John Marks, Psychiatrist, Chapel Street Clinic, Widnes.

Widnes and Runcorn (population 150.000) have had a drug dependency clinic offering maintenance opiate management for many years. Bootle had no such clinic until 1985, but counselling, withdrawal and detoxification had been available at both Widnes and Bootle. It was hypothesized that illicit drug use would have spread more widely in Widnes than in Bootle because of this difference in service provision and that referrals would reflect this. The opposite was found to be the case. Follow-up of chronic drug addicts in Widnes is reported. This study confirms Vaillant's (1983) view of drug dependency as a chronic relapsing condition with a spontaneous remission rate of roughly 5% per annum.

If the patient survives, this remission rate yields a 50% chance of recovery after 10 years (Stimson, 1982).

Of the Widnes cohort 20 (22%, 1989) are now drug free and have lower criminal records than would have been expected, and are physically healthier (Fazey, 1987). This rate of recovery is not different from those not prescribed drugs but from Stimson's research sixteen deaths would have been expected among the Widnes cohort after seven years. There have been no deaths among the maintained Widnes addicts. If the remission rate is spontaneous and impervious to external agency, medical intervention should try and ensure healthy survival until the ten years has elapsed.

Explanations are sought for our paradoxical result that prohibition appears associated with increased drugtaking, but slight relaxing of drug control is associated with an order of magnitude reduction in drugtaking. On a national scale, it is noted that England had an insignificant drug problem between 1870 and 1960. Before 1870 there was little or no control and intoxication was endemic. After 1960, with strictly enforced prohibition, a contemporaneous rise in notifications is well-attested. In 1920 controlled availability (by tax and prescription) was followed by a steady reduction of English consumption of alcohol and opium. By contrast, American prohibition (after an initial fall in consumption when legal sources of drugs and alcohol disappeared) was followed by a steady increase in illicit consumption. Indeed, US domestic heroin consumption has increased every year since 1923 when the drug was prohibited (Trebach, 1987). Since World War II, England's controlled availability policy for alcohol has

been systematically dismantled. This has been followed by an inexorable rise in alcohol consumption and alcohol-related problems. We are now almost back in Hogarth's days of Gin Lane, when England was floating on alcohol (and dreaming on opium). Those early nineteenth century years of no controls corresponded with periods of very high alcohol and drug consumption. How are these apparently conflicting facts to be reconciled?

The epidemic effect of black markets is explained, leading to the conclusion that the supply - demand curve for intoxicants is not exponential, but quadratic. This suggests a test experiment: slight relaxation of a prohibited substance (Dutch cannabis policy) or slight tightening of a freely available one (Danish alcohol policy) should both lead to a fall in consumption. This is found to be so.

State rationed drugs: an absurd policy?

In the Mersey Region, drugs are prescribed on an indefinite basis to drug users because there is not then the necessity to commit acquisitive crime to buy drugs, there is no need to sell drugs to others to finance one's own use, there is no need to risk one's (and other's) health, and possibly life, with adulterated drugs, and it is likely to promote re-attendance at the clinic for considered appropriate clinical action. An important side-effect is the removal from criminals of a lucrative source of revenue. Provision of a state-controlled (through responsible drug dependency clinics), supply of drugs rapidly brings into contact with the authorities a large majority of the most serious drug problems that other services, SIMPLY BECAUSE THEY DO NOT SUPPLY DRUGS, never see.

Five questions are commonly asked about such a seemingly absurd policy, viz:

1. Won't such prescribing undermine motivation, for why give up drugs if free heroin is available?

2. Is it not better to counsel and treat someone than give him drugs?

3. Won't such a policy increase total consumption of drugs in society when our aim is to reduce it?

4. How can you justify providing drugs to drug takers? For why not provide drink to alcoholics, brothel tickets to rapists or jewellery for thieves?

5. Do not all the prescribed drugs leak out to the black market anyway?

Why give up drugs if free heroin is available?

In dealing with drug users, we are confronted with individuals who will lie, cheat, deceive and rob often from their nearest and dearest to obtain drugs. They risk arrest and imprisonment, beatings by gangsters, injury or death from adulterants and disease. What greater sanctions are there than alienation from one's family and friends, loss of liberty, poverty, disease or death? If these do not act as deterrents, any effect a prescription of heroin may have will be marginal and greatly outweighed by the beneficial effects of harm reduction. For confronted with this degree of determination, the choice such addicts allow is not detoxification or prescribed drugs from a clinic: it is drugs from the black market or drugs from a clinic.

Vaillant (1984), Sobell (1990) and other studies collected by Schneider (1988) have shown how impervious the addictive mental state is to external intervention. According to Stimson (1982) addiction is a chronic condition of years' duration. If during this time nothing can make an addict give up, the best medical intervention is to ensure healthy survival until then. This is done by judicious prescription of pure, pharmaceutical drugs for an indefinite period of time. Such prescribing is called "maintenance prescribing" since it maintains a drug-user's habit until he is prepared to give up. Enforced or premature 'cures' will result in relapse and disillusionment if staff had been led to expect such 'cures' from maintenance. One practitioner wrote:

"It is a pity that the National Health Service drug dependency clinics set up for the management of patients addicted to opiates appear to have 'failed'. I was a consultant in charge of one of these clinics when it first opened in 1967 and felt no misgivings about the maintenance prescription of injectable heroin. Unhappily, these feelings were not shared by many of my colleagues, and the clinic experiment changed into a race between colleagues to see who would prescribe the least heroin. I think that this race was engendered by a mixture of good and bad motives, the good motives having to do with the genuine wish to replace injectable drugs with oral drugs such as methadone, and bad motives having to do with the innate tendency of many doctors to moralize to and about their fellow creatures. Thus those of us who were prepared to continue prescribing injectable heroin were subjected to a moderate amount of criticism. It also led to some absurdities - for example, a colleague from another clinic would teleph

one and ask me to prescribe heroin because he knew that I did, whereas he did not feel able to although he was licensed so to do. This seems to me to be as near farce as one can get. It is perhaps hardly surprising that the drug dependency clinics 'failed'. They never had a chance". (Willis, 1983)

Maintenance is simplistically misperceived as 'treatment', but in fact merely continues addiction, but there is no evidence showing it prolongs addiction: nothing does: there is a spontaneous remission rate of, at most, 5% per annum regardless of what you do. This yields an average period of addiction of ten years. If drug addicts get better in spite of doctors and policemen and not because of them, then the best intervention is to keep them healthy, legal and alive until the ten years or so has elapsed. This does not mean that during the years of maintenance one should not continue to persuade patients to try and give up their drug use. The fault is not with maintenance but misperceptions about the natural history of addiction. This is reflected by such questions as why give up drugs if free heroin is available? For the question seems to imply that if no free heroin were available, addicts would give up drugs. One only has to look at America to see how false that is.

Is it not better to counsel someone than to give him drugs?

Yes, if the drugtaker would assent to this. But anyone who goes to a pub only to endure a twenty minute homily on the evils and dangers of alcohol before he can have his pint of beer will soon take his custom elsewhere. Rightly or wrongly, drugtakers view their drug consumption exactly as you or I view our beer (or even coffee) drinking. For the vast majority of drug-users, uninvited counselling is a detested intrusion into their own lives and vehemently rejected. A patient who attends a clinic and is refused drugs and offered only counselling is more likely (than a patient who is prescribed drugs) to line the pockets of the Mafia buying dangerously adulterated street drugs; to rob or steal from your house and my car for cash for drugs; to adulterate and sell to others parts of his own drug supply to finance further purchases; and, perhaps most pertinent from a medical point of view, such a patient is far less likely to re-attend for help and advice when it is needed. You can have the best counselling i

n the world, but it is wasted on thin air if there is no-one to hear it.

Before the clamour is raised by counselling agencies of their legion of attenders, all the non-prescribing clinics in the Northwest describe a phenomenon known as 'the ticket syndrome'. Drug counselling agencies have sprung up everywhere. A young woman who has a problem with housing or a gas bill may, having attended the relevant departments, seek to press her case further by attending a drug clinic and saying, "I take drugs (she may occasionally do so) and I would give up if I could get my housing/gas bill/husband/children sorted out". In this she readily recruits a lobby of motivated, skilled articulate helpers to her cause.

Parker and Newcombe and Fazy have shown the high re-attendance rate at clinics where 'user-friendly' attitudes such as needle exchange, clean drugs and no uninvited 'counselling' are available. Johnson eloquently describes the woes of the opposite situation.

* Regime (Widnes)

Referrals to the Drug Dependency Service are via general practitioners and temporarily resident patients will not normally be treated. All addicts are initially offered detoxification as in-patients. A few agree to this, thinking it is what they should say. When a bed is offered there and then, a lame excuse is usually presented. One addict even declined because it was 'getting close to Christmas'. Only about two per hundred thousand catchment population per year take up our offer of detoxification. The vast majority who decline, because they only want drugs, are referred to the Widnes Drug Dependency Clinic, 74 Victoria Road, Widnes. They cease to be called 'patients' and are called 'clients' or even 'customers' instead.

Addicts must attend at 9:30 am sharp for a group lasting one hour, or forfeit that week's script. This is followed by individual assessment of addicts when the monthly script is due for renewal. Any addict can, however, be seen should he wish it. There are currently two hundred regular addicts for a population of 300.000. About twenty each week are reviewed individually between the end of the group at 10:30 am and mid-day. At these sessions the 'bizarre oriental haggle' of Bewley (1970) is fielded by the social worker, probation officer, and nurse as well as the psychiatrist. The addict has to convince this 'jury' if he wants a change in his drugs etc. Examination for intravenous use, urinalyses or naloxone provocations are performed randomly. The modal maintenance dose is 60 mg methadone syrup daily. No-one receives less than 10 mg daily unless on a withdrawal regime. Besides methadone syrup, currently patients receive dipipanone syrup, morphine tablets, cannabis tablets, methadone tablets, methad

one ampoules, heroin ampoules, cocaine syrup, amphetamine ampoules, amphetamine syrup, cocaine ampoules, morphine ampoules and we have recently introduced (1989) reefers of heroin, morphine, methadone, cocaine and amphetamine. Use of in-patient detoxification is less than 5 patients per year, despite there being no waiting list, but the in-patient unit is no longer clogged with poorly motivated patients seeking what drugs they can, while in-patients, and generally undermining those who are motivated. Prescriptions are posted one week in advance to chemists distributed throughout the district, and chemists are provided with ID cards for each addict. Philosophically, unless patients were prepared to come in for detoxification, they were considered as not wanting medical treatment, but rather maintenance at the drug clinic which was deemed a social remedy. They became 'clients' rather than 'patients'. The clinic was thus shifted from the psychiatric unit into the community, next to the probation office and

near to the police station. Excuses for non-attendance must be notified a week in advance and are usually only permitted for court attendances etc., or regular employment. Checkable documentary evidence must be produced.

* History of the Group

The ground rules of the group meeting took at least six months to establish. Every chink of the regime was tested, resulting in some seemingly petty rules e.g. whether it was 9:30 was established by reference to the psychiatrist's watch, bladders had to be emptied before attending; no newspapers would be read; etc., etc. The sanction in all these circumstances was loss of script for one week. One cigarette is permitted at ten o'clock. A phase of grumbling resignation then lasted a month or so. This was characterized by irritated questions and remarks from them, such as, "What do you think this farce achieves?" and "This is so boring" (to this latter our usual answer was, roughly, "Well, we're getting paid for it. If you don't want to use it more constructively, then be bored"). For the past twelve months the group has been firmly in Prochaska's stage 1 (Prochaska 1983) of talking about the pros and cons of drugtaking. Roughly one per week thinks the cons outweigh the pros and starts considering strate

gies for stopping (Prochaska's stage 2). Most of these return to stage 1 by the following week. The group is told that the doctor co-operates with the drug squad and that offences may be reported.

* Characteristics

All the individuals are verbally able. The modal age is 26 years and the ratio of men:women is 3.75:1. Though many are ignorant of most matters related to drug addiction, there are always a few with an intimate knowledge of chemistry, a different few with a similar knowledge of the law, yet others who know well the workings of prisons or the habits of doctors, so that collectively as a group they are very knowledgeable. Currently, six (14%) are in regular employment and need only attend, to be seen individually, once per month.

The doctor, in this clinic, has two distinct roles:

1. In prescribing, the doctor is essentially a state shopkeeper, akin to the managers of the Scandinavian state alcohol monopolies. He is more the instrument of 'social workers' (usually probation officers) managing criminal propensities.

2. In psychotherapy or when a patient agrees to admission, the doctor assumes his traditional medical role.

In the management of drug dependency, both roles are necessary, though seemingly conflicting. The first role is only taken up by doctors because the 1920 Act stipulates a medical monopoly of opium prescribing.

It is estimated by the local police and Home Office coordinators that the Widnes clinic takes £5,000 per 100,000 population per week out of the black market.

Won't the policy increase total drug use in society?

Making drugs available to those who will use regardless, reduces the need to trade to finance their use of drugs. The prolific epidemic quality of prohibition is thus undermined. If drugs are made too readily available, the minimum is passed and use starts rising again, as may be seen today with alcohol.

Whenever a novel substance is presented to a society, whether because it is prohibited or foreign, phases of use are seen that may be described as experimental, recreational and dependent use.

If a six year old is given a tube of Smarties and told to eke them out until the following week, they are nevertheless likely to be consumed within the hour and, if he is a sociable lad, they will be shared with his mates - 'pushed'! A not dissimilar phenomenon was seen when the Red Indians first came across alcohol. Colleagues of mine from the Indian sub-continent remark "The trouble with you English is that you do not know how to use good opium properly, you go and get stoned", it is noted with derision. We have actually, most of us, gone through this phase with England's social drug:alcohol. During the experimental' teen we experimented, and got drunk. Now matured into sensible, socialized, recreational use of our drug, we seldom get drunk. But if alcohol (or tobacco or coffee) were prohibited, who would continue a recreation that may end in prosecution? So all the English ever see of opium use is the first and third phases: the equivalent in alcohol use of immature teenage drunkenness and the sad

derelicts of skid-row. Now the reasons that lead to the first phase of experimentation are magnified if the substance is also prohibited, providing an aura of rebellion on top of curiosity. And teenage years are years of rebellion, so drug use invites adoption as a totem of sophistication and rebellion against parents and establishment. Conversely, if a drug is available, as through the Norwegian state alcohol monopoly, with neither advertisement promoting nor prohibition making it alluring to the immature, then a minimum use in society is achieved: heroin use becomes boring and its use is given up rather than continued.

Not long ago a Glasgow shop-keeper was prosecuted, quite rightly, for selling glue sniffing 'kits' to children. At the time, however, someone had the foresight to dissuade the government from a prohibition of glues. It is notable that since then there has not been the epidemic rise in recreational use of glue as there has been of cannabis and opium derivatives. True, the sad teenager whose parents are separating, or who is being bullied at school will be detected sniffing glue, rather like the paracetomol parasuicide. There will always be such distress signals using what harmful means are to hand. Why has a glue epidemic not continued? Recently when taking a routine history of substance abuse from a Bootle youth, I asked him about solvent abuse. He eyed me defiantly and said, "Ee docta, tha's divvy gear", which translated from the Scouse means roughly, "I wouldn't be seen dead using such childish stuff". This attitude to glue, despite its availability, is precisely what England achieved with the Phar

macy Acts of the nineteenth century and the Rolleston Committee (which later made the mistake, not foreseeable at the time, of placing the monopoly of opium for non-medical use in the hands of doctors). We achieved the same attitude to opium, cocaine and their analogues that the Bootle youth had to glue: available to those who will use it, but rather a pathetic thing to do, hobbling around on a chemical walking stick. This eventually yielded 500 addicts in 50 million or 0.001 of 1%. It is milleniaristic to suppose the population between the wars was 'special' or that the post-war youth culture is unique. The most obvious variable was controlled availability of opium until 1960 then the prohibition of opium and a return to freely available, heavily promoted alcohol. The rises and falls in opium and alcohol abuse have parallelled these changes in fiscal and legal policy as surely as heating water makes steam and cooling it makes ice. Indeed, the probability of the null-hypothesis, that the quadratic rel

ationship between supply (availability) and consumption (demand) arose by chance is vanishingly small.

The Dutch and English viewed opium as a private vice, but once air-travel made all societies of the world accessible to each other, prohibition or controlled availability would have to be imposed world-wide, otherwise gangsters from prohibition countries, like currency speculators chasing the best exchange rate, flood into the more tolerant societies. America being most powerful post-war, and in the grip of Anslinger's policies, the world was pushed down the prohibition path, despite the recent lesson of the alcohol prohibition.

If you contrived to do so, it would be difficult to imagine a more unhealthy, more dangerous, more criminalizing, more socially destructive, more expensive, more efficient way of making heroin available than we do now under prohibition. The United States spent seven thousand million dollars in the year 1983/84 enforcing the most rigorous prohibition that country has seen, including a little navy in the Gulf of Mexico. What has been the result? Mr Mellor reported in 1985 that for its enormous outlay, the US was reaping a return of 5,000 new users every day. This should not be a surprise. US domestic heroin consumption has risen every year since 1923 when the prohibition was applied. Illicit alcohol consumption in Chicago at the height of the prohibition was 600% up on the level when prohibition began. As Willis (1973) has said: Repressive anti-drug legislation in the United States has contributed to one of the major social disasters of that country's development... Such a situation as has developed in

the States should be avoided in other countries at all costs".

Two questions immediately arise: "Why does prohibition fail?", indeed not only fail but is counterproductive; and: "Why is the policy of prohibition pursued in the face of such overwhelming evidence against it?". There has always been a demand for intoxicants throughout history to thole the vicissitudes of life, and no society is without its social drug. Either that, or there is a harsh, fanatically imposed, psychological opium such as Christianity in Guatemala, Mohammedanism in Iran or Marxism in Ethiopia. In a free society, reducing the supply of a commodity with a continued demand leads to a rise in price. The more rigorously this is pursued, the higher the price is inflated until smuggling and black markets flourish. A phenomenon of 'natural selection of gangsters' occurs with the cleverest, richest, most ruthless and most violent gangsters surviving until little wars are waged with vicious armies, and vast sums of money are 'laundered' efficiently through obscure banks. I call this mechanism the D

arwinian effect of prohibition. This occurs whatever the means of repression. For example, the legislation to seize the assets of drug dealers naturally selects those adept at laundering money and eliminates their competition for them. The only way to get out of this is to get rid of the conditions that give rise to it and end prohibition as the Americans did on alcohol. This does not mean commercially promote opium on every media channel for that would only yield a problem many times greater than the alcohol problem. Controlled availability, such as rationing produces controlled use. Prohibition or promotion produces uncontrolled use. Currently we have the former with drugs and the latter with alcohol, and society suffers at both these extremes.

A second mechanism, 'Wheeling and dealing' accounts for the prolific epidemic effect of prohibition. Black marketeering keeps the prices as high as the market can sustain. Youth, on the dole, spending an average of £100 a day on a typical 1 gram habit, have to buy 5 grams and find four new people to sell four of these five grams to at a higher price and 'cut' (adulterated) to keep weight. Each one who buys has, in turn, to do the same: so a gigantic pyramid-selling effect operates. Prohibitions are thus inherently epidemic and promote the consumption of the thing prohibited. Each addict then sells to others in order to sustain his own habit. About four fifths of the cash needed is obtained by an addict in this way. The remaining fifth, £20 is stolen or otherwise nefariously obtained. But since a 'fence' (receiver of stolen goods) will only give the addict one fifth of the real price of the goods stolen, the addict has to steal £100 worth to obtain £20 cash. In other words, he has to steal the whole

daily cost of his habit in addition to wheeling and dealing. The daily cost comes from your house, my car, city center shops... no wonder insurance premiums are rising. Conservatively there are fifty thousand addicts in England, so they're stealing about five million pounds a day or one and a half thousand million pounds a year. This swings the enforcement agencies into action with more prohibition, higher black market prices, more wheeling and dealing, and the merry-go-round goes on. The logic of these arguments is cogent and the evidence to support them is even more compelling. So why continue such policies?

Havelock Ellis wrote at the turn of the century on his visit to America of the zeal of the Christian missionaries during the 19th century religious reaction against the secular revolutions of 1776 and 1789. It has given America the 'Bible Belt' and its coin 'In God We Trust'. In an obscure southwestern state he happened across some upset missionaries who, aware of their salesman-like success, had come up against some Amerindians who ate cacti as part of their sacrament much as the Christians use wine. The hallucinogen in the cacti, which the Indians interpreted as putting them in communion with their God, rendered them, said the distraught missionaries, "Resistant to all our moral suasions". The missionaries had recourse to the state legislature and cactus eating was forbidden. Between the turn of the century and the First World War these laws were generalized to all states of the Union and to all substances, including alcohol. The Americans adopted prohibition in response to a strong religious lobby fo

r whom all intoxicants were direct competitors for the control over the minds of men. It is thus not surprising that a strong moral stricture has applied to drugtaking. In response to this, the politicians have retreated behind more and more prohibitionist measures. They have eventually painted themselves into a corner where the increasing expense of a costly prohibitionist policy and consequent ruinous crime wave are compelling re-appraisal: but the image they have painted and encouraged in the media renders following a sensible route politically suicidal. Meetings with the Home Office are thus something out of 'Yes Minister' with Sir Humphrey knowing full well the force of the argument and the evidence, but also knowing how unpalatable the solution would be to Jim Hacker.

England had the remarkable 'British System' from 1920 - 1960 which was essentially controlled availability, i.e. a state rationing system, and we had an insignificant drug or alcohol problem compared with now or the 19th century. So why was it abandoned? The sixties also saw the advent of accessible trans-Atlantic travel. A prohibitionist society came into contact with the British system, and unscrupulous American refugees sought to exploit it. The same phenomenon was seen when German heroin addicts descended on Holland's 'barge' in Amsterdam and when Spain decriminalized cannabis and the French smugglers travelled south for profits. Britain, Holland and Spain, reasonably feeling they didn't want others' riff-raff, put up the shutters and started down the prohibitionist path with sad consequences we now know so well. Also the managers of the state ration in the British system were doctors, and in the new idealism of the NHS they did not need this monopoly originally taken for venal reasons. They incre

asingly refused to operate the ration saying it was not a medical act. The fact that they had taken on this monopoly of the ration for non-medical reasons in 1920 was conveniently forgotten.

Undoing the harm of prohibition is difficult to do in isolation without incurring the wrath of the remaining prohibitionist societies. The most powerful ideological states seem currently bent on continuing prohibition because individual intoxication threatens the imposition of uniform ideology. The answer, controlled availability, is a happy medium between total prohibition and irresponsible pressured advertising.

Schemes elsewhere are well illustrated by the Dutch and Danes, in the control of cannabis and alcohol respectively. The Dutch moved from prohibition to de-facto decriminalization of cannabis. The Danes reined in and controlled the former free promotion of alcohol and curtailed the outlets of sale.

In each case, controlled availability led to a reduction of consumption. In India, the Sepoys were given an opium ration analogous to the navy's rum ration, to reduce excessive consumption. 'Controlled availability' is thus a rationing exercise. It produces control of inevitable use by making alternate methods uneconomic. Freely promoted alcohol, now causing so much damage to society, would not be worth risking if laws strictly curtailing advertising were enacted. Conversely, black marketeering is not economical if the ration is sufficient to undercut the costs and risks of law-breaking. Society thus avoids the consequences of 'market saturation' practised by the brewers and of 'Wheeling and dealing' practised by the gang. Both these are a loss of control (by the state) over intoxicant use. Controlled availability doesn't stop drug use (nothing will) but controls it. Exactly where to pitch the degree of control is a matter of empirical tinkering with the legal and marketing mechanisms, but there is

no shortage of models. Dutch consumption of cannabis has decreased since the relaxing of the prohibition by 33% over 12 months in a population of 15 million. During the Reagan administration (US), $21.5 billion has been spent on drug enforcement. This has yielded an annual consumption (of cocaine alone) of 210 tonnes or 20 mgs cocaine a week for every man, woman and child in the entire Union. England has achieved similar wonders pursuing prohibition. Having spent £45 million a year on enforcement alone, (excluding the costs of legal process, prison or any social and health costs) heroin and cocaine became more readily available and cheaper in price.

If the state is to control the supply of any commodity such as drugs, it must actually have a supply or it abdicates it to the criminals who are very efficient, ruthless marketers. The control of the supply must not be too lax but neither must it be too tight.

Why not give jewels to thieves?

In the Socratic dialogues and more recently in Rousseau, it is argued that a society arises as the consequence of a contract between the individuals and the state. Individuals agree to obey the laws of the state and in exchange the state undertakes by means of enforcing laws to guarantee maximum freedom. But if I were free, for example, to shoot you and you to shoot me, one of us may end up with not very much freedom. So paradoxically, introducing some restrictions, laws, leads to greater average individual freedom. Insufficient laws yield anarchy, excessive laws, tyranny. In general, an optimum is reached when any act that impinges upon another's liberties is forbidden and any act that doesn't even if it harms oneself, is permitted. If a citizen is to be responsible it means he is arbiter over acts that damage himself (the law will reinforce his responsibility not to damage others) otherwise he is not a responsible citizen. The society of optimum liberty thus leaves self-denial or self-indulgence to th

e responsible citizen.

This restraint, from intruding into another's personal life (and imposing one's own yardstick on those activities of another that harm no-one but himself) is a relatively recent development. It is little realized, for example, that a Alabama statute of 1809 forbade love between a man and wife in any but the 'missionary' position (i.e. woman supine beneath, man prone above). Aside from the absurdity of enforcing such a law, there has been a steady retreat from such intrusion under the principle of 'consenting adults in private' so that homosexuality, prostitution etc., and even the ultimate in self-destruction, suicide, have been decriminalized. Dutch observers see the whole drug problem as arising from this intrusion of the public law into private vice.

If you wish to waste your life 'stoned' on opium, drunk on alcohol, or whatever in the privacy of your own home, so be it. But if you step outside and are effectively drunk and disorderly and a threat to another's liberties (or certainly if you drive a car while under the influence) the drugtaker shall feel heavily the full force of the law. On this yardstick, one should not give a thief jewels: a thief has no right to restrict the liberty of another to wear jewellery.

We already give alcohol to alcoholics, by sale through pubs. This should be controlled. Prohibition, however, would be retrograde: indeed if you were an alcoholic in the Chicago of the thirties, and had just stolen your grandmother's purse to buy a tot of filthy, adulterated meths, at an exorbitant price, from Mr Capone, I would have a clear conscience in prescribing you a dram of best Scotch whisky. Similarly, it is claimed by some prostitutes organizations that given the opportunity to organize their business properly, they could safely ameliorate the lot of inadequate and incompetent men, reduce the rate of sexual crimes and possibly 'treat' and rehabilitate or re-educate some offenders. No matter how absurd some of these ideas may appear, an empirical approach will do no harm and may yield great benefit.

Empirically the prescribing of drugs, in a controlled fashion to drug users, worked in England between 1870 and 1960. Prohibition in the United States and England since 1960 has coincided with an alarming rise in drug use, the rise being greater as more money is expended enforcing the prohibition.

Don't all drugs leak to the black market anyway?

Where was the black market in 1950? Where is the alcohol black market now? Greater legal supply gets rid of the circumstances that give rise to black markets. Surprisingly, and paradoxically, slight increase in supply (i.e. rationing) to those who will use regardless, generally results in a lowering of total availability and hence consumption in society as a whole. Of course, making any control too lax would simply return us to Hogarth's days. This is now, sadly, the case with alcohol.

In the drug dependency clinics in the Mersey Region, to police 'leakage' close liaison is kept with the local drug squad. The clinic staffs reserve the right to report any criminal activities to the police. In practice much borrowing and lending of drugs between addicts at the clinic is ignored, but sale to outsiders is scrupulously forbidden. Clinic staff ask the drug squad to observe patients they think are deceiving staff. The system appears to work well and police and staff are confident of it. Patients have been prosecuted as a result of such trading of information, but in thousands of patients, there have been fewer than a dozen such cases.

Marjot has estimated (from patients' average consumption and notification figures) a minimum consumption of 5000 kg illicit heroin per year. Prescribed heroin or methadone totals 50 kg per year, so even if it all leaked to the black market, a far greater problem remains with illicit heroin.

Nevertheless, in Liverpool, we asked the drug squad to examine all arrested drugtakers for evidence of clinic-prescribed drugs. Hundreds are detained weekly. The survey continued for six months, at the end of which Superintendent Deary was able to report not a single case of an addict being found in possession of clinic drugs to which he was not authorized (Minute 153,LDDC,10/6/87). No doubt some leaks, but it is not a great amount. A small fraction of 50 kg in 5000 kg is a legal drop in the ocean of illicit heroin.

11* No

12* No

13*

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G. V. Stimson & E. Oppenheimer, Heroin Addiction, Tavistock, London, 1982.

W. Schneider, Zur Frage von Ausstiegschanzen und Selbstheilung bei Opiatabhaengigkeit, Sucht-gefahren, 34:472-490, 1988.

J. H. P. Willis, Prescription of Controlled Drugs to Addicts, Br. Med. Jnl, 287:500, 1983.

H. Parker & R. Newcombe, Heroin Use and Acquisitive Crime in an English Community, Br J Sociol, 1987, 38:331-350.

C. Fazey, The Evaluation of Liverpool Drug Dependency, Clinic Mersey RHA, 1988.

B. Johnston, Scottish Office rules behind needle scheme closure, Druglink, 1983, 3:1:17.

T. H. Bewley, An Introduction to Drug Dependence, Br J Hosp Med, August, pp. 150- 161, 1970.

J. O. Prochaska, Toward a Comprehensive Model of Change, J. Con Clin Psych, 51:390-395, 1983.

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