coordination between programs results in much inefficiency, needless duplication
of efforts and facilities, and poor program auditing. We have programs for
addicts financed separately by the City, State, and Federal governments with
no real opportunity for the management coordination required. In methadone
treatment, the City has programs, private hospitals have programs, public hos-
pitals have programs, and many newly generated non-profit corporations have
programs. Drug-free therapy in New York is funded privately as well as by a
variety of government agencies. New York City has taken a step in the right
direction by consolidating its addict treatment programs, but the City controls
funding for only part of the narcotics rehabilitation in the City itself. Currently,
judged by any standard of cost-effectiveness, decreased addiction, or decreased
crime rate, the program — or lack of sCn organized program — has many short-
•comings.
— We must recognize that attacking drug addiction requires a coordinated
multifaceted approach, with creative, effective management.
— We must recognize that it is essential that medical care for addicts involve
government as well as private efforts.
— We must recognize that existing programs and institutions are neither logis-
tically nor administratively capable of handling the huge increase which
would result if every addict were put under care.
— We must recognize the need to decrease bureaucracy and wastefulness that
normally are found when public funds are invested in attempting to solve
social problems.
3406
If we recognize all of these things, it is essential in setting a national goal to
establish a management structure at the national and local levels that can oper-
ate creatively and relatively free from political vicissitudes.
My second recomincudatiori to achieve a national goal of putting Every Addict
Under Medical Care Witliin Five Years, is that we make use at national, State
and local levels of a public-henefit corporation strticture to provide the adminis-
trative and organizational guidelines and the creative minds to fulfill this na-
tional objective.
I believe the Federal government is making a serious error in attempting to
channel federal support and funds through existing federal agencies (Labor,
H.E.W., etc.) Narcotics addiction solutions need strong and creative federal lead-
ership as free as possible from the existing multi-agency bureaucracy. One federal
agency or public corporation should control and allocate all our resources applied
to the addiction epidemic.
I have great respect for Dr. JafEe, but I do not believe he can succeed with the
Special Action Ofiice on Drug Abuse Prevention (SAODAP) without the neces-
sary total management control and authority over the implementation of the
program. In effect, Dr. Jaffe and SAODAP are serving a staff function whereby
they should be serving a strong administrative or line function.
In New York City a separate public corporation would be established to exe-
cute the responsibility. It would coordinate and administer all government ef-
forts, provide programmatic and financial audit, and set local policy within
national guidelines. Such a public corporation could, with proper planning and
use of computers, keep track of each addict. Without losing local initiative, it
could provide coordination of program successes as well as learn from program
failures. It could help support law enforcement activities coordinating the
efforts of law enforcement officials with other addiction programs for a unified
productive approach. And, it could help decrease the effects of political consid-
erations on program continuity and leadership. American business has demon-
strated unparalleled problem solving and administrative expertise in the private
sector. We must now employ this management expertise in the public sector.
Initial progrummatic approach
I believe the goal of Every Addict Under Care Within Five Years Is to have
every addict become drug free and also to help every addict develop a sense of
human dignity and satisfaction from his accomplishments. We have learned a
considerable amount from recent work in drug programs, which should be em-
ployed in reaching our goal :
A. We have learned that no single treatment is successful for every addict.
Some addicts do better with some programs than do others. We must attempt
to determine how each addict should be medically treated in order that resources
are effectively allocated. Thus, addiction treatment must be individually tail-
ored so that every addict may be brought under some form of medical care with
the greatest potential for the success for the particular individual.
B. We have learned that the addict requires tivo separate and distinct treat-
ments — one which deals with his physical cravings for drugs and the other which
deals with his psychological needs, including sociological and vocational consid-
erations. These are different, although related, problems and each addict has
particular needs in approaching their solutions. Both are essential parts of our
national goals. Programs that deal only with physical addiction through the
administration of various drugs (chemotherapy), but not the rehabilitative care
of the addict, are limited at best in their successes and are not in the long-range
national interest, treating as they do only one aspect of the social disease.
C. We have learned that an essential step in the rehabilitation of the addict
is the creation of an individual sense of dignity in society. For these reasons,
part of the cure of addiction must involve the training, motivation, and oppor-
tunity — ^including counselling and placement — for every addict to have a decent
job. Obviously then, solving the problem of addiction is closely related to the
Nation's commitment to full employment. But in addition to increased employ-
ment opportunities, we must deal with the problem of job discrimination against
the addict who is under medical care.
My third recommendation, because there is no national program for employ-
ment of addicts, is that we establish an association of the nation's businessmen,
and public leaders to educate potential employers as to how to best employ
3407
ex-addicts and to solicit commitments for such employment. Hesponsihle employ-
ment plays such an important part in rehabilitating so many addicts, that this
aspect of the program is absolutely essential if we are truly to be successful
with the great majority of the addict population.
Recently we have concluded the lirst phase of an experiment at 0TB in New-
York, providing work for addicts under medical care in an 0TB office supported
b.v ct)unseling provided by the Vera Institute of Justice with funds provided by
the Law Enforcement Assistance Administration of the United States Depart-
ment of Justice. This experiment has been very successful. Of the original 23
addicts, about half of whom were on welfare but no longer are, two have been
promoted to supervisory positions. All who have taken the company-wide super-
visory test passed, several well above average. Some will be transferred at their
request to other branches. Four of the addicts have married (one family is ex-
pecting a child), three have attained high school equivalency diplomas, and
one is now attending a local universit.v. Because of this success, in the next
month OTB plans to open a second office employing addicts who are veterans
of the Vietnam war, bringing to 2 percent the percentage of OTB employees who
are ex-addicts. This successful experiment indicates to us the potentiality of
bringing the addict totally back to society through a properly coordinated
program.
The former addicts in this program had the three elements required for success
in addiction treatment. First, their physical sickness had been treated where
necessary — in this case, with methadone. Second, they were provided with
-psychological support. Third, they had the opportunity for a decent job.
Unfortunately, most employers are totally ignorant or misinformed as to the
potential employability of methadone maintenance or drug free ex-heroin addicts.
Dr. Vincent Dole, one of the discoverers of methadone treatment, indicated that
of more than 4,000 methadone maintenance patients surveyed, 92% of these
Avho had been treated for three years and 74% of those who had been treated
for two years are currently employed. Yet most of these patients are forced to
hide the fact of their methadone treatment from their employers.
This situation must be remedied. Concerned employers, well informed on the
true nature of addiction treatment, have the expertise to put together an educa-
tional and job development program and the ability and creditability to put such
a program across.
Today, our programmatic approach to addiction deals totally either with the
physical challenge of addiction — some form of chemotherapy — or purely with the
sociological-psychological challenge of addiction — drug free therapy or . other
•counselling programs. Almost no programs are available dealing specifically with
the vocational needs of the addict and those that do are for the most part either
insufficiently large or insufficiently successful at job development. What is
worse, proponents of different programs frequently find themselves at odds with
each other over the best form of treatment, when in fact, they all have a com-
mon goal : a solution to the addict's illness.
An examination of the two main approaches currently used in treating ad-
diction help to indicate what the immediate short-range national goal should be
in expanding our program on addiction and reaching our goal of Every Addict
VtuJer Medical Care Within Five Years.
Drug Free Therapy. — This is the most desirable treatment. These programs,
tising group therapy, have had many successes and have made great strides in
learning how to deal with the psychological challenge of addiction and the
gradual rehabilitation of the addict t:p re-enter society. However, drug free
therapy is usually only successful today with addicts highly motivated to be in
such a program. The dropout rates in these programs are high. Possibly less
than 20 or 30% of the addicts in this country would be initially successful in drug
free therapy. Yet it is the best cure for the highly motivated addict. Tliere is no
question that these programs should be expanded and outreach procedures de-
veloped so that the existence and availability of those programs can be made
known to tliose who want to try this route to cure. They may be coordinated
with treatment programs like methadone which deal with the physical and some
of the counselling, needs of the addict in order that a drug free therapy poten-
tial may be reached. It should be remembered that a goal of Every Addict Under
3408
Methadone Maintenance. — The fastest growing treatment for addiction is
methadone maintenance. Methadone, as we know, is chemically close to heroin
and deals principally with the physical sickness of the addict, making it possi-
ble for him to begin to confront his social, psychological, and vocational prob-
lems. Many addicts enter methadone treatment already motivated by the per-
sonal disaster of their heroin "treatment" on the streets. The nature of their
particular psychological needs and the strength of their motivation often makes
it possible for them to enter society on a positive basis after or during methadone
treatment. For many addicts dealing with their physical addiction along with a
certain amount of psychological counselling may be successful. Unfortimately,
most methadone programs lack what many addicts need most, sufficient voca-
tional training and job development and placement, and sufficient rehabilitation
support for those who are placed in jobs. Almost no existing methadone pro-
grams or drug free therapy programs are able to adequately cope with the job
needs of the addict.
One drug free program which has been relatively successful. Phoenix House in
New York City, indicates that for addicts who stay with the program for more
than one year, arrest rates for the year prior to entering Phoenix House and
the year after leaving Phoenix House show a 70% positive change. But an inte-
gral part of the Phoenix House program is addict employment. Without a job
the addict is, in most cases, merely being sent back to the same hapless and
hopeless environment.
Yet despite this rehabilitative shortcoming in the vocational area, we have
waiting lists in New York of 10,000 to 15,000 addicts who want to volunteer for
methadone maintenance programs. These programs should be expanded rapidly
and their rehabilitation services strengthened under strict management control
conditions in order to meet this unconscionable shortcoming. We have facilities
for 20,000 and probably need facilities for 50,000, but the expansion must be con-
trolled to avoid needless waste of public monies. Additionally, major work must
be done to wean addicts from addictive methadone so that they may enter drug
free therapy. This is all part of the concept of Every Addict Under Care Within
Five Years.
The initial short-range program of expanding methadone and drug free therapy
underlines a major dilemma regarding existing forms of treatment. That
dilemma is twofold : how do we treat the addict who fails in either of these
programs (failures in methadone run about 20 to 30%) ? and how do we attract
those who are psychologically incapable of making a commitment to give up
their addiction voluntarily? They simply do not want to enter either treatment
program. While it is difficcult to estimate the percentage of addicts in the latter
group, it could be as high as 50 to 70 percent of all addicts.
To help solve the first part of the dilemma, treatment failures, the Vera Insti-
tute and I offered an experimental proposal to use heroin in the treatment of
230 addicts who have failed on methadone. This program is not a commitment
to heroin maintenance. It makes clear that heroin treatment would be available
only for a short period of time, to a limited category of addicts : those over 21
years old, with a 3 year history of addiction, who have failed a methadone main-
tenance program. The addicts physical needs would be treated ; at the same time
he could be provided with a full program of psychological counselling and social
and vocational services to motivate him to return to methadone or to enter
drug free therapy. We realize that the idea of treating addicts, even initially,
with heroin, elecits emotional responses in this country. But I believe this ex-
periment is essential so that once methadone therapy is provided on a national
basis, we may also have an answer for addicts who fail in this program.
This limited exi^erimental program would not attempt to duplicate the British
clinic system. Rather, it would develop an approach appropriate to a particular
group of American addicts and would be grounded in the American experience
with narcotics. Social services, supported work and manpower training would
be key elements of the program ; in addition, in contrast to the British system,
all heroin or methadone used in the program would be administered within the
clinic under close supervision to prevent its sale or diversion. The program
would also have a detailed criminological, social and medical evaluation.
The second part of the dilemma, those addicts who do not want to enter any
program will be more difficult to serve. The Vera Project may give us some
insights into possible solutions. Improving vocational opportunity and expanding-
3409
present facilities will help. These two factors along with better administration
of existing programs will hopefully lead to increased treatment successes. More
addicts will be encouraged to enter a truly promising program than one which
offers a chance of cure but depends more heavily on addict motivation to over-
come program shortcomings. We must not lose sight of the fact that the addicts
psychological motivation to be in the program is a part of the cure. For the
remainder of the addict population who continue to refuse treatment, another
alternative, which I shall discuss later, may be the answer. For the present,
our initial goals are to expand and improve existing treatment methods and to
develop the national management organization needed for the five year goal.
In the meantime, research other than heroin treatment must be intensified.
The federal organization must coordinate this research to find practical heroin
antagonists and other chemotherapy treatments. The results of this research
could then be systematically applied on a national basis through the suggested
Federal, State and local corporations. But a miracle drug may never be found..
In the meantime, we must prepare alternatives to treat addiction.
Public policy after five years
The establishment of the necessary corporate administrative apparatus in the
form of public benefit corporations, national and local, and expansion of exist-
ing programs and research are immediate steps which will help to limit the
spread of the heroin epidemic during the implementation of a long-term pro-
gram. Such a long-term program would, of course, incorporate the incremental
improvements suggested, and would be aimed not at stopgap measures, but at
dramatically reducing the heroin problem.
To accomplish such a task, a program of a scope never before attempted may
be required. Such a program should, however, only be undertaken after existing
programs have been altered and expanded in the ways I have suggested. If the
suggested changes are to be successful, as I believe they will be, we shall be
left principally with the problem of reaching the remaining "unreachable"
addicts.
1. Every addict in the country mu.H be required to register. — Although all
addicts are not criminals they are carriers of a contagious social disease. So-
ciety has a right to know the whereabouts of such carriers for its own pro-
tection. The application of a coordinated and computerized approach combined
with the fact that the criminal stigma of addiction will no longer be held
over the addict should make such a goal a realistic one. Obviously, registra-
tion is meaningful only when sufficient facilities for medical treatment of ad-
dicts are available. The required registration of all addicts raises some civil
liberties questions which must be explored. However, I believe that a new bal-
ance must be struck between the rights of individuals and the rights of society
on this question. Just as treatment is required for carriers of contagious diseases,
so must we require treatment for addicts.
2. Every registered addict must then he brought under medical care. — The
addicts's medical care will insure society's right to be protected from further
spread of the epidemic. Any addict refusing treatment would be put in a
hospital as protection to himself and society and released at such a time as he
responds to treatment.
3. The proposed local public benefit corporations must dramatically expand
the number of local treatment centers where all varieties of existing treatment
could be administered on both an in-patient and out-patient basis according to
individual requirements and professional recommendations. — As new research and
experimentation proves successful, it should be incorporated in the kinds of
treatment offered.
4. The centers would provide both physical and psychological addiction treat-
ment as well as counselling and job placement. — It would be the task of the
corporation to coordinate job development and related community relations
programs as well as educational addict prevention programs. The suggested as-
sociation of employers to aid in the tasks of education of the business community
and .iob development and placement could take place under the administrative
umbrella of the national corporation, with local as well as national applications.
Supported work programs, where desirable, could be easily implemented by such
a corporation.
5. Every addict under care must be weaned from his physical addiction on an
out-patient basis wherever possible by a reasonable deadline, probably one year
3410
111 the case of heroin and two or three years in the case of methadone. — These
deadlines may change according to the successes of the program, but no addict
Avill be kept permanently under treatment with an addictive drug. The addict
has a responsibility to society and himself to cure his addiction. During treat-
ment the addict would be assisted with psychological and vocational counselling
but after the deadline he would be expected to be drug free. Counselling would
then continue for as long as was necessary for the addict to be cured completely.
Experience has shown a wide variance in the period required by individual ad-
dicts. Those unable to reach the deadline would remain in the custody of the
treatment center as in-patients until their physical addiction was cured.
Costs of such a program could be as much as $4,000 to $5,000 per addict an-
nually, perhaps 3-billion dollars nationwide. But even these costs are far less
than existing penal and societal costs of what is currently an unsuccessful ap-
proach to addiction, not to mention the human costs to addicts. In addition,
contributions to the gross national product of cured, employed, taxpaying ex-
addicts would more than offset the cost of the program. Also it should be remem-
bered that the coordination and expansion of existing programs, along with
extensive efforts in the vocational areas of addict treatment are anticipated
to produce greater success rates. Not only will this decrease costs in the area of
public assistance to unemployed addicts, and in the law enforcement and judicial
areas, but fewer addicts may then require expensive in-patient care. Obviously,
the federal government would be the only governmental organization with the
requisite resources and coordinative overview necessary to implement such a
program.
Tills proposal, while neither cheap nor easy, is cost-effective and humane. It
employs few new devices which have not been proven. What it does is to coordi-
nate and apply the proven devices in a way that has never been done or suggested
before.
As a resiilt of four years of study and my own close personal involvement
with heroin in my family, I am convinced that a program of this sort must be
undertaken if the spread of heroin is to be checked and the existing addict
population is to be detoxified.
Yale Law School,
New Haven, Conn., October 30, 1972.
G. Robert Blaket, Esq.
Chief Counsel, Committee on the Judiciary, Suicommittee on Criminal Laws and
Procedures, U.S. Senate, Washington, D.C.
Dear Mr. Blakey : At the hearings on May 24, 1972, on revision of the federal
criminal laws. T was asked to comment on the suggestion of Mr. Jack Greenberg
that a failure-to-act provision be added to the proposed Code in the civil rights
area. I have had an opportunity to read and reflect on Mr. Greenberg's proposal,
and am accordingly now in a position to respond.
There are three separate issues raised by the proposal — the power of the Con-
gress to act upon it ; the dimensions of the problem addressed ; and the propriety
of attempting to deal with that problem through federal criminal law enforce-
ment. I shall state my views on each of these matters, and also, in connection
with the third one, say something about how the proposal would fit with other
parts of the proposed Code.
First, I have no doubt as to the power of Congress to enact the proposed
section. The rights protected by Sections 1511 and 1512 of the revised codes are
right.s properly protected by federal statutes, because they are derived either
directly from the Constitution itself (especially the Foui'teenth Amendment) or
from federal legislation en?cted by Confess, such as the Civil Rights Act of 1964,
under various powers granted to it by the Constitution.
There is no question as to the general power of Congress to forbid, by the
enactment of federal criminal laws, interference with the exercise of such rights.
If Congress has the power, as it clearly does, to prohibit such interference by
law enforcement officials (either state or federal), as well as by private citizens,
I see no reason why it cannot constitutionally define interference to include know-
ing failure to act. See, for example. United States v. U.S. Elans, 194 F. Supp.