The use of opiates rose gradually in the United States during the 19th century, hitting a peak in the 1890s. Cocaine became popular after 1884, and its use peaked in the first decade of the 20th century. These early waves of drug use eventually passed by the general public but continued to swirl around persons on the fringe of society. These users were burdened with the image of what Caroline Jean Acker calls the "heroin-addicted male urban hustler." Easy access to habit-forming drugs did not encourage members of American society to accept them, but rather prompted them to demand that cities, then states, and finally the federal government crack down on suppliers, including those in the medical profession. Indeed, physicians were widely believed to be responsible for at least half of American addicts. These events -- a keen source of public concern at the time -- have mostly been forgotten, as has any connection to the drug epidemic that began in the 1960s. Acker, an associate professor of history at Carnegie Mellon University, has resurveyed this crucial era in the formulation of drug policy in the United States, when official positions were established against any nonmedical use of habit-forming drugs: policies were established for closely monitoring health professionals, for guarding against optimistic expectations for the recovery of addicted users, and for severely punishing possessors or sellers of illicit drugs. In her detailed study, Acker argues that a distinctive American approach molded the negative picture of the drug user, giving rise "to an image of deviance that has shaped American drug policy ever since and helped reinforce the moral underpinnings of the war on drugs." As social constraints tightened, the reciprocal effect was to drive addicts "further outside the bounds of respectability and legality, and their behavior strengthened social disapproval of addiction itself." After World War I, the image of the junkie was not "the inevitable result of a particular character or personality type, or of inherent criminality . . . nor . . . simply the outcome of the pharmacological effects of heroin." The result of restrictive laws was an image so negative that the addict elicited no sympathy and was thought to deserve a lengthy prison sentence. Yet, Acker argues, it did not have to be that way; another culture might have established policies that supported care and respect for the addict. A cofounder of a needle-exchange program in Pittsburgh, she advocates "harm-reduction" policies and wonders why there is so much opposition to such programs. As a historian, Acker has pursued this question in a number of innovative and thoughtful ways. She pored over the fascinating records of interviews with addicts that were collected in Philadelphia in the mid-1920s under the auspices of the Bureau of Social Hygiene, financed by the Rockefeller Foundation. Using their life histories, she illustrates the various ways in which drug users coped. These documents are particularly helpful in understanding addicts' strategies after the passage of the Harrison Narcotic Act of 1914, the federal government's effort to harmonize conflicting state drug policies by outlawing addiction maintenance. Acker also does an excellent job of dissecting the interests of the professionals who divided up the research on addicts. The best understanding of the addict's lifestyle, she believes, comes from sociologists, who looked on the world of addiction much more neutrally than did their medical and laboratory colleagues. The research of psychiatrists and pharmacologists appeared to support the federal approach, while the work of sociologists provided an alternative perception of drug users. In 1925, U.S. Public Health Service drug expert Dr. Lawrence Kolb concluded that the persons likely to become addicted were psychopaths -- that is, they had a preexisting character that found heroin or morphine particularly attractive. Kolb's research tried to answer the centuries-old question: Is everyone equally likely to become addicted, or are just those with special characteristics likely to become so? As middle-class drug users became increasingly rare in the 1920s, the remaining users were seen as often having two problems: addiction and a coexisting psychiatric disorder. This is very similar to contemporary experience with "comorbid" diagnoses. Acker, however, sees Kolb's view as the acceptance of "prevailing social norms" that supported federal attempts to shut off drug supplies. The question left by this well-written and thoughtful book is this: How significant was the change in attitude toward addicts after 1890 in imposing a negative image on them? Undoubtedly, addicts fell in public esteem, but their image had never been very high. For example, Dr. William Osler, in his great book The Principles and Practice of Medicine (1892), warned that "persons addicted to morphia are inveterate liars, and no reliance whatever can be placed upon their statements." (One wonders what one of his addicted patients, Dr. William Stewart Halsted, thought when reading that sentence.) Or take an even earlier response to addicts, this by Oliver Wendell Holmes, Sr., speaking to the Massachusetts Medical Society in 1860: "A frightful endemic demoralization betrays itself in the frequency with which the haggard features and drooping shoulders of the opium-drunkards are met with in the streets." These expressions far antedated the federal attack on drug use. Acker presents a fascinating account of how addicts' negative image came to dominate public and official perceptions, as well as how it forced some users into that mold. Her careful analysis of research findings will make this book of interest to historians, drug-abuse workers, and anyone else who wants to examine the origins of American drug policy.
David F. Musto, M.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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