Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 860 - 879)



Mr Prosser

  860. The reports we hear in this country about your various experiments tend to concentrate very much on the prescription of the drug rather than all of the other surrounding therapies you started to describe today, can you tell us a bit more about those complementary therapies? You mentioned fighting social exclusion and helping with employment matters, how far does that stretch? Does that stretch out to support with housing issues and accommodation?
  (Dr van Santen) Yes. We just discussed it while we were waiting in the corridor together, that the other interventions come out with empirical evidence and what shows is that the case management is the most effective approach, we think, meaning that every patient is assigned with an individual professional who makes a treatment plan and controls and supports its realisation. This treatment plan not only covers to the medical domain but extends itself to other fields of function like living, working, income and relationships. This is empirically the most effective and necessary thing, together with prescribing medications.

  861. You describe the prescription or medication almost as a means of allowing you to manage this person's life
  (Dr van Santen) Yes.

  862. They are totally complementary, you could not separate parts of the therapy and say, this is more effective, that is more effective, there is a holistic approach?
  (Professor Rehm) That is exactly one of accusations which the WHO has made in their evaluation of the Swiss trial. Basically the WHO said, we know your combination of it all is effective, we believe you, but you cannot say what contingents you need to be that effective, can you do without a programme to reduce debts for them. We do not know at this point, we have a holistic approach and the Dutch had a holistic approach, what is different for them is they had either methadone or heroin but the rest was the same in their experiment. In the end the differences between the methadone and the heroin is clearly the contribution in addition which heroin makes. If you give heroin without any of the other things I do not think you would not have success. It is not like you give a pharmacological agent and everything is better, you have to have complementary things.

  863. Although you both made the point that the results of the scientific study will not be completed until February I picked up the message, we all picked up the message, that you are both absolutely convinced of the value of your various schemes, you might expect that to be the case, but at the same time Professor Rehm was bit a bit more scientific with matters, giving us all of the reservations and caveats and almost said that all of these therapies if taken to the limits could be shown to have failed, or words to that effect, in that whatever case studies you make there will be failure and setbacks. Is it not the case even if you looked at the therapy you were providing and even if it stretched out to 12 months, 15 months or two years, or even much longer, you could still look back and say, in terms of harm reduction it has been a huge success for as long as that person is engaged, even if it never come to total abstinence. Is that the case with either of you?
  (Dr van Santen) You have a variety of treatment goals and also you are bringing the issue of quality of the treatment staff. That is where I am personally responsible to constantly improve the quality of the treatment. I think in the field of addiction treatment there is much to improve, many scientific insights are simply not used, also in England.
  (Professor Rehm) Again, it depends how you look on how full or how empty a glass is. If you say, "We judge a programme by the outcome of total abstinence of substances," the Swiss programme is a failure because we have more than 90 per cent after six years of experience who still are not totally abstinent. If you say this programme has reduced criminality, has increased social integration, has increased the health status of those people, both mental and physical health, then you can say it is a complete success. We have to report all of those things to give you a full recognition of the different things and, of course, once you define the end form for a clinical trial, you can play around with those. If I would do something against such a trial, I would define an end point as total abstinence and of course, yes, they fail. If I want to be very favourable I would point to criminal behaviour or, even more absurd, I would say that there has been a reduction of illegal heroin. Clearly if you give them heroin for free they would use it so that is a trivial end point. In a lot of non-trivial end points, especially the social ones—criminality, social inclusion, exclusion—we have shown that it is a success, it is good for society, and it is tolerated by others in society.

  Mr Prosser: Can I just turn to some of the practical matters of administering heroin and other drugs through prescription. In this country we have the ability to prescribe but it is nearly always done by general practitioners who have got other practices in place. The licences are provided by the Home Office and they are very restrictive, there are only about 100 licences available and a couple of hundred addicts benefiting or being engaged—

  Chairman: Mr Prosser, can I stop you there. I think you are raiding questions further down the page.

  Mr Prosser: I was going to ask about the clinical approach and whether their systems use fully qualified doctors or, on the indication we had, that you inject yourself in the presence of a nurse.

  Chairman: I am afraid it does.

Mr Prosser

  864. Then my last question, if I may. If the British Government were persuaded to set up a pilot course, a trial course similar to your models, on the basis of your experience so far, are there any specific areas of advice you would give them, where perhaps you have seen errors or you can look at enhancements that would make the system more effective?
  (Dr van Santen) Juergen has already described what is a necessary line of research and I think we should share our problems on a larger scale and new research should be an adjunct to what has already gone. This happened between Switzerland, Holland and Germany and it would be a good suggestion to do the same if Great Britain is included.
  (Professor Rehm) I think what you could say at this point is that it is probably wise to have treatment centres delivered where you have not only medical doctors but also psycho-social care in the wider sense. That would be my résumé. That is not a clinical way to study those things. It is just based on the experiences of Holland and Switzerland.
  (Dr van Santen) And some integration with psychiatry.
  (Professor Rehm) Because the comorbidity in any study you do, no matter where in the world, there is a comorbidity of at least 40 per cent at a given time; drug addicts are depressive they might have anxiety disorders—you have the whole range of personality disorders, anti-social personalities and other personality disorders—so a lot of those people need some kind of psychiatric care.

  Mr Prosser: Thank you very much.

Angela Watkinson

  865. Could I ask you about polydrug users. Are they suitable for the courses of treatment that you give, and if they do embark on a course of either diamorphine or heroin, would you know if they were supplementing with other drugs from another source and would that negate the treatment they are receiving? Would they have to conclude the course? How do you deal with that?
  (Dr van Santen) For polydrug abuse, opiates are included and opiates are also the red line in this whole area of consumed drugs. So the professional standard is to treat opiate addiction first and aim your treatment goal at stabilising illegal heroin consumption, and further aim at abstinence before illegal heroin consumption and then look at what happens with the other drugs. The other drugs are considered as being not yet in remission, so you have an active drug consuming patient who does not reach these kinds of treatment goals. So the lowest treatment goal is harm reduction where you are satisfied on that and then come secondary preventative measures. If you go one step higher you go to stabilisation and other drugs are considered, continued use, and the art is to keep those patients in your programme and go to the plan for further improvement to get out of it the capacities of the patient.

  866. Could you compare the relative advantages or chances of success of methadone and diamorphine?
  (Dr van Santen) The relative advantages? I think we have a success rate with methadone alone—the dosage is an important factor—which after two years of treatment exceeds 60 per cent of patients on opiate consumption, so that is a good success. The experience we have now with heroin is that it is a simple thing, that you simply supply the desired heroin and then you can have 100 per cent success rate on the consumption of illegal opiates.
  (Professor Rehm) And scientifically we can measure legal opiates in the blood. That means we are not only basing statements like this on self report, there is a substance which can separate illicitly consumed heroin from the pure heroin we are giving, so it is not something where we are in doubt. We could give you the exact percentage of people who also consume illegal opiates, and we test for that.

  867. People on treatment cannot conceal additional drug consumption from you? You know if they are doing it?
  (Professor Rehm) No, it is not possible.

Mr Cameron

  868. Two practical questions really. Firstly, is it best when doing your heroin diamorphine prescribing that it is done in a doctors' setting or at a specific clinic? Given what you said about the need for other people at the same time, do you favour general doctors' surgeries or specific clinics?
  (Dr van Santen) Generally speaking, I am not so much in favour of specialised drug clinics but for the dispensing of medication you need some specialisation because in severe addiction self-control over medication is low, so what is necessary is strict control of the dispensing and in the studies we do now methadone can be prescribed at home by arrangement, but heroin has to be consumed on the spot and for that function you need a specialised service, but in general I am much more in favour of integrating addiction care in the normal echelons of health care, meaning within primary health care or in psychiatry.

  869. In this country the general practitioner offers a practice of four or five general practice doctors who are generalists so if you had a heroin prescription, would it be them who would be doing it?
  (Dr van Santen) For the prescription responsi- bility, okay, we also have a model of shared care where general practitioners participate in prescribing methadone. Heroin is still an experiment and perhaps in the future we can make it like that, but for the dispensing you need a special service, you need a state-owned opium kit, I think.
  (Professor Rehm) There are also three or four practical questions. You cannot pay a psychiatrist's salary to dispense three times a day. It is just too much to oversee things. And also, as we said, especially at the beginning, we need to look at housing, debt, social integration, trying to get things running again in life, which are not usually done by doctors. We are favouring a model where in the beginning you have a centre which is composed of multi-disciplines and then once they are very stable and it runs we would go to GP practices.
  (Dr van Santen) Medication compliance is a professional issue for nurses. They are good at it and you need them to dispense.

  870. Thank you, that is a very clear answer. What role do you see for residential centres for treating heroin addicts? Is it only necessary for abstinence treatment or do you think there are cases where people on prescription heroin should be in a residential setting?
  (Dr van Santen) I do not see the necessity for a residential setting. If it is necessary to detoxify a patient then a very short hospitalisation perhaps is necessary but not on a long-term basis, no. It is a patient treatment modality.
  (Professor Rehm) I am completely in agreement. I see residential care only necessary if side effects, meaning comorbidity, is requiring it, then they should get residential like anybody else. Under certain indications of sevese psychiatric disease you have to go to residential, but those would be a very, very minor percentage overall.

  871. Just one other thing, in the long term what percentage of heroin users do you think you could get on to your form of treatment?
  (Dr van Santen) Heroin addicts?

  872. What percentage of heroin addicts can you see in the long term, if everything works as well as you think it will, do you think could be reached by your sort of service?
  (Dr van Santen) I think we reach in the range of 70 per cent. I think we can expand that to 80 or 85 but the professional issue is whether the addiction is still reversible, you should not start it.

  873. You should not?
  (Dr van Santen) I do not think a heroin addict with a short career would be prescribed heroin from me; it is against my professional standards because I am not so convinced that it is not promoting or making problems worse.

  874. Thank you very much.
  (Professor Rehm) I would just say about the same numbers. If you look at the whole amount of people who have heroin addiction in Switzerland, I think we will continue to reach around 50 or 60 per cent by methadone. The very new users and those with very good social indicators can be reached by dia morphine and abstinence treatment. Some of the old people who have a career in substitution will also go into methadone, and heroin at the end will be around 15 to 20 per cent, and that will give us an overall reach of 85 per cent of all the addicts being in treatment. I think there will always be some ten per cent who for whatever reason we will not reach, no matter what is the continuum of treatment. The same is true of diabetes, it is much more true of diabetes. So overall we can increase it by another ten per cent.
  (Dr van Santen) The indicator for not coming into treatment may be stigmatisation and I think, therefore, you need to destigmatise the problem by doing things like being treated by your general practitioner.


  875. Gentlemen, in your experience do coercive treatments work? If a court releases someone on condition they undergo a course of treatment, does that work in your experience?
  (Dr van Santen) It is very difficult to organise, it is a practical matter. Coercive treatment from the nature of addiction theoretically should be effective because, in essence, it is an obsessive disorder so coercion by well-organised external control could help. So we are looking for co-operation with the probation services and things like that, but it is very difficult to organise.

  876. Does it happen in Holland?
  (Dr van Santen) Yes.

  877. In Switzerland?
  (Professor Rehm) I believe that a lot of addiction treatment is coercive. Some is legally coercive, other treatment is coercive by the employer saying "you have to get rid of this alcohol problem or else you are out of your job." Other forms of coercion will happen in the family. If we just limit ourselves to the legally coercive treatments, the majority of studies we have done have shown some success.

  878. So it can be successful?
  (Professor Rehm) It can be successful overall and there is empirical evidence that it has been successful and the question is only under what circumstances and how organised.

  Chairman: Thank you. Mr Russell?

Bob Russell

  879. Professor Rehm, earlier on you drew reference to the violence which is associated with the drugs world in a general sense and you said that non-violence is the strongest rule when dealing with drug addicts who are trying to come off drugs. How do you ensure the security of staff administering the drugs treatment with the violence that is associated with it?
  (Professor Rehm) As I said, overall we have had very few incidents during the last six years. Heroin is not usually a very violent drug. There is some violence but so far we have had no major incidents with violence. People who have been expelled mainly have been expelled for verbal aggression or mingling, nobody had to go to the hospital afterwards.

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