Drug Abuse

CHANGING IMAGES OF THE ADDICT AND ADDICTION

by Rachel Lart

BRITISH MEDICAL PERCEPTION FROM ROLLESTON TO BRAIN

The emergence of HIV and AIDS has shifted the focus of our interventions with drug users from the psychological to the physical. Is the recent emergence of a 'new public health's break with the British tradition, or does it have roots in an earlier tradition of medical epistemology?

INTRODUCTION

Between the two major British reports of the twentieth century, the 1926 Rolleston report and the 1965 Brain report, the medical definition of addiction shifted. Rolleston defined addiction as an individualised pathology, whilst the second Brain report explicitly described the condition as a socially infectious one. Different modes of treatment and institutional arrangements follow from these definitions. A theoretical explanation for the shift can be derived from the sociology of medical knowledge, specifically the work of Michel Foucault and David Armstrong.

Between the Rolleston report of 1926 and the second Brain report of 1965, what has been known as the 'British system' of treating addiction dominated the field of addiction in the United Kingdom. The basis of this was that any medical practitioner was permitted to use his or her own professional judgement in the decision to prescribe what were known as addictive drugs, in the treatment of a person believed to be addicted to those drugs.

During this period, the definition of addiction and the image of the drug user changed dramatically, from that of an individualised pathology affecting unfortunates, to a socially infectious condition, needing to be controlled. This paper offers an account and explanation of how that change, from understanding addiction as an individual pathology to the later construct of a socially infectious condition, came about.

MEDICAL PERCEPTION

Foucault ( 1976) describes how nineteenth-century medical knowledge directed its gaze at the body. The physical examination of the body, the careful noting of signs and symptoms, the recording of diagnosis and prognosis, the recording of observations and of the course and outcome of disease and, finally, the dissection after death of the body, became the practice of medicine within hospitals, and the mode of production of medical knowledge.

This form of medicine, practised on large numbers of people within hospitals, came to see disease in a reductionist way. Anatomo-physiological knowledge of the body allowed the construction of a normality, a 'standard of functioning and organic structure' against which deviations, in the form of disease, could be measured. The source of disease was understood to be directly related to abnormalities of function or structure within the body.

What is important in my argument concerning this way of understanding disease are the ideas of division and enclosure contained within it: division, because illness can be distinguished from health as a condition, and the unwell separated from the well; enclosure, because illness is seen as located in and coterminous with the individual body, and the sick individual is enclosed within an institution, the hospital, the appropriate site of medical care.

Taking Foucault's work as his starting point David Armstrong (1983) traces how medicine developed new ways of looking at illness and disease in the twentieth century, through new ways of practice. He describes how

'the medical gaze, which had, for over a century analysed the microscopic detail of the individual body, began to move to the undifferentiated space between bodies and there proceeded to forge a new political anatomy.'

The challenges to health of the early twentieth century were contagious diseases such as tuberculosis and venereal disease. These were diseases of contact, of relation ships between people, not between people and the environment as cholera and typhoid were seen. Armstrong takes the idea of the 'Dispensary' to represent a way o seeing illness. Dispensaries were special institutions for the diagnosis and treatment of TB, not on an inpatient basis such as the nineteenth-century hospital or the sanatoria, but as ambulatory care. The patient stayed in the community, but the condition was managed by the Dispensary. Also undertaken were screening, contact tracing, and the observation and monitoring of the course of the disease within the community.

What Armstrong argues was made possible by the Dispensary was the extension of the medical gaze, out of the hospitals and away from the individual body into the community. Instead of being located within and coterminous with the individual body, disease was located in the spaces between people, in the interstices of relationships, in the social body itself. In its concentration on the enclosed sick population of the hospitals, the gaze of nineteenth-century medicine had ignored or made assumptions about the unenclosed general population.

In the Dispensary, the gaze was extended out from the actually ill to the potentially ill: the 'normal' population. Contact tracing and notification of disease made visible the patterns of relationships between people. Similarly the institutional arrangements for dealing with venereal disease (sexually transmitted disease) brought even more personal and private relations and contacts under scrutiny and surveillance. So 'a new way of seeing illness': no longer enclosed within the body, but existing between bodies; no longer enclosed within the hospital, but visible in the community.

The medical gaze then 'began to focus with greater intensity on the potentially ill: the healthy and the normal'. Screening, to identify the potentially ill, became both technically possible and medically desirable. Armstrong traces the growth of the use of the survey to examine whole populations and the discovery that physical signs (hypertension or glycosuria, for example) or psychological states (anxiety or depression) that had been regarded as abnormal and that were part of the definition of illness were in fact present in large numbers of the 'normal' population. This surveillance thus arises from and, in turn, creates a perception of health in which the normal/abnormal divide begins to dissolve. The Panopticon had concentrated on the binary separation between the normal and the abnormal. The Dispensary extended the clinical gaze to the whole of society. Health and illness were no longer individualised and private matters between doctor and patient.

Armstrong's work provides a useful framework for looking at British drugs policy in the period from the 1920s to the 1960s. When drug use is constituted as an individualised medical entity, its treatment is a private issue between doctor and patient. When it is perceived as a social disease, in terms of being both a result of contact and a threat to the social body, it becomes a matter for Government statements and action, and the involvement of a wider range of welfare services. The story of British drugs policy in the twentieth century is not, then, one of a dichotomy between a medical and a penal model, but reflects the career of drug use as a disease entity in the private and the public health. This in turn reflects the wider story of medical perception and knowledge. Techniques of surveillance and control both create and are, in turn, created by the new perceptions of disease as 'public'.

THE ROLLESTON PERIOD

The career of drug use during the nineteenth century went from a habit to an addiction; a pathology of the soul and will has been traced elsewhere (Harding 1988). This analysis begins in the 1920s, by which time addiction was accepted as a disease entity by the British medical profession (Berridge, 1978, 1980, 1984; Parssinen and Kemer,1980; Harding,1988). Although the condition could not be linked to a specific lesion in the body, it was classed as one of the neuroses and seen as an area of legitimate concern for the profession; the major medical texts of the time usually included a chapter on the subject.

For those addicts the medical profession was likely to see and treat, the disease model and classification as a neurosis fitted the epidemiological evidence. Most were either doctors or other professionals with access to drugs, the 'professional' addicts, or else had become addicted in the course of treatment, the 'therapeutic' addicts. In all, addiction represented a 'very minor problem indeed, a middle-class phenomenon confined to a large extent to the medical profession itself' (Berridge, 1984). Working class use, of laudanum, for example, was a matter for control via the restriction of sales, and was not seen as a medical issue (Berridge, 1978). The disease was an individualised pathology: some people (principally women and physicians) were believed to have a predisposition, and the stresses of modem civilisation were regarded as a trigger for these sensitive individuals (Parssinen and Kemer,1980). The medical theory, therefore, 'singled out the addict as a distinct, abnormal personality' (Berridge,1988).

Outside Britain, most notably in North America, different views obtained. International conventions were agreed in the pre-war years outlawing narcotic drugs, and there was pressure on Britain to conform.

Bean (1974) sees the development of the international scene as important to an understanding of British policy; all the Acts concerning drug use passed in the period up to 1964 were 'directly implemented because of international agreements', or else to extend existing Acts. In the 1920s it was partly this pressure and the Home Office's wish to conform that put drug use and its control on the agenda. In the immediate post-war period, the extension of the wartime controls imposed on the military to the civilian population, the passing of the 1920 Dangerous Drugs Act and the attitude of the Home Office seemed likely to criminalize the field. Use of narcotics without medical validation was proscribed and the question became one of the delineation of acceptable medical practice.

At stake was the right of the medical profession to autonomy, both in defining addiction as a disease and in the choice of treatment. Was the prescription of narcotics for known addicts a reasonable course of action and therapy? This issue was complicated by the question of professional addicts prescribing for themselves. As Berridge (1980) says 'professional forces were not prepared to abandon addiction without a struggle' and the Home Office 'despite their wish to control the medical profession, nevertheless had to turn to the profession to validate their action'. 'The result was that two elite groups joined in defining the problem of narcotic addiction (. . .) and in policing and running a structure of control.'

The Rolleston Committee was set up in 1924 with a brief to advise the Home Office on the matter. Its role was to clarify medical opinion about the place of maintenance prescribing in the treatment of addiction. The committee was composed entirely of medical men, mostly experts in the field of addiction, and the report, in 1926, reflected foregoing medical opinion. It confirmed the status of addiction as a disease and the addict as sick, and asserted the right of the medical practitioner to use his discretion in the choice of treatment in this, as in other illnesses. Whilst the report advised that the treatment of choice in addiction was gradual withdrawal of the drug of dependence within an institution, reflecting a concern with treatment and cure, and the separation of the normal and the abnormal, there was also the recognition that this might not be possible for all addicts and so the use of maintenance prescribing was a legitimate course of action.

The report used case studies of 'stable addicts' to show how maintenance allowed some individuals to lead 'normal' lives even though engaged in an 'abnormal' activity. The Committee rejected the idea of notification of addicts to the Home Office when the British Medical Association opposed it, on the grounds that it would damage the confidentiality of the doctor-patient relationship. The report also recommended tribunals to deal with cases of over-prescribing, for self or others. This instituted a means of control, but kept its immediate operation in the hands of the medical profession, a situation that was acceptable to both the Home Office and the profession. In fact, these tribunals were never used, and were officially abandoned in 1953 (Trebach, 1980). The acceptance of the report and the expression of its principles in Home Office circulars was a mark of the incorporation of the medical profession into the policy-making structures.

Rolleston represented the medical profession's disease concept of addiction. The report looked back to the nineteenth century: the division of illness and health, and the enclosure of the sick in institutions for treatment. It protected the privacy of the doctor patient relationship and the professional right to clinical freedom within that relationship, subject only to the scrutiny of peers. It established what became known as the 'British System' of treatment of addiction, in the tradition of what Strong (1979) has called, in another context, 'bourgeois medicine': individualised and private. *

However, it can also be seen as looking forward to a' blurring of the line between the normal and abnormal. This should not be overstated, but the concept of the maintained addict carried within it an idea that health and disease are not so easily distinguishable, and that ambulatory care might be a means of what would now be termed 'management' of a condition in the community.

THE BRITISH SYSTEM

The essentially medical nature of this model of addiction was the main difference between the 'British System' and North American policy commented on by, among others, Lindesmith (1965, 1972) and Schur (1961, 1963). Lindesmith described the British System as 'an example of a relatively successful way of dealing with narcotic drugs' and argued that this was because the legislation put 'the treatment of addicts squarely into the hands of the medical profession'. The addict in Britain was 'a weakling or an unfortunate person to be pitied and treated with compassion', not a criminal, and the details of treatment were regarded as 'technical mat

ters to be settled by discussion among experts, rather than by public debate'. Schur draws a similar picture, commenting on the 'almost complete professional autonomy' of the British medical practitioner in the treatment of addiction and on the view of the addict as a 'troubled person'. It is somewhat ironic, as a sociologist, to see the call for more 'medicalisation' of the drugs question represented in the work of Lindesmith and Schur, given the tendency for sociologists to see many of medicine's claims to authority outside the direct clinical arena as imperialism and an insidious form of social control.

More recent commentators have questioned the conclusion Lindesmith and Schur drew that the British system was successful in preventing a drugs problem (e.g. Trebach, 1982; Berridge, 1984). Smart comments that the period is now seen more as one of 'non-policy' (Smart, 1984). The argument is that such a policy was only possible in the context of the small numbers and particular type of addict, rather than being an explanation for those numbers. Berridge (1978) points out that medical control was set within a framework of overall control by the Home Office, but that this was 'muted so long as addicts themselves conformed, as they did until the 1960's, to the medical model established'. By the 1960s and the changes in that model, the medical profession was firmly enough incorporated into the institutions of policy-making that all discussion of policy took place within a medical model of addiction, although a redefined one, and on the medical profession's terms.

THE EPIDEMIC OF THE 1960S

So how, by the 1960s, had the perception of addiction changed, from that of the Rolleston era, an individualised pathology, to the idea of a socially infectious condition, as manifested in the Brain report? What I want to argue is that over the period, the addict had been made visible by a form of surveillance, the expression of the overall Home Office control left intact in the 1920s. From 1934, the 'index', a working list of all addicts receiving prescriptions, was compiled by the Home Office Drugs Branch from police reports of the routine surveillance of pharmacists' records, from the Home Office's own inspection of these records and from information supplied by doctors, especially police surgeons. Also available from this scrutiny were doctors' patterns of prescribing.

At a time when even the black market was the overspill from prescriptions, this technique gave a picture of the course of the 'disease' of drug use through the social body. Knowledge of drug use was there in the observable facts as the prescription and dispensing of dangerous drugs. It was not so much the individual addict who was being observed (in spite of popular belief in the status of a 'registered addict') as the pattern of disease; the treatment of the addict was, as already discussed, a matter for the individual doctor.

A study by Bing Spear of the Home Office Drugs Branch demonstrates this (Spear, 1969). A young man, 'Mark', was arrested in September 1951 for theft from a hospital pharmacy in May of that year. Spear identified the links between 'Mark' and most of the new cases of 'non-therapeutic' addicts 'coming to notice' over the next 4 years. The story is told in terms of an infective agent arriving in ideal conditions for the spread of contagion. Up to this point the traffic in cannabis had been much more important to the authorities than that in opioids. Cannabis use was believed to be a feature of the lifestyle of black immigrants, but not of white youth. The raid on 'Club Eleven', a London nightclub, in April 1950, when about 200 people 'coloured and white of both sexes' were searched challenged this impression. Of the dozen or so men found to be carrying drugs (mainly cannabis, with some small amounts of cocaine), only one was black. This was the first evidence of 'young United Kingdom born subjects' use of drugs. The raid and preceding seizures of imports of cannabis led to a scarcity of the drug in London. The arrival of 'Mark' during this shortage, Spear argued, was the advent of heroin on the London scene, and the beginning of the 'case-to-case' spread of opiate addiction (Bewlay, 1965a) .

The report of the first Brain Committee (the Interdepartmental Committee on Drug Addiction, called after its chairman, Sir Russell, later Lord, Brain who was, appropriately, a neurologist), briefed in 1958 to review the Rolleston Committee's advice, did no reflect this changing picture. The Committee saw no reason to change the framework set by Rolleston; whilst institutionalised treatment was the ideal, the number of addicts were not sufficient to warrant the establishment of special institutions, registration would serve no useful purpose and, in contradiction to Rolleston and perhaps most importantly, the Committee saw no need for tribunals to investigate or discipline individual doctors' prescribing practices. The Committee had convened and taken evidence before the Home Office figures for 1961 were available, and before there was a awareness, beyond those immediately responsible for the collection of the figures, of the changes that started to take place.

By the time the report was published this awareness was more widespread. The index charted the progress of addiction as the image changed from a disease of rather sad middle-aged or elderly individuals, who had become addicted in the course of therapy or because of professional access to the drug, to a contagious condition of the young (Bewlay 1965b; Glatt, 1965; Sames, 1971). The emergence of these young 'recreational' or 'non \ therapeutic' addicts once again posed questions about the medical justification for prescribing. Was it right to prescribe for these young addicts in the same way as for the older 'stable' addict?

THE SECOND BRAIN REPORT

The Brain Committee was reconvened in 1964 to review their earlier advice 'in relation to the prescribing of addictive drugs'.

The issue centred round a few doctors, mainly in London, who were regarded by their peers as being responsible for the supplies of prescribed drugs which constituted the black market at that time. These doctors were general practitioners, mostly working in the private sector, and were subject to severe and, in some cases, highly personalised criticism by the specialists who were coming to regard addiction as part of their domain. Spear describes how Lord Brain, after hearing the evidence of one of these doctors, Lady Frankau, told the Home Office Inspectors 'Well gentlemen, I think your problem can be summed up in two words - Lady Frankau' (Interview, 1988). One psychiatrist concluded that 'if potential addicts had less contact with addicts and less ease of access to narcotics there would be less addiction' (Bewlay, 1965a).

The second Brain report stated that 'not more than six doctors were responsible for the excessive prescribing' and that 'they had acted within the law and according to their professional judgement'. In rejecting the idea of tribunals in 1961, the Committee had rejected the means of opening that 'professional judgement' to scrutiny. In its second report the committee sidestepped the issue by making the treatment of addiction a matter for specialist psychiatrists and removing the general practitioner's right to prescribe (Fazey, 1979). The Committee's main recommendations were: the notification of addicts, the establishment of 'special treatment centres' with powers of compulsory detention, and the restriction of the prescribing of heroin and cocaine for addicts to the staff of the treatment centres. An advisory committee to 'keep under review the whole problem of drug addiction' was also recommended.

The word 'notification' was used deliberately to reflect the belief that addiction was a 'socially infectious condition'. The special treatment centres (whose establishment was now justified by numbers) were to have 'facilities for medical treatment, including laboratory investigation and provision for research'. It was suggested that 'the centre might form a part of a psychiatric hospital or of the psychiatric wing of a general hospital'. Although the report did not give details of how these centres were to be run, the Brain Committee's view contained elements of the binary divide separating the 'sick' addict who was to be institutionalised, on a compulsory basis if necessary, for treatment, from the rest of the community to whom the disease could 'become a menace'. In fact, compulsion was not taken up as an issue, and when the clinics opened, outpatient or 'ambulatory' care was the dominant mode of delivery.

THE NEW DRUG-DEPENDENCY CLINICS

The way that the clinics eventually emerged was the result of debate within the medical profession. The Home Office had no wish to impose 'a massive treatment organisation' (Interview, 1988) or even to see addiction become the sole concern of psychiatrists (Trebach, 1982). Their worry had been that a return to the Rolleston tribunals would have been a way of dealing with this (Interview,1988). It was from the medical profession's new definition of the disease of addiction that the public heath measures of specialist clinics, notification and controlled prescribing emerged.

Three linked articles in the British Medical Journal in May 1967, by two psychiatrists, Thomas Bewlay and Philip Connell, and one general practitioner, Petex Chapple, all of whom were involved and influential in the field, dealt with options for policy (Bewlay, 1967; Chapple, 1967; Connell, 1967). What the writers reveal are different ways of seeing disease and responding to it.

The first, by Bewlay and closest to Brain in ideas, presented a model of centralisation and fairly overt control. There should be a small number of units, in close contact, to standardise treatment and practice. The notification system and exchange of information between clinics would prevent addicts going from one clinic to another, and would make contact tracing easier. The need for inpatient facilities for assessment was stressed, as it was the difficulties of assessing an addict's 'true' dependency which had led to the overprescribing of the past. There was a 'need to consider' whether voluntary or compulsory treatment was best. The emphasis was on the monitoring of the individual addict's body: inpatient assessment, a discussion of the practicalities of supervised injecting 'if addicts are to have heroin', the possibility of compulsory treatment (Bewlay, 1967).

Between this and the view of the other psychiatrist, Connell, the focus shifts to a wider consideration of the 'field of drug dependency'. This presented a range of service as being necessary, talking about a 'therapeutic spectrum'. The outpatient clinics should be distributed between a large number of hospitals to 'spread the load', with addicts making fortnightly maintenance visits. Separate inpatient units were necessary; this was to facilitate the development of a 'team approach' to treatment, to provide an opportunity to study 'methods of treatment and control' and to prevent the spread to other patients. The need for better training of doctors, nurses and social workers was stressed but the writer was dubious about the involvement of the voluntary sector who might lack the necessary objectivity. The services should not be limited to heroin users but should treat the users of other drugs such as amphetamines as well. There was also a need for social security support to prevent addicts having to deal while unable to earn their living in other .ways. The mechanisms of control, although still there in the standardisation of records, procedures for transfer between clinics and uniform maintenance schemes, were lighter and more subtle; the case for compulsory treatment had 'not been made', and research into new techniques of more 'objective' monitoring - urine testing, for example - and other biochemical measures of drug use were necessary (Connell, 1967).

The gap between the perception of the two specialists and that of the general practitioner reflects that between the perceptions of 'hospital medicine' and 'biographical medicine' (Armstrong, 1979). Chapple started from the premise that institutionalised treatment was bound to fail because addiction was a disease that had to be dealt with in the world where the addict lived, and with the addict's co-operation. The appropriate site for treatment was 'in the community', by experienced practitioners who could provide a continuity of care and 'a human and friendly therapeutic atmosphere'. Monitoring by techniques such as urine testing would be used, but the emphasis was on the patient as a person and the surrounding social networks (Chapple, 1967).

All three writers disliked the idea of prescribing, particularly injectables: 'incorrect for the treatment of addiction' (Chapple, 1967), 'anathema to many doctors' (Connell, 1967), but agreed that 'greater disasters occur when these drugs are available only illegally' (Chapple, 1967 - who also pointed out that sterile water and syringes could be made available).

Once the clinics were established, how did they operate? Stimson and Oppenheimer (1982) give a picture of how the relationship between clinic staff and addicts in the early days was often one of conflict and confusion in which the usual norms of medical encounters, what Strong (1979) calls the 'ceremonial order', could not be adhered to. The staff were unusually explicit about their role in controlling a social problem and there were coercive measures: contracts, negotiations and sanctions, which would not be considered ethical in other medical settings. These were justified by staff as being 'reasonable' because of the nature of the patients. Addicts were seen as being disenfranchised in some way. They did not want to get better, did not seek help or co-operate with treatment and behaved as if absolved from their social obligations. They did not, in short, understand the sick role and the obligations it placed on them and so confounded staff's expectations of patient behaviour. This was explained in terms of psychopathology by the staff.

To the addicts, the staff generally represented hurdles that had to be overcome; part of 'managing' was managing the clinic staff. This is an experience similar to that reported by women seeking abortions (Allen 1981), another aspect of medicine where many of the norms of medical encountering do not operate.

The staff themselves were monitored, but this was not perceived as a threat to clinical freedom, reflecting the perception of the clinics' role in controlling an infectious condition.

THE CLINICS: A BREAK OR CONTINUITY?

Smart (1984) takes issue with analyses of drugs policy that define the Brain report and the ensuing changes as representing a significant shift, saying that: 'the conceptualisation of the addict as a sick person and threat to public health which emerged co-terminously with the construction of addiction as a social problem in the nineteenth century remained the unshaken epistemological basis of policy in the 1960's.' Instead of a break, she sees the clinics as the rationalisation of existing policy, made possible by developments and applications of scientific knowledge: the development of methadone as a substitute for heroin, techniques of biochemical screening, and the recording and collation of records.

Drawing on Foucault's work, she locates drugs policy in the process of regulation and disciplining of bodies by the application of rational scientific knowledge to human behaviour.

A problem with Smart's argument is in her implication that there had been no change in the way addiction was perceived as a disease and a threat to public health, or indeed in the conceptualisation of public health itself. The nineteenth-century sources she quotes define the addict as becoming a 'worse than useless member of society'. In this formulation the addict is a 'problem' because he or she is a waste of resources, an individual, unhealthy member of the social body, unable to play his or her role in an increasingly organised society.

In fact, what was different about the picture of the addict in the 1960s was the idea of infection or contagion, and the threat posed by the dissolution of the divisions between the ill, the potentially ill and the healthy that this implied. Disease concepts of addiction have followed the twentieth-century redefinition of the site of illness and health. The post-Brain era did represent a new concern about control, as evidenced by Stimson and Oppenheimer's observations, because addiction was seen as existing in the spaces between bodies. The institutional arrangements of this control were a halfway stage between the enclosed, hospitalised ideal of the nineteenth century and the Rolleston report, and the open, community-based model offered by Chapple.

The clinics had elements of the Dispensary. The technical developments Smart points to were important; the development of substitutes and methods of scrutiny of addicts' drug-taking away from the clinic made non institutionalised treatment possible. However, the collection and centralisation of information, which had started in the 1930s, was part of the process of redetining the concept of addiction as a disease, a redefinition which included the siting of the disease in the social body and thus created the need for non-institutionalised treatment.

Thus the change in the understanding of the drug user and of drug use that occurred between the 1920

and the 1960s, two periods when drug use and its treatment were on the policy agenda, can best be understood in terms of the wider changes that occurred over this period in the way that the constructs of health and illness were understood.

ACKNOWLEDGEMENTS

I am grateful to Gerry Stimson for comments on an earlier draft of this paper.

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