"*** morphine or heroin may be properly 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."

8

The committee made other recommendations for the guidance of doctors who handle drug users; these do not have the force of law, but exert considerable moral pressure upon medical men. They include warnings that the gradual withdrawal method of cure should be undertaken in an institution or nursing home, that the patient should be in the hands of a reliable and capable nurse, that a second medical opinion should be secured before the decision to administer drugs indefinitely is made, that the quantity of drugs prescribed should be carefully controlled, and that drugs should not be administered to a new patient who requests them without prior medical examination and relevant information from the doctor who previously handled the case.

9

Concerning incurable cases of addiction the committee observed: "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 previously been 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 could not be able to obtain medical advice. In all other cases he should be advised to place himself under the care of another practitioner."

The Home Office annually reports on the number of persons known to be using drugs regularly. It maintains a file in which the cases are classified into two sections, medical and nonmedical. The former contains data concerning persons regularly receiving drugs because of disease, such as cancer patients. The nonmedical file lists the cases of those persons who are simply addicts, that is, persons who are receiving drugs primarily because they are addicted to them, and not because of disease or any other medical condition. The figure of 335 known addicts in 1955,10 mentioned previously, was evidently secured by counting the number of cards in the nonmedical section, and represents an increase of 18 over the previous year. At latest reports the number of cases in the medical section also numbered a little over 300. The information recorded in these files is obtained from data voluntarily supplied by pharmacists and doctors as well as from regular inspections of their records.

Skeptics are likely to inquire whether the Government's figure of 335 addicts for a country with a population of more than 50 million people can be taken as any real indication of the actual number of drug users. Might there not be a considerable number of concealed addicts who secure their drugs entirely from illicit sources? Officials interviewed by the writer admitted the existence of such addicts, but refused to estimate their number. It was said that there were drug peddlers and traffickers in the Soho district of London; but, it was argued, the extent of the traffic was quite small, even in such large cities as London and Liverpool, and that it was practically nonexistent in other cities. It was also contended that this market is mainly concerned with drugs such as marihuana and cocaine, which are not regularly prescribed by doctors and

8 If the doctor does not know of these recommendations the Home Office may call them to his attention. If he does know about them, and disregards them, pressure can be exerted upon him by the medical inspectors of the Ministry of Health and by medical bodies such as those which supervise the National Health Act. Continued recalcitrance could theoretically lead to disciplinary measures by a medical tribunal authorized under the regulations for this purpose. Actually no such tribunal has ever been convened.

Quoted in appendix A of the 1948 Home Office Memorandum, op. cit., p. 10. 10 The Traffic in Opium and Other Dangerous Drugs, etc., op. cit., p. 5.

are prohibited in the United Kingdom as they are here in the United States. Two medical men who were interviewed estimated that there were 10 unkown addicts for every 1 that is known to the authorities. Other doctors and almost all Government officials who expressed an opinion regarded this estimate as extravagantly high and totally unreliable.

11

Among the reasons for believing that the number of concealed addicts is not large is the fact that very few addicts are sent to prison each year. During the last 5 years the number of addicts sent to prison for any offense whatever has run as follows: In 1952, there were 6; 1953, 16; 1954, 11; 1955, 11, and up to July 1956, 11. These figures do not suggest the existence of any large number of addicts among the criminal elements. When the writer observed to a Scotland Yard officer that pickpockets and shoplifters in the United States were frequently addicted, the officer ventured the opinion that there was not a single addicted pickpocket in London. Probation, parole, and prison officials and doctors are largely unacquainted with the addiction problem from personal experience. A police officer with 20 years' experience outside of London stated that he had encountered only 1 narcotics case, and it involved an American soldier who used marihuana.

12

The black market in drugs, such as it is, appears to be very different from that in the United States. Thus, the 1955 Government report states: "The 'addict' who is also a 'pusher' is unknown in the United Kingdom, though on occasions an addict may procure more than his own requirements in order to supply his friends." It is also stated that the black market in Britain is not organized; that it subsists to a considerable extent on addicts who wish to supplement their legally obtained dosage, and that it is supplied, primarily, by drugs unlawfully secured from legitimate sources, for example, from unethical or unscrupulous doctors. A London physician estimated that there were, per

13

haps, 5 or 6 such doctors in London. In the Government's 1955 annual report to the United Nations, the following statements about the illicit traffic occur: "The gradual decline in the traffic in opium, noted in the report for 1954, continued, and both the number of seizures of this drug, and the quantity confiscated, were the lowest for several years * * *. Illicit production of manufactured drugs and traffic in such drugs obtained from illicit sources is unknown. Isolated cases of the theft of legitimately manufactured drugs occur very occasionally, but in 1955 no such cases were reported. There were, however, some instances of addicts obtaining supplies from lawful sources by illicit means, for example, by forged prescriptions."

14

The Dangerous Drug Act of 1951 prescribes penalties as follows: "Every person guilty of an offence against this Act shall, in respect of each offence, be liable-(a) on conviction on indictment, to a fine not exceeding one thousand pounds ($2,800), or to imprisonment for a period not exceeding ten years, or to both such fine and imprisonment; or (b) on summary conviction, to a fine not exceeding two hundred and fifty pounds ($700), or to imprisonment for a term not exceeding twelve months, or to both such fine and imprisonment ***"

A qualification of the above is that anyone convicted for inadvertently violating the regulations for the dispensing of prescriptions and keeping of books cannot be sentenced to prison without the option of paying a fine not larger than £50. No mandatory penalties are prescribed. It is left to the court to fix the precise penalties in accordance with the circumstances of the case and the nature of the offense. In practice, the maximum penalties are scarcely ever applied. The court is also free to place the defendant on probation, and often does. A judge may place an addict on probation on the condition that he agree to accept treatment from a doctor.

In 1955 1 the actual sentences of imprisonment imposed for offenses involving manufactured drugs ranged from 6 weeks to 12 months; for those involving opium, from 28 days to 6 months; and for those connected with marihuana, the range was from 1 day to 3 years. Maximum fines for these categories of offenses were equivalent respectively to $140, $280, and $140. By comparison to American practice these penalties are extremely light; and one might suppose that they would have little or no deterrent effect. However, it must be remembered that laws carrying mild and flexible punishments are more likely to be enforced than those that impose harsh, inflexible penalties.

11 Unpublished figures given the author by a Home Office official.

12 Op. cit., p. 5.

13 Op. cit., p. 6.

14 Dangerous Drug Act, 1951, 14 and 15, Geo. 6, ch. 48, sec. 15.

15 The Traffic in Opium and Other Dangerous Drugs, etc., op. cit., pp. 6-7.

During 1955, 184 persons in the United Kingdom were prosecuted for violations of the dangerous drugs laws.16 Of these 169 were convicted, 17 for offenses involving opium, 115 for offenses involving marihuana, 30 for offenses connected with manufactured drugs, and 7 because they failed to keep drugs in locked receptacles or did not keep proper records. Sixteen of the seventeen offenses involving opium were committed by Chinese persons, usually opium smokers, who had prepared or raw opium in their possession, ostensibly for smoking, a practice expressly forbidden by British law. Persons convicted in the marihuana cases were largely of Asiatic, West Indian, and west African origin; and about 85 percent of the cases occurred in Liverpool and London.

The 30 convictions involving manufactured drugs were cases where the defendants were all British subjects of European origin, and most of them were addicts. Their offenses consisted mainly in forging prescriptions or obtaining prescriptions simultaneously from more than one doctor.

The nature and number of the offenses noted above gives no support to the idea that a considerable number of unknown addicts exists in the United Kingdom; rather, it supports the view of officials that the black market is of such a nature that an addict cannot rely on it indefinitely for his supplies. Even if he escapes arrest, it is felt that he will soon be forced to go to a physician, When he does, and the doctor prescribes for him, his name appears on the prescription and on the doctor's register; in short, he becomes a known addict. British officials are confident that if there were a substantial number of addicts depending upon the black market for their supplies, the situation would be bound to come to the attention of the law enforcement authorities.

The facts as explained are bound to raise two questions in the mind of any American familiar with the problem of narcotics control. Why is there a black market at all in a country where users can obtain low cost, legitimate drugs? And why do not all addicts go to physicians for their drugs? To answer them, the writer made extensive inquiries during the summers of 1955 and 1956 while he was in England. A doctor in London, who had considerable firsthand knowledge of addicts, said that one answer to these questions was that some addicts patronizing illicit sources were unaware that they could secure drugs from doctors. He urged a publicity campaign to inform them of this. Other addicts fear becoming known to the authorities, and avoid medical men for that reason. The responsible physician is apt to require, as a condition for accepting the addict as a patient, that he agree to cooperate in a treatment program designed to achieve a cure. The doctor may also ask the addict for his permission to inform the Home Office of his case at once, since the case will come to the attention of the authorities anyway as soon as the doctor's register is next examined. Addicts who are unwilling to accept these conditions may prefer to depend upon illicit sources in spite of the much higher costs to them.

In order to fully understand the manner in which the drug problem is handled in Britain, it is necessary for an American to appreciate that the entire problem is given very little publicity. The Home Office officials and the police officers who deal with it are largely unknown to the general public, and their pictures do not appear in newspapers and magazines. Nor are their accomplishments glorified in the movies and the press. The effect has been to make the public generally regard the details of medical treatment for addicts as technical matters to be settled by discussions among experts, rather than by public debate. It has also prevented the public, and sometimes also journalists, doctors, and addicts, from knowing much about how the drug problem is actually dealt with.

LAW ENFORCEMENT

Enforcement of the British drug laws is centered in the Dangerous Drug Branch of the Home Office, which is a nonpolice branch of the Government exercising general control over police policy, and cooperating closely with the police, the medical profession, pharmacists, and the Ministry of Health. A small narcotic squad in the London police force is assigned on a full-time basis to the narcotic problem; and the regular police are also empowered to arrest violators. As noted before, inspections of pharmacists' records are carried out as a matter of routine by the regular police, who report their findings to the Home Office. Inquiries to doctors and inspection of their records are made by the Home Office and by specially appointed regional medical inspectors. If violations of the

16 Ibid.

law are suspected or discovered, the police may be brought into the case to make investigations. If no violation of the law exists, but it is felt that a doctor's handling of the case is not up to standard, pressure is apt to be exerted upon him through medical channels; for example, a medical inspector may call upon him to give advice, since that is one of the functions of these inspectors. Doctors are sometimes convicted of offenses involving improper prescriptions or records, for instance, when they are trying to cover up their own addiction. During the summer of 1955 the writer attended a hearing in a London magistrate's court on the case of a London doctor charged with violating the law by aiding and abetting an addict in the deception of another doctor. It was established that the addict had received about 6 grains of heroin daily from each of two doctors. He had died early in 1955, and the cause of death at the inquest was stated to be an overdose of heroin. The magistrate who heard the case dismissed the charges with the following comment:

17

"It may well be that the patient committeed an offense here. It is not for me to decide one way or the other, but to my mind it would make nonsense of these regulations, which are designed to give duly qualified medical practitioners absolute discretion as to how they treat their patients and the quantities of drugs they shall prescribe, if I were to hold that these facts amounted to an infringement of these regulations by this defendant.

"There is nothing in these regulations to which my attention has been directed which limits the quantities of drugs which may be lawfully prescribed by a doctor. It may well be that this conduct of the defendant was gravely improper. It is not for me to decide any such issue.

"It may be that it is a matter which may be referred to the disciplinary body of the medical practitioners, but I have no doubt that the prosecution have failed to establish a prima facie case against this defendant of aiding and abetting another person to be in possession of this dangerous drug and I therefore dismiss the information."

During the course of the hearings on this case a woman who was said to have been an addict in the past appeared as a witness. She stated that she was now respectably employed and was no longer an addict, and asked that her name be withheld. When she appeared on the witness stand her name was accordingly written on a slip of paper and handed to the magistrate, but was not mentioned publicly. This incident is representative of the attitude generaly taken toward drug users. The public attitude may best be described as pity. When addicts appear in court charged with criminal offenses if they are treated differently from other offenders, they are apt to be dealt with more lightly. An addict who secures additional supplies of his drug by forging prescriptions or secretly consulting a second doctor will usually only be fined if he is not a chronic offender. If he is old and ill besides, he may merely be placed on probation. However, if an offender against the drug laws is thought to be operating from mercenary motives, for his own financial gain, he is apt to be dealt with more severely by being sentenced to prison.

In 1954, an incident occurred which is an illustration of the manner in which the British drug laws operate. An American entertainer performing at the London Palladium, a vaudeville theater, was known by the police to be a heroin user and was therefore watched. This person consulted a doctor from whom he received a prescription for heroin under a false name and identity. He was arrested, charged, and convicted for having given false information to the physician, and then deported. The writer asked what would have happened had the defendant not given false information to the doctor. The answer was that in that case nothing would have happened, because there would have been no violation.

THE BAN ON HEROIN

The recent attempt of the British Government to impose a ban on the manufacture and importation of heroin provides an excellent illustration of the sensitivity of the British medical profession to what it regards as encroachments on its prerogatives. Heroin was banned in the United States in 1924 when it was discovered that addicts were using this drug very widely. Since the heroin that was being used by American addicts at this time was already being used illegally, the ban had no particular effect; in fact, heroin has become even more popular with American users since, but not because, it was banned. The congressional hearings held before the ban was put into effect revealed that the

17 Quoted in the London Times, September 9, 1955.

medical profession in this country was divided on the question of the medical usefulness of heroin, a majority declaring that heroin was not indispensable. A minority opinion contended that heroin did have some therapeutic values not possessed by possible substitutes, and argued against the ban. This minority opinion was brushed aside, of course, by congressional action. Shortly after 1925, similar hearings were held in Britain which revealed a similar split in British medical opinion; but Parliament interpreted this as a reason for not imposing a ban because the medical profession was not in agreement.

In recent years American representatives to the World Health Organization of the United Nations spearheaded an international drive to ban heroin everywhere; and it is now an illegal drug in more than 50 countries of the world. It was the pressure of this drive that probably caused the British Government, to announce, rather suddenly in 1955, that the manufacture of heroin would be discontinued in 1956. Protests from medical sources were voiced immediately, and the issue was vigorously discussed in newspaper columns and in letters to the editor. The matter became a minor political issue in Parliament; and the part played by American pressure in the campaign to outlaw heroin was understood and discussed. The vigorous reaction of the British medical profession to the Government's action was based more on the feeling that the Government was interfering with the rights of the profession than on any attachment to heroin as a therapeutic agent. The Government was eventually obliged to postpone the banning of heroin to an indefinite date, and heroin is therefore still not a contraband drug in the United Kingdom as it is in the United States.

EFFECTS OF THIS SYSTEM ON THE DRUG PROBLEM

It would, of course, be a mistake to attribute the trivial nature of the British drug problem entirely to the control measures which have been sketched. Back in 1920, when present control measures were set up, the number of addicts in Britain was small in contrast to the situation in this country. Nevertheless, the fact that the problem has diminished since that time, and that the number of drug users is probably close to what one might call "an irreducible minimum," are strong arguments in favor of th British system.

Prior to 1920 English addicts were free to buy their supplies of drugs from -pharmacies without consulting a doctor. After that time they were compelled either to give up the habit or to consult a physician. They had a third alternative to obtain supplies from illicit sources-but this was scarcely practical because no illicit traffic that was sufficiently organized to provide regular supplies ever developed. By having to turn to doctors, addicts got the benefits of medical and psychiatric care and advice. Although the drug user is a difficult patient to handle, he is obviously better off in the hands of the medical profession than if left to his own devices.

British officials are concerned over the potential development of a clandestine traffic as it exists in the United States; but feel, in the main, that giving addicts access to low cost, legitimate drugs takes most of the economic motive out of such a traffic. At the same time, it is realized that the addict's access to drugs cannot be too free and unrestricted; hence the pressure on doctors to minimize dosage and to make prolonged attempts to achieve a cure. Undoubtedly there is some objection in Britain on moral grounds to indefinite administration of drugs; but this is counterbalanced by considering the greater evil of a large illicit trade in the hands of criminals. That the present system seems to work, in the sense that the problem is small and not growing larger, causes an understandable reluctance to change it in any important way.

English officials and the public do not regard addicts as criminals since their addicts are not criminals, or only in a minor sense of the term. They therefore have difficulty in understanding the American tendency to equate addiction with criminality, and to punish addicts more and more severely. It is felt in Britain that the addict is a weakling or an unfortunate person to be pitied and treated with compassion.

Since the British addict does not need as much money to secure drugs as he does to buy cigarettes, he does not have to steal, become a prostitude, or peddle drugs in order to support his habit. Indeed, there is a positive, special hazard and unncessary disadvantage for him in such criminal activities, since they may lead to entanglements with the law and to sudden interruptions of his habit. It is also disadvantageous for the criminal to become an addict, for he thereby adds greatly to the hazards of an already perilous occupation. A London police officer was asked what might happen if one approached a prostitute to inquire