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Drug abuse in Sweden
Table of contents
Aim of the present survey
I. Development of drug abuse
II. The present situation
(i) Pilot study on incidence of drug abuse among hospital patients
(ii) Hospital point prevalence study
(iii) Surveys on out-patients
(v) Estimation of total number of narcotic drug abusers
(i) Individuals in contact with police
(ii) Incidence study of arrested persons
(iii) Present and former prison inmates
(ii) Pupils in primary school grade 9 in Stockholm
(iii) Case studies of juvenile drug abusers
(iv) Children's Welfare Board
(v) Youth treatment schools
Author: Leonard GOLDBERG
Pages: 1 to 31
Creation Date: 1968/01/01
Drug abuse in SwedenProfessorM.D. Leonard GOLDBERG
Department of Alcohol Research, Karolinska Institutet, School of Medicine, Stockholm, Sweden; Member, Narcotics Drug Committee of the Swedish National Medical Board; Member, WHO Advisory Panel on Dependence-producing Drugs.
Table of contents
Aim of the present survey
I. Development of drug abuse
II. The present situation
A. Studies on patients
B. Studies on criminally engaged persons
C. Comparison between hospital patients and police cases
D. Studies on adolescents
E. Studies of selected groups
F. Incidence in the general population
The use of drugs for medical purposes, e.g. to counteract pain, and the use on other grounds, to alleviate misery, to reduce the effects of starvation, fatigue and social need, or to create new sensations or a flight from reality, are global problems. They are changing in importance from society to society, even between groups and subcultures within the same society. The border-line between use and abuse, as well as the degree of involvement of medical and social factors, also vary widely in different cultures. In some countries the abuse of drugs will interfere with public health, in others play only a minor role but demand a close interest because the problem may become acute in a country hitherto spared or interfere with the normal interchange between different nations.
The dynamics of drug abuse in Sweden, the rapid increase in number of individuals involved and the increasing interference with society from medical and social points of view are examples of the development of an acute public health problem, which was of no or very little importance only one or two decades ago.
Aim of the present survey
The aim of the present study is to survey the problem of drug use and abuse in Sweden mainly from an epidemiological point of view, i.e. considering the possible interplay between agent, man, and environment. This approach will be based on studies of a factfinding nature, i.e. surveys to obtain quantitative data, and evaluations of relationships between various factors, if possible of a causal nature, inherent in the dynamics of the existing situation; possible means of interfering with the situation will not be elucidated in the present work.
Thus this work attempts:
To give quantitative data on incidence and prevalence of use and abuse of narcotic drugs - and in some respects also of other types of drugs abused -, with respect to
The development of the situation in Sweden (I, II);
The actual state in various strata of the population, e.g. in hospitals, among groups with a criminal background and in different social sub-groups with varying characteristics (II);
The possible differences in types and patterns of drug use and abuse among various groups, with regard to age, involvement of juveniles, criminal background, and other social and sociological background data (II, III);
To characterize the present situation and its consequencies from medical (III, IV, V, VI), legal (VII) and social (II, III, VII) points of view, and
To elucidate some factors involved in the dynamics of the present situation (VIII) and the new elements differentiating the present state from drug abuse of an earlier date (IX).
Narcotic drugs
From a biological or purely medical point of view a "narcotic" drug means an agent inducing "narcosis", i.e. a depression of cell activity, e.g. reduction of cell metabolism, reactivity to stimulation, growth or reproduction. This definition comprises, for example, drugs inducing general anesthesia, analgesia, sleep, sedation or tranquillization.
From a legal point of view, however, narcotic drugs are defined as those encompassed by international or national conventions and having certain elements in common - compulsion to continue, psychic and/or physical dependence, withdrawal symptoms and damage to individual and society - independent of whether they have depressant or stimulant action. The international conventions cover three main groups of narcotic drugs: opiates - opium, morphine derivatives and synthetic drugs with morphine-like action - coca leaves and cocaine, and cannabis and its preparations.
Sweden has added two more groups of substances to its National Narcotics Drug List, viz. stimulant drugs and hallucinogens, due to these drugs being abused in Sweden.
The definitions used in the present survey for" narcotic drugs" follow those of the Swedish legislation, and comprise:
Opiates, cocaleaves and cocaine, cannabisand preparations thereof; these drugs being included in international conventions to which Sweden is a Party.
Stimulant drugs acting on the central nervous system, added to the National Narcotics Drug List and handled as narcotics in Sweden due to their being abused. These drugs comprise: amphetamines (1944) - amphetamine, metamphetamine, dexamphetamine -, phenmetrazine, e.g. Preludin (1959), methylphenidate, e.g. Ritalina (1959), and pipradrol (1959).
Hallucinogens,mainly mescaline, psilocybin and lysergide (lysergic acid diethylamide- LSD-25), added to the National Narcotics Drug List in 1966.
Addiction, habituation and dependence
The World Health Organization through its Expert Committee on Dependence-producing Drugs (formerly called the Expert Committee on Drugs Liable to Produce Addiction, or the Expert Committee on Addiction-producing Drugs) has defined various states and types of drugs: addiction and habituation and addiction-producing and habit-forming drugs in 1950-1952 and 1956-1957; and dependence of various types in 1963-1964.
When addiction and habituation are mentioned in this survey they refer to the definitions laid down by WHO in 1956-1957; when dependence is discussed, the definitions of 1963-1964 are referred to.
Drug abuse
Drug abuse means essentially the use of drugs for non-medical purposes or in doses - usually excessive amounts - not founded on ethical medical grounds.
In Sweden the term may mean several things, in some cases that the abuse has been of a rather short duration, in others the term may mean "leading to medical and/or social ill-effects ". In many cases the term "drug abuse" is used in the meaning of " addiction" or "habituation" according to the old terminology (WHO 1950-1957) or "drug dependence of a specified type" according to the WHO 1963-1964 definition.
As many of the studies reported in this survey have not gone into details regarding the types of abuse observed, it is at present impossible to elucidate the term further than was done in the original studies.
I. Development of drug abuse
Alcohol has been a problem in Swedish society and recognized as such for many hundreds of years - Magnus Huss [ 1] already at an early stage in his famous work "Alcoholismus chronicus" (1849) recognizing this state as a disease - whereas abuse of drugs, whether narcotic drugs or other CNS-active drugs, has not been considered an important public health problem until in the last decade. Single cases of drug abuse of various origin were formerly observed only now and then.
An abuse of barbiturates and organic bromide derivatives, resulting in an increase in tolerance, intake of large doses, 50-100 tablets, and many cases with chronic effects, among others affecting the nervous system, the CNS, spinal cord and peripheral nerves, was described by Rylander in 1933; in many cases the disease had also psychic complications, resembling dementia paralytica. An enquiry in 1940 to all state- and municipally-engaged physicians gave a total of 70 known cases of drug abuse, mainly of opiates.
The introduction in Sweden of the amphetamine drugs, amphetamine (e.g. Benzedrin) and metamphetamine (e.g. Pervitin), around 1938 started a new era. It was soon found that these drugs, besides a vaso-constrictor action systemically and locally - e.g, on the nasal mucosa - had an appetite-reducing effect and also had a stimulating action on the CNS. This stimulating effect was thought to decrease the need for sleep and the feeling of fatigue, to improve muscular and intellectual work and to enhance sexual potency.
Already around 1938-1940 amphetamines were recommended as "pep pills" in newspapers, weekly journals and in broadcasts for all kinds of people, from students to tired housewives - "Two pills are better than a month's vacation".
Within a few years large sections of the Swedish population had tried these drugs: enquiries e.g. on representative groups of students showed that 70-80 per cent of those interviewed had tried amphetamines on one or several occasions with varying effects.
As long as the amphetamines were used for purely medical purposes and mostly for local application they were sold in pharmacies but not on prescription. As a result of an increasing medical and non-medical use as early as in 1939, the drug was put on prescription as one step for the control of its use. This had some inhibiting effect on the use, and the sale was constant for one year, then it increased again.
A graph in figure 1 shows the sale of amphetamines in Sweden during the first six years after their introduction, 1938-1943.
Around 1942-1943 the over-all use of amphetamines was wide-spread and cases of abuse were seen, some in Sweden, most of them on the Continent, with an intake of high doses, up to 50-200 tablets a day, in many cases leading to acute intoxications with circulatory shock and collapse. Chronic abuse was also seen, in extreme cases leading to complications of a somatic and psychic nature - from vaso-motor collapse, speech disturbances, ataxia and aplastic anaemia to increased motor activity, hypomania, involuntary laughing and facial spasms, a diminished drive to work and loss of initiative, increased fatigue and extreme variations in mood. In severe cases also personality changes were seen, often of a schizoid character, delirious states and prolonged amnesia have also been described. Symptoms resembling true dependence appeared, with compulsion or craving to take the drug at any price, increase in tolerance and intake of amounts up to 50-100 times the therapeutic dose, and signs of psychic and some physical dependence. Even abstinence symptoms were described, mainly of a psychic nature, usually depression states with sleep disturbances and abnormal fatigue. The situation was reviewed by Goldberg (1944).
Fig. 1. Sales of amphetamines in Swedish pharmacies 1938-1943.
Prescr. - Sale of amphetamines on prescriptions only (1939).
Narc. - Warning issued to the medical profession by the National Medical Board on risks of use and abuse of stimulants (1943).
A warning to physicians was issued by the National Medical Board in April 1943, leading to a decrease in the sale by 40-60 per cent and a change in the attitude of the Press and other mass-media, which began to point to the risks involved in the uncontrolled use of the amphetamines instead of the "beneficial" effects. To reduce the risks for uncontrolled use the amphetamines were put on the National Narcotics Drug List in 1944, i.e. treated as narcoticsin the Swedish law.
A thorough study was made on the development of the turnover of amphetamines during the period 1938-1943 by closely following the sale in a number of pharmacies (Goldberg, 1944).
It was found that in 1938 the sale rose from month to month from 140,000 in the first half year of 1938, to 260,000 in the second, or a total of 400,000 tablets in 1938. The inhibiting effect, lasting for one year, of selling amphetamines only on prescription, is seen on the curve; then the sale rose continuously at an increasing rate. In 1942 a total of 6 million tablets were sold, a 20-fold increase in five years.
The highest sales were seen in some of the large pharmacies in Stockholm and Göteborg. Thus in 1942 each one of these sold around 50,000-100,000 tablets, against around 20,000-30,000 in the university towns, and 4,000-25,000 in pharmacies in smaller cities.
These differences in the distribution reflect the variations in the population at risk, from the high prevalence in large cities and university towns, to the low prevalence in smaller cities and urban areas.
Based on the figures for the total consumption of amphetamines, assuming a J-shaped distribution of users and abusers with occasional, regular and excessive use, and knowing the distribution of users with varying intensities of use and abuse of other drugs, including alcohol, an attempt has been made to estimate the total number of amphetamine users in Sweden at that time. It can be estimated that in 1942-1943 there were about 200,000 users of amphetamines in Sweden, corresponding to 3 per cent of the adult population. About two thirds, 140,000, were occasional users, one third, taking the drug only once, and one third 2-4 times per year. Of the rest some 60,000 would be taking the drug from several times a year to twice a month, and some 4,000 around once per week, all these taking 2-3 tablets on each occasion. Higher doses would be taken by some 3,000, from several times per week to daily, in doses up to 5-10 tablets per day. The number of excessive users was small, around 200, these showing different somatic and psychic symptoms of abuse, taking up to 10, 50, 100 tablets per day on a more or less continuous basis.
This period lasting up to the early nineteen-fifties is thus characterized by a vast and widespread use of stimulant drugs, but relatively few cases of abuse, a tenth of one per cent of the total number of users.
Abuse of new drugs
Around 1954 an abuse of amphetamines and opium derivatives was known to exist among artists and others in some clubs in the Stockholm Old Town, even a few school children being involved; the drugs were mostly obtained illegally.
The next phase began about 1956-1957, and culminated in 1958-1959.
The abuse spread to people of younger age, often with a criminal background, and abuse of stimulant drugs became the fashion. The drugs of choice were not only amphetamine but also dexamphetamine, introduced as a weight-reducing agent, acting by decreasing the appetite and thought to be void of habit-forming or addiction-producing properties, phenmetrazine (mainly as Preludin), like the amphetamines in chemical nature and introduced on the same grounds, and methylphenidate, (mainly as Ritalina) introduced around 1958-1959 as a stimulant drug.
Designation of stimulants as narcotic drugs
The increasing number of cases of abuse of these drugs on non-medical grounds led in 1959 to the designation of phenmetrazine and methylphenidate as narcotic drugs under the National Narcotics Drug Act.
In 1960 a circular was sent out by the National Medical Board warning the medical profession and naming the drugs that were mostly abused, viz. opiates, hypnotics, tranquillizing agents and stimulant drugs. The warning had an effect, leading to a reduction from 1960 to 1961 in the number of narcotic prescriptions by 11 per cent and in the quantities of stimulant drugs prescribed by 29 per cent.
The illegal trade
Around 1958 the criminal activity - falsification of prescriptions, theft of drugs from pharmacies and "peddling" of drugs, had taken on such proportions that the efforts of the police were intensified against this illicit traffic, and a public prosecutor was specially assigned to deal with cases of violations of narcotic laws.
The measures instituted were, however, not enough to hamper the illegal trade.
Many drug traffickers and individuals abusing drugs made it clear that up to 1962 they could get 95 per cent of their supply from doctors on prescription, i.e. by diversion of legal supplies.
There were many ways of obtaining the drugs. One was to simulate a disease, e.g. in opiate abusers to simulate pain due to gall bladder spasm or kidney stones - even producing red blood cells in the urine by a prick in the finger, the blood contaminating the voided urine--and in abusers of stimulant drugs to simulate depression or need for weight reduction.
One trafficker employed two girls to obtain the drugs "legally ". One of the girls was heavily-built and asked the doctor for amphetamines or phenmetraline as "weight-reducing" or "slimming" agents. The other girl being slim, pretended to be a photographer's model and asked for weight-reducing drugs in order to keep slim. Both girls went round from doctor to doctor and succeeded within a few weeks in obtaining total prescriptions for about 40,000 tablets, which were then sold by the trafficker.
Another trafficker put all doctors in an area, several hundreds, on filing cards, marking each with different colours, noting those who wrote prescriptions on narcotics and those who did not, and the pretext that he had used successfully to get a prescription. He then made a round, according to a plan, to those who wrote prescriptions on narcotics, visiting each one only once a month.
The theft of prescription forms from hospitals and pharmacies became very popular. One "expert" even broke into a doctor's office at night and used the doctor's telephone to contact a pharmacy, ordering narcotics by telephone and asking the pharmacist to call him back to check his identity !
Many individuals found that they could obtain drugs from doctors by telephoning them, pretending that their ordinary doctor was on vacation, that they had run out of their medicine and were just about to leave the country and needed the drugs while abroad, that they had small children who could not be left alone, etc. Mostly older doctors were deceived in this way. Several of them were even approached in person and threatened if they did not give in.
In spite of severe restrictions the illicit trade increased in volume due to several reasons: (i) an increasing number of abusers, (ii) the abusers increasing their doses, and (iii) the possibilities to obtain drugs by diversion of legally obtained drugs being restricted, smuggling became increasingly important.
Some illegal manufacture was also started in Sweden, several thousand tablets per day and a corresponding number of ampoules being sold out of this clandestine production. None of the three groups of persons engaged in this traffic and arrested during the last few years had had any professional training in chemistry. One of these individuals became suspect when buying a large amount of one of the chemicals needed for the synthesis, and another was arrested because tablets of an hitherto unknown type were found on the illegal market, the supply being traced back to his workshop.
Restrictions in prescription rights
These and other facts led the National Medical Board to issue a new warning to physicians in November 1962 and to induce certain restrictions in the right of doctors to issue prescriptions by telephone. The duty of the doctor to check the identity of the patient was stressed, and the right to prescribe narcotic drugs by telephone was limited to five tablets or suppositories while narcotics intended for injection could not be so prescribed.
These measures drastically reduced the number of prescriptions for narcotic drugs. The amount of opiates was reduced by 44 per cent from 1962 to 1963, and that of stimulants by 32 per cent. The number of prescriptions for narcotic drugs fell by 40 per cent.
The total sale of medicaments increased in the same time by 10 per cent, and the total number of prescriptions by 3 per cent.
The pharmacies were instructed to increase their vigilance on possible falsification of prescriptions, and to check with the doctor or to call the police on the slightest suspicion. The installation of theft alarms in pharmacies and the use of safes and other preventive measures brought down the number of thefts from pharmacies to a minimum.
The few surveys made during this time show the development of the problem.
The first systematic study to estimate the number of drug abusers was carried out by Lindgren and Krook of the National Medical Board in 1954-1955. Through questionnaires sent out to all psychiatric clinics and mental hospitals it was found that a total of 146 patients with drug addiction or drug abuse were treated in 1954; 62 per cent were males and 38 per cent were females. Of the various drugs abused 43 per cent involved morphine or opium, 21 per cent morphine derivatives (e.g. hydrocone and oxycone) and 14 per cent synthetic morphine-like drugs, e.g. ketobemidone. Only two cases of heroin abuse were seen. (Heroin was forbidden for therapeutic purposes in Sweden in 1952, following the recommendations of WHO.) The remaining cases involved abuse of stimulant drugs, two of cocaine abuse (1%), the rest, 21 per cent, abused amphetamines.
With regard to the types of persons involved 23, or 25 per cent, belonged to the medical profession, being doctors or nurses. Another group were former patients, the addiction in about 70, or about 50 per cent of all cases, being "iatrogenic", i.e. medically induced, following a period of prolonged prescription of the drug, usually an opiate for chronic pain, the most common diagnoses being post-operative states, gall and kidney stones and backache.
In these cases it could be claimed that the doctor had not shown enough prudence, and had overlooked that the analgesic given was an opiate or that synthetic drugs with Mo-like effects, e.g. pethidine, had addiction-producing properties.
It is also noticeable that at this time, 1954-1955, about one fifth of the few cases of drug abuse known, about 35, concerned abuse of stimulant, drugs, mainly amphetamines.
With regard to age, the average age of these patients was 44 years, only 17 per cent being under 30 years of age, and only 1.4 per cent being under 21.
It was further noticed that among these cases the combined abuse of drugs from various groups, e.g. of morphine and amphetamines, was extremely rare.
A survey in 1961 of the cases of drug abuse treated in psychiatric clinics and mental hospitals in 1960 showed a total of 190 cases. Opiates were abused by 65 per cent of the patients, stimulants by 35 per cent. Quite a few patients combined abuse of both types of drugs. The average age was 36.5 years, somewhat higher for opiate abusers than for those taking stimulant drugs, only 7 per cent (14 patients) being under 20 years.
In a search for drug abuse among juveniles in the period 1955-1957 only 17 cases were disclosed; after that time the figure rose abruptly.
In a study from 1963, 72 juveniles abusing stimulant drugs were described, 30 per cent boys and 70 per cent girls. These cases were said to be a selection only of a large group of juvenile abusers; all were seen after 1957.
The abuse began on an average at 16 years of age, somewhat earlier in girls than in boys. Before 1958 amphetamines were the starting drug, after 1958 in this group almost exclusively phenmetrazine (Preludin) was abused; some also abused opiates; intravenous use was common. (Takman 1963).
Toxicological viewpoints on drug abuse in juveniles, mainly on "sniffing ", i.e. inhalation of volatile industrial solvents, were published by Karlsson (1963), and psychiatric consequences of "sniffing" were given by Rylander (1963).
The consequences were also seen in the number of sentences for violation of narcotics laws, which from around two per year in the period 1955-1957, rose to 109 in 1961 or two per week, a 50-fold increase.
Public reaction
Problems of drug abuse were taken up by the Press, and Members of Parliament, police authorities and experts in the field suggested various measures including a study of the problem in its medical, social, economic and legal aspects, and the development of means of prevention and treatment. Public meetings were held by various influential civic and political organizations to stress the increasing importance of the narcotics problem. There was a |demand on municipal and governmental authorities to recognize the problem and treat it as a primary medical or social but not a criminal problem, and institute preventive measures and provide increased facilities for medical treatment of individual cases.
The organization of a Narcotics Drug Committee
In May 1965 the Minister of Social Affairs, in answering two interpellations in this respect in Parliament, stressed the importance of the growing narcotics problem in Sweden and announced that an Expert Group on Narcotics Drug Abuse to review the problem would be set up within the National Medical Board, the group starting its work on July 1, 1965. In January 1966 the group was reorganized and enlarged to form a Narcotics Drug Committee, [ 2] comprising five sub-committees, on legislative view-points, on therapeutic approaches, on technical-diagnostic problems, on social medical aspects, and on methods of prevention.
The aims of the Narcotics Drug Committee were to study the problems involved in abuse of narcotic drugs from medical, legal and social aspects, concentrating on (i) a fact-finding survey to give a picture of the strata of the population involved, the number, age and characteristics of drug abusers, and their background, to define the character of the abuse, e.g. types of drugs involved, and to study methods of diagnosis and the possible effects on the individual and on society of the abuse of narcotic drugs, further (ii) to study treatment, survey existing methods and suggest ways of enlarging present facilities or setting up of new ones, (iii) to investigate the legislative angles, and (iv) ro review methods of prevention from medical, legal and social points of view, and elucidate possible causal relationships and their importance for the origin of drug abuse, and its spread in society.
In 1967 the Committee presented the first two parts of its work.
In the First Report (SOU 1967: 25) the results of survey studies on the extent and characteristics of the abuse of narcotic drugs - and also of hypnotics, sedatives and tranquillizing agents, as well as volatile agents - among different strata of the population were given, various forms of treatment were discussed and evaluated, and suggestions as to facilities necessary for the purpose were made; the usefulness of a central recording of drug abusers was stressed.
In the Second Report (SOU 1967: 41) the stress was laid on a survey of the control system in its legal aspects and effects, and various suggestions as to changes were brought forward, from national as well as international points of view. The desirability of international control of those drugs with stimulant action that were dependence-producing and abused, and had proved a risk to public health was stressed. The possibility of continuous data-processing of prescriptions of CNS-active drugs, from narcotics to depressants and stimulants, was pointed out as one means to follow the development of the problem, and to be able to detect sudden changes at an early stage.
The main problems left to be presented and discussed in the third Report of the Committee, to appear in 1968-1969, are among others a survey of the dynamics of the problem, its origin, development and interrelation with other problems in society, including various measures of prevention and information.
The present survey will include in detail under headings II-VII the studies carried out so far by the Committee, amplified by a number of other studies carried out by other teams, and review the problems in a wider context (VIII-IX) as parts of an over-all epidemiological approach to a public health problem.
II. The present situation
The studies aimed at giving a picture of the present situation comprise a total of 17 surveys: five on hospital patients, three on persons engaged in criminal activity, five on adolescents, one on alcoholic patients, one on motor vehicle drivers, and finally two preliminary pilot surveys on representative samples of the general population.
A number of surveys have been carried out in order to obtain information on the number and types of patients with drug dependence and drug abuse treated in hospitals. Two are detailed studies of incidence and of prevalence, one relates to out-patients, and two are based on statistical information available in the National Medical Board.
(i) Pilot study on incidence of drug abuse among hospital patients
A pilot study to determine the number of drug-dependent patients in a psychiatric ward was carried out by Bergsman and Järpe (SOU 1967:25, and pers. comm.). They found that in 1963 in one psychiatric division 28 patients had been treated for drug dependence or drug abuse ( abusus alii according to the WHO nomenclature). But by analyzing the records of all psychiatric patients treated, 780 in all, they found another 31 patients who had also had all the symptoms of drug abuse and drug dependence, but not that diagnosis. These patients, who were thus "hidden" cases of drug abuse, were treated e.g. for psychasthenia, neurosis or depression, but no mention was made of their drug abuse problem in the final diagnosis.
Thus a total of 61 patients had abused drugs, or 8 per cent of all in-patients treated in that psychiatric division (61/780).
Extension of these intensive studies to four more hospitals in the Stockholm area showed the same picture. Out of 1919 patient records studied a total of 140 patients were found to be drug abusers, corresponding to 7.3 per cent of all patients, but only 56 patients had been diagnosed as drug abusers. Thus only a fraction of patients with drug abuse - from one fourth to one half - are found in the records under that diagnosis.
Characteristics of patients with drug abuse: The mean age was 36.2 years. The marital status of the patients differed markedly from that in the general population. Among the drug-dependent patients 31 per cent were single - against 12 per cent in the general population with the same age distribution -, 37 per cent were married - against 83 per cent normally, and 30 per cent were divorced - against 3.5 per cent in the normal population.
With regard to the types of drugs abused two-thirds (67%) abused mainly hypnotics, sedatives and/or tranquillizers. One third (33 %) abused narcotic drugs, divided among opiates (18%), stimulants (10%) and cannabis (5 %). Various types of drugs were combined in 15 per cent.
The drugs were mainly taken orally; only some 5 per cent injected drugs. Only rarely was drug-taking part of a ritual enacted with other individuals. The majority of the patients stated that the drugs were obtained on prescription; in one fifth of the cases the drugs were obtained by other means.
With regard to criminal background only three patients, or 5 per cent, had had any contact with police or other law enforcement agencies.
(ii) Hospital point prevalence study
In order to obtain an estimate of the number of cases of drug dependence treated in hospitals and the types of drugs abused, a nation-wide point prevalence study was undertaken by the Narcotic Drugs Committee (SOU 1967: 25). A questionnaire was sent out to all general hospitals, mental hospitals, psychiatric clinics and alcohol clinics in Sweden, requesting certain data concerning every drug-dependent person treated on a certain date, 5 October 1966.
The following items were asked for: age, sex, occupation, marital status, type(s) of drugs abused and way(s) of administration, duration of abuse, diagnosis and length of treatment. The drugs abused were classified into eight categories: (i) cannabis (hashish, marijuana), (ii) opiates - including morphine derivatives and synthetic morphine-like drugs, (iii) stimulant drugs - including amphetamines, phenmetrazine and methyl-phenidate, (iv) hypnotics - both barbiturates and non-barbiturates, (v) sedatives and tranquillizers, (vi) solvents - including trichlorethylene and thinner fluid, (vii) other substances, e.g. hallucinogens, and (viii) drug unknown or not disclosed.
Answers were obtained from all the hospitals under study, thus including all types of wards besides psychiatric divisions and mental hospitals, viz. divisions of internal medicine, surgery, neurology etc. A total of 556 drug-dependent persons - 339 men (61%) and 217 women (39 %) - were reported as in-patients on the day studied.
Age distribution
The males had a mean age of 36.7 years, the females 37.3, the average being 37.1 years. The age distribution is seen in figure 2. It is noted that the majority (41%) were over forty, and only 7 per cent were under 20 years of age.
Marital status
The marital status among the drug-dependent patients, illustrated in figure 3, showed a great change from what is normal for the same age group. [ 3] The proportion of single individuals was increased three- to four-fold, to 43 per cent, the normal for the age group in question being 12 per cent. The proportion of married was decreased by more than half, from normally 83 per cent to 33 per cent. The proportion of divorced showed a striking increase, from normally 3.5 per cent to 19 per cent in this material, thus a five- to six-fold increase.
Fig. 2. Hospital cases of drug abuse, seen in Swedish hospitals on 5 October 1966 (n = 556). Only cases with abuse of one drug are evaluated in the graph (n = 444).
Fig. 3. Hospital cases of drug abuse, seen in Swedish hospitals on 5 October 1966 (n = 556). Only cases with abuse of one drug are evaluated in the graph (n = 444}.
"Normal" refers to weighted means for the part of the population corresponding to the hospital age groups studied.
The same is also true of the proportion of widowed, being increased from 1 per cent in the normal population to 4 per cent in this material.
When analyzing this change in marital status in more detail by comparing the figures for each 5-year group of age, it was seen that the departure from normal was consistent and applied in every age-group; single persons, and those divorced or widowed being in excess as compared to normal, and married persons showing a lower proportion than in the normal population.
Fig. 4. Hospital cases of drug abuse, seen in Swedish hospitals on 5 October 1966 (n = 556). Only cases with abuse of one drug are evaluated in the graph (n = 444).
Pattern of drug abuse
Information about types of drugs was obtained from 93 per cent of the patients. The results are given in table 1v and figures 2, 4, 5, the proportions referring to those patients abusing one group of drugs only (n=444). Adding those abusing several types of drugs increases the figures given, but not the proportion between them.
It is seen that in this material of hospital cases the hypnotics and tranquillizers dominate the picture. These drugs were abused by 69 per cent of all drug-dependent patients.
Fig. 5. Hospital cases of drug abuse, seen in Swedish hospitals on 5 October 1966 (n = 556). Only cases with abuse of one drug are evaluated in the graph (n = 444).
The second largest group were the centrally acting stimulant drugs, [ 4] being abused by 18 per cent.
The classical narcotics, the opiates, [ 5] were abused by a minority only, by 4 per cent, and cannabis preparations by 1 per cent. Solvents, taken by inhalation, were abused by 5 per cent.
The majority abused one type of drug only, but in 13 per cent of all cases drugs with different pharmacological actions were abused, e.g. combinations of opiates and stimulant drugs as well as combinations of either opiates or stimulants with other drugs, e.g. hypnotics, tranquillizers or solvents (table 1).
These proportions mean in absolute figures that on one and the same day a total of 152 cases of narcotic drug abuse were treated in hospitals, 101 abusing one type of drug only, and 51 combining several types of drugs -- the latter being thus a high proportion.
When considering the narcotic drugs only, 18 per cent abused opiates only, this proportion rising to 28 per cent when opiates were combined with other drugs, e.g. stimulants. Five per cent abused cannabis, and 67-77 per cent abused stimulant drugs, the proportion depending whether cases with abuse of one group of drugs (77%) or combinations of drugs (67%) were included (table 1).
Influence of age: The pattern of drugs abused varied in a typical way with age. Figures 4 and 5 (pages 8 and 9) are based on the cases with abuse of one group of drugs only; when taking into account also those with combined drug abuse the proportions between the groups did not change significantly.
Distribution of drugs abused in hospital patients (n=556) (Point prevalence survey on 5 October 1966)
Number n
Per cent n = 444
Per cent n = 556
Mean age years
Hypn. + Tranq.
Volatile agents
Comb. of opiates + stim
Comb. of opiates or stim.
Comb. of other drugs
Adapted from Narcotics Drug Committee Report I (1967:25).
Abuse of solvents by sniffing dominated the youngest age group, 10-19 years, and was seen in 36 per cent of the cases (fig. 4). Stimulant drugs were next, abused by 30 per cent, hypnotics (18 %) and cannabis (12%) being third, opiates playing only an insignificant role (3 %).
In the age group 20-29 years, hypnotics and stimulant drugs dominated the picture, being abused by 43 and 42 per cent respectively, the other drugs being abused by a minority only.
In the next age group, 30-39 years, and still more in those over 40 the dominating drugs abused were the sedatives and tranquillizers, in 74 and 90 per cent of the cases; the other drugs were abused by a minority only.
The distribution of each single group of drugs over the various age groups is given in figure 5. Cannabis and solvents were mostly used in the age-group 10-19 years, stimulants mostly in the group 10-30 years and less over thirty years of age. Opiates showed a slight maximum in the 30-39 year group, but were on the whole abused by very few, while hypnotics and sedatives were already significantly abused in the 20-29 year group, but predominantly in the groups over thirty, the maximum being seen in the age group over forty, where 90 per cent abused hypnotics.
From these data an estimate can be made of the age when abuse of one or other drug dominated (table 1).
Cannabis smoking and inhalation of solvents dominated at the youngest age, the mean age in this material being 17.0 and 20.8 years respectively. Stimulants dominated in the next decade, the mean age being 28.5 years, while opiates dominated in higher ages, the mean being 35.9 years; the hypnotics dominated at 41.5 years.
The abuse of drugs in combination dominated at the age of the drug that dominated earliest. Thus the combined abuse of opiates and stimulants dominated at 28.5 years, and combinations of drugs other than opiates or stimulants had their maximum at 41.5 years, thus the same as the hypnotics.
Sex distribution: When studying the differences in the choice of drug it was noted that men in a higher proportion than women abused solvents (8% in men against 2% in females) and central stimulants (21 % against 14%), whereas women showed a higher proportion of drug abuse of hypnotics (78 % against 64% in men).
Modes of administration
The various modes of administration showed some characteristic traits (table 2).
Modes of administration of drugs in drug abusers in hospitals (n=556) (Point prevalence study on 5 October 1966) Percentage of total within each age group.
Age in years
-19 n = 36
20-29 n = 151
30-39 n = 136
40- n= 224
Total n = 547
Together with alcohol
Adapted from Narcotics Drug Committee Report I (1967:25).
About 14 per cent of the drug-dependent patients admitted having injected the drugs - which amounts to about half of those taking stimulants and/or opiates. Four per cent inhaled, corresponding to the proportion of solvent abusers (" sniffers "), the rest, 82 per cent, took the drugs orally.
There was no essential sex difference in this respect, with one note-worthy exception. Among the males, 40 per cent admitted having taken their drug together with alcohol, pointing to the role of alcohol abuse in this group, against 14 per cent of the females, also a high figure, but a considerably smaller proportion than in men.
When looking at the age distribution of the various modes of administration it was seen that the mode of administration closely followed the age pattern of drug intake. Inhalation, together with oral intake, was the mode in the youngest age group. Injection was preferred in the 20-29 year group, whereas oral intake predominated in the higher age groups. The taking of drugs together with alcohol showed a similar picture, being insignificant below 20 years, the proportion then increasing with age, to be 30-40 per cent over 20 years.
With regard to occupation and social grouping the individuals in social group III - the lowest group - were in the majority, while the two highest groups, I and II, were under-represented.
With regard to pattern of drug abuse the pattern was essentially the same in social groups II and III. A somewhat higher proportion of stimulants and lower of hypnotics were seen in group III.
Completely different patterns were, however, noticed among two distinct groups, which were thought to be of special interest, viz. "students" on one hand, being 7 per cent of the total, and housewives on the other, being 14 per cent of the total.
The main drugs among the studentswere stimulants (38 %) and solvents (28 %), then hypnotics (18 %), opiates (8%), cannabis (4%) and finally other drugs (3%): this choice corresponding more or less to the age groups represented, as a rule below 25. In 20 per cent of the cases several groups of drugs were combined.
A different pattern characterized the housewives.Here the abuse of hypnotics dominated the picture, being seen in 83 per cent of the cases. The rest were divided among all the other groups, including combinations of drugs.
An analysis was also made of the various diagnoses under which the patients had been accepted. A total of 200 diagnoses, including combinations of several diagnoses were recorded. A survey is given in tables 3 and 4.
In the males alcohol abuse and character disturbance dominated, appearing in 26.9 and 20.9 per cent of the cases respectively, or together in almost every second case, against 7.3 and 11.9 per cent of the females, or together in 19.2 per cent. In the women neurosis was the most common diagnosis, seen in 33 per cent, against 9.7 per cent among the men (table 3).
When studying whether the diagnoses showed a different pattern in different age groups it was found (table 4) that character disturbances (26.3%), abusus alii (23.6%) and somatic disease (21.1%) dominated in the young, below 20 years of age. With increasing age, neurosis and alcohol abuse increased, from 15.8 to 23.8 per cent for neurosis and from 5.3 to 21.6 per cent for alcohol abuse, while the proportions of the other diagnoses decreased.
Diagnosis on acceptance of patients with drug abuse in hospitals (n=556) (Point prevalence study on 5 October 1966)
Males n = 339
Females n = 217
Total n = 556
Somatic diseases
Abusus alii
Character disturbances
Alcohol abuse (includ. combin. with charact, disturb.)
Other combinations
No diagnosis
Adapted from Narcotics Drug Committee Report I (1967:25)
Diagnosis on acceptance of patients with drug abuse in hospitals (n=556) (Point prevalence study on 5 October 1966)
-19 n= 38
20-29 n = 153
30-39 n = 138
40- n = 227
Total n = 556
Somatic diseases
Abusus alii
Alcohol abuse (in-clud. combin. with charact. dis turb.)
Other combinations
No diagnosis
Adapted from Narcotics Drug Committee Report I (1967:25).
Abusus alii: It is noteworthy that abusus alii, i.e. the proper diagnosis of drug abuse according to the WHO classification, was given only in 13.5 per cent of all cases, 13.0 in men and 14.5 in women. Thus in the majority of cases other diagnoses were more frequently made.
This means among other things that an attempt to estimate the number of drug abusers from the number of cases of abusus alii would give only a small fraction of all cases; in this instance the true figure is 7.5 times the number of cases of abusus alii.
There may be several reasons for this discrepancy. One is that the drug abuse was not known when the patient was sent to the hospital, his main complaints being thought to be of other origin. Another reason is that other causes may have dominated the picture, the drug abuse being secondary to the underlying disease. A third reason may be reluctance on the part of the referring physician, or of the patient, to have the diagnosis of drug abuse known. The patient might be afraid that the doctor would "report his abuse to the police ", and thus that he might be submitted "to all the force of the law ", or he might not be willing to have it known that he is a drug abuser, e.g. in a divorce case.
The discrepancy between the actual number of cases of drug abuse treated and officially diagnosed is even greater than in the Bergsman-Järpe material, probably due to the fact that in this prevalence study other clinics besides psychiatric clinics are included, where the tendency to "hide" the drug abuse diagnosis is greater.
(iii) Surveys on out-patients
During 1966 a number of patients were treated as out-patients in two specially started out-patient clinics, one in Stockholm (" Stadshagspolikliniken ") and one in Göteborg (at Sahlgrenska sjukhuset).
During a period of 8 months in 1966 a total of 99 patients (71 men and 28 women) were treated in Stockholm, their average age being 28.8 years in men and 25.9 in women, or 28.0 in the whole material. A total of 27 per cent were below 21, and 10 per cent over forty (Ljungberg, SOU 1967:25).
With regard to the types of drugs abused 55per cent took only stimulants, 19 per cent combined opiates and stimulants, the rest, 25 per cent, abused hypnotics, tranquillizers, cannabis and solvents.
One third of the patients had earlier criminal offences.
In Göteborg during a period of 8 months in 1966 a total of 49 patients were treated on an out-patient basis for drug dependence. One third (33 %) were less than 21 years, and only 6 per cent were over forty, the mean age being 25.4 years, 37 per cent had earlier committed criminal offences.
Abuse of stimulant drugs dominated in 73 per cent of the cases, opiates in 8, cannabis in 11, and tranquillizers and solvents in 8 per cent. Abuse of combinations of various drugs was common.
Since many cases come at night and at odd times when the out-patient clinics are closed, stress has been put on the necessity to have facilities for treating, or accepting, patients at all times of the day. (Jansson and Holmberg, SOU 1967:25.)
Statistical studies on "abusus alii" 1962-1964
Since 1962 a central register is kept at the National Medical Board on all patients treated in hospitals, their diagnoses listed according to the WHO International Nomenclature. Cases of drug abuse should be found under the heading abusus alii, comprising both abuse of narcotic drugs (in Sweden including stimulants and hallucinogens) and of other drugs as hypnotics, sedatives and tranquillizers, or solvents.
Two pilot studies were carried out on this statistical material of reported cases from psychiatric clinics and mental hospitals, one for the years 1962 and 1963 by Bergsman and Järpe on all cases of abusus alii, alone or combined with other diagnoses, and one by the Narcotics Drug Committee for the years 1962-1964 on cases of abusus alii only.
Abusus alii (alone or combined)
Bergsman and Järpe made a survey of the cases officially recorded at the National Medical Board as abusus alii and treated in psychiatric clinics and mental hospitals during 1962 and 1963.
The total number increased from 458 cases in 1962 to 582 cases in 1963, or by 27 per cent. The proportion of new cases in psychiatric wards in 1962 was 54 per cent, against 24 per cent in mental hospitals, this difference beginning to be reduced in 1963.
These figures are certainly indicative of the general tendency, but are definitely minimal figures, the true number being much higher.
This assumption is based on several facts:
In Bergsman and Järpe's intensive study from four psychiatric clinics in Stockholm (n=1919)the true number of drug abusers was more than twice the number of cases listed under that diagnosis.
In the point prevalence study the diagnosis abusus alii was only seen in 13.5 per cent of all cases classified as cases of drug dependence or drug abuse.
An attempt to estimate the number of drug dependent patients will be given (vide infra).
No data are hitherto available concerning the types of drugs abused or other parameters of interest in the statistical cases referred to; an analysis of these data is foreseen.
Abusus alii (alone)
A pilot study was also made by the Narcotics Drug Committee of the officially reported cases of abusus alii (no cases included where this diagnosis was combined with other diagnoses) for the years 1962-1964. A total of 328, 385 and 443 cases were found for the three years studied, comprising 272, 324 and 375 individuals.
The mean ages were 44.0, 42.0 and 41.6 years for the three years in study, somewhat lower in large cities than in smaller cities and rural areas. The reduction in mean age over the three years is due to a successive increase of the proportion of younger age groups; this is also the explanation of the difference between urban and rural areas.
The average duration of the hospital stay was around 58 days in 1962, and 46-47 days in 1963-1964.
This material shows the same general tendency as the study by Bergsman and Järpe and thus illustrates a small fraction only of all cases of drug dependence, due to the way in which the diagnosis abusus alii is made (vide supra).
(v) Estimation of total number of narcotic drug abusers
From the three hospital studies mentioned, the prevalence study and the two statistical ones, estimates of the total number of narcotic drug abusers can be attempted in three different ways.
Based on hospital figures
The point prevalence figure of 556 drug abusers in hospital on one particular day in 1966 can be used as one base for the estimation of the size of the total population of drug abusers.
Assuming an average duration of hospital stay of 50 days (as found in the statistical study), no overlapping, and a new patient being admitted when one is released, the total number of patients during one year (1966), would amount to 365 / 50 x 556 = 4,150 patients.
Out of these 4,150 patients 23 per cent would be abusers of narcotic drugs, i.e. of cannabis, opiates and stimulants or 950 patients.
Based on officially reported figures (abusus alii, alone or combined)
When evaluating the reported patients in which abusus alii was the only diagnosis, or one of several diagnoses, from statistics available in the National Medical Board and from the study of Bergsman and Järpe, the figures for 1962 and 1963 would be 458 and 582. Assuming a 25 per cent increase per year, the estimated figure for 1966 would correspond to 1,125 patients.
Further, it is known from Bergsman and Järpe's intensive study of a psychiatric Stockholm material (n = 1919) that if only 40 per cent of all cases of drug dependence were reported, the total number would be 100 / 40 x 1,125 = 2,800 patients.
Based on the same study 33 per cent of the cases of drug abusers would constitute narcotic drug abusers, or 920 patients.
Based on officially reported figures (abusus alii only)
When attempting to estimate the total number of drug abusers (abusus alii) in psychiatric wards and mental hospitals from the statistics of the National Medical Board, up to 1964, an estimate must first be made of the figure for 1966, which is not yet available. The increase from 1962 to 1964 was 35 per cent (328 to 443); assuming the same rate, the estimated figure for 1966 is 600.
Further, it is evident from the hospital prevalence study that the pure diagnosis abusus alii was found only in 13.5 per cent of all cases with drug dependence.
On the basis of these assumptions, the total number of drug abusers, reported as well as non-reported, would be 100 / 13.4 x 600 = 4,450 patients.
Assuming as before, that 23 per cent of these were narcotic drug abusers, this would correspond to a total of 1,020 patients.
Thus all three methods yield approximately the same estimate: around 1,000 patients with narcotic drug abuse being treated in psychiatric clinics and mental hospitals in 1966.
Three surveys have been carried out on the incidence of drug abuse among individuals with a criminal background, one concerning persons coming in contact with the police, another concerning arrested persons and the third concerning present and former prison inmates.
(i) Individuals in contact with police
The police come in contact with an increasing number of persons who have problems of drug abuse. They may come to ask for help or to report on illegal activity, or they may have taken drugs, or they are taken into custody for alleged misdemeanours or felonies, or are arrested for having committed crimes of various kinds.
In order to get an impression of what kind of persons these individuals are and the types of drugs abused the Narcotics Drug Committee asked all police districts to file every case seen during a one-month period, 1-30 June 1966, on a special form. A total of 109 out of 119 districts returned the forms, comprising a total of 510 persons. The missing districts, when asked by telephone, had had no cases during the month in study.
The main results, analyzed by the Narcotics Drug Committee, will be given here (1967:25).
Age distribution
The age distribution is given in figure 6. The mean age in this material was 30.0 years. It is noticed that not less than 20.9 per cent were below 20 years of age, and 61.9 per cent below 30, only 18.8 per cent being over forty. The principal age group was 20-29 years.
Marital status
The marital status is given in figure 7. Seventy-three per cent were single - against 22 per cent in a sample from the general population with the same mean age, 13 per cent were married - against 76 per cent normally, and 14 per cent were divorced or widowed - against 3 per cent normally.
Fig. 6. Police cases of drug abuse (individuals seen by Swedish police 1-30 June 1966, n = 510). Only cases with abuse of one drug are evaluated in the graph (n = 373).
Fig. 7. Police cases of drug abuse (individuals seen by Swedish police 1-30 June 1966, n = 510). Only eases with abuse of one drug are evaluated in the graph (n = 373). "Normal" refers to weighted means for the part of the population corresponding to the police case age groups studied.)
When dividing the material into age groups, it was seen that there was a consistently higher proportion of single individuals in every age group, a lower proportion of married, and a higher proportion of divorced and widowed, which indicated the same tendency as in the hospital prevalence study.
Pattern of drug abuse
The types of drugs abused are seen in table 5 and figures 6, 8, 9.
The dominating drugs abused were the stimulants, being taken by 49 per cent of all individuals who had taken one group of drugs Only (184/373). The second largest group was the hypnotics, abused by 29 per cent, the third the solvents, found in 15 per cent, and finally cannabis (3 %), opiates (2%) and other drugs (2%).
In 59 cases, or 13.8 per cent of the total, several groups of drugs were combined. In 4.2 per cent opiates and stimulants were taken by the same individuals, in 6.3 per cent stimulants + other drugs, and in 3.3 percent other combinations.
When the combinations were included the percentage of abusers of stimulants rose to 51.0 per cent and that of opiate abusers to 5.7 per cent.
Influence of age
The distribution of the various types of drugs on the different age groups is given in figure 8.
Solvents (51%), stimulants (29%) and cannabis (11%) dominated in the youngest age group, 10-19 years, whereas the stimulants dominated both the 20-29 year group (68%) and the 30-39 year group (52%).
The hypnotics constituted 38 per cent of the total in the 30-39 year group, and were the main drug, 60 per cent, in the group over 40.
Distribution of drugs abused in police cases (Individuals seen by police 1-30 June 1966)
Number n
Per cent n=373
Per cent n=508
Mean age years
Hypn. + Tranq. .
Volatile agents
Comb. of opiat + stim.
Comb. of stim. + other
Comb. of other
Adapted from Narcotics Drug Committee Report I (1967:25).
Fig. 8. Police cases of drug abuse (individuals seen by Swedish police 1-30 June 1966, n = 510). Only cases with abuse of one drug are evaluated in the graph (n = 373).
When studying the various age groups and the distribution of drugs within each age group (fig. 9) it was obvious that both the abuse of cannabis and of the solvents characterized the youngest age group, 10-19 years, continued in the 20-29 year group, then became negligible in higher age groups.
The stimulants were abused by a substantial proportion in the youngest group, while their abuse showed the highest proportion in the 20-29 and 30-39 groups. They continued to be abused by a substantial proportion in the highest age group, over 40 (fig. 9).
The hypnotics showed an increasing proportion with an increase in age, predominating in the highest age group, over 40; the same pattern was essentially seen with the opiates.
Fig. 9. Police cases of drug abuse (individuals seen by swedish police 1-30 June 1966, n = 510). Only cases with abuse of one drug are evaluated in the graph (n = 373).
The data allow for calculating the mean age of the abusers of various types of drugs (table 5).
The mean age of the cannabis abusers was 17.5 years, and that of the solvent abusers 19.9 years. The mean age of the abusers of stimulant drugs was 28.7 years. The mean age of the hypnotic drug abusers was 37.8 years, and of the opiate abusers 39.5 years.
Thus the mean ages of the abusers of the various kinds of drugs agreed with those found in the hospital study.
Sex distribution
Men dominated the police material, 72 per cent (366/510) against 28 per cent women. It is not unlikely that the proportion of drug abusers among the women heard by the police was higher than that of the men.
When comparing the distribution of drugs abused, women abused stimulants (52 %) and hypnotics (31 %) in a higher proportion than men (46 and 26 %), but less solvents (8 against 18 %).
Modes of administration
Injection was most common among those abusing stimulant drugs; 81 per cent of the abusers of stimulant drugs injected the drug, 43 per cent of the opiate abusers and only 7.5 per cent of abusers of hypnotics.
With this background it is to be expected that the proportion of individuals injecting drugs should be correlated to the proportion of abusers of stimulants + opiates out of all abusers; actually a close correlation was found within each age-group.
A study of the occupation of drug abusers in relation to modes of administration showed the following:
Of those taking drugs orally, mostly hypnotics, half (50%) were employed, one fourth (28 %) had no jobs and one fifth were on sick pay (table 6).
Of those injecting drugs, i.e. mainly abusers of stimulant drugs, about one third only (31%) were employed, half (49%) had no work, and one fifth (19%) had sick pay, thus showing important differences from those taking drugs orally.
A similar picture is seen when comparing individuals taking different types of drugs (table 6).
Among individuals abusing stimulants, their mean age being 29 years, those holding no jobs dominated the picture (48%), followed by those holding jobs (34%), and those being on sick pay (19%).
Among the abusers of hypnotics, their mean age being 38 years, those being occupied dominated (48%) followed by those having sick pay (31%) and having no jobs (20%).
Finally a different picture was seen among those abusing solvents by inhalation, their mean age being 20 years; "students" (48%) dominated the picture; one fourth (27%) held no jobs, 20 per cent held jobs, and only 4 per cent were on sick pay (table 6).
Social groups
When dividing the material into social groups, according to type of occupation held, the two lower social groups, II and III, appeared most important, social group III being over-represented, as compared to the proportion in the total population.
Distribution of occupation among drug abusers in contact with police
(Individuals seen by police 1-30 June 1966)
Mode of administration of drug
No injection n=212
Injection n=165
Holding job (including study)
No work
On sick pay
On pension
Stimulants n=145
Hypnotics n=75
Solvents n=44
Holding job (including study)
No work
On sick pay
On pension
Adapted from Narcotics Drug Committee Report I (1967:25).
In both these groups the intake of stimulant drugs dominated, followed by hypnotics and by a small proportion of solvent abusers.
A considerable proportion of the total material seen' (about 14%) were "students ".Their pattern of abuse differed from the rest of the material, parallel to their lower age, stimulants and solvents dominating the picture, with both being abused in the same proportion; hypnotics were abused to a lesser extent in this group than in others.
A high proportion of the womenin this police material had no known occupation, which may be interpreted in two ways, viz. that many of them were housewives or had "other occupations ".
Criminal records
It was found that 20 per cent of the individuals seen had a criminal record, 24 per cent of the males and 8 per cent of the females.
With regard to the reason for the actual contact with the police (table 7), there was no unlawful behaviour in 75 per cent of the cases. The rest were divided among illegal possession (16%), peddling (5%), smuggling (2%), theft (1%), forged prescription (0.4%) and miscellaneous (1.6%).
Distribution of illegal conduct among drug abusers in contact with police(n=510) (Individuals seen by police 1-30 June 1966)
Per cent
Illegal possession
Forged prescription
Theft, etc
No illegal conduct
Adapted from Narcotics Drug Committee Report I (1967:25).
Other background data
About 10 per cent of the males had been treated for alcoholism, against 3 per cent of the females, and another 11 per cent of the males and 18 per cent of the females had been in contact with social agencies.
About 8 per cent of the males and 8 per cent of the females had been treated earlier for mental illnesses.
(ii) Incidence study of arrested persons
In order to investigate the number of individuals with intravenous abuse of drugs among persons arrested for possible criminal acts (not including cases of drunkenness and mentally disturbed persons) a study was conducted in Stockholm by Bejerot in 1965-1967 (SOU 1967:25).
During the first month studied, April 1965, 663 persons were examined. Out of these a total of 74, or 11.1 per cent were found with signs of intravenous drug abuse, mainly scars, sclerotic veins and local infection after injections.
All intravenous abusers among arrested individuals were found in the age groups below 40 years; none was seen among those over 40.
In the age group 15-39 years 20.6 per cent intravenous abusers were found among the males, and 27.8 per cent among the females.
The highest rate was seen in the 20-29 age group, 36 per cent among the males and 50 per cent among the females.
The mean age in the abuse group was 27.8 years. Only 2 per cent of the material in April 1965 was in the age group 15-19 years.
The study was then continued, and has now been going on for two years.
A survey of the material up to 30 June 1966, covering a period of 15 months, disclosed that a total of 995 per- sons indulging in intravenous drug abuse had been found during this time, out of some 10,000 individuals examined. This corresponds to 65-70 cases per month, or about the same number as during the initial month.
Of these cases 62 per cent (620/995) were new, and 38 per cent (375/995) were relapses.
There is a slight tendency to an increase of the number of abusers found during the 15 month period of observation, from 55 on an average in the first month to 80 in the last month reported.
The age distribution of the material so far analyzed --comprising only individuals under 41 years of age-shows a mean of 26.5 years, the age group 20-29 years being the largest, 35.2 per cent.
The change during these two years of study is significant. An increase in the proportion of individuals with drug abuse among those arrested for various crimes is noted, and an extension of the age limits of the material is seen, not only into higher ages, but also into lower ages. The proportion of persons under 20, being only 2 per cent in April 1965, and 7.7 per cent on an average for the period up to July 1966, had increased to 28 per cent in April 1967, i.e. a 10-15-fold increase.
(iii) Present and former prison inmates
A survey was made through the National Board for Criminal Care (Kriminalvardsstyrelsen) to estimate the incidence and prevalence of drug abuse among present and former prison inmates.
Three questions were asked: (i) number of interns on 1 August 1966, (ii) number of these having abused narcotic drugs while in prison, and (iii) number of interns on 1 August 1966 that could be assumed to be drug abusers. The results were reviewed by the Narcotics Drug Committee (1967:25).
Prison inmates
Out of a, total of 4,290 prison inmates 446, or 10 per cent, were judged to be drug abusers. Out of these 94 were known to have abused drugs during their internment, and 352 (8%) were known to have been drug abusers in the past.
The highest proportions were found among those interned, 20 per cent (130/639), and among a group of women, 20 per cent.
Former prisoners
A similar survey among former prisoners, still under surveillance, showed that 577 of these individuals, or 3 per cent of the total (577/18,663) were known to be drug abusers.
Among the different districts the proportion was highest in Stockholm, 8 per cent, and within the Stockholm area highest among those formerly interned, .32 per cent (63/195).
There was also a difference between different parts of Stockholm ,pointing to the importance of looking for the possible relation with other factors of a sociological nature, as housing, gangs, etc.
Former prisoners within Skyddsvärnet
Still higher proportions of drug abusers were found when studying those former prison inmates that were taken care of through a private agency, Skyddsvärnet .Whereas in earlier years alcohol abuse had been the great problem in this group, drug abuse has become more and more common in the last few years. During 1966 almost every second person, 112 in number, or 43 per cent out of the total of 259 persons calling at a doctor's consulting rooms were drug abusers.
These figures as well as those found in the two police materials studied point to the large number of drug abusers and the importance of this problem among criminal individuals; these points are further emphasized by the findings of Rylander on patients in the Forensic Psychiatry Clinic and the cases of hepatitis (Bellander) among prison interns (1967:25), referred to under chapter III.
The surveys carried out have clearly brought out the large differences existing between the two groups of studies surveyed, viz. between drug abuse seen in patients treated in hospitals on one hand and in cases with a criminal background on the other, or those seen by the police. The main differences may be summarized in the following:
Hospital patients
An average age of 37.8 years, with only 7 per cent below 20, and 41 per cent over 40 (fig. 10);
A high proportion of single and divorced individuals, and a low proportion of married;
Abuse of hypnotics and tranquillizers dominating the picture, and stimulants coming next, opiates, cannabis and solvents being a small proportion only; in 10-15 per cent combinations of drugs with different actions were abused (fig. 10);
Only a small percentage of abusers injecting the drug (14%), the majority taking the drugs orally (82%) or inhaling volatile agents (4%);
The drug abuse pattern varying with age; solvents and cannabis dominated among the young belowtwenty group, stimulants and hypnotics in those in the 20-30 group, and abuse of hypnotics and tranquillizers dominating in higher ages (figs. 4 and 5);
Fig. 10. Hospital material refers to cases of drug abuse found in Swedish hospitals on 5 October 1966 (n = 556). Out of these, only those cases are evaluated in the graph that abused one drug.(n = 444). Cp. fig. 2.
Police material refers to cases of drug abuse seen by the Swedish police 1-30 June 1966 (n = 510). Out of these only those cases are evaluated in the graph that abused one drug (n = 373). Cp. fig. 6.
Very few had a criminal record; an insignificant proportion only of the patients had had any connection with police or other law-enforcing agencies.
Police cases
An average age of 30 years, no less than 21 per cent under 20 and only 19 per cent over forty; thus a shift to younger persons (fig. 10);
A high proportion of single and divorced individuals, and a low proportion of married;
Abuse of stimulant drugs dominating the picture, hypnotics and tranquillizers coming next, and then solvents, with only a small percentage abusing opiates or smoking cannabis, thus a great difference from the hospital patients (fig. 10);
A high proportion of individuals injecting the drugs abused, 81 per cent of those abusing stimulant drugs, but also to a certain extent those taking opiates or hypnotics; these differences were seen within each age group (fig. 11);
Fig. 11. Hospital material refers to all cases of drug abuse treated in Swedish hospitals on 5 October 1966 (n = 556).
Police material refers to all cases of drug abuse seen by Swedish police 1-30 June 1966 (n = 510).
The drug abuse pattern varying with age - sniffing, cannabis smoking and injection of stimulant drugs in the younger age groups, and the taking of hypnotics orally, or injecting these drugs, in the highest age groups. Also when comparing hospital patients and police cases within the same age groups, the same differences are seen, with a clear shift to injection of stimulants in the police cases (figs. 4-5, 8-9);
About 20 per cent of the police material having a criminal record.
In some other groups of individuals with a criminal or a socially maladjusted background, e.g. the patients treated in some out-patient clinics, or the adolescents examined by Herulf and Sunesson (1967) or the arrested individuals examined in the Clinic of Forensic Psychiatry (see chapter III) even higher proportions of abuse of stimulant drugs and of injecting these drugs were seen.
A total of five surveys have been carried out on pre-valence and incidence of drug use and abuse among adolescents, prevalence of drug use among school pupils in Sweden and among school children in grade 9 in Stockholm, case studies of juvenile drug abusers in Stockholm, incidence of drug abuse among teen-agers seen by the Childrens Welfare Board, and abuse among juveniles in Youth Treatment Schools.
Pupils of the public and private school system
In order to obtain information on the extent of use and abuse of narcotic drugs among pupils of the public and private school system a pilot survey was carried out by the National Board of Schools (Skolöverstyrelsen) during the spring months of 1967.
A standard questionnaire was prepared by O. Österlind, Head of the Psychology Section of the School Board. In accordance with the exploratory nature of this study those schools interested in making a survey were invited to obtain questionnaires for use according to their choice and to have them evaluated by the Board.
Up to June 1967 a total of 130,061 questionnaires were evaluated. Some pertinent results will be given here, based on the preliminary Swedish manuscript by Österlind (publication in preparation) and the figures analysed by the Central Bureau of Statistics.
The pupils interviewed came from: (i) classes 7-9 of the public primary school system (" Grundskolan "), corresponding to ages 14-16 years, (ii) classes I-IV of the higher schools of the gymnasium (" Gymnasiet "), corresponding to ages 16-19 years, (iii) classes 1-2 of the continuation schools (" Fackskolan"), and (iv) classes 1-2 of the vocational schools (" Yrkesskolan "), both comprising approximately the same age group, and (v) a few other schools, comprising "People's Colleges ", private schools for girls and teacher-training colleges.
The pupils interviewed, 130,061 in all, represented 32 per cent of the total number of pupils in the schools and classes concerned, a higher proportion from continuation schools (58%), and less from vocational schools (11%); the total number in 1965 of the pupils in the school classes concerned was 409,000. The pupils interviewed represented 11 per cent of all school children in Sweden, comprising a total of 1,172,000 pupils, universities excluded.
Selection of material: The material of this pilot study is selected because the schools were invited to ask for questionnaires according to their own choice.
The selection so far comprises more pupils from urban areas than the population representation, and most probably more pupils from classes where the school authorities suspected some drug abuse. On the other hand the large cities, including Stockholm, are highly under-represented. Less than 1 per cent of the pupils in the Stockholm area were included in this pilot study, thus coming from an area that was expected to have a higher proportion of drug use than any other part of the country.
The net result of these considerations may therefore be that an extension of this pilot study to include representative samples from all kinds of schools may yield approximately the same results as the figures obtained from the pilot study.
A special study covering class 9 of the primary school in the Stockholm area, carried out by Herulf, will be given later (vide infra).
Smoking and drinking
As a background for the findings the informants were asked about smoking and alcohol consumption. The results are given in table 8.
Use of drugs among school pupils
Questioning of 130,061 pupils in Swedish schools, spring 1967
Use of drugs
Spirits wine
Strong beer
Inhaling solvents (sniffing)
Narcotic drugs ("knark")
Used occasionally
Used regularly
No answer
0. 3
0. 7
0. 5
0. 5
0. 9
Adapted from Report by O. Österlind of National Board of Schools (manuscr. 17/7-67).
On an average 46 per cent of those interviewed smoked, 59 per cent used distilled spirits or wines, and 57 per cent "continental" beer or export beer.
The frequency of smokers and of alcohol consumers increased with age. As an example may be mentioned that the proportion of smokers in the three highest classes of the primary school increased with age from 15 to 36 per cent, and in the higher schools (" gymnasiums ") from 27 to 40 per cent. There was no systematic difference seen between the primary school and the higher school children besides that due to age.
The tendency was the same as that seen in earlier surveys in Sweden (E. Jonsson, in mimeographed form).
Inhalation of volatile solvents (" sniffing")
The data concerning sniffing are given in table 8. On an average 5.8 per cent of those interviewed had been "sniffing" but had discontinued the habits, and 0.8 per cent were actually sniffing at the time of the interview.
Those sniffing daily corresponded to 180 pupils, those sniffing" one or several times a week" to 199 pupils and those "occasionally" to 785 pupils.
Sniffing was concentrated to the lower ages, showed the highest incidence in the highest classes of primary school, and did not increase after 15-16 years of age; lower proportions were seen in the other schools.
The difference between primary schools, vocational schools and continuation schools on one hand and higher schools on the other seems to be due to two reasons: (a) difference in age, and (b) difference in composition of the particular school population.
Of special interest is the high proportion found of individuals that had stopped sniffing at the time of the interview, a total of 5.8 per cent, or seven times as many as those that were engaged in sniffing at the time of the interview (0.8 %).
Use or abuse of narcotic drugs
In the questions formulated to obtain an insight into the use of narcotics or other drugs by the school pupils the Swedish colloquial word " knark"was used. " Knark" usually means a number of different drugs taken orally or by injection for non-medical purposes, from cannabis, opiates, stimulant drugs and hallucinogens to hypnotics, sedatives or tranquillizing agents.
Knowing other drug users: The first question asked was whether the informant knewof other boys or girls in the school who were taking "drugs" or " knark" . A total of 19 per cent answered in the affirmative; the proportion of those answering yes was highest in primary school, increasing from class 7 (15%) to class 9 (25%), and lower in all the other schools, from 8 to 21 per cent.
The proportion found can be looked upon as (a) an indication of a higher incidence of drug use in higher classes, (b) an indication of a more intense communication between individuals and maybe also preoccupation with drug talk in higher classes.
When asked if they knew somebody in their classwho took drugs occasionally, 7 per cent of the pupils answered yes. On the question if they knew anybody in their class who took drugs more regularly1.4 per cent answered in the affirmative, and the question whether one or more of their bestfriends took drugs was answered in the affirmative by 6.5 per cent. In all these instances the incidence was highest in class 9 of the primary school, and lower in the others.
Offered drugs: When asked if they had been offereddrugs, no less than 15.9 per cent answered yes which corresponds to a total of 20,563 pupils! Out of these, about one third had had the offer the present term, one third the preceeding term, and one third earlier. Of those who had been offered drugs, two thirds or 64 per cent, were offered cannabis, 20 per cent stimulants, 7 per cent LSD and 9 per cent unknown drugs. There was no essential difference in this respect between boys and girls, 17.3 per cent of the boys being offered drugs against 14.2 per cent among the girls.
The proportion of those having been offered drugs increased with age, e.g. in primary school from class 7 (9%) to class 9 (22%), and within certain limits also with type of school, the proportion varying between 11 and 22 per cent; these facts point to a possible selection with regard to the pupil population within each type of school.
When asked how the drug is procured, almost half (41%) knew how to obtain the drug: by being offered for free (10%) by buying from friends or grown-ups (15%), from drug pushers (12%), abroad (3%), or by other means (2%).
When asked where the drug is procured 33 per cent knew; 2 per cent answered "at school" - corresponding to 2,390 pupils, 11 per cent said in "cafés ", and 7 per cent "on the streets ", 3 per cent at youth centres, and 4 per cent abroad; this last figure corresponds to 5,323 pupils.
Own use of drugs: The most interesting part of the pilot study concerns the answers to the question whether the pupil was using drugs himself: 95.1 per cent had never used drugs, 2.1 per cent had used drugs earlier, but stopped, corresponding to 2,783 pupils, and 1.5 per cent, or 2,040 pupils, were using drugs, occasionally or more regularly. Out of these 11 per cent, or 242 pupils, stated they took drugs almost every day, 16 per cent weekly, 17 per cent monthly, and 46 per cent less than once monthly.
The types of drugs used were divided as follows: 75 per cent smoked cannabis, or 1,260 pupils, 7 per cent used LSD, or 121 pupils, 9 per cent stimulant drugs, or 153 pupils, and 9 per cent other drugs, e.g. hypnotics or tranquillizers, or 143 pupils; 363 pupils did not state the type of drug used.
The frequency of users increased with age, in the primary school from 0.9 per cent of the pupils in class 7 to 2.5 per cent in class 9. The figures for all the other types of schools varied between 1.3 and 2.1 per cent. Thus again the highest proportion was found in class 9 of the primary school.
There was a clear difference between boys and girls in this respect. Of the boys 2.6 per cent had stopped, and 2.0 per cent still took narcotic drugs or a total of 4.6 per cent, whereas among the girls 1.6 per cent had stopped, and 1.1 per cent took drugs, or a total of 2.7 per cent.
Thus a total of 3.6 per cent of all the pupils interviewed, or 4,823 individuals, took, or had taken, narcotic drugs.
(ii) Pupils in primary school grade 9 in Stockholm
A study intended to give data on use and abuse of narcotic drugs among pupils in grade 9 in the Stockholm area has been conducted by Dr. B. Herulf, a psychiatrist in the Children's Welfare Board. Only a preliminary analysis is so far available; the data given in the present survey are obtained by courtesy of Dr. Herulf from his preliminary manuscript.
There were several reasons for carrying out a more intensive study on a Stockholm material of school pupils: ( a) it was to be expected that the proportion of drug users should be higher in Stockholm than in other areas, ( b) the results of the intensive study by Herulf and Sunesson (1967) on juveniles referred to the Children's Welfare Board for narcotic abuse ( vide infra) made it imperative to study the whole, or a major part of the population from which this sample was drawn.
Assuming that grade 9, the highest grade of the primary school, had the largest percentage of juveniles with drug use and abuse, which has been proven to be correct, Herulf chose to study all individuals of grade 9 in Stockholm. These pupils were on an average 16 years old.
After a pilot study in two schools the study in grade 9 was conducted on one and the same day all over Stockholm, the 26th of April, 1967. The pupils had to answer a questionnaire with 15 questions, the anonymity being guaranteed and kept. Those who were sick or absent on that day had to answer later; all answers were obtained by 7th of June, 1967. A total of more than 99 per cent answers were obtained.
When analyzing the answers, out of 4,271 boys 20 had not answered (0.5%), out of 3,991 girls 14 (0.3%).
The sex distribution was 51.6 per cent boys and 48.4 per cent girls.
Further it was found that out of 91 who had not stated their sex 15 had not answered (16.5%). There were two reasons for pupils not stating their sex: ( a) they had forgotten to mark that point, or ( b) they were afraid that by stating their sex their identity might be disclosed, in spite of anonymity being guaranteed and kept.
Thus a total of 8,353 pupils had partaken in the survey.
Offered drugs: When asking how many of the children had been offered drugs, it was found that every third pupil (36%) had been offered drugs, half of these on a single occasion, and half on several occasions, thus a higher figure than in the Sweden school-study (15.9%).
Drug use
When questioned how many of the pupils had taken drugs themselves - in this context denoting cannabis, opiates, stimulants, LSD, hypnotics or tranquillizers - it was found that 21.5 per cent of the boys (918 individuals) and 16.2 per cent of the girls (646 individuals) had taken drugs on one or several occasions, or 18.9 per cent of all (table 9).
In the group of 91 who had not stated their sex 26, or 29 per cent, had taken drugs, which might be one indication of the fear that giving one's sex might lead to identification.
Drug use among 8,353 school children in primary school grade 9 (16 years) in Stockholm
(Point prevalence study on 27 April 1967)
Boys n = 4,271
Girls n = 3,991
No sex given n = 91
Total n = 8,353
Intensity of drug use
Per cent
Per cent
Per cent
Per cent
|1 time
More than 10
Per cent drug users of all pupils
Figures in heading give total number of individuals questioned in each group.
The data are obtained from Dr. B. Herulf, Children's Welfare Board, Stockholm (manuscr.).
Thus a total of 1,590 pupils in grade 9, or 18.9 per cent of all, were found to have used drugs.
The detailed analysis to follow, among other things showing the distribution of various factors on the two sexes, is based on 8,262 individuals, 4,271 boys and 3,991 girls, with a total of 1,564 drug users.
Intensity of drug use
With regard to the intensity of drug use it was found that four fifths (81.4%) had used drugs 1-10 times, and one fifth (18.6%) more than 10 times (table 9).
The duration of use was correlated to the intensity. Among those having used drugs 1-10 times, 20 per cent had used drugs for more than one year, against 42 per cent of those who had taken drugs more than 10 times (fig. 12).
Another way to obtain an understanding of the intensity was to see how many of the drug users had actually taken drugs during the month preceding the interview, and how frequently.
Among those with a lower intensity of use, having taken the drug 1-10 times, a total of 23 per cent had taken drugs during the preceding month; among those having taken drugs more than 10 times, no less than 74 per cent had taken drugs during the preceding month.
Those with the higher intensity also used drugs more frequently the preceding month (fig. 13).
Pattern of drug abuse
When analyzing the pattern of the drugs taken by those using drugs during the preceding month it is noted
Fig. 12. Duration of use - or abuse - of drugs (" Knark ") for non-medical purposes among all school children of grade 9 (16 years) of the public school system in Stockholm (n = 8,262, 4,271 boys and 3,991 girls).
Out of these 918 boys (or 21.5 per cent) and 646 girls (or 16.2 per cent) were drug abusers, corresponding to 19.0 per cent of all school children in Stockholm in grade 9.
Original data obtained from manuscript by Dr. G. Herulf, Children's Welfare Board, Stockholm. The material was divided according to intensity of use, 1-10 times, and more than 10 times. that many individuals had used more than one type; therefore the sum of percentages is over 100.
The majority, 81 per cent, had smoked cannabis. No less than 26 per cent had used stimulant drugs - out of these the greatest part, or 73 per cent, phenmetrazine (e.g. Preludin), the rest methylphenidate (e.g. Ritalina). Opiates had been used by 6 per cent, 5 per cent stated they had taken LSD, and the rest, 9 per cent, had used other drugs, e.g. hypnotics and/or tranquillizers (table 10).
Fig. 13. Frequency of use of drugs during the month preceding the interview by school children of grade 9 in Stockholm. Cp. fig. 12.
When analyzing possible differences between the two groups of drug users, those having taken drugs 1-10 times and those >10 times, a difference in choice is noted.
Whereas cannabis was smoked by 77 per cent and stimulant drugs were taken by 9 per cent of those with the lower intensity of use, cannabis was smoked by 87 per cent, and stimulants were taken by no less than 51 per cent of those with the higher intensity of use.
The same difference is also seen with regard to other drugs, especially with regard to opiates, being used by 3 per cent of those with the lower intensity against 9 per cent by those with the higher intensity, and LSD, used by 2 per cent in the lower intensity group against l0 per cent in the higher.
Thus besides using stimulant drugs to a higher extent, the combined use of different types of drugs is typical of the group with the more intense habits (table 10).
Modes of administration
These findings are reflected in the pattern of mode of administration. (Due to some individuals taking several kinds of drugs the sum of the percentages is more than 100.)
Among those having taken drugs 1-10 times 91 per cent smoked, almost 3 per cent injected drugs, and 11 per cent took drugs by mouth.
A different pattern is seen in those having taken drugs more than 10 times: 85 per cent smoked, no less than 19 per cent injected drugs, and 38 per cent took drugs orally.
Drug use among school children in grade 9 (16 years) in Stockholm
(Point prevalence study on 27 April 1967)
Survey of the drugs used during the month preceding the interview
Intensity Boys
Intensity Girls
Intensity All
1-10n=167 (n = 158)
>10n=131> (n = 238)
1-10n=164 (n = 165)
>10n=89 (n = 144)
1-10n=331 (n = 323)
>10n=220 (n = 382)
All n=551 (n = 705)
Hypn. + Tranq
Numbers in heading = number of individuals;
Numbers in brackets = number of drugs taken (several drugs in same individual);
Percentage figures in last column based on individuals.
The data are obtained from Dr. B. Herulf, Children's Welfare Board, Stockholm (manuscr.).
First choice
It seems that the pattern of administration is predetermined to an extent by the choice of the drug to which the individual was first introduced.
Stimulants were the "introduction" drug more often in the group with more intense use, in 12 per cent, against 7 per cent in the group with the less intense use. The same was true about opiates and other drugs, being 5 and 2 per cent respectively. These differences were more marked in girls than in boys.
Comparison between schools
In order to find some of the factors playing a role in the development of drug use and abuse a comparison was made between two schools, being at the two extreme ends of the scale. In school No. 28 a total of 9 per cent of the pupils stated that they had used, or abused drugs, against 40 per cent in school No. 46.
A great number of sociological background data were studied in order to see whether any significant factors could be detected.
Most of the factors studied in the two groups coincided well within the limits of error - the standard error being 2-4 per cent in the percentage figures given. There was a good agreement with regard to earlier or present somatic or nervous diseases, smoking habits, drinking beers and wines, and sociability, e.g. having friends.
The main differences between the two schools were seen with regard to choice of scholastic line, home conditions, use of distilled spirits, connection with teen-age groups of various types, contact with other drug users, and contact with youth boards (see table 11).
The pupils in school No. 28, with the lowest incidence of drug use, 9 per cent, had chosen subjects leading to gymnasial or theoretical studies, whereas the pupils of school No. 46, with the highest incidence of drug use, 40 per cent, to a great extent had chosen a practical line.
As regards the parents of children in school No. 28, five per cent were divorced - which corresponds to the average for the population - against 22 per cent in school No. 46, thus a 4-fold increase; 41 per cent of the parents of the pupils in school No. 28 belonged to social group I - the highest group - against 5 per cent in school No. 46; 43 per cent of the mothers in school No. 28 had work - against 60 per cent in school No. 46.
Forty-two per Cent of the pupils in school No. 28 drank spirits, against 63 per cent in school No. 46.
Of the pupils in school No. 28, 11 per cent called themselves "mods" and 5 per cent had had contact with the Youth Board, against 25 per cent "mods" in school No. 46, and 13 per cent who had had contact with the Youth Board.
Drug use among school children in grade 9 (16 years) in Stockholm
( Point prevalence study in April 1967 )
Comparison of two different schools, being extremely different with regard to use of narcotic drugs
School 28 (n = 151)
School 46 (n = 140)
Has taken narcotic drugs:
Yes: 1-10 times
>10 times
Choice of scholastic line:
Gymnasial line
Theoretical line
Practical line or other
Family background:
Lived with both parents
Parents divorced
Parent's social group (I, II, III)
|41, 38, 21
|5, 49, 44
Own background:
Somatic diseases
Nervous diseases
Contact with youth agency
Has a friend
Going steady
Member of group
"Rockers" .
"Mods" .
Strong beer
Has been intoxicated
The data are obtained from Dr. B. Herulf, Children's Welfare Board, Stockholm (manuscr.).
In school No. 28 36 per cent knew somebody of the same age using drugs, and 10 per cent somebody in the same class, whereas 73 per cent of the pupils in school No. 46 knew a drug user, and 41 per cent in the same class, thus a 2- to 4-fold increase.
When comparing the findings of this study and the one conducted by the National School Board all over Sweden, a number of conclusions can be drawn.
The pattern of drug use in the individual user among these 16-year-olds is essentially the same, cannabis smoking dominating the picture, but a substantial proportion also using stimulant drugs, phenmetrazine dominating, and quite a few already in this age taking drugs by injection. Further, it is noteworthy that some have also started abusing hallucinogens, especially LSD.
The proportion of drug users is, however, much higher in Herulf's Stockholm Survey, 18.9 per cent, than in the National School Board's Sweden survey, 3.5 per cent taking or having taken drugs.
The discrepancy may be due to a number of reasons, the most obvious one being that the incidence of drug abuse in Stockholm must be much higher than in other cities; among other indices, this is corroborated also by the exceedingly high proportion of sales of syringes in Stockholm as compared to that in other cities; 24 per cent of all syringes sold were bought by juveniles under 20 years of age.
Further, it may be added that the Stockholm area was under-represented in the Sweden survey, only 965 pupils in the Stockholm area being included, which represents 0.7 per cent of all pupils in Stockholm, against 130,061 in Sweden out of 1,172,000 pupils, or 11.2 per cent in the Sweden study ( vide supra).
Thus the two studies illustrate two different aspects. The Herulf study shows the conditions in Stockholm in grade 9, where the incidence is the highest of all classes studied. The Sweden survey, when more is known about its representative validity, seems to reflect the over-all picture.
Herulf's study is being continued in several directions in an attempt to disclose the interplay between factors of importance in the development of drug use among juveniles, from an epidemiological as well as a general preventive point of view.
(iii) Case studies of juvenile drug abusers
A detailed study on juvenile drug abusers was carried out by Herulf and Sunesson (1967). They studied all cases under 21 years of age, referred during a one year period, 1 July 1965 - 1 July 1966, for abuse of narcotic drugs to the Children's Welfare Board in Stockholm.
The material comprised 169 juveniles, 95 boys and 64 girls, which is a high number when considering that up to 1958 there were only single cases of drug abuse among juveniles in Stockholm.
The Children's Welfare Board serves a number of different institutions. The material studied was referred from "youth homes" and "youth treatment schools" in 33 per cent of the cases, from the Roslagstull Hospital - for infectious hepatitis- in 16 per cent, from psychiatric hospitals in 15 per cent, and outpatient clinics in 6 per cent, from physicians municipally engaged or in private practice in 14 per cent, and from other sources in 16 per cent.
The mean age was 17.9 years. The boys were 18.6 years on an average, the youngest being 15 years, whereas the girls were younger, 16.9 years on an average, the youngest being 14.
With regard to the parental background the father was dead in 11 per cent, and the mother in 4 per cent of the cases; 39 per cent of the parents were married at the time of interview, but the marriage was disharmonious in 35 per cent. In no less than 41 per cent of the cases the parents were divorced - against 2-3 per cent in the normal population.
In 20 per cent of the cases the children were in conflict with their parents.
Among the fathers psychic disturbances were noted in 9 per cent, alcohol abuse in 31 per cent, drug abuse in 4 per cent, and criminal or asocial behaviour in 11 per cent.
In the mothers psychic disturbances were seen in a higher proportion, in 23 per cent, alcohol abuse in 6 per cent, drug abuse in 1 per cent, and asocial behaviour in 2 per cent.
With regard to the background of the juveniles themselves 58 per cent had shown behaviour disturbances (61% of the boys and 56 % of the girls) and 12 per cent had had neurotic traits; no earlier disturbances were known in 24 per cent of the cases (in 19% in boys and in 31% in girls).
No less than 36 per cent had had alcohol problems (43% of the boys against 26% of the girls) and 21 per cent had been "sniffing ", i.e. inhaling volatile solvents (29 % of the boys against 9 % of the girls).
Earlier criminal activity was noted in 42 per cent of the material (in 62% of the boys against 16% of the girls).
Mental state
With regard to the mental state at the time of the examination, "acting-out" behaviour dominated the picture in 24 per cent, and lack of discipline, negativism and defiance were seen in 18 per cent. No desire to work, passive behaviour and no stimulus to act was evident in 43 per cent, and non-attendance at school, vagabondage, and escape from institutions were noticed in 39 per cent.
Anxiety, feelings of insecurity and attacks of alarm were seen in 25 per cent, and increased sensitiveness, and shyness in 15 per cent.
Confusion, paranoid and schizoid symptoms, depression, suicidal attempts and various phobias were seen in 18 per cent of the patients.
Promiscuity was evident in 25 per cent, prostitution, including homosexual contacts, in 7 per cent. Theft was seen in 16 per cent, and pilfering in 5 per cent.
The intelligence quotient estimated in 102 individuals was within normal limits, 50 per cent being between 90 and 110, and 24 per cent over 110.
Pattern of drug abuse
With regard to the pattern of drugs abused a continuous abuse, meaning administration of narcotic drugs several times a week for long periods of time, was seen in 71 per cent, in the rest of the cases the abuse was of a more occasional nature.
With regard to the types of drugs abused most of the individuals studied abused different types of drugs, not only drugs of the same principal group with the same general action, e.g phenmetrazine and methylphenidate, but also drugs with different actions, e.g. morphine and stimulants, or stimulants and hypnotics or tranquillizers; the sum of the percentages given is therefore more than 100 (table 12).
Stimulant drugs dominated the picture and were abused in over 90 per cent of the cases, phenmetrazine being the most common one (81%), methylphenidate coming next (36%), amphetamine being used only occasionally (6%).
Pattern of drugs abused in juveniles
Hypnotics, tranquillizers.
Adapted from study by Herulf and Sunesson (1967) on 169 juveniles, referred to the Children's Welfare Board in Stockholm 1 July 1965-1 July 1966.
Injection of drugs in 94 per cent of the boys and 77 per cent of the girls.
Mean age: Boys 18.6 years, girls 16.9 years.
From: Herulf and Sunesson, Läk. tidn. 1967, 64:1936.
Opiates were injected in around 9 per cent of the cases.
About one of five (18%) admitted smoking cannabis, whereas in this material only 1 per cent had used LSD.
Hypnotics and tranquillizing agents were abused by about one tenth.
Not less than 94 per cent of the boys and 77 per cent of the girls had administered the drugs by injection, a very high proportion.
With regard to duration the abuse had lasted for more than one year in 20 per cent of the cases, 6-12 months in 23 per cent, 3-6 months in 26 per cent, and less than 3 months in 27 per cent; no data were available in 4 per cent.
The average duration of the drug abuse was over 6 months.
No less than 50 per cent of all individuals studied had had inoculation hepatitis, due to lack of even the simplest elements of hygiene when injecting the drug. The same needles and syringe were used by different persons, the drugs being dissolved in whatever water that was available, and injections were made right through clothing, no disinfection whatsoever being applied, whether when administering the drug subcutaneously, intramuscularly or intravenously.
Herulf and Sunesson comment on these findings in expressing their astonishment that so many boys and girls could go around for months and even years with an intense drug abuse without it being noticed. One reason may be that these children came from family conditions which were very complicated and led to the parent(s) not being able to, or not managing, or not willing, to take interest in the activities of their children, this in many cases also being strengthened by animosity between parent and child.
This study is now being extended to a survey of every case of juvenile drug abuse referred to the Children's Welfare Board. A team of specialists is engaged in this work, including psychiatrists, psychologists and social workers; no results are yet available.
(iv) Children's Welfare Board
Statistical data from the Children's Welfare Board in Stockholm were made available for 1964, 1965 and the first three quarters of 1966. The material, comprising a total of 4,014 cases of abuse, was studied by the Narcotics Drug Committee (SOU 1967:25).
Cases of abuse of alcohol, narcotic drugs and solvents in Children's Welfare Board, 1964-1966
All clients
% (3 quart)
The referral to the Board is based on social and medical maladjustment. In the case of alcohol abuse the condition must have prevailed for a long period of time, up to several years, whereas with regard to drugs or solvents the abuse may have lasted for shorter periods of time.
Pattern of abuse. Abuse of alcohol was seen in 3,447 individuals, or 85.9 per cent of the total, abuse of narcotic drugs in 212, or 5.3 per cent, and abuse of solvents by inhalation in 355, or 8.8 per cent. The distribution during the three years in study is given in table 13.
The mean age was 17.9 years among the alcohol abusers, 17.5 years among the narcotic drug abusers, and 15.3 years among the solvent abusers.
Age: The pattern of abuse varied between the various age groups. Inhalation of solvents was dominant in the 10-15 year group, drug abuse in the 15-18 year group, and alcohol in the 18-21 year group (fig. 14).
Trend: The trend over the period studied is shown in figure 15. It is obvious that whereas the number of cases of abuse of solvents has decreased over the years, especially in boys, and the number of alcohol abusers has fluctuated considerably, with a possible trend down-wards, the number of drug abusers is increasing, both for boys and gifts (fig. 15).
The same tendency is also seen in the number of these cases compared to the total number of cases handled by the Board.
The total number has been rather constant during the last few years, averaging 1,000-1,200 boys and 500-600 girls per quarter.
The proportion of alcohol abusers has fluctuated considerably in boys, with a slight decrease, from around
23 per cent to 20 per cent in boys and around 6 per cent in girls.
The proportion of solvent abusers has decreased in boys, from 4 per cent of the total to less than 2 per cent, and in girls from 1.4 per cent to less than 1 per cent.
The proportion of narcotic drugs abusers has, however, increased, from 0.2-0.4 per cent in 1964 to 1.7 per cent in boys in 1966, and from 1 per cent to 4 per cent in girls.
Thus the decrease in abusers of solvents is substituted by a corresponding increase in abusers of narcotic drugs. The reasons for this change are not yet clarified, one reason may be that the same individuals switch from one type of drug: to another, depending on the fashion in their milieu.
Sex differences: With regard to possible differences between boys and gifts it was noticed that whereas abuse of alcohol and of solvents were more frequent among boys, narcotic drug abuse was more frequent among gifts. The same trend is also seen in youth treatment schools.
(v) Youth treatment schools
Delinquent juveniles may for a certain period of time be sent to "Youth Treatment Schools ". The stay in this special type of" school" substitutes in many cases a sentence for criminal acts that in older individuals might have led to confinement in prison.
In order to estimate the number of drug abusers among these pupils a point prevalence study was made on a certain day in June 1965, and again repeated on the same day in 1966. The results have been surveyed by the Narcotics Drug Committee (1967:25).
Fig. 14. Distribution of alcohol, solvents or narcotics abused by children referred to the Children's Welfare Board in Stockholm 1964-1966.
Alcohol abusers (n = 3,447) solvent abusers (n = 955) and abusers of narcotic drugs including hypnotics and/or tranquillizers (n = 212).
Out of a total of 1,748 pupils in 1965, 8.2 per cent were found to be drug abusers, and 11.5 per cent out of 1,711 pupils in 1966 (table 14).
There was a large difference in this respect between the sexes. The figures for boys were 4.1 and 6.1 per cent for 1965 and 1966 respectively, against 16.3 and 23.0 per cent for girls; the total number of boys for these two years was 1,160 and 1,162, and 588 and 549 girls (table 14).
Fig. 15. Distribution of alcohol, solvents or narcotics abused by children referred to the Children's Welfare Board in Stockholm 1964-1966.
Alcohol abusers (n = 3,447), solvent abusers (n = 355) and abusers of narcotic drugs including hypnotics and/or tranquillizers (n = 212).
The considerably higher incidence in girls was statistically highly significant.
One reason for this difference may be the indication for referral to this type of treatment, especially with regard to girls.
With reference to sociological background data a study was made by the psychologist K. Gordan of the National Social Board (Socialstyrelsen), carried out on all drug abusers treated on a certain day, 8 June 1966. This sample comprised 41 boys and 83 girls. The results were compared to a control material of 475 pupils, not showing signs of drug abuse. The study was reviewed by the Committee (1967:25).
Drug abusers among clients in Youth Treatment Schools
(Point prevalence study on same day June 1965 and 1966)
Boys Abusers
Girls Abusers
Total Abusers
% of all
% of all
% of all
June 1965
June 1966
Adapted from Narcotics Drug Committee Report I (1967:25).
The drug abusers had on a whole had a more difficult growth period, with a higher proportion of divorces, mental disease and alcoholism among the parents, more changes in educators, higher proportion of foster homes etc.
According to the results of psychological tests they were more intelligent than the average. Among the girls there were fewer signs of asocial behaviour, promiscuity and unwillingness to work than in the non-abuse group. The girls had, however, more often been away from school or left home.
Among the boys there were fewer criminal acts than among the rest of the pupils. Alcohol abuse, inhalation of thinner solutions and strong association with asocial gangs was, however, more frequent.
The drug abusers seemed to have been less well adjusted to the rules of the school, they caused problems of various kinds and often continued to abuse drugs and/or inhale solvents.
According to Gordan the inclination to "flight ", or escape, seems to be characteristic of drug abusers, rather than the "abusive" and agressive behaviour typical of so many of the other interns.
Drug abuse among alcoholics
A point prevalence study was made on a certain day, 10 June 1966, on inmates in institutions for legal confinement and treatment of alcoholics (alkoholistanstalter). The results are based on information from the personnel; no checks were made to confirm the diagnosis. The results were surveyed by the Narcotics Drug Committee (1967:25).
Out of a total of 1,924 inmates treated on that day a total of 308, or 16 per cent, were known to abuse drugs. This figure is definitely a minimum figure; some pilot studies are in the planning stage to estimate the percentage of drug abusers among alcoholics in groups of alcoholic patients in various stages of severity.
Alcohol, drugs and road traffic
One area of society where drug abuse may play a substantial role is in road traffic. An increasing number of individuals take drugs in therapeutic doses by self-administration or on prescription for medical purposes, or in excessive doses for non-medical purposes. A number of individuals also take alcohol, whether in moderate or in excessive amounts, and an increasing number of individuals drive, the ratio of motor vehicles to inhabitants in Sweden approaching 1 to 4. Therefore the chances of a combination of drug taking and driving, with or without the intake of alcohol, are increasing.
A large series of studies on the effects of alcohol under various conditions have elucidated the role of alcohol in road traffic. One result of this knowledge was the introduction in Sweden of severe laws concerning drunken driving, the first being introduced in 1934. The present law - from 1957 - states it is unlawful to drive with a blood alcohol concentration over 0.5 per mille (0.5 %, 50 mg%).
The role in traffic of drug intake alone or in combination with alcohol intake is, however, still not fully elucidated. One part of the work of the Narcotics Drug Committee is concerned with the development of methods to analyze CNS-active drugs and their metabolites in blood and urine, among others to serve as a basis for determination of the effect of drugs on various CNS-functions, including driving in an attempt to estimate the influence of different drugs on driver behaviour and road accidents.
Drugs and "drunken" drivers 1964-1966
Bonnichsen and co-workers have studied results of analyses from the Toxicological Department of the National Laboratory of Forensic Chemistry; a survey of the main results has been given by the Narcotics Drug Committee (1967:25).
In 467 cases, or in 1.2 per cent out of a total of 39,900 cases of drunken driving, studied during 1964-1966, intake of drugs was suspected as the cause of the intoxication, the impairment in driving or the disturbed behaviour.
In 212 cases, or 0.5 per cent of the total, the presence of various drugs could be determined. In the other cases no determinations were carried out, due to insufficient material (e.g. urine sample too small or lacking), or not completed due to other reasons. In 198 of these cases a quantitative analysis was possible. Among the drugs hypnotics, sedatives and tranquillizing agents dominated the picture, being found in 81 per cent of all cases, the hypnotics in 43 per cent, tranquillizers in 28 per cent and salicylates in 10 per cent.
Volatile solvents were found in 4 per cent.
Narcotic drugs were found in 15 per cent. Among these the stimulant drugs dominated, phenmetrazine in 9 per cent, amphetamines in 4 per cent and methylphenidate in 1 per cent. Opiates were seen in 1 per cent.
In one-tenth of all cases several drugs were taken in combination, and in one-fourth the drug-taking was combined with alcohol intake.
The concentrations found made it likely that the doses taken of the various drugs were overdoses.
When questioned at the police examination or at the time of the doctor's examination about 14 per cent of all drivers admitted having taken drugs; only in 1.2 per cent of all cases of drunken driving, however, drug intake was suspected as the reason for the deviant behaviour. One reason for this discrepancy might have been that the majority of those admitting having taken drugs or medicaments had taken them such a long time before driving, and in therapeutic doses, that the drugs had already left the body or had no longer an effect on the driving.
The 1-2 per cent incidence found by chemical analysis of drug-taking in drivers suspected of "drunken driving" may thus represent part of those having taken drugs in excessive doses in connection with the actual driving.
Drugs and" drunken" driving in the Stockholm area
A special study was carried out by Kvarby (1967) on the request of the Narcotics Drug Committee of all cases of impaired or "drunken" driving in 1966, in which "tablets" or "pills" were suspected as the cause of the impairment, in order to study the legal aspects and the differences between the Stockholm area and the rest of the country. Some results were reviewed by the Committee (1967:25), and others given in the present survey are quoted from Kvarby's manuscript (unpubl.).
A total of 239 cases from all over Sweden were found in which blood and/or urine samples had been sent to the Toxicological Department of the National Laboratory of Forensic Chemistry and analyzed for presence or absence of CNS-active substances. These samples represented about 1.3 per cent (239/18,000) of all samples from cases of drunken driving analyzed at the laboratory during 1966.
The 70 cases occurring in the Stockholm area in 1966 were further studied with regard to types of drugs found; out of these the presence of drugs was substantiated by the chemical analysis in 42 cases. Out of these 42 cases in the Stockholm material more than half, 24 cases, or 57 per cent, had taken stimulant drugs. The proportion of stimulant drugs found in 108 cases with positive chemical findings from the rest of the country was only 8.5 per cent (9/108). The proportion in 1966 for the whole of Sweden was 22 per cent (33/150), against 14 per cent during the whole period 1964-1966.
The abuse of stimulant drugs in connection with driving was thus concentrated in the Stockholm area, showing a 6-7-fold increase in frequency, when compared with the rest of the country. The rest of the "tablet-intoxicated" drivers abused mainly hypnotics and sedatives, opiates being found in single cases only. When analyzing the background of these "tablet-intoxications" it was found that 62 per cent of the Stockholm cases had a criminal record - against 34 per cent among those outside the Stockholm area. The average for the whole country among "tablet-intoxications" was 42 per cent.
It was observed that 35 per cent of these drivers with "tablet intoxication" in the Stockholm area were noted as abusers of drugs other than alcohol. It must be added that the amounts of the various drugs found corresponded to an intake of large doses, far in excess of those used for therapeutic purposes.
A number of studies are planned to assess the incidence and prevalence of drug users and abusers in the general population. So far only preliminary data are available.
General population
In a survey carried out in 1965 by the Swedish Broadcast-Television Corporation a total of 593 individuals were interviewed. One group of 282 persons were seen in connection with a TV-series on narcotics, and one control study on 311 persons was made after the series, both being random samples of the adult population in Sweden. The study was reviewed by the Narcotics Drug Committee.
A total of 72 persons (32 + 40), 32 in one and 40 in the second group, or 12 per cent of all stated they had come in contact with persons who had used narcotic drugs. Thirteen (6 + 7) or 2.2 per cent, had had direct personal experience; whether the drug had been taken occasionally or for a longer time was not known.
Adolescents in Stockholm 16-25 years old
A second study has been started by G. Inghe as a part of a large survey, based on interviews of a representative sample of adolescents in Stockholm aged 16-25 years. A total of 973 persons have so far been interviewed, about 70 per cent of the total group selected. The preliminary data were reviewed by the Narcotics Drug Committee.
Twenty-five per cent of the boys ( n = 505) and 10 per cent of the girls ( n = 468) had been offered narcotic drugs ( "knark" in the local jargon). Of the boys 60, or 12 per cent, had themselves used narcotic drugs at least once, of the girls 14, or 3 per cent. Eleven boys, or 2.2 per cent of all, or every fifth (18%) of the users, had taken the drugs 10 times or more; the corresponding figures were 2 girls, or 0.4 per cent of all, or 1.4 per cent of the female users.
The figures for both sexes would be 74 users, or 7.6 per cent, and 13 frequent users, or abusers, or 1.3 per cent.
It is too early to venture an estimate of the total number of users and abusers in Sweden; these, and other planned studies must be carried out first until enough data are obtained to be used as a basis for a reliable estimate of the incidence and prevalence in the general population. A project has been discussed to carry out some of these studies on a Scandinavian basis, allowing a comparison between the four sister countries. Such a study would increase the possibility, among others, of evaluating the role of various background data in the phenomenon of drug abuse.
[ To be concluded]
This study will be concluded in the next number of the Bulletin on Narcotics which will carry Part II with the following chapters:
III. Medical complications; IV. Drug identification, metabolism and effects; V. Therapeutic approaches; VI. Turnover of drugs and syringes; VII. Law enforcement; VIII. Factors of importance for the emergence of drug dependence; IX. New elements in the pattern of drug abuse.
The first Professor of Medicine at the Karolinska Institutet School of Medicine.2
The Swedish name is "Committee on Treatment of Narcotic Addiction ", in this context being translated to "The Narcotics Drug Committee ".3
The comparison is based on weighted means.4
"Central stimulants" or stimulants in this context denote amphetamines, phenmetrazine and methylphenidate.5
"Opiates" in this context denote opium, morphine and other phenanthrene ("morphine")derivatives as well as synthetic morphine-like drugs.