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NARCOTIC DRUG ADDICTION.

| WALTER L. TREADWAY

DIVISION OF MENTAL HYGIENE

| UNITED STATES PUBLIC HEALTH SERVICE

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WASHINGTON, D.C.

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ASSISTANT SURGEON GENERAL |

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Reprinted from Mental Health Bulletin, Vol. 12, No. 2

issued for the Department of Welfare Common-

at the request of the Board of Trustees,

Danville State Hospital, Danville, Pa.;

as issued by the Community Service

Department of the Hospital

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wealth of Pennsylvania, Harrisburg, Quarterly,

NARCOTIC DRUG ADDICTION

BY

ASSISTANT SURGEON GENERAL WALTER L. TREADWAY

DIVISION OF MENTAL HYGIENE

UNITED STATES PUBLIC HEALTH SERVICE

WASHINGTON,D.C.* OK OK

TABLE OF CONTENTS.

{ ♥ INTRODUCTION.

1♥Popular Connotation2♥Errors of Commission3♥Errors of Omission4♥Limitations

II ♥ NATURE OF CHRONIC OPIUM POISONING.

1♥Conventional Idea2♥Some Characteristics of Addicts3♥Withdrawal Symptoms4♥Mechanism of Tolerance5♥Mechanism of Abstinence Phenomena

Il] ♥ CAUSES.

1♥Ease of Access2♥Precipitating Causes2♥Predisposing Causes4♥Method of Operation

IV ♥ INCIDENCE OF ADDICTION.

1♥Difficulties Encountered2♥Estimates

3♥Probability4♥Significance

A

V ♥ EPIDEMIOLOGICAL ASPECTS.

1♥Occupation2♥Sex Distribution3♥Color4♥Marital Status5♥Education

6♥Urban and Rural Environment7♥Age Distribution8♥Significance

VI ♥ PUBLIC POLICIES FOR PREVENTION.

1♥A National and International Issue2♥The Hague Convention of 19123♥Ratification and League Functions4♥Limitations of Convention of 19255♥Convention of 19316♥Traffic and Distribution Control7♥ Addiction a Potential Market8♥Federal Policy of Segregating and Treating Addicts9♥Objects to be Attained10♥Penal and Correctional Methods Not a Solution11♥Objective of Early State Measures12♥State Limitations13♥Need for Uniform State Law14♥Adoption of Uniform State Law

VII ♥ THE ROLE OF PROFESSIONAL ACTIVITY IN PREVENTION.

1♥The Use of Dangerous Habit-Forming Drugs2♥Cautions to be Observed3♥Educational Measures

4♥Some Abuses5♥A Problem for Professional Groups

VIII ♥ TREATMENT.

1♥The Limited Knowledge of the Nature of Addiction2♥NoSpecific Cure Known3♥The Three Phases of Addiction4♥Institutional5♥Reasons for Seeking6♥Scope

NARCOTIC DRUG ADDICTION.

The term ☜narcotic drug addiction☝has come to be regarded by aninter-ested public as meaning thehabitualuse of opium orits derivatives, and ofcocaine. Indian Hemp! or Maria-huana has also been included, whereaspeyote or mescal button has been des-ignated a narcotic drug by one FederalawPopular conception of a term is not

always a true interpretation. Thusopium, which is a very complex sub-☜stance, contains two distinct groupsof alkaloids.? The first of these,known as the phenanthrene group,possesses analgesic, narcotic, and ad-diction properties, of which morphineis the more important. * The sec-ond, or isoquinoline group, is withoutnarcotic effects and does not techni-cally enter into the addiction situa-tion. Moreover, cocaine, commonlyregarded as a narcotic substance pro-duces marked stimulation and excite-ment. Larger doses cause depressionand variable degrees of muscular in-coordination that may be followed bynarcosis and convulsions. Because ofits exciting and stimulating effectcocaine is not strictly a narcotic sub-stance. > Indian Hemp or Maria-

☂ hauna has a somewhat similar stimu-lating effect to that of cocaine. Largerdoses produce excitement sometimesamounting to frenzy, and a deliriousphase characterized by disturbancesin time relations and later by narcosis.

The active principle of Mariahuanaiscontained in the resin of the driedflowering tops of hemp, it beingsmoked by addicts in the form ofcigarettes.Peyote or mescal button, ® a cactus

indigenous to the Rio Grande Valley,is used in religious ceremony by manyIndian tribes. It does not produceexcitement like that of Indian Hemp,but is characterized by an incessantflow of visions of infinite beauty andand grandeur, and of vivid color andform. It also produces incoordinationand muscular weakness of varyingdegree, but no drowsiness,the individ-ual remaining awake and fully awareof his surroundings. It is not a truenarcotic substance.

Narcosis, the mechanism of whichis not clearly understood, may be pro-duced in various ways, by cold, by fa-tigue, by oxygen deficiency, and strik-ingly by neutral hydrocarbons used inmedicine for their anesthetic, hypno-tic, and sedative effects. The morecommon of these substancesare alco-hol, ether, chloroform, and other vola-tile hydrocarbons, of which there areseveral. Those used largely for theirhypnotic and sedative effects includesuch substances as chloral, paralde-hyde, sulphonal, trional, tetronal, bar-bital, and other barbituric acid deriva-tives. It is known that the most conspic-uouseffects of all these drugs consist invariable degrees of mental dullness,in-

creasing with larger doses into narco-sis and anesthesia of central origin.☂They are subject to abusive and ha-bitual uses with deleterious andsometimes fatal results. Popular con-ception, however, does not place themamong habit-forming narcotic drugs.They may, however, assume such arole for a given individual, a desirefor temporary respite from the tediumof life☂s routine being an influentialfactor. Experience has taught thatsubstances possessing narcotic pro-perties may be subjected to habitualuse, resulting in loss of powerof self-control and endangering the health,safety, and welfare of the community.Alcohol is an example of such a sub-stance. Its uses and abuses are oftencondoned by a general public, how-ever. The habitual use of opium oritsphenanthrene derivatives is not con-doned by an interested public, for ittends to produce a situation differentfrom that observed from the habitualuse of other narcotic substances. Sincechronic opium poisoning is not con-doned by a general public and is ap-parently a most important form ofnarcotic drug addiction from a medico-sociological standpoint, this article is-limited to a discussion of the severalphases of that particular problem. Itembraces a consideration of the natureof the affliction, its causes, where,when, and under what conditionsit oc-curs, and measuresfor its prevention,control, and treatment.

THE CONVENTIONAL IDEA OF THE

OpruM ADDICT,The conventional idea of an opium

addict is one whois pale, hollow-eyed,and cadaverous in appearance. Thisconception partly results from themore or less characteristic symptomsseen in chronic opium poisoning whenthe drug is withdrawn. It is then thatthe individual, because of suffering,makes himself known as an addict.

The idea, however, is not an accurateone because many appear physicallynormal when able to maintain an ade-quate balance in drug supply. Earlywithdrawal symptomsor lack of drugbalance invariably give rise to more orless loss in body weight incident toimbalance in water metabolism. Whenthis is coupled with insufficient andimproper nourishment and unhygienicliving the addict is liable to be emaci-ated and sallow. Heis also subject tointercurrent diseases, both surgicaland medical. Pulmonary tuberculosis |occurs in about the proportion of onein every twenty, whereasirritation ofthe nose and throat is common. Skinabscesses occur in about 5%, whereasscars from former abscesses are foundin about two-thirds of all addicts.Syphilis occurs in about 18% of theindividuals, whereas oral sepsis, pyor-rhea, and carious teeth are commonamong them. Those without inter-current diseases who maintain adrug balance, receive regular andproper food, and live an outdoorlifeare usually well developed and wellnourished.®Contrary to oft expressed opinion,

Opium addicts are gregarious withtheir kind, but weak and vacillating.The fraternity and contrasting dis-loyalties are proverbial. They haveno continuity of purpose or interestexcept to maintain a supply of theirdrugs. It is their major interest, theirprincipal subject of conversation, andall motives, words, and deeds are con-centrated in that direction. Their dis-play of cunning, cupidity, persistence,and ingenuity to obtain and maintaina supply of drugs is often remarkable.Integrity and reliability are usually .unknown qualities among them.®

WITHDRAWAL SYMPTOMS

The symptoms associated with thewithdrawalof the drug, as seen inopium or opium alkaloid addiction, is

a striking phenomena. Perhaps noother substance to which tolerancehas been acquired manifests suchsymptoms. The four most constantabstinence symptomsare fear, insom-nia, restlessness, and loss of appetite.Often the case is characterized byaimless restlessness, yawning, andchilly sensations lasting a few toseveral hours, and sometimesfol-lowed by sleep from ten to twelvehours. This is called the ☜yen☝ sleepby the habitue.2 On awakening thesymptoms are intensified; profuseperspiration, tremors, muscular twitch-ing, sneezing, photophobia, vomiting,diarrhea, palpitation, and cramps beingthe most common. On the mental sidethere is groaning, whining restlessness,with anxiety, and fear. Other symp-toms may be encountered, such ashemorrhage into mucous membranes,albuminuria, double vision, distur-bances in locomotion, pain and cramps,hyperesthesia, delirium, and collapse.Death has been known to supervene.All these symptomsare relieved im-mediately by the administration of anopiate. Without the drug the symptomswill have subsided in seventy-twohours, but for several weeks ormonths thereafter cramps and othersymtoms may return. There is noquestion about the genuineness ofthose symptoms since they are shownby addicted monkeys. Nevertheless,there is always a tendency,especiallyin the presence of the inexperienced,for addicts to magnify and dramatizetheir sufferings. The intensity of someof these symptoms is undoubtedlysubject to control. With the subsi-dence of these symtomsall inhibitionsappear to be released, sensual conductand perversion being some outstand-ing reactions.

Specific treatment for chronic opiumpoisoning hinges upon a better under-standing of the mechanism of drugtolerance and of abstinence symptoms.

Many theories have been advanced toexplain them.!° The conclusions ofone group of observers, who seeminglyhad established some basic principles,have been refuted by others, so thatthe situation remains confused. Muchinvestigative work has been accom-plished, however, that may serve asguide posts for future inquiries, but agreat deal of it has been pocketed inblind trails that load nowhere.

THEORIES OF TOLERENCE

A situation wherein an individual,through long use of opium orits de-rivatives, may safely take large dosesof his drug that would be fatal to oneunaccustomed, has intrigued the inter-est of many observers. It has beenexplained on the grounds that the oxi-dation of morphine within the bodyproduces a toxic by-product that isneutralized by an additional intake ofmorphine, and unless so neutralized,gives rise to abstinence symptoms.This theory, together with that of asupposed development of active im-munity from the use of such drugs, isof historical interest only. Otherhypotheses deal with the fate of mor-phine in the human body. These hingeupon the theory that the rate of de-struction is increased through habitu-ation; that muscle tissue acting as abuffer, develops the power to storemorphine andto release it so graduallyas not to affect the nervous systemfatally; that body cells, particularlynervecells, are rendered less sensitivethrough continued use of the drug;and that the glycero-phosphoric orcholin lecithin portion of the cellmolecules is replaced by the alkaloid.A great deal of work is required, how-ever, before these hypotheses can beestablished on firm footings.Other theories have been advanced

to explain the phenomenaof tolerancebased upon physiological interpreta-tions. Thus, there is the one which

considers a simultaneous stimulationand depression of different parts of thenervous system, tolerance being es-tablished through accumulation ofhigher levels of stimulation that out-last and ultimately replace the morefleeting depressant effects. In theother, which concerns an imbalanceinthe automic and endocrine systems,conflicting opinions arise, and theyappear to be confused with the stimu-lation-depression theory already men-tioned. A conclusion that tolerance isno more than a question of physiologi-cal balance does not simplify an un-derstanding of its mechanism or howit operates.

ABSTINENCE PHENOMENA

Interest has long been manifest inan attempt to explain the phenomenaof torment and suffering shown byopium habitues when drugs are ab-ruptly withheld. The belief that atoxin is produced when such drugsare withheld is not supported by ob-servation. Other theories in explana-tion of abstinence symptomsare basedupon the hypothesis that nerve cells,having been depressed through con-tinued use of drugs, become hyperex-citable or hyperfunctional when re-leased from such depressive action;that tissue water imbalance is respon-sible; that lack of endocrine equilibri-ummay explain the phenomena; andthat the psychic element is an impor- .tant factor. Perhaps further studiesand investigations will clarify thiscomplicated question, and serve toguide a rational form of treatment forthe torment and suffering seen duringthe withdrawal period.

CAUSESEase of access to habit-forming nar-

cotic drugs must be considered an im-portant causative factor in addiction.It is usually established at a laterperiod in life among those who handledrugs professionally or legally than

among those unauthorized to handlethem for professional or business rea-sons. In every hundred addicts who,because of occupation, were author-ized to deal with narcotic drugs, ap-proximately four had become addictsbefore 25 years of age, seventeen be-fore 30 years, and forty-seven or lessthan half, before 40 years. Amongaddicts who were unauthorized orunregistered to handle narcotic drugsalmost half had acquired the habitbefore 25 years of age, and two-thirdsbefore 30 years of age.The important precipitating or im-

mediate causes of addiction are relatedto the previous uses of such drugs inmedical treatment, to self-treatmentfor the relief of pain, to recourse todrugs during emotional stress, to theinfluence and association with otherswho are habituated to their uses, toovercome drunkenness, and to indul-gence for the sake of experience,curiosity, a thrill, or bravado.The more important predisposing

or underlying causes of addiction arerelated to the inherent constitutionalmake-up of the individual.vously unstable person is more proneto embracethe habitual use of narcoticdrugs than one with a stable constitu-tion. This is one way of saying thatthose with mild psychic disorders, orthose of faulty personal constitutionor mental make-up, constitute a varia-ble proportionof addicts. An approachto the partial solution of narcoticdrug addiction must therefore takeinto account the mental hygienefactors involved.☝The causative factors of addiction

are found to be different in degreewhen comparison is made betweenthose unauthorized to deal legally innarcotic drugs and those authorizedto handle them. Among addicts li-censed to deal in narcotic drugs forprofessional or business reasons, andwho are accessible for study and ob-

The ner- °

servation, more than three-fourthsat-tribute their addiction to the previoususe of these drugs in medical treat-mentor to self-treatment for the reliefof pain. Relatively few attribute theiraddiction: to contact and associationwith other addicts, to a desire for ex-perience, to satisfy curiosity, to obtaina thrill, or to their use during emotion-al distress. Among the unregisteredgroup, almost half attribute their ad-diction to contact and association withother addicts. A proportion attributetheir addiction to a desire for experi-ence or bravado, to satisfy curiosity,to obtain a thrill, to allav emotionaldistress, or to overcome drunkenness.A proportion, however, attribute theiraddiction to the previous use of drugsin medical treatment and to self ad-ministration for the relief of pain.

INCIDENCE OF ADDICTION

It is impossible to determine theexact numberof narcotic drug addictsin the United States. Various estimateshave been made, however, based on avariety of factors, and approached indifferent wavs. A comprehensive pub-lication appeared in 1924 by Kolb andDuMez,® wherein previous estimatesand surveys were reviewed and anestimate of the numberof drug addictscalculated on the theoretical possiblequantity of drugs available to satisfythe craving of addiction. Their esti-mate places the numberas not greaterthan 150,000. These authors considerthat probably the more accurate andcorrect estimate would be near 110,000.Other estimates have been made,

based on first hand contact with theproblems of narcotic law enforcement.The number of narcotic addicts com-piled from that source is estimated bythe Bureau of Narcotics, of the Treas-ury Department, as not to exceed100,000. Terryestimates that thereare at least 90,000, based on an analysisof. the legal distribution of drugs in

Detroit. Other estimates have beenmade also which are not based on anystandard bodies of observations.

It is highly probable, based onknowledge available, that there is notmore than one narcotic drug addict toeach thousand of the general popula-tion of the United States. Any esti-mate in excess of two per thousand ofthe general population may be con-sidered, in the light of present knowl-edge, aS an exaggeration. However,it is not so important to determine theexact number of narcotic drug addictsin a country as it is to determine theextent to which addiction affects thevarious groups or components of thepopulation, and whetheror not it con-stitutes a medicosocial problem de-manding solution.

SOME EPIDEMIOLOGICAL ASPECTS

The practice of indulging in habit-forming drugs, like the problem ofchronic alcoholism and mental disor-ders, is not limited to any one class ofsociety; the high, the low, therich, thepoor, the weak and the strong areall re-presented. No one occupation possessesa monopoly of the practice of usinghabit-forming drugs, and no national-ity, race, color, or social class is ex-empt, for drug addicts are found inmost unexpected places. Contrary to

wide spread belief some drug addictsare engaged in lawful and gainfuloccupations. . These comprise usersaccustomed to small doses that arekept constant for years. Those tendingto increase their dosage are more oftenfoundamongthe irregularly employed,the unsteady, andthefloating,loafing,☜racketeer☝population ofa community.The migratory habits and unfixed res-idence of these people are proverbial.Males predominate among drug ad-

dicts coming within thefield of obser-vation in the proportion of about fourwhite males to one white female. Theproportion of women is somewhat

higher among the Negro group. Avery large number of women drug ad-dicts who come within the scope ofobservation are prostitutes.The distribution of drug addicts ob-

served among the white and the Negropopulations shows higherquotasamong the Negro group,especially forNegro females, when compared withwhite females. Studies of the nativityof drug addicts indicate that there isno significant difference in this respectfrom that observed in the general pop-ulation. The foreign born, the nativeborn of native parentage, and thenative born of foreign or mixed par-entage occur in about the same pro-portion in the addict and in the gener-al population groups.Separation and divorce are more

common among drug addicts than inthe general population, divorce ocur-ring about five times as often. Widowsand widowers are also found moreoften among addicts. Marriage amongfemale drug addicts occurs in aboutthe same frequency as marriageamong females of the general popula-tion. Marriage of male addicts, how-ever, occurs with less frequency thanmarriage of males in the general pop-

ulation, there being a disproportionatenumber of single men without homesor without family ties among them.The educational status of persons

addicted to the use of drugs is, on theaverage, somewhat higher than thatof the general population; illiteracy,

_ however, occurs somewhat more oftenamong those addicted. About the sameproportion of drug addicts finish thefifth and the eighth gradein schools,enter and finish high school, or go tocollege, as is observed in the generalpopulation. There is, howevera rela-tively higher proportion of the profes-sional classes in the addict group.Drug addiction is most prevalentin

the larger urban centers. It is also

10

observed in smaller cities and towns,and in rural communities. Studies ofthe commitments of drug addicts toprisons, jails and reformatoriesthroughout the country show variabili-ty in geographic origin. Investigationsof prison commitments for violationof the narcotic laws indicate that drugaddiction is very widespread and thatits geographic distribution corre-sponds generally with the density andgeographic distribution of the generalpopulation of the country. This is truefor those who are registered to deal inand handle narcotic drugs and forthose who are unregistered.Persons addicted to the use of habit-

forming narcotic drugs are found inall. age groups above the age of 15years. Relatively few come under ob-servation during thefirst two decadesof life, about one-fifth in the third de-cade, and more than one-third in thefourth decade, or about 57 per centunderthe age of 40 years. About one-third are representedin the two decadeage periods of 40 to 60 years, andrel-atively few after 60 years of age. Drugaddiction is therefore represented ineach age period above 15 years, butwith a greater concentration in the 25to 45 year age groups.These observations apparently indi-

cate that addiction to the use of habit-forming narcotic drugs is widespreadthroughout the United States; that allclasses and groups of the general pop-ulation are affected in one way or an-other; that occupation, periods of life,nativity, sex, color, marital or educa-tional status, are not exempting fac-tors. It appears that drug addiction issomewhat like an endemic disease, forit is through and on the people.If thisis true, drug addiction constitutes amedicosocial problem of concern andimportance to the nation, to the state,and to local jurisdictions, 5 16

11

PUBLIC POLICIES FOR PREVENTION

The first Federal measures for theprevention of chronic opium poison-ing, enacted in 1887, prohibited theimportation of non-medicinal opiuminto the United States by Chinesecit-izens or its importation into China byAmerican citizens. This legislationwas an attempt to eradicate the evil ofopium smoking which affected thoseareas most heavily touched by orientalimmigration. Other events crystallizedthe problem as a national and inter-national one. Thus the practice of☜farming☝ out the right to sell opium,discontinued in the Philippine Islandsin 1898, was revived in 1903. The pro-posal to reestablish such a systemcreated a national problem leading tothe appointment of the PhilippineOpium Commission. Asa result of thelatter☂s deliberations, the Congressofthe United States, in 1905, imposed ab-solute prohibition on the use of the drugexcept for medicinal purposes,effectivein March, 1908. At about this time thecontinental United States was also hav-ing an opium and drug problem of con-siderable magnitude. It imported in1907, 728,530 pounds of opium, presum-ably for medicinal purposes. An Act of1887 prohibited importations for anyother purposes. China was also makinga special effort to rid herself of opiumaddiction. Out of these situations therearose the International Opium Comis-sion to study the opium problem in theFar East. Before its meeting, however,in February, 1909, at Shanghai, it wasrealized that the subject of chronicopium poisoning wasof concernto thelarger opium producing countries thathad no possessions in the Far East,and to western civilization that hadbecome contaminated through the mis-use of opium or its derivatives.

Resolutions adopted by the Interna-tional Opium Commission of 1909 ledto the calling of an international con-ference during the winter of 1911-12,

leading to an agreement since knownas the Hague International Opium Con-vention of 1912, to which the UnitedStates is a signatory power. The Unit-ed States agreed with other countriesto enact laws and regulationsto limitexclusively to medical and legitimatepurposes, the manufacture, sale, anduse of certain habit-forming drugs, andto cooperate with other countries toprevent the use of such drugs for anyother purpose. The so-called FederalAnti-Narcotic Laws and their severalamendments had their beginning fromthe agreement of 1912.With the advent of world hostilities

in 1914, little progress had been maderegarding the ratification of the Con-vention of 1912. The Versailles Treaty,however, secured ratification of theConvention by all powers signatory tothat Treaty, and by Article 23 of theCovenant of the League of Nations, theLeague was entrusted with generalsupervision over the execution ofagreements with regard to **** thetraffic in opium and other dangerousdrugs. Leading to the administrationof these affairs an Advisory Committeeon Traffic in Opium was appointed bythe League. From studies of the situ-ation and reports of the Opium Advi-sory Committee to the League,a con-ference wascalled at Geneva in 1924,and a second in 1925, out of whichgrew the Geneva Convention of Febru-ary 19, 1925.These international conventions

which had for their object the controlof traffic in narcotic drugs were inade-quate to meet the situation since largequantities of such drugs were beingsmuggled all over the world and intothis country each year. These supplieshad their sources usually in countrieswhere drugs were manufactured inexcess of the medicinal andscientificneeds.!☝The United States could be protect-

ed against this avalanche of contra-

12

band best by an international agree-ment limiting the world manufactureof narcotic drugs to the amounts re-quired for medicinal and scientific pur-poses. The provisions of the GenevaConvention of 1931, 18 to which theUnited States Governmentis a signa-tory power, are intended to accomplishthis purpose, and further to controlthe movement of such drugs in inter-national trade. The Convention orTreaty of 1931, together with the exist-ing measures for domestic control,should play an important role in thesolution of the drug addiction problemin this country.The enforcement of restrictive meas-

ures imposed by Federal law govern-ing the importation, manufacture, anddistribution of narcotic drugs mustbear relation to prevention of addictionsince ease of access to such drugs isan associated causative factor of addic-tion. Inadequacies in Federal legisla-tion have led to further elaboration incontrol, until in the United States to-day all manufacturers,dealers, pharma-cists, physicians, dentists, and veteri-narians must be registered to deal legal-

☁ly in such drugs for professional orbusiness reasons. A complete record-ing system is ma☁ntainedofall imports,manufacture, sales, and exportsof these drugs.☝But Federal restrictive laws govern-

ing the commercein narcotics are notthe only measures to be applied in thesolution of this medicosocial problemfrom a national viewpoint. So long asthere are drug addicts within the coun-try and so long as addicts are madetrough contact with other addicts,whose every motive andinterestis cen-tered on obtaining and maintaining asupply of drugs, there will be depravedmen and women to supply them fromany source or sourceshumanlypossible.The need for destroying drug peddlingis obvious, but the potential marketfor contraband must not be neglected.

The isolation and segregation ofdrug addicts with the object☁of treat-ment instead of punishment appearsdesirable and necessary,for their pres-ence and contact with others in Amer-ican communities is a potential dangerand a causative factor in the produc-tion of further addiction. Their segre-gation and isolation should be for anindeterminate period, contingent onthe individual concerned in somewhatthe same way as the insane are segre-gated. A significant change in Federalpolicy toward this phase of the drugproblem occured in 1929, when Con-gress authorized two institutions forthe segregation and confinement ofpersons addicted to the use of habit-forming narcotic drugs who have com-mitted offenses against the UnitedStates, including Federal court,court martial, and consular court cases,for those placed on probation by suchcourts, and for those who may volun-tarily seek treatment. The objects,purposes, and designs of these institu-tions are to rehabilitate, restore tohealth, and train to be self-supportingand self-reliant those who are admit-ted. In addition, the control, manage-ment, and discipline is to be maintainedfor the safe keeping of the individualand the protection of the community.Industries are to be established to af-ford occupation, vocational trainingand education for inmates. Experi-ments are to be carried on to deter-mine the best methods of treatmentand research in this field, and there-sults disseminated to the medical pro-fession and the general public to theend that states may make some provi-sion and establish a-public policy forhelping to solve the problem of drugaddiction. The functions of these in-stitutions assume the character of atreatment and research center, of aneducational, industrial, vocational, andrehabilitation center, with certain cus-todial features superimposed. These

13

institutional provisions make an appealto the humane instinct and may playan important role in the prevention ofaddiction.

It is interesting to note that repeatedprison sentences are imposed moreoft-en on drug addicts than on any othertype of Federal prisoner, those withthree or more prison sentences occur-ring twice as often among addicts.This situation of repeated prison sen-tences challenges the usefulness ofhandling drug addiction through pris-on sentence alone. It is evident thata public policy that treats drug addic-tion solely as a penal and correctionalproblem is not contributing to its solu-tion. The desirability of modifyingpertinent public policies is suggestedby the variations in time elapsingbetween the ages when addictionbecomes established and the age whensuch individuals are sentenced to pris-on for the first time. Approximatelyhalf of the narcotic drug addicts sen-tenced to prison for thefirst time havebeen addicted to the use of habit-form-ing drugs for eleven years; about 25per cent have been addicted for twentyor more years, and 25 per cent for sixyears or less. In general, those addict-ed earlier in life have a greater timeelapsing between the date when ad-diction becomes established and thedate of first prison sentence. Thesefactors suggest that, so far as remedi-able public policies are concerned,drug addiction has been regarded as apenal and correctional problem, likethat of the insane of an earlier day,without cognizance being taken ofitsmedicosociological and economic sig-nificance. ☝

STATE RESTRICTIVE MEASURES

State restrictive measures for theprevention of drug addiction had theirbeginnings in various regulationsgov-erning the sale of poisons and the usesof narcotic drugs; in lawsrestricting

the sale and possession of such drugs;and in providing for the segregationand treatment of drug addicts. The ♥first object for regulating the sale ofnarcotic drugs, was in part aneffortto eradicate opium smoking, and alsothe abusive uses of morphine and thepromiscuous use of cocaine proximateto its introduction in medicine in 1884.Subsequent measures undertook torestrict the sale and, later, possessionof a variety of drugs, usually cocaineand opium and its derivatives, but thesale of other drugs came underrestric-tion also. The need for controlling andsegregating drug addicts as a preven-tive measure wasfirst recognized bythe enactment of_a compulsory com-mitment law in Connecticut in 1874,but after 57 years only 24 states hadcompulsory laws governing suchcases.☝The great diversity in the several

state laws governing the narcotic drugaddiction situation has long been re-cognized, and the need for greateruniformity attracted the attention ofthe Commissioners on Uniform StateLawsas early as 1922. At the meetingof the National Conference of Com-missioners on Uniform State Lawsin1932 a final draft of a uniform statenarcotic law was approved bythator-ganization and by the American BarAssociation, and plans perfected forthe printing and distribution to theGovernors of the several states. Withthe adoption of a uniform state narcot-ic law the Federal functions would belimited to the detection and elimina-tionof the larger wholesale sources ofillicit supply within our country, andthe control of importation, manufac-fure, and the legal distribution of suchdrugs required for medicinal andscientific purposes. Such matters asthe protection and prevention of theso-called illicit retailing of narcotics,the segregation and treatment of drughabitues, and the revocation of licenses

14

for the abuse of these drugs by thoseengaged in a business or a professionin the course of which narcotics areused, must, under a federated system ofgovernment,fall within the provinceofthe functions of the several states. 2!

THE ROLE OF PROFESSIONAL ACTI-

VITIES IN PREVENTION

Studies of the quantities of narcoticdrugs legally distributed to retailersand dispensers in various sections ofthe United States indicate wide varia-tions in the per capita requirements ofthe general population. Great diversityof needs is also observed in differentparts of the same communities. Thediversified per capita requirements fornarcotic drugs for medical purposes inthe several communities of the UnitedStates, and in the same communitiesat different times, involve a wide varie-ty of factors, none the least of whichconcern the choice of the individualpractitioner. Investigations, however,have revealed that narcotic drugs areprescribed when indispensable andwhen no substitutes are available orcan be employed. They are also pre-scribed inadvisedly, perhaps, and con-trary to pharmacologic facts and opin-ions, which are so valuable to the gen-eral practitioner. They are unfortu--nately prescribed, in some instances,for the mere satisfying of addiction.It has already been pointed out thataddiction is more readily induced insome persons than in others, one im-portant predisposing or underlyingcause being an inherent mental ornervous instability. Since it is knownthat addiction may be induced by theinjudicious use of drugs in persons ap-parently free from any mental or ner-vous instability, then it 1s necessarythat greater care must be exercised intheir administration to avert this re-sult in the unstable.☝

It is possible that the abusesof nar-cotic drugs may be avoided or prevent-ed by giving consideration to the pos-

sibility of substituting less dangerousdrugs whenever possible, When theuse of habit-forming drugsis essential,however, care should be taken not togive larger or more frequent doses thanare necessary to achieve the desiredend. Patients requiring daily adminis-tration of habit-forming drugs shouldbe seen often by the practitioner, andthe amount of drugs ordered or sup-plied should not exceed that requiredby the patient until seen again. Ad-ministration on the part of nursesshould be limited to prescription, and.changes in treatment should be inwriting. Patients should not bein-formed of the name or dose of thedrugs administered, and the hypoder-mic administrations should be avoidedif possible, and neverself-administered.The use of the drug should be discon-tinued immediately when no longerrequired; and if a craving has resulted,close supervision and appropriate treat-ment should be maintained until thepatient has been rendered independentof the drug.Valuable results in the judicious use

of narcotic habit-forming drugs mightbe obtained through the medium ofinstruction to professional studentsand to practitioners, and through themedium of an authoritative memoran-dum for guidance in this difficult andimportant problem. This phase of theproblem has been approached throughthe medium of the American MedicalAssociation. The Journal has publisheda series of articles on the indispensableuses of narcotic drugs. These articleswere prepared by various authors andare now available in book form. Thepublication has been issued in cooper-ation with the Committee on DrugAddiction of the Division of MedicalScience of the National Research Coun-cil and the Division of Mental Hvgieneof the United States Public HealthService, and made possible throughcontributions by the Bureau of SocialHygiene.

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Experience has shown that somepractitioners order for or supply nar-cotic drugs to individuals simply toenable those addicted to satisfy theircraving, or the circumstances of sup-ply are of such a character as to castdoubt on the method and intent asbeing bona fide medical treatment.Quantities of drugs have been pre-scribed over long periods of time forpersons seen at long intervals or notseen at all; drugs have been sent bypost for some alleged urgent need orhave been obtained concurrently fromtwo or more practitioners. In someinstances, large quantities of drugshave been purchased or suppliedpractitioners and used for administra-tion to themselves. It is evident thatnarcotic drugs have been supplied andused without the necessity for medicaltreatment and in contravention of theintent of tne law.

International treaties and the lawsof the land have rightfully made cer-tain professional groups the custodiansof these dangerous narcotic drugs.Thinking people of this and othercountries believe they have not mis-placed this trust, and they expectthese drugs to be used for bone fidemedical and scientific purposes. Theabusive uses of these dangerous drugsand the violations of this trust areproblems to be dealt with, corrected,and prevented by the concerted ac-tions of representative organizationsand leaders among these professionalgroups in cooperation with law en-forcement agencies having responsi-bilities in the matter.

TREATMENT

The present status of knowledgeconcerning the nature of drug addic-tion leaves much to be desired. Thephenomena of drug tolerance and ad-diction, the disturbances in water,lipoid and carbohydrate metabolism,the disfunction of the endocrine and

vegetative nervous systems, the effectsof these drugs on the mind, and theeuphoria experienced from the con-tinuous use of opium orits derivativesare all subjects on which great diver-sities of opinion exist. They demandfurther coordinate research for theirsolution, The exact nature of narcoticdrug addicton will be better under-stood through a chemicopharmacolo-gic, biochemical, psychobiologic andmedical approach.The necessity of prolonged or life-

long administration of narcotic drugsis not universally held in this country.The fact that it is held by someindi-viduals makes it difficult to assumethat the continuous administration innondiminishing doses is necessarilyinconsistent with ethical medical treat-ment. It is apparent that this phaseof the subject is much confused withand involved in the much broaderquestion of ambulant versus institu-tional treatment of drug addiction. Inthe United States the ambulatory treat-ment of drug addiction, while theoret-ically possible, has been condemnedas impracticable by the majority ofmedical opinion. According to themodern conception, crystallized in so-cially and legally sanctioned laws,drug addicts or persons requiring con-tinuous and nondiminishing doses ofopium or its derivatives are unpopularand regarded asa menace to the socialorder. They appear to constitute amedico-social problem demanding in-stitutional segregation and treatment.There is, however, no treatment fordrug addiction from the standpoint ofspecific cure that will miraculouslyoperate to rid drug addicts of theiraddiction.The treatment of drug addiction

automatically divides itself into threephases, involving, first, the detoxica-tion or physical rehabilitation stage;second, the emotional stabilization andreeducational phase; and third, the so-

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cial placement and community super-vision phase.

The problem of institutional treat-ment, however, must take into accountthe diverse motives or underlying rea-sons for seeking treatment, the inci-denceof intercurrent diseases and de-fects in such a group, the great differ-ences in the types of personalities in-volved, and the need for protecting theinstitutional community against theweaknesses and cupidity of its com-ponent individuals.There are, of course, some persons

addicted to the use of habit-formingdrugs whosincerely desire to throwoff the so-called slavery of the drug,but this sincerity vanishes when with-drawal symptoms appear. There arethose who seek treatment through co-ercion by friendsorrelatives, the indi-vidual having little sincerity or desireto throw off the habit. Then,too, thereare those who seek treatment becauseof their desire to impress the court orcourt official. Others seek treatmentbecause an institution offers a con-venient refuge from the police, becauseof a desire to reduce the daily dose ofthe drug, thus lessening the expenseof maintaining themselvesin a futuredaily supply, and still others becauseof their need for maintenance andsupport.

The intercurrent diseases observedamong these people embrace the wholecategory of medicine, and their needsinvolve provision for the ambulant,semi-ambulant, bedridden, and conva-lescent sick. The diverse personalitiesinvolved point to the need for appro-priate classification and groupings asa necessary corollary to treatment,based on first-hand knowledge of theantecedent, social, educational, indus-trial and economic background, togeth-er with an analysis of the charactertraits of the individual. The appropri-ate classification and grouping of these

people within an institution is impor-tant for rehabilitation purposes andfor the safety and protection of theinstitutional community and the com-munity at large.☝

CONCLUSIONS

This paper briefly deals with thesubject of chronic opium poisoning,but points out the errors of commissionand omission in the popular connota-tion of the term ☜narcotic drug.☝ Itembraces a discussion of the natureof chronic opium poisoning, the per-sonal characteristics of addicts; thesymptoms associated with the with-drawal of the drug; and the theoriesassociated with the mechanism oftol-erance and abstinence phenomena.The precipitating and predisposingcauses are enumerated, and brief con-sideration given to the methods oftheir operation. The probability ofthe incidence of addiction is also givenconsideration, especially to the diff-culties encountered in making an ex-act estimate as to its prevalence. Theepidemiological aspect of addictionisreviewed, together with those publicpolicies inauguratedforits prevention,segregating and treating addicts beingthe last link in the chain which hasfor its object a limitation of the abusiveuses of dangerous habit-forming nar-cotic drugs.The role which professional groups

may play in the prevention of addic-tion 1s approached by an analysis ofthe present uses and abuses of dan-gerous habit-forming drugs, the cau-tions to be observed in their adminis-tration, the educational measures thatseem desirable, and the scope of theproblem confronting the professionalclasses licensed to deal in or handlesuch drugs.The status of knowledge concerning

the nature of drug addiction leavesmuchto be desired, and asa result thereis no treatment for drug addiction from |

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the standpoint of specific cure that willmiraculously operate to rid drug ad-dicts of their addiction. The satisfac-tory treatment is essentially institu-tional, automatically dividing itself in-to three phases, involving the detoxi-cation or physical rehabilitation phase,the emotional stabilization or reeduca-tional phase, and the social placementor community supervision phase. Ba-sic facts on these subjects may not beestablished this year or the next, butsystematic and scientific studies bytechnically trained groups of workersshould pave the way toa better under-standing of this and related problems.

In concludingthis discussion of drugaddiction and measuresfor its preven-

tion, attention should be called to someexperiences of the past. These teachus that depraved men and womenareeager and ready to raid those suppliesdestined for medical and scientificuses when contraband narcotic drugsare not available or are unusuallydifficult to procure. They will seekevery meansto divert such suppliesfrom legitimate channels. The adop-tion of a public policy of segregating,isolating and treating drug addicts asa meansof solving this potential men-ace to the legal supply of dangeroushabit-forming narcotic drugs shouldserve to safeguard the interests ofthose professional and business groupswhoare custodians of these drugs.

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(3) ♥ Organic Chemistry, by J.S. Chamberlain, Second Edition, P. Blakiston☂sSon and Company,Inc. |

(4) ♥ Chemistry of the Opium Alkaloids, by Lyndon F. Small and Robert E.Lutz, Supp. No. 103, Public Health Service, Treasury Department,Public Health Reports.

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(9) ♥ Opium Addiction, Papers by Arthur B. Light and Edward G. Torrance,| et al, published by the American Medical Association, 1929, Phila.(10) ♥ Theories of the Mechanism of Addiction, by E. W. Adams, Bulletin of

Hygiene, Vol. VI, No. 10, October, 1932.

(11) ♥ Absence of Transferable Immunizing Substances in the Blood of Mor-

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Public Health Service, Division of Mental Hygiene, Washington, D.C., Journal of the American Medical Association, July 30, 1932, Vol.99, pp. 372♥379.

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(13) ♥ The Prevalence and Trend of Drug Addiction in the United States andFactors Influencing It, by Lawrence Kolb and A. G. DuMez, Reprint924, Public Health Reports, May 23, 1924, Treasury Department,United States Public Health Service, Washington, D.C.

(14) ♥ Report on the Legal Use of Narcotics in Detroit, Michigan, and Environsfor the period July 1, 1925, to June 30, 1926, to the Committee on DrugAddiction, by C. E. Terry, Mildred Pellens, and J. W. Cox, Bureauof Social Hygiene, New York, 1931.

(15) ♥ Further Observations on the Epidemiology of Narcotic Drug Addiction,by Walter L. Treadway, United States Public Health Service, Wash-ington, D.C., Public Health Reports, Vol. 44, No. 45, November3, 1929.

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(17) ♥ Opium as an International Problem, by W. W. Willoughby, The JohnsHopkins Press, 1925.

(18) ♥ Conference on the Limitation of the Manufacture of Narcotic Drugs,Geneva, Switzerland, May 27 ♥ July 13, 1931. Report of The Dele-gation of the United States to the Secretary of State, Washington,D.C.

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