Drug Addiction and the Practice of Public Health in Late Imperial and Early Soviet Russia

The People's Commissariat of Public Health's circular note N. 2409 of 18 December 1924, similarly, prescribed rules for distributing, storing and selling drugs and prohibited private companies from producing addictive medicaments after 1 January 1925 Ibid. L. 327-328 rev.. Lengubzdravotdel, meanwhile, issued its own circular note N. 30 on 14 January 1925, containing “instructions regarding the procedure for receiving, selling, keeping and accounting for such drugs as opium, opium extract, pantopon, cocaine and its salts, morphine and its salts, diacetylmorphine (heroin), hashish and similar drugs (marijuana) etc” TSGASPb. F. 4301. Op. 1. D. 1532. L. 117-118.. Specific regulations were issued for the sale of drugs from pharmacies subordinate to the regional public health section `Responses of pharmacies to the circular note with details of persons responsible for the storage of drugs are presented in: TSGASPb. F. 4301. Op. 1. D. 1532. L. 113-116.. In the second half of 1925, further regulations limited drug deliveries from the Administration of Medical Supply and Trade (Gubmedsnabtorg) to chemico-pharmaceutical factories, pharmacies and hospitals TSGASPb. F. 4301. Op. 1. D. 2538. L. 1-2.. While these documents often lacked any innovative measures, and largely repeated earlier, even pre-revolutionary regulations Rossiiskaia farmakopeia. P. 541-546; O poriadke otpuska. P. 1030-1031., their chronological “thickness” indicates that the struggle against drug addiction had also intensified in the medical realm proper.

Contemporaries criticized the new measures as unenergetic and unsystematic Futer D. S. O detiakh-narkomanakh. P. 62., but the intensification of control can indeed be traced through archival documents. For example, the documents from Leningrad public health offices in the Central State Archive of St. Petersburg, specifically, various inspection reports by Lengubzdravotdel employees Gol'dberg and Furman, show that after 1925 the conditions of drug sale from the city's pharmacies were intensively scrutinized TSGASPb. F. 3215. Op. 1. D. 276-278, 283-285, 289, 290; TSGASPb. F. 4301. Op. 1. D. 729-748, 1519-1527, 1938-1949.. Almost every inspection report contained a list of drug receipts and expenditures, which revealed the wasteful loss of addictive drugs when they exceeded the allowed norm of 4-5 % TSGASPb. F. 4301. Op. 1. D. 729, L. 174-174 rev.; TSGASPb. D. 733. L. 147-149; TSGASPb. D. 734. L. 185-185 rev.; TSGASPb. D. 737. L. 62-62 rev.; TSGASPb. D. 743. L. 81 rev. -- 82; TSGASPb. D. 745. L. 110 rev. -- 111; TSGASPb. D. 747. L. 49 rev. -- 50; TSGASPb. D. 745. L. 122.. These documents often contain critical remarks regarding storage of addictive drugs, such as the use of unauthorized weights TSGASPb. D. 729. L. 173., the storage of addictive drugs alongside regular ones in an unmarked or unlocked cupboard TSGASPb. D. 731. L. 68 rev.; TSGASPb. D. 733. L. 145 rev., and so forth. In some cases, however, the inspectors were completely satisfied with drug storage facilities TSGASPb. D. 734. L. 184; TSGASPb. D. 737. L. 61-61 rev.; TSGASPb. D. 743. L. 81 rev.; TSGASPb. D. 745. L. 110-110 rev.; TSGASPb. D. 747. L. 49..

Sometimes inspection reports contain explicit information about illegal drug-related activities at Leningrad pharmacies. For example, inspector Goldberg investigated a case in the pharmacy No. 41 at Vera Slutskaia hospital, in which supply pharmacist E. E. Levdikov stole 10 grams of morphine, 25 grams of cocaine and 35 grams of procaine TSGASPb. F. 4301. Op. 1. D. 729. L. 175.. Another incident concerned a major misuse of drugs at pharmacy N. 35 at the Institute for Maternity and Infancy in June 192 5 TSGASPb. D. 748. L. 186..

Intensified pharmaceutical control, however, was only one aspect of the struggle against drug addiction. Large sums of money were also assigned to medical propaganda, sanitary education, and the publication of popular medical literature about the dangers of drugs. Physician Aleksandr S. Sholomovich, for example, painted a bleak picture of cocaine addiction, complete with politicized images of drug dealers and rather hopeless prospects for addicts:

“Dark and unconscious human masses are wandering in the muddy streams of life, looking for the satisfaction of their various necessities; they are met .... by large predators -- cocaine smugglers and the network of their agents, who widely cast their nets and baited hooks for the bounty. Ignorant people blindly put their head in the noose, get the alluring little worm, swallow the hook as well and pay ... with the liquors of their body and the energy of a wounded brain ... perhaps, our story can help the ignorant man avoid the cunning hook that he will reach for tomorrow -- to avoid the noose of cocaine, which neither a loving family nor a psychiatric hospital can untie” Sholomovich A. S. Kokain i ego zhertvy: Nauchno-populiarnyi ocherk. Moscow, 1926. P. 4..

To help save the “ignorant” victims of drug dealers, specialized drug clinics opened in Moscow and Leningrad during the second half of the 1920s. The clinic in Leningrad was founded in September 1926 on the basis of V. M. Bekhterev's Clinical Hospital for Neurotic Patients, the former Pathologo-Reflexological Institute TSGASPb, F. 4301, Op. 1. D. 3414. L. 33. Cf. also documents on district narcologists, the social diseases division of Lenoblzdravotdel, and the Bekhterev Clinical Hospital: TSGASPb. F. 3215. Op. 1. D. 304-308, 310; TSGASPb. F. 4301. Op. 1. D. 2482; TSGANTDSPb. F. 313. Op. 1-1. D. 32, 35, 392.. In March 1927, it was complemented by a permanent Council on the Struggle against Alcohol and Drug Ad- diction Shkarovskii M. V. Sem' imen “koshki”... P. 475., which included such prominent physicians as Vladimir M. Bekhterev, Raisa Ia. Golant, and Nikolai N. Tutolmin. The tasks of the Council included “discussion and elaboration of alcohol and drug abuse issues for preventive medical initiatives ... participation in the organization of sanitary propaganda in this area ... discussion of the organization of campaign against alcohol and drug abuse” TSGASPb. F. 4301. Op. 1. D. 3414. L. 6..

The treatment of drug addicts in Leningrad hospitals, primarily in specialized drug clinics, is naturally an issue of special importance. As mentioned above, treatment was no simple matter. Archival sources reveal, for example, the problems that Russian patients suffering from drug addition faced in the late 1920s: insufficient beds in hospitals, inadequately trained medical personnel, bureaucracy, personal and professional conflicts with administrators, etc TSGASPb. F. 3215. Op. 1. D. 83. L. 3-4 rev.. Morphine addict Evgenii N. Kokh, for example, complained to the authorities that he had had to wait for about half a year before being admitted to the drug clinic and had been “in a state of complete incapacity” for one month after receiving some medication -- only to be discharged and prohibited from re-entering hospital after a quarrel with another patient (whom he described as “mentally abnormal”) and stinging remarks from Golant, the head physician TSGASPb. F. 3215. Op. 1. D. 83. L. 3 rev..

Treatment included calcium chloride, special baths and dipsetic food. Drinking lots of fluid caused diuresis, excessive perspiration, and thus eliminated the drug from the patient's body. Depression and irritancy were evident in addicts during the first 3-6 days, and then resumed after 1-2 months for 1-2 weeks. After this period, physicians usually turned to treatments such as hypnosis and psychotherapy; Evgenii V. Bliumenau particularly noted the effectiveness of these new techniques Bliumenau E. B. Okhmeliaiushchie durmany... P. 61..

For morphine addicts, one problematic issue concerned the speed of withdrawal: should it be gradual or immediate? During 1922-1925, Golant practiced gradual withdrawal of morphine in Leningrad, hoping to soften painful withdrawal symptoms. However, she found gradual withdrawal psychologically just as painful, and turned to immediate withdrawal from 1926. Responding to the new policies of intensified pharmaceutical control, physicians complied with the recommendation to “refrain resolutely” from prescribing any amount of drugs for “non-desperate cases” Golant R. Ia. Problemy morfinizma... P. 31; Bliumenau E. B. Okhmeliaiushchie durmany. P. 61; Kutanin M. P Voprosy teorii i praktiki.. P. 40. Cf. also: Sbornik nevropsikhiatricheskikh rabot, posviashchennyi iubileiu R. Ia. Golant. Leningrad, 1940. P. 13.. They also supported clinical stays lasting as long as several months.

Regarding treatment outcomes, Soviet medical thought during the 1920s found it useful to divide the patients into three groups: (1) occasional users, who had a favourable prognosis, (2) “not full-blown psychopaths” (ne rezko vyrazhennye psikhopaty) whose prognosis was unclear and depended on their social environment since “poverty, desperate unemployment and loneliness” would lead to a relapse, and (3) “severe psychopaths” whose prognosis was nearly hopeless Rapoport A. M. Kokainizm i prestupnost'... P. 48; Golant R. Ia. Problemy morfinizma. P. 31.. In any case, more than 36 % of 133 male opiate patients that Golant observed in the clinic in 1925-1929 left the clinic before the end of the treatment, mostly due to improper behaviour or stormy withdrawal symptoms Golant R. Ia. Problemy morfinizma.. P. 30-31. Golant notes that women were more compliant with the hospital rules, but does not give any figures on their treatment. Women constituted about one-fifth of opiate addicts (Ibid. P. 19).. Taking into account that another 27 % of the patients experienced relapses after 1 to 3 years, we should conclude that, even according to incomplete official statistics, the percentage of cured morphine addicts did not exceed 47 %. Even this figure seems suspiciously high, and in fact should be treated with skepticism. Subsequent drug treatment practice during the 20 ^th and 21^st centuries calls for a more complex approach combining medication, maintenance therapy and relapse prevention. Yet, even in the 1930s such statistics were quietly challenged by other Soviet physicians Kantorovich N. V. Dispansernye nabliudeniia nad morfinistami // Sovetskaia psikhonevrologiia. 1936. Vol. XII, N 3. P. 69-75..

Stalinism and the Treatment of Drug Addiction

Radical economic and societal changes in the early Soviet period and the liquidation of `capitalist' NEP by 1930 were certainly greeted by physicians. However, these measures did not manage to eradicate drug addiction fully. The relative ineffectiveness of proper medical treatment, the non-existence of neuroleptics, and the ongoing politicization of cocaine, opiate and hashish addiction led to the introduction of work therapy. In the 1930s, drug clinics evolved first to medical-labor centers and finally -- to prison camps under the auspices of the NKVD. In Leningrad, work therapy was first introduced in the late 1920s with a medical-labor center with sewing and hosiery rooms for drug-using sex workers. In the early 1930s, however, the center was transferred to the former premises of Alexander- Svirsky Monastery near Lodeinoe Pole, about 240 kilometers away from Leningrad, under the control of the NKVD. Administrators of prison camps saw addicts as a source of cheap labor and began to use them in timber harvesting and agricultural work under the pretext of work therapy Izmozik V. S., Lebina N.B. Peterburg sovetskii... P 124, 131-132, 134.. About the same time, Leningrad Psycho-Neurological Institute, the new name of the Bekhterev Institute, introduced its own hosiery, locksmithery, cobbler's workshop, bookbinder and other shops, as well as an agricultural colony called “Lomaki” in Koporye, about 100 kilometers south-west of the city TSGANTDSPb. F. 313. Op. 1-1. D. 107, l. 6; Kratkaia istoriia Instituta: K 40-letiiu so dnia osnovaniia. Leningrad, 1948. P 36..

Despite the initial plans to kill two birds with one stone (to economize on the labor force and rehabilitate the addicts), both physicians and camp authorities acknowledged the “extremely low efficiency” and “beastly organization” of these institutions. In medical- labor centers addicts complained that they “are not allowed to go to the city.” They continually tried to “run away back to the city” from the “horrifying living conditions” of the former Alexander-Svirsky Monastery Izmozik V. S., Lebina N. B. Peterburg sovetskii. P 132, 134..

It should be noted, however, that the focus on work therapy in the treatment of drug addiction was not peculiar to Soviet institutions. Similar procedures also enjoyed popularity in the West. The controversial Federal Medical Center, sometimes known as the Narcotic Farm, was established in Lexington, Kentucky in May 1935. Partly inspired by the ideas of Thomas Kirkbride, it implemented mental health theories about “moral therapy,” manual labor in a pastoral setting, and deprivation of external stimuli Campbell N. D., Olsen J. R, Walden L. The Narcotic Farm: The Rise and Fall of America's First Prison for Addicts. New York, 2008; Tomes N. The Art of Asylum-keeping: Thomas Story Kirkbride and the origins of American psychiatry. Philadelphia, 1984; Lunbeck E. The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America. Princeton, 1995..

While `therapeutic pessimism' regarding drug addiction largely prevailed, there was also certain optimistic belief in the possibility of cure with the help of a certain miracle drug or technique. By the 1930s it certainly had become clear that the substitutions of morphine for heroin or cocaine (and the other way around) did not work particularly well. However, there were ambitious attempts to introduce other all-curing drugs, as was the case with gravidan -- a substance made from the urine of pregnant women and actively promoted by a Moscow doctor Aleksei A. Zamkov (husband of a famous Soviet sculptor Vera I. Mukhina). In particular, Iosif V. Strelchuk was very enthusiastic about the application of gravidan in the cases of alcoholism and drug addiction. Even though Zamkov's whole idea of `urogravidanotheraphy' had been largely discredited by the late 1930s, Strelchuk managed to pursue a successful career in addiction research and continued administration of gravidan well into the 1940s and 1950s Strelchuk I. V., Obnorskii P P Gravidanoterapiia v bor'be s narkomaniei // Biulleten' instituta gravidanoterapii. 1934. N 1. P. 37-44; Strelchuk I. V., Obnorskii P P., Dudko N. E. et al. Gravidan i problema bor'by s prezhdevremennym odriakhleniem pri alkogol'noi i morfiinoi intoksikatsii // Biulleten' instituta gravidanoterapii. 1935. N 2. P. 42-50; Strelchuk I. V. Klinika i lechenie narkomanii. 2^nd ed. Moscow, 1949. P. 64..

On the other hand, the practice of addiction treatment also challenges our common notion of the Stalinist period as an epoch of total control and intolerance towards social deviations. In Leningrad, Doctor Nikolai V. Kantorovich practiced continued administration of morphine, heroin and opium to opiate addicts well into the 1930s and observed very positive results. In particular, a certain patient Sh., who used to lead a miserable life of a homeless beggar, was able to find a new job in just a few days after he was accepted in the continued administration program. Moreover, he was later promoted as a residence director in a big dormitory (obshchezhitie) and received bonuses twice. Sticking to his daily dose of heroin, he “became 10 years younger”, and even got back in touch with his former wife, who was considering returning to him Kantorovich N. V. Dispansernye nabliudeniia... P. 73.. In my opinion, such cases broaden and change our understanding of the social history of drug addiction, the history of addiction research and treatment, and the Soviet Union under Stalin in general.

Conclusion

Despite physicians' efforts and the relatively generous support of their projects on the part of government authorities, drug addiction in Leningrad did not disappear in the 1930s. Marijuana was rather wide-spread, and there were no special regulations regarding this drug until 1934 Lebina N. B. Povsednevnaia zhizn'... P. 46.. We can also observe cases of drug use in the later period, though obscured by government rhetoric proclaiming the successful eradication of “remnants of the past” For example, drug theft from Lenmetallstroi pharmacy in 1935 (TSGASPb. F. 7384. Op. 2-s. D. 60. L. 250). Cf. also psychiatry syllabi from the 1930s: Arkhiv Severo-Zapadnogo gosudarstvennogo meditsinskogo universiteta im. I. I. Mechnikova, Nauchnaia chast'. D. 23. L. 20, 23, 35 rev., 36, 39 rev. -- 40, 46, 59, 74. See also: Deviantnost' i sotsial'nyi kontrol'. P. 47.. It should also be noted that the “gray market” situation by and large persisted well into the 1930s. The medical demand for opiates rose in 1939 in Northwestern Russia with the start of the Winter War with Finland, and then across the Soviet Union after the Nazi invasion in June 1941.

Mikhail V. Shkarovskii notes that by the mid-1930s the authorities had largely stopped monitoring the drug situation in the country. The social and psychological features of people prone to drug addiction were ignored; the operations of specialized clinics were suspended. Moreover, by the end of the 1930s, the authorities declared that drug addiction, like prostitution, poverty, child homelessness, and so forth, did not exist in the USSR. During this period, it becomes quite difficult to describe and evaluate the situation regarding drug addiction in Soviet Russia generally, and in Leningrad in particular Shkarovskii M. V. Sem' imen “koshki”... P 477..

The marginalization and repression of addicts and the politicization of cocaine and opiate addiction contributed to a strong tradition of stigmatizing drug addicts and drug dealers. Negative attitudes persist in Russian society to this day. The government authority to control the drug market goes unquestioned, even though narcotic policies are often costly, bureaucratic and inefficientme po_r examples of bureaucratic inefficiency from the 1920s, see TSGASPb. F 3215. Op. 1. D. 305. L. 155, 170, 189-189 rev., 209-211, 224. For a general critique of the government regulation of the drug market, see: Nadelmann E. A. Drug Prohibition in the United States: Costs, Consequences, and Alternatives // Science. 1989. N 245. P 939-947..

An evaluation of medical anti-drug measures should acknowledge their relative ineffectiveness in the period of 1914-1924. The second half of the 1920s witnessed the gradual intensification as well as qualitative improvement of these measures. Drug addiction was a relatively small and insignificant problem in comparison with other events of this turbulent period, which explains the substantial delay in addressing the drug problem. In the 1920s, a prosecutor in the Leningrad region, I. A. Krastin, commented on this seeming paradox: “Now these things do not pass unnoticed, but did we pay even the slightest attention to them in 1919?” Khuliganstvo i prestuplenie. Leningrad; Moscow, 1927. By modern standards, however, the medical measures employed in the late 1920s should be evaluated as largely ineffective Some medical papers of the late 1930s also hinted at this ineffectiveness and even argued for the continued administration of the drug to `incurable' addicts and some forms of `harm reduction'. See, e.g.: Kantorovich N. V. Dispansernye nabliudeniia. P 72-74..

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