20 November 2007

Management of the Narcotic Addict (Halliday R. 1963)

Below is the text for the VERY FIRST description of methadone in the treatment of addiction, two years before Dole’s publication. Note that Dr Halliday recommends 40mg in divided doses for the first three days then 30, 20 and 10mg over 12 days for detoxification with some patients needing treatment over a longer period of weeks or months under supervision and with appropriate safeguards and psychosocial support. He does not state why he recommends methadone, only that he does and in the absence of any other opioid. I have included a citation and abstract for a subsequent paper co-authored by Halliday describing their experience with methadone in Vancouver from 1959 to 1964 for both short and longer term prescribed patients. This is all insightful and way ahead of their time in my view. Yet it in no way detracts from the work of Dole and Nyswander who I understand were unaware of this work in 1963 when they were doing similar things in New York City - but without the stated aim of abstinence. AB ..

Halliday R. Management of the Narcotic Addict. 1963 British Columbia Medical Journal 5(10):412-414

In recent years there has been a change of opinion as to the nature of problems of the addict, and it is now generally accepted that the addict is a sick person physically, psychologically and socially, and as such requires medical and other treatments. The practising physician should be, as in other areas of medicine, a member of the treatment team, and it is assumed that there will be an increasing demand on his time and skill in this held of treatment.

According to Press and Parliamentary reports, the Minister of National Health and Welfare, Miss Judy La Marsh, has stated there is not any legal barrier against the prescribing of narcotics by a physician for an addicted person, provided that such treatment is directed toward withdrawal from narcotics and eventual abstinence. In other words, treatment is not to be considered as continued maintenance therapy on narcotics unless all other measures have been attempted and have failed. References are frequently made to the so-called “British System’ and it is believed that the small number of drug addicts in the United Kingdom is due to this system — the system being that of drug maintenance. This belief is erroneous and it might be pertinent at this time to state the facts since this might help to clear the confusion that exists in many people’s minds about this situation,

In 1955 Mr. J. H. Walker, who was then the United Kingdom delegate to the United Nations Narcotic Commission referred to his government’s attitude to drug addicts and their treatment in his submission to the Canadian Senate Committee enquiring into the use of narcotic drugs in Canada. He made a number of points quite clear; namely:

1. The policy of the Government was based on the recommendations of the Committee appointed in 1924, and headed by Sir Humphrey Rolleston, to advise the Ministry of Health on the implementation of the Dangerous Drugs Act. (This committee maintained, with few exceptions, addiction to morphine and heroin should be regarded as a manifestation of a morbid state, and not as a mere form of vicious indulgence), That the policy did not include the mistaken notion, held by many people, that addicts should be regularly supplied with drugs on a maintenance basis. A memorandum to physicians from the Ministry of Health included this statement: “the continued supply of drugs to a patient, either direct or by prescription, solely for the gratification of addiction is not regarded as a medical need.”

The Rolleston Committee concluded that morphine or heroin might properly be administered to addicts in the following circumstances:
(a) where patients are under treatment by the gradual withdrawal method with a view to cure;
(b) where it has been demonstrated that after a prolonged attempt at cure that the use of the drug cannot be safely discontinued entirely on account of the severity of the withdrawal symptoms produced;
(c) where it has been clearly demonstrated that the patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued.

The physician is the only person who interprets these recommendations, particularly the last one, in regard to the treatment of his patient, and it is because of misunderstanding about this that the concept of a “British System” in terms of maintenance therapy for all addicts has become a widely accepted, however erroneous, belief. This belief is another one of the legends that confuse ideas about the problem of narcotic addiction. Other legends include beliefs that British addicts are registered for treatment and that there are ‘drug clinics set up by the Government to which addicts report regularly for their drugs, either by drug supply or by prescription. Reliable investigators like Schur (2) and Brill and Larimore (3) have demonstrated that there is no such thing as a “British System” for these addicts and one agreed that the narcotic problem in the United Kingdom is a relatively minor one, largely owing to social and cultural factors rather than to superior legislative controls. The most significant and different attitude however is that of accepting the addicts as a sick person rather than a criminal.

In this country, as in the United States, the absence of community treatment facilities must he directly related to the social concept of the addict as a criminal first, and a sick person second. All available statistics from the treatment centres located in correctional institutions indicate that not more than 5% - 10% of addicts have been helped to abstain following such treatment alter a suitable follow-up period - say, 5 years. (4) One of the major drawbacks in such treatment programs, which within the institutional setting have been well developed in many instances, has been the lack of adequate follow-up and rehabilitation in the community as well as the lack of community facilities at which the addict might seek treatment in the first instance. The medical practitioner (and this is particularly true in the United States) has been threatened, and in many cases prosecuted, if he prescribed narcotics for addict patients when such patients were not in a hospital or clinic. It is true that it is extremely difficult to treat many addicts unless they are in a dosed setting such as a hospital or clinic and that ambulant treatment, as this has been practised in the past, is unsatisfactory. However it is not illegal to treat the patient on an ambulant basis. This being so, the physician may properly prescribe narcotics or other drugs for the treatment of the addict provided that such treatment is part of a more comprehensive program designed to help the addict eventually abstain from the use of narcotic drugs.

As it is not possible in most areas to admit the addict into a general or psychiatric hospital for the treatment of his addiction as such, it is suggested that the physician should do whatever he can to establish and maintain contact with the addict patients in his practice. The physician may need help from other colleagues, agencies and so on to ensure that a comprehensive treatment program is established for his patient. He can initiate a gradual withdrawal program by the administering of suitable drugs, either directly or by prescription. Such drugs may require to be dispensed on a daily basis or be given to a “sponsor” or “chaperone” where the patient is incapable of proper self administration, and this has been the practice at the Narcotic Addiction Foundation of B.C. A typical drug withdrawal program is as follows:
Tabs. Methadone 10 mgms. q.i.d. x 3 days, then
10 mgms. tid. x 3 days
10 mgms. bid. x 3 days
5 mgms. bid. x 3 days
Tabs. Perphenazine 4 mgms. t.i.d. 6 hourly
4 mgms. x 12 days
Chloral Hydrate Grs 7½ @ H.S. x 12 days

In selected patients a more gradual withdrawal program is set up, during which the patient may have narcotics (methadone) prescribed on a continuing basis over a period of weeks or months. Such a program demands careful selection of patients who are considered to have good motivation and prospects for rehabilitation, and also requires close and continuing supervision of the therapist or therapists concerned. It follows that narcotics are not then being prescribed in such instances ‘solely for the gratification of addiction’, but are being used because they are considered to be necessary in the overall treatment of the patient. A comparable situation might be the continuing and controlled prescription of tranquillisers to severely mentally ill patients, who are thereby able to live and function in the community, rather than to be hospitalized. In the last analysis the responsible physician determines his treatment program in the light of what is considered to be sound and ethical medical practice. Some clarification on this is required from the national and provincial Colleges of Physicians and Surgeons.

During the program of withdrawal medication, whether rapid or prolonged, the medication is constantly under review, and if necessary altered to suit the patient’s needs - e.g. depression may become a prominent and severe symptom, and anti-depressants may require to be introduced to alleviate this condition.

Other needs of the patient are explored by the psychiatric and social work staff of the Narcotic Addiction Foundation, and attempts are made to understand these and to develop a suitable treatment program around meeting these or giving the patient adequate support until his problems can be dealt with in a more satisfactory manner. Where in-patient treatment is desirable, the patient is admitted to the nine bedded unit available for this purpose. With such a small number of beds delays in admission for such treatment are unavoidable.

It is intended to make further communications on this complex problem of drug addiction but it is hoped that this introductory statement may be of some help to those physicians who are interested and are anxious to participate in the treatment of this problem which has made such extensive inroads into our own community.

If further information is desired please address enquiries to:
The Narcotic Addiction Foundation of B-C.
640 West Broadway, Vancouver 9, B.C.
or Telephone TRinity 9-4585


1. Proceedings of the special committee on the Traffic in Narcotic Drugs in Canada.
Queen’s Printer, Ottawa, 1955, pp. 362-363.

2. Schur, E. M. Narcotic Drug Addiction in Britain and America. Indiana University Press, 1962, p. 316.

3. Larimore, G. W. and Brill, H.
On the Site Study of the British Narcotic System Report to Governor Nelson Rockefeller, New York, 1959, pp. 23-26.

4. Pescor, M. J. Follow-up Study of Treated Narcotic Drug Addicts. U.S. Public Health Report Supplement 170, 1943, pp. 1-18.

5. Hunt, O. H. and Odoroff, M. Follow-up Study of Narcotic Drug Addicts After Hospitalization. U.S. Public Health Services Report, Volume 77, No. 1, Jan., 1962, pp. 41-54.

Paulus I, Halliday R. Rehabilitation and the Narcotic Addict: Results of a Comparative Methadone Withdrawal Program. CMAJ 1967 96:655-659

The purpose of this retrospective study was to compare (1) regular methadone withdrawal treatment and (2) prolonged methadone withdrawal treatment in 105 and 71 voluntary patients respectively, who attended the Narcotic Addiction Foundation (N.A.F.) between 1959 and mid-1964. Treatment consisted of individual counselling and medical care for all, and only residential care and psychiatric assessment for selected cases. The number of treatment sessions and the details of drug therapy are described.

One hundred and fifty-three of 176 patients (87%) were interviewed approximately one to five years after the first clinic contact. Forty-three per cent showed some overall improvement in their behaviour. Rehabilitation was defined as change in a specific area, drug use, work, criminal behaviour, community associations, friendship patterns and family relationships rather than in terms of abstention from drugs only. Age affected comparative results.