Control and treatment of drug addicts in Israel

Sections

The treatment of drug addictsat the Department
The experienceof the Drug Addicts Department
The results of the treatment
Conclusions
The use of the various drugs in Israel
The present situation
The means adopted in Israel to prevent the spread of drug addiction and plans for the future

Details

Author: Z. W. Jermulowicz,
Pages: 11 to 18
Creation Date: 1962/01/01

Control and treatment of drug addicts in Israel

Z. W. Jermulowicz,
M.D., District Psychiatrist, Tel Aviv District, and Director of Government Hospital for Mental Patients, Bat-Yam & Mag. A. Turnau, District Pharmacist, Tel Aviv and Central Districts, Ministry of Health

In the western cultural sphere the problem of alcohol-containing beverages has constituted a major social factor for many hundreds of years. In view of the special effect of alcohol it is customarily served at social gatherings in order to raise the spirits of those assembled. This effect of removing psychological inhibitions and raising one's spirits entrains certain psychological problems in that weaker characters tend again and again to resort to alcohol and thus become alcoholics.

The main psychological factors leading to this state of affairs are:

  1. The desire to overcome feelings of lack of security and inferiority;

  2. The desire to suppress or mute feelings of guilt or neurotic anxieties;

  3. The desire to forget personal worries and escape from the world of hard reality to a happier and more pleasant world of the imagination;

  4. Sometimes also certain states of depression.

Accordingly, addiction to alcohol in all countries of western culture is very widespread, while drug addiction is relatively less frequent, and is restricted mainly to people who became addicted as a result of physical illness or to certain bohemian circles in search of special stimulation as well as, to a certain extent, to members of the underworld, especially sexually perverted psychopaths (homosexuals, etc.).

Among the Muslim peoples, whose religion forbids the use of alcohol, the various intoxicating drugs constitute the same social factor as does alcohol among western peoples. The psychological causes leading to habituation or addiction to drugs are similar to those mentioned with respect to alcohol. In the Far East the use of opium was until recently still very common. In the Middle Eastern countries the use of opium and hashish is almost as common, whereas in Egypt the most widely used drug is hashish, while opium is used to a lesser extent. It should be pointed out that the Jews living in these countries adapted themselves to the prevailing habits and customs (although the Jewish religion does not proscribe the use of alcohol). Many Jews acquired the habit of using drugs - especially hashish and opium - in their country of origin at an early age. Naturally they continue using these drugs day in, day out, even after their immigration to Israel.

In Palestine, during the period of the British Mandate until the end of the war of liberation of 1948, neither drugs nor alcohol constituted a social or medical problem among the Jewish population. Indeed there were some Jews, especially from among the locally born, who jointly with the Arabs smuggled drugs, especially from Syria to Egypt. Among these there were some who themselves used drugs. This collaboration continued undisturbed even during the Arab anti Jewish riots. During the Second World War the smuggling of drugs increased considerably with the aid of soldiers of the various armies at that time stationed in the country and deriving a rich source of income from this activity.

On the establishment of the State of Israel in 1948, the Department of Pharmacy was set up within the Ministry of Health, headed by the Chief Pharmacist. In 1949 the three district pharmacists were appointed to assist the Chief Pharmacist in his various functions. They started to carry out the systematic supervision of the use of dangerous drugs. Thus the drug addicts who received their drugs through doctors' prescriptions and pharmacies were discovered.

The duties of the district pharmacies include control of the stock of intoxicating drugs in private and public pharmacies, pharmaceutical factories, hospitals and drug supply departments. This control comprises prescriptions for such drugs and the keeping of special registers, as well as the actual stock inventory (including particulars of production, consumption and losses). The pharmacists in Israel submit regular reports to the district pharmacists on the repeated use of intoxicating drugs by a given patient. At the health offices a card index is kept on such cases, including the name of the patient, his address, the names of the physicians who wrote the prescriptions, the kind and quantity of the drugs and the dates at which they were taken, as well as the diagnosis of the disease. Every drug addict sent to a hospital to be cured of his addiction is registered at the Pharmacy Department of the Ministry of Health, where all the data of the Ministry of Health concerning the use and production of intoxicating drugs and of registered drug addicts are concentrated. Physicians and persons belonging to various medical professions were discovered who were themselves drug addicts. Prescriptions which had been forged by drug addicts were found, and both doctors and pharmacists were discovered who supplied these wretched people with drugs for large sums of money. Some of the drug addicts were hospitalized in mental hospitals which did not dispose of special departments for their cure. With the establishment of the State on 15 May 1948, and the mass immigration from the Arab countries, the use of drugs steadily increased, so that the problem of drug addiction started to assume serious proportions in Israel. No appropriate means were available to overcome the problem. Hospital facilities for drug addicts were extremely limited owing to the shortage of beds in mental hospitals and the lack of a special institution dealing with the cure of drug addiction. Those addicts who succeeded in being hospitalized were kept together with mental patients. This caused a strong resistance against the very idea of hospita- lization among part of the addicts. At the beginning of 1950 the first drug addicts from Middle Eastern countries were admitted to Israeli mental hospitals. In the course of that year several such new immigrants were hospitalized who used opium, while one of them was addicted to injections of morphine. At a later period a further dozen or so of drug addicts were hospitalized, including two physicians and two nurses. Until 1953 about seventy drug addicts were registered at the various health offices in Israel which applied to us for help. The overwhelming majority were medical cases namely, people who had become used to taking drugs in the course of a physical illness. Until then only a few of those whose source of supply came from the underworld (i.e., all those who obtained the drugs through smuggling and illegal trade) had applied to us. When they did come they were in a state of serious physical and mental breakdown, so that immediate assistance was essential. From all the above it transpires that the number of known drug addicts until that time was still limited. Since immediate hospitalization, as required in most cases, was impossible owing to the shortage of hospital beds, and so as to help the drug addicts themselves and save them as well as their families from economic disaster, in 1952 the Ministry of Health, after profound deliberation, decided to allocate to these addicts drugs at official prices through the district health offices until they could be hospitalized. The physician of the health office issued an appropriate prescription - in particular for morphine injections - to the addict, and the district pharmacist "linked" him to a certain pharmacy from which he could obtain his drugs.

This arrangement prevented the drug addicts from being exploited by criminal suppliers of drugs, thus saving them from impoverishment, moral deterioration and the ruin of their families, as stated above. It may be said that the method of official allocations served a vital function and achieved the goals we had set ourselves with respect to' addicts who did not belong to the criminal underworld. In the course of time, however, when drug addicts belonging to this underworld started using this system to their advantage, the method proved to be a failure. In view of the large gap between the official price of drugs - especially ampoules - and their price on the black market, which was twenty rimes the official rate, there is serious ground to suspect that the drugs allocated by us were sold by some of the drug addicts at a high price, for part of which they then bought unrefined opium or hashish.

From 1953 onwards, a steady stream of drug addicts from the underworld started applying to us, pretending they were anxious to be cured while well knowing that we did not dispose of sufficient hospital space. Their sole purpose was to receive from us an allocation of drugs. Not only did they exaggerate their own demands, but they also sent us drug pedlars who simulated addiction so as to obtain drugs for purposes of trade and sale. These people used every means at their disposal to achieve their ends and obtain as large a quantity of drugs as possible. They did not hesitate to raise a scandal, to threaten the employees of the health office with knives, etc. It became a dangerous job to work at the health offices, to the extent that it was hardly possible to carry out the work pro- perly and a constant police guard was required. The number of drug addicts registered at the various health offices constantly grew, soon reaching about two hundred in number. A further unfavourable effect of the official allocation of drugs was that people who had hitherto used only opium started going over to morphine injections, a more severe and acute form of addiction. In the light of these grave developments the factors concerned - psychiatrists, the staff of the Health Ministry, public attorneys, a representative of the prison authorities and senior police officers - convened for urgent consultation. In the course of these conferences the general opinion was reached that a special institution for the treatment of drug addicts was required. On the proposal of one of the present authors 1 it was decided to open a special department of twenty beds for the cure of drug addicts at the Government Hospital for Mental Patients at Bat Yam. The preparation for the opening of this department lasted from the end of December 1955 until 1 May 1956. In the interim stage until the registered drug addicts could be hospitalized the method of providing drug addicts with injections at certain hospitals was substituted for the system used hitherto of supplying them with the drugs. The addicts had to appear twice or three times every twenty-four hours at the hospital in order to get their injection. A considerable number of addicts from the underworld absolutely refused to be weaned of their addiction in hospital, when their allocation of drugs was of course immediately stopped. The decision to open a special department for the cure of drug addicts was a major fundamental turning-point in the handling of the problem. The implementation of the decision, the formation and the management of the department were entrusted to the director of the Government Hospital for Mental Patients in Bat Yam. It was a difficult and daring venture for a man who lacked experience in the organization and running of a department of this kind. From the start it became obvious that the functions of this department were much wider than those of an ordinary psychiatric ward, and that weaning as such constitutes only one of the tasks, and not even the main one, of a department of this kind. We considered it our duty to assist the patients in making up for their defective education, to teach them a trade and care for their rehabilitation. Moreover, we intended to care for the transfer of the cured addicts and their families to new and healthier surroundings, we imagined that most cases would be new immigrants, and that even where they had been living in the country for a number of years they had not become sufficiently integrated in to the social environment of Israel. We considered it part of the function of the department to bring them closer to Hebrew culture, to teach them our language, etc. We therefore applied to the Ministry of Education to set up a small seminar for the study of Hebrew at the department to include lessons in Hebrew and lectures on the geography, history and culture of the country, etc. Two special courses were set up for the vocational training of addicts, one of which was for home maintenance, including plumbing and general repairs. The intention was that people without trade qualifications would, after leaving our institution, be able to make a living for themselves and their families. It was agreed with the Ministry of Labour that suitable certificates be issued on completion of the course, enabling the cured addicts to find adequate work at their place of living or elsewhere, and that they be provided with bicycles and tools so as to facilitate their rehabilitation. It was obvious to us that we would not be able to keep these people at our institution for any length of time unless we provided a minimum livelihood for their families. The Ministry of Welfare promised financial support to the families of the hospitalized addicts in the same amount as allocated by the local welfare departments, as well as support and constructive aid to convalescents. The staff of the department was expanded, and in addition to a physician, a social worker and a psychologist were engaged. Considering goals we had set ourselves it was clear that the period of hospitalization should be at least one year.

Dr. Z. W. Jermulowicz.

In view of the prevailing state of affairs at the health offices and the special circumstances of the period as compared with the small number of beds available, We decided to limit the average period of hospitalization to no more than half a year. Unfortunately, we were not able even to keep up with this reduced demand, so that the average stay in hospital did not exceed three months.

One of the most serious problems we had to face during the preparatory period was the creation of an appropriate character and atmosphere for the department. Our goals were to a certain extent contradictory: on the one hand we wanted to assure strict adequate control of the patients, while on the other we intended to give them the greatest possible freedom of movement. As regards external circumstances the problem was easily solved. We set up the department in a separate pavilion which was closed on the outside, but provided full freedom of action and movement inside. The patients had at their disposal a spacious dining room, a dayroom which also served for group gatherings, a wireless set, a large number of newspapers and journals, a small special library, various games, including table tennis and sports appliances. We realized that even under such circumstances we would not be able to keep physically healthy and mentally alert people locked up for any length of time within the narrow confines of the department. We tried to provide the patients, under the supervision of male nurses, with suitable amusement such as trips to the sea in summer, short trips, and from time to time visits to the cinema or theatre. While prior to the opening of the department the main stress had been laid on increasing the number of the personnel, we soon realized that physical force alone would hardly enable us to keep under control twenty or thirty people who mostly came from the underworld, with a criminal record and well versed in the use of both fists and knives. It is doubtful whether and to what extent even three to four times the number of staff at our disposal would have been able to maintain peace and order if such a course had been adopted. Hence from the very start we sought to create a spirit of cooperation and understanding among the patients and to a large extent relied on a system of" self-government ". We set up a committee elected by the patients themselves, and indirectly tried to get some of the most difficult and undisciplined patients to sit on this committee. We were successful in establishing good relations with the patients and using the committee for our purposes. At a later period we got to such a stage that regardless of the number of male attendants, the committee maintained law and order and enforced the various rules and regulations on which it had resolved by itself with our consent and under our influence. It was customary for the patients committee to receive each new addict on admission. The members of the committee persuaded him to obtain the required regulations at the department, to give his consent thereto and of his own free will to sign a pledge that he would stay at the institution for the period deemed necessary by the attendant physician. When after a certain time patients had to be given a short home leave, the members of the committee subjected them to a careful physical examination after their return to prevent drugs being smuggled into the hospital, the function of the nurses being merely to supervise such search. It happened that a patient did not return from home leave in time and then the members of the committee (who regarded themselves personally responsible for any leave granted) of their own initiative went to the man's home, accompanied by a sanitary officer, and returned him to hospital. At a joint meeting with the physician they also decided on punishments to be meted out for any breach of order or discipline which might have occurred. The most severe form of punishment consisted of a temporary transfer to another ordinary closed psychiatric ward. The committee was likewise responsible for the execution of the punishment. In this way we managed to avoid any serious outbursts or disturbances. While a certain number of patients did escape, they usually returned of their own free will within a couple of hours.

The treatment of drug addicts at the Department

It was decided from the first that drug addicts should be transferred to their own special ward only after termination of the first stage of physical weaning under strict control in an ordinary closed ward together with psychotic patients. This arrangement yielded excellent results. In their desire to be transferred as soon as possible to their own special ward, which seemed much more pleasant and convenient, the addicts tried to co-operate even during this preliminary period of weaning. Our method was at once to discontinue the administration of drugs including sodium pentobarbital, right from the moment of admission. This was successful in the overwhelming majority of cases (95%). Only in some cases, where the patients suffered from a heart condition or disturbances of the blood vessels or where their physical condition was extremely poor, the use of drugs had to be stopped gradually over a period of several days. In some cases which had been used to large doses of sodium pentobarbital over a prolonged period of time, a sudden stoppage of the administration of this drug brought an epileptic attack after ten to fourteen days and hence we went over to a method of gradual discontinuation of this drug. As is known from the literature, a sudden stoppage of the administration of sodium pentobarbital might cause slight delirium, especially at night, which passes after several hours. In our practice, however, we have not encountered this phenomenon. In the course of our treatment it was noted that the symptoms of physical weaning were very slight in our patients, and some-times lasted no more than a few days. It should be noted that among the long-habituated addicts who had been used to large doses over many years there were several who underwent the period of weaning without any physical symptoms whatsoever. The average time spent by the addicts in the closed psychiatric ward did not exceed a fortnight, and only a few of them spent up to three weeks in that ward. Our success as regards physical weanings is to our mind largely due to the use of Largactyl (Thorazin). This preparation was administered to our patients from the first day of hospitalization, and the dose was rapidly increased from 150 mg to an average of 400-500 mg per day. It is to be assumed that, thanks to the use of Largactyl, the vegetative symptoms of weaning (such as diarrhoea, abdominal pains, colds, etc.) which in the past had been so obstinate, became surprisingly slight in our department. We are still able to recollect cases where the vegetative symptoms of weaning lasted in acute form from twenty days to several months. Now these symptoms appear in a slight form for two or three days, and slightly longer in rare cases. Only in one patient, an addict of long standing aged about sixty who also suffered from severe diabetes and vascular disturbances, the signs lasted about three weeks. We have learned that the abdominal pains are to a large extent psychogenic and that one single injection, even of aqua distillata, is sufficient to provide relief as long as the patient is convinced he received a morphine injection.

As against the physical weaning symptoms, the psychological symptoms were more protracted and expressed themselves in stress and internal unrest that lasted for several weeks. Maximum stress was noted during the third week of hospitalization, when the addicts used every possible means, sometimes even force, to try to obtain the drugs they craved for. They resorted to every possible trick - either by attempting to obtain leave or otherwise as far as actual escape from hospital - to fulfil their craving. During this period they complained of various symptoms: ringing of the ears, headaches, general weakness, rheumatic pains, etc. Most of these physical signs were represented as a repetition of symptoms from which they had suffered in the past. After the termination of the physical weaning stage, the medical work at the drug addicts' department consisted mainly of psychotherapy - i.e., talks with the patients. Apart from regular group sessions the physician in charge of the department spent almost his entire day in talks with individual patients, the patients' committee and their families. It was found that a separation between administrative and psychotherapeutic functions was desirable. The physician engaged on psychotherapeutic tasks should not concern himself with administrative matters, since this interferes with medical treatment and the required spirit of understanding and co-operation between doctor and patient. It should be pointed out that these numerous talks, mostly based on persuasion, gave surprisingly good results. Even though the psychological complexes of the patients were not resolved from a psychoanalytic point of view, a "group super ego" was formed. A favourable therapeutic atmosphere was created which was greatly enjoyed by the patients, who were extremely proud of their co-operation with the medical staff. Under this favourable atmosphere even neurotics calmed down and left our institution in a satisfactory and stable mental state. To quote an example: a young man of about thirty, an invalid of the war of liberation, who suffered from severe feelings of guilt because he had caused his younger brother to come to Israel contrary to the wishes of his parents - where he fell in the war of liberation. During the first months of hospitalization this patient caused a great deal of difficulty. He was riddled with doubts as to the value of our treatment and failed to co-operate. At the beginning of his period of hospitalization he tried in despair to commit suicide. After being made a member of the patients' committee and taking an active share in the work of the department he gradually calmed down and left our institution in a satisfactory and stable mental condition. He has been working for several years as a clerk, to the satisfaction of his superiors, and to the best of our knowledge no longer uses drugs. Another case is that of a patient, likewise about thirty years old, a native of the country, who owing to a severe and complicated heart condition which he contracted after his release from the army spent many months in the internal departments of various hospitals, where he became addicted to pantopon. When he needed the drug he entered a state of excitation followed by conditions of asthma cardiale. This patient had learned to use the psychosomatic mechanism in order to provoke serious attacks of asthma, thus forcing us to administer pantopon injections even during his period of hospitalization at the department. We regarded him as a lost case as far as a cure from addiction was concerned, and during an attack transferred him to a general hospital, where he stayed for some time and continued to receive drugs. A week after his release from the general hospital he applied to us again, asking once more for hospitalization. Despite our misgivings we agreed. This time he showed full co-operation, took part in the work of the patients' committee, calmed down generally and was weaned of his craving for drugs.

So far 274 drugs addicts have been hospitalized at the department, of whom 106 were recidivists. Thanks to the activities of our department we were able to stop the supply of drugs to addicts by the health offices, thus putting an end to the trading with these drugs and the cheating connected therewith. Now that most of the addicts registered at the health offices have undergone curative treatment and the health offices no longer supply such drugs, the pressure on the department has decreased, so that the average number of addicts hospitalized at present does not exceed more than four or six people at a time. Whenever a patient was released from our institution we endeavoured to maintain an adequate follow-up treatment. The addict was invited for repeat examinations at an outpatient clinic attached to the Bat Yam hospital. It should be pointed out that only the more positive elements maintained contact with us over a longer period of time for purposes of medical control; others used to appear from time to time to obtain various kinds of social aid. The majority disappeared immediately or after a short time and were seen no more. The means at our disposal did not enable us to trace addicts who had discontinued their contacts with us. It is intended to improve contacts with ex-addicts who have left our institution, through public social nurses. At present we are expanding the services of the out-patient department attached to the Bat Yam hospital, which will assist in the accomplishment of the more comprehensive follow-up aimed at.

The experience of the Drug Addicts Department

Our experience in the treatment of drug addicts has taught us that the most toxic drug of those used in Israel is pethidine, which is manufactured locally under the name "Dolestine". In addition to all the symptoms of drug addiction it also provokes a toxic stimulation of the brain. When used for an extended period of time (one year to a year and a half) this toxic reaction leads to epileptic seizures. In some of the pethidine addicts it was these seizures which drew attention to their disease and led to their hospitalization. The relatively least serious among the drugs used in Israel is hashish. The number of cases who require psychiatric treatment owing to the use of this drug is so small (less than 1 per thousand of hashish smokers) that it might be said that it does not constitute a medical problem in Israel. It was noted that in the overwhelming majority of cases, hashish does not lead to addiction at all; nor does it produce signs of a "hunger" or craving after the drug. At the same time it is regarded as a kind of preparatory breeding ground for the use of other, more dangerous, drugs.

It was noted that drug addicts of a higher standard of culture and intelligence (physicians, nurses, etc.) who appreciate the risks involved in the use of drugs and try to subsist on minimum doses, as far as possible avoiding any increase in the amount, have succeeded in continuing their work for many years without any serious hindrance. On the other hand we have found that primitive people of psychopathic character and a low standard of intelligence constantly increased the dose in a childish attempt to obtain the maximum pleasure. They furthermore tend to take the next dose before the effect of the previous one has worn off, in an exaggerated fear of the symptoms of drug "hunger". In this way they incur both physical deterioration and economic ruin within the short space of one to one and a half years. This was the state in which most addicts reached our institution. Most of them used to inject themselves intravenously with two ampules of 0.02 g each of morphine every three to four hours, and some even more. The average close reached by the morphine addicts hospitalized in our department ranged from 8 to 12 ampoules of 0.02 g morphine each per twenty-four hours. Some even exceeded this amount. Obviously, with such an exaggerated use of drugs, the addicts' entire care and attention was devoted to securing a sufficient supply of drugs, so as to avoid reaching a state of "hunger". In this state they are prepared to commit any and every act of forgery or theft, including breaking into pharmacies so as to obtain their drugs.

While we were successful in the physical weaning of the hospitalized addicts, we were less successful in the re-education and rehabilitation of the patients. The reason for this lay in the fact that 98.5% were of clearly psychopathic character, of whom 90% were primitive people with the lowest possible standard of education, about 80% stemming from the underworld. Forty-three people reported being without a profession. These were obviously underworld characters, many of them pimps and brothel-keepers with a rich criminal past who had been imprisoned more than a dozen times for various offences, both in Israel and abroad.

However, even those who presented themselves as belonging to various trades (port workers, tailors, porters, electricians, etc.) usually engaged only partly in their actual trade, being in one measure or another connected with the underworld. The most difficult to handle from an educational point of view were the unqualified illiterates who in their country of origin had become used to opium since the age of adolescence (sixteen to eighteen). Some of them had been using this drug for twenty to thirty years. Especially among the underworld characters there were many who were completely disinterested in learning a trade. Some of them earned a considerable amount of money without doing any work, as pimps. In people of this kind it is naturally difficult to awaken the desire to learn a trade or do any productive work whatsoever. Another sector that presented difficulties were those over the age of forty-five, who had never done any creative work in all their lives. Even in their country of origin they had been pedlars and the like, and were not prepared to change their way of life. A third much smaller group were those who did not need any vocational rehabilitation (doctors, nurses, clerks, a writer, etc.). It is encouraging to note that the patients did not include a single adolescent, either from among working youth or students.

The results of the treatment

A year after the concentrated effort at stopping the allocation of drugs by the health offices we were still convinced that we had achieved a stable cure of close to 20% of all hospitalized cases. About a year and a half after the treatment we still estimated the percentage at 15%. From then on this rate started to decline rapidly, and by now, after about five years have elapsed, we may state with certainty that those who have failed to relapse constitute no more than 2-3%.

Conclusions

It was found that a special department for drug addicts within the scope of a general mental hospital constitutes a disturbing and foreign element within the hospital.

The treatment of drug addicts requires an extremely strict discipline and general approach. This contradicts the liberal attitude prevailing at present in mental hospitals with respect to psychotic patients. It is obviously extremely difficult to adopt a twofold policy in one and the same hospital. Keeping the difficult human material represented by drug addicts from the underworld within the framework of a hospital ward, with all the dangers involved (organized breakouts, escapes, smuggling of drugs, attacks on female patients, etc.) constitutes a constant physical and mental strain for the entire personnel. The running of such a department constitutes a constant source of worry for everyone concerned at the hospital. It was felt that we were unable to maintain it permanently in the form given to the ward during the period of the "anti-drug campaign" when a concentrated effort was made to stop the allocation of drugs. A further conclusion was that the treatment of drug addicts of a psychopathic character requires a hospita-lization period of from three to five years in special institutions. The actual hospital is able to carry out merely the first phase of treatment (physical withdrawal and diagnosis of the personality in a mental hospital for a period of four to six weeks). Afterwards drug addicts should be dealt with according to the psychological findings, according to which they divide into:

  1. Those whose chances of treatment of any kind are very slight in view of their severely anti-social psychopathic character. In case of any clash with the law their place is in prison.

  2. The large majority of drug addicts of psychopathic character who after a period of physical weaning should be transferred to a special institution of the nature of a work camp or a farm, far removed from any major community. There they should be kept under strict supervision by court order for a period of three to five years or for an unlimited period of time, with a possibility of release at the decision of a legal psychiatric commission.

  3. A small group of people, including members of the free professions and particularly those who became addicted as a result of physical illness. These should stay in hospital for a protracted period for both physical and psychological treatment. These include clearly neurotic cases which require psychotherapy that should be continued on an ambulatory basis also after their release from hospital for a prolonged period.

It is well known that the results of treatment against drug addiction are far from satisfactory all over the world. They are all the more disappointing in Israel, where apart from the small department at the Hospital for Mental Patients in Bat Yam there are no other alternative institutions whatsoever for the treatment of persons of psychopathic character in general and drug addicts in particular. It is therefore obvious that curative action in Israel is quantitatively extremely restricted and that for these reasons the time of treatment is likewise limited. Consequently, therapeutical medical activities are confined mainly to physical withdrawal and superficial brief psychotherapeutic treatment. In the overwhelming majority of cases there is no possibility of providing basic psychotherapeutical treatment or proper re-education. It is thus clear that all our efforts must be directed towards stopping the spread of the evil of drug addiction and its prevention.

The use of the various drugs in Israel

This country has always constituted a transit route for the traffic of drugs among the neighbouring countries. Smuggling of the various drugs through Palestine is a regular occurrence, and part of these drugs remains in the country for local use. Among the drugs employed by the addicts registered with us the first place is taken by hashish, followed by opium, heroin, morphine and pethidine. We have not met with any cocaine addicts.

Cases of addiction to amphetamine are very rare. Throughout the years we have encountered only three or four such cases. Lately the use of sodium pentobarbital tablets has become widespread. It serves as an addition to other drugs and as a substitute for other more expensive drugs which are sometimes difficult to obtain. About 45% of addicts used this drug in tablets of 0.1 g up to twenty tablets per day (four to six tablets at a time). It is a typical phenomenon in Israel that drug addicts from amongst the underworld use any kind of drug they can lay their hands on, from opium and morphine down to heroin and sodium pentobarbital tablets. Among those who are addicted to synthetic drugs, such as pethidine and amidone, there is a relatively high percentage of physicians and medical workers, while the members of the underworld in Israel neither know of nor use these drugs.

The present situation

At present there are some three hundred drug addicts to all the various drugs registered at the health offices in Israel. These include almost all medical cases who started using drugs as a result of a physical illness and obtain them through doctors' prescriptions (about 25%) as well as the members of the underworld who applied to us either in consequence of a severe crisis or were sent to us by the police or else registered at the time in order to obtain drugs at the official price. The distribution by age of the drug addicts registered at the health offices is as follows:

Age

Percentage

20-30
20
31-40
35
41-50
15
51-60
25
Over 60
5
TOTAL
100

Among the addicts discovered in 1960 there is a shift increasing the 20-30-year age group to 30%; on the other hand the 51-60-year age group has decreased to about 12%. The number of female addicts is relatively small, not exceeding 10% at most, of whom about 60% belong to the 20-40-year age group.

Furthermore, about 2,200 persons are known to the Israel police, against whom police files were opened in connexion with drugs in the course of the years under review. Part of these are drug pedlars, while most of them are users. This number also includes persons who smoke hashish. A number of addicts who applied or were directed to the health offices appear in the registers both of the police and the health offices, so that the total is about 2,300-2,400, constituting 1 ? per thousand of the total Israel population. Person swho smoke hashish are generally not registered at the health offices, but only those who are addicted to more dangerous drugs, such as opium, morphine, heroin, pethidine, etc.

In the fight against drug addiction there exists the fullest co-operation between physicians, pharmacists and the health authorities. Whenever an addict is discovered, he is registered at the health office. His anamnesis is taken by a team consisting of the medical officer of the health office and the district pharmacist, whereupon he is transferred to the care of the district psychiatrist.

According to the Law for the Treatment of Mental Patients published in Israel in 1955, the country, from a psychiatric point of view, is divided into three zones, each headed by a district psychiatrist. The function of the district psychiatrist is to exercise control over all government psychiatric institutions, as well as the public and private institutions within his zone, and to provide for the required hospitalization of mental patients. He is entitled by law to hospitalize mentally sick persons even against their own will if they constitute a danger to their surroundings or to themselves. The existing law makes no mention at all of the term "drug addict" or "drug addiction". This constitutes a major obstacle in the hospitalization of drug addicts against their will and even more so in keeping them in a closed institution for a protracted period of time otherwise than on a voluntary basis. Whilst as long as the addict is actually intoxicated by drugs he may be regarded as a mentally sick person, this is by no means the case after the preliminary period of withdrawal. It should be noted that not a single addict has been hospitalized against his own free will at the order of the district psychiatrist. From a legal point of view a drug addict may receive treatment at any open or closed psychiatric institution or even with a private physician. Experience has shown that the treatment of drug addiction is feasible only in a closed institution and over a protracted period of hospitalization. All ambulatory treatments or treatments in open institutions have generally proved useless. Since according to the Dangerous Drugs Ordinance in force in Israel a physician is not allowed to supply dangerous drugs to a patient, and may prescribe them only for purposes of bona fide treatment, a private physician treating a drug addict might come into conflict with the law if he yields to the demands and pressure of his patient.

Since the Government Hospital for Mental Patients at Bat Yam has since 1956 constituted the centre for the treatment of drug addicts in Israel, all addicts in need of hospitalization are directed by the health offices or the other district psychiatrists to the district psychiatrist of the Tel Aviv zone (which comprises the hospital in Bat Yam). The addicts are examined at the outpatients' clinic of the Bat Yam hospital either by the district psychiatrist himself or by a psychiatrist authorized for this purpose.

According to this examination it is determined whether hospitalization is of idmediate urgency, when the addict is admitted immediately of his own free will, or whether hospitalization may take place at a later date. Of those addicts who have so far agreed to appear for examination no one has refused to enter the hospital for treatment. Even where admission has to be postponed, no allocation of drugs is made except in isolated instances where there is a clear medical indication in this respect in view of the physical condition of the addict.

Opinions are divided as to whether the problem of drug addiction in Israel has by now passed its peak or not. Developments during the next few years will depend on the nature of immigration to the country. With increased immigration from oriental countries the number of addicts is certainly likely to increase for a certain time. On the other hand, since there is a large measure of identification among oriental youth in Israel with Jews of western European origin and their way of life, and since drug addiction among European Jews is negligible, the risk of any large-scale spreading of drug addiction is thus eliminated. It is interesting to note that none of the children of drug addicts brought up in Israel has become addicted.

By a comprehensive control of pharmacies and doctors' prescriptions practically all medical cases of drug addiction are known to us, and their number is not very great. Drug addiction in Israel has thus become fundamentally a social problem among those who procure their drugs illegally. If we succeed in restricting the illicit trade in drugs - and most energetic steps are being taken in this direction - and if in the course of time we manage to localize the foci of this evil, we shall be able to prevent the spreading of the problem.

The problem of drug addiction should be compared to the problem of alcoholism. While the problem of alcoholism is practically non-existent in Israel, the problem of drug addiction does exist to a certain extent. From the point of view of the State it hardly matters which means are adopted by part of the population in order to arrive at a state of physical and economic ruin. There are countries, and particularly those of a high cultural level, where alcoholism constitutes a most serious social evil causing a considerable rate of invalidity towards middle age, with chronic cases of liver disease, gastritis, polyneuritis, delirium, etc. Alcoholics are always hospitalized on a background of physical illness or pronounced mental disturbances. Such is not the case with respect to drug addicts. We have found that drug addicts applied to us in low physical condition mainly because of lack of an adequate diet, but not because of any real illness resulting from the use of the drugs themselves. Some of them wanted to be hospitalized because they were unable to obtain their drugs (usually owing to lack of funds) or because of the pressure exercised on them on the part of their family, or in order to evade punishment when faced with a criminal suit for some offence or another. There are also quite a number who want to be weaned of the large doses to which they have become habituated in order afterwards to start anew with smaller doses. We have noted that drug addiction leads to economic ruin at a much faster rate than alcoholism. The addict turns into an asocial element ruining the life of his family by his craving for the drug. The dependence on drugs is much greater than the dependence on alcohol. On the other hand, in the case of alcoholics who submit to treatment owing to physical complications the damage is as a rule too far gone to be completely cured and only limited improvement is possible. Not so in the case of drug addicts: even those who are admitted in an extremely low physical condition are completely healed in this respect within a relatively short period of two to three months, and leave the institution as physically and intellectually healthy persons even after a most extended use of drugs, over many years.

The means adopted in Israel to prevent the spread of drug addiction and plans for the future

Steps are being taken to achieve closer co-operation amongst all those concerned with the control of dangerous drugs, with addicts and the treatment of drug addiction: the various divisions of the Ministry of Health, the police and the law courts. It is thus intended to intensify the fight against drug pedlars, middlemen, and drug salesmen in restaurants and various places of entertainment. Much heavier punishments are imposed for offences against the Dangerous Drugs Laws and long periods of imprisonment are ordered in this connexion by the local courts. Severe measures must also be taken against the pimps in this connexion since they are one of the factors leading to the spread of drugs and addiction. Strict control is maintained over the sale of drugs, including preparations containing sodium pentobarbital, and energetic steps are being taken (as mentioned above) by the Israel police in combating the trade and use of illegal drugs. Adequate instruction and publicity activities are carried out among physicians and pharmacists in order to reduce the supply of drugs to the minimum. A proposed amendment of the law is under examination with a view to introducing special prescriptions for dangerous drugs bearing the seal of the Ministry of Health. If this amendment is passed we hope that it will contribute towards reducing the number of prescriptions for such drugs so as to prevent to some extent the danger of addiction.

Our entire experience has taught us that the principal stress must be laid on the prevention of drug addiction, since psychological weaning of drug addicts depends on so many factors that its chances of success are hardly favourable.