DEPARTMENT OF HEALTH

OF THE

CITY OF NEW YORK

ROYAL S. COPELAND, M.D., COMMISSIONER

 

No. 87 REPRINT SERIES FesRuARY, 1920

 

THE NEW YORK CITY NARCOTIC CLINIC

AND

DIFFERING POINTS OF VIEW ON
NARCOTIC ADDICTION

BY

S. DANA HUBBARD, M.D., AcTING DIRECTOR

BUREAU OF PUBLIC HEALTH EDUCATION,
DEPARTMENT OF HEALTH,
CiTY.OF NEW YORK

 

Public health is purchasable. Wirthin natural limitations
a community can determine its own death rate.

25A-5001-’20-B
 
THE NEW YORK CITY NARCOTIC CLINIC AND DIFFERING
POINTS OF VIEW ON NARCOTIC ADDICTION

BY S. DANA HUBBARD, M.D.
Acting Director, Bureau of Public Health Education

py

The problem of narcotic addiction has been in the public eye for
some time, and the differing points of view regarding narcotic addic-
tion have been provocative of some very interesting discussion.

In the spring of last year, the Federal authorities having made -
several raids on trafficking physicians and druggists, an acute emerg-
ency was created whereby it was feared by some that a panic of these
miserable unfortunates would ensue. These conditions -caused the
New York City Department of Health to open a narcotic relief clinic
in order to study and examine into the subject of narcotic drug addic-
tions.

The problem of narcotic drug addiction is somewhat to be com-
pared with village gossip—but few know the actual facts—and it is |,
extremely interesting to find how many peculiar and extravagant opin-
ions are expressed regarding such mysteries. This is very applicable
to the facts regarding drug habits.

Number of Drug Addicts in New York City

Many opinions regarding the prevalence and frequency of drug
addiction have been expressed. No doubt many of these statements
are far from true. We do not know who the addicts are, nor how
many there are of them, either here or elsewhere in this country.
Why? From opinions expressed, and from the literature on this
subject, we have been lead to believe that addiction was allocated
with certain definite physical stigmata: pallor, emaciation, nervous-
ness, apprehension, snuffling, needle puncture markings, and tatto skin
evidences; but in actual experience with hundreds of acknowledged
‘drug addicts, persons actually seeking their drug supply, we find, like
the weather indications, all such signs failing.

There are drug addicts constitutionally inferior, and superior;
feeble minded, and strong minded; physically below, and above par;
morally inferior, and superior. No one class of society seems, in our
experience, to enjoy a monopoly in this practice. Our opinions, there-
fore, regarding the number of drug addicts, heré and elsewhere about
 

“4 S. DANA HUBBARD, M. D.

this country, have very naturally had to be revised. While it was
the current opinion to think that they existed in vast numbers—esti-
mated by some as one per cent. of the community, and even two and
three per cent. by others—we, today, think that this is greatly over-

‘estimated.

It was formerly held that drug addiction was so general and so
frequent that if the law—the Harrison Act—was enforced, as it
should be, a panic would be created by the immense numbers of addicts
who would seek relief.

The efforts of the New York City Department of Health, actu-
ated and urged by the Commissioner of Health, Dr. Royal S. Copeland,
showed that this fear of the production of a panic was a false one.
‘Our efforts were given wide publicity, and the cooperation of medical
and scientific societies earnestly and zealously sought to help solve
this problem. It might be added also that the raids initiated by the
Federal authorities—arresting illicit prescribers and dispensers—to- —
gether with the New York State Narcotic Commission requiring
registration of all addicts in this locality have not occasioned any
undue excitement among these individuals. We, naturally, must
infer that the enormous numbers of drug addicts supposed to exist, in
this vicinity at least (and it was supposed to be greater here than
anywhere else) are mythical and untrue and that therefore the fear
of a panic of these misearable unfortunates was negative.

From our experience with narcotic relief and registration in New
York City, we now are of the opinion that the present law—the Harri-
son Act—should be strictly and uniformly enforced. To do so would
bring these tipplers in drugs to the front, and would hurt no one, not
even the users themselves. These opinions, while radical, are not
given to belittle the opinions previously expressed by persons sup-

- posedly well-informed on this matter, but are the results of an actual

practical and intimate working knowledge of this subject.

Character of Addicts

It has been said that the experience in the Department of Health
emergency narcotic clinic was unique; that the character of the addicts
visiting this service was very exceptional. Possibly our experience
dealt with an unusual feature of this problem, but from personal con-
sultations with many acknowledged addicts—in all walks of life—
journalists, ministers, writers, physicians, clergymen, teachers, business
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 5

men, etc., seeking interpretation of the law’s requirements, as it affected
them individually—they being addicts—we naturally had an oppor-
tunity for first-hand information.

The arrest ‘of several trafficking physicians and druggists for vio-
lating the narcotic laws caused the Department of Health to open a
relief clinic, which began as an emergency and was expected, naturally,
to be only a temporary expedient, but the necessity was so acute, and
attracted so much attention from those interested, that the Commis-
sioner of Health decided to continue it for some time, in order to
study this subject and obtain data regarding this problem.

The Narcotic Clinic, 145 Worth Street, New York City, was
opened April 10, 1919. The clinic ministered to those willing to be-
come its patients. The acute enforcement of the narcotic law by the ©
Federal authorities made trafficking physicians and druggists fearful
to prescribe and dispense for their addicts, and this factor sent these
persons to this public emergency clinic. They appeared to come from
all stations of society, and seemed to represent a fair average of these
habitués.

We feel that we have had an unusually wide and peculiarly general
experience with drug addicts of all classes—classes so large as to make
us think that others’ experience in this form of practice has not been
nearly so extensive.

The public, narcotic clinic is a new thing. In fact there are only a
very few in existence and, if we may judge from our experience, they
are not desirable, and do not satisfactorily deal with this problem.
We have given the clinic a careful and thorough as well as a lengthy
trial and we honestly believe it is unwise to maintain it longer.

The clinic has been found to possess all the objectionable features
characteristic of the so-called “ambulatory ” treatment, as practiced
by the trafficking physicians, except one, the financial profit to a few
physicians (about one-half of one per cent. of the doctors of this city)
. performing this character of service.

Length of Time Using Drug

The average duration of our patients on the drug was 6 to 7 years
—79 per cent. being under ten years’ duration. This is interesting,
because, when they drift from drug using, where next do they go?

Those who have studied and followed carefully the chronic alco-
holic addict, know very accurately that he goes down, down, down, -
Pd

6 S. DANA HUBBARD, M. D.

drifting from usefulness to idleness, from good to bad conduct, finally
from health to disease, and indulgence foreshortens the life period
by a high percentage. The ear-marks of chronic alcoholic indulgence
are not pathognomonic, yet they are generally recognized in our pre-
cociously advanced cases of poverty, disease, and early death; in these
there are indications, in very many instances, where the history of »
chronic alcoholic indulgence and the clinical phenomena correlate cause
and effect. This, in our study of narcotic drug addiction, is not so
obvious. In our institutions for the poor, the aged, and the feeble-
minded, drug addicts are exceptional, in fact it might be safe to state |
that they are rare. Now, what becomes of these drug habitués? Our
dead, found in public places, and our deaths by suicide, as well as our
pauper dead, fail to indicate, as the cause of such endings, any connec-
tion with the habit of drug addiction. This drug indulgence must leave
a mark on the system, in many instances, especially in the cases of those
addicts using hypodermic needles—here the tattooing and abscess
cicatrizations, while perhaps in many instances not positively indicative,
yet are so characteristic that it is felt certain that if one of these
cases was found dead, the drug addiction marks would be quickly
determined by either the Coroner or City Examiner, or last attending
institutional physician, and these complicating facts noted in the final
record. | | |

Dr. Charles Norris, Chief Medical Examiner of New York City,
advises us regarding such instances as follows:

- Deaths from Over-dose of Narcotics, New York City
| January 1—December 1, 1919

 

 

Manhattan. Bronx. Brooklyn. Queens. Richmond. Total.

 

Morphine ....... 28 3 1 i 32
Heroin ......... 12 wi 1 13
Opium .......... 3 1 2 6
Cocaine ......... 1 1

Aggregate .. 43 1 7 1 . 52

 

e

Total number of deaths from all causes reported to Medical Examiner.. 10,828

 

The doctor also states: “There is one thing that has impressed
me in the morgue work in Manhattan, namely, the relative infrequency .
of finding marks of hypodermic areas of cicatrizations. I cannot tell
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 7

you at the moment how many: of the 43 cases had marks but they are
comparatively few.’ In our experience at the clinic—where we per-
mitted the addict, when he had obtained his supply, to administer his
dose to himself—the unmistakable markings on the person appeared
to be quite frequent and of a permanent character. These, without
doubt, would be easily discoverable upon a corpse. ._

4 Most—in fact 70 per cent—of the addicts, in our clinic, are young
people; they have had no really’ serious experiences—surely none
sufficient to occasion a desire to escape all of life’s responsibilities by
recourse to the dreams of narcotic drugs; therefore the one and only
conclusion that we can arrive at, is that the acquirement of this prac-
tice—drug addiction—is incident to propinquity, bad associates, taken
together with weak vacillating dispositions, making a successful com-
bination in favor of the acquirement of such a habit. Being with
companions who have those habits, they, in their curiosity, give it a
trial (similar to the acquirement of cigarette smoking in our young)
and soon have to travel the same road to their own regret.

f.

omen

“Free Masonry” of the Addict

Another remarkable concomitant of which we knew but little, here-
tofore, was shown—the free-masonry of the drug addict. They know
one another by. association; but by name, not at all, perhaps a “ nick-
name,” or abbreviated first name, being the only appreciable recogniz-
able fact of a connection between them. “ May” knows “ Ike,” and
“ Shorty ” knows “ Whitey ” ; while “ Smoke ” pals with “ The Duke ”’;
and, as for homes, they have none. They meet in places convenient
for secret conference, toilets being the most often selected, and in
such dens of iniquity as will tolerate such lounging and’ loafing.
Their hours are as irregular as those of a stray cat, and neither day nor
night is of any particular consequence, save that the cover of dark-
ness suits their convenience for obtaining a renewed supply of their
drug. As for meals, they depend on the effect of the drug most often
to assuage any hunger, but they will eat candy, particularly nut choco-
late bars. For these, addicts all display a fondness, and when offered
to them, will never be refused.

All that this class of drug addicts—the confirmed habitué—ap-
pears to care for is to have a supply of “ dope,” and a place where it
can be obtained. Having this, he is as happy and contented, and as —
apparently comfortable as any blessed mortal on earth desires. Thirst
8 S. DANA HUBBARD, M. D.

~he knows not. When a sensation develops, he regards that as a need
for another “ shot,’ and so every thing that would be natural in the
usual daily life of the ordinary man, to him, is unnecessary.

Addicts confide in one another—they are loyal; in their own way,
stealing from the weak or those that have it, to be in turn imposed
upon by others in. similar fashion. From their pals, in their set—for
there is. caste—and the hangers-on of such a group or tribe, they bor-
row even to the last cent, and it appears to be loaned willingly, even
though knowing it may never be returned. If one loans to another,
he, in turn, borrows from others more fortunate than himself. They
are typical human parasites. The following is interesting as relating
to this fellowship: A young fellow, unclean, ragged, and apparently.
‘in abject pain and misery, applied, got his “script” (slang for pre-
scription) but on going to the pharmacy of the clinic found that the
amount of money required to fill it was.beyond his financial abilities ;
he dropped out of the waiting line, mingled with his more fortunate
companions, borrowing a penny here and another there, mo he made
up the required amount. He then returned to the liné and secured
his supply. Then, as he went toward his retreat to take a “ shot,” he
was accosted by one of lower depths, bent on borrowing; he gave his
precious all and returned to borrow enough of the drug from his pals
to meet his needs until he could secure another prescription; on the day
following. |

After one of these borrowing excursions, one of these less fortunate
individuals approached one more fortunate and asked “ for a part of
a shot.” The poor addict had his little outfit ready to take a dose; he
was pale, anxious, and apparently suffering keenly. He pinched up
his skin, turning and twisting the needle point, sent it home, slowly
injecting the solution, and when about half accomplished, noticing the
despair on his companion’s face, he withdrew the needle, and turned
his syringe over, half filled, to his pal in misery. The poor chap had
felt that he needed a little, but also that he could divide with one who
appeared to need it more than he, so he took sufficient to “ set” him,
and willingly passed over the outfit to his beseeching companion in
misery.. This beggar seized the outfit, jabbed the needle through cloth-
ing and all into his belly skin and slowly shot the: ‘contents, to the last
drop, home.

Having witnessed this charitable and brotherly act, I waited and,
when the outfit was returned, I had it refilled and returned to its
owner. This chap dropped to his knees and kissed my shoes. I tried
' DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 9

to restrain him, and told him the clinic was intended to aid and com-
_fort those in need. Imagine my chagrin, to observe, on the following
day, the same game practiced by others, clearly stamping this as a ruse,
a frame-up, to obtain the drug without paying, by playing upon the
emotions of those in charge. Persons that practice such deceptions
‘to serve their selfish purposes are not “on the square,” and cannot be
trusted because they incite others to practice further impositions.

Another similar instance of imposition played upon the volunteer
workers was the following: Early on opening the clinic, there ap-
peared a lad, surely not over 20 years of age, who had the great mis-
fortune to have had both legs cut off at the hip. He propelled himself
by having a board strapped to his torso and attached to the bottom
of this board was a pair of roller skates. In his hands he had a pair
of wooden handles, like dumb-bells, which he would place on the
ground and with a shove he would send himself rolling along faster
than one could walk. He was alacrity itself, and agile as a cat. He
got about gracefully, followed always by a white spitz dog of the toy
type. Like master, the pup was very, very dirty. The boy in his
crippled condition, accompanied by his faithful dog, naturally attracted
attention as well as keen sympathy. This boy was not particularly
pallid, nor emaciated, and, on examining him later, no needle marks
were discovered. The addicts who snuffle the drug have a sniffling
respiration—a constant catching of the breath on inhalation through
the nose which, with the presence of excessive nasal secretion, gives a
mucous rattle. This symptom was also absent in this case. We were
certain that this cripple was not an addict. What was he? His con-
nection was developed later. The clinic was always crowded—jammed
was a better and more fitting description—but on this occasion it was
unusually congested. Suddenly the crowd surged to a corner and,
thinking some accident (an addict overcome through an over dose)
had happened, the floor captain (a lady volunteer worker) went over
to investigate, and returned stating that the roller skate cripple had
had his dog stolen and was crying bitterly. The sympathy of the
captain was aroused and, to comfort the boy, she passed the hat about
the building and collected a neat sum of money. The money, naturally,
consoled the chap, and he left the clinic with his tear ducts dry.

On opening the clinic, the following day, there was our little cripple,
and, lo! with him was his spitz dog. I approached him and said: “I
thought that you had lost your dog?” “I did,’ he replied. “How

did you get him back so quickly?” He said, “I heard a feller had him

3
10 S. DANA HUBBARD, M. D.

and I got my pal to go to him and buy him back—it cost me twenty-
five dollars.” The story seemed honest, but the price to redeem so
inconsequential a “ mut’ was unreasonable. .The chap was marked
for more careful observation. We permitted the boy to come and go
‘freely, giving him his supply, and, owing’ to his crippled condition,
he was advanced in the several lines, preference being given him at
all times. This kindness was his undoing. One day, soon afterwards,
our detectives brought in our little cripple, charging him with acting
as a “bootlegger ”’—selling drugs. When brought into the consulting
room he was searched, and, strapped to his back, resting on his roller
skate board, was a dirty bag containing “ coke decks ” and sixty dollars
in silver coins—in fact it was the tinkling of this pile of-coin that
.exposed him. To arrest a cripple, on such a charge, in our quarters,
where sanctuary had been proclaimed, would make others think: that
we had “framed” the boy and were not playing the game fair. We
decided not to arrest him, but to try and get into his good graces, if
he had any. The scheme worked. The little chap was not above par
when it came to matching wits, so he was quickly and easily caught
and confessed to being a “coke” peddler. Not being an addict, he
- was excluded from the use of the clinic, and later fell into the hands
of the police. In his confession, he said that the dog story had always
been successful, and that no one had ever before seen through it. He
also told how it had always netted him from ten to twenty dollars a
day. He said that, at first, his conscience had bothered him about
gulling the ladies, but the money came so easily that, later, he never
gave it a second thought, and, when he needed money he would go
to some crowded place, hang around until known to have a dog and
then a chum, on a signal, would secrete the pup, and the stage being
set, he’d break out crying—using glycerine in his eyes to make the
tears flow freely. With his dirty, wet face and his deformity he was
able, as long as the crowd lasted, to get money from the gullible. As
he had played the game so long, and so successfully, we had visions.
of a neat bank account set aside for the proverbial rainy day, but he
gleefully informed us that he did not save anything. That when he
found the gang hanging about, he would play craps, and that he was
always unlucky, and soon lost his day’s makings. He was asked how
he accounted for his ill-luck, and he laughingly replied, “I guess the
blokeys use ponies (loaded dice) on me.” “Then why do you keep
itup?” “If I didn’t play, I’d lose me pals. They wouldn’t have me
hanging around, if I did not do as they do.” This seemed to furnish

&
‘DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 11

another key to this problem. As clever as was this crippled chap,
his pals knew how he made his money, so they considered it “ only
fair’ to get it away from him for their purposes.

The display of wit and natural cunning by these chaps, to meet
_their selfish purposes, is positively uncanny. We believed that drug
addiction sapped the memory and dulled the intelligence—with the
experiences of dramatic cleverness exercised to extract the coin of
the realm from the unwary, often times to use for gambling or to
obtain a supply of “dope,” naturally our opinion now is that indis-
criminate largesse is exceedingly harmful to general public welfare.
Without the drug, these individuals, male and female, appear listless,
weary and apathetic, then as the misery becomes more acute they are
restless, peevish, and distressingly irritable. One very peculiar and
universal characteristic is that they, one and all, are insistently selfish
and self-concerned. For others they care not at all.

Another pathetic case of an addict devising ways and means to
raise the necessary capital to continue the drug habit and which in-
formingly demonstrates to what extremes one of them will go, is
well illustrated in the following case: A young girl, small of stature,
comely, sweet of face, and with a gentle manner, came to the clinic
with this story: She worked in a large department store in New York
City, in which there are several hundreds of girls employed. Her
wages were $16 a week. She took 31 grains of heroin a day and paid
fifty cents for each ten grain lot to the prescribing physician, and seven
cents a grain to the druggist for dispensing; $10.50 a week to the
doctor, and $15.19 a week to the druggist—a total outlay of $25.69 a
week on an income of $16, board, lodging, clothing and_other neces-
saries still to be considered. How did she do it? She was asked,
and her reply, with astonishing lack of shame, was: “ Girls have a way
of making money which men have not got.”

Effect of Drug Addiction on the Public.

The emergency relief narcotic clinic has brought out a mass of’
material, from which it is possible to study this problem, heretofore
more or less vaguely thought about, and on which there were but few
statistical data. |

Habits usually only affect the individual but, in drug addition,
indulgence appears to react on the community. The effect on the in-
dividual is in proportion to indulgence and the individual’s physical
12-7 S. DANA HUBBARD, M. D.

and mental resistance. But the effect on the community is evidenced
be debauching of its citizenry, by increase of crime and anti-social
vices. The extent also spreads like a pestilential disease. |
_ There may be those who say drug addiction is a mysterious disease ;
that it creates a disease mechanism; that it is not a matter for the
authorities, particularly for the Department of Health; that there are
laws which are sufficient for the regulation of drug addiction. Our —
opinion is that this habit is not a mysterious disease; that from a
purely scientiflc point of view it would be interesting to have more
light on the problem of tolerance, but there is a very general and com-
\ plete understanding of drug addiction from the therapeutic standpoint
among all who have dealt with it in institutions. In our opinion, drug
, addiction is simply a degrading, debasing habit, and it is not necessary
cece
and that those who are charged with correcting and aieveutin stitch
tendencies should be stimulated to do so to their utmost, and all efforts
exerted in this direction should be free from restraint, absolutely
unhampered, and that all physicians interested in the general welfare
of the people should earnestly encourage such action.

There may be other views regarding: the control and prevention
of drug addiction, but we opine that this is the natural and sane one
to be generally expressed. It can be safely said, without contradiction,
that drug addiction, per se, is not a disease, nor to be so regarded any
more than excessive indulgence in cigarettes (to which all of these
addicts appear to be committed), or an over-indulgence in alcohol
(which but few of them require). Experience in our clinic appears
to indicate that drug addiction affects the human economy in about
the same way as does any vicious abuse, excess, or bad practice, each
attacking and weakening along the channels most susceptible.

Cocaine Addiction.

Some have expressed the thought that cocaine caused a condition
in the system requiring its continuance; it has been learned that such
is not a fact. On the contrary, cocaine is used as a stimulant or anti-
dote to certain undesired after-effects of other drugs—to overcome
the drowsy effects of morphia or heroin.. When cocaine is used in
combination with either morphia or heroin, the addicts say that the
“ day-after ” feeling is not so depressing.

Cocaine does not produce in the system a need similar to that from
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 13

the continued use of morphia. The cocaine habit is like. the alcohol
habit—a man may want the drug, but if he cannot get it he will, and
can easily, do without it, and will not have any actual physical misery
or distress. We judge, from the amount of these drugs used ex-
cessively by the uninformed drug addict, that excessive dosage is
probably the reason for melancholic after-effect—misunderstood by
the addict, and encouraged by the illicit prescriber and dispenser for
purely financial reasons. These latter charge by the amount; the pre-
scriber, usually 50 cents for each ten-grain prescription, and the drug-
gist charges by the grain. We also learned that most of this un-
pleasant depression was obviated when the excessive dosage was
avoided, and addicts who co-operated in this study quickly became
aware of this fact and so reported—which was not only to their physical
advantage and comfort but financially more economical.

Cocaine was distributed on the first day the clinic was operated,
but on ascertaining the fact regarding its effect on the individual, it
was immediately discontinued and not again prescribed or dispensed.

Clinic Dosage.

The practice of the clinic was not to prescribe for any new ap-
plicant an amount over 15 grains—10 grains being the usual amount.
Reduction was by a gradual daily lessening of the amount prescribed ;
this was %4 grain on each alternating day. When the amount ap-
_ proached the “irreducible minimum ”—an amount below which the
- addict would show the phenomena of deprivation, peevishness, irrita-
bility, nervousness—if there was no opportunity to put the addict in
the hospital (for want of an available bed), this method was discon-
tinued for such periods as would enable us to hold the addict until a
vacancy occurred. It was found that some could be reduced to as low
as 2 or 3 grains; some, however, showed unmistakable suffering when
6 to 8 grains was reached. Others, disloyal to the clinic and them-
selves, would, when deprived by the clinic, refuse to accept our regula-
tion and would buy additional amounts outside.

The bed capacity of our hospitals amounted to about 500, so it
was necessary, with a daily attendance at the clinic of 500 to 1,000,
to hold on a waiting list a number which would have been entirely
unnecessary had we been able to place them immediately under in-
stitutional control. |
2

14 S. DANA HUBBARD, M. D.
Drug Supply Obtained by Deception.

Many addicts endeavored to get from the clinic actually more than
they themselves needed. First, it was natural to expect that it would
be tried as the cost of the prescription had been obviated, and the drug

~ was sold much below the general retail price—the price at drug stores

was 7 to 11 cents a grain to the addict; while, at the clinic, the maxi-
mum price was 3 cents a grain and, later, this was reduced to 2 cents.

Some individuals would endeavor to deceive and actually would go
through registration and examination in order to obtain the drug to
sell to addicts at an advance of the clinic price. We found wives trying —
to get-a supply in this way for absent husbands, and brothers trying to
deceive to get the drug for a sister. This practice was difficult to
detect, but the numerous instances actually found demonstrated con-
clusively to what an extreme persons will go to help an unfortunate
member of the family, or an interested friend or pal. However, as we
became better acquainted, many desisted voluntarily, and others would
inform us of the deception being practiced on the clinic. It was mainly
through endeavoring to obtain the good will and co-operation of the
addicts themselves that much helpful saving work was effected.

*

Propinquity in the Dissemination of the Drug Habit.

The outfits used by the addicts, both male and female, their method
of preparing the drug for use, and method of administration, as well
as many other peculiarities of the addicts, indicate clearly personal
association as the chief cause of this debasing habit.

As a physician, I thought that the person who “ needled” himself
used a physician’s hypodermic outfit, but this did not follow. Here
again we met with a practice so unique and so frequent, that it was
positive evidence that drug addiction was a practice incidental, almost
entirely, to association. Instead of a hypodermic syringe, which but
few possessed, there was used a rubber tipped pipette (such as the
ordinary medicine dropper) and on this was placed a hypodermic
needle, and the coupling made tight by wrapping with some thread.
This pipette and hypodermic needle was the outfit in general use by
the addicts. Some few would take a small medicine dropper, wrap
the small end with a few turns of cigarette paper moistened with saliva
and twist this into the screw end of a hypodermic needle. Such a
medicine dropper is retailed at about 5 cents, and a needle is obtained
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 15

for fifteen cents, while the cheapest glass hypodermic syringe costs,
at wholesale, usually from thirty to fifty cents. This method of in-
serting the needle into the skin was also unique. This was very differ-
ent from the way an injection is given by a doctor or a nurse. The
addict takes the outfit in one hand and holds it between thumb and
finger, placing the point of the needle on the site selected. He twists
and presses slowly until the skin is benumbed, when he continues until
it has bored its way through the true skin and, when at the depth
desired, he slowly presses the bulb and sends the “ shot ” home, main-
taining pressure until all of the fluid is injected. The mechanical in-
genuity of the addict was peculiarly interesting, and the unusual outfit
made this phase of the study more than ordinarily interesting and in- |
forming. Again the methods of preparation of the drug were so
similar and primitive as to indicate personal instruction. The inject-
ing outfit described was supplemented by a spoon with its handle bent
back on itself so as to enable one to place it on a surface without its
toppling over. The tearing off of a piece of newspaper to make a
dipper, to take the powder out of the box and place it on the spoon,
was another method which showed personal instruction, and the pass-
ing of such practice from person to person.

The method of preparation was about as follows: The addict
would select some place where he could prepare his “shot” undis-
turbed—usually some toilet—and quite often took the water necessary
to make the solution from the toilet itself. He would unwrap a soiled
and well-handled little bundle of newspaper, from which he would
take his little primitive syrihge, his box of “ dope,” a cigarette paper,
his spoon, and a match with a little piece of very dirty cotton. - He
then proceeded to prepare his dose. The spoon was placed on the edge
of the toilet seat, the cigarette paper was folded into a V, with which,
as a dipper, he measured out the amount he desired to take. Then
he would fill his little syringe, and empty this measured water into the
bowl of the spoon. Then, with aid of the match, boil the solution.
When boiling, he would place the point of the needle into the cotton,
_ squeeze the bulb and suck up the solution entirely. The skin of the
arm, the thigh, and sometimes the belly, would then be pinched up
and he would inject, as described above. The dose having been taken,
he would wrap his little bundle up, without washing or further clean-
‘ing, and then go.on about his business. Time and again we warned
them of the danger of using water from the toilet, but it was ineffective,
so we closed up the toilets. We gave them rooms for self-administer-
16 S. DANA HUBBARD, M. D.

ing their medicine, furnished with gas stove, clean water, tincture of
iodine and glasses, but they would have nothing to do with such things,
preferring their own method and instruments. Here again our former
opinion of the lack of ingenuity of the addict and his resourcefulness
must be reversed. This shows conclusively that when a thing has to
be done, and these individuals are handicapped by the law and its
officials, they can circumvent all, not only by making their own hypo-
dermic but by finding a way to administer their dose in secrecy, un-
disturbed. : ,

Disposition of the Drug Addict.

Having demonstrated certain peculiar conditions regarding the
narcotic drug addict, with a study of several thousands, covering a
long period, and after consultation with many well informed on this
subject (and who were not in any way economically concerned except
for social betterment of individuals), we concluded that narcotic drug
addiction serves no useful purpose; that there is no justifiable reason
at all for its continuance, and that the certainty with which this in-
dulgence benumbs and blunts moral fibre, the practice being indulged
in the majority of instances (69 per cent.) by the young boy or girl,

_makes its control absolutely necessary. That the control is not a cor-

rectional problem from the prison viewpoint, but one for medical super-
vision. That ambulatory treatment is farcical and useless, and is only -
putting off what should be immediately done. .Physicians should not
be permitted, under guise of treatment, to prescribe narcotics for such
indulgence. Laws should be so amended that the narcotic addict,
when determined, should be sent by due process of commitment to a
suitable institution and held there until a medical officer considers it
safe for him to return to society. That after-care should be in an
open-air environment—a farm, or outdoor gymnasium, or recreational
institute being preferable—and continued until the psychic phase is
entirely passed, and the addict can again resume his place and main-
tain himself in society.

Narcotic indulgence in the young adult exists without adequate
reason, and the mere fact that such a habit has been acquired in-
nocently is not an adequate reason for condoning this fault. Our
opinion therefore regarding treatment of these miserable unfortunates
now seems to be in the order of reversal. Formerly many held the
opinion that it was difficult, unsafe, and required expert care to cure
an addict, but it is not so by any manner of means. A plan called by
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 17

the addicts “cold turkey ’—abrupt withdrawal (practiced in Kings _
County Hospital, and without a death)—is not only possible but
practical. It does occasion some suffering, and the plan treated of -
in another article in this issue gives our method. We hold no brief
for either plan, but we state with positiveness that the plans are simple,
but to be successful absolute control of the addict in preventing renewal
of supply is the essential factor.

From an experience with many hundreds, passing through our
clinic and hospital, it is our firm opinion that entire withdrawal may,
in many instances, be successfully performed. That all that is needed
is to have the withdrawal process supervised by a physician, so that
those who need medical care may get it when it is required.

Strict, adequate, and proper, as well as uniform enforcement of
the law—the Harrison Act—throughout this city and country is now
demanded, and is essential towards preventing recruits to these miser-
able ranks.

CONCLUSIONS.
Number of Addicts.

The estimate of one per cent. of our population addicted to the use
of narcotic drug indulgence as a habit—addiction—is very likely greatly
exaggerated. .

Class of Addicts.

Instead of many persons being made narcotic drug users incident to
improper prescribing by careless doctors, it is found that drug addic-
tion spreads like a pestilence through association.

In a study of over 7,500 addicts in this city exemptions requested
for persons ill of some malady numbered less than 250.

Physical Condition of Addicts.

Instead of drug addicts being of that thin, emaciated, starved, hol-
low-eyed, cadaverous type of individual, many—very many—physically
appear normal. .

Feeble Mindedness of Addicts.

Many, yes, very many of these unfortunates are easily determined
as belonging to this group in one of its several degrees. Some, are,
however, of the constitutionally inferior type and many of these are
of the underworld stripe.
18 S. DANA HUBBARD, M. D.

The mental condition of addicts adds impetus to the opinion that
more recognition must be given in our schools to the boy or girl of
the mentally inferior type, so that by special attention and training—
oftentimes individual—many may be prevented from the acquirement
of such a vicious habit.

Duration of Habit.

From our experience, few seem to continue the habit for a very
long period—the vast majority of these cases seem to be under ten
years and there are comparatively few longer than this period.

Acquirement of Habit.

- This appears to vary with localities. Our experience points, in the
great preponderance of instances, to bad and vicious associates, 69
~ per cent. from their own statements.

« Raising the morale of our public assemblies for the young and mak-
ing programs in our_shops and factories may materially aid in pre-
venting this reprehensible practice. .

Efforts to prevent and avoid mental and physical fatigue in in-
dustry with a careful regard for opportunities for acquirements of this
habit by the le sadustrially employed is strongly indicated.

Results of Habit.

The practices of drug addicts to meet the demands of their depraved
appetites-causes financial embarrassment, and to meet these desires
‘the addicts become immoral and anti-social. When in need of the
drug, or over-stimulated from indulgence, all moral influence and self-
control are lost.

_ These individuals either in need of the drug or under its stimulat-
ing influence are a distinct menace to society. They will commit the
most revolting of crimes in cold blood. It is from the ranks of these
that petty thieves are recruited.

Treatment.

Drug addiction is not a mysterious disease. From a purely scientific
point of view it would be interesting to have more light on the problem
\ of tolerance, but on therapeutic indications and possibilities there is
but little difference of opinion.
DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 19

Drug addicts, under careful medical and supervisory nursing, pre- °
sent no pathological condition—only a disturbed or perverted function- |
ing.

The action of internal organs are inhibited or functionally disturbed,
but, when these influences are removed and normal action permitted,
this derangement quickly disappears.

It is our opinion that any form of cure can take an addict off his
drug provided this is done promptly. This was done at Riverside
-Hospital, in 3 to 5 days, without discomfort to the patient.

From information obtained from the large number of addicts, who
have come to our clinic, most of whom have taken various methods ~
of our cure, it may be concluded that all methods of withdrawal are
equally efficacious and only differ in regard to the comfort of the
addict while taking the cure. Aftercare is always essential.

Treatment of the narcotic drug addict by private physicians pre-
scribing and druggists dispensing, while the individual is going about,
is wrong. The giving of a narcotic drug into the possession of an
addict for self administration should be forbidden. Until this is
done by law, all honorable physicians should aid in stopping this
vicious practice.

The case of drug addiction that can be cured by ambulatory treat-
ment is the rare exception, and so unusual as to make one think it
impossible. -_

Physicians generally are of the opinion that ambulatory treatment
is not good practice, and few doctors use this form of treating addicts,
it is believed that those so doing must be either ignorant of proper
methods, or do so in bad faith.

Harrison Act Enforcement.

Our study of this problem in this city indicates, most positively,
the necessity for the general and uniform enforcement of the statutes.
There will be no panic or falling in the streets, or robbing of drug
stores or crowding of physicians’ offices by the addicts affected. If
they cannot obtain a supply, they will reform, and it is certain that
not a fatality will be recorded.

~ General Conclusion.
The work of reclaiming the narcotic drug addict in this vicinity at
least—judging from those we have seen and helped—is more than
worth while.
20 S. DANA HUBBARD, M. D,

The clinic is not the solution—but it aids in bringing the secretive
| addict out of his lair. He becomes friendly disposed and, deprives, of
his supply, he is willing to be cured.

y Our experience, as indicated in the statistical data quoted, is that
/ nearly 70 per cent. of the addicts are under 30 years of age, and have
~~ been less than ten years on their drug, and that comparatively few have
any physical reason for indulging in the practice.

The physical condition of many of these youths, male and female,
indicates that most of them can be saved and reformed into useful
citizens. They are down, but are very far from being out.

No doubt, with suitable organization and funds to institutionalize
and adequately and properly care for them, not only to effect with-
drawal of drugs, but to rehabilitate by several months after-care in
the open country, together with efforts to get the individuals away
from bad and demoralizing associates, into new and more useful en-
vironments, many will revert to useful and normal lives.

Many of these addicts have never had a square deal, and only need
a fair chance to change their ways. Already many of them have been
returned to useful lives, and many more can be revamped with proper
and necessary help. .

‘With success in many instances, in spite of the disadvantages under
which the clinic has operated and under which this study has been
made, we report our experiences, that others may be induced to enter
into this work, appreciating its difficulties and complexities, but know-
ing that success is possible, in many cases.

We are more than pleased with our efforts, and the results of these
labors, and appreciate the cordial support and advice given so freely |
by all those who co-operated. It is impossible to name any of these
persons, but we desire to hereby register our public appreciation of
- their aid and assistance.

With reduction of addiction, generally, the incidence of the abuse
of drug tippling, especially in the industrial world, will make future
prevention and control easier.

_-Many lectures to hundreds of persons have been given by the staff
of the Bureau of Public Health Education and this publicity will no
doubt deter many from taking up addiction through curiosity or
ignorance.
ee a

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\ DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION 21
> Narcotic EMERGENCY CLINIC STATISTICAL ANALYSIS.
re “ 5
& Report of the Apothecary.
t April 10, 1919, to January 16, 1920.
yf : .
‘ ~ | Prescriptions Dispensed ..... gdeeiNld a Benak ides Css Jovas 289,362
=e e. | Receipts ............ ain B04 fewie Fa eee bikaets fade Va'e 3 $75,940. 27

‘Sf

ae

Ke tr trhty
/ LNA
-” ‘ed

 

 

_ Drugs Dispensed—

X \) ~} Heroin, ounces ...... Sheva tan ea dvs pe eo oeeee 4,385 17/28
: | Morphine, ounces ...........ccc cece cece cece ceceeeeees 1,215 14/28

Report of the Director of Clinic,

Ny ye |
= i} | General Classification—
Sh J SS]
So 7" < | Males. cole cece ese ccneceteneeesebjeceedede 5,882
\ ™~ = } ~| Females ..........000cc0ees paginas ebro pace eeds pees 1,582
RT| a nea
IVT Sy] Total oie. ke cuss cect eeeweo ea veeee teins 7,464
i New w~ D4 , , =
“AUN. « | Racial Grouping—
‘ , od ping
as Nw. i | :
WA, = Sof White. ie van bea uae eee begin | 6,429
Sas PY. Black ..... lean ee ngs padi oen see salen eg este 1,035
: ” LS | ween
eG < | Total rete ete e vente eee teeres CVesw eet eneets 7,464
Sh ~\ § *
| Ps Reasons Assigned by Addicts for Acquiring Habit
C Ss Bad Associates ..... Teepe bene eee ease nsec es 5,190 69%
ON Illness ....... fea soncpeislu ee enaeeect4e itaGs ... 1,994 26%
}?PS Other Causes .............0000 Shan nears 280 5%
$ \ Age Grouping (66% Under 30).
ae fe MBE eS 4. 15-19 20-24 25-29 30-34 35-39 40-50 Over 50 ‘Total
Ss Number ........... 743 2,142 2,218 1,155 766 365 75 7,464
S Percentage w......5- 9 8&8 9 4. 0 9 1 100
; / Z Der ation of Habit (79% Under 10 Years).
& { Years hehe Ja iene qe aceite er Under 1 1-5 5-10 10-15 Over 15 Total
“Number ...... Be Re op teins Ek aLN 272 ~=—-2,796 «2,838 + 1,103 461 += 7,464
Percentage .....-.. eee ee ee eee 34 SF: 39 15 6 100
AF
4 & Q ,
nT
6 To AMC fw 3 Og
4 —

ISG rh penser: at hore ‘A deft Aaritd hegkiac:

 
22 S. DANA HUBBARD, M. D.

_ Nationality (Birthplace).

 

* 23% of clinic patients.

 

 

Australia .... cc cece eee eee aee 1 Treland 1... cece cece cece eens 231
Africa .... ccc cece beeen eee eens 1 1) A ‘Zea 190
Austria ........008 Syd wees 26 Japan ....ccee ese e eee ee evens 1
Belgium ........c0. scree enone 4 IY oe (ove 7
Canada “nie... eet in sews ecenes 88 NOrway ..ceceeeee eee sere eee 1
Cuba. .... csc wesc ee recews Bese 16 Rotumania 1... cece eee e ee ees 320
China ..... cence cece eee eeees 41 RUSSia oe eee eee cece ee eens 710
Denmark .......0cce eee ee eens 4 Spain. -.. cael eee wees coweees 4
England ..........- Vaan eeees 38 Scotland ........ Sa pangs ates 7
France ....c cece eee e cece eens 9 Sweden .......... cece eee e ees 12
Germany ........eceeeeeeeees | 418 South America ...........06. 4
Greece Lo. cece cece eee eeee 112 United States ..........e scene 5,182
Holland .........eseeee eee ees 6 West Indies ..........--.e eee 17
Hungary ......... CU p pees os 4 ———
Total o.oo. e ccc eee eee 7,464
Voluntary Commitment to Hospital.
Riverside Hospital 2.0... 0... ccc cece eee ee etter eee eeees 1,581
Metropolitan Hospital ....... 02. cette cece eee tenet eeeee 78
Bellevue Hospital 20... 00. ccc cece eee eee ce teen eas 36 «
Queensboro Hospital .................00.- vetceutyecs wees 32

Kings County Hospital... 0... ccc ccc cece eee cece eens 5

Workhouse Hospital ........ cece cece eect eens 12

Total -....0 ccc hence sci veccswecuttbaapeccccs tt eavesi *1,744

OccUPATION

Accountant ...... ee ccc eeeeeee 5 Bookbinder ......06 ccc cee eens 7
ActOL ci ceccccccuecceeetveres 98 Bookkeeper .......cceceeecece 15
Actress ......-. gia leeds see 68 Bootblack ......... cece eee ees 10
Agent ....cccceeeeeeees ee — 25 Boxmaker 2.2... .cee eee eeseee 8
Appraiser wi. ces e cee ween eee 1 Brakeman ........eeecee cence 19
Artist... cece ee cece eee eee 5 Brass polisher ............5.- 1
Assembler ........0.00ceeeeee 5 Bricklayer .......... ee ee eeeee 18
Attendant ...-.... cece ee eee ee 2 Bus DOY ...c.ee eee e eee e ee eeee 1
Baker ..... ccc cc cece eee tenes 12 Butcher 1.0... cc cece cece ewes 20
Barber ..ecccccce ccc eeeee cece 29 Butler 1.0... cc. cee cece eens 6
Bartender ........ css eee eeee 17 Buyer -veasvca sens cose saan tee 5
Bell boy ........0.05. een ens: 25 Cabinetmaker .........-...04. 1
Bill poster ...... cece eee eee 1 - Candymaker ............0000. 1
Blacksmith ...........0.200s 13 Cashier ......c. cece cceeeeeeee il
Boilermaker ..............45. 3 Carpenter ...... cece sees eee ee 31