9 The Sacrifice of Our Sick - by Denying Legal Medicines
DOLORES KOPPINGER and Milton Polansky died so that the nation could continue to pursue the impossible goal of making the rest of us drug-free. While they were quite different in many ways, they were alike in that their perceived drug addiction was used by the medical profession to justify the denying of currently legal medicines for the treatment of major pain due to organic illness. Although no doctor or official intended them to die, the results were the same: it is as if these grandparents were considered scapegoats and thus sacrificed to propitiate the gods of the drug war. The rationale for their sacrifice on this martial altar was that by denying medicine to ease the suffering of our sick the nation maintains the wall of prohibition that denies drugs to criminal addicts. On the basis of such delusions, of such hurtful myths, multitudes of our decent family members, friends, and neighbors have suffered, many of them eventually dying in agony.
These people are the saddest victims of our drug wars and deserve our greatest concern. If we do nothing else, we must implement whatever protections are necessary to insulate them from assaults by those drug warriors who haunt American medicine.
DOLORES KOPPINGER: DEATH OF A GRANDMOTHER
Dolores M. Koppinger was a salt-of-the-earth, Middle-American, decent, loving wife, mother, and grandmother. She and her husband, John, a truck driver, worked hard together to raise two good children, a boy, named after his father, and a girl, Paulette, the mother of Mrs. Koppinger's much loved only grandchild. Mrs. Koppinger had great times with her family, especially her grandson, and was looking forward to the day when her son, too, would marry and when she would have more grandchildren to enjoy. She was also looking forward to the expected retirement of her husband within a few years. At 53 years of age, she functioned well, cooked a big meal every day, kept a clean house, was involved in several community organizations in the Sacramento, California, area, and attended a social function with her husband almost every weekend. There was not a hint of involvement in crime or illicit drugs about this lady or her family.
However, Mrs. Koppinger had a long history of painful illnesses, including bleeding ulcers and spinal fusion, which required numerous operations. Often, she needed the relief provided by analgesic (painkilling) medicines. It is also true that on one occasion many years earlier, she had developed symptoms of drug dependency, apparently after taking diet pills prescribed by a doctor, as was frequently done at the time. The patient was detoxified in a hospital and showed no further symptoms of amphetamine dependence. Her most persistent medical problems were created by recurring migraine headaches from which she had suffered for at least twenty years. Such headaches create disabling misery in the poor souls who have them and, if they are honest, humility in the most brilliant physicians. Medical science does not know their cause. In most cases such headaches produce nothing remarkable in chemical or electronic tests and there is no known cure or standard remedy. Every treatment involves much guesswork because science provides so little guidance.
Over the years, various physicians had tried different medicines to treat this puzzling condition in Mrs. Koppinger. Eventually, they had settled on Darvon. It appears likely that during her last years, the lady was taking approximately 195 milligrams of this drug every day, in three 65-milligram capsules. In fact, her Sacramento doctor provided her with slightly less than that: a oncea-week prescription for 20 capsules. This dosage seemed to control her pain most of the time. To the world and to her family, she seemed an ordinary sweet-natured contributing citizen, certainly not an addict or a social problem.
Her medicine had been created by Eli Lilly and Company and first marketed in 1957 as a safe treatment for mild to moderate pain. Originally, this wholly synthetic compound was controlled only loosely by federal law and was not even labeled a narcotic. Patients found the medicine very helpful and during its first 21 years of existence, physicians prescribed approximately 22 billion doses of the drug, which has the generic chemical name of propoxyphene hydrochloride. It proved particularly beneficial for patients who could not take enough aspirin or codeine to obtain relief without suffering disabling side effects. Because each person's organic and emotional structure is different, no scientist can predict in advance who will be helped by one analgesic or another.
There was comfort in the minds of physicians and patients in knowing that Darvon was a relatively mild painkiller. While comparing potency of drugs is not a precise science, it would appear that Darvon is approximately five times more potent, dose for dose, than aspirin, one half as powerful as codeine, 1/24 as powerful as morphine, and 1/50 to 1/100 as potent as heroin. While reasonable experts might dissent from some of these estimates, few would disagree that Darvon is in roughly the same league as the mild painkillers but wholly outclassed by the more powerful narcotics.
Yet, as always throughout the history of painkillers, this mild analgesic was soon being abused by some of its users, especially by those who took more than the recommended dosages or who combined it with alcohol. Even though no painkilling drug has ever been discovered that did not carry some risks of addiction and abuse, the company claimed originally that the drug offered the therapeutic advantages of the opiates, such as codeine, "without causing addiction or drug dependence." In line with past history, though, Darvon addicts soon appeared in doctor's offices and on city streets. So also did bodies in coroner's offices, whereupon autopsies determined that thousands of abusers were dying from the drug, often from suicide. In 1977, Darvon was finally placed in Schedule IV of the federal Controlled Substances Act, which limits prescriptions to five every six months and requires special records by druggists. Moreover, the Health Research Group, a Ralph Nader organization headed by liberal activist Dr. Sidney Wolfe, launched a crusade in the late Seventies to ban the drug totally or, failing that, to place it in Schedule II, along with morphine, where it would be strictly controlled.
On both counts the HRG failed, but on January 21, 1980, the DEA threw it the bone of classifying Darvon as a narcotic. This action tightened up controls somewhat, in particular by indirectly making it a crime to provide this drug to a narcotic addict for maintenance treatment of addiction, that is, to prescribe it for more than 21 days in a nondiminishing dose where the main disorder was dependence on any narcotic. Few doctors, though, were aware of the precise impact of the governmental action in this respect. Most simply started approaching Darvon with greater concern in the treatment of the organically ill, especially since the new classification had been preceded by warnings about possible misuse of this mild medicine from both the government and Lilly. The Food and Drug Administration cautioned the public and doctors, "Dependence may occur if patients take as few as 8-12 pills a day."
There was nothing essentially wrong in these actions—except that they went from one extreme to the other, treating Darvon first as virtually risk-free and then as a unique chemical threat to the public health, when all along it should have been approached as a painkiller that, like all others, carried benefits and risks. The hysteria promoted by a liberal organization fit into the mood of drug fear then permeating the political spectrum from left to right.
The California Board of Medical Quality Assurance, the state agency which polices doctors, had launched a campaign several years earlier against what it saw as improper prescribing by doctors. Within a few years, it claimed to have stopped the work of approximately 300 "scriptwriters," doctors who write prescriptions of controlled medicines purely for profit. After this, BMQA (pronounced "bumqwa" by some doctors in the state) turned its attention, in the words of the national professional magazine, Medical Economics, to "the next logical step—an effort to control physicians who might be inadvertently contributing to the drug-abuse problem by writing prescriptions that could be passed on to street addicts or could otherwise lead to patient harm." In 1979, as the fears about Darvon and other drugs began to spread throughout the country, BMQA investigators turned their attention to Dr. Harvey L. Rose, a physician who had practiced for 25 years in Carmichael, the Sacramento suburb where the Koppinger family happened to live. Dr. Rose was faced with loss of his license and subjected to public humiliation for years, as will be explained in detail later. Fear of similar treatment spread throughout the medical community of the area.
In the midst of these public events, Dolores Koppinger was taking her medicine every day and minding her own innocent business. Her consumption of the drug was at a very low level, so low that some experts might say that it was functioning like a placebo. It was far below the minimum level of abuse listed in the warnings by the FDA. Moreover, no claim was ever made that the lady had ever diverted any of her medicine to improper channels. Then one day in the spring of 1983, her Sacramento doctor told her that he wanted her to cut down on the use of Darvon and to enter a hospital for drug detoxification. When a shocked Mrs. Koppinger pushed for an explanation, according to the version of these events claimed by the Koppinger family, the doctor could point to nothing in the conduct or condition of his patient that could justify it but rather indicated that his action was for the benefit of himself. "Look what happened to Dr. Rose" are the words John Koppinger now recalls the doctor saying.
The headaches returned with increasing frequency. Dolores Koppinger attempted to treat them with aspirin and Tylenol. It is likely that the aspirin caused stomach distress, brought on in part by previous stomach surgery. Because she was in pain and had perhaps lost count of the tablets, the sick lady took more of the only medicines available to her. Her husband pleaded with her to go back to the doctor for medicine to ease her misery. She would usually reply, "What's the use? He won't give me anything anyway." At 6:00 A.M. on April 11, 1983, when Mr. Koppinger was away on a truck-driving trip, her son discovered his mother unconscious and called an ambulance. Despite intensive care at the hospital, she died at 11:30 the next evening.
A report of a Sacramento County coroner's investigation stated the cause of death to be "Toxic Ingestion (Aspirin and Acetaminophen)," the latter being the generic chemical name for Tylenol. (The threat of these common, over-the-counter drugs is often not appreciated. Yet, according to the government's Drug Abuse Warning Network—DAWN—which covers perhaps a third of the country, 283 people died from overdoses of one or both of these two drugs that year; 221, from Darvon.) Because her blood showed indications of at least 35 tablets of the two drugs and also because of her prior medical history, the coroner classified the case as a suicide.
In a remarkable series of events, the family issued a public statement accusing the doctor of indirectly causing the death of Dolores Koppinger by withdrawing her medication for fear of "getting in trouble with the BMQA." The statement declared, "We hear of over-prescribing but never under-prescribing." Moreover, Dr. Rose, who had treated Mrs. Koppinger briefly for migraine several years before, and Mr. Koppinger convinced the coroner's office that Mrs. Koppinger was not suicidal and that she must have lost count of the pills she was taking due to her intense discomfort. An amended coroner's report concluded that Mrs. Koppinger had resorted to aspirin and Tylenol "because of the reduced availability of Darvon." On the front of the form the word "Suicide" was crossed out and in its place was substituted "Accidental overdose."
The doctor who cut off Mrs. Koppinger's medicine still has his medical license and practices in Sacramento. He has issued no public statements to challenge the charges openly made by the Koppinger family nor has he contacted them to apologize or to comfort them. The man's reputation as a competent, caring doctor seems intact. When I questioned him late in 1985 about his actions in this case, he painted Mrs. Koppinger as an addict who could not be trusted with medications: "I know she was abusing a lot of drugs." Therefore, the physician explained, "I didn't feel comfortable continuing to give her her prescription." Was not the withdrawal of the medicine actually based upon fear of the BMQA? The physician denied this allegation, declaring, "No one threatened me. I practice medicine as I see fit." He offered no information to support his charge that his patient was abusing a lot of drugs, nor has anyone else. In my opinion, Mrs. Koppinger had not been abusing any drug while she was being prescribed Darvon.
When I asked Mr. Koppinger why he had not gone back to confront the doctor over this tragedy, he replied that he was trying to put it all behind him, and also, "I was afraid that I would have punched him in the mouth." The officials of the board with the responsibility for assuring quality medical care to the citizens of the state had quite different emotions. An investigation of the death of Dolores Koppinger produced no action by the board. It would seem that the Koppingers were correct: under-prescribing is a safe course of action, at least for the doctor.
Moreover, when pressed for an explanation of the nonaction by the BMQA in late 1985, Assistant Executive Director Steven Wilford refused to talk to me specifically about this case for the very reason that no action was taken. "Speaking generally," however, the official suggested that it was quite possible that a patient such as Mrs. Koppinger was addicted to Darvon and that, in light of her past history, withdrawal of the drug was a proper medical choice—because in such cases, often there were significant problems of addiction. As for the headaches, the question would have to be asked, Mr. Wilford stated, whether "the Darvon caused the pain or the migraine." The state official thus viewed Mrs. Koppinger as quite possibly an untrustworthy addict, and seemed unaware that the creation of migraine symptoms by a narcotic would be a rare event indeed in the annals of medicine. Indeed, Dr. Barry Beyerstein, a leading Canadian researcher on opiates and brain functioning who operates a laboratory at Simon Fraser University, told me that the truth was quite likely exactly the opposite: "There is some evidence that the brain's endorphin [naturally occurring "opiate" or painkiller] system may be involved in migraine attacks. Because Darvon may interact with endorphin dynamics, Mrs. Koppinger's use of Darvon may possibly have had some beneficial effects over and above the analgesia she might have obtained from it.
It seems highly likely that Dolores Koppinger would be alive, functioning, and enjoying life today if her minimal prescription of this mild narcotic had been continued. The withdrawal of her medicine and her death were needless, and contributed nothing to the health and safety of America's surviving citizens. The number of such needless sacrifices to the drug war is unknown, in part because their existence is either denied or ignored.
HARVEY ROSE: TORMENT OF A GOOD DOCTOR
The torment inflicted on Harvey L. Rose suggests that not only are there far too many of these sacrificial lambs among helpless patients but also that when doctors come to their aid, those physicians may become victims themselves. Rose graduated third in his class from the University of Southern California Medical School and was a board-certified family practitioner. During 25 years of practice in the Sacramento area, he had developed a solid professional reputation and an interest in alternative medicine and holistic therapies—including acupuncture, hypnosis, and biofeedback—which involve virtually no use of drugs. "I have always tried to avoid the use of drugs in treating my patients," he stated recently, "but what do you do when all else fails?"
All else had indeed failed for a number of his patients. These were the chronic pain group, most of whom were suffering from nonmalignant and nonterminal organic diseases, and who required painkilling drugs for indefinite periods. While they constituted a small minority of his patients (approximately 20 out of 2,000, or only one percent), they required a good deal of his time and attention. Many of them had tried every conceivable nondrug and drug regimen without success—and were thus living in misery. Dr. Rose had listened to their needs and developed drug therapy for them, along with other treatments, that allowed almost all of them to function as productive citizens without needless or incapacitating pain.
In some cases, this involved prescribing drugs far in excess of commonly accepted medical standards, such as those contained in the Physicians' Desk Reference, the ubiquitous PDR. During the course of my research, I have discovered that in deviating from these norms, Dr. Rose was following a path trod by numerous perceptive physicians over recent decades in many countries. By observing the needs and concerns of their patients, these doctors found that many could function well only on higher dosages, in innovative combinations, and over longer periods of times than commonly accepted. In some countries and at certain points in history, this deviance has been viewed as a matter of rational professional disagreement, points of difference to be smoothed out perhaps at a medical seminar or decided objectively by controlled research. In, for example, the United Kingdom, when the authorities became concerned about a doctor by an inspection of pharmacists' prescriptions records, the situation was often handled by a quiet visit to the physician's office. All too often in the United States, however, medical detectives have read the lists of prescriptions and seen in them the smoke that reveals the presence of the fire of criminal abuse. Tally-ho. That is precisely how the BMQA read the records of Dr. Rose's prescriptions.
Based only on those records and not on interviews with any of the patients or with the doctor, the board concluded that the patients were addicts (meaning, in this context, dangerous, unworthy social deviants) and that the doctor was fueling their addiction. The officials then went to great pains to prove these accusations, which were founded, as is so much of modern drug control, upon numerous layers of fundamental misconceptions. Unknown to Dr. Rose, the investigation had started in 1979 when the state board had sent two undercover agents to his office for prescriptions of narcotics. They failed. The reason for their failure should have given pause to any halfway intelligent official on the hunt for an irresponsible prescriber: this doctor accepted new patients only on the basis of referrals. The agents could not even get an appointment.
Nevertheless, the investigation continued. Some of Dr. Rose's patients were contacted directly and were quite frightened by the investigators. Because he had nothing to hide, he urged them to cooperate with the officials, and did so himself by providing full records on patients when asked by the agents over a period of several years. The doctor heard nothing from the board for months and thought the matter was settled. His first knowledge that the board was launching a full-scale assault on his right to practice medicine and might even be trying to get him criminally prosecuted came from a newspaper reporter who called on August 4, 1981, to ask, "What have you to say about the charges the BMQA has filed against you stating you are prescribing to drug addicts without prior examination or medical indications?"
"What are you talking about?" the startled doctor shot back. "I don't have any drug addicts. That's a bunch of crap! I have chronic pain patients but they're not drug addicts.... By the way, I hope nothing of this is going to show up in the papers until I have a chance to know what's going on." His hopes were smashed the next morning, a few days before his forty-ninth birthday, when he picked up the morning paper outside the door of his house and saw the headlines: "Carmichael Doctor Faces State Charges." The state agency had gone to the press before informing the doctor. For the next four years, this caring physician and his organically ill patients were involved in an emotionally draining, gut-wrenching battle with decades of institutionalized ignorance as personified by the medical experts of BMQA.
The formal charges were that when Dr. Harvey L. Rose had prescribed medicines to six specified patients, identified only by letters A, B, and so on, he had not acted "in good faith," which is the standard set out in the Harrison Narcotic Act of 1914 and followed by all state laws. California law adds the requirement that physicians adhere to "community standards" in writing prescriptions for controlled drugs. Many doctors believe that none of these rules provides helpful guidance to a physician who truly deals with his patients' problems on an individual basis. It's one doctor's guess against that of another. One of those who expressed that position during this controversy was Dr. William W. Tucker, past president of the Sacramento—El Dorado Medical Society, who did not support the huge dosages Dr. Rose prescribed, but nevertheless observed, "It's like a driver being stopped for speeding by a highway patrolman. When the driver asks the officer just what the speed limit is, the officer answers, `I don't know, but you were over it.' "
Dr. Rose seemed to be clearly over the limit, for example, in the eyes of investigators who read the records of Charles Grooms. On one occasion, Dr. Rose had written a prescription for 1,500 one-grain codeine tablets to tide this patient over a vacation in Mexico. (A grain is a venerable measure based on the size of an average small grain of old English maize or corn; it is now deemed equivalent to 64.8 milligrams.) This same patient regularly took 60 one-grain tablets, a total of 3,888 milligrams, of this natural derivative of opium every day. Dr. Rose himself admitted that Mr. Grooms's narcotic consumption was "huge, but necessary to keep the patient functioning well." And function well he did, even on the huge amount of narcotics he needed to control his pain.
Charles Grooms had been an airman in World War II, when his plane had been shot down over Italy, and he had suffered terrible burns and a broken back. After surviving the rest of the war as a prisoner of the Germans, much of the time as the treasurer of a prisoners' escape organization in the infamous Stalag depicted in the movie The Great Escape, he returned with his pain, especially from his back injury but also eventually from diseases of his heart and lungs and from diabetes. The war hero had been through a whole series of doctors and pain treatments, but his misery continued. Then he encountered Dr. Rose and for ten years before this investigation had become living proof of the effectiveness of the physician's methods of providing a meaningful quality of life and virtually normal functioning for his patients, many of whom had been bedridden in the past. Whether or not veteran Grooms was an addict, as the board charged, no evidence was ever put forth that he did not function well. Nor was there any indication that he ever sold any of his drugs, such sales being one common sign that a patient may be a criminal addict. Instead, there was every indication that Charles Grooms, who received the largest dosage of drugs of any of the accused patients, was a respected member of the community. He kept on working throughout his illnesses as one of the leading salesmen for Commerce Clearing House, a major national publisher of business and law books. Mr. Grooms had also served as president of the Sacramento Yacht Club and won his share of races.
No one knew about the medical problems of this prominent local citizen or about his drug intake. Before the accusations became public, he died in the hospital of a variety of organic problems, including heart and lung disease. Dr. Rose believes that his addiction to tobacco was a major cause of his death. There is no evidence that the opiates contributed to his demise. Quite the contrary, it appears that the huge amounts of drugs allowed him to continue to live a decent life much longer than he could have expected without them, and they soothed the agony of his last days in the hospital.
Despite the brave saga of Mr. Grooms and the humane efforts of his doctor, the memory of the war hero was slandered by the medical authorities of California, who included his case among the six patients to whom Dr. Rose allegedly prescribed in bad faith. His widow showed up to defend her husband and his doctor at Dr. Rose's formal hearing before the board, which began on May 10, 1982, in a Sacramento courtroom. More than 300 people, many of them Dr. Rose's supporters and patients, tried to jam into the room, necessitating a move to a larger room. Scheduled for five days, the dramatic proceedings took 13 days and stretched over three months. At every session, no fewer than 30 Rose partisans appeared; at the last one, each sat with a rose in hand.
In addition to the six patients in the original complaint, a group which included Mr. Grooms, Dr. Rose was later required to justify his action regarding yet a seventh patient. In this case, he had to defend his alleged lack of good faith in prescribing what one BMQA medical consultant labeled as "horrendous dosages" during a two-day period: 50 milligrams of Demerol and 2 milligrams of Dilaudid every three hours, plus at times one-half a grain of morphine. (Demerol is approximately 1/8 as powerful as morphine and Dilaudid five times more potent. Both are valuable synthetic opiates.)
Unlike most of Dr. Rose's patients, this patient, Mrs. Elizabeth Schildt, was bedridden and terminal. The board charged that Dr. Rose overprescribed for this patient without a medical indication, and a BMQA medical expert implied that it amounted to euthanasia.
During an emotional two-hour session on the stand, Dr. Rose testified that Mrs. Schildt was a close friend of his family, had been "like a grandmother" to his two daughters, and then at the age of 85 was suffering from the effects of a massive cerebral hemorrhage. She was nearly choking on a swollen tongue while going in and out of a coma, as death seemed to be approaching. One attending nurse had stated that the tongue was causing particular pain since it "was extremely swollen, protruding out of her mouth with her teeth imbedded in it," a condition she had never seen before in 22 years of nursing. That nurse, other testifying doctors, and the patient's family had all supported Dr. Rose's decision to seek to give Mrs. Schildt some measure of comfort in her last hours by prescribing those narcotic medicines. While explaining all of this on the stand, Dr. Rose broke down and wept, creating a scene which made headlines the following morning.
In regard to the other patients, who were ambulatory and receiving much smaller dosages of drugs than either Mr. Grooms or Mrs. Schildt, the board never denied that they were functional. Yet its experts maintained throughout the ordeal that they were addicts whose state of addiction was created or pandered to by Dr. Rose. Antony C. Gualtieri, M.D., chief medical consultant to BMQA, stated he warned Rose that "giving drugs to an addict might mislead you into feeling you're improving his quality of life." Dr. Rose resented such constant references to his organically ill, decent patients in such derogatory terms and bristled at such persistent misunderstanding of the nature of drug therapy by some of the most respected doctors in the state. Moreover, he recalls that warning by the state board's leading medical expert as having been couched in even harsher terms; Harvey Rose claims that in a settlement conference Antony Gualtieri had stated: "Doctor, we are concerned about your attitude. You've got to get over this preoccupation with the quality of life—you have to be concerned with the appropriateness of medication."
Dr. Rose also recalls the advice he got when he asked a prominent physician at a local medical society meeting, "What do you do with chronic-pain sufferers?" The reply from the physician, a past president of the California Medical Association, was, "I get rid of them."
In September 1982, the California Board of Medical Quality Assurance issued its judgment. It described Dr. Rose as "a competent practitioner who renders above-average patient care. He is very dedicated to his patients." Yet the judgment also declared that the physician was guilty of "unprofessional conduct," "gross negligence," and "incompetence" because of his prescribing practices, conceding, however, that "none of the violations ... was motivated by personal profit or gain." The board placed Dr. Rose on probation for seven years and imposed severe restrictions on his prescribing powers.
The doctor fought back in the media and in court. He was joined by the patients originally accused of being drug addicts, none of whom had ever been even accused by the board of selling excess drugs. The patients filed a joint complaint against BMQA, demanding a halt to any further actions against their doctor. The Sacramento County Superior Court threw out the entire case on a technicality. BMQA stated it would bring the same charges again, and would add more complaints, including the charge that Dr. Rose was providing drugs to yet another alleged addict, a 73-year-old woman receiving three to four doses of Darvon a day for arthritic pain.
Eventually the parties met in the office of State Senator Leroy Greene and hammered out an agreement: all charges were dropped by the state; on his part, Dr. Rose consented to taking a new examination on drugs and to having a panel of three doctors monitor his prescribing practices for up to three years. The doctor continued to campaign against the irrationality of the drug war to the extent that it intruded into medical practice and made victims of innocent pain patients and their doctors. A new California law was enacted as a result of the case, which provides an educational option for well-intentioned doctors found to be misprescribing by the BMQA. This nondisciplinary review approach, Dr. Rose contends, was how his case "should have been handled from the outset." The harsh, secretive, punitive prosecution he suffered cost this physician dearly: $140,000 in legal fees so far and severe emotional trauma, which at times during his ordeal created such severe depression that he often contemplated suicide.
Out of the needless torment of this good doctor have come a few positive events. The doctor's patients and some of his medical colleagues rallied around him and contributed over $20,000 to his defense fund. There has been heightened awareness of the extent of destructive myths about drugs believed by leading medical experts. Those chemical misconceptions still dominate California medicine and that of the entire nation.
Yet there are many doctors who take a humane and rational view of pain medication, including the three who happened to be appointed to Dr. Rose's monitoring panel. The ultimate irony in this irrational story occurred at his final examination. A panel member asked how he would treat a patient who had certain chronic pain symptoms. Dr. Harvey Rose gulped and answered honestly that he would provide a wide array of treatment, including prescriptions of some narcotics over time—precisely as he had dealt with the original six patients. The panel seemed perfectly satisfied. On June 12, 1986, BMQA medical consultant H. H. Schwamb, M.D., sent Dr. Rose a letter saying that he was off the hook; he had passed the examination and would no longer be monitored.
To laymen this may seem unbelievable. It is disturbing to see how precise, predictable scientific principles play such a minor role in delineating the line between good and bad medicine when it comes to the use of drugs in treatment.
CHRONIC PAIN: YOU ARE BETTER OFF IN ENGLAND
Dr. Harvey L. Rose continues, in the midst of a busy practice, to seek new insights from American history and the experience of other nations into how to create ethical and effective guidelines for prescribing to chronic pain patients. It was in the course of that quest that he contacted me for information on a planned trip to England because he had read my writings dealing with that country and also knew of the periodic drug-policy institutes I have presented there. After his return, he wrote to his friends in his holiday greetings circular letter for 1985, "If you have chronic pain, benign or malignant, you are better off in England."
Chronic pain sufferers in England are comforted by the application of a set of simple and humane principles first fully enunciated by the famous Rolleston Committee Report in 1926. Its civilized advice regarding organically ill people is still largely followed in that country. The essence of that humane code is: when a patient is suffering pain from a recognized organic illness, the use of any narcotic drug over a long period of time is presumed to be proper, even though the patient might already be an addict or might become addicted. If the person is functioning well and living a relatively decent life, the dosage and type of narcotic is considered a private matter between doctor and patient, not at all the business of medical societies or the police.
The enactment of such a code in America—through laws and codes of ethical practice—is the most important reform that could be made to ease the suffering of the saddest victims of our drug wars. Its need is urgent in part because most experts are not aware of the extent to which we sacrifice our sick on the drug-war altar. Even the English are not fully aware of the importance of this commandment because it does not exist, completely fleshed out, in their law. It exists, rather, in a combination of custom and practice, barely understood as anything out of the ordinary by those enforcement officials and physicians most responsible for its application, day in and day out.
This can be seen by a brief glance back at the marvelous work of that committee of distinguished physicians, led by Sir Humphrey Rolleston, Baronet, president of the Royal College of Physicians. The main mission of the committee was to face up squarely to an issue with which we are not dealing at this moment—"the circumstances, if any, in which the supply of morphine and heroin ... to persons suffering from addiction to those drugs may be regarded as medically advisable." They concluded that maintenance of addicts with these drugs was medically proper, first, where the patient suffered severe withdrawal pains without the drug and, second, where the patient could lead a fairly normal life with a steady supply of the medicine but not without it.
As a sort of preface to their answer to that continually vexing question of prescribing drugs to people suffering only from addiction, the committee dismissed out of hand any hesitation about the dispensation of these two powerful drugs to any patient, in or out of the hospital, "for the relief of pain ... due to organic disease such as inoperable cancer." These physicians readily agreed that it was possible that the continual use of narcotics might produce a craving that would continue if the organic disease were cured. Yet they made the gentle, ethical decision, not dictated by medical science or the law, to ignore temporarily the possibility of addiction for such people in pain. The Rolleston Committee stated flatly that "there can be no question of the propriety of continuing to administer the drug in quantities necessary for relief of the disease, so long as it persists, ignoring for the time being the question of possible production of addiction."
In other words, this small professional group saw sixty years ago that the first duty of a physician in such cases was to relieve suffering. Later, the problem of addiction could be treated. The committee also gave implicit recognition to the fact that the same person might suffer from the intertwined conditions of organically based pain and addiction, both together requiring the long-term supply of powerful narcotics. It calmly accepted the possibility (1) that the controversial drug heroin might well be given to a person in pain from organic disease or from addiction withdrawal, and (2) that both types of pain might exist in the same person. One result of these principles was that all powerful narcotics, including the feared heroin, have always been used in the treatment of the organically ill in England.
Moreover, the committee gave credence to the existence of a certain type of human being whose authenticity is widely questioned by leading medical experts, especially in America, to this day: the stabilized addict. Many practicing physicians and drug-abuse researchers assume that the process known as tolerance—users needing more and more of a drug to obtain the same effect—operates like an immutable principle of physics. In fact, tolerance seems to affect some users and not others, or it affects users to different degrees. Some people take the same dosage of the same drug, day after day, year after year.
Thirty-five years later, another group of English physicians, the first Brain Committee, led by Sir Russell Brain, explicitly recognized the existence of stabilized addicts in England and provided typical case histories. In each case, the patient was middle-aged or elderly, had contracted some organic illness, was receiving one or more of a whole range of narcotic drugs in relatively stable doses, functioned reasonably well on the drugs, but suffered terribly when attempts were made to withdraw them. Like Dr. Rose's six patients, none of these was suffering from cancer pain and none was receiving heroin or morphine. In its report of 1961, the Brain Committee, in a further coincidence, described six patients by letter—as did the state board that attacked Dr. Rose in California, but with quite a different purpose and sense of ethics. For while each of the English patients was recognized as an addict, each was nevertheless regarded as a decent citizen and a patient in need of and entitled to painkilling medication.
Case 6, for example, was described as Mr. F., a clerical worker past middle age. "He suffers from a painful disease which has necessitated the amputation of limbs.... Over the last four years his dose of phenadoxone has been steady at the rate of 20 10-milligram tablets daily." The synthetic drug phenadoxone, sold in the United States as Heptalgin, is nearly as potent as morphine. Accordingly, our middle-aged clerk was taking a massive though steady dose of a powerful narcotic every day, the equivalent of nearly 200 milligrams of morphine. Yet the committee came to conclusions about him that directly contradict dominant American medical opinion: "On this quantity he appears to have shown no mental deterioration; on the contrary he continues to work responsibly. When other, nonaddictive drugs have been substituted from time to time, his pain has returned with renewed severity."
While Mr. F. was receiving the largest dosage of narcotics of any of the six Brain Committee patients, all were roughly similar to the six chronic pain patients whose treatment Dr. Rose was forced to defend. Had they lived in the United States, in some communities and at some points in time, all of the British patients might have suffered the agonies and humiliation visited upon Dr. Rose's patients and upon Mrs. Koppinger. And their doctors might have suffered the same fate that Harvey Rose did.
There is an additional powerful factor that would support a gentle approach to patients like Mr. F. or Mrs. Koppinger. It was not explicitly dealt with by any of the major British official addiction-study committees of this century and has been largely ignored by the medical-legal primitives who dominate most American policy in this arena, such as those who lead the California Board of Medical Quality Assurance. There is a high probability that, viewed in the proper light, virtually none of these patients should be considered addicts at all, either stabilized or otherwise. Indeed, it is quite possible that in the event that their organic condition changed, thus eliminating the basis for their pain, they would stop taking their narcotic drugs.
Thus it is always difficult to tell when a patient is or is not an addict—nor does the best of medical science contain a definition of addiction that is widely accepted. There is no accepted laboratory method by which addicts may be identified. The most humane, intelligent experts disagree on many specific cases. Some of the reviewers of drafts of this book, for example, urged me not to include Mrs. Koppinger and Dr. Rose's patients in the same chapter as people who admitted they were drug addicts and had ties to the streets and crime. I hope that I will be forgiven for keeping them in the same chapter. Because there is no definitive test for determining addiction, my test for deciding on the propriety of powerful drugs for pain is whether or not the suffering of the patient might be relieved. I apply that test usually without regard to moral qualifications or status of addiction. A patient in pain is a patient in pain, whether the pain comes from an organic illness, addiction, or a combination of them—and regardless of the morality of the sufferer.
Much American medical and legal folklore holds that many patients remain hooked on their medicine even when the underlying organic disease is cured and that therefore it is the irresponsible prescribing of drugs by American doctors over the decades that has been the main cause for the creation of huge numbers of dangerous addicts. My review of every scrap of the available historical record proves exactly the opposite to be true, and it is a pleasure to be able to expose a bum rap which has been placed at the door of our medical profession, but too often believed and perpetuated by its own members. A 1982 editorial in The New England Journal of Medicine confirmed the persistence of this myth among doctors and nurses and countered with the observation that "addiction among patients who receive narcotics is exceedingly unlikely; the incidence is probably no more than 0.1 percent."
Many American doctors use drugs and other treatments very well to control pain and anxiety. Even when they do not use drugs properly, the fears about the rate of addiction from medically prescribed narcotics is vastly exaggerated.
In part, this low incidence of addiction is due to the most ignored element in the entire field of drugs and medications, the expectations of the user and those nearby about its impact; in other words, set and setting. Most people in pain perceive themselves as patients taking a medicine. So also do their doctors and nurses. When their pain recedes, those users expect to stop taking the medicine. Such has been the pattern for centuries among over 99 out of 100 patients, in millions upon millions of instances. The most dramatic example I have encountered of the impact of that process of expectations upon the taking of narcotic drugs was reported some years ago at one of my London institutes by the famed research pharmacologist and hospice director, Dr. Robert G. Twycross of Oxford. The hospice patient was a 16-year-old girl suffering from bone cancer. The accompanying pain necessitated increasing doses of oral heroin over a period of weeks, dosages which plateaued during weeks 8 to 12 at 200 milligrams daily.
Thus this slight young person was taking daily the equivalent of roughly 600 milligrams of morphine, a dosage far in excess of each of Dr. Rose's patients and in excess of the great majority of all American patients known to medical history—as well as in excess of the actual potency of the drugs taken by most American street addicts daily in their highly adulterated doses. When, however, the young girl's cancer started to go into remission, the heroin dosage was slowly reduced over a period of weeks, and eliminated completely by week 15. She showed no signs of addiction or withdrawal after discharge from the hospital. For several years thereafter she was reported to be alive and well, and not seeking drugs of any kind. The young patient did not think of herself as an addict and did not act like one.
MILTON POLANSKY: WE PRONOUNCED HIS DEATH SENTENCE
Milton Polansky did perceive of himself as an addict. In fact, that's how he identified himself when he happened to get through my answering system early one morning a few years ago, and asked in a very direct voice, laden with a strong Baltimore accent, "Is this Arnold Trebach?" Braced for some form of verbal assault before I was fully awake, I said hesitantly that yes, it was. He immediately replied to my relief and surprise, "Well, God bless you! This is Milton Polansky. I'm a heroin addict. I've read your book, The Heroin Solution, and bought copies for my doctors." During the brief acquaintanceship that ensued, I returned his admiration, not because he was an addict who agreed with my view of the world, but because he seemed to be a mensch (Yiddish for a vibrant human being with integrity) who was honest about his weaknesses and who often laughed at the foolishness of the laws that made him a criminal. In an engaging way, he seemed to be saying that you can't let the bastards grind you down and one way to fight back is to joke about their utter stupidity and cruelty.
Thus Milton thought of himself as a heroin addict, nothing to hide, chin out, them's the conditions that prevail. "Who am I hurting?" he asked me defiantly one day over lunch. We both knew that, despite the views of many drug-abuse experts, there was no scientific evidence that the narcotics caused any significant organic harm to his body. Yet, there was sound medical research documenting the harm caused by persistent injecting of the skin, including abscesses and the many diseases that may be transmitted by dirty needles, such as hepatitis. Accordingly, I asked him if he was not hurting himself by the constant injections since 1940 when he started using heroin as a soldier. The look of disbelief that came over his face suggested that he viewed any person who did not use proper procedures in injecting as a fool. Once, "during the war" in about 1943, "I was at a long party with a jazz band and we shared a needle, in New Orleans, and I ended up in the hospital with hepatitis for a while," but that was the last time he remembered suffering from injections.
However, it would be misleading to portray Milton Polansky as simply a sweet old grandfather, a helpless victim of the drug laws, although that is how he appeared at the tragic end. He was also part devil, a scheming and successful manipulator of doctors and the drug laws and the prescription system. One of his fellow addicts, with long years of experience, told me that Milton was virtually without peer in his ability to "make" doctors, to convince them to "write" for him. In some cases, this was accomplished by pitiful appeals to the doctor's sympathetic nature; in others, by appeals to the physician's pocketbook. Milton would then fill these prescriptions, using some of the drugs and selling the rest to a small circle of fellow addicts. During recent years, it is likely that he took in tens of thousands of dollars every year in drug sales. Of course, when his supply ran low, he would spend roughly the same amounts to buy drugs for himself, often from within that same small circle of addicts. On some occasions, however, this would require venturing onto the mean streets of Baltimore, into rough neighborhoods such as one notorious area known as "the block." Unlike Dolores Koppinger, or Mr. F., or any of a multitude of innocent organically ill people who need analgesic medicines every year in America and in many other countries, Milton Polansky, doting father and grandfather, was a criminal narcotic addict.
It is important that his status as a criminal be recognized because that status puts him in the same category, speaking in broad terms, as some of the most destructive inhabitants of America. The manner in which we react to people who are both addicts and criminals is important. They are a challenge to our sense of ethics. Each of them presents unique problems and opportunities. If we can understand how we threw away the human opportunity in this case, if we can see the cruelty that we as a nation imposed on this one "criminal" addict, Milton Polansky, late of Baltimore, Maryland, there is some hope that we can commence evolving a more humane and effective approach to all of our unfortunate neighbors whom personal stupidity, fate, biology, or bad luck, separately or together, have pulled into addiction and some degree of related crime.
Milton's behavior as a criminal addict did not preclude his functioning in many ways as a decent human being. As far as can be discovered, he never committed a violent act or a burglary or a theft to obtain his drugs, which were not difficult for him to obtain for most of his addicted years. He was virtually unknown to police blotters, at least for serious offenses; the man did seem to get stopped often by the police for driving without a license. During much of his life, which commenced in November 19, 1918, Mr. Polansky was a successful Baltimore businessman, engaged in such fields as building renovation and real estate. He was a regular contributor to many charities. While he was not greatly successful in his marriages, he adored his children and grandchildren and I am told that they felt the same way about him. In most respects, he was a nice neighbor.
As the years passed, Milton Polansky developed a number of serious organic and painful diseases. None of them, to my knowledge, was attributable to his use of narcotics. Thus, like many addicts I have encountered, he was soon taking powerful narcotics as a form of self-medication to deal with both his addiction and his organic diseases. Also in line with the patterns of many of these dependent users, there were drugs he preferred and then there were those he found acceptable. In Milton's case, as with many addicts, his drug of choice was heroin and the acceptable substitute was Dilaudid, that legal synthetic opiate which may be several times more potent, dose for dose, even than heroin. He took methadone as a last resort but in general looked with disdain on the favorite drug of the addiction-treatment experts of America. There you have him, warts and all, a far-from-perfect being.
That flawed human package walked into the office of Seymour H. Rubin, M.D., in a Jewish neighborhood in the north of Baltimore, on October 20, 1982. Dr. Rubin knew a great deal about Milton and his family, having treated his brother, who had died 17 years earlier from diabetes and heart disease. He had not seen Milton since those days, and wrote in his notes, "I am shocked by his horrible and changed appearance. He looks thirty years older than his stated age." The patient, then aged 62, shuffled along haltingly and needed a cane. A medical examination revealed an even more shocking list of organic ailments. Dr. Rubin was especially concerned about the impending gangrene of both legs. Other serious conditions of the patient included diabetes, kidney failure, recurrent transient strokes, heart disease, and high blood pressure with congestive heart failure. Any one of these conditions, along with allied complications, could have rapidly fatal results, Dr. Rubin knew, especially if they were not treated properly. And, of course, those potentially terminal organic illnesses were being ignored by the patient because he was finding it increasingly difficult to find a steady source, legal or illegal, of medicines to treat his diseases—and thus his energies focused on an obsessive search for drugs to feed his addiction.
Seymour Rubin, a native of Baltimore and five years younger than Milton, is a graduate of the University of Maryland Medical School and board-certified in internal medicine. He has little experience, expertise, or interest in treating drug addicts. Yet, through a series of unrelated events, he has come to disagree strongly with the current medical-legal approach to them. While a frontline infantryman in World War II, he saw at a newly liberated concentration camp how harsh deprivation of basic needs can reduce decent, proud human beings to sniveling, conniving beggars. Later, at medical school in the late Forties, he heard Harry Anslinger of the old FBN tell the students in a guest lecture how to think about addicts: they are basically evil people; they'll do anything to get drugs; if they don't commit themselves to the Lexington hospital for detoxification, they should be put in jail and the key should be thrown away. "I feel that our medical profession is still guided by that attitude," Dr. Rubin now declares. "And yet I have found out that drug addicts are not all evil people. Many of them are pathetic people who have to be helped, to be led.... If, though, we treat any group of people badly enough, like what I saw at Dachau, we can turn them into whining puppy dogs.... If you just kick them out of the door, you may be protecting yourself as a doctor but you are not doing anything for the patient.... You're being a rotten doctor."
To avoid the common failing of being a rotten doctor in regard to a known drug addict, Dr. Rubin wanted to act rationally on his objective clinical assessment of Milton Polansky. That extensive evaluation concluded that the major threats to his health, indeed to his life, came from his multiple organic medical ailments and not from his incidental though "very repugnant" problem of drug addiction. He decided to provide periodic prescriptions of Dilaudid and then to seek to persuade his patient to go into a local hospital for treatment of his other major medical conditions. Milton refused to go into the hospital because he feared that the doctors there would attempt to detoxify him from Dilaudid and also perhaps put him on methadone, "which would tear me apart." He had been through 15 to 20 drug-treatment programs within the previous quarter-century and none had worked for him; he did not want to risk another attempt even if it was a prelude to easing his organic conditions. "I'll die of withdrawal!" he cried.
Seymour Rubin knew that every prescription of Diluadid he wrote for this known addict put his entire career at risk, and he knew also that the risk would continue even if his patient were to be hospitalized. It was all very chancy, though (as we saw with Dr. Rose and his final examination). Very often, doctors were not bothered by the medical or legal authorities; in other cases, they were and their careers destroyed. He called a leading state drug-enforcement official, who said he believed Mr. Polansky should be prescribed narcotic drugs, as had other law-enforcement officials over the years, according to Milton. But the physician was worried about his medical colleagues. Dr. Rubin told me that he wanted to be able to say, "Milton, I don't want any bullshit from you! You'll get Dilaudid but you must cooperate in this program of treatment." At that point, the doctor would have practically dragged his patient into a treatment slot he had ready at Baltimore's Sinai Hospital, especially for his limbs, which were becoming gangrenous. But Dr. Rubin knew that he could not assure his patient of a steady supply of Dilaudid, which he was then taking in dosages of about 40 milligrams per day (down from a high in the past of 240 milligrams). After several months of treating this difficult patient and agonizing over the case, Dr. Rubin finally concluded that he had to protect himself somewhat, and he called the head of the medical committee that polices doctors for the state medical society: Stephen A. Hirsch, M.D., Chairman, Committee on Drugs, Medical and Chirurgical Faculty of the State of Maryland.
Dr. Rubin's case notes for December 28, 1982, relate that in response to his call, Dr. Hirsch had emphatically declared "that Milton is well-known to his committee, that he has manipulated many physicians, and that I should not prescribe Dilaudid for him. I will comply with his wishes." Those wishes were communicated in writing a few days later, along with barely concealed threats: "Our very strong advice to you is that you not prescribe any controlled substances for Mr. Polansky, although you of course may treat him for conditions other than his addiction.... Mr. Polansky has been advised of the availability of drug-treatment programs in the community and that he should obtain treatment there for his addiction. Again, we appreciate your timely call. You have probably avoided much future difficulty."
Seymour Rubin was indeed out of difficulty with the medical powers who could obliterate his right to practice his profession, but not with his own conscience. He could not sleep well for weeks because he felt so ashamed at his weak compliance with the inhumane and ignorant decisions of the appointed state medical drug experts. There was no way to separate Milton's organic diseases from his addiction—and certainly no drug-treatment program of Dr. Rubin's knowledge that could cure his addiction. It was about this time that I called Dr. Rubin at Milton's urging, and while he agreed to talk with me, he asked that his name not be used because of his personal sense of shame. Since then, his sense of outrage has taken over.
"Even though I will prescribe no more Dilaudid, there is considerable conflict with what I consider the reasoned and compassionate practice of medicine," Dr. Rubin's notes stated. "Has Milton manipulated doctors, perhaps including me, because he is basically an evil person? No, he has done so because that is the only way available to him to obtain relief from his pains and agonies. Yes, he is at fault for having started his atrocious habit many years ago but do we treat chronic smokers and alcoholics in the same manner? ... He is incurably addicted and more Dilaudid pills will do him no harm.... If we can take care of his other problems, his significant renal disease, his uncontrolled diabetes, etc., then we might make an attempt at treating his addiction. He is in far greater danger of the former than the latter, and is more likely to die of them." Operating on his own sense of medical science and ethics, Seymour Rubin had arrived at roughly the same humane point as had the Rolleston Committee some 56 years earlier. Yet he found himself unable to act on his convictions.
Dr. Rubin periodically responded to crisis visits and calls from his patient, to whom he would prescribe no more narcotics. He saw him deteriorate further before his eyes. On March 13, 1984, Milton showed up without an appointment at the doctor's office in a state of collapse. Dr. Rubin pleaded with him to enter the hospital immediately for treatment of all his conditions. Milton refused for all of his usual reasons. He was in enormous pain and shouted that he would lie on the examining table until Dr. Rubin gave him a prescription for Dilaudid. Even though he could barely walk because of the impending gangrene, he threatened to go out and rob a drug store if the doctor did not relent. The doctor did not. The elderly grandfather cursed and shouted and raved that Seymour Rubin was "just like the rest of the fucking asshole doctors."
After that incident, Dr. Rubin lost touch with Mr. Polansky. "I had heard rumors that these were agonizing times for him," Dr. Rubin told me. Almost a year passed. Milton somehow carried on although his doctor later observed, "It was a surprise he lasted as long as he did."
Milton Polansky, heroin addict, was pronounced dead by the medical examiner on March 8, 1985, at 3:50 P.M. Apparently, the old man died alone, perhaps in pain. His body lay undiscovered on the floor of his apartment for some time—since the medical examiner estimated on the death certificate that the date of death was March 3. The immediate cause of death was listed as "Arteriosclerotic Cardiovascular Disease." A contributing condition was listed as "Diabetes Mellitus." There was no mention of narcotic use or overdose.
Dr. Seymour Rubin shot off an angry letter to Dr. Stephen Hirsch and the state drug committee containing rare words of professional condemnation: "Your committee's concern with his drug addiction ... was disproportionate and tangential. I thought it was more derived from sanctified dogma and bogus fears rather than from any true feelings about the quality of life or even the life itself."
Sitting in his office, alone with me on a quiet day during the holiday season at the end of 1985, Dr. Rubin was still ashamed and bitter: "In essence, I felt that we in the medical profession had pronounced his death sentence. If he had any chance of living, we took it away."
KENNY FREEMAN: THE NICE-NEIGHBOR JUNKIE
"A mature addict with a legal supply of clean drugs may well be a nice neighbor" was a thought I had put in a column that appeared in the Washington Post early in 1984. It had been written partly with Milton Polansky in mind, but I was also thinking of other drug addicts I had met since the early Seventies, many of whom were decent people. Drugs, I had found, were morally irrelevant. Some people who take narcotics behave immorally in other ways but not because of the drugs. Some people who are absolutely drug-free are also free of any morals. The truly important issues for me have become not so much whether people take drugs but rather how they treat those to whom they should be showing love and care. All of those thoughts were behind that sentence.
A copy of the paper ended up in a library in Jerusalem where the article was read and touched the heart of an American named Kenneth Freeman, who understood all of my underlying emotions, my unstated feelings, very well.
His letter in response touched my heart as well. He wrote: "I was really pleased by what you said, esp. about being willing to have a junkie live next door to you. That was sweet, and rare. You're absolutely right, as of course, you know; even the worst of us can get stabilized, and live normal lives.... On behalf of all of us junkies all over the world, thanks."
Kenny Freeman is a noncriminal, stabilized narcotic addict. He is not suffering from any other established disease or defect. To me he seems as healthy as an ox and a normal, stable, warm human being. Like many regular consumers of narcotics, he claims that "junk keeps me healthy." There may be some truth to that, at least in regard to respiratory diseases. The important point, however, is that Kenny represents still another group of confirmed drug users, distinct from any of those discussed in this section so far—mature, decent, noncriminal, addicted, and with no known organic health problem. Yet a "junkie," hands down, no excuses.
While living in a middle-class neighborhood in affluent Montgomery County, Maryland, in the beautiful Washington suburbs, Kenneth Freeman knew in advance that he was going to be a narcotic addict and bought himself a set of needles for injecting, which he stored, waiting for the inevitable day when they would be called for. At the age of fifteen!
Looking back on it all and now knowing about the discovery of endorphins, those natural painkillers in the body, he has made the diagnosis that he probably suffered from an endorphin deficiency, and still does. If he can make that scientific case, then, of course, he will have established an organic basis for his continuing need for narcotics, a theory only a few drug experts now support.
Even in the absence of strong scientific endorsement for his views, Mr. Freeman is quite certain of another unorthodox principle that may outrage even the most sympathetic observers. Far from decrying his involvement with drugs, or from urging young people to "avoid my mistakes," he believes that some youngsters, particularly those who would otherwise be suicidal, should be prescribed analgesic, mind-altering medicines from an early age. "I should have been medicated by doctors starting at age fifteen. As a teenager I was in a lot of trouble. The high school wouldn't let me keep coming unless I was in psychiatric care because I fought with the teachers. Also, the Juvenile Court ordered me to be treated by a psychologist. I was in five car crashes while I was in high school. I needed something then, and I didn't get it."
He now recounts that he has been using drugs heavily for a quarter of a century and for the past 17 years has been an addict. As of this writing Mr. Freeman is 43. For the most part, his internal needs, whatever their cause, necessitated self-medication and a good deal of agony. For the past 12 years, he has been on a stable, maintenance dosage of Darvon.
During many of these years, he has been a productive, contributing member of society. As a free-lance writer, he has been involved in one of the world's touchiest problems, Arabs and Jews in Israel. He lived for a year in Nazareth and also worked in the Gaza Strip. His articles have appeared in the Jerusalem Post, Israel Review, Jewish Opinion, and many other periodicals.
However, as a typical white middle-class college student and drug abuser of the early Sixties, he tried a staggering variety of chemicals, periodically getting in serious trouble with one drug or another. A life pattern of ups and downs emerged. Kenny did extremely well in college, graduating in three years with high grades and fellowship offers. Two years later, however, while in the graduate clinical psychology program at the University of Michigan, he was told by the faculty that he was "in danger of becoming another Timothy Leary" and was invited to transfer to the social psychology program. "To them, I was a Pied Piper of drugs who consistently proclaimed that psychology was full of lies. I was guilty of both charges."
Later, while at the University of North Carolina, he dropped out of graduate school and did nothing but inject amphetamines for eighteen months. Like thousands of other hippies (his own label), he found that being a speed freak was a full-time and destructive activity, for him "a total disaster." Friends convinced him that it would be much safer to inject another drug then quite easily available in Chapel Hill. Thus the young scholar found salvation by "becoming a simple heroin addict." He discovered, as have other, more objective experts, that compared to many drugs widely used and abused, heroin is a gentle chemical, although it is seductively addicting. "Heroin was much safer than Methedrine. It was much kinder to my body."
Then he went through a better period. Things quieted down and he went on with his education. He went back to school and eventually obtained a prestigious masters degree in public health from Johns Hopkins University in Baltimore. Mr. Freeman also obtained numerous professional jobs, doing research, consulting, and training in the drug-abuse field, often under contracts awarded to various firms by the federal government. To my surprise, he informed me that one was a firm I founded and headed for some years in the Sixties, where he had been hired as a research specialist. (To my embarrassment, I did not remember him.) In the years that followed, he became a professional journalist, an ardent Zionist, divorced, remarried, and the father of three children.
Kenny was a regular user of narcotics during this entire period. Upon reflection, he believes now that he was unconsciously involved in a process which he insists is common for many mature narcotic addicts: a search for the proper dosage at the lowest possible level of "his" proper drug.
The search had its risks. In 1969 Kenneth Freeman was arrested for possession of narcotics, along with his wife at the time, who was five months pregnant. This, coming on top of many trips to emergency rooms for injecting contaminated drugs and of the eighteen months of being too sick to work or do anything else, gave him the motivation he needed to start thinking about change.
Opportunity arrived in the form of a job as one of the first ex-addict counselors hired by the D.C. Department of Corrections. Kenny was given two weeks "to clean up," which he did, and was then placed on urine surveillance. For four months he ran encounter groups for addicts coming out of the Lorton prison complex.
Here he saw many of the clients in his group go on methadone. He also had friends taking methadone. Kenny's reaction was quite negative: "It scared me!" During 1969, while employed as an ex-addict researcher at my old consulting firm, he kept trying to stay clean and kept suffering severe pains, which seemed to be based at least in part on physical ailments, and in part on a good deal of anxiety. The leaders of programs he visited along with a friend, also working as an ex-addict, constantly raised questions: maybe they were keeping clean, but they "appeared sick."
A Washington physician advised both that they were headed for methadone, but an alternative might exist: propoxyphene or Darvon. They both tried it. For Kenny it worked. His colleague later went back to heroin, was arrested, disappeared.
Kenny insists that he always used Darvon as a medication to treat illness, not to get high. It was always prescribed by physicians for his "pain and sickness." Did the sickness exist before he ever used drugs? Did drugs cause the sickness? Does he suffer from a chronic withdrawal condition? Is it a physical problem or a conditioned reflex? No one knows.
Kenneth Freeman does know that Darvon worked. For years he used nothing else, no other narcotic, barbiturate, amphetamine. Nothing! He kept developing his "rules for surviving as a drug addict"—the smallest dose of the weakest possible narcotic. And, in his case, never injecting.
Over the years, he kept trying to reduce his dosage of Darvon but found that when his regular daily amount was reduced to approximately half, he became physically ill and felt harsh muscle cramps and leg pains, as well as mental depression. Nevertheless, he kept attempting to cut down. While a student at Johns Hopkins, he went into treatment with both a doctor and a social worker connected with the school, who took him on as a patient for several years. In the process they both came to the conclusion, at first against their own better judgments, that he should stop attempts at withdrawal because lessons from methadone treatment had taught them the value of regular, stabilizing doses. The Johns Hopkins experts accordingly advised their patient that he would be better off as a stabilized user of Darvon. That is precisely what Kenny Freeman became, with prescriptions for generic propoxyphene provided by the doctor, filled in bulk at wholesale prices directly from the manufacturer.
For several years, therefore, this narcotic addict had a legal habit costing $88 per year. Neither his regular use nor his possession of drugs in quantity—bottles of 1,000 pills four times a year—created a problem for anyone. Unfortunately for him, and the rest of us, the United States government in its majestic wisdom soon not only designated Darvon a controlled narcotic but, as we have seen, also made it a federal crime for any doctor to prescribe it to an addict except for detoxification, that is, for 21 days or less. At that point, like so many junkies, the young drug-abuse expert was heaved out into the borderland of the law and of society. He went from being a victim of his own internal needs to being a victim of the drug war. He was forced to go from doctor to doctor seeking relief. His doctor at Johns Hopkins fumed that the damned government was not going to tell him how to practice medicine but even he was aware of the new risks in his continued prescribing to this patient.
When that doctor left the country, Kenneth Freeman joined several group health plans and health-maintenance organizations. Out of fear of the law and often against their own sense of medical ethics and justice, the doctors in all of them eventually pushed him toward detoxification or oral methadone, the two grand choices of America's vast drug-abuse treatment empire.
He resisted methadone and opted for detoxification. Each time, that process dominated his life and threatened to tear it apart. Nothing else mattered but staying drug-free, not his wife, not his children, not his job. For him, as for so many addicts, detoxification was not a time of personal triumph, as the popular propaganda tells it, but of continual personal disasters. Detoxification never worked and he was soon back on his regular ration of Darvon. Because of the new legal restrictions, however, he was usually classified by his physicians as being in a period of detoxification. Therefore, he continued to receive legal prescriptions of his drug, but these were often stopped by various doctors.
In 1980, he went in despair to one of the country's leading medical experts on drug addiction, then practicing in the Washington suburbs, with whom he had had some prior professional association. The physician was quite uncomfortable to have this patient in his office, explaining that "of all the doctors in America, I am under the greatest public scrutiny." Even though the doctor recognized that Kenny was being harmed unfairly by an inflexible legal-medical system, he advised him, "Find a doctor who writes prescriptions for money and don't make a fuss. There are plenty of doctors out there who write scrips." Kenny turned down this cowardly invitation to commit multiple crimes. Indeed, since he became a stable Darvon addict, he has never used narcotics obtained illegally.
Somehow, the family stayed together during all of this stress and by late 1981 had emigrated to Israel. To his relief, Kenny discovered that Darvon in some forms was not a closely controlled drug there. The monkey suddenly was off his back.
Citizen Kenneth Freeman could walk into any drugstore in Israel and buy a weak Israeli-made compound of propoxyphene and acetaminophen over the counter without a prescription. For four years, this young professional man maintained himself—for the first time without medical supervision. Nothing changed, except that he did not think about it. "It was like insulin, a medication I took. No thrills. No highs. No sickness. No craving. Just ordinary, stable life."
While the Israelis were tough on hard-drug dealers and street junkies, and provided only methadone under the care of a doctor for addict maintenance, they seemed virtually to ignore addicts who could maintain themselves on the numerous less potent drugs available without a prescription. "In the U.S. I was a rotten junkie, being driven from doctor to doctor, while here I am a normal person," he wrote me. "And now, no one, but no one, treats me like a junkie."
From his newly secure position in Israel, addict Freeman urged me to begin work on a project I had mentioned to him: an international organization with the primary goal of securing more humane treatment for addicts. "We need it. Real bad. Why not start with me? Meaning, I think I've been treated awfully inhumanely, and my whole life has been turned around by what I consider to be an obvious endorphin deficiency that finally got treated correctly, only to have the treatment taken away.... I think that's where the answers will lie in terms of treatment in the future. . . . Someday, they'll figure out what each person needs to be `normal' and that'll be that. In that more humane future. Please do something for us poor junkies."
That plea took on a note of personal urgency when the family came back to America in December 1985. They had returned primarily because Mr. Freeman's wife had been offered a very good position with the federal government. When asked why in the world he would return to the harsh drug-control system of America, he replied, "I was naïve. I thought that within a short time, I'd get it all straightened out. It didn't even occur to me to take extra Darvon from Israel, which I could have easily done—legally, as far as I know."
Thus he was again caught in the limbo where America places addicts who want to live within the rules. He created problems for everyone, but by all rational lights he should have been treated only with kindness and care.
For the previous 12 years, he had been living proof that addicts can learn to live decent lives and to stabilize themselves, even on low-potency drugs that rarely attract press attention. Kenny takes three 65-milligram capsules of Darvon four times a day, a total of 780 milligrams each day, a dosage that has not varied, except under pressure, since 1975. While on that dosage he has been a good husband, father, journalist—and neighbor.
Nevertheless, it is now illegal in America for any drug other than oral methadone to be used in the maintenance of addicts. Doctors and patients who participate in a drug-maintenance plan utilizing Darvon, or any other narcotic, in nondiminishing doses for over 21 days are in violation of federal and state laws, and face the possibility of severe sanctions, including prison sentences. There is absolutely no scientific basis for this legal distinction among narcotics (as I documented, I believe, in The Heroin Solution), and thus the law is fundamentally unjust. Nevertheless, Mr. Freeman was now back on the fringes of society. His Darvon supply from Israel was running low. A few caring American doctors prescribed for him but they became concerned about how long they could continue. One suggested that he enter a methadone maintenance program.
As the days went by and his anxiety increased, Mr. Freeman considered that option which he had hitherto resisted. The Washington, D.C., methadone program offered to put him on 50 milligrams of that approved drug a day. When he sought my advice, I said that it made no sense. Despite what one of his doctors said, these narcotics were not interchangeable. There were qualities in Darvon, as yet unexplained by science, that made that drug work for Kenny. The situation brought to mind an old American frontier maxim: if it ain't broke, don't fix it. Kenny Freeman was living a decent life on Darvon; methadone might tear up that life. Moreover, methadone was approximately 24 times more potent, dose for dose, than Darvon. Laws and allied medical principles that force a patient to needlessly substitute a drug that is both different in quality and also 24 times more potent than one now doing the job are obscene.
And what happens, he asks, if government funds for methadone are cut to balance the budget, or if the program is legislated out of existence? Kenny would be dependent on a narcotic 24 times more powerful than the one to which he is now addicted. What could he and other addicts do then? After all, when Kenny's doctor at Johns Hopkins put him on a maintenance dose of Darvon in 1974, it was perfectly legal and a standard treatment for patients with chronic pain. When Darvon was made into a narcotic by the magic wand of the law in 1977, no provision was made for patients like Kenny Freeman. "How can I trust the government now with an even stronger drug?"
In order to get on that more powerful drug legally and regularly, moreover, he would have to be treated as if he were a criminal, irresponsible, in need of daily supervision. After 12 years of continual, private maintenance, obtaining his medication every few months, he will be forced to go to a clinic every day, seven days a week, year in and year out.
Clearly, law and medical concepts must be changed so that the multitudes of decent, law-abiding, mature, stabilized addicts in America may be treated by their doctors with prescriptions of the currently legal drugs to which they are addicted. While such people may not necessarily be organically ill, they are all suffering from a widely recognized disease, that of narcotic addiction. This new freedom of treatment for such sick people must also include the right to all of these drugs in injectable form, along with a proper supply of clean needles, although Kenneth Freeman is not now interested in that option. Such reforms would save suffering on the part of many thousands of addicts and also of their neighbors—because fewer mature addicts would be forced to engage in crime or to buy in the black market. Accordingly, drastic reductions would take place in the profits for organized crime, in the temptations for police corruption, and in violence associated with criminal drug trafficking. If new statutes do not provide these freedoms for decent addicts, then lawyers must bring innovative lawsuits to establish them.
At this writing, Kenny Freeman is again going through withdrawal and he and his family are in pain. He is confronted with a drastic choice. To stay in America, he will have to give himself over to methadone, if detoxification fails. This will mean that he must act as if nothing happened in the last 16 years, that he is the same street addict that he was in 1968, and that he should expect to be treated like a junkie in a junkie clinic. Or he can return to Israel where, he says, "I would be treated simply as a normal person."
STREET ADDICTS: HOW IN THE NAME OF GOD ... ?
Street addicts present a severe threat to society. Up to this point in this chapter, we have talked only of patients who are organically ill and of addicts who are, for the most part, now mature, noncriminal, and nonthreatening. However, it is much more difficult to imagine a truly compassionate treatment program for a predatory street criminal, whose drug taking is far from stable. Our initial approach to such addicts should be that they can expect to be arrested and punished for their predatory and violent crimes. I am not inclined to make excuses for their crimes because they are addicted—although I empathize with the pressure they feel. I empathize; I do not excuse. At the same time, medical treatment should be fully available to deal with their addiction, preferably in the form of detoxification and abstinence. If they survive an initial period of street criminality, and if they remain addicted while becoming more decent in their lifestyle, however, they should be treated along the lines proposed for Kenny Freeman, at least with a whole range of currently legal drugs.
At the same time, it should not be assumed that street addicts fit a single mold. Many of those who might bear that label are also pathetic, sick people, as was Milton Polansky, who at times was only one faltering step away from the street. For all of them, young and old, doctors must be allowed the option to attempt treatment with a wide range of drugs on a maintenance basis if necessary. It is difficult to look upon street addicts with anything but repugnance. I know from personal experience because my wife and I were once robbed by one in Rome, but at some points in their lives compassion is in order. They are also human and deserving of caring treatment. At the very least, we should increase the number and variety of gentle options we offer to such potentially harmful criminals, especially when they have reached the state of being social derelicts.
There are more heroin addicts, in all stages of health, in New York City than in most countries of the world. In a major report to the governor of New York in 1982, former HEW secretary Joseph A. Califano, Jr., now a leading Washington lawyer, declared that New York City was the heroin capital of the country. Of the 450,000 to 600,000 addicts in the country, he estimated that 234,000 were in New York State and 177,500 in New York City alone. Thus one out of every forty people in that city was a heroin addict! No expert has any easy solutions to the staggering problems presented by that concentrated horde of misery and criminality. To deal with many of those addicts, those involved in predatory crimes, the most appropriate methods involve policemen with guns and jailers with keys—at least initially. If, however, we analyze objectively who those addicts are, we would conclude that many of them, more than anything else, must be considered organically ill; accordingly, we should treat their addiction as a less important ailment.
Mr. Califano encountered just such an addict, in the company of many other fellow sufferers, on October 12, 1981. The prominent lawyer was being led on a tour of the addiction scene by police captain Philip Sheridan, the head of the Narcotics Division's Street Enforcement Unit. They entered a shooting gallery in a brownstone at 360 West 116th Street in Harlem. Perhaps fifty addicts, in various stages of despair, crowded the filthy floors of the building. Nobody ran away even though the police were coming in the building. Many of the addicts had arms and legs that looked like rats had gnawed at them because of constant injections with dirty needles. A policeman asked Mr. Califano to look at an addict sitting in a corner.
"I turned. He looked like he had elephantiasis of the legs. His ankles were swollen to the circumferences of thighs, his skin was so crusted with infection and so dried out that its dark color seemed faded to a worn-out tan.... His toes were so swollen they had all merged together. Like an elephant's hoof, I thought." In other parts of the building they found a young addict whose legs were so torn up by injections that he could not even walk. Captain Sheridan explained that most of these addicts got their money for their regular fixes by regular and extensive predatory crimes. Yet, as he drove away, the thing that bothered Mr. Califano was the image of those desperately sick people, all of them, lying about in misery. "I couldn't get the question out of my head," he wrote in anguish. "How in the name of God did the richest nation in the history of the world let any of its people get here?"
That was a worthwhile question. Yet a more important one is: how in the name of God can we allow those poor souls to remain there? That is what the lawyer and the police captain and the mayor and the governor and the President and everyone else has done. That, and recommending, as did Mr. Califano's report, more police and more courts and more jails to lock them up, because the criminal justice system of New York has reached the point of utter saturation with drug offenders. Nowhere in Mr. Califano's acclaimed report did he recommend that such obviously diseased addicts as the man with the elephant's hoof be offered what such a sick citizen would be allowed in England and what Dr. Rubin wanted to offer Milton Polansky, whose own legs were at the point of collapse: a place in the hospital for treatment of all of the organic diseases along with regular doses of powerful narcotics. Those medicines would have served that poor man a number of purposes, including maintenance of the addiction, even after he left the hospital. It is highly likely that the old addict in Harlem, like the old addict in Baltimore, would have happily accepted the legal Dilaudid in place of the illegal heroin, and stayed within the arms of legitimate medicine and off the backs of the rest of us.
In the end, therefore, the circle of concern runs from a Sacramento grandmother, who was probably not addicted and certainly not criminal, to a Baltimore grandfather, who was certainly both, to a Washington father, who was definitely addicted, had been a criminal and now was not, to an old man in Harlem, who may well have been somebody's grandfather and was also both addicted and criminal. The line that pulls the circle together is that all of these people were sick. All could have been helped by the more humane dispensation of currently legal medicines under the care of a doctor.
Those medicines were denied to these sick people because of irrational fears believed by leading professionals: The fear that narcotics in medicine may create hordes of street addicts. The fear that patients given narcotics will be unable to give them up when the sickness is over. The fear that once a patient does become an addict that person is doomed to a life of escalating doses of drugs and resultant degradation. The fear that providing drugs to a known addict will harm that person more than any other pain or infirmity suffered by that patient. All of these fears have a basis in reality for only a relatively few patients. For most, they are groundless and result in inhumane treatment.
One widely held fear is real. Doctors who treat patients with any type of narcotic in stable dosages for more than a few weeks outside of a hospital are in danger of professional destruction by supporters of the drug war.