Barbiturate intoxication and addiction as a public health problem in Oslo
An essential prerequisite for obtaining reliable information about the frequency of the various forms of drug addiction in a population group is that suitable case-finding methods which are both accurate and cheap should be available. Until a comprehensive investigation of a representative group has been made by such methods, any assumptions we may make as to the extent of the drug addiction problem in the community are bound to be based on conjectures and therefore unreliable.
Author: Erik Kass, Nils Retterstöl, Tollak Sirnes
Pages: 15 to 28
Creation Date: 1959/01/01
Tollak Sirnes Ulleval Hospital, ward IX (Head: Prof. Dr. H. J. Ustvedt) and the psychiatric ward for men (Head: Dr. Per Anchersen)
An essential prerequisite for obtaining reliable information about the frequency of the various forms of drug addiction in a population group is that suitable case-finding methods which are both accurate and cheap should be available. Until a comprehensive investigation of a representative group has been made by such methods, any assumptions we may make as to the extent of the drug addiction problem in the community are bound to be based on conjectures and therefore unreliable.
The difficulties in getting such a mass investigation of drug addiction carried out in a representative population group are almost insuperable, if only because it cannot be expected that the kind of intimate psychiatric examination required, including corroborative information from the patients' relatives, will be possible in the case of persons selected at random. At the present time, this sort of investigation represents the best available case-finding method.
To provide something potentially useful in the absence of such a method, we thought it might be worth while investigating the extent and the social consequences of drug addiction over a two-year period among the patients of an internal medicine department of a hospital where in-patients suspected of suicidal tendencies or drug addiction must be assumed to be willing to agree to a thorough psychiatric examination by psychatrists attached to the department as members of the medical staff. With a psychiatric service closely linked to a medical department in this way, there is less likelihood of any drug addiction case admitted on other grounds failing to be recognized.
As it seemed likely a priori that many of the patients admitted to the ward for treatment of acute narcotic intoxication would prove to be drug addicts, we shall deal first with this category of patients principally from the psychiatric point of view.
ACUTE CASES OF BARBITURATE INTOXICATION
A long series of investigations have shown that barbiturates are the means most frequently employed in cases of suicide, or attempted suicide. In England and Wales, for example, eight times as many persons committed suicide by means of barbiturates in 1954 as in 1945 ( [ 1] ). In most statistics of attempted suicide at the present time barbiturate intoxication accounts for about 70% of the cases. It is therefore natural that attempted suicide cases should primarily be placed in the internal medi-
On the subject of barbiturates, see Bulletin on Narcotics, vol. IV, No. 3: WHO Expert Committee on drugs liable to produce addiction; vol. VIII, No. 2: Report of the Interdepartmental Committee; vol. VIII, No. 3: Illicit traffic in narcotics; vol. IX, No. 1: WHO Expert Committee; vol. IX, No. 2: Abuse of barbiturates. The problem of barbiturates in the United States.
cine ward. Lingjærde & Romcke ( [ 2] ) found, for example, in their research on changes in the composition of an internal medicine ward over the period 1935-1952 that narcotic intoxication cases had more than doubled in number during that time - from 0.75% to 1.6%. It seems clear that barbiturates are the commonest means of suicide today. There are many reasons for this. The range of their therapeutic effectiveness is relatively narrow. The dose needed to induce tranquillity or sleep in persons suffering from acute anxiety is not much below the dose which, unless treatment is given, produces fatal intoxication. Barbiturates represent a painless method of suicide. In addition they are within reach of most potential suicides because they are widely used in psychic illnesses. It is difficult to say whether the absolute figures for suicide and attempted suicide have increased because barbiturates are easily accessible in so many homes, but Wiingaard ( [ 3] ) may be right in asserting that whereas at one time domestic rage was vented on the crockery, people nowadays take a pull at the medicine bottle.
Relatively few studies have been made in Scandinavia which throw light on the psychiatric aspects of cases of attempted suicide with barbiturates admitted to internal medicine wards. Dahlgren's findings ( [ 4] ) cover not only internal medicine departments of hospitals, but also psychiatric departments, which accounts for the high incidence of psychoses (35%).
Nor do Krane's ( [ 5] ) researches cover data on intoxication which can be regarded as typical of an internal medicine ward. Krane reviews the cases of attempted suicide admitted to Ulleval hospital between 1940 and 1948, and referred for polyclinic psychiatric examination. Only a fraction of attempted suicides are subjected to such examination.
Ettlinger and Flordh ( [ 6] ) carried out a psychiatric examination of 500 attempts at suicide among 457 patients who were at one time or another admitted to various wards of Soder hospital. They found that barbiturates were used in 73% of instances. In 58% of the cases of attempted suicide, the patient's condition was dangerous, in 34% it was felt that the patient needed to be kept under observation, and only 7% of the cases were regarded as harmless. The majority of cases were in the 20-40 age group, and were either divorced people or persons receiving public assistance. The most frequent causes of suicide were found to be conflicting passions, generally sexual or domestic in character. Other common causes were abuse of alcohol, economic troubles and housing difficulties.
In 66% of the cases, personality disorder symptoms were present. The men generally showed lack of moral fibre and a psychopathic condition; the women immaturity and emotional instability. Fifty per cent of the cases were transferred to the psychiatric ward.
The rest of the material available from non-psychiatric departments does not cover cases which have undergone systematic psychiatric examination; in some instances, the compilers themselves call attention to this lacuna, especially where the purpose is to analyse the motives underlying attempted suicide and the seriousness of the attempt. Matrimonial and sexual conflicts seem universally to be a frequent cause of attempted suicide, especially among women.
We have gone through the case histories of patients admitted to ward IX, Ulleval Hospital, between 1 November 1955 and 31 October 1957, where the diagnosis was narcotic intoxication.
Since 1 November 1955 a regular system of psychiatric care has been operating in ward IX. One or other of the house physicians or assistant physicians in the psychiatric department for men has been assigned to ward IX for a period of six months at a time on a half-day basis. The psychiatrist is taken on to the strength of the medical ward, takes part in the examination of new patients, and is considered by both patients and staff as one of the ward doctors. By going through the case records and interviewing the incoming patients, the psychiatrist forms his impression as to which patients need psychiatric attention. The doctor in charge, the house physician or the assistant physician may order special psychiatric examination for patients who during their stay in the ward appear to need it. This system means that more patients are given psychiatric study than under the previous system when there was only a polyclinic service. Out of a total of 3,751 patients treated during this period of two years, 606 in all, or about 16%, were subjected to such examination, whereas under the old system with the polyclinic service, only about 4% were similarly examined.
As a regular practice, all cases of poisoning are sent for psychiatric examination. The only exceptions are cases of obvious accident or clearly unintentional intoxications where the patient is discharged at once. The fact must also be considered that some of the patients are admitted while the psychiatrist is away on holiday. The type of psychiatric examination carried out has been, on the whole, more thorough than is usual with the general polyclinic examination. The actual conversations with the patients have been longer and the psychiatric case histories which are written up have on the whole been on a par with the basic case histories in the psychiatric observation ward. In addition, conversations between the patient and the psychiatrist are often incorporated in the case history; and wherever possible, corroborative information has been obtained, and some of it is of decisive importance in getting anywhere near to the real situation in the case of patients in whom the conscious or unconscious play of fantasy is more evident than with most other psychiatric or internal medicine cases. In a number of instances supplementary information is obtained from the psychiatric departments in Ulleval Hospital.
The barbiturate content of the serum is determined by a spectrophotometric method described by Per Lous ( [ 7] ). The results obtained by this method for N-methyl derivatives such as Enheksymal are insignificant or negative.
Acute Cases of Barbiturate Intoxication
During the two-year period covered by the study, 207 cases admitted to the ward, or 5.5% of the total admissions, were diagnosed as narcotic intoxication. Of these 207 cases, 137, or about 66%, were cases of barbiturate intoxication.
Distribution by Age, Sex and Marital Status
The cases of acute barbiturate intoxication comprised 81 women and 56 men; 63 were married, 37 unmarried, 24 divorced or separated, and 13 widowed. The age distribution is shown in table 1. There does not seem to be any indication of predominance of a particular category, except that of the patients under twenty, all six were women.
Age and sex distributionof 137 barbiturate intoxication patients
In 35 cases (26%) it was impossible to obtain accurate information about the type of barbiturate used. The diagnosis of barbiturate intoxication in these cases was based on the presence of barbiturates in the serum. In 34 cases, the drug used was Pentymal (5-ethyl-5-(3 methylbutyl)-barbituric acid), in 30 cases Allypropymal (5-allyl-5-isopropylbarbituric acid) and in 6 cases, Hexobarbital (5-methyl N-methyl-5-cyclohexanyl-barbituric acid). Slower-acting barbiturates were less often employed. Fenemal (5-phenyl-5 ethylbarbituric acid) was used in 13 cases and Diemal (5-diethyl barbituric acid) in one case. Analgesics with a barbiturate content, generally Diemal or Fenemal, had been taken in 17 cases. In 9 cases, barbiturate intoxication was combined with another narcotic, usually of the morphine type. In 37 cases, alcoholic intoxication was diagnosed at the same time.
Barbiturate Concentration in the Serum
In 35 cases, no barbiturate content in the serum was established. These were mostly slight cases where during anamnesis reliable information that barbiturates had been taken was available. In 14 cases, the test was negative. The patients had taken fast-action drugs, and had been sent to hospital relatively late. In 7 cases, only traces of barbiturates were found. The other 81 patients showed positive quantities averaging 3.4 mg/100 ml, all except 4 being less than 10 mg/100 ml. The highest figure was 30.5 mg/100 ml in a patient who died shortly after admission. In 26 patients, who were comatose when admitted, the barbiturate concentration, where known, averaged 3.6 mg/100 ml.
The medical treatment proper was of the kind which is now common. Where not too long a time has elapsed since the barbiturate were taken, aspiration is carried out, with a ventricular lavage and use of carbon granulate where necessary. The anaesthetist is often called in to ensure that the air passages are free, and to assist his colleagues generally. Antishock therapy with control of the fluid balance and supply of oxygen is of vital importance. Treatment of the patient with antibiotics and change of surroundings are part of the general therapy. Analeptics of the old type were not used. But in 10 cases, beta-ethyl-beta-methyl-glutarimid and 2,4-diamino-5-phenylthiazol hydrochloride were used.
In 37 cases, the patients were comatose when admitted, and 20 of them showed clear signs of shock. Aspiration was carried out in 47 cases. The anaesthetist was called in to 20 patients. In 14 cases, the treatment was considered decisive in curing the illness and possibly in saving the patient's life.
Seven patients - 2 women and 5 men - suffering from barbiturate intoxication died (ca. 5%). Their average age was 66.6 years, the youngest being 57 and the oldest 86. Two of the patients had taken Allypropymal, and 3 had taken barbiturates "with lasting effect ". In 2 cases, the barbiturates used were unknown, and 2 of the patients who died were suffering from incurable diseases of which they were aware (myelomatosis, cancer of the prostate with metastasis).
In all, 117 of the 137 cases of barbiturate intoxication were examined by psychiatrists. The method of diagnosis used is multi-dimensional like that employed at the psychiatric clinic for men, Ulleval hospital. This means not only that the diagnosis is made on the basis of the most salient characteristic in the actual clinical condition (reaction diagnosis), but that an effort is also made to determine the underlying personality (personality diagnosis) and the circumstances which may have been decisive (situation diagnosis). The psychiatric diagnoses are set forth in table 2.
Interpretation of the Significance of the Suicide Attempt
It may be difficult to decide whether the attempt at suicide was made in earnest, whether the poisoning is an attempt by the patient to convince his relatives of his suicidal intentions, or whether a pure "accident" has occurred. We therefore confined ourselves to a close investigation of those patients who had undergone a psychiatric examination. We found it relatively simple to exclude cases where on the whole it was not the patient's intention to poison himself, although of course from the viewpoint of depth psychology an apparent "accident" may perhaps still conceal unconscious death wishes. Proceeding on this principle, we concluded that in
Psychiatric diagnoses of 117 patients admitted to hospital with acute barbiturate intoxication
a Of the alcohol and drug addicts, 10 also had a diagnosis of depressive neurosis, 1 a hysteric reaction, 1 a diagnosis of delirium and 2 of behaviour disorders.
27 of the 117 cases examined there was probably no real intention on the patient's part to commit suicide or to make his relatives believe that his life was in danger. Thirteen of these 27 were cases of overdoses taken by addicts. (By acquiring a tolerance to the drug, the addict has to take larger and larger doses in order to reach a state of euphoria, and he may find himself taking so much that he loses consciousness.) In a state of alcoholic intoxication, too, a patient may continue taking tablets till he becomes unconscious. This was what happened in 10 of the 27 cases. In 4 cases the accident happened in a state of sobriety. One case was an instance of the phenomenon which has been called "tablet automatism" or "serial consumption" ( [ 8] ), a process which is certainly more frequent than diagnosis can show. Now and then when barbiturates fail to induce sleep a sort of twilight zone can envelope the patient so that he does not remember that he has already taken the medicine in the prescribed dose. It may thus happen that without realizing the fact he takes all the tablets within reach. A wrong diagnosis of suicide may then be made if he does not wake up, since in actual fact what has happened is an accident. If he regains consciousness, he will as a rule be suffering from amnesia as regards the period when he was half conscious, and will not even be aware if the act of swallowing the tablets was due to suicidal intentions at a certain stage. Ettlinger & Flordh ( [ 6] ) came to the conclusion that this was the situation with ca. 28% of 365 attempted suicides using barbiturates.
In the 90 cases where it may be assumed that there was either a genuine suicidal intention or else a wish on the part of the patient to make others believe that he had suicidal intentions without endangering his own life, we tried to evaluate the seriousness of the problem underlying the patient's attempt at self-induced intoxication. This is extraordinarily diffcult to assess, and the psychiatrist's opinion will often be decisive. We assigned these patients either to the group consisting of mainly serious attempts at suicide or to that consisting of attempts mainly not seriously intended. Actually, it often happens that the one intention does not exclude the possibility of the other existing at the same time, so that the attempt will be doubly motivated. A "successful" suicide is often the expression of a death wish in the patient, but this does not rule out the possibility that the motive was also to evoke a definite sympathetic reaction in one or more of his relatives. This latter motive will make itself felt, however, to a more considerable extent in patients who do not have really serious intentions. The factors we took into account in making this difficult distinction are as follows (in itself each is inconclusive, but taken together they are significant): the patient's pre-morbid personality; the question whether he has taken steps to ensure fatal results (closed doors, tablets taken in an isolated spot, etc.); the size of the dose; and the patient's emotional reaction to the intoxication when he recovers consciousness. The size of the dose, however, is not an absolute guarantee that the suicide attempt was serious, since it cannot be presumed that the patient has a sufficient knowledge of pharmacology to know what constitutes a fatal dose. It sometimes happens that the results are fatal even though the patient had no real suicidal intentions. On the other hand, there may be quite serious intentions underlying an attempted suicide which is not medically dangerous.
The attempts which were on the whole not serious in the case material available to us cover 64 patients (42 women and 22 men). The personality diagnosis in 29 cases (22 women and 7 men) was psycho-infantilism. The reaction diagnosis in 30 cases (24 women and 6 men) was hysteria. The most frequent situation diagnosis - in 29 women and 8 men - was sexual conflict, using the term in the widest sense, so that matrimonial conflicts fall under this head. Of these patients, 5 women and 5 men had already previously attempted suicide.
The patients who had seriously attempted suicide numbered 26 (17 women and 9 men).
In this group there were several whose personality had been regarded as in no way peculiar hitherto ( [ 11] ). The most frequent reaction diagnosis (in 16 cases) was depressive neurosis. Four patients were psychotics (constitutional psychosis in three cases, melancholic depression in one). In 6 cases, the diagnosis was chronic alcoholism and drug addiction, with a hysteric reaction. Sexual conflict was the determining factor in 9 of these patients, while in 9 others the cause was loneliness, the death of a near relative or the complications of life. There were evidence of previous attempts at suicide in 7 cases.
From the medical angle, 4 of the 64 not seriously intended suicide attempts were assessed as critical, 38 as requiring observation, and 22 as not dangerous. The corresponding figures for the 26 serious attempts were 8, 16 and 2.
Measures to be taken
In many cases the attempts at suicide were comparatively innocent, and it could very quickly be established that there was no continuing danger of suicide. Thus, the duration of hospitalization amounted to only 3.9 clays per patient, and in most cases vigilance could be relaxed after the psychiatric examination.
In some cases, the patients were so violent that the police had to be called in. For a medical department, this was a most unfortunate occurrence. The reason was partly that the patients were continually in need of medical observation and therapy, and partly that there were difficulties in regard to space in the psychiatric wards.
Of the patients subjected to psychiatric examination, 19 were transferred to the psychiatric department. Some of them declined to move, a frequent reason given being that it was a form of discrimination to house them in a psychiatric ward, or that they had not the time for a long stay in hospital.
Because of the limited time at the psychiatrist's disposal in the medical department, which obliges him to confine himself essentially to the task of diagnosis, there was little time for psychotherapeutic conversations. However, these were held as far as was possible. Often the psychiatrist's initial conversation with the patient was of therapeutic value. In many cases, therapeutic treatment is given in consultation with the family, often the very people whom the patient would have hurt if the suicide attempt had succeeded. The critical situation, in conjunction with the attempted suicide, is often a favourable starting point for significant action which may prevent further reaction of the same kind. In many cases, we advise the patient to consult a private psychiatrist. Where the social situation was a considerable factor in the patient's breakdown, the social worker attached to the department was the one to institute rational therapy measures.
"Intoxication "following Therapeutic Doses
Among our case material we found three patients whose condition could be regarded as having been aggravated by therapeutic doses of barbiturates, so that hospitalization was necessary. All three cases were elderly women over seventy. Two were admitted for apoplexy. Both had been taking therapeutic doses of Allypropymal every evening for some months. They were somewhat confused mentally on admission, but recovered their faculties after two or three days. In one of them, the serum showed a barbiturate concentration of 9.9 mg/100 ml; in the other, there were only traces. The third woman had become mentally confused and incapable of work after taking therapeutic doses of Fenemal for three weeks. The barbiturate content in the serum was 4 mg/100 ml when she was admitted; she recovered her faculties after the barbiturates had been discontinued.
Is Barbiturate Intoxication a Frequent and Important "Internal Medicine Ailment "?
The reason why in our case material acute intoxication accounts for as much as 5.5 % of all cases admitted to hospital, as compared with 1.5% in Lingjærde Romcke's ( [ 9] ) material is perhaps essentially the frequency of intoxication in combination with drug addiction and alcoholism in a large city as compared with small towns and rural districts. Particularly among the relatively few youngish patients admitted to internal medicine departments today, there are many cases of intoxication. In fact, our forty-one patients under forty years of age with acute barbiturate intoxication constituted 18% of all the patients under forty admitted to the ward during the two-year period. Thus, one out of every five patients under forty is admitted to an internal medicine department as a result of a dangerous somatic condition in which psychic origin is clearly evident.
In contrast with the data on successful suicides, in the material we compiled women are more numerous than men - in fact, there are about twice as many of them - both among the predominantly serious attempts at suicide, and among the predominantly not seriously intended attempts. Amongst our unsuccessful suicides there were also relatively far more younger people than in the statistics on actual suicide.
The mortality from acute barbiturate poisoning has fallen in the last twenty years from 20% to 3-6%. There is little likelihood that it can be further reduced, since there will always be some cases where the patient has taken such large doses, or where so long a time has elapsed before hospitalization that their lives can no longer be saved. The mortality figure of ca. 5% in our material is not so much higher than that reported from Bispebjerg Hospital ( [ 17] , [ 18] ), and can be attributed to chance factors such as the patient's age, the type of preparation mainly used, and the length of time that elapsed before treatment was begun. The fact that in acute barbituric poisoning the prognosis is so much better today than twenty years ago is not exclusively the result of more effective therapy. It is probable that nowadays relatively slight cases of intoxication admitted to hospitals are more numerous, partly because the predominantly not seriously intended suicide attempts appear to have increased in frequency, and partly because today barbiturates with an effect of short duration are used more than before and the prognosis for these is better than in the case of barbiturates which are slowly eliminated. The high average (66.6 years) of the fatal cases is to be ascribed partly to the fact that serious attempts at suicide are more frequent among the elderly and partly to the fact that, in general, older people tolerate intoxication less easily. Apart from that, our experience tallies with what is generally recognized - namely, that mortality is greatest inmen, in persons who have used barbiturates with a lasting effect and in those who have strong reasons for committing suicide ( [ 2] , [ 4] , [ 6] , [ 7] ).
The relative frequency of barbiturate intoxication as a result of overdoses of analgesics with a barbiturate content (17 cases, one of them fatal) may be taken as an indication of the widespread use of such preparations. Barbituric analgesics sold in Norway all contain barbiturates with lasting effect, mostly Diemal and Fenemal; this makes them unusually dangerous as means of suicide. The pharmacological theory behind such a combination as a means of increasing the pain-relieving effect of, for example, phenacetine, is extremely doubtful. Boreus & Sandberg ( [ 11] , [ 12] ), in an investigation carried out with experiments on animals, found that Diemal in relatively large doses has a negative effect on the antalgic properties of phenacetine. There is every justification for requiring producers of these combined antalgics to get rid of the barbiturate component or, at any rate, to replace it by a barbiturate which is quickly eliminated.
Our results show an astonishingly high percentage of barbiturate intoxication cases in barbiturate addicts who were responsible for 44 out of 117 cases.
If we include the 12 cases diagnosed as chronic alcoholism, there were in all 56 addicts in our case material. Thus, as half the patients admitted for acute barbiturate intoxication are either addicts or chronic alcoholics or both, the relatives must be called in as a routine procedure to provide corroborative information, since any further step would otherwise be unrealistic.
The prevalence of drug addiction and alcoholism and the frequent combination of barbiturate intoxication and acute alcoholic poisoning are explicable on several counts. Some were heavy drinkers before they started taking barbiturates; others had taken barbiturates to excess as a result of deprival symptoms, thus bringing on acute poisoning. On regaining consciousness many had no idea what had induced them to take so many tablets. Under the narcotic effect of barbiturates and alcohol suicidal impulses and also other undesirable impulses of which the patient when sober is himself unaware come to the surface. The impaired judgement and the increased tendency to unconsidered affective reactions consequent upon intoxication also perhaps play their part. In cases where barbiturate addicts have taken overdoses, the intoxication is strictly unintentional. The tolerance of the cerebrum for the drug results in the addict being obliged to take bigger and bigger doses to achieve euphoria. In the end, the hopeless economic and social situation in which he finds himself may prove decisive in bringing about an attempt at suicide.
Among the predominantly serious attempts, there was the same preponderance of women as among the predominantly not serious attempts. About a quarter of the cases of predominantly serious attempts had already tried, in most cases seriously, to commit suicide. Moreover, in a relatively high proportion of cases, the personality had not previously been peculiar. The suicide attempts in this group may be regarded as one of many manifestations of serious mental illness; thus, psychosis was diagnosed in 4 cases, and depressive neurosis - more often than not with trauma of a more or less decisive kind - in 16 cases. Only 2 of these 26 serious attempt cases were regarded as medically not dangerous. The "seriousness" of these intoxication cases may be questioned on the grounds that the patients had after all arranged things in such a way that they were found and given treatment. This only means that the will to live was stronger than the urge to self-extinction. The motivation of such a serious step is understandably enough often ambivalent. But it is true of the group as a whole that as far as the patient himself was concerned, the will to commit suicide was experienced as something real, and that self-extinction may more often be regarded as an aim in itself and not as a means to influencing the attitude of relatives. Surprisingly often it was the feeling of loneliness, of being unwanted and useless, the lack of a sense of belonging to a group or, as it has been called, "excommunication", that was the fundamental cause of desillusionment. In accordance with the greater seriousness of the underlying psychiatric trouble, a relatively large number of these patients were transferred to the psychiatric wards, where for the most part they were kept on for psychotherapeutic conversations, and strongly advised to visit a psychiatrist after discharge.
Even though it transpired from the psychiatric examination of these patients that the attempt at suicide must be regarded as seriously intended, many of them were not considered as still having suicidal tendencies. There were many reasons for this apparently illogical conclusion. It is not uncommon for the very fact of having stood at the threshold of death in this way to have a salutary effect on the patient's psychosis. Moreover, the serious attempts at any rate will finally convince the relatives that the patient is really ill, so that their attitude changes in a direction favourable to him.
It is remarkable that in the whole of our case material there was not a single case of anxiety neurosis, and that there was only one case of depression which might have been connected with a manic-depressive condition. As pointed out by Levine ( [ 13] ) and others, melancholia as such accounts for only a very small fraction of potential suicide cases. Thus, while it is always correct to associate the concept of melancholia with the danger of suicide, the converse is not equally true, because suicide and, more particularly, unsuccessful suicide attempts are so frequent among patients who are not melancholics.
As was to be expected, in a body of material on cases where psychiatric investigation of the intoxication was regularly carried out, a considerable number of them were assessed as "predominantly not seriously intended ". About two-thirds of our patients were considered to be in this category. Their average age was lower; they included a greater number of cases which, from the medical point of view, were not dangerous; and their stay in hospital was shorter. On the basis of his knowledge of the patient's pre-morbid personality, present way of life and emotional attitude towards one or more relatives after regaining consciousness, it was often not difficult for the doctor to interpret the significance of the suicide attempt. In not a few of these cases, such large aspects of the personality were functioning in dissociation from the conscious life that they were unaware of the element of "domination technique" in their suicide attempts. For most of the patients of this type, in fact, self-extinction as such is not the most important motive, but only one of many possible means of attaining their aims in regard to important persons about them. Schopenhauer's words, "Der Selbstmörder will das Leben und ist bloss mit den Bedingungen unzufrieden, unter denen es ihm geworden" (The suicide desires life and is only discontented with the conditions under which he has obtained it) ( [ 14] ) apply with particular appositeness to these patients.
The frequency of psychopathic-hysteric traits in this group was strikingly high. Often the immediate provocation was a conflict with the spouse or other near relative arising out of an attempt by such person to refuse the patient's unreasonable expectations and demands. Rightly or wrongly, many people feel themselves responsible for what happens to their nearest and dearest. The gesture of attempting suicide can in such circumstances be a very effective expression of "domination technique" which terrifies the intended person into continued surrender. With the patients in question it was often jealousy, a feeling of being wronged and an unconscious desire for revenge that lay behind the attempted suicide. But even if not wholly seriously meant, such attempts nevertheless mean in many instances that the person is toying with death. Generally it can be said that the stresses which the patients have reacted against were frequently not overwhelmingly great; the traits of his personality are the main cause of his difficulties. The trauma which provoked the act was rarely sufficient to explain the reaction. This was essentially conditioned by the patient's personality, only the actual timing being determined by the trauma.
Among the predominantly not seriously intended suicides, there were relatively fewer cases where previous attempts at suicide had made hospitalization necessary though, on the other hand, intimations of suicide threats were often forthcoming during anamnesis. It therefore seems as if attempted suicides of this type are rather in the nature of non-recurring phenomena. Little or no guilt feeling or self-reproach was evident. As a rule there was a serious discrepancy between the patient's knowledge of himself and his behaviour in his personal intercourse with others. The total lack of insight into the primitive character of his own motivation and the tendency to project himself outward made it often difficult to apply psychotherapy. Nor were these patients anxious to undergo psychotherapy. They were not easy to live with, and many conversations with relations revealed that the latter had long since given up the struggle in despair, and become resigned.
The question has been asked how far easy access to barbiturates in many homes has increased the incidence of suicides or attempted suicides. In defence or barbiturates, it has been argued that they also save many human lives. In the first place, they can rid the anxious person of his or her tension, and give the potential suicide a good night's sleep and with it a new courage to live. It is also asserted that many potential suicides take barbiturates as an alternative to a more drastic and more irrevocable self-destruction. As the immediate prog- nosis of acute cases of barbiturate poisoning is so good, with a mortality of only 3-6%, it should be possible to save many human lives in this way. There may perhaps be something to be said for these arguments in the case of really seriously intended suicidal intoxication, but this applies to only a fraction of cases (about one-third). Furthermore, there are available to us today tranquillizers and antihistamine preparations which can compete with barbiturates in efficacy as sleeping draughts, and have a much broader therapeutic range. In the majority of predominantly not seriously intended attempts at suicide with barbiturates, we believe that easy access does in fact increase the frequency of intoxication cases requiring hospitalization. It is characteristic of this type of patient that under an acute emotional reaction in a personal relationship situation he has recourse to the medicine which is accessibleas an alternative to other outlets for anger and irritation, as Wiingaard ( [ 3] ) has asserted. We would say that if practising doctors were as prudent in prescribing barbiturates as most psychiatrists are now, a considerable number of suicide attempts of the not seriously intended type could be avoided. They represent a category of patients who in the first few days, at any rate, require continual watching. Practically speaking, all these not really seriously intended cases of attempted suicide are admitted to hospital late in the evening or during the night, and represent an additional problem on that account.
The decrease in mortality in acute cases of barbiturate poisoning from about 20% to about 4% in the course of the last twenty years is striking. But here, as in many other fields, what has been achieved is a development from mortality to morbidity. If, in the future, such patients are not merely to be prevented from dying but also helped to live without relapse, an extension of the psychiatric services for this category of cases is required. What we have said up till now has, in the main, merely given us an opportunity to draw attention to some of the complex problems which arise in this connexion.
Particularly in the years immediately following the First World War, a lively discussion went on as to whether barbiturates could produce addiction. The literature available now makes it clear that there is indeed a great danger of addiction through the use of barbiturates ( [ 15] , [ 16] , [ 17] , [ 18] , [ 19] , [ 20] ). This swing in opinion is strikingly brought home by a comparison of the 1940 and the 1954 editions of Goodman & Gilman's textbook of pharmacology ( [ 17] ). In the 1940 edition, not a word is said of barbiturate addiction, chronic poisoning being regarded solely as the cumulative result of the therapeutical use of prolonged-action barbiturates. But the latest edition lays great stress on the danger of addiction from the use of barbiturates, particularly the rapid action types, and categorically states that barbiturate addiction is a far more serious problem than morphine addiction. This change in attitude is primarily due to the conclusive results produced by Isbell and his collaborators ( [ 21] , [ 22] , [ 15] ) at the Lexington hospital. *
See Bulletin on Narcotics, vol. IX, No. 2: Abuse of barbiturates, by H. Isbell, M.D.
Over the years, the concept of " drug addiction" has been variously defined. The WHO Expert Committee on Drugs Liable to Produce Addiction defined it as follows in 1950: **
"Drug addiction is a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include:
"(1) An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means;
"(2) A tendency to increase the dose;
"(3) A psychic (psychological) and sometimes a physical dependence on the effects of the drug."
With regard to concepts, a distinction must be drawn between addiction, as defined above, and habituation. In the latter condition, there is no compulsive need of the drug, but only a strong desire for it. Furthermore, there is little or no tendency to increase the dose; dependence on the drug is psychological and not physical, hence there is no abstinence syndrome, and any detrimental effects trouble the individual rather than anyone else.
Our own material takes account only of unmistakable cases of addiction conforming to the criteria laid down by the WHO Expert Committee.
The questions to which we were mainly concerned with finding an answer were the following:
How often is drug addiction diagnosed among patients in a medical department with psychiatrists in permanent attendance, and how often is it a case of addiction to barbiturates? How often is addiction to barbiturates found in conjunction with other drug addiction ? On what diagnoses were the patients admitted to hospital ?
What psychiatric diagnoses have such patients had ?
What is the marital status and working capacity of the patients ?
What measures did the psychiatrist recommend and what has been done in regard to further treatment for this group of patients ?
To try to answer these questions we went through the case histories of patients admitted to ward IX at the Ulleval hospital between 1 November 1955 and 31 October 1957, and diagnosed as drug addiction cases.
In the two-year period covered by the inquiry, drug addiction was diagnosed in 63 patients in all, and of these 60 (1.6% of total admissions to the ward) were cases of addiction to barbiturates alone or to barbiturates as well as other narcotic substances. The other 3 were cases of abuse of morphine or similar preparations which we can ignore.
Age and Sex Distribution, Marital Status and Fitness for Work
The case material consisted of 20 women and 40 men, 28 being married, 18 single, 7 divorced or separated, and
See Bulletin,vol. IV, No. 3.
Age and sex distribution Of Sixty barbiturate addicts
Employment status of sixty barbiturate addicts
7 widowed. Their age distribution is shown in table 3, from which it will be seen that more than half the cases were in the 40-60-year age group. Table 4 shows incapacitation and employment situation. Thirty-four patients, or more than half, had either been without regular employment for years or had more recently become unfit for work. Only 18 of the 60 barbiturate addiction cases were gainfully employed.
Reasons For Admission to Hospital
Of the barbiturate addiction cases, 44 were admitted with a diagnosis of intoxication. In 9 cases, this was attributed to a serious attempt at suicide, in 24 to attempts without any real intention to commit suicide, while 13 cases were assumed to be due to the addicts' having taken an overdose of barbiturates. Of the remaining patients, 2 were admitted for curative treatment. Twenty-three cases had been previously admitted to hospital for poisoning, 16 of them two or more times (2 had been in 12 times before and one 9 times).
The other 14 cases were admitted on other somatic diagnoses.
Duration of Addiction
The approximate duration of abuse of drugs was known in the case of 44 patients; these had indulged in abuse of barbiturates for periods varying from one to 25 years, the average being 7.7 years. Other patients admitted to having indulged in such abuse for "some years ".
Forty-three patients engaged in abuse of barbiturates only (in 6 cases Pentymal, 3 cases Allypropymal, 2 cases Fenemal and 1 case barbituric antalgics, the others taking various barbituric preparations). In 17 cases there was evidence of simultaneous abuse of other euphoria-producing substances, mostly morphine, but also amphetamine, bromine and in one case marihuana. Thirty-four of the 60 patients were or had been alcoholics.
In 14 cases barbiturates were the substance to which the patient first became addicted, in 6 cases morphine, and in 33 cases alcohol; in 7 cases the substance taken was unknown.
Barbiturate Concentration in the Serum
The presence of barbiturates in the serum was detected in 37 cases, the average concentration being 4.4 mg/100 ml. In the case of those addicts not admitted on a diagnosis of intoxication, the average concentration was 3.4 mg/100 ml. The highest concentration was 30.5 mg/100 ml in a patient who was admitted for intoxication and died. In 2 cases, only traces of barbiturates were found and in 2 cases the test result was negative. In 19 other cases the concentration was not measured, mainly because the intoxication was slight and the patient was soon discharged.
Of the 60 barbiturate addicts, 54 in all were given a psychiatric examination. The personality diagnoses for those examined are set out in table 5. In all cases the reaction
Personality diagnoses of fifty-four addicts subjected to psychiatric examination
diagnosis was drug addiction, and in 47 cases there was an additional reaction diagnosis. In 34 cases (8 women and 26 men), the additional diagnosis was chronic alcoholism. Ten patients (5 women and 5 men) were found to be neurotic, 6 of them having depressive neurosis, 2 giving a neurotic insufficiency reaction, one having angst neurosis and one suffering from neurasthenia. Three of the patients were psychotics, 2 of them with delirium.
The situation which led them to become addicts (situation diagnosis) is unknown in most cases, but 15 patients (8 out of 20 women, 7 out of 40 men) were brought to it through prolonged use of narcotic drugs medically prescribed for an illness. Ten of them had a definite somatic condition, the other 5 disorders of mainly functional origin.
Thirty-three of the patients had previously been admitted to a psychiatric ward.
The average number of days in hospital for barbiturate addicts was 10.8, the actual number varying from one to 100 days. Twenty patients were in the ward 3 days or less.
They were treated with heavy doses of vitamins B and C, often in combination with small doses of insulin (3 plus 2 nordic units a day). Some of the patients also received tranquillizers, in the form of chlorpromazine, reserpine or meprobamate. For agitation during the first few days reserpine -e.g., in intramuscular injection of 2.5 mg 2 to 3 times a day-can safely be given. Reserpine has no intensifying effect worth mentioning on alcoholic or barbiturate intoxication, and the intensifying effect of chlorpromazine presents no danger factor from the practical clinical standpoint. Eighteen patients were given barbiturates or other narcotic drugs in the ward. In no case was any patient given the full addict treatment with isolation and ban on visits. Thirteen of the patients examined by psychiatrists were transferred to the psychiatric ward. Eleven others were offered a transfer to the ward but declined. Of the remainder, 9 were removed to other institutions (nursing homes, convalescent homes or institutions).
Eleven of the patients were readmitted to hospital on grounds of the same drug addiction during their observation period, which averaged a year.
ARE BARBITURATE ADDICTS A LITTLE-KNOWN PUBLIC HEALTH PROBLEM ?
As our case material on barbiturate intoxication shows, no less than 44 of the 117 patients with barbiturate poisoning were drugs addicts - i.e., about 40 per cent, which is a surprisingly high proportion. There were a further 14 patients who had been admitted to the ward on the strength of other diagnoses and were classified as addicts during their stay.
The frequency of admission of addicts to a medical ward is no pointer to the incidence of such conditions amongst the population. There is scarcely any morbid condition where the disproportion between the number of patients and the number seeking treatment in hospital is so marked as in drug addiction. A genuine resolve to put an end to the abuse is very seldom found, and even among these cases not all are willing to be admitted to hospital because of the discriminatory treatment they assume they will receive from doctors and hospital staff. Furthermore, the vast majority of those who either decide of their own accord to enter hospital, or are in such a state of exhaustion that their relatives take action, are admitted to the psychiatric ward. Over half our patients were either without regular employment or unfit to work.
All these circumstances considered, the figure of sixty in the course of a two-year period must be said to be high for an internal medical department, where a considerable number of urgent cases are received.
Even though the material we have is limited, it does bring out one fact-namely, the frequency of barbiturate addiction. The material includes all cases of drug addiction admitted during a period of two years. All but three cases displayed a dependence on barbiturates either by themselves or in conjunction with other narcotic drugs. Thus, from the material we have, it seems that we must support Goodman & Gilman's claim that addiction to barbiturates is a more serious problem than morphine addiction.
Can any conclusions be drawn from our material regarding the presence of common traits in the personality structure of the addicts ? Comparison of the personality diagnoses for cases of acute poisoning with those of the addict group shows that a psycho-infantile personality is less frequent among the addicts. The majority of the addicts are described as unstable or psychopathic and there are many cases of cerebral damage or feeble-mindedness among them. There were relatively few who had not previously had something odd about them. Most of these patients seem to have been already suffering from a radical personality defect. Attention must, however, be drawn to the great difficulty of forming an opinion on the premorbid personality structure of such patients when their personality has often been greatly altered through prolonged abuse of drugs.
Our experience tends to show that there is no specific type of personality which has a predilection for a particular drug. There seems rather to be a general addiction or, perhaps better, a craving for euphoria, it being more or less a matter of chance whether the substance that happens to be used for the purpose is alcohol, barbiturates or morphine preparations. In very many cases a combination of several substances is used. The super-ego, the inhibiting and controlling faculty of our personality, has been facetiously described as "that part of the psyche which is soluble in alcohol ". An unimpaired cerebral cortex may be taken as an essential condition for the proper functioning of that faculty. Barbiturates and morphine may also be presumed to affect the faculty in the same way. Müller ( [ 23] ) defines intoxication in general as a state in which the function of the brain proper is more or less diminished. Positive mental euphoria, which the addict cannot resist the temptation to enjoy, consists in all probability in a release from inhibitions. The material in our possession sheds very scant light on any external factors which might be decisive in regard to drug addiction. The information obtained from the addict himself rarely corresponds to the true state of affairs. The addict is often convinced that his abuse of drugs is due to an undeserved stroke of fate that has befallen him, and musters up considerable resistance to the explanation that is often as plain as a pikestaff to his close associates, that it is primarily tendencies and a craving within him that have led him to intoxicate himself instead of facing up to external difficulties. Half of our patients have at some time been admitted to a psychiatric clinic, on an average about four times each. Their case histories and observations based on them point to the conclusion that addiction is to be regarded as only one of many manifestations of a deep-seated personality defect, but dependence on narcotic drugs represents a malignant complication of the basic psychiatric disorder. This complication is in itself difficult to overcome, and makes it pointless to achieve a successful treatment for the basic disorder. By helping to turn a neurotic into a drug addict, a physician who prescribes barbiturates can easily ruin the patient's chances of cure by radical psychotherapy. This fundamental problem is best brought out by the following remarks by Kubie: "They (the Russian physiologists of the Pavlov school) demonstrated that it is only in a state of craving that important new connections can form in the central nervous system. The psychoanalytic version of this fact is Freud's observation that an analysis makes best progress in the presence of deprivation."
The material compiled by us shows no preponderance of persons in occupations connected with the production, distribution or prescription of medicines. This may be because the material is not representative, but it may also be that the circumstances are different when addiction is due to barbiturates and when it is due to morphine. Anchersen ( [ 25] ) found in his material on morphine addiction that roughly one-third of the victims were connected with occupations giving easy access to morphine. The fact that it is not so hard to lay hands on barbiturates as on morphine probably explains why the difference in frequency of "unexposed" and "exposed" occupations is not so great in the case of barbiturate addiction, the position being more similar to that found in the case of alcohol.
Anchersen also found from his data on morphine addicts that a good half of those admitted to psychiatric clinics between the years 1928 and 1942 has shown clear signs of psychopathic disorder before. In our case material, too, psychopathic disorder is very frequent. In relatively few cases is neurosis or endogenic disturbance at the root of the drug addiction. In such cases the reason for abuse of drugs can be said to be a longing to return to a lost state of normality. The great majority of addicts, to begin with, take their drugs rather to achieve something than to escape something. As the contemporary French author and member of the Academy, Jean Cocteau, puts it: "Trying to persuade a drug addict to give up his poison is like urging Tristan to slay his Isolde on the plea that he will feel so much better afterwards." ( [ 26] ) But, quite apart from the addict's pleasurable experience and from the complex of personality defects and the circumstances of his life which led to his abuse of drugs, fear of the abstinence syndrome helps to make him continue such abuse. The emotional immaturity which is at the root of many cases of drug addiction often reveals itself in the patient's life story. In other matters, too, he will have shown little ability to forgo immediate satisfaction or make present sacrifices for the sake of a more distant goal.
With our case-material it was impossible to obtain any reliable information either from the patients or their relatives on the amounts of barbiturates consumed. According to the findings of Isbell ( [ 15] ), it can be assumed that a barbiturate addict absorbs on an average 0.8 gr of the substance per day. Apparently the dose must be in the neighbourhood of this amount for a clear case of addiction to develop. It is a known fact that there are persons who for years have taken 0.10 or 0.20 gr of barbiturates daily in order to get a good night's sleep with no noticeable ill-effects. That does not alter the fact that certain individuals - it is not easy to say which beforehand - gradually develop barbiturate addiction in such circumstances. With habituation the sleep-inducing power of the drug declines, the dose has to be increased, and the effect of the barbiturates changes, inducing, instead of sleep, a state of mental well-being, which the patient feels as a cheerful mood, but which more often strikes his relatives as passiveness and loss of critical sense. When barbiturates are taken in much larger doses than prescribed by a doctor and during the day, they are no longer a soporific, but an intoxicant. Our material shows that even many alcoholics are tempted to change over to that "intoxication which does not stay on the breath ". It is a well-known fact that abuse of barbiturates is one of the most common and serious complications of chronic alcoholism.
There are, however, quite definite cases where the craving has been induced in relatively normal persons who previously had never felt an unusually strong need for euphoria but have been given analgesics or cough cures for troublesome physical ailments over a long period. It is to be hoped that the pharmaceutical industry will ultimately produce specific analgesics, anti-tussives, sedatives and astringents that do not have the troublesome secondary effect of inducing euphoria. For in all cases, with the possible exception of amphetamine, the euphoria-inducing property of the drugs in question is not an indispensable feature that has to be accepted in order to obtain the desired symptomatic effect. Morphine and similar preparations are intended to have an analgesic, anti-tussive or astringent effect, barbiturates are designed to induce sleep or calm in acute anxiety disorders. The development in recent years of various tranquillizers and specific anti-tussives generally without inhibitory effects on the central nervous system holds out the hope that the risk of drug addiction can be successfully reduced. Experiments over a long period with tranquillizers in the treatment of drug addicts have proved disappointing. Though they dispose of the abstinence symptoms during the withdrawal stage, after discharge the addict is not satisfied with the relaxed feeling they give, but demands the euphoria brought on by the effect of the drug in dulling the consciousness. More often than not the patients slide back into their old abuse, thereby revealing their true nature as euphoria seekers.
The fact that so few serious abstinence symptoms were found in our case material is due to a variety of factors. One is that eighteen of the patients were given barbiturates or other narcotic drugs in the ward, another that some of the patients are transferred to the psychiatric wards relatively soon after their admission. Again, most of our patients are admitted to the ward on the grounds of barbiturate intoxication and therefore have an accumulation of barbiturate in their system, which is subsequently eliminated. Finally, many demanded during their first few days in hospital to be discharged and continue their abuse of the drug. Of the three cases of psychosis, two were abstinence psychoses.
As our findings show, the opportunities for treating the addicts were limited. It may be generally said that it is difficult to carry out treatment for drug addiction in a medical department. There, the most important thing is to treat the patient's somatic symptoms and work on his mental state so as to persuade him to undergo in-patient treatment over a long period in a psychiatric institution. There is no way of treating addicts who do not wish to be treated, since at present a patient cannot be ordered to enter an institution. This is a grave deficiency where the treatment of drug addicts is concerned. From the epidemiological standpoint if from no other, the position is an unfortunate one, since many addicts, especially the socially depraved, constitute foci for the propagation of the disorder.
The prognosis for a lasting cure for firmly established drug addiction is bad. So long as there are still no special clinics for addicts, we have to try to get them into a psychiatric observation ward and then induce them where necessary to go voluntarily into a home. It is the private medical practitioner's duty to try and persuade his patient to accept treatment. By adopting a more severe attitude towards the addict in the matter of prescribing barbiturates, he can put pressure on him to submit to treatment.
The prognosis being so bad, proportionately more weight must be laid on prophylaxis. The importance of restrictive prescribing of barbiturates, as a long-term prophylactic measure, is not to be underestimated.
In a ward with 175 beds, 30 barbiturate addicts are admitted per year. In Oslo there are about 1,300 medical ward beds in hospitals with regular medical staff. As it may reasonably be assumed that the incidence of drug addicts in the other medical wards is about the same, probably 240 barbiturate addicts are admitted to medical wards in Oslo in the course of a year. To these must be added the barbiturate addicts in private medical nursing homes without regular medical staff. Since, as already pointed out, the figure of thirty we have given is a minimum, we may take it that the extent of the problem for all medical wards together is more or less as stated. The other specialist departments presumably have their drug addiction problems too, but probably to a lesser degree. For withdrawal treatment patients are practically without exception admitted to psychiatric wards, and those of the Oslo Municipal Hospital, where the vast majority of such patients in Oslo are undoubtedly to be found, admit about 120 barbiturate addicts per year. Thus, at a conservative estimate, in the city of Oslo with a population of 400,000, one barbiturate addict is admitted per day to a hospital medical department.
These considerations would suggest that barbiturate addiction is a far greater problem than it was hitherto thought to be in this country. The Ministry of Health is constantly receiving reports on cases of drug addiction from doctors, pharmacists, and the relatives of addicts. Apart from these reported cases, there are also registered addicts who are discovered through the regular auditing of narcotic drug registers in pharmacies. The Ministry of Health keeps a list of addicts, but it does not include those patients who have agreed to enter a hospital as in-patients for withdrawal and curative treatment.
The addicts reported to the Ministry of Health during the eight-year period from 1950 are shown in table 6, classified according to sex and type of addiction. It will be seen that of 231 drug addicts registered with the Ministry of Health in the eight-year period 1950-1958, only 65 - i.e., about 30 per cent - indulged in abuse of barbiturates alone or in combination with other drugs.
The low figure for reported cases of barbiturate addiction can probably be attributed in part to the fact that many doctors and pharmacists have not hitherto looked upon dependence on barbiturates as a form of drug addiction. Barbiturates have also been relatively easier to obtain than other drugs, and abuse is therefore more difficult to detect. A further reason why so many cases of barbiturate addiction remain unknown may be that barbiturate addicts do not suffer from malnutrition so often as morphine addicts.
Drug addicts registered with the Ministry of Health in the eight years 1950-1958, analysed by sex and drugs used
OFFICIAL STEPS TAKEN IN NORWAY TO KEEP DOWN THE ABUSE OF DRUGS
Despite the relatively low official figures, the public health authorities have been aware that abuse of narcotic drugs is a serious social and medical problem in this country, and have enacted new legal measures to cope with it.
The right of medical practitioners to prescribe drugs with a narcotic effect is restricted under the royal decree of 27 September 1957. This stipulates that prescriptions for a whole series of medicines which are set out specifically cannot be repeated. Quantities must be stated in figures and words. Pharmacists are legally bound to retain the prescriptions and keep them for three years, and to hand them over to the public health authorities if so requested (cf. Medical Practitioners' Rights and Duties Act, quoted below). The substances covered are amphetamine, dexamphetamine, diacetylmorphine, dihydrocodeine, hydrocodone, hydromorphine, ketobemidone, cocaine, methadone, morphine, oxycodone, opium, pethidine and tetrapon.
Restrictions have also been placed on barbituric acid derivatives by the following provision:
"In order to be valid an endorsement permitting the repeated dispensing on the same prescription of a medicine whose sole or chief constituent is a barbituric acid derivative or like substance which may offer temptation to abuse must contain an indication of the minimum time that must elapse between each dispensing - e.g., ' Rep. III times - ter - 3 weeks' interval'."
The Act of 29 June 1957, supplementing the Medical Practioners' Rights and Duties Act of 27 April 1927, as amended by the Act of 19 June 1936, contains special provisions designed to prevent misuse of the rights to prescribe narcotic substances. The following are some of its provisions:
Article 5. 1 Subject to any restrictions laid down by law or in regulations issued under the law, every medical practitioner has the right to prescribe such medicines as are necessary for the exercise of his profession. However, by making a declaration to the Ministry, he may for a specified period renounce the right to prescribe all narcotic drugs or certain groups of such drugs.
Subject to the limitations arising from professional secrecy, the Crown shall issue general provisions on the wording of prescriptions and may, after consulting the Faculty of Medicine and the Medical Board, determine that prescriptions for specially designated drugs shall be kept in pharmacies for inspection by the appropriate control authority. The production of such prescriptions as evidence may be demanded in criminal cases or when action is taken to deprive a medical practitioner of the right to exercise his profession or hold the post of a medical officer of health, or when cases are brought before the Supervisory Council for the Prescription of Narcotic Drugs.
Article 5a. 1 Where there are reasonable grounds for assuming that the prescription of narcotic drugs by a medical practitioner may be regarded as an unjustifiable medical activity, the Ministry shall warn him, and, if the warning is not heeded, shall bring the matter before the Supervisory Council for the Prescription of Narcotic Drugs.
The Ministry may from the time when the case is submitted to the Council, deprive the medical practitioner of the right to prescribe narcotic drugs until a final decision has been taken on the case.
Article 5b. 1 If the Council finds the medical practitioner has prescribed in an irresponsible manner, it may deprive him for a specified period not exceeding five years of the right to prescribe all or certain groups of narcotic drugs.
Before taking such decision, the Council shall give the practitioner a hearing and acquaint him with the documents and other information relating to the case.
The Council may restore to the medical practitioner at his request the right to prescribe narcotic drugs before the expiry of the time fixed.
Article 5c. 11. The Supervisory Council for the Prescription of Narcotic Drugs shall consist of a chairman, a deputy chairman and two other members who, with their alternates, shall be nominated by the Crown.
The chairman and deputy chairman shall possess the qualifications of judges of the High Court. The two other members shall be experienced medical practitioners.
No decision of the Council shall be valid unless all the members are present.
The decision to withdraw from a medical practitioner the right to prescribe narcotic drugs must be unanimous.
Similarly, the decision to restore that right to a medical practitioner before the expiry of the time fixed must be unanimous.
The Council shall give reasons for its decisions.
The regulations concerning disqualification in the law of 13 August 1915, concerning tribunals, article 106, 1 to 4, and article 108, shall apply, mutatis mutandis, to the Council.
The members shall be entitled to remuneration for their meetings and to travel and subsistance allowance in accordance with regulations to be laid down by the Department.
The Crown may issue more detailed regulations concerning the composition, working-time and procedure of the Council.
Law of 28 June 1957.
Article 5d. 1 Where in virtue of the preceding provisions a medical practitioner has lost wholly or in part the right to prescribe narcotic drugs, the drugs necessary for his practice shall be prescribed by the competent medical officer. However, in individual cases, the Ministry may authorize another medical practitioner willing to do so, to write out such prescriptions.
The Crown may lay down more detailed regulations concerning such prescriptions.
Article 5e. 1 Any medical practitioner shall, without prejudice to the rules of professional secrecy, if required by the Ministry, provide information necessary for any inquiry into eventual abuse of narcotic drugs.
Article 5f. 1 The Crown shall determine which drugs are to be regarded as narcotic drugs for the purpose of the provisions of this law.
. . . . .
20. Any person contravening the provisions of this law, or regulations issued in virtue thereof, shall be liable to a fine or to imprisonment not exceeding three months unless a more severe penalty for such contravention is laid down in the general criminal code. A medical practitioner who prescribes narcotic drugs after he has voluntarily relinquished his rights under article 5, or has been deprived of the rights under article 5a, paragraph 2, or article 5b, shall be liable to the same penalty.
The legal authority for treating drug addicts in Norway is to be found in the Act of 26 February 1932 on temperance boards and the treatment of inebriates, together with the supplementary Act of 6 July 1957. The latter Act, which applies the provisions of the earlier Act to drug addicts as well, was adopted but not put into effect because of the lack of facilities for placing drug addicts in institutions.
The Act provides for the establishment in each commune of a democratically elected temperance board consisting of not less than three members of the municipal council, its tasks being partly preventive and partly administrative. Thus, the board shall make proper arrangements for alcoholics or drug addicts if so requested by the patient himself, his next of kin or any of a number of clearly specified public authorities.
If such person refuses to comply with the board's order or if the Board deems it otherwise necessary, it may under its regulations and without regard to his own wishes in the matter, order him to be committed to an approved institution for treatment for up to two years when, through abuse of alcohol or narcotic substances, the said person:
Maltreats his spouse or children or exposes his children to moral danger or neglect;
Fails to fulfil his maintenance obligations under the law;
Exposes himself to serious bodily or mental harm, endangers his own life or that of others, or repeatedly makes himself a public nuisance;
Becomes a burden on public assistance or on his family;
Dissipates or gambles away his worldly goods to such an extent that he or his dependants may become indigent.
When a decision involving deprivation of freedom has to be taken, the board's proceedings shall be presided over by the district or local magistrate.
The person concerned shall be summoned to a hearing and shall have the right to be assisted by a lawyer or by another representative acceptable to the board's chairman.
If it sees occasion to do so, the board shall, without resorting to compulsory commitment to an institution, try to have the addict cured of his habit. It shall also apply a series of practical measures, which are specified in detail, to help the drug addict and his family.
The experience of psychiatric clinical wards in Norway suggests that 75% of the drug addicts are using barbiturates.
At present, a thorough psychiatric examination with corroborative information from other sources constitutes our most reliable case-finding method as far as drug addiction is concerned. It is difficult to detect the drug addicts in a typical population group. Over a two-year period in an internal medicine department with regular staff psychiatrists, all patients giving grounds for suspicion of drug addiction were given a psychiatric examination. A very large number of drug addicts were found among patients admitted after attempting suicide with barbiturates; hence all such patients were subjected to systematic psychiatric examination.
Of a series of 207 cases of acute intoxication, 137 (81 women and 56 men) were cases of barbiturate intoxication. In 37 cases, alcohol poisoning was diagnosed at the same time. Of the 117 patients subjected to psychiatric examination, abuse of barbiturates was found in 44 cases. In 90 cases, suicidal intentions were taken to be the reason for the intoxication, 26 being genuine cases of abortive suicide, the other 64 having no real intention of taking their own lives. Erotic conflict or family trouble was the commonest cause of attempted suicide. The most usual type of personality was the psycho-infantile type, particularly among the cases of not really serious attempts at suicide.
A "paradoxical barbiturate effect" was found in three elderly patients who developed symptoms of derangement after therapeutic doses.
Among the 3,750 patients admitted during the two-year period, 63 were drug addicts, 60 of them being addicted either to barbiturates alone or to barbiturates in conjunction with other narcotic drugs. Forty-four of the patients were admitted to hospital with acute intoxication, and more than half of them were also suffering from chronic alcoholism. In 15 patients (" medical addicts ") addiction had developed after prolonged treatment with narcotic drugs prescribed by a physician for various complaints. In the other cases (" social addicts ") the main cause of addiction was taken to be a personality defect with social maladjustment. More than half were out of work, and on an average addiction was of 7.7 years' standing. Over half had previously been treated in a psychiatric institution.
The prognosis in the case of well-established drug addiction is bad; hence the main emphasis must be placed on prophylaxis. The importance of restricting the prescribing of barbiturates, as a long-term prophylactic measure, is not to be underestimated. Most Norwegian psychiatrists nowadays are agreed that any use of barbiturates as a daytime sedative is contra-indicated in treating nervous states. The administration of barbiturates can be viewed without misgiving only for occasional insomnia in persons with no apparent psychological abnormalities. Most Norwegian psychiatrists refrain from prescribing barbiturates at all, and do not feel the loss of them.
In conclusion, reference is made to the measures put into force by the Norwegian health authorities to combat the spread of drug addiction. Mention is made of the legal basis for compulsory commitment of drug addicts to institutions. One of the main problems in that connexion is that of appropriate restrictions to prevent the uncritical prescribing of narcotic drugs. A new Act now makes it possible in Norway by administrative action to deprive a medical practitioner of his right to prescribe narcotics without depriving him of his licence to practise.
Even though drug addiction must be regarded as a symptom and complication of a more deep-seated psychiatric disorder, it is of great importance from the standpoint of mental hygiene to combat dependence on drugs. A secondary drug addiction renders impossible both spontaneous recovery and the application of psychotherapy to the fundamental personality disorder.
It is to be hoped that the new tranquillizers will lead to fewer psychiatric patients' falling victims to barbiturates in future.
Editorial: Lancet, I: 293, 1956.002
LINGJÆRDE, P. & ROMCKE, C., Tidsskr. for den norske Laegefor., 75: 1, 1955.003
WIINGAARD, P., Ugeskrift for Laeger , 111: 346, 1949.004
DAHLGREN, K. G., On suicide and attempted suicide . Lund, 1945.005
KRANE, B., Tidsskr. for den norske Laegefor ., 69: 290, 1949.006
ETTLINGER, R. W., FLORDH, P., Attempted suicide. Acta Psych. & Neurol. Scand. , Suppl. 103: 1955.007
LOUS, P., Acta pharm. & toxicol. , 10, 134, 1954.008
RICHARDS, R. A., British Med. Journ. , I: 331, 1934.009
AAMODT, T., Tidsskr. for den norske Laegerfor ., 76: 606, 1956.010
GAUSTAD, V., Ibid., 74: 743, 1954.011
BOREUS & SANDBERG, Acta Physiol. Scand., 28: 6, 1953.012
BOREUS & SANDBERG, Ibid., 28: 266, 1953.013
LEVINE, M., Psykoterapi i medisinsk praktik ., Natur och Kultur, Stockholm, 1946.014
SCHOPENHAUER, A., Die Welt als Wille und Vorstellung , I.: Verlag von Philip Reclam jun. Leipzig.015
ISBELL, H., ALTSCHUL, S., KNORNETSKY, C. H., EISENMANN, FLANARY, H. G. & FRASER, H. F., Arch. Neurol. & Psychiatr., 64: 1, 1950.016
Symposium on Drug Addiction, Am. Journ. Med ., 14: 537, 1953.017
GOODMAN, L. S. & GILMAN, A., The Pharmacological Basis of Therapeutics , The MacMillan Company, New York, 1956.018
ANCHERSEN, P., Tidsskr. for den norske Laegefor ., 72: 129, 1952.019
ANCHERSEN, P., Ibid., 72: 303, 1952.020
ANCHERSEN, P., Ibid., 76: 979, 1956.021
KONNETSKY, C. H., A.M.A. Arch. Neurol. & Psychiat., 65: 557, 1951.022
HILL, H. E. & BELLEVILLE, R. E., Ibid., 70: 180, 1953.023
MÜLLER, K. O., Stimulanser, Gyldendal Norsk Forlag. 1947.024
KUBIE, I. S., Practical and theoretical aspects of Psycho-analysis , International Universities Press, Inc., New York, 1950.025
ANCHERSEN, P., Acta psychiatr. & Neurol. , 22: 153, 1947.026
COCTEAU, J., cit. K. O. Müller (23).