The Lancet, 22 giugno 1990

"BLESS the Lord for giving opium to the human race," wrote Thomas Sydenham. Three centuries later, the penalty for supplying opium could be as severe as 14 years' imprisonment. Opium is not alone in experiencing the pendulum swings of fashion. The case of tobacco is instructive. Tobacco smoking was widely proscribed as late as the 18th century. In Germany the smoker was fined, in Russia exiled, and in Italy excommunicated. In Iran the smoker's pipe was driven throught his nose and the unfortunate subject paraded around town. In Turkey and Arabia torture and death were punishments. Nevertheless, by the mid-20th century, many fashionable figures, such as film stars, chain-smoked. Smoking had become a sign of maturity an sophistication. Many people believe that solvent-sniffing was unknown before the 1970s. Ether parties, however, were popular in Austria and Prussia after the 1914-18 war and the clergy were engaged in stamping out an epidemic of ether sniffing in Ulster at the turn od the century. What is surpr

ising, perhaps, is not the changes in fashion but the fickle nature of scientific opinion. In a medical textbook of 1909, two eminent physicians wrote of the public alarm at the excessive use of a popular stimulant: "the suffere is tremulous and loses his self command; he is subject to fits of agitation and depression. He loses colour and has a haggard appearence... As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery". This drug was coffee.

Knowledge of the volatile opinions about other drugs makes the attitude towards opium seem not usual. In 1819 an individual could buy any drug from a druggist. In that year, Parliament decided to try and protect the public from irresponsible dispensing of arsenic, oxalic acid, and corrosive sublimate. Parliament failed that time, but in the succeeding 100 years doctors and pharmacists effected a monopoly of most commonly used drugs. The driving force behind protecting the public from poison was the lucrative nature of such a monopoly. And the biggest prize was opium - used as a panacea by the 19th century population. A series of Pharmacy Acts throughout the century culminated in 1917 in the "defence of the Realm" Act, which gave an additional reason for control of alcohol, opium, and other psycotropic substances inebriation of the men threatened the outcome of the 1914-18 war. So alcohol was taxed, premises supplying it had to be licensed, and hours of opening were restricted. Opium was similary restricted,

but on an individual basis under medical prescription. The medical profession established criteria for prescribing for addicts was reasonable if the patient could not be withdrawn without serious withdrawal symptoms; if the patient was undergoing a gradual withdrawal; and if the patient needed the drug to lead a useful and normal life. The measures were spectacularly successful when judged by the plummetting death rates from cirrhosis and convictions for intoxication.

After 1920, a divergence in practice between England and America became marked. The United States prohibited alcohol and opium completely and this measure drew the following response from the British: "Barbarians is not too strong a phrase to use of people who have such an extraordinary savage idea of stamping out all people who happen to desagree with their political views. (Hansard, 1920). The Americans retorted that the British System was "the epitome of amoral expediency" and, even as late as 1972, the American Attorney-General described the British approach as "surrender". THe period from 1920 to 1940 represents therefore one of the most comprehensive "controlled trials" in history and its outcome was a significant defeat for the American attitude, The Prohibition gangsters of the 1930s rocked American society and eventually drove the Government to abandon prohibition. The experiment continued until 1960, however, since opium prohibition continued. Gangsterism arose once again, this time, involving opiu

m derivates and cocaine. In England, the Brain Committee met in 1960 to consider drug abuse, and pronounced themselves satisfied that everything was well in Britain and horrified by the American experience.

Then something happened in the '60s that still provokes varying interpretations. The events that have been claimed relevant are the Vietnam War, the student revolt, hippy philosophy (make love not war, flower power, and so on), the decline of state religion, and affluence. Some North Americans came to Britain in the early '60s and some private medical practitioners prescribed enormous quantities of drugs. It is not difficult to imagine that, given American demand, profits were to be made by both parties. A drug "craze" occurred among British youth, alarming the authorities into reconvening the Brain Committee, which came up with the following frustrating conclusion: "The information we have is not what we want. The information we want is not what we need. The information we need is not what we may obtain". Britain organised the Dangerous Drugs Act of 1967 and restricted prescribing for addicts to licensed clinics. The situation seemed not dissimilar to that concerning alcohol in 1917, but few clinics were se

t up and, the fashion for drugs still being in full swing, a black market flourished. England had started to tread the American path. And, as the American experience showed, further moves toward prohibition only aggravated the situation. Black market violence started to deter doctors from dealing with addicts, and even where the Home Office succeeded in establishing clincs, it was difficult to find psychiatrists willing to risk the aggression connected with prescribing to addicts.

Prohibition appears to lead to gangsterism and free availability to epidemic intoxication. It is ironic that adolescent indulgence in ethers, opium, and hallucinogens is occurring side by side with widespread alcoholism in men (and increasingly women) and dependence on benzodiazepines in women. The real cost of beer (in terms of minutes a man must work to earn it) has declined steadily since the 1939-45 war and benzodiazepines were readily prescribed for all vicissitudes, rather like amphetamines in the '40s and '50s. A happy medium of social use seems to be called for. Illicit consumption of addictive drugs is inherently epidemic. Addicts have to finance their own consumption by selling their possessions, others' possessions, or by "trading". An addict may buy 5 g of a drug and finance his or her 1 g consumption by selling 4 g at a higher price. He or she may also dilute the drug with an adulterant and sell it as pure. Illicit consumption is thus maintained by a pyramid selling operation. Most addicts are a

lso traders.

The debate about controlled drug prescribin has split the profession down the middle. It may be summarised thus:

THE ARGUMENTS CONCERNING THE PRESCRIPTION OF CONTROLLED DRUGS

1. Against: it maintains the condition of addiction;

For: the addict will maintain the condition anyway

2. Against: it was a public health exercise to protect people from the black market;

For: a stable supply benefits the addict and provides pure, clean drugs;

3. Against: it is not a doctor's job to control the illicit use of drugs;

For: doctors are obliged, like anyone else, to help society combat the breaking of the law;

4. Against: barbiturates and alcohol are not prescribed because they are damaging - why opium?

For: if alcohol were prohibited, it would be more humane to presribe a daily dram of whisky than see someone sell their last possession for methelated spirits;

5. Against: the illegal use of drugs is not curbed by prescription;

For: there are still insufficient properly controlled clinics;

6. Against: addicts traffick their prescriptions;

For: prescribe less;

7. Against: addicts supplement their prescriptions;

For: prescribe more;

8. Against: the efficacy of maintenance doses is not proven;

For: the contrast between the USA and England 1920-50 suggest otherwise.

Madden, talks of the "soil" (the personality), the "seed" (nature of the drug), and the "environment" (society or culture), a metaphor that has been embellished by "the what?" (what sort of person in what culture using what drug), "the how?" (how often and how controlled is the drug use, and how the drug is consumed), and "the why?" (with as many answers as there are drug takers). Law and custom govern the environment. Alcoholism in Arabia, for instance, is rarer than in Scotland. This rule is supported by a coincidence of addiction rates and the culturally approved drugs. For example, among 50 million English (among whom alcohol is socially used, even promoted), there are 500.000 alcoholics - 1% rate. Among 40 million Siamese (among whom opium is socially used, though increasingly officially discouraged), there are an estimated 400.000 addicts - 1% rate. Opium, like alcohol, can be widely used without the inevitability of addiction. The prevalence of addiction to a particular drug is critically affected by

its availability and acceptability. Both of these are controlled by laws and mores. In addition, there are rapid temporal fluctuations in the incidence of drug abuse. Of American servicemen who had become addicted to opium in Vietnam, only 10% remained addicted one year later. Times of social stress seem to lead to greater consumption of drugs. It is probably not a coincidence that the current increase in opium use occurs at a time of high unemployment and the demise of organised religion, opium (of one sort or another) is the religion od the people.

Addicts give up when they are ready to and special detoxification units do little to expedite this. Probably all the units do is enable addicts to survive until they are prepared to stop. Addicts will return to their drug taking unless they have reviewed the advantages and disadvantages of use and feel the disadvantages to be greater. Psychiatric treatment must discover why addicts abuse drugs or alcohol and then work with them to seek alternative methods of dealing with the problems muffled by drug dependence.