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change of information would provide groundwork. Establishment of lines of national liaison would be the first step.
I suggest that each State could provide a team of experts to attend such a conference, the expenses of that team to be borne by the State. Tentatively I would suggest that each team include representatives of the Governor and his enforcement branch, the Commissioner of Health, the Attorney General, the Correction, Welfare and the Mental Hygiene Departments, plus such non-government medical experts as are available.
The need for a change in the Federal Government's present narcotics program is pointed up by the bill introduced in the 84th Congress by Sen. Payne. But even beyond the steps proposed therein there are opportunities for tightening the machinery and broadening the scope of our national effort.
Two important long-range goals are within the reach of a national conference:
a. The development of a national medical research program, and;
b. Assessment of Federal and State activities in all phases of the problem of narcotic addiction and how they may be improved and coordinated.
The need for a Federally-sponsored research program has been touched on several times in this report. Precedents on the Federal level for such a program abound not only in the field of health but in agriculture, mining, shipping, aviation and many others. A concerted drive on the problem through facilities of universities and hospitals under the direction of a National Health Council should prove fruitful.
The Payne Bill (S.J. Res. 19) is chiefly concerned with a method for making Federal hospital facilities available for addicts committed by State courts, a subject I will come to with my last recommendation. At this point, however, I want to bring other features of it to your attention as indication of the need for overhauling the Federal narcotics program.
The Payne bill highlights the present gaps in preventive work by containing provisions to subsidize education programs with regard to causes and effects of narcotic addiction. The programs would be for teachers.
The bill also provides for increasing penalties for convictions of narcotic violations in Federal courts.
5. Further Use of Federal Hospitals: At the present time there are only two Federal narcotic treatment centers available; one at
Lexington, Kentucky, and one at Fort Worth, Texas. It is one of the paradoxes of the vexing narcotic problem that while there is some additional space available at these hospitals for addicts, they would be overwhelmed if they undertook to accept all worthy cases. The number of vacant and available beds at both these institutions could not accommodate, apart from persons committed for offenses in Federal Courts, in excess of 350 to 500 additional patients - and New York City cases alone could exceed that figure.
Nevertheless, the Payne bill attempts to make some of these beds available by authorizing the Surgeon General to admit for care and treatment addicts committed by State Courts. The bill limits the obligation of the Surgeon General to making beds available only after addicts committed in Federal Courts have been accommodated. The bill further requires that the States committing addicts for treatment in the Federal facilities shall agree to pay for the care and treatment at costs determined by the Surgeon General. It is in this respect of having the States absorb the costs that the Payne bill differs markedly from the one introduced in the 83rd Congress by Senator Ives and by me as a Congressman and by others. It appears now to me that this feature is more equitable and I urge support of this bill.
At best, it is understood, such a Federal measure would not end the pressure upon the States for more hospital space, but once in effect it might serve to underscore the value and need of extra facilities, leading in time therefore to a program of expansion.
Again, this recommendation is to be recognized only as a first step. But, like the other four it is a step that can be taken now when action is needed.
Council on Pharmacy and Chemistry
REPORT TO THE COUNCIL
Some months ago in a random sampling 50 physicians in California were asked the question, “If a narcotics addict came to you for treatment, what disposition would you make of the case?"
Inasmuch as four of the physicians queried indicated that they would treat the addict, while the others gave varied answers, the Council, believing that physicians in general would appreciate a discussion of the question, has authorized publication of the following statement. This statement has been prepared by the Committee on Drug Addiction and Narcotics of the National Research Council with the assistance of Dr. Harris Isbell, Director, National Institute of Mental Health Addiction Research Center, United States Public Health Service Hospital, Lexington, Kentucky. R. T. STORMONT, M.D., Secretary.
WHAT TO DO WITH A DRUG ADDICT
A recent questionnaire circulated in southern California revealed that many physicians were uncertain as to the proper course to be taken when drug addicts appeared in their offices. This paper has been prepared to provide information on the proper procedure in this situation. It will deal only with addiction to those substances covered by the Harrison Narcotic Act and similar laws, such as the Marihuana Tax Act. Specifically, the drugs concerned are opium and all mixtures containing opium, morphine, heroin, dihydromorphinone (dilaudidR), methyldihydromorphinone (metopon), 3-hydroxy-N-methylmorphinan (dromoran®), codeine, dihydrocodeinone (hycodan®), dihydrohydroxycodeinone (eukodal), meperidine (demerol®), methadone (dolophine,® adanon®), marihuana, and cocaine.
PERTINENT FEDERAL REGULATIONS
All physicians who prescribe and dispense narcotics are furnished by the Bureau of Narcotics, U. S. Treasury Department, with Regulations No. 5 relating to the "dealing in, dispensing and giving away of opium or çocoa leaves, isonipecaine or opiates, or any compound, manufacture, salt, derivative or preparation thereof" and with Pamphlet No. 56, "Prescribing and Dispensing of Narcotics under the Harrison Narcotic Law." All physicians should be familiar with these two publications and, furthermore, should realize that the synthetic narcotics, meperidine, methadone, and dromoran, have been legally defined as opiates and subjected to the same regulations as are
morphine and its derivatives. The most pertinent statement concerning addiction is Article 167 of Regulations No. 5, which reads in part as follows: "An order purporting to be a prescription issued to an addict or habitual user of narcotics not in the course of professional treatment, 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 person filling such an order, as well as the person issuing it, may be charged with violation of the law."
This regulation is interpreted in Pamphlet No. 56, which reads in part as follows: "The responsibility for the proper prescribing and dispensing of narcotic drugs under the Harrison Narcotic Law rests upon the physician in charge in any given case . . . [and] corresponding responsibility rests upon the druggist who fills the prescription to determine, in good faith, that the prescription was issued in the course of professional practice and not for the purpose of gratifying addiction . . . The good faith of the physician and the bona fides of his treatment in a given case will be established by the facts and circumstances of the case and the consensus of medical opinion with regard thereto, based upon the experience of the medical profession in cases of similar nature. Physicians will be expected to exercise such care in every case where narcotic usage is indicated, that the patient under treatment shall receive no quantity of narcotic drug greater than that sufficient for bona fide medical needs in order that there may be no surplus available for possible diversion by the patient to illicit use . . . Mere addiction alone is not regarded or recognized as an incurable disease. It is well established that the ordinary case of addiction yields to proper treatment and that addicts can remain permanently cured when drug taking is stopped and they are otherwise physically restored to health and strengthened in will power."
Many of the individual states have passed narcotic control laws and the physician must be familiar with the laws and regulations of his particular state as well as with the Federal laws. In general, the physician will be acting in accordance with the consensus of medical opinion with regard to addiction and will be complying with the letter and spirit of the regulations if he follows two principles: (1) Ambulatory treatment of addiction should not be attempted as institutional treatment is always required; (2) Narcotic drugs should never be given to an addict for self-administration.
The reasons for establishing these principles are set forth in a committee report adopted by the House of Delegates of the American Medical Association in 1924. The following are excerpts from this report: "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 . . .
"In the opinion of your committee, the only proper and scientific method of treating narcotic drug addiction is under such conditions of control of both the addict and the drug that any administration of any 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."
DIAGNOSIS OF ADDICTION
Most frequently, addicts who appear in a physician's office are transients who are unknown to the physician. Such persons are likely to appear when circuses and carnivals are present in a community. Less commonly, addicts may be nontransient persons who are fairly well known to the physician. Frequently, nontransient addicts are neurotic persons or are patients who are known to have been chronic alcoholics. It is not unusual for the nontransient addict to be a physician. In recent years, it has not been unusual in certain areas for an adolescent boy or girl to be brought to the physician by relatives or by representatives of social organizations for advice relative to the treatment of addiction.
Most frequently, the diagnosis of addiction is made at the onset of the interview by the patient's statement that he is addicted to and needs drugs. The addict may attempt to conceal his addiction and may present a glib story of some physical illness; most frequently mentioned are atypical angina pectoris, kidney colic, migraine, or hemorrhoids. Generally, the story culminates with the suggestion that other physicians have found that the only adequate remedy is a prescription for narcotic drugs. Frequently, addicts of this type may appear armed with a formula which they state was given to them by another physician and which they have found very effective for the relief of their alleged symptoms. The formula will usually contain morphine, laudanum, or cocaine. If refused morphine, many addicts will ask for either methadone or meperidine. They will state that these drugs are not opiates but are synthetic drugs and are nonaddicting. All too frequently, uninformed physicians will be taken in by this story and will prescribe the synthetic analgesics. It is not unusual for addicts to attempt to obtain narcotics on the basis of some mild, chronic, nonfatal disease, such as asthma, arthritis, or chronic osteomyelitis, for which narcotics are not usually required or given. They will state that these diseases cause them terrible pain, that physicians in another town have been prescribing narcotics, and that their own physicians are away and they need drugs only until he returns. Occasionally,