Drug addiction in the medical and allied professions in Germany

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1. STATISTICAL DATA

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Author: H. Ehrhardt
Pages: 18 to 26
Creation Date: 1959/01/01

Drug addiction in the medical and allied professions in Germany

Professor Dr. H. Ehrhardt President of the German Society for Psychiatry and Neurology

Psychiatry in Germany has always shown a certain partiality for inquiries into the essential nature of addiction, and since the Second World War a number of authors - von Gebsattel, Mitscherlich, Wagner, Schultz, Zutt and others - have resumed the investigation of the familiar subject from particular psychological and anthropological points of view. These researches provide the psychopathologist with a variety of new and illuminating findings and have set the scientific discussion of the subject in motion again.

One reason for the revival of the discussion of addiction is the fact that, relatively frequently, addicted persons from the upper strata of society, and especially medical practitioners, enter German clinics for treatment. In the case of such patients we usually find no - or at least no convincing - medical, social or economic circumstances that adequately explain their addiction. In cases of this kind an interpretation of the addiction from the point of view of what is known as depth psychology, or " understanding anthropology ", may in some measure satisfy the diagnostic requirements of the physician, so long as he is not over-optimistic in his expectation of therapeutic guidance from such an interpretation. It would be quite wrong, however, to seek to explain in the same way the use - and more especially the abuse - of narcotics among primitive peoples. The Chinese opium smoker, the coca-chewing Indian of Bolivia and Peru, and even the alcoholic casual labourer of Hamburg have, so far as the causes of their addiction are concerned, little in common with, say, the pethidine-addicted senior house surgeon of a Munich or Chicago hospital.

The control of narcotics addiction at the international level under the auspices of the United Nations Economic and Social Council and the World Health Organization can never be based on the psychological and metaphysical uniqueness of the patient with which psychiatrists rightly concern themselves; such international control can only take as its starting-point the sociological structure of various nations and the specific social and economic circumstances in which the many and varied forms of drug addiction manifest themselves. The control of narcotics addiction among doctors and other members of medical and para-medical professions is, in this connexion, a special problem, of particular professional significance, to which far too little attention is as yet paid in many countries. Precisely for this reason, it is most desirable that the World Health Organization and the United Nations should concern themselves with these matters.

In Germany, the central and paramount topic is that of "addiction and the medical profession"; by comparison with it, all problems of addiction to which varying degrees of importance are attached in other countries are secondary - at least for the time being. (I would, however, stress that in saying this I am deliberately excluding alcoholism from the scope of this study.) The existence of narcotics addiction in the Federal Republic of Germany as a problem with social, health and criminal aspects is due to the fact that there are doctors who prescribe narcotics and doctors who are addicted to them. In this country, the doctor is now almost the only channel through which narcotics come into the consumer's possession. As a consequence, the doctor's responsibility has substantially increased, and Kraepelin's much-quoted dictum "that there would be no morphine addiction if there were no doctors" is emphatically confirmed. It is an unfortunate fact that the country's legislative provisions - which in themselves are perfectly serviceable, are repeatedly brought to the notice of every medical man and are reproduced in the medical textbooks dealing with morphine and in almost every pharmaceutical and therapeutic reference work - have not as yet been able to prevent the prescribing of far too many narcotic drugs of the most varied kinds, and have certainly not led to a decrease in the number of addicted physicians.

For the purpose of illustrating prevailing conditions in Germany, this paper will comment first - in the light of statistical data relating to the years 1954-1957 - on the incidence of addiction and on the consumption of narcotic drugs. These comments will be followed by a discussion of a few legal questions of general significance and, in conclusion, by a statement of what are in practice the most important problems of therapy, rehabilitation and prevention. The central figure of this study is throughout the addicted doctor. While it is true that dentists, veterinary surgeons, pharmacists and members of the other para-medical professions in the aggregate represent a large proportion of the total number of addicts, any one of these occupational groups, taken alone, accounts for a substantially smaller share than does the medical profession proper. Apart from these purely quantitative considerations, experience has shown that under the conditions prevailing in Germany an effective control of addiction can come only from the medical profession itself.

1. STATISTICAL DATA

There are both national and international statistics, partly very sound and trustworthy, concerning the production and consumption of narcotic drugs, the licit trade in such drugs and narcotic offences. By contrast, statistical data concerning the extent and effects of various forms of addiction in many countries are very incomplete. This remark is particularly true of statistical data concerning addiction among doctors, even though they form, in all countries, a fairly well organized professional group which should, for that reason, be easy to supervise. This shortcoming is doubtless due in no small degree to a mistaken feeling of professional solidarity, to a misconceived respect for the rights of the individual and, finally, to ignorance of the individual and social consequences of drug addiction, in particular of addiction on the part of a doctor.

The late Mr. P. O. Wolff, at one time the distinguished chief of the Addiction-producing Drugs Section of WHO, referred shortly before his death to the problem of the addicted doctor; one of the points he emphasized was that clarity in this field was desirable in the interests of the medical profession itself. Rasor, Crecraft and Pescor in the United States have each reported on the proportion of addicted physicians in three or four age-groups of patients at the two large institutions for addicts which the federal United States authorities maintain at Lexington and Fort Worth. Vaille & Stern, in the period from 1946 to 1949, noted that there were seventy-five doctors among 687 addicts in France as a whole; in the department of the Seine the 768 cases recorded in the period from 1945 to 1953 included fifty-eight doctors and forty-nine persons connected with other professions in the medical field, including ten wives of doctors, one doctor's daughter, and one pharmacist's wife. In an official report by the United Kingdom Government to the United Nations relating to the year 1954 it was stated that, out of 317 addicts, sixty-nine were medical practitioners, two dental surgeons and one a pharmacist. And from private communications received from certain medical officers of hospitals we gather that in other countries (Austria, the Netherlands, the Scandinavian countries and Switzerland) doctors likewise account for a high percentage of the persons hospitalized by reason of addiction.

Thanks to the painstaking work of those responsible at the Federal Narcotics Bureau (Bundesopiumstelle), in the Public Health Division of the Federal Ministry of the Interior, and at the Federal Criminal Office (Bundeskriminalamt), since 1952 we have had at our disposal a mass of statistical material which, if critically used, is of the utmost value, for it takes into account specifically the extent of drug addiction among doctors and members of other professions in the medical field. To reproduce the voluminous material in toto would exceed the scope of this paper, especially as the reader can be refered to the Government's annual reports to the United Nations. However, for a proper comprehension of this study it is necessary that the reader should have some idea of the number and distribution of the addicts covered by the statistics, with special reference to the medical and paramedical professions and to the nature and frequency of use of the drugs consumed.

Table 1 gives some figures reflecting the trend in the period 1954 to 1957 inclusive. Of the 4,861 addicts covered by the 1957 statistics, 2,791 were males and 2,070 females. The number of new cases each year is slightly over one thousand, while that of the cases deleted is somewhat lower. Of the cases added in 1957, 300 were accounted for by recidivists. What strikes one above all is that the figures are so constant; there are no substantial fluctuations at any point. The shift to 1: 640 in the ratio of addicted members of the dental profession is explained by the fact that about 17,000 dentists (not being medical doctors) were included in the statistics for the first time in addition to the dental surgeons formerly solely considered, under section 19 of the Dentistry Act of 31 March 1952 ( BundesgesetzblattI, 221). The number of addicted pharmacists (less than 10 per 12,000) has become virtually insignificant. The shift in the ratios for all members of the medical and para-medical professions is explained by the inclusion of several professional groups not previously taken into consideration in this sector. Special attention is drawn to the high proportion of medical men in the total number of addicts (12-14%) and in the number of addicted members of medical and paramedical professions (60-68%). The ratio of addicts to non-addicts in the population as a whole, including West Berlin, is about 1: 10,000.

A more careful perusal of the statistical evidence also reveals the gaps and shortcomings of our present system of drug-addiction control. The statistical tabulation was prepared on the basis of the reports which the chief public health authorities of the various Lander compile from the returns of the individual public health offices and which these authorities submit annually to the Federal Narcotics Bureau. At present the only lawful means of identifying and keeping a check on drug addicts is the supervision, by the medical officer of health (Amtsarzt), of the narcotics registers kept by pharmacists pursuant to sections 27 and 28 of the Prescriptions Order (Verschreibungsverordnung) of 19 December 1930. Any-one who comes into contact with drug addicts professionally knows that this system, the only one at present possible in the Federal Republic for determining the abuse of narcotic drugs, is inadequate. Precisely among the more intelligent addicts we must therefore assume the existence of a hidden number which can hardly be estimated.

We also have doubts when we read that 67.2% of the addicts comprised in the 1957 figures had become addicted through the administration of narcotics which was necessary for therapeutic reasons. This internationally customary differentiation between the therapeutic and the non-therapeutic origin of addiction is questionable because, as experience has shown, many addicts seek to veil their past history. In particular, doctors and other members of medical and para-medical professions almost invariably advance a therapeutic pretext. Furthermore, these figures unfortunately conceal the group of " iatrogenous addicts " - a group which can probably never be taken into account in the statistics survey - in whose case one cannot say that the use of narcotic drugs is necessary except on pseudo-therapeutic grounds. In clinical practice, it hardly ever happens that one finds an addict whose addiction is a consequence of the administration of appropriate doses of narcotics for a prolonged period in conformity with a genuine medical indication. According to our experience, genuine therapeutic grounds in the past history of the addicts included in our statistical survey exist in only a very small proportion of the cases, though it is scarcely possible to demonstrate this affirmation statistically. For that reason it seems to me that the customary distinction between the therapeutic and non-therapeutic origin of addiction is unfortunate and calls for revision.

TABLE 1

Drug addicts in the Federal Republic of Germany

 

1954

1955

1956

1957

Number of drug addicts
5 228 5 378 4 784 4 861
Of which members of medical and para-medical professions (per cent)
1 062 (20.3%)
1 088 (20.2%)
1 093 (22.8%)
970 (20.0%)
Of which doctors:
 
 
 
 
Actual figures and as a percentage of the total of addicted persons
723 (13.9%)
737 (13.6%)
687 (14.4%)
586 (12.0%)
As a percentage of addicts members of the medical and para medical professions
64.5%
67.5%
62.9%
60.5%
Ratio of addicted to all doctors
1: 95
1: 95
1: 98
1: 111
Ratio of addicted to all dentists
1: 214
1: 220
1: 228
(1: 640)
Ratio of addicted to all pharmacists
1: 570
1: 670
1: 1 100
1: 1 200
Ratio of addicted to all members of the medical and para-medical professions
1: 570
1: 490
(1: 701)
(1: 750)
Unlawful obtaining of narcotics:
 
 
 
 
(a) By addicts covered by the statistics (percentage of cases)
42.0%
37.0%
37.8%
33.0%
(b) By addicted members of the medical and para-medical professions (percentage of cases)
72.5%
71.0%
69.6%
64.0%

Table 2 shows the frequency with which particular narcotics were used in the years 1954-1957; the percentages were calculated from the data of the Federal Narcotics Bureau. This table likewise does not disclose any notable changes in recent years. About two-thirds of all addicts use the four substances heading the list, viz., morphine, methadone, pethidine and oxycodone. Among the substances less frequently used and not listed in the table, mention should perhaps be made of Pantopon and tinct. opii, which were, respectively, used by 2.4% and 1.9% of the addicts, in 1957.

The preparations of the amphetamine-benzedrine group, which are not internationally recognized as addiction-producing drugs, still play an important part in the Federal Republic, mainly in the form of Pervitin and of the identical preparation Isophen. In the years 1956/57, Elastonon (benzedrine), on the other hand, was taken by only 0.3% of the addicts included in the statistics. According to our experience, the power of Pervitin to produce genuine addiction is relatively slight. If addiction does develop, however, this substance has a marked tendency to produce psychotic reactions. The endeavours to draw as sharp a distinction as possible between addiction-producing and habit-forming drugs - e.g., the new definition approved at the seventh session of the World Health Organization's Expert Committee on Addiction-producing Drugs in 1956 - are most welcome. Experience shows, however, that it is precisely this substance, Pervitin, which is used by many addicts either as a supplementary drug or alternately with a true narcotic or with barbiturates. In the interests of effective control of addiction we therefore continue to urge the inclusion of the amphe-tamine-benzedrine group in the list of narcotic drugs.

TABLE 2

Frequency of use of particular drugs of addiction (percentages)

Narcotic

1954

1955

1956

1957

Morphine
21.40 19.40 19.80 18.90
Methadone
17.50 17.10 18.50 18.80
Pethidine
16.40 14.20 14.70 15.60
Oxycodone
9.80 10.60 10.00 9.10
Pervitin
6.80 6.10 6.20 6.30
Hydromorphone
6.40 6.10 6.45 7.20
Hydrocodone
6.30 5.60 5.60 5.50
Acetyldihydrocodeinone
2.70 4.30 3.80 4.05
Ketobemidone
4.50 4.20 4.30 4.40
Levorphanol
2.80 2.60 2.85 2.90
Codeine
0.90 0.60 0.60 0.70
Extr. opii
0.60 0.95 0.80 0.60
Cocaine
0.09 0.10 0.10 0.05

A further feature observed by clinicians is the substantial increase in the number of addicts using several drugs with different effects. Such cases are particularly common among doctors, who use concurrently a number of drugs some of which have contrary effects (such as amphetamine and barbiturates) in addition to opiates proper. The statistical record, which shows that about 25% of the addicts included in the 1957 statistics took two or more narcotics at the same time, seems to me only partially to confirm this observation. The combinations mainly used were combinations of natural, or unconverted, with synthetic narcotics.

2. FORENSIC PROBLEMS

Although the purely numerical incidence of drug addiction is relatively low in modern Germany, regulations concerning narcotics and to some extent even a specific practice built up by the courts are found in nearly all branches of law. These statutory provisions are applicable with special force to doctors and other members of the medical and para-medical professions, and in the relevant case-law the same group of persons plays a prominent part.

Turning first to criminal law, we may note, as a preliminary observation, that the drugs of addiction at present commonly used in Germany are of only trifling significance as a factor leading to crime. When in the official language of the police statistics on crime reference is made to drug criminality or drug offences, the offences in question belong to one of the following three groups:

  1. Illicit trade in or smuggling of narcotics;

  2. Unlawful obtaining and possession and unlawful transfer of narcotics;

  3. Offences under the Narcotic Drugs Prescriptions Order of 19 December 1930, as amended.

According to the police statistics on crime, 1,371 new cases of drug offences were reported in 1957. They accounted for only 0.08% of the total number of criminal offences reported, and the number of narcotics offences per 100,000 inhabitants was only 2.5. Even without further evidence, these figures prove that "drug criminality" hardly constitutes the central feature of the addiction problem in Germany. What is more important in this connexion, however, is that, according to the statistics (reproduced above) of the Federal Narcotics Bureau, 65% of addicted doctors and 64% of all addicted members of the medical and allied professions came into possession of narcotics unlawfully, by such means as the use of unjustified prescriptions, falsely pretending to be suffering from disease, wrongfully prescribing for another person, the forgery of prescriptions, the theft of prescription forms, and so on. In recent years, however, never more than two-thirds - and sometimes only one-half- of these offenders figured in the returns of the criminal law enforcement authorities as well.

In the field of criminal law the medical expert is often faced with very difficult problems in the certification of addicts, especially addicts of his own profession, in the light of the provisions concerning responsibility and irresponsibility. All attempts to find a universally applicable formula are, in present-day circumstances, doomed from the outset to failure. It has become more difficult than it used to be to recognize drug addiction in medical practice, because the classic clinical picture of morphinism has become rarer. No reliance can be placed either on contraction of the pupils -a much-quoted symptom-or on withdrawal symptoms. It is a matter of general clinical experience that even in a straightforward case of morphine addiction the abstinence symptoms are now seldom observed in the intense and conspicuous form which used to be so familiar in the past. At the moment it is not possible to give a convincing explanation of this peculiar change in the clinical picture of addiction and withdrawal. One reason is certainly the use of new drugs and the combination of several drugs. Another reason is that most of the semi-synthetic and synthetic analgesics of opiate character produce fewer withdrawal symptoms. In the case of an addict using methadone, benzedrine and barbiturates in combination, the phenomenon of drug craving is, for physiological and pharmacological reasons alone, different in nature from that traditionally associated with "classic" morphinism.

Accordingly, a separate and thorough investigation in each individual case is necessary to determine whether and to what extent the capacity to act with discernment - and in some cases the capacity to discern-was, at the time of the offence, diminished either through the action of narcotics or through abstinence phenomena. Under section 51 (2) of the Penal Code, it is a condition of any mitigation of the penalty that there must have been substantially diminished responsibility. The psychopathy which so often can be diagnosed in an offender who is an addict does not, per se, as a personal factor, constitute a diminution of responsibility sufficient to satisfy the condition of the Penal Code. Subject to the qualifications, the conditions laid down by section 51 (2) of the Penal Code may be said to be present in offences which, by reason of their motivation, are connected with the phenomena of addiction or withdrawal, and especially in offences whose purpose is to obtain narcotics for the offender's own use. In rare cases, where there is a serious disturbance of consciousness or a pathological disturbance of mental functions in the state of acute intoxication with symptoms indicating a psychosis, or where there hasbeen a profound change of personality (e.g., through the abuse of drugs over a period of many years), the conditions of irresponsibility within the meaning of section 51 (1) ofthe Penal Code may be present.

The provisions of the criminal law specifically applicable to addicted doctors are contained in section 42 (1) of the Penal Code. The court may debar the offender from the exercise of his profession for a period up to five years if he has committed an offence which, in addition to constituting an abuse of the profession or a gross breach of his professional duties, is punishable by imprisonment for a term of not less than three months, and if the ban on his practising is necessary for the purpose of protecting the public against further risk.

Provisions affecting members of the medical and allied professions are embodied in the "Act concerning Dealings in Narcotics" (the Opium Act), of 10 December 1929, as amended, and in the "Orderconcerning the Prescription of Medicaments containing Narcotic Drugs and the issue of such Medicaments by Pharmacies", of 19 December 1930, as amended. By virtue of the Constitution of 23 May 1949, these provisions, forming part of the law of the former Reich, were continued in force and are now federal law. The aforesaid Opium Act and the order have left scarcely any loophole by which a person who is patently a drug addict can escape a conflict with the law. Under section 10 (1) of the Opium Act a person who contravenes any of the Act’s provisions - which contain an elaborate catalogue of the numerous forms the offences may take - is liable to a term of imprisonment of not more than three years, or to a fine, or to both penalties, in so far as he is not liable to a more severe penalty under some other provision of the penal law. Under section 3 (4) of the Opium Act, pharmacies holding a trading licence and general authorization granted by the Narcotics Bureau may acquire and convert narcotic drugs, and may deliver such drugs against presentation of a prescription made out by a physician, a dental surgeon or a veterinary surgeon. The supplementary provision - which affects the medical practitioner-of section 6 of the order reads: "The medicaments may not be prescribed except by a medical practitioner, a dental surgeon or a veterinary surgeon and may be so prescribed only if the administration of the narcotic drug in question is justified by medical, dental or veterinary considerations." This provision, which seems so gratifyingly clear, is overlaid in the subsequent sections (sections 7 to 20) of the order with an almost bewildering mass of detailed regulations.

The placement of an addict in an institution for the purposes of a withdrawal cure and rehabilitation is in practice the biggest problem facing the medical expert, and is at the same time the central problem of addiction control in the Federal Republic of Germany. According to the principles of treatment applied in the Federal Republic, withdrawal treatment cannot be given effectively except in a closed psychiatric institution. According to prevailing legal opinion, it is deprivation of liberty (Freiheitsentziehung) within the meaning of section 104 of the Constitution to place a person in such an institution without either his explicit consent or a court order. Voluntary placement and voluntary submission to a withdrawal cure are of doubtful effectiveness, since the addict is not only free to leave at any time, but does in fact leave if for any reason the situation becomes too uncomfortable for him, or if he, or his relatives or his lawyer should take the view that he is cured and no longer in need of treatment or supervision. For this reason many nursing establishments decline to carry out a withdrawal cure unless the patient is committed to the establishment under a court order.

The compulsory committal of a drug addict may be ordered by virtue of provisions of the criminal law or, as the case may be, of administrative or police regulations. Committal under criminal law- a procedure that has yielded satisfactory results in Berlin, for example - cannot be ordered except on proof of the commission of a punishable act. The procedure is as follows: first, the police authorities satisfy themselves by evidence that an abuse of narcotics has occurred and that the narcotics were obtained by unlawful means; after the medical officer or medical specialist has conducted an examination and expressed the provisional opinion that a case of drug addiction is involved - or that there are grounds for suspecting drug addiction - and that at the time when he committed the punishable acts in question the responsibility of the person concerned was at least substantially diminished, the judge makes an order, under section 126 a of the Code of Criminal Procedure, for that person's temporary committal. If the criminal and medical aspects of the case are confirmed by the preliminary inquiry, which is carried out with the greatest possible dispatch, then, if the addict is declared to be either a person with diminished responsibility or an irresponsible person, he is committed to an institution for treatment and care pursuant to section 42 b of the Penal Code. Success depends on the speedy completion- in a period of about four weeks- of the proceedings before the court of first instance.

In this connexion attention should be drawn to one other provision of criminal law which constitutes an innovation (most welcome from the point of view of social psychiatry) in the control of addiction. Under sections 23 to 25 (new) of the Penal Code, which were introduced by the Criminal Law (Amendment) Act of 25 August 1953, a sentence of imprisonment for a term not exceeding nine months may be suspended and probation ordered in its stead; the period of probation lasts not less than two and not more than five years. Under section 24 (1) (3) of the Penal Code the court has the power (among other powers conferred on it) to order the convicted defendant, during the term of probation to submit to medical treatment or to a withdrawal cure. If the prisoner fails to obey this order - i.e., if he fails to observe the conditions of his probation - then the court revokes the suspension of the sentence.

For the time being, the procedure for the compulsory committal of an addict under administrative or police regulations is governed by the provisions of the so-called Deprivation of Liberty Acts, which have been enacted to give effect to section 104 of the Constitution at various times since 1949 in the several Landerof the Federal Republic (except Bremen, Rhineland-Palatinate and the Saar, in all of which, however, appropriate orders have been enacted). This is not the place for a detailed description and analysis of the legislation, and the reader is therefore referred to the relevant literature (Ehrhardt (3)). Doubt concerning the procedure's efficiency is reinforced if it is considered that in Berlin, for example, scarcely a single addict has been committed under the Deprivation of Liberty Act in recent years, whereas in Lower Saxony between one-half and two-thirds of all addicts compulsorily committed were committed under this procedure. One of the most serious defects of the system under which deprivation of liberty is regulated by Landerlegislations is the lack of uniformity in the law (or lack of uniformity in the interpretation and application of identical provisions).

It is to remedy these defects that the German Society for Psychiatry and Neurology (Deutsche Gesellschaft für psychiatrie und Nervenheilkunde) has for years been advocating the enactment of federal legislation dealing with the welfare of mental patients and addicts. As yet, however, only a number of drafts have been prepared. It is an unfortunate fact that in many other countries statutory enactments are likewise in force which, in utter disregard of medical considerations, regulate so serious a public health matter from the purely legal standpoint. The present opportunity is therefore taken to emphasize that, in the case of a mental patient or a drug addict, deprivation of liberty, being an essential component of the treatment, is a specifically medico-psychiatric measure which, by its intrinsic meaning and purpose, is wholly distinct from deprivation of liberty whose object is, for instance, coercion or punishment. Deprivation of liberty, in the case of a mental patient, is more than mere confinement in a particular place. An intelligent and serviceable Welfare Act for mental patients and drug addicts can have no value and no practical effectiveness unless it is matched by a readiness thoroughly to re-examine certain legal concepts with a view to determining their content of truth and the extent to which they reflect reality.

Let us now consider the procedure employed for the committal of an addict against his will under the Deprivation of Liberty Acts now in force. To begin with, there must be proof of addiction to drugs or to alcohol; in addition, there must be, in consequence of the addiction, a serious danger to the person himself or to the community at large. The committal order, or the decision concerning the propriety of making such an order, is made by the competent district judge on the application of the administrative (public health) authority or of the police. The application must be accompanied by the medical specialist's or medical officer's certificate or opinion relating to the mental condition of the person concerned and confirming the need for his committal; the certifying medical officer must have carried out his examination not more than fourteen days previously. In addition to this regular procedure, which is complicated, all these Deprivation of Liberty Acts make provision for an emergency or summary procedure by which a patient may, if he constitutes a public danger, be committed - at the instance of the police authorities, for example - to a closed institution either directly or through the intervention of the medical officer. The measure must be reported without delay to the district court and to the administrative authority, as the court's decision must be given at the latest by the end of the day following that of the patient's admission to the institution. In addition, all the Acts contain diverse provisions concerning temporary or provisional committal for a period varying from six weeks to two or three months for purposes of observation and the preparation of an expert opinion or for the purpose of determining the presence of other conditions which have to be fulfilled before a definitive committal order can be made (in the case of a drug addict such an order may not provide for confinement for a term of more than two years).

Even though their operation is hampered by cumbrous detail (in certain Lander the appearance of counsel on behalf of the patient is mandatory), these Acts nevertheless offer perfectly suitable machinery for the purpose of the committal of an addict who has not yet violated provisions of the penal law, with a view to a withdrawal cure or rehabilitation. In practice, the procedure is often frustrated by inadequate co-operation among the officials and official bodies concerned - the medical officer, the judge, the administrative authority and the police - and through failure fully to recognize or to assess adequately the peculiarity and degree of dangerousness of the addict's drug addiction and personality. Where drug addiction is demonstrably present, there is always a substantial degree of danger either to the addict himself or to the public. It is immaterial whether police offences have in fact already been committed or whether there is present or imminent danger to life and limb; the decisive factor is the "potential dangerousness" which, according to general medical experience, is inherent in the subject's mental condition or addiction. If, for the purpose of proving how dangerous an addict is to himself, evidence must first be produced of the ruin which he has brought on his family and on himself, then there is hardly any need for legislative provisions concerning committal. What is involved here is a question of interpretation - and by no means a new one - which it ought surely to be possible to solve if all concerned show a measure of common sense, a sense of proportion and goodwill.

The fact is that, notwithstanding the abundance of the possibilities open under statutory provisions, there are still considerable obstacles in practice to the committal of a drug addict, and that there is an appreciable lack of uniformity in the approach to such committal in the territory of the Federal Republic. Because there is at present in this country a widespread and pronounced reluctance to interfere with the rights of the individual, an attitude which has its origin in an exaggerated or misdirected concern for constitutional principles, the consequence in not a few cases is that the addict is protected from necessary and, more particularly, from timely treatment.

In civil law, as in criminal law, the medical expert's opinion concerning an addict has to be based entirely on the specific circumstances of the particular case. Only rarely will it be possible to prove total "legal incapacity" within the meaning of section 104 (2) of the Civil Code in the case of an addict. "Placement under guardianship" on account of mental illness, for which provision is made in section 6 (1) (1) of the Civil Code, is likewise exceptional in the case of addicts. One possibility in such a case is the placement under guardianship by reason of impaired mental faculties, of which the consequence in law is a limited legal capacity of the person concerned to manage his affairs.

What is important is that under articles 1631 and 1800 of the Civil Code an addict who is placed under guardianship may, against his will, be placed by his guardian in a closed psychiatric clinic for a withdrawal cure and rehabilitation. Under section 1906 of the Civil Code an order for provisional placement under guardianship may be made which offers interim protection to a person who is to be deprived of legal capacity; before such an order can be made there must be an application and proof that the person or property of the individual is in jeopardy (he must have attained the age of majority). This practice has also failed to achieve general application in the case of addicts, first because it is often difficult to find somebody who is prepared to make the necessary application, and secondly because many courts interpret the concept of jeopardy inadequately in cases of drug addiction.

An order for an administration of affairs under section 1910 of the Civil Code is likewise of questionable value in the case of a drug addict. In the exceptional cases in which such an order is made with the subject's consent, he is free at any time to apply for its revocation under section 1920 of the Civil Code, and this is what generally happens either at the time of his committal to a clinic or at any rate as soon as the difficulties inherent in a withdrawal cure begin to make themselves felt. An order for the administration of his affairs cannot be made without the consent or against the will of the subject unless an understanding with him is impossible. This condition, if narrowly or even literally interpreted by the judge, is inapplicable to many addicts, even in cases where the medical diagnosis and the social prognosis are perfectly clear. Experience has shown that only statutory provisions which can be administered speedily and flexibly are truly useful for the purposes of the effective treatment and control of addiction.

For the purpose of other civil law matters (capacity to testify, capacity to participate in judicial proceedings, testamentary capacity, capacity to commit a wrong, and divorce) the rules for determining the psychiatric condition of drug addicts are a logical corollary of those described above.

3. THERAPY, REHABILITATION AND PREVENTION

Medical treatment in the form of a withdrawal cure to wean the subject of his addiction is only one aspect of addiction control and, taken alone, does not, unfortunately, hold out more than a limited prospect of success. The control relies heavily on preventive measures, which can be implemented only with the support of the authorities- i.e., by the State. The statutory provisions cited above, and more particularly the Opium Act of 1929 and the Prescriptions Order of 1930, have in some cases made it so difficult to obtain drugs that certain forms of addiction- such as addiction to heroin or cocaine- have become practically negligible in Germany.

In modern Germany , drugs of addiction reach the consumer almost exclusively through the doctor and the pharmacist. There is virtually no illicit traffic or smuggling of narcotics in the Federal Republic. On account of this state of affairs doctors as a group have an added responsibility, for it is on their attitude that the future development of drug addiction in the Federal Republic of Germany will depend in the main. Neither our statutory regulations- which while somewhat prolix and complicated are nevertheless serviceable in themselves- nor the constantly repeated appeals to the sense of responsibility of the doctors have succeeded in curbing to any material extent the prescription of the most varied kinds of addiction-forming or habit-forming drugs with inadequate justification or with no justification at all.

The competent medical organizations have repeatedly tackled these problems. At the forty-seventh Conference of German Physicians and Surgeons (ärztetag), held at Danzig in 1928, the general theme was " The dangers of narcotic drugs to the German people, and how to control them ". The rapporteurs were Dr. Gaupp, the psychiatrist, of Tübingen, and Dr. Rost, of the then Reich Office of Public Health, Berlin. They proposed twelve" guiding principles ", and these were accepted by the conference as binding on the entire German medical profession (Ehrhardt (2)). It was also urged at that conference that the legislation should be supplemented by provisions under which medical practitioners would be liable to the withdrawal of their licence to practise. These guiding principles have become obsolete in a number of respects. Some of them were embodied in the Prescriptions Order, 1930. while others had to be supplemented in the light of more recent knowledge of addiction and its control.

The next important step in the control of addiction took place in 1943 on the initiative of the Reich Medical Chamber (Reichsärztekammer). After consultations with leading psychiatrists, " guiding principles for the treatment of doctors addicted to morphine" were formulated with the approval of the Society of German Neurologists and Psychiatrists. These principles contain elaborate details concerning the withdrawal cure, while ignoring completely such important practical questions as finance, the appointment of a locum tenens, the conditions governing applications for the suspension of the licence or the revocation of the licence. At any rate, the technique of the withdrawal cure is no longer of paramount interest in Germany; for that matter, it is described in every textbook on psychiatry. Of much greater importance is the creation of the necessary preliminary conditions for long-term rehabilitative treatment of lasting effect.

Directives intended to be applied generally in the treatment of addicts and taking modern opinion into account were published in 1955, on the proposal of the German Society for Psychiatry and Neurology, by the Executive Committee of the Conference of German Physicians and Surgeons under the title Guiding principles concerning the dangers of drug addiction and concerning the control of addiction (cf . ärztliche mitteilungen, 40 : 897, 1955). These directives largely coincide with the principles elaborated for the World Health Organization by a study group and published under the title Treatment and Care of Drug Addicts (WHO Tech. Rep. Ser. 1957, page 131). However, it should be stressed that most German clinicians continue to regard abrupt withdrawal as the method of choice.

It is axiomatic that the treatment should be carried out early and as thoroughly as possible and with a view to the optimum prophylactic effect. The out-patient treatment of drug addiction is not successful, and is therefore a breach of the doctor's professional duty. The treatment, which cannot be carried out elsewhere than in a closed psychiatric department or clinic, is divided into two phases: withdrawal (taking four to eight weeks) and rehabilitation (generally taking six months). The two phases together constitute a single obligatory therapeutic unit. Rapid withdrawal is the method preferred. Whether and to what extent the abstinence phenomena are obviated by medication- for example by the administration of phenothiazine or reserpine preparations- depends on the psychotherapeutic picture, which is also very important for the success of the cure. The cure - i.e., the process of weaning the patient of his addiction - should be invariably effected in hospital departments having adequate facilities for appropriate and varied occupational therapy and for individual and adaptable psychotherapy, since experience has shown that only a therapeutic technique offering this combination holds out any favourable prospects of successful rehabilitation. Even after the completion of the actual withdrawal cure and weaning process, continuous supervision for about two years is necessary, together with further psychotherapeutic care, if needed. Fundamentally, the doctor should look upon the addict as a sick person, and not as a criminal or depraved person. This approach must not, however, prevent the doctor from resorting to anti-addiction measures which are medically necessary and permitted by the law.

As has been stressed repeatedly, the control of drug addiction in Germany is primarily a problem of the medical profession as a whole. Only doctors themselves can change the present depressing state of affairs by specific measures of voluntary self-discipline, which are, after all, in the interest of all their colleagues. Unfortunately, what has been done so far in this direction is insufficient. The urgency of the problem was emphasized once again at the Conference of German Physicians and Surgeons in 1951, the central theme of which was "The control of addiction". At that time, the incidence of drug addiction in the medical profession was estimated at about 3 per cent, of which only about 1% is reflected in the statistics. An attempt - but unfortunately not a very successful one - to remedy this situation is embodied in the Directives to be observed in the treatment of potential and actual drug addicts in the medical profession, which were published by the Executive Committee of the Conference (together with the "guiding principles" mentioned earlier) on 20 October 1955.

The present version of the" directives" originated in a proposal submitted by the Scientific Advisory Board of the Federal Chamber of Physicians (Bundesärztekammer) which had been elaborated by representatives of the society of neuropsychiatrists in conjunction with representatives of the societies for forensic medicine and pharmacology. Unfortunately, some of the vital points in the Advisory Board's proposal have been either omitted or else amended in important respects.

To begin with, emphasis is placed on the idea of fraternal assistance for the addicted doctor. It is recommended that the local Chambers of Physicians (ärztekammern) should make one or more medical specialists responsible for advising addicted colleagues. For this purpose, the medical officer, or the physician in charge of a hospital, reports to the specialist any members of the medical profession who are suspected of being drug addicts; the wives of such addicts or suspected addicts are warned of the dangers of the addiction and informed of the need for a withdrawal cure and of the facilities available for assistance in meeting financial difficulties during the period of rehabilitation. The addict, or suspected addict, is invited to enter a closed psychiatric department or clinic voluntarily. Only if the doctor concerned agrees to submit to the regulations - embodied in the "guiding principles" - concerning withdrawal, rehabilitation and subsequent supervision may the Chamber of Physicians support him by appointing a locum tenens and furnishing a loan. If an addicted doctor who has undergone appropriate treatment suffers a relapse, the suspension of his licence is to be applied for; if, in addition, he commits a criminal offence steps may have to be taken with a view to the revocation of his licence.

As is evident from the official statistics of recent years, the new "directives" have had no influence either on the incidence or on the control of drug addiction in the medical profession. In thecase of about 55 per cent of the addicted doctors included in the statistics in 1957 no restrictions whatsoever were imposed concerning the prescription of narcotics; in the case of 24 per cent, the public health authorities imposed an embargo on the prescribing, or on the receipt of supplies, of narcotics; 10% were temporarily suspended from practice; and 7% were permanently disqualified from exercising their profession. In the case of 4% of the addicted doctors, the proceedings instituted had not yet been completed.

Conspicuously absent from the "guiding principles" and "directives" in their present form is the check on narcotics prescriptions which the Scientific Advisory Board proposed as an internationally recognized and proved measure of addiction control in countries in which the general situation is comparable. The checkingof prescriptions, which has proved effective in about fifteen States, should accordingly be recommended in the strongest terms. Narcotics should never be prescribed except on numbered prescription forms, with duplicates, issued by the authorities. This would constitute reliable machinery for supervising prescriptions and serve as a safe-guard against forgery and theft. In addition, for the purposes of an effective system of addiction control the following measures are necessary: the compulsory reporting of all persons who receive narcotics for a period of more than four weeks; a central register of all persons requiring, and of all persons addicted to, narcotics; energetic action against doctors who relapse into addiction and doctors who commit criminal offences; the establishment of joint committees in the Chambers of Physicians to implement and supervise these measures. A particularly delicate problem in the field of addiction control, and one which can be only briefly touched upon here, is the timely identification of new medicaments as addiction-producing drugs and the determination of their relative intrinsic therapeutic value.

In the fight against drug addiction, especially among doctors and other members of the medical and para-medical professions, some interference with the rights of the person cannot be altogether avoided. Only too often, the right time for treatment, with good prospects of success, is missed owing to a misconceived sense of professional solidarity. The consequences, which are usually serious, have to be borne not only by the addicted doctor himself and his family, but also by the medical profession as a whole and, last but not least, by the patients. While it is true that the addict is himself a sick man, drug addiction is not simply a "disease" that can be treated and cured as, for example, a case of pneumonia. Precisely for this reason the emphasis in the control of addiction should be laid on prevention, and success will depend in the last resort on the sense of responsibility of the doctors and on their willingness to assume responsibility.

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