Giver of delight or Liberator of sin: Drug use and "addiction" in Asia
V. Causes and Effects
VI. Control and Enforcement
VII. Treatment and Rehabilitation
VIII. Education and Prevention
X. Conclusions and Recommendations
Author: Joel FORT
Pages: 13 to 19
Creation Date: 1965/01/01
V. Causes and Effects
VI. Control and Enforcement
VII. Treatment and Rehabilitation
VIII. Education and Prevention
X. Conclusions and Recommendations
Long tradition of general cultural acceptability (and sometimes encouragement) of drug use exist in many Asian countries; religious writings and traditions sometimes include the use of opium or cannabis; indigenous medical systems utilise these substances as an important component of their pharmacopoeia; social events, celebrations and festivals have made use of them. Such additional factors as beliefs that the drugs cure diseases, relieve fatigue and hunger, and intensify sexual pleasure, as well as the quest for euphoria or relaxation, bring in psychological aspects also, and play an important role, often in combination with socio-cultural factors. In some countries it has been a common practice to administer opium to infants for sedation and control of disease symptoms, thus establishing acceptance of drug use at an early age as normal and natural. Also in some areas ready availability at low cost and economic dependence on opium as a cash crop of people such as hill tribesmen are a major cause of drug abuse.1
The term Asia as used here does not include the Asian portions of the USSR, the Near East (Turkey, Syria, Lebanon, Jordan, Israel) and the Arabian peninsula.2
Director, Center for Special Problems, San Francisco Department of Public Health. Formerly: Social Affairs Officer, United Nations, Consultant, World Health Organization; Lecturer, School of Criminology, University of California, Berkeley.3
The first four chapters were published in the Bulletin on Narcotics, Vol. XVII, No. 3.
The etiology of drug abuse has often been the subject of over-simplification and myth making but in fact there is not any single cause of drug use or abuse. Individuals are affected in markedly different ways by mind-altering drugs, depending on a combination of their personality structure, the pharmacology and dosage of the drug and the social context in which the drug is taken. Not all users are to be considered as abusers or addicts. Whether a given individual uses opium, cannabis, alcohol, etc. will depend upon a balance of the social factors mentioned above, his or her psychological needs, the availability, over-all and in terms of his income, of the drug, and an element of chance. Since research efforts have been negligible, no scientifically precise conclusions can be drawn as to etiology. The few studies done, for example in Hong Kong, Thailand, Japan and Singapore, give as "causes" such factors as curiosity, insomnia, depression, association with other users, desire to increase longevity, need for relaxation, building up of physical strength. The growing shift to heroin use seems to reflect an increase in the emotional component as a cause of drug abuse, although where extensive opium use persists, social tradition remains uppermost as a cause.
Despite the dearth of scientific studies, two things seem clear: notwithstanding the sanctions against drug use which have been relatively recently superimposed from outside, the long-standing cultural acceptance of drug use as normal persists as a major cause of contemporary use in Asia and, as in other regions, a great many factors are involved.
Even more difficult to assess are the effects of the abuse of opiates and cannabis, the most widely used drugs. Since drug abuse is usually intertwined in Asia with the core problem of under-development poverty, disease, illiteracy, hunger it is not surprising that most illicit drug users are affected by these problems. These may well be causes and not effects of drug use. Cannabis does not produce physical dependence or permanent physical damage to the body but there have been some reports of insanity having occurred as a result of cannabis use, usually the very potent forms (charas or hashish). It is, however, possible that the psychoses ante-dated the drug use if chronic or occasionally happened from an excessive dose and disappeared after the drug affect had worn off. With opium and heroin, chronic excessive use usually brings about constipation, loss of appetite and impotence but these are all reversible when the drugs are discontinued. There is no evidence in Asia of a decreased life span as a direct result of drug use although one can presume that frequently diseases such as tuberculosis would be aggravated and thus progress more rapidly.
1. Opium hidden in a pineapple can
It is in the more subtle psychological and social dimensions that effects need to be carefully assessed. As has been pointed out, the pharmacological effects of these drugs are quite variable. It has sometimes been suggested that opium and cannabis have been popular in Asia because they fit into the more passive contemplative traditions as compared with the popularity of alcohol in the west because of the tradition of "agression" there.
Direct association of drug addiction with crime, family disruption, job loss or other possible important social problems is difficult to assess. Since the imposition of abrupt bans on opium and cannabis in the past twenty years, those using or handling these drugs for non-medical purposes became and continued to be criminals but this is of course quite different from saying that drug use produces criminal behaviour either in the sense of property crimes or crimes of violence. As the heroin traffic has developed, and the price of both heroin and opium increased and these narcotics became more difficult to obtain, the problem has become interwoven with crimes against property to obtain money for drugs, with delinquency among young people, with prostitution, and in the case of the traffic, with organized crime.
Since most known illicit users are unskilled workers or periodically unemployed, it is difficult to determine whether chronic drug use alters their employment pattern on a long-term basis. The author's studies suggest that on an over-all basis, in Asia opium or cannabis use has had little effect on vocational life. With heroin the context is quite different since the problem has appeared quite recently and since the drug leads to physical addiction: there is much more detrimental effect on the individual and society although how extensive this is is impossible to know precisely.
Concerning the use and abuse of these drugs, the most important question in terms of effect and the least answerable is a philosophic one: is individual energy or initiative lost or diverted into relaxation or euphoria or escape to such a degree that the person's creative potential cannot be realised and the development of the country retarded or made impossible, or can the person sufficiently divert himself from poverty and misery through the use of these drugs to function effectively in the society? For the under-developed nations of Asia where extensive drug use is common the answer is extremely important. The position taken by the Commission on Narcotic Drugs of the United Nations on that question is unequivocal: the development of the individual and society is harmed by drug abuse.
Historically the countries of Asia either let drug use go uncontrolled or imposed regulations on distribution and pricing. It was not until the close of the second world war that imposition of bans on the drugs and prison sentences for those using or selling these drugs or cultivating their raw material came about. Since that time the movement towards controlling drug use through the imposition of criminal sanctions has continued and accelerated in Asia, although the penalties for use have in general remained lighter than in other regions of the world and some countries have followed different pathways. The countries with the most complete criminal legislation covering this subject are Japan, Hong Kong, Thailand and Iran.
Most of the countries of Asia are parties to at least one of the multilateral narcotics treaties in force and it is relevant that the first international conference on narcotics met in Shanghai in 1909. The aim of the international treaties is to prevent misuse of narcotics, by providing for the control of production and distribution, suppressing the illicit traffic, establishing local control and administration, and reporting to international organs. The 1953 Opium Protocol allows for the production of opium for export by only seven countries including India and Iran. At present Iran is not exercising that right but India has under cultivation 25,000 hectares, (which will be reduced to 13,000 in the near future), of opium poppies with a total annual harvest of from 640 to 950 tons, about half of which is exported. An elaborate system of controls under a narcotics commissioner exists for this production and only negligible amounts are diverted into illicit channels. The production is also used for the legitimate supply to the practitioners of the traditional system of medicine and to the "quasi-medical" users. In the development of drug laws in India, opium-smoking has been considered more as a vice than opium-eating, although in both cases control policies have been gradual, particularly as applied to the user as opposed to the trafficker. The control policies in India are left to the individual states and most of the larger states permit registered users to buy opium or cannabis ( ganja since charas is banned) at licensed shops in limited amounts. The criteria for registration by out-patients medical examination are not very explicit but the over-all emphasis is on preventing new users rather than eliminating the existing ones. New users are not registered and the amount sold to the old ones is reduced over the years.
A sharply contrasting control system exists in the other countries of Asia, a number of which have established formal centralized narcotics control administrations, usually of an inter-departmental nature under the direction of law enforcement agencies such as police, customs (or excise). Co-ordination, exchange of information, planning and international co-operation are carried on by these administrations and sometimes efforts of rehabilitation or education.
There are usually several different drug laws with multiple amendments in each country and a given individual may receive quite different penalties for identical offences. In most instances the penalties for illicit use or possession range from six months to several years in prison, plus a fine, and the penalties for illicit production or sale are somewhat more severe.
Unfortunately in the imposition of these penalties the law oftens fails to distinguish between the different drugs which represent problems of different seriousness, e.g. opium, heroin, cannabis, and often fail to sufficiently separate users from traffickers.
There is considerable variation and inconsistency in enforcement, prosecution and sentencing, both within a country and comparing one country to another. Some countries do not enforce the laws against addicts either because the enforcement officials do not consider it an important problem or because they do not have adequate staff and equipment. In a few countries the addict is sent to a hospital rather than a prison and does not appear as a prisoner in the records. Other countries place the main emphasis of their enforcement policies on the users and no country is apprehending a significant number of the top businessmen of the illicit narcotic traffic. One reason for this is the complexity of the production and distribution but equally important are the existing duplication of efforts, poor organization and competition of enforcement services in some countries, lack of training, low salaries and sometimes corruption. The existence of other more important social or political problems for the officials to occupy themselves with and the political difficulties of developing adequate border controls between neighbouring countries also play a part in that respect.
2. Drug addiction in Hong Kong
Criminal statistics relating to addiction which could be considered adequate or meaningful are not always available in Asia and it is therefore very difficult to reliably assess the effectiveness of the present enforcement and control systems. The apparent increase in illicit traffic, however, both within and outside the region, the growing use of heroin rather than opium and its increasing association with crime and delinquency, would all indicate that these systems are not very successful in Asia.
Since to some extent drug addiction is a " crime without victims " in sociological terms, much of the enforcement effort depends upon informers and the incentives or rewards provided for such informers. This technique of enforcement is used in varied degrees and with varying success by the Asian countries. A few countries with major heroin problems have attempted to control the importation of acetic anhydride which is used in the conversion of morphine to heroin.
One must include in over-all control efforts in Asia aid provided internationally and bilaterally, including the efforts of the United States Government. The United Nations have provided expert services and fellowships, have held seminars, participated in surveys and have also contributed by the outposting in the region of officers of the Division of Narcotic Drugs of the United Nations Secretariat. Also a United Nations Advisor has been provided to Iran for several years and additional special advisors on intelligence and rehabilitation are presently being provided to that country. CENTO has also given some aid to Iran (and other Near Eastern countries) on this problem. That despite all of these actions, the over-all problem has worsened should be a source of great concern to all.
With the exception to be mentioned in the next chapter, the jails and prisons of Asia provide only incarceration and custodial care as their part of the enforcement process.
On an over-all basis, treatment and rehabilitation programmes for addicts are rare in Asia. With a very few exceptions, those prisons and hospitals that are designated as " rehabilitation facilities " provide only physical care and work. Adequate and proper withdrawal treatment, voluntary commitment procedure and after-care programmes are rare. Little attention is given to correcting the underlying social and psychological causes of drug abuse and dependence. There is also an insufficient number of trained personnel to carry out even the existing quite limited programmes.
The most extensive rehabilitation programme in Asia is found despite the small size of the territory, in Hong Kong. Those addicts, either male or female, who have been arrested go to a general prison where some partial withdrawal treatment is provided. A selected minority of the male prisoners with shorter sentences are sent to a specialized addict prison, Tai Lam, which provides a work programme, physical rehabilitation, and limited after-care. Some after-care is also provided by a Discharged Prisoners Aid Society. Relatively small numbers of male volunteers seeking, for various reasons, to give up drugs are provided with an excellent programme jointly operated by the Castle Peak Mental Hospital and the Society for the Aid and Rehabilitation of Drug Addicts (SARDA) which is gradually taking over responsibility for the entire programme from the Government. Methadone withdrawal treatment is provided followed by some psychiatric care, social work service, a work programme with incentive pay and active recreation, for up to six months, then trial home visits with nalorphine tests, and follow-up visits after discharge. Some of these patients after completing the hospital treatment are sent to Shek Kwu Chau island for up to five months of convalescent care including work, food and recreation. Other social welfare agencies provide help to some addicts in Hong Kong and there is a society which meets weekly as a self-help movement similar to the American "Narcotics Anonymous".
Macau has a Centre for Treatment and Rehabilitation of Narcotic Addicts which is run by the government and administered by the police. Male addicts are admitted irrespective of residence (unlike Hong Kong) and with no waiting period. Both volunteers and prisoners are accepted and provided with withdrawal treatment, work, and physical rehabilitation.
Iran provides methadone withdrawal for addicts awaiting trial, in the main prison in Teheran and maintains a special addict hospital which gives three weeks of methadone withdrawal, limited social work services and some physical rehabilitation for small numbers of male and female volunteers. There is a long waiting period and the hospital is greatly understaffed.
3. Heroin addict: three phases (21.7.61 - 20.3.63 - 5.8.63)
Singapore provides tincture of opium withdrawal for addicts in its prisons and maintains the well-known Opium Treatment Centre on St. John's Island. Due in large part to the knowledge and dedication of Dr. Leong Hon Koon, male volunteers and carefully selected prisoners are provided with tincture of opium withdrawal, physical rehabilitation, work, social services, a rudimentary six-month's parole system for prisoners, and medical follow-up for three months after release.
Korea maintains eight quarantine camps in different parts of the country, and these provide one month of tranquillizer withdrawal treatment and physical rehabilitation for volunteers and selected prisoners.
Thailand has both a Government Narcotic Hospital for volunteers at Rangsit, and a new Addict Prison in the same location, near Bangkok. Withdrawal treatment using opium or methadone, physical rehabilitation, minimal psychiatric care, social work services, and three-month's after-care follow-up for a small number of patients are provided. In-patient convalescent care has been provided at the Rangsit Hospital in the past and a new hospital is in an advanced planning stage.
All of these facilities and resources are fairly recent in origin and have treated only a small number of opium or heroin addicts. No specialized facilities exist for cannabis abusers.
Nothing approaching a comprehensive and adequate out-patient and in-patient treatment and rehabilitation programme exists in Asia. Such a programme should be developed as soon as possible in those countries with major drug abuse problems and should include for narcotic addicts a combination of methadone withdrawal, physical rehabilitation including correction of underlying physical illness, occupational and recreational therapy, vocational training, education, group and individual psychotherapy, self-help movements, nalorphine testing, probation or parole supervision for those who have been arrested, civil commitment procedures and, most important, long-term out-patient follow-up services to help users fight relapse and adjust to a normal way of life. Centres need to be established on a decentralized basis in all the areas of the country where there are large numbers of addicts. Extensive professional training programmes are necessary to provide the staffs of such programmes which would include physicians, psychiatrists, nurses, social workers, and many others.
In Asia educational efforts are very few in number, quite limited in scope, sporadic, and mostly in the nature of propaganda.
Such campaigns have been conducted in Hong Kong and Macau consisting of anti-narcotics statements in posters, leaflets, broadcasts, etc.
Tai Lam Prison - Prisoner due for release. During the time he was at Tai Lam, he gained more than 14 lb. in weight. He told the photographer: "I'll never come back to prison again. No more drugs for me."
Japan has also used anti-narcotic posters and brochures. Taiwan and Thailand have had a few days of anti-narcotics propaganda in recent years and the latter country has had posters printed in the past.
None of these efforts appear to have had much effectiveness.
As has been mentioned, training seminars have been held within the region for enforcement officers by the United Nations, for representatives of many of the Asian countries.
Despite the size of the drug abuse problem in Asia and the failure of current approaches to the problem, research has yet to be developed, in most countries, even in terms of simple collection of accurate statistical data.
Hong Kong has the most extensive research programme and has collected considerable social data on addicts, has initiated some psychological (one of which found a sample of addicts to be more neurotic than the average) and follow-up studies, and is engaged in experimentation with nalorphine and with aversion (faradic) shock as methods of discouraging narcotic use.
The Teheran School of Social Work has carried out a number of worth-while projects, including an analysis of social information obtained from 4,000 hospitalized addicts, depth analysis of a stratified sample of 30 of these addicts, and an attempted follow-up of those with addresses in the records.
Much social data has been collected from Singapore addicts but it has not yet been analysed.
Japanese research in this field is mostly pharmacological. Some analysis of social data and follow-up of selected criminal addicts has also occurred.
Detailed social data about the addicts seen at Rangsit Hospital in Thailand has been compiled.
The picture in other countries is mainly one of limited anecdotal and superficial information on arrested addicts, collected by enforcement agencies.
The production, use and abuse of mind-altering drugs is an important social and health problem in Asia, affecting not only several of the major countries, but the region as a whole and the international community. Unfortunately, despite the extensive laws, organizations and institutions which have been developed to deal with the problem, only the most general estimates are available on its extent and pattern, and it appears to be growing worse in many significant respects.
There is often a tendency to minimize the seriousness of heroin, sedative and stimulant abuse, and on the other hand, to exaggerate the seriousness of opium and cannabis use.
Perhaps the most important recommendation one can make is to urge that the present preoccupation with administrative and enforcement approaches to this problem be accompanied by preventive and rehabilitative efforts directed at the socio-psychological and economic roots. Such a recommendation is somewhat utopian considering the deficiencies of "human nature" and the complex "vested interests" which want to maintain things as they are. Some rapid change of emphasis is imperative if the growing use of heroin is to be checked.
Use of a drug must be carefully distinguished from abuse, and consideration given to such factors as potency, amount taken, method of administration, frequency of use, etc.
A total programme of drug addiction control in Asia or elsewhere must include simultaneous efforts to reduce the availability of the drug, rehabilitation of those already using or abusing it, and prevention of new addictions. Even massive efforts directed at only one of these areas can only be partially successful if the other areas are neglected. Thus, local cultivation must be eliminated; borders controlled; smugglers, chemists, salesmen apprehended; and public attitudes changed.
Detailed comments have already been made in the above sections on what is needed to provide adequate enforcement and rehabilitation programmes in Asia. Quality should replace quantity, e.g., a well staffed small hospital with a comprehensive programme is better than a poorly staffed large hospital providing only minimal withdrawal treatment, food and work. Most needed (and much less expensive than building and staffing institutions) are out-patient programmes including clinics and parole and probation services where long-term help can be provided to prevent relapse. The professional disciplines required for a satisfactory out-patient (or in-patient) programme hardly exist in most of the Asian countries, so existing medical and other professional schools and hospitals must train at least minimal staff, perhaps with the United Nations and World Health Organization's assistance.
Basic data collection and record-keeping procedures should be taught to the responsible officials and adopted into their on-going programmes, so that they and others will have some basis for assessing "progress".
A number of important research studies are desirable, and possible only in Asia, including cross-cultural comparisons of opium and heroin use by Chinese, Japanese, Iranians, etc.; epidemiological studies of the shift from opium to heroin in some countries; measuring the effects of religious belief (Moslem, Buddhist, etc.), urbanization and family disruption on drug use; studying the effects of chronic opiate use on health, life expectancy and work performance and comparing opium to heroin, determining the pattern of use over many years, follow-up studies of "cure" rates and comparisons of treatment effectiveness; and investigations of inter-relationships between opium, heroin, cannabis and alcohol use and personality and character structure. With adequate planning much research can be built into the clinical and correctional programmes that are developed. The most beneficial new legislation for most of the Asian countries would be a civil commitment law which would provide that both those volunteering for treatment and those arrested for various offences (who can have the criminal proceedings dropped or suspended) can be sent under civil (non-criminal) procedures to a narcotics hospital for up to six months followed by required attendance at an out-patient clinic for up to two years. The many different laws covering drug offences should be replaced by a single new one liberalizing the penalties for use (and separating the different drugs) and possession and leaving the more severe penalties for the traffickers. Medical and public health departments should play a leading role in narcotics control administrations and all rehabilitative, educational and research efforts.
At least minimal educational programmes are needed in most of the Asian countries, including alcohol and synthetic drugs as areas of concern as well as the opiates and cannabis. The two major goals of such programmes would be to develop negative attitudes towards drug use, using objective information and to encourage early detection and treatment of drug abusers. Opinion leaders and young people should receive special attention. Indiscriminate campaigns using fear techniques should be avoided. Target audiences should be clearly delineated and the content of the educational effort individualized and communicated in terms of the particular group.
The most valuable outside assistance which could be provided through international and bilateral aid programmes would be individual consultants in each of the major areas where improvement is needed, or perhaps a travelling seminar.
Long-range (5-10 years) planning with establishment of priorities and co-ordination at all levels is essential. When drastic changes are contemplated, a policy of gradualism would seem desirable with full appreciation of cultural traditions and awareness of the danger of the user substituting new and more dangerous drugs, or more deviant forms of behaviour. Early efforts to forestall further abuse of sedatives and stimulants may prevent future development of problems as serious as those which presently exist with opium or heroin.
Although we have observed that drug abuse in Asia is found with quite varied political and social systems, religions, climates and histories, all of these countries share its detrimental effects. What should be of concern to society - more than the use of a "pleasure-giving" drug by an individual - are such things as impaired mental and physical health, job and family disruption, loss of creativity and productivity, accidents and crime, in so far as these occur as a direct result of drug abuse. The experts and specialists in the field could, to advantage, try to determine whether their attitudes are based on moralistic, mythical and ethnocentric foundations or on objective verifiable reality. In the region that once knew Buddha and Confucius, is it remiss to speculate on the alternative means of pleasure there are for the tensions and miseries produced by the perennial Asian problems of war, disease, poverty, hunger, and illiteracy? Is it not perhaps more surprising that so many Asians are not using these drugs, than that so many are?