The Treatment of Opium and Morphine addicts in Japan: Note by Professor Miyajima, communicated by the Japanese Representative. 2. Memorandum on the Treatment of chronic morphinism in Chosen, by Dr. M. Suwö, Medical Officer of the GovernmentGeneral of Chosen, Chief of the Clinic for Morphine addicts, established by the Bureau of Police Affairs of Keikidô, communicated by the Japanese representative. The Treatment of Opium and Morphine Addicts in Japan. 1. Note by Professor Miyajima. Communicated by the Japanese Representative. In Japan proper the abuse of opium and morphine by the inhabitants was so little known up to a comparatively recent date that the people in general were not even aware of the evil effects of the result of habitual use of narcotic drugs. Our medical experts therefore paid little attention to the etiology and treatment of opium and narcotic addiction. Quite recently, however, some abuses of drugs have been brought to the attention of the authorities especially among the Korean immigrants who introduced the habit contracted in Korea. This new problem together with the desire of checking the possible spread of the habit among the population has attracted the attention of the Japanese experts who have undertaken experimental researches into the causes of addiction and the scientific treatment of drug addicts. As regards the institutional treatment of addicts we find first in Osaka that drug addicts who became a public charge were from time to time brought to Nakajima Hospital attached to the Prefectural Asylum, but the number was very small and the method of treatment was of the traditional type of confinement and gradual withdrawal of morphine without any experimental scientific basis. It failed to produce any marked scientific result. On the other hand in Korea, as the result of the absolute prohibition of opium smoking under the Japanese regime, many persons have contracted the drug habit. In order to check the spread of this evil, the authorities have instituted control of the manufacture and sale of the drugs and have arranged for medical treatment of addicts in Relief stations and clinics established in the principal centres of the country. A marked result has been obtained from this treatment. In Kwantung Leased Territory in South Manchuria where most of the inhabitants are Chinese, a large number smoke opium while others have taken to the habit of using narcotics. The Government of the Leased Territory has instituted opium monopoly and at the same time has established a clinic in Dairen to give the necessary treatment for opium and other drug addicts. When the medical experts found that it was necessary to give treatment to the narcotic addicts, the pharmacological laboratories of the Medical College of the Keio University of Tokio under Professor Abe undertook a prolonged experimental research which was supported by a generous endowment given by Mr. Arima. Prof. Abe and his co-workers have announced recently the result of the research which has led to a new theory on chronic morphinism. Of the results obtained by the experts in Chosen, Kwantung Leased Territory and Japan proper that of Chosen has already been reported by Dr. Suwô, the Medical Officer of Health of the Government of Chosen and that of Professor Abe will shortly be published in part. Therefore it may be of some interest to give here a brief account of the work done by the Government of Kwantung Leased Territory at its clinic at the Relief station in Dairen. Treatment of narcotic addicts in Kwantung Leased Territory. It is estimated that there are about 670,000 Chinese living in the Leased Territory. But owing to a large number of immigrant coolies moving in and out every year, the exact number is difficult to ascertain. According to the investigation, however, made by the Government authoritie s of the Leased Territory, the number of opium smokers and drug addicts in the Kwantung Leased Territory has been as follows: 1922 27,154 1923 28,252 1924 29,521 1925 29,172 1926 29,172 1927 31,062 In order to treat the addicts a charitable organisation was established in Dairen in 1924 under the direction of Kôsaizendo - a Relief station, to which were admitted most of the addicts on public charge. This station was taken over by the Government of the Leased Territory in July 1928 and came under direct control of the authorities. The following table shows the results obtained by the station since 1924. Year. Number Completely Loft station Average No. of admitted. cured. uncured. days treated for all the addicts cured. 1924 203 134 49 15 1925 528 386 142 15 1926 335 260 75 21 1927 425 341 86 18 1928 367 309 67 19 1858 1430 419 13 - 5 - The method adopted by this station was gradual withdrawal of morphine to the minimum amount which would sustain the addicts without giving excessive withdrawal effects. The following preparations are used in order to minimize the withdrawal effects and complete the cure in as short a period as possible. Liquor Kalii arsenicosi (Fowler's solution) 0.02 gram, iodine 0.5 gram and calcium chloride 1.0 gram are mixed and in the process of compounding these substances, iodine hydric acid is extracted. It is then dissolved in 100 grams of Ringer's solution. The solution is colourless and transparent. The normal amount used daily is about 40 c.c. which is injected into a vein once a day, By this method it usually takes from seven to eight days before the daily allowance of narcotic drugs can be completely stopped, Within a comparatively brief period of four to five days after the drugs have been completely stopped, body movement becomes normal and weight tends to increase. The addict gradually ceases to desire the drugs within about 15 to 20 days (in rare cases it took over forty days). The average number of days required was 18. During the treatment some of the addicts experienced insomnia but this ceased within two or three days and these were no withdrawal effects. Most of them ceased to desire the narcotic drugs. As regards the result of the treatment, out of 1601 addicts admitted to the clinic, 1207 or 76.3% were completely cured and 374 or 23.7% left the clinic during treatment. A comparison of the treatment of opium and morphine addicts shows the following results: 79.6% of the former and 64.6% of the latter have been completely cured, showing more satisfactory treatment for the opium addicts than for the morphine addicts. The reason advanced for this difference was the different degree of absorption of morphine between the opium smoker and morphine addict. Professors Kubeta and Nakajima of the University of South Manchuria have after experiment reached the conclusion that the quantity of morphine absorbed by the opium smoker is only 1/7 of the total alkaloid contained in the opium used. Perhaps this explains why an opium smoker absorbs comparatively little morphine contained in the prepared opium and at the same time explains why habitual opium smokers attempt to use morphine in place of smoking opium as the habit causes a desire for increased intoxication. In the present treatment certain secondary symptoms appeared in about 10% of the addicts treated in the clinic. The chief among them was gastro-intestinal disturbances and there were a few cases of insomnia. -7- 2. MEMORANDUM ON THE TREATMENT OF CHRONIC MORPHINISM IN CHOSEN, By Dr. M. SUWO, Medical Officer of the Government of Chosen, Chief of the Clinic for Morphine Addicts, established by the Bureau of Police at Keikidô. Communicated by the Japanese Representative, I. Preliminary Remarks. In treating chronic morphinism and opium addicts, there are two wellknown methods: 1) the method of complete abstinence from drugs and 2) the gradual withdrawal of drugs in treating habitual addicts. The former needs strict supervision and the addict suffers from sudden withdrawal of the habitual drug. Even in the latter treatment, certain supervision is necessary and the treatment is generally much longer than in the former case, in order to avoid withdrawal with effects. Others are using/more or less varied results, a certain substitute such as: codeine or narcopone in treating the addict. In America the Quayle Treatment and treatment by Hyoscine which was adopted by the hospital annexed to Blackwell are said to have obtained certain results. Along with other experiments undertaken by European experts, I may cite here the work done in Japan by several experts. Dr. Nakano used spermatin for female addicts with some success and Dr. Shibata reported that he succeeded in treating female addicts by using spermatin, ovalmin and a vitamin. At the Belief Institute for Kwantung Province, Dr. Kuroi treated opium addicts with success by administering certain preparations by Dr. Ozawa, but for the morphine addicts his method requires a much longer treatment. Quite recently Dr. Abe of the Medical Faculty of the Keiô University had found a method of treating the addict in a comparatively short period by administering a brom-hydrochloric acid-scopolamin preparation. Since 1925 I have directed the work of the clinic for morphine addicts which was established by the Prefectural Government of Keikidô and have experimented on the various methods reported in Japan and elsewhere. The results obtained however are not quite satisfactory. In our experiment we came to the conclusion that in order to treat the addict satisfactorily it is essential to avoid the withdrawal effects, which are caused by stimulation as the result of the sudden disappearance of morphine from the tissues. Furthermore in order to treat the addict within a comparatively short time it is necessary to paralyse, (a similar effect may be produced by morphine), the central nervous system and especially the vegetative nervous system on which the habit-forming narcotics mainly react and at the same time it is necessary to shorten the period of excitation caused by the disappearance of morphine from the body organs. In order to bring the abnormal central nervous system caused by morphine and that of blood changes back to a normal state I prepared "antimohl" No. 1 and No. 2 for injection into the addict. The result was that the withdrawal effects were lessened and also that the period of treatment was much reduced. 2. Nature and action of the preparations. A. "Antimohl" No. 1. This preparation is the solution in which Extractum Hyoscyami and Extractum scopoliae are mixed in the proportion of 1 to 2 respectively. To this mixture is added 100 grams solution containing 0.0355 per 100 grams of all alkaloids. - 9 - 0.01 gram of brom-hydrochloric-scopolamin and 0.5 gram of codeine phosphate is dissolved in this solution, The preparation is colourless and clear, hut of slightly bitter taste, and it is injected subcutaneously into the upper part of the arms and intrascapular region. The effects caused by this preparation are first of all paralysis of the central nervous system and particularly of the vegetal nervous system, and a slight increase in the pulse rate. Although the frequency of respiration does not change, the blood pressure slightly increases, By the injection of this solution, the rate of sedimentation of erythrocytes (red blood corpuscles) is markedly retarded. Furthermore, it tends to decrease the leukocytes. As regards the digestive organs it dulls the gastrcenteric activity. It causes photophobia and hypermetropia in the eyes. It checks secretive action in the glands and causes dryness of the throat, B. "Antimohl" No. 2. This preparation contains 0.015 grams of Liquor Kalii arsenicosi (Fowler's solution), 1.0 grams of calcium chloride and 0.3 grams of calcium iodatum which are dissolved in 100 grams of Ringer's solution. It is colourless, transparent, odorless and has a slightly brackish taste. It is injected into the anconal vein. The effect of the injection does not give any change except to produce a sensation of warmth. 3. Precautions required for treatment by Antimohl. No persons suffering from cardiac symptoms, kidney diseases, asthenia or glaucoma should be treated by this preparation. Others who should be treated with care are persons of advanced age, persons subject to tuberculosis, pregnant women, and of persons suffering from gastro-enteric ulcer. For these persons the amount of morphine which is to be reduced each day should be the minimum quantity in order to avoid sudden reaction. 4. Treatment by Antimohl. An addict of narcotic drugs, opium, morphine, and others, has an intense desire for the drugs to which be is accustomed and the greatest anxiety produced by the withdrawal of the drug. He craves for the drugs and tries to obtain them by all possible means. For these reasons, it is absolutely necessary to keep close watch over the addict under treatment. (a) Determination of the quantities of drugs needed by the addict. The quantity of drug asked for by an addict for his daily need is usually a quantity superior to the amount medically required. In order to determine the minimum amount, an addict should be placed under observation at least 24 hours in a clinic while certain diminishing quantities of morphine are at certain intervals administered, care should be taken that he does not suffer from any severe withdrawal effects (or detoxication effects). hen the - 11 - minimum quantity is reached, that quantity is fixed as the amount of the drug daily required by the addict. (b) Treatment of slightly addicted persons. (amount of morphine daily required than 0.1 gram). Note.- The degree of addiction of an opium smoker is equivalent to about 0.05 grams of morphine daily required by a morphine addict. (The treatment given in the following table is for an addict who requires Oil gram of morphine per day). Daily Drugs used . tre atment. Morphine. Antimohl No.1 Antimohl No. 2. 1st flay. 0.1 gm. x 40.00 gms. 2nd " 0.05 " 0.5 " 40.00 " 0 5 " 3rd " 0.025 " 0.5 " 40.00 " 0.5 " 4th " 0,01 " 1.5 " 40.00 " 5th " x 0,5 " 40.00 " 6th " x X 20.00 " 7th " x x 20.0 0 " .... 20th " x x 20.00 " The quantit y of morphine administered on the firs t day is the same as tha t require d by th e addict , From the second day and following, i t is reduced to half the amount used on the previous day, and this amount is given in a number of differen t injections. The use of morphine is completely stopped afte r the fourth to sixt h day. The antimohl No. 1 is administered on the second day in doses of 0,5 grams from one to thre e times dail y and continue s as indicate d in the table , up to the morning afte r the morphine injectio n is stopped, The antimohl No. 2 is administered twice , in doses of 20 grams each, dail y from the first day of the treatment and reduced to 20 grams the next or following day afte r the morphine injectio n ceases. I t continues for about ten days. (c) Treatment of othe r addicts. (Amount of morphine dail y require d less than 0.5grams). (The treatment given in the following tabl e is for an addic t who require s 0.2 grams of morphine per day). Daily Drugs used (in gram). Treatment. Morphine. Antimohl No. 1. Antimohl No. 2. 1.5 1st day. 0.2 3.0 40 1.5 2nd " 0.1 3.0 40 1.5 3rd " 0.05 3.0 40 1.5 4th " 0.025 3.0 40 1.5 5th " 0.01 3.0 40 0.6 6th. " 0.005 0.8 40 7th " x x 20 8th " x x 20 9th " x x 20 20th x x x The quantit y of morphine administered on the firs t day is tha t determined by medical observation . On the second and following days, the quantit y is dail y reduced to half the - 15 - amount used on the previous day and this amount is given in a number of injection s for from 5 to 7 days. The Antimohl No. 1 is administered dail y on the second day from 0.5 gram to 1.0 gram from once t o thre e times and cease s afte r one injectio n in the morning of the day following the complete cessatio n of morphine. The Antimohl No.2 is administered from the first day of the treatment twice each day (SO grams in the morning and afternoon) and is reduced to 20 crams daily afte r the complete cessatio n of morphine injection . I t continue s for about ten days. (d) Treatment of seriousl y addicted persons. (Amount of morphine dail y require d in excess of 0.5 gram). (The treatment given in the following tabl e is for an addic t who require s 0.7 gram of morphine per day). Daily Drugs used (in gram). Treatment. Morphine Antimohl No. 1 Antimohl No. 2. 1st day. 0.7 x 40,00 2nd " 0.5 3.00 40.00 3rd " 0.3 3.00 40.00 4th " 0.2 3.00 40.00 5th " 0.2 x 20.00 6th " 0.2 x 20.00 7th " 0.2 x 20.00 8th " 0.2 x 20.00 9th " 0.2 x, 20.00 10th " 0.1 1.50 3.00 40.00 1.50 11th " 0.5 3.00 40.00 1.50 12th " 0.025 3.00 40,00 - 14 - Morphine Antimohl No. 1 Anitmohl No.2. 13th day, 0.01 1.50 40.00 3.00 14th " 0.005 1.50 40.00 3.00 15th " x 0.6 20.00 0.8 16th " x x 20.00 30th x x x The amount of morphine administered on the first day of treatment is that determined by medical observation. On the second day and following days, it is reduced as indicated in the table , until i t reaches 0.2 gram per day. It is then continued for 5 to 7 days until the addict is accustomed to the quantity of 0.2 gram per day. At this stage the treatment given is similar to that of the addict of category (c), The Antimohl No. 1 is administered for the first period in doses of 1.00 gram, thrice daily until the amount of morphine is reduced to 0.2 gram per day. It is then stopped for a time, and resumed again with an interva l of a few days in the same manner as in the treatment of category (c). The Antimohl No. 2 is administered as indicated in the table. 5. The clinica l results. The following result has been obtained by the treatment given in 1927 and 1928 in the clinic s established in five Prefectures. Results obtained in 1927: Number of addicts treated in the clinics during 1927 684 Number of addicts cured 660 Average days required for treatment 20 days. Results obtained in 1928: Number of addicts treated in the clinic s during 1928 805 Number of addicts cured 765 Average days required for treatment 21 days. (1) Table showing the number of addicts admitted to the clinic s in 1927 and number cured (by sexes and prefectures). Sex Prefectures : Keik i Chunan Zenhoku Zennan Keihoku Kôkwai Tota l Admitte d Male 205 14 31 212 114 69 Female 27 2 6 x 1 5 Tota l 250 16 57 212 115 74 684 Cured. Male 196 13 5 1 212 101 66 Female 27 2 6 x 1 5 Tota l 223 15 37 212 102 71 660 - 16 - (2) Table showing the number of addicts treated, number of days required for treatment and average days in 1927, Number cured by Prefectures. Keiki Chunan Zenhoku Zenhan Koihoku Kôkwai Total. 223 15 37 212 102 71 660 Shortest number of days required 3 4 11 6 7 4 Longest No. of days required. 20 52 51 20 20 20 Average No. of days. 15 22 20 13 13 19 Total days for treatment of all the addicts. 3,348 349 754 2,878 1,341 1,415 10,085 (3) Table showing the number of addicts admitted to the clinics in 1928 and number cured (by sexes and by prefectures). Keiki Chunan. Zenhoku Zennan Keihoku Kôkwai Total. Admitted Male 256 57 103 152 48 137 753 Female 23 5 10 14 x x 52 TOTAL 27 9 62 113 166 48 137 805 — Cured. Male 250 54 98 152 33 130 717 Female 22 4 9 13 x x 48 TOTAL 272 58 107 165 33 130 765