by Edward M. Brecher and the Editors of Consumer Reports Magazine, 1972
The United States Supreme Court's 1962 characterization of the drug addict as "one of the walking dead" can no doubt be illustrated many times over among addicts living under twentieth-century conditions of high opiate prices, vigorous law enforcement, repeated imprisonment, social ignominy, and periodic unavailability of opiates. The court's major error was to attribute the effects it so vividly described to the drugs themselves rather than to the narcotics laws and to the social conditions under which addicts live today. To illustrate, let us consider the effects of opiate addiction on a few distinguished addicts who throughout their lives had adequate access to continuing supplies.
Perhaps the most remarkable case was that of Dr. William Stewart Halsted (1852-1922), one of the greatest of American surgeons. Halsted, the scion of a distinguished New York family, and captain of the Yale football team, entered the practice of medicine in New York in the 1870s and soon became one of the promising young surgeons of the city. Interested in research as well as in performing operations, he was among the first to experiment with cocaine-a stimulant drug similar to our modern amphetamines (see Part V). With a small group of associates, Halsted discovered that cocaine injected near a nerve produces local anesthesia in the area served by that nerve. This was the first local anesthetic, and its discovery was a major contribution to surgery.
Unfortunately, Halsted had also injected cocaine into himself numerous times. "Cocaine hunger fastened its dreadful hold on him," Sir Wilder Penfield, mother famed surgeon, later noted. "He tried to carry on. But a confused and unworthy period of medical practice ensued. Finally he vanished from the world he had known. Months later he returned to New York but, somehow, the brilliant and gay extrovert seemed brilliant and gay no longer." 1
What had happened to Halsted during the period of his disappearance? A part of the secret was revealed in 1930, eight years after his death. Then Halsted's closest friend, Dr. William Henry Welch, one of the four distinguished founders of the Johns Hopkins Medical School, stated that he (Welch) had hired a schooner and, with three trusted sailors, had slowly sailed with Halsted to the Windward Islands and back in order to keep Halsted away from cocaine.
The effort was not successful. Halsted relapsed and next went to Butler Hospital in Providence, where he spent several months. Again he relapsed, and again he went to Butler Hospital. Halsted's biographers reported that thereafter he was cured. Through magnificent strength of will, after an epochal struggle, he had cast off his cocaine addiction and gone on to fame and fortune as one of the four distinguished founders of the Hopkins. Or so the story went.
In 1969, however, on the occasion of the eightieth anniversary of the opening of the Johns Hopkins Hospital, a "small black book closed with a lock and key of silver" 2 was opened for the first time. This book contained the "secret history" of the Hopkins written by another of its four eminent founders, Sir William Osler. Sir William revealed that Halsted had cured his cocaine habit by turning to morphine.
Thus Halsted was a morphine addict at the age of thirty-four, when Welch invited him in 1886 to join the distinguished group then laying the foundations for what was soon to become the country's most distinguished medical school. Welch knew, of course, of Halsted's addiction, and therefore gave him only a minor appointment at first. Halsted, however, did so brilliantly that he was soon made chief of surgery and thus joined Osler, Welch, and Billings as one of the Hopkins "Big Four."
"When we recommended him as full surgeon," Osler wrote in his secret history, ". . . I believed, and Welch did too, that he was no longer addicted to morphia. He had worked so well and so energetically that it did not seem possible that he could take the drug and do so much.?
About six months after the full position had been given, I saw him in a severe chill [evidently a withdrawal symptom caused by Halsted's seeking to give up morphine once again] and this was the first intimation I had that he was still taking morphia. Subsequently I had many talks about it and gained his full confidence. He had never been able to reduce the amount to less than three grains [180 milligrams] daily; on this he could do his work comfortably and maintain his excellent physical vigor Jor he was a very muscular fellow). I do not think that anyone suspected him, not even Welch.3?
While on morphine Halsted married into a distinguished Southern family; his wife had been head nurse in the operating rooms at the Hopkins. They lived together in "complete mutual devotion" until Halsted's death thirty-two years later.
Halsted's skill and ingenuity as a surgeon during his years of addiction to morphine earned him national and international renown. For Lister's concept of antisepsis-measures to kill germs in operation wounds Halsted substituted asepsis: measures to keep germs out of the wound in the first place. In this and other ways, he pioneered techniques for minimizing the damage done to delicate tissues during an operation. Precision became his surgical trademark. A British surgeon, Lord Moynihan, admiringly described the Halsted technique at the operating table as one of "frequently light, swift, sparing movements with the sharpest of knives, instead of free, heavy-handed deep cutting; of no hemorrhage or the minimum of hemorrhage instead of the severance of many vessels, each bleeding freely until clipped ." 4 For pioneering improvements such as these, Halsted became widely known as "the father of modern surgery."
In 1898, at the age of forty-six, Osler's secret history notes, Halsted reduced his daily morphine to a grain and a half (90 milligrams) a day. Thereafter the surviving record is silent-though Osler in 1912 expressed a hope that Halsted had "possibly" given up morphine.5 Halsted died in 1922, at the age of seventy and at the pinnacle of his exacting profession, following a surgical operation. He remained in good health, active, esteemed, and in all probability addicted, until the end.
Unfortunately, we have no physical or psychological test data on Halsted following his decades of addiction to morphine. We do have such data, however, on another addicted physician, known in the medical literature as "Doctor X." A complete case history of Doctor X was published in the Stanford Medical Bulletin in 1942 by Dr. Windsor C. Cutting of the Stanford University Medical School." The following account is taken from that report.?
Doctor X was born in 1858 and entered medical school in 1878. Two years later he began spitting blood. His illness was diagnosed as tuberculosis, and he was sent home with a bottle of "Scott's Emulsion," to which a quarter of a grain of morphine per dose had been added. Six months later he was well enough to return to medical school-"but found that, when he did not take his prescription, he had a 'craving.' ?
To be without the drug for 24 hours made him nervous, sleepless, nauseated, and subject to hot flashes. On the other hand, when he took morphine, he experienced no excitement, but a "delightful sensation of strength-bodily and mentally," and could "concentrate upon [his] work to a remarkable degree." He therefore took morphine by mouth, usually twice a day. ?
Doctor X graduated from medical school among the top ten members of his class, interned in a large city hospital, and entered practice-first in an Eastern industrial town, later in the Far West. ". . . His addiction caused him little inconvenience," except that he was, like most addicts, constipated. He weighed only 114 pounds at his heaviest-but he was short, and had had tuberculosis. Sometimes he went for a few days, or even weeks, without the drug, but then "suddenly the overpowering desire would come," and he would start taking morphine again.
Doctor X married twice, and had three children. On three occasions he took cures-"but each time returned to the drug after periods of as long as a year. Thus the habit continued over many years."?
In 1925, the forty-fifth year of his addiction, Doctor X got into trouble with the authorities for the first time. "His addiction came to the attention of the state board of medical examiners." This meant, of course, that he might lose his license to practice medicine. He therefore took the cure a fourth time-and this time remained abstinent for six years. "Then, during the course of a severe infection, he was given morphine, and has continued taking it until the present [eleven years later]. The average daily dose at present is 2 1/2 grains (150 mg.) taken hypodermically. This is several times the daily dose of a typical New York City addict of the 1970s.
Doctor X continued to practice medicine until he retired at the age of eighty-one, in 1939. Three years later, at the age of eighty-four, he was subjected to a thorough physical examination. Departures from the normal were few for a man of eighty-four in the sixty-second year of his addiction. "The evidence of damage is surprisingly slight," Dr. Cutting summed up, "as regards both physical and mental functions." The only serious disease from which Doctor X suffered was pulmonary emphysema-a disease associated with his cigarette smoking rather than with narcotics addiction.
Psychological tests were administered to the eighty-four-year-old physician by Miss Vee Jane Holt of Stanford. "The evidence is very clear," she wrote, that Doctor X has been, and is yet, a person of very superior mental ability, even when compared with persons much younger than himself. Scores on the information and comprehension tests ... are significantly above mean score of persons in their twenties-the age level at which intellectual function is generally regarded as maximal-and therefore almost certainly far above those of the average person at his own age level. On the solution of arithmetic problems ... he did as well as the average person of 45 to 49 years of age.?
He did well on several other tests as well. Indeed, he failed only one test. When given a series of five random numbers-such as 5-3-8-2-6 he was able to repeat them forward but not backward. (The reader might try this test on himself.) "This is a typically hard operation for old persons," the psychologist explained.
Another noteworthy case of a distinguished addict was reported in 1962 by Commissioner Harry J. Anslinger of the Federal Bureau of Narcotics. "This addict," Commissioner Anslinger stated, "was one of the most influential members of the United States Congress. He headed one of the powerful committees of Congress. His decisions and statements helped to shape and direct the destiny of the United States and the free world." Commissioner Anslinger heard of this man's addiction, recognized the political damage that might follow exposure, and therefore arranged a continuing supply of drugs for the elderly Congressman from a pharmacy on the outskirts of Washington. When a nationally syndicated columnist got a tip on the story from the pharmacist, Commissioner Anslinger staved off exposure by warning the journalist that "the Harrison Narcotic Act provided a two-year jail term for anyone revealing the narcotic records of a drug store."7I The Congressman died in office, still legislating, still addicted, and still unexposed.*
* Commissioner Anslinger also told the story of a Naval Academy graduate who, despite his addiction to narcotics, "held the rank of commander and was co-author of 32 books, some of them best-sellers." 8
That many addicts live lives as respectable as those of Dr. Halsted, Dr. X, and Commissioner Anslinger's friend in Congress is well established. In 1950 Dr. Eugene J. Morhous of the Clifton Springs Sanitarium and Clinic in Clifton Springs, New York, reviewed the records of 142 narcotics addicts treated for their addiction at that expensive private institution. The average age of these mid-twentieth-century addicts, as in the nineteenth century, was forty-nine years; the oldest was eighty-one. A substantial proportion of the patients (46.1 percent) were women. The occupations represented are shown below.
|Occupation||Number of Patients|
There is little doubt that many addicts today are like those Dr. Morhous described in 1950. The Ad Hoc Panel on Narcotic and Drug Abuse of President Kennedy's 1962 White House Conference on Narcotic and Drug Abuse indicated that "a significant number of persons in the higher socioeconomic classes regularly receive narcotic drugs without detection or apprehension by enforcement agencies." Among its grounds for this belief the Ad Hoc Panel cited "individual reports from public figures, chance findings among hospitalized patients, and comments by practicing physicians." 10
Incredible as it may seem, even a few poverty-stricken American addicts today make a reasonably successful adjustment to their addiction. "It doesn't happen often," Dr. Marie Nyswander concedes, "but once in a while, one of the so-called vilest addicts in East Harlem finds a doctor who gives him drugs or he gets an easy source from a friend. Under these conditions, he is likely to keep a job, maintain his family intact, and cut out his criminal activity. We see more of this kind of adjustment among middle-class and wealthy addicts who either have a medical disease which gives them a legal excuse for acquiring a regular supply, or who discover a brave doctor. With these people you see no social deterioration. I've yet to see a well-to-do addict arrested." 11
Referring to today's addicts, Dr. Jerome H. Jaffe-now Director of President Nixon's Special Action Office for Drug Abuse Prevention-has this to say in Goodman and Gilman's textbook (1970):?
The addict who is able to obtain an adequate supply of drugs through legitimate channels and has adequate funds usually dresses properly, maintains his nutrition, and is able to discharge his social and occupational obligations with reasonable efficiency. He usually remains in good health, suffers little inconvenience, and is, in general, difficult to distinguish from other persons.12?
Dr. Morhous's 1950 study points in the same direction. "A great majority of these persons," Dr. Morhous noted, "were actively engaged in their chosen livelihoods, and some had even made definite upward gains since they had become addicted to narcotic drugs." 13
The Federal Bureau of Narcotics has through the years insisted that all or substantially all narcotics addicts are criminals who support themselves by preying on society. During testimony before a Senate Committee in 1964, for example, when Federal Narcotics Commissioner Henry Giordano was asked whether addicts can hold jobs and lead useful lives, he replied: "I would say absolutely no, I have never seen any that have been able to efficiently operate while under drugs. This doesn't mean that they can't do some jobs. But the efficiency is impaired and generally they are unable to hold a job. In many cases they are unskilled and it makes it even more difficult." 14?
There is reason to believe, however, that the files of the Federal Bureau of Narcotics itself contain evidence to the contrary. The only occasion, so far as is known, when those files were opened to outsiders was during the 1960s, when a Boston consulting firm, Arthur D. Little, Inc., was employed to make one study of addiction problems for the President's Commission on Crime and another for the National Institute of Mental Health.
In July 1969, Dr. Stephen Waldron of Arthur D. Little, Inc., presented some of the findings of these two studies in testimony before the House Select Committee on Crime. The Federal Bureau of Narcotics files and the Lexington data, he reported, independently led to the same conclusion, that "roughly 30 percent of all the drug abusers actually are legitimate people, in the sense that they have a job which they keep-whether because of, or in spite of, using drugs, it is hard to tell.?
They tend to be professional people, doctors and lawyers, quite a number of housewives, some musicians but not too many, people who appear to the outside world to be fairly normal, and people who do not seem to get in trouble with the law, except after long periods of use, when they may get picked tip through a contact, or in some cases where they turn themselves in for treatment in the Public Health Service Hospital.15?
Further confirmation comes from Vietnam, where only slightly adulterated heroin became readily available to members of the United States armed forces during 1970 and 1971. Tens of thousands of young Americans tried it, and thousands became addicted. Despite daily use of doses of heroin far larger than those commonly available in the United States, these men continued to perform their military duties without detection, and in some cases with distinction. Indeed, military personnel addicted to heroin were indistinguishable to their superior officers from their unaddicted comrades-in-arms-so indistinguishable that military authorities found it necessary to introduce urine tests to identify heroin users. Addicted military personnel whose terms of duty expired before the urine tests were introduced sometimes re-enlisted-either while in Vietnam or after sampling civilian life and civilian heroin in the United States in order to be close to the supply of low-cost, high-quality Vietnam heroin; these addicts were welcomed back into service with open arms, for their addiction was clinically undetectable."' (For a further discussion of heroin addiction in Vietnam, see Chapter 20).
But what of the "street addicts," those who earn their living by theft, mugging, prostitution, and petty graft or rackets? For them, heroin has been described as an escape from "psychological problems and from the responsibilities of social and personal relationships-in short, an escape from life." 17 These addicts have been characterized as "passive, anxious, inadequate," 18 and as "retreatists and double failures who cannot qualify for either legitimate or illegitimate careers." 19
Even with respect to such street addicts, however, there are differences of opinion. The 1956 British Columbia report, for example, observes that the, typical street addict finds in heroin a purpose in an otherwise purposeless life. The activities of the drug addict become a full-time job. Formerly living with no real objective, with indolence and unemployment perhaps intimately related, the addict now finds he has to hustle. If he is going to use drugs steadily he must End each day, by illegal means, the funds for the purchase of his drugs. This usually involves daily thieving, the sale to a "fence" or to beer parlor habitu6s of the goods he has stolen, the locating of a drug pedlar, negotiating for his supply, then the actual securing of the drugs at a designated time and place, followed by the locating of a presumably secure place where be can inject his drugs and rest and relax for several hours after the injection. He may take his last injection of the day at midnight, having in reserve a supply for his first "fix" the following morning oil awakening. A program such as this keeps the addict busy all day. He has no time for boredom. He has barely time enough after each injection to enjoy the effects before he may have to start another phase of this cycle. In other words, the addict now has a job, a full-time job ... not governed by regular hours as is most legal employment.20?
A remarkably similar profile of the addict's life on the streets of New York City today, entitled "Taking Care of Business," was presented in the March 1969 issue of the International Journal of the Addictions by an anthropologist, Professor Edward A. Preble of the Manhattan State Hospital Drug Addiction Unit, and an economist, John J. Casey, Jr., of Georgetown University. Preble and Casey studied hard-core urban addicts from the heart of New York City's slums-mostly black or Puerto Rican, but with Irish, Italian, and Jewish addicts among them.
Addicts in New York City, Preble and Casey report, are ?
actively engaged in meaningful activities and relationships seven days a week. The brief moments of euphoria after each administration of a small amount of heroin constitute a small fraction of their daily lives. The rest of the time they are aggressively pursuing a career that is exacting, challenging, adventurous, and rewarding. They are always on the move and must be alert, flexible, and resourceful. The surest way to identify heroin users in a slum neighborhood is to observe the way people walk. The heroin user walks with a fast, purposeful stride, as if he is late for an important appointment-indeed, he is. He is hustling (robbing or stealing), trying to sell stolen goods, avoiding the police, looking for a heroin dealer with a good bag (the street retail unit of heroin), coming back from copping (buying heroin), looking for a safe place to take the drug, or looking for someone who beat (cheated) him-among other things. He is, in short, taking care of business, a phrase which is so common with heroin users that they use it in response to words of greeting, such as "how you doing?" and "what's happening?" Taking care of biz is the common abbreviation. Ripping and running is an older phrase which also refers to their busy lives. For them, if not for their middle and upper class counterparts (a small minority of opiate addicts), the quest for heroin is the quest for a meaningful life, not an escape from life. And the meaning does not lie, primarily, in the effects of the drug on their minds and bodies; it lies in the gratification of accomplishing a series of challenging, exciting tasks, every day of the week.21
?Typical of the New York street addict, Preble and Casey add, was one who told them: "When I'm on the way home with the bag safely in my pocket, and I haven't been caught stealing all day, and I didn't get beat and the cops didn't get me-I feel like a working man coming home; he's worked hard, but he knows he's done something......". The feeling of hard work rewarded by accomplishment, this addict continued, was strong even though I know it's not true."
"If anyone can be called passive in the slums," Preble and Casey conclude, "it is not the heroin user, but the one who submits to and accepts [slum] conditions." 22