XV Treatment, Prevention, and Control of Addiction

It is perhaps axiomatic that, if there were no access to narcotics for a sufficiently long period, there would be no narcotics addicts. It is not equally obvious that efforts to suppress uncontrolled traffic in narcotics offer an effective means of significantly reducing, to say nothing of eliminating, narcotics addiction. Opiates are not exempt from the law of supply and demand. The very effectiveness of efforts to suppress the traffic creates a situation in which prices rise if there is no corresponding decrease in demand. From a business viewpoint, all that this means is that an increase in risk is balanced by an increase in potential profit. If the businessman is not adept in the mathematics of risk and is, moreover, inclined to gamble (as is likely to be the case for someone engaged in the narcotics traffic), he may even be willing to operate under quite unfavorable conditions of risk relative to the possibilities of profit if the potential returns seem to be great enough. In other words, the effectiveness of police activity may simply have the consequence of increasing the efforts to outsmart or to corrupt the police, the volume of business fluctuating around some stabilization point. Thus, it is not enough that police activity be moderately successful in catching and convicting violators of the narcotics laws; it must offer the promise of being almost perfectly successful for a long period before we can take it seriously as a measure of control.

Price is, of course, not unrelated to demand. In a normal commodity market, an artificial or natural shortage of a particular nonvital commodity may drive its price to a level at which its purchase entails the frustration of other economic and psychological wants (for instance, in addition to other desired commodities, a desire to maintain a safe margin of savings and desires not to look like a fool or like one who cannot control his own avidity). As such a point, varying from person to person, is approached, the individual's desire to purchase the commodity declines. As the price goes up, the number of potential purchasers who decide that purchase is not worth their while increases, and the market demand decreases. If the supply does not correspondingly diminish and if the retired potential purchasers cannot be replaced by more avid ones or persuaded that they have underestimated the value of the commodity, the price comes down.

Why should the same considerations not apply to narcotics? That is, why would it not be enough to have the effectiveness of enforcement carried to such a point that the price could no longer rise and still find a market sufficient to justify the risk? An increment of effectiveness beyond such a point, no matter how small, could not then be matched by a price rise balancing the risk. Marginal entrepreneurs would drop out, decreasing the number of lawbreakers whom the police must outwit and thereby permitting the police to increase their effectiveness. Soon, no narcotics traffic. A beautiful vision, indeed!

The fact of the matter is that illegal narcotics are not in a normal commodity market. The customers have long since established themselves as individuals virtually immune to competing considerations, so vital does this commodity seem to them; and the market price of heroin is already far beyond the level that the majority of customers can afford, to say nothing of the perils to the consumer-purchaser of dealing in the market. The higher the price, the more desperate the stratagems to which these consumers will resort, and these often include efforts to convert others to the likes of themselves. In other words, they turn to fund-raising crime to manage the costs, and they become a potent force in spreading the market.

It seems a rare month, indeed, when newspaper-readers are not treated to accounts of the smashing of a major narcotics ring. We cannot but admire the persistence, the ingenuity, and the devotion to duty of the narcotics officers who score these triumphs. Nor can we persuade ourselves to believe that these victories make much difference in control of the traffic. The more successful the police, the greater the inducement to new rings. In fact, we find it quite easy to believe that, if the police were to desist entirely, the narcotics traffickers themselves would carry on for them. The illegal narcotics traffic cannot afford free competition, and, considering the unprincipled characters involved, it seems likely that, if there were signs of competition's developing, they would start assassinating one another—as even now they seem to do from time to time. The police, of course, carry on the job of reducing competition in the business in a socially more acceptable way.

We are not questioning the integrity of the enforcement officers. Nor do we have any reason to doubt that they do the job that has been laid out for them as well as it can possibly be done with the resources at their command. We do not doubt that, given additional resources, they could do this job even better. We are not saying that they do not have a most important, proper function in narcotics control. We are saying that the job laid out for them makes no sense and that this is not their fault, although it is quite understandable that a person who has been assigned to a senseless job should try to convince himself and everyone else that his job is of the utmost significance. That the enforcement officers believe in what they are doing and that they should be inclined to view any critic as an enemy of society is perhaps a credit to their high morale, but it can hardly be taken as compelling evidence that they are right. The important point is that, barring an enormous increase in the resources at their command for a long period (and this would entail great sacrifices with respect to far more pressing social needs), they cannot possibly have much impact on the volume of the illegal narcotics traffic if there is not, independently, a great reduction in demand.

There is an obvious expedient for reducing the demand—if not the demand for narcotics per se, then at least the demand on the illegal market—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.

Whenever there is a strong push for a major change in social policy, one may anticipate a powerful mobilization of effort in the opposite direction. The issue of the discretionary prescription of narcotics is no exception. Unfortunately, the issue has been confounded and confused by arguments about the so-called English system. The simple facts seem to be that British physicians do have the discretion of administering narcotics (including heroin) to addicts and that, despite allegations to the contrary, they do in fact exercise this discretion. It is, moreover, generally agreed that the total number of addicts in England is extremely small—a maximum of perhaps five hundred cases—and there is every reason to believe that the method of counting addicts inflates the figures in England, just as it does in the United States. Considering the small number of English addicts, it is understandable why some Americans who go to England to study the system seem to find it impossible to locate English physicians who have patients to whom they continue to prescribe narcotics. And there are other reasons why the British are inclined to deny the existence of an English system that is, in practice, in any way different from the American system,1 especially to physicians from the United States whose initial skepticism may carry an aura of hostility to the system.

Apart from disputations as to whether the English system actually exists, the big argument settles down to the question of the relevance of the English experience to the United States. The pro's attribute the small numbers of English addicts to the existence of the system; the anti's argue that England is entirely different from the United States. The facts are with the anti's. Not only are there major differences in culture, tradition, population composition, and social organization, but the sheer numerical difference may be a materially relevant fact. Moreover, English addicts are geographically dispersed, rarely in contact with one another, and probably predominantly middle-class. And there is no tie-in between the illegal sale of narcotics and large-scale criminal syndicates (the latter being the sequela of another noble American experiment in suppression).

The relevance of the British experience is consequently, at best, highly debatable apart from the purely negative conclusion that it has not produced a situation comparable to that which exists in the United States; but it is also quite trivial in terms of the effect on the illegal traffic of introducing low-priced, high-quality narcotics in competition with the illegal product. It is time, we think, to forget about England and to consider the issue on its merits vis-à-vis the United States. There are many arguments against the adoption of such a plan.

The first concerns the addicts themselves. Let us for the moment confine ourselves to the purely economic aspects. It is argued that addicts will continue to buy their supplies on the illegal market. Addicts, it is argued, are irresponsible, irrational, immoral people. They will dislike the discipline of keeping medical appointments. They will be unhappy about the quantities that physicians will prescribe for them and, if they cannot succeed in getting themselves treated by more than one physician simultaneously, will supplement their prescription on the illegal market. They will not want to run the risks of being identified as addicts (as though substantial numbers of them could now escape these risks and as though being known to the police were preferable to being known to a physician or clinic).

Suppose all this were so. Still, no one contends that no addicts would take advantage of the availability of narcotics via medical treatment. Or, to put the issue differently; if addicts were to take only trivial advantage of the opportunity to receive drugs legally, the present situation would not be materially altered by giving physicians total discretion as to whether to prescribe narcotics. If, on the other hand and as is far more likely, many addicts were to take advantage of the opportunity, then, even though many of the same individuals were to continue to purchase some of their supplies on the illegal market, the demand on the latter would markedly diminish—provided, of course, that there were no compensatory increase in the number of addicts making some use of the illegal market.

There are two important qualifications in the preceding sentence that call for some discussion. But let us, for the moment, assume that we can accept the first ("even though . . . on the illegal market") with equanimity and that there is no great danger of the second ("no compensatory increase . . . making some use of the illegal market"), and follow the economic implications. Under the envisioned circumstances, the more difficult it would be for an addict to obtain his supplies on the illegal market (and increasing prices represent one factor of difficulty), the greater would be his incentive to turn to the legal market; the demand pressure on the illegal market would not adjust freely to diminished supply, and a safety valve would be introduced that limited price increases. Consequently, the illegal market must lose in its flexibility to adjust to effective law enforcement activity. In this event, even the present level of effectiveness might be sufficient to make the business unprofitable, and any increase in effectiveness would make it even more likely that the business would become unprofitable.

Why talk of the possibility of increased effectiveness in the present context? On the assumption that the new policy would not increase the number of addicts, for every addict who passed into the legal channels, the number of lawbreakers must decrease; and even for those addicts who made only partial use of the legal channels, the total volume of lawbreaking must diminish. The enforcement officers would consequently have less to occupy them on the addict front and, with no increase in their resources, would be able to concentrate greater efforts on the manufacturing, importing, and wholesale end of the business.

The definition of drug use per se as a matter of occupational concern solely to the medical profession would force a basic redefinition of the proper function of the enforcement authorities. The Harrison Act and all its derivatives were aimed at preventing the indiscriminate use of narcotics. More and more local and state enforcement efforts seem to be turning to "internal possession" as a legal violation and to the development of means of establishing internal possession. That the Harrison Act took the form of a tax measure does not gainsay its fundamental intention; it attests, rather, to the fact that the fundamental intention was politically repugnant, so that it could only be expedited by devious means, and the essential dishonesty of the internal-possession construction speaks for itself. One might speculate whether dishonest means can ever be anything but self-defeating, even with regard to the noblest of intentions; this, however, is irrelevant to our present concerns.

Immediately relevant is the fact that the new policy would deny that the law has any primary business with whether people do or do not take narcotics; that is the business of medicine. This is not to say that the law has no business with narcotics. It is a proper function of the law to protect the public from adulterated drugs, from drugs that are packaged in ways that mislead consumers as to the dosage levels that they contain, and, by implication, from unprincipled manufacturers and distributors of drugs; if the most immediately affected part of the public happens to be composed of addicts, so be it. But, once the law had been freed of its preoccupation with drug use, it would become clear that the addict-pusher represents a relatively trivial aspect of its proper function, and it would be freed to deploy its resources in the direction that would do the most good from the viewpoint of its proper functions, namely, concentration on the manufacturing, importing, and large-scale distributing of illegal narcotics.

We have argued that, unless enforcement can be made enormously more effective than it now is, the enforcement approach to the control of the illegal traffic in narcotics must be self-defeating if there is not an independent reduction in the demand on the illegal market. We have further argued that such demand could be reduced by providing legal access to quality-controlled and much less expensive narcotics through the discretion of the medical profession. We have, finally, argued that by-products of the medical-discretionary policy would be a more tenable definition of the function of law with regard to narcotics and more effective, non-self-defeating enforcement with no increase in—but with considerable redeployment of—enforcement resources.

There is an increasing likelihood of some small-scale experimentation on the discretionary administration of narcotics in the management of addiction. It is to be noted that such small-scale experimentation could not test the large-scale economic effects we have been discussing.

Our argument, however, rests on certain assumptions which must now be examined. The most important of these is that the new policy would not result in an increased number of addicts making use of the illegal market. There are two parts to this assumption: that it would not result in an increased number of addicts and that, even if it did, the new addicts would not use the illegal market enough to maintain demand on it. Note that a mere increase in the number of addicts would not upset the force of the economic argument as long as they do not make more than trivial use of the illegal market. Since new addicts are, by the very novelty of their habit, least integrated into the addict subculture and least set in their ways of maintaining their supplies of narcotics, they should be the ones who could be most easily moved into the legal channels of supply. Hence, unless the number of new addicts greatly exceeded in number those current addicts who defect in greater or lesser degree from the illegal market, our economic argument remains valid.

Would a policy of total medical discretion, however, increase the number of addicts? Small-scale experimentation might answer such a question, but the selection of the subject population for such an experiment would have to be made on a principle diametrically contrary to the principle espoused in current proposals for small-scale experimentation. All current talk about such experiments is in terms of "carefully selected cases"—meaning cases with most favorable prognoses and those most likely to abide by the discipline of medical treatment. These are precisely the cases least likely to take an active part in the induction of new addicts. For small-scale experiments to have any bearing on the present issue, the cases selected should be the "worst" cases, not the "best."

In any event, there is not the slightest reason to suppose that the new policy would increase the number of addicts. If anything, it would tend to inhibit the induction of new cases. The logic of the expectation of an increase is simple—childishly simple: A person who takes a narcotic must have got both the idea of taking it and the supply from someone else; therefore, addiction is contagious; therefore, every addict is the narcotics analogue of a "Typhoid Mary"; therefore, anything which makes it easier for addicts to get along in the open environment is bound to bring with it an epidemic; therefore, permitting physicians to use their own discretion about prescribing narcotics for addicts is bound to increase the number of addicts.

These non sequiturs overlook some relevant facts, for instance: (1) that many habituated users sought the initial supply on their own; (2) that attempting to convert others is not induced by missionary zeal, but is a practical adaptation by many addicts to the problem of maintaining their own supplies under the conditions of current public policy; (3) that the addict who would impulsively or out of a desire to look like a "big shot" share his legally obtained supply of narcotics with others would, thereby, also be endangering his own supply, since no one would be offering him unlimited supplies; (4) that the pushers in high-use gangs tend to "lay off" their most vulnerable acquaintances —fellow gang members who have recently returned from hospitalization or imprisonment; (5) that one factor making the use of narcotics attractive in the delinquent subculture is precisely the fact that it is illegal; (6) that it takes much more than an occasional shot to make an addict, namely, apart from frequent repetition, a high degree of personal alienation and psychopathology; (7) that the epidemiology of addiction was self-limiting even under the completely open market prior to the Harrison Act, together with the common practice of including dependency-producing levels of narcotics in many proprietary medications; and (8) that 65 per cent or more of those listed as addicts by the Federal Bureau of Narcotics are not again heard from for at least five years as users of narcotics.

The opponent of legalization can also abuse the medical profession. He must be careful, of course, never to charge openly that physicians are unworthy of trust, since that might remind the public that it daily puts its trust in the physician in matters personally far more consequential than whether the number of addicts goes up or down. Also, he should not raise the question of what the untrustworthy physicians are likely to do that would increase the number of addicts. Appeals to unreason are often most effective if they are subtle. So, if the opponent of legalization gets into an argument about whether to give total discretion to physicians in matters of the use of narcotics, he might casually mention some of the abuses that led to court decisions which have in effect strait-jacketed the medical profession in the treatment of addicts, for instance, the case of the physician who was conducting a national mail-order business in prescriptions for narcotics. He should be careful not to mention the fact that the medical profession has developed highly effective machinery for dealing with abuses of professional ethics. Also—and this is a most effective form of argument—he should be certain to introduce a special version of the numbers game mentioned in Chapter II. He can point out that the drug-addiction rate among physicians is higher than for any other occupational subgroup in the population, and the argument will go across even more strongly if he leaves out the qualifier, "occupational." He should not raise the question of what "addict" means in this context; nor mention that the "highest" rate is still very low; nor, above all, mention that the cure rate among physician addicts is extraordinarily high—so high, in fact, that it has been remarked that the most effective form of treatment of drug addiction may well be to send all addicts to medical school. Mention of the cure rate might only raise questions as to what the word "addict" means in such a context.

There was a second assumption in our argument for giving total discretion in the use of narcotics to the medical profession. It was that we can accept with equanimity the possibility that many addicts who would take advantage of the opportunity to obtain narcotics from physicians might supplement their supplies on the illegal market. There are actually a number of assumptions concealed in this one.

One is that many addicts would not be content with maintenance doses. In fact, no true addict is content with maintenance doses because such dosage levels do not satisfy his craving; because of the effects of tolerance, they do not ease his anxiety, give him relief from tension, or provide the experience of the "high." We see no reason, however, if there are no other contraindications and if there is no better form of treatment available (not merely in principle, but in fact—and that means, among other things, that the cost of providing him more fundamental treatment would be covered), for limiting him to maintenance doses, especially if giving him his "high" would keep him off the illegal market and provide the "high" under conditions of maximum safety to him and others. In fact, we see nothing wrong, under the conditions stated, with having the physician help such an addict plan his drug-taking strategy—switching drugs from time to time, helping him with planned and optimally spaced withdrawals, mixing drugs, or whatever it takes.

In other words, it would be quite feasible to reduce the addict's inducement to resort to the illegal market to a minimum—a minimum, rather than zero, because the typical addict is not the most responsible and controlled of individuals. If he did not get along with his doctor, for instance, he might well turn to the illegal market just out of spite. Or, he might find the very acceptance of his infirmity too much to take, arousing strong masochistic needs. What should concern us most, however, is not that he would be getting more narcotics than his physician had prescribed for him, but that he would be getting them from an unreliable and dangerous source. The former may be contraindicated, but the latter is far more dangerous.

There is, thus, a far more fundamental assumption in our argument than our ability to accept with equanimity an occasional foray by an addict into the illegal market, namely, our ability to accept with equanimity the addict's taking any drugs at all, under any conditions. We are well aware that we have written some fighting words and can anticipate opposition. We think it high time, however, to call a policy of forcing the addict from degradation to degradation, and all in the name of concern with his welfare, just what it is—vicious, sanctimonious, and hypocritical, and this despite the good intentions and manifest integrity of its sponsors.

We are not suggesting that any addict automatically be given all the narcotics he wants and, in effect, abandoned to his addiction. We are not even suggesting that every addict be continued indefinitely on at least maintenance doses. We are saying that 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, whether on maintenance or higher doses and whether in conjunction with other treatment or not, then he is entitled to this treatment. Addicts have been known to lead productive and useful lives as long as they were free of harassment.

We have no objection to any plan that would put so momentous a decision in the hands of a medical, psychological, sociological, and soctal-casework review board, rather than leaving it to the individual physician, provided that such a plan were adequately financed, ensured that each case receive the full and prompt attention of the board, and that the implementation of such a plan not endanger other vital services by absorbing an excessively large proportion of competent personnel. Simply to put the matter in proper perspective, we would similarly have no objection to any realistic plan guaranteeing that no one would ever have to undergo major surgery without the consensus of a number of expert consultants.

Up to the last few paragraphs, we have put the argument entirely in economic terms. We have said that an enforcement approach to addiction, by itself, cannot work. We have pointed out that providing a legal channel for drugs, even to the point of more than maintenance doses, would relieve the demand on the illegal market, make it possible for enforcement with redefined objectives to become effective, and would not aid the spread of addiction. In the last few paragraphs, we have gone beyond the economic argument. We have argued that any human being in distress is entitled to the best that can be offered him by way of alleviating or minimizing the distress, preferably by getting to the root of the trouble, but, if necessary, by purely symptomatic treatment. In extreme cases, it may be that the best that can be offered an addict is to help him stay chronically narcotized; if so, the person is as entitled to such treatment as is a terminal cancer patient.

Let us now assert that the premise that human beings in distress are morally entitled to the best help that can be offered them is valid regardless of the effect on the illegal narcotics traffic. The only condition that can ever justify any action contrary to this premise is a due-process judgment, reluctantly arrived at in the light of overwhelming evidence, that the welfare of an individual must be sacrificed for the general welfare. This is basic to the democratic way of life, and it is basic to those religions which take it as given that every human being was created in the image of God. We can think of no valid reason to suspend the premise in the treatment of addiction.

We have deliberately left a hole in our argument thus far because it involves a much larger issue than whether and under what conditions an addict should have access to narcotics. Suppose that the policy we are advocating were adopted. We have argued that a normally adjusted person is not attracted to narcotics, except perhaps by way of flirtation with a novel experience, in which event he will not become addicted. There are, however, a great many people who are not normally adjusted. Many of these may perhaps now stay away from narcotic's out of fear. What would happen to them if we removed the occasion for fear? Would they not discover a means of ridding themselves of their miseries and deliberately get themselves addicted? We strongly doubt that there can be many such (and, just to avoid any confusion with regard to our earlier argument, let us point out that, if there were, they would get off the illegal market as quickly as possible). We are here envisioning action in accordance with a long-range plan based on an assessment of one's problems. Addiction-prone individuals are simply not given to such action.

Suppose, however, if only for the sake of argument, that there were, in fact, many people who would pursue such a course of action. Note that we are positing that they would be doing this in order to escape from their miseries. In other words, these would be individuals who had already failed to find alternative solutions to their problems and who had not received any effective help in doing so. It follows that the posited line of action would, for them, be adaptive; they would be seeking what seemed the best available treatment for their distress. It may be that, in thus calling attention to themselves and to their problems, they could be helped to find more adequate solutions. But what if not? By the very premise we have just been discussing, what moral right would we then have to interfere? If the best that our society has to offer them is narcosis, what moral right would we have to withhold it from them? Dare we, in our arrogance, take the position that it is proper to keep these people from finding relief merely because their method of finding relief is offensive to us? Is a society which cannot or will not do anything to alleviate the miseries which are, at least subjectively, alleviated by narcotics, better off if it simply prevents the victims of these miseries from finding any relief?

Drug use breeds on certain forms of human misery. The major problem posed by narcotic addiction is not at all the problem of getting people to stay away from narcotic drugs. It is the problem of getting at the sources of such misery. Unless and until we have got to work with a will to do something effective about coping with them, we will not have begun to touch on the real problem of narcotics addiction.
In principle, we believe that it should be discretionary with the physician whether to prescribe narcotics for a given case, and we favor establishment of the principle. In practice, however, the privately practicing physician would not be within the reach of the great majority of addicts. There are other reasons, too, that indicate clinics as the best place for the treatment of addiction. And it is no ordinary medical clinic that we think of as optimal.

A clinic geared to the treatment of addiction should include a wide variety of services. Addicts could be referred to other agencies for special services, but every additional step that they have to take and every additional waiting period increases the likelihood of failure. The clinic should provide (not necessarily in one physical plant, but in close proximity), in addition to basic medical services and a withdrawal unit, psychotherapeutic opportunities, family casework, vocational counseling, a sheltered workshop,2 and at least the beginnings of vocational retraining, job placement facilities, chaplains, food, financial assistance, a lounge where the addicts would be welcome to just come and relax, and a residential shelter. Such a clinic should be open on a twenty-four—hour basis, although it is not necessary that each of the services be available on such a schedule. All this would have to be provided with a minimum of stress and without the herding of patients, the long waiting periods beyond appointment hours, and the depersonalization that characterizes so many medical clinics. It calls for infinite patience and a high degree of frustration tolerance as patients backslide, break appointments, come in without appointments, and the like. This implies not merely a high professional-to-patient ratio, but a great deal of in-service training to affect the attitudes of the clinic personnel toward the patients.

Above all, what the average addict most needs as a first step in his rehabilitation is a place with the homelike qualities that he never found in his own household and the discovery that he, as an individual human being, matters and can be respected as such. At the beginning, he may need to learn that he can be accepted by authority figures completely on his own terms and to master the anxiety that such acceptance can evoke. One can be reasonably certain that he will be testing for such acceptance by attempting to provoke outright rejection. This does not mean, that those who deal with him must pretend to share his values or be indifferent to his failures, but that he needs to be convinced that the manifest difference in values will not lead to a loss of acceptance or of respect for him as a fellow human being. He needs to be convinced that his being accepted is not contingent on any desire to manipulate or mold him into someone else's image. Basic acceptance of himself and trust in others is a necessary condition of his maturation. One has to remember that, though matured in years, he has not yet successfully managed the developmental hurdles of infancy (the acquisition of what Erikson has called "basic trust") and that, unlike the infant who has before him the tasks of achieving self-acceptance and trust in others, the addict is already carrying the psychic scars of his own failures and of the social world that has failed him.

It may be a long time before he is ready for such services as vocational counseling and even longer before he is ready for anything but supportive psychotherapy. His first introduction to the latter may be a simple invitation to attend group therapy, just to see what it is like; and, if he makes progress, his help may be enlisted to try to make it easier for the "weaker" newcomers to these sessions. In time, he may be rewarded with a supervised "big-brother" relationship to another addict; and his introduction to individual psychotherapy may take the form of discussion of the problems of his "little brother" and of his own problems of dealing with him. Similarly, in the sheltered workshop, there may be a progression from timid, sporadic, "observer" visits to the role of mentor to one or more others. In effect, we envision a series of progressive exercises in ego development, adapted to the individual patient in accordance with experience with him.

At the beginning, the patient might be given his shots without question and be asked to come in, or just to stick around; he might then be introduced to the discipline of hygienic self-administration. Later, he might be encouraged to introduce delays, if only to enhance his relief. In time, he might be given a supply sufficient for a day or two. In effect, the very ritual of taking narcotics may become a starting point for training in disciplined behavior. He would merely be informed that other services were available and that he could take advantage of them if he wanted to, but that this was in no way a condition of his welcome. Later, as the relationship with him developed, he might be given more positive encouragement to participate, if only as an observer, and so on. The first contacts with him, apart from such ministering to his needs as he requested, could be casual conversations with him in the lounge or in the course of the need-ministering treatment, designed merely to demonstrate that he was a person of interest to the clinic personnel.

Not every addict need be dealt with as though he were at the zero point of human development. There are, for instance, even under present conditions, addicts who are capable of and who succeed in keeping their jobs. Nor do we believe that all addicts need to be bribed with the maintenance of their addiction to avail themselves of the clinic services; many are sincerely motivated to quit, provided that they can be helped to cope with their other problems. The demands made on them by the staff and by their circumstances are not excessive; occasional backsliding does not turn them into pariahs or convince them of the hopelessness of trying; and they can be helped to keep in proper perspective the fact that the use of narcotics is not their major problem. The important point is that the clinic be able to provide many kinds and levels of service according to the assessment of individual needs. Not all the clinic services need be aimed directly at the patients or conducted on the clinic premises. A good deal of work may, for instance, be focused on the patient's immediate environment in the form of family casework and counseling with the patient's employers, to say nothing of the job of locating individuals who are willing to employ addicts and accept counsel concerning the conditions of their employment.

It is theoretically possible to divide such a variety of services among a number of social agencies instead of allocating them all to one. We believe, however, that this would be a mistake, even though it is now the common pattern for providing social welfare services. The point at issue is contained in an old vaudeville script, in the course of which a patient complains to her physician: "My head aches, my eyes are burning, there is a buzzing in my ears, my nose is stuffed, my throat is sore, my stomach feels queasy . . . and I myself also don't feel so good." The needy individual finds an agency concerned with his finances, another agency concerned with his marital problems, another concerned with his health—and in this agency there is one department concerned with his ears, nose, and throat; another with his eyes; another with his stomach; and so on. In all this welter of fractionated services, there does not seem to be anyone concerned with him as a person. The "I myself" somehow is ignored. The addict, more than most people, needs to feel that he, as a person, is of concern to others. This feeling can be most effectively conveyed within the framework of one agency through a continued relationship with one staff member who guides the addict through the various services, personally introduces him to the various staff members with whom he will be dealing, is interested in his reactions to his experiences, and makes certain that a maximum of coordination is maintained.

It must be expected that progress with most patients will be extremely slow and the setbacks numerous; there may be some with whom no progress seems possible.

We have placed the ideal treatment in a "clinic," rather than in a hospital. We do not mean to preclude the possibility of relatively brief periods of hospitalization. We do, however, regard with great skepticism current proposals of relatively long, enforced periods of hospitalization, whether by induced self-commitment (e.g., as an alternative to a jail sentence) or by court commitment. Although it has become quite fashionable, even among enforcement authorities, to declare that addiction is an illness and hence requires hospitalization, we think that this new outlook is merely a device to get addicts out of the open society. The idea is to lock the addict up. Currently, an addict can be locked up only if he is convicted of committing a crime—in some localities, including the crime of "internal possession." But, if he can be declared to be suffering from a dangerous disease that requires commitment, then he can be locked up even though there is no legally sufficient proof of the commission of a crime. This idea has the further virtues of relieving both the overcrowding of the jails and the consciences of the enforcement people, who are finally beginning to understand the essential inhumanity of the enforcement approach. If the maneuver results in the useless overcrowding of hospitals instead of jails, and if the consciences of the hospital personnel become afflicted as they come to understand their fruitless participation in a gigantic social hypocrisy, that is their problem; the pressure on the jails and on the consciences of the enforcement people will have been relieved.

The simple fact of the matter is that, short of physical measures (e.g., shock therapy, brain surgery, and, under some circumstances, drug therapy), no treatment of psychic disturbances can be successfully accomplished by force. All that force can accomplish is to heighten the dependency and the alienation of the patient, and this is a most undesirable result in the treatment of the addict, since his is a passive-dependent, alienated personality to begin with. To be sure, in the hospital,environment, he may seem like a well-adjusted person, displaying no signs of craving; but this is precisely because the management of his life has been taken over, and, if he is a true addict or even another of the varieties of addicts described in Chapter II, he will shortly revert to narcotics when he returns to his normal environment. He will in no sense have been cured.

Success in overcoming the illegal traffic in narcotics and in the treatment of individual addicts will still have done nothing toward meeting the manifold social and personal problems that make so many individuals vulnerable to drug use and addiction. What is called for is a multipronged program going far beyond the direct, manifest problems of addiction to intensified family casework services and special services designed to increase the supports for and incentives to legitimate endeavor. The details of such a program are far beyond the scope of this book. The most general objectives are easily stated: to provide convincing evidence to the individual that he does not stand alone and that his fate does, in fact, matter to society and to provide him, in the fullest possible measure, with the competencies and aspirations most fitting to a human being. There are obviously strata of our society for which no special program with such an objective is needed. The stratum from which most addicts (not to mention delinquents, psychotics, and human derelicts) come is much in need of such a program.

If the ideas presented in this chapter seem visionary, then those who fall by the wayside are, by that very token, entitled to their drug-induced nirvanas. Obversely, if that seems intolerable, then we cannot afford to regard these ideas as visionary. The price of moral indignation is civic responsibility.

1 See Edwin M. Schur, Narcotic Addiction in Britain and America (Bloomington: Indiana University Press, 1962). Apart from the light that he throws on the reluctance to talk about the English system, we may take as a crude index of the difficulty in locating physicians with addict patients the fact that, according to Schur, the thirteen physicians whom he interviewed had contact with virtually all known English addicts.

2 A sheltered workshop is a subsidized manufacturing enterprise in which (1) the line workers are individuals who could not otherwise hold jobs because of physical or mental handicaps, (2) the foremen are specially trained to cope with such workers, (3) the higher-level personnel include social workers, psychologists, and psychiatrists, and (4) work inefficiency, absenteeism, chronic lateness, and the like are dealt with as adjustment problems rather than as reasons for dismissal. Some of the client-employees may never learn to manage jobs in the open market, but for most the sheltered workshop is a step toward complete rehabilitation.