H. J. ANSLINGER
United States Commissioner of Narcotics
WILLIAM F. TOMPKINS
United States Attorney for the District of New Jersey Former Chairman, Legislative Commission to Study Narcotics, General Assembly of New Jersey
NARCOTICS AND MODERN MEDICAL SCIENCE
NO OTHER DRUG IS SO UNIVERSALLY USEFUL IN THE PRACTICE OF medicine as opium, either as such or in the form of morphine. It is unexcelled as a pain reliever, and is widely used in disorders of the intestinal tract, in pulmonary diseases, and in certain cardiac disorders.
Unfortunately morphine induces in persons who employ it for any considerable time a condition of dependence upon it which leads to serious physical and mental disorders. Morphine produces a condition of euphoria in the individual and gives release from mental worries and from bodily discomforts with a resulting feeling of well-being. When the euphoria passes off the old worries and discomforts return, perhaps with increased mental depression. These symptoms can be relieved by another dose of morphine and thus the addiction is established. In addition tolerance to the drug is established in the individual so that larger and larger doses are required to produce the same results.
Because of the dangers resulting from the addicting properties of morphine and opium, most governments have enacted legislation in an endeavor to confine its use to medical and scientific purposes. In the United States, passage of the Harrison Act in 1914, together with the ceaseless efforts of enforcement officers of the Government, has resulted in a very considerable decrease in the number of narcotic addicts.
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In 1929 the National Research Council appointed a Committee on Drug Addiction and undertook a definite program of study.* in 1939 the work was taken over by the National Institute of Health and all the experimental work was transferred to Washington. From 1929 to 1939, the program consisted of two divisions--- experimental, including laboratory and clinical studies, and a review of the literature of the subject in both its chemical and pharmacological aspects.
The chemical portion of the experimental work was carried out at the University of Virginia under Dr. Lyndon F. Small and Dr. Erich Mosettig, together with a staff of chemists and graduate students. This portion of the work embraced a study of the chemistry of the morphine molecule with the synthesis of allied compounds, and also of compounds based upon the phenanthrene nucleus which is contained in morphine. In all, more than four hundred compounds were prepared during the ten years of work.
The pharmacological study of these compounds was carried on at the University of Michigan by Dr. Nathan B. Eddy. From the large group of substances received from Dr. Small a small number were selected for clinical trial and these were studied in various hospitals especially as to their effect upon pain and cough. Only those compounds were subjected to clinical trial which showed in the pharmacological study that they possessed strongly some of the desired characteristics of morphine without being too toxic or exhibiting undesirable side actions. The addicting property was studied principally upon man.
The clinical investigation was largely carried out under the United States Public Health Service, Studies were made upon addicts confined in the Federal Prison at Leavenworth, Kansas, and later at the U. S. Public Health Service Hospital at Lexington, Kentucky, The hospitals of the Health Department of Massachusetts at Waltham and at Pondville, the Walter Reed Hospital at Washington, the Marine Hospital at Baltimore, and the
* See Appendix B for a summary of the accomplishments of this committee.
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University of Michigan Hospital at Ann Arbor, were all used in the various clinical studies.
The study of the literature naturally divided itself into two portions, chemical and pharmacological.
CHEMISTRY OF THE OPIUM ALKALOIDS
Chemistry of the Opium Alkaloids prepared by Dr. Small, Consultant in Alkaloid Chemistry, United States Public Health Service, was published by the United States Public Health Service in 1932 (Supplement No. 103 to the Public Health Reports).
The material in this volume was assembled in the course of a systematic study of the literature of the opium alkaloids undertaken in -a research project established at the University of Virginia by the Committee on Drug Addiction of the National Research Council. It makes accessible what is known of the chemistry of these alkaloids and their derivatives. The literature to January 1, 1932 was covered, and every reaction and every compound described in the literature is mentioned. The volume extends far beyond the scope of a systematic collection of facts, however, in describing historically the discovery and investigation of each opium alkaloid, and in discussing critically and exhaustively the structural question. The author has himself made valuable experimental contributions to the chemistry of the opium alkaloids.
In Part I the benzylisoquinoline and minor alkaloids are considered in separate chapters, each having a bibliography.
The phenanthrene alkaloids are treated in Part II, with bibliography arranged to facilitate specialized study.
Practically all data have been taken from the original literature, which is widely scattered in the journals of all lands. Copious literature references are supplied, and the source of every statement made is shown.
Dr. Small has used painstaking effort and care in organizing the extensive material on the opium alkaloids into this excellent monograph. It is of vast assistance to those interested in the subject.
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THE PHARMACOLOGY OF THE OPIUM ALKALOIDS
A review of the biological work on opium and its alkaloids entitled The Pharmacology of the Opium Alkaloids, (two volumes) constitutes the second portion of the survey (Supplement No. 165 of the Public Health Reports). The responsibility for the preparation of this material was assumed by Dr. Eddy, as director of the experimental staff. He has done much more than prepare a composite picture of the effects of morphine as they have been established experimentally. The types of experimental work which have been done are described thoroughly, the net results are summarized, and the large gaps which still exist in our knowledge of this substance are indicated.
A feature of the book which proves of great value to anyone interested in the field is a very complete subject index, covering not only the text of the monograph itself, but also the main features of all of the papers in the enormous bibliography, papers all too numerous to have received notice in the text.
Its author and the Committee on Drug Addiction expressed the hope that this study of the literature,* presenting a picture of current knowledge of this subject, would prove of value to workers in the field as a starting point from which new investigations could be carried on.
Nine years of effort went into the preparation of this survey of the pharmacology of the opium alkaloids. Part I was published in 1941. Part 2 is contained in a separate volume published in 1943. It has a very extensive bibliography. The substances selected for inclusion in Part 2 are related to morphine. It surveys all that has been written on the physiological effects of these drugs and summarizes it without loss of anything but unimportant details. The material has been classified first according to drugs, next according to the same physiological divisions adopted for morphine, and finally according to the animals studied.
One interesting development of this study was the discovery
*The literature on addiction prior to 1940 has been summarized by Krueger, Eddy and Sumwalt in The Pharmacology of the Opium Alkaloids. The literature on addiction which had appeared since 1940 was reviewed by Isbell in the Journal of Pharmacology and Experimental Therapeutics, 99: 355-397, August, 1950.
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of desomorphine, which is eight times more powerful than morphine, but unfortunately as addicting, so that its manufacture has not been permitted in the United States.
Much of the work done by Doctors Eddy and Small has been the basis for the recent development of new narcotics which have proved very valuable in the practice of medicine.
NARCOTICS IN MEDICINE
In an effort to disseminate information to the medical profession concerning the use of various derivatives of opium in the legitimate practice of medicine, first, from the standpoint of their indispensable use, second, from their ill-advised use, and third, from their abusive use, the American Medical Association published in their journal a series of articles from March 14 to June 6, 1931, and subsequently published in book form, entitled Indispensable Uses of Narcotics.
DANGER OF OPIATES IN SEVERE ASTHMA
In an article entitled "Death from Asthma--- A Warning" which was published in The Journal, June 13, 1942, a warning is given that the opiates should be rigorously avoided in the treatment of severe asthma, and especially so since other drugs such as ephedrine derivatives, epinephrine, and aminophylline are superior.
OPIATES IN CANCER CASES
A study entitled "The Relief of Pain in Cancer Patients" published by the United States Public Health Service in 1936, concludes that a lesser amount of narcotic drugs is necessary in cancer cases than is ordinarily supposed.
MORPHINE VS. OTHER REMEDIES
Morphine deadens pain of all descriptions (neuralgia, intestinal pains, wounds, etc.) by diminishing the sensitiveness of the
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cerebrum. In the same way it induces sleep, and is particularly effective when pain is the cause of sleeplessness. It is not, however, necessary to use morphine for all pain, as there are many other remedies. It is a medical malpractice to employ morphine simply as a soporific. Morphine is often the only practical remedy for excessive excitement produced by various causes. It also allays irritation of the upper air passages, but, for this purpose, can nearly always be replaced by codeine. Morphine has a powerful influence on respiration; it reduces the rapidity of the breathing and allows deeper breaths to be taken.
GUARDING AGAINST ADDICTION
In the hands of the physician, drugs are indispensable medicaments, while in the hands of the layman they spell ruin. All habit forming narcotic drugs have this in common-that their continued use and abuse in every case leads sooner or later to loss of moral control and even to physical and mental collapse.
Whenever, in persons who are by constitution and general predisposition mentally unstable, the balance of the mental and physical functions is upset, this can be remedied by the use of opium or morphine. In order, however, that these substances may give this relief, these psychical conditions must be present; they need not have manifested themselves actively, but may be latent and may be brought into operation by the supply of morphine to the system. The first effect of morphine upon such persons is a feeling of extraordinary well-being and vigor, a state of euphoria which a man in an unbalanced psychical condition seeks to recreate by further supplies of the drug. Later on, however, the effect of the same dose is only to produce satisfaction at the feeling of "normal health" attained by the use of morphine. The action of morphine on the addict may perhaps be conceived of in this way-that it has become a factor in the process of cell metabolism. If this factor is absent, the functions of the cells are thrown out of gear. If the drug is supplied afresh, the functions apparently become regular once more.
The intensity and duration of the condition induced by morphine vary from one individual to another. Many persons who
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are used to taking morphine are content with relatively small amounts--- in some cases, over longer periods at a stretch. In the majority of cases, however, increasingly numerous and stronger doses are needed to produce the illusion of approximately normal health or to avoid a feeling of depression. Any unnecessary excess over the quantity required to counteract that feeling--- a luxury dose so to speak-may produce a real euphoria, in which morphine and opium act as a screen preventing the unpleasant impressions and the worries of life from reaching the surface of consciousness.
Such people are, of course, in special danger, for, with the prolonged use of morphine, habituation sets in, manifesting itself principally in an ever-growing craving and increased bodily tolerance. The tolerance shows itself in this way: that doses of morphine, toxic in themselves, are then tolerated without any of those acute symptoms of poisoning which would necessarily appear in persons not thus habituated. In order to alleviate pain and produce euphoria, increasingly large doses are needed. There is then an uncontrollable and tormenting desire for ever-larger quantities. Finally, the amount of morphine taken is so great that the cells can no longer assimilate it.
APPRAISAL OF VALUE OF NEW OPIATES
A thorough and exact study of the different properties of opiates-analgesic, cough-relieving, hypnotic, etc.---is always a matter of some difficulty, and this difficulty is greatly increased if account is taken of the individual's constitution and condition, the special reaction of his autonomic nervous system and the nature of his endocrine formula.
Appraisal of the value of new opiates calls for a comparative examination of the different pharmacological and chemical effects. Research on these lines will indicate the group of opiates to which the new drug should be assigned and show its peculiar reactions in the human body. Where drugs of the morphine group are concerned, this work of systematic comparison is the more needful, since those who prescribe or generally recommend them are taking a serious responsibility. However, the clinical
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examination, which is usually of primary importance, is particularly difficult in the case of these various substances, which are very similar in nearly all respects.
The effects on the respiratory centre are difficult to judge by experiment. The real value of a medicament as a cough-relieving agent can be tested only on the human body, because the animals which are habitually used for these experiments are not subject to coughs. Only recently have experimental conditions been produced in them which may be equivalent to the chronic irritation associated with a cough in the human patient.
Also, recently a way of objectively measuring the influence of any remedy on a cough has been found. In the main, however, the physician must fall back on observations carried out with the utmost care, and on the evidence of the patient. If optimum conditions are to be ensured, the research can only be reliably conducted on intelligent patients in a hospital.
The influence of new opiates on pain and sleep is relatively easier to assess, but here also we have to take into consideration individual response, and depend for our evidence on the intelligence and goodwill of the patient. To measure the intensity of pain in a patient, we have no objective scale, and none either for the degree of alleviation of pain. Furthermore, it is impossible to compare absolutely equal intensities of pain to assess the analgesic strength of two drugs. Finally, and this applies particularly to opiates, one can never be quite sure whether the patient's own judgment of the pain-stilling power of a drug is unaffected by any euphoric influence.
Whether a new drug is habit-forming or not can be judged only after collecting all the necessary facts. Whenever a new opiate comes on the market, it is often claimed to be non-habit-forming and not to have the undesirable by-effects commonly associated with the older drugs of the same group. One particularly famous example of this kind was that of a drug put on the market several decades ago-heroin; but there have been other instances in more recent times. The great difficulty in estimating the degree of euphoria arises from the observation, often repeated, that individuals vary in their reactions to drugs. Some of them feel unpleasant by-effects of morphine to a very high degree, and to
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such persons it would be almost impossible to administer morphine in an emergency. Others feel the typical effects of euphoria, and they return to the doctor to try to obtain more. These facts, known to every experienced physician, afford the best proof of the difficulties entailed in judging the comparative value of opiates.
SUBSTITUTES FOR MORPHINE
A brief consideration will be given of several of the other opium derivatives which have been used as substitutes for morphine-cucodal, dicodid, and dilaudid. The drugs will be considered in relation to morphine as a basis of comparison. This is only a study of the literature.
Eucodal is regarded as a derivative of tbebaine, but it has no longer the characteristics of this substance. It does not cause convulsions; on the contrary, it is as narcotic as morphine (and codeine). Its action is also based on a central effect, and, generally speaking, is not only much more powerful than that of codeine but may sometimes surpass even that of morphine.
As an analgesic, eucodal is superior to morphine. Order of decreasing strength: heroin, eucodal, morphine, codeine, dionine.
As a cough cure, eucodal is less potent than codeine and dionine. It seems that eucodal, like morphine, effects a reduction of the sensitiveness of the respiratory tract commensurate with the degree of narcosis produced. Order of decreasing strength: codeine, dionine, heroin, eucodal, morphine. Its ability to create euphoria is less pronounced than with morphine. Order of decreasing strength: heroin, morphine, eucodal, codeine, dionine.
The toxicity in the rabbit is reflected in the convulsive power. Order of decreasing strength: heroin, dionine and eucodal, codeine, morphine.
The toxicity for man is inferred from the depressing effect on the respiratory function of the rabbit. According to these observations, eucodal seems to be slightly more dangerous than morphine,
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but less to be feared than heroin. Order of decreasing strength: heroin, eucodal, morphine, codeine, dionine.
If we try to assign eucodal to its appropriate place in the opiate group, we have to put in between morphine and codeine; but it is closer to morphine in type of its effect. Its fundamental characteristics are very similar to those of morphine, but perhaps less pronounced, especially in the matter of concomitant effects, addiction properties, etc. (Kleinschmidt) W. E. Dixon is of opinion that eucodal is more similar to heroin than to morphine.
Eucodal frequently proves superior to morphine in swiftness of action and intensity of the effect, but the duration of the former is generally shorter-on the average 6 hours, instead of 12 with 0.02 gram of morphine (Pfeiler). Other authors have not observed this shortness of effect, e.g., Wohlgemuth. In many cases, eucodal seems at least equivalent to morphine, and in some even superior (Baumm).
If one should try to sum up in a general way the addiction properties of eucodal, one would say that the danger of contracting a habit through taking eucodal should not be thought to be a less serious matter than the risk of morphine addiction, a conclusion which is borne out by the evidence collected by means of a questionnaire and published in 1928 (P. Wolff).
The second of the three newer habit-forming drugs under consideration, dicodid, has been known since 1923.
Dicodid is really a derivative of codeine, but with some of the characteristics changed, and occupying in the sequence of the opiates a position somewhat different from that of codeine.
Gottlieb came to the conclusion, in the light of his experiments on different animals, that dicodid should be placed-with respect to pharmacological character-between morphine and codeine. Eddy and Reid also judged that dicodid is more effective than codeine, but less so than morphine.
The main effect of dicodid is its sedative action on coughs.
The sedative effect of dicodid on the brain is similar to that of morphine, and much more distinct than that of codeine (Rickmarm). In comparison with morphine, the general narcotic effect
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of dicodid is considerably less (Sametinger), whilst the soothing action on the respiration is more powerful than that of codeine, and the narcotic effect on the sensation of pain equal to that of morphine.
It is well known and recognized that dicodid creates euphoria and addiction, but the degree to which this is the case will now be explained more fully.
There is no question but that dicodid is able to create euphoria (Sametinger, Wehl, Simon, and others); it seems, however, that the euphoria is less intense than with morphine (Roller, Castelhun). R. F. Mayer states, on the other hand, that euphoria seemed to endure longer in his observations than that of morphine, because it does not have the same sleep-inducing effect as the latter. This slighter degree of euphoria may explain why the danger of contracting a habit seems to be less strong (Castelhun, Weinberg, Hecht, Bing). Furland and Schelenz state, accordingly, that the effect on coughs is not diminished by the administration of dicodid over a longer period. With dicodid, therefore, the danger of misuse seems to be considerably less than it is with morphine, even when dicodid is administered over lengthy periods (Sametinger). But there is no doubt, as has been said before, that cases of addiction to dicodid are known (Sametinger, Mueller de la Fuente). Dicodid has not been found to be an equivalent substitute for morphine (Castelhun). Abstinence symptoms are described as being relatively slight, passing off quickly (R. F. Mayer). The drug could always be withdrawn without great difficulty (Ries, Sametinger), even in cases of depression (Richtzenhain). Abstinence symptoms in animals are less pronounced than with morphine or dilaudid (Eddy and Reid).
Addiction to dicodid seems to be rarer and easier to combat than that of morphine or eucodal.
The question of dilaudid has been studied with great care by R. B. King, C. K. Himmelsbach and B. S. Sanders as reported in Supplement No. 113 of the United States Public Health Reports, 1935.
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From observations made on morphine addicts, involving the substitution of dilaudid for morphine, it was concluded that:
1. Dilaudid is an effective substitute for morphine.
2. Dilaudid possesses definite addiction liability.
3. Definite morphine-dilaudid cross-tolerance exists.
4. The potency of dilaudid is approximately four times that of morphine, but the duration of its action appears to be considerably less than that of morphine.
5. In the presence of a daily laxative, equally effective doses of dilaudid are as constipative as morphine.
6. In equally effective doses, dilaudid appears to effect sleep as does morphine.
7. Dilaudid appears to possess no therapeutic advantage over morphine.
FALLACY OF LEGALIZING DRUG ADDICTION
To carry into effect the Hague Convention of 1912 "to limit exclusively to medical and legitimate purposes the manufacture, sale and use of morphine, cocaine and their respective salts," the Congress of the United States enacted, in 1914, major legislation in the form of the Harrison Narcotic Act. It stopped the indiscriminate purchase across the counter in the United States of drugs for the purpose of satisfying drug addiction.
Under this law the responsibility for the proper prescribing and dispensing of narcotic drugs, rests upon the physician in charge of any given case. Without reference to the question of addiction, a physician acting in accordance with proper medical practice may prescribe or dispense narcotics for the relief of acute pain or for any acute condition. Mere addiction alone is not recognized as an incurable disease.
THE CLINIC PLAN
The clinic plan recently advocated by a small minority group in one section of the country, would radically change the present plan of enforcement and revert to dispensing narcotic drugs to drug addicts for the purpose of maintaining addiction. Under this plan anyone who is now or who later becomes a drug addict
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would apply to the clinic and receive the amount of narcotic drug sufficient to maintain his customary use. The proponents of the plan claim that the "dope peddler" would thus be put out of business.
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.
Any plan which, like the one under discussion, tends to maintain and increase the spread of drug addiction is not only in direct contravention of the spirit and purpose of the international drug conventions, which the United States solemnly entered into along with seventy-two other nations of the world, but also constitutes a complete reversal of settled national policy of more than twenty years standing with respect to narcotic drug traffic control. This national policy is firmly rooted in the national legislation as interpreted by the highest Federal Court, and supplemented by concomitant State narcotic legislation.
The supplying of narcotics to addicts merely for the purpose of maintaining addiction certainly constitutes distribution for abusive use even if taken over by practitioners, and to recognize such procedure as legal would be not only a gross repudiation of our international obligations, but also a reversion to conditions prior to the enactment of national control legislation and a surrender of the benefits of twenty-four years of progress in controlling this evil, in which control the United States has been a pioneer among nations.
The answer to the problem is not, therefore, to accept narcotic drug addiction as a necessary evil and calmly proceed to ration with a daily supply each and every person who applies for the ration. It should rather be the provision by the States of facilities for scientific treatment of these unfortunates, looking toward a cure, coupled with vigorous and unremitting efforts toward elimination of improper sources of supply so as to facilitate complete rehabilitation of the reclaimed addict and prevent the addition of recruits to the ranks of these unfortunates. By scientific treatment is meant that professional treatment which includes confinement
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or restraint upon the addict to insure that no surreptitious source of supply is available to him that would defeat the purpose of the attending physician.
COURT DECISION ON THE NATURE OF PRESCRIPTIONS
One of the provisions of the Harrison Narcotic Law makes it unlawful to sell, barter, exchange, or give away the specified narcotic drugs except pursuant to an official order form, but there is an exception to the requirement of an official order form in the case of a practitioner who prescribes or dispenses to a patient "in the course of professional practice only." Within a very few years of the date the Harrison Law became effective, the United States Supreme Court was called upon to rule upon the application of this exception to the prescribing by a physician of narcotic drugs to an addict merely to gratify drug addiction. In the case of Webb and Goldbaum vs. United States (1919) 249 U. S. 96, the following question was propounded to the Supreme Court:
If a practicing and registered physician issues an order for morphine to an habitual user thereof, the order not being issued by him in the course of professional treatment in the attempted cure of the habit, but being issued for the purpose of providing the user with morphine sufficient to keep him comfortable by maintaining his customary use, is such order a physician's prescription under exception (b) of section 2 (of the Harrison Narcotic Law)?
In reply to this question, the United States Supreme Court held that
To call such an order for the use of morphine a physician's prescription would be so plain a perversion of meaning that no discussion of the subject is required. That question should be answered in the negative.
It is pertinent in this connection to quote from a report of a special committee of physicians, which was adopted by the American Medical Association and printed in The Journal of that Association June 14, 1924, reading in part as follows:
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 per
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son 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.
The Federal Bureau of Narcotics has never approved ambulatory treatment for drug addiction, for the reason that experience has shown where the addict controls the dosage he will not be benefited or cured. Medical authorities agree that the treatment of addiction with the view toward effecting a cure, which makes no provision for confinement while the drug is being withdrawn is a failure, except in a relatively small number of cases where the addict is possessed of a much greater degree of will-power than that of the average addict.
ABUSE UNDER THE CLINIC PLAN
The clinic plan for dealing with the narcotic addict problem is not a new development, as stated in the League of Nations Document 0. C. 1614. A number of clinics were opened in various cities in the United States during and after the year 1919 in an effort to deal with the problem, but whether or not the original intention was to attempt a cure of the so-called patients, it soon developed that the average clinic merely represented a supply depot for drug addicts. In some cases, so far from a reduction in treatment, it was found that so-called patients were actually receiving increased dosage from the clinic and in one case where a peddler was convicted in Texas for a violation of
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the Harrison Law it was shown that he had gone directly from Leavenworth Penitentiary to the clinic at Shreveport, Louisiana, in order to gain access to a cheap supply of morphine.
In an investigation of the alleged patients of one of the clinics many were found to have criminal records and perhaps the majority of the so-called patients were not local residents but were individuals who had been attracted to the city by the cheap source of supply for morphine and who managed to make a living, including the price of the drug, by petty thievery, panhandling, and other anti-social and parasitic activities. With literally hundreds of so-called patients on the rolls of the clinic, it is obvious that this large group could not receive anything approaching proper attention from the few physicians assigned to the clinic and even if a conscientious attempt were made at giving the reductive ambulatory treatment, the plan was foredoomed to failure because of the fundamental inefficiency of this treatment. By the end of 1925 most, if Dot all, of these clinics had been closed because the State authorities themselves had realized the failure of the plan. Not only did the clinic plan fail to solve the narcotic drug addict problem but it actually introduced new problems involving the public welfare.
At a session of the Opium Advisory Committee of the League of Nations, the question of clinics and the rationing of drug addicts was brought up and it was the consensus of the many nations there assembled that to establish clinics in countries which have a narcotic drug problem would be as sane as to establish infection centers during a smallpox epidemic. The rationing of addicts has been frowned upon by the signatories to the narcotic conventions, and the only place in the world where such a policy is now in force is in the Far East.
THE FORMOSA PLAN
With regard to the plan which is in effect in Formosa, we have a valuable and informing contribution to our knowledge on the subject by Dr. Tsungming To, Health Commission of Formosa. After classifying 57,073 crimes committed during seven years by natives of Formosa, his records show that based upon the relative proportion of opium users to non-users we find 70.83% criminality
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among opium users as against 29.17% criminality among non-users. In Formosa, opium smoking is licensed and the cost of opium is very small. Under these conditions the only attributable cause for greater criminality among narcotic addicts than non-addicts is the direct effect of the use of narcotics upon the character of the user. Dr. To gives us the answer. It is because drug addiction causes a relentless destruction of character and releases criminal tendencies.
ASSOCIATION AS CAUSE OF ADDICTION
In a certain city in our country, during a recent period when there occurred an influx of criminal addicts from neighboring cities and States to obtain narcotic drugs from several doctors and druggists, highway robbery increased from 55 cases in the corresponding period of the previous years to 97 cases; larceny from 738 to 1,025; and burglary from 11 to 58. In another city, the chief of police reported that theft and burglary complaints dropped noticeably following a narcotic clean-up. Thus it will be seen that from a business, social, and moral standpoint, the presence and contact of narcotic addicts in American communities is a potential danger. One survey showed that 67-1/2 percent of the addicts under observation had criminal records. Here too it might be stated that association is the largest single cause of drug addiction-all authentic surveys on the subject have shown that 50 percent or more of the addicts acquired their habit through association with other addicts.
The consensus of world-wide study of work and solutions pertaining to narcotic drug addiction gives no credence to any school of thought which fosters the rationing of drug addicts under the so-called clinic system. The problem is one which cannot safely be temporized with. The American Government could not advocate or approve any policy that would tend to make easier the access to narcotic drugs by a group which has proved itself, both by habit and precept, lacking in the physical willpower and mental stamina necessary to solve the problems which led them to drug addiction in the first place, much less to solve the addiction itself.
It is believed that easy or unrestricted access to drugs tends
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materially to increase addiction. In the light of present and past knowledge, the very best thing that can be offered to a drug addict, for his own good as well as for the good of society, is confinement and treatment with a view to cure and rehabilitation.
The United States has spared neither time nor money in getting at the basic truth in regard to drug addiction and every effort has been made to help the addict, but it is known that the narcotic clinic has been of no avail. The clinic idea, which simply supplies the addict with his drug for an indefinite period, creates a vicious circle. In this connection, it is interesting to note that most of the advocates of this system do not even go so far as to advocate a "cure." It is simply set forth as a plan whereby the addict maintains his old habit and invariably returns to the clinic where a fresh supply is administered or given to him for a small sum, and the victim again set at large to contaminate others to his ranks; this procedure to be continued indefinitely.
This method of treatment has never yet proved successful anywhere in the world, and it has been given sufficient trials that would have shown the merits if any had existed. Certainly anyone with even cursory knowledge of the situation realizes the complete futility of the narcotic clinic. The American Government would never tolerate such a system based on the degradation of its citizens.
As earlier stated, to conform to the clinic idea, it would be necessary to abrogate the treaties into which the United States solemnly entered along with sixty-four other nations of the civilized world. This Government has received many tributes of admiration for its leadership in narcotic control work, and if it hopes for the continued approval of the world, it cannot afford to compromise or slip from the high pinnacle it has attained and now occupies in the family of nations.
NARCOTIC CLINICS IN THE UNITED STATES
During and after the year 1919, forty-four or more narcotic clinics or dispensaries were opened by municipal or state health
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officials in large cities throughout the United States in an experiment which it was thought might present a simple and easy solution of the problems arising from narcotic drug addiction. Drugs were sold to addicts at prices as low as two cents a grain.
There seems to be no doubt that the clinics were started in good faith but at that time there was a general lack of familiarity with the facts regarding the addiction evil and, according to a report made in 1921 by a member of the Committee on Narcotic Drugs of the American Medical Association, it had not been realized that:
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.
The 1921 report continues:
Public opinion regarding the vice of drug addiction has been deliberately and consistently corrupted through propaganda. 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 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.... 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 . . . well calculated to create in their favor popular prejudice.
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This same line of thought which prompted the clinic experiment in the early days of narcotic law enforcement has recently been exploited again as a solution of the present narcotic addiction problem.
The clinics were operated for varying periods and in one city as long as four years. The most comprehensive series of facts, having real scientific value that bad then been compiled anywhere in the world, was embraced in the published statistics gathered from analytical study of the nearly 8,000 cases of addiction registered and cared for in narcotic clinics during about ten months by the Department of Health of the City of New York. These cases were subjected to most careful observation and study by specialists qualified to make scientific analysis and arrive at sound conclusions. They reported, "We have given the clinic a careful and thorough as well as a lengthy trial and we honestly believe it is unwise to maintain it any longer."
In some clinics careful physical examinations were given addicts before enrollment, and various methods of registration were practiced, including the furnishing of identification cards containing physical descriptions, photographs, and fingerprints of the addicts. (In clinics where the addicts were fingerprinted, numerous fugitive criminals were located and returned to the States where they were wanted.)
In some clinics addicts were given diminishing amounts of narcotics until reaching a minimum dosage which would prevent withdrawal symptoms; in others, cures of addiction were attempted in hospitals operated in conjunction with the clinics, as in New York City, if the addict would submit himself to treatment. In still others, the customary dosage was maintained or often increased upon the demands of addicts. Administration of drugs to addicts on the premises was attempted and proved to be completely unworkable because the addicts were unwilling to go the required distances to the clinics every six or eight hours during the day and night when they wanted a shot.
By the end of 1925 all of these clinics had been closed by the various State authorities for the reasons quoted herein.
As an indication of the vast extent of addiction during the several years around 1920, four hospitals in New York and the U. S.
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Penitentiary at Atlanta, Georgia, reported 25,000 cases of drug addiction; and the New York City Prison reported 12,000 cases. (In all of the 25,000 cases where immediate and absolute withdrawal of the drug was routine practice there were no deaths resulting.)
At Sing Sing Prison in 1920, the number of drug addicts received increased over 100 percent; in 1922 they increased over 500 percent; and in 1923 the increase was over 900 percent.
In 1922, 20 percent of the prisoners incarcerated in the Atlanta Penitentiary were drug addicts; at the Woman's Workhouse, Blackwell's Island, New York, practically all prostitutes committed were drug addicts; and from 60 to 80 percent of all committed there were drug addicts.
This illustrates the situation with regard to crime and drug addiction during the period when the narcotic clinics were in operation.
In 1952, 7.8 percent (1,157) of the prisoners committed to Federal institutions were narcotic addicts, and 1.4 percent were marihuana addicts.
In New York City it was stated by the Department of Health that "the purpose of this narcotic clinic is to provide temporary care for addicts who have been patronizing profiteer doctors and druggists." The clinics practically eliminated this profiteering practice, but there suddenly mushroomed and thrived in its place a tremendous illicit traffic in narcotics which supplemented and nullified the reduction treatments of addicts in attendance at the clinics.
In a one-year period in the early 1920's when these clinics were in operation, the volume of illicit peddling of narcotics reached the point where an incredibly large amount of 71,151 ounces of narcotic drugs was seized in the domestic illicit traffic-or more than fourteen times as much as was seized in 1952.
In New York State alone, when sixteen or more narcotic clinics were in operation throughout the State, almost 4,000 ounces of narcotic drugs were seized in illicit channels during a year or almost as much as was seized in the entire United States during 1952.
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THE NEW YORK CITY NARCOTIC CLINIC
Excerpts from Report published February, 1920, by S. Dana Hubbard, M.D., Acting Director, Bureau of Public Health Education, Department of Health, City of New York:
The arrest of several trafficking physicians and druggists (in the spring of 1919) for violating the narcotic laws caused the Department of Health to open a relief clinic, which began as an emergency and was expected, naturally, to be only a temporary experiment, but the necessity was so acute and attracted so much attention from those interested that the Commissioner of Health decided to continue it for some time, in order to study this subject and obtain data regarding the problem.
We feel that we have had an unusually wide and peculiarly general experience with drug addicts of all classes-classes so large as to make us think that others' experience in this form of practice has not been nearly so extensive.
The public narcotic clinic is a new thing. In fact there are only a very few in existence and, if we may judge from our experience, they are not desirable and do not satisfactorily deal with this problem. We have given the clinic a careful and thorough as well as a lengthy trial and we honestly believe it is unwise to maintain it longer.
The clinic has been found to possess all the objectionable features characteristic of the so-called "ambulatory" treatment, as practiced by the trafficking physicians.
From our experience with narcotic relief and registration in New York City, we now are of the opinion that the present law-the Harrison Act-should be strictly and uniformly enforced. To do so would bring these tipplers in drugs to the front and would hurt no one, not even the users themselves. These opinions, while radical, are not given to belittle the opinions previously expressed by persons supposedly well-informed on this matter, but are the results of an actual practical and intimate working knowledge of this subject.
Most-in fact 70 percent-of the addicts, in our clinic, are young people; (9 percent, or 743 out of a total of 7,464, were in the 15-19 age group) they have had no really serious experiences-surely none sufficient to occasion a desire to escape all of life's responsibilities by recourse to the dreams of narcotic drugs; therefore the one and only conclusion that we can arrive at is that the acquirement of this practice--- drug addiction-is incident to propinquity, bad associates, taken
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together with weak vacillating dispositions, making a successful combination in favor of the acquirement of such a habit. Being with companions who have those habits, they, in their curiosity, give it a trial (similar to the acquirement of cigarette smoking in our young) and soon have to travel the same road to their own regret. (Reasons assigned by addicts for acquiring the habit were: Bad Associates ... 5,190 or 69 percent; Illness . . . 1,994 or 26 percent; Other Causes ... 280 or 5 percent.)
The emergency relief narcotic clinic has brought out a mass of material, from which it is possible to study this problem, heretofore more or less vaguely thought about and on which there were but few statistical data.
Habits usually only affect the individual but, in drug addiction, indulgence appears to react on the community. The effect on the community is evidenced by debauching of its citizenry, by increase of crime and antisocial vices. The extent also spreads like a pestilential disease.
There may be those who say drug addiction is a mysterious disease; that it creates a disease mechanism; that it is not a matter for the authorities, particularly for the Department of Health;
Our opinion is that this habit is not a mysterious disease; there is a very general and complete understanding of drug addiction from the therapeutic standpoint among all who have dealt with it in institutions. In our opinion, drug addiction is simply a degrading, debasing habit, and it is not necessary to consider this indulgence in any other light than an antisocial one, and that those who are charged with correcting and preventing such tendencies should be stimulated to do so to their utmost, and all efforts exerted in this direction should be free from restraint, absolutely unhampered, and that all physicians interested in the general welfare of the people should earnestly encourage such action.
There may be other views regarding the control and prevention of drug addiction, but we opine that this is the natural and sane one to be generally expressed. It can be safely said, without contradiction, that drug addiction, per se, is not a disease, nor to be so regarded any more than excessive indulgence in cigarettes (to which all of these addicts appear to be committed), or an overindulgence in alcohol (which but few of them require). Experience in our clinic appears to indicate that drug addiction affects the human economy in about the same way as does any vicious abuse, excess, or bad practice, each attacking and weakening along the channels most susceptible.
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The practice of the clinic was not to prescribe for any new applicant an amount over 15 grains--- 10 grains being the usual amount. Reduction was by a gradual daily lessening of the amount prescribed. It was found that some could be reduced to as low as 2 or 3 grains. Others, disloyal to the clinic and themselves, would, when deprived by the clinic, refuse to accept our regulation and would buy additional amounts outside.
Many addicts endeavored to get from the clinic actually more than they themselves needed. The drug was sold much below the general retail price-the price at drug stores was 7 to 11 cents a grain to the addict; while, at the clinic, the maximum price was 3 cents a grain and later this was reduced to 2 cents.
Some individuals would endeavor to deceive and actually would go through registration and examination in order to obtain the drug to sell to addicts at an advance of the clinic price.
Having demonstrated certain peculiar conditions regarding the narcotic drug addict, with a study of over seven thousand, covering a long period, and after consultation with many well informed on this subject (and who were not in any way economically concerned except for social betterment of individuals), we concluded that narcotic drug addiction serves no useful purpose; that there is no justifiable reason at all for its continuance, and that the certainty with which this indulgence benumbs and blunts moral fiber, the practice being indulged in the majority of instances (69 percent) by the young boy or girl, makes its control absolutely necessary. That ambulatory treatment is farcical and useless, and is only putting off what should be immediately done. Physicians should not be permitted, under guise of treatment, to prescribe narcotics for such indulgence. Laws should be so amended that the narcotic addict, when determined, should be sent by due process of commitment to a suitable institution and held there until a medical officer considers it safe for him to return to society.
Narcotic indulgence in the young adult exists without adequate reason, and the mere fact that such a habit has been acquired innocently is not an adequate reason for condoning this fault. Formerly many held the opinion that it was difficult, unsafe, and required expert care to cure an addict, but it is not so by any manner of means. A plan called by the addicts "cold turkey'-abrupt withdrawal (practiced in Kings County Hospital, and without a death) ---is not only possible but practical. It does occasion some suffering.... We hold no brief for either plan, but we state with positiveness that the plans
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are simple, but to be successful absolute control of the addict in preventing renewal of supply is the essential factor.
From an experience with many hundreds passing through our clinic and hospital (when the addicts approached the "irreducible minimum" of the drug they were sent to the hospital for cure), it is our firm opinion that entire withdrawal may, in many instances, be successfully performed. That all that is needed is to have the withdrawal supervised by a physician, so that those who need medical care may get it when it is required.
Strict, adequate, and proper as well as uniform enforcement of the law-the Harrison Act-throughout this city and country is now demanded and is essential towards preventing recruits to these miserable ranks. Drug addiction spreads like a pestilence through association. In a study of over 7,500 addicts in this city exemptions requested for persons ill of some malady numbered less than 250.
The practices of drug addicts to meet the demands of their depraved appetites causes financial embarrassment, and to meet these desires the addicts become immoral and antisocial. When in need of the drug, or overstimulated from indulgence, all moral influence and self-control are lost.
These individuals either in need of the drug or under its stimulating influence are a distinct menace to society. They will commit the most revolting of crimes in cold blood.
Drug addiction is not a mysterious disease. From a purely scientific point of view it would be interesting to have more light on the problem of tolerance, but on therapeutic indications and possibilities there is but little difference of opinion.
Drug addicts, under careful medical and supervisory nursing, present no pathological condition-only a disturbed or perverted functioning.
The action of internal organs is inhibited or functionally disturbed, but, when these influences are removed and normal action permitted, this derangement quickly disappears.
It is our opinion that any form of cure can take an addict off his drug provided this is done promptly. This was done at Riverside Hospital, in 3 to 5 days, without discomfort to the patient.
From information obtained from the large number of addicts who have come to our clinic, most of whom have taken various methods of our cure, it may be concluded that all methods of withdrawal are equally efficacious and only differ in regard to the comfort of the addict while taking the cure. Aftercare is always essential.
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Treatment of the narcotic drug addict by private physicians prescribing and druggists dispensing, while the individual is going about, is wrong. The giving of a narcotic drug into the possession of an addict for self-administration should be forbidden.
The case of drug addiction that can be cured by ambulatory treatment is the rare exception and so unusual as to make one think it impossible.
Physicians generally are of the opinion that ambulatory treatment is not good practice, and few doctors use this form of treating addicts; it is believed that those so doing must be either ignorant of proper methods or do so in bad faith.
Our study of this problem in this city indicates, most positively, the necessity for the general and uniform enforcement of the Harrison Act.
The clinic is not the solution.
A number of clinics were established by the Commissioner of the State Narcotic Drug Control Commission in the State of New York. There was no legal authority for the establishment of these clinics, and in appointing physicians to conduct them the Commissioner of the State Narcotic Drug Control Commission usurped the authority."
ALBANY, N. Y. (Estimated cost for one year for prescriptions and narcotics for 120 addicts, $52,000.00. Two doctors running the clinic had total weekly income of $429 from narcotic prescriptions; the profits made by the drugstore which filled prescriptions netted $17,000 yearly.)
Police gave information that most of the addicts attending this clinic had criminal records; many of the women were prostitutes, and some of the men were living from the earnings of the women; many others were engaged in selling narcotics in the underworld.
A number of the addicts stated that they were not addicted to the use of cocaine prior to attending the clinic. The youngest addict attending the clinic in 1920 was 21 years of age.
No cures were effected at this clinic. Criminal addicts and women prostitutes were drawn to this clinic from Detroit, Michigan; Cincinnati, Ohio; Pittsburgh, Pennsylvania; New York City and Utica, New York. The following are comments made by members of the Police Department concerning the clinic:
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Capt. F. L. "The Narcotic clinic is a crime. Criminal addicts are attracted from all parts of the country."
Capt. G. P. I am opposed to the clinic. The addicts turn to the easiest way of getting the amount of money they need, which is dangerous to any community they may be in."
Detec. A. G. "The clinic is no good. It is a disgrace. Certain women addicts solicit men on the streets in order to get their money for morphine and cocaine at the clinic. Some of the addicts in attendance are peddling dope and others are buying additional quantities from peddlers. Most addicts reported getting at the clinic more narcotics than they needed."
ROCHESTER, N. Y. Sixty-five addicts were in attendance at the clinic. The profit of the doctor operating it was around $7,000 per annum and it was said he devoted from 9 to 10 hours time weekly to the clinic. Assuming that he spent ten hours weekly, fifty-two weeks a year, 520 hours or 52 days, ten hours each, his compensation was therefore $7,000 for 52 days' work. He supplied addicts with narcotic drugs sufficient to last them for periods ranging from 2 to 10 days. This clinic, like most others of the ambulatory type, was condemned by men high in medical authority.
Police had required 24 of the addicts attending the clinic to leave the city. There were a great many narcotic peddlers in the city who were selling drugs to some of the addicts obtaining only a limited supply of morphine at the clinic. Several of the addicts attending the clinic were peddling drugs smuggled from Canada. There were at least 45 addicts in Rochester who were not enrolled at the clinic and who obtained supplies from peddlers.
The clinic bad been located at three different addresses due to the fact that the landlords of two buildings where it was previously located considered it undesirable to have addicts coming in and out of their buildings.
Statements concerning narcotic clinics in other States:
NEW HAVEN, CONNECTICUT. Four physicians connected with the clinic stated that it was not probable for any cures to be effected by the ambulatory treatment. They all agreed that the majority of the addicts enjoyed good health other than the ill effects brought about by their addiction. They also agreed that in their opinion many of the addicts obtaining morphine at the clinic disposed of it illegally among other addicts.
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A number of known addicts residing in New Haven were not enrolled at the clinic and obtained their supplies from illicit sources. There were peddlers in New Haven all the time the clinic was in operation. Dr. S. L. Spier stated that occasionally he learned of an addict who supplemented his supply of drugs which he obtained at the New Haven clinic by visiting other clinics.
At the New Haven clinic it was disclosed that one addict operated a railroad signal switch tower, working on the midnight shift, and that he was in control of the most important switches on the main line of this railroad. The throwing of a wrong switch might cause a serious train wreck and the loss of many lives.
Another addict was engaged in the delivery and taxi business. He was unable to obtain a driver's state license under his own name as he was a known addict, and as a subterfuge he used a fictitious name under which be secured the license.
PROVIDENCE, RHODE ISLAND. Dr. Clifford Griffin, police surgeon in charge of the clinic, stated that no cures could be effected in their clinic and that "Isolation is absolutely necessary if an attempt is to be made at a cure. This means restraint in an institution. Most cases must be restrained by legal commitment to be held until a cure has been satisfactorily effected."
Peter F. Gilmartin, Superintendent of the Police Department, stated that be was very much opposed to the clinic because it effected no cures and only fed the addicts, making it attractive for their remaining in Providence; and that the only way to successfully treat and cure an addict was to put him in an institution.
One addict who obtained morphine from this clinic was under Federal indictment for having sold morphine so obtained.
Another addict stated that it was not an uncommon practice for some of the addicts obtaining daily amounts of morphine of seven grains, or even less, on prescriptions at the Providence narcotic clinic, to peddle part of the drug so obtained. This man bad been discharged from Blackwell's Island Hospital, New York City, and pronounced cured of drug addiction. As soon as he returned to Providence he resumed the habit by visiting the clinic and persuading the physician to issue him prescriptions.
ATLANTA, GEORGIA. Many known drug peddlers were patronizing the clinic and receiving their supply which was freely peddled. Drug peddling in Atlanta was exceedingly prevalent notwithstanding the clinics in that city.
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At this clinic there were no records of cures by the ambulatory reductive method.
Ten of the addicts attending the clinic volunteered to be sentenced for a term of one year to the Federal penitentiary for the purpose of curing their addiction to drugs.
One addict attending the Atlanta clinic received a prescription for morphine daily. While attending the clinic be was indicted by the Federal grand jury for having 20 ounces of morphine in his possession.
A young woman attending the clinic stated that she married her husband when a young healthy girl; that he was an addict and taught her to use the drug, after which he sent her to rooming houses to obtain money through prostitution.
Several of the addicts attending this clinic were working in positions hazardous to public safety, such as railroad switchmen and chauffeurs.
Many of the addicts sold and exchanged drugs among themselves. Most of them were of the underworld type.
No cocaine was prescribed by the physicians in charge of the clinic, which caused the addicts to purchase that drug from peddlers, as well as additional quantities of morphine.
The city health authorities stated that the clinic system was a nuisance, that clinics were generally abused with bad practices, and that they were a burden on the city.
Dr. F. K. Boland, President of the Fulton County Medical Society, stated that he did not approve of an ambulatory clinic; that institutional treatment is the only method; and that the narcotic clinic was of no benefit to drug addicts or to the community.
Two City Physicians stated that the only effective treatment for drug addicts is confinement, and that the clinic system was of no benefit to the city.
Dr. T. F. Abercrombie, Secretary of the Georgia State Board of Health stated that the narcotic clinic was not beneficial to anyone and on the contrary drew narcotic peddlers and many undesirables to the city; that the addicts should be placed in an institution.
Mayor James Key of Atlanta stated that the clinic system was very bad and that be could not think of anything that could be worse.
Chief of Police Lamarr Poole stated that the clinic does not benefit the addict or the community, but attracts many thieves to the city; that it is difficult to handle the thieves when the city authorities were providing narcotics for them. He urged that clinics be abolished. The
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narcotic clinic or dispensary operated under seemingly legal authority tended to approve and encourage rather than discourage the drug habit.
Eighty-five of the 190 addicts served at the clinic had police records and two were known dope peddlers.
Practically all in attendance at the clinic were without visible means of support.
SHREVEPORT, LOUISIANA. It was estimated that 75 percent of the drug addicts in Texas made their headquarters at Shreveport following the operation of that clinic. One addict in Texas was apprehended receiving a package through the mail containing 8 grains of morphine sulphate bearing the label of the Shreveport Clinic, The defendant stated that he had a friend in Shreveport who obtained 20 grains of morphine from the clinic daily and that he always received half of it.
Forty percent of the addicts gave a history of venereal disease or examinations showed its presence.
In this clinic many fugitive offenders were caught by the police and sent back to places where they were wanted.
The clinic sold monthly $2500 worth of narcotics, at a monthly profit of about $1800.
Several prostitutes attended the clinic and plied their trade on the streets of Shreveport. One, 19 years of age, and another, 23, had never been addicts until they registered at the clinic.
The addicts said they would take less drugs if the cost were higher; in some cases daily amounts were increased from 5 or 8 grains to 10 grains daily. Addicts who had used 2 grains daily before coming to the clinic were demanding 10 grains. Addicts who got supplies at the clinic sold to other addicts who would not attend. Some of the addicts were also buying narcotics from peddlers while attending the clinic. Many of the addicts came from distant States and said they would be off the drugs if it were not so easy to procure them. One addict who bad never taken drugs previously was induced to buy drugs from an addict in attendance at the clinic and later persuaded to accompany her to the clinic. The former made a regular practice of selling narcotics she got from the clinic and of getting morphine from other persons she persuaded to go to the clinic.
One citizen of Shreveport stated: "The clinic is an outrage; it should be discontinued; it brings a lot of bums here; nothing is safe on the streets, and the quicker the clinic is closed the better." Another stated:
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"One of the greatest things that can be done for this community is to close the narcotic clinic." These statements were typical of the public opinion on the subject.
Evidence showed a continuous traffic in narcotics between clinic patients and others, and that numerous persons who had never used drugs previously, or who had been cured of addiction over severalyear periods, registered at the clinic and started using as high as 10 grains daily. Many of the persons used fictitious names and addresses, and were without visible means of support. One addict stated that when he came to Shreveport before the clinics were established, the same doctor who was in charge of the clinic had cured him of drug addiction, after which he had discontinued the use of drugs for 18 months. As soon as the clinic went into operation he applied for 8 grains of morphine a day, and when his case was investigated be was receiving 12 grains daily at the clinic from the same doctor who had previously cured him of addiction. Another addict who had been cured of addiction before be registered at the clinic stated that "It would be one of the finest things that ever happened if there were not a grain of morphine obtainable because the only reason that myself and others are addicts is due to the fact that the 'stuff' is so easy to get in Shreveport."
One addict went direct to Shreveport from Leavenworth Penitentiary where he had served a year for narcotic law violations. He was put on the clinic register and given 10 grains of morphine daily. A woman who had been off drugs for a considerable length of time before she went to the clinic was receiving 11 grains of morphine daily.
There was a continuous illicit narcotic traffic being carried on in Shreveport, both in supplies procured from the clinic and in narcotics obtained elsewhere by peddlers. It was never possible to procure evidence of illicit sales of drugs as agents were always confronted with bottles bearing the clinic label.
This clinic was conducted not only in violation of the Harrison Act but in defiance of orders of the Louisiana State Board of Health after a thorough investigation approved by the Louisiana Medical Association a year prior to the date in 1923 when it finally ceased operations.
ALEXANDRIA, LOUISIANA. This narcotic dispensary was closed by the Louisiana State Board of Health for the reasons heretofore mentioned.
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LOS ANGELES, CALIFORNIA.
Addict No. 101 received 8 grains on his first visit to the clinic; this amount was later increased to 12 grains instead of being reduced. He admitted he had been purchasing as much as a dram a week on the outside from peddlers.
Addict No. 131, an actor addicted to morphine for ten years, obtained sufficient morphine to give 6 grains daily to another actor.
Addict No. 17, using 8 grains daily, returned to the clinic several times stating he had broken the bottle and requested an additional supply, which was furnished to him.
Dr. J. W. Nedins, in charge of the clinic, stated that he had never made any special study of drug addiction but expressed doubts if any cures would be effected by clinic treatment, and advocated institutional treatment for satisfactory cures.
Dr. James T. Fisher, a neurologist, head of the clinic board, stated that the so-called clinic was nothing more than a dope supply house for addicts and should have been closed a long time ago; further that no attempts at cure were being made at the clinic, that none could be effected, and the quicker it was Closed the better.
Dr. E. H. Williams, a member of the Board of Supervisors, stated that the clinic only touched about 30 percent of the actual addicts in the district, and the other 70 percent would not present themselves at a public clinic.
EXCERPTS FROM THE LOS ANGELES EXAMINER: "The Municipal Narcotic Clinics of both Los Angeles and San Diego have been officially ordered closed finally and the wholesale traffic in dope which has been carried on by the municipal clinic for half a year will be a thing of the past.
"Action follows Examiner exposé. Again the Examiner has been vindicated!
"Months ago the Examiner exposed the evils, the immorality, the illegality of the municipal narcotic clinic.
"Even were the operation of these clinics legal, they are morally wrong, inadequate, ineffective, and the clinics themselves, not only here, but elsewhere, are failures. They have made an earnest effort to make the clinic a success, but we know that no clinic of an ambulatory nature ever can be successful. The only practicable treatment is that in which the patient is confined in a hospital or sanatarium and is under the thumb of the physician at all times.
"The best known clinic, that established in New York, was soon found a failure. Men high in the medical profession, like Dr. S. Dana
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Hubbard of New York Department of Health, who himself conducted the New York clinic, which was closed; Dr. Oscar F. Dowling, president of the Louisiana State Board of Health, and many others, all condemned these clinics. The ambulatory treatment of drug addiction was emphatically denounced.
"This clinic has resulted in numerous dope fiends flocking here from other cities, among them many criminals. When I came in today I met one hop-head on the train who admitted that he was coming here from San Francisco to get dope at the clinic. And a few minutes later I met another at the clinic.
"I have been informed that Chief of Police Patrick of San Diego said that he was not in favor of the clinic there, that it did more harm than good, and it was only a means for furnishing addicts with dope. He further added that twice as many addicts were in that city as before the clinic opened. I know that conditions here parallel those at San Diego.
"All clinics should-and they will-be closed. They are indefensible from either a legal or a moral viewpoint."
Dr. Paschal, the Assistant Health Commissioner, stated that in his opinion the clinic not only accomplished no good but that it actually tended to condone the use of drugs by the addicts.
The extent of operations of this clinic is shown by the fact that several hundred thousands of grains of morphine were sold to addicts in four months at a clear profit for the city of more than eleven thousand dollars from sales at ten cents per grain.
The police records of Los Angeles revealed that "not only has the so-called crime wave not diminished since the establishment of the clinic, but on the contrary, it has increased to a very great degree."
CLINICS IN CANADA
A formidable opponent of the ambulatory treatment of drug addiction in Canada is Colonel C. H. L. Sharman, former chief of the Canadian Narcotic Service, a member of the former Opium Advisory Committee of the League of Nations, Canadian Representative on the United Nations Commission on Narcotic Drugs and member of the Supervisory Body located at Geneva, Switzerland. Colonel Sharman is a distinguished international drug expert and has had remarkable success in reducing drug addiction in Canada. He shared the views expressed by R. S. S. Wilson,
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former superintendent of the Royal Mounted Canadian Police who is a veteran drug fighter of many years.
Excerpts from Mr. Wilson's analysis follow:
The solution to the narcotic problem does not lie in the creation of government clinics where narcotic injections are given to addicts at cost price. This amounts to nothing more than officially condoning drug addiction and placing the stamp of public approval upon a vicious and soul-destroying habit, and comes close to realization of the addict's dream of a "barrel of heroin on every street corner."
It would no more stop drug addiction than the legal sale of opium in government dispensaries has stopped the drug traffic or stamped out narcotic addiction in the Far East.
The sale of alcoholic beverages in government liquor stores helps to control bootlegging but it does not stop it nor does it solve the problem of the chronic alcoholic.
ABSTINENCE ONLY SALVATION
The only hope for his salvation lies in complete abstinence. A person addicted to alcohol would never be satisfied with a "minimum required dosage" of liquor a day even if be could purchase it for a few cents at a government-operated clinic. Certainly, he would be glad to take the alcohol so generously provided by the government, but would promptly thereafter resort to the nearest illicit source for an additional supply.
In many ways-and the leading medical authorities are in agreement in this--- there is a close similarity between addiction to alcohol and addiction to narcotic drugs. The same authorities likewise agree that there is only one cure in either case-complete and unqualified abstinence.
Contrary to what the committee seems to think, the addict who received a daily "shot" in a government clinic would not be satisfied with this, but would seek an additional supply from illicit sources. In other words, the government clinic would merely fill the role of another drug peddler.... Because it did not furnish all the addict's requirements there would still be peddlers catering to his wants.
This means that the addict would continue to be an addict and would still be obliged to resort to crime to obtain the money with which to purchase his narcotics.
No medical practitioner could ascertain the exact quantity of a drug which, administered, say three times a day, would stabilize the
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addict unless the person in question were confined under close supervision for several days in a hospital.
EVER INCREASING DOSES?
The addict derives no relief (which he terms "pleasure") from the underlying emotional instability which led to his becoming an addict in the first place. If he can't get the additional drug at the clinic, the addict will seek it elsewhere, of that we may be sure.
Will the clinic cater to the addict's wants by giving him ever increasing doses of the drug until he reaches the saturation point and dies of acute narcotic poisoning?
Where, before the war Canadian addicts used opium and morphine, they are now almost 100 percent addicted to heroin, a drug so deadly in its habit-forming characteristics that its medical use is forbidden throughout the United States and in all hospitals in this country operated by the Department of Veterans Affairs.
Does the committee propose administering heroin to our addicts? I can hardly credit the thought. But if they do not, and resort to the considerably milder morphine or codeine, the addicts will most definitely not be satisfied and, more than ever, will seek to get "high' or steamed up" on illegally procured heroin.
To be quite frank, I cannot visualize the Government of Canada, as it is obliged to do by international treaty, including in its annual estimates of internal consumption to the United Nations Narcotic Commission an item covering the legal administration of morphine, much less heroin, to Canadian drug addicts.
Insofar as heroin is concerned, the system of international control is so strict that countries, such as Canada, which do not produce it have to make a special request to the government of the exporting country.
Moreover, import certificates covering heroin can be issued only in favor of a government department and in this way the, importing government assumes special responsibility in respect to heroin and undertakes to supervise strictly its subsequent distribution.
There are a number of other reasons I could advance, if space permitted, why the whole idea of government-operated narcotic clinics is, in my opinion, quite impractical.
PSYCHOLOGIC FACTORS VITAL
However, of far greater importance is the fact that we should remember that we are not treating with ordinary every-day sick people
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when we are dealing with drug addicts. As one eminent authority, Dr. J. H. W. Rhein, puts it: "Any effort to correct the evils of drug addiction must be based on a thorough understanding of the psychologic factors underlying the cause. The cause of development of the habit is inherent in the individual. The drug addict is a psychopath before he acquires the habit. He is a person who cannot face, unassisted, painful situations; he resents suffering, physical, mental or moral; he has not adjusted himself to his emotional reactions. The most common symptom that requires relief is a feeling of inadequacy; an inability to cope with difficulties. These conditions call for an easy and rapid method of relief which is found in the use of drugs."
Habitual criminals are psychopaths, and psychopaths are abnormal individuals who, because of their abnormality, are especially liable to become addicts.
To such persons drug addiction is merely an incident in their delinquent careers, and the crimes they commit, even though they be to obtain money with which to buy narcotics, are not directly attributable to the fact that they are drug addicts.
More than 95 percent of all drug addicts are the criminal addicts whose addiction in its inception and in its continuance is due to vice, vicious environment, and criminal associations. Experience definitely shows that in nearly all cases the addict was a criminal before he became addicted.
That is the actual situation as it exists here in Canada and it is useless to draw comparisons with other countries which are not faced with a drug problem and to say that such countries do not understand our concept of the criminal addict because their addicts "are not driven to crime in order to support their addiction."
One would gather from this statement that drug addicts were originally quite decent people who have been forced into a life of crime as a result of becoming addicted.
This is not so and the fact that in nearly all cases the addict was a criminal before he became addicted must be constantly borne in mind if we ever hope to make a realistic approach to the solution of the narcotic problem in Canada.
It has been amply demonstrated in the past that addiction cannot be cured by the ambulatory method, that is, by the administration to the addict of gradually decreasing quantities of narcotics by a pbysician in his office.
This holds true not only for the main bulk of the addict population, which is made up of thieves, shop-lifters, prostitutes, forgers and such
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like underworld characters, but also for the tiny remaining noncriminal fraction.
FORCED COMMITTAL BETTER
It has been found that far better results in effecting cures are obtained in the case of prisoners who are compulsorily committed for treatment and subsequently released on parole, than in the case of the 11 voluntary committals" who enter the hospital of their own volition and may leave whenever they please.
The latter (and the same would hold true here in Canada) largely treat the hospital as a "rest-centre" where they may with a minimum of physical discomfort cut down their drug habits to a manageable level.
While a comprehensive follow-up service is essential, this will not work without compulsion. The history of institutional treatment of drug addiction by the federal government in the United States not only shows that compulsory treatment is much more effective than voluntary treatment, but also that the lack of completely satisfactory results in that country is largely attributable to the absence of stringent and legally enforceable parole regulations, with recommittal the penalty for their violation, governing all cases after release from treatment.
In actual point of fact, a drug addict can be cured. However, due to the present lack of adequate provision in this country for the treatment of drug addiction, there is only one class of addict for whom there is any hope of a permanent cure.
These are the relatively few professional and business men who have families and business and social responsibilities. Such individuals, upon their release from a mental hospital or private sanitarium, return to their daily work and surroundings freed from the contaminating influence of contact with other addicts; they usually are of superior mental attainments and have a definite incentive-their home, families and business-to fight against any reversion to the habit.
in Canada there are today well over 150 members of one group alone who although previously addicted, are now leading normal lives and have been doing so for periods of from two to 14 years. The successful results achieved in the federal narcotic hospitals in the United States, and in this country when dealing with cases where there is no underworld association, proves conclusively the incorrectness of the general belief that a drug addict can never be cured.
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CONCENTRATE ON ADDICTS
If we accept the proposition that the narcotic problem is capable of solution, and no right thinking man would wish otherwise, how then should we proceed?
It is my definite and considered opinion that drug addiction as we know it today, with all its attendant crime and evil, can be wiped out in Canada within a very few years if we are but willing to face the facts and attack the problem from a realistic point of view.
We can stop the drug traffic in Canada if we will do three things:
1. Maintain international and domestic control over the legal traffic.
2. Continue to wage war on narcotic smuggler and internal traffickers.
3. Cure and permanently control the drug addict.
Mental disease is not an ordinary ailment which can be treated at home or in jail. Society recognizes that the mentally ill must be forcibly confined and consequently we have enacted legislation providing for their committal to proper institutions.
In the old days lunatics were punished because it was believed their infirmity was self-imposed through deliberate association with evil spirits. But today we would regard as morally indefensible any attempt to punish an insane person, even though his affliction were selfimposed, as for example general paresis, which is a direct result of self-imposed vice, namely venereal disease.
However, we have made no such progress when it comes to drug addiction. Yet the drug addict, even though he be a criminal who deliberately addicted himself, is essentially a psychopath whose addiction is actually due to his underlying mental instability.
If we are prepared to accept the proposition that there is a close similarity between insanity and narcotic addiction, then we should be willing to take the next step and provide the necessary legislation for the enforced committal and control of the drug addict.
It is the opinion of the writer that the Opium and Narcotic Drug Act should be amended to provide that a drug addict, after certification as such by three physicians, must be committed for a period of not less than 10 years to a narcotic hospital operated by the Federal Government.
The act should further provide that the first year of the 10-year committal period must be spent in the hospital as an in-patient, but that after the expiration of the first year the addict would be eligible for release on parole.
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The narcotic hospital would be competently staffed and the emphasis would be on mental cure and rehabilitation and training for a useful occupation. There would be no suggestion of punishment.
The hospital would provide the very latest medical techniques for withdrawal of the drug of addiction and restoration of the patient to normal physical health.
The second and more protracted stage of mental rehabilitation would be accomplished through up-to-date methods of psychotherapy designed to treat the underlying psychopathic condition which led the patient to become an addict and to reeducate and reconstruct his personality so that he can learn to adapt himself to his emotional reactions.
Combined with this treatment would be occupational therapy to ensure that the patient's physical and mental energies were directed into channels best suited to his needs and most likely to make him into a useful and self-supporting member of society.
After the expiration of one year in the hospital the patient would be released, but only on parole and to outside employment. Unless the patient were willing to go to the job provided him and signed an undertaking to remain on that job and otherwise to abide implicitly by the terms of his parole, he would not be released.
Such terms would provide that the parolee report regularly to the parole officer, that he not associate with members of the criminal classes or visit persons or places where there was any possibility of narcotic contamination, that he not change his employment or place of abode without prior report to and approval of the parole officer, and that he undergo periodical medical re-checks.
"LIFE" AFTER 2 RE-COMMITTALS
Parole would continue until the expiration of the 10-year period, unless the individual violated the conditions of his parole, in which case a warrant would automatically be issued for his re-committal.
In the event an addict were re-committed on two occasions he would be classed as incurable and sent for life to a special institution reserved for such cases. There he would once more be physically cured and given an opportunity to follow a useful avocation, but permanently within the confines of the institution.