1294 DRUG ADDICTION SIR,-Comment on the second report of the Interdepartmental Committee on Drug Addiction by both lay and medical press seems focused mainly on the quality of prescribing by some six London general practitioners who look after heroin addicts. It seems possible that a misleadingly narrow view will be taken of the general medical problems of the British
addict. limited number of doctors look after addicts in the not altogether the choice of the doctors themselves : the British system requires that doctors should look after addicts, and many general practitioners will not undertake this work. The quality of the general medical care needed by the addict in the community requires some emphasis. In the winter of 1963-64 a third of the total practice-time of one of these doctors was absorbed by his sixty addicts. In the same practice 25 % of the addicts required hospital admission for conditions such as pneumonia, hepatitis, anaemia, peripheral neuritis, and epileptic fits.2Septicaemia has been noted as a cause of death.3 The patients are noted for their unstable and impulsive demands, and the reluctance of many general practitioners to look after them is not surprising. It is of course right to condemn unsatisfactory prescribing wherever it occurs. On the other hand it seems possible that the standard of general medical care required by the addict outside hospital may be underestimated, and if the goodwill of the doctors who have looked after addicts is lost a problem may well occur in the medical management of this small but extremely vulnerable group. PATRICK MULLIN. Glasgow, W.2. That
SIR,-The few general practitioners who have to do with drug addicts on the National Health Service must jump for joy at the recommendation of the Brain report that they should be prohibited from prescribing for cocaine and heroin addicts. I am not one of those quoted whose prescriptions run into thousands of tablets, but nevertheless I should hesitate to claim that I have not made some contribution to the " black market ". It is this subject of the black market which it seems to me the Brain report evades. The report wishes to supress supply of the black market by doctors and blissfully hands over the responsibility of supression entirely to the criminal-law authorities. This presumably means customs officers and the police. This is exactly the method adopted in the United States-with what success the whole world knows. The number of addicts in the United Kingdom is round about 700, while in New York alone the number is 60,000 or over. I do not see that our authorities have reason to expect more success than their colleagues in America. So, if the Brain report becomes law, we may confidently expect a black market supplied by large-scale imports of heroin and cocaine. The only way that I can see out of this dilemma is by ruthlessly eliminating the trade of drug-pedlar. The pedlar plays the same role to the addict as the fence does to the burglar. At present the pedlar is usually an addict who is getting more than he needs himself, and who sells the rest. If he is caught he gets a few months in prison as does his customer who is charged with illegal possession. Now, since a pedlar is really selling a slow poison, as the mortality statistics of addicts will show, my suggestion is that if ever there was a need for a deterrent sentence it is here. A swindling financier can get 14 years in prison. I see no reason why a pedlar should get less. The threat of 3 months’ imprisonment cleared the street of soliciting prostitutes. It is said that it has only driven them underground. Drug pedlars are always underground. I do not know if even the severest deterrent would operate on the mind of the drug addict, who seems unable in general to relate an effect to its cause, but it would be worth a trial. A. J. J. HAWES. HAWES. London, W.I. 1. 2. 3.
Hewetson, J. Communication to the Conference on Heroin Addiction held at Tooting Bec Hospital, London. February, 1965. Hewetson, J., Ollendorf, R. Br. J. Addict. Alcohol, 1964, 60, 114. Bewley, T. Lancet, 1965, i, 809; Br. med. J. 1965, ii, 1286.
SIR,-Your statement in your annotation (July 31), that "little reliable information has been gathered about the incidence of alcoholism", holds good for this country even more than for many others. The two available estimates are widely divergent, Jellinek’s figures of 86,000 " chronic alcoholics " and roughly 350,000 total alcoholics in England and Wales (1951)contrasting sharply with Parr’s finding of less than 40,000 alcoholics known to general practitioners (1957).2 In an attempt to find out which of these two estimates was likely to be nearer the real figures, the steering group on alcoholism set up several years ago by the Joseph Rowntree Social Service Trust, under the chairmanship of Mr. W. B. Morrell, encouraged health visitors and probation officers in five English towns to investigate the numbers of alcoholics coming to their attention. After a pilot survey at Harrow in 1960 under the joint direction of the medical officer of health and the senior probation officer, subsequent surveys were carried out in the other towns in 1962-63. Statistical analysis of the findings by one of us (G. P. W.) showed the number of alcoholics, among the population segment likely to become the responsibility of probation officers, to be just over 10,000, and the health visitors’ survey gave a figure of about 55,000 alcoholics.34 How do these findings relate to the earlier estimates ? Naturally, the great majority of alcoholics, who in their early stages maintain a foothold at home and at work, are unlikely to come to the attention of probation officers-e.g., only 8% of alcoholic admissions to Warlingham Park Hospital about 10 years ago were referred by probation officers.The class of family coming frequently to the attention of the probation officer is as a rule not sufficiently well known to G.P.s to give them a fair chance of detecting alcoholics: this class includes the unemployed, the criminal, and any men to whom regular employment is not important, and who thus do not require medical certificates from their G.r. Thus it seems justified, since there is no likelihood of too much overlapping, to add together the numbers of alcoholics known to probation officers and to G.P.S. The number of alcoholics found by the health visitors is well above that found in the G.P.s’ inquiry,2 which, however, showed that the observed incidence of alcoholism diminishes as the size of the single-handed practice increases. It seems likely that smaller practices give G.P.s better opportunity and more adequate time to diagnose alcoholism; if one were to assume that in the G.P.s’ inquiry a practice size of 500 to 1500 represented efficient awareness and coverage thus making possible the detection of well-established alcoholics, their number would be 80,000 rather than 40,000; and if one were to include practices of up to 2500 patients, alcoholics would number 60,000, a figure not very different from that of the health visitors’ survey. Were one to add together the 10,000 " probation officer alcoholics " and the " smaller practices alcoholics ", the result (of the order of at least 70,000 wellestablished alcoholics) would approximate to the Jellinek estimate of 86,000 " chronic alcoholics "; and as in the case of Jellinek’s figure the total number of alcoholics could be expected to be several times that of the well-established ones. Thus in England and Wales, as in the American and Australian studies cited in your annotation, alcoholics are often not recognised by medical practitioners. There may be several reasons for this-e.g., the too-great case-load, the difficulties inherent in the problem of uncovering the alcoholic who is a master in covering up, and, partly, the neglect of adequate specific education of the medical student in this field. One of the studies 6referred to in your annotation leads the Practitioner7 two the conclusion that " the real significance of this report is the devastating evidence it produces of the extent of 1. 2. 3. 4. 5. 6. 7.
Jellinek, E. M. Tech. Rep. Ser. Wld Hlth Org. 1951, 42, Parr, D. C. Br. J. Addict. Alcohol, 1957, 54, 25. Prys Williams, G. Chronic Alcoholics. London, 1965. Prys Williams, G., Glatt, M. M. Unpublished. Glatt, M. M. Acta psychiat. neurol. scand. 1961, 37, 88. Nolan, J. P. Am. J. med. Sci. 1965, 249, 135. Practitioner, 1965, 195, 145.