CHAPTER 10 THE PATTERN OF REFORM
Reform of present methods of handling addiction ought to take into consideration a number of objectives concerning which there should be relatively little controversy.. The controversy focuses on what are the best methods of reaching the objectives rather than on the objectives themselves. The goal of all drug control measures is, in a general way, the enhancement of the common or social good. When we say this, we should keep in mind that the drug addict is a member of society and that drug control measures ought to take his welfare into account.
Concerning the addiction problem as a whole, the following aims would probably be agreed upon as desirable by all parties in the current controversy:
1. Prevention of the spread of addiction and a resultant progressive reduction in the number of addicts.
2. Curing current addicts of their habits insofar as this can be achieved by present techniques or by new ones which may be devised.
3. Elimination of the exploitation of addicts for mercenary gain by smugglers or by anyone else.
4. Reduction to a minimum of the crime committed by drug users as a consequence of their habits.
5. Reducing to a minimum the availability of dangerous addicting drugs to all non addicts except when needed for medical purposes.
6. Fair and just treatment of addicts in accordance with established legal and ethical precepts taking into account the special peculiarities of their behavior and at the same time preserving their individual dignity and self-respect.
Other aims and principles of an effective program which are of a more controversial nature but which are implied by the above are the following:
7. Antinarcotic laws should be so written that addicts do not have to violate them solely because they are addicts.
8. Drug users are admittedly handicapped by their habits but they should nevertheless be encouraged to engage in productive labor even when they are using drugs.
9. Cures should not be imposed upon narcotics victims by force but should be voluntary.
10. Police officers should be prevented from exploiting drug addicts as stool pigeons solely because they- are addicts.
11. Heroin and morphine addicts should be handled according to the same principles and moral precepts applied to barbiturate and alcohol addicts because these three forms of addiction are basically similar.
THE PROGRAM IN GENERAL
The most effective program for achieving these ends in Western nations seems to be one which gives the drug user regulated access to the medical profession with the physician determining the mode of treatment in accordance with the circumstances of the particular case. Characteristically, this type of program almost invariably involves, wherever it is used, some sort of supervision and regulation of medical practice with regard to addicts by public health officials. Police measures enter the picture only infrequently when medical controls fail.
The British program has been described in detail because it is an outstanding example of this system which has been emulated by other nations. It is not suggested here that the United States ought to adopt the British or any other program, lock, stock, and barrel. What is suggested is that successful foreign programs, including the British, should be intensively studied and intelligently adapted to American needs and to special conditions existing in this country. Particular attention needs to be given to the manner in which a reform program is introduced into the United States because of the extraordinarily- large numbers of addicts in a relatively few large cities. Too precipitous change might well discredit a new program before it was given a real chance.
The final result or goal of the reform program which is implicit in this entire book is 2 situation in which most of the addicts in the United States would be in the hands of private physicians. The latter would be free to treat addicts in accordance with accepted medical standards without fear of prosecution. The Public Health Service might be the logical agency to exercise a supervisory and advisory control over practitioners with drug users under their care, but 2 matter of this sort is a detail that should be left to medical officials. The police and federal narcotics agents would be expected to inspect the records of drug stores, drug manufacturers, importers, and distributors as they do at present, and to apprehend persons engaging in the illicit traffic-including any addicts who might do so.
It is absolutely essential, if addiction is to be treated as a medical rather than as a police problem, that doctors be permitted to prescribe regular supplies of drugs to addicts when this is, in their judgment, indicated. If this is not permitted, addicts will continue to be exploited by the underworld as they now are. It should be realistically assumed that even under relatively favorable circumstances no large percentage of drug users will be permanently and immediately cured. Nevertheless, the regular administration of drugs to users should always continue to be regarded as a temporary expedient designed to protect the addict's reputation and to keep him out of underworld hands pending withdrawal and cure. It is assumed that physicians would keep the addict's daily dosage at a minimal level and minimize, as far as possible, the evil physical effects of addiction while they attempted to persuade him to undergo institutional withdrawal and to try to break his habit. Institutional facilities for withdrawal should obviously be provided in hospitals, not in jails, and medical authorities should, when necessary, be authorized to employ restraint upon the addict during withdrawal and for a brief period of time thereafter.' Many addicts currently ask to be committed to jail in order to break their habits. If humane and intelligently worked out plans and facilities, such as those at Lexington, were generally available, addicts would quickly learn of them and would present themselves for voluntary, cures much more frequently than now. Despite assertions to the contrary, there are very few addicts who do not desire to be freed of their habits. This is true also in countries where addiction is not a criminal matter.
It needs to be emphasized that the reforms suggested here do not include the establishment of narcotics clinics, like those of the 19zo's, where drugs are doled out or administered to addicts. The clinic plan has serious disadvantages as a general program, and there is no country in the world today which has such a program. On the other hand, the system of placing the narcotic addict in the hands of the private medical practitioner has been extensively used for many years in many countries throughout the world with uniformly satisfactory results.
It is much more practical to get at the addict through the doctor than it is to try to handle him at centrally located clinics. The clinic idea involves the danger of perpetuating the evils of congregate treatment by, bringing addicts together rather than keeping them separate. There are more doctors than addicts in the United States. Hence, theoretically if each doctor in-the country were to agree to accept one addict as a patient this would more than take care of all addicts. Such a program would be difficult to organize, but if anything could be done to encourage drug users now concentrated in large cities to move to smaller communities or rural areas, this would be a distinct gain which would make it easier to administer the program and also make it easier for addicts to refrain from relapse after being taken off drugs. An effect of this nature might be achieved by at first limiting the number of addicts who could be handled by any one physician in the larger cities where users are now most numerous.
TRANSFER OF AUTHORITY TO THE MEDICAL PROFESSION
If addiction is a medical problem and the addict is to be handled medically, it is necessary that the authority to determine what specific program will be applied to the user be placed in medical hands. This means that power now being exercised by legislators, lawyers, judges, prosecutors, and policemen must be transferred to the medical profession. This transfer of power will be resisted by some of those who will have to surrender it, but the issue is clear. It is absurd to call addiction a medical matter and then permit policemen, prosecutors, and legislators to specify how it shall be treated.2
The legal basis for putting doctors in charge of handling addiction already exists in the decisions of the Supreme Court. The basis in popular opinion also exists, for most Americans today are quite ready to accept the idea that drug addiction, like alcohol addiction, and perhaps like cigarette addiction, ought not be dealt with as a police matter. What is needed is an appropriate plan of action by administrative officials. The first point of attack should probably be the regulations of the Treasury Department which threaten the physician with criminal prosecution for prescribing drugs for users except under the two conditions: (a) terminal disease such as cancer, and (b) an aged and infirm user-who might die if the drug were withdrawn. The New York Academy of Medicine has already assailed these regulations and has forcibly pointed out how they have for many years put physicians in a straitjacket with regard to narcotic addiction.3
The first step in reform might therefore well be a conference sponsored by the A.M.A. perhaps with the New York Academy of Medicine at the invitation of the Secretary of the Treasury and the Attorney General, with a mandate to revise the existing regulations so as to bring them into conformity with the Supreme Court's doctrine that addiction is a proper subject of medical care. Delegates to such a conference should be predominantly medical practitioners with direct clinical experience with addicts, especially in private practice. There are, and have always been, sharp differences of opinion among medical practitioners concerning the proper treatment of addiction. A statement of standards formulated after a free and open discussion would presumably make allowances for such divergent views. Minority opinions held by substantial numbers within the profession should not be ruled out of court by majority vote. The limits of legitimate treatment for addiction should be determined, in short, in about the same way as they are for venereal disease or for tuberculosis.
A revision by medical men of Treasury Department regulations would certainly either remove entirely or greatly reduce the threat of criminal prosecution to conscientious physicians who undertook to care for addicts. This fact might make it feasible for the medical conference to accept another mandate, namely, that of surveying and bringing into the full light of public examination the facts concerning addicts who are now being handled as medical cases and shielded from the police and punitive action. Little is presently known of these users except that many are thought to be physicians and nurses and that Most are members of the upper social classes. Such a survey would facilitate more realistic planning and would serve to enlighten many members of the medical profession concerning the narcotics problem and existing medical techniques being applied to it.
Removal of the threat of prosecution would in all likelihood lead automatically to a gradual increase in the number of addicts under the care of physicians as the latter came to realize that medical judgment, rather than the police or the criminal law, had become the controlling factor. Such gradual expansion of a medical program would be highly desirable because of the large numbers of addicts in this country and because it would permit members of the medical profession to become acquainted with the problem over a period of time rather than having it thrust upon them abruptly. A sudden transition might well lead to chaos and confusion in the large narcotics centers.
The President's Advisory Commission recommended. in its report that "the definition of legitimate medical use of narcotic drugs and legitimate medical treatment of a narcotic addict are primarily to be determined by the medical profession."' The Commission completely ignored the 1963 report of the New York Academy of Medicine dealing directly with this matter. Instead, it asked the American Medical Association and the National Research Council of the National Academy of Sciences to make a statement on the issue. The result was a masterpiece of diplomacy and noncommittal doubletalk, and was published as part of the report of the Presidential Commission., It stipulated that it is the duty of doctors to
obey all laws, rules and regulations at federal, state, and local levels, and simply reiterated the current regulations of the Treasury Department as the definition of proper medical treatment of addicts, without indicating that the definition was drawn from Treasury Department regulations.
The Commission evidently assumed that the A.M.A.-N.R.C. report automatically made the view of the New York Academy unacceptable-and illegitimate. But proper medical treatment of diseased persons is not something which is settled by majority vote of A.M.A. officials. That body cannot and does not dictate to physicians how they are to treat diseases. Such questions, like scientific questions, are never settled by majority vote. If they were, and departures from sanctioned practice were prosecuted in the criminal courts as they are in this instance, there could be little progress. The President's Commission, despite its gesture to the medical profession, clearly did not accept the idea of full medical control as advocated by the New York Academy of Medicine. That was no doubt why it made no reference whatever to that organization's position, and why it summarily brushed aside any serious consideration of European programs.
The President's Commission, instead of proposing any plan which would have given physicians the authority they must have if addiction is not to be handled punitively, recommended a program of civil commitment, not as a substitute for imprisonment, but as an alternative to it in selected instances. The Attorney General and the Judiciary, it suggests, should make the "crucial determinations" at the federal level and the Bureau of Prisons, the Public Health Service, and the probation and parole services should manage the actual program.6 This program explicitly avoids giving any important authority to medical persons. It also leaves the addict's status under the criminal law unchanged, does nothing to remove the threat of prosecution for doctors, and leaves the hapless user in the hands of the illicit traffic. The Commission, in short, did not suggest any transfer of power to medicine, but envisaged the establishment of a rehabilitative medical program for drug addicts within the confines of prisons. Anyone acquainted with prisons knows that they are chronically understaffed, underfinanced, overcrowded, and generally ill equipped to undertake constructive programs of this sort even for inmates who are much less difficult and troublesome than narcotic addicts. Diseased persons are not ordinarily treated for their ailments in jails and penitentiaries.
MONITORING THE PROGRAM
As has been indicated, there are presently privileged addicts to whom the usual penalties and rules are not applied, who are given access to legal drugs and handled medically. Revision of the Treasury Department regulations, it has been suggested, would probably increase the number of addicts under medical care by encouraging doctors to treat users of humbler social status. As the number of users under such medical care increased it would probably be regarded as desirable that the program be monitored by an agency which would continuously collect statistical and other types of data concerning the operation of the plan, perform advisory and inspection services, and continuously evaluate the program. In European countries these functions are generally handled by the public health authorities and there seems to be no reason why the same procedure should not be followed here. In Britain the Ministry of Health uses medically trained inspectors for the job of consulting with and advising, doctors in cases where the use of narcotics is.. an issue.
The proposal advanced here assumes medical control of the program, with changes made in accordance with medical judgment on the basis of experience with the plan. It is therefore, in a sense, presumptuous or pointless to suggest in advance a detailed mode of operation or a specific plan for every contingency. Nevertheless, one may speculate that it might be deemed desirable to establish rules for the guidance of physicians in accepting addicts for medical treatment. The experience of Lady Frankau, as she reports it, suggests, for example, that addicts might be accepted only if they indicated willingness to take and hold 2 regular job and to maintain a stable residence, and if they gave some indication of a desire to rid themselves of their habits. An advantage of such rules might be to motivate addicts to meet these conditions, and also, conceivably, to prevent the medical practitioners in large cities with many addicts from being overwhelmed by them.
Another conception is suggested by the 196 3 Report of the Neu, York Academy of Medicine which points out that there is a variety of medical situations for which the current Treasury Department regulations are inadequate and unduly restrictive.' The expansion of medical services to addicts might therefore begin with a gradual relaxation of these regulations, with the following types of addicts being admitted to the program in some sort of sequence:
1 . Addicts with non-fatal diseases and chronic illnesses should be among the first to be included.
2. Aged addicts who have been addicted for many years and taken many cures, and for whom cure seems cruel, pointless, and hopeless.
3. Persons who have become addicted in the course of medical treatment. The addicted patient should continue to be a medical responsibility.
4. Addicts who come from good families and cultural backgrounds, have no criminal records, and have regular jobs and stable places of residence.
5. Persons who acquired their addiction in the military service.
6. Any housewife who is a user. This would be for the purpose of making it unnecessary for her to be a prostitute or to help her escape from prostitution.
Ultimately if this scheme were carried out there would remain a residual group of addicts which would probably consist of the
hopelessly degraded and demoralized criminal addicts unwilling to give up their illicit way of life, users not interested in quitting, and other hard-core types. For these, civil or criminal commitment would be appropriate and would serve the function of exerting pressure upon them to qualify for the medical program. There would be a residual illicit traffic catering to this remaining group of derelict and recalcitrant types which would be an appropriate object of police attention.
SOME ANTICIPATED EFFECTS
What the effects might be of a program such as that described in this chapter may be indirectly indicated by citing some of the conversations recorded in congressional hearings at which the advisability of subjecting barbiturates and amphetamines to penal controls was considered and rejected. In 195 1, for example, Mr. Anslinger commented as follows on the idea that his Bureau handle barbiturates in the same way as heroin:
"It would be worse than prohibition. It would rake us years finally to get that under control, and we do not have enough men right now.... It would take $5,000,000 and take five times as many men as we have, and then you would have conditions similar to prohibition. I think it would become a very unpopular bureau in this country.... Certainly it is not a peddling traffic like morphine, heroin and cocaine. It is in the hands of the doctors and druggists. I do not think we ought to take it out of their hands and put it in the hands of the underworld, and certainly it is not in the hands of the underworld today. . . ."
Mr.-Simpson: "I would like to get clear on one thing. You would not want morphine and opium, and so forth, in the control of druggists and physicians? That would not suit your purposes, Would it?"
Anslinger: "No, Sir."
Simpson: "Then why would barbiturates be safe in their hands? Are they not as dangerous in their hands? That is what I cannot get."8
In 1955, again before the Boggs subcommittee, the following exchanges took place:
Mr. Anslinger: "When you are after 2 peddler he will not sell you barbiturates or amphetamines.''
Mr. Boggs: "But there is no reason for him to."
Mr. Anslinger: "That is true."
if the theory that you can become addicted to barbiturates is true then it seems to me that in that field they are doing just what some of these doctors in New York [the New York Academy of Medicine] have advocated they do in the field of other narcotics, which is a proposal which does not appeal to you at all ......
Mr. Karsten: "Do you have a history, Mr. Commissioner, of barbiturate users graduating, then, later on to narcotics? Do they follow a pattern like that?"
Mr. Anslinger: "We have not seen that pattern, Congressman; that is something which you would think would follow, but they do not go in that direction. The marihuana user is usually the one."9 '
We see in these conversations a perfectly explicit awareness of the conditions that are needed to produce an illicit traffic and of the inconsistency of public policy concerning various types of drugs. Mr. Anslinger's reply to the suggestion that he was not consistent was that the punitive program was necessary with respect to opiates because they are more dangerous and destructive than barbiturates. However, Public Health Service experts had been showing the congressmen films on barbiturate withdrawal and gave them evidence which pointed to exactly the opposite conclusion. We have previously noted that in 1937, before the federal antimarihuana bill was passed, Mr. Anslinger also said that marihuana users did not go on to heroin.10 Perhaps if barbiturates were prohibited in the same manner that heroin now is its users would also graduate to the latter drug.
The former head of the Federal Bureau of Narcotics has provided other illuminating material concerning the advantages of a program of medical, rather than punitive, treatment for drug users. For example, speaking of the treatment of addicts, he had this to say:
There is no single set way to deal with those trapped in the tentacles. I personally have dealt with many of the individual cases. Each has been different. I am not, for instance, a believer in what doctors call "ambulatory treatment"-giving a patient withdrawal treatment in his office, with no check on what the patient may do, or how much he may use the addict, employed this method.
The addict in one case was a Washington society woman. I had known her personally for some years. She was a beautiful, and gracious lady. She had become so badly addicted to demerol that no doctor would prescribe for her; her demand was too great. Word of her case came to me through some of her friends. Was there any way I could help? The woman, I learned, was ready to kill herself. She would not deal with pushers nor would she take a cure or go voluntarily to a hospital herself. Moreover, if I made a case against her, it would destroy her completely-along with the unblemished reputation of one of the nation's most honored families. I agreed to help her, through a trusted physician to whom she appealed for drugs. She was not to know my role. I also learned that she was so afraid that pharmacists would try to cut the strength of her demerol, with sugar of milk or some other non-narcotic substance, that she insisted on receiving only unopened, sealed bottles of demerol from the druggist. That complicated the business but I called in a pharmaceutical manufacturer who agreed to work with us. Each bottle of demerol, specially packaged and sealed, delivered in routine fashion from the drug store, on the prescription of the physician, contained less actual demerol than the previous bottle. Within three months, without the woman realizing, she went from a large daily "ration" of demerol to none at all. What she was getting, in the bottles, was not demerol but sugar of milk." The woman was subsequently informed that she was cured of her addiction and "broke into tears of joy."
Another similar instance involved an addict who was described as one of the most influential members of the Congress of the United States. This man was completely "'intractable," refusing to consider medical treatment and defiant of anything that might be done to him by the police. In this case Mr. Anslinger offered the congressman the proposition that if he would agree not to go to underworld pushers his supply of morphine would be underwritten by the Bureau. It was stipulated that the man was to obtain his supplies from an "obscure druggist" on the outskirts of Washington. The lawmaker naturally accepted the offer and went on using legal morphine till he died with only Mr. Anslinger, the druggist, and the addict himself knowing what was going on.12
From the analysis of these two instances we can see that Anslinger had the following desirable effects in mind: (I) protection of the reputation of the addict and his family; (2) making it possible for the addict to escape exploitation by underworld drug peddlers; (3) breaking the habit in an effective and humane manner; (4) preventing suicide on the part of the user; (5) permitting the user to continue in a legitimate occupation and to be self-supporting; and (6) making it unnecessary for users to congregate with other users.
For the medical profession Mr. Anslinger has formulated rules which prevent the physician from handling addicts in this manner:
"Ambulatory treatment of drug addicts should not be tried. Institutional treatment is always required."
"An addict should never be given drugs for self-administration."13
The questions raised by Mr. Anslinger's cases include the following: How many American addicts offered the same deal as that proposed to the congressman would accept and abide by it? How many users could be successfully taken off drugs by physicians using Mr. Anslinger's method, and others that medical men might devise? What percentage of American addicts might engage in productive labor, like the congressman, if they were handled in an equivalent manner' On what principles sh ould addicts of lesser status, who are not personally acquainted with prominent officials in Washington, be excluded from the opportunities offered these two?
In chapter 6 we have referred to a report from London on the fate, in that city, of forty Canadian drug users who sought refuge there from Canada's punitive program. 14 From this report one may infer: (I) that there is 2 probability that a significant percentage of addicts under medical care might work for a living even if they failed to break their habits; (2) that many persons who are addicts first and criminals secondarily would welcome the chance to be law abiding; (3) that an intelligently handled, voluntary program of medical treatment and withdrawal would attract the cooperation of a significant percentage of addicts; and finally (4) that even many addicts who are "criminal" in the genuine sense of the word are not entirely beyond redemption.
EFFECTS ON THE SPREAD OF THE HABIT
In earlier chapters it has been suggested that the spread of the drug habit in modern times has been closely linked with the prohibition system of control and its invariable accompaniment, the illicit traffic. The illicit traffic makes drugs available, but it does more than that. The very facts of illegality and expensiveness give drugs a symbolic significance and attractiveness to some segments of the population which they would not otherwise have. Taking drugs has become for some persons a group way of life, a means of protest, and a way of revolt against accepted values. Nowhere in the Western world are there as many young addicts as there are in the United States, and it is in this country that the so-called "addict subculture" and the drug-using juvenile gang have become especially prominent.
From a study of youthful Negro narcotics users in Chicago, Harold Finestone has provided an excellent analysis of the motivations of a relatively new type of drug user.15 The title of the article, "Cats, Kicks, and Color," suggests its themes. The Negro "cat," says Finestone, substitutes "hustle" for legitimate work, which he aristocratically disdains; the main purpose of his life is to experience the "kick" from performing acts tabooed by "squares" and beyond their comprehension. The use of drugs, from the standpoint of the cat's revolt against middle-class morality, is the supreme, the ultimate kick. It gives excitement to the cat's life and, in his own eyes at least, sets him off in an elite conspiratorial group:
It is this limited, esoteric character of heroin use which gives to the car the feeling of belonging to an elite. It is the restricted extent of the distribution of drug use, the scheming and intrigue associated with underground "connections" through which drugs are obtained, the secret lore of the appreciation of the drug's effects, which give the cat the exhilaration of participating in a conspiracy."
Finestone notes that the young Negro user of narcotics manifests a certain zest in his mode of life, particularly during the initial or honeymoon period. This zest is especially associated with the cat's adventurous and dangerous life on the city streets, with his contest against the whole world to maintain his supply of drugs, and with the game of hide-and-seek that he plays with the police. It is part of this adventurer's way of life to "play it cool" in crises such as those which are represented by withdrawal distress, jails, prisons, and the police.
It is this fact-that drug use in the United States has become a group way of life, a form of protest or revolt against the dominant conventional values of the society-that has contributed heavily to the epidemic character of the postwar drug problem. The meaning of drugs for the adolescent Negro cat is not unlike its significance for "beats" or for many jazz musicians.
Of special importance is the apparent fact that while there are adolescent groups in foreign countries which resemble the American "beats" and "cats," such as the "Teddy Boys'' of Britain and the "Bodgies" or "Wedgies" of Australia, the use of heroin seems not to have been taken up by these foreign groups. The reasons for this, one may speculate, are probably connected with the manner in which heroin addiction is handled in these countries. When it is dealt with as a medical problem, the use of heroin evidently does not serve as a symbol of protest or revolt nor does it become a group way of life. Addicts under the care of physicians have no special reasons or need for association with each other or with the underworld. While the direct effects of drugs obtained from physicians are the same as those from illicit supplies, the fact of being under the physician's care no doubt leads the drug user to think of himself more as a sick or diseased person than as a member of an underground conspiratorial group. At any rate, there does not appear to be a single instance of a country in which opiate addiction is handled medically where the use of opiates has acquired the status of a fad or become an epidemic as it has in the United States. This leads to the supposition that 2 medical attack on addiction in this country would undercut the cat's way of life, as Finestone and others have described it, both by isolating addicts from each other and by changing the significance of drug use.
Dissident, deviant, or antisocial subcultures or groups in foreign countries sometimes emphasize the use of drugs other than the opiates. Marihuana, for example, is used in London by West Indian groups and in certain clubs, as well as by some jazz musicians. However, no appreciable tendency has been noted in Britain to substitute heroin for marihuana. A similar situation exists in Jamaica and other parts of the Caribbean area where marihuana use is very widespread and heroin addiction rare. In Jamaica, in particular, marihuana cultivation and use, both of which are prohibited and heavily punished, have become an important part of a back-to-Africa protest movement promoted by an organization known as the Ras Tafari. It appears that only illegal drugs tend to acquire this kind of symbolic significance. Thus, while there is some morphine addiction in Jamaica, it seems to be completely unconnected with the Ras Tafari and marihuana and is regarded only as a minor medical problem."
The use of addicting drugs by young persons is a matter of especially serious concern. The evidence seems to indicate quite clearly that the situation most favorable for the spread of drug use among young persons is one in which addiction is dealt with as a criminal matter and one which includes a flourishing illicit traffic. It is in this situation that drugs become glamorous and attractive to youth, and these are also the conditions which seem to favor the creation of subcultures of drug users which, by recruitment of new members, tend to become self-perpetuating.
A common argument advanced against a program of the type under discussion is that, with the legal penalties removed, there would be fewer obstacles to becoming addicted and that those already addicted would have a free hand and an open invitation to spread the habit to others. What is overlooked in this argument is that everywhere in the world, availability of drugs for addicts through medical prescription is necessarily linked with nonavailability of drugs for other persons because of the relative absence of a black market. It is true, of course, that the habit tends to spread from users to nonusers but this probably occurs to a lesser extent in countries with medical programs because these programs keep addicts relatively separated from each other, thus giving them a chance to keep their habits secret. The profits of the illicit trade also probably play a part in promoting the spread of addiction.
LONGTERM ADVANTAGES OF A MEDICAL PROGRAM
From the discussions in other portions of this book and especially from the description of narcotics control programs in other parts of the world in chapters 6 and 7, most of the effects envisaged as long-run consequences of a medical program for addicts are fairly obvious. Some of the less obvious ones should perhaps be specifically stated.
One of the great difficulties in the United States today, as we have seen, relates to the lack of reliable information about our addicts. A medical program automatically generates more reliable statistical data than does a police program. In most European countries figures available from druggists and doctors tell most of the story of addiction, and police data contribute only a minor supplement.
Dealing with addicts by congregate methods in large and expensive public institutions has many obvious evil effects upon the inmates and tends to impede reform and rehabilitation. In addition such a program requires large outlays of public funds and creates a special bureaucracy of narcotics officials. The medical program envisaged here makes use of existing institutions and medical personel, avoids the evils of congregate treatment, does not necessitate the creation of a special narcotics bureaucracy, and costs little in the way of public funds. Under such a program some addicts, certainly many more than now, would be able to work and pay their own way; others might conceivably be covered by insurance for the costs of medical treatment of addiction; others could be subsidized by relatives and friends.
A medical program would reduce the crime problem in a variety of ways, the most obvious being that the user would not have to steal to pay fantastic illicit prices. This fact would in turn react upon the illicit traffic by reducing demand, prices, and profits. The argument that making drugs available to addicts stimulates the illicit traffic and that the clinics in this country around 1920 had this effect is patently false, as we have shown (chapter 5). As Lady Frankau's report from London suggests, a medical program can sometimes motivate the addicted criminal to abandon crime, and in general it makes it possible for an addict to abandon crime even though he may not abandon his habit. Another effect of a similar nature is that the non criminal who becomes addicted is not forced into crime. For example, if a nurse in a hospital is discovered to be an addict and is arrested and jailed for stealing narcotic supplies from the hospital. the most probable consequence is that she will become a prostitute and an associate of pimps, addicts, thieves, and drug peddlers if she does not commit suicide. Under a non punitive program she might be taken off drugs and put on duty in a situation where drugs were not accessible to her.
One of the most interesting therapeutic implications is in the effects upon the general availability of drugs and the repercussion this might have upon the chances of helping users to remain free after breaking their habits. We have already seen that Lady Frankau urged Canadian addicts in London not to seek out other users. Dr. O'Donnell, in a study made in Kentucky of former patients at the Public Health Service Hospital at Lexington, observed that many of those who were abstaining from drugs had moved away from the sources of illicit drugs into communities where there was no illicit market or where they did not "know the ropes." O'Donnell concludes that "This factor of unavailability may go far in explaining the high rate of abstinence in this group [relatively rural], in contrast to previous follow-up studies which were conducted in, or included, large metropolitan areas where the illegal narcotics market has never been completely abolished."18
It was long ago that a prominent police administrator, August Vollmer, said:
Drug addiction, like prostitution and like liquor, is not a police problem; it never has been and never can be solved by policemen. It is first and last a medical problem, and if there is a solution it will be discovered not by policemen, but by scientific and competently trained medical experts whose sole objective will be the reduction and possible eradication of this devastating appetite. There should be intelligent treatment of incurables in outpatient clinics, hospitalization of those not too far gone to respond to therapeutic measures, and application of the prophylactic principles which medicine applies to all scourges of mankind.19
Giving medical men in general the right to handle addicts would contribute to the end envisaged by Vollmer, making this particular scourge a subject of -inquiry and experimentation for many other, than a small number of medical men in the Public Health Service. The United States might, in this way, convert into a positive advantage the fact that she now has more heroin addicts than all of the nations of Europe combined.
It may be contended that one of the most important long-range effects and advantages of the medical treatment of addicts is that it is the decent, just, and humanitarian thing to do. Apart from the abstract ethical arguments suggested by this thought, there is the fact that people tend to support programs which they regard as just and fair and to admire their courts and the machinery of justice when they operate to produce real justice and when they seem to promote the basic human values of our society. Official cruelty and disregard for human values tend to lead to the opposite result. It has been argued, in support of severe penalties and the use of compulsion, that such devices have worked well with doctors who are addicts. When faced with the alternatives of staying off drugs or being deprived of their licenses to practice medicine, about ninety per cent are said to have remained free of drugs for five or more years. The others almost invariably committed suicide. Does this represent the kind of ethical values and attitudes toward human life which we wish our citizens to have? Is this suicide rate a fair price to pay for the result claimed?
Another consequence of handling the narcotic addict within the orbit of the doctor-patient relationship is the gain in privacy. Like the details of many other problems that people take to their family physicians, the details of addiction to narcotics are not pleasant. Under existing arrangements the circumstances of addiction are exploited by the tabloids and the addict never knows when the details of his habit and his personal life may appear on the front 'Pages of his community newspaper. With addiction a private matter between the doctor and his patient, the yellow journals would be deprived of raw material and the user would have a chance to keep knowledge of his addiction from becoming public.
CIVIL COMMITMENT OF ADDICTS
The idea of civil commitment of drug addicts is actually quite an old one, for many of the states have long had statutes on their books authorizing such commitment.20 These laws have been largely unused. One of the difficulties has been that when civil commitment proceedings are undertaken and the user discovers this fact, he can flee the community unless he is forcibly detained. Forcible detention, however, requires that he be charged with an offense, and this means criminal rather than civil procedure.
The new program which has become popular during the last few years avoids the difficulty noted with respect to the older and now defunct program by using the leverage of a criminal charge to keep the addict in custody before commitment. In the New York program under the Metcalf-Volker Act of 1962 the criminal charge is held over the addict's head to encourage him to cooperate in the civil commitment proceedings and the attempted rehabilitation under the direction of the Department of Mental Hygiene. If the addict proves unworthy and the rehabilitation program fails, he can then be brought back to criminal court and tried on the criminal charge. Under the California program adopted in 1961 and amended in 1963, the addict is first tried and convicted, and the civil commitment proceedings are then substituted. When the program fails, the user may then be returned to the criminal court for sentencing. The President's Advisory Commission recommended California procedure over that of New York in this respect, because of the difficulty under the New York plan of trying 2 case after the lapse of so much time.21
Civil commitment as currently conceived and recommended by the President's Ad Hoc Committee, as described at the White House Conference, and as recommended by the President's Advisory Commission on Narcotic and Drug Abuse in 1963, originates from police sources. The logic is - follows: addiction is a dangerous communicable disease; the addict should be "quarantined" to check the spread of the disease; if the addict relapses repeatedly after being taken off drugs he should be quarantined for long periods or for life. The Federal Bureau of Narcotics has long promoted this view and it is this fact which is the main basis for its claim that it favors a medical approach to addiction. In the Bureau's pamphlet on narcotic clinics, it has included in later editions a statement by a retired Canadian policeman who recommends that addicts who are certified as such by three doctors be committed to federally operated narcotics hospitals for a period of not less than ten years. If a user were twice committed it was suggested that he be sent to an institution for life, and that he be provided with a useful avocation "but permanently within the confines of the institution."22
The civil commitment program now being urged upon the states and recommended at the federal level does not in fact involve medical control or a real medical program, although it does use some of the vocabulary of the healing professions. The President's Advisory Commission, describing its federal scheme, specifies that "The crucial decisions would be made by the Judiciary and the Attorney General."23 In California, addicts who are civilly committed are sent to establishments which are operated by the Department of Corrections and which differ from prisons mainly in name. There is no real qualitative difference between the "rehabilitative" program imposed upon addicts and that imposed upon those who are being punished for the commission of crimes. From the addict's viewpoint, he is being punished because he is forcibly deprived of his liberty and suffers the social stigma of the criminal. On the assumption that addiction is a proper subject of medical care the civil commitment program would have to be characterized 'as a sham, or as a travesty of a real medical plan.
The worst features of the current civil commitment fad may well be connected with its pretense of being something other than
punitive. Its current popularity is probably largely due to the fact that it seems to offer advantages to both the police and the medical philosophy of addiction. To the former it offers the continuation of the old practices of locking addicts up and of dodging the constitutional guarantees of the Bill of Rights which are built into the procedures of the criminal law. To the liberals and medically oriented it offers a gesture toward a new and more humanitarian approach and a hew vocabulary for old practices. For the addict the situation remains substantially unchanged even if he can qualify as one of the select few eligible for civil commitment, except that he may expect to spend more time in institutions. The price of illicit drugs and the illicit traffic are untouched by this program, and the addict must still commit crimes to maintain himself. He still lives in fear of the police and is still exploited by peddlers. If he seeks to quit his habit voluntarily the only establishments to which he has easy access are jails and their equivalents.
The threat of tyranny and injustice inherent in the rationale of compulsory civil commitment for drug addicts may be illustrated in a variety of ways. Suppose, for example, that we apply the same logic to alcoholics or to those with venereal disease, making them all subject to being locked up. California law applies compulsory civil commitment not only to actual heroin addicts. but also to those who "by reason of repeated use of narcotics or other restricted dangerous drugs are in imminent danger of becoming addicts." Compulsory commitment processes are appropriately applied only, when the person to be committed is shown to be dangerous or helpless and satisfactory evidence on this is presented in a court of law. Justice requires that each case be handled on an individual basis. The civil commitment program bypasses the whole concept of due process of law while pretending not to, by prejudging addicts as a group. This is accomplished by leaving unchanged present laws which automatically make virtually 211 addicts law violators It is not necessary to demonstrate, for example, that an individual user is a social threat of any kind, nor would it be a defense if an addict could prove in court to the satisfaction of a jury that he was neither helpless nor a menace. Suppose that a druggist who is an addict is discovered because he falsifies his book; to conceal the fact that he is diverting drugs to his own use. Civil commitment proceedings against this man would destroy his reputation and his usefulness to society just as effectively as criminal commitment. The civil commitment of addicts is another instance in which "treatment" may well turn out to be more punitive than "punishment."
The civil commitment program is customarily linked with a program of close parole supervision after release, sometimes associated with a nalline testing program. Nalline is a drug which indicates from the effects it produces whether the individual has recently had doses of opiates. Parolees who are required to take these tests are said to relapse less often and quickly than otherwise. With a cooperative addict there seems to be little doubt that nalline could be advantageously used for therapeutic ends. It is presently being used primarily for punitive ends, and sometimes it is part of local programs designed to chase addicts into other communities. Capt. T. T. Brown of the Oakland, California, Police Department, who is one of the staunchest champions of the nalline program, frankly says that "the rest is a boon to the community utilizing it and a bane to neighboring metropolitan centers for many addicts flee the area using nalline .... "24
The following remarks by C. S. Lewis seem peculiarly appropriate to the civil commitment scheme:
But do not let us be deceived by a name. To be taken without consent from my home and friends; to lose in liberty; to undergo all those assaults upon my personality which modem psychotherapy knows how to deliver; to be remade after some pattern of normality" hatched in a Viennese laboratory to which I never professed allegiance; to know that this process will never end until either my captors have succeeded or I have grown wise enough to cheat them with apparent success
Who cares whether this is called Punishment or not? That it includes most of the elements for which punishment is feared--shame, exile, bondage, and years eaten by the locust-is obvious.25
Those who hope for basic reform are sometimes inclined to regard the civil commitment bandwagon as the opening wedge of a movement toward more important changes. This view may be right. It may, on the other hand, have the opposite effect because it is often viewed as 2 non punitive, quasi-medical program. If it fails or accomplishes little, ideas like that of locking addicts up in concentration camps may gain ground.
A compulsory civil commitment program of the type now in force in New York and California, if it is linked with a long period of close parole supervision and possibly with a nalline testing program, is an expensive one. During periods of public excitement generated by the mass media there is likely to be greater willingness to spend public funds than during periods of quiescence. That is why it is very likely that some of the more elaborate programs now in use will be abandoned in the future and that others will degenerate, changing from high-minded, rehabilitative, well-staffed programs to routine, poorly staffed, custodial ones.26 Penologists are thoroughly accustomed to this degenerative process. No matter what arguments are presented from the humanitarian viewpoint concerning the ultimate social advantages of curing addicts of their habits, the fiscal facts are that addicts are relatively difficult and unresponsive and that money spent on them could be spent with greater justification, in terms of results, on others. As long as public funds are limited, this view will be an important one. A proliferation of programs for drug addicts also occurred after the First World War and almost all of them have vanished without a trace.
LIMITED TREATMENT PROGRAMS
In recent years there has been a considerable proliferation of various types of experimental treatment programs for addicts. Some
of these are aimed at testing the feasibility of new ideas, as, for example, the selection of addicts to be placed on maintenance doses
to determine whether they would be able to work. Others ate aimed to reach addicts in prison to motivate them to stay off drugs or to help them when they are released by providing psychiatric and counseling services or helping to secure employment. There has been a considerable expansion of halfway houses which seek to ease the path of the addict as he tries to get used to living outside of prison. Others, handled by medical men or psychiatrists, have included management of the physical withdrawal of drugs followed by aftercare and the attempt to get at the emotional problems which are thought to underlie addiction.27
Despite the apparent abundance of these programs, they collectively reach only a small number of addicts and many of them are of a temporary nature, destined to vanish when the funds run out, when the initial enthusiasm disappears, or when the individual who is the center of inspiration for the program dies, moves away, or changes his interests. Most of these programs find themselves faced with heavy odds created by the present policy which inspires strong sentiments of fear, resentment, suspicion, and hopelessness in the users. Sometimes police interest in the users embarrasses these programs, and sometimes, if the program is managed by physicians who think they have the right to prescribe narcotics to addicts, the police may watch the establishment very closely with the idea of putting it out of business. The main objective of the bulk of these private, semiofficial, or experimental programs may fairly be described as seeking ways of counteracting evil effects created by the official program.
Two of the more permanent organizations of this nature are Narcotics Anonymous and Synanon. Both are self-help organizations in which addicts encourage each other to quit and stay off drugs. The former is modeled after Alcoholics Anonymous. The latter has also been influenced by A.A. but has developed a unique and highly interesting program of its own.28 Synanon's headquarters are in a large old building on the Santa Monica beach.
From there it has spread to a number of other localities and the number of members has increased appreciably but does not exceed more than a few hundred. Statistics of a reliable nature concerning the effectiveness of Synanon and Narcotics Anonymous are not available and very extravagant claims are made, especially for the former. Narcotics Anonymous groups exist in a number of prisons as well as outside.
The Synanon program has attracted a great deal of attention from the mass media and a great deal of support, At the same time, it, like other similar groups of addicts, aroused determined opposition from Santa Monica citizens who tried to force it out of that community. It appears to he rather studiously ignored by the narcotics officialdom.
Synanon accepts addicts who volunteer and meet certain standards. The newcomer is attended by older members in relays during the first few days while he is breaking his habit. When this is done he finds himself drawn into an intense, organized program of activities which are planned both for his own good and for the good of the organization. Synanon houses both men and women and, in some instances, children, and its members represent all social classes and a wide variety of social types. Any visitor will find it a fascinating place and a beehive of purposeful activity. It is something in the nature of a cult and a way of life for its members. From the publicity that has been accorded it, Synanon is known to drug users throughout the United States and it is certainly a symbol of hope for many.
The existence and expansion of the Synanon movement represents a challenge to the prevailing conception of the drug addict as a psychological cripple, or as one who is masochistically happy in his vice and has no desire for anything but his drugs and a life of crime. It is also a challenge to the officially sponsored view that drug users respond only to authoritarian handling and will not of their own volition seek to break their habits. The latter belief is also belied by much other evidence including the fact that many thousands of drug users submit themselves for commitment to jail in order to get help to carry them through withdrawal.
A curious aspect of the reaction to Synanon has been the indifference and even hostility of narcotic officials both within the state and at the federal level." It is reported that the parole and probation of addicts was revoked when they entered Synanon and that a commission of six officials making a study in 1960 stopped briefly at Synanon but did not mention it in their report to Governor Brown. Although Synanon representatives went to the White House Conference, they were largely ignored there and also by the President's Advisory Commission. Perhaps the officials are resentful of the fact that the Synanon movement seems to be doing very well without them and that this program, operated by the addicts themselves, has caught on to a far greater extent than any that has been imposed upon the users by outsiders.
SOME OBJECTIONS ANSWERED
Many objections are made in this country to the type of program advocated here, which may be brushed aside with little discussion, because they are of a purely hypothetical sort or are made by persons who do not understand our narcotics problem and who are unacquainted with foreign programs. It is sometimes said, for example, that the proposed program might cause the underworld to make a systematic effort to create new addicts to replace those who would be removed from the illicit market. Sometimes it is argued that if there were no punishment more persons would want to become addicts. It is said that the program is in violation of our international agreements respecting narcotics. It is suggested that addicts might refuse to go to doctors and insist, instead, on buying high-priced, heavily diluted drugs from pushers. It is also argued
that addicts who now commit crimes to raise money to buy drugs prefer this to a system which provides them with legal drugs and makes crime unnecessary for them. It is sometimes assumed that what is being advocated is free availability of drugs to all.
All of these arguments, and quite a few others, are refuted by the experience of dozens of foreign countries which practice the type of program in question. In none of them have the nefarious effects suggested above made their appearance. The nations that presently handle addiction as a medical problem are parties to the same international agreements. that we are. The assumption that the underworld might engage in a systematic campaign of proselytising new addicts indicates a complete lack of understanding of illicit operations and of how the drug habit is acquired. A similar lack of understanding is indicated by the idea that if addicts were not punished many people would at once set out deliberately to become addicted. The assumption that the program being considered here involves free availability of drugs to all is contradicted by all foreign experience and by logic and is an essentially frivolous objection. Availability by prescription makes narcotics relatively inaccessible; it is the illicit traffic that makes for indiscriminate availability.
There are many persons in the United States, some of them favorably disposed toward reform, who feel that the drug problem and cultural conditions in the United States are so unique that there is little or nothing to be gained from the study of foreign experience. From this point of view, it is contended that what is needed is an extensive research program to explore, first, the nature and extent of the present problem, and then the probable effects of any proposed changes.
The cry that "more research is needed" before anything can be done is a familiar, time-honored device used by those who are opposed to reform or who do not care to face issues. It is true that research is desirable; but it will not necessarily provide answers to policy questions. Research results are always subject to variable interpretations and to misrepresentation. If reform is to wait until research has made it certain what all the consequences of given changes will be, it will wait forever. Moreover, on many relevant issues no research is needed. We do not need it, for example, to demonstrate that our present narcotics laws are unjust and ineffective, that successful medical programs for handling addicts exist abroad, or that jails are not ideally suited for the treatment of disease.
On the matter of the absolute uniqueness of the American narcotics situation, the burden of proof would seem to rest on those who assume this view. It too is a last ditch defense of the status quo. The medical system of handling addicts is used in virtually all of the countries that resemble us most closely and from which our people, our language, our customs, our legal and social institutions are derived. The behavior of addicts, moreover, is remarkably the same everywhere in the world and very highly predictable in the sense that one can assert with confidence that addicts everywhere will do whatever they must to obtain their supplies.
An argument that is as baffling as any is that providing addicts with drugs is immoral and wrong and should be prohibited by the criminal law. From this point of view a medical program for addicts is "legalization" and this in turn means social approval of addiction. It is argued by some adherents of this view that since addiction is an admitted evil it must be forbidden by the criminal law even if this should in turn lead to even greater evils, as it does. There should be, in short, no compromise with the Devil. An argument of this sort is essentially absolutistic and unanswerable. The only remedy that suggests itself is that persons holding these views should become personally acquainted with some drug users.
Legalization, it should be unnecessary to say, does not mean approval. Alcoholism and venereal disease are both legal, for example. The threat in this kind of moralistic thinking is that it opens the door to comstockery and prohibitionism of the kind that gave us the Volstead Act. If heroin users are criminals, why not declare that the use of alcohol and tobacco are 21SO sinful practices to be forbidden by the law and stamped out by the police'
The program of reform suggested here is a gradual one which would aim at increasing progressively the number of addicts receiving legitimate medical care from practitioners. Since some users are already being taken care of in this way the proposals amount merely to an extension of what is already being successfully done on a limited scale. This program could be put into effect by a gradual and progressive liberalization of present restrictions upon medical men. It is anticipated and assumed that close supervision and control would be exercised over the entire program by the Public Health Service in collaboration with the medical profession. It is suggested that doctors would be authorized to handle addicts only when they were qualified and willing to do so. It would be essential that hospital facilities be made available throughout the nation to handle addicts during the withdrawal period.
A program such as this, in its initial stages, would involve little public expense, since it would first be applied mainly to drug users with sufficient means to pay their own way. Hospitalization for withdrawal should be included in the scope of medical insurance programs and handled like any other hospitalization. Ultimately, some special provision at public expense might be deemed desirable for the most hopelessly demoralized users who could not be reached by the above means. The narcotics dispensary-clinic offers one possibility, compulsory institutionalization another.
The essential, basic idea of the entire program would be to use the leverage which the drug habit provides to prevent addicts from violating the law. Drug users would be given a fighting chance to be law-abiding persons even though they were addicts. Through the physicians caring for them pressure would be exerted upon them to reduce and control their dosage and to attempt to quit. This pressure ought to be nicely balanced so that it encourages the addict to quit without causing him to resort to desperate or illegal means of acquiring drugs, The addict purchasing illicit drugs would be subject to prosecution and punishment just as he would if he violated any other criminal law. The work of the police would have to do, as it does now, with the apprehension of illicit drug smugglers, dealers, and distributors and with addicts who persisted in patronizing this market. The effects of such police activity upon addicts would be to exert pressure upon them to resort to the physician f or supplies and treatment. The drug user, in short, would have strong positive motives for going along with this program and he would suffer inconvenience, discomfort, and punishment if he did not.
It is sometimes contended that heroin addiction is the product of disorganization, tension, and alienation, particularly as manifested in the city slum, and that it is visionary to suppose that these conditions can be corrected by anything but fundamental social change. The error in this argument is the failure to recognize that availability of drugs is a sine qua non for the existence of drug addiction. European cities, like those of the United States, also have their slums. The drab, urban wastelands of Chicago and New York can be matched by those of London, Liverpool, Glasgow, and other British cities. The critical difference between British and American slums is that the latter contain an extensive illicit drug traffic while the former do not.
While it would be desirable that the Harrison Act be repealed and a fresh legal start made, this is not absolutely necessary. The proposal to permit physicians to handle addiction is not in conflict with present federal statutes or with present doctrines of the federal courts. It is in conflict only with the administrative regulations of the Treasury Department, which could be changed without any new congressional legislation, particularly since they now appear to be in conflict with Supreme Court interpretations of the Harrison Act.
While the public may not at present be prepared to demand reform, it is also unlikely that there would be any important popular outcry against the reforms suggested. While there is 2 general public concern over addiction and strong popular support for heavy penalties, it is also true that the public has become accustomed to regarding narcotics abuse, along with alcohol and barbiturate addiction, as something akin to disease. The heavy penalties provided by present laws are viewed as appropriate for the peddler rather than the addict. A program which quietly began to place larger and larger numbers of addicts under the care of doctors would therefore probably meet with little public disapproval, for there is much greater public confidence in the medical profession than there is in the police, lawyers, and prosecutors who are now in charge.
The program that is being advocated here is not British. It is rather a proposed expansion of an unofficial medical program that
is presently being applied in the United States to privileged addicts of the upper social strata. What is advocated is that the same consideration that is extended to an addicted society lady from Washington, to an addicted member of Congress, or to addicted members of the medical profession also be extended to drug users of humble social status who have no important connections. It is a plan for giving all addicts genuine equality before the law. It is consistent with our basic ideals of justice, of individual rights, of the proper treatment of the sick, and of the right to be judged as an individual rather than as a member of a category. It is a program toward which the United States is moving and for which there is no substitute.
introduction | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10
i. This apparently cannot now be done legally except through the use of the criminal sanction; it is a serious obstacle to an effective voluntary program because the addict characteristically changes his mind before withdrawal is complete.
z. A powerful statement on this point is found in Isidor Chein, Donald L. Gerard, Robert S. Lee, and Eva Rosenfeld, The Road to H: Narcotics, Delinquency, and Social Policy (New York: Basic Books, 1964), PP. 323-34
3- Committee on Public Health, New York Academy of Medicine, "Report on Drug Addiction Il." The Academy's first r~port appeared in Bulletin of the New York Academy of Medicine, 31, 2nd series, No. 8 (Aug., 1955), 592-607. In the 1963 report (P- 70) the Academy suggested that the Federal Bureau of Narcotics "gracefully bow out of the practice of medicine" by removing the "unwarranted restriction" on medical practitioners contained in section 151-392 of Regulations No. 5 of the Treasury Department.
4. Final Report: The President's Advisory Commission on Narcotic and Drug Abuse, p. 8.
5- Ibid., pp. 83-101
6. Ibid., P. 7 3
7- "Report on Drug Addiction IV' PP- 36-45.
8. Boggs Subcommittee Hearings, 1951, pp- 205-6.
9. Ibid-, 1955, PP- 195-96
10. Chapter 7,P- 731
11. H. J. Anslinger and W. Oursler, The Murderers!, pp. 175-76.
12. Ibid.,pp. 18z-82.
13- H. J. Anslinger and W. F. Tompkins, The Traffic in Narcotics, P- 230
14. Lady Frankall, "Treatment in England of Canadian Patients," 421-24
iS. Harold Finestone, "Cars, Kicks and Color," Social Problems, 5 (July, 1957), 3-13
16. Ibid., io.
17. From personal interviews by the author with numerous officials, police officers, and marihuana users in Jamaica.
A. John A. O'Donnell, "A Post-H-Pital Study of Kentucky Addicts--A Preliminary Report," journal of the Kentucky State Medical Association (July, 1963), 577.
ig. August Vollmer, The Police and Modern Society (Berkeley:
University of California Press, 1936), p. 118.
2o. E.g., see C. E. Terry and M. Pellens, The Opium Problem, pp.
z i. On civil commitment plans see Proceedings: The White House
Conference on Narcotic and Drug Abuse, pp. 173-2 2 1; Final Report: The President's Advisory Commission, pp. 6773; E. M. Schur, Narcotic Addiction in Britain and America, pp. 217-19.
z2. Narcotic Clinics in the U.S., P. 23
23. Final Report: The President's Advisorv Commis6on, P. 73.
24. T. T. Brown, The Enigma of Drug Addiction, P. 3 18. "Nalline"
is an abbreviated version of "N-allyinormorphine," a morphine antagonist.
25- C. S. Lewis, "The Humanitarian Theory of Punishment," Res
Judicatae, 6 ( 195 3 ), 2 z4
7.6. In the Los Angeles Times, Jan. 26, 1964 (section B, p. x), there
appeared an article which asserted that the California program was facing failure because of "court decisions" which were causing addicts to be sent to jail and prison rather than to the Corona rehabilitation center.
27- See Dr. Marie NySwander, The Drug Addict as a Patient (New
York: Grune and Stratton, 1956). One of the best sources on current schemes and experimental programs is NAPAN Newsletter published
monthly by the National Association for the Prevention of Addiction to Narcotics, Hotel Astor, New York City. The New York Times, March 9, 1964, PP. 1, 32., described a number of experimental and research programs in New York, including one in which zo 2ddicts were
to receive sustaining daily doses of narcotics. T . T. Brown, The Enigma -of Drug Addiction, p 262-333, has a brief discussion of a variety of P.
treatment schemes and a detailed one of the nalline program which is his specialty.
28. See Daniel Casriel, So Fair a House: The Story of Synanon (New
York: Prentice-Hall, 1963); Rita Volkman and Donald R. Cressey, "Differential Association and the Rehabilitation of Drug Addicts," The American Journal of Sociology, 69, No. 2 (Sept., 1963), 129-42; Lewis
320 Notes for Pages 2Y5-297
Yablonsky, "The Anti-Criminal Society," Federal Probation, z6 (Sept., 1962), 50-57; David Sternberg, "Synanon House-A Consideration of its Implications for American Correction," The Journal of Criminal Law, Criminology and Police Science, 54, No- 4 (Dec., 1963), 447-55.
29. "Synanon: On the Side of Life," ManaS, 26, No. 52 (Dec. z5, 1963),4.