CUMMING t Wnt aerk July 23,1925, Doctor Alexander Lambert 43 East 724 Street New York, UY. Dear Doctor lambert: m I em in receipt of your letter of July 7th in further reference to obtaining data as to our legitimate narcotic needs by surveying hospitals of the country in order to de~ | termine how much they use per patient, and then applying this ‘result to the entire country on the assumption that a certain percent of the population is sick during the year, Since my last letter to you I have thought a great desl on the subject -, pome doubts have srisen in my mind as to the reliability of the method and the value of the data after they are secured, «~*~ We*eould by surveying the hospitels find within a small margin of error how much narcotics they use in a given year. This would be one fact upon which to work but ell the other factors to be considered in drawing conclusions would be ) indefinite and intangible, or mere guesses, If, for instance, we could find how many people were sick outside of hospitals amd assumed that they had conditions oe for narcotic | needs, compared with those treated in hospitals, wo wold still be at sea unless we also knew the average length of time spent ¥ patients in hospitels as well as the average duration of iliness for those treated on the outside. It would probably — be pogsible to fini how the average patient remains in the hospital but for those i11 on the outside we oan neither find their number mor the average duration of their illness, : . &t is reasonable to assume that 50 or 60% of the population are sick during the year because it has been shown that this proportion of workers in certain places are given sick leave, but we have to remember that workers ere ustally a seleeted ‘@lass from the standpoint of health ami for the entire population the index of sickness might be larger. aaa se os . Thies Doetor Alexander Lambert-2 | It is generally believed by those of us who have studied the subject, that patients outeide of hospitals receive more opium than hospitsal patients ani we know that som of this excess is due to unnecessary oreseribing; but we it well stop to consider whether or not the * proportion of chronic invalids are treated at home, have no statistics to een 3 4 me but I am rather inclined to believe they are, especial if we do not for this study include among chronic invalids the. —— whe are in hospitals and presumbly need very little ODUM. _ In contrast to the uncertainties of the mthod we have — discussed,ate the very definite figures furnished by the Bureau of Internal Revenue. They show how much narcotics is released each year to physicians, dentists, druggists, eteetera; and it is known that very little of this finds itesway into illegitimate chamnels, no larger proportion than would be ‘the ease if the amount allowed were arbitrarily reduced, — The amount now released represents as you know the equivalent of about 136,000 pounds of opium, and the more I think of it the more I am convinced that when the yearly emount ie averaged up over a period of four or five years will have & nearer a seen due Hi 95 of legitimate needs than sny — eonsideration of Indefinite values ¢mild giw, If the Porter resolution succeeds in its purpow and no more opium is smuggled in, the addicte will necessarily be eureds they will then no longer come over and over again for treatment requiring a certain amount of legitimate preseribing and the quantity of opium needed will to thet extent be reduced. —— th the continued operation of our present laws and better informed medial men will gradually reduce the legitimate requirements until, on the basie of our present population, it might be about 45,000 pounds- as you have sugges ted. I am assuming here that any prescription for narcotics iven in accordance with our present laws and eas is degitimte. This does not mean thet such preseriptions are always necessary or useful; in fact we know that some of them Show gross seer cee or Garelessresa on the part of physicians. But it is difficult to see how by arbitrarily reducine the amount of opium alloved the profession senseless prescribing would be done away with. If 45,000 pounds now represents actual useful needs and the medical profession had to get along with that quantity, a tremedous machinery would have to be set up in order to prevent the ignorant end careless physicians from Dector Alexander Lamberte2 : using up nearly all the avdilable stock and leaving an in- sufficient supply to relieve actual suffering, Our physicians in private practice prescrive more opium than is necessary just as they do with drugs in gencral, The whole thing is a reflection of our American prosperity and extravagance and it is done partly. because the doctor so often feels he must give something to satiafy hie patient, This is unfortunate-but the remedy is eduction and not restrictions beyond those imposed by our present laws. These restrictions have an educational value and the y prevent the giving of opium to addicts 4+ dong periois of time under the pretext of treatmnt. mdiecal profession would resent any law beyon’ this which interefered with their personal opinions as to : when opium or any other drug is beneficial, If the amount of opium released is suddenly reduced to what is actual scientific medic&l requirements, our lews and regulations will have to ~~ say it shell be prescribed for certain eomditions, in certain anounte, over certein periods of time ond it shail no t be ae preseribed for any other conditions, and each doctor wold have to be checked up three or four times each years Otherwise physicians who needed opium to relieve bilisry or zenal colic would not have any because others would have elready used up the avallable supply for whet som of us would consider umnecessary purposes, ge | apa 136, pounds of opium would supply about 62,000 addicts for one year if used entirely Ms them. The prescribing of thie much by our physicians for legitimate mdical oses can, therefore, cause very little addiction, The remedy for the Situation ie not to attempt by law to regulate mdical opinion. This would do more harm then good. The remedy lies in the continued enforcement of our laws as they stand @na the — prevention of smuggling by an international agreement limiting production to what «doctors actually prescribe, and not to what we might think they ought to prescribe. If a survey of hospitals tended to show that thirty or fouby thousand pounds should betisfy all real needs, a regulation might be enforced limiting our supply to that amount. This, for the reasons | I have given, would be exteemely unfortunate. It is conceivable that by law or regulation the physicians’ supply might be , peduced even if limitation of production fails. The addict. would then continue to thrive while the sufferer would often because of a shortage of drug continue in discomfort ami pains With the foregoing objections and possibilities in my mind I feel that a survey of hospitals ought not to be mde at the present time, but I would like to hear further from you about it. Although o general survey of hospitals does nbt seem advisable, we have not entirely given up the idee of surveys. The Service has for some time been making a health etudy of Washington County, Maryland. Part of the work includes a k ‘ ‘ . Doe tor Am haath orted sickne a8 gurvey of severei. ‘thou sant families over 2 period of one year, ani we ere now conalidering