Drug Addiction, Crime or Disease?

Interim and Final Reports of the Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs.

APPENDIX B

An Appraisal of International, British and Selected European Narcotic Drug Laws, Regulations and Policies

GREAT BRITAIN

The British experience in controlling drug addiction has become a subject of controversy in the United States. The Federal Bureau of Narcotics insists that the English have an illicit drug traffic of the same magnitude and viciousness as our own, and that the enforcement policies of the two countries are identical." Since 1954 the Bureau has been circulating a document entitled, "British Narcotic System"l3 which asserts: "Several years ago a professor of sociologyl4 at an American university ...wrote an article in which he advocated that the United States adopt the British system of handling drug addicts by having doctors write prescriptions for addicts. He reported that this system had abolished the black market in narcotics and that consequently there were only 326 drug addicts in the United Kingdom....

"Nothing could be further from the truth. The British system is the same as the United States system. The following is an excerpt of a letter dated July 18, 1953. from the British Home Office, concerning the prescribing of narcotic drugs by the medical profession: "'A doctor may not have or use the drugs for any other purpose than that of ministering to the strictly medical needs of his patients. The continued supply of drugs to a patient either direct or by prescription, solely for the gratification of addiction is not regarded as a medical need.'...

"The British Government is a party to all of the international narcotic conventions to which the United States is a party. They enforce treaties in the same manner as the United States. The British and United States systems for enforcing narcotic laws are exactly the same." Giving full weight to such disparity of views, it is nonetheless stated here without hesitation that England (and the U. K. countries which follow her pattern) has no significant drug-addiction problem, no organized illicit trafficking, and no drug-law enforcement activities that could be regarded as comparable to those which preoccupy our own authorities.

The key to this difference appears to be that the British medical profession is in full and virtually unchallenged control of the distribution of drugs, and this includes distribution, by prescription or administration, to addicts when necessary. The police function is to aid and protect medical control, rather than to substitute for it.

Some of the distinctions are subtle. Discrepancies between British form and British substance, in the endearing tradition of "muddling through," make it possible to focus upon statements, like that quoted from the Home Office letter in the document referred to above, which are true and yet misleading apart from their qualifying context-i.e., in the instant case, doctors include the imminence of withdrawal symptoms among the "strictly medical needs" of their patients, and ministering to an addict under the conditions which will be discussed below is not regarded by either the profession or the authorities as "solely for the gratification of addiction." The controlling fact is that the medical profession accepts and treats addicts as patients so that virtually none are driven to support a black market; the prime corollary is that if all curative efforts fail the incurable addict may still be provided for on a medically-supervised regime; and the remarkable consequence is that the number of persons in the incurable or extended-regime category--out of Britain's population of over fifty millions--remains year after year in the range between three and four hundred. At the end of 1956 the figure was 333.

It is of interest that around one hundred of these chronic cases are from the ranks of the medical profession itself (75,000 doctors, plus nurses, hospital staffs, technicians, and persons in related careers). British authorities concede that some persons--scores, perhaps--may be obtaining and using narcotics by some personal arrangement which makes it unnecessary for them to appear on the Home Office list. But the list is inclusive, with only this minimal degree of probable error.15 It does not include persons whose addiction has been medically induced, i.e., terminal cancer patients and other chronic sufferers; another list of addicted persons in this category averages about the same length, remaining at less than four hundred.

The British first imposed controls on narcotic drugs in the same period (1920)16 when our enforcement policies were being developed under the Harrison Act. Their regulatory pattern is very similar to ours:17 everyone who has occasion to handle "dangerous drugs" must register, obtain a license, and keep accurate records. With respect to distribution,18 pharmacists must preserve prescriptions and record all sales, and pharmacists' records are inspected periodically by local police officers (who also keep an eye on the distribution of other substances in the dangerous drug and poison categories). Pharmacists are thus watched with some care. The requirement that doctors keep records, however, is not vigorously enforced, but if a doctor's practice in the matter is questioned, or if the prescription records show him to be prescribing unusual amounts, he may be approached by a medical inspector from the Ministry of Health, though he would never be called to account by the police agencies.19 The Act now provides maximum penalties of one thousand pounds' fine and ten years' imprisonment,20 though such penalties are not meted out in practice. The usual kinds of offense are petty defections like the forgery of personal prescriptions, or the practice of deception by an addict's representing himself to be in need of treatment simultaneously to more than one doctor. It is of interest that the latter offense is cast by the regulations solely in terms of the deception practiced on the second prescriber, so the doctors themselves cannot become implicated. The offense of unauthorized possession is qualified as follows:21

"Provided that a person supplied with a drug or preparation by, or upon a prescription given by, a medical practitioner shall not be deemed to be a person generally authorized to be in possession of the drug or preparation if he was then being supplied with a drug or preparation by, or on a prescription given by, another medical practitioner in the course of treatment, and did not disclose the fact to the first-mentioned medical practitioner before the supply by him or on his prescription."

In 1956, sentences for offenses involving opium ranged from 2 months to 6 months and fines from 5 pounds to 100 pounds; for marihuana offenses, from 6 weeks to 5 years and from 5 pounds to 250 pounds; and for manufactured drug offenses (heroin, morphine, etc.), from 1 day to 6 months and 10s. to 100 pounds.22 Addiction among doctors is a comparatively serious problem, as has been noted, but the sanction applied in such cases is loss of authority to prescribe narcotic drugs under the Dangerous Drugs Act, and not loss of authority to practice medicine. If an addicted doctor puts himself under the care of another doctor, he is not likely to encounter any sanctions or difficulties.

The first regulations under the Dangerous Drug Act of 1920 actually left unsettled the same ambiguity which has given so much trouble in interpreting the Harrison Act: whether the treatment of addicted persons is bona fide medical practice or not. They merely exempted classes of persons from the ban on possession in the following general language: "Subject to the provisions of these Regulations a person who is a member of any of the following classes, that is to say:

(a) duly qualified medical practitioners;

(b) . . .

shall be authorised, so far as may be necessary for the practice or exercise of his said profession, function or employment, and in his capacity as a member of his said class, to be in possession of and to supply drugs."23

Paralleling the course of development in the United States even further, the Home Office early took a narrow view of this exemption. Its ruling--still set forth as a guide for practitioners24 and hence still properly cited as in the letter referred to by the Narcotics Bureau (supra, p. 126) was as follows:

"7. The authority granted to a doctor or dentist to possess and supply dangerous drugs is limited by the words so far as may be necessary for the practice or exercise of his profession. In no circumstances may dangerous drugs be used for any other purpose than that of ministering to the strictly medical or dental needs of his patients. The continued supply of dangerous drugs to a patient solely for the gratification of addiction is not regarded as 'medical need'. In a number of cases doctors and dentists who have obtained drugs ostensibly for the needs of their practices and have subsequently diverted them to the gratification of their own addiction have been convicted of offenses under the Dangerous Drugs Act."*

*Emphasis in original.

Here, however, the parallel ended, for after several years of confusion, while the Home Office refrained from prosecutions based on bona fide ministrations to addicts in view of the ambiguity of the law and regulations, the British medical profession took matters into its own hands.

In 1926 the Rolleston Committee, a committee of eminent doctors appointed by the Government to advise on the point, concluded that providing addicted drug users with drugs under suitable controls was distinguishable from supplying "solely for the gratification of addiction,"25 and set forth the following guiding precepts:

"Precautions to be Observed in the Administration of Morphine or Heroin.

The position of a practitioner when using morphine or heroin in the treatment of persons who suffer from addiction to either of these drugs obviously differs in several important respects from that in which he is placed when using the drug in the ordinary course of his medical practice for the treatment of persons not so affected. Not only will the objects of treatment usually differ but also the dangers to be avoided, and the precautions that are therefore necessary. It is thus convenient to discuss these precautions separately as regards:

(i) The administration of the drugs to persons who are already victims of addiction, and

(ii) The ordinary use of the drugs in medical and surgical practice.

"In the preceding section, the conclusion has been stated that morphine or heroin may properly be administered to addicts in the following circumstances, namely, (a) where patients are under treatment by the gradual withdrawal method with a view to cure, (b) where it has been demonstrated, after a prolonged attempt at cure, that the use of the drug cannot be safely discontinued entirely on account of the severity of the withdrawal symptoms produced, (c) where it has been similarly demonstrated that the patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued.

"Precautions in the Treatment of Addicts by the Gradual Withdrawal Method.

In these cases the primary object of the treatment is the cure of the addiction, if practicable. The best hope of cure being afforded by treatment in a suitable institution or nursing home, the patient should, if possible, be induced to enter such an institution or home. If he is unable, or refuses to adopt this course, the practitioner must attempt to cure his condition by steady, judicious reduction of the dose. The general lines of the treatment, as carried out by the practitioners of special experience, have already been described.

For success it is necessary that the patient should be seen frequently, be under sufficient control, and be in the care of a capable and reliable nurse. The practitioner should endeavour to gain his patient's confidence, and to induce him to adhere strictly to the course of treatment prescribed, especially as regards the amount of the drug of addiction which is taken. This last condition is particularly difficult to secure, as such patients are essentially unreliable and will not infrequently endeavour to obtain supplementary supplies of the drug. If, however, the practitioner finds that he cannot maintain the necessary control of the patient, he must consider whether he can properly continue indefinitely to bear the sole responsibility for the treatment.

"When the practitioner finds that he has lost control of the patient, or when the course of the case forces him to doubt whether the administration of the drug can, in the best interests of the patient, be completely discontinued, it will become necessary to consider whether he ought to remain in charge of the case, and accept the responsibility of supplying or ordering indefinitely the drug of addiction in the minimum doses which seem necessary. The responsibility of making such a decision is obviously onerous, and both on this ground, and also for his own protection, in view of the possible inquiries by the Home Office which such continuous administration may occasion, the practitioner will be well advised to obtain a second opinion on the case.

"Precautions in Treatment of Apparently Incurable Cases.

These will include both the cases in which the severity of withdrawal symptoms, observed on complete discontinuance after prolonged attempted cure, and the cases in which the inability of the patient to lead, without a minimum dose, a relatively normal life appear to justify continuous administration of the drug indefinitely. They may be either cases of persons whom the practitioner has himself already treated with a view to cure, or cases of persons as to whom he is satisfied, by information received from those by whom they have been previously treated, that they must be regarded as incurable. In all such cases the main object must be to keep the supply of the drug within the limits of what is strictly necessary. The practitioner must, therefore, see the patient sufficiently often to maintain such observation of his condition as is necessary for justifying the treatment. The opinion expressed by witnesses was to the effect that such patients should ordinarily be seen not less frequently than once a week.

The amount of the drug supplied or ordered on one occasion should not be more than is sufficient to last until the next time the patient is to be seen. A larger supply would only be justified in exceptional cases, for example (on a sea voyage), when the patient was going away in circumstances in which he would not be able to obtain medical advice. In all other cases he should be advised to place himself under the care of another practitioner, who should be placed in communication with his previous medical adviser in order that he might be informed as to the nature of the case and the course of treatment which was being pursued.

"A practitioner when consulted by a patient not previously under his care, who asks that morphine or heroin may be administered or ordered for him for the relief of pain or other symptoms alleged to be urgent, should not supply or order the drug unless satisfied as to the urgency, and should not administer or order more than is immediately necessary. If further administration is desired, in a case in which there is no organic disease justifying such administration, the request should not be acceded to until after the practitioner has obtained from the previous medical attendant an account of the nature of the case. Requests from one practitioner to another for such information should obviously receive immediate attention."

Thus it came to be recognized and established many years ago that the addict in British society remained the addict-patient; he never became, as in ours, the addict-criminal. The precepts just quoted, from the Rolleston Report, have been printed ever since as an appendix to the Home Office Instructions on the Duties, etc. of doctors under the Act.20

The official attitude is well summarized in the Government's current report to the U. N. Commission:21

"There is no compulsory treatment of drug addicts in the United Kingdom.... In the United Kingdom the treatment of a patient is considered to be a matter for the doctor concerned. The nature of the treatment given varies with the circumstances of each case."

Nor is it as illogical as might appear at first blush to leave the Home Office statement and Sir Humphrey Rolleston's in juxtaposition in the current regulatory instructions. Lurking behind all regulatory efforts in the 'twenties was the spectre of the "script doctor," the truly unethical practitioner who abused his license to fill the role, in effect, of our detested dope peddler. If he appeared in England, and did not yield to the gentle suasions of his professional confreres and the civil authorities, it is safe to surmise that he might have been--and could still be--vigorously prosecuted as a grave offender against the Act and Regulations.

The British medical profession has remained, with the inevitable occasional exception, very responsible in the application of the foregoing principles. The primary aim of treatment is to cure the patient by freeing him from his affliction if possible, precisely as in other branches of therapy. Consultation and the concurrence of a second medical opinion are sought as a matter of course before an addicted person is put on any kind of permanent regime.

Great care is ordinarily taken to examine and probe into the condition and history of any new patient who claims a history of addiction. And doctors cooperate informally with the Home Office by reporting addicts under treatment to the Dangerous Drugs Division.

The last mentioned cooperation by the medical profession is, of course, supplemented by the reports of the police inspectors who check pharmacists' registers from time to time. Addicts who are receiving a steady supply of narcotic drugs will be revealed by this check, as well as those who falsify prescriptions or are receiving double dosages by practising fraud--the offense at which police activities are primarily aimed. The number of addicts presently known to the authorities by virtue of this double check, less than 400 in the non-medical category, as has been noted, hence seems quite likely to be a reliable measure.

Enforcement officials in the Home Office say that there is simply no illicit trafficking in the opiates; that no drugs of British manufacture have ever been identified in seizures in the illicit markets of other countries; and that new addicts usually become known to the authorities within six months. The possibility of some epidemic-like change in the pattern is recognized (as has been observed, on a minute scale, in the use of marihuana); but the situation has remained stable for many years and there are no present indications to suggest any significant growth in the addict population.

In 1956 the Minister of Health, allegedly responding to pressure from the United States, announced that he proposed to ban the use of heroin in Great Britain for medical purposes. Following this announcement medical practitioners began to buy up supplies,28 prices rose, and it is believed that a small black market may have made its appearance. Some prominent doctors thereupon organized a campaign to oppose the ban, prevailing upon the Minister, after a much-publicized controversy, to prohibit only the exportation of the drug. Thus the Minister "saved face" while leaving the profession free in the matter. There is still mild resentment over the fact that because heroin was removed from the British Pharmacopeia in 1956 when the ban was proposed, American authorities hailed this as a prohibition and still make statements to the effect that England has joined the United States in outlawing the drug.

Home Office officials believe that even if they stopped all lawful importation of opiates for all purposes, the problem of addiction would remain because addicted persons would be compelled to sustain their condition by the development of a black market. They complain that most of the publicity and press comments about drug problems in the United Kingdom are not authoritative. It was suggested that some of the addicts who have run afoul of the law (or who may be importing their own drugs) are simply unaware of the true state of affairs and of the fact that they can obtain relief and assistance from the medical profession merely by application to a doctor.

The foregoing general and statistical observations were confirmed in a study of local conditions in Glasgow and Edinburgh. In Glasgow, with a population of 1.45 million, four officers of the police department are assigned to enforcement of the regulatory provisions of the Dangerous Drug Act, devoting their full time to inspecting pharmacies, checking records, and investigating alleged violations and abuse. These men are wholly unaware of any serious problem of addiction, and state that there is no black market, with the possible exception that hemp and smoking opium may sometimes get past the customs authorities and into the waterfront district to Chinese and West Indian consumers. There are approximately 350 pharmacies in the city, less than a score of known addicts, and two doctors (out of a total of 40 in the United Kingdom) whose authority to prescribe drugs is currently under suspension.

One of the two doctors has succeeded in curing himself of his addiction, and it is expected that his authority to prescribe drugs will be restored if he makes application.

The officers reflected an attitude of great respect for the medical profession, and stated that they are "not encouraged" to approach the doctors in matters within their jurisdiction; if a questionable or unusual practice comes to their attention, they are expected to report through channels to the Home Office and the matter may then be taken up through the Ministry of Health and the local medical boards.

It was also stated that although the pharmacists are universally cooperative, some doctors, especially the older practitioners, would probably refuse to cooperate with the police concerning their patients under any circumstances, and the suspicion was voiced that 90% of the doctors up here don't keep any records at all.22 There was no identification between addicted persons and persons engaging in criminal activity.

In Edinburgh, with a population of half a million, two men are assigned to policing the Dangerous Drugs Act, and one investigation conducted by them within the last eighteen months has resulted in the preferring of charges.

This was the case of an addict who had made application simultaneously to more than one doctor for care, with a long record of similar activities in the past. Because his wife cooperated with the police in reporting on his activities, he was let off without a sentence as a result of their recommendation to the prosecutor. The officers speculated that he might receive a short prison sentence if he were caught and charged again. They also recalled one case in the preceding year involving a doctor-addict who appeared to have violated the Act by making personal use of drugs purchased by him for administration to his patients. This case resulted in the conveyance of a warning to the doctor without the preferment of charges.

There are seven firms manufacturing narcotic drugs in Edinburgh, accounting for a substantial part of the industry in the United Kingdom. There has been one case of theft from one of these firms since World War II. The police cooperate informally with the firms in checking any applicant for employment about whom there may be suspicions (either of addiction or as a possible thief).