Thursday, March 14, 2013

Origins of Methadone, Part II. The Narcotic Clinics


To understand methadone maintenance, one must first go back in time, before even methadone was ever synthesized. We must first look to the start of opiate prohibition in the US, the Harrison Narcotic Tax Act. While the HNTA was on the surface a tax, it was really a prohibition. It works something like this: you can still sell opiates, but the government is going to tax each gram by an outrageous amount. If you got caught with opiates without paying the tax, you went to jail for tax evasion of all things! A loophole was made available for doctors, who were exempt from the tax by paying a very modest registration fee.

Why would congress prohibit drugs in such a roundabout manner? The constitution does not give congress the power to prohibit drugs outright, to prohibit alcohol it required an amendment to the constitution. In principle a very strong case could be made that drug prohibition violates protections enumerated in the United States Bill of Rights. The taxing scheme fell under the "Commerce Clause" of the US Constitution, "...to regulate commerce with foreign nations, and among the several states, and with the Indian tribes." Congress abandoned the taxation mythology long ago and have passed laws prohibiting drugs outright (even drugs that may not even exist yet!), but short of a constitutional amendment, congress does not have the authority to prohibit opiates. 

It was called the Harrison Tax Act. You know, the drafters of the Harrison Act said very clearly on the floor of Congress what it was they wanted to achieve. They had two goals. They wanted to regulate the medical use of these drugs and they wanted to criminalize the non-medical use of these drugs. They had one problem. Look at the date -- 1914. 1914 was probably the high water mark of the constitutional doctrine we today call "states' rights" and, therefore, it was widely thought Congress did not have the power, number one, to regulate a particular profession, and number two, that Congress did not have the power to pass what was, and is still known, as a general criminal law. That's why there were so few Federal Crimes until very recently. 
In the face of possible Constitutional opposition to what they wanted to do, the people in Congress who supported the Harrison Act came up with a novel idea. That is, they would masquerade this whole thing as though it were a tax. To show you how it worked, can I use some hypothetical figures to show you how this alleged tax worked? 
There were two taxes. The first (and again, these figures aren't accurate but they will do to show the idea) tax was paid by doctors. It was a dollar a year and the doctors, in exchange for paying that one dollar tax, got a stamp from the Government that allowed them to prescribe these drugs for their patients so long as they followed the regulations in the statute. Do you see that by the payment of that one dollar tax, we have the doctors regulated? The doctors have to follow the regulations in the statute. 
And there was a second tax. (and again, these are hypothetical figures but they will show you how it worked.) was a tax of a thousand dollars of every single non-medical exchange of every one of these drugs. Well, since nobody was going to pay a thousand dollars in tax to exchange something which, in 1914, even in large quantities was worth about five dollars, the second tax wasn't a tax either, it was a criminal prohibition. Now just to be sure you guys understand this, and I am sure you do, but just to make sure, let's say that in 1915 somebody was found, let's say, in possession of an ounce of cocaine out here on the street. What would be the Federal crime? Not possession of cocaine, or possession of a controlled substance. What was the crime? Tax evasion.
          Charles Whitebread, The History of the Non-Medical Use of Drugs in the United States

Here is the relevant sections from the actual text of the Harrison Narcotic Tax Act.
Sec. 2 Nothing contained in this section shall apply -

(a) To the dispensing or distribution of any of the aforesaid drugs to a patient by a physician, dentist, or veterinary surgeon registered under this Act in the course of his professional practice only: Provided, That such physician, dentist, or veterinary surgeon shall keep a record of all such drugs dispensed or distributed, showing the amount dispensed or distributed, the date, and the name and address of the person to whom such drugs are dispensed or distributed; except such as may be dispensed or distributed to a patient upon whom such physician, dentist, or veterinary surgeon shall personally attend; and such record shall be kept for a period of two years from the date of dispensing or distributing such drugs, subject to inspection, as provided in this Act.

That the provisions of this Act shall not be construed to apply to the sale, distribution, or giving away, dispensing, or possession of preparations and remedies which do not contain more than two grains of opium, or more than one-fourth of a grain of morphine, or more than one-eighth of grain of heroin, or more than one grain of codeine, or any salt or derivative of them in one fluid ounce, or, if a solid or semi-solid preparation, in one avoirdupois ounce, or to liniments, ointments, and other preparations which contain cocaine or any of its salts or alpha or beta eucaine or any of their salts or any synthetic substitute for them: Provided, that such remedies and preparations are sold, distributed, given away, dispensed, or possessed as medicines and not for the purpose of evading the intentions and provisions of this Act. The provisions of this Act shall not apply to decocainized coca leaves or preparations made therefrom, or to other preparations of coca leaves which do not contain cocaine.[Bold added -Ed]

Some historians seem to think the HNTA was merely designed to institute orderly regulation to the pharmaceutical industry. On reviewing congressional testimony Arnold Trebach concluded that the HNTA was indeed intended to be a prohibition on "non-medical" drug use (Trebach, 1982). Charles Whitebread, in his speech to the California Judges Association also agrees that the HNTA was meant to be a criminal prohibition, "Some of you may have come this morning thinking that we have used the criminal law to deal with the non-medical use of drugs since the beginning of the Republic or something. That is not true. The entire experiment of using the criminal sanction to deal with the non-medical use of drugs really began in this country in 1914 with the Harrison Act." Edward Brecher notes how the wording of the bill did not seem to be a criminal prohibition. What constituted medical use would determine the legality of the drugs, a question the courts would eventually take up.  
On its face, moreover, the Harrison bill did not appear to be a prohibition law at all. Its official title was "An Act to provide for the registration of, with collectors of internal revenue, and to impose a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes ." The law specifically provided that manufacturers, importers, pharmacists, and physicians prescribing narcotics should be licensed to do so, at a moderate fee. The patent-medicine manufacturers were exempted even from the licensing and tax provisions, provided that they limited themselves to "preparations and remedies which do not contain more than two grains of opium, or more than one-fourth of a grain of morphine, or more than one-eighth of a grain of heroin . in one avoirdupois ounce." Far from appearing to be a prohibition law, the Harrison Narcotic Act on its face was merely a law for the orderly marketing of opium, morphine, heroin, end other drugs-in small quantities over the counter, and in larger Quantities on a physician's prescription. Indeed, the right of a physician to prescribe was spelled out in apparently unambiguous terms: "Nothing contained in this section shall apply . . . to the dispensing or distribution of any of the aforesaid drugs to a patient by a physician, dentist, or veterinary surgeon registered under this Act in the course of his professional practice only." Registered physicians were required only to keep records of drugs dispensed or prescribed. it is unlikely that a single legislator realized in 1914 that the law Congress was passing would later be decreed a prohibition law.

The provision protecting physicians, however, contained a joker hidden in the phrase, "in the course of his professional practice only ." After passage of the law, this clause was interpreted by law-enforcement officers to mean that a doctor could not prescribe opiates to an addict to maintain his addiction. Since addiction was not a disease, the argument went, an addict was not a patient, and opiates dispensed to or prescribed for him by a physician were therefore not being supplied "in the course of his professional practice." Thus a law apparently intended to ensure the orderly marketing of narcotics was converted into a law prohibiting the supplying of narcotics to addicts, even on a physician's prescription.
          -Edward M. Brecher, Licit and Illicit Drugs. Chapter 8

What constitutes "medical need" was of course not determined by the individual, but rather the doctor, medical establishment and government bureaucracies. For the majority of the history of the human species, and certainly within the US up to this point, self-medication was the rule. Suggestions for treatment options have always been sought from healers, but ultimately the individual was responsible for their own health. This was especially true for the poor who could seldom afford medical care, and when they could they rationed it for only the most serious illnesses. Opium was always considered a valuable medicine, for even if it did not cure it did palliate pain and make the disease more bearable. Prior to 1914 there were local bans on smoking opium, mainly blatantly racist attempts to harass the Chinese (if opium is a dangerous and debilitating drug, it certainly didn't hurt the Chinese, otherwise it would have been encouraged and not prohibited), but for the first time in the history of the United States the people no longer possess the right to choose opiates as a treatment for their ailments. The right to self-medicate with opiates was transferred to doctors, who limited their use to a few "legitimate" conditions.

There remained the problem of what to do with the addicts, those individuals dependent on opiates but judged not to have medical need.  Attempts to detoxify and "cure" the addicts were made, unfortunately opiate addiction is a rather intractable condition. Even once detoxed and free of their dependence, addicts tended to relapse to opiate use. This gave rise to two opposing views of addiction: medical disease and deviant criminal behavior. The response from society to someone who is sick is very different from someone who is a criminal. If the addict is sick, a cure should be attempted and absent that, the disease should be managed in such a way as to maximize the quality of life of the patient. If the addict is a criminal, they deserve to be punished for their deviant pharmacological preference.

Doctors at first were supportive of the prohibition, believing opiate addiction could be brought under their control by making the supply of opiates available solely through medical channels. In retrospect this seems hopelessly naive. There were, of course, other less altruistic reasons for opiate prohibition, nevertheless the sudden creation of a black market caught many off guard. There were doctors who recognized the risk to both the humanity of the addict the the threat to a harmonious society the black market posed. Once such was Dr. Charles E Terry,
"It would seem unnecessary to state that the narcotic drug addict must be supplied with his drug in doses physically necessary until such time as he may receive treatment which will leave him in at least as good condition as that in which it found him. That to supply this drug is not only necessary, but is vital, that to deny it is to cause a physical and possibly a moral wreck, while to heap contumely upon narcotic drug addicts as a whole is to drive them to the underworld for their supply, It never must be lost sight of that among the sufferers from this disease are numbered many of the highest intellectual types of men and women in the business and professional worlds, and that individuals of this type May not contemplate the indignities which many administrators seek to heap upon them, through their ignorance of the true nature of this condition and their apparent misconception of the character of its victims."
Sympathetic doctors like Terry set up clinics specializing in dispensing opiates to addicts in regular, non-diminishing doses; in essence the addiction was maintained. Narcotic maintenance clinics sprang up in numerous cities throughout the US. There are  advantages to society as well as the addict. The high cost of the black market compelled many impoverished addicts to commit crimes to raise money, with narcotic clinics drug-related crime reduced. With any drug market, addicts consume more than the average user's amount of the supply. Alcohol addicts (alcoholics) may drink up to half of all the alcohol sold. Without addicts drug dealers face a significantly diminished market, in some rural areas they may not be able to establish a market at all. Black markets bring their own additional violence as dealers fight over market share, diminished activity also makes the black market less profitable.

The advantages to the addict are life-changing. Opiates do not cause damage to the human body in the way alcohol or tobacco does. Short of maintaining the addiction, opiates are not causing the addict harm. The poor quality and uncertain dosages of black market drugs put the addict at risk of overdose and numerous medical problems; especially infections resulting from lack of sterile technique, adequate filters to remove particles and laws against syringes which encourage blood-born infectious diseases to easily pass between users. In case the reader thinks problems resulting from syringe-sharing are limited only to users (perhaps as punishment for having an addiction, similar to the view that HIV is God's punishment for homosexuality), consider than many of these infections (eg HIV, Hep C) can be passed through sexual contact and that many addicts eventually give up their addictions. Since opiates are very cheap to produce, the cost of the drugs does not require raising large amounts of money. The addicts can then maintain the addiction with minimal cost and not have to resort to crime.

There is a common myth that assumes given free access to opiates like heroin, the addict will increase their dose indefinitely. In reality every user eventually hits a threshold beyond which they face rapidly diminishing returns, and high doses are experienced as being unpleasant. Everyone eventually hits this plateau, or therapeutic dosage. The actual drug and dosage may vary considerably between individuals, one might respond well to codeine, another diamorphine. Once the addict is on a stabilized dose, taking the drugs do not cause impairment. Not everyone responds to opiates in the same way, but there are countless examples of addicts who succeeded in careers as diverse as surgery and medicine, politics, music and writing. For every famous addict there are doubtless numerous others who's names will be lost to history, yet were otherwise normal citizens, husbands, wives, parents and so on while being addicted to opiates. This is hard for non-users to understand, but a stabilized addict is no more impaired by his medicine as is a diabetic impaired by insulin.

Perhaps the best run clinic in the country was operated in Shreveport, Louisiana by Dr. William P. Butler from 1919-1923. In 1919 crime in Shreveport peaked as federal agents cracked down on supplies. Dr. Butler was approached by the president of the Louisiana Board of Health to set up a treatment program for addicts. The Shreveport clinic used morphine with a median dose of 486 mgs, with an upper limit at the 700-800 mg range. All were "vein shooters" according to Dr. Butler and there were no overdoses. Rarely were addicts unable to function even while taking massive (by modern standards) doses. When opiate addicts are on a stable dose they are no more impaired than tobacco addicts. It didn't take Dr. Butler long to realize that addicts were not fundamentally criminals, but rather were in a condition that resembled a medical illness:
"No matter what different persons may call the condition, the patient is a sick person, and as such is entitled to and should have proper consideration, care, and treatment, either for the causes that are responsible for him being an addict, or for the addiction itself...The fact that he cannot get his medicine in some legal way does not mean that he will not, or in many cases that he should not get it in some other way. If we fail to provide a legal way for the needy suffering to obtain relief, are we to blame them for seeking relief from some other source? They suffer with mental and physical troubles and should be given proper and humane consideration."
Opiate addicts were a popular scapegoat on which many of society's ills were blamed, a trend that continues to this day. When people actually get to know an addict they are often surprised to see how they fail to live up to the stereotype. Similarly many people who advocate harsh prison sentences for addicts suddenly change their opinions when the addict is someone they love, or even themselves (like Rush Limbaugh [1]).

Initially local law enforcement opposed the clinic, the commissioner of public safety (as head law enforcement officer he was also effectively the chief of police) in Shreveport once criticized the clinic and its clients, saying if he could he would throw the "bums and street characters" into the river. The good doctor took umbrage at this statement, and asked the commissioner for a word in private. He then went on to inform the man, "I'm going to violate the confidence of one of my patients now...I want you to know that your mother is one of those patients that you would like to drive into the river."

The commissioner was, understandably, shocked. "I've never denied my mother anything. You know I'm a man of considerable wealth...But I have wondered why she was spending so much money and what for?"

"On peddlers...getting illegal drugs..." Dr Butler replied. (Quoted from Trebach, 1982)

From that day forth the commissioner supported the clinic to the furthest extent of his power, lauding it with praise at every opportunity. When addicts are only "those people" they are easily dehumanized as "bums and street characters" (or worse), when they are loved ones the stereotypes shatter. Rather than being viewed as criminals, the addicts were viewed as sick. In this light providing regular doses of morphine was a valid treatment for their condition, once stabilized the addicts were able to function normally.

Despite having the support of the mayor, local medical community, local federal judge and prosecutor and local police, federal narcotics agents killed the clinic. It was a death by a thousand cuts, despite finding no evidence of criminal activity the last clinic in the country closed its doors in 1923. The Shreveport clinic was the last operating narcotic maintenance clinic in the US. A series of supreme court decisions decided prescribing narcotics to addicts for the purpose of maintaining the addiction was not part of professional medical practice, doctors could now be prosecuted for giving drugs to addicts [2]. Addicts quickly became pariahs of medicine, often denied basic medical care (in violation of their human rights). What followed has been known as the "classical" period of American narcotic control policy, classic in the sense of being simple and harsh.
The meeting [to decide the fate of the clinic] took place in the Federal Court House with District Attorney Mecom presiding. Dr. Butler was present with Cunningham and two other agents. After some discussion it was agreed that the clinic would close on February 10, 1923. Dr. Butler described the meeting later in a letter to the Atlanta Georgian newspaper as being amicable: 
No records were gone over, no patients, officials, or doctors were called and nothing was gone into except the closing of the dispensary. I have felt all along, and still do, that I am right, but rather than enter an endless controversy without reasonable hope of what I consider right to prevail I agreed to discontinue the so-called clinic. 
All was very harmonious, and I must say the Inspectors appeared to be very nice gentlemen, far different from Mr. Wouters. I was told that I am not in any way accused of wrongdoing or bad faith, but that the work that I am doing here caused trouble because other places contended that if Shreveport be allowed to have a "clinic," they should be allowed such a privilege.

         -Waldorf, Dan, et al. Shreveport and the Clinic - the 1920's. In: Chapter 1. Morphine Maintenance: The Shreveport Clinic 1919-1923. Washington: Drug Abuse Council; April 1974: pp. 50.[Link]

From then on addicts were treated as criminals deserving of prison. On the common practice of jailing addicts Dr. Butler warned, "I have never seen a patient who was forced into jail, and forcefully treated (or rather mistreated) [sic] remain well when released. That method is inhuman and wrong...I consider the usual 'iron bars' or 'cold steel' treatment to be as cruel and wrong as an operation with no anesthetic." The "cold steel" treatment would remain the dominant policy of American narcotic control policy until the 1960's, a period that witnessed an explosion of all types of drug use. It would take two doctors, Vincent Dole and Marie Nyswander, and an esoteric synthetic opioid first synthesized in Germany, to bring back the concept of narcotic maintenance.

It is worth noting that the UK took the opposite approach to the "problem" of opiate addicts (a problem if not caused then exacerbated by opiate prohibition). The British government formed a committee on morphine and heroin addiction, led by Sir Humphry Rolleston, and published the Rolleston Report in 1926. The report recommended providing addicts with maintenance doses was necessary for addicts whom:
(a) Those in whom a complete withdrawal of morphine or heroin produces serious symptoms which cannot be treated satisfactorily under the ordinary conditions of private practice; and . (b) Those who are capable of leading a fairly normal and useful life so long as they take a certain quantity, usually small. of their drug of addiction, but not otherwise.
What later became known as the "British System" worked well in the UK, opiate addiction was largely treated as a medical problem. This system changed in the 1960's, a tumultuous period of social change that also saw an explosion of drug use among the youth.

Further Reading:

Shreveport Morphine Clinic

The Rise of the Criminal, Deviant Addict

There are three conditions that turn an addiction from a private affair to a public disaster:
1. Dependence: The individual literally depends on a chemical to function normally. There are a number of conditions (eg diabetes, opiate addiction) that require regular doses of a chemical without which they become ill. Everyone is chemically dependent on air, some essential vitamins and minerals, and a source of food (calories).
2. Pleasure: The drug is experienced as pleasurable, which we can define either in a positive sense (makes you feel better) or negative sense (absence of pain and anxiety). Using drugs for pleasure has always been a popular human activity. The belief that using drugs for pleasure is morally wrong is known as pharmacological calvinism, “a general distrust of drugs used for non-therapeutic purposes and a conviction that if a drug makes you feel good it must be morally bad”(Kramer, 1993). Drugs used to feel good (or feel better) are often derisively referred to as "recreational" or "non-medical," and common targets of prohibitions from abstinence idealists obsessed with enforcing their beliefs upon everyone else.
3. Scarcity: The supply of the drug may run scarce due to natural occurrences like drought, or for artificial reasons like a government prohibition. Prices reflect availability, when supply cannot meet demand due to an artificial scarcity, black markets arise to serve the excess demand.

Addiction, by itself, is not a disabling condition. There are numerous examples of opiate addicts who rose to the top of their profession. With a regular and low-cost supply, addicts often lived otherwise normal lives not unlike tobacco addicts today. When supply becomes reduced, stereotypical drug-seeking ("junkie") behavior  ensues. This is true of all chemical addictions, and perhaps also with behavioral addictions (eg gambling).[3]

The social change from a pre-prohibition society to a post-prohibition society involved a change in scarcity. Opiates went from an available, and therefore cheap substance, to a scarce and therefore expensive substance. The change for the addict was paradigmatic. In short it turned what was viewed by most as a minor vice into a disaster for the addict and society. Quitting any addiction is hard, but as anyone who has experience with addiction can attest, the problem is not returning to the addiction (ie relapse). Only if the drug was completely unavailable to the addict would a prohibition succeed in "curing" the addict, something the government has never able to accomplish. And even then the addicts would most likely switch to another substance, very likely alcohol, benzodiazepines or some other sedative. It is quite possible that opiate prohibition has led to increased addiction to alcohol, a drug noted for its toxicity following chronic use (alcohol is particularly hard on the liver) as well as bringing out anti-social tendencies in some users.

Tobacco Prohibition: The Next Big Gift to International Drug Trafficking Organizations?

A particularly relevant analogy is tobacco; tobacco addiction may have health consequences for the user, but little for society beyond medical costs. The argument for a tobacco prohibition, based on "addictiveness" and toxicity, is actually stronger than that for opiates. Tobacco is highly addictive and currently has no recognized medical uses; both are criteria used for schedule I drugs, the most restrictive schedule in the federal classification scheme.

Tobacco addiction is often colloquially referred to as a habit, and intensive treatment for tobacco addiction is unheard of. Alcoholics Anonymous, which ostensibly requires its members to abstain from all non-prescription, addictive drugs, seems to ignore tobacco. As long as tobacco is relatively cheap and available, tobacco addiction is a minor social concern (as least in the sense that tobacco users are not violating the rights of others). There will always be anti-drug moralists unwilling to learn from history. Soon after tobacco is prohibited, the price will go from $5 a pack to $5 a cigarette and tobacco addicts will be committing crimes to support their addictions. In 1990 the Soviet Union faced a major cigarette shortage, there were people rioting in the streets [4].
Siberians angered by shortages of liquor and cigarettes smashed cars and shop windows, tossed firebombs and tried to storm police headquarters in the country's most violent disturbance triggered by the disintegrating Soviet economy.                                                      
More than 100 people were detained and dozens were injured in three days of riots ending early Saturday that shook Chelyabinsk, a large industrial city 1,200 miles east of Moscow.

The latest rampage in the city of more than 1 million people on the eastern slopes of the Ural mountains followed two days of similar outbursts. On Wednesday, angry consumers lined up for alcohol at the largest supermarket in Chelyabinsk went on a rampage, shouting "Give us sausage, give us sugar, give us tobacco!" when sales clerks refused to open the doors without police to maintain order.[Bold Added - Ed]
          Shortages Prompt Riots in Siberia : Soviet Union: Tobacco, liquor, food and other consumer items grow more scarce. The incidents are the worst yet in the disintegrating economy. LA Times, August 1990

It doesn't matter whether an individual is dependent on drugs or not, what matters is their behavior. The most important question that is never asked is whether the person is better off addicted or not. Especially in contemporary discussions about opiate addiction, it is usually just assumed that addicts are better off not being addicted. Yet some opiate addicts are high functioning while being addicted, indeed they only feel truly well while on opiates. To keep them from their medicine is callous and cruel. I leave the last word to Whitebread, who predicts tobacco as being the likely target of the next great drug prohibition, and identifies the theme common to all criminal prohibitions:
And so, yeah, we will continue the War on Drugs for a while until everybody sees its patent bankruptcy. But, let me say that I am not confident that good sense will prevail. Why? Because we love this idea of prohibition. We really do. We love it in this country. And so I will tell you what I predict. You will always know which ones are going out and which ones are coming in. And, can't you see the one coming right over the hill? Well, folks, we are going to have a new prohibition because we love this idea that we can solve difficult medical, economic, and social problems by the simple enactment of a criminal law. We adore this, and of course, you judges work it out, we have solved our problem. Do you have it? Our problem is over with the enactment of the law. You and the cops work it out, but we have solved our problem. 
Here comes the new one? What's it going to be? No, it won't be guns, this one starts easy. This one is the Surgeon General has what? --Determined -- not "we want a little more checking it out", not "we need a few more studies", not "reasonable people disagree" -- "The Surgeon General has determined that the smoking of cigarettes will kill you." 
Now, all you need, and here is my formula, for a new prohibition every time is what? We need an intractable, difficult, social, economic, or medical problem. But that is not enough. There has to be another thing. It has to divide by class --- by social or economic class, between US and THEM.

References and Further Reading:

The History of the Non-Medical Use of Drugs in the United States. A Speech to the California Judges Association 1995 annual conference by Charles Whitebread, Professor of Law, USC Law School

Kramer, Peter., Listening to Prozac, New York, NY: Viking, 1993.

Trebach, Arnold. The Heroin Solution, Binghamton, NY: Yale University Press, 1982

Brecher, Edward M., and the Editors of Consumer Reports. Licit and Illicit Drugs: The Consumers Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and Marijuana-Including Caffeine, Nicotine, and Alcohol. Boston, MA: Little, Brown and Company, 1972. [Link]

Notes:

[1] "What this says to me is that too many whites are getting away with drug use. Too many whites are getting away with drug sales. Too many whites are getting away with trafficking in this stuff. The answer to this disparity is not to start letting people out of jail because we’re not putting others in jail who are breaking the law. The answer is to go out and find the ones who are getting away with it, convict them and send them up the river, too." -Rush Limbaugh
Law-enforcement sources tell Newsweek that Rush Limbaugh's exposure as a pain-pill addict began when his former housekeeper Wilma Cline, 42, showed up at the Palm Beach County state attorney's office late last year eager to alert the cops to her boss's drug use. Her motive remained murky, but her story-how she had met Limbaugh in parking lots to exchange sandwich bags filled with "baby blues" (OxyContin pills) for a cigar box stuffed with cash-was luridly damning, reports Thomas. 
According to Cline, Limbaugh took as many as 30 OxyContin pills a day. It is not clear why Cline went to the authorities. She could still be prosecuted, despite a partial grant of immunity, say law-enforcement sources. The investigation has so far produced an arrest of a Palm Beach County couple accused of pushing hydrocodone and OxyContin. 
Journalists who have spent time with Limbaugh have been struck by the contrast between Rush the Radio Know-It-All and the private, ill-at-ease Limbaugh. Friend Bill Bennett, whose book, "The Moral Compass," Limbaugh touted on radio, says he knew nothing of Limbaugh's pill popping. "He's a very private man," Bennett told Newsweek. "He takes problems into himself." 
Radio Talk-Show Host Rush Limbaugh's Addiction On Newsweek Cover

[2]
In 1919 two important Supreme Court decisions were made that had a large impact on addicts and the ways they were being treated by doctors. In March of that year, on the very same day, the Supreme Court decided: (1) that the Harrison Act was constitutional and (2) that doctors who maintained addicts were in violation of the Harrison Act. In the first case, the Supreme Court reversed an earlier District Court decision that dismissed an indictment against Dr. Charles Doremus. Doremus, of San Antonio, Texas, had been arrested in 1915 for providing a large supply (500 one-sixth gram tablets) of morphine to a known addict, a violation of the Harrison Act. When he appealed the arrest, the District Court decided that the Harrison Act as a revenue measure could not restrict the medical practice of Dr. Doremus. in other words, the way the law was used to prosecute Dr. Doremus was unconstitutional. The Federal government pursued the case to the Supreme Court, and in a five to four vote won a reversal of the decision of the District Court. They found Dr. Doremus in violation of the Harrison Act and thus affirmed the constitutionality of the act. 
In the second decision, Dr. Webb's appeal of a Harrison Act indictment was denied because he had supplied morphine to an addict with the intention of maintaining his accustomed use. This decision established that the maintenance of an addict was against the law unless it was part of a cure. Maintenance, for decades before the decision, had been a common practice. In the event that a doctor could not successfully treat some illness or disease, doctors felt justified in relieving the accompanying pain and suffering. For the addict the relief was opiates.

         -Waldorf, Dan, et al. Shreveport and the Clinic - the 1920's. In: Chapter 1. Morphine Maintenance: The Shreveport Clinic 1919-1923. Washington: Drug Abuse Council; April 1974: pp. 50.[Link]

[3] Drug use is also a behavior, some readers may take issue with my separating drug addictions from behavioral addictions. Further discussion would require going into defining addiction, which is beyond the scope of this article.

[4] Apparently the prohibitionists never learn, rather than reduce the harm of tobacco by instituting harm reduction methods (E-cigs or smokeless methods of administration) politicians think they can stop addiction by eliminating supply.
Defense Minister Sergei Shoigu has reportedly drawn up a rule to end the longstanding practice of providing enlisted troops and cadets with 10 cigarettes a day. According to the Russian newspaper Izvestia, the reason is pretty straightforward: Russian soldiers choke down cigarettes, and the subsidy is encouraging the next generation of uniformed addicts.
[...]
But troops may not be able to handle losing their free smokes. “Tobacco shortages will affect the psychology of the smokers,” Valentina Melnikova, executive secretary of the Union of Soldiers’ Mothers’ Committee, a human rights organization focused on the military, told Izvestia. “Platoon or company commanders will start collecting money from the ranks, including non-smokers. This will result in speculation, extortion, bullying and even violence.” (In case you were wondering, the Defense Department included free cigarettes in some K-rations until 1975.)

The reason, Melnikova implies, is that troops won’t necessarily quit smoking, and won’t have enough money to pay for cigarettes over the counter, leading to a black market within the military. It wasn’t until January that service members saw a raise from 500 to 1,000 rubles, or $16.50 to $32 per month. Before the raise, many soldiers spent much of their take-home pay on cigarettes, according to RIA Novosti, even with the government ration. (Smoking’s expensive.) Izvestia also suggests that troops would need their salaries to quadruple to support their habit.
          Russia Fears Its Troops Will Riot if Cigarette Rations End Wired Magazine, March 2013

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