The Search for Rational Approaches to Heroin Use

Almost any discussion of nonmedical drug use in this country stirs up powerful and often irrational emotionalism. This instant, pointless passion may well constitute the most severe aspect of dealing with the problem. Of course, one man's excessive emotionalism is another man's rational statement, and we may have to plunge on at high decibel levels for some time to come because we can document as truth very little about nonmedical drug, especially opiate, use. However, perhaps by noticing that the excessive fear and hysteria that surround the issue significantly complicate and distort the problem, we can begin by searching for areas on which people with different points of view can agree.

In this chapter, I will report my experience with the English system of heroin control and its implications for the arguments against the establishment of an experimental heroin induction clinic with the hope that areas of agreement can emerge.

In order to begin to have an argument, there must be mutual agreement about at least one basic premise. I am presupposing that heroin addiction is not a monolithic syndrome. That is, no single group of people exists who all choose this drug for roughly the same reason. Rather, several groups of people with widely differing motives have selected the same answer. Different types need different treatments, so we will have to isolate the groups and find out what is the most felicitous manner of working with each. This assumption per se is not highly controversial. Dr. Jerome H. Jaffe, Director of the Special Action Office for Drug Abuse Prevention, and a powerful advocate of this idea, has insisted that most of the addiction treatment programs supported by his agency have a multiplicity of services available. This means that the program must provide a variety of treatment and rehabilitation resources so that addicts can expect individualized responses to their problems.

We might hope that such a rational position would demand that all preventive, treatment, and rehabilitative possibilities be explored. Then multi-modal, the term in use for a variety of services, would include every approach that has shown itself to be useful. Unfortunately, it has not turned out this way. Different experts have anathematized different approaches, and our basic, rational premise has been thus ignored.

Among the many difficulties in conveying how programs with addicts work is the use of jargon to standardize treatment. "Give methadone to addicts," for example, deindividualizes and dehumanizes both the person who receives the drug and the dispenser. Anyone who has worked with drug users can tell you, usually with some despair, how different in his values, idiosyncrasies, troubles, and itches each is. Nevertheless, the public continues to think in monolithic terms. Besides the extent to which this attitude degrades the individual addict, it gives credence to the feelings of low-skilled working-class people that "they," the dominant white middle class and their official representatives, want to control and debase the minority groups with drugs. These underprivileged peoples fear that methadone, or any maintenance program, exists for the convenience of the middle class. Then the complexity and individualization of a good working maintenance program gets lost.

Although Dr. Jaffe supports methadone maintenance along with drug-free proposals, he is highly suspicious of any thought of either heroin maintenance or heroin induction. Later on in this chapter I will discuss the Howard Samuels/Vera Proposal (Samuels, 1972) and its critics. Dr. Vincent Dole, pioneer and advocate of methadone maintenance, finds the emphasis on multi- modality almost as difficult to bear as the idea of heroin maintenance. Dr. Judy Densen-Gerber of Odyssey House passionately supports drug-free proposals and equally strongly opposes methadone maintenance; she will accept heroin maintenance. David Roderick, representing many of the ex-addicts who are a powerful political force in the drug field, damns all maintenance proposals as "copouts." Some minority group spokesmen agree with Roderick and contend that "maintenance is a diabolic and systematic plan of extermination of the Black and Puerto Rican people." Operation Helping Hand wrote that accusation.

Before trying to discuss these sharply differing views, I want to describe a recent experience of mine in England. In the 1930's, the US Treasury Department used the Harrison Narcotic Act, a tax measure, as a vehicle to repress opiate use. The Department began by prosecuting physicians whom it contended were largely responsible for the problem of addiction. At the same time, England, under the Rolleston Act (Zinberg and Robertson, 1972), treated the issue as a medical problem and permitted individual doctors to prescribe heroin as they thought the drug was indicated.

For years heroin users were few in England, so the issue prompted few headlines.

Then by the middle 1960's English heroin use began to increase. Although the number of registered users remained small (1530 in 1968 - the peak), the percent of increment was great, resulting in gloomy headlines and national anxiety. The Brain Commission was formed. Since overprescribing by a few doctors was seen as the root cause of increased use, the Commission recommended heroin control clinics, which recommendation was implemented in July 1968. Although individual doctors no longer prescribed heroin, its use remained a medical problem. It was simply more closely controlled and regulated by the state.

Because this new system forced many unregistered addicts out into the open, the 1968 figures showed a large increase. This sudden exposure aroused enormous fears. British newspaper accounts reflected this apprehension. By extrapolating from the rise between 1967 and 1968, one story in April 1969 predicted 100,000 heroin addicts by 1973 or 1974. But the cries were premature. By 1969 no further rise was reported, and 1970 showed a significant drop in both total number of addicts and number of new addicts (Ford Foundation, 1972). There was general concession in England that the program was working. Even the police, who are notoriously afraid of any underestimation of the issue, agreed. Inspector Spears, Assistant Head of Scotland Yard's drug squad, said: "The problem now seems under control" (London Times, 1971).

"Experts" in the United States have watched this saga with great interest. Predictably, they have disagreed about everything: why the number rose in the first place; why it then declined; whether there is anything at all in this that can be applied to the United States experience. During this same 6-year-period, heroin addiction in the United States became an issue of national concern second only to war, with the estimates of rise in number of addicts going from a mean of 150,000 in 1966 to 350,000 in 1972.

In 1968-1969 I went to England to study the new clinic setup. After pondering those same questions, it was hard for me then and it is hard for me now to imagine that we can learn nothing from the British experience. I gathered a number of second-hand reports during 1968-1969 about the transaction between addicts and doctors in charge of the new clinics. Although I had interviews with both, I never sat in on the actual interaction in the clinic setting.

In July 1972, Dr. Martin Mitcheson of the University College Hospital Drug Dependency Clinic kindly permitted me, as a visiting physician, with the agreement of his patients, to accompany him throughout his clinic day. This included observation of his patient interviews. The interchanges began in the traditional fashion of a follow-up medical interview and was characteristic of all the interviews: "How are you doing?"

"Well, Doc, it's been a hard two weeks. My sister had to go away suddenly and I had to see that her kid got into a home. It was rough, Doc, and that last script wasn't enough. It didn't hold me through all that bloody trouble."

Such beginning remarks would set the stage for the rest of the interview. In this case, Dr. Mitcheson probed into the details of how the patient had managed over the fortnight. He emphasized the positive, i.e., he pointed out that since the patient had managed to function in a difficult situation, this would indicate that he needed less heroin for an ordinary time. Mitcheson also asked whether the patient had supplemented his need with street heroin or barbiturates. This the patient stoutly denied. The doctor was particularly severe about barbiturate supplementation and reminded the patient that barbs made him aggressive, which led him into fights and other troubles. The patient described his anxiety during this period and his growing fear that he couldn't make it without more heroin. Mitcheson reassured him on that count, gave him a script for the same amount of heroin he had been getting (60 mg/day) and told him to discuss his problems concerning his sister and her child with the social worker.

Although many directors of drug clinics use Dr. Mitcheson's technique, there are several other methods. One doctor I talked to insisted that he never even mentions the drug during his discussions with patients. He only talks about their feelings and life style. One feature remained constant, however: both patient and doctor regarded the drug problem as a health issue. All of the traditional social rituals, the role differentials, the respective responsibilities of the patient to more or less correctly describe his symptoms and of the doctor to do his part to alleviate them were accepted. I do not mean that addicts in England do not consciously or unconsciously lie to their doctors. Anyone working with addicts anywhere would recognize the naiveté in such an assumption. But the lying, or "distorting," occurs within an accepted social framework that permits a degree of manipulation on both sides. Mitcheson was also manipulating when he pointed out that if the patient made it with 60 mg/day of heroin during a crisis, he might make it with less during an average week. These mutual manipulations do not undermine the sense of trust. The ongoing conflict did not erode this framework. Mitcheson's patient under the English system believed that the doctor wanted to help him despite their mutual awareness of their basic disagreement over how much heroin the patient really needed.

I was reminded at this time of a discussion I overheard between an allergist and a patient in this country about antihistamine intake. It was an almost identical discussion: How much drug are you taking? Does it control the symptoms? If you take too much, does it make it hard to function? Does too little result in discomfort? In this case the patient wanted to try a little less but the physician, fearful of a self-cycling increase in out-of-control symptoms, wanted him to use more: a reversal of the positions in the English interview, but an identical acceptance of the social roles and rituals involved.

Think about what trust means in the doctor/patient relationship to us in the United States. We let doctors stick needles and pills in us all the time. Suppose the physician were sadistic or crazy. Suppose there were no medical ethics or tradition of confidence in his wish to do what he can to help with the presenting complaint. If we did not have a socially regulated understanding between doctor and patient, we would not have a viable health system. A doctor may lecture to a patient for overeating or oversmoking or for not taking the prescribed potion. But outside of this area, he is neither a moralist nor a policeman except where nonmedical drug use is concerned. Here, US physicians dogmatically support the reigning cultural outlook and turn sufferers away. And the basic traditional trusting relationship is permanently undermined.

Look at the history of the free clinics such as David Smith's in Haight-Ashbury (Smith, 1972). Although that group of patients had lost their confidence in the benevolence of our social institutions, including organized medicine, they could reestablish the traditional, socially supported relationship with an individual physician. But first they had to go outside the feared institutional setting. The health-oriented specialist made a special effort to reach people who could no longer trust or tolerate any of the institutions that saw them as enemy deviants.

The mutual trust that was taken for granted in our English interview could not exist between an American junkie and his doctor in a normal social setting. The junkie is seen and sees himself as an enemy deviant. He is, once an addict, at war with society. This includes doctors, social workers, ex-addicts, and everybody else. Whether he was at war before he became an addict is a moot, much debated, point. Probably some addicts were but many were not, including some returned Vietnam veterans.

Since we presently lack the underlying trust that permits the addict a confident relationship with a doctor or a doctor surrogate, we cannot adopt the English system. Much of that system is actually inadequate. The English have too few services for rehabilitation and counseling; drug- free situations are more poorly financed (as are most services there); and oral methadone has been underexploited. But certainly all addicts should have someone in this society with whom they can confidently, if not openly, interact. Whether this someone is a doctor or not is immaterial. We have made a few great advances: The addict who is sufficiently motivated to make it on methadone can feel comfortable in a methadone clinic; those who wish to strive to be drug free have a place to turn. In New York City, the methadone and drug-free facilities are approaching sufficiency, that is, they can care for those who wish to or are able to use these forms of treatment. Yet no one believes that all or even most addicts have any place to turn to keep them related to society. What about this hooked majority? To reach all the rest of these addicts we need more and different approaches, one of which may well turn out to be the use of heroin itself.

Some segments of the black and Puerto Rican communities will neither discuss nor consider the implementation of any use of heroin. This is obviously powerful and important opposition. On July 20, 1972 (New York Times, 1972a) Congressman Rangel, an acknowledged spokesman for this point of view, said that heroin maintenance was "an effective technique for keeping Spanish- speaking and black youth immobilized." Most of the statements on this issue have the same hyperemotional quality. They are full of words such as enslavement and genocide, and they are very serious. It is, after all, an inescapable fact that for at least the last 40 years these communities have suffered grievously from addiction. Yet the history of opiate addiction in this country does not bear out a convincing conspiracy theory against either blacks or Puerto Ricans. Meritricious references such as the one in the movie, "The Godfather," wherein white thugs set out knowingly to addict blacks for profit, but decide to protect the white community, badly distort the facts.

Until the unexpectedly vigorous enforcement of the Harrison Narcotic Act, opiate addiction in the United States was a rural problem. That enforcement dried up opium supplies in the rural United States (O'Donnell, 1969). Then those poor souls who could not easily make the shift to alcohol headed for urban seaports where they could obtain an illegal supply of heroin. The rural drug users quickly merged with the poorest, most deprived and suffering parts of the urban population, which included the immigrants. The population most at risk has always been the children of immigrants. Blacks moving from the South to urban seaports became part of that frightened, dispossessed group. Blacks then constituted the largest single group until the Puerto Ricans arrived. The lure of heroin and the resulting oblivion are natural temptations for this underprivileged potpourri of people. The conspiracy theory is a myth.

If no conspiracy exists, why do these groups fight tooth and nail against proposals that are in fact intended for their chief benefit? They are terrified of an epidemic theory. This view equates addiction to an inevitable spreading disease, its seductive attraction as inescapable as the plague bacillus. It sees the rise in the rate of British addicts during the mid-1960's as directly related to drug availability because of overprescribing. That is, the deadly "germ" was put into the air.

The proponents of the infectious disease theory reason as follows: Yes, the English clinic system offers greater controls in that almost all addicts and the amount of drugs prescribed are now known. However (at least until the last few months), it has knowingly shut its eyes to a limited oversupply in order to keep a "gray" market going that would preclude the development of a black market. Most of the clinic doctors knew that many addicts, when things were tough, needed a little more. Then when things were easier, the addicts could spare a little. The doctors also recognized that this wheeling and dealing among the addicts was not pushing in the classical sense, but was a kind of group activity, almost occupational therapy. Because under the clinic system some illicit heroin, or later, methadone, was still available in England, proponents of the epidemic theory would expect to see a continued rise in overall use and particularly in new addicts. They cannot explain the subsequent drop in British heroin use under the clinic system. Today, some British research projects on drug use are even being held up because not enough new addicts are available to form a sample.

There is no consistency to the ratio of heroin availability and its resultant use. In Vietnam heroin use spread rapidly among servicemen; yet in Thailand, where it was even more readily available and cheaper, the rate of use was very low. The New York Times Magazine recently quotes Dr. Nils Bejerot (Markham, 1972), a Swedish psychiatrist, whose prescription for addicts was published in August 1971 in the Israel Annals of Psychiatry. He would "arrange for them in the best possible way, on some pleasant 'drug island' where they are allowed to live in peace with their addiction." Dr. Bejerot managed to discuss the Swedish amphetamine problem without once mentioning the continuous Swedish struggle with addiction, particularly with alcohol, which is one of the worst in the world despite considerable repression and a welfare state. The infectious disease thesis is insoluble. Different social and psychological reasons account for the rise or fall of a drug in a particular country at a particular time. It is impossible to "prove" anything.

We must try to understand the myriad "why's." Does everyone wish to be an addict? Is heroin so powerful or so pleasurable that it is irresistible to most youngsters? The answer yes does not fit what we know about opiates and about addicts.

About 10 years ago and long before the present panic, Dr. David C. Lewis and I published a study of opiate use in the New England Journal of Medicine (Zinberg and Lewis, 1964; Lewis and Zinberg, 1964). This study examined six groups of repeated users. One group used little or no opiates but pretended to be addicts because they cared about the life style. A second was addicted to needles rather than the drug; they liked to stick things in themselves. A third was addicted to a particular person, sometimes a doctor, lover, or relative; the drug was secondary. A fourth was severely self-destructive and developed serious physical symptoms or depression. To them the drug was important only as an alleviation. Although a fifth used opiates regularly, they continued to function and did not develop overwhelming tolerance or an abstinence syndrome. It was relatively easy for this group to be self-regulating and to keep their doses low because many were doctors, doctors' wives, or nurses, and had easy access to their drug. Only the sixth group exhibited the stereotyped addict career complete with craving, growing tolerance, and a great fear of withdrawal. The great increase in addicts over the last few years has not refuted this work. In fact, the confirmation that addicts differ in personality and motivation is growing. Although most of the people in our study were in serious trouble, little of it was directly related to the drug. If their favorite - heroin, morphine, Demerol, methadone, barbiturate, or amphetamine - was not available to them, they could and would use another.

Of course a fraction of our population is in serious trouble. But this has little to do with a drug epidemic. Although that fraction will drug itself with something, the drugs are not the problem. Why do we persist in the belief that most of us are at risk? Why do we so overestimate the charismatic power of these drugs?

I recently collected a sample of 100 patients who entered a general hospital with a serious specific (i.e., not psychological) medical or surgical problem that required regular dosing of opiates for 10 days or longer with doses far higher than can be obtained using street drugs. Once their pain receded, only one recalled having any wish for an injection of the drug and that happened when he thought his condition had recurred.

And why do we so overestimate the extent of the pleasures from drugs? Is the effect of heroin as euphoric or orgiastic as we have been led to believe? Let us approach this issue in reverse. We were told in the past that a drugged state was completely enthralling both physiologically and psychologically. Withdrawal, therefore, was almost unbearable. "The Man with the Golden Arm" substantiated this thinking. Addicts were terribly fearful of withdrawal. But this myth began to be exploded once any group paid serious attention to addicts. "The Concept," a play put on by residents of Daytop Village, all severe ex-addicts, stated sharply that much of heroin withdrawal (barbiturate withdrawal is another matter and deadly) is psychological. Drug withdrawal in Vietnam then proved beyond doubt just how exaggerated was our previous view of the stranglehold heroin had on people. Many enlisted men withdrew themselves before leaving that sad country. Formal rehabilitation units withdrew men cold turkey on an outpatient basis. Some of these had enormous heroin habits. We already knew from the work of John O'Donnell (O'Donnell, 1969) and others that many heroin addicts at some point give up their drug voluntarily. Then they turn to alcohol. Even during their addictive period when they spend their time in jail or hospital, or have to cope with the problem of being broke, it is more on-again off- again than we had supposed.

We have surely overestimated the seductive power of heroin. We have also given it more credit for pleasure production than it deserves. I think that most straight people cannot understand the motives of addicts. In an attempt to comprehend, they imagine reasons that would be true for them but are probably not true for addicts. Straights know that it would take something incredibly wonderful to make them stick needles in themselves and risk their health and freedom. But these straights do not become addicts.

When I was discussing the heroin high with an enlisted man in Vietnam (Zinberg, 1972a, b) who used a great deal of heroin, I told him that I did not think I would like the experience. He said, "That's because you can leave. You're not in pain." Since then many soldiers and other addicts have echoed those same words. The truth is that heroin is not a drug of pleasure. It reminds me of that old joke: "Why do you beat your head against the wall?" "Because it feels so good when I stop." Under the influence of heroin, a person goes a long way away in his head. He sinks down a long tunnel where he can watch people, including himself, moving around swiftly and rather aimlessly. Sometimes the user loses interest. Then he slips away, drifts off, from all that activity. But if he wishes, he can pay attention. He can tell the foolish experimenter whether an object is sharp, very sharp, blunt, or a feather. The "pleasure" comes from the drug's capacity to move a person away from pain. In the case of an IV (intravenous) shot, the "tunnel" entrance appears almost at once. Hospital patients as well as junkies describe the blessed relief from physiological or psychological pain that comes from derivatives of the poppy. But this relief is not pleasure; it is cessation of pain.

How can we therefore preclude the infectious disease theory? After all, are not many of our people, particularly our poor, in pain? Yes, they are, but they are in life too. And heroin's metaphorical thickening of the walls, the erection of that long tunnel between the user and life, including the people in life, is a price too lonely for most people to pay.

The proponents of the infectious disease and conspiracy theories are still with us, however. One of their myths used to surround an evil pusher who hung around schoolyards seducing youngsters by a free sample into the hideous thrall of addiction. This facet of the conspiracy theory has been astonishingly tenacious without any evidence for it. I think it has survived so long because straights have wanted personally to understand why anyone would take this drug. Hence, they dream up ignorance and seduction. The modern version of the same myth lurks in the amoral peer who cannot wait to induct his ignorant friend into the mysteries.

It is true that most new addicts do become so through the ministrations of a friend. It is harder to get and use heroin than straights imagine. Many returned Vietnam veterans have discovered this fact. Certainly a kid in the ghetto has more access to drugs than a middle-class kid who has to go to an unfamiliar and hostile part of town to make a connection. But even the ghetto kid needs more "scratch" than he usually possesses and he must find out what the going price is. Then he must learn how to use the paraphernalia of injections, to cook up a shot (even for skinpopping), and to find veins. Although these are not overwhelmingly difficult procedures, a supportive mentor is generally required.

Certain charismatic types naturally make better teachers than others and these are sought out by neophytes. I have interviewed several such addicts who have admitted starting people off on the junkie trail. Without exception, they spoke of their reluctance and told me how many they had talked out of continuing. At first, I thought such tales reflected most addicts' inability to face reality and their own lives. They would wish to invent a less destructive world. And addicts are often terribly guilt-ridden people. I have been following up a sample of "chippers" (occasional users), however, and I find that more addicts try to talk them off heroin than on. A standard horror tale concerns the wife or girlfriend who more or less unwillingly becomes an addict and then a prostitute simply to be close to her addict consort. But my work shows a greater number of couples where only one is an addict - this is true of alcohol addiction as well - and the other strives valiantly and unsuccessfully to help. How can the contagion theory explain these couples?

A recent study by Leon Hunt (Hunt, 1972) goes even further. Hunt suggests that only during the first flush of drug use, perhaps even before addiction, will an addict act as mentor. If this is true, as I believe it is, using civil commitment, quarantine, preventive detention, or whatever to isolate addicts may help with crime. But isolation will not help contain the spread of addiction, which is, after all, the chief aim of the quarantine concept.

The next move would be early detection of addicts, which means compulsory urine testing in the schools, on the job, or in the vestry. Analogies to smallpox vaccination and tuberculin tests assume an infectious disease model of addiction. This model ignores the complex social and psychological considerations that are inherent in the victim who seeks out the drug "disease." Should this disease model be accepted, the problems of assembling on a national scale the apparatus for such testing and the implementing of it seem insurmountable.

Of course, we could select high-risk areas to try out these procedures. Such areas would not only have to endure the loss of civil liberty and the self-incrimination that is implicit in the existence of compulsory urine testing, but also they would have to deal with the issues of confidentiality, hassles about the correctness of the urine findings (at this stage, at least, they are often inaccurate.) And finally, what would we do with "tainted" urines, once found? Would we automatically quarantine all people thus identified? For how long? Should we differentiate between exposed heroin addicts and barbiturate users? How many antagonists to how many drugs should they receive? This last is no trivial question. So far the toxicity of antagonists may be greater than the initial drug, and in themselves habit forming. Are all or any of the proposed "treatments" involuntary at all stages? And so on.

One of our greatest misconceptions lies in the belief that users and pushers are legally, morally, and socially separate. The key question is who seeks out whom; the key word is "ignorant." In my interviews with opiate users, both here and in Vietnam (Zinberg, 1972), the users have acknowledged that they sought out someone to teach them. They wanted to use heroin and in most cases outside Vietnam, despite some half-hearted denials, knew that they wanted to get hooked. Almost all of these users admitted that they had pushed their mentor to teach them. They were not ignorant about the drug, but hoped to learn more. One of the army's more naive educational campaigns in Vietnam was built on its belief that soldiers did not know that the white powder being offered them was heroin and not cocaine. When I asked soldiers if they had ever thought it was cocaine, both users and nonusers guffawed. This campaign was based on the typical straight belief that nobody would knowingly seek out "shit."

If they had no faith in either the conspiracy or infectious disease theory, the minority groups would lead the participants and exponents of treatment diversity. On every count minorities are most injured by addiction. According to arrest figures, individual black, Puerto Rican, and Chicano users are consistently more harassed by police agencies (New York Times, 1972d). Although heroin causes little if any primary physiological damage, hepatitis, infections, and debilitation come from dirty needles and the other derivatives of its criminal status. Minority groups are physically more harmed by these secondary physiological consequences of addiction and have less access to good medical care. Psychologically, it is harder to measure the harm that results from addiction for we know so little about the various psychic states that drive someone to crave it. If we could calm the minorities' irrational fears of epidemics and contagion, both the individual and his community would surely treasure any treatment that offered addicts a chance for a functional life that avoids the constant harassment of police and illness.

In the meantime, as this interminable discussion continues, the age of users sinks lower and lower. Again, in such a charged atmosphere, even this terrifying fact is not dealt with rationally. First, many investigators have found that it is exaggerated. For example, when a proposed adolescent treatment program in New York considered beginning their operation in collaboration with one high school, it was assumed that most of the dropouts left because of drugs. When 25 dropouts were followed up - no easy matter to track them down - it turned out that 4 had a drug problem (Danaceau, 1973).

Although this is a high percentage, it is nothing like what had been expected. The other 21 had serious troubles with the school and chose truancy for social and cultural reasons. It is true that many of those 21 are at risk as far as drugs are concerned. But to label them already drug users implicitly or explicitly, by way of newspaper headlines or what have you, surely increases their risk. Comparing their friends to a plague and giving the dropouts little hope of escaping the disease opens the psychological door to heroin for some of those 21. Furthermore, it discourages rational and realistic approaches to their real difficulty, which is connecting with a school that does not understand their language, perspectives, or values. Labeling them all carriers of an infectious disease gives the problem a false clarity that can easily become a self-fulfilling prophecy.

We know that the heroin trade thrives on economic exploitation. As a result of the illegality of the drug, a small group who are willing to chance getting caught are granted a virtual monopoly. And the law enforcement agencies "cooperate." They restrict the supply so that the illegal operators can set an exploitative and inelastic price that guarantees them enormous profits. Given the powerful addict-consumer drive and the restricted, expensive supply, the result is not surprising: customers turn criminal to pay the price.

How much addiction is directly responsible for how much crime is another area of great disagreement. The extent of the influence of addiction on police corruption, however, certainly hurts the minority groups most (New York Times, 1972e). The numbers game in all these matters leads inevitably to the "liar's figger" reaction. Each side quotes figures that are diametrically opposed. And both are partly right. Undeniably, addicts steal to support their habit. A recent Massachusetts survey estimated that addicts were responsible for 88%, or $127,500,000, of the property stolen in that state (Buckley, 1972). The extent to which they are responsible for terrifying, assaultive crimes is far less documented. But many addicts were surely stealing before they chose addiction. And we cannot assume that they would stop once they were off drugs or stabilized through some inexpensive legal regulatory dosage.

Although we cannot gauge the potential drop in the quantity of crime if the direct link between crime and addiction were severed, the nature of the crimes would almost certainly change. Generally speaking, addict stealing is uncontrolled and irrational. I picked up the Monday, August 28,1972 New York Daily News (New York Daily News, 1972) at random. In that paper one story told of a subway assault by an addict for no profit and another of an assault by a 17-year-old user on a 76-year-old woman for her handbag within sight of a policeman. Of course, addicts try to take things they can resell, but they do so helter-skelter, as quickly as possible. And they take extraordinary risks because they care little for themselves and a great deal for the few quick bucks that can be translated into a fix. It may seem strange to speak of stealing as rational or irrational. But rational crime carefully balances the risk against the gain. This type of crime can be guarded against and can be understood by its victims. Irrational addict crime leaves chaos in its wake. Its victims see this frantic rampaging as senseless representative of a growing breakdown in the structure of society and its institutions of social control, such as the police and the courts. They cannot understand such crimes.

This is particularly true in the black communities where addict crime is common. Addicts like neither to travel nor to take the time for the fattest pickings. They usually operate close to where they live and to where they can make a connection. Hence, ghetto communities are terrorized. One of the saddest byproducts of this victimization surfaced recently. Residents of a black community were asked what prevented them from attending community meetings aimed at improving a variety of local conditions including the use of the neighborhood as a "shooting gallery." Many stayed home because of their fear that junkies would either break in, if they were out to an advertised meeting, or mug them in the street (Packer, 1972).

If addiction is an infectious disease, its victims must be quarantined to prevent its spread. So reason the adherents of the epidemic theory. Then this false concept of prevention drains all the energy and money from valid clinical research or treatment programs. In fact, it operates ideologically against them. For who can consider supporting small, carefully structured programs such as the Vera proposal when a plague threatens society? Advocates of the epidemic idea wish to remove the diseased victims from our vulnerable, healthy atmosphere. Quarantine is a euphemism for the arrest and confinement of addicts simply because they are addicts. Were it not so serious a matter, it would be amusing to hear Senator James Buckley complain to the Senate about heroin maintenance: "... thousands of persons being totally dependent on the Government" (Congressional Record, 1972). Would he, I wonder, support incredibly expensive detention centers such as have cost New York state over three-quarters of a billion dollars since 1967 for handling approximately 20,000 addicts altogether and with a census as of this writing of 368? (New York Times, 1972f)

Their expense is a small part of the detention centers issue. If and how they would work are the major questions. So far, all of the accumulated evidence confirms a relapse rate of between 80 and 90% following any sort of commitment for treatment, whether to jails, civil commitment programs, or hospitals. Richard Stephens and Emily Cottrell of the National Institute of Mental Health at Lexington, Kentucky, recently published a comprehensive study that reported an 87% relapse rate (Stephens and Cottrell, 1972). They observed that this rate was identical to the findings of earlier studies. Long-term, continued surveillance involving parole or outpatient treatment cuts that figure only a little.

To understand this persistent relapse rate, we must further explore the nature of addiction in the light of two popular explanations. The first relies on a biochemical concept, which assumes that the individual had a preexisting defect of some sort, such as a thyroid deficiency. This defect is corrected by opiates and allows the user, for the first time in his life, to feel whole.

Followers of the second explanation, a metabolic disorder concept, think that a cycle of heroin addiction somehow changes the body metabolism either permanently or for a much longer time than any usual idea of detoxification. To rebalance the metabolism, heroin or another opiate is the only relief. Vincent Dole and Marie Nyswander (Goldstein, 1972) developed the methadone maintenance procedure based on the idea that this long-acting, orally effective drug would "correct" the metabolic deficiency without the many accompanying problems of heroin: illegality, need for injection, highs and lows, and so on. As my initial premise stated, addiction should be looked at in many ways, so the above descriptions may well apply for some addicts. The English addicts who bargain for more heroin "medicine" and who insist then and only then can they function "normally" make beguiling examples to reinforce the metabolic disorder theory.

Nevertheless, most addicts do not seem to fit in the metabolic mold. A surprising number of addicts, when put into a protective environment, such as a hospital, jail, or a therapeutic community, once detoxified, do not report the overwhelming drug craving that exponents of the metabolic disorder theory would expect. Indeed, this resultant comfortable functioning is one of the arguments advanced by believers in the infectious disease theory who want to lock addicts up.

Avram Goldstein of Stanford, an outstanding pharmacologist, is now working exclusively on the psychopharmacology of opiates. Dr. Goldstein supports a behavioral conditioning theory which, for once, does not conflict with a dynamic psychological explanation of addiction and of how opiate maintenance works (Goldstein, 1972). He points out the similarity between a withdrawal syndrome and a classical anxiety attack: sweating, weakness, chills, gooseflesh, nausea, and vomiting. Dr. Goldstein has observed addicts self-administer the drug after experimenting with many other ways of extinguishing anxiety. These individuals use it to quell an overwhelmingly painful stimulus. A set is thus developed. Certain specific behavior, i.e., the atmosphere of a certain neighborhood, certain people, or a specific act (the fixing ritual and injection), stands for relief of the painful stimulus. Notice that it is the behavior within a given set that essentially relieves the anxiety. The drug is secondary. This explanation thus deflates the metabolic theory.

Many addicts, observed by police and others, report that they develop a withdrawal syndrome immediately after using heroin if they find themselves in it situation, such as a jail, which they associate with withdrawal. And conversely, in a hospital setting many addicts declare that the opiates there do not "work." I have seen addicts after a while become paranoid and insist that they are being fooled and are receiving a placebo. (Unfortunately, their suspicions are sometimes true. Fooling addicts is a game that some doctors play in order to test addicts' powers of observation.) I am referring to situations where the addict does receive what he is told he is being given. The addict soon discovers that the "cure" for his disease, anxiety, is only temporary. The anxiety returns after the medicine wears off. What is worse, his response to the loss of his medicine is a redoubling or more likely, multiplying of the original anxiety symptoms. It is thus only reasonable for him to experience a compulsion to seek and use heroin.

Goldstein postulates the possibility, chiefly based on animal experiments, that heroin reaches a specific reward center in the brain (Goldstein, 1972). Although that may be a part of the explanation, it is not a necessary one. Anxiety hurts. Those unfortunates who either live in the anxiety pit or who are unusually sensitive to the bite of its snakes know how much anxiety hurts. The extent of their discomfort causes them to seek out the heroin "cure." Leon Wurmser of Johns Hopkins (Wurmser, 1972) and Edward Khantzian of Harvard (Khantzian et al. 1973) have recently agreed that many addicts in this country use heroin as a form of self-treatment, and not at all as a vice or for antisocial purposes.

Most humans have the capacity to tolerate a good deal of anxiety. Animals may or may not have such a capacity. Some people do not have adaptive mechanisms at their disposal (animals in captivity certainly do not). They therefore arrange life situations that are less likely to stimulate pain or they select activities whose positive attributes balance it. Methadone, like heroin, reduces intolerable anxiety. When injected, it apparently works as well as heroin although it lasts longer (more about the although later). When taken orally, methadone may not be quite as effective in reducing anxiety. This may account for the heroin-seeking forays by some persons in methadone programs. They quickly learn, however, that methadone will stave off the secondary anxiety-like withdrawal syndrome.

Without the protection of maintenance, individuals who cannot deal with anxiety invariably relapse into heroin use. Those who have not been thoroughly detoxified, and Goldstein suggests the total process may take from 6 months to a year (Goldstein, 1972), can be frightened of an impending withdrawal syndrome or set off by any stressful incident. Then they blindly seek a fix, often without forethought or previous motive. But what about those who, under our current system of punishing addicts, have been incarcerated for a long period of time and are to the extent of our present knowledge entirely detoxified? They, too, return to their heroin use in an astonishingly short time after release either from jail or a US Public Health Service hospital. This can be explained by a simple behavioral conditioning model. The detoxified addicts leave the protected atmosphere to return to a less structured life filled with potential dangers. The sight of a friend or a familiar atmosphere revives powerful old memories and sets in motion the series of conditioned acts that ends in shooting up. A dynamic psychological explanation would also take into account the extent to which the addict feels that society sees him as an enemy. When he emerges from incarceration, he therefore enters combat. Also most addicts envision their incarceration as an unjust punishment. They feel "entitled" to their beloved/hated medicine and act accordingly, no matter how irrational this progression of thought may appear to the straight observer.

Let us agree that both the metabolic and psychological explanations are applicable to at least some addicts. Quarantine would surely not work for them. How long would we keep them in "camps" simply for being addicts? Could we lock them up long enough for them to "get over" heroin? Addicts who have remained in jail 5 to 10 years return to their habit within a single day. How would we "cure" them in the camp? Addicts are unrepentant deviants, a group notoriously untouched by any form of therapy. Once we discover a narcotic antagonist that is long-acting, nontoxic, and itself not dependency producing, we will have another form of maintenance therapy. This is supposed to take the "pleasure" out of the high and decondition the addict. But will it "cure" this person's inability to tolerate anxiety? And if it does not, will he not probably seek out other drugs? Barbiturates and amphetamines are both far more deadly than heroin. Alcohol used as a substitute for heroin may also carry greater risks than heroin.

The total cost to the individual of any social policy must be considered. We must first calculate the cost of our current policy. We must then assess the cost of future plans whether these involve the maintenance or quarantine of users.

Until we introduced the concept of maintenance, the current policy of attempted total repression of users was extremely costly to individuals and to society. And it was not working. To buttress our current program, official agencies, led originally by the old Federal Bureau of Narcotics, have constructed myth after myth. When pushers in schoolyards, drug progression, drugs turning brains to jelly, and other tales of horror are not supported by facts, they postulate and publicize others: drugs affect chromosomes; drugs are a contagious disease. Officials go on manufacturing myths such as the chromosome scare long after they are disproved on the self-righteous assumption that "if they have scared one kid off using drugs, it was worth the lie." This blindness to the costs of business-as-usual is unfortunately absolutely typical. The current hope of the new Federal Bureau of Narcotics and Dangerous Drugs is to restrict the drugs at their source; buy up the Turkish poppy fields and thus limit availability of heroin in the United States by interfering with the growth of the necessary plants. This naive plan in our modern world was finally exploded by the report "World Opium Survey 1972," prepared by President Nixon's Cabinet Committee on International Narcotics Control and reported in the New York Times (New York Times 1972c). The report declared that, in spite of our greatly improved and expanded police surveillance, only a "small fraction" of the illicit flow is seized. Since only a few square miles of poppy are necessary to supply all illegal United States needs, the report acknowledges that there are several areas of the world ready, willing, and able to step in as suppliers should we succeed in curtailing the Turkish trade.

Has there been any change in policy as the result of this list of standbys? Of course not. In fact, the money and energy that should support the reassessment of such outmoded policies instead support the fight to maintain the status quo and to squash any efforts at innovation. Maintenance with oral methadone is no panacea, and indeed the need to improve most existing "gas stations" (methadone programs without supporting services, which just hand out the drug) is enormous. Also the issue of how to control the drug used so that it does not leak back to the community as a black market item is important and difficult. But, in general, methadone has resulted in some success. Although figures vary from program to program, they all reflect the progress of individual addicts. Many of those who were previously incapacitated are now functioning in work and life with a concomitant reduction in their criminal activity. Even some programs, such as Phoenix House, which have been totally committed to a drug-free ideology are now considering methadone maintenance as stepping stone to a drug-free state.

Opponents of any form of drug maintenance fear that the addict will be drug dependent for his lifetime and that the addiction will increase rather than decrease. It is easy to understand how some people who fear maintenance and are aware that our present repressive policy has failed offer greater repression as the answer. Our policy has failed, they argue, not because of the repression but because there was not enough of it. Permissiveness (the worst of bad words) will, according to them, create millions of addicts overnight. Now we must round up our addicts, fence them outside society for as long as necessary, and brand them (one plan envisions taking distinctive footprints which, like fingerprints, provide positive individual identification). Not only will this plan not work, but it can be accomplished only through a serious curtailment of individual human liberty. And such a curtailment of liberty will repress the poorest fraction of the population. How can the minority communities consider supporting such political action? It could deprive some of them of their rights to a trial by peers and deny them protection from what is now unlawful search. And it could recognize and possibly punish some addicts for what is essentially a life style or a personality orientation. Yet some of the strongest support for a quarantine program comes from the unlikely alliance of extremely conservative politicians, such as James Buckley, who oppose busing, guaranteed annual wage, and the like, and blacks such as Charles Rangel, who is against everything else Buckley is for.

Those minority group supporters of quarantine must be aware of what the Knapp Commission hearings in New York have shown. Herbert Packer, Stanford Law School professor, pointed out before the hearings that police corruption and discriminatory police practices go hand in hand with criminal laws that try to regulate morality, such as abortion, homosexuality, gambling, prostitution, and drug use (Packer, 1972). Packer used the Knapp hearing findings to show that our intertwining of criminal law with morality precepts in our treatment of heroin use has already led to serious problems for civil liberties. Nine-tenths of the cases that come before the Supreme Court involving an alleged illegal search and seizure are narcotics cases. Proponents of the Omnibus Crime Control and Safe Streets Acts of 1968 and John Mitchell's Organized Crime Act of 1970 relied heavily on the legislators' fears of a heroin epidemic to get the more repressive features of those acts passed. To pass the no-knock entry section of the 1970 law, for example, they claimed pushers could flush the white powder down the toilet if the law's invaders warned them by knocking before entering. Heroin traffickers vied with the Mafia to justify the need for electronic surveillance. Incidentally, these two groups are often wrongly connected. There is little or no evidence of organized crime's direct participation in heroin trafficking. Another potent assault on civil liberties can be found in John Kaplan's (another Stanford Law School professor) estimate that over 50% of those incarcerated under California's commitment laws were Chicanos, who make up only 12% of the state's population (Kaplan, 1971).

Hence, it seems reasonable to expect that if we were to make urine testing for narcotic use compulsory, the schools or districts first in line to receive this honor would be densely populated with minority group members. The proponents of quarantine have assured the public that the control of narcotic use is their sole aim and that the urine testing and footprinting would never be used for any other program of social control. This still sets a dangerous precedent. The decision of an individual to use drugs is a complex physiological, psychological, and social phenomenon. If we can view this as a plague that justifies the suspension of his liberties, it does not seem a great step to the curtailment of other like political and social activities.

Most of the black leaders who rail at the use of heroin in any treatment program also fear that maintenance would divert attention from the root social causes of addiction. Yet they want detention camps, or in public health terms, quarantine, to deal with what they regard as a social problem. Let us imagine that these camps would work, and authorities agree to isolate rather than treat this "infected" minority. Why should this "success" reinforce the desire to alleviate the social conditions that are at least partly responsible for the troublesome minority? It would seem equally plausible that once we found this "solution," we could apply it to other troublesome minorities. Does not political radicalism spread from one convinced advocate to others? And this would let us minimize the "waste" of money to remedy social ills. After all, if things get bad again, "we know where we stand," a marvelously ambiguous phrase made popular by a Massachusetts politician to convey opposition to racial integration without overtly declaring her bigoted policy.

The use of the concept of quarantines threatens both the civil liberties and social advancements of minority groups. A maintenance program offers them chiefly benefits. The addict who willingly chooses maintenance relieves himself of the frantic search for a connection and for the scratch to buy it. If he has any preexisting skills or is personally motivated to learn to do some kind of work, he can make more consistent and regular relationships with people. As straights understand this process of love and work, he should gain in confidence and self-esteem. Society would certify the drug as God's medicine rather than the devil's potion. The reformed sinner would be accepted back into the social fold. Because he is drug dependent, he is still, in my view unfortunately, seen as weak. But he is not "bad."

Since the individual on maintenance is treated humanely, he is less likely to steal from his neighbors, which, of course, helps the surrounding community and the larger society, but in addition, illegal wealth is no longer plowed back into other crime and corruption. Addicts on street dope suffer numerous health problems from adulterants, unsterile needles, and the like. These secondary problems crowd local hospital facilities and spread more prosaic bacterial infections. Maintenance would minimize these mundane health costs. Police would be freed from searching for drugs and pushers to protect communities from non-drug-related crimes. Scarce public monies could be put to other use. In Massachusetts it was estimated that in 1971 the criminal justice system itself spent $9,457,833 on drug-law violators and drug-related property crimes instead of on better lighting, patrolling, faster trials, and more rehabilitation facilities (Buckley, 1972). And it is ironic that all of these are more necessary in the areas where drug use flourishes than in any other. Were we to change our current, expensive, repressive system and put the funds saved into these improvements, think what profit poor communities would reap. And maintenance involves no risk to individual liberty, which risk is inherent in the so-called preventive measures of compulsory urine testing, footprinting, and quarantine.

If we accept the principle of maintenance, then why only oral methadone? From the point of view of the straights, the answers are obvious: no more horrible sticking with needles; one long- lasting dose replaces many disappointingly short ones; the fear of withdrawal abates; and adequate functioning is possible. Since some lethargy accompanies methadone maintenance, this last is a bit questionable. Of course, no straight would become an addict in the first place unless, according to his myth, he were unwittingly seduced into it in the first place. The most avid proponents of oral methadone estimate that no more than 40-50% would willingly stick with that regimen. They recognize that many addicts are attached to the needle as well as the drug and that many crave the quick highs and lows. Remember the British addict who did not "like" methadone even when it was injected? We know that the flirting with withdrawal and the self- destructive life style are immensely seductive for some, particularly if these activities are shared with a special person. And, finally, the addict is justified in feeling that our society has declared him an enemy deviant. How can he trust us to give him a drug that would help him with his pain? Whether he was suspicious of and at war with society before his addiction or whether these feelings resulted from his experience after he chose to use heroin is academic. Many American addicts will so suspect any clinic that represents straight society that they will automatically reject it. But maybe they could trust a clinic that permits them their drug and their needle.

Let us now examine the modest heroin maintenance research experiment proposed by Howard Samuels and the Vera Institute of Justice, and dissect the objections to it. Perhaps in this way we can find a base of rational agreement that will let workers in the field bury their small arms and get on with the job. This proposal is extremely modest (Samuels, 1972). It is intended strictly for clinical research and begins with 30 addicts to determine feasibility. If these results are encouraging, at its height it would only study 100. Only addicts who have demonstrably failed at other treatment modalities including oral methadone maintenance will be accepted into the program. The drug will be made available solely on the premises. The research aims to discover if an American addict can be stabilized on heroin so that he can feel relatively comfortable on a determined dose and can function both psychologically and physiologically. Longer-lasting injectable methadone, when possible, will be substituted for heroin. If he can be initially stabilized, as over 50% of British addicts are, he will be moved within a year from injectable opiates to either oral methadone or a drug-free state. Ergo, this is actually a heroin induction program; it is not simply heroin maintenance.

The money for this experiment will be obtained from research funds. It will not interfere with a single penny of support for existing treatment programs. We need this kind of small-scale expensive research to tell us what is possible with a small group. To quote the Vera proposal, those selected will be "...that group for whom every effort at rehabilitation has been exhausted." Although it is true that the results of this experiment will not necessarily help us to understand how heroin induction would work on a large scale using hundreds or thousands of addicts, many of the objections raised to the Vera program criticize the research for not doing what it has not set out to do. The proposal recognizes that there are two problems: to find out what, if anything, can be done with heroin induction with any number of addicts at all; then to apply on a large scale what has been learned from the first research. One of the most frequent objections to this experiment is that it would not work on a large scale. This may well be true, but it is not a relevant point.

The current overemotional atmosphere lends itself to internecine war over how best to cope with drug users. Opponents of the Vera proposal want something to fight about. If they can find no appropriate objections in the proposal, their commitment to controversy will manufacture some. In exactly the same way, many persons have responded to the Vera proposal as if it proposed full-scale heroin maintenance, which it does not. For example, the Committee on Youth and Correction has stated that "there is no justification for adopting heroin maintenance even on a limited basis as public policy at this time" (New York Times, 1972b). Some persons who really favor heroin maintenance either also oppose the Vera proposal or support it for the wrong reason. It is generally frustrating to have to tell opponents or proponents of the proposal that they oppose or support something that is not proposed. At its worst, this irrational reading of the proposal will prevent this or any other desperately needed effort to develop valid research with carefully evaluated, clinical information about the treatment of addiction. Indeed, it can defeat the whole problem.

James Buckley in the Senate and Congressmen Peyser, Rangel, and Biaggi in the House introduced a bill in 1972 barring any research that would involve dispensing heroin (Congressional Record, 1972). They regard such research as sufficiently dangerous to warrant full-fledged Congressional action. They fear that the government agencies that approve such research, i.e., Federal Bureau of Narcotics and Dangerous Drugs, Food and Drug Administration, Justice Department, National Institute of Mental Health, and the White House Special Action Office for Drug Abuse Prevention, cannot be trusted to safeguard the interests of our individual citizens and our social institutions. It is exactly this sort of hysterical response that makes up the social setting in which drug use takes place. Each escalation of emotionalism inhibits the search for rational approaches; the enemy deviant label attached to the user becomes more real for him and for those sticking on labels; and around we go in a vicious circle. This destructive circle makes it harder and harder to get addicts and citizens to relate within the programs.

At present, the pervasiveness of this varied opposition to any change in the social status quo of heroin and its users is hard to see because many who might react to it are caught up in the struggle for more and better drug-free, methadone maintenance, and other modalities of treatment. The wish to use optimally what is currently available occupies the Special Action Office for Drug Abuse Prevention and other agencies, and offers hope for more addicts than are now under treatment. But remember, no one estimates that more than 50% of addicts can be reached by existing modalities. When this limit is reached, more comprehensive efforts will be expended in desperation. Meanwhile, the unreached 50% may have become more intransigent because of the current limited concept of what is possible. The desperate need to cope with them could result in poor treatment and worse evaluation. The decision not to find out what is possible is not a neutral decision. It is a significant part of the heroin problem.

Any heroin induction experiment must consider what it asks of the addict. Must he suddenly change his life the moment he seeks treatment? The difficulty in giving up everything that has been his life, peculiar as this problem may seem to straights, on the day he enters a clinic door seems to many addicts a vast and impossible undertaking. In theory, heroin induction permits a transaction. This must be tested. Give up some things: the hustling for heroin; but keep the beloved/hated drug and needle. Then if a reasonable human relationship can be established, more withdrawal can follow. The more entrenched in war are addict and society, the harder it is for them to establish such reasonable relationships.

The persistent misreading of the purposes inherent in the Vera or any such proposal leads to other dangers even should the research get under way (which seems very unlikely at the moment). For there are plenty of problems involved in such research. Considering their alienation from straight society, can this intransigent group of addicts be induced into a treatment situation with injected heroin at all? In fact, some of the most important questions this kind of program would answer would be whether such research is possible and, if so, how do we execute it. Will addicts restrict themselves to the limited, stabilizing doses available at the clinic when there are readily available, unlimited supplies on the street? In England, virtually all heroin is clinic heroin so that the country need not contend with this serious question. Will the addicts forego the hustling, crime, and other potent excitements in addict life style? Even if the experiment establishes results similar to England's, which show that technically addicts can function and work on heroin, will American addicts be motivated to do so? How will the addict respond to taking heroin in a clinic setting as opposed to the street surroundings he is used to? Which is more important to most addicts: the drug or the street ritual? What sort of personnel will be most effective in establishing relationships with which addicts? That is, can we discover any consistent differences among those addicts who want to deal with a doctor, those who prefer a nurse, and those who seek out nonprofessional, perhaps ex-addict, clinic workers?

These are some of the questions that will be considered by the Samuels/Vera proposal. It is true that the researchers do not know in advance the answers to the questions to be studied. Although this hardly seems a reasonable objection, every question listed above has been raised as an objection to beginning the proposal.

The principles behind the Vera proposal are, first, to find out more about traditional and innovative treatment of addicts. The affected individual must be involved in deciding which combination of methods works best for him because, after all, he knows the most about his relationship with drugs and life. But the addict will not make the final decision about his treatment method. His relationship with drugs naturally affects his judgment. No drugs or treatment method should be offered out of context or proposed as the only treatment that is possible or efficacious. Ancillary services for rehabilitation should be available. These services should employ only people with whom the afflicted can form a dignified relationship, not a manipulative one. The nature of the problem of addicts and addiction will be presented reasonably, non-controversially, and factually to the public. This may well include facing unpleasant realities, i.e., the experiment at heroin induction may fail completely. This would squash that treatment idea. If the induction succeeded, but not the transfer to modalities other than heroin, we would have more knotty problems to unsnare. The transfer may succeed but be inoperable on a large scale, and so on. If we wish to consider these issues in a factual context, obviously, we must first carry out the experiment. Above all, the goal is for the addict to find a way to personal freedom as an individual who can function constructively and with a comfortable degree of acceptance in this society.

At this writing, I doubt that the United States will ever exactly apply the English system of controlling and regulating heroin use. Perhaps we should not even strive for such a parallel. I am sure, however, that we should accept our addicts into some aspect of our social system in the same way that the addicts in the English Dr. Mitcheson's office felt included. Anyone who has been part of a nonrepressive system recoils with horror from our repressive, punitive approach. And these like reactions come from diverse sources as, for example, veterans of the 1919 clinics such as Leroy Street and the addicts I talked to in England. We all agree that total repression makes a bad situation worse.

References

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