World Health Organization Expert Committee on dependence-producing drugs:
A better understanding of drug dependence
Significance of specific opiate antagonists in respect of abuse
New approaches in treating drug dependence
Sociological implications of drug dependence
Abuse and control of drugs not falling under international conventions
Testing for dependence liability
ANNEX 1 Sociological implications of drug dependence
Pages: 29 to 32
Creation Date: 1967/01/01
Fifteenth Report 1
The Expert Committee on Dependence-producing Drugs of the World Health Organization held its fifteenth session in Geneva from 4 to 9 July 1966. The following are extracts 2 from the Expert Committee's report:
On the subject of coca leaf chewing the Committee "noted the progress made in the realistic appreciation of the various factors and circumstances connected with it, in the planning and development of control and remedial measures. Their vigorous prosecution should be helped by general acceptance of the fact that for therapeutic purposes cocaine can be adequately replaced by synthetic substitutes.
It would appear that accurate appraisal of the extent and severity of drug abuse in a given area is still greatly hampered by the lack of appropriate and practicable methods of case finding and accounting; this is borne out by difficulties encountered in summarizing, evaluating and comparing relevant reports from various quarters of the world. 3
A step towards more uniform and meaningful data might be the enumeration of individuals receiving, on medical prescription and over a certain minimum period of time, one or more of the drugs subjected to one or other of the international control regimes; this would at least provide an indicator of the extent to which drug dependence may arise in connexion with the legal consumption of such drugs. In conjunction with specific information, where such exists, on known drug-dependent persons and with the information available on violations of narcotic laws and regulations, as regards both drugs and individuals concerned, this information would aid materially in clarifying the total picture of the use and abuse of dependence-producing drugs.
1WHO: Techn. Rep. Ser., 1966, 343.
2 Reproduced with minor editorial modifications, and italics by the Editor.
3 United Nations, Commissions on Narcotic Drugs, Summary of Annual Reports of Governments (Document E/NR/1963 Summary).
The Committee noted further the growing acceptance of the improved terminology in respect of drug dependence, recommended in the fourteenth report , 4 and its usefulness for more adequate descriptions of the various types of drug abuse."
The Expert Committee endorsed the need for:
More accurate statistics on the actual extent of drug abuse in various countries;
More research on particular factors involved in the varying etiology of drug dependence in different parts of the world; and
Adequate facilities in all areas for treatment and rehabilitation of drug-dependent persons."
"The study of the specific opiate antagonists continues to be the most promising lead towards separation of analgesic and dependence-producing properties and abuse liability. Chemical modifications of the morphine, morphinan, benzomorphan and pethidine series are providing a wide range of compounds with antagonistic action. Their examination, however, has not yet provided any indication of consistency in the relation of structure to analgesic action, dependence-production, or antagonistic action. Nevertheless, the range of activity is known to include high analgesic potency both with and without high frequency of disturbing side effects and, at the most, mild atypical dependence production. Antagonistic action, particularly its characteristic precipitation of abstinence phenomena in an established dependence of morphine type, virtually precludes significant abuse liability. Altogether, research on these compounds is encouraging and promises improvement and greater safety in the relief of pain.
4 Wld. Hlth. Org. Techn. Rep. Ser., 1965, 312,7 (section 4).
The Committee reviewed an experiment of over two years' duration in which a group of subjects predominantly dependent on heroin were stabilized on large single daily doses of methadone. These subjects have been helped to find work and accommodation but continue to visit the clinic regularly for their drug, always given orally, and for monitoring of drug intake by urine analysis. They appear to have lost interest in other narcotics, but their attitude towards other drugs is less certain. The pharmacological explanation would appear to be that a high degree of cross-tolerance to the subjective and other effects of heroin and related drugs has been established in these subjects. The majority of the subjects seem to have abandoned their antisocial activities and to show substantial improvement in their social adjustments. The avowed intent has always been eventual withdrawal from drugs, but no effort towards this has yet been made and there is at present no time schedule for such withdrawal. It must be emphasized that this methadone maintenance programme should be looked upon as a research procedure on a limited scale which it is hoped will yield valuable information on the phenomena of drug dependence. However, at present many questions remain unanswered and many investigations to elucidate the precise role of methadone as against that of surrounding conditions need to be initiated.
The Committee is of the opinion that in so far as maintenance on methadone is not carried out simply for gratification of the individual but is used as an adjunct to vigorous efforts towards social rehabilitation, the employment of this procedure under very carefully controlled conditions will continue to be of considerable scientific interest.
In the present methadone maintenance programme, the drug is given at a high uniform dose level for an undefined period. On the other hand in the use of methadone to mitigate the severity of abstinence phenomena the doses are small and rapidly diminished over a few days. These two uses are in no sense comparable and must not be confused.
The Committee also reviewed the recently introduced experiment involving stabilization on cyclazocine. In this instance heroin-dependent or other narcotic-dependent persons first have their drug withdrawn and after a brief drug-free period receive the antagonist cyclazocine in increasing doses to a level sufficient completely to block the euphorigenic effects of their initial drug of dependence. These patients also are helped to estab- lish good social relationships and working habits. As in the methadone experiment, the subjects appear to be progressing towards rehabilitation. Pharmacologically, however, the explanation is different. The cyclazocine blocks the essential effects of the opiate whereas methadone establishes a high degree of cross tolerance. Furthermore, cyclazocine stabilization is not maintenance of drug dependence of morphine type. Again, there are many unanswered questions including the precise role of antagonist blocking as a long-term treatment procedure.
In any case, the experiments described above indicate that more subjects with a drug dependence of morphine type may be willing to accept social rehabilitation than had been generally believed.
The Committee's attention was directed to a number of community-oriented programmes for the treatment of drug dependence. A positive feature of the philosophy involved in some of these is the emphasis on the prospects of successful treatment. To this end, patients at different stages of treatment are employed for direct help of those who have made less progress than themselves, and eventually for recruitment of new candidates for treatment. The Committee approves this outlook.
The concepts and significance of these problems are discussed in some detail in Annex 1. The Committee has repeatedly drawn attention to the need for epidemiological studies on drug dependence and drug abuse. 5 It appreciates the opportunity to extend its activity towards the sociological aspects of drug dependence and would emphasize the need for research along the following lines:
Fact-finding with respect to incidence (on a continuing basis) as regards sex, age, occupation, groups at risk and the drugs abused.
Definitions of "use" and "abuse" in various cultures.
Investigation of cause-effect relationships based on:
sociological background (home, family, work, etc.);
medical, psychological, economic and cultural factors.
Prevention by education and legislation.
Factors affecting the design of treatment programmes:
Dynamic consequences of enactment of drug-control measures:
deterrence of drug abuse by some, perhaps the majority of individuals in a given society;
promotion of drug abuse by a minotiry of individuals in that society;
formation of deviant subcultures in which abuse of proscribed drugs is a distinguishing feature;
possible dangers of provocation of the society towards creation or further alienation of deviant groups on account of increasingly punitive attitudes in the interpretation and implementation of legislation.
5 Wld. Hlth. Org. Techn. Rep. Ser., 1957, 131, 11 (section 6); 1960, 188, 10 (section 4); 1962, 229, 11 (section 7).
The abuse of dependence-producing drugs of depressant, stimulant and hallucinogenic 6types continues to increase and to grow in importance not only for the countries in which there is a significant problem, but also for neighbouring countries. The Committee has repeatedly urged the adoption of adequate national measures of control. These were set out in detail in its fourteenth report, 7which in addition envisaged the possibility of international measures.
6 These terms in this context include not only barbiturates and amphetamines but also any drug that is found to have dependence-producing action of barbiturate or amphetamine type and shown to be abused because of depressant or stimulating effect on the central nervous system, but excluding alcohol and substances under narcotics control.
7 Wld. Hlth. Org. Techn. Rep., 1965, 312, 9 (section 7).
The Committee was informed of a meeting convened by the United Nations Commission on Narcotic Drugs to explore the steps that might be taken towards adequate control. It recognized the timeliness of this meeting and emphasized, as did the World Health Assembly, 8 that control within a country, however satisfactory, may not afford adequate protection for that country or others without international co-ordination of control measures.
The Committee has drawn attention to the diversity of the drugs abused and would point out that control could not and should not be instituted on the broad basis of any classification, but that in each specific instance the recognized risk to public health should be the paramount consideration. If control measures in this connexion are to be established, they should include means for evaluating the risk involved.
The Committee has from time to time considered the methods available for the determination of dependence liability of different types. A description of the procedures has been published 9and facilities are now available for screening purposes with respect to sedatives as well as substances that may have morphine-like effects. An outline of the technical conditions for making use of these facilities has since been prepared. 10 This may be particularly timely and helpful in view of what has been said about the increasing abuse of non-narcotic agents not now under international control and the consideration being given to plans for their control."
8 Off. Rec. Wld. Hlth. Org., 1965, 143,31 (Resolution WHA18.47).
9 Wld. Hlth. Org. Techn. Rep. Ser., 1964, 287.
10 National Academy of Sciences - National Research Council, Committee on Problems of Drug Dependence (1966) Minutes of the twenty-eighth meeting. Addendum 1, Washington.
As a result of historical, political, cultural, religious, economic and other antecedents there exist, in a given society at a given time, a number of beliefs and moral attitudes towards uses and effects of certains drugs and a number of ways of perceiving drug users that may or may not coincide with the beliefs and attitudes of the users themselves or, for that matter, with "objective" scientific information. Such beliefs and attitudes define the social settings in which drugs may or may not be used for designated purposes and these, in turn, influence the behavioural effects of drugs to varying extents. Persons whose drug-usage patterns deviate from the norms approved by the larger society in which they live may then be perceived by the latter as "deviants" requiring separation from it. This alters the deviant drug user's percep tion of himself and leads him to withdraw further from the larger society, to identify with others like him and with his new "peers ", and to create a subculture with beliefs, attitudes and corresponding patterns of language and behaviour that are even more alien to the larger society. In turn, such increased alienation reduces the larger society's tolerance of deviance, with a consequent increase in the number of persons perceived as deviants, giving further impetus to this "positive feedback system." 1l Operating against this system are, of course, the deterrent effects of social
11Wilkins, L. T. (1965 ) Some sociologic factors in drug addiction control. In: Wilner, D. M. & Kassebaum, G. G., ed., Narcotics. New York, McGraw-Hill, pp. 140-156.
disapproval that limit to some degree the recruitment of new deviants; in a given society, the number of deviant drug users and the characteristics of their subcultures will be determined by the resultant of these opposing processes. Hence, the social problems arising from deviant drug-use change in time and need periodic re-examination for their proper solution.
Although a considerable amount of descriptive information is available about patterns of drug abuse throughout the world, knowledge of how the variables mentioned above interact is still very fragmentary, being limited mainly to a results of a few studies on drug dependence of morphine type in circumscribed areas. In future studies, attention should be focused on the following factors and their interaction:
I. Antecedents of varying present-day beliefs and attitudes toward drug usage and drug users (compare, for example, the USA, the United Kingdom and Asia).
II. Variations in social settings and drugs effects (compare, for example, the purposes and modes of use of opioids and cannabis products among different social and occupational groups in Europe, the USA, and in India and other Asian countries).
III. Characteristics of deviant, drug-using subcultures.
Urban, opioid-dependent groups in the USA. Concentration in the slum districts of large metropolitan areas with:
extreme poverty, high delinquency, ready availability of drugs of all sorts;
unstable family relationships, weak or non-existent models of successful males in the home; sense of futility with regard to long-range prospects of education, employment and security; emphasis on short-term satisfaction; distrust of "law and order"; identification of "success" with illicit activities;
prevalence of "street corner" society; pressures to join deviant subgroup; initiation into drugs use by peers and "pushers"; positive reinforcement by sense of "belonging".
"Avant-garde" and "beatnik" groups in the USA and Europe (not economically or culturally deprived; role of "protest" and "adolescent rebellion").
IV. Drug control laws and their consequences (compare especially the USA and the United Kingdom; controversies regarding differences in "perception" of drug-dependent persons; current trends in both countries).
Further research should, in particular, be directed towards the following:
Cross-cultural studies on "perception" (and "misperception") of drug use and drug users.
Distinction between "use" and "abuse" of drugs in various cultures.
Socio-economic factors in development of deviance.
Social teaching, learning and identification of drug users with deviant subcultures.
Modes of enforcement of drug-control laws and their consequences.