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Chapter 4, Part 3

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 and narcotic addiction that occurred among American troops during the Korean conflict. The writer has no detailed study or statistical data to offer, but rather observations and impressions gained while serving as psychiatric consultant to the Far East Command on the prevalence of these phenomena and the degree and manner in which they added a further burden to our medical and administrative efforts. From this standpoint it can be categorically stated that alcohol and narcotic offenders constituted a relatively minor problem in the overall logistical difficulties of the Korean campaign, yet one of constant and ominous concern to commanders, particularly those officers responsible for troops stationed in Japan and rear Korea. Combat units were far less involved, unless they were held for a lengthy period in rear areas.

It should be realized that alcoholic liquors and narcotic drugs were readily available to the Occupational forces in the Far East prior to the onset of hostilities. Tax-exempt American whiskeys and various native spirits were freely purchasable at less than one-half their usual cost in the United States. As a result, social drinking at least was quite common among officers and men. Narcotic drugs were also easily obtained at reduced prices in Japan and not infrequent instances of heroin addiction were noted, especially from 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 military narcotic offenders in the Far East Command. The extent of this increase in drug addiction was the subject of an item in the periodical Newsweek of 16 February 1953, which read as follows: "The Defense Department reported that in the Far East Command arrests of GI narcotic users or possessors had more than tripled since 1949. Statistically in 1949, 41 users and 160 possessors were arrested. In 1951, 300 users and 415 possessors. No figures were 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 drugs in the Far East are contained in a recent publication by Anslinger and Tompkins (1). Mr. Harry Anslinger, the senior author, is the United States Commissioner of Narcotics and American delegate to the UN Commission on Narcotic Drugs. The book cites a SCAP (Supreme Commander for the Allied Powers in Japan) report dated 10 March 1952, which states that the total of heroin seized in 1950 was three times the amount seized in 1949. The authors gave convincing reports of investigations, arrests and seizures which prove conclusively that all the heroin seized in Japan and South Korea originated from Communist China. They furnish documentary evidence that details names, dates and places of a highly organized Communist effort which directs the cultivation, processing and distribution of opium products, particularly heroin.

Further confirmation of Communist activity in the drug traffic comes from the fact that 30 to 40 percent of the traffickers arrested in Japan were Communist Chinese and North Koreans, although these entire groups comprise only 2 percent of Japan's population. Shipments of heroin were traced repeatedly from factories in Communist China through North Korea and Hongkong to Communist leaders in Japan and Communist agents in South Korea. The authors conclude that there are two reasons for the large-scale Communist participation in the narcotic traffic. First, profits of this smuggling are utilized to finance Communist activities, both in China and abroad. Second, it is a subtle tool of war designed to undermine the physical and moral strength of UN troops, and is thus similar to the use of opiates by the Japanese Imperial Army in its efforts to conquer China prior to and during World War II.

The foregoing data should make apparent the basic cause for the narcotic problem during the Korean conflict. As before hostilities began, units in the vicinity of Yokohama and Kobe had the highest incidence of narcotic offenders to which the war added Pusan, South Korea. In these areas it was not uncommon for officers to state that 50 percent or more of men in their units were narcotic users. Undoubtedly these stories were exaggerated since they were not confirmed by the relatively small number of personnel apprehended. Many efforts were made to remedy the situation, particularly in the Kobe area. Lectures were given to the troops by chaplains and medical officers that emphasized the devastating action of narcotic drugs upon the moral, physical and mental functions of the individual. Undercover agents of the CID were placed into suspect units but were apparently readily spotted and obtained little success. Unannounced shake-downs and physical inspections also gave sparse results. Experience in such physical examinations indicated 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 known withdrawal symptoms were seldom manifest, even when known users were confined in the locked wards of a psychiatric service. Perhaps in some cases drugs were smuggled in to the addict, as proved in one instance at the 361st Station Hospital. However, a more likely reason for the lack of withdrawal symptoms can be found in the relative youth of the suspects and the low dosage of opiates involved. Civilian experience with teen-age addicts has demonstrated conclusively that generally these individuals exhibit little or no distress when confined during drug removal (2).

It is also well known that the intensity of withdrawal manifestations is dependent upon the quantities of drug ingested. Moreover, there is some evidence to indicate that the withdrawal syndrome is a learned process compounded out of physical discomfort from physiological dependence and anxiety from psychological dependence. Thus, teen-age users who were sent to the Federal narcotic hospital at Lexington, Kentucky, had severe withdrawal symptoms in contrast to the mild or no distress displayed by similar youthful offenders incarcerated at hospitals such as Bellevue in New York City (3). Presumably association with confirmed and older addicts at the Federal institution may have influenced the newcomers to exhibit a heightened response to drug withdrawal.

The absence of withdrawal manifestations in most of the young soldier users would indicate that either they were in an early stage of addiction and maintained on small dosages or only indulged in narcotics periodically on weekends or at parties. Their diagnosis and confession was most difficult to obtain since only occasionally could possession of drugs or the injection paraphernalia be proved. Random and well distributed needle scars could readily be explained away by the suspect who rarely exhibited the loss of weight or physical stigmata that characterizes the confirmed and older addict.

The modus operandi in which addiction arose and narcotics were distributed among troops remained obscure. Certainly it was most common in locations of greatest drug availability, where narcotics could be readily obtained from prostitutes, small shops, indigenous night clubs and other places of entertainment. Units in these areas seemed to accept in a matter-of-fact manner the using of narcotic drugs much as alcoholism is condoned. Vulnerable newcomers were initiated into the pleasures of opiates by user members of the unit. Groups of narcotic addicts developed who acquainted each other with tricks of avoiding work and detection. Sick call was a made-to-order means of escape from duty and the theft of supplies a relatively easy method of obtaining needed extra funds. Non-drug users of the unit,


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including high ranking noncommissioned officers, either feared to report members of the strong drug group or came to believe that it was none of their affair, since it was a "police" matter. From a cultural standpoint, the giving of information to the authorities of alleged derelictions of fellow soldiers or "telling tales" has never been popular and is condemned even by those who ordinarily abide by the rules. Occasional deaths resulted from overdoses of opiates, particularly heroin. Other rare deaths by violence or poison were rumored to have occurred to users who either threatened to inform on their source of supply or had cooperated with the authorities. No doubt stories of this type did much to deter any prospective informer.

The vulnerability of certain types of persons to drug addiction has been repeatedly noted (4). Generally it is agreed that narcotic addicts arise from neurotic, immature and antisocial or psychopathic personalities. Obviously, many individuals in these groups are present among soldiers of draft age and are inducted into the Service. Whether they become narcotic users depends upon the availability of the drug, together with chance assignment and association with groups that foster antisocial conduct, including the ingestion of opiates. Those with the same personality disorders do not become narcotic addicts when assigned to the combat zone, or other areas where opiates are not available and where the use of narcotics is not tolerated by the group. It was not infrequent to find chronic addicts who had been using drugs since their teen-age years. Apparently they had slipped through the screen of the induction process with little difficulty by withholding pertinent information, perhaps with the hope on their part or on the part of their relatives that military service would cure their addiction by removal from old associates and sources of supply. However, one such addict frankly stated that he reenlisted and asked for an assignment to Pusan because narcotics were far cheaper in this area than in the United States. No doubt these chronic addicts form the nidus from which the narcotic user group develops.

Perhaps because the incidence of narcotic addiction in the Far East was not sufficient to constitute a major problem, there was no uniform legal or administrative procedure for the disposition of these addicts. Local commanders used varying methods. In the Pusan area during the first year of the Korean conflict known and confessed addicts could not be undesirably discharged from the Service as provided for under the provision of AR 615-368, Discharge-Unfitness. Medical recommendations for such a disposition were invariably disapproved since it was believed that even an undesirable discharge would be regarded as a reward and serve as an incentive for others to utilize similar 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 upon the civil populace. As a result, the disposition of narcotic users for at least one year in Pusan could only be accomplished by a general court-martial conviction, which required that evidence of drug possession or of using paraphernalia be obtained. Obviously, such evidence was difficult to secure and in many cases required months of surveillance or detective work. Thus known narcotic addicts were allowed to continue their spread of the narcotic habit with other illegal behavior, such as the theft of supplies. In Japan, disposition under AR 615-368 was generally permitted. However, often the psychiatric or medical recommendations were not followed when the individual stoutly denied using drugs and neither withdrawal symptoms nor prominent needle scars were present.

The relatively few cases that occurred among combat troops (12 were reported for the 25th Infantry Division in one year, and 2 in the 3d Infantry Division during an 8-month period) arose from chronic addicts whose only source of narcotic drugs was medical supplies which they obtained either by stealing or by bribing medical personnel. They were discharged by general courts-martial or under the provisions of AR 615-368.

In retrospect it may be worth while to consider ways and means of implementing both the prevention and disposition of military narcotic offenders in overseas situations similar to those that prevailed in the Far East Command during the Korean campaign. Any plan must endeavor to control the narcotic traffic or, in other words, to dry up the source. However, such a goal is virtually impossible to achieve in Japan and Korea where the civil population is not under military control, and especially when traffic in narcotics is skillfully promoted by an organized Communist effort, which uses its preformed political network and communications to effect distribution of opiate drugs. Also the enormous profits involved in the narcotic traffic are a constant temptation to the unscrupulous and needy components of the population. It is therefore mandatory that measures for the specific protection of troops be implemented.

Most pertinent in this respect is the importance or significance placed upon the phenomena of narcotic addiction in military personnel. If it is regarded as a relatively minor matter that only occurs in a few degenerate persons and of little moment in the overall picture of effectiveness and manpower loss, then narcotic addicts will be handled casually by both officers and men. On the other hand, if narcotic drugs are looked upon as an enemy weapon in the form of a subtle poison or an insidious type of chemical warfare, then the using and transmission of opiates becomes of legitimate military concern from a tactical and security standpoint. When this viewpoint is dis-


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seminated among troops and confirmed by prompt and stern measures against military users, possessors or peddlers, a corresponding attitudinal change by officers and men can be expected. Lectures upon the evils of narcotic addiction have been demonstrated to be of little value, similar to their ineffectiveness in the prevention of venereal disease. However, when, as in the problem of frostbite, officers and noncommissioned officers were held responsible for the number of cases under their command, the incidence of frostbite promptly and sharply declined.

It is herein submitted that the noncommissioned officers of a unit are the key personnel who are not only in a favorable position to know which of their men are narcotic users, but can prevent, disperse or render innocuous the narcotic group formation that initiates the vulnerable soldier in the drug habit. It is important that noncommissioned officers of units in areas where drugs are available be charged as part of their leadership qualifications with preventing and eradicating drug addiction as much as they are responsible for reporting and eliminating enemy sabotage. The proven addict should be promptly removed from the unit with severe penalties for possession or proselyting. For suspects, medical findings that indicate the use of or addiction to narcotic drugs, should be given credence even when possession cannot be proved, and such individuals should be rapidly removed from the Service by an appropriate discharge.

The question of whether an undesirable discharge as under AR 615-368 constitutes a reward in an overseas combat theater is not the primary issue; more pertinent is the prompt removal of narcotic users in order to prevent the infection of others. Such a viewpoint highlights the extreme gravity of allowing narcotic users to associate with vulnerable personnel. Perhaps the confessed or proved narcotic addict should receive a type of discharge which carries with it an enforced period of treatment at one of the Federal narcotic hospitals.

In essence the foregoing proposals are based upon the known fact that when the soldier group does not tolerate or allow certain forms of abnormal behavior, such conduct either ceases or becomes negligible. When the ingestion of narcotics is linked to cooperation with the enemy and/or considered as a deliberate attempt to evade duty by the self-injection of an injurious agent, then a strong motivating viewpoint can be given to officers and men, insofar as their personnel and command responsibilities are concerned. This function of officers and noncommissioned officers is only a restatement of their traditional role as leaders of men. As such they must provide the vulnerable and non-vulnerable soldiers with better and more socially acceptable outlets than narcotic addiction. It is reiterated that noncommissioned officers 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 them not to be aware of the identity of narcotic users in their unit. Therefore, it is vitally necessary that the noncommissioned officer be motivated to stamp out narcotic addiction ruthlessly. Perhaps the current plan to separate the technician from the noncommissioned officer group is a step in the right direction since then the noncommissioned grade will reflect meaning in 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 of social drinking in moderation. However, there were complications and abuses frequently observed in the consumption of alcoholic liquors which did create medical problems and behavioral difficulties that are pertinent to the contents of this symposium.

As in civil life, the most common alcoholic disorder concerned excessive intake or alcoholic intoxication. The availability of whiskeys in Japan at reduced cost and the increased tensions of overseas life, along with the presence of a certain number of combat troops determined to rest and relax on their 5-day leave in Japan, accounted for an increased incidence of 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 irregularly continued excess alcohol consumption in individuals who had been previous social drinkers. This type of temporary addiction seemed to be a neurotic flight reaction to the stress of overseas separation, frustration in work, guilt or other sources of tension. The resultant loss of efficiency was all the more unfortunate since officers and noncommissioned officers were not infrequently involved. Various complications of alcoholism, such as liver disease, transient psychotic disorders, avitaminosis, and in older individuals a gradual deterioration in mental functions, brought these cases under medical jurisdiction. After improvement in the hospital, with physical restoration, their further disposition posed many difficulties. Return to duty was almost invariably followed by a recurrence of the alcohol habit, since follow-up psychiatry was not too successful, or even desired by the person involved. Medical evacuation to the United States was the simplest method of removing the individual problem from the Theater. However, such an action could be construed as a misuse of medical channels and an aid in the perpetuation on active duty of ineffective personnel, who were utilizable only in limited or non-stressful assignments.


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An alternative method of disposition was medical recommendation for administrative action, either under the provisions of AR 605-200, Demotion and Elimination, for the elimination of noneffective officer personnel, or by AR 615-368 for the discharge of undesirable enlisted personnel. But experiences in this sphere indicated that there was a general unwillingness to employ such punitive action against this type of alcohol offender, first, because of the difficult administrative procedure involved, particularly in the case of officers, and second, because of the accumulated years of prior effective service achieved by many of these individuals. Obviously, there is no easy solution to the problem. Each case must be individually judged. If neurotic illness is the major cause, medical evacuation, with removal of stress, is the most reasonable method. Where this type of alcoholism represents a repetitive pattern of behavior under even slight stress, administrative action is considered to be the proper disposition.

To a lesser extent, a similar problem was presented by the chronic alcohol addict. This group contained relatively few officers. Most were enlisted personnel with various periods of previous military service, whose duty performance had been unsatisfactory for one or more years. Such individuals were not particularly affected by situational stress but represented seemingly permanent behavior patterns which involved both physical and psychic dependency upon alcohol. Delirium tremens, and other confusional states due to alcohol withdrawal and avitaminosis, often caused their hospitalization. Frequently they were drunk on duty, involved in minor disciplinary difficulties and in general were ineffectual members of their unit. As with most chronic alcoholic addicts, they drank any source of alcohol if regular supplies were not obtainable. Efforts to remove these alcoholics by medical evacuation were common. However, unless physical or mental disease was present, they were returned to their units for administrative elimination. But because there were no uniform criteria for such a disposition much time was lost as frequently the individual was retained on duty, and this resulted in repeated hospitalizations.

A not infrequent type of alcoholic disorder observed, particularly in Japan, concerned individuals with barely latent emotional conflicts in whom the ingestion of usual or excessive quantities of alcohol produced bizarre conduct of psychotic manifestations. In many of these patients dissociative phenomena occurred with rage reactions which included excited and assaultive behavior that required restraint and closed ward management. The following day they generally returned to self-control and professed complete amnesia for the events of the preceding day or night. Usually they denied excessive alcohol intake


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prior to their disturbed actions, but such denials are difficult to believe, since often the blood alcohol level indicated otherwise.

In other and more rare instances a paranoid episode of psychotic intensity resulted during an alcohol bout. Such a case was exemplified by a young combat officer who was on a 5-day convalescent leave after a brief period of hospitalization in Japan. This officer began drinking whiskey with Japanese civilians with whom he was traveling on a train. After several hours of convivial imbibing, he began to believe that his new-found Japanese friends were Communists who were trying to poison him. He left them and went to a Japanese hotel, but soon became convinced that the civilians moving about were also Communists about to close in on him. Thereupon he drew and fired his service pistol in "self-defense," killing one civilian and wounding others. The following day he returned to normal awareness, could not understand the cause of his actions, but remembered the previous night's events as if they were a hazy dream.

In combat veterans, alcohol would at times precipitate a period of abreaction identical with the reliving of battle episodes obtained by intravenous barbiturate technics. Usually this experience was only frightening to the individual so involved and only distressing to the onlooker. Occasionally, however, during the emotionally charged period there were hostile actions toward Japanese or Korean civilians who were interpreted as being enemy soldiers or guerrillas. In this group of vulnerable persons, alcohol served its classic function of lessening or removing inhibitory control thereby permitting the release of abnormal or hostile impulses which were apparently close to surface awareness. In this category were a group of psychiatric problems whose symptoms were only indirectly related to alcohol consumption. These cases occurred in individuals who ordinarily maintained strict self-discipline in the moral sphere, but upon ingestion of alcohol at a party or while on "R & R" leave in Japan, permitted themselves to indulge in illicit sexual acts. Their resulting depression was sometimes difficult to overcome and in rare instances appeared to be the precipitating event of a schizophrenic disorder.

In Korea, a special alcohol problem was present, particularly during the first year of the campaign. This condition was primarily due to the relative unavailability of American or other reputable brands of alcoholic liquors in Korea as compared to Japan. As a result, alcoholic spirits, of various types, were hastily improvised by unscrupulous native civilians in order to profit from the needs of military personnel. Such mixtures not infrequently contained methyl alcohol and probably other toxic substances, such as the higher alcohols. The clinical syndromes produced by the ingestion of these liquors were


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reminiscent of those seen in the United States during the prohibition era. Toxic reactions were commonly observed, which included markedly excited behavior, blindness, shocklike states, with coma, cyanosis, disturbed respiration, and deaths. Obviously the contents of indigenous alcoholic beverages were not uniform, some being more toxic than others. In one brief period during early 1951, 12 deaths from native whiskeys occurred in the Seoul area. Extraordinary measures were necessary to prevent further deaths as clearly a lethal product was being sold. All military vehicles leaving Seoul were searched and all alcohol-containing fluids confiscated. Gradually, reputable brands of alcoholic spirits became more and more available, as men returning from leaves in Japan brought with them supplies of American whiskey.

From the foregoing material, it is evident that the manifestations of alcoholism in military personnel of the Far East Command were not dissimilar to those observed in peacetime U. S. A. However, the stresses and strains of combat and the vicissitudes of overseas existence provided greater opportunities for the cultural use of alcohol as the anodyne for the relief of tension and, therefore, quantitatively at least, alcohol problems were more prevalent. In considering measures for prevention, it may be profitable to regard the abnormal ingestion of alcoholic spirits as a disease. But as stated by a recent WHO report (5), "the ailment is not the excessive drinking but rather the psychological and social difficulties from which alcoholic intoxication gives temporary surcease." By this concept excessive drinking becomes an illness due to a loss of control over the alcohol intake. If the early manifestations of loss of control were considered to be the initial signs of disease rather than a form of misconduct or the personal business of the individual, then perhaps corrective action for the underlying psychological or social difficulty would be more readily given and received by the involved person. Obviously, the early recognition and prevention of alcohol problems is an integral component of leadership, the scope of which must be constantly clarified and restated in order to maintain adequate standards for this function. Thus the commissioned and noncommissioned officer must assume an ever greater interest and responsibility for the welfare of their men. As previously stated, these key personnel, particularly the noncommissioned officers, are in the most favorable position to exert a sustaining force in the soldier's struggle for emotional equilibrium. Moreover, by such close interest and scrutiny of their men, those with incipient alcoholic disorders can be referred for early psychiatric and other medical help, which is far more effective than the later hospitalization of confirmed or chronic alcohol offenders.


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References

1. Anslinger, H. J., and Tompkins, W. F.: The Traffic in Narcotics. Funk & Wagnalls Co., New York, 1953.

2. Conferences on Drug Addiction Among Adolescents. The Blakiston Company, New York, 1953.

3. Ibid.

4. Ibid.

5. World Health Organization Technical Report Series No. 48. Palais Des Nations, Geneva, August 1952.