Tobacco Documents Online

I I I I This report contains the collective views of an international group of experts and does not necessarily represent the deci- sions or the stated policy of the World Health Organization. WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES No. 551 ~ / WHO EXPERT COMNIITTEE / ON DRUG DEPENDENCE I I I I I I I I I I I Twentieth Report WORLD HEALTH ORGANIZATION t~ O, GENEVA yp ~. 1974 ~ ~ +ti'+ ~ I

I I I I I I I I I I ISBN 92 4 120551 2 ! ' 0 World Health Organization 1974 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. , For rights of reproduction or translation of WHO publications in part or in toto, application should be made to the Office of Publications and Translation, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such ~ applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Director-General ' of the World Health Organization concerning the legal status of any country or territory or of its authorities, or concerning the delimitation of its frontiers. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in ' preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. ~ O , PRINTED IN SWITZERLAND ~ 1~. ~ ~ ^'

I I I I I I I I I I I I I I I I The Committee was informed about a number of other resolutions adopted by international bodies that, amona other things, (a) invited appropriate international agencies to cooperate fully in the United Nations programme of action in this field and " to pay special attention, in the formulation of their own programmes relating to the socio-economic con- sequences of drug abuse, to appropriate means of combating this abuse "; I (b) considering that " action by governments and international organs and organizations must be taken simultaneously on all fronts : prevention of abuse, repression of illicit traffic, control of production, manufacture, dis- tribution and consumption, development of training and education, scien- tific research, treatment and rehabilitation " and that better coordination of all efforts was required, requested " the Secretary-General to study the problem and attempt to solve it "; 2 (c) authorized the establishment of a " sub-commission on illicit drug traffic and related matters in the Near and Middle East " and work on the same problems by an Ad Hoc Committee for the Far East Region ; 3 and (d) recommended " Governments that are not yet parties to the Convention on Psychotropic Substances " to ratify or accede to this Convention ".b In connexion with point (b) above, the Committee was pleased to learn of a recent meeting of various United Nations agencies convened by the Administrative Committee on Co-ordina- tion at which it was recommended that an inter-agency advisory committee on drug abuse control should be established to address itself to the coordi- nation of programmes in this field. In connexion with item (d) above, the Committee was disappointed to learn that only 13 countries had so far adhered to the Convention on Psychotropic Substances and expressed the hope that the Convention would soon come into force.6 3. INTERNATIONAL NARCOTICS CONTROL BOARD The International Narcotics Control Board had continued to exercise its responsibilities under existing international treaties limiting the use of 1 United Nations General Assembly. Resolution 3014 (XXVII). In : Official Records of the General Assembly, Twenty-seventh Session, Supplement No. 30 (A/8730), p. 68. 2 United Nations, Economic and Social Council (1973) Official Records, Fifty fourth Session, Resolutions, Supplement No. 1, Document E/5367, pp. 19-20 (Resolution 1777 (LIV)). 3 United Nations, Economic and Social Council (1973) Official Records, Fifty fourth Session, Resolutions, Supplement No. 1, Document E/5367, pp. 19-21 (Resolutions 1776 and 1780). 1 United Nations (1971) Conference for the Adoption of a Protocol on Psychotropic Substances, Vienna (Document E/CONF.58/6). a United Nations, Economic and Social Council (1973) Official Records, Fifty fourth Session, Resolutions, Supplement No. 1, Document E/5367, p. 19 (Resolution 1773 (LIV)). ° Adherence or ratification by 40 countries is required. 11 -

I I I I j I I I I I I I I I I I I narcotic drugs to medical and scientific purposes and to implement, on a provisional basis, the 1971 Convention on Psychotropic Substances. In response to requests from governments for technical advice and assistance on means of improving the effectiveness of druQ control systems. it had undertaken a number of consultations and fieldvmissions during the past year. 4. UNITED NATIONS EDUCATIONAL, SCIENTIFIC AND CULTURAL ORGANIZATION The Committee learned that the United Nations Educational, Scientific and Cultural Organization, using assistance provided by the United Nations Fund for Drug Abuse Control, had convened three meetings within the last year to consider a number of matters related to the nonmedical use of dependence-producing drugs.' 5. INTERNATIONAL COUNCIL ON ALCOHOL AND ADDICTIONS The International Council on Alcohol and Addictions had continued to facilitate contact between persons working to alleviate and reduce the problems associated with the use of alcohol and other dependence-producing drugs. To this end, conferences and meetings had been organized at inter- national and regional levels, including meetings of small groups of researchers interested in a particular area of investigation. Special attention had been given to the nonmedical use of drugs in African countries with a view to fostering the development of improved programmes in those countries. PART II PREVENTION OF PROBLEMS ASSOCIATED WITH DRUG USE 1. GENERAL Throughout history and in all parts of the world, substances that alter mood, perception, or behaviour have been taken by people for a variety of 1 United Nations Educational, Scientific and Cultural Organization (1973) Education in more developed countries to prevent drug abuse, Paris (Document ED/MD/26, report on a Meeting) ; (1973) Methodologies for evaluation of mass media programmes for pre- vention of drug abuse, Paris (Document COM/MD/25, report on a Meeting) ; (1974) Youth and the use of drugs in industrialized countries, Paris (Document ED /M D: 34, report on a Meeting). 12

I 1 I I I I I I I I I I I I I I I I recreatioaal, ritualistic, and health purposes. The use of these substances in a manner unrelated to acceptable medical practice often leads to various problems for the drug users and the society in which they live. The seriousness of the health and social problems involved, the growing concern expressed about these problems, and the importance of utilizing more effective means for their prevention can hardly be overemphasized. The United Nations General Assembly 1 and the last four World Health Asseriiblie:, 2 have on several occasions voiced concern about these matters. A drug-related problem can be said to exist when some agent or agency judges that a given, presumably drug-related phenomenon is producing or is capable of producing harm to or difficulties for an individual or society, even though it may later be found that the phenomenon is not harmful or that it is not related to the use of the drug in question.3 Conversely, it is likely that not all of the drug-related phenomena capable of producing problems are currently known. Some may go unrecognized for long periods of time, as was the case with the health hazards of heavy cigarette smoking. It may be expected, therefore, that new drug-related problems will continue to be defined and older concerns modified and revised as our knowledge expands. The Committee was of the opinion that, in many parts of the world, problems associated with the use of beverage alcohol far exceed those associated with the nonmedical use of less socially accepted dependence- producing drugs, such as those of the amphetamine, cannabis, and mor- phine types. The human problems related to the nonmedical use of drugs may stem primarily from (a) man-drug interaction (e.g., traffic and other accidents during intoxication, the development of tissue pathology such as disorders of the lung or liver or death due to an overdose of heroin or a barbiturate) ; (b) nlan-society interaction (e.g., stigmatization or imprisonment for drug use) ; or (c) a combination of these and other factors (e.g., unlawful or asocial behaviour such as theft or desertion, or infections due to the use of contaminated drugs or injection equipment). While these problems are drug-related, they should be considered as " problems of people " more 1 United Nations General Assembly. Resolution 2719 (XXV). In : Official Records of the General Assembly, Twenty-fifth Session, Supplement No. 28 (A/8028), p. 85 ; Reso- lution 2859 (XXVI). In : Official Records of the General Assembly, Twenty-sixth Session, Supplement No. 29 (A/8429), p. 95 ; Resolution 3014 (XXVII). In : Official Records of the General Assembly, Twenty-seventh Session, Supplement No. 30 (A/8730), p. 68. 2 Off. Rec. Wld HIM Org., 1973, No. 209, p. 27 (Resolution WHA26.52) ; World Health Organization (1973) Handbook of resolutions and decisions of the World Health Assembly and the Executive Board, Vol. 1, 1948-1972, p. 123 (Resolutions WHA23.42 and WHA24.57) ; p. 124 (Resolution WHA25.62). ,1 W1d HIM Org. techn. Rep. Ser., 1973, No. 526, p. 18 (section 3). 13 I

I I than as simply " drug problems ". The difficulties encountered in their prevention are likewise human rather than drug problems, including the difficulty of imposing effective controls on the availability of drugs. 1.1 Use of terms The Committee adopted the following definitions and usages for the purposes of its report. Drug. " Any substance that, when taken into the living organism, may modify one or more of its functions. " 1 Drug dependence. " A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, charac- terized by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug. " 2 Psychic dependence. A condition in which a drug produces " a feeling of satisfaction and a psychic drive that require periodic or continuous admi- nistration of the drug to produce pleasure or to avoid discomfort. " s Physical dependence. "... an adaptive state that manifests itself by intense physical disturbances when the administration of the drug is sus- pended ... These disturbances, i.e., the withdrawal or abstinence syn- dromes, are made up of specific arrays of symptoms and signs of psychic and physical nature that are characteristic for each drug type. " s Dependence producing drug. " A drug having the capacity to interact with a living organism to produce a state of psychic or physical dependence or both. Such a drug may be used medically or nonmedically without necessarily producing such a state. The characteristics of a state of drug dependence, once developed, will vary with the type of drug involved. Some types of drug, including those present in tea and coffee, are capable of producing drug dependence in a very broad sense. The existence of such a state is not necessarily harmful in itself. There are, however, several types 1 Wld Hlth Org. techn. Rep. Ser., 1969, No. 407, p. 6 (section 1.1). This definition is intentionally broader than that used in connexion with substances intended always to be of benefit to a patient. See Wld HIM Org. techn. Rep. Ser., 1966, No. 341, p. 7 (section 2). 2 Wld Hlth Org. techn. Rep. Ser., 1969, No. 407, p. 6 (section 1.1). ~ ' Eddy, N. B., Halbach, H,, Isbell, H. & Seevers, M. H. (1965) Bull. Wld HIM Org.C 32,723. ~ ~ 14 0 0 ~ Q~

I I I I I I I I I I I I I I I I I I of drug that, because they can produce substantial central nervous stimula- tion or depression, or disturbances in perception, mood, thinking, behav- iour, or motor function, are generally recognized as having the capacity, under certain circumstances of use, to produce individual and public health and social problems. Drugs of the types listed below can produce substantial effects and problems of the kinds mentioned above. As used in this report, the term ` dependence-producing drug(s) ' means one or more drugs of the following types : (1) alcohol-barbiturate type-e.g., ethanol, barbiturates, and certain other drugs with sedative effects, such as chloral hydrate, chlordiazepoxide, diazepam, meprobamate, and methaqualone ;1 (2) amphetamine type-e.g., amphetamine, dexamphetamine, metham- phetamine, methylphenidate, and phenmetrazine ; (3) cannabis type-preparations of Cannabis satim L., such as mari- huana (bhang, dagga, kif, maconha), ganja, and hashish (charas) ; (4) cocaine type-cocaine and coca leaves ; (5) hallucinogen type-e.g., lysergide (LSD), mescaline, and psilo- cybin ; (6) khat type-preparations of Catha edulis Forssk ; (7) opiate [morphine] type-e.g., opiates such as morphine, heroin, and codeine, and synthetics with morphine-like effects, such as methadone and pethidine ; and (8) volatile solvent [inhalant] type-e.g., toluene, acetone, and carbon tetrachloride. " z Tobacco. " Though not listed above, it clearly is a dependence-producing substance with a capacity to cause physical harm to the user, and its use is so widespread as to constitute a public health problem. However, unlike the types of dependence-producing drug just noted, it produces relatively little stimulation or depression of the central nervous system, or disturbances in perception, mood, thinking, behaviour, or motor function. Any such 1 Despite the similarities in the signs and symptoms of alcohol and barbiturate intoxication and withdrawal, the Committee considered them separately from the pre- ventive point of view because of psychological and social differences in the problems associated with their use. 2 WId Hlth Org. sechn. Rep. Ser., 1973, No. 516, pp. 8-9 (section 2.1). For a more complete discussion see, for example, Eddy, N. B., Halbach, H., Isbell, H. & Seevers, M. H. (1965) Bull. Wld Hlth Org., 32, 721-733. 15 I

I I I I I I I I I I I I I I I I psychotoxic effects produced by tobacco, even when it is used in large amounts, are slight compared with those of the types of dependence- producing drugs listed above. It is for this reason that dependence on tobacco-perhaps the most widespread form of drug dependence-is not given specific attention in this reoort. Attention has been restricted to the ~ use of dependence-producing drugs capable of exerting major psychotoxic effects. " 1 Nonmedical use of drugs. " The use of dependence-producing drugs of the types noted above other than when medically indicated." 1 Drug control. National law or international agreement governing and restricting production, movement, and use of a drug to medical and scientific needs in the interest of public health and for the prevention of problems associated with the nonmedical use of drugs.2 Epidemiology. " The study of the distribution of a disease or condition in a population and of the factors that influence that distribution. " 3 Incidence rate. " The rate at which illnesses or other conditions develop during a defined period in a population at risk. " 3 Prevalence rate. " There are two indices of prevalence : (a) point prevalence-the number of cases at one point in time in relation to a defined population ; (b) period prevalence-the number of cases existing during a period of observation expressed in relation to a defined population. " 3 Central case register. " A formal record of defined ' cases ' maintained by a` central ' agency. A` case ' may be, for example, a patient with a diagnosed illness, a person presenting designated signs or symptoms, or someone who has exhibited a particular behaviour, such as taking depend- ence-producing drugs, or been involved in a particular incident, such as being arrested. To add cases to such a register, it is necessary that one or more individuals or institutions report specified information to another (central) agency. The central case register may contain limited or more detailed information about the person or ` case ' in question. The data included must be recorded in standard form. The records of a treatment 1 Wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 9 (section 2.1). 2 Based on a definition in Wld Hlth Org. techn. Rep. Ser., 1969, No. 407, p. 6 (sec- tion 1.1). 3 WJd Hlth Org. techn. Rep. Ser., 1973, No. 526, p. 17 (section 3). 16 I

I I I I I I I I I I I I I I I I I I centre or an individual researcher are not considered to constitute a central case register. " 1 Primary prevention is aimed at ensuring that a disorder, process, or problem will not occur. Secondary prevention is aimed at identifying and terminating or modi- fying for the better a disorder, process, or problem at the earliest possible moment. Tertiary prevention is aimed at stopping or retarding the progress of a disorder, process, or problem and its sequelae even though the basic condi- tion persists. 1.2 Focus of report Many formal and informal policies have been established and numerous actions taken in an effort to prevent entirely or reduce the seriousness of the individual and social problems associated with the use of various types of dependence-producing drug.2 Many of the existing policies and programmes are based on differing and sometimes conflicting assumptions and goals, even in one and the same community. For example, some programmes are based on the belief that most drug taking, especially that involving a socially disapproved drug or manner of use, is a moral problem, while other programmes appear to be founded on the assumption that drug use stems largely from either individual or social ills. The goal of reducing the health and other costs of alcohol-related problems is more often than not in conflict with the goal of obtaining profits or revenues at individual, cor- porate, and governmental levels. Unfortunately, many policies and pro- grammes have not been adequately evaluated for their effectiveness in achieving intended goals. Indeed, in many instances the goals appear to be vague and are only implied rather than stated explicitly. It will be emphasized repeatedly in this report that it is often pointless or even dangerous to recommend or implement preventive actions for drug- related problems until (a) both the broad goals and the more specific objectives are expressed in as quantifiable and measurable terms as pos- sible, and (b) careful thought is given to the possible risk of producing unintended, undesirable side effects. A measure directed toward the preven- tion of one drug-related problem may actually aggravate other problems. 1 Wld Hlth Org. techn. Rep. Ser., 1973, No. 526, pp. 17-18 (section 3). 2 For example, those of the alcohol-barbiturate, amphetamine, cannabis, cocaine, hallucinogen, khat, opiate (morphine), and volatile solvent (inhalant) types. See Eddy, N. B., Halbach, H., Isbell, H. & Seevers, M. H. (1965) Bull. Wld Hlth Org., 32, 731-733 ; Wld Hlth Org. rechn. Rep. Ser., 1973, No. 516, p. 9 (section 2.1). 17 I