Examination of Witnesses (Questions 860
TUESDAY 18 DECEMBER 2001
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 onescriminality, social inclusion, exclusionwe
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.
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 disordersyou have the whole range
of personality disorders, anti-social personalities and other
personality disordersso a lot of those people need some
kind of psychiatric care.
Mr Prosser: Thank you very much.
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 alonethe dosage is an
important factorwhich 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.
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
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?
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.