REHABILITATION ‘OF THE DRUG ABUSER . NINTH INSTITUTE ON ~ REHABILITATION SERVICES LIBRARY OF THE UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN SOs aeowo Inssr. na Pu ‘t nN hare “i “i ‘) % a ; y P ie i q ” A A 2 | 3 4 a i ya, fe 4 i ea an i sf aa : to | ” . : pe ¥ } “Nt . #4) ! a a ii MY aa A a NDEs ty ee 3 re pe es es M.S ‘ae rab J Tee bs * a REHABILITATION of the DRUG ABUSER A Report from the Study Graup on Rehabilitation of the DRUG ABUSER The Library of the PERE e rl be ka boinc : ai ee at Urbana-Champaig Philip Kolber Illinois Division of Vocational Rehabilitation University Coordinator George Se Hitas wihda.)D. Assumption College Worchester, Massachusetts NINTH INSTITUTE ON REHABILITATION SERVICES May 10-12, 1972 San Antonio, Texas Final Preparation and Printing by The Clearing House Rehabilitation Counselor Training Program Oklahoma State University with support in whole or in part by Grant No. 44-P-—30277/6-01 U. S. Department of Health, Education, and Welfare Social and Rehabilitation Service Rehabilitation Services Administration Washington, D. C. 20201 Etesmaverralsein thse pubbicauron dOsnoG necessartly represent the official views of the Rehabilitation Services Administration nor of State vocational rehabilitation chet alenlory | MDsteaiA lei, alenoidenes, Wile, cig attempt by State vocational rehabilitation WONKEYS MON exXDLOre aes teni TT CanumaspeCct on their programs in order’ to encourage evaluation and stimulate professional growth. skal FOREWORD Problems relating to the uncontrolled use of drugs have reached both national and international proportions with an impact that proverbially leaves us "grasping for straws." Effects upon lives, especially our youth, are so profound, widespread, and often tragic that a nation's resources are challenged in an unprecedented manner. Preventative and ameliorative solutions leave much to be desired: however, our, current planning, and objectives are; directed at developing the knowledge, resources, and methodologies necessary for us to meet this challenge head-on. Prise voocunentu sts ne urs. etcuemplu wo DULL torether some basic information as a guide for rehabilitation staff in serving clients with drug abuse problems. It is not a definitive document on Giessubjecu.snOr could ai Dewconstoering. the: stave, of Une art. There is a growing awareness among "drug abuse" professionals that medical model treatment efforts such as detoxification or maintenance alone are insufficient to return drug abusers to conventional society. Hopefully, the following material will stimulate interest and action regarding the contributions of the vocational rehabilitation program to the overall drug abuse treatment and rehabilitation effort. Sichonriel oy Fe fo Hdward Newman Commissioner as Uk Digitized by the Internet Archive In 2021 with funding from University of Illinois Urbana-Champaign https://archive.org/details/rehabilitationof0Oinst PREFACE Prime Study Group I was assigned the task of preparing a Training Guide on The Rehabilitation of the Drug Abuser, reviewed its original charge, and modified it to include the following: Nature and Extent of Drug Abuse, Evolution of Drug Abuse Legislation, Eligibility and Feasibility, Differential Aspects of Client Study, Staff Attitudes and Counselor Skills, and Service Programming. The intent of this Training Guide is to present basic in- formation regarding drugs and drug abuse as specifically related to the rehabilitation process and the responsibilities of State DVR agencies. The training material is designed to meet particu- larly the needs of the rehabilitation counselor working with a client who has a disability of drug abuse. The outlook of this document is realistic and optimistic, for it is the optimism of a counselor as he confronts realities that will enable the client to respond positively. Any endeavor, however successful, relies upon the coopera- tion of many people. Prime Study Group I was fortunate in its membership. The members of Prime Study Group I were Mr. Vernon M. Arrell, Mr. Joseph Carano, Mr. Frederic Clanagan, Mr. John F. Curley, Mr. H. Dorsey Devlin, Dr. George S. Elias, Mr. Philip Kolber (Chairman), Mr. Paul Primavera, Mr. Jerome N. Rubino, Dr. Daniel Sanford, Mr. David Siddle, and Mr. Thomas J. Skelley. Their sincere desire to be of service in this undertaking and the quality and quantity of their efforts were most gratifying. In addition, the committee greatly appreciated the guidance of Les Blankenship and Ray Simmons. In the preparation of the final draft we were fortunate in having the editorial services of Professor Donald Letendre of Assumption College, the typing skills of Mrs. Mary MacLeod, and over-all secretarial assistance of Miss Esther Johnson of the Institute for Social and Rehabilitation Services at Assumption College who played a crucial role in coordinating the efforts of many people and thus greatly facilitated the work of the Study Group. Philip Kolber Chairman George S. Elias University Coordinator py | . . ‘ | ; 4 at Pr a7 | 7 hd ; '' ie i ’ 5 ae. of if na AG vi) ( ai a wat, bean 4 ae eel aia | | aye: 7 als a's mrt t. it tad) } eee i te 1, “i rows UE duds pe abel he Ped ed aes Dud eae bat hae tl val a aC) ‘y La ih, i 1's m= a a) 7 ree pay i it Lee Yo. vr 2 pad we ' 404. ona) ead ag ben @' 2. 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Chapter I II Ms IV TABLE OF CONTENTS NATURE AND EXTENT OF DRUG ABUSE Nature of Drug Abuse Factors Associated with Drug Abuse Pharmacological Aspects Psychological Factors Associated with Drug Abuse Sociological Aspects EVOLUTION OF DRUG ABUSE LEGISLATION Early Legislation U. S. Supreme Court Decisions Legislation of the 1960's Legislation of the 1970's ELIGIBILITY AND FEASIBILITY Federal Regulations Physical or Mental Handicap Feasibility Considerations DIFFERENTIAL ASPECTS OF CLIENT STUDY: SPECIAL CONSIDERATION AND NEEDS Differences Among Drug Abusers Social Characteristics of Drug Abusers Psychological Characteristics of Drug Abusers Medical Characteristics of Drug Abusers Vocational Characteristics of Drug Abusers A Counseling Approach vii yy Page N 11 12 17 18 19 24 23 24 25 27 28 29 30 32 = ay V VI Appendix A (1) STAFF ATTITUDES AND COUNSELOR SKILLS Positive Factors Ambivalent Attitudes Counseling Strategies "Open Door Policy" SERVICE PROGRAMMING Relevant Considerations Comprehensive Service Strategies Historical Background Treatment System Current Treatment Modalities Training, Placement, and Follow-up Services APPENDICES Prime Study Group I Study Committee I Charge to Prime Study Group I Interview with a Former Drug Addict Drug Glossary Confidentiality of the Records of the Vocational Rehabilitation Agency Questionnaire Summation of Questionnaire Results A Training Guide for Rehabilitation of the Drug Abuser Schema for Examining Job Readiness Selected Films Bibliography Drug Abuse Products Reference Chart wtaaig lah Page 61 62 65 67 85 Ts) 21S 101 105 109 Mand WEY ea CHAPTER I NATURE AND EXTENT OF DRUG ABUSE Nature of Drug Abuse Drug abuse may be generally defined as the use of a drug for non-medical or non-scientific purposes, with the potentiality of harm to the user or to society. To cover all kinds of drug abuse and to replace the terms addiction and habituation, the World Health Organization, in 1964, selected the term drug dependence. Drug dependence is a state of psychological or physical dependence, or both, on a drug, which results from chronic periodic or continuous use. In this paper, the terms associated with drug abuse are defined as follows: Addiction "is physical dependence upon a drug. Its scientific definition includes the develop- ment of tolerance and withdrawal. As a person develops tolerance he requires larger and larger amounts of the drug to produce the same effect. When use of the addicting drug is stopped abruptly, the period of withdrawal is characterized by such distressing symptoms as vomiting and convulsions. A compulsion to repeat the addicting drug is under- standable because the drug temporarily solves one's problems and keeps the withdrawal symptoms away. Drugs other than narcotics can become addicting.” Habituation “is the psychological desire to repeat the use of a drug intermittently or continu- ously because of emotional reasons.” Psychological dependence "is an attachment to drug use which arises from a drug's ability to satisfy some emotional or personality need of an individual. This attachment does not require a physical dependence, although physical dependence may seem to reinforce psychological dependence." Factors Associated with Drug Abuse No final agreement has been reached as to the precise effects of mind-altering substances on the human body. Although much is known about the effects of drugs with abuse potential, the user himself remains the enigma. Slum environments, easy access to drugs, pushers, and organized crime have been blamed for the problem. Although any of these factors may contribute, no single cause or set of conditions clearly leads to drug dependency, for it occurs in all social and economic classes. The five major classes of drugs are marijuana, stimulants, sedatives, hallucinogens, and narcotics. The power of thé drug varies to a very large extent according to the user, and depends on the amount and manner he uses these substances. The most important general effect characteristic of all mind-altering drugs is loss of self-control, which, in one form or another, leads to self-destructive and anti-social behavior. All responsible observers tend to agree that much is still unknown about drug abuse, even though the amount of written material is quite large. In this wealth of excellent articles and books, few have brought together the fields of pharmacology, physiology, psychology and sociology in a consistent presentation. Therefore, we strongly urge those who try to comprehend the phenomenon of drug abuse to be wary of oversimplified explanations. GENERALIZED BEHAVIOR Certain observations on the effects of the major types of drugs, based largely on knowledge of their chemical composition, may be advanced in spite of our word of caution. (See Chart in Appendix) Certain kinds of noticeable behavior are associated with and can be linked to the major types of drug abuse. In general, any striking change in the personality of the individual observed should arouse suspicion. The abuser of stimu- lants may show a marked change from listlessness to excited activity. Conversely, the likely abuser of tranquilizers and barbiturates may change from hyperactivity to sedate, cautious, or even listless behavior. Changes in conduct, such as work attendance, performance, personal appearance and habits, warrant attention. Suspected abusers may wear sunglasses in moderate light or darkness to hide the size of their pupils; they may always wear long sleeves so as to conceal needle marks. The appearance of intoxication without the smell of alcohol is 3 often the result of barbiturates. A person on stimulants may be nervous and have dilated pupils. The drying effect of these agents on the mucuous membranes may cause halitosis, repeated licking of the lips, and scratching of the nose. Let us now proceed to brief discussions of our five major categories of drugs. Pharmacological Aspects MARIJUANA (CANNABIS) / Marijuana, known for nearly 5,000 years, is a drug found in the flowering tops and leaves of the female Indian hemp plant, Cannabis sativa. This plant grows in mild climates throughout the world, especially in Mexico, Africa, India, and the Middle East. It also grows in the United States, where marijuana is also known by a variety of names, such as "pot," "grass,"' "weed," and "tea,'' to name but a few. Marijuana can easily be detected when smoked because of its sweetish smell, similar to that of burned rope or dried grasses. There seems to be substantial agreement that whereas most other drugs have clearly deleterious effects on the abuser, the threat posed by marijuana is less clear-cut. Literature on this subject reveals substantial disagreement even among well-informed scientists and medical practitioners. The following illustrates this disagreement: "Marijuana, which is not a narcotic, does not cause physical dependence as does heroin or other narcotics. This means that the body does not become dependent on con- tinuing use of the drug. Neither does the body seem to develop a tolerance to the drug which would make larger doses necessary for the same effects. Withdrawal from marijuana does not produce physical sickness.'"4 "There are certain dangers of vivid visions and exhilaration which result from use of marijuana, and abusers become accident prone because of time and space sense disturbance. Dependence (psychic but not physical) leads to anti-social behavior and could be the forerunner of the use of other drugs." In certain significant areas, however, there is agreement among reputable and informed authorities. The following illustrates this agreement: 1. Marijuana is universally recognized as a mind- altering drug which in varying degrees and with unpredictable effects produces a state of intoxication sometimes referred to as “euphoria.” 2. Marijuana dominates the drug scene on U. S. college campuses and is customarily used for the explicit purpose of inducing this state of intoxication. 3. In varying degrees this state of intoxication can cause a lessening of psychomotor coordination and a distortion of the ability to perceive time, distance, and space. These symptoms, however, are not accompanied by a diminution of muscular strength. 4. The habitual use of marijuana is particularly prevalent among individuals with marginal personalities who exhibit feelings of inadequacy, anxiety, disaffection, alienation, and frustration, or who suffer from neuroses, psychoses, or other mental disorders. 5. Marijuana may have a disinhibiting effect upon the user which tends to aggravate or exaggerate his pre-existing mental state or disposition. Thus, its effects can vary with individuals and on different occasions. 6. Marijuana has no accepted use in modern medicine. It is impossible to determine the exact extent of marijuana use in the United States. Some health authorities estimate that 4 to 5 million Americans may have used the drug at least once. Other estimates run as high as 20 million. (When one realizes that marijuana must be bought, directly or indirectly, from pushers who can, and sometimes do, put the buyer in touch with hard drugs, it becomes evident that the criminal aura of marijuana is fairly extensive.) Marijuana dominates the drug scene according to a national survey of college students completed in December 1970 by Gallup Poll. This survey, which included proportional representation of students from private, public, and denominational schools, repre- sented 61 campuses. Current use of marijuana varies according to the backgrounds of students and the type and location of the college. The most frequent user was found to be a male senior or graduate student whose father has a college background and who is studying the social sciences or humanities at an Eastern college. Despite warnings by some medical authorities, the overwhelming majority of student marijuana users think the drug not harmful to their health. It appears that many of the popular myths concerning marijuana will not be dispelled until more convincing evidence of its long-range effects becomes known. STIMULANTS / The most commonly used stimulants are amphetamine (Benzedrine), dextroamphetamine (Dexedrine), and methamphetamine (Methedrine). All are legitimate drugs, essential to the practice of medicine; legitimate manufacture and distribution are confined to ethical drug channels. Benzedrine, Dexedrine, and other stimulant drugs do not pro- duce physical dependence as do the narcotics. "Although the body does not become physically dependent on their continued use, it does develop a tolerance to these drugs so that larger and sea ts doses are required to feel the effects.” Medical authorities speak of another kind of dependence, however, in connection with the abuse of stimulants -- "psychological dependence," that is, use can become a habit for mental or emotional reasons. The American Pharmaceutical Association reports that normal doses of amphetamine produce wakefulness, increased alertness, and a feeling of increased, initiative. Intravenous doses produce cocaine-like psychotoxic effects. Conversely, amphetamines can cause high blood pressure, abnormal heart rhythms, and even heart attacks. It has been reported that teenagers often take them to increase their "nerve." As a result they may behave dangerously. Excess or prolonged usage can cause hallucinations, loss of weight, wakefulness, jumpiness, and dangerous aggressiveness. Tolerance to large doses is acquired by abusers. Psychic dependence develops but physical dependence does not. There is no characteristic withdrawal syndrome; however, abruptly withdrawing the drug from the heavy abuser can result in a deep and suicidal depression. Long-term users of amphetamines are usually irritable and unstable and, like other heavy drug abusers, they show varying degrees of social, intellectual, and emotional breakdown. As for the most adverse psychological effects, stimulants can, in a paranoid individual, inspire violent behavior which may result in homicide. SEDATIVES This group includes the barbiturates made from barbituric acid, the most widely abused of the depressants. Drugs in this family are manufactured for medical purposes to relax the central nervous system. All are legally restricted to prescription use only. The drugs may be taken orally, intravenously, or rectally by the abuser. Usually the appearance of drunkenness without an alcoholic breath indicates barbiturate intoxication, Other symptoms of barbiturate abuse are slurred speech, staggering gait, and mental sluggishness. The person on these drugs may be irritable and antagonistic. Because coordination is affected, the person is prone to stumble and drop things. Often he is bruised and has cigarette burns. Unfortunately, barbiturates are extremely popular with young people and are often used in combination with alcohol. The combina- tion of these two agents has a synergistic (greater than the sum of both) effect on the central nervous system and, in combination, may cause respiratory depression and death. This same combination may cause the person to vomit, and in a stuperous state to inhale the vomitus, thereby causing a chemical pneumonitis which may be fatal. Chronic misuse of barbiturates is always accompanied by the development of tolerance and both physical and psychological dependence, "The tolerance developed to barbiturates is only partial’ and of such a nature that’ it may lead to disastrous results. A person indulging in barbiturates develops resistance to their psychic effects but does not develop tolerance to the respiratory depressant or lethal effect. Thus, as the individual constantly increases his dosage in an effort to overcome the resistance to psychic effects, the dosage grows closer to that having lethal effects. Many individuals being unaware of this particular mechanism have accidentally taken overdoses of barbiturates with catastrophic results." Barbiturates are a leading cause of accidental poison deaths in the United States. They are also one of the chief means of suicide. Overdoses, particularly when taken in conjunction with alcohol, result in unconsciousness and death, unless proper medical treatment is promptly given. Barbiturate intoxication is much more dangerous than alcoholic or narcotic abuse. Indeed, some experts consider barbitu- rate addiction more difficult to cure than a narcotic dependency. / HALLUCINOGENS / The illicit drugs that come under this category are LSD-25 (Lysergic acid diethylamide); Mescaline (Peyote), a chemical taken from peyote cactus plant; and Psilocybin, synthesized from Mexican mushrooms. All of these drugs are usually taken orally, but non-intes- tinal absorption is also possible. The effects of these drugs are unpredictable. They are given the name "hallucinogens" because they may produce hallucinations or illusions affecting the various senses. It has been found, as with stimulants and depressants, that the user of hallucinogens may develop a psychological dependence upon these drugs. Unlike depressants, however, hallucinogens do not produce a physical dependence or withdrawal syndrome. Little can be said at this time about two of the hallucinogens: Psilocybin and Mescaline. Psilocybin is a naturally occurring com- ponent of a Mexican mushroom. Mescaline is a naturally occurring alkaloid in the flowering head (button) of the peyote cactus. It has long been used in religious ceremonies by North American Indian tribes. As yet, the legal attitude toward this drug is not altogether clear. Considerable information is available, however, about LSD and DMT (dimethyltryptamine). The latter is a short-acting hallucinogen found in the seeds of certain plants native to the West Indies and parts of South America. Both are synthetic compounds generally available on the black market as a tablet or sugar cube in which a few drops of liquid chemical have been absorbed. Current research about the biologic hazards of LSD and other hallucinogenic drugs is considered incomplete. However, the research being carried on by NIMH is wide in scope and activity; NIMH is promoting surveys and epidemiologic studies through basic biochemical and experimental psychopharmacologic research. Hope- fully, there will be a better understanding of the biochemical basis of learning and memory at the conclusion of these studies. The dangers associated with LSD, although seldom noted in the lay press, have been well established. LSD may intensify psychosis, cause inadvertent or intentional suicide, and result in chromosome breakdown. Suicide may be brought on by panic re- action or by deluded behavior, such as attempting to fly out of windows. Some users become stultified to the point of walking into heavy traffic on a highway. Investigators speak of the phenomenon of recurrence, that is, a reliving of a psychedelic experience, originally induced by LSD, without use of the drug. These recurrences are reported to occur at times of stress and as long as two years after the initial ingestion of LSD. Another ominous aspect of LSD is that its use without ill effects in no way guarantees exemption from intractable reactions after later uses. Recent articles point out that prolonged be- wilderment and fear may strike unexpectedly and last for weeks or months. Such unexpected recurrences are, of course, a disrupting factor in any rehabilitative process. NARCOTICS ‘ The term narcotic refers generally to opium and drugs made from opium, such as heroin, codeine, and morphine, all widely used as pain-killing drugs. In addition, a number of specially defined synthetic drugs, called "opiates,'' are also classified as narcotic drugs under the Federal law. Cocaine (made from coca leaves) and marijuana are classified legally, but not chemically, as narcotic drugs. These drugs depress the central nervous system to produce marked reduction in sensitivity to pain, and consequently they are some of the most valuable drugs available to physicians. The abuse of narcotic drugs, which dates from ancient times, is today becoming increasingly widespread. Under the influence of morphine-like narcotics, the abuser is usually lethargic and indif- ferent to his environment and personal situation. When the abuser of a narcotic becomes addicted, his body requires repeated and larger doses of the drug. This happens because the body develops a tolerance for the drug. One of the signs of heroin addiction is that withdrawal symptoms may develop. Characteristically, they may include ner- vousness, anxiety, sleeplessness, yawning, running eyes and nose, sweating, enlargement of the pupils, increase in breathing rate, hot and cold flashes, to list a few. The intensity of withdrawal symptoms varies with the degree of physical dependence and the amount of drug customarily used. Authorities state that symptoms begin about 8 to 12 hours after the last dose and that they in- crease in intensity and reach a peak in 36 to 72 hours. At this point the symptoms of withdrawal gradually diminish over the next 5 to 10 days, but insomnia, nervousness, and muscle aches and pains may last for several weeks. Although the possibility of death from an overdose of narcotics is an everpresent danger, the harmful effects to the addict are usually indirect. He is usually preoccupied with the technicalities of drug taking and with getting a continued supply. This prevents the addict from continuing either his education or his job. He neglects his health, and as a result his life may be shortened. He is usually in trouble with his family and almost always in trouble with the law. Under the Federal law some preparations containing small amounts of narcotic drugs may be sold without a prescription. However, exempt narcotics must be sold in limited quantities, and the pharmacist selling these exempt preparations must have a Federal narcotic stamp. Some of these exempt narcotics are paregoric and certain cough mixtures. While many of the exempt 10 cough mixtures containing codeine have been abused, they are reasonably safe and free of addiction potential when used as directed. Heroin, by contrast, is highly dangerous. "In the realm of drug abuse probably no substance produces greater psychological dependency and, with few exceptions, greater physical dependency and tolerance than heroin. Once the young initiate has experienced the effects of heroin, his psychological dependency develops extremely rapidly and he is willing to commit any act in order to obtain his drug. The rate of development of the psychological and physical dependency does not depend so much on the duration of use but rather on the quantity of drug and the continuity of administration. He also soon finds that he develops tolerance quickly and the quantity of drug that he needs each day increases rapidly. In a short period of time he realizes that if he does not receive heroin or a similar agent at given time intervals, he undergoes a severe withdrawal reaction. As his need for the drug increases, he finds that he is no longer able to work and must devote all of his time to various methods for obtaining money to pay for his heroin. In a relatively short period he finds that regardless of how much drug he in- jects, he is unable to attain the initial’so called ‘“hish* that che niay have had originally and realizes that he is taking the drug only to satisfy his psychological and physical dependency." 8 Heroin may be administered by any one of these three methods: by snuffing the powder into the nostrils, by an injection of the substance into the skin or "skin-popping," or by injecting the drug into a veinwore; mainland ne ss. 11 Heroin is mixed with any one of the following substances: milk-sugar (Lactose), quinine, benita, or procaine (a local anesthetic)s The combination of heroin and procaine gives rise to a stimulatory feeling of warmth and a "tingling sensation" over the entire body, referred to as a "flash." Since*too much procaine may cause the heart to fail or stop, to use it as a dilutant for heroin is extremely dangerous. This same "flash" can be experienced by mixing heroin with cocaine. This is called "speedballing."' Since cocaine is expensive, it is less often used than procaine. It is rare that a person using heroin will change to any other substance while the drug is available. Only as a last resort will he seek one of the hallucinogenic or other type agents. Psychological Factors Associated with Drug Abuse In his treatise on the "Pharmacological Principles of Drug Dependency,” James E. O'Brien, M.D., says: "When we speak of drug dependency, let us . remember that the psychological dependency on drugs is not the result of any specific reacuLon op. toe drus) itselt.: There) is nothing in these agents which imparts to the brain a desire for more drugs. It is the inadequate personality of the individual and the drug's ability to relieve his ten- sions and anxiety that lead to dependency. Once he has learned to enjoy the experience and, at least in his mind, reaches the con- clusion that the reward justifies the risk, he is a drug dependent person.” One cannot divorce the human problems of drug abuse from the scientific and still be well informed. Because of this awareness, the Federal government. has moved toward a two-pronged approach of regulation and research. Experience has taught us that we must look beyond the specific problems of the various agents (drugs of abuse) to an understanding of some of the underlying causes of widespread drug use. Whether we wish to admit it or not, we live in a drug-oriented culture. Consequently, there is but one way to get to the root of the drug abuse problem. Let us have regulation, 12 but at the same time investigate (research) and identify the under- lying problems which lead people to choose to distort or ward off reality with drugs. The behavioral scientists use the term "alienation" to describe the cross-generational conflict epitomized by the youth- coined expression, "Don't trust anyone over 30." Alienation has been characterized as "rebellion without a cause---rejection without a program---a refusal of what is, without a vision of what should be.” 19 From what we see today, drug abuse by many of our youth is an anti-adult orientation that manifests itself in a number of anti-social behavior patterns. There is defiance of the established conventions and traditional norms. The alienated often show themselves aggressive, overactive, impulsive and head- strong, but not always willing to pay the price when ethical standards of society are broken. The problem of drug abuse cuts across almost every segment of our society. It challenges our values and aspirations, and rouses our fears. In many instances the emotional impact clouds judgment and makes effective communication difficult. Some adults have preconceived notions about many of our young people. Adults are uncomfortable and defensive about dis- cussing drugs with adolescents, and they immediately become anxious whenever there is evidence of any departure from the preferred ("accepted") life styles and customs of the majority. Consequently, it is very important to keep lines of communication open at all levels. It is important to remember that the above material, which presents an overview of drug abuse information, cannot be defini- tive because the field of study is relatively new and new under- standings are emerging almost daily. It is important, therefore, that the counselor keep abreast of current literature regarding drugs and drug abuse. However, if we are to restore adequate emotional, social and vocational functioning, the most effective preventive and rehabilitative techniques must be developed. Sociological Aspects PREVALENCE As far as can be ascertained from a survey of the litera- 13 ture, there is no single type of drug use or drug abuser. Drug abuse seems to cut across all ethnic, economic, and social boundaries. All segments of our society appear to be experimenting with drug-taking. "The rich and the poor, the urban and the sub- urban, the young and the middle aged of both sexes are involved," 11 Millions of persons are exposed to drugs, of course, by reason of medical need; relatively few of these people, however, turn to a bite tOfearups. Ly as crue that in metropolitan areas there “are invariably groups of “hard-core” users and that a large proportion of the young persons who use drugs live in the: ghetto areas. Indeed, U. S. Public Health Service reports show that heroin addic- tion today is found chiefly among young men in ghetto areas. Our law enforcement officers tell us that drugs may be available on street corners in metropolitan areas; however, only a small per- centage of the individuals exposed join the ranks of abusers. The National Institute of Mental Health, through its Center for Studies of Narcotic and Drug Abuse, has long been involved in a broad and comprehensive program of support for narcotic addiction research, training, and treatment. The incidence of drug abuse in specific areas is often dif- ficult to determine. Because a recent study indicated a significant incidence in New York, particularly New York City, efforts are being made to assist the New York City Health Department in compiling a reliable, up-to-date, unduplicated count of addicts in the city. Research efforts such as these will provide information concerning the specific characteristics of the population that runs the risk of drug abuse, For the most part, research samples and data collection have focused on populations affiliated with legal and medical agencies (the courts, law enforcement officials, medical facilities, and schools). The abusers who fall outside of the above samples may constitute a larger number than we suspect. Also, their character- istics may differ significantly. SOCIAL CONSEQUENCES Drug abuse is rapidly becoming a major health and social issue. In a document such as this, one can only touch upon the gravity of the consequences of drug abuse. The problem has spilled into suburbia and is affecting middle-class youth. As a result, 14 social and legal norms are being challenged and the public is becoming increasingly aroused. Efforts to locate and control the causes of the behavior, and such programs as rehabilitation, which assist in reducing the consequences of drug abuse, are gaining widespread support in all segments of the population. Drug abuse may have any number of consequences on an individual's social, as well as his physical, functioning. To protect society from evils of the manufacturer, smuggler, and pusher, we have attempted to effect control through legislation. In some ways these laws have been both beneficial and harmful. Our government has been made aware by an aroused public that research, prevention and innovative treatment now characterize a major portion of the government's effort to cope with the problem of drug abuse. Hopefully, we shall come up with reliable and useful materials to dispel the many prevailing myths. oe ct oy ie 10. ie |B REFERENCES tions About Drug Abuse, Washington, D. C.: G.P.0., 1971. [bigs Drug Abuse: Escape to Nowhere, Philadelphia, Pa.: Smith, Kline and French Laboratories, Publisher, 1970. "Students and Drug Abuse - Facts About Drugs," Reprint from Today's Education, NEA Journal, March, 1969. 'A Guide to Some Drugs Which are Subject to Abuse," Drug Abuse Education, American Pharmaceutical Association, 1969. Ibid. James O'Brien, M.D., Pharmacological Principles of Drug Dependency, Unpublished paper, 1970. Tbe Ibid. Resource Book for Drug Abuse Education, National Clearinghouse for Mental Health Information, 1964. a EEE ese 0 eso © ieee Marijuana, and Other Dangerous Drugs, testimony presented before Congressional committee, October, 1969. Nr ian) 2 i oa Kon seen peti an are ee x . a a : = | ‘ties ‘ ei heey hay = looky . emi bie or ral AN ONS andl . a D6, ‘ Pe Dla ‘ "ah hs Pah ha Pate arr aketn pA'y iit - ae | ; » a ay “Uh pr ive ‘ ate nite ee pa ia ie oe met in cv | ea _ Pio ; * ,; Bethe Bibs. . 7 7 ey e _ oN ; in ne +) ae a f ° ay qa in 7 Py we apag Ue y i ‘ 4 a ek A a a) my Oye en 7 i ; igetsy 1 | We rte " ih sid Lhe ie Js r on a a : . a . »¥ hs! BF. ‘ : ill of | | ; fal 4 1 ord may ri? nl & A rose dy int a} i . An a - . am ies has ‘iat, AUC ar | his *) (eRweee ee it! ae a — , 7 7) ee ‘ ' eee len yt Ft ) i : Avs rab eh LAD DYN REM Di ; ‘eh ail we ey 1 ws - + eM P ; ; _ ae ae re Le oe tr wee re lee oer My We i. - | - + i | a h i. ys 4 4 ars i ) P44 a 8 7 > Ps, f ' ; . oe we gp me: iy | : Sat 2 ity Ws Ave - he 4 » 7 bs ot 4 a eer - - - ‘ ¥ ow “ ‘? ; 4 i ne 7 eng , ; io a NI tid a 4 : ut AS 7 4 et ,. d i re _ i ’ - i y hi Oa seed, Ps ‘ . am | -. Ne | 4 * sit f ; | ‘ ‘ | ’ . | 9 we on eet | ies a " ny basi aes A ne asia , | hi eR ASR Lae Me. 2AP1 7 tan =A) aw a ' ea Te ee) , Slums Caen : : 7 A = ‘Pia . © CHAPTER ITI EVOLUTION OF DRUG ABUSE LEGISLATION Early Legislation The first formal controls on narcotics and dangerous drugs in the United States were instituted on the State and local levels about 1885. The development of the hypodermic syringe, the use of morphine to treat the wounded during the Civil War, opium smoking as introduced by Chinese immigrants, and the widespread avail- ability of patent medicines containing narcotics helped create a population of drug-dependent persons. In 1909 the first Federal law, "An Act to Prohibit the Importation and Use of Opium for Other than Medicinal Purposes," was passed. The term "medicinal purposes" was not defined, but opium prepared for smoking was specifically excluded. All in- portation was to be regulated by the Secretary of the Treasury. American representatives to the Hague Convention in 1912 urged other governments to establish systems for the domestic con- trol of narcotic drugs, as well as mandating control of the inter- national market. On the international level, this was the first of a long series of agreements culminating in the "Single Conven- tion" of 1961 at a United Nations Conference. This convention was signed by the United States and became a treaty obligation on June 23, 1967. It replaced eight multilateral treaties and represents an attempt to balance legitimate international trade ioeparwousmarice while Minimizing iilicdtotratilic..» To oversee compliance with its provisions, the convention established the International Narcotics Control Board. The Board, however, has no enforcement powers. Ccnusequently, large quantities of drugs enter the illicit world tzade. Domestically, the Hague Convention provided impetus for what is popularly known as the Harrison Narcotics Act of 1914. Passed in the form of a revenue measure, it mentioned neither addicts nor addiction. It required the registration of persons handling narcotic drugs, the use of special transfer forms, and set nominal fees and excise taxes. The purpose of the Act 18 seemed to be to make drug distribution a matter of record. No mention was made of denying drugs to addicts or of any treatment of addicts. In regard to interference with medical practice, the act provides: "Nothing contained in this section shall apply -- (a) To the dispensing or distribution of any of the aforesaid drugs to a patient by a physician, dentist, or veterinary surgeon registered under this Act in the course of his professionale practicemon | ya U. S. SUPREME COURT DECISIONS The freedom of a practioner to treat drug users as he saw fit, however, was repeatedly restricted by Supreme Court decisions (asor Webb Ve Uroe. 2498 Uo. 6 Ot Oo) eee eve MU Vereen remneee U.S. 9169 GLoO20) ie sand” UsSev Behrman, 250 ,Ulor mol Cloe)))emeliece decisions convinced doctors that they were risking arrest and prosecution if they gave drugs to addicts in the course of any treatment other than in decreasing doses and in an institutional setting. Because addicts were seldom accepted at hospitals, and outpatient care was seemingly illegal, they were deprived of all access to legal drugs. The Treasury Department, charged with en- forcing the Act because it was a tax measure, drew its regulations in accordance with these decisions and their implicit feeling that addiction was not a sickness but rather a willful indulgence meriting punishment and not medical treatment. The view was somewhat softened by Linder v. U.S., 268 U.S. 5 (1925). The Supreme Court held that a physician acting in good faith and according to fair medical standards may give an addict moderate amounts of drugs for relief of withdrawal symptoms without necessarily violating the law. The Court explicitly stated that addiction was a disease and that addicts were proper subjects for treatment. But this decision had little practical effect, possibly because physicians had been intimidated and did not want to gamble their careers. At any rate, the Supreme Court did not expand its dictum until almost forty years later. In the case of Robinson v. California in 1962, the Supreme Court declared unconstitutional a California statute which made it a crime “to be addicted’ to the use ormnarcoticse. meUndermiciis Statute the penalty was at least 90 days in the county jail. The Lg Court considered this a "cruel and an unusual punishment." It emphasized the disease aspect of addiction, stating "Even one day in prison would be a cruel and unusual punishment for the 'crime' of having a common cold.” The State and Federal legislation which followed this de- cision largely reflects the necessity of providing medical treatment for what was finally judicially recognized as a medical problem. LEGISLATION OF THE 1960'S In 1963 the President's Advisory Commission on Narcotic and Drug Abuse recommended the substitution of civil commitment to treatment facilities in lieu of criminal prosecution. At that time, both California and New York had civil commitment legislation on the books, California having had such a program since 1927. The Narcotic Addict Rehabilitation Act of 1966 is the most far-reaching Federal response to the need for a medical approach. In Title I it provides, in lieu of prosecution, for the civil com- mitment of narcotic addicts charged with Federal criminal offenses. In Title II, it permits a court to sentence a convicted narcotic addict to a treatment program, in lieu of imprisonment. [In addi- tion, it sets up a treatment program for addicts who are not charged with a criminal offense (Title III). An addict may be committed into this program by a related individual, or he may commit himself. Certain classes of addicts are not eligible for treatment under the Act; for example, addicts charged with or convicted of a crime of violence are not eligible under the first two Titles, respectively. Treatment consists of a period of institutional care followed by a longer period of "'on-the-street aftercare. An addict who relapses to the use of narcotic drugs during the aftercare period may be returned to the treatment facility for further care. For Title I, the treatment period is three years; for Title II, indeterminate but not exceeding ten years or the length of the prison term that could have been im- posed for the offense of which the addict stands convicted, whichever is the lesser; and for Title III a maximum of 42 months. Under none of the three Titles may an addict voluntarily withdraw from the program. iB) The Public Health Service has had a role in the medical treatment of drug abuse problems since 1929, when Congress author- 20 ized the construction of two hospitals "for the confinement and treatment of persons addicted to the use of habit-forming narcotic drugs.'' One hospital opened in 1935 at Lexington, Kentucky, and the other in 1938 at Fort Worth, Texas. It also created within the Office of the Surgeon General of the Public Health Service an administrative division, called the "Narcotics Division," which soon became the Division of Mental Hygiene, and eventually became part of the National Institute of Mental Health. The Public Health Service role in drug abuse stems from this legislation, (P.L. 6/72- 70th Congress, January 19, 1929), the provisions of which are now part of the Public Health Service Act, Title III. This act was amended in 1968 to authorize grants to nonprofit organizations for the construction and initial staffing of narcotic addict treatment facilities’. | The National Institute of Mental Health supports consider- able research on abused drugs, their effects, and methods of treatment. It also supports the National Clearinghouse for Drug Abuse Information, which is intended as a national locus for all knowledge of abused drugs and their related problems. The Clear- inghouse provides information to both private individuals and professionals. Much of this material will be computerized for easy access. Historically, Federal drug abuse legislation was developed in response to new knowledge of the abuse potential of certain substances, in recognition of channels of illegal trade, and in response to concerned public opinion. In 1922 the Narcotic Drug Import and Export Act was passed, amending the Act of 1909 and establishing administrative mechanisms and penalties to reduce drug traffic. In 1924 the commercial manufacture of heroin was outlawed. The Bureau of Narcotics was created in the Treasury Depart- ment in 1930 for enforcement activities. This Bureau and the Food and Drug Administration's Bureau of Drug Abuse Control were merged into the Bureau of Narcotics and Dangerous Drugs, a Bureau of the Justice Department, in 1968. The Marijuana Tax Act of 1937 imposed an occupational excise tax on marijuana dealers and a transfer tax and it also made provisions to "safeguard the revenue therefrom by registery and recording."' The transfer tax was $100 per ounce of marijuana in transactions to a non-registered person. Framed as a revenue measure like the Harrison Act, the tax in this case was set high enough to constitute an outright prohibition rather than simply zi to identify traffic in the drug. Penalties for violation of Federal drug laws have been re- peatedly increased. They were increased in 1937, by the Boggs Amendments in 1951 and again by the Narcotic Drugs Control Act of 1956. The Narcotics Manufacturing Act of 1960 established con- trols over the manufacturing of all narcotic drugs. A major reason for this act was technological advances which had made possible the development of new narcotic drugs. The "Drug Abuse Control Amendments of 1965" specified the regulation of depressant and stimulant drugs and of hallucinogenic substances. In addition to the Narcotic Addict Rehabilitation Act of 1966, important Federal legislation concerning the treatment of drug-dependent persons includes the Community Mental Health Centers Act of 1963 and the amendments thereto in 1968. As a result, a variety of services may now be provided drug-dependent persons without uprooting them from their communities. LEGISLATION OF THE 1970'S The most recent legislative acts are the Comprehensive Drug Abuse Prevention and Control Act of 1970 (P.L. 91-513) and the Drug Abuse Education Act of 1970 (P.L. 91-527). The purpose of the Comprehensive Drug Abuse Prevention and Control Act of 1970 is: "To provide increased research into, and prevention of, drug abuse and drug depen- dence; to provide for treatment and rehabilitation of drug abusers and drug- dependent persons; and to strengthen existing law enforcement authority in the field of drug abuse." The first Title of this Act liberalizes the language of the Community Mental Health Centers Act to allow services to more people, and it broadens the treatment authority in Public Health Service Hospitals for persons with drug abuse problems. It pro- vides also for education and training activities. The second Title, the Controlled Substances Act, comprehensively defines and categorizes drugs and substances with ae abuse potential, provides rules and regulations concerning the manu- facture, distribution and dispensing of controlled substances, and gives schedules of offenses and penalties for violation. Additional Titles deal with administrative and enforcement provisions, including the establishment of a Commission on Marijuana and Drug Abuse, and with the importation and exportation of controlled substances and the concomitant adjustments in revenue laws. The Drug Abuse Education Act of 1970 authorizes the "Secretary of Health, Education and Welfare to make grants to con- duct special educational programs and activities concerning the use of drugs and for other related educational purposes." The projects authorized under the Act may encompass (1) the development of curricula on the use and abuse of drugs, (2) testing the effectiveness of such curricula, and (3) the dissemination of curricular materials and other significant information regarding the use and abuse of drugs to public and private elementary, secondary, adult, and community education programs. This overview of drug abuse legislation is intended to illustrate societal attitudes from the punitive level to the re- habilitative to the preventative. It is important for the counselor to keep abreast of current legislation, for the evolutionary process in drug abuse legislation has accelerated rapidiy: CHAPTER III ELIGIBILITY AND FEASIBILITY Federal Regulations Eligibility and feasibility considerations for persons with a drug abuse problem who are seeking State rehabilitation services must begin with the Vocational Rehabilitation Act and the current regulations pertaining to the Act. In section 401.30, the Federal Regulations state the following general provisions for eligibility: "The State plan shall provide that eligibility requirements will be applied by the State agency or local rehabilitation agency without regard to sex, race, creed, color, or natural origin of the individual. The State plan shall further provide that no group of individuals shall be excluded or found ineligible solely on the basis of their type of disability. In addition, the State plan shall specify that no upper or lower age limit will be established which will, in and of itself, result in a finding of ineligibility for any handicapped individual who otherwise meets the three basic eligibility requirements....” In the same section, the basic conditions of eligibility are specified as follows: 1. The presence of a physical or mental disability. 2. The existence of a substantial handicap to employment. 24 oe A reasonable expectation that vocational rehabilitation services may render the individual fit to engage in a gainful occupation. The regulations, however, give the State rehabilitation counselor further latitude in the eligibility process with the use of the extended evaluation provision which essentially asserts that, if the first two basic conditions exist but the counselor is unable to determine the third condition of eligibility, he may provide an extended evaluation, including the provision of vocational rehabilitation services. The duration of the extended evaluation period for a handicapped person with a drug abuse problem is not in excess of six months, but if certain other disabling conditions exist, such as mental illness or organic brain damage, the client may be eligible for an extended evalua- tion not in excess of eighteen months. Physical or Mental Handicap Both the general and basic conditions of eligibility focus on the disabled person. In the Federal regulations a physical or mental disability is defined as: "a physical or mental condition which materially limits’, (contributes to: Limiting sory in nor con rected, will probably result in limiting an individual's activities or functioning. It includes behavioral disorders characterized by a pattern of deviant social behavior or impaired ability to earry out normal relationships with family and community which may result from vo- cational, educational, cultural, social, environmental, or other factors." Drug abuse frequently is a multi-disabling condition which may cause dependency, endanger health, and strain personal rela- tionships. It is also a problem because of a frequent negative 25 attitude on the part of the general public. The drug abuser is commonly seen as a socially unacceptable individual with question- able motivation. Drug abuse is also a possible environmental problem, frequently asseciated with the ghetto. Poor social conditions and the availability of abusive drugs make the ghetto a haven for drug users and drug pushers. Drug abuse, however, is not exclusive to the ghetto: the prime reason for drug abuse appears to be within the individual. The marginal functioning individual, who is unstable, easily frustrated, immature, and emotionally depressed, is an easy prey for drug abuse. Studies of various forms of drug abuse indicate that a majority of drug abusers have some emotional disorder, usually a personality disturbance. | Substantial Handicap to Employment With a complete understanding of the wide range of fac- tors which may influence or cause drug abuse, the counselor must establish if the client's functional limitations are severe enough to constitute a substantial handicap to employment. He must determine how drug abuse impedes the client's occupational performance by assessing how the client is prevented from ob- taining, retaining, or preparing for employment in accord with his abilities and capacities. Of particular relevance in the determination of the employment handicap is the examination of medical, psychological, vocational, educational, cultural, social, and environmental factors. Rehabilitation Potential Having determined that an applicant has a substantial employment handicap, the counselor must establish that there is a reasonable expectation that vocational rehabilitation services, when completed, will lead to the individual's employment. At the beginning of the eligibility process the counselor determined whether or not the disability and limitations were severe enough to establish a substantial handicap; now he must determine whether or not the limitations are too severe. The counselor must evaluate the potential capacity of the individual to enter eventually into some type of gainful employment. He must decide what type of programs the client needs and when those should be initiated so that he can reasonably be expected to complete successfully the State rehabilitation program. In 26 some cases, treatment may be required before he begins the State rehabilitation program. This determination is based on the coun- selor's evaluation of the client's potential capactiy to succeed. The counselor must review the pertinent history of the client and evaluate, through counseling, the client's interest, motivation and aptitudes. Before making a final decision, the counselor may consult with a psychiatrist and/or pscyhologist. If he is still unable to reach a definitive judgment concerning rehabilitation poten- tial, he may consider the utilization of the extended evaluation provision, as previously described. CHAPTER IV DIFFERENTIAL ASPECTS OF CLIENT STUDY: SPECIAL CONSIDERATIONS AND NEEDS Two large variables are to be noted in the consideration of differences among drug abusers. One is inherent in the nature of the drugs themselves, and the other is inherent in the drug abuser's individual make-up. The characteristics of such a state (drug dependence) will vary with the agent involved, and these character- istics must always be made clear by designating the particular type of drug dependence in each specific case; for example, drug dependence of morphine type, of barbiturate type, of amphetamine type, etc. Drug abusers fall into three groups: (1) situational abusers, (2) spree abusers, and (3) hard-core abusers. The situational abuser employs the drug to cope with certain situa- tions, for example, the student who uses amphetamines to stay awake. The spree abuser employs the drug to escape boredom or to fill an emotional void. The hard-core abuser has passed the experimental stage during which he tries a number of drugs and now has developed a strong dependency on a particular drug, usually heroin. Since pharmacological factors have been dis- cussed earlier, emphasis will be placed upon the "hard-core" drug abuser in contrast to the individual who has been experi- menting with various types of drugs over a relatively short period of time and who has not developed as yet strong dependence on any particular drug. In this discussion the druc abuser's characteristics are broadly grouped under four headings: social, psychological, medical, and vocational---all of these overlap, of course, to some degree. 28 Social Characteristics of Drug Abusers Most drug abusers present a history of social disorganiza- tion, including the disruption of the employment pattern, family disintegration, disengagement from the community, and rupture of customary social relationships. Drug abuse resulting from social disorganization is currently found on all socio-economic levels and is associated with social antecedents of alienation, which may stem from broken homes, absence of the father, death of the mother, and from a wide variety of other emotionally-fraught conditions. Feelings of alienation often seem related to efforts to escape from threatening surroundings or to fill an emotional void. Generally, drug abuse is initiated in adolescence. Con- fronted with few easily attainable goals, teenagers and those entering adulthood feel strongly the need for identity. As a consequence, drugs may appear to many adolescents as a passport to friendship, status, and membership in the in-group. Although an important factor in determining the use of drugs is their availability, possibly of almost equal importance are the social factors of custom, fashion, and fad. These play a large role in initial experimentation, in the epidemic spread of drugs in a community, and in their persistent presence. \Closely associated with custom, fashion, and fad is the adoption of the drug-culture attitudes and behavior of the drug abuser sassociates.., Lb is) not uncommon ston druceapusecsm.o adopt the habits of other drug abusers who serve as models for observational learning. Individual and group contacts reenforce these tendencies: to avoid and run away from difficulties (not connected with obtaining drugs); to disregard cultural expecta- tions; to turn night into day and to regulate activity by the need for drugs; to exhibit suspicion and hostility and to outwit and "con" persons with whom they deal. These characteristics tend to be the outgrowth of past disappointments and a history of failures. In pointing out some of the social characteristics which are most prominent and help differentiate the drug abuser, it is important to realize that the drug abuser is pulled between two worlds: the life of the non-user, which appeals because of 29 its obvious comforts and degree of community acceptability, and the life of the drug abuser with its transitory intense delights followed by a feeling of utter despair. Thus, the drug abuser develops attitudes of ambivalence and may attempt to live in both worlds at once. Society has generally developed a negative attitude toward drug abusers, frequently resulting from the association of addiction with criminality and a presumption of psychosocial deterioration from continued drug usage. A spiral of rejection has occurred. There has been a tendency on the part of society, as well as of professionals, to view the drug abusers with dis- approval; anti-social behavior has reinforced this negative attitude, The consequence is that the addict has become more hostile and alienated. Interrupting this spiral of rejection by effective application of our increased knowledge and more sophisticated technology represents a major challenge to vocational rehabili- tation agencies. While drug abuse is a serious social disease, our more recent experience indicates that the abuser can be rehabilitated. Psychological Characteristics of Drug Abusers When measured by conventional professional instruments, most drug abusers tend to function below their full potential because of extraneous factors which distort the testing situa- tion. In many instances the evaluation is accompanied by high anxiety which depresses scores and ratings. At other times the drug abuser may look upon the evaluation with suspicion and doubt. The result is a desultory performance which, in turn, reflects his inherent distrust of, and sometimes even contempt for, established evaluative procedures. “Feelings of self-devaluation are common among drug abusers.” Very often, these feelings find expression in antici- pation of disappointment, expectation of failure, the drug abuser's view that he lacks the ability to compete in business and social activity. The presence of these feelings explains why the drug abuser comes late to an appointment or even misses completely. \.In a rehabilitation program the drug abuser sometimes 30 speaks of the period when he maintained his habit as "wasted years,'' because it represents lack of accomplishment and failure to acquire useful skills. He realizes that he had focused on the narrow objective of purchasing drugs at a time when many of his age-peers were achieving mastery over a wide range of prob- lems. As a result, he has failed to acquire an arsenal of knowledge and skills as well as the self-confidence that increases with every successful achievement. In other words, he did not develop adequate ways of coping with day-to-day challenges. Consequently, he tends to react rigidly and with- out variability of response, and his behavior repertoire is limited, | any drug abusers tend to expect immediate grati- Gunes and achievement _ in any pl an entered upon in In planning ¢ (okey ohn initiating a a program, m, they often cae ee ere ee ee eee for their present satisfactions. Theoretically, there may be some connection between the immediate ee ee ene SESE ee eepieraaticn demanded by m any dru ug users and weet) rapid gratification cation obtained whenever th they take y take — drugs. The outstanding characteristiceof the drug abuser's life is "crisis" generated by his intense and periodic need for drugs. Indeed, if he must support his drug "habit" by illegal means, this behavior tends to re-enforce his life style until it may be- come habitual and, indeed, if his affairs run too smoothly, he may feel somewhat uncomfortable. The implication for working RELL) ehe drug abuser setae he may need y need considerable adjustment re ree eee work on an jo Medical Characteristics of Drug Abusers Two types of problems require medical expertise: (1) those related directly to drugs, such as withdrawal and overdose, and (2) those indirectly related, such as care and supervision of the drug abuser's health. It is generally agreed that medical with- drawal from drugs does not present much of a problem. On the other hand, adequate health care and supervision are frequently difficult due to the very poor relationships which drug abusers have with the medical profession. a, Often drug abusers conclude that medical care is not important for them. This attitude stems from their primary pre- occupation with drugs, their lack of easily discernible health problems, their youth and immaturity, or their poor personal relationships with doctors and physicians who have refused them prescriptions for narcotics. Nevertheless, the drug abuser is subject to a wide variety of diseases as a result of his expo- sure over long pw riods of time to unsanitary conditions, his failure to engage in elementary health precautions, his lack of adequate and proper nutrition, and the misuse of his body by hasty injections with unsterilized needles. Respiratory problems are probably rated the number-one health problem among drug abusers. Most prevalent among the respiratory diseases are chronic lung disease, obstructive and ventilatory abnormalities, and tuberculosis. A second large area of illness among drug abusers is liver disease or an ailment related in some way to the liver. Many drug abusers have hepatitis or some variant of it. I1l- nesses resulting from excessive use of alcohol are another problem area among drug abusers. Those who are abstaining from the use of heroin, either through methadone maintenance or some other means, sometimes resort to alcohol as a "crutch" or substitute. Alcohol is cheap, easily available, legal, and socially acceptable. A physician made the following observation to those seeking information: Medical programs which remove the craving for heroin (or block it) but send the drug abuser back into his previous neighborhood, expose him to the problems of living which he still must cope with: adequate housing, management of health, and employment. / Deterioration in health and in personal and social adjustment begins when the drug abuser has excessive time on his hands and when he starts to use other drugs such as alcohol and ampheta-~ mines. The most prevalent diseases in addition to those mentioned above, appear to be the following (mot arranged in order of fre- quency): endocarditis, dermatologic difficulties, multiple as infections, skin breakdowns, abcesses due to unsterilized needles, dental problems gastrointestinal complaints, and edema due to injury to lymphatics and venous system. Vocational Characteristics of Drug Abusers Vocational counseling is essential for the full rehabili- tation of the drug abuser. Whether he is pursuing a rehabilita- tion program with such aids as methadone or cyclazocine, or whether he has been able to give up drugs without such help, vocational counseling is required for him as much as it is for other disabled persons. Except in the most unusual circum- stances, he will need help in securing employment that is suitable, even though he remains off the street as far as drugs are concerned. Accordingly, attention should be given to all characteristics which will contribute to suitable placement, that is, not only to his abilities and past experience, but also to his goals, aspirations, plans and proposals for achieving them. In our earlier experience, the drug abuser often pre- sented a history which lacked sustained achievement in middle- class cultural pursuits and included failure to complete high school and inability to obtain steady, skilled employment. He frequently lacked close familial attachments, and was often the product of a broken home. He might have developed a | pattern of anti-social behavior leading to arrest, conviction, . and incarceration. More recent experience indicates that drug abuse in industry now has emerged as a problem of considerable magnitude, which continues to grow. Except for a few of the larger employ- ers, industry has not attempted to establish personnel policies, medical practices, or administrative procedures for control of the problem. Some employers report that when the user is discovered and confronted with this problem, he drops out of employment. As a result, the rehabilitation counselor may find himself increasingly involved with a somewhat more sophisticated drug abuse client who may offer a recent attach- ment to the labor market and a broader array of skills and aptitudes. Upon completion of vocational rehabilitation services, and with the assurances of the State agency, the last employer may well consider the re-employment of such an individual. a A COUNSELING APPROACH At the very beginning the counselor should direct attention to the stated reason for the drug abuser's coming to him, what . ehelp.he can expect to obtain, and what first steps ayodid be taken to achieve his declared goals. The counselor should utilize the interviewing session as an opportunity to convey his respect for the self-actualization potential of the client, and to manifest sincere interest in him as an individual, so as to capitalize on motivation for vocational achievement. There is no implication in what has been said that the counselor must accept the stated vocational goals of the drug abuser. More than likely these goals may be completely unrealis- tic because of the drug abuser's lack of understanding of his own abilities and his lack of knowledge of the occupation he has selected. The counselor, however, must work with these choices; he must point out specifically their unsuitability and the reasons why they are unfeasible, if such is the case, and en- courage the drug abuser to discuss_and..seek alternatives. Attitudes of complete dependence on the counselor may be exhibited by the drug abuser. Having come or been sent to the counselor for help, he may expect the counselor to choose the most suitable goal or training program for him. He asks, "Isn't that what the counselor is supposed to do?" Rather, the coun- | selor works with the drug abuser in the situation which presents itself and helps him to assume responsibility for choices and | for making arrangements to implement them. — The drug abuser is most often accustomed to talking about his drug experiences (he may enjoy doing so) and he will probably expect the counselor to offer to "cure” him of his drug dependen- cy. Instead, the counselor should make the wea aban understand that abstention from drug use, and not the "cure’ of the individual's drug” dependency, is the initial concern and that their mutual interest is primarily in gaining satisfactory emp loy-| ment. Many times the drug abuser looks upon vocational counseling as simply the selection of an occupation, believing that once a choice has been made, he can easily obtain his chosen job. The question frequently raised is, "When can I begin?"; or if train- ing is required, "Can I start school tomorrow, and how long do I iy ; 34 need to go?" The drug abuser is frequently unaware of the need for readiness for employment. Whereas he has some grasp of the need to develop specific skills, he has little comprehension of the need to acquire acceptable work habits, to change his attitude and self-image, and to increase his self-confidence. The drug abuser with limited work history is very often faced with difficulty in securing employment, even after he has completed months of training and has learned the necessary skills and "know-how."' The counselor finds that, similar to other clients with limited work history, the drug abuser may lack rudimentary knowledge of how to seek a job, how to dress for and act in an employment interview, and how to fill out an application form. Often he has meager work experience, with long non-employment intervals which must in some way be accounted for. Generally he has a police record in addition to a drug history, and fears his prospective employer's reaction to both of these. Some of his fears are real and some imagined. In terms of the real, the counselor and the client should be aware of any limitations and constraints imposed upon possible job opportunities as a consequence of the police record, for example, licensing or bonding. While these factors may not be applicable to the newly emerging group of drug abusers in industry, it is obvious that there are no pat answers to many of the individual problems that are bound to arise. The drug abuser should be aware that certain embarrassing questions will be raised and that these will have to be confronted by him, in many instances with the help of the counselor. CHAPTER V STAFF ATTITUDES AND COUNSELOR SKILLS Positive Factors Recent work with drug abusers has demonstrated that size- able numbers, greater than previously estimated, can be rehabilitated. In large measure, the favorable results obtained stem from better understanding of the disability populations, the cooperation of professionals and concerned persons in meet- ing the client's special needs, the strengthening of the rehabilitation model for service, better client management, and increased availability of facilities and other critical resources. The counselor who is not closely associated with con- certed rehabilitation and medical programs is usually more successful as a participant in a shared attack upon the drug abuser's problem. In an area which benefits from a rich variety of rehabilitation facilities, the counselor often has an opportunity to develop skills and attitudes not otherwise possible. Ambivalent Attitudes From the earlier days of skepticism among professional colleagues, disappointments among counselors, and despair or cynicism among the drug abusers themselves, there has been con- tinuing positive growth and development in staff attitudes and counselor skills. Nevertheless, the counselor still finds the drug abuser often has siagke abn pea ad toward help, desiring aid but doubtful of the counselor's ability to provide it. The counselor~has to deal simultaneously with the drug..abuser's : current-and past fears, his refusal of help, his.undependability, and-evén his attempts eG manipulate. the. worker. whom he distrusts. As a result, the counselor may find himself in a dilemma: Should he adopt an attitude of vigilance and suspicion, so as not to be outmaneuvered by his client, and in the counseling session call attention to the client's subterfuges, inaccuracies, mis- 4 36 Statements and untruths; or should he look upon the drug abuser as a helpless person, who requires more than the usual degree of counselor acceptance and support, because of his feelings of ; alienation, self-devaluation, and attitudes of general inadequacy? Counseling Strategies [ Faced with alternatives that are extreme, the skilled counselor undoubtedly will choose some intermediate position, which will stress the development of mutual confidence by coun- selor and drug abuser, |so as to allow, on the one hand, for the client's ambivalent feelings, uncertainties and failure to cooperate and, on the other, for the counselor's setting limits and his insistence upon adherence to agreed upon arrangements and understandings.; At no time should the counseling relation- /ship descend to an unquestioned acceptance, or rubber-stamped | approval, of the drug abuser's plans. The counselor should _keep constantly in mind that one of his major objectives is to | build a mutual-trust relationship that can be carried ‘over in some degree by the drug abuser to the workaday world. fj Willineness on the pant or the lcounselor (togdcaimn En what is important to the client at the present time is another means by which he may demonstrate confide in the drug abuser as a person and an interest in his Reciceresd| This is an effective counseling strategy, particularly with the drug abuser who has been interviewed by specialists on repeated occasions inquiring about his past history and his ultimate goals for the future. /The counselor makes a practice of asking about the client's “present vocational plans; he concentrates upon the necessary steps to accomplish these, encouraging the drug abuser where the plans are realistic and attainable.) On the other hand, the counselor does not refrain from pointing out firmly any im- practicalities and irrelevancies. He emphasizes his interest in the drug abuser as a person by limiting the discussion to plans for the immediate future, not for the rest of the client's life. SPECIAL CONSIDERATIONS The drug abuser is an individual who needs careful handling, can withstand only slight stress, and requires con- tinuing counselor support during the entire rehabilitation process. Whatever the counselor does and says, he should act a so as to bolster the drug abuser's self-image, showing | confidence in him, presenting him with situations where he can | be successful and where his success can be recognized, because | lack of success will re-enforce feelings of inadequacy. The counselor who works successfully with narcotic addicts must be honest with them in interpersonal relations and at all times avoid actions and words which to the drug abuser may seem evasive and misleading. In describing situa- tions and conditions to his client, the counselor should elaborate them with particular care, because in so doing he enables the drug abuser to make more realistic choices and, equally important, to assume full responsibility for them. The approach avoids impulsive decision-making, characteristic of the drug abuser. The suspicion and craftiness which the drug abuser some- times brings to meetings with the counselor, particularly at the beginning of their association, must be offset by the counselor's demonstrated genuine concern. Painstakingly he should work out, with the client participating in each step of the process, a vocational program from the initial phases to the end, making sure that the client understands each part and its relation to all the other parts. An essential characteris- tic of the counselor working with drug abusers is patience, the ability to capitalize on the client's motivation but, at the same time, to restrain the drug abuser's impetuosity in choosing an occupation and in making hasty and unfounded long-term decisions. Above all, since the drug abuser in his style of life pays little attention to conventional habits and expectations, the counselor should explain the necessity for adequate and extensive job preparation and, where needed, for developing skills and attitudes to meet job requirements. "OPEN DOOR" POLICY Panic often occurs when the drug abuser moves from the sheltering confines of the training program into the seemingly hostile setting of searching for employment or actually starting to work on the job. This may be just the time when the counsel- or needs to give the drug abuser more encouragement and greater confidence. Again, if the drug abuser has been working for a FO ITIL 38 few weeks and loses his job, whether through his own fault or not, the counselor needs to come to his early assistance with help and support such as might not be required for a person with greater inner resources. Even when the’ client's case may officially be closed and no longer active in the case load, the drug abuser needs the knowledge that the counselor's door is still open to him at any time for help and support. He should feel confident that in times of anxiety he can turn to the counselor, to whom he has ready access. During the transition period from searching for employ- ment to becoming firmly and securely established on a job, the counselor should, as part of his counseling skills, encourage the drug abuser to utilize two other means of support and relief of anxiety: lL. He should urge the client to maintain or establish contact with the rehabilitation referring agency: outpatient departments, rehabilitation center, or probation officer, to whom the client may turn in case of need. 2. The counselor should pave the way, if possible, for the client in times of anxiety and need to approach his em- ployer or immediate supervisor for reassurance and help. Clearly, these means of support will have to be adjusted to individual needs. Nevertheless, mere awareness on the part of the drug abuser that the "open door" policy is in effect may provide him, however remotely, with the support needed to main- tain self-control and take the next positive step in the direction of self-responsibility. CHAPTER VI SERVICE PROGRAMMING This chapter focuses on the concepts and principles of service programming and includes a description of the components of comprehensive service. Relevant Considerations AGENCY CLIMATE A fundamental factor that influences counselor service is the agency climate. In discussing community-based rehabilita- tion programs for the drug abuser, Wiener refers to such a climate as having the following attributes: '"Hopefulness rather than defeatism; it is necessary that a little optimism be engendered in the field, tempered with a measure of reality....Patience; it is essential that the impression not be given that positive results will appear overnight” 1 and recognition of the need for "pioneering effort." He adds that "Knowledge and skills are not always equal to the task in all its complexities and that failure will occur.” é It should be noted that there is no imputation of ab- sence of service-promoting qualities. Rather, it is suggested that these attributes be strengthened. SERVICE-PROMOTING QUALITIES Agency Administration should explicitly recognize the severity of the disability and the problematic outcome for a segment of the drug abuse population. In spite of these limitations, adequate allocations of staff time and money must be assured. Essential, too, is administrative endorse- ment of pioneering effort on the part of counselors, that is, liberality in accepting clients and in testing innovative service approaches. These elements, together with training programs to enhance counselor competencies, foster an essential spirit of service optimism. COUNSELOR CHARACTERISTICS The counselor is a critically important agent in the 40 process. Diskind,? in his description of the program of the New York State Narcotic Treatment Bureau, indicates greater treatment effectiveness with personnel characterized by "high frustration level, infinite patience and ability to form sound professional relationships with clients because of an outgoing warm personality." It is essential for the counselor to be aware of his own feelings and behavior toward drug abusers; this whole area of the counsel- or's acceptance of, and empathy for, the drug abuser is one that should be considered in the counselor training program. COMPREHENSIVE SERVICE STRATEGIES Since the concept of the holistic is integral to the philosophy and practice of State VR Agencies, it may be superfluous in this context to repeat the crucial importance of treating the whole man. The literature reasserts the interrelatedness of the physical, psychological, social, and vocational elements within the life situation of the drug abuser and the urgent need to provide service in all areas of dysfunctioning. The central importance of comprehensive service, then, merits reemphasis. In its service process, the State VR Agency must attend to the client's discernible progress and his eventual gainful employment. The counselor, within his responsibility for discretionary use of case service monies and because of the focus on vocational placement, needs a method for appraising on a continuing basis the client's motivation and progress. Such appraisal is necessary because the drug abuser's adjustment is often tenuous. Perhaps the service process can so be structured to provide an ongoing appraisal of progress consistent with the counselor's responsibility to the agency and also accommodate the client's needs within the agency's expectations. The method of carefully defined interim goals is related to a chain of service elements. The strategy is to make the provision of some subsequent services contingent upon completion of a prior service. A progression of services, for example, from pre-vocational training, through vocational training, and culminating in placement assistance can thus be structured and "contract- ed" between the client and counselor. Obviously, this strategy will not be applicable to 41 many individuals who need immediate gratification. Conversely, there is some opinion that the experience of set limits is a neces- sary developmental learning experience for such individuals and that there is an abdication of professional responsibility in not imposing a distinct structure. Within this latter orientation, the "contract,’’ provided it is viewed by the client as rewarding, has the potential of serving both the client's needs and the counselor's monitoring function. This suggested approach does not advocate a "lock-step" operation. Rather, there is a diversity of services and options within the several service stages of the rehabilitation process. The client chooses within these options but is obliged to pursue activities deriving from service choices. Historical Background EARLY CLINICS In the early part of the century, addiction was viewed solely as a medical problem. Treatment was provided by general practitioners all over the United States. When the Harrison Act was passed in 1914, it no longer was legal for private physicians to disburse narcotics to sustain addiction. As a consequence, thousands of addicts were cut off from their legal supply of drugs. Approximately 44 clinics or narcotic dispen- saries were set up between 1919 and 1923 to remedy the Situation. Some of these clinics operated only for a few weeks, others for as long as four years. On the whole, the clinics seemed to have no purpose other than the dispensing of drugs to addicts in order to prevent exploitation of the patients by drug peddlers and other underworld figures. The directors of most clinics did not attempt to cure patients of their addiction, but merely to sustain it. Some beneficial results were claimed from the operation of the clinics. They were supposed to have brought the addict out of hiding and made him accessible to examination and to efforts at rehabilitation. On the.other hand, opponents claimed the clinics actually achieved no good results; they maintained that drugs were given out indiscriminately, addicts clustered around clinics, and peddling of narcotics increased. To evaluate the clinics is impossible because of the incomplete nature of the data. 42 With the closing of the last of the clinics in 1924, medical treatment gave way completely to the dominance of legal efforts at control. PUBLIC HEALTH SERVICES HOSPITALS A new era in the treatment of drug abuse started in 1934 with the opening of the Public Health Services Hospital at Lexington, Kentucky, and Fort Worth, Texas. This treatment attempt here was basically a medical model. These hospitals accept both voluntary patients and those committed on conviction of Federal Narcotic Laws. They have a combined capacity of about 2,500 in-patients. About 40% of the patients at Lexington and Fort Worth are repeaters and, although estimates of the rate of relapse vary consider- ably, generally authorities agree that the proportion of addicts remaining abstinent for prolonged periods of time has been small. In an attempt to remedy the situation of a high re- lapse, the National Institution of Mental Health conducted a five-year demonstration program in New York City. From 1957 through 1961, addicts discharged from U. S. Public Health Services Hospital in Lexington, Kentucky, were counseled at the New York City Center and referred to community health and welfare agencies. The Center was established on the premise that increased use of community resources would improve chances for the addict's recovery. The result was that gradually some addicts showed improved general functioning in socialization, greater drive to overcome addiction, and an increase in the intervals of abstinence. But over all, the results were limited. There have been recent attempts to increase the treat- ment effectiveness of their program, and both Federal hospitals are endeavoring to provide a comprehensive treatment program including gradual drug withdrawal, vocational planning, recrea- tional activity, and some psychotherapy. The Federal Hospitals and other early programs have helped to set the direction of our current treatment efforts. Most of the current drug abuse treatment program may be characterized as community-oriented and are quite different 43 from the early focus which may be characterized as institutionally-oriented. Treatment System DEFINITION Drug abuse treatment is best understood as a process taking place over a period of time. In the process the patient receives a variety of services provided by staff, located in a network called a "system," which consists of agencies, pro- grams, and facilities. Some of these facilities provide services specifically for the drug abuser; most, however, pro- vide a general range of services which are available to the public and also to the drug patient. COMPREHENSIVE CARE The effectiveness of the system for treatment of drug abusers varies greatly. In some jurisdictions no specialized facilities exist for rehabilitating drug-dependent persons. This may be because the general level of health and social services is too low to support special programs for drug treat- ment; or because mental and public health services are generally available, but with limitations which effectively close them to drug-dependent persons. But all too often, the pressing problem is the lack of communication, cooperation, and coordination among the agencies and facilities involved, thus making it diffi- cult for the patient to receive a coherent pattern of care. Even in jurisdictions where specialized facilities do exist for treatment and rehabilitation of the drug user, he is still dependent for comprehensive care upon services from a variety of related sources, including mental and public health programs, private and public social service agencies, parole and probation service, and vocational rehabilitation programs. In many drug abuse treatment programs, it is evident that there are many gaps in the system, for example, when a hospital treats a medical emergency involving an overdose of barbiturates and then releases the patient without referral for any further treatment; or a patient is released from a drug treatment facility for vocational service and is told that there are no openings in the training program and that he must 44 wait six months. Individual programs or agencies within the system may be quite good, but the drug user's rehabilitation depends upon the availability of the full range of services and not merely those offered by one agency. CONTINUUM OF SERVICES Rehabilitation can then be seen as requiring a continuum _of services given by a number of different agencies. Many com- munities are presently developing organizations which seek to initiate, coordinate, and monitor a comprehensive, area-wide network of collaborative programs. These organizations empha- size the necessity of developing a broad base of community support for planning/programming. They attempt to bring together a variety of services and programs including mental and public health programs, social service programs, parole and probation, police, and vocational rehabilitation programs. STAGES IN REHABILITATION CONTINUUM The patient's progress in the rehabilitation continuum may be.divided into) three stases:. (4) Intake, (2), sintensive treatment, (3) Aftercare. len ainiake The intake stage leads up to and into the treatment system. It is characterized by casefinding, diagnos- tic evaluation, and referral functions. It may also include medical services for detoxification in case of an emergency. At the present time, the intake process takes place on a rather haphazard basis. Unfortunately, a great many agencies performing intake functions (for example schools, courts, mental health centers, social service agencies) have only a limited under- standing of the programs and facilities available for treating drug-dependent persons. 45 Intensive Treatment The intensive treatment stage is characterized by the provision of a range of services intended to be therapeutic and rehabilitative. These thera- peutic services are designed to identify and modify those characteristics of personality and behavior underlying or contributing to drug abuse; the re- habilitation services are designed to strengthen the patient's capacity for social adjustment and techniques for coping with reality. Needless to say, there are overlaps in rehabilitation and therapeutic services since both are providing services simultaneously. Treatment components include medical service; individual, group and family counseling; education, vocational re- habilitation and training; and therapy led by an ex-addict. The latter is only one of the many illustrative examples that could be included. Usually treatment is thought of as beginning with inpatient care and then graduating to out- patient status. Some programs, however, do away with the inpatient stage; they may begin in a half-way house setting or operate on an out- patient basis from the start. Treatment services are usually provided by one of five types of facilities: (a) a specialized unit in a larger institution such as a state men- tal hospital or prison, which is primarily devoted to treatment and rehabilitation; (b) a self-help community mostly utilizing confrontation therapy (for example, Synanon); (c) a private psychiatric or general hospital often admitting a patient under a psychiatric diagnosis; (d) a state mental hospital but not in a special drug unit or treat- ment program; and (e) community mental health center-addiction units. At the present time it is impossible to determine how many treatment programs and facilities actually exist or how many are needed to meet the need. 46 Aftercare Once the patient has withdrawn from the use of drugs and has begun to understand and deal with the emotion- al and behavioral problems associated with drug dependence, he needs a range of supportive services and assistance in finding his way back into the community. He may need to return for additional therapeutic services during periods of stress, for family counsel- ing because of problems in adjusting to a new life, for occupational guidance, and for social services relating to housing, legal assistance, etc. These aftercare services help facilitate the difficult process of re-entering society; without them the patient all too often is again overwhelmed and re- lapses into renewed dependence on drugs. These services can be provided in basically three kinds of settings: (1) a protected setting, such as the half-way house or sheltered workshop; (2) an outpatient facility either autonomous or associated with the treatment facility; and (3) out in the community--on the street, in the home, - on the job, wherever the patient is--utilizing a "streetwork" staff. There seems to be a growing awareness that provision of aftercare services to persons emerging from intensive treatment programs is essential to successful rehabilitation. Drug dependence does not lend itself to easy and quick solutionses iturequiresra, long-termierrore. All treatment modalities are designed to improve the effectiveness of a client in his everyday functioning. Through this improved functioning, the individual's potential for employment is enhanced. The emphasis and philosophy of these treatment modalities, however, differ greatly from the one extreme of total abstinence to allowing the addiction to continue under con- trolled conditions. 47 CURRENT TREATMENT MODALITIES The three major kinds of current treatment modalities are: (1) Methadone maintenance and antagonists, (2) Self-help communities mostly utilizing confrontation therapy, and (3) Multi-modality programs based on psychotherapeutic concepts. Methadone Maintenance and Antagonists Methadone maintenance is a drug substitution program in which the narcotic methadone is given to persons who are dependent on heroin. The methadone treatment is the result of intensive research work conducted at Rockefeller University by Vincent P. Dole, M.D., a metabolic research scientist, and Marie Nyswander, M.D., a psychiatrist _ with long experience in drug addiction problems. In 1963 they discovered that an addict's drug hunger could be successfully blocked by large doses of a known drug called methadone, and that he remained impervious to the effects of heroin as long as he maintained his methadone level. In this study, they further discovered that, even if the methadone- maintained patient experimented with heroin, the drug had no effect on him at all. Thus, with his drug hunger removed and an effective narcotic block- ade achieved through methadone, the patient became receptive to rehabilitation. The study concludes that methadone is fully as addicting as heroin; taken orally, methadone pro- vides no euphoric "high” and thus does not interfere with the user's day-to-day functioning; daily oral administration of high dosages (100 mg) effectively blocks the "narcotics hunger” in some heroin addicts; and it is legally prescribed as part of a public program and thus does not involve the user in the desperation and criminality so often associated with dependence on heroin. Methadone has been criticized by some on the follow- ing bases: it does not cure the medical condition; much more clinical experience is needed before we 48 can venture to make this a full-scale public program; it supports a drug addict in his addiction.; it is dangerous to the individual and to society to have a whole class of persons totally dependent on the state for a substance which they cannot do without: and it is admis- sion that there is no traditional method of rehabilitating the herion addict. Jerome H. Jaffe, M. D., Director, Special Action Office for Drug Abuse Prevention, observes that: "The methadone maintenance approach is predicted on the proposition that any medication that permits a compulsive narcotics user to become a law-abiding productive member of society should be considered as a therapeutic technique. If the dedication is a narcotic, it need not be eliminated from considera- tion since the goal of treatment is socially acceptable behavior, rather than abstinence per se--~- Methadone maintenance has been criticized as the "substitution of one habit for another’ implying that all habits are equally deleterious. This implication is supported neither by common sense nor by observation." 5 Methadone maintenance is a useful approach to rehabili- tating heroin addicts, but is no panaces. In many communities there seems to be an increasing trend towards methadone maintenance. A recent article in The New York Times reported that many of New York's elected officials are turning away from psychotherapy as a way to treat heroin addicts and are relying instead on chemistry, (that is,,Methadone maintenance). While methadone dominates chemotherapy now, some are promoting research projects to find alternative chemicals. Cyclacozine and Naloxone are in a group called "antagonists." Like methadone, the antagonists block the effects of the opiates; unlike the methadone, they are non-addictive. \ - In the self-help approach, drug use is seen as the immature personality's escape route from reality. The object of the treatment, therefore, is to help the patient achieve sufficient emotional maturity so that he can face life on his own without depending on drugs. Their techniques include (1) placing the drug user in a structured peer group setting of former drug users and (2) using the social pressure of their combined support or disapproval (aided by status and occupational rewards). Because former drug users themselves have only recently become converts to the straight life, there is an element of zeal which tends to reinforce their efforts. Self-help approaches to drug treatment and rehabi- litation may take a variety of forms. Some resemble Synanon in California; others are closer to Alco- holics Anonymous; still others are linked very closely to a religious experience and are associated with religious organizations. lb. deen.Challenge An example of the religious approach, Teen Challenge of New York City requires that all new members undergo immediate detoxification without medication. At the Induction Center members participate in Chapel services, Bible classes, recreation, and group therapy. After a few weeks, they are then sent to more intensive training centers outside New York Gity. 2. Synanon The Synanon Movement, one of the earliest self-help groups, was founded in 1958 by Charles E. Dederich. Synanon today has grown to such an extent that it is con- sidered one of the major agencies in the 50 area of drug addiction. “Synanon is a nonmedical program of residential group living which is operated exclusively by recovered addicts. Of the original 2,000 mem- bers, it is estimated that 100 to 200 have returned to the community and that the rest are working in Synanon business activities. Applicants to Synanon are screened by interview. On admission, each applicant must undergo a process in which he recognizes in a frank and unwavering way the extent and seriousness of his problem. Once in the organization, the new- comer has to endure withdrawal in full view of other residents. Reports state that the physical Symptoms are almost always mild; this is ex- plained on the basis that withdrawal distress is as much a reaction to the emotional deprivation of drugs and the impersonality of a hospital or cell as it is a physical response. A resident usually becomes a lifelong member and works in new centers now being established. 3. Daytop Lodge and Village There are a number of outgrowth programs from Synanon; one of the better known is Daytop Lodge and Village. It shares with Synanon the practice of group sessions where addicts are exposed to intensive testing of motives and attitudes in the hope that they will learn to face reality. Un- like Synanon, it accepts referrals by the court and other agencies and prepares its members for discharge after a period of approximately one to one and a half years. Daytop and other similar programs differ from Synanon in that they employ some professional staff to assist in the treat- ment program. Some of the major criticism of the self-help approach are that the theory of personality maturation is far more complex than the self-help proponents realize; that con- frontation sessions face the patient with only a very 51 limited form’of "reality" and hence may not be ade- quate preparation for re-entry into society; that the very abrasiveness and harshness of criticism during a confrontation session may, for some patients, be destructive rather than therapeutic. Nevertheless, the self-help theory approach has gained widespread interest and support. Many self- help facilities are receiving financial support, some on a fee-for-service basis, from Federal and State entities. It seems likely that at least some elements of the approach will become standard parts of the continuum of drug abuse rehabilitation. Multi-Modality Programs Based on Psychotherapy ~ The third major treatment method may be described as a multi-modal treatment approach based on psychotherapeutic concepts. Until quite recently, most persons treated for drug dependence did not participate in either methadone main- tenance or self-help programs. They usually entered programs which provided a range of more traditional services including medical detoxification, individual and group psychotherapy, and so cial ‘and rseronad counseling. These programs were located in different kinds of settings, but all had a common reliance on medical, mental health, social services profes- sionals as therapists and directors of the rehabilitation program. SOc The emphasis on psychotherapeutic services was related to the assumption that drug dependence is a function of under- lying psychological problems and that the way to treat depend- ence is to treat the underlying emotional problems. To understand this mode of treatment, it must be noted that within the general helping services there have been sig- nificant changes in the traditional psychotherapeutic approaches. Two of the most important changes are the move- ment away from institutionalization to treatment in community- based centers, paraprofessionals and other people (for example, ex-addicts) ie treatment programs. (For further clarification of this movement see Principles of Psychiatry by Gerald Caplan ON According to the Chicago Drug Rehabilitation Program, the ex-addict with training is the primary therapist De in their treatment program. Professionals serve primarily in administration, supervision, and research roles. ~~ Thus, while psychotherapeutic services may still form a backbone of the treatment process, they now tend to be offered in combination with numerous other kinds of services including methadone maintenance, as well as self-help con- frontation groups with ex-addicts functioning as therapists ---hence, our use of the term "multi-modality.'' These pro- grams, while quite new, do have tremendous possibilities, especially when well coordinated. In summary, the development of all three types of pro- grams should be encouraged and supported as part of a compre- hensive approach because different patients respond to different kinds of treatment. Only by continued experimenta- tion will it be possible to develop improved and more effective rehabilitation methods. Training, Placement, and Follow-up Services The medical and psychotherapeutic services afforded to the client occur typically within the treatment modalities described. Training, placement, and follow-up--the traditional contributions of the State VR Agency--exist concurrent with, or subsequent to, the medical and psycho- therapeutic services. A description of these services available to a drug abuse population follows: TRAINING i Pre-vocationaleiraining The importance of a pre-vocational training program with its evealuapion and adjustment components is suggested by Richman’ in reporting the experience of the New York State VR Agency in serving drug addicts. He states that a major factor for lack of success is failing to recog- nize that the addict "after detoxification or drug substitution continues to be the same vocationally limited individual...even though he may appear able to work and in need of work."8 This "fragile state of equilibrium,’’ Richman continues, makes adjustment services and the use of a rehabilitation facility vital in a total program of services. at As previously indicated, the psycho-social elements in the drug abuser's situation often preclude an accu- rate assessment of his vocational potential by means of paper-and-pencil tests. Too, because many drug abusers are members of disadvantaged communities, the validity of standardized testing in appraising their vocational potential is open to question. In dis- cussing cultural bias of testing, Cody? notes that "many individuals are discriminated against because they lack the experiences that would enable them to do well in a testing situation" and consequently | “would be less likely to be selected to get further education or a better job."' It would appear, then, that for this population it is highly important to employ a work evaluation center which offers a work- sample type of evaluation and, in addition, evaluation of other significant work-related behavior: work hab- its, interpersonal relationships, reaction to super- vision, and the ability to structure one's work. The work-adjustment training process is familiar and well utilized within State VR Agencies and, therefore, no extended description is necessary. As for applicability to the psycho-social and vocational needs of the drug abuser, the fundamental nature of the program as stated by Leshner!9 is of interest: "The client is offered a progression of success experiences, achieved with some strain at his readiness level. It is developmental, learning by doing activity, operating on the broad principle of building confid- ence, general work competency and particular coping behaviors...The ‘process is often coupled with an array of supportive services that pertain to special health, family casework, education, and counseling services." The outcomes, according to Leshner, are orientation to selection of training or of occupations, and the initial capacity to enter and maintain these endeavors. 54 Vocational Training The deterioration of employment skills during the disability of the older drug abuser and the failure to acquire vocational skills on the part of the younger drug abuser point to the importance of voca- tional training and of its precursor, pre-vocational training. The positive relationship of vocational skills to placeability is axiomatic in vocational rehabilitation, and development of such skills should substantially increase placement opportunities for this disability population which generally has SUch marginal access to employment. Pressure by the client for immediate placement, a not uncommon factor, in apparent disregard of a substantial vocational future, cannot be ignored or resolved easily. The counselor should explore with the client his perceptions and motivations regarding the urgency for immediate em- ployment at the possible expense of future vocational substance, and he should identify as clearly as possible the reality factors involved. The traditional constituents of vocational guidance in occupational choice and related vocational preparation should be maintained at this stage: Occupational choice and related training deriving from: (1) ap- praisal of mental ability, aptitudes, personality, i.e., attitudes, values and needs; (2) physical capacities commensurate with the demands of the occupation selected, and the potential for satisfac- tion of financial and personality needs within the occupation. The psycho-social area of functioning, or dysfunc- tioning as related to the social norm, is quite likely a predominant problem for the drug abuser. Central is his self-concept of inadequacy, which frustrates his acceptance of the worker's role. It would seem, there- fore, that for many clients a therapeutic approach aimed at helping the individual develop coping abilities should precede and later accompany the training program. Properly selected, however, the training situation of itself can strengthen the client by providing him with success experiences, such as the mastery of job skills on curricula, ays) The counselor should be particularly careful to select and recommend those training facilities which offer full vocational preparation for existing or projected job opportunities. In addition, the participation of the client should be maximized as his investment and contractual obligation. For example, if several situations offer comparable training, the client should be expected to visit these and make his own selection. In considering training facilities the counselor should be alert to the *'feeling-tone" of the facility. To be considered are the "climate" factors that affect the client's course of training, such as receptivity to the handicap, the apparent intent to assist with placement, and the relationship qualities of the training staff. The counselor's intuitive judgment of these fac- tors should be respected. On-the-job training deserves some special emphasis as perhaps particularly responsive to the client's need and/or demand for immediate employment. Be- cause it offers an opportunity in concurrent skill development and wage earning--a prevalent factor in the immediate employment demand--on-the-job training appeals to many clients and is an appropriate step for them, Additionally, the possibility of structuring this type of work-learning experience to the needs of the individual client increases the potential for success. The usual implied agreement by the trainer-employer to hire the trainee upon successful completion of the traineeship further enhances the possibility of a successful outcome. Placement Although data concerning the attitudes of employers toward hiring the drug abuser are currently not available, it must be presumed that a substantial negativism exists. Employers share the prevailing perception of the drug abuser as anti-social, unstable, and irresponsible, and fear is voiced that he is a possible source of contagion in the place of employment. Nor can it be denied that 56 this appraisal is based on the actual experience of some employers with drug abusers; the nature of the drug abuser's illness in its active process precludes respon- sible and stable work behavior. Additionally, treatment success has progressed slowly and is not widely publi- cized, so that a momentum of employer confidence in the rehabilitation potential of this disability group is yet to be generated. Given a stereotyping which tends to stigmatize the drug abuse population generally, the critical issue in placement is to encourage employer receptivity. In the approach to employers, the factor of differentiation must be stressed. The distinguishing quality of the State VR client referred for specific employment is a demonstrated potential of at least minimal acceptable capacity for the job sought, a potential arising from client's progress within foregoing services which can be documented to the employer. This is not an assurance of success to the employer; rather, a probability of success is being offered. To maximize this opportunity for success for both client and employer, it is essential that the client's capacities for the prospective job situation be fully appraised. Counselor and client, together, must evalu- ate job readiness. Several schema outlining the attributes of physical, psychological, occupational, and placement readiness have been developed to assist the counselor. An example of this evaluative instrument developed by Viccelitl is given in the Appendix. Because of the considerable difficulty to be ex- pected in effecting placement, it is probably helpful to enlist the support of members of the community "power structure." Trellis, 12 in describing a pilot treatment program of narcotic addiction, states that because of the intercession of a prominent local employer on behalf of program clients, finding employment for them was not a major problem. This strategy is also illustrated in the work of Bill Sands; because he aroused the interest of influential community members in penal offenders, a ai hard-core, difficult-to-place group was released and employed. It should be reaffirmed that counselors have, as placement prospects, screened individuals who present the employer with perhaps a lesser risk than "off-the- street'’ hiring. Whenever an employer has reservations about hiring because of the possible instability of the client, the counselor should state forthrightly his com- mitment to continuing service to the client in areas necessary to maintain employment. The counselor's con- tinuing interest and the availability of various resources of the Agency should also be stressed, Generally, the characteristics and functions of productive placement programs for the disabled are applicable to the drug abuser. Extended descriptions of these programs appear in several sources. For the purpose of an overview, the components of such pro- grams are summarized below: 1. Pre-contact Planning The development of working relationships with community agencies to get information about prospective employers and secure in- fluential support for employer contact. 2. Approach The "sales" presentation to the employer emphasizing the advantage of hiring the handicapped person. Integral here is promoting interest and positive action. Ae Lane av Sa On-site analysis of the job to determine its suitability for the client. 4. Job-Entry Assistance Counselor service in preparing the super- visor and co-workers for introduction of the 58 client to the job situation; concurrent preparation of the client for the specific work setting. Follow-up It must be emphasized that the individual newly placed in employment enters a new environment with its particular demands and set of relationships. Despite the individual's preparatory training, this new en- vironment holds some unfamiliar aspects and possibly disturbing elements. Consequently, the individual may require considerable clarification and support in order to adjust to the situation. The counselor's ready availability to the client may be a prime factor in effecting the adjustment. Full recognition must be taken, too, of the pos- sibility that situations external to the job setting may disrupt the client's work functioning and introduce the need for the counselor's intervention. Stability of the client's family situation, for example, may be presumed to have a positive effect on employment stability. Recent evidence specific to the drug abuser appears to support this observation. A report on The NYC District Office: Addiction Program!3 of the New York State Office of Vocational Rehabilitation for a one- year period (1968-9) states, "Marital status can be considered as significantly related to rehabilitated outcome, and being married or having a spouse appears to have prognosticated 'success' in a rehabilitation program."’ Thus, the input of ameliorative services, through the efforts of the counselor to job external problem areas as, for example, procurement of case work services for critical marital problems, may be of major importance. The question of fostering dependency sometimes arises in connection with this type of continuing services. Sinick's!4 reply is pertinent: “While weaning a client away from dependency is a common responsibility, the client's ultimate adjustment is a 59 greater responsibility. If follow-up would serve this end, it should be con- ducted with weaning occurring concur- rently. Follow-up activities would be planned to taper off appropriately.” This statement implies no fixed cut-off date for follow-up services but rather it suggests concluding this service when the counselor is satisfied that the individual has achieved a reasonable level of social and vocational functioning. | The "counselor availability” factor--of prime importance in this stage of rehabilitation--requires that the counselor keep well apprised of the client's situation and that he plan for as frequent contact and service intervention as the situation indicates. No particular duration or frequency of contact is suggested; the client's individual circumstances and the counselor's judgment should determine these factors. Experience indicates, however, the need for greater frequency of contact during the first several months following place- ment, because this period is typically more stressful; thereafter, contact may be less frequent. Job retention, although primarily and properly a focus on service to individuals, should be recognized as having also a collateral value. When a drug abuse client is satisfactorily placed, he contributes not only to a positive employer experience, but hopefully pro- motes receptivity to the employment of other rehabili- tated clients within this disability category. 1. 2. ale. 4, ef Oe ge oe whe LO, Mas oe La 14. 60 REFERENCES Frederick Wiener, "Planning Aftercare Community Services," Rehabilitating the Narcotic Addict, Washington: G.P.0O., 1967. lore. Meyer H. Diskind, "The Role of the Parole Officer on the Use of the Authoritative Case Work Approach,” Rehabilitating the Narcotic Addicts Washington Gok sO, a L967% Vincent P. Dole, M. E. Nyswander, and A. Warner, "Successful Treatment of 750 Criminal Addicts," Chicago: The Journal of the American Medical Association, 1968. Vol. 206, pp. 2703-2711. Jerome H. Jaffe, "Statement on August 8, 1969, before the Subcom- mittee on Alcoholism and Narcotics of the Committee on Labor and Public Welfare," as quoted in Drug Use and Treatment Programs for Drug Dependent Persons in New England, Boston: The New England Economic Research Foundation, 1970, pp. 35-36. Gerald Caplan, Principles of Psychiatry, New York: Basic Books, Inc@ 1964, Chapter 7. Sol Richman, ''The Addict as a Rehabilitation Client," Rehabilitation Record, 1966. ibid. John J. Cody, "Appraisal of Disadvantaged Youth,' Counseling the Dis- advantaged Youth, (W. E. Amos, ed.), New Jersey: Prentice Hall, 1@ Saul S. Leshner, "The Relationship of Work Evaluation to Work Adjust- ment Training,” Journal of Rehabilitation, 1970. Unpublished paper. Emil S. Trellis, M.D., "A Pilot Project in the Pittsburgh Area," Rehabilitating the Narcotic Addict, Washington: G.P.0., 1967. Statistical Report: New York District Office Drug Addiction Program, New York State Office of Vocational Rehabilitation. Daniel Sinick, "Training, Job Placement, Follow-Ups," The Vocational Rehabilitation of the Disabled, (D. Malikin and H. Rusalem, ed.), New York: University Press, 1969. 61 APPENDIX A Prime Study Group I Mr. Philip Kolber (Chairman) Counseling Instructor, Staff Training Division of Vocational Rehabilitation 623 E. Adams Street Springfield, Illinois 62706 Dr. George S. Elias (University Sponsor) Director, Institute for Social | and Rehabilitation Services Assumption College 500 Salisbury Street Worcester, Massachusetts 0160 Mr. Vernon M. Arrell (Rep. at Large) Assistant Deputy Commissioner VR Special Programs Texas Rehabilitation Commission 1301 West 38th Street Austin, Texas 78705 Mr. Joseph Carano Education Service Specialist Bureau of Community and Institutional Services Division of Vocational Rehabilitation . 600 Asylum Avenue Hartford, Connecticut 06105 Mr. Frederic Clanagan Assistant Regional Representative Rehabilitation Services Administration John F. Kennedy Federal Building Government Center Boston, Massachusetts 02203 Mr. John F. Curley Rehabilitation Counselor Bureau of Vocational Rehabilitation 3rd Floor - Commerce Building 100 8th Street Cincinnati, Ohio 45202 Mr. H. Dorsey Devlin (Rep. at Large) Supervisor Division of Vocational Rehabilitation Suite 407 - Professional Arts Building Court Square Hagerstown, Maryland 21740 Mr. Paul Primavera, Senior Supervisor in Education (alcoholism and drug dependency) Massachusetts Rehabilitation Commission 296 Boylston Street Boston, Massachusetts 02116 Mr. Jerome N. Rubino Associate Regional Representative Rehabilitation Services Administration Federal Building 26 Federal Plaza New York, New York 10007 Dr. Daniel Sanford Rehabilitation Counselor New York Office of Vocational Rehabilitation 225 Park Avenue South New York, New York 10003 Mr. David Siddle Institute for Social and Rehabilitation Services Assumption College Worcester, Massachusetts 01609 Mr. Thomas J. Skelley, Chief (Central Office Consultant) Division of Disability Services Rehabilitation Services Administration Washington, D. C. 20201 62 Study Committee I Laurine E. Bean Washington, D. C. Lionel Billeaudeau Little Rock, Arkansas Robert L. Brocklehurst Richmond, Virginia E. J. Buchanan, Coordinator of Research Utilization Office of Vocational Rehabilitation 1616 Missouri Boulevard Jefferson City, Missouri 65101 W. B. Creel, Area Supervisor Vocational Rehabilitation Department ~ 34 George Street Charleston, South Carolina 29401 Herman T. Culpepper, State Supervisor Vocational Rehabilitation 2129 East South Boulevard Montgomery, Alabama 36111 John Foreyt, Psychological Consultant : Department of Health and Rehabilitation Services Division of Vocational Rehabilitation 254 Charley Johns Building Tallahassee, Florida 32304 R. W. Gibson, State Coordinator Mental Health Programs Division of Vocational © Rehabilitation Department of Public Instruction Raleigh, North Carolina 27602 Clyde Grubbs, Jr. Jamestown, North Dakota Robert Hasbrook, Counselor Division of faeerinneil rane pulcraeyels. 1821 University Avenue St. Paul, Minnesota 55104 J. Ray Hays Houston, Texas Kenneth H. Hutcheson, Supervisor Fort Logan Mental Health Center 3520 West Oxford Avenue Denver, Colorado 80236 Mr. Cary C. Jones Supervisor of Psychological Services Vocational Rehabilitation PepOv boxe / Baton Rouge, Louisiana 70804 John J. Keate, Coordinator of Field Services Division of Vocational Rehabilitation 1200 University Club Building 136 East South Temple Salt Lake City, Utah 84111 Curtis O. Little, Supervisor, Staff Development : Arkansas Rehabilitation Service 211 Broadway, Room 227 Little Rock, Arkansas 72201 Clyde A. Martin Supervisor, Staff Development Rehabilitation Services Department of Institutions, Social and Rehabilitative Services Pe OembOxmeD Soe Oklahoma City, Oklahoma 73125 Ray Mount, Consultant for the Mentall Ill, and District Supervisor Division of Vocational Rehabilitation 402 East 3rd Street, Box 587 Yankton, South Dakota 57078 Study Committee I (Continued) Miguel Perez State Coordinator for Physical and Mental Restoration Services Commonwealth of Puerto Rico Department of Social Services Vocational Rehabilitation Program Poe. pox ELLs Hato Rey, Puerto Rico 00919 Ruth Sanford New York, New York Tony Sokolowski, Rehabilitation Counselor . Vocational Rehabilitation Service Kent-Sussex District Office PIO.) BOxs4935 Dover, Delaware 19901 J. Michael Sprague Lincoln, Nebraska Larry Walker, Chief Coordinator of Mental Health Rehabilitation Services 629 State Office Building Atlanta, Georgia 30334 Myron V. Wotring Regional Director - Region VI Division of Vocational Rehabilitation 93 Main Street Annapolis, Maryland 21401 Mrs. Anita Greenspan Department of Vocational Rehabilitation 1331:H Street, N.. W. Washington, D. C. James L. Jackson, Assistant Director Vocational Rehabilitation Special Programs Texas Rehabilitation Commission 501 Medical Park Tower 1301 West 38th Street Austin, Texas 78/705 val Yi r. ne 7 i . . a . Rene 19 Hake ne pa wie ¥; ae r _ a es r) neh i Savane a $38 pe i, i / im me _ Shh eau | ty ae hh tat nel 28 PaRRE ae Veni ie Fi a a ee 2 | Lieke (een Renee PRR he Us, ae iz ia a La | OOS Dini ig eo a eee bons rae ips! ae leapt yy. 4 % Lopes Ney eg AIO, SY ners EL 05.0 WR ‘ ‘"« i a ; vig LOR Phaaei’ Sete ear 24’ ae dfons: Here cil bd ¥en eal ‘ tp i i / tt a . 7 ' t Pe Fated ih Ma 'y j } e . | tiaabat Lieder cae a - | .s | * 727s } : . aS | aha ms J ade) o>. ei t) : eh) : : j . ; Aus ny if 44 : ae i od « a + Te. Mig an 7 ) rie be ap ee Cee ; ‘ ew : e. i i pyet LG ; 5) - = vy own i roUrny 3 z F “ _ + he 7 7h i s — . ; , r TBA Fai ‘ ; zt a ' 4 7 ) s » 1 j : | ia j f ¥ 7 if ; iis L id f ¢ * 7 rina, e en ; ¥ 7 7 é int Oa8 ‘oA ieee vWD ifs ' a 77 ' | HA a } ® j f ’ 7 ~ , ; oe ‘ 7 | ; . ‘ one pre: jm" Seo ie). cs ‘4 aie an ; = ; ape . J 4 rn rd a elie panee ee 65 APPENDIX B CHARGE TO PRIME STUDY GROUP I Title: Rehabilitation of the Drug Abuser Objective: The purpose of this study group is to study concepts, principles and techniques in the rehabilitation of the drug abuser with the goal of developing suggested operating procedures for the rehabilitation agency and its counseling staff. The following charges were outlined by the Planning Committee for the 1971 Institute on Rehabilitation Services: A. To ascertain the nature and extent of the problems of drug abuse and the implications of these problems for vocational rehabilita- tion by the State VR Agency. In this connection, the subcommittee Suggests that the prime study group might consider the following study elements: 1 Surveying the literature. 2 Compiling appropriate demographic data. 3. Defining terminology in current usage 4. Defining the specific role of the State VR Agency in the community of treatment resources for the drug abuser. 5. Examining eligibility criteria in relation to client acceptance. | 6. Examining the social context of drug abuse. B. To identify the population that should be served by the State VR Agency and the supporting reasons for client acceptance as directed by eligibility criteria. Here the subcommittee suggests examination of the medical, legal, social and vocational meanings of drug abuse as assisting in defining the population to be served. C. To describe a model of State VR Agency service to drug abuse clients encompassing organizational structure, procedures, staff skills, and facilities necessary for service. Possible areas of suggested study include: 1. Agency climate of acceptance: Administrative and staff attitudes. 2. Financing special programming. 3. Case Finding. 4. Staff knowledges. a. Psychodynamics of drug abuse. b. Medical information. c. Special counseling skills. d, Treatment e. Law enforcement and legal considerations. 5. Needed service resources. 6. Services to families. 7. Follow-up services. D. To develop a document covering the subject matter of the above charges and to select appropriate collateral readings to accompany this document. To provide also within the document a glossary of technical terms and jargon current among drug abusers. | A net) ee a | 7 | " Al CIE | ae ons they , We os pie : faa in cea Cae ge eed PLD ae aes i fe | - i 7 c fi Five ee we * 7 pai a a? oot LP rahe AGA; nt ise ! ae j "te - , ee acs,’ Aine owt ; A Ipice ® bibs yer we 3 - b 1 x ) % i Petasl. 7 Cli 3 Ve : ‘ : ( 4 U a, ¢ 4 “et (agN. | ory s 4 - | Z ' be i¥ P J P ‘ 1 ~ ‘ , . 4 , ‘ j i % Le % < { as ; L3 he i g 7 ‘ ; ; X nA : ; . . . | = ; et P sais : F —? i => ea : : 7 i en area Sure ete SRT: ft ee fn Ae =as ; 3 ho . d i 7 ‘ — - Pe Pn, 4 Vi | F t ‘ ; o> Pg De 7 o » ot) ae s —?) gic 4 inet a , ’ ¥ ‘ . Pi ; ) ; . : ‘ 4s a te a) 7 , is fey aa! i ’ ; ie ! ws eh P x 7 r Jy Mis 36 - ‘ - 7 . oa —_ oa b) : 7 : 7 a oe a = ua ; / taht ae te TT he peu HA BA Be) itu we ai e i soa : ii ae DN aa abana Sel ANS “inom nals CiStiid Jil ela etyeaeh tA Opener os - a P A "1h OO Ta F J % 7 i (ian ps? Agee ar ae “| : : : 2 he y re we om : » ‘ a) a S ke . We _ - 7 ~~ we “yy igetyy) As eee ee pes miter nth ys “ris a . ee of ri ie | - : a | al Liana on ; y oy 4c | Saal och singles x Massie | hota ; pees) haste pac) riaae as > ss : 67 APPENDIX C Interview with a Former Drug Addict Recorded February 5, 1971. The person interviewed in this tape transcript had been a drug addict for twelve years. For the past two years he has served as a counselor to drug addicts in a hospital. The reasons for including the interview in this document were discussed with him fully and agreed upon--both verbally and in writing. We will refer to the person as Paul. The comments made by Paul are his, and do not neces- sarily reflect the thinking of Prime Study Group I. Interviewer (I): Paul, would you tell us about yourself and your background? Pa UnGP.): I'm now thirty-five years old. My first experience -with heroin was at the age of fourteen in New York City. But I didn't become addicted at the time; it was just a one-or-two-time thing. Later, in 1958, I became addicted to a cough syrup which I took for about two years. This cough syrup is no longer being produced; it was taken off the market. It was merely a matter of transition from this opiate, which was codeine, to heroin. By 1960, I was actively engaged in the use of heroin. iy Paul, at what point in your life did you realize that this had become such a problem that you needed help and how did you go about seeking this help? eA Well, it was almost immediately after I became addicted to the drug. I knew my first experience with withdrawal. Iwas in New Jersey, on my way to New York on the New Jersey Turnpike. My car broke down and I had some other difficulty with the police on the turnpike and I was incarcerated for three days. This was approximately 1960. Within a three-day period, I went through with- drawal and it was a very miserable experience, very frightening. At the time I didn't know where to get help. There wasn't too much help available for addicts in those days, even in New York. So 68 over the next ten years it was a matter of trying to support this habit by stealing and various other nefarious activities. I was arrested approximately 17 times in four states. It got to the point where it became physically impossible for me to go on. My veins retreated to the bone in self-defense almost. By this time, treatment programs were springing up all over the country. With the help of Methadone Maintenance I was able to kind of break this thread. Are you currently taking methadone? Yes, I am. Paul, what did this habit cost you? Well, I think the highest was around $80 a day in New York City. Were you working at all during this time? Noe Vhetound Pecowldn st holdeay joumnoupany slenothmo bet imecmmet t I had the drug, it was impossible to work. The supply wasn't a continuous one and, of course, the cost was prohibitive. I couldn't support my habit with a normal job. This is important then to the rehabilitation counselor in his approach tomavaruye user), abuser OnmeuGTCt mis Gali Yes, it is indeed. What would you advise the rehabilitation counselor to do in this respect? He may consider himself rather inadequate to deal with this. Would you advise that he team up with someone, a person such as yourself, go as to facilitate counseling? Possibly, in the beginning. But I think that in working with addicts a counselor learns on a trial-and-error basis whether he can function with the addict. He learns the addict's psycho- methodology if he works with him long enough. Could he make some mistakes, though, in such a procedure? Let's assume that the addict, to support an $80-a-day habit, will be manipulating. There doesn't seem to be much that the rehabilitation counselor can offer him. You know, the coun- selor may say, "I can get you an $85 a week job.” This is not very intriguing, is it? 69 Well, I don't believe you can function in that way with an active addict. I believe that an addict, first of all, in order to engage in gainful employment or to do anything constructive, must be in treatment. He has to be motivated. If he's not, then the words are just little bits of air. Paul, during the many times that you were incarcerated, did you get any kind of treatment at all within the confines of the prison system? No. I found that the jails in New York and Baltimore and New Jersey shied away from treatment of addicts. From time to time some of our prison officials have included in their budgets an item for treatment and drug therapy for the addict. Do you feel this ought to be part of the budget in the correctional system? Yes, but it should be more than a mechanical dispensing of methadone. I think the addict needs a certain degree of therapy and supportive help also. Methadone Maintenance is really not necessary in jail on a long-term basis because if the jail is secure there is no heroin anyway, and they don't have a heroin problem. Maybe to bring about withdrawal, yes. But as far as maintenance is concerned, I don't see the need for it really. Paul, have you found any problem "functioning normally" while using methadone? Yes. Methadone does have certain disadvantages. The physical ones, of course, are constipation (but this does not last), certain reduction in the sex drive (which can be quite a prob- lem). Now, of course, methadone is a habit-forming drug. It does not create or produce the euphoria that the opiates do, but the methadone taker is dependent on it and he can't, you know, journey too far away from the clinical sources of supply. This is a problem in the event that he wants to travel, or go on a vacation, or engage in some sort of activities that involve going away. As far as functioning on the job, it doesn't hinder you in any way? 70 No. As a matter of fact, for the first time in many years, after I began taking methadone, I was able to function normally on the job. Methadone doesn't create euphoria and so a person can function. His equilibrium is maintained and his thought processes are just about normal; so, he can function. Paul, in many cases we hear the addict state that he becomes an addict due to his background and he usually tries to relate this to some psychogenic overlay. How much of this do you feel is true? Over the years I have met addicts from all walks of life, all economic strata, all types of people, and it's my belief that in order for a person to become addicted to a drug, in order for a person to use heroin, three things must exist: there has to be a degree of emotional instability; there has to be an available supply; and, of course, there has to be a method of bringing the two together. Without any one of these the addict wouldn't exist. Many of our counselors feel quite uneasy working with an addict. You've been a counselor. Would you tell us some things you think a counselor ought to do or ought to know when dealing with the addicts? Some guidelines? Well, first, of course, I think the counselor must attempt to understand the addict's problems. He must realize that this is a man or woman who, except for being addicted, prob- ably would have been just like himself. The counselor has to be-sincere; he has to»make the addict, feel that, he is really attempting to help and it's not merely a job. You've got to remember that the average addict comes in contact with many people--social workers, judges, probation officers- in the course of his addiction, and he is able to sense sin- cerity. He is able to sense a person's interest in him and he is pretty sharp. Never underestimate an addict; he's a pretty sharp guy. He can manipulate; that's what he has been doing all day for probably years in order to support his habit. And he is very perceptive, as you know. Manipulation and conning, these are hazards that a counselor feels. He, too, knows that he is being manipulated, and he is always wondering: "When do I really tell this guy that he 71 is conning me? When do I tell him that I'm being manipulated, that I'm getting a little sick of it, and let's level with each other?” I wouldn't be too afraid of the word "manipulation." There is positive manipulation also. Everybody manipulates. The degree to which you succeed in life is based on the ability to manipulate. It's when this ability becomes negative that you have to watch out. So, it might possibly be to the coun- selor's advantage that this guy is manipulative, but in a positive sense. We hear today that only ex-addicts can make good counselors with the drug user now. How do you feel about this? Cana professional really relate? Does he have to know the jargon? Does he have to have highest experience with drugs himself to really be helpful to the addict? I don't believe so. I don't believe a doctor has’ to have a baby in order to be a baby doctor. It might help in under- standing the psychomethodology of the addict, but it's not necessary to do the job. The addict, you know, is pretty sensitive, and he can feel things. If the counselor makes too great an effort to get down to his level, he can perceive Paiemand i ber knowsad tussancame,, it's al lieveic simet the. way this man really is. And if this man will do this, then what won't he do, you know? The counselor should be for real. He should be himself and attempt to develop a kind of rela- tionship which contributes to what he is trying to do for the addict. In many areas counselors are assigned to addicts only. Some- times those who make these assignments are in a little bit of a quandary. Should an addict work with addicts only? Would he be better off working with people across the board whatever the disability and have addicts as only part of his case load? How do you feel about this? Of course, just because a person is an addict does not qualify him to work with people. There are all types of addicts. You have addicts who can work with people, and you have addicts who can't. But an addict with any degree of intelligence usually has lived close to the margin. Let's say he knows people, he has lived in the street, he has been involved in iz that sub-culture, and he might be a little more perceptive to people's problems if he knows the resources that are necessary to help a person. He probably would make a very good counselor. | I was thinking of our general counselor who handles addicts as part of his case load as compared to having a total case load of addicts. Oh, I see.) Indon't know;)2) could’ t answer that. I suspect that it may relate to theories of counseling that if your icanvcounse le withvonestype sol) disabllt byes Cheneposs, bio, you\are: coingacobevertecliverwithaal Baty pesca me bULe md ecus pecn all types of vocational rehabilitation counselors nationally do have some doubts about this new population of drug addicts. Perhaps we need to go to school, or perhaps we need to join hands with counselors like you, who are now involved. In the 18 months that you worked in the hospital facility as a counselor, what kind of vocational needs have come to your attention in the population you worked with? Usually when we got the addict, he was in the last stages of addiction, What I mean by that is if the addict was re- ferred to us by the courts, or the parents brought him in, or if he came in for any other reason that his own free will, we found that we didn't have too much success. Regardless of how good the quality of the counseling was, he wasn't ready. You find that you have much more success with the motivated addict. This is the guy who is tired of hustling, he is tiréedvofsusinesdrics: wicwisstiredaomaithestiire alsmandacripula= tions ofvobtaining SS0vorms90ba)daymiebe ss titredsor coingeto jail, he's tired of the whole bit. He's tired, he's sick and tired, he's tired of being sick and tired. And with this kind of guy you'll find that he's uprooted. He doesn't have a job, he might not have any stable living arrange- ments, his family and friends have forsaken him, and he's just in bad shape. Most of the counselor's work will be in referring this man to specialized agencies; for example, to the Department of Welfare, the Department of Social Services, in order to provide for his subsistence and and shelter needs until he's able to find gainful employ- 73 ment, and to help him find a place to stay, if possible out of the sub-cultural climate that he is used to. These are the types of problems that you have. If the fellow has been a drug addict long enough and is old enough, you'll find in a number of cases that he has broken down physically. He might have abscesses, he might be damaged internally, his liver or circulatory system and his heart might be damaged, and of course, if this is the case, you have to straighten this out before you can even begin to hope to straighten him out. How about training needs for new skills and new jobs? How much of this is a need? It all depends. For some reason, people believe that addicts are unskilled. As I said, there are all types of addicts. It all depends when the person became ad- dicted. Now I have found that if a guy began using drugs at 16 and he stopped at 30, he is still 16 in a lot of ways. He doesn't know what responsibility is. He has functioned in such a way that he hasn't been an asset to himself and society. Even though he's 30, Der srstilho.) slp those cases you micht f£indithat the guy can't do anything. But, of course, you have addicts who become addicted at 25 and who have worked for 10 years. There's no stereotype for addicts; it all depends on the individual. You can't answer that question generally. Paul, when a rehabilitation counselor begins with an addict and tries to develop a service program for hin, there is a great deal in the literature about the drop- out rate, or his not using service, not coming back. What are some of your views as to how the counselor can get into this area? What are some of the things the addict needs to keep him in the rehabilitation program? You've got to remember that this is a man. He's been an addict for ten to eleven years and he hasn't worked. He's infected by the street. He is not used to routine. He has been spending large amounts of money on drugs daily, usually what amounts to a week's salary for most of us. He doesn't really appreciate what money is. Every dime he's got is going through his arm instead of 7h on his back. And if he's not on a treatment program and if he's not motivated, you're not going to have too much Success with anything you do with this guy. Usually the motivated addicts and the ones who respond to your efforts are people who are on treatment programs; they are not as susceptible to recidivism. You will probably find that with good counseling you can succeed in whatever you want to.do with this uy, if)at's mot’ above his: ability to accomplish. Are his needs more specialized, and in what way as com- pared to other rehabilitation clients? What are the particular needs of addicts a counselor must deal with? The biggest problem you'll have with the addict is the possibility of his returning to drugs. Now, there is no one answer as to why he'll do this, but I think this is one of the biggest problems you will have. Try to head him off when he seems to be backsliding. The chances are that you can be successful with him. What does he need to head him off? It all depends on his circumstances. What should a counselor's reaction be to backsliding? Should the attitude be one of "I-told-you-so" and total rejection of services at that point? How do you see this? Well, with the rate of recidivism as high as it is, I think that you should keep in mind that the possibility GXists .. 0 As “aimabterm (0 te hacteyehtas SmpbODS Dp) Cemag! nane doesn't backslide and use drugs again, then you know that something is being done right (even though you might not know what it is) and just thank God this is being done. If the intervals of slipping and the return to drugs keep getting further apart and less frequent, you con- sider this real progress? Yes, indeed. From time to time you have mentioned the levels of addiction; what do you mean by levels of addiction? Maybe I can answer the question this way. There is usually a process a person goes through when becoming a heroin addict. He doesn't begin using heroin daily. He might begin on Friday nights and Saturdays and this might go on for as long as a month or longer. It depends on the per- son, the supply, etc. Then he might begin using it on Saturday, Sunday, and Wednesday. Then he might take it Saturday, Sunday, Wednesday, and Friday. And all of a sudden he is using it seven days a week. Now at no time, I think, does a person believe that he will become addict- ed to heroin. Everybody believes, "I can use it once and then to heck with it.” But it is a very pleasurable sen- sation, it is very magnetic and you usually rationalize yourself into believing that one more time won't hurt. And you use it long enough or to the extent where your metabolism becomes dependent upon this opiate. At that stage, of course, you're addicted. I've found that the people who have been addicted to heroin the shortest period of time are really the hard-core addicts. These are the guys who haven't been made miserable by the acquisition of heroin. They haven't experienced the trials and tribulations for a long enough period of time so that they are really motivated to stop. It seems that it is easier to work with the addicts who have been addict- ed for ten, eleven, or more years. The younger boys, the younger people who are using heroin now and are addicted , seem to be the hardest ones to work with. They usually come to us through the courts, because they've been arrested, or their parents bring them in, or anything but coming in by themselves. And I think that the way a per- son seeks help is an indication of how he will benefit by ati. Earlier, we talked about the return to drugs while the counselor is working with the addict. At what point do you think the counselor should do some disciplining of the addict, or do you think this in order at all? I think it should be tried, but, as I say, addicts don't usually respond to words. They respond to actions. 76 It's my belief that when a person goes back to the use of drugs, he's already gone too far so that words can't help him. If you can put that type of pressure on him before he actually begins using drugs (now, I don't really mean pressure, you know), but if you can make-him understand that he is progressing, that he is doing well, why give it all up for something that is not tangible, like heroin use, when he is doing as well as he is? I think, if he is motivated at all, you can just about head off the recidivism. The counselor should be willing to accept some slips then? Yes, of course. He should expect them, Paul, do you think a single counselor should deal with the addict, or would a group or team be better? That again also depends upon the personality of the addict. If you listen to what an addict has to say, rather than concentrate on what you have to say to him, you'll find a lot of clues as to the treatment, the best response to use, or what's necessary to get him to do what. I think it's a decision based on the individual. Paul, I doubt if today there is a school in any of the states that doesn't feel that there may be an addiction problem of some kind within its system. Would you tell us a little bit about this since you have been in the field? It seems that during certain years of a person's life, mainly as young as ten now and as old as twenty-two, he seems to be more susceptible to this curiosity thing that makes a person involve himself with drugs. In all the years that I have been involved with drugs, I really know no one over thirty-five who, as a result of curi- osity,began using drugs for the first time. And I think that this is why we are having this hard drug problem in schools. They are just at that age to have the attitude: "What's all this talk about drugs? Let me see what the heck it is.’'’ And, as I say, drugs do produce a pleasure- able sensation and do solve some problems that emotionally disturbed people have. Then they rationalize on having 77 an excuse to use them over and over again, and they become physically dependent. It isn't a matter of curiosity any- more; it*s a matter of having to do it. And they've started on the chase, Do you think that some of our high school drop-out rate has been the result of an attempt to subsidize the drug? They drop out and work to get money to stay on the drug? Sure. When you begin using heroin or any habit-forming drug, your moral and ethical values are affected. Your conscience almost disappears. You have no iniative and all of your effort is channeled into obtaining money to satisfy this need. I don't think you can go to school or work and be an addict, too, for any length of time. So far we have talked mainly about heroin use and a treatment process using methadone. Would you comment about the use of amphetamines and barbiturates which seem to be a problem especially among the school age kids where curiosity and experimentation occur? Even though I have never been involved in the use of amphetamines or barbiturates, I think that amphetamines and barbiturates are so prevalent among young people because of the source of supply; in other words, it is so easy to get. Their parents might be a possible source, and of course, I understand that many times the drug being used is produced actually in this country, and there is a lot of it around. Barbiturates are not like heroin in that they are not considered a neutral; they are highly habit-forming. As a matter of fact, I understand that the results of barbiturate use are much worse than the results of heroin use, We hear that speed kills and so forth, and we've talked about the team approach or whether a counselor really deals on a one-to-one basis with the addict. I'm wondering when we have a problem that is extremely dangerous and needs medical attention, when we're dealing with amphetamines and barbiturates, whether we don't really have to have a medical person involved. Vhs: Yes, I would say you would have to have a medical person involved. The prime difference, or one of the more im- portant differences, between the use of barbiturates and heroin, is that if withdrawal occurs in barbiturate use, barbiturates will not bring a person out, whereas heroin will, or methadone will. Epileptic seizures occur in barbiturate use, and there is the possibility of brain damage. This is true of hallucinogens, too, like LSD and that sort of thing. Do you have any experience with those? No; aieidonst. Paul, in terms of the peer group and hanging around with the "old gang," what's your attitudes about those? I have never known a heroin addict who uses drugs for the first time to be by himself, to go out as the result of curiosity and purchase heroin and the paraphenalia to use it, and to use it by himself. He is usually with someone else, a peer. I've read about peer groups being used to bring people out of heroin use--peers, of course, who don't involve themselves in the use of heroin. But I know that if a person becomes addicted to drugs and ~ stops, the chances are that if he continues to associate with the same people, the peers who use drugs, he will almost always revert back to the use of drugs. So any counseling with the addict should be toward establishing a new set of friends and perhaps a new environment? The funny thing about that is I don't think a counselor can be very effective in helping a person establish a new set of friends. A person has to want someone as a friend. If he is motivated, he understands what is necessary to remain drug free once he has become an addict This» willebe a normal thincawithehingesbe. Lt see the need to establish new friends. He'll be tired of the whole life, the whole bag, and he'll come around himself. So, I don't think the counselor can be very effective in that respect. It's a personal sort of thing. 79 Do we have any statistics concerning the educational levels, the average levels, of the addicts you are working with? Are they school dropouts primarily? Now, you can do surveys to determine the education level of addicts, but whether you can say that all addicts are addicts because they are school dropouts--well, do you understand what I am trying to say? It doesn't neces- sarily connect. There seems to be no correlation between the level a person attains educationally and the prob- ability of him using drugs. But, people who use drugs and are in school will probably drop out. From your experience with addicts seeking service or treatment, in the main what about their work records? What about their past educational experience? How good a work record? How high an educational background? They seem to have poor work records and poor education- al backgrounds. From time to time we get addicts who ask to be relocated. They express fear of physical harm from the old gang because they have turned over a new leaf, so to speak. How realistic is this? Does the old gang resent a person going for treatment? In the black community, in the ghetto, the attitude now isetchateitesea drareco useyneroin. A person, inthe) old gang who stops using heroin is given encouragement be- cause his friends would like to do the same thing, but can't. I have found, however, that the attitudes seem to be different in suburban neighborhoods and the county in regard to white drug use. It seems to be the thing to do. Drugs have existed in the ghetto for a number of years, and it is not a new thing at all there. As far as I'm concerned, it has been just in the past five or six years that it has become a problem to this extent in the counties and it's a possibility that they have to go the route before they get disgusted with it, too. I don't know. Paul, in terms of a public relations program to really get across the story about drugs, do you have any 80 suggestions? In talking to young people who are using drugs, it seems that a lot of their curiosity was a result of all of the publicity given to drugs--the bad publicity and all. The publicized deaths of well-known people, due to drugs, don't seem to make any difference. People have a tendency to believe that it won't happen to them. "These are just three or four individuals in a thousand who overdid it; it won't happen to me.” I believe that curiosity is stronger than fear. You know, we say that the good guys wear white hats, this type of thing, and I think Madison Avenue probably has a great influence on what we buy and how we behave. From counseling standpoints I don't think that we could say that anybody using drugs is bad. But how do we go about sayinewethiss | DO we save 1 si) cood a ayouL Te diseased,''"you have a problem"? What approach do we use? This.is, a hard question to answer. It's just the way it is. .L've seid often that man has» come wencywutar in the last seventy years. He's got the automobile, air- plane, television, telephone, atomic energy; he's on the moon today. And it seems we just haven't been able to keep up socially without kicking ourselves in the pants. It's created pressures and problems and anxie- ties for some people, and drugs seem to be the easiest way to alleviate these anxieties. And it's just being done more and more. Paul, one of the questions that the counselor is faced with today is does marijuana lead to the use of harder drugs. As a counselor with addiets: for-eighteen months, what are your feelings on this? I don't believe it does--not physically so. But I will say this. People who will use marijuana are more likely to use heroin. People who depend on this sort of sensation are more likely to use mari- juana than use heroin. In, the *slippine andareturnwotethe addict ado they 81 sometimes substitute alcohol for the drug? No. Alcohol and heroin don't mix too well. I've had | a number of friends die from what was considered an over- dose of heroin, when, in reality, that was not the case. Heroin is a depressant and slows up metabolism. Normally, your liver is able to assimilate an ounce of alcohol every 75 minutes. When you drink alcohol and you're under the influence of heroin, more alcohol in the pure form gets in the blood stream, It's the alcohol that kills you, not the heroin. Heroin and alcohol just don't go hand in hand. In your capacity both as an addict and a counselor in the field, I'm sure you have known some pushers. Do pushers sell both heroin and some marijuana, or are they two separate fields? Well, they are two separate fields. Marijuana pushers consider selling marijuana a little safer. The cus- tomers they have are not as frantic; they don't have to go out and steal to support their habit. So, the chances of the customers getting arrested and informing on the pusher are not so great. The pushers will not make as much money, but usually they are afraid of heroin. They don't even use it. The heroin pushers don't bother with marijuana because it's too slow. What's happening now, however, is that as a result of the drug abuse pro- grams in certain cities, the number of heroin pushers is decreasing and the number of cocaine pushers is increas- ing. The reason for that is that methadone does not block out the effects of cocaine use, the sensation involving cocaine use. And there is a lot of cocaine being used now, whereas at one time cocaine was unknown in many of these cities. One of the other objectives of the vocational rehabili- tation counselor is placement. I've heard counselors say that they hadn't had much success sending the addict back into the field, such as drafting, engineering, and so on, and that most of their successful placements have been where the addiction has been kept right in focus, that is, in jobs directly related to drug addic- tion. How do you feel about this? 82 You'll find that when you're placing addicts in jobs, unless it's a job that they really want to do, some- thing that will hold their interests, something that is creative as far as they're concerned, you might not have too much success. Remember that the addict has been involved in drug use which was to him very time-consuming, very enjoyable for a while, and his whole day was involved with doing this enjoyable thing. For him to work now and de something less enjoyable is a hard thing to do. I don't know if I put that right, but I think I got the thought over. He has to be doing something that to him involves more interest than heroin use. You have been a counselor for the addict now for a number of years. How many other jobs did you try in the meantime and how many failures did you have? Would you have any idea? Oh,yes. I didn't get a full-time job until after I graduated from college in 1958. Between then and 18 months ago, I had no permanent job because of my drugs. How did you manage to get through college and sponsor your habit at the same time? Well, that's another story. I didn't have a habit when I went to college. As I said, my first contact with drugs was when I was a thirteen-year-old. It was something new in those days, and I remember using heroin possibly for the same reason a kid smokes his first cigarette. There were no addicts around; nobody knew what this stuff was. I remember the first time I used it, it made me pretty sick. But I grew up with a very curious bunch of fellas (when I say curious, I mean we were very adventurous), and we involved our- selves in just about all kinds of things. We were juvenile delinquents. At the age of sixteen I commit- ted a robbery, a felony, and I went to the reformatory for five years. I graduated from high school in the reformatory. Iwas released in thirteen months so I could attend college. I wasn't matriculated, however, and I was allowed to transfer to another college. As 83 a fully matriculated student a year after I came off parole, I graduated from college. Soon after, I got involved in drugs. Who sponsored your college training? My parents. In those days college education wasn't too expensive. I think it cost something like $140 a semes- ter. It was cheaper than that for state students. It kind of shielded me for four years. My parole officer required a B average of me, and in order to stay in college I gave it to him. Paul, in terms of job placement for an addict-client, what kinds of special problems should the counselor be on the look out for? What kinds of continuing services, if any, might the addict need? Counselors should remember that the businessman is not a sociologist. His primary concern is profit, and so when an addict or an ex-addict is considered for employ- ment, the counselor should make sure that his client can do the job. If he can't do the job, the results may, of course, be anti-therapeutic and may lead to recidivism. It may create anxieties and result in his going back to the use of drugs. I think what is most important is that Paul, what kinds of attitudes have you run into recently with employers? Do you tell employers, "This is an addict; yet he has the skill or training to do the job!''? It depends on the type of job the client is going to do. Now, there are jobs where an employer isn't concerned as to whether a man is an addict or not. Some employers are a little more lenient in their attitudes about hiring ex- addicts or ex-convicts or people who have social problems. When this is the type of employer, we try to involve him in our approach of getting our client employed. We feel this type of employer can be a definite help in assisting our client to do the job and remain drug free. If the employer is the type who doesn't understand the problem, we take a chance. The main thing is to get the client actively involved in something that is profitable for 84 him and society. From time to time we hear that a teenager uses the addic- tion as a means of "getting authority," that is, parents, teachers, police, etc., that he is really guarded in his use and has no intention of becoming an addict. Could you tell us about ‘this? Well, I don't understand a lot of young people myself. There is a generation gap with me, too. I know of some young people who are becoming, instead of drug-oriented, revolution-oriented. And some might, of the two, rather see them get involved in drugs. We've had patients who because of the use of drugs calmed down and became less of a threat to society. But I do believe a lot of young people use drugs and attempt to shake up society and the establishment and their parents. Paul, what are your recommendations to a rehabilitation counselor working with an addict? Well, it's very unfortunate that the counselor can't really involve himself in the sub-culture that the addict comes from so that he can really know the life style of the addicts he works with. There are different types of addicts, but one thing they do have in common is that they all involve themselves in the same sub- cultural activities. If the counselor could, unknown to the addicts, mingle with them on their own grounds, I think that he could have a better idea of how to help them. Thank you, Paul, for the interview and for being so forthright with us. I think these many things we have discussed will be helpful to the vocational rehabilita- tion counselor, 85 APPENDIX D DRUG GLOSSARY A the amphetamines; any amphetamine; methedrine A-head frequent or regular user of the amphetamines or methedrine Acapulco a superior and powerful form of marijuana, said to grow gold in the Acapulco region of Mexico; often, any strong marijuana Acid LSD; LSD-25 (lysergic acid diethylamide) Acid freak chronic and frequent user of LSD Acid head more or less regular user of LSD Acid rock music influenced by the psychedelic experience or thinking process Amys vials of amyl nitrite, a vasodilator Bad trip a panic reaction, or psychosis after taking a hallucinogen, especially LSD Bag (1) a quantity of drugs; for marijuana users, a "nickel bag"; for heroin addicts, a quantity of heroin; for ‘amphetamine users, a quantity of methedrine; (2) a mood, a direction, an emphasis, style or taste Ball Absorption of stimulants and cocaine via genitalia Bang (1) sudden, sensual flush of pleasure as an intravenously injected drug--heroin or methedrine, usually--begins to take effect; (2) to have sexual intercourse Barbs barbiturates Beat to rob or cheat one out of money or goods Behind (1) under the influence of a drug, as in: "I hallucinated Dewindsec ids? eo. be addactredeto iedrus: "That cat's strung out behind H." Bennies benzedrine, an amphetamine Bent high or intoxicated from a drug Bindle packet of narcotics Bit time served in jail Blank extremely low-grade narcotics Blast to smoke marijuana (an obsolete term) or the strong effect from a drug Blind to be under the influence of a drug, often marijuana, to such an extent that one is unable to function normally Blow to inhale heroin or cocaine through the nose Blue Amytal, a barbiturate angels Blue Paregoric (camphorated tincture of opium) and Pyribenza- velvet mine (an antihistamine) mixed and injected Bombita Boo Boss Bread Brick Bring down Bum trip, bummer Burn Bust Buttons Buzz Can Cap Carrying Chipping Chippy Clean Coasting Cocktail Coke Cokie Cold turkey Come down Connection Cook Cop 86 Amphetamine injection, sometimes taken with heroin marijuana; although generally obsolete, sometimes used humorous ly authority or domination of drug, good quality money a block of marijuana, compressed and packaged; usually a kilogram in weight; although sometimes slightly less to lose one's high; anything which causes one to lose one's high; that which causes one to lose any positive euphoric feeling; anything which is depressing a negative or unpleasant experience with a psychedelic drug; generally, any unpleasant experience to sell someone else a quantity of drugs, and not deliver them, or give adulterated drugs to arrest the sections of the peyote cactus a slight tingle of a drug feeling, used especially with marijuanase 1 just ot) abuzz errom thats oint. « a quantity of marijuana, slightly more than one ounce; more often used in some geographical locales than others--Chicago, for instance (see 'lid'"’) a capsule of a drug, usually LSD to be in possession of a drug taking narcotics occasionally to use an addicting drug, usually heroin, sporadically, so that one does not become addicted (1) to prepare marijuana for smoking by removing stems, twigs, and seeds; (2) not to be in legal possession of any drug, so that when the police search one's dwelling or person, no drugs will be found; (3) among addicts: abstention from an addicting drug under the influence of drugs a "roach" or a small amount of marijuana or hashish twisted into a regular tobacco cigarette cocaine | cocaine addict sudden withdrawal of narcotics (from the gooseflesh, which resembles the skin of a cold plucked turkey) see "bring down," recovering from a trip drug supplier or source to heat the mixture of heroin, to dissolve to obtain or buy a quantity of drugs--see '"'score"; generally, to obtain anything Cop out Crash Crash pad Crutch Crystal Cubehead Cut Deal Dealer Deck Dexies Dime bag Dirty Do Dollies Doojee Dope Doper Downs Down Dried out Drop Dummy Dynamite Factory Fall out Fed Fiend Fix Flash Flip Floating 87 quit, take off, confess, defect, inform to "come down" from the long-term effects of the amphetamines place where the user withdraws from amphetamines a device, often a folded matchbook, used for holding a burned-down marijuana cigarette butt (see "roach"') to prevent one's fingers from being burned; a "roach holder" methedrine frequent user of LSD dilute drugs by adding milk sugar or another inert substance to sell drugs a seller of drugs, usually on a large scale commercial basis packet of narcotics dexedrine, an amphetamine ten dollars worth of a drug possessing drugs, liable to arrest if searched to take a drug; see "make" Dolophine (also known as methadone), a synthetic narcotic heroin, also spelled dugie, duji humorous term used by drug users for drugs, usually mari- juana: "I smoke dope”; often heroin person who uses drugs regularly barbiturates or tranquilizers anything depressing detoxified, withdrawn from a drug swallow a drug purchase which did not contain narcotics an exceptionally powerful and pure quantity of a drug; "That's dynamite grass"; often denotes anything exceptionally good clandestine location for processing illicit drugs to go to sleep, often after taking a drug a federal narcotics agent see "freak" injection of narcotics see "rush" become psychotic under the influence of drugs Freak Freak out Front Fuzz Gage Garbage Good trip Gab. Grass Gold Guide H Habit Hard naccoLres Hard stuff Hash Hay Head Hearts leat High Holding Hooked Hophead Horse Hot shot Hustle Hustler Hype Joint Jolly pop beans Jones Joy-pop Junkie Key, ki 88 a chronic and heavy user of a drug, never marijuana; the term has a distinctly negative connotation to have a psychotic experience with a psychedelic drug false display of respectability the police obsolete (sometimes humorously used) term for marijuana weak, heavily diluted heroin happy experience with psychedelics goofballs; barbiturates marijuana see "Acapulco gold” someone who accompanies a person taking an LSD "trip" heroin being physically dependent upon a drug opiates, such as heroin and morphine heroin hashish, the resin of Cannabis marijuana (1) user of a drug; contains no negative connotation; (2) mood, thoughts, opinion, taste; ‘Where's your head at?" dexedrine tablets (from the shape) the police to be under the influence of a drug having the influence of drugs addicted narcotics addict heroin overdose of heroin, or poison activities involved in obtaining money to buy heroin prostitute narcotics addict marijuana cigarette pep pills habit or addiction inject narcotics irregularly narcotics addict a kilogram, usually of marijuana (or sometimes hashish) Kick the habit Kif Lay on Layout Leapers Lemonade Lid M Mainline Maintain- ing (The) Man Make Manicure Mesc Meth Methhead Mikes Mary Jane Nark, Narco Nickel bag Nod, nod CULO 89 stop using narcotics (from the withdrawal leg muscle twitches ) North African cannabis to give someone someone something, often a quantity of drugs: 'I laid some grass on the cat''; could also mean to tell someone something equipment for injecting drugs amphetamines poor heroin a quantity of marijuana, generally slightly more than an ounce; usually regionally distinctive for California and the West Coast morphine inject drugs into a vein keeping at a certain level of drug effect the police (1) to take a certain drug, to have experience with a specific drug, as in: "Did you ever make acid"? (2) to have sexual intercourse remove the dirt, seeds, and stems from marijuana mescaline, the alkaloid in peyote methamphetamine (also known as Methedrine, Desoxyn) habitual user of methamphetamine micrograms (millionths of a gram) an obsolete term for marijuana, sometimes used in jest narcotics agent five dollars worth of a drug, often marijuana to become extremely lethargic and sleepy under the influence of a narcotic drug, usually heroin on the nod Panama Red Panic Pillhead opium to take an overdose of a drug (never marijuana), usually heroin an ounce, usually marijuana powerful form of marijuana, usually coming from Panama the general unavailability of a drug in a given area heavy user of pills, barbiturates or amphetamines or both 90 Pod obsolete term for marijuana Poison heroin Poke (1) a puff of marijuana (2) the jab of a needle into one's sk Pop inject drugs Popped to be arrested by the police Poppers vials of amyl nitrite Pot marijuana Pothead heavy marijuana user Pound Sa Prince. a quantity of marijuana, or a "'can,'' so-called because Albert it was once put into an empty Prince Albert pipe | tobacco can Psychedelic having the quality of "expanding” the mind Pure relatively undiluted heroin Purple dexamyl, a combination of dexedrine and amytal (from hearts the shape and color ) Pusher obsolete term for a seller of drugs Quarter 1 ounce of marijuana, worth $25 Bag Quill a matchbook cover for sniffing Methedrine, cocaine, or heroin. see "crutch" Rainbows Tuinal (Amytal and Seconal), a barbiturate combination in a blue and red capsule Rap to talk or speak Red devils Seconal, a barbiturate Reefer marijuana cigarette Reentry return from a trip Roach marijuana butt Roach device for holding the butt of a marijuana cigarette holder Run an amphetamine binge Rush the sensuous feeling of an injected drug Satch cotton used to strain drugs before injection; may be cotton used again if supplies are gone Scag heroin Scene where the action is, a place to be Scots (lL) .tovswal loweaidrupvorall ye ii(2petoseat Scoop a makeshift object to sniff cocaine or heroin (matchbook) Score (1) to obtain a quantity of a drug; see "cop; (2) the quantity of drugs that one obtains; (3) have sexual intercourse Shit Shooting gallery Skin popping Smack Smoke Snappers Snort Snow Spaced out Speed Speedball Speed- freak Spike Spit Spoon Stash Stoned Stone Stick Stoolie Strung out Siejetiee Tab Taste Take ofr Tea Throw rocks Toke Tools Tracks Trey 91 any drug, but usually heroin; occasionally, marijuana place where addicts inject to inject a drug subcutaneously, rather than intravenously, usually to avoid addiction heroin marijuana or wood alcohol vials of amyl nitrite to inhale a drug sharply through one's nostril; used with heroin and methedrine among the less frequent users (the heavier users more often inject the drug), and almost always with cocaine often heroin, sometimes cocaine to be high usually methedrine, but can be any of the amphetamines an injection of a stimulant and a depressant, originally heroin and cocaine . habitual user of speed a hypodermic needle to leave (1) a level teaspoon of a drug, usually methedrine, (2) the device used to hold heroin or methedrine while it is being heated and liquified in preparation for intra- venous hypodermic injection a quantity of any drug that is hidden; generally, an amount of a drug to be very high superlative, completely, absolutely, the ultimate obsolete term for "joint" or a marijuana cigarette informer addicted narcotics, usually heroin a tablet of a drug, usually LSD a small amount of a drug, often given in exchange for a favor, or as a sample (1) see "get off"; (2) to steal a quantity of drugs somewhat lighthearted term for marijuana commit crimes a puff of marijuana (sometimes opium) equipment for injecting drugs scars along veins after many injections a three dollar quantity of a drug Les ie Turn on Turps we) Ups, uppers Using Waste Wasted Weed Weight Wiped out Wig Wig out ; Works Yard Yellow jacket Yen sleep Zonked. zonked out a2 a psychedelic drug experience; generally any involved and dramatic experience (1) to take a drug; (2) to take a drug for the first time, almost always marijuana; (3) to become high for the first time, usually on marijuana; (4) generally, to introduce or sensitize someone to something elixir of Terpin Hydrate with codeine, a cough syrup LSD (from its original designation, LSD-25) stimulants, almost always the amphetamines taking drugs destroy to be under the influence of a drug to such an extent that one is able to do little else but rest or sleep marijuana " a large quantity of a drug, usually marijuana, often for selling purposes. Vi'm) looking to cop weicht.| see "wasted" an insane person to have a psychotic episode under the influence of a psychedelic drug; see "freak-out,” "flip out" the equipment used to inject drugs intravenously, the needle, especially $100 nembutal, a barbiturate a drowsy, restless state during the withdrawal period see "wasted"’ generally, also, to be tired 95 APPENDIX E Confidentiality of the Records Of The Vocational Rehabilitation Agency The State Vocational Rehabilitation Agency may on occasion be served with a subpoena for disclosure of information in agency files relating to Drug Abuse Clients. Where disclosure in re- sponse to such subpoena would not be for a purpose directly con- nected with the Administration of a Vocational Rehabilitation Program and the Drug Abuse Client has not consented to the release of information, Section 401.39 of the Regulations and relevant State Plan Provisions would prohibit such disclosure. Should the State Agency accede to the subpoena by produc- ing the case files, the Agency would then be in direct violation of the Federal regulation relating to confidentiality. The Agency may also be violating applicable State statutes since the basic State Vocational Rehabilitation Act contains an all- inclusive acceptance provision relating to the Federal legal requirements. In the event that the State Agency is served with a subpoena, assistance should be sought from the State Attorney General's office to obtain relief from the subpoena. If the subpoena is allowed to stand, it is suggested that the State Agency representative be accompanied to court by a member of the Attorney General's office. Upon being called to produce Agency records, relief would be requested again since the dis- closure would be in clear violation of the Federal and State legal provisions governing the operations of the Federal-State Vocational Rehabilitation Program. Failing in this, the State Agency should rely on the advice of the Attorney General's office as to what action should be taken. Mee: ory Te | > : i4gsov' pages eet OS ee ee Le as ij amroains eetea ma) op hae a ae =] an | ee 7 . 6 @ 9 it cx a f ey. «@ 95 APPENDIX F IRS PRIME STUDY GROUP I THE REHABILITATION OF THE DRUG ABUSER QUES TIONNATRE Statistical study of drug abusers non-rehabilitated (NR, 08, 30, 28) and rehabilitated (R, 26)* by State VR Agencies for the fiscal years 1967, 68, and 1969. Les REFERRAL SOURCES Hospitals and Sanatoriums Other Health Agencies Welfare Agencies State Employment Service Individual, Except Client Self-Referred Persons Correctional Institutions Other Sources AGE 14-19 yrs. 20-24 25-29 30-34 35-39 40-44 45-54 55 and over SEX Male Female 1967 Number Hitt 1967 Number HHH TILL 1967 Number 1 1968 Number NR Ht 1968 Number 1968 Number NR R 1969 Number *In referring to 26 Closures we are interested only. in those with the major disability of "drug abuser" (or 521). 8. 96 The number of referrals with disabilities reported as drug abuse or Eyal ke 7 1967 1968 1969 Number Number Number RACE 1967 1968 1969 ) Number Number Number NR R NR R NR R Caucasian Negro Number of referrals with a disability as reported drug abuse or 521 closed at the status 08. 1967 1968 1969 Number Number Number The number of clients with the major disability of drug abuse or 52] 1967 1968 1969 Number Number Number 7] 2 ae The number of clients with the secondary disability of drug abuse Or 2 1F, 1967 1968 1969 Number Number Number athe: 9. MARITAL STATUS 1967 1968 1969 Number Number Number NR R NR R NR R Married Widowed Divorced Separated Never Married 10. EDUCATION 1967 1968 1969 Number Number Number Grade Completed 1-7 8 9-11 12 13-15 16 and over Special Education 11.MONTHLY FAMILY INCOME 1967 1968 1969 Number Number Number NR R NR R NR R 0.00-199.99 200.00-299.00 300.00-399.00 400.00-499.00 500.00-599.00 600.00 and over L2se jae 14. i 98 How many of the client - drug abusers received case service with cost to your State Rehabilitation Agency? . 1967 , 1978 SeELUOG Of this number, what were the percentages receiving specific types of services? Services 1967 1968 1969 Percentage | Percentage | Percentage Diagnostic Physical Restoration Training Maintenance & Transportation How many client - drug abusers were closed at Status 28 or 30? 1967 1968 1969 Number Number Number 28 30 28 30 28 30 Can a client in your State be accepted for VR services with a primary disability of drug abuse without any written diagnosis of a behavior or psychiatric disability? (Yes, No) any comments? Can a client in your State be accepted for VR services with disability of drug abuse in remission? (Yes, No) any comments? a **16. Does your State operate any facility which works directly with the rehabilitation of the drug abuser? (Yes, No) If so, who has the responsibility for its operation? **17, If your agency is not responsible for the operation of such a facility, then does your agency formally participate in it? (Yes, No). In which do you participate? To what extent does your agency participate? **18. Does your agency formally participate in any private facility (i.e., therapeutic community, half-way house, free clinics) that work with the drug abuser? (Yes, No) In which do you participate? To what extent does your agency participate? **For questions 16, 17, and 18, if you have any information regarding such facilities, please forward copies of such information with this questionnaire. FS Be 100 Does your State agency have counselors with a specialized case- load working only with drug abusers? (Yes, NO) The following three questions are aimed at the counselors who work with the drug abuser. If possible, it would be appreciated if you could get a sampling of responses from them or of some person working closely with them. Le Do you have any specialized training in working with the drug abuser? (Yes, No). If so, please indicate. When working with the drug abuser, do you find that counseling is often the most important service rendered? (Yes, No) If not--what is? When working with the drug abuser, do you require, or highly recommend the client to be involved with some facility which directly works with drug abuser while he is receiving services from V.R.? (Yes, No) Any comments? TOL APPENDIX F (1) SUMMATION OF THE REHABILITATION OF THE DRUG ABUSER QUESTIONNAIRE In an attempt to compile information regarding the current role of State VR agencies in their work with the drug abuser, a questionnaire was sent to each of the states. The percentage of returns was high -- 80%; the data, however, is inconclusive. The reasons for the inconclusive data are best stated in comments from many of the letters included with the returned questionnaires. Before sharing some of these comments, it is important to note one significant point which emerged from the data:most of the state VR agencies are working with drug abusers. What obscures the data is the manner in which the states accept and classify a client who is a drug abuser. The following comments illustrate this point: 1. "I regret to report that Items 1 through 13 cannot be com- pleted. We show no drug abusers in our caseloads through 1969. This is not say that we have none. I would suspect that there were some, and that their disabilities were disguised under one of the character behavior or psychiatric disability categories. "Ttems 14 through 19 would be answered 'No.' Again, I suspect that there are a few drug abusers in our caseloads known to the counselors but not reflected in our statistical data." 2. "The closest we come to collecting information on Drug Abusers is Drug Addicts (Code 521 in the VR Manual)." 3. "We enjoyed reviewing and completing as much of the question- naire on drug abuse as was possible. We have noticed a substantial increase in drug abuse referrals in the past three years and we feel this disability deserves our special attention. "Unfortunately, the data you requested regarding code 521, drug addiction, is not available presently in our data system. For instance, during fiscal year 1969-70, only four cases were coded as 521, although our work with the drug abuser increased dramatically. This discrepancy can be explained easily by understanding that the agency Manual of Policies had no clear guidance on how to work with the drug abuser. Therefore, counselors coded these cases according to psychological con- dition, such as 522, personality disorder, 500, psychotic, or 510, psychoneurotic. 4. Dre 102 "A manual revision this fiscal year included a section on drug abuse and addiction and we anticipate more use of code 521. However, it will be at least June of 1972 before any reliable data can be pulled from our data system.” "We would like to call attention to the point that many cases have been served by the Agency which have a drug abuse problem but have been coded under the disability code of character, personality and behavior disorder, code 522, rather than drug addiction 521. We feel this is probably true in many states because of the eligibility determination provisions and regu- lations.” "Questions 1 through 13 of the attached questionnaire remain blank since our Agency, at this time, has not categorically served the drug abuser, or at least our records do not enable us to make such categorical identification." Another factor which obscures the data appears to be attitudinal and is one with which the states must come to grips. The following excerpts illustrate this point: 6. "The only report we can presently provide concerns addiction. We do not have a definition of drug abuse locally or from the RSA for legally determining eligibility for DVR services. The simple use or abuse of drugs of itself cannot qualify an individual for DVR services. "Our principal emphasis is rehabilitation, not prevention, and as such makes our services inappropriate for most of the problems usually associated with drug abuse. On the other hand, the hard core addict who is on hard drugs is a poor risk for services delivered in the community. We are not equipped with the resources or techniques for dealing with a counter-culture that spurns work and 'the system.’ Seen as a consequence of the aforementioned, the number of addicts with whom we work is quite small, and no dramatic increase in the program is anticipated.” "T have deliberately held the questionnaire hoping that we could come up with something that might be of significant help to your group but, as you can see from the statistics that we have gathered for the past fiscal year, we have not and ve Die 2, 13% 14. 103 yet initiated a program here and gained information which will be helpful at this time.” "The above information is scanty at the best; however, real assistance to other than the hard drug users has not been a prominent part of our program. We have worked with drug users since the inception of our mental service program. However, in the many years I have been associated with Vocational Rehabilitation, we have not been able to realize the complete rehabilitation of any client who has been a mainliner." "This state has not made a concentrated effort to serve this particular group so our figures would be few in number. We also suspect that some drug abusers were probably coded 522 instead of 521; so, there is a further problem of identification.” A third problem in the collection of data is mechanical is best stated by the following: "The information you request is either nonretrievable, not available, or terribly time-consuming to obtain. I have, however, made some very rough guesses.” "{J have attempted to complete the questionnaire on drug abuse; however, for the most part it was found that the information was not retrievable." "We are sorry to be so late in returning the questionnaire; however, we have tried very diligently to get as much of the numerical information you requested as possible. As you can tell, we were not terribly successful in getting a great deal of the information relative to the number of drug abusers served by our agency." "After reviewing the enclosed questionnaire, I find that, for our own Agency, the major portion of the requested material is not retrievable. I regret that more substantial informa- tion cannot be provided." "Much of the information requested on the survey form is not readily available from our records. I am sure other state lo. NG). 104 agencies will have the same problem in replying to the ques- tionnaire and particularly those areas where statistical information is required. We do not have the type of statis- tical reporting wherein this data could be readily retrieved." "Rehabilitation has but few clients with the primary disability of drug abuse. These are spread throughout the state and it would require a long and diligent search to find pertinent statistics on them.” "IT have attempted to complete the questionnaire on drug abuse; however, for the most part it was found that the information was, not retrievable.’ As was stated earlier in this section, the one point which did emerge from the data is that the state VR agencies are working with the drug abuser--even though he is assigned to many different disability categories. There is evidence, however, that some states are looking at ‘drug abuse’ as a distinct category. Lees box Ate i "As the drug abuse program is relatively new to this state's Division of Vocational Rehabilitation, and we have only had drug abuse clients since fiscal year 1968, we will furnish the information for fiscal years 1968, 1969, 1970 on your ques- tionnaire." "As a matter of fact it is only within the current year that we have had any clients on our rolls for whom ‘drug abuse' was listed’ as the cause of disability.” "We are very interested in the outcome of your Study Group, as we are beginning to enter into the provision of vocational re- habilitation services to the drug misuser on a statewide basis." Hopefully, this last comment will develop into a national Grende 105 APPENDIX G A TRAINING GUIDE A training program for State agency personnel on the Rehabilita- tion of the Drug Abuser should have a dual focus of information and insight. It is essential, of course, for the rehabilitation counselor to be informed about drugs and drug abusers; it is equally important that he acquire insight into his own attitudes, feelings, and prejudices toward drug abusers. For these objectives to be attained, the training program should be a continuous one. While being fully appreciative of the State agency's responsi- bility for servicing other disability groups and for case loads whose demands impose time constraints on State training programs, the Prime Study Committee believes that a commitment to service the drug abuser requires minimally a two-day training session followed by a second two-day session after a six-month interval. The first of the two-day sessions should focus primarily on information and begin to explore attitudes and feelings. The second training conference should ascertain the extent to which the information has become part of the "working knowledge" of the counselors and then place its major emphasis on counselor attitudes and feelings in working with the drug abuser. Both training conferences should foster within the counselor positive attitudes toward the drug abuser and lead to a willingness to service this disabled population. Outline for the First Two-Day Training Conference This suggested training guide is for the first of the two-day conferences. At least two weeks prior to the conference, a copy of this publication, Rehabilitation of the Drug Abuser, might be sent to each of the participants so as to provide some basic information. FIRST DAY Morning Session 1. Over-view of conference objectives (with emphasis on positive aspects of working with drug abuser). 2. Client's perception of the drug abuse problem and DVR services. (An articulate drug abuser who has been re- habilitated would serve as an excellent keynote speaker and help set the "tone of the conference). 106 3. Coffee break. (At this point a coffee break enables participants to discuss informally the conference objectives as well as the keynote presentation). 4. Formal presentation of Chapter I, "Nature and Extent of Drug Abuse." (It is important that the speaker be knowledge- able in the pharmacological aspects of drug abuse. The presentation should emphasize the distinction between "types" of drugs as well as the physical and psychological effects possible from each). 5. Small group discussion of Chapter I and formal presenta- tion. (The group leader should be skilled in group dynamics so as to elicit discussion. The discussion should attempt to assess the extent to which the participants understand the nature of drugs and the degree to which they perceive their own attitudes toward drug abusers). 6. Lunch. (Ample time should be provided for informal discussion). Afternoon Session 1. Formal presentation of Chapter II, "Evolution of Drug Abuse Legislation," and Chapter III, "Eligibility and Feasibility.’ (The speaker should stress the change in societal attitudes from punitive to rehabilitative. Emphasized should be (1) current legislation as it applies to eligibility and feasibility, and (2) interagency cooperation). 2. Small group discussion of Chapters II and III and formal presentations. (These chapters offer an excellent opportunity to explore the attitudes of participants. The group leader should note to what extent the participants are in agreement with current legislation and what pro- posals emerge from the discussion). SECOND SESSION Morning Session 1. Formal presentation of Chapter IV, "Differential 107 Aspects of Client Study," and Chapter V, "Staff Attitudes and Counselor Skills.’’ (The speaker should be knowledge- able on a first-hand basis. Counselors within the agency who are working with drug abusers should be asked to share their experiences. This should be a planned sharing and not spontaneous). 2. Small group discussion of Chapters IV and V and formal presentations. (Participants should be encouraged to ex- plore their feelings regarding the drug abuser. Usually, "role playing’ is effective as a means of facilitating discussion of counselor attitudes and feelings). Afternoon Session 1. Formal presentation of Chapter VI, "Service Pro- gramming.*’' (A discussion of treatment modalities should avoid a qualitative judgment as to which type is best. The emphasis should be on an understanding of the rationale for each type. Placement is a major part of this chapter and is central to the rehabilitation pro- cess. The special problems in placement should be presented with a positive emphasis). 2. Small group discussion of Chapter V. (Role playing is an effective vehicle for presenting problems and ap- proaches in the placement of the drug abuser). Summary Session NOTE: It is desirable to have a conference summary which focuses on the feelings and attitudes of the partici- pants. Two or three persons should be assigned to the exclusive responsibility of circulating among the discussion groups and of sampling feelings and atti- tudes of the participants. The conference should conclude on the theme: "Where do we go from here’'? As a follow-up to this conference the participants should be encouraged to visit drug treatment programs and to become better ac- quainted with drug abusers. To the extent that it is possible, the 108 visits should be planned and supervised. The counselor should be provided an opportunity to ask questions and discuss feelings. A knowledgeable person should be available to provide the necessary assistance. 109 APPENDIX H SCHEMA FOR EXAMINING JOB READINESS* A. Physical readiness 1. Is client at his maximum level of physical capacity? 2. Can client travel to and from a job? 3. Can client meet the physical demands of the kind of work sought? B. Psychological readiness - Do client and his family accept his limitations? Do client and his family recognize his capabilities? Is client sincerely motivated toward employment? Can he adjust to the strains and pressures of a work environment? dt WhO Fe C. Occupational readiness 1. Are client's aptitudes, skills, knowledge, and experience commensurate with job requirements, current and future? 2. Is the client really interested in job under consideration? 3. Are the job's non-monetary, psychological rewards in keeping with client's needs, values, and long-range goals? 4. Is client aware of opportunities and requirements for entrance to other jobs or tasks? D. Placement readiness To what extent can client participate in job-finding process? . Does client know sources of job loads? Can he develop a personal information packet? Can he satisfactorily complete an application? - Can he present himself adequately in job interview? in F&F WN Re e ® The extent of the evaluation suggested in the above schema is ad- mittedly time consuming, even recognizing that much of the information required is accrued in previous stages of the rehabilitation process. Its eminent virtue, however, from the point of employer-agency rela- tionships is the ability to "sell" the employer a qualified job applicant as a selective placement. Unpublished paper. tenlwel ree Sa] Neen On ed > Weel ¥ iy, > of °: ‘ ar. we & ae hs ae heh + ip: F f 1 i " 9 Ta “* 4 Ae R F ; ve 1 se it a! Le oo ra i. se 7 Te ” we t ; eG 7s ' i" , eS *« ~ » Hi4 wt rete snd 4 Af 7 5 oe Ls : = ° 7 ey } ) ) ?: hae . ny bs 7 py i (Piva ‘|. f ; . a ‘ f 6 ¥ ted 1] 5 - - a ; a re ] = ‘" a v Flow + ' ot he oe on a2 A AL Fi i] 1 anay he Aart “ Ay ‘ ' . = ' i. ¥ ia ; a ‘tia 4 2 x 4 | 2 7 fi a - ~ ere i 6 > + : i | : ¥ >i 7 i Seer ba ; ’ r 5 P| ’ <: ‘ Vv | P 4 ue ? _# ol ee by va oF 7 i { , 4 i *y r ; i ae 7 it ‘ : ‘: ; ( . Ls iad © 6 A = j \ ¢ _ * or a od tah : a ‘ 7 _ a aah ah we ave ; Mis Tiel ts ht | ie ciel . La , , ; icy r p a PPE ole aia ee ee ea ioe bein eo gary os a Let es Ses ne ee ; 3 wuerc vase . # aw at Sada me ; wiles ei 9 rt. ry OWE fia i 44 a se : en See eee ee re . . LP imeeee ‘Vinee ay oy. 99 1G) in bahia ie ne iad pete | . : Pay, " : | : a td) Ange ma ae cake lw A Salesian eateat epg iach ies 2 thee gs: re oat 7 ii j ger, a ~ ‘Hinge Tears hy+ oe : ae ee iim I. It. UE APPENDIX I SELECTED FILMS Listings of Drug Films (With Evaluations) DRUG ABUSE FILMS Prepared by the National Coordinating Council on Drug Abuse Education and Information, Inc., under contract to the National Institute of Mental Health, 1211 Connecticut Avenue, N.W., Suite 212, Washington, D. C. 20036. A 46-page review of nearly 100 titles of drug education films and other audio- visual materials. Copies of the evaluation are available from the Council at $2.00. SELECTED DRUG ABUSE EDUCATION FILMS Prepared by the National Clearinghouse for Drug Abuse In- formation, 5454 Wisconsin Avenue, Chevy Chase, Maryland 20015. For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. 12-page booklet at 10 cents a copy. ANNOTATED LISTING OF DRUG ABUSE FILMS From the RESOURCE BOOK FOR DRUG ABUSE EDUCATION prepared by the U.S. Department of Health, Education, and Welfare, National Institute of Mental Health, Chevy Chase, Maryland 20015. October, 1969 issue; pages 95-98. PROJECT D.A.R.E. University of California at Los Angeles, Los Angeles, California. A list of films rated "good" or “excellent" by student viewers. Selected Films 1. Almost Everyone Does - Scenes from an "average" middle-class family illustrate what some people do to get rid of bad feel- ings. The film asks, "When does a drug that changes the way a person feels become harmful or dangerous?’ Contact: Gene Feldman, Wombat Productions, 87 Main St., Hastings-on-Hudson, Nov.» 107.06 De 6. Buz Darkness, Darkness - The film listens to a dozen people, all middle-class whites, whose lives in some way have been touched by heroin. Contact: Nolan, Wilton and Wootten, Inc., 374 Waverley St., Palo Alto, Calif. 94301 A Day in the Death of Donny B. - The film portrays what could be a typical day in the life of a heroin addict in a ghetto slum. Contact: National Audiovisual Center (GSA), Washington, D.C. 20409 The Distant Drummer - Paul Newman narrates this edited version of two shorter films, ''Flowers of Darkness" and ‘The Movable Scene.'' Beginning with a historical perspective of the origin of opium, the film discusses opium's refinement to a morphine base and to heroin. It traces the import route of heroin from the Far East to Mexico and the United States, along with the accompanying price rise. Several rehabilitation techniques are briefly discussed against a review of Federal rehabilita- tion laws. The film focuses on the use of drugs by young, rebellious, middle-class Americans. Spontaneous interviews with drug users depict the drug scene in San Francisco, New Orleans and New York, as well as in several foreign cities. Contact: National Audiovisual Center (GSA), Washington, D.C. 20409 Drug Abuse: Everybody's Hang-up - This film, which takes a documentary-like look at the "drug scene,’"' is designed to heighten awareness of, and concern with, the problem of drug abuse. It does not attempt to provide answers, but does offer some suggestions that may help keep children off the chemical road to nowhere and narrow the "generation gap."" Contact: Smith Kline & French Laboratories, 1500 Spring Garden St., Philadelphia, Pa. 19101 Drugs and the Nervous System - Particularly appropriate for junior high school students, this beautifully filmed pre- sentation discusses basic facts about misuse of airplane glue, stimulants, depressants, marijuana and LSD. The major portion of the film explains the serious disruption of the nervous system caused by using these substances for "kicks.'' The film emphasizes the dangers of drug abuse without sermonizing. Enhanced by a good musical score and animation. Contact: Churchill Films, 662 N. Robertson Blvd., Los Angeles, Calif. 90069 10% Lae Lee 13% LS Drugs Are Like That - The film says that some drugs can make you feel funny, can make you look stupid, are against the law, and don't always do what they look like they'll do. Contact: Junior League of Miami, Inc., 201 Douglas Village, 800 Douglas Rd., Coral Gables, Fla. 33134 Escape to Nowhere - The camera travels with Debbie, a 16-year-old addict, moving through her lonely world as she describes how she started on drugs and reveals the futility of her present existence. Contact: Professional Arts, Inc., P, O. Box 8484, Universal City, Calif. 91608 Grooving - The film focuses on a group of teenagers - drug users, ex-users and non-users - who explore and evaluate reasons behind drug use. Contact: Myron Solin, Benchmark Pits. eric. eto ocarborougherd, s=Briarcliffs N.Y) PLO510 Help - Live scenes filmed at a hot-line crisis center in Philadelphia portray the staff in action as they offer telephone counseling, give medical examinations or trace potential suicide calls. Contact: Concept Films, Suite SUZ ello PLD Ene@st., oN .W.. Washinstony’ D.C. *20005 Hide and Seek - Film depicts, with excellent photographic technique, the anguish and despair of a teen-ager caught by the narcotic habit and unable to shake it. The real- life addict narrates his helplessness and the realization that he has unwittingly committed himself to a joyless and hopeless existence. The events shown in the film are actual experiences. Contact: Center for Mass Communica- tion, Columbia University Press, 440 W. 110th St., New York, N. Y. 10025 Hooked - Young people, ages 18 20 25, in what appears to be a security institution, describe experiences with drugs. The descriptions are uninhibited, sometimes shocking, and make frequent use of addicts' jargon. The young people speak with candor about what impelled them to use drugs, how drug abuse affected relationships with others, and the disgust with which they now regard their drug experi- ences. Contact: Churchill Films, 662 N. Robertson Blvd., Los Angeles, Calif. 90069 I Think - The film illustrates how expectations of parents, teachers and peers help form attitudes, and how attitudes determine actions. Contact: Gene Feldman, Wombat Produc- tions, 87 Main St., Hastings-on-Hudson, N.Y. 10706 14. Lye EO AS MS lug) 20% 114 LSD-25 - This film which provides a current, accurate and balanced view of LSD use, emphasizes the unpredictability of the drug and its terrifying power. It succeeds in dis- couraging LSD experimentation without adopting a "preachy" tone. It is also superior from a visual and technical point of view, and should hold the interest of the most sophisticated audiences. Contact: Professional Arts, Inc., P.O. Box 8484, Universal City, Calif. 91608 Marijuana - This CBS documentary surveys the controversy over the social and legal aspects of marijuana use. Contact: Carousel Films, Inc., 1501 Broadway, New York 10036 Narcotics - Why Not - This film presents extemporaneous interviews with male and female residents of the California Rehabilitation Center. Both teen-agers and young adults relate how they started using glue, stimulants and depres- Sants, marijuana and heroin. They tell what it is like to be under the influence of dangerous drugs, discuss their regrets, and examine hopes for the future. The realistic film has impact that could not have been achieved by using actors. Contact: Aims Instructional Media Services, P20. Box, LOLO> Hollywood.) Calif .90028 A Nice Kid Like You - Students from two unidentified east- ern colleges reveal their feelings about drugs, sex, parents, the education system and American society in general, Contact: Extension Media Center, University of California, Berkeley, Calif. 94720 scag: - The film relates ,thevaddiction experiences, of 4 middle-class white male and an inner-city black girl, traces the import route of heroin into this country and focuses on several rehabilitation facilities and methods. Contact: Concept Films, Suite 312, 1155 15th St., N.W. Washington, D.C. 20005 Skezag - Wayne, a 21-year-old black living in New York City, talks at length about a variety of topics, including the Vietnam war, his use of heroin, why he won't become addicted, his attitude towards his mother, his friends and the white race. Contact: Cinnamon Productions, Inc., 508 Broadway, New York, N. Y. 10012 Speedscene: The Problem of Amphetamine Abuse - The film presents evidence against use of amphetamines in any form for other than medical reasons. Contact: James Ganzer, Bailey Film Associates, 2211 Michigan Ave., Santa Monica, Calif. 90404 Zt 115 Weed - The film covers the legal, historic and sociological aspects of marijuana use. Contact: Concept Films, Suite Si27 Liss Viothst.,, News, Washington, D.C. 20005 ye a ee oe - j ht : a - a at ee any Veer. : : aA : 7 , =e i hl arene i” ap oF a Le ¥ vey me ti View! oa cide 1 ah mee >A chee nae oe hol ehh he arn 11 | ) pal a ahaa sie De 7: Ge .. vr his ane ens te, : ae nese ; a 7 ay | ee te ae , ioe tom) ve a ; | i j i vale int ts y 7 a eee he repaia t)he ary, ra anes? Saya A c 98, eee = _ ea rea is Oey ds.) Liga by gly er « | emai ay Mean Ao a Ath sie Mabe Fb CE evens hes, oo ome a : prety . if by F . j alt mh wi , al rt as fen . Y Ta AD: r a's te _J ; 4 i) ; i | | $3 1 e | rt a 5 iif eS ate e ans) “ES ig, ai { oe ae } Hiab . viwes i on oe Ate i ae enh tee ne hea aek SAP te ails bide: iiptien | Sie, Coie “Rte an We, ; Una i ) ' oa | mk ol. | me ry - Pe AT ee : fe MMe. hina, Cree es Piot: taakl Lola ee f 2 a % fy A a on We i a) ater my me : wi = ONre , " : . rors EV ae oy A Pt r =¢ . | P : - Fre ‘ i . 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a. " : ‘wre ) of a “ \ , ; d. : : oe ‘a Fr R — a : 7. ; tt * _ 7 : ar .) od 7 : ray pv . i , cna Nie Pan ) - i : p aa 7 he Sa) ji aor ike ent Me SO eEeS q : 7 ; i i é ead ee ‘ ry a yy yy a 7 +i) © a) ws;<, hb 7 - : Pe | lide > Men TOs! ee, Ra a eae ‘mit fbas . ‘ | : ; | ; 7 we nea? on ot pk sip hdd de a he ohaN! bes: Se , ‘} aes in A’ ee {iu a thee ua: Seu ae , foie f *) Nay! oy a . F i ee ye eat A ms fet, } ee? ae nes he ws ; by Lp Aen OM o A ad Je Lie fag om a. pe ng TY road ie ay : ef ‘> i i a rae aati hi Se A WME a yl ow, oleae at | | j iT th en i ay, 7 ve AM f vies a) io ver mr | Ae i A bul? a wv +4 uy : on a . ‘ y ae é Phe J P ge Le 7 Sucian ~ Ay 7 teal : Bu. Ail a _ ca 7 is ot > at a — POS du? sonimian Gs ti af | APPENDIX J BIBLIOGRAPHY In many of the references cited below there are extensive bibliographies, some of which are annotated. The intent of this bibliography is to suggest some basic sources to be used as a supplement to this document, The Rehabilitation of the Drug Abuser. A Bibliography on Drug Dependence, compiled by Helen F. Sells, Fort Worth, Texas: The Texas Christian University Press, 1967. A Community Guide to Drug Abuse Action, Washington, D. C.: National Coordinating Council on Drug Abuse Education and Information, inec.., 1970. Questions About Drug Abuse, Washington, D.C.: G.P.0., 1971. Directory of Narcotic Addiction Treatment Agencies in the United States 1968-69, (Public Health Service Publication # 2095,) Washington, D. C.: Superintendent of Documents, 19/0. Resource Book for Drug Abuse Education, Washington, D.C.: National Clearinghouse for Mental Health Information, 1964. A Guide to Some Drugs Which are Subject to Abuse, New York: American Social Health Association, 1969. Anslinger, H.J., and Tompkins, W.F., The Traffic in Narcotics, New York: Funk and Wagnalls, 1953. Barber, B., Drugs and Society, New York: Russell Sage Foundation, 1967. Blum, R.H. and associates, Utopiates: The Use and Users of LSD-25, New York: Atherton Press, 1964. Caplan, G., Principles of Psychiatry, New York: Basic Books, Inc., 1964. Cliteie tN eI tru l63: 118 | Chein, I., et al., The Road to H, New York: Basic Books, Inc., 1964. Cody, J.J., “Appraisal of Disadvantaged Youth,'’ Counseling the Dis- advantaged Youth, (W.E. Amos, ed.), New Jersey: Prentice Hall, 196% Committee on Alcoholism and Addiction and Council on Mental Health, ‘Dependence on Amphetamines and Other Stimulant Drugs,” Journal of the American Medical Association, 1973 1023-1027, 1966. eames GED 0 OMESSEE Ce Association, 193: 673-677, 1965. Diskind, M.H., "The Role of the Parole Officer on the Use of the Authoritative Case Work Approach,” Rehabilitating the Narcotic Addict ..Washingtongm@D.1G. eG. k.0 sone LoOWE Drug Abuse: A Manual for Law Enforcement Officers, Philadelphia: qa SSE EEE GT Se Smith, Kline, and French Laboratories, 1966. Drug Abuse: A Primer for Parents, Washington, D.C. 3. National Education Association. Drug Abuse: Escape to Nowhere, Philadelphia: Smith, Kline and French Laboratories, 1970. Drug Abuse: The Empty Life, Philadelphia: Smith, Kline and French Laboratories, 1965. Drug Addiction: Crime or Disease? Interim and Final Reports of the American Bar Association and the American Medical Associa- tion on Narcotic Drugs, Bloomington: Indiana University Press, T9635, Drug Abuse Education: A Guide for the Professions, Washington,D.C.: ESE Se —> Gia ee 6S American Pharmaceutical Association. Drug Dependence: A Guide for Physicians, Chicago: American Medical Association Order Department. Eddy, N.B., et al., "Drug Dependence: Its Significance and Charac- teristics,” Bulletin of the World Health Organization, swat (PUNT Bye UeNos ye Eldridge, W.B., Narcotics and the Law, New York: New York University Press, 1962. 3 Food and Drug Administration, The Use and Misuse of Drugs, Publica- ESE ES | CLGner 6, Washington, D.G.: Gl PP.) Of 1968% Goode, E., (ed.) Marijuana, New York: Atherton Press, 1970. Kaplan, R., Drug Abuse: Perspectives on Drugs, Dubuque, Iowa: Woz GC. Brown Co. 3719707 Kolb, L., Drug Addiction, Springfield, I1l., Charles C. Thomas, Publisher, 1962. Lasagna, L., M.D., “Drugs Through the Ages,'' in The Medicated Society, edited by S. Proger, M.D., New York: The Macmillan Gor. 1968. Laskowitz, D., "Psychological Characteristics of the Adolescent Addict," Drug Addiction in Youth, edited by E. Harms, New York: Pergamon Press, 1965. Leshner, S.S., ‘The Relationship of Work Evaluation to Work Adjustment Training," Journal of Rehabilitation, 1970. Indiana University Press, 1965. LSD,Some Questions and Answers, (Publication #1828), Washington, D.C.: Superintendent of Documents. Marijuana, Some Questions and Answers (Publication #1829) Washington, D.C.: Superintendent of Documents. Mental Health Monograph 2: Narcotic Drug Addiction, Public Health Service Publication #1021, 1965. Mental Health Monograph 3: Rehabilitation in Drug Addicts. A Report on a Five-Year Community Experiment of the New York Demonstration Center, Public Health Service Publication #1013, 1964. Narcotics: Some Questions and Answers, Publication #1827, Washington, D.C.: Superintendent of Documents. National Institute of Mental Health, Facts About Narcotic Drug Addiction, Public Health Service Publication #1322, Washington, D.C.: Superintendent of Documents, Nowlis, H.H., Drugs on the College Campus, New York: Anchor Books, 1969. 120 The President: Advisory Commission on Narcotic and Drug Abuse: Final Report, Washington, D.C.: Superintendent of Documents, 1963. Richman, S., "The Addict as a Rehabilitation Client,” Rehabilitation Record, 1966. Sinick, D., "Training, Job Placement, Follow-Up," The Vocational Rehabilitation of the Disabled, (D. Malikin and H. Rusalem, ed.), New York: University Press, 1969. Task Force on Narcotics and Drug Abuse, the President's Commission on Law Enforcement and Administration of Justice, Task Force Report: Narcotics and Drug Abuse, Washington, D.C.: Superintendent of Documents, 1967. Trellissuk 6S... M.D.,9SAPiloty Project @inithe, Pitts burgheAreals Rehabilitating the Narcotic Addict, Washington, D.C.: Superintendent of Documents, 1967. Weinswig, M.H., and Doerr, D.W., ed., Drug Abuse: A Course for Educators, Indianapolis: Butler University, 1968. Wiener, F., "Planning Aftercare Community Services,” Rehabilitating the Narcotic Addict, Washington, D.C.: Superintendent of Documents, 1967. Yablonsky, L., The Tunnel Back: Synanon, New York: Macmillan Co. ,19Gs 121 APPENDIX K DRUG ABUSE PRODUCTS REFERENCE CHART* POTENTIAL FOR PHARMACOLOGIC PHYS ICAL DRUGS CLASSIFICATION MEDICAL USE DEPENDENCE Morphine (an opium Central Nervous To relieve pain Yes derivative) System Depressant Heroin (a morphine Depressant To relieve pain Yes derivative) Codeine (an opium Depressant To relieve pain Yes derivative) and coughing Paregoric Depressant For sedation and to’ Yes (preparation counteract diarrhea containing opium) Meperidine Depressant To relieve pain Yes (synthetic morphine- like drug) Methadone Depressant To relieve pain Yes (synthetic morphine- like drug) Cocaine Central Nervous Local anesthetic No System Stimulant Marijuana Hallucinogen None No Barbiturates Depressant For sedation, sleep Yes (e.g.,amobarbital, producing,epilepsy, pentobarbital, high blood pressure secobarbital) Amphetamine drugs Stimulant For mild depression, No (e.g.,amphetamine, anti-appetite dextroamphetamine, — narcolepsy methamphetamine-- also known as de- soxyephedrine) 3D Hallucinogen (Medical research No (also mescaline only) peyote, psilocybin, DML, STB SHC) he Glue Depressant None Unknown (also paint thinner, lighter fluid) *Permission to reproduce this chart was granted by Smith, Kline and French Laboratories. The original chart appears in Drug Abuse: Escape to Nowhere. 122 DRUG ABUSE PRODUCTS REFERENCE CHART CONTINUED POTENTIAL FOR PSYCHOLOGICAL POSSIBLE EFFECTS HOW TAKEN DRUGS DEPENDENCE TOLERANCE WHEN ABUSED WHEN ABUSED Morphine Yes Yes Drowsiness, or Orally or by stupor, pinpoint injection pupils Heroin Yes Yes Same as morphine Sniffed or by injection Codeine Yes Yes Drowsiness, Orally pinpoint pupils (usually as cough syrup) Paregoric Yes Yes Same as morphine Orally or by injection Meperidine Yes Yes Similar to morph- Orally or by ine, except that injection at higher doses, excitation, tremors and con- vulsions occur Methadone Yes Yes Same as morphine Orally or by injection Cocaine Yes No Extreme excita- Sniffed or CLOn ee Cremors, by injection hallucinations Marijuana Yes No Drowsiness or Smoked or excitability orally dilated pupils, talkativeness, laughter, hallucinations Barbiturates Yes Yes Drowsiness, Orally or by staggering, injection slurred speech Amphetamine Yes Yes Excitation: Orally or by dilated pupils, injection tremors, talk- ativeness hallucinations LSD Yes Yes Bxeleation, Orally or by hallucinations, injection rambling speech Glue Yes Yes Staggering, Inhaled drowsiness, slurred speech C B/T stupor *PB-7200-33 5-13 i if oh io n SRY tee Nae + et nf i AR, i va | fy a tv 1 iy MNS cH) Ut ie Ms Bert nr ") i ? : 1 uy é‘ , d % ; } (o ms - iN hone 3 % hea ie Vi Ry LT PAS ee ke } amy nal iy ; ines ie hoon ‘ee ey lle fs ae } Mt | ine A Kae ; “uh Ay ela Wan iit. ; * ay eps: . ye aii a ers rF ve i 4a * ny y, 4 : i ; See | th | utara ara SR i it . he aa ity . | vy Fisch gd, Wao ree ON a Roky od axl UNIVERSITY OF ILLINOIS-URBANA 362 .293IN83R C001 REHABILITATION OF THE DRUG ABUSER$WASH D 0