46

DOCTORS, PATIENTS, AND POSSESSION OFILLEGAL DRUGS

SIR,—Two men, presenting with a foreign body in the ear, werevague both about its nature and about how it got there. The materialwas firm and dark, and it had to be removed under generalanaesthetic. It was found to be cannabis resin. A similar,non-clinical dilemma would arise with an unconscious patientbrought in for medical care and in possession of an illegal drug. In

- such circumstances the patient has probably committed an offence -but should the doctor notify the authorities and thus compromisethe confidentiality of the doctor/patient relationship or should he donothing and thereby perhaps himself commit an offence? Thematerial removed from the first patient was sent for incinerationbefore any decision or further action was taken. The second

specimen was taped to the operation note, and a medical defenceorganisation advised informing the hospital administration andleaving them to take any further action. The administration’sresponse was that where a small quantity of cannabis presumablyfor personal use, was found the matter should be taken no further.The clinician’s concerned (M. S. T. and S. S. then sought moreprecise legal advice from a barrister (F. G. D.).

Cannabis resin is a class B controlled drug under the Misuse ofDrugs Act 1971. It is an offence for anyone to possess it withoutlawful authority or reasonable excuse. A doctor faced with thissituation has four options:

(1) If he keeps the cannabis he might run the risk of being chargedwith illegal possession or with aiding and abetting an offence.

(2) If he keeps the substance with a view to destroying it or tohanding it to someone entitled to take custody of it he cannot beguilty of unlawful possession. However, the burden of proof wouldrest with the doctor, so it may be advisable to go one step further andinform the police. Indeed if he fails to inform the police he may beguilty of impeding the apprehension of someone who hascommitted an arrestable offence.

(3) In the circumstances a doctor would be within his rights toarrest the patient, but he is unlikely to do this-for one thing, hewould risk being sued by the patient for false arrest.

(4) Notifying the police is the most practicable action to take. Thepolice would then have to decide whether to arrest the patient orinvestigate a possible offence.Many doctors think that they are entitled to withhold information

from the police (or the courts) on the grounds of medical

confidentiality. They are not, though at a trial a judge has thediscretionary power to tell a doctor that he need not answer aquestion that would oblige him to talk about something he regardsas confidential.The situation described here may surprise doctors. If a doctor

finds a patient in possession of an illegal substance, his safest courseof action is to inform the police and hand over the material. To fail todo so, on ethical grounds or on the advice of a medical defencesociety or hospital administration, could in fact leave him open toprosecution. Furthermore, professional confidentiality does notapply to police inquiries about a criminal offence.

ENT Department,Manchester Royal Infirmary,Manchester M13 9WL;and Magistrates Court,

Huntingdon, Cambs

M. S. TIMMSF. Q. DAVIESS. SAEED

PRESCRIBING FOR DRUG ADDICTS

SIR,—That the pattern of black-market drug use involves severalsubstances does not imply that an addict could not be satisfied with astable supply of his chosen substance, contrary to Dr Lipsedge andDr Cook’s unjustified and unsupported doctrine (May 30, p 1265).90% of the addict population is not just The Lancet’s estimate,

but also that of the Home Office, police, and customs (with regard toundetected drugs), and it accords with our estimates.’ Thetreatments offered them would be those of orthodox psychiatry-offered by Cook and Lipsedge to the 10% of addicts who attendthem. They could not treat the 90% because they would never seethem.2 For that majority without social and psychological problems,psychiatric methods may be inappropriate: the main thrust wouldbe to prevent illegal acts and deal with rebellious or subcultural

behaviour. This may be best done by a pharmacist, probationofficer, or social worker.

Wiepart et al’s increased recording of offences by addicts3 may bean artefact of the sustained observation that prescribing for addictsallowed them: Anderson and Nutter’s result* is not an argument foror against prescribing unless we know the effects5 on their patientsof withdrawing maintenance: Smart et al’s study6 that showed mostwere still addicted is exactly what one would expect from the naturalhistory of addiction, and claims of better results are unsubstan-tiated .7

Lipsedge and Cook’s parochial complaint about alcohol

prohibition in America ignores the global perspective. India’s

problems from a western-inspired prohibition on opium andcannabis are identical to 1930s America. Arabian prohibition onalcohol is similar to American prohibition on opioids.

Opioids were widely used in the nineteenth century for social andrecreational purposes, but less so than alcohol. It has takentwentieth century prohibition to spread the drug’s social use

efficiently.8 Physicians do not need to prescribe for alcoholics: thestate does so already, through institutions called "pubs".

Lipsedge and Cook’s final swipe at methadone is an argument forprescribing heroin. The assertion about the "flourishing black-market" in methadone is insupportable. Over six months our localdrug squad examined all addicts arrested in the city forunauthorised possession of drugs prescribed by our clinic. Ofthousands examined, not one had any prescribed drugs to which hewas not entitled. No doubt some legally prescribed drugs leak ontothe black-market. D. H. Marjot (North-west Thames RegionalHealth Authority) estimates illicit heroin consumption at 5000 kgper annum and prescribed opioids for addicts at 50 kg per annum.So the fraction of prescribed drugs that leak are a drop in the oceanof illicit heroin.

I sympathise with Dr Robertson and C. A. Skidmore’s alarm(June 6, p 1322) at the prospect of a change in policy, but they mustface the simple fact that the imported American methods areunsuccessful. In America, despite rigorous prohibition, drug abusecontinues to increase. In Holland, after decriminalisation, cannabisconsumption has decreased by 25%. The logic for controlledavailability appears false but is on analysis, compelling, and theevidence is unequivocal. We cannot afford a spread of drug abuse bygiving support to a failing method simply because we find it

ethically more comfortable. This is treating ourselves and not ourpatients.

Liverpool Drug Dependency Clinic30 Hope Street, Liverpool L1 9BX JOHN MARKS

1. Marks JA. What happens to drug addicts? Update 1986; 32: 555-57.2. Dally A. The heroin problem. Br Med J 1984; 288: 10073. Wiepart GD, d’Orban PT, Bewley TH. Delinquency by opiate addicts treated at two

London clinics. Br J Psychiatry 1979; 135: 14-23.4. Anderson GS, Nutter RW. Clients and outcomes of a methadone treatment program.

Int J Addict 1975; 10: 937-48.5. Senay EC. Methadone maintenance treatment. Int J Addict 1985; 20: 803-21.6. Smart R, Eveson A, Segal R, Finlay J, Ballah B. A four-year follow-up study of

narcotic-dependent persons receiving methadone maintenance substitution

therapy. Can J Publ Health 1977; 68: 55-58.7. Vaillant GE. Addiction 100 years on. Dent Memorial Lecture, Centennial Symp Soc

Study Addiction, Royal Society, London, 1984.8. Marks JA. The paradox of prohibition. Mersey Drug 1987; 1: 5.

QUALITY-ADJUSTED LIFE-YEARS

SIR,-Professor Williams (June 13, p 1372) claims that my paperon quality-adjusted life-years (QALYs) (p 1134) contains

misconceptions, but he does not say what they are. I think that Ifully understand the procedures. However, many publishedcalculations of QALYs are based on inadequately founded

assumptions about the reciprocal commensurabililty of quality andduration of life, and they are often used without due consideration ofthe propriety of a utilitarian philosophy for the distribution of healthcare resourses.

Many of the ostensibly QALY-based decisions now being madein the National Health Service use data that are little more than

guesswork. Whatever the limitations of traditional methods ofdecision-making (and I was careful to acknowledge these

limitations) they do not persuade those who use them that they have