The abuse of psychotropic drugs

Sections

Abuse of amphetamines and amphetamine-like drugs
(a) Amphetamine taking to increase "energy"
(b) Mood modifying with amphetamines
Abuse of hypnotics, sedatives and trafiquillizers

Details

Author: Istvan BAYER
Pages: 11 to 25
Creation Date: 1973/01/01

The abuse of psychotropic drugs

Dr. Istvan BAYER Director, National Institute for Pharmacy, and Professor of Pharmacy, Postgraduate Medical School, Budapest, Hungary

The development of modern drug therapy is one of the greatest achievements of our century: millions of people are treated and cured by means of new medicaments. Scientific research is going on uninterruptedly, and the close co-operation of physicians, pharmacologists, microbiologists, pharmacists, biologists, chemists and other highly specialized people working in teams at universities, research institutes and in the pharmaceutical industry, produces every year a great number of new drugs providing the medical profession with new therapeutic agents to combat illnesses. It is well known that the use of medicaments has its own risks, and the study of "adverse drug reactions" and "side effects" has become a complicated and very important new branch of medicine. But undesirable side-effects are not limited to individual drugs: the development of the materia medica, the extension of drug therapy and the constant increase in the consumption of drugs have developed their "side effects" too. There is a number of adverse drug effects (including lethal cases) due to the misuse of relatively toxic medicaments like antibiotics, but the most characteristic symptom of our society, where anxiety, tension states, insomnia and other manifestations of stress are common, is the steady increase in the incidence of cases of abuse of psychotropic drugs.

In the United States, [ 1] 1965, some 58 million new prescriptions and 108 million refills were written for psychotropic drugs, and these 166 million prescriptions accounted for about 14 per cent of the total prescriptions of all kinds written in that year. (It is estimated that approximately three-fourths of the prescriptions for psychotropic drugs were written by general practitioners and about 1 in 20 by psychiatrists.)

It is estimated that in 1967 [ 2] a total of 1.1 billion prescriptions for drugs of all types were filled in drugstores throughout the United States (at a retail cost of US$ 3.9 billion). Major tranquillizers, minor tranquillizers, antidepressants, stimulants, sedatives and hypnotics made up about 17 per cent of this total, or 178 million prescriptions. These figures do not include those preparations which are mixtures of a psychotropic drug with a non-psychotropic drug; if these combinations were added, the percentage accounted for psychotropes might rise to almost 25 per cent of all prescriptions.

In the United Kingdom, "an average of a little over 5 prescriptions per person per year are written under National Health Service and about 16 per cent of the tons of medicines represented by these prescriptions are for psychotropic drugs". [ 3]

TABLE 1

Psychotropic drugs prescribed in the United Kingdom in 1968 unter the National Health Service a

Drug group

Prescriptions in million

Barbiturates b
24.7
Benzodiazepines
12.7
Phenothiazines
6.1
Non-barbiturate hypnotics
5.5
Tricyclic antidepressants
5.0
Amphetamines
4.0 (approx.)
MAO inhibitors
0.4
 
b Including compound preparations containing them.

a See footnote 3 above.

b Including compound preparations containing them.

In the Le Dain Report [ 4] we can find the following statement: "(In 1968) some 55,600,000 standard doses of amphetamines and some 556 million standard doses of barbiturates were produced or imported for consumption in Canada. A study by the Addiction Research Foundation in 1966 found evidence indicating that on an average day seven per cent of the Toronto population over 15 years of age would be using, on prescription, a mood-modifying drug. This study estimates that 24 per cent of all prescriptions written in Toronto were for drugs of this type; 44 per cent of these were for sedative and hypnotic drugs; 40 per cent were antidepressants and major and minor tranquillizers."

The figures and quantities are impressive, but the data quoted above are only illustrations of the steady increase in the consumption of psychotropic drugs and do not indicate who the consumers of the huge quantities of these drugs were. "Society" is a term too wide to define drug takers because drugs are consumed by individuals and not by society.

Psychotropic drugs are "legal" medicaments; their use is "justified" by real or alleged therepeutic indications and it would be a mistake to confound their use with their abuse, but the extent of their abuse is obscured by their very great "legal" use. Global figures do not give any idea about "consumers "; therefore, before undertaking an analysis of abuse patterns, it would be useful to attempt to find an answer to the question: who are the users of psychotropic drugs?

There are very few studies on this subject; one of the best is a study published by the Division of Research of the New York State Narcotic Addiction Control Commission. [ 5] It is based on evaluation of data which were obtained by face-to-face interviews with 7,500 carefully selected persons aged 14 and above in New York State. One of the results of this sample survey was the presentation of a report on "Differential Drug Use Within the New York State Labor Force". The report has the great merit that it reflects drug use by the general population, eliminating the "personally and socially dysfunctional" persons such as "heroin street addicts ", "speed freaks" or "acid heads ".

The report contains detailed data on the respondents' use of 17 classes of drugs and the frequency of use, classifying frequency as follows:

  1. Non-user: has never taken or used the drug;

  2. Former user: has taken or used the drug but not within the previous 6 months;

  3. Infrequent user: has taken or used the drug within the previous 6 months but not as much as 6 times during the previous 30 days;

  4. Regular user: has taken or used the drug at least 6 times during the previous 30 days.

The following table 2 is a simplified reproduction of one of the summary tables of this report, showing the estimated number of regular users of "legal" psychotropic drugs in the New York State population (estimated population: 13,690,000).

The general conclusion which can be drawn from these figures is that 10.7 per cent of the New York State general population are regular users of one of the psychotropic drugs.

An analysis of other American data by Balter and Levine [ 2] completes this picture, as follows: " ... The large bulk of psychotropic drug prescribing occurs in the over 20 years age group, principally for age 40 to 59. Further it is clear that stimulant drugs are used much more extensively during young adulthood while the sedatives and hypnotics are most frequently used in advanced ages. Use of minor tranquillizers and antidepressants is greatest in the age range 40 to 59. These data coincide with clinical knowledge that somatic disorders with stress components such as cardiovascular and gastrointestinal disorders, which are frequently treated with sedative drugs, occur in later life as do general problems of insomnia. The use of stimulants at an earlier age is strongly related to their use as appetite suppressants and antiobesity agents. Females account for approx. 67 per cent of all psychotropic drug usage, whereas on non-psychotropic drugs they account for 60 per cent; stimulants and antidepressants are overwhelmingly 'female drugs' and account for 82 and 72 per cent of the use, respectively.''

The paper by Balter and Levine gives a general idea about the desired effect for which psychoactive drugs had been prescribed (see table 3).

These data are related to the general use of psychotropic drugs and not to their abuse. There is a relationship between use and abuse because the number of prescriptions, the quantities consumed, as well as the number of consumers, show such high figures that they cannot be justified by therapeutic needs, consequently an (unknown) proportion of the many tons of psychotropic drugs is being deliberately or involuntarily abused.

"Mind-affecting drugs are now an integral part of American life. Prescriptions are a major distribution route." This statement made by B. R. Ditzion [ 6] seems to be confirmed by the 225 million prescriptions for stimulants, sedatives and tranquillizers filled by American pharmacists in 1970 [ 7] and by data on the illicit traffic in psychotropic drugs, since it would be very surprising to see medicines being obtained by illicit means for real therapeutic purposes. It is very difficult to obtain reliable data on the illicit consumption of psychotropic drugs, even more difficult than in the case of narcotic drugs. Legal supplies of narcotic drugs are subject in the majority of countries to effective control measures, and their distribution is recorded until their administration, which is not the case for psychotropic drugs; while the consumption of the latter drugs is in a much higher order of greatness than those of narcotics used for therapy.

TABLE 2

Estimated number of regular users of "legal" psychotropic drugs in New York State population a

   

Barbiturates

Other sedatives

Minor tranquillizers

Major tranquillizers

Anti-depressants

Pep pills

Diet pills

1.
Professionals, technical workers, managers and owners
44000 21000 50000 3000
-
14000 34000
2.
Clerical and other white collar workers
23000 12000 81000 20000 4000 12000 35000
3.
Skilled and semi-skilled workers
27000 21000 36000 15000 8000 9000 21000
4.
Unskilled workers
7000 6000 10000 1000 1000 1000 2000
5.
Service and protective workers
33000 10000 38000 4000
-
7000 4000
6.
Sales workers
71000 1000 25000 12000
-
8000 21000
7.
Farmers
-
1000
-
-
-
-
-
8.
Not employed housewives
73000 55000 161000 11000 17000 8000 81000
9.
Other not employed
99000 46000 124000 19000 7000 51000 27000
 
TOTAL
377000 173000 525000 85000 37000 110000 225000

a See footnote 5.

TABLE 3

Use of major classes of psychotropic drugs by desired action (1968) a

(In percentage)

Desired action

Major tranquillizers

Minor tranquillizers

Anti- depressants

Stimulants

Sedatives

Hypnotics

Tranquillization
36
43-58
1-6
  7  
Sedation
16
20-27
0-4
  68  
Anti-depression
2  
80-85
5    
Anti-emetic
18          
Anti-convulsant
        14  
Anti-hypertension
        3  
Anti-insomnia
          88
Anti-obesity
      90    

a Representative drugs of the class and not the entire class tabulated.

The best studied field of the illegal consumption of psychotropic drugs is the drug-taking by youth in some European and North American countries where this is considered a major problem. The following table 4 gives a general idea of the size of the consumption of narcotic and psychotropic drugs by students in the United States. This table was compiled and published by the Bureau of Narcotics and Dangerous Drugs (BNDD) as a summary of data collected during various surveys in the USA. [ 8]

The table clearly shows that amphetamines and barbiturates have an outstanding place among psychotropic drugs consumed by students.

A more detailed study of the abuse of psychotropic drugs in general would be a self-aim; and in the following chapters we shall study the specific problems connected with the abuse of the various classes of psychotropic drugs which are used for therapeutic purposes. Major tranquillizers (for example phenothiazines) and antidepressants (such as imipramine) are excluded from this study, because these psychotropic drugs generally do not produce any form of dependence.

Abuse of amphetamines and amphetamine-like drugs

There is an apparent similarity between the problems of abuse of stimulants and sedatives: the huge number of people who have become abusers of both, taking these drugs alternately or consuming one of the many fixed dose amphetamine-sedative preparations (for example Drinamyl) seems to confirm this theory. Despite this formal similarity the argument is false; there is a fundamental difference between the therapeutic importance of sedatives and that of the stimulants. In the opinion of British experts amphetamine therapy is not justified except in the case of narcolepsy. (In the United Kingdom, the number of such cases was estimated to be about 200 in a population of 56 million.) In countries where prescriptions of amphetamines have been subject for several years to the same regulation as that for narcotics, their consumption is minimal. In Hungary, for example, the per capita consumption of amphetamines was of 0.0007 table in 1996, compared with 35 tables in the United States of America in the same year. [ 9]

TABLE 4

1967 surveys of illicit use of drugs by highest and lowest rates of usage

 

Extent of use

 

Extent of use

Drug

University or college

Highest %

Lowest %

High School

Highest %

Lowest %

Marihuana
UCLA
34.9  
Seniors in a private high school in Michigan
33.7  
 
Mary Washington
  5.6
Seniors in two rural high schools in Michigan
  0.0
LSD
Wesleyan
7.0  
Three high schools in Castro Valley (male juniors and seniors)
15.4  
 
Yale
  2.0
Seniors in five Michigan high schools
  0.0
Amphetamines
Ithaca College (male students)
14.0  
Three high schools in Castro Valley (male juniors and seniors)
21.5  
 
Ithaca College (female students)
  7.0
Mamaroneck Senior High School
  5.5
Barbiturates
California Institute of Technology
7.1  
Three high schools in Castro Valley (male juniors and seniors)
15.7  
 
Ithaca College (female students)
  1.7
Mamaroneck Senior High School
  3.4
Opiates
Ithaca College (male students)
3.3  
Three high schools in Castro Valley (male juniors and seniors)
4.7  
 
Four colleges in California
  1.0
Mamaroneck Senior High School
  1.4

It is very difficult to draw any conclusion from total consumption data concerning barbiturate abuse, because millions of tablets of various barbiturates are needed for legitimate therapeutic purposes. In the case of amphetamines the situation is quite the opposite: the therapeutic need for amphetamines is small, consequently high production and consumption data clearly indicate an abuse situation. From the size of the amphetamine production, it is very easy to draw the conclusion that in many countries huge quantities of these drugs are consumed for non-therapeutic purposes.

The flourishing black market and clandestine production confirm this conclusion. Illicit trafficking in drugs is not however the subject of the present study, and the few examples which follow (taken from Sadusk's paper) are illustrations only:

"A person, known as a short-line jobber, who was also involved in counterfeiting and illegal sales of stimulant drugs, obtained the following quantities of amphetamines to carry out his illegal business: (1) from a Detroit firm, 8 million amphetamine tablets in a nine-month period in 1962 and 1963; (2) from a small manufacturer in New Jersey, over a half million amphetamine tablets between December 1961 and September 1962; (3) from a manufacturing firm in North Carolina, over 2 million tablets; and (4) from two firms, one located in Illinois and the other in Pennsylvania, 3 million amphetamine tablets. In addition, the Pennsylvania firm shipped this man 150,000 barbiturate tablets."

"We [ 10] estimated that about 8 billion or more tablets per year of amphetamines are produced. Of this amount, our Division of Field Operations estimates that 50 % of the quantity produced finds its way into illicit channels of distribution ...." [ 9]

The usual forms of amphetamine taken by addicts (and by the huge number of "occasional" consumers) is per os or intravenous injection. In the present chapter there is an attempt to describe: (a) The taking of amphetamines to increase "energy "; (b) Their use as mood-modifiers.

The group of " mainliners" was left out from this study, because the phenomenon of injecting excessive quantities of methamphetamine, phenmetrazine or dexamphetamine intravenously (speed scene) is much more closely linked to the use of drugs such as heroin and cocaine than to the subject of the present study (e.g. the abuse of psychotropic medicaments).

(a) Amphetamine taking to increase "energy"

(Increase of alertness and concentration, elimination of the sensation of fatigue and sleepiness).

The "mildest" form of amphetamine abuse is the preparation of students for examinations with the help of amphetamine tablets. "Mildest ", because the risk of this amphetamine taking is apparently low; "low" because the incidence of direct harmful effects on the health of the individual is rare. But the risk is only apparently "low ", because this student layer is a population at risk; and this "harmless" activity has been detected as at the origin of the majority of amphetamine dependency cases. The stress during the examination period is increased by amphetamine taking, and to counteract nervous strain many students start to take tranquillizers or sedatives. Among students the prevalence of simultaneous or alternate stimulant/sedative abuse on a regular or occasional basis is relatively high.

There are comparatively few statistical data about amphetamine consumption by students, but the summary table (see table 4) compiled by the BNDD [ 8] shows clearly that amphetamine comes just after cannabis among all narcotics and psychotropic drugs as the choice of drug of abuse.

Examinations do not constitute the exclusive origin of students' amphetamine consumption; many young people started to take amphetamines (" uppers") during week-ends in order to prolong Saturday or Sunday nights.

Regular amphetamine consumption is very frequent among car drivers and especially among lorry drivers. It is difficult to illustrate this phenomenon with statistical data, but let us quote Sadusk's paper [ 9] further:

"... approximately 90 % of this illegal traffic emanates from truck stops, bars, gasoline stations, and restaurants. The early development of illegal traffic in amphetamines occurred primarily along truck routes because truck drivers learned that amphetamines permitted them to drive for longer periods without rest and to make more trips per week."

The phenomenon is not limited to America. The situation is similar in several other countries and the author of this article had the personal impression in West Africa that lorry drivers are the most important customers of the flourishing amphetamine black market in Africa.

Some similarity exists between the amphetamine abuse of car drivers and the "doping" of athletes; both techniques are intended to increase performance. Doping is a special problem (the illegal use of drugs for doping is only a part of it) but amphetamines are the specific drugs, the most frequently used ones for this purpose. The danger of amphetamine doping is evident : amphetamines do not constitute a supply of energy, they suppress only the sensation of fatigue and under their effect the sportsman exceeds the limit of his physical strength. The problem is similar for car drivers who take a great risk warding off sleep with amphetamines because they may - and do - lose control or even collapse during driving, immediately after the amphetamine effect has worn off.)

News is frequently published in the press on doping by athletes, on "pep pills" taken by youth, on amphetaminism in the show business and on the problem of " wakers" used by car drivers, but reports about the largest group of "legal consumers ", e.g. armies, are very rare.

Few countries have published data about amphetamine stocks or consumption in their armies, but from the few available data it is possible to draw the conclusion that amphetamines were used by many armies during World War II following the introduction of this practice in Germany in 1938. The British Army consumed 72 million "energy tablets" during World War II, and at the end of the war, it was detected during an inquiry at a military hospital in the U.S.A. that about 25 per cent of the soldiers in custody were amphetamine abusers and 89 per cent of them had become regular users during their military service.

The most systematic large scale amphetamine consumption was introduced in Japan, where regular taking of amphetamine tablets had been practically compulsory for everybody working in the war industry. The huge amphetamine stocks of the pharmaceutical industry produced a disastrous amphetamine abuse situation in post-war Japan. The following data published by the Ministry of Public Health and Welfare give an idea about the extent of amphetamine abuse in the early 1950s:

Year

Number of arrests for amphetamine abuse

1951 17528
1952 18521
1953 38514
1954 55664
1955 32148
1956 5233
1957 803
1958 271

The report by Professor Masaki [ 11] applies to 1954, when the epidemic reached its maximum. In his opinion, 1.1 per cent of the population of Kurkuma had been amphetamine takers; this proportion was about 5 per cent in the age group of 16 to 25 years old. During May and June 1954 10 148 persons were arrested in Japan for possession of amphetamines and 52 per cent of them were addicted to amphetamines. The number of amphetamine takers was estimated by Masaki to be between 500 000 and 600 000, half of them being dependent on this drug. This is in conformity with Goto's estimate. [ 12]

Youth was the layer of the population most affected by the amphetamine epidemics in Japan; based on about 11 000 abuse cases the following statistics were published in Japan about age groups and sex:

 

Per cent

under 15 years
0.7
15 to 19 years old
22.9
20 to 29 years old
66.6
over 30 years
9.8 and
male
71.5
female
28.5

A very open and critical report was published on military stocks and consumption of amphetamines in 1971 in the United States of America. [ 13]

The report states that the bulk of the legally produced amphetamine quantities were bought by the Army, as illustrated by the latest available data:

Staff

Produced quantity (amphetamine tablets of l0 mg)

Tablets/year per capita

Army 11 512 000
9785000 a
6.4
Navy 1 086 000
11503805 b
10.5
Air Force 862 000
10488099 12.1

a 20 million per annum in the previous years.

b33.5 million tablets in 1966.

(b) Mood modifying with amphetamines

In 1959, 5 600 000 pharmaceutical preparations containing amphetamine or phenmetrazine were prescribed by physicians in the United Kingdom. [ 14] Connell's publication is based on a study of 214 million National Health Service prescriptions; this study was presented by the Brain Committee [ 15] in its 1961 Report. In other words, 2.5 per cent of all prescriptions were accounted for by stimulants of the amphetamine type. Prescriptions of 19 physicians in North-East England had been studied by Brandon and Smith; [ 16] amphetamine-derivatives were prescribed for 0.8 per cent of all patients. 14.5 per cent of these prescriptions were for men and 85.5 per cent for women, mainly housewives from the age group 36-45; 20.5 per cent of them could be considered as dependent on the drug. Weight control was the indication for prescribing amphetamines.

The age group of 36 to 45 years old women was pointed out clearly by the Brandon-Smith study as the population group with the highest incidence of amphetamine abuse of therapeutic origin. The case history is generally the same: development of psychic dependence during regular amphetamine (or mainly phenmetrazine) taking for weight control. There is a correlation between the anorexiant and stimulant effect of these drugs, [ 17] consequently it is quite understandable that the prevalence of dependency cases is high in the above-mentioned psychically very sensitive layer. [ 18] The same conclusion can be drawn from the excellent study conducted by the Narcotic Addiction Control Commission on the use of narcotic and psychotropic drugs in New York State (see table 2).

There are 335 000 regular amphetamine users in New York State, 225 000 of them take slimming pills containing amphetamines; the proportion of housewives in this latter group is of 36 per cent (81 000).

This female group of amphetamine abusers, characterized by the therapeutic origin of abuse, disappears in countries where the abuse of stimulants has reached epidemic proportions. The best examples of such cases are the situation in Japan in the 1950s, the stimulant abuse in Sweden and the abuse of phenmetrazine in Czechoslovakia in the early 1960s.

The relatively easy availability of phenmetrazine provoked an exaggerated consumption of this drug in Czechoslovakia. In 1964, 40 per cent of all drug abuse cases treated at the Psychiatric Clinic in Prague were phenmetrazine abusers. The highest incidence of abuse was noted in Prague and among physicians and nurses. [ 19] This phenmetrazine abuse in Czechoslovakia could be stopped by strict control measures, but as a consequence of this phenomenon, the number of stimulant abusers was still estimated in 1969 to be about 18 000. In a country where no other problem of drug abuse existed, this figure is high.

Abuse of hypnotics, sedatives and trafiquillizers

It is relatively easy for a national health service to find indications for the abuse of a drug having a limited field of therapeutic indication: an increase inthe consumption of morphine, pethidine amphetamine derivatives is always a warning sing, indicating an increase in the incidence of abuse cases. It is much more difficult to draw such a conclusion from global consumption data in the case of drugs which are needed in substantial quantity for the day to day therapy. Barbiturates provide the best example. According to British statistics for 1968, [ 20] hypnotics (mainly barbiturates) constituted 10 per cent of all prescriptions in that country; in the opinion of Brooke and Glatt [ 21] hypnotics accounted for 20 per cent of National Health Service prescriptions in 1964.

Sometimes it is not easy to make a clear distinction between hypnotics, sedatives and tranquillizers; in many cases hypnotic or sedative effects depend exclusively upon the dose of the same drug (for example: phenobarbital), and some of the minor tranquillizers can be used as sedatives (for example: meprobamate).

The high frequency of therapeutical barbiturate administration is motivated mainly by three factors: ( a) the living conditions of the twentieth century (longer life expectancy, urbanism, too frequent changes in the life of societies and individuals, etc.) justify the large scale administration of hypnotics and sedatives, ( b) barbiturate therapy has well-founded traditions (more than half a century of medical experience), ( c) in therapeutic doses barbiturates are safe drugs: compared with the frequency of their administration their side and adverse effects are relatively rare. [ 20]

There is no contradiction between this last statement and the fact that barbiturates are at the origin of the majority of intoxications with medicines. There is a number of incidental or voluntary overdoses (mainly attempted suicides) which have nothing to do with therapeutic doses and it would be a grave error to confound these cases with drug therapy or drug abuse. (Barbiturates poisoning cannot be compared with heroin-overdoses: the latter being always a sign of drug abuse.)

The amount of legitimate consumption is not the only difficulty in the study of barbiturate abuse and dependence: the drug abuser who takes barbiturates only is a rare case, for the overwhelming majority of barbiturate abusers are multiple drug abusers, and in the multiple drug abusers' repertoire barbiturates are practically always included.

There is a huge number of drug abusers who take barbiturates and amphetamines, in association or alternatively, and there are many alcoholics and heroinists among people dependent on barbiturates.

Dependence on barbiturates andheroin is perhaps one of the best known forms of multiple drug abuse.

The oldest forms of the association of heroin with a barbiturate are the "Chasing the Dragon" and "Playing the Mouth Organ" techniques in Hong Kong. More than 90 per cent of drug dependent people treated in Tai Lam Treatment Centre take heroin in conjunction with a barbiturate. Multiple dependence (on barbiturates andheroin) is consequently quite common in Hong Kong.

Treatment problems connected with the same double dependence directed attention to the study of barbiturate abuse in the National Institute of Mental Health Clinical Research Centre (formerly U.S. Public Health Service Hospital at Lexington). The difficult treatment of barbiturate dependence is frequently complicated by heroin dependence overshadowing the symptoms of dependence on a barbiturate. There were individuals who, due to the development of tolerance, did not show acute barbiturate intoxication symptoms even if their daily barbiturate intake exceeded doses of 2 gm. Somnolence might be the consequence of the taking of an opiate, and opiate and barbiturate withdrawal symptoms (e.g. insomnia or psychic troubles) can overlap each other. The parallel use of barbiturates and drugs of the opiate type was studied by Hamburger [ 22] in 1,000 consecutive hospital admissions (see table 5).

TABLE 5

Type of narcotic drug used by barbiturate users

 

Not using barbiturates

Using barbiturates

Total

Heroin
504 228 732
Codeine-camphorated opium tincture
63 33 96
Pethidine
29 12 41
Morphine
30 23 53
Dilaudid
25 17 42
Methadone
10 8 18
Pantopon
4 3 7
TOTAL
665 324
989 a

a 11 patients used such a great variety of drugs, it was impossible to determine the nature of their narcotic drug choice.

Among the 324 individuals dependent on an opiate and a barbiturate, 228 had shown clinical symptoms of physical dependence on barbiturates.

The contribution of the Lexington institute to the better understanding of barbiturate dependence has been substantial; Isbell's publications are landmarks of this research work. [ 23]

An interesting comparative study was published by Chambers [ 24] (also from Lexington); statistical data from 1957 were compared with data collected in 1966. The proportion of barbiturate dependent patients among heroin addicts treated in Lexington was 18 per cent in 1957 and 35 per cent in 1966. The incidence of sedative abuse cases increased from 39 per cent (in 1957) to 54 per cent (in 1966); the following table 6 [ 24] indicates significant changes in the drugs chosen for abuse.

The most interesting feature of this comparison is that the leading position of pentobarbital (in 1957) had been taken over by glutethimide; a non-barbiturate sedative.

An increase in the incidence of barbiturate abuse cases among narcotic addicts was observed in the United Kingdom too. Among 65 heroin dependent patients 62 were found by Mitcheson [ 25] in 1969 to be abusers of barbiturates. 80 per cent of these addicts had administered the barbiturates intravenously; this is not the "characteristic" form of barbiturate abuse, but the intravenous techniques appear from time to time as a fashion or epidemic on the barbiturate abuse scene. This ws the case in 1969 in England and this is reflected in the high proportion of "mainliners".

TABLE 6

Changes in the sedatives chosen for abuse in the USA from 1957 to 1966

Barbiturates-sedatives abused

1957 %

1966 %

Chloral hydrate
-
3.2
Glutethimide
-
38.7
Meprobamate
-
6.5
Phenobarbital
4.5 3.2
Pentobarbital
86.4
-
Secobarbital
9.1 29.0
Tuinal (amobarbital + secobarbital)
-
19.4

With the reproduction of Wikler's summary data [ 26] on doses and abstinence symptoms we return from multiple drug abuse to dependence on barbiturates (see table 7).

We have seen that, from our point of view (drug abuse and dependence), any distinction between hypnotics and sedatives is quite meaningless, and it would be illusory to consider barbiturates and non-barbiturates as members of two distinct drug categories. It would be much better to classify all these drugs according to their " pleasure giving potency ". The short-acting and medium-acting barbiturates (e.g. secobarbital, amobarbital) are much more popular among drug abusers than the long-acting phenobarbital; the explanation is quite simple: long-acting barbiturates do not usually produce euphoria. There are too few data published on this subject, and unfortunately the majority of the studies on barbiturate abuse or dependence do not make any distinction between euphoria-producing and other barbiturates.

In assessing the abuse of tranquillizersone is even more handicapped by the lack of meaningful abuse data. Data are available about production and consumption of tranquillizers, but such global figures do not facilitate an analysis of the abuse situation. When considering, however, the 12.7 million National Health Service prescriptions for benzodiazepines in 1968 in the United Kingdom; [ 3] the half million consumers of minor tranquillizers among the 13.7 million population of New York State; [ 5] the proportion of tranquillizer-taking students in California (19 per cent) [ 27] and in Canada 9 per cent [ 4] (except British Columbia where this proportion was of 27.3 per cent); Gardner's statement [ 28] that there were approximately 800 million daily dosage units of minor tranquillizers distributed in the United States in 1969, and the Le Dain Report's statement that Canadians and Americans spend well over $500 million annually for minor tranquillizers, one cannot help wondering whether consumption was proportional to therapeutic needs. Without knowing too many details, it seems justifiable to conclude that the consumption of tranquillizers is out of proportion to well-founded therapeutical needs and consequently that the extent of absue of tranquillizers must be substantial.

TABLE 7

Summary of data on relationship of dosage of secobarbital or pentobarbital to intensity of physical dependence

 

Patients

Number receiving

Number of patients having symptoms

Total Number

Secobarbital

Pentobarbital

Daily dose of barbiturate g

Days of intoxication in hospital

Convulsions

Delirium

Minor symptoms of significant degree

18 16 2
0.9-2.2
32-144
14 12 18
5 5   0.8
42-57
1 0 5
18 18   0.6
35-57
2 0 9
18 10 8 0.4 90 0 0 1
2 1 1 0.2 365 0 0 0

Interesting findings were made by Whitehead, Smart and Laforest during their study of 12,428 students in Halifax, Montreal and Toronto. [ 29] These authors presented a number of statistical data with the conclusion that there are three categories of tranquillizer-taking students: (1) those who take tranquillizers for therapeutical purposes (self medication included), (2) those who use tranquillizers as psychological support (the characteristic of this group is the use of legaldrugs in general), (3) those who belong to the "drug subculture", the users of both illegal and legal drugs, including tranquillizers. The number of tranquillizer-users who belong to the first category is negligible compared with the other two groups; this is one of the most important observations made by Whitehead and his co-authors.

There is a "natural" explanation for the large scale consumption of tranquillizers: living conditions and the rhythm of life in the twentieth century. A physician is ready to prescribe a tranquillizer for a town dweller without looking for signs of a latent mental illness, because the personality of the latter is troubled enough by his way of life. Due to their low grade toxicity and the apparent infrequency of side reactions, in the majority of countries many tranquillizers are easily available without medical prescription. In the case of some tranquillizers (for example meprobamate) there is a risk of the development of dependence, but in the light of the incidence of dependency cases it would be exaggerated to declare that tranquillizers are dangerous dependence-producing drugs. We face a controversial situation: there are relatively few people who have become dependent on tranauillizers but society has become dependent on them having, accepted and integrated mood-modification by chemical means. We are not very far from the chemical "conditioning" of society described by Huxley in his "Brave New World ".

We have to return to the fundamental question, which studies of the chemical, pharmacological or dependence-producing properties of drugs have not yet answered: what is the social function of a substance? If the correction or prevention of a pathological state were to be the social function of a drug, there is a certain doubt whether the social function of psychotropic drugs, in particular that of tranquillizers, would be in conformity with this definition.

1

H. J. Parry: "Use of psychotropic drugs by U.S. adults ", Public Health Reports 83, (10), 799-810 (1968).

2

M. B. Balter and J. Levine: "The nature and the extent of psychotropic drug usage in the United States ", Psychopharmacology Bulletin, 5, (4), 3-13 (1969).

3

Sir Denick Dunlop: "The use and abuse of psychotropic drugs ", Proc. Roy. Soc. Med. 63, 1279-82 (1970).

4

G. Le Dain et al: "Interim Report of the Commission of Inquiry into the Non-Medical Use of Drugs ", Queen's Printers for Canada, Ottawa, 1970.

5

C. D. Chambers: "Differential Drug Use Within the New York State Labor Force". New York, 1971, State of New York, Narcotic Addiction Control Commission.

6

B. R. Ditzion: "Illegal Use of Psychoactive Drugs", J.A.M.A. 216, (13). 2144 (1971)

7

International Herald Tribune, March 14, 1971.

8

Dorothy F. Berg: "Extent of Illicit Drug Use in the United States". Division of Drug Services, BNDD, US Dept. of Justice, Washington, 1969.

9

J. P. Sadusk: "Size and extent of the problem ", J.A.M.A., 196(8), 707-09, (1968).

10

Food and Drug Administration.

11

WHO Expert Committee on Drugs Liable to Produce Addiction, 6th Report, WHO Technical Report Series 102 (1956).

12

A. Goto: "Personal and social factors in connection with the etiology of amphetamine addiction", Folia Psychiat. Neurol. Jap., Suppl. 7, 376-377 (1963) cit. in: F. Lemerle: "Danger of amphetamine dependency ", Amer. J. Psychiat. 123, (5), 569-572 (1966).

13

91st Congress, 2nd session. "Amphetamines ", Fourth Report by the Select Committee on Crime, Washington, 1971.

14

P. H. Connell: "Amphetamine dependence ", Proc. Roy. Soc. Med. 61, 178-181 (1968).

15

Interdepartmental Committee on Drug Addiction.

16

S. Brandon and D. Smith: "Amphetamines in general practice ", J. Coll. Gen. Practit. 5, 603 (1962).

17

L. J. P. Duncan and J. F. Munro: "The present status of anorexiant drugs", The Practitioner 200, (1195), 167-173 (1968).

18

Fifty-two per cent of all drug dependency-cases treated in Swiss hospitals are housewives (see P. Kielholz: "Enquête suisse sur la fréquence des abus de médicaments ", Schweizerische Arztezeitung 49, (45), 1229-1248 (1968).

19

V. Vondráček et al.: "Recent patterns of addiction in Czechoslovakia ", British J. Psychiat. 114, (508), 285-292 (1968).

20

" Today's Drugs, Hypnotics ", British Med. J. 2, (5602), 409-411 (1968).

21

E. M. Brooke and M. M. Glatt, Med. Sci. Law 4, 277 (1964).

22

E. Hamburger: "Barbiturate use in narcotic addicts ", J.A.M.A., 189, 366-368 (1964).

23

H. Isbell: "Addiction to barbiturates and the barbiturate abstinence syndrome ", Annals of Internal Medicine 33, 108-121 (1950); H. Isbell et al: "Chronic barbiturate intoxication: an experimental study ", Archives of Neurology and Psychiatry 64, 1-28 (1950).

24

C. D. Chambers: "Barbiturate-sedative abuse: a study of prevalence among narcotic abusers ", Intern. J. Addict. 4, (1), 45-57 (1969).

25

M. Mitcheson et al: "Sedative abuse by heroin addicts ", Lancet 1970, 606-607.

26

A. Wikler: "Diagnosis and treatment of drug dependence of the barbiturate type ", Amer. J. Psychiat. 125, 6, 758-765 (1968).

27

R. H. Blum et aL: "Students and Drugs-Drugs II ". San Francisco, Jossey-Bass, 1969.

28

E. A. Gardner: "Psychoactive drug utilization ", Journal of Drug Issues, 1, (4), 295-300, (1971).

29

P. C. Whitehead, R. G. Smart and L. Laforest: "Les tranquillisants: drogues ou médicaments ", Toxicomanies 4, (3), 225-241 (1971).