Examination of Witnesses (Questions 468
TUESDAY 27 NOVEMBER 2001
468. Good morning gentlemen, thank you very
much for coming. We are now well over half way through an inquiry
into government drugs policy in which we hope you are going to
assist us. We have received more than 170 submissions, many of
which are flatly contradictory and we need your help to pick our
way through them. May I start by asking each of you to say for
the record who you are and what you do?
(Mr Hickman) I am Matthew Hickman, I am an epidemiologist
and work at Social Science and Medicine at Imperial College School
(Professor Stimson) I am Gerry Stimson. I am a social
scientist. I am Director of the Centre for Research on Drugs and
Health Behaviour and I also Chair the United Kingdom Harm Reduction
Alliance which is an advocacy group.
(Professor Henry) John Henry. I work in the Accident
and Emergency Department at St Mary's Hospital and my particular
interest is in the toxicity of substances.
(Professor Nutt) I am a psychiatrist who is also a
pharmacologist. I am Professor of Psycho- pharmacology at the
University of Bristol and I am interested in how drugs work in
469. I am going to ask a couple of simple questions.
The first one is: is government policy working?
(Mr Hickman) No, it is not working and the reason
it is not working is because it is not focused towards the area
of greatest harm which in public health terms is drug injecting
and heroin use. The most important public health harms are drug-related
overdose and transmission of blood borne viruses such as HIV,
hepatitis B and hepatitis C. The drug policy does not really mention
those areas, or they are subsidiary aims. That would be my view.
470. Is the strategy having any impact on morbidity
and mortality rates relating to the various substances, cannabis,
cocaine, crack cocaine, heroin, ecstasy? You may want to speak
about any or all of those.
(Mr Hickman) I would not have thought so because it
has not actually resulted in any interventions to prevent those
deaths. Also, the most important drug-related death is overdose
relating to heroin, not to those other substances. I do not know
of any examples of a cannabis death.
(Professor Nutt) The policy on ecstasy which the Home
Office developed a few years ago and John and I helped develop
was helpful in that it was an educational policy and trying to
reduce harm through improving the knowledge base of the users.
There has probably been some evidence that that has helped and
there are fewer deaths through water intoxication at least. Previously
the policy of needle exchanges has clearly been shown to be helpful,
so you can say there are some policy initiatives which have been
helpful, but I do share Matthew's view that there is a long way
471. What do you feel about the question: is
the policy working?
(Professor Nutt) The policy is working a bit but there
is a long way to go.
472. Do you want to elaborate on the impact
of the strategy on morbidity and mortality rates with drugs other
(Professor Nutt) It has not impacted much at all on
473. Professor Henry, what would be your response
to: is government policy working?
(Professor Henry) I agree with the other speakers
that while some aspects may be working, there are other aspects
which are clearly not working. In my own practice the problem
we see most now is cocaine coming into the emergency department
with all kinds of medical complications and to back that up the
numbers of deaths from cocaine have rocketed between 1996 and
1999 which are the latest figures we have. I am quite sure that
that graph is still pointing in an upwards direction, so the use
of cocaine is causing medical problems, probably in line with
two things: the increased availability and also the image that
it has in the public eye of being something recreational and mild,
which is very far from the truth.
474. Are you referring to crack cocaine?
(Professor Henry) Both. Many people start with the
snorted variety and end up on crack. The American experience and
the image of cocaine is very different there because they have
been through it over the last 15 years or so and they have seen
what it does to people, whereas that has not yet been seen in
this country. Similar things apply to other drugs. With cannabis,
for example, we have not seen the steady state health impact of
cannabis because the strength of it has increased in the last
few years, the amount used has increased enormously, the usage
is going up and with cigarettes or alcohol we have a general idea
of the overall health impact, whereas with cannabis we just have
not reached that stage yet.
475. We have not got to that stage yet with
cocaine. You said cannabis. You did not mean cannabis, did you?
(Professor Henry) I do mean cannabis in this case,
yes. Use is increasing but many of the long-term problems, the
mental health problems and the damage to lungs and the cardiovascular
system will not become apparent for years.
476. Professor Stimson, would you tell us your
views as to whether the Government's policy is working?
(Professor Stimson) It could be working better. It
is not working well in one key area and that is the area of health.
There was a fundamental flaw in the formulation of the strategy
in 1997 when the four key areas for the strategy were picked upon.
Those were: young people, communities, treatment and availability.
There was no clear individual or public health aim within the
strategy. I was quite alarmed to find the initial strategy report
and the subsequent reports from the UK Anti-Drugs Co-ordinator
with barely a mention of some of the key health problems which
can be associated with drug use such as HIV, hepatitis C and hepatitis
B. Those words hardly figure at all in the strategy document.
If you do not have a key plank which promotes the health issues,
both individual and the public health issues, those areas start
to be neglected. We are not yet in danger but if we go back and
caricature two periods of 1987 to 1997 it was broadly a public
health approach to drug policy and from 1997 onwards in the last
period of government mainly a drugs and crime focus on the strategy.
In a sense the Department of Health did not exactly give up but
was somewhat marginalised from 1997 onwards. We made significant
public health achievements from 1987 onwards in the prevention
of HIV infection and it is quite extraordinary in international
terms that we have so little HIV infection connected with drug
injecting, around one per cent of injectors have HIV. We have
done recent surveys where we find no HIV amongst injectors who
are under 25-years old or injecting under five years. Those advantages
can be lost if you do not keep pushing forward the public health
prevention aspects. I can elaborate a little bit later on hepatitis
C. We have some relative advantages over other countries but there
is a clear danger that we will lose those advantages unless we
give more prominence to health in the strategy.
477. Is there evidence that people are using
needle exchange less since 1997?
(Professor Stimson) There is a problem with how much
evidence there is. We did a survey which Rosemary Jenkins reported
when she spoke to you where we looked at the availability of syringe
exchange around the country and the volume of needles distributed.
There are reports of some cutbacks and there are no public health
targets in the strategy. So if budgetary decisions are being made,
you are likely to put the money where it meets the targets. From
our calculations, both with respect to looking at the availability
of syringes and having some guesstimate about the number of injectors
there are out there, and more recently trying to do some epidemiological
modelling work to look at how we might turn around the hepatitis
C epidemic, we consider that the current syringe supply will probably
need to be increased by 50 per cent or 100 per cent to make a
major impact on blood borne viruses. There is provision but it
is probably insufficient.
478. You seem to be saying that the policy up
to 1997 was working. Yet we still see dramatic rises in the number
of addicts in society. Whereas it might have been working for
health purposes, it was not necessarily working in other ways.
(Professor Stimson) That is a difficulty for policy
because you have measures of consumption and measures of use and
also measures of harm and it is trying to balance one against
the other, trying to have less harm, but harm is a function both
of the numbers of people using drugs and the different types of
drugs they are using, but also the way they are using them. I
would not attribute the increase in the numbers of hard drug users
to the policy; it is affected by things far wider than that, events
in other countries and so on.
479. I am going to come back to this question
of harm and use and what changes you would like to make to the
strategy. First, could we try to reach a consensus, at least amongst
you, about the dangers to health of the substances we are looking
at as measured by short-term risks, long-term risks, addictiveness,
those three headings: cannabis, cocaine, crack cocaine, heroin,
ecstasy. Could we go down the list perhaps starting with Professor
Nutt as you are good on what it does to the mind and perhaps Professor
Henry could join in on each of those?
(Professor Nutt) Starting with cannabis: dangers to
health, short-term very slight; long-term mostly equates to smoking
of the leaf; addictiveness low to moderate.