Drug Abuse

SPECULATIONS ON THE NATURE AND PATTERN OF OPIUM SMOKING

John C. Kramer

John C. Kramer, M.D. is Associate Professor in the Department of Psychiatry and the Department of Pharmacology at the University of California, Irvine. His research is largely on historical aspects of drug use and is aimed at better understanding the interrelationships between society and drug use.

Opium smoking began spreading slowly but steadily in China from early in the 18th Century. It grew through the 19th Century to the point that by the end of the century it became a nearly universal practice among males in some regions. While estimates vary, it appears that most smokers consumed six grams or less daily. Addicted smokers were occasionally found among those smoking as little as three grams daily, but more often addicted smokers reported use of about 12 grams a day or more. An individual smoking twelve grams of opium probably ingests about 80 mg. of morphine. Thirty mg. of morphine daily may induce some withdrawal signs, while 60 mg. daily are clearly addicting. While testimony varied widely, it appears likely that most opium smokers were not disabled by their practice. This appears to be the case today, too, among those peoples in southeast Asia who have continued to smoke opium. There appear to be social and perhaps psychophysiological forces which work toward limiting the liabilities of drug use.

The observation that opium could be smoked was probably first made late in the 16th or early 17th century, in China (Spence, 1975:147). Opium had first been brought to China about 800 AD by Arab traders. Though there are some references to its use as a euphoriant from about the 10th century, it was used primarily as a medicine during those early years (Edkins, 1894:148-51).

By 1729 reports of extensive opium smoking had reached Peking and a prohibitory edict was issued by the Emperor. Nevertheless, the practice continued and grew gradually. Late in the eighteenth century individual British entrepreneurs began bringing Indian opium into China. The profits realized by this trade guaranteed its growth. It continued despite the efforts of various Chinese governments to halt it. During the first half of the nineteenth century importation grew steadily, and with it presumably an increase in the prevalence of opium smoking. The ports, the coastal areas, and the navigable rivers-were most accessible, and thus were the areas in which the practice was dominant during this era. The Opium Wars of 183942, and particularly 1856-60 led to the de facto legalization of opium smoking in China. After this, the Chinese themselves began to grow the poppy extensively. Importation reached its peak about 1880, after which the native product so dominated the market that importation from India began to decline.

Though several provinces, Szechuan and Yunnan particularly, were massive producers, opium was cultivated throughout China. Eventually, the total home grown product substantially exceeded the largest quantities imported. No longer was opium smoking predominantly found in the cities, but reached the countryside. The peasants were the last social class to become extensively involved in the practice.

What were the levels of individual consumption?

A report by the British Imperial Maritime Customs in 1881 contained a note entitled, Opiumin China: How Many Smokers Does the Foreign Drug Supply (Hart, 1881). At the time, imports amounted to about 6 million Kg. annually., Since about 30 percent of the weight was lost in preparing the opium for smoking, this provided about 4.2 million Kg. of the smokable product. From reports of the 19 British customs commissioners in China, it was estimated that the average daily dose was about 12 Gm., enough for about one million smokers of the foreign product at that rate of consumption (Imperial Maritime Customs, 1881).

The Customs Service erred in their assumptions. For instance, opium was repeatedly resmoked. The opium ash, or dross, amounts to 40 to 60 percent of the original opium and contains a substantial proportion of morphine, the principle narcotic ingredient (Chopra and Chopra, 196:189-90). The British Medical Journal (1880:757) reported that the ash yields 50 percent opium.

Other estimates of average consumption are available. Kane (1882:64) reported one survey of the daily consumption of 1000 smokers:
646 smokers used between 1 and 8.5 Gm.
250 smokers used between 11 and 21 Gm.
104 smokers used between 32 and 107 Gm.

Thus, about two thirds of the smokers surveyed used substantially less than 12 Gm. daily and probably few of the heaviest smokers approached the maximum consumption listed.

A table describing 50 patients treated for addiction at the Medical Missionary Society's Hospital, Canton, (Imperial Maritime Customs, 1881:55) shows a range of daily doses from about three Gm. per day to 32 Gm. per day with an average of about 13 Gm. per day. These, however, were individuals who were seeking relief from their physical dependence.

Kane (1882:64-5) noted that one missionary stated that the average consumption was about one Gm. per day. Another authority stated that the "medium dose" was about two Gm. daily In his own experience among Chinese in America he guessed the average to be four Gm. daily. In an 1855 letter from a Dr. Hobson to Sir J. Bowring, the doctor stated that the average quantity smoked daily was six Gm. with many people consuming less (British Parliamentary Papers, 1840-85:320).

The British Medical Journal (1880:757) indicates that, "Deducting the unconsurned opium, few moderate smokers consume more than one pound and a half a year . . . " (or under two Gm. per day). Among addicted patients seeking treatment at the Foochow Opium Asylum, the American Journal of the Medical Sciences (1883:550) reported they consumed an average of either eight or twelve Gm. daily. In a more recent study, Mo (1932:807-14) indicated that the average opium smoking addict in treatment in the Nanking Anti-Opium Hospital had been consuming about eleven Gm. of opium per day.

In a still more modern report Phillips notes (Geddes, 1976:222) that 1.34 Kg. of raw opium is a one year supply for an "addicted" smoker. Reducing this by 30 percent (for preparation of the smokable product) and dividing by 365 we find average daily consumption to be 2.57 Gm. If resmoking is considered, each user thus consumes about five Gm. per day.

We find rather consistently that "average" consumption is generally estimated at up to six Gm. daily, while average daily consumption among those seeking treatment for dependence is usually around twelve Gm. daily.

Morphine Equivalent of Opium

Morphine is the principle narcotic in opium. Codeine is present too, but in substantially smaller quantity. Because of its lower narcotic potency, its effects are still less, proportionately. For our purposes we shall consider only the morphone content of opium. While there is variation in the percent of morphine in opium, it is ordinarily considered to be ten percent of opium. It is uncertain what effect the preparation of opium for smoking has on the proportion of opium in the product. According to the author, William Burroughs (1978), smoking opium runs about seven or eight percent morphine. Dixon (1921:819) found a sample of dross (smoked opium) to contain 7.35 percent morphine.

While inhalation of drug vapors is a very rapid method of ingestion, its efficiency in terms of proportion of the active ingredient absorbed, is low. In the case of opium smoking some of the morphine may be destroyed by incineration, a portion remains in the residue in the pipe, and some is exhaled.

In his travels to learn of the extent of suppression of Chinese opium growing in 1910-11, Hosie (1914b:243) reported that five of his crew who had been inveterate opium smokers indicated to him that swallowed opium was about ten times as effective as the smoked substance. Indirect support for this approximation comes from a study of Chinese heroin users. Examining the efficiency of inhaling vaporized heroin, Mo and Way (1966) analysed the total urinary output of opiate of their subjects for three days following ingestion. When heroin was provided by intravenous injection, 68 percent was recovered . When "chasing the dragon" was used, 26 percent of the heroin was recovered. ("Chasing the dragon" is the technique of inhaling through a straw or match box cover the fumes of a heroin- barbiturate mixture which is vaporized from a receptacle held over a name.) Using the "ack-ack" technique the recovery rate was 14 percent. ("Ack-ack" is the method in which the, heroin is placed at the end of a cigarette from which some of the tobacco has been removed. It is then lit and inhaled.) "Ack-ack" is more like opium smoking than is "chasing the dragon", because temperatures of over 750 degrees celsius are characteristic of burning tobacco and are, perhaps, comparable to the temperatures to which smoked opium is exposed. In the chasin g-th e -dragon technique heating is held to that in which the heroin-barbiturate mixture is just vaporized.

Since 14 percent, the urinary recovery rate in "ack-ack" smokers is about one-fifth of 68 percent (the urinary recovery rate in intravenous heroin users) it appears that only one fifth of the heroin is absorbed in the "ack-ack" technique.

The entire batch of heroin is vaporized or oxidized in the "ack-ack" technique. However, opium smoking, unlike heroin smoking, leaves a substantial residue (about 50 percent) of partially burned, morphine-containing opium. In light of this, Hosie's suggestion that smoked opium is about one tenth as potent as swallowed opium seems reasonable. A recent report by Westermeyer (1973) states that smoking required "a much greater quantity of opium" than eating the drug.

It seems reasonable to assume that about one tenth the available morphine is absorbed by the smoker from the preparation. Thus, there is consistency among the findings of Mo and Way on the ack-ack technique of smoking heroin, Hosie's report that swallowed opium was ten times as potent as smoked opium, and the statement in the Encyclopedia Britannica (1955, vol. 16:811) that, "The smoker does not absorb more than one-tenth of the total amount of morphine contained in opium . . . "

Addiction Level

We have seen that three or four Gin. per day of opium is a consumption level at which a few individuals become physically dependent. It has been proposed that smoking-opium often contains about seven or eight percent morphine; and that about one-tenth of the available morphine is absorbed by the smoker. Thus Four Gm. of opium smoked daily should contain about 300 mg. of morphine, of which the smoker would absorb about 30 mg.

Isbell (1978), describing some unreported work by Dr. E. G. Williams writes, (He) attempted to study dose-time relations in regard to physical dependence. He studied ten mg. four times daily (40 mg.), 15 mg. four times daily and 20 mg. four times daily (80 mg.) for two weeks and four weeks. The drug was morphine sulfate given I.M. to "former addicts." Briefly, there were mild withdrawal signs even with 40 mg. daily for two weeks but "clinically significant" Himmelsbach point scores (20 points or more daily) were not reached until the dose was 60 mg. daily for one month.

Williams reported (Williams and Oberst, 1946:21) that two subjects receiving 20 mg. of morphine sulfate subcutaneously daily showed changes when the drug was withheld, which though small were in the same direction as those found during withdrawal in bona fide addicts. Scoring according to the Himmelsbach point system would have yielded very few or no points. Similar observations were noted even when the subjects were being given only two doses of 20 mg. morphine sulfate per week.

Jasinski (1977:207) reported that subjects dependent on 30 mg. of subcutaneous morphine daily showed abstinence signs of sufficient magnitude for the conduct of suppression. While Jasinski clearly indicates that 30 mg. of morphine per day produces significant abstinence signs and leads to drug-seeking behavior, elsewhere (Jasinski, 1977:226,247) he suggests that 30 mg. per day of morphine may produce only marginal dependence, and more important, that the intensity of withdrawal scores may not be a prime indicator of compulsive drug seeking behavior. Sixty mg. morphine per day, however, given subcutaneously, is obviously addicting (Jasinski, Martin and Hoeldtke, 1971:634) when similar methods of evaluation are used. Thus, while 30 mg. or even 20 mg. of morphine taken regularly may produce some signs of abstinence, 60 mg. or 80 mg. were necessary to induce substantial withdrawal signs.

The average smoking-opium consumption of addicts in treatment is about twelve Gm. daily, though some patients indicated that their daily use was substantially less. Twelve Gm. of opium probably contains about 800 mg. of morphine. Apparently about one-tenth is absorbed (80 mg.).

According to the findings of Williams, Williams and Oberst, Jasinski, and Jasinski and colleagues, 20 or 30 mg. of morphine taken daily is marginally addicting while 60 mg. is clearly so.

The Effects of Opium Smoking

When the Royal Commission on Opium (1894:154-843) carried on its investigation in 1893-4 they interviewed or corresponded with many individuals who possessed varying degrees of familiarity with the question of opium smoking. Many were from India or the "native States." Some were familiar with opium smoking in China or among the Chinese residing outside their native country. Opinions regarding the dangerousness of the habit varied considerably. In general, missionaries, including physicians who were missionaries, condemned the practice heartily. Government workers and employees of British companies expressed the least concern, in general. Those who might be expected to be most objective ordinarily spoke of a substantial incidence of excessive use, but indicated also a predominance of moderate use. But the Royal Commission on Opium is conceded to have been strongly biased in favor of continuation of the opium trade.

The American investigation conducted by The Philippine Commission did not suffer from that bias. (Committee on the Philippines, 1906:57-165), yet opinions solicited follow a pattern similar to those in the Royal Commission's Report. Again, missionaries are strongest in condemning the practice and in implying that it is almost always totally disabling. Most physicians, including several who were life insurance examiners, indicated that most smokers were moderate in their consumption. Use of up to 8 Gm. per day was permissible in granting life insurance coverage.

"Moderate" use was not necessarily non-addictive. Many moderate users would become ill for several days if deprived of the drug, but could resume work thereafter.

Dr. T. F. Pedley who treated many Chinese patients in Rangoon over a period of 25 years noted that, A Chinese takes a smoke of opium somewhat as an Englishman takes aglass of sherry. Some Englishmen must have two or three drinks of whiskey; in the same way, one Chinese may be contented with one-half of a grain (? gram) of opium, while another must have two or three grains. They think it is a great mistake to go to excess (Committee on the Philippines, 1906:108-9).

Rev. Timothy Richards, who resided in China for 33 years, recognized that he disagreed with many of his fellow missionaries. He indicated that use of opium was not usually considered an important issue in hiring employees. He granted that use often led to a low level dependence, but he also knew of places where consumption was typically intermittent. Elsewhere, notably in some western provinces, he stated, it was used by 80 to 90 percent of the people (Committee on the Philippines, 1906:84-7).

Kane (1882:77) wrote of the exaggerations of well-intended writers regarding the inevitable evils of opium smoking. Compared to oral or hypodermic use, he believed smoking took longer to induce a habit, that it was less injurious, and that it was easier to cure.

Miskel (1972) has traced medical opinions during the mid-nineteenth century regarding the relative harmfulness of opium use. In 1840 only a small minority of British physicians at one symposium denounced regular opium use both as unequivocally dangerous and addictive. He notes that Dr. O'Shaughnessy, who practiced in Bengal, contended that the drug was harmless; and that another physician attributed the presumed dangers of opium to poor hygiene, rather than to the drug.

He recounts that around 1850 pharmacologists, Pereira and Johnston, denounced opium indulgence as both physically and morally corrupting. Opinions were generally polar: habitual use was either denounced as an unmitigated harm or an innocuous pastime. However, Miskel states that:

. . . The majority of physicians with firsthand knowledge of opium smoking in the Orient tended to view it as a harmless vice. Most of these men can be fairly charged with unprofessional bias. Drs. Eatwell and Imprey were employees of the world's largest opium producer, the East India Company. Drs. O'Shaughnessy and McPherson also had connections with the company. J. Carroll Dempster and John Wilson worked for the British government which was, after all, at least indirectly involved in the opium trade. Perhaps it was no coincidence that all of these men took so sanguine a view of the drug habit (Miskel, 1973:7).

He also states that physician missionaries, on the other hand usually, though not uniformly, were condemnatory. The missionary saw opium as a hindrance to the propagation of the Christian faith in China, or conversely, that the absence of Christianity deprived the Chinese of protection from the vice.

Few Chinese sought out the cures offered by the missionary doctors, perhaps because unacceptable conditions were so often imposed on those applying for the treatment. And yet "the Medical Missionary Society was the most (financially) successful wing of the missionary crusade because of its widespread repute as the healer of opium smokers."

What Miskel does not point out, however, is that since most Western physicians in Asia were associated either with missionary groups on the one hand, or the British Government or East India Company on the other, bias of one sort or another was general.

The bias of the missionary doctors seems to have been more distorting of the facts. Though many addicts were curious about the cures the mission hospitals offered, they tended to avoid attending them. The missionary doctors looked upon addiction, of itself, as a degrading vice, and in their attempts at cure, often without benefit of gradual dose reduction, observed the distress of the withdrawal process. And those smokers who overcame-their reluctance and sought help were likely to be among the most desperate.

The nature of many reports, in which, for example the proportion of farmers, rickshaw drivers, merchants, soldiers, etc. who were opium smokers was provided, as well as an abundance of testimony declaring that a large proportion of smokers were not disabled, indicates that the government-allied doctors were probably more accurate in their descriptions than the missionaries.

Professor E. Leong Way (1978), the renowned opiate pharmacologist, recalls his experiences with Chinese farmhands in the San Joaquin Valley of California in the late 1910s and early 1920s. Of 30 or 40 men who lived in the bunkhouses, perhaps half smoked opium, most of them in the evening only. A few, particularly one older man, also smoked during the midday break. Their attitude toward the practice was very casual, "no more than smoking cigarettes." They were, however, aware that one could become addicted.

Professor Way's father, the farm owner, smoked occasionally, perhaps three times a year, typically at an all male social gathering.

Some Current Patterns and Effects of Opium Smoking

Today, among the poppy-growing hill tribes of southeast Asia, there appears to be a powerful measure of social control over Me use of opium. Westermeyer (1971) first reported that 20 to 35 percent of the Meo smoke opium, but subsequently indicated (Westermeyer, 1978) that that village actually had a low rate of addiction because so few of the residents of the village he studied were involved in production or commerce of opium. He states that overall addiction rates in the Yao and Hmong (Meo) villages producing opium are seven to ten percent. A few individuals are referred to as "habitual" users, that is, they smoke once daily in the evening, consuming one or two pipefuls. Many of these return to occasional smoking, some go on to heavier habits. The "working addicted," he says, smoke two to four times a day and constitute 0.5 percent of the population. "Incapacitated addicts" smoke five to ten times a day and perform little or no work. While he met several incapacitated smokers, only one occurred in his survey of 400 adult meos.

In another study of Laotian opium smokers Westermeyer (1974) says:The finding that most addicts in this sample (90 percent) were farmer-peasants or middle-class workers varied from the common stereotype, in which a decrease in social competence is thought to accompany addiction

... To be sure, a few (3) of the (40) subjects were unable to maintain their roles as productive family members and became beggars or day laborers. Nevertheless, addiction was sensed as a burden, particularly after many years of opium smoking.

Geddes (1976:221-2) reviewed the Thai government's 1965-6 survey of addiction: The Miao were reported to have a 9.55 percent addiction rate, the Lahu 11. 17 percent and the Yao, 15.9 percent. The overall rate for the tribes studies was 3.6 to 6.1 percent among males and 1.2 percent among females. He says that though addiction is recognized as a social problem among the Miao, it is not severe in most Mao communities. In one village he noted "a number" of occasional and moderate smokers, one of whom had retired as headman, and was still vigorous for his age. Four to 5 percent of the village were "seriously" addicted.

Discussion

Among the Chinese, the prevalence of opium smoking varied depending on location and era. From the late eighteenth century till about the 1860s the practice tended to concentrate in the cities, on the coast and along the navigable rivers. Afterwards, the cultivation of the opium poppy in China increased immensely, particularly in the western provinces. To A large extent, locally produced opium was consumed in the vacinity of its cultivation, thus such provinces as Szechuan and Yunnan dominated not only its production, but also its consumption. By the end of the nineteenth century many observers believed that in these areas opium smoking was almost universal among adult men. Even those who were not regular consumers would occasionally smoke on important social occasions.

While there is no certain way to assign proportions among occasional, regular but nonaddicted, mildly addicted, and heavily addicted groups, all available information suggests that there was a tendency, over time, to increase the quantity of opium used, yet for some reasons, disabling addiction appears to have been limited to a minority. There are some inferences that most smokers, aware of the problems that heavy addiction entailed, voluntarily limited their consumption.

One survey about 1880 of 1000 opium smokers suggests that the heaviest using 10 percent of the group consumed 50 percent of the opium (Kane, 1882:64). Projecting a curve from this data, it appears that 40 to 50 percent of this group used 3 Gm. or less per day. Over threefourths used 8.5 Gm. per day or less. Since about twelve Gm. a day is probably the consumption necessary to achieve substantial withdrawal symptoms, it appears that most Chinese opium smokers were, at most, only mildly addicted.

The reasons for this pattern of moderation may lie partly in the realm of psych ophysiology, partly in that of culture. Psychophysiologically, there may be an optimum (rather than a maximum) level of intoxication which most drug users seek. Even with the tolerance that opiates induce many users may prefer to experience low levels of intoxication rather than high levels. Higher levels of intoxication may cause undesirable symptoms which they choose to avoid. Culturally, there may be an acceptance of moderate levels of intoxication, while there is disdain for the individual who over-indulges, particularly if he thereby reduces his functional capacities or violates social sanctions which are separate from mere indulgence in the drug.

This appears to be the case with alcohol. While many people drink, only some become alcoholic. This may be due both to a dislike of the effects of drunkenness and because there are social sanctions against the effects of excessive consumption. We have assumed, evidently erroneously, that opiates including smoking opium are so seductive and tolerance to it so profound that moderation is impossible.

The possibility that social controls may be more important than psychophysiological ones is suggested by Geddes' (1976:222) statement regarding the present-day Mao culture:

The lowering of health and human dignity which addiction may bring is kept vividly before the eyes of the Miao at Meto by the spectacle of the Karen addicts who labor in Miao fields for wages ranging from two to fivebaht per day usually paid in opium. No Miao would wish this condition for themselves and none at Meto have reached it. The Karen provide not only a convenient work-force but a warning.

For whatever reason, most evidence suggests that moderation in the consumption of smoking opium was the rule both in China and elsewhere. As with alcohol today, it exacted a heavy toll from some people and caused moderate disability for even larger numbers. This is not an argument favoring moderate use of opium. It is rather an indication that social and perhaps psychophysiological forces work toward limiting the liabilities of drug use within society.

NOTES

1. Original materials give weights in avoirdupois or Chinese measures. In this paper all weights are given in approximate metric equivalents.

2. Heroin is rapidly metabolized to morphine and morphine salts. It is these which are measured in the urine.

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