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Dealing with Drug Abuse

A Report to the Ford Foundation

THE DRUG ABUSE SURVEY PROJECT

STAFF PAPER 7

Narcotics Addiction and Control in Great Britain
by Edgar May

Background * The Clinics * Law Enforcement * Research * The Statistics * Results * Personal Observations

After a decade of spiraling narcotics addiction in England, the trend was reversed in 1970.

The British narcotics problem admittedly is minor when compared with that of the United States. England had never counted more than 3,000 narcotics addicts; estimates in the United States range from 150,000 to 250,000. However, while American drug experts warn of a continuously growing number of addicts, Britain's Home Office recently reported a drop of almost 8 per cent, the first since the drug problem became a serious national concern.

The slowdown had already begun in 1969, when the annual increase of addicts was held to a trickle, one year after the government tightened its narcotics policies by limiting the prescribing of heroin to staff physicians of government-run drug clinics. Previously, any general physician was permitted to prescribe heroin. Until the clinic system had been operating for a year, the number of narcotics addicts in England doubled every -sixteen months. The reversal of this trend has been accompanied by a significant drop in new addicts. In 1968, a total of 1,476 previously unknown cases were reported. In 1969, the figure was 1,030, and by 1970 it had dropped to 711.

These encouraging figures, however, concern only a part of the British drug-abuse problem, albeit the toughest and the one over which there is the most public concern. But addicts and abusers of amphetamines and barbiturates are not included in this count. Furthermore, there is a far greater and increasing army of marijuana and hashish users, for which there is no accurate tally.

But, while the latest statistics may give the English drug scene a more optimistic appearance than it deserves, the bizarre anecdotes that have been published in both the English and American press may have colored the past picture with more despair than is justified.

In the twitching kaleidoscope that is Picadilly Circus, the scene is as harsh and distorted as the electric letters that flash their spasmodic messages from high about the throng. The pallid young addicts, staggering out of doorways to panhandle enough for a fix, casting furtive glances at passersby while pills or other drugs are exchanged . . . a jab of a needle in the toilet of the Underground ... a hypodermic protruding between the toes of a grimy, infected foot . . . a spurt of fresh blood on a soiled shirt . . . a young girl collapsing in a doorway after taking a barbiturate injection. It's all there and more.

These scenes may have become part of the tourist attractions of London's Times Square, but they don't reflect accurately the addiction problem in England. Although it is risky to offer findings in the complex and often-disputed field of drug addiction, some basic trends are clear:

Heroin addiction is no longer the major "hard" drug problem in England. The rising tide of new heroin addicts has been stopped and, in fact, has significantly receded. The quantity of heroin prescribed in government clinics continues to decline. Methadone is the most frequently used drug in England today and is replacing heroin. But the drop in heroin is not fully matched by the rise in methadone. New addicts tend to be addicted to methadone rather than heroin, but the number of newcomers addicted to anything is smaller than in previous years.

Methadone maintenance generally is not practiced in England as it is in the United States, in that far more English addicts inject methadone than take it orally.

British hard-drug users often are polyaddicts, injecting a variety of drugs, obtained both legally and illegally. The most recent craze is the injection of barbiturates, a particularly damaging habit that has raised the concerns of all those working in the British drug field.

Although the backbone of the English drug program is the government-sponsored clinic, where addicts obtain free drugs, the phrase "British clinic system" is misleading. There is very little system to the clinics beyond the fact that they all prescribe narcotics. Clinics vary widely in services offered, treatment approach, staff, and facilities. Nevertheless, the clinics are credited widely with curbing the heroin problem, while the degree of their contribution to the problem of methadone addiction is debated. Furthermore, clinics are considered to have had an impact on improving the total hard-drug picture, but evidence for this generally is subjective rather than objective and statistical.

Although there is some black-market activity in all drugs, it appears to be on neither a major nor a very professional scale. No one interviewed claimed that there was a vast, hidden opiate-addict population supplying itself from the black market.

No one in England saw any correlation between drug addiction and a rise in crime.

Finally, the commonly held view in the United States that heroin addiction automatically turns the user into a completely antisocial, unproductive misfit is simply not shared in England. Many English addicts hold regular jobs. Estimates of employment of all known addicts range from 40 to 50 per cent.

But perhaps to find the most glaring difference between the two countries, you have to go back to the hurlyburly of Picadilly Circus. There, in a locked cabinet on a medicine shelf at Boots the Chemist, which attracts a disproportionate number of addicts because it is open all night, you can find heroin tablets in small bottles. A printed-in-red retail price list says:

Heroin 100 tablets 18 S.

At the 1970 rate of exchange, this is $2.16. On New York's streets, the retail price for the same amount of heroin can run as high as $1,000.

BACKGROUND

Unlike the United States, England has consistently treated drug addiction as a medical problem. Even while moving toward more restrictive policies in the drug-abuse field, the nation has never wavered from this medical point of view. "The addict should be regarded as a sick person, he should be treated as such and not as a criminal, provided that he does not resort to criminal acts,"' said the Brain Committee, which formulated the first significant changes in the country's drug laws seven years ago.

Hard-drug abuse in England, also unlike the United States, became a problem only in the last ten years or so, as Table 7-1 clearly indicates. In 1954, the first year nationwide heroin statistics were available, there were only 54 identified heroin addicts. The majority of the 335 known drug addicts that year, a total of 179, were addicted to morphine, and most were women. Also, the majority of these addicts had become addicted after receiving a narcotic to relieve pain related to a lengthy illness. Among the few nontherapeutic addicts, a high proportion were doctors and nurses 'who had experimented with narcotics and subsequently became hooked.

Today, of course, the numbers, the reasons for addiction, and the average addict age (see Table 7-2) have all changed. For example, only 2 per cent of the reported addicts in 1968 were classified as therapeutic. Among heroin addicts that year, 32 per cent were under twenty years of age. Men outnumbered women by more than 3 to 1.

TABLE 7-1

NUMBER OF KNOWN ADDICTS, SEX, AND DRUGS USED

Number Sex Drugs used*

Year Of

known Meth- Mor- Co- Peth-

addicts M F Heroin adone phine caine idine

1945 367 144 223

1950 306 158 148

1955 335 159 176 54 21 179 6 64

1960 437 195 242 94 68 177 52 98

1961 470 223 247 132 59 168 84 105

1962 532 262 270 175 54 157 112 112

1963 635 339 296 237 55 172 171 107

1964 753 409 344 342 61 162 211 128

1965 927 558 369 521 72 160 311 102

1966 1,349 886 463 899 156 178 443 131

1967 11729 1,262 467 11299 243 158 462 112

1968 2,782 2,161 621 21240 486 198 564 120

1969 2,881 21295 586 1 @417 11687 345 311 128

1970 2fi6l 2,071 590 914 1,820 346 198 122

* Alone or in combination with other drugs.

SOURCE: Drugs Branch, Home Office.

England differs from the United States again in that its addicts today are not as a rule from disadvantaged families, are not members of minority groups, and do not "turn on" to blot out the economic dispair of the ghetto. "On the contrary," says Dr. David V. Hawks, a key staff member of the Addiction Research Unit of London's Institute of Psychiatry; "those notified in the 1960's were often construed as 'middle class dropouts' whose addiction, far from being explicable in terms of some material disadvantage, appears to have been motivated by the deliberate rejection of middle-class norms and opportunities."

TABLE 7-2

AGES OF ADDICTS KNOWN TO THE HOME OFFICE

* Beginning with 1969, this figure includes addicts to heroin and/or methadone.

SOURCE: Drugs Branch, Home Office.

This does not mean that the poor have escaped heroin addiction. They have not. But they aren't-by any count-in the majority.

The basic guidelines for Britain's drug-abuse policy were established in 1926, a dozen years after America passed the Harrison Act, which set the stage for the U.S. addict-criminal doctrine. A committee chaired by Sir Humphrey Rolleston, a prominent English physician, turned the problem over to doctors and steered it away from the police. The Rolleston committee said that doctors should be allowed to prescribe narcotics to wean patients off these drugs, to relieve pain after a prolonged cure had failed, and in cases where small doses enabled otherwise helpless patients to perform useful tasks and lead relatively normal lives.

The Rolleston Committee's findings were the basis of British drug policy for almost forty years. They were reaffirmed in general in 1961 by the Interdepartmental Committee on Drug Addiction, chaired by Sir Russell Brain. However, the addiction statistics began to move upward, the Brain Committee was reconvened, and a second report was issued on July 31, 1965. It recommended the first significant restrictions on the prescribing of heroin and cocaine.

The report succinctly stated the motivation and fears behind England's drug policies and their sharp differences with those of the United States:

We have borne in mind the dilemma which faces the authorities responsible for the control of dangerous drugs in this country. If there is insufficient control it may lead to the spread of addictionas is happening at present. If, on the other hand, the restrictions are so severe as to prevent or seriously discourage the addict from obtaining any supplies from legitimate sources, [they] may lead to the development of an organized illicit traffic. The absence hitherto of such an organized illicit traffic has been attributed largely to the fact that an addict has been able to obtain supplies of drugs legally. But this facility has now been abused, with the result that addiction has increased.

The Brain Committee recommended the following changes:

1. "All addicts to dangerous drugs should be notified to a central authority." (This authority later became the Chief Medical Officer of the Home Office.)

2. "To treat addicts a number of special treatment centers should be established, especially in the London area."

3. "There should be powers for compulsory detention of addicts in these centers." (This recommendation later was rejected by the Minister of Health.)

4. "The prescribing of heroin and cocaine to addicts should be limited to doctors on the staff of these treatment centers."

5. "It should be a statutory offence for other doctors to prescribe heroin and cocaine to an addict."

The government accepted these recommendations and incorporated them in the Dangerous Drugs Act of 1967. In February, 1968, the compulsory notification of addicts went into effect. By April of that year, heroin and cocaine prescribing was restricted to doctors in the newly created treatment centers.

During the almost three years that passed between the committee's report and the effective date of its recommendations, harddrug addiction soared. From 1964, the latest year for which a full year's statistics were available to the committee, to 1967, heroin addicts alone increased fourfold, from 342 to 1,299. A year later, the heroin-addict figure reached 2,240.

The committee's concern that "insufficient control may lead to the spread of addiction" was more than confirmed. Although it is unjust to blame the British medical profession alone for the sharp rise in addiction, the fact is that general over-prescribing and the activities of a few medical charlatans fueled the craving for heroin.

Some addicts were receiving prescriptions from general practitioners for as much as 20 or more grains of heroin a day (1,200 milligrams). Very few addicts used that amount themselves (a dosage, incidentally, that would kill almost any American adult). Most beneficiaries of overprescribing doctors sold their surplus and, of course, addicted others. What is surprising is that the Disciplinary Committee of the General Medical Council, the policing arm of the British medical profession, permitted this situation to continue as long at it did.

The problem of overprescribing doctors, with strong hints that their conduct was ethically questionable, was discussed in print as early as 1965 in the public report of the Brain Committee:

From the evidence before us we have been led to the conclusion that the major source of supply has been the activity of a very few doctors who have prescribed excessively for addicts. Thus we were informed that in 1962 one doctor alone prescribed almost 600,000 tablets (6 million milligrams or 6 kilos) of heroin for addicts .3 The same doctor, on one occasion, prescribed 900 tablets (9,000 milligrams) of heroin to one addict and three days later prescribed for the same patient another 600 tablets (6,000 milligrams) "to replace pills lost in an accident." Two doctors each issued a single prescription for 1,000 tablets (10,000 milligrams).

Overprescribing was so extensive during the years after the Brain Committee report and before the opening of the clinics that pure, British-manufactured heroin was readily and relatively inexpensively available on the black market, where imported, illicit heroin was virtually unknown. While prices for all consumer products rose during this period, black-market heroin-the overprescribed surplus-held the line against inflation and stayed at one pound sterling a grain. This meant that, for $2.40 a day, an addict could support a heroin habit. (Today, incidentally, British manufactured heroin is both relatively scarce and expensive on the black market, with a sixfold increase to six pounds, or $14.40 a grain.)

One psychiatrist, reviewing the years immediately preceding the opening of the clinics, felt that general practitioners were overprescribing to such an extent that, for every two addicts receiving prescriptions, at least one other was maintaining his habit from these supplies. Another psychiatrist believed that about a third of the reported addicts were not bona fide addicts at all but were merely sometime heroin users who conned doctors into issuing regular prescriptions that they would then sell.

But a few doctors clearly had not been sweet-talked by addicts into writing too-generous prescriptions. They had purposely turned the narcotics problem into a lucrative enterprise with the simple stroke of a pen. They wrote prescriptions for pay-at a going rate of one pound to two pounds per script. These were the junkie doctors whose names can be found in almost every London clinic's case records.

One of them, a dermatologist with a passion for gambling, ended his prescribing days issuing orders from a taxi parked in front of the Baker Street Tube Station. He was nabbed on a technicality-failing to keep proper narcotics records-spent a short period in jail, and finally had his license to practice revoked by the General Medical Council after numerous complaints of his activities from druggists and Home Office officials. Another was reported to have issued prescriptions to 140 addicts with a daily average of 6 to 8 grains at the height of his narcotics enterprise. He is also without a medical license today. He went to jail for conspiracy to commit murder.

While no one knowledgeable about the English drug scene will say that the nation would not have had a hard-drug problem had it not been for overprescribing doctors and outright charlatans, there is consensus that overgenerous prescriptions, whatever the doctor's motivation, helped significantly to create the chaotic drug scene that the government clinic program was expected to remedy.

THE CLINICS

In 1970, a monthly average of 1,154 drug addicts obtained government-paid-for heroin and/or methadone and a little cocaine from clinics scattered throughout England and Wales. Recently, the clinic figures have remained relatively stable, fluctuating by fewer than 100 addicts every month. The number of new addicts registered with clinics dropped from a monthly average of 66 to 41 in 1971. (See Table 7-3.)

Nevertheless, it is risky to conclude that this relative stability in clinic enrollment reflects containment of drug addiction in England. Some clinics appear to have set a quota of addicts and simply do not accept, or cannot accept, more because of staff or facility limitations. The slow reduction in new addicts, however, is a hopeful sign.

There are 14 clinics in London, which has four fifths of the country's addicts. Elsewhere, an addict may obtain drugs at 13 special facilities or at some 42 hospital outpatient departments These are prepared to service an occasional addict as part of their regular outpatient program.

The special clinics vary in every conceivable way-in type of facility, size of patient load, size of staff, treatment approach, and prescribing philosophy. There is no central authority over the clinics to provide specific guidelines for staffing or determine treatment or prescribing policies. Because of this, it is a mistake to refer to the English "drug clinic system." There is no common "system" beyond the fact that addicts may obtain heroin and methadone from government-supported clinics.

Each clinic director is doing "his own thing," based on his own particular approach to drug addiction. He works with the facility, staff, and budget he was able to get from his own hospital and Regional Hospital Board, the governing body that supervises medical care for a given area.

These various approaches have not been evaluated comparatively for cost or effectiveness. The addicts, however, are usually in agreement about which are the "best" clinics in a less than scientific rating system, which might be called the "Santa Claus" scale. It ranks candidates on their drug-prescribing generosity.

The lack of central direction is the result not of careless management but rather of design. Americans often have the impression that the British National Health Service is a monolith that dictates everything from aspirin dispensing to appendix removing, but the fact is that the government's Ministry of Health has approached physicians both within and outside of the National Health Service with the circumspection of an impresario dealing with a diva.

After the government accepted most of the second Brain Committee recommendations and prepared the necessary legislation to implement them, the Department of Health and Social Security issued a memorandum to Regional Hospital Boards and hospital governing groups.' The Ministry directed its memo particularly at mental hospitals and psychiatric departments of general hospitals. As a result, today the clinic directors are psychiatrists, most of whom follow a general psychiatric practice in addition to their interests in the drug field.

The Health Department memorandum included a list of the known addicts in each Regional Hospital area. Since most addicts were in the London area, it asked city hospitals with psychiatric departments to plan for drug clinics. At the same time, the Health Department asked hospitals to set up inpatient beds for withdrawal treatment and to assess addicts who would obtain their drugs as outpatients for the required dosage. Today most clinics have such beds available to them. Significantly, the "how" of operating clinics was not described.

The decision to supply an addict with drugs and whether to seek to substitute other drugs, the assessment of dosage, and the method of supply rest with the clinician. It is to be expected, however, that where possible, the dosage will be determined by assessment during inpatient observation and that this will usually be offered, though continued treatment cannot be made conditional on acceptance. [This in-hospital assessment is rarely done today, and it is clear that most clinic directors reject this Health Department "expectation."] The organization of services will depend on the method of supplying drugs that is adopted by clinicians. It is, however, desirable in any area that there should be a fairly uniform approach; otherwise, the organization of services and the sharing of the load will be obstructed because addicts will gravitate to those clinics where they think drugs are easiest to get. While direct administration of drugs by the medical staff of the treatment center is not excluded, supply by the hospital or by retail prescription is likely to be more generally practicable.

The clinics have certain statistical reporting obligations, both to the Health Department and the Home Office. There is an exchange of views and information among clinic directors and other medical staff members at periodic meetings called by the Health Department. A department official told me that these meetings generally are held every two months, but the records show that such sessions are usually held on an irregular basis. Minutes of the meetings indicate that not all clinics are represented at every meeting and not every clinic director attends regularly.

FACILITIES

The differences between clinics is apparent from inspection of their physical facilities. In the naval-base city of Portsmouth, the clinic is in a large general hospital tucked behind a door marked "Dental Waiting Room." In East London, the center is in its own building on the grounds of a mental hospital. In the Denmark Hill area, it is part of the hospital's general outpatient department.

If you visit St. Giles Clinic in the Church of England Community Center, you are reminded of an Alec Guinness movie. Dr. James H. Willis, a young psychiatrist, holds court resplendent in a white medical coat, seated behind a large wooden table in a room marked "Lecture Hall." He is flanked by two pianos and a bass fiddle. Above and behind his head, a brass plaque reads: "The trustees of St. Giles Center gratefully acknowledge the generous support given by the Rotary Club of Camberwell."

It is doubtful that the Rotarians would rush to support the effort now going on in the lecture hall. It is lack of such support that has prevented Dr. Willis from using a new $192,000 building specifically constructed for his drug clinic by the two hospitals and the Regional Hospital Board sponsoring it. The building, which includes eight single rooms for inpatient assessment, stood empty for more than a year after it was completed. Public protest -exploited by local politicians-forced the hospital to rescind its decision to bring young addicts into the middle-class neighborhood of St. Giles.

In his churchly retreat, Dr. Willis has no facilities even for basic medical examinations, and patients leave urine specimens in the center's men's room.

STAFFING

A most basic difference among clinics is in the kind and size of staff that operate them. One of the most significant contrasts is between St. Clement and Lambeth Hospital Clinics. The staffing patterns are as follows:

LAMBETH (96 active patients)

Doctors:

1 31/2 days a week

1 21/2 days a week

I 1 1/2 days a week

Social worker:

1 21/2 days a week

Nurse:

1 full time

Secretary:

1

ST. CLEMENT (71 active patients)

Doctors:

1 full time

1 1 1/2 days a week

I psychiatric intern 1 1/2 days a week

Social workers:

2 full time

Nurses:

10 full time

Secretary: 1

The nurses at St. Clement function like social workers: they counsel patients and make home calls both to patients and to their families, relatives, or close friends.

The Lambeth Clinic, run by Dr. Thomas H. Bewley, a wellknown author of medical articles on the English drug scene, is far closer to the English clinic prototype.

The besieged Dr. Willis at St. Giles, incidentally, was even worse off when it came to staffing. With 75 active patients and 64 inactive patients, the clinic included three doctors, two full time and another one-third time. Although there were two slots for social workers, both were temporarily empty. Dr. Willis has no nursing help. His only other assistance comes from a secretary and a hospital porter, who acts as factotum around his piano-flanked emporium.

St. Clement, in terms of staff time for the addict, is clearly exceptional. It was originally intended as a day hospital where an addict would come for the entire day, returning to his home only at night. The original staffing pattern was retained when the clinic was turned into what can be described more accurately as a day center that addicts of the clinic may or may not attend. There is a ping-pong table, art classes, and a "fixing room" where addicts can inject themselves. Individual and group therapy sessions also are held in the day center.

Among all London clinics, the amount of social-work time provided to addicts varies from 475 hours per week (St. Clement) to none, according to a questionnaire filled out by the clinics themselves.

Because of the difference in staff time between St. Clement and Lambeth, the addict's relationship to these clinics is vastly different. At St. Clement, each social worker and nurse has about ten cases. They know each addict by his first name, and the easy, relaxed relationship that comes with familiarity is evident. One addict, for example, came in to show his nurse pictures of his recent wedding and to thank her for her congratulatory telegram.

At Lambeth, the lone social worker, who provides twenty hours a week, has a caseload of 30 addicts out of the 96 active with the clinic. Of the 30, she estimated that she has what she called "a deep relationship" with a half dozen. "They get a good half hour a week."

Of the clinic's work, she said: "We're containing it, regularizing it a bit; but, we're not treating it. I think I do first aid a lot."

At St. Clement, staff members were slightly, but not much, more encouraging. Not only did this clinic represent the most concentrated staff effort with addicts, but its patients resemble American ghetto addicts more closely than any other London group.

St. Clement is a 128-bed mental hospital in East London, an area that in terms of income and class-but not color-can be compared to New York's Harlem or Bedford-Stuyvesant. The addiction clinic of St. Clement serves patients from the surrounding neighborhoods, the bleak row houses that bring to mind a Charles Dickens novel. Eighty per cent of St. Clement's addiction clinic customers are East End boys; the other 20 per cent come from the far more affluent middle- and upper-class West End.

While an estimated 10 per cent of the East End population is colored (i.e., Negro, Indian, Pakistani), only one of the clinic's 100 patients is half-Negro. This appears to reflect accurately the fact that in England few "colored" are involved with narcotic drugs.

The clinic is located on the hospital grounds in a separate pre-fah building constructed especially for this use at a cost of 14,000 pounds, or $33,600. The annual operating cost for salaries and drugs is estimated by its director to be about the same amount.

Psychiatrist John Denham is both clinic director and head of the St. Clement Hospital. Much of the day-to-day operation of the clinic fell on Dr. Margaret Tripp, the full-time psychiatrist who served at the clinic from the summer of 1968, when it opened, to 1971.

Neither Dr. Denham nor Dr. Tripp makes any grand claims for the clinic, even though they, and it, have received considerable publicity in U.S. media (Look magazine, various television and radio networks). Dr. Denham has a thick file of letters in response to this publicity requesting permission to visit and interview him. He does not trade on this notoriety.

As is true of virtually all other clinics, St. Clement's heroin dispensing is dropping monthly-from 214 grams in March, 1969, to 73 grams in May, 1970. Methadone, both ampoules for injection and oral, has increased at St. Clement, but not in proportion to the drop in heroin. Dr. Denham attributes this heroin reduction to the use of methadone, to more conservative prescribing, and to greater expertise among clinic doctors. He readily admits to the confusion that apparently hit every clinic in the opening period of 1968. "A drug addict presented himself and said he needed six grains of heroin a day. We knew he could do with two, but that he would settle for four. It was as haphazard as that.29

The same kind of candor is evident in a paper published by Dr. P. H. Connell, another of the early pioneers in drug-addiction control in England.' Reporting on 107 narcotics users attending a London clinic between March, 1968, and February, 1969, Dr. Connell acknowledged that some of these patients had become addicted to drugs by the clinic.

REGISTRATION

How do you begin obtaining free drugs?

Some of the addicts interviewed are convinced it is getting harder to get on the rolls. Some say that, for a new addict to get on, be has to buy black-market narcotics for a while and then show wicked withdrawal symptoms.

Doctors discount the severity of these statements but acknowledge that they are getting more conservative. Interclinic monthly heroin and methadone prescription quantities are distributed among the clinics, and this may have developed a touch of competition to stay in the range of low prescribers. At St. Clement, for example, a monthly graph is kept showing its standing against the all-London average.

Doctors agree that identifying an addict and prescribing the correct quantity of drugs is the toughest part of their jobs. They use words like "haggling" and "bargaining" sessions to describe the difficulties of deciding how much an addict should receive.

The Health Department's suggestion of in-hospital assessment before prescribing to addicts generally is not part of the procedures of the London clinics. An occasional applicant may be sent for observation for several days, but this is the exception and not the rule.

In Portsmouth, however, Dr. Ian Christie will not accept a new patient unless he agrees to three days of hospitalization to determine the kind and size of his habit, or, for that matter, if indeed he has one.

In London, addicts arriving at a clinic for the first time, or to reapply, usually are given at least two interviews. The first may be with a nurse or social worker and the second with a clinic psychiatrist. After acceptance, addicts generally report once every week to their psychiatrist or social worker. Some are requested to come in several times a week, while others, who may be more stable, are permitted to report every two weeks.

Before acceptance, one, and sometimes several, urine tests are scheduled, usually two or more days apart. Drug-positive urine tests play a key role in the decision-making process.

Urine tests, incidentally, are not regularly scheduled for every addict after he has been accepted by a clinic. Their frequency varies from clinic to clinic. At St. Giles, Dr. Willis formerly demanded only sporadic urine tests. Now, however, every patient gives a sample at each clinic visit. In other clinics, it appears that tests are made when there is some suspicion of other than clinic-prescribed drug use.

A key step in the preacceptance interview procedure is the completion of a form outlining the addict's biography, his drug history, and his physical characteristics. This is sent to the Home Office, where it is compared with the master list of registered addicts. The procedure helps to identify previously unknown addicts and to prevent duplicate registering at two or more clinics.

Have addicts succeeded in getting on the rolls of two different clinics? Yes, but how many or how often is difficult to document. At St. Clement, Dr. Denham does not remember a case where the Home Office check produced duplicate registration. However, he does recall an incident indicating that the problem is real. Not long after the clinic opened, a boy, while stoned, told his fellow addicts that he was obtaining drugs from two clinics. This came to the attention of the staff, and a nurse was sent to the clinic closest to St. Clement. Seven addicts were identified as St. Clement boys and five others confessed to duplicate registration. At the time, this represented 12 per cent of the St. Clement caseload.

"Did that surprise you?" I asked Dr. Denham.

"At the time, it annoyed me."

Dr. Connell, in his study of 107 drug users, also found that four had been attending other clinics, where they requested help without, of course, acknowledging the duplication.

From observation, it appeared that a seasoned addict with a long Home Office or clinic record, or both, had much less difficulty in re-registering at a clinic than a previous "unknown." Dr. Bewley permitted me to sit in on a series of interviews with addicts applying to the Lambeth clinic. All had been previously interviewed by the clinic's part-time psychiatrists, who also sat in on these second interviews.

My notes for this session are as follows:

1. Male, out of prison since May 1. Was with Lambeth a year ago, had received 200 mg. daily of heroin and methadone; long criminal record, most recent possession of burglar tools, cannabis; told to return for urine test. Dr. Bewley indicated he probably will be reregistered with 20 mg. methadone a day as starter.

2. Male, long criminal record, now under three-year suspended sentence; long drug history, longest period off drugs was six weeks; told to come back for urine test. Dr. Bewley indicated he probably will be put on clinic rolls.

3. Male, 23, in and out of series of building industry jobs; said he started with drugs at 16, shooting heroin and methadone at 20; said now buying six ampoules of methadone a day on black market at $1.20 per ampoule or $7.20 for day's supply; no criminal record; first urine test showed methadone; told to come back after weekend for another urine test. Bewley estimated there was a 50-50 chance he would not be back. If he comes and test is positive, he probably will be accepted.

Dr. Connell, in his study of the previously cited 107 drug users at a London Clinic, found a large dropout rate between urine tests. "Refusal to prescribe at first attendance, whilst awaiting results of urinalysis, led to a high incidence of failed reattendance. Thus 92 per cent prescribed heroin reattended, whilst only 35 per cent prescribed no drugs returned." This was true, even though 22 out of 36 who had been given no drugs had positive urine tests.

This led Dr. Connell to conclude: "In view of the essential need for accurate diagnosis, it seems inescapable that a prescribing method of management should not be adopted until firm evidence of daily use is obtained by, say, three consecutive positive urines collected on different days and over a period of ten days or more to take into account the fact that methadone is excreted more slowly than morphine."

4. Female, 23, no previous history with clinic; arrested four times, shoplifting, abuse of floor walker; said she was taking 130 mg. heroin daily obtained from black market. She was turned down.

The psychiatrist who first interviewed the girl acknowledged, as did Dr. Bewley, that much of this decision-making process is guesswork. Will this girl now go out and steal enough merchandise to fuel what may be a drug habit? Will she overshoot herself to convince Lambeth or another clinic that she really is addicted? No one could answer these questions.

DRUG DISPENSING

None of the London addicts receives his drugs from the medical staff in the clinics. Rather, a prescription is mailed directly to the druggist of the addict's choice. Only on rare occasions does the addict receive a prescription personally-for example, if it is clear that the post office cannot deliver it in time to fill an immediate need.

Each prescription form is filled out by the clinic physician, generally for a week's supply. Prescription blanks are kept under lock and key, for there is a black-market price on blank National Health Service prescription forms.

Although a week's order may be on one prescription, the addict must collect his supplies from the druggist daily. On Saturday, he generally receives two days' supply because of Sunday closing. Black-market prices for drugs, incidentally, are highest on Sundays, because of weekend demands by occasional users and addicts who have shot up their two-day supply on Saturday.

Drugstores are monitored periodically by the police. However, these reviews generally are confined to the larger distributors of drugs. The Scotland Yard Drug Squad has four detectives specifically assigned to inspecting drugstores.

Drugstores keep detailed records of both incoming and outgoing drugs. I examined this procedure in Boots Picadilly, the all-night drugstore in London's famed square. Dangerous drugs are kept in a special locked cabinet. Each prescription is double checked and, of course, recorded. One pharmacist will make up the order and initial the package, which is checked by a second pharmacist. This particular store served 36 addicts daily at the time of this review.

Retail prices are standardized. Heroin is a bargain compared with the various forms of methadone. The 1970 retail prices were as follows:

Heroin 100 tablets (10 mg. each) 1000 mg. $2.16

Methadone 100 ampoules (10 mg. each) 1000 mg. 7.50

Methadone linctus (syrup) 5 bottles (200 mg. each) 1000 mg. 7.80

Since addicts come under National Health Service coverage, the drugs are free except for a small-25 cents-weekly service charge. Disposable needles and syringes are provided directly to addicts by some clinics or are supplied by the drugstore.

I was able to locate only two clinics in England that provide drugs administered directly by the staff. These are in Southampton and Portsmouth. I visited the Portsmouth clinic, directed by Dr. Ian Christie, in St. James Hospital. Because of the small number of patients, significant conclusions cannot be drawn from the in-clinic, drug-administering approach at this hospital. Seven addicts, six receiving methadone and one heroin, come to the clinic twice a day for their injections. These are given by hospital nurses in early-morning and late-afternoon sessions in the hospital's dental department. Injections are given in the deltoid muscle. The methadone addicts I interviewed said that they do not get a "flash" from the methadone intramuscular injection as they did from heroin when they administered it intravenously themselves in preclinic days.

Although all addicts mentioned the inconvenience of coming twice a day to the hospital-which is not centrally located-only one complained vociferously about it. He said he had to take a cab from work daily in order not to miss his second injection, at the 5:15 afternoon clinic. His employer was unaware of his addiction and, he said, probably would fire him if he found out.

In addition to the twice-daily clinic patients, Dr. Christie has four others receiving methadone linctus which he provides via prescription and two heroin addicts-a husband and wife with a long history of addiction-who also receive prescriptions and administer the drug themselves. "This probably was a mistake," Christie said.

None of those receiving any drug is provided with any rehabilitation services. "if they chose drugs, they get drugs," Dr. Christie said.

He gives each addict alternatives: hospital in-patient withdrawal ("Everyone who has tried that method has relapsed"); in-hospital assessment with subsequent in-clinic daily drug taking; and, finally, entry into a therapeutic community, called the Alpha Unit.

PRESCRIPTION TRENDS

Since the clinics began operating in 1968, the quantity of heroin used by English addicts has been greatly reduced. In the clinics, the monthly total grams of heroin have dropped from 2,177 in January, 1969, to 1,131 in December, 1970 (see Table 7-4).

Furthermore, while in 1968 the vast majority of English addicts were taking heroin, today the majority are taking methadone alone or in combination with heroin. Whatever the opiate, the daily amount each addict takes is generally significantly less than the preclinic daily quantity.

Statistics show that only 10 per cent, or 140, of all known addicts receiving opiates were receiving heroin alone on December 31, 1970. However, this may be somewhat misleading, not only because the reporting procedure may be less than perfect, but because prescribing physicians frequently change both the quantity and the kind of drug prescribed.

It is important to remember that methadone in England most frequently is provided for intravenous injection (as is heroin), and not for oral consumption, as is common in the United States. More than twice as much methadone is prescribed for injection as orally. Most important, injected methadone has a good "rush" -oral methadone does not.

Most clinics have adopted the policy of moving from heroin to methadone. Often, this is done gradually by giving a combination of heroin and methadone for a certain period and then shifting to methadone only. Finally, an attempt is made to shift to oral or linctus methadone. Psychiatrists agree that the hardest task beyond total drug abstention-is to convince the addict to give up the needle.

This prescribing trend is reflected in the individual clinics. Here are some samples:

Larnbeth-8 on heroin alone, 12 on methadone and heroin, 76 on methadone alone

St. Clement-36 on methadone and heroin, 35 on methadone

St. Giles-54 on heroin or methadone and heroin, 1 1 on methadone for injection, 10 on methadone oral

Charing Cross-2 on heroin, 10 on methadone and heroin, 45 on methadone for injection, 33 on methadone oral

Portsmouth-3 on heroin only, 6 on methadone for injection, 4 on methadone oral

The shift from heroin to methadone is further indicated by the fact that clinics today infrequently interview a new heroin addict. The head nurse of the largest London clinic, Charing Cross, could not recall the last time a new heroin addict had been interviewed; all the new cases were methadone addicts. In Portsmouth, Dr. Christie said, no one addicted to heroin had applied for help in the previous year; all the newcomers were methadone addicts.

METHADONE MAINTENANCE

Directors of government clinics do not practice the Dole Nyswander methadone-maintenance technique, emphasizing blocking the effect of heroin. Significantly, four clinic directors expressed doubts about the effectiveness of the blocking method. Dr. Christie, for example, believes that methadone blocks heroin in American addicts because they are accustomed to receive low and diluted doses of the latter drug. "When an addict takes only four or five $5 bags a day, which don't contain more than 20 milligrams of heroin, then it works." The others agreed that an addict who takes large doses of heroin daily cannot be blocked with methadone.

However, a private London clinic, run by Dr. Peter A. L. Chapple, has experimented with the methadone-maintenance approach known in the United States. This is the National Addiction and Research Institute, which has at least as many active patients as the biggest government clinic. Dr. Chapple prescribes only oral methadone. He is not licensed to prescribe heroin in his clinic, and he is opposed to prescribing methadone for injection because it perpetuates the needle cult. In 1969, he prescribed oral methadone to 106 patients, 70 per cent of whom were receiving blocking dosages (between 100 and 200 milligrams a day). There are no scientific data available indicating whether these addicts actually were blocked from the effect of heroin. Recently, however, Dr. Chapple said that he has been trying to reduce the dosages of oral methadone. "It probably was a mistake to go as high as 200 milligrams a day," he added. The maximum is now 100 milligrams a day, while younger addicts are more likely to be around the 30-milligram-per-day level. Dr. Chapple said he has shifted from giving a blocking dose because there is less heroin around. He said he wanted to satisfy the drug hunger and not necessarily to block heroin.

*Interclinic statistics kept only since September, 1969. SOURCE: Department of Health and Social Security.

He acknowledged that it is very difficult to work with younger addicts using oral methadone, largely because of their delinquent and erratic behavior. Last year, a young addict died as a result of taking barbiturates while also taking oral methadone. (Dr. Connell, in his examination of 107 addicts at a government clinic, also recorded an oral-methadone overdose death. This involved an addict on 100 milligrams a day who obtained the next day's supply shortly after midnight and drank both within hours of each other.)

If England's drug doctors do not subscribe to methadone maintenance, why have they shifted so dramatically to methadone from heroin?

First, the very creation of the clinic approach was prompted by what England viewed as a growing heroin epidemic. There was public and political pressure to halt the rise in heroin addicts. The monthly distribution of a dossier showing the amounts of heroin prescribed by each clinic made it clear to each clinic director where he stood among his peers in this respect and undoubtedly created pressure to bring the quantity down.

Secondly, there is general agreement among clinic physicians that methadone has a longer-lasting effect than heroin. Thus, the addict needs fewer injections a day.

Thirdly, methadone for injection is considered somewhat more sterile than heroin, since it comes in liqui4 form, so that the addict merely transfers the ampoule content directly into his syringe. With heroin, he mixes a 10-milligram pill with water, usually unsterile and sometimes from a tap or even a toilet bowl, to dissolve the pill before injecting.

Finally, methadone for injection is viewed by a number of doctors as the bridge to oral methadone. Breaking the needle cult is considered an important success step in the drug-treatment program in England.

Unfortunately, addict performances on heroin, methadone for injection, and oral methadone have received no detailed scientific comparison in England. Furthermore-surprisingly, to an outsider-methadone continues to be available outside of the drug clinics. There is nothing to prevent general practitioners from prescribing it. A few, in fact, do. (Scotland Yard Drug Squad detectives, who monitor drugstores, say that about six London doctors prescribe methadone on a regular basis.) Ironically, the second Brain Committee foresaw the possibility that a substitute drug might become potentially as dangerous as heroin. When the committee urged and achieved prescribing restrictions on heroin, it said: "If, in future, circumstances should change, and other drugs of addiction should take the place now occupied by heroin and cocaine, it would be necessary promptly to amend the 'restricted' list accordingly." A number of leading professionals have urged that methadone be placed on the "restricted" list, but this has not been done.

The clinic shift from heroin to methadone, plus the absence of prescribing prohibitions on general practitioners, undoubtedly had led to a new metbadone-addiction problem. The key issue is how big a problem it is. The over-all clinic drug-dispensing statistics indicate strongly that considerably lower quantities of combined heroin and methadone are being prescribed today than the largely heroin-only prescriptions at the beginning of the clinic era, but exactly how much lower is impossible to show, since methadone statistics were not reported until September, 1969.

However, it appears that there has not been a simple switch from a heroin to a methadone problem. Doctors interviewed are concerned about rising methadone cases but do not suggest that they are replacing heroin cases on a one-for-one basis. That is, the methadone increase is moving at a considerably slower pace than the sharp drop in heroin addiction, although no one can document the relative rates of change.

The police, however, are less inclined to make distinctions. In a 1970 report, Scotland Yard said:

There has been a transference of addiction in as much as the treatment centers have succeeded in reducing the amount of heroin prescribed to addicts, thereby reducing the availability of this drug on the "illicit market." But, in so doing, they have increased the prescribing of methadone to counterbalance this reduction; consequently, there is now far more methadone available on the "illicit market."

DRUGS OUTSIDE THE CLINICS

How many other drugs do addicts take to supplement those prescribed by the clinics?

While evidence in this area is both fragmentary and sometimes disputed, there is agreement that English addicts often supplement the clinic-prescribed drug diet, with a wide assortment of chemicals that affect both the mind and the body. These include black-market methadone or heroin, amphetamines, barbiturates, tranquilizers, and marijuana, or, for that matter, a smattering of all of them. In short, the addict in England more often than not is a polydrug taker.

The most significant evidence comes from a wide-ranging study conducted by two staff members of the Addiction Research Institute. Between March and November, 1969, they interviewed in depth I I I heroin users attending the London clinics, representing about 10 per cent of all clinic patients in England.' The results showed that only a small proportion of English addicts can be considered "stable" in their drug-taking habits.

Several clinic directors expressed reservations about the study, claiming that it did not represent a true cross-section of their population since it included only active heroin addicts. At the time of the interviews, they said, many of their patients, particularly the more promising ones, had already been weaned off heroin and onto methadone only. The study, however, did include 91 (of the 111) who were receiving heroin in combination with methadone.

Eighty-four per cent reported to interviewers that in the month prior to the interview they had used drugs other than those prescribed for them by the clinics. Among these other drugs, the largest number reported using barbiturates and tranquilizers (75 per cent), which, in the majority of cases, were prescribed by private physicians. This is an important indication that extracurricular drug taking did not necessarily mean adding larger doses of illegally obtained narcotics.

The range of drugs used is demonstrated in Table 7-5. These statistics show that the one additional drug all 1 1 1 heroin addicts had used was marijuana or hashish (cannabis).

An interesting sidelight brought out during the interviews was that 37 per cent had on occasion sold, lent, or exchanged at least some of the drugs the clinics prescribed for them. In addition, the study confirmed the worst fears of physicians about the unsterile procedures that are an important risk when addicts administer drugs to themselves. The report speaks best for itself:

All subjects were using heroin by injection. In the week prior to interview 28 (25%) subjects had injected themselves at home only, a further 17 (15%) had injected themselves at their clinic or at a day center as well as at their home, 46 (41 %) had injected themselves at some time during the week in a public toilet as well as at home, clinic, or day center, and 20 (18%) had injected themselves in a "public place"-e.g., shop doorways, in the street ' or in telephone kiosks-in addition to any of the above places. Sixty-two (56%) had injected themselves whilst other addicts were present and also injecting themselves.

The majority of subjects ( 101, 91 %) used a disposable syringe for their injections and of these 67 (66%) regularly used their syringes more than once. Seventy-two subjects (68%) did not clean their arms prior to injection.

Although the most frequent method for preparing an injection was to dissolve heroin in sterile water, 54 (49%) had at some time during the week used ordinary unboiled tap water, and 12 (11%) had used water from a lavatory basin. Nine subjects reported sharing a syringe with another addict during the week.

If injection practices are defined as sterile when normal medical procedure is followed (i.e., using a new disposable syringe for each injection or using an adequately sterilized glass syringe, not sharing a syringe, cleaning the arm prior to injection, and making up the injection with sterile water) then in the total sample, 12 subjects (11%) are using sterile injection practices. In the week prior to interview all others had engaged in some non-sterile practice.

This kind of unsterile drug taking often led to medical complications. Thirty-nine per cent had been in hospitals for treatment of septicaernia, hepatitis, abscesses, or overdose. Of all addicts interviewed, 40 per cent reported hepatitis and overdose and 46 per cent reported abscesses treated both in and outside of hospitals.

Although this report indicated no particular trend in polydrug taking, since the clinics began doctors have seen definite increases in two drugs: methylamphetamine (speed) and barbiturates. In 1968, methylamphetamine was injected by addicts with such frequency that authorities asked its manufacturers to agree to withdraw it from the retail market and restrict its distribution to hospital pharmacies. Within weeks of its disappearance from retail drugstores it disappeared among the addict population.

Misuse of barbiturates. by addicts became an acute problem in 1969. Some physicians, however, feel that it has slowed somewhat since the last part of 1970. Addicts inject barbiturates even though they are not manufactured, so that they will dissolve completely in water. The undissolved particles result in collapsed veins and serious abscesses on addicts' arms and legs. Addicts I've interviewed said that they resorted to barbiturates when they couldn't get enough heroin or methadone from the clinics. This, like all addict testimonials, is open to question.

The degree of barbiturate abuse-particularly by injection-is another aspect of the English drug scene that is left largely to conjecture. A study in 1969 of a small sample of heroin addicts -again conducted by a team from the Addiction Research Unit-showed that among this sample the problem was huge.' Sixty-five heroin addicts were interviewed in May, June, and July of 1969, and 80 per cent were found to have injected barbiturates. Almost all of them-62 of the 65-had taken barbiturates either by injection or orally. Of course, some had used the drug only to help induce sleep. However, 65 per cent acknowledged they had taken it for no medical reason and only for "kicks."

A few addicts will take barbiturates with them to the clinics, although they may have obtained them from a general practitioner or bought them illicitly. I observed an especially bizarre scene in one of the clinics.

There were two chairs in the room, a steel sink, a length of rubber hose to use as a tourniquet, some cotton, and a supply of paper towels. The walls and the chairs were stained with dried blood; in general, the physical appearance of the room was far from the kind of antiseptic clinic presented by the likes of Drs. Kildare and Ben Casey. The characters on this stage were two young addicts, both unsteady on their feet from drugs taken earlier. One took a syringe from his pocket, washed it out with tap water from the sink, pulled a folded piece of paper from another pocket, removed a barbiturate capsule, broke it in half over the syringe, and emptied its contents into the tube.

Once the white powder was in the syringe, he added tap water, shook the contents vigorously for several seconds, and handed the syringe to his friend. Since his arms and ankles were marked with sores, however, it took several minutes to locate a usable vein. Finally, he settled on a spot about eight inches below the knee. (The other addict, incidentally, shortly afterwards injected himself in the sole of his foot.)

A third addict, more stable, helped the first boy out of the clinic by steadying him with an arm around his shoulders. But once outside the clinic, the boy sagged and collapsed on the grass. A few addicts nearby helped to drag the boy out of the sun to a tree, where they sat him up against its trunk.

I was not alone in observing this sequence; a clinic psychiatrist watched the entire scene with me. No effort was made to assist, dissuade, or reprimand the addicts. We were both spectators, like a couple of medical students watching surgical techniques from behind a glass partition.

LAW ENFORCEMENT

Although the English have consistently viewed drug addiction as a medical problem, this does not mean that the police have been dismissed from the drug scene. Possession, selling, and importing most dangerous drugs are against the law.

An addict can go to a government clinic and, after convincing doctors of his addiction, obtain free heroin, but this does not mean that anyone can walk around London with a pocketful of "horse" or any other opiate. Possession of heroin, methadone, and similar dangerous drugs is illegal without a prescription. In the case of heroin, the only source of such a prescription is a government clinic.

Marijuana and hashish are illegal, period. There are no prescriptions given for these drugs and no medical "cover" exists to protect the owner of them. In England, they are clearly the number-one illegal drug, and their use continues to rise along with the arrest statistics of those who are caught with them. From 1968 to 1970, the number of cannabis offenses more than doubled from 3,071 to 7,520. In 1970, cannibis seizures amounted to 11/4 tons.

Unlike the United States, Britain has no national police agency for drugs. For that matter, if there is no equivalent to the U.S. Bureau of Narcotics and Dangerous Drugs, neither is there one for the Federal Bureau of Investigation. Scotland Yard is essentially a London agency, and, when a Scotland Yard man is found looking for clues on some fog-shrouded English moor (usually in a paperback detective thriller), he is there on loan from London. In short, there is no national police force.

Drug squads have been created largely because of need or, sometimes, because of the personal interest of an individual police officer. These squads have no nationwide resources available to them either from an enforcement or from a training point of view. Drug-squad members, including the higher-echelon officers in charge of them, are largely self-educated about drugs. Even Scotland Yard's Drug Squad is likely to have a director today who next month or next year may be shifted to a completely different area of police work.

However, this does not mean that expertise has not built up. There is no better example of expertise constructed largely out of self-developed personal interest than Detective Sergeant Alan Russell, who heads the drug squad in Portsmouth. If a national police drug force ever should be established, as some are urging, Sergeant Russell should have a prominent role in it on the basis of his record in Portsmouth.

Russell has an excellent, and unpublicized, working relationship with Dr. Christie of the Portsmouth drug clinic: Christie doesn't squeal on addicts and Russell doesn't give away police plans, but it is clear from the way the two men speak of each other that each has developed a warm respect for the other's approach to addiction. The addicts appear to respect Russell as well. When the residents of Alpha Unit, the therapeutic community directed by Dr. Christie, decided to hold an open house, they invited Russell even though he had arrested a number of them on past occasions.

Because of the Christie-Russell liaison-and addicts corroborate it-there is virtually no black market in heroin or methadone in the Portsmouth area. In 1969, Russell's squad arrested two persons for possessing heroin, and this involved only minute traces found in a syringe. During the entire year, there were 12 to 15 methadone-possession arrests.

Russell, however, regards opiate addiction as only a small part of his concern. "Dependence on opiate drugs is only the tip of the iceberg," he says. "You have millions of people in this country who are dependent on barbiturates and amphetamines."

In the greater Portsmouth area, with a population of about 500,000, he estimates that there are as many as 1,500 users of marijuana, barbiturates, and amphetamines, some of whom may dabble with all of these drugs. This estimate is in marked contrast to the very low numbers of hard-drug addicts-14 in the clinic and 17 in the Alpha Unit therapeutic community.

Possibly in part because of his respect for Dr. Christie, Portsmouth's chief drug police officer has a very positive attitude toward the clinics. "Make no mistake about it-and some people tend to forget it-a few years ago this country had a serious heroin problem."

In London, there is considerable criticism of the clinics among members of Scotland Yard's Drug Squad, although not a single police officer whom I interviewed was willing to scrap the clinics. Several officers thought that some clinic doctors were still being conned by addicts into issuing larger prescriptions than required. However, all the officers agreed that overprescribing had been reduced drastically since preclinic days.

As an example that the problem has not been eliminated entirely, they cite a case in 1969: A member of the squad searched the apartment of a longtime addict who had been receiving drugs from one of the central London clinics before his death. The search uncovered a horde of heroin-900 tablets or 9,000 milligrams, worth more than $2,100 on the British black market and easily three times as much on the U.S. market. Although there was no evidence that the addict had been selling from this cache, the police felt strongly that it corroborated their overprescribing charge.

Furthermore, police are annoyed that there is no limit on the amount an addict with a clinic prescription may carry. Recently, they stopped an addict with 40 grains (2,400 milligrams) of heroin. He told officers he had been reducing his prescribed quantity, and no arrest was possible, even though the police strongly doubted his story.

Yet, such dramatic anecdotes are the exception. A review of squad arrest records shows that, from the beginning of June to September 7, 1970 (the date of the interview), there hadn't been a single heroin arrest and only two methadone-possession arrests. (These were not the only London drug arrests; for, although the squad is the only police unit concerned solely with drugs, other London policemen make drug arrests in the course of their regular activities.)

Some members of the drug squad frankly admit that they would be in trouble if heroin were completely outlawed. None is campaigning for such a move. One top drug-squad officer, a critic of the present clinic approach ("They sustain addiction . . . there is no place in England where a drug addict can be cured") is not interested in abolishing them, either. He would like to see all drugs administered by the clinics in the clinics. Instead of fourteen separate clinics in London, he would like four open on a twenty-four-hour-a-day, seven-day-a-week basis.

Scotland Yard detectives acknowledge that the clinics have reduced not only the quantity of heroin prescribed but the amount available on the black market. Cocaine, they say, has also been reduced dramatically. Like their colleagues in Portsmouth, however, they are often more concerned about the other drugs that are available on the black market.

The lead drug, of course, is marijuana. They claim that large scale trafficking is mainly carried on by England's new immigrant population, primarily the Pakistanis. Marijuana comes into England frequently by parcel post directly from the producing countries. Students also bring it in from such well-known drug centers as Morocco.

LSD most often comes from the United States, even though in 1969 English police raided and closed down at least two illicit laboratories producing LSD for both local consumption and export.

There appears to be little organized importation of heroin. What there is generally comes from Hong Kong and is imported by Chinese sailors and distributed by inhabitants of the small Chinese community in London. Addicts generally are not fond of Chinese heroin because of its uncertain strength and, since it comes in powder form, the necessity to heat it in a spoon-in the U.S. mode-before mixing it for injection.

Police acknowledge that one can buy a variety of illicit drugs in the network of side streets in and around Picadilly Circus and in some other areas of London where youth congregate, often in or around the late-night clubs. However, these illicit business enterprises are small and unorganized, particularly in the hard drug line.

Black-market prices in 1970, according to the addicts and confirmed by clinic physicians and police, are as follows:

Heroin (British-manufactured) $14.40 a grain (60 mg.)

Heroin (Chinese) $3.60 a packet (30-60 mg.)

Methadone $7.20-$12.80 a grain (60 mg.)

Barbiturates 25 cents a capsule

There is no evidence anywhere that large numbers of hard-drug users are supplying themselves from this black market. Furthermore, there is no evidence at all that heroin manufactured in France-the principal source of supply for U.S. addicts-is being smuggled into England. The market just isn't big enough to make such an enterprise profitable.

Scotland Yard does keep track of international and particularly European illicit-drug activity. Its principal source for this information is not Interpol but the European office of the U.S. Bureau of Narcotics and Dangerous Drugs. The drug-squad detectives express a great deal of respect for their American colleagues and are quick to admit that, if they need information or have a common problem, they will call Paris rather than Interpol. Often, they say, an American narcotics agent will arrive on the next plane.

In 1970, the BNDD for the first time assigned a permanent man to the embassy in London, as part of its over-all European expansion of manpower. A London slot was created because of the LSD traffic from the United States to England and the marijuana and hashish flow from England to the United States.

John T. Cusack, the BNDD's European regional director, is not enthusiastic about the English clinic approach. Of all police officers interviewed, he was the most strongly negative about the clinic program. "The clinics are not going to work giving away heroin. They are going to sustain and create some addicts," he said.

He had three principal objections: " [I] It fools society. It kids all of us that it's doing a job when it isn't doing a job. [21 The addicts will take what they can get from the clinics and then they will get some more from the outside. [31 The clinics flirt with a conflict of the Hypocratic oath of the medical profession. They sustain a medical-psychiatric sickness." (This argument is also made by some British physicians, like Dr. Ian James, a British prison psychiatrist.)

Cusack, however, is not a throw-them-all-in-jail police officer. He wants medical treatment for addicts and believes that governments don't spend anywhere near what they should on hospital care for addicts. "I feel so strongly about it that I'd like to sweep up all the addicts off the New York streets and put them into hospitals. It's incredible to me to leave addicts on the street. It's a big, expensive job to bring them in, but we don't let our mental patients run loose, do we?"

If Cusack strongly disagrees with the English clinic philosophy, his London police colleagues sharply differ with their American counterparts over one vital aspect of the drug problem: the connection between crime and addiction. No one in England-from the toughest London detective to the most liberal-prescribing clinic physician-suggested to me that narcotics addiction increases criminal behavior. This does not mean, of course, that drug addicts are crime-free. On the contrary, a significant number of addicts engage in criminal behavior, and some criminals are addicts. But in England there is no cause-and-effect relationship.

Scotland Yard says it in writing. In a 1970 report, its drug expert wrote: "There is no concrete evidence to connect any particular criminal activity with those dependent on the 'hard' drugs (e.g., heroin) but without doubt, the increasing demand for the amphetamine-type drugs leads to thefts from chemists' premises, hospitals, and, in a smaller degree, to thefts of prescription forms."

Study after study documents the fact that sticking a needle into his arm doesn't propel a man into the robber and burglar fraternity. More likely, he will have been initiated long before. What these studies do show is that addicts often have a whole series of antisocial "hang-ups," of which addiction is just one more on the lengthy list.

In the previously cited 1970 study of 111 heroin addicts attending London clinics, 51 per cent reported a conviction for a nondrug offense before their first use of heroin. Thirty-six per cent reported such a conviction since using heroin.

A 1967 study of 50 addict-criminals in London prisons again indicates that a track record in court and prison often is established before track marks on the subject's arms.' Brixton Prison psychiatrist Ian James found that 22 addicts had a history of juvenile-court conviction and 16 had adult-court convictions prior to heroin addiction. In all, "Three quarters had a history of court convictions predating their addiction to narcotics, and there was usually a story of personal and social maladjustment dating from adolescence (educational dropout, employment instability, sociopathic conduct, etc.)."

Ten of the subjects had been convicted only since they became addicted, but only two were in prison for their very first conviction. Dr. James found, too, that, if one discounts drug convictions, fewer convictions for crimes were recorded after addiction than before.

Although it is risky to draw conclusions about United States addicts based on English findings, one young American doctor did suggest that what was true about preaddiction delinquency in Britain may be even more valid in the United States. Dr. Michael Paris, formerly on the staff of the Federal Hospital for Addict Rehabilitation at Lexington, Kentucky, worked with Dr. Bewley in 1970 in his London clinics. Asked to compare U.S. and British addicts, he said that the Americans he saw at Lexington had bad at least twice as much antisocial behavior in their early teens as the London addicts.

In the first study of heroin users in a provincial town, investigators found a reduction rather than an increase in crime after addiction began. Twenty of 37 heroin users had been convicted of breaking the law."

The crimes not involving drugs were generally petty in nature, such as stealing two pints of milk, minor shopliftng, and taking and driving away a motor vehicle. Of the ten people who had been convicted of nondrug offenses, three had committed them before using any drugs at all, and seven between first trying drugs and first trying heroin. There was only one person who was convicted of a nondrug offense after heroin use began, and this person had already been convicted of such a crime before the onset of heroin use.

These findings prompted investigators to suggest further research:

Many of our subjects were in full-time employment or were full-time students; most were still living at home with their parents, a high proportion of whom knew of their heroin use. Although there were instances of nondrug crime before heroin use began, there was only one such conviction (a second offense) afterwards. Whether drug use is for some people an "alternative" to other types of delinquent behavior is a question which suggests itself for investigation and remains open, but it is clear that our sample in no way constitutes a drifting criminal subculture,

RESEARCH

Until 1967, research in drug addiction in England depended on the personal interest of a physician. A handful of doctors wrote papers based on their personal experiences with addicts. Public awareness of the problem still was slight, and concern and knowledge among doctors in general were not much greater. Funds for research simply were not available.

Today, the veterans of the predrug-crisis era continue to produce papers for both national and international medical publications, but they have been joined not only by individual newcomers but by a government-supported research project as well.

The Addiction Research Unit is a kind of scientific conglomerate that investigates three of man's major vices-drinking, smoking, and drug addiction. The unit, a part of the Department of Psychiatry of London University's Institute of Psychiatry, began in 1964 as an alcoholism research group. In 1967, after the Brain Committee report was translated into legislation and public concern heightened with the catapulting addiction statistics, political pressure prompted the Health Department to provide funds for drug-addiction research. Drug investigations were added to the unit's agenda, and sufficient funds were supplied to construct a separate building on the grounds of Maudsley Hospital. Research on smoking was added in 1969.

Each area of investigation has a separate staff and coordinator, with the largest number in the drug-addiction field. Dr. Griffith Edwards, whose earlier interest was in alcoholism, is director of the entire unit, and Dr. David V. Hawks, a psychologist, is coordinator of the eleven-man (and woman) Drug Research Group.

Another organization, the Institute for the Study of Drug Dependence, a privately financed group, does no clinical research, although it is looking for funds to finance both clinical and other investigations. The Institute, with Sir Harry Greenfield as board chairman, is directed by a retired foreign-service officer with a personal interest in addiction. In the two years since it began, this struggling enterprise-financed by small foundation grants-has carved out a useful function as an information clearinghouse. It is the one place in England where a researcher can find extensive, indexed, and easily available material on the English drug scene as well as numerous items involving other countries.

Until now, the national Department of Health has done no specific drug-addiction research of its own. In 1970, a joint committee of the Health Department and the Home Office was created primarily to try to straighten out the sometimes confused drug statistics. It recommended establishment of a Drugs Research Group to be staffed by both agencies. While no specific research program was proposed, the committee suggested the following areas of investigation:

1. Developing a typology of heroin users.

2. Measuring the effectiveness of different forms of treatment in the existing clinics.

3. Comparing the effectiveness of compulsory treatment (in prison) with voluntary treatment in hospitals.

More important, perhaps, was the committee's recommendation that statistical information be compiled on all persons addicted to any dangerous drug in England and Wales. The Department of Health is now building such a data bank, which already includes a total of 2,400 names, with the basic information obtained when an addict applies to a clinic or is hospitalized. Other government statistical records to be tapped include:

1. Dates and causes of death from the General Register office.

2. Admissions and length of stay in psychiatric hospitals from the Department of Health and Social Security records.

3. Details of employment histories, sickness and unemployment payments from the Department of Health and Social Security's Mental Health Inquiry Records.

4. Criminal records and prison statistics from the Home Office Statistical Division.

This will be a vital resource for investigators and will open numerous research opportunities into drug addiction in England.

THE STATISTICS

How accurate are the drug statistics in England today?

It is difficult to generalize. Some statistics are clearly more solid than others. A number of persons interviewed expressed skepticism about the validity of one or more sets of statistics. Included among the skeptics was a Department of Health official who works with the drug numbers.

The problem with the statistics is that reporting depends on individual physicians and clinic personnel whose information is not channeled through a system of cross-checks. The new Health Department data bank should help to improve the accuracy of some of these statistics.

Among the numerical data available, the clinic figures reporting quantities of drugs prescribed appear to be least open to significant error. Apart from an occasional bookkeeping mistake, these statistics should accurately reflect the downward trend of heroin use and the rise in methadone.

The monthly clinic-attendance figures should stand up. However, the number of new addicts that clinics report every month may be a somewhat soft statistical area, because clinics may vary in their definition of a new addict.

The clinic figures for the percentage of addicts employed could be on the high side, since "employment" depends on the individual's definition, and the accuracy of the addict's statements is questionable. The data bank, which will include employment records based on social-security information, should provide a cross-check for these claims.

The vital Home Office figures on addicts have to be separated into addicts reported any time during the year and addicts known to be receiving drugs at the end of the year.

The figures for the total year tend to be accepted as reasonably correct by those interviewed, with the general acknowledgment that obviously not every addict in England is known to the Home Office. However, no one suggested that the number of "unknowns" is as large as the numbers listed. Opiate addiction, under the English drug approach, is difficult to conceal if it is taking place on any significant scale. The highest estimate for unreported opiate use was 25 per cent, but this guesstimate included occasional users as well as addicts.

The Home Office figures for 1968 may be unusually high because inauguration of the clinics may well have flushed out previously unknown addicts. As a result, the tiny increase in the total 1969 figures may not accurately reflect the degree of change. Not until the end of 1970 did England have a firm statistical basis for concluding that the narcotic-addiction spiral of the 1960's had been halted.

RESULTS

There is a shortage of hard statistical data about the success or failure of Britain's drug approach, either before or after the clinic program was begun. Most available evaluations were done prior to the inauguration of the clinic program. These do not generate applause.

For example, in 1968, a study of 1,271 heroin addicts who became known to the Home Office between 1947 and 1966 showed that 70 per cent were still taking opiates in 1966." Of the nontakers, some 293 addicts-64 per cent-were in prison, hospital, or other institutions, and 89 were dead, the majority as a result of overdose, suicide, or sepsis.

The death rate among English addicts has been very high according to the Bewley study, twice as high as among U.S. addicts. However, this study was conducted prior to the clinic program, when British addicts were receiving huge amounts of heroin prescribed by general practitioners. The death rate among addicts included in this review was 28 times greater than the rate for the equivalent age group in the general population.

Studies of withdrawal treatment in hospitals are not more encouraging. In one follow-up of 23 hospital admissions, 12 relapsed within a week, five within a month, and three within two months. Only three were still avoiding narcotics three months after discharge."

Like their American brethren, the English today have no file folder marked "cures"; there is no computer printout on clinic performance that supports either the critics or the defenders of the program.

There is, however, a cautious thread of optimism that runs through conversations with clinic directors and also a surprising degree of candor in identifying areas of shortcoming and outright failure. Furthermore, these subjective evaluations by different directors generally make nearly identical points of both promise and disappointment. Finally, they are echoed by those who have no particular vested interest in the clinics.

Dr. Margaret Tripp, a doctor at St. Clement with no previous experience with drug addicts, frankly admits that her charges conned her in the beginning. Two years later she said: "I think we are controlling legal heroin. Much to my surprise, we have stabilized the addicts-they're not dead, and they are better. They are more stable than before; their drug use has gone down, they work longer, and they are less of a nuisance to everybody."

Dr. Tripp chooses her words very carefully: "Three or four of the [present] cases are reasonably off drugs."

Dr. Willis, at St. Giles, also avoids words like "success" and "cure." He also cites the drop in heroin and agrees that the rise of addiction has slowed. "It's been possible to mount a general tidying-up operation. They are more stable now than they were a year ago. Their general appearance is better. They are not asking for more drugs, and they are not claiming as much drug loss [in order to obtain replacements] as they did before."

Dr. Connell, who is among the handful of English drug-treatment veterans, a consultant to the national Health Department and director of the Maudsley Hospital drug clinic, summed it up this way:

I'm pleased that the frightening curve of heroin addiction has leveled off. I'm disturbed that methadone and barbiturates have risen. In terms of containing the heroin problem, they [the clinics] are successful. They have provided some treatment services where none have existed. All of the terrible prognostications of American workers in the drug field have been unfounded. But [Dr. Connell added] in terms of research they are a failure.

Similar sentiments are voiced by those who are being asked to evaluate their own work.

Even the most hardened policeman-as we noted in the law enforcement section-is not prepared to suggest that England should scrap the clinics. Despite the grumbling about doctors who are either too softhearted-in the eyes of the police-or simply conned by addicts, the interviewer is left with the distinct impression that even law-enforcement officers believe that the hard-drug picture has improved somewhat.

Among druggists, there also is cautious optimism for the clinic approach. For example, Jerry Young, chief chemist at Boots Picadilly, says flatly:

I'm very pleased with the clinic system. I'd even be more pleased if they'd take the whole thing in their hands [administer drugs directly in the clinics]. We see more stability in the addicts. They don't come in making exorbitant demands on our service and our time. The genuine addicts are less of a nuisance. On the whole, they took physically better. They respond better.

Asked for some tangible proof of his assessment, Mr. Young said that, prior to the spring of 1968, when the clinics began, he had to call the police on the average of twice a week to control an unruly addict in his pharmacy. Now, he said, he can't remember a recent call for police assistance with a clinic addict. Occasionally, he asks police help with a forged prescription or when someone under the influence of barbiturates makes a disturbance.

Mr. Young's analysis, like those of the physicians who send him prescriptions, is subjective. However, there are at least a few statistical indications-developed since the clinic program began -that tend to support these assumptions. To find them, you have to go to an institution dealing with a considerably larger clientele than drug addicts.

Brixton Prison, with its incongruous flower-filled inner courtyard, is to London what the Tombs is to New York. It is a remand prison, where all London-area male prisoners are brought while awaiting trial. There are 12,000 "receptions" there annually.

Brixton, in 1970, had on its staff the one man who may have seen more English drug addicts personally than any other individual. Dr. Ian James, the prison psychiatrist, has a long interest in drug addiction. His small prison office is lined with maps showing the routes by which drugs come to England, the location of addict arrests in London, the location of clinics, the arrests of those who are off drugs-all appropriately marked in clusters of multicolored pins.

In 1969, Dr. James saw 223 drug addicts who were at Brixton for both drug and other offenses. They represented about 10 per cent of all heroin addicts reported to the Home Office during the year. Significantly, Dr. James said it was rarely that he saw an addict unknown to the Home Office.

Dr. James in the past has been a vocal opponent of the clinic program. His opposition was based largely on medical ethics.

Nobody prescribes two bottles of gin a day with duly enriched Vitamin B for alcoholics. The doctor knows that the addict will use an unsanitary procedure to satisfy his habits. He will take unsterile pills [heroin tablets], hold them in his sweaty hand, and put them in a syringe which he pulls from his grimy pocket. What kind of medicine is that?

But Dr. James's own statistics are softening his anticlinic stand to the point where he said: "I think the clinics are succeeding, but on the wrong premises."

Dr. James's accounting may not give overwhelming proof to the statement that the clinics are having a positive impact, but it does add some significant bone behind the subjective flesh of cautious optimism.

In 1970, a third fewer drug addicts were admitted to Brixton than during the previous year, Almost three-fourths of all addicts received at Brixton in 1970 were attending a drug-addiction clinic prior to their arrest. In 1968, only three-fifths of the drug addicts were clinic-registered.

These statistics not only buttress the cautious optimism of English drug experts but also cast doubt on any contention that there is a large addict population unknown to the Home Office or to the clinics. If such an "unknown" addict pool in fact existed, sustaining itself from the high-priced black market, a significant number of its members surely would appear periodically inside the steel gates of Brixton.

There are other substantive indications that the narcotics situation is improving. At three London centers, the number of addicts holding jobs almost doubled in two years. In these same clinics, a series of urine tests given a year apart showed that, while many addicts still were taking more and different drugs than those prescribed, such misuse had been reduced." In yet another survey, there were fewer arrests a year after addicts had been with a clinic than before.

But what does all this mean for the United States? What relevance does it have to America's ever-increasing narcotics problem? In the past, almost all visiting American drug experts have said flatly: None." The two countries, they said, are just too different. Not only do some key narcotics laws point in opposite directions, but the two societies' traditions, youth culture, and race problems are so disparate that what works in the row houses of London could not possibly work in the walk-ups of New York.

A young researcher at the Addiction Research Unit may well have given an explosive jolt to such blanket dismissals. Jim Zacune, a social psychologist, in 1970 examined in detail the performance of Canadian addicts in their native land and after they emigrated to England. His study is significant to the U.S.-Britain narcotics-policy argument, since Canada's approach to opiate addiction is largely patterned after ours.

Zacune traced and interviewed 25 of the 91 Canadian addicts who are known to have come to England in the 1960's. The rest of the emigres could not be located or had either died or been deported. For those he was able to interview, Zacune compared work records, prison records, and crime records in the two countries. He diplomatically says that his findings should not be used to condemn one country's addiction approach while praising another's, and cautions that his sample may have included the most stable of the Canadians who packed up their syringes for England. But his findings are nevertheless startling:

At home, the Canadians spent 25 per cent of their addicted years, a combined total of 141 years and 2 months, in jail; in England, less than 2 per cent, a combined total of 2 years and 5 months.

At home, they compiled 182 offenses; in England, 27.

At home, in the high addict-crime category of theft, which included robbery and burglary, they committed 88; in England, 8.

Not only did they commit far fewer crimes, but, while in England, many of them were crime-free. In Canada, 16 of the 25 had committed five or more crimes, with one of them recording more than 20 separate offenses. In Britain, none committed more than four offenses and nearly half (12) were never charged with any unlawful behavior.

Despite the fact that the Canadians consumed far more daily heroin than the London average, many of them became job holders and led fairly normal lives while in England. Their living accommodations were far more stable. In Canada, only five had a constant residence for more than three years; in England, ten had lived at their present address for two or more years, eight for one to two years, and five for less than one year. Two were in the hospital at the time of the survey.

The employment record showed the most dramatic difference between the two countries. In Canada, only one addict claimed to have worked steadily while addicted. In England, the majority (13) worked full-time, and four worked part-time. Six had held the same job for at least three years. Seven had semiskilled or skilled manual jobs, two were office workers, one in sales, and one worked as a croupier. One was a full-time housewife and one a student. "For once we could work and live like humans," the addicts said. The interviews contained again and again this and other personal and pragmatic assessments. "There is less trouble from the police . . . we don't constantly have to be paranoid . . . there is less pressure . . . there is no need to steal."

This study may encompass too small and special a group of addicts to permit definitive conclusions. But, together with the other fragmentary evidence, it suggests that the English approach is an alternative not to be dismissed summarily, as it is in a widely distributed U.S. Government pamphlet, which claims that "The British system is considered a failure and has been modified to meet the increasing problem of addiction.""

PERSONAL OBSERVATIONS

For the American visitor, the most pervasive impression of the English drug scene comes in the form of a question:

Why has the United States, decade after decade, continuously viewed narcotics addiction as largely a criminal, instead of a medical, problem?

With all its imperfections and inconsistencies, the British approach to drug addiction convinced me that the United States will never make significant headway with the drug problem until it shifts the emphasis from the criminal to the medical. Until this national policy is changed, American addicts will continue to be an ostracized subculture-morally exiled and often barred from the very medical and social-work help they need so desperately, but physically very much present in the criminal countdown of the larger society, which has had to lock itself behind doors for the luxury of guarding an unworkable dogma.

Until this national policy is changed, the black market will continue to flourish no matter how many more narcotics agents are enlisted, and daily will help to infect others, because of the astronomical profits to be made.

Based on my research in England, I believe that the United States should experiment with both a methadone- and -a heroin maintenance program under more controlled and restrictive conditions than generally prevail in Britain today.

I believe that England provides significant research opportunities about the effects of different opiates, which could fill the knowledge void that is plaguing the addiction field in so many countries. For example, what is the precise difference between the effects of heroin and of injected and oral methadone? What are the differences in work performance, antisocial behavior, and life-styles among addicts who use heroin and injectable and oral methadone? Because heroin addicts can be observed in England under relatively controlled circumstances, a whole series of comparative clinical and sociological studies are possible.

No simple "yes" or "no" answer can be given to the question: "Is the British approach to addiction a success or a failure?" The question itself may not be valid in a field that has so much difficulty with the word "success." A more accurate question may be: Is the British approach to addiction helpful or harmful? Even then, the answer may only be "Yes, but . . ."

Can the British and American approaches to addiction legitimately be compared? The study of Canadian addicts' performance in England certainly suggests that such comparisons no longer can be dismissed out of hand. In England, at least, comparisons are made. Everywhere I went, opinion on this was uniform. On my final day in London, a Home Office official, whose knowledge of drug addiction has brought him an international reputation, summed it up:

"We don't want to force our system on you, but for God's sake don't bring your system over here."

NOTES

1. The Second Report of the Interdepartmental Committee on Drug Addiction (Brain Committee), para. 22, July 31, 1965.

2. There are about 500 British physicians licensed to prescribe heroin and cocaine to addicts. This is a far larger figure than the actual number of physicians working within the drug clinics. However, a special license to prescribe these drugs has become part of the British medical profession's kitbag of status symbols. The Home Office is hopeful of reducing this figure.

3. That is enough heroin to support over 800 American addicts with a $20-a-day habit for an entire year.

4. National Health Service, The Treatment and Supervision of Heroin Addiction, memorandum issued March 7, 1967.

5. Ramon Gardner and P. H. Connell, "One Year's Experience in a DrugDependence Clinic," The Lancet (1970), pp. 455-58.

6. G. V. Stimson and A. C. Agborne, A Survey of a Representative Sample of Addicts Prescribed Heroin at London Clinics, Addiction Research Unit, 1970.

7. Martin Mitcheson et al., "Sedative Abuse by Heroin Addicts," The Lancet (March 21, 1970) @ pp. 606-7.

8. Op. cit., p. 370.

9. 1. Pierce James, "Delinquency and Heroin Addiction in Britain," British Journal of Criminology (April, 1969).

10. Kosviner et al., "Heroin Use in a Provincial Town," The Lancet (1968), i, pp. 1189-92.

11. Bewley, ben-Arie, James, "Survey of Heroin Addicts Known to the Home Office," British Medical Journal (1968), 1, pp. 727-30.

12. Zacune, Mitcheson, and Malone, "Heroin Use in a Provincial TownOne Year Later," International journal of the Addictions (1969), IV, 55770.

13. Bewley, James, and Mahon, "Effectiveness of Prescribing Clinics for Narcotic Addicts in the United Kingdom," 1968-70. A paper, presented at the International Symposium on Drug Abuse, University of Michigan, Ann Arbor, on November 9, 1970, evaluating the efficacy of such clinics.

14. Among the few exceptions was Professor Alfred R. Lindesmith of Indiana University, who has concerned himself with the drug problem for more than thirty-five years. He was a defender of the British view of addicts as sick people long before England moved to the clinic approach. Because of these views, Professor Lindesmith has been one of the academic betes noirs of the old U.S. Bureau of Narcotics, predecessor to the present BNDD, as well as to the drug professionals who in the past shared its addicts-are- criminals view.

15. A Federal Source Book: Answers to the Most Frequently Asked Ouestions About Drug Abuse (Government Printing Office, 1970), p. 25.

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