Drug Addiction

DRUG ADDICTION (from the Greek narkao to benumb, stupefy, and mania madness, derangement), a morbid, irresistible craving for one or more narcotic substances used by man (per os, subcutaneously, through mucous membranes, etc.) for the purpose of excitation, sedation, and achieving at least a more or less short-lived pleasant sense of well-being (euphoria), intoxication, stupefaction, or sleep. In this primary sense, drug addiction denotes a serious mental illness usually associated with such poisons as alcohol, hashish, opium, morphine, cocaine, and the like (the term "toxicomania" proposed by some authors is less apt, since habituation and craving do not develop for nearly all poisons). Alongside this, one must distinguish narcotism in the broad sense of the word, encompassing a significant portion of mankind, which in the majority of cases does not progress to a pathological craving and demands not so much individual medical intervention as broad social and preventive measures. In this understanding, narcotism embraces the use of such substances as tobacco, tea, kava-kava, betel, and others, since they are usually taken not for nourishment, gustatory stimulation, or treatment, but to achieve a narcotic effect. All these substances have much in common in their etiology and the mechanisms of craving and habituation, although they differ in their principal active agent, method of use, and degree of harmfulness. Some of them, such as opium, morphine, and alcohol, lay the groundwork for clearly morbid abuse with ever-increasing doses of the poison, exerting a destructive effect on the organism—that is, drug addiction in the proper sense of the word; the use of others remains almost always within moderate, relatively harmless limits (tea, betel, etc.). History of dissemination. Man's first acquaintance with narcotic substances is apparently explained by accidental causes: the inhalation of carbon monoxide in a cave during the burning of plant matter was probably the first source of stupefaction for prehistoric man. Further, the particularly strong stupefying effect of smoke from the burning of certain plants of a specific species (hemp and others) was noticed. It is no accident that the most ancient methods of narcotization are based on the inhalation of smoke, on smoking. Herodotus, in an account of the life of the Scythian tribe of Massagetae (Central Asia), says that they "sat around a tree, threw certain fruits into a burning bonfire, and became intoxicated by the smoke from these fruits, as the Hellenes are intoxicated by wine." Another way of becoming acquainted with narcotics must have been the accidental chewing or ingestion of plant substances containing stupefying alkaloids, followed by the fixation of this fact in the memory and daily life of the tribe. People could become acquainted with alcohol-containing beverages by accidentally consuming the fermentation products of various saccharine substances (the first alcoholic drink was apparently wine, which is mentioned in the earliest written records; however, a number of varieties of not only wine but also beer were already known to the ancient Egyptians). Among the most widespread narcotics, special attention is deserved (excluding alcohol and tobacco) by morphine, opium, hashish, cocaine, and heroin; ether, veronal, codeine, and a number of others are also of importance. In the process of their historical dissemination, we observe both the displacement of one narcotic by another and the simultaneous coexistence of various narcotics (e.g., the smoking of opium and hashish in the East). Hashish, used by 150–200 million people (Lewin) and known in the East under various names (kif, bang, kenaf, anasha), is mentioned as early as ancient Greek, Chinese, and Hindu books (Herodotus, Shu-King, Yajurveda) dating back to 400–500 BC. Originating in Central Asia, hashish spread together with the Muslim conquerors and at present is widespread in Central and Western Asia (Turkey, India, Afghanistan, the Central Asian republics of the USSR, Persia) and in North Africa (Egypt). Hashish is smoked in water pipes (qalyan, nargileh), often together with tobacco, opium, or chewed with betel leaves, etc. (see Hashish). Mention of opium, which is the dried juice of incised poppy heads (Papaver somniferum), is found as early as the Iliad, later in Diagoras of Melos (380 BC) and other writers of antiquity (Theophrastus, Dioscorides, Celsus), judging by whom opium was obtained at that time in Greece and Asia Minor; it is believed that it was subsequently carried by the Arabs further east. Opium penetrated into India during the period of its conquest by the Muslims. The rulers of India, the Mughals, in their time made the cultivation and trade of opium a state monopoly, which was later appropriated by the British East India Company. The Chinese obtained opium from India initially as a medical remedy, but from the mid-17th century predominantly as a narcotic. It achieved particularly wide distribution at the end of the 17th century in connection with the ban on tobacco smoking. In 1729, opium smoking in China was strictly prohibited. However, the growth of smuggling, especially from India, nullified the efforts of the Chinese government and led to a series of so-called "opium wars" (with England and others), which dragged on intermittently from 1839 to 1860, whereby under the peace treaty the defeated China was forced to permit the import of opium in unlimited quantities. Since then, China's attempts to achieve the abolition of opium imports into its territory under conditions of unequal treaties, concessions, and interventions remained unsuccessful despite certain internal measures directed against the cultivation and use of opium (the ban in 1917). With the division of China into spheres of influence of individual generals and governments, the situation regarding opium smoking naturally worsened even further. The policy of the European powers in purely colonial countries is even more overt; thus, in the Dutch colonies (Java, Sumatra, etc.), alongside public houses, opium dens operate legally, rented by private entrepreneurs from representatives of the Dutch government (in the single city of Batavia in 1928, there were no fewer than 20 concessionary opium dens). Europe became acquainted with opium in the Middle Ages, but here its use proceeded primarily along medical lines, and opium was used in the form of drops or for smoking, etc., by relatively numerous drug addicts, whereas in the Asian colonial and semicolonial countries it achieved enormous distribution, acquiring the character of a national disaster that engulfed tens of millions of people in China alone. The scale of world opium production was determined (for 1922) by the League of Nations Consultative Commission to be over 3½ thousand tons (on average, 1 hectare yields 6 kg of opium, or 1,200–1,500 kg of mature poppy heads with seeds). Among the derivatives of opium in Europe and the USA, morphine (see) became widespread, especially in the last quarter of the 19th century. The Franco-Prussian War, where doctors first widely used morphine injections, left as a legacy, among other things, quite a few morphinists among former military personnel. Subsequently, morphine spread predominantly among medical personnel and persons of other professions whose activities require great nervous tension and at times special exaltation (artists, musicians, painters, writers, etc.). Morphine (as well as a number of other narcotics) became very widespread among the criminal underworld, prostitutes, etc. However, first place among morphinists still belonged to medical personnel, not by virtue of the specific conditions of their work, but by virtue of the comparative ease of obtaining the narcotic. If the Franco-Prussian War gave rise to an increase in morphinism, the imperialist war sharply increased all types of narcotism, and the specific weight of medical workers among drug addicts fell sharply. Thus, according to data from a special institution for drug addicts (Friedrichsberg), among the patients treated there, physicians accounted for up to 36% of all admissions during the 42 years up to 1918; during the 8 years after the World War (1919–26), however, the percentage of doctors fell to 15. Yet even now, morphinism as a socio-pathological phenomenon is most widespread among medical workers. According to Bonhoeffer's data, the absolute number of morphinists admitted to corresponding institutions in Berlin was 104 people in 1913–18, and 375 people in 1918–24 (see Morphine, Morphinism). In recent years, heroinism has sharply advanced among other drug addictions, having arisen and achieved special distribution in the USA, and recently in China as well. In 1919, in New York City alone, 2,178 heroinists were registered. It is interesting to compare this figure with data for the same year concerning other types of drug addiction: among registered drug addicts, the following were used: heroin only—2,178; morphine only—690; cocaine and morphine—42; cocaine and heroin—305; morphine and heroin—41; for a total of 3,256. Thus, heroin takes first place, far outstripping not only cocaine, but morphine as well. The last of the major European-American drug addictions is cocainism (see). There are many other secondary narcotic substances, many of which also serve the purposes of drug addiction, especially in the USA, which has recently earned the title of the classical country of capitalism, social contradictions, nervousness, and drug addiction. These include veronal, chloral hydrate, ether, and others, which nevertheless play a significantly lesser role than the most widespread narcotics mentioned above.

Among the widely distributed and comparatively harmless stimulants, aside from the well-known tea and coffee, one may also mention mate—the leaves of a plant cultivated in Argentina, Paraguay, and southern Brazil (Ilex paraguayensis, amara, etc.). The infusion of these leaves is consumed throughout South America in the manner of tea; their effect is based on a content of 0.5% to 2.5% caffeine. Among other plant substances containing caffeine, one should mention the seeds of the cola tree (Cola), which grows in tropical Africa. In South Asia, there is a favorite local means for chewing—betel leaves (see), which in their effect resemble cola seeds. At the present time, there is not a single people or tribe that is completely free from narcotism (the consumption of narcotizing substances). Even the inhabitants of remote taiga regions and tundras prepare an infusion from certain poisonous mushrooms (e.g., fly agarics), by means of which they bring themselves into a state of intoxication and frenzy followed by subsequent depression (hangover). Such a wide distribution of narcotism and the variety of narcotics, from which not a single nationality is free, and especially the wide spread of drug addiction among advanced capitalist countries, makes it necessary to raise the question of the causes of this phenomenon. The principal causes must be considered to be social inequality and the exploitation of oppressed classes, leading them to physical and psychological exhaustion. Excessive labor with an imordinately long working day, the unhealthiness of workers' quarters, housing congestion and the lack of elementary sanitary and hygienic conditions, the lack of sensible entertainment, and above all the hopelessness of existence, the lack of purpose toward the class struggle in years of reaction, etc.—these are the main causes of narcotism; to this is added uncertainty about the morrow and the nervousness caused thereby. Thus, a whole series of causes acting upon the individual "synergistically" in one direction lead to narcotism, and in many cases to drug addiction. In this complex of causes, special account must be taken of the need for doping, i.e., for a means that makes one forget the feeling of fatigue, which creates in a person the impression of a surge of strength. Narcotism enters into daily life, firmly fuses with living conditions, and is frequently an invariable companion of religious festivities, rites, and customs. Thus, narcotism becomes one of the environmental factors that influences many individuals through the order of fellowship and imitation. To all this must be added that the ruling classes (including the priesthood and the clergy developing from it), for the purpose of stupefying the oppressed classes and obtaining additional income from them, very actively promoted the establishment and spread of narcotism and drug addiction (tax farming, monopolies, treating the proletariat in Rome, treating vassals by their suzerain, workers by their contractor, etc.). All this contributed not only to the spread of narcotism and drug addiction, but also played a considerable retarding role in the deployment of the class struggle on the part of the oppressed classes, introducing into their ranks fragmentation, disorganization, a peculiar corruption, decay, and masked or open strikebreaking. This policy is carried out particularly nakedly and unceremoniously in the colonies, where the native population was and is most frankly plied with liquor (furthermore, tobacco infusion is added to vodka or whiskey, for example), habituated to opium or cocaine, or to some other narcotic, which not only facilitates the exploiters' main task—breaking the resistance of the natives—but leads to the actual extinction of many tribes and nationalities, whose land territories and holdings pass to the "victor" colonizers. Such was the policy of the tsarist government in Siberia and the Far East, such is the policy of the English bourgeoisie in Asia (China, Burma) and Africa (Cape Colony), such is the policy of the French bourgeoisie in northern Africa, the Dutch bourgeoisie in its colonies in southeast Asia (Java, Sumatra), and a number of other imperialist powers of the second rank. Such are the main exogenous factors of mass narcotism, and against their background, such moments as the increased development of drug addiction among certain social groups, already mentioned above, appear already secondary. Likewise, one can consider as comparatively secondary the certain spread of narcotism and drug addiction on the basis of chronic pain, which arises from the desire to obtain relief from suffering (chronic sciatica, radiculitis, etc.). In this case, no small role is played by the careless (and in some cases, especially where private practice is significantly widespread, unconscientious) use of narcotics by medical personnel. Additional factors of narcotism in the West are the lack of a healthy, vigorous ideology and purposefulness, the thirst for thrills, unhealthy yellow literature and motion pictures, numerous cafes, cabarets, dance halls (dancing establishments), open and hidden prostitution. Against the background of all the enumerated social factors of narcotism, constitutional factors are comparatively secondary, forming a predisposition already to severe drug abuse, to drug addiction in the proper sense. The fact of some increase in the number of psychopaths among severe drug addicts can be considered established, though the role of this factor in the origin of narcotism in the broad sense of the word is comparatively small. The psychopathic nature of many drug addicts is also attested by data of hereditary burdening. Thus, out of 36 cases by Meggendorfer, suicides among relatives were noted in 13. Among the 400 cocaine-offenders studied by Rapoport, the number of persons with hereditary burdening turned out to be significantly greater than in the general mass of Moscow criminals of the same period (84.3 versus 67%). One thing is certain: the wider a given form of drug addiction is distributed in a given place and time, the smaller the percentage of psychopathic individuals among its adherents, and the more purely everyday drug addicts there are among them. On the other hand, the psychopathic nature of the individual predisposes them to a more rapid and profound illness with drug addiction. Classification of narcotics and their effect on the organism. According to their composition, the most important narcotics are divided into two main groups: chemical substances of the so-called fatty series (alcohol, ether, sulfonal, veronal, chloral hydrate, etc.) and plant-based ones, the effect of which is based on the presence of special substances, plant bases—alkaloids (in coca leaves—the alkaloid cocaine; in opium—morphine, narcotine, codeine, etc.; in Indian hemp—cannabinone; in tobacco—nicotine). According to their principal effect, all stimulating narcotizing substances (in the broad sense of the word) can be divided into the following groups (according to Thorn's classification). First, pain-relieving agents (anody-na, analgetica). They act on the central nervous system, suppressing pain sensitivity even in small doses with comparatively preserved consciousness. These include opium and its derivatives, such as pantopon, laudanon, etc., as well as pure opium alkaloids such as morphine, codeine, narcotine; Indian hemp (hashish) with the alkaloid cannabinone, belladonna and thornapple with the alkaloids hyoscyamine and scopolamine extracted from them. The next group is formed by anesthetic substances, which cause a temporary loss of sensitivity by inhibiting sensory nerves. Anesthetic substances in turn are divided into: a) inhalable (laughing gas, chloroform, ether), which lower the excitability of the central nervous system and cause general clouding of consciousness as well as loss of sensitivity, and b) local anesthetics, the effect of which is manifested only on a limited local area, with consciousness being preserved. Such an effect is produced by the rapid evaporation of highly volatile liquids such as acetone, chloroform, ether, menthol. As a result of cooling, vasoconstriction and inhibition of the sensory nerves of the skin occur here. However, the most important representatives of local anesthetics are cocaine and the artificially prepared substitutes eucaine, novocain, etc. These substances are used in surgical operations. A separate group should be made of sedatives (sedativa) and hypnotics (hypnotica). As sedatives, various bromine preparations are usually used (potassium bromide, sodium bromide, bromural, etc.), while among hypnotics, the most important are chloral hydrate, amylene hydrate, paraldehyde, sulfonal, trional, veronal, and other barbituric acid preparations. Comparatively harmless stimulants should be considered coffee, tea, mate (with the alkaloids caffeine, theobromine, etc.) and finally significantly more harmful and universally distributed—tobacco and alcohol, regarding which, especially alcohol, one should speak not only of a stimulating, but also of a depressing and narcotizing effect. To the enumerated substances can be added many more, partly found by man in the surrounding nature, partly artificially prepared: niopo, peyote (the alkaloid mescaline), cola, kava-kava, etc. If we consider all these substances depending no longer on their effect, but on their g e o g r a p h i c a l distribution, we can distinguish the following groups: 1.

Substances of local significance, used only in the region where they were first discovered, and having barely crossed its borders. This includes a number of so-called native stimulants, such as pituri in Australia, cacti (peyote) in Mexico, niopo in South America. 2. Substances of wider distribution, the use of which, however, is associated with certain geographical, ethnographic, or religious groups of the population and has remained within the boundaries of the historical distribution of these groups: such are kola among the western Negroes, hashish in countries occupied by Mohammedan peoples, and coca in Peru (however, the alkaloid of this plant—cocaine—has gained significant distribution in America and Europe over the past few decades, causing severe drug addiction—cocainism). 3. Substances having mass distribution and many centers of this distribution; these include opium among the Chinese, Indians, Malays, as well as among many drug addicts in Europe and America; betel among the Indians, Malays, and others; kava-kava in the Malay Archipelago, among the Melanesians, and others. 4. Substances that have spread from one or several (few) points to almost the entire globe—tobacco, coffee, tea. 5. Substances used all over the earth and in various epochs—alcoholic beverages. Various types of them differ in degrees of distribution, but wine, beer, and vodka usually displace other alcoholic beverages. According to the method of primary application, all stimulating narcotic substances can be divided into smoking (tobacco, opium, hashish), snuffing, drawn through the nose (niopo, cocaine), directly eaten (peyote), used for chewing, usually mixed with other substances (coca leaves, betel), in the form of infusion (coffee, tea, maté), in the form of hot drinks (alcohol). Among narcotic substances, the most important in view of their wide distribution are hashish, opium and its derivatives (morphine, heroin, etc.), cocaine, tobacco, and alcohol. The use of morphine in its pure form or its artificial derivatives (heroin), as well as opium preparations (pantopon, laudanum, eukodal, etc.), is no longer a mass spontaneous evil, like the use of opium or alcohol, but a narrower disease affecting not the popular masses, but individual groups of the population. In all substances of the alcohol group, the suppression of the functions of the cerebrum (consciousness, pain sensitivity), spinal cord (reflexes, muscle tension), and finally the medulla oblongata (regulation of respiration, blood circulation) proceeds sequentially, whereas in substances of the morphine group, the action on the spinal cord and medulla oblongata occurs almost simultaneously. The difference in the action of morphine (opium) on the central nervous system from alcohol, ether, etc., also consists in the fact that the general analgesic effect of morphine manifests itself before the impairment of consciousness, and that morphine, while narcotizing the cerebrum, at the same time increases the reflex excitability of the spinal cord and enhances reflexes. In the action of most narcotics, two main phases can be traced: initially, a stage of excitation, when the activity of the nervous system increases above the normal level; mood is elevated at the same time, the perception of external impressions is facilitated, criticism and volitional inhibitions are weakened; unpleasant sensations are mitigated or disappear, etc. In some cases, it comes to ecstatic states, sharp motor excitation, deceptions of the senses (illusions, hallucinations). The second stage—depression—is characterized, on the contrary, by a drop in mood, fears, inhibition; lethargy, relaxation seize the organism, deceptions of the senses have a gloomy, threatening character; finally, especially with large doses, sleep sets in. Under the prolonged action of a heavy narcotic, e.g., opium (morphine), the following phenomena develop in the drug addict: disorder of appetite, sleep, gastrointestinal activity (diarrhea, constipation); the skin becomes dry, pale, nails lose their luster, hair falls out; frequent heart palpitations, sweating; movements uncertain, trembling; significant emaciation, physical weakness, and decrepitude. Along with this, serious mental changes occur: the person becomes lethargic, passive, spineless, suggestible; breaks away from the surrounding real world, becomes withdrawn, retreats into his artificial world. All external interests are limited to the desire to get his drug, of which more and more is usually required due to habituation. Lying, oblivion of any sense of duty. Such are the typical traits of the opium smoker (as well as other serious drug addicts). Upon an attempt to abandon the drug, severe withdrawal phenomena develop, the so-called "abstinence", which are expressed especially sharply in morphinism. These abstinence phenomena greatly complicate the cessation (treatment) of drug addiction. Such are the grave results of chronic opium smoking (morphinism) and many other drug addictions leading the organism to exhaustion and premature death. We have a similar picture with the use of various preparations of opium (pantopon) and morphine (heroin, dionin, etc.). In cocainism and hashishism, fears, delusional ideas, hallucinations, and true psychoses often develop. Unfortunately, the negative side of narcotic addiction is recognized by its victims too late, with pathological habituation, and at first the drug addict finds only a positive effect in his poison; thus, with opium, he experiences the loss of all physical unpleasant sensations, an elevated mood, daydreams, calming, and after several hours of smoking—sleep. The action of heroin is almost no different from that of morphine, except for a more elevated well-being, activity, and self-confidence during intoxication with it. Heroin is an even more dangerous poison than morphine in the sense that pathological habituation forms faster, and the withdrawal period, abstinence, is accompanied by almost equally severe phenomena, as well as often serious seizures. Personality changes in chronic heroinism and morphinism completely coincide. It is curious that when the question of the withdrawal of heroin from medical practice and the prohibition of its manufacture was raised at the 2nd Geneva Opium Conference (1925), German, English, and French doctors energetically protested, citing the extreme importance of this remedy: meanwhile, in its main application against cough, it can be easily replaced by a relatively harmless and similarly acting codeine. Veronalism (see Veronal) is a very severe form of drug addiction, because stubborn insomnia prevents withdrawal, sometimes driving the patient to suicide. In severe veronal poisoning, anxiety, confusion of consciousness, amenzia and manic states, loss of corneal and abdominal reflexes, sleep, and coma are observed. In chronic poisoning with small doses of veronal (also luminal), states resembling progressive paralysis are produced; disorders of the pupils and eye muscles, especially the light reaction. Speech becomes unclear, monotonous, scanned. Handwriting is disturbed, hands tremble, gait is unsteady. From the mental side—attention disorders, apathy, etc. Due to the severity of this drug addiction, doctors are required to be especially cautious when prescribing narcotics of the veronal group to patients treated for sleep disorders, especially in outpatient practice. Ether is often used for the purposes of drug addiction (sniffing, drinking) and leads to etheromania (see Ether). Each of the narcotics has its own peculiarities of action: thus, the "power" of hashish is in its daydreams, brightly colored illusions, and hallucinations; that of opium and morphine is in a calming, analgesic, soothing effect; that of cocaine is in light pleasant excitement, cheerfulness, increased self-confidence, sociability. In these properties of narcotic agents lies part of the explanation of the emergence and spread of drug addiction despite their pernicious consequences. Suffice it to say that the number of consumers of opium and hashish is determined by many millions, although of course not all of them are drug addicts in the proper sense of the word, and in every country where any narcotic agent is widespread, one should distinguish the main mass of consumers without sharply expressed morbid phenomena and the smaller part of immoderate consumers, whom drug addiction quickly leads to ruin. In this sense, the situation, e.g., with hashish in Persia, with coca in Peru, etc., resembles the situation with alcohol in European countries. On the mechanism of anesthesia—see Narcotic substances. If we turn to the action of various plant bases, alkaloids, on the organism, then here the narcotizing effect is achieved both by the direct action of the poison on the cells of the central nervous system and by the serious influence of narcotics, especially with prolonged use, on the autonomic nervous system, on the smooth musculature of vegetative organs, etc. Some authors attach special importance to the action of alkaloids on glandular organs, on secretion. Others believe that under the action of morphine, parasympathetic tone is elevated, sympathetic is lowered; morphine acts in a suppressing manner on the thyroid gland and the sympathetic and adrenal systems associated with it. Other opium alkaloids are close to morphine in their action on the autonomic nervous system. The causes of habituation and the abstinence phenomena associated with it are of a mixed character.

On the one hand, there is the formation of associative connections, the development of a peculiar conditioned reflex to the drug, the habit of escaping into anesthesia from the blows of the environment, from endogenous disorders, mood, etc. On the other hand, there is biochemical habituation to the poison, which soon turns into a habitual stimulant, the withdrawal of which is associated with the disruption of a certain artificially established equilibrium between the sympathetic and parasympathetic systems, endocrine activity, and overall metabolism. Thus, Wuth believes that the phenomena of morphine abstinence are associated with a drop in parasympathetic tone and excitation of the sympathetic system upon the withdrawal of the drug. A similar explanation can be given to the phenomena of nicotine abstinence, which are, of course, significantly weaker. Accordingly, David, Kahle, and others recommend the use of parasympathomimetic substances in opium (morphine) abstinence (quinine, potassium salts, thyroid preparations, sex gland preparations, etc.). Habituation to drugs and the phenomena of so-called "craving" are linked by some authors to the formation of special substances (e.g., oxydimorphine in morphine abstinence; Magtö). The need for ever-larger doses during habituation to achieve the same narcotic effect is explained not by the production in the body of any antitoxins, protective bodies, or an increased ability of the body to assimilate the drug, as previously thought, but is based on the ability to destroy it more rapidly. Thus, Schweisheimer showed that equal amounts of alcohol were absorbed into the blood and burned in the bodies of chronic alcoholics twice as fast as in teetotalers (7 hours and 15 hours); Faust established that a body accustomed to morphine possesses the ability to rapidly destroy (oxidize) the overwhelming part of the administered morphine (Straub; up to 99%). Thus, habituation in the sense of increased tissue immunity does not occur here either. The treatment of drug addiction consists first of all in isolating the patient in conditions that deprive them of any opportunity to obtain their drug, which is achieved only in a specialized hospital (psychiatric clinic, etc.). Furthermore, the physician must take care to alleviate withdrawal symptoms as much as possible. Bed rest and cardiac medications (digitalis, digalen, etc.) must be used from the very beginning. For restlessness—long warm baths (while monitoring the heart!). For insomnia—luminal (0.3 in hot milk), etc. Against digestive stagnation—hot drinks and mild laxatives. For hyperacidity, belching—mineral waters (Borjomi, Essentuki). Of great importance during abstinence is active psychotherapy, distracting the patient's attention and encouraging them; one should keep in mind the often observed conscious and unconscious exaggeration of their suffering by the patient in order to elicit pity from the medical staff and obtain the drug; hysterical overlays often play a role in the picture of abstinence, even morphine abstinence. The doctor's behavior toward the drug addict must be firm and clear, which has the best effect on the patient. The question of the possibility of immediate and complete withdrawal of the drug in a hospital is decided positively with regard to cocaine and hashish; as for opium (morphine) and their derivatives, opinions are divided here. Older authors recommend gradual withdrawal over 8–10 weeks, others prefer relatively rapid withdrawal over 8–10 days (with subsequent infusion of saline solution for several days). Still others insist on immediate withdrawal of the drug, pointing out the absence of danger to life if the heart is supported (see Morphine, Morphinism). What has been said regarding morphine is fully applicable to heroin, and here serious phenomena with a threat of respiratory paralysis and epileptiform seizures have been observed during abrupt withdrawal; therefore, gradual withdrawal (over several days) with initial replacement by small doses of opium or codeine can be recommended here. Ether and alcohol are withdrawn immediately, although withdrawal symptoms in the form of tremor, restlessness, and insomnia are often observed here in the first days. Hypnotics, such as chloral hydrate and veronal, should also be withdrawn immediately, replacing them initially with small doses of other hypnotics or sedatives (e.g., bromine with codeine) in view of the stubborn insomnia that sometimes develops during abstinence. The treatment of serious drug addictions, such as opium smoking, morphinism, etc., on an outpatient basis through a gradual reduction of doses can yield results only in exceptional cases, and final withdrawal must still be carried out in inpatient conditions under careful observation. As for the treatment of alcoholics, some results can be achieved here through the outpatient-dispensary method using frequent patient visitation, all types of psychotherapy (hypnosis), physiotherapy, and pharmacotherapy (including injections of oxygen, strychnine, etc.). In this sense, the experience of pre-war outpatient clinics (Mendelssohn, Minor) and Soviet drug dispensaries (and drug offices at neuropsychiatric dispensaries) is of interest; their work developed primarily along the lines of treating alcoholics and smokers with a relatively small number of actual drug addicts (Mazur). Of course, the drug dispensary must be connected in its work with the general public, the society for the fight against alcoholism, sobering-up stations, a clinic for early cases of alcoholism, and a labor treatment colony for the long-term re-education of alcoholics (and actual drug addicts), especially those with antisocial inclinations. A relatively complete chain of these institutions exists in our country only in the Moscow Oblast; in other places, only individual links of this chain are present. The duration of hospitalization for a drug addict (from several weeks to a year) depends on the severity of the case and external conditions; in any case, the longer the duration, the greater the chances of recovery. The prognosis for such drug addictions as morphinism is quite severe, and the percentage of cured patients here is estimated by various authors at 1 to 14. However, for post-war drug addicts, we have a more favorable prognosis, since among them there turned out to be many accidental, non-predisposed individuals. In cocainism, hashishism, and etheromania, the prognosis is better than in morphinism. Factors worsening the prognosis include: early onset of drug addiction, previous relapses, psychopathic personality of the patient, insufficient activity or pessimism of the attending physician. The prognosis in outpatient and inpatient treatment of alcoholics is more favorable, with a positive treatment outcome noted in 15–30% of cases. With the mass spread of any drug addiction, the treatment prognosis is better, because there are then more accidental, non-psychopathic personalities among the drug addicts. Psychiatric expertise in drug addiction depends on the specific circumstances of each individual offense, the degree of social danger, and the degradation of the personality under the influence of the drug. In severe cases, where we are dealing with completely degraded people with physical and mental signs of chronic poisoning of the nervous system, who are completely under the power of their craving and commit crimes to obtain the drug (often through prescription forgery), the question of compulsory treatment must be raised. However, the expert must exercise caution in cases where drug addiction is of a mass character, since this must be taken into account; one must also keep in mind the wide spread of drug addiction among criminals, where it is usually not the cause of entering a criminal path, but a companion of the criminal underworld. Drugs are also often resorted to "for courage" when committing a crime. Morphinism, cocainism, and other drug addictions are rarely serious factors in criminal delinquency. They have little effect on property crimes (except for prescription forgery, minor forgeries, etc.); crimes against the person are sometimes committed in a state of agitation and delirium under hashish; morphine (opium) plays almost no role here. The opinion about frequent severe crimes committed by cocainists is incorrect: when comparing 400 cocainist offenders and 2,000 other criminals by type of crime (Rapoport), almost no difference was found (the percentage of bandits and murderers was actually lower among cocainists). Only alcoholism (see) is a serious factor in criminality, especially crimes against the person (assault, wounding, insult, hooliganism, etc.); it plays a significantly smaller role in property crimes. Various kinds of sexual perversions (homosexuality, pedophilia, exhibitionism), developing in connection with disorders of sexual desire (libido) and sexual capacity (potentia), often bring the drug addict into conflict with the law. Our criminal code does not recognize diminished responsibility for crimes committed in a state of intoxication (except for cases of pathological intoxication); the German code (Radbruch's draft) stands on the viewpoint that the lower the sanity at the time of the offense, the less responsibility and punishability; the Italian code (Ferri's draft) provides, on the contrary, for increased punishment for crimes committed in a state of intoxication, proceeding from the consideration that the personality of an alcoholic or drug addict who commits a crime is more dangerous to society than an ordinary criminal, and the very fact of intoxication is an additional offense. Prevention of drug addiction

It is necessary to distinguish between legislative and social prevention of drug addiction on the one hand, and medical prevention on the other. Regarding the former, one can observe in capitalist countries an extremely large gap between legislation and the practice of combating it, on the one hand, and between legislation and the pressing demands of protecting the interests of the overwhelming majority of the population, on the other. The production of narcotic drugs is in the hands of the big bourgeoisie, which is directly materially and politically interested in planting and spreading narcotic drugs, which are an object of trade and enrichment.

as a means of influencing the class struggle in a direction desirable for the bourgeoisie. Therefore, the legislation of capitalist countries is very tolerant regarding the production and distribution of narcotics. Not a single law directed pointedly and directly against large-scale producers and distributors of narcotics actually exists (or is applied) in any capitalist country. All the stings of legislation and police organizations are aimed against small-scale distributors of narcotics and, in particular, against their consumers. The history of recent years is rich in examples of bourgeois hypocrisy in matters of jurisdiction and in the practical implementation of half-hearted decisions. True, it may be noted that in Europe and the USA, in connection with the enormous growth of drug addiction after the imperialist war, there has been a sort of activation of anti-narcotic legislation. The French Criminal Code, issued in 1924, concerns producers, sellers, and in part consumers of narcotics. According to the law, not only the illegal sale of cocaine, morphine, hashish, and similar poisons is punished, but also their consumption in company and any facilitation of the consumption of these poisons for a fee or even free of charge by providing premises or in any other way. Various terms of imprisonment, fines, and deportations are provided for the distributor and consumer. In case of recidivism, the punishments are doubled. According to the Italian law of February 28, 1924, anyone who, without a special permit, sells cocaine, morphine, and generally poisonous substances having a stupefying effect in small doses is punished with imprisonment (2 to 6 months) and a fine. The possession of these substances for the purpose of sale and their dispensing to persons not entitled to them are also punished. When dispensed to a minor, the punishment is doubled. The provision (for mercenary purposes or gratuitously) of one's premises for gatherings of persons consuming narcotics is punished with imprisonment and a fine. In the German Criminal Code (1924), there are no direct articles punishing the sale of cocaine, morphine, etc., but there is Article 367, clause 3, according to which anyone who, without a police permit, manufactures, stores for sale, sells, or in any other way provides another with poisons or medicines the trade in which is not free, is subject to a fine or arrest. The law of December 19, 1930, places responsibility on physicians prescribing narcotics. In the USA, a general act on combating narcotic substances was issued as early as 1915. According to this act, the trade, storage, and distribution of narcotic substances must be carried out in strict accordance with existing laws. Physicians, dentists, and veterinarians may use narcotics only for therapeutic purposes, but how to establish or verify for what purpose a narcotic was given (therapeutic or otherwise) is not stated in the legislation. Any violations of this law committed through evil intent or omission are punished by a fine of up to 2,000 dollars or imprisonment for up to 5 years. In accordance with this federal act, individual states have implemented their own local regulations. In some of them, measures have been introduced that are very strict: thus, in the state of Massachusetts, even possessing instruments for subcutaneous injections is prohibited for persons not of the medical profession. If necessary, a written permission from a physician is required. But all these measures are circumvented with the tacit consent of bourgeois "society" and are not in the slightest degree directed against the main bearers of evil, the producers and wholesale distributors of narcotics. Aside from the measures of individual governments, "attempts" were also made to organize the fight against drug addiction on an international scale. Thus, in 1909, the international opium commission sat without result. In 1911, on the initiative of the USA, an international conference on the opium question gathered in The Hague, where, with the participation of representatives of China, Germany, the USA, Russia, France, Great Britain, Japan, Persia, Italy, the Netherlands, and Siam, a convention was drafted, which all other countries were invited to join. The convention concerned the enactment of laws or regulations governing the production and distribution of opium, morphine, cocaine, and heroin. Various forms of state cooperation were provided for the purpose of controlling the drug trade, combating smuggling, prohibiting the export of narcotics to countries where their import is prohibited, mutual information, etc. The convention yielded no concrete results, as was to be expected given the serious economic interest in its failure by the majority of conference participants (large narcotic industries in Germany, England, France, Switzerland, the income of the English government in India from opium of 60-70 million rubles a year, etc.). The World War long undermined the convention, which was renewed only upon the signing of peace treaties, the ratification of which was also the ratification of the convention. General control over its implementation has since been entrusted to the League of Nations, under which the Opium Advisory Commission was created. The work of this commission has also yielded no concrete results despite a series of sessions where the sabotage of the convention by almost all participants was clearly revealed. Thus, the Geneva Opium Conference (1925) ended with the demonstrative departure of the Chinese and American delegations. (The USA occupies a less hypocritical position in this matter than other powers, since it has neither opium plantations nor industrial export of narcotics.) In any case, attempts at an organized international struggle against narcotism have hitherto been completely unsuccessful, mainly due to the existence of a great material interest of a number of capitalist countries in the production of narcotic substances and the extensive private medical practice in these countries. The Committee of Experts of the 2nd Geneva Opium Conference (1924) estimated the world production of opium plantations at 8,600,000 kg. The fight against narcotism and drug addiction is organized on completely different foundations in the USSR; Soviet legislation is pointedly directed both against the production of narcotics and against their distribution, punishing not only small-scale dealers, but to a significantly greater extent den operators, wholesalers, and producers of narcotics, if such were discovered. The center of the fight against drug addiction here has been shifted to cultural and educational work and, furthermore, to the fight against the primary sources of the production and distribution of narcotics, which naturally must yield (and does yield) completely different results than in capitalist countries. One can note a significant reduction in the consumption of narcotics and a decrease in the number of cases of drug addiction in the USSR, which is also explained by the reconstruction of labor and living conditions, as well as by the cheerful purposefulness and enthusiasm of the working people (industrialization, planned socialist construction, shock work); the absence of unemployment, the growth of atheism, and other factors play a role. At present, the USSR is the only country where the cultivation and preparation of narcotic substances are regulated by legislation and their use is guaranteed exclusively for medical and scientific purposes. By a decree of August 27, 1926, the monopoly on all opium produced in the USSR was transferred to the Akospo Joint-Stock Company, to which all opium planters had to surrender their harvest under contracts. Since 1930, Akospo has been merged with the All-Union Society for the Production and Export of Medical Raw Materials (Lektechsyroye). Having the monopoly on the export of raw opium abroad, this organization must nevertheless obtain a special export license from the Soviet government in each individual case, which is issued to them only on the basis of the consent of the government of the importing country. The entire quantity of opium going to the domestic market (for medical and scientific purposes) is transferred to the state production organization Gosmedtorgprom, in whose hands lies the monopoly on the production of narcotics (morphine, cocaine, heroin, etc.), based on a pre-determined annual demand of all union republics, as well as the distribution of narcotics. All narcotics imported into the USSR must be addressed to the People's Commissariats of Health of the respective republics, which monitor their correct distribution. The opening of pharmaceutical laboratories and plants takes place with the permission of the Presidium of the Supreme Council of the National Economy and its local bodies. By a resolution of the Central Executive Committee and the Council of People's Commissars of the USSR of May 23, 1928, the free circulation of cocaine, its salts, hashish, morphine, heroin, dionine and their salts, and pantopon was prohibited within the USSR. There is also a special instruction of the People's Commissariat of Health of the RSFSR "On measures to regulate the trade in narcotic remedies," according to which the non-pharmacy sale of narcotic preparations (opium and its derivatives, opium extract, morphine, heroin, dionine and their salts, pantopon, as well as cocaine and its salts and hashish) on the territory of the RSFSR is permitted only from state enterprises having the right to wholesale trade in medicines; the instruction regulates in detail the dispensing of narcotics from pharmacies on doctors' prescriptions in order to avoid abuses, etc.

Regarding criminal liability, there is Article 104 of the Criminal Code, according to which "the manufacture and storage for the purpose of sale and the very sale of cocaine, morphine, ether, and other stupefying substances without proper authorization entails deprivation of liberty or corrective labor for a term of up to one year, with or without confiscation of part of the property. The same acts committed as a trade, as well as the maintenance of dens in which the substances listed in this article are sold or consumed, entail deprivation of liberty with strict isolation for a term of up to 3 years, with confiscation of all property." Such is, in brief, Soviet legislation, which, alongside the general social policy of the Soviet government, ensures a successful fight against drug addiction. The attached tables (Tables 1–3) give an idea of the scale of manufacture of morphine, heroin, and cocaine in the most important countries, as well as their export and import (materials of the League of Nations Opium Commission, 1930). Table 1. Manufacture, import, export, and consumption of morphine for 1925–29 (in kg). Table 2. Manufacture, import, export, and consumption of heroin for 1925–29 (in kg). Table 3. Manufacture, import, export, and consumption of cocaine for 1925–29 (in kg). Thus, across all these countries, we see a significant excess of drug production over domestic consumption. As for data on the number of actual drug addicts in Europe and America, it is difficult to have any reliable information here, since, depending on the sources, the figures sometimes differ by 10–15 times. The figures for registered drug addicts in New York were cited above. In 1926, according to official data, there were 91,250 people in the USA, or 1 drug addict per 1,242 people. However, according to other sources, the number of drug addicts in the country was 1 million. It is easier to judge the dynamics of drug addiction, which is reflected in data on the movement of drug addicts through medical institutions. Thus, German private psychiatric hospitals housed (according to Bonhoeffer): in 1911–13 (combined)—1,497 drug addicts, in 1920–22 (combined)—3,084, in 1923—1,283, in 1924—1,430, in 1925—1,623. The role of the imperialist war and subsequent social upheavals in this growth of drug addiction is clear. In the USSR (and old Russia), only alcoholism became widespread, and the problem of drug addiction in the proper sense was never seriously posed. Neither the peasantry nor the proletariat had or have almost any relation to opium, morphine, cocaine, etc., if we do not count the accidental and almost eliminated spread of cocainism in 1920–25, which, however, even then did not seize the broad masses of the population, but only its separate, relatively small groups (bohemians, lawbreakers, homeless children), and certain regions in Central Asia, where opium (taryak) and hashish (anasha) still penetrate through smuggling across the Afghan and Persian borders. As for morphinism, it was and remains with us a disease almost exclusively of medical personnel. From data collected in 1931 by the Moscow Institute of Neuropsychiatric Prophylaxis, it is clear that in none of the Union republics (except for the Central Asian ones) do the issues of drug addiction in the proper sense play any serious role. The absolute figure of drug addicts, at least for the city of Moscow, cannot be given, since drug addicts are not registered with us, and an approximate idea can be given by the figures for the admission of drug addicts to dispensaries and hospitals in Moscow. Below are data on the number and percentage ratio of alcoholic drug addicts (primary patients) who passed through Moscow drug dispensaries from 1924 to 1929 (where the main mass of patients consisted of alcoholics and then smokers) (Table 4). From the table presented, a sharp decrease in the absolute as well as the relative number of drug addicts, especially cocainists, is evident over this entire period. A greater stability is shown by the numbers of drug addicts treated in the psychiatric hospitals of Moscow, as can be seen from Table 5. When examining this table, one should keep in mind both the significant population growth of Moscow during the reporting period and the fact that we are dealing here with repeat patients, incurable drug-addicted recidivists who repeatedly entered and were discharged from hospitals. Many drug addicts from all over the USSR come to Moscow looking for special inpatient treatment and usually settle in the same psychiatric hospitals. Here too, as a percentage of the total number of patients treated, we have a decrease from 2.5% in 1923 to 1.7% in 1928 and 1.6% in 1929. Abroad, many drug addicts are treated in sanatoriums. If we take for comparison data from one of the large Moscow neuropsychiatric sanatoriums, "Sokolniki," we get the following negligible figures for drug addicts in recent years: 1928—6 morphinists, 1929—7 morphinists, 1 cocainist, 1930—5 morphinists. Data from the district psychiatrist of one of the large districts of Moscow—Sokolnichesky—with a population of about 300,000 people, appear as follows. The number of drug addicts (morphinists and cocainists) per 10,000 population: 1925—1.04, 1926—0.58, 1927—0.24, 1928—0.31, 1929—0.08. If we distribute drug addicts (for 1926) by social groups, it turns out that the main role here is played by the unemployed (often declassed elements) and workers are completely absent (Table 6). All these data confirm the fact of a significant decrease in the already small indicators of drug addiction in Moscow, as well as throughout the USSR. The cessation of economic exploitation, the decisive change in conditions and Table 6. Distribution of drug addiction by designated social groups in 1926 (ratio per 10,000 population of designated social groups).