The treatment of narcotic dependence in the United Kingdom

Sections

Introduction
The treatment of narcotic addiction before 1968
The recommendations of the Brain Committee and their implementation
Treatment of heroin addiction since 1968 - dimensions of the problem
The work of the hospital treatment clinics
In-patient treatment
Rehabilitation outside the hospital
The contribution of prevention
Research and evaluation
Conclusion

Details

Author: J. E. GLANCY
Pages: 1 to 9
Creation Date: 1972/01/01

The treatment of narcotic dependence in the United Kingdom

McA. M.D. F.R.C.P. F.R.C.Psych. J. E. GLANCY Senior Principal Medical Officer, Department of Health and Social Security, London.

Introduction

The purpose of this article is to describe the main features of present arrangements for the treatment of narcotic dependence in the United Kingdom.

The treatment of drug dependence in the United Kingdom-as opposed to its prevention-is regarded primarily as a medical and psychiatric responsibility and, like other forms of medical treatment, is provided through the National Health Service. The view that addiction is an illness was first set out authoritatively in the 1926 report of the Ministry of Health Committee on Morphine and Heroin Addiction (the Rolleston Committee) ( [ 1] ) which endorsed the general view of its witnesses that "the condition must be regarded as a manifestation of disease and not as a mere form of vicious indulgence". This concept has been accepted without reservation ever since as the basis for general policy and was reaffirmed in the first report (1961) of the Interdepartmental Committee on Drug Addiction (the Brain Committee) ( [ 2] ) which stated that "addiction should be regarded as an expression of mental disorder rather than a form of criminal behaviour". The treatment of addicts is not, however, regarded as the exclusive responsibility of doctors. People who become dependent on drugs exhibit a great variety of problems for attention extending to such everyday matters as employment and housing. A wide range of treatment and rehabilitation services, official and voluntary, is involved both in hospitals and in the community, and many of these services are not concerned exclusively with the needs of drug addicts.

The rapid development during the past few years of_ international concern about the growth of drug misuse and the problems associated with it has been accompanied by a considerable amount of comment about the " British system " of treating dependence on drugs. In much of this comment this term " British system " seems to be equated simply with the administration or prescribing of narcotic drugs to patients as part of their treatment. Used in that way the term may give rise to misunder standing in two respects. Firstly, it is the fact that no one form of treatment is practised in England to the exclusion of others. The corollary of treating drug dependence as an illness is that the method of treatment is determined by the individual doctor. To the extent that particular practices, such as prescribing narcotic drugs, are commonly employed, their significance may vary from one treatment to another. Secondly, recent years have seen changes in the incidence and social effects of narcotic dependence and consequent modification both in the law and in the over-all approach to treatment. To apply the term " British system " indiscriminately to present and past treatment is to ignore the changes that have taken place both in the specific context of therapy and the wider context of rehabilitation.

The treatment of narcotic addiction before 1968

The 1926 Rolleston Report, one of whose conclusions has already been mentioned at the start of this article, was particularly concerned to define the circumstances in which a doctor might properly supply a drug of addiction to an addict. The report defined the patients for whom this might be done as:

  1. Those who are undergoing treatment for cure of the addiction by the gradual withdrawal method;

  2. Persons for whom, after every effort has been made for the cure of the addiction, the drug cannot be completely withdrawn, either because:

    1. Complete withdrawal produces serious symptoms which cannot be satisfactorily treated under the ordinary conditions of private practice; or

    2. The patient, while capable of leading a useful and fairly normal life so long as he takes a certain non-progressive quantity, usually small, of the drug of addiction, ceases to be able to do so when the regular allowance is withdrawn.

This view was accepted by the medical profession and the Government of the day. It was interpreted by both not as giving carte blanche for prescribing heroin or morphine to any addict under any circumstances, but as discouraging the prescribing of such drugs to any addict patient unless, in the opinion of the doctor concerned, there were overwhelming reasons for not subjecting the individual patient to complete withdrawal. The essential right of the doctor to prescribe drugs if he judged it necessary for the treatment of his patient was not challenged, but the doctor was expected to apply the Rolleston Committee's guidance in judging whether his patient's functioning would be improved or impaired by continued use. At this time - and indeed until the early 1960s-the number of addicts known to the Home Office was relatively small and static. Most of them were middle-aged and it is known that a majority were of " therapeutic " origin - that is, had first obtained drugs by having them prescribed for the treatment of illness.

This freedom of doctors to prescribe narcotic drugs to addicts unfortunately left open a door to abuse. What happened has been documented in these pages by Glatt ( [ 3] ) and Bewley ( [ 4] ). In 1961 the Interdepartmental Committee on Drug Addiction under the chairmanship of Sir Russel Brain (later Lord Brain) (see above) which had been set up to review the Rolleston Committee's advice in the light of recent developments - particularly in the use of drugs other than narcotics - had reported that in relation to the misuse of narcotic drugs the situation was not one which warranted any change in existing practices. Evidence however had begun to emerge of a sharp increase in the incidence of heroin addiction, particularly among young people. The Committee were reconvened in 1964 to examine the situation again in the light of the new evidence. In their second report ( [ 5] ) published in 1965 they reported that (see table 1) there had been an alarming increase in addiction to heroin and heroin used in conjunction with cocaine, especially among young people. The number of heroin addicts under the age of 34 had risen from 35 in 1959 to 259, including 40 aged under 20, in 1964. The Committee found that the main source of supply had been the over-prescribing of heroin and cocaine by a small number of doctors. They mentioned instances in which large quantities of drugs had been prescribed on a single occasion and commented that " No more than six doctors have prescribed these very large amounts... and these doctors have acted within the law according to their professional judgement. " It appeared to the Committee that the sharp rate of increase in the number of addicts would continue unless something were done to stop it.

The recommendations of the Brain Committee and their implementation

The problem facing the Committee was to reconcile something which was established as an important element in the treatment of a number of addicts - that is, the practice of " maintenance prescribing " - with the need for more effective protection of society generally against the continuing spread of addiction. The general approach adopted was to seek to establish controls which, while not violating medical responsibility for the treatment of addiction, would limit the number of doctors authorized to supply heroin and cocaine to addicts, would ensure that the supply of drugs took place only in a setting where there was a comprehensive range of treatment facilities, and would establish a measure of scrutiny over the problem of addiction as a whole. The Committee's recommendations included the following:

  1. Compulsory notification of addicts to a central authority.

  2. The provision of treatment centres as part of psychiatric hospitals or of the psychiatric departments of general hospitals.

  3. 3. Prescribing of heroin and cocaine to addicts to be restricted to doctors on the staff of the treatment centres.

  4. Compulsory powers to be provided for detaining addicts for brief periods during acute episodes in treatment they had voluntarily accepted.

  5. The establishment of a Standing Advisory Committee to keep the whole problem of drug addiction under review.

TABLE 1

Number of addicts known in the United Kingdom and drugs used, 1958-68

 

Sex

Origin

Drugs used a

Year

No. of known addicts

M

F

T b

N/T c

UK d

Morphine

Heroin

Cocaine

Pethidine

Methadone

1958 442 197 245 349 68 25 205 62 25 117 47
1959 454 196 258 344 98 12 204 68 36 116 60
1960 437 195 242 309 122 6 177 94 52 98 68
1961 470 223 247 293 159 18 168 132 84 105 59
1962 532 262 270 312 212 8 157 175 112 112 54
1963 635 339 296 355 270 10 172 237 171 128 59
1964 753 409 344 368 372 18 171 342 211 128 62
1965 927 558 369 344 580 9 160 521 311 102 72
1966 1,349 886 463 351 982 16 157 899 441 123 156
1967 1,729 1,262 467 313 1,385 31 158 1,296 462 112 243
1968 2,782 2,161 621 306 2,420 56 198 2,240 564 120 486

a Alone, or in combination with other drugs.

b T = Therapeutic.

c N/T = Non-therapeutic.

dUK = Unknown.

The Committee's recommendations (except for the provision of limited compulsory powers of treatment) were accepted almost in their entirety by the Government of the day. The action required to implement them was of two kinds - legislative and administrative. Legislation was introduced in 1967 in the shape of the Dangerous Drugs Act 1967. The Act enabled regulations to be made restricting the supply of dangerous drugs to addicts and requiring their statutory notification. Regulations were introduced in the following year. The Dangerous Drugs (Supply to Addicts) Regulations 1968 provided that " a medical practitioner shall not administer, supply or authorise the administration or supply to persons addicted to any drug, or prescribe for such persons, any substance to which this Regulation applies except:

" ( a) For the purpose of relieving pain due to organic disease or injury; or

" ( b) Under the authority and in accordance with the conditions of a licence issued to him by the Secretary of State in pursuance of these regulations. "

The regulations applied only to heroin and cocaine. The Dangerous Drugs (Notification of Addicts) Regulations 1968 provided that " any medical practitioner who attends a person who he considers, or has reasonable grounds to suspect, is addicted to any drug shall, within seven days of the attendance, furnish in writing to the Chief Medical Officer at the Home Office such of the following particulars with respect to that person as are known to the medical practitioner, that is to say the name, address, sex, date of birth and national health service number of that person, the date of attendance and the name of the drug or drugs concerned ". For the purpose of both sets of regulations, a person was regarded as addicted to a drug " if as a result of repeated administration, he has become so dependent upon the drug that he has an overpowering desire for the administration of it to be continued " and a drug was regarded as " any substance for the time being specified in Part 1 of the Schedule to the Dangerous Drugs Act 1965" (this covers drugs controlled under the Single Convention).

Administrative action comprised the provision of facilities for the treatment of addiction. As mentioned above the Brain Committee recommended the establishment of special treatment centres for this purpose. This recommendation related only to the London area; the Committee took the view that outside London the extent of addiction was not sufficient to warrant the provision of special centres. The Committee envisaged that facilities would in every case be provided as part of the hospital service and this was the approach adopted by the Government. Hospital authorities were asked by the Ministry of Health (predecessor of the present Department of Health and Social Security) to provide facilities in mental illness hospitals or in the psychiatric departments of general hospitals for the in-patient treatment of addicts willing to accept withdrawal. They were also asked to provide out-patient services for the treatment of those addicts who would not accept withdrawal. The role of out-patient treatment was explained by the Ministry in the following terms:

... complete refusal of supplies will not cure ... addiction - it will merely throw [addicts] on to the black market and encourage the development of an organized illicit traffic on a scale hitherto unknown in this country .... The aim is to contain the spread of heroin addiction by continuing to supply this drug in minimum quantities where this is necessary in the opinion of the doctor, and where possible to persuade addicts to accept withdrawal treatment ( [ 6] ).

There had been no requirement before 1968 for doctors to notify addicts whom they treated but the Government was able on the information available to it to estimate that there were some 1,000 heroin addicts in the London area and a further 200 in the rest of the country. To meet the estimated need in the London area arrangements were made for special out-patient clinics to be established at 14 hospitals. A number of special in-patient units were also planned. Outside London arrangements were made for addicts to be treated by the ordinary hospital psychiatric services, but in a few centres where the number of addicts was known to be relatively substantial special clinics were established on the London pattern. Everywhere the provision made formed part of the ordinary hospital services provided for the whole population through the National Health Service; no special administrative structure was created.

The arrangements for issuing licences to doctors under the Dangerous Drugs (Supply to Addicts) Regulations to prescribe heroin and cocaine to addicts were linked with the planning of the hospital services. The objective was that drugs should be prescribed only within the context of the arrangements for hospital treatment. Each of the special clinics for heroin addicts was under the direction of a consultant psychiatrist and licences were issued to these consultants and to doctors on their staffs. In places where there were no special clinics licences were issued to psychiatrists in the hospital service on a sufficient scale to ensure the availability of treatment in any place where the need for it might arise. The licensing formalities were completed and the Dangerous Drugs (Supply to Addicts) Regulations brought into force as soon as the arrangements for providing hospital treatment were well established. Many of the special clinics were in operation some months before the Regulations came into force.

The two sets of Regulations made it the responsibility of every doctor to decide whether a patient whom he attended should be notified as addicted to drugs, or whether he genuinely needed drugs for the relief of pain. To advise doctors who might find themselves in doubt as to whether there was a genuine need for drugs to relieve pain, advisory panels were established whose members were doctors representing a wide range of specialties. Little difficulty, however, appeared to be experienced by doctors generally in complying with the new requirements and very few have found it necessary to consult the advisory panels.

The Brain Committee's recommendation that an advisory committee should be set up to keep the whole problem of drug addiction under review had already been given effect in 1967 with the establishment, by administrative action of the Government, of the Advisory Committee on Drug Dependence. (The subsequent work of the Advisory Committee demonstrated clearly the valuable part to be played by such a body, and its functions have now been put on to a statutory basis by the Misuse of Drugs Act, 1971, which establishes the new Advisory Council on the Misuse of Drugs.)

Treatment of heroin addiction since 1968 - dimensions of the problem

The Dangerous Drugs (Supply to Addicts) Regulations came into operation on 16 April 1968. Table 2 shows the numbers of in-patients and out-patients being treated by hospitals for heroin addiction in successive quarters from the beginning of 1968 to the end of 1970. It will be seen that during the year 1968 the numbers being treated increased rapidly as the restriction of the supply of heroin and cocaine took effect. Since the later part of 1968, however, the numbers have remained relatively stable with only minor fluctuations. The eventual number of patients was very close to the estimate of the number of addicts made by the Government in 1967; there were about 1,000 in London and a further 200 elsewhere.

The population of addicts consists predominantly of young people. Of the 1,430 addicts known to the Home Office to be using drugs at the end of 1970, more than 50% were aged under 25 and more than 70% under 30. Some preliminary study by the statistics and research division of the Department of Health and Social Security ( [ 7] ) of the population of addicts who were first notified by hospitals from the beginning of 1968 until 1970 reveals some general characteristics of the group. In the population studied males outnumbered females in the ratio of over four to one. The patients were asked about the occupations of their fathers and a picture was formed on this basis of the way they were drawn from the various social classes. The distribution of the male patients among the various social classes was found to differ little from that of the general population, but among the females there was a slightly higher proportion than expected whose fathers were in the professional and intermediate occupations as opposed to the partly skilled and unskilled occupations. A high proportion of the patients - 39% - had been found guilty of at least one criminal offence in the juvenile courts and 42% had been found guilty in either a juvenile or adult court of an offence connected with the illegal use of drugs. Most of the patients surveyed in the study had used or were using a variety of drugs and not only narcotics.

The work of the hospital treatment clinics

The pattern of work in the treatment of drug dependence is not in any way dictated by any Government agency. The consultant psychiatrist in charge of each treatment centre has individual responsibility for the treatment of his patients. There is nevertheless a basic common purpose shared by all the treatment centres and this is recognised in various ways. At the time the special clinics were established in 1967 and 1968 there had been relatively little experience of treating addiction in the hospital service, certainly on an out-patient basis. It was clearly important in such a relatively uncharted field for common problems to be identified and for experience as it developed to be shared widely. To help achieve this the then Ministry of Health instituted periodic conferences of the consultants in charge of the treatment clinics, which continue to be held. Doctors and others involved in the field of addiction consult with each other freely and informally as the need arises. Despite differences of practice which reflect the individual judgement of the different consultants there are a good many points on which concerted action has been agreed between them as a matter of common interest, and individual decisions can take account of the collective experience of the clinics as a whole.

TABLE 2

Number of patients under treatment for heroin addiction (England)

 

1968

1969

1970

At end of month

Out-patients

In-patients

Total

Out-patients

In-patients

Total

Out-patients

In-patients

Total

March
555 108 663 1,160 98 1,258 1,160 91 1,251
June
1,023 148 1,171 1,170 109 1,279 1,133 85 1,218
September
1,133 117 1,250 1,158 106 1,264 1,160 105 1,265
December
1,139 102 1,241 1,144 91 1,235 1,131 122 1,253

TABLE 3

Quantities of heroin and methadone prescribed per month to heroin addicts attending out-patient clinics in England, 1968-1970 (In grammes)

 

1968

1969

1970

Month

 Heroin

Heroin

Methadone

Heroin

Methadone

January
2,561
(Not recorded
1,600 980  
February
2,155
before
1,567 835  
March
2,131
August 1969)
1,668 1,050  
April
2,010 1,671 1,085    
May
1,923 1,452 1,209    
June
1,850 1,409 1,256    
July
2,690 1,849 1,382 1,292  
August
3,209 1,837 918 1,359 1,241
September
2,858 1,612 1,055 1,329 1,295
October
2,919 1,679 1,100 1,321 1,308
November
2,624 1,533 1,057 1,274 1,306
December
2,596 1,639 1,051 1,358 1,331

Records have been maintained since the establishment of the special clinics of the quantities of addictive drugs prescribed. Table 3 shows the total quantities of heroin and methadone that have been prescribed to addicts by hospitals and clinics in England and Wales in successive months from July 1968 to December 1970 (figures for methadone have been centrally recorded only since 1969 but it is known that the drug was relatively little used by the clinics before that time). It will be seen from this table that the quantities of heroin being prescribed have fallen steadily and substantially (by more than half) from their highest level. In the later part of the period this decrease was offset to some extent by an increase in the quantity of methadone. As has been mentioned the total number of patients to whom these drugs were being prescribed has changed very little. Cocaine is seldom prescribed at all.

Addicts being withdrawn from heroin sometimes have methadone substituted for heroin as a preliminary stage and this accounts for part of the use of methadone by the hospitals and clinics. In addition there are some clinicians who consider that patients being maintained on drugs on a longer-term basis may benefit by the substitution of methadone for heroin. Among the advantages attributed to methadone are that it is less euphoriant, and that, as its action lasts longer than that of heroin, it needs to be taken less frequently and so is less disruptive of the patient's normal life. Although table 3 shows that most of the methadone prescribed by the hospitals and clinics has been for intravenous use, it is possible that a patient who has taken the step from heroin to injectable methadone may subsequently find it easier to abandon the practice of injection and accept methadone in the oral form. Little if any use appears to have been made in Britain of " blockade " doses of methadone in the oral form; generally the objective of giving minimum doses seems to have been followed with methadone as much as with heroin. Little or no use has been made of narcotic antagonists.

The action taken by the Government in 1967 and 1968 to implement the recommendations of the Brain Committee had two basic purposes - to prevent the spread of addiction and to ensure that those who had already become addicted were given suitable treatment and rehabilitation. The primary concern of the treatment clinics was with the second of these objectives, but the fact that the clinics became in effect the only source from which addicts could legally obtain heroin or cocaine meant that the objective of preventing the spread of addiction could not be achieved without adequate safeguards against evasion of the new controls. Such safeguards govern both the acceptance of patients for treatment and the arrangements for supplying drugs.

If a new patient presents himself at a clinic the clinic tries to satisfy itself on two points before considering his acceptance for any form of treatment which involves the prescribing of drugs. First, is he genuinely addicted to such an extent that it is justifiable to prescribe drugs either as a prelude to gradual withdrawal or for " maintenance"? Various means are employed by clinics to gauge the presence and extent of addiction, including biochemical tests to establish the actual fact of drug use. A patient is not normally accepted at his first appearance but is asked to return on at least one further occasion so that it can be seen whether he is using the drugs in question persistently. Secondly the clinic tries to make sure by enquiry of the Home Office central index of narcotic addicts that the patient is not already obtaining drugs from another clinic. If the fact of addiction is established, the decision whether to attempt an immediate start on withdrawal of the drug, or to institute prescribing on a longer term ("maintenance") basis is a matter entirely for the clinical judgement of the responsible doctor. This judgement involves an assessment of the extent of the patient's dependence and of the degree to which he can be motivated towards withdrawal. It can be expected that the doctor's first preference will always be for an early cessation of the use of the drug, especially in the case of very young patients (at the end of 1970 only 18 patients under the age of 18 were receiving heroin or methadone). But if motivation is weak, the risks inherent in continued prescribing have to be balanced against those involved in withholding the supply - for example, the danger that the patient will seek drugs from an illicit source. It is the welfare of the patient that will always be the first consideration.

Special precautions are taken against the fraudulent alteration of prescriptions and the illicit sale by patients of the drugs prescribed to them. Under a scheme agreed between the consultants in charge of the clinics the actual prescription forms are normally not handled by the patients themselves but are sent by the clinic to a pharmacy which is near either to the patient's home or to his place of work. It is normal for a single prescription to cover a week's or a fortnight's supply of drugs, but in order to prevent the addict from holding such a relatively large quantity in his possession at any one time the prescription usually specifies that the drug be dispensed in daily doses and the patient goes to the pharmacy each day to collect that day's supply.

When the out-patient clinics were being established the main emphasis was placed on their function of making drugs available to those addicts who could not be persuaded to do without them; constructive treatment and rehabilitation was seen as necessarily starting with withdrawal from drugs in hospital (see above). There has however been an important evolution away from this narrow conception of the out-patient clinics' role. The role of the clinics, and the relationship between out-patient and in-patient treatment, were considered in some detail by the Advisory Committee on Drug Dependence in their report on " The Rehabilitation of Drug Addicts " ( [ 8] ) which was published in 1969. This report was one of a number published by the Committee on different aspects of drug misuse and dependence. In it the Committee rejected categorically the conception of out-patient clinics as " mere prescribing units without any positive objective ". They advanced the view that:

Rehabilitation begins with the first contact with the addict. Use must be made of the opportunity which prescribing in the hospital out-patient clinics gives to build a constructive relationship with the addict so that he can be influenced towards withdrawal. The clinics are strategically placed to form the focal point for the whole process of rehabilitation.

In making specific recommendations the Committee placed particular emphasis on the appointment of adequate numbers both of doctors and of social workers, who should be employed full time in the clinics and should be full members of the therapeutic team. They recommended that social workers involved in intensive social work with addicts and their families should not have a caseload of more than 25 patients at one time. They also made recommendations designed to ensure that the work of the clinics was effectively co-ordinated with other services available to addicts mentioning in particular general practitioners, voluntary bodies and local authorities.

The Advisory Committee's recommendations were commended by the Government to hospital authorities. The subsequent staffing of the clinics has generally been based on the pattern recommended by the Advisory Committee, though the Committee itself recognized that because of general shortages of certain categories of staff - particularly social workers - it would not be possible in the short term for their recommendations to be implemented in full.

The concept of a clinic as the focal point for the whole process of rehabilitation is of course fundamentally different from that of a mere prescribing centre. In "The Rehabilitation of Drug Addicts", again, the Advisory Committee defined the aim of rehabilitation as " to re-educate the individual to live without drugs and to assume or resume a normal social life ". Rehabilitation involves "paying attention simultaneously to an addict's physical, psychiatric and social well-being". A central part of this task is the establishment of a continuing relationship between the patient and the staff of the clinic which can give him a point of reference outside his own sub-culture. The key members of the treatment team are the doctor and the social worker, but at a number of clinics nurses also play an important part, in some instances undertaking case work with patients and their families in the community. The approach is essentially a broad-fronted one in that the clinic seeks to help the patient, or to arrange for help from other sources, with the whole range of his problems. It follows from this approach that a clinic's success cannot be gauged on any single scale, since the objective is not the simple one of achieving abstinence but the far more complex one of improving the patient's total social functioning. This comprises such things, among others, as finding a settled home and stable employment. Above all the clinic aims at flexibility. With some patients the primary need may be for psychiatric help, with others it may be family casework, with others again it may be guidance on practical problems. The demands which this multiple role implies for the staff of the clinics are formidable.

In-patient treatment

If the out-patient clinics have assumed a larger role correspondingly less use has been made of in-patient treatment facilities than was generally expected. A number of clinicians now believe that many patients, providing they have the necessary motivation, are better able to undergo even complete withdrawal from drugs while being treated as out-patients. Be that as it may all the out-patient clinics are able to refer patients for in-patient treatment and a number of patients are referred in this way both for withdrawal and for supportive treatment during acute episodes of the condition. In addition there are a number of doctors treating addicts who are known positively to favour in-patient treatment which they regard as the more effective approach. Table 2 shows that the number of in-patients being treated at any one time has always been substantially less than the number of out-patients though this may be partly because in-patient treatment usually lasts for a shorter time. Those hospitals which treat addicts as in-patients are of course obliged to deal with many of the same problems as the out-patient units since the same task of enabling the patient to " assume or resume a normal social life " has to be faced. The support of social work, occupational therapy and other specialized departments of the hospital is equally available where in-patient treatment is given.

Rehabilitation outside the hospital

We have mentioned the role of the out-patient clinics in helping their patients, among other things, to find jobs and homes. It would not be possible in practice for the hospital staff to involve themselves deeply in the technicalities of such problems and an important part of their work consists of putting the patient in touch with agencies which can give specialised help. Some of these agencies are statutory, operated by central government or local authorities, and others are voluntary. In the statutory field patients who are unemployed may be put in touch with the Disabled Persons' Resettlement Service of the Department of Employment which can seek employment for them and may arrange for special training in some cases. Of the addicts studied by the Department of Health and Social Security who were first notified by hospitals between 1968 and 1970 (see above), 39 % were in employment. A relatively high proportion of addicts at one time or another commit or have committed offences (see above) and a number are placed on probation. In such cases the probation officers may undertake important social casework and social workers and other staff in the clinics are often able to co-operate closely with them. Local authorities have a statutory responsibility for social work in the community and in so far as this involves drug addicts they co-operate in various ways with the hospital service. Some of the social workers employed in the out-patient clinics are in fact seconded full-time or part-time from local authorities.

There are a number of voluntary organisations which take a special interest in the problems of addicts. The help they give takes such forms as hostels or emergency accommodation, day centres which can supplement the work of rehabilitation undertaken by statutory agencies, or employment agencies concerning themselves specially with addicts. This independent help is welcomed by the statutory services.

One of the matters dealt with in the report on " The Rehabilitation of Drug Addicts " was the provision of special hostels for addicts who had completed hospital treatment and been withdrawn from drugs. A number of such hostels have now been established as the report recommended. Most of them are run by voluntary organizations but a number receive financial help from local authority sources. In two of them - Phoenix House in South London and Alpha House in Portsmouth-which are being run on the pattern of the Phoenix Houses in the United States, the Department of Health and Social Security is financing a research evaluation of the work of the hostels; in the case of the Alpha House the Department also provides part of the operational costs.

" The Rehabilitation of Drug Addicts " also recommended the establishment of short-stay residential accommodation for homeless addicts attending out-patient clinics. This has proved difficult to establish but two hostels for addicts still using drugs have now been opened near London.

The contribution of prevention

The treatment of dependence, which has been surveyed in this article, is of course only one of the ways in which society responds to the broad problem of drug misuse. This is not the place for detailed discussion of education, of law enforcement and of other activities through which society aims to prevent addiction from arising or at least to restrict its occurrence. But these activities are of course no less important and no approach to the problem would be possible which did not include this element as well as the one of treatment. British policy aims at the closest co-operation between those treating addiction and the other agencies concerned with the problem. In a number of areas local liaison committees have been established whose membership may include staff of the drug addiction clinic, general practitioners, local community workers, educators and representatives of the police and of the public health services.

Research and evaluation

It was recognized by the Government when the special clinics for the treatment of addiction were being established that research and evaluation would form important corollaries to their work. Reference has already been made (see above) to the work that has been done by the Statistics and Research Division of the Department of Health and Social Security, and this is continuing. It is anticipated that the information being collected will in time provide a fairly comprehensive picture of the involvement of the patients with the clinics and of what happens to them subsequently. Other possibilities for research in this field are being considered.

Conclusion

It is certainly not our object to make exaggerated claims for the effectiveness of the methods of treating narcotic dependence used in the United Kingdom. We have, we hope, made it clear beyond any doubt that the procedure of prescribing heroin or methadone is far from being regarded as a panacea. The risks which this procedure entails are fully recognized by all concerned with the treatment of the condition. On the other side, however, there has to be balanced the risk that the addict will seek illicit supplies, perhaps engaging in crime to get them, and in the process will run very much greater dangers to life and health and become yet further alienated from the rest of society. The decision to prescribe drugs to an addict can never be taken lightly. A doctor will do so only if he judges that it is this course of action which will on balance best serve the interests of his patient.

We have explained that the activity of prescribing drugs is not carried out in isolation but is one part only of the work of the hospital treatment clinics, whose rehabilitation facilities are available to all their patients and are extensively used. The desirability of ultimately securing the patient's withdrawal from drugs is well recognized and we have mentioned the rehabilitation hostels whose work is enmeshed with that of the hospital centres. The supplying of the drug is only one of the weapons in the armoury of those physicians who undertake the treatment of dependence. It is handled with all the circumspection that such a potentially dangerous weapon - dangerous both to society and the individual - demands.

What success have the clinics achieved in their three or four years of life? This question needs to be answered in terms not only of numbers of " cured " addicts but also of addicts who have been helped by their association with the clinics to adjust to the demands of society by having a regular job, a settled home, steady family relationships and so on. Substantial numbers of the addicts or ex-addicts who attend the clinics are in regular work (see above) and in other respects too are more or less successful in functioning in society. What is difficult to ascertain is the extent to which this is the result of the work done by the clinics. Research studies such as those mentioned in this article should in course of time make possible a better assessment of the impact the clinics have had, and of how the patients they have treated compare with others treated in different ways. But it is still rather early - after only three or four years of experience with the present arrangements - to form a definitive judgement of success in dealing with a condition like drug dependence which is generally recognized as having a protracted natural history and a high incidence of relapse.

If evidence about the success of treatment and rehabilitation is at present still incomplete, there is a fortiori at least an equal lack of evidence that the job could be done better in some other way. Of course even without full knowledge of what happens to all their patients, the clinics can and do develop and evolve in response to changes in the drug situation and to the staffs' own judgement of the effectiveness of what they are doing. Although the need for hard evidence in this field is unquestioned, sensitivity to practical needs and problems (both general and local) will always remain an indispensable element in developing a service which reflects the needs both of the patient and of the community.

As mentioned above, the clinics' job of treatment and rehabilitation carries with it a responsibility in relation to the efforts of Government and other agencies to prevent the spread of drug addiction and misuse. In this area it is impossible to identify the precise contribution of the treatment services separately from that of other agencies. But at least the over-all picture is not, as far as can be seen, a disheartening one, in that the rapid increase in addiction to heroin which was taking place up to 1968 appears now to have been checked, and not to have been replaced by any comparable increase in addiction to other narcotic drugs. Indeed in 1970 for the first time the figures compiled by the Home Office for the total number of addicts known to be using scheduled dangerous drugs showed a slight decrease as against the previous year.

It may be objected of course that aview based on numbers of known addicts can only be a narrow one completely ignoring the existence of any hidden addiction. There is, of course a problem of covert addiction and it would be foolish to deny it. After all, the heroin addict presenting himself at a clinic is certain to have become addicted through heroin illicitly sold or supplied to him and it must be faced that some totally illicit heroin (the so-called " Chinese " heroin) is being trafficked in addict circles. Nevertheless there are indications which cannot be ignored in any careful appraisal. For example, there is no evidence as yet from the enforcement area, from the prisons, the hospitals or from coroners that illicit heroin is giving rise to any substantial pockets of hidden addiction. The number of criminal convictions involving heroin decreased in 1970 compared with 1969. The amount of heroin licitly manufactured in the United Kingdom for domestic consumption also decreased, for the third year running, and the progressive decline in the quantity of heroin prescribed for addicts was maintained. All these indicators point in the same direction, supporting the belief that the problem is at least being contained.

An assessment in these terms should not leave unacknowledged the wealth of dedicated effort given in recent years to the care of individual addicts and the elaboration of facilities by the relatively small numbers of doctors, pharmacists, nurses and social workers concerned.

References

001

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

002

Ministry of Health, Department of Health for Scotland. Drug Addiction. Report of the Interdepartmental Committee. London, 1961.

003

Glatt, M. M. A review of the Second Report of the Interdepartmental Committee on Addiction. Bulletin on Narcotics , XVIII, 2, April-June 1966.

004

Bewley, T. Recent changes in the pattern of drug abuse in the United Kingdom, Bulletin on Narcotics , XVIII, 4, October-December 1966.

005

Ministry of Health, Scottish Home and Health Department. Drug Addiction. The Second Report of the Interdepartmental Committee, London, 1965.

006

Ministry of Health. The Treatment and Supervision of Heroin Addiction. HM(67)16. Unpublished Hospital Memorandum, 1967.

007

Bransby, E. R. A study of patients notified by hospitals as addicted to drugs: first report. Health Trends 3, 4, 75-78. London, 1971.

008

Home Office. The Rehabilitation of Drug Addicts. Report of the Advisory Committee on Drug Dependence. London, 1968.