§ 2.57 p.m.
§ Mr. Norman Fowler (Nottingham, South)
Over the past few years there has been a growing concern about the use and abuse of amphetamines and a growing realisation that they have a very limited medical use. In this debate I should like to touch on some of the problems, and to draw attention to what I believe to be one of the most hopeful schemes for tackling the problem that we have seen in this country.
First, it is worth emphasising that the use of amphetamines brings with it considerable risks. I say this because even today, even after all the publicity that there has been, it does not always seem to be realised. Although heroin is generally accepted as a dangerous drug, there is still an assumption that the limited use of amphetamines is relatively harmless. This may spring from the common description of amphetamines as pep pills. But at drug dependence clinics many of the patients are treated because amphetamines are the major drug of dependence. For example, in the Nottingham drug dependence clinic almost half the patients treated during the year have amphetamines as the major drug of dependence.
Amphetamines are stimulants which affect the central nervous system. They include dexledrine and the mixtures like drinamyl, the old purple hearts, and the so-called black bombers. Far from being 746 safe, their use can lead to psychosis, and when this happens the user must be withdrawn. In the depressed period which follows there is the risk of suicide, and after-care may take six to 12 months. In some cases the patients will need continuous psychiatric supervision and treatment. In the words of the British Medical Association working party, which reported at the end of 1968, their misuse can produce mental and physical deterioration. In short, amphetamines are a problem to be taken very seriously.
There is one other point worth making. We sometimes think of this problem as being confined to young people. There is no question that it is a problem of young people and that many of them are introduced to the illegal drug scene by way of amphetamines. But it cannot be pretended that it is confined to them. Half the people admitted to psychiatric hospitals in the period 1966 to 1968 and who were shown to have used amphetamines were women. Half these women were aged over 30. This perhaps throws some light on the problem of the middle-aged woman using amphetamines, perhaps for purposes of slimming or to combat depression but who are put at risk as a result.
This brings me to the problem of prescription. The middle-aged woman does not get her amphetamines from the clubs or discotheques but through prescriptions from doctors. In 1969, 1,700,000 prescriptions for amphetamines were made in England and Wales. I realise that this was a reduction on the totals for 1967 and 1968, but by any measure it is still formidable. The effect does not stop with just those people for whom amphetamines are prescribed. There is also a risk that pills surplus to requirements get into the black market. There is even a risk that children may find them lying about at home. There is also the attendant fact that chemists' shops have to keep stocks. I shall come to that later, but I should say now that, although I am a parliamentary adviser to the Pharmaceutical Society, I am not in this debate stating a society view of the situation.
At this stage, I should distinguish between the ordinary general practitioners and the few rogue doctors thrown up in the last few years. Every profession has its rogues and the medical profession is 747 no exception. But it should be emphasised that it has only a handful. These rogue doctors have operated in various ways. The simplest way is plain over-prescription. Some doctors, particularly in London, have been prepared to prescribe amphetamines for all kinds of people. They become rapidly known to the users, who flock to them. Their conduct is utterly irresponsible and it is reassuring that in the last few years some of them have been brought to justice.
We should recognise the part which newspapers have played in exposing these men. In particular, the Daily Mail carried out a number of investigations with great care and success. We look forward to the Daily Mail carrying on this valuable rôle over to the new paper which it is to become.
But it would be a mistake to think that such doctors only operate from dingy surgeries and street corners. One or two are fashionable doctors with smart consulting rooms. I think, in particular, of the one or two doctors who specialise in slimming treatment and prescribe amphetamines for purposes of slimming. Here the pickings can be rich. One practice is reputed to have a turnover running into several hundred thousand pounds a year.
No, only do the middle-aged want slimming treatment, but also, of course, there is a demand from young girls of 17 or 18, straight from school or college, who also require this kind of treatment. What is objectionable here is not only that amphetamines should be prescribed but that those who take them are not told what they are. I have had one case referred to me. A girl of 18 went a couple of years ago to one of these doctors I have referred to for slimming treatment. She was given various tablets to take. Some of them are in the bottle I have here. It is only now that we find that quite unknown to her these pills are amphetamines—that is what she was prescribed. It is worth stating that authoritative medical opinion holds that amphetamines have no use in slimming treatment. They also have no use for the treatment of depression or fatigue. Their use is confined to one fortunately rare condition, that of narcolepsy.
Some of the black sheep in the medical profession have already been dealt with, 748 and it is my hope that the others will be dealt with when the Misuse of Drugs Bill becomes law. But that still leaves the problem of the perfectly legal prescription, and here I draw attention to a scheme started in Ipswich and now extended elsewhere which I believe is a very great step forward. Under this scheme, doctors have voluntarily agreed in these areas to restrict the prescribing of amphetamines. This amounts to a voluntary ban on prescribing except in very few special cases. They have worked together in co-operation with the local pharmacists and the scheme has had two major effects.
First, it means that the number of prescriptions has fallen dramatically. In Ipswich, for example, there are now no more than a dozen prescriptions a year for amphetamines. It means that there is no opportunity for tablets to get into other hands and into the black market.
Secondly, it means that, as pharmacists know that doctors will not be prescribing amphetamines, there is no need for them to keep big stocks. This is a major advantage, because break-ins to chemists' shops have provided a great source of supplies of amphetamines for the black market. This has been a big problem in some cities, including Nottingham, but the problem has been virtually solved overnight by such action in these areas.
The scheme has now spread far beyond Ipswich. I understand from the British Medical Association today that it is now in operation in about 30 out of a possible 200 areas. These areas include major cities like Glasgow, Liverpool and Nottingham, and also central London and areas like Hertfordshire. It is an excellent scheme and is worth supporting and encouraging by the Government in every way.
Clearly, legislation on drugs is important but that alone is not the answer. Voluntary agreements have already shown their worth. I refer here to the problem of methedrine and injectable methedrine of a few years ago, when serious abuse occurred. By the action of the medical profession and the Pharmaceutical Society, supplies of methedrine were confined to hospital pharmacies and the problem was solved by that voluntary action. I believe that the voluntary scheme which is now being undertaken by many doctors also has that potential.
749 The aim should be to extend these voluntary agreements so that the whole country is eventually covered, and therefore I ask my hon. Friend the Under-Secretary of State not only to give support to this valuable scheme but to give an undertaking to take all steps to assist and encourage its extension.
§ 3.10 p.m.
§ Mr. Ernle Money (Ipswich)
I am grateful to my hon. Friend the Member for Nottingham, South (Mr. Fowler) for the chance briefly to intervene in this important debate and to pay my tribute to the work of Dr. Frank Wells, Dr. Roy Webb and their colleagues in Ipswich whose research and initiative introduced the scheme in my constituency in the first place. I mention research because one of the important things which Dr. Wells and his colleagues did was to look at the nature of amphetamines and the extent to which they were relevant to many of the diseases for which they were prescribed. Over and over again the same reason why they were being used as a palliative came out—that they had simply become something which hard-pressed members of the medical profession were being expected to hand out to their patients because their patients wanted something visible to be the result of a trip to the surgery.
The immediate result has been that Ipswich to all intents and purposes, with very few exceptions, has gone dry, at least of amphetamines, and a development resulting from that is that the medical risks, the social nuisance and the financial burden which my hon. Friend mentioned as being some of the great disadvantages of the over-prescription of these drugs have been significantly cut. It may also be to that, fortunately, that in the County Borough of Ipswich we can attribute the remarkably low crime figures over the last few years, as opposed to the situation in other parts of the country, such as Hertfordshire, where the manufacture of drugs of this sort has led to a constant series of cases both of breaking and entering and the misuse of drugs at both quarter sessions and assizes.
I hope that the Minister will be able to go from here to consider the broad question of over-prescription of all kinds of prepared drugs, because I believe that the lesson of the Ipswich experiment is 750 that in the long run so often it has turned out that drugs which have crept into the semi-conscious part of national use were not only not necessary, but sometimes downright harmful to the recipient and, secondly, very costly to the taxpayer. In a situation in which we have sometimes been described as rapidly becoming a nation of hypochondriacs, one of the most significant results of the restriction of over-expenditure would be that my hon. Friend's Department would be able to take a long cool look at the way in which the drugs bill has been growing and the risks extending from that.
I quote only one case to show the way in which amphetamines, for instance, have been exploited, not, as my hon. Friend pointed out, as a result of rogue doctors, but simply because of doctors getting so sick of patients turning up for whom no other palliative was acceptable that amphetamines were prescribed as the best way in which to get the patient off the doctor's back. Towards the end of last year, my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton) and I were involved at the Central Criminal Court in a case of murder in which the defendant had been receiving amphetamine pills at a terrifying figure, perfectly legally, because his general practitioner was getting so sick of him that the easiest thing to do was to write out a large number of prescriptions to cover a period of time.
He was being issued with what one might call a stock issue for 200 pills a week. The result was that the defendant found himself in the happy financial position of being able to market these things at the taxpayer's expense. When the opportunity occurred he found he was able to market even more than he was being prescribed. He took to selling perfectly harmless tablets such as aspirin wrapped up in silver paper as a means of extending the fairly extensive supplies which the taxpayer was producing for him.
The tragic end was that when two of his clients came to remonstrate with him a fight ensued in which one of them lost his life. This is an extreme example of the kind of risks involved. There is evidence that we are becoming a drug-hungry nation. This is not just to do with cannabis and even possibly heroin 751 but with the drugs mentioned by my hon. Friend. I believe that the initiative shown by some of my constituents, now followed by the B.M.A. in many different parts of the country, is something which will be a substantial protection to the inhabitants of the country as a whole. Equally important it will enable a substantial saving to be made, providing more badly needed funds for my right hon. Friend's Department to be spent on other things nearer to his heart.
§ 3.17 p.m.
§ The Under-Secretary of State for the Department of Health and Social Security (Mr. Michael Alison)
I am grateful to my hon. Friend the Member for Nottingham, South (Mr. Fowler) and my hon. Friend the Member for Ipswich (Mr. Money) for raising this problem of the misuse of drugs of dependence. I am glad to see in his customary place as usual when we discuss anything to do with the pharmaceutical industry the hon, Member for Liverpool, West Derby (Mr. Ogden). I feel secure in the double-barrelled representation of this society. Although the House has had occasion fairly recently to consider formally measures designed to regulate the misuse of drugs such as amphetamines, it is desirable that we should devote some time to considering other more informal and non-statutory ways of tackling the very serious social problems posed by the misuse of drugs.
It is undeniably a serious contemporary social problem. I entirely agree with what my hon. Friend the Member for Nottingham, South said, that it has to be taken very seriously indeed. All of us who are associated with the problem must take the greatest care neither to exaggerate its scale, nor, in our anxiety to bring misuse under control, to advocate measures that might have the effect of inhibiting the use of valuable drugs for genuine therapeutic purposes.
Draconian measures of compulsion should be contemplated only rarely and then only after exploring every possible alternative. The problem here is well illustrated by the history of amphetamines, so well described by Baroness Wootton's Committee in its Report on Amphetamines and L.S.D. The House will recall that amphetamines had for many years a small, if not a particularly 752 significant place, in therapeutics, and my hon. Friend has defined that place.
This was before they achieved their present notoriety. The possibility of dependence had been noted as long ago as 1937 but it was not until restrictions on the prescribing of heroin and cocaine were contemplated as recently as 1967 that misuse of amphetamines, particularly of injectable methedrine, was adopted by addicts. The possibility that the Dangerous Drugs (Supply of Addicts) Regulations, 1968, which limited the prescription of heroin and cocaine for addicts to doctors specially licensed for the purpose, might lead to a wide extension of the abuse of drugs by intravenous injection and that amphetamines might be used in place of heroin was recognised by my Department even before the Regulations were brought into operation.
Our Chief Medical Officer wrote to all general practitioners and chairmen of general medical advisory committees and medical advisory committees of teaching hospitals in March, 1968, in order to alert them to this twofold threat and, at the same time, to remind doctors thata substantial body of authoritative opinion holds that the use of amphetamines for the suppression of appetite is unnecessary and is largely ineffective in the treatment of depression".This opinion was reinforced in November, 1968, by the British Medical Association's own working party on amphetamine preparations, which recommended that amphetamines and amphetamine-like compounds should be avoided as far as possible in the treatment of obesity, and should generally be avoided in the treatment of depressionas they appear to have no place in the modern treatment of this condition".The fears expressed by the Chief Medical Officer in his first letter were borne out by experience in the spring and summer of 1968 when there was a rapid increase in the abuse of methylamphetamine by injection. So rapid was this increase that it became necessary, in the absence of statutory powers to control distribution, to have recourse to a purely voluntary arrangement—which both the medical and pharmaceutical professions fully supported—whereby supplies of injectable methylamphetamine were no longer available on prescription but were confined to hospital pharmacies and 753 made available through them to general practitioners who required them in strictly limited quantities. The Chief Medical Officer wrote again to all doctors in October, 1968.
Following this voluntary restriction of supplies, a few doctors began to prescribe powdered amphetamines. These doctors were visited by my Department's regional medical officers and, though contrary to their terms of service, pharmacists were advised by the Council of the Pharmaceutical Society, with the agreement of the General Medical Council, not to dispense prescriptions for powdered amphetamines.
Although abuse of amphetamines continued to pose a problem, the scale—which in 1966 was estimated to be less than that of the misuse of alcohol as reflected in the number of alcoholics—has gradually declined. An indication of the extent of this decline can be gained from comparison of the average number of National Health Service prescriptions for amphetamines dispensed per week in 1967, 60,000, down to an estimated 25,000 a week last year. I take my hon. Friend's point that, although this is a sharp decline, the number is still too great.
There is every reason to expect the decline to continue, especially since an increasing number of local medical committees are following the example set by the Ipswich Local Medical Committee in resolving to abandon the prescription of amphetamines altogether. As my hon. Friend rightly said, this self-denying ordinance is welcome for several reasons, not least because it is a purely voluntary arrangement.
I am glad of the opportunity of repeating the answer which I gave to the hon. Member for West Lothian (Mr. Dalyell) on 2nd February last, in which I made it clear that the Government welcome this voluntary ban and especially the fact that the example set by Ipswich has been followed by other local medical committees, including, I am glad to say, the Inner London Local Medical Committee. The House will also be glad to know that the B.M.A. is arranging a meeting in July to consider ways and means of extending the voluntary ban, Ipswich-style, and my right hon. Friend has accepted an invitation to address the meeting.
754 My hon. Friend the Member for Ipswich asked me to give an undertaking that we propose to support and extend the Ipswich arrangements. Although the extension of the Ipswich experiment is welcome as a useful step towards bringing abuse of amphetamines under control, it should not I think be assumed that it is necessarily a complete answer to the problem. Ipswich is a rather special case. Apart from anything else, all the doctors get on extremely well together. Arrangements of this kind, welcome though they are, are not by definition mandatory on all members of the profession. There is always a minority—or there may be in places outside Ipswich—who are not prepared to accept the view of their colleagues. Nevertheless, it would be a pity if, in a natural anxiety to control the irresponsible actions of a few doctors, Parliament were to introduce measures which might unreasonably restrict the prescribing of the vast majority of doctors who prescribe drugs of dependence with the greatest care and discretion.
I conclude on this point by saying that we warmly support the Ipswich experiment. We hope to see it extended. My right hon. Friend will be alluding to it when he addresses the B.M.A. meeting. One has to recognise the fact that it does depend on the willing and active co-operation of a group of local doctors, and where they may be in substantial competition with one another, as may be the case in areas of more concentrated practice, it may not be so easy. But we are right behind them.
It has always been a principle of medicine in this country that a doctor should be free to prescribe any drug or medicine which he considers necessary for the treatment of his patient. This is a principle which one would not want lightly to abandon or restrict. The case for freedom goes further than that, for, as the Wootton Committee pointed out, it is a feature of the drug misuse problem that once the misuse of one substance appears to have been checked another immediately takes its place. Thus, restrictions on the prescribing of one drug may lead addicts to adopt another drug, which in turn will lead to demands for the imposition of similar controls on the prescribing of the new drug, and so on. It is vital that the 755 sudden upsurge of abuse of a drug which has wider therapeutic uses than, say, amphetamines, should not be subjected to restrictions which may be positively disadvantageous from the standpoint of the ordinary patient.
Experience of the misuse of amphetamines in recent years has prompted the introduction of the Misuse of Drugs Bill. The introduction of that Bill demonstrated, I think, what the Government, both the last Government and this, felt to be the inadequacy of the powers to take action swiftly enough to deal with irresponsible and reckless prescribing, particularly private prescribing, and I think that it was anxiety about this that led to the Misuse of Drugs Bill which, as my hon. Friend knows, has completed all its stages in this House and is now in another place, and which will certainly be on the Statute Book before long.
Regional medical officers of my Department have discussed prescribing patterns with general practitioners in the National Health Service, and there are long-standing arrangements for special informal visits to be paid to those doctors whose prescribing is substantially above that of their colleagues. In the last resort, where, having regard to the character and quantity of the drugs he has prescribed, there is prima facie evidence to suggest that the cost of a doctor's National Health Service prescribing is excessive, the facts can be reported to his local medical committee, and in those instances where the evidence suggests that a doctor's prescribing of drugs of dependence is grossly excessive or irresponsible, it is customary to report the facts to the General Medical Council. In the last year my Department has laid information before the Council in three such cases, and in one the name of the doctor concerned has been struck off the medical register.
In passing, whilst I welcome the concern which my hon. Friend the Member for Ipswich shows about the danger of escalation of drugs costs, and their being a larger share of the National Health Service budget, or that it may grow, the drugs bill in fact, as a proportion of the total expenditure of the National Health Service, has remained static at about 9 per cent. to 10 per cent. for some time now.
756 The collection of evidence in these cases is, as my hon. Friend can imagine, a lengthy and time-consuming process. It is more difficult when the doctor is prescribing privately—and a good deal of irresponsible prescribing of drugs is private—and it is even more difficult where, as I understand is the case of the slimming clinic mentioned by my hon. Friend, drugs are dispensed directly by the doctor—I understand, in most cases without reference to the general practitioner of the patient who is attending the private practice concerned.
I say in parenthesis how warmly I applaud my hon. Friend's reference to the publicity given in the Daily Mail, and, I may add, the publicity given by Mr. Simon Dring in the Daily Telegraph, for the very reason that it may draw the attention of innocent members of the public, particularly young girls, to the fact that some of the drugs prescribed to them may contain amphetamines, though they have no idea that that is the case. I take my hon. Friend's point.
It is to expedite the handling of such cases that the Government brought forward the Misuse of Drugs Bill—in short, to enable my right hon. Friend the Home Secretary to collect and analyse information, particularly about the private prescribing of drugs of dependence and to identify and deal with those doctors whose prescribing of these drugs appears to be irresponsible.
I am sure that the general approach which I have described—the Misuse of Drugs Bill, the voluntary agreements, trying to find a balance between not going too far and at the same time taking an effective position of control—is the right one. It not only ensures that all doctors receive up-to-date and authoritative information about the misuse of drugs generally and about the potential hazards of particular drugs, in a way which will enable them to bring an informed judgment to their own prescribing, but at the same time it strengthens our powers to identify and deal promptly with the irresponsible minority, while still preserving the freedom of the honourable and responsible majority to prescribe for their patients any drug or medicine which they consider necessary.