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tion was taken in certain cities recently. For example, the narcotic clinics conducted in the cities of Los Angeles and San Diego for a brief period in 1920, were based on this principle, and produced results that were encouraging, to say the least.
The Los Angeles clinic was started as a department of the board of health, with the approval and assistance of the municipal authorities, for the purpose of giving preliminary medical treatment to the narcotic addicts. This clinic endeavored to supply persons who required the constant use of an opiate with the necessary amount of their narcotic in gradually decreasing doses and at a nominal price. It was conducted by physicians detailed by the health commissioner, and under the immediate direction of a narcotic board composed of prominent physicians, public-spirited citizens, and Federal, State, and municipal officers who volunteered their time and services.
It was not the purpose of this clinic merely to supply the opiate addicts of the community with narcotics. On the contrary, the clinic was established for the purpose of medical treatment, with gradual withdrawal of the drug, and final cure when possible. Complete cure by this method would not be possible in most cases, of course; but it was possible to reduce the amount of drug used, and improve the patients' physical condition so that they could be treated successfully in some suitable institution at the proper time.
The things actually accomplished by this clinic attained, in a measurable degree, the object for which it was created. During the 5 months of its activity more than 500 drug addicts applied for treatment. It was a motley company representing every walk and condition of life. Every degree of financial status was represented, every shade of dishonesty, as well as every grade of intellect. Some came from purely criminal motives, others with the exalted purpose of being cured of their habit. Still others, in the hope that they could escape the clutches of the illicit peddler and his extortionate prices.
A record of the obstacles that had to be overcome in putting this experimental clinic into practical running order, the mistakes that were made, the trickery and deception that were practiced, as well as the honest endeavors of the deserving addicts and persons suffering from painful bodily afflictions, would make a volume of intensely interesting and variegated narrative. But the important things accomplished may be summarized in a few paragraphs. For one thing, illicit peddling was reduced to a minimum. When the patient could get morphine honestly for 10 cents a grain, why be dishonest at 10 times that price with a good chance of landing in jail into the bargain? The peddlers complained, almost openly, that they were "being ruined" by the clinic.
To the class of persons suffering from painful afflictions, such as tuberculosis and cancer, whose condition made the continued use of an opiate an absolute necessity, the clinic was a veritable godsend, for it enabled them to procure their necessary drug at a reasonable price and in a legitimate manner. Thus they were able to reduce the amount of the narcotic, since, curiously enough, the uncertainty of being able to get a supply of the drug always tends to make the addict use more of it.
The clinic made it possible for several individuals to engage in honest occupations for the first time in many months. Heretofore, the uncertainty of the source of supply, and the ruinous prices demanded by the peddler had kept these patients in such a state of physical dilapidation that they were unable to work. Thus the clinic enabled many of these victims to again become honest breadwinners. Several of them were now able to provide for their families and again live in a respectable and self-respecting manner. And meanwhile their general health was improved by the gradually reduced doses dispensed at the clinic, and the release from the harassing anxiety about obtaining their drug. It is a fact well known to persons familiar with the subject, but not appreciated by the generality of people, that almost every drug addict wishes to be freed from his bondage. In many instances the desire is an inadequate and feeble one, of course, while in others it is insistent and compelling. The members of the clinic exemplified this in an amazing degree, all things considered. Within 2 months after opening the clinic, 24 individuals had made earnest application to be placed in some institution for the final treatment and cure of their addiction. And it is most illuminative that after the clinic was closed, no less than 26 persons were given this curative treatment in private institutions from the accumulated funds: and fully as many more had filed applications for taking similar treatment and were bitterly disappointed when they found that no more funds were available. This alone, the fact that half a hundred persons out of a total of 500, were 71515-56-pt. 5-28
sufficiently earnest in their desire to be cured that they were willing to surrender themselves for radical treatment, is convincing evidence of the usefulness of this experimental clinic.
Moreover, the clinic enabled the officers to determine pretty accurately the number of drug addicts in the community, particularly the class of drug takers likely to become a public menace. And the surprisingly small number of these individuals seems to refute the popular idea that drug addiction is running riot in our communities.
The fact that so many of these clinic patients were anxious to take a final curative treatment in some proper institution, and that such a relatively large number of them actually did so is an indication of what might be accomplished with a clinic having hospital facilities at its disposal. Such an arrangement is, of course, the one now in vogue for treating almost all physical ailments; and even mental diseases are now so cared for in certain favored communities.
A similar arrangement, modified to meet the various conditions, would put the legal and medical authorities closely in touch with the addicted patients and with the narcotic situation, in a manner similar to our arrangements for controlling other serious diseases, such as tuberculosis. This factor alone, it seems to me, justifies the reestablishment of clinics along similar lines to the experimental ones tried with such a measure of success in Los Angeles and San Diego. Undoubtedly great modifications would be necessary. But great modifications are always necessary in any progressive experimental work.
In addition, some special hospital provisions should be made, just as in the case of insanity. And there should be some governing body of specially qualified medical examiners to determine the requirements of each case similar to the medical commissions that determine the status and dictate the treatment in insanity cases.
Unlike the existing laws governing insanity, however, the final decision about any case should not be left to the judgment of juries composed of laymen, for the average layman knows less about opiate addiction than he does about the psychoses. And one can scarcely expect intelligent assistance and cooperation from any body of men who know practically nothing about the subject they are called upon to decide.
Perhaps the best practical solution of the whole narcotic problem would be to place it unreservedly in the hands of the United States Public Health Service. This would bring it under control of intelligent physicians who also have legal authority to enforce any clinical or custodial measures that seem necessary.
In any event, the narcotic addict is with us, and like the poor, and the bad, and the unfortunate, he is likely to remain with us. Only the visionary idealist, or persons ignorant of human nature and of human history, can believe otherwise. No great compelling human vice or disease has ever been completely stamped out. And the best that we can hope to do by our most concerted efforts, for the present at least, is to reduce narcotic addiction to a state of reasonable control.
EXHIBIT No. 7
[From American Medicine, January 1920]
A RÉSUMÉ OF FACTS AND DEDUCTIONS OBTAINED BY THE OPERATION OF A
By M. W. Swords, M. D., Secretary, Louisiana State Board of Health, physician in charge narcotic dispensary, New Orleans, La.
Narcotic laws in vogue being apparently defective in controlling the drug traffic and narcotic addiction, the State of Louisiana recently enacted a new State narcotic law, directed toward the better control and regulation of said drug traffic, particularly through its principal offenders, the "trafficker," "vendor," "morphine doctor" and "dope apothecary." This legislation created a drug "panic" in addict circles, causing drug "vendors" to cease their activities temporarily, by cutting off the main source of drug supplies. In desperation, addicts applied to the Louisiana State Board of Health for relief, the only place where they could have reasonable assurance of assistance.
It was apparent, after reflection, that in the passage of this antinarcotic law, the addict, the principal one affected, had been overlooked. His unfortunate plight had not been sufficiently considered, and the possible results of the law
not intelligently comprehended.
The Louisiana State Board of Health came to the conclusion that addicted humans were deserving of consideration and care, as well as those unfortunates afflicted with other diseases, and a remedy was sought to meet the occasion.
Neither the State nor board was financially able to care, even temporarily, for these sick people. It was expedient that immediate means must be had by which a grave condition could be met. It was decided, therefore, to supply addicts with their drug at cost price, plus a sufficient margin to meet expenses incidental to the opration of the dispensary.
It was found that opium (and its derivatives) was the one drug of physiologic necessity insofar as addiction is concerned. Consequently, it was decided that morphine, the principal opium derivative, should be the only drug dispensed.
The narcotic dispensary having been established, other questions presented themselves, the most important of which was "Why so many addicts?" and "Whence the enormous supply of drug?" It was found that the main supply was through "drug traffickers," made up of irresponsible "vendors," "unscrupulous apothecaries" and "morphine doctors." Knowing the supply, the natural question was "How to combat it?" Laws being ineffective, it was determined that some rational means be established to strike at the heart of this nefarious evil.
Legitimate supply seemed to be the most logical plan that presented itself. To meet the illegitimate vendor and prescriber of drugs on a common ground, the narcotic dispensary supplied addicts in a legitimate way at a price so low that the vendor would not take chances of falling into the hands of the law for the small profits brought about by this new form of competition. The effect of this modus operandi was apparent. The vendors of drugs utilized their wits unsuccessfuly in attempting to combat a practical demonstration of legitimate supply, with the result that their activities became less, many of them being forced to seek more profitable sources of revenue.
Cause and effect, profit and supply are the basic principles that must be met in the solution of the drug problem.
What is the cause? The medical and allied professions, environment of the "tenderloin," and association are the principal causes.
In reality drug addiction is a physiologic changing of the proper functioning of every organ and tissue, creating the pathologic mechanism of a definite "disease" characteristic in its symptomatology and pathology and which cannot be combated except by scientifically adapted measures. Drug addiction, as applied to opium, and its derivatives, is a disease and not a human frailty, and must be recognized as such before any rational solution of the problem can be understood and any treatment successfuly directed toward its cure and eradication.
What is the supply. Doctors, hospitals, and the underworld, through illegitimate vendors.
What actuates this practice? Millions of dollars each year spent by men and women which go into the coffers of the "man higher up," who directs the business and is the real recipient of this enormous profit.
How to combat it? By furnishing a legitimate supply. Addicts are not necessary, but are with us; their addiction disease is a part of themselves, a condition eternally demanding relief. A legitimate source of supply should be provided at a price so low that the illegitimate vendors must meet it or go out of business. Legitimate supply is the basic principle on which this narcotic dispensary is combating the drug evil. It will take time and education to effect perfect results. Necessarily there are other scientific problems for solution. The first is to extricate the poorer addict from his unwholesome surroundings. This we have attempted to do by establishing a dispensary that in appearance and respectability inspiries dignity and confidence.
In our dispensary, as the photographs will show (see fig. 1), there are five separate entrances, designated as "Private Office," "White Female," "White Male," "Colored," and "Clinic," each separated from others by partitions. You will also note (see fig. 2) the business-like appearance of the offices. The three booths, viewed from "Private Office" are shown also in the photograph (see fig. 3). The private office (see fig. 4) is so arranged that it can be curtained off for additional privacy. The dispensary is thoroughly equipped and well lighted. We have a well-equipped laboratory.
Our medical clinic (see fig. 5) is equipped for determining any physical disability or illness of its clientele. This clinic has in attendance two doctors and a trained nurse. Histories are taken and filed, covering past and present condi
tion of patients, together with statements of physical irregularities. Each addict is examined to establishd primarily whether he or she is an addict, the cause of addiction and every other detail pertinent to the physical and mental condition. In our dispensary we endeavor to practice the highest type of medicine.
OBJECTS OF THE DISPENSARY.
1. We realize that a permanent cure of those afflicted with drug addictiondisease is impossible, in the great majority of cases, unless the addict be placed in a position to secure scientific treatment. The sole object of this dispensary is to relieve suffering until such time as a scientific treatment may be had.
2. The basis of operation is legitimate supply versus illegitimate trafficking. 3. To prevent a victimized people from being more thoroughly victimized by heartless, profiteering "ghouls." To prevent the making of new addicts.
4. Diminishing petty thievery which constitutes a tax, or burden, on society. for the reason that many addicts, unable to pay the price of $1 to $3 per grain, are forced to criminal methods.
In the operation of this dispensary, we have refrained from "registration” of addicts, compulsory hospitalization and police interference, all of which would intimidate the addict and drive him back to the underworld supply, and thus defeat our primary purpose. We have no "registration" to compromise addicts or subject them to possible blackmail. Their secret is guarded in strict confidence. We work in harmony with officials, but not to the extent of betraying confidences.
This dispensary does not attempt to cure addicts, realizing that this is a problem that can only be solved when addiction-disease is better understood. We are establishing, however, in connection with our dispensary, a research laboratory with the hope that ultimately this may lead to some scientific means by which cures may be effected.
Much has been written regarding addiction that has been actuated by mercenary interests. Facts regarding morphinism are known to but few. The literature is filled with various treatments, a few only by scientific men who have a conception of drug addiction-disease and what it means.
The reduction treatment is much discussed. In our opinion, it is a fallacy, pure and simple. The "hot shot" and other forms of treatment are empirical and not based on scientific knowledge. Some are effective, no doubt, in individual cases, but this obtains only in isolated cases and must not be confused with the entire problem of addiction-disease.
The forcible reduction treatment will do more harm than good, and is worse than no treatment at all, and I quote from an article, written by Dr. Bishop, of New York, an excerpt which meets with our approval:
"The forcible reduction of dose without regard to the environment, economic, physical or other conditions of the average and individual addict, and absolutely ignoring the considerations of the mechanism and symptomatology of his addiction-disease is barbarous, harmful and futile. Enforced reduction of dose below the point of body need is not worth what it costs in nerve strain, suffering and physical inadequacy. The extent of addiction-disease and degree of progress in its remedy cannot be measured in terms of amount of drug administered. It must be measured in terms of clinical symptomatology. Reduction of dose below the amount of body need constitutes a serious therapeutic handicap and is most decidedly contraindicated. It is practically as hard to withdraw a narcotic drug from any addict whose body need is half a grain a day as it is from one whose body need is five grains a day. The average narcotic addict must support himself and family. His physical well-being and economic efficiency are considerations in the community in which he lives. In view of what I know can be done for final cure, I do not hesitate to say that it is much wiser to supply to this man the drug of his addiction to the extent of his body need and to teach him how to use the drug of addiction in such a way as will maintain his physical and economic efficiency than it is by enforced reduction of dose to deprive him for a long time of working ability and his family of his support. Furthermore, the addict who is insufficiently supplied with narcotic drug turns in desperation to the use of other things more harmful to him that the drug of his addiction. This he does in the vain hope of obtaining mental and physical stimulus and support and some surcease of his misery. The many wrecks of addicts to be seen trying to endure through insufficient supply of narcotic drug, self-poisoned with other drugs which
they purchased, alcohol, bromide, coal-tar products, cocaine and, of late, hyoscine their addiction-disease unrelieved and undiminished-are sufficient argument against mere reduction of dose. The ultimate withdrawal of drug from the narcotic addict is simply one stage and is not, by any means, the most important stage in his rational handling."
The dispensary has accomplished the following: Temporary relief of addicts at minimum cost. No new recruits through this dispensary. Petty thievery diminished among the lower class of addicts. We have made economic assets of many who formerly were human derelicts. We have made many happy mothers and children by enabling fathers and husbands to keep honestly employed. We have raised the morale of addicts to the extent that they no longer wish to steal, since the actuating motive has been removed. We have concentrated and segregated the principal offenders in petty crime. We have surrounded the high-type addicts with security and protection. All addicts are known and if any are "wrongdoers," they are apprehended. This instills a fear of crime and results in good behavior. The addicts have come to know the dispensary as their best friend where the hand of sympathy and understanding is held out to them. All of this has been accomplished at no cost to State or board of health. Our fight has been hard, due to the ignorance of laity and medical profession as well.
We knew that our efforts were directed properly when the American Public Health Association held its last annual meeting in New Orleans, and corroborated our deductions. Comprehensive discussions on the subject gave us courage to go forward.
We will finally conclude by using the language of Dr. Bishop, which expresses sentiments that can neither be improved upon nor added to:
"Before we can know what we can do for them, we must know what they are; before we can help them, we must know what is the matter with them. We have talked of drug addicts as if they were a class or type of person who might be typified by this title; as if there were drug addicts as differentiated in common characteristics from those who are not drug addicts."
EXHIBIT No. 8
[Excerpt from ch. XIII, Control (continued) Municipal, pp. 863-872]
The following is a brief history of the life of the narcotic clinic and hospital treatment at Shreveport, La., instituted as control measures under authority of the State Board of Health of Louisiana. We have already quoted from the minutes of the board and from opinions of the State attorney general and assistant attorney general upon whose authority the board's action was taken in establishing the New Orleans dispensary. While the Shreveport clinic was begun as a State activity, the greater part of its existence occurred under the authority of the municipality. It is included, therefore, in this chapter.
From the unpublished reports with which W. P. Butler, medical director, has supplied us, we have obtained the following outline of the clinic as operated under his supervision. Inasmuch as this clinic has given rise to much discussion we are including also such expressions of opinion from organizations and copies of correspondence as dealt with it during the different periods of its existence.
Inception, development, municipal activity, reasons for closing
During 1916 four physicians of Shreveport were indicted for violating the Harrison Act. They were not convicted but the incident had a psychological effect upon the medical profession as physicians hesitated, as Dr. Butler says in his report, to care for cases of addiction lest they unintentionally violate the Federal law, avoiding the handling of these cases rather than studying the law, the case itself and the problem as a whole.
This state of affairs became apparent to Dr. Butler, the parish physician, as the chronic users of opium applied to him for assistance and very quickly developed a sociologic problem which the community was not equipped to handle.
1 Source: Terry, Charles E., and Pellens, Mildred, The Opium Problem. The Bureau of Social Hygiene, Inc., New York, 1928; 1042 pp.