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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment A Century of American Narcotic Policy David T. Courtwright American narcotic policy has been highly variable, having passed through at least four major stages during the past 100 years. In the nineteenth and early twentieth centuries, government involvement was minimal. Drug use was largely a private matter, as was drug treatment. Addiction was understood as either a personal or a medical problem, and various treatments were provided on a fee-for-service basis. In 1909-1923, however, the federal government became progressively more involved in the field as a series of important laws, court cases, and administrative decisions effectively criminalized nonmedical narcotic use and proscribed certain treatments, notably long-term maintenance and ambulatory detoxification. The following four decades, from 1923 to 1965, might be described as the classic era of narcotic control—"classic" in the sense of simple, consistent, and rigid. Few avenues of treatment were open to addicts, and American narcotic policy was unprecedentedly strict and punitive, both in comparison with other Western countries and with what it has become in our own time. During the 1960s the police approach was challenged and gradually superseded by a hybrid approach, combining traditional law enforcement with new treatment strategies, including methadone maintenance and therapeutic communities. Since 1965 drug abuse has been regarded as a medico-criminal problem, the likely pattern of the future, although there are signs that the pendulum is beginning to swing back in the direction of strict law enforcement. The following narrative history of these events is based on written primary and secondary sources, as well as oral history interviews with former addicts, physicians, and police personnel.1 A good deal of attention is paid to the changing epidemiology and sociology of narcotic abuse because the changes in government policy (and hence in the array of David T. Courtwright is professor and chair of the Department of History, University of North Florida, and a member of the Committee for the Substance Abuse Coverage Study.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment medical treatments available) are unintelligible without knowledge of the changing demographic and social backgrounds of the users themselves. Although this narrative focuses primarily on opiate and cocaine addiction and treatment, there is also a brief discussion of other drugs, especially alcohol. Often told separately, the histories of drug and alcohol use in America are in fact intertwined, perhaps never more so than in the last decade. THE SOCIAL AND LEGISLATIVE ORIGINS OF NARCOTIC CONTROL During the nineteenth century there was virtually no effective regulation of narcotics in the United States. Various preparations and derivatives of opium were freely available and widely used. Several states had statutes governing the sale of narcotics, and many municipalities forbade opium smoking, but these laws were only sporadically enforced. In practice just about anyone could secure pure drugs with little bother and at modest cost. Pharmacists even delivered drugs, dispatching messenger boys with vials of morphine to houses of high and low repute. Some customers were actually unaware of what they were purchasing: proprietors of patent medicines were notorious for slipping narcotics into their products, which before 1906 bore no list of ingredients on their labels. Doctors, too, frequently overprescribed narcotics. Opiates were among the few effective drugs they possessed, and it was tempting to alleviate the symptoms (and thus continue the patronage) of their patients, especially those who were chronically ill. The result of all this was a narcotic problem of considerable dimensions, with perhaps as many as 300,000 opiate addicts at the turn of the century, plus an unknown number of irregular users.2 Today there are perhaps as many as 500,000 narcotic (mainly heroin) addicts in the United States, but the country's population is also much larger. On a per capita basis, narcotic abuse was certainly as bad and probably worse in the late nineteenth century. Victorian Americans were much less worried about drugs, however, than they were about drink. An influential reform coalition, consisting mainly of native-born, white, middle-class Protestants, attacked alcohol as the principal source of social problems. Drinking was wrong because it led to drunkenness, and drunkenness led to battered wives, abandoned children, sexual incontinence, venal voting, pauperism, insanity, early death, and eternal damnation. Drinking was also objectionable because it was associated with groups whose morality was highly suspect: Catholic immigrants, machine politicians, urban blacks, demimondaines, criminals,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment tramps, casual laborers, and others of the lower strata. Reformers sought to uplift and reform drunkards, but they were also frank in their desire to control their behavior and to minimize the social costs they generated. The more ardent among them fought for and achieved prohibition, first on a local and state level, and then, in January 1920, on a national basis. Given the prevalence of narcotic use, why were Americans initially so much more agitated over the drink question? One answer lies in the comparative effects of opiates and alcohol. It was a commonplace that drink maddened whereas opium soothed. Alcoholics were notoriously obstreperous and often injured others as well as themselves. Their behavior was a public nuisance and a scandal. Addicts, by contrast, tended to be quiet and withdrawn. Although they might merit reprehension for their enslavement to a drug, theirs was a private vice, unlikely to affect anyone outside their immediate family—and in some cases even the family did not know. These distinctions were grounded in pharmacological reality, insofar as narcotics are potent tranquilizers, capable of producing a pacific and languid state. It is easier for an addict to remain inconspicuous than a drunkard. Who the narcotic users were was as important as how they acted. There was what might be termed a "hard core" of opium smokers, mainly Chinese laborers and white criminals; they were contemptuously regarded and likely to run afoul of the law. Opium smokers, however, made up only a minority of regular users. Addicts were more often found among upper-and middle-class women, many of whom had begun using morphine to relieve the symptoms of various illnesses. Surveys taken in the late nineteenth century consistently showed that two-thirds of those addicted to medicinal opiates, such as laudanum or morphine sulfate, were female. Given that so many addicts were respectable women of ailing body and docile comportment, it is understandable that they occasioned less alarm than heavy drinkers. Narcotic addiction was not entirely ignored by the medical profession. As the number of addicts grew in the 1870s and 1880s, some physicians began to specialize in treating addiction and to develop theories about it. They debated its etiology; whether it, along with alcoholism, was symptomatic of a more general neurological disorder; whether gradual or rapid withdrawal was to be preferred; whether withdrawal could or should be palliated with nonnarcotic drugs and, if so, which ones. A hundred years later, most of these issues are still not completely resolved. Nineteenth-century physicians interested in addiction were handicapped by the embryonic state of medical science—they knew nothing of drug receptors or endorphins or narcotic antagonists—but they did have at least one advantage over modern researchers: almost total freedom. There were no federal regulations and no bureaucracy to deal with;
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment moreover, medical institutions, such as they were, largely steered clear of the problem. Doctors were thus at liberty to experiment, to prescribe purges, baths, electric therapy, dietary regimens, and various exotic concoctions for their addicted patients. Many of the leading authorities in the field operated private asylums where treatment was tailored to their particular theories of addiction. Addicts, too, had a fair amount of choice. They could stay at one of the private asylums or attempt withdrawal as an outpatient under the supervision of a physician. Some bought ''opium habit cures,'' patent medicines that were often laced with narcotics and hence no cure at all. Or they could do nothing and simply continue to use undisguised narcotics. Few addicts were legally committed to institutional treatment. When they made an effort to quit, it was generally motivated by a sense of disgust, combined with health and financial worries and pressure from family and friends. Addicts, in short, were far less likely than alcoholics to be involuntarily confined. A handful of late-nineteenth-century medical specialists saw addicts in a less benign light. They argued that addiction and alcoholism were in fact related, that both were a manifestation of an underlying nervous disorder called inebriety, and that "inebriates" needed institutional care, against their wills if necessary. They failed, however, to carry this last point. The public thought of addiction as neither a crime nor a fit object for mandatory treatment. Whatever resentment existed against addicts was diffuse and lacked institutional expression. Within 25 years these attitudes had dramatically changed. Even as the country was having second thoughts about alcohol prohibition, there was virtual consensus on the need to suppress narcotic addiction. (Some extremists in the 1920s and 1930s even proposed firing squads as a permanent solution for the drug problem, on the theory that the only abstinent addict was a dead one.) This pronounced attitudinal shift was related to changing perceptions of who drug addicts were, how they acquired their habits, and how they behaved under the influence of drugs. After the turn of the century there were fewer new cases of medical addiction as physicians became more conservative in their use of narcotics and the public became more chary of self-medication, thanks to the Pure Food and Drug Act (1906) and the efforts of muckrakers like Samuel Hopkins Adams. Some existing medical addicts detoxified and remained abstinent, but the majority probably continued using morphine. Because many of them were old and ailing, however, they soon disappeared from the scene, leaving a residue of generally younger, less sympathetic users who had begun experimenting with drugs in such decidedly nonmedical establishments as brothels and saloons.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Opium smoking remained popular in the white underworld and continued to attract recruits, even though the number of Chinese living in America had begun to decline. Two powerful new drugs, cocaine and heroin, quickly spread outside medical practice and became popular euphorigenic agents. Cocaine, although not pharmacologically a narcotic, was often described as such and became associated in the public mind with crime sprees, particularly by black men. In the 1910s and early 1920s heroin use became widespread in the immigrant slums, where young men took to snorting small packets of the white powder. For some it was a passing fancy, but for others it became a lifelong preoccupation. In 1924 New York City Corrections Commissioner Frederick A. Wallis described what he took to be a typical case: The young man, 16 to 20, leaves school because he won't study, he doesn't like discipline, and shows inclination toward truancy and dishonesty. Out of school, his bad habits increase. He visits pool-rooms and dance halls, and chop suey restaurants and becomes one of the neighborhood rowdies or corner loafers. He goes with a gang and becomes reckless and is soon participating with the gang in neighborhood thefts. If he has a job, it becomes burdensome, and offensive to him. He then neglects his work, loses his job, and all his ambitions are in sympathy with criminal tendencies. He is arrested first for a minor offense, spends five to ten days in prison, loses self-respect, is released and returns to society with less regard for law and constitutional authority. . . . Having served a term in prison, he is now qualified by the gang for exploits in the underworld. . . . He soon learns. . . the easiest and most profitable way to get money with less personal hazard to himself and a lighter prison sentence, [and he] becomes a drug peddler and distributor. Before he realizes the danger he has been taught to use the drug. Soon he must have the drug at any price. He resorts to shoplifting and indulges in other petty offenses to obtain the drug. The next step is prison again, and he returns to society again, and then is arrested for a more serious crime. The craving for drugs is growing all the time. He must have more drugs. The requirement of $2.00 a day has grown into $5.00 or $10.00 a day. In his intensified craving he becomes a bandit, a hold-up man, murder follows. A wreck, mentally, physically and morally, he is given a life sentence or the electric chair.3 What is particularly interesting about this account is its harsh, judgmental tone. It was not just that the old-fashioned medical addicts were disappearing and being replaced by a new breed, it was how people felt about it. As had been the case with alcohol, disdain for users, tinged by
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment ethnic and class prejudice, was an impetus for restrictive legislation. Change a very few words in Wallis's description and one finds the old stereotype of the drunkard as a menacing, irresponsible wretch. Addiction thus went from being a pathetic condition to a stigmatized one. Like venereal disease, it came to be understood as something that was acquired through forbidden indulgence with evil associates. Also like venereal disease, it could afflict, or destroy, the lives of innocent others—the spouse, the family, the fetus, or the newborn child. Both diseases were, in a broad sense, communicable: addicts (and venereal patients) were alarming, not only because they had gotten themselves in trouble but because they might put others in the same situation. After inadvertent medical addiction ceased to be much of a factor, it was clear that the majority of new users were introduced to drugs by and often became part of a network of experienced users and dealers. A deviant subculture was in place and perpetuated itself through continuous recruiting. Deviant groups in American history have sometimes been dealt with by informal, local means—harassment, exile, even lynching. But when such groups become large enough, or threatening enough, they often evoke a legislative response. The resultant laws serve a dual purpose. They are symbolic in that they define and reiterate majority norms; they are also instrumental to the extent that they employ the police power of the state to restrict or eliminate the objectionable behavior. There have been many instances of this, from the 1675 Massachusetts law attacking the "damnable haeresies" of the Quakers to the 1940 Smith Act, which was used to prosecute domestic communists and Nazi sympathizers. Narcotic control seems to fit neatly into this pattern. As the legal scholars Richard Bonnie and Charles Whitebread put it, "Once opiate use became identified with otherwise immoral or unliked populations, prohibition was almost automatic."4 The word "almost" must be stressed, however. The negative social and behavioral connotations surrounding nonmedical narcotic use were not, in any meaningful historical sense, a sufficient cause of the ensuing prohibition and criminalization. There was still room for the play of expert judgment and legislative discretion, and it is well known that contemporaries in other developed countries, such as Britain, arrived at less Draconian solutions. It is fair to say, however, that the sinister transmogrification of narcotic addiction was a critical precondition for the legal developments that followed. It would have made no sense—politically, culturally, morally, or in any other way—to repress addicts if they had still consisted disproportionately of sick old women. Even after the laws were changed, physicians and law enforcement officers often tacitly permitted the dwindling number of iatrogenic addicts to continue their "medication."
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Being ill, these patients were sympathetic figures and, because they were isolated from the street drug subculture, posed no threat to anyone. The transformation of American narcotic laws, like the transformation of the addict population itself, evolved over a period of time. The catalytic event was America's growing involvement in Asia, a region long notorious for its opium trade. American military governors in the recently acquired Philippines, missionaries in China, and diplomats studied the problem and sought to coordinate international efforts to eliminate or reduce the traffic. As a result of their efforts an international opium commission met at Shanghai in February 1909. The American delegation, anxious to assume a leadership role but fearful that the laissez-faire narcotic market at home left them open to charges of hypocrisy, pressed for at least token congressional legislation. This they received in the form of a hastily enacted law forbidding the importation of opium "for other than medicinal purposes," that is, opium for smoking. Banning this form of the drug cost the federal government more than $800,000 in annual revenues, but it was politically feasible because opium smoking had such low-life connotations and few American firms had a large stake in its continued importation. Reformers were not satisfied with this one measure, however. They continued to work for a more comprehensive narcotic law, both to address the domestic problem and to bring the country into line with the provisions of an international treaty then being negotiated. Their most forceful advocate was Dr. Hamilton Wright, American delegate to the Shanghai Commission and later the Hague Opium Conference (1911-1912). Wright compiled an official report for Congress, complete with authoritative references to drug-inspired rape and miscegenation, as well as statistics that seemed to show that narcotic use was outstripping population growth. (In fact it was not; per capita consumption was down after 1900, largely owing to increased therapeutic conservatism.) Wright also played up the prevalence of lower-class and criminal use, as may be seen from his specific addiction estimates in Table 1. The percentages reproduced here are as unfounded as they are pretentious: Wright's research was highly unsystematic and hardly merited numerical expression, let alone two-and three-decimal-point precision.5 He was, however, magnifying an epidemiological reality: by 1910 criminals and prostitutes did have much higher rates of use than the general adult population and possibly (although this is not certain) higher rates than medical personnel, who historically had a serious addiction problem. Wright was, moreover, believed. His statements and statistics were given wide circulation in the popular press, medical journals, congressional committee reports, and other official documents. Despite his skills as a propagandist, Wright got a bill neither as soon
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment TABLE 1 Opiate Addiction Estimates for Various Groups in the United States Made by Hamilton Wright in 1910 Group Percentage Addicted General criminal population 45.48 Chinese 25.0a Prostitutes and their companions 21.6 Prisoners in large jails and state prisonsb 6.0 Medical profession 2.06 Trained nurses 1.32 Other professional classes 0.684 General adult populationc 0.18 College and university students "practically unknown" a percentage estimate includes those who smoked a pound-and-a-half or more per annum but excludes "social smokers." b As distinct from the "general criminal population," which committed lesser crimes and hence ended up in local jails rather than large or state institutions. c Exclusive of the groups enumerated above. Source: U.S. Senate, Report on the International Opium Commission and on the Opium Problems as Seen Within the United States and Its Possession (Washington, D.C.: U.S. Government Printing Office, 1910), pp. 42, 47.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment as nor as stringent as he wanted. He ran into opposition, especially from drug companies that did a large wholesale business in narcotics. He also encountered philosophical and constitutional difficulties, as the limits or even the existence of a federal police power were not then generally agreed upon. (Indeed, in 1918 and again in 1922 the Supreme Court would strike down something as seemingly proper and desirable as federal child labor laws.) The regulation of medical practice was a matter traditionally left to the states, and narcotics were still very much a part of medical practice. The measure that finally passed, the Harrison Narcotic Act of 1914, was a complex compromise. It required anyone who sold or distributed narcotics—importers, manufacturers, wholesale and retail druggists, and physicians—to register with the government and to pay a small tax.6 When they sold or otherwise distributed narcotics, they had to make a detailed record of the transaction, open to government inspection. Unregistered persons caught with narcotics in their possession were presumptively guilty of violating the law, unless the drugs had been "prescribed in good faith by a physician, dentist, or veterinary surgeon registered under this Act." If convicted, they could be fined and imprisoned for up to five years. It was anticipated that such sanctions would make the narcotic traffic transparent and confine it to legitimate medical channels. Two features of the Harrison Act are of particular interest. One is the definition of narcotics as opium-and coca-based drugs. As previously noted, opium and coca are medicinally distinct. One is a central nervous system depressant, the other a stimulant. They were combined legislatively, however, because of the assumption that both were euphorigenic, potentially habit-forming, and associated with crime. It was for similar reasons that marijuana would also later be described as a narcotic.7 The second point is the law's failure to address the question of whether an addict could receive, on an indefinite basis, a prescribed supply of narcotics. In retrospect, this was one of the most crucial lacunae in any federal statute enacted in the twentieth century. The Treasury Department officials who administered the law assumed a negative stance and initiated several prosecutions against addicts, physicians, and pharmacists for conspiracy to violate the Harrison Act. At first the Supreme Court rebuked the Treasury Department for attempting to stop physicians from prescribing for addicts; ultimately, however, it reversed itself and narrowly ruled in favor of the antimaintenance position. In two cases decided March 3, 1919, the Court sustained the constitutionality of the Harrison Act and ruled that a physician might not write prescriptions for an addict "to keep him comfortable by maintaining his customary use." The circumstances of these cases, United States v. Doremus and Webb et al. v. United States, are revealing. Doremus was a physician who prescribed, for a price, large quantities of heroin to one Alexander Ameris,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment alias Myers, who was "addicted to the use of the drug as a habit, being a person popularly known as a 'dope fiend'."8 Ameris's ethnic surname, use of heroin, and large habit were all negatives, summed up in the epithet "dope fiend." Dr. Webb was similarly accused of gross overprescription; before he was arrested he averaged more than 80 morphine prescriptions a week, at 50 cents apiece. Government attorneys decried such unprofessional behavior, likening it to a barkeeper dispensing whiskey to a drunkard.9 Five members of the Court agreed, and Webb's original conviction was upheld. Had either case involved only small amounts of narcotics prescribed by a reputable physician, it is highly likely that the decision would have gone the other way. Six years later, in Linder v. United States, the Court unanimously reversed the conviction of a respected Oregon practitioner who had prescribed one tablet of morphine and three tablets of cocaine for a stool-pigeon addict.10 The Prohibition Unit of the Treasury Department nevertheless treated Webb as the governing decision and pursued an aggressive antimaintenance policy. By threats and actual prosecutions they were able to drive a wedge of fear between the legal providers (physicians, pharmacists) and the addicts. Prosecutions of those who supplied addicts might fail, as they had with Dr. Linder—but they might also succeed, as they had with Dr. Webb and numerous others. Even if a defense were successful, the potential legal fees and loss of reputation made a physician think twice before reaching for his prescription pad. Doctors, moreover, were less and less favorably disposed toward nonmedical addicts, whom they perceived as devious, troublesome, and notoriously resistant to cure. There were, however, some physicians who continued to write prescriptions for addicts, if only on an occasional basis. They were motivated by pity, or greed, or simply by a desire to get the users off their backs and out of town. Even at the height of its powers, the Bureau of Narcotics never completely succeeded in closing off all medical supplies to addicts. A small but significant gray market of pure drugs persisted as an alternative to the black market of adulterated heroin. Some users managed to develop extensive connections in the former and stay out of the latter altogether. Still, medical sources were chancy and could not be counted on indefinitely; doctors who wrote prescriptions too often or too openly were sure to be visited by a federal agent. That fact, as far as addicts were concerned, was the chief legacy of the Harrison Act and the 1919 Supreme Court decisions. There was one other alternative to the black market, but it was short-lived. Following the Webb ruling, a number of cities and towns set up facilities to dispense narcotics to addicts. If private maintenance were disallowed, then organized, public maintenance might yet take its place. There were altogether 35 of these municipal "narcotic clinics," so named
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment because they sold morphine cheaply to their registered patients. A few also sold cocaine or heroin. What is sometimes misunderstood about these clinics is that they were not homogeneous, that their methods of operation varied. Some were geared toward indefinite maintenance, others toward detoxification through gradual withdrawal. Some were run for profit, others merely to break even. Some were models of efficient administration, others fly-by-night operations. One thing, however, they did have in common: all were eventually closed by the federal government, most within a year of opening their doors. Treasury Department officials, determined to eliminate both licit and illicit sources of narcotics for addicts, viewed the clinics as dangerous precedents and potential obstacles to the rigorous enforcement of the Harrison Act, as recently interpreted by the Supreme Court. Consequently, they moved to abort them through a combination of critical inspections, threats, and legal pressure. February 10, 1923, when the last clinic in Shreveport, Louisiana, was finally forced to break off maintenance operations, is as appropriate a date as any to mark the beginning of the "classic" police era of narcotic control.11 The unprecedented nature of federal narcotic policy after 1923 is underscored by the fact that alcoholic beverage prohibition applied only to manufacture and sale. Neither the Eighteenth Amendment nor the law that implemented it, the Volstead Act, barred personal use and consumption by alcoholics or, for that matter, anyone else. National prohibition, moreover, was controversial from the start and lasted only 14 years. Large numbers of apparently normal people continued to drink; they resented both the prices they had to pay for bootlegged alcohol and the prohibitionists who meddled with their customary freedoms. The laws proved virtually unenforceable, as criminals manufactured or diverted alcohol and speakeasies spread across the land. The byproducts of Prohibition-gangsterism, corruption, and methanol poisoning—filled the front pages. Ardent supporters grew disenchanted. Powerful business and opinion leaders such as Pierre du Pont and William Randolph Hearst campaigned for repeal. A well-funded national organization, the Association Against the Prohibition Amendment, maintained a drumfire of criticism and propaganda. The public was told that the noble experiment had backfired and was creating a nation of drunkards. The war against narcotics, by contrast, was thought to be successful in reducing nonmedical addiction and was so portrayed by government officials.12 The onset of depression in 1929 handed the antiprohibitionists a new and decisive argument: money. "If the liquor now sold by bootleggers was legally sold, regulated, and taxed," one writer observed, "the excise income would pay the interest on the entire local and national bonded indebtedness and leave more than $200,000,000 for other urgently needed pur-
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Jerome L. Himmelstein, The Strange Career of Marijuana: Politics and Ideology of Drug Control in America (Westport, Conn.: Greenwood Press, 1983). 44 James Hitchcock, Years of Crisis: Collected Essays, 1970-1983 (San Francisco: Ignatius Press, 1985), 57. 45 The head of New York's Phoenix House drug treatment program, Dr. Mitchell S. Rosenthal, makes a similar point in "Time for a Real War on Drugs," Newsweek 106 (September 2, 1985), 12-13. Conventional prosecute-the-dealer tactics, he concludes, are ineffective "unless we reach a consensus on the strict enforcement of drug laws. What is needed is broad societal disapproval of illicit drug use" (his emphasis). Rosenthal is correct. Informal social controls such as the disapproval of parents or peers are undoubtedly more effective than formal controls; moreover, drug laws are better enforced when an antinarcotic consensus exists. The problem is that there has been no such consensus since the middle-1960s; nor can it simply be willed back into existence, given that today's moral and social climate is so profoundly different from that of the classic era. 46 Morgan, Drugs in America, 159-161. 47 Drug Addiction: Crime or Disease? Interim and Final Reports of the Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs (Bloomington: Indiana University Press, 1961; seventh printing in 1969), 19, 104-105. 48 Comments on Narcotic Drugs (Washington, D.C: Bureau of Narcotics, 1958), 1, 51, 81, 95, 119, 135, etpassim; Diller in Sloman, Reefer Madness, 199-200. Anslinger had reacted in a similarly violent fashion to the so-called LaGuardia Report of 1944, which de-emphasized the dangers of marijuana smoking. McWilliams, "The Protectors," 189-190. 49 "Federal Narcotics Czar," 162. 50 American Disease, 1973 edition, 234. The American Bar Association/ American Medical Association report controversy is discussed further in King, Drug Hang-Up, Chap. 18; Lindesmith, The Addict and the Law, 247-248; and William Butler Eldridge, Narcotics and the Law: A Critique of the American Experiment in Narcotic Control, 2nd ed. (Chicago: University of Chicago Press, 1967), Chap. 3.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 51 370 U.S. 660; quotation at 666. Stewart's language reminds us again of addiction's status as a stigmatized disease. By the early 1960s, however, the Court, as well as the medical research establishment, was placing more emphasis on the disease aspect and less on the stigma. 52 Narcotic Addiction, 169. Eldridge's Narcotics and the Law, cited above and first published in 1962, carried a similar message: "the treatment of addiction and research into possible preventative medicine are medical problems and should be dealt with as such." Eldridge accorded a role to law enforcement but argued that physicians should be free to individualize treatment, just as judges should be free to individualize sentences (118-125). Narcotics and the Law was published under the auspices of the American Bar Foundation. 53 King, Drug Hang-Up, 235. 54 President's Advisory Commission on Narcotic Drug Abuse, Final Report (Washington, D.C.: U.S. Government Printing Office, 1963), 6-9. 55 Under the Controlled Substances Act of 1970, rather than the Harrison Act and related federal laws of the 1910s and 1920s, which have been superseded. For an overview of the statutory and regulatory changes that occurred during the 1970s, see Edward Lewis, Jr., and William M. Lenck, "Role of Law and State," in Sachindra N. Pradhan and Samarendra N. Dutta, eds., Drug Abuse: Clinical and Basic Aspects (St. Louis: Mosby, 1977), 515-534. 56 Two very good articles on this subject are Mark Peyrot, "Cycles of Social Problem Development: The Case of Drug Abuse," Sociological Quarterly 25 (1984), 83-96, and Ronald Bayer, "Heroin Addiction, Criminal Culpability, and the Penal Sanction: The Liberal Response to Repressive Social Policy," in James C. Weissman and Robert L DuPont, eds., Criminal Justice and Drugs: The Unresolved Connection (Port Washington, N.Y.: Kennikat, 1982), 94-103. "The current institutional system for dealing with drug abuse is a conglomeration of two contradictory approaches," Peyrot summarizes, "the newer, clinical approach has been 'tacked onto' the earlier criminal adjustment approach, rather than supplanting it'' (91). Chap. 5 of Peter Conrad and Joseph W. Schneider, Deviance and Medicalization: From Badness to Sickness (St. Louis: Mosby, 1980), is also of interest. David F. Musto shows, in Chap. 12 of the expanded edition of The American Disease (New York: Oxford University Press, 1987), that the hybrid police-medical policy was most in evidence
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment during the 1970s. During the 1980s enforcement efforts received relatively higher priority. 57 John Kaplan, The Hardest Drug: Heroin and Public Policy (Chicago: University of Chicago Press, 1983), 169, 182. 58 Interview with Densen-Gerber, August 5, 1981. 59 "Special Message to the Congress on Drug Abuse Prevention and Control, June 17, 1971," Public Papers of the Presidents of the United States: Richard Nixon. . . 1971 (Washington, D.C.: U.S. Government Printing Office, 1972), 739-749. 60 "Reminiscences of a Drug Czar," in William R. Martin and Harris Isbell, eds., Drug Addiction and the U.S. Public Health Service: Proceedings of a Symposium Commemorating the 40th Anniversary of the Addiction Research Center at Lexington, Ky. (Washington, D.C.: Department of Health, Education, and Welfare, 1978), 287. The evolution of White House staff attitudes toward methadone is discussed in Edward Jay Epstein, Agency of Fear: Opiates and Political Power in America (New York: G.P. Putnam's Sons, 1977), especially Chaps. 13 and 14. 61 Robert G. Newman, in collaboration with Margot S. Cates, Methadone Treatment in Narcotic Addiction: Program Management, Findings, and Prospects for the Future (New York: Academic Press, 1977), xix. New York City had already embarked upon large-scale methadone maintenance in 1970, the year before SAODAP was created. 62 Musto, American Disease, expanded edition, 259. 63 National Institute on Drug Abuse, Federal and State Laws Pertaining to Methadone (Washington, D.C.: Department of Health, Education, and Welfare, 1974), 6; see also Newman, Methadone Treatment in Narcotic Addiction, 73-74. 64 Interview with Nyswander, June 22, 1981. 65 Interview with Newman, July 24, 1981. 66 Alan G. Sutter, "The World of the Righteous Dope Fiend," Issues in Criminology 2 (1966), 171-222, quotation at 200; see also Bill Hanson et al., Life with Heroin: Voices from the Inner City (Lexington, Mass.: Lexington Books, 1985), especially 126, 135-173.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 67 Paul J. Goldstein et al., "Drug Dependence and Abuse," in Robert W. Amler and H. Bruce Dull, eds., Closing the Gap: The Burden of Unnecessary Illness (New York: Oxford University Press, 1987), 89-101, quotation at 97. 68 H.W. Cohen et al., "Behavioral Risk Factors for HTLV-III/LAV Seropositivity among Intravenous Drug Abusers," paper presented at the International Conference on the Acquired Immunodeficiency Syndrome (AIDS), Atlanta, April 14-17, 1985. 69 Robert R. Redfield et al., "Heterosexually Acquired HTLV-III/LAV Disease (AIDS-Related Complex and AIDS) . . .," Journal of the American Medical Association 254 (1985), 2094-96; Normand Lapoint et al., "Transplacental Transmission of HTLV-III Virus," New England Journal of Medicine 312 (1985), 1325-26. 70 Kung-Jong Lui et al,, "A Model-Based Estimate of the Mean Incubation Period for AIDS in Homosexual Men," Science 240 (1988), 1333-1335. 71 C.f. Thomas J. Spira et al., "Prevalence of Antibody to Lymphadenopathy-Associated Virus among Drug-Detoxification Patients in New York," New England Journal of Medicine 311 (1984), 467-468; Jrog Schupbach et al., "Antibodies to HTLV-III in AIDS and Pre-AIDS and in Groups at Risk for AIDS," New England Journal of Medicine 312 (1985), 265-270; Giacchino Angarano et al., ''Rapid Spread of HTLV-III Infection among Drug Addicts in Italy," Lancet (1985, Part 2), 1302; and J. R. Robertson et al., "Epidemic of AIDS-Related Virus (HTLV-III/LAV) Infection among Intravenous Drug Users," British Medical Journal 292 (1986), 527-529. See also Lawrence K. Altman, "New Fear on Drug Use and AIDS," New York Times, April 6, 1986, Sec. 1, pp. 1, 30; Ronald Sullivan, ''New York State Rejects Plan to Give Drug Users Needles," New York Times, May 18, 1987, Sec. 1, p. 38; Lionel C. Bascom, "AIDS Shift Seen from Gay Men to Drug Users," New York Times, July 19, 1987, Sec. 11, pp. 1, 19; and Philip M. Boffey, "Spread of AIDS Abating, but Deaths Will Still Soar," New York Times, February 14, 1988, Sec. 1, pp. 1, 36. 72 S.R. Friedman et al., "AIDS and Self-Organization among Intravenous Drug Users," International Journal of the Addictions 22 (1987), 201-219; Don C Des Jarlais et al., "Risk Reduction for the Acquired Immunodeficiency Syndrome Among Intravenous Drug Users," Annals of Internal Medicine 103 (1985), 755-759.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 73 Don C Des Jarlais et al., "AIDS and Needle-Sharing within the IV-Drug Use Subculture," in Douglas A. Feldman and Thomas M. Johnson, eds., The Social Dimensions of AIDS: Method and Theory (New York: Praeger, 1986), 111-125. 74 J. Jackson and S. Neshin, "New Jersey Community Health Education Project: Impact of Using Ex-Addict Educators to Disseminate Information on AIDS to Intravenous Drug Users," paper presented at the International Conference on AIDS, Paris, June 23-25, 1986; Jeffrey Schmalz, "Addicts to Get Needles in Plan to Curb AIDS," New York Times, January 31, 1988, Sec. 1, p. 1. 75 William French Smith, "Drug Traffic Today—Challenge and Response: Excerpts from a report [sic] to the President's Cabinet Council on Legal Policy, March 24, 1982," Drug Enforcement 9 (Summer 1982), 2-6; Michael Hanchard, "New Varieties of Heroin Showing Up More In State," Hartford Courant, June 9, 1986, C1; "Special Report: Black Tar Heroin in the United States'' (unpublished TS from Strategic Intelligence Section, Drug Enforcement Administration, March 10, 1986), i-ii; Peter Applebone, "On Border Patrol: Arrests and Futility,'' New York Times, August 3, 1986, Sec. 1, pp. 1, 22; and Peter Kerr, "Chinese Now Dominate New York Heroin Trade," New York Times, August 9, 1987, Sec. 1, pp. 1, 30. 76 John P. Lyle, "Southwest Asian Heroin: Pakistan, Afghanistan, and Iran," Miguel D. Walsh, "Impact of the Iraqi-Iranian Conflict," and John Bacon, "Is the French Connection Really Dead?" all in Drug Enforcement 8 (Summer 1981), 2-6, 7-12, and 19-21, respectively; Alfred W. McCoy et al., The Politics of Heroin in Southeast Asia (New York: Harper and Row, 1973), 53-54, 244-246. 77 Erich Goode, The Marijuana Smokers (New York: Basic Books, 1970), 3. 78 Timothy Leary, "Some Superficial Thoughts on the Sociology of LSD," in Lester Grinspoon and James B. Bakalar, eds., Psychedelic Reflections (New York: Human Sciences Press, 1983), 32, 36. Chap. 2 of Goode, cited above, presents sampling data to the effect that marijuana smokers were more likely than nonsmokers to reject traditional values. 79 Edward M. Brecher et al., Licit and Illicit Drugs (Boston: Little, Brown, 1972), 422; U.S. Senate, Marijuana-Hashish Epidemic and Its Impact on United States Security: Hearings Before the Subcommittee to Investigate the Administration of the Internal Security Act and Other Internal Security Laws
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment of the Committee on the Judiciary (Washington, D.C.: U.S. Government Printing Office, 1974), 7-8; Institute of Medicine, Marijuana and Health (Washington, D.C.: National Academy Press, 1982), 36; Glenn Collins, "U.S. Social Tolerance of Drugs Found on Rise," New York Times, March 21, 1983, Al, B5; James Mills, The Underground Empire: Where Crime and Governments Embrace (New York: Doubleday, 1986), passim; Christine Russell, "One-Third of College Students Try Cocaine... Use of Marijuana and Other Drugs Appears to Have Declined," Washington Post, July 8, 1986, A3. 80 Interview with Peter Santangelo, August 23, 1982. 81 Institute of Medicine, Marijuana and Health, 37. 82 Denise Kandel, "Stages in Adolescent Involvement in Drug Use," Science 190 (1975), 912-914, and Bruce D. Johnson et al., Taking Care of Business: The Economics of Crime by Heroin Abusers (Lexington, Mass.: Lexington Books, 1985), 182, 226-229. 83 Table 1 in Kandel, above; 1982 National Household Survey on Drug Abuse data reproduced in Collins, "U.S. Social Tolerance," B5. It is also of interest that, among those who did progress to heroin, many apparently took precautions to avoid full-blown dependence. Heroin's reputation as an addicting drug preceded it. See Norman E. Zinberg, "Nonaddictive Opiate Use," in Criminal Justice and Drugs, especially 15. 84 Carl D. Chambers and Leon G. Hunt, "Epidemiology of Drug Abuse," in Pradhan and Dutta, eds., Drug Abuse, Table 2-2, 13; Irving Faber Lukoff, "Consequences of Use: Heroin and Other Narcotics," in Joan Dunne Rittenhouse, ed., Report of the Task Force on the Epidemiology of Heroin and Other Narcotics (1976), 124-126; Leon Gibson Hunt, "Prevalence of Active Heroin Use in the United States,'' and S.B. Sells, ''Reflections on the Epidemiology of Heroin and Narcotic Addiction from the Perspective of Treatment Data," both in Joan Dunne Rittenhouse, The Epidemiology of Heroin and Other Narcotics, NIDA Research Monograph 16 (Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, Division of Research, 1977), 63-78 and 161-163, respectively; John C. Ball et al., "Characteristics of 633 Patients in Methadone Maintenance Treatment in Three United States Cities: 45 Preliminary Tables" (Report of the Methadone Research Project, 1986), Table 602. Sells remarks, "[a] polarity can be observed between low socioeconomic level street heroin users, at one extreme, and the youthful, middle class, maladjusted, nonopioid users, at the other" (163; italics in the
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment original). Among minority groups, use by Hispanics has grown most rapidly in recent years, at least in New York City. See Blanche Frank et al., "Current Drug Use Trends in New York City, June 1986" (New York Division of Substance Abuse Services report), 1. 85 Harry Anslinger and Kenneth W. Chapman, "Narcotic Addiction," Modern Medicine 25 (1957), 176. 86 Harold M. Schmeck, Jr., "Cocaine is Re-emerging as a Major Problem, While Marijuana Remains Popular," New York Times, November 15, 1971, p. 82. In 1937, by comparison, federal officials seized more than 118 kilograms of heroin, as against only 827 grams of cocaine. 87 Thomas L Dezelsky et al., "A Ten-Year Analysis of Non-Medical Drug Use Behavior at Five American Universities," Journal of School Health 51 (January 1981), 52-53; "The Growth of Cocaine Abuse: A Report by the Strategic Cocaine Unit of the DEA Office of Intelligence," Drug Enforcement 9 (Fall 1982), 18-20; Charles Blau, "Role of the Narcotic and Dangerous Drug Section in the Federal Government's Fight Against Drug Trafficking," Drug Enforcement 11 (Summer 1984), 17; Peter Kerr, "Rising Concern on Drugs Stirs Public to Activism,'' New York Times, August 10, 1986, Sec. 1, p. 28; Joel Brinkley, "Experts See U.S. Cocaine Problem as Continuing Despite Big Raids,'' New York Times, August 24, 1986, Sec. 1, p. 1; Louis L. Cregler and Herbert Mark, "Medical Complications of Cocaine Abuse," New England Journal of Medicine 315 (1986), 1495-1500; Elaine Sciolino with Stephen Engelberg, "Drive Against Narcotics Foiled by Security Fears," New York Times, April 10, 1988, Sec. 1, p. 1; and Rensselaer W. Lee, III, The White Labyrinth: Cocaine and Political Power (New Brunswick, NJ., and London: Transaction Publishers, 1989). 88 Selwyn Raab, "Drug Flood Altering Patterns of Use," New York Times, May 20, 1984, p. 50. Statistical information on the use of cocaine and other drugs by methadone patients may be found in Ball et al., "Characteristics," Tables 621-626. 89 Newman interview, cited above. See also Barry Spunt et al., "Methadone Diversion: A New Look," Journal of Drug Issues 16 (1986), 569-583, and James V. Spotts and Franklin C. Shontz, The Life Styles of Nine American Cocaine Users: Trips to the Land of Cockaigne (Washington, D.C.: U.S. Government Printing Office, 1976), 14. A good, if somewhat exaggerated, example of the criticism generated by diversion and "cheating" is Epstein, Agency of Fear, 246-250.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 90 The idea that increased cocaine consumption was partly a substitute for amphetamines is developed in Brecher et al., Licit and Illicit Drugs, 267-303. Brecher published his study in 1972; for most of the 1970s amphetamine use continued to decline as cocaine use rose. See Robert D. Budd, "Drug Use Trends among Los Angeles County Probationers over the Last Five Years," American Journal of Drug and Alcohol Abuse 7 (1980), 59; Goldstein et al., "Drug Dependence and Abuse," 94. 91 Wholesale price data are in "Nation's No. 1 Concern, but Politics Blurs Facts," New York Times, September 9, 1984, p. 12; for retail prices see Thomas E. Ricks, "The Cocaine Business: Big Risks and Profits, High Labor Turnover," Wall Street Journal, June 30, 1986, p. 1. Terry Williams, The Cocaine Kids: The Inside Story of a Teenage Drug Ring (Reading, Mass.: Addison-Wesley, 1989), is a superb ethnographic study of the spread of cocaine trafficking and use among the urban poor. 92 "Special Report: Black Tar Heroin in the United States," 19; the shotgun analogy is from Dr. Frank Gawin, remarks made at "The Cocaine Epidemic: A Symposium on Assessment and Treatment Approaches," University of Hartford, June 13, 1986. 93 Robert D. Budd, "The Use of Diazepam and of Cocaine in Combination with Other Drugs by Los Angeles County Probationers," American Journal of Drug and Alcohol Abuse 8 (1981), 249-255. [William Hopkins], "A Study of Crack Smokers" (NYDSAS Report, June 6, 1986), 2, notes that a variety of drugs, including pills, alcohol, and marijuana, have been used to cope with the after effects of crack. For more on the spread of crack smoking and its consequences, see James N. Hall, "Cocaine Smoking Ignites America,'' Street Pharmacologist 9 (January, 1986), 1, and Williams, Cocaine Kids. 94 Newsweek is representative of the change. In 1971 its coverage was balanced, matter of fact, and decidedly not alarmist; by 1986 crack was on the cover and held responsible for "an epidemic of urban lawlessness" and the destruction of "thousands of young lives" (cf. "It's the Real Thing," Newsweek 78 [September 27, 1971] and Tom Morganthau et al., "Crack and Crime," Newsweek 107 [June 16, 1986]). 95 Quoted in Erik Eckholm, "Cocaine's Vicious Spiral: Highs, Lows, Desperation," New York Times, August 17, 1986, Sec. 4, p. 24. See also the comments by Frank Gawin in Virginia Cowart, "National Concern About Drug Abuse Brings Athletes Under Unusual Scrutiny," Journal of the American Medical Association 256 (1986), 2459.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 96 Sheila Blume, "National Patterns of Alcohol Use and Abuse," in Robert B. Millman et al., eds., Research Developments in Drug and Alcohol Use (New York: New York Academy of Sciences, 1981), 6; David E. Kyvig, Repealing National Prohibition (Chicago: University of Chicago Press, 1979), 202. On the recent decline in consumption, see U.S. Department of Commerce, Bureau of the Census, Statistical Abstract of the United States, 1986 (Washington D.C.: U.S. Government Printing Office, 1985), 759. 97 "Letter from a Master Addict to Dangerous Drugs," British Journal of Addiction 53 (1957), 128. This article was written in Venice, Italy, in 1956 and published in January 1957. 98 Gawin symposium remarks. 99 Santangelo interview. 100 On the European situation see Lee I. Dogoloff and Caroline M. Devine, "Internation al Patterns of Drug Abuse and Control," in Millman et al., 17, and Laura M. Wicinski, "Europe Awash with Heroin," Drug Enforcement 8 (Summer 1981), 14-16. 101 David L. Westrate, "Drug Trafficking and Terrorism," Drug Enforcement 12 (Summer 1985), 19-24; Alan Riding, "Colombians Grow Weary of Waging the War on Drugs," New York Times, February 1, 1988, Al, A14; and Mills, Underground Empire, 3, 547, 561, 807, 1139-1143, 1149-1158, et passim. The DEA agents were Enrique Camarena, who was murdered in a way that suggests official collusion, and Victor Cortez, who was tortured by the Jalisco state police. 102 Mathea Falco, "The Big Business of Illicit Drugs," New York Times Magazine, December 11, 1983, p. 110; "Lucrative, Illegal and Corrupt," World Development Forum, 5 (November 15, 1987), 2. Lee, The White Labyrinth, is particularly good on the importance of cocaine to the Andean economies. 103 James Chace, "Getting to Sack the General," New York Review of Books 35 (April 28, 1988), 52-53; Mills, Underground Empire, 218-223, 358-365, 383-385, 727, 731, 788-789, 1133, 1140-1142; McCoy et al., Politics of Heroin, 218, 264-281, 309-313, 350. 104 This occurred chiefly during World War II, which was otherwise a boon to Anslinger's efforts to control the international traffic. The American
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment branch of the Mafia collaborated with the Office of Naval Intelligence in providing waterfront security for New York City, the Sicilian branch helped the army with the reconquest and occupation of Mussolini's Italy. One result was that Luciano was released from prison, deported, and able to play a key role in reviving the postwar heroin trade (McCoy et al., Politics of Heroin, 20-29). 105 "Reagan Urges Crusade Against Drug Scourge," Hartford Courant [from combined wire services], August 5, 1986, Al, A8; Bernard Weinraub, "Reagan Seeks Drug Tests for Key U.S. Employees," New York Times, August 5, 1986, A24; videotape of President and Mrs. Reagan's televised address of September 15, 1986. 106 The Reagan administration subsequently reneged on some of the promised expenditures; cf. Linda Greenhouse, "Congress Approves Anti-Drug Bill as Senate Bars a Death Provision," New York Times, October 18, 1986, pp. 1, 33, and Bernard Weinraub, "In Reagan's Drug War, Congress Has the Big Guns," New York Times, March 15, 1987, Sec. 4, p. 5. The political logic of this bill, which President Reagan signed into law on October 27, 1986, is apparent when one considers poll data showing that Americans then ranked drug abuse as a national problem second only to the federal deficit (Wall Street Journal/NBC News Poll, p. 1 of the Journal for October 24, 1986). Politicians were not the only ones to jump on the antidrug bandwagon. Journalists and editorialists also scrabbled aboard: ''It's time to take the gloves off. Time to act ruthlessly, without pity. Without remorse. Remove the scum that peddles this poison. What is so difficult? Arrest them. Lock them up and throw away the key" (full-page ad sponsored by Hartford Courant, November 19, 1986, E9). The same sort of rhetoric could have been found in virtually any Hearst newspaper in the 1920s and 1930s. 107 See Brecher et al., Licit and Illicit Drugs, passim. 108 Grinspoon and Bakalar, eds., Psychedelic Reflections, 22. 109 Quoted in "What is Our Drug Problem?" Harper's 271 (December 1985), 51. 110 William Butler Eldridge, Narcotics and the Law, 2nd rev. ed. (Chicago: University of Chicago Press, 1967), 118. 111 For a review of the statistical information on this point, see Chap. 4 of Alfred Lindesmith, The Addict and the Law, and Chap. 5 of Courtwright,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Dark Paradise. There was a long-term decline in the total number of narcotic addicts between 1910 and 1940, but this was due primarily to a decline in medical addiction. Very few new medical addicts were being created and many old ones, left over from the nineteenth century, were dying off. The Bureau's efforts were targeted at nonmedical addicts, and their numbers did not appreciably diminish, except during World War II.
Representative terms from entire chapter: