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H--328 I rACK N ev., Zealand Deprtmenf cy Health LIBRARY Box 5013Wehnyfon ••. W7O•;. Classification: •AccssonNo..................................... •• . • Locn4on: ................................................. S •.: NO1Nfl1M HI1VRH O iNN1'dvd0 \2 s nip jo asn e ue asn at4l THE USE AND ABUSE OF DRUGS A HANDBOOK FOR HEALTH EDUCATORS The Board of Health Committee on Drug Dependency and Drug Abuse recommended in its First Report "that a comprehensive education programme on the proper and improper use of drugs be instituted". The Handbook has been prepared to assist all community educators in presenting factual information to the population at risk. It is not intended that this Handbook be used in isolation and it will be necessary to refer to other resource material. The Department of Health acknowledges with appreciation the assistance and cooperation of the Division of Health Education, Department of Public Health, New South Wales, and the advice and suggestions of the Board of Health Committee on Drug Dependency and Drug Abuse, New Zealand. CONTENTS Page Drugs - their origins and use The problem of drug abuse 10 Type of drugs - use and misuse 18 Signs and symptoms of drug abuse 29 Control of drugs and treatment of drug abuse 34 Drug abuse slang 42 Tabulated drug information chart 46 DRUGS - THEIR ORIGINS AND USE 1. An introduction to drug education It is the nature of Man to be curious, to explore new ideas and territories in the world around him. How and why he behaves as he does is the particular concern of sociological and psychological studies. However, actions that may result in damage to the body through careless behaviour or misinformation are of concern to all as others are often involved or harmed in the process. In his investigations into his own surroundings, Man has made remarkable use of the products of Nature in providing for his own basic needs and comforts. Food, clothing, and hundreds of other products have been produced from these natural sources for better living. Early in his search for useful materials in Nature, Man discovered certain products that eased pain and infection when taken internally or applied to his wounds. Continued study and refinement of these products have made available to medical science the great variety of drugs and medicines we have today. Unfortunately, many of these substances have dangerous and damaging effects on the body if used indiscriminately. But in spite of their drawbacks modern medicine could not function without the help of potentially dangerous drugs, and their use by the medical profession is increasing, particularly in the developed countries. Accompanying the increased use of such substances by the medical profession, is a growing tendency for the ordinary citizens to use drugs obtained without medical prescription or expert advice as well as abusing those prescribed legitimately. A substance may not be dangerous of itself; but the improper use of nearly any substance can be dangerous. Unfortunately the search for drugs has, in the past, often been a search for "magic" and, except in scientific evaluation, this is still substantially the case. Society has two means by which it can prevent individuals from using potentially harmful substances for other than socially approved purposes. The first of these is through legislation. This may place the manufacturer and distributor under strict control, or make the manufacture or distribution illegal, or permit forceful restraint to be employed whenever an individual makes other than approved use of potentially harmful substances. A shortcoming of legal restrictions which applies particularly to drugs, is that the reasonably successful control of one substance often leads to the emergence of another as a substitute. There are other shortcomings too - such as the arousing of acute resentment; and making it difficult for offenders to seek treatment. The second means at society's disposal is the provision of educational programmes that provide opportunity for every individual to acquire adequate knowledge about potentially harmful substances, and to develop attitudes that will lead him to make correct decisions about the use of the variety of substances available. Neither of these means is likely to be effective alone, but it is apparent that education offers society the greatest opportunities to prevent the misuse or abuse of potentially harmful substances. 2. The nature and origin of drugs (a) What isadrug? There is no precise definition of the term "drug" which will convey adequately the complex range and functions of therapeutic substances available to modern man. The origin of the word itself is unknown although variations of it appear in many modern languages. Generally speaking, any chemical substance, natural or synthetic, which alters or is claimed to alter the structure or function of the body, may be labelled a drug. Some drugs exert their effects on every cell in the body but most have selective effects on certain kinds of cell, or on particular organs. The drugs with which we are principally concerned generally affect the nervous system. They are used both for medical treatment and for modifying man's perception of the real world or his subjective sensations. Substances of this kind have been in use since the dawn of history for producing three kinds of effect; stimulation, sedation, and hallucinatory perceptual changes. (b) Types of drugs Drugs range widely in their nature, and just as widely in their application. Some people think only of narcotic drugs like opium and heroin when the word "drug" is used, but this is a very narrow idea of what drugs really are. There is, for instance, the very wide range of medicines prescribed by the family doctor, which contain such drugs as the antibiotics, anaesthetics, sedatives, hormones such as insulin and thyroid extract, tranquillizers, pain relievers, and so on. To this we must add an equally wide range of proprietary medicines and household and industrial chemicals which can be bought without the need for a prescription. These can include laxatives, mild pain relievers such as APC powders, corn cures, preparations to prevent or treat sunburn, and medicated creams and lotions. All of these preparations and many more besides, contain drugs. Vitamins may be used to treat specific deficiency diseases, and to this extent they may be considered as drugs. We sometimes include drugs in such everyday toiletries as soaps, toothpastes, haircreams, and deodorants. 3. Origins of drugs Drugs have been used by man from the beginning of recorded civilization and possibly before. The use of narcotic drugs extends so far back in time that they appear to have been known to Stone Age Man. The seeds and capsules of the opium poppy have been found in the pile works of the Swiss lake dwellers of 4,000 years ago, and evidence suggests that the plant was deliberately cultivated. The drug was used medicinally by the Ancient Egyptians, Persians and Greeks. Homer describes the affects of a "sorrow easing" opium, and the cultivation and preparation of drugs described on clay tablets by the Sumerians about 700 B.C. are substantially the same as the methods used today. Marijuana was known to the Assyrians as early as the seventh or eighth century B.C. They used it as incense under the name of "Qunnabu", a term apparently derived from an old East-Iranian word "Konabu", the same as the Scythian name KavvaBis (cannabis). Herodotus, writing in 500 B.C., speaks of the use of hemp as a narcotic by the Scythians of Asia Minor. There has always been a close connection between drug cures and faith healing. Through the ages an immense number of substances has been used to treat disease, but only a few of these substances have had any direct influence on the symptoms of a disease, and some are actually harmful in their effects. Most of the substances that have been used as remedies depend upon their appeal to the imagination for the healing virtues they are believed to possess. Curative properties have been attributed to nearly every substance when it was new, unusual or difficult to obtain and which could be forced into the human system. The use of naturally available materials for medicinal purposes became the prerogative of special persons; the priests, the medicine men or the witch doctors - and to make their effects more dramatic, ritual ceremonies were developed. Thus, drugs have been used by primitive peoples in tribal rituals such as puberty rites, and to combat and neutralise various taboos. The American Indians extracted from desert plants the drugs mescaline and peyote, in belief that it would enable them to communicate with their dead ancestors. Similarly warriors sometimes smoked hashish to endow them with superhuman strength before battle, and the Indians of the Andes chewed coca leaves, so extracting the cocaine, for energy and virility. The Maoris had many plant materials which they used as drugs but scarcely any so far have been found to have any notable value. The tohungas, wise men learned in philosophy and traditional knowledge and in the ways of their fellow men, used these drugs only as an adjunct to their teaching of what they had evolved as healthy living habits. In our own society the fallacious belief is still widely held that drugs in some mysterious way are a necessary part of the treatment of all diseases. Folk-lore, word of mouth, and the pecuniary interests of advertisers and proprietors perpetuate excessive belief in what drugs can do. As a result, much self-applied drug treatment is really of little value, often unnecessary, and of little more than palliative or psychological effect, while a selflimiting illness abates as it would without any treatment. 4. The development of modern drugs There are two main fields of development of modem drugs. The first is the extraction of active principles from plants which have been known for centuries to possess healing properties. The second is the testing of entirely new substances, some produced by moulds, yeasts, and other simple living organisms, and others produced by chemists in the laboratory. Thus, from living organisms we obtain the range of antibiotics now available, while the list of synthetic drugs is enormous. (a) Drug extraction from plants There are many examples of modern drugs that are extracted from plants which have been used for hundreds or thousands of years to treat illness. For instance, there is the heart drug digitalis and its derivatives which come from the Foxglove, a plant commonly grown in England and Northern Europe. The Autumn Crocus is the source of colchicine, a drug used in the treatment of gout. Leaves of the Belladonna (Italian for "Beautiful Lady") were crushed and an extract used by women of fashion to dilate the pupils and so give the eyes a sparkling appearance, hence the plant's name. From this we now obtain atropine, a drug with wide medical application. And of course there is the opium poppy, from the unripe seed capsules of which opium is obtained. From this we extract morphine, used for the relief of severe pain. A large part of the morphine extracted commercially from opium is converted chemically to codeine. Although it is not as potent a pain reliever as morphine, codeine is less addictive but it may also have harmful effects if used to excess. (b) Synthetic drugs The pattern of development of synthetic drugs varies widely, for as yet we do not have a sufficient knowledge of the mechanism of body processes to be able to predict what a particular substance will do, simply by looking at its chemical structure. Neither can we predict accurately what chemical structures will be required in a group of substances so they will exert a desired effect. In some instances we do know what chemical characteristics are responsible for the activity of a particular group of compounds, but often we do not. Discovery of useful drugs is therefore still very much dependent upon chance. The usual process begins when a research chemist makes a series of new compounds. He may be experimenting with an entirely new chemical, quite unrelated to any drug already in use, but he is more likely to be preparing a range of compounds, which differ in some small way from a compound which has already been found to have useful properties. In this way the research chemist may prepare small quantities of dozens of closely related substances, but at this stage he will have no idea of whether or not they have any of the properties he is looking for. The next step, then, must be a series of "screening" tests to see whether any of the substances may-be useful. More than 150,000 substances are tested every year in the pharmacological laboratories of Western European countries, but only approximately 50 new drugs - excluding combinations of already known products are actually introduced each year; this is equivalent to one new pharmaceutical product for every 3,000 chemical substances investigated. If he is wise, the person conducting these tests will be looking for a wide range of possible effects, as small variations in chemical substances can quite markedly affect their biological properties. If the person doing the screening only looks for the one effect he is trying to achieve, he may cast aside a new compound with very useful properties in another direction. There are many instances where useful effects have been found in substances being prepared in search of quite different properties. For example, a substance useful for treating ringworm was found while looking for a more effective chemical to relax muscles during operations. 5. Use of drugs (a) Medicinal The most familiar use to which drugs are put is, of course, the treatment of illness. Where the illness is something easily recognised and of a minor nature, we will often purchase something and treat ourselves. This is quite satisfactory in the case of such simple conditions as the occasional headache or the pain of a bruise, which are relieved with aspirin or other simple analgesics (pain relievers). If we get carsick or have a stuffy nose due to a cold, other drugs give relief. Even in conditions like these it is advisable to seek advice on the first occasion on which the 8 drug is used, as some can cause unpleasant reactions in some people. In some instances they may cause drowsiness so that driving a car can be dangerous. Where a condition persists for a long period, such as continuous or repeated headache or a cold that does not get better, a doctor should always be consulted. Continuing to use drugs without medical advice can have serious consequences because taking analgesics could mask the symptoms and in so doing prevent a correct diagnosis and treatment. Many illnesses and symptoms are self limiting. The use of drugs as palliatives for these mean that excessive virtue has been ascribed to palliatives - but these merely alleviate pain or discomfort without curing. (b) Experimental Some drugs can also be extremely useful in helping to explain living processes. If a drug is known to enhance or suppress a normal body process, the working of the body under the influence of that drug can often tell us something about the process itself, or the way it influences other body functions; it may even help us to learn something about diseases which affect that particular body function. Thus, drugs are not only useful for treating disease, but may assist us to learn something about the nature of the disease itself. These experiments must be carried out under carefully controlled conditions by qualified personnel. (c) Cultural A number of drugs have at various times been associated with the customs of a particular race or society of people. Betel nut chewing is prevalent among native inhabitants of New Guinea, India and other similar countries. Tobacco smoking was a custom developed by the North American Indians and brought to Britain and Europe in the sixteenth century. Alcoholic drinks produced by fermentation of various fruit juices have been consumed for many centuries, the main variation being due to the natural material available to produce the sweet juices upon which yeasts can act. These are all examples of the cultural use of drugs, and, as is shown elsewhere, this form of drug use can often cause serious illness itself. In fact, these are frequent forms of drug abuse, a subject which is referred to in more detail later. 6. Faulty use and abuse Much unwise use of drugs, some of which leads to abuse or to actual illness arises from the persuasiveness of tradition or of advertisements. This should be critically examined. First the cause of illness needs to be determined and the causes corrected or removed. Then understanding care of the person is the most important need. Use of drugs should only follow an objective assessment by a person appropriately trained. The drugs then used may be palliative only, to suppress some of the transient discomfort while the patient recovers, or have some fundamental effect. Departure from this procedure leads to faulty use or abuse. 9 Sig 2 THE PROBLEM OF DRUG ABUSE Cultural and social factors are important in understanding the use of drugs, for drug abuse is largely a problem related to the community attitudes toward drugs. Every culture permits certain methods of tension reduction, e.g., alcohol is to many an approved way of reducing tension in our society. The permitted social uses of drugs may be implied from the traditional mores or rules that form part of the culture of each society. An almost invariable tradition is that drugs are used in group situations; e.g., some primitive cultures restrict drug use to religious occasions. Commonly drugs are used to promote gregarious social functions, which may be contrasted with another traditional valued social function - to assist in inflaming hatreds against an external enemy of the group. On different occasions the same drug may be used for a variety of purposes consistent with the aims of the society of the users; marijuana is used by some societies to promote a pleasant happy state, but it has been claimed that it was used deliberately to promote homicidal impulses in members of a political group of professional murderers in Persia. The group was active for centuries in medieval times and their use of hashish (marijuana) is reflected in the term "assassin". Most cultures also embody rules that attempt to control drug abuse. In contrast to drug use in a social setting, solitary. use of,a drug is usually censured. European Jewish culture resulted in a society that achieved satisfactory drug use with practically no abuse in the case of alcohol: a very low rate of alcoholism exists in spite of a high degree of acceptance of alcohol. Clearly many other factors are involved but it is probably significant that the use of alcohol is mandatory in Jewish religious ceremonies of special social consequence, such as the wedding ceremony and the family service during the Passover. Even in the case of opium, before the Opium Wars disrupted the traditional social and administrative controls there was comparatively little abuse of opium in China where it had been known and used since the ninth century. Regardless of the widely disparate types of drugs adopted by different societies, they are used for identical social purposes. In the Pacific area, societies using khava, an intoxicating beverage and also a sedative, are distinctly separate from those using betelnut, a stimulant. Other societies that use stimulants are found in South America (cocaleaf, containing cocaine), around the Red Sea (khat), and in Asia (betel nut). Marijuana has effects broadly similar to alcohol andis used extensively in Asia, Arabia, and Africa. Opium and its derivatives have an extensive use, as distinct from abuse, and it may not be too much to claim that abuse of drugs in these societies is a problem of the same order of magnitude as abuse of alcohol in alcohol-using societies. The reason for the current trend towards drug abuse is often presented as aconsequence of modern life: the soul-destroying pace of the competitive world, the disruption of traditional standards, and the elevation of materialistic and hedonistic drives. In fact, the use and abuse of drugs has been a general trend over the span of recorded history and the influence of urbanisation on drug abuse is not yet clear. 10 Epidemics of drug abuse usually erupt when a population is exposed to a new drug, the use and control of which is not incorporated in its culture. The destructive effects of alcohol on native populations exposed to European colonisers is only one special example. The European population was also exposed to new drugs when the returning colonisers brought back tobacco and a variety of other drugs. The widespread abuse of opium in Europe followed its importation on a large scale by the East India Company. Alternatively, a population may be exposed to a drug already known and incorporated in its culture when the usual controls are disrupted by a conquering civilisation: the extensive use of the coca leaf in South America as a drug of addiction followed the disruption of the Inca civilisation by the Spaniards. Before this, its use was restricted to the aristocracy, who in turn were restricted to enjoying its effects only in the course of religious ceremonies. Today, the number of addicts in South America is variously estimated to be from 8 to 15 millions, which is not remarkable considering that in Bolivia and Peru alone the estimated coca leaf production is 10,000 tons a year. The international drug problem The increase in the abuse of drugs in recent years is world-wide. At the 20th World Health Assembly held in mid-1967, a resolution sponsored by ten countries noted "with great concern" the increasing abuse of certain classes of drugs and called for immediate co-ordination of national control measures against this threat. Drugs about which the Assembly expressed particular concern were LSD and related hallucinogenic substances, and drugs of the sedative and stimulant types. Measures were proposed for greater control of the manufacture and supply of drugs and WHO undertook to carry out a pilot project over 3 years with the aim of establishing an international system of monitoring adverse reactions to drugs. Later the United Nations Economic and Social Council sponsored a conference at which a treaty, the Convention on Psychotropic Substances, was written in 1971. The most widely abused drug under international control is Marijuana (cannabis). In 1968, 1,440 tons (1,440,000 kilograms) of cannabis and 9 tons (9,000 kilograms) of cannabis resin were confiscated compared with 34 tons (34,000 kilograms) of opium, 205 kilograms of morphine, 258 kilograms of heroin, 20 tons (20,000 kilograms) of coca leaves, and 109 kilograms of cocaine. (Annual Report of U.N. Commission on Narcotic Drugs, 1968). A World Health Organisation Expert Committee has reported that 200 tons of opium is diverted from legal production annually and only one-tenth is recovered by seizures. As well as the opiates, cannabis and cocaine, there has been a rise in the world consumption of the synthetic drugs like "Pethidine". This drug has proved to be just as dependence producing as the natural opiates. The following figures indicate the number of therapeutic doses of analgesic and cough depressant narcotic drugs consumed annually per 1,000 inhabitants over the period 11 2' 1964-69: Denmark Finland Atistralia United Kingdom New Zealand Canada United States Japan 18,046 14,225 12,443 11,582 9,038 8,003 5,736 2,556 Of all psychiatric admissions in New Zealand, one patient in 62 is rated as drug dependent. The chief problem has so far been with barbiturates and the amphetamine group rather than with the narcotic drugs or LSD. What is drug abuse? The Committee of Experts on Drugs Liable to Produce Addiction, World Health Organisation, defined addiction as: "A state of periodic or chronic intoxication detrimental to the individual and to society, produced by the repeated consumption of a drug. Its characteristics include: (1) an overwhelming desire or need (compulsion) to continue taking the drug and to obtain it by any means; (2) tendency to increase the dose; (3) a psychic (psychological) and sometimes a physical dependence on the drug". Drug dependence Recently, the term drug dependence has come into general use to replace "addiction" and "habituation", because it has become scientifically unsound to maintain a single definition for all forms of drug addiction and/or habituation. A feature common to these conditions as well as to drug abuse in general is dependence, psychic or physical or both, of the individual on a chemical agent. The new term "drug dependence" is thus defined as a general term applicable to all types of repeated or continuous drug abuse. It is a state of psychic or physical dependence, or both, which may arise after repeated or long-term administration of a drug. Describing the type of dependence is an integral part of the new terminology (i.e., morphine-type, cannabis-type, amphetamine-type). People can become dependent on a wide variety of chemical substances that produce central nervous system effects varying from stimulation to depression. When psychic dependence develops there is a feeling of satisfaction and a drive that requires periodic or continuous use of the drug to produce pleasure or avoid discomfort ("craving"). Some drugs also produce physical dependence, i.e., an adaptive state that shows itself by intense physical disturbances when the drug is stopped. These disturbances are known as withdrawal or abstinence syndromes. Some drugs such as marijuana have now no medical purpose. If a drug were quite harmless, no objection could be raised against its indiscriminate use, other than the waste 12 of money and effort involved. However, no drug is without some toxicity, whether physical, behavioural, or both. Where a drug is being used to cure or relieve an illness, some degree of hazard, related to the seriousness of the illness, can be permitted. Drugs that are being used to fulfil a medical need cannot be said to be subject to abuse while they are being used to satisfy that need. But once the necessity for medical use is over, any further use, whether out of habit or desire, must constitute abuse. This brings us back to consider the purposes for which a definition of dependence is necessary. The purposes are (1) scientific and medical and (2) social and legal. For scientific and medical purposes the main feature is the overpowering desire or need for the agent; the loss of power of self-control; the abuse of the drug on which the drug taker is dependent. For social and legal purposes the main feature is that the dependent himself and the community to which he belongs are harmed by his dependence. Factors concerned in drug dependence Three main factors operate in the occurrence of drug dependence: (a) the pharmacological and physiological properties of the drug; (b) the personality, stability and attitudes of the individual; (c) environmental and socio-cultural influences. (a) Pharmacological and physiological factors Dependence inducing drugs are usually those which produce some noticeable subjective effect within a short time of their administration. These effects are desired by the individual either to escape from problems or be relieved of anxiety or to capture new experiences. These drugs, if taken over a sufficiently long period of time and in sufficient doses, may produce physical dependence and this is enhanced by the tolerance for the drug which develops with the consequent need to increase the dose to produce the desired effects. The person then becomes enslaved because he is unable to withstand or cope with the withdrawal effects of the drug, i.e., he needs to continue the drug to feel reasonably normal. The most recent work based on investigations in monkeys and human beings has established that there are minimum requirements regarding daily dosage, interval of administration, and total duration for the establishment of dependence. The figures for opium derivatives have not yet been finally worked out but those for barbiturates are now well-established. The daily intake needs to be 0.5 of a gramme, which is five times the normal medical dose, at intervals of 6 to 8 hours for 4 to 6 months. (b) Personality of the drug dependent person • There is little which persons who abuse drugs appear to have in common. They can be found among young and old, rich and poor, and every social class. The crucial questions: what are the attributes, psychological, physiological, or biochemical which render certain individuals exposed to drugs, more likely to 13 become dependent or conversely, what are the attributes which militate against the development of dependence in those similarly exposed? It is now clear from animal and human experiments that anyone can become physically dependent on some drugs if the dose is high enough, given sufficiently frequently for a sufficiently long period of time. Despite this, some persons may recover from their dependence whereas others remain dependent for the rest of their lives. Various surveys of dependents reveal that they show the whole range of personality characteristics, from the normal to the neurotic, psychotic, psychopathic, and sexually deviant. Certain traits of personality would appear to be conducive to the development of drug dependence, for example, low tolerance for anxiety, distress, discomfort, pain, or frustration of the person's needs. This may be relevant in the inability to cope with the distress of the withdrawal state. Although many dependents show marked personality disorders, with emotional instability, immaturity, impulsiveness and although these undoubtedly increase vulnerability to dependence these traits are also quite common in non-dependents. It is also clear that a number of drug dependents were previously stable, well adjusted persons and it is important to bear in mind the harmful habitual effects of dependence, particularly on the person's interpersonal and social relationships. The behaviour changes, the falling off in reliability and efficiency, the need for deception, the measures needed to obtain drugs to counteract abstinence syndromes can all exert adverse effects on the person's disposition and personality, but these are not necessarily permanent as follow-up studies of addicts have shown. (c) Environment, social and cultural factors (i) latrogenic A certain proportion of dependence arises from the unwise and prolonged use of drugs, prescribed originally for quite valid medical reasons. (ii) Profession Doctors and nurses; because of the availability of drugs, constitute a wellknown proportion of dependents. (iii) Socio-cultural aspects Dependents can come from all social classes and from all races and countries but there tends to be a difference in prevalence which is related to cost, availability, degree of social acceptability, religion, economics, class consciousness, ethics, group mores, and many other factors which influence the acceptance of certain drugs. Moslems, in general, reject alcohol but accept the consumption of hashish, although both are officially banned by the Moslem religion. Oriental opium-producing countries show a much higher rate of dependence than do other countries such as Scandinavia. But many observers have noted that Orientals keep their opium habits under much closer control than do non-Orientals. 14 It may also be said that the use of drugs creates a fraternal spirit among users which may lead to the formation of their own particular kind of social organisation, which in turn is reinforced by their rejection by society and through economic and psychological factors: In our society the prohibitions placed on the use of drugs may make their consumption-more attractive to some adolescents. A classification of major causes of drug dependence (i) Teaching or example We all have some figures whom we idealise, whether they be parents, older brothers or sisters, friends, people with whom we come in contact such as the family doctor or people who have acquired a following such as "pop" singers. The less mature we are, the more likely we are to accept everything they do as correct or acceptable behaviour. The key here is emotional maturity. The mature person can make his own assessment of what is right and wrong, and act accordingly, without unquestioningly accepting what he sees others doing. (ii) Medical induction Most drugs have a legitimate medical purpose, and their use for this purpose is part of sound medical treatment. When the need for continued treatment no longer exists, any further use constitutes abuse, whether the reason for continuing to take the drug is due to liking for its effects or simply due to habit. It is important that no drug should be taken for a prolonged period except on the advice of an expert, in this case the doctor. Many persons are introduced to the use of drugs by their physician as relief for pain in long periods of severe illness. Constant effort is maintained by doctors and hospitals to avoid drug dependence; however, experience with drugs and their effect in relieving tension and pain leads many people to ignore the warnings of professional advisors on the dangers of uncontrolled and habitual use, and they try to obtain drugs from other sources. (iii) Escape There are probably occasions when each of us feels overwhelmed by problems which beset us and often there is a desire to seek some way of removing those problems. The obvious and sensible method isto tackle the problem itself, but many people seek ways of escape. Drugs which can produce a feeling of detachment or oblivion are sometimes resorted to. Of course this does nothing to settle the difficulty, but simply makes it seem less urgent or pressing. If possible, the problem itself should be faced and solved, or if this is not possible, ways of escape less harmful than self-medication should be found to relieve tension. (iv) Experimentation It is natural for all people to experiment. Unless we accept without question what we read or are told, this is themain way we learn. So it is natural that people will wish to experiment with drugs, to try and discover by personal experience the effects of different drugs, particularly those which have some stimulant or depressant effect. Because of the possibility of harm which can come from such drugs, and the dangers of becoming dependent upon some of them, experimentation must be strongly discouraged except by persons with 15 expert knowledge in the handling of drugs. Thrillseekers, looking for new experiences, investigating all sorts of novel or different situations or substances, are especially susceptible to the ill effects of drugs. Their emotional immaturity which makes them dissatisfied with normal relationships with other people and with everyday experience also makes them particularly liable to become dependent upon drugs with which they might experiment while seeking "something different" (v) Boredom Boredom can be a very real problem for some people, particularly if they are required to do tedious, repetitive jobs or jobs which do not sufficiently occupy their minds. Housewives can very easily drift into this sort of situation. The obvious way out is to seek interests outside the home or hobbies or crafts which can help fill their spare time. Unfortunately it is common for people in this sort of situation to turn to drugs to try and overcome the depression caused by tedium or to relieve the minor aches and pains which are magnified when they have too much time to pass. (vi) Persuasion A major proportion of known drug dependents are introduced to the habit by peddlers, confirmed dependents, or other drug abusers. Through ignorance of the damaging effect on the body and mind produced by narcotics or because "a friend" or "the gang" uses a drug many individuals are persuaded to undergo their first experience in self-administration of drugs in one form or another. The first few doses or shots seem perfectly safe. The clever peddler or firm addict often supplies the novice free of charge, knowing that once he is dependent he will pay almost any price to satisfy his craving. (vii) Easy availability Especially when they are under extreme stress, as in wartime and periods of intense and exhausting hospital training, professional medical personnel sometimes turn to drugs for relief and come to depend on them, because the supply is so readily available. Younger age groups The problem of drug dependence in our society tends to, be centred mainly on the younger age groups, although a considerable problem exists with the middle-aged group. The rebellious non-conformist is likely to resort to drugs as well as to other means of demonstrating his independence of the moral codes of society. Adolescence is a period of experimentation and rebellion, and the real problem is the possible - though not yet existent - large-scale use of drugs by normal young people in an attempt to follow seemingly modern trends and to express the normal adolescent' desire for independence. Being curious about the affect of drugs often leads young people to accept invitations to parties in the hope of seeing how others are affected by certain drugs. This can result in conflict with the law and being identified with a group "known to the police." It is among young people, therefore, that our main educational programmes need to be developed. 16 Some results of drug abuse Physical harm The type of ill-effect will vary according to the particular drug involved. Aspirin causes irritation to the lining of the stomach, and minute capillary bleeding into the stomach may occur when aspirin is taken. If it is taken to excess over a long period of time, sufficient irritation can occur to produce a stomach ulcer. Phenacetin has been shown, particularly in some susceptible persons, to cause serious harm to the kidneys if it is taken in large amounts over a period of time. People who habitually consume APC powders or tablets are therefore quite likely to develop gastric ulcer, or kidney disease. Stimulants are used to combat fatigue. The first few doses will also raise blood pressure. The prolonged continuous use of stimulants, however, is likely to produce hallucinations which are particularly dangerous when operating machinery or driving a car. Drivers have crashed trying to avoid imaginary objects. Another possibility is a feeling of over-confidence, resulting in risks being taken which are unnecessary and dangerous, with occasional fatal consequences. With sedatives, the opposite occurs. Abuse of sedatives can result in a perpetual state of stupor, with a lack of awareness of all that is going on, a slowed reaction time which can result in the affected persons being unable to get out of a dangerous situation in time, whether as a pedestrian, a car driver, or an operator of any other mechanical device. Continued abuse of bromide-containing sedatives leads to a condition known as bromism, in which bromide replaces chloride in the body tissues, resulting in impairment of nerve impulse transmission. Excessive use of some sedatives has been reported to result in a state of forgetfulness. Some apparent suicides have been thought to be possibly due to this condition, the person concerned forgetting that a dose has already been taken and swallowing a further dose, then another, and so on until a coma results. The dangers to a person under the influence of hallucinogens, where they are in a dream world largely divorced from reality, are obvious. The possibility that this condition may recur without further drug use makes these drugs potentially highly dangerous, and until we know much more about their effects they must be treated with extreme caution. 17 TYPES OF DRUGS - USE AND MISUSE TYPES OF DRUGS LIABLE TO ABUSE The chemical agents which, Man may abuse are remarkably diverse in chemical composition, pharmacological action, and subjective effects. They can be conveniently classified into the following groups: (a) Analgesics. (b) Tranquillisers. (c) Depressants. (d) Stimulants. (e) Opiates and opioids. (f) Hallucinogens. GENERAL EFFECTS All dependence-producing drugs have powerful actions on the central nervous system. Their harmful and adverse effects are related to neurological and behavioural changes. It will be' seen that the nature of the effects varies according to the groups of drugs. Dependence may be psychological or physiological or both. All drugs can create psychological dependence, that is to say that the drug is taken as a means of coping with life's stresses and to produce various effects, desired by the person, on his emotions, drives, perceptual powers, conflicts and problems. Physical dependence varies in its intensity. This is very marked with the opiate drugs and less marked or absent with other drugs such as amphetamine and marijuana. The abstinence syndrome varies in form according to the choice of dependent drug. TYPES OF DRUGS ABUSED Drugs subject to abuse appear invariably to be those drugs which affect the central nervous system. They may vary from solvents contained in such common household and industrial preparations as paints, thinners, glues, petrol, and thy cleaning fluids, through familiar medicines like headache powders, sedatives, and cough mixtures to the more potent and dangerous hallucinatory drugs, sleeping capsules and tablets, stimulants, and opiates. Decongestants, drugs which contract blood vessels and appear to relieve blocked nose and throat, often have a "rebound" effect, the symptoms being worse when use of the drug has ceased, even though the cause has gone. This can lead to continued use and habituation. Drugs particularly likely to be the subject of abuse fall into the following categories: (a) Analgesics Analgesics, or pain relievers, are used for the relief of mild to moderate pain. Some analgesic preparations, such as APC powders and tablets, also contain caffeine, a mild stimulant. (i) Aspirin (Acetyl Salicylic Acid). This drug is widely used for relief of pain but may cause irritation of the gastric mucous membrane and even bleeding from the stomach. For children, in particular, it is generally safer to use soluble aspirin (e.g., 18 the calcium salts of acetyl salicylic acid). Excessive use of aspirin over a long period may result in ringing in the ears, giddiness, nausea, and mental aberration. (ii) APC. These initials stand for - Aspirin, Phenacetin, and Caffeine. Phenacetin has three adverse effects on the body: (a) It can cause cyanosis (blueness) by oxidising in the iron in the haemoglobin molecule in the red blood cells so that oxygen cannot be effectively transported. This occurs in people who take the drug frequently. (b) It can cause kidney damage (a form of chronic nephritis) when used over a long period. (c) It can cause headaches and result in the repeated use of phenacetin ostensibly to relieve the headaches the drug has caused. Caffeine is usually well tolerated in small amounts. It may, however, cause insomnia, rapid pulse, and increased excretion of urine. It can be dangerous to people with heart damage. The initials APC sometimes are used to mean Aspirin, Phenacetin, and Codeine (e.g., in "Veganin", "Codis", "Codaphos", "Codiphen", etc.). Codeine is generally given to people suffering from pain, diarrhoea, or severe cough. It may, however, cause nausea, vomiting, drowsiness, or constipation. Taken in excessive amounts over a prolonged period Codeine may also cause mild morphine type dependence - or support already developed dependence. WI Tranquillisers Unlike barbiturate-type sedatives, tranquillisers can be used to counteract tension and anxiety without producing sleep or significantly impairing mental and physical function. The more potent tranquillisers have been used with great success in treating mental disturbances. However, they are not a general panacea, and even the mildest tranquilliser may produce dependence in the regular user. Tranquillisers may be divided into two groups - "major" or "minor" - based on their usefulness in severe mental disorders (psychoses). "Major" tranquillisers are those prescribed for the treatment of psychoses and include primarily the phenothiazine and reserpine-type drugs. The antipsychotic tranquillisers are not known to produce physical dependence, and abuse of this type of drug is almost nonexistent. "Minor" tranquillisers include a number of chemically quite different drugs. For the most part they are not effective in psychotic conditions, but are widely used in the treatment of emotional disorders characterised by anxiety and tension. Members of this group are abused by some patients or others who have access to them, the two most common being merprobomate and chlordiazepoxide. Chronic abuse involving increasingly larger daily doses, may result in the development of physical and/or psychological dependence symptoms during misuse and following abrupt withdrawal which closely resemble those seen with barbiturates. 19 (c) Depressants, or sedative drugs This group includes a variety of old and new drugs which have a depressant effect on the nervous system. They may be prescribed in small doses to achieve a general feeling of calmness, relaxation, drowsiness, or stupor, or in larger doses to produce a condition of deep sleep or narcosis. The most widely used drugs in this class are the barbiturates, which are used for epilepsy, high blood pressure, insomnia, in the treatment and diagnosis of mental disorders, and before and during surgery. Alone or in combination with other drugs, they are prescribed for almost every kind of illness or special situation requiring sedation. Under medical supervision, barbiturates are safe and effective. When self-administered or taken in excessive amounts, they are dangerous as their depressant effect on the central nervous system may result in mental disorientation and physical incapacity. A person under the influence may appear to be intoxicated - judgment and muscular co-ordination are impaired. Reaction time, visual perception, and attention are affected by even small doses. Often, these drugs are taken to counteract the effects of stimulants. However, when combined, amphetamines and barbiturates do not counteract each other completely; the one may even exaggerate the euphoriant effects of the other. "Purple Heart" pills ("Drinamyl" tablets) are deliberately abused for this effect. BARBITURATE ABUSE Barbiturates can be taken orally, intravenously, or rectally. Although barbiturate intoxication closely resembles alcoholic intoxication, barbiturate abuse can be far more dangerous than alcohol abuse or even opiate abuse. Unintentional overdosage can easily occur. Convulsions, which may follow withdrawal, can be fatal. Over-indulgence in alcohol before barbiturate ingestion may result in fatal depression of respiratory and cardio-vascular systems. The barbiturate abuser exhibits slurred speech and staggering gait. His reactions are sluggish. He is emotionally erratic and may be easily moved to tears or laughter. Frequently, he is irritable and antagonistic. Sometimes, he has feelings of euphoria. Because he is prone to stumble or drop objects, he often is bruised and has cigarette burns. Chronic misuse of barbiturates is accompanied by the development of tolerance and both psychological and physical dependence. Physical dependence appears to develop only with continued use of doses much greater than those customarily used in the practice of medicine. In a physically dependent barbiturate abuser, abrupt withdrawal is extremely dangerous because of convulsions, which can be fatal. Whether or not convulsions occur, there may be a period of mental confusion. Delirium and hallucinations similar to the delirium tremens (DT's) of alcoholism may develop. Delirium may be accompanied by an extreme agitation that contributes to exhaustion. 20 Bromides are a traditional sedative which, because of their ill effects, are not much use today. In some countries where, unlike New Zealand, they continue to be available without a doctor's prescription, the use of the organic bromides, carbromal, and brom. valetone is increasingly being found to have a cumulative action resulting in depression, sometimes of a severe degree and requiring psychiatric treatment. Alcohol increases the rate of absorption of bromide. Bromides accumulate slowly in the body and produce insidious symptoms among those who continue to take the many proprietary medicines containing them for years. Constant headache, irritability, emotional lability, and confusion may cause them to be labelled as neurotic. Hallucinations, amnesia, and speech disorders lead many into psychiatric institutions. Skin rashes of many types, which resist treatment, occur in a proportion of cases. (d) Stimulants This group includes drugs which directly stimulate the central nervous system and therefore induce wakefulness. However, although such drugs may keep a person awake, they do not help him to concentrate. Likewise, although they stimulate physical activity, they do so at the expense of fatigue - causing the body to ignore its natural warning to rest. Thus, when artificially stimulated activity is indulged in, the body adds a second fatigue burden to the first. Obviously the body cannot continue to ignore fatigue in this way indefinitely without suffering some ill-effects. Nervousness is a direct result and severe depression frequently follows as the effect of the stimulant wears off. Stimulants also have some effect on the appetite, and are sometimes used for slimming, although their activity is limited in this direction and no great benefit has been demonstrated beyond the early period of treatment for excessive weight. Stimulants related to amphetamine and ephedrine can be of value in treating hay fever and colds because they shrink the nasal membrane and ease stuffiness. They also have a stimulating effect on the heart and cause constriction of blood vessels which may result in acute or permanent damage. Mild and relatively harmless stimulation can be obtained from "stay-awake" tablets containing caffeine, but the same stimulating effects can be obtained from drinking tea or coffee - both of which in normal strength contain roughly similar amounts of caffeine. Cola drinks, too, are refreshing as a result of their caffeine content, but they contain quite a high percentage of sugar which may be to the detriment of good nutrition. So far as the drug effects of these drinks are concerned, the average healthy adult can drink them in moderation without fear of serious consequences. Nevertheless, caffeine can have a definite habit-forming effect, although not nearly as serious as the dependence which can be developed to the stronger stimulants. Continued use of stimulants may lead to a psychosis indistinguishable from schizophrenia, with delusions of persecution, hallucinations, etc. The more tolerance to the drug that occurs in stimulant dependents, the greater the risk of psychosis. There is no appreciable withdrawal physical syndrome with stimulants. Stimulant abuse is an increasing problem among social rebels, delinquents, and adolescents seeking excitement. It may also be a larger problem than is generally realised among women who have been taking slimming pills containing amphetamines for long periods. 21 At least one reason why stimulants present such a danger is that the intoxicated individual is not rendered incompetent, as with alcohol or barbiturates, and is not peacefully content, as with marijuana or opiates. Even when suffering from a drug-induced paranoid psychosis, he has no clouding of consciousness and is able to act on his delusions of persecution. The danger has been recognised with cocaine, but it would appear to be equally relevant to other stimulants in direct proportion to their relative potency. Cocaine Cocaine was formerly used extensively to produce local anaesthesia particularly for dental surgical procedures. In this field newer synthetic compounds are being used. It is an uncommon drug of abuse in New Zealand. Cocaine is generally taken intravenously, although it is still occasionally taken as a snuff. Dependents will inject 2-3 grains of cocaine every 10-15 minutes and may take 20-60 grains of the drug in 24 hours. Cocaine is extracted from the leaf of the coca plant, native of South America. It was used by the Inca civilisation, which was fully developed before the tenth century, but limited to the aristocracy. When the Spaniards disrupted the Inca civilisation the habit spread and was encouraged as a means of enslaving the native populations. There is still an enormous trade in it in South America. Towards the end of the last century cocaine was used extensively in Europe before its dangers were recognised. Conan Doyle portrayed his own cocaine habit in Sherlock Holmes. There is no physical dependence on this drug, but the main dangers lie in the violent stimulation it causes and in the subsequent paranoid feelings. The paranoid may try to counter-attack the supposed enemy. The less serious physical effects of cocaine are digestive upsets, sleeplessness, excitability and an increased heart rate. Amphetamines ("Pep Pills") The amphetamine group of stimulant drugs is widely used for purposes such as slimming, keeping awake for study, or for long journeys, increasing athletic performance, or simply for "kicks". Amphetamine was first synthesised in 1887 but it was not until 1932 that it was used therapeutically (as an inhalant for head colds). In World War II it was used extensively in Britain to counter fatigue and was sold in the form of "energy tablets". Stimulation has been shown to lead to depression and in turn to suicide in severe cases. Common amphetamines are: Amphetamine (Benzedrine) (Durophet) Dexamphetamine Sulphate (Dexedrine) Methylamphetamine (Methedrine) and mixture of amphetamines with other drugs such as Drinamyl (Purple Hearts). These products are generally manufactured as 5 mgm white, yellow, blue, or purple tablets. Some people obtain these drugs fraudulently by visiting numerous doctors and having the prescriptions made up at a variety of pharmacies, thus avoiding detection. Many of these drugs are also purchased on the black market. 22 About one-third of amphetamine dependents report increased sexuality, often with the appearance or exaggeration of perverse activities. Increased promiscuity, homosexuality, transvestism, exhibitionism, and seduction of children have occurred under the influence ofthe drug. The outstanding physiological change that accompanies dependence is an extraordinary tolerance to the drug. Doses as high as 1,700 mg have been tolerated by them whereas a number of deaths have been reported from less than 150 mg taken by non-tolerant adults. Physical dependence is practically non-existent for stimulants. Drinamyl (purple hearts) is a most serious drug of dependence. The psychological reason for danger is that it has the qualities of immediate sensory gratification. The self regulation of pleasure-seeking demands is corrupted and the adult returns to infantile responses demanding immediate relief. It is the craving for pleasure which encourages its use. A close relationship has also been found between dependence on stimulants, particularly amphetamine, and crime. In one study petty crime, such as shoplifting, thieving, breaking and entering, and false pretences, has been found to be common in the case histories of stimulant dependents. It is usually related to the need to replenish supplies and the reluctance or inability to obtain gainful employment. (e) Opiates and Opioids This term usually refers to opium and its derivatives and includes the most dependent drug of all - viz., heroin. The classical narcotic is opium, although its main active constituent, morphine, is now more commonly used. From morphine chemists have manufactured a number of other drugs, some extremely potent like heroin, and others much less dangerous like codeine. A number of synthetic compounds with morphine-like effects have also been made during the past 30 years. These include pethidine, methadone (Physeptone), normethadone (Ticarda), dextromoramide (Palfium), and levorphan (Dromoran). Natural and synthetic morphine-like drugs are the most effective pain-relievers in existence and are among the most valuable drugs available to the physician. They. are widely used for short-term acute pain resulting from surgery, burns, etc., and in the latter stages of terminal illnesses such as cancer. The depressant effect of opiates produces drowsiness, sleep, and reduction in physical activity. Side effects may include nausea and vomiting, constipation, itching, flushing, constriction of pupils, and respiratory depression. Their appeal lies in their ability to reduce sensitivity to both psychological and physical stimuli and to produce a sense of euphoria since they dull fear, tension, and anxiety. Under the influence of morphine-like narcotics, the drug dependent is usually lethargic and indifferent to his environment and personal situation. If a woman is dependent on drugs and continues to use opiates during pregnancy, her baby will be born physically dependent. 23 The price tag on the abuse of these drugs is high since chronic use may lead to both physical and psychological dependence. Psychological dependence is the more serious of the two, since it is still operative after drug use has been discontinued. As the need for the drug increases, the dependent's activities become increasingly drug-centred. The most commonly abused narcotic drugs include: Opium is the less refined product obtained from the opium poppy. It takes up to 1 lb of opium to produce 1 oz of morphine, therefOre opium itself, being more bulky and therefore more difficult to smuggle, Is less common than its derivatives such as morphine. Morphine and other opium derivatives are available legally on a doctor's prescription for the alleviation of pain or for cough suppression. Morphine is marketed for legitimate use as white tablets and in ampoule form. Sources of unlawful morphine circulated by drug peddlers are by theft from pharmacists or doctors' surgeries or from warehouses, or are obtained through the use of a forged prescription on forms stolen from doctors. Codeine is derived from morphine. It has a milder pain killing action than morphine; it is used as a white tablet, either alone or in combination with aspirin and sometimes caffeine as well for the relief of pain, or in a syrupy combination as Linctus Codeine for the suppression of a cough. Codeine tablets and codeine linctus are a source for illegal preparation of morphine for illicit use. Heroin is a white or off-white powder at least four times more toxic than morphine and has a far greater dependence producing potential. The importation of heroin into New Zealand was forbidden in 1952. (f) Hallucinogens Distortions of perception, dream images, and hallucinations are characteristic effects of a group of drugs variously called hallucinogens, psychotomimetics, dysleptics, or psychedelics. They include mescaline, d-lysergic acid diethylamide (LSD), psilocybin, and dimethyltryptamine (D.M.T.). At present they have no general clinical medical use except in research. However they are being encountered with increasing frequency as drugs of abuse. There is much we do not yet know about these drugs, as their action is to modify the processes which are taking place within the brain, the part of the body which is least understood. We do know that it is the mid-brain, in the part which modulates emotional responsibility and regulates awareness, where the drugs produce their unique effects. Because people differ so much from one another in their emotions, their fears, beliefs, affections and reactions, their reaction to the use of hallucinogenic drugs is unpredictable. For some it is pleasant, for others a nightmare. A common feature is detachment from reality and an inability to react normally. There is a danger that a depressed person may be driven to suicide, or that the mind may in some cases be permanently affected, although this is an occasional observation which has yet to be adequately investigated. Marijuana (Cannabis) Although chemically distinct from the hallucinogens just named, marijuana is also considered an hallucinogen because its effects are similar. 24 The intoxicating substance which gives marijuana its activity is found primarily in a resin from the flowering tops and leaves of the female plant. The potency of marijuana varies with the geographical location in which the plant grows, time of harvest, and the plant parts used. Unlike other drugs which are abused, marijuana has no present day therapeutic use. Marijuana may be smoked, sniffed, or ingested, but effects are experienced most quickly with smoking. When marijuana is smoked there is initially apparent stimulation and exhilaration, followed by sedation, depression, drowsiness, and sleep. The effects, however, are variable and unpredictable. Few herbs show such variations in their content of active alkaloid ingredients. Even in the individual, the response to marijuana varies from time to time. The neurophysiological effect is muscular inco-ordination, but this is not often obvious by clumsiness or unsteady gait. Other effects include dizziness, dry mouth, dilated pupils, and red and burning eyes, urinary frequency, diarrhoea, nausea and vomiting, hunger, particularly for sweets, and a rise in pulse rate and blood pressure. The effects on mood vary from extreme elation and exhilaration to depression, panic, and severe anxiety. In general marijuana promotes a sense of well-being and relaxation, and an alteration in consciousness and an altered way of feeling and reacting to sensory stimuli. Anxiety and emotional tension may be reduced and critical faculties inhibited. It may induce striking illusions and hallucinations. The ditortion of time perception is especially marked, and time appears to pass more slowly. Fantasy and imagination may be stimulated. Ideas may be plentiful but disconnected and disorganised with forgetfulness of recent events. There may be increased auditory perception and sensitivity to rhythm. Listening to music after taking the drug may produce unusual aesthetic responses. In terms of some effects on behaviour, moderate use of marijuana is roughly comparable to moderate abuse of alcohol (also a drug). Like alcohol, it tends to loosen inhibitions and increase suggestibility, which explains why an individual under the influence of marijuana may engage in activities he would not ordinarily consider. Although the marijuana smoker sometimes feels himself capable of extraordinary physical and mental feats, he seldom acts to accomplish them for fear of disrupting his "euphoric" state. Marijuana does not produce physical dependence or an abstinence syndrome. Once the user has established the amount of marijuana needed to achieve his particular "high", there is little tendency to increase the dose, indicating that tolerance doesn't develop. Moderate to strong psychic dependence can develop in accordance with the user's appreciation of the drug's effects. However the drug can have unpredictable effects even on people accustomed to its use. To date, available information indicates that marijuana has few detrimental effects on an individual's physical health. When it is used frequently enough to produce psychic dependence it may lead to extreme lethargy, self-neglect, and preoccupation with use of marijuana to a degree that precludes constructive activity. Additionally, the use of marijuana may preciptitate psychotic episodes or cause impulsive behaviour in reaction to fear 25 or panic. According to a 1965 report on drug dependence in the Bulletin of the World Health Organization: "Abuse of cannabis (Marijuana) facilitates the association with social groups and sub-cultures involved with more dangerous drugs, such as opiates or barbiturates. Transition to the use of such drugs would be a consequence of this association rather than an inherent effect of cannabis. The harm to society derived from abuse of cannabis rests in the economic consequences of the impairment of the individual's social functions and his enhanced proneness to asocial and antisocial behaviour". Thus while the use of marijuana does not usually cause mental or physical ill-health, it may lead to social and legal problems. For example, it can be dangerous to drive a car under the influence of marijuana, owing to altered perception and lack of co-ordination. There are, therefore, two principal arguments against the widespread use of marijuana; one is individual and the other social. From the individual point of view, marijuana smoking is most dangerous to those with the greatest unfulfilled needs and those seeking escape from reality. The effects on such people, particularly the immature, are not predictable. At the very least, they become irresponsible and silly, and if in charge of a vehicle or in a position of personal risk of injury, they are likely to make grave errors or judgment. Sometimes violent behaviour results from marijuana intoxication, more often it induces inward looking detachment. The social risks of "legalising" marijuana are even more serious than the individual, in that its widespread use may encourage too ready withdrawal from social responsibility. No urban society can tolerate a threat to the social organisation of this nature, particularly in view of the indeterminate dosage margins which divide euphoria from anti-social behaviour. There are other hazards which could follow in the train of "legalised" marijuana usage, one of which is multiple habituation to drugs, common in the young experimenter, and extremely rapid in development and difficult to treat effectively. One should not forget the highly vulnerable state which marijuana may induce in those with personality disorders or social or intellectual maladjustment. It is illegal for the young to consume alcohol yet all to easy for them to obtain it. It would be a dereliction of social duty to make yet another potent intoxicant available which can and does lead to continued heavy indulgence in some cases with consequent physical and mental disturbance, and in other cases introduces the young and immature Person to undesirable elements of society from which he may find it difficult to withdraw. A cheap, easy, and also a common way of drifting into drug habituation is to begin by smoking marijuana. Most heroin addicts come through a series of preceding drug misuse. Marijuana is for many the most enjoyable substance (until they find others). But there is no reason to believe that marijuana use inevitably leads to the use of other drugs. It may indeed follow other drug misuse in some instances. LSD d—Lysergic acid diethylamide, one of the most potent of the hallucinogens, is derived from an alkaloid found in the fungus ergot. 26 The importation, manufacture, and use of this substance, except for restricted medical research use is illegal under the Poisons Act. On the illicit market, the drug may be obtained as tablets, gelatine flakes, a small white pill, as a crystalline powder in capsules, absorbed on paper, or as a tasteless, colourless, or odourless liquid in ampoules. Frequently, it is offered in the form of impregnated sugar cubes, or biscuits. LSD is usually taken orally, but may be injected. LSD primarily affects the central nervous system, producing changes in mood or behaviour. Very small amounts of the drug produce hallucinations, intensification and distortion of sensory perception and may lead to panic, impulses toward violence, suicidal acts, and loss of sanity. A millionth part of a gramme per kilogramme of body weight is enough to produce hallucinations. The effect depends to some extent on the environment and the expectation which the subject brings to the experience. LSD may cause synaesthesia wherein colours produce sounds and where music is seen as well as heard. The subject may then feel himself "slipping out of his body" like an egg eased from its shell. This is followed by the "trip", i.e., the feeling of taking a journey. The subject feels himself to be "flowing on a cosmic wave", or "flowing with the universe". During "trips" LSD users experience hallucinations and heightened powers of perception. In general, the LSD experience consists of changes in perception, thought, mood, and activity. Perceptual changes involve senses of sight, hearing, touch, body image, and time. Colours seem to intensify or change, shape and spatial relation appear distorted, objects seem to pulsate, two-dimensional objects appear to become three-dimensional, and inanimate objects seem to assume emotional import. Sensitivity to sound increases but the source of the sound is elusive. Conversations can be heard but may not be comprehended. There may be auditory hallucinations of music and voices. There may be changes in taste and food may feel gritty. Cloth seems to change texture, becoming coarse and dry or fine and velvety. The subject may feel cold or sweaty. There are sensations of light-headedness, emptiness, shaking, vibrations, fogginess. Subjects lose awareness of their bodies with a resultant floating feeling. Arms or legs may be held in one position for extended periods of time. Time seems to race, stop, slow down, or even go backwards. Changes in thought include a free flow of bizarre ideas including notions of persecution. Trivial events assume unusual significance and importance. An inspiration or insight phenomenon is claimed by some LSD adherents. The mood effects of LSD run the gamut. There may be bursts of tears, laughter, or the subject may feel no emotion at all. A state of complete relaxation and happiness, not apparent to an observer, may be experienced. A feeling of being alone and cut off from the world may lead to anxiety, fear, and panic. Accordingly the LSD session is frequently monitored by an abstaining LSD-experienced friend to prevent flight, suicidal attempts, dangerous reaction to panic states, and impulsive behaviour, such as disrobing. There may be a feeling of enhanced creativity, but this subjective feeling rarely seems to produce objective results. Experiences under the drug are related to the previous personality of the person. Some describe the experience as frightening and feel they have passed through a living hell, 27 others delight in the experience. Others experience severe panic, and also prolonged psychotic episodes (even in experimental subjects when the personality of the volunteers is carefully selected). "Freak outs" occur, i.e., bad trips after pleasant ones. The physical effects of LSD are; increase in blood pressure and heart rate; the blood sugar goes up; there may be nausea, chills, flushes irregular breathing, sweating of the hands, and trembling of the extremities. Sleep is virtually impossible until at least 8-10 hours after the LSD episode is over. The pupils of the eyes are widely dilated, so that dark glasses are often worn, even at night for protection against the light. The view that LSD is harmless and safe is not supported by the figures of untoward reactions. Common complications are psychotic reaction with hallucinations, anxiety which can amount to severe panic - depression, and confusional episodes with disorientation. These may occur at the time the drug is taken, and may sometimes recur, particularly under stress, for several weeks after. Judgment may be so disordered that a person may believe that it is possible and safe to float down from a height. Medically unsupervised use of LSD has been described as analogous to playing "chemical Russian Roulette". Although the drug is still largely an unknown quantity there are well documented instances of LSD induced psychosis and well documented instances of panic states under the influence of the drug. The "LSD state" may recur months later, e.g., with disturbances of reality while driving a car or while on a high building ("Flash-back phenomenon"). LSD has been reported to be a "chromosomal toxin"; fragmenting and re-arranging chromosomes which determine a person's appearance, sex, and other characteristics. If the reports are confirmed this makes the drug potentially dangerous to the user and to his or her descendants over several generations. 28 SIGNS AND SYMPTOMS OF DRUG ABUSE* It is often difficult to detect persons misusing drugs simply by observation, as many of the observable effects of drugs are similar to the signs of other quite unrelated conditions. A student may be sleepy simply because of one or more late nights, he may be feverish due to an infection, or he may be irritable through worry or domestic tensions. Symptoms of central nervous disorder may be due to organic disease. Although it is difficult to recognise drug abusers, many potential "hard-core" addicts can be rehabilitated if their involvement in drug abuse is spotted in its early stages when professional help can be brought to bear on the problem effectively. THE KEYNOTE IS PERSISTENT CHANGE IN APPEARANCE OR BEHAVIOUR Common symptoms of drug abuse Not all drug abuse-related character changes appear detrimental, at least in the initial stages. For example, a usually bored, sleepy student may - while using amphetamine be more alert and thereby improve performance. A nervous, highstrung individual may, on barbiturates, be more co-operative. What we must look for, consequently, are not simply changes for the worse, but any sudden changes in behaviour out of character with a person's previous conduct. When such behavioural expressions become usual for an individual, there is a causal factor. That factor may be drug abuse. Signs which may suggest drug abuse include sudden and dramatic changes in school attendance, discipline, and academic performance. With the latter, significant changes in legibility, neatness, and calibre of homework may be observed. Drug abusers may also display unusual degrees of activity or inactivity, as well as sudden and irrational flare-ups involving strong emotion or temper. Significant changes for the worse in personal appearance may be cause for concern, for very often a drug abuser becomes indifferent to his appearance and health habits. He is also likely to be disinterested in school and social activities, but may become interested in new and older companions or acquaintances. There are other, more specific signs which should arouse suspicions, especially if more than one is exhibited by a single person. Among them are furtive behaviour regarding actions and possessions (fear of discovery), sunglasses worn at inappropriate times and places (to hide dilated or constricted pupils), and longsleeved garments worn constantly, even on hot days (to hide needle marks). Of course, association with known drug abusers is a sign of potential trouble. Because of the expense of supporting a drug habit, the abuser may be observed trying to borrow money from a number of individuals. If this fails, he will not be reluctant to steal items easily converted to cash, such as cameras, radios, jewellery, etc. And if his habit is severe enough to force him to use drugs during the school day he may be found, at odd times, in places such as storage rooms, cupboards, toilets, and parked cars. *NOTE - This section is written with particular reference to the school situation. 29 In addition to these general behavioural clues which are common to most drug abusers, each form of abuse generally has specific manifestations that help identify those engaged in it. They are as follow: The stimulant abuser The behaviour of the abuser of stimulants, such as amphetamine and related drugs, is characterised by excessive activity. The stimulant abuser is irritable, argumentative, appears extremely nervous, and has difficulty sitting still. In some cases, the pupils of his eyes will be dilated even in a brightly lit place. Amphetamine has a drying effect on the mucous membranes of the mouth and nose with resultant bad breath. Because of the dryness of mouth, the amphetamine abuser frequently licks his lips to keep them moist. This often results in chapped and reddened lips, which, in severe cases, may be cracked and raw. Dryness of the mucous membrane in the nose, cause the abuser to rub and scratch his nose vigorously and frequently to relieve the itching sensation. Incessant talking about any subject at hand, and often chain smoking, may also be signs of amphetamine abuse. Finally, the individual who is abusing stimulant drugs often goes for long periods of time without sleeping or eating and usually cannot resist letting others know about it. The depressant abuser The abuser of a depressant drug, such as the barbiturates and certain tranquillisers, exhibits most of the symptoms of alcohol intoxication with one important exception: there is no odour of alcohol on his breath. Students taking depressants may stagger or stumble in classrooms or halls. The depressant abuser may fall into a deep sleep in the classroom. In general, he lacks interest in activity, is drowsy, and may appear to be disoriented. The hallucinogen abuser It is highly unlikely that students who use hallucinogenic drugs (such as LSD) will do so in a school setting. Such drugs are usually used in a group situation under special conditions designed to enhance their effect. Persons under the influence of hallucinogens usually sit or recline quietly in a dream or trance-like state. However, the effect of such drugs is not always euphoric. On occasion, users become fearful and experience a degree of terror which may cause them to attempt to escape from the group. Other signs include decreased sensitivity to pain (comparable with effect of opiates), loss of apprehension, impaired intellectual functioning, loss of contact with reality. LSD users often experience dramatic shifts in values. A pupil who has been doing well in school and has established goals for himself may suddenly lose interest and decide to drop out of school. And the pupil who is an LSD user may think he is achieving at a higher level when his performance has actually decreased. In contrast to the users of other drugs, who attempt to conceal their actions, the LSD user frequently talks about using the drug and encourages friends to use it. Speaking the jargon associated with LSD may be indicative of association with LSD users. 30 The marijuana user: While marijuana is pharmacologically an hallucinogen its widespread use warrants separate discussion. The user of marijuana ("pot", "grass") is unlikely to be recognised unless he is heavily under the influence at that time. Pupils will probably never come to school while they are in the early stage of marijuana use - characterised by hilarity, talkativeness, and generalanimation - or even when they are in the later stage - one which is characterised by depression, drowsiness, and incoordination. However, they may come to school wearing clothes that carry the odour of marijuana smoke, and this can be identified because it is similar to the odour of burning hay or rope. The eyes - depending on the recency of use - may be reddened, and the pupils of the eyes may appear frozen and dilated. To conceal this tell tale sign, the smoker will often wear dark glasses. The marijuana smoker is also likely to have badly stained fingers for two reasons: (a) the practice of holding the cigarette until it is almost consumed: (b) the way the "reefer" is smoked. Because of the rapid burning and harshness of the marijuana cigarette, it is generally passed rapidly, after one or two puffs, to another person. The smoke is deeply inhaled and held in the lungs as long as possible. The cigarette is often cupped in the palms of both hands when inhaling to save all the smoke possible. If a person is indulging in more than occasional marijuana smoking, he may appear sleepy, perspire freely, and show marked pallor. A teacher should be alert to identify these signs, even though they may indicate health abnormalities; and when they are noted the teacher should refer the pupil to the school health service, for, regardless of what causes the conditions, an investigation is imperative. The glue sniffer The glue or solvent sniffer usually retains the odour of the substance he is inhaling on his breath and clothes. Irritation of the mucous membrances in the mouth and nose may result in excessive nasal secretions. Redness and watering of the eyes are commonly observed. The user may appear intoxicated or lack muscular control, and may complain of double vision, ringing in the ears, vivid dreams, and even hallucinations. Drowsiness, stupor, and unconsciousness may follow excessive use of the substances. Discovery of plastic or paper bags and rags or handkerchiefs containing dried plastic cement is a telltale sign that glue sniffing is being practised. The opiate abuser Few opiate abusers are seen in school, situations; they usually cannot function within the ordered confines of such institutions. However, a rare individual may begin narcotic abuse while still attending school. Such individuals are likely to be drinking paregoric or cough medicines containing small quantities of opiates. The presence of such bottles in waste baskets or around school grounds is a clue to this form of abuse. The medicinal odour of these preparations is often detectable on the breath. / 31 Other "beginner" opiate abusers inhale drugs such as heroin in powder form. Sometimes, traces of this white powder can be seen around the nostrils. Constant inhaling of narcotic drugs makes nostrils red and raw. The opiate user is sometimes peevish, irritable, and restless and at other times drowsy and apathetic. In either case he is uncommunicative and disinterested. He shuns his former friends and classmates, shows lack of interest in others, and is generally antisocial. In order to secure money to support his habit he may find it necessary to steal from his mates. He is likely to show little or no interest in physical activities and to exhibit poor capacity for muscular exertion.For maximal effect, opiates usually are injected directly into a vein. The most common site of the injections is the inner surface of the arm at the elbow. After repeated injections, scar issue ("tracks") develops along the course of such veins. Because of the easy identification of these marks, such drug abusers usually wear long sleeves at odd times. Females sometimes use make-up to cover marks. Some males are tattooed at injection sites. The presence of equipment ("works" or "outfit") used in injecting is another way to spot the abuser. Since anyone injecting drugs must keep his equipment handy, it may be found on his person or hidden nearby in a locker, washroom, or some place where temporary privacy may be found where the user disappears from group activities for prolonged periods while preparing a "fix". The characteristic instruments and accessories are a bent spoon or bottle cap, small ball of cotton, syringe or eyedropper, and a hypodermic needle. All are used in the injection process: the spoon or cap holds the drug in a little water for heating over a match or lighter, the cotton acts as a filter as the drug is drawn through the needle into the syringe or eyedropper. The small ball of cotton ("satch cotton") is usually kept after use because it retains a small amount of drug that can be extracted if the abuser is unable to obtain additional drugs. The bent spoon or bottle cap used to heat the injection is easily identifiable because it becomes blackened by the heating process. In time the opiate user is likely to lose weight and appear emaciated. This is because in his preoccupation with drugs and the means of securing them he is prone to neglect his physical wellbeing. Identification of drugs No one can effectively identify a drug by sight, taste, or smell for one reason - all the drugs discussed, except for marijuana, can be found in tablet, capsule, powder, and liquid form - and in varying colours and shapes. Even marijuana, which is usually smoked, can be found as a sweet. Marijuana biscuits and marijuana tea also exist. The original "Turkish Delight" contained marijuana in resin form. The only way, therefore, that most drugs can be correctly identified is through a series of complicated laboratory procedures performed by trained technicians. The best a person can do is to suspect the possibility of abuse when drugs are found under peculiar circumstances or in the possession of someone exhibiting unsual behaviour. 32 What to do Obviously no young person attending school should be summarily labelled as a user of drugs because one or more of the indications described in the foregoing are present. It is possible that he could be suffering from some problem, defect, or disease quite unrelated to drug abuse. In either case an appropriate investigation should be instituted in an endeavour to secure any medical help and treatment that might be needed. Most unusual, but highly critical, is the emergency situation. In a case of unconsciousness which may be drug-induced, rapid action is vitally important. If there is not a standing procedure for emergencies a doctor should be called immediately, or the victim taken to a hospital. If breathing fails, some form of artificial respiration should be administered until medical help arrives. Parents should be advised of the situation as soon as possible. Because of the contagious nature of drug abuse every effort should be made to determine sources of supply and names of other persons who may be abusing drugs. Experience has shown that drug abusers attempt to pass their habit to friends and associates in order to raise money. The drug abuser, therefore, must be identified to help prevent the spread of drug abuse. 33 CONTROL OF DRUGS AND TREATMENT OF DRUG ABUSE Legislation controlling the distribution and use of drugs of dependence takes into account a number of factors. The first is the nature of the drug itself, for obviously a drug that quickly produces dependence in any person taking it must be more rigidly controlled than one which must be taken to excess over a period of time. The second factor is the usefulness of the drug. Where a drug has no recognised medical or other useful property, prohibition of its use may be possible, whereas this may not be applied to a useful and perhaps, even irreplaceable drug. A third factor is what we intend legislation to achieve, in relation to those who may promote the misuse of drugs (peddlers) and those who may be the victims of misuse (dependents and their associates). Considerable confusion has been created in the use of words. In some contexts the terms "addiction" and "dependence" have been used interchangeably. W.H.O. Expert Committees and other United Nations Organisations have for many years recommended replacement of the word "addiction" by the word "dependence", supplemented where it is necessary by a brief, usually one word, description of the type of dependence. Originally used in pharmacology as an adjective and adverb, to describe an effect which is dose related, increasingly in law (New Zealand followed suit in the Narcotics Act 1965) the word "narcotic" has been used as a noun. Not every substance that can have narcotic effect (e.g, alcohol, petrol, barbiturates) is stated by the law to be a narcotic (noun). Some drugs of abuse which have little or no narcotic effect (e.g., hallucinogens) have been named in the law as "narcotics". Use Of the word as a noun should be restricted to the legal meaning. International control of drugs liable to misuse Drug dependence is a world health problem, and a problem that must be tackled internationally. As early as 1909 it was realised that action on an international scale was imperative in order to combat successfully the growing opium traffic. The question of limitation of production of opium in China was made the subject of international study by the International Opium Commission which met at Shanghai during that year. Three years later came the Hague Convention which was aimed at limiting the use of opium and its derivatives and cocaine to medical and scientific purposes. The Hague Convention was wide in scope but confined itself to general principles leaving signatory nations free to adopt differing methods of putting them into practice. This Convention was signed by the United Kingdom on behalf of the British Empire. The inadequacy of the Hague Convention of 1912 was felt when the League of Nations endeavoured to co-ordinate the activities of nations into a more effective campaign against the illicit traffic in narcotic drugs. In 1925 the First Opium Conference was held and it resulted in an Agreement, limited to countries having Far Eastern territories and dependencies, and a Protocol to the Agreement, relating to the gradual suppression and eventual elimination of use of opium prepared for smoking. 34 The Second Opium Conference was held in the same year, resulting in the conclusion of the Geneva Convention of 1925. This convention replaced certain sections of the Hague Convention and made more detailed the obligations of signatory nations, particularly in regard to national controls, international trade and the furnishing of statistical information to the Permanent Central Opium Board set up under the terms of the Convention. The Gevena Convention of 1925 produced a much more effective control over the use of narcotic drugs but there still remained one big weakness, namely that existing conventions placed a limitation only on use of drugs and as a result there was production of raw materials and manufactured drugs far in excess of the world's requirements for legitimate use. It was realised that the continued existence of these surplus substances increased the danger of diversion of narcotic drugs into illicit channels. Limitation of production, manufacture, importation, and exportation of such substances to medical and scientific requirements was considered to be the most effective answer to this problem. The Limitation Convention of 1931 resulted from international action to attain this objective, although less emphasis was placed on limitation of production of raw materials than on limitation of manufacture and sale of refined drugs. The first pästwar achievement of note was the Protocol of 1948 which brought under the Limitation Convention of 1931 drugs of a type formerly outside its scope. Medical advances prior to and during the war resulted in a number of synthetic narcotic drugs being developed. The Protocol of 1948 enabled international control of such substances to be exercised in the same manner as for "natural" narcotic drugs. The postwar years showed a rapid increase in the production of raw opium, until the estimated stocks were sufficient to supply legitimate world demands for many years and annual production was far in excess of requirements. Such overproduction was reflected in increased illicit trafficking of raw opium. It became clear that the Limitation Convention of 1931 did not place sufficient emphasis on the limitation of cultivation of opium poppies and production of opium. In an endeavour to overcome this weakness an international opium conference was held in 1953. The Conference concluded the Opium Protocol of 1953, the object of which was to place the cultivation and production of Opium under a regime of control as stringent as that applying to the manufacture of refined narcotics. Single Convention on Narcotic Drugs, 1961 With the coming into force of the Opium Protocol of 1953, the total number of associated conventions and protocols reached nine. It has long been realised by parties to these agreements that they should be codified into a single document setting out the obligations more clearly and eliminating anomalies caused by some of the treaties not being complementary in all respects. In 1961, after more than 10 years of preparation, such a document was signed by representatives from 61 countries throughout the world. This agreement, known as the Single Convention on Narcotic Drugs, '1961, sometimes referred to simply as The Single Convention, replaces all previous treaties. 35 Being a codification of the previous agreements the Single Convention covers all aspects of the control of narcotics. For the first time it provides for the names of all drugs brought under this international control to be listed in or, by simple amendment procedures, added to the one document, Parties are obliged to keep their imports and manufacture within the limits of their estimates and may not export to another party, quantities in excess of the estimates of that country. Parties to the Single Convention are required to furnish information to the Narcotics Commission including an annual report of the operation of the Convention. The annual report must include detailed statistics of drug dependence. Details of narcotics legislation passed and reports of cases of illicit trafficking must also be supplied. The basic requirements of domestic control of the illicit trade as contained in the Single Convention are that: (a) manufacture, trade, and distribution of narcotics shall be permitted only under licence, issued to properly qualified persons; (b) supply of specified narcotic drugs to the public, shall be on prescription only; (c) detailed records of all processes and transactions involving narcotic drugs must be kept by licensees and all commercial operations subject to regular government inspection; (d) action must be taken against illicit trafficking, with national authorities coordinating their preventive and repressive measures and co-operating with other countries; (e) serious offences involving narcotics are required to be punishable by adequate • penalties, particularly imprisonment; and (0 parties are required to give special attention to the provision of facilities for the medical treatment, care, and rehabilitation of drug dependents. Further International Control Almost immediately after the Single Convention came into effect it was clear that the problems of drug dependence and drug abuse were expanding explosively and that the drugs involved extended far beyond those which were under international control. Most of these are synthetics - some known for many years, but the majority of quite recent origin. The Commission on Narcotic Drugs of the Economic and Social Council of the United Nations, together with the World Health Organisation, asked for an evaluation of this newer type of drug abuse and co-ordinated a search for methods of control. From this study the community of nations has enacted a new treaty, the Convention on Psychotropic Substances 1971. Psychotropic substances are drugs which have an effect on the mind and are liable to be abused or to induce dependence. By this convention, signatory countries undertake and bind themselves: (a) To strengthen (or, in a few countries where it has not already been instituted, to put into effect) internal controls on psychotropic substances; (b) To institute a licensing system for manufacture, trade, import, export, and distribution; 36 (c) To give special attention to the provision of facilities for medical treatment, care, rehabilitation, and social reintegration of dependents on psychotropic drugs; on much the same lines as provided for narcotics. Control of Narcotics and Psychotropic Drugs As a party to the Single Convention on Narcotic Drugs, New Zealand already has obligations, and is likely to have more, which require control of the legal trade, distribution and possession of a wide range of drugs, and suppression of illicit trafficking in them. The "competent authority" to do this is the Director-General of Health, but the responsibility for all aspects of suppressing illicit activity, and for some aspects of legitimate distribution and use is given by Parliament to the Customs Department and the Police. The Health Department is responsible for legitimate distribution and medical use within the country and is the co-ordinating body for the purposes of the Single Convention and any Protocols that may be added to it. New Zealand's performance in controlling drugs is under the constant surveillance of the international controlling bodies - the Commission on Narcotic Drugs of the Economic and Social Council ("ECOSOC") of the United Nations, the International Narcotics Control Board, and the International Criminal Police Organisation (ICPO or Interpol). An annual report on the operation of the Single Convention is required to be furnished by the Director-General of Health to the Secretary-General of the United Nations Organisation, and the Commissioner of Police reports to Interpol. There is a continued exchange of information, in their appropriate responsibilities, between these people and bodies. Types of Control of Drugs Every country develops its own system of control of drugs. Superficially these systems may appear dissimilar because they operate under different types of constitutional or legal framework and in countries of varied economic and social development. Function ally they all embody application of the same principles and aim at similar end results. But drugs affect people, so some of the law appears to be directed to people rather than to drugs. A number of laws are involved in New Zealand and these divide drugs into several categories to which different conditions apply. Prohibited Substances This is a misnomer, for there are no drugs which are absolutely prohibited in New Zealand. What happens is that possession, distribution, and use is illegal outside a specific or general authority which can be given sometimes by the Minister of Health and sometimes by the Director-General of Health. It is in this way possible to "tailor" an authority which is appropriate to the particular drug and the purpose of use. These restrictions can arise partly under the Narcotics Act, but principally under the Poisons Act with drugs such as cantharidin, LSD, thalidomide, mescaline, and D.M.T. or under the Food and Drug Act with new drugs about which not enough is known and research is necessary. Narcotics The classification in law is not to be confused with the pharmacological (effect on the body) meaning. Many drugs having pharmacological narcotic effect are not legal RIVA Narcotics: a few legal Nacotics do not have narcotic effect. They are the drugs recognised as having the greatest potential for causing or supporting dependence. There are various types of dependence - the morphine type, the cannabis type, the cocaine type. All have elements of compulsive use. Only persons licensed or authorised to do so may import, export, manufacture, distribute in any way, or be in possession of any of these drugs. Most of these are required to keep balanced accounts of their receipts, disposals, and stock. A patient may receive the drugs only on a medical prescription. Prescription Poisons and Restricted Drugs These are drugs which should, for a wide variety of reasons, be supplied and used only upon the written prescription of a medical practitioner. Some are anti-infective agents like antibiotics, sulphonamides, and drugs used for the control of tuberculosis, the indiscriminate use of which may decrease their effectiveness through the appearance of drug resistant organisms. Some alter the hormonal balance of the body. Some can, as "side effects", cause serious damage to various functions or organs of the body - blood cells, kidneys, thyroid function. Some have not been used long enough for their probable dangers to be known. An evaluation of the benefit which the drug may bring compared with the unwanted effects must be made in individual cases. Some of the prescription poisons have a profound stimulant or depressant effect upon the brain, and have been used to excess for their ability to delay fatigue, as an escape from the problems of daily living, or simply for "kicks". Most of this group can produce dependence, often physical, always psychological. It is probable that most of this group will be controlled more closely in a somewhat similar manner to the Narcotics under the Convention on Psychotropic Substances. Only persons licensed or authorised to do so may import, export, manufacture, distribute in any way, or be in possession of, any prescription poison or restricted drug. A patient may receive them only on a medical prescription. Traders are required to keep records of all disposals and be able to produce evidence of receipts. Medicinal Poisons These fall into two groups, and may be sold only in pharmacies; the first by a pharmacist, personally; the second by an assistant with the pharmacist's agreement. In many cases (particularly when there is a doctor's prescription) a record of the supply must be kept. The pharmacist has the responsibility of pointing out to a person being supplied, any danger in the use of the drug and has the right (indeed the duty if he thinks there is likely to be misuse) to refuse any sale. Some drugs in these groups can be abused and can cause some dependence. But their potential is not as great as is that of the narcotics or the prescription poisons. Open Selling Drugs There is a limited number of drugs which may be sold by anyone. This does not mean that their use is altogether free from the risk of causing harm. They can be misused or overused and cause mild types of dependence or, in a few cases, iatrogenic illness. 38 Advertising of Drugs The Food and Drug Act sets out some requirements and some prohibitions in advertisements for drugs. As instances; the name and address of the advertiser must appear; claims must not be false or misleading; testimonials or claims that any person uses the drug are prohibited; references to many illnesses are prohibited or restricted; statemenst must not qualify or be contrary to, any that are specifically required by regulations; The Poisons Regulations prohibit claims that any drug is safe or non poisonous or non habit forming and require a few statements like "Poison" or "Caution: It is dangerous to exceed the stated dose" to appear in advertisements.The legal principle of Caveat Emptor - let the buyer beware - still applies. There is nothing to insist that the advertisement be "balanced" in setting out advantages and disadvantages of the drug. The prominence to be given to required statements is not specified, so a reader- may miss them. There is nothing to prevent advertising puffery; the promotion of imaginary needs which the product advertised can claim to satisfy; or the making of the "open ended comparison" which cannot be tested; or the use of other such promotion techniques. Labelling and Storage Good labelling is designed to encourage users to read warnings before opening containers. As -a minimum labels are required to show: (a) The name or identity of the drug. In some cases this may require reference to the prescription records of a pharmacy, hospital, or doctor to establish clear identity. (b) If for internal use, the recommended dose and frequency of dose; (c) The name and address of the supplier - either the immediate supplier or wholesaler or manufacturer. - In some cases additional information or warning may be required. Labels are also often advertisements and should be subjected to the same critical view. It is usually difficult, if not impossible, by looking at drugs to identify them or to tell their strength or whether they have deteriorated. Deterioration may take place by access of moisture, air, light, or chemical interaction with some other substance (perhaps another drug). It is of considerable importance, then, to keep drugs and medicines in their closed original containers with the original label, protected from light and moisture and, because many can be poisonous if improperly used, to ensure that children cannot gain access to them. It is also important to destroy drugs and medicines when the purpose and time for which they were obtained is past. (The best method of destruction is probably the simple one of putting them down a drain.) Availability Under the groupings of general classes of drugs given above, brief reference is made to the circumstances and conditions under which they may be sold. But it must be remembered that in the majority of cases the word "sold" has the extended meanings of "give", or "bartered", or "lent", or "supplied as part of a service". It follows that except for the small group of open selling drugs, their supply must be by a doctor, dentist (or veterinary surgeon - for animals), hospital, or pharmacy, on the conditions which apply to these licensees or authorised persons, or the supply is illegal. 39 Possession The possession of narcotics, prescription poisons, and restricted drugs is illegal unless the person who has them is licensed or authorised - much in the way that the driving of a motor vehicle is illegal unless the driver is licensed. And in the manner that the onus of producing his licence is on the driver, the responsibility of showing that he has authority or reasonable excuse for having them rests with any person found to be in possession of any of these drugs, often whether he knows what they are or not. This is an added reason for never removing drugs from the labelled container in which they were received, because the label often has the information of the name of the supplier, the patient's name, and a prescription number which will enable proof of the authority to be traced. Dealing with offenders New Zealand Narcotics Law clearly distinguishes between trafficking and possession, the penalties for which are light by overseas standards. In fact the Courts may, and generally do, impose far lesser penalties than the maxima set out in the relevant Acts having regard to the person involved as well as to the seriousness of the offence. Often rehabilitation of the offender is the immediate aim, and the Court may order and arrange for this in lieu of other penalty, or as a condition of probation. Procuring, receiving, storing, using or otherwise having in possession, and without reasonable excuse, any prescription poison or restricted drug renders the person liable to up to 3 months' imprisonment or to a fine of up to $400 or to both. For illegal importing, exporting (including smuggling), cultivation, production, selling, supplying, administering drugs classed as narcotics under the Narcotics Act sometimes even for offering to do these things, or possession for the purpose of trafficking, a Court is empowered to impose up to 14 years' imprisonment or, in special cases, a fine of up to $2,000. For mere possession of narcotics and for some other offences, the maximum penalty is 3 months' imprisonment and/or a fine of $400. For theft or "receiving" of narcotics or false pretences or fraud to obtain a narcotic, the maximum penalty is imprisonment for 7 years. Prescribing of drugs In New Zealand the legislation makes provision for the prescribing of narcotics, prescription poisons, and restricted drugs only for medical treatment. What medical treatment is has not been defined; it depends on the professional judgment of medical practitioners individually and collectively, and in realtion to the particular person who is being treated. It may in some cases where there is also psychiatric or medical illness, extend to the continuing prescribing of drugs for a person who is dependent on them. But a drug dependent will sometimes not submit to the regiment of medical treatment. He may seek illicit suppliers, or attempt forging prescriptions or taking other fraudulent action, or seek attendance by more than one doctor. Because of the system of records, inspections, and reporting, this soon becomes apparent if the drugs are narcotics. It is less conspicuous if they are psychotropic substances. A Medical Officer of Health may invoke the appropriate restricting provisions of the Narcotics Regulations or of the Poisons Regulations. If he is satisfied that the person is 40 dependent or likely to become dependent on the drug, he may issue a notice restricting the person to seeking the drug, or prescription for the drug, from one named medical practitioner (or hospital). He may restrict the dispensing of prescriptions to a named pharmacy, and may either prohibit the seeking and obtaining of any supplies of the drug or drugs, or name and limit the maximum quantities of drugs that may be sought or obtained. If the person oncerned departs from the terms of such a notice the seeking, obtaining, or possession of the drugs is illicit and the person becomes liable to the penalties set out above. The ultimate sanction is an order for detention and treatment under the Alcoholism and Drug Addiction Act. Treatment of dependence Persons dependent on alcohol, narcotics, psychotropic stimulants or sedatives should be treated with a combination of the psychological, medical, and social methods best suited to their individual needs, and then rehabilitated. Not all hospitals can provide satisfactory treatment programmes for such patients as yet. Treatment services should be so planned as to provide support and supervision right up to final rehabilitation. The problem has so many facets - medical, psychological, social, and economic - that a wide range of services must be employed, closely linked with the health services. In addition, any country with a problem of alcoholism or drug dependence needs to establish at least one specialised research and teaching hospital (or hospital unit), associated with a university, to provide facilities for investigating every phase of dependence from withdrawal to rehabilitation and to train medical and auxiliary staff. Doctors, dentists, pharmacists, nurses, and social workers should receive instruction on the subject of dependence. The range of personnel, who should ideally be involved in clinical programmes on drug dependence is wide; it includes physicians, psychiatrists, social workers, psychologists, nurses, occupational therapists, and religious or lay counsellors. In some cases, good work can be done by unqualified persons, particularly those who have themselves recovered from dependence on drugs. Treatment has to be preceded by diagnosis; so health workers, police, and magistrates should be trained to recognise dependence. High success rates have been recorded with special groups of narcotic addicts, but the relapse rate is also very high. Even the most active treatment programmes reach only a small proportion of those affected and are, at best, effective with only 50 percent of those they reach. It is probable that more new drug abusers appear annually in any country than are reached by treatment services. Hence the importance of prevention. In short, drug dependence is an illness which needs treatment. A patient may never be completely cured, but by gradual withdrawal of the drug, a return to comfortable, drugfree life is possible. Psychiatrists and social workers can help to abolish psychological dependence upon the drug in time. The personal problems which first led to drug taking can be understood and dealt with. Above all the sober fact that a return to drug dependence is very easy can be faced up to. 41 DRUG ABUSE SLANG Some drug abusers have a language of their own which covers almost every aspect of the abuser's life as affected by his habit. There are variations in this vocabulary from one locality to another and there are periodic changes, even in the same area such change may occur rapidly. The following list contains formal terms and the equivalent jargon that is spoken by persons who are using drugs or associating with drug abusers. Although this jargon originated with persons using drugs and their associates, it should be remembered that these terms are often picked up as slang by non-abusers, particularly teenagers, and therefore use of many of these terms cannot be considered evidence of drug abuse. However, persistent use of these terms by pupils should alert teachers to the fact that pupils are at least interested in drugs and to the desirability of discovering the reasons for this. Expressions Associated With General Use of Drugs Formal Usage Drug supplier To purchase drugs To attempt to purchase drugs Container of drugs To have drugs Prescription for drugs Effect of a drug Under the influence of drugs To inject drugs Equipment for injection drugs Needle for injecting drugs To take small amount of, on an irregular basis To be dependent on drugs A fatal dosage of drugs To abandon a drug habit Withdrawn from drugs 42 Slang Connection, peddler, pusher, the man, dealer, friend To connect, to make a meet, to hit, to cop, to score, to make a buy To buzz, to hit, to make it Bag, cap (usually a capsule), a can To be holding, to have gear Reader, ticker, script Bang, Loot, buzz, jolt, kick, coasting, let down, flash, nod (i.e., on opiates), high High, turned on, on the nod, hopped up, charged up, blasted, coasting, floating, lit up, wasted. Taste, hit up, to drop, bang, mainline (i.e., directly into a vein), pop, shoot up, job, skin pop, joy pop (small amounts irregularly) Fit, spike, biz, factory, layout, machinery, works, outfit Spike, needle, gun, hypo Dabble, week-end habit Hooked, hung up, habit (i.e., to have one) Hot shot, overdose, OD Kick Turned off, washed up, off Formal Usage Sudden drug withdrawal Non-user of drugs A personal problem Party Money To have money Arrested Police Wanted by police Out of jail To alibi or confess To understand Slang Cold turkey, come down Cube, square Hang up Ball, blast, scene Bread, lace To be flush, heeled Been had, busted, hit Man, bull, heat, fuzz, pigs Hot On the street Cop-out To be hep, to he hip, to have savvy Expressions Associated with Dangerous Drugs Formal Usage Amphetamines Methamphetamine Benzedrine Dexedrine Barbiturates Barbiturates mixed with amphetamines, and the like One who uses (prescription poisons) Under the influence of barbiturates Amphetamine intoxication Slang Speed, beans, yippee beans Crystals Bennies Dexies Barbs, candy Goof balls Pill freak, pill head, pilly Goofed up High Expressions Associated with Marijuana Formal Usage Slang Marijuana Marijuana user Grass, hay, weed, hemp, tea, T, pot, shit Weed head, hay head, pot head, tea head, head Under the influence of marijuana Flying high, high, on the beam, out of this world, way out Marijuana cigarette Joint, reefer, stick, pot, weed Roach Butt of a marijuana cigarette Light a marijuana cigarette Torch up 43 To smoke a marijuana cigarette Slang Turn on, to blow a stick, blast, blast a joint, blow, blow hay, blow jive, blow pot, blow tea, get high Stack A quantity of marijuana cigarettes Blasting party, tea party, pot party Marijuana smoking party Formal Usage Expressions Associated with LSD Formal Usage LSD Sugar cube or water impregnated with LSD One who takes LSD Under the influence of LSD An LSD "trip" The act of taking LSD Feeling the effects of LSD The feelings a person experiences while under the influence of LSD To have unpleasant experiences while on a "trip" Vicarious experience that occurs by being with someone who is on a "trip" An experienced LSD user who helps or guides a new user Parties or sessions where LSD is used A pseudo experience obtained through the use of lights and sound; to have the same type of experience that one has with a drug A deprecative term applied by LSD users to social conformity and to the normal activities, occupations and responsibilities of the majority of people Emerging from an LSD experience Slang Acid Cube or wafer Acid head On a trip, on a rip, on a voyage, bent out of shape Experience Turning on Tuning in Out of the body, outside of myself Freak out, bum trip Contact high Sitter, tour guide, guru, travel agent Kick parties Happening Ego games Coming down Expressions Associated With Narcotics Formal Usage Slang Any narcotics Dope, goods, junk, shit, stuff, gear Powdered narotics Sugar 44 Formal Usage Slang Morphine Dope, junk, M, stuff, white stuff, hard stuff Cocaine Heroin Hard stuff, flake, star dust, dust, coke Hard stuff, Harry, joy powder, scat, dope, junk, sugar, white stuff Speedball Fix, shot, jolt Morphine or heroin mixed with cocaine Dose of a narcotic Poor quality narcotics Various amounts of a narcotic Small packet of narcotics To adulterate narcotics A narcotic addict Occasional user of narcotics In possession of narcotics Opium addict Under the influences of narcotics Narcotic habit Attempt to break the habit Method of curing addiction without tapering off Nervous or jittery because of need or desire for narcotic injection Paraphernalia for injecting narcotics An injection of narcotics To sniff powdered narcotics into nostrils One who injects narcotics into veins Place where narcotic addicts inject drugs Prescription or packet of narcotics A capsule purported to be narcotic but filled with a non-narcotic substance To inject narcotics Blanks, Lipton tea, flea powder Bag, bird's eye (extremely small amount), cap, paper, piece (1 oz, a large amount usually heroin), taste, things, deck Bag, balloon, bindle, deck, foil, paper To cut, to sugar down Hop head, hype, junkie, hooked, on the stuff, strung out Joy popper, skin popper, chippy Dirty, holding, straight Gow head High, litup, goofed up, knocked out, on the nod, stoned, wired Habit Kick, kick the habit, sneeze it out Cold turkey, cold Frantic, sick Biz, business, dripper, dropper, factory, fit, gun, joint, kit, lay-out, machinery, outfit, point, spike, works Shot, fix, bang, hit, jolt, pop Snort, sniff, horn, smack Hype, junkie, mainliner Shooting gallery Paper Turkey Shoot up, mainline 45 Appendix - TABULATED DRUG INFORMATION CHART .rotenuai sor uepl Pharmacologic ClassificationControlsMedical Use Physical Psyc Drugs 1. Morphine (an opium derivative) Central nervousNarcotic system depressant (Narcotics Act 1965) To relieve painYesYes 2. Heroin (a morphine derivative) DepressantNarcotic (Narcotics Act 1965) To relieve painYesYes 3. Codeine (an opium derivative) DepressantNarcotic To relieve painYesYes (Narcotics Act 1965) and coughing For sedation and YesYes 4. Paregoric (preparationDepressantPoison (Poisons Act 1960)to counteract containing opium)I diarrhoea DepressantNarcotic 5. Pethidine (synthetic morphine-like drug) (Narcotics Act 1965) To relieve painYesYes 6. Methadone (syntheticDepressantNarcotic (Narcotics Act 1965) morphine-like drug) To relieve painYes 7. Cocaine Local anaesthetic No 8. Marijuana Central nervousNarcotic system stimulant (Narcotics Act 1965) I Hallucinogen 9. Barbiturates (e.g., amylo- Depressant barbitone, pentobarbitone quinalbarbitone) Narcotic (Narcotics Act 1965) Yes Yes None NoYes Prescription PoisonFor sedation, sleep YesYes (Poisons Act 1960)producing, epilepsy, high blood pressure 10. Amphetamine drugs (e.g., Stimulant amphetamine, dextroamphetamine, methamphetamine - also known as desoxyephedrine) Prescription PoisonFor mild depres- -NoYes (Poisons Act 1960)sion, anti-appetite, narcolepsy 11. LSD (also mescaline,Hallucinogen peyote, psilocybin, DMT) Narcotic (Medical research NoYes (Narcotics Act 1965) only) Prohibited Substance (Poisons Act 1960) 12. Glue (also paint thinner, I Depressant None 46 None Unknown Yes / V)M 27041329 N.Z. Dept of Health. The use and abuse of drugs. S1AC 342 WM 270 NEW 41329 LIBRARY, DEPARTMENT OF HEALTH. P.O. BOX 5013, WELLINGTON. 25,000 Bks/2/71-4494D ¼ -,t4vk - 1. 4 4 V -. I 1' 4 4 4 5o I - -- -. ¼ I 4. 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