Influence of certain social factorson the development of drug dependence

Sections

I. Drug dependence - a world scourge
II. Drug dependence as an epidemic "disease"
III. Importance of reviewing the aetiological factors in drug dependence,particularly from a sociological standpoint
IV. Main changes in the structure of drug abuse
Summary and conclusions
ANNEX
Bibliography

Details

Author: Marcel GRANIER-DOYEUX
Pages: 1 to 8
Creation Date: 1973/01/01

Influence of certain social factors on the development of drug dependence *

Professor Marcel GRANIER-DOYEUX
Vice-President, International Narcotics Control Board

I. Drug dependence - a world scourge

Drug dependence has increased to such a degree that it has almost assumed the proportions of a world-wide scourge. It is making rapid and alarming progress, particularly among young people. New forms of drug dependence have emerged, including dependence on drugs not yet under international control. There is a real danger of the development of a "sub-culture ". It is at present virtually impossible to predict with any accuracy how widespread this phenomenon will become, how it will develop and how long it will last, since complete and up-to-date information is still unavailable.

It cannot be over-emphasized that drug abuse, which is continually increasing, necessarily calls for interdisciplinary remedial action at both the national and international levels. The problem has become almost world-wide in scope and no single country, regardless of its wealth and resources, has the means of solving it, even within its own territory. Consequently, a collective effort and the co-operation of all countries at the international level are absolutely essential, but the action taken must be closely co-ordinated if it is not to lead to mediocre or even worthless results.

It is only fair to recognize that several international organizations and many Governments have become aware of the dangers of this terrible scourge and are making every effort to eradicate it.

II. Drug dependence as an epidemic "disease"

Since epidemiology is concerned with epidemic diseases and their causes, their communicability and ways of eradicating them, it is essential to demonstrate that drug dependence has now reached the stage where it can be described as an epidemic, the term used to refer to a morbid condition affecting a large number of people. Moreover, drug dependence often has the characteristic of contagiousness frequently to be found in epidemic diseases.

The World Health Organization (WHO) has repeatedly stressed the need to provide the necessary resources for the collection and exchange of important epidemiological data on drug dependence and drug abuse. Among the additional activities suggested in the report of the Director-General to the forty-seventh session of the WHO Executive Board is the organization of "epidemiological intelligence on an interdisciplinary basis with the participation of persons knowledgeable about problems of drug dependence and abuse and representing such disciplines as anthropology, biostatistics, clinical psychopharmacology, clinical psychology, epidemiology, internal medicine, public health administration, psychiatry and sociology. These persons would be available to study as a team selected populations in which there was reason to believe that an outbreak of drug dependence or change of drug abuse pattern might be occurring."

* This paper was read at the Sixth Congress of the International Medical Association for the Study of Living Conditions and Health, held at Varna (Bulgaria), in October 1972.

The European Public Health Committee of the Council of Europe has also concerned itself with the need for such epidemiological studies and has endeavoured to obtain an over-all picture of the extent of and trends in the various types of drug dependence. The following is a summary of some of the conclusions and recommendations in the report of this expert group:

  1. The spread of drug dependence has reached epidemic proportions in the 19 countries covered by the survey;

  2. The epidemic is still increasing and, in view of the lack of complete, accurate and up-to-date information, there is no possibility of forecasting its course, dimensions and duration;

  3. Drug addiction is spreading alarmingly and rapidly among juveniles; in some European cities, where at least 25 per cent of juvenile groups are at present involved and new patterns in drug dependence among juveniles are developing;

  4. Drug dependence is increasing in the whole population, especially dependence on those drugs which are not yet under international control;

  5. There is a real danger of the formation of a "sub-culture ";

  6. There is a serious lack of information;

  7. A detailed programme is needed if prevention and treatment are to be successful;

  8. Since the facts of the problem are changing from month to month, the study group feels the necessity for carrying out further studies in the field and for taking immediate measures.

To further emphasize the epidemic nature of drug dependence nothing could be more appropriate than the following passage from a statement made by Jean Mabileau in Buenos Aires at the Seventh International Conference on Health and Health Education: "The drug addict has a contagious disease. We must therefore transpose the epidemiological method and analyse the role of communication in the spreading of the disease. The following three poles of interest can readily be identified: the drug, the addict, the environment." One of the great difficulties in preventing and eradicating drug dependence and drug abuse is that the true extent of these scourges is not yet sufficiently well known. There is already a very extensive bibliography relating to the epidemiology of drug dependence and drug abuse. Many studies and surveys have been made in various countries. However, the application of the epidemiological method to this problem, although justifiable in many respects, presents many difficulties and, as T. H. Marshall has rightly pointed out, because of the relative lack of instruments, it is difficult to devise any analytic approach which will reduce complex problems to simple formulas. P. Mason goes even further when he states that statistics on the incidence of drug dependence are extremely unreliable and adds that there is still no standard or mandatory method permitting the recording of information on a central register, since most of the figures and data are obtained by extrapolations from police, prison and hospital records. For this reason, the United Nations Commission on Narcotic Drugs has pointed out that the collection of information on all aspects of the drug problem is a most important prerequisite for the institution of any large-scale programme because no serious effort can be made to reduce the incidence of drug addiction without having the clearest possible idea of the number and characteristics of the persons affected.

At its twenty-fourth session, the World Health Assembly again stressed the need for drug dependence epidemiological planning and monitoring to develop comparable approaches for epidemiological studies of drug dependence in different socio-cultural settings and monitor changing patterns of drug use in selected high-drug-use localities.

Some countries have already been able to provide useful epidemiological information, but others-unfortunately far more numerous-have not yet been able to furnish any information on the nature and extent of this scourge or on the human and environmental factors which are associated with the various types of drug dependence.

Consequently, the information on drug dependence and drug abuse communicated to the Secretary-General of the United Nations is unfortunately very incomplete; it was collected on the basis of non-uniform criteria.

It is impossible at present to give accurate figures showing the true number of drug addicts. This lack of information should not be unfairly attributed to a desire on the part of authorities to conceal the results of statistical studies. It is mainly due to the causes which have already been pointed out. The inquiries carried out so far have been limited in scope. It will be necessary first of all to take really concerted action under national and local programmes. The frequently excessive fragmentation of these programmes and the fact that they are carried out by far too many official, semi-official and private agencies are among the main obstacles to the preparation of studies or inquiries likely to provide accurate figures.

A report containing a study on the use of narcotic and psychotropic drugs by young people submitted in 1970 by the Secretary-General of the International Criminal Police Organization to the thirty-ninth session of its General Assembly, contains some very interesting data. However, the information in this report gives only a very broad picture of the problem and its magnitude at the world level. In the first place, only 55 of the national central offices of INTERPOL replied to a questionnaire which was sent to them. In addition, the figures communicated related only to young drug addicts or occasional users caught in the act of using, buying and, in a few cases, selling narcotic drugs. Although these statistics do not provide precise information on the total number of drug addicts, they nevertheless give very useful information concerning the types of drugs used in various countries.

III. Importance of reviewing the aetiological factors in drug dependence, particularly from a sociological standpoint

Another extremely important aspect of the epidemiological study of drug addicts is the aetiology of drug dependence. Only a few years ago, the cause of drug addiction was viewed from two basic standpoints: (1) the personality of the drug addict; and (2) the way in which he came into contact with the drug and his means of obtaining it. In 1971, Harris Isbell stated: "Habituation is caused by human weakness-not by the drug-and it is a sympton of a maladjustment of the personality rather than an illness as such. "In 1925, Kolb, and subsequently Felix, studied the personality disorders to be found in "potential" or confirmed drug addicts. According to Vogel, Isbell and Chapmann, "Drug addiction should be regarded as a symptom of a basic underlying personality maladjustment ". The drug addict is a person who is emotionally immature. Consequently, he can never adjust to the problems of life and deceives himself into believing that the euphoria produced by the drug is a satisfactory adjustment, while his behavioural adjustment patterns continue to be inadequate.

He is in a false situation. Many people are incapable of obtaining sufficient emotional satisfaction; this is why they seek in alcohol or drugs a means of blunting the pain of reality and finding gratification in fantasies. Some drug addicts yearn for affection. Most of them suffer from "social anxiety" and lead a solitary life. The narcissist, unable to derive full enjoyment from heterosexual activity, will seek enjoyment and happiness in drugs. Under the effects of the drug, his capacity for self-esteem will be rendered tolerable.

Drug addiction was traditionally attributed to the following causes:

  1. Therapeutic (or "medical ") origin:

    Patients subjected to prolonged treatment with dependence-producing drugs develop a degree of tolerance which leads to psychological, and sometimes physical, dependence. This cause of addiction is not as frequent as was once believed, particularly since in such cases the "personality" factor plays a most important role in the development of the illness.

  2. Occupational origin:

    Drug addiction is reported to be much more common among members of the medical and para-medical professions, because they have more ready access to drugs.

  1. Imitation and proselytism:

    Some persons are first attracted to drugs by what is called "mental infection ". The evil is then propagated like a communicable disease and may reach epidemic proportions.

  2. Special affective states:

    Drug addictions of an "affective" nature may arise from a need to forget some grief or emotional disappointment. But this aetiological factor is always linked with emotional maladjustment. The drug thus bridges the gap between the unrealizable ambitions or desires of the individual and a semblance of realization.

  3. Influence exerted by other addictions:

    The abuse of one drug may predispose the addict to abuse of another and even of several drugs simultaneously. This poses an extremely important problem. Habitual alcoholism may easily lead to abuse of barbiturates and even of opiates. It is fairly frequent to see habitual smokers of cannabis becoming heroin addicts. Users of amphetamines may eventually replace these drugs by cocaine. Several addictions may coexist in the same individual.

  4. Congenital origin:

    Charcot and his pupil F?r? had observed that, during pregnancy, the foetus showed signs of distress when the drug was withdrawn from a morphine-addicted mother; the distress manifesting itself in spasmodic movements. Similarly, the newly-born babies of drug-addicted mothers showed withdrawal symptoms after the cutting of the umbilical cord. Perlstein, much later, confirmed these facts and carried out a more detailed study.

  5. Tradition and rites of certain peoples:

    An example of this cause is the coca addiction (coca-leaf chewing) which is encountered among the natives of the Andean countries, and more particularly in Bolivia and Peru. Another example is the consumption of hallucinogenic mushrooms for ritual purposes by certain Mexican tribes.

Ideas on the aetiological factors in drug addiction have now had to be revised because new factors have come into being in the course of the last few years. Here, for example, are the conclusions of the WHO Expert Committee on Drug Dependence in 1970:

  1. Drug dependence may be a manifestation of an underlying character disorder in which immediate gratification is sought in spite of the possibility of long-term adverse consequences and at the price of immediate surrender of adult responsibilities;

  2. It may be a manifestation of delinquent-deviant behaviour in which there is pursuit of personal pleasure in disregard of social convention, so that to some this is primarily a moral problem;

  3. It may be an attempt at self-treatment by persons suffering from ( a) psychic distress either of the normal variety seen, for instance, in adolescence or as a reaction to social and/or economic stress, frustration, or blocked opportunity; or the more persistent problem of depressive illness, chronic anxiety, or other psychiatric disorders; ( b) physical distress-hunger, chronic fatigue or disease; ( c) a belief that the drug has special powers to prevent disease or to increase sexual capacity;

  4. It may provide a means of achieving social acceptance in a social subculture, particularly for the socially inadequate;

  5. It may be a manifestation of a permanent or reversible metabolic lesion brought about by the repeated use of high doses of drugs;

  6. It may be part of a rebellion against conventional social values relating to pleasure, tradition, success, and status;

  7. Even in the absence of pre-existing psychopathology, it may result from the acquisition of a complex set of instrumental and classically conditioned responses and may therefore be a form of learned behaviour;

  8. Even in the absence of underlying psychopathology, it may result from socio-cultural pressures leading to heavy use of a drug, for example, alcohol;

  9. Any or all of these factors may play a role in the causation of drug dependence in a given individual.

It may be useful to recall the following points put forward by A. Boudreau on drug consumption and abuse among young people which he believes is encouraged by:

  1. The lack of models: Young people constantly seek to identify themselves with models capable of satisfying their desire to transcend the self. In the absence of any models with whom they can identify, young people seek to find in chemical products a means of transcending themselves for a few hours;

  2. The spiritual void: Resulting from a lack of faith, then from the preceding generation's deification of material values, the spiritual void necessitates a" psychedelic" compensation-a liberation of the spirit, ecstasy-with its meditation sessions and its "high priests ";

  3. The search for an artificial safety valve that will help to ease the state of tension in which we live, in view of the difficulties we have in using natural means of relaxation.

The French Health and Social Education Committee published an interesting pamphlet containing "information on drugs ", in which it indicated the main causes which might give reason to fear an increase in drug abuse among young people, namely:

Weakening of the family unit;

Disappearance of restraints on curiosity;

Rebellion of the social group of the young against an adult world judged to be absurd;

An increasing desire to imitate idols;

A desire to escape from the anguish of the modern world;

Infection within the group;

Ignorance of the real dangers of drugs;

Relative ease of supply as a result of the persistence of the pushers, particularly where they themselves are addicts;

Publicity given to drug cases and to the various divergent views on the problem.

In 1970, Claude André Piva submitted a thesis for a doctorate in medicine, entitled "Contribution à l'étude des toxicomanies" (Contribution to the study of drug addiction). This study was carried out under the supervision of Professor Etienne Fournier in Professor Michel Gaultier's department at the Fernand Widal Hospital; it includes an epidemiological inquiry which deserves to be considered one of the most useful and important carried out in France. The type of " record sheet" kept on each patient might serve as a model for future studies in this field. Another example of a "record sheet" is the one which we used, from 1966 onwards, with our pupil, Alfredo González Carrero, now Director of the Venezuelan Criminal Police Laboratory. It differs from the one proposed by Piva in that we included police and judicial data in addition to data of a strictly epidemiological nature (see annex).

In addition to the aetiological factors already mentioned, there are others which we are beginning to know a little better and which play a very important role in the development of drug dependence. Among them must be included a kind of rebellion of the young against conventional social values relating to pleasure, tradition, success and status. Even disregarding any pre-existing or underlying psychopathology, drug dependence could occur as a form of learned behaviour, resulting from the acquisition of a complex set of instrumental and classically conditioned responses, or from socio-cultural pressures leading to the abuse of certain substances, such as drugs themselves or alcohol.

IV. Main changes in the structure of drug abuse

Several changes are apparent in the actual structure of drug abuse. In our last report, the members of the International Narcotics Control Board placed great emphasis on the need to study the nature of these changes and their special characteristics. There are at present roughly four categories of transitions which we might consider:

  1. From a single drug to a combination of several drugs;

  2. From one drug to another of the same strength;

  3. From comparatively harmless drugs to other, more powerful drugs;

  4. Even from powerful drugs to less powerful drugs.

Summary and conclusions

  1. Drug dependence is now assuming the proportions of an almost world-wide scourge.

  2. Drug dependence has acquired the character of an epidemic disease.

  3. The aetiological factors of this disease should be reviewed, particularly from a sociological standpoint.

  4. Several significant changes requiring study are apparent in the actual pattern of drug abuse.

  5. This situation necessarily calls for inter-disciplinary remedial action.

  6. A collective effort and international co-operation are absolutely essential. However, such action must be closely co-ordinated, both at the national and international levels.

ANNEX

Several different kinds of "record sheet" could obviously be suggested for the conduct of a useful epidemiological study. However, the following data appear, on the whole, to be the most useful:

I. Information on the individual observed:

  1. Identity: (A) Family name and given name; (B) Sex; (C) Age (date of birth); (D) Place of birth; (E) Present marital status. Specify whether the person concerned has been married, how many times, or whether he or she has lived (or is living) in consensual union, etc.

  2. Previous family history (with particular reference to the preceding generation). Specify: absence of father, divorce of parents, normal parent situation, other situation(s). Indicate the known existence of drug addiction in the parents or other close relatives.

  3. Sexual activity: heterosexual, homosexual.

  4. Educational level: (A) primary; (B) secondary; (C) higher (this simple classification has been adopted because the assessment of the level of education varies from country to country).

  5. Present activity or activities: profession, employment, year of studies, professionally inactive, unemployed, etc.

  6. Previous activities: duration, cessation of activity, resumption, etc. (if possible indicate the cause).

  7. Present place of residence: (A) with parents; (B) own dwelling; (C) hotel or boarding house; (D) with a friend or acquaintance.

  8. Circumstances leading to consultation (or to arrest, in cases where the individual was apprehended by the police authorities).

    (A) Circumstances leading to consultation:

    1. family (preceding generation);

    2. present family (spouse, brothers, cousins, etc.);

    3. common law husband or wife, friend(s), etc.;

    4. social circle;

    5. professional;

    6. police, judicial;

    7. personal: health reasons, lack of drugs, voluntary withdrawal cure.

  9. Present or previous complications:

    These may be of various kinds and, occasionally, two or more are present at the same time.

    (A) abscess or local infection; (B) jaundice; (C) septicaemia; (D) accidents due to an overdose; (E) feverish state, short attack of shivering and trembling immediately after an injection (referred to by drug addicts in France as" poussières "); (F) suicide attempt (present or previous); (G) induced abortion; (H) tera tological phenomena in the offspring; (I) other; (J) pathomimesis.

  10. Out-patient consultation: (A) once; (B) several times (how many?).

  11. Hospitalization: (A) first time; (B) several times (how many and when?). Indicate whether hospitalization was voluntary. (C) Release on request; (D) drug(s) administered during withdrawal; (E) admitted relapse(s); (F) post-treatment consultations; (G) results (successful?) (failure (s)?).

  12. Psychological tests: (A) which tests?; (B) refused?; (C) results and interpretation.

  13. Judicial record: (A) minimal; (B) held on remand; (C) imprisonment (duration); (D) sentence(s) imposed.

II Drug(s) used:

  1. At first (" initial" drug);

  2. At present;

  3. Mode of administration: (A) preferred; (B) other;

  4. Subsidiary drug or drugs already used and their mode of administration;

  5. Duration of addiction: (A) recent onset (less than a month); (B) "average" duration (one to three months); (C) more than three months.

For addicts consulting a doctor and for those who are hospitalized, it will, of course, be necessary to draw up a full "case history ". For the purposes of a purely epidemiological study, however, the data requested in a record sheet containing the basic points listed above would be amply sufficient.

Bibliography

Council of Europe - European Public Health Committee, "Public Health Implications of recent Developments in Drug Dependence " - Report prepared by S. Kaymakcalan, K. Kryspin-Exner and A. Teigen; presented by P. Kielhoz. Strasbourg, 1970.

Granier-Doyeux, M. and Siegbert Holz, "Compendio de Farmacologia ", Ed. de la Biblioteca de la Universidad Central. - Caracas 1965.

Granier-Doyeux, M. and A. Gonzalez Carrero, "Drogas que producen dependencia", Ed. de la Escuela Nacional de Policia Judicial, Caracas 1970.

Ingersoll, J. E., Statement to the U.N. Commission on Narcotic Drugs, Geneva, 28 September 1970.

International Criminal Police Organization. XXXIXth session of the General Assembly. Report (No. 14), Brussels 1970.

International Narcotics Control Board. Report of the INCB on its work in 1971. Doc. E/INCB/13.

Mabileau, J., "Face aux toxicomanies: Psychosociologie de la communication" (Discussions a la tribune). VIIe Conference internationale sur la santé et l'éducation sanitaire, Buenos-Aires, 10 September 1969.

Marshall, T. H., "Sociology at the Crossroads and Other Essays ", Heinemann, London, 1963.

Mason, P., "Drug Dependence", J. Mt. Sinai Hosp., 33 (1): 28-31; 1966.

Narcotic Addiction Control Commission, State of New York - Research Division (Director: C.D. Chambers).

Report of 41 pages; 1971.

Piva, C. A., "Contribution à l'étude des toxicomanies ", Thèse pour le Doctorat en medecine, Dactylo-Sorbonne, Paris, 1970.

World Health Assembly: WHA, 23. 42, par. 3.1 (Resolutions). Off. rec. Wld Hlth Org. 184, 22.

World Health Organization - WHO Expert Committee on Drug Dependence, Eighteenth Report, Wld Hlth Org. techn. Rep. Ser.,No. 460; 1970.

Zacune, J., "A comparison of Canadian narcotic addicts in Great Britain and in Canada", Bulletin on Narcotics, XXIII, 4, pp. 41-49, 1971.