What’s so new about the new What’s so new about the new abstentionism? History and abstentionism? History and

treatment policytreatment policy

Virginia Berridge Virginia Berridge

Centre for History in Public Centre for History in Public HealthHealth

LSHTM, University of LondonLSHTM, University of London

Purpose of the lecturePurpose of the lecture

1.The rise of the idea of treatment.1.The rise of the idea of treatment.

2.Treatment, the profession and the state.2.Treatment, the profession and the state.

3.Recent debates and their historical 3.Recent debates and their historical context.context.

Do we need treatment?Do we need treatment?

‘‘The neighbours The neighbours indulge in the same indulge in the same lethal habit and lethal habit and encourage the fatal encourage the fatal termination by good termination by good naturedly lending their naturedly lending their own private store of own private store of laudanum’ .laudanum’ .Boston , mid C19thBoston , mid C19th

De Quincey

Stages of changeStages of change

1.The rise of inebriety and the inebriates 1.The rise of inebriety and the inebriates acts: treatment and criminal justice .acts: treatment and criminal justice .2.Rolleston and the ‘British system’ in the 2.Rolleston and the ‘British system’ in the 1920s.1920s.3.Changes in the 1960s and 70s: the public 3.Changes in the 1960s and 70s: the public health approach.health approach.4.HIV/AIDS : the first phase.4.HIV/AIDS : the first phase.5.HIV/AIDS: the move to criminal justice.5.HIV/AIDS: the move to criminal justice.6. Recent debates and the revival of 6. Recent debates and the revival of abstention. abstention.

Inebriety and the inebriates acts: Inebriety and the inebriates acts: treatment and criminal justice treatment and criminal justice

Disease of inebriety.Disease of inebriety.

Prison to treatment.Prison to treatment.

Licensing Act and Licensing Act and committal of women.committal of women.

The’ future of the race’ The’ future of the race’ and hereditaryand hereditary defect.defect.

Norman Kerr

What did treatment consist of?What did treatment consist of?

In the cricket season we have a half day’s match In the cricket season we have a half day’s match every week… often some medical men and every week… often some medical men and clergymen come up for tennis, so that there are clergymen come up for tennis, so that there are plenty of means both for exercise and plenty of means both for exercise and amusement on the premises…we begin the day amusement on the premises…we begin the day with prayers…and finish the day with prayers. with prayers…and finish the day with prayers. Breakfast at nine o’ clock, which consists of Breakfast at nine o’ clock, which consists of porridge (to which I attach a great importance), porridge (to which I attach a great importance), bacon and dried fish, varied with eggs, bacon and dried fish, varied with eggs, sausages, bread, butter, jam and marmalade’sausages, bread, butter, jam and marmalade’

Rolleston and the ‘ British system’ Rolleston and the ‘ British system’ in the 1920sin the 1920s

The Home Office The Home Office and the Ministry of and the Ministry of Health.Health.

Doctors decide.Doctors decide.

Uncertainty about Uncertainty about what was best.what was best.

Rolleston

The basis of treatmentThe basis of treatment

‘‘..if the addict is unwilling to ..if the addict is unwilling to enter the relationship of patient enter the relationship of patient to physician, but admits he is to physician, but admits he is merely coming to obtain merely coming to obtain supplies of a drug which he supplies of a drug which he cannot otherwise get, then it is cannot otherwise get, then it is the clear duty of the doctor to the clear duty of the doctor to refuse the case. But if the refuse the case. But if the habitué desires treatment as a habitué desires treatment as a sick person for the relief of his sick person for the relief of his pathological condition, the pathological condition, the physician must be allowed to physician must be allowed to use his discretion…’ use his discretion…’ Dr EW Dr EW Adams memorandumAdams memorandum

The myth of RollestonThe myth of Rolleston

Not a medical victory nor a Home Office Not a medical victory nor a Home Office defeat.defeat.

‘‘a system of masterly inactivity in the face a system of masterly inactivity in the face of a non existent problem’of a non existent problem’David DownesDavid Downes

Changes in the 1960s and 70s: the Changes in the 1960s and 70s: the public health approach?public health approach?

‘‘Sir Russell’s optimism amazes me….A short Sir Russell’s optimism amazes me….A short while ago I came across an addict who was while ago I came across an addict who was completely unknown to the Home Office .He completely unknown to the Home Office .He presented his prescription to a shop for presented his prescription to a shop for something like 30 grains of cocaine or 40 to 50 something like 30 grains of cocaine or 40 to 50 grains of heroin….This was prescribed by a grains of heroin….This was prescribed by a doctor whom I know for a fact was making every doctor whom I know for a fact was making every effort to treat these people .Therefore there was effort to treat these people .Therefore there was no question of the doctor abusing his authority to no question of the doctor abusing his authority to prescribe….’ He went on ‘…I personally can prescribe….’ He went on ‘…I personally can record 40 0r 50 cocaine, heroin and morphine record 40 0r 50 cocaine, heroin and morphine addicts in the London area alone…’ addicts in the London area alone…’ Pharmacist Pharmacist Benjamin at RSM 1961Benjamin at RSM 1961

New definitions and conceptsNew definitions and concepts

‘‘addiction is a socially infectious addiction is a socially infectious conditioncondition’’

Medicine or control?Medicine or control?

Medical and social?Medical and social?

Public health old and new?Public health old and new?

HIV/AIDS : the initial responseHIV/AIDS : the initial response

There is…a serious risk that infected drug There is…a serious risk that infected drug misusers will spread HIV beyond the presently misusers will spread HIV beyond the presently recognized high risk groups and into the recognized high risk groups and into the sexually active general population…..There is…sexually active general population…..There is…an urgent need to contain the spread of HIV an urgent need to contain the spread of HIV infection among drug users not only to limit the infection among drug users not only to limit the harm caused to drug misusers themselves but harm caused to drug misusers themselves but also to protect the health of the general public. also to protect the health of the general public. The gravity of the problem is such that on The gravity of the problem is such that on balance the containment of the spread of the balance the containment of the spread of the virus is a higher priority in management than the virus is a higher priority in management than the prevention of drug misuse.’ prevention of drug misuse.’ McClelland Report ,1986McClelland Report ,1986

The initial impactThe initial impact

Prescribing and harm Prescribing and harm reduction.reduction.

Pre-existing debates on Pre-existing debates on treatment and its locationtreatment and its location

Wider drug policy Wider drug policy community community

What did the change What did the change amount to?amount to?

HIV/AIDS: the criminal justice HIV/AIDS: the criminal justice responseresponse

Political involvement.Political involvement.

NTORS and the NTORS and the criminal justice criminal justice agenda.agenda.

Expansion of Expansion of treatment : NTA.treatment : NTA.

Methadone Methadone maintenance maintenance expands.expands.

Past, present and futurePast, present and future

What's not new?What's not new?

Interrelationship treatment and criminal Interrelationship treatment and criminal justice.justice.

Tension between maintenance and Tension between maintenance and abstinence. abstinence.

The expanding role of the state.The expanding role of the state.

Past, present and future 2Past, present and future 2

What’s continuing?What’s continuing?

Who is addicted affects Who is addicted affects treatmenttreatment

Beliefs about disease and Beliefs about disease and public healthpublic health

Professional disputes Professional disputes about ownershipabout ownership

Research used to fit Research used to fit agendas not define them.agendas not define them.

Past, present and future 3Past, present and future 3

Treatment for all?Treatment for all?

The Foresight view.The Foresight view.