HJNO Mar/Apr 2022

DRUG ADDICTION 28 MAR / APR 2022 I  HEALTHCARE JOURNAL OF NEW ORLEANS   (cannabis) has been largely consumed— eaten and later smoked—in Islamic cultures. All these substances have a long history, intricately interwoven with myth, bearing witness to man’s predilection for psycho- active substances.The oldest seeds of cul- tivated vines so far discovered and carbon dated were found in Georgia and belong to the period from 7000 to 5000 BC. 8 Accord- ing to Jewish and Christian tradition, one of Noah’s first actions after coming out of the Ark was to plant a vineyard; he drank some of its wine and became drunk (Genesis 9, 20-21). Coffee was largely used through- out the Islamic world at the end of the 15th century. Its use spread rapidly in Europe, and Europeans introduced coffee plants into their colonies. Tea’s history is much older, since the plant was already being harvested in China in the 3rd century BC. These staple commodities have long been the object of official attention, for the pur- pose of collecting excise tax rather than controlling abuse. In order to extract rev- enues, rulers inAncient Egypt and Babylon established production or sales monopo- lies. 9 Ordinances limiting consumption have coexisted and alternated with free supply, in close temporal and geographic proxim- ity. Temperance movements led to a clear decrease in liquor use in Western Europe in the early 20th century, culminating with prohibition in the United States (from 1920 to 1933) and in a few Nordic countries. In preceding centuries, tobacco and cannabis had also known prohibition. Smokers ran the risk of having their lips cut under the first Romanov tsar, Michael Fiodorovich, or of being beheaded under the Ottoman sultan Murad IV. In 1378, the Ottoman emir in Egypt, Soudoun Sheikhouni, was deter- mined to stamp out hashish use: farmers growing hashish were imprisoned or exe- cuted, and those found guilty of consuming were said to have their teeth pulled out. 10 Devising more potent compounds In the course of history, many psychotro- pic plants have been refined and adminis- tered through new routes, allowing faster access to the brain in higher concentrations. The fermentation of cereals containing starch produces beer with an alcoholic con- tent of around 5%, whereas the same pro- cess with grape sugar yields wine containing up to 14% alcohol. Distillationmade it possi- ble to obtain beverages with a much higher alcohol content. People could drink alcohol with strength of 50% and more, making it easier to become drunk. The construction of stills, associating an alembic to distill a liquid with arrangements to condense the vapor produced, seems to have started only in the 11th or 12th century around the medi- cal school of Salerno in Italy. 11 Distillation, though it did not create the problems with alcohol, could intensify them. 12 The “water of life,” as it was called in many languages (Latin aqua vitae) conquered Europe with great speed. That name still survives, as in the Danish akvavit and through the Gaelic uisge beatha to the English whisky. In Eng- land, drunkenness was to become con- nected with distilled spirits, especially gin, as dramatically pictured in Hogarth’s Gin Lane. Alcohol without liquid (AWOL) is a more recent process that allows people to take in liquor (distilled spirits) without actu- ally consuming liquid. The AWOLmachine vaporizes alcohol and mixes it with oxy- gen, allowing the consumer to breathe in the mixture. Vaporized alcohol enters the bloodstream faster, and its effects are more immediate than its liquid counterparts, producing a euphoric high. Traditionally, coca leaf is chewed in the regions of pro- duction in Southern America, for instance by Andean miners to diminish fatigue. At the other pharmacokinetic extreme, the smoking of crack cocaine produces short-lived and intense effects that are felt almost immediately after smoking. Opium is another example of a substance whose pattern of use changed in the last centuries, from a medication used for pain relief and anesthesia to a substance associated with abuse and dependence. Opium’s capacity to induce dependence was probably bolstered by the recent purification of morphine, and the synthesis of heroin, more potent com- pounds that are available for injection. Simi- larly, cigarettes, which allow nicotine to be rapidly absorbed into the bloodstream and to reach the brain in a few seconds, were associated with more dependence than pre- vious modes of tobacco use (snuff, cigars, chewing) which did not promote deep inha- lation into the lungs. THE HISTORICAL ROOTS OF ADDICTION MEDICINE Chronological milestones Abnormal patterns of substance use have been described since antiquity, at least since Alexander the Great’s death in 323 BC was precipitated by years of heavy drinking. Aristotle recorded the effects of alcohol withdrawal and warned that drinking during pregnancy could be injurious. 13 The Roman physician Celsus held that dependence on intoxicating drink was a disease. 14 The birth of addiction medicine in modern times is sometimes credited to Calvinist theologians who offered explanations for the phenomenon of compulsive drinking, which were later accepted by physicians. 15 Dr. Nicolaes Tulp, a Dutch physician depicted in Rembrandt’s painting “The Anatomy Lesson,” adapted theological models to explain the loss of control over various types of behavior (1641). In this process, what was considered sinful behavior was given medical explanations. A few decades later, one of Tulp’s colleagues, Cornelius Bontekoe, applied his teaching to the progressive loss of willful control over alcohol intake. With the colonial era, industrial revolution, and international trade, addiction became a global public health problem. In the 18th century, opium’s addictive potential was recognized when a large number of Chinese people became addicted, and the Chinese government tried to suppress its sale and use. In Europe, the working classes were threatened by alcoholism. 16 At that time, psychiatry had matured into a scientific discipline, established nosological classifications, and taken stands on societal issues. The American physician Benjamin Rush, writing in the 18th century, maintained that