ROLLESTON REPORT OF 1926 (U.K.)

The Rolleston Report of 1926 helped to establish British policy toward Opiates, Cocaine, and other drugs. It institutionalized a drug policy in which medical expertise and public-health considerations were given importance along with punishment and criminal penalties. The British policies were, in this sense, different from U.S. policies toward drugs that emerged during the same period and in response to similar international agreements. The historical background leading to the formation of an elite committee of British physicians, chaired by Sir Humphrey Rolleston, had four major phases.

ENDING THE COMMERCIAL OPIUM TRADE

During the nineteenth century, the British established commercial opium trading by fighting and winning two Opium Wars with China: Opium grown and sold by monopoly in British-dominated India provided a quarter of the revenue for the British government in India. Prepared opium (for smoking) was exported to Chinese ports by the East India Company, where British authorities collected tax revenues on it for the Chinese government. Missionaries in China and their anti-opium allies in Britain, the United States, and Canada lobbied strongly against profiting from the British-sponsored vice. They also educated the public about opium smoking and commercial opium trading.

The U.S. government stimulated the convening of several international conferences from 1909 to 1914. These conferences reached agreements that all signatory governments would enact legislation ending commercial opium trading and restricting opium and cocaine to "legitimate medical practice." The Indo-Chinese opium trade ended in 1914. These international conventions were included in the Versailles Treaty that ended World War I. "Legitimate medical practice" and appropriate controls and/or penalties were not specified in the international treaties.

OPIUM CONTROLS AND GROWTH OF THE MEDICAL PROFESSION

During the nineteenth century, opiates were the only effective way to relieve the symptoms of many physical ailments (most medicines used today, including aspirin, became available only in the twentieth century). Opium and its derivative Morphine (Britain was the world's leading manufacturer) were available in patent medicines, in alcoholic solutions, and in other commercial products. The emerging professions of pharmacist and medical physician with advanced training and specialized knowledge were anxious to differentiate themselves from a motley group of healers—chemists, herbalists, barber-dentists, patent-medicine sellers, and others. In the 1850s, such persons could provide opiates to patients since they were not then illegal, and preparations containing opiates provided substantial revenues. Opium eating and Laudanum (an alcoholic solution of opiates) consumption were then widespread in Britain.

British pharmacists became eager to restrict sales of opiates to qualified sellers—but only in such a way that "professional" trade would not be harmed and could be expanded. The 1868 Poisons Act restricted opiate sales to pharmacists. This act mandated the labeling of opiates and required pharmacists to keep records of purchasers. (Similar restrictions on opiate sales in the United States did not occur until the 1906 Food and Drug Act.) Pharmacists, however, could continue to sell opiates directly to customers without a prescription from a physician, and physicians could prescribe or sell opiates to patients. In the early 1880s physicians and researchers in Europe, England, and the United States almost simultaneously began to write about the opium habit and morbid cravings for opiate drugs. In 1884 physicians in England founded the Society for the Study of Inebriety, which promoted a disease model of addiction and the need for treatment.

By 1900, physicians emerged as an elite group who defined all aspects of health care and medical practice in British society; pharmacists "policed" the Poisons Act and effectively retained control of dispensing opiates and other drugs. Thus, by 1914, British pharmacists and physicians had almost a half century of experience, professional collaboration, an ongoing professional association concerned with the dispensing of opiates, and attempts to contain opiate consumption and habitual use.

PRESSURE TOWARD CRIMINAL PENALTIES

In 1914, when the international opium convention (Hague Convention) was to go into effect, several British agencies could not decide which one should take responsibility for implementing legislation and regulation of drugs. Then World War I began in August 1914 and Sir Malcolm Delevingne, an undersecretary at the Home Office, took primary responsibility. He suggested using the War Powers Act to stop sales of cocaine and opiates to soldiers unless they were based on a prescription by a doctor that was "not to be repeated" (refilled without further prescription). Violators, however, could be fined only five pounds. Two or three cases were publicized and introduced the British public to "dope fiend" fears, but they continued to be rare.

After World War I, Delevingne argued that drug control was a police responsibility for the Home Office (where it has remained ever since). The 1920 Dangerous Drug Act was vague about two critical issues—whether doctors/pharmacists could prescribe for themselves, and whether doctors could "maintain" addicts. In 1921 and 1924, the Home Office proposed regulations that ignored the rights of professionals and imposed many complex procedures. It also sought powers of search and seizure, higher fines, and longer sentences for convictions. Thus, the Home Office was making regulations that would subject doctors to criminal sanctions and circumscribe their prescribing practices—as was already happening in the United States.

APPOINTMENT OF THE ROLLESTON COMMITTEE

The Home Office needed the cooperation of the medical profession to determine the appropriateness of maintenance dosages for addicts, and it sought to determine whether gradual reduction was the appropriate treatment for addiction. The Home Office and the medical profession each recognized the legitimacy of the other's position. Both realized that a partnership was needed. Thus, these two elite groups began a collaboration to define and resolve problems and appropriate practices regarding narcotics control. All persons appointed to the committee were medical personnel representing government agencies or nongovernment physician-interest groups. The chairman, Sir Humphrey Rolleston, was president of the Royal College of Physicians and a noted exponent of the disease view of Alcoholism. Another member had written the authoritative article on narcotic addiction in 1906. Police and law enforcement officials without medical training were not represented.

Committee Deliberations and Recommendations.

The committee was to consider and advise as to the circumstances, if any, in which the supply of morphine and heroin (including preparations containing morphine and heroin) to persons suffering from addiction to these drugs, may be regarded as medically advisable and as to the precautions which it is desirable that medical practitioners administering or prescribing morphine or heroin should adopt for the avoidance of abuse, and to suggest any administrative measures that seem expedient for securing observance of these precautions.

During a year and a half of deliberations and twenty-three meetings, the committee heard evidence from thirty-four witnesses. The Home Office submitted a memorandum that structured the questions and inquiry. Witnesses represented a wide diversity of opinion, particularly regarding appropriate treatment for addicts. Prison doctors favored harsher treatment, especially abrupt withdrawal of opiates (going cold turkey). Even consultants specializing in treatment rarely agreed on points of procedure and treatment. Most witnesses and commission members accepted the disease nature of addiction.

There was wide agreement, however, that addiction to Heroin or morphine (both opiates) was a rare phenomenon and a minor problem in Britain. Most addicts were middle class and many were members of the medical profession. Relatively few criminal or lower-class addicts were then known, so criminal sanctions appeared unneeded and inappropriate. The committee report concluded that "the condition must be regarded as a manifestation of disease and not as a mere form of vicious indulgence."

From this conclusion, many recommendations followed. The most important was that some addicts might need continued administration of morphine (or other opiates) "for relief of morbid conditions intimately associated with the addiction." Thus, the committee effectively supported maintenance of an addict for long periods of time, possibly for life.

The committee also made several recommendations for administrative procedures to lessen the severity of the drug problem. Practitioners were mandated to notify the Home Office when they determined someone was addicted; but physicians could continue to provide treatment and prescribe opiates to addicts. Gradual reduction rather than abrupt withdrawal was the recommended treatment, in part to keep addicts in treatment rather than to drive them to illicit suppliers. A medical tribunal was established to promote the profession's own policing of members who became addicted. The committee also opposed banning heroin (which was a useful medication and a very small problem in Britain at the time).

LEGACY OF THE REPORT

Shortly after the Rolleston Report was completed, its recommendations were included in amendments to the Dangerous Drug Act (1926). Although this act has been amended numerous times since then, the provisions adopted from the Rolleston Report remain in effect in the 1990s. Although cocaine was included as a narcotic in this report, separate recommendations for treatment were not made. Cannabis (Marijuana) was not included in this report. The Rolleston Report did not address the issue of illegal sales or transfers of opiates; no criminal or penal sanctions were recommended.

The British Medical Journal was content: The medical view of addiction as a disease needing treatment, and not a vice necessitating punishment and penal sanction, had been formally accepted as government policy. Medical professionals, rather than criminal-justice personnel, would be responsible for individual decisions about whether patients were addicts, and prescribe appropriate quantities of opiates, including on a maintenance basis. Any questions about appropriate prescribing practices and physician addiction would be handled by a committee specializing in addiction. As a result, almost no British physician has been arrested and/or tried for opiate-related violations.

The foundations of what is sometimes called the British system of drug policy had been established. From 1926 to 1960, this system worked well. Names of fewer than 1,000 addicts were forwarded to the Home Office each year, most of them medical personnel. Local practitioners could and did prescribe heroin and other opiates to their patients, including registered addicts. Some addicted patients were maintained on heroin, occasionally for years. They received their drugs from a local pharmacy. Addicts were also provided with clean needles and syringes. Drug treatment consisted almost entirely of individual physicians counseling addicted patients and providing drugs. Almost no illicit sales of opiates or cocaine occurred during these years. One staff member at the Home Office was responsible for all registrations and personally knew most of the addicts in Britain; he frequently helped addicts find doctors and/or assistance. The Home Office also covened meetings with addiction specialists to address any policy issues that arose. Thus, the British established what might be described as a system of drug control that gave due weight to medical values and public-health considerations. Most observers now agree, however, that the "system" worked because the problem was limited in size rather than that the problem was small because of the system. It worked well for half a century until the numbers of addicts increased substantially, because of drug dealing on an international scale, the widespread use of drugs during the 1960s-1980s countercultural revolution, and the increased immigration to Britain of former colonial citizens of the crumbling empire. By the 1960s, the upsurge in heroin use and the abuse of cocaine, marijuana, and other drugs left Britain with a drug problem of both licit and illicit substances that outstripped even the British system's handling capabilities.

(See also: Britain, Drug Use in ; British System of Drug-Addiction Treatment ; Heroin: The British System ; International Drug Supply Systems ; Opioids and Opioid Control: History ; Policy Alternatives: Prohibition of Drugs Pro and Con ; Sweden, Drug Use in )