Some Aspects of the Social Medical Problem as seen by the General Practitioner

Abstract

The problem of drug addiction is extremely important nowadays, because of the very various factors, chiefly social and economic, which produce individual and collective moral disorders. It is therefore imperative that the general practitioner should be acquainted with the core of the problem, the pathogenesis of addiction and the complex of phenomena of which it is composed, so that he may be able to deduce measures of prevention and cure.

Details

Author: Demetrio Mayoral Pardo
Pages: 21 to 22
Creation Date: 1954/01/01

Some Aspects of the Social Medical Problem as seen by the General Practitioner

Professor M.D. Demetrio Mayoral Pardo Director-General of the Department of Health and Welfare of Mexico

The problem of drug addiction is extremely important nowadays, because of the very various factors, chiefly social and economic, which produce individual and collective moral disorders. It is therefore imperative that the general practitioner should be acquainted with the core of the problem, the pathogenesis of addiction and the complex of phenomena of which it is composed, so that he may be able to deduce measures of prevention and cure.

Before entering into the substance of the matter it may be useful to define some terms. Cardenal defines the Spanish word toxicomania (drug addiction) as "an irresistible urge towards poisons, in particular narcotic substances". Hábito (habit), he says, is a custom or practice acquired by frequent repetition of the same act, and habituación (habituation) is gradual adaptation to a stimulus or to the environment.

The definition of the word toxicomania essentially implies a substance which enslaves, an uncontrollable desire for it, and an increasing tolerance of its effects. Tiffeneau suggested, to express slavery to a drug or poison, the term asuetud(habitude, addiction); this is better because it avoids the word "mania" (mania, madness), which rather has the meaning of mental illness or excessive preoccupation (e.g., erotomania, dipsomania). "Toxicomania"would thus be distinguished from "acostumbramiento" or "habituación", which imply that a person is habituated or used to a drug but not dependent upon it as a necessity.

Aristotle said that habit or use was a type of behaviour of a permanent nature. By repetition it tends to become automatic, and thus the repeated use of an organ or function in a particular way and the repeated performance of an act or operation give rise to a habit.

The World Health Organization's Committee of Experts on Drugs liable to produce Addiction probably had similar considerations in mind when it defined habituation (acostumbramiento) to drugs as follows:

"A habit-forming drug is one which is or may be taken repeatedly without the production of all the characteristics outlined in the definition of addiction and which is not generally considered to be detrimental to the individual and to society."

Thus such euphoric drugs as tobacco and caffeine- like substances are included in this category.

The Committee of Experts defines drug addiction (toxicomania) as a state or periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated consumption of a drug (natural or synthetic) causing:

  1. An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means

  2. A tendency to increase the dose (as a result of tolerance)

  3. A psychic (psychological) and sometimes a physical dependence on the effects of the drug (addiction or slavery).

Thus the definition sets forth the characteristic phenomena: tolerance, and physical and psychic dependence. The first concept explains how the addict's organism can tolerate enormous doses, sometimes much greater than the lethal dose; physical dependence enables us to understand the spectacular and sometimes fatal effects (psychosomatic syndromes) of abstinence from the drug. Psychic slavery or dependence results from the characteristic feeling of well-being and euphoria which creates in the patient the irresistible desire to continue to take the drug in ever-increasing doses.

It should be pointed out that strictly speaking the only drugs which should be called drugs of addiction are those which cause addiction without fail, inevitably, when used over varying periods in average doses. For example, tobacco may apear to be indispensable to a smoker, and abstinence from it may cause more or less serious disturbances and disorders; but these depend basically on the individual and his temperament, not on the drug itself. The effects of morphine are entirely different. Any physically or psychically normal person who uses morphine regularly for some time is thenceforward tragically compelled to continue its use, for it has become indispensable to the tissues and cells of the organism. Abstinence, by disturbing the cell-drug balance which has been set up, will cause functional and organic disturbances which are always serious. One might almost say that a drug of addiction acts as a cell constituent-in fact, as an integral part of the organism. This explains the intensity and seriousness of abstinence phenomena.

What, then, are the factors causing the present increase in drug adiction? The answer is, perhaps, that an unbalanced social structure, terrible economic and social injustices, loss of moral values and disappearance of the sense of responsibility all cause irreversible biological changes in the personality.

To these factors may be added the disrupting impact of the world wars, the tension and anxiety which have marked this post-war period, increasingly-distressing economic problems, and other ills. It is then easy to understand that the degradation of human values and the intensely aggressive temper of this age of haste and anxiety cause an individual who is constantly assailed by harsh reality to yield to the instinct which tempts him into the attractive paths of phantasy opened to him by the drug-which indeed society itself seems to offer him as a discreditable sort of compensation.

Since one of the tendencies of present-day medicine is to look beyond the study and treatment of the individual patient to collective problems, drug addiction should interest all doctors, as well as public authorities and society in general. A doctor therefore needs to know the basic facts about this very disturbing problem and to apply prophylactic measures, which are always preferable to treatments of doubtful value.

Further, the assumption by the State of many social medical problems which used to be dealt with only by doctors and voluntary societies has meant that public health authorities now tackle the problem; but unfortunately they often do so only from the penal or police point of view, without squarely facing the relevant facts of human structure and biology.

They give the impression that society is being protected, but all they do is to isolate the drug addict by unilateral action, wrongly assuming that his addiction to the drug arises out of a moral degeneration which he could remedy by an effort of will. They forget that society itself is responsible to a certain degree, since it has been unable or unwilling to raise the cultural level of all its members. An insolent display of money, frequently ill-gotten, inflames the craving for wealth and material pleasures. This, being frustrated, sets up personal conflicts and serious behaviour problems which tempt the individual to escape into phantasy by means of drugs.

Biological and human discontent, failure to satisfy complex appetites, non-acceptance of pain and suffering, undoubtedly lead the unwary and those lacking in spiritual human values to resort to the artificial paradises provided by alcohol, marijuana, cocaine and morphine.

Many doctors still regard the drug addict only as a nosological entity and do not allow for the biological and social factors which have produced him. That is the traditional attitude and should not exist. In these times drug addiction should be regarded as a genuine social illness, since most of its etiology and pathogenesis consists of disorders produced by civilization and by economic and social inequality in individuals who are discontented, who lack the spirit of struggle and sacrifice, and whose moral values are very defective.

This moral and cultural background of the drug addict is ignored and an attempt is made to appeal to his will and to impose upon him the same obligations as a normal person. Thus treatment fails-not only, be it noted, in poverty-stricken environments such as our own but even in economically-privileged countries like the United States.

I repeat that it is infinitely more desirable to tackle the serious problem of drug addiction, like that of contagious diseases, by prophylactic and preventive measures: that is, to deploy all the resources of the State in a determined attack on the illicit drug pedlars who dominate the susceptible and the addicted.

Medical students should be emphatically warned against the dangers of using drugs capable of causing addiction, and shown how easy it is in most cases to use other analgesic prescriptions in order to avoid such drugs as morphine, the prolonged use of which causes addiction.

It is to be hoped that public health authorities will ruthlessly hunt down illegal traffickers, and also restrict the use of these drugs even for lawful medical purposes.

There should be an international campaign not only to restrict production of drugs causing depression or addiction, but also to abolish most of them outright, as in many countries heroin has been abolished.

Let us hope that before long the pharmacologist, improving on the marvellous laboratory of nature by removing and adding radicals, will finally produce what Professor Pablo Oswaldo Wolff, of the Argentine, has called "eumorphine", so that the doctor, in obeying the divine command to relieve pain, will not expose humanity to the danger of drug addiction.

Mexico, August 1953