Participation of the Health Committee of the League of Nations in the campaign against the abuse of narcotic drugs
Author: Erich Knaffl-Lenz
Pages: 9 to 12
Creation Date: 1952/01/01
Participation of the Health Committee of the League of Nations in the campaign against the abuse of narcotic drugsPr. Dr. Erich Knaffl-Lenz
The increasingly widespread abuse 6f opium caused President Theodore Roosevelt in 1908 to convene an international conference in Shanghai which discussed measures for curbing this abuse. As a result, in 1912, a second conference was convened at The Hague, at which a Convention was concluded which would have controlled the manufacture, trade, export and import and gradually suppressed the improper use of opium, morphine, cocaine and any derivatives thereof which could be misused.
The Convention did not come into effect because of the First World War and the task was therefore assigned to the newly-founded League of Nations. States Members of the League of Nations were under obligation to accede to the Convention. For this purpose an Opium Advisory Committee was established consisting of the representatives of eight States particularly interested in opium production. At a later stage a representative of Germany also took part in the meetings. The main function of this Committee was to register and supervise manufacture, imports and exports and to seize illicitly imported narcotic drugs.
In 1923 the General Assembly decided to convene a new conference to give closer definition to the provisions and also to deal with the hashish problem. In addition, medical requirements were to be determined and the production of narcotic drugs was to be limited to covering these requirements. The preparatory committee envisaged two conferences: the first to deal with the opium problem in Asia and the second with alkaloids and their production.
The Assembly was of opinion that excessive overproduction of narcotic drugs led to abuse and that one of the most urgent questions was therefore to determine the amounts needed to cover needs for medicinal world purposes so that production could be reduced accordingly.
This question was referred to a sub-committee consisting of two members of the Opium Advisory Committee and two members of the Health Committee. At its first meeting in January 1923 the following methods were proposed for ascertaining world requirements for medicinal purposes:
System I. By accurate and regular methods of supervision, such as those carried out for example in the United States of America and in Germany.
System II (applied, e.g., in Switzerland). By direct inquiries made in hospitals and from chemists, dispensing physicians, dentists and veterinary surgeons. From these inquiries the quantities consumed for medical purposes will be obtained.
System III. By determining the extent of the incidence of diseases in any given country, taking as a basis the statistics of insurance companies and funds which insure against disease. Ascertaining from inquiries addressed to a limited number of general hospitals the average consumption of narcotics per patient and per year. By multiplying the first figure by the second, the average annual legitimate consumption throughout the country is obtained.
System IV. By statistics obtained through the application of import and export certificates.
In March 1923 the writer of this article was invited to join the Health Section and asked to deal, inter alia, with narcotic drugs questions. The joint sub-committee, which met in September 1923, appointed him its expert.
As the methods proposed were not calculated to provide reliable consumption statistics, the expert suggested that data be obtained on the average consumption of opiates per day of treatment in general hospitals in a number of countries and that the amounts thus obtained, including morphine and its derivatives, be expressed in opium equivalents, opium being taken as 10 per cent. Commercial opium contains between 12 and 14 per cent morphine so that there is sufficient margin for losses in processing and conversion into derivatives. Codeine is not covered by the provisions of the Convention and is often not included in the statistics. Consumption varies greatly in the different countries, ranging between 25 and 75 per cent. Since three times as much codeine is needed to produce the same result, the total consumption of opium is considerably affected. To eliminate this error in the comparison it seems advisable to reckon one-third of the codeine consumed as morphine.
Allowing for these sources of error, it appears that the consumption of opiates in countries on the same level of public health development differs only slightly. Climatic conditions may also be a factor; consumption in Sweden and England is, for instance, higher than in Central Europe.
In Belgium, Germany, Austria, Poland, Czechoslovakia and Switzerland a large section of the population has to belong to health insurance funds which defray the cost of medical treatment in and outside hospitals. The funds therefore have all the medical prescriptions. By analysing them it was possible to determine accurately the annual requirements per person insured. In Austria the consumption in 1923 under the federal health insurance scheme, which covered all civil servants and their dependants (373,517, including 204,920 children), was calculated. If opiates used in the course of hospital treatment are also included, the consumption amounted to 360 mg. of opium, 53 per cent of which was prescribed in the form of codeine.
The figures thus obtained for three Berlin health insurance funds (Allgemeine Ortskrankenkasse (Schoneberg), Betriebskrankenkasse (Berlin, 68,000 persons insured), Landeskrankenkasse (Berlin, 16,937)) were much higher, as dependants were not covered by the insurance. The highest figures were those of the Betriebskrankenkasse and the lowest those of the Landeskrankenkasse. Codeine consumption was from 50 to 100 per cent that of morphine. Similar figures were also obtained in the canton of Basle where about 80 per cent of the population was insured.
Opium consumption is greatly affected by the number of morphine addicts. Under the federal health insurance scheme in Austria twenty-six morphine cases consumed 40 per cent of the total. Investigations in Germany gave much the same, results. If a further 20 per cent is added for scientific and veterinary purposes and for additional consumption of codeine, the figure comes to approximately 450 mg. of opium annually per habitant. Cocaine requirements were, estimated at 7 mg. Practically no country consumes such large amounts. Only Great Britain and Sweden used considerably more. These figures were accepted by the Health Committee and put forward. If the medicinal requirements of Africa and Asia are assessed at half the amount, it would appear that world production at that time was at least ten times too great. The Opium Advisory Committee, on the basis of partially erroneous calculations, obtained the figure of 600-900 mg., but the Health Committee refused to accept it.
At this meeting the question, raised by the present writer, of prohibiting the manufacture of diacetylmorphine was discussed. Most doctors, particularly hospital physicians, consider it can be completely dispensed with for therapeutic purposes and can be replaced, with no harm to the patients, by other much less toxic morphine derivatives. Not only the physiological but also the toxic effects are three to four times greater than those of morphine. Addiction and physical and moral degeneration set in much more quickly and dehabituation is much more difficult. Its stimulative effect incites to abuse even-those who are psychologically normal and it has superseded most other narcotic drugs particularly in criminal circles. Its small volume makes it particularly' suitable for illicit traffic. An international ban on its manufacture, as had already been demanded by the United States, would therefore be fully justified. The Health Committee supported this view. The representatives of the Opium Advisory Committee, however, stated that the sub-committee had no power to discuss this question as they had not been asked to do so, a view contested by the members of the Health Committee. As no agreement could be reached on the matter, no further meeting of the sub-committee was held. Thereupon, the Health Committee appointed its own sub-committee to which the writer was seconded as an expert.
The International Opium Conference; convened in November 1924 at Geneva pursuant to the Assembly's decision, dealt at its first session exclusively with the opium problem in Asia. All those taking part agreed that the manufacture of smoking opium should be completely abolished and that opium smoking should gradually be suppressed. The United States demanded an annual reduction of a specific amount, whereas the colonial Powers would agree only to a gradual reduction. As no agreement could be reached, on the point, the United States representatives left the conference, and took no further part in the meetings.
The second conference in 1925 dealt exclusively with medicinal opium, morphine and its derivatives, cocaine and ecgonine and, lastly, with hashish extracts and tinctures. All these drugs were brought under the provisions of the Convention with the exception of pharmaceutical preparations containing less than 0.2 per cent morphine and 0.1 per cent cocaine. On the other hand, all preparations containing diacetylmorphine were put under control.
The exceptions thus made are not justifiable from the medical point of view as the preparations in question are of very doubtful therapeutic value and could be prescribed by doctors at any time and then brought under the provisions. In the first place, these provisions allow unknown quantities of narcotic drugs to escape control and registration and in the second place, they make it possible to isolate the pure alkaloids and introduce them into the illicit traffic.
Two articles of the Convention provided for cooperation between the Health Committee and the Permanent Committee of the Office International de l'Hygiene publique in Paris. Paragraph 8 lays down that narcotic drugs, which, because of being compounded with other substances can no longer be used for improper purposes, may be exempted from the provisions of the Convention.
Article 10 of the Convention provides that drugs to which it does not yet apply, may be included in the Convention if they have habit-forming properties or if they can be transformed into habit-forming substances. In both cases the Health Committee requests the Permanent Committee in Paris for its opinion on the matter. A permanent committee of experts was accordingly set up to deal with these questions. After the Health Committee in Geneva had accepted the proposals, the Council was informed accordingly and it notified the member States.
The effect of this complicated procedure was that it took from one to one and a half years to secure a final decision. It would have been more advisable to make the provisions applicable to new morphine derivatives while they were being examined by the committee of experts. The 1931 Convention provides for a similar procedure.
Under article 10 a series of new morphine derivatives with habit-forming properties could be subjected to the same control as morphine. These were dihydro-hydrooxycodeinone(eucodal), dihydrocodeinone (dicodide) and its acetyl ester (acedicone) and dihydro-morphinone (dilaudide)
At the end of the 1920's very large quantities of morphine esters were being produced in two countries not parties to the Convention exclusively for the illicit traffic. They contributed largely to the narcotic drug epidemic in Egypt. The drugs in question were benzoyl-morphine and acetylpropionylmorphine (dionyl). They were also brought under the Convention.
As previous experience showed that all morphine esters produced similar effects to those of heroin and could be reconverted into morphine by saponification, the present writer proposed that all esters, including those not yet produced, should be treated in the same way as heroin, a view with which the Health Committee agreed. But non-expert circles in the Opium Advisory Committee doubted whether this view was correct. It was also objected that the provisions of the Convention could not be applied to a series of substances. The Health Committee declined to deal with the point, claiming that it was a juridical question outside its competence, and maintained its point of view.
In the United States a morphine derivative, dihydro-desoxymorphine-D, very similar to dilaudide, was synthesized by Dr. Small and was considered to be non-habit-forming, although it had the same analgesic properties as morphine. Subsequent investigations made in the United States showed, however, that it was also habit-forming and its use and manufacture were prohibited. In view of the great importance which a derivative producing similar effects to those of morphine without being habit-forming would have, the Opium Advisory Committee requested the Health Committee for its opinion. The experts of the Office were therefore asked to examine the question. Straub (Munich) showed by experiments on mice that the sedative and stimulative effects were similar to those of morphine but ten times stronger. Tieffenau (Paris) was able to prove by experiments on dogs that desomorphine had similar but much stronger effects than morphine and that habituation supervened more quickly. The writer found from experiments on mice that both its effects and its toxicity were much greater than those of morphine. Experiments on rabbits proved that the sedative effect on the respiratory centre was also greater, though of much shorter duration. Experiments on an addict suffering from cancer showed that withdrawal symptoms could be eliminated by using even small doses, but that the effect was only short-lived. The tests therefore confirmed the view of the American experts that a ban on manufacture was justified.
The Opium Advisory Committee considered it absolutely necessary to devise an international method of measuring morphine and cocaine quantitatively. The Health Committee set up an international expert committee of pharmaceutical chemists to study this question, of which the present writer was a member. It proved possible to solve the problem of determining the amounts of cocaine and ecgonine very satisfactorily but this was not so in the case of morphine. As most chemists use the so-called calcium method, whereby morphine is extracted from raw opium in the form of calcium morphinate, most of the committee members felt that this method should be retained but that its intrinsic defects should be overcome. The feeling was that some method could probably be evolved which would permit the quantitative isolation but not the quantitative extraction of pure morphine, so that a relatively higher empirical correction factor had to be used. A method proposed by Eder, which avoids this error, proved to be too lengthy for practical purposes and could also not be given a further test as the committee had to stop its work. A method proposed by the writer at the last meeting could also not be taken into consideration. It has latterly been further developed and published under reference St/SOA/Ser.K/3 I.VIII.52.
The second opium conference at Geneva in 1925 did not discuss the question of determining world requirements of narcotic drugs, as it considered the figures computed by the Health Committee to be insufficiently based.
No solution to the heroin problem was found either as the conference did not consider itself competent to take such action.
On the writer's initiative the Austrian Government proposed, at the 1931 Conference on the Limitation of the Manufacture of Narcotic Drugs, that the manufacture of heroin from opium should be reduced and the question should be referred first to the technical committee for an expert opinion on the harmful effects of diacetylmorphine and on the possibility of dispensing with its use in therapeutics to be obtained from the committee of experts placed at the disposal of the Conference. This committee consisted of leading experts from Germany, France, Great Britain and included the present writer.
Both proposals met with the stiffest resistance from the producing countries, whereas Poland, the United States, Italy and China supported it warmly. Finally, after long discussions, it was decided to refer the matter to the technical committee. Simultaneously, Poland submitted a proposal to prohibit exports in case the proposal was rejected. The Austrian delegation asked the experts in the technical committee to produce replies to the following questions:
What are the properties of diacetylmorphine which make it particularly suitable for use as a narcotic drug and in the illicit traffic ?
What are the therapeutic advantages of diacetylmorphine as compared with morphine and other morphine derivatives ?
Are the properties of diacetylmorphine such that they cannot be replaced by other medicaments without harming the patient ?
Are the dangers which diacetylmorphine constitute for mankind not incomparably greater than the advantages of its use in therapeutics ?
After the expert committee had confirmed in document Conf. L.F.S. Com. techn. the extremely harmful effects of diacetylmorphine and had replied in the affirmative that it could perfectly well be replaced by other less harmful morphine derivatives, the Austrian delegation pressed strongly for acceptance of its proposal. Objections, however, were raised by some of, the producing countries, particularly France and Great Britain, which emphasized that it would be inhuman to deprive chronic invalids of this valuable medicament and that such far-reaching decisions could not be adopted without consulting the medical bodies in the various countries. The British expert, Professor Dixon (Cambridge), brilliantly refuted the objections raised by medical laymen.
In spite of the finding returned by the committee of experts and the unhappy experiences in Egypt, the proposal was rejected by a tie-vote, and the Polish proposal to prohibit exports came up for discussion. In view of the great danger that this proposal might also be rejected, the Austrian delegation proposed, particularly in order to counteract the French objection that poor patients should not be deprived of this medicament, that the governments of countries which did not themselves produce heroin, should be allowed to import the amounts they needed but must keep them in their own charge. This joint Polish-Austrian proposal was strongly contested but was finally adopted by 10 votes to 5, with 2 abstentions. It was also adopted at the, plenary meeting and incorporated in article 10 of the Convention.
Time has shown that this provision could do nothing to prevent the abuse of heroin.
It would be desirable that at a future conference only the views of medical experts should be taken into account on purely medical matters. An international ban on the manufacture of heroin, which can be easily produced from morphine with no special technical knowledge, would be successful only if draconic sentences, such as the confiscation of property, deportation or several years' hard labour, were introduced for the manufacture or possession of, or traffic in, the drug. It should also be considered whether the manufacture and traffic should not be classified as crimes againts humanity.
This attitude would seem justified in view of the heroin epidemic in Egypt.
These brief observations show that the Health Committee of the League of Nations has, within the limits of the provisions of the 1925 Geneva Convention, made a very valuable contribution to the campaign against the abuse of narcotic drugs.
League of Nations publications:
C.10.M.7, C.213.M.69, C.224.M.80, C.579.M.205.
CH. OC mixte 7, OC CH/S.C mixte/P.V.2.
CH/Opium C/P.V.I. P.C.C.I.
Extract from the monthly bulletin of the Office international d'hygiene publique, vol. XXX, 1938, fasc. no. II, p. 2562.