Medical Science Publication No. 4, Volume II
DRUG ADDICTION AND ALCOHOLISM-PSYCHIATRIC CONSIDERATIONS*
COLONEL ALBERT J.GLASS, MC
This presentation proposes to discuss the problems of alcoholism andnarcotic addiction that occurred among American troops during the Koreanconflict. The writer has no detailed study or statistical data to offer,but rather observations and impressions gained while serving as psychiatricconsultant to the Far East Command on the prevalence of these phenomenaand the degree and manner in which they added a further burden to our medicaland administrative efforts. From this standpoint it can be categoricallystated that alcohol and narcotic offenders constituted a relatively minorproblem in the overall logistical difficulties of the Korean campaign,yet one of constant and ominous concern to commanders, particularly thoseofficers responsible for troops stationed in Japan and rear Korea. Combatunits were far less involved, unless they were held for a lengthy periodin rear areas.
It should be realized that alcoholic liquors and narcotic drugs werereadily available to the Occupational forces in the Far East prior to theonset of hostilities. Tax-exempt American whiskeys and various native spiritswere freely purchasable at less than one-half their usual cost in the UnitedStates. As a result, social drinking at least was quite common among officersand men. Narcotic drugs were also easily obtained at reduced prices inJapan and not infrequent instances of heroin addiction were noted, especiallyfrom soldiers stationed near or at the major seaports of Yokohama and Kobe.
Drug Addiction
With the onset of war on 25 June 1950, there was a rise in militarynarcotic offenders in the Far East Command. The extent of this increasein drug addiction was the subject of an item in the periodical Newsweekof 16 February 1953, which read as follows: "The Defense Departmentreported that in the Far East Command arrests of GI narcotic users or possessorshad more than tripled since 1949. Statistically in 1949, 41 users and 160possessors were arrested. In 1951, 300 users and 415 possessors. No figureswere available for 1952."
*Presented 27 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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Factual data concerning the source and distribution of narcotic drugsin the Far East are contained in a recent publication by Anslinger andTompkins (1). Mr. Harry Anslinger, the senior author, is the UnitedStates Commissioner of Narcotics and American delegate to the UN Commissionon Narcotic Drugs. The book cites a SCAP (Supreme Commander for the AlliedPowers in Japan) report dated 10 March 1952, which states that the totalof heroin seized in 1950 was three times the amount seized in 1949. Theauthors gave convincing reports of investigations, arrests and seizureswhich prove conclusively that all the heroin seized in Japan and SouthKorea originated from Communist China. They furnish documentary evidencethat details names, dates and places of a highly organized Communist effortwhich directs the cultivation, processing and distribution of opium products,particularly heroin.
Further confirmation of Communist activity in the drug traffic comesfrom the fact that 30 to 40 percent of the traffickers arrested in Japanwere Communist Chinese and North Koreans, although these entire groupscomprise only 2 percent of Japan's population. Shipments of heroin weretraced repeatedly from factories in Communist China through North Koreaand Hongkong to Communist leaders in Japan and Communist agents in SouthKorea. The authors conclude that there are two reasons for the large-scaleCommunist participation in the narcotic traffic. First, profits of thissmuggling are utilized to finance Communist activities, both in China andabroad. Second, it is a subtle tool of war designed to undermine the physicaland moral strength of UN troops, and is thus similar to the use of opiatesby the Japanese Imperial Army in its efforts to conquer China prior toand during World War II.
The foregoing data should make apparent the basic cause for the narcoticproblem during the Korean conflict. As before hostilities began, unitsin the vicinity of Yokohama and Kobe had the highest incidence of narcoticoffenders to which the war added Pusan, South Korea. In these areas itwas not uncommon for officers to state that 50 percent or more of men intheir units were narcotic users. Undoubtedly these stories were exaggeratedsince they were not confirmed by the relatively small number of personnelapprehended. Many efforts were made to remedy the situation, particularlyin the Kobe area. Lectures were given to the troops by chaplains and medicalofficers that emphasized the devastating action of narcotic drugs uponthe moral, physical and mental functions of the individual. Undercoveragents of the CID were placed into suspect units but were apparently readilyspotted and obtained little success. Unannounced shake-downs and physicalinspections also gave sparse results. Experience in such physical examinationsindicated that needle scars
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must be looked for, not only in the forearms but also in the feet, legs,buttocks and abdomen. Noteworthy also was the fact that the well knownwithdrawal symptoms were seldom manifest, even when known users were confinedin the locked wards of a psychiatric service. Perhaps in some cases drugswere smuggled in to the addict, as proved in one instance at the 361stStation Hospital. However, a more likely reason for the lack of withdrawalsymptoms can be found in the relative youth of the suspects and the lowdosage of opiates involved. Civilian experience with teen-age addicts hasdemonstrated conclusively that generally these individuals exhibit littleor no distress when confined during drug removal (2).
It is also well known that the intensity of withdrawal manifestationsis dependent upon the quantities of drug ingested. Moreover, there is someevidence to indicate that the withdrawal syndrome is a learned processcompounded out of physical discomfort from physiological dependence andanxiety from psychological dependence. Thus, teen-age users who were sentto the Federal narcotic hospital at Lexington, Kentucky, had severe withdrawalsymptoms in contrast to the mild or no distress displayed by similar youthfuloffenders incarcerated at hospitals such as Bellevue in New York City (3).Presumably association with confirmed and older addicts at the Federalinstitution may have influenced the newcomers to exhibit a heightened responseto drug withdrawal.
The absence of withdrawal manifestations in most of the young soldierusers would indicate that either they were in an early stage of addictionand maintained on small dosages or only indulged in narcotics periodicallyon weekends or at parties. Their diagnosis and confession was most difficultto obtain since only occasionally could possession of drugs or the injectionparaphernalia be proved. Random and well distributed needle scars couldreadily be explained away by the suspect who rarely exhibited the lossof weight or physical stigmata that characterizes the confirmed and olderaddict.
The modus operandi in which addiction arose and narcotics were distributedamong troops remained obscure. Certainly it was most common in locationsof greatest drug availability, where narcotics could be readily obtainedfrom prostitutes, small shops, indigenous night clubs and other placesof entertainment. Units in these areas seemed to accept in a matter-of-factmanner the using of narcotic drugs much as alcoholism is condoned. Vulnerablenewcomers were initiated into the pleasures of opiates by user membersof the unit. Groups of narcotic addicts developed who acquainted each otherwith tricks of avoiding work and detection. Sick call was a made-to-ordermeans of escape from duty and the theft of supplies a relatively easy methodof obtaining needed extra funds. Non-drug users of the unit,
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including high ranking noncommissioned officers, either feared to reportmembers of the strong drug group or came to believe that it was none oftheir affair, since it was a "police" matter. From a culturalstandpoint, the giving of information to the authorities of alleged derelictionsof fellow soldiers or "telling tales" has never been popularand is condemned even by those who ordinarily abide by the rules. Occasionaldeaths resulted from overdoses of opiates, particularly heroin. Other raredeaths by violence or poison were rumored to have occurred to users whoeither threatened to inform on their source of supply or had cooperatedwith the authorities. No doubt stories of this type did much to deter anyprospective informer.
The vulnerability of certain types of persons to drug addiction hasbeen repeatedly noted (4). Generally it is agreed that narcoticaddicts arise from neurotic, immature and antisocial or psychopathic personalities.Obviously, many individuals in these groups are present among soldiersof draft age and are inducted into the Service. Whether they become narcoticusers depends upon the availability of the drug, together with chance assignmentand association with groups that foster antisocial conduct, including theingestion of opiates. Those with the same personality disorders do notbecome narcotic addicts when assigned to the combat zone, or other areaswhere opiates are not available and where the use of narcotics is not toleratedby the group. It was not infrequent to find chronic addicts who had beenusing drugs since their teen-age years. Apparently they had slipped throughthe screen of the induction process with little difficulty by withholdingpertinent information, perhaps with the hope on their part or on the partof their relatives that military service would cure their addiction byremoval from old associates and sources of supply. However, one such addictfrankly stated that he reenlisted and asked for an assignment to Pusanbecause narcotics were far cheaper in this area than in the United States.No doubt these chronic addicts form the nidus from which the narcotic usergroup develops.
Perhaps because the incidence of narcotic addiction in the Far Eastwas not sufficient to constitute a major problem, there was no uniformlegal or administrative procedure for the disposition of these addicts.Local commanders used varying methods. In the Pusan area during the firstyear of the Korean conflict known and confessed addicts could not be undesirablydischarged from the Service as provided for under the provision of AR 615-368,Discharge-Unfitness. Medical recommendations for such a disposition wereinvariably disapproved since it was believed that even an undesirable dischargewould be regarded as a reward and serve as an incentive for others to utilizesimilar conduct in order to return home. It was also argued that narcotic
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addicts should not be returned to the United States and inflicted uponthe civil populace. As a result, the disposition of narcotic users forat least one year in Pusan could only be accomplished by a general court-martialconviction, which required that evidence of drug possession or of usingparaphernalia be obtained. Obviously, such evidence was difficult to secureand in many cases required months of surveillance or detective work. Thusknown narcotic addicts were allowed to continue their spread of the narcotichabit with other illegal behavior, such as the theft of supplies. In Japan,disposition under AR 615-368 was generally permitted. However, often thepsychiatric or medical recommendations were not followed when the individualstoutly denied using drugs and neither withdrawal symptoms nor prominentneedle scars were present.
The relatively few cases that occurred among combat troops (12 werereported for the 25th Infantry Division in one year, and 2 in the 3d InfantryDivision during an 8-month period) arose from chronic addicts whose onlysource of narcotic drugs was medical supplies which they obtained eitherby stealing or by bribing medical personnel. They were discharged by generalcourts-martial or under the provisions of AR 615-368.
In retrospect it may be worth while to consider ways and means of implementingboth the prevention and disposition of military narcotic offenders in overseassituations similar to those that prevailed in the Far East Command duringthe Korean campaign. Any plan must endeavor to control the narcotic trafficor, in other words, to dry up the source. However, such a goal is virtuallyimpossible to achieve in Japan and Korea where the civil population isnot under military control, and especially when traffic in narcotics isskillfully promoted by an organized Communist effort, which uses its preformedpolitical network and communications to effect distribution of opiate drugs.Also the enormous profits involved in the narcotic traffic are a constanttemptation to the unscrupulous and needy components of the population.It is therefore mandatory that measures for the specific protection oftroops be implemented.
Most pertinent in this respect is the importance or significance placedupon the phenomena of narcotic addiction in military personnel. If it isregarded as a relatively minor matter that only occurs in a few degeneratepersons and of little moment in the overall picture of effectiveness andmanpower loss, then narcotic addicts will be handled casually by both officersand men. On the other hand, if narcotic drugs are looked upon as an enemyweapon in the form of a subtle poison or an insidious type of chemicalwarfare, then the using and transmission of opiates becomes of legitimatemilitary concern from a tactical and security standpoint. When this viewpointis dis-
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seminated among troops and confirmed by prompt and stern measures againstmilitary users, possessors or peddlers, a corresponding attitudinal changeby officers and men can be expected. Lectures upon the evils of narcoticaddiction have been demonstrated to be of little value, similar to theirineffectiveness in the prevention of venereal disease. However, when, asin the problem of frostbite, officers and noncommissioned officers wereheld responsible for the number of cases under their command, the incidenceof frostbite promptly and sharply declined.
It is herein submitted that the noncommissioned officers of a unit arethe key personnel who are not only in a favorable position to know whichof their men are narcotic users, but can prevent, disperse or render innocuousthe narcotic group formation that initiates the vulnerable soldier in thedrug habit. It is important that noncommissioned officers of units in areaswhere drugs are available be charged as part of their leadership qualificationswith preventing and eradicating drug addiction as much as they are responsiblefor reporting and eliminating enemy sabotage. The proven addict shouldbe promptly removed from the unit with severe penalties for possessionor proselyting. For suspects, medical findings that indicate the use ofor addiction to narcotic drugs, should be given credence even when possessioncannot be proved, and such individuals should be rapidly removed from theService by an appropriate discharge.
The question of whether an undesirable discharge as under AR 615-368constitutes a reward in an overseas combat theater is not the primary issue;more pertinent is the prompt removal of narcotic users in order to preventthe infection of others. Such a viewpoint highlights the extreme gravityof allowing narcotic users to associate with vulnerable personnel. Perhapsthe confessed or proved narcotic addict should receive a type of dischargewhich carries with it an enforced period of treatment at one of the Federalnarcotic hospitals.
In essence the foregoing proposals are based upon the known fact thatwhen the soldier group does not tolerate or allow certain forms of abnormalbehavior, such conduct either ceases or becomes negligible. When the ingestionof narcotics is linked to cooperation with the enemy and/or consideredas a deliberate attempt to evade duty by the self-injection of an injuriousagent, then a strong motivating viewpoint can be given to officers andmen, insofar as their personnel and command responsibilities are concerned.This function of officers and noncommissioned officers is only a restatementof their traditional role as leaders of men. As such they must providethe vulnerable and non-vulnerable soldiers with better and more sociallyacceptable outlets than narcotic addiction. It is reiterated that noncommissionedofficers have the opportunity and the close associations to know intimately
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the activities of their men. It would be almost impossible for themnot to be aware of the identity of narcotic users in their unit. Therefore,it is vitally necessary that the noncommissioned officer be motivated tostamp out narcotic addiction ruthlessly. Perhaps the current plan to separatethe technician from the noncommissioned officer group is a step in theright direction since then the noncommissioned grade will reflect meaningin terms of leadership ability.
Alcoholism
In considering the problem of alcoholism during the Korean campaign,this paper does not propose to discuss either the evils or benefits ofsocial drinking in moderation. However, there were complications and abusesfrequently observed in the consumption of alcoholic liquors which did createmedical problems and behavioral difficulties that are pertinent to thecontents of this symposium.
As in civil life, the most common alcoholic disorder concerned excessiveintake or alcoholic intoxication. The availability of whiskeys in Japanat reduced cost and the increased tensions of overseas life, along withthe presence of a certain number of combat troops determined to rest andrelax on their 5-day leave in Japan, accounted for an increased incidenceof alcohol overdosage. In most instances the medical problem was insignificant,but there occurred the usual disciplinary infractions of brief AWOL periods,disorderly conduct, fighting, minor injuries, and the like.
The next most frequent disturbance encountered involved irregularlycontinued excess alcohol consumption in individuals who had been previoussocial drinkers. This type of temporary addiction seemed to be a neuroticflight reaction to the stress of overseas separation, frustration in work,guilt or other sources of tension. The resultant loss of efficiency wasall the more unfortunate since officers and noncommissioned officers werenot infrequently involved. Various complications of alcoholism, such asliver disease, transient psychotic disorders, avitaminosis, and in olderindividuals a gradual deterioration in mental functions, brought thesecases under medical jurisdiction. After improvement in the hospital, withphysical restoration, their further disposition posed many difficulties.Return to duty was almost invariably followed by a recurrence of the alcoholhabit, since follow-up psychiatry was not too successful, or even desiredby the person involved. Medical evacuation to the United States was thesimplest method of removing the individual problem from the Theater. However,such an action could be construed as a misuse of medical channels and anaid in the perpetuation on active duty of ineffective personnel, who wereutilizable only in limited or non-stressful assignments.
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An alternative method of disposition was medical recommendation foradministrative action, either under the provisions of AR 605-200, Demotionand Elimination, for the elimination of noneffective officer personnel,or by AR 615-368 for the discharge of undesirable enlisted personnel. Butexperiences in this sphere indicated that there was a general unwillingnessto employ such punitive action against this type of alcohol offender, first,because of the difficult administrative procedure involved, particularlyin the case of officers, and second, because of the accumulated years ofprior effective service achieved by many of these individuals. Obviously,there is no easy solution to the problem. Each case must be individuallyjudged. If neurotic illness is the major cause, medical evacuation, withremoval of stress, is the most reasonable method. Where this type of alcoholismrepresents a repetitive pattern of behavior under even slight stress, administrativeaction is considered to be the proper disposition.
To a lesser extent, a similar problem was presented by the chronic alcoholaddict. This group contained relatively few officers. Most were enlistedpersonnel with various periods of previous military service, whose dutyperformance had been unsatisfactory for one or more years. Such individualswere not particularly affected by situational stress but represented seeminglypermanent behavior patterns which involved both physical and psychic dependencyupon alcohol. Delirium tremens, and other confusional states due to alcoholwithdrawal and avitaminosis, often caused their hospitalization. Frequentlythey were drunk on duty, involved in minor disciplinary difficulties andin general were ineffectual members of their unit. As with most chronicalcoholic addicts, they drank any source of alcohol if regular supplieswere not obtainable. Efforts to remove these alcoholics by medical evacuationwere common. However, unless physical or mental disease was present, theywere returned to their units for administrative elimination. But becausethere were no uniform criteria for such a disposition much time was lostas frequently the individual was retained on duty, and this resulted inrepeated hospitalizations.
A not infrequent type of alcoholic disorder observed, particularly inJapan, concerned individuals with barely latent emotional conflicts inwhom the ingestion of usual or excessive quantities of alcohol producedbizarre conduct of psychotic manifestations. In many of these patientsdissociative phenomena occurred with rage reactions which included excitedand assaultive behavior that required restraint and closed ward management.The following day they generally returned to self-control and professedcomplete amnesia for the events of the preceding day or night. Usuallythey denied excessive alcohol intake
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prior to their disturbed actions, but such denials are difficult tobelieve, since often the blood alcohol level indicated otherwise.
In other and more rare instances a paranoid episode of psychotic intensityresulted during an alcohol bout. Such a case was exemplified by a youngcombat officer who was on a 5-day convalescent leave after a brief periodof hospitalization in Japan. This officer began drinking whiskey with Japanesecivilians with whom he was traveling on a train. After several hours ofconvivial imbibing, he began to believe that his new-found Japanese friendswere Communists who were trying to poison him. He left them and went toa Japanese hotel, but soon became convinced that the civilians moving aboutwere also Communists about to close in on him. Thereupon he drew and firedhis service pistol in "self-defense," killing one civilian andwounding others. The following day he returned to normal awareness, couldnot understand the cause of his actions, but remembered the previous night'sevents as if they were a hazy dream.
In combat veterans, alcohol would at times precipitate a period of abreactionidentical with the reliving of battle episodes obtained by intravenousbarbiturate technics. Usually this experience was only frightening to theindividual so involved and only distressing to the onlooker. Occasionally,however, during the emotionally charged period there were hostile actionstoward Japanese or Korean civilians who were interpreted as being enemysoldiers or guerrillas. In this group of vulnerable persons, alcohol servedits classic function of lessening or removing inhibitory control therebypermitting the release of abnormal or hostile impulses which were apparentlyclose to surface awareness. In this category were a group of psychiatricproblems whose symptoms were only indirectly related to alcohol consumption.These cases occurred in individuals who ordinarily maintained strict self-disciplinein the moral sphere, but upon ingestion of alcohol at a party or whileon "R & R" leave in Japan, permitted themselves to indulgein illicit sexual acts. Their resulting depression was sometimes difficultto overcome and in rare instances appeared to be the precipitating eventof a schizophrenic disorder.
In Korea, a special alcohol problem was present, particularly duringthe first year of the campaign. This condition was primarily due to therelative unavailability of American or other reputable brands of alcoholicliquors in Korea as compared to Japan. As a result, alcoholic spirits,of various types, were hastily improvised by unscrupulous native civiliansin order to profit from the needs of military personnel. Such mixturesnot infrequently contained methyl alcohol and probably other toxic substances,such as the higher alcohols. The clinical syndromes produced by the ingestionof these liquors were
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reminiscent of those seen in the United States during the prohibitionera. Toxic reactions were commonly observed, which included markedly excitedbehavior, blindness, shocklike states, with coma, cyanosis, disturbed respiration,and deaths. Obviously the contents of indigenous alcoholic beverages werenot uniform, some being more toxic than others. In one brief period duringearly 1951, 12 deaths from native whiskeys occurred in the Seoul area.Extraordinary measures were necessary to prevent further deaths as clearlya lethal product was being sold. All military vehicles leaving Seoul weresearched and all alcohol-containing fluids confiscated. Gradually, reputablebrands of alcoholic spirits became more and more available, as men returningfrom leaves in Japan brought with them supplies of American whiskey.
From the foregoing material, it is evident that the manifestations ofalcoholism in military personnel of the Far East Command were not dissimilarto those observed in peacetime U. S. A. However, the stresses and strainsof combat and the vicissitudes of overseas existence provided greater opportunitiesfor the cultural use of alcohol as the anodyne for the relief of tensionand, therefore, quantitatively at least, alcohol problems were more prevalent.In considering measures for prevention, it may be profitable to regardthe abnormal ingestion of alcoholic spirits as a disease. But as statedby a recent WHO report (5), "the ailment is not the excessivedrinking but rather the psychological and social difficulties from whichalcoholic intoxication gives temporary surcease." By this conceptexcessive drinking becomes an illness due to a loss of control over thealcohol intake. If the early manifestations of loss of control were consideredto be the initial signs of disease rather than a form of misconduct orthe personal business of the individual, then perhaps corrective actionfor the underlying psychological or social difficulty would be more readilygiven and received by the involved person. Obviously, the early recognitionand prevention of alcohol problems is an integral component of leadership,the scope of which must be constantly clarified and restated in order tomaintain adequate standards for this function. Thus the commissioned andnoncommissioned officer must assume an ever greater interest and responsibilityfor the welfare of their men. As previously stated, these key personnel,particularly the noncommissioned officers, are in the most favorable positionto exert a sustaining force in the soldier's struggle for emotional equilibrium.Moreover, by such close interest and scrutiny of their men, those withincipient alcoholic disorders can be referred for early psychiatric andother medical help, which is far more effective than the later hospitalizationof confirmed or chronic alcohol offenders.
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References
1. Anslinger, H. J., and Tompkins, W. F.: The Trafficin Narcotics. Funk & Wagnalls Co., New York, 1953.
2. Conferences on Drug Addiction Among Adolescents. TheBlakiston Company, New York, 1953.
3. Ibid.
4. Ibid.
5. World Health Organization Technical Report Series No.48. Palais Des Nations, Geneva, August 1952.
