virtually everyone who used any drug used marijuana. Marijuana had served as the introduction to drugs for most of those who went on to other drug use. Half of the marijuana users never used any other drug, and 1/3 did not continue the use of marijuana for more than 1 year. The younger 213 " the person was when first using marijuana, the more likely was he to go on to heroin addiction. Marijuana appeared to be the most widely available and most widely used drug among both Negro men and Negro teenagers. Socio-economic status and elementary school performance did not prove predictive of drug use. However, there was a correlation between dropping out of high school-and experimenting with drugs. Delinquency and absent fathers predicted the progression from marijuana use into heroin addiction. CONCLUSIONS The findings suggested that there is a group of Negro boys most vulnerable to heroin addiction. The authors suggested that this group would be a reasonable target for a program hoping to prevent addiction. 214 IV. 02 Dai, Bingham. Opium addiction: A sociopsychiatric approach. In: Burgess, E.W., and Bogue, D.J., eds. Contributions to Urban Sociology. Chicago, Illinois: University of Chicago Press, 1964. pp. 643-654. DRUG Opium SAMPLE SIZE 2559 SAMPLE TYPE Opium addicts AGE Adults SEX Both Male and Female ETHNICITY Not specified GEOGRAPHICAL AREA Chicago, Illinois METHODOLOGY Exploratory/Descriptive, Case study DATA COL _ECTION INSTRUMENT Interviews, Observations, Questionnaires DATE(S) CONDL 7.TED 1928-1934 NO. OF REFERENCES 0 SUMMARY A brief history of opium addiction was presented, including reasons for the spread of its use in the late nineteenth century in the U. S. Statistical material was then presented on 2,518 addicts in Chicago for the period 1928 to 1934. In addition, life history materials, including case histories were presented for 41 addicts. Sociocultural factors were seen to be important in studying the development of an individual's opium addiction. 213 METHODOLOGY Statistical information was gathered on 2,518 addicts from 19281934. The material was obtained from a combination of federal, municipal and private agencies or institutions. Life history material on 41 addicts was gathered by means of the protracted interview method. Whenever possible, an addict was seen for an extended period of time, ranging from several weeks to several months. FINDINGS Of the 2,439 addicts whose ages were known, only 12 were under 20 years old. The ratio of male addicts to female was 3 to 1. Opium addiction was not shown to be inherently associated with any specific group by ethnicity or nationality. The great majority of the addicts came from urban environments. Of 111 female addicts, 44. 1% had left home before 17. The educational levels of addicts did not cornpare unfavorably with those of the general population of Chicago at the time. The occupations of addicts implied an unstable, mobile, heterogeneous environment highly conducive to personal disorganization. The habitual use of opium did not seem to have much deteriorating effect, physically, on the'addict. Addicts were not found to be mentall; ill in the usual sense of the word; their outstanding symptom was found to be addiction itself. The development of drug dependence implied a disordered personality in combination with a specific sociocultural context. Most of the addicts had acquired their habit after the Harrison Narcotic Act went into effect which served to reinforce the theory that stricter laws were not enough. The most important etiological factor in addiction seemed to be the influence of other addicts. Criminal activities appeared to begin after the drug habit began. The areas with high rales of addiction were either in or around the central business district. Those addicts in the areas with the highest rate of addiction were highly mobile and unattached men. Eighty percent of a sample of 1,591 lived less than 2 miles from the centers of drug traffic. The second part of this study dealt with an inquiry into the ways in which opium addiction as a cultural pattern is taken over by the individual and becomes his habit. Data came from protracted interviews with 41 opium addicts. 216 d t:rt, , The acquisition of the opium habit always involved a specific social situation, which involved the novice and transmitters. The novice perceived drug using situations in terms of his own needs. Certain emotional needs were found to be associated with the initial contact with opium: (1) the need to relieve anxiety where fear of failure is present, and (2) the need to identify with a group whereby increased self-esteem may be established. CONCLUSIONS The opium habit of an individual can only be completely understood in the context of the total personality in relation to the sociocultural environment. It is invariably in concrete social situations that opium addiction as a cultural pattern is taken over by the individual and becomes his habit. 217 IV. 03 Gay, George R. , et al. Cocaine in perspective: "Gift from the Sun God" to "The rich man's drug. " Drug Forum, 2(4):409-430, Summer, 1973. (32 references). SUMMARY This study traces the history of cocaine, outlines its pharmacology, the development of laws regarding its use, and current epidemiologic trends. Because it is scarce and expensive, cocaine has become the "champagne of drugs" in the drug subculture. Sniffing cocaine has to some extent supplanted intravenous use. One of the complications arising from this practice has been the frequent perforation of the nasal septum. In addition, a reactive hyperemia or clogging of nasal airways by engorged membranes occurs as the vasoconstriction wears off. At the Haight-Ashbury Free Medical Clinic a striking rise was seen in the incidence of cocaine use beginning in mid-1970. Between March 1971 and April 1972, 741 heroin addicts had been seen at the clinic. Among the 303 clients seen between March and September 1971, 10% reported moderate to heavy use of cocaine within the previous 2 months. Of the 264 clients seen between September 1971 and January 1972, moderate to heavy use within the last 2 months was reported by 13. 6 %. Of the 147 seen between February 1972 and April 1972, the percentage was 20. 7%. These statistics indicated that the incidence of cocaine use rose rapidly during 1970 and the first half of 1971, then increased more slowly until mid-1972. Cocaine users tended to be significantly younger, less often Caucasian, more often Catholic, more often single than their non-using or rarely using counterparts. Clients who were recent users of cocaine were slightly more middle-class in background, education, and employment. From July 1971 to July 1972, a less rapid increase in cocaine use was seen. These users tended to be significantly younger when they first used drugs and also when they first used heroin. Their use of all illegal drugs was more extensive. 218 Increased seizures of cocaine reported by the Department of Justice in that period of time indicated that use of cocaine on a national scale had also increased. Cocaine seizures rose from 370 lbs. in 1969 to 751 lbs. in 1971. Arrests involving cocaine rose from 987 in 1969 to 1, 284 in 1971. Such statistics, while not proving that cocaine use rose, did bear out Haight-Ashbury statistics on cocaine use. Cocaine reinforces the highest aspirations of American initiative and achievement by providing the user with greater energy and optimism. On the negative side are the exhaustion, paranoia, and violence also caused by the use of cocaine. The drug produces strong psychic dependence without physical dependence. Therefore there is an absence of an abstinence syndrome when the drug is withdrawn, but a powerful tendency to continue use. While neither physical dependence nor tolerance develops, cocaine is capable of producing a profound and dangerous type of drug abuse. 1 219 N. 04 Chambers, Carl D.; Taylor, W.J. Russell; and Moffett, Arthur D. The incidence of cocaine abuse among methadone maintenance patients. The International Journal of the Addictions, 7(3) :427 -441, 1972. DRUG Cocaine, Heroin, Methadone SAMPLE SIZE 173 SAMPLE TYPE Treatment (outpatient) AGE Cross-Age SEX Both Male and'Female ETHNICITY Black and White GEOGRAPHICAL AREA Philadelphia, Pennsylvania METHODOLOGY Case Studies DATA COLLECTION INSTRUMENT Laboratory/Examination DATE(S) CONDUCTED December 1969 NO. OF REFERENCES 23 _ SUMMARY This paper reported on the development of a simple and reliable urine screening method to detect the presence of cocaine in the urine of methadone maintenance patients, and the results of the surveillance that was made possible by the procedure. Poly-drug use has necessitated adequate laboratory surveillance to detect the use of the nonnarcotic dependency-producing drugs, but in the past these screening methods have not normally included the detection of cocaine, which is common among narcotic addicts throughout the nation. The writers feel a screening for cocaine must be part 220 of the proper" management of any methadone substitution program. "Cocaine cheaters" are compared with "noncheatersu on various demographic, personal adjustment, and deviant behavior dimensions. Special references are made to the total detected drug abuse patterns of both groups. METHODOLOGY The urine screening method, involving the separation of cocaine from methadone during the thin-layer chromatographic process using cation exchange paper, was developed at the Clinical Pharmacology-Toxicology Center at the Philadelphia General Hospital (a detailed description of the detection procedures is given). It permitted an assessment of the abuse of cocaine among the 173 heroin addicts participating in an outpatient methadone maintenance program located at the Philadelphia General Hospital during December 1969. The 32 methadone maintenance patients who were not abusing cocaine, were compared statistically. FINDINGS The statistical comparison of the cocaine "cheaters" and "noncheaters" produced a number of significant differences, as well as some which were not statistically significant. (1) Cocaine abuse was significantly related to the age of the addict - patients. While a majority of the 173 maintained addictpatients were under the age of 35, among the 32 cocaine abusers, 62.5% were over 35; 60.3% of the nonabuse...s were under age 35. Only 12. 4% of those addict-patients under age 25 were abusing cocaine, while 26. 3% of those age 35 or older were detected as "cheaters." Cocaine abuse was found to be significantly related to the (2) race of the addict-patients. While the total maintained population (3) was 58. 4% White and 41. 6% Black, the cocaine cheating subpopulation was only 34. 4% White and 65. 6% Black; only 10. 9% of the White addict-patients were found to be abusing cocaine, but 29. 2% of the Blacks were. Cocaine abuse was found to be significantly related to the marital status of the addict-patients. Addict-patients who were abusing cocaine were more likely to be divorced or separated than the nonabusers. Over 40% of all the cocaine abusers were found to be either divorced or separated, as compared to 10. 8% of the single addict-patients and 16. 0% of the addict-patients with intact marriages. 221 4 Cocaine abuse was found to be significantluelated to the employment status of the addict-patient at the time of admission into treatment. Those addict-patients who were maintaining a legal work role at the time they sought treatment significantly less often were cocaine "cheaters. " Only 18. 8% of the cocaine abusers had been working at the time of admission, compared to 44. 7% of the rionabusers. Of all addict-patients who were working at the time of admission, only 8. 7% were found to be "cheating" with cocaine during the study period, while 25.0% of those who had not been working were detected as cocaine "cheaters. " Cocaine abuse was found to be significantly related to the (5) length of the addict-patients' drug - taking careers. A full 81. 3% of all the cocaine "cheaters" had been abusing drugs for a minimum of 10 years before entering this methadone maintenance program. This compares with 53.2% of all the "non-cheaters*" Only 8. 3% of all the addict-patients with abuse histories of less than 10 years were cocaine "cheaters, " but 25. 7% of those with more than 10 years were detected abusers of cocaine. (6) Cocaine abuse was found to be significantly related to the continuation of criminal activity while undergoing treatment. These analyses revealed that 39. 1% of all those addict-patients who continued a criminal involvement, e. g. , theft, gambling, etc., were also abusing cocaine. Only 9. 9% of the "non-cheaters" were criminally involved, but 28. 1% of the cocaine "cheaters" had remained involved in illegal activities. A wide range of characteristics and attributes were analyzed which did not produce differences which were statistically significant, among which were sex differences, differences in arrest histories, differences in prior treatment histories, and differences in treatment and adjustment characteristics. This study showed a rather high incidence of cocaine abuse among methadone maintenance patients -- 18. 5% had abused cocaine at least once during a 30-day study period. A composite of the addict-patient with the highest incidence of cocaine abuse would be: a Black male over 35 years of age who had been a heroin addict more than 10 years and who had continued to abuse other drugs and engage in criminal activities after being stabilized. During the subsequent 30-day period, when the addict-patients first became aware their urine was being analyzed for the detection of cocaine, the incidence of detected cocaine decreased to 10. 4%, a statistically significant decrease which appeared to be a permanent decline. The decline in cocaine "cheating" has been attributed to the confrontation of the addict-patients with their urine test results; if it is an accurate interpretation that such a (4) 222 t 1 confrontation can produce a decline in drug abuse behavior among methadone maintenance patients it would be the most significant result of this research. CONCLUSIONS This study indicates that an adequate surveillance of methadone substitution programs must include tests for cocaine as well as for barbiturates, amphetamines and opiates. Future analyses must focus upon different patterns of use in the various programs and attempt to relate these differences to programmatic , client population, subcultural, or other differences. 223 IV. 05 Chambers, Carl D., and Taylor, W. J. Russell. Patterns of "cheating" among methadone maintainence patients. In; Keup, Wolfram, ed. Drug Abuse: Current Concepts and Research. Springfield, Ill.: Charles C. Thomas, 1972. pp. 328-336. DRUG SAMPLE SIZE Methadone, Multi-Drug 40 SAMPLE TYPE Treatment (outpatient) AGE Adults SEX Both Male and Female ETHNICITY Black and White GEOGRAPHICAL AREA METHODOLOGY DATA COLLECTION INSTRUMENT DATEIS) CONDUCTED Philadelphia, Pennsylvania Case Study Interviews, Laboratory/Examination, and Program/Clinic Statistics May 1969 to January 1970 c, NO. OF REFERENCES 0 SUMMARY This paper reports results from testing the theory that addicts stabilized on methadone will develop a "Blockade" to narcotics, which will reduce or extinguish their craving for drugs. Urinalyses were used to detect patient abuse of heroin, barbiturates, amphetamines and cocaine. Interviews were conducted to establish use of extra methadone, psychedelics, marijuana and alcohol. 224 f-a Extensive cheating while on the maintenance program was established, with the incidence of cheating increasing over time. It was also determined that cheating data obtained from interviews were not reliable. Finally, the paper compiles a profile of the drug addicts who cheated while under treatment. METHODOLOGY Analyses of the incidence and patterns of cheating among methadone maintenance patients were conducted through the ambulatory clinic of the Philadelphia General Hospital during May 1969, and again in January 1970. Only patients who had been on a maintenance program for at least 6 months were included in the study group - this criterion was met by 40 patients. Sources of data were (1) Interviews between counselor and patient, (2) Interviews between counselor and researcher, (3) Urine samples taken from each patient during his visit to the clinic, and (4) Clinical records maintained on each patient. FINDINGS From urine surveillance techniques, it was established during May, 1969, that 82. 5% of the patients had abused at least one of the detectable drugs, 60% had abused two different classes of drugs, and 22. 5% had abused three classes. Heroin was found to have been used in the greatest percentage of cases, followed by barbiturates and amphetamines. On the basis of interviews, it was established that 5% admitted psychedelic abuse, 7. 5% had smoked marijuana, and 25% hid been intoxicated at least once. Eight months later, during January 1970, the incidence of cheating had increased from 82. 5% to 97.4%. Heroin cheating had increased from 77. 5% to 92. 3 %; barbiturate cheating had increased from 30% to 43. 6 %, and amphetamine cheating had increased from 25% to 69. 2 %. At this time, techniques were expanded to detect cocaine; its abuse among the patients was established at 43.6%. During the second test period multiple cheating was also found to have increased. Cheating with two drugs increased from 60% to 76%; cheating with three drugs increased from 22.5% to 51. 3%; and 20. 5% cheated with four drugs. 225 IL.. -0 CONCLUSIONS The study clearly shows unreliability of data obtained from interviews with the patient, even when conducted by highly trained personnel. It was concluded that patients were unwilling to volunteer information on cheating, and that clinical judgments of the interviewers were at least 70. 6% inaccurate. The authors conclude that the incidence of cheating among drug treatment patients is quite high. It is further concluded that adequate laboratory equipment is essential to meaningful drug rehabilitation programs. 226 IV. 06 Schuster, Charles R.; Smith, B. Baddeley; Jaffe, Jerome H. Drug abuse in heroin users. An experimental study of self- administration of methadone, codeine, and pentazocine. Archives of General Psychiatry, 24(4):359-367, April 1971. DRUG Methadone; Codeine; Pentazocine SAMPLE SIZE 88 SAMPLE TYPE Treatment (outpatient) AGE Not Specified SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA Illinois METHODOLOGY Controlled /Experimental DATA COLLECTION INSTRUMENT Interviews; Observations DATE(S) CONOUCTED Not Specified NO. OF REFERENCES 8 SUMMARY A double -blind study was conducted to determine the abuse potential of orally administered methadone, codeine, pentazocine and placebo in ambulatory heroin addicts. Eighty-eight subjects were allowed to return to a clinic daily for 10 consecutive days to obtain one of the medications. Frequency of return for each drug was used as a measure of its potential for abuse. Return rates for codeine and methadone were greatest. Pentazocine had the lowest return of the four drugs, indicating that it is less liable to be abused, at least at the dose levels used. 227 t,;( _1 Li METHODOLOGY Eighty-eight medically acceptable subjects, due to enter treatment within 2 weeks of completion of this study, were selected from the State of Illinois Drug Rehabilitation Program. Nineteen subjects were assigned to the methadone group and 23 subjects to each of the remaining 3 groups. Doses of 50 mg of pentazocine, codeine, and methadone were each placed in individual capsules. Identical placebo capsules contained 50 mg of dextrose. Eight capsules of each medication were placed in individual plastic bottles, each coded and labeled day 1 through day 10. The procedure was carried out on a doubleblind basis. After a physical examination, the subjects were randomly assigned to one of the 4 medication groups and each given individual code numbers. They were told they would receive $2. 00 a day for travel expenses, whether or not they took their medication, that medication would be available to them for 5 consecutive days, and to obtain medication they had to fill out a 30-minute paper-and-pencil test, submit a urine specimen, and participate in a brief interview. Contingent upon completion of this chain of behavior each day, each subject received a bottle containing 8 capsules of medication. All subjects were told the recommended safe dosage was 1 to 2 tablets every 4 hours. On the fifth day of the study the subjects were told that medication would be made available to them for 5 more days, again contingent upon completion of the -same chain of behavior, but that they must pay their own carfare. A maximum of 30 subjects could be run at any one time (approximately 7 or 8 in each group) and the study was replicated 4 times. FINDINGS As the results of the 4 consecutive studies were essentially similar they were combined for analysis. It was expected that the number of capsules taken would provide some measure of the reinforcing efficacy of the different medications. With few exceptions, however, all subjects who returned for additional medication reported having taken all the capsules the previous day. The lack of variability in this measurement (verbal report of tablets consumed) left only one objective measure of the reinforcing capacity of each drug; the total number of opportunities available to each group of subjects to receive medication was compared to the number of opportunities utilized. In both 5-day periods codeine and methadone groups showed a higher utilization rate (more subjects returned for additional drugs) than either the pentazocine or placebo groups. An analysis of the two 5day periods, the first with a monetary payment and the second without such an incentive, indicated that the placebo group was not significantly different from either the pentazocine or methadone groups in the first 5 days. The codeine group, however, showed a significantly greater return rate than either the placebo or the pentazocine group, but not more than the methadone group. The pentazocine group had the lowest return rate of the four. It was significantly different from both the methadone and codeine groups but not from the placebo group. 228 I Results indicated that the receipt of 400 mg ol codeine or 40 mg of methadone daily was sufficiently reinforcing to maintain the behavior of coming to a clinic and completing the required testing to a significantly greater degree than either 400 mg of pentazocine or placebo daily. Pentazocine, at a unit dosage of 50 mg, was not significantly different from placebo, and had the lowest return rate of the 4 medication groups, indicating that it was less liable to be abused, at least at the dose levels used. CONCLUSIONS In future studies the authors planned to evaluate the importance of unit dosage of methadone as a variable affecting its reinforcing efficacy, as it was expected methadone would have been more reinforcing than codeine. These conclusions regarding the reinforcing efficacy of methadone, codeine, and pentazocine are limited to active heroin users. The methodology utilizing self-administration procedures on an ambulatory basis is, however, applicable to the study of the abuse potential of a wide variety of drugs. Clearly the nature of the responses upon which the drug is contingent, as well as a variety of environmental variables, including previous and current drug use, may affect the reinforcing efficacy of any pharmacological agent. 229 IV. 07 Inciardi, James A., and Chambers, Carl D. Patterns of pentazocine abuse. In: Keup, Wolfram, ed. Drug Abuse: Current Concepts and Research. Springfield, Ill.: Charles C. Thomas, 1972. pp. 337-351. DRUG Pentazocine SAMPLE SIZE 1. 1096 SAMPLE TYPE Treatment (inpatient/outpatient) AGE Not Specified SEX Both Male and Female ETHNICITY Not Specified GEOGRAPHICAL AREA More Than Two Cities METHODOLOGY Exploratory/Descriptive; Case Study DATA COLLECTION INSTRUMENT Not Specified DATEIS) CONDUCTED 1967-1970 NO. OF REFERENCES 19 2. 273 3. 125 SUMMARY This study was conducted to assess the "true addiction" potential of pentazocine. The NIMH Clinical Research Center, Lexington, Kentucky, reported on a series of controlled experiments. Their results indicated that the drug produced a euphoric effect and physical dependence, and that an abstinence syndrome typical of drug-seeking behavior was observed. Specific questions were addressed to three groups to determine the process and structure of pentazocine abuse: (1) 1,096 narcotic addicts at the NIMH Center in Lexington, (2) 273 addicts treated at the Philadelphia General Hospital Narcotic Rehabilitation Clinic, and (3) 125 narcotic addicts 230 at two New York State Narcotic Addiction Control Commission facilities. Less than 6 percent had ever abused pentazocine, and slightly less than 1 percent had become addicted. Several divergent patterns were gleaned from their case reports as well as from a survey of medical literature. Among 69 narcotic addicts who simultaneously abused pentazocine, 75.4 percent reported that a legally manufactured and distributed drug was the onset drug of abuse. The abuse potential of pentazocine was most clearly illustrated in the cases where pentazocine was the only drug abused by addicted individuals. This pattern is typified in the case study of one individual who became addicted to the drug following recovery from a war injury. Because the drug was proven to have a euphorogenic effect, and because there is a mistaken belief that pentazocine is not addicting, it is readily available with little regulation on its distribution. The potential for the creation of a future population of highly visible addicts is stressed. METHODOLOGY Specific questions regarding the misuse of pentazocine were addressed to (1) all 1,096 narcotic addicts consecutively admitted to the NIMH Center in Lexington, Kentucky, during the period May 1967 to July 1969; (2) all 273 addicts undergoing treatment at the Philadelphia General Hospital Narcotic Rehabilitation Program in December, 1969; and (3) 125 addicts in treatment at two facilities of the New York State Narcotics Control Commission in June and July 1970. FINDINGS Eleven cases of physical addiction to pentazocine were found among the study group. In these cases the patients were mostly white, male, and predominantly from Southern residences with marriages intact. They had a median age of 29 and above average education. Legally manufactured and distributed drugs were the onset drugs for nine of the eleven addiction cases. Twelve additional cases were mentioned in medical literature. Here the cases were predominantly female and medical onset was recorded in most. Dependence and tolerance were observed in all cases. The abuse potential of pentazocine was depicted in a case study where that drug was the only one abused by the addicted individual. A Vietnam veteran was addicted through purchase of pentazocine from a hospital staff member after morphine treatment had been discontinued. He continued to purchase the drug on false prescription until he sought treatment for addiction. His experience illubirates the fallacy of pentazocine as a non-addictive drug and shows that the drug is accessible. M1 231 M1zJ`1 ti In 69 cases of pentazocine abuse, there was insufficient extent and duration of use to produce addiction. Generally, use was simultaneous and incidental to abuse of other drugs. In the majority of abuse cases (75.4 percent), the first drug experience was with legally distributed and manufactured drugs. Later, most of this group abused heroin as their drug of choice. As with other new drugs, experimental use was noted and is expected to spread. CONCLUSIONS Abuse and addiction of pentazocine is most closely associated with medical situations. The areas of most concern are seen as the prescription, distribution to the individual through pharmacies, and improper controls for storage and use in institutions. It is strongly suggested that greater knowledge of the abuse patterns be determined and that the control of the drug in its distribution, particularly in the medicine-medical context, be strengthened. It is further implied that the advertising of the drug under its trade name, Talwin, is misleading. 232 IV. 08 Langrod, John. Secondary drug use among heroin users. International Journal of the Addictions, 5(4):611-635, 1970. DRUG Heroin; Secondary Drugs SAMPLE SIZE 422 SAMPLE TYPE Treatment (inpatient) AGE Adolescents; Adults; Aged SEX 422 Males ETHNICITY 45% Black; 30% Puerto Rican; 25% White GEOGRAPHICAL AREA New York State METHODOLOGY Exploratory/Descriptive DATA COLLECTION INSTRUMENT Interviews; Questionnaires DATEIS) CONDUCTED August-September 1968 NO. OF REFERENCES 28 SUMMARY This study described secondary drug use patterns among a population of heroin users prior to being institutionalized. Previous studies have focused on the abuse of specific drugs, rather than an overall description. The use of heroin as a secondary drug has been described by a number of researchers, but the sample size with one exception was rather small. This report examined the following questions: (1) What is the extent of secondary drug abuse'among heroin users?; (2) Do heroin addicts who use secondary drugs such as LSD, methedrine ("speed") or barbiturates form a separate subculture?; (3) What is the sequence of secondary drug use? Which drugs are used 233 before initiation of heroin use and which subsequently?; (4) Which drugs are used concurrently with heroin, and what relationship do they have to the use of heroin?; (5) Is there any relation between the cost, length, and frequency of heroin use, and the type and number of secondary drugs used? ; (6) To what extent and in what way do age and ethnicity relate to secondary drug use? ; (7) What are the changing drug use patterns and fads? ; (8) What are the psychological, social, and environmental factors that influence the type and extent of secondary drug use among heroin users?; and (9) What inferences can be made from the preceding questions for treatment, prevention, and further research? METHODOLOGY Data were collected from 422 male heroin users who were interviewed in 6 different treatment facilities in New York State, 1 hospital, and 2 of the New. York City Addiction Service Agency's Phoenix House s during August and September, 1968. The residents were told the interview was voluntary and confidential. The 12 interviewers formed 3 teams, each containing 1 Black and 1 Spanish speaking interviewer. The questionnaire included mainly structured questions, with some openended items. In the opinion of the interviewers, 97% of the. respondents "usually told the truth" in answering questions. The mean age of the respondents was 24,7 years (median age 23 years) with a range from 15-68 years. Ethnic composition was 45% Black, 30% Puerto Rican, and 25% White. Sixty percent of the respondents were high school dropouts (Whites being most likely to have finished high school.) A majority of Puerto Ricans and Blacks and 1/3 of the Whites came from homes in which both parents were not always present. Roughly 1/3 of the Black and Puerto Rican respondents and 12% of the Whites reported that their families had been on welfare when they were growing up. Sixty-eight percent of the respondents had never been married. FINDINGS Over 80% reported using heroin 7 days a week prior to their institutionalization, and injecting it intravenously during the last year of use. Almost three-fourths (72 %) considered themselves addicts at the time of interview. The secondary drug use patterns are descriptive only of heroin addicts who have been institutionalized. Nearly all heroin addicts reported having used marijuana, and over one-third had used such drugs as cocaine, amphetamines, and barbiturates. The mean number of drugs used, not counting heroin, was 3.4. Only 1 in 10 reported using none or one other drug in addition to heroin. The majority of those who had used a drug more than 6 times reported having used it last in 1967-1968 (the year of or preceding institutionalization). Virtually all the respondents also used heroin during this period. An exception was airplane glue, which was used by only one-third of the group concurrently with heroin. 234 L,) Over three-fourths (77%) of the respondents first used marijuana before using heroin. The use of all other secondary drugs besides marijuana occurred after the beginning of heroin use for a majority of the sample. Barbiturates and airplane glue were first used by only 13% and 11%, respectively, of the sample prior to heroin. Preheroin use of other drugs occurred even less frequently. In general, those individuals who used drugs other than marijuana prior to heroin tended to report a higher absolute number of secondary drugs used. Ethnicity was closely related to both the number and type of secondary drugs abused, Whites being much more likely than either Puerto Ricans or Blacks to abuse a larger number of secondary drugs more than 6 times. Ethnicity appeared to be the variable that accounted for the major differences in secondary drug use patterns. Whites were more likely than Blacks to have used all secondary drugs other than cocaine more than 6 times. Whites were most likely to initiate drug use with all drugs (other than marijuana), prior to first heroin use. It may therefore be among Whites that the crossover from other drugs to heroin is more likely. Those respondents who reported an abstention from heroin of 3 months or more were more likely to substitute other drugs during that period if they had a prior history of extensive secondary drug abuse. Those respondents who scored high on an adjustment index to abstention from heroin used a smaller number of secondary drugs than the low-scorers. The poorly adjusted respondents were more likely to have used barbiturates, cocaine, and amphetamines more than 6 times, compared to the high-scorers on adjustment. The number of secondary drugs used generally tended to increase more with length of heroin use than with age and cost of heroin habit. Airplane glue and cocaine were most likely to be used by the youngest heroin addicts regardless of length of use. CONCLUSIONS Knowledge about abuse of secondary drugs by heroin addicts is important because a special type of withdrawal regimen is necessary for those who are concurrently addicted to drugs like barbiturates. The presence of extensive secondary drug abuse by heroin addicts is a factor in determining eligibility for admittance to treatment programs. The indication that the sample was composed predominantly of heroin addicts for whom the use of secondary drugs occurred after initiation of heroin use might reinforce the hypothesis that secondary drug.use depends on availability and the role that the drug plays for the heroin users. A case could be made that a heroin subculture of high multiple drug use exists among the White heroin addicts. The White heroin addict switches to "mainlining" faster than his ghetto counterpart, and is 235 more likely to have begun using other drugs before heroin; the ghetto addict on the other hand may have access to stronger heroin and is more likely to be selling drugs and using cocaine. Secondary drug use by heroin users should be seen as an interplay between the drug, social sanction by the group, age, social class, and the socio-psychological make-up of the individual and availability. Multiple drug use as a predictor of acceptable social functioning in the community is being tested in a follow-up with the patients interviewed in this study. Further research needs to be done on the way secondary drugs are used by heroin addicts, on whether heroin addicts with a history of secondary drug abuse are more likely to continue using these drugs upon cessation of heroin use, how drugs are obtained, and the reasons for acceptance and/or rejection of specific drugs by different ethnic groups. 236 IV. 09 Watkins, Torrington D. , and Chambers, Carl D. Oxymorphone abuse among narcotic addicts. In: Keup, Wolfram, ed. Drug Abuse: Current Concepts and Research. Springfield, Ill.: Charles C. Thomas, 1972. pp. 307-312. DRUG Oxymorphone (Numorphan) SAMPLE SIZE 309 SAMPLE TYPE Treatment (outpatient) AGE Adults SEX Both Male and Female ETHNICITY Black; White GEOGRAPHICAL AREA Philadelphia, Pennsylvania METHODOLOGY Exploratory /Descriptive DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED January 197 0 NO. OF REFERENCES 8 SUMMARY Numorphan (oxymorphone), a semi-synthetic narcotic analgesic, was found to be the object of increased abuse since its appearance in 1966. Reasons for its popularity seem to be that it provides rapid onset of action and prolonged duration of effect. The drug is said to be about 10 times more potent than morphine upon parenterar administration and about twice as potent when administered orally. The authors found abuse predominantly among White males. 237 ') METHODOLOGY During January 1970, 309 addict-patients of the Narcotic Addict Rehabilitation Program outpatient clinics of Philadelphia General Hospital were interviewed about Numorphan abuse. FINDINGS Of those interviewed, 20. 1%, or 62 addicts, reported they had abused Numorphan one or more times. Of the 62 addicts, 95.2% had been supplementing abusers of the drug, with 3 sub-jects reporting abuse of Numorphan exclusively for 1 or several weeks. While a number of patients indicated a preference for this drug over heroin, heroin was declared to be more readily available. The belief that tolerance to Numorphan builds very rapidly may also be a factor in its low rate of substitution for heroin. Statistical comparisons of the 62 Numorphan abusers and the 247 addicts not using Numorphan established that White males, regardless of age, had abused Numorphan at the same rate--40%. Only White females aged 25 or less had abused Numorphan. Black males, regardless of age, had abused Numorphan at the same rate--10%. No Black females had abused the drug. CONCLUSIONS The study demonstrated widespread abuse of Numorphan as both a preference drug and as a drug to supplement other narcotics. While prevalence was found to vary within various addict populations, Numorphan abuse predominated among White males. The authors believe their findings suggest the first stages in the evolution of a drug abuse pattern. 238 V. THEORIES OF ADDICTION 239 2$8 V. 01 Isbell, Harris. Perspectives in research on opiate addiction. In: Wilner, Daniel M., and Kassebaum, Gene G., eds. Narcotics. New York: McGraw Hill, 1965. pp. 36-50. SUMMARY This article reviews the research done on opiate addiction from various perspectives. Because of the complexity of addiction, the article deals with the psychologic, physiologic, biochemical, and socioeconomic factors that are involved in the process. The oldest and most developed approach is the pharmacologic approach. Pharmacologic investigations began in 1929 with an attempt to develop new derivatives of morphine which would not be as addictive. A clinical unit for drug testing was first set up in Kansas, later transferred to Lexington, Kentucky in 1935. Little was achieved in dissociating the useful properties of morphine from addictive properties. Synthetic analgesic: drugs were developed in one of 2 ways: by accident or by synthesis of a chemical structure closely related to one already known. Certain drugs were developed, such as Nalorphine, which was found to relieve pain without causing addiction, but produced disturbing mental effects. Other compounds are now under study that work as analgesics without causing addiction. The author stated that even if such nonaddicting analgesics were developed, it would have little effect on the addiction problem in the United States. Physiologic research has shown that addiction involves primarily the central nervous system. Further neurophysiologic investigations need to be done to settle unanswered que.dons, Biochemical investigations have shown that there are no basic alterations in the way in which morphine or similar drugs are catabolized, distributed within the body, or excreted during cycles of addiction. Little is known about the changes in the chemical activities of neurons during cycles of addiction. Perhaps the most striking biochemical change has been the demonstration that, in man, maintained addiction to morphine causes significant depression in the excretion of 17-ketosteroids and 17-hydroxycorticosteroids. The need for biochemical research in addiction remains very great. The changes underlying the phenomena of physical dependence and tolerance must have a biochemical basis. 240 J There have been 3 main psychologic formulations of the addiction process. In the psychobiologic theory, specific personality reaction patterns are supposed to develop because of mental stresses arising from the individual's environment. Neurotics use opiates to allay anxiety this is referred to as negative pleasure. A second theory sees people with sociopathic traits as using drugs to obtain euphoria or "positive pleasure". According to the third theory, "normal" persons become addicted only as a result of therapeutic use of drugs to relieve physical pain. Choice of drug is largely due to the particular drug available in the environment. Psychoanalysts regard addicts as individuals whose psychosexual development has been arrested, or has undergone regression to infantile, or even more primitive, levels. "Oral craving" may arise as a substitute for normal satisfactions achieved through the family. The author found this formulation not completely satisfactory. According to Wikler, there is a strong interdependence between specific drug action and the psychologic importance of physical dependence. He postulated that abstinence symptoms can be conditioned. His approach is a pharmacodynamic formulation. The author hypothesized that in the United States addiction may be another manifestation of delinquent or antisocial behavior. A fairly clear picture of the epidemiology and ecology of addiction in the United States has emerged from the many studies done. It is known that most addicts are between 20 and 30 years old, are members of a minority group and come from lower socio-economic classes. The writer called for more detailed studies of the natural history of opiate addiction in the United States. Because most addicts are under 35, the author the,orized that a large number of addicts may mature out of addiction. The author felt that the greatest deficiency in the study of addiction has been the lack of any well-designed and well-executed therapeutic trials. For this reason, it is still not known whether the present system of managing addicts is useful, or is harmful. Those who have studied the problem have been impressed that the most obvious lack in treatment has been the absence of long-term postinstitutional supervision and assistance. What these should be is still not clearly understood. Any new treatment system should have a built-in evaluation system. There should be controlled therapeutic experimentation, so that treatment systems can be judged as successes or failures. 241 V. 02 Ausubel, David P. Causes and types of narcotic addiction: A psycho-social view. Psychiatric Quarterly, 35:523-531, July, 1961. (7 references). SUMMARY The author attempts, in this article, to explain drug addiction from a psychosocial point of view. He states that physical dependence and withdrawal symptoms, while being genuine physiological phenomena, are not sufficient factors to explain why an individual becomes a drug addict. There are many different kinds of drug addicts, and the causes of drug addiction are multiple and additive in their impact, rather than mutually exclusive. The causes of drug addiction include both internal factors originating within the affected individual, and external factors originating within the environment. These factors can then be further categorized as precipitating or predisposing. Availability of drugs is an external precipitating factor. This would explain why the rate of addiction is so much higher in slum areas and among members of the medical and allied professions than in middle-class neighborhoods or among other occupational groups. But external factors alone cannot explain all of the khown facts about the incidence and distribution of drug addiction. In the area of predisposition, certain individuals fail to undergo adult personality maturation, characterized by long-term drives with corresponding motivational traits. They are generally passive, dependent people who desire immediate self-gratification. For these people the euphoric properties of opiates are most attractive, as they help to replace normal adjustive processes. Fcr others, the adjustive value of the drug is less specific and efficient, and the resulting type of addiction tends to be a transitory aberration similar to juvenile delinquency. Both types of addiction are found most commonly among adolescent males in the urban slums. Developmental and social stresses, high availability of the drug, and high community tolerance combined with motivational immaturity, produce the high addiction rate in urban slum areas. The author feels that misunderstanding of drug addiction is due, in part, to the scarcity of definitive research that deals w;th the physiological, psychological, and social aspects of addiction. 242 Distorted accounts of the causes of drug addiction become a great comfort to the addict, and in a sense absolve him of all responsibility. Mass media misinformation only serves to reinforce the addict's position of helplessness in the face of addiction. The author maintains that the addict's dependence on continued use of narcotics to avoid withdrawal symptoms is not a significant factor in causing drug addiction. +.4 243 V. 03 Lindesmith, Alfred R. Narcotic addiction. In: Burgess, E.W., and Bogue, D.S., eds. Contributions to Urban Sociology. Chicago, Illinois: University of Chicago Press, 1964. pp. 616-628. DRUG Opiates SAMPLE SIZE 70 SAMPLE TYPE Volunteer AGE Not Specified SEX Not Specified ETHNICITY Not Specified GEOGRAPHICAL AREA Chicago, Illinois METHODOLOGY Case Studies DATA COLLECTION INSTRUMENT Interviews DATE(S) CONDUCTED 1937 NO. OF REFERENCES 15 and 1947 SUMMARY Lindesmith's theory of drug addiction is based on his interviews with approximately 7Q narcotic addicts, 30 interviewed repeatedly. These subjects came to the author voluntarily through personal referrals. No attempt was made to secure more subjects through the police department, so that the confidence of the volunteer addicts would be retained and any bias encountered in the attitudes of the policemen would be avoided. The idea of interviewing prison inmates was rejected because of their purported reluctance to disclose any incriminating information while incarcerated. The 244 1 author intentionally avoided familiarizing himself with the current literature on drug addiction until after arriving at his own theories from his extensive interviews. THEORY Lindesmith defines addiction as "a complex of behavior characterized primarily by an intense, continuous, conscious desire for the drug which dominates the addict when he is on drugs and impels him to resume its use when he is abstinent." This definition excludes all other organisms (such as human infants or chimpanzees, which may have been given opiates either medically or experimentally), even if they experience physical withdrawal symptoms, since they can express no desire for additional doses to relieve their symptoms. Thus, Lindesmith defines physical dependence as habituation and psychological dependence as addiction. Individuals begin to become addicts when they use drugs after experiencing deprivation, withdrawal, and the almost instantaneous relief of another injection. People who have experienced these feelings but escaped from constant drug use acquire an attitude of fear toward the drug and are-psychologically "addicts" in the same way that an ex-drinker is always an alcoholic: neither person can thereafter be a social user without the fear of relapse. The craving can be explained by the basic survival mechanism of experiencing immediate beneficial effects; in this instance, however, the instinct is nonadaptive and detrimental to the organism. The addict experiences relief from distress rather than exhiliration, contrary to popular public belief. CONCLUSIONS A potential addict is anyone who has drugs available and will take them repeatedly. Even if consistent personality traits could be isolated as common to all addicts, it would be necessary to demonstrate that any other personality type would not become addicted after repeated withdrawals in order to disprove the theory. The punitive attitude toward addicts in the United States, has only encouraged illicit drug traffic and provided sources of "tax-exempt income" for syndicated crime, while doing nothing to treat or rehabilitate the addict. 245 V. 04 Lindesmith, Alfred R. Habituation and addiction. In: Lindesmith, A.R. Addiction and Opiates. Chicago: Aldine Publishing Co., 1968. pp. 47-67. (13 references). SUMMARY This article compared the state of the person who is physically dependent on opiates, often receiving long-term dosage, but not addicted, with the state of the addicted individual. One condition involves pharmacological tolerance and withdrawal distress upon removal of the drug, without the usual manifestations of intense desire that occur in addiction; the other concerns, in addition to these 2 symptoms, intense and persistent desire. In this article the term "habituation" was used for the former and "addiction" for the latter. The similarities and differences between habituation and addiction were described and sharply differentiated. THEORY The definition of addiction that the article proposed is one that focused on what is believed to be essential, common, or universal aspects of the behavior of addicts, whether they use drugs intravenously, by inhalation, by smoking, by drinking, or any other way. It excluded from consideration peripheral and idiosyncratic variations as well as any element of moral judgment. Addiction was defined as that behavior which is distinguished primarily by an intense, conscious desire for a drug, independent of the physiological conditions of tolerance and physical dependence, and by a tendency to relapse, evidently caused by persistence of attitudes established in the early stages of addiction. Relapse rates' in all parts of the world are high and the impulse to relapse is probably permanent and ineradicable; relapses have occurred after 10 or more years of abstinence. Addiction remains even when physical dependence is removed. Other correlated aspects are the dependence upon the drug as a 24-hour-a-day necessity, so that the addict organizes his entire life around his need for the drug, the impulse to increase the dosage far beyond bodily need, and the definition of one's self as an addict. In contrast, mere drug use without addiction, habituation, exhibits a different pattern. Patients who use or take drugs to the point of physical dependence,or even for long periods,do not necessarily become addicted; the discontinuance of the drug does not predispose them to resume its use, unless the pain or disease for which it was being used recurs. 246 Preoccupation is with a disease rather than with the effects of opiates; withdrawal distress is not recognized as such. Drug craving, as expressed verbally and as manifested in devious devices employed by addicts to obtain narcotics, is absent. As long as a patient believes he is using the drug solely to relieve pain, and regards it as a "medicine, " he does not become an addict. Habituation usually differs from genuine addiction also in the size of the dose and in its progressive increase; in therapeutic treatment a daily dose of 3 or 4 grains is regarded as an extraordinary amount, while an addict would consider it a small allotment and would have an insatiable appetite for a larger dosage. The physiological conditions produced by the drug when it is habitually assimilated by the body are essential to addiction, but other factors seem to be also present, for the physiological conditions are not always followed by addiction. CONCLUSIONS The factors which account for the transition from a biological condition, induced by regular drug administration for a period of time, to a psychological state of addiction or craving, need to be isolated. Undoubtedly the physiological concomitants play a role in addiction, but the psychic aspects must also be taken into account. Physiological factors are not causal in the sense that they "produce" such behavior. The biological aspects of addiction are an essential but not a determining part. Physical dependence may exist without addiction, and addiction without physical dependence. If one is interested solely in the bodily effects of opiates it is necessary to study the phenomena of physical dependence and tolerance, but if one is concerned with the social psychology of addiction, with behavior, the definition of addiction must be in behavioral terms. 247 V. 05 Lindesmith, Alfred R. Problems in the social psychology of addiction. In: Wilner, D. M., and Kassebaum, G.G., eds. Narcotics. New York: McGraw Hill, 1965. pp. 118-139. (30 references). SUMMARY Research on addiction was reviewed in order to develop a general theory concerning addiction to opiate-type drugs. The author was concerned only with matters that seemed relevant to the development of a general theory at the level of social psychology. Four basic methodological assumptions were reviewed: Addiction must be defined so that all persons can be sorted 1. into 2 contrasting categories, addicts and nonaddicts, with a small number in transition. A definition of addiction should be the result of an investiga2. tive process which specifies the common aspects of behavior. A general theory of addiction must be applicable to all cases. 3. An acceptable general theory should be falsifiable. 4. Definition of Addiction There has been considerable confusion about its definition. Because addiction is a behavioral phenomenon, it cannot be defined, as some have, only in terms of physical dependence and tolerance. Problems arise when defining a "cured addict, " or labelling those who are not currently using drugs because they are locked up or voluntarily abstaining. Lindesmith regards behavior designated as the "craving" for drugs as the central and defining feature of addiction, the tendency to relapse and other commonly emphasized features as corollary aspects. The Effects of Opiates To understand the effects of opiates one must either talk with and observe someone who uses them, or one must oneself use the drug. The assessment of the drug's effects is a matter of central importance to theory. One of the most interesting features of the effects of drugs is the marked differences at all stages of drug use between the reports of addicts and those of nonaddicts or persons who do not know what they are receiving. Many of the perceived or reported effects of drugs upon addicts are not so much effects of the drug as they are of the user's craving for drugs. 248 There are inconsistencies in the theory that addicts use drugs to obtain an ecstatic sense of pleasure and euphoria. If this theory were true, and pleasure alone were the key, then marijuana, not opium, would be the prime drug of addiction. The only generalization that can be safely made about the effects of an opiate on addicts is that this drug does relieve the pains of withdrawal. Further research is needed to be able to distinguish more sharply between the essential effects of the drug and those that are peculiar to a specific mode of use. Motives of Addicts Motives for opiate use differ widely and it is probably impossible to make any generalization about them. Reasons for drug use have varied over the years and vary from one culture to another. Whatever the initial motives may have been, they tend to change with continued use because the effects of the drugs change. No general motivational theory can be based on a particular group of addicts and their methods. One must take into account the many other patterns that are known. Cloward and Oh lin and others have theorized that the addict is a "retreatise who has withdrawn from the legitimate and/or criminal worlds. This concept fails to account for addicts in the medical profession; addicts who are successful criminals, and addicts who hold responsible, eminent positions. For example, the correspondence between addiction in the medical profession and the slums is not found in the area of motivation or personality, but in the general availability of narcotics. The Addiction-Prone Personality Characterizing the addiction-prone personality depends strongly on the investigator's experiences with addicts and his training and orientation. There is much confusion between the antecedents and consequences of addiction. Psychodynamic and cultural factors strongly influence evaluations of addicts. Whenever general intuitive evaluations are replaced by specific objective tests, alleged special attributes of addicts either disappear or are found both among addicts and nonaddicts. Most of the terms used to characterize addicts are also applicable to other groups such as prisoners, tramps, thieves, sex offenders and alcoholics. A General Theory of Addiction The characteristic craving of the opiate addict is generated in the repetition of the experience of using drugs to relieve withdrawal 249 distress, provided that this distress is properly understood by the user. A person defines himself as an addict because he realizes he is one. An addict relapses because of the previously established craving. The origin of addiction, according to this theory, can be attributed to experiences which all addicts undoubtedly have. The addict's craving is basically an irrational compulsion arising from the repetition of a sequence of experiences in a process like that which leads to a conditioned response. Observed effects of addiction upon personality and character follow from the indirect,conceptually mediated effects which addiction has upon the person's conception of himself and his status in society. The hypothesis implies that if a randomly selected group of ordinary adults received regular shots of heroin over a prolonged period, all would become addicted regardless of personality, character, social class or motive. CONCLUSIONS Many problems with respect to addiction remain to be examined. It is important to know more about individual motives and the social environments conducive to the abuse of drugs. It would also be of interest to examine and account for various public attitudes toward addicts and the narcotics problem. 250 V. 06 Laskowitz, David. Psychological characteristics of the adolescent addict. In: Harms, E. ed. Drug Addiction in Youth. New York: Pergamon Press, 1965. pp. 67-85. (43 references). SUMMARY The paper supports the theory that although human behavior involves a homeostasis of 3 systems, biological, social, and psychological, addictive behavior is developed essentially in a psychological context, with biological (pharmacological) considerations being of lesser importance. The identification of the psychological structure of the addict-prone is central to this theory of drug abuse, which accepts the proposition that the study of drug addiction concerns itself not with the pharmacological effect of the drug but the impulse to use it. Several studies have distinguished between addicts and non-addict nondelinquent controls. In contrast there has been considerable difficulty in distinguishing between addicts and non-addicted delinquent controls. One survey of background characteristics of the juvenile addict indicated that over 70% of the patients had a history of committing one or more offenses and approximately 20% of the patients were diagnosed as psychotic, in contrast with a 3% incidence for the national population. Treatment experience with pre-adult addicts has indLcated that they need habilitation rather than rehabilitation. They usually present a clinical picture of pervasive underdevelopment--emotionally, academically, vocationally--rather than a transient interruption of psychological growth occasioned by experimentation with drugs. The typical patie.A at Riverside Hospital in New York City (set up specifically for treating drug users aged 14-21) began using opiates at the age of 15 and when seen for treatment had an average of 9 years of schooling, often of a marginal calibre. At age 15 he had already begun getting involved in a variety of compelling instrumental behavior best characterized as narcotic -cente red. Phenomenological accounts of being "high" suggest that there is an experience of superpleasure associated with the suspension of selfcritical ability (apparently linked with the cortical depressant action of the opiates), which serves to generate a heightened feeling of personal value and security and more specifically, an augmented confidence in being able to master the anticipated stress associated with everyday life. Presumably the reinforcement (adjustive) impact of drugs is so great for the addict, with his anamnesis of failure experience either real or fantasied, that the narcotic habit becomes 251 t difficult to extinguish. Empirically, the energy output to support the narcotic habit suggests the craving for drugs has assumed primary drive characteristics. The phenomenon of relapse, probably the least understood aspect of addiction, must constantly be considered in a program of rehabilitation. It is known that there are non-specific environmental factors linked with a gamut of psychiatric and social problems, including drug addiction. From a sociological point of view, addict behavior, like other forms of delinquent behavior, is learned in association with others, according to the frequency, intensity, priority, and duration of contacts. The question of whether there is a predisposing personality pattern that makes for liability to addiction has stimulated papers which have more vigor than rigor. Linked with this is the intriguing question of whether the potentiality for addiction exists in everyone. Inevitably, a viable theory of drug abuse will have to consider the impact of the early experience of the addict, especially since it is known that: (a) early habits can be persistent and can prevent the formation of new ones; (b) early perceptual learning can profoundly affect all future learning; and (c) early social contacts are an important determiner of adult social behavior. 252 f ;1 SELECTIVE BIBLIOGRAPHY The following studies were recommended by the peer review group for additional reading. Ball, John C. Two patterns of narcotic drug addiction in the United States. Journal of Criminal Law, Criminology, and Police Science, 56(2):203-211, June, 1965. Bess, Barbara; Janus, Samuel; and Rifkin, Alfred. Factors in successful narcotics renunciation. American Journal of Psychiatry, 128(7):861-865, January, 1972. Chein, Isidor. "Psychological Functions of Drug Use. " Paper read at Symposium on the Scientific Basis of Drug Dependence, London, April 8-9, 1968. 19 pp. Gerard, Donald L., and Kornetsky, C. A. Adolescent opiate addiction. Psychiatric Quarterly, 29:457-486, 1955. Lander, Bernard, and Lander, Nathan. A cross-cultural study of narcotic addiction in New York: Preliminary report. In: Rehabilitating the Narcotic Addict. Report of Institute on New Developments in the Rehabilitation of the Narcotic Addict, Fort Worth, Texas, February 16-18, 1966. Washington, D.C.: U.S. Government Printing Office, 1967. pp. 359-369. Levengood, R.; Lowinger, P.; and Schooff, K. Heroin addiction in the suburbs--An epidemiologic study. American Journal of Public Health, 63:209-214, March, 1973. Lindesmith, Alfred. Opiate Addiction. Bloomington, Indiana: Principia Press, 1947. Maddux, James F. Treatment of narcotic addiction: Issues and Problems. In: Rehabilitating the Narcotic Addict. Washington D.C.: U.S. Government Printing Office, 1966. pp. 11-22. 253 Morhous, Eugene J. Drug addiction in upper economic levels: A study of 142 cases. West Virginia Medical Journal, 49:189, July, 1953. Mott, Joy. The psychological basis of drug dependence: The intellectual and personality characteristics of opiate users. British Journal of Addiction, 67(2):89-99, June, 1972. Newmeyer, J.A. , and Gay, G.R. The traditional junkie, the Aquarian age junkie and the Nixon era junkie. Drug Forum, 2(1):17-30, Fall, 1972. O'Donnell, J.A. A post-hospital study of Kentucky addicts--A preliminary report. Journal of the Kentucky Medical Association, 61:573-577,604, July, 1963. O'Donnell, John A. Research problems in follow-up studies of addicts. In: Rehabilitating the Narcotic Addict, Report of Institute on New Developments in the Rehabilitation of the Narcotic Addict, Fort Worth, Texas, February 16-18, 1966. Washington, D.C.: U.S. Government Printing Office, 1967. pp. 321-334. Oltman, J.E. , and Friedman, S. Twenty years of drug addiction. Diseases of the Nervous System, 25:90-96, February, 1964. Sheppard, Charles; Fiorentino, Diane; Collins, Louis; and Merlis, Sidney. Ravens Progressive Matrices (1938): Normative data on male narcotic addicts. Psychological Reports, 23(2):343-348, 1968. Soloway, Irving. Methadone and the culture of addiction. Journal of Psychedelic Drugs, 6:2, Spring, 1973. Stephens, Richard Charles. "Relapse among Narcotic Addicts: An Empirical Test of Labelling Theory. " Unpublished doctoral dissertation. University of Wisconsin, 1971. Ann Arbor, Michigan: University Microfilm no. 71-16, 103. Stern, Roy. Changing friendship patterns in addict groups. Pennsylvania Psychiatric Quarterly, 6(2):3-10, 1966. Trussell, Ray E. Treatment of narcotic addicts in New York City. International Journal of the Addictions, 5(3), 1970. 254 Wakefield, Dan, ed. The Addict. Greenwich, Conn. : Fawcett, 1963. 191 pp. Waldorf, Dan. Careers in Dope. Englewood Cliffs, New Jersey: Prentice-Hall, 1973. 186 pp. Wellisch, David K., and Gay, George R. The walking wounded: Emergency psychiatric intervention in a heroin addict population. Drug Forum, 1(2):137-144, January, 1972. Weppner, R.S. Drug abuse patterns of Vietnamese war veterans hospitalized as narcotic addicts. Drug Forum, 2(1):43-54, Fall, 1972. Wikler, A. Opiate Addiction: Psychological and Neurophysiological Aspects in relation to Clinical Problems. Springfield, Illinois: Charles C. Thomas, 1953. Williams, Joyce E. , and Bates, William M. Toward a typology of female narcotic addicts. Proceedings of the Southwestern Sociological Association 18:152-156, March, 1967. This section of the bibliography lists autobiographies and biographies of and by heroin addicts. These are true life style histories, told in a rich language by those who know the story best. Anonymous. An addict tells his story. In: Riessman, F.; Cohen, J. ; and Pearl, A., eds. Mental Health of the Poor. New York: Free Press of Glencoe, 1964. pp. 620-636. Anonymous. Go Ask Alice. Englewood Cliffs, New Jersey: Prentice-Hall, 1971. 159 pp. Becker, H.K. Carl Koller and cocaine. Psychoanalysis Quarterly, 32:309-373, 1963. Blake, James. The Joint. New York: Doubleday and Company, Incorporated, 1971. Breathnach, C. S. Francis Thompson- -Student, addict, poet. Journal of the Irish Medical Association, 45:98-103, October, 1959. 255 Bruce, Lenny. How to Talk Dirty and Influence People, an Autobiography. Chicago: Playboy Press, 1966. 240 pp. Burroughs, William S. Kicking drugs: A very personal story. Harper's, 235:39-42, July, 1967. Clark, Janet. The Fantastic Lodge. Boston: Houghton Mifflin Co., 1961. Cortina, Frank M. Stroke A Slain Warrior. New York: Columbia University Press, 1970. 231 pp. Crowley, Alistair. The Diary of a Drug Fiend. New York: Lancer Books, 1972. Fisher, Florrie. The Lonely Trip Back. Garden City, New York: Doubleday, 1971. 212 pp. Hahn, E. The big smoke. New Yorker, 44:35-43, 1969. Harris, John D. The Junkie Priest: Fr. Daniel Egan. New York: Pocket Books, 1969. 81 pp. Hentoff, Nat. A Doctor Among the Addicts. New York: Grove Press, 1970. 136 pp. Holiday, Billie. Lady Sings the Blues. New York: Doubleday, 1956. 250 pp. Alexander. Mine Enemy Grows Older. New York: Simon and Shuster, 1958. King , Kron, Y. J. , and Brown, E.M. Mainline to Nowhere: The Making of a Heroin Addict. New York: Pantheon Books, 1965. 208 pp. Larner, Jeremy, and Tefferteller, Ralph. The Addict in the Street. New York: Grove Press, 1964. 288 pp. Lenoir, Cecil de. The Hundredth Man, Confessions of a Drug Addict. New York: Claude Kendall, 1934. 288 pp. Luce, John. The end of the road: A case study. Journal of Psychedelic Drugs, 4(1):50-52, Fall, 1971. Lyle, David. The logistics of junk. Esquire, 65:59-67, 138-144, March, 1966. 256 Mac Callum, W. G. William Stewart Halsted, Surgeon. Baltimore: Johns Hopkins Press, 1930. 241 pp. Melody, Roland. Narco Priest. New York: World, 1971. 133 pp. Penfield, Wilder. Halsted of Johns Hopkins. The man and his problems as described in the secret records of William Os ler. Journal of the American Medical Association, 210(12):2214-2218, 1969. Siege (pseudonym). The drug scene -An addict speaks. Thought processes of an active addict. Paediatrician, 1:3-7, 1972. Stern, Bill, and Fraley, Oscar. A Taste of Ashes. New York: Henry Holt and Company, 1959. Thomas, Piri. Down These Mean Streets. New York: Alfred A. Knopf, Inc., 1967. Trocchi, Alexander, Cain's Book. New York: Grove Press, 1960. 252 pp. Wood ley, Richard. Dealer: Portrait of a Cocaine Merchant. New York: Holt, Rinehart and Winston, 1971. 210 pp. 257 INDEXES The numbers in the indexes refer to the unique identification code found in the upper right-hand corner on the first page of each abstract. Roman numerals reference categories from the Table of Contents; Arabic numerals reference abstracts within categories. It should be pointed out that a given index term refers to an entire abstract rather than to pages within an abstract. The keyword terms selected for the indexes are those terms used in the literature; no terms were inferred. The most specific term was used whenever possible. Thus, some material on marijuana will be found under that term but other material may be found under the term cannabis. Similarly, studies of heroin use may be indexed under heroin but also under opiates. For convenience to the reader, the indexes have been divided into the following five sections: Drugs Includes general and specific names of all drugs mentioned in the abstract, as used by the authors of the document. Sample Types Terms which describe as specifically as possible the sample population studied. Geographic Locations Organized by state, the location where the study was carried out; includes also names of universities, schools, drug programs, committees, etc. , in the order in which they occur in the abstracts. Subjects Terms which describe the subjects or concepts of the studies; included also are names of specific data collection instruments, evaluation tools, and questionnaires. Authors All authors named in the citation to each abstract are listed in the author index; however, this does not include all authors of the materials abstracted since documents with more than two authors have been cited with et al. 259 AUTHORS Langrod, J. IV. 08 V.06 Laskowitz, D. Lau, M. III. 20 Lerner, M. III. 27 Levine, S. I. 04 V.03, V.04, V.05 Lindesmith, A. Lombardi, D. III. 02 McEntee, R. III. 17 Maddux, J. III. 24 Meyer, A. I. 12 Meyers, M. II. 02 Moffett, A. III. 13, III. 22, III. 23, III. 26 Agar, M. I. 17 Allain, A. III. 03 Ausubel, D. V.02 Abbott, W. Ball, J. Bates, W. III. 18, III. 20 III. 12, III. 21, III. 24 Berliner, A. III. 24 Berzins, J. III. 01 Brotman, R. I. 10, I. 12 Brown, B. Capel, W. II. 02 III. 28 I. 14 IV. 04 Casey, J. Chambers, C. III. 14, III. 22, III. 23, IV. 04, IV. 05, IV. 07, IV. 09 Clifford, H. III. 13 Cuskey, W. III. 13, III. 23 Dai, B. IV. 02 DeFleur, L. III. 18 Duvall, H. II. 17 Ellinwood, E. III. 16 Feldman, H. I.06 Fiddle, S. I.01 Finestone, H. I. 13 Freedman, A. I. 10, I. 12 II. 02 Gauvey, S. Gay, G. I.08, I.09, III. 09, III. 17, III. 29, IV. 03 Gendreau, L. III. 04 Gendreau, P. III. 04 Gilbert, J. Glaser, D. Glaser, F. III. 27 O'Donnell, J. II. 05, II. 11 Perkins, M. II. 19 Pittel, S. III. 07 Powell, D. II. 01 Preble, E. I. 14, III. 19 ProctoF, M. I. 18 Ramer, B. III. 29 Ray, M. II. 04 Richman, A. II. 15, II. 16 Robins, L. IV. 01 Ross, W. III. 01 Rubington, E. I. 02 Schasre, R. II. 06 Schuster, C. IV. 06 Sheppard, C. I. 09, III. 06 Siegel, A. III. 30 Smith, B. IV. 06 Smith, D. I.09, III. 29 Smith, W. III. 16 11.1. 02 III. 26 III. 15 Goldsmith, B. III. 28 Gregory, R. I.03 Hinesley, R. III. 14 Hughes, P. I. 15, I. 16 Inciardi, J. IV. 07 Isbell, H. V.01 Sparr, R. III. 18 Stark, S. II. 02 Stephens, R. I.04 Jaffe, J. I. 16, IV. 06 Jones, J. III. 22 Lander, B. Moldestad, M. III. 14 Monroe, J. III. 10 Murphy, G. IV 01 Newmeyer, J. I. 07, I. 08 Nurco, D. I.05, II. 20, III. 11, Stewart, G. III. 05, III. 28 Sutker, P. III. 03, III. 08 III. 26 269,. Sutter, A. I. 11 SAMPLE TYPES Taylor, W. IV. 04, IV. 05 Trussel, R. II. 18 adolescent III. 19, III. 24,111. 29, Vaillant, G. II. 10, II. 12, II. 13, V. 02, V. 06 II. 14, III. 16, III. 25 Blacks III. 10, III. 12, III. 13, Waddell, K. III. 05, III. 28 Waldorf, D. II. 03 Watkins, T. IV. 09 Wellisch, D. III. 17 Williams, J. III. 21, 111.22, III. 25, III. 26, III. 27, IV. 01 Chinese III.20 ethnic groups I. 06, I. 14, I. 17, III. 12 Winick, C. II. 07, II. 08, II. 09 Winkler, J. L.08 DRUG alcohol I. 08, II. 03, II. 11, II. 19, III. 09, III. 16, III. 24, III. 29, IV. 05, V. 05 amphetamines I. 09, 111.27, III. 30, IV. 05, IV. 08 barbiturates I.08, I.09, II. 11, III. 09, III. 20, III. 22, III. 27, III. 28, III. 29, III. 30, IV. 05, IV. 08 chlorpromazine III. 09 cocaine I.08, III. 27, 111.29, IV. 03, IV. 04, IV. 05, IV. 08 codeine III. 15, IV. 06 hallucinogens I. 09, III. 07, III. 09, 111.27, IV. 05 LSD I. 08, I. 09, III. 27, IV. 08 marijuana 1 . 0 9 , 1 11 . 1 4 , 11 1 . 1 5 , III. 18, III. 20, III. 22, III. 23, III. 24, III. 26, III. 27, III. 28, III. 29, III. 30, IV. 01, IV. 05, IV. 08 meperidine (Demerol) II. 09 methadone I. 18, II. 10, II. 15, II. 19, III. 05, III. 06, III. 09, III. 28, III. 29, IV. 04, IV. 05, IV. 06 pentazocine IV. 06, IV. 07 speed I. 08, III. 29 II. 03, II. 13, II. 15 ex-addicts II. 06, II. 14 females III. 01, III. 12, III. 13, III. 14, III. 15, III. 16, III. 17, III. 22, III. 23, III. 29 immigrants III. 25 Mexican-Americans III. 23, III. 24, III. 29 lower class I. 06, I. 14, I. 16, III. 25, III. 26, V. 02 middle class 11.01, III. 15, III. 29, IV. 03, V. 02 neophytes II. 06 occasional heroin users II. 01 Orientals III. 29 Puerto Ricans III. 12, III. 14, III. 18, III. 19, III. 25, III. 7.6 siblings III. 26 U.S. armed forces III. 30 GEOGRAPHIC LOCATOR California III. 23 Haight Ashbury Free Medical Clinic I. 07, I. 08, I. 09, III. 07, III. 09, III. 17, III. 29, IV. 03 Los Angeles II. 06 San Francisco I. 07, I. 08, I. 09, I. 11, III. 07, III. 09, III. 17, III. 29 Canada British Columbia II. 16 Ontario III. 04 District of Columbia II. 02, III. 12, III. 21 261 2 ;,./ Illinois Chicago I. 13, I. 15, I. 16 IL. 18, III. 12, IV. 02, IV. 06, V.03 Kentucky addict vocabulary I. 17 "bag follower" I. 15 "cats" I. 13 "cool cat" I. 04 "cool operator" I. 13 "dealer" I. 05, I. 11, I. 15 "garbage junkies" I. 11 Lexington I. 17, II. 03, II. 10, II. 11, II. 12, II. 13, II. 14, "hustlers" I.10, I.11, I.12, II. 17, III. 01, III. 10, III. 12, I. 15 III. 13, III. 14, III. 15, III. 16, II mackman" I.11 III. 18, III. 20, III. 21, III. 22, "squares" I. 13 III. 25, IV. 07, V. 01 "stand -up cat" I. 06 Louisiana III. 18 "tecato" III. 24 New Orleans III. 03, III. 05, "tout" I. 15 III. 08, III. 28 "workers" I. 15 Maryland III. 21, III. 27 addictive process II. 20, III. 04 Baltimore II. 20, III. 11 cessation patterns II. 06 Massachusetts conformists I. 10, I. 12 Boston II. 01 "conning" behavior I. 04 Mis souri "copping areas" I. 15, I. 16 St. Louis IV. 01 criminality II. 16, III. 18, III. 22 New Jersey cultural background I. 03, III. 25 Newark III. 02 dechemicalization I. 01 New York I. 06, I. 18, II. 03, demographic data I. 16, III. 15, II. 10, II. 15, IV. 08 III. 22, III. 23 Manhattan State Hospital I. 14 detoxification I. 09 Metropolitan Hospital I. 10, drug substitutes II. 03 I. 12 economic careers I. 14 New York City I. 14, I. 18, education II. 03 II. 03, II. 05, II. 12, II. 14, employment I. 05, II. 14 II. 17, II. 18,11. 19, III. 06, epidemiologic data I. 16 III. 19, III. 20, III. 25, existentialists I. 01 III. 26 Exodus House I. 18 Narcotic Addiction Control family backgrounds II. 12 Commission IV. 07 Federal Bureau of Narcotics II. 02, Riverside Hospital II. 18, V. 06 II. 08, II. 09 Pennsylvania IV. 04, IV. 05, first use II. 02 IV. 07, IV. 09 follow up studies II. 05, II. 10, II. 11, II. 12, II. 14, II. 17 habit reduction I. 10 Harrison Narcotic Law of 1914 Texas III. 21, III. 23, III. 24 SUBJECTS abstinence II. 02, II. 04, II. 11, II. 14, II. 16, II. 17 addict identification method III. 10 262 I. 02 ideology 1. 06 initial illegal act II. 02 locus of control III. 01 Maslow's hierarchy I. 03 mass media V. 02 maturing out II. 07, LI. 09 Minnesota Multiphasic Personality Inventory (MMPI) unemployment II. 17 urban I. 16, II. 01, II. 12, In. 12, LI. 15, III. 03, III. 04, III. 06, III. 07, III. 08, III. 17 O'Donnell II. 10 withdrawing LI. 02, V.02, V.05 pain-prone III. 15 pathology III. 02, III. 06 physical addiction LI. 06, V. 03, V. 04 psychological dependence V. 03 psychiatric characteristics II. 13, III. 02 psychotic ILI. 06, III. 09, III. 17 questionnaires and inventories III. 05 race differences ILI. 14, IV. 04 relapse LI. 04, V. 06 residence III. 11 secondary drug IV. 08 social influence I. 02, LI. 04, II. 06, LI. 13, II. 20, III. 11 sociopathic personality III. 06, III. 08 sociopsychiatric IV. 02 suburban LI. 01 therapeutic success II. 18 typology I. 03 Easy Rider Syndrome III. 17 "New Junkie" I. 08, I. 09, ILI. 07 "Old Style Junkie" I. 07, I. 08, I. 09, ILI. 07 "righteous dope fiend" I. 11 "retreatist" I. 01 "shooting- gallery addict" I. 01, I. 05 "street addict" I. 04, I. 05, ILI. 03 "Transition Era Junkie" I. 07 I. 08, I. 09, III. 07 "two worlders" I. 10, I. 12 "Watergate Era Junkie" I. 07 263 III. 16 Vaillant LI. 10 DHEW Publication No. (ADM) 75-189 Printed 1975 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION NATIONAL INSTITUTE ON DRUG ABUSE