OPIATE NARCOTICS

223. The term narcotic has had wide and inconsistent usage in lay, legal and scientific circles. Some use the word to characterize any drug which produces stupor, insensibility or sleep; many apply it only to derivatives of the opium plant ('opiates'); others consider the term equivalent to addiction-producing; and in legal matters, 'narcotics' may refer to almost any allegedly dangerous drugs (for example marijuana and cocaine are often considered with opiate compounds in narcotics regulations in spite of the fact that they have little in common with them). To reduce some of this ambiguity, the specific phrase opiate narcotic will be used in this report, and will be restricted to drugs which are derivatives of, or are pharmacologically similar to products of the opium plant papaver somniferum.

224. The earliest unambiguous description of opium to which we have access was written in the third century B.C., although some scholars have cited references to opiate-like drugs dated more than 5,000 years ago.29 Many believe that Homer's 'Nepenthe' was opium. These drugs are obtained from the juice of the unripened seed pod of the opium poppy plant soon after the flower petals begin to fall - no other part of the plant produces psychoactive substances.

Although 'opium eating' has been known in Asia for thousands of years, widespread use of the drug did not occur until the development of the British East India Company's wholesale opium empire in the eighteenth century. The practice of smoking opium developed in China soon after American tobacco was introduced to the Orient. Chinese prohibition of the British opium precipitated the 'opium war' in which the world's greatest naval power forced China to open its door to the British (opium) trade. 223

225. In 1805, the major active constituent in opium was isolated - an alkaloid given the name morphine, after the Greek God of Dreams, Morpheus. In the next half century, various other alkaloids were discovered, such as codeine and papaverine, both if which are in general use today. Since then, a variety of semisynthetic (e.g., heroin, in 1874) and synthetic (e.g., methadone, Demerol* and Alvodine*), opiate-like drugs have been developed. These compounds have the potential of producing qualitatively similar actions (at different doses), although there is considerable variability among them in the potency of the different opiate effects. Heroin, more potent on a weight basis than morphine, is usually the choice of the chronic opiate narcotic user. This drug was originally considered 'non-addictive' when put on the market. Those members of the medical and related profession who use these drugs non-medically, as well as others who have become dependent as a result of medical use, tend, to use morphine or the synthetics. Because of the similarities among these drugs, they will, with a few exceptions be dealt with as a group. Heroin (and sometimes other opiate narcotics) is often referred to as 'H', 'horse', 'junk', 'scrag' or 'smack'.

226. Until the nineteenth century, 'raw' opium was either smoked or taken orally. There is a decidedly lower dependence liability -with these techniques than: with 'practices' which followed and it was not until the isolation of morphine and the invention of the hypodermic needle that the opiate narcotics became a serious problem in the Western World. Morphine was widely acclaimed among medical practitioners and was used freely, to treat pain during the American Civil War, sometimes producing a dependency called 'soldiers' disease'. General use of tincture of opium in many patent medicines (e.g. Paregoric) made the quasi -medical use of opiates a common practice in North America at that time. On the West Coast, the influx of Chinese labourers, some of whom smoked opium, apparently stimulated non-medical use to some degree. The extent of opiate narcotic problems in the nineteenth century is difficult to ascertain, however, it would appear that the use of these drugs was not a major moral issue. In the early part of the twentieth century, some of the problems of morphine and heroin dependence became apparent, and most opiate products were removed from the open market in North America and non-medical possession was prohibited.

227. Because characteristics fluctuate with social change, a description of drug users is necessarily tied to a given population at a given point and time and may have little general application. There is little information on opiate narcotic users in North America prior to this century, but many researchers contend that far more women than men made use of these drugs at that time. Since the general opiate prohibition in the early part of this century, men have become the predominant users. While Chinese opium smokers were not uncommon a half century ago, there appear to be very few Orientals in North America using opiate narcotics today. In recent decades, the use of these drugs in Canada has tended to centre on a few urban areas. Medical and related professions represent a frequently noted high-risk group with respect to the development of drug dependency. For various reasons, statistics on the incidence of dependency in this group are quite inadequate. Many researchers contend that health profession dependents constitute a significant proportion of the total chronic opiate narcotic using population.28 For many years, the known opiate narcotic users have made up about 0.02 per cent of the overall Canadian population.

228. Although many observers do not feel that the non-medical use of opiate narcotics is currently a major public health problem in Canada, there are numerous reasons for directing attention to this group of drugs. Historically, the popular conception of the 'narcotics addict dope fiend' has established an image of the non-medical drug user which persists and intrudes into almost every examination or investigation of drug use today. Furthermore, the opiate narcotics have played an important role as a model in much of the past and present drug legislation, and in general crimino-legal approach to the control of socially censured drug use. Although many important questions about the opiate narcotics are still unanswered, it is clear that much of what has commonly passed for fact, is fiction, and often bears little resemblance to scientific information.

Medical Use

229. Most of the current medical uses for the opiate narcotics were fairly well understood and established in Europe by the middle of the sixteenth century, and were probably well known in certain areas long before that time. These drugs are primarily used in the relief of suffering from pain, in the treatment of diarrhoea and dysentery, and to reduce cough. Hundreds of related compounds have been synthesized in attempts to retain the clinical benefits but reduce the dependence liabilities of the opiate narcotics. These efforts have not been very successful, and thus morphine and related drugs are still considered by physicians to be among the most valuable drugs available to the practitioner today. Heroin is no longer used medically in North America.

Administration, Absorption, Distribution and Physiological Fate

230. Opiate narcotics are produced in a variety of tablets and capsules, elixirs, cough syrups (with codeine), injections, rectal suppositories and, on the illegal market, are also available in a gummy solid or powdered form. Codeine is often mixed with other non-opiate analgesics (e.g. APC & C*; 222's*). While the opiate narcotics are well absorbed from the gastrointestinal tract, this route is often erratic and unpredictable compared to injections. Among non-medical users, subcutaneous ('skin popping') and intravenous ('mainlining') injections are commonly used with heroin and morphine. Raw opium is usually eaten or smoked and the powder is sometimes sniffed ('snorted'). Only a minute fraction of the drug absorbed actually enters the central nervous system. The duration and intensity of the effects vary considerably with the different drugs in this class (and as a function of dose), although the major action might typically last from three to six hours. These drugs are usually inactivated in the liver and excreted in the urine, often along with small quantities of free morphine.

Physiological Effects

231. Pure opiate narcotics produce few significant non-psychological effects in therapeutic doses. The immediate or short-term physiological response usually includes a general reduction in respiratory and cardiovascular activity, a depression of the cough reflex, a constriction of the pupil of the eye, and minor reduction in visual acuity, slight itching, dilation of cutaneous blood vessels, warming of the skin, a decrease in intestinal activity (often causing constipation), and, in some individuals, nausea and vomiting. In higher doses, however, insensibility and unconsciousness result. The primary toxic overdose symptoms are coma, shock and, ultimately, respiratory arrest and death.

232. There appears to be little direct permanent physiological damage from chronic use of pure opiate narcotics. Numerous complications are observed, however, if the overall drug use pattern involves adulterated street samples, unsterile administrations, unhygienic living standards, poor eating habits and inadequate general medical care - all of which are commonly part of the criminal-addict behaviour syndrome. Commonly reported disorders in street users are hepatitis, tetanus, heart and lung abnormalities, scarred veins ('track marks'), local skin infections and abscesses, and obstetrical problems in pregnant females. At one time, malaria was also commonly seen in this population.

233. The general mortality rate among heroin dependents is considerably higher than normally expected for their age group. Sudden collapse and death following intravenous injection has been reported in a number of these individuals. Such fatalities have often been attributed to overdose resulting from erratic and unexpected variations in the purity of drugs obtained from the black market. However, there is considerable evidence that many of these deaths are not merely due to overdose but are a consequence of partly soluble contaminant substances in the sample and, perhaps, some drug hypersensitivity phenomenon.43

234. The subjective effects of narcotics may vary considerably among different individuals and situations. Most persons reportedly do not enjoy the experience and may actively avoid its repetition in a controlled or experimental situation, while others describe feelings of warmth, well-being, peacefulness and contentment. Euphoria or dysphoria, nausea, drowsiness, dizziness, inability to concentrate, apathy and lethargy are commonly noted. Certain individuals, especially when fatigued may be stimulated into feelings of energy and strength. Higher doses produce a turning inward and sleep. Often a pleasant dreamlike state occurs. Some regular users describe their drug experiences in near ecstatic, and, often sexual terms (especially the 'rush' of intravenous injection).

The potential of the opiate narcotics to relieve suffering from pain depends upon several mechanisms. The major effect is not on the sensation directly, but on the psychological reaction to it. Often individuals can still feel the pain sensation, and rate its intensity reliably, in spite of the fact that much or all of the negative or unpleasant aspects are absent. In other words, they may still feel the pain, but it does not bother them to the same extent. Morphine has little effect on the other senses and unlike non-narcotic analgesics and sedatives, it can often control pain at doses which do not necessarily produce marked sedation, gross intoxication or major impairment of motor coordination, intellectual functions, emotional control or judgement.110 In addition to reducing the anxiety of pain and therefore the motivation to avoid it, the opiate narcotics also tend to decrease other primary motivation associated with sex, food, and aggression.

235. The psychological effects of chronic opiate narcotic use are often rather straightforward extensions of the short-term response. In regular users, much of the variability and unpredictability of the immediate response is lessened, partly because individuals who find the experience unpleasant tend to avoid additional exposure, and also because many who were initially upset by the unusual physiological and psychological sensations caused by the drugs learn to tolerate and even seek them and may no longer be distressed in the situation. While some individuals who become dependent on the opiate narcotics withdraw from regular social activities, and live what might appear to be an immoral, criminal and slovenly existence, others are able to lead an otherwise normal life with little change in work habits or responsibilities. Possible factors underlying these differences will be discussed later.

Tolerance and Dependence

236. Tolerance to the different actions of opiate narcotics varies with the magnitude and frequency of administration, and the response being measured. In chronic use, a considerable degree of tolerance occurs to the sedative, analgesic, euphoric and respiratory depressant (and, therefore; potentially lethal) effects; less tolerance develops to the constipating and pupil-constricting activity. Consequently, persons who are motivated by the chronic avoidance of pain or other unpleasant subjective conditions, or perhaps simply by the positive euphoric effects of the drug, are likely to increase dose and may eventually tolerate several times the quantity which would be lethal to a normal individual. Occasional use does not produce tolerance, however.

237. The degree of physical dependence acquired to these drugs is closely related to the tolerance developed. With low dose or infrequent use, little dependency occurs and withdrawal symptoms may be nonexistent, or merely resemble the symptoms of a mild flu. Withdrawal of the drug after chronic high-dose use results in a severe and painful pattern of responses which are similar to those associated with alcohol and barbiturate dependence (although it is not as physically dangerous). Usually less than half a day after the last administration, the dependent begins to feel irritable, anxious and weak; he sweats and, shivers and his eyes and nose become watery. A few hours of uneasy sleep may intervene before he begins the 'cold turkey' phase. The skin becomes clammy, the pupils dilate, chills, nausea, vomiting, and severe abdominal cramps occur with uncontrollable defecation; tremors and, rarely, convulsions may develop. While death has been reported, fatalities are much rarer than with sedative withdrawal. The major symptoms of the abstinence syndrome generally last several days, and gross recovery usually occurs within about a week, although complete recuperation may take up to six months .145 Tolerance is eliminated or greatly reduced with withdrawal. Babies born of dependent mothers are also physically dependent on the drug, and may die if withdrawal symptoms are not recognized and treated soon after birth. It should be noted that the different opiate narcotic drugs have varying dependence-producing potentials, and physical dependence is rarely seen in opium smokers or users of codeine (although strong psychological dependence may occur).

238. Considerable cross-tolerance and cross-dependence exists among the opiate narcotics. An intravenous injection of any of these drugs, in sufficient dose, can completely eliminate the withdrawal syndrome in a matter of minutes. Methadone can prevent withdrawal symptoms at doses which provide little psychological effect, and is frequently used in chronic 'maintenance' programmes designed to rehabilitate dependents. Although the sedatives and opiate narcotics do not usually show significant cross-tolerance and dependence, barbiturates can ease the pain of opiate withdrawal. Nalorphine (Nalline*) antagonizes the effects of the other opiate narcotics and precipitates the withdrawal syndrome in dependent individuals. This drug has been used to 'test' for dependence in suspected users.

219. ' The role of physical dependence in the overall picture of chronic opiate narcotic use has been the subject of much controversy and many observers feel that the psychological components are the most important. Some investigators argue that the fear of withdrawal is often the primary motivating factor behind continued use, while others emphasize the profound craving seen in some individuals, or the drug's positive reinforcing or reward potential. Many dependent persons return to the drug at some time after withdrawal, and some have occasionally been known to voluntarily undergo withdrawal in order to lose tolerance (for economic reasons), and immediately initiate chronic use again, at a less expensive level. This practice suggests that, with some individuals, psychological factors other than mere avoidance of the abstinence syndrome can be dominant in the drug dependence. Whether this motivation is related to the desire to escape or avoid a life that is unpleasant, or emotionally painful or depressing, or perhaps a more directly hedonistic demand for pleasure or 'kicks', or even a disguised attempt at self-destruction is not clear - no simple answer could be expected to have much generality or validity. It has frequently been observed that some individuals become dependent on the hypodermic syringe (or 'point') in a way which is, in some respects, independent of the pharmacological properties of the drug. Persons showing such conditioning are often called 'needle freaks'.

240. It is interesting to note that there are only a few middle-aged persons who are dependent on opiate narcotics. Most individuals spontaneously lose interest in the drugs before they turn 45 years of age (barbiturate and alcohol dependents show no such decline in use). Whether this is due to psychological or physiological factors is uncertain.

Opiate Narcotics and Crime

241. A consensus exists among medical, law enforcement and research authorities, as well as drug users themselves, that few crimes of violence are directly produced by the use of the opiate narcotics. On the other hand, there is a considerable relationship between crime and opiate narcotic dependence in North America and many drug dependent persons have non-drug criminal records. This apparent paradox can be explained by two important factors. To begin with, both in Canada and in the United States, many individuals who become dependent on opiate narcotics have a prior history of behavioural problems and delinquency and have continued these practices. The second factor is economical, and is associated with the high cost of heroin on the black market and the demands made by extended tolerance.

Because of the illegal nature of the drug, the cost of a heavy heroin habit may run anywhere from $15.00 to $50.00 a day and higher, in spite of the fact that the medical-cost of the drugs involved would just be a few cents. There are very few legitimate ways in which most individuals can afford to meet that kind of an expense. Consequently, when tolerance pushes the cost of drug use above what the user can afford legitimately, he is forced into a decision - either quit the drug and go through withdrawal, or turn to easier, criminal, methods of acquiring the necessary money. While many users refuse to become involved in such activities and stop using the drug, at least temporarily, many turn to petty crime, small robberies, shoplifting and prostitution. These are the individuals who regularly come to the attention of the law enforcement officials. More affluent persons may be able to support the habit and continue indefinitely without running afoul of the law. Medical profession dependents, for example, apparently have less tendency to commit non-drug offences - perhaps (in addition to predisposing psychological and sociological factors) because they can often steal with little risk or purchase the necessary drugs at low cost.

As Jaffe has stated:111

The popular notions that the morphine addict is necessarily a cunning, cringing, malicious and degenerate criminal who is shabbily dressed, physically ill and devoid of the social amenities, could not be farther from the truth. The addict who is able to obtain an adequate supply of drugs through legitimate channels and has adequate funds, usually dresses properly, maintains his nutrition and is able to discharge his social and occupational obligations with reasonable efficiency. He usually remains in good health, suffers little inconvenience and is, in general, difficult to distinguish from other persons. Good health and productive work are thus not incompatible with addiction to opiates. However. ... such continued productivity is the exception rather than the rule.

The Development of Dependence

242. There have been a number of popular misconceptions about the pattern of development of opiate narcotic dependence. Rumours have frequently been heard that marijuana and hashish had been spiked with heroin to produce opiate addiction in the unsuspecting user. Similar rumours have been heard about 'spiked' LSD. In fact, there are no known documented cases in Canada of opiate narcotic adulteration of other drugs alleged to be pure. The high price of illicit heroin renders such a hypothesis extremely improbable. Furthermore, it would be highly unlikely, if not impossible, for tolerance and dependence to develop without the user knowing it. The majority of users, both here and in the United States, were apparently first 'turned-on' by their friends and peers. Blum (in the United States Task Force Report) points out:28

There is no evidence from any study, of initiation as a consequence of aggressive peddling to innocents who are 'hooked' against their will or knowledge. . . The popular image of the fiendish pedlar seducing the innocent child is wholly false.

243. The once popular notion that the opiate narcotic experience is intrinsically so pleasurable, or that physiological dependence develops so rapidly, that most who are subjected to it are promptly addicted is without support. In one experiment, injections of morphine were given to 150 healthy male volunteers. Only three were willing to allow repeated administration and none indicated that he would have actively sought more. The investigators42 conclude:

. . .opiates are not inherently attractive, euphoric or stimulant. The danger of addiction to opiates resides in the person and not the drug.

Lasagna et al 126 also report that the majority of normal pain-free individuals found effects of opiates quite unpleasant. Beecher22 reports that only ten per cent of a normal population liked the morphine experience. Furthermore, many individuals who developed tolerance and physical dependence in a medical situation show little interest in the drug experience itself and tend not to resume use after withdrawal. Even in non-medical cases, there is evidence that only a small proportion of drug users who have experimented with opiate narcotics in the streets become physically dependent on them.42

244. Many observers contend that certain, social and personality factors predispose some individuals to drug dependence and that otherwise normal individuals rarely, if ever, become chronically dependent. There is considerable evidence that both the ready availability of the drug and a social milieu tolerating or encouraging drug use (either medical or non-medical) are also important factors. Although there are numerous individuals who have gradually worked up from occasional 'skin popping' to chronic 'mainline' dependence, there is at present, little evidence that a large proportion of the Canadian population is running this particular risk. However, there is cause for apprehension because of the rapidly growing incidence of heroin use among the young in the United States. Although there are no known methods of predicting the likelihood of dependence for any individual at this time, the use of opiate narcotics involves a risk of considerable proportions for anyone.

Opiate Narcotics and Other Drugs

245. In the United States, the opiate narcotic offender coming to the attention of the law enforcement officials was often reported to have previously and concurrently been a heavy user of alcohol, barbiturates, tobacco, and marijuana. In Canada, the pattern appears to be much more variable and heterogeneous. Alcohol and barbiturates (and probably tobacco) have apparently been the drugs most often associated with opiate narcotic use here246, 215, although recent indications suggest that many new heroin users may have experience with marijuana and other psychedelic drugs as well. 170a There are reports that LSD is generally not popular with regular heroin users, however.41 Some opiate narcotic users also make use of stimulants such as amphetamine and cocaine.

1. Much attention has been and is now being given to the 'stepping-stone' or 'progression' theory of opiate narcotic dependence. Although there is no pharmacological basis for the hypothesis that one drug creates a 'need' for, or necessarily leads to another, there are numerous social factors which might link together the use of various drugs. It may well be that the questions of 'progression' or predisposing experiences can never be definitively answered. Like other characteristics associated with deviant behaviour, they must be continually evaluated anew as the social context changes. Some observations on the possible relationship between marijuana and opiate narcotic use were presented in the previous section on cannabis.