DRUG ADDICTION may be defined as an overpowering impulse for narcotism or intoxication by any drug possessing nar cotic or intoxicating properties. It is best exemplified by the overpowering influence possessed by opium and its preparations, and its alkaloids or derivatives such as morphine and heroin, and by cocaine and substances containing it. Persons who have be come habituated to the continued use of these drugs find that they have become enslaved to them, and that it is with the greatest difficulty that their use can be abandoned. Addiction drugs cause very great mental and moral deterioration, usually progressive in character.
Drug addiction is by no means confined to the above-named drugs. Other examples are well known; thus, the barbituric acid derivatives (q.v.), the sulphonal group of hypnotics (q.v.), cannabis indica (Indian hemp, bhang or hashish), may give rise to addiction. It has been observed in the use of chloral, ether and chloroform.
It is with the first group of drugs that addiction is very danger ous and most marked, and where a habit is produced which it is most difficult to eradicate.
In Sept. 1924 a Departmental Committee was appointed by the British Minister of Health to enquire into morphine and heroin addiction, and specially to consider the circumstances under which these drugs may be supplied to persons suffering from addiction and the precautions necessary for the avoidance of abuse. This Committee took evidence and finally issued its report on Jan. 21, 1926.
Occurrence.—The universal opinion of those most competent to judge is that drug addiction is rare in Great Britain. In America special attention has been devoted to the subject during recent years and many official reports on it have been issued.
The "opium problem" has been before the world for many years. Thus Warren Hastings, the first Governor General of India, in 1788 declared opium to be "a pernicious article of luxury which ought not to be permitted but for the purpose of foreign commerce only." The United States became directly con cerned in the Far East opium problem when the Philippine Islands were ceded to them by Spain in 1898. The International Opium Commission of Shanghai was largely the result of President Roosevelt's initiative and in consequence of this the International Opium Convention at The Hague in 1911 and 1912 resulted. The recommendations of the Convention formed part of the Peace Treaty of Versailles and the consenting nations agreed to frame Acts dealing with the dangerous drugs under consideration.
As a result, in Britain "the Dangerous Drugs" Act was passed in Sept. 192o. In May 1921 regulations were passed dealing with the carrying out of the provisions of the Act and further minor regulations were made in 1921 and 1923. In May 1923 the Dan gerous Drugs and Poisons Amendment Act was passed. Thus the motive factor for this legislation was the international problem and not the evil of drug addiction in Great Britain.
Legislation when once passed by Parliament in Great Britain is, as a matter of course, rigidly enforced, and in consequence of this the regulations as regards the sale of dangerous drugs are efficiently carried out in Britain. Pharmacists and medical practitioners have, it is true, experienced great difficulty and inconvenience in the carrying out of the many regulations en tailed, but they have loyally complied with their requirements.
(2) Members of the general population. The commonest cause of drug addiction in the ordinary case is undoubtedly prescription of the drug for medical purposes. This may arise from (a) necessity of relieving pain; (b) the necessity of inducing sleep.
Again for the relief of pain of a neuralgic type the drugs mor phine and heroin often act as a charm. But should they be con tinuously prescribed an addiction habit is almost certain to de velop. Much to be preferred therefore is the employment of other drugs such as phenacetin, pyramidon and aspirin whose use is not attended with this danger.
Often a psychological complex of a depressing type exists in patients of this group who are affected with mental worry and anxiety. There is a subconscious cry for relief from mental suffering. This is temporarily obtained by means of a narcotic drug, and as surely as this occurs so inevitably does a still deeper stage of mental agony develop which is only to be relieved by the further resort to the narcotic and so drug addiction becomes established.
Treatment.—Drug addiction is to be regarded as a disease rather than a vice. When it has developed it requires special care and medical treatment just as would a case of organic disease such as typhoid fever. The first and most essential part of the treat ment is complete and thorough supervision and care of the patient. This can only be ensured by treatment in an institution or nursing home. In early cases sudden withdrawal of the drug may be adopted, but where the addiction has continued for long periods, such as a year or more, gradual withdrawal is advisable so that after one to three weeks no drug is being given. A long further period of treatment is still required to improve the general health of the patient and above all to educate and restore his will power. For this purpose psychotherapeutic treatment (q.v.) is of value. The prospect of cure depends on the extent to which the will power of the patient is restored and on the establishment of confidence and hopefulness so that he is able to resist the desire to take the drug again.
In some cases of drug addiction hyoscine treatment has been advocated. This consists in the hypodermic administration of frequently repeated small doses of hyoscine so that a condition of mild delirium lasting from 36 to 48 hours is produced. When this passes off no addiction drug is given. The hyoscine treatment is not free from risk, since some fatal cases from its use have been recorded and in general it does not appear to possess any ad vantages over the carefully regulated gradual withdrawal method.
Drug Addiction of Long Duration.—When an addiction drug such as morphine or heroin has been taken over a period of many years the prospect of cure is not good. In such cases it is probable that organic changes have resulted in the nervous system and other changes of a biochemical nature have occurred which alter the metabolic processes of the body. Where re peated attempts at cure have failed the situation has to be faced that the only way in which a person can carry on his normal avoca tions is to allow a minimal daily allowance of the drug to which he is addicted. The allowance should be so fixed that increase in dos age is prevented. Patients of this type are often able to carry on their daily work on a fixed allowance of the drug and to keep in fair health for years.
The Departmental Committee above referred to accepted the view that certain cases of drug addiction of long duration could only be regarded as incurable and that in such cases a daily minimal allowance of the addiction drug might wisely be permitted.
Prevention.—There is no doubt that the dangerous drugs regulations, irksome as they are to pharmacists and physicians, have done much in reducing drug addiction. Their rigid enforce ment must prevent the development of fresh cases of addiction owing to the great difficulties entailed in obtaining constant supplies of the drugs in question.
The control of production of opium and of coca leaves, and the alkaloids obtained from them, strikes at the very root of the problem. An international control of the production of the "dangerous drugs" is required but has not yet been attained. There should be no surplus available for non-medicinal and non scientific purposes.
Care on the part of medical practitioners in the prescription of drugs of addiction is a most important factor in prevention of the drug habit, and there is every reason to believe that in point of fact the utmost care is being taken in this respect.
Illegal trafficking in dangerous drugs such as morphine, heroin and cocaine undoubtedly occurs to some extent, and this must be stamped out at all costs. Fortunately the full penal powers given by The Dangerous Drugs Acts are such as to render this trafficking a most dangerous pursuit, and the number of those actually engaged in it in Great Britain is consequently very small.
(W. H. WI.) BIBLIOGRAPHY.-D. E. S. Park, "Treatment of Drug Addiction," Bibliography.-D. E. S. Park, "Treatment of Drug Addiction," Practitioner (1926) , CXIX., 297 ; E. S. Bishop, The Narcotic Drug Problem (New York, 192o) ; W. A. Bloedorn, "Studies of Drug Addicts," U.S. Nov. Med. Bull. (1917) , XI., 305 ; S. Graham-Mulhall and others, "Symposium on Narcotic Drug Addiction," etc., Ann. J. Pub. Health (1921), XI., 25; R. G. Perkins, G. W. Meloy and P. H. Bryce, Report of Committee on Narcotic Drug Addiction, Ann. J. Pub. Health (1921) , XI., Io66 ; A. C. Prentice, "The Problem of the Nar cotic Drug Addict," J. Amer. Med. Assn. (192I) , LXXVI., 1551 ; S. P. Jewett in Tice, Practice of Medicine, vol. viii. (Hagerstown, 1924) ; A. Lambert in Osler and McCrae, Modern Medicine, 3rd ed. vol. ii. (London, 1926) .
In the United States, about 95% of all narcotic addicts use found only in a few States along the Atlantic seaboard, and mor phine addicts outnumber them by about i 2 to I. Opium smoking was once fairly common, but is now confined to a few Chinese in the large cities. Cocaine is used sporadically by about 5o% of the more dissipated type of morphine and heroin addicts, but con tinued addiction to cocaine alone is very unusual. Most normal subjects, who became addicted years ago through self-medication with opium, and many of the less unstable of the abnormal group have been cured permanently, leaving a very unstable group who constantly relapse because of the instability that was responsible for their original addiction. Many of these have been "cured" from Io to 20 times.
A study of delinquent addicts has shown that their original psychopathic character, rather than mental and moral deteriora tion due to the use of narcotics, is responsible for the offences they commit ; but some of them lie and steal in order to supply them selves with opium. Normal addicts do not suffer appreciable men tal or moral deterioration. In hospitals for the insane only a small fraction of one per cent have psychoses attributable to the use of narcotics.
The trend of drug addiction was upward from I 86o to about 1900, at which time addicts totalled 250,00o to 300,000. The number remained practically stationary during the next decade, after which drug addiction declined to about one-third what it used to be. In 1924 the division of the Bureau of Internal Revenue having charge of narcotic law enforcement estimated the total number of addicts to be i io,000; the U.S. Public Health Service set the figure as between iio,000 and i 5o,000. In 1926 the num ber was estimated at less than 95,000 and it is constantly declin ing. The United States enforces all the recommendations of the Hague International Opium Convention of Jan. 23, 1912. In 1909 the Federal Government forbade the importation of smoking opium, but the first restrictive legislation was the Ohio Anti-Opium Smoking Law of 1885. Practically all other anti-narcotic legisla tion has been enacted since 1897. By 1912 every State except Delaware had an anti-narcotic law. At present every State and Territory has such a law, but the most important one is the Federal anti-narcotic law known as the Harrison Act, which be came effective in 1915. It has been amended and supplemented so that the Federal Government now traces opium and cocaine from the time a permit to import the crude drug is issued, until the finished product reaches the consumer. Violations of the nar cotic laws are punished by large fines and imprisonment of from one to ten years.