British System of Drug-Addiction Treatment
BRITISH SYSTEM OF DRUG-ADDICTION TREATMENT
To many observers from outside the United Kingdom (U.K.), the British System is synonymous with heroin maintenance, with doctors supplying drugs on demand to addicts. To some it has been viewed as an approach of extreme folly; to others it is an effective policy of supreme pragmatism. To those who know and work within it, the British System is somewhat more complex. Indeed, the extent to which a clearly defined system can be identified has been the focus of debate. Here, we will demonstrate that a particular set of factors have combined in the U.K. to create an evolving system of care for drug takers, which has been responsive both to the changing drug scene and to the individual needs of the drug taker. This review will identify the key characteristics of the British System. Important historical milestones in the development of the system will be identified. Finally the effectiveness of the system will be discussed.
WHAT IS THE BRITISH SYSTEM?
Since a key characteristic of the system has been its evolution during the twentieth century, observers at different stages in this process have had different views as to its nature and purpose. This late twentieth-century view proposes the following five characteristics of the British System:
1. An Evolving System of Health and Social Care for Drug Takers. Since the 1920s, the British policy toward addiction has been principally in the form of treatment conducted by medical practitioners. This differed from most other jurisdictions, particularly the United States, where addiction was deemed a deviant and criminal activity under the Harrison Narcot-Ics Act (1914) through and until the revisions of the late 1960s and early 1970s. While the burden of care for drug takers has expanded over time from the general practitioner to specialist psychiatrist and then back to the generalist (often the general practitioner), the British System has to a large extent been located in the public-health sector, latterly in the National Health Service. Specialist drug-dependence clinics were established throughout the U.K. from the 1960s onward.
Two important consequences of the emphasis on health rather than correctional services have been (1) the attention to the health and social needs of the drug taker—particularly crucial in the wake of the recent human immunodeficiency virus (HIV) epidemic in injecting drug takers, and (2) the opportunity to influence the development of public-health strategies on a national scale through the existing system of health-care services. This second point has been important in the rapid development of new services, including injecting-equipment exchange schemes in the 1980s as a public-health measure to reduce the spread of HIV.
2. Control and Monitoring of Drug Takers and Their Physicians. The extent to which the British System has aimed to exercise control over drug takers has been variable. However, part of the purpose of prescribing drugs in the context of addiction treatment (see below) has been to attract drug takers to have contact with statutory services. An index of drug takers (mainly of Heroin and Cocaine) known to physicians has been maintained by the Home Office since 1968. This has allowed some indication of the scale of the problem to be known as well as preventing individuals from attending more than one clinic. At the same time, in response to concerns over irresponsible prescribing by certain physicians, only those physicians in possession of a special license issued by the Home Office were entitled to prescribe heroin and cocaine to drug takers. Although the recent (early 1990s) policy has been to encourage the increased involvement of general practitioners in prescribing Methadone, the prescribing behavior of all doctors in relation to addictive drugs remains closely monitored.
3. Drug Prescribing. The overall contribution of drug prescribing as a component of the British System has been important, but overestimated by some. Certainly, the right of physicians to prescribe, and drug takers to receive, addictive drugs in the context of treatment has been a key part of the British System since its inception. At various times, opiates (including injectable heroin and methadone), cocaine, Amphetamines, and Barbiturates have been prescribed in this context. The aims of such prescribing, as well as the prescribing practices, have varied over time. The principal aim throughout has been to provide a method of detoxification that is as comfortable and medically safe as possible. It has also been accepted at a policy level, however, that some individuals who are either unable or unwilling to stop drugs may require long-term prescribing, with a view to stabilization or maintenance treatment—in some instances with injectable drugs. Since the 1970s, oral methadone (in the form of tablets or linctus—a syrup) has been the opiate prescription of choice in view of its greater safety and lower resale value on the black market. The prescription of other drugs had largely ceased in this context by the mid-1980s. Heroin prescribing and the prescribing of injectable methadone still have a few proponents, despite a lack of controlled scientific evidence to support their effectiveness (see below). Although there is international interest in the right of British doctors to prescribe injectable heroin, fewer than 200 patients receive such treatment (in the early 1990s). Of more interest is the prescribing of injectable methadone as a potential intermediate step in converting the heroin injector to oral methadone.
Drug prescribing within the British System has been characterized by a greater permissiveness and flexibility than is the case in most other jurisdictions, alongside a continued overall conservative approach by most medical practitioners to prescribing agonist drugs to the drug abuser.
4. Competition with the Black Market. A prominent aim at various times in the history of the British System has been that of attracting the drug taker away from the black market and into treatment. The putative benefits of such a scheme would be to remove demand for illicit drugs, leading to elimination of the black market; improve health benefits to the drug user for taking pharmaceutical rather than illicit drugs; and reduce criminality associated with purchasing illicit drugs. While there were relatively few heroin takers in Britain until the 1960s, the continued nonexistence of an imported black market meant that prescribed heroin was the main source of supply, but it actually contributed to a growth in the number of drug takers. Since no convincing evidence has emerged to support the value of this approach, the prescribing of drugs has become based more on individual medical indications than on economic policy.
5. Flexibility. Perhaps the most striking feature of the British System has been its capacity to evolve in response to the changing drug problem. Whether this has been the result of deliberate policy or benign laissez faireism is open to debate. The result has allowed a flexible response without overt government intervention in medical practice (beyond the constraints described). Flexibility has been possible at two levels. At the system level, experiments in the provision of a range of services have been possible, including a wide range of drug prescribing-and-injecting equipment exchange schemes. At the individual level, treatments may be tailored to individual needs rather than having the imposition of tightly restricted, prescriptive, and blanket approaches.
MILESTONES IN THE HISTORY OF THE BRITISH SYSTEM
Introduction of the Dangerous Drugs Act following the International Opium Convention at the Hague (1912). This restricts the dispensing of several drugs to physicians, including opiates and cocaine.
The Rolleston Committee publishes its report (see Rolleston Re-Port), which establishes the right of medical practitioners to prescribe drugs in the context of the treatment of addiction.
Small numbers (approx. 400-500) of mainly "therapeutic addicts" and addicted physicians receive opiate prescriptions as treatment for addiction.
The first Brain Committee publishes its report. In reviewing the period since the Rolleston Committee's report it reaffirms the medical practitioner's role and recommends no change in the system.
A small number of physicians, mainly in London, are prescribing large quantities of heroin leading to a rapid increase in the number of heroin injectors (in-creasing to 2,000 in number) and growing public alarm.
The Brain Committee is reconvened to consider the increasing problem and publishes its second report. It recommends several restrictions including (1) the establishment of specialized treatment clinics, (2) the licensing of medical practitioners for prescribing, and (3) the Home Office Addicts Index.
The Dangerous Drugs Act implements the recommendations of the Brain Committee and prohibits physicians from prescribing heroin or cocaine to drug takers (except for the purpose of relieving pain caused by organic illness or injury) unless specially licensed by the Home Office. This practically restricts prescribing to the newly established specialist clinics.
An epidemic of heroin taking occurs on a scale not previously encountered in the U.K.—mainly as a result of new illicit trade routes opening up from the Golden Crescent (Iran, Pakistan, Afghanistan, etc.) to supplement the Far East's Golden Triangle trade. The epidemic is mainly among young Caucasian males in inner city areas throughout the U.K. and leads to a rapid increase in crime (to support the habit). The estimated number of heroin takers increases from around 20,000 in the early 1980s to as many as approximately 150,000 by the end of the 1980s.
The Advisory Council on the Misuse of Drugs (ACMD) publishes its Treatment and Rehabilitation report. The specialist clinics are overwhelmed by the upsurge in demand; a new recognition emerges that drug takers represent a heterogeneous group, many of whom do not require specialist treatment. The report recommends (1) an expanded role for the generalist, (2) the development of nonmedically based treatment approaches, and (3) a requirement for health authorities to monitor the scale of heroin problems in each community. This results in more restrictive opiate prescribing and a broadening of the range of treatment options.
Guidelines for Good Clinical Practice in the Treatment of Drug Misuse are published. This is the first central guidance to physicians since the inception of the system, which indicates the flexibility of practice that physicians had been accorded.
The ACMD publishes two reports on AIDS and Drug Misuse. This major policy review is prompted by the epidemic in HIV infection in injecting drug takers. The reports recommend greater emphasis on attracting and retaining in treatment drug takers unable or unwilling to change their behavior. This results in less restrictive opiate prescribing practices, the introduction of low threshold and user friendly services, and the further expansion of injecting-equipment exchange schemes through the late 1980s and early 1990s.
New Guidelines for Good Clinical Practice is published. These are written by physicians for physicians and aimed at the generalist.
Targets for reductions in drug injecting are introduced as part of the British Government's Health of the Nation white paper—and also formed a part of the AIDS response.
The ACMD's third report on AIDS and drug misuse is published. The constituency of concern is broadened from opiate injectors to those who inject amphetamines and Benzodiazepines. Recommendations include a focus on the impact of hidden drug-taking populations, through outreach, and the introduction of oral methadone programs (along North American and Australasian lines).
HAS THE BRITISH SYSTEM BEEN EFFECTIVE?
Clearly, the question of effectiveness is difficult to answer in the context of a national problem subject to many external and internal influences, within a system that has evolved over many years. Further, it is difficult to compare the effects of policies toward drug problems in various countries: Drug problems are often culturally specific, and attempted solutions that may be acceptable in one setting may be unwelcome or unhelpful in another. On one level, it is clear that the U.K. has not been spared the epidemic rise in heroin taking experienced by other Western industrialized countries; nor has it avoided the spread of HIV in intravenous drug takers—however, the epidemic of HIV has been far less severe than in several other European countries and in the United States. Regional variation in the pattern of the HIV epidemic in the U.K. suggests that the areas where prescribing and specialist clinics were limited, such as in Edinburgh, Scotland, experienced a much more rapid spread—although closer examination reveals this to be insufficient as the sole explanation.
At times, there have been disadvantages to the British System. In particular, a situation where addictive drugs were overenthusiastically prescribed contributed to a worsening of the problem. Further, the U.K. experience with barbiturate and amphetamine prescribing was wholly negative and resulted in its complete discontinuation.
At an individual level, remarkably little controlled research has been carried out to evaluate different prescribing or other treatment approaches, given the opportunity available to do so in the British System. One controlled trial with ninety-six heroin takers involved the random assignment to either injectable heroin or oral methadone maintenance. The results suggested advantages and disadvantages in both treatments. At one year follow-up, more in the methadone group were abstinent than in the heroin group, but more had also returned to illicit drug use in the methadone group.
With the increasing emphasis on treatment in the primary care setting in the 1980s, specialist Community Drug Teams were established with the brief of encouraging the increased involvement of general practitioners. The main advantage of such an approach is, in theory at least, that this should allow greater availability of services than could be provided by specialist clinics alone. During the 1990s, there has been an important but modest increase in the extent of general practitioner involvement, but this still falls short of the goal of universal availability of treatment for drug takers.
Overall, it can be said that the principal benefits of the British System have been (1) to ensure the humanitarian handling of drug takers, through treatment services, and (2) to allow the evolution of a system of care responsive to changing needs—which also has been relatively free from unnecessary governmental constraints.
(See also: Britain, Drug Use in ; Injecting Drug Users and HIV ; Needle and Syringe Exchanges and HIV/AIDS )
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D. Colin Drummond
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