every problem presented by dischargees and to assist them by supportive help and by referral, interpretative, and intensive casework services.

2. Adult dischargees with family and other resources

When adult dischargees return to families and other relatives, some of the problems detailed above are relieved-only to be replaced by others. Dischargees still face the problem of financing themselves, finding employment, etc. Though families try to help, they may themselves be living in marginal circumstances and able to offer only limited assistance. They may not, for example, be able to help dischargees with clothing-an important item since many dischargees pawn their clothing at the height of their addiction before hospitalization. Even where families are in a position to assist, they may hesitate to offer substantial sums of money which may be used to purchase drugs.

Many dischargees are ambivalent about returning to their families and previously hurtful relationships; they may resent the close scrutiny and pressure although they require the warmth and support of the familiar environment. This ambivalence is frequently augmented by the family's mistrust of a dischargee's ability to remain off drugs, so that they question him and even examine his body for telltale needle marks. These suspicions may tend to undermine the dischargee's confidence in his ability to remain off drugs. When the dischargee has resistence to seeking employment because of various blockings, fears, or confusion as to how to proceed, the family's criticism may increase his resentment or depression.

Families may further complicate dischargees' difficulties by superimposing their own ambivalent feelings. Though they fear that the dischargees may relapse or again become involved in illegal activities, they may simultaneously resent the need to support an adult person who should be independent. In their anxiety, families are themselves in need of much interpretative and supportive help. They may not trust their own ability to help dischargees remain off drugs and seek to obtain outside assistance, though occasionally also identifying with dischargees in their fear of outside agencies. Families are frequently avid for information which will help them cope with the problems of the dischargees.

Where dischargees have relapsed, the pressures upon the family may become intolerable. They are then placed in the untenable position of either supporting the expensive habit or seeing the dischargees resort to illegal activities. At such times, families are desperately in need of some counseling service which can help them resolve their conflicting feelings and plan for a resolution of their dilemma.

3. Adolesent dischargees with family resources

It is clear that many of the problems discussed under paragraphs 1 and 2 have reference to this group as well. To these, others may be added: families of adolescents generally feel a great responsibility to scrutinize all the activities of their teen-age youngsters and may adopt an authoritative tone which may increase the rebelliousness of the boys, though at times they are too anxious to act decisively in any direction. Much more turmoil and frustration may be involved when the families are still hopeful about their ability to break the vicious cycle of the habit.

Certain problems, such as the vocational, require special attention in view of the lack of training and employment experience of the youngsters. Of even greater importance are the conflicts around dependency. Adolescents have not yet resolved the question of breaking away from the family and may have extraordinary difficulties in making the transition to adult responsibilities. Their inner tensions may be made more acute by the anxieties inherent in an atombomb age and a time of crisis and war. They may then prefer to eschew any long-range planning in favor of a catch-as-catch-can existence.

Some therapists and social agency representatives have tended to deplore the too facile inclination to consider adolescent addicts as a group uniformly accessible to treatment and about whom we can afford to maintain an undiluted optimism. It is their feeling, rather, that adolescent drug users frequently pose treatment problems as stubborn as those of older men-to which may be added unbelievable lanses in judgment and failures in discrimination. Gerard and Kornetsky indicated in a recent study of adolescent opiate addiction that ado

16

16 D. L. Gerard and C. Kornetsky, Preliminary Report on Adolescent Opiate Addiction, paper read at the American Orthopsychiatric Association meeting in Cleveland on February 25, 1953.

lescent patients exhibit a level of addiction similar to that of older addicts, in terms of their physical and emotional dependence on drugs, and that the addiction was clearly associated with emotional maladjustment of a severe, deepseated nature. Their patients fall into the following groups: (1) overtly schizophrenic; (2) incipient or borderline schizophrenic; (3) delinquency-dominated character disorders (a) pseudo psychopathic delinquents, (b) oral dependent characters; (4) inadequate personalities.

It becomes apparent, then, that further help must be offered the dischargee, thus far compelled to confront alone a complex of problems--psychological, financial, vociational, and medical-during a period of stress when he is uncertain of his ability to avoid a relapse and fearful of any pressures which may undermine his determination to stay “clean." Even should there be no immediate problems, there is a kind of confusion, isolation from people, suspicion of the outside world, and hesitancy as to how to proceed. These points suggest that, ideally, a followup agency closely associated with the hospital program would be the logical starting point for continuing plans made during hospitalization and sustaining the dischargee in the stressful first weeks following his discharge. Such an agency, equipped to offer general and intensive casework services, could contribute much toward preserving the gains made during hospitalization, helping provide the basis for change, and avoiding the relapses so costly to the individual and to society as well.

AN ANALYSIS OF THE NARCOTIC DRUG MENACE FROM A PHYSICIAN'S POINT OF VIEW By Hubert S. Howe, M. D.

No one in this audience will doubt that, under circumstances as they now exist in the United States, drug addiction and its attendant crime is a serious problem.

As addiction and related crime have both legal and medical aspects, and as I feel that the medical aspects of addiction have not always been fully understood, I am glad of the opportunity to emphasize some of the points which have come up in my study of the subject.

It may be well to say at the outset that when I speak of narcotics, or drugs, or narcotic drugs, tonight, I am referring to opium and its alkaloids, and to certain synthetic narcotics. Therefore morphine, heroin, and demerol are those particularly referred to unless I indicate otherwise. Marihuana and cocaine are not included.

To begin with, it may be appropriate to say that there is no "wonder" drug, and no magic treatment for the cure of drug addiction. Addiction produces habits of both mind and body, as well as habits of association and conduct, which result in a complex of great subtlety.

Addiction to a narcotic drug is medically considered to be an altered condition of the cells, tissues, and organs of the body, brought about by the continuous administration of the drug, with the result that the coordinated body functions require the presence of the drug in the body fluids. Cessation of use of the narcotic causes painful physical and mental disturbances. Nonaddicted persons generally do not fully realize the suffering an addict experiences when the concentration of the drug in his body is diminished below a certain point. To maintain the necessary concentration, administration of the drug must be repeated at intervals of 4 to 5 hours.

The physical pain resulting from absence of the drug can be overcome by proper withdrawal procedures in a relatively short time. Relief from the physical distress, however, has frequently been mistaken for a cure.

In addition to the physical bondage, there remains a mental dependence of a much more stubborn character. Not only does the mental dependence become a conditioned reflex which is not easily broken-even if the individual himself wishes to do so-but the situation is further complicated by the fact that one of the physiological effects of narcotic addiction is to diminish the mental stamina, or will power, of the individual, as well as his ability to withstand pain or discomfort of any kind without returning to his drug.

In addition to these problems, there are matters of environment, evil associates, lack of skill to earn a living by honest means, and a highly developed skill to provide a living by resort to criminal expedients.

To understand the problem of drug addiction, it is necessary to recognize the distinct characteristics of two classes of diets.

There are, first, persons who have become addicted as a byproduct of treatment for serious medical disease; and, second, victims who have become involved through the agents of organized crime.

It is this second group with whom we are at this time primarily concerned, and to whom we refer when the term "addict" is used. The latter group presents by far the most complex problem which has been the object of a rising tide of public anxiety. As report has followed report, there has been a growing realization of the personal debauchery suffered by the addicted individual, and the danger to the entire community from the crimes which invariably follow in addiction's train. It is generally recognized that an addict is under extreme compulsion to obtain his drug, but few people perhaps understand the economic strain under which he is put by the necessity of his having to patronize the available channels of illicit trade. Evidence from thousands of cases studied underline the now undisputed fact that in order to pay for his narcotic drug, the addict must regularly engage in crime. In fact, the physical, emotional, and economic demands of his habit are so great that he has no real opportunity for honest labor, and so addiction becomes not merely a habit but an all-controlling way of life. Addiction is his habit--but his education is for the practice of crime.

In the early portion of the 19th century, opium was freely prescribed by physicians. There was practically no other satisfactory remedy for pain or for relief from the myriad of symptoms grouped under the designation of "nervousness." During this period narcotic drugs were as freely accessible as aspirin is today. There was little public knowledge concerning their sinister properties, and their use became a common practice. In 1882 there were an estimated 400,000 addicted individuals in this country from a population of 50 million.

Through the education of the public, and greater care being exercised by physicians, the number of persons addicted decreased, so that by 1914, with almost double the population of 1882 (92 million), there were an estimated 150,000 to 200,000 addicts. The Harrison narcotic law was enacted by the Federal Government in 1914. This law effectively stopped the unrestricted sale of opiates by drugstores and made it illegal for physicians to furnish narcotic drugs to addicts.

Unfortunately, however, the Harrison law provided the necessary setting for a flourishing illicit traffic in narcotic drugs. From this point on, the character of the narcotic problem profoundly changed. We exchanged one type of evil for another.

In 1918, a commission appointed by the Secretary of the Treasury estimated that there were 1 million drug-addicted persons in this country. Thus it will be seen that within 4 years' time we had 5 times as many affected individuals as before the passage of the Harrison law. There was, however, a radical change in the method of obtaining opiates by addicts. The closure of the legitimate channels brought into existence an illicit traffic of tremendous proportions. Thus, virulent criminality was added to what was formerly simple immorality.

It is also well established that the type of individual becoming addicted has greatly changed. During the pre-Harrison law period, addiction was usually contracted as a result of what would now be considered improper use of drugs in illness, and because of their unrestricted availability in pharmacies. In that period addicts were mostly older persons. Prices of narcotics were low and most addicts were able to support themselves by legitimate means. Their associates were mostly law-abiding citizens. They and their families suffered a severe inconvenience by their addiction, but in general they were not forced to crminal acts, either by criminal associates or by the expense of their habit. At present, however, the new addict generally starts as an immature youth. Adolescent children, with their natural curiosity and desire to experience new sensations, are the logical prey of the narcotics merchant who offers them free marchandise. Their sales resistance is lowered by an utter lack of knowledge of the devastating slavery which these drugs induce.

The situation of the individual addicted as an adolescent, under present conditions, is far different from the pre-1914 type. The cost of his narcotic need is high-seldom less than $5,000 a year. He has become addicted before he has acquired any skills by which he can earn any such amount of money by honest means. Addiction of the adolescent is particularly unfortunate also because the use of the drug deprives hilm of his normal emotional development. It impairs the normal maturation of his sex life. Moral values are warped before they have been normally formed, and he is rendered relatively incapable of

benefiting from any educational training he may receive because of the time and effort ncessary to satisfy his habit, and also as a result of the sedative and emotional effects of the drug.

If the adolescent addict seeks legitimate employment he finds either no opportunities at all, or very unattractive and unremunerative ones. Employers do not want him. He tends to drift away from his unaddicted friends, and at last he is ostracized by them and finds himself mainly in the company of criminals. He can earn the money required by his habit only by becoming a pusher himself, or by resorting to theft or other criminal pursuits. He knows no life but crime, and feels a bond with no one but criminals.

In addition to all these complex forces, he lives in an atmosphere of compound fears. These fears are of three basic types: Fear of not being able to obtain his drug; fear of being apprehended for his criminal activities; and, finally, fear of the persons who supply his drug. This latter fear stems from the fact that by delivering to the addict an overdose, the supplier can cause the addict to kill himself. The user has no way of determining the amount of the dose until after it is too late. This simple fact imposes a stern discipline over the slavery which the drug induces.

Here, then, we find economic and social compulsions leading to crime and the sternest of all human disciplines-the power of the pusher to inflict torture by withholding the supply, or death by delivering too much. Furthermore, this is a day-to-day, hour-by-hour compulsion which is never absent. One can hardly conceive a stronger, more constant, incentive to crime.

In a report to the United States Senate on the "Illicit Narcotic Traffic," published January 23, 1956, it is stated that "The Nation's illicit narcotic traffic grosses more than a half-billion dollars a year." This report also states that "Drug addiction is responsible for approximately 50 percent of all crimes committed in the larger metropolitan areas, and 25 percent of all reported crimes in the Nation."

The Federal Bureau of Investigation Uniform Crime Reports for 1954 state that "Crime, up 26.7 percent since 1950, has increased almost 4 times as fast as the population, and that persons under 18 years of age represented 57.6 percent of all arrested for auto thefts, 49 percent of all arrested for burglary, and 43.6 percent of all those arrested for larceny." What percentage of these crimes against property were committed by individuals addicted to narcotics is unknown, but it may be safely estimated that they comprise a large proportion.

The United States has the highest crime rate of any civilized country in the world, and the largest black market in narcotic drugs. Mr. J. Edgar Hoover states that crime costs each family in the United States an average of $495 per year.

It must be clearly recognized that addicts are of many types. Although the present pattern seems to indicate that most addicts commence the use of narcotics in youth, it would be a serious error to believe that they are all youths at present. Some are newly addicted, while others have been addicted for many years. Their mental makeup varies as much as in any other class of diseased humanity. Some are educated; many are ignorant. Some have valuable skills; others have none. Some are deeply addicted; others are not. Nothing could be clearer than the fact that the same pattern of treatment will not succeed for all. Like other diseased persons, a high quality of individual judgment must be applied in the solution of their physical, emotional, social, and economic needs. Among those who deal with the problem of addiction there is a growing realization of the fact that there is little justification for the hope of a complete and permanent cure of many addicted individuals. A fact that has never been officially accepted in the United States is that some addicts can be, and remain, useful and law-abiding citizens if they are provided with their minimum requirements.

Cure, therefore, is a very difficult problem, involving much more than simply getting the addict "off the drug" for a few days, a few weeks, or a few months. Institutions sometimes seem to proceed as though this is all there is to it, with the result that they are processing, and often reprocessing, an ever widening stream. Permanent cures are few and far between.

Genuine, permanent cure involves social and economic rehabilitation, rebuilding habits of moral and mental stamina and self-reliance, as well as relief from the physical bondage of the drug. Such a program is unlikely to succeed as a result of filling larger and larger penal institutions with more and more addicts. This is especially true because of the fact that while in institutions, addicts are in contact with many other addicts and criminals, from whom they obtain fur

ther education in all the ramifications of addiction, and the techniques and contacts of organized crime. Placing addicts in institutions under compulsion (unless they are imprisoned for life) would be simply to establish under the aegis of the state, great incubators of addiction and crime. Addicts should be privately treated and kept away from other addicts as much as possible.

Rehabilitation, under the present regulations, can only be carried out after the patient has undergone withdrawal treatment. Rehabilitation of addicts skilled only in the devices of crime is not simple; it involves not alone teaching them some peaceful occupation, but remedial, psychiatric, and social guidance over a considerable period of time. In the Report on Drug Addiction recently issued by the New York Academy of Medicine, in regard to rehabilitation in our Federal hospitals, it is stated: "Under the present system, rehabilitation ceases before it is finished. The addict, following his stay at the institution, is given carfare to his home and a warm farewell; then he is dumped as a solitary figure, penniless, very often friendless and without work, in a hostile society. It would test the mettle of a healthy man to undergo this experience; it must be a real trial to the discharged addict.

Under these conditions it is to be expected that a large proportion of these discouraged individuals will quickly return to drug use.

Most addicts cannot be kept away from drugs long enough to effect even the most superficial rehabilitation. It seems reasonable to suggest that rehabilitation could be undertaken before the addict is required to give up his drug. When he has regained his place in society, and had training to enable him to support himself by productive means, he may consent to be relieved of his physical dependence on the drug, with more expectation that the cure will be enduring.

So much has been said about the partnership of addiction and crime that it may be useful to comment on the conduct of addicts while under the influence of their drug. Many uninformed persons believe that addicts, under the influence of opiates, are dangerous. This is a false conclusion, resulting probably from the common familiarity with the effects of alcohol.

There is, however, a fundamental difference between the disease of alcoholism and that of opiate drug addiction. The alcohol habitue is normal only when he has no alcohol, while the narcotic addict is normal only when he takes his drug. Thus the narcotic addict is dangerous, not when he has his drug, but rather when he is without it. This is a very important fact, and one which has escaped many observers. Crime comes, not from the use of the drug, but in order to assure a supply of it.

You may ask, even if narcotic addition is difficult to cure, can't we at least prevent its spreading? From a medical point of view, this would seem entirely possible to do, for there is no uncontrollable desire resulting from the clinical or psychiatric effect of narcotics which drives one addict to infect another. Furthermore drugs are ordinarly taken in solitude and not in groups so that there is little social impulse to the spreading of addiction. While there is no clinical, physiological, psychiatric or social desire to spread addiction, the incentive to do so, in order to obtain funds to supply the addict's own needs, is tremendous. Addicts turn to all types of crime from which they hope to obtain money for their drug, but "pushing" or selling to other addicts is especially common. Thus we have a situation resulting from a high-priced illegal black market in which the financial necessities of the users have made addiction practically a chain reaction.

The growth of crime connected with the illegal narcotic traffic, of course, has not gone unobserved by the agencies of law enforcement. Early in the game, smart Government lawyers noted that it would be a violation of the Constitution to prohibit persons from taking drugs. They, therefore, invented the idea of placing a high tax on the product. The legal infraction in the narcotics business is, therefore, tax evasion, and that presumably is why the Federal Bureau of Narcotics is under the Treasury Department. Be it not thought that the effectiveness of the Bureau of Narcotics has been hampered by constitutional obstacles. On the contrary, their ardor is unexcelled.

In this country, drug addiction has been thought of most ofen as a vice, rather than a disease requiring individual medical and psychiatric care. In fact, this concept has gone so far in enforcement circles as to practically deprive addicts of competent medical advice, even when they want it. Under directives issued by the Commissioner of Probation, with the approval of the Secretary of the Treasury, from 1919 to 1921, physicians are restricted with respect to the prescription of narcotic drugs.