Drug dependence in Italy: some statistical, clinical and social observations

Sections

PART I - Size of the problem
TABLE 1 - Admissions for drug dependence in psychiatric hospitals (1926)
TABLE 2 - Admissions for drug dependence in psychiatric hospitals
TABLE 3 - Statistics of drug dependence in Italy
TABLE 4 - Cases of alcoholism and other forms of drug dependence admitted to nineteen psychiatric hospitals in Italy in 1966
TABLE 5 - Drug dependence trends in the G. Antonini Provincial Hospital, Limbiate (Milan), 1903-1968
TABLE 5 (continued)
PART II - Current influences on the situation
PART III - Clinical data
TABLE 6 - Admission to the Maggiore Psychiatric Hospital, Milan
TABLE 7 Psychiatric ward No. 1 - Origgi Department Maggiore Hospital
TABLE 8 - Psychiatric ward No. 1 - Origgi Department Maggiore Hospital
TABLE 9 Admission of psychiatric cases to the Polyclinic, Milan
PART .IV - The causes of drug dependence The "classical" drugs
The stimulants
The hallucinogens
Characteristic causes of modern trends
Summary
Acknowledgements

Details

Author: Alberto MADEDDU, Giannangelo MALAGOLI
Pages: 2 to 11
Creation Date: 1970/01/01

Drug dependence in Italy: some statistical, clinical and social observations *

Professor, Deputy Director Alberto MADEDDU
Dr., Assistant Psychiatrist Giannangelo MALAGOLI Ospedale Provinciale "G. Antonini", Limbiate, Milano Province

PART I - Size of the problem

In a statistical study published in 1965 [ 6] we stated that the number of persons dependent on the classical narcotic drugs in Italy was small.

In fact, according to official statistics, deaths in Italy due to drug poisoning have amounted to a few dozen a year over the past five years, and the total number of drug addicts hospitalized or admitted to nursing homes is assumed not to exceed 500 [ 2] .

The original of this article is in Italian.

TABLE 1 - Admissions for drug dependence in psychiatric hospitals (1926)

 

Males

Females

 

Cocaine

Morphine

Cocaine

Morphine

Northern Italy
10 8 1 1
Central Italy
3 4 2 3
Southern Italy and Islands
3 1 0 1
TOTAL
16 13 3 5

The ratio of one "registered" drug addict to ten who escape detection - generally regarded as acceptable in statistics - does not substantially alter the findings of a survey which places Italy among the very minor nations of the world in this respect (table 3).

TABLE 2 - Admissions for drug dependence in psychiatric hospitals

 

(1926) Prof. Modena

(1956) Prof. Somogyi

 

M

F

Total

M

F

Total

Northern Italy
11 9 20 15 15 30
Central Italy
7 5 12 2 3 5
Southern Italy and Islands
4 1 5 5 2 7
TOTAL
22 15 37 22 20 42

M= Males; F= Females.

From the volume Le intossicazioni voluttarie nella societê italiana-1965 (Voluptuary drug addiction in Italian society) (Belloni-Porta). See bibliography.

TABLE 3 - Statistics of drug dependence in Italy

(Percentage)
 

1961

1962

1961-61

Drug addicts registered with the police
270 204  
Therapeutic cases
110 120 49
Medical cases
35 31 14
Traffickers
8 2 2
Addicted to
     
Morphine
164 105  
Pantopon
18 20  
Hydrocodone
10 5  
Laudanum
2 5  
Heroin
3 4  
Derivatives of opium, total
    72
Cocaine
10 12 4
Pethidine (mephedine)
43 34  
Methadone
15 14  
Ketobemidone (cliradon)
5 5  
Opium substitutes, total
    24
Men
     
30-35
10 6 9
35-50
35 36 38
Over 50
57 41 53
Women
     
30-35
12 8 11
35-50
40 40 43
Over 50
35 51 46

From the volume Le intossicazioni voluttarie nella societê Italiana - 1965 (Voluptuary drug addiction in Italian society) (Belloni-Porta). See bibliography.

Owing partly to its geographical position, which makes it an intermediary between two major production areas (the Middle East and North Africa) and places of sale and consumption (Northern Europe and North America), Italy is notoriously one of the main countries of transit for illicit traffic.

The resultant ease with which supplies can be obtained did not seem until quite recently to have much influenced our people's drug dependence tendencies; for few substances which frequently pass through in the illicit transit traffic have reached the consumer.

A view held by many authors would thus appear to be confirmed [ 13] : "Though the drug used is often that most easily obtained in a given environment and in given circumstances, people in every country choose as a means of escape those drugs that suit their temperament, the latter being almost inevitably conditioned by their specific biological constitution."

The comparison of sub-alcoholic and alcoholic problems (expressed in alcoholic dependence figures) with problems posed by other forms of drug dependence yields highly significant results, which have been repeatedly confirmed in the literature [ 7] , [ 8] .

On the other hand, it must be remembered that comparative data in this field are often badly distorted. It is sufficient to point out, for example, that the obscurity of the evidence in Italy is increased by inadequate diagnostic criteria for drug dependence given to health officers by the major national sickness insurance institutes.

The institutes (INAM, ENPAS) suspend all forms of medical, pharmaceutical and economic assistance in "cases of intoxication by drugs and alcoholism". This discrimination is of more than merely statistical importance, for INAM and ENPAS insure approximately 40 million Italians (both employed and retired).

If therefore the circumstances of the drug addict do not allow him to find other solutions (in Italian, or often Swiss private clinics), the diagnostic label of addict will nearly always be attached to him during treatment in a psychiatric hospital to his grave disadvantage vis-a-vis the insurance companies.

A glance at the verifiable figures, however, meaning those which show the psychiatric treatment of drug dependence in a psychiatric institute, confirms that in Italy the number of "classical" drug addicts is small-so small, in fact, as (in this case) to completely upset the commonly-held view that opiates such as morphine, and cocaine still constitute a social danger (tables 1 and 2).

The most recent comprehensive statistics are those of the Institute of Pharmacology in the University of Rome, where a centre for drug addicts has been set up.

This centre organized a national cross-section survey of persons admitted for "alcoholism and addiction to other intoxicants" in nineteen Italian psychiatric hospitals in 1966 (table 4). While 2,671 males and 264 females were admitted to institutions for various forms of alcoholism, the corresponding figures for drug addiction are 6 males and 3 females for addiction to morphine, 4 males and 2 females to barbiturates, 5 males to amphetamines, and 4 males and 2 females for undefined drug addiction.

TABLE 4 - Cases of alcoholism and other forms of drug dependence admitted to nineteen psychiatric hospitals in Italy in 1966

 

Men

Women

Total

Alcoholism
     
Chronic alcoholism
2063 207 2270
Delirium tremens
179 5 184
Acute alcoholic hallucinosis
80 14 94
Chronic alcoholic hallucinosis
88 10 98
Wernicke's encephalopathy
0 0 0
Korsakoff's psychosis
15 6 21
Alcoholic dementia
129 15 144
Marchiafava Bignami disease
0 0 0
Alcoholic paranoia
109 7 116
Alcoholic psychosis
8 0 8
Dependence on morphine and opiates
6 3 10
Dependence on barbiturates
4 2 6
Abuse of psycho-stimulants
5
-
5
Other forms of dependence
4 2 6

(P. Mattei and L. Canerini, 14th International Seminar on the Prevention and Treatment of Alcoholism. Mastrangelo, Milan 1968).

Due allowance must be made for the absence of any "centralized" co-ordination of data collection (very typical of the aversion of many Italian medical officers to statistics); but the figures of the census (questionnaires had been sent to all psychiatric hospitals, which at present number more than 90) clearly show the progressive decline to very small proportions in admissions for psychiatrically-motivated drug addiction. The set of figures, admittedly for a single sector but in our view relevant, given in table 5 is taken from the drug addiction data recorded in the Giuseppe Antonini Psychiatric Hospital, Milan, from the date of its foundation (1865) to 1968 inclusive:

The first admissions were women and date back to 1903, prior to which no one had been admitted for drug dependence.

As a matter of history, though the peculiar properties of some drugs have been well known since the earliest times, as far as Europe is concerned, the first cases of opium and cocaine dependence were described at the beginning of the century.

The first male patients were admitted during the First World War: 5 in 1916 (1,400 male admissions for various mental diseases), 7 in 1917 (out of 7,311) and 10 in 1918 (out of 2,899).

During the Second World War admissions for drug dependence averaged one male and three females per annum. The largest numbers for both sexes are recorded in the post-War years.

Drug dependence in Italy 3

TABLE 5 - Drug dependence trends in the G. Antonini Provincial Hospital, Limbiate (Milan), 1903-1968

 

Men

Men

 

Admission for drug dependence

Relapse

 

Admission for drug dependence

Relapse

Year

Total admissions

Number

Per cent

Number

Per cent

Total admissions

Number

Per cent

Number

Per cent

1903 459
-
-
-
-
348 1 0.29
-
-
1904 423
-
-
-
-
333
-
-
-
-
1905 493
-
-
-
-
364
-
-
-
-
1906 471
-
-
-
-
350 1 0.28
-
-
1907 638
-
-
-
-
422
-
-
-
-
1908 733
-
-
-
-
411 1 0.24
-
-
1909 683
-
-
-
-
426
-
-
-
-
1910 681
-
-
-
-
423 1 0.23
-
-
1911 606
-
-
-
-
444
-
-
-
-
1912 713
-
-
-
-
508
-
-
-
-
1913 784
-
-
-
-
557
-
-
-
-
1914 840
-
-
-
-
543 2 0.35 1 50
1915 958
-
-
-
-
552 1 0.18
-
-
1916 1400 5 0.35 1 20 578
-
 
-
-
1917 2311 7 0.30 2 28 898 1 0.11
-
-
1918 2899 10 0.34
-
-
561
-
-
-
-
1919 1571 3 0.18
-
-
625 1 0.16
-
-
1920 1010 3 0.29
-
-
566 1 0.17
-
-
1921 989 7 0.70
-
-
609 2 0.32
-
-
1922 1100 9 0.81 1 11 628 1 0.15
-
-
1923 1084 8 0.78 3 37 586
-
-
-
-
1924 810 12 1.41 3 25 489
-
-
-
-
1925 824 9 1.10 2 22 524
-
-
-
-
1926 894 3 0.33
-
-
535
-
-
-
-
1927 843 4 0.46 1 25 573
-
-
-
-
1928 925 8 0.86 2 25 634
-
-
-
 
1929 1115 6 0.53 1 16 600 2 0.33
-
-
1930 1123 4 0.35 1 25 679 1 0.14
-
-
1931 1096 8 0.72 2 25 747
-
-
-
-
1932 1177
-
-
-
-
710 1 0.14
-
-
1933 1240 1 0.08
-
-
788 1 0.12
-
-
1934 1231 2 0.15
-
-
852
-
-
-
-
1935 1186 5 0.42
-
-
857 1 0.11
-
-
1936 1244
-
-
-
-
887 2 0.22 1 50
1937 1216 2 0.16 1 50 895
-
-
-
-
1938 1293
-
-
-
-
969 3 0.31 1 33.33
1939 1041 1 0.09
-
-
749 2 0.26
-
-
1940 1090 1 0.09
-
-
662 4 0.60
-
-
1941 933
-
-
-
-
650 3 0.46
-
-
1942 1182 3 0.25 1 33.33 688 2 0.29
-
-
1943 1187 3 0.25
-
-
719 1 0.13
-
-
1944 834 8 0.95 4 50 574 4 0.69
-
-
1945 913 3 0.32 1 33.33 713 7 0.98
-
-
1946 1073 7 0.65 2 28 653 3 0.46
-
-
1947 1139 17 1.41 4 23 638 5 0.78
-
-
1948 1273 20 1.57 2 10 810 9 1.11 2 22.2
1949 1319 15 1.12 2 13 808 10 1.23
-
-
1950 1482 13 0.87
-
-
864 10 1.15
-
-
1951 1283 11 0.85 1 9 840 8 0.95
-
-
1952 1566 4 0.25
-
-
756 9 1.19
-
-
1953 1606 5 0.30
-
-
884 10 1.13
-
-
1954 1539 2 0.12 1 50 1013 10 0.98 1 10
1955 1803 3 0.16
-
-
1071 7 0.65 1 14.28
1956 1881 4 0.21 1 25 1217 4 0.32 1 25
1957 2074 6 0.28 3 50 1190 5 0.42
-
-
1958 1817 5 0.27 2 40 1166 4 0.34
-
-
1959 2026 6 0.29 4 66 1172 5 0.43 1 20
1960 2505 3 0.11 1 33.33 1260 2 0.15 1 50
1961 2767 8 0.28 4 50 1260 3 0.23 1 33.33
1962 2700 6 0.22 2 33.33 1343 2 0.14
-
-
1963 2564 8 0.30 3 37 1356 3 0.22 1 33.33
1964 2400 2 0.83 1 50 1320 4 0.30
-
-
1965 2254 2 0.08
-
-
1182 4 0.33 1 25
1966 2315 5 0.21 2 40 1074 2 0.18 1 50
1967 2467 2 0.08
-
-
1149 3 0.26
-
-
1968 3047 5 0.16 3 60 1309 4 0.30
-
-
GRAND TOTAL
  294   64     173   14  

NOTE. The first admissions for drug dependence were registered in this hospital in 1903 for women and in 1916 for men. Previously there had been no case of drug dependence.

For more detailed analysis (age groups, civil status, occupation, sex ratio), we refer to previous publications [ 6,7,8] , which also provide comparative date of admissions for alcoholism. In the G. Antonini Psychiatric Hospital and in many others in Northern Italy, these account for 40 or 50 per cent of all male and 6 or 7 per cent of all female admissions.

Of the other psychiatric hospitals of the Milan provincial administration, the P. Pini Psychiatric Institute admitted seven males for drug dependence out of a total of 2,974 male patients (0.23 per cent), including one case of relapse; of a total of 2,308 female patients admitted for various forms of mental illness only one was a drug addict.

Only one female drug addict was admitted to the Ugo Cerletti Psychiatric Institute in 1968 (for transfer to the G. Antonini hospital).

PART II - Current influences on the situation

The consistent nature of the data and the very slight fluctuation of the variables may be regarded as sufficiently representative of drug dependence trends as registered at psychiatric hospitals. It should be pointed out that although only relatively precise, the figures we have given are still indicative, above all where they relate to persons "hooked" on the traditional drugs. Such persons, who are not only registered but are truly identified by their recurring detention in psychiatric hospitals, are through their early and compulsive dependence more likely to seek public assistance, and their "career" is often quite predictable. The regulations governing the supply of specific drugs make the checking of such addicts still easier.

If, however, we consider the ferment which the so-called psychedelic revolution (now spreading at a disconcerting rate on American university campuses, where it originated) has caused among the Italians, numerical classification becomes extremely difficult.

Newspaper reports have here preceded systematic investigation. There are daily denunciations of acts beyond the "tolerance threshold" (cases not just of unusual behaviour but of behaviour punishable by law).

The so-called hallucinogens (the range of which is continually increasing to meet the requirements of the "consumer society") are also so easy to obtain in Italy, that they place an artificial paradise within the reach of the general public and of the members of the "affluent society".

Here proselytism, by the most modern means of communication (press, television, films, surveys, interviews, gramophone records) and subtly persuasive practices and examples, under cover of the easy respectability of the need to inform the public, has already obtained much more serious epidemiological results than those of the "contagion through books" which were noted many decades ago among opium and morphine addicts.

The most consistent and detailed bibliographical source for the use of hallucinogens is, we repeat, our press: its comments, often without scientific basis, provide captivating descriptions of the manner in which the new magic substances are used, and of their wonderful effects.

These daily reports spread the "message" among the young and the very young, who are as a rule more accessible and vulnerable.

We report parenthetically the results of our investigation into the files of the Corriere della Sera of Milan, a highly representative newspaper which notably follows a strong anti-sensational policy, and carefully filters news by self-censorship of a traditional kind.

Under the heading "Narcotic Drugs" the files for 1968 contain 62 articles involving 127 addicts or habitual users. The most widely represented age groups are 41 persons between 21 and 30, followed by 32 under 20 and 14 between 31 and 40. The largest occupational groups are 19 students, 16 singers (mainly of "beat" rhythm) and, after a long gap, 5 barmen.

The type of drug most frequently mentioned is marihuana (or hashish), in 22 news items and articles; it is followed by opium and heroin (each in 6 news items and articles).

There are repeated reports and descriptions of smoking dens, which are sometimes on the move, with photographs of the necessary equipment.

While we were completing this report, a series of articles on drugs began to appear in the Giorno (a daily paper with a fairly large circulation); and in the Espresso (one of the most often quoted and most popular weeklies) a third article appeared entitled "Drugs and young people: narcotics enter Italian grammar schools". No. 44 (October 1969) of the Europeo (a political weekly of topical interest) contains an investigation of the United States ("Four drugged boys confess"), which supplements our incomplete but fairly significant material.

That some of the particulars in the various articles are authentic was confirmed by enquiries which we made at the Milan police headquarters. For 1968 partial data from one section alone related to 70 reports on possession, and use of drugs concerning 46 adults and 24 minors, including 12 minors not in custody.

Investigations which we made later among sample groups of pupils at various secondary schools in Milan pointed in the same direction. The replies to an "anonymous" questionnaire initially circulated to obtain data on the use of alcoholic beverages suggested a tendency (among a fair number) of young people either to associate alcohol with psycho-drugs or to consume - not only occasionally, - amphetamine or similar substances allegedly as stimulants but for purposes unrelated to examinations or a desire to learn. Consumption of "hard" drugs is only rarely admitted, but such admissions are accompanied by technical details which leave no doubt of at least a theoretical acquaintance with "trips".

We repeat that the questionnaire was phrased in order to collect information on the attitude of groups of friends (both sexes) or of families to the consumption of alcohol. Questions chiefly aimed at collecting opinions and advice on the desirability of preventive and prophylactic arrangements "against alcoholism" [ 11] in the school environment and on the forms that such arrangements might take.

The existence of these premonitory symptoms, to which repeated reference has also been made in our previous publications [ 7,8,9] , has obviously done nothing to modify the reticence of the medical organizations.

PART III - Clinical data

We have tried to further improve our investigations so as to obtain an up-to-date picture of current drug habituation trends from the public health standpoint although we are aware that such attempts are bound to be incomplete and inadequate.

We confined the collection of "verifiable" official data to the Milan urban area, making enquiries at the reception offices and psychiatric wards of the city's civil hospitals. In this way we established significant drug dependence trends among a sample group sufficiently representative for all purposes.

We must state first of all that repeated enquiries among other institutions and private clinics which are more or less marginally or occasionally required to act in this field have given disappointing results; it may be presumed but cannot be demonstrated that diagnosis is often "masked" and extrapolation is therefore arbitrary.

In the two detection centres in Milan, which are of major if not exclusive importance, it was possible to check the admission registers for 1968.

Concerning the work of admission centres (first-aid and clearing stations), we reproduce registration figures in a table merely in order to illustrate the complete statistical inconsistency of the data, since most of the patients were immediately taken to psychiatric institutes already included in our census, and the relevant percentages were incorporated in data previously collected and described.

Thus in the psychiatric admission office of the Maggiore Hospital at Milan, of 9,100 persons examined in 1968 a total of ten men were registered for drug dependence (four of them under 20, five under 30 and one 35 years old). Three were addicted to amphetamines, three more to barbiturates, two to morphine, one to hallucinogens and one to an unspecified drug.

In addition, four female addicts were registered (two 20, one 40 and one 64 years old). Two were addicted to analgesics, one to amphetamines and one to barbiturates. They all came from Milan (table 6).

In addition to these cases which passed through the admission office of the Maggiore Hospital, twenty men and twenty women were detained in the psychiatric clinic (Origgi Department) of the Maggiore Hospital (tables 7 and 8) for various forms of drug dependence.

Among the males, fifteen out of twenty were unmarried, one was a widower. The largest occupational groups in order were: four students, three workmen and three employees. Among their regions of origin, Lombardy comes first (seven), then Venetia (four), Emilia (two), Apulia (two), Sicily (two), Sardinia (one), Calabria (one); the origin of one was not ascertained.

TABLE 6 - Admission to the Maggiore Psychiatric Hospital, Milan

 

Male drug dependence

Female drug dependence

Total admission

No.

Diagnosis

Age

Origin

No.

Diagnosis

Age

Origin

(1968) 9,100 1
Unspecified case of drug dependence
16
Milan
1
Amphetamines
22
Milan
  2
Morphine
18
Milan
2
Antineuralgics
20
Milan
  3
Amphetamines
28
Milan
3
Barbiturates
40
Milan
  4
Hallucinogens
24
Milan
4
Pain-killers
64
Milan
  5
Barbiturate-like products
22
Milan
       
  6
Amphetamines
35
Milan
       
  7
Miscellaneous drugs
20
Milan
       
  8
Amphetamines
25
Milan
       
  9
Barbiturates
23
Milan
       
  10
Barbiturate-like products
16
Milan
       
  9,100   10       4  

TABLE 7 Psychiatric ward No. 1 - Origgi Department Maggiore Hospital

 

Admissions for alcoholism

Admissions for drug dependence

Sex

Total admissions 1968

Total

per cent

Total

per cent

Men
2,280 1,018 44.65 20 0.87
Women
2,069 162 7.83 20 0.96
Ratio of men to women
11:10
63:10
 
1:1
 

TABLE 8 - Psychiatric ward No. 1 - Origgi Department Maggiore Hospital

Forms of drug dependence (registered in 1968)

Men

Women

Hallucinogens
5 1
Amphetamines
1
-
Antidotes to anxiety; tranquillizers
1 8
Antineuralgics
1 4
Barbiturates and similar drugs
7 2
Cocaine
-
-
Morphine
-
-
Cocaine associated with morphine
5
-
"Psycho drugs" (not specified)
-
2
Analgesics (not specified)
-
3
  20 20

Types of drug dependence: to hallucinogens, five (three under 20); to barbiturates and similar substances, seven (five between 21 and 25); five were addicted to morphine and cocaine associated with and added to alcohol (three under 20 and two between 20 and 30, one of them married - two students, two workmen and one employee). One other was addicted to amphetamines, one to tranquillizers and one to anti-neuralgics.

Among the women in the Origgi Department, twelve drug addicts were married and one was a widow (of about 20). Main occupations: eight housewives, three workers, two advertising agents and two employees. The main age-groups were seven between 20 and 30, five between 30 and 40, and three under 20. The most important regions of origin were Lombardy (five), Apulia (four), Campania (four), Venetia (two).

Types of drug addiction: eight to tranquillizers and antidotes to anxiety, four to antineuralgics (two to Optalidon, one to Veramon [both containing barbiturates], one to aspirin), two to barbiturates, two to psychotropics associated with alcohol, one to hallucinogens, and three to unspecified analgesics.

The addiction trends reflected in the figures of the psychiatric wards of civil hospitals for the various types of substances and age-groups seem in general fairly consistent with what the more reliable sources of information have shown for some time (tables 5, 6, 7, 8 and 9).

A delayed reflection of the increase will perhaps also be found very soon in the returns of the psychiatric institutes, where statistical imprecision is still really due above all to the considerable number of patients discharged undiagnosed. (Recent liberalizing legislation (March 1968) favours discharge in order to encourage a rapid turnover in institutions and reduce periods spent in hospital.)

In the absence of intermediate centres and structures (in Milan and in Italy as a whole), current attitudes involving a refusal to confine persons to an asylum reflect a moral and medical position in which the association of disease with guilt is again being propounded in terms which are not only out-of-date but senseless.

TABLE 9 Admission of psychiatric cases to the Polyclinic, Milan

Men

Women

Total admissions 1968

No.

Drug dependence diagnosis

Age

Origin

Total admissions 1968

No.

Drug dependence diagnosis

Age

Origin

2,530 1
Drug dependence
17
Macerata
2,280 1
Antidotes to anxiety
36
Milan
  2
Antidotes to anxiety
22
Taranto
  2
Amphetamines
38
Milan
  3
Barbiturates
25
Milan
 
3*
Barbiturates
19
Milan
  4
Barbiturates
18
Bari
  4
Amphetamines
47
Brescia
  5
Opium and marihuana
22
Milan
  5
Antineuralgics
30
Milan
  6
Morphine
46
Bari
  6
Morphine derivatives
51
Bergamo
  7
Amphetamines
31
Milan
         
  8
Amphetamines
25
Cremona
         
  9
Amphetamines
20
Mantova
         
  10
Barbiturates-alcohol
30
Turin
         
  11
LSD-marihuana
21
Cremona
         
  12
Opium
20
Venice
         
  13
Barbiturates-alcohol
54
Milan
         
  14
Morphine
45
Milan
         
  15
Unspecified
22
Milan
         
  16
Antineuralgics
24
Milan
         
  14
Barbiturates
31
Agrigento
         
  18
Unspecified
34
Milan
         
  19
Amphetamines
22
Milan
         
  20
Morphine
32
Milan
         
  21
Amphetamines, LSD
18
Palermo
         
  22
Unspecified
43
Venice
         
  23
Barbiturates
22
Milan
         
  24
Unspecified
17
Milan
         
  25
Barbiturates
58
Romania
         
  26
Barbiturates
22
Milan
         
  27
Antidotes to anxiety
31
Cava Tirr.
         
  28
Cocaine
36
Piacenza
         
  29
Marihuana
20
Rome
         
2,530 29       2,280 6      

No. 3 had two relapses in 1968.

PART .IV - The causes of drug dependence The "classical" drugs

Among the collective factors in causation, most investigators recognize anxiety, the pace of life, uncertainty, insecurity, strain caused by the pressing need to prove ability and stand up to competition, stress and friction due to the alienating forces of life in large cities, frustrations - in short, all the characteristics of a highly-industrialized society. The individual factors include those which occur in everyone's personal, family or working life; a failure to react or break free, being caught in the meshes of a situation from which the only escape is into a private world created by the drug.

Until a few years ago the search for anaesthesia as an escape from pain (or from boredom or responsibility) by way of the "magic substance" had always had an intelligible motive and apparent justification.

The individual or collective defence reaction to internal or external stress by turning to drug dependence in its various forms and degrees of intensity, had a presumed immediate purpose which was regarded as positive. The long-term ill-effects, even if rationally known, carried no weight, because they were projected into a vague future.

Thus the power to stimulate the senses traditionally attributed to drugs in their numerous direct or indirect connotations with erotism and sexuality (shedding of inhibitions - excitement) absorbed the more or less markedly decadent tendency to perverse behaviour (which is admired in some circles) and was looked upon as the positive side of traditional forms of drug dependence.

The stimulants

Moreover, the temporary increase of efficiency, due to stimulation by amphetamines, could always be counted as one of the positive factors, so that it was made psychologically "comprehensible" in Jaspers's sense.

The disturbing descriptions of the dissociation states (with frequent attacks of delirium) following protracted abuse of stimulants could always be considered after-payment for a pleasure which had been "enjoyed", even if only for a fleeting moment.

Much more difficult to classify are the masochistic tendencies and self-destructive impulses which underlie the search for pseudo-mystical experiences through a "chemical religion" and which take a constantly increasing variety of forms. Thus, as the formulae multiply, the magic substances (the tickets which open the doors to transitory and less and less ecstatic ecstasies) - - often contain elements of frightening and confusing disturbances, which greatly reduce the power to stimulate the senses in the "modern" as compared with the traditional drugs. This encourages a further "decadence of vice", a more desperate search for the lost paradise [ 9] .

The steady output of "new" drugs superseding each other in the fickle tastes of their customers, with a versatility suited to the despotic needs of the affluent society, by itself impedes a scientifically planned analysis of the problems posed by drug dependence of the so-called "minor" drugs which have a long-term toxicity.

The hallucinogens

Where drugs such as the hallucinogens have been subjected to carefully thought-out tests, clinical observation shows features markedly different from the patterns traditionally associated with drug dependence.

Pharmacological and clinical investigations have long revealed an acute and chronic symptomatology and toxicity associated with the tetrahydrocannabinols contained in different and variously-active percentages in the resin (hashish, chira, charas) and the flowering and fruiting tops (marihuana, kif) of the cannabis plant, and also in their various edible or liquid preparations, or in blends with tobacco.

In the sensory hyperaesthesia, the instinctive-motor automatism, and rapture (with auto- or hetero-aggressiveness), the serenity of the chronic states (which recalls schizophrenic abulia rather than the detachment of nirvana), the immediate "advantage" is still recognizable. The damage which has long been described in the ample scientific literature, seems to be altogether ignored in the extravagant campaigns for liberalization of controls on cannabis made recently by persons of consequence, but little knowledge of this field [ 12] .

Whereas the evidence is clear that overdosage of amphetamines can cause states of dissociation, and of quasi-schizophrenia and depressive withdrawal syndromes, anxiety symptoms have also been described on withdrawal of marihuana after a short period of use [ 4] .

Fear fantasies and a humiliating sense of inadequacy, inferiority and defeat (in an age dominated by the craze for success) appear punctually with an obsessiveness equal to the tenacity of those trying to flee to the "miracle shore". This strange symptom is common to all forms of drug dependence but is particularly associated with lysergic acid diethylamide.

Lysergic acid diethylamide and other hallucinogens are sometimes used in psychopathological analysis to intensify the symptoms of mental disease. So-called "experimental psychoses" are, it will be remembered, induced with suitable doses of LSD. All authors who have studied the effects of the drug on normal persons, psychoneurotics, psychotics and themselves testify that the experience upsets temporarily, but profoundly, the subject's psychic system.

The "LSD psychosis" and the "typical psychoses" are marked not only by general non-specific subjective symptoms (malaise, fatigue) and the specific symptoms (feelings of intoxication, of cold, of heat, tremors, unsteadiness when standing and moving, lightness, heaviness, headache, nausea, and so on) but also by an expansion or restriction of consciousness with a characteristic incapacity to control the direction of the psychic flux, with marked discomfort and even with terror [ 3] , [ 9] .

This disturbance breaks up the feeling of unity of the ego, and causes the well-known symptoms analogous to schizophrenic dissociation. Delirious states may and often do occur, and sometimes lead to a more or less florid delirium of varying duration [ 3] , [ 9] .

Changeability of mood (from euphoric excitement to anxious depression, inhibition and apathy) often accompanies psycho-sensory visual phenomena (e.g. limitation and distortion of vision) [ 3] .

Hallucinatory disturbances of vision, from the most elementary to the most complex (as in all forms of exogenous toxicosis), cover a wide range of images, which may be dramatic, with a plot often relating to conflicts or childish experience and not always pleasurable [ 3] , [ 16] .

In previous comparative work on the use of LSD and of psilocybine respectively by persons suffering from alcoholic hallucinations, we have reported hallucinatory disturbances (visual and sometimes auditory) completely identical in the two groups and almost identical with those caused by prolonged consumption of alcohol. What we wish to point out in this connexion is that none of the subjects, whatever symptoms occurred during the tests, asked to repeat the experiment. In particular, no one asked for a further dose of the drug [ 7] , [ 9] .

Even in the experiences of "immersion, confinement in a capsule, levitation", or in those where all the features of the world are felt to be unusuWal and rewarding, "the strangeness" (autopsychic or allo-psychic) has seemed to interfere greatly with the pleasure of escape when added to the deviations of perception, the ideational obstacles and the dysphoric states. It should be noted that LSD "has a much slighter effect on psychotics than on normal persons" [ 3] .

Characteristic causes of modern trends

In experiments with LSD we often meet some of the relatively modern characteristics of drug addiction: internal defencelessness, a confused sentiment of unformed aspirations and tension are symptoms of drug dependence of every kind [ 9] . Another relatively modern feature is that, whereas drug dependence was once an isolated phenomenon, a privileged "remedy" against boredom for a few famous persons or (at least in Italy) the shady legacy of some provincial clubs or the more personal "adventure" of an individual, the new drugs "belong" to ever larger groups tied to rituals and costumes which are often grotesque and sensational. In many cases, the type of drug chosen reflects an attitude of rejection pushed to the limits of madness and beyond. The violations of the unity of personality caused by hallucinogens, with frequent crystallization of clearly aberrant psychic symptoms, are not accepted as a distant threat or as a danger vaguely imminent after protracted use (according to the usual pattern in traditional forms of drug dependence), but are anticipated from the very moment of initiation [ 9] . This "taste for misfortune and self-effacement", is not new but it is shared in Italy by an unprecedentedly large number of people; part of it can be attributed to the problems of individuals; how much is due to group pressures is difficult to determine.

The pattern of drug dependence has been explored from the somatic angle (Williams' vitamin deficiencies, Smith's endocrine combinations, Forsander's specific tolerance), from the psychic angle (the concept of the psychopathic personality, Belloni's coenaesthophrenia, Freud's oral erotism in the various interpretations of his many disciples, behaviouristic theories); from the psychemetric angle (hypertrophy of the ego, feminine passivity, immaturity, vulnerability, inability to adapt, narcissism), and from the psychological angle (deficient "basic security", childhood emotional deficiencies, the psychological crime of parental dominance). It should be stressed that these multifarious investigations have led to the well-known formula of non-specificity. All the factors which have been adduced as aetiological may be found in almost any other form of deviation from the given norm. In general, theories and hypotheses have their day without ever illuminating the general conditions of abnormal behaviour and seem to provide explanations a posteriori!

A sociological approach, with examination of the role of voluptuous intoxication in the various types of society (stratified, vertically centred and rigid or paternalistic authority, or democratically levelled on a horizontal plane), generally produces no more than a description of the institutionalized aspects of toxicosis.

Ritual competitive games, initiations to adult life, sacred or sacrilegious festivities, conformist imitations, snobbish search for distinction, rebellion - each stage of the journey has been exhaustively studied.

In addition to these studies, which are complementary, we have the "inverse" parameters of investigations into the psychological characteristics of individuals or groups appearing, in a particular environment, which are immune to, or refractory to, one or several types of intoxication [ 1] .

If, however, we look beyond slippery theories, then drug dependence trends in Italy - as far as it has been possible to probe them - seem to show the predominating influence of social and cultural factors, and the importance of " milieu" (in the widest sense of the term), as causes of rebellion, and of the spread and continuance of the appetite for drugs.

In this connexion we consider the change now appearing in toxicological tendencies among the Italian people to be significant. For years Italy has been anchored in certain traditions and habits; wine is our national beverage, and five million Italians are directly or indirectly involved in the production and sale of alcoholic beverages. We are among the foremost consumers of alcohol in the world, and have very serious problems of alcoholism.

The increasingly psychiatric character of alcoholic poisoning (in some psychiatric institutes of northern Italy more than 50 per cent of the male patients have been admitted for various forms of alcoholism) has come to light in our hospitals.

In contrast, until a few years ago despite the influx of a large number of the most varied drugs in commercial transit through our country (from east to west and from Africa to the northern countries) there was no contamination of our own people except for isolated cases.

But now the flood of news via the ceaseless hammering of the press, films, documentaries, photographs, interviews, sample surveys and music (on records produced by world-famous companies) has radically weakened our resistance to drugs, already softened by prolonged immersion in alcohol.

So in our society too, the message is spreading among adolescents, who are as a rule predisposed to crises of eccentricity and to general and specific protests against conformism, against order, against the gerontocracy, against others, against all, and against themselves [ 9] .

It is difficult to argue that the increasing collective tendency to seek escape through chemical means in particular, is due to the sudden emergence of changes which warp individuals biologically or psychologically. The reaction of an ever larger number of "recruits" points to different factors; seductive and pernicious proselytism using more powerful means than in the past, calls for serious study in connexion with the proved predominance of certain drugs (particularly hallucinogens), and the spread of dependence among our young and very young people.

In Italy, as elsewhere, group pressures are making the drug a consumer commodity; those who succumb to these pressures, show weak or qualified acceptance, excessive malleability, consent to inertia, mechanical repetition, and forms of protest whose authenticity has become degraded by imitative passivity and by being in the form of "transplants" from other countries.

If we take a more general view embracing those other aspects which concern us less in the present context, we may add that in a world in which some of the catalysis of human greatness (obstacles, failures, sacrifice and the very experience of despair and renunciation) have been lost, epidemiological research into drug dependence provides very revealing insights.

The "magic" experiences for which people seek drugs everywhere may, in the final analysis, have the quality of an anaesthetic which is indispensable, if not for the human condition then at least for the liquidation of man's personality, of man as a minor protagonist who has sadly survived the destruction of his own myth, to live on in the relentless pathogenesis of an existence lost beyond rescue. In this sense, could not drug abuse arise out of a profound pessimism, which stops just short of suicide?

Summary

The authors quote the percentages of admissions into psychiatric hospitals for drug dependence.

Statistics published in Italy in recent years, and the registrations of the G. Antonini Hospital at Milan (with figures for admissions going back more than a century to the foundation of the hospital), show the psychiatric insignificance of the phenomenon.

Alcoholism, though not classified among the major forms of drug dependence, creates other serious institutional problems, to which, indeed, the authors have often drawn attention.

The quantitative and qualitative inconsistency of psychiatric statistics with the daily evidence of the most authentic information media (e.g. the press) has compelled the authors to widen the scope of their investigation.

Data have therefore been collected not only from other psychiatric institutions of the province of Milan

(the P. Pini and U. Cerletti Psychiatric Institutes), but also from private clinics and from the psychiatric wards of the general hospitals.

Reference is made to the results of a sample survey (by anonymous questionnaire) in some secondary schools at Milan, and to data collected from the files of a Milan newspaper (to ascertain the frequency with which news items on drugs appeared in 1968); these provide significant evidence of the increase in the general susceptibility to drugs.

According to the authors, the distinction between traditional and modern forms of drug addiction is confirmed by the dysphoria associated with the pharmacological effect of some drugs enjoying present popularity (including LSD).

In the collective search for escape through drugs imitation plays the decisive role so far as the recruitment of new followers of these drug-using cults is concerned.

The universal spread of the phenomenon has reached such numerical proportions that it cannot be explained by biological or psychological changes, but confirms the importance of group pressures in breaking down the defences of personality.

The decisive influence of proselytism conducted by technological means (radio, television, press, films, records) is particularly evident in Italy, a thoroughfare and market for drugs where, however, local consumption (500 registered drug addicts) had not markedly changed in the past.

Today, under the flood of "messages" side by side with the old problems of alcoholism, recourse to drugs publicized as a consumer commodity has taken root in our country also, where adequate welfare institutions and measures are practically non-existent.

Acknowledgements

We thank Professor C. L. Cazzullo, Director of the Institute of Clinical Psychiatry, University of Milan, Dr S. Luccarelli, head of the Psychiatric Ward, Maggiore Hospital, Milan; and Dr Visentin of the Corriere della Sera, for their permission to use the material contained in the report.

We also thank Dr V. Frossi of the Maggiore Hospital, Dr G. Ubezio, and Mr Spinola, social worker, of the Antonini Hospital for their valuable collaboration.

Drug dependence in Italy 11

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