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Drug Addiction, Crime or Disease?
Drug Addiction, Crime or Disease?
Interim and Final Reports of the Joint Committee of the American
Bar Association and the American Medical Association on Narcotic Drugs.
An Appraisal of International, British and Selected European Narcotic Drug Laws, Regulations and Policies
by RUFUS KING
In canvassing existing sources and planning its own studies, the Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs had necessarily to inquire about the workings of comparable narcotic drug control systems in other parts of the world.
It quickly developed that American authorities are in conflict about other systems; especially with respect to the situation in Great Britain there is disagreement even as to whether a so-called narcotics problem exists on any significant scale.
It was therefore decided to make some of the resources provided by the Russell Sage Foundation available to permit observations at first hand (facilitated by the fact that a Joint Committee member was already committed to be in Europe in connection with Bar Association activities).
The conclusions which follow are thus supported by direct study and interviews with public officials and others in the United Nations headquarters in New York and Geneva, and in England, Scotland, Denmark, Norway, Sweden, Belgium and Italy. No effort has been made to appraise conditions in areas other than the United Kingdom and Western Europe because analogies with nations which produce drugs domestically on an extensive scale, or whose political and cultural patterns differ widely from our own, seem sharply limited in value as guidance for the Joint Committee.
The conclusions reached in this study are two: first, efforts to control drugs by international prohibition measures, though desirable and successful in part, are unlikely to be a major factor in solving our domestic addiction problem within the United States; and second, the experience of comparable national communities in Europe in recent years has been startlingly different from our own with respect to the drug addiction problem, owing largely to a difference in their attitudes and enforcement policies regarding addicted persons and the medical profession.
INTERNATIONAL TREATIES AND AGREEMENTS
No one sensitive to the deplorable part our forebears played in the Opium Wars and the commercial exploitation of the traffic in smoking opium in the Far East can wholly deprecate international efforts to suppress the drug traffic. Early in this century the United States gave vigorous leadership to a world-wide movement to stamp out opium smoking. President Theodore Roosevelt initiated the discussions which led to the Hague Opium Convention of 1912 1 (and our own Congress had been attempting to stamp out American participation in the traffic since the first Opium Tax Act of 1890).2 Opium smoking and the illicit traffic in crude opium are no longer a problem of significance except domestically in national communities where the poppy is still cultivated.
But, perhaps because of this success, the United States has also remained a vigorous supporter of international efforts to prohibit trafficking in manufactured drugs (morphine, heroin, etc.) as well. And here its leadership has been less universally acknowledged. Because the raw materials of drug manufacture are not produced in this country and manufacture is relatively easy to control, our illicit traffic has always been fed almost exclusively by smuggling activities. Thus if all other nations could be induced to agree to curb manufacture, export, and uncontrolled trafficking in the drugs which feed our illicit market, our problem would be solved.
The extent to which American spokesmen have continued to dominate the international scene in this field is impressive. Our representatives have always been principally identified with the activities of the narcotic drug section of the League of Nations and its Opium Advisory Committee. Our Federal Narcotic Bureau has never lost its close connections with the work of the League and its successor organization, the Commission on Narcotic Drugs of the United Nations Economic and Social Council. Today the U. S. Commissioner of Narcotics serves as Chairman of the fifteen-member UN Commission.
The 1912 Convention, besides committing its signatories to impose limits and controls on the production, manufacture and distribution of opium and coca products, bound them to enact national laws curbing the export of drugs to illicit foreign markets. There have been eight international agreements since: the Geneva Convention of 1925,3 attempting to set up a production quota system and establishing the Permanent Central Opium Board to administer it; the Geneva Opium Agreement of 1925,4 binding the principal Asiatic producers of opium to establish government monopolies for easier control; the Geneva Convention of 1931,5 extending the limitations on manufacture and distribution of drugs and creating an international Drug Supervisory Body to police them; the Bangkok Agreement of 1931,6 calling for government monopolies of the retail sale of opium in Asiatic countries; the 1936 Convention7 (with less than a score of adherents), establishing direct criminal sanctions to punish trafficking; the Protocol of 1946,8 bringing all prior Conventions under the supervision of the United Nations and establishing the UN Commission; the Protocol of 1948,9 providing machinery for the addition of new drugs to the controlled categories by action of the World Health Organization; and the Protocol of 1953 10 (With only a handful of adherents), agreeing to limitations on the cultivation of poppies.
The UN Commission has now under way a project for combining all of the foregoing agreements into one Convention, though this work appears to be proceeding slowly and to be encountering resistance.
It is sometimes charged that Communist countries, particularly Red China,11 actively engage in fostering our domestic traffic in illicit drugs, but there is no substantial evidence that this is done--at least not as a matter of national policy--by any nation. Large producers of opium in the East and Near East are unwilling to repress lucrative industries, and most nations which have no serious problem within their own borders tend to be apathetic.
Of course it must be conceded that if all the existing international agreements were universally adhered to and vigorously enforced, they would have a marked effect on the how of smuggled drugs into the United States. Our domestic problem responded remarkably to the isolation and interruptions of foreign commerce which characterized the period of World War II. But even full cooperation among nations would be unlikely wholly to eradicate addiction; and the goal of effective collective action appears to be unattainable under existing circumstances.
The conclusion that drug addiction within the United States cannot be effectively controlled through international cooperation does not, of course, entirely negative the value of such activities as the exchange of information, the pooling of resources at administrative and police levels to control drug shipments and combat smuggling, or even efforts to impose limitations on raw material production.
The problem is merely one of balancing perspective; far less than a full solution for our problem is likely ever to be found in prohibitory activities at the international level.
The British experience in controlling drug addiction has become a subject of controversy in the United States. The Federal Bureau of Narcotics insists that the English have an illicit drug traffic of the same magnitude and viciousness as our own, and that the enforcement policies of the two countries are identical." Since 1954 the Bureau has been circulating a document entitled, "British Narcotic System"l3 which asserts: "Several years ago a professor of sociologyl4 at an American university ...wrote an article in which he advocated that the United States adopt the British system of handling drug addicts by having doctors write prescriptions for addicts. He reported that this system had abolished the black market in narcotics and that consequently there were only 326 drug addicts in the United Kingdom....
"Nothing could be further from the truth. The British system is the same as the United States system. The following is an excerpt of a letter dated July 18, 1953. from the British Home Office, concerning the prescribing of narcotic drugs by the medical profession: "'A doctor may not have or use the drugs for any other purpose than that of ministering to the strictly medical needs of his patients. The continued supply of drugs to a patient either direct or by prescription, solely for the gratification of addiction is not regarded as a medical need.'...
"The British Government is a party to all of the international narcotic conventions to which the United States is a party. They enforce treaties in the same manner as the United States. The British and United States systems for enforcing narcotic laws are exactly the same." Giving full weight to such disparity of views, it is nonetheless stated here without hesitation that England (and the U. K. countries which follow her pattern) has no significant drug-addiction problem, no organized illicit trafficking, and no drug-law enforcement activities that could be regarded as comparable to those which preoccupy our own authorities.
The key to this difference appears to be that the British medical profession is in full and virtually unchallenged control of the distribution of drugs, and this includes distribution, by prescription or administration, to addicts when necessary. The police function is to aid and protect medical control, rather than to substitute for it.
Some of the distinctions are subtle. Discrepancies between British form and British substance, in the endearing tradition of "muddling through," make it possible to focus upon statements, like that quoted from the Home Office letter in the document referred to above, which are true and yet misleading apart from their qualifying context-i.e., in the instant case, doctors include the imminence of withdrawal symptoms among the "strictly medical needs" of their patients, and ministering to an addict under the conditions which will be discussed below is not regarded by either the profession or the authorities as "solely for the gratification of addiction." The controlling fact is that the medical profession accepts and treats addicts as patients so that virtually none are driven to support a black market; the prime corollary is that if all curative efforts fail the incurable addict may still be provided for on a medically-supervised regime; and the remarkable consequence is that the number of persons in the incurable or extended-regime category--out of Britain's population of over fifty millions--remains year after year in the range between three and four hundred. At the end of 1956 the figure was 333.
It is of interest that around one hundred of these chronic cases are from the ranks of the medical profession itself (75,000 doctors, plus nurses, hospital staffs, technicians, and persons in related careers). British authorities concede that some persons--scores, perhaps--may be obtaining and using narcotics by some personal arrangement which makes it unnecessary for them to appear on the Home Office list. But the list is inclusive, with only this minimal degree of probable error.15 It does not include persons whose addiction has been medically induced, i.e., terminal cancer patients and other chronic sufferers; another list of addicted persons in this category averages about the same length, remaining at less than four hundred.
The British first imposed controls on narcotic drugs in the same period (1920)16 when our enforcement policies were being developed under the Harrison Act. Their regulatory pattern is very similar to ours:17 everyone who has occasion to handle "dangerous drugs" must register, obtain a license, and keep accurate records. With respect to distribution,18 pharmacists must preserve prescriptions and record all sales, and pharmacists' records are inspected periodically by local police officers (who also keep an eye on the distribution of other substances in the dangerous drug and poison categories). Pharmacists are thus watched with some care. The requirement that doctors keep records, however, is not vigorously enforced, but if a doctor's practice in the matter is questioned, or if the prescription records show him to be prescribing unusual amounts, he may be approached by a medical inspector from the Ministry of Health, though he would never be called to account by the police agencies.19 The Act now provides maximum penalties of one thousand pounds' fine and ten years' imprisonment,20 though such penalties are not meted out in practice. The usual kinds of offense are petty defections like the forgery of personal prescriptions, or the practice of deception by an addict's representing himself to be in need of treatment simultaneously to more than one doctor. It is of interest that the latter offense is cast by the regulations solely in terms of the deception practiced on the second prescriber, so the doctors themselves cannot become implicated. The offense of unauthorized possession is qualified as follows:21
"Provided that a person supplied with a drug or preparation by, or upon a prescription given by, a medical practitioner shall not be deemed to be a person generally authorized to be in possession of the drug or preparation if he was then being supplied with a drug or preparation by, or on a prescription given by, another medical practitioner in the course of treatment, and did not disclose the fact to the first-mentioned medical practitioner before the supply by him or on his prescription."
In 1956, sentences for offenses involving opium ranged from 2 months to 6 months and fines from 5 pounds to 100 pounds; for marihuana offenses, from 6 weeks to 5 years and from 5 pounds to 250 pounds; and for manufactured drug offenses (heroin, morphine, etc.), from 1 day to 6 months and 10s. to 100 pounds.22 Addiction among doctors is a comparatively serious problem, as has been noted, but the sanction applied in such cases is loss of authority to prescribe narcotic drugs under the Dangerous Drugs Act, and not loss of authority to practice medicine. If an addicted doctor puts himself under the care of another doctor, he is not likely to encounter any sanctions or difficulties.
The first regulations under the Dangerous Drug Act of 1920 actually left unsettled the same ambiguity which has given so much trouble in interpreting the Harrison Act: whether the treatment of addicted persons is bona fide medical practice or not. They merely exempted classes of persons from the ban on possession in the following general language: "Subject to the provisions of these Regulations a person who is a member of any of the following classes, that is to say:
(a) duly qualified medical practitioners;
(b) . . .
shall be authorised, so far as may be necessary for the practice or exercise of his said profession, function or employment, and in his capacity as a member of his said class, to be in possession of and to supply drugs."23
Paralleling the course of development in the United States even further, the Home Office early took a narrow view of this exemption. Its ruling--still set forth as a guide for practitioners24 and hence still properly cited as in the letter referred to by the Narcotics Bureau (supra, p. 126) was as follows:
"7. The authority granted to a doctor or dentist to possess and supply dangerous drugs is limited by the words so far as may be necessary for the practice or exercise of his profession. In no circumstances may dangerous drugs be used for any other purpose than that of ministering to the strictly medical or dental needs of his patients. The continued supply of dangerous drugs to a patient solely for the gratification of addiction is not regarded as 'medical need'. In a number of cases doctors and dentists who have obtained drugs ostensibly for the needs of their practices and have subsequently diverted them to the gratification of their own addiction have been convicted of offenses under the Dangerous Drugs Act."*
*Emphasis in original.
Here, however, the parallel ended, for after several years of confusion, while the Home Office refrained from prosecutions based on bona fide ministrations to addicts in view of the ambiguity of the law and regulations, the British medical profession took matters into its own hands.
In 1926 the Rolleston Committee, a committee of eminent doctors appointed by the Government to advise on the point, concluded that providing addicted drug users with drugs under suitable controls was distinguishable from supplying "solely for the gratification of addiction,"25 and set forth the following guiding precepts:
"Precautions to be Observed in the Administration of Morphine or Heroin.
The position of a practitioner when using morphine or heroin in the treatment of persons who suffer from addiction to either of these drugs obviously differs in several important respects from that in which he is placed when using the drug in the ordinary course of his medical practice for the treatment of persons not so affected. Not only will the objects of treatment usually differ but also the dangers to be avoided, and the precautions that are therefore necessary. It is thus convenient to discuss these precautions separately as regards:
(i) The administration of the drugs to persons who are already victims of addiction, and
(ii) The ordinary use of the drugs in medical and surgical practice.
"In the preceding section, the conclusion has been stated that morphine or heroin may properly be administered to addicts in the following circumstances, namely, (a) where patients are under treatment by the gradual withdrawal method with a view to cure, (b) where it has been demonstrated, after a prolonged attempt at cure, that the use of the drug cannot be safely discontinued entirely on account of the severity of the withdrawal symptoms produced, (c) where it has been similarly demonstrated that the patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued.
"Precautions in the Treatment of Addicts by the Gradual Withdrawal Method.
In these cases the primary object of the treatment is the cure of the addiction, if practicable. The best hope of cure being afforded by treatment in a suitable institution or nursing home, the patient should, if possible, be induced to enter such an institution or home. If he is unable, or refuses to adopt this course, the practitioner must attempt to cure his condition by steady, judicious reduction of the dose. The general lines of the treatment, as carried out by the practitioners of special experience, have already been described.
For success it is necessary that the patient should be seen frequently, be under sufficient control, and be in the care of a capable and reliable nurse. The practitioner should endeavour to gain his patient's confidence, and to induce him to adhere strictly to the course of treatment prescribed, especially as regards the amount of the drug of addiction which is taken. This last condition is particularly difficult to secure, as such patients are essentially unreliable and will not infrequently endeavour to obtain supplementary supplies of the drug. If, however, the practitioner finds that he cannot maintain the necessary control of the patient, he must consider whether he can properly continue indefinitely to bear the sole responsibility for the treatment.
"When the practitioner finds that he has lost control of the patient, or when the course of the case forces him to doubt whether the administration of the drug can, in the best interests of the patient, be completely discontinued, it will become necessary to consider whether he ought to remain in charge of the case, and accept the responsibility of supplying or ordering indefinitely the drug of addiction in the minimum doses which seem necessary. The responsibility of making such a decision is obviously onerous, and both on this ground, and also for his own protection, in view of the possible inquiries by the Home Office which such continuous administration may occasion, the practitioner will be well advised to obtain a second opinion on the case.
"Precautions in Treatment of Apparently Incurable Cases.
These will include both the cases in which the severity of withdrawal symptoms, observed on complete discontinuance after prolonged attempted cure, and the cases in which the inability of the patient to lead, without a minimum dose, a relatively normal life appear to justify continuous administration of the drug indefinitely. They may be either cases of persons whom the practitioner has himself already treated with a view to cure, or cases of persons as to whom he is satisfied, by information received from those by whom they have been previously treated, that they must be regarded as incurable. In all such cases the main object must be to keep the supply of the drug within the limits of what is strictly necessary. The practitioner must, therefore, see the patient sufficiently often to maintain such observation of his condition as is necessary for justifying the treatment. The opinion expressed by witnesses was to the effect that such patients should ordinarily be seen not less frequently than once a week.
The amount of the drug supplied or ordered on one occasion should not be more than is sufficient to last until the next time the patient is to be seen. A larger supply would only be justified in exceptional cases, for example (on a sea voyage), when the patient was going away in circumstances in which he would not be able to obtain medical advice. In all other cases he should be advised to place himself under the care of another practitioner, who should be placed in communication with his previous medical adviser in order that he might be informed as to the nature of the case and the course of treatment which was being pursued.
"A practitioner when consulted by a patient not previously under his care, who asks that morphine or heroin may be administered or ordered for him for the relief of pain or other symptoms alleged to be urgent, should not supply or order the drug unless satisfied as to the urgency, and should not administer or order more than is immediately necessary. If further administration is desired, in a case in which there is no organic disease justifying such administration, the request should not be acceded to until after the practitioner has obtained from the previous medical attendant an account of the nature of the case. Requests from one practitioner to another for such information should obviously receive immediate attention."
Thus it came to be recognized and established many years ago that the addict in British society remained the addict-patient; he never became, as in ours, the addict-criminal. The precepts just quoted, from the Rolleston Report, have been printed ever since as an appendix to the Home Office Instructions on the Duties, etc. of doctors under the Act.20
The official attitude is well summarized in the Government's current report to the U. N. Commission:21
"There is no compulsory treatment of drug addicts in the United Kingdom.... In the United Kingdom the treatment of a patient is considered to be a matter for the doctor concerned. The nature of the treatment given varies with the circumstances of each case."
Nor is it as illogical as might appear at first blush to leave the Home Office statement and Sir Humphrey Rolleston's in juxtaposition in the current regulatory instructions. Lurking behind all regulatory efforts in the 'twenties was the spectre of the "script doctor," the truly unethical practitioner who abused his license to fill the role, in effect, of our detested dope peddler. If he appeared in England, and did not yield to the gentle suasions of his professional confreres and the civil authorities, it is safe to surmise that he might have been--and could still be--vigorously prosecuted as a grave offender against the Act and Regulations.
The British medical profession has remained, with the inevitable occasional exception, very responsible in the application of the foregoing principles. The primary aim of treatment is to cure the patient by freeing him from his affliction if possible, precisely as in other branches of therapy. Consultation and the concurrence of a second medical opinion are sought as a matter of course before an addicted person is put on any kind of permanent regime.
Great care is ordinarily taken to examine and probe into the condition and history of any new patient who claims a history of addiction. And doctors cooperate informally with the Home Office by reporting addicts under treatment to the Dangerous Drugs Division.
The last mentioned cooperation by the medical profession is, of course, supplemented by the reports of the police inspectors who check pharmacists' registers from time to time. Addicts who are receiving a steady supply of narcotic drugs will be revealed by this check, as well as those who falsify prescriptions or are receiving double dosages by practising fraud--the offense at which police activities are primarily aimed. The number of addicts presently known to the authorities by virtue of this double check, less than 400 in the non-medical category, as has been noted, hence seems quite likely to be a reliable measure.
Enforcement officials in the Home Office say that there is simply no illicit trafficking in the opiates; that no drugs of British manufacture have ever been identified in seizures in the illicit markets of other countries; and that new addicts usually become known to the authorities within six months. The possibility of some epidemic-like change in the pattern is recognized (as has been observed, on a minute scale, in the use of marihuana); but the situation has remained stable for many years and there are no present indications to suggest any significant growth in the addict population.
In 1956 the Minister of Health, allegedly responding to pressure from the United States, announced that he proposed to ban the use of heroin in Great Britain for medical purposes. Following this announcement medical practitioners began to buy up supplies,28 prices rose, and it is believed that a small black market may have made its appearance. Some prominent doctors thereupon organized a campaign to oppose the ban, prevailing upon the Minister, after a much-publicized controversy, to prohibit only the exportation of the drug. Thus the Minister "saved face" while leaving the profession free in the matter. There is still mild resentment over the fact that because heroin was removed from the British Pharmacopeia in 1956 when the ban was proposed, American authorities hailed this as a prohibition and still make statements to the effect that England has joined the United States in outlawing the drug.
Home Office officials believe that even if they stopped all lawful importation of opiates for all purposes, the problem of addiction would remain because addicted persons would be compelled to sustain their condition by the development of a black market. They complain that most of the publicity and press comments about drug problems in the United Kingdom are not authoritative. It was suggested that some of the addicts who have run afoul of the law (or who may be importing their own drugs) are simply unaware of the true state of affairs and of the fact that they can obtain relief and assistance from the medical profession merely by application to a doctor.
The foregoing general and statistical observations were confirmed in a study of local conditions in Glasgow and Edinburgh. In Glasgow, with a population of 1.45 million, four officers of the police department are assigned to enforcement of the regulatory provisions of the Dangerous Drug Act, devoting their full time to inspecting pharmacies, checking records, and investigating alleged violations and abuse. These men are wholly unaware of any serious problem of addiction, and state that there is no black market, with the possible exception that hemp and smoking opium may sometimes get past the customs authorities and into the waterfront district to Chinese and West Indian consumers. There are approximately 350 pharmacies in the city, less than a score of known addicts, and two doctors (out of a total of 40 in the United Kingdom) whose authority to prescribe drugs is currently under suspension.
One of the two doctors has succeeded in curing himself of his addiction, and it is expected that his authority to prescribe drugs will be restored if he makes application.
The officers reflected an attitude of great respect for the medical profession, and stated that they are "not encouraged" to approach the doctors in matters within their jurisdiction; if a questionable or unusual practice comes to their attention, they are expected to report through channels to the Home Office and the matter may then be taken up through the Ministry of Health and the local medical boards.
It was also stated that although the pharmacists are universally cooperative, some doctors, especially the older practitioners, would probably refuse to cooperate with the police concerning their patients under any circumstances, and the suspicion was voiced that 90% of the doctors up here don't keep any records at all.22 There was no identification between addicted persons and persons engaging in criminal activity.
In Edinburgh, with a population of half a million, two men are assigned to policing the Dangerous Drugs Act, and one investigation conducted by them within the last eighteen months has resulted in the preferring of charges.
This was the case of an addict who had made application simultaneously to more than one doctor for care, with a long record of similar activities in the past. Because his wife cooperated with the police in reporting on his activities, he was let off without a sentence as a result of their recommendation to the prosecutor. The officers speculated that he might receive a short prison sentence if he were caught and charged again. They also recalled one case in the preceding year involving a doctor-addict who appeared to have violated the Act by making personal use of drugs purchased by him for administration to his patients. This case resulted in the conveyance of a warning to the doctor without the preferment of charges.
There are seven firms manufacturing narcotic drugs in Edinburgh, accounting for a substantial part of the industry in the United Kingdom. There has been one case of theft from one of these firms since World War II. The police cooperate informally with the firms in checking any applicant for employment about whom there may be suspicions (either of addiction or as a possible thief).
Narcotic addiction (aggravated by war-accumulated stocks of morphine) was recognized as a problem in the waterfront area of Copenhagen in the nineteen forties, but it is now believed to be largely confined to sailors off foreign ships. There have never been extensive smuggling operations, nor evidence of organized black market activities.
Danish officials have found no apparent relation between addiction and criminality.
It is believed that there have been approximately a score of cases of addiction among Danish medical practitioners in the last decade. Addicts in prison populations are an insignificant proportion, less than one percent. Copenhagen has also been plagued with a mild outbreak of hemp (marihuana) smoking, centered along the waterfront and related to the recent upswing in juvenile delinquency in the same "tough" areas.
The Danish law regulates the importation, manufacture and distribution of drugs by a licensing and required records system. Neither addiction nor possession is an offense per se, and most violations involve the forgery of prescriptions, punished by fines or very light prison sentences. Addicted persons may be hospitalized for voluntary detoxification, but they do not come into custody except by the commission of some ordinary criminal offense.
Following a governmental study in 1953-4, reportedly provoked by complaints about the loose practices of a few doctors in Copenhagen, the Danish statutes were revised29 to give the Board of Public Health broad authority over the practices of physicians in the prescribing of euphoriants (including prescription for themselves). Prescription records are scrutinized by the Medical Officer of Health, and if a doctor violates the Medical Officer's rulings, or abuses his rights to prescribe, the latter right may be suspended, after notice and hearing, by the Board of Public Health for a period of one to five years. Provision may be made for the issuance of prescriptions, on behalf of a suspended doctor to meet the needs of his practice, by a regional medical officer or by a colleague designated for the purpose. A doctor who violates a suspension order may be subjected to prosecution, fine and imprisonment. (The maximum penalty for any offense is two years' imprisonment.) By the same enactments the Minister of Home Affairs and Housing was given broad authority to curb the importation and use of any drugs found by the Board of Health to be "highly dangerous by reason of their narcotic properties," and to make regulations to confine the use of such drugs to use for medical and scientific purposes only.
Under this authority the prescribing of drugs for addicts has been centralized in the control of a special committee of doctors in Copenhagen, which passes upon each case of allegedly incurable addiction and prescribes or authorizes the prescription of proper stabilizing doses of drugs.
Officials with many years' experience disclaim any recollection that drug addiction has ever been a major problem in Denmark. The new law and regulations are recognized as a restrictive trend, but their aim is to tighten control over the practices of doctors, in professed emulation of the British system, rather than outright prohibition.
The laws of Sweden,30 last revised in 1933, impose controls on the import, manufacture, distribution and sale of narcotic drugs, by means of licensing and reporting requirements under the jurisdiction of special administrative units in the Royal Medical Board and the Division of Pharmacies. Penalties of up to two years are provided but in practice the courts give very light sentences, and offenses are in the petty misdemeanor category (forging prescriptions, failure to keep records, etc.). The administration of the laws and regulations is very loose and informal. There are only two inspectors to cover the country (500 pharmacies; population, 7 million). Prescriptions are supposed to be filed by the pharmacist and held for two years, but no registers are kept and there is no supervision over medical practitioners except that incidentally given by the chief medical officer of each of the twenty-five counties (a doctor who has general responsibility for supervising the providing of all medical services).
In Sweden the pharmacist (Apotek) is a professional man of considerable standing, and such control as exists is principally exercised through him. He is also a semi-official functionary under the national health laws, with certain duties as a civil servant. There are supposedly 500 to 600 addicted persons in the country, and according to a 1954 survey, approximately 20% of these are medical doctors.
In that year 130 addicted persons received treatment in hospitals, and public health institutions.
In the official view, addiction in the ranks of the medical profession itself is a serious problem. Doctors also sometimes become "easy prey," in prescribing freely and becoming, in effect, peddlers. When this is discovered (through reports from the chemists or inspection of their records) the Royal Medical Board sends for all prescriptions issued by the doctor for analysis, interrogates him informally, and if he is found to be offending, may refer his case to the Board of Medical Discipline. If found guilty by the Board, the doctor may be warned, or sometimes his right to prescribe narcotics may be limited to the issuance of prescriptions to be filled by one or two chemists, or it may be cut off completely. For flagrant offenses the Board may suspend his medical license.
Doctors cannot dispense drugs directly to patients except in case of emergency, and seldom do so. They do not buy drugs from a wholesaler, but must file prescriptions with the chemist, showing whatever purchases they wish to make as destined for use in their own practice. Regulations fix maximum dosages which may be dispensed per one prescription, and the chemists are held strictly accountable for delivering any drug in violation of these prescription regulations.
A Swedish doctor may prescribe narcotics to a known addict in the course of a bona fide attempt to effect a cure, but ordinarily the doctors recommend hospitalization, and it is possible to commit an addict by medical order. There are no special institutions for treating addicts, but the facilities of Sweden's excellent mental hospitals are available for this purpose. Doctors are not permitted to prescribe stabilizing dosages for addicts, so that, besides the loose prescription practices of a number of doctors, there is considerable amount of dissembling by addicts, forging of prescriptions, etc. And there is believed to be a small black market in drugs. It is noteworthy that there is practically no diversion of drugs from the seven companies which manufacture them, or through the chemists (one offense in the latter category every two or three years).
Heroin has never posed a special problem, but Sweden imposed a ban upon it in 1952, and this has caused continuing dissatisfaction among some members of the profession. Some doctors assert, however, that heroin is much more dangerous in terms of addiction liability than the other opiates.
Outpatient treatment of addicts in the open departments of public health hospitals is not regarded as a success because, "the drug peddlers are right in the lounge waiting." In sum, Sweden seems to illustrate the consequences of a policy which neither vigorously represses drug addiction nor yet seeks to alleviate it by vigorous health measures.
The problem remains small-scale, but abuses and the illicit traffic have made their appearance.
The Norwegians are concerned about their drug addiction problem, with an estimated 700 addicts31 (mostly concentrated in the Oslo area), in a population of 4 million.
Controls have been very lax. Doctors may treat addicts, including the administration of stabilizing doses, but if they do so too freely the Ministry of Health may issue a warning or suspend the doctor's right to prescribe drugs.
No doctors have ever been prosecuted for violating drug laws and regulations.
Though registration and licensing requirements are provided, they have not yet been vigorously enforced. For example, unlimited "repeat" prescriptions were freely permitted until the adoption of a new regulation last year.
Most addicts have met their needs by addressing themselves to one of twenty or thirty doctors (half of them in Oslo) who have acquired a reputation for prescribing drugs freely, and this situation has caused the Department of Health to press for new regulations which would create a control board similar to that established in Denmark.32 If a doctor wishes to reduce the dosages of a patient under his care (which happens in thirty or forty cases per year), he may notify the Health Department, which then puts out a bulletin on the case to pharmacists and other doctors, advising against the prescription of drugs to the individual patient involved. Local health authorities may initiate the same arrangement in the case of addicts who come to their notice, referring the case to a doctor to be handled in this fashion. Mental hospitals will accept patients for treatment on a voluntary basis, for periods up to nine months, but there is no provision for involuntary commitment for addiction alone.
The prescription records kept by pharmacists are supervised by two inspectors (who also have many other duties) and if a doctor's prescription practices appear to be far out of line, the Health Department may write to him or refer the matter to the medical officer of his district, though the Department had no power to impose penalties or enforce its views prior to the new regulations referred to above. It is emphasized that the police never take the initiative in connection with any narcotic drug matter, and that there are no officers specially assigned to this field. The law enforcement arm acts only upon the complaint of the Health Department.
There are a few cases of theft of drugs annually and many (several hundred) cases of forgery and fraud in connection with prescriptions. These offenses are not seriously regarded by the courts and the sentences given are light.
Ten to fifteen doctors a year get into trouble with their medical boards for personal addiction (two such cases ended in suicide last year).
Health Department officials recount that publicity about the new regulations has provoked a number of visits and communications from addicted persons, who are leading normal lives and who are very much concerned that repressive policies would drive them into supporting an illicit market.
There is little relation between addiction and criminality; addicted persons are virtually unknown in Norway's penal institutions; and those who end in prison usually are there for repeated petty offenses, such as the forging of prescriptions.
Belgian narcotics laws impose registration, license and record requirements on the narcotic traffic at all levels: import, manufacture, sale and distribution. Drugs may be dispensed only on prescription, and prescriptions must tally with the doctor's record book and inventory. Nine inspectors constantly check the records of Belgium's 4,000 pharmacies (in a population of 9 million).
Formerly, if it appeared from prescriptions that the doctor was prescribing drugs irresponsibly, the inspector could refer the matter directly to the Department of Justice, which might initiate a prosecution. This has been changed, and the new procedure is for complaints to be referred to a Commission Medical Provinciale. There are nine of these commissions, established on a regional basis, and each inspector (who is also a pharmacist), belongs to one commission. This change is for the protection of doctors, who used to be subjected to almost certain disgrace and ruin in their professions by being put on trial on complaint of the Justice Department regardless of the outcome.
Doctors are also subject to the jurisdiction of one of the provincial medical boards, semi-public bodies presided over by a judge, which have authority to censure them for misconduct or, in flagrant cases, to deprive them of their right to practice medicine. There have been few actions against medical practitioners under these provisions.
Addiction is not a crime per se, but addicts frequently commit petty crimes in connection with sustaining their addiction, so that they are liable to prosecution. The Justice Department uses this as a lever to compel submission for voluntary treatment (detoxification), which is provided in special sections of public mental health facilities. The number of persons in institutions for this purpose varies from ten to twenty-five.
There is probably some illicit trafficking. Convictions for forging prescriptions for narcotic drugs average ten per year. Addiction is almost always medically induced at the outset. In 1954 the pharmacy inspectors detected 203 new addicts in the course of checking prescription records (which is done periodically and does not cover all pharmacies every year); 8 doctors, 3 pharmacists, and 2 addicts were convicted of offenses involving prescriptions; sentences ranged from 15 days to 3 months (suspended in both addict cases), and fines from 500 to 2000 Belgian francs ($10 to $40).33 If a doctor has an addicted patient for whom therapy has failed, he may report the fact to the Commission Medical Provinciale and, with the Commission's approval, he may then proceed to set up a stabilizing regime. He is protected in this, since the local inspector is a member of the Commission. But the number of instances in which such arrangements have been made is trifling.
Italian officials know of only a few hundred addicts, approximately fifty of whom are sent each year to public mental health institutions. It is estimated that in the life of the Italian narcotic drug laws, which have been in force for fifty years, approximately one hundred medical practitioners have been subjected to prosecution.
A recently enacted law34 is considerably more severe, however, and the Ministry of Health is now policing the medical profession rigorously. Supervision is provided through a provincial health officer in each of the ninety two provinces, but when an offense is suspected, the matter is promptly turned over to the police and the Justice Department for processing as a criminal case. A Central Narcotics Bureau has been established, and personnel is assigned to it from the national and local police arms. The new law prescribes mandatory minimum sentences in a comparatively harsh penalty structure.35 Pharmacists are rigidly controlled because of a strict limitation on the number of licenses (15,000 in the country), resulting in keen competition for the right to operate a pharmacy. Any deviation from the regulations as to the keeping of prescriptions and records, when discovered in the course of inspection by the regional health officer or the police, may result in loss of the pharmacy license.
Because of this strict hold on pharmacies, the pharmacist is used as an observer-informant, and if his suspicions are aroused he is expected to communicate promptly with provincial officers. Doctors are also under a direct obligation under the new law to denounce any known addict to the police,36 and their rights to prescribe are limited to bona fide medical purposes which do not include prescriptions for addicts.
Although addicts may be incarcerated directly in a mental health institution by the police, to be held at the discretion of the hospital staff until it is determined whether they can be rehabilitated,37 in practice the police often hold addicts in jail and put them through "cold turkey" withdrawal. The authorities also not infrequently succeed in prosecuting addicts on the basis of their presumed intent to sell illegally, from the fact of possession of large amounts of drugs.
There is a provision by which, after incarceration in a mental hospital and observation by a special medical commission, an addict may be determined to be incurable, in which event the medical commission may recommend that he be permitted a stabilizing regime. In practice, however, this provision is used only for addicts with medical complications.
The largest problem, in the official view, is the transit traffic in narcotic drugs being imported in raw form, and processed for trans-shipment to the United States black market. The special narcotic squads of metropolitan police departments are mostly concerned with this type of smuggling and clandestine manufacturing activity. There is also a considerable amount of forgery of prescriptions, theft of drug stocks, and similar crimes, indicating an unsatisfied demand for drugs.
Miscellaneous additional information acquired in the course of this study seems worthy of passing note. In Switzerland the basic law of 1924 was revised in 1951 38 to give the Federal Health Service comprehensive rulemaking powers. But licensed physicians may acquire and dispense drugs without restriction, except for local regulations in a few cantons. Doctors may report addicts to the cantonal authorities if they believe the authorities should intervene to protect the interests of the addict's family or the community. There were 109 known addicts in Switzerland in 1954, and 8 offenses against the federal law, punished by fines of 100 to 500 francs and sentences of 1 to 6 months.39 France, which provides compulsory treatment for delinquent addicts,40 reported the detection of 129 addicts in 1953, and 93 in 1954.41 West Germany reports 4,374 known addicts, including 618 doctors,42 and has just adopted a new code, imposing rigid controls with severe penal sanctions.43 For many years the USSR disclaimed any drug problem in its reports to the U.N.:
"The social evil of drug addiction has been eliminated in the USSR as a result of the fundamental economic and social reforms of 1917 and the continuing rise in the well-being of the workers." But in 1957 the Russian Health Ministry issued new regulations,44 providing in part as follows: "All medical and pharmaceutical establishments in the USSR shall report all drug addicts, when they first come to them for assistance, to the psychoneurological establishments (or dispensaries) in the patient's place of residence so that he may be registered and given the necessary treatment.
"All medical establishments and doctors shall avoid prescribing narcotic drugs for a patient, particularly over a long period except in cases of absolute necessity, bearing in mind that it is carelessness on the part of doctors which is almost the sole cause of drug addiction in the USSR.
"The vicious practice of giving drug addicts prescriptions enabling them to obtain drugs shall be prohibited." Japan enacted a severe Narcotic Control Law in 1953 45 with graduated penalties of 5, 7 and 1-10 years for repeated offenses, including unauthorized possession. The law provides: "No narcotic practitioner shall apply narcotics or supply same for application or prescribe narcotics for any purposes other than medical treatment.
"Despite the provisions in the preceding paragraph, no narcotic practitioners shall apply narcotics or supply same to other persons for application or prescribe narcotics for the purpose of easing the toxic symptoms of narcotic addicts or curing the toxication."
The Republic of China has experimented with total repression in its Order of 3 June, 1955,48 involving the national emergency powers of the government "to thwart the policy of the communist regime of spreading the evils of narcotics." The Order required all addicts to present themselves to a court or police agency within one month, and to undertake to cure themselves (at their own expense, if medication or institutional care was required) within six months. Any addict succeeding in this undertaking "shall be exempt from punishment." For others, the punishment for being a drug user is 3-7 years' imprisonment (1-3 years for marihuana users), the same penalty is increased by two-thirds for a relapse, and for a third offense, the penalty is death. For the sale, transportation, manufacture or cultivation of poppies or opiates, the penalty is death (life imprisonment or death, at the court's discretion, if the offense involves marihuana). Other penalties include trafficking in poppy seeds, 7 years to life; dealing in the paraphernalia of addiction, 1 to 7 years; possession of drugs with intent to sell, to years to life; and possession of poppy seeds, not less than 5 years.
Anyone maintaining a place for the use of narcotic substances, for gain, is punishable by death or life imprisonment, and any government official or member of the armed forces committing any offense, or shielding a perpetrator of an offense, suffers the death penalty. The Regulations direct, "The suppression of narcotic drugs shall be completed within one year from the date of the promulgation of these Rules," call for the establishment of "a network of detection and intelligence services... by coordinating the work of all investigating agencies," and set up an elaborate system of rewards for informers and penalties for neglectful local officials.
1. 38 Stat. 1912, T. S. NO 612.
2. 26 Stat. 620, 1890.
3. L. N. T. S. No. 1845.
4. U. N., First Opium Conference Agreement, 1947 (PP. 5-14).
5. 48 Stat.1543, T. S. No. 863.
6. U. N., Conference on the Suppression of Opium Smoking, PP. 3-15).
7. U. N. Conference on the Suppression of the Illicit Traffic in Dangerous Drugs, 1947.
8. 61 Stat. 2280, T. I. A. S. N0. 1671.
9. 62 Stat. 1796, T. I. A. S. No. 1859.
10. U. N. Pub. S. No. 1953-xi.6.
11. See, e.g., S. Rep. No. 1440, 84th Cong., 2nd Sess., 1956 (pp. 2-4), and the documentation offered on behalf of the United States to the United Nations Commission on Narcotic Drugs in May, 1955 (reproduced in Hearings on "Illicit Narcotics Traffic," Sen. Judiciary Committee, Subcommittee on Improvements in the Federal Criminal Code, June 2, 3 & 8, 1955 Exhibit 9, pp 275-79).
12. See e.g., Anslinger & Tompkins, The Traffic in Narcotics, New York, 1955 (P. 290); Hearings, Sen. Judiciary Committee (see #11), Part 5. Sept. 20, 1955 (P. 1437).
13. Reproduced in Hearings on "Traffic in, and Control of, Narcotics, Barbiturates, and Amphetamines," House Ways and Means Committee, Nov. 7. 1955 (PP. 470-71).
14. The reference is to Dr. Alfred R. Lindesmith. See, e.g., Lindesmith, Opiate Addiction, Evanston, Ill., 1947; and "The British System of Narcotics Control," Law and Contemporary Problems, Vol. 22, No. 1, Winter, 1957 (pp 138-154)
15. It is also conceded that some difficulties are being encountered with marihuana (which is not an addicting substance) in metropolitan areas and mostly among West Indian immigrants, and that there is still some opium-smoking among Chinese in the London and Liverpool dock areas.
In 1956 there were 103 convictions in the courts of the United Kingdom for offenses involving marihuana, 12 for offenses involving opium, and 29 for offenses involving manufactured drugs (heroin, morphine, etc.). Of the latter, over half were "addicts who obtained drugs by forged prescriptions, or by getting supplies simultaneously from more than one doctor," and 8 were for failure to keep drugs in locked receptacles or to keep required records. "Report to the United Nations by H. M. Government ... on the Working of International Treaties on Narcotic Drugs for 1956" (pp. 6-7)
16. Dangerous Drug Act, 1920, 10 & 11 Geo. 5, Ch. 46.
17. Supplementary legislation of major importance is contained in two enactments: the Pharmacy and Poisons Act, 1933, 23 & 24 Geo. 5, Ch. 25, and the Dangerous Drugs Act, 1951. 14 & 15 Geo. 6, Ch. 48.
18. Governed by interpretative regulations, currently Dangerous Drug Regulations, 1953, S. 1. 1955 No. 499, Reg.17. as amended in minor respects by Dangerous Drugs Regulations, 1954, S. 1. 1954. No. 1047
19. Initially the regulations provided for the disciplining of medical practitioners by a special tribunal of medical officers; this provision has never been invoked in the entire history of the Act, and in the 1953 revision of the regulations it was therefore deleted.
20. Scaled upwards from maxima of 500 pounds and two years, for second offenders, in the 1920 Act, by the Act of 1951. On summary conviction (without indictment) the maxima are 250 pounds and 12 months; and if the court is convinced that any breach of a regulation is through inadvertence, the offender shall be fined only, not more than 50 pounds.
21. Regulations, 1955, Supra, Reg. 9.
22. Report to United Nations, etc., 1956. See #15. supra.
23. Currently set forth in Regulations, 1959, supra, as Reg. 4.
24. "The Duties of Doctors and Dentists under the Dangerous Drugs Act and Regulations," Home Office, DD 101 [6th edition], 1956, par. 7.
25. Report, Departmental Committee on Morphine and Heroin Addiction, Ministry of Health, 1926.
26. See #24, Supra, Appendix IV (pp. 13-14).
27. See #15. Supra (p. 4).
28. In the view of many therapists heroin has properties of unique value in treating certain conditions, especially in the respiratory tract.
29. Acts No. 168 and 169, 14 May 1955. An extensive collection of narcotic laws and regulations has been published, in English translation, by the Social and Economic Council of the United Nations. The Danish acts are identified in this series as E/NL/1956 (pp. 99 & 129) Reference to the U.N. source will be made wherever possible in citing foreign authorities in this paper.
30. No. 559. Laws of 1933.
31. U. N. Commission on Narcotic Drugs, Summary of Annual Reports of Governments, 1955. E/NR/1955 (p. 49).
32. Promulgated 27 Sept. 1957, and not yet implemented. The Danish pattern, which in turn derives from the British, will be closely followed.
33. See #31, supra (pp. 45-46).
34. Law No. 1041 of 22 Oct. 1954, E/NL/1954 (p. 144).
35. 3-8 years and 30,000-4,000,000 lira fine for major offenses, including possession in some circumstances.
36. The criminal penalty for failure so to report within two days is a 10,000 to 50,000 lira fine for the first offense and 1 year's imprisonment, with suspension of the right to practice for an equal period, for subsequent offenses.
37. The law provides: "Art. 21. Any person who, by reason of serious mental deterioration caused by the habitual improper use of narcotic drugs, endangers himself or others or causes a public scandal may, at the request of the public security authorities or other interested party and after receipt of a medical report, be ordered by a magistrate to be removed to a clinic, curative establishment or mental hospital for detoxification treatment."
38. Law of 3 Oct. 1951. E/NL/1952 (p. 33).
39. See #31. Supra 1954 (P. 31).
40. Act of 24 Dec. 1953 E/NL/1954 (p. 1).
41. See #31, supra, 1955 (P. 19); 1954 (P. 32).
42. See #31, supra, 1958 (P. 20).
43. E/NL/1957 (pp. 57-84).
44. Order of 6 April 1957, E/NL/1957 (p. 61).
45. Law No. 14, 1953, E/NL/1954 (pp. 145-52).
46. Implemented by Regulations, 29 July 1955. E/NL/1956 (pp. 86-88).