Self-administering narcotics has a long history in the United States and elsewhere. In the nineteenth century, opium and morphine (as well as cocaine) were contained in thousands of over-the-counter preparations. They were called "patent medicines," and were used to cure headaches, toothaches, teething pains, menstrual cramps, insomnia, nervousness, depression, rheumatism, athlete's foot, diarrhea, dysentery, consumption, the common cold, and even baldness and cancer; they were panaceas, or ineffective cure-alls, and they were sold under names such as Ayer's Cherry Pectoral, Mrs. Winslow's Soothing Syrup, McMunn's Elixir of Opium, Dover's Powder, Godfrey's Cordial, and Hamlin's Wizard Oil.

During the nineteenth century, no restrictions whatsoever existed on what was put into these potions or what claims the manufacturer was allowed to make as to their medical effectiveness; indeed, the contents of these concoctions did not even have to be listed on the package or the bottle. They were sold to anyone, without benefit of a prescription, in pharmacies, grocery stores, general stores, through mail-order catalogues (the 1897 edition of the Sears Roebuck catalogue offered hypodermic kits for sale), and at traveling medicine shows. Patent medicines containing narcotics were as easily obtainable as aspirin is today . Nineteenth-century America was truly a "dope fiend's paradise" . In 1898, heroin was synthesized, and it quickly joined the 'To make things confusing, the drug called "China White" that Inciardi mentions turned out to be fentanyl. However, the New York City police claim that they are now seeing a new strain of heroin from Southeast Asia, which they call China White. To confound the issue even further, there are a number of chemical analogues or variants of fentanyl, ranging in potency from roughly the same as heroin to 3,000 times as potent. Of the latter, one authority said, "You could kill fifty people with the amount that fits on the head of a pin" (Blakeslee, ranks of the ingredients in the pseudomedicines freely available to the American public.

It is necessary to stress three crucial points about nineteenth- and early twentieth-century over-the-counter patent medicines containing narcotics. First, they were taken for medical (or pseudomedical) reasons, not for the purpose of attaining a high or euphoria. They were used by people with medical ailments who did not consult a physician to determine the most effective cure, and by people whose physicians were quacks. The reason why these concoctions often appeared to be effective was that, since they contained opiates, they dulled the pain of the disease; eventually, the body overcomes most diseases, and thus the potion appeared to be the curative agent. Often, however, after the disease passed, the user of the patent medicine was left with a physical dependence.

Second, a very large number of individuals were taking these patent medicines. It is impossible to estimate with any degree of precision just how many addicts the freely available over-the-counter narcotic preparations created. Figures at the time were notoriously unreliable; in fact, the concept of physical addiction was not yet clearly understood. Estimates as to the total number of addicts at the turn of the century range from a low of 100,000 to a high of several million. In 1919, the Treasury Department issued a report claiming that approximately a million individuals were addicted to narcotics at the turn of the century. Other estimates, based on extrapolations from several local surveys, range from less than a quarter of a million (Terry and Pellens, 1928) to just under half a million.

And third, narcotics users and addicts at, just before, and just after the turn of the century were, for the most part, respectable folk. The heavy users of patent medicines were disproportionately drawn from the middle and upper-middle-classes. Said one article published in 1881, "opium eating" is an "aristocratic vice and prevails more extensively among the wealthy and educated classes than among those of inferior social positions" . While some criminals did use narcotics—mostly they smoked opium—the vast majority of narcotics users were users for medical reasons, and were not involved in a life of crime. There was no necessary connection between the heavy, chronic use of narcotics and criminal behavior, as there is today. The addict was seen as an unfortunate, sick person in need of medical attention, a helpless victim but not a criminal.

Four additional facts are of interest here. First, the late nineteenthcentury, early twentieth-century addict was more likely to be a woman than a man—in several surveys conducted at the time, roughly two-thirds of heavy opiate users were women. Second, users tended to be middle-aged rather than young. In a Chicago survey, the average age of male users of opiates was 41, and of females, 39; in Iowa, the average age was 46; and in Tennessee, it was 50 . Third, some indications point to the fact that Blacks were underrepresented among the users of opiates eighty to a hundred years ago. And fourth, it is likely that users were drawn from the entire rural-urban spectrum; use, in other words, did not appear to be heavily concentrated in large cities. Users were as likely to come from Iowa farms as from New York City, on a per population basis.

By the 1920s, the public image of the narcotics addict had become totallv transformed into that of a criminal, a willful degenerate who was immoral and depraved, a hedonistic thrill-seeker in need of a stiff prison sentence. Moreover, the actual social composition of narcotic addicts also underwent a transformation so that by the 1930s, they bore no resemblance whatsoever to the turn-of-the-century addict. For roughly half a century, users and abusers—and especially addicts—of heroin and the other narcotics have been predominantly or overwhelmingly in search of euphoria or a high rather than a medical cure for a disease; of relatively low rather than relatively high socioeconomic status; criminals rather than respectable folk: males rather than females; Black rather than white; young rather than middle-aged; and from large cities rather than less heavily populated areas.

What accounts for this transformation? Why did the image of the addict change? And what brought about the total turnaround in the socioeconomic portrait of addiction?

In December 1914, Congress passed the Harrison Act, which outlawed the sale of over-the-counter narcotic preparations and placed the addict in the hands of the physician. Whatever the intent of the law, it is clear that most addicts simply continued to receive drugs from their physicians, on prescription, instead of directly from their local pharmacists. If a physician construed the administration of morphine to a patient to be within the scope of legitimate medical practice, he had the right, within the law, to maintain that addict on morphine. On the face of it, then, the law did not change anything. It was the Supreme Court that drew a restrictive interpretation of the Harrison Act and that decided what was to constitute "legitimate' medical practice; in a series of decisions from 1919 to 1922 the Court declared maintenance of an addict to be outside the scope of medical practice and therefore illegal. However, in 1925, in the famous Linder case, the Supreme Court overturned its earlier decisions, declaring addiction per se not to be a crime and paving the way for the legality of maintenance. The Court affirmed the decision in 1962, in Robinson v. California.

Thus the present punitive policies are a consequence of decisions made by the Supreme Court between 1919 and 1922, decisions that were superseded anc reversed by later rulings. A good case could therefore be made for the unconstitutionality of present legal policies.

Because of police harrassment of physicians following the passage of the Harrison Act and the wave of arrests of doctors following the Supreme Court's decisions, most physicians became unwilling to shoulder the legal risks attendant upon treating the addict and eventually discontinued administering narcotic drugs. One study estimated that in the two dozen year? after the Harrison Act—and primarily after 1919—25,000 physicians were arraigned on narcotics-selling charges, and 3,000 actually served prison sentences (New York Academy of Medicine, 1963). Thousands more had their licenses revoked. The authorities could not have encouraged the emergence of an underworld traffic in narcotic drugs better even by design. The arrest of physicians during this period took the following form: Selling drugs was declared illegal, thus driving most physicians out of the practice of treating addicts; the few who continued to do so, whether for idealistic or mercenary reasons, naturally attracted a sizable clientele—and just as naturally were charged with "trafficking" in narcotics.

Apparently, the dilemma was at least dimly perceived by some officials, since in 1919 and 1920, forty-four ambulatory clinics were opened with a view toward the rehabilitation and eventual cure of addicts. The programs were highly variable in method and effectiveness. In the New York clinic, which received the most attention and publicity, drugs were handed out more or less indiscriminately to anyone who claimed to need drugs; moreover, through various tricks many addicts were able to obtain much more than their share and to sell what they did not use to other addicts. The New York clinic was investigated by the Bureau of Internal Revenue, and a highly critical report of its operations was written. Muckraking journalists attacked the program; several reporters posed as addicts and discovered that they could receive addicting drugs almost upon demand. There was a public outcry; campaigns were launched to close the clinics. All but one of the forty-four clinics had been shut down by 1921, and the project was entirely abandoned by 1923. The program was branded a disastrous failure. Actually, the New York clinic, the object of the most vigorous criticism, was the least well run and most clearly unsuccessful. The clinics in New Orleans and Shreveport, Louisiana, appeared to have been successful in their stated goals: (1) relieving the addict's suffering; (2) offsetting the illegal drug trade; (3) curtailing the spread of addiction; and (4) reducing the criminal activity of addicts. These efforts, however, received little public attention.

The demise of the public clinics, engineered by prohibitionistic officials, pas then used by them to galvanize popular sentiment against the strictly medical approach to addiction. The public came to support the view that the addict had to be dealt with punitively, that addiction was a matter for the police and not the physician. Actually, the medical approach was not tried in most clinics; rather simple maintenance, or handing out drugs without any medical treatment whatsoever, was the rule. The more carefully run, medically oriented programs did not convince those in power that a true medical approach could in fact work. Addiction came to be seen as inherently untreatable—and inherently criminal. A shift in enforcement came about at almost the same time as the demise of the public clinics. In 1919, :he first year of their operation, there were only 1,000 federal arrests on narcotics charges. In 1921, when all but one of the public clinics had closed, here were 4,000 federal arrests. And by 1925 there were more than 10,000 arrests .

Clearly, then, what happened as a result of the Harrison Act arid subsequent Supreme Court rulings was not simply the diminution of a once-large population but the appearance of a totally different population. Far from simply reducing the problem of drug addiction, legislation and enforcement practices appear to have created some problems.

It is obvious, then, that the first half of the 1920s witnessed the dramatic emergence of a criminal class of addicts—a criminal class that had not existec previously. The link between addiction and crime—the view that the addict was by definition a criminal—was forged. The law itself created a new class of criminals.

Probably the most important contribution that law enforcement has made to the problem of addiction is the creation of an addict subculture. It is important to emphasize that prior to 1914 no addict subculture of any significance existed in the United States, and there was no inevitable link between narcotics and crime. There was a small population of opium smokers, consisting primarily of Chinese immigrants and of bohemian, literarv. underworld, and demimonde figures who learned the habit from the Chinese. Addicts did not display any special cohesion or loyalty as a group; the possessed no lore concerned with the acquisition and administration of drugs, no ideology elaborating the qualities of various drug highs, no justification for using drugs, no status ranking unique to the world of addiction. no rejection of the nonaddict world.

During the formative 1920s, these elements of an addict subculture began to emerge. Alfred Lindesmith has said that by 1935, when he was studying addicts in Chicago, "there already was a subculture without doubt (Alfred Lindesmith, 1971, personal communication). It was the criminalizatK of addiction that created addicts as a special and distinctive group, and it is the subcultural aspect of addicts that gives them their recruiting power. Up until the pas few years, external factors have played a more important role in curtailing the spread of addiction than anything the police have done. Alcohol prohibition (1920-1933) focused the activities of organized crime on the distribution of liquor rather than narcotics—in fact, got organized crime started on a big-business scale.

The Depression of the 1930s also had a delaying effect on the growth of the addict subculture. And the disruption of drug suppl • lines during World War II slowed down to a considerable degree the recruitment of new addicts. By the end of the war some experts thought that addiction to narcotics had ceased to be a problem of any magnitude; at that time there were only 20,000 known narcotic addicts in the United States. But starting in 1945, and especially in the late 1960s, addiction began to rist dramatically. It is entirely reasonable to view this rise as largely due to the recruitment powers of a gradually developing subculture of intensely committed addicts. And it was through the efforts of the police and the courts that this subculture came into being in the first place.

A second major consequence of the punitive police approach to drue was the rise in the criminal activity of addicts. The view that addicts are "inherently" criminal is totally without foundation. The Harrison Act and the lega^ decisions that followed in its wake created a class of criminal addicts. Beginning in the 1920s, every narcotic addict was by definition a criminal. Soon thereafter, nearly all narcotic addicts, except the very wealthy and members of the medical profession, were also criminals in a second sense as well: Most engaged in money-making criminal behavior. Before the turn of the century, it did not cost a great deal of money to maintain an opium or morphine habit. But the process of criminalization changed that; narcotics became expensive and difficult to obtain. Moreover, it became profitable to sell narcotics, products that were both expensive and highly valued. Addicts wanted it, and criminal gangs were eager to sell it. Thus one of the consequences of criminalizing addiction was that it served to forge a strong link between using narcotics and engaging in criminal behavior.

It cannot be doubted that criminalizing narcotics early in the twentieth century had the short-term impact of reducing the number of addicts in the population. It is almost certain that the less heavily involved users of the medicinal narcotics discontinued their habit without a great deal of difficulty following the Harrison Act. Some users may have turned to other drugs, such as the newly marketed barbiturates, as a substitute. But it is also true that there were a number of unanticipated and undesired long-range consequences of the punitive approach to the narcotics problem; clearly several of these consequences included the generation and growth of the criminal addict subculture, the intensification of the involvement of its members in money-making crimes, and the strengthening of the recruiting powers of this subculture. Today, of course, we have far more addicts than existed at the turn of the century, although possibly the same percentage, taking size of population into account.

If nineteenth-century America was a "dope fiend's paradise," what is late twentieth-century America?