MINISTRY OF HEALTH
SCOTTISH HOME AND HEALTH DEPARTMENT
THE SECOND REPORT
ON DRUG ADDICTION
HER MAJESTY'S STATIONERY OFFICE
LORD BRAIN, M.A., D.M., F.R.C.P. (Chairman).
A. LAWRENCE ABEL, M.S., F.R.C.S.
DONALD W. HUDSON, M.P.S.
PROFESSOR A. D. MACDONALD, M.SC., M.D.
HENRY MATTHEW, M.B., Ch.B., F.R.C.P.
S. NOY SCOTT, M.R.C.S., L.R.C.P.
MAURICE PARTRIDGE, M.A, D.P.M., D.M., M.R.C.P.
A. J. PITKEATHLY, O.B.E., M.B., Ch.B.
ROY GOULDING, M.D., B.Sc. - A. H. H. JONES Joint Secretaries.
ON DRUG ADDICTION
REPORTTo The Rt. Hon. Kenneth Robinson, M.P., Minister of Health.
The Rt. Hon. W. Ross, M.P., Secretary of State for Scotland.
1. We were originally convened in 1958 with the following terms of reference:
to review, in the light of more recent developments, the advice given
by the Departmental Committee on Morphine and Heroine addiction in
1926; to consider whether any revised advice should also cover other
drugs liable to produce addiction or to be habit-forming; to consider
whether there is a medical need to provide special, including
institutional, treatment outside the resources already available, for
persons addicted to drugs; and to make recommendations, including
proposals for any administrative measures that may seem expedient,
to the Minister of Health and the Secretary of State for Scotland".
In our report, published in 1961, we concluded that addiction should be
regarded as an expression of mental disorder rather than a form of
criminal behaviour (paragraph 27); that the satisfactory management of
cases of addiction was not possible except in suitable institutions,
but that the compulsory committal of an addict to such an institution
was not desirable (paragraph 28); and that, as the problem was small,
the establishment of specialised institutions, for the treatment
of drug addiction was not practicable (paragraph 30). We felt
that initial treatment of an established addict could best be
undertaken in the psychiatric ward of a general hospital (paragraph 31).
We further concluded that a system of registration of addicts would not
be desirable or helpful (paragraph 35), as on the evidence before us
the incidence of addiction to dangerous drugs was very small and there
seemed no reason to think that any real increase was occurring, We
thought, too, that special tribunals should not be set up, to
investigate particular cases and advise whether a doctor's authority to
possess and supply dangerous drugs should be withdrawn, as
irregularities in prescribing these drugs were infrequent and would not
justify further statutory controls (paragraphs 40-45).
4. We were re-convened in July, 1964, with the following terms of reference:
to consider whether, in the light of recent experience', the advice
they (1) gave in 1961 in relation to the prescribing of addictive drugs
by doctors needs revising and, if so, to make recommendations ".
The only changes in membership of the re-convened committee were the
appointments of Dr. Henry Matthew and Dr. A. J. Pitkeathly in place of
Sir Derrick Dunlop and Dr. A. H. Macklin, who were unable to serve
In so far as " the advice they gave in relation to the prescribing of
addictive drugs " was specified for revision, we interpreted our terms
of reference as meaning that we were not being invited to survey the
subject of drug addiction as a whole, but rather to pay particular
attention to the part played by medical practitioners in the supply of
7. We have held eight meetings. We first studied
submissions from the Home Office, the Ministry of Health and the
Scottish Home and Health Department setting out the developments in
drug addiction since 1961.1 Then we invited written and oral evidence
from a number of persons with a special experience in this field.
Throughout our proceedings, too, we had the assistance of officers from
the three Government departments mentioned.
The new situation
8. We learned that:
the years 1959-1964 the total number of addicts to dangerous drugs (2)
known to the Home Ottice had risen from 454 to 753.(3)
During this period, the number of heroin addicts had risen from 68 to
342, while the incidence of addiction to other dangerous drugs remained
more or less the same (Appendix I). Most of the new addicts were taking
(ii) The number of cocaine addicts had increased from 30 in
1959 to 211 in 1964. Virtually all of these were using the drug in
conjunction with heroin (Appendix I).
(iii) The number of those who
had become addicted to dangerous drugs other than as a result of
medical treatment had risen from 98 in 1959 to 372 in 1964. For heroin
the corresponding figures were 47 and 328 respectively (Appendix I).
Thus, out of 342 heroin addicts, 328 were of non-therapeutic(4) origin.
There had been a significant change in the age distribution of addicts.
In 1959 only 50 out of 454 (i.e. 11 per cent) were less than 35 years
old ; by 1964 this group numbered 297 out of 753 (i.e. nearly 40 per
cent), 40 of them being under 20 years of age (1 being as young as 15).
All 40 under 20 and the majority under 35 were taking heroin (Appendix
(v) In 1962 the United Kingdom produced 36 kilogrammes of
heroin and consumed 40 kilogrammes In 1964 production had risen to 55
kilogrammes and consumption to 50 kilogrammes (Appendix III).These
quantities far exceed those of any other country for which returns are
published. This is to some extent due to the fact that the United
Kingdom is one of the relatively few countries where heroin can legally
be used for medical treatment, but the figures are nevertheless very
(vi) The increase in addiction to heroin and cocaine
appeared to be centred very largely on London, but indications of a
similar trend, on a much smaller scale, had been observed in one or two
of the other large cities.
How have the new addicts obtained their supplies? In our first report
we recorded the view of the Home Office and the police that the
trafficking in illicit supplies was negligible. We have looked again at
the possibility that an organised traffic has produced a wave of
addiction, but we are satisfied from our enquiries of the Home Office,
the Metropolitan Police and our witnesses that there is at present no
evidence of any significant traffic, organised or otherwise, in
dangerous drugs that have been stolen or smuggled into this country.
Supplies of dangerous drugs have sometimes been obtained by forging or
altering prescriptions, or by obtaining second prescriptions on the
false plea that the first has been lost, or by approaching various
doctors under assumed names. But we doubt whether, in view of the
vigilance of the medical and pharmaceutical professions and the careful
work of the police and the Home Office Inspectorate, such methods have
contributed substantially to the quantities of dangerous drugs
available to new addicts.
11. From the evidence before us we have
been led to the conclusion that the major source of supply has been the
activity of a very few doctors who have prescribed excessively
for addicts. Thus we were informed that in 1962 one doctor alone
prescribed almost 600,000 tablets of heroin (i.e. 6 kilogrammes)
for addicts. The same doctor, on one occasion, prescribed 900 tablets
of heroin (9 grammes) to one addict and, three days later, prescribed
for the same patient another 600 tablets (i.e. (6 grammes) " to replace
pills lost in an accident ". Further prescriplions of 720 (i.e. 7-2
grammes) and 840 (8.4 grammes) tablets followed later to the same
patient. Two doctors each issued a single prescription for 1,000
tablets (i.e. 10 grammes). These are only the more startling examples.
We heard of other instances of prescriptions for considerable,
if less spectacular, quantities of dangerous drugs over a long
period of time. Supplies on such a scale can easily provide a
surplus that will attract new /recruits to the ranks of the addicts.
The evidence further shows that not more than six doctors have
prescribed these very large amounts of dangerous drugs for
individual patients and these doctors have acted within the law and
according to their professional judgment.
13. Some of the doctors
concerned told us that they had embarked on the treatment of addicts
out of a sense of duty because they felt that the treatment facilities
elsewhere were inadequate.
Measures to curtail supplies
In considering measures for the better control of prescribing and
supplying we have borne in mind the fact that doctors in this country
have always had the right to use dangerous drugs. We said in our last
report that this system had worked well. We remain convinced that the
doctor's right to prescribe dangerous drugs without restriction for the
ordinary patient's needs should be maintained.
15. We have also
borne in mind the dilemma which faces the authorities responsible for
the control of dangerous drugs in this country. If there is
insufficient control it may lead to the spread of addiction — as is
happening at present. If, on the other hand, the restrictions are so
severe as to prevent or seriously discourage the addict from obtaining
any supplies from legitimate sources it may lead to the development of
an organized illicit traffic. The absence hitherto of such an organised
illicit traffic has been attributed largely to the fact that an addict
has been able to obtain supplies of drugs legally. But this facility
has now been abused with the result that addiction has increased. To
prevent this abuse without sacrificing the basic advantages of the
present arrangements we suggest : —
(a) a system of notification of addicts;
(b) the provision of advice where addiction is in doubt;
(c) the provision of treatment centres;
(d) the restriction of supplies to addicts.
Our special concern has been heroin and cocaine to which most of the
new addicts have become addicted. We therefore consider that special
restrictions should apply to these two drugs alone, which, in the
remaining paragraphs of this report, we refer to as "restricted drugs".
But this is not to imply that their medical use should be banned.
If, in future, circumstances should change, and other drugs of
addiction should take the place now occupied by heroin and cocaine, it
would be necessary promptly to amend the "restricted" list accordingly.
Definition of an addict
For the purposes of our proposals an accepted definition of an addict
is required. We suggest that it should be on the following lines: "A
person who, as the result of repeated administration, has become
dependent upon a drug controlled under the Dangerous Drugs Act and has
an overpowering desire for its continuance, but who does not require it
for the relief of organic disease". This definition embraces addiction
to all dangerous drugs and not just that to heroin and cocaine, with
which we are specially concerned at the moment.
Notification of addicts
We recommend that all addicts, as defined above, should be formally
"notified" to a central authority and this authority should keep an
up-to-date list of such addicts with relevant particulars. The term "
notification " is used in the Public Health Act, which lays upon
doctors the duty to notify patients who are suffering from certain
infectious diseases. We think the analogy to addiction is as apt for
addiction is after all a socially infectious condition and its
notification may offer a means for epidemiological assessment and
control. We use the term deliberately to reflect certain principles
which we regard as important, viz. that the addict is a sick person and
that addiction is a disease which (if allowed to spread unchecked),
will become a menace to the community. We would object to any attempt
to equate the term with "registration", which we rejected in our
previous report. Apart from any other consideration "registration"
might seem to imply that the addict is officially recognised as having
the right to an approved quantity of dangerous drugs.
19. It should
become the statutory duty of any registered medical practtitioner who
comes into professional relationship with an unnotified addict, as
defined in paragraph 17, to make notification to a central authority.
Provision should be made so that any registered medical practitioner
can refer to the list promptly and at any hour of the day or night if
there is need to check whether or not a particular addict has been
notified, or to obtain further particulars about an addict's history.
A doctor may sometimes be in doubt as to whether a patient is an addict
according to the definition. He should then be able readily to obtain a
further professional opinion from a member of an officially recognised
panel of doctors covering the country. Membership of this panel should
reflect a wide variety of medical and surgical interests, so that all
relevant factors may be taken into account before addiction is
diagnosed and notification made. This panel should not be
confined to doctors who are on the staff of treatment centres
which we describe below (paragraph 22 and following).
routine scrutiny of pharmacists' records (see footnote 3 on page 5) for
repeated prescriptions of dangerous drugs to particular patients will
provide a means of ascertaining addicts who have not been notified.
Since, as we have said, the addict should be regarded as a sick person,
he should be treated as such and not as a criminal, provided that he
does not resort to criminal acts. In our previous report we stated that
satisfactory treatment of addiction was possible only in suitable
institutions. To this principle we still strongly subscribe. But while
at that time we could say that the problem was so small that the
establishment of specialised institutions for the treatment of
addiction was not justifiable, the position has now changed to such an
extent that we consider that such centres should be set up as soon as
possible, at least in the London area. Each centre should have
facilities for medical treatment including laboratory investigation and
provision for research. A centre might form part of a psychiatric
hospital or of the psychiatric wing of a general hospital.
the rest of the country addiction to dangerous drugs does not seem to
be a. serious problem at present. But while we do not think that the
establishment of special units, such as we have outlined in paragraph
22, is as yet necessary beyond the London area, we feel nonetheless
that some arrangements for treatment must be made on a national basis.
We think that the Health Departments should ensure that all Regional
Hospital Boards make suitable provision for the treatment of
addicts in selected hospitals in their regions. Some Boards, we
understand, have already initiated measures of this kind.
formulating these proposals we are mindful of the obstinacy of some
addicts and the likelihood that some of them will not attend a
treatment centre. Since compulsory treatment seems to meet with little
success, there is little that can be done for these people beyond
restricting the possibility of illicit supplies. Others may wish to
break off treatment after they have embarked upon it. This may be a
short-lived feature caused by the discomfort of the withdrawal
symptoms. We think that the staff of the treatment centres should have
powers to enable them compulsorily to detain such a patient during such
a crisis. This, we appreciate, would require legislation.
The withdrawal of a drug is only the first step in the treatment of an
addict. Those who are discharged after satisfactory withdrawal of the
drug of addiction may soon relapse on returning, to their old haunts.
Indeed, it is generally recognised that the prognosis for the severely
addicted is not very hopeful, so that some patients may have to remain
indefinitely under the care of treatment centres. The situation would,
in our view, be greatly improved if there were proper facilities for
long-term rehabilitation, both psychological and physical, in the
treatment centres and elsewhere. To go into more detail about this
would be outside our terms of reference, but we wish to emphasize that
the organisation and provision of these facilities is essential if
relapse is to be avoided.
Limitations on supplies to addicts
We said in paragraph 16 that our special concern at this time has been
the extent of the addiction to heroin and cocaine. We are satisfied
that the dangers described in paragraph 11 justify the introduction of
statutory controls to confine to doctors on the staff of the treatment
centres we have described, the prescribing, supply and administration
of these "restricted" dangerous drugs to drug addicts. It would then be
the duty of the doctors at the treatment centre to determine a course
of treatment and, if thought necessary, to provide the addict with
drugs. Treatment should be available on both an in-patient and
out-patient basis. We repeat that our proposals are dependent on
such treatment facilities being readily available at short notice.
We see no need at present to confine the prescription, supply and
administration of other dangerous drugs for addicts to doctors on the
staff of recognised treatment centres. These drugs are far more widely
used than heroin and cocaine in the management of organic disease and
other conditions. Addicts who use these other drugs form a limited
group whose addiction has usually arisen from their administration
during the course of medical treatment and has not given rise to the
same problems as have arisen with addiction to heroin and cocaine. We
think therefore that the inconvenience that would be caused by the
limitation of supply of these other drugs to treatment centres would
not be justified.
28. Under the statutory powers that would be
required to implement these proposals a doctor, other than the members
of the medical staff at a treatment centre, would be prohibited from
supplying, administering and prescribing "restricted" dangerous drugs
to addicts. In an emergency - when, for example, an addict is prevented
for the time being from getting to a treatment centre, or meets with a
serious accident, or becomes organically ill — we think that the doctor
in charge of the case should get in touch with the apropriate
treatment centre and seek authorisation before he orders or
administers such drugs.
29. We think it right to emphasise that the
restrictions we have suggested apply at present only to heroin and
cocaine and only in respect of prescription, supply or administration
to addicts. Doctors should retain the right to prescribe, supply or
administer any dangerous drug required for other patients in the
treatment of organic disease.
Private hospitals and private practice
We intend our recommendations to apply to all doctors whether in
private practice or working in the National Health Service. Both are
already subject to the same controls under the present law as far as
dangerous drugs are concerned. In the case of hospitals and nursing
homes that are outside the National Health Service, we recommend that a
managing body wishing to offer facilities for the treatment of addicts
should be required to obtain the approval of the central authority to
be regarded as a treatment centre and that the central authority should
be empowered to lay down such conditions as might be necessary for the
establishment and its staff to play the full part in co-ordinated
treatment, research and notification that we have described in
paragraphs 19 and 22.
31. If the proposals we have put forward above are accepted, it will become an offence for a doctor
to fail to notify , the central authority of an addict (as
defined in paragraph 17) with whom he has come into professional
relationship and who is not already notified ; and
(b) not being a
recognised member of the medical staff of a treatment centre, to
prescribe for, administer to or suplly to an addict "restricted"
dangerous drugs except in accordance with the procedure laid down
for emergencies (see paragraph 28).
32. Let us consider, first, how
such cases will, under the arrangements we have proposed, come to
notice. As we have mentioned in paragraph 21, the routine inspection of
pharmacists' registers under the present machinery for the enforcement
of the Dangerous Drugs Act and Regulations, should bring to light any
case in which a doctor is repeatedly prescribing dangerous drugs for a
particular patient. Where a doctor was found to be prescribing "
restricted " dangerous drugs, he would—as at present—be interviewed by
a Regional Medical Officer of the Health Departments and, if necessary,
by a member of the Dangerous Drugs Inspectorate. In most cases the
doctor would be able to give good reasons for the supplies. If , for
instance he could show that the patient required the drug for adequate
medical reasons (e.g. someone in the painful stage of a malignant
disease , or if he could show that he had obtained the opinion of one
of the officially recognised panel of doctors referred to in paragraph
20 that the patient was not an addict as defined in paragraph 17, that
would be a sufficient explanation and no further action would need to
33. If however, the doctor was unable to satisfy the
Regional Medical Officer or, if necessary, a member of the
Dangerous Drugs Inspectorate and had failed to consult a member of the
official panel, or declined to give any information, it seems to us
that the case could justifiably be regarded as a prima facie one of a
doctor prescribing "restricted" dangerous drugs for an addict. But we
do not consider that it would be appropriate for a case of this kind to
be dealt with by a court of law, as the issues involved are primarily
those of professional judgment and conduct.
34. We therefore
recommend that any doctor against whom a prima facie case of this kind
can be made out (and we would expect such cases to be very rare) should
come before a tribunal of his professional colleagues to justify his
action. As the case would reach this stage only if the doctor had
refused to obtain a second opinion from a member of the official panel,
or if he had refused to give information about the case, the onus
should be on the doctor to show that his patient was not an addict and
that the prescribing of " restricted " dangerous drugs was justified by
a need for their use in medical treatment.
35. We further suggest
that the appropriate tribunal for this purpose would be the
Disciplinary Committee of the General Medical Council. Already
this body deals with questions of professional conduct, and the
over-prescribing of restricted dangerous drugs, we think, comes into
36. The procedure we then envisage would be for the
central authority, having established a prima facie case against a
particular doctor, to bring the facts to the attention of the
Disciplinary Committee. If that body, on examination of the facts,
finds the case proved, there should be provision for the doctor's
authority, to prescribe, supply and administer restricted dangerous
drugs to be withdrawn. Legislation would be necessary to enable the
General Medical Council to assume this responsibiity.
In our last report we said that there was no need to introduce a
distinctive prescriction form for dangerous drugs. if the
recommendations we have made above are adopted, we think there is still
no need for such forms. We think, however, that in view of the greater
danger of forgery to circumvent the new restrictions we have proposed,
there should be a statory duty on all doctors under the Dangerous Drugs
Regulations, when writing prescriptions for dangerous drugs, to use
words as well as figures to specify the quantities. This has already
been recommended to doctors as good medical practice by the British
Medical Association and the Health Departments.
We believe that the proposals which we have made will make it more
difficult for addicts to obtain supplies of heroin and cocaine. The
immediate effect may be to bring into the open a number of addicts now
.dependent for their supply on addicts who are receiving their drugs
from doctors. As pointed out (footnote 1 on page 2) the number of these
ad iets cannot be precisely estimated. We should not feel
disturbed if a number came to notice provided facilities were organised
to treat them. At the same time the risk that illicit traffic in drugs
will in any event increase has to be accepted. It will be for the
appropriate authorities to ensure that the criminal law is
Other habit-forming drugs
In our previous report we drew attention to the extensive use of drugs
affecting the central nervous system, other than those controlled under
the Dangerous Drugs Act. We said then that the position required
careful watching, although we could see no grounds at that time for
suggesting further statutory control. Although this problem is not
within our present terms of reference and we have not specifically
taken evidence about the present position, we feel obliged to say that
we are disturbed at the large quantity of habit-forming drugs currently
in circulation. We have noted with approval the operation of the Drugs
(Prevention of Misuse) Act 1964 and the action taken by the Health
Departments to draw the attention of doctors to the methods that
persons dependent on these drugs use to obtain excessive supplies.
We are particularly concerned at the danger to the young. Witnesses
have told us that there are numerous clubs, many in the West End of
London, enjoying a vogue among young people who can find in them such
diversions as modern music or all-night dancing. In such places it is
known that some young people have indulged in stimulant drugs of the
amphetamine type. Some of our witnesses have further maintained that in
an atmosphere where drug takin is sociall acceptable, there is a risk
that young people may be persuaded to turn to cannabis, probably in the
form of "reefer" cigarettes.
There is a further risk that if they reach this stage they may move on to heroin and cocaine
The phenomena of habituation, dependence and addiction involve a
complex variety of social, medical and psychological factors. The
present trends, particularly in wider consumption of "pep" pills, may
foreshadow a significant change in public attitudes to the taking of
dangerous drugs. We feel that this feature of contemporary life
deserves thorough study so that remedial action on all relevant fronts
may be planned with full knowledge and understanding.
Dependence on drugs is not a static but a changing problem. We think
that it should be under constant observation. We therefore recommend
the establishment of a standin advisor committee to survey the whole
field and to call attention to any evelopment that may be a cause for
concern or worthy of closer study. The constitution of the committee we
leave to discussion between the relevant government departments, the
medical and other professions. We consider that it should have a
broadly-based representation, that it should concern itself with misuse
of all dangerous drugs and other drugs which are likely to produce
dependence, and the causes and effects of such misuse, and that it
should have authority to advise on corrective health and social
We give below a summary of our main conclusions and recommendations. We
realise that, for many of them to be put into effect, new legislation
will be needed.
(i) There has been a disturbing rise in the
incidence of addiction to heroin and cocaine, especially among young
people (paragraph 8) ;
(ii) the main source of supply is the over-prescribing of these drugs by a small number of doctors (paragraph 11) ;
(iii) there is now a need for further measures to restrict the prescribing of heroin and cocaine (paragraph 16) ;
(iv) for the purposes of our report we have suggested a definition of an "addict" (paragraph 17) ;
(v) all addicts to dangerous drugs should be notified to a central authority (paragraph 18) ;
to treat addicts a number of special treatment centres should be
established, especially in the London area (paragraph 22) ;
(vii) there should be powers for compulsory detention of addicts in these centres (paragraph 24) ;
the prescribing of heroin and cocaine to addicts should be limited to
doctors on the staff of these treatment centres (paragraph 26) ;
(ix) it should be a statutory offence for other doctors to prescribe heroin and cocaine to an addict (paragraph 31) ;
disciplinary procedures against doctors alleged to have prescribed
heroin and cocaine irregularly to addicts should be the responsibility
of the General Medical Council (paragraph 35) ;
(xi) when prescribing dangerous drugs, a doctor should indicate the quantities by words as well as figures (paragraph 37) ;
(xii) an advisory committee should be set up to keep under review the whole problem of drug addiction (paragraph 42).
We are greatly indebted to our Secretaries, Dr. Roy Goulding and Mr. A.
H. H. Jones, for all that they have done to facilitate and expedite our
work, and to the following for their valuable assistance: Dr. J. M.
Johnston of the Scottish Home and Health Department ; Mr. P. Beedle,
Mr. T. C. Green, Mr. C. G. Jeffery and Mr. H. B. Spear of the Home
Office ; and Mr. R. F. Tyas of the Ministry of Health.
A. LAWRENCE ABEL
DONALD W. HUDSON
A. D. MACDONALD
S. NOY SCOTT
A. J. PITKEATHLY
ROY GOULDING - A. H. H. JONES Joint Secretaries
31st July, 1965.
(1) i.e. the Interdepartmental Committee
(2) In this report the term " dangerous drugs " refers exclusively to
those substances controlled under the Dangerous Drugs Act, 1965 (which
consolidated the Dangerous Drugs Acts, 1951 and 1964).
(3) The Home Office obtains information about prescriptions of
dangerous drugs from the routine police examination of records kept by
pharmacists. It also receives information from other sources and, with
the assistance of the Health Departments, makes enquiries to establish
cases of addiction. At any one time there are probably some addicts who
are getting supplies from illicit sources and have not come to notice.
Their number cannot be precisely estimated.
(4)By " non-therapeutic " we mean persons whose addiction originated
other than from the administration of dangerous drugs for medical