Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 600 - 619)



  600. So an analysis of that is that you cannot impose a reducing dose unless the person wishes.
  (Dr Brewer) It is unwise. You can encourage, do a little gentle arm twisting and you can also offer people various ways of withdrawing. A lot of the people I have on maintenance are actually quite keen at some stage to withdraw, but it is quite difficult. There is a number of techniques which are increasingly used in various countries which make it virtually certain that once you have started a detoxification you will complete it and in somewhat less discomfort than is usual with conventional methods. It is a pity that the standard response to an 18, 19, 20-year-old who has started to use heroin is not usually withdrawal, even though quite a few of them would quite like to be withdrawn before they get too deeply into it. The waiting lists for withdrawal are truly a national disgrace. They are much worse even than the waiting lists for methadone. People wait months or years to get in and that is really bad.
  (Professor Strang) This issue about coercion. I would not want you to go away thinking that there was not benefit to coercion. It all depends on what you mean by it. Some degree of nudging or coaxing or pointing out to people the implications of their behaviour is a crucial part. It is what we want GPs to do with their patients about their smoking and their drinking and similarly their injecting. All of us, I am sure, virtually everybody we are seeing, is in treatment under coercion. It may be family pressure, it may be the courts, but it would be a mistake to disregard the healthy side of this pressure. Your question about the objectives, I think they have to be health gains. The only legitimate justification for treatment is that the patient benefits from the treatment. There are then spin-off benefits which are a huge bargain for the rest of us. There are public health gains of less injecting, less HIV, less hepatitis C, there are criminal justice benefits and they are huge. But the real legitimacy of the treatment is that the patients themselves derive benefit. They achieve stability, they get physically better, they are less likely to overdose. Once you are in a methadone programme, your likelihood of dying of an overdose is massively reduced. Incidentally, on the subject of overdose, we do not pay attention to overdose properly. Dying of overdoses clearly gets missed by what we have addressed as key issues. It has become a big issue in the last year.

  601. Presumably you have to have the co-operation of the addict, otherwise they would go and supplement their supply illegally.
  (Professor Strang) Yes, but that is what you are dealing with. Part of what you are working with is that coercion. There is one aspect about overdose which I hope you might pick up which is a slightly different one. There is a controversy at the moment about how acceptable it is to engage addicts, users, their family and the wider public in teaching resuscitation, training to resuscitate each other. And also a key issue about whether naloxone, which is an opiate "antidote" should be available. We have recently started introducing it in a few places in this country but there are also concerns being voiced that this is condoning the behaviour. I would have thought it would be very legitimate for you to look at the rights and wrongs of it and I should be delighted if you formed a view on it. The argument is that it is a complete reversal; rather like Dr Brewer's naltrexone, this is a rapid, short acting, antidote. It is what gets given in the casualty department or in the ambulance. The proposal has been to go one step further: why should the parent or the partner or the user themselves not have that antidote? Personally I think the arguments are overwhelming. I cannot see a logic for not doing so. But it has to be said that opinion is divided and other people think this is condoning the behaviour and sending a mixed message. It probably is but I believe that if it is saving a life, then I can cope with the odd mixed message.
  (Mr Nelles) I have to say that in my experience coercion is rarely successful in helping drug users to abandon their drug use. The factors which lead people to decide to stop are many and varied. If you have a system—and indeed we had a system in this country in the late 1970s and early 1980s—where you really abandon providing maintenance treatment and you go over to short detox because you feel it is important that people come off the drugs, it is of course important that we give people every assistance to come off when they want to, but we have to recognise that, particularly with opiate use, this is something which is physiologically reinforced by the chemistry of the brain and the way that the brain changes when someone takes opiates for a long period of time. Opiates are very benign drugs on the body but they do cause a significant change in brain chemistry, in the endorphin system. In some people this is very hard to return to normal and we are getting more evidence now of what we mean when we say that. We now have the ability to look inside some of these very delicate systems in the brain. We have to understand that some people cannot exercise a choice over whether or not they give up opiates; it is not something they can do. What they can do is live and manage that dependency. We should recognise that this is perhaps our greatest obligation to drug users: to help them stay alive.


  602. Given that we think coercion does not really work, would you say the Drug Abstinence Order which the courts now have the power to impose is not a good idea?
  (Mr Nelles) Drug treatment orders are possibly a good idea. To have abstinence as the end goal is probably mistaken.

  (Dr Brewer) There is one situation where coercion is very valuable and that is when you are treating someone in the context of a probation order in a judicial setting. As you will gather, I do not particularly mind whether people cease their anti-social behaviour by a good methadone programme or a good naltrexone programme, but if people are having adequate doses of oral methadone, perhaps even of injectable methadone and they still are offending in order to get heroin, you have to say to them that clearly they have to try something else, at least unless heroin prescribing were available, which might in that case be quite useful. If it is not available and if people are still offending, you cannot suddenly change the law and the way it is enforced in order to suit them. A probation order is an ideal setting because quite a few people are coming into a probation order having been in prison and if they are lucky having been detoxified in prison. It is an ideal situation for using naltrexone as a condition of probation. During the Government's much trumpeted trial of drug treatment and testing orders, which most of us in the business think were actually not very much of a success, not because it could not succeed, but because it was badly planned, badly executed, the total number of people treated with naltrexone was one. That seems to me to be a terrible lost opportunity. We know from good controlled studies that if you take it as a condition of probation, it massively reduces the amount of heroin people use and reduces the amount of time they need to spend in prison. That seems to be an enormous goal and well worth having.

Bridget Prentice

  603. To some extent some of you have answered some of the points I wanted to raise. Mr Nelles said two things in his last comment which I should like to take up again, when he talked about taking addicts off when they want. What happens if the addicts do not want? You also said that we have an obligation to drug users. Why? Why do we have an obligation to them?
  (Mr Nelles) Because they are human beings, they are our brothers, they are our sisters, they are our family, they are part of the fabric of our nation. They may have made a choice which was mistaken and they will pay for that choice in many cases, but I certainly do not think that we should abandon our commitment to these people as human beings and as people who need the best treatment and the best interventions we can give them.

  604. Is it not an argument that if they have made that choice, they should be allowed to get on with it?
  (Mr Nelles) If everyone were punished for the choices they make we would have a very, very different world. I am sorry, human nature being what it is . . . My own case would be illustrative here. I started using opiates when I was studying to be a nurse. I was someone who it could be said certainly had an intellectual understanding of the problems which would come from continuing to use these substances. But because the effects of the drugs were pleasurable and because I managed very well because I was able to get clean, sterile drugs, it was not really until I came back to Britain and found that the treatment system refused to prescribe injectable drugs that I really started to run into problems. I did very well on oral methadone eventually, but I sustained a lot of harm in the meantime and that is why I do feel that injectable prescribing is very important. To go back to your other point, I can understand the concern that people feel, the general public feel, at the idea of drug users dying, at the idea that young peoples' lives are taking different directions and they do not realise their potential, but I feel what we need is a compassionate and caring approach which encourages people to make contact with treatment providers and does not blame them overly—we should not applaud it but we should not blame them overly—for a mistake which people made often when they were younger and for which they pay for many years.

  605. I have no disagreement with what you are saying personally. On the other hand, a lot of the evidence we have been given would suggest that a lot of these drugs, as Nick Davies of The Guardian said, harm neither body nor mind.
  (Mr Nelles) I would not agree with that. Heroin does harm people in the sense that they fail to reach their potential. We should not encourage people to use it but we have to be realistic and accept that at this point in our culture, heroin is very available; we do not seem to be able to do anything to stop that. I have seen so many occasions when we have been told we are going to get harder on this, we are going to deal with it in a more robust way and I do not see things changing. What I do see changing is the situation in countries like the Netherlands and Switzerland where they have perhaps been more canny and started to realise that by helping addicts to manage their dependency, they then actually get a lot of benefits back for society in reduced crime, reduced acquisitive crime. These sorts of benefits would have their impact on public opinion in this country. If you ask people in Holland what they think of drug users, the public opinion is much more ameliorated than it is in this country because in this country there are no good facilities, therefore many heroin users are a problem.

  606. I want to go back to the business of the GPs. You gave me the example of Holland and Switzerland and that drug management actually makes people generally more tolerant and co-operative with drug users. I have to say quite frankly I am appalled by what you tell us about GPs. I suspect that this afternoon the Chancellor of the Exchequer is going to pour yet more money into the National Health Service and I am beginning to wonder what the point is if the GPs are simply refusing to treat people. Can you give me one other example of where GPs refuse to treat a class of people?
  (Dr Brewer) Abortion, at one time, not now.
  (Lord Adebowale) Poor people.
  (Professor Strang) One of our papers was entitled Discrimination on Grounds of Diagnosis. That is essentially what you have.
  (Lord Adebowale) Homeless people, poor people, to go back to what I was saying about the 88 worst estates and access to GPs. Services are very poor in those areas.

  607. You are making the case for GPs even worse than I first thought.
  (Lord Adebowale) I am a bit concerned and I hope that we move onto other areas of substance misuse because the focus on injecting heroin can give a distorted picture Certainly the use of crack cocaine is something we should be as concerned about and the use of stimulants simply because the use of those drugs is attracting members of the community who are particularly young, particularly members from minority ethnic communities. It is my view that we have an opportunity to put strategy in place to deal with stimulant misuse if we are brave enough, which is not to say we should ignore or indeed—


  608. Yes, by all means move onto these other areas briefly, bearing in mind that we have had a lot of witnesses and many of them have dealt with these areas already. If you want to touch on them we should be very grateful.
  (Lord Adebowale) I feel a lot has gone on and may I just comment quickly on the answer to your question. I am a pragmatist so perhaps I will give a pragmatic answer to "Why bother?". First of all, four million people take illegal drugs in this country, far more imbibe alcohol, which is a drug, to the point where it is a danger to themselves and others. It would seem to me that many of those people pay taxes and we should therefore provide a service for that reason if for no other. You asked four questions.

  609. You wanted to talk about crack cocaine.
  (Lord Adebowale) At Turning Point what we have seen is a gradual increase in the numbers of people we see who have crack cocaine problems. Five years ago one per cent of the users in the southern region were crack cocaine users; it is now 12 per cent. We are seeing a rapid increase. There does not appear to be a huge body of evidence about what we do with crack cocaine users in this country. There is no methadone prescription, there is nothing. The debate about prescribing and injecting heroin seems to me to revolve around a moral issue when the practical solutions are staring us in the face. Fine, we can have an interesting debate about that, but it seems to me that is getting into the area of angels and needles. The fact of the matter is that there is a solution. Crack cocaine however is a far more problematic issue because there is no ready off-the-shelf solution. We are still in the area of experimentation. It is a highly addictive drug and we are now seeing the assumptions about crack cocaine being smashed on a daily basis, that is the assumptions that it is an inner city drug, generally used by black people. We are now seeing professionals starting to use crack cocaine, it is increasing in use and we do not appear to have an approach other than a criminal justice one. It seems to me that the use of crack cocaine is not known to be as widely used as heroin although there is some evidence that crack cocaine users also use heroin.

  610. Do you have a suggestion?
  (Lord Adebowale) Firstly, there is not enough treatment—funnily enough I come back to that point again—for crack cocaine and stimulant users. Secondly, we have not started fully looking at the research base in terms of what works for crack cocaine users. Enough work is not being done on poly drug misuse. One of the issues which was raised earlier about motivation and accessing services for heroin users assumes that is all they are using. Many heroin users are also using alcohol and using stimulants—

  611. Including crack cocaine.
  (Lord Adebowale) Exactly, including crack cocaine. Turning Point has been using some alternative interventions, acupuncture and massage, to try to attract crack misusers into our services and that appears to be having some effect. I suppose what I am calling for is a rapid increase in the attention given to crack and research into what works and the rolling out of what works and a national crack strategy. That is going to be the next problem.

  612. Anybody got any suggestions for this national crack strategy beyond the ones we have just heard?
  (Mr Nelles) It is very important that there are residential rehabilitation places which can take people for fairly short periods of time. In my experience crack cocaine is something one recovers from reasonably quickly if one can abstain from it; when I say "reasonably quickly" I mean the physical addiction is not as powerful a problem to detoxify from as opiates. It is very addictive though and people should be gently separated from the drug in places which are very caring, very quiet. The idea of respite care is important here. The idea of giving people a break from cocaine use, being able to eat well, sleep, get all the things we know will build people back up.

  613. That is no good if they go back to the environment from which they came, is it? As Dr Brewer said earlier, somebody knocks on the door on the day they return, do they not?
  (Mr Nelles) This is a real problem. I am not sure I think dealers are quite so hard-nosed. I have met a great many dealers in my time and whilst many of them want to sell their product, to say that they have no concerns for their clients is perhaps an over-statement. That is not to say they are the kindest people either. I have seen two bids put in for residential respite houses for crack, both of which do not seem to have got anywhere. That is a great shame because that is exactly the sort of thing which should be piloted. I sit on the board of City Roads, a well-known London agency and we certainly want to take that forward. It is very hard to find the money and the facilities to do it.
  (Dr Brewer) There are several companies working on a kind of naltrexone for cocaine. In principle you can now make a blocking agent, an anti-body, an antidote to almost any drug of abuse. This is one of the benefits of the new genetics. We hope that within a few years we shall actually have some drugs of this kind and that there is a reasonable chance they can be tailor-made for any drug of abuse with the possible exception of alcohol, simply because alcohol is such a weak drug you have to take it in tens of grams. I do think one thing the Government can do is push a lot more money into basic research of the kind David Nutt does. We punch well below our weight in research in this area. Generally in medicine Britain punches above its weight, but in this field of fundamental research into brain processes, the amount spent is probably rather small.
  (Professor Strang) With regard to cocaine, the most honest answer we can give you is that there is nothing very special we can tell you and that there are no very special treatments. It is not that it does not matter, but I feel a bit like a cancer specialist coming to you saying we can do great things around better quality treatment for breast cancer and you asking why we cannot do the same for lung cancer. The plain answer is that it is just much worse news to have lung cancer. The message I hope we get across to you is that there are some types of addiction problems where it can make a massive difference with very specific types of treatments and there are others where we are reliant on general principles such as you outlined, like getting somebody to change the environment they are in, what might be known as "doing a geographical" and those things. They are important, but they are not so much the subject of debate.

  614. One of the arguments made by those who argue for a liberalisation of the heroin regime is that that would then free criminal justice resources to focus on the most damaging drugs for which there are no medical solutions, to wit crack.
  (Professor Strang) I should have thought it was irrelevant either way. People are arguing that from both ends of the divide. I suspect it would be completely neutral.
  (Lord Adebowale) You mentioned the environment in which people come from. It is important to emphasise that it is connected to the issue of resources. We have a £1 billion neighbourhood renewal programme currently in place. It is supposed to focus on the 88 worst estates in which you will find the whole range of drug problems. If you look at that strategy, and I bear some responsibility for some pages of that, those bits which refer to young people, you will find little reference to the spend on drug treatment. I think it would be scandalous for us to go off and do this exercise without emphasising the need for those neighbourhood renewal programmes to provide treatment for those people who most need it in the areas where they are most needed. People are far wiser, certain drug misusers are far wiser, than we have given them credit and people are perfectly capable of staying away from the dealer if they are given access to the treatment. I do not go along with Professor Strang's last statement simply because the amount of time wasted in debating the issue of injecting or not injecting and the paraphernalia around that debate takes our minds away from what we should be focusing on, which are areas like crack misuse and cocaine misuse which we know very little about and which tend to affect those clients, young, minority ethnic young people, the population of which is going to soar over the next 20 years. We need to be paying much more attention to that area.

Mr Prosser

  615. On the theme of the thousand flowers blooming and all the various treatments for various people's needs, is it not right that even taking into account the pyramid effect for injectable or prescribed drugs and the various types of residential and abstention treatments, we are really getting down to two basic principles: abstention or prescription? I think that is almost self-evident. If that is the case, can you give us a feel, I have no idea at all, even in your own personal experiences, how that breaks down, 50 per cent would require one or something else?
  (Mr Nelles) There is no contradiction in having both approaches working together, but it is difficult to do them in the same agency or in the same department. It is very important that we have harm reduction initiatives and prescribing approaches for people who are not able to give up and we have rehabilitation and detoxification approaches for people who do want to give up. That is incredibly important.

  616. On the issue of residential care, Dr Brewer told us about 80 per cent are re-offending and coming back, re-using and retaining a problem. I have a private centre in my constituency, Northbourne, and they assure me that their figures are the opposite and that 80 per cent do not go back to drugs.
  (Mr Nelles) I have to say that the NTORS study evidence is really quite strong on this, that 51 per cent of people are drug free after a significant number of years after attending residential rehab. It is important to understand that residential rehab is very important. It changed my life. Without a doubt, by going into residential rehab at the time I did, I learnt essential principles of self-discipline which kept me alive and that is why it is very valuable. I do not think we can say that it works for everybody and the best places do not seem to get a result of much more than about 55 to 60 per cent, in fact I think that is a slight exaggeration.
  (Lord Adebowale) Two points. The first is that Turning Point does not subscribe to abstention or management; we provide both. It is true that it is horses for course. One person who might start with abstention in mind might end up managing and vice-versa. You have to provide the appropriate opportunities for the individual. I understood, and perhaps Professor Strang will tell me I am wrong here, but there is something called the Prochaska and di Clemente's, a cycle of recovery, which is, and I believe this to be true, that people generally do not give up and walk away and never come back. Some do, but generally people relapse; that is what they do. They do on alcohol and they do on most other drugs. Part of the problem we have—and I have talked to many civil servants and Ministers—is that they do not apply the same rules to everyone else which are apparent in their own lives. The expectation that someone who has a life-long addiction to a very addictive drug, be it cigarettes or alcohol or any of the others, has three months in a residential facility and then they just stop can be unrealistic. What you have to do is provide the basis on which we understand that relapse is part of the recovery process for some people and that they will relapse and that you require a treatment regime which enables them to come back when they relapse and that they are held by that treatment regime and that they do not fail. Having invested the time and the money to get them to the point where they are even at a pre-contemplative stage or contemplating recovery, or indeed having experienced recovery, to then abandon them because they relapse, seems to me to be a complete waste. That is part of the problem in talking about 80 per cent dropping out. They might do, but many come back.
  (Mr Nelles) And many will have benefits from the period of time they have spent in residential rehabilitation. That is important to bear in mind.
  (Professor Strang) NTORS has been mentioned to you and I am now concerned that you have not even come across their reports. For example, I hope you have had copies of the NTORS publications because it is one of the very few bits of substantial research done in this country and it addresses not all but quite a number of the issues you have raised. I am also delighted that such a setting gives you such educational opportunities as Prochaska di Clemente's, cycle of recovery. What Victor has said is an excellent summary. All sorts of things in health care give a health gain and you come back again and that goes for chronic bronchitis, athletes' foot, anything you can think of. Looking at substantial health gain while you are doing it, you are aware that there is a risk it might relapse but if so you want then to treat it faster. There is nothing very special about the addiction field from that point of view.

  617. If we were to find ourselves making recommendations to government to decriminalise or legalise drug use and provide prescriptions, could Dr Brewer give us some advice, three or four points on the stages we should recommend to move from where we are now to where you would like us to arrive, the return to Victorian values? How would you do that?
  (Dr Brewer) First of all I should get you to read Professor Berridge. This is written by our leading historian of legislation and opiate use, Opium and the People by Virginia Berridge. Some of the final chapters give a very good explanation—it would be quite funny were it not so tragic—of the arguments which went on in 1916 and how really America inflicted a sort of pharmacological colonialism on the rest of the world. That is what happened. Nobody else was terribly concerned about banning opiates. It was an American initiative. Perhaps there are some resonances for today. I should start by reading that and realise that actually when you could buy the stuff fairly freely in a chemist's shop the British Empire did not grind to a halt. I would make one change, which is that I suspect that quite a lot of the Victorian opiate users were not teenagers and adolescents; the teens perhaps started earlier and ended earlier in those days. You have to do something in the way of testing in schools to identify those people still under some sort of tutelage and supervision who are starting to use drugs early, starting with nicotine. Early smoking is one of the best predictors of later disaster. It is very rare for me to come across a heroin addict who does not smoke and never has smoked. You have to monitor what goes on in schools and perhaps introduce some sort of sanctions while you have them up to the age of 16 in a situation where you can actually do a bit of insisting. After that I would experiment with the less controversial drugs, of which cannabis obviously heads the list. Ecstasy, in terms of its abilities to cause serious harm and more importantly serious anti-social behaviour, is really quite small beer. We have to return to the idea that people have a right to make mistakes, provided those mistakes do not impinge unduly on the rest of society. We do not dispute the right of people to drink alcohol and to get drunk on alcohol, even though that regularly causes catastrophic damage for families and individuals and for society. I really cannot for the life of me see the difference in principle between getting intoxicated on alcohol, getting intoxicated on cocaine and getting intoxicated on heroin except that heroin addicts, if they have too much, generally just fall asleep somewhere quietly and do not disturb. I would look very seriously at the history of this. After all it started across the road in Parliament presumably. It seems to have been passed on the nod like other important legislation. According to Professor Berridge, at one important stage of the debate there was barely a quorum in the House. We got into this mess unthinkingly and here we still are 80 years later.
  (Professor Strang) That is a pretty wide-ranging response. I would come at it from the other end. I would look at where we are now and whether a change in one direction or another direction would be a change for the better or worse. Personally I think you should first charge us or charge whoever else you can charge, charge the Government, with making sure there is universal access to good quality oral methadone maintenance. Here is a treatment on which we now have a worldwide evidence base. Within our NHS it is scandalous that there is not prompt access to bog standard good quality oral methadone maintenance treatment. My next objective would then be to ensure that we had some extra treatments for more unusual cases or people who do not benefit from the treatment at the first level or layer. That is where I bring my injectables in as the next layer up. You would need to work out what it is that warrants your need to move up to the next level of treatment. It would not be very difficult to work it out, and you would need a working percentage, maybe ten per cent of the people in treatment would need to go up to that next level of injectables. With that are security implications. How would you do that in a way which did not just leak out onto the streets? Some of them are commonsense measures like returning ampoules which you have heard about today.
  (Mr Nelles) Not giving people too large a supply at one time.
  (Professor Strang) We should look very carefully at—both the Swiss and the Dutch have set them up—supervised injecting rooms as one measure, not as a universal necessary requirement but as part of that. I would see those as tinkering with what we have to make what we have work better.

  618. What would you say to those who say legalise heroin, make it available.
  (Professor Strang) I would get them to remind me how many people it is, what percentage of this country currently who have gone down the pathway of ever using heroin: something like one per cent, probably less.

  619. A lot less than that.
  (Professor Strang) A pretty small proportion. There is a mistaken belief that the rest of the general public just would not. If you want the most extreme other end, that if circumstances get bad or you feel they are bad what proportion of honourable and upright citizens might get caught up in a heroin addiction problem, I realise it is a very different situation, but clean-cut American kids were sent off to Vietnam and over 40 per cent of them got involved in heroin addiction out there.

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