Fall 1983 – Issue 30 - Stanford Lawyer - Stanford University

it will be less so if we adopt a heroinmaintenance system. Indeed, thereare reasons to think that more nonaddictswill be able to purchaseheroin under a prescription maintenancesystem.One reason would be the greatersocial integration of the new class ofsellers. Freeing addicts from theneed to pursue their own heroin requirementsmakes it easier for themto integrate themselves into moreareas of our society. Indeed, that isone of the purposes of heroin maintenance.The problem is that so manyaddicts have become more adept atillegal than legal methods of earningincome. The likely prospect is thatmany of them would supplementtheir incomes by selling some oftheir prescribed heroin to their new,nonusing associates.The effect of a prescription system,then, would be to expose amuch larger segment of the populationto access to heroin. It would notonly lower the financial cost of thedrug to large numbers of people, itwould greatly lower the nonfinancialcosts as well-the difficulty, inconvenience,and danger of obtainingheroin.Enrollment of NonaddictsNonaddicts might even be able toobtain heroin through the prescriptionsystem directly rather than indirectlyfrom those addicts inmaintenance. It has been allegedthat the almost automatic provisionof welfare payments to those enrolledin certain methadone programshas acted as a significantinducement to nonaddicted heroinusers, and even some nonusers, topass themselves off as addicts andenter maintenance.Similarly, the opportunity to profitfrom the sale of prescribed heroincan act as an incentive to both addictsand nonaddicts to enter themaintenance system. The incomefrom heroin sales would presumablybe considerably greater than thatfrom welfare payments today, andwould provide a more exciting and,in some circles, a more respectableway of earning a living.Unfortunately this income wouldbe gained at considerable social cost.It would increase the number ofheroin sellers, increase the costs ofthe maintenance system by addingextra clients, and be a far more explosiveissue politically than welfareis today.It is true that if a heroin maintenanceprogram were run with considerablecare, it could avoid takingmost nonaddicts onto its rolls. Thisis not, however, so easy as mightappear.Although we tend to use the term"addiction" as if it were a precise,either/or condition, the fact is that itis a very imprecise term. Often thequestion of addiction will turn out tobe one of degree - and even then dependentupon the expectations of theuser.Admittedly, injection of an opiateantagonist will throw into withdrawalsomeone with a relativelylow degree of physical dependence,while it will not affect a mere user.There are disadvantages in thissomewhat drastic screeningmethod, however. First of all it islikely to make signing up for themaintenance program considerablyless attractive to those who are addicted.More important, it requires aconsiderable degree of care and skillto administer - characteristics whichmay not always be in great supply ifheroin maintenance proliferates.Worse yet, our experience withmethadone programs gives us reasonto expect that patients and staffwill sometimes collude. Prospectivepatients counterfeit addiction forvarious reasons. The staff membersignore the safeguards meant to barnonaddicts, both because the supportfor such clinics is based on a perpatient payment and because theyare sympathetic with the reasons thenonaddict wants to join. This, as wewill see, has been a problem withmaintenance systems using methadone,a much less troublesome andless attractive drug than heroin. Wewould have to expect that considerablymore would go wrong with anysystem making use of heroin itself.Costs of a PrescriptionSystemA prescription heroin maintenancesystem would entail significant administrativecosts. First of all, onpurely therapeutic grounds, it wouldentail expenses for monitoring andprescribing for the addicts.In addition, we would need to establishcareful controls to preventthe wholesale embezzlement of heroin.We would have to invest a considerableamount in auditing thepractices of clinics to prevent prescriptionfraud and other corruption-though, of course, our effortscould never be completely successful.Similarly, the pharmacies thatfilled the prescriptions would have tobe protected from robbery as well asembezzlement.Finally, the social cost of a prescriptionmaintenance system includesnot only the resourcesexpended on it and the increases inaddiction it might bring, but also theresults of the inevitable police effortsto stem the tide of diversion. Thegreater these efforts, the more theoverall system takes on the disadvantagesof our present heroin prohibition,in the consumption of lawenforcement resources, fostering ofpolice corruption, and violations ofcivil liberties.On-the-Premises SystemThe intractable problem of diversionfrom a prescription maintenancesystem forces one to examinemore carefully the other major typeof heroin maintenance: the on-thepremisessystem. Here, diversionwould be minimized by not allowing62Stanford Lawyer Fall 1983