Heroin Addiction Care and Control: the British System 1916 to 1984 (original) (raw)

‘The plain truth is that there is no British System’, said John Strang and Michael Gossop in 19941. For a considerable time, people have debated what constituted the British system of drug treatment and control. The term is generally taken to mean the approach that operated from the 1920s to the 1960s but perhaps the British system is one of those things that you don't know you have until it's gone.

Over the twentieth century, treatment for an initially small number of addicts changed from private care, which could involve detoxification or the prescription of heroin or morphine, to the entrance of NHS practitioners, and then, as the number of drug users increased, the removal of treatment from primary care and into new specialist health service treatment centres. Initially these clinics prescribed injectable heroin and methadone, but, under the leadership of some influential London psychiatrists, they began to move to oral methadone, encouraging others to do the same. Heroin prescribing became a minority activity, and those who advocated it were increasingly shunned by their colleagues2,3.

The medical prescription of opioid drugs to addicts had been officially sanctioned on the recommendation of the 1926 Rolleston Report which defined drug addiction as an illness and therefore the responsibility of doctors4. Doctors could prescribe opioids for:

‘Persons for whom, after every effort has been made for the cure of the addiction, the drug cannot be completely withdrawn, either because:-

  1. Complete withdrawal produces serious symptoms which cannot be satisfactorily treated under the ordinary condition of private practice; or
  2. The patient, while capable of leading a useful and fairly normal life so long as he takes a certain non-progressive quantity, usually small, of the drug of addiction, ceases to be able to do so when the regular allowance is withdrawn’5.

While this may have not constituted a ‘system’ in terms of a centralized policy or set of rules, the clinical freedom it allowed doctors and the underlying spirit of compassion towards addicts certainly existed in the minds of many of those in policy and treatment. One of those minds was Bing Spear, who saw himself as defending Rolleston's legacy through his work in the Home Office Drugs Inspectorate. His book, Heroin Addiction Care and Control: the British System 1916 to 19846, has been awaited with much anticipation, even impatience.

Henry Bryan ‘Bing’ Spear joined the Home Office Drugs Inspectorate in 1952 and became its Chief in 1977 until ill health forced him to retire in 1986. At the beginning of his career, 56 heroin addicts were known to the Home Office, and by his retirement there were many thousands. Heroin use had moved from a small, mainly metropolitan phenomenon supplied chiefly by doctors and the overspill from their prescriptions, to a habit affecting all parts of the country met by a labyrinthine international black market.

The response to the widening scale and nature of the country's drug use which established the specialist clinics under the leadership of psychiatrists was, according to Spear, ‘an unmitigated disaster’ because ‘the moral high ground was seized by a small group within the medical establishment, and by psychiatrists in particular, who over the years succeeded in imposing their own ethical and judgemental values on treatment policy’. He opposed the move from heroin to methadone in the clinics, believing it was led by dogma rather than evidence. The publication of this examination of what happened to the UK's heroin prescribing last time around is particularly timely when David Blunkett has been revisiting the topic. The Home Secretary has been talking about encouraging doctors to prescribe heroin, and the relevant clinical guidelines are currently being prepared.

Described as ‘a most unusual civil servant’, Spear worked not only to police the medical prescribing of dangerous drugs, which was part of his duties in the Inspectorate, but also took a personal interest in the welfare of individual drug users. The almost legendary status he achieved in the drugs field, and his deep knowledge of the ‘scene’, account for the excitement with which the book (left to Joy Mott, his literary executor and friend, to complete) was awaited.

There are, in its publication, a number of surprises. Many people expected an autobiography, but the book begins some time before his birth in 1916; and, even after he becomes actively involved, Spear is somewhat absent from the descriptions of historical developments. The book aims more for a detached history, although informed by the personal, and is copiously referenced. There will be disappointment for those who, primed by the recent tendency of cabinet ministers to reveal their most intimate indiscretions, were looking for ‘insider’ takes of the events he was party to. Most of the historical sources he used are available to academic historians, although his extensive knowledge clearly directed his quest. Joy Mott's editing has produced a seamless, elegantly written document which will be of great value to researchers and students. She has, apparently, removed some of Spear's more caustic remarks about individuals, but his irritation, particularly at historians with whom he disagreed, still comes across.

Another missing element is the Home Office Drugs Inspectorate itself. Very little has been written about this intriguing branch of the Civil Service, whose responsibilities date back to the Inebriates Acts of the nineteenth century, and no one was better placed to write an account of its work. But the book also does more than its title suggests, covering many drugs as well as heroin, including cocaine, the barbiturate use of the 1970s and amphetamines.

Bing Spear's uniqueness in the drugs field was the fusion of three strands. His role in the Drugs Inspectorate was pivotal, bringing him into contact with addicts, ministers, civil servants, doctors, the police, academics, pharmacists and pharmaceutical manufacturers. Secondly, he witnessed and took part in an historical period which saw some of the greatest changes in the UK's drug use, supply, treatment and policy responses. Added to these were his personal qualities, remarked upon by so many, which took his interest and concerns well beyond the job description.

As a researcher on drugs policy who never met Bing Spear, I find one of his most remarkable characteristics, emerging from oral history interviews and documents, was his ability, when debates raged fiercely, to retain the trust of all parties. In the bitter disputes over whether addicts should receive long-term ‘maintenance’ prescriptions, or injectable rather than oral methadone, and whether private doctors should be allowed to write prescriptions for controlled drugs, he was claimed as the champion of those on both sides, sometimes to exaggerated effect. Many doctors professed to be the inheritors and defenders of the ‘British system’ but their understanding of what this meant did not always match Spear's. Perhaps the fact that he enjoyed the support and confidence of such diverse interests reflected not only Spear's personal skills as a civil servant but also the indeterminate nature of the system itself.

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