Comments on

by Advisory Committee to the Federal Bureau of Narcotics

JULY 3, 1958.

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Associate Clinical Professor of Psychiatry, Stanford University, School of Medicine Examination of the report and its appendices reveals one characteristic which should be borne in mind by individuals who may be interested in narcotics problems. The report differs from the papers of most scientific and judicial committees in that it is not an impartial enquiry into a problem, with an assembly of evidence from all sides of a question. On the contrary, the report is a polemic for a radical revision of the present methods for handling narcotics addiction in the United States. Such evidence as is presented consists largely of selected quotations from individuals and from the literature. The remainder of the report consists of opinions.

The position of the committee may be summarized as follows: If addicts were treated medically by physicians and if the instances of failed treatment were managed by provision of narcotic drugs at a minimal cost, the incidence of addiction would decrease and the illegal traffic in drugs would be priced out of existence. The English experience is cited as an example of the successful application of this approach. An experimental clinic to study 100 cases is proposed.

Our first comment on the report and its recommendations deals with the nature of the criminal addict population. On pages 33-39 of his appendix Judge Ploscowe quotes several studies which indicate that the United States addict population consists of a very small proportion of normal individuals; the rest are persons with psychopathic personalities, inebriates, habitual criminals, and persons with chronic psychoses. Those designated as normal or psychoneurotic constitute less than 12 per cent.

General psychiatric experience indicates that various psychiatric syndromes which comprise the vast majority of addicts have in common the fact that they are remarkably unresponsive to any form of treatment. Irrespective of whether or not they are addicted, these individuals characteristically get into all kinds of difticulties. When rescued from one problem they are almost magnetically attracted to another.

My own experience is limited to the treatment of a relatively small number of cases which I chose because they appear to have exceptionally good personality resources. We have never had much difficulty in getting these individuals free of narcotics during a 3-week hospitalization. We have applied some new pharmacological devices which are of assistance in separating addicts from their drugs. After hospitalization we have continued to see patients and to assist them in such ways as are feasible. It is after hospitalization that the trouble is likely to start. Almost all of these selected patients, freed of addiction, have turned or returned to another variety of antisocial behavior-barbiturate addiction, dexedrine excesses, severe alcoholism, and all kinds of bouts with the law and with society. It has seemed as if these patients had been antisocial personalities, first, who had just happened to find an expression of their deviation in addiction. Cured of addiction, they find another expression.

Interesting as these patients may be, they are a constant headache to a psychiatrist. They monopolize his time and demand that he get them out of one predicament and then another. We regarded these patients as educational rather than remunerative, and so were not disappointed when they almost never paid their bills. The experience which these patients indicates, however, that the physician in private practice is not likely to find that his income will be augmented by treating persons who correspond to the various psychiatric categories which are characteristic of addicts in the United States. Even when there is no experience of addiction, patients in these categories tend to be culled out of private practice, and if they are treated at all, it is within the framework of public clinics or institutions.

It should be pointed out that in England medicine is socialized, and the physician's income is not dependent on fees for service. The British physician is not concerned with the ability of the individual patient to pay. He can treat an indigent addict with the same office routine as a medical case. Our experience suggests that if the American form of medical practice is not to be transformed into one of socialized medicine, then the management of addicts would have to be a public responsibility.

The varieties of psychopathology which are found in the addict population raise several practical and statistical problems with regard to the experiment with 100 cases which is proposed by the committee.

If it is hoped that the study will lead to generalizations regarding addicts, then the experimental population must be a random sample of addicts. This means, according to Dr. Pescor's figures quoted by the committee, that in the sample of 100 cases there would be about 4 individuals with normal personalities, 6 with psychoneuroses, 55 with psychopathic diathesis, 12 with psychopathic personality, 22 inebriates, and 12 psychotics. The study would certainly be inadequate unless data on the differential prognosis of these categories were obtained. Except for the psychopaths, the number of cases are much too small for predictive value. A three- to five-fold increase might be necessary.

The proposed "experiment" lacks the sine qua non of research, a controlgroup. This would again double the number of cases. Without a control group, carefully equated with the experimental or treated group, no conclusion of scientific acceptability could be reached by the study.

It is pertinent to examine what is implied in dollar-cost of the proposed study. It is suggested that 100 addicts be taken off their drug for 90 days in a hospital. Before, during, and after their release there would be extensive medical and social studies, together with considerable psychiatric guidance. The study would have to carry on for at least 2 years. Our conservative estimates of cost run to a half-million dollars. But if the study were expanded to the point that real comparisons, predictions, and generalizations regarding addicts could be made, increased numbers of experimental and control patients could easily run the cost to several million dollars.

The costs which have been mentioned relate only to the conduct of a scientifically-valid experiment. An all-out effort to rehabilitate 50,000 addicts would run into astronomical figures. It may be pertinent to question the wisdom of selecting one segment of the population for such lavish care. What of the other and more common varieties of antisocial personality--those who turn to alcoholism or robbery? And what of the indigent sick, or the aged? It would seem that the needs of all of these groups deserve at least proportional consideration.

Another aspect of the committe's report may be examined--the situation as it is said to obtain in England. Quoting British officials and reports, it is stated that in a population of 50 million there were 333 incurable addicts. This is contrasted with estimates of 50,000 for the threefold greater United States population. Admittedly, there are differences in the habits of law-observance in the two countries, and there are greater proportions of negroes and other groups which seem to be narcotics-vulnerable, in the United States. And there are differences in the methods of control. When all of these are taken into consideration, the figure of 333 is just simply too small to be creditable. The sources of information which are quoted-official records--should certainly be supplemented by a careful on-the-spot survey before the British scheme should be set up as an ideal and copied.