While the principal effort of the government in the field of narcotics has been in the area of prohibition, there are two other types of experiments which should be mentioned here. The first of these was clinics. A few years after the passage of the Harrison Law, the public became alarmed by the great increase in the number of addicted individuals and sought to find remedies for this serious condition. It seemed obvious that if a reduction in the enormous profits realized by those engaged in smuggling and the promotion of addiction for commercial purposes could be stopped, this whole nefarious business might disappear. With this purpose in mind 44 or more clinics were opened by municipal or state health officials in the larger cities where drug addiction was a definite public health problem. In these clinics drugs were sold to supposedly addicted individuals at prices as low as two cents a grain. Dr. S. Dana Hubbard of the Department of Health of New York City, in describing the operation of the New York Clinic, stated, "The practice of the clinic not to prescribe for any new applicant an amount over 15 grains. 10 grains being the usual amount. Reduction was by a daily lessening of the amount prescribed. It was found that some could be reduced to as low as 2 or 3 grains a day. Others when deprived by the clinic, refused to accept our regulations and would buy additoinal amounts outside. Many addicts endeavored to get from the clinic actually more than they themselves required." The clinics were closed in 1920 by order of the Commissioner of Internal Revenue, and although they encountered many difficulties, in retrospect it seems that their most important error was the requirement in the law which made it necessary for them to supply to each patient reduced amounts of drugs in accordance with an arbitrary predetermined schedule. This arbitrary legal formula for medical treatment, in my opinion, foreordained the failure of the clinics. The second notable government effort to treat drug addiction occurred when the Public Health Service opened the Lexington Hospital in 1935 and another hospital at Fort Worth, Texas, in 1938. The former medical officer in charge, Dr. Vogel, has stated that in 1951 there had been admitted 38,000 patients for treatment in the two institutions since their opening. Of those discharged from Lexington Hospital approximately 40 percent apply for readmission, but no one holds that the entire 60 percent who do not return are cured. Rather liberal estimates for arrested addiction with no recurrence of drug use range from 3 percent to about 15 percent of those who have suffered from true addiction. However, a number of addicted persons who have been treated at Lexington have made estimates saying that as few as 2 percent are cured. CRIME AND PUNISHMENT The Uniform Crime Reports for 1952, as published by the Federal Bureau of Investigation, disclosed the fact that all major crimes increased in all urban areas, and for the first time there were over two million crimes committed in the United States. Reports from 383 cities have indicated that the value of property stolen was $225,492,490. A study made in Detroit in 1937 estimated that at that time Detroit merchants lost $2,000,000 a year in merchandise shoplifted by addicted persons. The Chicago Crime Prevention Bureau recently estimated that the cost of the crime depredations by addicted persons in that city amounted to $200,000 a day. In New York City six to eight out of every ten persons arrested for mail theft are addicts. An addict needing $15 a day to purchase his drugs, which is about the lowest figure, must steal merchandise valued at about four times this figure in order to realize that sum of money. Therefore, he must steal articles worth over $20,000 a year. Commissioner Anslinger stated that addicts comprise a large proportion of the shoplifters, pickpockets, card sharpers, and other criminals of this general class and that the police recognize the fact that a wave of burglary, pocket picking, and thievery may be broken up by rounding up the addicts in the neighborhood. The United States has the highest crime rate of any civilized country in the world and the largest black market in narcotic drugs. Mr. J. Edgar Hoover states that crime costs each family in the United States an average of $495 per year. The compulsion in addiction is so severe that increased penalties do not seem to provide a sufficient deterrent to stop the quest of the addict for his drug. Addicts are arrested again and again without any noticeable effect on their conduct. The Federal Bureau of Narcotics states that of those apprehended 65 percent have had previous violations of Federal laws. The idea of inoreasing the severity of punishment meted to addicts is not new. By an edict published in 1729, Emperor Yung Ching prohibited the domestic sale and smoking of opium and provided that the sellers of opium were to wear a wooden collar for a month and be banished to the frontier. The keepers of opium shops were to be strangled. Their assistants were to be beaten with a hundred blows and banished to a distance of a thousand miles. The confiscation of any vessel which carried opium was also provided for, as well as the death penalty for anyone offering to buy any of its cargo. How There is no definite evidence as to the immediate results of the Emperor's severity, but in the long run nothing could stop the tremendous flow of opium into China. From the beginning of the opium trade to the present time, those engaged in its distribution have understood how to evade the law. The production of opium has been prohibited in China for the past twenty years. ever, within the past three or four years the Chinese have offered 500 tons of opium for sale or barter. This is an amount sufficient to supply 340,000 addicts for one year. The fact appears to be clear that no punishment has yet been devised which will stop the use of narcotic drugs by addicts as long as these drugs are available. Everyone agrees, however, that the punishment for the nonaddicted merchants should be extremely severe. ADDICTION WITHOUT CRIME Among those who deal with the problem of addiction, there is a growing realization of the fact that there is little justification for the hope of a complete and permanent cure of many addicted individuals. The one point of view that has never been officially accepted in the United States is that some addicts can be, and remain, useful and law-abiding citizens if they can be provided with their minimum requirements. There is much evidence, as a matter of fact, that many chronically addicted persons are able to carry on their occupations and meet their responsibilities if continuously allowed a small amount of narcotic drug at a price they can afford. The poet, Samuel Taylor Coleridge, was unable to free himself from the slavery which filled the first portion of his life with wretchedness and horror, but under the care and in the home of Dr. Gilman, who rationed the amount of opium Coleridge was allowed, he lived a fairly normal life for eighteen years before his death. The renowned statesman, William Wilberforce, who, as a member of Parliament was chiefly instrumental in the abolition of the English slave trade, was never able to give up the use of opium, but with small dosage he remained an eloquent leader in the political society of London of his day. CONDITIONS IN GREAT BRITAIN Perhaps nothing better illustrates the British attitude as contrasted with our own than do the definitions of addiction. One of our distinguished authorities defines addiction as a condition where an individual uses as drug "to such an extend that the individual or society is harmed.” Dr. J. Yerbury Dent, editor of the British Journal of Addiction, states that "an addict is one who cannot be normal without a drug.” The British have a different conception of the proper method of caring for the addict than is our practice in this country. Dr. W. Norwood East, in the "British Government Report to the United Nations on the Traffic in Opium and Other Dangerous Drugs, 1949,' states: "There is, of course, no compulsory treatment of addicts in the United Kingdom, and there are not State institutions specializing in the problem of addiction. Treatment is left to the discretion of the doctor in charge of the case." The Honorable John H. Walker, Assistant Secretary of the British Home Office, speaking before a meeting of the Association for Psychiatric Treatment of Offenders, on June 3, 1953, stated: "There are only 314 known addicts in the United Kingdom. Allowing for possible unknown cases, there are no more than Isbell, H. Co., 1953, p. 38. In Conferences on Drug Addiction Among Adolescents, New York, Blakiston 7 East, W. N.: ibid. 49: 70 (Jan.-July) 1952. 400 addicts in all. These include people addicted to manufactured drugs and marihuana. Among the known addicts, 100 or more are physicians and an occasional nurse, pharmacist, or veterinarian. Of the remainder, one-half are medical addiction cases. The balance represents a mixed lot. There is no regular illicit drug market, no peddlers, nor places to buy drugs illegally." THE PROBLEM AND THEORETICALLY POSSIBLE SOLUTIONS Reduced to its simplest terms, the problem is fourfold: (1) to reduce the number of individuals becoming newly addicted, (2) to care for those presently addicted, (3) to cure all addicted persons possible, and (4) to reduce the crime resulting from addiction, Theoretically the problems of drug addiction, and the crime which flows from it, could be wiped out quickly by any of four different measures. First, of course, the complete and permanent elimination of the supply of illegal narcotic drugs. This is the solution we have been trying for over forty years. Second, all addicted individuals might be incarcerated for life in hospitals or jails. This is t somewhat repulsive idea in a free country, and of course it would be immensely difficult of achievement and tremendously expensive in maintenance. Third, a completely satisfactory medical treatment for addicted individuals, in addition to the usual features of successful medical treatment, should make the cured patient completely unwilling to become readdicted and provide a new group of law-abiding friends for him. It must also furnish sufficient skill to permit his earning a satisfactory living and leave him emotionally adjusted to the unfamiliar environment of the law-abiding world. This is quite an assignment for some future superwonder drug. The fourth solution would be to educate all individuals so they would never use narcotics improperly. All would agree that this is a direction in which we should move. It may be confidently hoped that it would have some efficacy in cutting down the number of persons newly addicted. but few would urge that individuals now addicted could be saved by teaching alone. On the other hand, it seems amply clear that education must be an important part of the drug program both for protection against the growth of new addicts and to adjust present or former addicts to a fruitful and law. abiding way of life. The difficulty of applying theoretic solutions to complex human problems is frequently great. No magic formula has appeared for relief from the problems of addiction, but progress should be possible from the coordinated application of all available channels of approach. No single process will make an automobile or prepare a person for life. All we can do is to apply and properly coordinate every appropriate technic, whether medical, sociologic, economic, or penal. This coordination seems to be the factor that has been lacking in the past. Even coordination is not enough. Every appropriate tool must be used in each individual case only to the extent that it is necessary or appropriate, and the applica tion will vary markedly in the cases of different individuals. Thus, the plan must have great flexibility in order to deal with the usual exceptions as well as the typical situations. With these criteria in view, I have endeavored to formulate an approach to the problem which would seem to be appropriate, with minimum modifications of present statutory requirements, and at minimum expense. No attempt has been made to spell out mechanics in detail. Only a broad general outline is suggested for your consideration. It seems to me that progress should be possible if an appropriate number of narcotic hospital facilities were to be organized under Federal, state, or municipal auspices in cities which are centers of addiction. These hospitals would be equipped to examine, classify, hospitalize, and treat addicted persons on their premises for necessary periods, after which they would refer appropriate cases to specially commissioned physicians who would be appointed by the hospital staff. These physicians would operate under strict supervision of the hospital but would treat addicted patients in their offices. Although it would be hoped that many addicts could be cured during the first visit to the narcotic hospital facility, it must be recognized that in the past such cures have usually been temporary. By permitting the uncured patients to be cared for by commissioned physicians after initial treatment, an opportunity would be provided for the patient to make progress toward social and economic adjustment, while assured of his needed supply of drug at a reasonable price. After achievement of an adequate social and economic adjustment, the patient would be returned to the narcotic hospital for final cure. When this had been completed, he would again be placed under the care of a commissioned physician, who would endeavor to prevent a relapse during the critical period when he is becoming adjusted to his resurgent sexual and other emotions, which were dulled or warped by the drug and now emerge with a vigor for which the addict is usually unprepared. By supplying deeply addicted persons with their requirements at low cost during the period of their need, the black market would be destroyed; pushing would become unprofitable; the illegal supply would dry up, and all addicts would be forced to apply at the narcotic facility. Thus we might stem the horrible tide of heroin. DISCUSSION Robert B. McGraw, M.D., New York City.—I have had the opportunity to read Dr. Howe's paper in a somewhat more extended version and to hear it here today. He has been courageous and forthright in his presentation. My personal experience in the problem of drug addiction of the narcotic variety is limited. With clinic and private practice I see a rather large number of individuals, but I see very few with narcotic problems-one in my private practice last year and four or five of the 350 to 400 new patients seen in the Psychiatric Department of Vanderbilt Clinic in a year. This Department would be expected to see all problems of addiction in the Vanderbilt Clinic patient population, which is a large number. Perhaps the foregoing is evidence that I am not really qualified to discuss this paper. It is also evidence that drug addicts do not appear in large numbers in some settings in which they might be expected to appear. I am pleased to discuss the paper because it is interesting and provocative and because it has been prepared by a wise and experienced neuropsychiatrist who has given this problem very careful consideration for a number of years. Also I have received help from Dr. Lawrence Kolb of Washington, D. C., who for a number of years was director of the Federal Hospital for the Treatment of Narcotic Addiction at Lexington, Kentucky. The present-day addicts are, it is believed, recruited from the ranks of individuals with psychopathic personality, those who are unstable, and those who are deviates or easily deviated, and not from the run of the mill. When drug addiction was more prevalent in this country, cures were common because stable people then who became addicted could be taken off the drug and would stay off more readily than the unstable people who now comprise the bulk of the addicts. Before we had narcotic restrictions laws, prior to 1915, the number of women addicts was about three times the number of males. The restrictive laws cured them by the hundreds, and being more socially conscious, they remained cured. As to crime, Dr. Howe plays this down, and I believe that he is correct. It is difficult to get it out of the people's minds that the opium drug itself causes crime. Unthinking people consider that arrests for narcotic law violations are synonymous with direct crime-impelling effects of opiates when, as a matter of fact, it is doubtful whether anyone ever committed a crime because of the exciting or disturbing effect on personality of any opiate, including heroin. Addicts steal to get the drug or the wherewithal to buy it, but this is because of the builtup need for the drug which comes out so strongly when one is deprived of it. Dr. Howe's section concerning the problem of addiction in the United Kingdom is very good. The probable reason why Great Britain has so few addicts is that they do not have a super detective force looking for them as we do here. In other words, they are not hysterical about addiction. A British writer of the last century made this succinct comparison, "Opium soothes, alcohol maddens." There the government and the medical profession are composed of physicians who have put their feet down immediately on all hysterical outbreaks about drug addiction. Dr. Howe advocates hospital facilities where addicts would be given needed drugs at low cost. Clinics were started after the Harrison Narcotic Act went into effect in 1915 and were later forced to close by action of the Federal government. It was claimed that they spread addiction. It is not to be expected that the government would approve such a procedure again unless strong evidence and pressure is forthcoming. The narcotic laws have been responsible for an enor mous reduction in drug addiction since 1915, but they have been unnecessarily harsh and cruel in their operation in individual cases. Lawson G. Lowrey, M. D., New York City.-Dr. Howe has presented briefly but adequately the larger social and medical implications of the issues involved in narcotic addiction as it exists these days. Addiction is no longer a medical problem in the sense that it formerly was; it has become chiefly a police matter. In my high-school days, when I worked in a very minor capacity in drugstores. the pharmacists knew the local addicts and their daily requirements. Most of them were highly respected and effective in their jobs, and most had become addicted for medical reasons. Alcoholic people were likely to be much more troublesome in social and police terms. Addiction, at least in our part of the country, was a very minor problem. A more serious one, at least so it seems in retrospect, was the widespread use of patent medicines and what that could and did do to people who innocently thought they were curing their “dyspepsia" or whatever it might be. The major issues which Dr. Howe raises are matters of serious concern to all of us. Let me say frankly that it is my best judgment that adults in 1954 are no different from adults in 6000 B. C. We still tend to blame the adolescent, the teen-ager, for all the ills of the world. Actually, it is we, the supposed adults, who build the world in which they grow up to be adolescents. It's just possible that "once upon a happy time" we knew what we wanted and were willing to work and fight for it. To be sure, it was a somewhat different world, but not completely. Esau and Jacob and Isaac and Rebekah weren't so different after all. Dr. Howe's program, with which one must agree in general, raises some questions for me. My interest is in the addict as an individual, not necessarily sick or perverted, but definitely a person and not just a "statistick." I have some reservations about the extent of juvenile or in the phrase of today-teen-age delinquency. Every two or three years for the last thirty or forty years there has been great clamor in the newspapers, in the popular magazines, and even in scientific journals about the juvenile delinquent. Two weeks ago I attended a conference on "Vandalism," a discussion of the destructive tendencies of the teen-age group. Dr. Howe has brought up here a number of questions about the adolescent and addiction problems. In 1950, according to the U. S. Census, there were nearly 22 million persons aged ten to nineteen (inclusive) in this country, slightly more than half being in the fifteen- to nineteen-year group. Reader's Digest recently reported an increase of 80 percent in cases of rape by contrast with the 1939 figures. The actual number of arrests reported by the FBI for 1952 was 2,051. That would be an increase of 80 percent from 1,200 arrests. These seemingly irrelevant comments are made for this reason. It seems to me, and to many others who work rather extensively with adolescents, that there is too great a tendency to forget the very real problems with which they are faced. and increasingly so. Just what proportion of adolescents are involved in delinquency, vandalism, and any type of narcotic addiction? Is the proportion actually greater or less than it was thirty or forty years ago? Shouldn't the addict, adult or adolescent, have psychotherapy? How will this be carried out in this program? Who will do the necessary family and personal social work? What about vocational training or rehabilitation, which is definitely shown by Dr. Howe to be necessary? What about job finding? This in itself is a most difficult and important issue. All of my experience indicates that in such complicated medical, psychologic, and social problems as the addict presents, there is need for an organized, coordi nated treatment program, bringing to bear upon the issues every resource that medicine, psychotherapy, and social work can offer. |