be accompanied to the institution, whenever possible, by some responsible person, preferably a physician or a nurse.

No absolute rule can be laid down for the amount of narcotics to be given during the time arrangements for admission to a proper institution are being made. However, no amount of narcotic should be used in excess of that necessary for the immediate need of the patient. Either morphine or methadone may be used since these two drugs will adequately control abstinence from any of the other narcotics. It is advisable to limit the initial dose to 16 mg. (1⁄4 grain) of mbrphine or 10 mg. (% grain) of methadone. It practically never should be necessary to exceed as a single dose 60 mg. (1 grain) of morphine or 30 mg. (1⁄2 grain) of methadone. Even in patients with very severe heart disease, there is little danger of abstinence from morphine causing death if the above dosage schedule is followed. The type of drug given and the dose should be unknown 'to the addict and all possible precautions should be taken to prevent the addict from obtaining narcotics from other sources.

THE ADOLESCENT ADDICT WITH OR WITHOUT DEMONSTRABLE DEPENDENCE ON NARCOTIC DRUGS

Despite their ages, adolescent addicts must be separated from their usual environments. Institutional treatment for adolescents with demonstrable dependence is just as necessary as for adult addicts and the same procedures should be followed. Adolescents without physical dependence might possibly be sent to a camp, farm, or some other environment where rehabilitative treatment may be attained rather than sent to institutions where contact with older, more hardened addicts is unavoidable.

PATIENTS WITH INCURABLE, FATAL, PAINFUL DISEASES Persons in this class are usually patients who are dying with advanced carcinoma, tuberculosis, or some other chronic disease. The problem in such instances is completely different from those described above. The physician is properly concerned, primarily, with relieving suffering and, only secondarily, with the addiction. Federal and State narcotic laws were not designed to prevent narcotics from being prescribed in such cases. Proper, ethical medical practice, however, demands that certain principles be followed.

Physicians prescribing narcotics for such patients should personally be attending the patient. A diagnosis of a painful, incurable disease should be confirmed by consultation with another physician. All means of relieving pain other than prescription of narcotics should be exhausted. Such measures include the use of drugs other than narcotics, physical therapy, and surgical procedures designed to relieve pain. When administration of narcotics becomes necessary, the physician should initially use drugs of lesser potency, such as codeine. When use

of more potent narcotics is required, they should be given in the smallest possible dose and the interval of administration should be as long as possible. Precautions should be taken to ensure that the amounts of narcotics prescribed are no greater than those actually required for the particular patient so that there will be no surplus for diversion to illicit use. Whenever possible, the drugs should be given orally rather than hypodermically. Drugs should not be given directly to the patient for self-administration. The status of the patient and his disease should be reviewed periodically to inake certain that the diagnosis is correct and that definitive, curative therapy is not possible.

COCAINE AND MARIHUANA ADDICTS

Since physical dependence on these drugs does not develop and there is no withdrawal illness, the patient should simply be advised to seek treatment in a properly staffed institution. Hospitalization until admission to an institution can be obtained is not necessary or advisable.

CHOICE OF INSTITUTION

The choice of an institution depends upon the type of case, the financial situation of the patient, and other factors. Many private sanatoriums in the United States make a specialty of the treatment of narcotic drug addiction. Advice concerning these institutions can be obtained from local medical societies, the American Hospital Association, The American Psychiatric Association, or the American Medical Association. Alternatively, the physician may investigate the possibilities of having the patient admitted to a public, local, or state institution. Information concerning such institutions can be obtained by contacting local or state health departments. Lack of suitable local facilities remains one of the difficulties in the treatment of addiction. Physicians should support the establishment of such facilities in states in which no provision for addicts has yet been made. Where local facilities are not available, addicts can be referred to the two federal hospitals maintained by the U. S. Public Health Service at Lexington, Kentucky, and Fort Worth, Texas. Persons addicted to opiates, synthetic analgesics, cocaine, and marihuana are eligible for admission to these institutions. Patients who are addicted to alcohol, barbiturates, or bromides are not eligible for admission to these federal hospitals unless they are also addicted to morphine, synthetic analgesics, marihuana, or cocaine. If the patient is indigent, treatment is available without charge. If the patient has funds, he is required to pay $5.00 daily for his treatment. Addicts entering these institutions are asked to remain at least 135 days before being discharged. Ordinarily, there is no waiting list for male patients and admission can be arranged readily by writing or telephoning the Medical Officer in Charge of either hospital. Only the institution

in Lexington has facilities for female patients, consequently, women usually must wait for a short time before they can be admitted.

THE NEED FOR COMPULSION

Unfortunately, many addicts will not go to an institution or remain there until treatment is completed unless compelled to do so by legal means. There is a great need for legislation in most of the states which would make it possible to commit addicts to institutions where they would be forced to remain_until maximum benefit of treatment had been obtained. The Federal Bureau of Narcotics has drafted a text of such a proposed law and will distribute copies to interested persons on request. Legislation has also been proposed which would make it possible for the two U. S. Public Health Service Hospitals that treat addicts to accept and hold addicts committed under state laws. Passage of such laws deserves the support of all physicians.

TREATMENT FOLLOWING DISCHARGE FROM INSTITUTION

The follow-up treatment after the patient has been discharged from an institution is usually the weakest link in the overall treatment of addiction, and it is in this particular phase of the problem that the ordinary physician can make the greatest contribution. The physician should do what he can to assist the addict to find a job following discharge from an institution. He can attempt to make arrangements, utilizing such social agencies as are available, to separate the addict from the environment which played a role in engendering the addiction. He should encourage the former addict to participate in the activities of community groups, such as churches and clubs. The physician can advise the relatives of a former addict respecting environmental and familial factors which may be contributing to the patient's difficulties. He can also administer such forms of psychotherapy as he is qualified to carry out. When suitable facilities are available, intensive psychotherapy by a qualified psychiatrist is of great value provided the patient is willing to accept such treatment. The addict should remain under close supervision for at least two years following discharge from an institution. Although the tendency to relapse is very great in addiction, the physician should maintain an optimistic attitude even in the face of repeated recurrence and should continually encourage and support the addict.

MANAGEMENT OF DISEASE IN FORMER ADDICTS

When a person who formerly has been addicted to morphine become afflicted with a disease for which narcotics are usually prescribed (this situation usually develops when a surgical operation becomes necessary), he should be handled just as if he had never been addicted. Since the former addict has been withdrawn from narcotics and has lost his tolerance to them, narcotics should be prescribed in the same doses and at the

same intervals as is customary with persons who have never been addicted. Larger doses are not required. Narcotics should never be given to the former addict for self-administration and use of narcotics should be discontinued as soon as possible. The addict should then be supervised closely for a month or so in order to avert relapse to uncontrolled use of drugs.

MANAGEMENT OF ADDICTS WHO HAVE RELAPSED

The management of patients who have relapsed to abusive use of narcotic drugs should follow the same lines as detailed above. The only difference is that the period of supervision following discharge from an institution should be extended.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

Reprinted from The Journal of the American Medical Association July 26, 1952, Vol. 149, pp. 1220-1223

Copyright, 1952, by American Medical Association

EXHIBIT No. 21

[From the Journal, American Medical Association, May 23, 1942]

INDISPENSABLE USE OF NARCOTICS

[Now that the sources of supply for narcotics have been largely shut off, their use in medical practice must be confined to the absolutely indispensable. In 1931 The Journal published a series of articles entitled "The Indispensable Use of Narcotics"; these articles were collected and published in book form. This material is now republished-revised, rearranged and shortened-to guide physicians in the present attempt to confine the use of narcotic drugs to an irreducible minimum.-ED.]

USES AND ABUSES OF NARCOTICS

Properly speaking, cocaine is not a narcotic. Although one of the most dangerous habit forming drugs and included under the Harrison Narcotic Act, it will not be considered here. Opium and its derivatives are the only narcotic drugs to be discussed. Opium itself is a complex substance containing some 20 alkaloids, only 4 of which, however, are of practical importance, namely morphine, codeine, narcotine, and papaverine. Morphine has four actions on which its therapeutic uses depend: (1) In small amounts it is a depressant to the pain perceiving centers of the cerebrum. (2) In somewhat larger doses it depresses the intellectual functions and thereby exerts a somnifacient effect. (3) It is a depressant to the respiratory center, in small doses lessening its response to irritation and in large doses reducing the amount of air moved. (4) It tends to lessen glandular activity, probably affecting to a greater or less degree all the secretions of the body except the sweat. (5) The older writers also ascribed to it an important effect in diminishing the contractility of the unstriped involuntary muscles, especially those of the intestine, but recent investigation indicates that its action may be stimulating rather than depresssing to peristalsis.

Narcotine, which is the next most abundant alkaloid after morphine, despite its name is not narcotic. It exerts neither analgesic nor sleep-producing effects. Its most important action is a stimulation of the medullary centers governing respiration. In this it is directly antagonistic to morphine.

Papaverine has a feeble narcotic action, its dominant effect being to lessen the irritability of unstriped muscle. Like narcotine, it is stimulant to the respiratory center. It has been recommended in various spasmodic conditions of the involuntary muscles, such as asthma or colic. It is a relatively feeble drug, requiring about a grain (0.065 gram) to produce sensible effect on a man and is present in opium in such small amount (about 0.5 to 1 percent) that it can play only a minor part, if any, in the effect of opium.

Codeine is similar in its general actions to morphine, although much weaker. It has relatively slight action on pain perception or intellection and is much less liable to give rise to an addiction. Ordinarily opium yields from 1 to 2 percent of codeine.

The therapeutic purposes for which opium is used may be considered under six heads: (1) locally, (2) as an analgesic, (3) as a somnifacient, (4) as a respiratory sedative, (5) as a sudorific, (6) for its effect on the intestine.

As. an assuager of pain, morphine stands unrivaled at present by any other drug or combination of drugs. Nevertheless it is used more frequently and in larger quantities than is necessary and often to the detriment of the patient. By the use of other anodynes the physician can often contrive to get along with surprisingly small quantities of opiates. The decision as to whether or not to use morphine in any given case should be based on three factors: The severity of the pain, its probable duration and its underlying cause. One of the most difficult problems of therapeutics that the physician has to face is the alleviation of pain in certain chronic diseases, such as arthritis or neuritis, which may be so intense as to demand an opiate and yet promises to be of such long duration that it is likely to lose its anodyne power and to present great risks of causing addiction. Physicians may, by the exercise of more thought in practicing, do much to avoid censure in relation to narcotic addiction. In this endeavor the substitution, whenever possible, of nonhabit forming drugs for morphine or other opium alkaloids is of paramount importance. When narcotics are indispensable, however, no more should be administered than is necessary to achieve the desired end. Patients requiring daily administration should be seen often by the physician,