Epidemiology of criminal narcotic addiction in Canada

Sections

Summary
Introduction
Methods
Trends in criminal addiction, 1956 and 1966
Course and prognosis for individual criminal addicts
TABLE V Proportion of criminal addicts imprisoned in 1954-55 attending particular treatment agency 1955-65
Discussion
References
MISCELLANY
MORBIDITY AND MORTALITY FROM HEROIN DEPENDENCE.
COMPARATIVE TOXICITY OF HEROIN; MORPHINE AND METHADONE
NEW LEGISLATION IN SPAIN: DRIVING UNDER THE INFLUENCE OF NARCOTICS
ACCIDENTS AND ABUSE OF PSYCHOTROPIC DRUGS

Details

Author: Alex RICHMAN, Barry HUMPHREY
Pages: 31 to 40
Creation Date: 1969/01/01

Epidemiology of criminal narcotic addiction in Canada

M.D., M.P.H. Alex RICHMAN Associate Professor, Division of Epidemiology and Director, Training Program in Psychiatric Epidemiology, Columbia University School of Public Health and Administrative Medicine, New York City
M.D. Barry HUMPHREY Research Assistant, Department of Psychiatry, University of British Columbia, Vancouver, Canada

Summary

Canadian trends in criminal narcotic addiction are analysed from data compiled between 1955 and 1966 by the Narcotic Control Division of the Department of National Health and Welfare. Heroin continues to be the drug most frequently reported, although the use of synthetic narcotics has increased.

Newly reported addicts are 20-60 times more frequent in British Columbia than in the other Canadian provinces. During 1965-1966 the annual recognition rate for new addicts in British Columbia reached a peak of 64 per 100,000 for males aged 20-24. One-third of the newly reported addicts from British Columbia in 1965-1966 used methadone believed to have been obtained from medical sources.

A sample of 177 addicts imprisoned in British Columbia during 1954-1955 was followed to 1965. About one-half of the addicts voluntarily attended an addiction treatment centre in Vancouver before the middle of 1965. The characteristics of those attending were not different from those of the non-attenders in terms of age, sex, year their addiction began, number of previous attempts to quit drugs voluntarily, or period of initial contact with the police. Abstinence was presumed for those addicts who, for a three-year period during 1961-1964 had no records of conviction for Narcotics Act violations or any other felonies, were not considered addicts or narcotic pedlars by the Royal Canadian Mounted Police, and were alive and out of prison. About one-fifth of the 177 addicts were thus deemed abstinent during the period five to eight years after imprisonment.

The relation between outcome and contact with the Vancouver addiction treatment agency was determined. Abstinence during 1961-1964 was presumed for 5% of those addicts contacting the addiction treatment agency during 1956-1960 in comparison to 34% of those with no contact with the agency.

The chaotic reporting of outcome criteria and methods for follow-up studies of addiction is outlined. The concepts of relapse and abstinence, and their implications for various models of the natural history of narcotic addiction are discussed. Methods for preparing national evaluations of the course of criminal narcotic addiction are described for Canada and their feasibility considered.

Introduction

Dependence on barbiturates, amphetamines, tranquillizers, mood-elevators and hallucinogens is believed to be increasing in Canada, as in certain other countries. Global studies of the whole spectrum of drug dependence are confounded by problems arising from geographic differences in usage; the relatively frequent transfer by individuals from one drug to another; the not infrequent use of drugs in combination; complex and changing patterns of abuse and the rapid development of new drugs with potentialities for abuse [ 1] . Because of these problems, over-all changes in the prevalence, incidence or duration of all forms of drug dependency combined cannot be assessed.

Recent changes in British legislation are intended to provide more extensive data on the extent and characteristics of narcotic addicts. Such data would enable better assessment of the effectiveness of various changes in legislation, social or health services by using such measures as changes in morbidity.

Little is known about the sources, spread or long-term course of addiction. It is commonly assumed that narcotic addiction is an unremitting condition of long duration and relatively uniform course. However, in Canada the estimated number of criminal addicts decreased from 9,000 in 1924 to 3,000 in 1948 [ 2] . Winnick [ 3] has speculated that addiction may be a self-limiting process for nearly two-thirds of addicts in the United States. Recent follow-up studies of individual New York City addicts have shown that although relapse in the early years of follow-up was frequent, abstention rates of 29-399 were attained five years after discharge from Lexington [ 4] . The success of special forms of treatment for addiction is best estimated by conducting properly designed clinical trials; until these are done, claims should be based on comparison of results with the improvement rates observed in the presence of conventional forms of management.

National records on criminal addicts have been compiled in Canada since 1955. This article adds some epidemiologic analyses which provide perspective to the clinical studies on etiology and treatment results.

Methods

A national register of known addicts has been systematically maintained and revised annually by the Narcotic Control Division of the Department of National Health and Welfare. This register is based on information provided by police, physicians and pharmacists. Physicians are not required to submit reports but pharmacists must submit detailed information on all prescriptions for narcotics. Addicts on this register are classified into one of three groups - criminal, medical or professional.

Criminal addicts are defined as persons who have:

Been convicted of illegal possession of narcotics;

Been convicted of any non-narcotic offence, and are known to be narcotic addicts by the police, or are addicted, and are suspected by the Royal Canadian Mounted Police of having engaged in criminal activities or associations but have not been convicted.

The reporting of convictions has been uniform since the start of the register. Most of the criminal addicts (93%) recorded on the register in 1966 has been reported from police sources. It is recognized that this register does not include all Canadian narcotic addicts. The term "criminal addicts ", used throughout the rest of this article, refers to addicts recorded on this particular register.

Names are retained on the list of criminal addicts until death, deportation, or a period of ten years without adverse information has elapsed. The Department of National Health and Welfare prepares annual tabulations for the criminal addicts listed on this register. Such tabulations have been prepared since 1955 for criminal addicts known to be alive in Canada and for whom some adverse information on addiction has been received by the Narcotic Control Division within the past ten years. The annual tabulations represent a ten-year period prevalence of criminal addicts. More recently, since 1965, tabulations have been prepared of the characteristics of criminal addicts newly reported during the previous year.

Medical addicts are persons who must be considered addicted even though this state has arisen due to treatment with narcotic drugs for a medical condition which continues. Another group of "medical addicts" are those in whose case the medical condition has been cured but the addiction continues: both types of medical addiction arise out of medical treatment.

Professional addicts are members of the medical and related professions including pharmacists and nurses, for whom easy availability of drugs has played an important part in creating the state of addiction.

Trends in criminal addiction, 1956 and 1966

Number and location, 1956 and 1966

Between 1956 and 1966 the number of recorded criminal addicts increased 19% from 2,678 to 3,182; During the same period medical addicts decreased 26 % from 352 to 259, and professional addicts decreased 28% from 211 to 151.

TABLE I

Number of addicts by type and location

 

Canada

British Columbia

Other Provinces

 

1956

1966

1956

1966

1956

1966

Criminal addicts
2 678 3 182 1 570 2 023 1 108 1 159
Medical addicts
352 259
n.a.
32
n.a.*
227
Professional addicts
211 151
n.a.
13
n.a. *
138

n.a. - not available.

Criminal addicts were concentrated in one region. British Columbia, with 9% of the population, had 59% of Canada's criminal addicts in 1956 and 63% in 1966. Within British Columbia criminal addicts were found largely in Vancouver city where they form about 0.2% of the population. On the other hand, there was no similar concentration of medical or professional addicts in British Columbia.

Historically, the Canadian concentration of criminal drug addicts has moved westward. From 1930-1934 Montreal was the centre of narcotic addiction, to be succeeded in a few years by Toronto. Winnipeg had its peak number of convictions in 1937. At the end of World War II drug addiction was at an all-time low in Canada with no significant concentration in British Columbia. Subsequently, the prevalence of addiction rapidly increased and addiction in British Columbia became a problem of major proportions by 1952. Between 1956 and 1966 the number of criminal addicts increased 29% in British Columbia and 5% in the remaining provinces.

Choice of narcotic

Changes in the choice of narcotic have been more marked than changes in the number of criminal addicts. While the number of persons addicted to opiates decreased 25%, from 172 to 130, addicts to heroin increased 26%, and those addicted to "synthetics" increased fourteenfold, from 25 to 338.

Increases in the number of heroin addicts, 56%, were more marked in British Columbia than in the other provinces, 5%. Opiate use decreased to a greater extent in British Columbia than elsewhere. Synthetic narcotics, however, showed marked increases in both British Columbia and the remaining provinces.

Prevalence ratio

As described above, data are available on the prevalence of addicts for whom adverse information has been received within the past ten years. The prevalence rates for criminal narcotic addicts per 100,000 population are 10-40 times higher for British Columbia than the other provinces in the various age-sex groups. In British Columbia the prevalence of younger male addicts (aged 20-24) has decreased while the ratio of male addicts to the population aged 35-49 has increased. This reduction in existing cases (prevalence ratio) among the young is likely due to a decreased onset of new cases associated with the reduced availability of illicit heroin. Analysis of data on ascertainment is necessary to assess to what extent the creation of new criminal addicts has been reduced. Since prevalence may also be reduced by changes in the duration of a condition, one must in addition consider whether duration may be decreasing due to changes in mortality, abstinence or emigration.

TABLE II

Narcotic drugs used by criminal addicts

 

Canada

British Columbia

Other Provinces

 

1956

1966

1956

1966

1956

1966

Heroin
1 658
62%
2 236
70%
961
61%
1 503
74%
697
63%
733
63%
Opiates
172
6 %
130
4%
70
4 %
33
2 %
102
9 %
97
8 %
"Synthetics"
25
1%
338
11%
3
-
196
10%
22
2%
142
12%
Other drug, or unknown
823
31%
478
15%
536
34%
291
14%
287
26%
187
16%
TOTAL
2 678
100%
3 182
100%
1 570
100%
2 023
100%
1 108
100%
1 159
100%

Percentages do not add to 100% because of rounding.

TABLE III

Criminal addicts British Columbia and other provinces 1956, 1961 and 1966 (Number and prevalence per 100,000 population)

 

Number

British Columbia

Other Provinces

British Columbia

Other Provinces

   

1956

1961

1966

1956

1961

1966

1956

1961

1966

1956

1961

1966

Males
20-24
126 138 112 13 46 29 276 289 170 2 9 4
 
25-34
442 460 497 144 231 208 421 414 424 13 20 18
 
35-49
328 457 489 286 255 261 228 285 277 21 16 16
Females
20-24
74 79 106 24 76 55 182 166 166 5 14 8
 
25-34
149 192 225 111 185 200 147 186 203 10 17 18
 
35-49
94 124 132 116 101 115 67 75 75 9 7 7

NOTE. Prevalence is defined in the text.

Ascertainment of criminal addicts 1965-1966

Recently, data on the characteristics of 555 criminal narcotic addicts newly added to the lists of the Narcotic Control Division during 1965 and 1966 have become available. These statistics on ascertainment may be used as a baseline for assessing future changes in the recorded onset or recognition of addiction. The population distribution for newly reported addicts is different from that for existing addicts. Females aged 15-19 had higher rates of recognition than males, but in the older age groups reporting was higher for males. Peak rates of ascertainment were recorded for those aged 20-24.

British Columbia rates were 20-60 times higher than those for the rest of Canada in the various age groups. The recognition rate of 64 per 100,000 for males aged 20-24 is based on a denominator for all British Columbia and would therefore be higher when based on a denominator for metropolitan Vancouver, where the majority of addicts reside.

It is believed that about one-third of the 439 cases newly reported from British Columbia involved methadone hydrochloride obtained from medical sources. These were addicts who became known to the authorities after getting prescriptions for methadone from some private physicians who were willing to provide methadone maintenance treatment in their private practice. When multiple prescriptions were found to have been obtained by an addict, this attracted the attention of the authorities who advised the prescribing physicians of the duplication. The treatment of addicts by methadone maintenance provided by private physicians has been reduced. It is not possible to determine how many of these methadone addicts newly coming to attention via scrutiny of prescriptions were previously using heroin obtained illegally. However, there has been a definite tendency for some private physicians in British Columbia to prescribe methadone to addicts seeking such medication as a "cure" for their heroin addiction. Many of the addicts concerned contacted several physicians, obtained increasing quantities of medication and, in some cases, shared their supplies with others as a source of revenue. The control of abuse and reduction of the spread of addiction requires better understanding and greater knowledge by physicians of addiction and its treatment. The second report of the British Inter-departmental Committee on Drug Addiction noted that the large-scale supply of narcotics by a very few doctors can easily provide a surplus that will attract new recruits to the ranks of the addicts. Any study of the long-term effects of prolonged methadone treatment of addicts must consider the consequences of this new source of supply upon the creation of more addicts.

TABLE IV

Newly reported cases of criminal narcotic addiction, Canada, 1965-1966

 

Male

Female

 

15-19

20-24

25-29

30-34

15-19

20-24

25-29

30-34

Canada
               
Number of 1965
3 46 38 17 19 34 11 4
new cases 1966
4 44 32 15 7 27 15 8
Annual rate per 100,000 population
(0.4) 6.5 5.9 2.5 1.5 4.5 2.2 1.0
British Columbia
               
Number of 1965
2 37 29 11 14 28 8 2
new cases 1966
2 39 28 13 7 18 9 7
Annual rate per 100,000 population
(2.6) 64.4 53.7 20.7 14.3 37.0 16.0 (8.4)
Other Provinces
               
Number of 1965
1 9 9 6 5 9 3 2
new cases 1966
2 5 4 2 0 9 6 1
Annual rate per 100,000 population
(0.2) 1.1 1.2 (0.7) (0.3) 1.4 (0.8) (0.2)

NOTE. Population denominator from population estimates for 1 June 1965. Rates are shown in brackets when the cases are less than 10.

Course and prognosis for individual criminal addicts

Nature of follow-up

A previous paper [ 5] has described the follow-up of a 50% sample of the 356 criminal addicts gaoled in British Columbia during a twelve-month period in 1954-1955. It was felt that this group included most of the criminal addicts in the province who, during the study period, were not already serving a prolonged prison sentence. Data on the forensic histories during 1954-1964 were supplied for most of the addicts by the British Columbia Corrections Branch, the Narcotic Control Division of the Department of National Health and Welfare, and the Royal Canadian Mounted Police Finger Print Service. The Finger Print Service is a national register based on the finger prints of persons charged with felonies by municipal, provincial and federal police forces and includes reports from police forces in the United States and Britain.

Individuals imprisoned during 1954-1955 were classified as follows:

  1. Deemed abstinent during 1961-1964: These persons were considered to have been abstinent from the use of narcotics for at least three years since 1960. The group satisfied the following four criteria:

  1. No record of conviction under the Opium and Narcotic Drug Act or the more recent Narcotics Control Act since 31 December 1960;

  2. Not included in the Annual List of Addicts and Peddlers prepared by the Royal Canadian Mounted Police in 1964;

  3. No convictions for any felony recorded by the National Finger Print Service since 31 December 1960;

  4. Not reported from sources ( a), ( b) or ( c) as having died.

  1. Active users during 1961-1964: These persons were considered to be regular users of narcotics in 1964 or until their death as evidenced by one of the following:

  1. Conviction under the Opium and Narcotics Drug Act or the Narcotics Control Act during the years 1961-1964;

  2. Included in the 1964 Annual List of Addicts and Peddlers prepared by the Royal Canadian Mounted Police;

  3. Death attributed to overdose of drugs.

  1. Miscellaneous: A heterogeneous category for those remaining persons:

  1. Serving prison terms during 1961 to 1964 for convictions prior to 1961;

  2. Convicted of felonies associated with narcotic use since 1960;

  3. Reported to the Narcotic Control Division as being treated for addiction or obtaining narcotics from doctors;

  4. Whose whereabouts were unknown or who could not be traced. (Some of these individuals might well be abstinent and therefore the abstinence ratios are minimized.)

Contact with Narcotic Addiction Foundation of British Columbia

It is useful in evaluation of treatment programmes to consider the use of services by the patient population for whom they are intended as well as the result of the treatment (and the durability of that result). Analyses of the extent to which services are used by those in need, and comparison of the characteristics of users and potential users give useful measures of the accessibility of such treatment services, (even though it may not be possible to differentiate the components of users' attitudes and motivations from the facilities provided by the agency).

It has been possible to categorize the patients in the follow-up study in terms of their contact with the Narcotic Addiction Foundation of British Columbia. This agency was instituted in Vancouver for the treatment and rehabilitation of addicts on a voluntary basis. Out-patient treatment was started in 1956, and residential treatment was later added. All phases of treatment, including withdrawal, rehabilitation, and after-care were carried out in the residence, as well as individual and group psychiatric treatment and counselling, occupational, recreational and social therapy and attempts to secure employment. The out-patient facility provided many of the same services. In 1959, the centre began to offer withdrawal with methadone hydrochloride for both in- and out-patients [ 6] .

Addicts imprisoned in 1954-1955 were classified as to their attendance at the agency up to the middle of 1965. Over-all 44% of the criminal addicts attended the clinic at some time before the end of 1965. An additional 6% had perfunctory contact by telephone, mail or one visit without further follow-up. It should be noted that in addition other addicts not imprisoned in 1954-1955 were being seen at the clinic. Not all of the criminal addicts in the follow-up study remained in the Vancouver area and it is possible that some may have received treatment elsewhere.

The characteristics of addicts attending the clinic were compared with those not attending. In the group of addicts so followed, attenders did not differ from non-attenders in characteristics such as age, sex, birthplace, age on arrival in British Columbia, year their addiction began, number of attempts to quit drugs voluntarily, or period of initial contact with the police. There is no evidence of selective bias in the use (or accessibility) of the treatment agency by the criminal addicts in terms of these criteria.

TABLE V Proportion of criminal addicts imprisoned in 1954-55 attending particular treatment agency 1955-65

TABLE V

Proportion of criminal addicts imprisoned in 1954-55 attending particular treatment agency 1965-66

Attribute

No.

Percentage attending (95% Confidence Limits)

WHOLE SAMPLE
177
35.6 - 50.6
Age (1955)
   
Under 24
32
29.0 - 65.5
25 - 34
72
39.0 - 59.0
35 +
66
24.5 - 49.0
Sex
   
Male
130
39.0- 57.0
Female
47
21.0 - 49.0
Birthplace
   
Vancouver
36
33.0 - 67.0
British Columbia
26
39.5 - 76.0
Outside British Columbia
112
30.0 - 48.5
Age on arrival in British Columbia
   
Born in province
62
40.0 - 66.5
Under 10
35
26.5 - 60.5
11 - 17
33
22.5 - 57.5
18 +
44
20.5 - 50.0
Year started drugs
   
Before 1944
68
28.5 - 52.5
1945 - 1949
47
36.0 - 66.0
1950 +
45
27.5 - 57.5
Number of times quit drugs voluntarily
   
0 39
25.5 - 58.0
1 - 2
68
37.0 - 61.0
3 +
19
21.0 - 64.5
Year of first police contact
   
Before 1944
99
34.0 - 54.0
1945 - 1949
45
32.0 - 62.5
1950 +
18
15.0 - 54.0

NOTE. Attributes were not known for all of the 177 addicts.

Results of follow-up

About one-fifth of the criminal addicts were deemed abstinent within the period five to eight years following imprisonment. The prospect for abstention increased with age of the addict; among addicts 35 years or older, 31% of males and 40% of females were reported abstinent. Abstinence did not decrease with increasing duration of narcotic usage, or prolonged duration of police contact. Addicts with numerous previous attempts to quit drugs voluntarily were found to be abstinent as frequently as those with no previous attempts.

TABLE VI

1964 follow-up of 177 criminal narcotic addicts, imprisoned 1954-55

 

Both Sexes

Male

Female

Deemed abstinent 1961-1964
21%
19%
25%
Active Users
50 %
51%
47 %
Miscellaneous
29 %
30 %
28 %
TOTAL NUMBER
177 130 47

Relation between agency attendance and presumed abstinence

Finally, the relation between presumed abstinence and contact with the particular agency was determined. Presumed abstinence during 1961-64 was found among 5% of those addicts (N = 41), who had initiated contact before the end of 1960, 8% among those (N = 37), who had initiated contact in 1961 or later, and 34% among those (N = 89) with no contact.

It need hardly be said that this form of analysis is not equivalent to the standard clinical trial with randomization of treatment. Although attenders and non-attenders were derived from the same population (those imprisoned in 1954-55) and did not differ in their demographic and addiction characteristics at that time, their attendance at the agency was not determined by random allocation. It is speculative to consider what factors may later have intervened to produce such differences in the frequency of presumed abstinence. There is no evidence to suggest that at the time of their 1954-55 imprisonment clinic-attenders were more severely addicted, or had fewer psychosocial resources than non-attenders.

It is known that addicts attempt rehabilitation by moving away from the source of drugs and the company of other addicts. Even in the unlikely circumstance that 89 persons with no agency contact had moved away from Vancouver the achievement of presumed abstinence by 34 % is striking.

Discussion

Evaluation of the effectiveness of treatment services for narcotic addiction is essential. The criteria for estimating effectiveness must be logically connected to whatever the treatment objectives may be; these aims may vary from detoxification to cessation of drug abuse or criminal activities by the addict, or enabling the addict to secure or maintain work, or even the establishment of the addict as a socially productive and stable member of the community. Programme effectiveness cannot be considered in terms of the provision of services alone, (e.g. 16,000 treatment interviews, 400 psychological tests and 160 new patients seen during the year) since sheer activity is no measure of an ultimate goal [ 7] . Neither can evaluation be restricted to interviewing a biased sample of persons for whom some form of follow-up was possible, selected from the skewed minority of patients having more than a certain number of interviews or agency contacts.

TABLE VII

Attendance at a treatment agency and presumed abstinence in 1961-1964

 

Both Sexes

Male

Female

Agency attendance up to July 1965 by addicts imprisoned 1954-1955

Number

Proportion presumed abstinent

Number

Proportion presumed abstinent

Number

Proportion presumed abstinent

Contact initiated before 31 Dec. 1960.
41
5%
29
-
12
16%
Contact before 31 Dec. 1960 only
15
13%
9
-
6
33%
Contact before and after 31 Dec. 1960
26
-
20
-
6
-
Contact only after 31 Dec. 1960
37
8%
33
9%
4
-
Minimum contact by telephone or not more than one visit
10
10%
7
-
3
33%
No recorded contact
89
34%
61
36%
28
31%
TOTAL
177
20%
130
19%
47
25%

NOTE. Presumed abstinence is defined in text.

The present reporting of outcome criteria and methods of follow-up for treatment programmes for narcotic addiction has been described as chaotic [ 8] , [ 9] . For heroin addicts, elimination of heroin usage and drug seeking behaviour is regarded by Dole and Warner as "...no more than the first step toward rehabilitation... the stopping of drug abuse is necessary but not sufficient ". Paulus and Halliday, 1967, state: "... abstention is perhaps the most difficult state to determine accurately, even if one agreed on this sole criterion, because the question arises - abstention from what? ... how does one absolutely ensure that there is complete abstention? This is simply not possible, and referral to official statistics is no measure of validation."

Furthermore, there are similar discrepancies in the methods of assessing relapse or abstinence. A disturbing lack of information on abstinence was described by O'Donnell (1965) in his review of the eleven reported follow-up studies of American addicts. Each of the studies showed major flaws in describing the kinds of evidence obtained, the steps used to classify the patient as relapsed or abstinent, and the reliability and validity of the classification itself. The idea of prolonged use of drugs after relapse was not supported in the literature reviewed by O'Donnell (1965). Not one of the eleven studies was able to establish that "...most addicts, after a period of enforced abstinence, relapse to drugs and continue to use drugs, or that addicts spend most of their time outside of institutions using drugs ... ". Rather, the opposite was shown in Duvall's follow-up where the use of narcotics decreased as more time elapsed.

Abstinence and relapse, though reciprocally related, have different implications for assessing outcome. While relapse pertains to the occurrence of an event, the state of abstinence refers to an interval of variable length during which relapse did not occur. Relapse (the first return to addiction) would be an appropriate criterion of the outcome of treatment if narcotic addiction were an unremitting condition of long duration and relatively uniform course; however, if addiction is a process involving frequent alternations of periods of drug use and non-use, then indices of abstention are more suitable. O'Donnell (1964) considers that the most negative of the outcome criteria is relapse defined as any post-discharge period of addiction (irrespective of duration.) Such a definition of relapse produces the paradox of a high percentage of relapse being associated with a fairly low percentage of persons being addicted at any given point in the follow-up and addiction taking up a fairly low percentage of the follow-up time [ 10] . The abstention rates described for British Columbia are not unique. They do not differ grossly from those described by Duvall in the United States or Bewley in the United Kingdom.

The criterion used by Duvall, abstinence five years after discharge, is the index which, among the eleven United States follow-up studies reviewed by O'Donnell, is the most similar to the one used in the present paper. In order to make more suitable comparisons between the British Columbia and New York addicts Duvall's data have been re-analysed. The duration of abstinence differed in addiction and the New York addicts were hospitalized at their own request, while the British Columbia addicts were imprisoned. As might be expected, the abstention rates for the younger males differed more, but none of the rates were significantly different. For the older New York addicts 39% of males and 36 % of females were abstinent five years after discharge, while abstinence was presumed among British Columbia addicts for 31% of males and 40yo of females during the period 5-8 years after imprisonment.

TABLE VIII

Abstention rates for narcotic addicts in British Columbia and New York after 5-8 years of follow-up

 

Younger age group

Older age group

 

Proportion abstinent and 95% confidence limits

 

Proportion abstinent and 95 % confidence limits

 
 

Number

   

Number

   
Males
           
British Columbia
74
11%
5-20
51
31%
19-46
New York
49
32%
19-47
75
37%
26-49
Females
           
British Columbia
30
20%
8-39
15
40%
16-68
New York
40
29%
15-44
72
36%
25-48

Source.Duvall et al., 1963; Richman, 1966.

NOTE.

  1. Abstention for New York patients referred to the non-use of drugs for at least three consecutive months five years after discharge; for British Columbia abstinence was presumed for a three-year period 5 to 8 years following imprisonment.

  2. New York addicts were a stratified sample of voluntary admissions to Lexington Hospital who were reported as having completed their withdrawal period during 1952-1955. Vancouver addicts were imprisoned during 1954-1955.

  3. All New York addicts were white, 80 % of British Columbia addicts were white.

  4. Older age groups consisted of those 30 and over for New York, and 35 and over for British Columbia.

  5. In New York all of the younger patients followed were first admissions to Lexington; two-thirds of the older males· and one-half of the older females were re-admissions. Few of the British Columbia addicts were being imprisoned for the first time.

Abstention for heroin addicts in the united Kingdom has been reported by Bewley [ 11] . Among the 751 heroin addicts recorded between 1947 and 1965 by the Home Office, 14% were considered to be alive and not taking opiates at the end of 1966.

Finally, the feasibility of systematically evaluating Canadian programmes for criminal narcotic addiction from national data should be considered. The criteria described in this paper for presuming abstention are the converse of those used to define the onsetor presenceof criminal addiction, and are therefore available from the up-dated lists prepared annually by the same sources. Longitudinal records of criminal addicts are maintained by Narcotic Control Division from physician, pharmacy and police reports; and the criminal histories of addicts are collated by the Finger Print Service of the Royal Canadian Mounted Police. It would seem feasible to systematically combine these sources of information to provide a continuing perspective on changes in the incidence and duration of recognized criminal addiction in Canada.

The Judicial Section of the Dominion Bureau of Statistics is developing an integrated record system for crime statistics derived from reports received from a variety of police and prison agencies in Canada. A punch card record system, which includes Finger Print Service Identification, is being prepared [ 12] . Current data-processing technology would allow the systematic determination of presumed abstinence for addicts followed from previous years, as has been done in the follow-up study outlined in the present paper. A national follow-up of persons who had been in contact with various types of correctional and treatment programmes in Canada would provide a base-line of results against which individual programmes could compare their results. Such base-lines would provide a much needed perspective on the comparative results and durability of treatment in this chaotic area of conflicting claims.

To conclude, we might recall the remark of a co-worker more than a hundred years ago:

"... in a slow disease, presenting so much diversity in individuals, it is evident that the superiority of any system of treatment can only be determined by the average results, by a comparison of the recoveries and deaths, in fine, by statistics ..." [ 13] .

* * *

This research was assisted in part by the Mental Health Research Fund Award of the Canadian Mental Health Association and United States Public Health Service Grant Number MH 11105.

The assistance of Mr. R. C. Hammond, Division of Narcotic Control, Ottawa; M. S. Rocksborough-Smith, British Columbia Department of the Attorney General; Dr. R. Halliday, Narcotic Addiction Foundation of British Columbia; Mrs. S. Maleszewski and Mrs. C. Eston is acknowledged.

Requests for reprints should be addressed to the authors at 722 W. 168th St., New York, N.Y. 10032, U.S.A.

References

MISCELLANY

MORBIDITY AND MORTALITY FROM HEROIN DEPENDENCE.

Three papers have been published by Th. H. Bewley et al in the British Medical Journalon "Morbidity and Mortality from Heroin Dependence".

1. Survey of Heroin Addicts known to Home Office

The data of 1,272 heroin addicts were studied. This number includes all cases first known to the Home Office from 1947 to the end of 1966. The increase in the incidence of heroin addiction is illustrated by annual statistical data (the number of cases increased from 10 in 1956 to 521 in 1966). The number and proportion of young addicts are steadily rising: from the 7 heroin addicts under 20 known in 1962 (10 per cent of the total) this number reached 198 (38 per cent of the total).

The number of enw cases reported continues to double every 16 months, and if this continues at least 800 new cases will have been recorded in 1967, and there may be 1,200 for 1968.

The mortality rate among heroin addicts was 28 times the expected rate and chiefly due to sepsis, overdose, and suicide.

2. Study of 100 Consecutive Inpatients

One hundred consecutive male heroin addicts discharged from Tooting Bec Hospital between October 1964 and 31 December 1966 were selected for study. (The total number of admissions was 155).

Immediately after admission the mean daily dose of the patients had been 260 mg heroin and 110 mg of cocaine - median values were 180 mg of heroin and 120 mg of cocaine. Almost all had regularly taken cocaine or methylamphetamine intravenously with heroin, and an increasing number are still using methylamphetamine - 21 of this group of 100 patients admitted before 31 December 1966 had been dependent on mehtylamphetamine, but 39 of the first 50 admitted to the hospital in 1967 and 44 out of 50 in Brixton Prison at the same time had been using methylamphetamine intravenously (30 mg in 1.5 ml, taking up to 10 ampoules a day).

Of the one hundred heroin addicts 88 used two other drugs in addition to heroin, 75 had convictions, 39 had had septic complications from drug administration, and 17 had overdoses. Statistical data are presented in 11 tables.

3. Relation of Hepatitis to Self-injection Techniques

A total of 121 cases of hepatitis among heroin addicts were traced. There was an epidemic in the Notting Hill area of London in 1966 because of widespread sharing of syringes and needles. Extensive liver function tests carried out on 284 further addicts showed that 60 per cent had evidence of hepatocellular damage. Fifty addicts were questioned about their methods of self-injection and much data on this aspect is presented in the article. ( British Medical Journal 1 (5594), 719 (1968).)

WITHDRAWAL FITS IN BARBITURATE ADDICTS

Studies on withdrawal symptoms have shown that barbiturates can lead to physical dependence (Isbell, H., "Addiction to barbiturates, barbiturate abstinence syndrome", Ann. intern. Med., 1950, 33: 108-121).

Four documented cases of fits in barbiturate addicts following withdrawal of the drug have been reported. In each case withdrawal fits occured 1-2 days after the drug was discontinued. The fits subsided slowly after the first 2-3 days. With the fits and other symptoms it becomes reasonable to render a diagnosis of epilepsy; consequently the patient may receive further supplies of the barbiturate. The possibility of barbiturate withdrawal should be considered in all new cases of apparent epilepsy. (Gardner, A. J., Professioral Psychiatric Unit, St. Geroge's Hospital, London S.W.1., England, Lancet, 2: 337-338 (August 12) 1967).

COMPARATIVE TOXICITY OF HEROIN; MORPHINE AND METHADONE

Dundee et al have made ovservations in female patients who were to have minor gynecological operations. Diacetylmorphine (heroin, diamorphine) is claimed to have certain advantages over other opiates, and comparisons have been made with morphine and methadone. The drugs were administered intramuscularly and evalueated 90 minutes later via a double-blind technique.

Diacetylmorphine appears to yield more sedation than morphine or methadone in eqie-analgesic doses. There appeared to be little difference in the ability of the drugs to relieve apprehension or cause euphoria. Diacetylmorphine was less emetic than morphine, and it appears to have an earlier onset and shorter duration of action than morphine or methadone. The sudy did not reveal any obvious advantages of diacetylmorphine, nor is there a significant difference in toxicity from morhpine of methadone. (Dundee, J. W., Clarke, R. S. J., and Loan, W. B., University Department of Anesthetics, Institue of Clinical Science, Grosvenor Road, Belfast 12, Ireland, Lancet 2: 221-224 (July 29) 1967.)

NEW LEGISLATION IN SPAIN: DRIVING UNDER THE INFLUENCE OF NARCOTICS

According to the Act No. 17 of 8 April 1967 (amending certain articles of the Criminal Procedure Act), if a person drives a motor vehicle under the influence of narcotics, he shall be liable to penalty or a fine of not less than 5,000 or more than 50,000 pesetas, and suspension of his driving licence for a period of not less than three months and one day and not more than five years. The driving licence is permanently withdrawn in the case of the offender being sentenced on two occasions to the suspension of his licence. The Act applies only to the substances, natural or synthetic, which are included in Schedule I and II of the 1961 Convention (Article 2 of the Act).

Furthermore, by an Order of 31 July 1967, the following hallucinogenic substances: LSD-25 (lysergic acid, diethylamide, lysergide), mescaline and psilocybine were placed in Schedule I.

ACCIDENTS AND ABUSE OF PSYCHOTROPIC DRUGS

During a discussion at the Necker Hospital in Paris, it was demonstrated that when meprobamate had been administered in large doses and for prolonged periods, its sudden withdrawal produced and acute pathological state similar to that described in cases where barbiturates were withdrawn under the same conditions. The problem of wether individuals under the influence of tranquillizers (or possibly unter that of a neuroleptic preparation with a tranquillizing effect) should be allowed to drive moter vehicles was also discussed. ( Presse médicale, 21, 71-74, 1968.)

By an order of 5 July 1967 the Ministry of Public Health of the USSR has taken measures to prevent the use of soporivic or narcotic drugs by transport drivers on duty or about to enter on duty.

001

World Health Organization, Fourteenth Report of the WHO Expert Committee on Mental Health (1967); Services for the Prevention and Treatment of Dependence on Alcohol and Other Drugs, Geneva

002

A. Richman, A. Borschneck and A. Rienzi (1964), Canad. psychiat. Ass. J . 9, 431.

003

C. Winnick (1962), Bulletin on Narcotics 14, 1.

004

Duvall, J. Henrietta, B. Z. Locke and L. Brill (1963), Publ. Hlth Rep ., Wash., 78, 185.

005

A. Richman (1966), Canad. psychiat. Ass. J . 11, 107.

006

Paulus, Ingeborg and R. Halliday (1967), Canad. med. Ass. J . 96, 655.

007

H. E. Hilleboe (1963), Health News (New York State), 40, 7.

008

J. A. O'Donnell (1965), in Narcotics (edited by D. M. Wilner and G. G. Kassebaum) New York: McGraw-Hill.

009

V. P. Dole and A. Warner (1967), Amer. J. publ. Hlth. 57, 2000.

010

J. A. O'Donnell (1964), Amer. J. Orthopsychiat . 34, 948.

011

T. Bewley (1968), Brit. med . J. 2, 725.

012

W. A. Magill (1964), in Proceedings of the Social Statistics Section, American Statistical Association, 1963, Washington.

013

W. Farr (1841), Journal of the Royal Statistical Society 4, 17.