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
(No Transcript)
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
(No Transcript)
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