50. The position of a practitioner when using morphine or heroin in the treatment of persons who suffer from addiction to either of these drugs obviously differs in several important respects from that in which he is placed when using the drug in the ordinary course of his medical practice for the treatment of persons not so affected. Not only will the objects of treatment usually differ but also the dangers to be avoided, and the precautions that are therefore necessary-. It is thus convenient to discuss these precautions separately as regards :---
(i) The administration of the drugs to persons who are already victims of addiction, and
(ii) The ordinary use of the drugs in medical and surgical practice.

51. In the preceding section, the conclusion has been stated that morphine or heroin may properly be administered to addicts in the following circumstances, namely, (a) where patients are under treatment by the gradual withdrawal method with a view to cure, (b) whore it has been demonstrated, after a prolonged attempt at cure, that the use of the drug cannot be safely discontinued entirely, on acount of the severity of the withdrawal symptoms produced, (c) where it has been clearrly demonstrated that the patient, while capable, of leading a useful and relatively normel life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued

52. Precautions in the Treatment of Addicts by the Gradual Withdrawal Method. - In thise cases the primary object of the treatment is the cure of the addiction, if practicable. The best hope of cure being afforded by treatment in a suitable institution or nursing home, the patient should, if possible, be induced to enter such an institution or home. If he is unable, or refuses to adopt this course, the practitioner must attempt to cure his condition by steady, judicious reduction of the dose. The general lines of the treatment, as carried out by practitioners of special experience, have already been described. For success it is necessary that the patient should be seen frequently, be under sufficient control, and be in the care of a capable and reliable nurse. The practitioner should endeavour to gain his patient's confidence, and to induce him to adhere strictly to the course of treatment prescribed, especially as regards the amount of the drug of addiction which is taken. This last condition is particularly difficult to secure, as such patients are esesentially unreliable and will not infrequently endeavour to obtain supplementary supplies of the drug. If, however, the practitioner finds that he cannot maintain the necessary control of the patient, he must consider whether he can properly continue indefinitely to bear the sole responsibility for the treatment.

53. When the practitioner finds that he has lost control of the patient or when the course of the case forces him to doubt whether the administration of the drug can, in the best interests of the patient, be completely discontinued, it will become necessary to consider whether he ought to remain in charge of the case, and accept the responsibilty, of supplying or ordering indefinitelt the drug of addiction in the minimum doses which seem necessary. The responsibility of making such a decision is obviously onerous and both on this ground and also for his own protection, in view of the possible inquiries by the Home Office which such continuous administration may occasion, the practitioner will be well advised to obtain a second opinion on the case.

54. Precautions in Treatment of Apparently Incurable Cases.- These will include both the cases in which the severity of withdrawal symptoms, observed on complete discontinuance after prolonged attempted cure, and the cases in which the inability of the patient to lead, without a minimum dose, relatively normal life appear to justify continuous administration of the drug indefinitely. They may be either cases of persons whom the practitioner has himself already treated with a view to cure, or cases of persons as to whom he is satisfied, by information received from those by whom they have been previously treated, that they must be regarded as incurable. In all such case the main object must be to keep the supply of the drug within the limits of what is strictly necessary. The practitioner must, therefore, see the patient suffeciently often to maintain such observation of his condition as is necessary for justifyng the treatment. The opinion expressed by witnesses was to the effect that such patients should ordinarily be seen not less freqently than once a week. The amount of the drug supplied. or ordered on one occasion should not be more than is sufficient to last until the next time the patient is to be seen. A larger supply would only be justified in exceptional cases, for example on a voyage, when the patient was going away in circumstances in which he would not be able to obtain medical advice. In all other cases he should be advised to place himself under the care of another practitioner who should be placed in communication with his previous medical adviser in order that he might be informed as to the nature of the case and the course of treatment which was being pursued.

55. A practitioner when consulted by a patient not previously under his care, who asks that morphine or heroin may be administered or ordered for him for the relief of pain or other symptoms alleged to be urgent, or order the drug unless satisfied as to the urgency, and should not administer or order more than is immediately necessary. If further administration is desired in a case in which there is no organic disease justifying such adtninistration, the request should not be acceded to until after the practitioner has obtained from the previous medical attendant an account of the nature of the case. Requests from one practitioner to another for such information should obviously receive immediate attention.

.
56. The evidence we have heard would appear to indicate that there has been a recent diminuation in the prevalence of morphine addiction, and that this in due to the operation of the Dangerous Drugs Acts in making, it difficult to obtain the drhugs except from or on the prescriptions of doctors. (See para. 24.) This enhances the importance of consideration of the precautions that are necessary in the use of these drugs in ordinary treatment, in order to reduce to a minimum the risk that a patient may develop a craving for them. These precautions are, we think, fairly well recognised among competent and careful practitioners in all branches of the profession, and the conclusions here stated, based on the testimony of our medical witnesses, including representative general practitioners, may, we believe, be regarded as expressing fairly the opinion of all members of the profession who have given the requisite attention to the subject.

57. Where the patient is suffering from organic disease for the treatment of which the drugs are necessary, the matter may be considered under two aspects, (a) cases in which the administration of morphine or heroin may be necessary for an indefinite period and in which the probability of a cure of the disease is remote (c.g., inoperable cancer and the like), (b) cases in which administration of the drugs is called for in order to deal with conditions which, though due to organic disease may be expected to be of a more or less temporary duration (such as renal or biliary colic, etc.). In regard to class (a), since consideration of the possibility of the establishment of a craving cannot be allowed to influence the administration of such doses of the drugs as are considered necessary for the adequate treatment of the organic disease it will be in those rare cases only in which there is some prospect of partial or complete recovery from the disease that any attention can properly be given, during the course of treatment, to such measures as are likely to mitigate or avert the risk of subsequent persistence of any craving which may have been produced. In respect of class (b), the employment of these measures becomes of paramount importance.
They are identical with the discussed in paras: 59 and 60, and consist. mainly in the substitution, when possible, of other drugs for morphine and heroin, in close supervision by the practitioner of the amounts used and of the frequency with which they are administered, and in withdrawal of the drug as soon as the necessity for its administration has ceased.

58. In stating the precautions which we think should be observed in cases other than those referred to in the preceding paragraph, we shall. be understood to have in mind, particularly, those cases in which it is thought necessary to administer, say, morphine, in such doses, with such frequency and for so long a period as may be requisite, for example, for the relief of pain after surgical operations, or in cases of severe neuralgia in which the necesary relief cannot be obtained otherwise.

59. In cases in which it appears that the use of morphine or heroin may be thus desirable, it must first be considered whether the purposes of treatment can be substantially as well served by other drugs that do not involve the risk of addiction. Constant attention is necessary to adjust the dosage to the varying needs of the case. The intervals at which it is desirable to see a patient (not an addict) who requires the administration of morphine or heroin will necessarily be determined by the nature of the case. In cases of chronic disease requiring a more or less prolonged administration of the drugs, the patient need only be seen at such intervals as are appropriate on other medical grounds, butt in cases such as renal or biliary colic, in which the necessity for the administration may cease at any moment, it may be important to see the patient more often than would otherwise be necessary in order to guard against the production of a craving.
The quantity supplied or ordered at one time for use by those nursing the patient should not ordinarily exceed what will be recquired before the patient is seen again. Where any discretion is given to nurses as to administration it should be strictly limited by prescription, and any change made in the treatment should similarly be stated in writing. The practitioner will realise that the responsibility for administration is entirely his, and cannot properly be delegated to any person not medically qualified, It is desirable also that the patient should not be informed of the name of the sedative drug employed; particularly inexpedient is the handing over to the patient of original packages containing morphine tablets, or the like, which bear on their lables a clear statement of the exact amount in each tablet.. Hypodermic administration of the drug by the patient to himself is to be strongly deprecated.

60. The use of the drug; should. be discontinued as soon as possible, and if unfortunately a craving has formed close supervision and appropriate treatment must be maintained until the medical attendant is satisfied that the patient has been rendered independent of the drug. It is to be noted in this connection, that, in the opinion of some authorities, a month's continuous administration of morphine may suffice to produce in a person who previously appeared normal a condition of addiction; and in persons with an inherent predisposition, administration for a shorter period may have this effect.

61. Most of our medical witnesses have concurred as to the desirabilty of special instruction to medical students on the precautions necessary in the use of morphine and certain other drugs in order to avoid the development of addiction. One or two medical witnesses, on the other hand, expressed doubt whether such instruction might not accentuate the undue timidity which they believed was not uncommon among practitioners, with the untoward consequences above described (see para. 32). We think, however, that such a result need not be feared from a full exposition of the actions, both valuable and harmful, of these drugs, the indications for their use, their proper place in treatment, the dangers to be guarded against, and the best means of averting these dangers. We think also that medical practitioners already in practice should welcome the issue of a Memorandum affording guidance on this important and difficult subject.