Fall 1983 – Issue 30 - Stanford Lawyer - Stanford University

smaller percentage of British addicts.White youths are overrepresentedamong British addicts, whileethnic minorities are overrepresentedamong American addicts.Another important but often-overlookedpoint is that medicine is practicedquite differently in the twonations. Heroin maintenance fitscomparatively well into an organizedsystem of health delivery such as theNational Health Service. Our presentanarchic medical system mayhave some advantages over socializedmedicine, but a number of commentatorson the British systemhave pointed out how much easier itis to care for heroin addicts in a clinicsetting where a wide variety of otherailments are also treated, and in asystem which also cares for themany health needs of addicts apartfrom their maintenance.Finally, the number of addicts inthe United States is so much largerthan the number that British heroinmaintenance has ever coped withthat the changes in the scale of theproblem might produce genuinedifferences in kind.In short, though the British experiencewith heroin maintenanceprovides us with a considerableamount of arguably relevant data, itis not very helpful in decidingwhether the United States should attemptsuch a system. Perhaps themost reliable conclusion we candraw is that our heroin problemswould probably be fewer today hadwe begun some kind of opiatemaintenance at the time we passedthe Harrison Act. Turning back theclock and starting from that point asecond time is obviously impossible,however, so we must consider thecosts and benefits of heroin maintenancein today's world.Heroin Maintenance OptionsHeroin maintenance is an extremelyplastic concept. As the British ex-perience indicates, relatively smallchanges in the method of implementation-such as the shift from prescriptionby private physicians tothat by specialized clinics - mayresult in very different consequences.Let us look at two quite differentways of maintaining addicts onheroin- the prescription system andthe use-on-the-premises system. Aswe will see, each of these has its ownproblems. Afterward we will examinethe more complex policyissues related to any governmentnarcotics maintenance program.The Prescription SystemAt the one extreme, we might followthe pre-1967 British system andsimply allow any private physician toprescribe heroin for the maintenanceof his addict patients. This measurewould be unlikely to work, since itfailed even in Britain. Rather thanopen ourselves to the charge of settingup a straw person, then, let usadopt, as our extreme, the model ofheroin maintenance that the Britishused in 1969, in the early stages ofthe clinics.Heroin clinics would prescribeheroin on the basis of the clinicphysician's assessment of the addict'sneed, and the addict thenwould pick up his supply at a pharmacyof his choice. Such a systemwould probably have a strong appealfor the great majority of addicts. Theamount of time and energy theywould have to spend in getting theirheroin would be vastly reduced, andthey would be using a safer and farcheaper drug.Many of the social costs of heroinprohibition would be lowered bysuch a system. A higher percentageof addicts would be able to stabilizetheir doses and become more productivecitizens. And even thosewho continued to steal would at leastnot have to meet the demands of anexpensive heroin habit. Moreover,the system would not be very expensiveto administer. The best recentestimate of the cost per addict isabout $2,500, or about one-fifthmore than a well-run methadoneprogram costs today.The Problem of LeakageThe prescription system, however,has one major and intractable disadvantage.Those addicts who pickup their supply of low-cost heroinwill have a strong incentive to resellat least part of their supply. Thisproblem is not a mere consequenceof sloppy administration. It is inherentin any system that allows theaddict to possess resellable heroinoutside the confines of a guardedclinic, laboratory, or hospital.Of course, the clinic staffwill try tolower the amount of heroin the addictcan sell by prescribing no morethan he needs. Several factors, however,make their task extremely difficult.First, it is impossible to tellhow much heroin an addict doesneed. Often he will be able to make aconvincing case that his tolerancehas increased his need.To complicate the matter further,today's heroin addicts have learnedhow to get along on wildly fluctuatingheroin dosages. Their intakevaries enormously when times ofheroin glut are succeeded by shortages,and even during periods ofstable price and supply, when theirincome changes. If the addict wishesto earn money by selling part of hisprescription, he can lower his use,either temporarily or permanently,and simply get along on less.In addition, since methadone willprobably remain available on thestreet at a lower price than heroin, itis likely that an addict would be ableto stave offwithdrawal by using thatdrug. This would allow 4im to sell all(continued on p. 61)Fall 1983 Stanford Lawyer9