1951 as during 1948. The Federal Narcotics Bureau confirms this trend nationwide by reporting 6,149 arrests in fiscal 1950-which was 1,048 more than in fiscal 1949.

Let's take a look at the success we've had in curing addiction, and at what it costs.

The chief treatment centers are the two Federal hospitals, one at Fort Worth, Tex., with about 400 beds, and the older, better known one at Lexington, Ky. There is space at Lexington for about 1,500 patients. About 4,000 are admitted each year for a minimum treatment time of 41⁄2 months. In 1946, 3 percent of these patients were under 21. In 1951, 18 percent were under 21; 1 was 13 years old. It costs the Public Health Service $3 million per year to run these two hospitals. Dr. John D. Reichard of Lexington says that of their patients, 13.5 percent abstain after their "cure." He also says 39.9 percent relapse in 9 months to 3 years. The remainder are either dead or not known. This, a recent official report, indicates that at best not more than one-quarter of the people who go to Lexington are permanently cured. And many knowledgeable people scoff at these figures as being ridiculously high. One man who has been treated at Lexington and who has studied addiction for years says, "It's closer to 3 percent cures." Yet nearly everyone, doctors, social workers, enforcement officers, and addicts themselves, say cure without confinement is impossible. Or, at least, it's hardly ever been done.

Exact figures are not to be had, but each cure at Lexington (if we divide the cost of operation by the number of real cures) costs at least $4,000. A part of this expense is paid by some of the voluntary patients, and since no one actually knows how many cures are made, this figure is little more than a guess. To this cost of treatment should be added that of enforcement. The Narcotics Bureau will spend $2 million this year, its largest budget in history. Many States have their own narcotics squads; so do many cities. Clearly all these add up to astronomical even though unobtainable figures.

And still Americans, many of them normal people and far too many of them children who don't know what they are doing, are having their lives destroyed by drugs. The cost to these people in New York City alone is more than $100 million per year.

II

It seems clear that our present efforts to eliminate or even control the drug traffic are not working. It's time to try something else. What should a rational narcotics program accomplish?

First, it should reduce the number of addicts sharply.

Second, it should prevent the making of new addicts, especially among our youth.

Third, it should eliminate crime caused by the need for drugs.

Fourth, it should take the fantastic profit out of the narcotics traffic. .

Fifth, it should discover who the addicts are and how many there are.

Sixth, it should determine more facts about addiction, medically and psychologically. The ignorance of addicts about their affliction is abysmal and tragic, and doctors themselves admit they know far too little.

There is a way to win every one of these objectives. Useful citizens can at the same time be made out of addicts who happen to be incurable, as even the Federal Bureau of Narcotics, which hounds and reviles them, admits a great many probably are. There seems to be no doubt that many people must live as addicts until they die, and they rarely die of drugs. People have lived, 20, 30, even 40 or more years as addicts.

What is this method and what reason is there to believe it will work?

For the answers to these questions we must go back to 1919 and the early 1920's, when many narcotics clinics were operating in the United States. Usually under control of State, city, or county health officials, these were run by physicians of excellent standing, with the blessing and active cooperation of medical societies, many of which were affiliated with the American Medical Association. In them addiction was recognized as a medical and public-health problem. Persons who came in and could establish the fact of addiction were given advice and information, and drugs were dispensed to them. Moral, social, and welfare aspects of the problems, however, surprising as it now seems, were generally ignored. In spite of this fact doctors in charge reported that their work reduced crime, made useful citizens, blasted the illegal drug traffic, and in some cases established cures.

These clinics existed, at one time or another, in 15 or more States. New York City had such a clinic from July 17, 1919, until March 6, 1920, and 16 other cities in New York State had them. Among the most successful were those at Los Angeles; Portland, Oreg., and Shreveport, La. Many States, such as Tennessee, had modified clinic systems providing for medical care of addicts and the dispensing of drugs to them.

What happened to these clinics? Why is there not a single such institution in the United States today? If they were so successful, why did they close? The answer is simple-and shocking.

The basic Federal narcotics law is the Harrison Act of December 17, 1914. This is a revenue act, not a prohibitory law. It neither forbade doctors licensed under it to prescribe drugs nor did it limit the amount they prescribed. It required only that they keep a record of how much they prescribed to which patients, with dates.

In 1921 a four-page advisory leaflet, inspired by a report of a committee of the American Medical Association, was issued by the Prohibition Bureau, then in charge of narcotics law enforcement. This leaflet stated that addicts should be confined during treatment for addiction. The four members of this committee were physicians of excellent reputation and there is no doublt they sincerely believed in their recommendations, but other members of the AMA of equal experience and reputation, who were actually running narcotics clinics, just as sincerely believed they had found the answer to the drug problem.

Yet on the basis of this leaflet, which had no legal status and for which none was claimed, the clinics were closed. Patients were driven to despair and crime. Many became dope peddlers to protect their own supply, and in order to sell enough dope to earn the cost of their own they made addicts out of the easiest marks-young, ignorant, frustrated kids. This single bureaucratic step, unauthorized by Congress, destroyed all honest attempts, other than forced hospitalization, to treat addiction as a medical problem instead of a crime. Many observers have remarked that on this single, almost forgotten, leaflet the present narcotics trade, the narcotics crime picture which we see today, in fact much of the narcotics evil is based. In European countries today, where doctors can treat addicts as sick people, the appalling picture of crime and teen-age addiction does not exist. It did not exist in cities with clinics in this country as it does now, before the release of this leaflet.

This damaging misinterpretation of the Harrison Act has not gone unobserved. Doctors, welfare workers, and even the Supreme Court of the United States have noted it. The entire matter was succinctly and completely aired in Congress on June 15, 1938, by Congressman John M. Coffee, of Washington. Mr. Coffee wanted to transfer the entire narcotics enforcement problem from the Bureau of Narcotics to the United States Public Health Service. He spoke of $2,735 million a year cost of addiction as a "needless burden imposed on the people, not by conditions inherent in the problem of drug addiction, and not by the operation of the law, but by the mistaken interpretation of law made by the Federal Narcotics Bureau." Continuing, he pointed out that "in examining the Harrison Special Tax Act we are confronted with the anomaly that a law designed (as its name implies) to place a tax on certain drugs, and raise revenue thereby, resulted in * * * developing a smuggling industry not before in existence. Through operation of the law as interpreted there has developed the racket of dope peddling; in a word, the whole gigantic structure of the illicit drug racket, with direct annual turnover of upward of a billion dollars." [Italics ours.]

Mr. Coffee went on to summarize the findings of the United States Supreme Court in the Linder case of 1925 and the Nigro case of 1928, both of which clearly established that the Harrison Act was a pure revenue act, and the AAA case of 1936 which established that Federal law has no control over the practice of a profession. Said Coffee: "The Narcotics Bureau ignores these decisions and assumes authority to prevent physicians from even the attempt to cure narcotic addicts unless the patients are under forced confinement." Coffee went on to recommend putting addicts in the care of physicians who would prescribe what medicine they might need, presumably including narcotics. Confidently predicting the end of the narcotics traffic if this were done, Coffee asked why the Harrison Act should not function as originally intended and as the Supreme Court said it should. In reply to this question he said "the opposition comes from a small coterie of persons in authority who are in a position to benefit from the status quo." He particularly desired "to question the Commissioner of Narcotics and to observe how he may endeavor to justify the activities that cost the American people not far from $3 million per year."

71515-56-pt. 529

III

Actually Congress would have to pass no law to reopen these clinics, other than an appropriation measure. All that would be necessary would be a reversal in policy by the Federal Bureau of Narcotics. Unfortunately it is far too late to return to this simple clinic system. It is too late to legalize prescription by doctors which, although it works in Europe, never functioned well here. (In 1919 the Treasury Department estimated that 30 doctors in New York City wrote 1,500,000 legal prescriptions for drugs each year. Their "patients" were addicts, and no control was exercised over the drugs they bought freely on prescription. Abuses such as overdoses and resale of supplies were very common.) The problem must now be handled in a different way in order to meet today's much more difficult conditions.

The Federal Government, probably through the United States Public Health Service, which runs the hospitals at Lexington and Forth Worth, should be enabled to open clinics in places where the problem is acute and to permit designated physicians to take over similar functions in smaller places. The purpose of these clinics would be to cure or alleviate addiction, to wipe out the illegal narcotic traffic, and to eliminate crime by addicts in need of drugs. There would also be secondary functions which will be discussed later.

Any person, regardless of age, should be able to come into one of these Federal clinics and register as an addict by filling out a form. He would be required to state that it was his desire to be cured of addiction and would plege cooperation with the physicians. Naturally, because of the nature of his affliction, this pledge would in no way relax the extreme care and close supervision which is always necessary. In other words, the physicians in charge would not agree to believe everything they were told.

The addict would then get a thorough physical examination to determine whether he was truly an addict and to what degree. Great care would be necessary to prevent the deliberate picking up of the habit or reversion to it by former addicts, and this scrupulous medical attention would be an essential part of clinic operation. Each registrant would be photographed and his fingerprints sent to the FBI to check the legitimacy of his identification and to prevent registry at another clinic under another name. Each registrant would receive a tamperproof laminated card with his signature, address, photograph, and fingerprints on it. Corresponding records with space for recording each medication given, would be kept at the clinic office.

The addict's identification cleared, the physician in charge would proceed to determine how much of what drug he had been taking and what quantity of morphine might lead to a balanced dosage. (Heroin, not in the United States Pharmacopoeia, would probably not be dispensed; morphine is less harmful and can be substituted.) A balanced dosage is the smallest amount which will keep an addict reasonably free from the nightmarish withdrawal symptoms. Its establishment is far from easy and may take weeks, even months, of careful watching, recording, and analysis. But it is an important step on the long, hard road to recovery.

At this point three important things will have been accomplished for the addict himself. First, he will have gone on to the least harmful drug which will satisfy his need; second, he will know how much he really needs; third, he will be released from the tension of worry over where the next dose is coming from. A gradual relaxation may be expected to follow which will make a balanced dosage and a reasonable attitude easier to establish. An actual cure would not be attempted until much later, in a few cases perhaps never. There would be no urgency to get an addict off drugs in a hurry, since this would defeat the whole purpose of the clinic by driving him back to the illegal market.

Dosages would be carefully measured and recorded, not cut, as is universally done in the illegal traffic. Instruments would be sterile, not contaminated. Advice would be freely given, questions honestly answered.

The dosage established, would always be dispensed at the clinic. Neither prescriptions nor a supply-not even enough to last one day--would be put in the hands of the addict to carry away. Whether by needle or mouth, all doses would be taken at the clinic. The price of each dose, regardless of size, would be nominal-probably 10 cents. This would cover the actual cost of the drug. Pauper addicts would be treated free.

Each registered addict would be given a booklet on the first visit explaining the medical facts of his affliction. He would watch educational films and listen to lectures. He would have what psychiatric help could be made available.

His personal, home, employment, and other problems would be discussed with social workers and job specialists. Efforts would be made to find him a job. He would be referred to religious counsel of his choice. Whether contrite or not, he would be treated as a person with serious problems, as a medical and social case, not as a criminal.

No registrant would ever formally be told he was incurable, even though the doctors thought so. Whether or not ambulatory cures are actually possible no one has ever conclusively proved or disproved under properly controlled conditions. There are doctors who believe they are possible. Here again, we are dependent on information which would be scientifically gathered through the experience of the clinics. The hospitals would remain open in any case and would be more effective because the clinics would provide followup treatment, advice, and aid not now available to the discharged addict. Patients of both hospitals and clinics would, in fact, be required to report to the clinics for checkups at intervals for some time after their cure had been accomplished, if indeed it had been accomplished.

IV

What would be the effect of this modern, comprehensive clinic program? First, it would provide every addict who registered with complete information about addiction and what could be done for it.

Second, it would place his photograph and fingerprints on file. The primary purpose would be to prevent duplicate registration in another clinic. But it would also be easier to catch up with addicts who, in spite of the removal of their needs for big money, got into trouble.

Third, while criminal addicts could be caught more easily, this program would itself make crime quite unnecessary for most addicts as indicated above. In addition, it would make addicts very wary of criminal activities because not only would they be almost certainly caught, but once caught they would be subject to the ordeal addicts most fear-immediate, total withdrawal of their drug supply. It might even, in some cases, lead to speedy reform of minor criminal tendencies.

Fourth, many experts believe that the program would virtually wipe out the illegal drug traffic by removing the profit from it. (Only addicts afraid to register would have to pay the high illegal prices.) If no stigma and no publicity were attached to registry few would avoid it. And the capture of unregistered criminal addicts would become far easier.

Fifth, the program would give youths the true facts of addiction and make them more amenable to cures, which are much easier for young people than for old and much easier for new addicts than for those of long standing. Thus it would reduce both the number of addicts and the degree of their addiction.

Sixth, and this is most important, it would tend to save teen-agers from addiction. At present teen-agers get their first few doses free. Once "hooked" they must pay, and through the nose. However, from the peddler's point of view, what would be the use of giving away expensive drugs to get another customer if, the minute addiction was established, he was lost to the Federal clinic? And the peddler who sold drugs only to get his own supply, as many do, would immediately remove himself from the market. It would no longer be necessary to make sales by infecting young people who knew no better. He could get his own supply at the clinic, and help and advice with it.

Seventh, it would provide medical information which we now sadly lack. Certainly the proposed Federal clinics would not solve all drug problems. Hospitals would still be needed, and narcotics police to prosecute the illegal traffic, and international agreements and cooperation. But without such clinics all our present efforts are useless; with them as an integral part of the plan, there is promise of a solution.

What are the objections to such a plan? Many people feel that nothing should be done for addicts, that they are worthless, vicious, and dangerous, and that the only real answer is to wipe them off the face of the earth. In 1936 the Chinese Government of Chiang Kai-shek was calmly shooting as many as a hundred of them at a time for no crime other than smoking opium-which actually kept them out of trouble by putting them into a sound sleep. Our occidental culture would recoil from such inhuman methods even if they were effective. In China they were not effective. The reason is quite simple. You cannot kill all addicts because you cannot find all addicts, and the ones you don't find will infect others to protect their own supply. You can kill people of whom you are blindly afraid

for no good reason, but when you have finished you will be no better off. You will simply have a fresh crop.

Other people raise their hands in horror at the suggestion that the Federal Government dispense drugs to addicts. Well, addicts will get their drug anyway. Why not give it to them under controlled, safe conditions instead of driving them into the criminal jungle? Why shouldn't the Government dispense drugs if by so doing it can better the condition of the addicts, sharply reduce crime, blast the illegal narcotics racket, and, most important of all, save its youth from a living death?

"Addicts won't register," say other critics. Maybe a few of them won't. But on the first day the New York City clinic opened in 1919, no less than 1,500 did register, and others trooped in on following days. And 15 States didn't support health programs that had no patients. Obviously they had patients-addicts did register and there is no reason to think they won't again.

Several addicts objected to the idea of getting dope only at the clinic. "Some people need a shot every 3 or 4 hours," they said.

But unfortunately the experience of the twenties indicates that this is the only way doses can be given without cheating by addicts. It's more trouble and more costly but it's the only way to prevent fraud and safeguard the program. However, there are various ways of increasing the intervals between doses when physicians are in charge and it is quite unlikely that this would be a serious problem except in a few cases which ought to be hospitalized anyway. These clinics would be run less for the comfort and convenience of addicts than for the good of the Nation.

"It would cost too much." Yes, it would be expensive. But if you add the cost of enforcement, cures, and crime to the amount of money thrown to the jackals who sell the drug today, even the cost of running clinics as they should be run does not look so large. Nothing more than a guess is possible, but probably the clinics would cost less than one-third as much as the Nation spends on addiction today.

"Some addicts will cheat." Yes, some will. What of it? Under present conditions they all cheat. And cheating can be cut to a minimum by watchfulness on the part of clinic personnel.

"Ex-addicts will revert if they know they can get the stuff free." The answer to this objection is slightly more complicated but very important. The determi nation of actual addiction is medically far from simple. It is, however, possible, and would become increasingly certain as clinical experience built up. It is quite unlikely that more than a very small percentage of ex-addicts would be able to deceive the clinic physicians. And suppose a few do revert? It's still a vast improvement. As things are now, nearly all revert.

The recognition of addiction as a complex sociomedical problem offers the only hope of getting rid of it. Clinics would reduce sharply the making of new addicts. would cut the illegal drug traffic and crime caused by it, and would save our youth. By the grace of God addicts, like other people, eventually die. If no new addicts are made, addiction would disappear with them. And in the meantime Federal clinics would make them useful citizens until that, for them, happy time.

EXHIBIT No. 11

STUDIES ON NARCOTICS USE AMONG JUVENILES 1

Research Center for Human Relations, New York University

When in 1952 our group at NYU and others started investigating juvenile drug use at the request of USPHS, we were exploring a virtually unknown territory. Available information was for the most part unsystematic or unreliable or both. This condition largely determined the design of our studies: It was necessary to obtain, first, a bird's-eye view of each of the many aspects of drug use among

1 The studies reported on here, except for that of Drs. Donald L. Gerard and Conan Kornetsky, have been supported by the U. S. Public Health Service under a series of special grants. The Gerard and Kornetsky study was done while both of the authors were in the USPHS. Our own studies were conducted by Eva Rosenfeld, Daniel M. Wilber (until July 1954), Robert S. Lee, and Donald L. Gerard (since September 1954), under the general direction of Isidor Chein.

The present paper was read by Isidor Chein at a meeting of the Committee on Drug Addiction and Narcotics of the National Academy of Sciences and the National Resear Council, September 30, 1955.