Mr. ROGERS. I know you may not have it all now, but if you could, please submit for the record material on all the abused drugs that we have a known method of treatment for, an accepted method of treat ment. (The following information was received for the record:) ABUSED DRUGS FOR WHICH WE HAVE AN ACCEPTED METHOD OF TREATMENT Although drugs for treatment are listed in the accompanying material, it is understood that in all cases of drug dependence more than simple administration of a therapeutic drug entity is necessary for proper medical treatment of a drug dependent person. Chemotherapeutic treatment is limited essentially to the treatment of heroin addiction. Medical treatment involves the entire gamut of services usually associated with attempts to successfully rehabilitate the individual. S Dependence on Amphetamines timulant drugs of the amphetamine type have been used in medical practice for the past 35 years. During this period identifiable patterns of abuse and misuse have been established, and it has been demonstrated that, for many persons, these substances have dependence-producing* characteristics which can bring about serious clinical and personal problems. However, unlike that with narcotics or barbiturates, over-medication with stimulants does not lead to physical dependence. Abuse of these substances arises from and is perpetuated solely by psychic needs to overcome depression or fatigue or to attain the euphoric and excitatory effects associated with the drugs. The routes to dependence on stimulant drugs are varied. Some start in the physician's office where a prescription for amphetamine is given as treatment for depression or as an adjunct to weight reduction. Most cases, however, stem from illicit channels where drugs are sold indiscriminately to a variety of customers, such as truck drivers who want to stay awake during long hauls or teenagers and young adults looking for "kicks." The actual incidence and prevalence of cases of drug dependence of the amphetamine type are unknown. Clinical experience in the United States and other countries indicates an increase in amphetamine abuse, ie, unsupervised self-administration. It also has become increasingly clear that many physicians have not fully appreciated the inherent dangers in prescribing these medications, and that in many cases their presumably therapeutic actions can constitute misuse of the drugs. The degree to which the abuse of stimulant drugs stems from over-prescribing or from black market sales is not known. However, the problem is serious enough to warrant the concern of the medical profession and an examination of the use, misuse, and abuse of the stimulants. In this communication "use" refers to the proper place of stimulants in medical practice; "misuse" applies to the physician's role in initiating a potentially This statement was prepared by the AMA Committee on Alcoholism and Addiction, reviewed by the Council on Drugs, and approved by the Council on Mental Health. *Dependence has been used here to replace "addiction" in conformity with recent action of the Expert Committee of the World Health Organization. dangerous course of therapy; and "abuse" refers to the self-administration of these drugs, without medical supervision and particularly in large doses, that may lead to psychological dependence, tolerance, and abnormal behavior. Historical Note The main stimulant drugs are amphetamine and methamphetamine. Both were synthesized in the 1920's as part of the search for a substitute for ephedrine. The first clinical use of amphetamine was as a vasopressor, by Piness et al, in 1930. As a generic class of drugs, the amphetamines have certain pharmacological properties in common with other sympathomimetic or adrenergic drugs, such as epinephrine and other catecholamines and their effect on the autonomic nervous system, cardiovascular system, and smooth muscle. The amphetamines, however, have a much greater capacity for stimulation of the central nervous system. With small doses of amphetamines, this stimulation is limited to elevation of mood and the induction of a state of "well-being." As the dosage is increased, apprehension, volubility, tremor, and excitement occur. It soon became apparent that the amphetamines were effective in retarding fatigue-induced deterioration in psychomotor performance and that, under medical supervision, they had some appropriate use for persons required to do routine tasks for prolonged periods under adverse circumstances. For example, under medical supervision, amphetamine was administered to an orbiting astronaut prior to reentry. It was also noted that these drugs allayed the sensation of hunger and they have been prescribed for weight reduction of obese persons. During the past 15 years, a number of amphetamine-like substances have been marketed as anorexiants. These drugs also stimulate the central nervous system to varying degrees and therefore have a potential for psychic disturbance and dependence. Amphetamine-type drugs were in widespread use before their dependence-producing properties were recognized. However, their ability to cause euphoria, dysphoria, and psychic stimulation did lead to the removal of amphetamine from over the-counter nasal inhalers. Restricting the legal acquisition of stimulants to prescription medications did not, however, put an end to their misuse or abuse; today these drugs are part of a major medical and social problem. The United States is not the only nation so affected. In the late 1940's and early 1950's, Japan had a major outbreak of abuse of stimulants. At the onset, amphetamines were available on a nonprescription basis. It is estimated that in the peak year of the stimulant epidemic, between 500,000 and 1 million persons, including many teen-agers, were regular abusers. During that period, many cases of toxic psychosis were reported, and in one year, 1954, Japanese police arrested 55,000 abusers of amphetamines. In that same year, strong amphetamine-control laws were passed. However, the episode conditioned a pattern of drug abuse in Japan that continues today. Other stimulants, still outside legal controls, are being widely abused, and there has also been a marked increase in the abuse of central nervous system depressants and heroin. Great Britain also has a serious problem involving the abuse of dextroamphetamine, primarily of a tablet containing dextroamphetamine and amobarbital. At one time, the chief abusers were women in the age range of 35 to 50 years who initially received the drug for weight control. Today, an alarming number of younger persons are reported to be abusing stimulants. In 1965, concern in the United States about the growing problems of drug dependence and abuse led to the passage of legislation, supported by the American Medical Association, that gives the Food and Drug Administration authority to control the manufacture and distribution of substances having a potential for abuse, ie, stimulants, depressants, and hallucinogens. The Drug Abuse Control Amendments of 1965 require that detailed records be kept on the manufacture, shipment, and distribution (including pharmacy prescription records) of the drugs covered. This law should be useful in reducing the amount of these drugs diverted to illicit channels. Amphetaminetype drugs are also illegally synthesized for distribution on the black market, and this trade will be difficult to control. The law also stipulates that a prescription for a stimulant or depressant drug under control is valid only for six months and, in that time, is limited to five refills. However, misuse is still possible within these limits. Definition of the Problem Stimulant Production in the United States A survey by the Food and Drug Administration indicated that, in 1962, over 100,000 lb of amphetamine and methamphetamine products were available in the United States. The amount in this one-year inventory is enough to supply 250 mg of these stimulants to every man, woman, and child in the country, ie, 25 to 50 doses per person. (6) Control appetite. (7) Induce insomnia and counteract fatigue in persons occasionally required to perform mental or physical tasks of long duration. (8) Enhance the action of analgesic drugs. With the exception of the first two items, the indications for the proper medical use of stimulants are subject to varying degrees of professional controversy. The debate, waged on both scientific and ethical grounds, is focused on the efficacy of these drugs as well as on the hazards involved in initiating a treatment regimen that, in susceptible individuals, can result in the development of psychic dependence and tolerance. It should be recognized that, with the exception of Items 3, 5, and 7, stimulants are currently used in treatment programs often involving long-term, continuous medication. If medical use is not to become medical misuse, any such program necessitates careful evaluation and supervision of the patient; control of the dose; and being certain that other physicians are not prescribing amphetamine-type drugs for the same patient. When used as anorexiants, the amphetaminetype substances apparently help some individuals curb their food intake for short periods. However, in long-term (more than a few weeks) programs of weight reduction, the superiority of these substances to placebo has not been demonstrated. Particular scrutiny should be given to patients who request amphetamine-type drugs for weight control. Amphetamines appear to be effective for some persons as part of the treatment of acute situational reactions with symptoms of mild depression. However, it is considered poor medical practice to administer stimulants without simultaneously instituting other therapeutic efforts aimed at alleviating the underlying emotional disorder. Published studies have indicated that, in general, dextroamphetamine is only slightly more effective than a placebo in ameliorating depressive symptoms. The use of stimulants to antagonize drug-induced depression in acute poisoning may be proper. However, the prolonged administration of stimulants to alcohol- and barbiturate-dependent persons is not proper, since this permits the patient to take increasing amounts of depressant drugs-a practice which can result in mental and physical deterioration. Also hazardous is the regular use of amphetamines to counteract the "hangover" effects of excessive alcohol or barbiturates. In fact, the |