mitted. It is important that au addict be supplied a bed as soon as he decides
to seek help."
The California program
The present California law providing civil commitment for nai'cotic addicts
has been in effect since 1961. In summary, it provides commitment for addicts
convicted of misdemeanors and of felonies other than crimes of violence, and
for addicts who voluntarily seek commitment or whose relatives or friends
seek to have them committed after examination and hearing processes. The
California commitment process is in general patterned upon the laws governing
commitment of mentally ill persons.
If the commitment is involuntary, the maximum period of commitment is 7
years ; if the addict voluntarily sought help, the maximum period is two and a
half years. With certain exceptions dictated by court decision, no person is
usually eligible for parole until he has been a patient for 6 months, and no
person on parole is eligible for discharge from the rehabilitation program un-
less and until he has .successfully abstained fi-om the use of narcotics for 3
consecutive years. All patients are committed to the California Rehabilitation
3232
Center at Corona, Calif., administered by the State Department of Correction.
The superintendent of the center, Roland W. Wood, testified that since the
inception of the program, a total of 3,375 patients had been committed, of
whom 1,220 had been paroled into the aftercare program in their home commn-
nities. Of those released under supervision of caseworkers, 436 have been re-
turned to the rehabilitation center for various reasons, principally because
they violated the provisions of the original commitment. Dr. Wood pointed out
that about 50 percent of the former addicts remained in their communities
under supervision without visible evidence of returning to narcotic usage.
Dr. Wood emphasized his firm belief that the California civil commitment
program has, during its 3-year period of operation, demonstrated that (1) ad-
dicts can be treated in nonpunitive settings; (2) addicts can be retiirned for
additional treatment when they relapse into narcotic usage. l)ut without seri-
ous readdiction or criminal activity: (3) addicts can be successfully controlled
to prevent the spread of addiction: (4) when carefully supervised, addicts can
readjust to society and live in a drug-free atmosphere in their own communi-
ties: (5) efforts to treat addiction on a volutary basis will not generally prove
successful.
Although the intents and purposes of the New York law and the California
law are generally identical, the efforts in California manifestly have been more
successful, probably because addicts who enter the California program must
stay in it for specified periods of time, while New York's program has a high
attrition rate because addicts in large numbers disappear from treatment and
rehabilitation facilities. Furthermore, addicts in the California program are
carefully supervised in a drug-free environment after release insofar as that is
possible. As IMr. Wood told the subcommittee, "* * * we do have some positive
indications that the program is working and are encouraged at this point that
we can make headway in returning men and women to the community where
they can live responsible drug free lives."
Proposals for amhulatorn maintenance of narcotic addicts
The majority of witnesses before the subcommittee expressed stone views
tliat civil commitment for addicts provides the most satisfactory results and
offers the best avenues for the eventual return of addicts to useful living. At
the same time, most of these witnesses who spoke on behalf of the civil com-
mitment procedure and its corollary, supervised aftercare, also testified that
they firmly opposed certain proposals which would provide continuous ambula-
tory administration of maintenance dosages of narcotics to addicts, making the
drugs available through legal channels at relatively low prices. These propos-
als are generally known as "ambulatory maintenance" programs.
There were, of course, witnesses who provided professional views, opinions,
and conclusions in behalf of the ambulatory maintenance philosophy. This re-
port will summarize the positions of each side in this principal controversy
about the treament and rehabilitation of addicts, first I'eviewing tlie statements
made by those who favor ambulatory maintenance, then considering the testi-
mony of those opi)osed.
There were two organizations which furnished support for the ambulatory
maintenance theory, the Advisory Council of Judges of the National Council on
Crime and Delinquency, and the New York Academy of Medicine. Representa-
tives of bo*^}! groups provided statements for the record and were questioned
about their positions in staff interrogations. Witnesses for the Advisory Coun-
cil of Judges were Milton G. Rector, exective director of the National Council
on Crime and Delinquency, and Sol Rubin, counsel for the National Council.
The New Y'ork Academy of Medicine was represented by Dr. Lawrence C.
Kolb, a member of the Academy's subcommittee on drug addiction.
A primary point presented in the policy statement of the Council of Judges
was that the council believes that the Bureau of Narcotics, through its law en-
foT-^o'rient nolici'^s hns deter^-r^d doctors ^'"^m. ad^uni-tering ^'laintenance dos-
ages of narcotics if such dosages are medically indicated. The result of this
policy of the Bureau, said Mr Rector, is that "* * * it is pushers and racket-
eers who are 'treating' addicts rather than the medical profession, which
should have the primary responsibility both for treatment of addiction and re-
.search to find the ultimate cure and prevention."
!Mr. Rector said that the policy statement of the Advisory Council of Judges
supports these points :
1. The narcotic drug addict is a sick person, physically and psychologically,
and as such is entitled to qualified medical attention just as are other sick
3233
people. "We do not advocate that addicts he sustained on maintenance does
[emphasis supplied], but that if in a doctor's opinion such doses are necessary
for treatment of the illness, they should be administered for such time as the
doctor thinks necessary." :Mr. Rector exphiined that the Advisory Council of
Judges believes that "civil commitment of addicts is supported by advocates of
special hospitals or institutions. Such an approach seems to envision little more
than the institutionalization of all drug addicts under an illusory pretense of
noncriminal pr(»cedure * * *."
2. Narcotic traffic is properly controlled by legislation and effective penal
sanctions, and the traffic is a big isusiness of organized crime. Police action
The addict should concentrate on criminals at the upper administrative level,
should have medical help and should not be criminally prosecuted unless he
has committed a crime that requires his addiction to be considered secondary
to the nature of the crime.
3. The Council opposes mandatory prison terms in narcotics cases and op-
poses the exclusion of probation or parole. The Council feels that penal institu-
tions have ))ecome glutted in recent years with "small-fry pushers and addicts
serving long terms * * *."
Mr. Rector stated that the Advisory Council of Judges hopes, through advo-
cacy of the points made in its policy statement, to achieve (1) a change in the
I'egulations of the Narcotics Bureau to support the community treatment of
addiction as an illness; (2) the setting up by doctors and medical groups of
treatment centers, including clinics, and the freedom of individual doctors to
treat addicts.
The New York Academy of ]Medicine was represented at the sul^committee's
hearings by Dr. Lawrence C. Kolb, director of the New York Psychiatric Insti-
tute and chairman of the Department of Psychiatry at Columbia University,
who summarized two reports of the Academy concerning drug addiction, one
published in ld^5 and the other published in 1963. The program advocated by
the Academy was outlined by Dr. Kolb in the following points :
1. That addicts be reconized as sick persons.
2. That this recognition guide all agencies dealing with the narcotics prob-
lem.
3. That the medical approach to narcotics and addiction problems be encour-
aged by "recission of the present threatening regulation which denies to the
physician freedom to treat addiction according to his clinical judgment." Dr.
Kolb explained that such recission could be accomplished, in his view, "if the
Narcotics Bureau * * * would gracefully remove itself from the practice of
medicine * * * and remove the existins" unwarranted restriction now specified
in section 151.392 of Regulation No. 5" of title 26, Code of Federal Regula-
tions.
4. That all addicts should come under medical supervision or treatment.
5. That a national program for the eradication of addiction reflecting the
new policy be designed and put into effect.
Dr. Kolb emphasized in his statement to the subcommittee, that, following
the 1955 report of the New York Academy of Medicine, point No. 3 summa-
rized above was the focus of attention, and that the x\ca demy's program "was
misunderstood and misinterpreted by many organizations and persons." The
Academy, therefore, published a second report in 19(53, and Dr. Kolb summa-
ried its reflections of the Academy's position and program :
1. There has been progress in recognition that addicts are sick persons.
2. A tendency has developed to ignor"i2 or play down the role of profit in the
spread of addiction.
3. The regulation of the Bureau of Narcotics controlling the treatment of
addicts still stands. "* * * the physician is not permitted to exercise his clini-
cal .i'l'lsment * * *. Instead he must adhere to a narrow course laid down by
the Bureau * * *. The only method of treatment, that of immediate with-
drawal or detoxication, is outmoded * * *. Accordingly, there are therapeutic
decisions in which the physician must exercise his clinical judgment: whether
to institute withdrawal or recommend maintenance ; when to start withdrawal
and the choice of mode."
It is proper here to state that Dr. Kolb testified (P. 1294) that only a small
percentage of the addicts discussed in the report of the New York Academy of
Medicine, "possibly" 10 percent, could be treated as ambulatory outpatients. It
should also be pointed out that the policy of the Bureau of Narcotics (P. 664)
is to rely upon the American Medical Association and the National Research
3234
Council for recommended treatment for addicts and that the Bureau does not
initiate policy in this field.
Viewpoints favoring ambulatory maintenance
Proponents of ambulatory maintenance programs for narcotic addicts empha-
sized their views about certain results that they belive would be achieved by
initiation of such programs. These witnesses were Dr. Kolb, Mr. Rector, and
Mr. Rubin. In summary, they believe that all present methods of treatment
have failed, and that clinics to dispense driigs to addicts are the logical an-
swer to the serious problems of drug addiction. Under present practices, they
say, the underworld thrives on the profits from drug traffic and thousands of
addicts are forced to turn to crime to siipport their habits.
In clinics that would provide free drugs, or drugs at minimal cost, addicts
would be given narcotics under medical supervision, and would receive the psy-
chiatric care they need in a nonpunitive setting, and would be given family,
personal, and employment counseling that would enable them to take up u.seful
and responsible lives.
The primary results expected by the advocates of ambulatory maintenance if
addicts are placed luider medical supervision or treatment to the exclusion of
other practices were stated by Dr. Kolb in his statement to the subcommittee:
"As a result, one source of spread will be reduced ; another source, illicit traf-
fic, with its profit, will cease ; and sick persons will be restored to health."
As the proponents of maintenance see the effect of such programs, addicts
who are able freely to ol)tain from physicians the narcotics they need will
tend to avoid occasions of crime, whether the addicts are habituated to theft
and burglary to obtain money to sustain their habits or whether they are en-
gaged in the narcotic trafiic itself at the consumer level in order to obtain
drugs for their own use. The advocates of maintenance further state that the
extension of medical care to addicts and the administration of drugs as neces-
sary would, in the language of the report of the Advisory Coiincil of Judges,
"* * * deprive organized crime of a constantly increasing percentage of its cu-
tomers and would weaken the foundation of narcotics syndicates, which came
into existence only after the drug addict was 'criminr.lized." "
The judges' report declares that the illegal handling of narcotic drugs today
is a big business of organized crime, and that law enforcement efforts should
concentrate on reaching the criminals at the upper administrative level. The
New York Academy of Medicine strongly supported the viewpoint tli.it addic-
tion can only be spread by the source of supply.
The Academy of ?Iedicine report stated: '"* * * i*emoval of profit is the easi-
est and most effecive way by mass action to check and stamp out the spread
of illicit traffic. It is highly probable that without profit the illicit channels
would close and the supply of narcotics would dry up. Hence, the xVcademy
strongly espouses the virtual removal of profit from narcotics supply."
The Academy further said that removal of jirofit from the illicit traffic
would be accomplished by conferring full responsibility on physicians for dis-
tribution of narcotics.
Both the Council Judges and the New York Academy of Medicine linked the
pro.spects of success for their proposals to a reversal of the position that they
believe the Bureau of Narcotics holds on the distribution of narcotics 'oy physi-
cians. The proponents of ambulatory maintenance declare that the Bureau of
Narcotics so interprets decisions of the U.S. Supreme Court that the Bureau in
effect intimidates physicians and limits their freedom to prescribe narcotic
drugs under the Harrison Narcotic Act of 1914. The New York Academy of
Medicine report states : "Today the Treasury Department still continues to ig-
nore the Supreme Court." The proponents of ambulatory maintenance further
.say that since the Bureau of Narcotics has its own noti-m of treatment of ad-
dicts and since it realized that many physicians do not share its view, it does
not trust them and will not allow them to exercise their professional freedom
and responsibilit.v.
It should be pointed out tha*: Sol R'^bin. counsel of t!"> Advisory Touncil of
Judges, indicated in his testimony that the .iudges wIk; are meinheis of tlie
council approved the report as published, v.'ith only one limited dissenting
view. However, the sul)committee received from Judge William F. Smith, of
the U.S. Court of Appeals for the Third Circuit, a strong dissent from the
views expressed in the Advisory Council's report, and his statement is printed
in the record of the hearings (pp. 1275-1281). Judge Smith stated that he did
3235
not endorse the policy statement of the Advisory Council, because, in his view,
it was superficial and lacked "depth and objectivity," and because the state-
ment was primarily an attack ujion the validity of the Bureau of Narcotics'
regulation governing the prescription of narcotics, as well as a defense of the
policy espoused by liie New York Academy of Medicine in its report on drug
addiction.
Pers'.ns who favor tlie ambulatory maintenance progran^s have cited the so-
called "British system' of liandling the narcotic problem. The experience of
the United Kingdom in treating addiction, and subcommittee was told by sev-
eral witnesses, has frefiuently l)een propounded as a basis for American action.
British regulations provide that the individual doctor may treat an addict as
the doctor judges best from a medical point of view. The effect supposedly is
that some addicts are gradually withdrawn from narcotics by physicians, oth-
ers are prescribed for in minimiun dosages at regular intervals, and still oth-
ers are maintained on sui)posedly stable maintenance dosages after ever effort
has been made to cure the addiction. All doctors are prohibited from prescrib-
ing or dispensing narcotics solely to gratify addiction.
While none of the representatives of the New York Academy of Medicine or
of the Advisory Council of Judges who appeared at the hearings directly advo-
cated the adoption of the British system for the United States in their state-
ments or in the course of staff interrogatories, both organizations did refer fa-
vorably to the British system in the reports which they submitted.
The New Y'ork Academy of Medicine, for example, in its report relied
heavily upon the findings of E. M. Schur, assistant professor of sociology at
Tufts University, wlio has written extensively on the subject of British addic-
tion and is a strong proponent of adoption of the British system for use in the
United States. The Academy's "Report on Drug Addiction — II," pages 463^
364, states the Academy's findings :
In most respects, the British situaton contrasts sharply with that in this
country. Nevertheless, Schur sees no reason for not applying the British
approach, both in policy and practice, in the United States.
Argument on the British approach — its merits, its pertinency, and its ap-
plicability in the United States — has been going on for a long time : agree-
ment seems to be no nearer. The one certainty is that addiction here will
not pause aAvaiting a settlement. The Academy has no direct observations
of the situation in England. But on balance of the two conflicting present
tions, it finds Schur's arguments and interpretations the more cogent.
From all the observations and different interpretations, it finds nothing
that alters and much that supports its conception of what ought to be
done in the United States.
The Advisory Council of Judges also reported a supporting viewpoint on
page 13 of its statement:
In England a doctor is free to prescribe for an addict (a) under grad-
ual withdrawal treatment, (&) when it has been demonstrated that the
drugs cannot be safely discontinued, and (c) when it has been demon-
.strated that the patient is capable of leading a relatively normal life
under a minimum dose of morphine or heroin but not when the drug is en-
tirely discontinued. Although some believe that the British experience is
not applicable here, the weight of medical opinion supports the view that
the British program has been successful in avoiding a rise in addiction, in
keeping the addict from turning to crime, and in preventing racketeering
in narcotics.
While the above quotation from the report of the Advisory Council of
Judges stated that "the weight of medical opinion" supports the view that the
British program has been successful, it should be emphasized that the view-
point of the American Medical Association and the National Research Council,
who spoke for the overwhelming majority of American doctors, was that the
maintenance of stable do.sages for addicts is "generally inadequate and medi-
cally uiisound." and the ambulatory clinic plans for the withdrawal of narcot-
ics from addicts are "likewise generally inadequate and medically unsound."
Viewpoints opposed to ambulatory maimtenance
Dr. Harris Isbell director of the Federal hospital at Lexington, Ky., who is
opposed to and)ulatory maintentince, declared that the proponents of' this plan
have made the following erroneous assumptions :
1. Addicts are antisocial only because they require drugs ; if drugs were sup-
plied to them, they would not need large amounts of money and their anti-
social behavior would cease.
3236
2. Tf addicts wore snpii'ied with the drugs they require, the illicit market
would be eliminated. This would in turn reduce addiction, because it would
end recruiting by peddlers. Further, the underworld traffic would be abolished
because the profits would be eliminated.
3. Great Britain's addiction problem has been controlled because physicians
are permitted to supply addicts with narcotics on a continuing basis. The pro-
ponents believe that the United Kingdom's minor addiction problem is due to
this practice.
4. Supplying drugs to addicts would bring them into the open and would
permit the meui -ul profession and other persons to treat them, rehabilitate
them, and withdraw them from narcotics.
At the outset, it should be noted that the testimony of witnesses who op-
posed systems for the ambultory maintenace of narcotic addicts was greater by
far in volume than that of proponents of such systems. The following sectioa
of this report is therefore a marshaling of the main arguments against ambu-
latory maintenance.
The joint statement of the American Medical Association and the National
Research Council, published in May 1962. was introduced in testimony by Dr.
Dale C. Cameron. The views expressed in the statement received the "complete
approval'' of the Bureau of Narcotics. The joint statement not only di.sap-
proves of ambulatory maintenance, but it states the recommendations of the
two orgaizations for treatment and rehabilitation. The statement's pertinent
paragraphs are therefore quoted:
The maintenance of the stable dosage levels is generally inadequate and
medically unsound and ambulatory clinic plans for the withdrawal of nar-
cotics from addicts are likewise generally inadequate and medically un-
sound.
As a result of these conclusions the American Medical Association and
the National Research C'^aincH oppose on the basis of present knowledge
such ambulatory treatment plans (p. 1152).
*******
These two organizations support (1) after complete withdrawal. foUowup
treatment for addicts, including that available at rehabilitation centers,
(2) measures designed to permit the compulsory civil commitment of drug
addicts for treatment in a drug-free environment, (3) the advancement of
metliods and measures toward rehabilitation of the addict under continu-
ing civil commitment, (4) tlie development of research designed to gain
new knowledge about the prevention of drug addiction and the treatment
of addicted persons, and (5) the dissemination of factual informatii-n on
narcotic addiction (pp. 1155-1156).
Dr. Cameron, chairman of the joint committee that issued the statement,
w^as questioned about the controversy covered in the statement :
The Chairman. What is the source of the opposition to these reconnuen-
dations. or these methods?
Dr. Cametion. I am not aware that there is enormous opposition to these
methods. The three organizations that I just quoted are, it seems to me,
the three preeminent organizations in this field in the country (p. 11.56).
The joint statement contained an appendix supplied by Commissioner Gioi'-
dano of the Bureau of Narcotics, wliieh said, in part :
The Bureau is pleased to note that the American Medical Association
has I'eaflirmed its position opposing the eslalilishment of community ambu-
latory clinics for the withdrawal of narcotics from addicts and the con-
tinuing maintenance of addicts on narcotics.
The testimony that condemned ambulatory maintenance as "generally inade-
quate and medicary unsound" involved discussion of a number of important
considerations in the eA'aluation of ambulatory maintenance. A basic factor
among these w^as the tendency of narcotic addicts regularly to increase their
"tolerance" to the drugs to wdiich they are addicted. Tolerance is defined as
the j)hysical phenomenon by which the addict requires constantly increasing
quantities of the drug as its effectiveness for him diminishes, since he cannot
control his physiological depende!)ce nor achieve the principal psychological ef-
fect of addiction — eui)horia or an illusory sense of well-being — wittioiit regu-
lar'y adding to his daily intake.
Dr. Camron testified that the tolerance factor makes it not feasible to try to
maintain an addict on a stabilized dose of narcotics daily in an uncontrolled
setting. "Most addicts," he said, "will tend to increase their dose under these
3237
ciroiimstanees, if they can get the dnig."" He testified tliat certain addicts liave
tolerances for quantities of drugs wbicli would kill nontolerant persons, and
that he had once treated an addict who had a tolerance for (34 grains of medi-
cal morphine a day. Dr. Rohert W. Baird, chairman of the Haven Clinic, in