World Health Organization Expert Committee on Dependence-producing Drugs: Fourteenth Report
Work of International Bodies concerned with Narcotic Drugs
Single Convention on Narcotic Drugs, 1961
Relation of Physical and Psychic Dependence to Drug Abuse
Compounding of Substances under Narcotics Control with Other Therapeutic Agents
Abuse and Control of Drugs not falling under International Conventions
Coca Leaves and Cocaine
Drug Dependence and Drug Abuse in the Monitoring of Adverse Drug Reactions
Coded Information on Narcotics
Pages: 43 to 46
Creation Date: 1965/01/01
The expert Committee on Dependence-producing Drugs of the World Health Organization held its fourteenth session in Geneva from 19-24 July 1965. Extracts from the report of the Expert Committee are reproduced with minor modifications.
An essential task of the Expert Committee is to advise the World Health Organization in making its finding and decisions under the international treaties on narcotic drugs, on extension of control to new drugs or exemption of drugs from control. The part of the Expert Committee report dealing with opinions and recommendations on the control status of drugs is not included here, but is referred to in a note on page 47 of this issue of the Bulletin.
From the report of the nineteenth session of the Commission on Narcotic Drugs of the Economic and Social Council, [ 2] the Committee noted that two-thirds of the drugs at present under international narcotics control are of synthetic origin. This is an indication of the extent and diversity of developments in this field through synthetic chemistry and of the close attention that has been given to avoiding the possible risks to public health that might result. More than half the synthetic agents at present under international narcotics control, however, have not come into general medical use, and only a very few agents per year are now being notified by Governments for consideration of the need for control.
The Committee was pleased to note the resolution of the Economic and Social Council with respect to khat, [ 3] confirming the view that the abuse of this substance is a regional problem and may best be controlled at that level. However, it was disturbed by indications of increased acreage to be devoted to the cultivation of khat. Economic considerations seem to be taking precedence over the risk to public health that increased supplies would involve. The Committee hoped that the countries concerned would take recognizance of this situation and try to attain the objective of the aforementioned resolution.
The Committee considering the reports of the Permanent Central Opium Board on its work in 1963 [ 4] and 1964 [ 5] was especially concerned by the figures for the diversion of opium from legal production. This is estimated at about 200 tons annually, of which only approximately one-tenth is recovered by seizures. Also of great importance is the production of opium in uncontrolled areas; in South-East Asia alone this is estimated at about 1,000 tons. Although much of this opium is consumed locally, it provides a major source of morphine and consequently heroin in illicit traffic. This situation largely vitiates efforts to control drug abuse and, as stressed by the Board, can only be overcome by close co-operation among all international and national bodies concerned. The present weaknesses of international narcotics control are lack of interest, inadequacy of reports on local situations, and insufficient international solidarity.
The Committee noted the differences in the rank order among countries for consumption of narcotics for analgesic and antitussive purposes, as reported by the Board. A review of the factors that might account for the differences suggests that the pattern of national medical practice is of great importance. It would appear that in some areas the relief of pain, or of cough, is being attained by the use of substances not under narcotics control.
The Committee noted that the transfer from WHO to the United Nations Commission on Narcotic Drugs of authority for placing substances under international narcotics control may sometimes lead to serious risk to public health through the inevitable time lapse between recommendations by WHO and sessions of the Commission. Consequently, the Committee suggests the desirability of a search for ways to minimize the delay and ensure prompt action of Governments on findings by WHO with respect to the need for control. [ 6]
The Committee noted further that, in as much as the Single Convention is in force, action might now be taken with respect to certain of its recommendations [ 7] that had not yet been considered by the Commission.
Noting that under article 38 of the Single Convention parties should give special attention to the provision of facilities for the medical treatment, care and rehabilitation of drug addicts, the Committee suggests that this should afford a unique opportunity for initiating planned co-operation on all sources of information and technical assistance in this field. In this co-operation WHO can play a significant role, in as much as it has repeatedly emphasized the public health aspects of the problem and offered specific recommendations through its expert committees, study groups and conferences, especially with respect to treatment programmes, regional seminars and training of professional personnel in this field.
Acceptance of the term
The Committee was pleased to note the generally favourable reaction to the recommendation, made in the thirteenth report of the WHO Expert Committee on Addiction-producing Drugs [ 8] for substitution of the term "drug dependence" (with a modifying phrase to distinguish the type) for the terms "drug addiction" and "drug habituation". Since there is still some misunderstanding, however, it is important to be clear about the relationship between drug abuse and drug dependence within the scope of this recommendation.
Drug abuse is the consumption of a drug apart from medical need or in unnecessary quantities. Its nature and significance may be considered from two points of view: one relates to the interaction between the drug and the individual, the other to the interaction between drug abuse and society. The first viewpoint is concerned with drug dependence and the interplay between the pharmacodynamic actions of the drug and the physiological and psychological status of the individual. The second - the interaction between drug abuse and society - is concerned with the interplay of a wide range of conditions, environmental, sociological, and economic.
Individuals may become dependent upon a wide variety of chemical substances that produce central nervous system effects ranging from stimulation to depression. All of these drugs have one effect in common: they are capable of creating, in certain individuals, a particular state of mind that is termed "psychic dependence".
Some drugs also induce physical dependence, which is an adaptive state that manifests itself by intense physical disturbances when the administration of the drug is suspended or when its action is affected by the administration of a specific antagonist.
It must be emphasized that drug dependence and drug abuse, as used by the Committee, are general terms and carry no connotation of the degree of risk to public health or of the need for drug control or for a particular type of drug control.
The Committee would point out again that the recommendation for the use of the terms drug abuse and drug dependence of this or that type must not be regarded as a re-definition; rather, these terms are intended as descriptive expressions for clarification in scientific reference, interdisciplinary discussions, and national and international procedures.
Characteristics of types of drug dependence
Pursuant to the statement in the thirteenth report of the WHO Expert Committee on Addiction-producing Drugs regarding the desirability of preparing an expanded description of drug dependence of various types. [ 9] a paper on this subject has now been published, [ 10] the synopsis of which is as follows:
"It has become impossible in practice, and is scientifically unsound, to maintain a single definition for all forms of drug addiction and/or habituation. A feature common to these conditions as well as to drug abuse in general is dependence, psychic or physical or both, of the individual on a chemical agent. Therefore, better understanding should be attained by substitution of the term drug dependence of this or that type, according to the agent or class of agents involved, in discussions of these conditions, especially interdisciplinary. Short descriptions, followed by concise listings of their characteristics, are formulated for the various types of dependence on at present widely abused major groups of substances."
The diversity of types of drug dependence just referred to indicates the desirability of expanded efforts to develop techniques for the detection and evaluation of these various types. Methods for evaluation of physical dependence have been fully described recently. [ 11]
A broad programme directed at the detection and measurement of psychic dependence by self-administration techniques in animals is now going forward. A study of drug-induced temperature changes in rats may afford an additional technique for the detection of tolerance and physical dependence. In the same species, a new procedure is being explored for the detection of dependence of barbiturate type.
The attention at present being given to the abuse of barbiturates, amphetamines, etc. and to their control indicates that ways must be found to assess the dependence and abuse liability of such agents under clinical conditions. At the moment, techniques for this purpose are seriously inadequate. Exploration of the subjective and objective affects of doses beyond the therapeutic range may be helpful.
A current study in man of chemically identified cannabis-like principles in comparison with cannabis as such should add materially to knowledge of this type of dependence.
Recent developments indicate that certain specific opiate antagonists, in spite of their interfering influence on physical dependence of morphine type, may produce a physical dependence of their own specific type resembling, but not identical with, that of morphine. The antagonists produce disturbing dysphoric effects. Hence, there appears to be no psychic dependence and no likelihood of abuse. Inasmuch as the antagonists are shown to have significant analgesic potency, any physical dependence property that they may possess need not militate against their clinical use, and the lack of abuse liability should facilitate it.
In contrast to the above, what appears to be significant psychic dependence has been reported for clinically useful agents for which no physical dependence properties are demonstrable. The clinical use of such agents must be scrutinized carefully because the psychic dependence would favour abuse which might eventually require restrictive measures.
The Committee noted the great number of such combinations. It was of the opinion that the additional ingredients do not a priori affect the abuse liability of the narcotic substance. Unless there is evidence to the contrary, the abuse liability of the mixture must be considered to be at least equal to that of the controlled narcotic substance therein.
The Committee noted again "the increasing frequency of abuse of sedatives or stimulants not classified internationally as narcotic drugs" and "the epidemic-like spreading of this abuse particularly among young persons in certain countries ''. [ 12] Previous WHO Expert Committees [ 13] have repeatedly recommended the need for better control of sedatives and stimulants at the national level. Realizing nevertheless that national efforts are still often insufficient, the Committee would now recommend the following measures to improve the situation:
Availability on medical prescription only, as repeatedly recommended in earlier reports;
Full accounting of all transactions from production to retail distribution;
Licensing of all producers;
Limitation of trade to authorized persons;
Prohibition of non-authorized possession; and
Establishment of an import-export authorization system.
The last might be brought about by concurrent national legislation, amendment of the Single Convention on Narcotic Drugs, 1961, as provided for in its article 47, or by a new international convention.
While the last recommendation might seem to envisage a control similar to that applicable to narcotics, it does not, in fact, do so because no reporting to and accounting by an international agency is contemplated. Nevertheless, national measures must be seriously impeded if there is no control of flow of the materials into and out of the country.
The Committee considered that, with respect to its recommendations for control, the terms "sedatives" and" stimulants" should include any drug that has been found to be dependence-producing and shown to be abused because of its sedative or stimulant effects on the central nervous systems, but excluding alcohol and substances under international narcotics control.
The Committee noted from the report of the Permanent Central Opium Board [ 14] the steady downward trend in world consumption of cocaine; this is certainly related to reduction of medical needs for cocaine because of its replacement by synthetic local anesthetics devoid of psychic dependence properties. The world consumption of cocaine levelled off about 1961, and about the same time increased abuse of cocaine was noted in certain areas. Since medical use of cocaine is virtually obsolete, the availability for abuse can be reduced by control of the cultivation of the coca bush. The Committee recommends such control.
As pointed out previously, medical need for cannabis as such no longer exists. It is becoming increasingly apparent that tetrahydrocannabinol is its most important constituent from the point of view of pharmacodynamic effects, and tetrahydrocannabinol or related substances, whether naturally or synthetically produced, may eventually be shown to have medical applications.
Research on cannabis will be facilitated if all investigators will calibrate their methods and results using the same uniform sample. Such a sample has been prepared by the Narcotics Laboratory of the United Nations.
Having been made aware of the national and international programmes for monitoring adverse drug reactions, the Committee suggests that drug dependence and drug abuse be included among the reactions to be monitored. In so far as the monitoring programme is successful, early indication of drug abuse, especially of new agents, and help in identification of the characteristics of such abuse will be obtained. Valuable information on the epidemiology and regional occurrence of drug abuse and drug dependence of different types should also result.
In view of the continuous appearance of new agents with dependence-producing properties, the changing pattern of drug use and abuse, and the changing attitudes towards and procedures of handling drug-dependent patients, narcotics control authorities should recognize the need for continuous technical advice, particularly as to medical aspects. In a few instances, control authorities are seeking such advice by the setting up of panels of independent and unbiased specialists. Such panels should also perform useful service in fact finding with respect to the occurrence of drug dependence, adequacy of treatment programmes and surveillance of abuse liabilities of new agents.
The Committee endorses this approach and recommends its wider utilization wherever feasible.
The Committee was informed of progress towards the objective of a central source for information on all aspects of drug dependence, as advocated in previous reports of the WHO Expert Committee on Addiction-producing Drugs. [ 15] Plans are now under way for revised coding in depth of such material, abstracting of important documents, and machine storage and retrieval. The last will be able to provide bibliographies, abstracts and reproductions of the original material.1
WHO: Techn. Rep. Ser., 1965, 3122
United Nations: Commission on Narcotic Drugs (1964) Report of the Nineteenth Session (May 1964) - ( Economic and Social Council, Official Records: thirty-seventh session, Supplement No. 9) (Document E/3893).3
United Nations: Economic and Social Council (1964) Official Records: thirty-seventh session 13 July - 15 August 1964, Supplement No. 1: Resolutions (Document E/3970), p. 14.4
United Nations: Permanent Central Opium Board (1963) Report to the Economic and Social Council on the Work of the Board in 1963 (Document E/OB/19).5
United Nations: Permanent Central Opium Board (1964) Report to the Economic and Social Council on the Work of the Board in 1964 (Document E/OB/20).6
See Resolution WHA18.46.7
WHO: Techn. Rep. Ser., 1964, 273,8 (section 3).8
WHO: Techn. Rep. Ser., 1964, 273, 9.9
WHO: Techn. Rep. Ser., 1964, 273, 15 (annex 1).10
Eddy, N. B., Halbach, H., Isbell, H. & Seevers, M. H. (1965): Bull. Wld Hlth Org., 32, 721.11
WHO Scientific Group on the Evaluation of Dependence-producing Drugs (1964), WHO: Techn. Rep. Ser., 287.12
See resolution WHAI8.47.13
WHO: Techn. Rep. Ser., 1957, 116,10 (sections 9 and 10); 1958, 142,10 (section 6); 1961, 211,9 (section 2.2).14
United Nation: Permanent Central Opium Board (1964), Report to the Economic and Social Council on the work of the Board in 1964 (Document E/OB/20).15
WHO: Techn. Rep. Ser., 1957, 116, 11 (section 11), 1958, 142, 11 (section 9); 1959, 160, 10 (section 7), 14 (Annex 2); 1962, 229, 12 (section 8); 1964, 273, 11 (section 8).