Trial and failure of the ambulatory treatmentof (opiate) drug addiction in the United States

Sections

The Narcotic Situation in the U.S.A. in the Early 1900s
Reasons for establishing the Clinics
The Clinics in Operation
Recent Policy Statement on Medical Practice in Treatment of Opiate Addicts
Constructive Results of Present U.S.A. Enforcement Programme
The Weaknesses and Dangers of the Clinic Plan

Details

Author: L. Malachi HARNEY
Pages: 29 to 40
Creation Date: 1964/01/01

Trial and failure of the ambulatory treatmentof (opiate) drug addiction in the United States

L. Malachi HARNEY

Late in the second decade and early in the third decade of this century there were operated in the U.S.A. some forty-four so-called narcotic "clinics ". These were an experiment, or more exactly, perhaps, an expedient to control narcotic addiction. As such they were a dismal failure, foredoomed by their very nature and their underlying philosophy. This philosophy in its briefest simplification was that narcotic drugs "to maintain his habit" should be supplied to the addict by local governmental agencies at low cost or free. It was supposed that in some manner this would result in an amelioration of the narcotic evil. The addict would be relieved of an expensive burden in buying drugs, he would have more time for legitimate pursuits, more opportunity to earn an honest living, he would be relieved of the incidental sufferings that he might undergo if the source of narcotic supply were interrupted, etc. Presumably, it was hoped that in some way the addiction of some might be cured. But this curative aspect was not emphasized, perhaps for the very good reason that just enough was known about opiate addiction in those days to indicate that any cure or arrest of the course of addiction under the conditions was unlikely. For that reason in its first appearance in this article we have put the word "clinics" in quotation marks.

In our dictionary the word "clinic" is a wholesome, hopeful word, originating from the bedside teaching of the truths of medecine. Those well-intentioned persons who contributed to the setting up and operation of what were called narcotic clinics did not foresee that what would emerge was something for which the name clinic is a perversion. In some cases an attempt was made to reduce the addict's drug intake. In some instances he was offered an opportunity to transfer to a hospital for treatment looking towards abstinence. Only a small percentage availed themselves of this offer, and few remained to complete hospital treatment. But by and large the clinic emerged as an institution wherein the accustomed daily narcotic ration of the addict was maintained or increased.

By 1925 the last of the narcotic clinics in the country had been closed. Their operation, lack of success and the opium they produced had considerable effect in shaping the narcotic-control policies in this country. A review of this clinic picture may have valuable lessons for present-day specialists in the narcotic field. The clinic idea is revived sporadically and agitated in this country. It is now being vigorously pushed by a small and most articulate band of propagandists who urge that the answer to the United States problem in some manner lies in the distribution of free or cheap narcotic drugs to addicts "to take the profit out of the drug traffic" on the supposition that the problem then will just go away. To make plausible a proposition which on first impact might seem naive, the argument is often coupled with the assertion that such programmes have succeeded elsewhere, notably in the United Kingdom. Although the existence of any narcotic give-away programme in England has repeatedly been denied on high authority such as the Drug Addiction Report of the Interdepartmental Committee, Ministry of Health, Department of Health for Scotland, 1961 (page 9), etc, the allegations of such a British system persist, and through repetition there is some wide acceptance of this as a fact in this country.

The Narcotic Situation in the U.S.A. in the Early 1900s

Because of the global audience of the United Nations Bulletin on Narcotics, it might be well to preface a discussion of details of the early United States narcotic clinics by an indication of the problems they were designed to meet. And the American reader may profit by a recall of the situation, the nature of which may have been obscured by the mists of more than four decades of narcotics control history. So at the outset, we should be reminded that in the last decades of the 1800s and for most of the first twenty years of the present century we had in the U.S.A. a rate of narcotic addiction the height of which has not been approached since, and the virulence of which is not always comprehended, even by persons relatively well informed on the present status of our narcotic problem. In 1928 there was published a book, The Opium Problem, by Terry & Pellens. This volume, with an extensive bibliography, runs to more than 1,000 pages. One might disagree with many of the stated conclusions of the authors, as we do, but it is a useful compendium of most of the literature then available on the United States opiate problem. There is a lengthy discussion of the growth and extent of addiction in this country. The authors refer to numerous estimates of addiction throughout the preceding half-century. While they constantly remind us of the difficulties inherent in counting addicts, there plainly emerges a picture of an opiate addiction of most substantial scope, not approached in this country today.

In the annual report of the U.S. Bureau of Narcotics for 1939, Traffic in Opium and Other Dangerous Drugs, there is an illuminating discussion of the extent of opiate addiction as it was known in the State of Michigan in 1877. This is excerpted from an 1878 Michigan State Board of Health report which refers to a survey based primarily on information gathered from pharmacists. With the personally operated pharmacy which was common in those days, these druggists were in an excellent position to make realistic counts of' persons in their communities who might be addicted to opiates. After counts and estimates of the number of opiate addicts in Michigan, and studies of the amounts of opiates imported into the U.S.A., and applying these figures country-wide, this Michigan report arrives at an estimate of the number of narcotic addicts in the U.S.A. in 1877 as probably about one in every 400 of the population.

Most persuasive to this writer as reflecting the extent of addiction in any period are the day-to-day files of the U.S. Bureau of Narcotics and its predecessor and allied agencies in the U.S. Treasury Department. The writer worked with these files for many years. They reflect the volume of importation of duty-paid narcotics, the amount of seizures of contraband drugs, the prices of illicit narcotics in the underworld market, the statements of traffickers and informants reflecting the day-to-day and year-by-year fluctuations and the trends of the traffic, indexes of known addicts, and numerous counts and estimates of the addict population. On such facts and indications the office of the U.S. Commissioner of Narcotics has estimated that up to about 1920 the number of opiate addicts in this country was not less than one in every four hundred of the population. This may not be considered a heavy rate by some standards, but it was obvious enough and serious enough to be profoundly disturbing to the American public at the time.

The first comprehensive U.S. narcotic law (the Harrison Act) became effective in this country in 1915. Not much manpower was devoted to its enforcement until about 1919. Before this time many states and local communities, alarmed by the evidence of opiate addiction in the populace, had passed laws designed to outlaw traffic in narcotic drugs. However, enforcement of the local laws was sporadic and desultory. While in the early 1900s references are often seen to the high cost of drugs to the addict, the fact is that law enforcement had not then acquired sufficient impetus to make the contraband scarce. Opiates were freely available in underworld markets at relatively low prices and, as will be seen, were otherwise cheaply available to the addict from several sources.

To evaluate properly the significance of this discussion of the American narcotic clinic, one facet of early history must be made crystal clear. The relatively large pre-Harrison Act addict population - ten times that of the present day and accustomed to a daily individual intake of perhaps ten times that of the present-day addict - developed in a situation where narcotics were a relatively free article of commerce and were cheap, very cheap, within the means, let it be said, of any ambitious newsboy. The lapse of time from those days and the constant repetition of an unsound premise have made many believe that in some way any presence of narcotic addiction in America is solely due to the machinations of vast illicit narcotic cartels which proselytize and exploit addicts to make new customers for a conscienceless racket. While the exploiter has his place and is important in any commercial operation, the inescapable fact is that when we had by far our greatest rate of addiction and when it was spreading at a rate which triggered our present domestic and international control programme, this scourge of opiate and cocaine use was based on and fostered by drugs which were then a stable article of commerce, and cheap.

Referring to 541 addicts registered as using some form of opium in a Jacksonville, Florida, narcotic clinic in 1913, Terry & Pellens ( supra) state (p. 25): "The traffic could not have been lucrative as free prescriptions were available to any user asking for them and the price of the drug in the drug stores was in the neighbourhood of 60 cents for a drachm of morphine when sold in original bottles or large fractions. With this price it is evident that [illicit] pedlars could not compete with profit."

No highly organized illicit traffickers engineered, for example, the spread of heroinism among young underworld habitues in this country in the 1900 and 1910 decades. Instead, it was principally because the word spread among and from the opium smokers and eaters and the morphine users of those days (particularly in the eastern United States) that heroin - the new highly recommended cure for T.B., other respiratory ailments, a panacea for everything, including morphinism - was to the addict the best thing yet to maintain an opiate habit. (" History of Heroin ", United Nations Bulletin on Narcotics, vol. 5, No. 2, April-June 1953, p. 7.) It could be obtained from the corner drug-store for nickels. As Terry & Pellens ( supra) put it (p. 84), "It has been stated that the widespread use of heroin as a substitute for morphine and as a more stimulating narcotic drug first became a matter of general knowledge in the underworld, and that long before the average physician had become aware of the dangers of the drug it was being used freely by certain groups of individuals, especially young men, frequenters of the underworld districts. This is borne out in the report of the Health Department of Jacksonville, Florida, when in 1912 the extent of opiate use was investigated."

An elderly surgeon acquaintance of the writer liked to tell this story of narcotic conditions in the city of Chicago in the pre-Harrison Act era. As a young medical student he had occasion regularly to pass by a pharmacy in a squalid neighbourhood in the outer Loop. Here early in the morning there would be on the sidewalk a line of nondescript people (addicts) waiting for the drug store to open so that they could get a narcotic supply, principally morphine and opium, often as laudanum.

In those days there also were many cocaine users. 1 Sometimes cocaine was used by itself as an exhilarant. More often in the then existing situation of cheap and plentiful opiates it was used in combination with these for a special effect, and often to overcome the stupor of heavy opiate intake. To take care of the early-morning narcotic rush, the pharmacist for a time pressed into service his porter and handyman to help parcel out the cocaine. This was done from a big receptacle using a ladle like a housewife's sugar scoop. But finally the pharmacist had to dismiss his porter. It was discovered that some of his dramatic dispensing motions were a finesse to conceal constant sniffing of the cocaine. As the morning wore on the porter would become more and more liberal with his measure. Buyers were quick to perceive this, reacted accordingly, and the cocaine profits vanished. This is an illustration of the sort of supply atmosphere in which we had our greatest height of addiction.

1

Cocaine abuse has been practically non-existent in this country for many years as the result of alternative medicines, law enforcement and effective controls by the producing countries.

Reasons for establishing the Clinics

As one reads the contemporary accounts of those days, there were apparently two overriding urges for the establishment of clinics to give away or furnish drugs cheaply to addicts. One was to "relieve the sufferings" of "the poor wretches who would undergo excruciating withdrawal symptoms if deprived of their drug."

[Here, by digression, one must comment on some changes accomplished in 40 years. The distress of withdrawal is, of course, very real. It would have been so in this setting when opiate habits were heavy, perhaps 10 to 20 grains of morphine a day. "Thousands of addicts in the State (New York) are taking fifteen grains of morphine per day and hundreds use 25 and 30 grains a day." (Walter R. Herrick, Annual Report, New York Narcotic Drug Control Commission, 1920.) The addict usually never sought to minimize the seriousness of withdrawal distress, particularly if he had an audience that might be influenced to give him the "medecine" which would accomplish his immediate relief. With many addicts the distress of withdrawal is painful enough to be a good reason not to discontinue drug use. But the recollection of the past distress may not be persuasive enough to prevent a relapse of the disintoxicated addict. Severe withdrawal distress is no more serious, of course, than the distress encountered in many major illnesses and accepted as an inevitable incident to be thankfully endured if one survives. Today in America one sees little of the classic withdrawal symptoms in addicts. The opiate intake is so light for reasons that will be alluded to later that the victim acquires little tolerance or dependence. In a rare case, perhaps one out of twenty-five or thirty, where there is a good degree of dependence, the opiate can be withdrawn over a few days without great discomfort by the substitution of a drug such as methadone, and the subsequent withdrawal of the substituted drug.]

The second compelling reason advanced to justify the habit-maintaining narcotic clinic was that it would relieve the addict as a victim of the predatory drug pedlars. By 1919 the effects of local, state and federal laws were making themselves felt. As legitimate sources of opiate supplies were shut off, many addicts discontinued taking drugs. This was particularly true of female addicts, and of other Persons who may have been introduced to opiates by medical or quasi-medical routes. The hedonist and the underworld character in quest of narcotics had to develop a black-market supply.

One objective of the narcotic give-away clinic was "to draw the addicts away from the class of doctors and apothecaries, who commercialize the vice" who Herrick ( ibid.) estimated supplied one-third of the addicts, and from "pedlars and other illicit sources", who supplied twice the number ", according to Herrick.

Sometimes the underworld source was not even considered consequential enough to be mentioned, although in retrospect it is our opinion that it was more elaborate and highly developed than realized either by the medical profession or the law-enforcement authorities. Of course, much of the original narcotic supply of pedlars in those days was obtained from "script doctors ", or pharmacists, and repeddled. So the "script doctor" was a prime target (Dana S. Hubbard, M.D., Acting Director, Bureau of Public Health Education, Department of Health, City of New York, in a report published in February 1920) and the outrage of the medical profession at the errant conduct of a relative few of its members is apparent in the contemporary accounts and in the subsequent actions of organized medicine and individual medical bodies. ( Report on Narcotic Addiction, American Medical Association, Council on Mental Health, 1957.)

In fairness to the great profession of medicine it should be pointed out as we have done heretofore ( The Narcotic Officer's Notebook, Harney & Cross, p. 23) that not all, by far, of the physicians who seemed to cater to addicts were actuated by anything except humanitarian motives and what they considered proper professional judgement. They were aware that they had before them what could soon become a distressed human being. There were no ready hospitals or other institutions to which he could be referred. If aged or infirm, or if he were suffering from a severe organic disease, abrupt separation, or any separation, from his drugs might be dangerous. The doctor took what he considered to be the humane course, and the medical profession supported the habits of a great horde of opiate addicts.

Of course, in this great physician-supported addiction there was no element of proselytizing by the seller, so mistakenly considered by so many in this country today to be the essence of drug addiction. Instead, addicts spread their way of life to their contemporaries, and the new recruits beat a pathway to the door of the script doctor or any other available source of supply.

The Clinics in Operation

And so, in the course of a very few years, principally in 1919 and 1920, the narcotic clinics were opened, flourished, and were closed as it became apparent what they really were. Some forty-odd of these have been listed (there were also many small counterparts in the way of small privately managed sanatoria which imitated the official clinics). It should be apparent that the idea of the clinic did not gain quick and complete countrywide acceptance. In fact, the theory was imme- diately denounced in many quarters. The clinic institution had restricted distribution geographically. The greatest concentration was in New York State, where there were more than sixteen upstate, in addition to the principal clinic in New York City. There were four or more in Connecticutt and several in Ohio, Louisiana, Tennessee and California.

By far the largest and perhaps the most intelligently conceived of the narcotic clinics was in New York City, a place then as now having the largest concentration of narcotic addicts in this country. There were perhaps twice as many addicts there then as at present. As a ratio, the incidence for New York City would be about I to 260 then as compared to about I to 700 in 1960. 2 There were other differences in the addict population which might be of interest. Ethnically, that of the 1920s was predominantly Caucasian. There were then a noticeable number of Chinese addicts, not great in total but significant enough in our small Chinese population to indicate a disproportionate percentage of addiction in that nationality. In 1963, addiction was predominantly among Negroes and Puerto Ricans, a development during only the last two decades, and a trend which may be reversing.

The New York clinic was opened in 1919 with high hopes. The immediate occasion for starting the clinic is stated by S. Dana Hubbard, M.D. ( supra), "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 expedient, 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." As indicated above, the addict handling programme provided that in addition to a" clinic" where the addicts' drug ration was supplied, the victim also was given an opportunity to avail himself of hospital treatment looking towards disintoxication and abstinence. Relatively few addicts applied for this, and fewer persisted.

According to Dr. Hubbard ( ibid), "The practice of the clinic was not to prescribe for any new applicants an amount over 15 grains - ten 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 two or three grains. Others, disloyal to the clinic and themselves, would, when deprived by the clinic, refunse to accept our regulation, and would buy additional amounts outside.

2

Census year.

"Many addicts endeavoured 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 seven to eleven cents per grain to the addict; while at the clinic the maximum price was three cents a grain and later this was reduced to two cents. Some individuals would endeavour to deceive and actually would go through registration and examination in order to sell to addicts at an advance of the clinic price .... Drug addiction spreads like a pestilence through association."

Dr. Hubbard said further, "We have given the clinic a careful and thorough as well as a lengthy try and we honestly believe it unwise to maintain it any longer. The clinic has been found to possess all the objectionable features characteristic of the 'ambulatory' treatment practised by the trafficking physic cians .... 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 a narcotic addict for self administration should be forbidden.

"The case of drug addiction that can be cured by ambulatory treatment is a rare exception and so unusual as to make one think it impossible."

In 1955, the U.S. Bureau of Narcotics compiled from its files and presented in pamphlet form some notes on the clinics entitled Narcotic Clinics in the United States. The following is quoted therein from press reports in 1920 of statements of officials having to do with the New York clinic.

Officials of the dispensary soon were convinced that it offered no solution of the narcotic problem.

Here are some of the facts observed:

Addicts often obtained more of the drug than they needed and sold the excess to other addicts or peddlers.

Addicts induced friends or relatives, who were not addicted, to register and attend the dispensary in order to obtain additional supplies, in some cases making new addicts.

Prescriptions were forged or raised, dosage sheets were tampered with, false dosage sheets sold and a business sprang up of buying and selling registration cards.

No cures are known to have been effected by means of the reduction system as used at this clinic. So far as known, all cases sent to the hospital were "cured" in the sense that the withdrawal of the drug left no physical need or craving, but quite a number of these cases relapsed after discharge, some returning to the "clinic" under assumed names.

After observation of the practical working of the ambulatory treatment, New York health officials concluded:

That the ambulant dispensary treatment, whether practised by private physicians or public authorities, is vicious in principle and in effect.

That the institutional withdrawal of the drug is so simple, easy, prompt and effective - and comparatively without any danger, there not having been a single fatality - that there is no need for prolonging addiction by a continued supply of narcotics.

That the average addict will not voluntarily submit to institutional or other withdrawal treatment so long as he or she can obtain a supply of the drug, but will go to a hospital if unable to get more of the drug.

Encourages illegal traffic. A public dispensary does not tend to get rid of peddlers. If a dispensary issues to all comers all the drug they desire, it may, by competition, put peddlers out of business, but in that case there would be nothing to choose between the peddling evil and its alleged remedy. If the dispensary does not supply the drug ad libitum, it encourages the traffic of peddlers by keeping up the demand.

A dispensary does not tend to prevent petty crime by addicts. For instance, a jeweller could prevent burglary by opening his store to thieves and inviting them to help themselves. The surest way to prevent crimes arising from an addict's craving for drugs is to cure the addict and remove the craving.

A dispensary tends to increase, rather than decrease, the number of addicts.

A dispensary does not prevent death or suffering. Death does not result from sudden deprivation of the drug. Suffering caused by deprivation is not as severe as it may appear on the surface, and is of short duration.

There is no excuse for a public or private narcotic dispensary.

The following is also from the U.S. Bureau of Narcotics pamphlet:

The Medical Society of the State of New York on March 22, 1920, condemned the ambulatory treatment for addicts. Dr. E. Elliott Harris, chairman of the Medical Society of the State of New York, Committee on Public Health, stated that "clinics are in competition with the illicit peddler ".

In New York City, on November 10, 1919, Dr. Ernest S. Bishop stated:

"We are in a very bad state here in New York. Conditions are probably worse than ever. I am told, and I believe it to be true, that more opiates are peddled than ever before. The Board of Health Clinic has not been a success."

Excerpt from a letter dated May 1, 1920, to the Commissioner of Internal Revenue from Dr. E. Elliott Harris, chairman of the Medical Society of the county of New York, Committee on Public Health:

"I am writing to call your attention to recommendation No. 1 (that the ambulatory treatment of drug addiction as far as it relates to prescribing and dispensing of narcotic drugs to addicts be emphatically condemned) which passed the Medical Society of the State of New York unanimously on March 22, 1920, and the American Medical Association on April 29, 1920; also to say that all look upon the New York Clinic as a positive demonstration that addicts must be under institutional control, or any other kind of absolute control. There is no question that a public clinic is simply in competition with the narcotic practitioner and the illicit peddler.

"They all furnish ambulatory treatment. Therefore, the Government should control narcotic drugs and be the only source of supply for legitimate medical purposes. The only hope is of cutting off the supply of drugs as completely as possible. Therefore, no public clinics."

Terry & Pellens stated in The opium Problem: "Drug peddling in New York City was very rife at the time of the operation of the clinic, and every opportunity was offered those who could afford to pay the prices charged by the illicit traffickers in drugs to secure their supplies without submitting to the requirements of the 24-hour supply provisions or registration at the clinic."

In ten months of operation in New York City, the clinic had demonstrated that as a control for narcotic addiction it was not only futile, but dangerous; and it was closed.

As stated, a number of narcotic clinics were established in upstate New York. Generally, these were opened in the later part of 1919 and early in 1920 at such places as Albany, Saratoga Springs, Elmira, Syracuse, Buffalo, Binghamton, Corning, Oneonta, Port Jervis, Rochester, Utica, Watertown, Schenectady, Troy, Cornell and Middletown. A very few of these were constructively operated. In most, there seemed to be considerable administrative abuse. Politics and incompetency pervaded the operation. In some, the clinic was conducted at a considerable profit to the physicians and pharmacists involved. Some clinics sought to monopolize the narcotic buisness to the extent of attempting to force away from private physicians patients who had a legitimate need for long and substantial administration of narcotic drugs. In some cases one pharmacy was given a monopoly on the sale of drugs to addicts attending the clinic. In addition to these abnormal abuses, the clinics demonstrated the inherent weak- nesses to be expected. No cures were effected; few efforts were made in this direction. In one clinic cocaine was dispensed routinely to 113 patients. Underworld characters were attracted to the cities where the clinics were located and intensified police problems. Many addicts sold part of their supply to other addicts. Addicts often registered at two or more clinics. Narcotic rations of many addicts were increased. Addicts often supplemented clinic dosage with underworld narcotics. Some addicts attending the clinics were peddling drugs smuggled from Canada. There were many addicts in the communities who did not register at the clinics, but who obtained their supplies by diversion from drugs purchased by persons who were so registered. Most of these clinics were closed during the years 1920- 1921.

Some five of these clinics were operated in New England, and the experience of the authorities there was in line with the New York results. One law enforcement officer, exasperated at the type of persons; attracted to the community by the clinic, commented, "At. least I know where to find any burglars in New England between five and six o'clock on Tuesdays and Thursdays." These were the clinics' dispensing hours. (M. L. Harney, Problems and Progress in Narcotic

Law Enforcement, Pacific Coast International, September- October 1940. A narcotic clinic was operated in New Orleans, Louisiana, from 1919 to early 1921. The U.S. Bureau of Narcotics report on clinics (supra) summarizes some information in its files as follows:

NEW ORLEANS, LA. - Dr. William Edler, the physician in charge, Bureau of P.S.M. of the Social Hygiene Board, stated: " My observation of this clinic extended over a period of a year and a half, and I had ample opportunity to note the patrons of the institution. It was obvious to me long ago that this clinic represented in New Orleans a social menace exceeded by nothing- and that is saying a great deal for a city like New Orleans. I have seen many of the patrons of this clinic injecting morphine into themselves and each other on the street corners, swappings drugs on the street and selling them. Twenty percent of the clientele were reported to me by one of my inspectors after an exhaustive survey as being prostitutes. In addition to these, pimping chauf feurs, criminals of all types confined in the parish prison - all had been patrons of the place. All of the law enforcement officers of New Orleans were agreed that this place ought to be closed. From a medical and social standpoint it is criminal to permit the place to exist. I sincerely hope that the institution will be closed and I feel sure that such action will meet with the approval of all social institutions in New Orleans."

Sheriff Frank Sullivan, in charge of the parish prison, characterized the presence of such a large number of addicts in New Oleans and the open sale of drugs to them by the dispensary as a disgrace to the city.

The president of the Louisiana State Board of Health stated that his inspectors had caught addicts selling drugs. He was positive in his stand that the clinic was detrimental and should be closed, and he so recommended to the Louisiana State Board of Health.

The superintendent of police stated that he considered the dispensary was not only accomplishing no good whatsoever, but that its operation flooded the city with drugs and accounted for the presence in New Orleans of a vast number of undesirables. He said plainly he did not feet disposed to arrest narcotic peddlers for selling drugs when he regarded the local dispensary as being engaged in the very same business.

A number of the addicts stated under oath that during the entire time they were receiving a daily supply of drugs at the clinic, they were consistently buying drugs from illicit dealers in addition. One addict who came from San Francisco to New Orleans for the sole purpose of attending the clinic received drugs from the clinic while serving a jail sentence in the latter city. He and several other addicts stated that the only thing accomplished by the clinic was that it fastened their narcotic addiction more completely upon them. Morphine obtained at the clinic was continually resold by the patients to others who were not carried on the clinic rolls, and the vials after being emptied were refilled with illicit drugs which could not be seized by the Government because they bore the label of the dispensary. A notorious thief from St. Louis was selling morphine he obtained from the dispensary, and was arrested while selling it to a government prisoner in the custody of the United States marshal. He stated he obtained the morphine at the clinic under a fictitious name. Narcotics were dispensed to thieves, ex-convicts, prostitutes, and drug peddlers from Missouri, Louisiana, Mississippi, Kentucky, Florida, and California. One addict ;on the clinic rolls had been arrested 27 times in a 3-year period.

In the same Bureau of Narcotics release, the clinic at Shreveport, Louisiana, is described as follows:

SHREVEPORT, LA. - 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

SHREVEPORT, LA. - 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

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 $2,500 worth of narcotics, at a monthly profit of about $1,800.

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 had 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: " 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 several-year 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 he 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 he registered at the clinic stated that " it would be one of the finest things that ever happened if there were not a grain of rnor- phine obtainable, because the only reason that myself and others are addicts is due to the fact that the I stuff ' is so easy to get in Shreveport."

One addict went direct to Shreveport from Leavenworth Peni- tentiary where he had served a year for narcotic law violations. He was put on the clinic re; 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.

In reviewing the clinic files in the Bureau of Narcotics, one of the things that stands out- is the almost unanimous and very strong denunciation of these by the police authorities. In many cases the original attitude might have been sympathetic. But experience soon brought about comments like these, which are representative:

Albany, New York, police officials: " The narcotic clinic is a disgrace. Criminal addicts are attracted from all parts of the country." "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." "The clinic is no good. It is a disgrace. Certain women addicts solicit men in 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 buying additional quantities from peddlers. Most addicts reported getting at the clinics more narcotics than they needed."

Rochester, New York: Police had required twenty- four of the addicts attending the clinic to leave the city.

Hartford, Connecticut, Chief of Police: "It attracts people to Hartford who are not desirable."

Providence, Rhode Island: The Chief of Police said the clinic merely fed the addicts, making it attractive for them to stay in Providence.

Atlanta, Georgia: The Chief of Police said that the clinic does not benefit the addict or the community, but attracts many thieves to the city; that it was difficult to handle thieves when the city authorities were providing narcotics for them.

Youngstown, Ohio: The Chief of Polices tated that at first he was in favour of the clinic, but after it had been in operation for several months he found it was a drawing card for criminal addicts from all over the country to come to Youngstown for the purpose of getting dope.

Cleveland, Ohio: The police authorities reported that about twelve of the addicts who -obtained their supply at-the clinic were peddling drugs.

Houston, Texas: The Chief -of Police said the clinic attracted criminals from all over the country, that immediately following the opening of the clinic there was a crime wave which, on investigation, was shown to have been caused by narcotic addicts; that this condition ceased after the closing of the clinic, and that most of the addicts left for Shreveport to attend the clinic there.

San Diego, California: The Chief of Police said the clinic did more harm than good; that it was only a medium for furnishing narcotics to addicts, that there were twice as many addicts in the city as before the clinic opened.

Los Angeles, California: The police records reflected 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." (From "Narcotic Clinics in the United States," U.S. Bureau of Narcotics.)

This is something worthy of careful note. Many well meaning people are convinced that cheap narcotics for addicts means less crime in that the addict will not have to rob or steal or be otherwise predatory to get funds to pay the high cost of contraband drugs. There is an apparent superficial logic here which disappears upon examination. Many surveys made by the U.S. Bureau of Narcotics have demonstrated that the vast majority of addicts were involved in criminal activity before their first experience with a narcotic drug. A survey by the State of California statistical authorities in 196l revealed that 77.7% of all addict users had such prior criminal activity. A recent survey by the Federal Probation Office in New York indicated that 75% had criminal experience before addiction. This chronology must be true in the American setting where by the very nature of things acquaintance with opiates, the association of the potential victim with addicts and the proselytizing go on almost exclusively in the criminal underworld. Canada's addiction problems in many respects resemble those of the U.S.A. At the 18th session of the United Nations Commission on Narcotic Drugs the Canadian representative, Mr. Robert E. Curran, is quoted as stating that "The term ' criminal addict' was hardly a misnomer, for most of the addicts had had criminal records before taking to drugs. Those who tended to consider drug addicts as poor, misguided people were over-simplifying the threat they represented to the community; it was wrong to think that, but for their addiction to drugs, addicts would be useful members of Society." (E/CN.7/ SR.508, p. 4.)

A young man who has adopted the thieves' code that "only chumps work for a living" and then becomes addicted might not suddenly reverse this philosophy just because drugs become cheap or free.

Further citations of the actual experiences with various narcotic clinics would be merely repetitious. The end results and the by-products are monotonously the same: no cures, increase in the number of drug addicts, increase in the daily intake for most addicts, an additional source of contraband for the illicit market, the apparent official condoning of the perpetuation of vice and disease, and the furnishing of cover-up facilities for a parallel distribution and use of drugs from illicit sources. There does not appear to have been a single area of advantage in the clinic system. Of course the great preponderance of the addicts were completely happy with the clinics except when someone took too seriously a project of reducing the daily narcotic intake. Even then the addict could be assured of at least a minimum dosage to supplement from clandestine sources.

This writer has had a long acquaintance with the history of these clinics as it appeared in the Bureau of Narcotics files and elsewhere. We have personally known a number of addicts who had patronized the clinics and we have associated for many years with narcotic officers and local police who worked on clinic problems. Consequently it was with the feeling that we were reliving history that we perused the article "Control and Treatment of Drug Addiction in Israel" (Jermulowicz & Turnau) appearing in the April-June 1962 issue of the United Nations Bulletin on Narcotics. It appears that in 1952 Israel was confronted with a situation which in a few respects was somewhat akin to that obtaining in 1919-1920 in the U.S.A. (although the number of Israeli addicts--about 70--was actually and proportionately very small). Many of these addicts had been introduced to drug use through illness, and some might be considered to have a legitimate need for opiates. Lacking hospital facilities, Israel decided to allocate to these addicts drugs at official (low) prices. This programme, in the opinion of the authors, did serve a vital function; but soon--and here is the reminiscent part-" It may be said that the method of official allocations served a vital function and achieved the goals we had set ourselves with respect to addicts who did not belong to the criminal underworld. In the course of time, however, when drug addicts belonging to this underworld started using this system to their advantage, the method proved to be a failure. In view of the large gap between the official price of drugs--especially ampoules -- and their price on the black market, which was twenty times the official rate, there is serious ground to suspect that the drugs allocated by us were sold by some of the drug addicts at a high price, for part of which they then bought unrefined opium or hashish.

"From 1953 onwards, a steady stream of drug addicts from the underworld started applying to us, pretend ing they were anxious to be cured while well knowing that we did not dispose of sufficient hospital space. Their sole purpose was to receive from us an allocation of drugs. Not only did they exaggerate their own demands, but they also sent us drug pedlars who simulated addiction so as to obtain drugs for purposes of trade and sale. These people used every means at their disposal to achieve their ends and obtain as large a quantity of drugs as possible. They did not hesitate to raise a scandal, to threaten the employees of the health office with knives, etc. It became a dangerous job to work at the health offices, to the extent that it was hardly possible to carry out the work properly and a constant police guard was required. The number of drug addicts registered at the various health offices constantly grew, soon reaching about two hundred in number. A further unfavourable effect of the official allocation of drugs was that people who had hitherto used only opium started going over to morphine injections, a more severe and acute form of addiction."

In preparing this paper, the writer has been in correpondence with Mr. Owen Lewis, who may be the last surviving government official who participated actively in the investigation of the narcotic clinics when they were operating. As an Internal Revenue officer, he was a member of a team which made a survey of the upstate New York and New England clinics. He has kindly supplied a comparison of the number of addicts registered at these clinics as contrasted with the Bureau of Narcotics count of known addicts for certain cities in 1961. Of course, these figures should not be considered as a direct comparison, since it is so amply demonstrated that the clinic had a tendency to attract addicts to the clinic city from other areas, but in our opinion this comparison does have some significance in indicating how the American addicts are now so highly concentrated in only a few cities

Addicts registered at clinics in 18 cities, 1920, and addicts enumerated by U.S. Bureau of Narcotics in those cities, 1961

 

Number of addicts

City
1960
1961
Port Jervis, N.Y
17 0
Middletown, N.Y
30 0
Albany, N.Y
120 40
Saratoga Springs, N.Y
30 0
Schenectady, N.Y
30 1
Syracuse, N.Y
92 6
Corning, N.Y
22 0
Elmira, N.Y
60 0
Binghamton, N.Y
32 1
Oneonta, N.Y
37 0
Watertown, N.Y
15 1
Rochester, N.Y
65 11
Hornell, N.Y
9 0
Utica, N.Y
18 1
Providence, R.I
101 7
Cleveland, Ohio
80 *
92
New Haven, Conn
91 11
Waterbury, Conn
35 2

Although only 80 addicts were registered at the clinic, in August 1920 the Cleveland Police Department estimated that there were between 5,000 and 6,000 addicts in that city. The Cleveland Clinic was established on 16 July 1918. .

Mr. Lewis, who perhaps has had more years of service in narcotic law enforcement than any other person in this country and who has had personal acquaintance with many hundreds of addicts, observes that in his career of more than 43 years, he knew of only one addict who seemed to maintain a stabilized dosage in his addiction.

Some writers, even Terry & Pellens ( supra), express uncertainty as to the real reason for closing the U.S.A. narcotic clinics at the time. To this author the reasons seem crystal clear and most persuasive. The Harrison Narcotic Act was drawn as a taxing measure so that the authority of the Federal Government could be invoked in what might normally be a state and local police field. It sought to regulate the legitimate opiate and cocaine traffic through tax channels and provided heavy tax penalties and criminal sanctions for any irregular traffic. (" The power to tax is the power to destroy.") Exempted from the scope of these provisions were narcotic drugs dispensed or prescribed by a practitioner "to a patient" and "in the course of his professional practice only". The only justification for dispensing drugs in a clinic was the assumption that this was legitimate medical practice. Apparently, much of the medical opinion at the time was to the contrary. Even some of the persons who had to do with the operation of some of the clinics also had doubts. But these were resolved in favour of a conception of proper professional practice. However; as early as March 1919 the U.S. Supreme Court (Webb & Goldbaum v. U.S. - 249 U.S. 96) in a case involving a physician and a pharmacist answered the question:

"If a practising 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 an order a physician's prescription under exception ( b) of section 2 of the Harrison Act?" as follows:

"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. The question should be answered in the negative."

In the Jim Fuey Moy case (1920) and in the Behrman case (1922) the Supreme Court emphasized this concept. Manifestly this left little ground for the legal existence of addiction perpetuating institutions and little discretion to the law enforcement authorities except to urge closing. In 1921 a reference committee submitted to the House of Delegates of the American Medical Association a recommendation 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 drugs placed in his hands for self-administration is an unsatisfactory treatment for addiction, begets deception, extends the abuse of habit-forming 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 so-called ambulatory methods of treatment of narcotic addiction, whether practised by the private physician or the so-called narcotic clinic dispensary." Eventually (1924) this view was formally approved by the American Medical Association.

Some of the modern advocates of another experiment with the narcotic clinics contend that the institution was not given a sufficiently long trial, that action in 'closing these was by premature exercise of governmental authority. In the official files of the narcotic office in the Internal Revenue Service (the predecessor of the U.S. Bureau of Narcotics) there appears strong evidence to the contrary. In permitting the clinics to operate in the face of expressions of disapproval from much of the medical profession and decrees of the Supreme Court in effect condemning the ambulatory approach the Internal Revenue officials were on the defensive. This they early recognized. But for a long period they sought by conference and persuasion rather than by seeking prosecutions to bring an end to a dubious operation in the state and local field - for which it had become increasingly apparent there was no warrant in medicine or law.

Recent Policy Statement on Medical Practice in Treatment of Opiate Addicts

Recently (19 June 1963) the Council on Mental Health of the American Medical Association and the Committee on Drug Addiction and Narcotics of the National Research Council, National Academy of Sciences, issued a statement on The Use of Narcotic Drugs in Medical Practice and the Medical Management of Narcotic Addicts in which this appears:

"Continued administration of drugs for the maintenance of addiction is not a bona fide attempt to cure, nor is it ethical treatment except in the few unusual circumstances which will be discussed later [Emphasis supplied in original.] Ambulatory maintenance can be considered as ethical medical practice only if consultation has been had and it is agreed by the physicians concerned that (a) withdrawal would be hazardous to life or ( b) continued drug administration is necessary for a chronic or terminal painful condition other than the drug addiction itself and for which no other mode of treatment is feasible."

The statement also includes this:

"Withdrawal on an ambulatory basis is generally medically unsound and not recommended on the basis of present knowledge. Only under exceptional circumstances* is it proper to attempt withdrawal on an ambulatory basis and then only by a physician with special skill and experience in the management of addicted patients."

The statement further observes:

"The opiate addiction problem can be described in terms of the interplay of three epidemiological factors:

" I. The Agent

"Heroin is the drug of choice of most addicts in the United States and accounts for the bulk of the problem.

" II. The Host

"At the present time young adult males of certain minority groups constitute the great preponderance of the cases. Many other groups of addicts can be distinguished.

" III. The Environment

"Drug addiction is at present chiefly a problem of certain large cities, particularly in their low socio-economic areas. It may, however, involve any part of the country or any socio-economic class."

A fatal fallacy of the clinic plan is that it preserves the agent in a problem having an epidemiological pattern.

Constructive Results of Present U.S.A. Enforcement Programme

Although much is still to be desired, restrictive narcotics controls have shown some remarkably good results when the full picture is seen. Following the enactment of federal and state controls and the development of international programme, opiate addiction in the U.S.A. declined steadily from 1920. (Cocaine abuse has practically disappeared except in occasional sporadic incidents). Opiate addiction dropped almost to the vanishing point during World War II, which is of course the obvious result of the almost complete disappearance of available opiates. There was a flareup of new addiction in the late 1940s, alarming in intensity but rather narrowly restricted to certain urban areas. This upsurge now seems to be reversing except in a very few places. Over all, the incidence of addiction at the present time is estimated to be about one in four thousand ot the population as compared with one in four hundred in 1920. Also of the greatest significance, the daily opiate has been greatly reduced, to the degree that, as we have said, only about one of twenty-five addicts, if abruptly deprived of drugs, will show withdrawal symptoms of any severity. This comes about principally from the scarcity, and fantastically high price, of the narcotic drugs in this country. This scarcity has brought about great dilution of the narcotic drugs on the illicit market, down to three to 10% with a profound impact on the U.S. type of addiction. Dr. Harris Isbell, Director of the Addiction Research Center, U.S. Public Health Service Hospital, Lexington, Kentucky, in a personal letter (27 June 1963) to the author gives an excellent summary of some of the consequences, based on present day knowledge and concepts of narcotic addiction:

"Included among the factors to be evaluated and the circumstances to be considered, are elements such as the extent of delinquency record, degree of motivation and nature of introduction to drug use."

"This has several effects: First of all, the potential addict or daily user can afford only a limited amount of the drug, even though he obtains the money for the drug by thievery. Secondly, the low dilution means that the addict never really gets a good bang and that he does not develop a great deal of dependence. He therefore is less driven to go out and get more and more. In other words, he would act more like the marihuana user- he really doesn't have to have the drug, so if he misses the connection he can wait until tomorrow. In addition, the fact that his connection is very frequently ' knocked off' means that he is periodically withdrawn for a day or more, and therefore keeps his habit kicked.

"Battling the dilution by increasing the number or the size of the shots is a losing game. The more shots you take the faster the veins are used up, the more abscesses one gets, and there is a greater chance of getting an intercurrent illness from a contaminated injection."

Testifying before a subcommittee of the Committee on Appropriations, U.S. House of Representatives, U.S. Commissioner Henry L. Giordano said on 6 March 1963:

"The President's Science and Technology Group appointed an ad hoc committee to prepare some information for the White House Conference (on narcotic drugs). When they were in New York ... the Committee found out that the medical authorities in New York in the past two years have not seen what they referred to as classical withdrawal symptoms. The addict who comes to their attention in New York is addicted in such a weak product that his withdrawal symptoms are the mildest they have ever seen. Lexington (Federal Narcotic Hospital) in the past three years has not had an addict who suffered the classical withdrawal symptoms."

So impotent is the diluted heroin mixture sold on our streets that when careless mixing or an inexperienced dealer accidentally releases a reasonably unadulterated mixture this can be hazardous to addicts. Within three months in 1963 there have been two separate instances where prominent professional athletes who had apparently been dabbling with heroin use died after taking potent doses.

The Weaknesses and Dangers of the Clinic Plan

Consequently any clinic plan, whether designed for the frank maintenance of addiction or continued in the hope that any great proportion of addicts would become abstinent when narcotics are available, would be a particularly cruel delusion at this time. One of the first results would be to re-establish real addiction, real tolerance and dependence in our users. Much time and attention is given by some writers to the concept of a small stabilized dose which seems to satisfy some unusual addicts. We are too likely to forget the stantard pattern, the inevitable build-up as shown in the classic demonstration of Abraham Wikler, M.D., in the Lexington Hospital, where in an experimental self-regulated addiction to morphine an addict in a little more than three months built his habit to approximately 20 grains of morphine daily. ( Opiate Addiction, Abraham Wikler, M.D.)

This of course is just a "laboratory" confirmation of something which any experienced narcotic law enforcement officer will have seen "on the street"; i.e., in the narcotic addict underworld. The opiate addict will quickly adapt his daily drug intake to the available supply. If drugs are plentiful and cheap, the build-up might be even more rapid than in Dr. Wikler's experiment.

As stated in League of Nations document O.C. 1614, 22 October 1935, Experience in U.S.A. with the Plan of selling Drugs to Addicts at Low Prices, "the theory on which they (clinics) were established took no account of the well demonstrated fact that association with addicts is one of the most fertile causes of the spread of addiction, nor did it envisage the profit which an addict could easily make by drawing more of the drug than he would need for this own use and selling the balance in the illicit traffic".

H. J. Anslinger, U.S. Commissioner of Narcotics (retired) and U.S. Representative on the United Nations Commission on Narcotic Drugs, has said: "This (clinic) plan would elevate a most despicable trade to the avowed status of an honourable business, nay to the practice of a time-honored profession."

In the United States, progress in the field of quickly and effectively dealing with the narcotic addict when he appears has been exasperatingly slow, although this has been the subject of almost continous discussion. There is hope that well conceived and realistic programmes in this area may soon be demonstrating their effectiveness. (Harney, United Nations Bulletin on Narcotics, vol. 14, No. 3, July-September 1962).

Whatever forms these programmes take, we have the sharp lessons of history-as well as the appeal of reason, I would think - that they should not be in the nature of a dispensing narcotic clinic.

Terry & Pellens ( supra, p. 540) quote the French physician Paul Sollier (about 1910) to the effect that the only way of curing an addict is not to give him another poison, but to remove the one he is taking. We know that that is not all there is to curing all addicts, but it is an indispensable step.