The tail that wagged the treatment dog: a personal view of training and the Haight Ashbury Free Clinics.
Keywords--conferences, prescribing practices, training and education
In my 33-year tenure with the Haight Ashbury Free Clinics (HAFC), I held a variety of jobs and titles. These included: Office Manager; Chief Executive Officer; Director of the HAFC Training and Education Projects and Information & Education Director for the Office of the President. My very first job with the Clinics was half-time janitor and assistant secretary. I was hired in February 1973, became Managing Editor of the Journal of Psychoactive Drugs in 1995 and retired from the Clinics to continue as Editor-in-Chief in 2006.
I had earned a masters' degree in English and Comparative Literature with an Emphasis on Creative Writing at Sonoma State University three years earlier in 1970 and immediately bought four one-way tickets to England where I intended to become an expatriate counterculture feature writer for the London Times and live with my wife and two young children in a picturesque village within bicycling range of the local greengrocer. For a variety of reasons, none of this worked out. We left California in the wake of the Kent State killings, heading for an idealized Beatles' "Yellow Submarine" vision of an England that didn't really exist and ended up flying back into New York less than a week later. After crashing with a Greenwich Village kif dealer and then hitching north and informally teaching I Ching interpretation at a dissident student-occupied Goddard College in Vermont, we returned to Northern California. I soon discovered that recent literature graduates needed to learn the phrase, "Would you like fries with that?" As it turned out, however, even the Golden Arches were chockablock with other degreed intellectuals willing to work long hours for little.
After a winter of discontent, unsuccessfully job hunting and trying to sell my experimental thesis novel, Summer Come Loudly, I teamed up with the ex-academic dean of Milton College in Wisconsin, Doctor Bonard Wilson, who had moved to California in hopes of founding an experimental, student-centered college based on the teachings of Carl Rogers. Compost College was indeed experimental. We like to say that everyone graduated, including the faculty and administration, in a little over a year. I wrote a book on the experience (Seymour 1997) and moved into an apartment in San Francisco with my girlfriend and future wife, Sharon, and her roommate, Virginia, in the fall of 1972.
Half-time janitor and assistant secretary did not sound very promising. The Haight Ashbury neighborhood, in the process of devolving from a psychedelic haven into a crime-ridden teenage slum, many of its businesses boarded up and its streets littered with garbage and dog feces, did not bode well either. However, such menial employment meant some money that I sorely needed by then to finance my ongoing search for a "real" job.
Within a few weeks, the other half-timer quit for personal reasons and I was promoted to full-time janitor and secretary. After the daily emptying of wastebaskets, my duties were similar to those I had performed as a clerk typist in the U.S. Air Force in the late 1950s. Soon, I was taking minutes at the Clinics' various board meetings and learning to use phrases like "discussion ensued followed by a vote."
My desk was directly across from the entrance to 1698 Haight Street, the Clinics' executive offices, so I was the first person encountered by anyone from the outside world. Annie, the head secretary, made sure that I kept a short length of iron pipe, its nether end filled with lead, by my chair--just in case. Fortunately I never needed it.
While Annie was the primary secretary, my real boss was Richard Frank, a smart and able administrator who bore the title Central Administrator. His was in many ways a thankless job and several months alter I arrived he left to return to graduate school. A troika composed of the Clinics' founder Dr. David Smith, Dr. George (Skip) Gay, Director of the Drug Detoxification, Rehabilitation and Aftercare Project, and Anne Gay, Skip's exwife and Head of Accounting, undertook interim management of the Clinics and I was promoted to office manager.
The Clinics' Board of Directors decided that a strong but diplomatic force was needed at the top and met in a special session at the Copper Penny Restaurant on Masonic Street in San Francisco. I was there to take minutes of the meeting. As the directors solidified their thoughts on what was needed, a startling and in ways frightening thought came to me: "'I can do it! I can be the leader they are looking for!"
When the Board took a break, I followed David Smith into the men's washroom and told him that I wanted the job. David nodded and when the meeting resumed he recommended that I be put in charge of the search for a new Clinics chief executive.
In December the Haight Ashbury Free Clinics Board of Directors was ready to meet the candidates and choose a new chief executive. I had posted ads in appropriate publications and gathered resumes and applications that a board committee had winnowed down to six people, including myself, that they considered potentially eligible for the job. I had also written up a plan of action, based on my experience serving as business manager, outlining what I would do if I were chosen and distributed it to individual board members. I had also had my hair and beard trimmed.
When my turn came, I was called into the Board meeting room down the street from 1698 at the Crackerjack vocational rehabilitation center. Dianne Feinstein, board member and future Mayor of San Francisco and Senator for California, had read a draft copy of my book Compost College (Seymour 1997) and was presiding over the selections process. She pointed out that the Clinics needed a leader who was willing to take risks and asked me if I was willing to do so.
"You've read my book, Dianne," I answered. "If I take risks and fail, I can always go back to my plastic wickiup in Mendocino."
She laughed and thanked me. I was later told that when I had left the room, she turned to the rest of the board and said, "There is our new Chief Executive Officer."
CHIEF EXECUTIVE OFFICER WITH PLUNGER
I find it highly symbolic that my first act as Clinics CEO was to take a plunger down the street and unplug the Drug Detoxification, Rehabilitation and Aftercare Project's toilet at 529 Clayton Street. The next five years of my administration were a continuing roller coaster ride as the Clinics experienced more trials and triumphs than I care or have room to describe in this present article. It was also a time when the Haight Ashbury Free Clinics continued their emergence as a major national and even international force in community medicine and substance abuse treatment, research and education.
Dr. David Smith, the Clinics' founder and President, was already approaching legendary status. He and Dr. Donald Wesson had developed the outpatient phenobarbital withdrawal technique in 1968 (Wesson 2011; Wesson & Smith 1977). Both spent much of their time traveling throughout the country and educating legislators and health professionals on new developments in the treatment of substance abuse and addiction.
The Haight Ashbury Free Clinics were at a pivotal point in its history in 1973. The Clinics had opened six years earlier at least in part as a response to the surge of young people from all parts of the country into San Francisco's Haight Ashbury neighborhood. In his article in a previous issue, Dr. Donald Wesson (2011) describes the Human Be-In celebration held in Golden Gate Park on January 14th of 1967 and its aftermath. David Smith and a few colleagues foresaw the potential medical consequences of the Summer of Love and with little or no help forthcoming from the city health authorities devised the concept of a free clinic in the Haight. Over the next six years, the Clinics evolved from a completely volunteer medical facility into a dynamic hybrid as their expanding staff responded to a succession of drug-related crises. Detailed descriptions of the Clinics' development and growth can be found in Love Needs Care: A History of San Francisco's Haight-Ashbury Free Medical Clinic and its Pioneer Role in Treating Drug-Abuse Problems (Smith & Luce 1971), The Haight Ashbury Free Medical Clinics: Still Free After All These Years 1967-1987 (Seymour & Smith 1986) and Dr. Dave: A Profile of David E. Smith, M.D., Founder of the Haight Ashbury Free Clinics (Sturges 1993).
By the early seventies the war in Vietnam was winding down and thousands of troops were coming home, many of them addicted to the heroin and other drugs they had encountered in the Far East. At the same time, legislators were waking up to the fact that increasing numbers of young substance abusers were now their own sons and daughters and those of their friends and neighbors. Veterans and members of the growing counter culture were in desperate need of help. What had started in the Haight Ashbury spread across the country in recognition of the free clinic tenet that "health care is a right, not a privilege" and in time over 600 free clinics were born in the United States and overseas and seen as the best hope for help for these populations (Smith, Bentel & Schwartz 1971). The federal government began reacting to the need and funding was appropriated for supporting a National Free Clinic Council and training free clinic personnel in outpatient treatment of opiate, stimulant and sedative drug abusers.
Further, in the course of their work with treating addiction to short-acting barbiturates and other sedative hypnotics, Smith, Wesson and their colleagues had uncovered a mother lode of middle class prescription drug addicts who needed treatment every bit as much as their psychedelic, poorer and upper-downer counterparts (Smith & Wesson 1973). Drug abuse was no longer being seen as limited to criminal elements. Smith and Wesson were working with the federal National Institute on Drug Abuse (NIDA) to form a national response to middle-class polydrug abuse. Their efforts resulted in the formation of the prototype West Coast Polydrug Abuse Treatment and Research Project of the HAFC.
In my five years as CEO, I presided over HAFC's liaison as a guiding force in the increasing federal presence in substance abuse treatment and research. I traveled to Washington, D.C., and Bethesda and Rockville, Maryland, by redeye flight on at least a quarterly basis to confer with our project officers at NIDA and the President's Special Action Office on Drug Abuse Prevention (SAODAP), meeting with such pioneers in the field as Robert L. DuPont, M.D. (1997) and Sidney Cohen, M.D. (1981). During that time, the HAFC developed a variety of national prototypes, including polydrug research and treatment (Seymour & Smith 1987), vocational rehabilitation, women's treatment, special populations as well as providing a fiscal and administrative center for the growing National Free Clinics Council.
NIDA initiated an annual National Drug Abuse Conference (NDAC) at which Drs. David Smith, Donald Wesson and George Gay were early presenters. By NDAC '75 in New Orleans and NDAC '76 in New York City, Darryl Inaba, Pharm. D., John Newmeyer, PhD, myself and many other HAFC staff members participated. It was no great surprise, but a distinctive honor, that David Smith and the HAFC were asked to host NDAC '77 in San Francisco. This was the one and only time throughout their tenure that a free clinic was chosen to present a national drug abuse conference and the Clinics and their Training Division went all out to make it a memorable one.
NDAC '77 was held at the newly completed showplace Hyatt Embarcadero Hotel, with its multistoried garden lobby, its glassed external elevators and its revolving penthouse lounge with views of the entire San Francisco Bay Area. For a week in May, the Haight Ashbury Free Clinics, celebrating the tenth anniversary of their founding in 1967, hosted over 3,000 drug abuse professionals at what NIDA representatives described as the most professional and harmonious gathering that the field had ever seen.
Although every section of the Clinics was involved in the event, David Smith personally took charge of the conference's organization. Heeding lessons in national diplomacy that had been learned in the formation of the National Free Clinics Council, he held a series of organizational workshops at which every minority caucus and field interest group had a say about how the conference should be put together. The effort involved was grueling but it paid off. Both the conference and the proceedings, A Multicultural View of Drug Abuse (Smith et al. 1978), dealt extensively with racial and sexual issues in the field of chemical dependency and provided a forum for all minorities to air their concerns.
THE CRASH OF '76
One would think that the Haight Ashbury Free Clinics were on top of their world and for the moment, they were. The national conference was a success. Funding for all Clinic sections seemed more than secure. A new president had been elected and had chosen Peter Bourne, a man who had trained at the Haight Ashbury Free Clinics, to be his chief advisor on drug treatment issues. Our Training Division had developed and housed the most innovative training program for physicians and other health professionals in the field. To David Smith and others, the millennium seemed at hand.
Then disaster struck. Dr. Peter Bourne departed from government service and was replaced by a bureaucrat with little familiarity with drug treatment issues and his own ideas of how things should be run. The three-month HAFC/UCLA intensive training program was scrapped by NIDA and replaced by what were called Regional Support Centers and the national program for polydrug research and treatment was terminated. Within six months, 75% of the Clinics' funding had either run out or been diverted to the federal/state system. Given the Clinics' experience and expertise, we would be able to regain funding through the state and local programs, but it would take time that we couldn't afford without some form of financial relief.
Faced with potential fiscal disaster, David Smith, key staff and board members and I searched for a solution, and we found one. In recognition of the growing problem of addiction to prescription drugs, the new federal administration called on the pharmaceutical industry to fund research and professional training to combat the problem. The Clinics' Training Division, a subdivision of the drug treatment unit, had reorganized to present NDAC '77 and was in a prime position to bid on new industry-funded research/training programs. I resigned as Clinics CEO in favor of a team that could organize new grants within the state/community system and took the job of Training Director. Sitting in a back room at the Training Division office at 409 Clayton Street, I drafted first-year research and training proposals for Smith, Kline & French, the chief U.S. manufacturer of amphetamine and other stimulant drugs, and Hoffman LaRoche, the developers and manufacturers of Librium and Valium, based on meetings David Smith had attended with representatives of both companies. The proposals included a clinical research component headed by Donald R. Wesson, M.D., physician training and consultation, publications and, from Smith, Kline & French, provision for a national conference on amphetamines to be held the following year. These proposals were accepted and the first year's activities paid for in advance.
Both contracts, and all of Haight Ashbury Training's future contracts with the pharmaceutical industry specified that the Clinics were free to publish any and all of its research findings without industry strictures. The high degree of transparency that resulted from these contracts resulted in a realistic assessment of the abuse and addiction potential of prescription psychoactive medications, while the industry exhibited remarkable responsibility in financing and supporting dissemination of accurate information and the training for health professionals in the understanding and treatment of addictive disease.
The National Amphetamine Conference, held at UC San Francisco, was followed by conference proceedings, Amphetamine Use, Misuse and Abuse (Smith et al. 1979), produced in the same inclusive, hard-bound format as the NDAC '77 proceedings. Just before the start of the 1980s, an unexpected phone call added an additional dimension to the training and education mix.
THE ETHICS AND PRACTICE OF PRESCRIBING ABUSE POTENTIAL DRUGS
The phone call I got on a day in 1979 was from Dr. Joseph Cosentino, head of the State of California Board of Medical Quality Assurance (BMQA). Dr. Cosentino explained that BOMQA had instituted a program in conjunction with the state Bureau of Narcotic Enforcement (BNE), utilizing triplicate prescription reports to apprehend "script docs," i.e. physicians who sold prescriptions for psychoactive drugs. The triplicate system had been developed in part to allow drug enforcement authorities to track the prescribing of scheduled psychoactive pharmaceuticals. According to the head of BMQA what they often found in their excessive prescribing nets were doctors who were bewildered by changing drug laws. These were often the victims of predatory scam artists, experts at faking illnesses to get prescriptions that they could either use to feed their own addictions or retail to other addicts. These "dated and duped" doctors were attempting to practice good-faith medicine, but were overwhelmed by the changes that had occurred since they began practicing. In the course of my conversation with Dr. Cosentino, it became clear that only a small fraction of the physicians caught in the BNE net were actually guilty of selling prescriptions knowingly for profit. What the great majority of these doctors needed was not prison but education. With that clear, Haight Ashbury Training and Education set about designing a course for the working physician, "The Ethics and Practice of Prescribing Abuse Potential Drugs" in partnership with BMQA, BNE and the newly formed California Society for the Treatment of Alcoholism and Other Drug Dependencies (Seymour & Smith 1986; Smith & Seymour 1980a, b). The latter evolved into the California Society of Addiction Medicine (CSAM) and was a key step in the development of the American Society of Addiction Medicine (ASAM) and eventually the formation of the International Society of Addiction Medicine (ISAM).
The prescribing practice course was developed as a two-day program, aimed primarily at physicians who had been identified by BMQA and the BNE as excessive prescribers of scheduled drugs. It consisted of psychopharmacological and clinical presentations on the nature and effects of these drug types; role-playing on dealing with drug scammers and useful presentations on correct diagnoses and prescribing practices. It included a distinctly disturbing talk by the director of the Bureau of Narcotic Enforcement that concluded with him waving a pair of handcuffs at the audience and declaring that, "If the circumstances call for it, I will place these on your wrists, sir, inform you that you are under arrest and march you out of your office through your waiting room."
Once more traveling to Washington, D.C. in 1979, I was able to gain support from NIDA and the Carter White House for the prescribing practice program and we were able to present the first conference in San Francisco within months of the project's inception following a phone call for help from the head of BMQA. Over the next few years, we presented several more prescribing practice courses, traveling throughout Northern and Southern California and into Nevada. Working with CSAM, we developed a county-level model that was presented with county medical societies in Sonoma, Butte and other rural California counties. David Smith attended a meeting at the White House in Washington, D.C. where our prescribing practice concept was greeted as the "California Solution" to the national misprescribing problem. A model prescribing practice course was presented as a two-day physician training program at the National Drug Abuse Conference at the Washington Hilton and the concept was adopted by a number of other states. Back in California, CSAM, under the direction of Gail Jara, took on the role of continuing state presentations of the program we had developed.
THE IMPAIRED HEALTH PROFESSIONAL
Besides problems of misprescribing, physicians at that time had one of the highest rates of impairment due to mental problems, alcoholism and other forms of addiction of any profession. The problem was further exacerbated by the medical professionals' response to such draconian practices as the loss of medical license by maintaining a general code of silence when one of their colleagues was so impaired. This created a greater danger to not only the physician who would continue to deteriorate without treatment but to the whole medical profession and endangered patients as well.
In response to the problem, G. Douglas Talbot, M.D., of Atlanta and Training and Education organized a national network for the treatment of alcoholic and addicted physicians. Providing Dr. Talbot with a west coast anchor for his network, Haight Ashbury Training and Education added the impaired health professional to its scope. Working in the field of addictionology with Jess Bromley, M.D., of the California Medical Society, and Gail Jara of the California Society for the Treatment of Alcoholism and Other Drug Dependencies, David Smith, Donald Wesson and the Training staff were instrumental in developing a state diversion program for impaired physicians whereby they could enter treatment for addiction without permanently losing their licenses (Smith & Seymour 1985). In the process, Dr. Smith appeared on a 60 Minutes segment publicizing the plight of addicted doctors. Moving beyond help for physicians, staff members Millicent Buxton (Dr. Smith's future wile) and Marty Jessup, R.N., set up a State Impaired Nurses Project, funded by the California Nurses Association.
RISKS AND TRANSPARENCY
Even though the government had essentially mandated it, funding from the pharmaceutical industry was not without its risks. After all, the manufacturers had a stake in what was said and done about their products and it was up to us to avoid the potential appearance of conflicts of interest by maintaining control over whatever findings our research produced and over the dissemination of that information. Maintenance of transparency was our solution to the potential problems and our contracts with the industry were written to the effect that our fiscal affiliations were clearly spelled out, as was our autonomy over any findings.
An example of the effectiveness of those policies can be seen in the October 1982 conference, "Benzodiazepines: Two Decades of Research and Clinical Experience," an international conference supported by Roche Laboratories. A key point involved the contention by Roche that the benzodiazepines, when properly prescribed and taken at prescribed dosages within a treatment regimen could not produce addiction. In the time prior to the conference, Roche funded research conducted by Smith and his research associates that showed that addiction to benzodiazepines could and did occur in addiction-prone patients. Smith met with representatives from Roche Laboratories and presented these findings.
Roche responded by funding and participating in Haight Ashbury Training and Education's most ambitious project since NDAC '77 (Seymour & Smith 1986), presenting the new findings by bringing in the key experts from throughout the world to speak on how to deal with the problem of benzodiazepine addiction. It brought together the research chemists from Hoffman La Roche's Swiss headquarters who had originally developed the benzodiazepines, the physicians who had pioneered their use, the clinicians who had treated their abuse, the researchers who had studied their effects and representatives from the manufacturers, the Drug Enforcement Administration, the Food and Drug Administration, and NIDA. David Smith and Donald Wesson presented their research on abuse potential that indicated addiction-prone people could become dependent on benzodiazepines, even at clinical dosages, and discussed how physicians could deal with this problem.
After the conference, Training hosted a two-day summit meeting on physician and drug abuse issues with representatives from industry, enforcement, regulation and medicine at the national level. This meeting acted as a continuum from the White House meeting of 1979 on prescribing practices for psychoactive drugs and solidified a working relationship among all parties. Once more, the paradox became apparent of how a counter-culture based free clinic, founded on the premise that "love needs care" and "health care is a right, not a privilege," consistently impacted national and international drug policies through perseverance and transparency.
ANOTHER CONFERENCE, ANOTHER BOOK
Yearly national drug conferences hosted by Haight Ashbury Free Clinics Training and Education Division featuring speakers who were key national and international experts in their field and yielding comprehensive proceedings continued for several decades under the guidance of Dr. Smith and myself and the expert management of Stephanie Fletter-Ross, Training's able administrator. These included programs on both licit and illicit drugs, including research and treatment information on benzodiazepines, opiates, designer drugs, phencyclidine (PCP) and MDMA.
The Clinics' Operation Board, composed of the director and an elected representative from each Clinics' section, met monthly, and in a moment of whimsy decided to choose theme songs for each Clinic section. One representative, Leigh Davidson, suggested that the theme song for Haight Ashbury Training and Education should be "Another Conference, Another Book." At subsequent meetings, I could hear some of the members humming the tune of "Another Opening, Another Show" as background to my reports on Training and Education's current activities. It was music to my ears.
Cohen, S. 1985, 1981. The Substance Abuse Problems: Volumes One and Two. New York/London: Haworth Press.
DuPont, R.L. 1997. The Selfish Brain: Learning from Addiction. Center City, MN: Hazelden.
Seymour, R.B. 1997. Compost College: Life on a Counter-Culture Commune. Walnut Creek, CA: Devil Mountain Press.
Seymour, R.B. & Smith, D.E. 1987. Drugfree: A Unique, Positive Approach to Staying off Alcohol and Other Drugs. New York: Facts on File Publications.
Seymour, R.B. & Smith, D.E. 1986. The Haight Ashbury Free Medical Clinics: Still Flee After All These Years, 1967-1987. San Francisco: Partisan Press.
Smith, D.E. & Seymour, R.B. 1985. A clinical approach to the impaired health professional. International Journal of the Addictions 20 (5): 713-22.
Smith, D.E. & Seymour, R.B. 1980a. Prescribing practices: The educational alternative for misprescribers. In: Proceedings of the White House Conference on Prescription Drug Abuse. Washington, D.C.
Smith, D.E. & Seymour, R.B. 1980b. The prescription of stimulants and anorectics. In: C. Buchwald (Ed.) Frequently Prescribed and Abused Drugs: Their Indications, Efficacy and Rational Prescribing. Medical Monograph Series II(I). Rockville, MD: National Institute on Drug Abuse.
Smith, D.E. & Wesson, D.R. 1973. Uppers and Downers. Englewood Cliffs, N J: Prentice-Hall.
Smith, D.E. & Luce, J. 1971. Love Needs Care: San Francisco's Haight-Ashbury Free Medical Clinic and its Pioneer Role in Treating Drug Abuse Problems. Boston: Little, Brown and Company.
Smith, D.E.; Bentel, D.J. & Schwartz, J.L. (Eds.) 1971. The Free Clinic: A Community Approach to Health Care and Drug Abuse. Beliot, WI: Stash Press.
Smith, D.E.; Anderson, S.M.; Buxton, M.; Gottlieb, N.; Harvey, W. & Chung, T. 1978. A Multicultural View of Drug Abuse: Proceedings of the National Drug Abuse Conference, 1977. Cambridge, MA: G.K. Hall & Co./Schenkman Publishing.
Smith, D.E.; Wesson, D.R.; Buxton, ME.; Seymour, R.B.; Ungerleider, J.T.,; Morgan, J.P.; Mandell, A.J. & Jara, G. 1979. Amphetamine Use, Misuse and Abuse: Proceedings of the National Amphetamine Conference, 1978. Boston: G. K. Hall & Co.
Sturges, C.S. 1993. Dr. Dave: A Profile of David E. Smith, M.D., Founder of the Haight Ashbury Free Clinics. Walnut Creek, CA: Devil Mountain Press.
Wesson, D.R. 2011. Psychedelic drugs, hippy counterculture, speed and phenobarbital treatment of sedative-hypnotic dependence: A journey to the Haight Ashbury in the sixties. Journal of Psychoactive Drugs 43 (2): 153-64.
Wesson, D.R. & Smith, D.E. 1977. Barbiturates: Their Use, Misuse and Abuse. New York: Human Science Press.
Richard B. Seymour, M.A., Editor, Journal of Psychoactive Drugs.
Please address correspondence and reprint requests to Richard B. Seymour, M.A., 90 Harrison Street #C, Sausalito, CA 944589; email: Rick11@aol.com
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|Author:||Seymour, Richard B.|
|Publication:||Journal of Psychoactive Drugs|
|Date:||Sep 1, 2011|
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