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Experiences in Narcotic Drug Control in the State of New York

By Sara Graham-Mulhall

New York Medical Journal, Vol. 113 (January 15, 1921), 106-11.

As administrator of the First District, which includes the Greater City of New York, where drug addiction has so focussed that the city is called the plague spot of the country, my task has been to study intensively a hitherto insoluble problem and to interpret and apply the law. My work may be classified as both repressive and humanely constructive. I have secured wholehearted cooperation and support from physicians, manufacturers, wholesalers, and druggists, in my campaign against the misuse of drugs of addiction. The results achieved are due in large measure to the success of these methods of cooperation. The repressive work has grown out of the department's supervision of the transactions in drugs by certain physicians, registered dealers and druggists, resulting in the detection of irregularities, frauds and illegitimate practices. Some idea of the vastness of this whole narcotic problem may be gathered from the following number of certificates issued:

Physicians 10,364

Apothecaries 4,415

Wholesalers and manufacturers 286

Dentists 2,275

Veterinarians 342

Institutions and hospitals 336

MANUFACTURERS AND WHOLESALERS

With the exception of medicine prescribed for patients by physicians, all orders for narcotic drugs involving the purchase or transfer of opium or cocaine or their derivatives must be made on official order blanks, serially numbered, which may be obtained from the Department of Narcotic Drug Control by registered dealers or users, or by government, public, or private hospitals. The only exceptions to this provision are, first, the permission to sell certain exempt preparations without any formal blanks, these preparations being remedies and medicines containing not more than a specified small amount of drug not considered dangerous and known as the lawful quantity; second, the exemption of such preparations as liniments and other ointments, which, while containing more than the lawful quantity, are in such form that the drug cannot be used except for external purposes. A record must be kept, however, even of these preparations.

PAREGORIC NO LONGER EXEMPT

Although heretofore exempt, a late ruling has brought paregoric under control. At Bluefield, West Virginia, in May, 1919, a druggist was found guilty of selling paregoric for other than medicinal purposes to an addict, through a second party, for several months. The penalty was imprisonment for two months or a fine of $200. Through this decision the department has been enabled to fight the paregoric habit in rural districts. We find that laudanum and paregoric are sold in large quantities by druggists and grocers in rural and suburban localities.

The reports, which the law requires at present from physicians, manufacturers, wholesalers and druggists, include a record of all drugs received for local use or distribution, and all drugs sold within the state, with the amount, date, name and address of purchaser. These thousands of narcotic reports are carefully scrutinized, and when violations are found, department inspectors are immediately detailed on the case. This system of control by the department has resulted in reducing the amount of narcotics distributed by seventyfive per cent.

In no division of control has greater vigilance to be exercised than in that which grants licenses to manufacturers and druggists. Reputable manufacturers have from the beginning sent in carefully compiled reports which constitute valuable data for the department, and in all ways possible they have aided the department in the carrying out of the antinarcotic act. Since the department has exercised control over the manufacturers and druggists, there has been a great increase in the number of those seeking to enter the field of narcotic manufacture. These applications are subjected to rigid investigation by the department. How unfit the majority of applicants are to be trusted with such commercial manufacture is indicated by the fact that only ten per cent. of those who apply are granted licenses.

In a number of instances those applying have already been granted Federal licenses. In other instances applicants upon writing for licenses have given addresses that upon investigation are found do not exist. In one instance, an applicant who thus gave a fictitious address was finally arrested and found with $200,000 worth of illegally procured narcotics. He was tried and convicted. Some of those who apply for licenses are gangsters, and some former addicts. A common trick is to secure a store or a loft in a busy building, pay rent in advance, and paint the windows so heavily with green or black pigment as to render them opaque. No furniture is put into the office until a license is granted, indicating that they do not intend to deal in the manufacture of drugs generally, but merely to specialize on narcotics. If the license is not granted, the applicants disappear so that they cannot be traced.

There has been a great increase in the number of applicants for druggists' licenses, showing that the activities of the department have stimulated applications in this division. Great vigilance is exercised over drug stores. While the majority of druggists cooperate with the department, some of them violate different provisions of the law. These fill doctors'prescriptions which are illegally made out; others who cater to the narcotic trade have such a tremendous rush of business that they do not properly care for prescriptions. In one instance a drug store, suspected by the department of illegal practices, was raided, and thousands of prescriptions were found in the cellar, so that the State and Federal officials literally waded in them. It was necessary to secure a Dumber of bags and to engage a truck to take these to headquarters. The druggists encouraged their addict customers to loiter around their shops, either in the place itself or on the adjacent corner. Drugs were the sole topic of conversation among these loiterers, who smoked incessantly. The department brought the matter to the attention of the druggists and requested them not to permit their addict customers to remain in the store or in the vicinity longer than to have their prescriptions filled, and they were to go home before administering it. The addicts were threatened with arrest if they continued to make public nuisances of themselves. Many druggists were warm in their expression of appreciation of the department's vigilance in this regard.

THE PHYSICIAN

An erroneous opinion in regard to the physician has been held by the public, that he is solely responsible for the spread of addiction. Intensive study of the narcotic situation shows unmistakably that in ninety per cent. of the cases the addict under thirty acquired the habit through bad association and home environment, and the middleaged and elderly become addicts through selfrnedication. Experience with thousands of addicts at the clinic, through registration procedure, at hospitals and with hospital releases, demonstrates that the narcotic addict is a medical responsibility for ten daysduring the withdrawal period-after which he becomes solely a sociological problem.

LEGITIMATE PRESCRIBING

The only way the addict may obtain drugs legitimately is through the instrumentality of the physician, who may either administer or dispense them himself, or write a prescription for them. It is at once evident that a very important power is given to the physician and that a great deal depends on the use he makes of this power. Most physicians are exercising great care; others are careless in prescribing drugs, and some are known to be unscrupulous, using their professional license as middlemen in the nefarious practice in the enslavement of addicts. It is because of these conditions that the

Department of Narcotic Drug Control has had to exercise great vigilance in administering the law. This is a very delicate problem, since the general purpose of the law is not to add to the burden of reputable physicians, but to check those whose activities are questionable.

MISUSE OF THE OFFICIAL BLANK

A woman arrives in New York with letters from the physicians in her home city, in which it is stated that she has a painful facial disease. The woman comes under the notice of the department when no fewer than four physicians, no one of whom knew of the others prescribing, sent reports and requests concerning her to the department. It appears that when a physician, after prescribing, explains to the woman that she must come under the law and that he can treat her but once on an unofficial blank, she does not return to him, but applies to another doctor, who innocently prescribes for her and in turn appeals to the department in her behalf, not knowing that she is a peripatetic addict.

Here is an instance where a patient tried to take an unfair advantage of the unofficial blank and thus escape registration. Unfortunately for her, the physicians whom she approached were law abiding men, who refused to treat her the second time without a certificate, and reported her to the department.

Another case is that of a hospital orderly who was registered as an addict with the department, his dose being one grain a day. As his prescriptions ceased to come in, an investigation was made. It was found that the man had gone to a commercial prescribing doctor who knew him to be an addict and from him he received prescriptions for four grains on unofficial prescriptions.

The department has uncovered thousands of cases of the misuse of the unofficial blank. Such violations of the narcotic act have been so flagrant and difficult to unearth that a ruling to abolish the unofficial blank is the only possible method of control.

EXCESSIVE DOSES

When I took office in April, 1919, prescriptions of from forty to inety grains of morphine or heroine were frequent. The group of commercial narcotic prescribing doctors aggregated in their prescriptions in one month 1,760,000 grains of narcotic drugs. The department early adopted the policy of following up such prescriptions, and the pressure it brought to bear has resulted in great reductions in the amounts prescribed. It is now exceptional to find prescriptions calling for more than ten grains of morphine. Cocaine is restricted to a few grains a month, and heroine has been practically eliminated.

In May, 1919, there were in my district sixty-five commercial narcotic prescribing doctors. These physicians controlled the narcotic situation to a large extent. It was unfair that so small a group, composed mainly of foreigners, should throw discredit on the whole medical profession. No time was lost in bringing pressure to bear on this group. A striking example of the violation of the narcotic act was furnished by one of the group. This popular narcotic practitioner left the upper sash of the basement window lowered. Into this opening his hundreds of patients daily tossed their registration cards. These were gathered up by his wife and carried to the doctor. On the morning of his arrest he was found by the officers of the law, in bed, in an upper story, with the registration cards of forty-five of his patients, in which he was busily engaged writing prescriptions for addicts whom he did not see. It was the custom for his wife to return these cards to the patients. Thus he was enabled to secure a princely income with very little effort.

Previous to my taking office, one of these physicians prescribed in one month 68,282 grains of heroine, 54,097 grains of morphine, 30,280 grains of cocaine. This same physician after supervision by the department prescribed 18,000 grains of morphine in one month, no heroine and no cocaine. By November, 1920, the number of commercial prescribing doctors in my territory was reduced to four, having over twenty-five patients, the highest number prescribed for by any of the four being a hundred.

A startling instance of a doctor prescribing a grain a day for an infant shows a sinister phase of careless prescribing. This infant was habitually le f t on the sidewalk in a perambulator between 11 a.m. and 3 a.m. When the mother was questioned, she explained that she was obliged to leave the child on the street as she earned her living by cleaning saloons and drug stores after 1 1 p.m. She could not leave the infant at home because she asserted that it was an addict and she administered the drug to it at stated intervals. This she could not trust anyone else to do. As the weather was warm, the infant was more comfortable in the open air. I wish to emphasize that this infant received a grain a day on the prescription of a narcotic prescribing physician. When the infant was placed in a hospital under the observation of Dr. L. Emmet Holt, the child showed no withdrawal symptoms. This infant was being drugged on the supposition that it was an addict because its mother was an addict.

Another condition requiring control was the unexpected result of an order issued July 31, 1919, by the then commissioner of the Internal Revenue Department, Daniel C. Roper. This order to his subordinates stated that the vigorous enforcement of the Harrison law must be carried out in such a manner as not to produce unwarranted suffering on the part of the addicts. This was interpreted by the commercial prescribing doctors as license to issue emergency prescriptions.

An example of flagrant prescribing is furnished by one physician, who wrote eight hundred emergency prescriptions in one day. Another development of this relaxation of the law was a flooding of the department with demands for exemptions by the commercial group from the rules and regulations, until a total of eight thousand were received. This entailed careful investigations and medical examinations, with the result that only five hundred of the applicants were found to be entitled to exemptions.

Further study of the situation revealed that the addict was being supplied with drugs from many sources; from the prescriptions of physicians legitimately and also in illegal ways. The first step in the control of his drug supply was the establishment of a narcotic clinic. The department also ordered compulsory registration, appointing the commissioner of health, Dr. Royal S. Copeland, its agent. On July 14, 1919, registration went into effect under his supervision. On and after that date every addict was required to be registered. When he presented himself at the clinic, he was physically examined by a physician, after which he received a registration card which contained his photograph, his name, his address, his age, and his dose sheet. Each time the doctor prescribed for an addict, he was required to sign a designated blank space on the dose sheet for that day, as was also the apothecary when filling the prescription. It was hoped that the addict would not receive more than one prescription for that day because the next doctor or apothecary would see that the space on the calendar dose sheet for that day had already been signed, and therefore would not violate the interpretation of the United States Supreme Court's decision. Over 7,500 addicts were thus registered, which is undoubtedly much fewer than the total number of addicts in the city.

The dose sheets served to show, however, how commercial prescribing doctors took advantage of technicalities under the guise of the ambulatory treatment. They accepted at face value the claim of the addict as to the amount of drug he required, and wrote the figures in such a way as to make forging easy.

Apothecaries who were catering to this kind of trade winked at the violations. Counterfeit dose sheets soon made their appearance, and were forged as to the amount of drug allowed. The extent of the violations may be judged by the fact that the department has a collection of 1,500 counterfeit dose sheets, in which the same doctor prescribed for the same addict twice a day on each of two such dose sheets. The commercial prescribing group signed their names illegibly, often with a mere wave of the pen, making forging easy, and giving no ground for prosecuting the apothecary who accepted the prescription offered with such dose sheets. Again and again the department realized what a conspiracy ambulatory practice allowed.

Under this prevailing practice the addict is commonly treated by what is known as the ambulatory method, by which the patient agrees to submit, or pretends to submit, to the reduction of his dose gradually by a slight amount while going about his customary business, in the hope that eventually the dose will be so small as to enable the addict to abandon it altogether without serious discomfort.

Can such a method succeed? It has been shown that the craving for drugs is of the most pressing and insistent sort; and that enforced abstinence produces extreme agony. It has also been shown that he cannot be trusted with any considerable amount in his possession. Is it not contrary to all reason and experience, therefore, to expect success from a method by which the addict is asked to undergo with fortitude and selfcontrol one of the most critical stages in the cure of his habit?

Even those addicts who insist that they are determined to rid themselves of the habit, after they have had the usual dose, change in their mood, lose determination and relapse when their supply seems to be in danger. Many addicts have had the courage to begin treatment under the reduction method, and have placed themselves wholeheartedly under the care of an honest physician. For a brief time they have resisted temptation, and have held out against violation of their pledge to the doctor while the dose was being diminished by very slight amounts. But sooner or later, the dose seemed inadequate or reached too low a point; they felt great pain and complained of being ill. No restraint but their own feeble will, weakened by years of addiction, has stood as a barrier to their impulse to relieve their suffering and deceive the doctor. They have bought drugs "on the street" or have gone to another doctor for "treatment" thus doubling their dose. The physician soon gets an inkling of this condition, and it discourages his hopes of achieving a cure. The drug addict thus learns to deceive.

The consensus of opinion among all those who have given careful study to the problem of drug addiction condemns this method, as is brought out clearly in the report of Dr. E. Eliot Harris, chairman of the Special Committee on the Narcotic Situation in the United States, appointed by the American Medical Association. The large number of repeaters who went to the clinic and to penal institutions gave strong support to this view which condemns the ambulatory method of treatment. The clinic was organized for the humane purpose of saving the addict from the profiteering doctor and the profiteering druggist and to prepare him for hospitalization. Addicts received their medicine at wholesale prices and they had every attention. They came by thousands when they found that they could get the drug for very little money and without doctors' fees. The first day the clinic was opened, cocaine was dispensed, but it was stopped on the second day, no cocaine being again dispensed there. The chief drugs sold were heroine and morphine, ninety per cent. of the addicts who came to the clinic being heroine users, who acquired the habit through bad association. All classes attended the clinic-the underworld, the criminal, respectable men and women, including physicians, clergymen, nurses and actors. The addict was started on the maximum dose of fifteen grains, regardless of whether he had formerly received thirty or seventy grains (these being the average doses prescribed for thousands of addicts throughout the city). Thereafter the dose was regularly reduced in accordance with the decision of the United States Supreme Court. Demoralization set in and the addicts became discontented.

As the third step in control, a hospital at Riverside was opened and when the addicts reached the irreducible minimum, they were compelled either to go to the hospital or were refused further doses at the clinic, the monthly dose sheet being then denied them. At this period in the history of the clinic we lost sight of thousands of addicts. The number of prescriptions issued will give some idea of what the work entailed, some days over two thousand prescriptions being issued. As the dose became smaller, the demoralization grew. The constant reduction of the dose incensed the addict and he resorted to petty larceny-stole pocketbooks, fountain pens, any small saleable object that he could lay his hands upon. He also lied and forged in order to obtain additional drug.

The majority of the addicts who patronized the clinic were of the underworld type and the respectable men and women who were compelled to go there through poverty were soon demoralized, their addresses were secured and they were followed to their homes. Peddlers openly plied their trade in the clinic in spite of six supervising policemen. When one peddler more daring than the others was arrested, another immediately took his place. In the course of time the addicts were shut out of the lavatories and retiring rooms which had been assigned to them to selfadminister the drug, as they grossly abused these privileges. The addicts then resorted to an adjacent park where in the open air and before groups of school children, they applied the hypodermic needle and generally conducted themselves in an unseemly manner. The scenes became so scandalous that petitions were sent to the Governor of the State and to others calling for the suppression of these demoralizing daily exhibitions by the closing of the clinic.

Within a period of eleven months the clinic had run its course. It had failed as a clearing house for the hospital, had become a profitable market for peddlers, and the socalled reduction method failed to cure any addicts. It was only through the authority the department imposed upon them, supplemented by moral suasion, that even so few as 2,800 of the 7,700 registered addicts were induced to go to the hospital. The narcotic clinic stands out as an enormously expensive and colossal failure. The third step in attempted control was the hospital.

The experiment was made with a municipal hospital, where the treatment was scientific and skillful, which resulted in ideal conditions for the short-term hospital experiment. The full treatment there was for a period of six weeks only. Patients in all stages of physical condition, undernourished, drug saturated, highly nervous, or deadened by narcotics, were received. These were each subjected to a preliminary treatment suited to the needs of the individual.

Quoting Dr. Braunlich in charge of this municipal hospital: "The marked abstinence symptoms on withdrawal of the drug are selflimited to seventy-two hours. After the drug has been withdrawn and the addict has passed through the mild hyoscine treatment, he finds himself in the convalescent building. Although he is much weakened, he is able to be up and around, but because of his muscular weakness and his sleeplessness, he is at his worst as to his craving for the drug. This is the danger period for the addict and it is during this time that he needs the most careful watching and medication." At this hospital those in charge administered at this period hypnotics such as bromides, veronal, and chloral. Within another week the patient was sent from the convalescent ward to the dormitory building where he was given suitable work. He received no more medicine of any kind except for some intercurrent affection.

Among all convalescent addicts a peculiar state of mind exists, a craving for the drug which persists even after its withdrawal. The tendency of the mind is to revert to narcotics and this becomes more pronounced if the former addict knows how to get the drug or has hoped to get it. Dr. Braunlich states that if the patient has any hope of getting the drug during the six weeks' period of treatment, he will undoubtedly relapse into his old habit.

The addicts when discharged from the hospital showed an average increase of from twenty-five to forty pounds in weight. Peddlers and fellow addicts met the hospital discharges on the New York boat landing and tempted them with an offer of free drugs under the guise of good fellowship. Of those who withstood the first onslaught, a percentage succumbed when they returned to their old neighborhoods and met the boys and their former narcotic physicians. We have demonstrated that the municipal short term hospital, although administering a benign and effective cure, has been conceded by all those in charge as lacking in the scientific feature of classification. Criminals, defectives, the tuberculous, the moral and the immoral, and those whose only weakness was drug addiction, were accepted indiscriminately. This is a serious defect of the short term hospital and is largely responsible for the number who are buying drugs on the street.

When the department took office it found that the addicts were generally despised and without either officials or laymen to plead that they be treated humanely. It was assumed without basis of fact that the addict was a wilfully vicious creature who refused to abandon his habit although he could do so if he would. Acting upon this theory the courts, the police and the jail keepers treated him as a despicable creature who merited only severe treatment and this was usually accorded him. Even the court forms for voluntary commitments to hospitals were couched in punitive terms. The department has materially modified these hard conditions.

New York city was peculiar in its form of drug addiction, as over ninety per cent. of its drug users were addicted to heroine, the most baneful, the most powerful of habit forming drugs, and the most detrimental in its effect upon the user. It is cheap, because it demands neither lay out nor hypodermic syringe, and can be taken for some time without disturbing the health; it stops the craving without diminishing the working capacity to a degree which would prevent the earning of money to buy the drug. It is sniffed through the nose on a quill, and the addict can take heroine without fear of being detected or being interfered with. This drug has developed a distinct class with a certain amount of freemasonry and cooperation among themselves, which is necessary to make it easy for users to procure heroine and also to safeguard one another in the indulgence of a practice forbidden by law. The majority of the heroine users were young men whose easy sociability developed into gangs. In their leisure hours they flocked together in dance halls, pool rooms, roller skating halls, and movies. For some time the boys remain in good health and possess a fair degree of intelligence. Because of their youth they lack individual initiative, are imitative and easily led, and fall into the habit easily, the tragic part being, ignorantly. Once the habit is established, interest is lost in work. The addicts become late and irregular in their hours of work and finally they throw up their positions. Many are good workmen, but they only work long enough to procure money with which to buy the drug.

On March 6, 1920, the department instituted a moral drive against the prescribing of heroine. The cooperation of doctors and druggists was asked through every possible means of communication, they being requested to substitute morphine for heroine all along the line. The response was cordial and prompt, and within forty-eight hours from the time the signal was given to the first doctor, heroine was taboo in the Greater City of New York. I am in receipt of many letters from both physicians and addicts warmly thanking me for the order. The improvement reported is a lessening of nervousness, improvement in appetite, and restful sleep, an experience many of them had not enjoyed for many months.

Dr. B. reports: "It gives me pleasure to inform you that your ruling eliminating heroine has been a blessing in disguise to many addicts. The first few days were a nightmare to both the addict and the physician; however, as soon as the systems of the addicts adapted themselves to the new drug (morphine) very few complained, in fact at least ten openly expressed their happiness at the change. Do not let anyone tell you that an addict cannot let heroine alone, and don't let any one tell you that he will die. I think you made a glorious move in doing what you did (attack on heroine) March 8, 1920."

Now it is rare for the department to receive a physician's prescription calling for even the smallest amount of heroine. As you probably know, heroine is being sent into China to a considerable extent, large amounts being exported from this country. The heroine habit there is taking the place of the far less dangerous vice of opium.

It is not always the perversion of the social instincts alone that is responsible for the creation of new addicts. Among those interested in such gangs are the illicit peddler, the smuggler, and the trafficker, whose commercial motives result in the enslavement of new victims. In its most vicious phases, the power of dispensing the much prized drug is one of the surest ways for a "Fagin" to hold his pupils or a white slaver to maintain control over his prey.

Peddlers, like drug addiction, flourish in centres of large or congested population. True to the name, the peddler has no store or permanent place where he carries on his trade. He may take up his stand at a certain street corner or in the middle of a block for a day, possibly a week, after which he will move to a position a mile or two away in the same city, or even move to another city. The smuggled drug is not, however, the peddler's sole source of supply. He will often finance the drug addict. As an illustration, the addict may be too poor to pay for a doctor's prescription, or to pay the druggist for filling it. The peddler will give him the necessary money, it being agreed between them that when the addict procures the drug he will divide it with the peddler. A peddler who thus finances from twenty to fifty drug addicts will obtain not only a fair supply of the drug, but reap a material profit on his initial outlay of money, for he sells the drug at a rate in excess of that charged by the druggist, and he adulterates it in order to make it go further, the most used substance for adulteration being sugar of milk, or some other article sufficiently white to resemble the drug. I have known of instances where the addict who had paid at the rate of a dollar a grain would get six tenths of a grain, and many more instances where he would be sold nothing but pure sugar of milk. I realize that this will naturally cause the question to be asked, Why then does the addict buy from the peddler? There are three answers: The hesitation of having his addiction known to the authorities, as it would be if treated by a doctor or at a clinic; the inclination to satisfy his craving by illegitimate means, and the fear of having his dose reduced by the doctor or the clinic.

The speedy elimination of the narcotic peddler is the object of a plan I submitted to Commissioner Enright, of the New York Police Department, a plan which he accepted. It called for the creation of a special narcotic corps with a criminologist, who is also a physician, at the head. This corps supplements the Federal, State and Municipal narcotic agents and its special duties will be the detection and arrest of illicit peddlers. The physician whom I suggested as head of the corps had been for more than a year in charge of the department's clinic, where by special orders he was permitted to study the conditions and histories of thousands of addicts, also the policies and future plans of the department. This cooperation between the State narcotic department and the municipal police has resulted in a vigorous campaign against the peddler. I have also enlisted the cooperation of the State constabulary, the chairman of which is Dr. Lewis Rutherford B. Morris, for the outlying cities and towns of my district. With these aggressive bodies continually on their trail, the peddlers will soon realize that New York is no longer an open town.

My appeal is now in behalf of 22,000 registered narcotic addicts, together with unnumbered thousands in this State, who are neglected and shunned by the public. The following facts are pregnant with meaning:

1. The addict cannot free himself.

2. He needs institutional custodial care to relieve him permanently of his habit and to rebuild him spiritually, mentally, and physically, so that he can be returned to society an asset.

There is no gainsaying these statements. What provision do the State and the city make to meet adequately these desperate needs? New York city closes its hospitals-Bellevue, Metropolitan, Kings County, and the remaining hospital, Riverside, is being run on a three weeks' schedule instead of one of six weeks as heretofore. Its present capacity is from fifteen to twenty-five, formerly a capacity for 800. The patients are now released when they are psychologically and physically unprepared to be sent back to their old environment and its temptations. The results of this short term hospital emphasize the fact that such limited treatment is a waste of time and money.

The United States Government has fully recognized that addiction is a country wide problem, but it has only emphasized the punitive attributes of the Harrison antinarcotic law rigidly enforced. This is the crux of the whole situation. Due to these one sided measures of attack, this problem has remained unsolved because the Federal Government has thus far failed to recognize that the humane attitude and the law enforcement attitude are antagonistic and nullify each other unless united, as they should be in a great State institution for the proper custody, care and cure of the addict. The same argument holds good for the several States.

The initial step in this combination of effort is the establishment of institutions where the addict can be properly cared for on the institutional colony plan, which admits of segregation of the several classes and employment in the arts and crafts and farming. Such institutions should be under medical direction.

Under a plan for commitment of drug addicts, the State institutions can be used for the permanent reclamation of these unfortunates. After the addict is taken off the drug, he will be placed under the observation of experts for classification.

Class I: Those who suffer from a disease or ailment requiring the use of narcotic drugs.

Class II: Addicts are those who use narcotic drugs for the comfort they afford and solely by reason of an acquired habit.

Class II may be subdivided into: a, correctional; b, mental defectives; c, social misfits; d, fortuitous (occurring by chance).

For those who are found to be true defectives, the State institution will not be the proper place, as institutions are already in existence for the care of mental defectives, where they are segregated and made as useful as possible. Among the correctional cases there will probably be worked out certain subclasses. Those who are true criminals will be sent to other institutions. There will also be borderline mental cases which can be industrially reclaimed and returned to the world, if kept under the supervision of a wise probation system. The true cases for this colony life will be found among the social misfits, who will find here their great chance to make the start in life that they never had, under such direction as will assist them to find their proper place. Such a life will also be of the greatest benefit to those who are normal except for their drug addiction.

The present is full of hope because we have found, upon investigation and experiment, that the drug addiction problem is soluble. To begin with, the average age of the addicts is only twenty-four years. We have brought the general public to a realization of the extent and the menace of drug addiction which it now knows transcends in seriousness the much discussed alcoholism, and this awakened public opinion can be relied upon in the future to support all worthy measures designed to relieve this country of drug addiction. In spite of the failures of the clinic and the short term hospital, they have served the useful purpose of pointing the way to the only possible solution of drug addiction, that is, the State narcotic institution on the colony plan, for the rehabilitation of the addict, physically, mentally, and morally. The department is grateful to the members of the medical profession for the cooperation extended in the past, and it looks forward to their cooperation and help in the future.

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