Pubdate: Thu,  5 Oct 2000
Source: New England Journal of Medicine (MA)
Vol. 343, No. 14
Copyright: 2000 by the Massachusetts Medical Society
Author: Pablo V. Gejman, M.D. University of Chicago


By a Working Party of the Royal College of Psychiatrists and the Royal
College of Physicians. 291 pp., illustrated. London, Gaskell, 2000. UKP9.50.
ISBN 1-901242-44-7

The abuse of psychoactive substances is among the leading causes of
disability and criminal activity in the world. Drug addiction is difficult
to study. Most drug transactions are effected illegally, which limits the
acquisition of accurate data on drug abuse. However, in 1997, the United
Nations International Drug Control Programme estimated that illicit drug
trade accounts for about 8 percent of all international trade and shows no
worldwide trend toward a reduction. In the United Kingdom, where drug
addiction is less of a problem than in the United States, there has been a
steady increase in drug use in the past 40 years, with the use of heroin
reaching epidemic proportions.

Drugs: Dilemmas and Choices, written by a working group established by the
Royal College of Physicians and the Royal College of Psychiatrists, covers a
broad range of issues, including history, the individual and social
consequences of drug addiction, the international drug trade, and policies
for prevention, control, and treatment. The work was meant to stimulate
debate and influence public-policy debates, and the authors write for a wide
audience, in clear, nontechnical language.

The sections of the book on the history of drug misuse provide some
instructive examples from the United Kingdom, the United States, Japan, and
Russia. Interestingly, at various times, the British have been at opposing
ends of the drug trade. In the 18th century, opium was still freely
available in England, and the British were the leading suppliers of opium to
the Chinese market. Opium addiction in China had devastating consequences
because it affected large sectors of the society, including the imperial
troops and the official classes. When the Ching dynasty imposed restrictions
on opium, the so-called Opium Wars followed. The Chinese capitulated in
1842, Hong Kong was ceded to Great Britain, and ports were opened to opium
trade. Now, ironically, Asia is the main supplier of illicit opium to the
United Kingdom.

The book also compares the history of drug policies in the United Kingdom
and in the United States. The United Kingdom has traditionally had a less
radical approach to drug enforcement. The authors discuss the effects of the
banning of alcohol during Prohibition in the United States, a measure they
interpret as a partial failure: although alcohol consumption and associated
deaths from cirrhosis decreased, the lack of compliance in conjunction with
economic factors made Prohibition untenable. The authors reflect that
restrictions on the availability of drugs may be ineffective when a large
proportion of the population opposes them.

The history of the use of stimulants in Japan after 1945 is less well known
to the general public. Amphetamines had originally been manufactured for the
military to increase the alertness of the troops, among other purposes.
After the war, army stocks were released, and an epidemic of amphetamine
abuse occurred in a country already devastated by war. The amphetamine
epidemic was over by 1957, superseded by a lesser one of heroin use -- a
sequence that raises the issue of causal relations between successive drug

Missing from this book is the history of the antitobacco and antialcohol
movement in Nazi Germany, which is known mainly from the work of Robert
Proctor. Eugenics, race "hygiene," and the antidrug movements were
intimately intermingled in Nazi Germany and shaped public policy. This
information would have served as a cautionary tale against the
implementation of any ideals of social purity in the fight against drugs.

In the United Kingdom, law enforcement and customs or interdiction efforts
account for about 75 percent of the expenditures to combat drug misuse and
result in the interception of as little as 5 to 10 percent of illicit drugs.
Interdiction does not work for many reasons, including the fact that
powerful drugs require the trafficking of very small volumes to satisfy the
demand, even a very large demand. For example, despite interdiction efforts,
the price of heroin in the United Kingdom has decreased substantially since
the 1980s, and the same is true in the United States. Very little of the
budget for the "war on drugs" is devoted to research in general, including
scrutiny of whether the current drug policies decrease drug misuse. There
are also limited data on the demand for drugs, but some reports suggest that
prevention programs may be less effective in reducing demand than once

Hence, a key topic is whether or not treatment works. The answer is that
comprehensive programs (i.e., programs that involve detoxification,
pharmacotherapy, psychotherapy, counseling, housing, employment, and
continued monitoring) work best. The book shows evidence collected by RAND
in the United States that, dollar for dollar, treatment is much more
effective than interdiction.

Over the past decade, use of the tools of molecular biology has led to
important advances in our understanding of some of the biologic mechanisms
related to addiction. This subject is not well covered in the book.
Appropriate references (and updated discussions) are often missing in
sections that deal with genetics and with biology.

Despite continued progress, particularly during the past few years, the
biologic processes underlying drug addiction remain largely unknown, and
little is known about the intersection of biologic and nonbiologic factors
in drug addiction. In spite of the difficulties, the book makes sense of a
large portion of the current body of knowledge on drug addiction. Policy
makers in the United Kingdom and in other countries should give serious
consideration to the book's arguments and advice.
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