Our council on mental health held a joint meeting on September 10 in Chicago with our subcommittee on narcotic addiction, which consists of Dr. Robert H. Felix, Director, National Institute of Mental Health, Bethesda, Md.; Dr. Harris Isbell, Director of Research, NIMH Addiction Research Center, Public Helath Service Hospital, Lexington, Ky.; and Dr. Jerome L. Leon, American Medical Center at Denver.

At that meeting we listened to evidence presented by the Federal Bureau of Narcotics and pertinent material presented by Dr. Andrew A. Eggston of New York, Dr. Herbert Berger of New York, Dr. Hubert Howe of New York, Mr. Rufus King of the American Bar Association, and Dr. Eugene Carey of the Chicago Police Department. The subcommittee on narcotic addiction plans to fully investigate the material presented, and other pertinent material, in the coming months and present a report to our council toward the end of this year or early in 1956. I should like to say tentatively, however, that the evidence presented by the Bureau of Narcotics concerning the uselessness of clinics for treatment of narcotic addicts was not entirely satisfactory in my opinion.

There was other evidence presented by the New York group that the experience with clinics had not been totally unsuccessfull, notably in the States of California and Florida, where clinic treatment was said to have resulted in rehabilitation of some of the addicts to the point where they could again assume responsibility for themselves and for their family's care, and effectively resume some type of gainful employment.

There was also some evidence presented by Mr. Rufus King of the American Bar Association and others that since the early 1920's doctors generally have not had a sufficiently clear understanding of what their rights under the law might be concerning ambulatory treatment of narcotic addicts and because of this they have tended to avoid accepting addicts as patients.

Regarding the possible use of clinics for these types of patients I would like to state, as a personal opinion, with the understanding that this is consistent with but possibly broader than the present official position of the American Medical Association, that I certainly feel that some type of clinic needs to be made available for the followup treatment of narcotic addicts when their need for immediate drug taking has been relieved by hospitalization in the Federal narcotic hospitals or in other hospitals that may accept them, and that such clinics should have the objective of bringing about a psychotherapeutic approach to these patients.

This approach should be aimed toward reaching and alleviating the basic emotional disturbances that these patients always have. It is these emotional disturbances in the addict which lead to drug taking in order to feel normal. Treatment would be a long-term process with the clinics continuing to provide the emotional support that such patients require while they are gaining a new understanding of their own emotional needs, and regaining a place in our society.

In other words, we do not consider drug addiction as a disease in itself. It is, rather, a symptom or behavior pattern that masks much deeper underlying emotional disturbance and conflict.

Again from a strictly personal viewpoint, and concerning the possibility of providing clinics for the direct treatment of addicts with

out prior hospitalization, I must say that the kind of evidence that our council has heard so far has not convinced me that ambulatory treatment in a properly controlled clinic, in a university setting, or in the setting of a general medical center is impossible, nor am I convinced that such a method would be possible.

I would like, however, for the consideration of this committee, to draw what might be considered a parallel between such an approach to drug addicts and the usual approach to emotionally disturbed patients that psychiatrists frequently must make with many patients in early stages of treatment.

Many patients who come to a psychiatrist's office for treatment who have been suffering for years from emotional disorders have been selfmedicating themselves with large doses of barbiturates, or bromides, or other sedative drugs for long periods of time.

When a psychiatrist undertakes the psychotherapeutic treatment of such patients he would most certainly feel it inadvisable to immediately prohibit the emotional calming effects that these drugs produce. Such a move might not only interfere with his immediate treatment of the patient but would in all likelihood bring about a situation wherein the patient would reject the therapist and refuse further treatment.

In patients of this sort it is only after a long term of treatment during which time a feeling of confidence had been allowed to develop between the patient and his doctor and when much of the patient's anxiety and apprehension had been relieved that the patient would feel secure enough in the doctor's care to slowly cut down his need for such sedative drugs.

Although this may not be an exact parallel to psychotherapeutic treatment of the drug addict, certainly there are strong elements in both types of patients that are the same and I would think, therefore, that it would be necessary for a psychiatrist or other doctor in the treatment of drug addicts on an ambulatory basis to continue to supply narcotics over at least a part of the time that the patient is under his care.

The attending doctor must be free to determine the proper timing of the withdrawal, as this process is an intimate and important part of his treatment. Psychotherapeutic treatment of these kinds of patients would probably require a period of several years.

To return, therefore, to the possibility of establishing clinics for the ambulatory treatment of these kinds of patients I can only say that the evidence that we have heard in our council so far is inconclusive. There was good evidence that in many instances the way in which addicted patients were handled in the old clinics was not within a proper medical setting, and in some instances in settings that in no way resembled proper medical control.

The association recognizes that while narcotic drugs, properly used, are a great boon, their use even by physicians may bring about danger of addiction. We have, therefore, published cautionary articles to the profession from time to time. In the thought that such a statement may be of value to the committee, I should like to leave with you for insertion in the record or such other use as you see fit, a special article entitled "Indispensable Use of Narcotics," which

appeared in the Journal of the American Medical Association on May 23, 1942.

Senator BUTLER. Doctor, it will be received and made a part of the appendix to the record.

The document referred to will be found in the appendix at p. 1936.) Dr. BARTEMEIER. As I have said previously our council hopes to present in the not too distant future a comprehensive report and recommendations in a much more concrete form concerning this matter to the American Medical Association's board of trustees.

Senator BUTLER. Doctor, do you feel that the clinical treatment would have to be on an involuntary basis or a voluntary basis to be successful?

Dr. BARTEMEIER. This is one of the great problems in the treatment of the narcotic addict that I heard nothing about today, and that is that the addict is a person who has found his own medicine as a solution for his own problems.

Addicts, like alcoholics, so frequently are persons who are lacking in the desire, in the wish, in the urge to be well, using "well" in the sense of getting along without the drugs.

You know, Mr. Chairman, that this is a very important factor in the treatment of any illness by any physician; it is the great stumbling block.

Now, it is possible that a certain percentage of addicts, if they can be seen regularly by the same physician, can be stirred to a wish. to get along without their drugs.

From the point of view of one who has been in private practice a good many years, and who has seen in his practice only a few addicts, I was never willing under any circumstances to undertake the treatment of such a patient outside of a hospital. It always had to begin in a hospital. It had to continue with a hospital for quite a long time, and then it had to be very closely followed after the hospital discharge.

Senator BUTLER. Thank you, doctor.

Senator Daniel?

Senator DANIEL. Doctor, does that mean that in treating the addicts that you have personally come in contact with, that all administration of narcotic drugs would be while inside the hospital?

Dr. BARTEMEIER. Inside the hospital; until such time as one has found ways and means, either by substituting other medicines-and reserpine is now being used with some success with some patientsuntil such time as one can be reasonably certain that his patient can get along without the use of the narcotics, until then one does not feel inclined, and one has the sense of responsibility not to let this patient out of the hospital.

Senator DANIEL. In other words, do I understand that that is still your opinion, that the addict should not be given drugs outside of the hospital?

Dr. BARTEMEIER. I think that is my opinion, yes.
Senator DANIEL. That is your opinion?

Dr. BARTEMEIER. That is my opinion, and it is

71515-56-pt. 5—11

Senator DANIEL. The only inclination that you have toward administration of drugs to addicts is for the purpose of withdrawing them to where finally they can be free of them entirely?

Dr. BARTEMEIER. That is right, sir.

Senator DANIEL. I judge from that then you personally would not subscribe to the idea of giving them maintenance doses on a permanent basis?

Dr. BARTEMEIER. No, sir; I would not.

Senator DANIEL. So that we might know just exactly and to be sure about the procedures to be followed, your committee on narcotics will make its recommendations to the Council on Mental Health? Dr. BARTEMEIER. And when it does, Mr. Chairman, we will be pleased to send you a report of those recommendations.

Senator DANIEL. We appreciate that. That is the committee headed by Dr. Felix, who is here in the room?

Dr. BARTEMEIER. Who is here with us today.

Senator DANIEL. Do you have the membership of the Council on Mental Health?

Dr. BARTEMEIER. I do have, sir.
Senator DANIEL. The names?

record?

Could you furnish that for the

Dr. BARTEMEIER. Yes, we will be glad to.

Senator DANIEL. We appreciate that, and that will be inserted at the end of your remarks.

(The information referred to follows:)

The membership of the Council on Mental Health, American Medical Association, is as follows:

Leo H. Bartemeier, M. D., chairman, Baltimore, Md.

Lauren H. Smith, M. D., vice chairman, Philadelphia, Pa.

Richard J. Plunkett, M. D., secretary, Chicago, Ill.

Walter H. Baer, M. D., Peoria, Ill.

Hugh T. Carmichael, M. D., Chicago, Ill.

Francis M. Forster, M. D., Washington, D. C.
George E. Gardner, M. D., Boston, Mass.
Francis J. Gerty, M. D., Chicago, Ill.

M. Ralph Kaufman, M. D., New York, N. Y.

Senator DANIEL. Let me also suggest that we insert here in the body of the record the various actions of the American Medical Association in the past, and which constitute the present policy of the association, with the article entitled "The Problem of the Narcotic Drug Addict," by Alfred C. Prentice, M. D.

Senator BUTLER. It will be so ordered.

(The full reports of the various actions of the American Medical Association and the article entitled "The Problem of the Narcotic Drug Addict," by Alfred C. Prentice, M. D., may be found in the appendix at pps. 1943 and 1982, respectively. The excerpts from the reports referred to follow :)

REPORT OF THE COMMITTEE ON THE NARCOTIC DRUG SITUATION IN THE UNITED STATES JAMA, 74: 1324–1328 (MAY 8) 1920

Recommendations:

1. That the ambulatory treatment of drug addiction, as far as it relates to prescribing and dispensing of narcotic drugs to addicts for self-administration at their convenience, be emphatically condemned.

REPORT OF COMMITTEE ON NARCOTIC DRUGS OF THE COUNCIL ON HEALTH AND PUBLIC INSTRUCTION, AMERICAN MEDICAL ASSOCIATION, JAMA, 76: 1669-1671 (JUNE) 1921

Recommendations:

Your committee desires to place on record its firm conviction that any method of treatment for narcotic drug addiction, whether private, institutional, official, or governmental, which permits the addicted person to dose himself with the habit-forming narcotic drugs placed in his hands for self-administration, is an unsatisfactory treatment of addiction, begets deception, extends the abuse of habit-forming narcotic drugs, and causes an increase in crime. Therefore, your committee recommends that the American Medical Association urge both Federal and State governments to exert their full powers and authority to put an end to all manner of such so-called ambulatory methods of treatment of narcotic drug addiction, whether practiced by the private physician or by the so-called narcotic clinic or dispensary.

In the opinion of your committee, the only proper and scientific method of treating drug addiction is under such conditions of control of both the addict and the drug, that any administration of habit-forming narcotic drug must be by, or under the direct personal authority of the physician, with no chance of any distribution of the drug of addiction to others, or opportunity for the same person to procure any of the drug from any source other than from the physician directly responsible for the addict's treatment (No. 8, p. 1671).1

Senator BUTLER. Thank you, Doctor, ever so much.

Dr. BARTEMEIER. Fine and dandy.

Mr. GASQUE. There is one question, Dr. Bartemeier, I should like to ask. In complete fairness to the work of the Bureau of Narcotics, there has been some discussion that doctors need the role of the physician clarified as to what they can do with the treatment of narcotic addicts when they come to the office.

Do you feel that that is necessary or do you feel now that there is sufficient knowledge of that?

Dr. BARTEMEIER. Well, I think it is information that could well be published repeatedly from time to time in our official journals and various communications to our doctors across the country.

Mr. GASQUE. You feel that the Bureau of Narcotics has made itself sufficiently clear as to what a doctor can and cannot do?

Dr. BARTEMEIER. I am not in a position to answer that question.
Do you know?

Dr. PLUNKETT. I think that the doctors, generally, are not clear on what the Supreme Court decisions have been. I mean, I think, perhaps, the decision in the Behrman case has received more publicity than the decision in the Linder case. That would be my personal opinion. I do not know that it is the association's opinion particularly. Mr. GASQUE. I wonder if you would be kind enough to send to the committee any questions or any doubts in your mind as to the questions in those decisions or in the regulations in order that we might help you in gaining a clarification, if one is needed.

Dr. PLUNKETT. We will be very glad to do that.

This is perhaps the most important single document bearing on the operation and closing of the clinics. It is to be noted that the largest medical body in the United States, the American Medical Association, urged the Federal and State governments to exert their full powers and authority to put an end to the ambulatory treatment of addiction. In other words, the Bureau of Narcotics received a mandate from the medical profession to do what it has done, namely, suppress the clinics. This policy has never been withdrawn by the American Medical Association after its verbatim acceptance by the house of delegates in 1924 (JAMA 82: 1967, 1924).