The American system of black-market heroin distribution, with its exorbitant prices for contaminated and adulterated heroin, has been described in the previous chapters. It can be contrasted with the American system of morphine distribution, which delivers at an amazingly low price some 40,000,000 doses a year of medicinally pure morphine, aseptically packaged and meeting the high standards for injectable products set by the United States Pharmacopoeia.

An addict who shifts from black-market heroin to morphine by prescription moves into another world. Suppose, for example, that be has been paying $20 a day for 40 milligrams of heroin mixed with 360 milligrams of hazardous adulterants and contaminants. An-ned with a prescription, he can walk into almost any neighborhood pharmacy and secure pure morphine, U.S.P., safely diluted in an appropriate vehicle, and sterilely packaged, at the full retail price of $5 per dram or less. He thus pays about five cents for 40 milligrams of morphine. If heroin were stocked in pharmacies, he could buy 40 milligrams of it, too, on prescription, for about a nickel-as British addicts do.

The question is obvious: Why shouldn't the addict be encouraged to secure his opiates legally, on prescription, in pure form, for a nickel a day, rather than be forced by federal and state laws to spend $20 per day in the heroin black market?

Early United States opiate clinics (1912-1924). The suggestion that heroin addicts receive their drug legally is hardly new or revolutionary. Indeed, narcotics-dispensing clinics were established in Florida and Tennessee back in 1912 and 1913. Following passage of the Harrison Narcotic Act in 1914, clinics for supplying addicts with legal heroin at low cost or without charge spread throughout the country; at least 44 of them are known to have been opened by 1920 or 1921.1

Some of these clinics actually dispensed morphine or heroin or both. Others gave addicts prescriptions. In either case, the addict received his unadulterated medicinal opiate legally, at low cost or without charge. If enough addicts were thus supplied, it was reasoned, the narcotics black market would wither away; it could hardly support itself by selling opiates solely to nonaddicts. And the task of the police would be greatly simplified. Instead of facing the herculean task of trying to keep narcotics away from addicts, law-enforcement agencies would have the minor task of cleaning out whatever remnants of a black market might continue selling to a few nonaddicted occasional users not registered in the clinics. In short, the clinics would care for the addicts, and the police would maintain an alert against clandestine sales to nonaddicts.

The fascinating history of these narcotics-dispensing clinics is currently being reviewed by Dr. David Musto, a Yale University psychiatrist, and need not here be reported in detail. On the whole, the clinics did a remarkably good job-except for the New York City clinic, which was a woeful failure. Then, as now, the New York City program was a bone of contention between state and city officials, and between Republicans and Democrats at both the state and city levels. The New York City clinic, moreover, was not a maintenance clinic. Its function was to give declining doses of opiates to patients until the dose reached zero-gradual withdrawal. Thus, it was a detoxification rather than a maintenance clinic, and its failure cannot be charged against maintenance programs.

In 1920, the Narcotics Unit of the Treasury Department-predecessor of the Federal Bureau of Narcotics-launched a successful campaign to close the dispensing clinics. The case made against them was on its face a plausible one. It was alleged that some addicts secured more morphine or heroin from the clinic than they needed, and sold the balance on the black market. Some addicts supplemented the small amounts of opiate they could get at their local clinic by buying more on the black market. Since the clinics were hurriedly set up, understaffed, and administered by physicians and laymen who knew little about addiction, they no doubt dispensed opiates by mistake to at least a few nonaddicts who then either used the drugs themselves or sold them on the black market. (In some cases, the nonaddict was a chauffeur or other emploVee sent to stand in line at the clinic on behalf of his addicted employer.) Some criminal addicts, moreover, unquestionably continued to pursue a life of crime while on clinic-supplied opiates. Newspaper readers were particularly shocked by allegations that morphine or heroin was being supplied to prostitutes. Thus a convincing and highly sensational case against the dispensing clinics-especially against the New York City clinic, which received nationwide publicity and condemnation-was easily made in the press.

The questions of the utmost public-health significance, however, were never asked. How extensive was the abuse? Between 1912 and 1924, at least 12,000 addicts received opiates from clinics, and the total was probably much higher.2 What proportion of the total black-market supply - tens of millions of doses a year-represented diversions from the clinics? If diversions had dropped to zero, would the black-market supply have been reduced by one-half of one percent? One-tenth of one percent? The clinics, unfortunately, were closed down by zealous law-enforcement officials before answers were secured to these and other crucial questions.

Their closing did not curtail the opiate supply; it simply buttressed the monopoly of the black-market suppliers, and returned thousands of addicts to that market.

Another series of questions also went unanswered: How much good did the opiate-dispensing clinics accomplish? How many doctors, lawyers, housewives, and others were enabled to continue their respectable lawabiding lives without being forced to patronize the illicit market? How many women (and men) did the clinics save from being forced to prostitute themselves to pay for black-market heroin? Could an adequate expansion of the maintenance system have prevented the rise of the illicit market in the first place? (This was what happened in Britain; see below.) Could a dispensing clinic drive an existing illicit market out of business?

Dr. Musto's current study of the 1912-1924 dispensing clinics is of great contemporary relevance-for by coincidence, today's methadonedispensing clinics are similarly under attack, with similar allegations appearing in the news media. Methadone maintenance clinics in 1971 were dispensing more than 9,000,000 doses of methadone annually to an estimated 25,000 addicts. It should hardly have been a cause of surprise (or alarm) that a few doses-perhaps even thousands of doses-were finding their way to the black market, or into the hands of nonaddicts (who could, of course, secure heroin on the black market just as easily). We shall consider this problem in more detail in subsequent chapters.

Later proponents of legal heroin (1936-1965). Despite the closing down of the 1919-1924 clinics by federal law-enforcement officials, the narcotics-dispensing idea never completely died out. In 1936, for example, fon-ner Police Chief August Vollmer urged the same basic approach in these terms:

The first step in any plan to alleviate this dreadful affliction should be the establishment of Federal control and dispensation-at cost---of habit-forming drugs. With the profit motive gone ... the drug peddler would disappear. New addicts would be speedily discovered and through early treatment some of these unfortunate victims might be saved from becoming hopelessly incurable.3

In 1952, a Special Committee on Narcotics of the Community Chest and Council of Greater Vancouver, British Columbia, Canada, recommended after thorough study: "The Federal [Canadian] Government should be urged to modify the Opium and Narcotic Drug Act to permit the provinces to establish narcotic clinics where registered narcotic users could receive their minimum required dosages of drug." 4 Such dispensing clinics, the committee predicted, would "protect the life of the addict and support him as a useful member of society." It would also "within a reasonable time eliminate the illegal drug trade. . . . The operation of such clinics would not entail anv reduction in the vigilance of lawenforcement agencies,"5 which would continue to be responsible for keeping narcotics out of reach of nonaddicts.

In 1954, a California citizens' advisory committee to the Attorney General on crime prevention proposed that an addict certified as incurable by a disposition board should legally receive specified doses of narcotics 6 and thereby remove said addict as a potential market for criminally or illegally secured narcotics's

Also in 1954, Dr. Edward E. Eggston, for the New York state delegation, brought to the annual convention of the American Medical Association a proposal that the AMA go on record as favoring "the establishment of narcotics clinics under the aegis of the Federal Bureau of Narcotics." 7 (The resolution did not pass.)

In 1955, the Medical Society of Richmond County (Staten Island), New York, recommended the "establishment of narcotic clinics in large centers where the problem is acute." It suggested, "Suitable private physicians can care for the occasional addict in isolated areas.... The addict will receive his narcotics only at the clinic, hospital, or doctor's office so that he cannot resell them elsewhere." 8

Also in 1955, the New York Academy of Medicine proposed "taking the profit out of the illicit trade by furnishing drugs to addicts at low cost under federal control." 9 The academy recommended that "clinics be attached to general hospitals, whether federal, municipal, or voluntary, dispensing narcotics to addicts, open 24 hours daily, 7 days a week." 10

In 1956 the Council on Mental Health of the American Medical Association, while opposing the immediate establishment of substantial numbers of drug-dispensing clinics as urged the previous year by the New York Academy of Medicine, did suggest "the possibility of devising a limited experiment which would test directly the hypothesis that clinics would eliminate the illicit traffic and reduce addiction." 11

Also in 1956, the American Bar Association and the American Medical Association established a joint Committee on Narcotic Drugs, which recommended in its 1958 Interim Report:

(1) An Outpatient Experimental Clinic for the Treatment of Drug Addicts Although it is clear ... that the so-called chnic approach to drug addiction is the subject of much controversy, the joint Committee feels that the possibilities of tr ing some such outpatient facility, on a controlled experimental basis, should be explored, since it can make an invaluable contribution to our knowledge of how to deal with drug addicts in a community, rather than on an institutional basis. It has been suggested that the District of Columbia, being an exclusively federal jurisdiction and immediately accessible to both lawenforcement and public health agencies, might be an advantageous locus for this experiment.12

In 1962, the Ad Hoc Panel on Narcotic Use and Abuse of President Kennedy's White House Conference on Drug Use and Abuse stated that it would "welcome careful, rigorous, and well-monitored research designed to learn if there exist in this country certain addicts who cannot be weaned permanently from drugs, but who can be maintained in a socially acceptable state on an ambulatory basis." 13

In 1963 the New York Academy of Medicine again recommended that narcotics be prescribed for addicts if deemed necessary in the judgment of a physician.14

Also in 1963, President Kennedy's Advisory Commission on Narcotic and Drug Abuse-a commission that grew out of the 1962 White House Conference-endorsed the 1962 suggestion of the Ad Hoc Panel. The advisory commission's Final Report urged "that properly designed experiments should be initiated to explore whether ambulatory clinics for the dispensation of maintenance doses to addicts are feasible." 15

An editorial in the Wall Street Journal for April 17, 1963, recommended that Americans "start searching for ways in which the tragic incurables can be put on sustaining doses that will keep them from desperate acts." 16

In their comprehensive 1964 study of narcotics addiction among New York City adolescents, The Road to H, Dr. Isador Chein, professor of psychology at New York University, and his three coauthors concluded that opiates should be dispensed by physicians to addicts:

There is an obvious expedient for reducing the demand [for black-market narcotics]-and that is to make a better quality of narcotics, and far more cheaply, available to addicts on a legal market. There are many advocates, the present writers included, of one variant or another of such a plan; and the numbers seem to be increasing. No one, of course, advocates Putting narcotics on the open shelves of supermarkets. The basic idea is to make it completely discretionary with the medical profession whether to prescribe opiate drugs to addicts for reasons having to do only with the patient's addiction....

We think it is high time . . . to call a policy of forcing the addict from degradation to degradation, and all in the name of concern for his welfare, just what it isvicious, sanctimonious, and hypocritical, and this despite the good intentions and manifest integrity of its sponsors.... Every addict is entitled to assessment as an individual and to be offered the best available treatment in the light of his condition, his situation, and his needs. No legislator, no judge, no district attorney, no director of a narcotics bureau, no police inspector, and no narcotics agent is qualified to make such an assessment. If, as a result of such an assessment and continued experience in treating the individual addict, it should be decided that the best available treatment is to continue him on narcotics ... then be is entitled to this treatment.17

An editorial in the New York Times for February 27, 1965, stated:

"The best hope for smashing the illicit traffic in narcotics lies in the dispensing of drugs under medical controls-particularly at hospitals in the necdv sections of the city, where physicians and psychiatrists can initiate well-rounded programs of medicine, counseling, and therapy as a basis for helping addicts overcome their dependence on narcotics."18

Also in 1965, the General Board of the National Council of Churches urged that physicians be given full power "to determine the appropriate medical use oi drugs in the treatment of addicts." 19

These were powerful voices demanding a change in the American system of heroin distribution. Yet they were voices crying in the wilderness. judge Morris Ploscowe explained why, in the Interim Report published in 1958 by the joint ABA-AMA Committee:

The spearhead of the opposition to legal narcotics clinics has been the present Bureau of Narcotics. For years it has opposed legal clinics and dispensaries for the treatment of drug addicts. Its main weapon against the establishment of present day clinics was the alleged failure of the approximately 44 earlier clinics .... 20

The British experience. Further light on the effects of dispensing morphine and heroin to addicts can be gained from the experience of Britain.

During the nineteenth century, as noted earlier, opiate use in Britain was much like that in the United States. Opiates were on open sale and were dispensed in enormous quantities without a prescription; even babes in arms were given remedies containing opiates. During World War I, it is true, a "Defense of the Realm" regulation forbade the nonprescription sale of opiates to members of the armed forces; but they still could be, and were, sold legally to civilians without a prescription. The United Kingdom, however, was under much the same pressure as the United States to pass a law implementing the 1912 Hague Convention for the international control of narcotics. In 1920, accordingly, Parliament enacted the Dangerous Drugs Act, which, like the Harrison Act in the United States, was designed to hold opiate distribution within medical channels.

In Britain as in the United States, the question naturally arose whether, under the new law, a physician could legally continue to prescribe morphine or heroin to his addicted patients. Tfre British, however, did not leave this crucial question to be decided by law-enforcement officers. Instead, the government appointed a committee of distinguished medical authorities, headed by Sir Humphrey Rolleston, to consider this and other policy matters.

Bv 1924, when the Rolleston committee met, the disastrous effects of the United States decision to refuse legal opium, morphine, and heroin to addicts were conspicuously visible. Dr. Harry Campbell came to the United States in 1922 to observe what had been happening during seven years of enforcement of the Harrison Act. What he saw flabbergasted him. Upon his return to England he informed his medical colleagues of the astonishing conditions he had observed:

In the United States of America a drug addict is regarded as a malefactor even though the habit has been acquired through the medicinal use of the drug, as in the case, e.g., of American soldiers who were gassed and otherwise maimed in the Great War [World War 1]. The Harrison Narcotic Law was passed in 1914 by the Federal Government of the United States with general popular approval. It places severe restrictions upon the sale of narcotics and upon the medical profession, and necessitated the appointment of a whole army of officials. In consequence of this stringent law a vast clandestine commerce in narcotics has grown tip in that country. The small bulk of these drugs renders the evasion of the law comparatively easv, and the country is overrun by an army of peddlers who extort exorbitant prices from their helpless victims. It appears that not only has the Harrison Law failed to diminish the number of drug takers-some contend, indeed, that it has increased their numbers-btal far from bettering the lot of the opiate addict, it has actually worsened it; for without curtailing the supply of the drug it has sent the price up tenfold, and this has had the effect of impoverishing the poorer class of addicts and reducing them to a condition of such abject misery as to render them incapable of gaining an honest livelihood.21

Profiting from the American mistake, the Rolleston committee recommended that "with few exceptions addiction to morphine and heroin should be regarded as a manifestation of a morbid state" 22-that is, an illness that anv physician could legally treat by supplying the necessary morphine or heroin.

This recommendation was accepted, and British physicians remained free to prescribe morphine and heroin for addicted patients through the succeeding decades.

One obvious advantage of this system was that it enabled the United Kingdom Home Office to keep tabs on the number of addicts currently receiving morphine or heroin. Some physicians voluntarily notified the Home Office when they added an addict to their roll of patients; other cases were picked tip quite easily by periodically checking the special prescription records that physicians and pharmacies were required to keep when they dispensed an opiate.

The results can best be described as magnificent. By 1935, the United Kingdom reported to the League of Nations that there were only 700 addicts left in the entire country.23 The number of addicts continued gradually to drop after 1935, as old addicts died off and few new ones were recruited, until the official figure of addicts known to the United Kingdom Home Office reached a low of 301 for the entire country in1951.24

These figures require some minor qualification. Since physicians were not required to notify the Home Office directly, the identification of some new addicts was delayed until their names were picked up during the periodic prescription audits. On the other hand, there was a similar delay in striking dead addicts off the list. Thus the figures fairly well represented the number of addicts receiving opiates legally.

Another qualification to the official figures concerns people who might be securing morphine or heroin in other ways than on prescription. There were certainly such uncounted cases. They had several sources of supply. Some British physicians, for example, freely prescribed very large doses of morphine and heroin to their addicted patients. Addicts naturally tended to gravitate to these generous physicians, and a patient receiving more than he really needed might be tempted to share his excess with a friend, or even to sell a part of it.

There was a very firm ceiling on the amount of opiates thus diverted, however. For if the friend or customer became addicted-that is, if he found that he needed a daily supply of the drug in order to keep well and socially functioning-he had only to go to a physician to secure the drug cheaply and legally, with an assurance of medicinal purity and quality. Thereupon be was added to the official count. The addict statistics cited above include addicts who secured their initial supplies from a friend or who bought them, and who thereafter turned to a physician when addiction set in.

A major feature of this system, in addition to the way in which it reduced the number of addicts to a negligible level, was its effect on law enforcement. There were, of course, violations of the law. Occasionally, for example, a physician or pharmacy failed to keep the required records in sufficient detail. Occasionally someone smuggled in a little heroin-though he could not get American prices for it because very cheap legal heroin was available. Occasionally someone stole morphine or heroin from a chemist's shop or warehouse. Yet law-enforcement officials had a very easy time of it, for their only real concern was to keep narcotics out of the hands of nonaddicts. Unlike their opposite numbers in the United States, they were not saddled with the hopeless responsibility of trying to keep narcotics out of the hands of addicts. Nor were the British courts and prisons jammed with narcotics offenders.

During the period from 1924 through the 1950s, Americans visiting Britain were naturally impressed with the British system, and on their return urged that a similar system be tried here. Many of the proposals of committees of the American Medical Association and the American Bar Association, and other similar proposals described above for legal narcotics dispensing in the United States, grew directly out of such visits to Britain.

These proposals were met by condemnation of the British system by United States Commissioner of Narcotics Harry J. Anslinger and the Federal Bureau of Narcotics. Repeated official American statements and speeches alleged, for example, that London, like New York, had a black market in heroin. This was unquestionably true. The market centered around Soho and Piccadilly. What the critics of the British system failed to add was that the market supplied a few dozen "weekend users," perhaps even a hundred or more. To jeopardize the entire system, and the contribution it was making to the nation's health and security, in order to try to stamp out a few peripheral shortcomings was simply not the British way. There was probably also a realization that the publicity accompanying raids on Soho and Piccadilly would attract additional customers and further popularize heroin.

Commissioner Anslinger and others also charged that the British addict count was phony, that Britain had addicts not included in the official reports. This, too, was unquestionably true. What the critics failed to add was that there were dozens of such unreported addicts, perhaps even a few hundred. The American heroin black market, in contrast, supplied tens of thousands of addicts-and made even an approximate count impossible.

Finally, Commissioner Anslinger and others insisted that if the British system worked in Britain, it was because Britain was an island, or because the British were law-abiding citizens, or because of other national differences.* This is a point to which we shall return.

* It has also often been alleged-most recently by Drs. Frederick B. Glaser and John C. Ball in the Journal of thc American Medical Association 21 in 1971-that the British system worked because it started out half a century ago with only a "negligible" addiction problem. This allegations as we have shown, does not square with British drug-use history.

Beginning about 1960, a modest change occurred in the British heroin problem. A group of fifteen Canadians plus a smaller group of Americans migrated to London to take advantage of high-quality, low-cost, legal heroin there-and proceeded to set up a "heroin subculture" on the American and Canadian model. They made a number of friends, and these friends also became addicted.

Only a moderate commercial black market developed, however. For at the very point when a potential black-market customer became addicted, be simply went to a physician and secured higb-quality legal heroin without paying the black-market price. The availability of lowcost legal heroin also made it unnecessary for this new crop of British addicts to become thieves or prostitutes.

Nevertheless, the British during the 1960s became understandably distressed as more and more young people became addicted to heroin. The numbers remained exceedingly small by American standards, but the trend seemed ominous (see Table 3).

The 162 new heroin addicts reported to the United Kingdom Home Office in 1964 may be contrasted with the 10,012 new addicts reported in that year to the United States Federal Bureau of Narcotics-with the warning that the British count was far more complete than the American count, since the British gave free heroin to those willing to be counted, while Americans who let their addiction become known risked imprisonment. If the British trend continued, of course, that country could expect several thousands of addicts during the 1970s.

In the United States, the Federal Bureau of Narcotics seized on this modest increase with great interest. Before 1960, the official United Kingdom statistics bad been dismissed as worthless. Now they were taken as gospel, and word was spread that addiction in Britain bad doubled in four years. Before 1960, the bureau had insisted that the British experience was not relevant to American conditions. Now the bureau reversed its field. It pointed to the "failure" of the British system as proof positive that supplying heroin to addicts would fail in the United States as well.

The British, too, reversed their field. Since 1924 they had prided themselves that by avoiding American methods they had avoided the American heroin disaster. Now they began to study American methods, in part because Britain had few experts of its own. With only a few hundred addicts spread through the country a few years before, most British physicians had never treated an addict, bad never been concerned with addition, and bad only a hazy understanding of the problem. Since the United States had such an enon-nous number of addicts, the British naturally concluded that our experts knew better.

The British newspapers and other mass media, moreover, followed American mass-media precedents with alacrity. During the 1960s, they published the same stories with which Americans are so familiar-the annual rise in number of addicts, the arrests of drug pushers, the teen-age boy or girl caught shooting heroin into his arm, a mother's plaintive first-person story of how heroin had ruined her child. Letters to the editor of the Times (London) sounded as vindictive as similar American letters in demanding that penalties be escalated. Prison was deemed too good for a heroin addict or pusher. A committee of distinguished physicians, under Lord Brain, recommended fresh measures to curb the heroin menace-whicb by now was claiming 162 new victims a year.

The 1966 Brain committee recommendations, which are currently in force, significantIv improved the basic British system. The committee noted that a few physicians under the old system bad been prescribing excessive amounts, that these few overgenerous physicians had naturally attracted manv addicts as patients, and that the excess heroin had flowed to the black market. They also noted that many of the new addicts were consulting physicians who had never seen an addict before and who knew nothing about addiction. Accordingly, the prescription of heroin was taken out of the hands of the medical profession as a whole and was concentrated instead in a limited number of clinics staffed by trusted physicians, who would thus be able to gain expertise on drug abuse problems .27 As Dr. Thomas H. Bewley, the head of one large new London heroin-dispensing clinic, remarked on a visit to the United States, the British had gone back to the old 1912-1924 American system of clinics for dispensing heroin.

The new British restrictions, however, apply only to heroin. Any physiCian can continue to prescribe morphine or methadone a synthetic Opiate that can take the place of heroin. Thus British addicts today are given a choice of drugs and drug sources. They can patronize an ordinary physician and get morphine or methadone, or they can go to one of the new clinics for heroin, morphine, or methadone. Britain never at any time seriously considered following the American policy of keeping opiates away from addicts and thus opening the door to a large-scale heroin black market. The disastrous effects of the American black-market system, and the beneficent effects of their own long-established system, were much too readily visible.

Once again, this British development was seriously misrepresented in the United States. Opponents of opiate dispensing here charged that even the British now conceded that their system was a failure and had abandoned it. American proponents of a better system of opiate distribution were condemned for proposing a plan that even the British had now abandoned. Few readers of this Consumers Union Report, it seems likely, are aware that in Britain today an addict can continue to get high-quality, low-cost heroin, morphine, or methadone legally from clinics-or, if he prefers, morphine or methadone from any medical practitioner.

Through the decades since the Rolleston committee report, British physicians (like their American opposite numbers) hoped to cure heroin addiction and made efforts in that direction. Like the Americans, they rarely succeeded. When the new ripple of addicts hit Britain during the 1960s, treatment facilities were expanded. There is to date no evidence, however, that the new British treatment facilities are having any greater success in achieving "cures" than the United States federal facilities, the California facilities, the New York State facilities, or the therapeutic communities.

Another change in British policy became visible about 1970. By then, a small but significant cadre of medical specialists in addiction problems had been developed within the clinics-men who now knew addicts and their problems at first hand. Excellent research projects were launched at the Addiction Research Unit (ARU) in London and in other centers. These studies were far more reliable than similar American studies, since addicts could speak frankly to the researchers, without fear that they would be imprisoned or that their supplies would be cut off.

Based on this fresh examination of the heroin problem, a growing number of British authorities had by 1970 reached the conclusion that the British "heroin explosion" of the 1960s could be only partly blamed on those few Canadian and American addicts who had migrated to London. Britain's American-style response to the modest rise in number of addicts during the first few years of the 1960s had also contributed to the explosion. The Soho and Piccadilly black markets in heroin were by now famous; indeed, they had become tourist attractions. 'Me attention of a whole generation of British young people had been focused on heroin. Warnings against heroin added to the publicity, and each warning became a lure. The whole antiberoin campaign in the mass media was thus one of the factors adding fuel to the heroin explosion. (We shall discuss this process further, as it occurs in the United States, in several subsequent chapters). In short, Britain had begun to adopt American antidrug propaganda methods, and was beginning to reap Americanstyle rewards in terms of a rise in youthful addiction.

A subtle change in British policy resulted from this reassessment. Reassuring statements were issued in 1970 and 1971. The public was informed in headlines that everything was under control-that the number of known addicts was in fact declining. Indeed, the British "heroin explosion" was shown to be in part a mere statistical artifact.

Prior to 1968, as noted above, notification of addicts to the United Kingdom Home Office was voluntary. The result of the 1968 compulsorynotification law, as might have been expected, was a marked rise in the number of addicts reported to the Home Office .28

As might also have been expected, however, the compulsory-notification law resulted in duplicate notifications and other statistical "bugs," which swelled the total. To avoid penalties for failure to notify, physicians sent in all doubtful names-including those who received opiates only briefly during the year, those imprisoned, those who died, those who gave up opiates, and so on. To eliminate duplication and other errors, it was necessary to determine the number of addicts receiving opiates on a given day-for example, the last day of the year. When ovemotification was thus eliminated, the British figures revealed not only a significantly smaller number of addicts at the end of 1968 but also a downward trend in 1969 and 1970.29

These totals, moreover, were not just for heroin addicts. As in the United States, efforts were being made to convert heroin addicts to methadone, a synthetic narcotic that has advantages over heroin, to be reviewed in later chapters. The effort had been highly successful. As of December 31, 1970, more than half of all British addicts (732 out of the 1,430) were being maintained on methadone alone. An additional 261 addicts were being maintained without heroin-on morphine (91) or other drugs and drug combinations. Only 140 addicts were being maintained on heroin alone, while 297 were being maintained on combinations of heroin and other drugs.:"' Heroin, in short, was rapidly becoming again a drug of only trivial importance in Britain.

Despite these facts, which cG-dld readily have been ascertained from the United Kingdom Home Office or any other informed British source, the Journal of the American Medical Association published on May 17, 1971, an article by Drs. F. B. Glaser and J. C. Ball that alleged once again that the British system of opiate maintenance is a myth and that 11 the British ... have moved in a direction similar to the United States" with respect to opiates.31

The British Medical Journal responded on August 7, 1971, with an editorial that was remarkably restrained under the circumstances. it described the JAMA article as "an incomplete interpretation of recent developments," and as "one which incidentally invites us to overlook what are still profound differences in emphasis." The British editorial continued:

To suppose that the British prescribing system was discredited by the alarming growth in heroin addiction in the 1960's, and thereafter abandoned, would be a considerable misreading of history. The same essential policy is being maintained as heretofore, with the difference that [heroin] prescribing is limited to specially approved doctors operating from specified clinics and with notification now compulsory. This issue should not be clouded. The British response still permits the prescribing of heroin and still gives central responsibility to the individual physician. And without undue complacency it may be claimed that this policy seems to have some real success in containing what threatened to be an explosive epidemic.32

In sum, the British system of supplying morphine, heroin, and other narcotics to addicts is not a failure. It has not been abandoned. Even at its peak in 1968, British heroin addiction was a trivial fraction of the American level, and at least a part of the peak could be attributed to the temporary adoption of American antiheroin propaganda methods.

Morphine, heroin, and other opiates, it is important to note, are not "legal" in Britain in the sense that anyone can buy them. There are strict laws against the unlawful importation, sale, or even possession of these drugs, specifying long prison terrns-long by British standards. The police still have a role in ferreting out illegal smuggling, possession, and sales, as in the United States. But the problem is trivial in scale, for few addicts patronize the black market. Physicians and clinics take care of them, while the police protect nonaddicts by maintaining an alert against smugglers and traffickers.

What of other countries?

Visits to Sweden, Denmark, and the Netherlands in the course of preparing this Consumers Union Report confirmed the fact that in none of these countries is a physician threatened with imprisonment for prescribing opiates to addicts. In these countries, as in Britain, physicians take care of the addicts while the police concentrate their efforts on keeping heroin out of the hands of nonaddicts. And in these countries, as in Britain, narcotics addiction, though a worrisome problem, has remained through the decades a small one by American standards.

A review of the literature, moreover, has turned up no other country in the world, except Canada, which tolerates anything approaching the heroin black market in the United States.

Of course, a system which has worked magnificently in Britain for decades (except for a few years in the 1960s), and which also does well in other countries, may not necessarfly work equally well in the United States. Accordingly, let us turn next to an examination of how the dispensing of legal opiates to addicts has been working through the decades here at home.

Legal opiates in Kentucky. In his 1969 study, Narcotics Addicts in Kentucky, cited earlier, Dr. John A. O'Donnell revealed one of the most closely kept secrets in the history of United States narcotics addictionthe fact that all through the years since the Harrison Act of 1914, a substantial though diminishing number of Kentucky physicians had continned to prescribe legal morphine or other opiates for their addicted patients-and no disaster bad resulted.

In the course of his study of Kentucky addicts, Dr. O'Donnell inquired carefully into the question of where they had gotten their narcotics. As might be expected, there were many answers. Some obtained the drug from relatives (often a spouse) or friends. Some bought from pushers. A few broke into pharmacies and stole drugs. A few forged prescriptions for narcotics. Seventeen of the 266 addicts in the O'Donnell sample were themselves physicians, pharmacists, or pharmacy employees with direct access to narcotics.:" But-in an amazing number of instances, these Kentucky addicts secured their narcotics (usually morphine) quite legally on prescription from their personal physicians.

Specifically, 67 percent of the men in the sample and 87 percent of the women reported getting their narcotics legally, from a physician or on his prescription, during at least a part of their careers as addicts after 1914.34 A quarter of the men and more than half of the women reported getting all or the major part of their narcotics legally from a physician throughout their careers as addicts.35

These latter addicts, Dr. O'Donnell Dotes, might get their drugs from one physician for a while, then change to another when that physician died or retired. "But these subjects never received narcotics outside of what was, or may have been, a normal physician-patient relationship." 36 Since it is legal for a patient to possess narcotics given him by a physician or secured on prescription, these addicted patients violated no law. Whether or not the physicians broke the law will be considered below.

The likelihood that an addict could secure his drugs legally from a physician depended in considerable part-especially for male addictson where in Kentucky he lived. Thirty-eight percent of the male Kentucky addicts residing in villages secured all or most of their drugs legally from a physician, as compared with 19 percent of those living in towns and 11 percent of those living in cities. For women, the comparable percentages were much larger but the differences based on place of residence were smaller: 62 percent in villages, 56 percent in towns, and 46 percent in cities.37

Physicians readily confirmed that they were providing opiates for addicts. "For example, the physician who prescribed for 13 subjects in one county confirmed this in all cases but two. In these he did not deny prescribing, but said be did not remember the names, which is credible because both subjects had left town almost twenty years before. In other older cases, be remembered he had prescribed for long periods of time, but could not specify the number of years. In the current and recent cases, however, his description tallied exactly with the accounts given by subjects." 38

How did physicians justify their prescription of narcotics to addicts after 1914? And how did they get away with it? Dr. O'Donnell's report suggests that no two cases were alike; they ranged from cases in which the medical prescription of narcotics was clearly justified by current illness to cases where it was simply a business transaction, with the addict buying medicinal morphine from a doctor instead of adulterated heroin from a pusher.

It is not illegal for a physician, in Kentucky or anywhere else, to prescribe an opiate for a patient who needs relief for a physical illness, even if he happens also to be an addict. In general, Dr. O'Donnell explains,

" elderly addicts will have acquired some physical complaints. If such an addict in Kentucky found a physician who would prescribe narcotics for the physical complaint, the narcotics agents did not question the need." 40 Here are two examples:

Case 45: "Subject's father had tuberculosis, and became addicted to narcotics about the turn of the century. His mother became addicted so she could keep going, to take care of her husband. When the subject was 9 years old, the family physician began giving him narcotics for asthma. He continued using them until his death." 40 This patient's original addiction occurred before passage of the Harrison Act. Following passage of the act, and following the mother's death, the physician cut off his supply and left him addicted but without narcotics. The subject scrounged for narcotics in various ways. He was admitted to Lexington for "cure" seven times in seven years. "Then he developed tuberculosis, and found a physician who prescribed for him to the time of death." 41

Case 179 was given an opiate after an injury. "He bad never before experienced the rest, relaxation and general feeling of well-being [see Chapter 2 on opiates as tranquilizers] which followed drug use. When his original supply ran out, he went to another physician for more.... Next, he made contact with sellers of morphine, and bought much of his narcotics on the illicit market.... Finally, when he was in his late sixties, a physician began prescribing narcotics regularly enough to maintain him on about five grains [300 milligrams] of morphine per day." 42

Other old-time Kentucky doctors did not wait until an addict was in his sixties to supply legal opiates. An outstanding example was a rural physician whom Dr. O'Donnell calls Dr. Smith. As other doctors in Dr. Smith's county died or decided (following passage of the Harrison Act) to give up prescribing opiates for addicted patients, their patients gravitated to Dr. Smith, who "professed to believe that after an addict has used narcotics for a number of years, abstinence is dangerous to life. " 43 Eventually Dr. Smith "inherited" some 20 addicts who had previously received their narcotics from other physicians. He at first sent youthful addicts to a state hospital to be "cured," but when he saw them promptly relapse, be concluded that cure was impossible and added these young addicts to his list for opiate prescriptions. He was also prepared to prescribe for local residents after their return from Lexington. In all, he dispensed in his prime some 500 grains (30,000 milligrams) of morphine per week-equivalent to 1,000 or 1,500 New York City "bags ." 44 Narcotics agents, aware of his practices, went over his records repeatedly but never brought charges against him. When interviewed for the O'Donnell study, Dr. Smith was nearing retirement and had only two addicted patients left; since the other physicians in the county had given up dispensing narcotics to addicts, no one knew what would happen to these patients if they outlived Dr. Smith.

Did this maintenance of addicts on legal opiates exist only in Kentucky, Or was it more general? When asked this question following publication of his report, Dr. O'Donnell replied:

My impression very strongly is that the practice in Kentucky did not differ from that throughout the Southern states. I personally knew at the Lexington Hospital individual addicts from all over the South, maintained by physicians, in what appeared to be the same pattern as I observed in Kentucky. Up to a few years ago, I also saw occasionally drug enforcement officers at the state level-again in Southern states-all of whom estimated that their states had from 200 to 400 or 500 elderly addicts ' maintained by physicians, against whom they had no idea of taking any action.

* This indicates that far more addicts were being maintained on legal opiates in the Southern states than in the whole of Britain.

My personal belief is that it has been, and probably continues to be, a general practice throughout the South to ignore the physician, provided a) be is prescribing for only one or a few addicts, b) these are elderly or obviously ill, so that there is at least some slight pretext for the prescribing, c) the physician clearly is not making any appreciable amount of money from his prescriptions, and d) the amounts prescribed would not allow the addicts who receive the prescription to divert any appreciable amount of drugs to other addicts.

My guess has been that enforcement agents ignore such cases both because they see little harm in them, and because it would be difficult to get a local jury to convict such physicians.'

I have much less information on non-Southern states, but my guess has been that the same considerations would lead to the same practices in them. In my occasional contacts with enforcement officers, in such places as New York and Philadelphia, they expressed much the same attitudes as did the Southern officers.45

There is some suggestion in the Kentucky report that economic and social status played a role in determining whether an addict could secure his opiates legally or had to patronize the heroin black market. If the addict were the kind of person the physician wanted as a patient, and if he paid his bills, be was more likely to get legal morphine. Much the same may be true elsewhere. In New York City in the 1960s, it will be recalled, Dr. Marie Nyswander reported: "I've yet to see a well-to-do addict arrested." 46 Even Commissioner Ansfinger himself, it will also be recalled, was willing to arrange a morphine supply for the chairman of a Congressional committee.

How well did the Kentucky addicts do while they were being maintained on legal opiates by their personal physicians? Overall, Dr. O'Donnell was not too favorably impressed, but he did cite some exceptions.

Fourteen of the addicts in his sample, for example, were physicians. "The practice of the addicted physician often deteriorated (but not always-some addicted physicians were described as 'the best doctor in town' )."47

In three cases Dr. O'Donnell compared life on illegal opiates with life on legally prescribed opiates-to the credit of legally prescribed opiates. "In all three, an improvement in work pattern followed the securing of a stable legal source [of drugs]. This can be interpreted as suggesting that the change in source of narcotics caused or permitted the improvement in employment." 48 In other cases, however, addicts were unemployed or poorly employed on illicit heroin and remained unemployed or poorly employed on legally prescribed opiates-suggesting that legal opiates are not a panacea.

* The Federal Bureau of Narcotics may also have been loath to have the constitutionality of the federal narcotics laws tested in cases such as this.

In one respect, however, Dr. O'Donnell is enthusiastic about legal opiate prescription-and the data fully support his enthusiasm. This concems,the relation of legal opiates to crime. Former Federal Narcotics Commissioner Anslinger, Dr. O'Donnell notes, insisted that drug addiction per se "causes a relentless destruction of character and releases criminal tendencies."49 The O'Donnell data, in contrast, indicate that addicts maintained on legal opiates lead law-abiding lives; crime is associated not with opiates but with the need to acquire opiates illegally.

Specifically, among 45 male addicts who received their opiates legally from a physician, 41 were never convicted of a crime during the entire course of their addiction. Among 82 male addicts who secured all or almost all of their drugs illegally, in contrast, 59 were convicted of crimes -and the majority of them were multiple offenders. Fourteen were convicted six or more times .50 Many of the addicts who secured their drugs illegally, moreover, supported themselves through daily crime--committing enormous numbers of offenses for which they were not convicted.

The data [Dr. O'Donnell states] ... confirm the generally accepted conclusion that drug use per se does not cause crimes. The subj . ects who received drugs from a physician were using as much narcotics as others, and in recent years probably more, since their drugs were not diluted like illicit heroin.... Yet only a few of them have a record of arrests, and there is much less indication for them than for others of undetected offenses.

... In this sample, addicts with a stable legal source of narcotics were unlikely to acquire a criminal record, while those who bought most of their drugs on the illicit market were likely to acquire one.... If stable and legal sources of narcotics had been available to more subjects in this sample, they would have committed fewer crimes."

Dr. O'Donnell cautiously adds, however, that this may not apply to all addicts. Merely supplying legal opiates to a professional criminal will not necessarily cause him to change his profession. The justification for supplying legal narcotics in such cases is much the same as the justification for supplying insulin to a professional criminal with diabetes.

One more aspect of the narcotics problem in Kentucky deserves brief mention. During the period under study, Dr. O'Donnell states, the Kentucky black market for opiates slowly withered away. For a considerable period of years after World War II, there was simply no place in Kentucky where an addict could go to buy illicit heroin. There were no pushers" because there weren't enough customers.

No doubt many factors contributed to this welcome development. But surely the substantial proportion of addicts maintained on legal opiates by their physicians was one of the factors which made heroin peddling unprofitable and contributed to the gradual disappearance of the black market.

During the 1950s and even more in the 1960s, as the older opiateprescribing doctors died off and younger doctors with a deeply ingrained distrust of addicts took their place, addicts found it harder and harder to secure a legal opiate source. And late in the 1960s, after the completion of Dr. O'Donnell's book, black-market opiates returned to Kentucky.

A tentative conclusion. If this Consumers Union Report were appearing in 1965, we would unhesitatingly join the late Police Chief August Vollmer, the New York Academy of Medicine, the Council of Mental Health of the American Medical Association, the joint Committee on Narcotic Drugs of the American Medical Association and American Bar Association, President Kennedy's Advisory Commission on Narcotic and Drug Abuse, the Wall Street Journal, the New York Times, and others quoted earlier in urging that planning begin forthwith for establishing a system of supplying morphine or heroin or both to addicts, under legal auspices, on at least a small-scale experimental basis. In taking such a stand, we would have emphasized the following factors.

Addicts themselves are far better off on low-cost, legal, medicinal opiates than on exorbitantly priced, adulterated, and contaminated street heroin.

• Society is far better off when addicts are on legal rather than exorbitantly priced illegal opiates.
• With addicts on legal opiates, law-enforcement agencies, courts, and prisons could concentrate on offenders who supply opiates to nonaddicts.
• It is economically disastrous and morally indefensible to permit the American system of heroin distribution to continue to flourish and enrich itself-without even trying to find an alternative.
• Even though serious flaws in the new system of distribution might develop, the new system could not possibly be worse than the existing heroin black market.

Since 1965, however, a new factor has entered the scene-the "methadone maintenance program" for the treatment of heroin addiction. We shall next consider methadone maintenance, and return later, in our Conclusions and Recommendations (Part X), to the question of dispensing heroin to addicts.