(Editor’s Note: Continued from Part I)
by Kawal Deep Kour (PhD, Indian Institute of Technology)
The Assam Opium Enquiry Committee Report of 1933 had disapproved the idea of imposing Prohibition and accepted addiction as a medical problem. It stressed the treatment of opium addicts in hospitals where they were entitled to medical care and supervision. This, as mentioned in an earlier post was an expression of the increasing contemporary interest in addiction research and studies at both domestic and international level. The committee was responsive to the various forms of medical treatments that were being experimented with for the prevention and treatment of opiate abuse. In 1932, the League of Nations communicated the positive results of treatment of drug addicts by the “Modinos treatment” (or injecting serum obtained from blisters in the skin to enhance the immune system of the addicts) in the Netherlands Indies. The Inspector-General of Prisons in Burma introduced it to his country’s incarcerated population, and the news of these experiments with Modinos caught the fancy of the 1933 Opium Enquiry Committee who suggested a similar trial in Assam. Similar experiments were also being carried out at the School of Tropical Medicine Calcutta by Colonel Ramnath Chopra and his team which also found mention in the 1933 Assam Opium Enquiry Committee Report. The findings of the team at the School of Tropical Medicine at Calcutta had greatly facilitated a scientific understanding of the progression of the opium habit including various forms of medical treatments available for prevention and treatment of opiate abuse. Highlighting the inefficacy of incarceration of opium users, it stressed the need to cure opium addiction in hospitals where addicts could be properly “policed.” Complete rehabilitation was however, ruled out.
In February 1939, the coalition Congress ministry in Assam announced an “opium treatment campaign” to be launched on April 15, 1939. The task of the treatment scheme was entrusted to Col. Chopra and his team. Addressing a gathering at Sibsagar on February 24, 1939, the then Premier of Assam and a popular leader, Gopinath Bordoloi, appealed to all sections of people to extend their full cooperation towards ensuring success of the Kanee Barjan Andolan (The “Give Up Opium” Campaign). Colonel Chopra was convinced that considering the dearth of available resources and requisite infrastructure in the subcontinent, and also in keeping with the contemporary advances in addiction medicine, the focus of treatment should be managing the mechanics of gradual narcotic withdrawal as the most suitable mode of detoxification of Indian patients. He thought this best achieved with the help of a certain bio-chemical preparation of gentian and nux vomica. Colonel Chopra cited minimal discomfort as the major advantage of the gradual withdrawal method. Another advantage was that post-withdrawal insomnia, an extremely distressing condition, was much less frequent. It was believed that this would encourage other addicts to seek treatment and help prevent relapse. Moreover, with slow withdrawal, it generally took about 3–6 weeks to effect a cure in most Indian addicts. Further, due attention was to be given to the psychological rejuvenation of the patient. Building a congenial doctor-patient relationship was imperative for the recovery of the patient.
Thus in April 1939, in Assam, began one of the largest anti-addiction initiatives ever carried out in India to date. Colonel Chopra and his team at the School of Tropical Medicine, Calcutta, experimented with two methods for the treatment of addicts in Assam: the Vesicatory serum therapy of injecting fluids from water blisters developed by Dr Polyvios Modinos of the European hospital at Alexandria, Egypt and the glucose-lecithin therapy (described in more detail below) developed by Chinese anatomist, Dr. Ma Wen Chao and his team at the Peiping Union Medical College in 1931.
In the Modinos detoxification method, the patient was to receive an injection for about five weeks under strict observation in a hospital. Their consent was required for an incision to be made and an injection of serum to be produced from his blood. The process was excruciating and patients resisted the treatment. Trials of Modinos treatment had been conducted on drug addicts in Burma following its approval by the League of Nations in 1932. The trials, covering 353 opium addicts were confined to prison in Burma and were conducted under the supervision of the jail superintendents. The treatment was hailed as a valuable method of withdrawal and “denarcotisation.” However, contrary to claims of cure, it appeared to provide only temporary relief and came to be regarded as a difficult and painful treatment. (Where its reputation as a painless modality originated remains unclear.) It encountered opposition among the addicts in Assam also owing to the risks of septic infections and other complications. It was discontinued after only a few trials.
The only treatment that appeared to suit the conditions prevalent in Assam, according to Chopra, was the use of lecithin and glucose. This therapy consisted of a three-phased intervention: (i) detoxification, (ii) withdrawal management, and (iii) recovery. The dosages of lecithin and glucose varied according to the severity of the symptoms. The duration of treatment was generally around 10 days. Throughout the period of treatment, addicts were encouraged to report voluntarily to treatment centres. On admission, they were subjected to a complete medical examination which included recording their detailed medical history as well as their name, age, sex, religion, occupation, social status, income, amount of opium consumed, duration of habit, reason for the habit, general state of physical and mental health. Based on the above, the patient was subjected to specific and “symptomatic” treatment. Lecithin was administered at a dosage of 10 grams twice or thrice daily while glucose was to be administered orally in solution or by intravenous injection (25% solution). Patients with signs of “toxaemia” (weak pulse, yellow eyes, “furred” tongue, and dry skin) were immediately put on isotonic saline intravenously along with a dose of diffusable cardiac tonic mixture. For “elimination of opium through the intestinal tract,” the patient was administered a full dose of calomel, ranging from 1 to 3 grams and some sodium bicarbonate at night. This was followed by a dose of magnesium sulphate to help restore the functioning of liver. However, this was discontinued if the patient had diarrhoea and then milk or curd was fed to the patient. Lecithin was administered in the form of pills from the second day, for a period of five to seven days. One pill thrice a day, along with one or two ounces of glucose, was believed to ameliorate the withdrawal symptoms.
Symptomatic treatment was followed for withdrawal symptoms that usually appeared within 36 hours. Nausea and vomiting were managed by sodium bicarbonate. In severe cases, ten drops of adrenaline hydrochloride solution (1 in 1000) were given under the tongue every two or four hours for relief. The most common complaint following the withdrawal was diarrhea, which was treated with minimal doses of opium, in the form of Dover’s powder, spread over a period of three to four days. Restoratives such as brandy, spirituous ammonia aromaticus, and digifortis strycnine were used to relieve low blood pressure, a feeble pulse and sinking sensation. To relieve insomnia, paraldehyde, sulphonal or chloral hydras were administered, while general weakness was sought to be alleviated by using tonics such as iron, strychnine or small doses of quinine. Other “intercurrent diseases” such as asthma, abdominal discomfort, dyspepsia, etc. were treated symptomatically.
Special attention was given to diet. During the detoxification phase, when the appetite was almost nil, the patient was fed well cooked rice with milk along with large doses of glucose (about one ounce per day), two or three times daily. This was believed to act effectively on patients suffering from jaundice and also to help the addicts in overcoming trauma. The first supplies of glucose for the experiment came from a German pharmaceutical company, Merck; these were later replaced by a solution of glucose, which was prepared and tubed locally at the Pasteur Institute at Shillong in India. Meanwhile, Messrs. Smith, Stani, Street, and Company of Calcutta were also approached at Chopra’s initiative for the local manufacture of lecithin. This not only ensured a steady supply but also stimulated local enterprise and generated great interest in various parts of the country.
It was found that during the preliminary period of treatment, when intravenous injections were given, the relief of the symptoms was so immediate that the addicts clamoured for these injections. Once it was found that it was possible and feasible to use the method safely under the prevailing conditions in the prohibition area, permission was given for its use in most of the centres. Though the normal practice was to examine the urine samples to determine the level of morphine, this could not be done in Assam, as the necessary reagents could not be obtained. Had it been possible to conduct such a test, it would have facilitated a comparison between the condition of those who had undergone specific treatment and those who had got over their withdrawal symptoms without any specific treatment. The official records reported on the positive results of treatment and their efficacy in the management of withdrawal symptoms and associated reactions. Col. Chopra, in an article, “Treatment of Drug Addiction in India,” hailed the experiment as “a unique campaign unparalleled in the history of drug addiction anywhere in the world.”
Its short-term efficacy aside, the combination of educative propaganda and therapeutic intervention was a novel initiative as it had certainly aroused public empathy for the opium users. It marked a paradigm shift in the outlook of the general public towards the opium users who were no longer looked down as offenders but as patients who needed medical care and attention. Such state initiative with medical collaboration was the harbinger of the emerging politico-medical discourse to effectively tackle drug addiction which had by then come to be regarded as a public health menace. It was expected that the involvement of the medical community would combine the twin objectives of scientific expertise and rational administration designed to promote social welfare by safeguarding public health.