history of addiction: a uk perspective

INTERNATIONAL PERSPECTIVE

History of Addiction: A UKPerspective

Mervyn London, FRCPsych

The level of substance misuse in Britain has fluctuated over recent centuries,reaching its nadir in the early twentieth century. Since then, the trends for alco-hol and drug abuse (though not for tobacco consumption) have risen steadily.British physicians have played a major role in the emergence of the addictionconcept, from the initial challenge to Galen’s theories to the now widely adoptedAlcohol Dependence Syndrome. While treatment has been influenced by con-temporary attitudes, it has been generally underpinned by pragmatism and hasavoided the punitive responses seen in other parts of the world. (Am J Addict2005;14:97–105)

A lcohol consumption in England dur-ing the Middle Ages was high, with

one licensed premises per 187 people dur-ing 1577, in contrast to one per 657 peoplein 1966.1 Consumption declined during thePuritan austerity under the reign of OliverCromwell but rapidly returned to old levelswith the Restoration. The invention of dis-tillation and the production of gin heraldeda dramatic change in drinking habits, whichin the 18th century became known as thegin epidemic. The landed gentry who domi-nated Parliament needed little encourage-ment to divert their surplus corn into ginproduction, and in 1701 the need for alicense to sell spirits had been abolished.

Gin consumption rose from 527,000 gal-lons in 1685 to 11 million gallons by1750.2 London was particularly badly hit,and parish records for 1740 to 1742showed that there were more burials thanbaptisms, despite a falling mortality in therest of the country. Deaths from dropsy,an oedematous disorder often associatedwith alcoholic liver disease, increased mark-edly between 1718 and 1751, and three-quarters of children christened between1730 and 1749 died before the age of five.The resulting outcry forced the govern-ment’s hand, and a combination of highertaxation, restriction of outlets, and a pro-hibition on reclaiming debts for alcohol

Received August 10, 2004; accepted September 14, 2004.From Cambridge Drug and Alcohol Service, Cambridge, United Kingdom. Address correspondence toDr. London, Cambridge Drug and Alcohol Service, Mill House, Brookfield Hospital, Cambridge CB1 3DF,United Kingdom. E-mail: [email protected].

The American Journal on Addictions, 14:97–105, 2005

Copyright # American Academy of Addiction Psychiatry

ISSN: 1055-0496 print / 1521-0391 online

DOI: 10.1080/10550490590924719

97

sold on credit led to the end of the epi-demic. It left a moral distrust of spirits,whereas beer and wine continued to beregarded as healthy drinks. The early Tem-perance Movement during the 19th centurycondemned only the drinking of spirits,while other alcoholic beverages were freelyconsumed by its members. However, theTemperance Societies that arose in the lat-ter half of the century were teetotal anddominated by the upwardly mobile workingclass who had personal experience of thedamage wrought by all alcoholic drinks.3

They also differed from the moderates intheir attitude toward the heavy drinker.Whereas inebriates had previously beenwritten off as a lost cause, the teetotal cru-sade welcomed them in the hope that theywould sign the pledge and join the brother-hood. If they were articulate, they couldbecome public speakers, gaining addedprestige and respect. Out of this environ-ment grew the Salvation Army, with itsmissionary and social work. Unlike in theUnited States, prohibition never took rootin Britain, despite vigorous lobbying by theUnited Kingdom Alliance to empower localauthorities to enforce abstinence withintheir localities.

At the outbreak of the First WorldWar, low productivity in vital industry wasattributed to drunkenness among the work-force, and the government introducedsweeping regulations. London pub openinghours were cut from 19.5 to 9 hours a day,and the country’s beer and spirit pro-duction halved between 1916 and 1918.4

Deaths from cirrhosis dropped to almosta third compared to the start of the war.5

Despite the end of hostilities, the regula-tions remained in place and convictionsfor drunkenness declined steadily from96,000 in 1920 to an all time low of20,000 in 1946. Rising affluence, changedlifestyles, and new patterns of shoppingsubsequently led to a steady rise in drinking.Per capita consumption of absolute alcoholrose from 5.2 litres per person in 1950 to

10.2 litres in 2000.6 While the deathrate from cirrhosis in 1950 was 23 per mil-lion, by 2000 it had reached 111 per millionamong men and 64 per million for women.

Until the 19th century, opiate con-sumption in Britain was restricted to themedical arena, where its use had beengrowing since the late Renaissance. Lauda-num, which contained both opium andwine, was popularized by the English phys-ician Thomas Sydenham (1624–1689). Thistincture was convenient to administer andalso provided a consistent dose.7 The earlypharmacopoeias listed a derivative in theform of a solid pill called, somewhat pro-saically, Solid London Laudanum, and eventhe colorful physician and English pirate,Thomas Dover, concocted an opiate rem-edy that he naturally named after himself.By the 19th century, the medical professionwas under pressure from unorthodox prac-titioners offering homeopathy, mesmerism,and other new ‘‘scientific’’ interventionsthat eschewed unpleasant standard treat-ments like blistering and bleeding. To retaintheir wealthy patients, physicians shiftedtowards managing symptoms rather thanattempting dramatic but painful cures, anddoctors increasingly prescribed opium.The situation changed radically when themedical profession lost monopoly controland a lucrative market emerged in pro-prietary medicines, which could be pur-chased directly from chemists and evengrocers.8 Opium imports rose from17,302 pounds in 1827 to 61,269 by1859.9 Britain became a major world sup-plier of narcotics through its colonial pos-sessions and only relinquished this roleafter World War I. During the 19th century,rapid urbanization cut people off from thecountryside and their traditional medicinalherbs. Unable to afford expensive consulta-tions with doctors, many visited pharmaciesseeking cheap remedies.10 Apart from theurban poor, opium consumption was highin the Fens of East Anglia, where agueand rheumatism were prevalent. By 1867,

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half of the imported opium went to theseEast Anglian counties, where it was soldas vials of laudanum and pills or squarelumps of crude opium.11 Public concerncentered on its role in quietening fretfulbabies and the consequent infant mor-tality.12 An elderly relative was often leftin charge of groups of children from work-ing families, and infant cordials and syrupswere inevitably used. The situation wascomplicated by the rivalry for monopolyprivileges among emerging professionalgroups, such as pharmacists and physicians,and the competing commercial interests ofdruggists and grocers.13 In 1868, the Poi-sons and Pharmacy Act was passed, whichrestricted the right to supply opium tohealth professionals and required preciselabeling and recording. Patent medicineswere restricted towards the end of the cen-tury, and in 1908, opium was placed on thePoisons List. During the five years after1868, accidental opiate poisonings fell by26%, and dropped a further 20% follow-ing the 1908 Act.10

In the early decades of the 20th cen-tury, opiate use was rare, and in the1920s, fewer than a hundred cases wereprosecuted each year under the DangerousDrugs Act.10 Heroin was unusual, and halfthe cases were Chinese men using opium.Of morphine users, two-thirds were doc-tors, nurses, or pharmacists, and mostoffenses were for forged prescriptions. Theillicit opiate trade was small, and the man-agement of opiate addiction was left largelyin the hands of the medical profession. Con-cern mounted in the 1960s when the profileshifted toward marginalized young menusing heroin in a way that was more akinto the situation in the United States. Thenumber of known heroin addicts grew fromaround 50 in 1957 to almost 1300 a decadelater, finally reaching 20,000 in 1996, halfof them new to treatment services.14 Therehas been a steady rise in opiate use, withconsumption spreading from metropolitancenters into rural communities and notable

surges in response to international eventsaltering the illicit chain of supply.

EMERGENCE OF THE ADDICTIONCONCEPT

Medicine in the seventeenth century wasstill largely dominated by Galen’s system,which viewed disease as a consequence ofthe morbid imbalance between the fourhumors. These ideas came under fire whenphysicians like William Cullen from theEdinburgh School of Medicine demon-strated the centrality of the nervous systemthrough animal experiments using opium.15

An emerging awareness of the part playedby personality and hidden motivation onhuman behavior began to influence theapproach to mental disorders. Slowly, eight-eenth century physicians came to speak ofmen addicting themselves to alcohol in amanner that implied overwhelming wishfulthinking distorting their view of reality.16

In 1804, these ideas were expressed inThomas Trotter’s seminal ‘‘Essay MedicalPhilosophical and Chemical on Drunken-ness.’’ He wrote that ‘‘the habit of drunken-ness was a disease,’’ and moreover, ‘‘adisease of the mind.’’39 Many neverthelessregarded drunkenness as an indulgence,that had no place in the new workingenvironment of the industrialized world.The temperance movement of the 19thcentury was also influenced by the Quakerdoctrine of a soul akin to a physical entity,which required nourishing activities likeindustry and moderation to maintain itsmoral faculty.8 Intoxicants weakened self-restraint, impaired this moral faculty, anddamaged the soul. This tension betweenmoral intolerance and a medical view ofaddiction as a disease has persisted to thepresent day. The latter view was expressedin its most extreme form by those who, likeinfluential German psychiatrist EdwardLevinson, discounted any psychologicalexplanation. Norman Kerr, who founded

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THE AMERICAN JOURNAL ON ADDICTIONS 99

the Society for the Study of Inebriates in1884, wrote that ‘‘inebriety is a disease’’and ‘‘a natural product of a depraved,debilitated or defective nervous organiza-tion.’’ He believed there was a metabolicor structural anomaly, although he couldnot demonstrate a site for this pathology.The logical consequence of such a stancewas for the patient to be cured once thewithdrawal symptoms were successfullytreated. However, most physicians in thefield avoided this extreme position andbelieved that a pathological defect weak-ened a person’s will to such a degree thathabitual behavior emerged. These beha-viors were not analyzed to any great depthand were assumed to involve the com-monly understood moral problems of will-power.8 Treatment sought to restore thismorally debilitated will so that patientscould then abandon their addiction. In1909, Oscar Jennings published ‘‘The Re-education of Self Control in the Treatmentof the Morphia Habit’’ and explained thataddicts were not willing victims but sickpeople whose will lay dormant ‘‘becauseof a psychosomatic affliction.’’

This attitude dominated British psy-chiatry throughout the first half of the20th century, when the relatively smallnumber of opiate addicts were either healthprofessionals or patients addicted in thecourse of treatment. By contrast, the Uni-ted States witnessed a burgeoning under-class of young addicts and, in a climate oflegislative intolerance, practice was domi-nated by explanations of personality dis-order underlying the addiction.17 Despitethe shifting patient profile after the 1960s,British psychiatry remained more amenableto a diverse response incorporating, whenappropriate, harm reduction and long-termprescribing.

Another strand to the theory of addic-tions in the late 19th century was theDegeneration Theory popular in continen-tal Europe. Drawing on Lamarck’s evol-utionary model, the theory defined

degeneration as the progressive accumu-lation of disabilities, such as epilepsy andimbecility over generations, leading towardextinction.18 Substance abuse could triggerthis condition and so harm both the nationand its progeny. This potent mix of scienceand morality was finally disproved in 1910by K. Pearson of the Galton Laboratoryfor National Eugenics at University CollegeLondon, when he carefully analyzed thereams of statistics collected over the yearsto support the theory.

During the 1930s, a fresh impetusarose outside the medical profession, whenAlcoholics Anonymous was founded in theUnited States. Alcoholics were regardedas constitutionally vulnerable, and overtime, the explanatory model shifted fromallergy to genetics and psychologicalthemes.19 The Big Book of the AA statedin 1939 that ‘‘the action of alcohol on thesechronic alcoholics is a manifestation of anallergy . . . and these allergic types can neversafely use alcohol in any form at all.’’40 TheBritish medical profession embraced theAA model on practical grounds eventhough the theory rested on the tautologyof defining alcoholism by the results ofdrinking. When Jellinek published hisDisease Models in 1952 and 1960, Britishphysicians, like their counterparts in the restof the world, welcomed it as providing newlegitimacy for the treatment of this patientgroup. In the 1970s, a new conceptualframework was promulgated by British psy-chiatrists based on current medical percep-tions of alcoholism and the recent advancesin cognitive behavioral psychology.20 TheAlcohol Dependence Syndrome was deli-neated from other forms of excessive drink-ing by seven elements, that embracedchanges in behavior, biology, and subjectivecraving. The new model was widely acceptedas a practical tool although its very flexibilityconcealed its weakness.21 Based largely onclinical impression, subsequent research failedto demonstrate a high correlation of its sevenfeatures within alcoholic populations.



TREATMENT OF ALCOHOL PROBLEMS

In the hard drinking society of eighteenth-century Britain, the populace regarded alco-hol as essential to good health. A man witha rotund figure and red face was undoubt-edly in good spirits. The medical professiongenerally supported this view, which theyreinforced by prescribing large doses ofalcohol in cordials and tonics for a multi-tude of conditions. Yet nobody couldignore the damaging effects of alcohol,particularly in the midst of the gin epi-demic. Few doctors were eccentric enoughto advise total abstinence, and most coun-selled moderation, although it had a some-what different meaning in Georgian Britain.Dr. George Cheyne, a fashionable prac-titioner who struggled valiantly with hisown appetites, wrote ‘‘for twenty years . . . Icontinued sober, moderate and plain in mydiet and . . . drank not above a quart orthree pints at most, of wine any day.’’16

In 1793, Matthew Baillie, the King’s phys-ician, published a landmark text in the his-tory of pathology, which contained theearliest illustrations of cirrhosis of the liver.By 1813, Thomas Sutton had describeddelirium tremens, and the doctors of thenew asylums soon recognized the linkbetween alcohol and mental disorder. Evenbefore the widespread acceptance of thedisease concept, many physicians knew thatthe sudden cessation of alcohol or opiatescould produce symptoms. John CoakleyLettsom, a Quaker physician and phil-anthropist, advocated gradual reduction byplacing a drop of sealing wax in the glasseach day until it would hold no furtheralcohol. In 1803 Robert Willan recom-mended a slow substitution of spirits withbeer or wine together with a good diet.

By the late 19th century, treatment foralcoholism was undertaken mainly in insti-tutions called ‘‘Retreats.’’ These wereinvariably run by religious and philan-thropic organizations who discriminatedaccording to class and the ability to pay.22

Treatment had little scientific basis otherthan to inculcate acceptable social valuesand behaviors.23 A small number of desti-tute residents came via the courts, and theHabitual Drunkards Act of 1879 allowedinebriate offenders to voluntarily enterthese institutions rather than prison.24 In1899, new legislation allowed those withat least four convictions for drunkennessto be compelled to submit to residentialtreatment. Between 1898 and 1907, threethousand were committed, and most werewomen with psychiatric or neurological dis-orders.25 Gradually the Acts fell into disuseowing to disillusionment with the results,falling resources, and the advent of theFirst World War. During the interwar years,the treatment of alcoholism officiallyshifted to outpatient clinics, which in realitywere mainly located in private practice.Only 29 public patients were treated atthe prestigious Maudsley hospital in 1931.By the middle of the century, a limitedrange of therapeutic interventions hademerged, which could be summarized asthe five As: apomorphine, antabuse, alco-holics anonymous, analysis, and aversiontherapy.26 Apomorphine was popularizedby Dr. Yerbury Dent, editor of the BritishJournal of Addiction and a physician with alarge private practice specializing inalcoholism. It produces drowsiness andnausea and seems to have been used totranquilize the patient in the first days ofwithdrawal from alcohol or opiates. It wasoften given as repeated injections, and prac-titioners were unsure if it acted as an anaes-thetic or had additional aversive propertieslike antabuse.27 The advent of benzodiaze-pines in the 1960s provided a safer alterna-tive for detoxification and coincided withthe creation of alcohol inpatient unitsemphasizing group therapy and modeledon the pioneering service at WarlinghamPark Hospital near London. By 1975, therewere twenty-one units providing a total of434 beds, but it was noted with dismay thatonly a third of alcoholics admitted to

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psychiatric hospitals entered such units.28

Consequently, there was a shift within theNational Health Service towards outpatientclinics and multidisciplinary teams and anexpansion of counseling services withinthe non-governmental sector. Unlike inthe United States, those who worked withinthese services were unlikely to be ex-alcoholics or ex-addicts. This encourageda more flexible treatment approach as seenin the response to the controversial con-trolled drinking debate of the 1970s.Despite similarities between dependenceon alcohol and addiction to illicit drugs,separate services have persisted in manyregions. This enabled politicians in the lastdecades to restrict new resources exclus-ively to drug services in response to popu-lar concern over HIV and crime despite thesteady rise in alcohol misuse.

TREATMENT OF DRUG MISUSE

At the close of the 19th century, restric-tions on patent medicines ensured that phy-sicians had regained monopoly control overthe supply of opiates. The introduction ofmorphine injections over recent decadeshad produced addicts dependent on farhigher doses than before. The typical lauda-num addict used up to two ounces a day,which was equivalent to two grains of mor-phine. Most injectors were using ten ormore grains a day, and the symptoms ofaddiction were obvious.10 Doctors wereappalled at their loss of control over thistreatment, and the arrival of alternativessuch as salicylic acid and barbiturate at theturn of the century encouraged more cau-tious prescribing. Nevertheless, drug addic-tion as a disease remained the preserve ofthe medical profession. The illicit tradewas insignificant, and fee-paying patientsreadily accepted the prevailing diseasemodel of addiction. In 1920, Britain intro-duced the Dangerous Drugs Act to meetits international obligations. The issue ofprescribing to maintain an addict’s habit

demanded clarification, and the HomeOffice invited Dr. Rolleston, president ofthe Royal College of Physicians, to providean answer. His committee consisted entirelyof doctors and took evidence from wit-nesses who were again mostly doctors.Not surprisingly, the report submitted in1926 recommended that each patient betreated as an individual, and while the goalof abstinence was desirable, where with-drawal was unlikely to be successful,ongoing maintenance was justified if itallowed the addict to lead a useful life.10

The Home Secretary accepted these recom-mendations in their entirety. Althoughadvocates of this ‘‘British System’’ arguedit created fewer drug problems, events ofthe 1960s showed it to be a consequencerather than a cause of the low level of drugabuse.

An awareness of the changing patternof drug use prompted the Department ofHealth to convene a committee under thechairmanship of Sir Russell Brain. Its firstreport in 1961 was based on past statisticsand concluded that no action was needed,as the level of addiction was static.14 How-ever, this report was rapidly overtaken byevents as the number of addicts known tothe Home Office doubled every two years.Instead of middle class professionals, thenew addicts were likely to be members ofa youth subculture using illicitly obtaineddrugs and sharing injecting equipment.The Brain Committee was hurriedly recon-vened and published its second report in1965. The rise was attributed to irrespon-sible prescribing by some doctors; conse-quently, specialist Drug DependencyClinics were created, and the right to pre-scribe heroin and cocaine for addictionwas limited to those doctors holding anew license from the Home Office. Theclinics opened in 1968, and the numberof known addicts presenting to these ser-vices rose to 2,782 as heroin and cocainebecame unobtainable from their generalpractitioners. In the following year, new



cases dropped to 711, but contrary toexpectations, referrals persisted and gradu-ally rose. The illicit trade in narcotics hadarrived. This may have been aided by Cana-dian addicts attracted to the earlier liberalsupply of prescribed heroin in London.They brought with them the knowledgeand experience of an organized blackmarket.14

The new clinics rapidly filled withmaintained patients on a variety of pre-scribed drugs that included injectable her-oin, oral methadone, cocaine, andamphetamine. In the 1970s, there was ashift towards greater uniformity as an influ-ential study also demonstrated little benefitin prescribing heroin over oral metha-done.29 By the 1980s, the Drug Depen-dency Clinics were pursuing anabstinence-orientated approach with reduc-ing methadone prescriptions linked tocounselling.30 The advent of HIV in the1980s accelerated a trend toward diversifi-cation of services, and in 1988, the Advis-ory Council on the Misuse of Drugspublished formal advice endorsing a hier-archy of treatment goals, ranging from thecessation of needle sharing through toabstinence. The creation of needleexchange schemes was instrumental incurbing the spread of blood-borne virusessuch as HIV;31 however, services remainedpatchy, with wide variations in practiceacross the country. In the last decade, thelink between addiction and crime has onceagain raised its public profile, and theNational Treatment Agency has been cre-ated to standardize services and channelnew resources. There has also been anattempt to shift away from specialist ser-vices and toward treating addicts withinmainstream general practice. At the sametime, the coercive criminal justice systemhas been coupled with drug treatment pro-grams. These include the early referral ofaddicts on arrest to services, communitysentences incorporating methadone pro-grams and urine testing, and proposals to

bridge the gap between prisons and thecommunity for those completing their sen-tences. It remains to be seen whether theseinitiatives can reverse the steady rise in opi-ate addiction across the UK.

STIMULANT ABUSE

Although cocaine was widely used in patentremedies in the late 19th century, itremained a rarity until the 1990s. Ampheta-mines enjoyed greater popularity and manymiddle-aged women were prescribed stimu-lants for depression or obesity. By 1957,2.5% of all National Health Service pre-scriptions contained amphetamine, oftenwithout clear therapeutic reason, and great-er awareness among the medical professionled to a decline in its use.32 Intravenousamphetamine abuse remained more com-mon in rural areas, but shifting fashionshave seen this population embrace heroinas its availability spread from urban conur-bations.33 During the 1980s, MDMAbecame closely associated with the ‘‘rave’’dance scene, and concerns were raised overthe long-term health consequences.34 Aharm reduction approach incorporatededucation with preventative measures atdance venues, and (fortunately) the ravescene has declined from its earlypeak. Cocaine has now emerged as the cur-rent challenge to treatment services.

TOBACCO DEPENDENCE

In 1598, a visitor to London observed thenew fashion for smoking tobacco throughclay pipes and wrote, ‘‘they draw the smokeinto their mouths, which they puff outagain . . . along with plenty of phlegm anddefluxtion from the head.’’35 It was notuntil the 20th century, with the inventionof the cigarette as the ideal delivery system,that tobacco addiction burgeoned. By 1948,40% of women and 65% of men were reg-ular smokers, and the rising death toll was

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documented in an influential UK study.36

By 1994, only a quarter of the populationwere regular smokers, but most of thisdecline was confined to the affluent sectorof the population. During the 1990s, cigar-ettes continued to cause thirteen deaths anhour in the UK.37 The UK relied on a com-plex set of regulations known as ‘‘voluntaryagreements’’ with the tobacco industryrather than legislation, with relatively poorresults. The introduction of the single Eur-opean market in 1992 meant that lawsaffecting trade had to be harmonized, andin 1998, legislation was passed enforcingthe European directive banning the adver-tisement and sponsorship of tobacco-products. Political resolve has beenstrengthened by a fall in tobacco-relatedincome from 12% of all governmentreceipts in 1960 to 3.6% in 1995. In1999, the UK government allocated newresources to set up Smoking CessationServices within the National Health Serviceand encouraged general practitioners toprescribe nicotine replacement and othertherapies. Although the overall trend hasfallen, the greatest challenge remains

among young people, particularly women,and lower socio-economic groups.38

CONCLUSION

From a relatively low prevalence in the firsthalf of the 20th century, there has been anescalation in the excessive use of bothdrugs and alcohol in the UK. In particular,the rising level of alcohol abuse, in contrastto trends in similar industrialized countries,is a cause of great concern. Nevertheless itis opiate misuse that has received the mostofficial attention, and services haveexpanded to meet the demand. While thediscipline of addiction psychiatry hasgrown, other professional groups such asgeneral practitioners have also becomeinterested in the field. It has not been poss-ible to include all substances in this review,but the abuse of hallucinogens, solvents,and that most widely abused drug, canna-bis, all figure within the work of substancemisuse services. As we enter the 21st cen-tury, addiction psychiatry in Britain con-tinues to face fresh challenges.

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