Until recently, most types of drug dependence were uncommon in Great Britain. The little dependence recorded was found in a few professional people, or patients who had become addicted accidentally in the course of medical treatment. There was very little addiction among those who had obtained drugs from any illicit source.
Author: Thomas BEWLEY ,
Pages: 1 to 14
Creation Date: 1966/01/01
Until recently, most types of drug dependence were uncommon in Great Britain. The little dependence recorded was found in a few professional people, or patients who had become addicted accidentally in the course of medical treatment. There was very little addiction among those who had obtained drugs from any illicit source.
This situation has now changed. There has been a marked increase in opiate addiction among young people. There has also been a similar increase in the misuse of amphetamines by young people and the third noticeable change is that cannabis has also been introduced into the country. Until a few years ago, misuse of cannabis was almost non-existent.
These three types of drugs have mostly been used by adolescents and it was concern over this rapidly increasing misuse of drugs illicitly obtained by this age group that led to the recall of an Inter-departmental Committee, under the chairmanship of Lord Brain, to review the situation. Owing to the rate at which the situation was changing, the Committee had to be convened again within five years of making its first report.
Originally, the misuse of illicitly obtained drugs was confined to London, but this has been changing, and in the past two years there has been a spread of this type of misuse to other parts of the country.
There have been other changes in the patterns of drug abuse in the United Kingdom. There has been an increase in the misuse of amphetamines and barbiturates originally prescribed for medical reasons. This change has not been confined to the London area, but has been found in all parts of the United Kingdom. There has also probably been a slow change in the incidence of alcoholism.
In this article, the changes in incidence of dependence on various drugs are examined separately.
Changes in the incidence of dependence on opiates
There has been a marked change in the pattern of addiction to opiates in the United Kingdom in the last twenty years. Most addicts recorded before that time had become addicted accidentally in the course of treatment, or belonged to professions with easy access to drugs; for example, doctors, nurses or pharmacists. Since then there has been an increase in the number of younger addicts. These have become addicted from contact with other addicts and most of these have been addicted to either heroin alone, or both heroin and cocaine.
Home Office figures
The index or register kept by the Home Office is commonly misunderstood. There appears to be a widespread belief outside the United Kingdom that it is possible to be a "registered" addict and that there is an index or register of addicts kept by the Home Office and that any person who is "registered" is entitled to obtain drugs. There has also been a lot of fruitless argument as to whether this is a good method for dealing with opiate addiction, and this system, the so-called "British System ", has been quoted much more widely than it has been understood. In fact, there has never been any such thing as a "British System ". A series of administrative practices grew up at a time when there were very few addicts and those mostly in professions with easy access to opiates. This was described at a later date as the "British System ". It probably developed because there was virtually no opiate addiction in the country, and was in no way a cause of the small numbers of addicts. In the last few years, there has been an increase in the amount of addiction, particularly heroin addiction, and since then it has been seen that the British practices have not been entirely satisfactory.
The Home Office index or register is a list of people who are known to be addicted to opiates, which is kept by the Home Office in order to make returns to the United Nations, and also to have information available about the numbers of addicts at any time in the United Kingdom. The fact that a person's name is on the Home Office register does not entitle him to more or different drugs than any other person. There have never been limitations, up to the present, on doctors prescribing opiates to addicts in order to sustain their addiction. This system worked well at the time there were very few addicts. Any doctor was entitled to prescribe opiates for an addict but in practice very few did so (until recently virtually none, as there were so few addicts).
The Home Office register or index itself is compiled from various sources. The most important are the routine inspections of retail pharmacists records. These inspections are carried out by the police and when they show regular or unusual supplies of drugs to particular individuals, this is reported to the Home Office. Further enquiry is made usually by a Regional Medical Officer of the Ministry of Health or Scottish Home and Health Department to discover whether the case is one of addiction or of genuine medical necessity. The police also report cases of addiction encountered in the course of other enquiries. Further cases may be reported to the Home Office by doctors, hospitals, social workers or similar sources. Addiction is not at present notifiable and doctors have no statutory duty to report such cases. However, if a doctor prescribes narcotic drugs for an addict, the addict's name will eventually reach the index after inspection of the records of the pharmacist dispensing the drugs. The annual statistics published by the Home Office show only those addicts known to have been taking drugs during the previous year; they exclude those who are not known to be currently taking drugs, for example addicts in prison or abroad, and those obtaining all their drugs from illicit sources as well as those permanently or temporarily cured. These figures do not give an accurate estimate of the total number of addicts as three groups will escape notice:
Those in the early stages who obtain all their drugs from addict friends, or from a black market source.
Those who do this permanently who will never be known to the Home Office unless they come to the notice of the police.
Those who have temporarily had their names removed from the register for one of the reasons given earlier in this paragraph. Most of the addicts on the index have been addicted for about a year when first noted, so that the numbers recorded will always be a year behind the true figure.
If the numbers of cases known to the Home Office are studied over a number of years since 1921, when the Dangerous Drugs Acts were first passed, it can be seen that there was a slow steady decline in the number of cases known to the Home Office. In 1955, however, this appeared to change (fig. 1). In 1945 the method of compiling the register was altered, and a number of names were taken off the list; before 1945 a name was not taken off the list unless the person had not been known to be taking drugs for a period of ten years. It can be seen that the decline in the total number of narcotic addicts in the country decreased from the year 1935 to 1955, and then started to rise again.
FIGURE 1
Method of compiling register altered.
There has been a similar increase in the number of convictions for offences concerned with manufactured drugs (fig. 2). This does not include raw opium or cannabis. The majority of these offences were committed by heroin addicts.
The increase in the total number of addicts is almost entirely accounted for by an increase in the number of addicts who have started their addiction by obtaining drugs from another addict (fig. 3). There has arisen a small black market for the sale of heroin, which is supplied by some addicts who have more drugs prescribed for them than they use, thus enabling them to sell the surplus. The black market price has remained at ? 1 for 1 grain (60 mg) of heroin for the past five years. A close examination of the figures published by the Home Office (fig. 4 and table 1) show that there has been a marked increase in adolescent addiction with a very considerable increase in the numbers known to be taking heroin alone or heroin and cocaine.
In view of this striking change in the last five years, all the heroin addicts whose names had been recorded in the past ten years were separately reviewed (Bewley, 1965). The majority of the new addicts were British born (table 2) and the rate at which new names of heroin addicts had been added to the register had increased rapidly (fig. 5). In 1954, there was not a striking difference between the number of heroin addicts who had become addicted in the course of treatment and those who had acquired their addiction from some other source. By 1964, this had completely changed and most of the addicts had started from some non-therapeutic source (fig. 6).
When these addicts were followed up, noting whether or not they were known to be taking heroin in any succeeding year, it was found that the majority were continuously taking heroin; 80% had either continued to take heroin or had died. Where those continuously taking heroin were compared with those not known to be taking heroin, and excluding those who had died or left the country or were untraced, it was found that four times as many continued to take heroin continuously as remained off drugs.
A further development in the past twelve months has been an outbreak of infective hepatitis among heroin addicts. Dr. O. Ben-Arie and I have traced 40 cases so far. This is not surprising in that about a third of all heroin addicts admitted to hospital admit to sharing syringes with other addicts. Dr. Vincent Marks found abnormalities when empirical "liver function tests" were carried out on an unselected group of 89 heroin and cocaine users. Six of these were jaundiced and showed laboratory findings compatible with but not typical of infective hepatitis. He thought that among heroin addicts seen in London, while some cases of jaundice were viral in origin, transient liver damage was more often the result of either a direct hepatotoxic effect of the large doses of heroin and cocaine used, pyrogens or other contaminants injected unwittingly, or subclinical bacteraemias due to the use of septic materials.
Dr. I. Pierce James made a follow-up study of all the heroin addicts who had died between 1954 and 1965. He found the mortality among heroin addicts in the United Kingdom first addicted from illicit sources to be 22 per 1000 per year (a figure 20 times the expected rate and approximately higher than among narcotic addicts in the United States).
Addicts known to the Home Office according to age
Year
|
Morphine alone
|
Pethidine alone
|
Heroin alone
|
Heroin
and cocaine
|
1958 | 174 | 99 | 42 | 12 |
1959 | 172 | 97 | 40 | 18 |
1960 | 150 | 81 | 42 | 44 |
1961 | 145 | 82 | 49 | 74 |
1962 | 140 | 89 | 63 | 104 |
1961 | 49 | 94 | 62 | 166 |
1964 | 145 | 109 | 125 | 201 |
1965 | 143 | 93 | 209 | 294 |
British born
|
587 |
Canadian
|
72 |
United States
|
19 |
Jamaican
|
10 |
Australian
|
7 |
Nine other nationalities
|
14 |
Total
|
709 |
Heroin addiction of this type was almost entirely confined to the London area, as was pointed out in the Second Report of the Inter-departmental Committee (1965). However, there has been a change since the publishing of this report, and in the last year there has been a striking increase in the numbers of heroin addicts outside London.
Misuse of cannabis (marihuana)
In the United Kingdom cannabis or marihuana is known by a number of names, for example "Charash", "Charge", "Gauge", "Gear", "Grass", "Hash", "Hashish", "Hemp", "Indian Hemp", "Rope", "Pot", "Stuff", "Tea", and "Weed". These are all terms that are also in use in other parts of the world. Marihuana has reached the United Kingdom by a Roundabout route from India, through Africa, the West Indies and the United States. In the United Kingdom, Marihuana is generally used in the form of a cigarette, And this is known as a "Joint", a "Reefer", a "Sausage", a "Smoke", a "Spliff", or a "Stick", all terms Known in the United States [see glossary in Appendix, p. 10].
Until 1945 there was very little misuse of cannabis in the United Kingdom, but between 1945 and 1960, there was a slow increase, and between 1960 and 1965, a marked increase in this misuse. It is difficult to estimate accurately the number of people who use cannabis. People who use it do not normally come to the attention of a doctor unless they have some other illness. Some idea of the trend can be gained from studying the number of prosecutions and convictions for misuse of cannabis, and also from studying the amounts and the number of seizures of cannabis recorded by H. M. Customs each year. There has been an increase both in the number of seizures and in the total weight of the drug seized, though this varies widely from year to year. Until two years ago most of the convictions for misuse of cannabis were among recent immigrants to the United Kingdom, chiefly West Indians and West Africans, but, in the last two years, such convictions have not been confined entirely to this group, and at present probably half of them are of British-born users of cannabis. The majority of the offences has been committed in the London area, though it is not entirely confined to the metropolis. It can be seen that there has been an apparent decline in the number of cannabis offences in Liverpool.
Cannabis offences are compared with offences where other drugs were concerned in figure 7 over the period 1921-1964. Following the coming into force of the Dangerous Drugs Act, in 1921 there were a number of prosecutions for technical offences, such as the failure by a pharmacist to keep proper records. There was an increase in opium offences during the war, but this was probably due to a re-routing of the international smuggling of opium, and most of these cases concerned offences in ports by seamen. The graph shows that there has been a marked change since 1959, with an increase in offences of all types, but most markedly so in the case of cannabis offences.
If it is assumed that for every conviction there are possibly ten or twenty people who are not convicted, it would give a figure for regular cannabis users in the United Kingdom of about 30 per 100,000 population. Also, if it were assumed that for every person who takes marihuana with some degree of regularity, there are as many people who might occasionally try it, then one would get a figure of about 60 per 100,000 population.
Users of cannabis are generally either recent immigrants or belong to a "beatnik" sub-culture. Probably more use of drugs of this type would be found among jazz musicians than other professions.
The taking of cannabis may be associated also with the taking of other drugs. The majority of younger heroin users described by me (1965) had taken this drug before taking heroin. There is still an argument among British psychiatrists as to whether cannabis misuse of this type leads to heroin addiction.
Misuse of amphetamines
In the past ten years there have been changes in the incidence of misuse of amphetamines in the United Kingdom. Attention was first drawn to this by Dr. P. H. Connell, who found a number of patients with amphetamine psychoses who were admitted to an observation ward in London. At that time a number of patients had taken amphetamines in very large amounts, having ingested the contents of nasal inhalers. (Other drugs have now been substituted for the amphetamine inthese inhalers.) Later there was an increase in misuse of amphetamines taken in the form of tablets or pills. These were mainly amphetamines combined with a barbiturate. This was originally something that was localised in the London area, and mostly to a particular part of the West End of London, specifically Soho. At this time the drug most frequently misused was drinanyl, in the form of tablets known as "Purple Hearts ", owing to their colour and shape. Since that date a number of other amphetamine and amphetamine/barbiturate combinations have been misused, and these have been sold widely on the black market. The name "Purple Heart" has been succeeded by a number of other names: "Blues ", "French Blues ", "Minstrels ", "Nigger Minstrels ", "Black and Whites ", "Black and Greens ", "Black and Tans ", "Black Bombers" and so forth, each one being derived from the appearance of the tablet.
These drugs appear to be stolen from legal stocks, often in large quantities, and they are then retailed in cafés and coffee bars. At present they are sold at about 1/6d to 2/6d per tablet, the higher prices being charged at week-ends. It would appear that the people who take these drugs are not all grossly abnormal. Many of them would appear to be adolescents who a few years ago would have been getting drunk on a Saturday night, and who now merely take a number of amphetamines in order to remain "high" while at parties, or in groups with other users. It is probable that large numbers of adolescents experiment with these drugs and, at a later date, abandon taking them and settle down to a more stable, better adjusted adult life. A small proportion of these users, however, does become at least psychologically dependent on them. Instead of taking them occasionally at week-ends, the pattern changes, and the drugs may be taken regularly through the week. Instead of 10 tablets over the week-end, now 20, 30, 40 or 60 tablets may be ingested daily, throughout the week. At this stage the users may develop paranoid psychoses, and they may come to the attention of psychiatrists, being admitted to an observation ward or mental hospital.
In February 1964 a series of articles appeared in the Evening Standard of London, describing the adolescent "Purple Heart culture" in Soho, London. This was followed by an increase in public concern over drugtaking by adolescents. This culminated in the passing of the Drugs (Prevention of Misuse) Act, 1964, which made it an offence to possess without "authority" drugs of the amphetamine type, or to import them except under licence. The penalties on summary conviction were a ? 200 fine and/or 6 months' imprisonment and, on indictment, an unlimited fine and/or 2 years' imprisonment. There has been controversy since the passage of this Act as to its effectiveness. If a café where there is trafficking in amphetamines is raided now by the police, vast numbers of tablets may be found on the floor, but not in anyone's possession.
A recent study in a London remand home by Dr. Peter Scott showed that one-fifth of boys on remand had been taking amphetamine substances shortly prior to their arrival at the remand home, as shown by urine tests. Many of these were not suspected to have been taking amphetamines and when they were compared with a similar group of boys who are not taking amphetamines they in no way differed from them in the types of crime committed or their types of personality. The author concluded that in this group there was probably no direct link between taking of amphetamines and committing of crime.
A further group of people also may become dependent on amphetamines and these are people for whom they are originally prescribed, usually by their own general practitioner. A survey by Kiloh and Brandon in Newcastle-on-Tyne showed that probably 500 people in a town with a population of 250,000 were psychologically dependent on amphetamines. The majority of these were middle-aged, many of them women, for whom amphetamines had first been prescribed as a treatment for depression. If these figures were extended to cover the rest of the country, it would appear that possibly somewhere in the region of 100-200 per 100,000 population are, at any rate to some slight degree, psychologically dependent on amphetamines.
To estimate the incidence of misuse of amphetamines that are obtained illegally, and not on prescription, is very much more difficult. It is difficult to decide whether to endeavour to include every one who has once taken an amphetamine tablet illicitly or only those who take them regularly (for example, at week-ends) or only those who have become dependent on them to some extent. A recent article in The Times of London estimated that at least some 10,000 adolescents probably misused amphetamines regularly in the London area. This was an estimate based on the pooled impressions of a number of people who had some experience of this particular type of misuse of drugs. There are no accurate figures and no careful studies have been done. It is possible that between 100-200 per 100,000 of the population of the United Kingdom might have taken these drugs illicitly.
It is perhaps easier to make a guess as to the number of people who have become seriously dependent on amphetamines, if one takes the number of people who are either spending long periods of time in a mental hospital or in prison because of their addiction. There are possibly about the same number of people in this cate- gory as there are addicts to heroin and cocaine, perhaps somewhere between 2 and 4 per 100,000 population.
Misuses of barbiturates
There have also been changes in the pattern of misuse of barbiturates, as pointed out by Dr. M. M. Glatt.
It is possible to get some idea of the extent of this misuse by studying a number of different phenomena: for example, deaths from overdoses of barbiturates, both suicidal and accidental; admission to hospital for barbiturate poisoning (overdose); admission to hospital because of barbiturate dependence, and surveys among samples of the general population to ascertain the incidence of use of barbiturates and incidence of dependence on them. There have also, of course, been changes in the amount of use of other sedatives as well as barbiturates, but the latter are still the most widely used sedative in the United Kingdom. Thirty years ago a far greater amount of bromides were prescribed, and bromide intoxication was not an uncommon illness. Bromide intoxication is now rare, since bromides are seldom prescribed, and have been superseded by barbiturates.
In the United Kingdom there has not been any striking change in the over-all suicide rate in the past 10 years, but there has been a change in the methods used. There has been an increase in the suicide rate from poisoning by analgesics and soporific substances, the most important members of this group being barbiturates. The suicide rate from barbiturate poisoning among men and women in three age groups has been shown by Glatt and Brooke (figs. 8 and 9). It can be seen there has been a sharp recent increase in the rates in both sexes and at all ages.
There have also been striking changes in the amount of non-fatal poisonings which require hospital treatment. The latest available figures show that admission rates for poisoning to National Health Service hospitals in England and Wales have increased markedly, and there has been a steady increase also in admissions for barbiturate poisoning. Total increase in admissions because of poisoning have probably been largely due to an increase in admissions for barbiturate poisoning. This is well illustrated in a table in an article by Professor Kessel, giving admissions to the poisons unit in the Royal Infirmary in Edinburgh. As he pointed out, the majority of these self-poisonings are not necessarily with suicidal intent, and many of them are due to seeking a temporary period of oblivion or escape from stress. From this it can be assumed that there has been an increase in the total amount of barbiturates consumed in the United Kingdom, and this is confirmed by studying the estimated amounts of barbiturates prescribed by general practitioners in the National Health Service (fig. 10).
As there has been an increase in the total amounts of barbiturates prescribed and consumed, it is likely that there has also been an increase in the amount of dependence on the drug. Recently Oswald and Priest have shown by EEG studies that even small amounts of barbiturates can cause physical dependence. Minor degrees of psychological dependence are also often found in that patients who regularly take barbiturates have difficulty in stopping. They find that they are restless and wakeful when they try to omit their accustomed doses. A recent survey was carried out in North London by Dr. B. G. Adams, which showed that 407 patients in a group practice of 10,000 had been given barbiturates over a long period of time. Though most of them continued to receive the drug without obvious addiction, there was evidence of increasing dosage in 47.
It is more difficult to estimate the extent of dependence on, or misuse of, barbiturates than the other drugs mentioned so far, but it is likely that the figure for the United Kingdom might be of the order of 150-250 per 100,000 population. Dr. Adams' figures suggest that 2 per cent of the population might be taking barbiturates regularly in small amounts.
Other types of misuse of drugs
Some misuse of lysergic acid has been noticed recently, and occasional cases are reported of misuse of other hallucinogens, these abuses occurring mostly in London. There has been public concern about misuse of LSD, though at present the persons affected probably only number a few hundreds. Because of this, however, LSD has been added to the amphetamines as a drug covered by the Drugs (Prevention of Misuse) Act.
Incidence of alcoholism
The largest problem of addiction in the United Kingdom is addiction to alcohol, or alcoholism. Several estimates of the extent of this have been made ranging from a total number of 35,000 to 350,000 alcoholics. The earlier estimates from surveys of general practice are generally considered to be too low in that many alcoholics may not have been diagnosed by their doctor, and indeed they may not even have seen him. A recent and more accurate survey by G. Prys Williams estimated that there were 300,000 alcoholics in the country, of whom 70,000 were assumed to have evidence of physical or mental deterioration.
The incidence of alcoholism will not necessarily remain unchanged. There has been an increase in the amount of alcohol consumed in the United Kingdom and there has been an increase in the number of convictions for drunkenness in the past ten years. Drunkenness among the young, however, has shown a relative improvement, though this may be because more young people who might otherwise get drunk are taking other drugs. The likelihood of developing alcoholism partly depends on the amount of alcohol consumed, and when there has been a general increase in this, it is likely that there will also be an increase in the incidence of alcoholism.
Summary
There have been very marked changes in the patterns of drug misuse in the United Kingdom in the past decade. There used to be very little dependence of any type, apart from alcoholism, and almost no illicit use of drugs. This has changed and there is now a small amount of illicit use of lysergic acid, and a markedly increased rate of appearance of heroin addicts who first obtained the drug illicitly. There has also been a large increase in the amount of illicitly used amphetamines and amphetamine-barbiturate combinations. Illicit use of drugs was confined to London at first, but it is now spreading to other parts of the country. There has been an increase in amphetamine dependence and barbiturate dependence from legitimate use also. It is likely too that there has been, and will continue to be, slow increase in the rate of alcoholism. It is difficult to make an exact estimate of the incidence of drug misuse in the United Kingdom at present, but table 3 attempts an evaluation.
Type of misuse
|
Comment
|
Rate per 100,000 population
|
Hallucinogens
|
A small amount illicit use of LSD
|
<1
|
Cocaine
|
Almost entirely used in combination with heroin
|
1-3
|
Morphine
|
The majority heroin addicts addicted from some non-therapeutic source
|
4-5
|
Cannabis
|
Illicit use without dependence
|
30-60
|
Amphetamines
|
a) Slight dependence on prescribed amphetamines
|
100-200
|
b) Illicit use of amphetamines
|
100-200
|
|
Barbiturates
|
a) Regular use with dependence
|
150-250
|
b) Regular use without dependence
|
800-1200
|
|
Alcohol
|
a) Obvious and chronic alcoholics
|
140 |
b) Alcoholics with early deterioration
|
400 |
Acknowledgements
I would like to thank the Home Office for much help in preparing this survey, also Mr. H. B. Spear, Dr. M. M. Glatt and Dr. I. P. James.
1, Adams B. G. et al., J. Coll. Gen. Practit., 1966, 12: 24.
002Bewley T. H., Brit. Med. J. , 1965, 2: 1284.
003Bewley T. H., Lancet, 1965, 1: 808.
004Ben-Arie O. & Bewley, T. H. (in preparation).
005Brooke E. M. & Glatt M. M., Med. Sci. & Law , 1964, 277.
006Connell P. H., Brit. J. Addict ., 1964, 60: 9.
007Drugs (Prevention of Misuse) Act, 1964 , H.M.S.O., London.
008Glatt M. M., Bull. Narcot., 1962, 14: 19.
009James I. P. (awaiting publication).
010Kessel N., Brit. Med. J ., 1965, 2. 1265-1270, 1336-1340.
011Kiloh L. G. & Brandon S., Brit. Med. J ., 1962, 2: 40.
012Marks V. & Chapple P. A. L. (awaiting publication).
013Oswald I. & Priest R. G., Brit. Med. J ., 1965, 2: 1093.
014Registrar General Statistical Reviews, England & Wales, H.M.S.O., London.
015Reports to the United Nations on the Working of the International Treaties on Narcotic Drugs , 1954-1964, Home Office, London (1954-1964).
01616- Scott P. & Wilcox D. R. C., Brit. J. Addict ., 61: 9.
017Second Report of the Inter-departmental Committee, 1965, H.M.S.O., London.
018The Times , December 20th, 1965
019Williams G. P., Chronic alcoholics: Rowntree Social Service Trust.