Heroin: The Treatment of Addiction in Twentieth-century Britain (review)

The “British System” of treating heroin addiction seems to hold a fascination for observers outside the United Kingdom, and it has been cited by commentators in order to make a variety of different points. However, it is far from clear that there ever was a specific and coherent British System in the way in which it is usually understood. It was largely because of the widespread misunderstandings and misinterpretations of the British System that John Strang and I published our earlier book (Heroin Addiction and The British System, 2005) on the subject.

Alex Mold looks at some of the developments in British responses to the treatment and management of heroin addiction from 1916 until the present. She begins the first main chapter (covering 1916 to 1961) by discussing the Defence of the Realm Act, which was, like so many other pieces of drug legislation, provoked by panic. In this case, the panic stemmed from the convictions of Horace Kingsley and Rose Edwards, who were found guilty of selling cocaine to Canadian soldiers on leave from the trenches during World War I. Kingsley and Edwards were sentenced to six months’ imprisonment, and the Defence of the Realm Act was to serve as an important foundation of twentieth-century British drug policy.

The period between 1962 and 1968 was a key phase in the development of a national response to heroin addiction. A number of private doctors in the London area were prescribing opiates and other drugs to addicts in ways that were causing concern, the number of heroin users was increasing, and the characteristics of heroin users were changing. The Second Interdepartmental Committee on Heroin Addiction (the Brain Committee) was reconvened to reconsider these and other issues. The committee regarded the establishment of specialist treatment centers as an essential response to what can now be seen in some respects as several of the early manifestations of the “modern” heroin problem. The establishment of drug dependence units (DDUs) was one of the most influential national responses to heroin addiction that occurred during the twentieth century in the United Kingdom.

In chapters 3, 4, and 5, Mold discusses the role and influence of psychiatry, the role of the general practitioner, and the role of private practitioners in the treatment of heroin addiction. These chapters are largely concerned with personalities and power struggles and provide a detailed (and rather claustrophobic) account of the comings and goings of some of key figures after the establishment of the DDUs and up until about the mid-1980s.

Chapter 6 is subtitled “Maintenance and Withdrawal 1980–1987.” As in earlier chapters, Mold does not discuss these issues in clinical terms but looks at how the key national players influenced the implementation of these treatment approaches. I felt that the book got itself into something of a tangle in this chapter, mainly as a consequence of presenting maintenance and withdrawal as polar opposites. There is no reason why a treatment service or a national treatment policy might not provide both withdrawal and maintenance. Indeed, I would have thought that it was essential that both should be provided within a treatment system. Some heroin addicts want to get off the drug and require treatment of their withdrawal symptoms, whereas others are unable or unwilling to stop using and thus require maintenance. It is, perhaps, simplistic to present the DDU psychiatrists as the “bad guys” who opposed maintenance (most of them continued to provide maintenance prescriptions during this period) and to contrast them with private doctors, who are presented as proponents of maintenance treatment (many GPs were resistant to treating drug addicts). My own understanding is that things were more complex than that. For me, the most interesting aspect of this issue is not discussed: how did the British System at that time come to invent its own muddled and poorly designed version of maintenance?

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