about illicit heroin. He suggested that she might well report to the police, since she knows that if she sticks to prostitution alone, the worst that will happen to her is that she will be fined 40 shillings about every 2 weeks, whereas if she becomes involved with drugs she might go to prison.

Because the British addict can maintain his habit without becoming a criminal, and the criminals not especially exposed to addiction by the existence of a large, illicit traffic or by great numbers of addicts in the underworld, these two groups remain relatively separate. This works not only to the public advantage, but also to their own; it should not be surprising, therefore, that London thieves show no special tendency to become drug addicts, or that London addicts are relatively noncriminal.

It is interesting that the use of marihuana, which in this country often leads to the later use of heroin, does not seem to have this consequence in Britain; there marihuana smokers obtain their supplies entirely from illicit sources, and the British police deal with this problem much as it is dealt with here. The fact that heroin, on the other hand, is not contraband, and that it may be prescribed for those addicted to it, may account for this difference in the use of the two kinds of drugs.

It has been said that British addicts do not show the same disposition as their American counterparts to spread their vice, but instead warn others who may become interested in it. On this point several aspects of the situation are relevant. One is that in England there is little or no economic incentive to spread the habit to others; and if the addict is under a doctor's care, he will certainly want to keep the supplies he receives rather than sell or give them away. If he sells them, he violates the law. Moreover, if the addict is under a doctor's care, he can keep his habit from becoming publicly known, since all records with respect to it are confidential. Thus he risks forfeiting his anonymity, as well as his status as a law-abiding citizen, if he violates the law.

A frequent criticism of the British program is that it does not place sufficient stress upon curing addicts because drugs are made available to them, and because they cannot be compelled to seek cures. In answer to this it is argued that compulsory cures are ineffective anyway, and that a drug addict, like a person addicted to alcohol, can only be cured if he wants to be and cooperates in the process. By putting the drug user in the hands of a doctor, and by not removing him from his community and family, the British program maximizes the resources which may be drawn upon for effective treatment by persuasion rather than by coercion. However, no really effective method of curing drug addiction has been found in any country of the world.

It is sometimes believed that controlled legal distribution of low-cost drugs to addicts would make drugs easily available and lead to the rapid spread of the habit. It has not done so, of course. This belief is based upon the mistaken premise that drugs made available by a doctor's prescription are generally easy to get. Such drugs are readily available to the addict diagnosed by medical men to be in need of them, but are relatively inaccessible to all others. It is difficult to imagine a teen-ager approaching a doctor to ask for a large quantity of heroin with which to entertain his friends. It is even more difficult to think that a doctor would accede to such a request. It is because addicts can obtain drugs

by prescription that those drugs are unobtainable otherwise.

The system of drug control in Britain, which we have discussed, is obviously based upon the premise that the medical profession, with a certain amount of instruction, experience, and supervision, can be trusted to carry out its obligations in good faith under a scheme of this kind. It is quite true that much responsibility is placed upon the individual doctor, and that this responsibility has sometmes not been met. An English doctor made the point that any scheme is bound to be abused to some extent, and that there are some irresponsible persons in all occupations. He did not believe, however, that there was any sense in abandoning a good program because of this small minority, or in making a new program adapted to the low ethical standards of this small minority. Specifically, he felt that measures which would keep the few irresponsible doctors in Britain in check, and punish them for unethical practices in respect to addicts, would set dangerous precedents and be detrimental to the medical profession as a whole.

On humanitarian and legal grounds, the British system may be defended as a just and humane one. Because the addict does not also have to be a criminal, it is made reasonable and just to punish him when he does offend. Addiction itself is not a crime, either in theory or effect, and the addict is never formally punished for it. On the contrary, the idea of such punishment is rejected by

public and official opinion as contrary to the principles of British law and common humanity. Because the addict, as elsewhere, is regarded as ill, weak, troubled, and an unfortunate person, fines and prison sentences are not thought of as appropriate ways of dealing with him. He has, moreover, the same legal protection and rights in court as anyone else, and is not deprived of them by legal technicalities or subterfuges. As a doctor's patient, he has the same standing as any other patient. As already mentioned, all official records are confidential; and, as a matter of practice, special care is taken to protect the addict from unnecessary exposure or publicity. Perhaps ultimately the greatest strength of the system lies in the fact that it is publicly recognized to be just and humane.

18

MISCONCEPTIONS OF THE BRITISH SYSTEM

During recent years there has been a growing interest in the United States in the methods of drug control used in West European countries, especially in Britain. Perhaps because the practices of these countries are different from our own, and seem to be more successful, American officials have not invited invidious comparisons by publishing information about them. In some instances false information has been disseminated.

A prevalent misconception equates the so-called clinic system, as used in the United States in the early twenties, with a program such as the one described in this paper. The alleged failure of the clinic idea in the United States is then cited as proof that any legalized distribution of drugs to incurable addicts must fail. There is little resemblance between the clinic idea and the British program, and any attempt to treat them as similar leads only to confusion.

In a recently published book on the narcotics question,1o Mr. Harry J. Anslinger, head of the Federal Bureau of Narcotics, contributes to this kind of confusion by discussing the "clinic plan" under the heading, "Fallacy of Legalizing Drug Addiction." He describes such a plan as follows: "Under this plan anyone who is now, or who later becomes, a drug addict would apply to the clinic and receive the amount of narcotic drug sufficient to maintain his customary use." He does not describe the British system or that of any other West European country. Concerning the British system he writes: 20 "No government in the world conducts such clinics, no matter what is said about England. What about all the seizures there? What about the trouble doctors are having keeping their bags from being stolen ?"

The latest official report of the British Government," for 1955, states concerning these questions raised by Mr. Anslinger: "The isolated cases of the theft of legitimately manufactured drugs occur very occasionally, but in 1955 no such cases were reported."

As far as nonmanufactured drugs are concerned, 48 seizures of opium and 48 of marihuana were reported for 1955.

Elsewhere in his book,22 Mr. Anslinger refers to "The present wave of drug addiction in the United States, Canada, Turkey, Egypt, England, Germany, and Japan," and makes the following specific remarks about England:

23

"In England, the British Government reports annually only 350 drug addicts known to the British authorities-mostly doctors and nurses. When we ask them about the statistics of seizures of opium and hashish (marihuana), they say: Negroes, Indians, and Chinese are involved. In this country we don't distinguish; we take the situation as a whole. England, during the last year, has had a surge of hashish addiction among young people. A year ago they were looking at the United States with an 'it can't happen here' attitude. Suddenly hashish addiction hit the young people. Ordinarily hashish is only something for the Egyptian, the Indian. Now the British press is filled with accounts of cases of addiction of young people."

Apart from the fact that marihuana, or hashish, is not a drug of addiction in the sense that the opiate derivatives are, it should be noted that the number of persons prosecuted for offenses involving marihuana reached a peak in Britain

18 For a recent example see Laurence Kolb, Let's Stop This Narcotics Hysteria, Saturday Evening Post, July 28, 1956.

19 Harry J. Anslinger and William F. Tompkins, The Traffic in Narcotics, Funk & Wagnalls Co., New York, 1953, p. 185.

20 Ibid., p. 290.

21 Op. cit., p. 6.

22 Op. cit., p. 11. 23 Op. cit., p. 279.

in 1954 with a total of 152.24 In 1955, there were 115 such cases. The number of these offenders who were of European origin, was 29 in 1954. These figures scarcely seem to justify the use of the word "surge" in describing the British situation.

Some deliberate attempts to misrepresent the nature of the British system have been made. In an anonymous mimeographed statement entitled, "British Narcotic System," distributed free of charge at the meeting of the American Prison Association in Philadelphia in 1954, the following statements appear:

"The British system is the same as the United States system. The following is an excerpt of a letter dated July 18, 1953, from the British Home Office, concerning the prescribing of narcotic drugs by the medical profession :

"A doctor may not have or use the drugs for any other purpose than that of ministering to the strictly medical needs of his patients. The continued supply of drugs to a patient, either direct or by prescription, solely for the gratification of addiction, is not regarded as a medical need." "

The above quotation is an extract from the 1948 Home Office memorandum, and was also quoted and explained earlier in this paper. The failure to explain that the Rolleston report interpreted regular administration of drugs to an addict by a medical practitioner as "treatment," rather than as "gratification of addiction," gives the statement the opposite of its actual meaning.

Other statements from his document on the British system follows:

"No doctor would give a prescription for marihuana in the United Kingdom as he would be charged with a narcotic violation."

Comment.-A doctor would not, of course, prescribe a marihuana cigarette, but he could, conceivably, prescribe marihuana in some other form without violating any law since prescriptions of drugs are subject to control by medical practice and not by law.

"There is also a black market for morphine and pethidine in the United Kingdom. Twelve percent of the illicit trafficking cases in the United Kingdom related to forged prescriptions or concurrent supplies from more than one doctor to obtain morphine or pethidine to gratify addiction. The British Government arrests these addicts who forge prescriptions for morphine and pethidine. They are handled the same way in the United States." [Italics not in original.]

Comment. The italicized part of this statement shows that the unknown author was aware of the fact that British addicts can obtain supplies legally from one doctor. The number of persons represented by "12 percent" was 14; 25 and there was probably no connection with the illicit traffic. Addicts who forge prescriptions and obtain dual supplies do so as a rule to supplement the supplies they receive regularly.

"There are also robberies by addicts of drug stores or other establishments handling narcotics in the United Kingdom."

Comment.-There are few such cases, and in 1955 there were none reported. There follows a brief discussion of the clinic plan in the United States, indicating that it failed, and that the American Medical Association opposed it. The final sentence in this anonymous statement reads:

"A pamphlet, Narcotic Clinics in the United States giving the history of the opening and closing of clinics, can be obtained free of charge by writing to the Bureau of Narcotics, Washington, D. C."

Comment. It would appear that any discussion of the clinic plan in the United States under the heading "British Narcotic System," is highly irrelevant since there are no clinics in the British system.

The idea of allowing morphine or heroin addicts to have access to legal drugs is often represented in American magazines and the press as a daring and revolutionary conception. It is nothing of the kind. It is the principle on which most drug control schemes in the Western Hemisphere are based, and on which American practice was based until about 1920. The annual reports of European nations to the drug control bodies of the United Nations demonstrate this.26 Methods for internal control of the drug problem are not dictated by the United Nations, and are rarely discussed in its publications, probably because of various national sensitivities, including particularly American sensitivity, on this question.

24 See the previously cited reports to the United Nations, 1954, pp. 4-5; 1955, p. 7. In 1951, the year referred to by Mr. Anslinger, the number of marihuana cases was 127. 25 As checked by a home office official who read the mimeographed statement.

26 Summary of Annual Reports of Governments, published annually by the Commission on Narcotic Drugs, Economic and Social Council, the United Nations, New York.

Because of his position as Commissioner of Narcotics, head of the Federal Bureau of Narcotics, and American representative to the United Nations on drug control matters, the opinion of Mr. Harry J. Anslinger are of special importance. They are often echoed by congressional committees and by the press, and are influential in shaping public opinion. Mr. Anslinger has been consistently and strongly opposed to any form of legalized distribution of drugs to addicts. He has, however, never described the British program, but has leveled his blasts at the clinic plan instead.

Some of his objections to the clinic plan are as follows:

27

"This plan would elevate a most despicable trade to the avowed status of an honorable business, nay, to the status of practice of a time-honored profession; and drug addicts would multiply unrestrained, to the irrevocable impairment of the moral fiber and physical welfare of the American people."

"(Such a plan) is * * * in direct contravention of the spirit and purpose of the international drug conventions, which the United States solemnly entered into along with 72 other nations of the world."

"(It would be a) reversion to conditions prior to the enactment of national control legislation and a surrender of the benefits of 22 years of progress in controlling this evil, in which control the United States has been a pioneer among nations."

"To establish clinics in countries which have a narcotic drug problem would be as sane as to establish infection centers during a smallpox epidemic."

"It is believed that easy or unrestricted access to drugs tends materially to increase addiction."

Not a single one of these objections is applicable to the program now in force in the United Kingdom and in most other countries of Europe. In the first place, none of them have clinics. All or most of them are also parties to the same international agreements that the United States has entered into, and all of them combined do not have as many addicts as the United States. The systems do not give "easy or unrestricted access to drugs," and have apparently controlled the spread of addiction, especially among young persons, far more effectively than has the American program.

CONCLUSIONS

The very success of the British and other similar European programs of narcotics controls has been a factor in preventing them from being widely known in the United States. The number of heroin and morphine addicts in Britain, for example, is so small that very few persons there have specialized knowledge of this subject. The literature is extremely scanty, consisting mainly of official reports and a few widely scattered articles in medical journals." Many of these works are not illuminating to American readers because they take for granted a knowledge of British medical practices. However, the apparent success of medically controlled, legalized distribution of drugs to addicts there is of obvious special significance for the United States.

28

It would be rash to advocate any wholesale indiscriminate importation of British methods to this country in the expectation of an immediate solution to the drug problem. The relatively large number of addicts here, their concentration in big cities and in certain segments of the population, clearly present special problems of extraordinary difficulty, as does the existence of a largescale illicit traffic of many years standing. Nevertheless, with due allowance for the differences in customs and social organization that exist between the two countries, it is reasonable to suppose that there is much in British experience from which we could profit. Drug addicts, after all, are pretty much the same throughout the world in many essential respects. Allowing for the smaller number of them in Britain, they still do not constitute the social evil there that they do here. The trend in the United States toward more and more severe punishment, for users and peddlers alike, has reached such an extreme that demand for a fundamental reevaluation of the present punitive program is very much in order. When it is undertaken, British experience could, and should, play an important role.

27 Op. cit., pp. 186, 189, 190-191.

28 The only recent book on narcotics known to the author which contains a fairly adequate description of the British system is by an English author, E. W. Adams, Drug Addiction, Oxford University Press, 1937.

[From the Nation, April 21, 1956]

TRAFFIC IN DOPE-MEDICAL PROBLEM

By Alfred R. Lindesmith1

For 40 years the United States has tried in vain to control the problem of drug addiction by prohibition and police suppression. The disastrous consequences of turning over to the police what is an essentially medical problem are steadily becoming more apparent as narcotic arrests rise each year to new records and the habit continues to spread, especially among young persons. Control by prohibition has failed; but the proposed remedies for this failure consist mainly of more of the same measures which have already proved futile.

The number of heroin and morphine addicts (the use of marihuana, cocaine, and other drugs is a separate problem not included in this discussion) is conservatively estimated by Mr. Harry J. Anslinger, head of the Federal Narcotics Bureau, at 60,000. This figure is a guess; its main virtue is that it is the lowest offered. Even so, the contrast with European countries is spectacular. For example, the English Government reports slightly more than 300 addicts known to the authorities in all of Britain, with a population of over 50 million. There are probably more addicts in the United States than in all of the other western nations combined, and more juvenile users in New York City than in the whole of Europe. Almost all English addicts are reported to be over 30 years old, while close to half of ours is under 25. What is even more significant, European users appear to add to the crime problem in only a minor way, and the illicit traffic there is feeble compared to ours. The American market is the hub of the drug traffic in the Western Hemisphere.

In recent years there has been a growing interest in the English system of control. General Sessions Judge J. J. Goldstein, of New York, mentioned it recently in connection with his advocacy of a system of controlled legal distribution of drugs to users. Dr. Hubert S. Howe, of New York, has also long urged such a plan, adopted by the New York Academy of Medicine, and has made references to the apparent success of the English system. Since about 1940, the writer himself has periodically suggested that an adaptation of the British idea be tried in this country.

The crucial difference between the American and British control systems is that the English physician is permitted to prescribe drugs regularly for the morphine addict while the American doctor is not. The decision as to whether or not regular prescriptions are to be given to the English user is left to the doctor, usually after consultation with another medical man. He does not have to report on the addicts under his care, but records must be kept both by him and by the druggists who fill the prescriptions. Through these sources the British Home Office and the police can secure information about addicts and keep close watch on them. Addicts are arrested for obtaining supplies from illicit sources or from two medical sources simultaneously. The addict cannot be coerced into taking a cure, but there is pressure on the doctor to do everything in his power to persuade the user to quit the habit.

The British addict under medical care is included in the doctor's panel of cases under the National Health Act. Apart from the taxes he pays under this act along with the rest of the population, the addict's expenses for maintaining his habit consist only in the shilling (14 cents) paid for each prescription. It is therefore unnecessary for him to engage in criminal activities to get his drug. The black market is small, limited primarily to London and a few other large cities, and caters to users who either don't know that they can place themselves under a doctor's care or don't wish to do so. Sometimes an addict will refuse medical care because he is afraid his addiction will become known, or because he does not want to try to cure himself of the habit. All black-market activities are, of course, prohibited by law, and the addict who patronizes peddlers risks arrest and punishment. In 1954 about 30 addicts were arrested, most of them for forging prescriptions or obtaining supplies from 2 doctors at once, and the majority were punished with fines up to a maximum of $280. The smoking of opium and the possession and use of marihuana are completely prohibited.

1 Alfred R. Lindesmith, author of Opiate Addiction, is professor of sociology at Indiana University. In 1955 he went abroad to study the English system of narcotics control under a research grant.