Heroin: Off the Streets and Into the Clinics

THERE IS a curious ambivalence about our present-day view of the heroin addict: although we often give lip service to the notion that he is a sick or psychologically disturbed person who needs understanding and treatment rather than punishment, our more basic and emotional response of revulsion, fear and hatred is reflected in our implicit acceptance of the fact that the use of heroin and other opiates continues to be dealt with primarily through prohibition and the imposition of criminal penalties. This means that addicts--with the exception of a few like physicians and pharmacists--have little choice but to seek illicit sources for supplies.

The fact of the matter is that crime connected with opiate addiction does not derive directly from any apparent acute properties of the drug, but instead from society's insistence on dealing with the problem of opiate addiction through attempts at prohibition enforced by excessive criminal penalties, rather than through more logical and probably more effective medical and social approaches. The addict suffers an extraordinary compulsion to get hold of his drug, and the more zealously and effectively obstacles are placed in the path of his obtaining the substance he desperately seeks, the scarcer the drug becomes.

This relative scarcity in turn demands greater ingenuity and risk by the pusher as well as the addict, and is reflected in higher prices. Most addicts ultimately are forced to turn to prostitution or crime (almost invariably against property, and only accidentally against person) to raise the money required for purchasing the drugs which will protect them from suffering the discomfort of a withdrawal syndrome. Thus the more completely enforced the prohibition, the scarcer the drug, and--in the case of a drug of addiction--the more crime will be associated with this drug, even though the capacity to induce antisocial behavior is not a pharmacological property of the drug.

Those who argue against a predominantly medical approach to the problem of heroin addiction, such as exists in Britain today, assert that it would lead to an explosive increase in the number of addicts. They erroneously point to the British experience for supporting evidence. The fact of the matter is that since 1969, when proper controls for dispensing heroin were instituted, there has been no such increase in the number of addicts in England.

The British experiment with heroin maintenance is not the first. When the Japanese took over Formosa in 1895, there were 200,000 opium addicts and a flourishing black market with all its attendant crime. The Japanese registered the addicts, and made opium available under controlled conditions. By the time they left in 1938, not only was there very little, if any, crime connected with opium, but the number of addicts had dwindled from 200,000 to 20,000, most of whom were over the age of 40.

It is a little known fact that there was a short-lived experience with heroin maintenance in this country. After World War I, approximately 44 out-patient clinics were established in various cities to administer opiates to addicts otherwise unable to obtain their drugs legally. Most of these clinics were understaffed and had little direction and purpose and even less knowledge. The persons in charge were usually uninterested in trying to cure any addictions and apparently decided very quickly that it was easier to give an addict a week's supply of his drug than to see him every day.

The results, abetted by management policies ranging from the slipshod to the scandalous, were an increase in illicit traffic, a rise in the number of addicts, and a migration of many addicts to cities where clinics existed with consequent disruption of their lives. The medical profession was soon united in vigorous opposition to the clinics, and in 1920 and 1921 two special committees of the American Medical Association strongly condemned these efforts at ambulatory treatment and called upon the government to act. The Treasury Department complied by closing the clinics.

However, one such clinic in Shreveport, La., survived for almost four years under the very able directorship of Dr. W.P. Butler. A letter written in 1920 from the Shreveport Commissioner of Public Safety to the Louisiana State Board of Health states:

. . . The writer feels that this letter is due the State Board, as well as simply an act of justice toward Dr. Butler, for upon the institution of the clinic I had grave doubts as to its efficacy, and in fact expressed myself as being bitterly opposed to it . . .

I wish to say that from a police standpoint, the City of Shreveport is greatly benefited by its being here. It has practically eliminated the bootlegger who deals in narcotics, and in this way alone has reduced the number of possible future dope users . . .

Our records show that the Clinic here has cured a number of those afflicted with this habit, and some are working here and are citizens that respect themselves and are respected by this department. The authorities in charge of the Police Department in Shreveport would regard it a calamity should this Clinic be removed from this point, and we are as earnestly for it at the present time as we were bitterly opposed to it upon its institution here...

Heroin maintenance programs will not cure drug addiction, but there is every reason to believe that they will result in smaller increments, if not decrements, in the prevalence of heroin addiction, and greatly reduce the crime associated with it. Good maintenance programs with first-rate treatment and rehabilitative capacities would be less expensive in human and financial terms than the present largely punitive approach. The difference in money and energy could more sensibly be spent for research on the root social and psychological causes of addiction, with an aim toward the ultimate goal of prevention.

Lester S. Grinspoon is an associate professor of Psychiatry and author of Marijuana Reconsidered.