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The Haight Ashbury Free Clinics - The 1999 HAFC Logo
The Haight Ashbury Free Clinics

Addiction Medicine in China
By David Smith, MD

Dr David Smith Web Site.
Dr Dave's Web Site

First Appeared in CSAM NEWS - Winter 2004

Addiction Medicine in China
By David Smith, MD

In September 2002, I went to China as part of an international delegation to the World Health Organization/Beijing University conference on substance abuse held at the Beijing Institute of Mental Health. I had the privilege of meeting the leading mental health and addiction doctors in China, including Professor Shen Yucun and to be part of a historic public health moment that introduced the concepts of twelvestep recovery to one quarter of the world's people.

Beijing University and the Beijing Institute of Mental Health are the primary institutions for the delivery of mental health services in China. The mental health hospital was founded in 1951. Professor Wu Zhengya, a psychiatrist famous throughout China, established a department of psychiatry for teaching and research. Professor Shen Yucun assumed a leadership role and was influential in bringing about modern addiction treatment and the fellowship of Alcoholics Anonymous to China. The conference was organized by Dr. David Powell, Director of the Asia Institute. He has long worked with China in the area of substance abuse and AIDS prevention.

I was privileged to be part of a faculty that included experts from around the world, including Dr. George Valliant, who has made such a contribution to the addiction medicine field with his research on the national history of alcoholism, including the crucial role of AA and long term recovery from alcoholism, and as leadership from Narcotics Anonymous International, and Dr. Wayne Moran, a leading addiction medicine expert in Hong Kong and fellow International Doctors in AA and International Society of Addiction Medicine member. Our delegation also included representatives of Narcotics Anonymous General Services Administration and Alcoholics Anonymous General Services Administration.

Dr. Moran indicated that while non-Chinese expatriates living in China had AA meetings, until two years ago, AA meetings for Chinese Nationals was illegal. Despite an escalating heroin problem in China, there were no Narcotics Anonymous meetings, and because of frequent needle sharing there is a dramatic escalation of HIV/AIDS.

In August 2001, Dr. Valliant and two members of AA General Services Administration were invited to the People's Republic of China to talk about alcoholism and AA. It was the first time members of the AA fellowship were able to share their experience, strength, and hope with the medical establishment in China and with the Pioneers of AA in China. The Pioneers of AA in China, who held the first meeting less than a year and a half prior to this meeting, met with the delegation from the United States to strengthen the acceptance of AA in China by explaining the 12-step process of recovery from an Addiction Medicine perspective.

My presentation focused on addiction as a brain disease and various techniques for detoxification and treatment of dependence on opiates, stimulants including amphetamine, cocaine, and alcohol, using techniques developed at the Haight Ashbury Free Clinics and principles of addiction treatment established by the American Society of Addiction Medicine.

Opium and Heroin in China
Opium and heroin have a long history in China. Many Chinese have bitter recollections of the opium wars of the 19th Century, when British traders backed by English government gunboats forced opium grown in British India into China and thereby virtually ruining the Chinese economy.

The First Opium War started when the Chinese government tried to stop British merchants from illegally importing opium. Britain responded by sending an expedition of warships to the city of Guangzhou. The British won a quick victory, and the conflict was ended by treaties under which China was forced to pay a large indemnity, open five ports to British trade and residence including the establishment of British Hong Kong as a lucrative port for the importation of heroin. The British also won the Second Opium War, fought for much the same reasons. The resulting treaty opened additional trading ports and allowed even greater privileges to Western countries. Dr. Moran described the creation of Hong Kong in the 1890s as "a drug deal gone bad" for China.

Today, Hong Kong still serves as the major drug smuggling port, not only into China, but worldwide.

In 1949, when China's communist government took power, there were 70 million opium addicts. The communists shut down the opium dens and declared the nation drug free, claiming that heroin addiction was a consequence of the capitalist system. Because of draconian measures and capital punishment of drug abusers, heroin addiction rates decreased dramatically. In 1988 it was estimated that there were less than 70,000 heroin addicts in all of China.

As a result of China's policy of rapid industrialization, with its opening of borders to free trade, there has been a dramatic increase in heroin addiction. Official estimates presented at our conference estimated the current number of heroin addicts in China at 900,000. Non-government epidemiological experts indicate that the actual number is much higher ranging from four million to ten million. This underestimation of the extent of addiction is largely due to the government's draconian approach. In China, drug traffickers are often executed and addicts are sent to labor camps - a similar approach to the US criminal justice system of boot camps and incarceration.

In his presentation, Dr. Moran painted a graphic picture of the victims of the potent heroin available, including needle abscesses and overdose deaths. Many overdose deaths occur after addicts are released from the labor camps and had lost their tolerance for heroin. They readministered the drug, overdosed and died. The success rate for heroin addicts when released from the labor/political rehabilitation camps was less than five percent according to the government, similar to the Lexington incarceration experience of the United States in the 1950s where only about 5% of the addicts stayed off heroin after their discharge.

As a result of the Chinese government's failure to control addiction, experts in our delegation were invited to present contemporary addiction treatment standards based on ASAM patient placement criteria ranging from antagonist therapy with naltrexone to agonist therapy with methadone as well as drug-free therapies including therapeutic communities. The Chinese government opposed agonist therapy such as methadone maintenance, but was more oriented toward antagonist therapy such as naltrexone. Based on the trainings given by Walter Ling, they were open to partial agonist therapy such as buprenorphine. US drug policy with its emphasis on supply side reduction, incarceration and just say "no" prevention message was presented by Charles Curie director of SAMHSA and Barbara Rogers of the Office of National Drug Control Policy.

Alcohol in China
Alcohol, first introduced 4,000 to 5,000 years ago, has a much longer history in China than opium and heroin. Chinese nobility consumed alcoholic beverages in the form of rice wine at social events and national ceremonies. Alcohol was romanticized and Chinese literature considered appropriate drinking a virtue to beautify, dignify, and philosophize. Despite this romanticization early Chinese medical literature recognized the potential for alcohol problems.

Chinese experts presented medical literature on alcohol problems including mentions of fetal alcohol syndrome symptoms in ancient medical textbooks. They used the following quote, "Intercourse after drinking will make your offspring inferior."

However, Chinese medical textbooks emphasize the health benefits of alcohol but contain very little on alcoholism. Since the 1980's, China has rapidly moved from a rural agricultural society to an industrialized, urban one. The attendant disruption of family has greatly increased the problem of alcoholism, particularly among males.

I had the privilege of attending a Chinese AA meeting and participating in medical grand rounds with Dr. Moran. Members of our delegation interviewed patients on the alcohol ward at the psychiatric facility and discussed cases with residents. Most of the alcoholic patients that entered the psychiatric facility came in because of alcoholic hallucinations and DT's. So their alcoholism had to be very far advanced with severe medical and psychiatric symptomatology before they were initiated into treatment.

Alcoholics Anonymous had gained a foothold of very little to what we would call post-hospitalization aftercare in China. Although the meeting was run in a fashion very similar to the US meetings, it was interesting that the psychiatrist that translated indicated that in China they do not believe in God and therefore use higher power in the third step. There are several different definitions for higher power and it appears that the spirituality of AA is much more applicable to current Chinese philosophy and society than a Western-style religion would be. The focus of AA and its traditions allowed AA to gain a foothold and help suffering alcoholics in China. A more traditional religious approach would have been rejected.

Tobacco and Other Drugs
Tobacco addiction was an enormous problem in China and had a long history. It was first introduced during the Qing dynasty in the middle part of the 19th Century. As previously discussed, this was a period of increasing Western influence and trade, which led to the Opium War and the Boxer Rebellion (1898-1900). The Qing dynasty, China's last, was overthrown by nationalist revolutionaries. Initially, tobacco use was strictly prohibited by the emperor, but it became the number one recreational drug until the introduction of opium. It was estimated that 35% of the population smoked. Today tobacco is a leading cause of medical death and disability.

There was also the recent introduction amongst the youth of a variety of drugs that have been long seen in the United States. In China, ice (d-methamphetamine) is beginning to make its appearance in clubs, especially in prosperous coastal cities, such as Shanghai, just as it did in the US during in the 1990's. Methamphetamine, manufactured mainly in illicit laboratories, has been increasing dramatically both in China and other areas of Asia such as Thailand. (Walter Ling has been organizing modern drug treatment at the request of the Thai Government.) Parallel to the increase in methamphetamine has been a dramatic increase in violence.

The Chinese call the drug ecstasy "Yaotouwan" or "headshaking pills." The concept of the rave club was first described in China in 2000, indicating that drugs, sex, and rock and roll have started to permeate China in the new millennium, particularly in more Westernized cities such as Shanghai, which interestingly enough was where Mao Tse Tung organized the first Chinese Communist Party meetings in the 1920's.

In the US, psychedelic rock concerts during the 1967 summer of love in San Francisco popularized the sound of Jerry Garcia, Grateful Dead, Janis Joplin, Big Brother and the Holding Company, Grace Slick and the Jefferson Airplane. All eventually did benefits for the Haight Ashbury Free Clinics. The Chinese government frowns upon these rave clubs and individuals that are caught using ecstasy. Even though they would not have what we would describe as an addiction problem, they are sent to the labor rehabilitation camps. Clearly, there is no concept of Rock Medicine in China.

Parallel to the rise in addiction and new sexual freedom there is a dramatic increase in sexually transmitted diseases. Over a million people are infected by HIV in China. Seventy percent of the new cases are IV drug users using contaminated needles. However, the Chinese government is ambivalent about both the rising HIV and drug epidemic. The medical community in Beijing wants to initiate Western-style addiction treatment and public health AIDS approaches. Dr. David Powell who organized our substance abuse delegation also met with the leading HIV public health experts in China to improve their approaches to HIV prevention and treatment.

However, on August 24, two weeks prior to our arrival, a public health expert in Beijing, Wan Ayanhai, was arrested and detained by the government for attempting to protest government AIDS policy using methods similar to Act-Up, a public advocacy citizen group that demonstrated in favor of improved HIV/AIDS care as in the United States. It became clear that while some public health approaches could be accepted, Western-style protest will not be.

I was reminded of the traditions of Alcoholics Anonymous of maintaining focus on our purpose, which was to help the suffering alcoholics and addicts in China. I was privileged to be part of this historic delegation and found the Chinese people to be informed and very friendly hosts. Surprisingly, they were also very computer literate. I found at the University they had accessed our Haight Ashbury Clinic website as well as our online medical service, AlcoholMD.com, and were quite familiar with our work at the Haight Ashbury Free Clinics, including our book Clinicians Guide to Substance Abuse and Dr. Daryl Inaba's book, Uppers Downers and All Arounders. In this age of the internet, I was able to find a computer and communicate with my family, friends, and colleges in the United States on a daily basis, but I couldn't figure out the phone system or how to get around Beijing on a bike without having a frightening experience in the unbelievable traffic. It was easier for me to communicate with the United States using e-mail than it was to talk on the phone to someone down the block. Despite these personal limitations and dependence on technology we were able to contribute to our mission and pass along our passion for science including epidemiology, detoxification and treatment, including changes in neurochemistry in association with addiction while maintaining a compassion for people including recovery and spirituality associated with AA and NA. Given the globalization of information the advances in China have been dramatic. The communication link between Haight Ashbury Free Clinics and Beijing University reminds me of the Grateful Dead line, "What a long strange trip it has been".


Opium smoking, forced into China by Britain in the
19th century undermined Chinese society


Scenes in the Patna Opium Factory, from the London Weekly Magazine,
The Graphic, 24 June 1882.


Dave Smith (ASAM), Wayne Newton (ISAM) and the director of the Beijing Psychiatric Institute at AA Meeting for Chinese Nations in front of a poster of the 12 steps in Chinese, the poster they are holding shows the 12 steps and 12 traditions in English.


[www.DrDave.org] [Haight Ashbury Free Clinics, Inc]

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