Morphine Maintenance. "Preface and Introduction"

Preface

In 1965 the clinical development of methadone, a synthetic opiate, as a drug for maintenance ushered in a new era of drug treatment. Prior to 1965 (and dating back to 1923) drug treatment in the United States was largely institutional and emphasized total abstinence. Addicts went or were sent to prisons, hospitals, and self-help communal programs (such as Synanon or Daytop), and were expected to remain drug free when they left. Most did not, and it was a sad fact of institutional treatment that addicts could not or would not live up to the goals or objectives set for them by these institutions.

After 1965, an opiate (methadone, although designated as medicine, is still an opiate with strikingly similar effects as other opiates but somehow without the moral stigma) became available to outpatient clinics for maintenance of addicts. The drug was accepted because it was long-acting and easy to use in a clinical setting. There was also a theory, or more properly a rationale, for the use of methadone, that the synthetic opiate blocked the euphoric effects of other opiates. Methadone given in high doses would because of the high tolerances developed, "block" the effects of the highly diluted street heroin presently available in the United States. It does not, however, "block" undiluted, high-quality heroin. Clinical experiences in England where both heroin (pure) and methadone are used do not support the methadone theory. On the contrary, English addicts continue to get high on heroin while using methadone regularly (Judson 1973). Methadone has been a boon to drug treatment programs. Used in a regular regimen, methadone allows addicts to give up drug-seeking as their life's work, to cut down on some of their more dangerous hustles, and helps them stay out of jail. Many go to work and join the "productive" bourgeoisie by starting bank accounts, buying cars, and making house payments. Methadone was a godsend in another way: it let society become a little more realistic about the addict. Drug programs that used methadone gave up the rather noble but grandiose objective (for addicts) of being drug free, and made a primitive bargain with their patients. If the addict went to work, or made an effort to go to work, and stayed out of trouble with the police, then the clinic would give him an opiate regularly.

Having tried one opiate as a maintenance drug and found that it works pretty well, one could ask, "Why not try another?" Very well, why not heroin? Why not morphine? Traditionally, the arguments have been, "Well, they are both illegal, and besides we tried them back in the 1920s and found that they did not work."

We agree about the first — both heroin and morphine are illegal; but so was methadone until it was developed clinically. in fact, methadone still is illegal except as it is used under the strict guidelines set down for clinics. The reply to the second argument about the 1920s clinics is not so easy. On the one hand, the New York City clinic did not work. There were numerous problems — with large numbers of patients and few or no controls. (Both of these issues are discussed at length in Chapter 3.) It was so badly run that Ernest Bishop, a firm advocate of opiate maintenance, wrote in November 1919:

We are in a very bad state here in New York. Conditions are probably worse than ever. I am told, and I believe it to be true, that more opiates are peddled than ever before. The Board of Health clinic has not been a success.

This, however, was only one of the clinics, and many of the others had far different experiences. Clinics in several other cities (Los Angeles, California; New Haven, Connecticut; Jacksonville, Florida; Alexandria and Shreveport, Louisiana) were run much more effectively and most reports were favorable if not praising. Unfortunately, the Narcotic Division of the Internal Revenue Service used the New York clinic as a negative model (perhaps to support an already established belief or policy) to justify closing all the clinics — even those which were run well and supported by their local communities. Most were closed within the first year or two of operation. The New York clinic was open only 11 months. Following the closings of the clinics, there was surprisingly little written about them, hardly any of which used original source data. Charles Terry and Mildred Pellens in their marvelous book The Opium Problem (1928) were the first to discuss them at any length. They described five clinics (Jacksonville, Florida; Los Angeles, California; New Orleans and Shreveport, Louisiana; and New York City). Of the five, only one, the Shreveport clinic, was described in any detail. This was surprising, because Terry himself had been the director of the Jacksonville clinic. Even their treatment of Shreveport lacked depth and real detail, which was particularly surprising since there existed considerably more data about Shreveport than the others. Perhaps the authors were being too cautious, too careful, to show their "unbiased scholarship."

Since then, most writers have been content to rely upon Terry and Pellens or on the negative propaganda of the Narcotics Bureau (US Treasury Department 1953) with two exceptions — Alfred Lindesmith and David Musto. Lindesmith, in his book The Addict and The Law (1965), traced the yearly reports of the Federal Bureau of Narcotic and Prohibition Units of the Internal Revenue Service and came to the conclusion that the clinics were closed when the Prohibition Unit took over the Narcotics Bureau and set a new policy as regards clinics. More recently, David Musto, in a painstakingly thorough documentation of the Narcotics Bureau's records and files, has come up with a critical presentation of the Narcotics Bureau's perspective of the clinics and their effort to close them. Also, in his book The American Disease, Musto presents new data from original sources that sketch the New Haven, Connecticut, clinic. Like many others, the New Haven clinic had been dismissed as being another failure. Musto found evidence that it was hardly that:

The Police Department clinic operated from August 1918 until September 1920.... No scandal seems to have been associated with the clinic, doctors, pharmacists, or mode of operation, and, in fact, it received high commendation from Agents [of the Narcotic Division of the Internal Revenue Service] Forrer and Lewis in 1920. Its only fault lay in that it violated the Harrison Act by providing addiction maintenance [Musto 1973:178].

New Data

Both studies suggest that there were original data and materials that have not been used. Indeed, this turned out to be the case when Dr. Ester Blanc, a medical historian working for Scientific Analysis Corporation (a non-profit research corporation located in San Francisco), decided to explore the possibility of doing a large historical study of the methods of treating addiction. One of her first efforts was to interview Dr. Jacob Geiger, a famous public health officer. Dr. Geiger is an international figure in public health. He has received 43 different honors and awards from foreign governments, published more than 200 articles, taught at the Universities of Chicago and California, and was San Francisco's Public Health Director for 20 years. Geiger told Dr. Blanc that Dr. Willis P. Butler, the Director of the Shreveport clinic, was still living in Shreveport.(1)

Dr. Blanc and Martin Orlick wrote and telephoned Dr. Butler shortly thereafter, and found out that he possessed medical records of patients of the old clinic and numerous letters and reports which would help describe the clinic operations. He granted us permission to use this material, and two of the authors went to Shreveport to review the materials and interview Dr. Butler.

Acknowledgments

The original idea for the study came from Dr. George Challas of Scientific Analysis Corporation in San Francisco, California, at one of the many stimulated and stimulating discussions held there. Dr. Ester Blanc of the University of California Medical School (with co-author Martin Orlick of Scientific Analysis Corporation) took up the idea after that, and did the original detective work to locate Dr. Willis P. Butler. Once found, Dr. Butler was most patient through all of our questions, and kind enough to give us permission to use his many records. Meme Clifford of Facts on File in New York diligently edited the first draft and helped to make it more readable. The Authors wish to acknowledge with sincere appreciation the support of the Drug Abuse Council which provided financial support for the investigation and publication of this report.

Introduction

Dr. Butler is a very gracious, charming, white-haired, 85-year-old man who likes to talk. He was pleased to recount the experiences of the clinic, and we interviewed him for approximately 34 hours over four days. All but ten hours were tape recorded. These interviews provided new information about the history and operation of the clinic.

The medical records provided by Dr. Butler consisted of a single page or cover sheet that summarized the patient. These records were in four different forms. The first was a narrative report that included the patient's name, address, sex, age, marital status, ethnicity, occupation, income, the reasons for initial addiction, length of addiction, the amount of drugs claimed, and the amount of drugs given. Actually, there were only ten examples of this form because once the clinic started full steam, a standardized form was developed. This second form incorporated the original data from the first form, plus other items such as the number of times previously treated, location of that treatment and the reason for the failure, etc. At the bottom of the form was a section for remarks which often included pertinent data about the patient-such things as his present condition, advisability of undergoing detoxification, when detoxification was undertaken, etc. The standardized form went through two other slight revisions that added several more items of data. Each form was also numbered and dated.

This data is available for 762 patients, or approximately two-thirds (62%) of the 1,237 patients that Terry and Pellens said attended the facility during its history. Reviewing these records, it is difficult to tell which are missing or excluded. Numbers for the records run consecutively and correspond with the dates appearing on the sheets. Low numbers appear during the first months, and high numbers toward the last months the clinic was open. The majority of patients appear during the first two years of the clinic's operation. The numbering system shows that 460 patients attended the clinic during the first year. This corresponds roughly with the 489 figure cited by Terry and Pellens; after that point, the correspondence between the numbering system and their data breaks down. Terry and Pellens say that 542 patients attended the clinic in 1920, and the numbering system shows only 378. Terry and Pellens' final total was 1,237, while the last numbered record was 762, dated January 23, 1923 (a month and a half before the clinic was closed).

Records also appear under every letter of the alphabet, and we were not able to detect any systematic exclusion. Both young and old addicts appear, rich as well as poor (a rich oil millionaire is listed, as is the mother of a city official and the owner of a large dry goods store). Persons given alias names (to protect their anonymity) appear just as those who did not use them. The reasons for the discrepancy of the number system and Terry and Pellens' data has not been resolved to our satisfaction, nor has Dr. Butler been able to clarify the problem. Dr. Butler is a very meticulous man, and one would expect that records would have been kept current and up-to-date under his supervision. During the time the clinic operated, the records were reviewed at least six times (three committees of physicians and three full scale investigations by the Narcotic Division of the Internal Revenue Service), and there were never any problems with the records at these reviews.

It is our opinion (and we want to be careful to qualify it because we are doing a historical study and a lot can happen to records in 50 years) that these face sheets were not made for most transients or persons undergoing detoxification immediately after starting the clinic. We expect that the records we examined are for long-term patients who were maintained for relatively long periods. We also know that a separate registry of dosage and payments was kept by the clinic, and conjecture that perhaps Terry and Pellens used that for their count rather than the numbering system of the records.(2) These explanations seem reasonable. One could expect that detailed records would be kept for long-term patients, but not necessarily for persons who made one or two visits to the clinic. At the same time, no detailed record would be necessary for persons who underwent detoxification immediately, because they received opiates for only a short time. The records of dosage and price might have been adequate for short-term patients, and satisfied the various investigations.

As stated earlier, we do not know exactly who were included in the records, but that the numbering system appears to be consistent and reasonable. Until we know better, and we do not know that we ever shall, we will presume that the records are for relatively long-term patients. More than likely, most transients were excluded, as were persons undergoing immediate detoxification.

Medical records tell only part of the story of Shreveport. The real story of Shreveport comes from the man who ran the clinic, and, from public and private records of the time. Dr. Willis Butler was a product of Northern Louisiana and Shreveport. Born in Gibsland, Louisiana, in 1888, he moved to Shreveport when he was 11 years old. As a boy he was quite aware of the problems of addicts. Working as a delivery boy for a pharmacist, he delivered drachma (half-ounce) bottles of morphine to customers. He graduated from high school in 1907 and went to Vanderbilt University the same year. His family was by no means rich, and he worked his way through medical school. Upon graduation in 1911, he was offered a teaching position at the university, but had to decline because he needed more money than the job offered. Returning home, he worked for a summer as a country doctor in one of the oil fields north of Shreveport. That same year he took a job as chemist and bacteriologist for the city's Board of Health. Five years later, he was selected by the Parish Physician and Coroner as a possible successor, and won his first election to those joint offices.

As Parish Physician and Coroner, he assumed responsibility for dealing with problems of public health. Dealing with the problems of addicts and addiction was only a small part of that job. At the same time that he supervised the clinic, he also ran a venereal disease clinic, supervised water and milk supplies, and cared for the mentally ill and prisoners in the county jail. The experience with the narcotics clinic, including its eventual closing, had little, if any, effect upon his professional life. During both 1920 and 1924, he successfully ran for re-election as Parish Physician. He held this position for 48 years.

After the clinic closed, Dr. Butler became interested in forensic pathology. During summers, he attended Cornell and Rockefeller Universities and worked with Dr. Milton Helpern in the New York City Coroner's Office. This eventually led to national recognition as he served in many national associations — the American Public Health Association, the National Association of Coroners, the American Society of Clinical Pathologists, the College of American Pathologists, and the American Academy of Forensic Sciences.

In Shreveport, Dr. Butler owned and operated two laboratories, served 12 four-year terms (48 years) as Parish Physician and Coroner, and was president of the Shreveport Medical Society and the Louisiana State Coroners' Association. He has earned and gained the esteem of both his colleagues and the townspeople. Dr. R. T. Lucas, a well-known pediatrician in Shreveport who has known Dr. Butler for over 50 years, said:

Dr. Butler had the full confidence of the public, the medical and legal professions [when he ran the narcotics clinic] which he rightfully earned. There was, and is, no more respected a man in town than Dr. Willis P. Butler.

Today, Dr. Butler is an energetic and lively man, looking forward to a new working career. In 1961 he retired formally as Parish Physician but kept up his interests in his profession by serving as an expert witness (as a pathologist) in numerous criminal cases. Very recently, he has decided to return to work part- time. He was asked to supervise a new blood bank for Shreveport. According to his new employer, "He is the only man in town who could do the job." Shreveport still has a place for Dr. Butler. Despite all the difficulties and the struggles to keep the Shreveport clinic open, his reputation never suffered. On the contrary, he seemed to grow taller with all the adversity. Certainly his reputation has grown — both locally and nationally.

Dr. Butler's story of the clinic is unusually balanced and objective. In general, the important features of the history of the clinic are supported by letters and documents from the period. Many were provided by Dr. Butler from his original files of materials — these include mimeographed reports of the clinic, letters, and records of the proceedings of the Shreveport Medical Society. These documents were supplemented by newspaper reports of many of the events of the history. The struggles of the clinic to stay open were important and timely news to Shreveport, and newspaper reports were detailed and extensive.

Unfortunately, time has taken its toll on the other actors in the Shreveport drama. All of the staff of the clinic are dead and none of the patients known to be alive. Ideally, we would have wanted other points of view and other recollections as well as Dr. Butler's, but this was not possible. Fifty years is, in the case of the clinic, a long time.

Very briefly, the form of this report will be as follows. In Chapter 1, we set he Shreveport stage and then describe the history of the clinic. Chapter 2 consists of an in-depth analysis of the 762 patients for whom we have records. This analysis is largely demographic, but it also reveals much of the functioning of the clinic. Chapter 3 deals with the specific methods and procedures of both the clinic and detoxification hospital. Finally, in a brief summary we attempt to relate our findings to some important contemporary issues, namely, the feasibility of drug maintenance.