Wednesday, 27 June 2012

The botanical and medical origins of opiates are mostly European

Much of what I'm going to say is straight from an article by Mike Jay in the London Review of Books of 21 June. The book is "Opium: Reality's Dark Dream" by Thomas Dormandy (Yale, ISBN 978 0 300 175325), I recommend it to the serious student of the history of drug policy. It helps to explain how we got where we are today, or rather, why our seemingly sensible policies only seem to make things worse. Much of what I'll say next is pure plagiarism, but I hope LRB and the authors mentioned will see it as free advertising.

Opiates are thousands of years old. As a drug they haven't changed, nor has our metabolism. The difference between feeling good on it and being dead is uncomfortably small, hence the reluctance of many medical men in ages past to use it. This is supposedly why Philips II of Spain, Charles II of England, and Lois XIV were among the masses who in their time died of protracted and unnecessary agony (as millions still do in poor countries today, thanks to the moral casino known as the INCB). The agony was unnecessary because opium as a painkiller was well known at the time. But doctors always know best. A 12th century medical man noted that many visitors to Mecca were "dangerously obsessed with their craving", still a problem today if the Saudi police are to be believed. Avicenna warned about the addictive and euphoric effects, and advised to collect your fee before dosing the patient, etc.

It wasn't until the 19th century that society begins to see pain relief as a necessity rather than a luxury. The spread of TB in the middle classes helped. As Mike Jay says "Despite resistance from some medical and religious authorities who maintained that pain was a physical or spiritual necessity, the use of opium to relieve it came to seem no more than common kindness". Palliative treatment had arrived, at least in the rich world.

As production was increased to feed this market, prices dropped. Opium was often cheaper than alcohol (and did a lot less damage in a crudely industrialising world). The article gives a tantalising vignette of Britain's most notorious opium growing area, the "poppyland" of the East Anglian fens, an area I know well, and more traditionally English than that you can hardly get. "Shopkeepers on market days would line up tots of laudanum tincture on their counters for visiting farmers to drink on the spot, with...bottles and jars of pills to see them through the week". For anyone who knows this area of England the image is surreal.

Opium had been known in China for ages, but he article claims that it was introduced, at least on the scale that European colonial powers were behind it, as an additive to Dutch tobacco, hence the design of the opium pipe, offering a way of more efficient vaporisation, inhalation, and a more intense high (at a time when most Europeans were still drinking the stuff).The market-induced Chinese custom transformed the drug from a private medication into a a convivially shared intoxicant, giving it ultimately its decadent and sinister, alien image.

By 1860 morphine had been developed out of opium, vastly improving its effectiveness as an (addictive) painkiller. Just in time really: By that time the American Civil War (the biggest single war of the 19th century) had created 50.000 amputees (not to mention 620.000 dead). It had accounted for the distribution of  more than ten million doses of morphine. Morphine addiction becomes a fairly familiar phenomenon in the States and elsewhere. By 1885 the American physician J.B. Mattison is quoted in the article as claiming that a third of all New York Doctors are morphine addicts. This led to problems in the medical professions (and their families).

And here we get to today's conundrum. This is where, in the US, addiction begins to be seen as specifically "un-American", not just immoral but rendering people decadent and socially useless. The latter is important. Henri Bergeron, in "Sociologie de la Drogue" makes a similar point about the social/political issue with drug use: the effect of drugs takes the form of a withdrawal from society (unlike alcohol, normally) and removes the citizen as a social actor and tax payer, thus rendering the state irrelevant. Not something the French are keen on.

By WWI legislation was coming in in various countries, as millions of men were given morphine on the battlefields of Europe. The article mentions one of the first prosecutions under the new laws, against Harrods of London, for selling gift-wrapped packets of morphine for friends and loved ones at the front. It goes on to describe the rising tide of drug control legislation as the 20th century progresses, and the growling moral tone of some of those laws. In the US, the Harrison Narcotics Act of 1914 stated that addiction was not a disease but a "self-inlicted moral infirmity". Like today's multilateral system of drug control, those laws failed to address the issue with any success. Heroin makes its appearance and is sold in cough mixtures and other over-the-counter products until 1913. WWII's demobbed heroes included untold numbers of men and women with amphetamine addictions induced by liberal but official prescription by the military. By 1946 the mob begin to control the drugs market, and the rest his history.

I leave you to read the book for the more constructive and well-founded conclusions, but this is an intelligent account of how the "disease model" of addiction is very imperfect to say the least. It tends to have much more support among policymakers than in the medical profession. So much for the evidence base. We still have a long way to go.

Carel Edwards

Friday, 1 June 2012

Shared irresponsibility

Europeans have lost the taste for armed conflict. They have been there and done that.
They don't like the war on drugs much either, which is why Europe has been a relatively civilised place in terms of drug issues for some years now, favoring harm reduction and tolerance over the sort of mass incarceration that we see in the US. 
We buy this peace for ourselves at the cost of keeping firmly out of the debate that increasingly desperate Latin American countries are trying to get us involved in. Last December's Tuxtla Declaration - and the Cartagena meeting that followed - clearly called on the consumer regions to experiment with market solutions, i.e. regulate the market in order to take it out of the hands of organised (and not so organised) crime. The Europeans are deaf to these pleas, that goes for the media as well as the governments. 
It seems that we are even beginning to prefer a "Stronger European response to drugs" (see previous posts on the EU Commission's Communication).  If words could solve problems we'd be home and dry, but studies done for the Commission itself have shown that it is very hard to find any reliable data that allow us to make a causal link between public policy and drug use in the first place. That goes for demand, but the situation is even worse for supply control; law enforcement does not like to be evaluated or scrutinised, certainly not by a bunch of bureaucrats in Brussels. As a result, we haven't a clue whether (very costly)  police intervention against drug trafficking is having any effect, but in this respect we are no different from any other major block or country. 

So where does this leave the European approach to drugs? More and more European countries are probably in breach of the UN Drug conventions today, at least by the standards of the now Inquisition-like INCB. If Europeans (and quite a few other countries) have no appetite for reviewing the conventions it is partly because they are afraid to open a Pandora's box (you might end up with something worse), and partly because they have a big economic crisis on their hands. But above all, I believe that it hasn't sunk in yet in the world's major drug consumer markets that the only way to take organised crime out of the market structure is for states to produce certain types of drugs themselves and to regulate the sale of them. This won't happen tomorrow; the idea is a vote killer and distasteful to large parts of public opinion, but growing pressure from Latin American countries, where states are crumbling under the effects of our inconsistent policies, may yet turn the tide. 

On 29 May, European members of the Global Commission on Drug Policy met in Brussels with members of the European Parliament and officials of the EU Commission and Council. They were Michel Kazatchkine, Executive Director of the Global Fund for AIDS, TB, and Malaria, and Pavel Bem, architect of the Czech drug policy and former Mayor of Prague. Both are medical doctors with extensive experience in political life. They called on the EU to strengthen its comprehensive and balanced approach, and to resist the siren voices of the new "tough" approach advocated by the EU Commission. To quote Pavel Bem: in politics, simple solutions to complex problems are the road to hell.

A full report on the Brussels meeting should appear soon on the website of IDPC and the Global Commission itself.