Comments on

by Advisory Committee to the Federal Bureau of Narcotics

JULY 3, 1958.

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In view of the document quoted below and the item in the A. M, A. Journal, the advisory committee has considerable doubt whether any inqiury was conducted in Denmark, other than possibly a casual conversation with someone uninformed with the situation in Denmark.

FROM PERMANENT CENTRAL OPIUM BOARD REPORT TO THE UNITED NATIONS ECONOMIC AND SOCIAL COUNCIL ON THE WORK OF THE BOARD IN 1956, PAGE 9 (DOCUMENT E/OB/12)

(c) Denmark.--In the reports on its work in 1951 and 1952, the board referred to the high licit consumption of morphine, codeine and ethylmorphine in Denmark, and to the explanations given by the Danish Government. To these three drugs must now be added certain synthetic narcotic drugs, the per capita consumption of which is also very high in Denmark. In fact, this country is now the world's biggest per capita consumer of codeine, methadone and ketobemidone; it occupies second place for morphine and fourth place for pethidine and ethylmorphine, Added together, the per capita consumption figures for the above six drugs not only single out Denmark as the world's biggest consumer but exceed by 60 percent the corresponding total for the country occupying second place, Leaving aside the figures for codeine and ethylmorphine, these drugs being regarded as less liable to produce addiction than the other four, Denmark's consumption is 11 percent greater than that of the next highest consumer. Furthermore, if, instead of merely adding together the per capita consumption of these six drugs, account is also taken of their therapeutic potency, which is in fact a more scientific approach, the differences become even more pronounced, And if the comparison were extended over a wider range of narcotic drugs the differences would be greater still.

These facts evidently deserve, and will doubtless receive, the careful attention of the Danish health authorities.

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, FEBRUARY 25. 1956

Drug addiction.-In 1949 the public health authorities started the so-called morphine register, which is compiled on the basis of the reports of the prescription of opiates sent in by all the pharmacies in Denmark. These reports are checked every month for Copenhagen and once or twice a year for the rest of the country. As these reports include the name of the drug prescribed, the dose, the name of the prescribing physician, and the name and address of the patient, it has been possible to compile an accurate census of Denmark's drug addicts.

About 50 percent of the 800 to 900 addicts known to the authorities are in Copenhagen, and many are physicians. In a recent lecture, Dr. Jorgen Ravn, who is in charge of a mental hospital in Middelfart, which admits 600 to 700 patients a year, pointed out that the medical profession must bear a large share of the blame for the present state of affairs in Denmark. In addition to the surgeon who light-heartedly prescribes opiates after operations and the psychiatrist who prescribes them to calm his patients, there is the manufacturer who advertises a new drug with an assurance that it can be taken without risk of addiction. A certain number of recruits to the ranks of addicts come from alcoholics whose alcoholism has been cured by disulfiram and whose craving for a substitute is met by some opiate. In his comments on the new narcotic law of May 1955, Ravn points out that additional powers are now given the authorities to deal with the physician who dispenses opiates too freely to his patients or himself. Such physician may now be forbidden to prescribe opiates for a given period, or he may be persuaded to abandon his right to such prescribing voluntarily.

In extreme cases, when the physician himself is convicted of addiction, he may be forced to submit to treatment in a hospital. Should he prove refractory, his right to practice medicine may be revoked.

FROM THE SUMMARY RECORD OF THE COMMISSION ON NARCOTIC DRUGS OF THE UNITED NATIONS, MAY 2, 1958

Mr. Vaille, delegate of France, was not convinced that the optimistic views expressec by the observer for the Danish Government were justified by the facts adduced in his report. It was suggested, for example, that the increase of approximately 40 percent in the number of prescriptions between 1949 and 1955 was partly accounted for by the increase in population, but the report did not reveal any correlation between the two factors. It was further stated that a special form had to be filled in every time narcotic drugs in group I were dispensed, but he would like to know whether that requirement was strictly complied with. According to the figures obtained by sampling in three districts, the total number of prescriptions in 1948 had been 6,031, and 8,556 in 1955. In 1955 there had been 1,029 prescriptions for thebacon and hydrocodone, 951 for ketobemidone and 659 for dexamphetamine, making a total of 2,639 for drugs added to the list of narcotics since 1949. If that total was subtracted from the total of 8,556 for 1955,

there remained a figure of 5,917, which was close to the figure for 1949. However, there were no grounds for congratulation, since that analysis showed that in Denmark the new synthetic drugs had been used to supplement the drugs used previously not to replace them. The report stated that although it had not been possible to compare the volume of doses prescribed in 1949 with that in 1955, there seemed in the case of some preparations to have been a decrease in the volume of single prescriptions. No evidence was offered in support of that statement. The returns made to the Permanent Central Opium Board were described as providing a very rough estimate of annual consumption; if those figures could not provide an accurate estimate, he would like to know what figures could. The report mentioned that methadone had not been brought under control in Denmark until 1952; he thought it significant that countries which claimed, on the basis of such arguments as those used by the Danish observer--that the high consumption of narcotics in his country was due to the comprehensive nature of the social welfare system--, to have no serious drug-addiction problem, were always the most reluctant to bring new synthetic narcotics under the control provided by the conventions.

It was asserted that one reason for the high consumption of analgesics in Denmark was that the Danish health insurance system was such that the sick had no economic difficulty in obtaining analgesics.

Even after the price of opium had doubled, the cost of an ampoule of morphine was inconsiderable compared with the other expenses of a serious illness, so that it could hardly be maintained that the cost of analgesics limited their medical use, and hence that a lower price

would entail an increase in consumption. Although in France approximately 80 percent of the population was covered by social security services, the lawful consumption of narcotics per head had been reduced through action taken by the Government to persuade doctors to use more caution in prescribing them. It could not be true that there was no causal relationship between the number of prescriptions for narcotic drugs and the level of drug addiction, since throughout Europe, addiction resulting from therapy was much higher than addiction resulting from any other cause, and there was no obvious why Denmark should be an exception.

It was further claimed that when allowance was made for the increase in population the prescriptions showed a decrease in consumption of narcotic drugs. That was true for morphine, since consumption had been reduced from 121.1 kg in 1949 to 85 kg in 1955. However, that reduction had been more than offset by an increase in the consumption of pethidine alone from 100.3 kg in 1949 to 214.9 kg in 1955. It was stated that opium alkaloids had to some extent been replaced by synthetic analgesics, ketobemidone being quoted as an example; but ketobemidone was known to be as dangerous as heronin producing addiction. The Danish authorities did not share the view, but since it had been supported by the experts at Lexington, or studies carried out by the World Health Organization (WHO) and by the recommendations of the commission itself, he felt that it was for the Danish authorities to state their grounds for disagreeing with those views.

It was stated that the percentage of all prescriptions represented by morphine groups A and B had been reduced from 40 percent in 1949 to 20 percent in 1955, but he pointed out that again that reduction was offset by an increase over the same period of 10 percent in methadone and 10 percent in thebacon-hydrocodone, both known to be addiction-producing.

Table 5, giving the breakdown of prescriptions by recipients in 1955 and 1949, showed that 7,835, or approximately 90 percent, had gone to private patients--the same percentage as in 1949 whereas; only 245, or 2.83 percent, had gone to hospitals, compared with 1.9 percent in 1949. In most countries narcotic drugs were administered only in serious cases, mainly in hospitals, and he thought that figures he had just quoted must indicate that in Denmark doctors prescribed narcotics, without due regard for their danger, for patients who were not in hospital, when other analgesics, less effective but much less dangerous, would serve equally well.

It was stated that only very small quantities of narcotic drugs for injection were coming on to the illicit market, but it would be interesting to know exactly what they were. He drew attention to the statement that out of a total of 5,500 doctors, 42 had been deprived their right to issue prescriptions for narcotic drugs, in most cases because they had issued unjustifiable prescriptions for their own use rather than for their patients. He asked how the terms "magistrate" and "official", used in table 3, mere to be understood; presumably the former meant doctors' prescriptions dispensed by pharmacies, but the latter appeared to have a different meaning from that which it normally bore since it seemed to cover any substance that was stocked made up in the dispensary, including proprietary products. He would like that point to be clarified.

He drew the WHO representative's attention to the reference in table 4 to item 28, cynoglossi; that showed the danger of proposing the deletion from the recapitulatory list of exempted preparations of those which were thought to be virtually obsolete.

He hoped that the Danish observer mould not misunderstand his criticisms of the report; they were intended to bring out the fact that a problem did exist, so that steps could be taken to solve it.

COMMISSION ON NARCOTIC DRUGS PROVISIONAL SUMMARY RECORD, GENEVA, TUESDAY, MAY 6, 1958

Mr. Tennyson (U. S. A.). My delegation would like to address two questions to the honorable representative from Denmark. We notice on page 6 of the English text of the report of Denmark, near the bottom of the page, it should likewise be emphasized that most of Denmark's drug addicts are people who suffer from serious illness accompanied by severe pain which can be

relieved only by use of narcotics.

We would like to inquire whether the Government of that country authorizes the administration or prescribing of narcotic drugs to addicts simply for the maintenance and gratification of drug addiction, without regard to any other medical pathology; and if so, is there required by the law and regulations on medical practice any effort made to reclaim these addicts by a permanent cure of their addiction?

Dr. Nimb (Denmark). With a clear NO, drug addiction is not accepted as a medical indication for giving narcotics and the doctor who does runs the risk of losing his right to issue prescriptions and may be deprived of his licensed practice. With reference to treatment with a view-toward cure in Denmark, drug addicts are treated like other mentally ill patients in state mental hospitals, most of whom come by their own inclination and others in cases which have received sentences from court if engaged in some illicit traffic in narcotic drugs.

In Denmark the annual consumption of narcotic drugs is 23,145 doses per 1,000 of the population whereas in the United States consumption is only 7,158 doses. The United States system therefore does not mask large scale undiscovered addiction.