Practically all antinarcotic legislation in the United States has been enacted since 1897. By 1912 every State, except Delaware, and many large cities, including the city of Wilmington in Delaware, had laws or ordinances designed to regulate in some way the prescribing or selling of the opiates or cocaine, or both of these products (21).

The Federal Pure Food and Drugs act, enacted in 1906, required manufacturers to state on the label the amount of opium, opium alkaloids or derivatives, and cocaine the preparation contained. In addition to other benefits, this provision did away with numerous opium cures that contained opium or opium alkaloids as the chief ingredient and were habit forming in themselves. In 1909 the importation of smoking opium was prohibited. Prior to that time, curiosity about this form of opium indulgence started many people on an addiction career. Opium smoking is rare at present in the United States, but former smokers now taking opium or heroin are occasionally met with.

The committee appointed to investigate the extent of the use of habit-forming drugs in Massachusetts (22) reported, in 1917, that 78 of 267 addicts supplied with morphine, or morphine and cocaine, by one physician, had originally been opium smokers. Simon (20) reports 876 opium smokers, mostly Chinese, among 8,174 addicts arrested in New York in three years. The Harrison Act became effective March 1, 1915. Since then other laws designed to regulate still further the traffic in narcotics have been enacted, and at the present time the Federal Government has a check on these drugs at every step in their handling from the time a permit is issued to the manufacturer to import the crude drugs until the finished product reaches the ultimate consumer.

The first result of the Harrison law was to cause large numbers of addicts throughout the country to seek treatment. Many who were relieved of their addiction then have no doubt remained cured. The rigid enforcement of the law continues to impel addicts, even those who started the habit viciously in recent years, to seek relief. It is common for this type to give as a reason for seeking a cure that they are tired of dodging the police, and occasionally an addict comes for treatment because the peddlers have grown suspicious and refuse to supply him with the drug. The superintendent of the Norfolk State Hospital (22) reported in 1917, that over 90 percent of the addicts who applied for treatment did so because they were having difficulty in securing their supplies of narcotics. Most of such cases relapse, but in the course of time those among them who are fairly normal are permanently cured.

Efficient as these laws have proved to be from a curative standpoint, their greater value lies in their effectiveness as preventive measures. When opium and its alkaloids could be bought anywhere, either in pure form or in proprietary medicines not known by the purchaser to contain narcotics, and when prescriptions for opium could be refilled, self-medication was a very common cause of the drug habit. This, no doubt, explains in part the great prevalence of addiction formerly noted in rural communities. Addiction by self-medication is now almost impossible, as narcotics in concentrated form can be obtained only on a physician's prescription, and exempt preparations contain too small an amount of drug to create the habit unless taken in enormous quantities. For the fiscal year 1923 (18) the quantity of taxable narcotic drugs purchased by manufacturers of nontaxable preparations was equivalent to approximately 3,300 ounces of morphine sulphate, an amount too small to permit of these preparations being used for the satisfaction of addiction to any great extent.

Physicians now make very few addicts unnecessarily. The numerous reports and forms which physicians are required to make out in order to prescribe narcotics in any form tends to keep them alert to the dangers of these drugs, and mild forms of addiction now caused by a few weeks, or even months, of necessary prescribing quickly clear up after a few days of restlessness on the part of the patient and he is no wiser or worse off because of it. Formerly he could experiment further with his "doctor's prescription" and become strongly addicted without realizing it until too late. To illustrate this point, attention is called to the following facts: The Tennessee survey, made before the Harrison law became effective, showed, according to Brown, that physicians were responsible for about 50 percent of the cases of addiction. In a recent report Simon states that less than 2 percent of approximately 10,000 addicts arrested or committed to hospitals in New York City during the past 3 years owed their addiction to physicians. The latter figures are supported by our own findings. Examinations made by one of us during the past 2 years have shown that less than 5 percent of the cases of recent addictions are caused by physicians. Comparison of New York City with the State of Tennessee is not altogether fair, because a certain type of addict tends to congregate in large cities and the class of persons from which the vicious

type is recruited is more easily corrupted in these cities, but the percentage is so near that found by us in the examination of addicts from all parts of the country that it is thought that they may be taken as fairly representing conditions as they exist today.

A survey which furnishes an excellent illustration in restrospect of the effect that the Harrison law has had in reducing the extent of addiction is one made by Terry (13) in the city of Jacksonville in 1913, 2 years before the Harrison law became effective. At that time there was a city ordinance which prohibited the dispensing of opium except upon a physician's prescription, and which required all physicians writing prescriptions for any habit-forming narcotics to send a copy of the same together with the name and address of the individual for whom they were intended to the board of health. Indigent habitues were given prescriptions at the office of the board. Apparently no effort was made to discourage addiction or to limit the use of these drugs. The record of duplicate prescriptions and of patients applying at the health department showed 887 habitual users for the year 1913, or 1.31 percent of the population. It is stated the figures do not represent the number of true residents, but include transients as well, and it appears that Terry personally saw and examined only 250 of the cases. William W. MacDonell (23), the city health officer at the present time, reports that in 1914 the number of addicts registered had increased to 1,073. Registration of addicts was then discontinued, but a census taken in 1919 showed 111 addicts. In 1920 there were 55 additional cases registered, but some of the 111 had moved away. Addicts are not being registered at the present time, but Dr. MacDonell reports that during the year ending in April 1924, there were only 20 addicts under treatment in Jacksonville, with 30 additional securing their supplies from peddlers, and a possible 50 more about whom there was no accurate knowledge.

Dr.

As previously stated, it was unlawful to sell narcotics except on a physician's prescription, but no attempt was made to prevent the use of these drugs. How this worked out is shown by the fact that among Terry's cases there were 346 to whom cocaine alone was given, and 445 of the total number received this drug. Probably cocaine addiction is better understood now than it was in 1913, but even as late as 1919-20 some of the clinics gave cocaine along with morphine. It is now known that withdrawal of this drug causes little discomfort and no danger, but a physician who would venture to prescribe it to satisfy addiction, as well as the druggist who filled such a prescription, would be liable to prosecution under the Federal laws.

An illustration of the effect produced by the tremendous drive against narcotic addiction which has been going on in recent years is given by the answers to the questionnaire sent out by Simon in 1923 to the physicians of New York State, asking how many addicts they had treated in 1922. The 51.6 percent who replied treated only 775 cases of addiction; and from the information furnished it seems that these were mostly old people or persons suffering from incurable diseases. In the Treasury Department survey, made in 1918, 37 percent of physicians in New York State were treating 12,365 addicts.

The increasing difficulties of an addict's career since 1918 have compelled many of them to seek cure, but the difference in the two surveys just discussed is too great to be attributed to this factor alone. Most of it is no doubt due to a change in the viewpoint and practice of physicians. Responding to the temper of court rulings, physicians no longer prescribe narcotics merely to satisfy addiction, and some of them are loath to prescribe for an addict at all, even when his physical condition would seem to require a continuation of addiction, although there is nothing in the law or rulings of the Bureau of Internal Revenue which justifies this attitude. In 1918, physicians probably reported transients and other addicts not regularly treated by them. The changing attitude toward the narcotic problem was sufficient to reverse this by 1923. The total result has been that one survey counted too many addicts and the other too few.

SUMMARY AND CONCLUSIONS

The evidence seems to show that a maximum estimate for the number of addicts in the United States at the present time would be 150,000. The estimates based on actual counts and on the available supplies of narcotics, together with the conditions reported by the physicians interviewed, point to about 110,000, which number is believed to be nearly correct.

The number of addicts has decreased steadily since 1900. Before this decrease set in there may have been 264,000 addicts in this country.

The greater number of addicts in prison at present as compared with former years is due to the rigid enforcement of recently enacted laws and not to an increase in the prevalence of addiction.

The average daily addiction dose of the opiates in terms of morphine sulfate or heroin hydrochloride is not less than 6 grains. The dose of cocaine hydrochloride is practically the same.

The quantities of narcotics imported by this country at the present time are believed to be only slightly in excess of the amounts required to supply medicinal needs.

While physicians have been credited with being responsible for the creation of many addicts in the past, it is concluded as a result of our studies and observations that but few cases of recent addiction can be so attributed.

Before the enactment of restrictive laws in this country there was much opium smoking and addiction to gum opium and laudanum. Today addicts use the alkaloids or their derivatives almost exclusively. Cocaine hydrochloride was used alone by a large number of addicts prior to 1915, but is now used only in conjunction with the opiates except in a few cases.

The proportion of the delinquent type of addict is gradually increasing. This is apparently not due to an increase in the number of this type, but to a gradual elimination of normal types.

From the trend which narcotic addiction in this country has taken in recent years as a result of the attention given the problem by the medical profession and law-enforcement officers, it is believed that we may confidently look forward to the time, not many years distant, when the few remaining addicts will be persons taking opium because of an incurable disease and addicts of the psychopathic delinquent type, who spend a good part of their lives in prisons.

REFERENCES

(1) T. D. Crothers. New York Med. J. (1912), Vol. 95, pp. 163–165. (2) Horatio C. Wood, jr. J. Am. Phar. Assoc. (1916), Vol. 5, pp. 1205–1208. (3) Martin I. Wilbert. Pub. Health Rep. (1916), Vol. 31, pp. 114-119. (4) Lucius P. Brown. Am. J. Pub. Health (1915), Vol. 5, pp. 323–333. (5) Report of the Special Committee of Investigation of the Traffic in Narcotic Drugs. Treasury Department. June 1919.

(6) S. Adolphus Knopf. Med. J. & Rec. (1924), Vol. 119, pp. 135-139. (7) Unpublished data furnished by officials of the Pennsylvania Bureau of Drug Control, with permission to use.

(8) Pearce Bailey. Med. Prog. (1920), Vol. 36, pp. 193–197. (9) Pearce Bailey. Mental Hyg. (1920), Vol. 4, p. 566.

(10) Reports by narcotic inspectors in the files of the narcotic division of the Bureau of Internal Revenue, Treasury Department.

(11) Reprint Series No. 87, Department of Health of the city of New York, February, 1920.

(12) Second Annual Report of the Narcotic Drug Control Commission of the State of New York, Albany, April 15, 1920.

(13) C. E. Terry. Annual Report of the Board of Health of the city of Jacksonville, Fla., for the year 1913.

(14) Willis P. Butler. Am. Med. (1922), Vol. 17, pp. 154-162.

(15) Commerce Reports, 1918, No. 96, pp. 331-333.

(16) DeQuincy. Confessions of an opium eater. A. L. Burt & Co., New York, N. Y.

(17) Report of Foreign Commerce and Navigation of the United States. Bureau of Statistics, Department of Commerce, Washington, D. C.

(18) Annual reports of the Commissioner of Internal Revenue for the fiscal years ended June 30, 1922 and 1923. Treasury Department, Washington, D. C. (19) Minutes, Fifth Session Advisory Committee on Traffic in Opium, League of Nations, May 24 to June 7, 1923. Annex 11.

(20) Carleton Simon. J. Am. Med. Assoc. (1924), Vol. 82, pp. 675-678. (21) Public Health Bulletin No. 56, United States Public Health Service, Novem

ber, 1912.

(22) Report of the Special Commission to Investigate the Extent of the Use of Habit-Forming Drugs in Massachusetts, Boston, Mass., January 3, 1917. (23) Data furnished by William W. MacDonnell, city health officer of Jacksonville, Fla.

EXHIBIT No. 4

[From Mental Hygiene, vol. IX, No. 1, pp. 74-89, January 1925]

DRUG ADDICTION IN ITS RELATION TO CRIME

(By Lawrence Kolb, M. D., Surgeon, Hygienic Laboratory,
United States Public Health Service)

REPRINT NO. 204, THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, INC.,
370 SEVENTH AVENUE, NEW YORK CITY, 1925

There is a widespread popular belief that narcotic-drug addiction has in recent years been responsible for much violent crime. This belief has been implanted in the minds of its adherents mainly by lay writers through the medium of popular articles in newspapers and magazines, although the physician has unwittingly contributed to its support by the publication of statistics as to the number of addicts in various prisons in the last few years. In many cases these statistics show increases and as no explanation of the cause of these increases accompanies the figures as a rule, the inference has been drawn that addiction throughout the country as a whole has increased, or that some condition has come into being which has caused addicts to commit crimes with greater frequency of late than they did in previous years. Most, if not all, of the supposed increase in the number of criminal addicts has been attributed to the use of heroin, the diacetyl derivative of morphine introduced into medical practice in 1898.

The present writer has been engaged for some time in a study of narcotic addiction in its various phases. A part of the work undertaken in connection therewith consists of an intensive psychiatric and personality study of addicts. These studies brought out so forcibly the fact that a criminal addict was, in the vast majority of cases, a criminal before he because addicted, and that no opiate ever directly influenced addicts to commit violent crime, that a statistical survey of this phase of the subject was made with a view to supplementing the personality data and of presenting a more complete picture of the relation of narcotic-drug addiction to crime.

The conclusions presented in this paper are based in part upon the personality study of 225 cases, but data on the character of the crimes committed are given only for the first 181 studied. These cases include addicts from all walks of life. By special arrangement some of these addicts were examined at their homes, but the majority of them were examined in city jails where they were confined, or in hospitals where they were given treatment by the writer.

The possible effect of narcotics in producing crime has been carefully studied in the 225 cases referred to above, especially in the delinquents and those with criminal impulses, and as a result of the study, the conclusion has been reached that there is probably no more absurd fallacy extant than the notion that murders are committed and daylight robberies and holdups are carried out by men stimulated by large doses of heroin or cocaine which have temporarily distorted them into self-imagined heroes incapable of fear.

Insofar its influence on crime is concerned, addiction to opium or any of its preparations creates two tendencies directly oppossed to each other. The immediate effect of excessive indulgence in all forms of the drug is to soothe abnormal impulses, while the ultimate effect is to create a state of idleness and dependency which naturally enhances the desire to live at the expense of others and by antisocial means. The effect of addiction on the psychopathic murderer is to inhibit his impulse to violent crime. At the same time it saps his vitality and reduces the ambition and courage that prompt him to convert his abnormal impulse into action. He, therefore, becomes less a murderer and more a thief. In other cases, where the degree of abnormality is not so great, the indirect effect is to increase the impulse to lie and steal. The factor most important in this is the desire to secure the drug in order to avoid the discomfort caused by the lack of it. No addict who receives an adequate supply of opium and has money enough to live is converted into a liar or thief by the direct effect of the drug itself. The direct effect is to remove the irritability and unrest so characteristic of psychopathic individuals. The soothing effect of opiates in such cases is so striking and universally characteristic that one is led to believe violent crime would be much less prevalent if all habitual criminals were addicts who could obtain sufficient morphine or heroin to keep themselves fully charged with one of these drugs at all times.

Cocaine stimulates both mind and body and up to a certain point increases confidence and courage. Beyond the point of maximum stimulation, it produces uncertainty, fear, and anxiety. A criminal who takes cocaine is for the time

being more efficient as a criminal unless he takes too much. The drug does not arouse criminal impulses in anyone, but it enhances the criminal's mental and physical energy so that he is more likely to convert his abnormal impulses into action. Beyond the point of maximum stimulation, the criminal and any other type of character become suspicious and fearful. They run away from imagined enemies, usually the police. They are in a paranoiac state, and in this state of fear might commit some act of violence if cornered. In the cases studied, addicts in this state have walked all night to escape imaginary policemen who peeped out from behind every tree; they have looked into bureau drawers, under beds, in matchboxes, and through keyholes for police. One attacked with a hammer a laundry bag in his bathroom, under the delusion that it contained a policeman looking for him. Persons in this state are, of course, dangerous, but any crime they might commit would be due to the frenzy of fear. Such a person would be incapable of planning and committing a deliberate murder or of holding up and robbing a bank.

The soothing effect of opium on abnormal impulses is believed to be well understood by the medical profession. It was correctly stated by Norman Kerr 1 more than 30 years ago in the phrases, "Opium soothes, alcohol maddens," and "The intoxicated by opium are serene, sedate, and lethargic," but it needs to be restated because of the misapprehension produced partly by lack of analysis of the statistics of the increased number of addicts in prison in recent years. The effect of heroin in particular needs to be set forth in its true light, because of the alarm created by certain persons, who without a thorough understanding of it, have seized upon and misinterpreted the phrase "inflation of personality" used in describing one effect of opiates, and out of it have constructed the heroin hero.

The mental and physical lethargy and the loss of ambition produced by morphine and heroin are incompatible with the simultaneous production of an aggressive hero. These effects are spoken of by all addicts who use these drugs in large quantities. The inflation of personality in inferior individuals actually occurs. In the present series of cases, 86 percent were nervously abnormal before they became addicted. A large proportion were psychopathic, and every criminal among them had committed crime before the use of narcotics was begun. All of these cases became addicted because of the pleasurable mental satisfaction that the first few doses of a narcotic gave them. The degree of inflation varied in direct proportion to the degree of pathology. It occurred only slightly or not at all in those considered nervously normal, but was very striking in some of the extreme psychopaths.

One of the effects of opium is the obliteration of mental conflicts and of the uncomfortable pathological strivings that result from them. The tensions, both physical and mental, produced by these strivings are relieved, and under its influence the neurotic or psychopathic patient feels free, easy, and contented. The contrast with his usual state is so great in some cases that he is actually happy. The condition may be expressed in another way by saying that the patient has sublimated his pathological impulses by the use of a narcotic. The objection to this form of sublimation is that it is itself temporary and pathological. The reflex from waning narcotism accentuates the original tensions, just as release from these tensions accentuates the pleasure of narcotics beyond normal expectations, and in the end the patient is worse off. The depression that so often follows the withdrawal of opium is in part explained in this way.

The point that it is desired to settle is: Does the so-called inflation of personality cause anyone subject to it to commit crime while in the inflated state? The cases under discussion clearly show that exactly the reverse of this is true. In nearly every instance where the drug has been taken in large quantities by a morose, irritable, restless, discontented individual, the inflation for the time being has made him agreeable, pleasant, and nonaggressive. The effect on less pathological individuals is similar, but less in degree. It is, in fact, the pleasant satisfaction with things as they are that causes addicts to lose ambition and willpower. Addiction to opium will not prevent criminals from committing violent crimes the inflation is too temporary to bring about such a good result, and when tolerance is established, the effect is diminished in intensity-but the drug in large doses does inhibit aggressive impulses of every kind, and the effect on an aggressive criminal is to make him less a murderer and more a thief. Under the influence of morphine or heroin, the addict suffers in courage and pride because, when his personality is inflated, everything is satisfactory and nothing matters Although the inflated state tends to lessen the tendency to crime, there is a "Inebriety or Narcomania," by Norman Kerr. Third addition. London; H. K. Lewis, 1894.