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BACKGROUND

Drug control in Britain was established between 1910 and 1930, with a solid grounding in public health and medical practice. This British approach to drug problems as public-health problems seemed especially attractive as an alternative to U.S. drug prohibition policies, even when the heroin problem in the United States was relatively small, back before 1960. Thus, beginning in the late 1940s, some Americans started to advocate the use of the British system in the United States—that is, a nonpunitive, public-health approach to the treatment of drug dependence, especially dependence on heroin.

In 1960, the drug problem was essentially a non-issue in the political life of Britain, although the structures for control in the two countries remained very different. In the United States, a prohibitionist policy continued in place whereby criminal penalties were imposed for heroin possession and use—and sometimes for being addicted to heroin. Physicians rarely treated opiate addicts and could not legally provide a known addict with opiates on a maintenance basis. As a result, from early in the twentieth century, virtually all heroin addicts purchased supplies from illegal heroin sellers. With the exception of a brief time during which maintenance programs were available, relatively few addicts sought drug treatment from doctors, and treatment for heroin dependence often was available only at two federal narcotic hospitals and select public and private facilities. In NEW YORK and CALIFORNIA, in particular, large numbers of heroin abusers were arrested and imprisoned for heroin sales, for possession, or for other crimes sometimes committed to gain funds to purchase illegal heroin (e.g., robbery, burglary).

In contrast, by 1960, Britain had had many years of experience with a "medical" or "public-health" policy for controlling heroin and opiates (originating with the ROLLESTON REPORT of 1926). Fewer than 100 heroin addicts and fewer than 500 abusers of all drugs were known in Britain in 1960. Persons identified by a doctor as being addicted to heroin or other dangerous drugs could be (and usually were) treated by a private practitioner. The physician was required to notify the Home Office of the names of the addicts but was at liberty to prescribe heroin or opiates for them in any amounts for long time periods. Their treatment became funded by the National Health Service after World War II, like any other medical service. No other treatment (at a clinic, hospital, or nonmedical facility) was available. Penalties for the illegal sale of heroin or opiates carried sanctions of less than a year and were rarely imposed. Few British prisoners were heroin addicts.

British drug policy has been and continues to be set primarily by Home Office staff in collaboration with leading physicians and addiction specialists. British law-enforcement and criminal-justice practitioners were largely excluded from policymaking—whereas their counterparts in the United States have a primary role in formulating American drug policy. Following the Rolleston precedent, several special committees issued reports establishing the basic directions of British drug policy. The first Brain Committee (1958) reaffirmed the Rolleston recommendation to provide heroin and allow maintenance doses of opiates; it opposed U.S.-sponsored proposals to prohibit heroin manufacture in Britain.

CHANGING MEDICAL POLICIES ON DRUG CONTROL

The situation changed in the early 1960s, however, and, based on recommendations of the second Brain Committee (1964), clinics for controlling and containing the heroin problem were implemented under the Dangerous Drug Act Regulations in 1968. Responsibility for the treatment of addicts generally was shifted from general practitioners (GPs) to Drug Dependency Units (DDUs). When a heroin abuser seeks treatment from a GP, however, the doctor can refuse treatment, refer the patient to a DDU, or provide declining methadone doses over six months (called long-term detoxification in the United States) or provide regular methadone maintenance (although this is rarely done by a GP).

The DDUs or drug clinics provide a range of services funded by the National Health Service. In 1989, thirty-five DDUs operated in Britain and were directed by consulting psychiatrists who specialized in addiction treatment and prescribing. In smaller towns without clinics, one or two GPs can be licensed by the Home Office to provide treatment for addicts in the area. New applicants are interviewed and their urine tested to verify opiate use. The clinic physician develops a treatment plan with the patient, arranges weekly conferences, and mails the prescription directly to a local pharmacy; it will be filled for the client on a daily basis. The Home Office also convenes meetings with several DDU directors to discuss common policies and practices, and to recommend approval or removal of licenses, when necessary, for physicians to prescribe dangerous drugs.

When the DDUs opened, most clinics made decisions to shift patients receiving prescriptions for injectable heroin onto injectable methadone. The pharmacist dispensed needles, syringes, and ampoules of methadone.

Over the period 1975 to 1983, many clinic directors shifted most patients from injectable to oral methadone maintenance. In the early 1980s, as illegal supplies of heroin became common in British cities, many clinics shifted away from oral methadone maintenance. Instead, the treatment policy at several clinics was to provide gradual withdrawal (detoxification in the United States); rarely were patients provided with long-term maintenance doses. As AIDS was tied to shared needles and syringes by injecting addicts, prevention became an important subgoal of drug treatment; however, new emphasis was then placed on oral methadone maintenance. In the early 1990s, the DDUs had heroin-abusing clients, many of whom received gradual reduction (detoxification) and others who received maintenance on methadone. Relatively few received prescriptions for injectable methadone or heroin, even though DDU doctors could legally and appropriately provide such services.

A continuing controversy within Britain in the 1990s has been whether the clinic system could stem or contain the heroin problem, and whether the clinic's shift away from prescribing heroin and injectable drugs contributed to the growth of black-market heroin. In discussion groups, some experts argued that many black-market heroin users would seek treatment if the clinics returned to prescribing injectable heroin or methadone. Such a policy also might reduce addict crime and prevent transmission of the AIDS virus. This, however, would change the profile of patients: Clinic directors would have to deal with addicts who have no intention of stopping heroin use.

The British have amended the Dangerous Drug Act several times since 1960, thereby making the illegal sale of heroin, cocaine, and marijuana criminal offenses. Although the vast majority of drug arrestees are only "cautioned," even after repeated instances of offense, many illegal sellers and heroin abusers arrested for robbery, burglary, and theft can be and are imprisoned. Thus, an increasingly larger proportion of British prisoners are heroin addicts. Between 1979 and 1984, seizures of illegal drugs went up tenfold, incarcerated drug offenders went up fourfold, and the consumption of heroin increased by 350 percent—but heroin prices decreased by 20 percent.

Rise of Nonmedical Drug Treatment.

The increase in black-market heroin, substantial increases in heroin abusers who avoid the DDUs, apparent increase in penal sanctioning, and a host of complex issues have led to dissatisfaction with the original British System, with its medical model of drug treatment. Influenced by U.S. therapeutic communities and outpatient local programs that promote a drug-free environment, British social service agencies have begun developing similar programs thereby "reaching out" to clients and providing alternative services in a context that is different from the practice settings dominated by the consulting psychiatrists at DDUs.

Other emerging British programs are increasingly built around a philosophy of "harm reduction." This emphasizes informing people of safer ways to take drugs for those who will continue to do so, helping addicts recognize drug-related problems (e.g., infections or diseases), and making sterile injection equipment and/or drug treatment available with minimal restrictions. The program's staff also suggests alternative ways of altering consciousness or seeking pleasure.

AIDS Prevention.

Since the years 1984 to 1985, the British have been international leaders in devising innovative programs to reduce the spread of the AIDS virus. Because of the legal provision of opiates by physicians and DDUs, the sale of syringes was never prohibited nor seriously constrained. Addicts using black-market heroin could always purchase sterile needles cheaply as well as receive instructions on safe injection practices although in some areas pharmacists might refuse to sell them to addicts.

Gerry Stimson, a sociologist who had conducted studies of heroin addicts from 1960 through the 1970s, became a leading government consultant in the 1980s in formulating British AIDS prevention policies. Together with other experts, he recommended establishing syringe exchanges to promote safe disposal of used needles (possibly infected with the AIDS virus) and to reach injecting drug users who avoid the clinics. His subsequent research established the facts that untreated addicts could be attracted to these exchanges but that retention rates were low. Possibly as a result of these efforts, the AIDS infection rate in Britain is much lower than that in many cities of the United States.

Heroin Abuse.

After 1960, several major increases in heroin use and abuse occurred in Britain. In the early 1960s, a few British physicians began prescribing large amounts of legal heroin to private patients, some of whom resold it to other people. The number of known heroin abusers grew to 2,240 in 1968 and then increased slowly during the 1970s. In the early 1980s, however, a major increase in illegal importation of heroin to Britain was followed by an epidemic of heroin use in that country—thus, 12,500 heroin abusers were reported to the Home Office in 1984. In the mid-1990s, many heroin abusers avoid clinics and doctors and are not reported to the Home Office. Therefore, the actual number of regular heroin abusers in Britain now is estimated to be between 50,000 to 100,000.

CONCLUSION

Since the 1960s, the British system of drug control has evolved and changed in many important ways. Although the heroin problem expanded dramatically in the 1980s, the major policy decisions of the Rolleston Report have continued to govern the British approach. The British government continues to collaborate closely with medical and public-health experts. Treatment practices have been refined by experience and practical considerations, but not because of imposition by government fiat. Prohibition of heroin did not occur and punishment of drug abusers remains a secondary consideration in British policymaking (but is still a dominant consideration in the United States). Since 1960, the British heroin problem has grown and become complex. Drug-policy and treatment response have become diverse and, therefore, there is less of a clear "system."

In comparison with the situation in the United States, British policymakers and the general public favor public-health considerations over other moral concerns. Some British newspapers do promote "dope fiend" images and demand punitive responses—and the American "drug free" and "just say no" philosophies are often articulated. Nonetheless, British drug policy and funding are primarily directed by medical and public-health specialists. This means that heroin addicts and drug abusers are not as heavily stigmatized as they are in the United States.

The British public accepts the idea of providing heroin and methadone as medicine, has few moral qualms about addicts, and little fear of needles. Lacking the harsh and punitive moral consensus against drugs that prevails in the United States, the British government has considerable latitude to experiment with differing policies, to shift treatment practices to accord with practical experience, and to keep modifying its policy responses to the ever-changing drug scene. Whether the British system could work in the United States, which is much larger and more populous than Great Britain, remains an open question.

(SEE ALSO: British System of Drug-Addiction Treatment; Needle and Syringe Exchanges and HIV/AIDS; Policy Alternatives)

BRUCE D. JOHNSON