Examination of Witnesses (Questions 540
TUESDAY 27 NOVEMBER 2001
540. That leads on quite neatly to what the
effect would be of decriminalisation or legalisation of drugs.
All four of you said that government policy is not working so
the crux of our inquiry is whether we leave things not working
or move on. I just wondered whether you could perhaps separate
cannabis and other drugs in your answer as to what the effect
of decriminalisation or legalisation of drugs would be if cannabis
were okay and the prevalence of drug use and the number of addicts.
(Professor Nutt) I need to be clear what you mean
by decriminalisation. Do you mean selling it, encouraging it,
marketing it, as tobacco currently is?
541. I do not think anybody is talking about
encouraging itat least I am unaware of thatbut it
being legally available through some sort of controlled outlet
like a pharmacist or something.
(Professor Nutt) I imagine it would have very little
impact on use. I think the market for cannabis is getting close
to saturation at present.
542. Professor Henry said earlier that nine
per cent of the population use cannabis and we have just been
told that is a declining figure. Is it nine per cent of the entire
population or certain categories?
(Professor Henry) Yes. This is the European figure
which is nine per cent of the UK population. Obviously there will
be certain age groups where it will be much more widely used and
I would suspect those are the younger age groups.
543. So four to five million people and if Parliament
is representative of the community, 60 MPs, are taking cannabis
which is illegal. What would happen if it were decriminalised
or legalised? Purely cannabis. Do you think those figures would
go up, remain static or possibly with greater education and the
drug being taxed, one assumes, would that fall?
(Professor Henry) I think there would be a rise in
cannabis use. It might not be a massive rise, but I cannot see
it going down, because a lot of people find it very difficult
to get hold of the stuff. I do not know how. If it were available
from recognised outlets for sale, for example, I am sure there
would be more people trying it and more people using it.
544. I believe your earlier evidence was that
cannabis is not as addictive as cigarettes.
(Professor Henry) Very true. It is not as addictive
as cigarettes and so many people are using it there must be compensatory
perceived benefits in users.
545. If there were an increase in cannabis use,
which I think you are saying there probably would be, would that
then lead on to an increase in so-called hard drugs?
(Professor Henry) There is evidence that prior utilisation
of any substance is associated with a higher incidence. Although
many people will not go on to use a further substance, the concept
of gateway applies. If somebody has tried one substance, then
they are probably more likely to try a further substance and so
on. Not that any specific substance can be regarded as a gateway.
(Professor Nutt) That is quite a difficult question
because one natural experiment we have was the Dutch experiment
where they in a sense have gone partly down that route. There
the evidence is the other way round, which is that if people get
cannabis in a controlled environment, they are less likely to
take heroin, because they are less likely to go into the heroin
market. While John is right, there may be a chemical effect to
encourage you to take other drugs, that may be overridden by the
separation of the market effects.
546. I am grateful for that last contribution
because that is in fact my next question. Having been to Holland
and seen two or three of the coffee shops, the evidence which
has been given is exactly that, that allowing free use of cannabis
has led to a reduction in hard drug use. Would you accept that
(Professor Henry) I accept that argument. The illicit
drug market almost certainly operates cohesively to a degree.
If one manages to separate out one of those substances, then you
might get a decrease in use. I accept that.
547. Do you think there is a case to be made
for saying that cannabis should be separated from other drugs
in terms of criminalisation and what is legal and what should
(Mr Hickman) Yes. In terms of Amsterdam, I should
not have thought they would say that separating cannabis has resulted
in a decline in heroin use, because I do not know what evidence
they have for that. They are separate epidemics and I do not agree
with a gateway hypothesis either. Making it legal would not have
any effect on the heroin using population.
548. As a professional would you feel that separating
cannabis from the other drugs in the eyes of the law is a step
forward or a step back?
(Mr Hickman) It is a step forward, if it comes attached
to a health education campaign. The most important thing is to
reduce the levels of drug use. Having it legal or illegal does
not do that at all. In order to reduce drug use you have to spend
some money on health education.
549. If there is a free-for-all either of cannabis
or all drugs being decriminalised, surely that would have an adverse
effect on the National Health Service and all the health problems
that go with it?
(Mr Hickman) What? Legalising would have an adverse
550. If there is an increased uptake in drug
use, then leading on to hard drug use.
(Professor Nutt) If. It is a complicated equation
because what you have to put into it are the health consequences
of illicit drug use and this is where epidemics like AIDS in America
and like hepatitis C here, have huge health costs which are often
not thought about in relation to drug use. There is a cohort of
hepatitis C positive patients now in this country and other countries
who will become a huge burden on the Health Service in the next
ten years as their livers slowly decay. It may well be that if
you made drugs more available in a way which avoided infection,
you would not have hepatitis C, in which case the health costs
of the way drugs are used now may actually be greater than the
extra costs incurred by extra addiction. It is a complicated equation.
I would not necessarily say that making drugs more available would
increase health costs. It would certainly increase psychiatric
costs, but that might be offset by the savings in other areas
Chairman: I hope you are going to pursue the
decriminalisation of heroin.
551. I did give our witnesses the opportunity
but I am looking at the clock and the time allocated. I am quite
happy to pursue that.
(Professor Nutt) The heroin issue is an important
one. May I just say a few things about it? Heroin is not illegal,
doctors and addiction specialists prescribe heroin and with some
success. The question at present is whether it should be prescribed
more or more often. That is a health economic argument and I should
be interested in what my colleagues here say. Heroin is significantly
more expensive than methadone and if the limiting factor in methadone
availability is cost, then, if the budget stays the same, you
are going to get fewer people treated if heroin is prescribed
than are currently treated with methadone. The other point is
that there is a major controlled trial of heroin prescribing going
on in Holland at present. It will be the first proper trial which
would meet the criteria for licensing a drug, that is it is a
double blind study which compares the intervention of prescribed
heroin against normal treatment. That is nearing completion now,
we should have the data from that study in the middle of next
year and that would greatly inform the debate as to whether prescribing
heroin is both effective medically and also cost effective.
552. I think you know something about the Swiss
(Professor Nutt) The Swiss experience is an open study
where they thought it would make sense to take people off the
streets and allow them to self-administer heroin in controlled
environments. Clearly that was effective in terms of reducing
deaths and stabilising people who had very disorganised lives.
It was not a controlled experiment. The Dutch one is the first
properly controlled experiment.
553. Does your instinct tell you that that is
the way to go here?
(Professor Nutt) No, I am not sure about that. The
health economic argument is a complex one and it may be that if
we have extra investment it might be better to invest it in methadone
and other treatments like buprenorphin, rather than prescribing
heroin. I have a very open mind on that at present.
(Professor Stimson) I conducted one study where we
gave patients the choice of heroin to inject or methadone to inject.
I can make the paper available to the Committee. We are just finishing
another study where we are looking at heroin prescribers in the
United Kingdom; how many there are and how many patients they
are prescribing for. The answer is that there are very few people
who prescribe heroin. In fact the Home Office does not have very
good records. The Home Office list of the licensed doctors does
not correspond to what we found when we wrote to them because
many of them claimed they did not have licences or they had moved
away from the address where the licence was held and so on. There
are about 40 or 50 heroin prescribers in the UK and around 450
patients who are receiving heroin on prescription.
554. That is a tiny sample of the whole.
(Professor Stimson) Yes. We were interested in why
there was not more, because in a sense this should be the country
where there would be more of it. We asked both the doctors who
hold licences why they did not prescribe more and the doctors
in drug clinics who did not have licences why they did not prescribe
more. The main arguments against prescribing would be resources
and cost, because heroin is more expensive than methadone, lack
of a research base, lack of research evidence for its effectiveness.
555. Presumably the fact that they do not want
their surgeries cluttered up by chaotic heroin users.
(Professor Stimson) Heroin users may not be chaotic.
I have done two studies, one of heroin users from 1968 whom we
followed eventually for 20 years and many of them were not chaotic,
though some were. In a small study I conducted where we gave people
a choice of heroin or methadone for their prescription and then
followed them for a year, these were long-standing people who
were resistant to the idea of giving up injecting drugs, they
had had several failed methadone treatments, they were older,
but there were health gains and the treatment retention was very
high. Some of them were chaotic but for the most part they were
helped to lead a slightly better life. I would not say it works
for everybody. To jump ahead a bit, there is probably a place
for more heroin prescribing, but it is not the single simple solution.
It is within the panoply of treatments which should be available.
556. The other argument against was leakage
as well, was it not?
(Professor Stimson) In the trials which are going
on in Holland and in Switzerland the people had to sit in this
room and be observed to be injecting, which may prevent leakage,
but was not very nice for the patients. In the trial we did we
asked for the ampoules to be returned and there was a very high
return rate on the ampoules. We also did some street interviewing
to check how easily available ampoules were and what their price
was on the market. Ampoules of heroin are very rare. They are
like gold dust and if people get them, they want to keep them
for themselves for the most part. That might change if there were
more heroin prescribing but for the most part, if you get NHS
heroin you do not want to let anybody else have it.
557. It would be very useful if you would make
those two papers available to the Committee. The major argument
which is being put to us for much wider prescription of heroin
is that you collapse the criminal drug market. I appreciate this
does not relate to making the health of the patient better or
worse, but there must be some truth in that, must there not?
(Professor Stimson) There might be. This was an argument
when the drug clinics were first introduced: doctors talked about
competitive prescribing to drive out the drug market by supplying
a sufficient quantity of heroin but not too much. If you supply
too much, you are creating the black market itself. Very difficult
to know. I would abstain on the answer to that.
558. We are not allowed to abstain.
(Professor Stimson) I am.
559. If this Committee were to recommend a much
wider prescription of heroin. . .
(Professor Stimson) We should not be against that.
It would bring in another population. You would have to be careful
whom you recommended it for, but different treatment modalities
attract different people at different stages in their drug using
life. More heroin prescribing would help a group of people, but
it is not the only solution.
(Mr Hickman) I would recommend a trial first. Most
criteria for people going onto heroin include that they failed
on methadone and they are a bit older. These are not the people
who are committing all the drug related crimes, who are younger.
You probably have people at different careers, different trajectories
and you want to get people who are committing the drug-related
crime into treatment early. I do not know whether heroin is going
to have a role in being able to do that. It would be interesting
to do a trial at least.
(Professor Henry) My comments would not be an expert