[Abstract from report of reference committee on legislation and public relations, proceedings of the house of delegates, 76th annual session, Chicago, June 9-13, 1924, pp. 36-39] REPORT OF REFERENCE COMMITTEE ON LEGISLATION AND PUBLIC RELATIONS1 Dr. J. A. Pettit, chairman of the reference committee on legislation and public relations, submitted a report of that committee as follows: 1. * * * 2. The reference committee on legislation and public relations recommends that the house of delegates approve recommendation No. 8 of the report of the committee on narcotic drugs of the council on health and public instruction, submitted by the council to the house of delegates at the Boston session, 1921, and printed on page 19 of the proceedings of that session, as follows: "S. 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. Therefore, your committee recommends that the American Medical Association urge both Federal and State Governments to exert their full powers and authority to put an end to all manner of such so-called ambulatory methods of treatment of narcotic drug addiction, whether practiced by the private physician or by the so-called narcotic clinic or dispensary. "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 a 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." 3. * * 4. * * 5. * * 6. The report of the reference committee on legislation and public relations was considered section by section. On motion of Dr. Pettit, the second section was adopted. Dr. Pettit then moved that the report of the reference committee on legislation and public relations be adopted as a whole. This motion was seconded and carried, and the speaker declared the report adopted. EXHIBIT No. 23 [Journal of the American Medical Association, 76: (23) 1551-1556 (June 4) 1921] THE PROBLEM OF THE NARCOTIC DRUG ADDICT Alfred C. Prentice, A. M., M. D., member of committee on narcotic drugs, council on health and public instruction, American Medical Association, Nw York The report of the committee on the narcotic drug situation in the United States, adopted by the American Medical- Association at the annual session in New Orleans, 1920, and published by the council on health and public instruction as one of its education pamphlets, has shown that existing conditions relating to narcotic addiction constitute a grave menace to society. Since reputable physicians generally lack familiarity with the facts regarding the addiction evil, because these cases are rarely encountered in ordinary medical practice, it seems proper at this time to call attention to some of the more important features of that report for the sake of needed emphasis. 1 Proceedings of the house of delegates of the American Medical Association, 75th annual session held at Chicago, Ill., June 9-13, 1924, pp. 36-39. PREVALENCE OF ADDICTION That narcotic drug addiction does exist, though its prevalence is enormously exaggerated by those who would have it persist while deploring its extent, and that it is common among degenerate denizens of the underworld, criminals, prostitutes, mental defectives, their condition rendered more hopeless and pitiable as social outcasts because of the slavery to the drug, cannot be denied. That in large centers of population, clerks, salesmen and saleswomen, bookkeepers, mechanics, artisans, conductors and motormen of streetcars, and chauffeurs of public and private vehicles are found addicted to the use of habit-forming narcotic drugs, constitutes a source of danger to everyone both physical and moral. It must also be admitted that, in isolated cases, victims of drug addiction may be found even among the educated and leisure classes; yet, though clandestinely maintained by these people, it may be in an atmosphere of supposed refinement, nevertheless the insidious danger of thus spreading the moral contagion may even be enhanced by its apparent respectability, and it must not therefore be compromised with or condoned in any class or social station. The vice that causes degeneration of the moral sense, and spreads through social contact, readily infects the entire community, saps its moral fiber, and contaminates the individual members one after another, like the rotten apple in a barrel of sound ones. HAGUE CONVENTION BASIS OF LAWS In 1912-14, an international convention between the United States and other powers was signed at The Hague, ratified by the Senate and proclaimed by the President, March 3, 1915, entitled, "Suppression of the Abuse of Opium and Other Drugs." This international treaty convention thus having become the supreme law of the land, and paramount to the mere act of a national legislature, the United States Congress, in conformity therewith, enacted three laws: one, regulating the importation and exportation of opium; another, imposing a prohibitive tax on smoking opium; and the third, known as the Harrison narcotic law, designed to regulate and control the domestic distribution of opium and cocaine. HARRISON LAW While nominally a tax law, entrusted for administrative purposes to the United States Treasury Department, the main purpose of the Harrison law was not to produce revenue for the general purposes of government, but rather, specifically to carry out our national treaty obligations, by establishing control of the distribution of the narcotic drugs in the United States, so as to prohibit their abuse, and to restrict their use to the proper channels of legitimate medical, scientific, dental, and veterinary practice. Through failure to recognize the serious international character of this obligation of the United States Government, and because of the license tax imposed, which with its other regulations may appear to some as unnecessarily burdensome, some loose thinking has been indulged in, and criticism of the Harrison law has been broached, even to urge that it be repealed. On this basis has arisen a sinister propaganda having for its object the creation of popular sentiment hostile to the requirements of this law, so as to render futile or difficult the most earnest efforts of the Government authorities to enforce it. Thus it may be seen how vital a matter it is to our national honor, in respect to its solemn treaty obligations, that the Federal Government shall, in good faith, actually enforce the provisions of this act of Congress. STATE LAWS It is equally important that the several States recognizing this fundamental motive in human progress, should enact legislation supplemental to and in harmony with the Federal laws, which shall enable the exercise of the special police powers of the States, in cooperation with the Federal authorities, in giving full effect to the clear purpose and intent of this Federal statute. Such laws have been written on the statute books in Massachusetts, Rhode Island, and Pennsylvania. LAW ENFORCEMENT INEFFECTIVE That the Harrison law has failed to prevent improper use and distribution of narcotics is a proper and just criticism. Failure to secure intended results of a law should not be charged to inherent weakness in the law itself, necessarily. In this case, it is clearly the natural result of inefficient efforts in its enforcement. Failure, also, on the part of the State governments to provide adequate cooperation through State legislation and application of their police powers has contributed to make difficult, slow and expensive the prosecution in the Federal courts of a small number of cases against physicians and druggists, violators of the law, which cases ought never to have been necessary to proclaim the binding authority of the law, if State laws had been in existence prohibiting the acts complained of in these indictments. Then the World War engrossed the activities of governments, and it was not unti March 1919 that this law was declared by the United States Supreme Court to be constitutional, or that a determined attempt had been made to enforce it. Since that time, however, various other court decisions of an interpretative character have been rendered, which have materially contributed toward making the Harrison law a most valuable and efficient legal instrument in preventing the abuse of narcotic drugs: Convictions are obtained regularly in the courts against dealers, druggists, and physicians engaged in its violation. IMPOSITION The report of the Commissioner of Internal Revenue for the year 1920 shows that during that period the sum of $1,513,919.50 was collected under the Harrison law. It is also a matter of record that Congress had appropriated for its enforcement for that period the sum of $750,000. The Department employed a field force of less than 175 men for the entire United States, and actually expended in the cost of administration of the service, and in the operations for enforcement of the law together, less than the sum appropriated. Since this act was not intended to operate as a revenue-producing measure, it does seem but fair to demand of the Government that no less than the total amount of moneys collected under the law in fees, fines, taxes, etc., shall be expended effectively in its proper and adequate enforcement. Otherwise, complaint of oppression in being compelled to pay a tax of $3 for the nominal license when the moneys collected are not used for the purposes of enforcement of this law, cannot be regarded as wholly groundless. CONSPIRACY From the beginning of serious attempts made to enforce the Harrison law, evidence has accumulated of a widespread and well-organized conspiracy that has arisen and is in active operation throughout the country, aiming to defeat the purpose of the law, or to circumvent its requirements. Those who find it profitable to exploit the victims of drug addiction by supplying them with narcotie drugs, while at the same time maintaining their addiction, through prescribing or dispensing to them over prolonged periods or quite indefinitely, would most naturally seek to retain their privilege as purveyors, and desire to be permitted to continue their exceedingly profitable traffic, if not legally, at least unmolested. because it is carried on under the pretense of medical treatment for an assumed "disease." PROPAGANDA Public opinion regarding the vice of drug addiction has been deliberately and consistently corrupted through propaganda in both the medical and the lay press. Cleverly devised appeals to that universal human instinct whereby the emotions are stirred by abhorrence of human suffering in any form, or by whatever may appear like persecution of helpless human beings; lurid portrayals of alleged "horrible suffering inflicted" on addicts through being deprived of their drug; adroit misrepresentation of fact; plausible reiteration of certain pseudoscientific fallacies designed to confuse the unscientific mind; downright false statement, and insidious innuendoes assiduously propagated are brought to bear on an unsuspecting public to encourage it to feel pity for the miserable wretches, "whose name is legion" we are told, and whose "sufferings," hysterically exaggerated. are graphically served up to be looked on as if they were actually being made "victims of persecution" by the authorities, who would deprive the wretches of even the drug they crave. The "righteous" narcotic practitioner, claiming that he alone understands their plight and can relieve them, standing ready as a ministering angel of mercy to prescribe for their infirmity, begs the right and privilege of placing in their hands for self-administration the drug that has debased them and brought them in his power-for as much money as he can squeeze out of them. The shallow pretense that drug addiction is a disease which the specialist must be allowed to treat, which pretended treatment consists in supplying its victims with the drug that has caused their physical and moral debauchery, and that the regular physician because lacking in their familiarity with the addict, his habits, desires, and emotions, is therefore incompetent to assume his proper treatment, has been asserted and urged in volumes of literature by the self-styled specialists. Significant articles of sensational character dealing with narcotic addiction have appeared in the public press during recent months, denouncing the alleged persecution of the addict and of his ministering angels, the narcotic practitioners, by local, State and Federal authorities, all of them characterized by a certain style indicating their probable emanation from a common source, and well calculated to create in their favor popular prejudice, in case their business or practice were called in question before some trial jury. Reputable members of the medical profession have been constantly libeled with the assertion that "the doctors have produced the addicts in the beginning," through careless administration of the drugs, and their "innocent victims" ought all the more to enjoy the sympathy and solicitude of the public; that the average doctor is an ignoramus, and is not competent to be trusted with dangerous drugs from which such evils may be evoked. Such fallacies may be found in American Medicine, Illinois Medical Journal, American Journal of Clinical Medicine, Medical Record, American Journal of Public Health, Washington Post, Chicago Tribune, New York Tribune, New York Times, New York World, New York American, Harvey's Weekly, New Republic, Metropolis and others. Emboldened by such successful publicity for their cause, which is the business interest, their emissaries have appeared wherever a hearing could be made useful-before legislative committees, boards of health, governors of States, in the Halls of Congress, before administrative officials of the United States Departments of Justice and Internal Revenue, and even before reference committees of the house of delegates of the American Medical Association. SCRIPT DOCTORS In the parlance of that underworld where the narcotic addict finds congenial atmosphere there exists a swift and secret means of communication—a sort of "free-masonry" of their kind-by means of which the "script doctors" in a community are well known and accessible to all the addict fraternity. These doctors, having a monopoly of firsthand knowledge of the drug addict, his habits, sufferings, emotions, and desires, whose heart bleeds in sympathy for the addict with his intolerable craving (for often it appears that the “doc" himself is addicted to the "dope"), whose defense of the business of supplying them with drugs is ever ready, suave, and plausible and, whose business sense, greed for money, is the creed of their professional practice-these are the "script doctors" invariably patronized by the addict, not because he has need for the advice or skill of the physician, but solely because he knows that the "doc" will give him his "script" or the "dope" itself, in whatever amount he says he needs. The drug thus "lawfully" obtained from a familiar druggist, of full weight, and of pure quality, at about 7 cents a grain, can then be self-administered at his convenience, or shared with a needy friend, or sold in the street peddling trade at sufficient profit to finance his next visit to the "script doctor's" office. NATURE OF ADDICTION Tolerance to considerable doses of morphine or heroin may be all too readily acquired, after the first few doses. The amount necessary to produce desired effects then requires to be gradually increased. When the effects wear off, there supervenes a lassitude, mental depression, nausea or epigastric distress, dilated pupils, tremor and hysterical apprehension, even actual fear of imaginary objects. All these symptoms are promptly relieved by another dose of the drug. The continued habit is evidenced in most of its victims by a peculiar pallor, a sallowness of complexion, anemia, emaciation, untidiness of the person, and generally, the appearance of one prematurely aged; restless irritability of the nervous system, itching of the skin, tremors, insomnia, dilation of the pupils (contracted under the influence of the drug), deranged digestion, loss of appetite, 71515-56-pt. 544 marked constipation, mental depression, impairment of mental function, and finally, by complete perversion of the moral nature-loss of the ethical sense. Osler says: "Persons addicted to morphia are inveterate liars, and no reliance whatever can be placed upon their statements. This is not confined to matters relating to the vice." An increase of their dose is, apparently, not always necessary. Many have carried on their ordinary business affairs successfully for many years on a satisfactory daily dose of from 2 to 5 grains of morphine. On the other hand, some have consumed 10, 20, 30, and even 70 grains daily for long periods. Eventually, in the terminal cases, an asthenic condition supervenes wherein the subject takes little or not food, dying from the starvation and toxemia, or from effects of some slight injury or intercurrent disease. TREATMENT Unless the addict is kept under constant supervision, carefully isolated from contact with every possible source of obtaining the drug of addiction, during the withdrawal period essentially (so that any administration of the drug must be given by the physician, and the addict may not procure any of the drug except from the physician directly responsible for his treatment), the proper treatment of addiction with the purpose of curing the condition is extremely difficult, and can rarely be carried out successfully by the general practitioner. Addicts must be maintained under rigid control, generally in a suitable institution, and should be in bed for from 3 days to a week during the withdrawal treatment. Withdrawal symptoms are typical, though not constantly present to the same degree. Some addicts enormously exaggerate their sufferings and complain bitterly, striving to excite sympathy by displaying an hysterical emotionalism, anticipating some concession to humane feeling and another dole of the drug. Others appear to be possessed of a fair degree of poise, evidencing a desire to exhibit their moral stamina, enduring their discomfort with stoicism for the sake of being through with it more quickly. They complain of abdominal cramps, nausea, vomiting, pains in the bones, great restlessness, insomnia and fear. All these symptoms can be masked to a great extent by the administration of one two-hundredth grain of scopolamin hydrobromate every 6 hours for the first 36 hours. During this period and, in fact, up to the end of 72 hours, the patients are disposed to remain in a semihypnotic condition, thirst being their chief complaint; and plenty of water to drink relieves that. To quiet their restless excitement, sulphonal, choral, paraldehyd, etc., may be used if indicated; but the hot pack, tub bath, drip sheet, and drip enema of physiologic sodium chloride or of sodium bicarbonate solution aid materially. It appears to make little or no difference in the result whether the treatment is masked by some sedative medication, or whether they are given "the cold turkey" (the addicts' term for immediate withdrawal without any treatment to allay their sufferings). In either case, they are taken off the drug immediately; in from 3 to 5 days their vomiting of bile has ceased, their appetite returns, they eat and digest substantial food, they gain in strength and weight, regularly increasing their weight by from 25 to 50 or 100 pounds in 2 or 3 months, and they are off the drug, having had none from the beginning of treatment. In the vast majority of cases, it must be stated by way of caution, the habit has been broken off, and the craving no longer requires that it be satisfied. But it may be reawakened and allowed to dominate the individual again, if he permits any relaxation of his self-control. His cure, in that sense, then, cannot be said to be permanent until he has regained mastery of himself. There is great physical danger, however, if he should relapse, in beginning again to use his previously accustomed dose of the drug; for the tolerance to considerable doses is soon lost, so that beginning anew with the old dose produces acute opium poisoning, and is known to have caused fatal results in a number of such cases. The explanation of withdrawal symptoms seems to be found in the starvation asthenia of the entire nervous system, including the depressed state of the endocrine gland activities, the obstipation and consequent diarrhea from depression of the splanchnic innervation of intestinal muscle and secretion, and the toxemia resulting from diminished oxidation as well as diminished elimination of excretory substances. The clinical picture is that of severe acidosis toxemia accompanied by profound depression of the automatic nervous system, and is |