Drug Addiction JOHN HARRINGTON

Consultant Psychiatrist, Uffculme Clinic, Birmingham 13, England

I hope you will not be disappointed when I say that my paper contains no confessions of an avowed opium eater, no inner revelations of one who is accustomed to snuffing cocaine, and no reflections on the pleasures I might have obtained from smoking marihuana. My only confession will be of my dubious competence to address an expert audience on a subject in which I have neither exceptional experience nor original contribution. I have been interested in the problem of addiction for many years and have encountered a number of drug addicts in my clinical practice, so that the opportunity to address you is one that I welcome. Psychiatry and forensic science have many common problems and addiction seems a good meeting point between people who all too seldom get together. I should like to emphasise at the outset that I will omit reference to alcohol, not because I do not like the stuff, but because this is really a separate chapter though technically speaking coming within the ambit of drug addiction.

Definition The World Health Organisation (1950) have defined addiction as "a state of

periodic or chronic intoxication detrimental to the individual and to society, produced by repeated consumption of the drug (natural or synthetic). Its characteristics include : (1) an overwhelming desire to continue taking the drug and to obtain it by any means ; (2) a tendency to increase the dose ; (3) a psychological and physical dependence on the effects of the drug." To the clinician this definition is not satisfactory because rigid adherence to all the criteria prevents the inclusion of cocaine, marihuana and stimulant drugs like amphetamine, which produce a clinical syndrome of addiction without full dependency as in the case of morphia.

Some general statements about drug addiction How big is the problem of drug addiction ? About the only thing we can

be sure of is that the available statistics are not a reliable index of the extent of the problem though it seems reasonably certain that the problem in this country is less than in others, notably the U.S.A. (the figures for 1936 of drug addicts were 616 and the figures for 1960 were 454). Drug addicts only become known when they are apprehended for breaking the law, when they seek treat- ment (and many don't), or when they come to light accidentally such as by admission to hospital for another purpose. There are certainly many un- detected drug addicts who obtain their supplies either illegally or through legitimate sources. There are in addition people who become addicted to compounds which are freely available without prescriptions; these have attracted a good deal of attention in recent years.

The reasons why people take to drugs are complex and varied. Most want to escape from the harsh reality of boredom of their lives ; to get a kick or a new slant on life, or to find a way to satisfy their true selves. Some patients are first introduced to the drug by their doctors in the treatment of pain or emotional disturbance. Some become "hooked" by the persuasion of an established addict or through the social group with whom they associate.

Epidemiological studies indicate that addicts are not randomly distributed through the population but tend to be concentrated in big cities. While addiction is no respecter of social class, there is a higher incidence amongst the underprivileged groups and in recent migrants even where addiction is not common in the area from which these migrants came. How far recent mi- gration to this country will produce new problems remains to be seen.

While the addict may pursue his cult as a lone wolf (this is true of doctors and others who have ready access to drugs), one does find a tendency for addicts to associate in special groups around the source of their supply. The setting in which drug addicts associate may be a jazz club or low dive in which drug- taking may not be an isolated vice but associated with sexual perversion, gambling and drinking. Amongst teenagers, smoking reefers may become a fad or the smart thing to do. Groups of addicts develop a social code and language of their own, refusing to inform on associates and adhering to the standards dictated by the group. Accurate information is difficult to obtain because these addicts are quite unreliable witnesses, making up fantastic stories to maintain the integrity of the group and the supply of their drug.

Addiction is by no means invariably associated with crime and many addicts are law abiding and maintain reasonable moral standards apart from any behaviour connected with obtaining the drug. While assured of adequate supplies of drugs, their behaviour and capacity for an average day's work often appears more or less normal but if for any reason this supply is not forthcoming they become overwhelmed by the need to obtain it immediately and at any cost, resorting to forging prescriptions and other crimes. The main criminal problems are focused on illicit narcotic traffic which is highly organised and on which I have no competence to speak. I must, however, mention the pusher who is himself an addict and who seeks to create new addicts in order to assure a better supply for himself through the peddler. I t is true that some addicts were delinquent before they developed the drug habit and these often continue their criminal career afterwards. Far more appear to have a clean record apart from crimes which may be connected with their obtaining the drug. In rare instances the taking of drugs may release aggressive uninhibited behaviour resulting in violent homicidal attacks and there is too the forensic problem of distinguishing between deliberate and accidental overdosage in addicts who may find a final solution in suicide. I am indebted to Dr. Peter Scott, a forensic psychiatrist, for a personal communication saying that in his experience juvenile delinquents quite frequently boast of reefer smoking but they do not seem to be much involved in compulsive taking of the weed. They do not become addicted and they do not steal or prostitute themselves in order to get it. In Dr. Scott's experience true drug addiction in the under-17 age group in this country is extremely rare but appreciable thereafter. In light of the horrifying accounts of juvenile drug addiction in the United States his comments are most re- assuring.

Personality and addiction

Addiction is caused far more by human weakness than the drugs themselves and from the psychiatric point of view is essentially a symptom of personality maladjustment. There is no typical addict personality but the development of addiction depends in no small measure on personality ; people with a low tolerance for discomfort, anxiety, frustration or feelings of depression are more likely to turn to drugs in the first place but the form of addiction depends more on the circumstances and opportunities with which the person is confronted. Emotionally mature and stable individuals seldom become addicted but people with inadequate, psychopathic or neurotic personalities fall easy prey. Nearly all addicting drugs produce relief of mental and physical discomfort and endow the taker with feelings of omnipotence in which all problems are solved in the imagination. Psychological dependency is produced not only by the pleasurable effects of the drug but also by the hangover effects which cause the patient to crave once again for further relief.

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Addiction to morphine, its derivatives and synthetic analgesics

I propose to discuss addiction to morphine and its derivatives in the same context as the Meperidine group, the Methandone series, the Morphinen and the more recent Dithienyl-butenes and butanes because the effects of addiction to them are similar to those caused by addiction to morphine despite differences in chemical structure. In all these drugs we find the phenomena of tolerance, physiological dependence and save in perhaps the Methandone series severe withdrawal symptoms. The most serious cases of addiction occur in patients using these drugs and their use is so to speak the end of the line for people who were previously addicted to other drugs. To use the addict's slang "From Sneaky Pete to Pot to Horse to Main-lining," translated this expresses a tendency to progress from cheap wine to marihuana to intravenous heroin. Pethidine deserves special mention because of the high relative incidence in the medical profession and nurses and the fact that it is more likely to cause toxic symptoms like confusion and convulsions. The symptoms of addiction to morphine-like drugs and the abstinence are well described in many books and I will not dwell on them here. I must, however, mention two recent developments in the form of Nalorphine (N-allyl-nor-morphine) a morphine antagonist which when given to an addict a t once precipitates withdrawal symptoms thereby providing a useful diagnostic test, and the use of Daptazole (amiphenazole) which is said to prevent tolerance developing and is of value in the treatment of morphine poisoning and the abstinence syndrome. There is no evidence this drug de- creases the addiction potential of morphine.

I want to make special reference to addiction to opium containing preparations that can be bought without prescription from the chemist. I refer especially to chlorodyne addiction, three serious cases of which have been investigated by my colleague Dr. Conlon in my own hospital. Chlorodyne contains about 1/48 gr. of morphine hydrochloride in 10 minims together with small quantities of alcohol, ether and chloroform. In Dr. Conlon's series the average daily consumption of chlorodyne was a t least 6 ozs. and the patients were consuming six grains of morphine hydrochloride quite legally obtained through a chemist. All three cases showed quite serious physical and psychological effects and Dr. Conlon's investigations have so far traced reports from coroners' inquests on 12 deaths from chlorodyne poisoning where there was evidence that these people had been addicted to chlarodyne for periods of 15 to 30 years.

Chlorodyne is not the only legal source of opium and my colleague, Dr. Paton, has drawn my attention to the fact that poppy heads containing opium alkaloids may be freely and quite cheaply purchased through the chemist without pre- scription. One chemist had told him of a customer who regularly buys as many as thirty at a time but what he doeswiththemisunknown. My colleagues and I feel that more investigation of this problem with a view to stricter control is necessary.

Barbiturate addiction Reports in the medical press have indicated some alarm at the increase in

barbiturate addiction in Britain though more cautious observers have pointed out that the incidence remains low considering the prodigious amounts of these drugs prescribed. This form of addiction develops most readily in the type of personality likely to become alcoholic and it is indeed commonly associated with alcoholism and addiction to amphetamine. Addiction is almost always to the short acting barbiturates like amylobarbitone and quinalobarbitone and almost never to long acting barbiturates like phenobarbitone. Once the patient has found the right dose there is little tendency to increase this, tolerance is not marked and more than the usual dose increases intoxication very markedly. The clinical picture of chronic intoxication resembles that of acute alcoholism.

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The patient may be disinhibited, over-talkative fuddled with slurred speech, ataxia, nystagmus and an impaired co-ordination. Large doses may lead to confusional states or delirium. There is a definite withdrawal syndrome with weakness, tremor, headaches, vomiting and sometimes fits and collapse with a state of delirium tremens. Most addicts find it relatively easy to obtain supplies through medical sources often by getting drugs tllrougll more than one doctor. Accidental death may occur through taking an overdose while confused or they may succumb to the potentiation of barbiturates by alcohol.

Amphetamines

These drugs have been increasingly implicated in cases of addiction in this country. Many cases are concealed and only come to light when toxic effects make treatment inevitable. Tolerance is common and the use of large doses of over 1,000 mgms a day have been recorded. Amphetamines are frequently combined with morphia and barbiturates and in my experience addiction to the combination of amylobarbitone and dextroamphetamine, the so-called "blue lieart" addiction, is particularly common in the Midlands. Of particular interest to the psychiatrist is the development of an acute paranoid psychosis in amphe- tamine addicts which is easily mistaken for schizophrenia.

Since the war there have been reports of an epidemic of amphetamine addiction in Japan with upwards of a quarter of a million addicts. The incidence was highest amongst the 16 to 25-year-olds and the Japanese have reported a strong relationship between amphetamine addiction and juvenile delinquency. A number of addicts committed crimes of a sadistic kind but I believe amphetamine has rarely been implicated in crimes of violence in this country. The situation in Japan has become so serious that major social and drug controls are required to bring the problem in hand. Some five years ago I came across three teenage preludin addicts, two of them with acute psychoses. At this time the drug was freely available through chemists without prescription but following reports in the medical press the drug has been sclleduled and I have seen no further cases.

Some recent developments

I want now to refer to some comparatively new forms of drug addiction that have recently caused public concern and have indeed been specially referred to by the interdepartmental committee on drug addiction. They are firstly addiction to carbromal and bromvaletone acquired through taking these drugs in proprietary preparations over the counter without medical prescription, and secondly addiction to anaesthetic gases. Cases of addiction to the two mild hypnotics carbromal and bromvaletone have been numerically few but some- times serious. They may perhaps be compared to the age old addictions to chloral, paraldehyde and the more recent sedative drugs like methylpentynol, meprobamate and librium. We are indeed living in a new age of psycho- pharmacology with many new drugs being marketed with actions on the central nervous system whose addictive properties are not yet known.

Addiction to ether has been known for many decades but the serious risks of addiction to anaesthetic gases have only recently come to light. The addiction is almost exclusively confined to anaestlletists who sniff gases before administering them. The number of such addicts probably does not exceed 20 but in two recorded cases the lives of patients were endangered. I must in this connection mention the report from H.M. Prison in Birmingham, of a 17-year-old girl who was addicted to the intoxicating effects of petrol vapour.

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Treatment Admission to hospital is essential a t some period in the treatment of addiction.

One of the main problems in treating the addict is to obtain adequate co-operation. While some profess themselves anxious to be cured many are reluctant and only seek treatment for negative reasons, for example when they are subjected to criminal proceedings when they may ask for treatment rather than face a prison sentence. Others only come under treatment after the onset of serious mental and physical symptoms. These often discharge themselves against medical advice when treatment is only half completed. A few develop psychotic symptoms and can be certified under the Mental Health Act.

We used to think that rapid withdrawal of all drugs allowing the patient to experience all horrors of the abstinence syndrome discouraged future drug taking. This so-called "cold turkey" treatment is now largely discredited and a modern approach is to delay withdrawal for some time after admission to hospital continuing to give the patient adequate supplies of drugs, so that his confidence is gained and lie is freed from deceit and the necessity to smuggle drugs into hospital. Once they are freed from the necessity of deceit the with- drawal phase is begun and this is done under the influence of other drugs, so as to minimise the unpleasant effects as far as possible. Once the patient is weaned of all drugs the phase of intensive psychotherapy and rehabilitation begins followed by the finding of suitable employment in a new environment. A full follow-up system with aftercare is as important as any other part of the treat- ment. In my view the best results are obtained by treatment in specialised units where the staff have a special interest and experience in the problems of addiction. Regrettably too few such units exist and there is no such centre in the Midlands.

Prognosis Tlle treatment of the addict is never easy and may be very difficult indeed.

I t is far easier to withdraw drugs from a patient than to persuade him to forswear them for ever. The reorientation of a patient's attitude to himself and the finding of socially acceptable sources of substitute satisfaction are important. The outlook depends a great deal on the previous personality and the relapse rate in the hands of most psychiatrists is high. In fact there are so many disappointments in treatment of these cases that many doctors fight shy of doing more than helping a patient over his most immediate difficulties.

Prevention There can be no doubt that the relatively small problem of addiction in this

country is due mainly to the success of measures which deny susceptible people access to dangerous drugs. The enforcement of the Dangerous Drug Act and the Pharmacy and Poisons Act and all the measures that go with them have been more remarkable for their success than their failure.

Public attitudes to drug addiction

The sentiments which our society shows towards drug addiction are mainly negative. The addict is a person to be scorned, derided and socially ostracised. If he transgresses the law hc must be punished. We have learned to regard addiction as a vice which is degrading and destructive and a reflection of weak- ness and depravity. How far are these hostile attitudes rational and justified ?

I must remind you that we are already a nation of habitual drug users taken in legalised socially accepted ways. The National Health Service spends several million pounds a year on tranquillizers, hypnotics, antidepressants and other psychopharmacologica1 agents. The use of these drugs under medical pre-

scription is sanctioned by most people save perhaps the Treasury who has to foot the bills. Such criticisms that are made are mainly on the grounds of financial cost and doctors as a whole see their use as an advance towards better mental health.

Some 30 years ago Aldous Huxley wrote in his book, "Brave New World," of a new society in which all citizens were conditioned to live in a state of perpetual ecstasy. If anyone's euphoria was threatened by anxiety or depression they were immediately restored to happiness by taking a gramme of "Soma". More recently the same author has extolled the value of taking mescaline and has foretold of the discovery of new chemical elixirs by which our civilisation may solve its complex problems and discover a new Utopia. In aworld threatened by atom bombs and other terrors who is to say how far he is wrong ? I would remind you too of the Chinese men of letters who have written of opium smoking as a way of reaching a perfect harmony with one's environment and ideal inter- personal relationships. In some Asian and South American cultures narcotic drugs have been seen as relatively harmless safety valves reducing the chances of violent social revolution. In India hemp is accepted by some sects as essen- tial to mystical experience and religious conversion.

Returning to this country we find people like jazz musicians who defend marihuana on the grounds that it heightens their perception, protects them from fatigue and enables a fluent and free improvisation which would not other- wise be possible. In my own clinical experience I have met vulnerable and maladjusted patients in whom a regular and indefinite taking of drugs like barbiturates enabled a better adjustment to life than they had ever had before. Attempts to wean such people have often been met with failure and one has had to content oneself by making the best of a bad job. In these cases we may have to see the use of drugs as the price that has to be paid for the best adjustment that is possible in the circumstances. In other words, drug addiction can in some instances be seen as protecting patients from something worse.

But what of the other side of the coin ? For what reason must our society continue to condemn and persecute the illicit use of drugs ? The main reasons seem to be social rather than individual. If we allowed narcotic drugs to be widely used for people to retreat into the comforts of drug intoxication our political, family, and cultural life would become enervated. People would no longer strive to compete and achieve and apart from the risk of economic disaster, we would fall easy prey to more aggressive nations. Drugs have been and still are used to keep peasant populations subservient to their tyrannical masters. A final and perhaps no less serious risk of the failure to control drug trafficking is the great danger to our young and most susceptible population. We hear much about juvenile delinquency, teenage morality, teddy boys and other problems of young people. If widespread drug addiction became common- place among them the consequence for our national future might be very serious indeed. Drugs have become an essential weapon in our fight against mental disease but we must see they are properly controlled and not used as a panacea for all the unhappiness and discontent of man.