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Title: P1247676906rPvRF


1
Adolescent Addiction Course, Module 2
Wednesday 26th January 2005 Harplands
HospitalEpidemiology of Substance Use
Historical and International Aspects
Martin Frisher Department of Medicines
Management Keele University
2
Topics
  • Drug use before it became illegal in the UK and
    the USA
  • Factors which lead to some forms of drug use
    becoming illegal
  • Major enquiries into Drug Use
  • International data on Alcohol Consumption
  • International data on Illicit Drugs
  • Drug Diffusion, HIV and AIDS
  • International Drugs Policy

3
Routes to altered consciousness
  • Music
  • Isolation
  • Sex
  • Sports
  • War
  • Hyperventilation

From Living with Drugs by Michael Gossop
4
Earliest Record of Drug Abuse
  • Genesis 920 And Noah began to be an husbandman,
    and he planted a vineyard
  • 921 And he drank of the wine, and was drunken
    and he was uncovered within his tent.
  • 929 And all the days of Noah were nine hundred
    and fifty years and he died.

5
European Drugs
  • Prior to the voyages of exploration, Europe had
    comparatively little choice in drugs.
  • There was no tea, coffee, tobacco little opium,
    cannabis, hallucinogens mainly alcohol
  • Today, alcohol is still the dominant drug

6
Doors of Perception. Aldous Huxley 1954
  • If the doors of perception were cleansed
    everything wouldappear to man as it is,
    infinite. William Blake
  • At breakfast that morning I had been struck by
    the lively dissonance of the flowers colours.
    But that was no longer the point.... I was seeing
    what Adam had seen on the morning of his
    creation-the miracle, moment by moment, of naked
    existence.

7
Trainspotting. Irvine Welsh, 1994
You don't have to worry about bills, about food,
about some football team that never wins, about
human relationships and all the things that don't
really matter when you've got a sincere and
truthful junk habit".
8
HISTORY
http//www.druglibrary.org/schaffer/History/HISTOR
Y.HTM
9
The Consumers Union Report on Licit and Illicit
Drugs, 1972
  • The United States of America during the
    nineteenth century could be described as a "dope
    fiend's paradise."
  • 1) Physicians dispensed opiates directly to
    patients, or wrote prescriptions for them.
  • (2) Drugstores sold opiates over the counter to
    customers without a prescription.
  • (3) Grocery and general stores as well as
    pharmacies stocked and sold opiates.
  • (4) For users unable or unwilling to patronize a
    nearby store, opiates could be ordered by mail.
  • (5) Finally, there were countless patent
    medicines on the market containing opium or
    morphine

10
Morphine and Opium
  • Morphine was legally manufactured from imported
    opium.
  • Opium poppies were also legally grown within the
    United States
  • The nineteenth-century distribution system
    reached into towns, villages, and hamlets as well
    as the large cities
  • The nineteenth-century use of opiates was similar
    in Britain.
  • A classic report on the English industrial
    system, The Factory System Illustrated (1842), by
    W. Dodd, noted that factory workers of the time
    used opiates--- notably laudanum--- to quiet
    crying babies.

11
British East India Company Opium
  • Opium and tea were the mainstays of the British
    East India Company, who had a monopoly on the
    opium produced in Bengal.
  • In 1772 Warren Hastings, then chief executive of
    the company, realised the potential for foreign
    revenue in exporting Indian opium to China.
  • Opium had been known in China for centuries, but
    imports had been banned in 1729 by decree of the
    Emperor.
  • Thomas De Quincey Confessions of an Opium Eater
    (1821)

12
Opium and Cannabis
  • In 1840 William Bingham Baring MP told the
    Commons that if the opium trade were suppressed
    then there would be a danger of users turning
    to drugs "infinitely more prejudicial to physical
    health and energy than opium".

13
Sigmund Freud and Cocaine
  • 1884 Sigmund Freud treats his depression with
    cocaine, and reports feeling "exhilaration and
    lasting euphoria, which is in no way differs from
    the normal euphoria of the healthy person. . .
    You perceive an increase in self-control and
    possess more vitality and capacity for work. . .
    . In other words, you are simply more normal, and
    it is soon hard to believe that you are under the
    influence of a drug."

14
Concerns about dependency
  • Although the dependency syndrome had been
    described two centuries earlier by Thomas
    Sydenham (1624-89), the risk was not taken
    seriously by most medical practitioners.
  • Following increasing reports of dependency
    symptoms after 1860, culminating in a series of
    articles in The Practitioner in 1870, the debate
    on the wisdom of permitting free access to opium
    accelerated.

15
Suppression of the Opium Trade
  • The Society for Suppression of the Opium Trade
    (SSOT), founded in 1874, became the best-known
    anti-opium organization
  • Controlled by Quaker businessmen and funded by
    one family

16
Drug Use in Victorian England
  • A few self consciously unconventional young
    artists and mystics searched for inner
    experience, rejecting vulgar materialism, but the
    majority of drug abusers, then as now, considered
    themselves to be taking medicines, to help them
    work or relax.

17
Opiates in Medicine
  • Physicians in the nineteenth century prescribed
    opiates for pain. They were also widely
    prescribed for coughs diarrhea, dysentery, and a
    host of other illnesses. Physicians often
    referred to opium or morphine as "G.O.M."---
    "God's own medicine."
  • Another nineteenth-century use of opiates was as
    a substitute for alcohol. As Dr. J. R. Black
    explained in a paper entitled "Advantages of
    Substituting the Morphia Habit for the Incurably
    Alcoholic," published in the Cincinnati
    Lancet-Clinic in 1889, morphine "is less inimical
    to healthy life than alcohol."

18
Drug Enquires
  • 1894, India, Indian Hemp Drugs Commission Report
  • This 3,281-page, seven-volume classic report on
    the marijuana problem in India by the British
    concluded
  • "Viewing the subject generally, it may be added
    that moderate use of these drugs is the rule, and
    that the excessive use is comparatively
    exceptional. The moderate use produces
    practically no ill effects."

19
Cannabis
  • One reason why cannabis was not as widely used as
    opium products, was the difficulty found refining
    an "active ingredient."
  • In 1889, Dr E.A.Birch described in the Lancet the
    successful use of cannabis in the treatment of
    opium withdrawal, drawing attention to the
    abolition of craving and the antiemetic (vomit
    suppressing) effects.
  • Around this time conflicting views on cannabis
  • http//www.idmu.co.uk/indian.htm

20
1926, England, Departmental Committee on
Morphine and Heroin Addiction
  • (The Rolleston Report) This study by a
    distinguished group of British doctors appointed
    by the government codified existing practices
    regarding the maintenance of addicts on heroin
    and morphine and recommended that they continue
    without police or medical society interference.

21
1929 US, Panama Canal Zone Military
Investigations (US Military, 1916-29)
  • After an exhaustive study of the smoking of
    marijuana among American soldiers stationed in
    the zone, the panel of civilian and military
    experts recommended that "no steps be taken by
    the Canal Zone authorities to prevent the sale or
    use of Marihuana."
  • The committee also concluded that "there is no
    evidence that Marihuana is a 'habit-forming'
    drug."

22
1930, US, Report on the Enforcement of the
Prohibition Laws of the United States
  • This report is important because it was the
    official Federal Government investigation into
    alcohol Prohibition - while Prohibition was still
    in effect. This report is interesting because the
    Conclusions are in such apparent contrast to the
    evidence amassed by the Commission.
  • The evidence showed that Prohibition enforcement
    was, at best, ineffective and, at worst, spawned
    law enforcement corruption on a grand scale.
    Prohibition was not a success and this report
    explains the reasons why.

23
1944, US, The LaGuardia Committee Report
Mayor's Committee on Marihuana
  • This study is viewed by many experts as the best
    study of any drug viewed in its social, medical,
    and legal context.
  • The committee covered thousands of years of the
    history of marijuana and also made a detailed
    examination of conditions In New York City. Among
    its conclusions "The practice of smoking
    marihuana does not lead to addiction in the
    medical sense of the word."
  • "The use of marihuana does not lead to morphine
    or heroin or cocaine addiction
  • "The publicity concerning the catastrophic
    effects of marihuana smoking in New York City is
    unfounded."

24
UK Drug Addicts 1951-1966
25
1961, England, Interdepartmental Committee,
Drug Addiction, (The First Brain Report)
  • When the Brain Committee first met at the
    invitation of the minister of health, its mission
    was to review the advice given by the Rolleston
    Committee in 1926.
  • That advice had been to continue to allow doctors
    to treat addicts with maintenance doses of
    powerful drugs when the doctors deemed it
    medically helpful for the patient.
  • Brain I reiterated that advice and in this first
    report recommended no changes of any significance
    on the prescribing powers of doctors. This report
    expanded on one important point alluded to in
    Rolleston-the authenticity of the existence of
    "stabilized addicts."

26
1961, US, Drug Addiction Crime or Disease?
Joint Committee of the American Bar Association
and the American Medical Association
  • This report was the result of a combined study of
    drug policy made by two of the most important
    professional societies in the country.
  • The committee presented a direct challenge to the
    tough policies of Federal Bureau of Narcotics
    Director Harry Anslinger, a philosophical
    ancestor of the "drug czar," William Bennett.
  • "Drug addiction is primarily a problem for the
    physician rather than the policeman, and it
    should not be necessary for anyone to violate the
    criminal law solely because he is addicted to
    drugs."

27
1965, England, Interdepartmental Committee,
Drug Addiction, Second Report, (The Second Brain
Report)
  • Brain II has been consistently misinterpreted by
    leading American scholars and officials. It did
    not recommend the dismantling of the British
    prescription system nor the compulsory
    registration of addicts, as has been claimed.
    Instead, Brain II urged that
  • doctors who wished to prescribe "restricted
    drugs" to addicts for the purpose of maintenance
    be required to obtain a special license from the
    Home Office
  • treatment centers be established for treating
    addicts who were to be regarded as sick and not
    criminal

28
1968, England, Advisory Committee on Drug
Dependence, Cannabis, (The Wootton Report)
  • This study report on marijuana and hashish was
    prepared by a group that included some of the
    leading drug abuse experts of the United Kingdom.
    There is no evidence that in Western society
    serious physical dangers are directly associated
    with the smoking of cannabis.
  • It can clearly be argued that cannabis use does
    not lead to heroin addiction.
  • The evidence of a link with violent crime is far
    stronger with alcohol than with the smoking of
    cannabis.
  • There is no evidence that this activity ... is
    producing in otherwise normal people conditions
    of dependence or psychosis, requiring medical
    treatment.

29
1970, US The Forbidden Fruit and the Tree of
Knowledge An Inquiry into the Legal History of
American Marihuana Prohibition Virginia Law
Review, Volume 56, October 1970 Number 6
  • This is the most definitive history of the
    marijuana laws. The authors concluded that the
    marijuana laws were motivated by three major
    factors.
  • The first state marijuana prohibition law came in
    Utah in 1915 and was enacted into law along with
    a number of other Mormon religious prohibitions.
  • The early state marijuana laws in the Southwest
    and West were passed because "All Mexicans are
    crazy and marijuana is what makes them crazy."
  • The other early state marijuana laws were passed
    out of the fear that opiate addicts, who had been
    deprived of legal access to opiates by the
    Harrison Tax Act of 1914, would turn to
    marijuana.

30
1972, US The Consumers Union Report on Licit
and Illicit Drugs
  • The recommendations in this report included
  • Stop emphasizing measures designed to keep drugs
    away from people.
  • Stop publicizing the horrors of the "drug
    menace."
  • Stop increasing the damage done by drugs.
  • Stop misclassifying drugs.
  • Stop viewing the drug problem as primarily a
    national problem, to be solved on a national
    scale.
  • Stop pursuing the goal of stamping out illicit
    drug use.

31
1989 UK AIDS and Drug Misuse, Part 1, Advisory
Council on the Misuse of Drugs
  • "The spread of HIV is a greater danger to
    individual and public health than drug misuse,"
  • In contrast to the Bush administration's war
    plans - a comprehensive health plan that seeks to
    prevent the use of drugs
  • Advisory Council accepted the lessons of the
    "harm reduction" programs of Liverpool area
    recommended that they be spread to the entire
    United Kingdom (e.g. needle exchanges and
    prescribed drugs for addicts).
  • "We believe that there is a place for an
    expansion of residential facilities where drug
    misusers may gain better health, skills, and
    self-confidence whilst in receipt of prescribed
    drugs."

32
ALCOHOL
  • International Data

33
World Alcohol Consumption
34
Cirrhosis in England and the EU
35
Diseases associated with alcohol
36
European School Survey Project on Alcohol and
Other Drugs (ESPAD)proportion of students drunk
2 times in last month 1995-1999
1999
1995
The 1999 ESPAD report Alcohol and other drug
use among students in 30 European countries, B.
Hibbell, B. Andersson, S. Ahlström, O.
Balakireva, T. Bjarnson, A. Kokkevi, M. Morgan,
the Swedish Council for Information on Alcohol
and Other Drugs (CAN), the Pompidou Group of the
Council of Europe, December 2000.
37
Leading risk factors for disease (WHR 2002) in
emerging and established economies ( total DALYS)
38
Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
39
Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
40
Illicit Drugs
  • International Data

41
Worldwide tobacco and illicit drug consumption
42
Global Drug Use
43
What is the current level of drug use in the
world?
  • The total number of drug users in the world is
    now estimated at some 185 million people,
    equivalent to 3 of the global population, or
    4.7 of the population aged 15 to 64.
  • Cannabis is the most widely used substance (close
    to 150 million people), followed by the ATS
    (about 30 million people for the amphetamines,
    primarily methamphetamine and amphetamine, and 8
    million for ecstasy).
  • Slightly more than 13 million people use cocaine,
    and 15 million use opiates (heroin, morphine,
    opium, synthetic opiates), including some 9
    million who take heroin.

44
Worldwide Drug use and Consequences
45
Changes in Drug Use
46
Drug Abuse Trends
47
10 year trends in global drug use as measured by
drug seizures
48
10 Year Changes in Heroin Abuse
49
Cocaine Use in Europe. 1991-2003
50
Summary of data on extent and trends of the drug
problem
  • less than 5 of the youth adult population use
    drugs (about ½ use heroin or cocaine, the two
    mainproblem drugs)
  • close to 30 smoke tobacco
  • global cocaine production fell by 30 between
    1999 and 2003, and by 18 between 2002 and 2003
  • mainly due to strengthened control efforts in
    Colombia
  • US student surveys show decline in cocaine use of
  • 23 between 1999 and 2003 and more than 60
    between 1985 and 2003 however, increases in
    South America and Europe

51
EU Cannabis and Cocaine Use, 1990-2002
COCAINE
CANNABIS
52
EU Drug Related Deaths and Drug Offences
53
Drug Diffusion, HIV and AIDS
54
More countries and territories in which drug
injecting is reported

55
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56
Global Areas of Drug User-Transmitted HIV
  • Europe
  • North America (U.S., Canada)
  • South America
  • Southeast Asia (Golden Triangle - Thailand,
  • Myanmar, Vietnam, NE India)
  • China (originally Yunnan, now most provinces,
  • highest in Xinjiang)

57
HIV rate among spouses of HIV positive IDUs -
Manipur, India
  • Year Rate Confidence Interval
  • 19901991 5.9 (1.2 10.8)
  • 19951996 44.7 (36.9 52.7)

58
IDUs and HIV - different epidemic scenarios
  • 1 - Uncontrolled epidemics
  • high prevalence and incidence
  • 2 - Prevented epidemics
  • low prevalence and incidence - UK, Australia
  • 3 -Initially prevented
  • Vancouver, Canada
  • 4 - Curtailed epidemics
  • high prevalence and incidence followed by
    declining prevalence and incidence - New York
    (USA), Amsterdam (Holland)
  • 5 - Reversed epidemics
  • high prevalence and incidence followed by low
    prevalence and incidence - Edinburgh (UK)

59
HIV/AIDS among IDU in the UK - a prevented
epidemic
  • Prevalence of HIV among IDUs in the UK is stable
    and low
  • IDU/HIV prevalence in England is 1 - no HIV in
    injectors under 25, or injecting less than 5
    years
  • estimated to be about 130 new IDU/HIV cases each
    year
  • cumulative number of IDU/ HIV cases about 3000
  • cumulative IDU/AIDS cases 1000
  • low prevalence is attributed to swift
    introduction of harm reduction interventions

The Centre for Research on Drugs and Health
Behaviour
60
HIV prevalence among IDUs in England Wales,
1990-1997

Year
61
(UK)
62
Proportion of all new HIV infections that are in
IDU, selected countries, 1998-1999
100
90
80
70
60
Percentage
50
40
30
20
10
0
Canada
China
Latvia
Malaysia
Moldova
Russian
Ukraine
Viet Nam
Federation
Source National AIDS Programmes
63
Rapid HIV spread among IDUsPrevalence quickly
rising to 40 or more
80
Myanmar
60
HIV prevalence ()
Manipur Yunnan
Edinburgh
40
Ho Chi Minh City
Bangkok
20
Odessa
64
Influences on HIV risk behaviours
  • individual level
  • individual choices knowledge, attitudes,
    behaviour
  • community level
  • community norms, injecting contexts
  • structural level
  • social, political and economic contexts laws,
    resources, public attitudes etc

65
Structural factors associated with the spread of
IDU and HIV in the NIS
  • trade, population mixing and migration
  • modes of drug production and distribution
  • economic transition and declines in health
  • increasing unemployment and impoverishment
  • growth in informal economies - drugs and sex
  • low public health revenue and infrastructure
  • political, ideological and cultural shifts
  • weakening state controls

66
DRUGS POLICY
67
Epidemiology in the 19 and 20th Centuries
  • Epidemiology has successfully participated in the
    worlds battle against infectious diseases.
  • Various microorganisms were identified and
    causally linked to devastating infectious
    diseases such as malaria, cholera, and smallpox.
  • Vaccines, medications, and environmental
    interventions were formulated to combat the
    diseases. In addition, technological improvements
    in sewage and waste disposal helped contain
    diseases.
  • Its successes have given it stature to continue
    to lead interventions for the prevention of
    disease

68
Drug Abuse Epidemiology
  • 1. In the community at large, how many people are
    affected by drug dependence?
  • 2. Where are the affected people more likely to
    be found?
  • 3. Why do some people in the community become
    drug dependent while others do not?
  • 4. What linkages of states and processes
    influence who becomes and who remains drug
    dependent?
  • 5. What can be done to prevent and intervene in
    drug dependence?

Galanter M, Kleber HD, editors Textbook of
Substance Abuse Treatment, Third Edition
69
Price of heroin 1990-2003
70
Increased availability of drugs in the UK
1978-2000
The road to ruin? Sequences of initiation into
drug use and offending by young people in
Britain. Stephen Pudney Home Office Research
Study 253. December 2002
71
International control
72
Illicit drug use and employment
73
Illicit drug use and income generation
74
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75
New synthetic drugs
  • Continuing its task of controlling new synthetic
    drugs, the Council of Ministers, in November
    2003, adopted a decision regarding control
    measures and criminal sanctions in respect of the
    new synthetic drugs 2C-I, 2C-T-2, 2C-T-7 and
    TMA-2.
  • These substances, which are not listed in any of
    the schedules to the 1971 United Nations
    Convention on Psychotropic Substances, are now to
    be subject to control measures and criminal
    penalties in the Member States.

76
UK drugs policy 2002 update
  • A tougher focus on Class A drugs.
  • A stronger focus on education, prevention,
    enforcement and treatment to prevent and tackle
    problematic drug use.
  • More resources. Planned direct annual expenditure
    for tackling drugs will rise from 1026 million
    in this financial year
  • a new education campaign for young people based
    on credible information about the harm which
    drugs cause
  • A major expansion of services within the criminal
    justice system - doubled the number of Drug
    Treatment and Testing Orders
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