Heroin Maintenance: An Historical Perspective on the Exhaustion of Liberal Narcotics Reform

Introduction

In the years immediately following the passage of the Harrison Act, a furious debate raged in the United States regarding the appropriate course of treatment for Opiate-addicted persons. Those who supported narcotic maintenance argued that addiction, whatever its etiology, constituted a physiological disorder and, as such, the proper course of treatment might involve the ongoing administration of narcotics in dosages sufficient to Prevent the onset of the withdrawal syndrome.(1) As the medical director of the Los Angeles maintenance clinic started in 1920 (Nyswander 1971):

It must be accepted that unless drug-balance is maintained addicts turn to illicit supplies.

Those opposing this point of view asserted that providing narcotics to addicts was "merely" a matter of pandering to the craving of depraved individuals which could in no way be considered appropriate medical practice. In lieu of maintenance it was argued that addicts be detoxified in institutional settings. While not ignoring the fact that dependency on opiates constituted a recognizable physiological condition, it was assumed that once detoxified the issue of continued abstinence was a matter of moral determination. The tendency of detoxified addicts to relapse to narcotics use after having been physiologically withdrawn was perceived as indicative of moral weakness and hence the proper subject of the criminal sanction. Indeed, sanctions were seen as an aid to those with weak moral dispositions.

It was this paradigm which guided the orientation of federal enforcement officials and the medical establishment (American Medical Association 1959). As a consequence by 1925, after five years of repressive activity,(2) the last of America's narcotic maintenance clinics was closed, ushering in a reign of abstinence which was to affect drug users, law enforcement officials and medical professionals for more than forty years.

After tracing the four-decade effort on the part of reformers to break the hegemonic status of the ideology of abstinence by reestablishing the social legitimacy of narcotic maintenance, I will attempt to show in this article that the progressive element of those efforts was exhausted with the establishment of methadone programs throughout the United States. Since the reformist position had become the core of the contemporary liberal argument on the issue of addiction,(3) this analysis will point to the exhaustion of liberalism in this quite critical area.

Part I

With both legal and medical establishments having closed ranks behind the anti-maintenance position, the pleas for reform in the years prior to World War II were quite isolated and easily, dismissed as the idiosyncratic preoccupations of a misguided few. Among the most significant heterodox calls for change which emerged in that period was that of August Vollmer the former police chief of Berkeley, California whose argument in the Police and Modern Society prefigured by almost thirty-five years the reformist stance of those law enforcement officials who in the early 1970's were to favor heroin maintenance.

After criticizing the efficacy of law enforcement efforts with regard to what are currently called the "victimless crimes" (prostitution, alcohol consumption and drug use), Vollmer stated:

and not the least evils associated with repression, the helpless addict has been forced to resort to crime in order to get money for the drug which is absolutely indispensable for his comfortable existence.(4)

Thus, unlike those police officials who argued with other "respectable" elements of society that heroin use predisposed the user to commit crimes, Vollmer asserted that it was prohibition itself which was the criminogenic factor. For him, as for other reformers, the only rational policy solution entailed the distribution, at cost, of narcotics to those who were addicted.

Only after the post-World War II upsurge in addiction did reformist efforts assume a quality of urgency. Suddenly the war-time reduction in the availability of illicit narcotics was reversed. The prohibitionist policy not only seemed incapable of stemming the rising incidence of heroin use but appeared to be an aggravating factor. While those aligned with a law enforcement approach to drug addiction took the opportunity to press for increasingly severe penalties for those convicted of the sale and possession of narcotic drugs,(5) reformers launched increasingly self-confident attacks on the premises underlying America's policy.

It was in 1947 that Addiction and Opiates by Alfred Lindesmith, the sociologist and leading advocate of reform of America's narcotics policies, was published with its powerfully argued call for allowing physicians to prescribe opiates to addicts. Several years later, Rufus King, a leading reform advocate among lawyers, published "The Narcotics Bureau and the Harrison Act: Jailing the Healers and the Sick" (King 1953). On a more popular level, Harper's Magazine published a reform proposal under the striking title "Make Dope Legal" (Stevens 1952). Finally, and indicative of the extent to which the journals of liberal opinion were to become forums for the expressions of the reformist position, the Nation published three important articles by Lindesmith, one each in 1956-1958.(6)

Reform-minded physicians and researchers, most notably Herbert Howe in New York, added to the agitation for change by proposing clearly articulated critical approaches to the dispensing of narcotics (Howe 1955). Far more important than these statements, however, was the support for maintenance expressed by elements of the organized medical profession, such support representing a break with the thirty-year-old policy of the American Medical Association. In 1953 the Medical Society of Richmond County in New York City adopted a resolution calling for the creation of maintenance clinics under the auspices of the United States Public Health Service.(7)

In explaining the rationale of the Richmond County proposal, Dr. Herbert Berger stated that an end to the rigid anti-maintenance policy of the prior thirty years would result in a reduction in crime and a consequent "emptying of the jails." Furthermore, narcotics maintenance would make a significant impact on the spread of addiction, since addicts who were often compelled to act as sellers of drugs to novices in order to raise funds to purchase their own narcotic supplies would no longer need to do so. Finally, Berger noted that while the goal of abstinence was certainly to be valued, it was clear that there was a class of "Incurable" addicts. Prohibiting legally authorized maintenance left only two alternatives for that group of "unfortunates": life-long incarceration or execution.

Though the New York Medical Society rejected the Richmond County proposal in 1953 by referring it to a reference committee for "further study" (Medical Society of the State of New York 1953) and the American Medical Association rejected a proposal closely modeled on that reform effort in 1954 referring it to a subcommittee on Narcotic Addiction of the Council on Mental Health,(8) a significant breakthrough for the clinical dispensing of opiates was achieved when the prestigious New York Academy of Medicine adopted in 1955 a pro-maintenance program.(9) Like all proposals for maintenance, the Academy stressed that abstinence remained the goal of any treatment for addiction and that any addict being maintained under medical auspices should be encouraged periodically to undergo withdrawal treatment. Yet recognizing the extreme difficulty which had been faced by all efforts to keep detoxified addicts drug-free, the Academy stated (Nyswander 1971):

Addicts resistant to undertaking therapy and continuously refractory to therapy, despite all efforts, should be supplied legally and cheaply with the minimum amount of their drug needs. (emphasis added)

Recognizing that some addicts might attempt to obtain narcotics from more than one clinic in an effort to attain a euphoric state rather than "drug balance," the Academy proposal suggested that sanctions in the form of hospital commitment be available for dealing with such persons.

This period not only witnessed growing opposition to the anti-maintenance policy among medical professionals but among some who were charged with the enforcement and overseeing of the increasingly harsh and inflexible narcotic statutes. Thus in 1954, a Citizen's Advisory Committee on Crime Prevention proposed to the Attorney General of California that addicts who could not remain abstinent be provided with legally supplied narcotics (American Bar Association/American Medical Association 1963). In New York State, Jacob Javits, the Attorney General, stated in a report on the problems of Addiction that "even the highly controversial Howe Plan" ought to be tested albeit on a tightly controlled scale.(10) Less tentative was the support given to heroin maintenance by Judge Jonah Goldstein of the Court of General Sessions in New York City, who like others concerned with the link between crime and addiction depicted prohibition as counterproductive (Committee on the Judiciary 1955).

Finally, ambivalent and highly cautious support for maintenance, stressing the need for controlled experimental projects, was reflected in the 1957 Interim Report of the joint Committee on Narcotic Study of the American Medical Association and the American Bar Association.

The joint Committee feels that the possibility of trying some such outpatient facility on a controlled experimental basis should be explored since it can make an invaluable contribution to our knowledge of how to deal with drug addicts in the community rather than on an institutional basis.(11)

Whether framed in terms of support for cautiously structured experiments or in forthright calls for a nationwide network of maintenance clinics, all the proposals aired in this period had in common certain significant features:

1. None of these proposals suggested that narcotic maintenance was appropriate for the episodic user of heroin, nor for the adolescent who had but a brief history of drug involvement. The establishment of clinics was to meet the needs only of the "deeply addicted" of "confirmed addicts." Other forms of therapy were the appropriate response to those who were less severely affected by the "disease of addiction."
2. Though asserting that abstinence from narcotics use as the preferred goal of treatment, all these proposals recognized that for some if not all "confirmed" addicts such a goal was unobtainable. For those addicts it was considered appropriate to provide minimal quantities of opiates to prevent the onset of withdrawal distress. Underlying these proposals for maintenance was a belief that addicts could be medically stabilized on narcotics and that when so stabilized they could "function normally." That which compelled the addict to seek narcotics was not the desire for euphoria and/or sedation, but, rather, a not fully understood "imbalance."
3. All the proposals suggested that the linkage between crime and addiction was an artifact of prohibition and that maintenance clinics would not only relieve the addict of the need to commit crime, but would lift the burden of the threat of crime from those who were not addicted.
4. The threat of diverting narcotics from appropriate clinical purposes to the illicit market was recognized as being of sufficient magnitude to necessitate very restricted prescribing practices. Thus some proposals would have required the addict to return to the clinic for each of the four or five needed daily doses of heroin, while others would have given registered addicts up to two days of "take-home" supply.(12)
5. In all instances the addict's use of narcotics was to be under the supervision of the medical profession; there was no suggestion that addicts had a "right" to use as much narcotics as they desired or that the use of such drugs, like the use of alcohol, was a life choice with which the state could intervene only under the most limited circumstances.

Despite the very sober manner in which these proposals were presented, those who adhered to an anti-maintenance position repeated their long-standing opposition to a "clinic system" in the most strident tones. Given the repressive thrust of both federal and state legislative efforts during this period (a mirror of the early Cold War anti-Communist hysteria), and the insistence on closed-ward treatment by the medical establishment and by law enforcement officials, this situation was not at all surprising.

Thus, after hearings on the New York Academy of Medicine plan a subcommittee of the United States Senate (Committee on the Judiciary 1956) stated:

The subcommittee is unalterably opposed to and rejects the 'clinic plan' proposals for supplying narcotic addicts with free or low cost narcotic drugs.... We believe that initial treatment must take place within a special institution, and that rehabilitation of a drug addict would not begin until he is off drugs.... We believe the thought of permanently maintaining drug addiction with sustaining doses of narcotic drugs to the addict to be utterly repugnant to the moral principles inherent in our laws and the character of our people.

Rejecting the effort to depict the relapse to heroin use after detoxification as an element of the chronic disease of addiction, the subcommittee reasserted the principle of individual autonomy and the virtue of self-control. Only moral weakness could account for the return to drug use. Providing drugs to addicts was thus a matter of "pandering" to that weakness.

On a somewhat different basis, the subcommittee on Narcotics of the Committee on Ways and Means of the House of Representatives (Committee on Ways and Means 1955) asserted:

Narcotic drug addiction serves no useful purpose. There can be no justifiable reason for its continuance. To permit a governmental institution to engage in the ghastly traffic in narcotics is to give the government the authority to render unto its citizens certain death without due process of law.

Thus, since "overdose" death was linked with illicit narcotics use, the Committee drew the dramatic conclusion that narcotic maintenance constituted a form of murder.

Though lacking the stridency of these polemical denunciations, the American Medical Association reaffirmed its own opposition to narcotic maintenance in 1957 when, on the recommendation of its Committee on Mental Health, it rejected the proposal of the New York Academy of Medicine. Couching this rejection in the more temperate language appropriate to a professional body, it suggested that its own position be "subject to frequent review in accordance with new scientific knowledge."

Part II

In the period between the late 1950's and the mid-1960's there was increasing vocal support from reformers for narcotic maintenance. That support found repeated expression in the journals of liberal opinion, with the not always understood "British approach" symbolizing a model of humane and effective treatment for addicts.(13) Similarly, the New York Times (Editorial 1962; 1963; 1964), the leading liberal American daily newspaper, was to argue consistently, against the prohibitionist response to addiction.

The most fully developed expression of the reformist position was, as in the earlier period, the result of Alfred Lindesmith's work (1965). His The Addict and the Law charged that American social policy on addiction was both cruel and stupid. Cruel in that it punished sickness, stupid in that it produced the most untoward consequences for the social order. In tracing the historical evolution and impact of that policy Lindesmith (1965) stated:

If we disregard the question of numbers and focus our attention exclusively on the evils connected with addiction, which are the result of the way in which the problem is dealt with, rather than the necessary consequences of addiction itself, then we may say that the drug problem today is one that has come into being since 1914 when the Harrison Act was passed and largely because of it.

Not only was the policy of prohibition responsible for crime but for the very extent of addiction. Reviewing the nature of social policy in those countries in Western Europe that permitted maintenance, Lindesmith stated that a repressive social policy like America's tended to be correlated, ironically, with larger numbers of addicts. While many of these arguments had been found in his earlier writings in the Nation, this major work gave Lindesmith the opportunity to discuss at length the American experience with narcotic maintenance clinics. His effort to "recapture" that history for the purposes of the reform movement was particularly, significant. Thus he disputed in some detail the account of that experience contained in the official reports of the Federal Bureau of Narcotics.(14)

The impact of reformist arguments on the thinking of public commissions charged with the investigation of policy options regarding addiction,(15) on judicial authorities,(16) and professionals concerned with the treatment of heroin users(17) was quite evident during the early 1960's. Yet the emerging support tended to be disposed toward limited clinical trials rather than the adoption of a widespread program of heroin maintenance. Indeed, though there were exceptions, a remarkable feature of this period was the extent to which those groups which had at one point supported a volte face on prohibition began to express more cautious support for experimental efforts. The modifications which occurred in the policy pronouncements of the New York Academy of Medicine and the Committee on Public Health of the New York State Bar Association are illustrative of this pattern.

It will be recalled that the New York Academy had in 1955 endorsed in unambiguous terms the concept of narcotic maintenance. By 1963 in a second "Report on Drug Addiction" (New York Academy of Medicine 1963) the Academy found it necessary to note that the group of addicts to be maintained would not be large," and that the duration of maintenance for that small number would not be long. By 1965 in a third report which placed great emphasis on the necessity of establishing firm medical "supervision" over all addicts by coercive means if need be, the pro-maintenance position was further eroded (New York Academy of Medicine 1965). Thus the Academy asserted that while it did not object to a "demonstration project" utilizing heroin it did oppose the "indiscriminate dispensing of narcotics to addicts."

A similar process of retreat from a pro-maintenance position characterized the evolution of the policy of the Committee on Public Health of the New York State Bar Association. In 1958, responding to the recommendation of its Subcommittee on Drug Addiction, the Committee supported a proposal that "confirmed addicts" be allowed to obtain narcotics from clinics and doctors (New York State Bar Association 1960). Acting on this proposal, the Committee made an effort to have the New York State Legislature enact pro-maintenance legislation.(18) In 1962 the Committee's position was broadened to include a demand for the establishment of maintenance clinics on a national scale.(19)

Quite suddenly the Committee's position began to shift in 1964, when its annual report "explained" that its support for a "pilot" maintenance project did not commit it to "general outpatient doles" (New York State Bar Association 1965). A year later in a report which was bitingly critical of the "British system," the Committee (1966) stated:

Responsible physicians working with addicts do not favor maintaining them on short-acting heroin.

Recognizing that narcotics maintenance might be necessary for some addicts, however, the report approvingly, acknowledged the experiment being conducted with methadone. While the next reports continued to support those experimental efforts, this support was never characterized by the same enthusiasm expressed for heroin maintenance in the late 1950's (New York State Bar Association 1967).

The retreat from a forthright position in favor of heroin maintenance to one which cautiously supported small experimental efforts must be understood in terms of the broader evolution of the social policy toward addiction. It is, of course, possible that the withdrawal from a forthright pro-maintenance position reflected the general social consternation regarding the spread of addiction and "addiction-related" crimes. It was, however, under very similar circumstances in the 1950's that the New York Academy of Medicine and the Public Health Committee of the New York State Bar Association had issued their initial broad calls for maintenance. A more adequate explanation must, ironically, take note of the growing stress on therapeutic intervention which characterized the social response to addiction in the early and mid-1960's.

Increasing emphasis on both the desirability and possibility of curing rather than punishing addicts made long-term heroin maintenance an anathema to many. Hence the appearance of such characteristically hostile phrases as "indiscriminate maintenance" and "unlimited dole" in the discussion of proposals for widespread adoption of a maintenance approach. Like the period just prior to and following the closing of the narcotic clinics in the 1920's, the fundamental hostility to heroin use, linked with therapeutic enthusiasm, provided the foundation on which a social policy, stressing abstinence as the only goal of treatment, could be built. It was no longer necessary to support maintenance as an alternative to prison incarceration. This was, it should be recalled, the period in which both community-based therapeutic communities as well as the advocates of civil commitment were arguing that addicts could be "cured" — made abstinent — as a result of total personality reconstruction.

Finally, it should be noted here that the State of New York had undertaken a small experimental project with low dose methadone maintenance at the end of 1963. That project, which received some publicity, was ostensibly designed with a view toward resolving the hotly debated issue of whether addicts could be stabilized on narcotics and whether, if so stabilized, they could "function normally."(20) With such an experiment utilizing a narcotic drug without the negative historical associations of heroin underway, the support for the use of the latter in a clinical program was undercut. Though the New York State experiment was a failure, the efforts of Drs. Dole and Nyswander at Rockefeller University and Beth Israel Hospital were a notable success, gaining widescale public attention and eventually obtaining massive public funding. With methadone maintenance becoming increasingly accepted, the institutional support among physicians and lawyers for heroin maintenance which had begun to emerge in the 1950's ebbed so that, at most, an experiment was considered necessary.

While support for heroin maintenance declined among medical and legal professional groups, for liberals who had adopted a reformist position it continued to possess considerable attraction. Thus in electoral campaigns in New York between 1965-1970 liberal Democrats repeatedly voiced support for heroin maintenance.(21)

On a legislative level, local liberal figures in New York introduced legislation in 1966 which would have established heroin maintenance clinics as an alternative to Governor Nelson Rockefeller's program of residential incarceration or "treatment."(22) In the early 1970's such legislation was introduced in each annual session of the New York State Legislature.(23) It is particularly interesting to note that such efforts rejected the attempts to distinguish between methadone — the approved narcotic "medication" — and heroin the disapproved narcotic "drug" — and suggested that narcotic maintenance clinics be permitted to dispense the most appropriate substance to addicts. The first years of the 1970's witnessed the reemergence of support among medical and law enforcement professionals for heroin maintenance as it became clear that the mere expansion of methadone maintenance programs would not solve the problems of addiction. By far the most significant attempt to launch a heroin project was that which was designed by the Vera Institute of Justice in New York City. The debate which that very thoughtful and limited experimental project generated clearly revealed the extent to which the issue of heroin maintenance had attained a symbolic status bearing little relationship to prevailing social practice with regard to narcotics users.(24) While a forceful reformist effort to mobilize support for heroin maintenance had made notable public inroads, the intense opposition from Blacks, conservative political groups and traditional anti-drug forces was of sufficient magnitude to set back indefinitely this most careful clinical trial employing heroin. Epitomizing the nature of that opposition was the strident denunciation by President Richard Nixon.

This concept of heroin maintenance represents a concession to weakness and defeat in the drug struggle, a concession which would surely lead to the erosion of our most cherished values for the dignity of man.(25)

That such statements could be made when the principle of narcotic maintenance had already been accepted on both federal and state levels through public support for methadone programs is striking. A medically controlled program of heroin maintenance, after all, involved significantly less of a radical departure than implied in the shrill call to defend the American social order. Like those who opposed the proposals for medically supervised heroin maintenance, many of those who supported it had not fully grasped the transformation which had occurred with the widespread availability of methadone maintenance programs. With the successful effort to establish methadone clinics throughout the United States, much of the argument for heroin maintenance was undercut. Methadone was an ideal maintenance drug, capable of allowing addicts to "function normally" while requiring a minimal disruption of personal daily routine.

The existence of thousands of addicts uninterested in medically supervised methadone maintenance programs posed a fundamental problem for liberals who had adopted the reformist program which had for decades been based on the irrationality of denying "sick addicts" their requisite narcotics. Dr. Robert Newman (1973), Director of the New York City Methadone Maintenance Program, drew the only possible conclusion.

When someone wants a heroin treatment program, when methadone maintenance is available that person is saying he or she is not willing to give up the narcotic effect that heroin will give. If the person no longer wanted to get high, then it would be really strange that he or she would prefer to go four or five or six times a day into a clinic where somebody is going to try to find a vein and inject some heroin.

No proposal for the medically controlled distribution of heroin envisioned giving the addict access to as much heroin as demanded. The reformist belief that providing heroin under such clinical conditions would at long last solve the remaining problem of addiction did not take into account the addict's continued desire to deal with personal and social strains through the "street life" and the pleasure of heroin euphoria. Like the opposition to heroin maintenance, support by reformists had assumed a ritualistic quality. Narcotics maintenance was well established as a social life in the United States, the limits of the medical model of reform had been reached. That this new situation was not comprehended by many liberals, that in some way it remained opaque, was a function of the exhaustion of their own therapeutically based orientation toward the problem of addiction.

Those who were willing to confront the issues involved were presented with a great dilemma. The continued restriction on access to narcotics to medically appropriate circumstances carried with it all of the same untoward social consequences which had been noted when opiates were denied under any circumstances. Crime and black market prices for narcotics were an unavoidable by-product of a restrictive social policy on narcotics distribution. Additionally, such a policy involved severe limitations on the life choices of those who desired to use narcotics. For some liberals this was an unacceptable attack on personal liberty.

The alternative to this situation involved a radical departure from the core of the reform position since the passage of the Harrison Act. For more than half a century the reform demand had been for the medicalization of addiction. Now it was being suggested by libertarians that it was time to "demedicalize" addiction. Such an option would entail allowing persons to purchase narcotics as they were allowed to purchase alcohol. The position was stated with admirable clarity by liberal legal theorist Herbert Packer (1972):

Enforcing personal morals through the criminal laws is one of this country's principle self-inflicted wounds. We can allow sick people — as we should allow nations to choose their own roads to hell if that is where they want to go — I should have thought that to be the most important lesson of liberalism.

The social consequences of adopting such a radical course would involve, at the very least, a rapid expansion of addiction, especially, among the poor Black and Brown underclass in the cities. To liberals, with a socially rooted understanding of addiction, that was indeed a heavy price to pay for change.

Thus the organizations committed to reform of the nation's narcotics policies and which had proclaimed in self-confident tones the need to adopt a clinic system for the dispensing of heroin were split on the appropriate course of action. The Cambridge based Committee for a Sane Drug Policy (1971) acknowledged, for example, that libertarians within its organization favored demedicalization while others with a greater concern for the social consequences of the uncontrolled sale of heroin were unwilling to opt for such a "solution." Similarly, the American Civil Liberties Union which began to give formal consideration to this issue in 1970 with a discussion of the so-called "liquor store" model of heroin decontrol had not by 1975 been able to resolve the issue on a level consonant with the libertarian principles of the organization.(26)

It is interesting in this regard to note that while liberals — who perceived in heroin use a response to social deprivation and to the unbearable conditions of everyday life in the ghetto — were experiencing great ideological stress on this matter, the libertarian but politically conservative psychiatrist Dr. Thomas Szasz (1972) could declare in his widely read "The Ethics of Addiction":

In an open society it is none of the government's business what idea a man puts into his head likewise it should be none of the government's business what drug he puts into his body.

With the exhaustion of the medical model of narcotics reform, liberalism was confronted with a dreadful choice between the scylla of compelling treatment-resistant addicts Into therapeutic settings — an undertaking long recognized as being of doubtful therapeutic utility — and the charybdis of a libertarian solution which in fact represented a failure to solve the problem of addiction. That this was the choice was a function of the most fundamental failure of contemporary liberalism to resolve the socio-economic problems of the capitalist social order — problems which liberals themselves asserted lay at the root of drug use.(27) Unable to confront either its own failure or the implications, liberals characteristically fell silent on the issue of addiction.(28) That silence represented the exhaustion of the progressive impulse of liberalism which in prior decades had made it the appropriate vehicle for the reform of America's narcotics policies.

Notes

1. See for a fully developed expression of this position, Terry, Charles C. Jan, 1920. Narcotic drug addiction and rational administration. Am. Med. Vol. 26: 29-35.

2. For a thorough account of this period see Musto, David. 1973. The American Disease. New Haven: Yale University Press.

3. Contemporary liberalism, having rejected the radical individualism of classical liberal thought, has tended to be sympathetic to deterministic explanations of human deviancy. Hence it is not surprising that an explanation of the heroin user's behavior in terms of a physiological disorder would be found especially congenial. It must be stressed, however, that while a pro-maintenance position characterized most liberal thought on the question of addiction from the 1950's on, there were exceptions. Additionally, there must be no confusion about the fact that for various reasons some elements traditionally identified with a conservative social posture also supported maintenance. This was, however, more the exception than the rule.

4. Cited in Lindesmith, Alfred. 1968. P. 235, in: Addiction and Opiates. Chicago: Aldine Publishing Co. (first printing, 1947) — considerable attention is given to Vollmer in Brecher, Edward M. & Editors of Consumer Reports. 1972. Pp. 52-53, in: Licit and Illicit Drugs. Boston: Little, Brown & Co. Vollmer serves as a reference point for reformers of later years, especially for those associated with law enforcement functions, seeking to give their own arguments historical precedent.

5. This was the period in which the repressive Boggs Act was passed. For a discussion of the rigidity of this legislation see Lindesmith, Alfred. 1965. The Addict and the Law. New York: Vintage Books and King, Rufus. 1972. The Drug Hang-up: America's Fifty Year Folly. New York: W.W. Norton & Co.

6. Lindesmith, Alfred. 21 Apr, 1956, Traffic in dope: medical problem. Nation pp. 337-339; Lindesmith, Alfred. 16 Mar, 1957. Dope: Congress encourages the traffic. Nation pp. 228-231; Lindesmith, Alfred. 21 Jun, 1958, Our immoral drug laws. Nation p. 558. These articles are discussed in some detail in Bayer, Ronald. Spring, 1975. Liberal opinion and the problem of heroin addiction 1960-1973. Contemp. Drug Prob. Vol. 4: 94-95.

7. Berger, Herbert. 15 Mar, 1956. The Richmond County Medical Society's plan for the control of narcotics addiction. NY St. J. Med. Vol. 56: 888-894. Recognizing the long standing fear of diversion of medically provided narcotics from clinics to the black market, the proposal would have allowed no narcotics to be taken by the addict from the clinic for "self-administration." The proposal was given popular exposure in Berger, Herbert & Eggston, Andrew. Jun, 1955. Should we legalize narcotics? Coronet pp. 30-34.

8. Proceedings entered as an exhibit in the Committee on the Judiciary, U.S. Congress, Senate, Illicit Narcotic Traffic, before the Subcommittee on Improvements in the Federal Criminal Code, Senate, 84th Congress, 1st Session 1955, p. 1453-1455.

9. New York Academy of Medicine, Committee on Public Health, Subcommittee on Addiction. 1955. Report on drug addiction I. Bull. NY Acad. Med. Vol. 31: 592-607. The proposal was reprinted in part in Nyswander, Marie. 1971. The Drug Addict as a Patient. New York: Grune & Stratton. (first printing, 1956). Of importance, especially in terms of the later history of methadone maintenance, was Dr. Nyswander's strong support for the proposal.

10. Javits, Jacob. 1955. Narcotic Addiction in New York State — 1955, a report by the Attorney General to the New York State Legislature. That suggestion, which first appeared as a footnote, was restated in public testimony before a committee of the United States Senate. In that testimony, Javits stated that he supported an experiment as one of the steps in "trying to find out what we ought to do about this dreadful illness."

I 1. American Bar Association/American Medical Association. 1963. P. 11, in: Drug Addiction: Crime or Disease? Interim and Final Reports of the Joint Committee of the ABA and AMA on Narcotic Drugs. Bloomington, Indiana: Indiana University Press (emphasis added). The Final Report of the Joint Committee was very ambiguous on the issue of supporting maintenance clinics. For a discussion of this ambiguity, see Eldridge, William. 1962. P. 39, in: Narcotics and the Law: Critique of the American Experiment in Narcotic Drug Control. New York: American Bar Foundation. Rufus King, op cit. pp. 161-175 contains a brief discussion of the internal politics of the Joint Committee.

12. On one occasion it was suggested that pharmaceutical firms might be able to develop a long-acting narcotic substance which would obviate the need for multiple daily visits. Berger, op cit. p. 894, states that Merck & Co. had suggested that it would be possible to develop a "repository" narcotic which would maintain an addict for 24 hours rather than the 4-6 hours typical of short-acting heroin. This, of course, is precisely what methadone ultimately was able to do. In justice Morris Ploscowe's report to the Joint Committee of the ABA/AMA, op cit. p. 107.

13. Sparks, Will. 25 Aug, 1961. Narcotics and the law. Compnonweal pp. 467-469; Meisler, Stanley. 20 Feb, 1960. Federal narcotics czar. Nation pp. 159-162; Editorial. 9 Mar, 1962. Narcotics victory. Commonweal P. 608; Lindesmith, Alfred. 13 Jan, 1962. Narcotics: the official view. Nation pp. 34-35. An early popularizer of the British "system" was Edwin Schur. See Schur, Edwin. Sep, 1960. Drug addiction in America and England. Commentary p. 241. Responses to the Schur piece were published by Commentary in December, 1960. There were a few notable exceptions to the generally pro-maintenance opinions expressed in the journals. See for example, Fort, Joel. 18 Sep, 1962. Addiction fact and fiction. Sat. Rev. Lit. pp. 30-31 and Peyser, Herbert, 13 Feb, 1965. Children of the Poppy. New Republic p. 20. Peyser, in terms not very different from those which had been associated with the harshest critics of maintenance, stated "to dole out to these people opium may be to give medicine a fundamentally immoral task — maintaining distressed people in distress by drugs." This issue is given full discussion in Bayer, op cit.

14. Lindesmith. Chapter 5, pp. 135-161, in: The Addict and the Law. Of special note is the comparison of two accounts of the clinic which was operated at Shreveport, Louisiana, pp. 149-161. Coming eight years later, David Musto, op cit. pp. 151-188 sought to provide a dispassionate account of the American narcotic clinics. The function of that analysis was clearly to explode the historical myths used by the opponents of maintenance.

15. See New York City, Office of the Mayor, Advisory Council on Narcotic Addiction. 1959-1960. A preliminary report. P. 12. This support was particularly important in that the Council had as members Leona Baumgartner, Commissioner of Health, a Presiding Justice of the Appellate Division of the New York State Supreme Court, a member of the New York Board of Hospitals and the President of the Community Council of Greater New York. See also Ad Hoc Panel on Drug Abuse of the White House Conference on Narcotics and Drug Abuse. 1963. P. 297, in: Report, Proceedings of the Conference. Washington, D.C.: Government Printing Office.

16. Indicative of the extent of judicial support was the position of the Advisory Council of Judges of the National Council on Crime and Delinquency. NY Times 22 Jan, 1964. See also for a characteristic statement: Gassman, Benjamin. 1964. The Harrison Act and drug addiction. NY County Lawyers Assoc. Bar Bull. Vol. 22: 22-27. Gassman was Judge of the Criminal Court in New York City.

17. See for example, the statements of New York City Council on Narcotics Addiction, Statement of Aims: 1963. Pp. 5-6. Files of the Association of Voluntary Agencies for Narcotics Treatment (AVANT). This position was reaffirmed in an Executive Committee resolution, 11 Feb, 1966. AVANT files.

18. The legislation was introduced by Assemblywoman Dorothy Bell Lawrence. After compulsory registration, would have been given the opportunity to obtain narcotics at cost from public health clinics or "authorized physicians." NY Times 18 Jan, 1960, p. 19.

19. New York State Bar Association, Committee on Public Health. 1962. Report. Rept. NY St. Bar Assoc. Vol. 85: 151. The Committee noted, however, that the creation of such a nationwide network was made impossible by the position of the Federal government. The language used to depict this situation reveals the depths of the opposition to these constraints:

The dogged adherence of the federal government to the archaic, punitive treatment of a public health problem is a deterrent to a progressive, modern and infinitely more promising policy.

20. Paul Hoch, Commissioner of Mental Hygiene, stated, "If the 20 patients show that they will require an increase in dosage the experiment will be over once and for all." NY Times 20 Sep, 1963, p. 35. See also NY Times 9 Mar, 1964, p. 1 for a discussion of the project which appeared under the headline, "State supplying narcotics to 19 addicts in new quest for helpful knowledge."

21. See for example NY Times 4 Sep, 1965, p. 46; NY Times 16 Oct, 1968, p. 28; NY Times 11 Jun, 1969, p. 56; NY Times 24 Mar, 1970, p. 48; NY Times 26 May, 1970, p. 28; NY Times 30 May, 1970, p. 24. This issue is discussed in Bayer, Ronald. Fall, 1975. Heroin maintenance, the Vera proposal and narcotics reform. Contemp. Drug Prob. Vol. 4.

22. NY Times 3 Feb, 1966, p. 50. The bill was sponsored by State Senator Manfred Ohrenstein and Assemblyman Jerome Kretschmer. A year earlier the New York State Senate, Committee on Mental Hygiene. 1965. Report on the Problem of Narcotics Addiction and Treatment. Legislative document, 32 P. 12, under Ohrenstein's chairmanship stated, "We should enable doctors in their discretion to provide narcotics to addicts if in their professional judgment a therapeutic purpose is served." Citing the example of diabetes, the report noted that the provision of drugs to those with chronic disorders was not alien to medical practice.

23. Interview with former Assemblyman Antonio Olivieri, 4 Oct, 1973, New York City. See NY Times 13 Feb, 1970. p. 42 for a discussion of one such effort.

24. For a discussion of the debate, see Bayer, Heroin maintenance op cit.

26. For a full analysis of the debate see Bayer, Ronald. Winter, 1975. 'Drug stores,' 'liquor stores' and heroin: an analysis of the libertarian debate. Contemp. Drug Prob. Vol. 4.

25. Statement contained in the files of the Vera Institute of Justice.

27. It may, of course, be argued that drug use is not limited to capitalist societies, the problem of alcoholism in the Soviet Union providing ample evidence that different social systems may generate or perpetuate forms of behavior designed to meet the needs of those whose lives are miserable. Nevertheless, the nature of opiate use in mid-century America — as virtually all prevalence and incidence studies have shown — is a phenomenon intimately tied to the problem of chronic unemployment, racism and inequality. The failure of contemporary liberalism with regards to these issues is a complex problem but is hardly a matter of dispute.

28. For a discussion of this phenomenon see Bayer, Liberal opinion op cit.

References

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Committee on the Judiciary, U.S. Congress, Senate. 1 Sep. 1955. P. 1447, in: Illicit Narcotic Traffic. 84th Congress, lst Session.

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