Treatment of drug addiction. Experience in India

Sections

General considerations
Treatment of drug addiction under Indian conditions: Different forms of treatment
Results of treatment with lecithin and glucose: Mass scale trials
Summary and conclusion

Details

Author: Sir Ram Nath Chopra , I. C. Chopra
Pages: 21 to 33
Creation Date: 1957/01/01

Treatment of drug addiction. Experience in India

Sir Ram Nath Chopra Drug Research Laboratory, Jammu-Kashmir
I. C. Chopra Drug Research Laboratory, Jammu-Kashmir

General considerations

Although drug addiction existed in the past on a more extensive scale in India than in any other country in the world, with the possible exception of China, relatively little attention was paid to its scientific, medical and social characters. Two commissions were indeed appointed to go into the matter during the last decade of the past century; a royal commission was appointed in 1893 to enquire into the prevalence of the opium habit, and a commission to investigate the question of cannabis drugs was appointed by the Government of India in 1895. These commissions collected a vast amount of valuable general information regarding the prevalence and effects of these drug habits, but unfortunately the medical and scientific aspects were not considered. More than sixty years have elapsed since these commissions did their work. Considerable changes have occurred since then in the two chief drug habits, those which relate to opium and cannabis. New drug habits have come into being. In spite of this, a study of the literature shows that very little attention has been paid to the problem, except perhaps that which is described in the limited studies made by the senior author of the present article and his colleagues. There is hardly any other reference to the drug addiction problem in the medical literature of India during recent years.

The habitual use of stimulant, sedative and euphoric drugs was probably prevalent in India before it was in any of the other countries of the modern world. The "Soma" juice was a favourite drink of the ancient Aryan settlers, and was regularly taken by them centuries before the Christian era. What exactly the soma plant was is not known, though a number of plants, such as Cannabis sativa, Ephedra vulgaris, Asclepias acida have been mentioned. During the Hindu period - i.e., up to the eight or ninth century - alcoholic beverages were commonly used, as well as the preparations made from Cannabis sativa. These not only produced sedative effects, but also brought about euphoria in the form of pleasant dreams, forgetfulness, feeling of power, and also, it would appear from the writings of that period, voluptuous satisfaction. The opium poppy and the opium itself were introduced on the west coast about the ninth century with the arrival of the Mohammedan traders, and opiates soon came into use. Opium, on account of its strong effects, appears to have taken a great hold of the people, and the poppy began to be extensively cultivated all over the country. Opium was eaten, drunk or smoked by all classes of society. A most pernicious feature was that it was given to infants to keep them quiet while the mothers were away at work. The authors have reviewed the habitual use of opium and cannabis drugs in India and its relationship to the quasi- medical use of these drugs in the country in papers already published in the Bulletin on Narcotics.* In the present paper, the object is to describe the authors' experience in the treatment of these and other common drug habits in India.

Special Features of the Problem

The problem of drug addiction in India presented many features which differed widely from those met with in western countries. In India, the drugs were generally used in a crude form and were mostly eaten, though smoking of opium and cannabis drugs was quite common. Purified alkaloids of opium were rarely used for their euphoric effects.

Habitual use of cocaine started quite accidentally three-quarters of a century ago in Bihar State. In spite of severe restrictions imposed on the importation, possession and sale of this drug by the Government of India, the habit spread from Calcutta along two main railway routes to Uttar Pradesh, Delhi, the Punjab, and to the north-western frontier (now in Pakistan). From Bombay, it spread to other large towns in that state, such as Surat and Ahmadabad. This drug was almost invariably taken orally, generally wrapped in betel leaf. It was hardly ever taken by injection or as snuff. During the period between the first and second word wars, the habit spread extensively and became a menace.

Of the other drug habits, the chloral hydrate habit deserves particular attention. It started when the price of spirituous drinks rose on account of increased excise duty. Most of those who drank alcohol habitually, especially the lower strata of society, took it for its intoxicating effects. When the price of alcoholic drinks went up, the ingenious idea of adding a gramme or so of chloral hydrate to the drink occurred to the drinkers, and the habitual use of chloral hydrate thus started in a limited area in the Punjab state. The drug was also taken in tea. Chloral hydrate is cheap, but toxic; and fatalities have occurred from its habitual use.

The habitual use of barbiturates and other similar drugs was and is very rare in India.

It is worthy of note that drugs used habitually in India were mostly raw or crude products. In many cases, they had to be prepared by the addict himself before use, which in itself limited their excessive consumption. Further, by using crude products, the addicts absorbed comparatively smaller quantities of the active principles which were responsible for producing the euphoric, narcotic and toxic effects.

Vol. VII, No. 3-4, and Vol. IX, No. 1.

A large number of addicts from the lower strata of society were so poor that they had not the means to carry the indulgence of even these crude and cheap drugs to excess; the upper classes were temperamentally more moderate. Besides, India is pre-eminently an agricultural country, which makes it possible for the majority of its inhabitants to lead a comparatively free and easy existence. The strain and stress of life which drive other people to the habitual use of sedative drugs is not very great.

In spite of all these factors, the problem of drug addiction assumed very great importance from its very extensiveness. The magnitude of the problem may be judged from the fact that, whereas in most of the countries in Europe and America the addiction rate of the population was from 0.1% to 0.2% or even less, in many states of India the rate was 1% to 3% or even more till recent years - i.e., the period between the two world wars. The drug habit was responsible for much economic loss, but also led to physical and mental deterioration of the habitues, thus making it a serious health problem.

Another noteworthy feature of drug addiction in India, especially in so far as opium and cannabis drugs are concerned, was. the religious and social aspects of the problem. Indulgence in opium on account of age-long usage and custom was sometimes compulsory on such occasions as marriages, deaths and social gatherings among certain classes. Cannabis was considered to be the food of the gods by some, and was offered in temples on religious festivals and ceremonial occasions. Some religious sects took these drugs in the belief that they help the individual indulging in them to free his mind from worldly distractions, and in this way to concentrate on the deity. This is the reason why in places of religious worship, such as Benares, Mathura and Puri, there was enormous consumption of these drugs which still persists, though such use has decreased considerably during recent years (Chopra & Chopra, 1955 and 1957).

The medical and quasi-medical use of opium and cannabis drugs was also a very important factor. In a vast country such as India, where the facilities for medical relief were poor, the majority of the population did not get the benefit of western medical science. Sedative drugs such as opium and cannabis preparations were largely used as household remedies, and habits were often formed from such use. The doping of infants with opium could partly be attributed to this. It was firmly believed by the ignorant masses that opium was a wonderful tonic for children, stimulating growth and preventing sickness. The present writers have discussed fully the medical and quasi-medical uses of opium and cannabis and the large variety of conditions for which these were used as household remedies (Chopra & Chopra, 1955 and 1957). Almost all the diseases for the relief of which opium and cannabis drugs were used were of a minor character. Often the drugs were taken to dry secretions from the conjunctiva and the respiratory tract. Many people suffer from toxaemias of focal sepsis, which produce pains of rheumatic and neuralgic type, mental depression, irritability and hypersensitivity of the nervous system. These drugs in small doses gave relief, and this occasionally led to habitual use.

Opium was believed to allay fatigue and even stimulate physical energy. Those who had to manage coolies in teagardens and labourers in rice and wheat fields in India appreciated the value of these drugs to those who had been exposed to cold and chill. The present writers found that in former times the use of opium often increased during the harvest season in many districts in the Punjab by as much as 50%.

Drug Addiction and the Medical Profession

The medical profession in India was unfortunately not very well informed on the subject of drug habits and their treatment. During the course of their work in different parts of the country, the present writers came across few medical men with any considerable knowledge regarding the harmful effects of habitual use of drugs or of the phenomena which accompany abstinence when the drugs are withdrawn in order to rid addicts of the habit. The general impression appeared to be, "Once a drug addict, always a drug addict; he is incurable and that is the end of him." Ordinary hospitals generally refused to admit drug addicts for treatment. The few mental hospitals that existed were not suitable, for many reasons. There were no specialized institutions anywhere in India, and institutional treatment of addicts under expert guidance was unknown. It would certainly have been an advantage if some institutions of the type of abstinence sanatoria found in western countries had been established in areas where the incidence of drug addiction was high, so that treatment could be carried out on scientific lines. There is no doubt that the public would have taken advantage of these institutions. The present writers' experience, so far as the treatment of drug addiction is concerned, was therefore limited to the non-institutional method.

It is indeed fortunate that the importance of prophylactic measures as preventive of drug addiction has now been fully appreciated by the medical profession in India, and most habit-producing drugs are now used with great care. While an analysis of histories of drug addicts in western countries shows that the medical man has sometimes been unwittingly responsible in starting addiction, in India the present writers have not come across many cases in which addiction to opiates or cannabis drugs could be attributed to their use by medical practitioners in the first instance. With cocaine and morphine addiction, however, this has occurred quite frequently. In India, where addiction to crude drugs was in vogue and addiction to purified substances was uncommon, the prophylaxis by the doctor does not play such an important part as in western countries. The stringent restrictions imposed by the Government on the distribution and sale of narcotic drugs (opium and its derivatives, cocaine, etc.) has to some extent safeguarded the spread of addiction to purified substances. Such drugs are not allowed to be sold except when prescribed by a qualified medical practitioner; the dispensing chemist has to keep a careful account of every grain of the drug sold in books kept for the purpose, which are frequently examined by the excise authorities.

Type of Drug Addicts to be treated

From the point of view of treatment, the drug addicts in India can be divided into three main groups:

  1. There is a large group which uses opium or cannabis drugs in small or very moderate quantities. The majority of these started the drug after middle age, generally for some minor disease or ailment. They usually started with a small dose and did not increase it. The narcotic and the euphoric effects of the drug have no attraction for them; indeed, these were not produced in this group at all. The habitues thus have not the temptation to increase the dose, in fact they fully appreciate the evil effects which could result from such an increase. Most of them are good and successful citizens, and carry on their daily work quite efficiently. The present writers have known numerous persons who have taken small doses of opium (half a grain or so) or cannabis drugs for twenty to thirty years without any apparent harm, and have lived to a ripe old age. The use of the drug was started during the middle period of life for some minor ailment such as cough, looseness of the bowels, mild joint pains, etc., and it was found that it afforded relief. It appeared to do no apparent harm and was therefore taken daily. As a matter of fact it appeared that the drug was actually doing them good, as its discontinuance made them ill and prevented them from carrying on their ordinary work. It stands to reason that, when a person can lead an active and useful life on fixed and unchanging doses, there could hardly be any mental or moral deterioration. Treatment in this group, which was not insignificant in the old days, would appear to be quite unnecessary. Some of this group, however, gradually increased their doses and suffered from the effects of the drug. In such cases only was treatment desirable or necessary.

  2. The next group - and a very large one - consisted of those who owed their entry into the paths of addiction entirely to association with and the example of other addicts. Some of these were normal individuals who were anxious to be treated, and they responded quite well to treatment. A proportion, however, started the habit from idle or deliberate seeking after new sensations. They took to the drug for its pleasure-giving effect and for sexual stimulation; these people were generally found in large towns. Many of them had some defect in their character and mental make-up, and appeared to be engrossed in furthering their indulgence and increasing the doses. They also had a tendency to indulge in more than one drug at the same time - e.g., alcohol and opium; alcohol and cocaine; alcohol, opium and cannabis drugs. This class of vicious addict was the most difficult from the point of view of treatment. Fortunately, this type, corresponding more to those met with in western countries, was not commonly met with in India. The few that existed belonged generally to the rich and indolent classes. They did not seek treatment, and nothing short of forced confinement in a special institution and prolonged training and reconstruction of character would restore them.

  3. There was the third smaller group of habitues who had started using the drug in an attempt to tide over a period of special strain, overwork and fatigue. This class of addict was the product of large towns, and their percentage was not nearly so high in India as in the west. This was the class anxious to get rid of the habit; they were easily amenable to treatment, and did very well even under non-institutional treatment.

Treatment of drug addiction under Indian conditions: Different forms of treatment

It may be stated at the outset that the term " cure " used throughout this paper is in the limited sense of successful complete withdrawal of the drug of addiction. It was not possible for us to keep the treated addicts under observation for sufficiently long periods to be sure that a radical cure had been effected and the habit permanently eradicated. Besides this, we had no facilities to carry out the after-treatment, which is absolutely essential, following the withdrawal of the drug. Nor was it possible for us to give them rehabilitation treatment which is an essential factor in the production of complete cure. This was the case in the small preliminary series of 200 addicts who were treated in the Carmichael Hospital for Tropical Diseases, and more so in the case of the mass treatment which was carried out in Assam.

Sudden and Gradual Withdrawals

The withdrawal of the drug by the " sudden " method advocated by Bonhoeffer has been recognized to be scientifically the best method of treatment in some countries. In spite of the success achieved with it in Europe and America in special institutions for the purpose, it has not been possible to carry it out in India. We have tried the method, but have met with little success. The reason is that the conditions under which the addicts were treated were far from ideal. There are no specially equipped institutions in India where addicts undergoing this form of treatment can be housed and can have all the facilities to help them through the critical period of withdrawal. The post-withdrawal insomnia and the digestive and other troubles have been extremely distressing and have needed careful and efficient handling. Some of our patients had to be treated in the wards of an ordinary hospital. Some were treated in their own homes, where the success of such treatment was doubtful from the beginning. Our experience, therefore, with regard to the "sudden withdrawal" method is limited and unsatisfactory from every point of view. Although we have no personal experience of such treatment in specialized institutions, we have no hesitation in saying that, as far as Indian addicts are concerned, the sudden withdrawal under existing conditions would imply a period of frightful physical and mental suffering which the majority of them would be unable to bear. The shock of sudden withdrawal would be too much for many of the addicts, and even those with strong will-power, determined to get rid of the habit, could stand it only with difficulty. It would make the most willing and determined of them lose confidence, and they would end by refusing to go through with the treatment. Their suffering would make them lose their faith in the treating physician, and they would become distrustful and hostile, so that it would become difficult to establish friendly relations or to inspire confidence in them. We have often heard inveterate opium eaters remark that they would rather endure hell than the abstinence syndrome. Experience in India is in accord with that of many authorities in the west who consider that the patients subjected to harsher methods of treatment, such as locking them up and letting them "suffer it out" are the very ones that are more likely to relapse and go back to the habit.

These remarks apply to the opium addicts only. In the case of cannabis drugs, cocaine, chloral hydrate, etc., sudden withdrawal can be carried out under non-institutional conditions, in the case of Indian addicts, without any great difficulty.

In opium addicts, we have met with a great deal of success with the slow or gradual withdrawal method. There is no doubt that whether the process of withdrawal is gradual or sudden, a great deal of suffering has to be undergone by the addict. Administration of other drugs in any amounts will not completely eliminate the distressing withdrawal syndrome. With the gradual method, however, the pain and discomfort of actual withdrawal are reduced to the minimum. If due attention is paid to the psychological side of the treatment and the patient is assured that the physician thoroughly understands his trouble and is doing his best to relieve him of his sufferings, the chances of a permanent cure are greatly enhanced. The patient may even carry not very unpleasant memories of his restoration period. Another advantage is that the post-withdrawal insomnia, which is an extremely distressing condition, is much less frequent. Moreover, under conditions existing in India, it appears to be the method of choice. If the withdrawal is effected with reasonable celerity and with as little discomfort to the patient as possible, it will encourage other addicts to seek the treatment, and those who have relapsed may also return.

While it cannot be said how long it would take an Indian patient to be cured, if he were to undergo treatment in a properly equipped institution by the sudden withdrawal method, the experience of many European institutions is that at least a three months' stay is necessary. The adoption of such treatment would therefore be very expensive for a country such as India. Our experience is that with the slow withdrawal method it takes three to six weeks to effect a cure in most of the Indian addicts who are going to be cured. The decrease in dosage is carried out very gradually at first, so that it is imperceptible. After a few days it can be effected more rapidly, especially if some pill such as that containing nux vomica, gentian and black pepper is given as a substitute. The substitution is started with the morning dose at first, leaving the evening dose untouched; this procedure prevents insomnia. Minor symptoms such as diarrhoea, epigastric pain and nausea may be controlled by giving ordinary alkaline mixtures. Usually in three to four weeks the drug can be entirely stopped.

It cannot be denied that in spite of all precautions there are a large number of failures. In many cases when it appeared that all was going well, it was suddenly discovered that the patient was secretly obtaining a supply of the drug. The ingenuity shown by the addicts in this connexion, and the extraordinary way in which they evade those on guard, are amazing. The chances of the treatment's being prematurely suspended are also great. Even by the slow method the withdrawal cannot be effected except by exercising a great deal of compulsion. Most of the patients start with good resolutions but give way on about the second or third day when the symptoms are very acute and at their peak. To keep control over such patients under ordinary hospital or home conditions is very difficult indeed. With full knowledge of all these difficulties the gradual method was tried under non-institutional conditions with a fair degree of success, especially in addictions of short duration. Considerable care and attention had to be exercised in the selection of cases. Before starting the treatment the patient had to be thoroughly examined and any physical conditions which may have led to addiction - e.g., septic foci, etc. - had to be treated. Duration of addiction is an important factor; cases under five to seven years taking ten to fifteen grains daily were generally amenable to treatment. In many persons taking over twenty grains daily for prolonged periods, circulatory distur- bances leading to collapse are likely to supervene if the drug is suddenly withdrawn. Sudden withdrawal is successful and can be recommended only with addicts taking under five grains daily.

The gradual withdrawal method is also suitable for mass treatment of opium addicts under non-hospital conditions. One of us during the First World War in the East African campaign was attached to a company of Sikhs about 200 strong. Most of them were heavily addicted to opium, some taking as much as 100 grains daily and some even more. With the co-operation of the officers of the company there was no difficulty in cutting down the dose to a few grains a day in a couple of months, without any of the men showing any signs of distress. They gladly went through the cure, and some of them gave up the habit entirely. As there were no towns near by, the chances of anyone's obtaining local supplies were completely eliminated.

Chopra (1937) has shown that there is a certain amount of psychic element in opium addiction and the production of withdrawal symptoms. He has come across cases of persons addicted to large doses of opium (20 to 100 grains a day) who had been sent to gaol for some criminal offence and whose supply was inevitably stopped; they did not, however, suffer from such marked abstinence symptoms as some of the others. During the treatment of addicts to rid them of the opium habit, the drug can largely or totally be replaced by substances such as gentian and nux vomica in pill form without the patients realizing it. An interesting observation is that if the patient is not aware that he is taking opium, the drug can be effectively given for weeks or even months for its therapeutic effects, without producing addiction or abstinence symptoms. A great deal can be done by obtaining the co-operation of the patient. Proper attention to the psychological side of the treatment ensures success in many cases.

Administration of Opium to Infants

The habit in infants and children is not difficult to break. In the usual course of events, the parents continue to give opium up to the age of two or three years and then, when the child can take care of itself, the drug is stopped. Both the gradual and sudden methods of withdrawal were tried with an equal degree of success, but it is better to adopt the sudden method. The psychological element plays a very minor part in children, and as a rule there is little discomfort. The withdrawal symptoms met with are looseness of bowels, diarrhoea, and loss of appetite. Nausea and abdominal pains also occur. Diarrhoea can easily be controlled by powders containing sodium bicarbonate, bismuth carbonate and aromatic chalk. In severe cases with mental irritability, a bromide mixture with a few minims of tincture of belladonna may help to relieve symptoms. The child is quite well in a few days, and a cure is effected; as a rule, no after-treatment is necessary. Even in the worst cases, with marasmus and emaciation, the patients begin to put on weight soon after they are rid of the habit.

Opium Smoking

The experience in India is that the habit of opium smoking is much more difficult to eradicate than opium eating. Fortunately, owing to enforcement of very strict regulations, the habit of smoking opium has practically disappeared. There appears to be little doubt that an opium smoker is much more attached to the drug than an opium eater. It would appear that, although smaller quantities of the alkaloids are absorbed (most of them must be destroyed by the heat produced), the absorption is very rapid through the large surface of the capillaries of the lungs, and the effects are sudden and more intense, resembling those of an injection of morphine. The treatment of opium smoking has not been properly worked out in India. Some authorities allow the patient to take the drug by mouth and gradually cut down smoking. Once eating is successfully substituted for smoking, the addict becomes more amenable to treatment.

" Post" (Unlanced Capsules of P. somniferum )

It is a common belief among the addicts that "post" does less harm than opium. Our experience in this respect, however, is not in accord with this view. A person addicted to poppy heads requires comparatively much larger doses of opium to produce a similar effect; moreover, the physical and mental effects produced by ordinary doses of "post" are much more marked than with moderate doses of opium. This in all probability is due to the potentiating effects that the constituent alkaloids of poppy capsules have on one another. It is more difficult to get rid of the habit of taking "post" than the habit of taking opium. The sudden withdrawal method is rarely practicable in these cases, the gradual method being the only one which meets with success. The dose is gradually reduced by half a capsule till a fourth of the original dose is reached, after which the drug is stopped altogether.

Cannabis Drugs

The treatment of the cannabis drug habit is not so difficult, though here again, as in the case of opium, it is easier to cure the eating habit than the smoking habit. Withdrawal symptoms, as they are met with in the case of opium addicts, are hardly ever seen in the case of cannabis drugs - indeed, the patients find no difficulty in giving up the habit of their own accord if they wish. In northern India, many people indulge in bhang drinking in the hot weather, on account of its reputed cooling and refreshing properties, and give it up in the winter quite suddenly without any discomfort. Cannabis preparations, when taken habitually by mouth, can be suddenly withdrawn without producing any marked abstinence symptoms, though keen desire to indulge in the drug is there. Temporary loss of appetite, constipation lasting for a few days and rarely palpitations and restlessness may occur; all these can easily be dealt with.

Charas and ganja are stronger preparations and, as these are generally indulged in by smoking, their effects on the system and particularly on the nervous system are more pronounced. The will-power of the smoker is weakened, and without the physician's help he is not able to give up the habit. Treatment in special institutions with facilities for forcible withdrawal is likely to give the best results. The psychological and mental treatment, and training and education of the addict are as important in the case of cannabis smokers as in opium addicts, in spite of the fact that the physical distress accompanying withdrawal is largely absent.

Cocaine

The habit of eating cocaine is easier to cure than that of cocaine injected parenterally. Removal of the addict from the environment in which he has acquired the habit and from associates in whose company he indulges in the drug, preferably to a place where he cannot get it, often effects a cure. The present writers know of many instances where individuals from one part of the country went for months to another part where they were unable to get the drug and where they had no associates; they were able to conquer the craving for many months at a time without difficulty or any marked distress. When, however, they returned to their old surroundings and associates they again succumbed to the temptation. Similar facts have been observed in addicts who have been confined in prisons. They also give up the habit during confinement and go for years without the drug, but they generally take it up again after discharge. We are convinced that cocaine eating is comparatively a much milder form of indulgence than cocaine administered by the parenteral route.

Psychotherapy and mental training are important; the psychological rearrangement of the personality by finding some innocent emotional compensation will often help the addict to give up the habit. The drug must be withdrawn all at once and symptomatic treatment given for the withdrawal symptoms. In our experience in India, the cocaine habit, next to the opium habit, is perhaps the most difficult one to eradicate.

Auxiliary Treatments

Atropine and hyoscine have been tried in the earlier stages of withdrawal of opium, and strychnine in the later stages, with good results. The belladonna hyoscyamus mixture recommended by Lambert is useful in that it lessens the shock, decreases diarrhoea and relieves insomnia. Gastrogenous phenomena are not so marked in the treatment of the opium habit as with morphine, and alkaline and acid treatments are not necessary. Adrenaline and ephedrine have been tried for mitigating the withdrawal symptoms in a few cases, with good results. It is rarely necessary in this country to use sedative drugs, such as codeine, narcosan, luminal, sodium amytal, pernocton, etc., in the g dual withdrawal treatment of opium eaters, and we have had little experience in the use of these drugs.

Insulin Treatment

Insulin either alone or in combination with glucose has also been tried in Europe. Sakel (1930) used insulin alone in doses up to 80 units in 24 hours to combat the withdrawal symptoms in cases where morphine was cut off abruptly, with satisfactory results. Braun administered bigger doses of insulin, and in addition employed soporifics such as luminal. We have tried this method with little success.

So far as opium eating is concerned, we have tested the effects of the drug on the blood sugar of both diabetic and normal Indian patients. Small and moderate doses of opium have little or no effect on the blood sugar of individuals who are not suffering from disturbances of carbohydrate metabolism. In case of persons whose blood-sugar content is abnormally low, opium may raise it. The blood sugar in the early and mild types of diabetes may be actually reduced. It is only in the severe forms of the disease that the blood sugar is actually raised. In some patients, opium does no more than raise the renal threshold of sugar excretion. Our findings with regard to opium agree with those of Simenauer & Pulfer and Anton, who found that in human beings, as opposed to animals, morphine produces little or no disturbances of the carbohydrate metabolism.

Diuretics

The usefulness of diuretics such as novasurol or euphyllin in the slow withdrawal method is doubtful. Our observations show that in addicts taking moderate and large doses of opium there is retention of fluid in the blood. In those taking small doses, however, the output of urine is actually increased, and the blood is not altered. When the kidneys are damaged and there is albuminaria, the administration of one to nine grains of opium daily produces an appreciable decrease in the quantity of urine passed. In none of the cases was there indications of added damage to the kidneys, which the drug is reputed to cause in such cases.

Vesicatory Serum Therapy of Modinos in Opium Addiction

This method is very simple. A cantharides cerate plaster to a size of 8 cm 2 is applied to the patient's chest or abdomen, and after ten hours serum varying from 2 to 8 cc. is taken from the resulting vesicles and re-injected into the upper part of the arm or leg. The operation is repeated on the third or fourth day, and a third injection is given four to six days after the second. The dose of the narcotic drug is rapidly reduced, and may be completely cut off within three to seven days. It is believed that antibodies are formed which create a distaste for the drug, but this view is not universally accepted, and this distaste is attributed by some to the production of hypersensitivity. Other authorities hold that the so-called hypersensitivity is not specific, but is merely psychological and may be obtained by injecting common salt solution. It is further stated that relapses after the treatment are as common as with other methods.

Our experience with this form of treatment is limited, but the method was tried in the treatment of opium addicts in Burmese gaols. Opinions among the medical officers trying the treatment were unanimous on one point - namely, that one or more injections of the autoserum from a blister make the addict sensitive to opium. The patients say they do not wish to take opium any more, not because they do not like it, but because the consumption of the drug even in small quantities did not produce the pleasure or exhilaration that it used to produce before. On the contrary, headaches, nausea, vomiting, etc., were produced. A distaste for the drug is thus developed, and since the euphoric effects are not produced, opium is not wanted. A control experiment was also tried in the following manner. Some addicts were blistered in the usual way and the fluid from the blister was injected; in a number of other addicts injections of normal saline were substituted. It was found that the addicts who had normal saline did not respond in the same way as those in whom actual serum was injected. In other words, mere blistering did not do any good so long as the serum was not reabsorbed; nor were the effects due merely to the psychological effects of the injection. It is difficult to say how long the sensitiveness to the drug of addiction will last, if it is produced. It must be remembered, however, that most of the addicts were prisoners under prison discipline and living under conditions in which temptations by way of easy access to opium did not exist. In one of the jails, the treatment was tried on two warders who were free to go about and could easily obtain opium if they so desired. In both cases, the injections of serum produced the same effects as in the prisoners.

Whether the treatment will eventually produce a permanent cure or not is difficult to say with any degree of certainty, but the results so far obtained are certainly striking in some cases. The patients got rid of the habit and gained weight after the treatment; appetite returned and general health improved in a remarkable manner. The following provisional conclusions can be drawn from the few data obtained:

  1. That the treatment with vesicatory serum injections is a valuable measure in the treatment of opium addicts.

  2. That the addicts who have any will-power left will probably be completely and permanently cured of the habit through its agency.

  3. That those who have no will-power left, although they may be temporarily benefited, will probably relapse as soon as they have the opportunity.

Lecithin Treatment

The lecitin treatment of opium addicts was suggested by Ma Wen-Chao (1932) and was tried in India by us. From certain observations made on the physical properties of the blood sera of opium addicts, it was found that the protein content, specially the neuro-protein content, was lacking or deficient, particularly during the withdrawal period. Ma Wen-Chao (1932), from a cytopathological study of chronic morphinism in albino rats, found that the withdrawal of the drug in the addicted animals led to severe pathological conditions of the Golgi apparatus in the cells of various organs. Without treatment these conditions are overcome in ten to twelve days. Feeding with lecithin, on the other hand, for a period of six days before and for some days after prevented the Golgi apparatus from becoming abnormally reduced; this was accompanied by a condition of general well-being of the animals, which was absent in those receiving no lecithin. The treatment with lecithin was tried successfully in China on 143 opium smokers. In addition to their ordinary diet, the patients were given six to nine eggs daily to enrich the diet in lecithin. The bouts of craving were overcome by administration of tincture of opium in small doses. The lecithin given was prepared from eggs and made into pills with glycyrrhiza powder. The usual daily dose given was four to six grains. It was found in most of the addicts that although lecithin prevented many of the untoward symptoms, it was insufficient to combat all the withdrawal symptoms by itself.

Our preliminary trials with lecithin treatment of opium addicts in India were. so successful that we decided to give it an extensive trial in cases under close observation in the Hospital for Tropical Diseases, Calcutta, and, if possible, to improve the technique of treatment. Intensive studies were undertaken in the first instance to determine the changes produced in the body by prolonged use of opium, which gave rise to such intense and unbearable abstinence symptoms. It was thought that these studies might give a clue as to how such symptoms could be combated. The result of these investigations was published in a series of papers.

Treatment with Lecithin and Glucose

In view of the biochemical and biophysical findings briefly described hereafter, a modification of the Ma Wen-Chao method of treatment of opium addiction was evolved and tried in a series of 200 addicts in the Hospital for Tropical Diseases, Calcutta. Briefly, the method is as follows:

On the evening before treatment was started, the patient was given a dose of two to three grains of calomel, followed by saline purgative the next morning. The drug was then suddenly and completely withdrawn, and the addict was watched for the development of withdrawal symptoms, which in the majority of cases started to appear on the same day and attained their maximum within twenty-four hours. The actual treatment was at first started when withdrawal symptoms became intense and unbearable, in order to study the biophysical and biochemical changes which are produced in the individual during this period. Later, it was found distinctly advantageous to start administration of lecithin and glucose the day before opium was withdrawn, so that the inconvenience to the patient was reduced to the minimum.

Lecithin (Ovo lecithin, Merck) was given orally in the form of pills containing five to twenty grains three times a day, and continued usually for five consecutive days. In a number of patients, lecithin administered by mouth caused nausea, and in such cases the drug was given by injection in the form of a colloidal solution, twice daily. Experience showed that lecithin, when given by injection, acted more effectively and better than when it was given by mouth. Besides this, the amount required to produce the desired effect was comparatively small, and consequently the cost of treatment was considerably reduced. During this period of abstinence, the patient was encouraged to take plenty of fluids and glucose by mouth, as these greatly ameliorated the withdrawal symptoms.

There is no doubt that in the majority of cases lecithin decreased the intensity of the withdrawal symptoms and shortened their duration. In spite of its administration, the abstinence symptoms were severe in some addicts, and in such cases intravenous injections of 20 ml of 25% glucose solution, as well as glucose administered orally, greatly helped to ameliorate the condition. These were given with a view to stocking the liver with glycogen, and in order to enable it to cope with the strain, which undoubtedly fell on this organ, during the process of elimination of morphine and other alkaloids of opium from the system. We usually gave an intravenous injection of glucose every morning for the first three or four days, and if necessary repeated it in the evening, when the symptoms were severe. The injections were then stopped, and oral administration of glucose was repeated if needed. In severe cases attended by cramps, an addition of 10 ml of a 10% solution of calcium gluconate to the glucose solution helped greatly. No other drug was necessary during this period except a brisk saline purgative every morning, to help in the elimination of the drug through the gastro-intestinal tract. As a rule, no further treatment was required after the first week.

The diet during this period was kept light because addicts as a rule could not take much, on account of the gastro-intestinal disturbances produced by the withdrawal. Glucose, milk and fruit juices were given freely by mouth for the first two or three days during the withdrawal period. On the fourth day, when the abstinence symptoms began to disappear and the appetite returned, a diet rich in proteins and lecithin in the form of eggs, milk, beans, fish, chicken, fruits, bread and butter was given.

After the completion of the actual treatment - that is, after the complete withdrawal of the drug was effected - the patients were kept under observation in the hospital for a fortnight or more. A twenty-four hour specimen of urine was examined for the presence of opium alkaloids, in order to see if any of the patients were taking the drug secretly Usually the alkaloids can be detected in the urine for four to five days after the withdrawal of opium; after that, they cannot be detected, except in rare cases where excretion is prolonged. If, therefore, the alkaloids were still found after this period, the presumption was that the patient was indulging in the drug. If repeated examinations of the urine showed the absence of alkaloids, it was concluded that the drug was no longer being taken, and the addict was probably cured of the habit.

On the second day of actual treatment, most of the patients reported that the discomfort was decreased by half. When seen a few weeks after the treatment, many reported that the drug had lost its taste and charm for them, and in some, very small quantities of it even produced a sensation of nausea. The treatment undoubtedly gave rise, in a number of cases, to a definite feeling of aversion to the drug, whether by smoking or eating, and craving for the drug was definitely stopped in many cases.

In order to effect a permanent cure, a complete overhaul of every patient should be carried out with a view to determining if any septic or toxic foci are present in the body, as morbid conditions of this kind are a common distributing cause of opium addiction in this country. If routine laboratory examinations revealed such conditions as dysentery, sprue, helminthiasis, sinusitis, conjunctivitis, etc., these were treated during the period of observation after treatment.

The mental outlook of treated addicts also showed a remarkable change. After the treatment, persons who were previously sad, morose and apathetic and who had pale and sallow complexions, became cheerful, and their appetite and general health improved and they put on weight. They also became more sociable, docile and respectful, and showed an inclination to do their ordinary work. They felt interested in their surroundings and became definitely more active. After discharge from the hospital, it was ascertained that most of them had become useful members of society and followed their vocations with interest.

The total course of treatment varied from seven to twelve days, and during this period the change in the conditions of the addicts was remarkable. The patients treated in the hospital were kept under further observation for a period varying from four to twelve weeks in order to rehabilitate and train them for their new environment, and to watch for the occurrence of relapse. The period of rehabilitation and rebuilding of the personality of an addict may sometimes extend to a few months.

In this special series of 200 cases treated in the Hospital for Tropical Diseases (Calcutta) by this method, complete cure was effected in 70%, the dose was reduced by 80% in 10%, and by 50% in 15% of the cases. The treatment failed completely in 5%, and there was a relapse to the habit in the remaining 5%. Thus, it appeared that the results were more encouraging than with any other forms of treatment which had so far been tried in this country.

Rationale of Treatment with Lecithin and Glucose

Observations made by such workers as Maguin (1909), Sollier (1910) and Pierce & Plant (1928) have shown that in addiction of long duration, general dehydration of the body takes place owing to excessive perspiration, abnormal salivation and obstinate diarrhoea. These facts strongly suggested that such a process of dehydration may have an ultimate effect on the fluid content of the blood. The changes in the physico-chemical properties or in the protein fraction of the blood in the addicts under treatment were determined. Chopra & Chopra (1935, 1937) found that in most of the addicts the state of addiction was invariably accompanied by an increase in the fluid content of the blood, and were inclined to believe that an excessive secretion on withdrawal would have a reverse effect, leading to an increase in the percentage of serum proteins.

The work of Chopra & Roy (1937) on the blood-lipoid changes in opium addicts before, during and after withdrawal pointed to the probability of a diminution in the water content of the blood on withdrawal, which led Chopra & Ganguly (1939) actually to determine the effect of withdrawal on the blood fluid, and also to attempt to explain the rationale of the treatment of opium addiction with lecithin and glucose. Blood sera from the addicts under treatment were examined for total proteins before, during and after the withdrawal of the drug. In most of the cases, it was found that concentration of proteins present in the serum before treatment underwent a definite increase during the withdrawal period and returned gradually almost to the pre-withdrawal value after the addict had undergone the prescribed treatment. The increase in the total protein content during the period of withdrawal, as a general rule, ran parallel to the appearance of withdrawal symptoms. Excessive outflow of water from the body caused the most marked withdrawal symptoms that have been observed in almost all the cases studied by us. This apparently points to a disturbance in the fluid equilibrium in general. The effect of treatment may therefore be taken to have restored the fluid equilibrium of the system to its previous level.

Chopra, Mukherjee & Chopra (1935) observed that increase of the euglobulin fraction in the serum of addicts probably meant an ultimate drainage of phosphate from the nerve cells. Lecithin treatment was, therefore, rational on that basis inasmuch as it would help to make up the deficiency. In the majority of cases, lecithin decreased the intensity of withdrawal symptoms and shortened their duration. But in spite of its administration, the abstinence symptoms were very severe in some of the subjects, and in these, intravenous injections, of 25 ml of 25% glucose solution helped to ameliorate the condition. Although lecithin by itself was unable to cope with the severity of the withdrawal symptoms, it doubtless removed the craving for the drug in the majority of cases.

The role of glucose in coping with the abstinence symptoms can thus be understood. By this treatment, the ultimate effect seems to be the restoration of the water balance. Therefore, any drug that confers a fluid-retaining power to the blood would be expected to have good effect. Carbohydrates in general and glucose in particular are known to possess this water-retention capacity. Glucose, therefore, in addition to stocking the liver with glycogen to enable it to cope with the unusual strain on this organ during the process of elimination of morphine, etc., helps the retention of water in the blood, and keeps up the blood hydration level to its normal value. From the above consideration, it may be concluded that lecithin tones up the nerves of the addicts by supplying the lipophosphates, and glucose helps to restore the disturbed water balance. It is, therefore, not difficult to see how these two together produce the desired effect in removing the drug craving and alleviating abstinence symptoms in opium addicts.

Abstinence Symptoms

We have already stated that in order to work out the rationale of the treatment, the addicts under treatment in hospital were allowed to develop the withdrawal symptoms in full before starting the actual treatment. The most common symptoms recorded during this period among the opium addicts were as follows.

Quite a number of patients suffered from cramps which were sometimes severe, epigastric pain, sinking sensation in the chest, insomnia, diarrhoea, vomiting, headache, asthenia, and inability to stand up and walk. A few patients taking large doses for prolonged periods developed feeble pulse, profuse perspiration, vomiting and severe diarrhoea, resulting in collapse. Spermatorrhoea and headache were also common. Hiccough was observed in a few cases.

Vasomotor disturbances such as sneezing, coughing and running from the nose and eyes were also commonly seen. Palpitation and cardiac distress were also observed in a few cases. Anorexia was a common symptom, and usually there was no appetite for the first three or four days and all food was refused. Over 50% of the patients suffered from insomnia, which was often very troublesome. It was observed that there was some psychical element in all these symptoms, and the addict could control the intensity of the withdrawal symptoms to some extent if he had a strong enough will-power to do so. Most of the addicts, however, especially those who were taking large doses, had lost their will-power entirely and were helpless.

Symptomatic Treatment

The following is a brief summary of the symptoms and complications which were observed and controlled in the course of treatment of this series of 200 cases in the hospital.

  1. Pains in the body and limbs, cramps and general malaise. The first two were very troublesome and often did not yield to ordinary analgesics; cramps were commonly met with, but they were not very severe. Simple measures such as massage, hot baths, aspirin and veramon were successful in some cases, but when the pain was severe an intramuscular injection of novalgin (Bayer) 2 ml. often proved effective. Hyoscine hydrobromide in 1/200 grain doses was also tried but was not found to be effective. The pains and cramps generally disappeared in three to four days after the administration of lecithin and glucose.

  2. Nausea and vomiting were common symptoms, and were observed in 40% of this series. In twenty addicts there was actual vomiting, and in two it was very severe and incessant. Sucking of ice greatly relieved these symptoms, and in severe cases 10 drops of adrenaline hydrochloride (1 in 1,000 in normal saline) under the tongue every two to four hours often gave relief.

    In two patients, severe bilious vomiting occurred, and the stomach had to be washed out with a solution of sodium bicarbonate (one drachm to a pint of water), after which the patients were relieved.

  3. Constipation was treated with administration of saline every morning and, if necessary, calomel in half-grain doses was given the previous night. Diarrhoea was also frequently met with, and for this condition no special treatment was given except fluid diet and withholding the daily dose of saline. In severe cases, bismuth and chalk mixture was given.

  4. Cardiovascular manifestations. These were feeble and irregular pulse, sinking sensations, cardiac embarrassment and collapse. These symptoms were greatly relieved by administration of glucose by the intravenous route and cardiac tonics such as brandy, cardiazol, digifortis, etc., were effective. Special treatment for heart conditions had to be resorted to in ten cases. They were all aged persons who had been taking the drug for over twenty years and in doses above 40 grains a day, who showed severe reactions during the period of abstinence. In one patient, an old man, aged sixty-five years, who had been taking the drug in doses of 45 grains for a period of forty years, collapse occurred on the fourth day of withdrawal owing to excessive loss of fluid, due to persistent bilious vomiting and diarrhoea. The treatment adopted was intravenous administration of four to five pints of glucose saline, cardiazol and atropine sulphate injections and brandy by mouth. No opium was given. This patient was discharged from the hospital as apparently cured after twenty-one days.

  5. Vasomotor disturbances such as sneezing, coughing and running from the nose and eyes. Unless severe these require little or no treatment but, when troublesome, a small dose of Dover's powder (5 grains) at bedtime gave relief.

  6. Spermatorrhoea was treated by a simple mixture containing 10 grains each of potassium bromide and ammonium bromide and 30 minims of tincture of valerian, administered twice daily; it allayed restlessness and induced sleep. This mixture was allowed to be taken after the patient was discharged from the hospital in cases where there were signs of restlessness and irritability.

  7. Insomnia. This was a very troublesome symptom and was often difficult to treat. It generally started early in the course of treatment and sometimes continued for weeks. Often no treatment was given for this condition for a day or two, the patient being instructed to exercise his own will-power and try to sleep. Sometimes he was helped by such simple measures as a hot foot bath before retiring, or a dose of a mixture containing bromides at bedtime. When these measures failed, a pill containing 7? grains of medinal administered at bedtime often succeeded in producing sleep for four to six hours. This produced a real change in the patient's mental condition and attitudes as he began to feel rested and gained confidence in the efficacy of the treatment. This drug should not be repeated for more than four successive nights. Other barbiturates and hypnotics, such as adaline, evipan, luminal, ortal (Parke, Davis & Co.) were tried with good results. In one serious case with intractable insomnia where nothing succeeded, 30 minims of tincture of Rauvolfia serpentina succeeded in producing sleep.

  8. General asthenia and loss of appetite. For anorexia, which was a common symptom during the first week or so, a mixture containing gentian, alkalies and nux vomica before food was useful. The general lassitude and weakness following withdrawal were relieved by a simple mixture containing iron, strychnine and arsenic, which was usually prescribed to be continued for a few weeks after discharge from the hospital.

After-treatment

The importance of the psychological aspects of treatment of drug addicts has already been stressed. The responsibility of the physician does not end after the drug is withdrawn. The period following the withdrawal is most critical, and unless great care is taken relapses may occur. The whole of the nervous system has been strained and a thorough reconstruction and rehabilitation of the personality and the character of the addict are imperative if a permanent cure is to be obtained. The physician can do much by way of encouraging the patient and making him believe that by his will-power and firmness he will get rid of the habit. A common belief among Indian addicts is that elimination of the drug habit will leave them sexually impotent. There is no basis for such a belief, and the patient should be fully assured that loss of sexual desire, which they observe after giving up the drug, is a temporary phenomenon and is a part of the general loss of tone of the organs. It usually passes off in four to eight weeks, and sometimes it may last for several months. During the period following withdrawal, a good tonic in the form of vitamins, iron, arsenic and strychnine is helpful. Occupational therapy is also very important. As soon as possible, the patient should start doing some work so that his attention is diverted in other directions. He must lead a quiet life and avoid excesses of all kinds for a year or more after withdrawal has been successfully effected.

Results of treatment with lecithin and glucose: Mass scale trials

Chopra & Chopra (1949) were fortunate to try out the efficacy of this treatment on a mass scale in Assam during the anti-opium campaign of the first congress Government in 1938. As early as 1925, the Assam Provincial Congress Committee, appreciating the demoralizing effects of the opium habit and its extensive prevalence among the population, appointed an inquiry committee to study the problem in detail (Assam Congress Inquiry Committee's report on the opium habit, 1925). The available data and suggestions embodied in this report are an excellent work of reference. In 1938, when the first Congress Government came into power, these recommendations were immediately put into practice.

After the necessary legislative measures had been adopted the state government derided to stop the sale and use of opium completely and immediately in the three upper and worst affected districts as an experimental measure, in spite of the fact that the prohibition meant a considerable loss of revenue to the already poor and undeveloped State of Assam. In April 1938, our colleague, Dr. G. S. Chopra, was deputed to assist the Government of Assam in conducting the great experiment of prohibition of opium. Previous to starting the campaign, vigorous propaganda was carried out through the local congress committees, missionary societies and other educational institutions all over the state. Public meetings were organized, and pamphlets and leaflets describing the harmful effects of the opium habit were distributed freely. The evils of the habit and the necessity for its eradication, together with the effectiveness of the treatment which the addicts were to undergo, were fully explained. This helped greatly in preparing the ground for a mass campaign of treatment which would lead ultimately to the rooting out of habitual use of opium.

Census of Addicts

Before actually starting the campaign, a census of both the registered and unregistered addicts was carried out with the help of the local excise and police personnel. The unregistered addicts - i.e., those who were taking the drug trough illicit means - were told that no action would be taken against them if they revealed their identity. From previous experience of such surveys, it was known that the actual figures on the official register did not represent the exact number of addicts. There were probably 10% more addicts not registered, but who obtained supplies through illicit sources. The ratio of registered addicts to the general population in some of these areas was as high as 5%. The total number of addicts traced was 12,460.

Medical Treatment Centres

Treatment of the opium habit was made available in all the government and tea-garden, hospitals throughout the whole area of prohibition. As these institutions were not considered sufficient to cope with the rush of addicts in a short period of twelve weeks, additional treatment centres were opened in suitable places. A special staff of forty medical men was also recruited for the campaign and given training in the technique of treatment.

Analytical Study of the Records collected

The records of the various hospitals and treatment centres after the campaign revealed that 10,200 persons presented themselves for treatment within about three months. It was, however, not possible for a comparatively newly trained staff to keep complete records accurately for statistical analysis and research purposes in such a large operation. In 8,000 addicts among those who presented themselves for treatment, reasonable data could, however, be gathered for statistical analysis. The results are given below in tabular form. This was a unique campaign unparalleled in the history of drug addiction anywhere in the world. Therefore, the details given below are not unimportant. A further reason for giving these figures is that they throw considerable light on some important aspects of drug habits generally, and the opium habit in particular, among the people of this country. For instance, (i) factors responsible for drug habits, (ii) intensity of drug addiction and its relations to dosage, (iii) principal withdrawal symptoms and their relative preponderance, (iv) relationship between age of addict, dosage, duration of addiction and success of treatment, have all been clearly brought out.

Firstly, aetiological factors which led to the habitual use of opium in this large series of addicts were analysed. The results are given in Table I.

Categories of Addicts

For the purpose of treatment, the addicts were classified in three groups, according to intensity of addiction as determined by factors such as age, daily dose, duration of addiction, general health, etc. (see Table II).

TABLE I

Factors responsible for the drug habit

Aetiological factor

Number

Percentage

1. Association and example of relatives and friends
2,800 35
2. To alleviate the symptoms of a disease, or as a cure for certain ailments
2,000 25
3. To overcome fatigue
1,600 20
4. For euphoric and pleasure-giving effects.
1,200 15
5. To replace another addiction, such as alcoholism
400 5
TOTAL
8,000 100

TABLE II

Classification of 8,000 addicts treated according to intensity of addiction based on factors such as daily dosage, age, duration of addiction, etc.

Number treated in each group

Percentage

Daily dosage in grains

Maximum age in years

Group I, 4,800
60
15 and less
40
Group II, 2,400
30
16 to 30
50
Group III, 800
10
31 and over
70

Group I: Consisted of 4,800 (60%) persons of whom all were below 40 years of age and were taking the drug in doses of less than 15 grains a day. The average duration of addiction in this group was shorter than in groups II and III.

Group II: 2,400, or 30%, in the series who took between 16 and 30 grains a day; the highest age in this group was 50 years.

Group III: The rest of the subjects - i.e., 800, or 10%. Most of them took the drug in doses of over 30 grains a day, and the average duration of addiction was more than in the previous two groups. The maximum age recorded was 70 years.

Withdrawal Symptoms

In spite of the intensive treatment given, withdrawal symptoms were encountered in quite a large number of addicts. The principal symptoms observed are detailed in Table III.

TABLE III

Principal withdrawal symptoms observed, with their relative preponderance in the cases of the different groups

Withdrawal symptoms observed

Group I 4,800

Group II 2,400

Group III 800

1. ain in the body and limbs, cramps, general malaise, etc.
3,840 2,160 800
 
(80%)
(90%)
(100%)
2. Vaso-motor disturbances, such as sneezing, running from the eyes and nose
2,880 1,920 720
 
(60%)
(80%)
(90%)
3. Cardio-vascular manifestations, such as feeble and irregular pulse, sinking sensation, cardiac embarrassment and collapse
960 770 400
 
(20%)
(30%)
(50%)
4. Insomnia
2,880 1,920 800
 
(60%)
(80%)
(100%)
5. Gastro-intestinal disturbances, such as nausea, vomiting and diarrhoea
960 720 480
 
(20%)
(30%)
(60%)

In all cases of relapse, the percentage in reduction of dose in each case was recorded. It was not possible to keep a watch over all the persons belonging to Groups I and II. A few in Groups I and II and the majority of addicts treated under Group III who, it was feared, were liable to relapse were kept under observation in their homes for a period varying from 4 to 24 weeks. Results of treatment are summarized in Table IV.

TABLE IV

Results of treatment

Results

Number of addicts

Percentage

1. Complete cure (addicts reclaimed as useful members of society)?
3,200 40
2. Reduction in dosage by three-quarters of the original dose
2,400 30
3. Reduction in dosage by half of the original dose
1,600 20
4. Failure of treatment
800*
10
TOTAL
8,000 100

Six cases died during treatment.

It will thus be observed that 3,200 (40 %) of the addicts treated in this experiment were completely cured of the habit when the campaign ended; 2,400 (30%) succeeded in reducing their daily dose by three-quarters of the original; and 1,600 (20%) showed reduction in dosage by half of their original dose. There were 800 (10 %) who showed little or no response to the treatment, and amongst these six died during the course of treatment.

TABLE V

Relation between the age of the addicts and the result of treatment

 

Age of addicts

 

Result of treatment

25 Years and below

26-40 years

41-60 years

61 years and above

Total

Complete cure
280 1,500 1,300 120 3,200
Dosage reduced by three- quarters
180 1,030 1,040 150 2,400
Dosage reduced by half
60 520 820 200 1,600
Failure of treatment
Nil
80 200 520 800
TOTAL
520 3,130 3,360 990 8,000

These results are very interesting. It will be seen that the number of persons cured in groups of older persons was much less than in the case of the younger ages. Thus, out of 3,200 cases who were completely cured, 1,780 were below 40 years of age, 1,300 between 41 and 60 and only 120 persons were above 60 years of age. In this series there were 520 persons below 25 and out of these 280 got rid of the habit completely. There were 3,130 persons between 26 and 40 years, and out of these 1,500 were completely cured. There were 3,360 persons between 41 amd 60, and out of these 1,300 were completely rid of the habit. Amongst the 990 addicts aged above 61 years, only 120 rid themselves of the habit completely.

Similarly, reduction of dosage was also more marked in the younger age addicts. Conversely, failure of treatment was more marked in the case of higher age groups. It will be observed that in the 26-40 years age group consisting of 3,130 addicts, treatment failed in 80 cases, while in 990 persons aged above 61, treatment failed in 520 cases - - i.e., in more than 60%. Thus, the younger addicts were more amenable to treatment than the older and more confirmed addicts.

TABLE VI

Relation between dosage and treatment

 

Dose in grains

 

Result of treatment

15 and under

16-30

31 and over

Total

Complete cure effected
1,200 1,150 850 3,200
Dose reduced by three- quarters
1,020 750 630 2,400
Dose reduced by half
525 325 750 1,600
Failure
98 200 502 800
TOTAL
2,843 2,425 2,732 8,000

It will be seen that cures were more marked in the addicts who had been taking smaller doses. Out of 2,843 persons consuming the drug in doses of under 15 grains a day, as many as 1,200 were completely cured as compared with 850 out of 2,732 addicts taking 31 grains and more a day. The reduction in dosage was also well marked in the case of the group taking small doses. Failures were more conspicuous among the group taking large doses. Thus, the results of treatment were encouraging in persons who took below 31 grains of opium a day.

TABLE VII

Results of treatment and duration of addiction

 

Duration of addiction in years

 

Result of treatment

10 years and under

11-20 years

21 years and over

Total

Complete cure effected
2,585 615 10 3,200
Dosage reduced by three- quarters
315 2,065 20 2,400
Dosage reduced by half
800 710 90 1,600
Failure
200 470 130 800
TOTAL
3,900 3,850 250 8,000

It will be seen that there were more cures among addicts of shorter duration, viz., 10 years and under, where out of 3,900 persons 2,585 completely responded to the treatment, as compared with 615 out of 3,850 with 11-20 years' duration and only 10 out of 250 with 21 years' and over duration. Conversely the failures of treatment were more marked in the case of addicts of longer duration and in addiction of over 20 years' duration, out of 250 persons 130 showed no response to the treatment.

Rehabilitation Treatment

It was not possible to organize proper treatment during the stage of rehabilitation for such a large group in a comparatively backward and poor state such as Assam. In only a small number of cases was it possible to arrange for vocational and diversional post-withdrawal treatment, which is so important in rebuilding the shattered personality of confirmed addicts of long standing. The individuals with a nervous diathesis and those liable to relapse were kept under observation through volunteers and relatives to prevent them from taking to the drug secretly. In order to rehabilitate and train addicts who had been weaned from the drug to a new walk of life and narcotic-free environment, attempts were made to provide diversional therapy by way of gardening and cottage industry such as basket-making, mat-making and other such vocations. Some reverted to the habit during the rehabilitation period, and the treatment had sometimes to be repeated twice. It was not possible for most of them to obtain a diet rich in lecithin on account of the expense it entailed. Addition of vegetables rich in lecithin (such as soya beans) to the diet was helpful in preventing relapses. The period of rehabilitation and rebuilding of personality in certain cases sometimes extended over several months and even up to a year depending on such factors as the personality and character of the addict, his environment, the cause of addiction, the presence of a nervous diathesis, heredity, etc. Patients with a nervous diathesis and with a sense of inhibition, specially the aged with longer duration of addiction, were more liable to relapse. Younger addicts with a stable nervous system, who had taken to the habit by mere association, were easier to treat. If during the rehabilitation period, chronic ailments such as toxic foci, malaria, dysentery etc., were attended to, chances of relapse were considerably reduced.

Persons who were suspected of taking the drug secretly were placed under observation, and their urine was examined for the presence of opium alkaloids.

Summary and conclusion

After a detailed study of the problem, the present authors tried various methods of treatment of drug addicts. The sudden withdrawal method from opium addiction was unsuccessful because there were no special institutes in which addicts could be admitted and treated. Some success was obtained with the slow or gradual withdrawal method. In the case of cannabis and cocaine, the sudden withdrawal method succeeded. Auxiliary treatments, such as the use of atropine, hyoscine and insulin, were tried with little success. Vesicatory treatment of Modinos was not uniformly successful in curing addicts. The lecithin treatment suggested by Ma Wen-Chao gave better results. A modification of this treatment in combination with glucose administered intravenously and by mouth, at the height of abstinence symptoms, gave even better results. Of 200 addicts treated in the Hospital for Tropical Diseases, Calcutta, 70% were cured. At the same time, the rationale of the treatment was worked out. Observations on the blood of addicts showed that there were marked disturbances in fluid equilibrium in the body. This treatment helped in restoring the fluid equilibrium to its previous level.

Unfortunately, for want of proper facilities, it was not possible to gauge the exact degree of ameliorating effects produced by lecithin and glucose, by observations on a control series of addicts side by side. From the general observations made, we have no hesitation in saying that the acute distressing symptoms which followed the withdrawal of the drug were, to say the least, made easily bearable in the large majority of cases. This in itself was an important factor in persuading the addicts to give up the drug. Their mental outloock underwent a remarkable change for the better after the treatment.

With regard to the ultimate results of treatment in the Assam series, the majority of addicts could only be kept under observations for a period varying from four to twenty-four weeks, and our observations recorded here were after this period. Table IV shows that 40% gave up the drug entirely. In another 50%, the dose was substantially reduced; and with the non-availability of opium, they eventually gave it up. Only in 10% of the cases was there complete failure.

It was generally believed that success of the campaign was dut to this treatment.

It will thus be seen that no satisfactory treatment of drug addiction has so far been developed. By administration of lecithin and glucose, the abstinence symptoms are eased and a break in the habit is effected, but this often is not a permanent feature.

Selected references

SOLLIER, P. : Journal de Medecine de Paris, 1910, XXX, p. 875. Assam Congress Inquiry Committee's report on the opium habit, 1925.

PIERCE, I. H.; PLANT, O. H .: Journal of Pharmacology and Experimental Therapeutics, 1928, XXXIII, p. 359.

CHOPRA, R. N.: The present position of the opium habit in India. Indian Journal of Medical Research, 1928, XVI, p. 389.

CHOPRA, R. N.: A preliminary note on addiction to Post (Uncleaned capsules of Papaver somniferum). Indian Medical Gazette, 1930, LXV, p. 361.

SAKEL, M.: Insulin in the treatment of symptoms accompanying withdrawal of morphine . Deutsche Medizinische Wochenschrift, 1930, LVI, p. 1777.

League of Nations: Commission of Inquiry into the control of opium smoking in the Far East (1930).

CHOPRA, R. N. & BOSE, J. P.: Opium and Albuminuria . Indian Medical Gazette, 1931, LXVI, p. 299.

CHOPRA, R. N. & CHOPRA, G. S.: Cocaine habit in India. Indian Journal of Medical Research, 1931, XVIII, p. 1013.

CHOPRA, R. N. & BOSE, J. P.: Psychological aspects of opium addiction. Indian Medical Gazette, 1931, LXVI, p. 663.

ADAMS, E. W.: Treatment of drug addiction - a review. Parts I and II. Practitioner, 1932, CXXIX, pp. 234 and 390.

CHOPRA, R. N. & CHOPRA, G. S.: Chloral hydrate and paraldehyde as drugs of addiction. Indian Medical Gazette, 1932, LXVII, p. 481.

MA WEN-CHAO: The effect of lecithin on opium addicts. China Medical Journal, 1932, XLVI, p. 806.

CHOPRA, R. N. & CHOPRA, G. S.: Morphine habit in India. Indian Medical Gazette, 1933, LXVIII, p. 368.

CHOPRA, R. N. & CHOPRA, G. S.: Administration of opium to infants in India. Indian Medical Gazette, 1934, LXIX, p. 489.

CHOPRA, R. N.; MUKHERJI, S. N.; CHOPRA, G. S.: Studies on the protein fractions of blood sera, Part I. Indian Journal of Medical Research, 1935, XXII, No. 3.

CHOPRA, R. N. & CHOPRA, G. S.: Opium habit in India. Studies on the physical and mental effects produced by opium addiction. Indian Journal of Medical Research, 1935, XXIII, p. 359.

CHOPRA, R. N.; MUKHERJEE, S. N. & CHOPRA, G. S.: Studies on the protein fractions of blood sera, Part II . Indian Journal of Medical Research, 1935, XXII, p. 561.

BULLETIN ON NARCOTICS l OCTOBER-DECEMBER 1957 33

CHOPRA, R .N.: Drug addiction in India and its treatment. Indian Medical Gazette, 1935, LXX, p. 121.

CHOPRA, R. N. & CHOPRA, G. S.: The treatment of the opium habit with lecithin and glucose. Indian Medical Gazette, 1937, LXXII, p. 265.

CHOPRA, R. N. & ROY, A. C.: Observations on the blood lipoid changes in opium addicts. Indian Journal of Medical Research, 1937, XXV, No. 1, p. 105.

CHOPRA, R. N. & GANGULY, S. C.: Abstinence symptoms in opium addiction and the rĂ´le of glucose in their treatment. Indian Journal of Medical Research, 1939, XXVI, p. 699.

CHOPRA, R. N. & CHOPRA, G. S.: Treatment of opium addiction with lecithin and glucose and its effect on abstinence symptoms. Indian Medical Gazette, 1940, LXXV, p. 388.

CHOPRA, R. N. & CHOPRA, G.S.: Withdrawal symptoms in opium addicts and the rationale of treatment with lecithin and glucose. Indian Journal of Medical Research, 1940, XXVIII, p. 225.

CHOPRA, R. N. & ROY, A. C.: Urinary excretion of morphine in opium addicts with and without lecithin and glucose treatment. Indian Journal of Medical Research, 1941, XXIX, No. 1, p. 192.

CHOPRA, G. S. & CHOPRA, R. N.: Opium addiction in Assam and attempts made to eradicate it. Indian Journal of Medical Research, 1949, XXXVII, p. 441.

CHOPRA, R. N. & CHOPRA, I. C.: Quasi-medical use of opium in India and its effect. Bulletin on Narcotics, 1955, VII, No. 3-4, pp. 1-22.

CHOPRA, I. C. & CHOPRA, R. N.: The use of the cannabis drugs in India. Bulletin on Narcotics, 1957, IX, No. 1, pp. 4-30