Medicine and law in the treatment of drug addiction
II. Nature, extent in U.S.A., and treatment of narcotic drug addiction
III. Areas of medical-legal impact in treatment of narcotic drug addiction
IV. Addiction and Crime
V. Learning more about narcotic addiction
VI. Community action in treating narcotic drug addiction
Author: James V. Lowry, Earle V. Simrell
Pages: 9 to 16
Creation Date: 1963/01/01
LL.B. Earle V. Simrell Special Assistant to the Chief, Bureau of Medical Services, USPHS.
In the United States there has been a long-standing double attack by legal and medical agencies on the problem of narcotic drug addiction. In many ways this has been a partnership, with the legal agencies preventing the spread of addiction by decreasing the available supplies, and the medical agencies treating addicted persons. The efforts of each have achieved a partial success.
Narcotic drug addiction has been a problem in the United States for a hundred years. Administration of morphine by the use of the then newly developed hypodermic syringe was a blessing to the painfully wounded of our Civil War, but it also resulted in the spread of addiction. Fifty years later, the Federal Government enacted legal controls on the distribution of narcotic drugs. In 1935 the U.S. Public Health Service opened its first hospital for the treatment of addicted federal prisoners.
Since then the activities of the Public Health Service have broadened greatly. A second hospital was established in 1938. Research began when the hospitals were opened and has been very productive. Research and demonstration projects are supported by grants to non governmental agencies. The states are assisted in meeting the health problems of addiction by grants for mental health services and for hospital construction and by technical assistance.
A physician is primarily concerned with the prevention and treatment of disease and the rehabilitation of those who become afflicted. He is not an expert in law or law enforcement, just as lawyers and law enforcement officers are not experts in the nature of disease and the methods of prevention and treatment. Because narcotic drug addiction and the illicit traffic in narcotic drugs are so closely interrelated, there is a strain on our ability to contribute what we can to common objectives without confusing our professional roles.1
1 Presented at the First Inter-American Conference on Legal Medicine and Forensic Science, University of Puerto Rico, Friday, 30 November 1962.
Justice Cardozo once addressed the New York Academy of Medicine under the title, "What medicine can do for law" (1). This expresses one aspect of the present subject; another is what law can do for medicine. As applied to narcotic drug addiction, my presentation is an exploration of certain areas of impact between law and medicine to consider how medicine can assist the law, and how the law can assist medicine, in the treatment of addiction.
Narcotic drug addiction is a state of physical and mental dependence on an opiate drug or a synthetic drug with opiate-like qualities. The essential characteristic is the physical and mental dependence which the addict describes as being "hooked ". He is subject to a psychological compulsion beyond his power of self-control, and physically has undergone changes in the central nervous system and the endocrine system which will produce withdrawal symptoms if he discontinues the use of narcotic drugs. Narcotic drug addiction has this characteristic in common with addiction to alcohol and barbiturates. It distinguishes true addiction from the use or abuse of these drugs and from episodes of intoxication with these or other drugs.
Introduction to the use of narcotic drugs is usually by association with an addict who shares his drugs and equipment. The initiate finds that drugs relieve anxiety, fear and frustration and provide an orgiastic-like pleasure and escape into a world of unreality. The body develops tolerance to the drugs so that a steadily increasing dosage is required to obtain the same effects. Ultimately the addict may find this demand impossible to satisfy, and still he cannot stop. What started as a voluntary experiment in pleasure, or relief from unpleasantness, becomes a compulsive drive to maintain what the addict considers his "normal" condition of euphoria.
Withdrawal symptoms are produced whenever the addict stops, or significantly reduces, his use of narcotic drugs. These symptoms include restlessness, profuse perspiration, muscle jerking, abdominal cramps, vomiting, diarrhoea, insomnia, increased blood pressure and temperature, and sometimes collapse and death. The severity of withdrawal symptoms varies with the degree of addiction; they represent an acute physiological illness and not the discomfort of giving up a bad habit.
Most of our statistics on addiction in the U.S. come from law enforcement sources. The U.S. Bureau of Narcotics lists about 47,000 persons known to have been addicted in the last five years (2). We know too little about the epidemiology of drug addiction, but we do know that drug addiction in the U.S. is concentrated mainly in a few urban areas that have a great many other social problems. Addiction is primarily a disease of young male adults between 21 and 30 years of age. Ethnic groupings suggest the importance of social and environmental rather than racial factors. Before World War II the rate of addiction among the U.S. Negro population was low. In 1961 the proportion of Negro addicts was reported to be over half, mainly in northern cities. Chinese addicts, once a principal group and the original importers of smoking-opium into the U.S., are now almost non-existent in the U.S., although plentiful in the Far East.
Addiction is usually associated with underlying mental, emotional, or personality disorders. Patients can become addicted from medical use of narcotics but this is unusual. Addiction usually develops in individuals who are made susceptible by anxieties, emotional disturbances, and feelings of inadequacy or personality disorders.
The two phases of treatment are ( a) treatment of physical dependence, and ( b) physical, psychiatric and social rehabilitation. The treatment of physical dependence usually precedes rehabilitation. Two British physicians recently reported on the treatment of a small series of addicts who were stabilized on drugs before being admitted to "private nursing homes" for treatment of physical dependence. Rehabilitation procedures were initiated before withdrawal and reinstituted afterwards. Of 51 patients treated, 32 obtained good results (3).
Effective treatment of physical dependence on narcotic drugs is not too difficult. Treatment of the psychological dependence and underlying mental disorders is both difficult and complex. In the PHS hospitals, treatment of physical dependence is by substitution of a synthetic narcotic, methadone, for whatever narcotic has been used and reduction of the dosage of methadone over a period of time. Patients are interviewed by members of the vocational, social service, and psychiatric staffs, and a programme of further treatment and rehabilitation is formulated. The programme varies from patient to patient but includes hospitalization for at least four months to complete the recovery from physical dependence and to initiate a pattern of living without drugs. Psychotherapy is included where it seems likely to be beneficial; group psychotherapy seems to be more suitable than individual psychotherapy for patients with personality disorders. Vocational training is provided, both for its value in learning to work with other people in constructive relationships and in order to prepare the patient for employment at the end of his hospitalization. Recreational activities are designed to develop interests other than narcotic drugs as a source of pleasure and social relationships. Religious services, group discussions,and individual counselling are available and play an important part in the lives of many patients. Patients who are prisoners or on probation are required to stay until the programme of hospital treatment is completed. Some who demonstrate their unsuitability for treatment are transferred. About two-thirds of the voluntary patients leave the hospital against medical advice before treatment is completed. We know that completion of the hospital treatment is not completion of rehabilitation for the patient. That can only occur when the patient has left the hospital and established himself in a community as a member of society able to live without narcotics (4).
The PHS method of treating narcotic drug addiction is not the only method. An interesting recent development is the "Synanon" project. As reported, this organization, founded some four or five years ago, houses about 100 narcotic-drug addicts and ex-addicts in a building in Santa Monica, California, and relies on voluntary treatment and group therapy. Addicts apply and are told the rules of the organization, including an absolute ban on narcotics. The sanction is not compulsion but expulsion. If admitted, the addict goes through "cold turkey" withdrawal with the help of sympathetic companionship of members, who have been through it. He becomes part of what the founder describes as "a more or less autocratic family structure ". He is told what to do, but he is free to earn his own status in the family. Members are their own and each other's therapists. Each becomes involved in and identified with the group, establishes his own role in the group, and develops constructive relationships in work and recreation with others. After a year or so, members are expected to get a job outside but continue to live at Synanon; still later they move out of the building, living and working in town but continuing to visit Synanon and take part in group sessions. It is too soon to measure long-term results, but Synanon is an interesting experiment (5).
Some reports give the impression that medical and law enforcement organizations are engaged in a jurisdictional struggle over narcotic drug addicts-the physicians seeking to treat them, and the law enforcement agencies seeking to put them in prison and keep them there. This is a distortion of the truth. Most physicians prefer to avoid treating addicts, and law enforcement agencies face a serious problem in the absence of an alternative to jailing addicts. We need to consider how physicians could do their part more effectively, and how addicts and incipient addicts could be removed from the illicit drug market by more effective and constructive methods than jail.
A recent and authoritative statement on the treatment of addicted patients was issued by the American Medical Association and the National Research Council in May 1962 and endorsed by the U.S. Bureau of Narcotics as consistent with federal law (6). It states:
"The successful and humane withdrawal of individuals addicted to narcotics in the United States necessitates constant control, under conditions affording a drug-free environment, and always requires close medical supervision.
"The successful treatment of narcotic addicts in the United States requires extensive post-withdrawal rehabilitation and other therapeutic services.
"The maintenance of stable dosage levels in individuals addicted to narcotics is generally inadequate and medically unsound and ambulatory clinic plans for the withdrawal of narcotics from addicts are likewise generally inadequate and medically unsound."
This statement requires some explanation. "Drug-free environment" means free of drugs that are not prescribed by the physician.
In the U.S.A., the current generally accepted course of treatment is in a hospital, with carefully controlled and gradually reduced administration of narcotic drugs until withdrawal is completed and rehabilitation advanced to a point where the patient has a fair chance of pursuing it outside the hospital; then to provide community health and social services that will strengthen the patient against re-addiction brought about by causes similar to those which contributed to his previous addiction. Unfortunately, the physician may find this course unavailable.
There may be no hospital available for the addict. New York City, for example, after efforts to open its hospitals to addicts during the past few years, is reported to have 400 beds (7) available for addicts with more than 20,000 known addicts (almost one-half of all addicts in the U.S.) and nearly 3,000 new addicts in the last year (8). In the U.S., jails are open to addicts, but hospitals commonly are not. The present availability of hospital treatment for addiction had been compared with that for mental illness a century ago. The physician who wants to hospitalize an addict-patient faces this situation. There should be more hospitals willing and able to provide adequate treatment for addiction. But what is the physician to do in the meantime?
A leading text, The Law of Medical Practice, by Professors Shartel & Plant of the University of Michigan, states, "About the only safe courses open to him are to refuse to deal with the addict or to see that he is hospitalized in order to cure his drug habit (9)." And the Council on Mental Health of the American Medical Association says in its 1957 Report on Narcotic Addiction, "A physician who furnishes an addict with a small quantity of narcotics to tide him over until he reaches an institution, or who gives an addict narcotics so he can arrange his affairs prior to entering a hospital for treatment is in danger of being charged with a violation of the law, despite the fact that he may be acting in what he regards as the best interest of the patient (10)." Whether these statements correctly reflect the law is not the primary question from the physician's point of view. Only the clearest sort of assurance, communicated to physicians through their professional groups and public health agencies as well as by sources of legal information, can be expected to bring physicians generally into the treatment of drug addiction on a more effective basis than refusing to deal with the addict unless he is hospitalized. This has nothing to do with a physician who misuses his practice to become a drug pedlar. When a doctor sold 4,000 narcotics orders in 11 months to anyone paying 50 cents each, the U.S. Supreme Court said, "to call such an order... a physician's prescription would be so plain a perversion of meaning that no discussion of the subject is required." (11)
Physicians fully support the basic standard of our federal narcotics laws that narcotics be used only in good faith in the course of professional treatment. The medical community in the U.S. has stated views quite consistent with the legal interpretations of the Federal Bureau of Narcotics (12). In addition to the joint statements of May 1962 by the American Medical Association and the National Research Council, a more detailed statement is that of the American Medical Association, published in its Journal in 1952 (13). This states the following basic position:
"In general, the physician will be acting in accordance with the consensus of medical opinion with regard to addiction and will be complying with the letter and spirit of the regulations if he follows two principles:
Ambulatory treatment of addiction should not be attempted as institutional treatment is always required;
Narcotic drugs should never be given to an addict for self-administration,"
It is the principle that" ambulatory treatment of addiction should not be attempted as institutional treatment is always required" that, combined with the lack of available institutional facilities, presents a doctor's dilemma in how to treat an addict patient.
Addicts may refuse hospitalization because they are not really seeking treatment of their addiction but only a source of drugs. In other cases the motivation may be genuine but circumstances may be a serious deterrent. Addicts who have been able to keep their addiction secret and maintain themselves in the community may reasonably fear that extended hospitalization will interrupt their employment and normal associations for too long a period. The choice between hospitalization or continuation of addiction is for them and their physicians a harsh dilemma.
There are many addicts who have a genuine motivation to seek treatment but not enough to overcome the compulsion of the addiction. These addicts are too sick to accept the necessary treatment. If facilities are available they can be involuntarily hospitalized in some states. If hospital facilities are not available, the prevailing practice in the U.S. is to abandon treatment. Some physicians would support efforts to maintain such addicts with medically administered narcotic drugs while trying every means to strengthen them to the point where they are willing and able to accept withdrawal.
In addition to the compelling facts of the unavailability of hospital facilities for addicts and the resistance of addicts due to the nature of addiction, there is need for some flexibility in the norm of hospitalization. The history of medicine, as of all science, included many beliefs that became dogmas and were accepted as scientific. Medicine has been credited by some with being more alert than law to this danger. It was a great jurist, Justice Holmes, who said, "An ideal system of law should draw its postulates and its legislative justification from science. As it is now, we rely upon tradition, or vague sentiment, or the fact that we never thought of any other way of doing things, as our warrant for rules which we enforce with as much confidence as if they embodied revealed wisdom (14)." If medicine is less open to this charge, it is because of the scientific discipline of continual testing of current beliefs and practices by research and experimentation. Neither medicine nor law should make hospitalization for the treatment of drug addiction a dogma unchecked by controlled research on other methods of treatment.
The trend of modern psychiatry is strongly in favour of voluntary treatment of patients with mental disorders. The nature of a disorder may make involuntary treatment necessary in some situations. Then medicine must look to the law for reinforcement. Medicine must also look to the law to provide social supports that help, and to control social stresses that hinder treatment.
In narcotic drug addiction there are three critical problems of this general nature. One problem is the addicts who are unwilling to undergo treatment. For these, one course of action is civil commitment, but the immediate question then is commitment to what. A committee of the U.S. Senate in 1956 reported: "A startling number of those states which have legislated against drug addiction and prescribed mandatory treatment have failed to provide even the minimum facilities required for treating addicts (15)." We need provisions for civil commitment for addiction as for other mental disorders, but we should not delude ourselves into thinking that commitment to purely custodial institutions means treatment. Unless hospitals are available for actual treatment of addicts, civil commitment laws are useless legal instruments, or devices for imprisonment under another name rather than for treatment and rehabilitation of the addict.
Provisions for civil commitment also need safeguards for continuing evaluation, improvement, and new methods of treatment. At the recent White House Conference on Narcotics, a knowledgeable and devoted community leader in the field of narcotic addiction, the Rev. Norman Eddy, said, "We of the New York Council on Narcotics Addiction are fearful that one approach may pre-empt the field. Specifically, we oppose the civil commitment and parole programme, except on an experimental basis (16)." These views on civil commitment are reconcilable and should be reconciled in any civil commitment programme. Experiments such as Synanon, for example, should not be thwarted by compulsory civil commitment to hospitals.
Some addicts who want treatment are too unstable to continue it long enough to be effective. Some addicts want treatment of their addiction, others want to reduce their drug requirement and get a fresh start on the insidious process of drug tolerance and physical dependence. They gain admission to a hospital, get some benefit of medical care and then leave prematurely. Some who enter with the best intentions are subject to acute anxiety and panic reactions during the withdrawal period or later over-optimism. Dr. Nyswander of New York City, a physician noted for her espousal of new ways of treatment for addicts, has written: "At some point in the treatment it is inevitable that the patient will become frightened by his own decision to go off drugs. At this juncture the physician will have to be extremely patient, retracing and reaffirming the thinking that went into the patient's original resolution. However, the addict's fright will often become so pronounced that no amount of reassurance will reduce it. This is the time to provide custodial care." Also she says: "The simple fact is that the finest medical treatment can be totally invalidated if the basic and ever present custodial needs of the patient are neglected (17)." But at any hospital treating addicts as voluntary patients, the convalescing addict may walk out - against medical advice. About one-third of the voluntary patients at the Lexington PHS hospital leave within two weeks.
Two ways of getting at this problem seem worthy of consideration. One is exemplified by New York State's statutory provision for civil commitment on voluntary application by the addict himself, so that it is his decision to seek hospitalization but his decision is reinforced by legal authority as well as medical advice when he has to fight his addiction through the crises of recovery. The New York State Legislative Committee on Narcotic Study points out that this provision dates from 1909 (18). Another way would be to maintain the voluntary character of admission but to provide for detention during periods of crisis during treatment. It would be intended to help the addict through his panic, as an alcoholic might be restrained through an attack of delirium tremens or any patient during a transient mental disorder.
Addicts commonly relapse after hospital treatment, but it is an over-simplification to relate this exclusively to the addict or the inadequacy of treatment. If a treated susceptible individual is re-exposed to an environment conducive to relapse he can be expected to relapse whether his disease is narcotic addiction or tuberculosis. An environment where drugs are easily, available assures relapse of treated addicts. Continued care is necessary to prevent re-addiction, even after the best of hospital treatment and effort on the part of the patient. Unfortunately only a little has been accomplished or even attempted in this phase of treatment of addiction. Repetitive hospitalization and jail sentences are common. Systematic preventive measures by competent health and other social agencies to maintain the ex-addict's rehabilitation in the community are scarce. California and New York have started programmes of post -hospital care. The Public Health Service has conducted a demonstration in New York City in order to assist local agencies to extend their services to former drug addicts, and to learn more of the patterns of relapse and adjustment. There are some heroic non-governmental efforts on a small scale, limited by insufficient financial support. The East Harlem Protestant Parish, under the leadership of the Rev. Norman Eddy, has had a programme ranging from the prevention of addiction to helping theex-addict get a job, psychotherapy, legal aid, religious support, and friendly social relationships that accept the ex-addict as an individual and sustain him in living without drugs.
Narcotics Anonymous, a society of ex-addicts similar to Alcoholics Anonymous, founded in 1948, has struggled against community suspicion and lack of resources to give some ex-addicts the support of mutual understanding and active personal interest in each one's fight to live without drugs.
One of the most encouraging projects in rehabilitating addicts and preventing re-addiction is that of the New York State Division of Parole. In the initial phase of this project, parole officers supervised 346 parolees who had been addicts. With 30 or fewer men for each probation officer, there was more personal attention, counselling and aid in employment, education, and supervision of leisure activities. The results over a three-year period showed that more than 40% of the parolees did not relapse to drugs. The costs of this project were estimated at $ 250 per year per parolee compared with a cost of custody in a correctional institution of over $ 1,900 (19).
These are all hopeful moves towards restoring ex-addicts to a normal life in the community but we need much more of both study and action. The ex-addict's problem is nothing less than the reconstruction of his life. He needs a home, a job, counsel that will build his self-respect and self-confidence. He needs associations that will take the place of those centred on the drug habit, and medical care to maintain his physical health, to ameliorate the underlying emotional and personality problems that make him susceptible. He needs help in crises when nothing seems as important as the relief that drugs can give him.
The ex-addict faces these problems with the added handicap of his identity as an addict, and probably as an ex-convict. If other elements of the community reject him on this account his former associates in the drug habit can usually be counted on to receive him and the police will do their job of enforcing the law as it is written. The treadmill continues, but the readdiction problem is not solved.
Two points in this connexion deserve special emphasis: the importance of continuity in treating addiction all the way from its incipiency to full rehabilitation; and the alternative between abandonment after a first or second or third relapse and successful rehabilitation even after multiple relapses.
When the first preventive measures fail and the drug user becomes an addict, it is time to look to his post-hospital rehabilitation as well as to the immediate need of hospital treatment. Before he leaves the hospital there should be assurance of what he is going to do for himself and what others are going to do to help him. Such devices as "half-way houses" deserve at least more trial than they have had. As the addict tries to establish himself in a life without drugs, any ordinary difficulty- lack of a job, family problems, simple loneliness- may send him back to drugs. His defences need to be continuous.
Any relapse to the use of drugs is serious but whether it becomes re-addiction or only a temporary set-back may depend on how it is treated. If it is taken as proof of the hopelessness of the case, the drug-user can be expected to give up too. If it is taken as a temporary set-back calling for treatment rather than punishment or abandonment, it may be no more than that. It is a mistake to over-estimate the significance of relapse. Relapse, even to the point of re-addiction, calls for treatment directed to the causes and prevention of further relapses. Underlying emotional and personality disorders are likely to bring about re-addiction unless the predisposing factors in the individual or his environment or both are corrected. This does not mean "Once an addict, always an addict." There are recoveries even after numerous relapses. The man who founded Narcotics Anonymous, for example, was hospitalized eight times before he made a complete recovery. The experience of relapse may be a preliminary to successful rehabilitation, because it provides the addict with recognition of the realities of himself and his disease.
Measures to prevent relapse may have to include an element of authority, whether the ex-addict is discharged from a hospital or paroled from a penal institution. Civil commitment laws should require post-hospital treatment and supervision. Venereal disease was controlled by making treatment mandatory. The authority of such "an autocratic family structure" as Synanon may serve the purpose. Whatever the particular means, the personality traits of dependency and immaturity characteristic of most addicts seem to demand, and be responsive to, this element of authority, provided it is a friendly, supportive authority rather than a hostile, threatening one.
What a narcotic drug addict, or anyone else, does is a matter of conduct subject to the prohibitions of the law; but addiction is a disease, a mental and physical disorder with which the addict is afflicted, not something he does. Addiction usually results from his conduct, but the disease is as distinct from his conduct as syphilis and paresis are distinct from the intercourse that preceded them. Our federal laws impose penalties on illegal conduct in relation to narcotic drugs, but there is no federal law that makes addiction a crime. Some state laws have done so, but the U.S. Supreme Court in June 1962 held it to be unconstitutional to make it a criminal offence to" be addicted to the use of narcotics ". In the words of the court:
"It is unlikely that any state at this moment in history would attempt to make it a criminal offence for a person to be mentally ill, or a leper, or to be afflicted with a venereal disease. A state might determine that the general health and welfare required that the victims of these and other human afflictions be dealt with by compulsory treatment, involving quarantine, confinement, or sequestration. But, in the light of contemporary human knowledge, a law which made a criminal offence of such a disease would doubtless be universally thought to be an infliction of cruel and unusual punishment in violation of the Eighth and Fourteenth Amendments.
"We cannot but consider the statute before us as of the same category (20)."
It would be convenient if physicians and legal authorities could separate their interests at that point and each concern himself solely with his special interest. But the addict is still one person even though his addiction is clearly a disease and what he does to maintain it is usually a crime, under both federal and state laws. As a consumer of illicit narcotics, the addict is an essential part of the illicit traffic, which our laws and our law enforcers are devoted to eliminating. The addict is a consumer of illicit narcotics, and hence a criminal, by force of his addiction. He may have started as a voluntary experimenter in the use of drugs but when he is addicted the compulsion to use drugs is ever present and overwhelming. Punishment does not cure him, or the fear of punishment deter him. He can be locked up, at great cost to himself and society, but to rehabilitate him as a useful member of society requires treatment of his addiction and its underlying causes. Strict laws and strict enforcement against illicit narcotics are also indispensable for the prevention of addiction or relapse of the treated patient. Our mutual concern, therefore, is to design our laws and their administration to get at the causes of addiction and minimize the disease, the illicit traffic, and crimes that addicts commit to pay for narcotics.
Considering the characteristics of addiction, and its underlying causes, how well are our penal laws adapted to controlling it ? Mr. Kuh, Assistant to the District Attorney of the County of New York, has said, "In combating heroin addiction in our largest cities, law enforcement has failed dismally (21)." This is a respected lawyer's judgement. Fortunately, since Mr. Kuh published this comment in 1961, there have been some improvements.
From a medical point of view, the following are some features of our federal or state laws in the U.S. that would seem to call for further consideration in terms of effectiveness:
Legal procedures, such as release of narcotic drug addicts on bail, which are appropriate to criminal prosecution but do not provide for the person's immediate need for treatment of his addiction;
Jail sentences that add to the addict's circle of criminal contacts and his own degradation and handicap him rather than help him in any attempt at rehabilitation;
Prison sentences, without parole, that destroy the individual's motivation to rehabilitate himself, crowd the prisons, and preclude post-institutional supervision;
Restrictions on judicial discretion that prevent intelligent consideration of individual cases.
Developing sound policy in these areas of over-lapping medical and legal interests is a task for all those concerned and not for any one professional group. Physicians are not equipped and have no ambition to write penal laws but they may be able to help. When Justice Cardozo gave his ideas of "What medicine can do for law ", he spoke particularly of the law of crime (1).
Some alternatives are already available for more effective handling of addicts who violate the law in order to maintain their addiction. Some alternatives depend on a policy decision. Some may require new programmes with facilities and staff to make them effective. Parole requires competent staff and community co-operation, but it releases custodial staff and overcrowded facilities. Its benefits can be made available by changing the laws that exclude its use and following through with such projects as New York's. Other restrictions on judicial discretion in sentencing are likewise matters of legislation and not dependent on construction of facilities or new programmes.
Treatment as an alternative to criminal prosecution does depend on facilities and staff to provide the treatment. This may require new facilities, but more could be done with existing facilities if they were opened to addicts. Jails and prisons also require facilities and staff. If the purpose is to take addicts out of the illicit narcotic drug market and rehabilitate them, the choice between prosecution and treatment is a question of effectiveness. One thing that can be said for our penal laws is that they have been used to coerce many addicts into seeking treatment. If this is sound it should be recognized as public policy and accomplished directly and openly. More of our health resources - hospitals, physicians, social agencies - should be enlisted to deal with the problem
Much excellent research has been done and is being done in the laboratory and hospital, but relatively little in the community. We do not have the data, or established methods for acquiring the data, that are needed about drug addiction as it exists in the community.
Public health knowledge in general rests on systematic reporting by attending physicians, and other sources of original information, to state or local public health agencies. The use of such reports by the public health agencies provides correlated, meaningful data and a basis for necessary public health action. In the field of narcotic addiction there is no systematic method of developing health information as a basis for health measures. In some states a start has been made and a more complete programme could be developed in the light of their pioneering and the general development of public health methods. In addition to the work that law enforcement agencies do in reporting data for law enforcement purposes, it is clear that health agencies have a distinct and additional job of health intelligence to perform. The difference between an offence against the narcotics laws and addiction as a medical condition underlies the important difference between health data and enforcement data. The responsibility of health agencies should be established on as clear a basis as that of enforcement agencies.
There are some obstacles to gathering necessary health data regarding narcotic addiction. In some states physicians are required by law to report any drug addict whom they attend. If such reports are made only to health authorities and used exclusively for health purposes, not for prosecution, it may be possible to encourage addicts to seek treatment. Fear of disclosure to enforcement authorities keeps the addict away from legitimate treatment. The confidentiality of the addict's disclosure of his condition to a physician, except as required for health purposes, would be a small concession to the need for more professional knowledge of addiction.
There is increasing conviction among those concerned with the prevention and treatment of mental disorders in general that community health services are the most effective method. The tradition of isolating mentally disordered patients in institutions removed from the community is changing even though it is far from being wholly replaced in practice. As expressed by the New York State Legislative Committee, "Narcotics addiction represents perhaps the one major mental health disease entity which is now completely ignored by community mental health resources (22)." The community approach is as valid for narcotic drug addiction as for other mental disorders. It would deal with the problem where the problem exists, and with the factors that contribute to the problem, in the individual's family, his school and work experience and his associations. It would utilize the variety of community agencies that are necessary. It would provide continuity in understanding and helping the susceptible individual, whether in preventing addiction, in treating it, or in preventing relapses.
As the World Health Organization's Study Group on Treatment and Care of Addicts has said, "It is in the community that the final phase of adjustment and adaptation should occur (23)." We seem to be learning that the intermediate stages may also best be dealt with in the community. Clearly, we have a long way to go, but the direction seems to be towards community services with appropriate state and federal assistance.
Proposals have been made for acquiring "definitive information" regarding all aspects of narcotic drug addiction and accomplishing a "sweeping reform" of our present laws and procedures. Such proposals are apt to be illusory. What we can do, both realistically and constructively, is ( a) to approach the problem in an attitude of seeking to make the best use of what knowledge we have while we develop through research and experiment more knowledge and more effective methods; ( b) to review whatever in our present laws or practices may be a handicap in our efforts to prevent and treat addiction and rehabilitate addicts as useful members of society; and ( c) to develop through collaboration such programmes as seem likely to move in the right direction. This means less emphasis on simple formulas for getting rid of the problem - whether by getting rid of the addicts by placing them all in institutions or by accepting their addiction as a way of life and making drugs easily available. It means combining experience and thought as in this Conference on Legal Medicine, and more translation of the product of this interprofessional exchange into the thinking of our policy-making bodies, including the citizens of our local communities who will accept or reject any proposed solution and determine how effective it will be in practice
CARDOZO, B.N.: "What medicine can do for law", address, 1 Nov. 1928, published in Law and Literature, 1931.002
Bureau of Narcotics: "Active Narcotic Addicts reported in the U.S. as of Dec. 31, 1961 ".003
FRANKAU & STANWELL: "The treatment of drug addiction ", The Lancet, 24 Dec, 1960, p. 1377.004
LOWRY, J. V.: "Hospital treatment of the narcotic addict", Federal Probation, Dec. 1956.005
YABLONSKY, L.: "The anticriminal society: Synanon", Federal Probation, Sept. 1962; "S.S. Hang Tough ", Time Magazine, 7 Apr. 1961; Senator Thos. J. Dodd, "A Study in Heroism ", statement in U.S. Senate, 6 Sept. 1962.006
Press releases, 14 May 1962.007
KUH, R. H.: "The narcotics offender and the criminal law", Inter-American Conference on Legal Medicine. XXV.008
Bureau of Narcotics: "Active narcotic addicts reported in the U.S. as of Dec. 31, 1961 ".009
SHARTEL & PLANT: The Law of Medical Practice, 1959, p. 320.010
Council on Mental Health, A.M.A.: "Report on narcotic addiction ", p. 51, reprinted from Journal of the A.M.A., 14 Dec. 1957.011
Webb v. U.S., 249 U.S. 96 (1919).012
Bureau of Narcotics: "Prescribing and dispensing of narcotics under Harrison narcotic law", pamphlet No. 56, rev. Sept. 1960.013
Journal of Amer. Med. Assn., vol. 149, 25 July 1952, p. 1220.014
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