Narcomania

NARCOMANIA (from the Greek narkao-I become numb, stiffen and mania-madness, frenzy), an irresistible pathological craving for one or more narcotic substances used by humans (per os, subcutaneously, through mucous membranes, etc.) for the purpose of stimulation, sedation, and at least brief pleasant sensations (euphoria), intoxication, stupefaction, sleep. In this primary sense, N. denotes a serious mental illness usually associated with such poisons as alcohol, hashish, opium, morphine, cocaine, etc. (the term 'toxomania' proposed by some authors is less appropriate, since addiction and craving develop far from all poisons). Along with this, it is necessary to distinguish between drug addiction in the broad sense of the word, which covers a significant portion of humanity, in most cases not developing into a pathological craving and requiring less individual therapeutic intervention than broad social preventive measures. In this understanding, drug addiction includes the use of substances such as tobacco, tea, kava-kava, betel, etc., since they are usually taken not for the purpose of nutrition, taste stimulation, or treatment, but to achieve a narcotic effect. All these substances have much in common in etiology and mechanisms of craving and addiction, although they differ in the main active principle, method of use, and degree of harmfulness. Some of them, such as opium, morphine, alcohol, create the basis for clearly pathological abuse with increasing doses of poison that destructively affects the body, i.e., for narcomania in the proper sense of the word; the use of others almost always remains within moderate, relatively harmless limits (tea, betel, etc.). History of spread. The first acquaintance of humans with narcotic substances is probably explained by accidental causes: inhaling carbon monoxide in a cave during the burning of plant substances was probably the first source of intoxication for prehistoric man. Then the particularly strong intoxicating effect of smoke from burning certain plants of a specific species (hemp, etc.) was noted. It is not accidental that the oldest methods of narcotization were based on inhaling smoke, on smoking. Herodotus, in his account of the life of the Scythian tribe of the Massagetae (Central Asia), says that they 'sat around a tree, threw certain fruits into the kindled fire and became intoxicated by the smoke from these fruits, just as people become intoxicated with wine'. Another way of becoming acquainted with drugs must have been the accidental chewing, consumption of plant substances containing intoxicating alkaloids, and then fixing this fact in the memory and life of the tribe. With alcoholic beverages, people could have become acquainted by consuming accidental products of fermentation of various sugary substances (the first alcoholic beverage was probably wine, which is mentioned in the earliest written sources; however, the ancient Egyptians already knew a number of varieties not only of wine but also of beer). Among the most common narcotics, special attention deserves (excluding alcohol and tobacco) morphine, opium, hashish, cocaine, heroin; of great importance are ether, veronal, codeine and a number of others. In the process of their historical spread, we see both the displacement of one narcotic by another and the simultaneous coexistence of different narcotics (e.g., smoking opium and hashish in the East). Hashish, used by 150-200 million people (Le-win) and known in the East under various names (kif, bang, kenaf, anasha), is mentioned already in ancient Greek, Chinese, and Indian books (Herodotus, Shu-King, Yajur-veda) dating from 400-500 years before the common era. Originating in Central Asia, hashish spread along with the Muslim conquerors and is now widespread in Central and the Near East (Turkey, India, Afghanistan, the Central Asian republics of the USSR, Persia) and in North Africa (Egypt). Hashish is smoked in water pipes (hookah, nargile), often together with tobacco, opium, chewed with betel leaves, etc. (see Hashish).-Mention of opium, which is the dried sap of incised poppy heads (Papaver somniferum), we find already in the Iliad, then in Dioscorides of Melos (380 years before the common era) and in other ancient writers (Theophrastus, Dioscorides, Celsus), according to whom opium was obtained at that time in Greece and Asia Minor; it is believed that it was then carried further east by the Arabs. Opium penetrated India during its conquest by Muslims. The rulers of India, the Mughals, at one time made the cultivation and trade of opium a state monopoly, which was later appropriated by the English East India Company. The Chinese received opium from India at first as a medicinal agent, but from the middle of the 17th century mainly as a narcotic. It became especially widespread at the end of the 17th century in connection with the prohibition of tobacco smoking. In 1729, opium smoking was strictly prohibited in China. However, the growth of smuggling, especially from India, nullified the efforts of the Chinese government and led to a series of so-called 'opium wars' (with England and others), which dragged on with interruptions from 1839 to 1860, and according to the peace treaty, defeated China was forced to allow the importation of opium in unlimited quantities. Since then, China's attempts to achieve the abolition of opium importation into its territory under conditions of unequal treaties, concessions, and interventions remained unsuccessful despite some internal measures aimed at combating the cultivation and use of opium (prohibition in 1917). With the division of China into spheres of influence of individual generals and governments, the situation with opium smoking of course deteriorated even more. The policy of European powers in purely colonial countries is even more overt; thus, in the Dutch colonies (Java, Sumatra, etc.), opium dens legally operate alongside brothels, rented by private entrepreneurs from representatives of the Dutch government (in the city of Batavia alone in 1928 there were no less than 20 licensed opium dens).-Europe became acquainted with opium in the Middle Ages, but here its application went mainly along medical lines, and opium was used in the form of drops or for smoking, etc. by a relatively small number of narcotic addicts, whereas in Asian colonial and semi-colonial countries it received enormous distribution, acquiring the character of a national disaster that covered tens of millions of people in China alone. The scale of world opium production is determined (as of 1922) by the advisory commission of the League of Nations at over 3¹/₂ thousand tons (on average 1 hectare yields 6 kg of opium, or 1,200-1,500 kg of ripe poppy heads with seeds). Among the derivatives of opium, morphine (see) became widespread in Europe and the USA, especially in the last quarter of the 19th century. The Franco-Prussian War, where injections of morphine were first widely used by doctors, left among other things a considerable number of morphinists among former military personnel. Subsequently, morphine spread mainly among medical personnel and persons of other professions whose activity requires great strain on the nervous system, and at times special excitement (artists, musicians, artists, writers, etc.). Morphine (as well as a number of other narcotics) became widespread among the criminal world, prostitutes, etc. But first place among morphinists still belonged to medical personnel, not due to specific working conditions, but due to the relative ease of obtaining the narcotic. If the Franco-Prussian War gave rise to morphinism, then the imperialist war sharply increased all types of drug addiction, and the proportion of medical workers among narcotic addicts fell sharply. Thus, according to data from a special institution for drug addicts (Friedrichsberg), among morphinists treated there over 42 years until 1918, doctors constituted 36% of all admissions; but in the 8 years after the world war (1919-26), the percentage of doctors fell to 15. But even to this day, morphinism as a socio-pathological phenomenon is most widespread among medical workers. According to Bonhoeffer's data, the absolute number of morphinists admitted to the corresponding institutions of Berlin was 104 people in 1913-18, and 375 people in 1918-24 (see Morphine, morphinism). In recent years, heroinism has sharply emerged among other types of N., which arose and received particular distribution in the USA, and more recently in China. In 1919 alone in New York, 2,178 heroin addicts were registered. It is interesting to compare this figure with data for the same year for other types of N.: among registered narcotic addicts used: only heroin-2,178, only morphine-690, cocaine and morphine-42, cocaine and heroin-305, morphine and heroin-41, and in total 3,256. Thus, heroin is in first place, far surpassing not only cocaine but also morphine. The last of the major European-American N.-cocainism (see). There are also many other minor narcotic agents, many of which are also used for the purposes of N., especially in the USA, which has recently earned the reputation of a classic country of capitalism, social contradictions, nervousness, and N. These include veronal, chloral hydrate, ether, etc., however, they play a significantly smaller role than the most common narcotics mentioned above.

Among the widely distributed and comparatively harmless stimulants, besides the well-known tea and coffee, one can also name mate—the leaves of a plant cultivated in Argentina, Paraguay, and southern Brazil (Ilex paraguayensis, amara, etc.). An infusion of these leaves is used throughout South America in a manner similar to tea; their effect is based on their content of 0.5% to 2.5% caffeine. Among other plant substances containing caffeine, one should name the seeds of the cola tree (Cola), which grows in tropical Africa. In South Asia, there is its own favorite means for chewing—the leaves of betel (see), which in effect resemble the seeds of cola. At present, there is not a single nation or tribe that is completely free from narcotism (the consumption of narcotic substances). Even the inhabitants of remote taiga regions and tundras prepare an infusion from certain poisonous mushrooms (e.g., fly agarics), which they use to bring themselves into a state of intoxication and frenzy, followed by depression (hangover). The wide prevalence of narcotism and the variety of narcotics, from which no nationality is free, and especially the wide prevalence of N. among the advanced capitalist countries, forces one to raise the question of the causes of this phenomenon. The main causes should be considered social inequality and the exploitation of oppressed classes, leading them to physical and mental exhaustion. Excessive labor with an excessively long working day, poor working conditions, housing congestion, and the lack of elementary sanitary-hygienic conditions, the lack of reasonable entertainment, and above all, the hopelessness of existence, the lack of commitment to class struggle in years of reaction, etc.—these are the main causes of narcotism; to this is added the uncertainty of tomorrow and the nervousness caused by it. Thus, a whole series of causes acting on the individual 'synergistically' in one direction lead to narcotism, and in many cases to N. In this complex of causes, one should particularly consider the need for doping, i.e., a means that makes one forget the feeling of fatigue, which creates in a person the impression of a surge of strength. Narcotism enters into the way of life, firmly merges with living conditions, and is often an invariable companion of religious festivals, rituals, and customs. Thus, narcotism becomes one of the factors of the environment, which influences many in the order of camaraderie and imitation. To all this must be added that the ruling classes (including the priesthood and the clergy developing from it) for the purpose of drugging the oppressed classes and obtaining additional income from them, actively contributed to the planting and spread of narcotism and N. (leases, monopolies, treating the proletariat in Rome, treating vassals by their suzerain, workers by their contractor, etc.). All this not only contributed to the spread of narcotism and N., but also played a considerable braking role in the development of class struggle on the part of the oppressed classes, introducing dispersion, disorder, a kind of corruption, disintegration, and masked and open strikebreaking into their ranks. This policy is carried out most blatantly and unceremoniously in the colonies, where the native population is being and has been openly intoxicated (for example, tobacco infusion is added to vodka or whiskey), it is being accustomed to opium or cocaine or to some other of the narcotics, which not only facilitates the exploiters' main task—to break the resistance of the natives—but leads to the actual extinction of many tribes and peoples, the land territories and lands of which pass to the 'victors'—colonizers. Such was the policy of the tsarist government in Siberia and the Far East, such is the policy of the English bourgeoisie in Asia (China, Burma) and Africa (Cape Colony), such is the policy of the French bourgeoisie in North Africa, of the Dutch bourgeoisie in its colonies in Southeast Asia (Java, Sumatra), and of a number of other second-rate imperialist powers. These are the main exogenous factors of mass narcotism, and against their background, such moments as the intensified development of N. among certain social groups, which have already been mentioned above, appear as secondary. Similarly, one can consider as relatively secondary the certain spread of narcotism and N. on the basis of chronic pain, which arises from the desire to obtain relief from suffering (chronic sciatica, radiculitis, etc.). In this case, a considerable role is played by the careless (and in some cases, especially where there is significant private practice, unscrupulous) use of narcotics by medical personnel. Additional factors of narcotism in the West are the lack of a healthy, vigorous ideology and purposefulness, the thirst for sensations, unhealthy yellow literature and films, numerous cafes, cabarets, dance establishments (dancings), open and hidden prostitution. Against the background of all the social factors of narcotism listed, the constitutional factors, which form a predisposition to heavy abuse of narcotics, to narcomania in the proper sense, appear as relatively secondary. The fact of a certain increase in the number of psychopaths among heavy narcotic addicts can be considered established, although the role of this factor in the origin of narcotism in the broad sense of the word is comparatively small. The psychopathic nature of many narcotic addicts is also evidenced by data on hereditary predisposition. Thus, out of 36 cases of Meggendorfer, suicides among relatives were noted in 13. Of the 400 cocaine-lawbreakers studied by Rapoport, there were significantly more people with hereditary predisposition than in the general mass of Moscow criminals of the same period (84.3% versus 67%). One thing is certain, that the wider this form of N. is spread in a certain place and time, the smaller the percentage of psychopathic personalities is found among its adherents, the more purely household narcotic addicts there are among them. On the other hand, psychopathic predisposes a person to a more rapid and deeper development of narcomania. Classification of narcotic substances and their effect on the body. By their composition, the most important narcotics are divided into two main groups: chemical substances of the so-called fatty series (alcohol, ether, sulfonal, veronal, chloral hydrate, etc.) and plant substances, the effect of which is based on the presence in them of special substances, plant bases—alkaloids (in coca leaves—the alkaloid cocaine; in opium—morphine, narcotine, codeine, etc.; in Indian hemp—cannabinol; in tobacco—nicotine). By their main effect, all stimulating narcotic substances (in the broad sense of the word) can be divided into the following groups (according to Thorns' classification). First, analgesic substances (anodyna, analgetica). They act on the central nervous system, suppressing even in small doses the pain sensitivity while consciousness is relatively preserved. These include opium and its derivatives, such as pantopon, laudanon, etc., as well as the pure alkaloids of opium, such as morphine, codeine, narcotine; Indian hemp (hashish) with the alkaloid cannabinol, belladonna and henbane with the alkaloids hyoscyamine and scopolamine obtained from them. The next group is formed by anesthetic substances, which cause a temporary loss of sensitivity by inhibiting the sensory nerves. Anesthetic substances in turn are divided into: a) inhalants (laughing gas, chloroform, ether), which reduce the excitability of the central nervous system and cause a general clouding of consciousness, as well as loss of sensitivity, and b) local anesthetics, the effect of which is manifested only on a limited local area, and consciousness is preserved. Such an effect is obtained from the rapid evaporation of volatile liquids, such as acetone, chloroform, ether, menthol. As a result of cooling, vasoconstriction and inhibition of the sensory nerves of the skin occur here. However, the most important representative of local anesthetic substances is cocaine and artificially prepared substitutes for it, eikain, novocaine, etc. These substances are used in surgical operations. Separately, one should place the group of sedative (sedativa) and hypnotic (hypnotica) substances. As sedatives, various bromide preparations (potassium bromide, sodium bromide, bromural, etc.) are usually used, while among hypnotics—the most important are chloral hydrate, amylene hydrate, paraldehyde, sulfonal, trional, veronal, and other preparations of barbituric acid. Relatively harmless stimulants should be recognized as coffee, tea, mate (with alkaloids caffeine, theobromine, etc.), and finally significantly more harmful and widely spread—tobacco and alcohol, in relation to which, especially alcohol, one should speak not only of a stimulating but also of a depressing and narcotic effect. To the substances listed, one can add many others, partly found by man in the surrounding nature, partly artificially prepared: niopo, peyotl (alkaloid mescaline), kola, kava-kava, etc. If one considers all these substances not according to their effect, but according to their geographical distribution, then the following groups can be distinguished: 1.

Substances of local significance, used only in the area where they were first discovered and hardly extending beyond its borders. This includes a number of so-called native stimulants, such as pituri in Australia, cacti (peyote) in Mexico, and niopo in South America. 2. Substances of wider distribution, however, the use of which is associated with specific geographical, ethnographic, or religious population groups and has remained within the historical boundaries of these groups: such as cola among western Negroes, hashish in countries inhabited by Mohammedan peoples, and coca in Peru (however, the alkaloid of this plant—cocaine—during the last few decades has gained considerable distribution in America and Europe, causing a severe N.—cocainism). 3. Substances having mass distribution and multiple foci of this distribution; these include opium among Chinese, Hindus, Malays, as well as among many narcomaniacs in Europe and America; betel among Hindus, Malays, etc.; kava-kava in the Malay Archipelago, among Melanesians, etc. 4. Substances that have spread from one or several (few) points to almost the entire globe—tobacco, coffee, tea. 5. Substances used throughout the earth and in different eras—alcoholic beverages. Different types of them differ in degrees of distribution, but wine, beer, and vodka usually displace other alcoholic beverages. By the method of predominant application, all stimulating narcotic substances can be divided into smoking (tobacco, opium, hashish), snuffed, inhaled through the nose (niopo, cocaine), directly eaten (peyote), used for chewing, usually in mixture with other substances (coca leaves, betel), in the form of an infusion (coffee, tea, mate), in the form of alcoholic beverages (alcohol). Of the narcotic substances, the most important due to their wide distribution are hashish, opium and its derivatives (morphine, heroin, etc.), cocaine, tobacco, and alcohol. The use of morphine in its pure form or its artificial derivatives (heroin), as well as opium preparations ( pantopon, laudanon, eukodal, etc.) is no longer a massive spontaneous evil, like the use of opium, alcohol, but a narrower disease affecting not the masses of the people but individual population groups. In all substances of the alcohol group, the suppression of functions of the large brain (consciousness, pain sensitivity), the spinal cord (reflexes, muscle tension), and finally the medulla oblongata (regulation of respiration, blood circulation) occur sequentially, whereas in substances of the morphine group, the effect on the spinal cord and medulla oblongata occurs almost simultaneously. The difference in the action of morphine (opium) on the central nervous system from alcohol, ether, etc. also consists in the fact that the general analgesic effect of morphine is manifested before disturbance of consciousness, and that morphine, while narcotizing the large brain, at the same time increases the reflex excitability of the spinal cord, strengthening the reflexes. In the action of most narcotics, two main phases can be traced: first, the stage of excitation, when the activity of the nervous system is enhanced above the normal level; mood is elevated at this time, perception of external impressions is facilitated, criticism and volitional inhibitions are weakened; unpleasant sensations are softened or disappear, etc. In some cases, it reaches ecstatic states, marked motor excitement, sensory deceptions (illusions, hallucinations). The second stage—that of suppression, depression—is characterized, on the contrary, by a decline in mood, fears, inhibition; lethargy, relaxation seize the organism, sensory deceptions have a gloomy, threatening character; finally, especially with large doses, sleep ensues.—Under prolonged action of a heavy narcotic, e.g., opium (morphine), in a narcomaniac the following phenomena develop: disturbance of appetite, sleep, gastrointestinal activity (diarrhea, constipation); the skin becomes dry, pale, nails lose their luster, hair falls out; frequent palpitations, sweating; movements are uncertain, trembling; significant emaciation, physical weakness and senility. Along with this, serious psychic changes occur: a person becomes lethargic, passive, will-less, suggestible; detaches from the surrounding real world, becomes closed, retreats into his artificial world. All external interests are limited by the desire to obtain his narcotic, which usually requires more and more due to habituation. Lying, forgetting any sense of duty. These are the typical features of an opium addict (as well as other serious narcomaniacs). When attempting to quit the narcotic, severe phenomena of withdrawal, so-called 'abstinence,' develop, which are particularly sharply expressed in morphinism. These phenomena of abstinence greatly hinder the cessation (treatment) of narcomania. Such are the serious results of chronic opium smoking (morphinism) and many other N.s, leading the organism to exhaustion and premature death.—'We have a similar picture with the use of various opium preparations (pantopon) and morphine (heroin, dionin, etc.).—With cocainism and hashishism, fears, delusional ideas, hallucinations, and actual psychoses often develop. Unfortunately, the negative side of narcotism is recognized by its victims too late, with pathological habituation, and at first the narcomaniac finds only a positive effect in his poison; thus, with opium he experiences loss of all physical unpleasant sensations, elevated mood, dreams, calmness and after several hours of smoking—sleep. The effect of heroin differs little from morphine's except for a more elevated sense of well-being, activity, self-confidence when intoxicated with it. Heroin is an even more dangerous poison than morphine in the sense that pathological habituation forms more quickly, and the period of withdrawal, abstinence, is accompanied by almost equally severe phenomena, as well as often serious convulsions. Changes in personality with chronic heroinism and morphinism completely coincide. It is curious that when at the 2nd Geneva Opium Conference (1925) the question was raised about the removal of heroin from medical practice, about prohibiting its manufacture, German, English, and French doctors energetically protested, referring to the extreme importance of this means; meanwhile in its main application against cough it can be easily replaced by comparatively non-dangerous and similarly acting codeine.—Veronalism (see Veronal) is a very severe form of N., since persistent insomnia prevents withdrawal, sometimes driving the patient to suicide. With severe poisoning by veronal, restlessness, confusion of consciousness, amentive and manic states, loss of corneal and abdominal reflexes, sleep and coma are observed. With chronic poisoning by small doses of veronal (also luminal), states resembling progressive paralysis are obtained; disturbances of the pupils and eye muscles, especially the light reaction. Speech becomes unclear, monotonous, scanned. The handwriting is disturbed, hands tremble, gait is uncertain. From the side of the psyche—disturbances of attention, apathy, etc. In connection with the severity of this N., special caution is required from doctors when prescribing narcotics of the veronal group to patients being treated for sleep disorders, especially in outpatient practice.—Ether is often used for the purposes of N. (sniffing, drinking) and leads to etheromania (see Ether). Each of the narcotics has its own peculiarities of action: thus, the 'strength' of hashish is in its dreams, brightly colored illusions and hallucinations; of opium and morphine—in the calming, analgesic, pacifying effect; of cocaine—in light pleasant excitement, cheerfulness, increased self-confidence, sociability. In these properties of narcotic substances lies in part the explanation of the origin and spread of N. despite their pernicious consequences. It is sufficient to say that the number of consumers of opium and hashish is determined by many millions, although of course not all of them are narcomaniacs in the proper sense of the word, and in each country where any narcotic substance is widespread, a distinction should be made between the main mass of consumers without sharply expressed pathological phenomena and the smaller part of immoderate consumers, whom N. quickly leads to death. In this sense, the situation e.g. with hashish in Persia, with coca in Peru, etc. resembles the situation with alcohol in European countries.—On the mechanism of narcosis—see Narcotic substances. If we turn to the effect of various vegetable bases, alkaloids, on the organism, then here the narcotic effect is achieved both by the direct action of the poison on the cells of the central nervous system and by the serious influence of narcotics, especially with prolonged use, on the autonomic nervous system, on the smooth muscles of vegetative organs, etc. Some authors attach special importance to the effect of alkaloids on glandular organs, on secretion. Others believe that under the action of morphine the parasympathetic tone is elevated, the sympathetic is lowered; morphine acts suppressively on the thyroid gland and the associated sympathetic and adrenal systems. Close to morphine in their effect on the autonomic nervous system are other alkaloids of opium. The causes of habituation and the associated phenomena of abstinence are of a mixed nature.

On the one hand, the formation of associative connections, the development of a special conditioned reflex to the drug, the habit of escaping into a narcosis from blows of the environment, from endogenous disorders, mood, etc. On the other hand, biochemical addiction to the poison, which soon turns into a habitual excitant, with the removal of which is associated with a violation of some artificially established equilibrium between the sympathetic and parasympathetic systems, endocrine activity and the entire metabolism. Thus, Wuth considers that the phenomena of morphine abstinence are associated with a fall in parasympathetic tone and excitation of the sympathetic system upon removal of the drug. A similar explanation can be given to the phenomena of nicotine abstinence, which are of course expressed much more weakly. Accordingly, David, Kahle and others recommend the use of parasympathetically acting substances in opium (morphine) abstinence (quinine, potassium salts, preparations of the thyroid gland, sex glands, etc.). Addiction to drugs and the phenomena of so-called 'starvation' some authors connect with the formation of special substances (e.g. oxymorphine in morphine abstinence; Magtö). The need for increasingly large doses in addiction to obtain the same narcotic effect is explained not by the development, as was previously thought, in the body of any antitoxins, protective bodies, and not by an increase in the body's ability to assimilate the drug, but is based on the ability to destroy it more quickly. Thus, Schweisheimer showed that equal amounts of alcohol were absorbed into the blood and burned in the body of chronic alcoholics twice as fast than in teetotalers (7 hours and 15 hours); Faust established that a body accustomed to morphine possesses the ability to quickly destroy (oxidize) the overwhelming part of the introduced morphine (Straub; up to 99%). Thus, no immunity of tissues is obtained in the sense of addiction. Treatment of N. consists first of all in isolating the patient in conditions that deprive him of any possibility of obtaining his drug, which is achieved only in the conditions of a special hospital (psychiatric institution, etc.). Further, the doctor must take care of possible alleviation of the phenomena of abstinence. From the very beginning, bed rest and cardiac agents (digitalis, digalen, etc.) should be applied. For restlessness - warm, long baths (watch the heart at this time!). For insomnia - luminal (0.3 in hot milk) and others. For constipation - hot drinks and mild laxatives. For increased acidity, belching - mineral waters (Borjomi, Essentuki). Active psychotherapy, which distracts the patient's attention and encourages him, is of great importance in abstinence; it should be borne in mind that the conscious and unconscious exaggeration of one's suffering by the patient in order to arouse the sympathy of the medical staff and obtain the drug is often observed; in the picture of abstinence, even morphine abstinence, hysterical layers often play a role. The doctor's behavior towards the drug addict should be firm and clear, which has the best effect on the patient. The question of the possibility of immediate and complete withdrawal of the drug in the hospital is answered positively in relation to cocaine and hashish; as for opium (morphine) and its derivatives, opinions are divided here. Older authors recommend gradual withdrawal over 8-10 weeks, others prefer relatively rapid withdrawal over 8-10 days (with the subsequent administration of a saline solution for several days). Others insist on immediate withdrawal of the drug, pointing out the absence of danger to life when the heart is supported (see Morphine, morphinism). What has been said in relation to morphine is fully applicable to heroin, and here serious phenomena with a threat of respiratory paralysis, epileptiform attacks were observed in sharp abstinence, which is why gradual withdrawal (several days) can be recommended here, with the initial replacement by small doses of opium, codeine. Ether, alcohol are withdrawn immediately, although here abstinence phenomena in the form of trembling, restlessness, insomnia are often observed in the first days. Hypnotics, such as chloral hydrate, veronal, should also be withdrawn immediately, replacing them for the first time with small doses of other hypnotics or sedatives (e.g. bromide with codeine) due to the sometimes persistent insomnia that develops during abstinence. The treatment of serious N., such as opium smoking, morphinism, etc., on an outpatient basis by gradually reducing doses can give results only in exceptional cases, and the final withdrawal should still be carried out in hospital conditions under careful observation. As for the treatment of alcoholics, here some results can be achieved on an outpatient basis with the dispensary method with frequent visits to the patient, all kinds of psychotherapy (hypnosis), physiotherapy and pharmacotherapy (including injections of oxygen, strychnine, etc.). In this sense, the experience of pre-war outpatient clinics (Mendelson, Minor) and Soviet narcological dispensaries (and narcological cabinets at neuropsychiatric dispensaries), the work of which has developed mainly along the line of treatment of alcoholics and smokers with a relatively small number of actual drug addicts (Mazur), is of interest. Of course, the narcological dispensary should be connected in its work with the broad public, with the society for the fight against alcoholism, with sobering-up stations, with a clinic for cases of alcoholism that have not gone far, and with a labor-educational colony for the long-term re-education of alcoholics (and actual drug addicts), especially those with antisocial tendencies. A relatively complete chain of these institutions exists in our country only in the Moscow region, in other places only individual links of this chain. The duration of hospitalization of a drug addict (from several weeks to a year) depends on the severity of the case and external conditions; in any case, the longer the period, the greater the chances of recovery. The prognosis for such N. as morphinism is quite severe, and the percentage of cured patients here is determined by various authors from 1 to 14. However, for drug addicts of the post-war period, we have a more favorable prognosis, since among them there turned out to be many accidental, non-predisposed persons. In cocaine addiction, hashishism, etheromania, the prognosis is better than in morphinism. Factors that worsen the prognosis: early onset of N., previous relapses, psychopathy of the patient, insufficient activity or pessimism of the treating physician. The prognosis for outpatient and inpatient treatment of alcoholics is more favorable, a positive result of treatment is noted in 15-30% of cases. With the mass spread of any N., the prognosis for treatment is better, since among drug addicts there are then more accidental, non-psychopathic personalities. Psychiatric examination in N. depends on the specific circumstances of each individual offense, the degree of social danger and degradation of the personality under the influence of the drug. In severe cases, where it is a question of completely degraded people with physical and mental signs of chronic poisoning of the nervous system, who are completely under the power of their craving and commit crimes in order to obtain the drug (often - falsification of prescriptions), it is necessary to raise the question of compulsory treatment. However, the expert must exercise caution in cases where N. is of a mass character, as this has to be taken into account; it is also necessary to bear in mind the widespread prevalence of drug use among criminals, where it is usually not the cause of entering the criminal path, but a companion of the criminal world. Often drugs are also used 'for courage' before committing a crime. Morphinism, cocaine addiction and other N. are rarely a serious factor in criminal offenses. They have little influence on property crime (except for falsification of prescriptions, minor frauds, etc.); crimes against persons are sometimes committed in a state of excitement and delirium under the influence of hashish; morphine (opium) plays almost no role here. The opinion about frequent serious crimes of cocaine addicts is incorrect: when comparing 400 cocaine-offenders and 2,000 other criminals (Rapport) there was almost no difference (the percentage of bandits and murderers among cocaine addicts was even reduced). Only alcoholism (see) is a serious factor in crime, especially crimes against persons (beatings, wounds, insults, hooliganism, etc.); it plays a much smaller role in property crime. Various kinds of sexual perversions (homosexuality, pedophilia, exhibitionism), developing in connection with a disorder of sexual desire (libido) and sexual ability (potentia), often lead the drug addict into conflict with the law. Our criminal code does not recognize reduced responsibility for crimes committed in a state of intoxication (except in cases of pathological intoxication); the German code (Rodbruch's draft) takes the point of view that the lower the capacity for responsibility at the time of the offense, the less responsibility and punishability; the Italian code (Ferri's draft) provides, on the contrary, for increased punishment for crimes committed in a state of intoxication, based on the consideration that the personality of an alcoholic, drug addict who commits a crime is more dangerous to society than that of an ordinary criminal, and the fact of intoxication itself is an additional offense. Prevention of N.

One should distinguish between legislative and public prevention of N. from medical prevention. With regard to the first, in capitalist countries one can note an extremely large gap between the legislation and practice of the struggle, on the one hand, and between the legislation and the urgent requirements for protecting the interests of the overwhelming majority of the population, on the other. The production of narcotic substances is in the hands of the large bourgeoisie, which is directly interested materially and politically in the planting and spread of narcotic substances, which are the subject of trade and enrichment.

as a method of influencing the class struggle in a desirable sense for the bourgeoisie. Therefore, the legislation of capitalist countries is very tolerant toward the production and distribution of narcotics. No law aimed directly at the major producers and distributors of narcotics actually exists (or is not applied); in no capitalist country. All the stings of legislation and police organizations are directed against small distributors of narcotics and especially against their consumers. The history of recent years is rich with examples of bourgeois hypocrisy in matters of jurisdiction and in the practical implementation of the half-hearted decisions adopted. It is true that one can note that in Europe and the USA, in connection with the enormous growth of N. after the imperialist war, there is as it were an activation of anti-narcotic legislation. The French criminal code, published in 1924, concerns producers, sellers and in part consumers of narcotics. Under this law, not only the illegal sale of cocaine, morphine, hashish and other poisons is punished, but also their use in company and any assistance in the use of these poisons for payment or even free of charge by providing premises or in any other way. For the distributor and consumer, different terms of imprisonment, fines and deportations are provided. In case of recidivism, punishments are doubled. Under the Italian law of 2/28 1924, imprisonment (2-6 months) and a fine are imposed on anyone who, without special permission, sells cocaine, morphine and generally poisonous substances that have a stupefying effect in small doses. The storage of these substances for the purpose of sale and their dispensing to persons not having the right to do so are also punished. In the case of dispensing to a minor, the punishment is doubled. Imprisonment and a fine are imposed for providing (for a fee or free of charge) one's premises for a gathering of persons using narcotics. In the German criminal code (1924) there are no direct articles punishing the sale of cocaine, morphine and others, but there is article 367 paragraph 3, under which a fine or arrest is imposed on anyone who, without police permission, manufactures, stores for sale, sells or in any other way provides to another person poisons or medicines, the trade in which is not free. The law of 12/19 1930 imposes responsibility on doctors who prescribe narcotics. In the USA, a general act to combat narcotic substances was issued as early as 1915. Under this act, the trade, storage, distribution of narcotic substances must be carried out in strict accordance with existing laws. Doctors, dentists, veterinarians may use narcotics only for therapeutic purposes, but the legislation does not say how to establish or verify for what purpose a narcotic was given (therapeutic or other). Any violations of this law, committed with malice or neglect, are punished by a fine of up to $2,000 or imprisonment of up to 5 years. In accordance with this federal act, individual states have adopted their own local provisions. In some of them, measures have been introduced very strictly: thus, in the state of Massachusetts, even possession of instruments for subcutaneous injections by persons not of the medical profession is prohibited. If necessary, written permission from a doctor is required. But all these measures are circumvented with the silent consent of bourgeois 'society' and in no way are directed against the main carriers of evil, the producers and wholesale distributors of narcotics. In addition to the measures of individual governments, 'attempts' have been made to organize the fight against N. on an international scale. Thus, in 1909, the international commission on opium met in Shanghai without result. In 1911, at the initiative of the USA, an international conference on the opium question was convened in The Hague, where with the participation of representatives of China, Germany, the USA, Russia, France, Great Britain, Japan, Persia, Italy, Holland and Siam, a convention was drawn up, to which all other countries were invited to accede. The convention concerned the enactment of laws or regulations governing the production and distribution of opium, morphine, cocaine, heroin. Various forms of cooperation between states were provided for with the aim of controlling the drug trade, combating smuggling, prohibiting the export of narcotics to countries where their import is prohibited, mutual information exchange, etc. The convention gave no concrete results, as was to be expected, given the serious economic interest of most conference participants in its failure (large narcotic industry in Germany, England, France, Switzerland, the income of the British government from opium in India of 60-70 million rubles per year, etc.). The world war for a long time undermined the convention, which was renewed upon the signing of the peace treaties, the ratification of which was also the ratification of the convention. General supervision over its implementation has since been entrusted to the League of Nations, under which an advisory commission on opium was created. The work of this commission also gave no concrete results despite a number of sessions where the sabotage of the convention by almost all participants became obvious. Thus, the Geneva opium conference (1925) ended with the demonstrative departure of the Chinese and American delegations. (The USA occupy a less hypocritical position on this issue than other powers, since they have neither opium plantations nor industrial export of narcotics.) In any case, attempts at organized international struggle against drug addiction up to the present time have been completely unsuccessful, mainly due to the presence of a large material interest of a number of capitalist countries in the production of narcotic substances and the extensive private medical practice in these countries. The commission of experts of the 2nd Geneva opium conference (1924) determined the world production of opium plantations at 8,600,000 kg. The fight against drug addiction and N. in the USSR is based on completely different principles; the legislation of the USSR is aimed at both the production and distribution of narcotics, punishing not only small traders but to a much greater extent the keepers of dens, wholesalers and producers of narcotics, if any were discovered. The center of the fight against narcomania here has been shifted to cultural and educational work and in addition to the fight against the primary sources of production and distribution of narcotics, which naturally should give (and gives) completely different results than in capitalist countries. One can note a significant reduction in the consumption of narcotics and a decrease in the number of cases of N. in the USSR, which finds explanation in the reconstruction of working and living conditions, as well as in the vigorous purposefulness and enthusiasm of the working people (industrialization, planned construction of socialism, shock work); the absence of unemployment, the growth of godlessness and other factors play a role. At the present time, the USSR is the only country where the cultivation and preparation of narcotic substances are regulated by legislative means and their use is guaranteed exclusively for medical and scientific purposes. By decree of 8/27 1926, the monopoly on all opium produced in the USSR was transferred to the joint-stock company 'Akospo', to which all opium growers had to deliver their harvest under contracts. From 1930, 'Akospo' was merged with the All-Union Society for the Production and Export of Medical Raw Materials 'Lektekhsyr'e'. Having a monopoly on the export of raw opium abroad, this organization* must, however, in each individual case obtain a special export license from the Soviet government, which is issued to them only on the basis of the consent of the government of the importing country. All the opium going to the domestic market (for medical and scientific purposes) is transferred to the state production organization 'Gosmedtorgprom', which has a monopoly on the production of narcotics (morphine, cocaine, heroin, etc.) based on the previously established annual needs of all union republics, as well as the distribution of narcotics. All narcotics imported into the USSR must be addressed to the People's Commissariats of Health of the respective republics, which monitor their proper distribution. The opening of pharmaceutical laboratories and factories occurs with the permission of the Presidium of the Supreme Economic Council and its local bodies. By resolution of the CEC and Sovnarkom of the USSR of 5/23 1928, within the USSR the free circulation of cocaine, its salts, hashish, morphine, heroin, dionine and their salts and pantopon is prohibited. There is also a special instruction of the Narkomzdrav of the RSFSR 'On measures for regulating the trade in narcotic substances', under which the non-pharmaceutical sale of narcotic preparations (opium and its derivatives, opium extract, morphine, heroin, dionine and their salts, pantopon, as well as cocaine and its salts and hashish) on the territory of the RSFSR is permitted only from state enterprises having the right to wholesale trade in medicines; the instruction in detail regulates the dispensing of narcotics from pharmacies on doctors' prescriptions to prevent abuses, etc.

As for criminal liability, there is Art. 104 of the Criminal Code, which states: 'the manufacture and storage for the purpose of sale and the sale itself of cocaine, morphine, ether and other intoxicating substances without proper permission entails deprivation of liberty or compulsory labor for a term of up to one year with confiscation of part of the property or without such confiscation. The same actions, committed as a profession, as well as the maintenance of dens where the sale or consumption of the substances listed in this article takes place--deprivation of liberty with strict isolation for a term of up to 3 years, with confiscation of all property.'-Such in brief is Soviet legislation, which, along with the general social policy of the Soviet government, ensures the successful struggle against narcomania. The scale of manufacture of morphine, heroin and cocaine in the most important countries, as well as their export and import, can be judged by the attached tables (Tables 1-3) (materials of the Opium Commission of the League of Nations, 1930). Table 1. Manufacture, import, export and consumption of morphine for 1925-29 (in kg). Countries k > i a,« Pi O a E-> o н o i ^щ и в æ i B o,o ш 5 <" a M И н Germany ..... Great Britain . . India (Brit.) . . . Japan ....... Holland ..... Switzerland .... 25 222 14 410 11 095 9 920 4 944 7 400 275 326 1025 998 873 10 132 17 921 5 058 7 528 10 578 6 870 14 449 5 548 2 757 972 875 4 580 219 225 Total . . 67 854 21 493 41 785 36 495 Table 2. Manufacture, import, export and consumption of heroin for 1925-29 (in kg). Countries and >> i O щ См a o. н Я н a o и o K CD i ° и S аз | K O, O o> >. «o м ° ^щ м в " France ...... Great Britain . . India ....... Italy ....... Switzerland .... 5 337 9 703 1534 20 5 163 10 203 2 268 2 320 5 328 4 456 2 309 9 293 6 920 Total . . 6 915 22 363 9 625 Table 3. Manufacture, import, export and consumption of cocaine for 1925-29 (in kg). Countries Germany . . . France .... Great Britain India..... Italy ..... Japan ..... Holland . . . Switzerland . . ^&в K a" 12 370 4 583 3 309 7 144 3 001 в Э "B Ч Я a> ?-П И н 654 1 719 769 43 257 1204 TOTAL.. 31 387 4 855 16 643 15 735 10 375 28 2816 1293 2 200 4 803 1 618 1 285 4 690 Thus, for all these countries we see a significant excess of drug production over their domestic consumption. As for data on the number of actual narcomaniacs in Europe and America, here it is difficult to have any reliable information, as depending on the sources, the figures sometimes differ by 10-15 times. Above were given figures of registered narcomaniacs in New York. In 1926, in the USA, according to official data, there were 91,250 people, or 1 narcomaniac per 1,242 people. However, according to other sources, the number of narcomaniacs in the country was 1 million. It is easier to judge the dynamics of N., which is reflected in data on the movement of narcomaniacs through medical institutions. Thus, in German private psychiatric hospitals (according to Bongeffer) there were contained: in 1911-13 (together)-1497 narcomaniacs, in 1920-22 (together)-3084, in 1923-1283, in 1924-1430, in 1925-1623. The role of the imperialist war and subsequent social upheavals! in this growth of N. is clear.-In the USSR (and old Russia) only alcoholism became widespread, and the problem of N. in the proper sense never arose seriously. Neither the peasantry nor the proletariat had and have almost any relation to opium, morphine, cocaine, etc., if we do not consider the occasional and almost eliminated spread of cocaineism in 1920-25, which however, even then did not capture the broad masses of the population, but only its individual relatively small groups (bohemians, lawbreakers, homeless people), and some areas in Central Asia, where opium (teriac) and hashish (anasha) still penetrate by smuggling through the Afghan and Persian borders. As for morphinism, it was and remains among us a disease of almost exclusively medical personnel. From the data collected in 1931 by the Moscow Institute of Neuropsychiatric Prevention, it is evident that in none of the union republics (except Central Asian ones) do issues of narcotism in the proper sense play any serious role. Although an absolute figure of narcomaniacs cannot even be given for the city of Moscow, since accounting for narcomaniacs is not kept here, an approximate idea can be given by the figures of admission of narcomaniacs to dispensaries and hospitals of Moscow. Below are data on the number and percentage ratio of alcoholic-narcomaniacs (primary patients), who from 1924 to 1929 passed through Moscow narcodispensaries (where the main mass of patients consisted of alcoholics and then smokers) (Table 4). From the table presented, one can see a sharp decrease Table 4. i * nlh Of them in % to the total number , , V³ в я в в 5 Й¹™ Им И cs et в в ей co K o V§ ев £§ <з p. и йв xg ao S B ли » a « s o g o в fto O яЗ O 2 в ft o B a K o *ч M к к K o £И Я И W 4 916 2,5 2,1 0,9 7 445 1,1 1,2 0,9 4 018 0,4 0,5 0,1 6 121 0,15 0,4 4 789 0,2 0,3 0,15 5,5 3,2 1,0 0,85 0,65 in the absolute, as well as relative number of narcomaniacs, especially cocaine addicts, over the entire period. Numbers of narcomaniacs treated in psychiatric hospitals of the city of Moscow show greater stability, as can be seen from Table 5. When considering this table, one should take into account both the significant growth of Moscow's population during the reporting period, and the fact that here we are talking about repeat patients, incurable narcomaniac recidivists, who were repeatedly admitted and discharged from the hospital. Many narcomaniacs from all the USSR come to Moscow, seeking specialized inpatient treatment here, and usually remain in the same psychiatric hospitals. And here, in percentage terms to the total number of treated patients, we have a decrease from 2.5% in 1923 to 1.7% in 1928 and 1.6% in 1929.-Abroad, many narcomaniacs are treated in sanatoriums. If we take for comparison data from one of the large Moscow neuropsychiatric sanatoriums 'Sokolniki', then here we get the following negligible figures of narcomaniacs for recent years: 1928-6 morphinists, 1929-7 morphinists, 1 cocaine addict, 1930-5 morphinists. Data from the district psychiatrist of one of the large districts of Moscow - Sokolnichesky-with a population of about 300,000 people-are presented as follows. Number of narcomaniacs (morphinists and cocaine T a b l. 5. Patients 1923 1924 1925 1926 1927 1928 1929 Men Treated patients. . 2 222 2 547 3 579 4 591 6 680 8 329 8 900 Of which: Morphinists .... Cocaine addicts .... Other narcomaniacs . . Total narcomaniacs . Women Treated patients . 1 746 2 058 2 207 2 631 3 161 3 521 Of which: Morphinist .... Cocaine addicts .... o Other narcomaniacs . . Total narcomaniacs . Total treated. . 3 923 | 4 293 5 637 6 798 9 311 12 421 Total narcomaniacs . 187 Percentage to treat- ed psychiatric 2,5 3,7 2,7 2,2 2,0 1,7 1,0 CH₃O.C< addicts) per 10,000 population: 1925-1.04, 1926-0.58, 1927-0.24, 1928-0.31, 1929-0.08.-If we distribute narcomaniacs (for 1926) by social groups, it turns out that the main role here is played by the unemployed (often declassed elements) and workers are completely absent (Table 6). All these data confirm the fact of a significant decrease in the already low indicators of N. in Moscow, as well as throughout the USSR. The cessation of economic exploitation, the decisive change in conditions and T a b l. 6. Distribution of N. by selected social groups in 1926 (relation per 10,000 population of selected social groups).