This section of the study will examine the development of theories of addiction in relation to the transformation of the addicted population within three specific eras: 1870 to 1900, 1900 to 1923, 1923 to 1963. For this section the sources of information will be obtained from the following books.
Historical eras are dominated by specific addicted groups, theoretical concepts about addiction, the development of specific treatments and the existence of particular social biases (Courtwright, 1982). Therefore, a major purpose of this chapter is to trace the accretion of stigma targeted to the opiate addicted population during the various eras over the past century. Eventually, the social biases and stigma directed to opiate addicts are expressed in federal, state and local legislation whose main purpose is to control behavior that is misunderstood and feared.
During the past century, the historical, socioeconomic and political forces of a given era shaped the nature of opiate dependency in the United States. Changing technology provided the means for more efficient routes for the administration of opiates (e.g., the invention of the hypodermic needle in the 19th century) and the synthesis of more potent opiates (e.g., synthesis of heroin from morphine) (Musto, 1973). The variety of social groups that constituted foci of opiate dependency suggests that causality of narcotic dependency is an availability phenomenon determined by social factors and biological vulnerability to addiction rather than the outward expression of a unique set of social or personality characteristics. Historical evidence argues against the concept of uniqueness, since widely diverse social and personality characteristics may enter into the causality of an addictive disorder.
Social and personal factors may be responsible for the introduction of narcotics to a particular individual or group. These factors may also help to understand the individual's behavior to obtain narcotics once the addiction process has started. However, neither social or personality theories explain the commonality of addictive behavior found in the variety of affected groups and personalities: the daily compulsive use of narcotics, the development of tolerance and physical dependence, the persistence of craving or drug hunger and the high rate of relapse to narcotics after withdrawal.
Theories of addiction reflect the ideas of a particular era and form the underlying basis upon which addictive behavior is perceived and interpreted. Social biases (e.g., class and race) that contribute to stigmatization of addicts are incorporated into the theoretical framework. Goffman's categorization of addiction as a socially stigmatized condition derived from "blemishes of individual character perceived as weak will, domineering or unnatural passions, treacherous and rigid beliefs and dishonesty" describes the underlying biases of most social and psychological theories of addiction that were formulated in the 19th and 20th centuries (Goffman, 1963). However, socioeconomic class and race also influence the perception of addicted groups. Stereotypes based on the perceptions and interrelations of class and race especially in times of economic crisis lay the foundation for the incorporation of related biases into theories of addiction and the type of legal statutes that are created to control addictive behavior (Helmer, 1975).
The Era 1870 to 1900
In the 19th century opium was one of the most widely prescribed substances in the medical pharmacopeia in the United States. Effective medications were rare and the etiology of major diseases was either unknown or beginning to be systematically studied. The physician faced with a host of ineffective remedies to treat disease turned to palliative substances that were able to relieve pain, induce a degree of comfort and, if possible alleviate troublesome symptoms (e.g., diarrhea) (Brecher, 1972). Dependence on opium, laudanum and possibly oral preparations of morphine (which was synthesized from opium in 1815) was not uncommon. Opium dependence affected notable figures such as Benjamin Franklin who was addicted late in life. Opium was also widely prescribed during the cholera epidemic in the 19th century.
Therefore, evidence from the 19th century suggests that the major cause of addiction was iatrogenic, the prescribing of opiates by a physician to relieve discomfort and pain. Patients who continued to take opiates after a course of prescription by a physician during the course of an illness were regarded, in a religious sense, with moral opprobrium. Continued addiction was considered sinful, a vice, affecting weak willed but normal people who according to J. Townley Crane, a Methodist minister, "learned to love the excitement which it produces." However, there was also asense of empathy toward opiate dependent persons since relief of pain was not only a major objective of medical practice but a major reason persons sought out a physician when little was known about the underlying causes of disease and pain.
The religious-based belief that opiate dependence is a vice was challenged by contemporary late 19th century physicians who considered addiction a form of inebriety that was characterized by an underlying mental disturbance (Parssinen, 1983). Inebriety, however, merged two previous 19th century medical and psychological theories degeneration and neurasthenia. Degeneration refers to worsening morbid conditions that are transmitted over generations within a family. Environmental factors such as alcoholism and opiate dependence may enter into the degenerative process as a catalyst for further pathology. Neurasthenia refers to inherited inadequate nervous systems that may make an individual prone to a variety of afflictions including opiate addiction. Social factors also played a part. Persons in the upper classes trying to preserve their social status may "exhaust their nervous systems" and be prone to afflictions such as opiate addiction. If a patient suffered from neurasthenia then opiates generated a craving proportional in strength to the neurasthenia (e.g., the greater the neurasthenia, the greater the addiction).
The concept of inebriation dominated the theoretical framework of addiction from 1880 to about 1915. In late 19th century Germany, however, two emerging conflicting views of addiction within the medical profession challenged the concept of inebriation -a physiological theory and a psychological theory. An important physiological concept of addiction was advocated by Dr. Eduard Levinstein of Berlin. Levinstein promulgated the idea that addiction was caused by physiological reactions to the administration of morphine and that any person could become addicted. He completed a follow-up study of addicts in his practice who were withdrawn from morphine and found a 75% relapse rate, which is comparable to relapse rates reported in follow-up studies in the twentieth century. Levinstein was of the opinion that addiction was at most difficult if not impossible to cure. He also noted deviant changes in behavior of previously upright persons to obtain narcotics after withdrawal.
The psychological theory described the addict within the newly emerging concept in German medicine of the psychopathic personality which evolved from an early 19th century English theory of moral insanity. In this theory, persons were not mentally ill with delusional fantasies but acted without a moral sense. They were capable of antisocial behavior and committing criminal acts without guilt, conscience or restraint. These two theories - the physiological and psychological - were further developed in the early 20th century to help explain addictive behavior.
The overwhelming majority of addicts (about 60%) in the late 19th century were white middle and upper class women addicted by their physicians who in turn also had exceptionally high rates of addiction because of their access to narcotics. Geographically, the greatest prevalence and incidence of iatrogenic addiction was in the southern United States.
Wounded veterans of the Civil War constituted another group of medical or iatrogenic addicts. During the Civil War, morphine salts were direcly administered into wounds and opiates were orally administered. Opiate addiction, so prevalent among Civil War veterans was known as "soldier's disease." The hypodermic administration of opiates to wounded soldiers was minimal during the Civil War and came into general acceptance in the late 1860s and early 1970s.1 Once the hypodermic needle was a fully accepted instrument within medical practice, it was freely used by physicians to inject morphine for a variety of conditions including cholera, dysentery, insanity, cancer, headaches and most frequently, physical and emotional problems affecting women.
Elderly iatrogenically addicted women and wounded Civil War veterans were considered legitimate medical patients to be treated with empathy and compassion. Others within the upper classes who were addicted to opiates such as successful businessmen, physicians and other professionals were considered to be individuals who had exhausted their central nervous system reserves to maintain their status and successful social positions. Explanations of addiction for these groups of opiate dependent persons appeared to fit the neurasthenic theory of inebriation and, in some upper class families affected by numerous mental disorders and incurable conditions, progressive degeneration another aspect of the theory of inebriation.
Opiates that could be administered orally were obtained through prescriptions namely morphine salts and opiate concoctions such as laudanum which consisted of a combination of opium and alcohol. Various nostrums containing opiates, advertised to relieve pain and migraine were available over the counter without prescriptions in pharmacies. As physical dependence on opiates increased among the middle and upper classes, numerous sanatoria were established at the end of the 19th century to treat addiction among the upper classes with bogus claims of "cures."
In the 19th century, however, there was a low prevalence of opiate addiction among blacks. It was hypothesized that blacks did not have the organized "delicate nervous systems" or stress related neurasthenia found among upper class whites to develop widespread addiction to narcotics. Also, among iatrogenically addicted white women (the modal group), physicians, businessmen and others, addiction occurred late in life usually after a middle age illness. Blacks who had little access to physicians, thereby avoiding iatrogenic addiction, and lived shorter lives on the average.
However, another group of opiate addicts existed in the late 19th century, namely opium smokers, as opposed to patients who administered opium orally in available mixtures. Opium for smoking and the opium pipe were brought to the United States in the 19th century by indentured Chinese laborers working in mines and on the construction of the railroads. These workers were forced into oppressive conditions of work and were in debt to Chinese merchants and investors who brought them to the United States. Most were poor peasants who had hoped to save money and return to their families in China. However, most failed to do so because of low wages, exploited conditions and mounting debts to their sponsors. Furthermore, dens, established within the locality of their housing, were available for smoking opium and the services of Chinese prostitutes who were probably also addicted to smoking opium. Opium dens were established in Chinese settlements or "Chinatowns" throughout the country.
Opium for smoking was legally imported and eventually found its way into the white marginal groups which included con or "sporting" men, gamblers and prostitutes. Although initially smoking with Chinese smokers, they eventually established their own smoking dens in cities throughout the country. This group of addicts, however, elicited strong feelings of rejection and stigmatization by the larger community, resulting in restrictivelocal ordinances and state legislation concerning opium smoking and the existence of opium dens. In some cities, the possession of opium pipes was prohibited by law, thus antedating the criminalization of possession of a hypodermic needle in many states during the 20th century. Legislation, however, did not decrease opium smoking. The main impact was increased prices of opium and the moving of dens to localities that had less restrictive or no ordinances.
Helmer indicates that groups at risk for addiction and identified as such by the government are related to the race and class structural conflicts within American society. As an example, he asserts that the anti-opium statutes in the late nineteenth century were enacted during periods of economic crisis. They were directed against Chinese workers who were not only in competition for jobs with whites but were paid lower wages than whites.
Social Paradigms of 19th Century Opiate Addiction
Social class, race, type of behavior, source of opiate, type of opiate, its route of administration, and voluntary or iatrogenic initiation into addiction are the factors that determined paradigms of addiction in the 19th century. For the group that was iatrogenically addicted, there was empathy and narcotic maintenance, for the others (opium smokers) there was legal control and stigmatization. It is estimated that by 1900 there were perhaps 300,000 narcotics addicts in the country, consisting primarily of two previously described groups: 1) the iatrogenically addicted, and 2) the opium smokers. The majority of the addicts (about 60%) in the 19th century were iatrogenically addicted females in group 1. Both groups had the same condition -the compulsive use of an opiate with a withdrawal syndrome upon cessation of use and relapse after withdrawal.
In the first group, iatrogenic opiate addiction was a condition that was socially tolerated, eliciting empathy, concern and shame. The group, as previously reported, was basically drawn from sick white middle and upper class females and wounded Civil War veterans. Both were regarded as nonthreatening to social values or the social order. Their addiction to basically orally administered and injected opiates was considered a personal tragedy, and the prescribing of opiates within private medical practice was considered a viable treatment option. When indicated, patients entered sanatoria for "cures." Their opiate conditions "fit" into the previously described theories that attempted to explain addiction (e.g., inebriation, neurasthenia, incurable painful physical condition).
However, poor Chinese laborers and white marginal criminal groups who smoked opium comprised group 2. This opium smoking group was subjected to the stigmatization of race, class and blemishes of character as described by Goffman. Addiction was another manifestation or symptom of the traits of an "inferior stigmatized group." The addictive behavior of group 2 threatened social values and, if allowed to persist, the social fabric of the greater society. They were not considered "sick" within the theoretical framework promulgated to explain addictive behavior in group 1 although their physiological symptoms were the same as those in group 1. Local ordinances and restrictive legislation were employed to control what was essentially perceived as degenerate hedonism.
In the 19th century, bacteria were discovered and the germ concept of disease evolved. Where possible, alternate therapies to prescribing narcotics were developed to treat disease and offer patients relief from ainful symptoms. Nineteenth century physicians also reported about the dangers of morphine and opium addiction, including descriptions and reports about withdrawal, craving and relapse. Leading physicians in the 19th century began to caution practitioners about the danger of the indiscriminant widespread prescribing of opiates. Iatrogenic addiction, therefore, began to subside by the end of the century.
In summation, a medical condition based on theory (inebriation, neurasthenia, chronic painful condition) is the basis of continued narcotic maintenance (oral ingestion or injection by hypodermic needle) in group 1. However, a weak will and immoral behavior is assumed to be the basis of continued addiction (smoking opium) in group 2. Persons in group 1 are considered legitimate medical patients but not those in group 2.
The theories and attitudes of the 19th century were further developed and modified in the 20th century. These developments would reflect major transformations in the addicted population and the availability of addicted substances. Two technological advances in the late 19th century would transform addiction in the 20th century the invention of the hypodermic needle in the 1850s and the synthesis of heroin from morphine in 1898.
The Era 1900 to 1923
This era is marked by a major transformation of the addicted population and the introduction of heroin as a street drug of abuse in addition to morphine and cocaine; the emergence of the United States as a world power in Asia confronting the opium problems in the Philippines and China; the prohibition of alcohol; an era of repression of civil liberties after World War I associated with a fear of a Bolshevik revolution as in Russia; further developments in theories of addiction first proposed in the 19th century; major federal legislation (the Harrison Act) and related Supreme Court cases; monitoring by the government that virtually prohibited the treatment of addiction in the practice of medicine; the opening and closing of a system of maintenance clinics to service addicted persons. Major population transformations occurred in American society (e.g., increase in poor urban and immigrant groups). Class conflicts within American society coupled with the worldwide social and political events of this era had a profound impact on the perception of addictive behavior, theoretical formulations about the causality of addiction, the type of treatment that was made available, legislation and the stigmatization of not only addicts but of the condition of addiction itself.
First Transformation of Addicted Population
With advances in medicine, physicians at the turn of the century were more cautious in the prescribing of narcotics than in the 19th century. Therefore, the incidence and prevalence of iatrogenic addicts in the South decreased. This decrease was further accelerated by the deaths of elderly opiate dependent females and wounded Civil War veterans. Both groups were regarded as legitimate patients and were not subjected to stigmatization becuse of their addictions. However, with the rise of industrialization and the waves of European immigration to northern cities starting in the last decade of the 19th century, the addicted population was gradually transformed. The immigrants themselves were not addicted nor did they succumb to addiction but their young male offspring in the slums and tenements began to smoke opium, snort heroin and cocaine and inject morphine. 2 Also included were the poor youth of native born persons who immigrated to cities for employment in the newly emerging industries.
However, by the end of the first decade of the 20th century, a distorted perception of the prevalence of opiate addiction in the United States was presented to the U.S. Senate by Dr. Hamilton Wright, a reformer with considerable political influence. Wright was the American delegate to the Shanghai Commission (1909) and the Hague Opium Conference (1911). His distorted statistics, presented to the Senate in 1910, exaggerated the prevalence of opiate addiction among the lower economic classes: general criminal population (45.48% addicted), Chinese (25% addicted), prostitutes and companions (21.6% addicted), prisoners (6% addicted), physicians and nurses (3.38% addicted), other professionals (0.684% addicted) and the general population (0.18% addicted).
This distorted picture of opiate addiction among the poor, the Chinese, the criminal classes and the male offspring of recently arrived Eastern and Southern European immigrant groups, especially in the slums of northern cities, was perceived as a major threat to the social order. The southern female iatrogenic addict, now perceived as the "minority addict," was regarded with compassion and the prescribing of narcotic drugs was continued as in the 19th century. In contrast, the counterparts of opium smokers in the 19th century, notably the poor males in northern cities who injected morphine and inhaled newly synthesized heroin, were considered a social menace and became the objects of control through legislation.
The proportion of nonmedical street addicts continued to grow during this period with the emergence of street dealers. Although dealers existed prior to the Harrison Act of 1914 in the slums of the cities, narcotics could also be obtained legally over the counter in pharmacies and through physicians' prescriptions. Restrictive legislation, therefore, helped extend and increase an underground illegal market.
The shaping of attitudes that denied legal narcotics to nonmedical addicts reflects the overall political and social thought of the post-World War I era. The fear of class conflict colored the perception of the government of those addicts from the lower socioeconomic classes. Unnerved by the success of the Bolshevik Revolution, the militancy of the labor movement and specifically the struggles of the International Workers of the World, the presence of a strong socialist movement led by Eugene V. Debs, an anarchist movement led by Emma Goldman and the antianarchist passions elicited by the Sacco-Vanzetti case, immigrants became suspect as a potentially revolutionary group. 3 Opiate use (e.g., opium smoking, morphine, heroin and cocaine) among the offspring of European immigrants, the poor in the cities and the Chinese, was seen as an individual degeneracy that could not be tolerated in a society enmeshed in fears of a possible successful revolution.
Also, if alcohol were prohibited by constitutional amendment, then maintenance drugs for addicts could not be tolerated. Furthermore, the failure of the scientific community to prove that addiction had a physiological basis gave impetus to the acceptance of psychological theories of addiction. Continued addiction, implying the presence of psychopathology, was perceived as a problem of moral degeneracy that would wreck personal and social values. It could not be supported by the medical profession or te government.
Legislation 1900 to 1926
The addictive qualities of narcotics were recognized by the end of the 19th century. Unlabeled patent medicines were a major source of narcotics and many individuals became addicted to opiates unknowingly. These patent medications were sold over the counter in groceries, general food stores as well as in pharmacies. The first important national legislation that controlled the distribution of narcotics was passed in 1906 as the Pure Food and Drug Act. The administration of this act was placed in the Bureau of Chemistry of the Department of Agriculture. The act required that the contents of patent medicine sold over the counter and shipped in interstate commerce be labelled for the narcotic and marijuana content. Although a sharp decrease in sales of medications containing habit forming drugs was reported following the passage of this act, sales continued in general stores and groceries. Therefore, pharmacists successfully lobbied to amend the 1906 act in 1908 by prohibiting the sale in interstate commerce of patent medicines containing narcotics without a medical prescription. The distribution of patent medicines containing narcotics and marijuana was thereby placed under the control of the medical profession and pharmacies.
Perhaps the most important change in the United States position on foreign policy concerning opiates followed the Spanish American War in 1898. The acquiring of the Philippines as a result of this war at the turn of the century transformed the United States into a world power rivaling the European colonial nations. The United States looked to Asia for the expansion of markets and influence on a par with Britain, France, Germany, Japan and the Netherlands.
However, the opium traffic in both the Philippines and China diminished these possibilities. Britain, in particular, controlled the opium traffic in China which was a major impediment to the opening of new markets for the United States. To bring the opium problem in Asia under control, the United States not only participated in but sponsored several conventions to reduce or eliminate the trade of opiates for nonmedical uses. The Shanghai Convention of 1909 and the Hague Convention of 1911 brought together nations to create agreements to end the opium traffic in Asia or at best lessen British control over this traffic.
To honor its international obligations, the Congress of the United States passed in 1909 legislation that banned the importation of opium for smoking. As indicated above, opium smoking was associated with poor indentured Chinese laborers and the white marginal underclass two highly stigmatized groups. Local ordinances prohibiting the establishment of "opium dens" and possession of pipes already existed. The federal legislation supported local ordinances. However, the net result was not the elimination of opium smoking, but an increase in price and exclusivity. Eventually an interesting opium smoking culture evolved in the United States that included persons from the arts, music, the theater, politics, the newly emerging movie industry and white marginal groups including con men, gamblers, prostitutes and gangsters.
The Harrison Narcotic Act of 1914 was passed by Congress to fulfill obligations of the United States to uphold the international agreements of the 1912 Hague Convention to cutail the opium trade in southeast Asia and China. Although mercantile and trade interests of the United States were at stake, the class transformation of American addicts to the white criminal underclass and the Chinese immigrant workers in the first decades of the century was used as an additional powerful rationalization for the enactment of the statute.
This act was not originally intended as a prohibition law but instead as a measure to regulate the manufacture, distribution and prescribing of opiates, coca and their derivatives. Those involved in these activities (i.e. manufacturers, pharmacists, physicians) had to be licensed, keep records for inspection, and pay a modest fee to the Internal Revenue Bureau of the Treasury Department. However, the Harrison Act did not deal directly with the question of physicians prescribing narcotics to maintain addicts. The bill and an amendment in 1919 allowed physicians to prescribe narcotics for "legitimate medical purposes" in the course "of their professional practice only." The 1919 amendment made possession of narcotics without a properly stamped package or proof of a medical prescription also a violation of the Harrison Act. This amendment, although continuing the prescription of narcotics for legitimate legal purposes, extended the act to include the addicts themselves who were excluded under the jurisdiction of the Harrison Act. Under the Harrison Act addicts could possess narcotics without proof that the narcotic was originally registered, packaged or prescribed. Therefore, a loophole was closed.
The Harrison Act, however, did not define the two phrases "legitimate medical purposes" and "in the course of medical practice." Since the Narcotic Division of the Prohibition Unit of the Bureau of Internal Revenue within the Treasury Department took the position that addiction was not a disease and addicts were not legitimate patients, it followed from their interpretation that physicians who prescribed drugs for maintenance were not legitimately prescribing to patients in the course of their professional practices. Hence, the Treasury Department adopted an anti-maintenance attitude which eventually resulted in the harassment and imprisonment of doctors who continued to treat addiction by prescribing opiates.
The drug policies of the United States during the major part of the twentieth century were essentially created by administrators within the Treasury Department in the second decade of this century. Lindesmith (1966)9 observes the following:
"It is a program (policy) which to all intents and purposes, was established by the decisions of administrative officials of the Treasury Department of the United States. After the crucial decisions had been made, public and medical support was sought and in large measure obtained for what was already an accomplished fact. Another unusual feature of the federal narcotic laws is that, while they are in legal theory revenue measures, they contain penalty provisions that are among the harshest and most inflexible in our legal code."
The anti-maintenance position of the Treasury Department was upheld in two cases heard before the U.S. Supreme Court in March of 1919 (Webb et al v. United States and United States v. Doremus) (King, 1972). The Court was of the opinion that the physicians were over prescribing narcotics. Dr. Doremus, in particular, was accused of prescribing narcotics for one Alexander Ameris alias Myers, described by the Supreme Court as a "dope fiend." The ethnic surnme of the addicted Ameris alias Myers, his use of heroin and the use of appellation "dope fiend" reveal the biases of the time. However, in two subsequent cases, the Court distinguished between physicians prescribing 'in good faith" in the course of medical practice to alleviate the discomfort and suffering caused by addiction (Lindner v. United States, 1925), and those who prescribed to "enable addicts to indulge their acquired longing for the drug and its effects" (Boyd v. United States, 1926). The Court reversed the conviction of Lindner indicating that the Harrison Act did not describe methods for treating addicts. However, in contrast to Lindner, the Court upheld the conviction of Boyd who prescribed abnormally large prescriptions with little concern about how the drugs were to be used. Taken together, the two cases repudiated the previous arguments in the Webb case and allowed physicians to treat addicts "in good faith" and "in the course of medical practice." This represents a subtle and precocious recognition of significant features of opiate maintenance with methadone, namely, the prescribed use of an opioid to relieve the discomfort and suffering of addiction. Notwithstanding the favorable decision in the Lindner case and the distinction between prescribing "in good faith" and prescribing without concern for the patient, the Prohibition Unit of Treasury Department continued its anti-maintenance policy as set forth in the Webb and Doremus decisions.
The immediate effect of the Harrison Act and the "physician's cases" was the creation of a criminal underclass of narcotic addicts who were separated from legal and medical sources of narcotics and forced into the street black market to purchase needed drugs. However, physicians were also harassed. With the Bureau of Narcotics adhering to its anti-maintenance stance, the harassment of physicians who prescribed narcotics to the opiate dependent eventually resulted in the arrests of about 38,000 physicians by 1938 and the imprisonment of about 5,000 (De Long, 1972).
The Prohibition of Heroin
Heroin was synthesized from morphine in 1898. Initially the drug was hailed as a "cure" for morphism and was an ingredient in patent cough medicines as a suppressant. Within a decade, however, its addicting qualities were recognized. Nonmedical addicts began to snort heroin, and with injectable morphine it became a street drug. Depending on availability, the two drugs were used by street addicts.
By the 1920s, heroin supplanted morphine as a street drug. Although initially snorted, injection of heroin, which may have started in the 1920s, eventually became the preferred route of administration by the 1930s. The concern about its addictive potential, its favored use by nonmedical addicts and the rising number of addicts in jails who preferred heroin to other addicting drugs including cocaine, prompted the passage of legislation in 1924 by Congress that prohibited the importation of opium for the purpose of manufacturing heroin.4 This legislation, however, was not emulated by other countries. Since heroin was not available legally in the United States, smuggled heroin became the alternative source of the drug for street addicts. With subsequent decreases in street purity, the addict was forced to inject the drug to experience its potent effects. Eventually injectable street heroin became the major drug of abuse for opiate addicts supplanting opium and morphine. Street crime related to the use of injectable heroin became a major concern beginning in the 1920s after the prohibition of heroin and the subsequent dependnce on the organized crime as the sole source of heroin. Control of the international traffic in injectable heroin was a dominant organizing factor of international crime and the inter-criminal warfare for control of the distribution of heroin in the 1920s and 1930s.
Theories of Addiction 1900 to 1923
The physiological theory of addiction was supported by a number of American physicians who treated addicts in the late 19th and early 20th centuries (e.g., Drs. Jansen Mattison, Charles Terry, Austin J. Pressey and Ernest Bishop). Similar in viewpoint to these physicians was Dr. Willis Butler, who operated a maintenance clinic in Shreveport, Louisiana. Since many of the addicts he treated were afflicted with other serious conditions (e.g., syphilis and tuberculous), Butler believed that addiction was related to physical illness and pain.
The view of addiction espoused by these physicians stemmed from observing the many types of patients from different social circumstances (e.g., white middle and upper class women, wounded Civil War veterans, physicians, etc.) who became addicted by taking opiates prescribed by doctors for varying acute and chronic medical conditions. Narcotic maintenance was steadfastly advocated by these physicians since there appeared to be no cure for chronic addiction. They rejected personality theories of addiction that in effect stigmatized addicts with unsavory character traits.
To replace theories of inebriety, neurasthenia and degeneration, advocates (e.g., Bishop) of the physiological theory of addiction misapplied contemporary theories of disease based on bacterial infection and the immune response of the body to produce antibodies to fight infection. These theories successfully transformed medical science and practice in the late nineteenth and early twentieth centuries. Simply stated, an analogous condition to bacterial infection was hypothesized when a narcotic, considered a toxin, was administered. In response, the immune system produced antitoxins analogous to the antibodies produced by pathogens and the immune response produced by vaccination. Addiction was considered to be an accumulation of antitoxins produced by the body as a reaction to opiates. Tolerance and physical dependence were readily explainable within the context of this theory: a sufficient amount of antitoxins would theoretically produce sufficient tolerance to protect addicts from overdose. Antitoxins, according to this theory, became toxins if continued intake of opiates were stopped. Thus, the conversion of internal antitoxins to toxins resulted in a decrease of tolerance and physical dependence and the emergence of the opiate withdrawal syndrome.
Opiate addiction was thus incorrectly explained within the context of contemporary medical theory, research and practice. However, the antitoxins to narcotics were never found.5 The technology and knowledge were not available during the first half of the twentieth century to test hypotheses confirming or negating the premise that opiate addiction was a physical disease or had a physical basis. The failure of science to prove that addiction was physical disease was in a sense the death knell of the physiological theory of addiction in the 1920s.6
The second major theory to challenge the theory of inebriation was promulgated by Dr. Lawrence Kolb of the United States Public Health Service and was based on psychological theory of mental illness to explain addictive behavior. The psychological explanations of addiction filled the vacuum created by the demise of the physiological theory of addiction.
The psychological theories of addiction were profoundly influenced by the transformation of American addicts that began in the last decade of the 19th century and proceeded into the first decades of the twentieth. The iatrogenically addicted population of southern elderly women and Civil War veterans was decreasing and being replaced by poor white young males and criminal elements from the poor ghettos of the northern cities and Chinese workers. Within two decades they became the majority of opiate addicted persons in the United States.
The theoretical stance of physicians evolved from their experiences treating patients in their medical practices and noting the social class of addicts coming to the attention of public health authorities. Dr. Kolb and other physicians7 were influenced by the social behavior of nonmedical addicts in the 1910s and 1920s. Therefore, a circular reasoning became manifest in the development of theories of addiction. These theories, primarily psychological, reflected observed behavior of the low socioeconomic class and immigrant group origins nonmedical street addicts. They differed in psychological and social class from the iatrogenically addicted females and males who received opiates from physicians, particularly those in the southern areas of the country and who entered and reentered sanatoria for "cures."
Addiction, according to Kolb, was primarily a manifestation of psychopathology. The character disorders or psychopathic manifestations of behavior were symptomatic of an underlying mental disease. Kolb advocated treatment over a punitive approach and became an effective spokesman having wide influence in the medical profession for his theoretical and clinical positions.8
Kolb categorized addicts into five basic subgroups: 1) iatrogenic addicts or psychologically normal persons who received opiates to relieve pain, a small and constantly diminishing group; 2) pleasure seeking individuals or those afflicted with "psychopathic diathesis;" 3) persons with neuroses; 4) psychopathic criminals; and 5) inebriates, usually persons with an alcohol problem who became narcotic addicts. The majority of nonmedical addicts came from the second and fourth categories. Throughout his career Kolb advocated that all addicts receive treatment rather than punishment and incarceration. The psychological theories of addiction promulgated by Kolb in the 1920s and 1930s greatly influenced medical thinking and were adopted, including his classification, at the United States Public Health Hospital in Lexington Kentucky. He was a voice of sanity, compassion and enlightenment in contrast to the demand that addicts be punished and or in extreme cases, executed.
In summation, two basic theories emerged. The physical theory that persons became addicted because of exposure to morphine espoused by the likes of Charles Terry and Ernest Bishop. This group advocated mantenance for the iatrogenic addicts. However, in their thinking a socioeconomic and cultural class line of distinction was clearly drawn between iatrogenic cases predominately southern female addicts and the newly emerging street nonmedical addicts in the northern cities. Nonmedical addicts, it was argued by Terry and others who advocated maintenance, should be treated in circumstances that take into account their deviant behavior and they should be placed under proper legal constraints. They were not to be confused with those who became iatrogenically addicted and were essentially complying medical patients.
The psychological theories promulgated by Kolb and eventually adopted by the medical profession emphasized mental illness and psychopathology. There was little room in this theory for a "normal" addict who needs maintenance because of exposure to morphine. There was no connection in the psychological theories between the common physical elements of addiction that cross class lines dependence, tolerance, craving and relapse after withdrawal. The recognition of differences in class and personality would have vitiated or lessened the underlying concept of mental illness which was basic to Kolb's conceptualization.
The theory that addiction was a physical illness was discredited in the 1920s by the failure to prove or demonstrate empirically through laboratory studies the basis of a physical addiction, thus making the cleavage between the two schools complete. The psychological theories therefore were adopted to explain addictive behavior among the addicts especially the nonmedical addicts who were the majority of users by the 1920s. Incorporated in the psychological theories were class fears especially of the under class who became addicted and as Helmer has indicated, reflected ongoing class conflicts especially in times of economic crisis.
Treatment for Opiate Addiction 1900 to 1923
Within the first two decades of the twentieth century, three basic approaches were developed to treat opiate addiction:
However, philosophically, the treatment of addiction was profoundly influenced by the failure to prove that addiction was a disease. The ethical role of physicians in prescribing medications, in this case narcotics, became questionable especially when the legitimacy of the illness itself is undefined. The problem was compounded by the transformation of the addicted population from iatrogenic addicts to street or nonmedical addicts. The understanding of addiction was transformed to one involving of serious social deviance. Therefore, morality and ethics entered into medical decisions in the first part of the twentieth century that continue to the present day regarding the prescription of narcotics. The attitude of the American Medical Association Committee of Narcotic Drugs was expressed in a pamphlet issued in 121.9 In the pamphlet, the condition of addiction in relation to treatment within the medical profession is stated as follows:
"The shallow pretense that drug addiction is a disease which the specialist must be allowed to treat, which pretended treatment consists in supplying its victims with the drug which has caused their physical and moral debauchery ... has been asserted and urged in volumes of literature by the self-styled specialists."
A truly effective medication for addiction did not exist in the 1920s. Long acting narcotics such as methadone were not even conceptualized. Therefore, inefficient medications such as morphine and opium that were available to physicians had to suffice but were rejected. In the book, Addicts Who Survived, Dole remarked about the lack of viable effective treatment for narcotics addiction prior to World War II. Nevertheless, similar objections targeted to the treatment of addicts in the early decades of this century were used against the methadone program a half century later.
1. Physicians' Prescriptions and Over the Counter Remedies
Prior to the passage of the Harrison Act in 1914, opiate dependent persons were able to obtain opiates through prescriptions and over the counter drug preparations containing opiates. Physicians prescribed narcotics for pain, medical conditions and for opiate dependent patients, narcotic maintenance. Addiction was in many cases iatrogenic and maintenance was considered a legitimate treatment. Physicians such as Terry and Bishop considered addiction a physical condition with parallel inferences to the germ theory of disease. Nevertheless, there were a few physicians who prescribed for profit without concern for the patient or the spread of addiction. With the enactment of the Harrison Act in 1914, narcotic maintenance by private physicians and over the counter narcotics was eventually prohibited through harassment and prosecution by the Bureau of Narcotics.
2. The Creation of Sanatoria
For the middle and upper class addicts, sanatoria offering bogus cures were opened. The most famous was the Towns Hospital located in New York City offering a bogus treatment developed by a Mr. Charles Towns.10 The charlatan soon became known as Dr. Charles Towns although he never earned a medical degree and was regarded for two decades as probably the most "knowledgeable professional" in the United States concerning the treatment of drug addiction. He offered a "cure" which he claimed could rid Asia of the scourge of opiate addiction as well as cure the upper class patrons of his hospital. Mr. Towns falsified outcome statistics. However, after a decade the medical profession realized the false nature of his claims and eventually Towns Hospital was closed. There were a number of sanatoria that were opened to treat iatrogenic addicts with ineffective treatment regimens. However, with false cures being revealed, the majority of the sanatoria were closed by the third decae of the twentieth century.
3. Clinics for Maintenance and Detoxification
Dr. Charles Terry conceived of, and opened in 1912, the first opiate maintenance clinic in the United States in Jacksonville, Florida. In Terry's view, addiction was not a curable condition and addicts had to be maintained. It is to be noted however that Terry's patients were primarily iatrogenically addicted females. The opening of the Jacksonville clinic was an augur of the opiate or narcotic clinics established after the passage of the Harrison Act in 1914 and the methadone clinics opened in the 1960s. Terry did not treat the newly emerging nonmedical street addicts from immigrant groups in the northern cities. As previously indicated he made a distinction between the iatrogenically addicted as legitimate patients and the criminally inclined nonmedical street addicts of the northern cities. He advocated that iatrogenic addicts were legitimate patients and that nonmedical addicts should be brought under legal authority for criminal acts committed in the course of addiction.
However, after the passage of the Harrison Act, about 44 maintenance clinics were opened in 14 cities throughout the country. Heroin, morphine and cocaine were dispensed in these clinics. Perhaps the most famous were the New York City clinic in lower Manhattan and the clinic operated in Shreveport, Louisiana by Dr. Charles Butler. The New York clinic was essentially an opiate withdrawal clinic giving addicts a choice of heroin or morphine. Patients were prescribed a decreasing dose until they were completely withdrawn. However, drug dealers loitered about the clinics selling supplementary drugs to patients. The New York clinic serviced a socially and economically mixed group of patients from the poor, immigrant and working classes. Most of the patients were white males and were nonmedical addicts.
The Shreveport clinic treated addicts with morphine and offered maintenance to the local addicted citizenry as well as withdrawal services to transients. The Shreveport clinic drew its patients from all classes of society including the mother of the local sheriff who was also a wealthy businessman. Dr. Butler kept scrupulous records and was successfully audited several times by the Bureau of Narcotics. The Shreveport clinic was eventually closed after the Bureau of Narcotics used entrapment, questionable witnesses and false information to discredit Dr. Butler.
Armed with a moral mission to save the country from perceived degeneracy of opiate addiction, the Bureau of Narcotics successfully closed all maintenance clinics by 1923. The clinics were of varying quality. Some were genuine public health programs, others were operated for profit and still others were poorly administered political sinecures. However, some clinics like the Shreveport clinic were well administered, with detailed record keeping. Irrespective of the quality or purpose of clinic (e.g., withdrawal, maintenance or both), the Bureau managed to find excuses to close the clinics either through legitimate criticisms or as in the case of the well run Shreveport clinic, using deception.
Addiction was regarded as behavior capable of unraveling stability and social values. Furthermore, prohibition of alcohol was in force through the passage of the eighteenth amendment in 1918, and it was inconsistent for the government to spport maintenance of narcotic addicts in clinics. Another important factor that strengthened the Bureau's opposition to maintenance was the inability of physicians to prove that addiction was a physical disease. The failure of physicians to validate the toxin-antitoxin theory of addiction gave credence to the belief that addiction was a condition reflecting mental illness and psychopathic behavior. Addicts, therefore, were transformed into an unwanted stigmatized group perceived as a potential danger to the values of country especially within cities where industry was expanding.
One of the major criticisms of the clinics was that addicts were not being cured. It should be noted that no programs or institutions servicing addicts during this period were effectively treating addicts. Long acting narcotics were not yet conceptualized and efficient medications for maintenance and withdrawal did not exist. However, within the limited medical pharmacopeia that was available, the only bonafide medical treatments in the second and third decades were inefficient withdrawal and maintenance procedures using short acting narcotics. In 1920 the American Medical Association adopted a resolution that opposed the operation of ambulatory maintenance clinics. This resolution gave the Treasury Department's Bureau of Narcotics the medical rationale to close all existing clinics.
After 1923, nonmedical addicts were essentially barred from receiving any medical treatment from physicians. Physicians, however, were permitted to prescribe narcotics to frail elderly iatrogenic, mostly female, addicts. Because of the prevailing philosophies and political climate of the country, the Bureau began to harass and prosecute physicians who prescribed narcotics to nonmedical addicts. The result was an almost immediate increase in drug-related street crime and the establishment of criminal networks for the distribution of drugs.
The 1924 to 1963 Era
This era is characterized by a punitive enforcement attitude towards the use of drugs, dramatic changes in the drug using population, increased legislation to control drug use, the emergence of competing major criminal organizations to control drug distribution, the establishment of an independent Bureau of Narcotics under the direction of Harry J. Anslinger who pursued a vigorous anti-maintenance policy and finally, advances and modifications in theories of addiction with the establishment of programs that reflected these theories. Throughout this era the stigmatization of drug addicts was consciously fostered by the Bureau of Narcotics to preserve power under the guise of preserving social values.
Narcotic Drugs of Abuse From 1924 to 1963
During this period there were major transformations of narcotic drugs that were used by street addicts. By the 1920s, organized criminal groups controlled the distribution of drugs listed as narcotics in the Harrison Act of 1914. The drugs covered in this legislation included opiates, cocaine and their derivatives, although cocaine is not technically a narcotic. Heroin, initially snorted because of its purity, was by the late 1920s injected intravenously.
In New York City, the price and purity of street narcotics was determined by competitive tactics between Jewish mobsters and Italian multitiered crime families in the 1920s. In the 1920s the drug traffic was dominated by Jewish crime groups. The price of narcotics was low, and the purity was high. However, in the 1920s and 1930s, multitiered Italian crime organizations wrested control of the drug distribution from the Jewish groups. This change of distribution coincided with a rising international price of opium, making this bulky narcotic unprofitable to import. The two factors an increase in international prices of opium and control of distribution by a multitiered criminal organization resulted in higher street prices and the dilution of the heroin at each level of the distribution network. While snorting heroin was previously sufficient to obtain euphoric effects, by the 1930s, heroin was sufficiently diluted and expensive that heavily addicted users eventually resorted to intravenous injection. Because of its more potent euphoric qualities, heroin eventually superseded morphine as a street drug of abuse, especially in New York City. The ascendancy of heroin is reflected in the admission statistics of the U.S. Public Health Hospitals in Fort Worth and Lexington in the 1930s, when morphine intramuscular injection predominated, to the 1960s when heroin intravenous injection predominated. The rapid shift in drug use and route of administration occurred in the late 1930s, reflecting the change in criminal distribution networks and international market prices.
Transformation of the Addict Population 1924-1963
Two transformations of the addicted population occurred during this particular period. The first major transformation in the addicted population reflects the changes in the general population and social transformations in the country. The second concerned the fate of a small group of opium smokers.
1. Major Transformation
By 1923, the iatrogenic addicts, namely white southern middle and upper class women and wounded Civil War veterans addicted in the 19th century were either dead or dying. With advances in medicine, physicians were more cautious in their prescribing of narcotics. The iatrogenic opiate addicts of the late 19th century were not replaced in great numbers during the 20th century. As the prevalence and incidence of iatrogenic addiction decreased, the incidence and prevalence of nonmedical addicts from poor white ethnic and immigrant groups in the inner cities increased. By 1923 they constituted the majority of addicts in the United States and remained so until the end of World War II. Although blacks had established themselves in New York City from the colonial period, addiction to heroin was a marginal but known problem in Harlem by the 1930s.11
After World War II, the addict population was again transformed by two major population shifts. Encouraged by favorable tax advantages, the building of roads, the increased manufacture of automobiles and the creation of suburbia by developers, the middle class, including the successful offspring of previous white immigrant groups and middle class blacks, moved from the inner cities which were foci of crime and drug abuse. They were replaced by poor Latinos, immigrating primarily from Puerto Rico, and blacks immigrating from southern rural communitie. By the 1960s poor black and Latino ghettos in the inner cities were epicenters of heroin addiction which was reflected in public health and crime statistics. In the late 1950s and 1960s, chronic narcotism associated with the injection of heroin, became the major cause of death in New York City for young adults between the ages of 15 and 35. Hepatitis caused by injection of heroin with contaminated needles became a serious public health concern and addict-related crime among nonwhite minorities and poor white ethnics became a major political issue.
2. Transformation Involving Opium Smokers
Opium, in the early decades of the 20th century, was usually smoked in groups rather than by isolated persons. The complicated preparation and smoking techniques were originally taught to the white marginal and criminal classes by Chinese smokers in the late 19th century. By the early 20th century, opium smoking groups were usually segregated and composed of smokers from a particular class, ethnic group or field of employment.
Opium smokers were an elite minority of the opiate addicts during this particular era. They did not consider themselves addicts and expressed disdain for those who injected heroin. Many were in entertainment, politics or music and were careful with whom they smoked. When opium was no longer available in cheap supplies after World War II, they had to resort to the use of injectable heroin. In general, they retained their fastidious habits by using clean needles in contrast to the street addicts who may have shared needles. Nevertheless, their lives began to unravel with the use of heroin, and some were forced into street activities including theft and prostitution to obtain money to support their addictions.
Transformations within the addicted population were also noted in jails and the Public Health Hospital in Lexington Kentucky. Prior to World War II the addicts in the Public Health Hospital in Lexington were primarily white. However, after World War II, the majority (56%) were black, Mexican American, and Puerto Rican (Ball and Chambers, 1973). Within one century, groups at risk for addiction had moved across different major socioeconomic groupings, each with a unique method of obtaining and administering opiates but with the same condition the majority who used narcotics daily irrespective of social origin and type of narcotic drug were chronic relapsing addicts. The circumstances under which the different groups at risk become addicts, namely their exposure to narcotics, varied but once addicted, the biological condition of addiction was the same.
Anti-Narcotic Legislation From 1924 to 1963
With the passage of the Harrison Act and the subsequent "physician cases" heard before the Supreme Court, Congress passed about 55 federal laws concerning the illegality of interstate possession and the transporting of narcotics. The Boggs Act was passed in 1951 and the Narcotic Control Act in 1956. These acts increased mandatory sentencing for possession and sale of narcotics. By the late 1960s hundreds of state and locallaws ("little Boggs Acts") were passed nationwide concerning possession of controlled substances (e.g., heroin, cocaine, marijuana). These laws were passed as the nonmedical street addict became the overwhelming majority within the addicted population. The small proportion of iatrogenic, mostly female, addicts were allowed to be maintained by physicians. With the creation of the Bureau of Narcotics as an independent agency under Anslinger in the 1930s, physicians were harassed and indicted if they prescribed narcotics for "maintenance of addiction."
Theories of Addiction From 1924 to 1950
The psychological and sociological codification of "immoral behavior and vices" imputed to addicts in the 19th and early 20th centuries was completed during this era. The moral failures, moral insanity and character weaknesses ascribed to addicts were transformed into terms such as the addictive personality, the character disorder, the psychopathic personality. With addiction extending itself into poor immigrant groups, social instabilities and poverty related crime were translated into sociopathic behavior.
Dr. Kolb, the preeminent American physician, espoused an almost contradictory view of the addict. Convinced of an underlying mental illness, Kolb argued for abstinence, hospitalization and therapeutic (e.g., psychological and psychoanalytic) treatment. Although against punishment for addictive behavior, Kolb was unable to develop an effective form of treatment. He incorporated and applied concepts from psychology and the emerging field of psychoanalysis into a conception of addictive disorders. However, conceptualization without a successful treatment or resolution played into Anslinger's moral crusade. Anslinger substituted for underlying mental illness, the conception of moral degeneracy that would unravel the social fabric of the country if addicts were maintained. Abstinence as a goal of treatment served two philosophies -the need to "cure an underlying mental condition" (Kolb) and the need "to eliminate a potential social scourge" (Anslinger).
Treatment of Narcotics Addicts From 1923 to 1963
During this era, theories of addiction as well as political considerations played a prominent role in the development of different approaches to the treatment for addiction. Foremost were psychological and social theories tailored to meet political considerations.
In 1930, Harry Anslinger, a respected civil servant involved with prohibition activities, was appointed director of the newly independent Bureau of Narcotics. He was a staunch anticommunist and in line with his thinking concerning communist influence in the United States, he regarded drug maintenance as a menace to American society. His anti-maintenance philosophy reflected the attitudes of the United States Government. Abstinence was the goal of treatmnt during the Anslinger reign. Anslinger's influence on drug treatment extended from 1930 to 1964, the year methadone maintenance was introduced.
Socio-psychological theories of addiction with a pathological base of mental illness fit into Anslinger's philosophical ideas. They were transformed into concerns about China destroying the United States as part of a world wide distribution of narcotics. However, his fear and hatred of communism was greater than his fear and hatred of maintenance. Senator Joseph McCarthy was a narcotic addict. Anslinger in the 1950s regarded McCarthy as an ally in Congress, respected his anticommunist investigations, supported the hearings and secretly supplied him with maintenance doses of morphine.
United States Public Health Hospitals
In 1929 Congress appropriated money for the U.S. Public Health Hospital in Lexington, Kentucky and Fort Worth, Texas. The hospitals were needed since addict-related crime had increased, and the jails were rapidly filling to capacity with addicts. Physicians were being harassed and prosecuted if they were found guilty of prescribing narcotics to maintain an addiction. The U.S. Public Health Hospital in Lexington opened in 1936, treating convicted addicts as well as those who entered voluntarily for treatment. The hospital had a capacity to treat about 1,000 addicts and a staff of 500. However, from the beginning, the hospital evinced serious and predictable shortcomings that reflected the contradiction inherent in the psychosocial theories: the lack of any effective provable treatment to cure or control addiction.
Lexington was essentially a prison hospital. Dr. Lawrence Kolb was philosophically opposed to the prison atmosphere, but his theories concerning underlying mental disturbance and psychopathic personality supported the punitive attitudes and approaches of Anslinger. Shortly thereafter, a second public health hospital to treat addicts was established in Fort Worth, Texas that catered to Latino addicts from the southwest.
Addicts entering these hospitals were medically withdrawn from opiates. Therapists were available for individual therapy. However, follow up studies from Lexington Hospital showed relapse rates of over 90%. The U.S. Public Health Hospitals were essentially expensive revolving doors. In the 1970s they were closed and turned over to the Federal Bureau of Prisons.
Riverside Hospital on North Brothers Island in New York City was used to treat and withdraw addicts since the 1920s. However, after World War II, it was used to treat adolescent addicts. Patients remained in the hospital for six months receiving therapy and social services. The hospital was closed in the 1960s when a major follow-up study showed that practically all addicts treated there had relapsed upn discharge. The small percentage who did not relapse were not addicts but dealers who chose to enter the hospital as an alternative to jail (Alksne, 1980).
Therapeutic communities for the treatment of narcotics addiction began with the creation of Synanon in 1956 by Chuck Dederich, a former alcoholic. The therapeutic community was an amalgam of sociology, psychology and the 12 step program. In fact, it could be considered a modified institutionalization of Alcoholics Anonymous. Instead of the 12 steps therapeutic communities generally had built into them a hierarchical structure that was extremely authoritarian. Synanon became a model for development of other communities in the 1960s (e.g., Daytop, Odyssey House, Phoenix House and Project Return). However, Chuck Dederich soon realized that he was unable to cure addicts since many left only to relapse. The philosophy in Synanon was to encourage people to remain in the program for the duration of their lives. By the 1960s, it appeared that only a small proportion of those who entered therapeutic communities (perhaps less than 15%) appeared able to remain abstinent from narcotics after leaving the program.
With the increase of minority addicts and rising social and racial tensions, heroin addiction among poor nonwhite males was regarded as a major social problem. To reduce the addicted jail population, civil commitment programs were initiated in the 1960s in California and New York. Both proved to be prohibitively costly with minimal results. The programs were based on the Lexington model with therapeutic and vocational services in what addicts called "candy-coated jails." To improve on the results of Lexington Hospital, an aftercare was organized and committed addicts were placed under supervision of an aftercare or parole officer. However, this scheme has ambiguous results. The majority of the addicts placed on aftercare either relapsed, were rearrested or absconded, essentially duplicating the experience of the U.S. Public Health Hospital in Lexington and the Riverside Hospital in New York.
The Use of Methadone as a Medication to Withdraw Addicts
Synthetic narcotics that were developed by the Germans as substitutes for morphine when supplies of Turkish opium were interrupted during World War II, were investigated at the Addiction Research Center of the United States Public Health Hospital in Lexington, Kentucky. Methadone, a long acting synthetic narcotic, was found to be similar in morphine in its effect but longer acting. Although having a half life of between 24 and 36 hours, its analgesic effect lasts for only about six hours. Its euphoric effect is duller and its withdrawal syndrome although milder than morphine's is more protracted. It was also found to be effective orally and if substituted at adequate doses to an addicted patient, could be used as an efficient medication for withdrawal with only one oral ingeston per day. By gradually reducing the oral daily dose of methadone, narcotic withdrawal became a relatively uneventful and painless process. It was, in summation, a better way of withdrawing narcotics from an opiate dependent patient than by the injection of short acting drugs every four hours. The withdrawal technique was soon adopted in hospitals throughout the country.
Other treatments initiated during the post World War II period included the formation of Narcotics Anonymous, a 12 step self help group analogous to Alcoholics Anonymous. The Narcotic Anonymous groups, by their very nature, are not conducive to follow-up studies since confidentiality is a major concern. However, while relapses have been anecdotally reported, the groups appear to have helped some addicts.
Special programs were developed in the 1950s and early 1960s to treat addicted parolees and probationers. Using the conditions of probation and parole as a leverage, both divisions in New York City developed Narcotics Units that employed urine testing and in the case of probation, arrangements for therapeutic treatment through a social agency. The authority of the criminal justice system which mandated treatment and the insights of psychotherapy, social work skills and nursing were supposed to produce insights and behavior changes leading to abstinence. However, when the outcomes of the probation and parole programs were examined, their success was not easily documented. The overwhelming majority of probationers and parolees probably relapsed to the use of narcotics, notwithstanding threats concerning revocation of their probation or parole status and a return to jail.
Call for Research and New Policies
With the failure of abstinence oriented programs advocated by the Federal government, the medical profession in the 1950s evinced a new interest in challenging federal policies. This change was prompted by the increase in nonmedical addiction within the inner cities, the increase in drug related crime, the diseases that were transmitted by contaminated needles (e.g., malaria and hepatitis) and the increase in heroin related deaths, which by the end of the 1950s was the leading cause of death among young adults between the ages of 15 and 35 in New York City.
In the 1940s, drug dealers began to mix heroin with quinine to prevent the transmission of malaria through contaminated needles. This measure effectively eliminated the transmission of malaria. However, the transmission of hepatitis remained a major public health problem. In the midst of this public health crisis, physicians were unable to prescribe narcotics to maintain confirmed addicts. The New York Academy of Medicine in 1955 issued a report critical of federal regulations that prohibited physicians from prescribing maintenance doses of narcotics toconfirmed addicts. This report was followed by a position paper issued in 1959 by the Joint Committee of the American Bar Association and the American Medical Association advocating research for prescribing narcotics to confirmed addicts in a controlled clinical setting. In 1962, the Medical Society of New York County supported the establishment of research on narcotic maintenance and took the position that physicians engaged in systematic research on narcotic maintenance with proper controls were practicing ethical medicine. In 1963 the New York Academy of Medicine and President Kennedy's Advisory Task Force on Narcotic and Drug Abuse recommended that clinics affiliated with hospitals be established to treat addicts by prescribing narcotics.
However, within the medical profession itself there was ambivalence towards the treatment of addicts and the concept of narcotic maintenance. The narcotic clinics that were closed by 1923 were presented by the federal government as a failure although some, like the Shreveport Clinic in Louisiana, appeared to be responsibly managed and administered. Nevertheless, the American Medical Association officially took a position that maintenance or treatment of addiction with a narcotic posed an ethical problem. The following statement was issued jointly in 1963 concerning the concept of maintenance by the Council on Mental Health of the American Medical Association and the National Research Council on Narcotics and Medical Practice of the National Academy of Sciences:
"Continued administration of narcotic drugs solely for the maintenance of dependence is not a bona fide attempt at cure nor is it ethical treatment except in ...unusual circumstances..."
This statement was used by the Bureau of Narcotics to bolster its position that narcotic maintenance is medically unethical and illegal.
Emergence of Modern Neuroscience Research
Two major breakthroughs occurred in neuroscience research in the 1950s and 1960s. The first at McGill University in the 1950s was the discovery by Olds and Milner (1954) of the brain reward system. This discovery changed the direction of neuroscience research in addiction. Psychological theories were challenged because of their circularity. For example, a drug addict uses drugs because of an "addictive personality." The discovery of the behavior reward system made possible the investigation of the neuropharmacologic properties of the drugs themselves and the common effects these drugs produce with humans and animals. Psychological reinforcement did not take into account the underlying complicated neurobiological mechanisms in the brain and the underlying biology of repetitive behavior of laboratory animals self administering certain classes of drugs and only those drugs (e.g., opiates, cocaine, stimulants). With the establishment of the United States Public Health Hospital in Lexington, Kentucky, a second major breakthrough occurred. Studies into the theoretical framework of addiction were implemented through the creation of the Addiction Research Cnter at the hospital. This important research center set the stage for major conceptualizations and neuroscience breakthroughs that were impossible during the earlier decades of this century. Talented scientists such as Himmelsbach, Martin and Jasinski investigated in the early 1960s the physical aspects of addiction: tolerance, dependence and abstinence in man and laboratory animals (Himmelsbach, 1968; Martin and Jasinski, 1962; Martin, Wilker, Eades et al, 1963). For the first time, detailed records and measurements of the physiological changes that occurred during the different phases of addiction, withdrawal and post addiction were investigated.
While tolerance and dependence were previously observed, the research team added to the scientific understanding and knowledge base by their detailed description of these phenomena. However, the withdrawal or abstinence syndrome, although described previously, was for the first time systematically investigated with metabolic measurements. In two seminal papers, one dealing with abstinence in laboratory animals and the other in man, Martin and Jasinski (1962; Martin, Wilker, Eades et al, 1963) established two important phases of withdrawal: 1) the primary abstinence syndrome, and 2) the protracted secondary abstinence syndrome of indefinite length. This was the first instance where an identifiable measurable physical phenomena, namely a derangement in physiological functioning, was causally associated with relapse.
The period from 1870 to 1963 witnessed profound transformations in the risk groups that were addicted to opiates. Within the course of ninety years, opiate dependency shifted from iatrogenically addicted middle and upper class women and Civil War veterans to risk groups within every sector of American society. Theoretical conceptualizations about addiction were continuously evolving and reflected the socioeconomic class and racial composition of risk groups and the science of a particular era. These conceptualizations reflecting class and racial tensions within American society became more pronounced during periods of economic crisis.
Transformations were also apparent in the source and causality of addiction. For example, physicians were the source of opiates for iatrogenic female addicts and wounded Civil War veterans, while dealers were the source of opium for opium smokers from the marginal white underclass and Chinese laborers in the 19th century, elite opium smokers from the field of entertainment and finally street heroin users from various poor urban groups (white, African American and Latino) in the 20th century. The source of opiates and the conditions under which they were obtained either through medical prescriptions or criminal networks also entered into the social perceptions of behavior and theoretical conceptualizations.
The cleavage between psychosocial and physical theories of addiction was already evident in the 19th century. Prescient scientists in every era postulated a physical basis of addiction which could not be validated because of limitations in scientific knowledge. Social biases about addictive behavior ensconced in religious moral values became transformed into concepts such as moral insanity and finally into psychology as psychopathic personality or character disorder to explain addictive behavior. The stigmatizing effects of psychological explnations of addictive behavior were challenged by physicians who backed physiological explanations for continued addictions among their patients especially those who were iatrogenically addicted.
The era was also marked by repressive legislative activity at all levels of government, stemming from the Harrison Act of 1914. The repressive measures and anti-maintenance attitudes emanating from the actions of the Bureau of Narcotics under the leadership of Anslinger resulted in serious social and public health problems. The interpretation of the Harrison Act and the Supreme Court decisions by the Bureau of Narcotics created a class of criminal addicts unable to obtain the medical help to treat their addictions. Diseases transmitted through the use of contaminated needles (e.g., malaria, hepatitis and endocarditis) were transformed into epidemics. Street crime related to addiction became a major political and social issue. Physicians were harassed and many were arrested prior to World War II for prescribing opiates to addicts.
Programs to treat heroin addicts reflected contradictory philosophies that were based in psychology (underlying mental problems) but also reflected political attitudes (criminal behavior that had to be controlled). These programs targeted abstinence as a goal of treatment. However, follow-up studies indicated that the majority of addicts relapsed after a course of treatment. By the 1960s there were calls from medical and legal groups to consider clinical research into maintenance for addicts. Most important, however, was the emergence of neuroscience in the 1950s and 1960s that began an inquiry into the physical basis of addiction.
What essentially started as a condition that evoked compassion in risk groups such as the iatrogenically addicted in the 19th century, became a highly stigmatized criminalized condition in the 20th century. The stigmatization directed to addicts drawn from immigrant and minority groups was essentially transferred over the course of the century to addicted persons in general. Federal and local legislation that essentially criminalized addiction and anti-maintenance attitudes by the Bureau of Narcotics that essentially closed off medical treatment, reinforced and increased the stigmatization of addicted people irrespective of class or ethnicity. By 1963, the accretion of stigma over the past century was complete. It had become codified in law, psychological theories and treatment: 1. Addiction was caused by an underlying character disorders and psychopathic personality thus creating a menace to the values of country. 2. Treatment was directed towards abstinence in lockup prison-like programs or sheltered abstinence oriented residences known as therapeutic communities.
The more hopeful development during this the 1950s and 1960s era were calls by various medical and legal committees for experimental programs to prescribe narcotics to addicts despite the resistance of the American Medical Association evinced in statements that maintenance was not considered ethical treatment.
Last Update: March 15, 2001