Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Anthony Cullen (DP029)

Executive Summary

Different drugs suggest different approaches to control. This document is concerned only with possible changes to the law regarding misuse of cocaine and heroin.

A Royal Society of Medicine expert symposium in 1995 “Alternative approaches to control of misuse of cocaine and heroin” concluded that the control policy at that time would never work and predicted that the situation could only get worse. This has happened, and changes to the law are now urgently required.

Government policy has failed because it has not been able to control the illegal retail trade in cocaine and heroin that produces such large profits and therefore perpetuates the cycle of addiction.

Illegal suppliers of cocaine and heroin must be driven out of business by competition: supply of a better product at a lower price. The Government is best placed to do this.

To deprive illegal suppliers of their trade, the Government must license cocaine and heroin users. Licensed users would obtain pharmaceutical grade cocaine and heroin from pharmacies for a nominal price. They would be immune to prosecution, whereas unlicensed users would face more severe penalties than now.

The licensed users would supply samples for testing and would be able to engage with counselling agencies.

Death and disease amongst licensed users would be greatly reduced because they would have purified and standardised products and recourse to medical help.

As licensed users no longer had to pay high prices, they would no longer need to turn to acquisitive crime and prostitution to support their addiction. Most users would therefore prefer to be licensed and would no longer buy illegal products. The prison population would be greatly reduced and crime associated with drugs would fall.

Over a period of time illegal suppliers would have fewer and fewer customers until they went out of business. They would no longer be recruiting new addicts.

Use of cocaine and heroin would remain illegal, except under licence, and therefore our international legal obligations would not be eroded.

Experience with the General Medical Practitioner prescribing of cocaine and heroin to addicts some decades ago suggests that this policy would work. It should be put into effect with monitoring of results to obtain factual evidence.

The rationale for this change in policy and the details of the way it would be implemented are described below.

Introduction to the Submitter

This submission is made by Gavin Anthony Cullen PhD BVetMed DipBact FRCVS. Most of my professional life was concerned with veterinary research. Much of my work was concerned with infectious diseases transmitted from animals to people. Because of this I became much involved with the Royal Society of Medicine, and was elected a Vice-President 1993 to 1995 (the only non-medical vice-president). At that time I already had a layman’s interest in the problems of drug dependence, especially misuse of cocaine and heroin.

In 1995 I organised and chaired a Royal Society of Medicine one day expert symposium “Alternative approaches to controlling the misuse of cocaine and heroin”. Leading experts took part. A report of the meeting is attached (Appendix 1). Later I realised that the right approach for cocaine and heroin is to license the users. For some year I have been trying to interest policy makers in this idea, which I am convinced is the solution that is needed, but to date Government has been unwilling to consider alternative approaches.



Proposal to Improve Control of the Misuse of Cocaine and Heroin in the UK


1. For some decades there has been concern about the ineffectiveness of UK policy on the control of dangerous drugs. The British Crime Survey of 2009–10 showed that self-reported drug use in the last year in England and Wales for Class A drug use was 3.1% compared with 2.7% in 1996, an increase over 13 years of 14.8%. Total use is likely to be much higher. Government policy has focused on prohibition, with measures to prevent import of dangerous drugs and severe penalties for possession or use of cocaine and heroin.

2. A new approach is required, and it is suggested that policy should be based on the long-term objective of ending the trade in cocaine and heroin, rather than short-term concerns about the number of drug users. Supply of illegal cocaine and heroin is a very lucrative retail business. The enormous profits empower the criminal suppliers and drives the recruitment of new addicts. It can only be stopped by competition: supply of a better product at a lower price. The Government is best placed to do this.

3. It is not an option to make cocaine and heroin legally available for sale to the general public because of our international obligations and because this would be going much too far, and be unacceptable to the majority of people of this country. Simply giving up arresting people found with these drugs would leave the supply in the same criminal hands, with dealers continuing to recruit new addicts, and all the other attendant problems

4. It is suggested that people who need cocaine and heroin should be able to apply for a personal licence, to enable them to use the drugs without fear of prosecution. The Government would supply licensed users with pharmaceutical quality products. Past experience suggests that addicts given properly standardised drugs can use them more safely and be more able to lead an acceptable life style. This used to be done, on a very limited scale, through General Practitioners who were themselves licensed to prescribe these drugs.

5. At the same time more would be done to help addicts who were licensed users to reduce their consumption of these drugs and lead more normal lives.

6. Objectives

The main purpose is to greatly reduce the amount of money paid by UK drug users to overseas drug cartels, leading in time to the drying up of illegal importations.

To reduce the harm to society due to the acquisitive crime and street prostitution associated with cocaine and heroin misuse.

To enable addicts to live more normal lives, with better contact with health and counselling services.

To help addicts reduce consumption, with less risk of disease and death.

To reduce criminal activity and associated drug gang violence.

To reduce the prison population by removing many drug addicts.

To reduce the high financial cost of the present drug control policy.

7. Proposal

The proposal is that cocaine and heroin users should be licensed.

8. Method

Any adult citizen who wished to become a Licensed Drug User could apply for a licence. (The minimum age would be for consideration. Some users start at a very young age.)

9. The first step towards getting a licence would probably be a consultation with a registered medical practitioner. GP practices would be invited to identify a member who would be happy to work in this area. Guidelines to establish standard procedures would be issued. (There might also be special units at hospitals, and Police Surgeons might have a role to play.) The drug user’s needs would be agreed (based on previous usage) and an application form completed and signed by the doctor and the applicant. The doctor would send the application to the Licensing Authority (The Home Office) together with the applicant’s fee (Suggested fee £50: free to those on benefit).

10. The Licensing Authority would issue a licence to the applicant. It would be subject to annual renewal. Names of licensed persons would be on a register, but not in the public domain. The Licensee could then take their licence to a pharmacist and obtain one week’s supply of drug(s) as stated on the licence. The licence would have a page with weekly spaces and the pharmacist would stamp and date the page to record the transaction. The Licensee would, in front of the pharmacist, provide a hair sample or sputum sample for testing.

11. The pharmacist would charge the Licensee the standard fee for an NHS prescription (free to people on benefit).

12. A licensed Drug User would be legally entitled to use the prescribed drugs without penalty.

13. The licensed user would be encouraged to make use of counselling and welfare services. They would need to return for a check up at intervals, at least once a year. (This is important because many users are at present afraid to approach any official body, such as Social Services, because they know that their usage is criminal and because of fear about other criminal activities they may be engaged in to pay for the drugs, including dealing in drugs. Therefore they absent themselves from possible lines of help.)

14. This legislation would be accompanied by much stronger penalties for anyone found to be in possession of or having used cocaine or heroin who is not a Licensed Drug User, because they would be paying the criminals who perpetuate the problem.


15. The consequences to the user would be to have a supply of purified, standardised drug at a low price, which would mean that they no longer had to turn to crime or prostitution to pay high prices for illegal drugs. They could use the drugs in a more informed way with much less risk to their health. They would be free of fear about prosecution and would not be imprisoned. They would interact more with Social Services. This would, in many cases, allow them to return to a more normal way of life, perhaps getting employment and developing social contacts and a responsible attitude to society. This in turn could lead to reduced drug usage and eventual freedom from the drug habit.

16. In recent years a new class of user has emerged. These are affluent recreational drug users who are not true addicts, but cause much harm because their money flows to the drug dealers. They would be able to apply to be licensed. An affluent recreational user would have the choice of being licensed or facing very severe penalties if found using or in possession. This might persuade many that it is no longer a smart thing to take cocaine at a dinner party.

17. The many advantages of being licensed would mean that most addicts would apply for a licence, so that the drug dealers would then have very few clients. Addicts who are themselves dealers, to raise money for drugs for their own use, would no longer need to do so. The profitability which maintains the system, and which leads dealers to recruit new addicts, would have gone. The UK could then lose its present dreadful reputation as one of the countries with very high imports of illegal cocaine and heroin. The crime associated with drug gangs and turf wars would also go.

18. The UK could greatly reduce the amount of money spent trying to detect illegal importation of drugs and other aspects of the present policy, which have failed to produce any worthwhile results over recent decades.

19. Health Service costs would be greatly reduced because users would be able to maintain better health, mentally and physically, due to use of purified and standardised products.

20. There would be a gradual decline in the prison population as addicts were no longer imprisoned for drug offences (unless unlicensed).


21. A system of checks would be in place, to ensure so far as possible that the Licensee was using the supplied drugs and not accumulating them for sale. This could be done by hair or sputum sampling: samples taken each week but tested randomly. Even if some of the supplied drugs were sold on, at least the money would not be going to overseas drug cartels and the users would get the health advantages of pharmaceutical grade product.


22. An advantage of the proposed system is that the use of cocaine and heroin in Britain would remain illegal, except under licence. Our existing legislation could remain in force, perhaps requiring only an Order in Parliament to allow individuals to be licensed under certain circumstances (analogous to the laws on shotguns). Probably less than 1% of the population would be licensed. Our present international responsibilities would still be honoured.


23. There would be costs associated with the setting up and running of the licensing system. There would be savings in costs associated with detection of importation of illegal drugs and savings of costs associated with reduced involvement of the criminal justice system. There would be great savings due to reduction of health problems associated with impure and poorly standardised drugs and there would be much less acquisitive crime. The savings are likely to be more than enough to pay for the licensing system.

Other considerations

24. Crime. It has been suggested that if licensing was put in place, criminal activity would just be displaced elsewhere. This is not so. Regarding crime, there are two categories of person who commit crime in relation to cocaine and heroin. There are a relatively small number of drug suppliers/dealers who commit crime by selling the drugs. There is the much larger number of drug users who commit crimes, mostly acquisitive crime, to pay for their drugs. It is true that the former category of career criminals might well turn to other crimes when they were no longer able to find buyers for their drugs. That would have to be dealt with in the normal way. The great reduction in acquisitive crime would come about because the addicts would be able to get their drugs free or at low cost. Also, many addicts are also small scale dealers and they would be able to stop dealing. Many addicts say the problem is not the heroin, it is paying for it. Without having to meet the high cost, most would gladly refrain from crime and could begin to lead more normal lives.

25. Response of users. Drug users would need to be reassured that they could apply for a licence without fear of prosecution for past drug use. Some people might apply for a licence who were very light users. They should be given counselling and help with other problems but should not be refused a licence, because doing so would drive them to illegal suppliers, which would defeat the object of the legislation. A few more drug users, in the short term, should not be a concern. They would be getting the health benefits of high quality product and their money would not be going to criminals.


26. The way this is presented to politicians and the public is very important; it must not be seen as a policy that is “Soft on drugs”. It should be presented as a policy that is “Hard on the dealers in hard drugs: drive them out of business.”

January 2012



Royal Society of Medicine
14 February 1995

The meeting began with a welcome by Dr Anthony Cullen, Vice President of the Royal Society of Medicine. He said that the subject of the meeting was a controversial one, and that the RSM itself held no view of its own. It remained outside political movements, but wished to provide a forum for discussion of important issues, and to encourage free debate amongst experts. The thinking behind this meeting was that there are a lot of observations and publications on the misuse of cocaine and heroin which need further discussion and evaluation. It was hoped that a meeting of this kind could identify the areas which deserve more active research or wider trial and application. To avoid the meeting becoming too diffuse, the speakers had been asked to restrict their observations mainly to cocaine and heroin and to focus their presentations on efforts to reduce the harm caused by these drugs to society as a whole.

The morning was devoted to the present approaches to drug misuse, and the first session was chaired by Dr Virginia Berridge (LSHTM), who introduced the first speaker Professor David Nutt (University of Bristol) who spoke about the clinical effects of cocaine and heroin. He said that the widespread use of illicit drugs has a number of both direct and indirect medical aspects. Direct effects refer to those actions immediately related to the pharmacological actions of the drugs whereas the indirect actions are a consequence of factors such as the procedures of drug administration and the means of drug procurement. The direct effects vary according to the stage of drug use. The main acute effects vary with the drug. They are either a consequence of intoxication and reduced judgement, leading to increased risk behaviours, such as automobile accidents or due to more specific pharmacological actions. Thus opiates cause depression of brainstem centres that control respiration and protective (gag) reflexes. This can lead to death or respiratory damage from inhalation of vomit. These effects are increased by co-use of sedative drugs and alcohol.

Most drug misusers try various mixtures of drugs, which complicates analysis of responses. So called “designer drugs” are now available which are more powerful variants of the conventional drugs. Stimulants (cocaine and amphetamines) act to release monoamine neurotransmitters in the periphery as well as in the brain, and this can result in cardiac arrhythmias. This action is accentuated by the local anaesthetic actions of cocaine and may be further exaggerated when cocaine and ethanol are taken together. Unlike the opiates, repeated use of cocaine leads to increased effectiveness of the drug.

The direct effects of chronic use are less well understood because of the overshadowing contribution made by non-pharmacological factors. It seems likely that long-term use of opiates, as in methadone maintenance programmes, is free of medical complications other than the risk of withdrawal. Maintenance therapy with stimulants is more controversial, perhaps because it is little researched. The transient pharmacokinetics of cocaine make it useless for maintenance treatment. The longer acting amphetamines can be used in a prescription programme, although some authorities believe this to be dangerous because of the risk of psychiatric sequelae. It is undoubtedly true that the long term street use of stimulants is associated with a high incidence of psychiatric illness, especially anxiety disorders, depression and psychosis, which serve to worsen the prognosis. It seems likely that chronic cocaine use might have cardiovascular complications, and when used nasally, local ischaemic tissue loss.

Indirect medical complications of drug use exceed the direct ones by many orders of magnitude. The most pressing issue at present is the increased risk of infections, especially HIV and hepatitis. These come from sharing needles, syringes and other drug paraphernalia and from high risk sexual behaviour, either as a consequence of intoxication or for money. Other aspects are the damage to blood vessels caused by injection and misdirected arterial strikes can lead to limb infection and gangrene that can require amputation (especially with i/v Tamazapan). Many misusers have to search for a good vein, progressing from hand and arm to leg and foot, then to the jugular.

Smoking related illnesses result from smoked cocaine or opiates. The rise in violent crime related to drug misuse also has major health implications. Many muggings, especially of old people appear to be drug related. Gun assaults on competing drug dealers are now common in Britain, although well behind the frequency seen in the USA. The consequences of drug misuse on the health of the next generation should also be considered. Although there is still disagreement over the long-term effects of drug use in pregnant mothers, short term problems are common. There are increased rates of miscarriage and of perinatal complications and death. Recognised withdrawal symptoms from opiates in neonates include hyper-excitability and seizures, tremor, weight loss and poor feeding. Treatment with opiates may be temporarily required.

Cocaine related complications include listlessness and distress. Finally, the long term psychiatric effects of chronic drug use should be considered: the loss of opportunity to engage in normal work and social relations may result in long-lasting problems of socialisation that can end in chronic depression and alienation. One advantage of maintenance programmes is their ability to promote self worth through improving social function. There is a rare example of treatment being better than prevention.

The next paper was on risk factors initiating and perpetuating addiction, by Professor Geoffrey Pearson (Goldsmiths College, London). He said that if one took a global view, it would be true to say that we are all at risk: historical studies and social anthropology reveal that the use of intoxicants is a near-universal propensity of human society. Nevertheless, drug related problems are not distributed evenly through society. The reasons for this are still not fully understood, and one must exercise caution in attributing cause to drug misuse. Risk factors have been identified as falling into two broad categories—individual and social. Research has sometimes claimed to have identified factors, unique to individuals, such as “the addictive personality”. Conversely, other research has focused on social and environmental factors. Observable factors which appear to influence the prevalence of drug misuse include age, gender, race, culture and ethnicity, together with poverty and social exclusion. In the context of an epidemic increase in illegal drug use, such as we have witnessed in Britain since the early 1980s, a focus on individual characteristics seems less important than the consideration of social and cultural factors. There is no reason to suppose that there has been a sudden upsurge in the “addictive nature”, but there have been profound social changes in Britain over the past decade. There is little doubt that availability of drugs is a core factor in development of drug misuse. Age is also a core factor, with many addicts typically starting very young by experimenting with alcohol and tobacco, then moving on to other drugs. However, an obsession with the problems of children must not obscure concern for the problems which occur later. Gender has a marked effect, the ratio of male to female drug misusers appearing to be about 2:1 in Britain at present. However, for various reasons there may be more “hidden” female users, unknown to the authorities. In Britain it is sometimes thought, wrongly, that the black minority is very involved in drug misuse. In fact black people were not much involved in the British heroin epidemic in the 1980s although more recently they might have become more prominent. Studies of Asian communities, such as in Bradford, have shown their pattern of drug use to be quite typical of white people. There is no drug resistant culture, but some cultures may be more likely to promote drug misuse. One aspect of this is the “comradeship” factor, in which a group of drug misusers will share their drugs and equipment, just as they would share food and drink, and generally try to support one another. This can have very serious adverse effects, which needle exchange schemes will not always overcome. They typical drug misuser in Britain today is a young unemployed male of poor social status and low educational achievement.

Social deprivation appears to be the major factor in initiation and perpetuation of drug misuse in Britain and elsewhere. The worst problems are associated with inner cities, where there is poverty, social deprivation and disease. Unemployment is not the only cause, but is at the core of much of the problem. It causes both poverty and boredom, with lack of self esteem. Added to this is the polarisation of these people to the cheapest part of the housing market, so that addicts and potential misusers come into close proximity. Here there will be availability of the drug, and a feeling of social exclusion, together with crime and prostitution, and relatively high levels of disease including HIV infection and tuberculosis. There will, of course be, a rebound of harm onto the local people who are not drug misusers, especially from theft, mugging and other crime. Thus there is a linkage between drug misuse and social exclusion, notably the “urban clustering” effects which gather together the most serious problems of drug misuse in neighbourhoods which already suffer from high levels of unemployment, poverty, housing decay and other forms of social disadvantage.

In considering the risk factors for drug misuse it is also pertinent to consider possible “protective” factors. There are some people who use drugs but come to no harm, and seem able to regulate their use. The reasons for this are not known. To make progress with control of drug misuse it is necessary to try to break the cycle of adverse conditions which place people at high risk. Tackling the underlying problems of unemployment and social deprivation will be essential, together with attempts to remove drug dealing from the streets. Multi-agency strategies will be needed to achieve better control of cocaine and heroin misuse in the future.

The next paper was an overview of the Government Green Paper on drug misuse, “Tackling drugs together”, by Dr Nicholas Dorn (Institute for Study of Drug Dependence). He reminded the audience that the Government had published a Green Paper, in the autumn of 1994, which set out a framework for collaborative action to combat drug misuse. The Green Paper has not attracted great publicity, and the response from agencies has so far been patchy. It is remarkable that the debate invited by the Green Paper is exclusively on domestic issues although there is great concern and considerable action within Europe about drug trafficking and the laundering of money.

The Green Paper is expected to be followed by a White Paper, setting out the policy agreed after the consultation process has been completed, but some Health Authorities appear to be regarding the intentions of the Green Paper as though they were already policy. Others are not satisfied with many aspects of the Green Paper, and some professional groups are questioning the relevance of some of the performance indicators, which have also been criticised for not being clearly thought out.

A description and analysis of the document was then presented. The focus is on local action. The three areas which it covers are, broadly, crime, youth, and public health. There is a timetable for action, with prescribed targets for each of the agencies and professions involved, over three years. The statement of purpose is to take action, by vigorous law enforcement and a new emphasis on education and health. Three major points are, to increase the safety of communities, reduce the acceptability as well as the availability of drugs, and to reduce the health risks and damage caused by drug abuse. Local action teams led by Health Authorities are expected to be set up, with members drawn from the highest levels of the constituent bodies (police forces, local authorities and other agencies). Their role is to reconcile National priorities with local realities. Information would feed back to government departments which in turn would link with the EU Drug Monitoring Centre in Lisbon. Common standards in the gathering and recording of information are required.

Law enforcement and community safety are given the highest priority. All criminal justice agencies are required to report to the Home Secretary with their plans. Drugs will be included in the five key objectives of the police. Schools are to develop a policy on how to deal with drugs in school and a policy on drug education. There will be new publicity about drug misuse. Treatment is described as something to be used with the objective of achieving a drug free state. Harm reduction, in relation to communicable diseases, is also an objective. An effectiveness review is in progress which will report later on the performance of the agencies. The Green Paper also makes it clear that the Government has no intention to implement any changes in drug legislation.

This was followed by a paper on the detention and management of drug misusers in custody, by Dr Margaret Stark, (Forensic Medical Examiner, South London). She said that police surgeons, also known as forensic medical examiners, see a lot of drug misusers, either because of their drug use or because they are being detained in connection with some other offence. Police surgeons are increasingly being asked by police to assess whether drug misusers held in custody are fit to be detained and fit for interview. Police surgeons are also in a good position to help drug misusers with their problem, and to provide maintenance while in custody. However, there is great variation in the attitudes and response of police surgeons to drug misusers. Although the General Medical Council has ruled that doctors must not withhold treatment because of a moral judgement that the patients’ life style has contributed to their problem, there is still a tendency to react negatively to drug addicts.

In 1991 the Department of Health published revised guidance on the clinical management of drug misuse and dependence. However, it was felt in the debate which ensued that the subject of the management of drug misusers when detained in police custody was not adequately covered in this document. Further discussion was stimulated in December 1992 when two general practitioners, who acted as police surgeons, were convicted of manslaughter for recklessly causing the death of a 23 year old former heroin addict. There has been little published on how police surgeons manage this controversial subject. In 1993 a questionnaire was sent to the members of the Association of Police Surgeons in Great Britain, in an attempt to assess their attitudes and the current practice.

It was found that police surgeons are very aware of the increasing drug problem, 76% reported that they are seeing an increasing number of drug misusers. Most of the police surgeons who completed the questionnaire were general practitioners, and 73% of them were in non-rural areas. Many of them exhibited a significantly negative attitude to the drug misusers, 80% regarding it as a self inflicted problem, and almost all thought it was a major cause of crime. Although two thirds of respondents said that drug misusers should be treated like any other patient, there was no common practice for prescribing controlled drugs. Replies indicated that 68% of police surgeons would allow a drug misuser to continue their prescribed methadone while in custody, 72% said that they would never initiate methadone treatment. Police surgeons have a great opportunity to advise addicts about the availability of treatment centres, the risks of infections such as HIV, and general counselling. Police surgeons should be helped to take a positive attitude towards addicts, encouraging them to admit their problem and to seek medical help. However the majority of respondents called for more training on drug problems and only 36% felt that police surgeons in general are experienced enough to manage drug misusers. Many police surgeons are the first to provide primary health care to the addict, and it is important that whatever is done is carefully documented and passed on to whoever may next be in charge of the patient while in custody and after release from custody.

Most police surgeons do not regards signs of mild opiate withdrawal as a reason not to detain and question a suspect, but there is no uniformity over the prescribing of maintenance treatment. It is probably best to continue supervised methadone or other treatment to maintain a reasonable physical and emotional equilibrium while the drug misuser is in custody. There is also an urgent need for specific guidelines for police surgeons on the management of drug misusers in custody, to address the arbitrary nature of current practice. There is also a need for improved initial training and continued education for doctors working in this complex medico-legal field. Since this research was completed a working party has been set up to produce guidelines that pay particular attention to the aspects of management that are unique to the care of the drug misuser in police custody. A booklet has been produced, and is in print, but has not yet been issued. This should now be made available, urgently. It was pointed out that similar problems occur in prisons, where a large number of prisoners are drug misusers. Better treatment facilities are needed in prisons.

After coffee, the chair was taken by Dr Neville Davis (Honorary Secretary, Royal Society of Medicine), who introduced the next speaker, Dr Michael Farrell (National Addiction Centre and The Maudsley Hospital, London) who spoke about present conventional prescribing protocols and the organisation of UK drug abuse treatment. He began by commenting on the rugged independence shown by doctors in the treatment of drug abuse in Britain over the past few decades. The approach was based on an implicit faith in the integrity of the physician and a healthy respect for the power and influence of the medical profession. It was backed by a monitoring system which was at best haphazard and at worst, non-existent. Historically, doctors have wanted to avoid treatment of drug misusers. However, the epidemic of heroin misuse in the 1980s led to a greater emphasis on primary care and the role of the general practitioner, although many were reluctant to become involved.

Heroin prescribing has always been a minority activity. The key shift in the 1970s was to move away from injectable prescribing and maintenance prescribing. At no time has there been any nationally defined treatment protocol for the prescribing of substances for drug addiction. In the mid-1980s guidelines for the management of drug dependence were published by the Department of Health. These focused on GP prescribing practices. It was left to doctors to use their clinical judgement, tailored to the needs of individual patients. This led to lack of uniformity of response, in different areas or following change in professional staff. The next phase was the development of community based services, driven by the central funding initiative. There are now about 300 community based services in existence. The central funding initiative contained an implicit resistance to maintenance therapy but no explicit statement. There was no outline of the prescribing which would be desirable in secondary care services. The most recent development is the introduction of the purchaser/provider split in health care, which allows local health authorities to choose the drug treatment strategy they prefer, and to choose a suitable provider. This puts drug treatment into competition with other health problems for allocation of resources. A case has to be made, based on need, defined as the ability to benefit from services coupled with an ability to define and deliver effective services.

Consideration must be given to what evidence is available to enable clear guidance to be given about effective treatment of drug misusers. There is a lack of evidence based on well conducted and controlled trials. One area where there is good information is on substitute prescribing with oral methadone, mainly from the United States, showing benefits from this type of intervention. Treatment protocols need to be optimised in regard to availability, access and acceptability, equity, accountability and flexibility.

Maintenance prescribing is the most controversial aspect. There was a period of enthusiasm for this, then a drop off, then in the mid-1980s a take off of enthusiasm for maintenance prescribing. However, neither the public, the medical profession, nor indeed addicts, have strongly supported methadone treatment. The absence of such support makes the funding of such intervention uncertain in the future. In other countries in Europe there has been a doubling of methadone prescribing over the past decade. It is probable that this has been driven by the risks of HIV infection. In most countries the amount of substitute prescribing falls far below the level of the problem. In 1993, figures for people in Britain on methadone or diamorphine maintenance were 18,000 and 200 respectively. In summary, there is still considerable lack of uniformity over prescribing, a lack of data on which to base recommendations, and a failure to tailor the treatment service to the needs of the population or to shape the services in response to the evidence of effectiveness.

The next speaker was Mr Steve Spiegel (Cocaine Anonymous, London) who gave a very clear insight into the problems and costs of obtaining cocaine and heroin illegally. He explained that he was working to help addicts to achieve abstinence rather than to maintain people on substances. The costs of cocaine and heroin addiction were not just financial, but were more to do with health and lost opportunities. He then gave a very moving account of the life style and problems of a typical drug addict, based on his own observations. This portrayed a boy from a good, hard working family, who was very lively at school, but who felt isolated and unsure of himself. He became involved in music then, at an early age, began using alcohol and then went on to drugs, starting with methadrine and purple hearts. When he first started it was marvellous, and he was able to communicate with people and it gave him the confidence that he had felt he was lacking. After a time, it stopped working. He had firmly decided never to go beyond this, and did not want to become an addict, but in the end he did all the things he had decided not to do, using cocaine and heroin, including injecting.

The next phase was to begin dealing in drugs and he saw his customers going through the same sequence as he had done. He used heroin for 20 years, and it caused him few problems: cocaine caused him more problems. His whole life was involved in the getting and using of drugs; it became more important than anything else in the world, regardless of any consequences. He did not believe in the risks, and did not even think he had a problem. He thought the problems were external, such as lack of money, and the need for a larger house and car. He did not realise the problems were all due to his drug taking. He then got out of his depth with heavy gangsters, and decided that he had had enough of drug using, but did not know there was help available. He then tried a number of treatments, including detoxification and sleep treatment, but the difficulty was that after the treatment he was put back in the world and faced with his own problem—himself. To him the drugs were the solution to the problem, so he went back to using again. He carried on using for a further 10 years, although the drugs were no longer really working. During that time he lost everything and everyone, and ended in the gutter. The drugs came before anything else.

Despite this his health appeared to remain good, although the drugs masked some health problems. Behaviour depended on the drug, with cocaine and alcohol he became very violent: with heroin he felt safe and warm. When given a methadone prescription he used more drugs, on top of it, than ever before. By this stage he had found out about free-base, and was spending £1,000 to £1,500 a week on drugs. He could fund this from dealing. He never made money from dealing, because the more money he had, the more drugs he used. A breakthrough came when he went to a meeting of Narcotics Anonymous. He could not face any more treatments. He felt so empty inside, exactly as he had as a child before he started taking drugs. He managed to stop, and remained free for a few years. He then had to change his thinking about himself and his behaviour patterns. A period of stress in his relationship took him back to drugs, and within days he was back to heavy using and dealing as if he had never stopped! He carried on like that for 20 months, even though he knew it was useless, and unnecessary, and was destroying him and his friends. He then went into a 12-stop treatment centre and started learning some life skills, which he had somehow missed out before, and this has enabled him to remain free of drug abuse ever since.

Mr Spiegel said he believed that drug misuse was a disease, or rather a dis-ease within the person themselves, but he was sure that it was within anyone’s capacity to give up drugs. He believed that unfortunately, the majority of GPs have no understanding or a total lack of interest in treatment of addicts. He said that he did not believe it was true to say “once an addict, always an addict”. He believed counselling at school on self value and life skills might help some children not to become addicts. He believed that anyone can stop using drugs, if they have sufficient desire to do so. He would like to see more emphasis on abstinence rather than on maintenance.

The final talk of the morning was given by Joy Mott (Loughborough University) who spoke about crime associated with illegal use of cocaine and heroin. She said that in recent years it had become taken for granted in this country that “drugs cause crime”. Reducing the incidence of drug related crime is a main objective of the Government’s drug strategy.

During the 1980s much of the research aimed at examining links between heroin use and crime studied dependent users attending drug treatment services or in contact with the criminal justice system. Many such users take a variety of other drugs, including cocaine. They are almost invariably unemployed and therefore unlikely to be able to pay for all their drugs by legitimate means. When asked how they raise funds for their drug use many say they commit acquisitive offences with shoplifting the most popular, as well as household burglaries, pick-pocketing, thefts from cars, cheque frauds and the like. Such findings have led to the assumption that the cost of illicitly used heroin is raised mainly, if not exclusively, from the proceeds of acquisitive crime. Estimates of the cost of crime committed by regular heroin users range from £2,000 million in 1992 (half the cost of all the thefts reported to the police in that year) to between £58 million and £864 million in the early 1990s. The size of these estimates depends crucially on the assumptions made about the number of dependent heroin users in the population, the amount and frequency with which they use heroin and the price they pay for it, as well as how much stolen goods can be sold for, usually assumed to be no more than a third of the replacement value. More recent research involving contacting and interviewing heroin and cocaine users in the community indicates that the proceeds of acquisitive crime provide only one of the sources of funds to buy drugs. Others include drug dealing, getting into debt, begging, prostitution and “doing favours”. The latter includes such activities as providing storage for drugs or allowing dealing to take place in the home.

There has not yet been a great deal of published research on crime associated with the use of cocaine or crack. What has been published suggests that since the 1970s much occasional recreational cocaine use takes place in social circles where there is “champagne, style and money”, with users legitimate income sufficient to cover the cost. During the late 1980s there was increasing evidence of cocaine use, in the form of crack, lower down the social scale. It may be that heavy cocaine or crack users engage in more acquisitive crime than dependent heroin users to pay for their drugs, since “user doses” of cocaine/crack are more expensive than heroin and some regular users report spending several hundred pounds a week on their drugs. It seems that violent crime is more likely to be associated with drug dealing, particularly of crack, than of drug use. The police have no doubt that violence is associated with crack distribution, with incidents involving the use of firearms by dealers being reported in several of our inner city areas.

The afternoon session was devoted to Future Approaches to the control of misuse of cocaine and heroin. The first chairman was Dr Richard Nicholson (President of the Open Section of the RSM). He introduced the first speaker, Mr. Ray Kendall (Secretary General, Interpol, Lyon) who spoke to the title of “Perceived defects in the present systems of control and management of cocaine and heroin abuse”. He began by explaining that he was the head of the international criminal police organisation better known as Interpol. From this position he had watched the phenomenon of drug trafficking develop and spread, for nearly a quarter of a century. ICPO-Interpol, as we know it, was established in 1946 with the aim of promoting cooperation between national law enforcement agencies in order to track down and thwart those forms of criminality that take advantage of the fact that police action is limited by national boundaries. To this end, 176 nations have joined ICPO-Interpol to date.

It was heartening to see the dedicated efforts of law enforcement officers around the world in combating the epidemic of drug trafficking. At the same time it was disconcerting to see nations succumb to the impact of this plague. To deny that there are deficiencies in dealing with the causes and effect of illicit drug use would be, at the minimum, naive. The question is, what can be done to correct deficiencies in managing substance abuse. To date, no comprehensive approach has been formulated to resolve the multi-faceted problem of drug abuse. However, there are some ideological approaches which must be embraced to gain ground in this seemingly losing battle. The biggest problem, perhaps, is to convince the politicians to have the will to provide adequate resources to get things done. However, the fact that there has been a 400% increase in the availability of drugs over the past four years should encourage better deployment of resources. The British Green Paper puts such emphasis on law enforcement, which will use a lot of resources. This will put more traffickers in prison, but will not reduce the amount of drug abuse in the community.

At the community level, joint action should continue on both the reduction of supply and reduction of demand, with at least as much resource put into reduction of demand as for reduction of supply. The tendency has been to put more money into reduction of supply, but this is expensive and does little to reduce the abuse problem.

There are not enough treatment centres available for addicts, and there is a need for more counselling of children. There are a number of other tactics which show promise in diminishing the demand side of the equation. These include: setting up community partnerships between the police and social/health agencies; police involvement in drugs education in schools; mandatory referral to treatment centres for drug misusers encountered by the police and the neighbourhood where drug dealing and usage can thrive. In all these activities it is important that both the police and social/health professionals recognise that they both have their own individual areas of expertise which must be respected.

There is also a need for the provision of much better review and evaluation procedures, and for partnership programmes, to judge their effectiveness and to engender improvements. Consideration should be given to the decriminalising of drug usage in order to diminish the flood of cases into the criminal justice system. By this is meant a policy of deliberately not prosecuting drug users. This is not to be confused with the concept of legalisation of drugs, which is something quite different and not acceptable.

At the national level, countries must create legislative and regulatory barriers to impede the ability of criminal organisations to profit from illicit drug trafficking. This means legislation to stop money laundering. There is a need to resolve to relentlessly root out corruption among public officials and to build in integrity requirements at the grass roots level of public service. The huge amounts of money involved in drug trafficking are sufficient to corrupt at the highest level. In the USA the cost of essential drug related crime represents about $500 billion per annum. This level of financial resource in criminal hands can pose a threat to democracy. Some large companies have some component parts which are financed with illegal money. Corruption in business and politics can influence policy, including drug policy itself. National drug control policies should be implemented which recognise national and ethnic peculiarities at the same time providing answers to the drug challenge, which can trickle down to communities for implementation. When a nation is a party to international agreements or resolutions relating to drug trafficking, it must live up to those agreements and contribute accordingly. However, it is now more cost effective to use resources on treating heavy users than on preventing importation of drugs.

At the international level, note must be taken of Resolution 48/12 of the United National General Assembly, passed in October 1993, which underlines the need to press forward in improving international cooperation by using existing mechanisms such as ICPO—Interpol to increase the exchange of information through data base expansion. This required member countries to fastidiously provide complete and comprehensive data of drugs seizures, known violators, and organisations involved in drug trafficking. International task forces should be set up to investigate organised criminal activities in the drugs arena, such as syndicates, cartels and Mafia-type organisations. The results must be provided to prosecuting services. In law enforcement we often fall prey to knee-jerk reactions to the problems that confront us. Counter-narcotics enforcement is an area where we may take a proactive, coordinated approach if we will only look beyond single issue remedies and parochial results. Interpol pledges to do its part, within its authority, to improve the control of substance abuse worldwide.

The next paper was by Mr. Allan Macfarlane (Drugs Branch, Home Office) who spoke on improvements to the present organisation of drug misuse treatment. He said that both heroin and cocaine are harmful to the users and to society. The trade in these drugs now appeals to organised criminals. It is a social problem in Britain. Three million people a year take a drug, although less than 1% of those over 12 years of age have taken heroin or crack. There are about 125,000 heroin addicts known to the Home Office and about 250,000 regular amphetamine users. It is hard to obtain an estimate of the amount of cocaine abuse: 1,300 are notified but that is almost certainly only the tip of the iceberg—indicated, for example, by the recent seizure of four tonnes of cocaine.

The chaotic poly-drug user will take any drug. Tamazapan is often stolen from doctor’s surgeries. There is a need for better control, but 200 million capsules a year are prescribed legally.

The Home Office is involved in this area mainly because of the Illegal Drugs Act and because of its role in supervision of the legal use of drugs. It has a supervisory function for the pharmaceutical trade. Home Office Inspectors are concerned to remove problems over treatment of drug misusers. They want to see more addicts treated.

The Drugs Inspectorate also gathers statistics from notifications made by doctors, and examines pharmacy registers. At least 3,000 doctors are engaged in treating drug addicts in Britain. The inspectors investigate about 200 doctors each year, and these are almost always amicable interviews. The inspector’s task is to ensure that the Department of Health Guidelines on management of drug misuse are followed. The inspectors are non-medical; their job is to keep doctors to the rules. Another of their concerns is to prevent diversion of drugs from treated persons to other users. In this context the over prescribing of drugs for treatment may be adding to the problem. Many doctors, who are treating addicts, do not know enough about the subject, and more, specialist training is required for them. Special licences are issued to 107 doctors to enable them to treat drug misusers with heroin. These are working in NHS Drug Treatment Centres. There is a pragmatic case for extending the use of heroin treatment for some addicts. At present very few persons, about 250 in total are being treating with heroin. There is a need for more research work on treatment protocols, including both the application of new methods and the evaluation of new drugs.

The next speaker was Dr Jeffrey Marks (Consultant Psychiatrist, Cheltenham) who talked about suggestions for alternative prescribing protocols. He began by saying that all addiction is bad and that we not only had to consider addiction to opiates, but also confront addiction to idealism.

His first suggestion for any prescribing protocol was a very hefty dose of realism. This seems to have been lacking with many drug treatment services. There are several reasons for this, but the medical establishment and the Department of Health must accept a considerable amount of responsibility.

In 1984 the Department of Health published a booklet. “Guidelines for good clinical practice in the treatment of drug misuse”. This was given to all doctors, and provides reference material from Home Office inspectors. In that publication it was stated that for opiate stabilisation the drug of choice was oral methadone, and that there were no clinical grounds for prescribing heroin unless the patient has intolerable side effects to methadone. This was replaced in 1991 by a new publication “Drug misuse and dependence—guidelines on clinical management”. It contains many improvements compared with the previous one, but the prescribing advice is the same as in 1984. It warns against prescribing drugs which are not intended for injection, but which could be injected by misusers, and might be sold on the black market. That is not unreasonable, but the problem is, what should the doctor do if the patient is clearly going to continue to inject? It gives no constructive advice on this point. However, it ends with a hint of reality by saying that long term treatment with a substitute such as methadone, with no intention of early withdrawal, may be justified in helping the drug user to achieve a more stable way of life.

Other reports have been influential, eg those of the Advisory Council on the Misuse of Drugs. The first of these said that HIV infection was a greater threat to public health than drugs themselves and this was very helpful. It recognised that some addicts are persistent injectors. Unfortunately, it went on to suggest limiting treatment with injectable drugs to an arbitrary three months. This is the advice which can be summarised by saying that it is good practice to give these patients clean injecting equipment, to inject themselves for as long as they wish, but bad practice to give them clean, safe, legal drugs on prescription with which to inject themselves. If harm reduction is to be the guiding principle, we need to have a wider range of realistic treatment options.

Most drug treatment clinics would agree that a patient, who is determined to continue injecting, should be given clean equipment and a supply of clean drug, but this is not often put into effect. Harm reduction should be the aim, and progress should be determined by individual patient clinical response as part of a properly monitored treatment programme. There should be a range of prescribing strategies to replace the illegal and impure drugs that the person is taking with pure, legal, drugs in whatever dose is required to stop them using the street drugs. The aim should be to find the right dose of the right drug, and to stabilise their drug taking so they can be helped to make improvements in their life style. The right dose is the dose with which the patient can function normally, without intoxication, and without withdrawal symptoms. The dose has to be determined for each individual, depending on their clinical response. Oral methadone is still an appropriate substitute drug for the majority of patients, but not for all. There are those who require injectable drugs and there are others who dislike the effects of methadone. Methadone has a totally different mental effect to heroin, and it is for the mental effect that most of them keep on taking the drug. Methadone keeps withdrawal symptoms at bay, but does not give the mental effects they get from heroin. It is no use forcing oral methadone on a patient who will only sell it to buy other drugs. Patients who have to keep injecting should be given injectable heroin, those ready to stop injecting can be given heroin tablets.

Strict criteria have to be adopted for the selection of patients before they are given these kinds of treatments. In the Cheltenham clinic, these are: objective evidence of intravenous drug abuse over a substantial period of time; objective evidence of current drug use; no motivation to be drug free; no motivation to stop injecting; previous treatment with oral methadone which did not succeed; no current abuse of drugs likely to induce psychosis; no evidence of active psychosis at present; the prohibition of alcohol or benzodiazepine abuse; agreement by the patient to abide by the rules of the service and to be cooperative. On the other hand there is no reference in the criteria for acceptance to HIV status or to age. The correct dose of heroin is carefully established for each patient by admitting them to hospital and observing their clinical response for several days.

The goals of the programme are to achieve stabilised drug addicts taking nothing but what is prescribed, using safe injection, safe disposal of injecting equipment and having identifiable improvements in physical and mental health and social circumstances. Heroin is only given in daily doses with strict collection arrangements. All the patients have regular monitoring and supervision with a key worker. Psychotherapy is also available if required. The patients are reviewed at intervals, and the goals are renegotiated as their chaotic life style improves. It is hoped that no patient should need to be in the programme for more than five years. There are now seven years of clinical experience using this system and the results have been very encouraging.

This was followed by a paper given by Dr Margaret Rihs-Middel (Swiss Federal Office of Public Health, Bern). She said that Switzerland was a country of seven million people, with about 30,000 addicts. There had been a rapid increase in drug abuse, and intervention during the early stages was difficult to achieve. The work of Dr Jeffrey Marks and others in Britain had influenced the Swiss response to the problem. They have introduced needle exchange schemes, reducing HIV infection, but hard drug use was not reduced. A drug programme had been introduced with the aim of reducing the number of drug misusers by the year AD 2000. This is based on several elements: repression, prevention, treatment support and harm reduction.

According to several decisions of the Swiss Federal Government, a longitudinal study embedded in multi-centric research design has been set up in order to analyse the long term effects of the medical prescription of narcotics (heroin, morphine and methadone) in 700 long term drug addicts with signs of severe social disintegration.

The following dependent variables are being considered; health status, risk behaviour, multi-drug use, psychological well-being, social integration, delinquent behaviour arid work capacity.

The trials, taking place in eight Swiss cities, are carefully controlled and monitored. All participants are questioned by outside evaluators and only accepted if they meet certain criteria. These include being over 20 years of age, having taken drugs for at least two years and having failed twice on another treatment methods. The drugs are supplied to the addicts at a treatment centre, and there have been no significant problems with diversion of prescribed drugs to other persons.

From January until November 1994, a total of 285 patients have been admitted to the prescription programme. Of these, 247 have been admitted to heroin, 47 patients to morphine, and 30 to methadone treatment programmes. Currently, 197 patients are being treated with heroin, 16 with morphine, and 20 with i/v methadone. An additional study with 16 patients took place in order to test the side effects of morphine prescription. The feasibility of the heroin prescriptions has been demonstrated during the course of 1994, with no major incidents. There were no safety problems with the programmes. In the case of morphine, side effects were observed. Both morphine and methadone were less acceptable to addicts than heroin. Results, so far, show that the heroin prescription programme has been associated with patients having improved health, better physical appearance, improved psychological well being, an improved capacity for work, and thus improved housing and social contacts. The programme has had some effect in reducing contact with other addicts. The compliance rate and retention rate have been rather good. These results should be treated with caution, however, since a longer observation period is necessary, in order to interpret the long term effects.

The final session was chaired by Mr. Jasper Woodcock (Past Director of the Institute for the Study of Drug Dependence). He introduced the first speaker, Mr. Roger Howard (Standing Conference on Drug Abuse). His subject was “Possibilities for legalisation of cocaine and heroin”. He said the short answer was that in Britain there was virtually no possibility, for the foreseeable future, of legalising cocaine and heroin, under either a Conservative or Labour government. The Government had given their reasons in the recent Green Paper stating “For those who experiment with cannabis as forbidden fruit, decriminalisation would simply make even more dangerous drugs more attractive… There would be no turning back from legalising cannabis or any other controlled drug”. In taking this attitude they have lost a rare window of opportunity to further debate about drug laws. In a recent House of Lords debate, a peer observed “It is important to realise that the case for change does not rest with those who seek to relax the law but with those who admit that the present law does not work, and that we need to do something to make sure that it does work” Mr Howard believed that the criminal law should be employed in the control of drugs only where is can clearly be shown to be necessary, justifiable and effective.

Debate on this subject requires consideration of political, social, economic, medical, legal and moral issues. So far it has been characterised by a simple dichotomy: either legalise or prohibit. Both sides produce powerful arguments in their support, and pay little attention to the reasoning of the other side. British drugs policy has traditionally been a classic compromise between commitment to prohibition and a degree of discretion in application of the law. This also applies in other countries such as the Netherlands and the USA. John Stuart Mill said that “in a civilised society the only purpose for which power can be exercised over a person against their will is to prevent harm to others”. Studies in the USA have shown no strong evidence that decriminalisation effects either the choice or frequency of use of drugs, either legal (alcohol) or illegal (marijuana and cocaine). People continue as before, irrespective of changes in the law.

There has been much talk about cost-benefit analysis of changing drug legislation, but little work has actually been done on this. Some of the economic benefits of legalisation include reduced costs of policing and criminal justice, reduced health care costs, and that taxes on drug sales could be a source of revenue. However, much caution must be exercised over these assumptions. If legislation led to greater drug use, there would be many additional costs to society through adverse effects on health, safety and productivity. The real issue however is largely to do with the moral one, of how people see their own society. Research in the USA and in Britain has indicated that there is a reluctance by the general population for moves to fundamentally change the drugs laws.

Even amongst those who have used illegal drugs, only about 1 in 3 supported moves to decriminalise or legalise. However, legalisation does not imply sanction. If it did, the existing laws would suggest that the Government approved of tobacco, alcohol and gambling, although of course such activities are subject to extra taxation!

The most fruitful approach to the possibility of legalisation of drugs is through risk assessment, which is rooted in reality rather than rationality or rhetoric. Politics is much concerned with risk assessment; risk to governments, individual political careers, and risks to local communities and individuals.

If laws are to be changed, this will be done by politicians, who will firstly look at the risk to themselves. They are likely to regard change as too risky for several reasons:

Our international and European commitments tie us to conventions and treaties which are going in an opposite direction to legalisation. There is also the weight of public opinion, which is opposed to legalisation. There are also risks to the institutions of the criminal justice system if there was a large reduction in activity following drug legalisation.

Further risks are that legislation would not be accompanied by a reduction in crime. In other areas, such as the arms trade, which is legal, there are supposed to be tight controls but it is rife with criminal trade. There is also the risk that with developing drug technology, legalisation of cocaine and heroin could lead to a switch in usage, perhaps a supply led incentive. What is required is to advance cautiously with policies which are low-risk politically. We could seek to ensure consistency in cautioning practices and in prosecuting and sentencing practices, in favour of diversion to treatment. Then we might explore the possibilities of decriminalising the possession of illicit drugs for personal use. Perhaps, after that would welcome the debate on the efficacy of legalisation. Realistically, we are a long way off the entire legalisation of cocaine and heroin.

The final speaker was Mr Mike Goodman (National Legal and Drug Services) who gave a review of options for change. He said that we were at a critical time in the development of drug strategies, both in Britain and throughout the world. There is growing public concern about increased use of illicit drugs. The Department of Health’s Effectiveness Review will examine the effectiveness of various forms of treatment. There is an increasing decriminalisation and legalisation debate, which is becoming more sophisticated and more public. All this increases the opportunities for change.

Mr Goodman suggested that there were about eight main models for change which should be considered. Before considering further models for change, the following objectives are those usually considered desirable in formulating drug policy; abstinence; reduction of injecting; reduction of secondary harm; reducing drug related crime; stabilising personal life style; preserving civil rights and liberties; the need for a policy to be rational, reasonable and consistent. The following options for change were described:

1. Prohibition

Law enforcement is the main feature of the present Government policy on drugs. Four-fifths of all spending on drugs in Britain is spent on law enforcement.

2. Prevention

Education and treatment. The Government has said it will put more resources into these areas, both in the pursuit of abstinence and for safer drug use. Drug education is regarded as a good thing in itself, but research indicates that it may not reduce the number of people using drugs. Its real value is still not known.

3. Review of prescribing

Possibilities of extending treatment options, the type of drugs to use, who should be licensed to prescribe what, and who should have specialist licences.

4. Review of the Home Office licensing system for GPs

This raises many issues, such as whether GPs should have the right to prescribe controlled drugs, including injectables. Whether we should extend the “British System”. Evaluating the efficacy of methadone treatment.

5. Licensed pharmacists

This is a more sensible suggestion than many people think. The existing system is often no more than a rationing system, with little monitoring or support and this could be done equally well by pharmacists.

6. The Mancroft model

Lord Mancroft has proposed that we should have State run premises and a State operated system of rationing, in which people would be allowed to go and use drugs on the premises. This would set some boundaries to and improve the safety of drug use. It would be a question of what would be allowed in such premises. The great advantage would be that the users could be monitored.

7. Decriminalisation

The non-enforcement of the law in relation to possession and use of drugs. This is not a perfect solution, as there will always be some tragedies, but the situation could be better than at the present time. There is a danger that it would be seen as condoning or even promoting the use of drugs. This would appear an extreme view. Given care over progressing in small steps, there could be progress on decriminalisation.

8. Legalisation

The proper regulation and control of the supply of drugs bringing this within the law. This does not mean a drugs free for all where anyone would have access to what ever drugs they wanted. On the contrary, it would place proper controls on drugs. There would be consumer protection. However it is not a realistic option in the near term.

There is one further concept with deserves mention which is to have an open market in “weak” drugs such as opium or cocoa leaves, which might be sufficient for many users, who at present go to hard drugs when something less powerful would satisfy their needs.

All the models which have been described are possibilities for the future. None of them are simple or perfect answers but all deserve careful consideration, and often need further data collection and research before conclusions can be firmly drawn about them, but eventually society will accept the need for a legalised regime for drug control.

Panel Discussion

The meeting ended with a panel discussion which ranged widely over the topics of the day. It was not possible to make an immediate assessment of the findings, but looking back over the papers, several conclusions emerge which should be noted-

Social deprivation appears to be a major factor in initiation and perpetuation of drug misuse. The Government Green paper was weak in regard to drug treatment, did not acknowledge the importance of unemployment as a risk factor, and repeated reliance on previously tried approaches which had not proved effective.

There is a lack of uniformity by doctors in prescribing for addicts and a failure to tailor treatment services to the needs of the population. More training is required for police surgeons and GPs. In Britain at present, few persons are being treated with heroin and this deserves wider use. There is a need for more research on treatment protocols, including the evaluation of new methods. At the same time, more support is needed for abstinence programmes.

Estimates of the cost of crime associated with drug misuse are variable, but organised crime is attracting huge sums of money through drug trafficking. International agreements which require attempts to control drug imports must be honoured, but it is more effective to use the resources on treatment of heavy users than on preventing drug importation.

There is no realistic probability of a major change in the law on drugs in Britain in the near future. It is, therefore, more useful to consider improvements within the existing legal framework. There is a need for standardisation of practice over decisions on whether or not to prosecute for drug offences, and more uniformity over sentencing with greater emphasis on treatment of offenders instead of punishment.

There are many possible models for improving control of misuse of cocaine and heroin in the future. Some require more research before changes in legislation could be made, but a gradual start could be made on decriminalisation. If a way could be found to remove the very high black market price of drugs, many of the problems would disappear.

G A Cullen

February 1995

Prepared 8th December 2012