Chapter 39. The Swedish experience

During the past few years, the American public has been warned of what happened to amphetamines in Sweden. Sweden, we have been told, was so blind to the hazards of the amphetamines that in 1965 these drugs were made available free of charge on the Swedish health plan. The results were 10,000 or 20,000 amphetamine "abusers" springing up practically overnight in a small country of 7,000,000. Now (the story goes) Sweden has banned amphetamines altogether, even on prescription. The Nixon administration's 1969-1970 drug bill proposed that the United States also prohibit amphetamine prescriptions except for a few special conditions–– thus profiting from the Swedish experience.

The actual Swedish amphetamine experience, investigated there for this Consumers Union Report, suggests a very different perspective.

Amphetamine was first placed on sale in Sweden in 1938, three years after its introduction into the practice of medicine in the United States. The Swedes, however, were much more prompt in recognizing the potential hazards of the drug; in 1939, though sales were still very small, they placed amphetamines on the list of drugs available only on prescription–– a step that the United States did not take until 1954.

Swedish physicians apparently found the drug useful, for by 1942 they were prescribing it to about 3 percent of the population.

Some 6,000,000 doses were prescribed during the year. A survey indicated that most Swedish users were using amphetamine sensibly and in moderation:

• 140,000 were occasional users, taking four amphetamine tablets or fewer per year. No doubt, like Americans at the same time, they used amphetamine on rare days when they had to work longer than usual, or faced some extraordinary challenge, or woke up depressed and out of sorts and needed something to "pull themselves together."
  
  
• 60,000 others were also occasional users, but with somewhat greater frequency; their usage ranged from five times a year to twice a month.
  
  
• 4,000 users took amphetamine only once a week or so, but often took two or three tablets at a time–– perhaps for a Saturday-night "high."
  
  
• 3,000 users might be described as "borderline." Their frequency of use varied from several times a week to daily–– and they sometimes took from five to ten tablets in a single day.
  
  
• 200 users–– less than a tenth of one percent–– could properly be labeled "abusers." They took from ten to a hundred or more amphetamine tablets a day, more or less regularly.

This spectrum of use suggests that amphetamines prescribed by physicians are drugs with only a modest potential for misuse. The figures may be contrasted with the estimated 10 to 12 percent of alcohol users who become problem drinkers or alcoholics, and the estimated one percent who become skid-row alcoholics.

The Swedish authorities, however, were not comforted by such statistical comparisons. Warnings against the amphetamines were circulated to all practicing physicians–– and in 1944 the prescribing of amphetamines was placed under much more rigid legal restrictions.

The new restrictive measures, of course, engendered nationwide publicity and once more alerted Swedes of all ages to the remarkable effects of the amphetamines. Thus at a time when these drugs were still known to only a minority in the United States, in Sweden they had achieved the status of near-universal familiarity, as a result of repressive measures.

The first effects of the tighter restrictions appeared to be favorable. "Sales dropped for a few years by one-half," Professor Gunnar Inghe of the world-renowned Karolinska Institute in Stockholm reports. But, as in the United States and other countries where the authorities rely on drug repression, undesirable side effects of the repressive measures made their appearance: increased use, a black market in amphetamines, the rise of an amphetamine-centered subculture, and the appearance of the speed freak."

In the middle of the 1940s, [Professor Inghe continues,] it became obvious that misuse of central stimulants was now taking shape in gangs on [a] collective basis, at first especially among Bohemians, writers, actors, musicians and other artists and their sycophants and admirers. At first there was only oral administration. Among the misusers there were however a few morphinists, and probably in the early fifties subcutaneous and later intravenous injection of central stimulants started. These forms of administration have gradually become the most common among large-dose addicts. Misuse had now very obviously started spreading among asocial and criminal groups, among whom it can be said to have become endemic. In the middle of the fifties instances of breaking into chemists' shops, forging of prescriptions, etc. became common, the number of narcotic gangs increased and the seizing of smuggled tablets started.

Each of these incidents, of course, was accompanied by widespread publicity; indeed, the antiamphetamine publicity in effect took the place of paid advertising in maintaining a booming sale of black-market amphetamines year after year.

The drive against smuggled amphetamine tablets no doubt helped raise prices and attract more smugglers, as in the United States. High prices also encouraged the switch from oral use to mainlining. In addition, however–– as in the United States–– repression and high prices led to the popularization of amphetamine substitutes: cocaine in the United States, phenmetrazine (sold under the trade name Preludin) in Sweden.

Preludin was introduced into Sweden in 1955. * "It was observed at once," Professor Inghe reports, "that this drug produced euphoria. It became rapidly popular in addict circles in preference to other central stimulants which it replaced." The parallel between Swedish and American policies and results is thus complete. The only difference is that the Swedes were far ahead of the Americans. The Swedes instituted antiamphetamine measures somewhat earlier–– and thus popularized both the amphetamines and amphetamine substitutes somewhat earlier.

* It is used in the United States as a "diet drug."

In 1959 the Swedes took the next obvious step. They subjected Preludin to the same strict legal controls as amphetamine, morphine, and heroin. A special prosecuting attorney was also appointed to concentrate on drug-law enforcement. "Since then, however," Professor Inghe reports sadly, "illegal import of Preludin has increased steadily." Originally "it came from the Boehringer factories in Germany." When the Swedes put economic and diplomatic pressure on the German government–– much as the United States has been pressuring the Turks and the French to cut off opium and heroin trafficking–– the smugglers switched their source of supply from Germany to Spain. Pressure on Spain was also effective. "Next came the smuggling of Preludin tablets from Belgium and various other countries, notably Italy," Professor Inghe states. Other amphetamine substitutes also became popular. "Phenmetrazine [Preludin] is still the most in demand," Professor Inghe reported in November 1968, "but amphetamine, methamphetamine, dexamphetamine, methylphenidate, and other drugs are used as well. Recent reports tell of an increasing abuse of weight-reducing preparations, which include diethylpropion [Tenuate, Tepanil]. . . . The misusers themselves have an incredible capacity for rapidly progressing to new euphoria-inducing preparations, which apparently without exception can prove both habit-forming and dependence-forming."

By November 1968, as smuggling controls over amphetamines and amphetamine substitutes became somewhat more effective, the Swedish black market, like the American black market a few years earlier, took the next obvious counterstep. As noted above, the raw materials out of which the amphetamines are made are common industrial chemicals, used in great quantity in ordinary manufacturing processes. Sweden imports these raw materials. A slight increase in such imports is very hard to detect–– yet sufficient to produce vast amounts of amphetamines. This, Professor Inghe told an international amphetamine conference in November 1968, was beginning to occur in Sweden." * This means that some part of the market now, as far as one can judge, is covered by illegal factories, at least partly situated in Sweden." The Swedes had belatedly discovered the "speed labs" which had begun flourishing in the United States six years earlier.

* According to another Swedish source, however, clandestine speed labs had operated in Sweden for some time; they simply escaped official attention until 1968.

The Swedish response to this 1968 development was to ban altogether –– except for a few uncommon conditions–– the prescribing of amphetamines and related drugs. Special permission was required from the National Board of Health and Welfare for each patient receiving amphetamines; during the second half of 1968, only 343 such permissions were granted for the entire country.

The sensible and occasional use of amphetamines under medical supervision was thus effectively curbed–– but a visit paid Stockholm in November 1970, in the course of research for this Consumers Union Report, indicated that the black market still flourished. Amphetamines and other stimulants were freely on sale in the city's large black market behind the Central Station–– a region of impressive new skyscrapers roughly comparable to New York City's Park Avenue in the fifties. The Swedes are convinced that they have today the worst amphetamine problem of any country on earth–– and they are almost certainly right.

The outcome of Swedish efforts to suppress amphetamine misuse between 1942 and 1970 can now be objectively evaluated. Prior to the repression, 240,000 Swedes received amphetamines legally on prescription from their physicians and used them occasionally and sensibly to help meet the minor crises of life–– chiefly overtime work and feeling out of sorts or depressed. This occasional legal use of amphetamines has now ended. Yet the "abusers"–– 200 in 1944-–– had by 1970 become an army estimated at more than 10,000–– and many had become mainlining speed freaks. The question inevitably arises whether Sweden might not have been wiser in 1944 to try, quietly and without publicity or publicized warnings, to reduce the number of its "serious" misusers from 200 to 150 or perhaps even 100, rather than trying to "stamp out amphetamine abuse."

One more parallel between the Swedish and American experience and between heroin and the amphetamines–– deserves mention. Because the United States has by far the largest heroin problem on earth, Americans also have the greatest number of heroin experts; at meetings of the United Nations, the World Health Organization, and other international agencies, the United States urges other countries to follow its lead in repressing the traffic in heroin. Other countries, looking at the results in the United States, are naturally loath to comply. The same is true of Sweden and the amphetamines. Through the years Swedish delegates to international conferences have urged that other countries also launch nationwide drives against the amphetamines, place them under the same controls as heroin and morphine, and curb international smuggling. Since the Swedish experts have had the longest and most extensive experience with amphetamine abuse, they consider themselves the best-informed experts. Other countries, however, have proved understandably reluctant to set off down the path that, beginning as early as 1944, led Sweden to its current amphetamine situation.

But if the facts are as here presented, what of the story, circulated in the United States for several years, that the Swedes have been tolerant of the amphetamines, have given them away free to addicts, and are suffering an amphetamine disaster as a direct result of this toleration?

The facts are quite simple and uncontroversial. In 1965, after Sweden had exhausted all repressive approaches to the amphetamines and amphetamine substitutes, a group of physicians applied for permission to supply modest numbers of amphetamine users with amphetamines as a research project. Permission was granted, subject to the condition that no physician supply more than 10 users. Two physicians exceeded the limit, so that as many as 250 or 300 users may have been supplied with amphetamines in the course of the project–– 250 or 300 out of an estimated 10,000 amphetamine abusers at the time the project was launched. The project gave added reason to conclude that an amphetamine maintenance program has little or nothing to recommend it, and it was abandoned after two years.

Thus, Sweden's amphetamine problem has been blamed in the United States on the experimental prescription of amphetamines to a few hundred users in a dispensing project that  followed rather than preceded Sweden's amphetamine explosion.

Japan, like Sweden, experienced an epidemic of excessive amphetamine use after World War II According to reports by Japanese and American observers, Japan successfully curbed this epidemic by law-enforcement methods–– sweeping arrests, stiff prison sentences and curtailing supplies. If true, this marks one of the few victories of law enforcement over drugs in the history of drug use. No on-site review of the Japanese experience was made, however, in the course of research for this Consumers Union Report; and no objective evaluation of the Japanese experience was found in the medical literature available in English. Nor have we found any cogent explanation of why law-enforcement methods that proved counterproductive in the United States, in Sweden, and in other countries against other drugs as well as the amphetamines–– proved so successful in Japan. Whether, on closer scrutiny, the Japanese amphetamine stories circulating in the United States might prove as misleading as the stories emanating from Sweden, is an issue of considerable importance which warrants further inquiry.

Footnotes
Chapter 39

1. Gunnar Inghe, "The Present State of Abuse and Addiction to Stimulant Drugs in Sweden," in  Abuse of Central Stimulants, ed. Folke Sjöqvist and Malcolm Tottie (Stockholm: Almqvist and Wiksell, 1969), p. 187.

2. Ibid.

3. L. Goldberg, "Drug Abuse in Sweden," United Nations  Bulletin on Narcotics, 2 (1968); 9-36.

4. Gunnar Inghe, "The Present State of Abuse and Addiction," p. 187.

5. Ibid., p. 189.

6. Ibid.

7. Ibid.

8. Ibid., p. 190.

9. Personal communication.

10. Gunnar Inghe, "The Present State of Abuse and Addiction," p. 190.

11. For example, Henry Brill and T. Hirose, "The Rise and Fall of a Methamphetamine Epidemic: Japan 1945-55,"  Seminars in Psychiatry, 1 (1969): 179-194.