3 The Unfinished Business of the Society

The idea that the United States should experiment with making heroin legally available to addicts has been advanced in several versions over the past decade. These suggestions—though, without fail, they cite the British experience of lawful heroin—have not come from the British specialists, but have been put forward by Americans. The British working in addiction are not ignorant of the American drug problem: just as American doctors and administrators have been visiting London by the score since the clinics opened, most of the leading British specialists have found a conference or a grant to bring them over to see what's being done about drugs in New York, Washington, perhaps elsewhere. The traffic in ideas about control of narcotics has been vigorous between the two countries. Nonetheless, the British have good reason to think that their approach to addiction is still oversimplified by Americans, not least by those who propose that government clinics to dispense heroin to addicts should be tried in the United States. English visitors who have spent time and thought on the American drug problem are troubled, of course, by many things they have seen. Certain observations recur. Even before the visitor has worked through his inevitable first impressions of size and complexity, he is likely to be struck by the sense of fear that pervades the American reaction to narcotics addiction, among professionals as well as ordinary people. The next time I saw Martin Mitcheson was not at his London clinic, but in Washington, at the offices of the Drug Abuse Council, in the spring of 1973, when he was near the end of a two-month tour that had taken him as far as San Francisco and New Orleans. "My impression is one of total confusion, really," Dr. Mitcheson said. "Because there are enormous and paradoxical differences in your drug scene between one city and another. And also because yours is a culture, after all, that is alien to me. And when I'm in England, I can think coherently about the steps in the whole addiction process, I can think about precipitating factors, I know my English addicts, I know my English sociological scene, I know the areas of social stress where drugs of various kinds are being used. And I can see what are reasonable strategies to adopt. Where a medical strategy, or perhaps an almost totally nonmedical strategy, is more or less appropriate. Here, people tell me about heroin in the ghettos, people tell me about violence in the streets—while they're driving me through the streets of Chicago, with our safety belts fastened, in a large car, after downing large dry martinis. I mean, anyone can make slightly satirical comments about it; but as a visitor, though I can see that people are frightened about addiction, I can't really feel whether they are right to be frightened. Or not." The second discovery that the English visitor comes to is the enormous amount of money in drugs in America—and what shocks him is not the money in the criminal distribution of drugs, which he has heard about, but the hundreds of millions being spent legally, by governmental and private agencies, on narcotics control. The next time I saw Margaret Tripp was also in Washington at the offices of the Drug Abuse Council in the spring of 1973; she was one of a group of eight ( the rest Americans ) whom the council had awarded yearlong fellowships for study and travel in the United States, and she was then six months into hers. "I've never had such a beautiful office," Dr. Tripp said, stroking the teak. "In the fellows' first meeting, we sat down out there in the conference room, and very quickly somebody asked, what are we doing here with these large salaries? And then, to the credit of this organization, they laid on for our first weeks some very good, top-line people to come and talk to us. One guy in particular talked about the financial and government side, and exposed us to the fact that this year for the first time, more than a billion dollars will go into drugs. Which is a lot of money." She had recently attended the fifth annual conference on methadone treatment, held that year in Washington, which had been organized, she said, like a trade convention, with the ground floor given over to commercial exhibitors' booths. "You should have been there. The conference was attended by three thousand people." Her voice got quieter. "All those people were getting salaries." She stopped abruptly. Then she said, "One of the statistics we were told was that, currently, for every American addict in any kind of treatment, there are two staff receiving salary."

Such perceptions of the American response to narcotics addiction are not unique to visitors; they reinforce observations that some Americans have been making recently—for example, in the final report of the U.S. National Commission on Marihuana and Drug Abuse, which was issued, as it happened, three days after my conversation with Margaret Tripp, and which warned in terms as vigorous as hers of "the drug abuse industrial complex." But the point is that, in this American context of anxiety and such massive reaction, proposals to make heroin legally available to addicts strike the British not as being wrong, necessarily, but as being different from their own approach not only in important practical details but in fundamental motive and principle. To begin with, the British have always thought that the Americans seem narrowly, obsessively preoccupied with the one chemical, heroin—whether for fifty years as the problem or, in the present debate, as its own solution. "I suffer so much, here, from people telling me what my `system' is," Tripp told me. "I find that it's almost impossible to do the one thing here that I thought I would be able to do, which was to talk to Americans about where the differences in approach really are. Very early on, I began to discover that people here come up to me and tell me the difference: `You give heroin.' And that is the beginning and the end of the conversation. Because to them this is such a terrible thing. And also such a simple and chemical thing. And therefore they do not have to find out whether this difference is a real one—like how much difference there really is between heroin and methadone, for instance—and they don't have to consider at all whether there might be other differences. Beyond heroin. And far more fundamental to success or failure in dealing with addicts."

The most conspicuous proposal to give American addicts heroin—and the one that seems to have set the terms of the current discussion—is the plan that the Vera Institute of Justice announced in New York City in the spring of 1972, after having circulated a more primitive version to city and federal officials a year earlier. The Vera Institute is a small, adventuresome research foundation that has earned respect for certain of its enterprises in criminology, notably a study of prisoners' eligibility for bail which led to reforms that have kept many people out of prison while waiting for trial. The Vera Institute's fascination with the British approach to addiction has been long-enduring and ambivalent. In 1966, a year after the second report of the Brain Committee, when the English were well aware that they had an epidemic, a group from the Vera Institute visited London and came up with a grandiose scheme for joint Anglo-American research into the causes of heroin addiction, in England. The preface to the proposal said that the British had failed, and predicted, flatly, "By 1972 England will have 10,000 heroin users"—or, in an exact calculation, 10,819. The projected research came to nothing. The projected 10,819 addicts, seized upon by journalists and the Bureau of Narcotics, served several years' hard labor building up the American belief that the "British system" was a demonstrated flop; they figured in the thinking of the Home Office, too. By 1972, the Vera Institute's judgment, confuted, was reversed. The plan for an experiment with lawful heroin in New York credited the British "clinic system," as the single cause, with stabilizing the number of British addicts at a level below that of 1968—and enlisted the clinics' example, and borrowed some of their practices, in support of a treatment program whose stated aims were different. The Vera Institute made its plan public at a time when gloom was spreading widely in the United States over the results obtained by established modes of treatment, and radical alternatives were being urged. Abstinent therapeutic communities had helped some addicts to reconstruct their personalities; but when funding agencies began to demand that the communities' enthusiastic reports be evaluated more carefully, it turned out that the long-term rates of success, in fact, were low. Even if they had been higher, the communities' intensive methods made them inherently slow to multiply. Methadone-maintenance programs had grown very fast indeed, and by that spring had taken on somewhere between fifty and sixty-five thousand addicts across the country; but by then, also, it was becoming clear that many of their clients had turned to alcohol and other drugs, that unknown and possibly large amounts of methadone were leaking from some of the programs into the black market, and that a great many addicts were not ready to enroll themselves. Nelson Rockefeller, in a speech, tried out the idea that New York should intensify the enforcement approach: "Pushers to Get Life," said the headlines The Bureau of Narcotics and Dangerous Drugs was completing a study that showed that the cheapest way to deal with addicts is by compulsory hospitalization; this caricature of the medical model was made still more grotesque by those—including some doctors and some black leaders—who talked about heroin addiction as though it really were an infectious epidemic disease, and should thus be treated by sequestering addicts in quarantine ("Put them on an island," one official said), for years if necessary. And at the other extreme, that spring, several political figures had begun saying that the only way to break the American connection between crime and heroin is to allow addicts to be maintained on the drug. This notion became fashionable. The New York Times disclosed that the Mayor's Narcotics Control Council had considered with interest the first draft of the Vera Institute's plan. In Washington, the Committee on Crime Prevention and Control of the American Bar Association recommended that test programs of heroin maintenance be started. An impulsive legislator introduced a bill in the New York State Assembly which would have opened heroin dispensaries for addicts. One serious advocate of the use of legal heroin alongside methadone maintenance and the various abstinent programs was Howard Samuels, chairman of New York's Off-Track Betting Corporation, warming up for his run for governor two years later. "We've already got heroin maintenance—on the streets of New York," Samuels said. He had been closely associated with the Vera Institute in other projects; he was on the platform at the press conference when the new plan was announced. The timing and sponsorship of the plan certainly gave plausibility to the argument of its opponents that it was intended to be the first step toward full-scale heroin maintenance for American addicts.

The plan itself, though, drew back from any suggestion of maintaining addicts on heroin for a long or indefinite time. The Vera Institute asked to be allowed to test a different idea: that there are a lot of addicts who have not been willing to accept methadone maintenance, or submit to the discipline of an abstinent, therapeutic group, who could be attracted to a treatment clinic by the offer of free legal heroin for a relatively short period—a year at most—during which they could be stabilized, brought into a durable, therapeutic relationship with clinic staff, and transferred before the end of the year to one of the more conventional modes of treatment. The aim was to reach the addict who has not been reached by the other modes. The method would use heroin as "bait" to induce him to come to the clinic, where he would find every sort of help towards rehabilitation, from psychiatric counseling to a protected and unstressful job. This would not be heroin maintenance in the British sense at all, the Vera Institute said. But also, `By initially attempting to stabilize the patient on heroin —his drug of choice—the first treatment efforts can focus on issues other than forcing the patient to substitute the `clinic's drug' for the `patient's drug'." There is a sly, essential perversion in that "drug of choice," which is properly a medical textbook phrase to designate the best of several drugs for a particular condition, to be chosen by the doctor—as, indeed, the drug prescribed for an English addict is chosen. That aside, the Vera Institute's argument is just the one advanced by psychiatrists at British clinics, like Martin Mitcheson or John Mack, who use heroin to work toward heroin detoxification. Yet the Vera Institute was ingenious in foreseeing political objections, ingenious even in technical details. Heroin would be injected only at the clinic; the addict would visit the clinic three, four, or five times a day, or would simply spend most of his time there; the clinic would be set up in a nonresidential part of Manhattan. Bargaining between addict and clinic over the dose would be met by inarguably rigid rules. Whether the addict was also using black-market drugs would be checked by frequent, randomly timed urinalyses; since the clinic's heroin would be pure, the urinalyses, besides tests for the usual substances, would look for the quinine with which street heroin in New York City is heavily cut. In the first year of the Vera Institute's experiment, a pilot group of thirty men would be chosen, each of whom had been an addict for at least three years, as proved by medical, police, or social-agency records, and each of whom had been in a methadone-maintenance program for at least two months, well before the heroin experiment was announced, but had failed, either by dropping out or being thrown out. If even fifteen of the pilot thirty stayed with the clinic, stabilized their dosages, and by year's end were successfully transferred to oral methadone or taken off drugs altogether, then a second, larger test of the scheme would begin. This would compare the fates of another hundred addicts at the heroin clinic with a matched group of equal size given the complete psychiatric and social services but maintained on oral methadone. The entire experiment would last four years and cost about a million dollars.

As it turned out, the differences in purpose, technique, and political finesse that were claimed for the Vera Institute's proposal mattered much less, for its reception, than the fact that this was the first plan to try legal heroin for American addicts which seemed fully worked out and which seriously asked for a decision. Opinion polarized along the simplest lines. Passionate opposition to the proposal built up even before it was publicly announced. It brought together black leaders, conservative politicians, the Bureau of Narcotics and Dangerous Drugs, The New York Times, partisans of abstinent therapeutic communities, and pioneers of methadone maintenance, in a rare unity. They protested the danger of making any exception to the American prohibition of heroin—and, almost without fail, cited the British experience as evidence. Congressman Charles Rangel, whose district includes Harlem, told the House of Representatives that "it is imperative that we dispel some of the myths about the British system of drug treatment so that the American people will open up their eyes and recognize heroin for what it is—a killer, not a drug on which a human being should be maintained.... The truth is that the failure of the English to control addiction since the beginning of the 1960s has them fumbling for a solution just as we are." John Ingersoll, then director of the Bureau of Narcotics and Dangerous Drugs, tuned his rhetoric to his audience when he told a convention of California police chiefs, in May, that 'we are once again hearing of proposals for the establishment of heroin maintenance clinics. We had first-hand opportunity to review a so-called research proposal of this kind and quickly discovered that it had virtually no support within the knowledgeable scientific community and that most of those advocating this approach had already made up their minds as to the conclusions which will be derived. They persist in subscribing to an idealized view of the so-called British system which the British authorities themselves would not support. These programs would provide intravenous injections of heroin including a lounge or `nodding room' reminiscent of the opium dens of a by-gone century. ... Free heroin is not going to solve the crime problem in the United States just as it has not solved the crime problem in Great Britain. What is going to contribute to its solution is the elimination of heroin addiction. What is the price we would have to pay for legalizing heroin in this fashion? First, it would be a virtual announcement of medical surrender on the treatment of addiction and would amount to consigning hundreds of thousands of our citizens to the slavery of heroin forever." Congressman Peter Peyser of upstate New York introduced bills in the House of Representatives specifically to outlaw use of heroin "in any drug maintenance program"; he got President Nixon's endorsement. Vincent Dole, the specialist in metabolic diseases who had invented the "methadone blockade" theory and had opened the first methadone-maintenance clinic in the United States, put the weight of his reputation into a signed editorial in The Journal of the American Medical Association, June 12:

Proponents of the heroin clinics appear to believe that 250,000 addicts could be kept happy with a daily ration of this drug, and thereafter would desist from crime. No one familiar with the pharmacology of heroin could make such an assumption. Heroin addicts cannot be maintained with a stable dosage. . . . Undoubtedly it would be possible to operate a small demonstration program (25 to 50 patients) if a large and experienced staff were available to negotiate with the patients on dosage and supervise their outside activities, but this would hardly be a realistic model for treatment of 250,000 heroin users. . . . What is most puzzling n the argument for heroin clinics is the claim that the dispensing of heroin is needed to bring addicts into methadone programs.

Judianne Densen-Gerber, a psychiatrist and lawyer who directs Odyssey House, an abstinent, therapeutic program in New York (she titled her autobiography We Mainline Dreams), said that "heroin maintenance is at least an honest admission that you can't do anything. Heroin is giving up.

Methadone is a lie." James Markham, an able journalist who writes about drugs for The New York Times, reviewed the controversy ignited by the Vera Institute, concluded the proposal was a bad idea, and interviewed a Swedish psychiatrist, Nils Bejerot, who has studied the epidemiology of drug crazes in several countries; if the United States adopted the "British system," Dr. Bejerot told Markham, "you could easily get up to three or four million addicts in five years.... Heroin maintenance? Only those who don't know anything about addiction can discuss it."

That June, the Bureau of Narcotics and Dangerous Drugs published what amounted to its counter to the Vera Institute's proposal: a cost-benefit analysis, written under contract by William McGlothlin and three colleagues in the Department of Psychology at the University of California, Los Angeles, in which they tried to compare various approaches to treating addiction by computing, for each one, what they called the "social profit"—meaning the direct and indirect savings to the national economy that would result from adopting the method of treatment, after subtracting nationwide running costs. The McGlothlin report was a coarse-gained example of the cost-benefit genre. It set up seven "treatment modalities" in terms of four sorts of "pre- and post-treatment social costs per addict per year." The methods of treatment included heroin maintenance, conceived as "a program similar to that currently existing in England," a couple of versions of methadone maintenance, therapeutic communities—and civil commitment. That last is a legal euphemism. The report defined civil commitment as "a period of incarceration or compulsory hospitalization followed by a period of parole or outpatient supervision"; in California, the state where civil commitment of addicts has been used most heavily, those two periods total seven years, and in New York the total is three to four years.

The report noted that the courts in those states have been slow to commit addicts, apparently because "the rehabilitative aspects of the program have not demonstrated an effective cure for addiction, and ... the alternative jail terms for most of the offenses are only a few months."

The four sorts of costs—that is, the direct and indirect savings—by which the methods of treatment were compared, are estimates of the value of addicts' thefts, of spending on measures against addicts' crimes, of "unemployment ( foregone production)," and of treatment measures. The calculations, though, were double-jointed. The total value of thefts by American addicts—but this total was the outcome of a spectacular martingale: 375,000 addicts, the average addict spending 60 per cent of his time at liberty and not abstinent, needing a median twenty dollars a day for his habit, getting the required income 60 per cent from theft, of which 20 per cent is theft of cash and the other 80 per cent theft of goods for which the fence pays him 30 per cent of true value—was placed at $2.827 billion a year. The figure contrasted with some others. Governor Rockefeller, sending his new tough enforcement plan to the New York State legislature, estimated that addicts in his state alone stole $6.5 billion a year to pay for drugs. The Federal Bureau of Investigation, in its yearly Uniform Crime Reports, put the total national value of all thefts, burglaries, and robberies at $1.3 billion in 1970, $1.5 billion in 1971, $1.2 billion in 1972. McGlothlin's assertions about addicts' crimes were not consistent with other research by the Bureau of Narcotics and Dangerous Drugs: Ingersoll, in his speech that spring to the California police chiefs, warned that the relation of heroin to crime "has been greatly overstated," and said that one study by the bureau had just found that heroin addicts commit less than a quarter of all thefts by all kinds of drug users. The issue is crucial. In the McGlothlin report, addict thefts accounted for nearly two-thirds of the total amount that opiate addiction was said to cost the American economy. The savings in theft which the authors imagined would follow adoption of each of the seven hypothetical methods of treatment were an even larger—and highly variable—proportion of the seven "social profits"' they computed.

"The only significant information on heroin maintenance is provided by the British approach," the report said, and "the current British system is functioning reasonably well." But the authors misread their sources. They made the tired mistake of thinking that the English addict is free to choose heroin, injectable methadone, or oral methadone; they were thus talking, not about a medical, but about a drug-dispensary model of treatment, and so were understandably pessimistic about the chances that any great proportion of addicts would stabilize their lives. They also abused the British statistics. For example, they understated the Department of Health's year-end figure for addicts in treatment in 1970, loosely exaggerated the Home Office's index figure for the year-long cumulative total of addicts of all narcotics ( see table, page 106 ) , and then mated these two creations to generate the statistical monster that "less than 50% of the addict population" has been attracted to the British clinics—which, if true, would score heavily against any proposed American experiment with heroin for addicts, and especially against the Vera Institute's, for which the attractiveness of heroin is essential. Again, the report put a price on a heroin maintenance program "similar to that currently existing in England" of $1,500 a year per addict, for the first 50,000 addicts, and $1,000 each for the next 100,000, though the real British costs ( see page 117) translated into American pay scales worked out in 1972 to at least $2,400 a year per addict, and economies of scale are not in sight. Such errors were the result of carelessness and incomplete information. But when the authors ignored the reflexive effects that implementing a mode of treatment for large numbers of addicts would have on the supply and cost of essential ingredients, like medical staff, then they abandoned the greatest justification of the cost-benefit method.

Assumptions about the amounts that addicts steal affect particularly the comparison that the McGlothlin report made between heroin maintenance and civil commitment, the two extremes of the seven treatment approaches. It costs a lot to keep addicts locked up, and not a little to keep them on tight parole, but the prevention of thievery can be presumed to be nearly total. In contrast, although the British police say that crime by addicts is not a problem, and credit the fact explicitly to narcotic maintenance through the clinics, McGlothlin and his colleagues supposed that reduction in theft in their hypothetical heroin program would be no better than fifty to seventy per cent. "Foregone production" was the next cost the authors listed, and it was far below addicts' thefts; the calculations were made by a mighty formula that spread across two pages, but when they figured the lost production that heroin maintenance would recover, they began with the assumption that these addicts are less employable than those maintained on methadone—a chief point, of course, that any experiment with heroin maintenance would be designed to test. The authors' reckonings were exclusively monetary; their sense of individual welfare or of civil liberties seems slight. They observed, in passing, that the first goal of the British approach is "to treat the addict in a non-compulsory manner." They explained that "the existing civil commitment programs have failed to accomplish their goal of controlling addiction because society is reluctant to deprive the addict of his freedom for such prolonged periods." But social terms had no place in their calculus of social profit. The report concluded that, with a sufficiently energetic program, "it appears probable that the large majority of the addict population would be committed within two or three years"; and if some therapeutic communities and a bucket of methadone were thrown in, the program would produce a net gain of at least $2.289 billion a year. Civil commitment all by itself would save $1.934 billion or more. Heroin maintenance might gain $1.573 billion a year—less than methadone maintenance. The conclusion is no surprise. Civil commitment is an approach to addiction the Bureau of Narcotics has favored for years. The influence of the McGlothlin report should not be overstated. Though it has circulated widely in Washington, it has not received the public scrutiny given to the Vera Institute's proposed test of a heroin clinic. It is significant, however, because the policy it frames is the radical alternative on the enforcement side.

When the excitement calmed, the effect of the Vera Institute's proposal was to force discussion—the first thorough, engaged, and consequential discussion—of the arguments for and against heroin maintenance in the United States. As one might expect, British observers are startled by the facility with which their experience is adapted to support almost any position in the American controversy. They themselves are scrupulous not to suggest that they have definitive lessons to teach, least of all about the broadest issues. The Vera Institute's particular variant of a heroin clinic, though, prompts several questions. "Why try such an experiment in New York City?" Martin Mitcheson asked. "I'm not sure you couldn't find thirty or 130 addicts in New York City who would show remarkable improvement in their lives by coming into a clinic to walk through hoops four times a day." In the late '60s, when the English were moving to set up their clinics and to restrict prescribing of heroin for addicts—a slight change compared to legalizing heroin in thev United States—the first outpatient drug-treatment clinic was the one begun by John Owens in Birmingham, where the number of addicts was relatively small and where the clinic had an immediate, important, measurable effect. Several English and American critics have suggested that any experiment like the Vera Institute's, to get clear and useful results, ought to be carried out in a town like, say, Portland, Maine, that is not one of the major centers of addiction. The Vera Institute's plan also envisions medically supervised injections at the clinic. Other American proposals for heroin maintenance have made the same provision. One can see the political, the public-health, and the police reasons: pure heroin is worth its weight in gold. Yet many American doctors are disgusted by the idea of supervising or administering narcotic injections to addicts; and the addict coming to the clinic for every shot, perhaps every five or six hours, would keep the clinic open around the clock, around the week. The British have never thought this would be practical, or attractive to addicts. Yet observers fear, perhaps rightly, that the British prescribing method would be too easily abused in the American setting. The dilemma is not easy to resolve. An assumption shared unthinkingly by all American comments on heroin maintenance is that addicts under twenty-one, or eighteen, would not be admitted. But heroin addiction in the present day is a problem of adolescence; more than half of American addicts have become addicted before they were twenty-one. English clinic directors do accept teen-age clients, with the usual precautions to make sure they are genuinely addicted. From London, the American prudishness about age seems grotesque. On the other hand, the Vera Institute's proposal counts on the use of intravenous methadone with some addicts at some times, as well as heroin; other American discussions of heroin maintenance, from the McGlothlin report to the Consumers Union study, also include injectable methadone as though its acceptability were a matter of course, once heroin is admitted. But British clinic directors, having begun the use of injectable methadone in part out of a misunderstanding of American methadone maintenance, urge that this is one of their clinic practices that Americans would be wise to examine skeptically. The Vera Institute's proposal raises more general questions, too. What would follow if the experimental clinic were judged a success? Suppose most of the thirty and then of the hundred addicts were stabilized on heroin and eventually graduated to oral methadone or to an abstinent community. Could the success—could the elaborate psychiatric and social services—of the experiment be duplicated on a large scale? Would the year's time limit for injectable opiates be retained? An experiment can't be conducted in isolation from the larger problems.

Opponents of heroin maintenance for the United States have a cluster of objections—often put with great emotional intensity—against the characteristics of the drug itself: that addicts given the choice will always prefer heroin, that it is not possible to stabilize heroin dosages, that heroin addicts lead chaotic lives. To these assertions, the English experience I think makes a clear response: heroin addicts differ; there can be stable heroin addicts, able to manage their doses and their lives, though these may not be the most usual and certainly are not the most noticeable; a clinic that offers sensible psychiatric and social services besides drugs, and where the physician can select other drugs besides heroin, can help a high proportion of its clients to live more healthily, more sanely, more effectively in society. The opponents' greatest fear is that heroin maintenance clinics in the United States would make addiction spread faster, lessening, implicitly, the social disapproval of heroin, decreasing the risks of experiment or occasional use —and even increasing the supply, since only the most wildly liberal clinics, they reason, could keep the addict from going right back to his illicit source for more. The danger of creating more addicts convinced the U.S. National Commission on Marihuana and Drug Abuse: "This speculation ... we do believe ... weighs heavily and tips the balance against heroin maintenance in this country at this time," the commission said in its final report. ( It recommended, however, that "the federal government should sponsor a continuous and systematic examination of the heroin maintenance program in Great Britain, not only to find out how well it has worked there, but also to determine in what way the British experience would apply to the American situation, and what ways it would not.") Advocates of the use of lawful heroin for treatment of addicts say, on the contrary, that it would cut deeply into the criminal supply system, as well as reducing crime by addicts in pursuit of drugs. The Consumers Union report on drugs argued, for example, that heroin maintenance must be tested because "it is economically disastrous and morally indefensible to permit the American system of heroin distribution to flourish and to enrich itself—without even trying to find an alternative." These issues are peculiarly American, however. The British, grateful for the warnings they have taken from the United States, over many years, against tying addiction to crime, have nothing here to reëxport. England has never had an illicit system of drug distribution like the American one —large, rich, well-organized, and entrenched—with which the lawful prescribing of narcotics to addicts had to compete. American proponents say also that addicts would be better off, physically and socially, at a clinic, with pure cheap drugs and sterile syringes, getting at least a minimum of medical attention and of regular contact with clinic staff, than they are on the street; to keep addicts living as many of them do is intolerable. No English observer could disagree: the British experience is the embodiment, the dramatization, on a small scale, of what this argument means. Yet that by itself, however inspiring, is not particularly helpful, for it's also clear that there is no way the United States can simply duplicate the British approach; the real question is whether an American heroin program could be designed that does not carry unacceptable penalties.

"My feeling about heroin maintenance is that we have to try anything," I was told in England by an American who was there to work for some weeks at one of the drug clinics. He is Norman Zinberg, a psychoanalyst at Harvard, who in repeated visits has spent more than a year in England observing the British approach to addiction; he also had a hand in drafting the Vera Institute's proposal. We talked first while watching the peacocks on the lawn of an English country house where he was staying; we met again more recently at his house in Cambridge, Massachusetts. Dr. Zinberg is a man who sometimes says subtle things in a deceptively categorical manner. He holds that Americans, from the medical profession and the adolescents in contact with drugs to the general public, must transform their relationship to drugs, particularly heroin. He sees experiments with heroin maintenance as part of the process of taking the curse off the drug; but what he has learned from the English is not that their approach to heroin would work in the United States, but that it is possible to cultivate different social attitudes toward powerful drugs, attitudes which doubtless need to be taken further than the British themselves have yet succeeded in doing, but which, if they can be developed, may provide the only civilized hope of bringing the drugs under control. "With the number of people in pain in our ghettos, maybe there is a need for something legal," Dr. Zinberg said. "I feel that what we have to do is to develop reasonable social rituals governing the way we use drugs." Zinberg suggested comparison to alcohol and LSD. "Alcohol users, a hundred and fifty years ago or even less, were exactly the same as heroin users today. You were an addict, or you were abstinent—not even abstemious, you were abstinent. As many as eighty per cent of alcohol users were drunks, alcoholics. But alcohol now is very much socially ritualized, and in that context I think we have achieved a fair degree of control. Though of course I'm aware that it can be disastrous, and that it is a major problem for anywhere from five to eight million people in this country. But we have 120 million drinkers. And I can argue this in a lot of ways: I think that one of the ways we got control of caffeine was with coffee breaks and things like that—while one of the ways we didn't get control over nicotine is that we never could hold to the social rituals, no smoking until after dinner when the ladies had left the table, things like that. Some of which some people are now trying to reëstablish." He offered me a whisky, which I accepted. "Now when it comes to heroin, and the development of sustaining, informal controls: what the United States has done is to push these people, the addicts, outside of any such social control, while what the English have done—or, at least, begun to do within the framework of the clinics—is to establish viable social rituals for narcotics." Such controls are clearly the extension of the sorts of interactions within the small group by which initiation into drug use—whether smoking, drink, or the needle—takes place. Sometimes controls emerge, Zinberg said, even when the larger society has not tried to shape them. "With LSD, not just LSD but that whole group of drugs, I think we have had a paradoxical development. There's every indication that the use of these drugs is going up. But the pattern of use has changed. In the middle '60s, people who had discovered LSD were taking it two hundred, three hundred times, taking incredible quantities. And maybe a quarter of the people who were being admitted to Bellevue and Massachusetts Mental Health Center were on bad LSD trips. But today what you find instead is that people use LSD or mescaline or whatever three or four times a year; a small group of friends will go off, to a good place at a good time, and they're doing this very special thing—and they'll have what they regard as a pleasure, their expectations are reduced and reasonable, they're not pursuing a profound mystical insight and all that. And what they've done really is to establish social rituals and relate them to their own `counter-cultural' institutional structures, and—gee! There hasn't been a bad trip in an American hospital for years, virtually. That's all gone. But use is up."

To find out more about social controls and heroin, Zinberg said, he has begun a study of occasional heroin users. "Increasingly I find in the United States—and I have a certain amount of research money to study this—that contrary to the conventional wisdom, which is that people who use heroin have to get addicted eventually, it seems to me it's quite possible to chip on heroin. What I've seen in England certainly suggests that. In our new study we're finding that chippers show very different patterns. There's the regular Saturday-night user. There are people who use for a while and then don't use for a while. There are spree users who then don't do it again for a long time. There are even addicts who cut down to chipping. We have a whole variety of chippers that we've found, not in enormous numbers yet, but with a lot of indication that many more are there. There's been very little in the literature about this so far." He mentioned the one study I had seen, Douglas Powell's preliminary report on twelve occasional heroin users, published in April 1973. "My hypothesis is that what keeps people from becoming junkies is just this matter of the extent to which the use is socially ritualized. One wants to be cautious in drawing conclusions. But the evidence seems to be that even heroin, and it's a very powerful drug, can really, under the right circumstances, be brought under the control of certain rituals. I'm certainly not suggesting it should ever be used as freely as alcohol; I'm just saying that these controls are not impossible even for so powerful a drug. People get a lot of control over highs—marijuana, LSD, even some junkies over heroin highs. What I've found so attractive in the English approach—and what I felt was extremely important for us to work towards, and to try to make some use of—is that through the clinics they are trying to get the addict into a relationship with a social institution in a way that is directly relevant to his drug use, and once he's there, to use the formalized and very sustaining social rituals of the doctor-patient relationship, the weekly visit and discussion, and the subsidiary informal relationships with the rest of the clinic, as a way to subject the heroin use to viable, accepted controls. The strength of the English approach to heroin is that they've tried this, and to some extent succeeded. And I argue very strongly that it is not a matter of cultural differences between us and the English; you can't just put it down to national character. Because look how badly the British have done with marijuana, you know? They've treated marijuana just as we did, as a police problem, a lot of people arrested, a lot of people sent to jail, it's become politicized—and they have developed the same kind of marijuana problem we have, growing use, growing anger in the colleges, political opposition, and the whole familiar thing. In the United States, with methadone, we are not really doing the same sort of thing the English have done with heroin. I think methadone is not as satisfactory as heroin: it's partly the drug perhaps, but more important, it's the addict's drug versus the clinic's drug. And methadone's by mouth, and a lot of people are hooked on needles. And except for Vince Dole's methadone clinic, where they tell the addict `It's medicine, it's good for you,' everybody else in the United States is hung up on the morality of the drug, and of drug use. Methadone is a bad thing, and `yes, we're giving you this bad thing 'cause you do a worse thing otherwise, and as soon as we can we'll straighten you out and get you back on the right path.'

"We've shown, it seems to me, very little imagination, given the problem we have," Zinberg said. "Certain new things like heroin maintenance we've been unwilling to play with at all. The first thing we need is a number of experimental programs using heroin. The Vera Institute of Justice program is no great shakes as far as research or anything else goes, but it's a start. And we can design others, quite different heroin-maintenance programs, each experimental, each with only a small number of addicts. To break through all these questions —is it culturally different, can you compete with the pusher on the street corner, will the addict stabilize his dose?—all those things that have paralyzed us politically about getting heroin under control. We've got to move in and try things, even to find out that they don't work. We're so frightened of moving."

Back in London, I had lunch again with Griffith Edwards—a pizza and a Guinness at a pub near the Maudsley Hospital—and asked him what further an American might learn from the British experience with heroin addiction. "I still see the English clinic approach, for better or worse, as medical," Dr. Edwards said. "I don't see the American methadone clinics as medical, but as technological. In the American mind there seem to be these two strands—first, the fundamentalism, or salvationism, or utopianism, and second, the technological. I think the bitter enmity between your abstinent therapeutic communities and your methadone clinics embodies the deep schism in the American soul between its fundamentalism and its technology. Bear in mind that it may be totally naïve to expect that decisions in an area like drugs can be based on objective data or rational calculation.

"More than that—I want to warn you: to try to answer the question `Should heroin be prescribed?' would be a dangerous narrowing down from the data you've got. The real questions to be considered have more to do with such things as the processes of decision making. And the relation of society to the individual. And the magnitude of a society's anxiety—anxiety to which drugs are a response, anxiety as a response to drugs, anxiety that creates the social distances from which society perceives those who take drugs. And eventually, yes, one must also reach this whole question of the ways that the individual is created and focused and controlled by the social forces that immediately surround him. Thus, heroin cuts to the unfinished business of the society. And of the understanding of society."

"There's nobody I love in America quite like your ex-addict," Margaret Tripp said, in Washington in 1973. "One of the things I ask people here—I know a guy, a beautiful guy, been on the street here for a long time, and survived, very active, intelligent, knows entirely where he is at: so I say to straight Americans, why do you have to turn this guy into somebody you label as a sick, inadequate personality who can't cope with life, in order for you to reëmbrace him, reintegrate him into society? Why do you not take him back on his own terms?" I asked her what answers she got. "No answers at all. I haven't had an answer yet. My answer is, of course, because he's a hustler. He's a good hustler. He is an image of the society. And you don't like that. And not only is this guy hustling, but he has preserved his freedom, the one thing the organization or corporate hustler knows he's given up. And the other thing, of course, that I notice: the first question an American is likely to ask me is, `What do you do about the pleasure? If you give addicts heroin, do you give it to keep them straight or do you give it for pleasure?' The heroin addict over here, it seems to me, is perceived not only as a hustler, and one who is free, but a guy who has access to pleasure. On a scale beyond the imagination. Even though of course it is totally not true."

( Ideas reverberate. A year earlier, I had had a conversation in New York with Graham Finney, then commissioner of the city's Addiction Services Agency. Finney had recently returned from a trip to England to visit the clinics; I was about to go. One thing he said was, "I think, more and more, that the addict is a caricature of American society—the hedonism, the demand for instant gratification, the urge to get it now. He's a caricature of many, many businessmen I've known." Later, he added, "You know, in a funny way the addiction problem brings into focus a lot of the unsolved business of this country.")

"I can't get American doctors, working in drugs, to see themselves as part of the total scene," Tripp said. "In London, as we cut down on prescribing heroin, we'd hear about it, we'd be told, `The guys are taking methadone instead and they're taking other things, amphetamines, barbiturates. You're responsible.' So at the time, when you're in the middle of it, you say no, I'm not responsible. And then you go away and you think about it. And you know that it's there. That you are part of the system that has moved the problem along. American doctors just don't perceive themselves as factors that cause change. When I was first here, I did a heavy stint of going around Washington, talking to people who were actually working on the streets, and to the guys themselves. And this has been a real credit to the police and the B.N.D.D.the drug at the street level had been cut to the point where it was less than two per cent heroin. The guys were injecting quinine and hardly any heroin at all. Right then while the people at the top level here were still talking about the heroin problem and what could be done about it, those who were on the streets of Washington, whether staff or patients, knew that nobody could get any heroin. So I said, `What's the problem, then, mate?' And they said, `Well we've got this terrible amphetamine problem, what is the solution?' And nobody saw the slightest connection between the one and the other. And in New York, as you probably know, the guys who are on methadone, if they want a party, they take wine, or alcohol—or cocaine. Cocaine is back on the streets in a big way. And it's an expensive drug."

(At the Anglo-American Conference on Drug Abuse, in London that spring, I met, for the first time, Daniel Freedman, Chairman of the Department of Psychiatry at the University of Chicago, who, I learned, had organized some of the early low-dosage methadone clinics in the 1960s. We had lunch at a restaurant on Charlotte Street—Bordeaux pigeon, little peas, and a bottle of claret—and talked about his research in the pharmacology of LSD. Dr. Freedman said, "The reason I'm interested in drugs, they're the greatest moral tale we've got, at the moment, to make people think about the complexity of the interactions through which society organizes our behavior.")

One man who completely reverses the all but universal rejection of heroin by the American medical profession is Elmer Gardner, who was head of the Division of Neuropharmacological Drug Products in the Food and Drug Administration until February 1974, and thus was one of the pivotal people for federal approval of any American experiment with heroin maintenance. Dr. Gardner came to Washington in 1970 from community mental-health work—what he calls "psychiatric epidemiology"—in Philadelphia. "Yes, I think heroin maintenance will be tried in the United States, at least experimentally," Gardner said, several months after the Vera Institute published its proposal. "The only reason we in this agency would have for stopping it would be lack of safety of the drug. Beyond experiment, I can only give you my own opinion. First of all, I don't see any harm in people having drugs for pleasure, even if the drugs are addictive, unless they have degenerative effects as well. About heroin, the things we really don't know are in the realm of chronic toxicity—for example, carcinogenic effects or liver damage—with long-term use. There have not even been good chronic-effect animal studies with heroin. Heroin is probably—but we don't know—physically less damaging than alcohol. Given that reservation, my feeling is that if someone needs heroin enough to get addicted, then he probably ought to be able to get it. It may sound strange coming from a psychiatrist, but I don't see this entirely as a matter of treating illness. I guess my answer is, yes, we do need heroin maintenance—in addition to methadone, and for some people, anyway. At least until we come up with something better, and by that I mean something better for pleasure and the relief of anxiety and all the rest of it."

Probably no English doctor, or none I've met, would go so far. The English doctors see every day the real nature of heroin, as no American physician can—its benefits and drawbacks, whether in general medical use or in the management of addiction. Even those who prefer to prescribe heroin for addicts will say, as Martin Mitcheson did, "My personal feeling is that heroin is far too powerful a drug ever to leave to normal social controls. I'm perfectly able to accept the idea that to a heroin addict heroin is such a rewarding drug that he is prepared to ruin every aspect of his life to get it."

I asked Dr. Mitcheson what he had seen in the States that he wanted to take back with him to England. "I am concerned, personally, to see people get free of drugs," he said.

"Some people here obviously get virtually free of drugs through methadone programs; these people I would guess are the more stable addicts, anyway. But apart from them I think there are people who need a therapeutic community of some sort—who need a much more radical reprograming." There are only four such communities for ex-addicts in England; they all derive directly and without real innovation from the early American model, Phoenix House. The British concede that in this approach to treatment of addiction the Americans are far ahead. Mitcheson described therapeutic methods and attitudes, new to him, that interested him very much in cornmunities he had visited in San Francisco, the Bronx, and Washington. "There are little things I want to take back with me, too," he then said. "Like the idea of prescribing Antabuse plus Librium for the alcoholic, which is a mixture the Chicago clinics have had to develop; they've got a considerable alcohol problem amongst their people on stable methadone doses. As they do in New York. Nowhere that I saw has anybody yet acquired our English addicts habit of injecting barbiturates; so everyone working in drugs just denied that this was any kind of a problem, and I found myself wanting to say, `Well, wait and see.' I tried to take a few bets on that, and I'm not a betting man. My belief about that is that if the Bureau of Narcotics maintains the pressure there's been recently on the heroin supply, and the local police keep stepping up the pressure on the addicts' financial resources—then the addict will either find himself in prison or, at a certain level of difficulty in making money, he will come into the methadone program. And what then? If he's taking his regular methadone, and wants to get something more? We're talking about somebody who has experimented with drugs anyway, and likes their effects, for whatever reason, whether it was self-medication of anxiety or for sheer hedonism, to which you must add the powerful reinforcing, conditioning effects of the drug use itself. So: I can't believe that solving the opiate aspect of the junkie's life—whether it's your methadone or our heroin, mind you—is going to cure everything. I think you are still left on the one hand with the environmental and societal problems. And on the other hand you're left with the conditioned addiction, as well as whatever psychopathology may have been troubling the person before he ever took drugs—and those two, I think, are the proper province of the doctor and his colleagues. But methadone or legal heroin—neither is going to solve the psychopathology. So I would anticipate that as your programs begin to look again at the quality of what they are doing, and at the extent of multiple-drug use, and as the addicts learn to look, still more, for what's available elsewhere—even if it's eventually only alcohol, in that distant day after amphetamines and then barbiturates have been removed from the pharmacopeia—then I think you'll see that the drug problem has changed, in some ways for the worse, but has not gone away. Whether, and to what extent, these multiple-drug users will be stealing and robbing in order to get the drugs to get high, or whether they will just be skid-row characters who need to be segregated out of the sight of the middle-class eye, I don't know. After all, alcohol is still a much greater problem-in your country as well as mine—in terms of personal damage, than heroin has ever been. Perhaps the problem will not be sufficiently disturbing to produce the funds. And that, I suppose, if I were a betting man, and were putting something into an envelope to be opened in three years' time, that I think is what I'd say."

(At that same drugs conference in London, I talked for a few minutes—over instant coffee and digestive biscuits—with Richard Blum, who had flown in from Stanford to present a paper on the international approach to drug problems. As we got up to go back to the auditorium, Dr. Blum said, "Drugs seem to be the final path of expression for almost any other social problem—poverty, race, families, social class. Drugs, I've come to think, are the chemical tracer that diagnoses the problems of society. An avenue of discovery for the doctor and the sociologist.")

The conversation with Mitcheson turned to the problem of doctors being used as agents of social control. "I had a session the other day with a man who runs a methadone program near here," Mitcheson said. "He's a young, suave doctor, I should think a liberal Republican, talks about himself as being `essentially a bureaucrat.' On the defensive. When I mentioned that I saw the methadone programs as a useful way to reduce crime, he started insisting that he was a doctor running a medical service, and crime was up to the police. So I asked him why, then, did he have that graph on his wall with two lines on it, one for the number of people in the methadone programs, going up, and the other for the crime figures, coming down. And you know, the question bothered him—`That's not claiming that the methadone's doing it,' he said. But let's be clear about it, this really is part of the job that the doctors have been asked to do. Of course we have our own way of going at it. But the only honest thing is to say, well, we are agents of social control. Among other things. But I don't find it difficult to justify this in terms of what happens to the individual if this form of behavior is not controlled. There is a very long tradition, in my view, of doctors being concerned with the public health."

As I hope I have conveyed, the problem of heroin addiction feels very different in England from the way it feels in the United States. I have talked with many English addicts over the past eight years. They are ridden by numberless petty dreads and hopes, as addicts seem to be everywhere. The old street junkies are indeed very far down; the automaton that we know lives in each of us has taken them over. The young ones may be cocky, but more often they seem very tired. Grudgingly, they admit that they like the clinics and feel safe there. "S'awright. 'Course, they never give you enough." They all claim that they supplement their clinic prescriptions with Chinese heroin. But then it is in their interest—about this they have a tacit but real alliance with the Home Office Drugs Branch—to persuade the clinic doctors that suppression of the black market requires that the tap be eased open on legal narcotics. Along the two blocks of Gerrard Street, the Chinese-restaurant quarter that has grown up at the southern edge of Soho, there is never the action you will see at any time on a New York corner like Broadway and Ninety-sixth Street. Indeed, on Gerrard Street at midnight the loudest sound is the click of mah-jongg tiles.

In the waiting room of Dr. Mitcheson's clinic at University College Hospital, I met an addict who has remained in my mind more than any other. He said that his problem was insomnia, and that his wife had the same trouble, and that the last thing at night they used their methadone syrup so they could get to sleep. He called across the room to a staff member for a supply of sterile disposable syringes. "Twenty-one, please—seven for my wife, fourteen for me. Don't worry about the swabs, we got plenty of swabs." Then he told me he was afraid of losing his job. What did he do? "I'm a fishmonger." Addict braggadocio. He was in fact a kitchen helper who killed the lobsters and crabs at one of London's oyster houses. He had held the job nearly nine months. Now he had begun to nod off at work. And he thought his boss had noticed a needle that had failed to flush down the employee toilet. And blood on the towel. His despair was terrible. But it was uniquely personal. An American addict would find it unrecognizably innocent.

Does the British approach to heroin addiction work? In the light of the inherent instability of the drug situation in every Western country, I think it has worked very well—for the British. Credit for limiting the epidemic, however, can hardly be given simply to the clinics' prescribing of narcotics. Once again, the medical model, though an improvement on enforcement and punishment, is not enough. Any explanation of what has happened with heroin in England needs to begin with the worldwide phenomenon of the 1960s: the coming of age of the children born—in such disproportionate numbers as to strain the social fabric—just after the Second World War. Behind all the teen-age phenomena so often described and imperfectly explained, there was an evident shift in the adolescents' axis of relationships: their lives became much less tied to their parents' generation, and much more strongly controlled by their own age group. We think of the continuity of generations as characterized by rebellion—not by indifference on such a scale. Now, part of the pleasure of living in England in the 1960s was the emergent youth. The delight was greater because of the most considerable difference between the English adolescent mood and the American, which was a quality of ease. One was told many times, "The Beatles—ah, yes, d'you see, the mums love them, too." The mothers did. "The working-class lad may have his mod clothes and hair to his shoulders, but Saturday night you'll find him drinking in the pub with his dad, short-back-and-sides, in his Burton suit," I was told, and that was true, too. Across the gap there was an unexpected degree of tolerance. If it was simple-minded to blame the English heroin epidemic on the overprescribing general practitioners, alone, it must be inadequate to credit the remission in the epidemic solely to the introduction of the clinics. At least as important was the particular continuity that life, the social fabric, was felt to have by the adolescents who drew back from addiction. So much for conjecture.

What everybody knows about the British and heroin is that they supply it on prescription to heroin addicts. The common knowledge obscures the fact that, in the years since the clinics opened, their aims have changed. The doctors have quietly refused to remain merely agents of social control: though they recognize the role, and acknowledge there are addicts whose addiction can only be supported, the clinic staffs have gradually come to have a commitment to the eventual integration of the addict into the community, and to the diminution of doses. In this fundamental respect, the English approach to heroin maintenance is the reverse of the surrender that many Americans take it to be.

In 1971, after a decline the year before, the total number of addicts of all kinds of narcotics who were known to the Home Office rose again, for the entire year cumulatively, to 2,769. Still, this was lower than the figure for the peak year, 1969. But in 1972 the total number rose to 2,944, the highest yet recorded. As before, there is a second set of index figures, for the last day of each year. On 31 December 1971, 1,555 addicts of all kinds of narcotics were known, which was also an increase; at the end of 1972, this figure had climbed to 1,619. The total number addicted to heroin or methadone or both remained fairly steady for three years-2,480 throughout 1969, 2,233 in 1970, 2,376 in 1971—but on 31 December 1971, there were believed to be 1,316 addicts of those two alternative drugs, and a year later, 1,418, which was the highest yearend figure yet. In 1971, for the first time since the clinics opened, the number addicted to heroin alone rose also, though only from 413 to 449; in 1972 this number dropped back slightly to 442. The number of addicts less than twenty years old has gone down every year since the peak in 1968, so that by 1972 there were just over one-third as many teen-age addicts as there had been four years earlier. Statistics for 1973 had not been released by 15 July 1974, but the figures will show an increase in the total number of addicts of all narcotics at the end of the year—up from 1,619 at the end of 1972 to about eighteen hundred on 31 December 1973. Yet in 1973, notifications to the Home Office of new cases of heroin addiction ran somewhat lower than the year before. The increase in the total was in great part due to old addicts returning to the clinics, whose rosters showed a parallel rise in the year. The situation still seems almost stable.

Does the British approach work? The British themselves have a wary confidence that it does. "Nonetheless, I think my overriding concern would be to avoid answering that question," Griffith Edwards said at the end of lunch. "One would be quite foolish to invest all one's pride and all one's cleverness in defense of one particular medicine—or system. The numbers game. How precise must the data be for intelligent policy making? And what is `the size of the problem'—simply its numerical dimensions, or the dimensions of the anxiety it generates? My impression is that the anxiety about narcotics here is surprisingly low. Just about right, in fact."

Just about right. In the course of a conversation I had at yet another English drug-dependence clinic, a doctor said something in passing that seemed so natural that it was an hour later, as I was boarding a train in the London Underground, that I woke to what he had said, and to what an overturning of my American expectations it represented. The doctor told me, "We have made it possible in this city for the addict to live without fear."