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Mr. NELLIS. My last question is a philosophical question, Mr. Zahn. I feel I can ask it of you because your late father and I were good friends.

You say in your statement: It is not up to the wholesaler to decide what quantity is right. We cannot, nor should we, be placed in a position to determine excessive purchases of the product. There is no way for us to know if our customers are abusing a particular drug.

Now, you are dealing in some highly sophisticated and dangerous substances; is that not correct?

Mr. Zahn. Correct.
Mr. NELLIS. You have a higher duty to the public than what you

describe here, I suspect. After all, you are not dealing in candy or in pantyhose, which is the only other thing that came to mind. You are dealing in very dangerous products. And you have a duty, it seems to me, over and above the duty of the ordinary vendor to make sure that the public interest is protected.

Do you agree to that?
Mr. Zahn. I do.

Mr. NELLIS. Then, certainly, you can't mean what you say here. We are not asking you do you want to be a policeman. You can't be a policeman, but you can certainly determine trends.

And when one of these dangerous drugs begins to appear on the streets and you begin to get prescriptions over and above the normal customary prescriptions that you have been used to getting, with the computer, especially, that should alert you to something:

Mr. Zahn. I don't think there is any question as to if there was or not an increase or a trend of a particular drug. The question is: I think it is our responsibility to make the proper authorities aware of that trend.

Mr. NELLIS. Certainly.

Mr. Zahn. In the question of Talwin, it was being investigated by two agenices in Illinois. It was being investigated by the department of registration and education, and it was being investigated by the enforcement agents. Both of those people were investigating this.

At that point, what else could we do?
Mr. NELLIS. I am not being critical.

Mr. ZAHN. I understand that, but I think, in the future, I take our responsibility not lightly. I think you are correct when you say that if you spot something, you should bring it to the right place. Beyond that, I think our hands are tied.

Mr. NELLIS. I agree.
Mr. Zahn. OK.

Mr. NELLIS. All I am saying is you should be alert, because you are dealing in these dangerous substances.

Mr. Zahn. I don't disagree with that.

Mr. Nellis. And when something like that happens, you are to call on DEA or the Illinois Dangerous Drug Commission. I am sure that you would get the right response, and you would be helped in effectuating a change.

Because, let me tell you, Mr. Zahn, this country is going to go down the track the hard way if we don't do something about the licit production of so-called ethical pharmaceuticals. We can talk about heroin

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and marihuana and cocaine until we are blue in the face, but it doesn't affect the large population that our licit drugs affect. And that is our biggest problem, our committee is beginning to believe.

Thank you, Mr. Chairman.
Mr. MURPHY. Thank you, Counsel.
[Mr. Zahn's prepared statement appears on p. 500.]

Mr. MURPHY. Are there any additional comments by the panel? We are running a little behind time, and I want to be fair so that everybody gets a response in here for the record.

Do you?
Mr. Rodwin. Nothing more.
Mr. MURPHY. Mr. Leach?
Mr. LEACH. No, sir.

Mr. MURPHY. Thank you very much, gentlemen. And we appreciate your coming and submitting the information for the record.

The next panel will be the "Role of State and Local Agencies”: Sgt. Thomas J. Eichler, Gang Crimes Investigation Division, Chicago Police Department; Robert Stein, M.D., medical examiner of Cook County; Thomas Kirkpatrick, executive director, Illinois Dangerous Drugs Commission; and Algis Augustine, chief regulatory officer of the Illinois Department of Registration' and Education; Alex M. Panio, director, drug dependence program, Northwestern Institute of Psychiatry

We also have in the audience a very distinguished law enforcement official, the sheriff of Cook County, Sheriff Richard Elrod.

And Sheriff, if you want, you can join the distinguished panel.
Will everybody rise and extend their right hand.
[The witnesses were sworn by Mr. Murphy.]

Mr. MURPHY. Dr. Panio, I understand, has a time problem. And to accommodate the doctor, if it is all right with the rest of the panel, we will hear from him first.

TESTIMONY OF ALEX M. PANIO, JR., DRUG DEPENDENCE PROGRAM,

NORTHWESTERN INSTITUTE OF PSYCHIATRY

Dr. Panio. Thank you. I want to preface my formal presentation and respond to some points that Dr. Speir and the representatives of Winthrop presented in their earlier testimony.

Northwestern Institute of Psychiatry is a comprehensive community mental health center accredited by the Joint Commission on Accreditation of Hospitals, under the direction of Dr. Harold Visotsky. As such, the institute maintains a comprehensive drug program, of which I was the first director and current director for some 7 years, maintaining an average patient weekly caseload of approximately 800 to 1,000 patient visits.

Our program is nationally recognized for its innovation in treatment and the comprehensive care and delivery of services to drugabuse individuals. We maintain both inpatient and outpatient services for

all types of chemically dependent individuals. Dr. Speir was contacted early in January 1978 by one of my clinical staff therapists, Mr. Warren Q’Mara who requested data and information, and also to inform Winthrop of the reoccurring Talwin problem that we were identifying in our outpatient program.

Some 31/2 months later on April 11. Dr. Speir called me from California, as he accurately indicated, and came to visit me for 35 minutes the following day. He couldn't stay longer, as I made notes, and I brought them with me. He had to catch a flight back to New York.

Dr. Speir expressed his sincere concern, but could not offer any explanation for the phenomenon of Talwin abuse, nor could he offer or identify any treatment suggestions based on Winthrop's experimental data.

He was invited back to review our assessment procedure, but unfortunately, never got in touch with us.

Dr. Speir raised some questions about our identification techniques, and I am certainly willing to comment on that.

I have been the director of drug programs for 10 years and was formerly trained by the National Institute on Drug Abuse, National Institute of Mental Health. I was one of the first narcotics rehabilitation counselors trained in Lexington, Ky., under the NARA program, by the same experts that the Winthrop group brought in, that is Drs. Jaffe and Martin.

In fact, my current director at that time was the director of mental health for the State of Illinois, who hired Dr. Jaffe to develop Illinois' most comprehensive and innovative drug treatment program, IDAP.

For the record, our program has screened and/or treated approximately 6,000 drug users in the last 612 years. We use the same standards for identifying and treating patients as set by the Illinois Dangerous Drug Commission, the National Institute on Drug Abuse, and the Food and Drug Administration.

The report that I am going to submit, or at least for the sake of time highlight for you this afternoon, was prepared with the cooperation of all of the clinical members of the Department of Psychiatry and Prentice Women's Hospital who serve as consultants to our comprehensive drug program.

The results or the data described in my report cover approximately a 10- to 12-month span and reflect actual case study analysis. Results include data from comprehensive intake and assessment procedures, laboratory, and physical examination results, urinalysis results utilizing our EMIT and toxicology service as well as the toxicology services provided by the Illinois Dangerous Drugs Commisison, directed by Dr. Kaistha.

In addition, the results of medical, psychological, sociolegal, prior drug abuse histories, and family history assessments were included as the basis for this report.

In addition, a specific Talwin questionnaire was developed to help track and identify current patterns of abuse of Talwin in the Chicago area.

The first case of Talwin abuse was seen and documented some 9 years ago. And during the past 7 years we saw no more than 8 to 10 cases a year. By the end of 1976 and early 1977, referrals from our emergency room, telephone inquiries, and patients interviewed for admission were requesting services for Talwin abuse and addiction. Admissions began to increase during the spring of 1977, which also correlated to the first study decrease of admissions for opiate abuse to our drug program,

The specific sample size, I would like to report to you this afternoon, is based on 108 individual different cases.

Mr. MURPHY. Did you present this evidence or medical testimony to Dr. Speir when he came out to visit you !

Dr. PANIO. At that time, I think we had roughly 30-some odd cases. So, all I am doing now is expanding the sample size with a bit more information that we were able to gather.

Of the 108 patients, 36 had been referred to us from the central intake facility under the direction of Dr. Edward Senay. So, these were not all patients that came into Northwestern. Some of these patients were referred from the central intake facility, which is also under the auspices of the Illinois Dangerous Drugs Commission.

According to our data, the overwhelming response by the majority of the patients was that Talwin, or T's, “can get you high every time

you fix."

The clear expectation and resulting self-stimulation by the abuser is for the intention of a euphorogenic effect. The Talwin abuser did not appear to be a multiple-narcotic abuser, which is validated by monitored urine specimens in which the samples were split and sent to the State as well as our own urine testing. So, we had dual crosschecking on our urinalysis tests.

The abusers profess a belief that Talwin is in fact addicting. We asked the question on our intake form. “Do you think this drug is addictive ?" And the answer overwhelmingly was "Yes.'

They reported an extremely high degree of accessibility of Talwin. In other words, Talwin was very easy to get. This accessibility has been significantly reduced since the recent rescheduling of the drug. And the patients now admitted to our program present somewhat of a panicky concern for future accessibility and eminent withdrawal complications. Patients still report drug cravings and exhibit and report drug-craving behavior, such as theft, increase in irritability, and aggressiveness as the cycle of the drug begins to wear off.

All of the patients assessed were able to present the actual pill or liquid vial of Talwin. This is something that we require. They have to bring in what they are taking. They were always able to identify the physical characteristics of the drug in terms of color, size, markings. Better than 70 percent of the users adjunctively used Pyribenzamine in combination with the Talwin, in the usual combination of three Talwin to one Pyribenzamine per dose.

Only 24 percent admit to having a legitimate prescription for Talwin, and 15 percent state they are under current medical care and supervision, with chronic back pain as the most recurring ailment; 13 percent of the patients stated that they have experienced convulsions and passed out from using Talwin, without prior histories of seizure disorders or having admitted overdosing on Talwin.

Subsequent medical followup evaluations of these patients did not merit use of analgesics as determined by the various medical clinics at Northwestern University Medical School.

Mr. NELLIS. Does that mean they were getting Talwin on prescription for reasons other than pain killing?

Dr. Panio. Their statement was they have pain, chronic back pain, and they were receiving the Talwin for that.

Each and every patient is routinely checked by our internist and then referred to either our pain clinic or one of the clinics in the medical school complex. None of the reports coming back on any of the Talwin patients were able to confirm a serious enough condition merit continued use of any analgesics.

It appeared in 1977-78, until recently, that Talwin represented a rather inexpensive, convenient, and accessible drug for novice drug abusers who quickly develop a pattern for dependence and resulting drug-seeking behavior. For most of these individuals their first exposure to narcotics was with Talwin and was described as their drug of choice. Illicit activity was described as minimal.

There are recent indications, since rescheduling, among older street addicts that Talwin is a drug of preference, even with the predictable antagonistic reactions to methadone and unpredictable hallucinogenic and psychotomimetic effects. In the recent months it is this group which has repeatedly presented themselves with larger Talwin habits, up to 48 Talwin tablets per day. Fewer use PBZ in conjunction with Talwin. Most express fear for the future and sought admission for inpatient detoxification and presented a greater incidence of cutaneous ulceration and soft tissue damage.

I have a brief profile that simply indicates the mean age, how long they have been using the drug, how they administer the drug, and how much they take during the course of the day.

Mr. Murphy. Were you able to give this information, Doctor, in evidence, to any of the drug companies involved?

Dr. Panio. The only contact that we had was the specific initial contact, the meeting in my office at the medical school, with Dr. Speir. On that date I did not have anything in writing.

Mr. MURPHY. Did he ask for anything in writing?
Dr. Panio. He did not, at that point.

As I mentioned, he was invited back at his own convenience for specific case results or to interview patients. And, as I say, that invitation was extended

Mr. MURPHY. Was it ever accepted ?
Dr. Panio. No, sir.

Six Talwin pregnancies have been identified. Two of the four that have been delivered represent the most unusual infant complications with mothers in our addiction program.

I might add we do have a perinatal treatment component, funded by the Illinois Dangerous Drugs Commission and monitored by that commission. I personally believe that it is certainly one of the most comprehensive components in our program, simply because it involves the expertise of maybe a dozen to 18 different clinicians on faculty in our medical school and services delivered in Prentice Women's Hospital.

The overwhelming evidence for substantiating the ability to produce and maintain a psychological dependence as well as a physiological dependence is contained in the large percentage of patients who have not completed detoxification because of the stated availability and accessibility of Talwin and the euphoric effect it maintains.

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