Updated: Aug 29
Editor’s Note: Today’s post comes from contributing editor Jordan Mylet, a doctoral candidate in history at the University of California, San Diego. This is Part 1 in a series on The Addict and Addiction Treatment Before the War on Drugs. The next installment will come in March.
It is common today to think about drug addiction as an illness or disorder, and the opioid epidemic as a public health crisis that deserves a robust medical response. This framework is often paired with an implicit (or not) rebuke of past ways of dealing with addiction as a sin or a crime, something to be shamed and punished. The fact of mass incarceration, which has filled jails with hundreds of thousands of drug offenders, predominantly of color, since the early 1970s, has rightfully precipitated a renewed emphasis on treating addicts as people in need of treatment, not prison time.
However, if one looks closely at the long history of medicalizing drug addiction in the United States, they might conclude that applying a treatment framework to addiction does not necessarily lead to clear-cut or even humane solutions. In fact, the mid-twentieth century architects and enforcers of narcotics control policy—with its street-level raids and mandatory sentences—also espoused a belief in addicts’ sickness and need for medical treatment. When public concern about drug addiction skyrocketed in the postwar years, the dilemma facing policymakers and medical professionals was what was to be done with the addict, given that she was sick. In this way, debates over addiction and rehabilitation were also clashes about the responsibilities of the state to its citizens and the limits of individual liberty.
Firstly, the notion that the addict was a sick person in need of treatment has been widespread throughout the twentieth century (and earlier)—though, of course, it was always shot through with moralism and prejudice along race, sex, and class lines.
Even as they raided narcotics rings in the 1930s, Federal Bureau of Narcotics agents publicly differentiated between the fiendish “peddler” of drugs and the pitiable addict who required institutional care. In 1935, a federal narcotics prison-hospital opened in Lexington, Ky., for just this purpose, as well as to study the physical and psychological phenomena of addiction in the hope of discovering a clear-cut cure. FDR vetoed immigration legislation in 1940 that allowed for the deportation of aliens who’d been institutionalized for drug use on the grounds that these “unfortunate addicts” should not be punished, since “addiction is to be regarded as a lamentable disease rather than as a crime.” Throughout the 1940s and 1950s, law enforcement officials and medical professionals asserted that drug addicts needed medical treatment and consistently pushed for Congress to pass a bill permitting their forcible commitment into public mental hospital facilities. In fact, the treatment experimentation of the 1960s was in many ways a reaction against the consensus position of earlier decades that institutional and/or expert medical care was the answer to addiction.
Seventeen-year-old girl at Lexington Hospital, circa late 1940s—early 1950s
Using the language and logic of disease in talking about drug addiction in the 1940s and 1950s did not mean that government policy or public opinion was less driven by fear or suspicion, however. Elected officials and law enforcement officers affirmed that addiction was a disease—albeit a fatally contagious one that could infect even the most unsuspecting people. Malachi Harney, the right-hand man of Federal Bureau of Narcotics (FBN) Commissioner Harry J. Anslinger, expressed alarm over the evolution of the “contagion” since World War II; it used to be that the “criminal element” was most susceptible due to the sheer proximity of “being thrown in with other addicts” in the underworld, but now naïve “young people” were coming down with the affliction. A 1951 Congressional report on organized crime concluded that “wholly innocent” teenagers and young adults had contracted the ailment “from bad associates or from the drug peddlers in the back streets and alleys” without realizing “that they [were] dealing with a highly contagious disease that brings degradation and slow death to the victim.” Another top FBN official considered it a “rule of thumb” that every addict was “good for four or five during his lifetime.” This type of disease framework made the addict the site of infection, catalyzing mini-epidemics wherever he went. An addict’s ability to move freely, spreading disease among criminals and law-abiding citizens alike, facilitated what officials deemed an urgent crisis.
The solution, then, was obvious to many public health and law enforcement officials in the postwar years: control and cure. In the late 1940s, those same officials began a forceful campaign that lasted throughout the next decade to strengthen the Public Health Service’s reach over voluntary patients in Lexington. While convicted narcotics violators had mandatory stays in the federal hospital, voluntary patients could come and go as they pleased. Dr. Victor H. Vogel, Lexington’s medical director, lamented the fact that “the majority of voluntary patients leave against advice before the 4 to 6 months usually recommended,” though he insisted that this was not due to “a lack of sincerity on the part of the patient but rather such behavior is an expression of one of the typical symptoms of drug addiction; that is, the loss of self-control.” By passing legislation to make Lexington’s admissions “patterned after the commitment of mental patients,” the voluntary patient could “protect himself against his premature departure.” Vogel further warned that “without control addiction spreads and persons become submissive, ambitionless, and abject.”
Anslinger supported the effort to implement compulsory hospitalization for addicts, arguing that “if you had 800 or 900 lepers running around the streets of the city, you would put them in a hospital.” If such legislation passed, he promised to “bring in a force of men to work with the police and pick up those addicts and have them hospitalized” to stop the disease from spreading. In the eyes of many law enforcement officials, treatment functioned as a quarantine measure until the day came when the illicit drug supply vanished—which would be accomplished by its own version of institutionalization: introducing and increasing mandatory prison sentences for distributors.
Of course, the postwar institutional approach provoked skepticism at the same time it was heralded as the solution. How could physicians, psychiatrists, and medical researchers explain the consistently low rates of cure at Lexington? What became of the patients who left Lexington only to return to the same neighborhoods in which they started using drugs? Was it constitutional to arrest people simply upon suspicion of being an addict? And underlying these questions was perhaps the most damning one of all: what was the point of shifting the criminal justice and public health systems ever more towards compulsory hospitalization if hospitals couldn’t even be counted on to provide a cure? As early as 1948, Rep. Frank D. Keefe (R-WI) wondered whether the state was “pouring money down a rat hole” funding a facility for “transients who blow in and out of there voluntarily,” given that Lexington had “not made any particular progress” since its opening.
Public Health Service officials reported deeply mixed assessments of their work. In 1950, Dr. G. Halsey Hunt, Chief of PHS’s Division of Hospitals, asserted that while a “very considerable proportion” of patients were likely cured, they couldn’t offer specific numbers, as the hospital had no follow-up program. He also explained that any cure for narcotic addiction would be “a temporal thing,” like “tuberculosis or cancer,” except addiction “has its root in emotional instability.”
Flash forward to 1958: Dr. James V. Lowry, Deputy Chief of PHS’s Bureau of Medical Services, acknowledged in a congressional hearing that it wouldn’t be “reasonable” to say that there was “any cure for this problem.” State medical officials working on addiction were caught in a dilemma: in order to justify further funding for their programs and facilities, they needed to show positive results, or at least a trajectory of progress—but they couldn’t, not unless they based their conclusions on speculation and wishful thinking. The truth is that many legislators and law enforcement officials knew this all too well. Anslinger, at the same time he was advocating for compulsory hospitalization, admitted that committing addicts to institutions was more convenient than effective: “I do not think that cure is the answer, although… if we could not send these addicts to some place, I do not know what we would do with them. I do not think the cure would go much over 17 percent.”
The dissonance between expectations and performance of state institutions engendered a certain amount of pessimism in public officials in the mid-late 1950s. After the Senate’s Subcommittee on Narcotics held nationally publicized hearings on narcotics control in 1955, its chairman, Senator Price Daniel [D-TX], got to work in 1956 on crafting new legislation to implement compulsory hospitalization for drug addicts in the District of Columbia. (D.C. is often the site of experimental legislation that ends up as the law of the land a few years later, since Congress has direct control over the area.) If D.C. police had “probable cause” in suspecting a person was an addict, they could pick him up and hold him in custody for medical examination; upon a formal diagnosis of addiction, the person would be sent to Lexington for a treatment term. Upon release, he would receive two-year probation, with any relapse sending him back to the federal hospital. In a statement that laid bare what congressmen actually expected from institutional care at this point, the subcommittee’s counsel remarked that “the effect of the Act, I think we will all agree here, knowing the nature of addicts, is to keep them under constant surveillance the rest of their lives.”
Given their expectation of “repeaters,” Daniel supported a “permanent confinement” provision modeled after legislation being considered by California’s legislature at the time. It was “the only answer,” Daniel argued, “for chronic addicts. You have got to have a farm some place, or colony, you can put them in and let them try to grow their own vegetables and do something around the place, but keep them out of society.” To this the Public Health Service Director responded, “Mr. Chairman, that has been our recommendation.” In the end, new facilities for permanent stays weren’t funded, but Congress passed compulsory hospitalization in D.C.—initiating the conveyor belt that would send hundreds more addicts to places in which their designers didn’t have much faith.
Announcement for an early meeting of Narcotics Anonymous in Southern California, 1953
Meanwhile, community and mutual aid groups started to create options for addicts outside of institutions and, in the process, articulate their own ideas about what type of disease addiction was and what kind of treatment was needed to cure it. While these groups did not position themselves in explicit opposition to state facilities or professional medical care, their rising popularity in the 1950s and early 1960s would kick off national debates about treatment, mental health and illness, and the boundaries of democracy.
(Part 2 in March)