Nils Bejerot (1921-1988), MD, is still relevant today. ”This 100th anniversary is a message in a bottle, the remarkable foundation for an effective drug policy, delivered to us today through the enduring wisdom of the remarkable Swedish psychiatrist,” writes Robert DuPont and Gerald Busch, American doctors in addiction, in an article about Bejerots works.
On this 100th birthday of Nils Bejerot, one can only imagine how he might reflect upon the twin pandemics presently afflicting the 21st century populace, COVID-19 and Substance Use Disorder. Although his principal career was consulting psychiatrist to the Stockholm Police Department, Dr. Bejerot studied epidemiology and public health at the London School of Hygeine and Tropical Medicine in 1963. He may have predicted that the legal dispensation of 3,127,638,015 opiate prescriptions from 2006 to 2019 in the United States would facilitate the second largest drug abuse epidemic in history.
Much of Bejerot’s insight emerged from the interviews of several thousand young IV amphetamine addicts at Remand Prison, noting, “The effects of central stimulants are decidedly more criminogenic, since on high doses self confidence increases and inhibitions and judgement are reduced.” During this time the “Liberal Prescribing Experiment”, the generous prescription of amphetamines and morphine to addicts, Bejerot observed that these same prescriptions disseminated widely on the black market, with significant disease spread to drug-naïve contacts. He had noted at the time that similar experiments in America and England also had adverse outcomes.
It might be assumed that IV drug users would be grateful when rescued from the clutches of illegal drug dealers, the costs of the drugs, and the terrible health consequences of continued substance use. This seemingly rational expectation fails to recognize that repeated substance misuse produces a sustained reorganization of the brain reward circuit, such that obtaining, using, and recovering from the effects of the drug emerge as the highest priorities of the addicted person.
Bejerot understood that addiction had the momentum of a freight train, unstoppable by such rational means, losses of family, friends, health, and safety. His understanding of addiction was as good or better than any modern day practitioner, demonstrated in this concise, humorous characterization:
“Ordinary voluntary hospitalization, when the patient has the right to leave the hospital when he wishes, often reduces the physician’s role to that of a hotel receptionist: the addicts come and stay to rest for a while; if the food was good and the room pleasant, he may expect his guests back again for short visits in the future.”
Bejerot’s second critical observation was that substance use spread from existing users to naive hosts – often out of sheer enthusiasm over the drug experience from the user and curiosity from the non-user – and therefore was a communicable disease.
He documented this mode of transmission in his patients in Remand Prison, garnered information how small groups of addicted individuals could spread the disorder to hundreds and then thousands, and provided an example of contact tracing of disease transmission in an outbreak in England.
The hijacked brain of addiction, which makes recovery from substance use disorders difficult, informed Bejerot’s third observation: meaningful and sustained coercion from the criminal justice system helped many addicted people become drug-free.
Bejerot recognized that the intervention of a doctor, family members, friends, and/or employers could add leverage against the overwhelming power of neuroplastic changes in the brain reward circuit, that in essence parasitize the host’s life; but that ultimately the criminal justice system was often the final immutable “wall” that an addicted person might encounter.
Substance use disorder progresses with increasingly focus on obtaining and compulsively using a substance, often to the exclusion of many important dimensions of living. While the brain reward model explains why people with substance use disorders divert their resources to obtain drugs, it does not explain Bejerot’s groundbreaking observation of the person-to-person transmission of the disease. Cases of substance use disorder do not arise spontaneously, like diabetes or hypertension, so called non-communicable diseases. Brain biology and genetics play important roles in the development of a substance use disorder. However, this potentially fatal disease is entirely preventable by not initiating substance use. Prevention requires the recognition that substance use disorders are triggered by person-to-person spread, with the youth population being the most vulnerable.
The drug epidemic, which was new and geographically limited in Bejerot’s life, has gone global, with exponential growth, and polydrug use a new norm. What started as a few agriculturally-based drugs – heroin, cocaine, marijuana, and alcohol – are now mostly synthetic derivatives, making them far more easily manufactured and far less expensive. The social tolerance of substance use worldwide has increased over recent decades with legalization of marijuana leading a trend which eventually will include many more, if not all, currently illegal substances.
The observations made by Bejerot in Sweden decades ago are unequivocally needed today to inform public health policy. His salient observation and public health model, the person-to-person transmission of substance use disorder, remains unrecognized and entirely unincorporated into the prevailing conceptions of Substance Use Disorder, appearing neither as part of the Brain Disease Model nor the DSM-V criteria.
To appreciate the impact of this missing piece, consider the ferocity of the Covid-19 battle – what if the understanding of person-to-person disease transmission vanished? Instead, imagine the molecular biology of the virus alone had primacy, and anti-viral compounds were considered as the public health approach. Measures to control disease spread were not considered, because the research and policy focused exclusively on anti-viral medications and their delivery to infected patients. This scenario reflects today’s drug policy, devoid of Bejerot’s monumental contribution that addictive disorders are transmitted from an active user to a naïve host.
A Bejerot 100th birthday anniversary gift: incorporating his splendid accomplisments into thoughtful policy, lest the global drug pandemic marches exponentially forward. The battles he fought 60 years ago fulminate today and tomorrow.
This 100th anniversary is a message in a bottle, the remarkable foundation for an effective drug policy, delivered to us today through the enduring wisdom of this remarkable Swedish psychiatrist.
ROBERT L. DUPONT, – MD, President, Institute for Behavior and Health, Inc.
First Director, National Institute on Drug Abuse
Second White House Drug Chief
GERALD BUSCH – MD MPH, Assistant Professor; Associate Program Director, Addiction Psychiatry; Department of Psychiatry, University of Hawaii John A. Burns School of Medicine