Some Basic Problems in Drug Addiction and Suggestions for Research*

*The author wishes to express his deep appreciation to Miss Marge Moraitis for her intelligent and painstaking assistance in the preparation of this report. The author also wishes to express his gratitude to the staff of the Russell Sage Foundation for their unfailing cooperation.

I. INTRODUCTION-SEVERITY OF PUNISHMENT AS DETERRENCE TO DRUG ADDICTION

In 1914 Congress, with the passage of the Harrison Act, embarked upon a policy of prohibiting legal access to narcotic drugs on the part of those addicted to such drugs. This prohibitory policy has been strengthened by subsequent legislation. It has been implemented with considerable vigor by the Narcotics Bureau of the Treasury Department and by other state and local enforcement agencies throughout the country, acting under the authority of state and local statutes. Despite this effort, a Senate Committee recently came to the conclusion that, "The United States has more narcotic addicts, both in total numbers and population-wise, than any other country of the Western World." Such a finding, that we have more drug addicts than any other Western country, despite forty years of enforcement of prohibitory laws, raises doubts concerning the wisdom of the prohibitory approach to problems of drug addiction. It would seem to require a re-examination of our narcotics policy. Nevertheless, the two Congressional Committees which recently conducted nationwide inquiries into problems of drug addiction and the drug traffic appeared to be oblivious to doubts concerning the wisdom of the current policy toward narcotic drugs. Both Committees took the basic position that even stronger prohibitions were required if our narcotic addiction problems were to be satisfactorily controlled.

(The first inquiry was conducted by a House Committee under the Chairmanship of Hale Boggs; the second by a Senate Committee under the Chairmanship of Price Daniel. Both Committees made determined efforts to get at the facts surrounding drug addiction and the drug traffic in this country. The printed records of the testimony taken run into several thousand pages.) Three basic concepts run through the recommendations of both Congressional Committees: (1) more stringent narcotic law enforcement; (2) severer penalties for offenders against the narcotic laws; (3) the permanent isolation of incurable drug addicts. The thinking of the Committees is contained in the following extracts from their reports: "Effective control of the vicious narcotic traffic requires not only vigorous enforcement, but also certainty of punishment. Conclusive evidence was presented during your sub-committee's investigation that the imposition of heavier penalties was the strongest deterrent to narcotic addiction and narcotic traffic." ...

"Unless immediate action is taken to prohibit probation or suspension of sentence, it is the sub-committee's considered opinion that the first offender peddler problem will become eventually worse and eventually lead to the large scale recruiting of our youth by the upper echelon of traffickers." ... "Some testimony received by the sub-committee that ... a distinction should be made between the non-addict trafficker and the addict trafficker, with the latter group being dealt with less severely. It is the view of your sub-committee that the addict trafficker is just as vicious a person as the non-addict trafficker." ...

"It is urged ... that the minimum and maximum penalties applicable to conviction for violations of the narcotic laws be increased on both the federal and state levels."3 "Criminal laws and procedures are insufficient to insure the apprehension and punishment of narcotics offenders." ...

"Penalties for narcotic violations are neither commensurate with the seriousness of the crime nor sufficient to remove the profits." ...

"The minimum and maximum penalties be increased for all violations of the narcotics law, with greatly increased penalties for sales to juveniles." ...4 "The Committee has found that whenever and wherever penalties are severe and strictly enforced drug addiction and narcotic trafficking have decreased proportionately." ...5 "That habitual narcotic addicts be committed to 'an indeterminable quarantine type of confinement on a suitable narcotics farm'." ...6

INTERIM REPORT

The Report to the President of the Inter-Departmental Committee On Narcotics' also stresses the vital importance of severe punishment as a basic means of controlling drug addiction and the drug problem.

"The Committee has arrived at the conclusion that there is need for a continuation of the policy of punishment of a severe character as a deterrent to narcotic law violations. It therefore recommends an increase of maximum sentences for first as well as subsequent offenses. With respect to the mandatory minimum features of such penalties and prohibitions of suspended sentences or probation, the Committee fully recognizes the objections in principle. It feels however that in order to define the gravity of this class of crime and the assured penalty to follow, these features of the law must be regarded as essential elements of the desired deterrents, although some difference of opinion still exists regarding their application to first offenses of certain types."8 These predilections for stringent law enforcement and severer penalties as answers to the problems of drug addiction reflect the philosophy and the teachings of the Bureau of Narcotics. For years the Bureau has supported the doctrine that if penalties for narcotic drug violations were severe enough and if they could be enforced strictly enough, drug addiction and the drug traffic would largely disappear from the American scene. This approach to problems of narcotics has resulted in spectacular modifications of our narcotic drug laws on both the state and federal level. The 84^th Congress passed legislation which provided that whoever "receives, conceals, buys or sells" heroin, etc., shall be punished by 5 to 10 years' imprisonment for a first offense. The giving, selling or furnishing of heroin to a person under 18 years of age was made punishable by sentences of 10 years to life or the death sentence if directed by the jury. Legal provisions permitting suspended sentence and probation for violations of the drug laws were struck from the federal statutes.

The states have followed the lead of the Federal Government in strengthening penalties for violations of the drug laws. In California, unlawful possession of narcotics was formerly punishable by a maximum of 6 years in the State prison. A 1953 amendment increased the maximum to 10 years and to 20 years for a second offense. In Illinois, illicit possession of a narcotic drug used to be punished by a maximum of one year in the County jail. It is now punishable by 2 to 10 years in the penitentiary for a first offense, and 5 years to life for subsequent offenses. In Michigan, unlawful possession of narcotic drugs was punishable by a maximum of 4 years imprisonment. At present, such possession is punishable by a maximum of to years for a first offense, 20 years for a second offense, and 29 to 40 years for a third offense. In Ohio, unlawful possession of drugs was punishable by a maximum of 5 years imprisonment. Today, the penalties for unlawful possession as a first offense are 2 to 15 years, for a second offense, 5 to 20 years, and for a third offense, 10 to 30 years. Stringent law enforcement has its place in any system of controlling narcotic drugs. However, it is by no means the complete answer to American problems of drug addiction. In the first place it is doubtful whether drug addicts can be deterred from using drugs by threats of jail or prison sentences. The belief that fear of punishment is a vital factor in deterring an addict from using drugs rests upon a superficial view of the drug addiction process and the nature of drug addiction. This will be apparent from the discussion of the nature and mechanics of drug addiction (see infra). It is also doubtful whether it will be possible to incarcerate indefinitely relapsing, uncured drug addicts as recommended by the Senate Committee. The Committee urged this step because of the fear that incurable drug addicts carry the contagion of drug addiction to others. In order to prevent such contagion, incurable drug addicts must be permanently incarcerated and permanently isolated from the community. There are thousands of men and women in this country who are confirmed drug addicts and who are incurable by present methods and techniques. If the Senate Committee recommendation is to be acted upon, places of detention will have to be set up for these thousands of men and women, by Congress and state legislatures. There is little likelihood that federal and state legislation will provide new places of detention for large numbers of confirmed drug addicts. Men and women may jam our prisons and penitentiaries for alleged violations of the drug laws. But it is not likely that in the foreseeable future there will be any wholesale round-up of chronic and incurable drug addicts for more or less permanent isolation.

Since all confirmed addicts cannot be incarcerated, permanently, there will always be addicts at liberty to serve as customers for an illicit drug traffic. Even where drug addicts are sentenced to penal or correctional institutions, they eventually come out. They may be off the drug when in the institution but they usually relapse to the use of drugs shortly after they are released from institutional confinement. Severe penalties and strict enforcement may deter or discourage some drug peddlers. But there will always be others attracted by the lure of the large profits to be made in the drug traffic. The very severity of law enforcement tends to increase the price of drugs on the illicit market and the profits to be made therefrom. The lure of profits and the risks of the traffic simply challenge the ingenuity of the underworld peddlers to find new channels of distribution and new customers, so that profits can be maintained despite the risks involved. So long as a non-addict peddler is willing to take the risk of serving as a wholesaler of drugs, he can always find addict pushers or peddlers to handle the retail aspects of the business in return for a supply of the drugs for themselves.* Thus, it is the belief of the author of this report that no matter how severe law enforcement may be, the drug traffic cannot be eliminated under present prohibitory repressive statutes.

*It should be noted that on occasion, law enforcement agencies themselves may act as suppliers of drugs to addicts. The greater the pressure upon law enforcement agencies, the greater the necessity of producing arrests in drug cases. Arrests in drug cases cannot be made without information. Stool pigeons or informers are vital suppliers of information. Nobody is better equipped to provide information concerning violations of the narcotic drug laws than the narcotic addict himself. One pays off the stool pigeon in money, in winking at his illegal activity, and in the case of the addict, sometimes in seeing that he obtains his drugs. Thus it has been alleged that the law enforcement agencies that are engaged in enforcing the narcotic laws may themselves see that drugs are supplied to addicts.

Moreover, even if it were [theoretically] possible to eliminate the drug traffic through strict and uniform enforcement of narcotic laws, this objective is practically unrealistic. In the first place, inefficiency in law enforcement is endemic in this country. The causes are many and varied.

Among such causes are inadequate recruiting and training of police officials, lack of specialized expert direction of police departments, political selection of police chiefs and district attorneys, part time and amateur administration in attorney's offices and courts, political selection of judges, lack of coordination between law enforcement agencies, lack of State supervision of local law enforcement, conflicts between uncoordinated law enforcement agencies, inadequacies in the law of arrest, search and seizure, and other branches of procedural law, etc.

Any particular community can overcome the factors contributing to inefficient law enforcement and stage a concerted drive against drug addicts and drug peddlers. Such a drive can result in imprisoning many individuals. But it will also bring about an exodus of drug addicts and drug peddlers to communities where the "heat" is not on, and the law enforcement is a little more lax and lenient. So long as our law enforcement agencies consist of thousands of independent units, there will always be communities where the enforcement of the drug laws will be viewed with relative indifference and where drug addicts and drug peddlers can wait out a flurry of law enforcement in their own communities.

Strict law enforcement and severe penalties are therefore not the easy answers to problems of drug addiction. We must look elsewhere for a rational drug control program for this country. Any such program must be based on a thorough understanding of the phenomenon that we are seeking to control. Failure to understand the nature of the phenomenon of drug addiction and the practical problems involved in controlling it are responsible for the fact that drug addiction has such serious consequences in this country.

II. THE DEFINITION OF DRUG ADDICTION

An authoritative definition of drug addiction is that propounded by the World Health Organization: "Drug addiction is a state of periodic and chronic intoxication detrimental to the individual and to society, produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (1) An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (2) A tendency to increase the dose; (3) A psychic (psychological) and sometimes a physical dependence on the effects of the drug." This definition of drug addiction includes many drugs which are not within the scope of our study, such as hypnotic and sedative drugs (barbiturates, etc.) alcohol, amphetamine, mescaline (peyote).9 We are interested primarily in the abuse of the opiate drugs and the synthetic-like opiates, such as heroin, morphine, opium, laudanum dilaudid, codeine, demerol, etc.

We are not engaged in anthropological investigation. Accordingly, we shall not study the abuse of mescaline or peyote, which is of little practical importance in this country and is used primarily by Indians in the Southwest for religious rites. We shall, however, pay some attention to cocaine and marihuana, which are included within the above definition, even though the effects of cocaine or marihuana differ from the opiate drugs. Cocaine is sometimes used alone. It is, however, frequently used as a concomitant of opiate addiction to obtain a special kind of thrill (speedball). The use of marihuana frequently precedes experimentation with the more powerful drugs, such as heroin. Neither cocaine nor marihuana, however, produces the characteristic withdrawal syndrome resulting from physical dependence on the opiates.

We shall not deal with the abuse of alcohol, even though there are many more alcoholics in the United States than opiate addicts. Nor shall we deal with the barbiturates or the amphetamine Problem, even though two Congressional Committees were concerned with their abuse. The legal, though regulated, distribution of alcohol, the barbiturates and amphetamine drugs presents a different set of problems from the complete prohibition of the non medical use and sale of the opiate drugs.* There are those who believe that the legal attitude of strict prohibition of the non medical use of opiate drugs is largely responsible for the character of the drug addiction problems in this country.

*We should note, however, that addiction to and intoxication with alcohol or the barbiturates may produce withdrawal symptoms or an abstinence syndrome which is the characteristic of opiate addiction. Addiction to barbiturates, moreover, may be even more dangerous and harmful than addiction to morphine or to an opium derivative. (See for example Nyswander, The Drug Addict As A Patient, Grune & Stratton, p. 126) The prime drug of addiction in this country is heroin. There is a great deal of use and experimentation with heroin, which does not quite fall within the above definition of the World Health Organization. There are many persons, particularly in the slum areas of our large cities, who have the drug habit--who use drugs more or less regularly, but who have not become addicted. While they may have become psychologically dependent upon heroin, they are not physically dependent upon it and deprivation of heroin may not, in these individuals, produce the characteristic withdrawal symptoms which appear whenever an addict to an opiate drug fails to obtain his usual "fix".

This is illustrated by the following comments of the N. Y. U. study, "Heroin Use and Street Gangs": "Heroin addiction is typified by regular use, increased tolerance and physical dependence. An addict uses at least one dose of heroin (or another drug) every day and his intake increases with time. Yet we find that not all of the 94 heroin users studied are seriously dependent upon the drug, even though most of them have been taking heroin for 2-3 years. For one thing, only 43% take one or more doses of heroin daily; only these can be presumed addicted. The rest take the drug two or three times a week or even less often and many of them remain on this non-addictive level, even though some of them inject directly into a vein. Furthermore, only about half of them (54%) Use the drug intravenously. Such casual or weekend use represents a type that is not usually encountered in the medical literature because such users do not show the typical characteristics of addiction, tolerance and physical dependence.

For this group, heroin use may be largely a social activity, the drug being taken as part of the leisure time patterns the boys have adopted." The terrific adulteration of the drugs sold may explain this phenomenon of use and experimentation with heroin without addiction. A Chicago police officer testified before the Senate Committee: "You see now there is something else. When we test the stuff in our crime laboratory, the quality is over 2%, what they are getting is all milk sugar. I remember years ago, back in 1928 and 1929 an addict would get a cap and it would last him 2 days because it was 50%, or 60% pure . . .

"Here is something else that is very important We have these addicts every day in our bureau and very seldom do we get an addict that is sick. They are all needle addicts. It is just a rare case of where we have an addict that is really sick and going through a withdrawal period"l0 A similar phenomenon was noted for Detroit: "I have tested 1,492 addicts.. . I would assume that there are at least half as many addicts unknown to us ... and when we refer to addicts . . . we are covering marihuana smokers, occasional and the regular type, people who are not really addicted. They are occasional users, what we call 'joy poppers’ - lightly addicted people. And the drugs in Michigan . . . are terrifically adulterated The average capsule of heroin on the street is almost 11/2 to 2%,. . . In other words, a lot of addicts are taking voluntary cures in this city." . . .11 Were it not for the aforementioned adulteration, our drug addict problem would be much more serious than it is at present. The greed of peddlers of narcotics has saved many from a full blown addiction. Nevertheless, there can be little doubt that much addiction results from the occasional or weekend use of drugs like heroin, even where the drugs are greatly adulterated.

III. THE EXTENT OF DRUG ADDICTION

It is impossible to give any exact estimates of the number of drug addicts in this country. Nor can one with full confidence determine the basic question as to whether drug addiction is increasing or decreasing. The strong social disapproval of the use of opiate drugs and the police pressures against drug users and traffickers necessarily cause drug addicts and drug takers to conceal themselves from strange or unfriendly eyes. They do not come into the open to be counted. Any statistics with respect to the extent of drug addiction must, therefore, usually be based on apprehended addicts or apprehended users of drugs. If we knew what proportion of drug addicts or users are arrested every year, we would have a reasonable basis for estimating the extent of drug addiction in this country. Unfortunately, we do not know the proportion that arrested drug addicts or drug users bear to the total addict and user population. Moreover, increases or decreases in the number of arrests are just as likely to reflect increases or decreases in police activity rather than an increase or decrease in drug use or drug addiction. A further complication is the fact that a person arrested as a drug user may not necessarily be an addict, even though he may be so classified by the police. Thus, any statements with respect to the extent of drug addiction and its changes from year to year must be viewed with a considerable degree of reserve and caution.

In 1924, Dr. Lawrence Kolb and A. G. DuMetz12 conducted a survey of the extent of narcotic addiction for the Public Health Service. They came to the conclusion, on the basis of an analysis of surveys of narcotics use, reports on narcotics clinics, statistics on narcotics imported into this country, interviews with physicians and other data that the maximum number of addicts in the U. S. was 150,000. However, Kolb and DuMez believed that the figure of 110,000 addicts for the country in 1924 was more "nearly correct." They also believed that the number of addicts had decreased steadily since l900. Before this decrease set in there may have been 264,000 addicts in this country. The careful analysis of Kolb and DuMez was criticized by Terry and Pellens, who believed that this estimate of 110,000 addicts for the country was too low: "We cannot agree that the ultimate estimate of 110,000 is warranted. While we on the one hand deplore sensational exaggerations, on the other hand we recognize the danger of basing maximal estimates on selected data."13 Until the second World War, the reports of the Bureau of Narcotics were full of statements concerning the reduction in drug addiction. For example, the 1935 Report states: "This recent survey shows that the total number of non medical addicts in the U. S. has decreased to the extent that there is now less than one addict known to the authorities in every thousand of the population"14 A similar comment is found in the 1937 Report: "From the present study it is evident that addiction has decreased to the extent that there are now less than two addicts known to the authorities in every 10,000 of the population."l5 Shortly after the second World War, the use of narcotic drugs appeared to have spread with epidemic force in the slum areas of our large cities, particularly among minority groups of the population. Negroes and Puerto Ricans were especially involved in this increasing use of narcotic drugs, particularly heroin. We do not have any specific statistics on the Puerto Ricans, but the fact that large numbers of Negroes were arrested in recent years for violations of the narcotics laws is apparent from the following figures. In Chicago in 1954, there was a total of 7,639 narcotics arrests; 6,601 of these were Negro arrests, 752 were White arrests and 286 were classified as "other races." In Detroit in the year 1955, Of a total of 1,812 arrests, for violations of the narcotics laws, ,593 were classified as Negroes; 184 were classified as White; 12 were classified as "Yellow"; and 23 were classified as Mexican. The Bureau of Narcotics made a survey of addicts in the United States in the year 1953-1954. Its report noted a total of 6,957 addicts in the Illinois, Indiana and Wisconsin areas; of this number 6,057 were Negro; 916 were listed as Caucasian and 2 were listed as Oriental. In the New York, New Jersey area, of a total of 7,931 addicts, 4,740 were listed as Negro; 3,037 were listed as White, and 160 were listed as Orientals. It should be noted that the ratio of male to female among the persons arrested for violation of the drug laws is approximately 5 to 1.* *For example, in Chicago in the year of 1954, of the 7,699 arrests for violation of the narcotic laws 6,182 were male and 1,457 were female. In New York in 1956, of a total of 6,098 arrests, 5,082 were male and 1,061 were female. In Detroit in the year 1955~ there were 1,812 arrests of which 1, 454 were male and 318 were female.

The most disturbing feature of the increasing resort to the use of narcotic drugs in the post-war period was the apparently increasing use of heroin by adolescents and "teenagers." As the Boggs Committee put it: "In 1948 an upsurge in addiction and an outbreak of teen-age use of narcotic drugs occurred. By 1950, narcotic addiction approached grave proportions in certain metropolitan areas of the country."16 A similar conclusion was reached by the New York Attorney General's Survey, 1952: "The investigation revealed with disturbing clarity that (a) Narcotic use and addiction ...has increased in tremendous fashion since World War II and particularly in the last two years.

(b) The disease has spread with alarming rapidity through the ranks of our adolescent society."17 A Chicago study of drug addiction made in 1952 determined that there were 5,310 individual drug addicts in the City of Chicago, "slightly more than 1/l0th of 1% of Chicago's 1950 population." Upwards of 90% of these persons acquired records as drug addicts during the five years 1947-1952. Males made up 83% of this drug user and addict population. Moreover, more than 4/5ths (84%) were non-white.

Public concern with the apparent increase in the use of drugs after World War II led to a spectacular rise in arrests for violations of the narcotic drug laws. Arrests for violations of narcotic laws appear in the table on pages 32-33.

It is apparent from the table below that arrests for narcotics violations of all types in New York were 712 in 1946 as against 5,965 in 1956; in Chicago the comparable figures were 424 and 9,011; in Los Angeles, 1,166 and 5,091; in Detroit, 339 and 2,646.

There appears to be little doubt that drugs like heroin were readily available in many of the slum areas of our larger cities in the post-war years, despite considerable pressure from law enforcement. This availability of heroin, together with a social and cultural climate in the areas which favored drug use, undoubtedly encouraged many teen-agers and many young adults to try heroin. This experimentation with drugs like heroin must have inevitably increased the drug addict population in this country. Just how much of an increase has resulted from the increased availability and the increased experimentation with heroin, it is difficult to say.

Despite the difficulties in determining the exact number of addicts in the country, the need for data on the extent of the problem has brought about a considerable acceptance of the Bureau of Narcotics' statement that there are almost 60,000 addicts in the country.l8 This estimate was accepted as reasonably accurate in the report to the President of the Inter-Departmental Committee on Narcotics.l9 "Many and varied estimates have been made as to the number of persons in the U. S. addicted to narcotic drugs. The Committee regards the current estimate of the Bureau of Narcotics as the most accurate available. This estimate of 60,000 is based on the records of its own agents and cooperating state and municipal authorities." "While there are far less drug addicts in the Nation today than there were before the Harrison Narcotics Act was passed and before the Federal Bureau of Narcotics was created, the figure of 60,000 addicts today is far more than the number reported by other western nations." There are indications that this estimate of 60,000 narcotics addicts for this country is too low. For example, a recent California report to the Attorney General on Narcotic Addiction stated: "What is the extent of addiction in California? No one knows with any degree of accuracy. It’ s known that we have in our State medical files some 32,000 persons who are legally using narcotics medicinally, although a certain percentage of them may be using it illegally because they are going to several different doctors concurrently The state criminal files reflect that there are approximately 10,000 additional illegal traffickers or users of narcotics in California. It is believed that 10,000 represents approximately one-half of the total illegal addicts in this State. Our estimated total, therefore, would be 32,000 medical or legal users and probably 20,000 illegal, a total of 52,000 persons.-If it is true that there are at least 20,000 illegal users of opiate drugs in California alone, then it is questionable that there are only 40,000 more addicts in the rest of the United States. It appears to be obvious that the exact number of drug addicts in this country is unknown. However, it is apparent that whatever the extent of drug addiction in this country may be, as Terry and Pellens pointed out almost 30 years ago: "The surveys and estimates indicate sufficiently the existence of a major medical-social problem.... As a matter of fact it is not necessary to know the exact number of users or even the minimal extent to realize that there are a large number in the country and that the problem is serious."21

IV. THE NATURE AND CHARACTERISTICS OF DRUG ADDICTION

The law has largely acted on the premise, which is supported by some of the earlier writers, that drug addiction was largely a vice, which an effort of the will could conquer. Severe penalties were necessary to compel the will to make the effort to conquer the vice. Medical writers, on the other hand, have taken the view that drug addiction was a disease and that the drug addict was a sick person. For example, Emest S. Bishop wrote many years ago: "The fundamental truth which applies to all cases of narcotic drug addiction is this--whatever may have been the circumstances of the primary administration of narcotic drugs, or whatever the physical, ethical or personal status of the person addicted... Continued administration of the drug creates within the body of the person to whom the drug is administered a physical disease process. A demonstration of material cause and effect in obvious symptomatology, in physical suffering, and in nerve strain and exhaustion, unless there is applied to that person in sufficient amounts the drug of his addiction. Every addict is sick of a disease condition... insufficiently recognized and insufficiently studied."22 Or as Dr. William G. Somerville put it: "Drug addiction is a disease, a pathological condition just as much as the psychoneuroses of any of the various toxic states."23 If the physiological and psychological need for the drug inherent in drug addiction is a disease, then it will be apparent from our discussion of relapse that it is a disease which is largely incurable by present methods and techniques. The course of the disease can only be controlled by the continued administration of the drug of addiction or some similar drug.

There are, however, many who do not regard drug addiction as a disease entity. Maurer and Vogel for example have pointed out that: "All the research done on drug addiction within the past two generations indicates that addiction is not a disease, rather a symptom of personality difficulties, which if they did not lead to drug addiction would lead to difficulties of other types."24

Maurer and Vogel would say that drug addicts are sick, unbalanced, disturbed, abnormal individuals. Unfortunately as we shall see in our discussion of the personality types of drug addicts (infra), it is easier to attach a psycho-pathological label to the drug addict than to explain how or why he became addicted or why he continues his addiction.

Many with similar psychological difficulties do not become addicted to drugs. Some become alcoholics rather than drug addicts. The mere designation of a drug addict as a sick, unbalanced, disturbed or abnormal individual conceals more than it reveals. This is clearly indicated by the comments of Dr. H. Isbell: "Addiction is a complex process in which pharmacological, psychological, socio-economic and legal factors play interdependent roles. It is viewed in two ways: (1) as a distinct disease; (2) as a symptom of an underlying personality disorder.

Both views can be supported by evidence established so far. Studies have shown that the majority of addicts have personality disorders which antedate drug use. Also, addicts use many drugs and change from one to another especially when their favorite drug is difficult to obtain. Drugs used by addicts also have diverse actions; they not only use drugs that cause 'depression' but also stimulants. The only common denominator among drugs abused by addicts seems to be that they all are compounds which exert powerful effects on the central nervous system. These facts suggest that there is nothing specific about the drugs that addicts take and, therefore, addiction is nothing more than a symptom of the personality disorder. This view cannot be accepted without reservation. The theories of personality that are used to explain addiction are the same theories that are used to explain neurosis, psychoses, character disorders, etc. Since it is known that many persons with personality characteristics similar to those of addicts never abuse drugs, it is apparent that factors other than personality must be operating. Furthermore, under conditions of equal drug exposure, one individual may choose opiates, another alcohol. This implies some sort of specificity in the choice of the drug of addiction."25

Whether addiction to drugs be viewed as a disease or as a symptom of personality disorder it usually involves the three characteristically related phenomena, noted in the definition of the World Health Organization, namely, (1) tolerance, (2) physical dependence and (3) emotional dependence. These phenomena have been described by Isbell and White as follows: "By tolerance is meant a decreasing effect on repetition of the same dose of a drug. This particular characteristic is very marked in addiction to the opiates and synthetic analgesics.

Patients with well developed tolerance have injected as much as 5 gm. (78 gr.) of morphine sulfate intravenously in less than twenty-four hours without developing significant toxic symptoms. Tolerance to the various effects of morphine and related drugs develops, however, at different rates and in different degrees. For example, tolerance to the toxic, sedative, emetic, analgesic and respiratory-depressant effects of morphine develops very rapidly and becomes marked, whereas tolerance to the miotic effects and to the spasmogenic effects on gastro-intestinal smooth muscle, if developed at all, is never complete. "Physical dependence refers to the development of an altered physiologic state which requires continued administration of a drug to prevent the appearance of a characteristic illness, termed an 'abstinence syndrome.' Physical dependence is an extremely important characteristic of addiction to morphine and similar drugs, since it leads to continuity of intoxication with resultant subservience of all phases of the addict's life to the one aim of obtaining and maintaining a constant supply of the drug.

"Emotional dependence is defined as a substitution of the use of the drug for other types of adaptive behavior. In other words, use of the drug becomes the answer to all of life's problems. Instead of taking constructive action about his difficulties, regardless of their type, the addict seeks refuge in his drug."26 It is simpler to describe the phenomenon of tolerance to and physical dependence upon opiate drugs, as Isbell and White have done, than to explain the exact mechanics of their action upon the human organism. A great deal of research has been done on both phenomena in the attempt to find such explanations. Much of value has been uncovered by this research. Nevertheless, the fundamental effects of narcotic drugs upon the human system are still obscure. As Maurer and Vogel have noted: "The action of the opiate drugs and their synthetic equivalents upon human beings is still imperfectly understood. This fact is striking when we consider that opium has been used generally for thousands of years, and that no single medicine is more useful or more generally used by the physician than the modern opium derivatives and opium-like synthetics .

Certain fundamental questions are still unanswered; many peripheral or incidental problems remain to be solved. With some of the basic reactions of opiates upon the human physiology and neurology still obscure, it is not surprising that the nature of addiction to drugs of the opiate series ...should still be a controversial matter. The nature of narcotic addiction is still not yet fully understood."27* *"An examination of Nathan A. Eddy's classic chapter on tolerance and addiction, which summarizes the studies up to 1940, indicates the soundness of the above observation. Dr. Eddy wrote as follows: "The last word has not been said by any means on the mechanism of tolerance and addiction to morphine. Evidence is accumulating that morphine is handled differently in the tolerant animal. In addition, the phasic character of morphine action (excitation on the one hand, and apparent depression on the other hand), seems to be intimately concerned in the tolerance development and addiction, whether it is a question of the time relations of the two effects or of an alteration of the biologic substrate. The disturbed autonomic and hormone balance in addiction and withdrawal needs further careful thorough study."28 Commenting on tolerance, Dr. Eddy stated: "The evidence as a whole points to a change in the cells of the nervous system as the important factor, but the exact nature of the change and its fundamental mechanism are still unknown." In the same volume as Dr. Eddy's study, Margaret Sumwalt analyzed the studies which attempted to answer the question of what the organism does to morphine. She pointed out that man disposed of between 1/3 to 1/10 of his intake of morphine in his urine and feces. Sweat and saliva carry trivial amounts. Milk perhaps more.

"The remaining 65 to 85% is got rid of rather promptly by unknown chemical processes ... The chemistry of morphine metabolism is unknown."29 The present status of research on tolerance and dependence is clearly summarized by Isbell, in his authoritative article, "Trends Research On Opiate Addiction." "Most physiological research in addiction has been concerned with tolerance and physical dependence. Two major hypotheses have been developed. The first is that of Tatum, Seevers and Collins and is based on the dual character of the effects of morphine on the central nervous system. Morphine has both excitant and depressant effects within the central nervous system. In animals, the excitant effects appear to outlast the depressant effects. Therefore, as morphine is repeatedly administered, the excitant effects constantly increase. This excess excitation requires more and more of the drug in order to obtain the excitant effects, which are still present, and unopposed by depressant effects; hence, abstinence symptoms occur. Recently this hypothesis has been expanded. It is conceived that morphine exerts its depressant effects by attachment to receptors within the cells. The drug at receptor sites on the cell surface is in equilibrium with drugs in body fluids, is easily detached and swiftly metabolized. Morphine hypothetically diffuses into and out of cells quite slowly, so that degradation of drug attached at this site is slow. Since drugs on the cell surface are more rapidly dissipated than are drugs within the cells, the excitant effects outlast the depressant. Unfortunately this concept is completely untestable with present technics, and there are also objections to the 'depressant-excitant' formulation. In the lower animals, codeine is a more excitant drug than is morphine. One would therefore, assume that symptoms of abstinence from codeine would be more severe than symptoms of abstinence from morphine; actually, the reverse is the case. Also, in the chronic spinal dog, morphine markedly enhances-'stimulates'--the ipsilateral extensor thrust reflex.

"If this is regarded as an excitant action of morphine, the reflex should be even more hyperactive following withdrawal of the drug. Actually, the extensor thrust reflex disappears during abstinence. "The other theory of tolerance and physical dependence was first formulated by Joel and Ettinger and has been further developed by Himmelsbach. In this formulation, it is hypothesized that the administration of morphine calls into play homeostatic responses which oppose the effects--chiefly the depressant effects--of the morphine. These homeostatic responses are gradually strengthened by repeated administration of the drug and, therefore, more drug is required to induce the initial degree of effect. When morphine is removed, the enhanced homeostatic responses still remain and are released from the brake imposed on them by the continued presence of morphine in the organism, thus accounting for symptoms of abstinence. This formulation seems to fit the facts. For example, morphine constricts the pupils and depresses respiratory rate in minute volume. When morphine is withdrawn, the pupils dilate and hyperpnea ensues. Many other examples could be stated. In fact, the development of counter responses which oppose the main effects of drugs may be a general pharmacological phenomenon... It is apparent, however, that the homeostatic theory is more descriptive than explanatory. It tells us what happens but not really how. We have very little knowledge of the mechanisms of the homeostatic responses that supposedly oppose the actions of morphine. Due to the researches of Wikler, we can describe them in neurophysiological terms. In the non-addicted chronic spinal dog, morphine enhances the extensor reflexes, and has little effect on the knee jerk. It can be inferred from these facts that morphine depresses reflexes which are mediated through multi- neuron arcs (the flexor) and has little effect on reflex arcs that are mediated through a single synapse (the patellar). As tolerance develops, multineuron arcs become hyperexcitable and, on withdrawal of the morphine, excitability in these arcs is unmasked and accounts for withdrawal symptoms. Similar phenomena have been observed in spinal man. It is also known that chronic decorticated dogs develop tolerance and symptoms of abstinence on withdrawal of morphine. One may infer therefore, that the cerebral cortex is not necessary for the development of physical dependence. Although these facts give us some concept of the neurophysiological changes associated with addiction we know little about the nature of the changes at levels between the cord and the cortex. Technical difficulties in studying the activity of these levels in chronically intoxicated animals have not yet been solved, but the current trend in neurophysiological research in addiction consists partly of attempts to develop such methods.

"Biochemical studies have shown that tolerance and physical dependence are not related to changes in excretion or distribution of morphine within the organism, and are also not due to any known degradation product of morphine. Eisenman and Fraser have shown that maintained addiction causes a decrease in the urinary excretion of 17-ketosteroids, 17-hydroxycorticoids, and of pituitary gonadotropin although the adrenal and the gonads remain responsive to ACTH and chronic gonadotropin. On withdrawal of morphine, excretion of 17-ketosteroids is increased, serum corticoid levels rise and eosinophile counts decrease. These results indicate depression of the adrenals, the gonads or both by morphine during maintained addiction probably because of depression of the pituitary through unknown central mechanisms. During abstinence, there is a marked adrenal discharge. These findings are very important since they explain the decreased libido and sexual activity present during opiate addiction. The psychiatric significance of this effect requires no comment. "Efforts to elucidate the biochemical mechanisms underlying dependence and tolerance have not yet proved fruitful. Though the technical difficulties are great, studies of this sort are now being pushed. Obviously, we cannot explain all the phenomena of addiction by physiological data alone. Physiological data, though very useful in understanding symptoms and in managing them, contribute to total understanding of the problem only insofar as correlation of physiological mechanisms with drug induced changes in behavior are possible. "30 Whatever the mechanics of tolerance and dependence, if the addict has reached the stage of physical dependence upon a drug, he must obtain the drug regularly if he is to avoid the distressing experience of the withdrawal syndrome. How much of the drug he will use, will depend in the first instance on how much he can get. If the drug is available, despite the mechanism of tolerance, each addict eventually tends to find a level or a physical plateau in the use of the drugs. He tends to stop increasing the dosage at a point where he feels right physically and psychologically or where the drug will give him the euphoria that he is looking for. But whatever his level or plateau, the addict must obtain enough drugs to ward off the withdrawal symptoms which inevitably follow any failure to obtain the drug.

The withdrawal syndrome or sickness is no mere figment of the addict's imagination, but an illness which constitutes one of the most stereotyped syndromes in clinical medicine.

Wikler has demonstrated that physical dependence is a real physiological entity and is not psychic in origin. He has distinguished the purposive from the non purposive features of the withdrawal syndrome as follows: "The train of events which follow abrupt cessation of morphine in the tolerant addict varies within limits in different individuals, and is related to previous dosage, duration of addiction and the degree of tolerance which had been developed. However, for any given dose level and period of addiction, the morphine abstinence syndrome is remarkably reproducible in any given individual. The significance of the morphine abstinence syndrome to the individual is also highly individualized and is partly determined by particular situations. Thus, it may serve as a means for expressing hostility, expiating guilt and even justifying relapse. When observed in a hospital situation after abrupt and complete withdrawal of the drug, the fully developed morphine and abstinence syndrome is characterized by the following changes, which may be separated into two groups: "

(a) NON-PURPOSIVE. These consist of yawning, lachrymation, rhinorrhea, mydriasis, gooseflesh (piloerection) tremors, muscle twitches (particularly in the lower extremities), restlessness, hot and cold flashes, nausea, vomiting, diarrhea, anorexia, weight loss, ejaculations in men and orgasms in women, elevation of body temperature, cardiac and respiratory rates and blood pressure, leucocytosis, hemoconcentration, elevation of blood sugar and a precipitous drop in circulating eosinophile count. In addition, the subject often exhibits a rather typical facies suggestive of an individual with an acute febrile infectious disease. Often the patient 'curls up' in the lateral recumbent position with a blanket drawn over his head, preferably on a hard cold surface, such as the floor. Curiously, alpha activity in the electroencephalogram if present in prewithdrawal records, continues during the abstinence period in spite of manifest 'anxiety', although an increase in slow activity may be observed during abstinence following periods of addiction to other morphine-like drugs.

(b) PURPOSIVE. This group of morphine abstinence changes refers to such behavior as appears to be directed toward obtaining the drug. It is expressed verbally in terms of 'craving' and demanding drugs. Also, the subject may exhibit patterns of behavior which are highly individualized-threatening suicide, or violence, assuming bizarre postures and exaggerating his distress in dramatic ways.

"The non purposive abstinence changes reach peak intensity about 48-72 hours after abrupt withdrawal of morphine and subside gradually over a period of about one week, although some physiological variables do not return to control levels for as long as six months, while the 'purposive' abstinence changes may continue indefinitely."31 According to Lindesmith, the necessity of avoiding withdrawal distress provides the basic explanation of the nature and the processes of drug addiction. "Addiction to opiates," he points out: "... is determined by the individual's reaction to the withdrawal symptoms which occur when the drug's effects are beginning to wear off, rather than upon positive euphoric effects often erroneously attributed to its continued use. More specifically, the complex of attitudes which constitute addiction is built up in the process of conscious use of the drug to alleviate or avoid withdrawal distress. This theory, though simple in form, has considerable explanatory value, and offers a means of accounting for varied and paradoxical aspects of the habit, such as the addict's claim that he feels normal under the drug's influence, as well as his tendency to increase the dose to a point where its use becomes much more unpleasant and burdensome than it need be. The hypothesis presented makes intelligible the constant preoccupation of the addict with the drug, and explains how the unpleasant and unwelcome appellation 'dope fiend' is forced upon him."32 "Addiction occurs only when opiates are used, to alleviate withdrawal distress, after this distress has been properly understood or interpreted, that is to say, after it has been represented to the individual in terms of the linguistic symbols and cultural patterns which have grown up around the opiate habit. If the individual fails to conceive of his distress as withdrawal distress brought about by the absence of opiates he cannot become addicted, but if he does, addiction is quickly and permanently established through further use of the drug. All of the evidence unequivocally supports this conclusion. "This theory furnishes a simple but effective explanation, not only of the manner in which addiction becomes established, but also of the essential features of addiction behavior, those features which are found in addiction in all parts of the world and which are common to all cases."33 Whatever the truth of Lindesmith's theory, there can be little doubt that once a user of drugs realizes that he has become addicted his entire life becomes centered around the search for the drug. He must obtain the drug in order to be comfortable and to be able to function. He may also want the drug in order to obtain an ever elusive euphoria. The drive and compulsion for the drug is such that family, friends, property, profession may all be sacrificed to feed it. The compulsion to take the drug cannot be stopped by a threat of jail or prison sentences.

V. THE EFFECTS OF DRUG ADDICTION

The compulsion to take the drug is one of the components of the "drug fiend" myth which has been propagated by irresponsible journalism and irresponsible law enforcement. Another vital aspect to this myth is the misconception concerning what narcotic drugs do to human beings and the kind of behavior that such drugs foster. It is alleged that drugs like heroin and morphine have devastating effects on the persons who use them. Murder on the installment plan is a phrase frequently used to describe heroin addiction. It is charged, moreover, that the use of narcotic drugs leads to the commission of all kinds of serious crime, particularly crimes of violence. The printed proceedings of the House and the Senate Committees are full of such charges concerning the use of narcotic drugs. The pernicious effects of narcotic drugs on human beings were the justification for the severe penalties that were recommended as a means of dealing with the drug traffic and problems of drug addiction.

Unfortunately, the facts concerning the effects of such drugs as morphine and heroin on human beings differ considerably from these misconceptions. The facts tend to indicate that the use of drugs like heroin and morphine is consistent both with a reasonable state of health and with a reasonable degree of efficiency on the part of the individual user.

Over thirty years ago, Dr. Kolb pointed out that there was no evidence that the use of a narcotic drug made one less efficient. It was lack of the drug and the constant pre-occupation with obtaining it which led to a loss of efficiency on the part of the individual. Thus, the drug addict is not, by virtue of the fact that he takes a drug, necessarily a parasite, who is unable to function in any productive capacity. Nor is he necessarily a degenerate human being who, because he takes drugs is sliding rapidly towards the grave. This is apparent from the comments of Dr. Nathan B. Eddy, who analyzed the world literature on morphine in 1940 and who observed: "Given an addict who is receiving morphine in amount and at intervals adequate to keep the withdrawal symptoms completely in abeyance, the deviations from normal physiological behavior are minor for the most part within the range of normal variations."34 Professor W. G. Karr, a biochemist of the University of Pennsylvania, wrote in a similar vein: "The addict under his normal tolerance of morphine is medically a well man. Careful studies of all known medical tests for pathological variation indicated, with a few minor exceptions, that the addict is a well individual when receiving satisfying quantities of a drug. He responds to work in the normal manner. He is as agreeable a patient, even more so, than other hospital cases. When he is abruptly withdrawn from the drug he is most decidedly a sick individual."35 The feeling of normality and well being which an addict has, when he is using the drug was observable by Dr. Marie Nyswander, when she tested a group of patients at Lexington by means of Rorschach tests, both before and after using morphine. She writes: "With the administration of morphine a striking change is observed in the Rorschach-a change which corresponds to the addict's subjective feeling that he has attained normalcy. The responses begin to fall into more normal categories; the constriction is lessened, and movement response and fantasy appear."36 Dr. Lawrence Kolb noted that many prominent people who led socially useful lives have been addicted to narcotic drugs, yet were able to function effectively in their business and profession.37 As a matter of fact some who at one time were gutter alcoholics have improved themselves and their social functioning by shifting to morphine. This notion that the use of an opiate drug may actually improve the functioning of a particular individual is clearly presented by Wikler and Rasor: "On further interrogation, the majority of such individuals explain that in ordinary life situations opiates (usually heroin or morphine) reduce appetite, pain and erotic urges of all sorts, heterosexual, homosexual or autoerotic. In addition, intravenous injection of these agents produces a transient 'thrill' akin to sexual orgasm, except that it is centered in the abdomen. After these effects have developed a sense of gratification or satisfaction is achieved and they feel more 'at ease' and free to do what they 'want to do.' In some situations they may 'want' to doze peacefully and enjoy daydreams of wealth, power or social prestige. In other situations they may want to socialize, and they feel more comfortable to the presence of women. Furthermore, some opiate users state that these agents do not impair, others state that they actually improve, their ability to do useful work and that under the influence of opiates, they are less aggressive and 'keep out of trouble.' "It is difficult, of course, to verify statements such as these relative to the contrasting effects of drugs in actual life situations. However, observations made under experimental conditions are in substantial agreement with them. Thus, as long as adequate amounts of opiates are administered, aggressive, antisocial behavior is practically never observed, personal hygiene is maintained, assigned responsibilities are discharged satisfactorily, psychologic tests of performance reveal little or no impairment, and the sensorium remains quite clear, while anxiety associated with anticipation of pain is reduced."38 Opiate drugs like morphine do have certain effects upon the individual. The use of the drug causes a loss of appetite. Thus there may be a failure to maintain a proper intake of foods. This may affect health. However, as Maurer and Vogel point out: "... it has not been possible to demonstrate that opiate drugs in themselves actually destroy tissue or are directly the cause of tissue deterioration."39 The existence of emaciation and anemia in drug addicts, "...may be due to the unhygienic and impoverished life of the addict rather than to the direct effect of the drug."40 The drug addict simply does not eat enough, because on the one hand the drug he uses reduces appetite and on the other hand, costs so much that he has no money left over for food. Another effect of drug addiction is in reducing the urge to sex.

"The reproductive system generally tends to become inactive. ... In both males and females, opiates have a general tendency to reduce or obliterate sexual desire, although there may be individual exceptions to this."41 This lowering of sexual desire resulting from narcotic drugs would cause one to be skeptical of the claim that heroin and morphine incite to violent sexual crimes. Drug addiction may result in moral and character deterioration. But here the legal and social policy concerning drug addiction may be at fault rather than the use of the drug. An addict can only obtain the drug from underworld sources. He is cut off from any legitimate supply. The underworld will supply him at a price. The price is high and most addicts do not have the kind of money necessary to feed a habit. The obvious alternative is to raise the money by theft or if the addict is a woman, by prostitution.

Once the addict is started on a criminal or prostitutional career, his moral deterioration becomes almost inevitable. But the question may well be raised whether it is the drug or the short sighted social policy which utterly fails to take into account the desperate need of the addict for his drugs which causes the breakdown in character.

As Lindesmith notes: "Addicts escape most of the alleged degenerate results of the drug if they are sufficiently well-to-do, and many addicts suffer serious 'character deterioration' only after the narcotic agents catch up with them. In other countries ... addicts do not suffer evil effects ... forced upon the American users. They do not steal, lie, engage in prostitution, or become derelicts to the extent that our addicts do. If the toxic effect of the drug on the central nervous system promotes degeneration, or if addiction is a bio-chemical affair,... why do not similar conditions result in other countries or in our own upper class."42

VI. PSYCHIATRIC AND PSYCHOLOGICAL FACTORS IN DRUG ADDICTION

As we have seen, medical men have tended to regard drug addiction either as a disease or as a symptom of a disturbed or abnormal personality that requires drugs in order to be able to cope with life's problems. Drug addiction may be considered a disease if the focus of attention is the pathologic process in the human organism created by addiction. A healthy human organism does not need morphine or heroin to ward off withdrawal symptoms. The diseased body of an addict, however, requires its daily dosage of drug for the addict to be comfortable. On the other hand, drug addiction is not an accidental process. Individual factors are at work in the determination of who will and who will not become addicted, even in those areas of our cities, where the incidence of drug use is high. There are individuals who are exposed to drug use, who through an effort of will, strength of character or force of personality reject all contact with narcotic drugs. These individuals will never become drug addicts. There are also some persons who although once addicted, through will power, or force of personality and character manage to stay off drugs. It is obvious that character and personality factors are at work in the selection of addicts and in determining which addicts will relapse to the use of drugs, once they have been taken off drugs.

Who, then, are the individuals who succumb to drug addiction? What factors of personality, of character, of psychological organization or disorganization distinguish the drug addict from the non-addict? Can the phenomenon of drug addiction be explained by the disciplines of psychology and psychiatry? Even the most casual reading of the psychiatric and psychological literature on drug addiction indicates that psychology and psychiatry are still far from satisfactory explanations as to why specific individuals take to drugs, and why others who may be similarly exposed do not take to drugs to resolve their personal problems. Over and over again, one reads that drug addiction is an expression of personality disturbance or maladjustment. An individual takes drugs to overcome the shortcomings of personality which make it difficult for him to cope with the world in which he lives. He needs drugs to enable him to deal with the anxieties and tensions arising from familial conflicts, sexual difficulties and the necessity of growing up and taking one's place in an adult society. A vast majority of drug addict patients, write Vogel, Isbell and Chapman, "... are fundamentally emotionally immature children like persons who have never made a proper adaptation to the problems of living."43 Not all drug addicts, however, fit into a single psychiatric classification or diagnosis. The personality disorders of drug addicts, "... run the gamut of the standard psychiatric nomenclature from the simple anxiety states to the major psychoses."44 Thus, all kinds of people, both normal and abnormal, become drug addicts. This can be seen from the summary by Vogel, Isbell and Chapman of the pioneering work on the classification of drug addicts done by Kolb* and Felix.** *In 1925 Dr. Lawrence Kolb made his pioneer study of 230 drug addicts recruited from prisons, a municipal hospital, a clinic "and other addicts in good social standing in various parts of the country." This fell into the following general classifications: 1. People of normal nervous constitution necessarily or accidentally addicted through medication in course of illness. This group constituted 14% of the total; 9% being necessary addicts and 5% were accidental cases.

2. Care-free individuals, devoted to pleasure, seeking new excitements and sensations, and usually having some ill-defined instability of personality that often expresses itself in mild infractions of social customs. This group constituted 38% of the total.

3. Cases with definite neuroses not falling into classes 2, 4 or 5. This group constituted 13.5% of the total.

4. Habitual criminals, always psychopathic. This group constituted l3% of the total.

5. Inebriates. (Only those who had a definite history of periodic drinking with sprees were considered for this study.) This group constituted 21.5% of the total.

In 1937. Dr. Kolb and Dr. Ossenfort attempted to refine the classification in this earlier study, based upon an analysis of the first 1,750 admissions at Lexington. The addicts were classified as follows: 1. Normal individuals accidentally addicted. This group includes persons of normal nervous constitution accidentally or necessarily addicted through medication in the course of illness.

2. Psychopathic Diathesis. This group includes individuals who show psychopathic dispositions or tendencies characterized by behavior resulting from misinterpretations of environmental settings or situations, but not a well-crystalized personality defect.

3. Psychoneurosis. This group includes individuals suffering with ordinary types of psychoneurosis.

4. Psychopathic personality without psychosis. This group is composed of persons who show deviation of personality usually expressed as constitutional psychopathic inferiority, psychopathic personality or constitutional states, where volitional and emotional control are gravely distorted from the normal.

5. Inebriate. This group includes individuals in whom alcoholic indulgence, either periodic or more or less continuous, played an important role as a precipitating factor in their addiction. They apparently have a so-called inebriate impulse.

6. Drug addiction associated with psychosis. This group includes addicts suffering with frank psychosis, organic, toxic or functional. In 1939. D'. Michael Pescor made an analysis of the personalities of 1036 addicts at Lexington, Kentucky, based upon the aforementioned psychiatric classifications. Dr. Pescor came to the conclusion that the 1036 addicts studied by him fell into the following:

1. Normal individuals, accidentally addicted--3.8%

2. Psychopathic Diathesis--54.5%

3. Psychoneurosis (ordinary type)—6.3%

4. Inebriate -Inebriate Impulse—21.9%

5. Psychopathic Personality Without Psychosis--11.7%

6. Drug Addiction Associated With Psychosis—11.7%

7. Psychosis Caused by Opiates--None.

**Dr. Robert H. Felix, in 1939, attempted to further define three categories in the above Kolb, Ossenfort, Pescor classification, namely the psychoneurotic, the psychopathic personality and the psychopathic diathesis.

His difficulties with these elusive categories are apparent from the following extracts of his article: "The concept of the psychopathic-diathesis group may not be as dear as that of the other two, but probably can best be described as a state in which, because of some ill-defined instability of personality, no better than a border-line adjustment is made. The individual is not fundamentally anti-social and, with some artificial assistance, can make an acceptable adjustment. The most striking characteristic of this group is the fact that, as a whole, they were adjusting marginally before they became acquainted with narcotics. After their first few experiences with the drug, they felt an exhilaration and a sense of relief comparable to the solution of a difficult problem or the shaking off of a heavy responsibility. Many of them also felt an increase in efficiency which, in some cases, at least, appears to have been an actual improvement. Having once found this new world of greater happiness and efficiency, they attempted to regain it and to live therein for all time.

"This phenomenon is not so prominent in the other two groups. The psychoneurotic takes his drugs to relieve himself of whatever type of symptom he may have. The psychopath uses narcotics rather as an aggressive behavior reaction--that is, he feels a desire to be more important or prominent among his associates. He wishes to excel in deeds of daring, to be more clever than his fellows, or to stand out as an object of admiration. Under narcotics, he feels that he has more nearly accomplished these ends. As Kolb has put it, his use of drugs is 'comparable to the compensation of little men who endeavor to lift themselves to greatness.' In other cases, he uses this means to gain an experience of pleasure over and beyond the requirements for comfortable living. He is a hedonist. What he desires to do, he does for the pure pleasure to be derived from it. He is morally defective and hence does not consider social or ethical standards a check upon its activity. The only restraint he recognizes is painful or physical in nature. The patient with a psychopathic predisposition, however, takes his opium as a medicine which he believes-- sometimes with good reason-helps him to make a more satisfactory adjustment to life as he finds it, and without which he feels inadequate to meet many of life's problems. "The same fundamental drive, then, is present in all cases--namely, the desire to derive from life more pleasure and satisfaction, which, after all is a striving present in all mankind. The differentiations made above are probably of theoretical rather than principal importance, but it is felt that they help to clarify the problem." "The kinds of personality disorders which underlie drug addiction have been well described by Kolb and Felix, who list four general personality types.

"The first group is made up of normal persons accidentally addicted. It consists of patients who in the course of an illness have received drugs over an extended period of time and, following relief of their ailments, have continued the use of drugs. These persons are frequently termed ‘accidental' or 'medical' addicts. Such persons are regarded by some authors as constituting a special group of addicts who are different from those persons who began the use of drugs as a result of association with persons who were already addicted. In our experience, all 'medical' addicts have some fundamental emotional problem which causes them to continue the use of drugs beyond the period of medical need. There is, then, no basic difference between 'medical' and 'non-medical' addicts except in the mode of the original contact with drugs. In persons with stable personalities, social pressure, conscience and well balanced emotional makeup negate the pleasure produced by drugs sufficiently to prevent their continued use.

"The second group consists of persons with all kinds of psychoneurotic disorders who, as Felix said, take drugs to relieve whatever symptoms they may have. The manifestation of the neurosis may be anxiety, an obsession or compulsion or any of the great group of psychosomatic disorders.

"The third and largest group consists of psychopathic persons, who ordinarily become addicted through contact and association with persons already addicted. They are generally emotionally undeveloped aggressive hostile persons who take drugs merely for pleasure arising from the unconscious relief of inner tension, as shown by this statement of an addict: I was always getting into trouble before I got on drugs-never could seem to get comfortable; I had to go somewhere and do something all the time. I was always in trouble with the law. Some fellows told me about drugs and how good they made you feel, and I tried them. From then on, I was content, as long as I had my drugs--I didn't care to do anything, but to sit around, talk to my friends occasionally, listen to the radio, and only be concerned with the problem of getting money for drugs. This I usually did by picking pockets or other such petty stuff.

"The fourth and smallest group is characterized by drug addiction with psychosis. The persons in this group, many of whom have borderline mental illness and sometimes frank mental illness, are seemingly able to make a better adjustment while taking drugs. Sometimes it is difficult to establish the diagnosis and not until drugs are withheld, does the psychosis become apparent.

"There is a category of patients not included in the aforementioned groups. Kolb originally listed these as patients with psychopathic diathesis. While it is true that some of these exhibit much of the overt behavior pattern of psychopathic persons, when studied carefully, they usually fall into a milder behavior or character disorder group, which has characteristics of both the psychoneurotic and the psychopathic groups. Included are persons with severe dependency problems, withdrawn schizoid types, emotionally immature adults, as well as those suffering with the milder degrees of maladjustment and inadaptiveness to the complications of living. Felix stated that most of the persons falling into this group were making a marginal adjustment to life before becoming acquainted with narcotics. After their first few experiences with narcotics, they felt an exhilaration and a sense of relief comparable to the solution of a difficult problem or the shaking off of a heavy responsibility. Many of them also felt an increase in efficiency which, in some cases, appeared to have been actual improvement. "In general, persons who never have been able to make a satisfactory adjustment to life, whose adaptive patterns of behavior have been inadequate, frequently find in morphine, much as the tired business man finds in the preprandial cocktail, a means of return to 'normal.' This is a false situation which may be recognized by the tired business man but is not recognized by the drug addict. Our studies indicate that patients who have made a marginal degree of emotional adjustment to life, and then have begun to use drugs, lose some of their normal adaptive patterns of adjustment. This regression in personality represents the greatest danger of drug addiction."45 A consideration of the aforementioned classifications makes it obvious that none of the classifications provide specific explanations for drug addiction. Large numbers of individuals fitting into the categories of psychopathic diathesis, psychopathic personality or psychoneurosis, never take drugs as a means of resolving their personality difficulties or emotional problems. One begins to see the wisdom of Dr. Wikler's observation: "The attractiveness of morphine for certain individuals seems to be related to some of its remarkable pharmacologic properties, namely, its effectiveness in reducing such anxiety as is associated with fear of pain, anger and sexual urges, without seriously impairing the sensorium or the effectiveness of internalized controls on behavior. The intensity of this attraction is enhanced greatly for such individuals as have been unable to gratify these needs by other means, be they 'normal,' neurotic or psychopathic..." "... the degree of attractiveness of morphine is related to 'personality structure' but not necessarily to 'neurosis' or psychopathy as such ..."46 This notion that the use of opiates is a highly individualized process and is not necessarily related to mental pathology is also expressed by Gerard and Kornetsky in their study on "Adolescent Opiate Addiction." They diagnosed 30 narcotic addicts and 30 adolescent non-addicts of roughly similar background and status.

The writers conclude as follows : "... The psychologic and psychiatric data of the study indicated that the addicts exceeded the controls in personality malfunction to a statistically significant and clinically impressive extent. These findings support the hypothesis that youths living in urban areas where illicit opiate use is widespread do not become addicted independently of psychiatric pathology. The data also indicate that the converse need not be true; as youths who exhibit personality malfunction similar to that of addicts need not become addicted. As the writers pointed out previously, becoming an opiate addict is a highly individualized process which can be understood only in the context of the individual's personality structure, past life situation and present interactions with the significant figures of his familial and peer groups."47 The addict as Winick points out: "... is responding to personality problems of great complexity. The drug addict is a person with certain personality characteristics who happens to have selected this way of coping with his problems for a variety of reasons, of which he is usually unaware. Not the least of these reasons is his access to a social group in which drug use was both practised and valued. He takes one drug rather than another because it provides satisfaction for him. Other people with exactly the same kind of personality substratum never become addicts and select other means of expression for their basic conflicts."48

VII. SOCIAL FACTORS IN ADDICTION

Psychopaths, psychopathic diathetics, psychoneurotics, emotionally disturbed persons, etc. would not use narcotics as a solution for their personal problems, unless such drugs were available. If such individuals happen to live in the slum areas of our cities, this offers no problem, for one of the facts of life in connection with narcotics is that illicit drugs can be purchased most readily in the slum neighborhoods of our large cities. Police officers from many different cities testified before the Congressional Committees that most drug arrests and violations of the drug laws occurred in certain limited areas of their cities, usually the areas of greatest social disorganization. In these neighborhoods live the most economically deprived groups of our population; the racial and religious minorities, and the recent immigrants into the cities. These are the areas of poor and squalid housing, of overcrowding, of a shifting disorganized family life. They are the areas with the largest number of relief cases; the highest rates of juvenile delinquency, adolescent and adult crime. They are also areas with high rates of mental disturbance and psychological bnormality.49 It is these disorganized slum neighborhoods, whether they exist in New York, Chicago, Los Angeles, Detroit or Washington, D. C., which develop a special cultural climate which is favorable to drug use and experimentation particularly by juveniles and adolescents. Two major studies in recent years (The N. Y. U. Study and the Chicago Study) were concerned with an analysis of the factors in such neighborhoods which were conducive to a high degree of drug use. The Chicago Study pointed out that the social environment for young males in these areas comes to be dominated by a "street corner society" and that such societies flourish in communities where the traditional influences and controls over youth tend to be weak and uncertain. The central feature of this society or culture is the support that it gives to behavior which is inconsistent with the norms of conventional society and often openly hostile to many of its expectations. This orientation on the part of the street boys is expressed in a variety of ways, particularly by delinquency and crime "and in the search for and exploitation of kicks." Success in the exploitation of "kicks" entails willingness to experiment with new drugs whose effects and properties are not precisely known to the user. However, the street corner groups appear to vary in the degree to which they court the double interest in delinquency and "kicks." There are, as an N. Y. U. study pointed out, street gangs with a high degree of narcotic use, a low degree of narcotic use and gangs which do not permit their members to use narcotics at all. Nevertheless, as the Chicago study notes, the introduction of heroin to street groups in Chicago, "...was facilitated by an established and pre-existing interest in the use of stimulants and intoxicants and by the tendency to experiment freely with new drugs."50 Heroin was "pushed" vigorously by the frenetic search of the street corner boy for newer, stranger and more status giving intoxicants, and after heroin use had been defined as "desirable and valuable by intimate associates whose views are meaningful to the potential user." The New York University studies came to similar conclusions : "We have learned that the social pattern of using narcotics is highly concentrated in the most deprived areas of the city; that it is associated with the type of delinquency that produces ready cash; that the pattern of using drugs spreads within the peer-group and apparently is meaningful in the context of the social reality in which the boys live; that the users (and nonusing delinquents) live in a special defiant and escapist subculture side by side with the other subculture of 'squares' who want to life themselves out of their depriving environment."51 Obviously not all the boys who participate in the activities of street corner society or of street gangs wind up as habitual or professional criminals or drug addicts. The wider, conventional society exercises its pressures for conformity even against the members of the delinquent and deviant sub-culture. As the boys grow older, the youthful preoccupations with delinquency, kicks, hell-raising, gang fights, etc., give way for many of the boys to a concern about the future, a steady girl, a job, a home, etc. The problem of who will and who will not become a professional criminal or a drug addict is dependent upon the personality of the individual boy. This is noted by both the Chicago and the N. Y. U. studies: "... Most likely to become extreme delinquents or drug users are those who by virtue of their personal histories are least responsive to the expectations of conventional society. Thus, the problem of differences between those who do and those who do not become drug addicts in the world of the street boy may be regarded as a problem of the difference in life history among individuals, with each life history constituting a unique equation of forces."52

"But as the group grows older, two things happen. Sport, hell-raising and gang fights become 'kid stuff' and are given up. In the normal course of events, the youthful preoccupations are replaced by more individual concerns about work, future, a 'steady' girl and the like. If most of the gang members are sufficiently healthy to face these new personal needs and societal demands and engage in the new activities appropriate for their age, the availability of drugs will not attract their interest. But for those gang members who are too disturbed emotionally to face the future as adults, the passing of adolescent hell-raising leaves emptiness, boredom, apathy and restless anxiety. In a gang where there are many such disturbed members, experimentation with drugs for 'kicks' will soon lead to frequent and, later, habitual use; cliques of users will grow quickly. Enmeshed in the patterns of activities revolving around the purchase, sale and use of drugs and the delinquent efforts to get money to meet the exorbitant cost of heroin, the young users can comfortably forget about girls, careers, status and recognition in the society at large. Their sexual drive is diminished, they maintain a sense of belonging in the limited world of the addict, they remain children forever. They may give up all sense of personal responsibility for their lives and conveniently project the blame for their shiftless existence on the 'habit'."53 It is obvious that in the production of a drug addict, just as in the production of a delinquent or a criminal, there is an interaction of personality and environmental factors. But there is also a shaping of personality by environmental factors, cultural attitudes, and interpersonal relationships. Nowhere is this more true than in the intimate confines of family life. The N. Y. U. group compared the family background of 30 White, Negro, and Puerto Rican families with a non addict boy and 30 such families with a boy who was an addict. All the families lived in a high drug use neighborhood. Almost all of the 30 addicts came from families where there was a disturbed relationship between the parents as evidenced by separation, divorce, overt hostility or lack of warmth and mutual interest.

The addicts experienced much more frequently than the controls, "... cool or hostile parent figures, weak parent-child relationships, lack of clarity as to the way in which disciplinary policies were established and vague or inconsistent parental standards for the boy."54 As a result of these findings, this study came to the conclusion: " ... that the pathologic personality characteristics of the juvenile heroin addict are consistent outgrowths of the disturbed pattern of family relationships to which he has been exposed."55

VIII. DRUG ADDICTION IN RELATION TO CRIME

One of the compelling reasons why more rational methods of dealing with drug addicts must be devised is the close relationship between drug addiction and crime. The compulsion for the drug makes every drug addict a law violator and a criminal. Mere possession of a narcotic drug which the addict must have to ward off withdrawal distress is a violation of the narcotic laws. Thus, every drug addict is subject to arrest by the police, and as we have seen, the arrests of addicts and of narcotic law violators have gone up by leaps and bounds. Addicts guilty of no other crime than illegal possession of narcotics are filling the jails, prisons and penitentiaries of the country.

However, this is only a part of the distressing picture of the relationship between narcotic addiction and criminality. For most narcotic addicts, predatory crime (larceny, shoplifting, sneak thievery, burglary, embezzlement, robbery, etc.), is a necessary way of life. This was clearly recognized by the law enforcement officials who appeared before the Congressional Committees and gave testimony concerning the close relationship between property crime and drug addiction in their communities. These officials were convinced that property crimes could be reduced materially if all drug addicts could be incarcerated.

The New York University and the Chicago studies on drug addiction support the notion that drug addiction necessarily leads to predatory crime as a way of life. For example, Chein and Rosenfeld make the following comments based on their studies of juvenile addicts: "Drug use leads to a criminal way of life. The illegality of purchase and possession of opiates and similar drugs makes a drug user a delinquent ipso facto. The high cost of heroin, the drug generally used by juvenile users, also forces specific delinquency against property for cash returns. The average addicted youngster spends almost forty dollars a week on drugs, often as much as seventy dollars. He is too young and unskilled to be able to support his habit by his earnings. The connection between drug use and delinquency for profit has been established beyond any doubt."56 A Chicago study comes to a similar conclusion: "...Almost without exception addicts resort to theft to obtain money for the purchase of the drugs. The compulsion of the addiction itself coupled with the astronomically high cost of heroin leads the addict inescapably to crime. For the addict there is very simply no alternative."57 There has been considerable debate as to whether the criminality of the addict preceded or is merely a consequence of the drug addiction. Studies like those of Pescor can be cited for the proposition that most narcotic addicts became delinquents and criminals after the onset of their addiction. Pescor found in 1943. that of the 1,036 patients at Lexington, studied by him, 75.3% had no history of delinquency prior to addiction.58 Anslinger, however, has the always taken the view that the drug addict was usually a criminal first before becoming addicted.59 The answer to the question of whether the addict was a delinquent or criminal prior to addiction largely depends upon the particular groups of addicts studied. For example, Kolb60, in 1928, studied a group of 119 so called "medical addicts", persons who became addicted to drugs as a result of the prescription of narcotics for ailments other than addiction. Kolb found that of these 119 addicts, 90 had never previously been arrested. However, the studies conducted in New York and Chicago present a different picture. These studies of drug addiction were conducted in areas with high rates of delinquency and crime. They were also concerned with youthful and adolescent offenders. The conclusion from the Chicago and New York studies is inescapable that "delinquency both preceded and followed addiction to heroin."61 "Persons who became users," stated the Chicago report, "were found to have engaged in delinquency in a group habitual form either prior to their use of drugs or simultaneously with their developing interest in drugs. There was little evidence of a consistent sequence from drug use without delinquency to drug use with delinquency."62 Nevertheless, even in the delinquency areas of our large cities, there are persons who become addicted to drugs without a prior career of delinquency and crime. After addiction, however, they will usually turn to delinquency and crime "often after overcoming severe psychological conflict occasioned by their repugnance to theft."63 Moreover, the addict who had previously been a delinquent loses all chance of shaking off habits of delinquency and crime as he grows older. Not all non addicted delinquents and adolescent offenders living in the delinquency areas of our large cities grow up to be habitual and professional criminals. Many abandon their delinquent and criminal pursuits when they reach early adulthood. They find jobs, marry and settle down to productive lives. But if the delinquent or adolescent offender adds narcotic addiction to his patterns of behavior, ". ..All possible future retreat from a delinquent mode of life is cut off regardless of whatever later impulses they may have to reject a criminal career in favor of a conventional one. They are constrained by their unremitting need and the high cost of heroin to continue in crime. This interpretation supports the conclusion that drug addiction results in a large and permanent increase in the volume of crime."64 Thus, the realities of the relationship between narcotic addiction and crime appear to be much more somber than the romantic myth, "that hold-up men, murderers, rapists and other violent criminals take drugs to give them courage or stamina to go through with acts which they might not commit when not drugged."65 Dr. Kolb has labeled this notion an "absurd fallacy." The crimes committed by opiate addicts are generally of a parasitic, predatory nonviolent character. Drug addicts may, on occasion, commit violent crimes. This is hardly surprising since so many are classified as psychopaths. A psychopath tends towards serious criminality with or without drug addiction. Generally, however, the use of opiate drugs (whatever may be the case with marihuana and cocaine) tends to discourage violent crime. As Maurer and Vogel point out: "The sense of well-being and satisfaction with the world are so strong that, coupled with the depressant action of the drug, the individual is unlikely to commit aggressive or violent crime after he is addicted, even though he habitually or professionally did so previous to addiction. In the words of Kolb, 'Both heroin and morphine in large doses change drunken fighting psychopaths into sober, cowardly, non-aggressive idlers ...' "...To date, there has been no evidence collected to show that any significant percentage of opiate addicts commit violent crimes either professionally or casually while under the influence of these drugs ... the reduction or elimination of sexual desire tends to remove the opiate addict from the category of psychopathic sex offenders, even though he might have a tendency to commit sex crimes when not addicted ..."66 Since opiate drugs do not act as a stimulant for the commission of violent crime, should not confirmed addicts have a means of obtaining such drugs legally, so that they will not have to engage in crime in order to raise the money necessary for their needs? This basic question goes to the heart of our present policy in dealing with drugs addiction.

IX. METHODS OF TREATMENT OF DRUG ADDICTION

1. The Doctor and the Drug Addict In Western Europe, and in England, the treatment of drug addiction and drug addicts is primarily a matter for the physician. (See Appendix B, appended hereto.) Physicians may prescribe drugs to addicts either in the attempt to cure them of their addiction or to keep them in a state of comfort so that they can function without fear of the dreaded withdrawal symptoms. In this country, on the other hand, the physician has largely been deprived of an appropriate role in the treatment of drug addicts. There are many who believe that the physician must be substituted for the jailer in dealing with drug addicts, before fundamental progress can be made in controlling addiction.

This requires a review of the development of the laws in this country which has to a considerable degree resulted in the exclusion of doctors from the field of drug addiction.

Prior to 1915 physicians were permitted to treat addicts as they saw fit, and opiates were available to the general public. But Congress, pressured by the public's concern over the growing number of addicts in the country, enacted the Harrison Narcotic Law67 which was designed to control the domestic manufacture, sale and distribution of narcotic drugs. The Act requires importers and manufacturers to purchase and affix stamps to all opiates and cocaine packages. In addition, importers, manufacturers, wholesalers, retailers, and doctors must register and pay a graduated tax for the use of narcotics. Narcotics can only be legally transferred under the Act by registered persons through the use of special order forms. The Act does not seek to interfere with the legitimate practices of medicine, nor with the medical treatment of addicts, for it provides that: "Nothing contained in this chapter shall apply to the dispensing or distribution of any of the drugs ... to a patient by a physician, dentist, or veterinary surgeon registered ... in the course of his professional practice only." If an addict is a patient of a doctor, narcotic drugs can be dispensed to him, if it is done in the course of the "professional practice" of the doctor. The Harrison Act did not seek to regulate the practice of medicine nor impinge upon a doctor's relationship to his patient. Nevertheless, despite the exception in favor of physicians many doctors were subjected to criminal prosecution because of the charge that their treatment of and prescription for drug addicts was not legitimate "professional practice" within the meaning of the Act. Targets of the initial prosecution were doctors who had many addict patients for whom they prescribed large amounts of drugs. Such doctors were charged with the illegal sale of narcotics in violation of the Act.

In the first Supreme Court case under the Act (United States v. Doremus),68 the defendant, a doctor, had dispensed 500 one-sixth grain tablets of heroin to addicts, and was convicted of a violation of the Act. He contended that the Act was unconstitutional because it sought the control of the distribution of narcotic drugs through the device of taxing- such drugs. It was contended that Congress could not constitutionally control the distribution of narcotic drugs. However, the Supreme Court, in a 5-4 decision, upheld the constitutionality of the Act, stating in the course of its opinion: "... the Act may not be declared unconstitutional because its effects may be to accomplish another purpose as well as the raising of revenue. If the legislation is within the taxing authority of Congress, that is sufficient to sustain it."69 This case did not directly pass upon the question of what a doctor may or may not do in the treatment of a drug addict. In the case of Webb v. United States70 however, which came before the Court on the same day, the Narcotics Bureau was able to persuade the Supreme Court to adopt its views concerning the treatment of drug addicts by physicians. Dr. Webb had been indicted and convicted for selling at 50 cents apiece, over 1,000 prescriptions for narcotic drugs, indiscriminately to anyone, and occasionally using fictitious names on the prescriptions. It was obvious that the defendant was a mere prescription peddler, who was neither treating patients nor practising medicine. His conviction, therefore, should have been affirmed since his activity in relation to drugs was not covered by the exception in the Act in favor of physicians. The Narcotics Bureau, however, apparently wanted more from the Supreme Court than the affirmance of a conviction. It wanted an authoritative expression of opinion from the Court as to what was and what was not, the legitimate practice of medicine in dealing with narcotic addicts. It therefore had a question certified to the Court for its answer, which went far beyond the facts of this case and which seems to impinge upon the domain of medical practice. The certified question reads as follows: "If a practicing and registered physician issues an order for morphine to an habitual user thereof, the order not being issued by him in the course of professional treatment in the attempted cure of the habit, but being issued for the purpose of providing the user with morphine sufficient to Keep him comfortable by maintaining his customary use, is such order a physician's prescription under exception (b) of section 2 (of the Harrison Act)?"71 A majority of the Supreme Court (5-4) answered this question as follows: "to call such an order for the use of morphine a physician's prescription would be so plain a perversion of meaning that no discussion is required."72 Under this decision, it became possible for the Narcotics Bureau to warn doctors against prescribing drugs to addicts for the purpose of avoiding withdrawal distress or keeping the addicts comfortable. The position of the Narcotic Bureau was strengthened by another flagrant case the following year,'" in which the physician had prescribed 8 to 16 drams of morphine at a time, indiscriminately to anyone, for $1 a dram. In dismissing the appeal from the conviction the Supreme Court observed: "Manifestly the phrase 'to a patient' and 'in the course of his professional practice only' are intended to confine the immunity of a registered physician, in dispensing the narcotic drugs mentioned in the Act, strictly within the appropriate bounds of a physician's professional practice, and not to extend it to include a sale to a dealer or a distribution intended to cater to the appetite or satisfy the craving of one addicted to the use of the drug. A 'prescription' issued for either of the latter purposes protects neither the physician who issues it nor the dealer who knowingly accepts and fills it."74 In the Behrman case75 two years later, the Supreme Court began to realize that the earlier cases may have trespassed upon the domain of medical practice in attempting to dictate what a doctor could or could not do in relation to a drug addict. The Court dismissed the demurrer to the indictment of Dr. Behrman, who had prescribed 150 grains of heroin, 360 grains of morphine and 910 grains of cocaine to an addict, at one time. But it observed in the course of its opinion that: "It may be admitted that to prescribe a single dose or even a number of doses, may not bring a physician within the penalties of the Act."76 It should be noted that the indictment in the aforementioned case did not allege bad faith on the part of the physician-defendant. Nevertheless the Court held that such wholesale prescribing of drugs to an addict regardless of good or bad faith of the doctor was a violation of the Act.

The aforementioned precedents enabled the Narcotics Bureau to prosecute many physicians, and unquestionably resulted in most doctors leaving the narcotic addict severely alone. However, a few physicians continued to treat and prescribe drugs for addicts. One such man was Dr. C. O.

Linder,77 who was charged with the unlawful sale to an addict "stoolie" of one tablet of morphine and three tablets of cocaine for self-administration in divided doses over a period of time. The Linder indictment, like the Behrman indictment, did not question the physician's good faith. But the Court sustained the demurrer to this indictment and observed: "Obviously, direct control of medical practice in the states is beyond the power of the federal government. Incidental regulation of such practice by Congress through a taxing act cannot extend to matters plainly inappropriate and unnecessary to reasonable enforcement of a revenue measure. The enactment under consideration levies a tax, upheld by the court ... and may regulate medical practice in the states only so far as reasonably appropriate for or merely incidental to its enforcement. It says nothing of 'addicts' and does not undertake to prescribe methods for their medical treatment. They are diseased and proper subjects for such treatment, and we cannot possibly conclude that a physician acted improperly or unwisely or for other than medical purposes solely because he has dispensed to one of them in the ordinary course and in good faith four small tablets of morphine or cocaine for relief of conditions incident to addiction. What constitutes bona fide medical practice must be determined upon consideration of evidence and attending circumstances. Mere pretense of such practice, of course, cannot legalize forbidden sales, or otherwise nullify valid provisions of the statute, or defeat such regulations as may be fairly appropriate to its enforcement within the proper limitations of a revenue measure."77 The Court refused to adopt the interpretation placed upon the Webb Case (supra) that no prescription to an addict which sought to keep him comfortable or ward off withdrawal distress could be justified under the Act: "The question (in the Webb Case) specified no definite quantity of drugs, nor the time intended for their use. The narrated facts show, plainly enough, that physician and druggist conspired to sell large quantities of morphine to addicts under the guise of issuing and filling orders. The so-called prescriptions were issued without consideration of individual cases and for the quantities of the drugs which applicants desired for the continuation of customary use. The answer thus given must not be construed as forbidding every prescription for drugs, irrespective of quantity, when designed temporarily to alleviate an addict's pains, although it may have been issued in good faith and without design to defeat the revenues."78 In commenting on the Behrman Case (supra), the Court stated: "This opinion related to definitely alleged facts and must be so understood. The enormous quantity of drugs ordered, considered in connection with the recipient's character, without explanation, seemed enough to show prohibited sales and to exclude the idea of bona fide professional action in the ordinary course. The opinion cannot be accepted as authority for holding that a physician who acts bona fide and according to fair medical standards, may never give an addict moderate amounts of drugs for self-administration in order to relieve conditions incident to addiction. Enforcement of the tax demands no such drastic rule, and if the Act had such scope it would certainly encounter grave constitutional difficulties."80* *In a subsequent case, Nigro v. United States, 276 U. S. 332 (1928), the case involved a layman who was accused of selling one ounce of morphine not in pursuance of a written order form, and he argued that the act only applied to professionals. The Court said: "In interpreting the act, we must assume that it is a taxing measure, for otherwise, it would be no law at all. If it is a mere act for the purpose of regulating and restraining the purchase of the opiate and other drugs, it is beyond the power of Congress, and must be regarded as invalid ...

Everything in the construction of section 2 must be regarded as directed toward the collection of the taxes imposed in section 1 and the prevention of evasion by persons subject to the tax. If the words cannot be read as reasonably, serving such purposes, section 2 cannot be supported."81 Thus, the Linder Case lays down the rule that a doctor acting in good faith and guided by proper standards of medical practice may give an addict moderate amounts of drugs "in order to relieve conditions incident to addiction." The Harrison Act does not regulate how much a physician may or may not prescribe to an addict nor delimit either the quantity or frequency with which a physician may prescribe for an addict in his practice. This is illustrated by the case of Boyd v. United States,82 where a physician had been convicted of unlawful sale of 30 to 98 grams of morphine, by means of prescriptions, issued to two known, confirmed addicts.

The trial court had charged the jury that: "... it was not admissible to issue prescriptions to a known addict for an amount of morphine for a greater number of doses than was sufficient for the necessity of any particular administration of it." The Supreme Court pointed out that this statement was: ... ambiguous and might be regarded as meaning that it never is admissible for a physician, in treating an addict, to give him a prescription for a greater quantity than is reasonably appropriate for a single dose or administration. So understood, the statement would be plainly in conflict with what this court said in the Linder case."83 The rule of the Linder Case was also applied by the Circuit Court of Appeals of the 10th Circuit in the case of Strader v. United States.84 There the trial judge had charged the jury that a prescription for morphine to an addict is a violation of the law, and that it may not be given merely for the purpose of relieving pain incident to addiction. The court in reversing the conviction stated: "We think the court incorrectly stated the law and unduly circumscribed the testimony. The statute does not prescribe the diseases for which morphine may be supplied. Regulation 85 (of the Narcotics Bureau) issued under its provisions forbids the giving of a prescription to an addict or habitual user of narcotics, not in the course of professional treatment, but for the purpose of providing him with a sufficient quantity to keep him comfortable by maintaining his customary use. Neither the statute nor the regulation precludes a physician from giving an addict a moderate amount of drugs in order to relieve a condition incident to addiction, if the physician acts in good faith and in accord with fair medical standards."85 Under these decisions, the exception in the Harrison Act in favor of physicians still has vitality. The Act does not purport to regulate medical practice, nor determine what drugs a physician may prescribe to an addict; nor indicate the quantity or frequency of the prescriptions.

The responsibility for prescribing rests upon the physician in charge of any given case, and the courts have been clear in holding that if he acts in good faith and prescribes a narcotic drug in the course of his professional practice, he is entitled to the benefit of the exception under the Act." As the court put it in the case of Bush v. United States:86 "A physician may give an addict moderate amounts of drugs for self administration, if he does so in good faith and according to fair medical standards." In the Strader Case (supra) the court ruled: "In Mitchell v. United States, 3 Fed 516 (6th Cir.,1925) the physician was indicted for dispensing drugs unlawfully. The defense argued that no offense was alleged because the indictment did not allege that the disposition of narcotics was not made to a patient in the course of the physician's professional practice. The court held that the indictment was defective because it did not negative the exceptions specified in the act.

* The Bush case involved a physician who was indicted for violating the act by issuing prescriptions for morphine, varying from 10o to 16 grains, to known addicts who pretended to be suffering with painful diseases. The indictment further charged that the quantities prescribed were enough to last more than one day. The defense relied upon the rule laid down in the Linder case that a physician is within his rights when he prescribes morphine to an habitual user as he sees fit.

"A physician issuing morphine prescriptions in good faith to a federal narcotics agent, whom he believes to be a bona fide patient, for the purpose of curing a disease or relieving suffering would not be guilty of violating the Harrison Act." But while the present law permits a physician to treat an addict in good faith and in the course of his professional practice, doctors are still reluctant to treat or prescribe for addict patients. A physician who treats and/or prescribes drugs for an addict patient in good faith according to medical standards will be protected from a conviction. But his good faith and adherence to medical standards can only be determined after a trial. The issue of whether the doctor acted in good faith and adhered to proper medical standards must be decided by a judge or a jury. If the judge or jury decide against the physician, the latter may be sent to prison or deprived of his license to practice medicine.

The physician has no way of knowing before he attempts to treat, and/or prescribe drugs to an addict, whether his activities will be condemned or condoned. He does not have any criteria or standards to guide him in dealing with drug addicts, since what constitutes bona fide medical practice and good faith depends upon the facts and circumstances of each case. (See Bush Case supra.) The physician's dilemma in treating drug addicts is illustrated by the case of Teter v. United States,"87 where the physician dispensed nine one-quarter grain tablets of morphine over a two week period to an addict who was used as an informer by the Narcotics Bureau. The defense argued that the indictment was insufficient because of the small amount of drugs dispensed. In sustaining the indictment, the court said: "While the quantity was not large, nevertheless there was evidence tending to indicate that the sales were not in good faith from a physician's standpoint, and were for no other purpose than to enable this addict to further indulge her unfortunate propensities ... Notwithstanding two other physicians testified that in the treatment of addicts, it was not improper to give them doses such as appear to have been given to the complaining witness, we are satisfied that under all the circumstances, it was for the jury to say whether or not these sales of drugs to the complaining witness were in good faith, or were solely for the purpose of pandering to the habit of a drug addict, and selling the drug."88* * In Hawkins v. United States, 90 F. 2nd 551 (5th Cir., 1987), the physician was convicted for prescribing 15 grains of morphine to three known addicts, who he claimed were suffering from serious pulmonary conditions. The government had one witness who testified that he examined the addicts and found that none of them were suffering from such a condition. After the trial, one of these addicts died from a pulmonary condition. The defense argued that the amount prescribed was small and therefore it comes within the Linder Case because it was not large enough to put it within the power of the addict to sell part of the drug and thereby violate the act. The court, in sustaining the conviction, held: ". . .15 grains of morphine was enough to present a question of fact as to the good faith of the doctor to be decided by the jury." In United States v. Brandenburg, 155 F. 2nd 110 (3rd Cir., 1946) the physician was convicted for prescribing drugs to a narcotics officer who was introduced to him by an addict "stoolie," as a "tubercular brother-in-law." The physician also prescribed drugs for the addict who claimed that he had serious gall bladder trouble and that his doctor who was out of town prescribed morphine. The defendant was treating this doctor's patients while he was away so that when the addict walked into the defendant's office, there was no reason to suspect him. Subsequently, the addict and the agent received additional prescriptions. In sustaining the conviction, the court said: "The frequency of the issuing of the prescriptions and the quantities prescribed were factors which made the question of good faith one for the jury." In the recent case of McBride v. United States, 2229 F. 2nd 249 (5th Cir., 1955) an " osteopath was convicted for falsifying his records and illegally dispensing codeine. The facts show that the Chief of Police of Houston, Texas, who was a personal friend of the defendant, had suffered a back injury and he was in constant pain. The defendant had given him a shot of codeine on one occasion in order to relieve a severe pain and when the Chief discovered that his pain could be relieved and that he was able to work, he asked the defendant to give him more; the defendant was reluctant to administer more of the drug because he feared the narcotics regulations. The Chief assured him that he would be within his rights if he dispensed the drug while treating him, and he brought in the regulations so that the defendant would be assured. Each time he prescribed the drug, he gave him an osteopathic treatment. The Chief had asked him not to use his name on the records which he kept because he feared losing his job if he was discovered; thus, he convinced him to use the name of an incurable cancer patient, again showing him the regulations, which he interpreted as being complied with so long as the dispensing of the drug was recorded. In sustaining. the conviction, the court observed that none of the expert witnesses (4 were called by the government, one being an osteopath and two were called by the defense) would say that the dispensing of codeine in quantities given by the defendant was standard medical practice, and it further said: "Evidence of the failure to follow standard medical practice shows a lack of good faith. So also as bearing on good faith is evidence of appellant's unorthodox attitude toward narcotics and addiction." The case of United States v. Anthonys89 crystalizes the problem which the physician faces in dealing with drug addicts. There, the defendant was approached by the City of Los Angeles to take over the treatment of addicts who were former patients at the City's narcotics clinic, before it was closed. These patients were confirmed addicts who were thoroughly examined by the defendant before he prescribed drugs for them, At the trial, three doctors testified that such prescription was good professional practice. Two other doctors testified that the ambulatory treatment of drug addicts was not proper medical practice under any circumstances. In acquitting the defendant, the court said:

"Good faith must be determined on the basis of evidence and expert testimony. The courts cannot arbitrarily say that, irrespective of the beliefs of the physician that he is effecting a cure or properly prescribing narcotics, the amount is excessive and ipso facto a violation of the law."

"There is no dogmatic rule which the courts have laid down for the purpose of determining what is good or bad professional practice."

"Ultimately, the question to determine is not whether the judgment used was good or bad, but whether the defendant believed... that the treatment he administered was proper by ordinary medical standards."90

This state of the law offers a challenge to the medical profession. It may question the somewhat misleading Regulation No. 5, Art. 167, of the Narcotics Bureau founded on the too sweeping language of the Webb and Behrman Cases to the effect that:

"...An order purporting to be a prescription issued to an addict or habitual user of narcotics, not in the course of professional treatment but for the purpose of providing the user with narcotics sufficient to keep him comfortable by maintaining his customary use, is not a prescription within the meaning and intent of the act; and the person filling such an order, as well as the person issuing it, may be charged with violation of the law."

Despite this regulation, physicians may legally treat addicts. They may prescribe narcotic drugs to addicts. But they must act in good faith and according to proper medical standards. However, the medical profession should not leave the task of determining good faith and proper medical standards to an ex post facto judgment made by twelve laymen on a jury. It should not be left to the conflicting opinions of so-called experts, who may have differing views on how to treat narcotic addiction. The profession itself, through its authoritative body, the American Medical Association, should lay down the criteria by which a physician's treatment of an addict can be judged.

The A. M. A. itself should determine the standards of good faith and the limits of proper medical practice in the treatment of addicts. If the A. M. A. were to lay down standards, then the physician will know what is proper medical practice in dealing with addicts before he acts. A physician will also know that he need not fear criminal prosecution if he adheres to standards laid down by his profession. He will not be at the mercy of the stool pigeon and the informer. He will not tend to divorce himself entirely from the treatment of one group of unfortunate individual s, whose troubles lie legitimately within the domain of medicine. In laying down standards for the treatment of addicts, the American Medical Association may have to reconsider its resolution of 1924 condemning all "so called ambulatory methods of treating narcotic addiction." Thus, the present law provides the framework within which the medical profession, acting through the American Medical Association, can authoritatively determine what the role of the doctor should be in the treatment of addicts and in the treatment of problems of addiction.

2. Outpatient Clinics Medical counseling outpatient clinics for drug addicts have been set up particularly for adolescents in such cities as Chicago, Detroit and Los Angeles.91 These clinics offer some social case work and psychotherapy as well as some medical help for the addict. None of these clinics supply drugs to their patients. These clinics were established as a result of the concern with narcotic addiction immediately after the war. They were established in various communities under pressure to do something about the narcotics problem. A clinic is cheaper and easier to operate than a hospital dedicated to the rehabilitation of drug addicts. Unfortunately, the founders of outpatient clinics were not fully aware of the difficulties involved in attempting to treat drug addicts. This awareness and understanding came as the clinic obtained actual experience. As the report of the Medical Counseling Clinic of Chicago pointed out: "The treatment of addicts is an extremely difficult problem, in large part due to the inadequate motivation of the person and to his instability and unpredictability, which results in sudden breaks of contact with treatment and a lack of noticeable progress over a long period of time. When the individual is able to continue in treatment over a sufficiently long period, we do observe movement and progress in adjustment, both in personal and social levels. It would then seem that successful treatment of the person with a history of narcotic addiction is a very slow gradual process taking place over a long period of treatment contacts, and fraught with difficulties created by outside social and legal pressures, as well as by the extremely inadequate and weak personality that we have to deal with."92 One hopeful development in connection with the outpatient clinics has been the establishment of agencies where the person who has been a patient at the federal narcotics hospital at Lexington or New York City's Riverside Hospital may come for advice, counsel, guidance and help.

For years, officials at the Lexington Hospital deplored the necessity of sending the released addict back to his community, where he had no one to turn to in case he needed help with his personal problems. Similarly, the officials at Riverside Hospital felt that contact must be maintained with the young addict after his discharge from this institution. A beginning has been made in New York City in providing after-care facilities for drug addicts discharged from Riverside Hospital. Similar facilities have been provided for Lexington graduates, in connection with a follow-up study of persons released from the latter institution. The clinics serve only a small part of the drug user or drug addict population in their cities. Confirmed addicts do not willingly attend outpatient clinics if they cannot obtain drugs there. Where they do attend such clinics, it is usually under pressure of official agencies such as courts, parole or probation officers or under pressure from parents or relatives. Contacts under these circumstances are restricted and are broken off at the earliest possible opportunity.

Many persons coming to the clinics may have been helped by their contacts with these agencies. Some may have been persuaded to stay off drugs. Many addicts may have been induced, by contact with these clinics, to take the more drastic institutional treatment at Lexington. One can, however, be skeptical as to whether outpatient clinics have any kind of decisive impact on the confirmed addicts living in the communities they serve.

3. Institutional Treatment of Drug Addicts Jail or prison is the usual method of treating drug addicts in this country. Drug addicts are incarcerated by the thousands all over the country for violations of the drug laws, or for thefts and other offenses committed in order to obtain money for drugs. Drug addicts also surrender themselves voluntarily for self incarceration under the laws providing for self commitment of drug addicts. The only value of jail or prison for the treatment of drug addiction is that the addict may be temporarily withdrawn from drugs during the period of incarceration. Even this objective may not be achieved if the jail or prison is one into which drugs may be smuggled. There are practically no facilities for treatment of drug addicts in jails or penal institutions, beyond the forcible withdrawal of drugs. As a result, the drug addict comes out of jail or prison with his basic problems unresolved. The tensions, anxieties, pressures and personality problems which caused him to take drugs in the first instance are still with him. He usually goes back to the same environmental setting which facilitated his use of drugs in the first instance. There he also finds the same friends and acquaintances who have the same basic interest in drugs as himself. Under these circumstances, relapse to drugs is almost inevitable. The only value of prison or jail incarceration is in diminishing the dose of heroin or morphine necessary to keep the addict comfortable. But once the addict takes his first shot or "fix," after leaving jail or prison, he starts on the inevitable treadmill of tolerance and dependence, requiring greater and greater doses to obtain the elusive euphoria. His capacity will be limited only by the amount of money that he can borrow or steal in order to obtain the drugs necessary for his physical needs. If the addict was released from prison on parole (as he may well have been) he is usually an extremely unsatisfactory parolee. No threat of reincarceration prevents an addict from continuing to use the drug. Parole officers cannot prevent continued use of the drug or association with other addicts from whom parolees can obtain drugs, when they need them. Beyond jails and prisons and occasional addicts who may be accommodated at mental hospitals or private institutions, the only other institutional facilities for large scale treatment of drug addicts are the two federal installations at Lexington and Fort Worth, and the Riverside Hospital in New York City. These institutions were set up because of the belief that it is only possible to treat drug addicts in an institutional setting; that treatment of a drug addict is impossible unless he is first hospitalized in a drug free environment. The advocates of the hospitalization of drug addicts feel that only in a hospital setting can the addict be withdrawn from drugs and given the supportive psychological, medical, vocational and educational therapy necessary to enable him to cope with life without the use of drugs.

The author does not wish to minimize the great contributions that institutions like Lexington, Fort Worth and Riverside Hospital have made to an understanding of problems of drug addiction. Nevertheless, the limitations on the scope of their operations and their impact on the control of drug addiction in this country must be clearly understood.

The capacity of Lexington is 1280, of Fort Worth 1,053 . Riverside, the only narcotics hospital in New York City, is open only to adolescents under 21. It has a capacity of approximately 180.

It is obvious that these institutions of limited capacity can accommodate only a small fraction of the drug addict population of this country. Lexington and Fort Worth take federal prisoners who are drug addicts and who are permitted to serve their sentences in these institutions.

No technique has yet been worked out whereby drug addicts who have offended against state laws can be committed directly to Lexington or Fort Worth. Within the limit of the capacity of these institutions such offenders may be admitted as voluntary patients at Lexington or Fort Worth for the q-6 months believed necessary for rehabilitation. Most voluntary patients at Lexington and Fort Worth leave long before it is thought advisable that they should do so.

But even if all patients at Fort Wo