A review of the Second Report of the Interdepartmental Committee on Addiction

Sections

1. The emergence of the Heroin and Cocaine problem in England
2. The Recommendations of the Second Report of the Interdepartmental Committee (1965): 23
3. Reactions to the Second (Brain) Report
Conclusion

Details

Author: M. M. GLATT
Pages: 29 to 42
Creation Date: 1966/01/01

A review of the Second Report of the Interdepartmental Committee on Addiction

Dr. M. M. GLATT
St. Bernard's Hospital (Management Committee) Southall, Middlesex, England

CONTENTS

   
Page
1.
The emergence of the Heroin and Cocaine problem in England:
 
 
( a) The Report of the " Rolleston Committee " (1926) and the First Report of the Interdepartmental Committee in 1961
29
 
( b) The effect of different public policies on the incidence of drug dependence
31
 
( c) The changing scene in England; the recent increase in heroin and cocaine dependence
32
2.
The Recommendations of the Second Report of the Interdepartmental Committee (1965)
33
3.
Reactions to the Second (Brain) Report:
34
 
( a) Problems arising out of regular heroin and cocaine prescribing
34
 
( b) The "prescribing doctors'" case against the Brain Report:
35
 
( c) Press Comments on the Second Interdepartmental Report
36
 
( d) Further discussion of the "pros and cons"
37
 
Conclusion
39
 
Tables
40
 
References
42

"The sun is setting on the junkies paradise in this country." ( One of the 'prescribing doctors', 1966) [ 1]

1. The emergence of the Heroin and Cocaine problem in England

(a) The Report of the " Rolleston Committee" (1926) and the First Report of the Interdepartmental Committee in 1961

In 1958 the Minister of Health and the Secretary of State for Scotland appointed a Committee with Sir (now Lord) Russel Brain as Chairman, its terms of reference being to review the advice of the Departmental Committee on Morphine and Heroin Addiction in 1926 (known as the " Rolleston Committee ") [ 2] , and if indicated to make recommendation that seemed expedient. As a result of the Rolleston Committee's proposals in 1926, amendments had been made to the Dangerous Drugs Regulations, which included the provision of a Tribunal in cases where a doctor was suspected of supplying, administering, or prescribing drugs otherwise than for medical treatment. It was made clear that prescriptions should only be given for purposes of medical treatment; and it was made an offence for a person receiving treatment from one doctor to obtain a supply of Dangerous Drugs from a second doctor without disclosing that he was being supplied by the first doctor.

" After careful examination " (first) Report of the Interdepartmental Committee (in 1961) [ 3] concluded that in Great Britain the incidence of addiction to Dangerous Drugs - including morphine, heroin, and other substances coming within the provisions of the

Dangerous Drugs Act, 1951, such as pethidine, methadone, levorphanol, etc., was still very small.

The figures provided by the Home Office (table 1) (" which might suggest an extension of addiction in Great Britain ") reflected, in the Committee's view, merely " an intensified activity for its detection and recognition over the post war period ". The number of doctors and nurses involved (table 2), though small in total, remained "disproportionately high ". The traffic in illicit supplies was " so small as to be almost negligible ", due in the Committee's view largely to two factors - social attitudes towards the observance of the Law in general, and to the taking of Dangerous Drugs in particular; and to the systematic enforcement of the Dangerous Drugs Act, 1951, and its Regulations. Despite the absence in Great Britain of a system of registration of addicts, the Committee felt satisfied that the " arrangements for recording manufacture and supply, and for inspection, continued to ensure that nearly all addicts are known to the Home Office, the Ministry of Health, and the Department of Health for Scotland." The Committee, like the Rolleston Committee, regarded addiction as an expression of mental disorder rather than a form of criminal behaviour, and recommended that every addict should be treated energetically as a medical and psychiatric problem; but whilst " satisfactory treatment of addiction was possible only in suitable institutions ", compulsory committal of an addict to such an institution was not thought desirable. In view of the small size of the problem, the establishment of specialized institutions exclusively for the treatment of drug addicts was considered " not practicable ". The best place for the initial treatment of the addict was the psychiatric ward of a general hospital, whereas long-term supervision would best take place at selected centres with facilities for research.

The Committee was " strongly opposed " to the suggestion that " registration " would be desirable or helpful, and it laid stress on clearing up the widespread misconception that addicts in Great Britain by a process of " registration " were entitled to receive supplies of Dangerous Drugs on prescription. " The continued provision of supplies to patient addicts depends solely on the individual decision made by the medical practitioner professionally responsible for each case ". (The Rolleston Committee had defined circumstances in which morphine or heroin may be legitimately administered to addicts, i.e. to " persons for whom, after every effort has been made for the cure of addiction ", the drug cannot be completely withdrawn because " of serious withdrawal symptoms which cannot be treated satisfactorily in general practice ", or because the addicts after withdrawal may no longer be able to continue leading a fairly normal and useful life. The Interdepartmental Committee was " impressed that the right of doctors in Great Britain to continue at their own professional discretion the provision of Dangerous Drugs to known addicts has not contributed to any increase in the total number of patients receiving regular supplies in this way ". At the same time the Committee " strongly condemned " the rare occurrence (only " two habitual offenders " during the past 20 years) of doctors issuing prescriptions to addicts "without providing adequate medical supervision, without making any determined effort at withdrawal, and notably, without seeking another medical opinion ". The Committee " strongly recommend (ed)... that every doctor should obtain a second medical opinion in writing before embarking on the regular prescribing of a Dangerous Drug for a lengthy period, say, in excess of three months... Furthermore, a general practitioner should prescribe only a limited supply of a Dangerous Drug to a patient temporarily under his care in the absence of a letter from the patient's own doctor ". The Committee concluded that special medical tribunals for investigation of grounds for withdrawing a doctor's authority to possess and supply Dangerous Drugs should not be established.

Thus the outcome was more or less a feeling that in regard to Dangerous Drugs there was not really much to worry about, and recommendations to leave matters at the status quo. This was more or less in line with the prevailing views. An annotation in The Lancet in 1960 [ 4] , e.g., stated that " serious addiction to narcotic drugs is a small problem here compared with the U.S.A.", referring to reports that in New York City alone there might be 50,000 addicts, half of them under the age of 21. However, it seems that at the time only few doctors and no hospitals took any special interest in the treatment of Dangerous Drugs addicts, and consequently few practitioners had much experience with them. Among the little written at that time was a report by two practitioners [ 5] reporting on the treatment of 53 addicts (between 1958 and 1960) in two phases. During the first and preliminary phase they were " given a supply of drugs whilst they were being stabilized and freed from black-market activities... Extra supplies were prescribed to prevent them returning to the black-market ". (The treatment also included psychotherapy, vitamins, etc.) This was followed by the second or withdrawal phase. The authors claimed that "as a result of (their) interference with the activities of the black market (they) were now able to treat our patients with more hope of success... because the black market has died away ". (This claim, as we shall see, was unfortunately not borne out by the later course of events.) Somewhat critically, a correspondent in The Lancet [ 6] congratulated the authors "... on a remarkable therapeutic feat in successfully treating 32 out of 51 addicts... results... never... remotely approximated by any other workers in this... field...". 1

Such good results necessarily attracted widespread attention abroad. Thus in the Monograph "Drug Addiction in Youth" (1965) L. Brill [ 7] refers to this "... experiment where patients are ' stabilized and carried on a daily dose of narcotics during a period of social and occupational rehabilitation, with the eventual goal of maintaining drug-free relationships' ". In the same volume I. Nyswander [ 8] , remarking on this work, and on "those patients in the English experience who withdrew from drugs but who... were unable to abstain permanently, were given drugs again by the physician and thus were able to continue their work and family life despite their affliction ", suggests that "since this method keeps the individual from the necessity of reverting to a vicious sub-culture for his supplies of drugs, and since it seems to encourage voluntary withdrawal, ... it might be advisable for us (in the U.S.A.) to experiment with this technique".

Not unnaturally, the legal availability of heroin and cocaine attracted many North American addicts to the U.K. (It was stated at an inquest that 70 Canadian addicts were treated over a 12-month period, 1963/64, by one London practitioner.). This work roused special attention in Canada and the U.S.A. - countries where according to many medical critics addicts were treated not as sick people but as criminals. The practitioner referred to was in fact invited to talk about these experiences in Canada, and reported that out of approximately 50 Canadian narcotic addicts treated in London, 18 had been "freed" from addiction, 17 were "at present under control and.., working steadily", and 2... "are preparing to reduce their doses of heroin and working steadily". [ 9] 1

In view of these reported good results of treatment methods allowed under the permissive English Laws and the relatively small size of the British heroin and cocaine problem, it is not surprising that many foreign observers regarded the so-called "British System" (which in many ways seems to constitute rather a lack of system) as certainly worthy of close scrutiny. To get the size of the problem in various countries in perspective, here are some very recent figures. According to recent newspaper reports, an American Senate Investigating Committee discovered that 10 kilograms of raw opium needed to produce 1 kg. of heroin were sold in Turkey for ?125, but had reached a price of ?80,000 once this consignment had got to the American Black Market and was sold to addicts there. Street sales of heroin to American addicts amounted to ?125 million per year. The number of narcotic addicts in the United States was estimated to be about 60,000. Criminal organizations were reported as making enormous profits from the illicit drug traffic. In spite of this, a Senate Committee in March 1965 rejected a proposal that the United States should adopt the "British System" of treating drug addicts by making narcotics available to them under legal control. In another part of the world, in Hong Kong, about 5% of the male working community are estimated to be heroin addicts, many of whom are unable to work; Hong Kong's 50,000 heroin addicts spend ?20,000 daily on their drug.

A more recent American article [ 37] quotes the practitioner concerned as having become much less optimistic about treatment results.

(b) The effect of different public policies on the incidence of drug dependence

One American observer attempting a close study of the drug situation in Britain (in 1960/61) was the sociologist and lawyer, E. M. Schur [ 10] . He sees as the main reason for the marked discrepancy between the American and the British figures of drug addicts the different official policies of controlling narcotics adopted by the two countries. In the U.S.A. widespread social disapproval of drug dependence - the addict often being regarded as a "dope fiend " - and the adverse legal consequences induce the addict to conceal his dependence. There is also in the U.S.A. "a thriving illicit traffic in drugs, a large amount of addict crime, and the spread of drug use and addiction by juveniles ". At the centre of these developments there stands-in Schur's view - "... the punitive approach to addiction embodied in American narcotic laws ". The high price of illicit drugs provides a powerful incentive for underworld trafficking, and is often a reason for crimes by addicts in order to obtain the means to purchase black market drugs. In contrast in Britain - with the medically-orientated approach, and with the management of addicts, regarded as sick people, lying essentially in medical hands - there is no incentive for illicit drug trafficking as the addict can obtain the drug from his National Health Service doctor legally and free from any charge. "The latitude (of the British policy) granted to physicians contrasts sharply with the restrictiveness of American policy..." During his two years' research in Britain, Schur found only little involvement of addicts in crime, and little resemblance of addicts to the stero-type " drug fiend " image. Many addicts in Britain belonged to those professions with easy access to drugs, to the middle class, and were in age-groups over 30; there was little evidence of an " addict sub-culture " and of the use of addict's slang. In all these aspects the problem in Britain differed from America.

(c) The changing scene in England; the recent increase in heroin and cocaine dependence

Schur's exposition illustrates his thesis that "who the addict is and how he behaves will vary with the policies 2 adopted to deal with the addiction problem ". But, although everybody in England interested in the problem of drug dependency will agree with Schur's criticism of a punitive policy and his advocacy of a medically orientated approach, already at the time his book, " Narcotic Addiction in Britain and America ", was published in 1962, there were clear signs pointing to a marked deterioration in the British scene [ 11] . It became clear that there was widespread smoking of marihuana reefers amongst youngsters as well as abuse of amphetamines, in particular "drinamyl ", popularly known as "purple hearts ". A few hospitals and institutions taking a special interest in the problem began to admit a number of teenagers who had "graduated" to the use of heroin and cocaine, [ 12] , [ 13] , [ 14] having started off with cannabis and amphetamines; it was clear however that only a minority-probably largely the psychologically more vulnerable segment-among such youngsters had gone on to this step [ 15] , [ 16] . All our young heroin and cocaine addicts seen were "non-therapeutic" in origin. Having started off with buying amphetamines or reefers, 3 usually in London's West End coffee bars, clubs, etc., they had been introduced to heroin (and somewhat later to cocaine) by friends, acquaintances, etc., at parties, clubs etc., and started taking it for "kicks ", new experiences, to "find out what it is like", because they did not want to be considered outsiders, etc., or because amphetamines and cannabis were no longer giving them the feeling of being "high ", etc. At first they experiment with small amounts, which they usually acquire for one English ? per grain (0.06 gram.) of heroin or cocaine from addicts who were themselves "registered" (the term which addicts themselves use, wrongly as we have seen) with a medical practitioner, and who manage to acquire a surplus. Such abusers thus act as addict-pushers. For a while - several weeks or months, on the average possibly about six months - the newcomer obtains his supply on the black market, but usually sooner or later, and often after he has progressed from "snorting" and subcutaneous "skin- popping" to intravenous" mainlining ", he can no longer manage to find the money needed to buy the increased amounts of drugs he needs; he "registers" with one of the few doctors ready to prescribe for addicts (and whose names are well known among addicts). Often, and in our experience the great majority, of these newcomers sooner or later themselves sell their surplus, thus introducing further teenagers to the use of heroin and cocaine [ 16] , [ 17] , [ 18] , [ 19] . 4

In the view of Wilkins [ 44] "... more important as a controlling factor than public policy..." may be public opinion, and more may perhaps be explained by "... preceptual... than (by) the procedural differences ". In Britain addiction is not only defined as an illness but tends also "to be perceived as such..." by the general population as well as by the authorities. "... Perhaps the image of drug addiction in Britain explains more of the situation than the control system ".

Among 90 of our young male heroin and cocaine addicts, the average age of starting on amphetamines had been 16.5 years, on cannabis 16.9 and heroin and cocaine 18.6 years. Corresponding ages in the case of 11 young female heroin and cocaine addicts had been 15.8, 15.5 and 20.6 years [ 14] .

Why it is that so many youngsters, fully aware that they can obtain these drugs legally and free of charge, so often prefer for long periods to pay black market prices for them? The reason given most frequently by them is that they consider it a much greater temptation and risk of becoming definitely "hooked" and ending up as established "junkies" once they put themselves in the position of getting the drug easily and regularly from a doctor without having to make any great effort (for instance by hanging around at midnight at all-night pharmacies, such as in Piccadilly, where "registered" drug addicts obtain their prescribed drugs, and without any expense.

Incidentally, in their talk these youngsters habitually use the addicts' slang; and they usually move in circles where drug-taking is prevalent and the "done thing ", and who have their own standards, customs, values, etc., so that certainly in London - and more recently also in other big cities - there has definitely emerged a drug addicts' sub-culture.

Official figures:

From discussing the matter with many drug addicts it is clear that at any one time there must be many about who have not (probably not yet) come to the attention of doctors, etc., and who are obtaining their drugs illegally [ 11] , [ 13] , [ 16] . The statement that almost all addicts are known to the Home Office is thus certainly not true; although nobody can say how much greater the number of addicts is than the "official" figures. However, the official figures too clearly reflect the steady increase of narcotic addiction in the U.K. over the past few years - a rise which has affected mainly youngsters, i.e. "non-therapeutic" and non-professsional addicts, and consists largely in an increase of heroin and cocaine dependence.

The figures in the second report of the Interdepartmental Committee (appendices I and II) show that in 1959 11 % of addicts were below the age of 35, and none was under 20; in 1961, approximately 20% were below 35 (mong these 2 under 20); in 1964, nearly 40% (including 40 addicts under 20). The total number of "known" addicts had risen between 1959 and 1964 from about 450 to 750, an increase of about two-thirds. In 1960 17% of addicts belonged to the medical and allied professions, in 1964 8%. The proportion of "therapeutic" addicts had fallen from about 80% in 1958 and 65% in 1959 to 45% in 1964. Heroin addicts numbered 39 in 1947, out of a total of 199 addicts; 69 in 1960 out of 437; 237 in 1963 out of 635, of whom 166 used heroin in conjunction with cocaine; in 1964 there were 162 new cases of heroin addiction - representing an increase of 50 % over the previous year - bringing the total of known heroin addicts to 342, i.e. 80% out of 753; of these 342, 206 used heroin in conjunction with cocaine.

The "pushing" of surplus drugs obtained by addicts on prescription was reported by all the hospitals in the London area admitting sizeable numbers of heroin and cocaine addicts (1964/65), namely St. Bernard's Hospital [ 13] , [ 16] , [ 45] , Tooting Bec Hospital [ 12] , [ 19] , West Park Hospital [ 46] and Spelthorne St. Mary [ 47] .

The 1965 figures in tables 3 and 4, which are the first to become available since the Second Report of the Interdepartmental Committee was published - show that this trend is still continuing, despite the publicity which followed upon the Report being published.

A recent survey of heroin addiction in the U.K. [ 20] reviewing the problem in the U.K. between 1954 and 1964 gives further interesting details (compiled with the help of Mr. H. B. Spear of the Home Office staff). (table 5).

Thus to the 57 heroin addicts known in 1954, 450 new cases were added in the following 10 years. Most of these were British; the mean age of British "therapeutic" addicts was about 61 years, of British" non-therapeutic" addicts 24 years. Of the 507 known addicts 55 had died, including 34 deaths among the "non-therapeutic" addicts at a mean age of 34 years.

As mentioned above, "non-therapeutic" addicts admitted to psychiatric hospitals and homes in recent years stated usually that they first obtained their supplies of heroin and cocaine from other "registered" addicts who thus served as a "focus of infection ". That "non-therapeutic" addicts rather than "therapeutic" addicts are instrumental in the Spread of the "heroin and cocaine epidemic" has been ascribed to the relative predominance among the former group of deviant personalities [ 20] , [ 21] . Such addicts also reported that as a rule it was not too difficult to get much higher doses than they really needed from certain practitioners by grossly exaggerating the amounts they needed; that they themselves had often "pushed" drugs; that often the dosage had increased gradually whilst under "treatment ", that sometimes they had easily been able to obtain such supplies "legally" whilst on leave from hospital or immediately after having been weaned off the drugs and having left hospital; and that hardly ever had any attempt been made to obtain a second opinion, or even an attempt by the prescribing doctor to get in touch with the patient's ordinary NHS practitioner; in the case of teenagers it seemed, too, that as a rule parents were not informed. Most general practitioners in the country apparently fight shy of embarking on a therapeutic programme which entails giving addicts regular prescriptions for a prolonged period. Only a few private and NHS practitioners think and act differently, and so it is not surprising that as soon as a practitioner was known to prescribe Dangerous Drugs, he became much sought after by other addicts. Thus when two London practitioners decided in 1962 to accept "any bona fide addict who was unable to get NHS prescriptions or to afford private prescriptions ", they found themselves within one year with 100 addicts on their list [ 22] , and their names, like those of a few others, became a household word among London addicts.

2. The Recommendations of the Second Report of the Interdepartmental Committee (1965): [ 23]

In view of such developments, it was not surprising that in July 1964, the Interdepartmental Committee was re-convened, in order to "consider whether, in the light of recent experience, the advice which the Interdepartmental Committee gave in 1961 in relation to the prescribing of addictive drugs by doctors needs revising and, if so, to make recommendations ". The Committee interpreted their terms of reference as being asked not to survey the whole subject of drug addiction, but rather to pay particular attention to the part played by medical practitioners in the supply of these drugs.

During the eight meetings held by the Committee, its members learned of the increase in the total number of addicts to dangerous drugs of addiction, of heroin and cocaine addicts, of young addicts, and of the "non-therapeutic" addicts. Out of 342 heroin addicts in 1964, 328 were "non-therapeutic" in origin (i.e. their addiction "originated other than from the administration of Dangerous Drugs from medical treatment ". The Committee also found the heroin production and consumption figures in the U.K. "very disturbing" 5 (see appendix III to the Report).

The Committee concluded that there had been a "disturbing rise" in the incidence of heroin and cocaine dependence, especially among young people. The "main source of supply is the over-prescribing of these drugs by a small number of doctors ". Thus in 1962 one doctor alone prescribed almost 600,000 heroin tablets (6 kg.) for addicts. The same doctor, on one occasion, prescribed 900 heroin tablets (9 g.) to one addict, and three days later, prescribed for the same patient another 600 tablets (6 g.) "to replace pills lost in an accident ". Further prescriptions of 720 (7.2 g.) and 840 (8.4 g.) tablets followed later to the same patient. Two doctors each issued a single prescription for 1,000 tablets (i.e. 10 g.) "... No more than six doctors have prescribed these very large amounts... and these doctors have acted within the law according to their professional judgment." The Committee therefore suggested further measures to restrict the prescribing of heroin and cocaine. Its recommendations include:

According to a 1965 Report of the Permanent Central Narcotics Board (United Nations), "The United Kingdon remains the leading producer and consumer of the drug (heroin)". [ 48]

  1. A system of notification of addicts to a central authority.

  2. The provision of advice - when addiction is in doubt - by an officially recognized panel of doctors (not confined to doctors on the staff of treatment centres) who can advise when the question of addiction is in doubt.

  3. The provision of treatment centres (part of a psychiatric hospital or of the psychiatric wing of a general hospital), to be set up as soon as possible, especially in the London area but also in selected hospitals in all other Regional Hospital Boards. The Treatment Centre staff should have powers for compulsory detention of addicts during crises arising during drug withdrawal.

  4. The restriction of supplies to addicts of heroin and cocaine (and later, if necessary, other drugs). Heroin and cocaine prescribing to addicts would be limited to doctors on the staff of these treatment centres. It should be a statutory offence for other doctors to prescribe heroin and cocaine to an addict. Disciplinary procedures against doctors alleged to have prescribed heroin and cocaine irregularly to addicts should be the responsibility of the General Medical Council.

  5. Prescribing: It should be the statutory duty of all doctors under the Dangerous Drugs Regulations, when writing prescriptions for Dangerous Drugs, to use words as well as figures to specify the quantities.

  6. Standing Advisory Committee: This should be set up to keep under review the whole problem of drug addiction and to advise on corrective health and social measures.

The Report also touched briefly on the subject of "other habit-forming drugs" (incidentally, the terminology used in the "Brain Report" does not employ the definitions recently suggested by the Addiction Subcommittee of the World Health Organization) [ 24] , with their danger for the young, and recommended thorough study of the involved social, medical and psychological factors, so as to plan appropriate remedial actions on all relevant fronts.

3. Reactions to the Second (Brain) Report

A great many comments have been made on the recommendations contained in this Report. An attempt will be made to present a critical review of the arguments which have been put forward, "for and against".

Problems arising out of regular heroin and cocaine prescribing

In general it seems agreed that there is little evidence of trafficking in illicit supplies brought into the country, apart from cannabis. Thus most reviewers accept the Committee's argument that the major source of supply has been the over-prescribing of a few doctors. These doctors acted "within the Law" although they did not follow the advice of calling in a second opinion and although it seems that they often equate prescribing of drugs with "treatment", a proposition with which many medical men would not agree. It also seems difficult to accept the argument that prolonged prescribing - by giving the doctor a chance to establish better relationships with the addict - in the long run would assist in his rehabilitation. Rather, it would seem that by prolonged prescribing the addict would become physiologically more and more dependent on the drug, and psychologically more deeply anchored in the habits and values of the addict sub-culture [ 17] . A recent English study has in fact shown that the more advanced "chronic addicts "fared less well with hospital treatment than those addicts who were in an earlier phase: only 2 out of 60 "chronic addicts" were (at the time when this study was reported) off heroin, as against 10 of those addicts in earlier stages [ 25] . No studies referring to the "maturing out" of addicts - as reported in America [ 26] have so far been made in Britain.

Another argument against the justification of prolonged prescribing is concerned with the great risk of infections arising out of the regular use of unsterilised needles, etc. Abscesses are very common among addicts and syringe-transmitted jaundice is seen occasionally; Marks [ 27] has recently described the common occurrence of abnormal liver function tests among heroin and cocaine addicts, which he ascribes as probably due to infective changes following such unsterile injections. Whilst it is sometimes stated that addicts may be able to continue work, in the experience of hospital psychiatrists the great majority of such addicts coming finally under hospital treatment have been unemployed for lengthy periods. Moreover, a doctor's habit of not informing the parents when he has prescribed heroin and cocaine for their adolescent child, seems open to serious objections, although one "prescribing doctor" stated that he felt it would be unethical to divulge it to parents. It would seem more in line with medical ethics that if a doctor felt it right and necessary for a youngster to be prescribed such a dangerous drug as heroin and cocaine - the dangers of which are known to him but not to the adolescent patient - to keep the parents informed as to what course he intends to follow. The argument, too, used by another "prescribing doctor" that parents never seemed to help when they finally got to know that their child was being given heroin and cocaine, seems to hold true only when they are asked to acquiesce in, and to support, a regime of regular prescriptions; one finds parents of such adolescents often only too anxious to co-operate fully when the aim is to get their children off these drugs. [ 13]

Another problem lies in the great difficulty of knowing how much an individual needs who first applies for a prescription. Addicts are usually a step ahead of doctors in this aspect. Needle marks do not mean anything, though usually quoted in this connexion [ 28] ; they may stem from any odd injection; occasionally they are due to methedrine injections, which has been used more recently by one or two of the "prescribing doctors" in place of cocaine (although methedrine in itself is a dependence-producing substance). The addict asks for 8 g. heroin and 6 g. cocaine; the doctor gives him 3 and 3, but in fact he may need only 2 g. heroin (and possibly cocaine not at all). Previous referral to hospital would at least enable one - by observing the strength of the abstinence symptoms 6 - to get some idea of the dosage required. Certainly hospital psychiatrists come across cases where one addict got sufficient supplies to provide a friend or wife regularly with a "fix".

Again, the method used occasionally to treat heroin and cocaine addicts with barbiturates is open to serious doubt. Barbiturates are - especially in such vulnerable personalities - in themselves dangerous dependence-producing drugs. We had recently in hospital a middle-aged heroin addict who for many months had received from a general practitioner a daily dose of 32 g. heroin plus 20 tablets (3 g. each) of Butobarbitone - the wife complaining bitterly that it was the barbiturate intoxication rather than the heroin which made her husband impossible to live with.

(b) The "prescribing doctors'" case against the Brain Report

What are the answers of the prescribing doctors to the criticism levelled against them by the Interdepartmental Committee? These doctors gave their reasons recently in an interview with a Sunday newspaper [ 1] . One important argument is, of course, the fear of the imported black market: "If the Brain proposals go through, I'm afraid it will lead to big business ". "I see our work as the front-line against the 'black market ' "; "Some addicts won't go to a Centre. God knows where they will get their drugs from."; "... they'll always get the stuff, somehow... They have a pertinacity which derives from their utter single-mindedness..."; "... Better the addict gets it through me, with some sort of supervision, than through the black market."

Although we, of course, do not advocate the "Cold Turkey" method.

Another argument given is that as "Junkies" cause so much trouble, most doctors do not accept them as patients, and "somebody has to do it ", and try to help them. "... Addicts are the despised of the earth-bums, wrecks, anything you like. But they are still human beings, and they have a right to my time".

The addict needs security and self-respect; "Paying for drugs gives them a bit of self-respect... The first thing you have to do with an addict is give him security, and, to him, that means drugs... You have to give them what they need before you start talking about withdrawal ". "We are not trying to get people off drugs unless they want to come off; it is useless, and it is no way to treat another human being. If the therapist will work very slowly and carefully, there is usually a chance."

Then there is the argument that addicts do not do well whatever way they are treated. "From bitter experience, I have learnt that it is hopeless to try to cut them down or cure them..." "I don't say we're curing many. I have got two people off heroin in 9 years. But I don't see any evidence of the hospitals doing any better ". "... They aren't going to prescribe with any more accuracy in these centres." But even if one wants the addicts to go to hospital, "there aren't enough facilities ". "I prescribe as little as I think they can get along with, and I try to get them into hospital. But the hospitals hate their guts ". One point is made that occasionally addicts given prescriptions are able to work; "... if they can be got off cocaine, which is more harmful but less addictive, there seems to be quite a good chance of keeping them going indefinitely on controlled quantities of heroin".

Some go further in their criticism of the Report. "I just don't feel that the people behind the Report got anywhere near the problem "; "... it's an utterly misdirected Report. But it's in a great tradition: confronted with a major social movement, introduce some... narrow restraint... It isn't just half a dozen G.P.'s at the bottom of this. You are up against the teenage explosion. If you have got five million teenagers with mowney, these people will experiment with drugs, pep pills, marihuana... Restricting supplies won't help a bit in treating these people... "Junkies" are often rather pleased when they manage to evoke authoritarian and disciplinarian responses. It gives them something else to resent..."

Other criticisms put forward by some of the "prescribing doctors" elsewhere include the allegation that the recommendations ignore the lessons of the U.S.A. drug problem, where there is virtually prohibition [ 28] . (A similar objection was voiced by a reporter in The Observer [ 29] . "The Brain Committee's Report... may be just the opening gun in a drive towards more oppressive laws... The trouble is - the harder you stamp, the more drug addiction you have. In America, possession of heroin is against the law for anyone - doctor or pharmacist as well as addict. As a result, New York now has more addicts than any other city in the world ". Criticism is levelled against the manufacture and consumption figures quoted in the Interdepartmental Report, as being meaningless and as ignoring countries such as the U.S.A., Canada and Hong Kong "with addiction problems roughly 20-fold as high as in the U.K." [ 30] .

(c) Press Comments on the Second Interdepartmental Report

A leading article in the British Medical Journal [ 31] , in general, is in agreement with the Report: "The Brain Committee's conception of drug addiction as a notifiable disease which, unless checked, will spread, is valuable in itself, and especially because it leads to the acceptable proposal of treatment centres, staffed by doctors with special experience. Any practitioner with a case of addiction to heroin or cocaine will feel relieved if he knows he can send such a patient for expert treatment elsewhere..." However, the Journal criticises the suggestion to make "... it a statutory offence for other than selected doctors to prescribe these drugs to addicts...", as being a "... grave step to take in order - it would appear - to control the over-prescribing habits of only a handful of doctors, serious and indeed tragic though the consequences of these habits are ". The paper states that this would be "the first time that a doctor's right to prescribe has been so restricted ". (Elsewhere [ 32] the Secretary of the British Medical Association called this proposed step "... one more inroad into the position of the family doctors ".) The B.M.J., therefore, suggests an alteration, i.e. to make it possible for any doctor to prescribe heroin and cocaine for addicts provided he does so only in consultation with an expert recognized in the way suggested in the Report. "Authorized medical supervision would automatically follow notification and would provide safeguards against social abuse ".

Doubt was also voiced by the B.M.A. Secretary whether the General Medical Council was the right body to discipline offending doctors, or whether an ordinary court would be the right tribunal.

A Lancet leader [ 33] , whilst stating that "... the Report may receive a general welcome ", adds that "it is inadequate in many ways ". Controls interfering with individual freedom to prescribe would be resented by doctors. Nevertheless, the profession as a whole might be wise to accept the limitation, which would "... save it much frustration in an area where therapy by non-specialists is virtually impossible ". "In fact ", The Lancet argues that the Committee's recommendations may "not go far enough in this direction". For example, cocaine prescriptions should be prohibited altogether as there are no longer any indications for its general use. Furthermore, "... the prescription of any dangerous drug besides heroin and cocaine to an addict by any doctor not on the staff of a treatment centre might be prohibited. Dependence not only on heroin and cocaine, but also to pethidine, dextromoramide and dipipanone has increased, and inexperienced doctors may all too easily give in to increased demands by addicts for addictive substitute drugs as alternatives for heroin and cocaine ".

Despite the Report's remarks on "provisions for research and long-term rehabilitation ", The Lancet feels that "Treatment Centre" seems something of an euphemism for" prescribing centre ", as without research into the manifold aspects of dependence in this country, rational treatment and prophylaxis is not possible. The Lancet criticises "other notable omissions from the Report ", such as that of a discussion of the extensive use of drugs affecting the central nervous system; of alcohol; of any interim advice to practitioners; of reference to the need for education of doctors and the general public. Finally, The Lancet criticises the Report's finding "that the addict is a sick person... provided he does not resort to criminal acts" (though in fairness it must be stated that the Report does not quite say that, but rather that the "addict should be regarded as a sick person, who should be treated as such and not as a criminal, provided that he does not resort to criminal acts " - which is not quite the same.

The Medico-Legal Journal, the organ of the Medico-Legal Society, in an Editorial [ 34] giving a factual review of the findings and the suggestions of the Brain Committee, states that "It is to be expected that no doctor on the staff of an addicts' treatment centre would supply regular quantities of hard drugs to registered addicts, prescriptions would be limited for short periods to those undergoing treatment." The Medico-Legal Journal ends its review by commenting that there was "a body of medical opinion which holds that no harm would be done if heroin and cocaine were abandoned altogether ". (However, an attempt by the Government 10 years ago to ban heroin in line with international request by the World Health Organization was defeated by the medical profession [ 35] .

A New Statesman article [ 36] comments that "Up to now, registered addicts have been able to earn enough money by selling to the unregistered addicts the surplus that they manage to talk their doctor into prescribing for them. But the efficient registration (in fact, the Brain Committee's Report speaks of "notification ", not "registration ") of addicts and the centralization of supply recommended by the Brain Report are aimed at reducing this traffic in surpluses... If he cannot have a surplus the addict will either have to work, get cured, or steal."

Finally, some views from the U.S.A. as presented in the Medical Tribune [ 37] : Two New York State public health officials, Drs. H. Brill and G. W. Larimore, had visited England some years ago and had concluded, in 1958, that the so-called "British Narcotic System" was no system at all but a "collection of administrative practices and informalities developed over the years in a situation so mild as to call for virtually no control ". Following a second visit in 1965 to England, Brill and Larimore commented that the suggested modifications of British permissive practices towards drug addicts were "... of great interest because Britain has been the one major country which has so long sought to maintain a theoretically permissive attitude with respect to narcotic drugs" [ 37] . Commenting on this article, Dr. H. Berger [ 38] remarks on the contribution of Commonwealth and American immigrant addicts to the increase of British addiction problems, and stresses "... the real point of the advantage of the British method (is that)... in England there are few, if any, crimes committed by addicts in order to obtain the huge sums demanded by (American) pushers for illicit drugs... The British by their studied hands-off policy have saved the vast majority of their unaddicted population the price of crime, broken homes, welfare payments, and the like. This is the crux of the problem. Certainly any physician who grossly abuses the trust reposed in him... can be dealt with by local authorities without creating a huge black market and a crime wave. Should England's new regulations be too restrictive, then they will surely reap all the problems which now beset (the U.S.A.)".

(d) Further discussion of the "pros and cons"

The preceding quotations from a number of widely scattered sources illustrate the vast differences of opinion regarding the suggestions put forward by the Interdepartmental Committee's Second Report. It would seem, however, that the great majority of interested medical men do not regard the prescribing practices of the few doctors criticised in the Report in a very favourable light as shown for example in a recent dicussion on the "Brain Report" held by the London Committee for the Study of Drug Addiction and following introductory talks by Dr. Ollendorff and the present writer. Incidentally, it seems that since the publication of the Report addicts find it much more difficult to get "registered" with the doctors criticised for their generous prescribing in the past but one or two other doctors are apparently proving more "helpful ". For example, a few weeks ago, a young addict immediately on release from prison - where he had spent several months free from drugs and received mainly psychotherapeutic treatment - had little difficulty in getting sizeable, regular supplies. Another addict who absconded from hospital after a period of several weeks without drugs managed immediately to obtain supplies not only for himself but also for a friend who likewise had been off drugs for over a month.

The finding that, despite the publication of the "Brain Report" and the ensuing, largely unfavourable publicity surrounding the activity of the criticised 'prescribing doctors ', addicts are able to find other practitioners ready to prescribe for them without ascertaining their medical need for the drugs, without going closely into their history, without asking for a second opinion, seems to show that mere disciplinary action against a few "offending" doctors would hardly prove sufficient to come to grips with the problem, as had been argued in some quarters. Any doctor known to have prescribed for one or two addicts will soon find himself beleaguered by others, and under stress to prescribe higher and higher amounts to more and more addicts, without having the time and the facilities for closer investigation.

Regarding the suggested " measures to curtail supplies ", it is clear also that in future the addict will be approached as a sick man and not as a criminal; (thereby avoiding his reaction of behaving like a criminal because he is treated as such); and under certain conditions the genuine addict in need of the drug will be able to obtain them legitimately although the exact method has yet to be worked out - a process which will probably tax the ingenuity of anybody concerned with the problem. In this way the developing situation should still remain basically different from the U.S.A. despite the risk of an imported black market in drugs. Such a risk, however, could hardly be made the excuse for condoning the practice of a medically produced and fed black market.

Recent practices of the few doctors concerned in the generous prescribing for addicts were clearly not in accordance with the Rolleston Report's recommendations of 1962 [ 2] which were largely endorsed by the First Interdepartmental Committee Report in 1961 [ 3] , in that hardly ever had there been made a "prolonged attempt at cure "before embarking on a regime of regular prescribing to the individual addict concerned; hardly ever a second opinion called in or notice taken as to whether "the patient (was) capable of leading a useful life so long as he (took) a certain non-progressive quantity..." and whether in fact he"... ceased to be able to do so when the regular allowance (was) withdrawn". Instead of first attempting a "cure" before proceeding to regular prescribing, the practice of the doctors concerned consisted in turning the recommended procedure the other way round, i.e. by starting to prescribe in the first instance, in the hope of effecting a cure later on. Thus the addict applying for drugs was given his prescriptions, notwithstanding the risk of developing into a focus of infection to other youngsters or the danger to himself of infection, over-dosage etc. In view of the risks to society and the individual one cannot just stand by and hope for the "maturing out" process to take place: ".. those.. concerned with the tremendous loss of human resources represented by the recruitment into the ranks of addicts of large numbers of youngsters.. cannot be satisfied with awaiting the "maturing out" that may occur 20 or 30 years later" (Freedman 39).

One obvious risk stemming from the recommendations of the Report concerns the provision that for the time being the "special restrictions" should apply to heroin and cocaine only. In the past whenever drugs found to produce dependence were put under certain restrictions other drugs immediately took their place in attracting the attention of the "dependence-prone" vulnerable segment of the population: for example, barbiturates were followed first by methylpentynol and later by other non-barbiturate sedatives, amphetamines by phenmetrazine [ 40] etc. The recent unfavourable publicity regarding cocaine seems to have been responsible for increasing prescriptions and abuse of methedrine. Often drug abuse in this country seems to have followed the American pattern, and at present L.S.D. abuse is also becoming more popular in England. Thus the special restrictions on heroin and cocaine are likely to lead rapidly to an increasing demand on general practitioners to prescribe other narcotic drugs. It might therefore seem preferable to restrict also these other drugs immediately, rather than waiting until their increasing abuse necessitates amending the "restricted list".

" Treatment Centres ": The Lancet's notion of equating "treatment" with "prescribing centres" is surely not what the "Brain Committee" had in mind. The main emphasis in such centres should be in giving the addict the motivation and incentives to come off drugs and helping him to reach and to maintain this objective [ 41] . Treatment centres should be also concerned and perhaps foremost, with rehabilitation and after-care, with assisting the addict in keeping away from his old haunts and friends and the trappings of the "addicts' subculture" (The addicts known to us who have successfully managed to stay off drugs are all people who managed to make a clean break from their old environment). Adequate facilities should be available for occupational therapy and vocational advice and training, for obtaining further education, for recreation etc. Treatment centres should have at their disposal adequate arrangements for research into all aspects of drug dependence including assessment of various treatment methods (without which proper preventive measures are not possible); they should provide for professional training and contribute towards the education of the general public. Such centres require an experienced, understanding staff in adequate numbers. For many patients closed wards will be necessary. All this would necessitate a considerable contribution from the Treasury, and much time and planning, and in the meantime (and this may extend over a very long period) there is an urgent need for interim arrangements and guidance.

The provision giving treatment centres the possibility to detain addicts during a withdrawal crisis is obviously a wise move; quite a few of our hospital patients wanted to leave during this period of great stress but having been persuaded to stay on they were later grateful for having done so. Just as mere sobering up and detoxication does not constitute treatment of alcoholism, in the same way drug withdrawal by itself is only a first aid measure which has to be followed up by a long term programme of re-education, emotional re-orientation, re-socialisation etc. A programme based on the therapeutic community principle and group-therapy [ 13] would seem, in our experience, to be helpful in this connection. In order to be effective a hospital stay of several months (possibly at least six months) would be required and this would have to be followed up by a lengthy after-care programme; possibly with the aid of a half-way house. In the case of the young, often highly undisciplined and rebellious addicts it would also seem - as far as our limited experiences show - that a heterogeneous group, for example, within the framework of a larger alcoholic group, would be more suitable so as to get the young addicts away from persisting within hospital with the customs, values, attitudes etc. of the subculture they had been used to. This would also give the more mature type of middle-aged alcoholic patients the opportunity to exercise some beneficial, socialising and stabilising influence on this youth. The youngsters often (though not always) come from a very unstable home background; they left school at an early age, never acquired any vocational skill but were yet immediately able to earn substantial wages, which made them even more independent from any remaining parental influence. Finally, they were "swallowed up" in a group of youngsters roaming around in the West End, and introduced to the taking of 'purple hearts' and the smoking of ' reefers ', before the more unstable or more "adventurous" among them proceeded to the "hard drugs ".

Limitation of supplies to addicts: The policy adopted by the different treatment centres will obviously vary to some extent, depending on the doctor in charge, but some coordination of policy would be necessary so as to prevent addicts flocking to those centres which are more generous with their supplies. These centres would have to be experimental in the sense that procedure and policy would need to be under constant scrutiny, that there would be regular comparison of findings and procedures in the various centres etc. Before putting addicts on a (minimum) maintenance dose (to be reviewed from time to time) as a rule, whenever feasible, a preliminary residential period of assessment might be required.

Few doctors in this country have much experience with heroin and cocaine addicts (and probably even fewer nurses) so that the staffing of the centres will present a problem. In fact in many ways the most experienced practitioners are the "prescribing doctors ". One group of addicts suggested the establishment of two different types of centres: actual treatment centres, and, separate from them" maintenance centres ", the latter to be staffed by those "prescribing doctors" who might be willing to co-operate. This suggestion, however, carries the obvious risk that in view of their strong opinions on this point such practitioners might continue with their lavish prescribing habits. On the other hand, one might feel that doctors interested in the problem should be given an opportunity to participate in some way or other: for example, by working in a centre, and by taking on the responsibility of supervising the aftercare of addicts seen at the centre, including the provision of maintenance supplies to those patients for whom this procedure had been found necessary in in-patient assessment. In this way the practitioner may be able to establish a positive relationship with the addict, to encourage him gradually to reduce the amount needed etc. The possibility of fixing a "ceiling" on the number of addicts on an individual practitioner's list (to protect him from being overrun by them) as well as of the dose allowable for the individual addict (the latter varying from case to case) might be explored. In such cases, if the addict begins to clamour for higher amounts of drugs he could then be referred back to the centre.

American observers have found [ 42] that maintenance on a fixed dose may sometimes be possible in those addicts who do not use the drug intravenously, who are not members of a "sub-culture ", and who have become addicted through therapeutic use. In all these aspects the new type of heroin-cocaine addict in England - young, non-therapeutic in origin, "main-lining" etc. - does not seem to be a hopeful proposition for maintenance therapy, and he should therefore be strongly encouraged to come off the drugs altogether. The present practice of a few doctors of putting youngsters on a regular heroin and cocaine regime should be strongly discouraged and, if at all possible, completely avoided. Possibly the older, longer established, "therapeutic" or professional addict might require and be more suitable for the" maintenance'' approach, on condition that a number of residential "cures" should have failed and that he should have demonstrated that he can lead a useful, relatively normal life without increasing his dose. In fact, the gradual superseding in England of the former therapeutic, professional, older addict able to continue with his work whilst on drugs (possibly because of his relatively better personality type), by the non-therapeutic, non-professional, unskilled, uneducated and unstable youngster, may have contributed greatly to the breakdown of the former apparently successful "British practice" of handling addicts. On the other hand, this practice has also apparently played its part in creating the modern young English addict although obviously wider social factors, immigration of North American addicts etc. must all have played a part. At any rate, it is clear that the programme of centres must be sufficiently elastic and adaptive to enable them to deal with any emergent problems, and it must incorporate a planned research programme.

The watch for any changing patterns in the field would be one of the tasks of the suggested Standing Advisory Committee. This recommendation, though hardly commented on by the critics of the "Brain Report ", seems to us one of its most important proposals. In this way the drug scene, which is bound to change and shift rapidly, can be continually kept under scrutiny and review, and appropriate measures suggested before matters get out of hand. If such a Standing Committee had existed in the past few years, it might possibly have forestalled the emergence of the present day situation with its increasing numbers of drug-hungry youngsters who so often claim that drugs such as heroin and cocaine cannot really be so harmful: "otherwise, why should doctors prescribe them so readily?" Among the tasks of the Standing Committee would obviously be a watch for the abuse of other narcotic drugs and substitutes, for the emergence of signs of an imported black market, etc.

Conclusion

The main part of our discussion dealt with the roles of the "prescribing doctors" and of the proposed treatment centres in the future. The Interdepartmental Committee viewed its terms of reference as applying not to the whole field of drug dependence but mainly as an investigation into the importance of medical practices in this connection. Although compared with conditions in certain other countries there has been a definite continuing increase of the problem of heroin-cocaine dependence in this country over the past few years, a problem which cannot be ignored or dealt with by shouts of "hysteria" and of "panic measures" [ 43] . 7The present day practice has not only failed to prevent the increase in the view of the Second Report of the Interdepartmental Committee - and as seen by several "neutral observers " - it has helped considerably to bring it about by creating a doctor-produced and doctor-maintained black market, small as it may be in comparison with the U.S.A. (with its punitive approach to the drug dependence problem). The Brain Committee recommends that in the future also the addict should be treated as a sick man and not as a criminal, and that the approach should remain medically-orientated. There are obviously other factors of great importance as for example the "teenage explosion". But this cannot be taken as an argument for removing the need for doing something immediately about the one, definitely known, important factor - without waiting for the investigation of the wider social issues involved, which is a task which may take a great many years. On the contrary, it makes it even more important to limit an obvious source of temptation for the affluent, bored, thrill-seeking type of youngster. The Committee recognises the danger of substitute addictions and of an illicit trafficking in imported drugs (as is already the case with cannabis); developments will have to be watched carefully, a task which among others will fall to the recommended Standing Advisory Committee. Beyond this, everyone recognises the overriding need for a comprehensive, large-scale programme of research, education, and prevention, as well as of rehabilitation. It remains to be seen, however, how much money the Treasury will be able to make available for these purposes in view of the competing claims of the so many other pressing social and other problems of our time.

In fact one might just as well question whether, had measures been taken a few years ago" to nip in the bud" the over-prescribing by a few doctors, the reservoir of heroin and cocaine addicted youngsters in this contry would be present at all today.

Tables

TABLE 1

Numbers of known addicts to each drug in Great Britain in 1936, 1937, 1938, 1939, 1947, 1950, 1954, 1958, 1959 and 1960

  1936 1937 1938 1939 1947 1950 1954 1958 1959 1960
Morphine
545 447 406 421 134 139 150 169 205 204
Diacetylmorphine
60 106 68 70 39 43 55 66 62 68
Cocaine
50 50 34 35 8 9 7 15 25 30
Medicinal Opium
-
7 3 2
-
-
-
-
-
-
Hydrocodone (Dihydro- codeinone)
-
-
-
-
1 1 1 2 1 1
Hydromorphone (Dihy- dro-morphinone)
-
7 4 3 1 3 3 6 4 3
Codeine
-
3 4 3
-
-
-
-
-
-
Pethidine
-
-
-
-
28 34 36 86 117 116
Methadone
-
-
-
-
2 5 17 32 47 51
Levorphanol
-
-
-
-
-
-
1 5 32 16
Phenadoxone
-
-
-
-
-
3 4 10 16 21
Dextromoramide
-
-
-
-
-
-
-
-
-
4
Dipipanone
-
-
-
-
-
-
-
-
-
1
TOTAL ADDICTS
616 620 519 534 199 226 260 347 442 454

NOTE. Where a person is addicted to more than one drug he is counted as an addict to each drug, but in arriving at the totals shown at the bottom of the table each addict is counted once only.

(From: Report of the Interdepartmental Committee, 1961)

TABLE 2

Numbers of known addicts in Great Britain belonging to medical, dental, pharmaceutical and veterinary professions, and of other addicts, by sexes

  1936 1937 1938 1939 1947 1950 1954 1958 1959 1960
Professional *
147 140 143 131 54 48 49 63 74 68
Non-Professional Male
166 160 103 138 41 54 70 107 126 131
Non-Professional Femalea
303 320 273 265 104 124 141 177 242 255
TOTAL
616 620 519 534 199 226 260 347 442 454

*Nearly all males.

a Includes addict nurses. The number of these for 1960 is 14.

(From: Report of the Interdepartmental Committee, 1961)

TABLE 3 *

Addicts to Dangerous Drugs

  1965
Total number of addicts to dangerous drugs
927
Number of addicts to heroin
521
Number of addicts to cocaine
311
Total number of addicts of non-therapeutic origin
580
Number of heroin addicts of non-therapeutic origin
509

*Provisional Home Office figures to be read with appendix I to the Second Report of the Interdepartmental Committee.

TABLE 4 *

Ages of Addicts to Dangerous Drugs

  1965
Age under 20
145
Taking heroin
134
Age 20-34
347
Taking heroin
319
Age 35-49
134
Taking heroin
52
Age 50 and over
291
Taking heroin
16
Age unknown
10
TOTAL
927

*Provisional Home Office figures, to be read with appendix II to the Second Report of the Interdepartmental Committee.

TABLE 5

Table I. Number of New Cases of Heroin Addiction Recorded, 1955-1964

 

British

 
 

Men

Women

Total

Canadian

Other Nationality*

Total

1955 4 5 9 0 1 10
1956 5 5 10 0 0 10
1957 5 2 7 0 0 7
1958 3 8 11 0 0 11
1959 4 6 10 1 0 11
1960 11 4 15 4 4 23
1961 18 9 27 24 5 56
1962 39 10 49 16 5 70
1963 54 23 77 10 3 90
1964 98 35 133 15 14 162
TOTAL for decade
241 107 348 70 32 450

Includes: United States, 13; Jamaica, 8; India, 3; Australia,-3; New Zealand, 2; Other, 3.

(T. Bewley, Brit. Med. J., 1965, 2, 1284. By kind permission of the author and the B.M.J.)

REFERENCES

001

Sunday Times (Weekly Review), 20 February 1966.

002

Report, Departmental Committee on Morphine and Heroin Addiction, Ministry of Health, 1926.

003

Interdepartmental Committee on Drug Addiction. First Report. HMSO, London, 1961.

004

The Lancet (Annot.), 1960, i, 587.

005

Frankau, I. M. - Stanwell, P. M., The Lancet 1960, ii, 1377.

006

Stungo, E., The Lancet 1961, i, 56.

007

Brill, L., in: "Drug Addiction in Youth ", ed. E. Harms, Pergamon Press, Oxford, 1965, p. 162.

008

Nyswander, I., ibid. p. 126.

009

Frankau, I. M., Addictions (Toronto), 1964, 11, 47.

010

Schur, E., "Narcotic Addiction in Britain and America", Indiana Univ. Press, Bloomington and London, 1962.

011

Glatt, M. M., Medicine, Science and the Law 1965, 5, 178. (Annotation).

012

Bewley, T., The Lancet 1965, 1, 808.

013

Glatt, M. M., The Lancet 1965, ii, 171.

014

George, H. R. - Glatt, M. M., Brit. J. Addict. 1966 (in the press).

015

Glatt, M. M., Public Health 1966 (in the press).

016

Glatt, M. M., Brit. Med. J. 1964, 1, 1116.

017

Glatt, M. M., The Lancet 1965, i, 910.

018

Howard, A., Med. Leg. J. (Camb.) 1965, 33 (2), 56.

019

James, I. P., The Lancet 1965, ii, 288.

020

Bewley, T., Brit. Med. J . 1965, 2, 1284.

021

Chein, I., Gerard, D. L., Lee, R. S. and Rosenfeld, E. "Narcotics, Delinquency and Social Policy" . Basic Books, New York, 1964.

022

Hewetson, J. - Ollendorff, R., Brit. J. Addict. 1964, 60, 109.

023

Drug Addiction. Second Report of the Interdepartmental Committee. HMSO London, 1965.

024

WHO Expert Committee on Addiction-Producing Drugs. Thirteenth Report. World Health Organization, Technical Rep. Ser. 1964, 273, 9.

025

Chapple, P. A. L., 2nd Conference Treatment of Heroin and Cocaine Addiction, London, February 1966.

026

Winick, C., Bull. Narcotics 1964, XVI, 1.

027

Marks, V., Brit. J Addict. 1966 (in the press).

028

A Physician, "Anarchy 60 ", 1966, 6, 33.

029

Corby, J., Observer, 5 December 1965.

030

Ollendorff, R., 2nd Conference Treatment of Heroin and Cocaine Addiction, London, February 1966.

031

Brit. Med. J., Leading Article, 1965, 2, 1260.

032

Stevenson, D., Medical News, 3 December 1965.

033

The Lancet, Leading Article, 1965, ii, 1113.

034

Medico-Legal J., Editorial, 1966, 34 (I), 1.

035

Brit. J. Addict. 1956, 53, 29.

036

Campbell, J., New Statesman, 3 December 1965.

037

Brill, H. - Larimore, G. W., as reported in Medical Tribune, 25th December 1965.

038

Berger, H., Medical Tribune, 15th 16th January 1966.

039

Freedman, A. M., Comprehensive Psychiatry 1963, 4, 199.

040

Glatt, M. M., Brit. J. Addict. 1963, 59, 27.

041

Glatt, M. M., The Lancet 1965, ii, 795.

042

Lindesmith, A. R., "Narcotic Addiction Perspectives ", Massachusetts Conference in 1964, p. 1.

043

Guy's Hospital Gazette, Editorial, 5th March 1966.

044

Wilkins, L. T., in: "Narcotics ", ed. Wilner, D. M. and Kassebaum, C. G., McGraw-Hill Book Company, New York, London 1965, p. 140.

045

Glatt, M. M., Nursing Mirror, 11 June 1965.

046

Chapple, P. A. L. - Marks, V., The Lancet 1965, ii, 289.

047

Patricia (Sister Superior), The Lancet 1965, ii, 544.

048

Permanent Central Narcotics Board (U.N.), Report to the Economic and Social Council on the Work of the Board in 1965, United Nations, New York, 1965, p. XLI.