Some Basic Problems in Drug Addiction and Suggestions for Research*

XI. THE SUGGESTED CLINICS FOR LEGAL NARCOTICS DISTRIBUTION

The dissatisfaction with present methods of controlling narcotic addiction has led to numerous proposals for the legal distribution of narcotic drugs to addicts. These proposals are not made by sensation seekers or by subversives who desire to undermine our society by spreading addiction to narcotic drugs. Proposals for the legalization of narcotics have been seriously advanced by conservative physicians, medical societies, lawyers, judges and responsible community groups. These individuals and organizations have been concerned with the fact that present methods condemn the addict to a life of parasitism and crime, while they also fail to control the illicit traffic or halt the spread of narcotic addiction.

Dr. Lawrence Kolb is one of many doctors who have strongly urged the legalization of narcotics under appropriate safeguards. In a recent Saturday Evening Post Article,97 he has written as follows: "A major move in the right direction would be to stop the false propaganda about the nature of drug addicts and present it for what it is--a health problem which needs some police measure for adequate control..."

"'We need an increase in treatment facilities and recognition that some opiate addicts, having reached the stage they have, should be given opiates for their own welfare and the public welfare, too..."

". . . A workable solution would be to have the medical societies or health department appoint competent physicians to decide which patients should be carried on an opiate while being prepared for treatment and which ones should be given opiates indefinitely..."

"The details of a scheme of operation should be worked out by a committee of physicians and law-enforcement officers, with the physicians predominant in authority." Other physicians and medical societies have favored the establishment of narcotic clinics, where drugs could be legally dispensed to addicts. Dr. Andrew E. Eggston of the New York State delegation submitted a resolution to the American Medical Association in 1954, which proposed that the American Medical Association go on record as favoring:

(1) The establishment of narcotics clinics under the aegis of the Federal Bureau of Narcotics.

(1) Registration and fingerprinting of narcotic addicts.

(3) Keeping of accurate records.

(4) Administering. optimal doses to addicts at regular intervals at cost or free.

(5) Prevention of self-administration.

(6) Attempt cures through voluntary hospitalization, if possible.

(7) Avoidance of forcible confinement.

The New York Academy of Medicine has proposed a more detailed plan which differs in many particulars from the aforementioned Eggston resolution. The Academy proposed a six point program to stamp out drug addiction by:

1. Changing the attitudes towards the addict. He should be treated as a "sick person, not a criminal."

2. Taking the profit out of the illicit traffic by furnishing drugs to addicts at low cost under federal control.

3. Medical supervision of existing addicts with vigorous efforts towards their rehabilitation through: (a) persuasion (b) appraisal of methods of treatment and their success, and (c) supervision of addicts resistant to treatment.

4. Continued efforts to suppress the illicit traffic in drugs.

5. Formulation of an education program on the dangers of drugs for adults as well as adolescents.

6. Obtaining an accurate count of addicts and knowledge of the success or failure of treatment, so that epidemiology and parthenogenesis of drug addiction can be properly studied.

To implement this program, the Academy proposed that:

1. Clinics be attached to general hospitals, whether federal, municipal or voluntary, dispensing narcotics to addicts, open 24 hours daily, 7 days a week.

2. No person be given drugs at such clinic unless he is willing to enter a hospital for evaluation of his drug needs. After a medical evaluation, he should receive at cost from the clinic the amount of the drug which he requires medically.

3. Safeguards against the addict registering in more than one clinic.

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.

5. The addict be re-admitted to the hospital for reevaluation of drug needs so that the factor of tolerance can be handled.

6. Addicts detected giving away or selling any or all of their supplies be liable to commitment to a hospital for attempted rehabilitation.

7.. Current enforcement machinery be maintained to continue suppression of the illicit market in drugs.*

* See also clinic plans advocated by Richmond County Medical Society which proposed the following: 1. Establishment of narcotic clinics in large centers where the problem is acute. Suitable private physicians can care for the occasional addict in isolated areas.

2. Fingerprinting, photographing, and registering the addict to be sure that the addict uses no more than one such facility.

3. The addict will receive his narcotics only at the clinic, hospital, or doctor's office so that he cannot resell them elsewhere.

4. Examination of the individual to determine whether or not he is actually an addict.

5. Attempt to permanently withdraw the individual from the drug.

Compare with plan advocated by Dr. Hubert S. Howe:

1. Establishing narcotic hospital facilities under federal, state or municipal auspices in cities which are centers of addiction.

2. Equipping these hospitals to examine, classify, hospitalize, and treat addicted persons on their premises for necessary periods, after which the appropriate cases would be referred to specifically commissioned physicians who would be appointed by the hospital staff.

3. Treatment of addict patients in the offices of the physicians under strict supervision of hospitals.

4. Returning patients to the hospital for final cure after achievement of an adequate social and economic adjustment.

5. Upon release from the hospital prevention of relapse through care of a commissioned physician, during the critical period when the patient is becoming adjusted to his resurgent sexual and other emotions.

An interesting plan for the dispensation of drugs legally to chronic addicts has been formulated by the Citizens Advisory Committee to the Attorney General of California, on Crime Prevention.98 This Committee consisting of eminent representative Californians proposed the following:

1. Upon a medical determination that a person is an addict, he shall be institutionalized for a period of at least 90 days, during which time the patient will be withdrawn from narcotics and exposed to an over-all educational and psychiatric program.

2. On release from this institutional treatment, the patient will be assisted by outpatient supervision It will include psychological, sociological, economic, cultural and other elements in an effort to determine the narcotic-proneness of the individual.

3. Treatment should be on either a voluntary self-commitment basis or involuntary. The patient must be required legally to continue the treatment supervision in the outpatient clinic. This phase shall be known as Treatment supervision.

4. It is recommended that a Disposition Board be established consisting of individuals experienced in the field of human relations who shall evaluate the disposition of cases and the duration of treatment and control.

5. If during outpatient treatment, it is ascertained by administration of Nalline or other means that the patient is again using narcotics as indicated by his withdrawal symptoms, the Disposition Board would have the responsibility of determining the further disposition of the case.

6. Should the disposition Board conclude, after repeated failures, that the patient is "incurable," he might then be certified or registered so that thereafter, he shall receive indicated dosages of narcotic drugs from a determined governmental agency and thereby remove said addict as a potential market for criminally or illegally secured narcotics. The establishment of this phase of the program should be deferred until two years after the institution of the over-all management program.

It is obvious that various clinic plans and plans for dispensing legal drugs to addicts differ in important particulars. For example, the New York Academy plan would provide morphine to addicts for self-administration, but no more than a two day supply at a time. Other plans do not envisage furnishing drugs to addicts for self-administration because of the fear that the addict would peddle the drugs given to him and thus help create new addicts. But if an addict does not have the drug for self-administration, then he must come to a clinic or hospital to get the drug several times a day, so that he can avoid withdrawal distress.

It is difficult for an addict to work on a job in any productive capacity if he must visit a clinic several times a day. To obviate this Dr. Eggston and Dr. Berger envision the use of a "depot morphine", a slow acting morphine whose effect would last at least 24 hours. Unfortunately, there is no such drug on the market today and none which has yet been devised, which does not have some rather bad side effects.

The aforementioned is an illustration of the practical difficulties which abound in all plans for the legal distribution of narcotics. The New York Academy plan envisioned hospital clinics open 24 hours a day, 7 days a week, where an addict could come and obtain his drug. This is a very expensive way of attempting to meet the needs of the addicts and would hardly find favor with hospital trustees.

Other examples may be cited. The plans envisage the distribution of drugs to confirmed addicts after a study of the addict and his needs to determine whether it may be possible to rehabilitate him so that he may care to live without drugs. Unfortunately, except for hospitals like Lexington, Fort Worth and Riverside, facilities do not exist for such study. New facilities will have to be provided in communities with a large addict population. The plans are vague and indefinite as to the nature of such facilities. Moreover, the criteria for distinguishing chronic unrehabilitable addicts who must be furnished drugs in order to lead a normal life and addicts who may be reclaimed from the curse of addiction are not sufficiently precise nor are they sufficiently well known to the medical profession generally.

Any adequate hospital treatment or study program concerning addicts requires follow-up facilities in the community to assist addicts in the process of rehabilitation.

The test of rehabilitation is not whether an addict can exist without drugs in an institution, but whether he can live, function and work without drugs in the community.

Before a decision can be made as to whether to supply an addict with legal drugs, he should be observed in the community, and helped in any resolve that he may have to live without drugs. Unfortunately, follow-up facilities for drug addicts do not exist at the present time. Nor do we have a blueprint as to the kind of facilities which are necessary.

An underlying assumption of all the plans is that addicts will not patronize illicit peddlers if they receive a sufficient dose of drugs to keep themselves comfortable. Unfortunately, this expectation does not sufficiently take into account the mechanism of tolerance, and the increasing need or desire for drugs on the part of the addict. None of the plans suggest how this matter of tolerance can be handled so that an addict will be satisfied with his legal supply of drugs and stay away from peddlers for additional supplies. Nor do the plans take any account of an addict's desire for drugs like cocaine, which will not be supplied by the clinic.

Finally, there is an insufficient realization in the various clinic plans that large numbers of addicts have serious personality difficulties even without the problem of drug addiction and that a mere supplying of drugs to such individuals will not solve such difficulties. A criminal psychopath drug addict is likely to continue his criminality despite the fact that he may be supplied with drugs legally. If clinics are to have success in rehabilitating drug addicts they may have to do a great deal more than merely serve as dispensaries for drugs. They obviously need social work and psychiatric facilities to deal with the personality problems of the addict. Unfortunately, even if such facilities were provided, successes in dealing with addicts are not assured. As the Council on Mental Health Report points out:

"... Psychiatrists, experienced in managing addicts, doubt that there would be any great success in persuading addicts to undergo withdrawal and to engage in psychotherapy as long as drugs are supplied to them. A large percentage of addicts are poorly motivated for treatment. They feel that, in the drug, they have the answer to their symptoms. They do not regard themselves as being psychiatrically abnormal and, therefore, are resistant to psychotherapeutic measures. All psychiatrists are familiar with the difficulties in treating psychopaths of the kind that constitute a large proportion of addicts. It would seem unwise in the light of lack of knowledge of the etiology and treatment of character disorders for the medical profession to promise good results in managing such persons by purely medical means alone."99

There has been a violent opposition to the plans for legalizing the distribution of narcotics to confirmed addicts and to plans for narcotic clinics. Dr. George H. Stevenson conducted a study of drug addiction problems in Vancouver and British Columbia. He examined the arguments for and against the legal sale of narcotics and came to the conclusion that: " ... the proposal for legal sale of narcotics if adopted would not only fail to solve the addiction problems but would actually make them more serious than they are at present."100

The U. S. Senate Committee also considered the legalization of narcotics and concluded:

"The sub-committee is unalterably opposed to and rejects the clinic plan proposed for supplying narcotic addicts with free or low cost drugs. We are opposed to all types of so-called ambulatory treatment... Finally, we believe the thought of permanently maintaining drug addiction with 'sustaining' doses of narcotic drugs to be utterly repugnant to the moral principles inherent in our law and the character of our people."101

The spearhead of the opposition to legal narcotics clinics has been the present Bureau of Narcotics. For years it has opposed legal clinics and dispensaries for the treatment of drug addicts. Its main weapon against the establishment of present day clinics was the alleged failure of the approximately 44 earlier clinics,* established between 1919-1923 by state and municipal health officials throughout the country to meet a purported emergency resulting from the Supreme Court decisions which prevented doctors from prescribing for drug addicts. The author cannot enter the debate as to whether these early clinics did or did not produce detrimental results.** There is too little objective data concerning the operation of these clinics. Most of the clinics operated for too short a time for any results to be evaluated. Many of the clinics were hastily organized to meet a threatened emergency without any serious planning or precise knowledge of the problems that they were intended to meet.

*See publication, Narcotics Clinics In The United States, U. S. Government Printing Office, 1955.

** See the discussion in Report on Narcotic Addiction of the Council on Mental Health, American Medical Association, page 3 et seq.

The ambulatory treatment aspect of these clinics evoked considerable criticism and was in part responsible for the resolution adopted by the American Medical Association in 1924, urging:

"Both Federal and State governments to put an end to all manner of so called ambulatory methods of treatment of narcotic drug addiction whether practiced by the private physician or by the so called narcotics clinic or dispensary."102

Incidentally, it should be noted that the condemnation of any system of treatment which places opiates in the hands of addicts for self administration is still the official policy of the American Medical Association. The Council on Mental Health of the American Medical Association reported after examining the arguments for and against narcotics clinics that: governments to put an end to all ". . . The Council does not feel that the American Medical Association should approve proposals for establishment of clinics which would dispense drugs to addicts at this time ..." However the Council did suggest: ". .. the possibility of devising a limited experiment which would test directly the hypothesis that clinics would eliminate the illicit traffic and reduce addiction."103

The author of this report tends to agree with the Council's recommendation that we should go slow in establishing narcotics clinics. He would like to see the various problems involved in the establishment of clinics carefully tested in a research setting. Clinics cannot be established on the basis of broad general principles alone. We need to know what facilities are necessary for the successful operation of any clinic. We also must be clear concerning the techniques and procedures that should be used by such clinics.

Careful research and planning may make a modern clinic a success, and avoid the mistakes which bedeviled their 1920 counterparts.