Two key pieces of legislation determined Kolb's career path during the 1930s. First, a 1929 act authorized the construction of two federal hospitals for the treatment of drug addicts. Second, in 1930, the Bureau of Prisons was established within the Justice Department. The enabling legislation mandated that medical care of federal prison inmates would be provided by PHS staff. At the same time, another bill authorized the establishment of a special hospital for federal prisoners who were "insane, afflicted with an incurable or chronic degenerative disease, or so defective mentally or physically as to require special medical care and treatment not available in existing federal institutions." The Senate committee noted that the government mental hospital, St. Elizabeth's, had long been overcrowded, and that regular prisons were poorly equipped to care for patients with tuberculosis, and (following the practice of that era) had to lodge them in tents within the prison grounds to protect other prisoners. Kolb was appointed superintendent of the new facility (called the Hospital for Defective Delinquents in its early years) which opened in 1932. The hospital was to be, as Kolb noted in his dedication speech, "a departure from existing methods in the treatment of criminals. It is in advance of anything previously attempted in that it is to be a complete medical unit for prisoners who are sick. It has grown out of the modern conception that crimes are largely due to distorted minds or abnormal personalities of the persons who commit them and that the handling of criminals is a joint problem for the courts and physicians." Working from this perspective, the 1,200-bed hospital would attend to the physical, and especially the mental illnesses of the prisoners, providing humane care comparable to that available on the outside. There would be a special emphasis on rehabilitation and occupational therapies. In the process, staff would also improve the scientific understanding of conditions underlying criminal behavior, and the improved knowledge would benefit public policy. Also, thorough physical and psychiatric examinations and diagnoses would help corrections officials make informed decisions about discipline and general treatment of prisoners, prisoner transfers, and release and probation planning.

The First Federal Narcotic Farm

In September 1934, Kolb left Springfield to serve as director of the first federal "narcotic farm," then under construction in Lexington, Kentucky. The narcotic farms (a second was opened in Ft. Worth, Texas in 1938) were an innovative federal response to a growing problem: aggressive enforcement of the Harrison Narcotics Act had sent so many addicts to prison that by the late 1920s they made up about thirty percent of federal inmates. Prison wardens complained of the overcrowding and the special difficulties of addict prisoners. PHS psychiatrists joined the wardens in arguing that this wasn't good for the addicts (whose crimes were often drug possession or use alone) or the prisons. Prison environments did not provide the treatment and rehabilitation addicts required. And incarcerated addicts caused problems when they attempted to obtain drugs and introduced other inmates to their use. James Bennett, who would soon be assistant director of the new Bureau of Prisons and PHS psychiatrist Walter Treadway (soon to be Assistant Surgeon General and chief of the new Division of Mental Hygiene) worked with congressman Stephen Porter (R-PA) to write legislation providing a new alternative: institutions that would treat addiction as a medical problem by providing medical and psychiatric support along with activities and training, rather than prioritizing punishment and discipline. They hoped this would help addicts to stay off their drugs and away from the legal and social troubles that were so common with addiction. Such a facility would also support research into the psycho-social causes and physiological mechanisms of addiction. Initially, Kolb was not in favor of funding separate federal hospitals for addiction treatment, believing it preferable to set up treatment units for addicted convicts within existing prisons, and expanding state mental institutions to treat other addicts seeking care.

The narcotic farms were hybrid hospital-prison institutions that took in four classes of addicts: those convicted and given a definite sentence in federal courts; those convicted but given probation on the condition that they be admitted to the narcotic hospital for treatment and stay there until pronounced cured; those who had finished a federal sentence but choose to continue treatment; and voluntary patients who could apply for treatment and agree to stay until cured. The provision for voluntary patients reflected the lack of other addiction treatment options; general hospitals, even those with psychiatric wards, were usually not equipped to treat addicts, and private sanitarium treatment was so costly that few patients could afford to stay long enough to be cured. The federal narcotic hospitals charged voluntary patients $1.00 per day, which could be waived for those who were indigent. Although the narcotic farm mandate included treatment of persons addicted to cocaine, hemp (cannabis), and peyote, almost all of those admitted were heroin or morphine addicts.

At Lexington, Kolb was in charge of a large, complex operation--a 1,500-bed hospital and rehab facility housing patients who were often federal prisoners. Like many large penitentiaries, it was also a farm (over 1,000 acres) where some of the residents tended crops and livestock that provisioned the hospital's kitchens. Like the Springfield medical center, it was also a new type of institution, part therapeutic and part correctional, that would take several years to run smoothly, especially with the added factor of voluntary patients.

Addicts arriving at Lexington, whether voluntary or convicts, were photographed, given a number, and methodically searched for drugs and paraphernalia. They were issued hospital pajamas and sent for medical evaluation which included a complete history of their drug use and psychological testing. Volunteers, who were usually still using drugs, were put into a detoxification ward, where they were given gradually decreasing doses of morphine over ten days to wean them off their physical addiction. Withdrawal was sometimes supported with hydrotherapy and non-opiate sedatives. (Most convicts were already drug-free on arrival, given the difficulty of maintaining a supply in prison.) During the first few weeks, the hospital staff also treated various underlying illnesses and conditions, including the dental problems which afflicted many addicts. Meanwhile, psychiatrists and social service staff gathered as much information as possible about the addict and his family and social history; the addict was then classified according to Kolb's scheme, and treatment planned accordingly. Treatment included individual or group psychotherapy, work assignments, and/or occupational therapy, and recreation. Patients could train and work in a variety of skilled activities, including needlework, woodworking and carpentry, food service, auto maintenance, hair cutting, as well as dairying, care of livestock, and other agricultural work. Patients could also use the tennis courts and outdoor sports fields, and indoor bowling alley, basketball courts, billiards room and rec rooms. Courses in art, creative writing, ceramics, sewing, and music were available; and because jazz musicians often came to the farm voluntarily or through the courts, Lexington became well-known for its excellent music program and performances. The wide menu of options at Lexington gave it a reputation as a "country club" among both convicts and voluntary patients.

Lexington's patient population was diverse. Many were urban, working-class men and women but some were from rural areas, and perhaps 15% were professionals, including physicians, nurses, bankers, and lawyers. Men and women were lodged in separate quarters (women were admitted starting in 1941), and voluntary patients were separated from convicts, but there was no segregation according to age or ethnicity. The length of their hospital stays varied: convicts were eligible for parole after completing half their sentence. Lexington staff preferred to keep patients for 6-12 months when they could. Volunteer patients rarely stayed that long, as they weren't legally compelled to.

Although the narcotic hospitals operated until the 1960s as a humane alternative to imprisonment, the number of patients "cured" of their addiction was not high. Addiction was and is a difficult problem; a physical habituation that fills various physical and psychological needs for an individual, addiction can also be a way of life with its own subculture. Relapse was common, as Kolb readily admitted. Quite a few voluntary patients came for treatment more than once. However, he believed that the treatment and medical support, together with vocational and recreational opportunity, often strengthened an addict's power to resist the influences that might cause a relapse. Kolb and his colleagues also recognized that addicts could require multiple attempts to quit their drugs for good, and did not view relapse as a reason to bar them from further treatment.

The Lexington narcotic hospital also was home to a unique research unit, the Addiction Research Center (ARC), where psychiatrists and pharmacologists investigated the neurophysiology of addiction. The field of substance abuse research originated at the ARC, and for over thirty years, most leading addiction specialists would get training there. As historian Nancy Campbell has noted, Lexington was the only place in the country where experienced drug users regularly came into contact with clinicians and researchers, and the only place where psychoactive drugs were tested on human subjects. The ARC did animal experiments to establish physiological baselines regarding addiction, tolerance, and withdrawal, but many essential questions about addiction--especially why some individuals seem prone to addiction and to relapse--couldn't be explored with animal subjects. "Post-addicts" possessed personal expertise in drug use and could articulate many aspects of the drug experience that animals could not.

Only a small number of Lexington patients were recruited for the ARC studies. They had to be healthy, male convicts and importantly, they had to be experienced drug users. Although informed consent wasn't yet an ethical or legal requirement for medical studies, the ARC staff made it an essential part of its work from the beginning, and their research publications included brief notes about subjects' voluntary participation. Subjects were informed about the nature of the study and the possible risks, and they were allowed to withdraw at any time. In many of the studies, the patients were re-addicted to and withdrawn from opiates and other drugs; the opportunity to have doses of various drugs provided incentives for some patients, even if they had to endure withdrawal later. (Prison inmates were sometimes used for medical experiments in that era, though it would be ethically untenable now. One letter in Kolb's papers, from July 1935, indicates that Kolb and his superior Walter Treadway discussed whether incarcerated persons could truly give free consent to participating in studies, and whether recruiting volunteers would be the best way to use convict patients in the ARC's research.)

In the course of this research, the ARC also provided a needed drug testing service for the federal government and pharmaceutical manufacturers, to determine whether new drugs had addiction potential. (In the pre-WWII era, drug manufacturers were only starting to do their own research and development, and there were fewer regulatory requirements for clinical testing.) Given the difficulty of "curing" drug addiction, there was great interest in finding chemical substitutes for opiates that would provide relief to users but not be addictive. Methadone was one of several such drugs studied at the ARC. A parallel interest was in discovering narcotic antagonists, agents that could reverse an overdose by blocking uptake of opiate drugs. The ARC would eventually do studies of barbiturates, cannabis, major and minor tranquilizers, LSD, and other substances.

Kolb might have stayed longer at Lexington, but in 1938 he was appointed Assistant Surgeon General in charge of the PHS Mental Hygiene Division, replacing Walter Treadway who stepped down due to health problems.