Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 580 - 599)



  580. Should it be licensed?
  (Dr Brewer) I am sorry, I should have said it does not have a product licence. You do not need a medical licence to prescribe it. Even though I do not have a licence to prescribe heroin I do have one patient who is maintained because he has an underlying painful condition for which I am allowed to prescribe. He functions perfectly well. He works hard despite his medical condition. If you were standing next to him on the Tube, you would not know he was any different from anyone else. He has about 400mg or 500mg of heroin daily which he actually injects intramuscularly and he buys it as heroin powder, which is not officially approved of, but it makes it about one tenth of the price. It costs him, on a private prescription, about £30 per week, which is something many people could afford. It is cigarette money.

  581. It sounds as though the message you are giving us is that for different forms of treatment you need different things. There is a sort of "Let a thousand flowers bloom". For some people it is methadone replacement; there ought to be more diamorphine prescribing. Is that a right message for us to be taking away?
  (Dr Brewer) As well as maintenance prescribing with opiates, we are seriously deficient in this country in the polar opposite of maintenance prescribing which is a drug called naltrexone, which is a heroin blocking drug. Once you are maintained on naltrexone you stop using heroin. In fact if I could have done, I would have brought a patient here to demonstrate. I was hoping I could inject him with a vast dose of heroin in front of you to show that when someone has swallowed naltrexone heroin has no effect.

  582. It has none of the pleasurable effects.
  (Dr Brewer) No effect at all. It just blocks it completely. It is very under-used here. In many other countries, particularly more in southern Europe, it is a standard part of the range of treatments. An addiction clinic should be rather like—

  583. This is a new one on me and I think on all of us. Can we just understand this? This is a drug which—
  (Dr Brewer) You have to be detoxified first.

  584. So you are no longer feeling the need for heroin.
  (Dr Brewer) On the contrary, you are feeling the need very much when you have been detoxified which is why most detoxified people relapse within a very short period of being detoxified. If you are taking naltrexone, and that means encouraging people to take it and usually involving the family in seeing that it is taken regularly, it is a great help as shown in several proper randomised trials, and it does help people resist the temptation. You go out of a hospital, out of rehab, usually back to your old environments with the same sights and sounds and smells and the dealers sometimes literally knocking on the door saying, "Hi. Welcome back. You've come out of rehab. I've got some really good stuff for you". It is asking rather a lot of human nature for people to say they will be strong, at least all the time. Naltrexone is not a miracle cure, I do not believe in miracle cures, but it is a very helpful alternative. I think that an addiction and treatment unit should be rather like a family planning clinic. You do not go to a family planning clinic to be told you can have the pill and nothing else. Everybody who goes to a family planning clinic knows broadly why they are there and you discuss sensibly with the staff a range of options and if you do not like one, they will offer you another. Addiction treatment has to be like that.


  585. Is naltrexone very expensive?
  (Dr Brewer) No; about £2 per day.

Mr Cameron

  586. In that context, any comments about the National Treatment Agency? If the theory is that we should be letting a thousand flowers bloom, does it make sense to have a National Treatment Agency trying to impose?
  (Lord Adebowale) On the question of methadone replacement, clearly it is one treatment in a whole plethora of other treatments. You have to get access to it and doctors are generally reluctant to work with people with addictions and there is an issue about access to appropriate equipment. The Hungerford project, which is a Turning Point project in Soho, relatively new, has been very busy. In the last eight months we have had over 25,000 contacts, an average of 150 a day and have seen approximately 1,500 different individuals. It comes back to the point, and it is worth making the point over and over again, that unless people have appropriate access to treatment, no matter how effective it is, it will not work. We have been working with something called locality prescribing, which is run in partnership with GPs which has helped gain access to methadone users. We prescribe in accordance with Department of Health guidelines. This particular method has been very popular with both GPs and users because the clinic is in familiar settings which are less intimidating that doctors' surgeries and drug users are accepted and their situation and needs are known by drug workers who work in partnership with the GPs. There are methods which do work and have been shown to work and are popular with drug users and GPs but they are not available everywhere. They are not available in those areas where they are needed most. May I just touch on the NTA and then on others? Turning Point is in full support of the NTA and indeed the response to the suggestion to let a thousand flowers grow is that the NTA is there to stop us from wasting a lot of fertiliser. That is why they are there. A lot of work and a lot of money needs to be spent on finding out what works. What we do know is that different people respond to different treatments and this is across both alcohol and other drugs. The NTA is a welcome resource for capturing what works and then spending appropriate sums on spreading the good work.
  (Mr Nelles) The example of shared care, which is what this process has become known as, where doctors work in alliance with local drug services, is very much the way forward. I speak as someone who started the first GP prescribing programme in Reading some 20 years ago. It is extremely important to bring GPs in, however they need training and they need assistance. We cannot expect GPs, very busy as they are, to carry the sort of case loads we would expect. What we need are people to work with the GPs and assist them, but we also need better training for GPs because while some do a very good job prescribing, others can cause harm through their initiatives. This is an important point that we need to make. Some of the harm which comes from drug use is to do with the drugs themselves and some is to do with the criminalisation process. We need to help people to manage their drug dependency in a way which we used to much more in the 1960s and I am afraid we have rather gone away from, because we feel that to help people learn to manage their dependency is somehow condoning and approving of the practice. This is very ill judged logic The important thing is that the treatment accepts that for some people abstinence is not realistic and they need the assistance and care which can come from prolonged contact with people who may provide them with clean and sterile supplies of the drugs. One thing I should also like to mention is that heroin does not have to be very expensive as a treatment. The way it is currently prescribed in glass ampoules is certainly expensive, but if we returned to the principle of having hypodermic tablets, for instance, which could be used quite safely, we would get a lot less expensive heroin programmes when we cost them. I do not want to say that heroin is the answer, because I do not think that it is, but it is one of the answers.
  (Professor Strang) I have another angle on the let a thousand flowers bloom. The whole point about it is that you then have to strip some of them out when you discover they are weeds or that others are doing better. You were obviously wanting to check out this issue of heroin prescribing. I would encourage you, if I might be so bold, to think more widely. The real issue is injectable prescribing of which heroin is the most famous. It may possibly be the most attractive but it is not the only one and in this country a far more common practice is injectable methadone prescribing. At least in your consideration, the big controversial practice which goes on in this country is injectable prescribing, whether it is heroin or methadone. In this area, it is injectable prescribing which sets this country apart from the rest of the world.

  587. Could you explain that in a bit more detail? At the moment most people who take methadone in this country are taking it orally.
  (Professor Strang) Yes. I would suggest that you should consider injectable methadone as if it was an altogether different drug from oral methadone. I know it is chemically the same drug, but in terms of its appeal and its contribution, it has something much closer to heroin in terms of—

  588. You get a more immediate high when you take it.
  (Professor Strang) Yes. I am not saying it is the same, but it is closer to heroin in its experience; and hence the injectable methadone debate is closer to the heroin debate. And, furthermore, injectable methadone debate, like injectable heroin, is there on your doorstep.

  589. Is your feeling that if addicts were allowed to have injectable methadone, they would find that closer to heroin and therefore would not buy street heroin? Is that what you are saying?
  (Professor Strang) Without question that is true. Whether that is the right choice or whether heroin might be a better choice or whether none of them would be a better choice is a different matter. But it is definitely true that in the continuum it is between the two and in my view it is one hell of a sight closer to the injectable heroin than oral methadone.

  590. Professor Strang, you obviously have strong views. What would you change if you were writing our report on the heroin front; heroin prescribing, methadone prescribing, oral, injectable? Where do you think policy should end up?
  (Professor Strang) I would probably go scurrying along to someone like Bill Nelles and ask his advice. You could be hard pushed to do much better. What you are wanting is a layered system. Let us look at an example first. Many people have heart disease. You do not say everybody has to have a heart transplant. You have the idea that, of 1,000 people with heart disease, you hope to be able to manage 750 of them in a straightforward way in a GP setting, another 100 might need something more specialist locally and only perhaps five or whatever might need the most expensive controversial treatment. Your equivalent in this field would be to ensure universal prompt availability of methadone maintenance treatment which would not be the sub-optimal treatment that we have, but would be good quality, proper doses, good psycho-social care. That would be universally available and it has an international stamp of evidence to support it. You then move on to more unorthodox less commonly prescribed treatments which might be more specialist and I would see injectable maintenance as being in that category and I would probably create a bit of a hierarchy within the injectable maintenance with injectable methadone being the next step in this pyramid and injectable heroin being the next level up. You can add as many levels as you want if it gives a better fit to the model. It would be absurd to be seeing heroin as your treatment response to early cases or first cases. But if we tried to implement this layered system today, we immediately encounter a problem. The problem is you do not have the capacity and you do not have the training infrastructure for that pyramid. For example, at the Maudsley we have a small supervised injecting clinic like the Swiss or Dutch one, very small. Our bid to the drug czar's treatment fund or ADCU's treatment fund was short-listed but that is not much use when it is then not funded. Our bid to local funders fails to get an increased capacity. We get other projects supported such as liaison workers but we do not get an increased straightforward treatment capacity.

  591. In order for you to produce this pyramid of treatments so you can have the right treatment for the right sort of addict which is going to help them eventually get off the drug, what has actually got to change in the Government's drug strategy?
  (Lord Adebowale) I am not sure whether your question is just referring to heroin and injecting users.

  592. On opiate users to start.
  (Lord Adebowale) Opiates. Firstly, what you have heard and what we would agree with, what I would agree with is that injecting treatments do have a place and the only objection to them is based on a kind of prurience and what the press might say. That is the first thing. We need to say it works. The second thing is that GPs need to be given the tools to get on with it and indeed they need to be encouraged to do it because there is evidence that GPs are reluctant not only to treat any person who has a substance misuse problem, whatever the substance, because they are concerned about the effect on their reputation professionally. That is a real problem. The third thing you heard and you will certainly hear it from me is that the barriers to providing shared care arrangements with GPs are not real. In other words, there are methods—my colleague has called it shared care, we call it locality prescribing—which deal with the potential for disruption within clinics, which have a controlled but appropriate group of clients which is managed in partnership with organisations like mine and we know that these prescribing regimes can also engage other medical professionals like nurses. There is a model there. There is a model, it works and it requires GPs to be appropriately trained, to be encouraged to use it and it needs to be made widely available. That only deals with a certain type of substance misuser and we must not see that as the only answer. May I very quickly respond to Dr Brewer's comments about residential services because I would not want that to lie as an answer simply because we provide a lot of residential services and because my own background tells me that there is a high proportion of homeless, rough sleepers who have substance misuse problems where accommodation is an essential base for treatment. It is not the treatment and that is often the error which is made. Residential services are not the treatment but they are required to treat those people who are extremely chaotic and may exist on our streets.


  593. Is Dr Brewer right that there is an 80 per cent drop-out?
  (Lord Adebowale) On some programmes I am sure there is a high drop-out rate, on others there is a significant retention. It all depends on the treatment programme which is attached to the residential service which is provided and how good that residential service is. Certainly that is not the case at Turning Point.

Mr Cameron

  594. One point I did not quite understand about what you said which was otherwise extremely clear and very, very helpful. Are you saying that GPs should be trained and it should be GPs who would be providing the injectable or oral or whatever, or would you see expansion of your own sector, the voluntary sector as being perhaps the provider of those services? You have all sorts of problems with GPs, their regular clients being worried about sharing surgeries and addicts etcetera.
  (Lord Adebowale) I am saying both things are the case. There is a general problem with GPs, if you talk to the Social Exclusion Unit, and the Department of Health would back this up, and that is first of all the recruitment of GPs and the reluctance of those GPs to work in areas where they are most needed. If you look at any one of the 88 worst estates in the neighbourhood renewal strategy you will see we have a problem with GPs generally. What we would argue for is better training of GPs. They are obviously a major resource and it is where people go when they have medical problems, but GPs themselves need to be supported with additional resources which the voluntary sector can provide. It is both.
  (Mr Nelles) They also need to be financed. One of the problems is that providing care to drug users is not what is called a core medical service for general practitioners. This is a real problem because general practitioners are expected to do a great deal on the budget they have. In my experience, one of the things which has encouraged GPs to become involved is paying them specific sums to set up specific treatment programmes for drug users. This is a very important point that we must not overlook.


  595. This is something which could be done by practice nurses rather than GPs.
  (Mr Nelles) Yes.

  596. If you look at Sunderland, part of which I represent, we have a chronic shortage of GPs.
  (Lord Adebowale) May I support that in that there are more nurses working in the substance misuse field than doctors and nurse prescribing is something we would certainly encourage. It needs to be properly evaluated of course and the training needs to be made available. It seems to me that the full panoply of health professionals needs to be brought to bear on what is a serious health problem. I find it astonishing that there is no incentive process to encourage GPs to work in areas where there is obviously greatest need and to work with those clients who have the most severe problems. Some of those will be substance misusers.

  597. Part of the problem is that all the doctors in the world really would like to work in California, is it not?
  (Lord Adebowale) So would most chief executives of charities.
  (Dr Brewer) One of the problems, I am sorry to say, is that most GPs hate addicts and wish they would all go and quietly die somewhere. That is not much of an exaggeration. They do not even like alcoholics, even though doctors being reasonably fond of a drop themselves can empathise rather more with alcoholic patients than with patients whose taste is for other drugs. It is not just a question as in the case of alcoholic patients of "I'm a doctor, I'm educated and middle class and you perhaps as an alcoholic patient are not, but at least we know what a glass of whisky tastes like", but with drugs it is a question of mainly middle class, middle aged, doctors completely unable to penetrate the culture which is a couple of generations removed from them of predominantly youngish working class, quite a few unemployed, but many employed, heroin addicts who work very hard to support their habit. It is like family planning. There are many doctors who would not prescribe the pill when it came out because like addiction it has a moral dimension. This is the great problem. It is not just a medical issue it is a moral and political one. You just have to find a way, as we did with family planning, of saying if they did not like prescribing the pill, fine, but they should not pretend they were a general practitioner in the fullest sense. You either pay people, you bribe people as in the case of family planning when we said if they provided a contraceptive service they would receive more money, so how about that, maybe that would change their minds, or we set up easily accessible clinics without much of a waiting list, staffed by people who either have a positive or at least a neutral attitude to the issue. That is the secret, because you are never going to persuade people who think that addicts should be shot to learn to love them. It is pointless to try.
  (Professor Strang) I very much agree with Dr Brewer's point about there being a major problem of GP reluctance. Part of the unit I run is a research unit as well as the treatment side. We have recently completed a national survey of GPs and 50 per cent of them would not prescribe methadone under any circumstances. Whether you regard the 50 per cent as good news or bad news is that old joke of whether you are an optimist or pessimist. The cautionary note I would add about the huge enthusiasm we have in this country for pushing it out to GPs is that it is rather like community care and psychiatry and mental health services: what was initially a good idea gets embraced by the accountant as being a good way of shifting costs with a complete disregard for the quality of what is then provided. Referring you back to what I know is now going to be your compulsive reading, page 227 of "Drugs dilemmas and choices", this gives you snippets of the key bits of information. Page 227 describes a very elegant study from the States comparing basic methadone maintenance treatment (with nothing much more, like the legally minimum extras of the social care), with a standard programme (with all the ancillary care) and then thirdly a deluxe treatment (like the Hilton equivalent). The drug is the same in all three of those and when they followed them up: just the drug on its own, 71 per cent of their people are still using drugs a year later; the standard treatment, only 53 per cent are still using; the deluxe treatment is hardly any better, 51 per cent. Going from just a methadone prescription to your broader social programme you are almost doubling the proportion who have managed to give up street drugs. The problem we have in this country is that, however much we might pretend otherwise, virtually everything we have in this country is what they had difficulty getting ethical approval for over there, because it is just the bare prescribing with virtually nothing added. We need to bring it up to that basic standard of care as a universal part of what is provided. It is not the drug bits, it is the broader social programme with quite active engagement of people in building those other aspects of their lives. The other issue about injectable prescribing where we have to be cautious about it is that unlike oral methadone maintenance, where there is a rock solid evidence base and because it was controversial fortunes have been ploughed into getting a good evidence base in the States so that it would be thrown out if it was no good, we have scarcely a single study of injectable maintenance. Indeed, it was only recently that, at the National Addiction Centre, we recently undertook and published the first ever controlled trial of oral versus injectable methadone. Why did it take us 40 years in this country to do it? Because there is no investment in the research side of the treatment process. Addiction research in this country still depended on us saying "To hell with it. We shall just try to do it in our spare time". That is a real problem for the future because decisions will be made in this sort of setting and five years from now we still will not know whether it was the right choice or not.

  598. Do other countries not have research we can draw on?
  (Professor Strang) They have not had injectable prescribing and we are at this moment being overtaken by the Dutch. It is really good news that we will have the results from the Dutch experiment. However, I hope collectively Government and society feel pretty ashamed of the fact that we could not be bothered to make that investment to find out for ourselves whether what we were doing was worthwhile. It shows a disregard for the subject as though we do not care about whether the treatment works.
  (Mr Nelles) I should like to make one important point about oral methadone and that is that it does tend to polarise the outcome of treatment more than prescribing heroin. The Mitcheson and Hartnoll paper in the 1970s represents a significant point at which practitioners decided to move away from managing addiction to trying to cure addiction because there was this evidence that if oral methadone only was provided, some people did better because they had an incentive to move forward, whereas a lot of people had harm because they dropped out of treatment because the oral methadone was not acceptable. I do think Professor Strang's point that the issue is about injectable prescribing is extremely important. There are some benefits to the prescription of methadone by injection. There are some problems but the big one is that people need to inject far less. Injectable methadone is usually one dose a day and one dose a day will hold people. Injectable heroin involves more injection episodes and even the best addicts with the best injection technique will eventually collapse their veins and have problems. It is at that sort of point that we are not very good at having interventions which will help people at that sort of stage.

Angela Watkinson

  599. I should like to ask what you perceive as the purpose or the aim of having a prescribing policy? Is it simply to maintain the habit of the addict for as long as they want on the dose they require, or is it to assume a reducing dose with the eventual aim of cure? Are drug addicts similar to alcoholics in that they have to make the decision before that sort of treatment could be successful? If they are not co-operating, would they then return to their habit when the course of treatment finished?
  (Dr Brewer) The word "cure" is one we rarely use in the addiction field. "Management" certainly and yes, some of our patients do oblige us eventually for a variety of reasons, sometimes to our surprise, by remaining free either completely of the use of the particular drug which caused them problems or they reduce it to a rate which does not really cause many problems. With alcoholics, if they are physically dependent on alcohol, in the sense that they are very uncomfortable if they do not have it, and they get the shakes in the morning and start seeing pink elephants, they can maintain themselves quite easily by just buying the stuff legally and there are many tens of thousands of alcoholics who do this. They are more obvious than the heroin addicts because they smell of alcohol, but otherwise their behaviour may be relatively straightforward, provided their blood alcohol level does not fall. With heroin, if you are not yet ready to contemplate giving it up, you either have to stick with your illegal source, which is the cause of so much crime and other problems, or you have to go for a maintenance prescription. I am sure John Strang will back me up, but the research shows that if you push people off a steady-state maintenance prescription before they are ready for it, it nearly always ends in tears; they usually go back to their drug of choice. Therefore the idea of maintaining people on a steady dose, sometimes for years, as a harm reduction or harm minimisation technique is quite acceptable. This is not controversial in most academic areas, but it goes against the grain at a kind of moral level for lots of people. I sometimes wonder whether one way of dealing with this is really to ask the addicts to pay for their methadone in whole or in part. It is not an expensive drug. My alcoholics pay for their alcohol when they are maintaining themselves, so why not methadone patients? Another analogy is that methadone treatment is just like nicotine treatment for smoking except that the current advice is that you should tail off the nicotine patches over a period of a few months, although there are quite a few studies which suggest you should stay on it for as long as you need. If you banned cigarettes, but said don't worry you can have all the nicotine patches you like, you would have a large riot on your hands because there are people who for various reasons have a habit of smoking. If they do not get their nicotine that way it is not the same. That is the analogy with injecting. It may seem a weird habit, but we cannot disinvent the syringe and some people, for a mixture of psychological, pharmacological even slightly sexual reasons, get so much out of the process of injection that they are just very, very reluctant to give it up. As long as they do it in private, I actually think it is less antisocial than smoking. At least they do not leave a ghastly trail of unpleasant smells behind them.

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