Comments on

by Advisory Committee to the Federal Bureau of Narcotics

JULY 3, 1958.

Note: To fully understand this document, and the context in which it arose, you should also read these other documents which are in the Schaffer Online library:

PERSONAL SURVEY OF THE DRUG ADDICTION SITUATION IN GREAT BRITAIN AND PARTS OF EUROPE, SUMMER, 1958

By Dr. JAMES C. MUNCH,

Department of Pharmacology, Hahnemann Medical College, Philadelphia, Pa.

Prior to my trip to Great Britain and parts of Europe in the summer Of 1958, I had discussions with representatives of the American Medical Association, and attended several conferences on narcotic addiction, including one held by the National Institutes of Health in Washington, D. C., in March 1958. As a result of discussing this situation with Commissioner Harry J. Anslinger of the Bureau of Narcotics, he gave me a great deal of information regarding the situation in the United States, and letters of introduction to various control agencies abroad.

Discussions were held with members of official control agencies, a member of the British Parliament, physicians, pharmacists, hospital administrators, social workers and police authorities in Great Britain, West Germany, Austria, Switzerland, Prance, and Belgium. The cooperation of these groups and individuals assisted greatly in reaching an opinion on various phases of narcotic drug control and addiction. Any conclusions expressed are my own and not official. The names and affiliations of my principal contacts are given in the appendix.

Answers were sought through these contacts to three specific questions :

(1) Is there reliable information as to the number of narcotic drug addicts in the various countries?

(2) Is there reliable information upon the success of the various methods of treatment and care of drug addicts?

(3) Is there reliable information regarding the regulations under British system, which is alleged to permit continuous administration of narcotics to addicts?

The answer to all these questions appears to be : NO.

(1) Is there reliable information as to the number of narcotic drug addicts in the various countries?

No general agreement has been reached by the different governments regarding the definition of an addict; often peddlers and users are combined; some countries report only on the number of arrests made; other countries do not distinguish between patients requiring an analgesic to subdue pain, and voluntary use to produce euphoria, and other effects associated with addiction. Other reports list addicts discovered during the current year, while still other reports cumulate data over intervals of 2 to 20 years or more. There is also some confusion in estimating the number of addicts per million population with respect to the lowest age considered (that is, whether the number of live individuals under age 15 should or should not be included).

As pointed out in United Nations Document E/CN.7/318, Analytical Study on Drug Addiction, the total number of addicts has not been calculated for any country or for the world. Furthermore, many addicts use more than one drug, making it impossible to determine the relative usage of the various addicting products. As long as the same governmental agency computes figures by the same method, there may be some degree of comparison. For example, Mr. Anslinger has estimated that there was 1 addict in every 400 persons in the United States (25,000 addicts per million population) prior to the passage of the Harrison Act, and now he estimates 1 addict in 3,000 persons (330 addicts per million). This shows the substantial decrease in the number of addicts estimated to be in the United States. However, difficulty arises when an effort is made to extend such estimates to other countries. Reports by each government to the United Nations Commission on Narcotic Drugs offer the best information available.

Such reports have been consolidated in table 1. The information for 1954, 1955, and 1956 with respect to morphine, to heroin, and to the total numbers may be informative. Values for a single year are underlined; cumulative values are not. Reports indicate that there were 18,712 addicts to heroin in 1954, and 9,669 new addicts in 1955 in the United States. Since there were estimated to be 10,882 new total addicts in 1955, this would mean more than 90 percent of the new addicts are using heroin.

In considering the world picture, it may be noted that there has been progressive increase in the estimated number of addicts in Hong Kong, and that 9,117 out of a total of 11,585 new in 1958, or about 90 percent, were addicted to heroin. Reports from the United Kingdom show a stationary heroin addict record of 54 subjects. In 1956 there were still 53 heroin addicts of a total 333, or less than 20 percent.

Lack of reports prevents further consideration of these data; however, it does confirm the United Nations statement that no reliable data are available for comparison between different countries in the world. A number of persons indicated that there were more addicts in a country than are formally reported. The situation was compared to the determination of the number of thieves in any country: No exact census has been taken and the best information available would be the report of the numbers that have been caught, tried, and convicted. This may be far from the truth.

Another approach to the use of narcotic drugs was attempted in United Nations Document E/CN.7/319, Survey of Available Information on Synthetic and Other New Narcotic Drugs, in which the total consumption of the principal narcotic drugs was expressed in terms of numbers of doses consumed per thousand of population.

Available data were compiled on morphine, at a dose of 10 mg.; on heroin at a dose of 5 mg.; and on the total natural and synthetic narcotics. Data are available for 1953, 1954, and 1955. This information is given in table 2. For the year 1955 the morphine consumed legally throughout the world averaged 170 doses per 1,000 population, or one-sixth dose per person. The total consumption of these narcotic drugs averaged slightly less than 2 doses per person. Comparisons of total consumption on this basis shows that the United States citizens received approximately 7 doses per person. The United Kingdom, Australia, and New Zealand consumed twice as much; Finland and Sweden somewhat more, and Denmark almost four times as much as the United States.

An attempt was made to contrast the number of known addicts against the number of doses per thousand of population in table 3.

This was not successful because of the uncertainties of the number of addicts. However, the available information suggests that a substantial quantity of narcotics is being used which is not reported in the doses per thousand of licit practice.

Since many persons indicate that there are more addicts than are being reported in many countries, and that an increase in the number of inspectors will show an immediate increase in the number of addicts, it would appear advisable to adopt a definition for "addicts" and to endeavor to get more comprehensive reports from the participating governments. Even though this has not been done, there is agreement that there are drug addicts, probably in the neighborhood of 300 per million population.

(2) Is there reliable information upon the success of the various methods of treatment and care of drug addicts?

World Health Organization Report No. 131 on the Treatment and Care of Drug Addicts (1957) summarizes reports from world literature. The various suggestions published in the United Nations Bulletin on Narcotics by Vogel, Isbell, Goldstein, Chopra, Lowry, Chapman, and their associates are based on trials in the hospitals such as the United States Public Health Service Hospital at Lexington, Ky. They indicate general acceptance of the idea that narcotic drug addicts should be committed to hospitals for treatment, either by abrupt or gradual withdrawal under medical supervision; that substitution with a drug such as methadone has proven satisfactory for relieving physical addiction; and that the use of tranquilizers needs to be explored further. Expanding his studies on the treatment of alcoholics in Great Britain, Dent has developed the use of apomorphine for treating narcotic addicts. All reports have agreed on the need for strengthening morale, aiding in finding addicts jobs on discharge and following up each subject to prevent relapse. Estimates of "cure" range from 5 percent in the general population up to 92 percent among physicians who are drug addicts. No consistent efforts were found in Great Britain or on the Continent to establish hospitals for the treatment of narcotic addicts, either on the basis that they had no problems of addiction, or that the cost would be prohibitive. There was no support for the establishment of narcotic clinics for ambulatory treatment of addicts, similar to that tested in the United States between 1920 and 1925. It appeared that medical support of an addict after ending the withdrawal of the narcotic drug is inadequate. Much further investigation is required for the development of effective methods of therapy; this is believed to be the held of a specialist and not of a general practitioner.

(3) Is there reliable information regarding the Regulations under the "British system," which is alleged to permit continuous administration of narcotics to addicts?

The Council on Mental Health of the American Medical Association in discussing narcotic addiction concludes by strongly recommending consideration of a plan endorsing regulations somewhat similar to those currently in force in England. The report drafted by members of a joint committee of the American Bar Association and the American Medical Association, in 1958, also advocates adoption of the "British system." These and similar publications infer that the lower incidence of narcotic addiction reported in the United Kingdom results from such a "system," and implies that this "British system" permits continuous administration without charge of narcotics to any and all addicts.

Investigation showed that this is completely erroneous. It is carefully pointed out by Mr. Green of the Home Office that the present policies are in harmony with those announced by Mr. Walker in 1953 and 1955, in discussions with visiting Americans. There is not in fact any such thing as a "British system." The fact is that in 1924 Sir Humphry D. Rolleston was appointed as the chairman of a committee of nine experts to advise as to the precautions that medical practitioners should adopt for preventing abuse in the supplying of morphine and heroin to persons suffering from addiction to those drugs. This committee held 23 meetings to hear a long list of witnesses, presenting a 37-page report in January 1926, summarizing their opinions. After pointing out proper methods of use of morphine and heroin to prevent addiction, and stressing the rarity of such addiction in Great Britain, a series of suggestions of precautions to be observed for using these drugs in ordinary medical practice as well as in the treatment of addicts are presented. These recommendations stress the advisability of having second opinion before undertaking

the treatment of any addict, and of treatment by gradual withdrawal for the cure of the addiction, in a suitable institution.

Recommendation 51 then states:

In the preceding section the conclusion has been stated that morphine or heroin may properly be administered to addicts in the following circumstances, namely, (a) where patients are under treatment by the gradual withdrawal method with a view to cure, (b) where it has been demonstrated, after a prolonged attempt at cure, that the use of the drug cannot be safely discontinued entirely, on account of the severity of the withdrawal symptoms produced, (c) where it has been similarly demonstrated that the Patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued.

This covered the situation in 1925. Many new drugs and methods of treatment of morphine or heroin addiction have developed during the past 33 years, like other changes in medical practice during this period, Therefore the Ministry of Health fostered legislation leading to the appointment, in the spring of 1958, of a new committee under the chairmanship of Sir Russel Brain, to review the various recommendations of the Rolleston Committee, to consider the advances in medical practice during this period, to advise regarding necessity for possible regulations for the Ministry of Health on the one hand or for enforcement of the Dangerous Drugs Act by the Home Office, on the other hand. Witnesses are to be called before this committee

for open discussion of many problems. I specifically asked a number of medical men who were interested in the treatment of various types of addiction regarding their experience in this section: How many patients who were morphine or heroin addicts had they personally treated with a continuing certain minimum dose to maintain the patients in useful and normal life? With great difficulty they were able to remember one patient they had treated 15 or 20 years ago, but none since. This was particularly so for heroin addicts. Other experts had never had any patients in this class, being able to obtain complete withdrawal by a proper followup system. This is one of the subjects on the agenda for thorough investigation by the Brain Committee.

This committee will also investigate the differences in sociological makeup and temperament of the native Britons, and of the recent groups coming into the United Kingdom, to learn what effect that may have on the incidence of narcotic addiction. I was advised that many physicians and hospitals bought large supplies of heroin in 1955 at the time a regulation was considered banning it from use in the United Kingdom, and that these present owners desire to use up their stocks under the National Health Service procedure before any ban is established. Also there are very few inspectors in the Bureau of Narcotics in terms of the 50 million inhabitants of the United Kingdom (by contrast there are about 300 inspectors in the United States with a population of 170 million). To supplement this, police inspect the narcotic registers of all the drug stores about

twice a year, reporting large distribution of narcotics through channels to the Home Office for investigation. This may not screen peddlers on the one hand or medical diversion, such as that of Dr. Adams.

Every effort is being made to enforce the provisions of the Dangerous Drugs Act in the United Kingdom with the facilities available. Apparently the medical men resented the attempt by the Home Office to ban heroin in 1955 by regulation, even though they were rapidly working toward discontinuing it in their practice. My thoughts were well expressed by the late Paul Wolff in 1932, discussing banning of heroin in Germany :

If at any time it should be decided to demand the complete abolition of this preparation in the world, the slight advantages of which are by far outweighed by its disadvantages, I am firmly convinced that no opposition would be encountered from the German medical profession. More resistance would appear to be forthcoming, however, from English and French physicians, who employ small doses of diacetylmorphine to a much greater extent.

I found this sentiment to be in harmony with thinking in Germany and in Switzerland, I was advised that the French have now banned heroin, which leaves the United Kingdom and its colonial possessions as the principal area in the world legalizing the use of heroin, steps to abolish it would have definite benefit in restricting narcotic addiction to other drugs throughout the world.

Summarizing my impressions gained in discussion with experts in Great Britain and parts of Europe, during the summer of 1958, there is no reliable method of determining the number of drug addicts in the various countries; no reliable information on the value of various methods of treatment and care of drug addicts; and there is no "British system," for control of narcotic addicts.

Data from UN publications.

APPENDIX

1. H. J. Anslinger, Commissioner, Bureau of Narcotics, Washington, D. C. Traffic in Opium and Other Dangerous Drugs for the Year Ended December 31, 1957; also December 31, 1956.

2. Boota (chain drug store), Piccadilly Circus, London, W. 1.

3. Olav J. Braenden, Ph. D., Addiction Producing Drugs Section, World Health Organization, Geneva, Switzerland.

4. Fritz von der Crone, M. D., Medical Director, Unichemie, Zurich, Switzerland.

5. C. R. Cuthbert, former Superintendent, Metropolitan Police Laboratory, New Scotland Yard. Science and the Detection of Crime, London.

6. Council on Mental Health, American Medical Association. Report on Narcotic addiction. Jour. Amer. Med. Assn. 165: 30, November 7, December 14, 1957.

7. John P. Dent, M. D. 34 Addison Road, London, W. 14. Various articles in British Journal of addiction; anxiety and its Treatment, 3d edition, 1966, London.

8. Max Dietrich, M. D., President, Chemosan, Vienna, Austria.

9. N. B. Eddy, M. D., Chief, Section on analgesics, Division of Chemistry, National Institute of Arthritis and Metabolic Diseases, National Institutes of Health, Bethesda, Md.

10. T.C. Green, Chief. Dangerous Drugs Branch, Home Office, Whitehall, London, 5. W. 1.

1l. Hadfield M. D., British Medical Association, Tavistock Square, London, W. 0. 1.

12. H.Halbach, M. D. Chief, addiction-Producing Drugs Section, World Health Organization, Geneva, Switzerland.

13. W. O. Hollis, secretary, The Proprietary association of Great Britain, 43, Gordon Square, London, W. C. 1.

14 W. G. Honner, Secretary, Brain Committee. 136 Regent Street, London, W. 1.

15. E. E. Krapf M.D., Chief, Mental Health Section, World Health Organization, Geneva, Switzerland.

16. A. Lande, Ph.D., Division of Narcotic Drugs, United Nations, Geneva, Switzerland.

17. Sir Hugh Linstead, M. P., 17 Bloomsbury Square, London, w. C. 1.

18. Maulhaus Apotheke, Constanz, West Germany.

19. C. Nichols, Division of Narcotic Drugs, United Nations, Geneva, Switzerland

20. F. Nickolls, Ph.D. Director Metropolitan Police Laboratory, New Scotland Yard, London, S. W. 1.

21. A. Prove, M. D., Medical Director, A. Couvreur, Cie., 78 rue Callait, Brussele, Belgium,

22. M. Sicot, Secretary General, International Criminal Police Organization (Interpol) 37 bis, rue Paul Valery, Paris, France.

23. Gerald Sparrow. Judge, 47 Begbie Road, Blackheath, London.

24. W. Stauffacher, Director Sando, Basle, Bwitzerland.

25. F. E. Stieve, M. D., Siemsstrasse, Munich, West Germany.

26. Ellis Stungo, M.D., 49 Harley House, London, N. W. 1. for the Study of Addiction.

27. Paul Wolff, M. D., Drug addiction--a World-Wide Problem. Jour. Amer. Med. Assn. 98 : 2175-2184, June 18, 1932.

28. G. Yates, Director, Division of Narcotic Drugs, United Nations, Geneva, Switzerland.

29. Series of United Nations, Bulletin on Narcotics, since 1949.

30. Series of United Nations, Commission on Narcotic Drugs Reports:

E/C/N.7/318. E/CN.7/319, E/CN.7/338, E/CN.7/345; 1956 Summary; MNAR 5/58