Drug Dependence

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					24 October 1964                                                  Correspondence                                                   BRITISH           '1073
of the cardiac adrenergic receptors (beta           report on the European Conference in the              improve the " public image " of that industry,
adrenergic receptors in Ahlquist's termino-         same issue (p. 502).                                  at present the target of so much criticism.
logy). When noradrenaline is infused at a              Incidentally, it is important to keep in              Obviously there will be practical difficulties,
moderate rate into the intact circulation (of       mind that " loss of control " does not mean           but as doctors intimately concerned in the
the order of 20 pg./minute in man) one              that the alcoholic will get drunk on each and         prescription, supply, and identification of an
usually observes a slight decrease in heart         every occasion when he starts drinking ; rather       ever-increasing range of drugs, we feel such
rate and in cardiac output. These effects of        does it mean that he could never be quite             a scheme merits earnest consideration by the
noradrenaline are entirely indirect; they are       certain that he would be able to stop once he         profession and pharmaceutical industry.-
reflex effects originating from the sino-aortic     had started to drink on a given occasion. For         We are, etc.,
baroreceptors which are activated by the            example, it is not very uncommon to meet                Grantham, Lincs.        F. C. CLOUTING.
peripheral pressor action of the agent. At          people who, for a while, are able to drink                                      J. WIGHTMAN.
a high rate of administration the reflex effects    " in moderation " when switching from spirits
are overwhelmed, the direct effects of nor-         to beer, or when drinking only with meals, or
adrenaline on the heart predominate, and the        when drinking only in company, etc. How-
heart rate rises above normal. When the             ever, sooner or later-and as a rule fairly               Plastic Shoes for Ultra-clean Wards
action of the cardiac moderator reflex is pre-      soon-this attempt becomes too much and
vented (atropinization, inactivation of the         they resort to the uncontrolled drinking.                SIR,-In discussing the provision of an
baroreceptors, administration of a blocker of          One might, perhaps, speculate on the possi-        ultra-clean ward, Dr. K. D. Bagshawe (3
the alpha adrenergic receptors) the direct          bility of a certain threshold of blood-alcohol        October, p. 871) states: " Other outstanding
cardiac effects of noradrenaline are apparent       concentration, varying from person to person,         problems that require further study are the
even at low rates of administration.                and in the same person from time to time,             design of suitable clothing and especially of
   It would be most unfortunate if Ahlquist's       below which the alcoholic could drink without         sterilizable footwear." I wish to suggest that
suggested classification of adrenergic recep-       losing control (depending possibly on psycho-         the solution of the problem of sterilizable
tors were misunderstood to mean that                logical, psycho-social, psychosomatic, or             footwear is to be found in the field of plastic
sympathomimetic amines which are primarily          chemical factors) but beyond which the " loss         shoes.
alpha-receptor stimulators in the peripheral        of control " becomes effective. However,                 Shoes of flexible plastic are currently made
blood-vessels cannot have highly effective          quite clearly, there is a need for further re-        in Australia and freely available in Sydney,
actions on the heart. A bit of reflection as        search and for attempts at an even finer              but do not appear to be on sale in London.
final evidence: since noradrenaline is the          differentiation between the various types of          I have seen two types-(1) Roman sandals,
sympathetic transmitter substance, how could        alcoholics.-I am, etc.,                               and (2) slipper shape without fastening.
the heart respond to sympathetic stimula-             St. -Bernard's Hospital,   M. M. GLATT.             These shoes are cheap, very hard-wearing,
tion unless the beta adrenergic receptors in            Southall, Middlesex.                              and comfortable, except that because the
the myocardium were stimulated by nor-                                                                    plastic is impervious to fluid perspiration
adrenaline ?-I am, etc.,                                                REFERENCES
                                                                                                          tends to collect under the sole of the foot.
                                                      Jellinek, E. M., The Disease Concept of Alcohol-    This can be minimized by wearing cotton
  Dept. of Pharmacology, JAN KoCH-WESER.                ism, 1960. Yale Centre of Alcohol Studies, Yale   socks. My own pair was originally obtained
    Harvard Medical School,                              Station, New Haven, Conn.
      Boston, Mass., U.S.A.                         2 Davies, D. L., Quart. 7. Stud. Alcohol, 1962, 23,
                                                                                                          for use as wading shoes, to protect my feet
                                                        94.                                               while studying seashore animals. They have
                                                                                                          successfully withstood repeated prolonged
                                                                                                          immersion in sea-water. Because the shoes
             Drug Dependence                                                                              are washable I have used them as operating-
                                                                   Code for Drugs                         theatre shoes. My practice was to rinse the
   SIR,-As pointed out in your leader on                                                                  insides and scrub the outsides of the shoes
drug dependence (22 August, p. 461), con-              SIR,-As dispensing doctors we have                 with soap and water. I have not yet tried
fusion surrounding the subject still has            recently noticed the increasing tendency. of          to sterilize them completely, but suggest that
remained despite the World Health Organiza-         drug firms to mark individual tablets and             after washing they could be soaked in an
tion's attempt clearly to differentiate between     capsules with the brand name or symbol of             antiseptic solution. Autoclaving might be
drug addiction and drug habituation. Such           each company. This has undoubtedly been               possible if care is taken not to damage the
confusion, for instance, was evident in the         stimulated by the introduction into this              shoes while hot and therefore soft.
frequent verbal quarrels as to whether the          country of tablets and capsules of similar               Plastic shoes of slipper form can be
amphetamines were habit-forming or addic-           appearance manufactured on the Continent.             changed quickly and easily when walking
tive drugs. However, the attempt to make a             We had not until now realized that it was          from a clean area into a dirty area or vice
clear pharmacological differentiation between       possible to mark a sugar-coated tablet or a           versa, the change being accomplished if
psychological dependence (" habituation ")          capsule, but now that the problem apparently          desired without touching the shoes with one's
and physical dependence (" addiction ") cer-        no longer exists we feel it is appropriate to         hands.-I am, etc.,
tainly had (and still has) its merits, as for       investigate the possibilities of introducing a          London W.12.               F. W. D. ROST.
instance in regard to the question of whether       comprehensive individual tablet-identification
sudden withdrawal is possible, as in the case       code using a series of letters and numbers.
of stimulating drugs, or whether tapering-off          Such a code would enable a doctor,
is necessary, as with barbiturates.                 chemist, nurse, or other qualified person to              Circumcision and Cervical Cancer
   Certainly, in the example of alcoholism          identify immediately without doubt an other-
which you quote, the difference between             wise anonymous tablet by reference to a                  SIR,-Your leading article on " Circum-
psychological and physical dependence proved        standard key. This information we believe             cision and Cervical Cancer" (15 August, p.
of great importance in Jellinek's recent classi-    would prove of inestimable value in the day-          397) is very important for the Turkish popu-
fication of the various types of alcoholism,        to-day use of drugs, apart from the more              lation, 99% of whom are Moslems and 96%
in which he describes only two of them as           dramatic and potentially life-saving effects          fully circumcised. The Moslem women in
" addictions "-namely, those producing              in cases of suicide and accidental poisoning.         Yugoslavia mentioned in your article live
pharmacological dependence. One of them is          The individual companies could, of course,            usually in areas where many of the men are
the " loss of control " variety (gamma              retain their- own tablet markings in addition         not circumcised, and these facts make assess-
alcoholism).' Dr. Davies's finding of a             to the code. A recognized body like the               ment of the problem difficult. Turkey
number of alcohol addicts who were able to          Dunlop Committee, in association with the             furnishes a suitable area of investigation in
return to normal drinking is certainly of high      Formulary Committee and the pharma-                   this field, since noncircumcised men are few
theoretical interest, but as Dr. Davies, in spite   ceutical industry, could no doubt devise,             and they are settled in definite regions of the
of his findings, states, "all patients should       assign, and publish code numbers for each             country. Intercourse between Moslem women
be advised to aim at total abstinence."' This,      drug.                                                 and the noncircumcised men is therefore un-
certainly, is the almost unanimous view of             The adoption of such measures would seem           likely and in some parts impossible. The
many European and American experts, with            to us a rational step in the control and use          incidence of cervical cancer among Turkish
wide experience, with whom I discussed this         of drugs. The advice and co-operation of              women is therefore of some interest. Our
question on recent International Conferences,       the pharmaceutical industry, so important in          survey' 2 of the material from different hos-
in spite of the exception quoted in your            such a system, would, we feel, go far to              pitals in Turkey has led us to the conclusion

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