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|Interim report of the Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs, 1958|
Interim report of the Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs
by Advisory Committee to the Federal Bureau of Narcotics
JULY 3, 1958.
Note: To fully understand this document, and the context in which it arose, you should also read these other documents which are in the Schaffer Online library:
by Dr. CHARLES T. BROWN, Fellow, Society for the Study of Addiction, London, England; Diplomate of the American Board of Psychiatry and Neurology; formerly chief, Mental Hygiene Consultation Clinic, United States Army Medical Field Service School
I would like to preface my remarks with a quotation from the late poet-philosopher, George Santayana: He who does not heed the lessons of history is condemned to repeat them.
In considering some of the proposals of the joint committee who have this authored interim report, we might pause and reflect on this brief quotation as to its most appropriate application to the subject at hand.
To assume that certain concepts and revolutionary proposals of this this joint committee, as set forth in their report, will meet with the approval of the American Bar Association is inconceivable. It is noteworthy from a historical standpoint, that the Harrison Narcotic Act, the spirit and provisions of which are now under attack by this same joint committee, has stood the test of time since its enactment in 1914. This, despite the innumerable attempts on the part of various groups to accomplish through legislation certain alterations in the provisions of this law, ranging from subtle and minor revisions, to even open and serious proposals that it be repealed. In spite of such attempts, the Harrison Narcotic Act has remained essentially unchanged since the day of its enactment. Such an effective guardianship may be attributed in a large degree to the keen awareness and remarkable understanding of the true nature and implications of narcotic addiction on the part of the vast majority of the legal minds of this country.
'The American Medical Association will doubtless repudiate the findings and opinions of its own members of this joint committee, and will most definitely reject the proposals as set forth in the interim report. These proposals are fraught with inherent danger to our people and the same have been repeatedly proven to be inconsistent with sound medical practice which I shall conclusively demonstrate in tbs remarks that are to follow. That the Harrison Narcotic Act is not to be tampered with is the traditional attitude, as well as the unalterable conviction of practically every physician in the United States. Let it not be forgotten, that it was the physician himself, having been blessed with the truth and admonitions of Hippocrates concerning the administration of any "deadly substance, although such be the supplication of his patient," who was the very one who conceived, and was instrumental in bringing into being, the Harrison Narcotic Act, certainly one of "the golden laws of mankind."
Further, for anyone to assume that any congressional committee of the United States might agree with the proposals as outlined in the interim report, would seem to indicate a failure on the part of such an individual to study historically the consistent attitude of such constituted bodies toward similar legislative changes in the Harrison Narcotics Act since the enactment of the law in 1914.
Finally, in some quarters there seems to be possibly an underestimation of the determination of certain persons, official and otherwise, who have spent the good time of a lifetime in their dedication I toward the accomplishment of the solution of the narcotic problem.
Such an accomplishment may well lie in the not too distant future. The only positive and progressive trends in this direction have through the sound and demonstrated effective policies of the Federal Bureau of Narcotics, the consistent cooperation of the majority of our physicians, the vigilance and cooperation of the pharmacists, and the continuing and most encouraging medical research in the field of narcotic addiction by the United States Public Health Service.
All other activities that might be proposed to solve the narcotics problem (not only in this country, but globally as well) aside from the constructive and vast amount of individual and private medical research toward this end, may well be considered as merely "straws the wind." I hope to present in my appraisal of the situation, not necessarily my own opinions, but the sound and proven facts as to the true nature of narcotic addiction, from both the medical standpoint as well the legal aspects of narcotic control from the time of Theophrastus during the middle ages, to the quarter of a century of incumbency of the present United States Commissioner of Narcotics. Under the present policy of the Federal Bureau of Narcotics which has been in a progressive state of evolution since 1914, it is my own personal opinion that the narcotic problem is destined to pass from the miseries of mankind, just as have other similar plagues, such as smallpox, diphtheria, typhoid, and the host of other human agonies. Too, we need only a little patience and to take heart by examining the positive tistics as to the work accomplished so far, especially within the past 25 years.
Reviewing the historical aspects of narcotic control since the Harrison Act, never has this Government of the United States altered its position as to any revision of this statute. True, there have been minor leniencies extended by the Federal Bureau of Narcotics for the convenience of the ethical physician in his administration to his patients (e. g., exempt preparations; certain humane considerations, such as the permission to administer to the incurable patient such amounts narcotics left entirely to the attending physician's discretion as may calculated to relieve or benefit said patient; the provisions set for in the Harrison Act, to allow the physician in the course of his legitimate practice to administer narcotics to the aged and infirm addict in those cases where deprivation of such drug would endanger said patient's life). All of the above, of course with the exception of the dispensing of exempt preparations, are contingent upon the physician in question contacting the Bureau and presenting the bona fide details of the medical problem confronting him in such type of patients.
All of the above is merely expounding the obvious; however, it illustrates that the Federal Bureau of Narcotics has through the years been most reasonable in their position as regards the physician, the addict, and their interpretation and enforcement of the act. I emphasize the above, in order to dispel any of the illusions that are implied in sections of the interim report that the Bureau is some "persecutory" agency set up in Washington directed at certain of our citizens.
The subject under consideration, i. e., certain revisions, alterations, revolutionary changes in the provisions of the Harrison Act, even to the extreme of its repeal, has come up from time to time, with annoying regularity. On such an occasion, especially with this particular document at hand, the interim report; there is nothing else to do but answer it.
It would seem by this time, that the true facts concerning the nature addiction, and the proven and only approach to effective narcotic control, would be common knowledge; especially to persons such as those who compose "the interim report's joint committee."
Chapter XI, Clinics for legal narcotics distribution--I had thought I would never hear of this proposal again; especially in consideration of the fact that since the welcome demise (around 1923, I believe) of the last of these "shooting galleries," that some 35 years of medical and legal enlightenment would permanently dispell such an illusion.
I have been amazed at the resurrection of this wornout issue as a solution to the problem. Even a school boy might grasp with ease, the premise that: You can't quit taking dope as long as you are taking it. Such is the conception of the "feeding station" (legal and unrestrained distribution of narcotics) on the part of those well meaning persons whose reasoning defies my comprehension, in their attempts to reclaim the toxicomaniac who is slowly dying from the accumulative effects of a deadly poison.
The "locus minor resistans" which is being emphasized in my answer to the interim committee is the simple and demonstrated characteristic addiction process, which will by its very nature result in the defeat of those proposed measures of the minority group representing the AMA and the ABA.
This is an inexorable factor of mathematical precision in the prolbem that shatters the "straw-man" as outlined in chapter XI of the report and invalidates the proposal therein due to their impossibility from a medical standpoint. No matter how plausible such proposals, experience has demonstrated the falllacy of such attempts to solve the tragic plight of the addict since the time of Theophrastus during the middle ages, who was quick to grasp the empasse even in the face the comparative unenlightenment of the times.
The inexorable factor that I have reference to, is the phenomenon of tolerance, one of the characteristics of the addiction process well known; however, apparently only lightly considered by the author in chapter XI. I am afraid that I will be constrained to point out some rather critical omissions in the bibliography. Among others, there have been omitted two of the most outstanding contributions our present understanding of the narcotic problem, and which will remain for a long time to come as classics in the field. I refer to:
(1) Rado, Sandor.--The Psychoanalysis of Pharmacothymia (drug addition). The Psychoanalytic Quarterly, 2: 1-23, 1933.
(2) Wikler, Abraham.--a Psychodynamic Study of a Patient During Experimental Self-Regulated Re-Addiction to Morphine. The Amer Journal of Psychiatry, pp. 271-293. (From the Research Branch: United States Public Health Service Hospital, Lexington, Ky.)
The omission of the factual considerations emphasized in the above two studies (incidentally, accepted by all serious students of the problem of addiction) render any presentation of the subject woefully incomplete. Too, it is regrettable that the author did not at least mention in passing, another classical tome of another era, in his implications of the myth of the stabilized dose of a narcotic drug. I refer now to one of the alleged proposals of the New York Academy of Medicine (p. 72, ch. XI) :
4. Drugs could be given to the addict for self-administration, but no more than two days' supply would be furnished at any one time.
This other "classical tome of another era" that might possibly shed some light on the question of tolerance is the work of Thomas De Quincy. As you are indeed familiar, this somewhat stoical courageous Englishman began with a modicum of 10 drops of Tincture of Opium and during the course of his addiction, he confesses to us that he was compelled to increase the daily quantum to 1 pint of the drug. As a passing thought, should it be possible to resurrect De Quincy, I fear that the proposed clinic would encounter some difficulty in keeping this gifted gentleman comfortable unless they had a fleet of trucks available to deliver Tincture of Opium in carboys.
The interim report has almost completely ignored the accepted and proven psychodynamics of narcotic addiction. Aside from certain clinical and practical obstacles in the path of some of their proposals, these constitute the major difficulty in the reclamation of narcotic addict.
Another point to consider is the somewhat paradoxical attitude of some of the authorities quoted in the references as to the possibly sulubrious and beneficial effects attendant to the use of narcotics, which I question. As to the use of opiates and related substances being of a nondeleterious nature, and compatible with a reasonable state of good health leading to a normal longevity, let me quote from the book, "The Opium Habit", by an early authority on this subject, Dr. Fitzhugh Ludlow, whose work as far as I have been able to ascertain was the first published on this subject in the United States, published in 1868. Here is what Dr. Ludlow had to say regarding the man who can indulge in narcotics with apparent impunity as regards his health, and effectiveness:
In the great conflagrations which at times devastate large cities, some huge mass of solid masonry is occasionally seen in the midst of the widespread ruin, looking down upon prostrate columns, broken capitals, shattered walls, and the cinders and ashes of a general desolation. The solitary tower unquestionably stands; but its chief utility lies in this: That it serves as a striking monument of the appalling and widespread destruction to which, it is the sole and conspicuous exception.
As regards the phenomenon of tolerance, from some of the sources that I am now uncovering in the literature, it would seem that the ability of the human organism to tolerate increasing doses of opium and its derivatives would stretch almost to infinity. I mentioned to the commissioner in some of our correspondence in the past as regards this facet of addiction, Tyson's case, in which his patient had begun with a dose of one-eighth grain of morphine sulfate, and then with a lightning progression reached the astronomical daily dosage of 800 grains. The patient remained recalcitrant and unsatisified; albeit the inroad of the somatic and severe symptoms of toxicity had long since begun to make their appearance. At this point, one might be interested in the route of administration, for obviously had the patient in question been using the needle route, in addition to the described emaciation, his resemblance to a "pincushion" could well be imagined. The patient took the drug by mouth. (Tyson's Practice of Medicine, 1906 Edition).
I mentioned also De Quincy's daily quantum of 1 pint of Tincture of Opium (beginning with 10 drops), and his contemporary man of letters, Samuel Taylor Coleridge, who declared with a piqued indignance that he considered Mr, De Quincy a mere dilettante in comparison to himself, when it came to the consumption of laudanum.
Now, I find another Englishman of a somewhat later date, whose appetite and tolerance for laudanum apparently would relegate the self-acclaimed champions to the bush leagues in the game of morpheus.
I refer to the physician-poet, Dr. Francis Thompson, who died in 1907 at the age of 47. His unfortunate addiction began at the age of 22, scarcely out of the medical college where he had pursued his studies for some 6 years at the Owens College of Manchester. Then began a pitiful life of degradation and horrible suffering, during which time he was never able to practice due to the infirmities incident to addiction. (At one period of his life, he was so reduced in circumstances, that he earned money to purchase laudanum by peddling penny boxes of matches on the streets of London. Curiously enough, he was a gifted poet, and during his lucid moments was able to pose such literature productions as to ensure his position for all time in the field of English letters.) The end came at last: "The last weeks were spent near Scawen Blunt's home in Sussex where he became more and more silent, his mind gone, but his need for laudanum incessant."'
Thus, if the United Kingdom has no narcotic problem at the present time,2 then my suspicions are becoming more and more confirmed, at least they have had one in the past.
As I mentioned earlier I merely submit that it might not be a bad idea to communicate with the various members of your committee while they are in the process of making their own reports to emphasize this factor of tolerance which is a powerful weapon indeed to ensure the invalidation of the proposals of this minority group. To be sure, there are other major considerations in the answer to the document that they have submitted; however, I believe that I am right as regards the importance of the factor as above outlined.
Now, as to another consideration aside from the above. This point has to do with the implications as to just what might have been accomplished by the Federal Bureau of Narcotics since its inception, along with the progressive reforms incident to the enactment of the Harrison Act since 1914. I now cite a phenomenon if it might be so called, or merely an indication, or manifestation of medical progress over the passage of half a century, which certain of your detractors might choose to term same; rather than to attribute this present state of affairs to any influence on the part of the Bureau.
In a certain small town in the southwest there were nine physicians in practice circa 1900, and naturally that was prior to legal restrictions as to the control of narcotics. All of these nine physicians were addicted to morphine. Obviously, such a condition would in this day and time be inconceivable. That the present legal controls and supervision pertaining to narcotics are responsible for a more healthy situation is a reasonable conclusion.
1 Ella Freeman Sharpe: British Journal of Medical Psychology. Vol. V, p. 325. 1926.
2. Marie Nyswander: The Drug Addict as a Patient. Grune and Stratton. New York. 1956.