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Rufus King Collection | Drug Hang Up
The Drug Hang Up, America's Fifty-Year Folly
by Rufus King
Enforcers Versus Healers
ALL IN ALL, the medical profession does not come off looking well in this story. America's drug problem has been attributable partly to the doctors on several counts: to their irresponsibility in the use of addicting and dangerous substances for medical purposes; to flagrant abuse of the prescribing privilege by a few (a very few); to repeated error in acclaiming discoveries like morphine and heroin as nonaddicting drugs; and to the failure of most practitioners to embrace the notion that addiction is pathological so it falls within the purview of the Hippocratic Oath. But there have been extenuating factors. If the doctors lacked courage in standing up for the right, it must be said for them that to have resisted the overbearing attacks launched against them by their government in the early 1920's would have required them to be very courageous indeed.
There is no question that in the Harrison Act Congress intended to make a wide exception for the use of controlled drugs by legitimate practitioners. That is what the law said, from 1914 to 1970, in so many words: "Nothing contained in this chapter shall apply to the dispensing or distribution of any of the drugs . . . to a patient by a physician, dentist, or veterinary surgeon . . . in the course of his professional practice only." The last word---'only' - was inserted because of the so-called scrip doctors whose abusive practices have already been noted.
Accordingly it was assumed in the early days of the Act that legitimate practitioners would not be affected by the new control patterns, beyond the simple obligation to register and keep records. And it was further assumed by most proponents that the main effect of the federal law would be precisely to bring addiction problems more into view, and hence more easily within the reach and control of the medical profession.
But that is not what happened. It quickly became apparent in the hysterical atmosphere which prevailed at the end of World War I that someone would have to make provision for the addict population-whatever its numbers really were when the free-and-easy sources of supply were suddenly dried up. It was for this purpose that Dr. Copeland opened his clinics in New York City and called for the establishment of similar facilities throughout the state; and simultaneously, clinics and dispensaries of various kinds were opened elsewhere around the country in cities where addict populations were large-New Orleans, Chicago, Jacksonville, San Francisco, Los Angeles-a total of nearly forty.
But they came almost immediately under attack. Copeland was accused by fellow doctors of intensifying the problem by giving out drugs too freely, and he responded by complaining bitterly that the medical community was giving him no support and was merely dumping the whole crisis in his lap. It was charged elsewhere that clinic facilities attracted "fiends" and other criminal types to the communities where they operated, and that they were simply "gratifying the cravings" of weak willed persons who would otherwise be compelled forthwith to give up their evil habits.
This clinic controversy, which has been raging ever since, was inflamed by a misunderstanding, or intentional distortion, which has not yet been fully straightened out. There is little question that in the administration of some of the narcotic facilities much harm was done by handing out drugs carelessly to addicted persons for self-administration, or by writing prescriptions for large amounts for the addict to fill f8r himself. When this occurred, drugs were badly abused by the recipients and were diverted to others in the newly born illegal market. Such irresponsible dispensing was attacked as 'ambulatory" treatment, i.e., giving out drugs for uncontrolled personal consumption as contrasted with administering or providing regulated dosages directly at the narcotic facility under the supervision of clinic personnel. Early in 1920 an American Medical Association committee recommended that "ambulatory treatment of drug addiction, as far as it relates to prescribing and dispensing of narcotic drugs to addicts for self administration at their convenience, be emphatically condemned."
But the word "ambulatory" was simultaneously pounced upon by the enforcement-minded faction as denoting a policy of leaving addicted persons at liberty in the community instead of locking them up in hospitals or prisons. So when responsible authorities deplored giving out drugs too freely, irresponsible enforcers claimed this was a mandate to put all the addicts they could round up behind bars.
Subsequently the medical spokesmen themselves contributed to this ambiguity, at least partially because it soon became clear that ministering to "ambulatory" addicts without the convenience of merely prescribing or handing out drugs was burdensome and unrewarding for the general practitioner. In 1921 the AMA Council on Health and Public Instruction created another committee which reported much more emphatically:
Your Committee desires to place on record its firm conviction that any method of treatment for narcotic drug addiction, whether private, institutional, official, or governmental, which permits the addicted person to dose himself with the habit-forming narcotic drugs placed in his hands for self-administration, is an unsatisfactory treatment of addiction, begets deception, extends the abuse of habit-forming narcotic drugs, and causes an increase in crime. Therefore, your committee recommends that the American Medical Association urge both Federal and State governments to exert their full powers and authority to put an end to all manner of such socalled ambulatory methods of treatment of narcotic drug addiction, whether practiced by the private physician or by the so-called narcotic clinic or dispensary.
Then the committee added the following ambivalent paragraph:
In the opinion of your Committee, the only proper and scientific method of treating drug addiction is under such conditions of control of both the addict and the drug, that any administration of habit-forming narcotic drugs 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 responsibl6-for the addict's treatment.
This 1921 recommendation was adopted verbatim by the AMA House of Delegates in 1924. It remained the official AMA position for years thereafter and will turn up again in our narrative, still causing trouble in the late 1950's.
In July 1919 Dr. Copeland, in the thick of the feud, set up a system for registering all the addicts who were then under treatment through the New York clinics (the number had already grown to 7,600), and issued to each one a dosage card on which had to be indicated each prescription or administration. Local doctors were sharply warned not to administer or prescribe narcotics to addicts except on presentation of a dosage card, and soon the police began to make arrests for violations of this edict --on technically doubtful ground, perhaps, but with attending publicity calculated to intimidate doctors and druggists, and plainly having that effect.
In August 1919 the New York authorities tried to establish facilities where addicts could be isolated in a drug-free environment (a concession to the "hard" anti-ambulatory school). John D. Rockefeller offered to contribute a building for the purpose, but by this time the public was so fearful of "fiends" and "maniacs" that no site could Se agreed upon. A proposed location in the Pelham Bay area of the Bronx aroused such a storm of local protest that it had to be rejected; then plans were announced to develop a hospital at Seaview on Staten Island, with the same result; and finally efforts were made to treat narcotic addicts at Riverside Hospital in New York, until other Riverside patients went on strike and so disrupted the hospital that the narcotics project had to be abandoned. In December 1919 the New York City Council threatened to cut off all funds for all of Dr. Copeland's facilities if he did not at once abandon any further ideas about thus congregating dangerous dope fiends where they might break out and harm the citizenry.
Besides pushing the idea that addicted persons could only be dealt with in total confinement, the enforcement authorities and a large segment of the medical profession, echoed by the press, also kept stressing the twin notions that drug addiction was a mere weakness of character which could be overcome by righteous and right-thinking people (an idea which, when reflected in medical-school teachings, has produced disproportionately large numbers of addicts among three generations of doctors) and that drug addiction and criminality were inseparable, that addiction always suggested latent criminality in those who had not yet run afoul of he law, and that it induced all manner of crimes among those who were "hooked." In short, strong forces converged to create around the addict a complete mythology supporting the "fiend" appellation.
Obviously if the clinic concept were allowed to develop and spread, T-men and local police authorities would be left without much responsibility except controlling any abuses that might grow up around the edges of the clinic administrations, not the much larger national prohibition commitment they envisaged.
Therefore, as might have been expected, the heaviest attack was launched by the Treasury. Dr. Charles E. Terry, the most authoritative chronicler of this period, described what happened to the clinics as follows:
As in all pioneer movements, they underwent a period of experimentation in which mistakes were made which, eventually, according to their proponents, might have led to valuable findings and encouraging results. Here again, however, the interpretations and enforcement procedures originating in certain regulations of the Department of Internal Revenue in its administration of the Harrison Narcotic Act resulted in their closing before their development could bear fruit through practical administrative and medical procedures. They were declared illegal, and closed.
It is generally agreed that Dr. Copeland's units in New York were among the most poorly run. No adequate records were kept, drugs-including nonaddicting cocaine were freely handed out, and prior to the abortive dosage-card effort no precautions were taken to see that the same addict did not present himself repeatedly, even at the same clinic, to accumulate supplies. Yet unfortunately the New York experiment received disproportionately more publicity than others which were reportedly far more successful, notably those operating in Louisiana and California. Copeland was forced to terminate his operations on January 5, 1920, in a storm of recriminations and controversy.-Summing UP the experience, and reflecting prevailing attitudes of the day, one of Copeland's associates, Dr. S. Dana Hubbard, wrote:
The clinic is not the solution-but it aids in bringing the secretive addict out of his lair. He becomes friendlily disposed and, deprived of his supply, he is willing to be cured. . . . No doubt, with suitable organization and funds to institutionalize and adequately and properly care for them, not only to effect withdrawal of drugs, but to rehabilitate by several months aftercare in the open country, together with efforts to get the individuals away from bad and demoralizing associates, into new and more useful environments, many will revert to useful and normal lives.
Many of these addicts have never had a square deal, and only need a fair chance to change their ways. Already many of them have been returned to useful lives, and many more can be revamped with proper and necessary help.
Clinics elsewhere throughout the United States were forced to close in 1921-22, with the exception of one at Shreveport, Louisiana, which held out until 1923. Doctors and public-spirited citizens who had inclined to view the plight of the addict as a medical problem were overwhelmed; those who shouted that the only solution was criminal repression won the day. Although Treasury itself had called for assistance from local authorities in relieving addicts caught without their supplies in 1919, the Commissioner of Internal Revenue's annual report for 1920 reveals a reversal of attitude (and a new tone which must have been hard at first for medical professionals to appreciate, as coming from mere tax collectors):
As a temporary expedient to relieve this seemingly critical situation a number of narcotic clinics or dispensaries were established. Some of the so-called clinics that have since been established throughout the country without knowledge or sanction of this Bureau apparently were established for mercenary purposes or for the sole purpose of providing applicants with whatever narcotic drugs they required for the satisfaction of their morbid appetites. Little or no attempt was made by some of these private clinics to effect cures, and prominent physicians and scientists who have made a study of drug addiction are practically unanimous in the opinion that such c1blics accomplish no good and that the cure of narcotic addiction is an impossibility unless accompanied by institutional treatment. Steps are now being taken to close these clinics, which are not only a menace to society but a means of perpetuating addiction. In many cases their continued existence constitutes a flagrant violation of the law.
Behind this official assault was the conclusion, propounded dogmatically by the federal fiscal authorities, that drug addiction was a curable condition. The Prohibition Bureau's regulations of this period began with the statement: "It is well-established that the ordinary case of addiction will yield to proper treatment, and that addicts will remain permanently cured when drug addiction is stopped and they are otherwise physically restored to health and strengthened in will power."
Moreover, a small but strident segment of the medical community went further even than the tax authorities in heaping abuse on addicts and beating the drums for a total-prohibition crusade. In 1921 a member of the American Medical Association's Committee on Narcotic Drugs, purportedly speaking officially for the Association, was quoted in a widely circulated Treasury publication as follows:
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 which has caused their physical and moral debauchery . . . has been asserted and urged in volumes of literature by the self-styled specialists.
The vice that causes degeneration of the moral sense, and spreads through social contacts, readily infects the entire community, saps its moral fiber, and contaminates the individual members one after another like the rotten apples in a barrel of sound ones.
Thus what had commenced as a controversy within the medical profession evolved into a relentless attack upon the medical community, carried on by police authorities whose leadership and direction came directly from Treasury officials in Washington. Doctors were hounded and bullied, and a campaign was launched to drive them away from the addict altogether.
One of the few dissenting voices which managed to make itself heard was that of a medical doctor who happened also to be a Member of Congress, Representative Lester b. Volk of New York. In January 1922 he spoke out:
It seems to me that the untutored narcotics agents of this great Government . . . might have been better employed than in taking sides in a medical controversy involving the broad subject of what will or will not constitute the proper medication in the treatment of addiction. Yet this was done, and I am sorry to say is now being done by our Government, and will continue to be done until the end of time unless some protesting voice is raised against undue interference by lawyers, policemen, and detectives in the practice of medicine, and furtherance of its research and study.
There has developed a tendency in carrying out the objects of the Harrison law to substitute for the provisions of the Act arbitrary administrative opinions expressed in rules and regulations which amount to practically a repeal and nullification of the law itself.
As a substitute for open discussion of known medical facts there has been set up a propaganda for the incarceration of all drug users, their treatment by routine methods, and complete elimination of the family doctor. An undeniable effort is now being made whereby physicians are to be denied any discretion and power in the prescribing of narcotic drugs and to force all those addicted to the use of these drugs into hospitals exploiting questionable "cures."
But such warnings were of little avail. The agents carried on unchecked, attacking those who disagreed and continuing their campaign to drive the doctors into full retreat. How this was accomplished-the episode to which we now turn-is perhaps the most remarkable of any we shall encounter in this saga: Treasury officials and the Attorney General of the United States succeeded in playing an out-and-out trick on the U.S. Supreme Court.