MEDICAL QUESTIONS:

(1) Prevalence of Addiction - Addiction to morphine or heroin is rare in this country and has diminished in recent years. Cases are proportionally more frequent in the great urban centres among persons who have to handle those drugs for professional or business purposes, and among persons specially liable to nervous and mental strain. Addiction is more readily produced by the use of heroin than by the use of morphine, and addiction to heroin is more difficult to cure.

(2) facility of access is an important factor in the production of addiction, and the recent diminuation in the number of addicts  to both these drugs is largely attributable to the restrictions imposed by the Dangerous Drugs Acts (paras 22-26)

(3) Nature and Causation of Addiction.- With few exceptions addiction to morphine and heroin should be regarded as a manifesatation of a morbid state, and not as a mere form of vicious indulgence (Para 27.)

(4) The immediate cause of addiction is the use of the drug for period sufficient to produce the constitutional condition manifested by "craving"  and the occurance of withdrawal symptoms when the drug is discontinued. Addiction is more readily in some persons than others, the most important predisposing cause being an inherent mental or nervous instability. There is evidence however, that addiction may be induced by injudicious use of the drug in a person apparently free from any manisfestation of nervous or mental disability, and, conversly that due care in administration may avert this result even in the unstable. other predisposing causes are chronic pain or distress, insomnia, overwork and anxiety (paras 30)

(5) In a considerable proportion of cases the circumstance which has immediately led to addiction has been the previous use of the drug in medical treatment. Other circumstances noted have been self-treatment for the relief of pain etc, recourse to drugs in emotional distress, influence of other addicts, and indulgence for the sake of curosity or the experience of pleasurable sensations. cases of addiction originating in use of the drugs otherwise than under medical orders must be expected in future to be less frequent than in the past (Paras 31-34)

(6) Treatment and Aftercare.- While the most eminent authorities differ as to the relative value of (a) abrupt or rapid withdrawal of the drug and (b) gradual withdrawal in the cure of addiction, the following conclusions may fairly be drawn from the evidence;-
(a) Abrupt or rapid withdrawal cannot be carried out safely except under conditions which afford complete control of the patient's access to the drugs and close and continuous observation of the effects of the treatment, such as are usually to be found only in special institutions or nursing homes.
(b) gradual withdrawal will therefore with rare exceptions be the only practcable method under the ordinary conditions of private practice and the only one applicable to patienst who cannot afford or are, for other reasons unwilling to enter institutions or nursing homes.
(c) Abrupt withdrawal may be adviable for young otherwise healthy adults in whom the addiction of recent date and so far has entailed moderate doses only, in other cases gradual withdrawal is on the whole to be prefreed even under institutional conditions.
(d) Abrupt withdrawal is especially dangerous in old or seriously debilitated persons, patients with organic disease and those taking exceptionally large doses.
(e) Institutional treatment, while with rare exceptions indispensable for the abrupt method, also affords the best hope of cure by the gradual method, and patients should always, if possible, be induced to undergo treatment in an institution or nursing home.
(f) Success in enabling any patient, by either method, to become (for the time being) independent of the drug must be regarded as the completion of the first stage of treatment only. For permanent cure a prolonged period of aftercare is necessary, in order to educate the patient's willpower and to change his mental outlook. For this part of the treatment information should be obtained by a close investigation, during the first stage of the conditions which brought about the addiction, and if a factor, such as pain or insomnia, contributed to the causation, every effort must be. made to remove or cure this before the patient is released from observation. Attention must also is paid to the possbility of improvement in the patient's social conditions (paras 31 -32)

(7) Prognosis. Estimates of the proportion of completed cures of cases treated vary from 15 or 20 per cent. to 60 or 70 per cent., the highest percentages being claimed by practitioners adopting the abrupt method who had carried out the treatment in institutions or nursing homes (para 43 and 44)

(8) There are two groups of persons suffering from addiction whom administration of morphine or heroin may be regarded as legitimate medical treatment.. namely:
(a) Those who are undergoing treament for cure of the addiction by the gradual withdrawal method ;
(b) Persons for whom, after every effort, has been made for the cure of the addiction, the drug cannot be completely withdrawn, either because:
(i) Complete withdrawal produces serious symptoms which cannot be satisfactorily treated under the ordinary conditions of private practice; or
(ii) 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. (Paras 45-49.)

(9) Under treatment by the gradual withdrawal method the addict should, if possible, be induced to enter a suitable institution or nursing home. If this is not feasible the practitioner must attempt to cure the condition by a steady judicious reduction of the dose, with a view to ultimate complete withdrawal. The patient should be kept under close observation by the practitioner should be in the care of a capable and efficient nurse and under sufficient control to preclude any possibility of obtaining supplies of the drug other than those medically ordered.

(10) If the practitioner finds that he is losing the requisite control, or tile course of the case indicates a probability that complete cure cannot be effected, he will be well advised to obtain a second opinion before assuming the responsibility of indefinitely prolonged administration

(11) Where indefinitely prolonged administration appears to be needed the main object must be to keep the supply of the drug within limits of what is necessary.

(12) The practitioner should be satisfied as to urgency before administring or supplying morphine or heroin to a patient concerning whom he has no previous knowledge and careful inquiries should be made from the patient, at the beginning. as to previous or concurrent sources of supply. The minimum dose necessary should be administred and (unless organic disease is present) repetition withheld until the the practioner has obtained from the previous medical attendant details on the nature of the case. (Paras. 51 - 1íi.)

(13) We recommend that the following precautions should be taken in the use of morphine and heroin in ordinary medical practice
(a) Regard should be had at all stages of the case to the possibility of substituting for morphinte or heroin, either temporarily or permanently, drugs which do not involve the risk of the development of addiction.
(b) If the use of morphine or heroin is essential, care should be taken not to give larger or more frequent doses, than are strictly requisite to achieve the object in view.
(c) Cases requiring the daily administration of morphine or heroin should be seen as often as the doctor feels to be necessary, and the amount ordered or supplied should not exceed that required until the patient is seen again.
(d) Discretion to nurses as to administration of the drugs should be strictly limited by prescription, and any change made in the treatment should be stated in writing.
(e) The patient should not be informed either of`the name or dose of the drug administered. Whenever other methods of administration will produce the desired effect, hypodermic injections should be avoided.
(f) In no circumstances should the patient be allowed to administer the drug to himself hypodermically.
(g) The use oÍ the drug should be discontinued immediately if it is no longer needed.
(h) if a craving has unfort:unately resulted from use of the drugs, close supervision and appropriate treatment should be maintained until the medical attendant is satisfied that the patient has been rendered independent of the drug. (Paras 50-51.

(14) Valuable results might come from the judicious instruction of medical students in the precautions necassary to avoid the production of addiction to morphine and certain other drugs. medical men already in practice should welcome the issue of some authorative Memorandum affording guidance upon this difficult and important subject and we therefore recommend that such a Memorandum be issued. (para 61)

(15) Withdrawal of Authorisation to Possess and Supply.- The present position under which a doctor's authorisation to possess and supply the drugs can only be withdrawn after a conviction under the Dangerous Drugs Acts is not satisfactory, either administratively or from the point of view of the medical profession
We recommend that the Home Secretary should have power to withdraw the authorisation without conviction in the Courts if so advised by a suitably constituted medical tribunal.
We recommend that Tribunals should be constituted whose function it would be to consider whether or not there were sufficient medical grounds for the administration of the drugs by the doctor concerned either to a patient or to himself, and that they should advise the Home Secretary whether the doctor's right to be in possession, to administer and to supply should be withdrawn
We recommend that there should be seperate Tribunals for:
(i) England and Wales
(ii) Scotland; 
and that they should be composed of one member nominated by the general Medical Council, one by the appropiate College of Physicians and one by the British Medical Association with a legal assessor. (Paras 62-75)

(16) Control of Prescribing. - Any doubt there may be as to the power of the Home Secretary under the present Regulations to control the prescribing of Dangerous Drugs should be removed by a suitable amendment to the Regulations, and we recommend accordingly
The Home Secretary should also have power after the conviction of a doctor in the Courts for an offence under the Dangerous Drugs Acts or on the advice of a Medical tribunal to withdraw the practioner's authorisation to prescribe dangerous Drugs, and we recommend that this amendment to the Regulations be also made (Paras 75-76)

(17) Obtaining of Second Opinions.- In the interests of patients and of practioners themselves it is desirable that the practice should be generally followed of obtaining second opnions before undertaking the responsibilty of continuing to administer drugs in cases in which there is no medical reason for doing so other than treatment of an addiction. This applies also to the group of cases in which the patient needs indefinite administration of the drug for the purpose of enabling him to lead a normal and useful life. The Regulations should not however require a practioner to obtain a second opnion but it should be regarded as a professional obligation such as is generally recognised in respect of the decision to carry out certain other forms of treatment (paras 79-87)

(18) Record of Purchases by Non-dispensing Doctors.- Doctors who do not dispense should be required to keep a simple record of their purchases of Dangerous Drugs and this could most easily be done if the invoices of purchases were pasted in a book. We recommend that the Regulations be amended accordingly (para 88)

(19) There is little if any abuse or danger of addiction arising from any preparations at present excluded from the scope of the Dangerous Drugs Acts with the possible exception of chlorodyne As regards this preparation there was considerable difference of opnion, but the evidence appears to show that the free sale of the preparation as a common domestic remedy has given and does give rise to certain risks of addiction. (Paras 90-102)

(20) There is no present need  for the prevention of addiction to decrease the limit of morphine content now fixed by the dangerous Drugs Acts
The position as regards chlorodyne would be met if it should be secured in some way that no preparation should be sold under the name Chlorodyne which contained more than 0.1 per cent of morphine (Para 103)

Finally the Committee wish to record their high sense of the services of the Secretaries Mr R.H. Crooke and Dr E.W. Adams

HUMPHRY ROLLESTON (Chairman)
W.H. WILCOX
JOHN W BONE
R.W. BRANTHWAITE
G. MATHESON CULLEN
W.E. DIXON
JOHN FAWCETT
A FULTON
J SMITH WHITAKER