Demons: Our changing attitudes to alcohol, tobacco and drugs.

Rao PR. Demons: Our changing attitudes to alcohol, tobacco and drugs. Natl Med J India 2017;30:174-5

Humankind has an ambivalent attitude towards psychoactive substances, which have been used for centuries as remedies for ailments, in religious rituals, or for recreational purpose as euphoriants. Many a time, the recreational use progresses to compulsive, habitual use leading to addiction, with devastating consequences. Humankind, over centuries, has tried to control the use of psychoactive substances by imposing restrictions on their availability. These restrictions are observed through unwritten rules in the form of customs and rituals, or more formally through laws and regulations. Thus, some substances have been declared as ‘illegal’, while others are legally available, but regulated through governmental controls. Currently, in most countries, alcohol and tobacco are legal drugs, whereas substances such as opioids, cannabis or cocaine are illegal. This should mean that alcohol and tobacco are less harmful compared to illegal substances. If one looks at the burden of diseases globally or deaths attributed to psychoactive substance use, alcohol and tobacco are high on the list.

It seems that science alone has not governed society’s label of legal or illegal substances. What else can account for this? Several factors come to one’s mind: role of industry, economics, social movements, etc. Many illegal substances were once legal and were widely used in social rituals or as medicines too; cannabis and opium are two examples. What accounts for society’s changing attitude?

This book offers answers to some of these questions. The author, Virginia Berridge, is a historian, and has used the lens of history to examine how and why psychoactive substances have gained the present state of acceptance and legal status or otherwise. She has focused much on British history (also the world history for most part of the past four centuries) to examine societal positions with regard to psychoactive substances. Opioids (and cocaine as well as cannabis to a lesser extent) have been taken as a proxy for illegal substances. There are also intermittent references to American history to compare and contrast the British attitude with other societies. The book covers, in twelve chapters, the changing attitude of society to psychoactive substances from the 19th century till now. In the introductory chapter, the author has clearly outlined her reasons for using the historical lens to understand this phenomenon.

The historical account begins with describing how British society of the 19th and early 20th century saw opium as the panacea for all ills of human beings, and that it was the aspirin or paracetamol of its day. It was available in various forms and all, rich and poor alike, consumed opium sold in the open market alongside daily consumables. Industrialization saw opium being used by the working class for dealing with their poor living conditions. The extensive use of opium came to notice due to increasing death rates in the working class, which was attributed to the sale of substandard opium; this eventually led to the sale of adulterated drugs becoming punishable in the 1870s. Alcohol (as locally brewed product) and tobacco remained culturally acceptable. The third chapter (Social movements: Temperance) focuses on alcohol becoming an issue for social movements in the early 19th century. Increased drinking was seen to be a lower class phenomenon, and a means of exploitation by the owners. Drinking also started being seen as anti-Christian, and non-drinking as a way to move up the social ladder. The social movement gained momentum with political and funding support from the church, and had its influence on two overlapping worlds, which were crucial for positioning of substances—culture and policy.

The fourth chapter discusses the role of professionals (doctors and pharmacists) and professional societies in positioning of substances in the 19th century. Pharmacy (a prominent field in the 19th century) was organizing itself in the UK, and various laws concerning pharmacy were enacted in a manner that pharmacists still held control over using opium in their preparations. With the advent of the germ theory of disease, inebriety also started being seen as a disease, and medical treatment was proposed as an alternative to punishment. Inebriety also brought alcohol and drugs together in the 20th century. The connection between inebriety and expanding theories of insanity also grew strong, bringing forward the concepts of dipsomania, monomania and chronic alcoholism. In chapter five (Fear: Dens and degeneration), the author describes how the immigration of Chinese in the late 19th and early 20th century changed the opium scene with the introduction of opium smoking (rather than oral use, which was the prevalent mode till then) in England. The fear of Chinese polluting the working class, which can then spread to the middle class leading to urban degeneration was played out in various literary works published at that time. The fear was at its peak after the First World War to justify an extensive system of international control on opium.

The sixth chapter (Economics and technology: The role of industry) describes the differential impact of economic and technical developments in shaping opinion on substances. Alcohol production changed from local ‘ale’ to mass production of beer, and later spirits. Similarly, the introduction of cigarettes saw an increase in the manufacture of tobacco. Globalization of substances was a profit-driven process, which had the government’s nod due to the huge potential for revenue generation. The opium story was different: invention of the hypodermic syringe led to an improved delivery system for opium abuse. Rising concerns over the abuse potential of drugs led to opium getting confined to a restricted market.

The seventh chapter (Internationalism and war) describes the impact of the First World War. Increased smuggling and use of drugs by troops, combined with lack of control over opium created ripples internationally. The Hague convention in 1919 gave the ‘League of Nations’ supervisory powers over the international narcotics trade. In Britain, medical expertise was established within a framework of criminal justice. The eighth chapter (Mass culture and subculture) shifts to tobacco becoming a mass culture phenomenon in the 1930s due to increase in tobacco advertising, and women liberation. However, opium use became a subculture phenomenon, and got associated with those on the margins of society.

Chapter nine (The new public health) discusses the shifting focus of public health to chronic disease epidemiology with successful control of infectious diseases. Research demonstrating the link to cancer led to a focus on reduction of smoking through various public measures, including counter-advertisement. Chapter ten describes how ‘public health’ ideas started permeating from tobacco to drugs and alcohol. The era saw the realignment of disease concept across substances. Policy agendas on smoking now included restricting advertising, sale, licensing and taxation. The Brain report (1965) led to replacement of general practitioners as a source of expertise to a psychiatric specialist hospital-based system. The key change was establishment of ‘drug dependence units’. The UK focused more on expansion of treatment and prescription of methadone (substitute opiate) and a new dawn for medicine-based treatment of opioid addiction. In chapter eleven (Hedonism or control?), the author talks about the shifting position of all three substances towards the end of the 20th and the beginning of the 21st century when tobacco started aligning with the idea of an illicit drug. Alcohol also took the same route, but later. The advent of human rights raised the issue of decriminalization mainly with regard to opioids. The author concludes with the twelfth chapter (Afterword: History and the future) by stating that a historian’s job is to observe and analyse change rather than to advocate courses of action in future. The future cannot be predicted but what it might bring is intriguing. Control rather than hedonism will continue to be the unifying practice across substances in future. However, the forces bringing these changes will remain the same.

The book might be difficult to read for a lay person, but it is very informative for healthcare professionals. It is highly recommended for mental health professionals interested in historical aspects of medicine. The book is well-researched; the large number of references add value to the book. In the debate the author has maintained a neutral position throughout the book without being judgemental on whether these positions were right or wrong, nor prescriptive with regard to directions for the future—a recommended book on the shelf of a serious practitioner of medical science.

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