Consultant Psychiatrist - with acknowledgements to H.B. Spear and J.H. Willis

ABSTRACT: The author illustrates the reasons why the state should be involved in supplying drugs while addressing the questions and doubts raised by those who advocate the need for drug prohibition. Legalization neither prevents the drug addict from abstaining nor entails necessarily an increase in overall drug use. The medical prescription of drugs is not seen as a hindrance to addict rehabilitation programs. Prohibitionism infringes upon the freedom of individuals.

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 theives?

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

Q1 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 for such addicts is not detoxification or prescribed drugs from a clinic: it is drugs from the black market or drugs from a clinic.

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 shared with his fellows if he is a sociable lad. A not dissimilar phenomenon was seen when the Red Indians first came across alcohol. Colleagues of mine from the Indian subcontinent remark, "The trouble with you English is 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 'teens 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 ma

y 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, alcoholic 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 the establishment. Conversely, if a drug is available, as though the Swedish state alcohol monopoly, with neither advertisement promotion nor prohibition making it alluring to the immature, then a minimum of use in society is achieved: heroin use becomes boring and its use is given up rather than continued.

Not long ago a Glascow 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 the 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 paracetamol 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 divvi gear", which translated from the Scouse means roughly "I wouldn't been seen dead using such childish stuff".

This attitude to glue, despite its availability, is precisely what England achieved with the Pharmacy acts of the Nineteenth century and the Rolleston Committee (which later made the mistake, not forseeable 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 the analogues that the Bootle youth had to glue: available to for 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 o0.001 of 1%. It is millenaristic 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 paralleled these changes in fiscal and legal policy as surely as heating water makes steam

and cooling it makes ice.

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.

Vaillant (1984) and Griffith Edwards (1967) 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. Maintenance is simplistically misperceived as "treatment", but in fact merely continues addiction (but there is no evidence showing it prolongs addiction). This does not mean that during the years of maintenance one should not continue to persuade patients to try and give up their drup use. The fault is not with m

aintenance, misperception 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.

Q2 Is it not better to counsel someone than to give him drugs?

Yes, if the drug-taker 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, drug-takers view their drug consumption exactly as you or I view our beer (or even coffee) drinking. For the vast majority of drug-users, univited 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 fron 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.

Before the clamour is raised by counselling agencies of their legions 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 use 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 Fazey have shown the high re-attendance rate at clinics where "user-friendly" attitudes such as needle exchange, clean drugs and no univited "counselling" are available. Johnson eloquently describes the woes of the opposite situation.

Q3 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.

Schemes elsewhere are well illustrated by the Dutch and the Danes, in the control of cannabis and alcohol respectiviely. The Dutch moved from prohibition to decriminalization of cannabis (i.e. no longer an offence to possess, but still an offence to supply). 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 strictily 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 satu

ration" practised by the brewers and of "wheeling and dealing" practised by the gang. Both these are 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 for 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 20mgs 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 costs of legal process, prison or any social and health costs) heroin and cocaine became more readily available and cheaper in p

rice.

Q4 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 to greater average individual freedom. Insufficient laws yield anarchy, excessice 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 an 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 opium liberty thus leaves self-denial or self-indulgence

to the 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 realised, for example, that an Alabama statute of 1809 forbade love between 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 drive a car w

hile under the influence) the drug-taker 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 Scottish whisky. Similarly it is claimed by some prostitutes organisations that given the opportunity to organise their business properly, they could safely ameliorate the lot of inadeguate and incompetent men, reduce the rate of sexual crimes and possibily "treat" and rehabilitate or re-educate some offenders. No matter how absurd some of these ideas may appear, an empricial 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 in England since 1960 has coincided wit

h an alarming rise in drug-use, the rise being greater as more money is expended enforcing the prohibition.

Q5 Don't all the drugs leak to the black market anyway?

Where was the black market in 1950? Where is the alcohol black market now? Greater availability gets rid of the circumstances that give rise to black markets. Surprisingly, and paradoxically, slight increase in availability (rationing) to those who will use regardless, generally results in a lowering of total 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, as described in the paper by Best et al. The clinic staffs reserve the right to report any criminal activity 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 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 5000kg illicit heroin per year. Prescribed heroin or methadone totals 50kg per year, so even if it all leaked out to the black market a far greater problem remains with illicite heroin.

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