DRUG REPORT ON BY ADDICTION UND THE NEW YORK ACADEMY OF MEDICINE* COMMITTEE ON PUBLIC HEALTH** SUBCOMMITTEE ON DRUG ADDICTION* INDER date of January 14, 1955, there was presented to the Senate of the United States by Senator Frederick G. Payne, Republican, of Maine, a joint resolution "to provide for a more effective control of narcotic drugs, and for other purposes." Co-sponsoring the Resolution with Senator Payne were forty-two other Senators from all areas of the Nation and from all political parties, including Independent Senator Wayne Morse of Oregon, The Interdepartmental Committee consisting of representatives from the Department of State, Department of the Treasury, Department of Defense, Department of Health, Education and Welfare, and the Department of Justice requested the Committee on Public Health of The New York Academy of Medicine to study this bill and submit a report. By the time the Subcommittee on Drug Addiction of the Committee on Public Health had an opportunity to convene it was informed that the narcotics bill had not come out of committee. However, representatives of the Interdepartmental Committee requested that the Committee on Public Health consider the narcotics problem and propose measures for suitable legislation. Today a number of cities are raising a hue and cry of apprehension and alarm over drug addiction. Charges and claims about it appear in the headlines, coupled with demands for action of the usual kind: crackdown by the enforcement officials. Presently it is linked with the larger problem of juvenile delinquency as one of its most serious components. Before attempting to appraise the existing situation, it is helpful to look at the legal provisions and administrative bodies designed to control narcotic traffic and addiction. LAWS AND ADMINISTRATION International Background: At the instance of the United States Government, the conference of the International Opium Commission convened in Shanghai in 1909 in an effort to obtain international action to control the traffic in opium and its products. The Commission recommended that drastic measures be taken by each government in its own territories to control the manufacture, sale and distribution of opium derivatives. Three years later the representatives of twelve world powers met at The Hague to formulate the recommendations of the Com Approved by Edward J. Donovan, M.D., President, The New York Academy of Medicine, June 7, 1955. "Approved by the Committee on Public Health of The New York Academy of Medicine, June 6, 1955. ***Report prepared by Subcommittee on Drug Addiction, comprised of: Hubert S. Howe, M.D., Chairman; Linn J. Boyd, M.D.; McKeen Cattell, M.D.; Milton J. Goodfriend, M.D.; Arthur Vose Greeley, M.D.; Lawrence C. Kolb, M.D.; Asa L. Lincoln, M.D.; Bernard J. Pisani, M.D.; Dickinson W. Richards, M.D.; Conrad M. Riley, M.D.; H. D. Kruse, M.D., Secretary. Reprinted from BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE mission into an international convention. Here was reached the first important international agreement on the subject, which is known formally as the International Opium Convention of 1912, and popularly as the Hague Convention of 1912. This Convention was designed to bring about the gradual suppression of the abuse of opium, its products and derivatives, and cocaine. The signatory powers contracted to enact effective laws, or regulations, for the control of the production and distribution of raw opium; for prevention of export of raw opium to countries which shall have prohibited its entry; for control of the export of raw opium to countries which restrict its import; and for restricting both import and export of raw opium to that made by duly authorized persons. They further agreed to take measures for the gradual and effective suppression of the manufacture, distribution and use of prepared opium. They also engaged to exert efforts to restrict the import and export of morphine and cocaine preparations to authorized persons and to limit the manufacture, sale and use of these drugs exclusively for medical and scientific purposes. Federal Background: Congress has no power to legislate for the mere purpose of restraining the purchase of opiates and other drugs. Rather, its power to enact Federal legislation regulating all phases of the production, manufacture, sale and use of narcotic drugs derives from the commerce clause and the tax clause of the United States Constitution. Under the commerce power, it may forbid the importation of drugs and make the violation of the statute a criminal offense. Under its taxing power it has been held that Congress may prohibit all purchase or sale of narcotics except in or from the original stamped package. On these constitutional bases, Federal legislation effectuating the Convention to bring about legal control of narcotics with restriction on their sale and use is contained in a series of statutes. In 1909 Congress adopted a law entitled "An Act to Prohibit the Importation and Use of Opium for Other Than Medicinal Purposes." Five years later, in fulfillment of the obligations of the United States under the Hague Convention of 1912, this law was amended to prohibit the export of narcotic drugs except to a country which regulated their entry. In that same year, in further implementation of the Hague Convention, this country enacted its basic narcotic law, the Harrison Narcotic Act. As an exercise of Federal power to tax, it was enacted as a revenue measure; but by imposing penalties for illegal manufacture and distribution, the effect of its provisions is to regulate the production, manufacture and distribution of narcotics, particularly to limit the availability of narcotic drugs to medical and scientific use. Thus, in an attempt to minimize the spread of narcotic addiction, the Harrison Narcotic Act has been applied as a measure to control the domestic narcotic traffic. In growing recognition that there was need for a more comprehensive measure of control over import and export of narcotic drugs than was provided by the Act of 1909, as amended in 1914, an extensively revised form of this older statute was re-enacted by Congress in 1922 as the Narcotic Drugs Import and Export Act. It authorized the importation of only such quantities of opium and coca leaves as the then Federal Narcotics Control Board found to be necessary to meet medical needs. With this legitimate exception, importation of any form of narcotic drug was prohibited. Exportation of manufactured narcotic drugs and preparations was permitted under a system of control designed to assure their use for medical purposes only in the country of destination. Under the special amendment to this statute in 1924, the legal manufacture of heroin in the United States ceased. With evidence of growing abuse of marihuana, the Congress enacted the Marihuana Tax Act of 1937, which requires the registration and payment of a tax by persons who produce, import, manufacture, sell, or transfer marihuana. When growing of the opium poppy, ostensibly for seed yield, sprang up as the result of a shortage of imported poppy seed during World War II, the Congress enacted the Opium Poppy Control Act of 1942, which prohibited the growth of the opium poppy in the United States except under a special license issued only upon a demonstrated need for domestic production of the opium poppy to supply opium derivatives for medical and scientific uses. Because the Harrison Narcotic Act has been used to exert control over domestic trade in narcotics, its constitutionality has been debated and subjected to test. Although nominally an application of the government's taxing power, the real function of the Act through its provision for penalties for illegal manufacture and distribution has been to restrict the distribution of narcotics to medical and scientific uses only and thereby to attempt to minimize the spread of narcotic addiction. Several cases have arisen testing the constitutionality of the Act on the grounds that it is not really a tax measure, but rather an indirect method of invading the police powers of the states; that it undertakes to regulate matters within the exclusive control of the states; and that the penalties amount to a denial of due process of law. The point at issue in test cases on the constitutionality of these statutes has been the extension of indirect control by the Federal government over objects which it is forbidden to regulate directly. The Harrison Narcotic Act has twice been declared constitutional by the Supreme Court, solely as a revenue measure and as an exercise of the Federal power to tax. Administration: Originally the Federal Narcotics Control Board had the responsibility of control over narcotic drug imports and exports. The duty of enforcing the Harrison Narcotic Law was assumed by the Bureau of Internal Revenue through its field officers engaged in enforcing all internal revenue laws. There was no separate, specialized group of officers bound exclusively to the duty of enforcing this statute. With a growing realization of the inadequacy of such an arrangement for law enforcement to cope with the control of narcotic drug traffic, the Congress in 1930 established the Bureau of Narcotics in the Treasury Department. To this Bureau were transferred all functions and duties of control over narcotic drug imports and exports and enforcement of the narcotic law which were previously exercised by the Federal Narcotics Control Board and the Bureau of Internal Revenue, respectively. The Federal Narcotics Control Board was thereby abolished. The policy of the new Bureau was to cut off the supply of the illicit drug traffic at the source. Steps were taken to curb the smuggling of large quantities of contraband narcotics. At the same time the Bureau attacked the illicit domestic traffic. The Law in Relation to the Addict: Among those apprehended in narcotic traffic, whether it be for possession or purveyance, the law recognizes no distinction between addict and non-addict. Judges, however, assert that they distinguish between the addict and the commercial supplier. They regard this distinction as fundamental in the application of penalty. They argue that the laws of penalty should have sufficient latitude to allow judicial discretion for imposing them on an individual basis. But, they complain, Congress has limited judicial power by enacting mandatory penalties. In actuality, quite apart from the length of the sentence, there are no criteria, no system, no uniformity of practice in the disposition of arraigned addicts. Some are disposed of as criminals, some as sick persons. What happens to the arraigned addict seems to be a matter of unpredictable chance, perhaps largely depending upon the attitude and degree of enlightenment of the court. The Law on Rehabilitation and Its Execution: Besides its enactment and enforcement of laws designed to limit the trade in narcotics to medical uses and thereby diminish the number of addicts, the Federal government has attempted to provide rehabilitation of the addicts through hospitalization in two Federal institutions. These hospitals in Fort Worth, Texas, and in Lexington, Kentucky, care for 1) those who, on conviction, are sentenced to confinement in such institutions, 2) those who are ordered to submit to such treatment as a condition of probation, and 3) patients who apply voluntarily for treatment. The statute authorizing the Surgeon-General to provide for the "care, protection, treatment, and discipline of" addicts commands: . . . Such care and treatment shall be provided at hospitals of the Service especially equipped for the accommodation of such patients and shall be designed to rehabilitate such persons, to restore them to health, and where necessary, to train them to be self-supporting and self-reliant." Of interest in the treatment of addicts is the confident and dogmatic pronouncement laid down in the Federal regulations. There it states: "It is well established that the ordinary case of addiction yields to proper treatment, and that addicts will remain permanently cured when drug taking is stopped and they are otherwise physically restored to health and strengthened in will power." In the Federal hospitals the addict is treated as a patient. Actual treatment begins with gradual withdrawal of the drug in order to break the addict's physical dependence on it. An important part of the treatment remains; for the problem contains a large psychological component. Narcotic Laws and the Private Physician: Under the law, which was enacted for revenue purposes, the medical and allied professions are charged with the responsibility of prescribing narcotics under restrictions. Physicians may prescribe narcotics to patients for the relief of pain and discomfort associated with disease. They may attempt to treat an addict to free him of this habit, but only in a manner dictated by the Federal regulations. They may not prescribe a narcotic drug to keep comfortable a confirmed addict who refuses withdrawal but who might under regulated dosage lead a useful life and later might agree to withdrawal. These prohibitions are specifically set forth in the Federal regulations: . . . This bureau has never sanctioned or approved the so-called reductive ambulatory treatment of addiction, however, for the reason that where the addict controls the dosage he will not be benefitted or cured." "This bureau cannot under any circumstances sanction the treatment of mere addiction where the drugs are placed in the addict's possession, nor can it sanction the use of narcotics to cover a period in excess of thirty days, when personally administered by the physician to a patient either in a proper institution or unconfined. If a physician, pursuant to the so-called reductive ambulatory treatment, places narcotic drugs in the possession of the addict who is not confined, such action will be regarded as showing lack of good faith in the treatment of addiction and that the drugs were furnished to satisfy the cravings of the addict." "An order purporting to be a prescription issued to an addict or habitual user of narcotics, not in the course of professional treatment in an attempted cure of the habit, but for the purpose of providing the user with narcotics sufficient to keep him comfortable by maintaining his customary use is not a prescription within the meaning and intent of the act; and the persons filling and receiving drugs under such an order, as well as the person issuing it, will be regarded as guilty of violation of the law." It should be added that a verdict of guilty carries a prison sentence. All things considered it is small wonder that most physicians would prefer not to have addicts appear as patients in their offices. Here is an instance where it would seem that control of medical practice has already come under Federal power. However incongruous it may seem, the government has achieved that control indirectly through a revenue measure. It has been seen that the Federal government has attempted to minimize the spread of narcotic addiction through restrictions on the sale and use of narcotics and through suppressing illicit traffic in narcotics both internationally and domestically. It has exercised control over export and import of narcotics; particularly it has aimed to cut off illicit supply at its source and to curb smuggling. It has also exercised control over domestic traffic by regulating production, manufacture and distribution of narcotics. It has restricted the drug to medical and scientific use. Violations of the narcotic laws carry penalties. Under these laws the government has attempted to apprehend and sentence those engaged in illicit traffic. As has been noted, it achieves its objective indirectly. These Federal regulations embody a philosophy of approach to the problem of drug addiction. First, it reflects the view that it is possible to stop the spread of drug addiction by prohibition of the drug. Deprivation of the drug is to be accomplished by stopping supply. Secondly, it reflects a punitive approach in that stiff penalties are to act as a deterrent. Thirdly, by virtue of possession or of selling the drugs, the drug addict is regarded as a criminal. Among violators of the narcotic laws no distinction is drawn between addicts and non-addicts. Fourthly, it exercises rigid control over the physician in the practice of medicine. It makes the physician responsible for administration of the drug; but it sets down medical opinions on prognosis and dictates the kind of treatment in statutes. The Harrison Act itself did not attempt to deal with the problems of the addict; it attempted only to regulate the flow of narcotic drugs. The interpretations of the Act, however, have altered what appears to have been the original intent of the measure in such a way that it is now difficult for physicians to render medical care to narcotic addicts except under carefully prescribed circumstances. THE EXISTING SITUATION How effective has been this approach? Here we are actually concerned with its bearing upon two separate but interrelated components: traffic in narcotics and the drug addict. The latter in turn has two divisions: the formation of new addicts and the rehabilitation of existing addicts. First to be considered are narcotic traffic and the spread of addiction. Has there been diminution in the volume of traffic and spread of addiction? Is there proportionately more or less traffic and addiction prevalent? What is the existing situation? Prevalence of Addiction and Illicit Traffic: There are assertions that there is an increased prevalence of drug addiction. If so, it may be inferred that there is an increase in drug traffic. But not all authorities accept this assertion. There are counter-claims that drug addiction under present regulations has diminished. The uncertainty grows out of a lack of substantiated and convincing statistics. There is no accurate information obtainable on the number of addicts in the country. Data on the number of arrests for violation of the narcotic laws do not give information on the number of undetected addicts in the nation; only those who come into contact with the law are now available for counting and even those do not provide an accurate measure of the prevalence of addiction because their arrests are too often recorded under other charges. A careful medical evaluation of those arrested as "thieves" would probably show that in a number of instances they should more properly have been classified as "addicts." Inasmuch as the addicts are classed and hounded as criminals it is just about |