Present problems of drug dependence in Switzerland

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Apparent forms of drug dependence
Preparation
Procedure
Bibliography

Details

Author: P. KIELHOLZ
Pages: 1 to 6
Creation Date: 1970/01/01

Present problems of drug dependence in Switzerland

Professor P. KIELHOLZ
Director of the Psychiatric Clinic, Basle University Member, WHO Expert Advisory Panel on Mental Health *

In all civilized countries there has been a great upsurge in the number of drug dependents. Three tendencies are discernible:

  1. A growing incidence in young people;

  2. An increasing number of women dependents;

  3. A rising frequency of multiple addiction.

In Switzerland, too, drug dependence, especially to hypnotics, analgesics and stimulants, is on the increase. Underlying causes of this development are the depersonalization of working conditions, automation, the disregard for values which is associated with a materialistic outlook, as well as social and economic factors, education and the vicissitudes of fashion, and the absence of religious ties in our age.

The motives which induce the individual to take the course of escape from reality, avoidance of discomfort, of pleasure-seeking and a desire for enhanced performance, are bound up with his character and thus his individual mode of response, and the environmental influence in early childhood, but they are also determined by the accessibility of the drug and the dictates of "fashion ". Addictive disorders can take any of four directions, namely deviant drives, compulsive smoking, alcoholic inebriation and stupefaction, and the procurement of mental dulling, relaxation, stimulation or euphoria by way of drugs (see figure I).

FIGURE I

Manic and addictive habits

Degenerative innate drives
excessive smoking
Alcoholism
Drug dependence
e.g. poriomania
   
morphine type
pyromania
   
barbiturate alcohol type
gambling mania
   
cocaine type -
collecting mania
   
cannabis (marihuana) type
candy eating mania
   
amphetamine type
kleptomania
   
Khat type
certain sexual aberrations
   
hallucinogenics type

In this capacity the author has also served as a Member of the WHO Expert Committee on Drug Dependence.

Apparent forms of drug dependence

We should speak of "drug dependence" only when a drug, by virtue of its effect on the central nervous system, produces indomitable psychic craving or physical dependence or both.

The growing abuse of hypnotics, analgesics and stimulants induced the Swiss Conference of Sanitary Officials in 1965 to order a national inquiry on the state of drug dependence in Switzerland. The results of the inquiry would serve as a basis for the prophylactic measures called for.

Preparation

The inquiry was preceded by consultations with various experts at home and abroad. Thus from the USA advice was sought from Dr. N. B. Eddy, Washington, Dr. H. Brill, New York and Dr. W. R. Martin, Lexington. All the questionnaires were first, tested for reliability in a pilot study. They were so elaborated as to provide a separate sheet for each drug dependent in order that the results could be evaluated with the aid of electronic data processing equipment. The programming was undertaken at the computing centre of Basle University. The inquiry embraced all dependence producing drugs, especially hypnotics, analgesics, stimulants, tranquillizers and narcotics.

Procedure

The inquiry covered the psychiatric clinics, the psychiatric and medical policlinics, the medical clinics, every fifth doctor with a general and specialized practice, the pathological institutes, the Swiss statistics office and chemists and drugstores.

A record was made of all first admissions of patients who were drug dependent to the psychiatric clinics from 1955 to 1964. The participation of the clinics was 97 %, and 1,964 questionnaires were returned for evaluation. Thus 1,964 drug dependents were treated for the first time at the psychiatric clinics in the course of a decade. Figure II shows the first admissions to the psychiatric clinics on account of drug dependence from 1955 to 1964.

FIGURE II Prime hospitalizations, by sex, because of drug addiction in 29 Swiss psychiatric clinics (1955-1964)

Full size image: 29 kB, FIGURE II Prime hospitalizations, by sex, because of drug addiction in 29 Swiss psychiatric clinics (1955-1964)

This graphic representation shows drug dependence to have steadily increased, the temporary decline in 1963 being perhaps due to a comprehensive education campaign undertaken at that time.

The growth rate of the number of dependents, especially to hypnotics, analgesics and stimulants, is seen to be larger than that of the population as a whole.

If we look at the individual groups of drugs, the addiction, sex distribution and motives, it is apparent that the largest increase is in the number dependent on hypnotics, with a distinct predominance of women being evident.

Unlike as in the USA, the chief object of drug dependence in Switzerland is the group of non-barbiturate hypnotics.

The major motives precipitating drug dependence are emotional tension and conflicts giving rise to insomnia, disturbed sleep and inner unrest. While in the initial stages hypnotics are taken only in periods of increased emotional tension, an apprehension gradually develops of anticipating that without them sleep is impossible. The subject thus begins to take the drug regularly, whereby an increase in tolerance develops. Only after a long period of habituation with corresponding dose increases does the secondary paradoxical activating effect occasionally occur, which induces the subject to take hypnotics also during the day as a stimulant.

FIGURE III Prime hospitalizations, by sex, because of hypnotic dependence in 29 Swiss psychiatric clinics (1955-1964)

Full size image: 32 kB, FIGURE III Prime hospitalizations, by sex, because of hypnotic dependence in 29 Swiss psychiatric clinics (1955-1964)

FIGURE IV Hypnotics as main dependence producing drugs

Full size image: 43 kB, FIGURE IV Hypnotics as main dependence producing drugs

A danger to which far too little attention is paid is that of hypnotics for motor-car drivers, particularly in view of their potentiating effect on alcohol.

The number of dependents of analgesics, especially women, has also increased. Since 1963, however, a flattening trend in the curve can be discerned.

The preparation by far the most frequently used by dependents of analgesics is Saridon. This is followed by Optalidon, Kafa, Contra-Schmerz, Treupel and Spalt-Tabletten, which are combined preparations (fig. VI).

In Switzerland, as well as in Germany, Austria, Denmark and Sweden, the abuse of "mild" analgesics (headache remedies) has increased since the Second World War. Recourse is had to these analgesics above all in urban environments, and especially by working women and housewives. Women, who predominate here in a proportion of 80%, take these drugs primarily against pain which in over 90% of cases is a psychosomatic concomitant of long-standing emotional conflicts. Emotional tension is occasioned above all by marital difficulties, disappointments in love, and unsatisfied striving after love, tenderness, acknowledgement and sex. A heavy emotional burden is found when mothers must also go out to work in addition to their housework, and caring for the children. The building up of emotional tension as a result of adverse environmental conditions and the impossibility of giving vent to their feelings precipitates mainly somatic disorders manifested as various pain syndromes, most commonly head pressure, head-shoulder syndrome, dorsal and sacral pain, gastrointestinal spasms and dysmenorrhea.

FIGURE V Prime hospitalizations, by sex, because of analgetic dependence in 29 Swiss psychiatric clinics (1955-1964)

Full size image: 33 kB, FIGURE V Prime hospitalizations, by sex, because of analgetic dependence in 29 Swiss psychiatric clinics (1955-1964)

FIGURE VI Analgesics as main dependence producing drugs Order of succession and frequency (Psychiatric clinics)

Full size image: 45 kB, FIGURE VI Analgesics as main dependence producing drugsOrder of succession and frequency (Psychiatric clinics)

Number of patients

Saridon Optalidon Kafa Contra-Schmerz

Saridon = Propyphenazon, Phenacetin, Persedon (Pyrithyldion) and Caffeine

Optalidon = Butabarbital, Aminophenazone and Caffeine

Kafa = Aminophenazone, Phenacetin and Caffeine

Contra-Schmerz = Acetylsalicylic acid, Phenacetin, Caffeine, Aluminium-hydroxyd

The drugs are taken primarily against the pain. As with analgesics, after prolonged use increasing tolerance develops and at the same time often psychic dependence. Only after several years of habituation and corresponding dose increases do the patients suddenly realize secondarily that side by side with its analgesic affect the drug now has a chiefly invigorating, stimulating, apparently performance-enhancing action. From then on they can no longer do without this secondary effect: they have become dependent to the drug. This dual action is probably due to the fact that the most common analgesics are combinations containing phenacetin, caffeine and a hypnotic or antipyretic, and that tachyphylaxis occurs at different times in respect of the individual components.

With the growing dependence on these combinations containing phenacetin, pathologists and internists have become increasingly aware that phenacetin or its degradation products can lead to hematological and renal damage when ingested for several years. Thus Gsell and others have shown that degradation products of phenacetin frequently give rise to anaemias as a result of toxic damage to erythropoiesis and the erythrocytes, with the formation of sulfhemoglobin and methemoglobin. Scheidegger and Zollinger demonstrated that years-long abuse of these drugs produces a disposition towards interstitial nephritis and pyelonephritis.

FIGURE VII Prime hospitalizations, by sex, because of amphetamine dependence in 29 Swiss psychiatric clinics (1955-1964)

Full size image: 29 kB, FIGURE VII Prime hospitalizations, by sex, because of amphetamine dependence in 29 Swiss psychiatric clinics (1955-1964)

On the sudden withdrawal of analgesics marked withdrawal symptoms occur within the first 24 hours. They reach their maximum intensity in two or three days and then slowly subside. They consist in unbearable anxious unrest, fine tremor, involuntary muscle twitching, headache, intermittent attacks of pain, nausea, vomiting, and a tendency to collapse due to orthostatic hypotension. Epileptic episodes of the grand mal type, delirious states and hallucinosis with visual perception disturbances are also occasionally seen.

The tormenting withdrawal symptoms, especially the anxious unrest, force the patient to return to the drug against all his efforts of will; he has thus become an involuntary prisoner of his drug.

Since 1962 the abuse of stimulants has shown a distinct, if slow, rise.

The ranks of dependents to stimulants are recruited from younger age-groups than with other drugs. Amphetamine sulfate (Amphetamine, Dexedrine) and methamphetamine predominate among the drugs used.

FIGURE VIII "Wakeamines' as main dependence producing drugs Order of succession and frequency (Psychiatric clinics)

Full size image: 42 kB, FIGURE VIII

In accordance with their effects, these drugs are taken for the following purposes:

  1. As a means of losing weight;

  2. To combat sleep during long night drives;

  3. To fight off fatigue when preparing for examinations;

  4. To enhance performance in sport;

  5. To intensify erotic experience.

On account of the rapid development of tolerance the dose must be increased at short intervals. Stimulants are especially dangerous when used for doping in sporting competitions, since they eliminate the natural feelings of tiredness and dull emergency reflexes. The absence of this biological fatigue causes the limits of performance to be rapidly exceeded. Thus states of collapse of the very greatest severity, and sometimes with a fatal outcome, have been seen in cycling races in which stimulants have been used. Stimulants are, however, not only self-administered by humans, but they are also given to race horses to enhance their performance, and this has led to the practice of taking samples of the saliva and sweat of the winners of flatraces in order to be able to examine in retrospect whether they had been doped.

All stimulants and similar drugs cause toxic psychoses when taken in high doses. Anxious, paranoid states are most frequently observed, with illusionary down to hallucinatory visual experiences, secondary delusions of persecution and ideas of reference, and flight of ideas. These states are not infrequently misinterpreted as acute paranoid schizophrenia.

In spite of the widespread use of tranquillizers in Switzerland only occasional cases of addiction to these drugs are seen. A risk ratio has been calculated for the individual drugs on the basis of the sales figures and the incidence of addiction. Giving analgesics a risk ratio of 1, that for hypnotics is found to be 2.7 and for stimulants 3.8, i.e. a high one, while that for tranquillizers is very low at 0.2.

On the strength of the results of all-Swiss inquiry into the incidence of drug dependence the Commission proposed the following measures to the Swiss authorities:

  1. All hypnotics and stimulants should be available on compulsory prescription only;

  2. The packings should bear a warning against abuse;

  3. Advertising to the general public should be forbidden;

  4. The public should be continually informed of the dangers of drug dependence;

  5. Continuous prospective research should be undertaken to detect new trends in drug dependence in order to be able to take specific prophylactic measures.

Bibliography

Battegay, R., Ladewig, D., "Vergleichende Untersuchungen fiber Glutethimid-(Doriden-) und Methyprylon-(Noludar-) abhängigkeit", Praxis 56, 47 (1967).

Dubach, U. C., Minder, F., Gsell O., "An Epidemiological Study of Analgesic Abuse ", Proc. 3rd int. Congr. Nephrol., Washington 1966, 2, 300-305 (Karger, Basel, New York 1967).

Gloor, F., "Phenacetinabusus und Nierenschädigung ", Schweiz. Med. Wschr., 92, 61 (1962).

Gsell, O., v. Rechenberg, H. K., Miescher, P., "Die primr chron. interst. Nephritis. Klinische, experimentelle und "tiologische Untersuchungen", Dtsch. Med. Wschr., 82, 1673 and 1718 (1957).

Gse!l, O., KielhoLz, P., Hegg J. J., "Phenacetinabusus: Vergleich psychiatrisch und internistisch behandelter Missbraucher phenacetinhaltiger Analgetica", Schweiz. Med. Wsehr., 91, 1529 (1961).

Gsell, O., Dubach, U. C., Raillard-Peuker U., "Phenacetinabusus und Nierenleiden", Dtsch. Med. Wschr., 93, 101 (1968).

Kielholz, P., "Abusus und Sucht mit phenacetinhaltigen Kombinationsprfiparaten ", Schweiz. Med. Wschr., 87, 1131 (1957).

KielhoLz, P., Battegay R., "Vergleichende Untersuchungen tiber die Genese und den Verlauf der Drogenabhängigkeit und des Alkoholismus ', Schweiz. Med. Wschr., 97, 28 (1967).

Kielholz, P., "Gesamtschweizerische Enquˆte tiber die Häiufigkeit des Medikamentenmissbrauches", Schweiz. Aerzte-Ztg., 49, No. 40, 1077-1096, 1968.

Miiller, Th., Kielholz, P., "Erhebung iiber Ausmass, Verbreitung und Prophylaxe des Medikamenten- insbes, des Analgeticamissbrauchs in der Schweiz ", Bull. Eidg. Gesundheitsamt B5 (1957).

Spühler, O., Zollinger, H. U., "Die chron, interst. Nephritis ", Z.f.klin. Med., 151, I (1953).

Zollinger, H. U., "Chron. interest. Nephritis bei Abusus von phenacetinhaltigen Analgetica (Saridon usw.)", Schweiz. Med. Wschr. 85, 746 (1955).

Zollinger, H. U., " Niere und ableitende Harnwege ", Bd.3 der spez. Path. Anatomie, Hrsg.v. Doerr W. und Uehlinger E. (Berlin, Heidelberg, New York 1966).