Chapter 19

Misuse, Abuse and Historical Junkies

COCAINE, HEROIN (DIAMORPHINE) AND morphine are the most serious drugs of addiction at the start of the 21st century. There are also significant problems with the abuse of other synthetic opioids and of illicit amphetamines too. These problems are widespread, as are those of the benzodiazepines, such as the ‘date-rape’ drug Rohypnol, flunitrazepam, and the sleeping tablet, temazepam. Barbiturates, once a severe problem, are little used now, except in the treatment of epilepsy.

Cannabis was used medicinally in the treatment of mania, migraine and as a sedative in the early years of the twentieth century. Its non-medicinal possession and use, however, was illegal in the UK until it was decriminalised in 2005. In recent years, however, more potent strains have been grown, some of which are more than 15 times stronger than the cannabis used in the 1960s. In some cases, this increased strength has resulted in severe psychotic episodes in those who have smoked it, and where this stronger form was used in conjunction with ecstasy, it was found to cause many memory problems, because of the permanent brain damage it caused. In January 2009, cannabis was reclassified again in the UK, back to its original place as a Class B substance, with harsher penalties for growing and supplying it than when it was Class C in Schedule 1 of the Misuse of Drugs Act. The next chapter covers the legalities involved in the possession and supply of medicines, including poisons.

LSD is a much more potent hallucinogen, and its use can lead to severe psychotic states during which the user’s life may be at risk. Dependence can result from continued repeated use, and this can cause extreme problems, with both physical and psychological symptoms on withdrawal.

Coke, crack, snow – abuse by any name

Cocaine, an alkaloid obtained from the Coca plant, was first isolated by the chemist, Albert Niemann in 1860 and, like opium, it quickly became a substance of abuse. Cocaine has many street names, such as coke, crack, snow, nose candy and many more. The addictive nature of cocaine is due to the rapidity with which it relieves exhaustion and lifts depression, making people feel good both mentally and physically.

Any problems the user finds with cocaine can be relieved with morphine, and this double use leads even more quickly to addiction. Even as long ago as 1921 it was estimated that 90 per cent of the opium and cocaine entering the United States was for use by addicts, and that only the remaining ten per cent was used for legitimate medicinal purposes.

Cocaine can be smoked, but is frequently taken as snuff, by inhaling the powder up the nose. Cocaine is now regarded as the most widely used drug of abuse. Initially a low dose of cocaine leads to a pleasant euphoria, but as the addiction progresses the abuse leads to rapid degeneration – morally, mentally and physically. The effects on the circulation system can also cause chest pain and even a heart attack or stroke.

Regular cocaine use can seriously damage the heart and also result in irreversible brain damage. The drug works by releasing a huge amount of noradrenalin from the nerve endings, which makes the blood vessels constrict, so giving a feeling of acute tension, or a ‘high’. Unfortunately, this results in damage to the blood supply of the nasal septum, which is the division in the nose between the nostrils. Eventually this leads to ulceration and perforation of the septum, flattening the nose, which will then appear to have only a single large nostril.

This problem was formerly only associated with certain types of masonry workers and the employees of chromic acid factories. But even today, some so-called ‘celebrity’ users have developed the large single nostril, to their great embarrassment. Plastic surgery is required to rebuild the nose and restore the nasal septum, but only once the addiction has been treated.

‘Crack’ cocaine is smoked and is extremely potent, with many psychological effects. Initially the effect is of euphoria, and then there is an opposite effect with a feeling of unease, depression and anxiety (dysphoria) and finally of a schizophrenic type of psychosis, with loss of control of reality. Users deal with the dysphoria by taking repeated doses to restore the euphoric sensation, and therefore need to take the drug continuously to feel even relatively well.

The effects are diminished as time passes, so users increase the dose again and again. During this time, regular users suffer from many physical symptoms, including seizures. An overdose can result in the user developing status epilepticus, with cardiac or respiratory arrest leading to death. This same pattern of use with escalating dosage leading to both physical and psychological dependence is also seen in users of amphetamines.

Those who peddle drugs seek to maximise their profits by ‘cutting’ their drugs with cheap inactive ingredients. In 1989, there was even a report from America of compounds containing arsenic being used to ‘cut’ cocaine, resulting in symptoms of arsenic poisoning occurring in those cocaine abusers who used it.

The opium poppy

Opium, and the opioid analgesics in general, can lead to dependence, both physical and psychological. And abrupt withdrawal can lead to a withdrawal syndrome. The severity of withdrawal depends on many factors: the individual, the drug he or she used, the dose, the frequency and the duration of the use or abuse.

There are a number of different types of opioid receptors in the body, and each opioid acts at one or more of them. As a result it has been found that cross-tolerance and cross-dependence can occur between different opioids, because they are acting at the same receptors. If addicts receiving daily treatment miss just a couple of days of treatment, they must see the doctor for a revised (lower) dose, due to their loss of tolerance during those missed days; taking the previous dose could now be an overdose.

Tolerance diminishes rapidly after withdrawal, so babies born of drug-dependent mothers can suffer withdrawal symptoms at birth, which must be treated gently and carefully, to wean them off the drug that their mother is dependent upon.

Opium was in use as a medicine for thousands of years. Certainly the ancient Egyptians used it, as did the ancient societies in India and China. In Britain, during the 18th century, demand was supplied with opium imported from Turkey and Persia, but it was very expensive because of the transport costs involved. To meet this ever growing demand, the opium poppy was grown in parts of eastern England and Scotland for over a hundred years.

This proved to be very profitable to the growers, and it pleased the customers too, as the home-grown product was so much cheaper. Apparently it grew particularly well in the area around Norwich. At this time, opium was the only drug that was used for its euphoric effects. Opium contains at least ten per cent morphine and two per cent codeine as well as a variable mixture of other alkaloids. Laudanum, the alcoholic tincture made from raw opium, was frequently the only medication to be found in many households.

Laudanum has been used by many well-known figures in the past. John Hunter (1728-93), the ‘Father of Anatomy’, disliked lecturing and public speaking so much that he nerved himself with 30 drops of laudanum beforehand, while a great actress faced the ordeal of the first night by means of seven drops of the same tincture.

Thomas De Quincey took his first opium, as laudanum, in 1804. He bought it from a druggist in Oxford Street, London, to relieve the pain of his facial neuralgia. By 1813, he was taking 320 grains (over 20g) of raw opium each day. This is an incredible amount of raw opium as the recommended maximum dose was two grains, although there are cases on record of those who took almost twice this amount per day and still lived to a ripe old age. In 1821, De Quincey wrote his Confessions of an English Opium Eater in which he praised the drug and the pleasure and serenity he derived from it.

It is said that Bramwell, brother of the Brontë sisters, read De Quincey’s book, and so began to purchase opium from Bessy Hardacre, the local druggist at Haworth, whose shop was opposite the Black Bull Inn where Bramwell Brontë drank. It seems to have been somewhat fashionable for creative writers and thinkers at that time to indulge in taking opium.

The writer Lord Byron took it as Black Drop – probably the famous Kendal Black Drop, which was four times the strength of normal laudanum. This version was also taken by Coleridge, who, while being a life-long opium addict, managed somehow to keep it secret, even though he drank as much as a pint of laudanum daily.

Amongst the ladies, both Elizabeth Barrett Browning and Florence Nightingale took opium. Miss Nightingale was one of the first patients to be given opium in the form of injected morphine. Wilkie Collins used it and persuaded Charles Dickens to try it, and so Dickens also became an opium user. John Keats, the poet, and William Wilberforce, who abolished slavery, also both used it. Even the prominent politician, William Gladstone, used opium, taking laudanum to steady his nerves before addressing parliament.

In the fens where the home-grown crop had flourished so well, the fenland agricultural workers were also addicted to it. In the nineteenth century, it was possible to buy opium from any shop that cared to stock it, but as time went on there was increasing pressure from both the medical and pharmaceutical professions for some control on its supply. The doctors wanted it to be available only on prescription, which would effectively mean that only the rich, who could afford to go to the doctor, would be able to obtain a prescription for it.

This proposal caused a great fuss from the chemists in the fenland area because opium sales to the poor agricultural workers and ordinary people were such a large proportion of their total trade that such a restriction would have put most of them out of business. The Pharmaceutical Society, on their behalf, managed to win the day, persuading the government to continue to allow sales from pharmacies, and so chemists and druggists continued to sell opium to all well into the 20th century.

‘Heroic’ heroin

Heroin was considered to be only a variation on morphine, the opioid painkiller used for severe pain. Morphine was first isolated from opium in 1806 by an apothecary’s assistant, Frederich Sertϋrner, who nearly killed himself in doing so, not realising how potent it was. Pierre-Jean Robiquet then isolated codeine from opium in 1832 and G F Merck isolated papaverine in 1850. In 1874, a team led by Frederick Pierce at St Mary’s Hospital Medical School in London first prepared diacetylmorphine (diamorphine), which today we know as heroin. This was one of the first drugs made by modifying a natural molecule – in this case, morphine. Twenty years later, the Director of Research for the Bayer drug company, Heinrich Dreser, was seeking more powerful morphine-like drugs, and selected diamorphine. But it was not until 1898 that the Bayer drug company marketed ‘Heroin’, named as such because they considered its effect as nothing short of heroic. They advertised it as ‘a magnificent sedative for laryngitis and coughs’, and claimed it was non-addictive! Little did they know.

So ‘Heroin’ was once a trade name, but it is now used as the generic street name for diacetylmorphine hydrochloride, known in medicine today by the more convenient name of diamorphine. It is now recognised as being more potent than morphine and therefore more likely to cause addiction.

In 1912, the International Opium Convention was held. This convention was concerned with the abuse of opium, morphine and cocaine, as well as with smuggling and the quantities imported and exported by different countries, supposedly for medicinal use. Even ten years later, many countries, including Persia, Argentina, Colombia, Costa Rica and Paraguay, had still not unreservedly ratified this Convention. It seems that things have not changed much in the last 90 years or so either.

However, the addictive qualities of opium, morphine and diamorphine have long been recognised. In a report printed in the British Medical Journal in 1921 regarding addiction, in the UK and the USA, diamorphine was actually vaunted as a cure for morphinism. The addicts were found to prefer it to morphine, which is hardly surprising as we now know that it is more potent and more addictive.

Between June 1922 and June 1923, more than a million dollars worth of heroin was seized from around the country by the authorities in the USA. And no doubt it was much purer than what is available on the drug scene today, ‘cut to ribbons’ – some of which is now found to contain as little as five per cent of the active ingredient.

Ergot abuse

Ergot is a fungal infection found on rye grains. The ergot alkaloids, derived from the fungal infection ergot, have to be carefully used in medicine. Their side effects are so severe that doses have to be kept very low in order to allow their use at all. Ergotamine is one of the alkaloids derived from ergot, which has mainly been used in the treatment of migraine. Several unfortunate cases of overdose are described in Chapter 14.

Large doses can result in severe peripheral vasoconstriction of the veins and arteries. This can be so severe that it can shut off the blood supply, and consequently may lead to the development of gangrene, particularly in the feet and legs. Prompt treatment, however, can rescue the situation and lead to a full recovery. Unfortunately, for some patients help comes too late, and the only recourse is amputation of the affected limbs.

Despite the risk of severe consequences, cases of abuse of ergotamine and related substances have occurred. Some of the other ergot alkaloids used to treat migraine are derivatives of lysergic acid, which is related to LSD, the hallucinogenic agent.

LSD and amphetamines

LSD is the shorthand name for the hallucinogenic drug lysergic acid diethylamide, also called lysergide. Drugs of this type are used for recreational purposes by drug abusers, as they induce a state of altered perception, thought or mood. Changes in visual perception are the commonest and most significant and there may be personality changes too. Although these drugs were tried out in psychiatric medicine in the middle of the twentieth century, they were not generally found to be of any use in the treatment of mental illness.

Babies born to mothers who used LSD during pregnancy were found to have a number of congenital abnormalities, including eye malformations. Psychological dependence and tolerance have both been found with hallucinogenic drugs. Some people had recurring panic attacks after using them, while others suffered from ‘flashbacks’, which either occurred spontaneously or could be induced by alcohol, stress or other drugs.

Various amphetamines have also been used as recreational drugs, for their stimulant action on the central nervous system, alleviating fatigue and producing a feeling of mental alertness and well-being. The main problem is that they are frequently taken alongside alcohol, which unfortunately creates additional problems. The acute effects can be severe, and there have been many fatalities, frequently associated with the development of an uncontrollable extremely high body temperature.

Other causes of death have been heart problems, convulsions, circulatory problems with widespread blood clotting within the veins, with muscle pain and tenderness, and acute kidney failure. Repeated use can cause liver damage and psychiatric effects such as psychosis and depression. Brain damage has also been reported. Abuse during pregnancy has led to a number of congenital abnormalities in the babies, including two cases of congenital heart disease.

Ecstacy, also called Adam, E, M7M, MDMA and XTC on the street, has the chemical name methylenedioxymethamphetamine. It is not new, having been first synthesised and patented by Merck as long ago as 1912. In the 1950s, the US army even briefly investigated using it as a possible brainwashing tool during the Cold War. In the 1970s, it was used by Californian psychotherapists.

At this time, ‘uppers and downers’ were readily prescribed by doctors and many people became addicted to them. Dexamphetamine was widely prescribed by doctors in the late 1950s and early 1960s, as an ‘upper’ together with a barbiturate to be taken at night as a ‘downer’, until the introduction of the benzodiazepines, such as diazepam. Dexamphetamine acquired the popular name of ‘purple hearts’ at that time, due to the colour and shape of the tablets, which doctors prescribed ‘as easily as smarties’, until they realised how addictive the drug was.

Speed, Crystal, Crystal Meth, and Ice Meth are just a few of the street names given to a smokable form of methylamphetamine hydrochloride, which is yet another amphetamine widely used for recreational purposes. In addition to its use on the street here, this drug is used in some areas of Asia by both children and adult farm labourers to enable them to work harder and longer. When the government in Thailand enforced a crackdown, drug dealers moved on to neighbouring countries such as Cambodia. The drug traffickers often tout the drug as a ‘super vitamin’ in rural areas, where its users are unaware of its addictive potential. Within three to six months of regular use, users begin to run the risk of permanent brain damage. And yet, because of its guise as a ‘super vitamin’, even schoolchildren in Cambodia have been taking it on a daily basis.

GHB and ketamine

Gamma-hydroxybutyrate, also called GHB, GBH and liquid ecstasy, among other names, was in the past promoted on the recreational drug market for weight loss, for bodybuilding and as a sleep aid. In medicine, it is used for its hypnotic qualities, being intravenously injected as a general anaesthetic. Recreationally however, it is much more harmful. Reports of acute poisoning following illicit use led the drug authorities in America to issue warnings about its potential for abuse and the development of physical dependence.

After misuse of GHB, patients in both the UK and USA have required hospitalisation and respiratory support for periods from two hours to as long as four days, after which the symptoms may resolve spontaneously. However, deaths have occurred. The severity of the symptoms is dependent not only on the dose taken but also on the use of any other drugs simultaneously, such as alcohol, amphetamines, benzodiazepines or cannabis. Regular users have experienced a withdrawal syndrome upon discontinuing use of GHB.

Ketamine is another anaesthetic that has become a substance of abuse in the last 20 years or so. In America, the dangers associated with abuse of ketamine were first reported in 1979, and in the United Kingdom more recently than that. When taken by mouth or via the nose at parties and raves, this drug is known as ‘Special K’, ‘Super K’ or ‘vitamin K’.

Its main effect is the production of hallucinations such as out-of-body or near-death experiences. It also causes severe loss of co-ordination, helplessness, loss of awareness of surroundings and profound analgesia, and so puts its users at severe risk of harm. Some users have experienced a state in which they no longer care whether they live or die – they think they can fly or that they are superhuman.

Hypnotic habits

Some people seem to be susceptible to the development of dependence when given certain sedatives or hypnotics. This type of dependence can also result from solvent abuse, such as ‘glue sniffing’, about which there will be more details later. Dependence means that there is a strong desire to continue taking the drug. Users might increase the dose and then develop both psychological and physical dependence on its effects.

Withdrawal produces a characteristic syndrome. Initial symptoms are of apprehension and weakness, followed by anxiety, headache, dizziness, tremors and vomiting. Then follow nausea, abdominal cramps, insomnia and increased heart rate. Low blood pressure and convulsions may even progress to status epilepticus after a day or two. Sometimes hallucinations and delirium tremens may develop later, after several days of withdrawal. These symptoms can be dramatically reduced in severity by a very gradual withdrawal: withdrawing the substance very slowly, over a period of days or weeks.

The barbiturates were first synthesised by Bayer in 1863, but it was not until 1903 that they began to be used as sedatives to calm nervous people and as hypnotics to help them sleep, for barbiturates depress the central nervous system. Prolonged use of barbiturates can lead to dependence of the barbiturate-alcohol type described in the previous paragraph, with both physical and psychological symptoms. The barbiturates were very useful in their day but have long since been superseded by less toxic alternatives such as the benzodiazepines, although they too have caused problems.

There are many disadvantages with the barbiturates: mainly, patients can easily develop tolerance, and so need a higher dose to produce the same effect, which can then lead to abuse. Barbiturates also cause a hangover effect in the morning when used as a sleeping pill. They can cause severe withdrawal effects, interacting with alcohol and other drugs. There are also severe toxic effects in overdose.

If given to pregnant mothers, the barbiturates will depress even the nervous systems of their babies too. These babies, like those born to heroin addicts, have been found to be very ‘jittery’ at birth and to have feeding difficulties. Such babies need to be given barbiturates from birth with the dose being slowly tapered off.

Today, the only medicinal use of barbiturates in the UK is that of phenobarbitone, used as an anticonvulsant in the treatment of some types of epilepsy. However, even today, there are a few old ladies still taking their barbiturate sleeping pills every night, as they have done for the last 40 years or more. It is considered to be kinder for such elderly patients to let them continue with what they know, rather than switching them to newer, shorter-acting sleeping aids.

In the past, barbiturate overdosage was a frequent cause of acute poisoning in which coma, respiratory and cardiac depression, low blood pressure and shock led to kidney failure and death. Marilyn Monroe died from an accidental overdose of her barbiturate sleeping pills. Barbiturates are used today by the Dignitas Clinic in Switzerland, given to patients who wish to end their lives at the time of their own choosing.

John Armstrong was a 26-year-old nurse at Gosport Naval Hospital, near Portsmouth. He was married to a young lady called Janet, who was only 19, and they had three children. One lunchtime in July 1955, the Armstrongs called the family doctor because their baby son Terence was ill. The doctor knew about the family since, the previous year, their oldest boy, Stephen, had died suddenly.

Baby Terence was dead when the doctor arrived at their home, so the doctor immediately notified the coroner, who sent two of his staff to collect the body. They also took away the baby’s feeding bottle and a pillow on which he had vomited the previous day, for forensic examination. The pathologist carried out a post-mortem on the tiny body. He found a shrivelled red shell, like a Daphne berry skin, in the larynx and more in the stomach. He carefully put them into a bottle of formaldehyde to preserve them, as he suspected that the death was due to some sort of food poisoning.

The coroner’s men went back to the house and found that there was a Daphne bush in the garden, with many berries on it. Mr Armstrong told them that the baby’s pram was placed underneath it and that the highly poisonous fruit could have fallen into it. When this was reported to the pathologist he thought he had solved the problem, but, when he looked at the sample bottle, he found that the formaldehyde was now coloured red and the ‘berry skins’ had dissolved. Further investigations showed no signs of Daphne berries or any sign of any known poison, but careful analysis found that the red dye eosin and corn starch were present. It turned out that the red dye was used to colour the gelatine capsule shell, which had contained a barbiturate called Seconal. Further analysis found traces of this barbiturate in the vomit on the baby’s pillow. Investigations at the naval hospital where the father worked revealed that 50 Seconal capsules had gone missing a year or so earlier, and had never been found.

The police now looked more carefully at the death of the other child, Stephen, the previous year, and found that his symptoms were similar. Their daughter, Pamela, had also been taken ill, a couple of months after Stephen, with similar symptoms, but had fortunately recovered while in hospital. Baby Terence’s body was then exhumed and his organs tested for the presence of barbiturates. The results were positive.

The police could not decide which parent had given the barbiturate to the baby, but some time later, Janet Armstrong admitted that her husband had got them from the hospital and they were both tried on the charge of jointly planning to commit murder by poisoning their baby. Janet was eventually acquitted, but John was found guilty, following charge and countercharge between the two of them. This was the first known murder involving the use of barbiturates.

The coming of Valium and Prozac

The benzodiazepines first appeared on the scene in the early 1960s – first Librium, then Valium, then over a dozen more. They calmed people down and helped them sleep, but were very much safer in overdose than the barbiturates had been. Doctors happily prescribed them, knowing how safe and free of side effects they were. It was not until the 1980s that the extent of the addiction they caused became known, with Ativan (lorazepam) becoming a particular problem. At that time, it was believed that up to a quarter of the UK population had taken them and that millions of people were addicted as a result. Patients were slowly weaned off the offending drug by reducing the dose in tiny amounts each week or month, as appropriate for that individual. For some patients this process took more than a year.

In 1988, the first SSRI (selective serotonin reuptake inhibitor) was launched – the Prozac age had arrived, with Seroxat not far behind. Once more, this new type of happy pill was hailed as a wonder drug that was safe. There is no denying that the SSRIs are very effective antidepressants for some people, but they have their own problems too. Some patients experience suicidal feelings while taking them or experience a withdrawal syndrome when they try to stop taking them, so withdrawal must be gradual. And for some depressed people, SSRIs do absolutely nothing at all.

And alcohol

Alcohol is probably as old as life on Earth. Man no doubt discovered alcohol by accident and liked the effect it produced. We have been producing it ever since.

Alcohol depresses the nervous system, causing drowsiness, which then impairs the ability to operate machinery or drive a motor vehicle. This was not a problem for the Stone Age man, but today a couple of pints of beer will make any driver five times more likely to have an accident than if they had not had the drinks. Alcohol also interacts with many drugs to cause even greater depression of the nervous system and more severe problems.

Dependence is liable to occur in susceptible people, even sometimes accidentally. In 1975, an American medical journal reported that seven patients who were undergoing long-term treatment by haemodialysis became addicted to the vapours of denatured alcohol during their treatment. And two of them had withdrawal symptoms when they tried to stop inhaling the alcohol fumes.

Alcohol can lead to memory defects and disorientation in time and space, referred to as Korsakoff’s psychosis, as well as mental confusion, paralysis of the eye muscles and unsteady gait, a set of symptoms described as Wernicke’s encephalopathy. It is likely that both these conditions are simply different facets of the same condition. Both conditions are treated with large doses of vitamin B1, thiamine.

Fatty deposits may occur in the liver of alcoholics, and these may go on to develop into cirrhosis. Babies born of alcoholic mothers are found to be suffering from foetal alcohol syndrome when they are born and need to be treated for it immediately after birth.

At the end of 2008, new government figures revealed that every three days in the UK a child under the age of ten requires hospital treatment for the effects of drinking alcohol. These children have mental and behavioural disorders from being drunk as well as other toxic effects, including liver disease. And the number of under 18-year-olds admitted to hospital because they have drunk too much has increased by over 80 per cent in only five years, due to more and more binge drinking.

From Mandrax to Nytol

In the 1960s, methaqualone was used as a sleeping pill. It was supplied alone or in combination with the antihistamine diphenhydramine in a product called Mandrax. The antihistamine’s main side effect was drowsiness, so it was included to make the product even more effective. Unfortunately methaqualone, particularly in combination with diphenhydramine, led to abuse and dependence of the barbiturate-alcohol type.

In 1967, a case of addiction was reported in a 47-year-old man. He had taken increasing doses of Mandrax over a period of four years, until he was taking 60 150mg tablets each day. Not surprisingly, when the tablets were stopped, he developed delirium tremens, which had to be treated with large doses of an antipsychotic drug called thioridazine. Another addicted patient even had a convulsion on the abrupt withdrawal of their methaqualone. Needless to say, once these problems became known the manufacturers decided to stop making Mandrax. The antihistamine diphenhydramine is still in use as a sleep aid in the 21st century, and the best-known brand in the UK is Nytol.

Solvent sniffing

A wide variety of organic solvents are used in industry, and workers may experience the effects of poisoning due to exposure to their fumes. Inhalation, ingestion or even absorption through the skin can cause problems. Solvents irritate the skin and mucous membranes and commonly affect the central nervous system. Continual exposure may result in permanent damage to the nervous system, the liver and the kidneys.

Any product that gives off volatile fumes seems liable to be abused, regardless of the risks involved, and solvents are no different. They have become substances of abuse, particularly by young people. Benzene, toluene, trichloroethane, xylene and kerosene are just a few of the better-known solvents abused by glue-sniffers and others in search of a ‘high’, but glues, plaster remover, cleaning products, and even petrol and aerosol propellants are all abused by sniffers.

High concentrations of trichloroethylene fumes have caused acute poisoning and even fatalities in the workplace, as we have seen in the chapter on occupational hazards. Dependence was reported in medical personnel and also in factory workers who regularly inhaled trichloroethylene fumes. A 16-year-old girl who deliberately inhaled the vapour given off from some 400 to 500ml of this solvent developed coma, respiratory difficulty, muscle spasms, hyperflexia, severe vomiting and a rapid heart rate. She needed to be treated with a tracheotomy and ventilator to help her breathing, as well as with intravenous dextrose and potassium, and she eventually recovered with no residual damage. However, three teenagers who inhaled the fumes of a commercial cleaning product, which contained trichloroethylene, developed acute liver damage, and two of them also had kidney damage.

A 14-year-old boy who intermittently inhaled petrol vapour for four months was found on one occasion to be breathless, flushed, frightened and hallucinated. Many other cases of such dependence have occurred over the years. Petrol vapour dependence can result in sudden unconsciousness and can end in death, due to liver and kidney damage. Glue sniffing of products containing toluene has also led to liver and kidney damage. Children who have been found glue sniffing may become comatose and suffer from reduced appetite, nightmares, visual problems and incoordination. Some may even have convulsions or develop psychosis as a result.

Even 40 years ago, glue sniffing was a problem. In America, of 110 deaths associated with sniffing solvents in the 1960s, 29 of them were linked to the use of trichlorethane. In 1979, a 22-year-old woman with a prolonged history of drug abuse, which included regular sniffing of various glues and organic solvents, was treated for end-stage kidney failure. She was given a kidney transplant, which unfortunately failed, and this led her to return to abusing solvents. She inhaled 400ml of Zoff plaster remover over a 36-hour period. On admission to hospital she was given supportive treatment together with her regular kidney haemodialysis, and, because it was suspected that she had taken a paracetamol overdose as well, charcoal haemodialysis was also performed. Clinical recovery was complete within 48 hours and, two days later, her liver function had returned to normal, the trichloroethane having been completely eliminated.

Dichloropropane is yet another organic solvent widely used in industry, and has also been used as a dry cleaning agent and agricultural defumigant. It is another victim of solvent abuse. Following the intentional inhalation of a stain remover containing it, one abuser suffered acute kidney failure, acute liver disease and circulatory problems, but after blood transfusions and haemodialysis this patient fortunately recovered.

An old-fashioned sedative

In Victorian and Edwardian times many patients took potassium bromide as a sedative to help them sleep. This old-fashioned sedative is not very effective unless used in precise dosages.

The writer, Evelyn Waugh, apparently used it with a gin and crème-de-menthe chaser. As a result he suffered from a distressing period when he had auditory hallucinations, a known symptom of bromism – the name given to poisoning caused by excessive use of bromides. These details of his life were revealed by Selina Hastings in her 1994 biography of the writer. After its publication, a number of people who knew him observed that his florid appearance and foul temper might well have indicated that he suffered from chronic bromism for much of his life.

Laughing gas

Nitrous oxide has been used as an anaesthetic for longer than any other agent. This gas was discovered by the famous English chemist Sir Humphrey Davy over 200 years ago in 1800, and it was initially referred to as ‘laughing gas’. When used alone, it tends to excite the patient; for a while it was fashionable to hold parties where the guests could experience the effects for themselves. It might have been considered the ‘ecstasy’ of its day. It was not until some 40 years later that it began to be used medicinally.

It is now used in conjunction with oxygen as a vehicle for more potent anaesthetic vapours. Although it is non-irritant and non-toxic, nitrous oxide must be given with oxygen – when used alone it causes asphyxia. In recent years, there has been a growing use of pure nitrous oxide as a recreational drug, primarily at middle-class dinner parties, but also at some nightclubs.

In January 2007, the practice of using nitrous oxide recreationally claimed its first fatality in the UK when Daniel Watts, a 23-year-old company director, was found dead at his home next to a large cylinder of the gas. Supplies are readily available from catering suppliers, as the gas is used for making whipped cream. However, such supplies carry no warnings about how nitrous oxide can cause severe injury, long-term disability and death when abused. The ‘high’ produced by a single inhalation is short-acting, so users tend to want to repeat the effect and can easily overdo it, not realising the importance of a supply of oxygen as well.

Accidental abusers

Not everyone who takes an overdose is intending to kill him or herself. In 1967, three boys, each being treated for leprosy, took large single doses of dapsone, a drug used to treat this disabling disease, in an attempt to simplify their treatment regime. They thought that one big dose of their medication would save them the inconvenience of many small doses. Two of them survived but the third died. And, in 1980, a man did attempt suicide by taking a massive 7.5g of dapsone. He survived but suffered permanent retinal damage to his eyes, due to the overdose.

Rifampicin is one of the drugs used in the treatment of tuberculosis. During treatment, while the drug is being taken, patients are warned that this drug will colour their urine red and discolour soft contact lenses if they are worn. A man who took an overdose of 40 rifampicin tablets developed bright red pigmentation of his skin, orange-coloured sweat and a deep red colouration of his plasma and urine. Despite this, he made an uneventful recovery but was left with some minor liver damage. Another man, aged 26, took a much larger quantity of the same drug and died.

The use and abuse of a wide variety of substances, not only medicines, can lead to dependence – a physical or psychological addiction (or both). Gradual withdrawal and therapy are effective treatments, but the addiction takes much longer to cure than it does to develop.