Drug Addiction:

Sections

INTRODUCTION
I. STATISTICAL DATA IN FRANCE
II. ANALYSIS OF CASES OF ADDICTION IN THE DEPARTMENT OF THE SEINE
III. COMPARISON WITH CANADA
IV. SUBSTANCES USED BY DRUG ADDICTS IN FRANCE AND METHODS OF ABSORPTION
V. RESPONSIBILITIES OF THE MEDICAL PROFESSION
VI. The role of the pharmacist
VII. ORIGINS OF DRUG ADDICTION
VIII. DRUG ADDICTION AMONG DOCTORS
IX. RECIDIVISM
CONCLUSIONS

Details

Author: C. Vaille , G. Stern
Pages: 1 to 17
Creation Date: 1954/01/01

GENERAL

Drug Addiction:

Medical and Social Aspects in France

C. Vaille
G. Stern

INTRODUCTION

In those regions of the globe where opium, cannabis or coca leaf are consumed on a large scale, drug addiction is rightly considered as a social scourge.

The practical problems raised by the consumption of narcotic drugs in Western countries are of a different kind. The number of persons who take narcotic drugs for non-therapeutic purposes is smaller; the principal narcotics used are the so-called white drugs (morphine, heroin, etc.) and the origin of their use is different. The Western peoples acquired their knowledge of narcotic drugs in the nineteenth century, through the medium of therapeutics. The illicit use of such drugs was rapidly checked by the enactment of very strict regulations.

In spite of the admittedly social nature of drug addiction, the amount of sociological information available on the subject is small. The numerous publications which have dealt with the question are not lacking in qualitative elements, but most of them are devoid of quantitative data.

I. STATISTICAL DATA IN FRANCE

A. Data for the country as a whole, 1946 to 1949

The authors have made a systematic study of the cases of addiction observed during the years 1946, 1947, 1948 and the first nine months of 1949.

During this period, 687 cases were investigated.

On the basis of this initial fact it may be stated that at present drug addiction in France in no way constitutes a social scourge. If we raise the above figure to 1,000, it would represent .002 per cent, for 42 million inhabitants, i.e., two addicts for every 100,000 inhabitants.

For the purposes of this inquiry, addicts were classified by sex, age, origin of addiction, substances employed and means of absorption and occupation.

  1. Sex: Of 687 cases 328 were men, i.e., 47 per cent, and 359 women, i.e., 53 per cent.

This small percentage difference provides no evidence that one sex is more liable to addiction than the other.

It may be noted that the above cases included 50 addicted couples; in other words, 14.5 per cent of the addicts are married to an addict.

  1. Age: The age of the addicts was ascertained only in 426 cases. The breakdown is as follows:

 

Number

Per cent

Less than 20 years of age
1 0.2
20 to 24 years of age
15 3.5
25 to 29 years of age
47 11
30 to 34 years of age
55 12.9
35 to 39 years of age
80 18.7
40 to 44 years of age
67 15.7
45 to 49 years of age
66 15.4
50 to 54 years of age
39 9.1
55 to 59 years of age
23 5.3
60 to 64 years of age
17 3.9
65 to 69 years of age
11 2.6
70 to 79 years of age
5 1.1
80 and over
0
 
 
426 99.4

These figures do not offer a true picture of the distribution of addicts among the various age groups, for the population, of course, is unequally divided, forming what is known as an age pyramid.

In order to deduce the actual relative numbers of addicts, a correction must therefore be applied.

The authors felt that the easiest way would be to proceed by a simple rule-of-three method and calculate what the distribution of addicts would be if all the age groups comprised the same number of persons, and then to compare the percentages in relationship to the whole.[1]

Figure 1

Full size image: 5 kB, Figure 1

We thus obtain:

 

Per cent

Less than 20 years of age
negligible
20 to 24 years of age
2.7
25 to 29 years of age
11.6
30 to 34 years of age
12.6
35 to 39 years of age
16.4
40 to 44 years of age
13.6
45 to 49 years of age
14.8
50 to 54 years of age
10.4
55 to 59 years of age
6.6
60 to 64 years of age
5.4
65 to 69 years of age
4
70 to 75 years of age
1.5
80 and over
0
 
99.6

These figures do not offer exact data concerning the optimum age at which addiction is developed, since they are based on the age of addicts at the time of their detection.

Two peak figures may be noted, one at thirty-five to thirty-nine years and the other at forty-five to forty-nine years. We shall see later that these two peaks correspond to different curves for men and women.

The rapid rise in the figures shows that young people in the strict sense of the term (below twenty-five years of age) are not really affected. The drop after the peak at the forties, although less rapid, is nevertheless appreciable. It suggests obviously that mortality among addicts must be very high as compared with general mortality. This view is supported by the fact that many addicts suffer from some serious disease.

The distribution by sex was established. (The ratio to the distribution of age-groups by sex was considered of no value, since the numerical differences as between men and women are very small, becoming fairly appreciable only after the age of sixty. The figures given here are therefore absolute; the comparison is by percentages.)

 

Men

Women

Age

Number

(Per cent)

Number

(Per cent)

Less than 20 years of age
0
 
1 (0.4)
20 to 24 years of age
7 (3.7) 8 (3.3)
25 to 29 years of age
17 ( 9 ) 30 (12.5)
30 to 34 years of age
23 (12.2) 32 (13.3)
35 to 39 years of age
26 (13.9) 54 (22.5)
40 to 44 years of age
33 (17.6) 34 (14.2)
45 to 49 years of age
38 (20.3) 28 (11.7)
50 to 54 years of age
21 (11.2) 18 (7.5)
55 to 59 years of age
7 (3.7) 16 (6.6)
60 to 64 years of age
7 (3.7) 10 (4.1)
65 to 69 years of age
7 (3.7) 4 (1.6)
70 to 79 years of age
1 (0.5) 4 (1.6)
80 and over
0
 
 
 
 
187 (99.5) 239 99.3

The comparison between men and women (see attached graph) reveals two curves of fairly similar general trend. There is also a marked difference: the peak for women is between 35 and 39 years and for men between 45 and 49 years.

B. Data for the Department of the Seine, 1945 to 1952

It was considered that after the general and rapid study of the data for France as a whole, a more detailed study of the Department of the Seine,[2] i.e., the urban area composed of Paris and its inner suburbs, would be of great significance, for the following reasons:

  1. In Western countries drug addiction is mainly found in the large urban centres. The Paris addicts studied here make up 57 per cent of the total number of cases detected in France as a whole since 1945.

  2. With the exception of the peasant class, which in any event has been scarcely touched by drug addiction, all the social classes are represented.

  3. Whereas in the provinces addiction is almost exclusively of therapeutic origin, in Paris there is a secret drug market. This has no equivalent in the provinces, where proselytism is a factor of less importance.

The addicts covered by the statistics were detected either by the Pharmaceutical Inspectorate or by the police.

While it is impossible to assess accurately the ratio of the number of cases of addiction which have been studied to the number actually in existence, it may be estimated to be fairly large, so that the statistics given below give a true picture of addiction in the Paris area.

  1. Number of addicts detected since 1945

The number amounted to 768, including 412 women, i.e., 53.6 per cent, and 356 men, i.e., 46.3 per cent.

The numbers of men and women are roughly the same. There appears therefore to be no evidence that one sex is more disposed to drug addiction than the other.

  1. Therapeutic origin of addiction

A study of the case histories has revealed the following facts:

There were 224 cases of therapeutic origin, 380 cases of non-therapeutic origin and 164 cases of undetermined origin.

In other words, for the known cases, 37 per cent were of therapeutic origin, and 63 per cent were of non-therapeutic origin.

By addiction of therapeutic origin we mean addiction contracted in connexion with treatment prescribed by a medical practitioner, such treatment being the patient's first contact with the drug.

Addiction of non-therapeutic origin is addiction contracted as a result of proselytism for reasons not strictly medical, such as personal distress or disappointments, etc.

  1. Sources of supply

Addicts procure narcotic drugs from two sources of supply: a. From the legal market, by licit or illicit methods (regular prescriptions, falsified prescriptions, forged prescriptions, simultaneous consultation of several doctors, wrong prescriptions); b. From the illicit market.

Out of 768 cases, 344 procure supplies from the legal market, 329 procure supplies from the illicit market, 91 procure supplies from both concurrently and 4 cases are undetermined.

It must be borne in mind that statistics relating to supply from the illicit market are harder to obtain than statistics of supplies from the legal market.

  1. Recidivism

During the 8 years covered by the study, 236 addicts (i.e., 30 per cent) relapsed into drug addiction, often several times.

  1. Addicts engaging in drug traffic

Certain addicts become drug traffickers. Incapable of meeting their needs, they try to use traffic in drugs as a means of indulging their own vice.

Such addicts are particularly dangerous because they try to attract new addicts in order to increase their clientele. There are 105 such cases, i.e., 14 per cent, among the total number under review.

  1. Drug addict couples

Such couples are frequently found; this study covers 61. In other words, 16 per cent of addicts are married to other addicts. The most common reason for the spread of addiction from husband to wife appears to be that narcotic drugs generally cause sexual impotence in men.

The 768 addicts studied were all of Western origin. In order to give a more accurate picture of drug addiction in Paris we should add:

Thirty-nine North Africans who smoke cannabis, Twenty-four Chinese who smoke opium.

However, while it may be stated that the 768 cases referred to represent a large proportion of the actual number of addicts, it may also be asserted that there are many more users of opium and kif[3] among the Chinese and North African Colony. That, moreover, is confirmed by the 1953 statistics for France and the Department of the Seine.[4]

Figrure 2

Full size image: 5 kB, Figrure 2

Figure 2 and table no. 1 show the distribution of addicts by various age-groups during a period of eight years. The curves resemble very closely those in figure 1.

Variation between men and women

The most obvious features are:

Coincidence of the curves before the age of 30 and after the age of 55,

Difference of 10 years between the peaks of the two curves,

Absence of juvenile addiction.

Table No. 1

DISTRIBUTION AND ORIGIN OF ADDICTION IN THE DEPARTMENT OF THE SEINE (A) Women

(A) Women

 

Origin of addiction

Age-group

Number

Per cent

Ta

N.T.b

c

Below 20 years of age
2 0.5 0 2 0
20 to 24 years of age
18 4.5 2 13 3
25 to 29 years of age
40 10 9 22 9
30 to 34 years of age
51 12.7 10 27 14
35 to 39 years of age
74 18.5 16 43 15
40 to 44 years of age
61 15 24 27 10
45 to 49 years of age
49 12.2 18 20 11
50 to 54 years of age
42 10.5 15 17 10
55 to 59 years of age
24 6 11 8 5
60 to 64 years of age
21 5.2 8 8 5
65 to 69 years of age
9 2.2 5 1 3
70 and over
9 2.2 2 1 6
a

T: therapeutic

b

N.T.: non-therapeutic

c

Undetermined

Table No. 1

DISTRIBUTION AND ORIGIN OF ADDICTION IN THE DEPARTMENT OF THE SEINE (A) Women

(B) Men

 

Origin of addiction

Age-group

Number

Per cent

Ta

N.T.b

c

Below 20 years of age
0 0
 
 
 
20 to 24 years of age
18 5.2 2 16 0
25 to 29 years of age
37 10.7 4 32 1
30 to 34 years of age
38 11 7 25 6
35 to 39 years of age
42 12.2 10 22 10
40 to 44 years of age
50 14.5 13 26 11
45 to 49 years of age
68 19.7 22 38 8
50 to 54 years of age
36 10.4 18 11 7
55 to 59 years of age
18 5.2 9 7 2
60 to 64 years of age
20 5.8 10 6 4
65 to 69 years of age
14 4 9 3 2
70 and over
3 0.8 3 0 0
a

T: therapeutic

b

N.T.: non-therapeutic

c

Undetermined

As has been seen above (footnote 2), if allowance is made for the age pyramid the percentages between 0 and 2 must be scaled up or down.

The absence of juvenile addiction is reassuring: in eight years, there were only two cases under 20 years of age, whereas in certain countries, the United States in particular, the use of narcotics by adolescents has gained ground at an alarming rate.

The difference of 10 years between the peaks of the curves relating to men and women is characteristic. It appears to be due to the following causes:

Painful illnesses occur at an earlier age among women than among men.

The ages 35 to 39 in women and 45 to 49 in men mark a turning point in life. Younger women and men will normally seek to rebuild their lives after setbacks of a social or emotional nature. On the other hand, women of 35 and men of 45 who start their lives afresh display a moral courage which makes it highly probable that they will resist the mirage of narcotic drugs.

Comparison of the origin of addiction for each age group shows, as is logical, that for both women and men the ratio of therapeutic origin to non-therapeutic origin tends to increase with age (see table no 1.).

II. ANALYSIS OF CASES OF ADDICTION IN THE DEPARTMENT OF THE SEINE

A. Analysis of female cases: 412

  1. Origins:

124 of therapeutic origin, i.e., 40 per cent of known origins,

188 of non-therapeutic origin, i.e., 60 per cent of known origins,

100 of undetermined origin.

The cases of therapeutic origin are therefore appre ciably more numerous among women than among men (34 per cent). However, the difference is too small to justify any definite conclusion. It may be due simply to the fact that there are more sick women than men.

  1. Sources of supply:

Legal traffic
189
Illicit traffic
186
Both concurrently
53
Undetermined
4
  1. Recidivists:

138, i.e., 33 per cent.

  1. Addicts engaged in drug traffic:

50, i.e., 12 per cent.

  1. Divorced women:

The vital records of women offenders show whether they are divorced or not. We were struck by the number of divorced women - 104, or 25 per cent. Since divorce does not indicate a harmonious or at least a well-adjusted life, it is not surprising to find so high a proportion of divorced women addicts.

  1. Occupations:

The 412 cases are distributed as follows:

Undetermined
 
 
 
 
10
Women of no occupation
 
 
 
 
253
 
Including
 
 
 
 
 
 
Prostitutes
 
 
90
 
 
Unmarried women
 
 
50
 
 
Married women
 
 
113
Women having occupations
 
 
 
 
149
 
Including:
 
 
 
 
 
 
Artists
 
 
40
 
 
Medical, etc
 
 
39
 
 
 
Including:
 
 
 
 
 
 
Medical practitioners
2
 
 
 
 
Nurses
15
 
 
 
 
Sickroom attendants
4
 
 
 
 
Midwives
2
 
 
 
 
Medical secretaries
2
 
 
 
 
Social assistants
2
 
 
 
 
Daughter of medical practitioner
1
 
 
 
 
Wife of pharmacist
1
 
 
 
 
Wives of practitioners
10
The other occupations are as follows
 
 
 
 
 
Shopkeepers
 
 
 
 
21
Office employees
 
 
 
 
19
Liberal professions
 
 
 
 
12
Domestic servants
 
 
 
 
8
Cafe-owners
 
 
 
 
5
Manual workers
 
 
 
 
5

Thus there are fewer addicts among working women. For such a comparison to be strictly valid, however, the general ratio of working women to the total female population of Paris would have to be known.

In the category "women of no occupation", married women should be separated off. There thus remain 140 who are in fact women of no occupation, including 90 who are known to be prostitutes. The latter thus form the most numerous group. The proportion of prostitutes indulging in narcotic drugs is not, however, considerable; the number of prostitutes in the Paris area is estimated at 25,000.

In subdividing the category "women having occupations"-as was considered essential-the criterion applied was "mode of life". This explains, for example, why the authors have included wives of medical practitioners in the group "medical, etc.". In evaluating these data the numerical size of the groups chosen should be borne in mind. We do not possess precise figures for these, but their general order of magnitude is a matter of common knowledge.

Table No. 2

SEINE: WOMEN OF NO OCCUPATION, 263

 

Origin of addiction

Source of supply

 
 

Th.

N.Th.

a

L.T.b

I.T.c

Both concurrently

Undetermined

Divorced women

Recidivistis

Addicts and traffickers

Undetermined: 10
2 1 7 6 3
 
1
?
0 0
Married: 113
46 41 26 58 48 6 1 17 25 8
Unmarried: 50
16 19 15 28 17 4 1 25 16 5
Prostitutes: 90
7 67 16 10 46 34 0 25 59 28
TOTALS: 263
71 128 64 102 114 44 3 67 100 41
a

Undetermined.

b

L.T.: legal traffic

c

I.T.: illicit traffic.

Thus, it is obvious that most addicts are to be found, proportionately, in medical and artistic circles. Since the utilization of narcotic drugs for therapeutic purposes, therefore, the medical profession has paid a heavy toll to drugs. As for the artistic world, that is well known to number many initiates of "artificial paradises". Proselytism also plays an important role here, as may be seen from tables no. 3 and no. 5.

However, the statistics at present by no means cover all drug-addicted artists. A film director who was planning a film dealing with drug addiction received 60 applications from actors asking for the part of the drug addict. They all claimed in support of their applications that being or having been addicts they were eminently qualified to play the role. Yet only 40 artists have been discovered amongst male addicts in 8 years!

Similarly, members of the medical professions have facilities for obtaining supplies of drugs, and are in a better position to escape supervision, however strict.

The existence of drug addiction among the poorer classes will also be noted. It is commonly held that narcotics are a monopoly of the idle rich. This view is out-of-date.

We shall now examine the female cases in detail, on the basis of the chosen criteria (tables no. 2 and no. 3).

Table No. 3

SEINE: WOMEN HAVING OCCUPATIONS, 149

 

Origin of addiction

Source of supply

 
 

Th.

N.Th.

a

L.T.

I.T.

Both concurrently

Undetermined

Divorced

Recidivistis

Drug addicts and traffickers

Artists: 40
8 26 6 13 23 4 0 10 9 6
Medical, etc.:39
22 7 10 38 1 0 0 9 8 0
Shopkeepers: 21
7 9 5 8 9 3 1 7 7 3
Office employees: 19
4 8 7 10 8 1 0 5 4 0
Liberal professions: 12
4 5 3 7 5 0 0 3 2 0
Domestic servants: 8
3 4 1 6 2 0 0 1 3 0
Cafes: 5
2 0 3 2 3 0 0 1 1 0
Manual workers: 5
3 1 1 3 1 1 0 1 4 0
TOTALS: 149
53 60 36 87 52 9 1 37 38 9
a

Undetermined.

There are marked differences between the total figures for "women having occupations" and "women of no occupation'':

 

Women of no occupation (Per cent)

Women having occupations (Per cent)

Therapeutic origin
36 47
Non-therapeutic origin
64 53
Recidivists
38 25
Drug addicts engaged in drug traffic
16 6

In the case of women with occupations the figures for the two origins are roughly similar, while in the case of women of no occupation the non-therapeutic origin is predominant. The percentage of recidivists and traffickers is much higher among women of no occupation.

The same situation may be noted in the case of men, and it may be considered-and is generally admitted-that the exercise of an occupation provides less favourable ground for drug addiction than idleness.

Prostitutes account for most of the non-therapeutic cases. In many cases they get their supplies from the black market.

The same considerations apply in the case of artists.

It should be noted that cases of persons obtaining supplies from the legal market are more numerous than cases of therapeutic origin.

Generally speaking, drug addicts who have been introduced to narcotic drugs through therapeutic treatment try to obtain supplies on the legal market; they always regard them as a medicine. Few of them would ever think of obtaining drugs in the streets.

Lastly, prostitutes account for more than half the number of drug addicts engaged in traffic. This occurs partly as a kind of solidarity; they lend each other a helping hand in case of need.

B. Analysis of male cases: 356

  1. Therapeutic origin:

100 cases were of therapeutic origin, i.e., 34 per cent of the known cases;

192 were of non-therapeutic origin, i.e., 66 per cent;

64 were of undetermined origin.

  1. Sources of supply:

Legal traffic, 155

Illicit traffic, 163

Both concurrently, 38

  1. Recidivists:

98, i.e., 27 per cent

  1. Addicts engaged in drug traffic:

55, i.e., 15 per cent

  1. Occupations:

Undetermined
 
 
10
Men of no occupation
 
 
100
Men practising occupations
 
 
246
 
Including:
 
 
 
 
Physicians
56
 
 
Artists
40
 
 
Shopkeepers
30
 
 
Office employees
26
 
 
Industrialists
23
 
 
Liberal professions
18
 
 
Para-medical professions
12
 
 
Manual workers
12
 
 
Armed forces
11
 
 
Cafes - hotels
9
 
 
Students
5
 
 
Landowners
4

Twenty-nine per cent of male drug addicts have no occupation. The proportion is a considerable one, but a large part of this group consists of individuals of a kind peculiar to large cities, who frequent the shady circles known as le milieu. However, another part, comprising 39 per cent, consists of persons who have lost their employment because of drug addiction.

As may be seen from table no. 4 most addicts engaged in drug traffic (41 out of 55) belong to the group "men of no occupation".

So far as concerns men practising occupations, the observations made in connexion with women remain valid. It may be noted that the physicians number fifty-six, or over 15 per cent. Allowing for their size, the groups shopkeepers, industrialists and liberal professions are far more affected than the manual workers and office employees. The members of the armed forces are all colonials who were introduced to opium in the Far East. The four landowners might well be classified among the industrialists in view of their mode of life, since they are large landowners living in Paris. Lastly, five students were victims of proselytism.

The relevant details are given in tables no. 4 and no. 5.

Table No. 4

Seine: men of no occupation

 

Origin of drug addiction

Source of supply

 

Number

Th.

N.Th.

a

L.T.

I.T.

Both concurrently

Recidivistis

Drug addicts

Undetermined: 10
4 3 3 5 4 1 0 2
No occupation: 100
19 60 21 34 45 21 51 41

Undetermined.

Table No. 5

SEINE: MEN PRACTISING OCCUPATIONS, 246

 

Origin of drug addiction

Source of supply

 

Occupations

Th.

N.Th.

a

L.T.

I.T.

Both concurrently

Recidivistis

Drug addicts

Physicians: 56
30 12 14 50 6 0 2 0
Entertainers: 40
8 25 7 8 29 3 8 2
Shopkeepers: 30
11 16 3 12 14 4 8 2
Office employees: 26
4 18 4 10 12 4 9 2
Industrialists: 23
7 13 3 8 13 2 5 0
Liberal professions: 18
9 8 1 9 9 0 8 2
Para-medical professions: 12
2 7 3 9 3 0 2 2
Manual workers: 12
5 5 2 8 4 0 4 0
Armed forces: 11
1 8 2 2 9 0 0 0
Cafes - hotels: 9
0 8 1 0 7 2 1 2
Students: 5
0 5 0 0 5 0 0 0
Landowners: 4
0 4 0 0 3 1 0 0
TOTAL: 246
77 129 40 116 114 16 47 12

Undetermined.

As in the case of women there are marked differences between persons with occupations and those of no occupation.

   

No occupation (per cent)

With occupations (per cent)

Origin:
 
 
 
 
Therapeutic
24 37
 
Non-therapeutic
76 63
Recidivists
 
53 19
Addicts engaged in drug traffic
 
41 5

Although non-therapeutic origin is predominant among men also, it is more common among men of no occupation. As in the case of women, the latter account for the highest proportions of recidivists and traffickers. However, it is more difficult for men than for women to obtain supplies on the legal market. There are several reasons for this; among them the fact that most of the female cases are of therapeutic origin and that women can more easily simulate illness and obtain medical prescriptions from doctors out of weakness or indulgence.

III. COMPARISON WITH CANADA

The absence of statistical data on drug addiction was emphasized at the beginning of this study. It is therefore difficult to compare the situation in France with that in other countries. However, an official study covering the years 1930-1946[5] has been made by the Canadian Department of National Health and Welfare. Unfortunately it deals only with persons convicted for offences committed under the opium and narcotic drug act and, consequently, the statistics include not only drug addicts but also individuals convicted on charges of trafficking. The author estimates that drug addicts account for 40 to 70 per cent (the figure varies from year to year) of all offenders. Subject to this reservation a comparison may be essayed at certain points.

In sixteen years 3,245 offences were recorded, including second or repeated offences, i.e., an average of 191 per annum. The sex distribution was 88 per cent men and 12 per cent women. However, the report emphasizes that this does not reflect the real sex distribution of drug addicts. It states that in this connexion the only reliable information is that relating to the admission of drug addicts into mental institutions, the figure for the period 1932 to 1945 amounting to 374 men and 187 women, or 67 and 33 per cent respectively. But these statistics, in view of the small number of cases covered, do not reflect the real position. The authors share the opinion of those experts who consider that in the case of drug addiction of therapeutic origin, at least, the number of women exceeds the number of men; we have already seen that this is the case in France.

On the other hand, we were struck by the age distribution (see table no. 6 below drawn up by G. H. Josie and figure 3).

Table No. 6

DISTRIBUTION OF DRUG ADDICTS IN CANADA

 

Males

Females

Total

Age-groups

No.

Per cent

No.

Per cent

No.

Per cent

16 - 18 years
10 0.74 2 0.72 12 0.73
19 and 20 years
6 0.44 19 6.88 25 1.53
21 - 24 years
69 5.07 31 11.23 100 6.11
25 - 29 years
202 14.85 70
25.36a
272 16.62
30 - 34 years
223 16.40 54 19.57 277 16.93
35 - 39 years
240
17.65a
36 13.04 276 16.87
40 - 44 years
156 11.47 23 8.33 179 10.94
45 - 49 years
134 9.85 9 3.26 143 8.74
50 - 59 years
156 11.47 14 5.07 170 10.39
60 years and over
46 3.38 1 0.36 47 2.87
Age not given
118 8.68 17 6.16 135 8.25
TOTAL:
1,360 100.00 276 99.98 1,636 99.98
a

Author&rsquos emphasis.

In figure 3 the peaks of the two curves of the graph show a difference of ten years, as in France. But the peak age groups are ten years younger than in France (25-29 years in the case of women and 35-39 years in the case of men).

What can be the reasons for the relatively early incidence of drug addiction in Canada ? It is difficult to suggest an answer to this question, for without a profound familiarity with conditions of life in Canada highly important factors may well be overlooked.

Figure 3

Full size image: 3 kB, Figure 3

From partial information collected in the United States it would appear that the situation there is similar. The percentage of drug addiction cases of therapeutic origin is much lower than in France, and a comparison between the curves for Paris and Canada confirms that the flattening of the curves towards the highest age groups is mainly due to the therapeutic origin of the drug addiction cases.

Any serious study carried out in this field should be of a social nature, bringing out the differences between France on the one hand and Canada and the United States on the other hand.

In order to explain the development of drug addiction in Canada, the author of the report quotes Dr. Adams, who says that people take drugs in order to "temper the wind of reality".

The occupational data given in the report are practically useless for our purpose owing to the categories used.

We may note the relatively high number of labourers (21 per cent of the total) and servants (18 per cent).

No comparison can be made in other categories, such as construction, transport and communications, manufacturing, finance and insurance, etc.

There are no figures for medical practitioners or artists.

On the other hand, statistics are given on the education of offenders. They are difficult for us to interpret as we are not familiar with the categories applied.

Table No. 7

DISTRIBUTION OF DRUG ADDICTS IN CANADA ACCORDING TO EDUCATION

 

Convictions under Opium and Narcotic Drugs Act

All convictions

Educational status

No.

Per cent

No.

Per cent

Superior
90 4.15 6,233 1.34
High school
67 3.09 14,024 3.00
Elementary
1,753 80.86 415,894 89.10
Illiterate
111 5.12 4,958 1.06
Not given
147 6.78 25,649 5.50
TOTAL:
2,168 100.00 466,758 100.00

This analysis shows, at all events, that drug addiction in Canada is by no means confined to the highest social classes.

The report also contains statistics on the religion of offenders.

The most numerous group absolutely consists of Roman Catholics, accounting for 34.96 per cent; however, the Protestants are divided into a multitude of sects: as a group they actually account for 42 per cent. These figures cannot be evaluated without relating them to the religious distribution of the population as a whole, which unfortunately, is not given. However, the proportion of Jewish offenders, 4.9 per cent, is undoubtedly much higher than the relative size of the Jewish population of Canada. The author rightly points out in this connexion that offenders under the Opium and Narcotic Drugs Act are mostly town dwellers, and that 87 per cent of Canadian Jews live in towns. Persons of no religion account for 1.06 per cent of the total. The author states that the proportion of offenders who are members of the Anglican, Baptist, Catholic and United Church groups is lower than their proportion of the population.

The author of the report ends his conclusions with the following words:

"There is some suggestion that a definite religious affiliation of some kind makes it less likely that a person will become a narcotic offender, but the causal relationship here is not clear since the break with formal religion may be associated with other social factors."

The data given in the report are therefore insufficient to allow of their discussion in this study.

Of the total of 3,245 offences, 1,899 were first offences, 302 were second offences and 1,044 were reiterated offences.

Moreover, the report provides no information on the etiology of drug addiction, merely citing the views of a few international experts.

IV. SUBSTANCES USED BY DRUG ADDICTS IN FRANCE AND METHODS OF ABSORPTION

A. Substances used

Allowing for multiple uses, 694 cases of the consumption of narcotic drugs were recorded. They may be classified as follows:

 

Number

Per cent

Heroin
243 35.1
Morphine
196 28.2
Dihydrooxycodeinoneaa
80 11.5
Opium (smoking)
62 9
Pethidine hydrochlorideb
52 7.5
Laudanum
31 4.4
Cocaine
21 3
Indian hemp (smoking)
9 1.2
 
694 99.9
a

Sold under the following trade-names: Eubine, Pancodine, Eucodal, etc.

b

Sold under the following trade-names: Dolosal, Demerol, etc.

Heroin easily heads the list and together with morphine accounts for about two-thirds of the cases.

The high percentage for Dihydrooxycodeinone should be emphasized. This substance, which began to be used in France only a few years ago, has proved to be particularly dangerous with regard to drug addiction. It seems to act more like heroin than like morphine. Similarly the use of Pethidine hydrochloride has already led to a fair number of drug addiction cases.[6]

The opium smoking addicts in France are mainly Orientals who have settled in our country and a few idle rich who were introduced to opium by a stay in the Far East.

Every year the police regularly arrest the gang of traffickers who supply the few dozen opium smokers in Paris, but new suppliers always come forward to take their place. The quantities of opium consumed are very small and it is very difficult to prevent clandestine imports. In view of the high price that rich addicts are always prepared to pay, there is naturally a supply adequate to satisfy the demand.

It would be a mistake to judge the extent of this type of drug addiction in France by the newspaper headlines reporting such cases.

In actual fact, the repressive measures taken by the police prevent the operation of any real opium smoking establishments.

Smokers generally indulge their vice at home, alone or with a few intimates. There is thus little danger of this practice assuming dangerous proportions.

Cannabis is smoked almost exclusively by North Africans who receive it in parcels sent by their families. Accordingly, it is difficult to put a stop to this illicit source of import; but here again the practice is a very limited one and there is nothing in France comparable to the vogue of Indian hemp, under the name of marihuana, in the United States.

The percentage of cocaine consumption (3 per cent) clearly indicates a downward trend, which it may be noted goes hand in hand with a relative decline in the therapeutic use of this drug. The "snow" period seems to have come to an end in France, but not, it appears, in other countries.

Drug addicts consume laudanum by injection, as has been proved by several recorded cases of tetanus accompanied by numerous multiple abscesses caused by injections of laudanum.

Here again, we are a long way from the vogue, dear to Thomas de Quincey, of laudanum taken orally.

The discovery of this practice has led to the suppression of all exemptions granted in respect of laudanum, in particular, the privilege of obtaining 5 grammes without a prescription. It has been found necessary to abolish this allowance whatever the form in which the laudanum is supplied-a French patent medicine for use in compresses containing a high proportion of Ipecac which was supposed to prevent its absorption by mouth was found to be taken by injection.

The foregoing definitely confirms an already well known fact: that heroin is the most dangerous drug.

B. Methods of absorption

The methods of absorption of narcotics by drug addicts were determined in 386 cases. They may be classified as follows:

 

Cases

Percentage

By injection
325 84.0
Through the nose
27 7.0
By suppository
19 4.9
By mouth
13 3.3
By rectal injection
2 0.5
 
386 99.7

The prevalence of the transcutaneous method is overwhelming. This is due not only to the efficiency of this method, but also to the "syringe complex" noted by certain authors.

In the past few years intravenous injection, which seems to have been quite exceptional before the war, has made considerable strides.

P. Desclaux, L. Derobert and R. F. Katz[7] attribute the development of this method since 1940 to the "increasing scarcity of the drug in ampoules" and to "the idea, inaccurate though it may be, that intravenous injection produces a more lasting effect, permitting smaller quantities to be used so that the stock of the drug can be conserved. The habit has remained, although the first reason no longer exists and drug addicts have been able to convince themselves that the second is false." But the same authors also give a third explanation: "Of course, the main consideration is no longer parsimony; what is sought is a more intense effect and initial sensations of greater coenesthetic euphoria. These, however, do not last longer, as addicts originally thought; on the contrary, they are shorter."

Drug addicts do in fact report that this method produces a more intense effect; and we are obliged to believe them, since that alone can reasonably explain the use of intravenous injection, a more difficult method than subcutaneous or intramuscular injection.

It should also be noted that subcutaneous and intramuscular injections quite often cause abscesses, whereas these are generally avoided by the use of intravenous injection.

The nasal method is found almost exclusively on the clandestine market properly so called, where heroin is generally sold in the form of salts.

A new method of absorption has appeared in the last two or three years with the development of suppositories for therapeutic treatment. Although this method of absorption is very recent, its effectiveness is proved by the appreciable percentage of cases already recorded.

Under certain exceptional provisions in force in France, limited quantities of suppositories containing narcotic drugs may be supplied without a prescription. When these provisions were introduced, it was thought that the quantities which could be absorbed by this method were limited, in view of the physical effect of suppositories and the volume representing an active dose for a drug addict.

That is not the case: most drugs have a constipating effect, and volume has not constituted the obstacle anticipated. In one case, for example, it was estimated that a drug addict had succeeded in obtaining and "absorbing" an average of 30 to 40 suppositories per day.

The information collected on this subject by the vice squad in Paris shows that many inveterate drug addicts, well known to the police, have completely adapted themselves to this method.

V. RESPONSIBILITIES OF THE MEDICAL PROFESSION

We have had the opportunity of studying the medical records of 574 of the 768 Paris drug addicts. This information comprised in each case the curriculum vitae of the addict, his clinical record and an estimate of his addiction.

These records were all drawn up by the same observer, the Chief Medical Officer of a psychiatric hospital of the Seine Department, and constitute a homogenous mass of material which is unique in France in its quality and size.[8] They provide data the value of which may be judged from the following:

Of the 574 drug addicts:

275 were supplied by medical prescription; yet the medical expert found only 52 sick persons among them, and considered moreover that treatment by narcotic drugs was justified for only 10 of them.

148 cases were of therapeutic origin,

104 cases were of non-therapeutic origin,

13 cases were of undetermined origin,

130 were recidivists, and

31 were also traffickers.

Thus, 38 per cent of the drug addicts supplied by doctors not only were not suffering from any illness, but had contracted their vice for non-medical reasons. However divided medical opinion may be on the advisability of prescribing narcotic drugs, and however severe the judgment of the expert may be, we are clearly faced here with an important aspect of the prevention of drug addiction. The number of quack doctors who "sell" their heroin prescriptions is very small, and nearly all doctors who prescribe drugs wrongly do so without any personal profit; on the contrary, they bring very disagreeable consequences upon themselves both from their "clientele" and from the public authorities.

The incompetent practitioners are the most dangerous.

Let us take some examples:

C. D ....."I was suffering from migraine, and

Doctor X ....prescribed P ....[9] for me."

J. T. smoked opium in the East, and on his return to Europe took up the classic substitute of heroin. He showed the expert a medical certificate reading as follows: "This patient has contracted a reactive opiate addiction as a result of chronic sciatica."[10]

P. V ...... an offender confined in a State hospital: "I suffer constantly, but not to any greater extent here, where I do not receive any drugs."

Mrs. K . . . . . , an asthmatic: "I must admit that I have had fewer attacks of asthma since I lost the habit." This addict had been treated from 1930; she has not repeated the offence since 1947, in which year she was charged and ordered to undergo denarcotization.

We may observe that Professor Vallery-Radot wrote as follows: "I never give morphine to asthmatic patients; I find that treatment very harmful in nearly all cases."

R. R . . . . . "At the age of 25 I had a carbuncle and the doctor gave me morphine . . ." R. R .... repeated the offence 4 times, in spite of 3 convictions.

Mrs. S . . . . became a drug addict as a result of a pregnancy treated as a hepatic colic. In 1946 she simultaneously consulted several doctors, three of whom did not observe that she was in the seventh month of pregnancy.

X . . . became a drug addict at an early age through proselytism, and was subsequently wounded in the arm during the war. He used his wound as a pretext to obtain prescriptions of drugs. He confessed to the expert, who observed that the scar was even, not painful to the touch and without neuralgic complications: "My arm does not hurt all the time, but I have got into the habit of giving myself injections, in a moderate way, whenever I get a fit of depression."

Mrs. V. M . . . . became a drug addict in 1942 as a result of treatment by morphine-due to a mistaken diagnosis. "I am delighted to have been denarcotized.

I should never have been given those shots." She has not repeated the offence since 1946.

There are also some doctors, though they are much rarer, who treat drug addicts with drugs. Here is Dr. Gouriou's appraisal of the case of N. J.:

"In the East, he smoked up to a hundred pipes a day; on landing at Marseilles, no longer able to get his usual ration, he fell ill. The doctor consulted came to the learned conclusion, on the basis of his analysis of the symptoms noted, that he was diagnosing a case of withdrawal pains, a so-called 'craving', and that this well defined syndrome could be cured by morphine injections. The addict, thus introduced by order of medical authority to an occidental and more modern form of drug addiction, remained faithful to it, save that he exchanged morphine for heroin, the effects of which are similar but twice as intense."

Do you think that these "patients" are grateful?

This is what they say of their doctors:

M. X.: "I went to see Dr. Y . . . . I don't want to pass judgment on him, but I think he is a weak man."

H. D. : "If you only knew how we behave in front of doctors-not at all as we do with you. If they are misguided enough to give us a prescription, we go back in a week. If the doctor gives one person a prescription, he is blackmailed by another who has been given his name, into doing the same; and so he is caught in the web."

Far be it from us to use these examples to evade the physician's problem of pain.

Narcotic drugs are an essential weapon in the therapeutic arsenal, and the struggle against the abuse of narcotic drugs is conducted in France in such a manner as never to interfere with the legal supply of drugs for sick persons.

We consider it absolutely essential that the interests of sick persons should never be harmed in the slightest by either international or national action.

The problem of pain cannot be dealt with within the limitations of this article. What the authors wish to make clear is that though they differ in their philosophies they are agreed that pain is harmful and that it is the duty of the physician to eliminate it. But plain common sense requires that one evil should not be replaced by a greater evil. Of course, that is easier to write than to bring about; but information collected over a period of eight years clearly shows that narcotic drugs are too often prescribed when other treatments could be used-treatments which would be just as effective.

Here is a striking example: until 1947, dihydrooxycodeinone was subject to certain exemptions, so that suppositories containing that substance could be issued without a prescription. Abuses of a patent medicine containing dihydrooxycodeinone having been reported, the exemption was withdrawn. The manufacturer protested that this meant discrimination against his suppositories, suppositories with a morphine base being still exempted at that time. He was given evidence of abuse, but remained unconvinced and decided to make a personal investigation. After an objective survey, he reported back that the information given him had fallen short of the truth; for example, he had found cases of narcotic drugs being prescribed against toothache!

Diagnosis of many types of chronic pain is difficult, and no one will ever criticize a doctor who prescribes narcotic drugs when in doubt. Before a long-term prescription is written, however, it is essential, first, that every possible check should have been applied, and second, that other methods of treatment should have been tried.

It is a commonplace that patients who are in pain and who may legitimately be prescribed narcotic drugs often ask for more than they need. Here are some examples:

Mrs. A. . . . had been the victim of an accident. She told the expert: "I must admit that I have carried the use of drugs to excess; at first one injection was enough for me."

Mrs. F. C. . . . was given prescriptions for dihydrooxy-codeinone in 1945. She was sent to hospital in 1948, stayed in hospital 5 months and left denarcotized. Has not resumed the habit:

"I could no longer distinguish between the pain of 'deprivation' and that of my cardiac condition."

The expert wrote the following opinion on a person suffering from stomach trouble who was charged with drug addiction: "The condition of craving is indeed even more painful than the abdominal attacks, and the combination of the two makes it impossible to report objectively on the development of the abdominal syndrome. The tyranny of the drug is such that the patient exaggerates his physical pain to obtain supplies." All denarcotized addicts admit such exaggeration.

The pain felt in the stumps of amputated limbs is well known. Professor Leriche has written on that subject as follows :11

"This is what should not be done:

"The complaints of an amputee who says that his stump is giving him pain should not be taken lightly.

"He should not be made to wait a long time for a careful examination, which alone can shed light on the mechanism of his pain and provide therapeutic guidance.

"He must not be allowed to become a morphine addict: an amputee addicted to morphine is incurable; however strong-willed he may be, sooner or later he will return to the habit."

Disagreeable as the admission may be, it must be recognized that the real origin of many cases of drug addiction is the incompetence of the attending doctor.

Physicians must therefore have the courage not to take the easy way out of drugs to make up for the absence of a diagnosis. For this reason, they must also take care not to fall too far behind in their knowledge of medical progress.

At the other extreme, we must cite an argument which some physicians have gone so far as to use. It runs more or less as follows: "I no longer prescribe narcotics because I do not want to go to prison."

We have still to be shown a doctor who has been sent to prison for writing legitimate prescriptions. On the other hand, we could point to many offences in good faith and even frauds committed by physicians which have cost them nothing but a mere courteous admonition. In dealing with a drug addict, the physician should try everything before prescribing narcotic drugs. On the other hand, when the disease requires it he should not hesitate to use a medicine whose beneficial effects have been proved.

VI. The role of the pharmacist

The social importance of the pharmacist cannot be exaggerated. His participation in the struggle against drug addiction is a characteristic example of the part he has to play. It cannot be often enough repeated that the best service that can be rendered to a drug addict is to cure him. The moral degeneration of these unfortunates is such, and the methods they use to satisfy their vices are so variously fraudulent, that the weapons which have to be used to cure them may shock the susceptibilities of some persons. Pharmacists, however, must not forget that it is a question of saving the lives of human beings, and that there could be no nobler purpose to justify the means used.

Once the drug addict has more or less fradulently obtained a prescription, he rushes to the pharmacist. A very heavy responsibility therefore rests on the shoulders of that practitioner; one which he alone must discharge. The poison cupboard in general and narcotic drugs in particular must be regularly supervised by the pharmacist, whether he is a dispensing pharmacist or a manufacturer.

This point may be illustrated by two examples. The first is the case of a pharmacist whose employee ordered narcotic drugs without his knowledge. In the second case, a manufacturer of ampoules had an assistant who regularly obtained ampoules of morphine which he wrote off to "manufacturing losses".

A dispensing chemist must in all cases supervise personally the execution of prescriptions for narcotic drugs. He should check their authenticity and make sure that they are written in legal form. If he is in the slightest doubt, he should telephone the doctor and ask him to confirm the prescription.

The pharmacist should always mistrust:

  1. Generally speaking, unknown clients, especially on closing days;

  2. Prescriptions written by doctors who do not live in his district, or whom he does not know, i.e., whose writing and signature he cannot recognize;

  3. Clients living in distant districts, in large cities, or in a different commune, in other cases.

The Decree of 19 November 1948 has given pharmacists in France an effective weapon by requiring them to ask for identity papers if a client is not known to them. This practice has no disadvantages, since pharmacists are bound to observance of professional secrecy. Moreover, the fact that prescriptions of narcotic drugs must be written in a counterfoil book is a serious obstacle to fraud. But what should a pharmacist do when he is certain that a fraud is being committed-when, for example, he is given a false prescription? He should at once inform his inspector of pharmacies, and meanwhile should avoid filling the prescription.

It may be noted that some pharmacists-fortunately they are rare-have thought to solve the problem by systematically refusing to fill prescriptions for narcotic drugs, for example, under the pretext of being out of stock. This attitude is unworthy of a profession whose members daily have occasion to display their high professional integrity. The pharmacist must not be satisfied with a correctly drawn-up prescription; the exercise of perspicacity will often enable him to discover anomalies.

Here is an authentic example: a client came with a properly drawn-up prescription reading as follows:

   
Sydenham's laudanum
 
aa 15 gr.
Camphorated oil
 

This was at a time when there was a shortage of fats and oils, and many pharmacists had no oil. The client, finding that owing to the shortage many pharmacists could not fill his prescription, was in the habit of coming with a bottle already half filled with oil, until one day the attention of an inspector of pharmacies was drawn to the prescriptions, which were in fact false. The obliging client used to pour off the laudanum and use it for injections.

There is one particular case in which a pharmacist can render valuable service: when he realizes that a client is having narcotic drugs prescribed by several doctors concurrently. His duty is to inform either his inspector of pharmacies or the doctors.

In brief, the pharmacist can play a very valuable part in preventing and combating drug addiction. Many pharmacists in France are aware of this and are playing an important part in the detection of drug addicts. There can be no doubt that the effectiveness of the struggle against drug addiction depends to a great extent on the members of the medical and para-medical professions.

VII. ORIGINS OF DRUG ADDICTION

We now come to the general problem of drug addiction. Why and how does a person become a drug addict? What are the contributing factors and what is their relative importance?

Much has been written on this theme.[12]

By making a rough selection amongst this mass of documents it seems possible to distinguish three kinds of hypotheses regarding the psycho-pathological origin of addiction to drugs.

I. First, we give an example of the fantastic extremes to which extra-scientific considerations may lead.

We quote the author's[13] own words in order not to distort his meaning; he draws the following distinction:

"The morphinomane is a pervert, a sensualist, of limited intellectual development, an abnormal creature who gives way to the abuse both of heroin and of alcohol. He is to be found among the dregs of society and in the lowest strata of the big cities.

"The morphinique, on the other hand, is frequently an exceptional individual who belongs to the highest levels of society. He often excels by his cultivated intellect, his standing in his profession and his mental gifts; he may be a distinguished doctor, a well-known politician, a fashionable writer, or a highly qualified naval officer. He discovers that by a sort of affinity of his constitution, perhaps of his gray matter, he has a predilection for morphine and heroin; he has no desire for other drugs. An injection of morphine, given for medical purposes and not at his own request, reveals, to his great astonishment, the beneficial effects of this drug on his organism, his constitution and his general condition. He learns of his need for morphine by pure chance, and the fact that he acquires a taste for it at the first dose is independent of his own volition. He continues to take it from a need to maintain a neuro-vegetative equilibrium until, through the mysterious phenomenon of habituation, he becomes forever a slave to the drug. The hellish cycle has been closed. Thus a well-known dictum is confirmed: nature makes the morphinique and a vital need confirms him in his addiction. It is believed that, unknown to themselves, such persons are subject to permanent disturbances of the 'coenesthetic sense' which can be dispelled only by morphine. It is a surprising fact that, leaving aside the question of habituation, morphine seems to be less toxic for a morphinique than for any other person. The morphinique lives to a good age and does not die of his addiction. The morphinomane, on the contrary, very soon reaches a stage of physical and moral collapse and becomes as repulsive as the leper of old."

The author continues:

"I have reached the conclusion that a complex, varied and often very serious clinical and biological syndrome is created by withdrawal . . . I have also reached the further conclusion that this serious syndrome is observable only in a special class of morphinomanes whose numbers are very limited, namely, the morphiniques.

" Morphinomanes do not suffer in the same way when deprived of morphine; they are more numerous and less interesting." ( sic)

The author himself tells us that these conclusions are the result "of fifteen years of impartial observation", and "of fifteen years of bibliographical research . . .".

This article is full of flagrant errors such as the statement that "morphine does not modify the normal state of the blood",[14] and of contradictions and puerilities such as this: "At present, in the case of an individual who suffers much from the deprivation of morphine, we have only one means of determining whether he is a morphinique or a morphinomane: the test of withdrawal."[15]

And further on he says: "We consider that in the case of morphiniques withdrawal should not be attempted."

II. The proponents of a second theory elaborate it as follows:

"It seems incontestable that in the process of digestion man utilizes both calorific matter and substances that may be termed expendable. The purpose of these latter seems to be either to stimulate the individual to some extent or to enable him at times to escape into dreams. This need, which is found among every social group and in every latitude, may be regarded as a deep instinctive tendency.[16] Drug addiction perverts this tendency and leads to the abuse of these substances which are both exciting and inhibitory.

"Considered under this aspect drug addiction is determined not only by the excessive use of a toxic substance but also by an anomaly or lack of balance in a personality."

Elsewhere the same authors say:

"It is possible to distinguish drug addicts who have no natural predisposition but are in fact attracted to drugs under the influence of external factors. Amongst these latter the importance of the excessive use of emotional traumatism for healing purposes is well known. The professional use of drugs is also highly significant, as stressed by recent works on the origin of alcoholism.

"Besides this category there are the real drug addicts who deliberately choose to live as they do without the compulsion of any external factor."[15]

The same report[16] goes on to say: "A point which has been stressed by many writers is the fact that these patients are incapable of social adaptation" and further on: "This incapacity for social adaptation is only an effect. It is the expression of a profound disturbance of the personality in which various tendencies are unable to harmonize."

For that statement the authors base themselves in particular on a bibliographical study of the psychiatric nosography of drug addiction, where theses put forward by some dozens of authors are noted and where almost the whole psychiatric vocabulary is employed. Generally speaking the psychiatric disturbance precedes the drug addiction and is the basic cause of it.

III. Finally a third theory is summarized as follows:[17]

"The essential effect of narcotic drugs consists in the effacing of painful impressions, whether conscious or unconscious. Physical pain, 'cares and worries', fatigue, feelings of humiliation, sadness, anxiety or despair give place to contentment, serenity, hope, a fugitive and deceptive sense of facility and self-confidence. All cases of drug addiction have their deepest roots in this quelling of an inner malaise, not in the exquisite delights, the incredible refinements of sensibility or intelligence, depicted in literature. The causes of dissatisfaction, discouragement, anxiety and suffering in human beings are unfortunately so diverse, and so constantly renewed that the possibility of effacing or forgetting them, even for an hour, will always offer a marvellous temptation, an illusory and facile paradise.

"But it is also at times a road of no return. If circumstances or an underlying predisposition encourage the individual to repeat the use of the drug, the return to lucidity, to contact with reality, painful enough in itself, is complicated by a secondary effect. Soon, by an apparently biological process (it has been found possible to produce cocaine addiction in monkeys) the absence of the drug creates a diffused organic malaise, a sort of anxious hunger, which is called the craving. This reinforces the causes which were responsible both for the individual's recourse to the drug and for its special effect on him. Irresistibly it drives sufferers to another offence and renders withdrawal excrutiatingly painful, indeed almost impossible if the addict is left at liberty. Very soon a vicious circle takes form: the drug itself calls for the drug, and by force of habituation larger and larger doses only bring increasingly incomplete and ephemeral relief.

"The intoxication-no longer now the subjective impressions produced by the drug but its direct harmful action on the organism-little by little takes deeper root and brings fresh sufferings.

"The craving becomes ever more imperious. Efforts to obtain the drug and the use of it monopolize the addict's time. His pressing irresistible need, together with the continuous anaesthesia, as it might be called, which the drug induces, lead to deplorable acts. To procure the drug, the addict wheedles, implores, lies, robs and brings his family and friends to despair and ruin. He often degenerates completely and sometimes ends up in physical and moral collapse."

We could quote a number of American authors to the same effect; suffice it however to cull from the American experience, the most extensive in the Western world, the following observations in support of this theory:[18]

Adolescents of thirteen to nineteen years of age do not have emotional difficulties or personality disturbances sufficiently marked to justify a diagnosis of psychiatric mental disorder. This, of course, does not take into account disturbances caused by drug addiction itself and its consequences.

sufficiently marked to justify a diagnosis of psychiatric mental disorder. This, of course, does not take into account disturbances caused by drug addiction itself and its consequences.

Amongst these theories where do our own observations lead us? All the studies we have been able to carry out incline us to the third theory: it is not essential to lay particular stress on the fact that man cannot be isolated from his environment and from nature-as is done by the sponsors of the first two theories quoted. Similarly, such researches as we have been able to carry out have not convinced us that drug addicts are already almost always mentally sick before they acquired the craving. It is undoubtedly true that unbalanced persons are an easier prey to drugs than normal persons; but mental unbalance alone is not enough, nor does it explain all the facts. Previous mental disease is not an invariable feature of drug addiction. It is of course only too easy to take the effect for the cause; for naturally it is quite undisputed that a person who has become an addict shows psychic abnormalities and may be considered as mentally unhinged.

It would appear that drugs are never an end, or a beginning, but only a means. Consciously or not, what the drug addict seeks is to dull the effects of either a physical or a psychic unbalance (indeed the trouble is almost always both physical and psychic) such as physical or moral pain, anxiety, social maladjustment, inadequacy of any sort, etc.

Unable to achieve a stable balance, the drug addict generally seeks forgetfulness of his misfortune and an escape from life; sometimes, too, he tries to fill the void of a joyless existence. Here are some statements by addicts:

M. V. . . . "Like all of us there is only one thing I want: to lie in bed quietly, have my shots and enjoy not suffering."[19]

M.A. . . . "I started taking drugs because I felt I was different from other people; to put a screen between life as it is and what I am."

M.S. . . . "It's when I have nothing to do that I tend to start taking drugs."

Mrs. O. . . . "I can't deny the pleasure I get from the hour's relaxation a pipe of opium gives me. It lifts me above things and consoles me for the worries of the day. I would compare it to the relaxation you get from a moment of prayer in church.''[20]

A.L. . . . "It's the feeling; it's a sedative for your anxieties and worries . I really smoke for no reason at all."

Later on the effect itself becomes the cause: whatever the reasons that led to the addiction and even if they disappear, the addiction remains. Moreover, very often it runs ahead of its causes. The addict then suffers most of all from the state of craving, and the only remedy he knows is the drug.

Two elements go to produce the phenomenon of "addiction": there must be the individual, i.e., the drug addict, but there must also be the drug. This commonplace is very often overlooked.

There is probably not a single person who, subjected to fairly prolonged treatment with drugs, would not become an addict.

No one is entitled to make any prediction about a case of drug addiction until he has eliminated the determining element, i.e., the drug.

The cure of an addict depends, then, on the discovery of the reasons which induced him to use the drug. There are no generalizations here; only individual cases.

The quest for euphoria as such is extremely rare. Dr. X . . . , an addict, states in this connexion: "I do not try to achieve euphoria-that is a myth; you only get it at the moment of injection, because the state of craving ceases."[21]

How many artists believe that they find inspiration in narcotics? Here is what M.B., a painter, says: "I take drugs from a need to achieve a sense of well-being, of lightness; then I get habituated and lose all sensation; I increase the doses, and then all I satisfy is the craving."

Dr. M. . . . "You increase the doses in order to escape being left face to face with reality."

Avoiding schematism, we can now, for purposes of analysis, distinguish two main classes of drug addiction:

  1. Addiction of therapeutic origin;

  2. Other types of addiction.

As we have seen, the former class comprises cases of addiction contracted in the course of medical treatment, cases which in a very general sense are connected with the need for the alleviation of physical pain. For subjects of this kind, drug addiction is only a harmful habit not resulting from any psychic abnormality.

Cases of the second class originate from causes which undoubtedly lie within the field of psychiatry, but of a psychiatry which must not forget that it is a branch of medicine, and which must in addition be supplemented by a sound knowledge of sociology.

There is nothing absolute in this distinction. A drug addict of the second type may very well make his first contact with the drug on being treated for an illness.

In other words: because of their lack of balance, some individuals offer favourable soil for drug addiction. But this is not a "deep-rooted tendency of the individual"; it is itself conditioned by organic physiological or social factors that must be determined if the patient is to be cured.

With regard to social factors, the authors, at the beginning of this study, brought out objective data relating to the sex and age-distribution of addicts, their occupations and the influence of the social environment.

Doctors should accordingly take this information into account when they are called on to prescribe drugs.

The authors have no wish to disguise the complexity of the problem: drug addiction may be caused by an infinity of factors. Yet it involves one easily accessible element: the opportunity to procure the drug itself. We repeat, therefore: no drugs, no addiction; a truism, of course, but a pregnant one. It is on this simple idea that the soundest system of prevention must be founded.

In our disturbed age, how many of us would become addicts if we were in contact with narcotics? If we think of the considerable spread of drug addiction caused by the last two world wars, we will readily imagine the catastrophe which would be brought about by any sudden termination of narcotics control. The absolutely essential thing is to do everything possible to ensure that individuals have no contact with drugs. That must be the aim of the public authorities in their effort to combat the clandestine traffic. But it must also be the aim of all physicians, who have the power to dispense drugs; that is one of the many grave responsibilities of their art.

VIII. DRUG ADDICTION AMONG DOCTORS

The number of addicts among doctors is high as compared with other groups. Fifty-eight cases were discovered in the Paris area alone. Yet none of them can be ignorant of the effects of narcotics. This has been the position since the use of morphine for therapeutic purposes was first introduced.

Analysis of 35 detailed case reports available to us has shown that 3 doctors were suffering from an illness justifying treatment with narcotics.

Twenty-three had started taking morphine for very questionable medical reasons.

Twelve had no medical reasons.

The most widespread cause is professional over-work; pain takes on alarming proportions when a doctor has to respond to a night-call or to start seeing patients again after an exhausting round of visits. At such a time, to stand the strain, the doctor takes a shot of morphine. "I know what morphine is; just one, that's all, just enough to dope me for an hour." . . . such is the downward path leading to a ruin worse for a doctor than for anyone else.

A case in point was that of a doctor who prescribed heroin for almost all his patients, gave them a few useless injections and kept the rest of the ampoules for himself. Another doctor extracted the morphine solution from the ampoules at hospital and replaced it with distilled water.

But this painful problem can be solved only within the medical profession itself.

IX. RECIDIVISM

In conclusion we should like to discuss the problem of recidivism.

Figure 4

Full size image: 2 kB, Figure 4

The curves in the above graph (figure 4) show that the decline in the number of recidivists is more gradual than that of the number of new cases. This feature is strengthened by the fact that most recidivists relapse after a number of years, and sometimes several times in the same year.

This would appear to be attributable to three causes:

  1. A sound system for the control of narcotics and the suppression of the illicit traffic has been in existence in France, particularly since 1946. It operates as an efficient preventive of drug addiction.

  2. A large number of denarcotization cures are ineffective.

  3. (The most serious factor) Addicts now take special precautions to evade . . . satistical registration.

The problem of the denarcotization cure is very complex. It need only be pointed out here that after a denarcotization cure in a hospital, the patient will inevitably relapse if the causes of addiction continue to exist. Moreover, if the environment is a predisposing factor, as in the case of prostitutes, the same causes will produce the same effects. That point was put tersely by a prostitute whose only excuse was: "I went back to Montmartre", or by another who said: "I stayed for too short a time at La Roquette".[22]

The denarcotization of an addict, therefore, is a longterm task which should be carried out only by a specialized institution with the assistance of the family doctor and the patient's kin.

That view is endorsed by specialists such as Dr. Vogel, who has devoted himself to the cure of addicts, the essential element of which, he believes, is readaptation. Vogel states that the second phase of treatment (after the process of denarcotization in the strict sense) is the most important part of the programme. "Its aims are to restore self-respect and self-confidence, in an entirely new way of life, to make a complete and radical break with the subject's past way of life. The action taken varies according to the needs of each patient. The medical staff must follow the development of the treatment of each subject very closely, and may suggest or prescribe a complementary psychotherapy or rehabilitative treatment when one or the other appears advisable."[23]

Generally speaking, this phase of rehabilitation involves the subject's introduction to a new kind of life, and often, in particular, his apprenticeship to a new trade suited to his aptitudes. At the Lexington (Kentucky) hospital for drug addicts this method has given good results, and the remarkable successes reported in this field show that until all the means already at our disposal have been put into effect any pessimism is unjustified.

CONCLUSIONS

Analysis of the cases of addiction brought to light in France, particularly in the Paris area, gives evidence of the important part played in the etiology of drug addiction by the factors of age, occupation and environment.

Although Paris is the centre of the illicit drug traffic in France, and although there exist in the capital milieux especially favourable to the propagation of the drug habit, the proportion of cases of therapeutic origin is very high.

Detailed study of cases of addiction, on the basis of expert medical examination, shows that the abuse of drugs, at least in cases of therapeutic origin, is not necessarily caused by psychic disturbances.

Moreover, it is not established that the mental disturbances noted in certain addicts are characteristic of drug addiction.

The cure of an addict seems to depend directly on the determination of the factors which occasioned his addiction. Such factors are of various kinds: organic, physiological, psychic or social.

However, there remains one element which is susceptible to direct action: the drug, without which addiction cannot exist.

Accordingly, any system of prevention, whether operated by the public authorities or by the medical profession, must begin with the restriction of the use of narcotics to the strict minimum necessary for therapeutic purposes.

Of course, substantial progress is still possible in this field. The responsibility of the medical profession is involved.

1

For example: at the 1946 census there were 3,362,000 persons between twenty and twenty-four years of age; 3,054,000 between 35 and 39 years and 1,710,000 between 65 and 69 years. By reducing all these age-groups to 10,000,000, we obtain:

Whereas, the uncorrected absolute figures were:

The differences are not negligible.

2

Population in 1946, 4,775,711.

3

Generic name given by North Africans to preparations of cannabis.

4

These statistics reveal nothing new but for this fact, and confirm the conclusions of this study. In 1953 the number of addicts detected in France amounted to 129, to which must be added 22 North Africans smoking kifand 9 Chinese smoking opium. Of the 129 addicts, 82, including 32 in Paris. were discovered for the first time, and 47, including 22 in Paris, were recidivists.

5

Gordon H. Josie: A Report on Drug Addiction in Canada, Department of National Health and Welfare, Ottawa. 1949.

6

In 1953, 16 per cent of the new drug addicts in France and 12 per cent of the recidivists used pethidine. This trend is becoming more marked.

7

Aspect d'actualite des toxicomanies in Recueil des Travaux de l'lnstitut National d'Hygiene, published by Masson, 1950, volume IV, part 1, pages 437 et seq.

8

We are glad to have the opportunity here of expressing our gratitude and admiration to Dr. Gouriou for the help and encouragement he gave us in our work and also for the competence which he has always shown in this highly specialized field of drug addiction.

9

Patent medicine based on full-strength extract of opium.

10

Authors' italics.

11

Professor Leriche: La chirurgie de la douleur, Paris, Masson and Co., 1940.

12

See especially the interesting bibliography of the article by P. Desclaux, L. Derobert and R. F. Katz: Aspects d'actualité des toxicomanies, 25th Congress of Forensic, Social and Labour Medicine, Bordeaux, 11-14 May 1949 (I).

13

J. F. Hayat: Morphinomanes et morphiniques - La Semaine des Hôpitaux, no. 63-64, 25-30 August 1952.

14

For example, for the action of morphine and heroin on glycemia, see Ch. Vaille: Contribution à l'étude des hyperglycémies medicamenteuses ou toxiques, Paris, 1937.

15

Our italics.

16

P. Desclaux, L. Derobert and R. F. Katz- op. cit.

17

Dr. L. Le Guillant: Les toxicomanies, Pages Sociales, no. 23, 1947.

18

See especially the works of Dr. Victor H. Vogel.

19

See P. O. Wolff: Quelques aspects actuels de la toxicomanie; Journées Thérapeutiques de Paris, 1950.

20

Our italics

21

Our italics.

22

Women's prison in Paris.

23

Retranslated from French (Translator's note).