British Narcotic Treatment Clinics After Five Years: Some Impressions About TheirEffectivenessAuthor(s): REGINALD G. SMARTSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 65, No.5 (SEPTEMBER/OCTOBER 1974), pp. 345-348Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41985930 .

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British Narcotic Treatment Clinics After Five Years:

Some Impressions About Their Effectiveness

REGINALD G. SMART1

A LONG-STANDING custom in North America is to look to Britain for

innovative solutions to drug problems, often without actually adopting those solutions. The prescription of maintenan- ce doses of heroin is probably the best known British practice. However, this practice has been in decline in the past five years largely as a result of the esta- blishment of special clinics for narcotic addicts. The clinics were established in 1968 and 1969 to replace the older system of heroin maintenance by indi- vidual physicians. They represent a departure from the past for Britain and from practices in other parts of the world. Because they have been credited with actually stopping the increase in new cases of addiction, they are worth examining. (Bewley, 1; Lewis, 2). Some journalistic reports attribute very striking positive effects to the clinics and allege that they are the sole reason for the recent decrease in the addiction problem. Recently, the author spent several months at the Addiction Research Unit, Institute of Psychiatry in London. During that time I visited a number of clinics, hospitals and drop-in-centres, as well as the Home Office Drug Section and Department of Health and Social Ser- vices. These experiences, together with a reading of the research literature on clinic populations and treatment are used here in an assessment of (i) the structure and effectiveness of such clinics and (ii) their possible value as a model for Canada. Heroin addiction in Canada is a large and unsolved problem both from the point of

1. Addiction Research Foundation, 33 Russell Street, Toronto.

view of prevention and treatment and therefore every innovation ought to be considered.

Historical Background for Development of Narcotics Treatment Clinics

Opium eating and smoking was tradi- tionally tolerated in Britain among both literary and political figures. There are reports of opium use by Lord Clive of India and William Wilberforce the politi- cian and slavery abolitionist. Alethea Hay ter (3) has pointed out that all English romantic poets (except Wordsworth) took some form of narcotic at least occasionally. Also, the frequent use of oral opium preparations by middle class persons in the early part of this century has been pointed out by Spear (4). However, the dangers of opiate dependen- cy were officially recognized soon after in Britain, and the Dangerous Drugs Act of 1920 provided controls on the manu- facture and sale of opiates. Other acts in the 1920's extended these controls so that possession of drugs was restricted to persons licenced by the Home Office and to persons prescribed them by physicians. At one point in the 1920's it appeared in Britain as if narcotic addiction would be defined as a legal and enforcement pro- blem under Home Office jurisdiction (see Edwards (5) for a review of this period). However, in 1926 the Rolleston Com- mittee (composed entirely of physicians) published a report which defined addic- tion as an illness, suitable for treat- ment. This Committee recommended that heroin and morphine be prescribed where withdrawal would fail or where an addict could take a "non-progressive" quantity and maintain social stability.

During the periods up to 1950 the numbers of known addicts in Britain were very small but there was no compulsion for doctors to notify or register addicts. The numbers known declined from 616 in 1936 to only 199 in 1947; however by the late fifties the numbers had increased greatly (442 in 1958). This caused sufficient concern for a new Committee to be set up to consider drug use pro- blems again. The Brain Committee issued a report in 1961 which concluded that the problem was still small and well managed and that trafficking was negli- gible.

Prior to the 1950's almost all addicts were over the age of 50 and were addict- ed to morphine, usually as a result of medical treatment. A further number were "professionals" e.g. doctors, nurses, dentists, pharmacists who frequently handled drugs in their work. The criminal narcotic addict, so common in North America, was more rare, and probably not more than 15% were of this type. However, during the 1960's addicts coming to notice were very much young- er and by 1971 about 75% were under 30 and 54% under 25. More addicts were also seen to be users of illicit drugs and to engage in criminal activities. The propor- tions of medical and professional addicts among new cases declined greatly so that by 1968 only 20% were of this type. These events occasioned the recall of the Brain Committee who issued a second and very different report in 1965.

The Brain Committee found the situa- tion in the mid-1960's much changed from that of the late 1950's. They attri- buted the increase in heroin addiction to overprescribing by about six doctors.

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Some of the doses being given were phenomenal and in some cases as high as five times as much as is now prescribed. This situation allowed a supply of cheap, pure heroin for the illicit market and created the possibility that the life of the maintained addict would appear safe and trouble-free. However, the Brain Committee wished to change both these circumstances by restricting heroin prescriptions to a few physicians and by emphasizing rehabilitation rather than mere maintenance. In brief, their recommendations were that:

1) notification of addicts by physicians to a central registry be made com- pulsory; until that time the Home Office registry had been compiled out of pharmacist records, criminal records and voluntary notifications by physi- cians.

2) treatment centres for opiate addicts should be established in psychiatric hospitals or psychiatric wards of general hospitals.

3) physicians should be especially licen- ced to prescribe opiates and cocaine.

4) it should be possible to compulsorily detain addicts for brief periods during their treatment.

5) a standing committee should be es- tablished to continually review the problem of addiction in Britain. These recommendations were accepted

by the British Government except that special compulsory treatment powers were not provided. Specialized clinics were established in 1968 and 1969 along the lines suggested and with the purpose of doing rehabilitation rather than main- tenance. Also, only physicians work- ing in hospitals or clinics were licenced to prescribe heroin, thus removing much of the treatment of addiction from general practice. Addicts were to be notified to the Home Office within 7 days of being seen by a physician.

The British Heroin Addiction Clinics represent a totally novel approach, based as they are on a compulsory notification system. No other country has ever tried such a method of management. Original- ly, the plan was to have clinics only in London and in 1967 and 1968 14 were established. However, others in cities out- side of London have been added (e.g.

346 Canadian Journal of Public Health

Oxford, Portsmouth, Cambridge, etc.) so that at present there are 25 operating. The size of clinics varies considerably but all contain at least one physician, a con- sultant psychiatrist and certain adjunctive staff such as social workers, nurses or psychologists. All are outpatient facilities but with access to in-patient beds for medical or withdrawal treatment.

There are no special laws or govern- ment departments regulating what is done in the clinics or what treatment approach is taken. Consequently, each director (usually a psychiatrist) has considerable freedom in the rehabilitative program offered. This has meant that some clinics (Crawley, 6) have a policy of giving small but decreasing amounts of heroin. Others (e.g. Oppenheim et al, 7) attempt to have all patients withdraw rapidly using only methadone. Others (e.g. Chappie and Gray, 8) may use methadone or heroin or both depending upon clinical judgement as to relative efficacy with individual patients. Probably most clinics employ a method in which clinical judgement, patient history and the like dictate what drug and how much of it is prescribed for any single patient.

Although there is no homogeneous treatment approach a number of general principles are adhered to, chiefly because of agreements made at regular meetings of the clinic directors. One of these principles is that high dose heroin main- tenance of the pre 1968 era would not be done. Treatment efforts were to be directed towards getting addicts to accept decreasing doses. The eventual aim is to have them withdraw altogether, once social and psychological stability are established. Another principle seems to be that many persons on heroin could more easily be maintained on methadone. Since 1969 the number of addicts on heroin alone has decreased from 148 to 111 in 1971 and the number on metha- done has increased from 705 to 916. Even more striking is that between 1969 and 1971 the number of grams of heroin prescribed dropped by nearly 50% while the total amount of methadone pres- cribed increased by about 40%. It is also the case that methadone is not typically given in high dose oral "blockage" doses as in North America (e.g. 100-120 mg).

However, smaller intravenous doses of 30 to 80 mg. are typically employed.

A further principle used by clinics helps to reduce the amounts of prescribed drug available for illicit sale. This prin- ciple involves the handling of prescrip- tions, wherein individual addicts do not actually obtain the scripts themselves. Usually they are sent to a pharmacy near the addicts' home or work and a single day or a few days' supply is picked up there. This means, of course, that addicts typically have very small amounts of drugs in their possession.

When addicts first approach clinics the decision has to be made as to whether the person is so addicted as to require clinic opiates. Exactly how this decision is made varies from one clinic to another. However, almost all require one or more positive urinalyses as well as drug use history and medical examination before prescribing opiates. A check is also made to see whether the addict is known to the Home Office and whether he is receiving drugs at some other clinic. Sometimes if no drugs are to be prescribed the Home Office check is not made.

Positive Aspects of Effectiveness There can be little doubt that the

clinics have had a limited success in cer- tain areas of activity. Hawks (9) has outlined the difficulties in assessing the effectiveness of the clinic approach and has concluded that much of the evidence required for a real evaluation is not avail- able. He has also pointed out that effect- iveness can be judged on a number of criteria or combinations of criteria. It has been claimed by Bewley (1) that the success of the clinics is indicated by (i) a decrease in new notifications (ii) a re- duction in the amounts of heroin pres- cribed and an increase in methadone prescribing (iii) a decrease in the numbers of addicted prisoners in Brixton prison. Of these, it would seem that only the decrease in heroin prescribing could be unambiguously attributed to the opera- tion of the clinics. The other changes could have a variety of reasons such as (i) a decrease in the addict population for other reasons or (ii) less tendency of addicts to come to official notice.

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It is worth looking especially at the reported change in new notifications, since this is one of the most often quoted indirect effects of the clinic establish- ment. Since the notification of addicts is "compulsory" it is often assumed that the system must reflect the real changes in the size of the addict community. However, just how good the notification system is has never been systematically investigated. The law requires physicians to notify persons to the Home Office they "attend" and "consider" or have "reasonable grounds to suspect" may be an addict. None of these terms has been clearly defined and conventions about notification probably vary from place to place. Most clinics notify any persons who are prescribed narcotics and this decision usually depends upon positive urinalyses as well as case history material. However, prison medical officers report about 35% of new notifications; they do not prescribe opiates and typically base their diagnosis of addiction on a case history rather than urinalyses. How well their definition of "addiction" would compare with that of persons seeking treatment for addiction is uncertain.

Some comparisons have been made of notification records with outside criteria of addiction. Gardner (10) found that only 24 of 138 addict deaths were not notified prior to death. However, a large scale census by Arroyave et al (11) in Oxford found that only 30% of "certain" cases and none of the "very probable, probable or suspect" ones were notified. Blumberg et al (12) also found that half the addicts seen at clinics reported that they had friends who were not noti- fied. Perhaps notification comes very late in the addict's career. This means that the number of new addicts may change considerably before being detected by the notification system.

Even if all of one's doubts about the system are set aside the possible effects of the clinics on new notifications may be small. It is often stated (13) that "since

early 1969 the increase in the number of new cases coming to notice has slowed down". However, this is based on the large number of cases in 1968 and 1969 (n = 1476 and 1030) - years which may have been affected by the compulsory

September/October 1974

aspects of notification instituted in 1968. Since 1970 the numbers of new cases are relatively stable with 711 in 1970, 111 in 1971 and 711 in 1972 i.e. somewhat higher than before compulsory notifica- tion in 1967 (664 cases). At present, the actual effects of clinic establishment on new notifications cannot be known with any certainty. That the effect was large or long lasting seems doubtful, but perhaps five years is not a sufficiently long time in which to see their effects.

There are other positive aspects of the clinic establishment sometimes over- looked. They have allowed the institution of consistent procedures and policies in the treatment of addicts which in the long run can be evaluated for their effect- iveness. Also, they have helped to focus interest and concern on the rehabilita- tion, as opposed to the maintenance, of addicts. Considering that there are fewer than 3,000 active known addicts in Britain the 25 clinics represent a rather high level of service, probably higher than that for alcoholics. Because clinics are usually sited in teaching hospitals opportunities for training medical and other personnel in addiction are made available, more extensively than they could be with treatment done by general practitioners. A further important role for the clinics is that of suppliers of data about heroin addiction and how it is changing. All generate information on patient characteristics and treatment status to a central data bank which is later used for studies of various addict characteristics, follow-ups of treated cases, and of addict mortality and morbidity.

Negative Aspects of Clinic Establishment Several aspects of drug use in Britain

reflect adversely on the clinic policies. Several studies have failed to show that either illicit drug use or criminality disappears when addicts are maintained on clinic opiates (Stimson and Ogborne, 14). It appears that addicts on main- tenance drugs do not decrease their use of opiates, they merely supplement clinic doses from illegal sources (Blumberg et al, 12; Hawks, 9). One of the pro- blems is that clinic doses are typically well below the addicts' estimated daily

requirements, since large "blockage" types of dose are not employed. There is nothing available which shows the system to actually decrease drug use on the part of addicts. We know only that their prescriptions are for smaller amounts than before the clinic establishment.

A variety of studies have shown that clinics have difficulty attracting and holding patients. Blumberg et al (12) showed that 50% of clinic patients had been regularly using opiates for 2 years prior to coming. Also, clinic drop-out rates are rather high. For example, Boyd et al (15) showed a drop-out rate of about 50% over a period of about 2 years. Oppenheim et al (7) found that 40% came for only one interview in a program oriented primarily towards abstinence after a period of short methadone assisted withdrawal. No follow-up is made of the one third of persons who come to a clinic on only one occasion and do not return.

One disconcerting finding for British authorities was that illicit heroin sales appeared to increase after the clinics were established. It was hoped in some quarters that the clinics would reduce the size of the illicit market, by decreasing the amounts of legal heroin available for it. This has happened but illicit or "Chinese" heroin appears to be even more available. Substantial increases in convictions for heroin possession and trafficking have occurred since 1968. In fact, the increase in 1971 over 1970 was 121%; figures for 1972 also show sub- stantial increases. Increases in convictions for other drug offences e.g. L.S.D., amphetamines, cannabis etc. have also occurred but they are less than for heroin. Clearly, the effect of the clinics has not been to control illicit heroin sale but it could be argued that the number of heroin convictions is so small (580 in 1971 for a population of about 50 million) as to be negligible.

Clinics have typically seen their role as one of treating opiate dependency chiefly by prescribing drugs for narcotics addicts; their role was not one of treating all aspects of drug dependency. This means that persons who are (i) multi-drug users and perhaps trifling with narcotics or (ii) addicted to amphetamines or barbiturates are typically not taken into treatment at

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these clinics. Several authors have pointed out the trend toward multi-drug use in Britain (Hawks et al, 9, Mitcheson et al, 16). Ritson et al (17) have claim- ed that this is the established pattern in the East Midlands (and perhaps else- where) and that opiate addiction is rare. Blumberg et al (12) have shown that persons who do not get an opiate script typically do not stay in contact with narcotics clinics and hence receive little help from them. Clearly, there is a large number of multi-drug users whose addict- ion does not fit the criteria for clinic attendance, but whose dependency problems are perhaps no less real. The extent of this problem and the best methods of dealing with it have not been extensively explored partly because of the concern with providing services for opiate addicts.

Do the British Heroin Clinics Represent a Model for Canada?

The author has argued elsewhere (Smart, 18) that the British and Cana- dian addict populations show some simi- larities but are not identical in charac- teristics such as criminality, social background and drug use. Unfortunately, research on the treatment of opiate addiction in Canada is rarely performed.

Even clinical trials are infrequent and high to medium dose methadone main- tenance seems the most popular therapy, even though there are many misgivings about it. Theoretically, an effective treatment in Britain should work in Canada. Unfortunately there is no eviden- ce that the British clinic system reduced drug use or criminality amongst its patients or in society as a whole.

The first role of clinics would, of course, be to rehabilitate addicts but evidence that they do this especially well is lacking. What seems most desirable about the clinics is the way in which they have achieved certain secondary aims. For example (i) they are established in teaching hospitals and thereby provide opportunities for research and profession- al education. Exactly how well these opportunities are used is uncertain but several clinics have a major and educa- tional role, (ii) A number of consistent policies about dosages, control of pres- criptions, administration, withdrawal as opposed to maintenance etc., have been developed. This is perhaps the major positive effect, (iii) There have been more clinical trials of different approaches to treatment than occurred under the older system of private physician treatment. Many of these trials are uncontrolled and

unsystematic but they provide an import- ant contribution.

In Canada, research on drug addiction is rarely performed: this is especially true of clinical research. Nor are the problems of drug addiction introduced into pro- fessional training. Whether the British style clinics would be worth establishing on the above bases is a moot point. Probably they would be worth intro- ducing in Ontario and British Columbia where the majority of addicts live. In order to give real similarity to the British narcotic clinics it would be necessary to have a compulsory notification and the right to prescribe heroin. Both of these may be some years in the future for Canada, but even with compulsory notifi- cation for those prescribed methadone, many aspects could be adopted. The author (18) has argued elsewhere that the prescribing of heroin has not been demonstrated to have major advantages over methadone. Current evidence suggests that the adoption of British style clinics would have many values but should not be expected to drastically reduce the numbers of addicts unless research were to establish a new treat- ment.

REFERENCES 1. Bewley, T.H. Evaluation of the effective-

ness of prescribing clinics for narcotic addicts in the United Kingdom (1968-1970). In C. Zarafonetis (ed). Drug Abuse (Proceedings of the International Conference.) New York, Lea and Febiger, 1972.

2. Lewis, E. A heroin maintenance program in the United States. J. AM A. 223, 539-46, 1973.

3c H ay ter, A. Opium and the romantic imagination. London, Faber and Faber, 1968.

4. Spear, H.B. The spread of heroin addiction in the United Kingdom. Br J. Addiction 64, 245, 1968.

5. Edwards, G. Drug problems U.K. /U.S.A. Proceedings of Anglo-American Confer- ence on Drug Abuse. London, 1973.

6. Crawley, J.H. A case-note study of 134 out-patient drug addicts over a 17 month period. Br. J. Addiction 66, 209-18, 197 h

7. Oppenheim, G.B., Wright, J.E., Buchanan, J. and Biggs, J. Out-patient treatment of narcotic addiction, who benefits? Br. J. Addiction 68, 3744, 1973.

8. Chappie, P.A. and Gray, E. One year s work at a centre for treatment of addicted patients. Lancet 1, 908-11, 1968.

9. Hawks, D.V. The evaluation ot measures to deal with drug dependence in the United Kingdom. Proceedings of Anglo- American Conference on Drug Abuse. London, 1973.

10. Gardner, R. Deaths in the United King- dom Opiate Users 1965-9. Lancet 2, 650-63, 1970.

11. Arroyave, F., Little, D., Letemendia, F. and D'Alarcon, R. Misuse of heroin and methadone in the city of Oxford. Br. J. Addiction 68, 129-35, 1973.

12. Blum berg, H.H., Cohen, O.S., Dronfield, E., Mondecai, E.A., Roberts, J.C. and Hawks, D.V. British Opiate Users: 1. People approaching London treatment centres. Int. J. Addictions 1973. (In press.)

13. Central Office of Information. The Pre- vention and Treatment of Drug Depend- ence in Britain. London, 1973.

14. Stimson, G.V. and Ogborne, A.C. Survey of addicts prescribed heroin at London clinics. Lancet 1, 1163-6, 1970.

15. Boyd, P., Layland, W.R. and Crickmay, J.R. Treatment and follow-up of adoles- cents addicted to heroin. Br. Med. J. 4, 604-5, 1971.

16. Mitcheson, M.C., Davidson, J., Hawks, D., Hitchin, L. and Malone, S. Sedative abuse by heroin addicts. Lancet 2, 606-7, 1970.

17. Ritson, E.B., Toller, P. and Harding, G. Drug abuse in the East Midlands: a study of 139 patients referred to an addiction unit. Br. J. Addiction 68, 65-72, 1973.

18. Smart, R.G. The probable value of heroin maintenance for Canadian narcotic addicts. Unpublished ms. Addiction Research Foundation, Toronto, 1973.

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