The consumption of narcotic drugs in Denmark

Abstract

Details

Author: M. Nimb
Pages: 1 to 5
Creation Date: 1958/01/01

The consumption of narcotic drugs in Denmark

Dr. M. Nimb
The following article has been communicated by the Government of Denmark.

This analysis is based on domestic wholesale statistics and draws a comparison between prescriptions dispensed in November I949 and those dispensed in November 1955. In Denmark, prescriptions for drugs subject to group I control under the international narcotics conventions cannot be repeated; that is, when the medicine has once been dispensed, the prescription is cancelled by the pharmacist and cannot be used again. The prescription for such drugs has to be entered by the pharmacist on a special form which has to be forwarded to the National Health Service at regular intervals.

The high rate of consumption in Denmark of drugs under international control has several times attracted the attention of the international control organs, which have instituted inquiries directed to the National Health Service in Denmark.

The Danish authorities, conscious of the complex nature of this problem, realized that the domestic wholesale statistics did not give adequate information on the consumption and distribution of narcotic drugs, and therefore commissioned Dr. P. Wiingaard to analyse 54,000 prescriptions for narcotics dispensed by Danish pharmacies durings November 1949.

TABLE 1

Number of prescriptions

«= municipality

 
Nov. 1949
Nov. 1955
Increase (%)
Frederiksberg
1803 2272
+ 26.0
Copenhagen «
11950 14863
+ 24.4
Copenhagen-Frederiksberg «
4611 7472
+ 62.0
Frederiksborg district
1502 2835
+ 88.7
Holbak district
1084 1822
+ 68.0
Praesto district
1433 2296
+ 60.2
Sorø district
1428 1611
+ 12.1
Bornholms district
378 593
+ 56.8
Maribo district
1610 1978
+ 22.9
Odense district
2963 4284
+ 44.6
Svendborg district
1708 2458
+ 43.9
Aalborg district
2284 3430
+ 50.3
Aarhus district
3214 4147
+ 29.0
Hjørring district
1158 2233
+ 92.8
Randers district
2087 3385
+ 62.2
Ribe district
2086 2914
+ 39.7
Ringkøbing district
2308 3645
+ 57.9
Skanderborg district
2827 2740
- 3.1
Thisted district
891 1308
+ 46.8
Vejle district
2243 3184
+ 41.5
Viborg district
1720 2120
+ 23.3
Aabenraa-Sønderborg district
1355 1474
+ 8.8
Haderslev district
959 1090
+ 13.7
Tonder district
463 730
+ 57.6
TOTAL
54065 74884
+ 38.5

By November 1955, the number of prescriptions for narcotics had increased to 75,000 (i.e., by 38.5%), and it was decided to analyse the prescriptions again, although less extensively than in 1949. This was facilitated by the fact that since November 1949 all pharmacies in Denmark enter the prescriptions on a special form every time narcotic drugs in group I are dispensed. Such copies are forwarded through the county medical officer to the National Health Service and have become the basis of the analysis.

Comparing the numbers, expressed in percentage, of prescriptions issued during the two trial months, there is a wide variation, as is shown by an increase of 92.8% in Hjørring and a decrease of 3.1% in Skanderborg, but comparing the number of prescriptions per 100 inhabitants the figures have otherwise approximated the average for the whole country. However, the three districts of Svendborg, Vejle and Ribe, which in 1949 were representative of the total consumption of the country, now show an increase which is the same as the average increase for the whole country. These increases were approximately 44%, 41% and 40% respectively, and these districts are therefore examined separately below. The total number of prescriptions for them was 6,037 in 1949 and 8,556 in 1955, but in this connexion it is pointed out that since 1949 more drugs such as ketobemidone and dexamphetamine have been added to the list of drugs for which prescriptions require to be entered by the pharmacists on a special form as above. Still others, already existing in 1949, such as thebacon and hydrocodone, have also been added to this list since 1949. The position in November 1955 may be analysed as follows :

Prescriptions for thebacon and hydrocodone
1,029
Prescriptions for ketobemidone
951
Prescriptions for dexamphetamine
659
TOTAL
2,639

Deducting this total of prescriptions for the " added " drugs from the 1955 total mentioned above - i.e., 8,556 minus 2,639 - the remainder, 5,917, shows close agreement with the 1949 figure of 6,037. Other factors to be borne in mind are the increase in population in the three districts concerned[1] and the more widespread use of drugs by older people in age groups which have increased more rapidly than those of the younger members of the population.[2]

A comparison between the volume of doses prescribed in 1949 and in 1955 has not proved feasible, although for some preparations there seems to have been a decrease in the volume of single prescriptions.

Table 2 gives the figures of the wholesale trade in narcotic drugs based on returns made to the Permanent Central Opium Board. These provide a very rough estimate of annual consumption and the variations over the seven-year period. Whilst there has been a considerable fall in the consumption of morphine, this is counterbalanced by an increase in the consumption of synthetic analgesics, especially pethidine. Methadone, which was not placed under control in Denmark until 1952, is not representative of the general trend, and ketobemidone, first used in 1952, has been consumed at a constant rate during the last three years.

The high rate of consumption of codeine is specially worthy of note, since it forms a very high proportion of all narcotic drugs consumed, but this is partly due to its widespread use in tablet form combined with mild analgesics and in mixtures containing other sedatives. Furthermore, codeine is widely used in cough medicines, the consumption of which is very high in Denmark because of the prevalence of infections of the respiratory system caused by the climatic conditions. A similar situation is found in Sweden and Finland. Although there is no treaty obligation requiring prescriptions for codeine, as a drug in group II under the international conventions, most codeine preparations require a prescription under national legislation; such prescriptions can be repeated only five times.

TABLE 2

Wholesale (in kilogrammes)

Year

Morphine

Cocaine

Oxycodone

Hydrocodone

Thebacon

Codeine

Ethyl morphine

Pethidine

Methadone

Ketobe-midone

1949 121.1 16.1 3.6 8.9 5.2 1 085 125.9 100.3
-
-
1950 183.2 22.9 4.9 14.5 7.6 1 614 130.2 213.3 (0.2)
-
1951 120.6 19.9 4.4 14.0 5.8 1 340 83.9 209.6 (0.4)
-
1952 129.7 10.4 8.2 13.2 7.9 1 062 76.3 166.0 15.2 9.0
1953 87.7 11.7 4.1 16.9 11.7 1 317 88.9 196.0 25.6 20.3
1954 93.8 14.4 3.9 14.0 10.2 1 612 82.9 186.3 21.9 19.7
1955 85.0 11.8 3.7 9.5 6.6 1 617 97.8 214.9 17.8 22.7

The consumption of ethylmorphine (a drug in group II under the international conventions) has never been so low as during the last five years.

Even if it cannot be said with certainty that the total consumption of narcotic drugs in Denmark has not increased during the past six years, the prescriptions indicate even a decrease in consumption when the changes in the population figures are considered.

Using Dr. Wiingaard's grouping, the drugs are classified as follows:

I.
Morphine group A
II.
Morphine group B
III.
Diacetylmorphine group
IV.
Pethidine group
VI.
Ketobemidone group
VIII.
Cocaine group
IX.
Amphetamine group
X.
Dexamphetamine group

One of the most important developments is the greater use of the potent synthetic analgesics in place of the opium alkaloids. Thus, prescriptions for drugs from groups I and II have decreased 50%, which is more than table 2 indicates; and, as mentioned above, it cannot be said that the rate of consumption is attributable to the volume of single pre- scriptions. For example : expressed as percentage, the share of the total consumption of methadone has not changed since 1949, and ketobemidone preparations are distributed to an extent surpassed only by pethidine.

Although ketobemidone is thought to be as dangerous as diacetylmorphine, and although the Economic and Social Council has urged governments to prohibit the manufacture, import and export of ketobemidone, its salts, its preparations and preparations of its salts, Denmark's non-compliance is due to the fact that experience in Denmark shows that ketobemidone is at least not misused more than morphine or other synthetic analgesics. This may be due to the fact that the main ketobemidone preparations sold in Denmark contain only one part of ketobemidone to five parts of "A 29" which is 1,1-diphenyl-3-dimethylaminobutene-1. There is a possibility that the atropine-like effect of large doses of "A 29" is so disturbing that the addiction-producing effect of ketobemidone is compromised.

The number of prescriptions containing diacetylmorphine has been reduced very much since 1949, so that this drug is now practically exclusively used as a low-concentrated ingredient of cough medicine and has almost everywhere been replaced by codeine and ethylmorphine. Prescriptions for cocaine have also been considerably reduced, probably as a result of the increasing use of synthetic anaesthetics.

TABLE 3

   

Number of prescriptions in 1955

     
 

Group

Magistral

Officinal

Total

%

1949 (%)

I.
Morphine A
184 170 354 4.1 8.7
II.
Morphine B
181 1 194 1 375 15.9 32.6
III.
Diacetylmorphine
41 10 51 0.6 2.2
IV.
Pethidine
62 1 292 1 354 15.7 13.1
V.
Methadone
12 834 846 9.8 9.8
VI.
Ketobemidone
1 950 951 11.0
-
VII.
Acetyldihydrocodeinone-hydrocodone
104 925 1 029 11.9
-
VIII.
Cocaine
73 5 78 0.9 2.5
IX.
Amphetamine
360 808 1 168 13.5 17.8
X.
Dexamphetamine
0 659 659 7.5
-
 
Remainder group
 
 
785 9.1 13.3
 
 
 
 
8 650 100.0 100.0

A moderate decrease in the number of prescriptions under the amphetamine group is counterbalanced by the additional prescriptions for dexamphetamine. Drugs in this group are not subject to the obligations of the international narcotic convention, but in Denmark prescriptions for amphetamine and dexamphetamine are subject to the same restrictions as those for group I narcotics - that is, they cannot be repeated, and have to be entered on a special form.

During the period 1949 to 1955, the drugs in the groups shown in the above table have changed as follows (the figure for 1949 is given in parentheses) :

Morphine groups A and B : 20 % (40 %)

Amphetamine-dexamphetamine : a little more than 20% (a little less than 20 %)

Pethidine : ca. 15% (13.1%)

Methadone : ca. 10% (unchanged)

Ketobemidone : a little more than 10% (0)

Thebacon-hydrocodone : a little more than 10% (not liable to be repeated)

Diacetylmorphine and cocaine : each under 1% (each ca. 2 %)

The remainder group : ca. 10% (ca. 13%)

Table 4 shows the prescription frequency for single preparations and, for purposes of comparison, ten of the most frequently prescribed preparations during 1949.

TABLE 4

1949

 

Preparation

%

1.
Trapon (mixed alkaloids of opium)
16.6
2.
Pethidine
13.0
3.
ecodrine
11.7
4.
gtt. Roseae (contains morphine)
10.1
5.
Butalgin (methadone)
9.8
6.
orphine HC1
8.3
7.
Amphetamine
6.3
8.
Thebaica (raw opium)
4.5
9.
xykon (oxycodone)
2.5
10.
Cocaine
2.5

1955

 

Preparation

Number of prescriptions

%

1.
Pethidine
1 354 15.7
2.
Ketogan (preparation containing ketobemidone)
923 10.7
3.
Tetrapon (mixed alkaloids of opium)
724 8.4
4:
Butalgin (methadone)
723 8.4
5.
Dexedrine
659 7.5
6.
Hydrokon (hydrocodone)
656 7.5
7.
Amphetamine
571 6.6
8.
Mecodrin (amphetamine)
486 5.6
9.
gtt. Roseae (morphine solution)
373 4.3
10.
Thebacon
350 4.0
11.
Morphine HC1
345
 
12.
Opium
230
 
13.
Nirvapon (mixed alkaloids of opium)
177
 
14.
Scopolamin c. tetrapono (containing mixed lkaloids of opium
145
 
15.
Opiopapaverini comp. (contains opium)
132
 
16.
Methadone
123
 
17.
Oxykon (oxycodone)
108
 
18.
Cocaine
78
 
19.
Algospasmin (contains mixed alkaloids of opium)
76
 
20.
Methylamphetamine
75
 
21.
Heroin comp. (contains diacetylmorphine)
50
 
22.
Opiatae comp. (contains opium)
48
 
23.
Algophon c. scop. (contains mixed alkaloids of opium)
48
 
24.
Pantopon (mixed alkaloids of opium)
38
 
25.
Cliradon (ketobemidone)
28
 
26.
Chloralico-morphine
26
 
27.
ufodrin
23
 
28.
Cynoglossi (contains opium)
18
 
29.
Acedicon (thebacon)
17
 
30.
Kemodrin
13
 
31.
Hydromorphone
9
 
32.
Morf. citr. mit. (contains morphine citrate)
8
 
33.
Dicodid (hydrocodone)
6
 
34.
Dilaudid (hydromorphone)
5
 
35.
Dolantin (pethidine)
3
 
36.
Bonain (contains cocaine)
2
 
37.
Diacetylmorphine
1
 
38.
Dromoran (racemorphan)
1
 
39.
Morf. citr. fort. (contains morphine citrate)
1
 

Table 5 shows that the prescriptions grouped according to recipients are practically unchanged since 1949.

TABLE 5

The recipients

 

Total

%

1949 (%)

Patients
7 835 90.58 90.89
Animals
45 0.52 0.86
To be used in practice
463 5.35 5.21
To be distributed
55 0.64 1.05
Hospitals, etc
245 2.83 1.90
For ships' stores
7 0.08 0.05
Unexplained
0
-
0.04
 
8 650 100.00 100.00

Conclusion and Comments

Available data indicate that there is no basis for the assertion that the rate of consumption of narcotic drugs in Denmark in the period under examination shows an increasing tendency; on the one hand, consumption of morphine is decreasing, while, on the other, that of the synthetic analgesics is increasing. The consumption of the latter now seems more stable, although a further increase might have been expected owing to population growth and the high proportion of older people.

Nevertheless, the consumption rate in Denmark, even when compared with those of other Scandinavian countries, continues to be high; and in respect of morphine,[3] codeine, pethidine and methadone the figures for Denmark per million inhabitants in 1954 were the highest, with the sole exception of Iceland, where pethidine consumption was exceptionally high.

Factors to be borne in mind when considering the high consumption rate are :

  1. The Danish Health Insurance System covers nearly the whole population so that the sick have no economic difficulties in getting analgesics.

  2. Narcotic drugs are given only on doctors' prescriptions, and subject to the additional safeguards described above.

  3. No cases of illicit production or import of narcotic drugs have been reported.[4]

Although realizing that the high rate of consumption carries a risk of widespread misuse, the Danish health authorities believe that this risk cannot be completely eliminated, and it is expected that the rate will remain high as long as (1) the social-medical service has the same structure and extent as it has now; (2) the frequency of painful diseases does not markedly decrease; (3) the increase in population is dominated by the absolute and relative increase in the old-age group compared with that in the average population; (4) the combating of pain by means of medicine can take place only with the help of dangerous drugs.

TABLE 6

Consumption in kg per million inhabitants

   

Denmark

Finland

Iceland

Norway

Sweden

Morphine
1946 33.41 25.54 22.73 12.24 9.23
 
1950 42.72 15.35 14.18 31.39 9.88
 
1954 21.06 6.44 6.49 18.87 6.24
Diacetylmorphine
1946 0.98 25.54
-
-
2.83
 
1950 0.47 5.2
-
-
2.29
 
1954 0.22 2.39
-
-
0.28
Codeine
1946 285.05 94.4 242.42 81.16 114.75
 
1950 371.85 141.83 212.77 68.33 142.43
 
1954 361.19 202.29 103.9 65.45 239.29
Ethylmorphine
1946 39.5 6.45 15.15 9.98 18.01
 
1950 26.38 20.54
(1953)*
5.85 35.36
 
1954 18.37 26.72 6.76 4.72 43.39
Cocaine
1946 3.41 1.03 7.58 9.02 2.68
 
1950 5.37 2.72 21.28 3.08 2.58
 
1954 3.14 1.43 6.49 1.47 1.25
Pethidine
1946
-
-
-
-
-
 
 
(1951) (1951) (1951)
 
 
 
1950 47.86 3.24 13.98 8.62 1.15
 
1954 41.68 2.86 71.43 12.09 1.11
Methadone
1946
-
-
-
-
-
 
 
(1952) (1951)
 
(1951) (1952)
 
 
3.44 2.99
-
0.61 0.28
 
1954 4.93 3.82
-
0.29 1.25

Legislative measures lately enacted to control narcotic drugs are :

1949 : Amendment to registration regulations so that liability to register includes drugs brought under group I control under the international narcotics conventions and, in addition, amphetamine preparations and compounds.

Furthermore, as mentioned above, in place of registers of prescriptions kept permanently in the pharmacies, pharmacies now make up a list of exact and complete copies of the prescriptions on special forms, which are forwarded to the National Health Service each month to be used as the basis for a card index which serves as a control of doctors' prescriptions and patients' consumption.

1955 : The Medical Act was made wider to give the National Health Service added authority to take measures against doctors who prescribe narcotic drugs in an unwarrantable way. Doctors became entitled, to renounce their right to prescribe narcotic drugs, and the National Health Service to deprive them of that right.

Denmark's 353 pharmacies are being kept currently informed as to the names of doctors who have lost their right to issue prescriptions for narcotic drugs. Forty-two of Denmark's 5,500 doctors have so far lost this right, and one of the 1,600 veterinarians, but none of the 1,400 dentists. As far as the doctors are concerned the unjustifiable prescriptions of narcotics have in most cases been for their own use and not for that of their patients.

It should likewise be emphasized that most of Denmark's drug addicts are people who suffer from serious illnesses accompanied by severe pain which can be relieved only by the use of narcotics.

Finally, it may be noted that the card index, established in 1949, relating to the consumption of narcotic drugs now contains material which, scientifically processed, may throw a better light on the quantitative use and misuse of narcotic drugs than has hitherto been possible. As these investigations are finished, they will be made available to the international agencies.

1

23,371 between 1945 and 1950 - i.e., 4.7%, as compared with 5.8% for the country as a whole.

2

The number of people aged 60 in the whole country increased from 506,451 to 572,459 during the period 1945-1950 - i.e., an increase of 13 %.

3

However, according to the 1955 statistics, the rate of consumption of morphine in Norway in 1955 was treble that in Denmark.

4

Only very small quantities of narcotic drugs for injection are coming on to the illicit market