DEPARTMENTAL COMMITTEE ON MORPHINE AND HEROIN ADDICTION (ROLLESTON) 1926
MINUTE OF APPOINTMENT OF THE COMMITTEE
I hereby appoint
Sir HUMPHRY D. ROLLESTON., Bart., K.C.B., M.D., P.R.C.P.,
Sir WILLIAM WILLCOX, K.C.I.E., C.B., C.M.G., M.D., F.R.C.P.,
J.W. BONE, Esq., M.B., C.M.. B.Sc.,
R. W. BRANTHWAíTE. Esq., C.B., M.D., D.P.H.,
Professor, W. E. DIXON, M.A., M.D.. F .R.S.,
JOHN FAWCETT, Esq., M.D., F.R.C.P.,
A. FULTON, Esq., M.B.. B.C.,
J. SMITH WHITAKER, Esq., M.R.C.S., L.R.C.P.,
to
be a Committee to consider and advise as to the circumstances, if any,
in which the supply of morphine and heroin (including preparitions
containing morphine and heroin to persons suffering from addiction to
those drugs may be regarded as medically advisable, and as to the
precautions which it is desirable that medical practitioners
administering or prescribing morphin or heroin should adopt for the
avoidance of abuse, and to suggest any administrative measures that
seem expedient for securing observance of such precautions.
I
hereby further Appoint Sir Humnphry D. Rolleston to be Chairman, and E.
W. Adams, Esq., O.B.E., M.D., and R.H.Crooke, Esq., to be Secretaries
of the Committee.
(Signed) JOHN 'WHEAT LEY .
30th September, 1924,
I hereby extend the Terms of Reference to the Committee as follows :-
To
consider and advise whether it is expedient that any or all
preparations which contain morphine or heroin of a percentage lower
than that specified in the Dangerous Drugs Acts should be brought
within the provisions if the Acts and Regulations and, if so, under
what conditions.
(Signed) NEVILLE CHAMBERLAIN.
12th February, 1925.
DEPARTMENTAL COMMITTEE ON MORPHINE AND HERON ADDICTION.
REPORT.
To The Right Hon. NEVILLE CHAMBERLAIN, P.C., M.P.. MINISTEROF HEALTH.
1.
We, the Committee appointed by your predecessor's minute of 30th
September, 1924, have the honour to submit the following report on the
subjects therein referred to us. namely : --
"To consider and
advise as to the circumstances, if any, in which the supply of morphine
and heroin (including preparations containing morphine and heroin) to
persons suffering from addiction to those drugs may be regarded as
medically advisable, and as to the precautions which it is
desirable that medical practioners administeringing or prescribing
morphine or heroin should adopt for the avoidance of abuse, and to
suggest any administrative measures that seem expedient for securing
observance of such precautions " ,
as well as on the subject,
subsequently referred to us on 12th February, 1925, in accordance with
the suggestion of the Committee, namely :-
" To consider and
advise whether it is expedient that any or all preparations which
contain morphine or heroin of a percentage lower than that specified in
the Dangerous Drugs Acts should be brought within the provisions of the
Acts and Regulations and if so, under what conditions."
2. We have held 23 meetings, at 17 of which we took oral evidence. A list of the witnesses is given in an Appendix.
3. The matters referred for our consideration appear to fall under four main heads, namely :--
(i)
the circumsstauces, if any. in which it may be medically advisable to
administer morphine or heroin to a person known to be suffering from
addiction to these drugs ;
(ii} the precautions which medical
practitioners ought to adopt in administering these drugs, both
generally and with particular reference, to persons suffering from such
addiction:
iii) the administrative measures, if any, which we
might think it advisable to recommend to secure due observance of
such precautions;
(iv) the advisability or otherwise of bringing
within the scope of the Dangerous Drugs Acts preparations of morphine
or heroin containing percentages of the drugs lower than are at present
included.
4. Our report is divided into six sections. The first
contains certain preliminary observations; the second summarises the
results of our inquiries respecting certain medical aspects of the
problem of addiction; the remaining four deal , in the order above
stated, with particular matters arising under our Terms of
Reference.
SECTION I.
PRELIMINARY' OBSERVATIONS.
5.
While the subjects on which the Committee was appointed to advise are
mainly medical, they also include administrative questions. The
main object of our deliberations has been to consider whether or not we
should recommend any modifications in the Regulations made under the
Dangerous Drugs Drugs Acts which relate to matters falling within the
scope of our reference. We have thought it desirable, therefore to
preface this report by a short summary of the provisions of the
Dangerous Drugs Acts and the Regulations made thereunder and the
present system of administration, so far as these bear on the subjects
of reference, followed by a statement of certain difficulties which we
are informed have been experienced in the course of administration, and
which it is hoped that our recommendations may be helpful in
overcoming. These statements are based on memoranda placed before us
and oral evidence tendered by the Home Office, the Ministry of Health,
and the Director of Public Prosecutions.
PROVISIONS 0F THE ACTS AND REGULATIONS AND ADMINISTRATIVE ARRANGEMENTS.
6.
The Dangerous Drugs Acts place restrictions on the import, export,
manufacture, sale, distribution, supply and possession of the drugs
specified therein, which include morphine and heroin and preparations
containing these drugs in more than a certain strength; this being 0.2
per cent. in the case of morphine and 0.1 per cent. in the case of
heroin. A Secretary of State is empowered to make regulations, subject
to the approval of Parliament, that are necessary for carrying the Acts
into effect, and Regulations have been made from time to time by the
Home Secretary accordingly. Under the Regulations the import, export,
manufacture, sale, distribution and supply of the drugs is restricted
to persons licensed or authorised for such purposes. Possession is
restricted to persons so licensed or authorised, and to persons to
whom the drugs are supplied by registered medical pracitioners for the
purpose of medical treatment (or by registered vetirinary
surgeons for use in the treatment of animals) or supplied by
chemists on and in accordance with prescriptions issued by registred
medical practitioners (or by registered dentists for local dental
treatment, or veterinary surgeons for the treatment of animals.
A registered medical practioner is authorised to be in possession of the drugs and to supply them, so far as is necessary for the practice of his profession.
(The qualification contained in the words italicted is of special
importance in relation to the matters which it has been our duty to
consider.
Medical prescriptions for the drugs must comply
with certain requirements as to dating and signature, they mast bear
the doctor's address (except in the case of National Health
Insurance prescriptions), as well as the name and address of the
person for whose use the drug is intended, and the total amount of
the drug to be supplied must be specified. The Home Secretary has
power, which it has not yet however been thougt desirable to excercise,
to require the use of an official form on which prescriptions for
Dangerous Drugs should be written.
7. All persons authorised to
supply the drugs, including medical practitiorers who dispense
medicines for their patients, are requirod to keep records of drugs
purchased and issued, but this requirement does not apply to drugs
administered by medical practitioners personally, or under their
immediate supervision. Practitioners who do not dispense, and therefore
do not supply drugs otherwise than by way of
personal administration; are not at present required to keep a
record even of their purchases.
8. The records kept by wholesale
chemists and by pharmacists are inspected by Home Office Inspectors or
by the police; but it was considered preferable that these kept by
medical practitioners should be inspected by medical officials, ans
such inspection is carried out, on behalf of the Home Office, by the
Regional Medical Staff of the Ministry of Health in England and Wales,
and by the Medical Staff and District Medical Officers of the
Board of Health in Scotland.
9. Through the system of inspection
described, the distribution of morphine and heroin imported into or
manufactured in the country can be traced and cases are from time
to time brought to the notice of the Home Office in which it has been
observed that exceptionally large quantities of these drugs have been
supplied to particular practitioners, or that individual patients have
received unusally large quantities of them on medical prescriptions.
10. As a result of further inquiries in such cases, and in cases brought to notice in other ways, it has been ascertained:-
(i)
That in a very small number of cases, medical practitioners have, by
their own admission, ordered or supplied Dangerous Drugs, not as a part
of medical treatment, but simply to enable persons who
had become addicted to the drugs to satisfy their craving;
(ii)
That in certain other cases, in which there was no such admission,
as circumstances have suggested at least a doubt whether the supply of
the drug could be regarded as forming a part of bona fide medical
treatment;
(iii) That sometimes practitioners have issued
supplies of, or precriptions for, the drugs in unusually large
quantities or over long periods, to persons whom they saw only at long
intervals, in some cases the drugs, or prescriptions for them, were
sent by post;
(iv) That sometimes practitioners have supplied drugs,
or prescriptions for drugs, in relative large quantities to persons
previously unknown to them, on the ground of some alleged urgent need,
e.g., acute pain, and without making any effort to ascertain the name
of, and communicate with, the patient's ordinary medical adviser;
(v) That there were cases in which persons had obtained supplies of the drugs from several practitioners concurrently;
(vi)
That in some cases large supplies purchased or prescribed by
practitioners were found to have been used mainly for adminstration to
themselves, it being doubtful if the use of the drug was medically
necessary.
11. Difficulties of Action.--
In the light of such cases it has appeared to the Home Office that, in
some instances, the drugs were being supplied and used in contravention
of the intention of Parliament. namely, that the use of Dangerous Drugs
should be confined to that which was necessary for medical treatment.
The Home Office, as the Department responsible for carrying out the law
in this matter had to consider, first, whether there had been
infraction of the intention of the Acts, even if not of the letter of
the Regulations at prsent made under the Acts; secondly, in the event
of such infraction, what course could be taken, either under the
present Regulations, or after appropriate modifications of the
Regulations, to secure better observance of the law in future.
12.
In most cases, the question whether the law had been broken turned
essentially on whether the drugs had been supplied for purposes of
medical treatment only, and the Home Office have informedi that in this
connection they have found it necessary to consider various points. The
first of these was whether it was medically necessary that in any
circumstances morphine or heroin should be supplied continuously for
long periods to persons who were not suffering from any organic disease
for the relief of which such drugs were eesential. They were aware that
some eminent physicians, especially in the United States, had expressed
the opinion that persons who had become addicted to the use of the
drugs could always be cured by sudden withdrawal under proper
precautions. At the request of the Home, the Minister of Health had the
literature on the subject carefully collated. As a result, the Home
Office were advised that even in the United States, where opinion is on
the whole more favourable than in this country to this method of
treatment, abrupt withdrwawal was advocated in those cases only in
which the addict could be treated in an institution and carefully
nursed and looked after. No statement by any responsible medical
authority had been found to suggest that such a method was practicable
in the treatment of an addict under the conditions of ordinary private
practice.
In some cases, abrupt deprivation of morphine or heroin
might cause not only intense suffering, but even fatal collapse. The
method of sudden withdrawal called for close supervision, under expert
judgement and skill, and trained nursing. The practicability of the
method depended, therefore, on the possibility of inducing the patient
to such an institution and institutional treatment is much more
difficult to carry out in this country than in the United States, on
account of the relative dearth of appropriate institutional
accomidation in this country as compared with the United States.
13.
Assuming the abrupt withdrawal treatment to be impracticable (even if
thought advisable) in a large proportion of the cases of addiction
occurring in this country, the question then arose whether this would
justify the practice, which had in some cases been observed, of
administering morphine or heroin over very long periods in
non-diminishing doses. The Home Office assumed that the object of
treatment in cases of addiction must be the care, if possible, of this
condition, by means of a steady diminution of the dose, with a view to
its ultimate complete discontinuance if found practicable. On this
assumption, could the observed fact of continuous administration for an
indefinite period in undimished doses be regarded as compatible with
the end aimed at, or must it be held to constitute evidence, prima
facie. that the drugs were not being administered solely for the
purposes of medical treatment? Inquiries respecting this point showed
that some physicians of great experience in the treatment of such
conditions held the view that there were two classes of persons from
whom, at all events: under the conditions of ordinary private practice
the drugs could not be entirely withdrawn. In one case such attempted
complete withdrawal produced severe distress or even risk of life; in
the other, experience showed that a certain minimum dose of the drug
was necessary to enable the patients to lead useful and relatively
normal lives, and that if deprived of this non-progressive dose they
became incapable of work.
While this view as to the possible
necessity of even life-long administration in certain cases was not
universally held, the fact that it was held by some eminent authorities
made it difficult to base action on the assumption that continuous
administration of non-diminishing doses, for however long a period, was
nessarily inconsistent with bona fide medical treatment.
14. A
question of another kind required consideration in cases in which
doctors supplied or ordered dangerous drugs for persons whom they saw
infrequently or for persons whom they saw for the first time, and
respecting whom they had no communication from the patient's ordinary
medical adviser. In such cases it had to be considered whether the
practitioner's opportunities of observation had been sufficient to
justify the statement that the drugs were being administered for
purposes of treatment in any legitimate sense.
15. In cases in
which the conduct of the doctor appeared to call for action of some
kind, various courses presented themselves for consideration. The first
was that of communication with the doctor, either by a letter from the
Home Office, or by instructing a Regional Medical Officer of the
Ministry of Health to see him, with a view to elucidating facts,
calling attention to the requirements of the Acts, and inducing the
practitioner to have due regard to these requirements. Such action has
in many cases been followed by beneficial results. Secondly, it would
be possible to prosecute doctors in the police court for offences
against the Acts, on the ground that they had supplied the drugs or had
administered them to themselves, otherwise than for the purpose of
medical treatment. Thirdly, it would be open to the Home Office, to
bring a case to the notice of the General Medical Council in which,
primo facie, it appeared that the doctor's conduct had been such as
might be regarded by the Council as "infamous in a professional respect."
16.
The Home Office however, were reluctant to take proceedings in either
of the two ways last mentioned with regard to cases in which the issue
must turn largely on questions of mediical opinion, until various
doubtful points had been further elucidated by an inquiry such as this.
Moreover, even if it were established that continuous administration of
morphine or heroin indefinitely in non-diminshing doses might in some
cases constitute proper treatment, it appeared possible that such
an inquiry might suggest precautions which should be observed by
practitioners during the treatment of such cases or of other cases of
addiction. Such an inquiry might also have a valuable ressult in the
suggestion of measures which should be adopted in the ordinary use
of morphine or heroin in medical practice, with a view to avoiding, so
far as possible, the development of addiction.
17. Some cases
have raieed questions of the desirability of certain amendments of the
Regulations. In the first place, in view of doubts that have arisen,
the question is raised of the need for a provision expressly forbidding
the issue of prescriptions for Dangerous Drugs except for purposes of
medical treatment. Secondly, doctors who do not themselves
dispense, but obtain the drugs for the purpose of personal
administration, or administration under their immediate supervision
only, are, as has been stated under no obligation tokeep a record even
of their purchases. Suspected abuses in the practice of these doctors
are therefore in some respects more difficult to deal with than in the
case of dispensing doctors, and the Home Office have had under
consideration the question whether doctors who do not dispense ought
not, nevertheless to be required to keep some simple record of their
purchases of Dangerous Drugs. Thirdly, the action of some addicts in
obtaining supplies or prescriptions from several doctors concurrently,
clearly contravenes the intention of the Acts, and is moreover highly
prejudicial to the best interests of the patient. Such cases ar,
however difficult to detect, and we have conisdred whether some kind of
notification might not be introduced to overcome the dificulty.
18.
Lastly, questions of exceptional difficulty have presented themselves
in the cases of doctors who are themselves addicts.Owing to the
authority possessed by medical practitioners to obtain the drugs in
their professional capacity, or to prescribe them for themselves, they
do not encounter the same obstacles in obtaining excessive supplies as
an ordinary member of the community, who can only obtain them from a
doctor, or on a medical prescription. They cannot at present be
deprived of their authority to be in possession of the drugs except
after a conviction for an offence under the Acts, and a Regulation
providing that doctors might not prescribe for themselves was withdrawn
by the Home Office on account of the objections raised by the medical
profession
19. The Home Offices have asked us to advise in our Report on the various matters mentioned in this Section.
SECTION II
MEDICAL ASPECTS OF THE ADDICTION PROBLEM,
20.
In the course of our inquiry we have received a large amount of
valuable information upon the nature, causation, and prognosis of
addiction.as well as upon upon the different mehods of treatment which
have been advocated from to time, In asmuch as such informationhas not
heretofore been available in so easily accessible a form, and as there
has not previously been so favourable an opportunity of eliciting and
collating the opinions of members of the medical profession
who have had special experience of the problems of addiction, we
thought it well to state the results of our inquiries somewhat fully,
for the information of the medical profession and the public, although
some of the points dealt with are less germane than others to the main
objects of our investigation.
Matters included in this Section of our Report are discussed under the following heads:
(a) Definition of Addiction.
(b) Prevalence.
(c) Nature and Causation
(d)Treatment and at After-care
(e) Prognosis.
(a) DEFINITION
21.
There has been some divergence of opinion among the witnesses we have
heard as to the best definition of addiction. These differences depend
to some extent on differences of opinion as to the causation and nature
of the condition commonly known as addiction.
In the present Report
the term " addict '' is used as meaning a person who, not requiring the
continued use of a drug for the relief of the symptoms of organic
disease, has acquired, as a result of repeated administration, an
overpowering desire for its continuance, and in whom withdrawal of the
drug leads to definite symptoms of mental or physical distress or
disorder.
(b) PREVALENCE of ADDICTION
22.
We have taken evidence on this subject from medical practitioners,
representative of several types of experience, who may conveniently be
grouped as follows:-
(1) Consulting physicians of wide experience in the treatment of nervous and mental disorders
(2) Medical man who have has special experience in the treatment of addiction.
(3) Medical Officers of Prisons
4.
Representative general practioners from various parts of the country, a
few of whom have had a relatively wide experience of the treatment of
this condition.
In addition we have been supplied by the Ministry of
Health with information obtained by the regional Medical Officers from
representative general practitioners of wide experience, respecting the
prevalence of addiction in the parts of the country with which they are
familiar.
23. This evidence has all tended in the same
direction, and the collective, effect is remarkably strong in support
of the conclusion. that in this country, addiction to morphine or
heroin is rare. Some experienced general practitioners have stated that
they had never been called upon to treat such cases; others that they
have only seen two or three such cases in the course of 20-30 years'
practice. As might perhaps be anticipated, the cases appear to be
proportionally more frequent in the great urban centres than elsewhere,
and persons engaged in occupations which entail much nervous and mental
strain are specially liable to be affected. It appears also that a
relatively high proportion of cases occurs among those who, by reason
of their occupation or otherwise, have special facilities for access to
the drugs.
24. There is also a general concurrence of testimony
to the effect that addiction has diminished in recent years, most
witnesses atributing the decline in the number of cases to the
operation of the Dangerous Drugs Acts which have made it difficult to
obtain the drugs otherwise than from, or through, doctors. Although
sources of illigitimate supply exist, it appears that those who might,
in other circumstances, have obtained the drugs from non-me:lical
sources are usually lacking in the determination and ingenuity
necessary for overcoming the obstacles which the law now places in
their way. Thus it would appear that persons who were already addicts
when the restriction came into effective operation have been driven to
placing themselves under medical care, or in less inveterate cases
have been themselves to overcome their infirmity. The effects of
the restrictions are even more important in respect of the class of
nervously unstable persons by whom addiction is most easily acquired,
and who may be designated " potential addicts." When morphine was
readily obtainable such persons were prone, on even small provocation
of pain mental stress, to seek relief in the drug. purchased on their
responsibility, and addiction was thereby quickly developped. Thus the
diminution in the number of addicts may be regarded as mainly due to
the fact that new addicts are not being created as they were under
former conditions. The importance of this conclusion in relation to the
administrative aspects of the problem of addiction needs no emphasis,
nor does the corollary that the prevention and control of addiction
must now rest mainly in the hands of the medical profession since, in
the main. it is through them alone that the drug can
be obtained.
25. We have also obtained evidence as to the
relative prevalence of morphine addiction and heroin addiction
respectively. This shows that, in this country, addiction to morphine
in any of its forms is much the more common. But this fact would appear
to be due to the greater familiarity of the public with morphine
preparations, and the much wider use of these than of heroin in medical
practice. Of those who take either drug for any purpose a larger
proportion of
addicts will be found in the case of heroin than of
morphine, and the addiction produced by heroin is the more disastrous
in its physical and mental results, and more difficult to cure. In a
small number of cases, the drugs are combined, and there are also some
cases in which each is used in conjunction with cocaine or with
other narcotics.
26. The mode of administration of the drug is of some importance.
In
the case of morphine, the evidence shows that hypodermic injection is
much more likely than other methods of administration to produce
addiction, and that with most addicts it is the favourite method of
using the drug. The addiction arising from the hypodermic use
of morphine is also more difficult to cure than that arising from
other methods of administration.
(c) NATURE AND CAUSATION.
27.
The nature and causation of morphine and heroin addiction are so
closely associated that they are most conveniently considered together.
While there were differences of opinion among the medical witnesses,
whom we heard as to the importance of the parts which different causes
may play in the production of addiction, there was general agreement
that in most well-established cases the condition must be regarded as a
manifestation of disease and not as a mere form, of vicious indulgence.
In other words, the drug is taken in such cases not for the purpose of
obtaining positive pleasure, but in order to relieve a morbid and
overpowering craving. The actual need for the drug in extreme cases is
in fact so great that when it is not administered great physical
distress culminating in actual collapse and even death, may result,
unless special precautions are taken such as can only be carried out
under close medical supervision, and with careful nursing. It is true
that there is a certain group of persons who take the drugs in the
first instance for the sake of a new and pleasurable sensation, e.g.,
the "underworld'' class, who often use heroin for this purpose as a
snuff. But even among these a morbid need for the drug is acquired and
the use is maintained not so much from the original motive as
because of the craving created by the use.
28. The condition of
imperative need just described will only be observed after the drug has
been taken habitually. The only immediate cause of addiction is the use
of the drug for a sufficient time to produce the constitutional
condition that is manifested in the overpowering craving and the
occurrence of withdrawal symptoms when use is discontinued.
Administration of the drug, however, will lead to addiction much more
readily in some persons than in others, and the causes of these
differences call for examination. Of such predisposing causes most
stress was laid upon inherent mental or nervous instability. One
eminent witness emphasised the frequency with which inquiry elicited
the history of mental disorder of a more or less serious kind in the
near relatives of the patient, and believed that a neuropathic heredity
could be traced in many of the cases. Some attached such importance to
this factor as to believe that not only could it be traced in most
cases of addiction, but might reasonably be assumed to have been
present in the remainder. In other words, the continuous
administration, of the drug would not, they believed, in itself produce
addiction in a person whose previous mental and nervous condition was
entirely normal. Others, however, while agreeing that persons
previously in some degree unstable were more liable than others to
become victims of addiction, and furnished the majority of the cases,
held that it was possible for a person who had previously appeared free
from any indication of mental of nervous instability to become a victim
of addiction as the result of prolonged administration of the drug.
Moreover, a person whose nervous system is not entirely normal in
its working may become an addict through the administration of
the drug who would otherwise have escaped. The point is of obvious
importance in its bearing on the value of preventive measures, and we
therefore feel called upon to state the conclusion to which we think
the evidence points, namely that addiction may be acquired by
injudicous use of the drug in a person who has not previously
shown any manifestation of nervous or mental instability, and that,
conversely, due care in administration may avert this consequence even
in the unstable.
29. Apart from inherent nervous instability,
the liability to addiction as the result of use of the drug may be
produced or enhancedi by various conditions which include chronic pain
of various kinds especially abdominal, the physical distress caused by
such affections as asthma, insomnia, and over-work, anxiety, and other
causes of mental distress. Some, indeed, hold that, even in the
nervously unstable, one or other of these causes has usually
contributed to the production of the habit.
30. The following
specific events have been regarded by medical witnesses as having
immediately led up to the development of addiction in different cases:-
(i) Use of the drugs in medical treatment.
(ii)
Self-treatment for the relief of chronic or recurrent pains
or distressing physical conditions, or for the relief of emotional
distress.
(iii) Example or influence of others.
(iv) Curiosity, bravado, and search for pleasurable experience
We proceed to discuss these separately.
31. (i) Use of the drug in medical treatment
was considred by the witnesses, with but one exception, to have been
the immediate cause of addiction in a considerable proportion of the
cases they had treated. Some regarded it as the cause in from
one-fourth to one half of their cases, and one thought that it
accounted for the majority. In some car the original object of
administration has been the relief of pain due to various causes.
Some
of the witnesses especially insisted that abdominal pain associated as
it so often is with mental depression, is the commonest type of pain
the relief of which by drugs leads to the formation of a habit. It was
generally held (as already stated) that addiction was more likely
to supervene when the drug was administered by hypodermic injection
than when it was given by the mouth or the rectum, and that the risk
was specially great when such injections were repeatedly given in
post-operative and accident cases.
32. In many of these cases,
it was considered that the drug had been administered injudiciously in
various ways, either as regard to the doses given, or the period for
which administration had been continued, or from lack of care to
diminish the doses and make the patient independent of the drug before
treatment was concluded. Attention was drawn to the special care needed
in the medical use of morphine or heroin in the case of the young, in
whom the danger of addiction is usually greater than in older patients.
On the other hand, one physician of wide experience expressed the view
that some practitioners had been too reluctant to administer morphine
in adequate doses at a sufficiently early stage in the treatment
of painful and other conditions, with the result that when at last it
was given the patient was in such distress and so worn out, and the
relief obtained so intense, that there was much greater danger than
there would otherwise have been of the formation of a habit. "The best
way," be stated, " to avoid addiction ensuing from the medicinal
employment of morphine, was thoroughly to relieve pain and to treat
insomnia, if present.."
33. (ii) Self-treatment for relief of pain, etc., and recourse to the drug in cases of emotinal distress
have undoubtedly been common causes in the past, especially, among
those whose occupation enabled them to obtain it otherwise than under
medical advice Cases, arising in such ways may however, be expected to
be less frequent in future, in view of the restrictions which the
Dangerous Drugs Acts have now placed on supply.
34. (iii) Influence of other addicts
We have received evidence of cases in whivh it was believed that the
addict had acquireil the habit through the influence of other addicts,
either by way of direct initiation into: the practice or throuzh
example. Cases arising from this cause may also be expected to be less
commonly met with in future, owing to the gradual dimmution in the
number of confirmed addicts, and the lessened facilities for obtaining
the drug.
(iv) Vicious indulgence and curiosity.
We have alroady mention cases in which the addiction took its origin in
the use of the drug through mere curiosity or search for pleasurable
sensations. Such cases appear to be exceptional, and may be expected to
become even lees prevalent through the operation of the restrictions on
supply.
(d) TREATMENT AND AFTERCARE. 35.
We have heard a considerable amount of evidence as to the relative
values of various methods of treatment, which differ chiefly in the
rapidity with which the drug of addiction is entirely withdrawn from
the patient. The methods of treatment described to us may be stated as
follows :--
36. The Abrupt Withdrawal Method.
In this method the addiction drug is abruptly cut of and certain
remedial measures are adopted to combat the withdrawal symptoms.
Among the remedies so employed as auxiliaries are hyoscine, bromides,
chloral, alkalies and intensive pargation. Occasionally, a dose of
morphine by the mouth is employed to treat impending collapse. Hot
baths, particularly at bed time, and massage, are held in great esteem
as a useful adjunct by som physicians. In addition to these medicinal
adjucts, physical measures such as the regulation of food and exercise
and attention to the general health are instituted.
While one
witness strongly advocated the use of hycscine as an auxiliary to the
treatment by abrupt withdrawal, it was not favoured by other witnesses
who had had experience of its employment, and they regarded it as
dangerous if pushed to the degree usually considered necessary.
37. The Rapid Withdrawal Method.
This method in its essential features differs only from that above
described in that the drug, instead of being suddenly withdrawn, is
rapidly reduced to zero in the course of a few days. The treatment is
assisted, as in the case of abrupt withdrawal, by various ancillary
measures, one being the employment of a belladonna., hyoscyamus and
xanthoxylum mixture pushed to the point of delirium.
36. The Gradual Withdrawal Method.--
The drug is withdrawn gradually on a systematic plan, and auxiliary
treatment by drugs and other agencies is given to suit the needs of
particular case's. The actual plan adopted by different experts varies,
but there is a broad similarity underlying all the various
modifications of the method. The following description gives a good
general idea of the procedure adopted. At the outset appropriate
measures must be taken to deprive the patient of any secret supplies of
the drug which he may have concealed upon his person or in his effects.
The first step in treatment is stabilise the amount of drug which the
patient receives, both in respect of dose and frequency of
administration, which will, in the first instance, usually be
hypodermic if the patient has been accustomed to that method of
administration. The dose is decided upon after consideration of the
circumstances of the case as regards physical state, duration of
addiction and customary quantity consumed. The initial dose generously
computed, and may be the full dose the patient has accustomed to take;
in addition the patient is assured that he is receiving this quantity.
The aggregate daily amount is divided into 3 or 4 doses and is given at
regular intervals during the 24 hour -the largest dose being
administered just before bed-time. After waiting a few days, the dose
of the drug is diminished by a certain proportion (e.g., one-tenth),
the reduction effected being such as the experience, of the physician
suggests will not be noticed by the patient. The reduction is
continued at appropriate intervals by cutting off succesively the same
proportion of the dose last given. If at any stage of the
treatment the patient appears to be bearing the withdrawal badly,
either by reason of the supervention of some minor illness or by reason
of mentai distress, the process of reduction is interrupted for a day
or two.
When by these means, the dose administered has reached a
fairly small amount, the number of doses is altered from 3 or 4 to 2 a
day. This alteration is often accompanied by a temporary increase in
the total amount given in order to enable the patient to become
reasigned to fewer doses; for every effort is made to secure the
patient's willing co-operation by sparing him unnecessary
inconvenience, and by explaining to him the reasons for the various
steps in the treatment. A valuable mental effect is secured by giving
the doses, however small they may be, in the same quantity of fluid
and, as before the largest dose is given just before. bed-time.
In
cases in which the addict has previously used hypodermic injection,
some physicians find it advantageous to subtitute oral for hypodermic
administration during the later stages of the treatment.
Ultimately,
a stage is reached in which none of the drug is being given at all. The
patient, however, is not made aware of the actual moment when the drug
has been totally withdrawn, for hypodermic injections of innocuous
solutions or, when oral administration has been substituted for
injection, certain harmless medicaments are continued for e week
or two after the withdrawal has taken place. The patient is then
surprised to learn that he is no longer taking the drug, and,
on realising the position, readily consents to do without further
medication.
The intercurrent symptoms which occassionally arise,
especially sleeplessness, must be treated on general lines. Some
authorities rely upon hypnotic drugs such as bromides, paraldehyde,
etc. Much attention, is, of course, also paid to the general health by
means of various physical and medicinal measures, and many of our
witnesses assign value to intensive purgation in suitable cases.
Various
estimates as to the period of reduction were given to us by individual
witnesses, and it is evident that the time taken to effect complete
withdrawal of the drug must vary according to the age, general
condition, and temperament of the patient, the size of the dose taken
and the duration of the addiction. The average period of treatment was
estimated by one of the wittnesses who had medical charge of a
well-known institution for the treatment of drug addiction, at about
three months, but he insisted that the patient should remain under
reliable supervision for some time afterwards. The most difficult
part of the treatment is the reduction of the last half-grain or so to
zero point.
39. Relative Value of Different Methods :
Certain of the witnesses were strongly in favour of the abrupt
withdrawal method, and regarded it as the most reliable or even the
only certain means of bringing about an effective and permanent cure.
The method was advocated especially by those of our witnesses who were
in medical charge of K M. Prisons, and we learned from them that they
had experienced no deleterious effects. One of our witnesses also, who
was not a prison medical officer, expressed the opinion that the cases
in which it was found impossible to reduce the dose below a certain
minimum, and necessary therefore to supply this dose for an indefinite
period, were cases of persons who had been treated by the gradual
reduction method.
Rapid withdrawal, combined with the employment of
a belladonna, hyoscyamus and xanthoxylum mixture pushed to the point of
delirium, was stated by one of the witnesses to have been attended
in his hands by considerable success. Other witnesses, however,
informed us that they had been unable to reproduce these favourable
results,
40. Opinion was on the whole, strongly in favour of the
gradual withdrawal method in prefernce to either of the alternative
plans.
The evidence appears to show that it is more generally
suitable, and more free from risk than either the abrupt or rapid
withdrawal methods. It entails less strain and distress upon the
patient, is unattented by collapse, and other withdrawal symptoms may
in large measure be prevented by its adoption;
41. Though
there was thus a distinct conflict of opinion as to the merits and
demerits of the various methods, the following inferences may, we
think, be regarded as established :--
(a.) That each patient requires individual consideration.
(b)
That abrupt or rapid withdrawal may be advisable in cases of young
healthy adults in whom the addiction is of recent date and only
moderate doses are being taken. Otherwise the gradual method is to be
preferrred.
(c) That abrupt or rapid withdrawal is specially
dangerous in the case of old or seriously debilitated persons, of
patients with advanced organic disease, and those who are taking
exceptionally large doses.
(d) That abrupt or rapid withdrawal
should not be carried out except in a well-appointed institution and
with the aid of skilled nursing and constant medical supervision. It is
therefore, unavailable for the treatment of those who cannot or will
not enter institutions.
(e) That it would be unsafe to draw any
conclusions of a general nature from the peculiar success which appears
to have attended the prison cases treated by the abrupt method. These
persons were confined under close observation and subject to a
discipline more strict than could be enforced in any voluntary
institution; they received prompt, medical aid in any emergency, and
the dose of the drug that had been habitually taken by most of the
prison addicts appears to have been comparatively small.
42. It
was specially insisted upon by several witnesses that actual withdrawal
of the drug of addiction must be looked upon merely as the first stage
of treatment, if a complete and permanent cure is to be looked for. As
one witness put it, the real gain to the patient by withdrawal of the
drug is to enable him to make a fresh start in new and more favourable
circumstances, and little more than that can be expected from the
actual treatment itself, whatever the method employed. A permanent cure
will depend in no small measure upon the after-education of the
patient's will power, and a gradual consequent change in his mental
outlook. To this end it was regarded as essential by one witness that
full use should be made of psychotherapeutic methods, both during the
period of treatment and in the re-education of the patient. it was not
considered that a lasting cure could be claimed unless the addict
had remained free from his craving for a considerable period- 1½ to 3
years after the final withdrawal of the drug. Scarcely less important
than psychotherapy, and education of the will is the improvement of the
social conditions of the patient, and one physician informed us that he
made it a practice, wherever possible, to supplement his treatinent by
referring the cases to some Social Service Agency. It was also regarded
as important that the physician in charge of the case should,
while the patient is under his care, make a thorough study of the
causes, pathological and other which originally led the patient to take
drugs, and try to readdress them. Pain, insomnia or other physical
malady must be treated before the patient is released from observation.
(e) PROGNOSIS
43.
Evidence we have received from most of the witnesses forbids any
,sanguine estimate as to the proportion of permanent cures which may be
looked for from any method of treatment, however thorough. Relapse,
sooner or later, appears to be the rule, and permanent cure the
exception. With two exceptions, the most optimistic observers did not
claim a higher percentage of lasting cures than from 15 to 20 per cent.
One eminent authority, however, who employs the abrupt withdrawal
method reinforced by certain auxiliary measures of a drastic character,
was of opinion that a real cure may be expected in about 66i per cent
of the cases in which the patient is willing to accept treatment: and
in whom the treatment is not contraindicated. The witness who had
practised the rapid withdrawal method (referred to in paragraph 39)
gives a percentage of cures as high as 70 per cent, but other observers
who have tried the method have failed to obtain succesful results in
such high proportions. In this connection may also be mentioned the
remarking results obtained by one of the general practitioner witnesses
who, by the employment of the gradual reduction plan, had obtained
success in 8 cases out of 12 which he had treated. Some of these cured
cases, had been under observation for years and had not relapsed.
44.
While therefore, the ultimate outlook in any individual case is always
serious it can by no means be considered hopeless and every effort
should be made by thorough and suitable treatment to free the patient
from his addiction. It must be borne in mind, however, that those
witnesses who were most sanguine as to the proportion of permanent
cures that could be obtained under the best possible treatment,
recognided that, the results they described could only be secured by
treatment in institutions. Looking to the small number of such
institutions in this country, as well as the cost of the treatment
which, reasonable as it usually is, is beyond the means of some of the
patients, and the impossibility under the law as it stands, of
compelling persons suffering from addiction to become inmates of
institutions, it is clear that under present conditions there must be a
certain number of persons who cannot be adequately treated, and whom it
is impossible
completely to deprive of morphine which is necessary
to them for no other reason than the relief of conditions due to their
addiction.
SECTION III.
CIRCUMSTANCES
IN WHICH IT MAY BE MEDICALLY ADVISABLE TO ADMINISTER MORPHINE OR HEROIN
TO PERSONS KNOWN TO BE SUFFERING FROM ADDICTION TO THESE DRUGS.
45.
This Section of our Report may conveniently be prefaced by some
observations as to the use of morphine or heroin for the relief of
pain. etc., due to organic disease, an, such as inoperable cancer. In
such cases, the adrninistration of the drug for prolonged periods may,
no doubt, produce a cravicng which might persist and develop into
an addiction if the disease were cured. .But there can be no
question of the propriety of continuing to administer the drug in
quantities necessary for relief of the disease, so long as it persists,
ignoring for the time being the question, of possible production of
addiction. No questions such as are discussed later in this Report
would therefore arise in these cases unless and until the conditions
calling primarily for administration of the drug were removed. In
that event, the addiction remaining would require consideration and
treatment in the same way as in any other case of addiction.
46.
It is, of course, also necessary for a time to administer morphine or
heroin to persons suffering from addiction to these drugs who are
under treatment by the gradual reduction method. In such circumstances
no question can arise as to the legitimacy of giving the drugs, in
pursuit of a definite plan of treatment, in such doses as may be
dictated by the experience of the physician. The precautions which it
is considered desirable to observe in dealing with such patients are
set out in the next Section of this Report.
47. Apart from the
cases dealt with in the two preceding paragraphs, we are satisfied that
any recommendations for dealing with the problem of addiction at the
present time must take account of and make provision for the continued
existence of two classes of persons, to whom the indefinitely
prolonged administration of morphine or heroin may be necessary :---
(a)
Those in whom a complete withdrawal of morphine or heroin produces
serious symptoms which cannot be treated satisfactorily under the
ordinary conditions of private practice; and .
(b) Those who are
capable of leading a fairly normal and useful life so long as they take
a certain quantity, usually small. of their drug of addiction, but not
otherwise.
48. Most of the witnesses admitted the existence
of these two classes of cases, though in some instances with
reluctance. Some physicians of great experience believed that if
thorough treatment could be carried out in all cases, it would very
rarely, if ever, be found necessary to provide any addict with even a
minimum ration of drug for an indefinite period. It was recognised,
however, even by these witnesses, that under present e conditions it
was not possible, for reasons already stated (see, paragraph 44),
thoroughly to treat all cases. There must, consequently, remain persons
in whom a complete cure cannot be expected.
49. Further, many of
the witnesses were of the opinion that, even were it possible to treat
thoroughly all cases, there would still exist a certain number of
persons who could be grouped in one or other of the two classes
above enumerated. When therefore, every effort possible in the
circumstances has been made; and made unsuccesfully, to bring the
patient to a condition in which he is independent of the drug, it may
in the opinion of the majority of the witnesses examined become
justifiable in certain cases to order regularly the minimum dose which
has been found necessary, either in order to avoid any withdrawal
symptoms, or to keep the patient in a condition in which he can lead a
useful life. It should not, however, be too lightly assumed in any
case, however unpromising it may appear to be at first sight, that an
irreducible minimum of the drug has been reached which cannot be
withdrawn and which, therefore, must be continued indefintely.
Though
the first attempt eritirely, to free a patient from his drug may be a
failure, a subsequent one may be succesful. In this connection a
paragraph may be usefully quoted from the précis of evidence furnished
to us by one of the general practitioner witnesses who has successfully
treated several cases of addiction: "I have encountered
cases where for a time administration had to be continued on
account of physical and mental distress when withdrawal was attempted.
In every case as soon as possible, further attempts to get the patient
to give up the habit were made. In two cases, for a period of several
months, it was necessary to continue administration of small doses of
morphine to allow the patient to lead a useful life. In both cases it
was finally given up"
The conclusion stated in paragraph 48 has an
obviously important bearing on the consideration of the administrative
measures discussed in Section V.
SECTION IV
PRECAUTIONS TO BE OBSERVED IN THE ADMINISTRATION OF MORPHINE OR HEROIN.
50.
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.
(i) PRECAUTIONS IN THE TREATMENT OF ADDICTS.
51.
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) whore it has been
demonstrated, after a prolonged attempt at cure, that the use of the
drug cannot be safely discontinued entirely, on acount of the severity
of the withdrawal symptoms produced, (c) where it has been clearrly
demonstrated that the patient, while capable, of leading a useful and
relatively normel life when a certain minimum dose is regularly
administered, becomes incapable of this when the drug is entirely
discontinued
52. Precautions in the Treatment of Addicts by the Gradual Withdrawal Method.
- In thise 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
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 esesentially 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.
53. 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 responsibilty, of supplying or ordering indefinitelt 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.
54. 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, 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 case 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 suffeciently often to maintain such observation of his
condition as is necessary for justifyng the treatment. The opinion
expressed by witnesses was to the effect that such patients should
ordinarily be seen not less freqently 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 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.
55.
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,
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 adtninistration, 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.
(ii) PRECAUTIONS IN THE USE OF THE DRUGS IN ORDINARY MEDICAL PRACTICE .
56.
The evidence we have heard would appear to indicate that there has been
a recent diminuation in the prevalence of morphine addiction, and
that this in due to the operation of the Dangerous Drugs Acts in
making, it difficult to obtain the drhugs except from or on the
prescriptions of doctors. (See para. 24.) This enhances the importance
of consideration of the precautions that are necessary in the use
of these drugs in ordinary treatment, in order to reduce to a minimum
the risk that a patient may develop a craving for them. These
precautions are, we think, fairly well recognised among competent and
careful practitioners in all branches of the profession, and the
conclusions here stated, based on the testimony of our medical
witnesses, including representative general practitioners, may, we
believe, be regarded as expressing fairly the opinion of all members of
the profession who have given the requisite attention to the subject.
57.
Where the patient is suffering from organic disease for the treatment
of which the drugs are necessary, the matter may be considered under
two aspects, (a) cases in which the administration of morphine or
heroin may be necessary for an indefinite period and in which the
probability of a cure of the disease is remote (c.g., inoperable cancer
and the like), (b) cases in which administration of the drugs is called
for in order to deal with conditions which, though due to organic
disease may be expected to be of a more or less temporary duration
(such as renal or biliary colic, etc.). In regard to class (a), since
consideration of the possibility of the establishment of a craving
cannot be allowed to influence the administration of such doses of the
drugs as are considered necessary for the adequate treatment of the
organic disease it will be in those rare cases only in which there is
some prospect of partial or complete recovery from the disease that any
attention can properly be given, during the course of treatment, to
such measures as are likely to mitigate or avert the risk of
subsequent persistence of any craving which may have been produced. In
respect of class (b), the employment of these measures becomes of
paramount importance.
They are identical with the discussed in
paras: 59 and 60, and consist. mainly in the substitution, when
possible, of other drugs for morphine and heroin, in close supervision
by the practitioner of the amounts used and of the frequency with which
they are administered, and in withdrawal of the drug as soon as the
necessity for its administration has ceased.
58. In stating the
precautions which we think should be observed in cases other than those
referred to in the preceding paragraph, we shall. be understood to have
in mind, particularly, those cases in which it is thought necessary to
administer, say, morphine, in such doses, with such frequency and for
so long a period as may be requisite, for example, for the relief of
pain after surgical operations, or in cases of severe neuralgia in
which the necesary relief cannot be obtained otherwise.
59. In
cases in which it appears that the use of morphine or heroin may be
thus desirable, it must first be considered whether the purposes of
treatment can be substantially as well served by other drugs that do
not involve the risk of addiction. Constant attention is necessary to
adjust the dosage to the varying needs of the case. The intervals at
which it is desirable to see a patient (not an addict) who requires the
administration of morphine or heroin will necessarily be determined by
the nature of the case. In cases of chronic disease requiring a more or
less prolonged administration of the drugs, the patient need only be
seen at such intervals as are appropriate on other medical grounds,
butt in cases such as renal or biliary colic, in which the necessity
for the administration may cease at any moment, it may be important to
see the patient more often than would otherwise be necessary in order
to guard against the production of a craving.
The quantity supplied
or ordered at one time for use by those nursing the patient should not
ordinarily exceed what will be recquired before the patient is seen
again. Where any discretion is given to nurses as to administration it
should be strictly limited by prescription, and any change made in the
treatment should similarly be stated in writing. The practitioner will
realise that the responsibility for administration is entirely his, and
cannot properly be delegated to any person not medically qualified, It
is desirable also that the patient should not be informed of the name
of the sedative drug employed; particularly inexpedient is the handing
over to the patient of original packages containing morphine tablets,
or the like, which bear on their lables a clear statement of the exact
amount in each tablet.. Hypodermic administration of the drug by the
patient to himself is to be strongly deprecated.
60. The use of
the drug; should. be discontinued as soon as possible, and if
unfortunately a craving has formed close supervision and
appropriate treatment must be maintained until the medical attendant is
satisfied that the patient has been rendered independent of the drug.
It is to be noted in this connection, that, in the opinion of some
authorities, a month's continuous administration of morphine may
suffice to produce in a person who previously appeared normal a
condition of addiction; and in persons with an inherent
predisposition, administration for a shorter period may have this
effect.
61. Most of our medical witnesses have concurred as to
the desirabilty of special instruction to medical students on the
precautions necessary in the use of morphine and certain other drugs in
order to avoid the development of addiction. One or two medical
witnesses, on the other hand, expressed doubt whether such instruction
might not accentuate the undue timidity which they believed was not
uncommon among practitioners, with the untoward consequences above
described (see para. 32). We think, however, that such a result need
not be feared from a full exposition of the actions, both valuable and
harmful, of these drugs, the indications for their use, their proper
place in treatment, the dangers to be guarded against, and the best
means of averting these dangers. We think also that medical
practitioners already in practice should welcome the issue of a
Memorandum affording guidance on this important and difficult subject.
SECTION V.
ADMINISTRATIVE MEASURES.
62.
We have given careful consideration to the administrative proposals to
which the Home Office invited our attention, and to others which
witnesses have suggested, or which have occurred to us in the course of
our deliberations. as an essential preliminary to this section
of our Report, we desire to emphasise the importance in the
prevention of addiction of the administrative measures which preclude
the importation, manufacture, sale and distribution of dangerous drugs
by unauthorised persons, and regulate the procedure of those who are
authorised. The administrative measures to which we refer in the
following paragraphs relate more particularly to cases in which medical
practitioners are concerned, as those upon whom the responsibility for
distribution ultimately rests.
CONTROL OF SUPPLY AND PRESCRIBING.
69.
Among the most important, and most difficult, of the matters thus
requiring attention is that of the administrative action which should
be taken in cases in which there is reason to think that a medical.
practitioner may be supplying or ordering the drugs otherwise
than for medical purposes, properly so called. The question of
irregularity in prescribing raises issues, under the Regulations, that
are somewhat different from those affecting supply, and it is to
"supply" that the immediately succeeding paragraphs relate.
Questions of Apparently Improper Supply.
64.
The cases, for consideration may arise in connection with (i)
administration or supply to other persons or (ii) administration by the
practitioner to himself
These two groups of cases are consistently considered seperately
65.
As explained in Section I of this Report (para 6) the drugs to which
the Dangerous Drugs Acts relate cannot be possessed by any person not
authorised by the Home Secretary for the purpose except, where they are
supplied or prescribed by a registered medical practitioner (or in
certain cases by registered dentists or registered veterinary
surgeons). Further, the drugs cannot be supplied except by a
person so authorised. Registered medical practitioners have a
general authority to possess or supply the drugs so far only as is
necessary for the practice of their profession.
66. This general
authority; to supply and posses may be withdeawn at the discretion of
the Home Secretary from individual practitioners who have been
convicted of offences under the Dangerous Drugs Acts, but as the
Regulations stand at present, withdrawal of authorisation must be
preceded by a conviction in the police court.
We have been
asked to consider the advisability of such modification of the
Regulations as would dispense with the necessity for police court
action in cases in which the Home Secretary was advised by a suitably
constituted Medical Tribunal that the authorisation of a medical
practitioner to posess; and supply might properly be withdrawn.
67.
We are of opinion that this proposal offers several advantages, both
administratively and from the point of view of the medical profession.
It is undesirable, in our view, that where it can be clearly shown
that, for the public protection, the authorisation of a practitioner
should be withdrawn, it should be necessary for the. Home Secretary to
take the case to the police court in order to obtain a conviction. We
are satisfied that there are many cases which would be adequately met
by the withdrawal of the authorisation, without recourse to those
penalties of fine and imprisonment which the magistrates have the
power to inflict. These penalties we are informed by the Home Office,
are in the majority of cases neither necessary nor desired. Further,
consideration must be given to the public odium of a criminal trial and
conviction which is specially felt when the prosecution takes place in
the district in which the doctor practices.
68. Again, it is to
be observed that the issue in such cases is essentially medical,
namely, whether there was, or was not, justification fot the
administration of the drugs in question. A Medical Tribunal would have
obvious qualifications for the investigation of such questions which
cannot be possessed by lay magistrates, acting without medical
assistance other than that of such medical witnesses as they may hear.
69.
Also it would in our opinion be advantageous that all cases in England
and Wales should be dealt with by one Tribunal., and that there should
similarly be one Tribunal to deal with all cases in Scotland; these
Tribunals would thus acquire special experience, and be able to apply a
uniform standard of judgement.
70. On these grounds we have no
hesitation in recommending that the suggested change be made in the
Regulations affecting the Home Secretary's power of withdrawal from
medical practitioners of the authorisation to possess and supply
Dangerous Drugs.
71. We assume that the cases referred to the
Medical Tribunal would be confined to those which involved the question
of whether the drugs had been supplied, administred or prescribed for
other than legitimate medical purposes.
72. After considering
various possibilities, we have come to the conclusion that
the most suitable Tribunal would be one composed of some medical
members, with a legal assesor, and that representative medical bodies
should be responsible for the nominations of the medical members.
73.
We suggest that, as regards England and Wales, one medical member
should be appointed on the nomination of the general Medical
Council, one on the nomination of the Royal College of Physicians
of London, and one on the nomination of the British Medical
association. In Scotland nominations might be made by the General
Medical council, the Royal College of Physicians of Edinburgh, and the
British Medical Association. It appears to as that the Legal Assessor to
the General Medical Council might properly be appointed Legal assessor
to the Tribunals.
74.
In the case of those medical practitionere who are themselves addicted
to the abuse of drugs, and whose authority to be in possession of the
drugs needs consideration on account of apparently improper use in
self-administration, the reasons for reference of the issue to such a
Tribinal are in some respects even stronger than in cases of
adminisration to others, It will be generally agreed that such
practitionere are a source of special danger to the community, and
their cases are usually such that avoidance, if possible, of police
court, proceedings is particularly desirable. Moreover, the withdrawal
of the authorisation to possess the drugs is specially valuable in the
interest of the practitioner himself.
75, We consider,
therefore, that a Medical Tribunal consituted on the lines listed above
would afford valuable assistance to the Home Office in securing that
possession and supply of the drugs by medical practitioners was
restricted to that required for legitimate medical purposes, and would
enable the Department to deal effectively, and in a manner satisfactory
to the medical profession, with cases in which there were strong
grounds for believing that a doctor was administering drugs for
illegitimate purposes either to himself or to others.
Limitation of Prescribing .
76.
We have reserved for seperate consideration the question of measures
for dealing with improper prescribing, as distinct from "supply"
In the fsrrst place, as has been pointed out in Section I of
this Report (para. 17), doubts have arisen whether, under the
presenet Regulations, prescribing of the druge is restricted, as are
possession and supply to such as is necessary for medical purposes.
Such a restriction of prescribing would be in accordance with the given
intention of the Acts. Under the Dangerous Drugs Acts a prescription
consitutes an authority without which the drugs cannot be supplied. It
is obviously necessary that, as in the case of drugs supplied by the
doctor himself, drugs should not be ordered except for the express
purpose of medical treatment. We recommend therefore, that it should be
explicitely provided by the Regulations that a prescription for
Dangerous Drugs shall not be given except, bona fide, for medical
purposes.
77. Secondly, we have been asked to consider the
advisability of power being given under the Regulations to the Home
Secretary to withdraw the right to prescribe these particular
drugs in certain conditions. It is clearly essential, from the
point of view of efficient administration, that some meansshould exist
whereby a doctor whose authorisation to possess and supply the drugs
has been withdrawn might be precluded also from prescribing them in
cases where this further step was thought to be necessary. In the
majority of cases in which the authorisation to possess and supply had
been withdrawn on account of the doctor's improper administration or
supplly of the drugs the object of the wthdrawal, as regards protection
of the community, would obviously not be achieved if he were still
permittedto prescribe.
78. If our recommendation as to the
procedure in the matter of withdrawal of authority to possess and
supply were adopted the most simple and direct method of dealing with
the question of withdrawal of the right to prescribe Dangerous Drugs
would be by providing that cases in which this question arose should be
referred to the same medical tribunal as as deals with questions of
possession and supply and that power should be conferred on the Home
Secretary by the Regulations to withdraw the right to precribe in cases
in which the Tribunal so advised and we recommend accordingly.
QUESTIONS OF OBLIGATIONS ON PRACTITIONERS (a) TO NOTIFY (b) TO OBTAIN SECOND OPINION
79.
We have considered whether certain special obligations should be placed
by the Regulations on medical practitioners when engaged in the
treatment of persons to whom morphine or heroin is being administred
continuously, without other necessity than for the relief of the
symptoms of addiction. The possible obligations thus considered
are (a) that, of notifying such cases to the Home Office
and (b) that of obtaining a second medical opinion in
certain circumstances.
80. The primary object of a system of
notification would be to enable the Home Office more readily to detect
cases in which patients were obtaining, the drug of addiction from
two or more doctors concurrently, a practice which not only
contravenes the intention of the Acts, but is obviously prejudicial to
the best interests of the patient. A requirement of notification would
no doubt tend also to diminish doubtfully justifiable supplying or
ordering of the drugs. Moreover it would assist practioners to
excercise firmer control over their patients and would tend to relieve
practioners who were acting in good faith from suspicion, and from the
liability to unknown inquiries, which at present are unavoidable.
81.
Against these advantages have to be weighed the inherent disadvantages
of all forms of notification in impairing the confidential
character of the relation of doctor and patient. The objections to
notification on this ground have been regarded as outweighed in
many other connectionsi by what were deemed by public opinion and by
the Legislature to be more important interests of the community
and of patienits themselves; but each proposal for extension of this
principle
to a new group of cases must be considered on its merits.
82.
In the present instance we are not satisfied the benefits of the
notification would suffice to outweigh the attendant
disadvantages. In abstaining from reccommending such a measure we have
had regard to the relative infreqency of morphine or heroin addiction
in this country at the present time, to the evidence of decrease
of the number of cases since the introduction of
legislative restrictions, to the expectation that the further
operation of the present restrictions on supply, coupled with greater
care by practitioners in the use of the drugs in treatment, may go a
long way to exinguish the evil, and to the view expressed by the
Home Office that notification, though it would be useful is not
essential for detecting persons who obtain drugs of addiction from more
than one doctor at a time. At the same time we consider that every
practitioner prescribing morphine or heroin for the first time to
a patient who does not require the drugs except for the treatment of
symptoms produeed by addiction will be well advised, in his own
interest and in those of the patient, to make inquiries from that
patient as to the source from which he obtained or is at the time
obtaining, the drugs in question, and as to the names and addresses of
practitioners under whose care he is, or has been.
83. We have
considered whether it would be advisable to provide by Regulations that
a practitioner should obtain a second medical opinion before consenting
to administer morphine or heroin for an indefinite time to a person who
does not need them otherwise than for the relief of symptoms of
addiction. It has been suggested that this would tend to secure better
observance of suitable precautions in the medical use of the drug.
84.
We have been impressed by the fact that most of the medical witweses we
have heard are of opinion that a second opinion should be obtained in
such cases, if practicable, both from the point of view of advantage to
the patient, and for the protection of the doctor if his
conduct in ordering the drugs should be subsequantly called in
question.
85. We do not, however, think it necessary or
desirable that any obligation of this kind should be
imposed by Regulations. We believe that it will suffice and is
eminently desirable that an effort should be made to impress upon the
profession generally, the extreme advisabilty of obtaining a second
opinion, in these cases and it is conconsidered that this might well be
ragarded more or less in the light of a professional obligation, such
as is already generally recognised to exist in cases in which certain
operations such as the emptying of the pregnant uterus, are
contemplated. The evidence including that given on behalf of the
British medical Association, justifies the belief that there would be
general support in the profession for this proposal.
86. It is
understood that in the case of patients who cannot afford the costs of
a second opnion, or where there might be difficulty in obtaining such
an opnion, the Ministry of Health would be prepared to place the
services of their Regional Medical Officer at the disposal of the
patient and the practioner if desired.
87.Two alternative measures which we have considered have presented less difficulty, and may be examined more shortly.
RECORDS OF PURCHASES BY NON-DISPENSING DOCTORS.
88.
The requirement (referred to in para 17) that doctors who do not
dispense drugs should keep a simple record of purchases would doubtless
entail a slight burden of book-keeping upon a section of the profession
who are at present free. We gather, however, that it would suffice for
the purpose if the invoices of such purchases were pasted in order in a
book, so as to minimise the work entailed. Doctors who dispense
are required to keep a record not only of Dangerous Drugs purchased,
but also of those supplied otherwise than by personal administration.
Such records facilitate investigation of cases calling for inquiry. In
the case of doctors who do not dispense there is at present no
corresponding record, and we understand that administration is to some
extent hampered in consequence We think the proposed requirement would
overcome a defect in the present system which should be remedied in the
manner suggested.
COMMUNICATION TO WHOLESALE HOUSES OF NAMES OF DOCTOR-ADDICTS.
89.
As a further measure for dealing with the case of the doctor addict, we
have been asked to consider whether it would be desirable that a list
of such doctors should be supplied to wholesale chemists with a request
that they would inform the Home Office of purchases made by doctors on
the list. We foresee grave objections to carrying out such a proposal,
and do not recommend its adoption.
SECTION VI
PREPARATIONS AT PRESENT EXCLUDED FROM THE SCOPE OF THE DANGEROUS DRUGS ACTS.
90.
In the course of our investigations it came to the notice of the
Committee that cases of addiction were said to result from the
consumption in large quantities of preparations containing morphine and
heroin of a percentage lower than that which would bring them within
the scope of the Acts. We deemed it advisable to inquire more fully
into this question, and our Terms of Referee were accordingly extended
as follows :-
" To consider and advisse whether it is expedient
that any or all preparations which contain morphine or heroin of a
percentage lower than that specified in the Dangerous Drugs Acts should
be brought within the provisions of the Acts and Regulations and is so
under what conditions"
Since this reference was received
the Committee were informed that at the Geneva Conference in February,
1925, under the auspices of the League of Nations, this country
assented to an International agreement to abolish the limit of 0.1 per
cent in respect of heroin and to bring within the scope of the
Dangerous Drugs legislation all preparations of heroin without
distinction of percentage. This has been effected by the Dangerous
Drugs Act, 1925.
We have, therefore, thought it unnecessary to consider preparations of heroin under this part of our reference.
91.
With reference to preparations of morphine we have taken evidence not
only from many of the medical witnesses who have appeared before us,
but also from representatives of wholesale and retail chemists, from
the Pharmaceutical Society of Great Britain and from the Society of
Apothecaries.
92. This evidence points in our view emphatically
to the conclusion that there is very little, if any, abuse of
preparations of this kind other than chlorodyne. Our further
observations in this Section relate, therefore, to this substance.
93.
"Chlorodyne," as is well known, is the trade name originally given to a
preparation introduced by Dr. J. Collis Browne. Since the proprietary
rights expired, several preparations are now sold under the name. Most
of these contain morphine in various strengths, and the morphine
content of particular preparations appears to vary from time to time.
Most of them now contain morphine in a strength under 0.2 per cent,
and, therefore, are exempt from the restrictions of the Dangerous Drugs
Acts, although in most cases they approach very closely to the limit.
Thus they can be, and are, sold freely in chemists' and other shops.
94. The
evidence appears to show that the quantity of these preparations sold
to the public since the passing of the Dangerous Drugs Acts has not
increased and is, in fact, tending to decrease.
95. Certain
medial witnesses considered that there was some possibility of abuse of
chlorodyne, and some stated that they had met with cases of drug
addiction which, in their opinion, were due to the consumption of one
or other of the preparations of chlorodyne.
96. A number of the
medical witnesses on the other hand took the view that chlorodyne was a
valuable domestic remedy, and widely used in cases of minor complaints,
and that, while there might be related instances of abuse, it did not,
except perhaps in rare instances, result in the formation of a drug
habit.
97. It was further suggested by some witnesses that, as
the amount of morphine contained in the preparation is so small, the
amount of chlorodyne which it would be necessary to consume in
order to satisfy craving for drugs would be large, and that it would be
an expensive and indeed, an inconvenient method of gratifying addiction.
98.
The fact, however, cannot be ignored that, though the cases are few,
chlorodyne is used as a drug of addiction, possibly as a result of the
ease with which it can be obtained and the difficulty of obtaining
morphine. The tendency, moreover, so to use it may increase, as the
difficulties of obtaining morphine in other forms increase through
the administration of the Dangerous Drugs Acts. We think,
therefore, that there is a case for considering whether in some
way the abuse of this particular substance can be checked,
though not necessarily by the adoption of the measure specified in
our supplementary reference.
99. it was represented to us that
the Labelling of Poisons Order, which comes into force in January 1926,
would require the morphine content of the preparation to be clearly
stated on each bottle, with the result that the public and medical
practitioners would be better informed than is at present possible as
to the exact composition of the preparation which is being taken or
prescribed. it was not, however clear to us that the operation of this
Order would deter such persons as at present use chlorodyne for
purposes of. addiction from continuing to use it.
100. It was
urged by some witnesses that if any restrictions on the sale of
chlorodyne are found neccesary they should take the form of requiring a
definite standard of morphine content to be established and that the
standard should be such as to bring the preparation automatically
within the scope of the Dangerous Drugs Acts. This proposal would have
the effect of rendering chlorodyne of that strength unobtainable by the
public except on a doctor's prescription, and of preventing the sale of
similar preparations of lower strength under the name of cholrodyne.
101. An alternative that seems to us well worth
consideration is that of fixing a standard of morphine content of
preparations sold under the name of chlorodyne which should be
well below the limit of the Dangerous Drugs Acts, say 0.1 per cent.
This would make the risk of use of such preparations for addiction
purposes negligible and would not interfere with the free sale of the
substance as a domestic remedy. It would contain sufficient morphine
for the purpose for which it can safely be so used. and where more
morphine was necessary it would be obtained under medical advise.
102.
Another way of achieving the same result would obviously be to fix the
limit under the Dangerous Drugs Acts at 0.1 per cent. instead of
0.2 per cent, as at presentt. There is no evidence however, of the use
for addiction purposes of any preparation, other than chlorodyne,
in the zone of strength between 0.1 per cent and 0.2 per cent.
This may be because chlorodyne is so widely known and relatively pleasant to take.
103. Our conclusions on this part of our reference are
(i)
That there is in our opinion no evidence to necessitate bringing all
preparations of morphine within the scope of the Dangerous Drugs Acts,
or lowering the standard of strength at present fixed by the Acts.
(ii)
That there might be some advantage in securing in some
way that no preparation should be sold under the name of
chlorodyne which contains more than 0.1 per cent of morphine.
CONCLUSIONS AND RECOMMENDATIONS
MEDICAL QUESTIONS:
(1) Prevalence of Addiction
- Addiction to morphine or heroin is rare in this country and has
diminished in recent years. Cases are proportionally more frequent in
the great urban centres among persons who have to handle those drugs
for professional or business purposes, and among persons specially
liable to nervous and mental strain. Addiction is more readily produced
by the use of heroin than by the use of morphine, and addiction to
heroin is more difficult to cure.
(2) facility of access is an
important factor in the production of addiction, and the recent
diminuation in the number of addicts to both these drugs is
largely attributable to the restrictions imposed by the Dangerous Drugs
Acts (paras 22-26)
(3) Nature and Causation of Addiction.-
With few exceptions addiction to morphine and heroin should be regarded
as a manifesatation of a morbid state, and not as a mere form of
vicious indulgence (Para 27.)
(4) The immediate cause of
addiction is the use of the drug for period sufficient to produce the
constitutional condition manifested by "craving" and the
occurance of withdrawal symptoms when the drug is discontinued.
Addiction is more readily in some persons than others, the most
important predisposing cause being an inherent mental or nervous
instability. There is evidence however, that addiction may be induced
by injudicious use of the drug in a person apparently free from any
manisfestation of nervous or mental disability, and, conversly that due
care in administration may avert this result even in the unstable.
other predisposing causes are chronic pain or distress, insomnia,
overwork and anxiety (paras 30)
(5) In a considerable proportion
of cases the circumstance which has immediately led to addiction has
been the previous use of the drug in medical treatment. Other
circumstances noted have been self-treatment for the relief of pain
etc, recourse to drugs in emotional distress, influence of other
addicts, and indulgence for the sake of curosity or the experience of
pleasurable sensations. cases of addiction originating in use of the
drugs otherwise than under medical orders must be expected in future to
be less frequent than in the past (Paras 31-34)
(6) Treatment and Aftercare.-
While the most eminent authorities differ as to the relative value of
(a) abrupt or rapid withdrawal of the drug and (b) gradual withdrawal
in the cure of addiction, the following conclusions may fairly be drawn
from the evidence;-
(a) Abrupt or rapid withdrawal cannot be carried
out safely except under conditions which afford complete control of the
patient's access to the drugs and close and continuous observation of
the effects of the treatment, such as are usually to be found only in
special institutions or nursing homes.
(b) gradual withdrawal will
therefore with rare exceptions be the only practcable method under the
ordinary conditions of private practice and the only one applicable to
patienst who cannot afford or are, for other reasons unwilling to enter
institutions or nursing homes.
(c) Abrupt withdrawal may be adviable
for young otherwise healthy adults in whom the addiction of recent date
and so far has entailed moderate doses only, in other cases gradual
withdrawal is on the whole to be prefreed even under institutional
conditions.
(d) Abrupt withdrawal is especially dangerous in old or
seriously debilitated persons, patients with organic disease and those
taking exceptionally large doses.
(e) Institutional treatment, while
with rare exceptions indispensable for the abrupt method, also affords
the best hope of cure by the gradual method, and patients should
always, if possible, be induced to undergo treatment in an institution
or nursing home.
(f) Success in enabling any patient, by either
method, to become (for the time being) independent of the drug must be
regarded as the completion of the first stage of treatment only. For
permanent cure a prolonged period of aftercare is necessary, in order
to educate the patient's willpower and to change his mental outlook.
For this part of the treatment information should be obtained by a
close investigation, during the first stage of the conditions which
brought about the addiction, and if a factor, such as pain or insomnia,
contributed to the causation, every effort must be. made to remove or
cure this before the patient is released from observation. Attention
must also is paid to the possbility of improvement in the patient's
social conditions (paras 31 -32)
(7) Prognosis.
Estimates of the proportion of completed cures of cases treated
vary from 15 or 20 per cent. to 60 or 70 per cent., the highest
percentages being claimed by practitioners adopting the abrupt method
who had carried out the treatment in institutions or nursing homes
(para 43 and 44)
CIRCUMSTANCES IN WHICH MORPHINE OR HEROIN MAY LEGITIMATELY BE ADMINISTRED TO ADDICTS
(8)
There are two groups of persons suffering from addiction whom
administration of morphine or heroin may be regarded as legitimate
medical treatment.. namely:
(a) Those who are undergoing treament for cure of the addiction by the gradual withdrawal method ;
(b)
Persons for whom, after every effort, has been made for the cure of the
addiction, the drug cannot be completely withdrawn, either because:
(i)
Complete withdrawal produces serious symptoms which cannot be
satisfactorily treated under the ordinary conditions of private
practice; or
(ii) The patient, while capable of leading a useful and
fairly normal life so long as he takes a certain non-progressive
quantity, usually small, of the drug of addiction, ceases to be able to
do so when the regular allowance is withdrawn. (Paras 45-49.)
PRECAUTIONS REQUISITE IN THE ADMINISTRATION OF THE DRUGS TO ADDICTS.
(9)
Under treatment by the gradual withdrawal method the addict should, if
possible, be induced to enter a suitable institution or nursing home.
If this is not feasible the practitioner must attempt to cure the
condition by a steady judicious reduction of the dose, with a view to
ultimate complete withdrawal. The patient should be kept under close
observation by the practitioner should be in the care of a capable
and efficient nurse and under sufficient control to preclude any
possibility of obtaining supplies of the drug other than those
medically ordered.
(10) If the practitioner finds that he is
losing the requisite control, or tile course of the case indicates a
probability that complete cure cannot be effected, he will be well
advised to obtain a second opinion before assuming the responsibility
of indefinitely prolonged administration
(11) Where indefinitely
prolonged administration appears to be needed the main object must be
to keep the supply of the drug within limits of what is necessary.
(12)
The practitioner should be satisfied as to urgency before
administring or supplying morphine or heroin to a patient
concerning whom he has no previous knowledge and careful inquiries
should be made from the patient, at the beginning. as to previous or
concurrent sources of supply. The minimum dose necessary should be
administred and (unless organic disease is present) repetition withheld
until the the practioner has obtained from the previous medical
attendant details on the nature of the case. (Paras. 51 - 1íi.)
PRECAUTIONS TO BE OBSERVED IN THE USE OF THE DRUGS IN ORDINARY MEDICAL TREATMENT.
(13)
We recommend that the following precautions should be taken in the
use of morphine and heroin in ordinary medical practice
(a)
Regard should be had at all stages of the case to the possibility of
substituting for morphinte or heroin, either temporarily or
permanently, drugs which do not involve the risk of the development of
addiction.
(b) If the use of morphine or heroin is essential, care
should be taken not to give larger or more frequent doses, than are
strictly requisite to achieve the object in view.
(c) Cases
requiring the daily administration of morphine or heroin should be seen
as often as the doctor feels to be necessary, and the amount ordered or
supplied should not exceed that required until the patient is seen
again.
(d) Discretion to nurses as to administration of the drugs
should be strictly limited by prescription, and any change made in the
treatment should be stated in writing.
(e) The patient should not be
informed either of`the name or dose of the drug administered. Whenever
other methods of administration will produce the desired effect,
hypodermic injections should be avoided.
(f) In no circumstances should the patient be allowed to administer the drug to himself hypodermically.
(g) The use oÍ the drug should be discontinued immediately if it is no longer needed.
(h)
if a craving has unfort:unately resulted from use of the drugs, close
supervision and appropriate treatment should be maintained until the
medical attendant is satisfied that the patient has been rendered
independent of the drug. (Paras 50-51.
(14) Valuable results
might come from the judicious instruction of medical students in the
precautions necassary to avoid the production of addiction to morphine
and certain other drugs. medical men already in practice should welcome
the issue of some authorative Memorandum affording guidance upon this
difficult and important subject and we therefore recommend that such a
Memorandum be issued. (para 61)
ADMINISTRATIVE MEASURES
(15) Withdrawal of Authorisation to Possess and Supply.-
The present position under which a doctor's authorisation to possess
and supply the drugs can only be withdrawn after a conviction under the
Dangerous Drugs Acts is not satisfactory, either administratively or
from the point of view of the medical profession
We recommend that
the Home Secretary should have power to withdraw the authorisation
without conviction in the Courts if so advised by a suitably
constituted medical tribunal.
We recommend that Tribunals should be
constituted whose function it would be to consider whether or not there
were sufficient medical grounds for the administration of the drugs by
the doctor concerned either to a patient or to himself, and that they
should advise the Home Secretary whether the doctor's right to be in
possession, to administer and to supply should be withdrawn
We recommend that there should be seperate Tribunals for:
(i) England and Wales
(ii) Scotland;
and
that they should be composed of one member nominated by the general
Medical Council, one by the appropiate College of Physicians and one by
the British Medical Association with a legal assessor. (Paras 62-75)
(16) Control of Prescribing.
- Any doubt there may be as to the power of the Home Secretary under
the present Regulations to control the prescribing of Dangerous Drugs
should be removed by a suitable amendment to the Regulations, and we
recommend accordingly
The Home Secretary should also have power
after the conviction of a doctor in the Courts for an offence under the
Dangerous Drugs Acts or on the advice of a Medical tribunal to withdraw
the practioner's authorisation to prescribe dangerous Drugs, and we
recommend that this amendment to the Regulations be also made (Paras
75-76)
(17) Obtaining of Second Opinions.-
In the interests of patients and of practioners themselves it is
desirable that the practice should be generally followed of obtaining
second opnions before undertaking the responsibilty of continuing to
administer drugs in cases in which there is no medical reason for doing
so other than treatment of an addiction. This applies also to the group
of cases in which the patient needs indefinite administration of the
drug for the purpose of enabling him to lead a normal and useful life.
The Regulations should not however require a practioner to obtain a
second opnion but it should be regarded as a professional obligation
such as is generally recognised in respect of the decision to carry out
certain other forms of treatment (paras 79-87)
(18) Record of Purchases by Non-dispensing Doctors.-
Doctors who do not dispense should be required to keep a simple record
of their purchases of Dangerous Drugs and this could most easily be
done if the invoices of purchases were pasted in a book. We recommend
that the Regulations be amended accordingly (para 88)
PREPARATIONS AT PRESENT EXCLUDED FROM THE SCOPE OF THE DANGEROUS DRUGS ACTS
(19)
There is little if any abuse or danger of addiction arising from any
preparations at present excluded from the scope of the Dangerous Drugs
Acts with the possible exception of chlorodyne As regards this
preparation there was considerable difference of opnion, but the
evidence appears to show that the free sale of the preparation as a
common domestic remedy has given and does give rise to certain risks of
addiction. (Paras 90-102)
(20) There is no present need
for the prevention of addiction to decrease the limit of morphine
content now fixed by the dangerous Drugs Acts
The position as
regards chlorodyne would be met if it should be secured in some way
that no preparation should be sold under the name Chlorodyne which
contained more than 0.1 per cent of morphine (Para 103)
Finally the Committee wish to record their high sense of the services of the Secretaries Mr R.H. Crooke and Dr E.W. Adams
HUMPHRY ROLLESTON (Chairman)
W.H. WILCOX
JOHN W BONE
R.W. BRANTHWAITE
G. MATHESON CULLEN
W.E. DIXON
JOHN FAWCETT
A FULTON
J SMITH WHITAKER
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