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WHAT TO DO ABOUT DRUG ABUSE
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THE OCCUPATIONAL MORTALITY SUPPLEMENT SiR,—The Decennial Supplement on Occupational Mortality for England and Wales for 1959-63 was published in December, 1971. Tudor Hartl greeted this in your columns with the subheading, Too Little and Too Late. Your welcome of the latest publication (Sept 13, p 610) might have been entitled Too Much and Too Soon. It is true that the commentary for the latest supplement was shorter than in previous editions, but there were reasons for this, which apply equally to occupational mortality as to social class. In my view, this office had an obligation to publish the full statistical data with minimum delay, while providing a detailed description of the method issues relevant to the interpretation of the data. I accept that this does not immediately serve the needs of those who want a synoptic comment and summary tables. However, our immediate contribution has been to make the report available as soon as we could, without holding up the data while we wrote a commentary ourselves. The data are needed by those concerned with occupational medicine, as well as by those interested in social class. As for comment on social class, some of the problems of measuring trends over time are complex, due to changes in classifications and in the structure of employment. OPCS is proposing to use the longitudinal study to make further investigations of the effects on the data of changes in the classification of occupations; the Social Statistics Research Unit at City University, in collaboration with OPCS, is planning to extend and update the analysis of trends in mortality by social class. It was only after the supplement had been sent for printing that staff within OPCS could devote limited time to some specific issues. Work on the brief paper that you so speedily published2 was carried out only after the supplement was "in press"-and this is why it was not included in the supplement itself. Moreover, Professor Morris (Sept 13, p 632) acknowledges some of the difficulties with this approach to overcoming the biases, and of course it still does not produce a full social class analysis. I consider that a major contribution of the supplement is to serve as a reference against which comments about possible occupational hazards can be checked. To study aetiology and the determinants of exposure to risk factors relevant to the wider context of public health requires a range of different types of study. Our (limited) resources are therefore divided between (1) ensuring early release of routine data, with suitable caveats on their use, and (2) assistance with various analytic studies (case-control and prospective), whenever an opportunity arises. However, the strong reaction to the supplement in both the medical and lay press raises the question whether our policy of early publication of data without a full commentary was correct. Perhaps next time we should either hold up the data until a full commentary can be prepared or, alternatively, separate the publication of data on social classes from the data on individual occupations. Office of Population Censuses and Medical Statistics Division, 10 Kingsway, London WC2B 6JP
people who can pick up the habit or relinquish it as the fancy takes them without becoming seriously dependent. Thus the widespread belief that hopeless addiction will follow one or two experimental intakes must be far from the truth-yet it is a central tenet in education programmes aimed at preventing young people starting the habit. The real or alleged consequences of drug abuse are almost all the result of the illegality of the drugs and not of their pharmacological or even toxicological properties. Most of the deaths are from overdosage; without quality control drug abusers often do not know how much drug they are using or even which drug. Similarly the shared use of needles would be highly unlikely in a legal setting. The main adverse effect of drug abuse is crime-both street violence, muggings, and break-ins and organised international crime—and this is solely the result of the illegality of drug traffic. More vigorous suppression may simply raise prices, profits, and the level of violence. The most tragic effect of this illegality is the final stage of distribution. The only means of acquiring the money to buy drugs are theft, prostitution, and selling on some of one’s own supply to friends. It thus becomes in the drug abuser’s own interest to persuade as many friends as possible to take up the habit and sustain it. Surely the time has come to consider a legal framework for the supply of cocaine, opioids, amphetamines, and cannabis and to control purity and dosage and fix prices so that it is no longer profitable to traffic in drugs. Such a policy should lead to a decline in organised crime, a fall in fatal overdosages, and a reduction in one form of transmission of AIDS and hepatitis B. Furthermore two potent stimuli to experiment with drugs-peer group pressure and rebellion against authority-would be removed. We would be left then with true addiction which we have already but which has been obscured by all the consequences of the illegal aspects of the drug culture. Substances are often labelled drugs of abuse in one society when they have been more or less freely available in others for years. Few doctors become dependent on opioids; other famous men of the profession have misused cocaine in ignorance and instantly abstained on discovering their mistake. Teenage solvent abusers experiment briefly with this appalling pastime but presumably shake themselves free since few are still involved as adults. The few of us who are potential addicts will find something to abuse, whilst the rest will not seek to abuse anything very much. Drug addicts, placed as they are in the most inaccessible part of society, cannot adequately be studied, understood, and treated. We fill gaps in our knowledge of drug dependence with nightmare scenarios that are pure hyperbole. There is no reason to suppose that we would have many more addicts as a result of legalising the social use of the drugs they abuse and we should be much better able to help those unfortunates who do become dependent.
Surveys,
ALEXANDER MACNAIR M. R. ALDERSON
TOBACCO AND ASBESTOS LITIGATION 1. Tudor Hart J Data on occupational mortality, 1959-63. Too little too late. Lancet 1972; i: 192-93. 2. Marmot MG, McDowall ME. Mortality decline and widening social class inequalities.
Lancet 1986; ii: 274-76.
WHAT TO DO ABOUT DRUG ABUSE
S1R,-The British government has sent a minister to see for coca plantations of South America. Earlier expeditions went to the "golden triangle" of South-East Asia where the opium
himself the
Poppy grows. Concerned experts in social medicine and law enforcement chafe impotently as drug abuse increases despite efforts to choke off supplies further and further upstream. Many drug abusers start their compulsive behaviour to flout the law and medical advice in a spirit of protest. Furthermore, the huge quantities of drugs of abuse that are sold are far greater than could be used by the small numbers of established addicts. Most usage of these drugs must be by occasional experimenters-or at least by
SiR,—Your Sept 6 note (p 587) reports on legal efforts to try to nail tobacco manufacturers for their responsibility for the lethal outcome of the use of their products. I share the hope that successful damages claims will eventually push up the price of cigarettes, though this seems unlikely to happen in the near future. You are mistaken to suggest, though, that this was the mechanism that caused the decline in asbestos use. It is the public perception of unacceptable risk which has led to the decline of asbestos, not increases in costs of asbestos products. The bad press that asbestos has received has overshadowed the fact that it is still a cheap, versatile, and useful raw material that can, with care, be handled safely. Unlike tobacco, asbestos has been responsible for saving many lives-for example, via its use in fire insulation materials and brake linings. Asbestos cement has technical advantages over other materials for certain sizes of mains water and sewerage piping, as well as being cheap and free of hazard.l Its continued use, particularly in developing countries, to provide clean water supplies, could provide vastly more health benefits than deficits. Many asbestos substitutes are far more
THE OCCUPATIONAL MORTALITY SUPPLEMENT SiR,—The Decennial Supplement on Occupational Mortality for England and Wales for 1959-63 was published in December, 1971. Tudor Hartl greeted this in your columns with the subheading, Too Little and Too Late. Your welcome of the latest publication (Sept 13, p 610) might have been entitled Too Much and Too Soon. It is true that the commentary for the latest supplement was shorter than in previous editions, but there were reasons for this, which apply equally to occupational mortality as to social class. In my view, this office had an obligation to publish the full statistical data with minimum delay, while providing a detailed description of the method issues relevant to the interpretation of the data. I accept that this does not immediately serve the needs of those who want a synoptic comment and summary tables. However, our immediate contribution has been to make the report available as soon as we could, without holding up the data while we wrote a commentary ourselves. The data are needed by those concerned with occupational medicine, as well as by those interested in social class. As for comment on social class, some of the problems of measuring trends over time are complex, due to changes in classifications and in the structure of employment. OPCS is proposing to use the longitudinal study to make further investigations of the effects on the data of changes in the classification of occupations; the Social Statistics Research Unit at City University, in collaboration with OPCS, is planning to extend and update the analysis of trends in mortality by social class. It was only after the supplement had been sent for printing that staff within OPCS could devote limited time to some specific issues. Work on the brief paper that you so speedily published2 was carried out only after the supplement was "in press"-and this is why it was not included in the supplement itself. Moreover, Professor Morris (Sept 13, p 632) acknowledges some of the difficulties with this approach to overcoming the biases, and of course it still does not produce a full social class analysis. I consider that a major contribution of the supplement is to serve as a reference against which comments about possible occupational hazards can be checked. To study aetiology and the determinants of exposure to risk factors relevant to the wider context of public health requires a range of different types of study. Our (limited) resources are therefore divided between (1) ensuring early release of routine data, with suitable caveats on their use, and (2) assistance with various analytic studies (case-control and prospective), whenever an opportunity arises. However, the strong reaction to the supplement in both the medical and lay press raises the question whether our policy of early publication of data without a full commentary was correct. Perhaps next time we should either hold up the data until a full commentary can be prepared or, alternatively, separate the publication of data on social classes from the data on individual occupations. Office of Population Censuses and Medical Statistics Division, 10 Kingsway, London WC2B 6JP
people who can pick up the habit or relinquish it as the fancy takes them without becoming seriously dependent. Thus the widespread belief that hopeless addiction will follow one or two experimental intakes must be far from the truth-yet it is a central tenet in education programmes aimed at preventing young people starting the habit. The real or alleged consequences of drug abuse are almost all the result of the illegality of the drugs and not of their pharmacological or even toxicological properties. Most of the deaths are from overdosage; without quality control drug abusers often do not know how much drug they are using or even which drug. Similarly the shared use of needles would be highly unlikely in a legal setting. The main adverse effect of drug abuse is crime-both street violence, muggings, and break-ins and organised international crime—and this is solely the result of the illegality of drug traffic. More vigorous suppression may simply raise prices, profits, and the level of violence. The most tragic effect of this illegality is the final stage of distribution. The only means of acquiring the money to buy drugs are theft, prostitution, and selling on some of one’s own supply to friends. It thus becomes in the drug abuser’s own interest to persuade as many friends as possible to take up the habit and sustain it. Surely the time has come to consider a legal framework for the supply of cocaine, opioids, amphetamines, and cannabis and to control purity and dosage and fix prices so that it is no longer profitable to traffic in drugs. Such a policy should lead to a decline in organised crime, a fall in fatal overdosages, and a reduction in one form of transmission of AIDS and hepatitis B. Furthermore two potent stimuli to experiment with drugs-peer group pressure and rebellion against authority-would be removed. We would be left then with true addiction which we have already but which has been obscured by all the consequences of the illegal aspects of the drug culture. Substances are often labelled drugs of abuse in one society when they have been more or less freely available in others for years. Few doctors become dependent on opioids; other famous men of the profession have misused cocaine in ignorance and instantly abstained on discovering their mistake. Teenage solvent abusers experiment briefly with this appalling pastime but presumably shake themselves free since few are still involved as adults. The few of us who are potential addicts will find something to abuse, whilst the rest will not seek to abuse anything very much. Drug addicts, placed as they are in the most inaccessible part of society, cannot adequately be studied, understood, and treated. We fill gaps in our knowledge of drug dependence with nightmare scenarios that are pure hyperbole. There is no reason to suppose that we would have many more addicts as a result of legalising the social use of the drugs they abuse and we should be much better able to help those unfortunates who do become dependent.
Surveys,
ALEXANDER MACNAIR M. R. ALDERSON
TOBACCO AND ASBESTOS LITIGATION 1. Tudor Hart J Data on occupational mortality, 1959-63. Too little too late. Lancet 1972; i: 192-93. 2. Marmot MG, McDowall ME. Mortality decline and widening social class inequalities.
Lancet 1986; ii: 274-76.
WHAT TO DO ABOUT DRUG ABUSE
S1R,-The British government has sent a minister to see for coca plantations of South America. Earlier expeditions went to the "golden triangle" of South-East Asia where the opium
himself the
Poppy grows. Concerned experts in social medicine and law enforcement chafe impotently as drug abuse increases despite efforts to choke off supplies further and further upstream. Many drug abusers start their compulsive behaviour to flout the law and medical advice in a spirit of protest. Furthermore, the huge quantities of drugs of abuse that are sold are far greater than could be used by the small numbers of established addicts. Most usage of these drugs must be by occasional experimenters-or at least by
SiR,—Your Sept 6 note (p 587) reports on legal efforts to try to nail tobacco manufacturers for their responsibility for the lethal outcome of the use of their products. I share the hope that successful damages claims will eventually push up the price of cigarettes, though this seems unlikely to happen in the near future. You are mistaken to suggest, though, that this was the mechanism that caused the decline in asbestos use. It is the public perception of unacceptable risk which has led to the decline of asbestos, not increases in costs of asbestos products. The bad press that asbestos has received has overshadowed the fact that it is still a cheap, versatile, and useful raw material that can, with care, be handled safely. Unlike tobacco, asbestos has been responsible for saving many lives-for example, via its use in fire insulation materials and brake linings. Asbestos cement has technical advantages over other materials for certain sizes of mains water and sewerage piping, as well as being cheap and free of hazard.l Its continued use, particularly in developing countries, to provide clean water supplies, could provide vastly more health benefits than deficits. Many asbestos substitutes are far more