Select Committee on Home Affairs Third Report


Harm to users

151.  Heroin is highly addictive and its illegality means that the addiction is difficult to satisfy safely. Numerous medical experts have told us that, if used in a sanitary and controlled way, heroin itself does not cause health problems—apart from a high level of dependence. Rosemary Jenkins from the Department of Health told us that "clean heroin is not in itself particularly dangerous except of course for the area we all know about which is that it is highly addictive and produces dependence".[151]

152.  Professor Nutt told us that, if managed properly, heroin use need not prevent an individual from having a relatively normal life:

    "Clean heroin clearly if used appropriately is safe...we have seen patients who have been using heroin for 20 or 30 years on a three to four times a day basis just to keep their dependence at bay. Some of these are very successful individuals. As long as you do not get the secondary complications of heroin like hepatitis or AIDS, then heroin is quite safe provided you do not overdose on it. You do get dependent on it, so it does affect the mind and there is no doubt that these people are heavily dependent but they are not physically harmed".[152]

153.  It is this dependence, frustrated by the illegality—and therefore inaccessibility—of the substance, which causes users to engage in a cycle of high risk and damaging behaviour in order to obtain the heroin on which they depend. The main harm to health associated with use of illegal heroin are overdose and risks associated with unsanitary using techniques, particularly injecting. These are both risks which can be managed. The reason people die of heroin overdose is largely because of the body's loss of tolerance. A user builds up tolerance to heroin very quickly, and correspondingly increases the dose needed to achieve a "high". If for some reason—entering into custody, abstinence treatment, or being unable to find a "fix" for some time—the individual does not have heroin for a short while, their tolerance is completely lost. If they then gain access to heroin and take the dose they were on before losing tolerance, they overdose. If an addict is to live safely, understanding and managing the correct dose of the drug is of utmost importance. Risky using techniques are usually sharing needles and using dirty equipment. This spreads blood borne viruses such as AIDS, Hepatitis B and C.

154.  Because users cannot easily purchase clean heroin and safe equipment, they will use whatever they can find: often dirty or shared equipment. Ignorance of how tolerance to the drug ebbs and flows will lead people to make fatal mistakes about safe dosages. Because their habit is illegal, they cannot—or do not—readily come forward for advice from health professionals. The Report of the Advisory Council on the Misuse of Drugs stated in its report Reducing Drug Related Deaths, "what stands out with total clarity is that year after year it is heroin misuse which is making the major contribution to drug-related deaths".[153]

155.  Deaths have also resulted from impurities present in street heroin, although we were told that this was a minor problem in comparison to that of overdose.[154] The presence of impurities also means that users cannot always know how much heroin they are taking, which may lead users to take a dangerous dose in error.


156.  Existing users must be able to have access to treatment. In the case of opiate use a treatment model exists which has been proven to work and to deliver not only health improvements, but also lifestyle improvements, reductions in criminality and an economic saving to society: methadone programmes backed up with help with housing, employment and other lifestyle problems.[155]

157.  However, we have heard widespread disappointment with treatment for heroin users. Although methadone is the standard treatment for opiate users, and has a strong evidence base for its effectiveness, we have heard that the number of available places for patients is much too small: "methadone treatment is...not universally available in this country, so we do not...have the standard intervention for long-term opiate drug use available to everybody in this country".[156]

158.  Professor Strang, Professor of Addictions and Director of the National Addiction Centre told us:

    "the Government...are missing a golden opportunity to harvest huge benefits. With some types of treatment for some types of drug problems you have treatments which more than pay for themselves for each day the person is in treatment. This is the equivalent of the Post Office or the Bank of England releasing bonds which you can buy for one pound each and cash them in the afternoon for a fiver. I have to say if that happened I would go out and I would buy, buy, buy. It is beyond understanding why that approach is not adopted with those bits of treatment where there is a rock solid evidence base that the benefit more than pays for the costs".[157]

159.  We also heard that methadone was not always given out in the correct doseages. Dr Colin Brewer told us: "The average methadone dose in this somewhere round about 50mg to 60mg whereas the national guidelines say that somewhere between 60mg and 120mg and an average probably nearer 90mg to 100mg is what we should be aiming at".[158]

160.  We recommend that the Government substantially increases the funding for treatment for heroin addicts and ensure that methadone treatments and complementary therapies are universally available to those who need them. We recommend that the guidance on the correct dosage of methadone to be used is strengthened.

161.  There are, however, many users for whom methadone does not work well, and there cannot be the expectation that one solution will work for everyone. As Dr Brewer suggested:

    "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".[159]

162.  We received evidence of effective work being done by residential centres for drug users. Mr Bill Nelles, General Secretary of the Methadone Alliance and former drug user, told us:

    "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".[160]

163.  This is a particularly important treatment for addicts living in a community where heroin use is common. Mrs Tina Williams of Parents and Addicts against Narcotics in the Community, told us "a lot of [addicts] cannot get clean in the community, there is too much [drug use] around them, they can see it all the time".[161] Lord Adebowale, Chief Executive of Turning Point, told us that residential facilities were particularly important for homeless people, to create some stability in their lives before treatment could start:

    "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".[162]

164.  We recommend that the broadest possible range of treatments is made available to opiate users, and that all treatments and therapies should have abstinence as their goal.

165.  It should be recognised, too, that there is no point in weaning people off their habit if, at the end of their treatment, they are returned to the environment that gave rise to their addiction. To be effective treatment will, therefore, have to be combined with other measures such as help with housing, education and employment to help put back together otherwise chaotic lives.

Methadone treatment in prison

166.  We have also been told that treatment within prisons for opiate misuse is not consistent with that available in the community. Entering custody can, therefore, disrupt a treatment package, making it less likely that treatment will succeed.[163]

167.  In particular, the Committee has heard, offenders are likely to be offered detoxification in the first instance. Mr Ainsworth seemed to confirm this when he said "Overwhelmingly, if they are going in and the length of sentence is such that detoxification can be completed, then whether or not they have been on treatment before they go in, detoxification is the road that people start to look at".[164] This is contrary to the medical best practice advice in the community, as Dr Andy Thompson of the NHS Alliance told us: "All the evidence that we have in opiate abuse is that in moderate to high dose maintenance methadone is the most effective treatment while waiting for people to realise that they want to come off opiates".[165]

168.  We noted this problem in our report of 1999 into Drugs and Prisons (the "new strategy" referred to below is the current National Strategy):

    "concerns centred on possible unjustifiable variations in practice in different establishments in the way detoxification was tackled and in the extent to which prisoners already on a prescribed drug substitution programme on entry into prison could continue the programme...Provision of appropriate prescription courses for drug misusers is, quite correctly, a matter ultimately for clinical judgement; nevertheless it is clear there is continuing dissatisfaction from qualified observers as to the lack of consistency in present practice. We trust that the new strategy, through increased availability of services, will enable some of the inconsistencies to be removed, but the Prison Service needs also to review whether further guidance needs to be prepared and distributed and whether implementation needs to be more closely monitored".[166]

169.  We recommend that appropriate treatment forms a mandatory part of custodial sentences and that offenders have access to consistent treatment approaches within the prison estate as well as outside it. This should include strictly supervised methadone treatment in the first instance, as the most effective treatment available.

170.  We have heard that an anomaly exists in respect of prison drug treatment facilities, in that, unlike services in the community, they are not audited by the National Treatment Agency. We believe that this situation is unsatisfactory.

171.  In the interests of consistency, we recommend that the National Treatment Agency should have responsibility for auditing drug treatment services in prisons, as it does for services outside prisons.

Helping users into treatment

172.  Not all users want to be treated. There will usually come a point when treatment does seem more appealing to most users than the other alternatives open to them, but for a large part of their using career this will not be apparent. It is vital that treatment programmes are well publicised, that addicts know where to go to seek treatment and that they are encouraged to join such programmes. However, some will still be reluctant. In the meantime it is necessary to minimise the harm which even these users are causing to themselves and others, in the hope of providing a bridge into a more ordered way of life. The user can then be offered treatment with the eventual goal of abstinence. One obvious possibility is the provision, under strict conditions, of legal, clean heroin (or diamorphine) to persistent heroin addicts.

Diamorphine provision

173.  Doctors in Britain are unusual in the world in already having limited access to diamorphine prescribing as a treatment for opiate addiction. The Home Office has the ability to grant a licence to prescribe in this way, upon application by a doctor. However, we have heard that this system is not operating very effectively, and that the number of doctors possessing and using these licences appears to be very small. Professor Gerry Stimson, Director, Centre for Research on Drugs and Health Behaviour, Imperial College School of Medicine and Chair, UK Harm Reduction Alliance, submitted to the Committee an unpublished report of a study he conducted into doctors prescribing diamorphine to opiate dependent drug users in the UK.[167] The study looked at the doctors listed by the Home Office as having a licence to prescribe diamorphine, and also asked 108 potentially eligible doctors, why they did not have a licence. The conclusions raised questions about the Home Office's record-keeping as well as about prescribing practices. Of 164 doctors on the Home Office list, thirty-two had moved away from the address held and could not be traced. Forty-one on the list reported that they did not, in fact, hold a licence. Seventy reported they currently held a licence, of which only forty-six were currently using it to prescribe.

174.  Practices of those using their licences varied widely, in terms of the number of patients to whom they were prescribing and the doses used. When asked under what conditions they might consider prescribing diamorphine to more patients, licence holders cited lower drug and dispensing costs, better facilities, evidence of effectiveness compared to methadone and more support from Government and health authorities for it.

175.  Doctors eligible for but not holding licences (108 eligible doctors asked and 59 replied) were asked their reasons for not holding a licence. Two had applied for a licence and been turned down. Others cited lack of resources, little research evidence or best practice guidance on diamorphine, the anticipation of problems for patients, the belief that diamorphine was unsuitable for opiate treatment, concern that a "honeypot effect" might overwhelm the clinic, and belief that there was no demand for it.

176.  The main conclusion of this study was that "in spite of eighty years of prescription of diamorphine to opiate addicts in the UK, no clear consensus has yet emerged for who should be treated and in what way, and what benefits they might expect to receive thereby". The article goes on, "these questions can only be resolved by research, but up to this date this has been inadequate".

177.  We conclude that the licencing system of providing a limited number of heroin addicts with diamorphine on prescription is badly monitored and evaluated, provides practitioners with inadequate training and guidance, and patients with a variable standard of care.

178.  We recommend that a proper evaluation is conducted of diamorphine prescribing for heroin addiction in the UK, with a view to discovering its effectiveness on a range of health and social indicators, and its cost effectiveness as compared with methadone prescribing regimes.

179.  We recommend that the guidance and training provided to practitioners prescribing diamorphine to heroin addicts is strengthened, with a view to spreading best practice.

Swiss and Dutch research

180.  Persuasive evidence of the effectiveness of diamorphine prescribing does, however, exist elsewhere in Europe. We took evidence from Professor Juergen Rehm, Director and Chief Executive, Addiction Research Institute, Zurich, Switzerland, and Senior Scientist, Centre for Addiction and Mental Health, Toronto, Canada, and from Dr Gerrit Van Santen, from Amsterdam Municipal Public Health Laboratory, both of whom have been involved with pilots of diamorphine prescribing to heroin addicts, in Switzerland and The Netherlands respectively.

181.  Professor Rehm's study found that treatment of heroin addicts in Switzerland with prescribed heroin was often successful, with many patients going on to methadone treatment or abstinence therapy after being treated with prescribed heroin.[168] Results from the Dutch trial were also positive. The study found that the treatment led to improvements in patients' physical and mental health, and significant reductions in illegal activities amongst the patients. The researchers found that they were able to deliver the treatment programme without serious health risks for the treatment staff or the patients. Nor were there serious public order and controllability problems for the treatment staff or the neighbourhood.[169] Both Professor Rehm and Dr Van Santen also told us that the programmes were set up in such a way that there was no leakage of pharmaceutical heroin from the clinics onto the black market.[170] The drugs were only dispensed under strict supervision. The Swiss study also found that the heroin prescribing programmes saved money for society. While the programmes were expensive to run, the reduced criminality of patients and improved health meant that, overall, savings were made to the criminal justice and health systems.

182.  The Home Secretary has indicated that he is looking at the possible expansion of heroin prescription to addicts, and has set up a team of experts to consider the issue. Mr Ainsworth explained:

    "What we are worried about is that the current guidance has led us to be a little too restrictive as to where we are prepared to offer heroin as a form of treatment and that there are situations where people are not being allowed access to that treatment where it may well be appropriate and that is in part because, or we believe it is in part because, of the guidance that we have given and the effective restriction of the guidance which has been given".[171]

183.  The group of experts is expected to report back with their conclusions by the end of 2002. We do not think that it is enough for the Government simply to expand the number of doctors licensed to prescribe diamorphine to heroin addicts.

184.  It has been persuasively argued to us that the legalisation and regulation of heroin would collapse the criminal market, drastically reduce the level of acquisitive crime and make addiction easier to treat. For reasons already given (see paragraph 65 above) we do not propose to go down this road. We do, however, accept that there is a strong case for bringing heroin use above ground, so that those who wish to be helped can be, and those who do not wish to be helped can at least indulge their habit at a minimum risk to their own health and that of the public. The obvious first step is the introduction of safe injecting houses (so-called "shooting galleries") of the sort that exist elsewhere in Europe. At their most basic these are places where addicts can go without fear of arrest to inject illegally purchased heroin and where practical advice is available as to the safest means of injection and the safe disposal of needles. The Home Office told us that "the current government position is that injecting rooms for illicit drugs should not be introduced in this country whilst we have no evaluations of those developed in other European countries".[172]

185.  We believe that such facilities may offer potential to reduce harm. As well as helping users to reduce the risks to their health, safe injecting premises could make a significant impact on the nuisance caused to others by illicit injecting. All members of the Committee have heard from constituents about the problem of discarded needles and other paraphernalia in the street posing a health and safety risk, particularly to children. If injecting users could be directed to safe premises, needles could be disposed of in a safe way and the problem contained.

186.  We recommend that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if, as we expect, this is successful, the programme is extended across the country.

187.  We go further. As we have seen, a number of other European countries have established carefully controlled programmes for the treatment of heroin users which involve making clean heroin (or diamorphine) legally available to users together with sanitary equipment and sound advice on dosage and injecting techniques. The aim is to help addicts manage their habit and in due course to wean them off their addiction. It also has the additional benefit for society as a whole that they no longer have to rely on acquisitive crime to fund their habit. As Mrs Tina Williams, whose son is addicted to heroin, put it to us "if you are treating the user with what they need to keep them well why would they go to the black market?".[173] The Association of Chief Police Officers said recently:

    "There is a compelling case to explore further the merits of prescribing drugs of addiction to patients with entrenched dependency problems who have not responded to other forms of therapy...this should include the wider use of heroin within a menu of treatments".[174]

188.  Opinion, however, is far from unanimous. Dr Claire Gerada, of the Royal College of General Practitioners, told us that providing diamorphine to addicts would mean "colluding and creating life long addicts".[175] We asked Mr Ralf Löfstedt, Deputy Director of the Swedish Ministry of Health and Social Affairs, for his opinion of heroin prescribing, given Sweden's more restrictive approach to drugs policy. He told us that providing prescribed heroin implied that some patients were "uncurable" and warned that society would be sending out inconsistent messages: "What will the effect on society be if we take more and more people directly from drug addiction into another type of drug addiction, but one sponsored by society?".[176] He also suggested that it might be harder to motivate addicts to take up treatment such as methadone and drug-free programmes if they were able to access clean heroin.[177] He told us that the reductions in crime which had been seen in the Swiss and Dutch programmes might not be sustained and suggested further that heroin treatment programmes might cause a rise in the numbers of new users.[178]

189.  Mrs Williams told us that "on humanitarian grounds to prescribe controlled diamorphine to people that are really sick and need it is not a signal to encourage people to take it".[179] The Dutch report addressed many of the objections to diamorphine prescribing:

    "It should be emphasised that drug users are not 'given up' when prescribing heroin, nor that it is accepted that these persons will remain addicted for the rest of their lives. Heroin prescription may be a new hold for heroin addicts for whom there has been no adequate treatment so far. By enabling drug users to return to their original intoxication through medically prescribed heroin, also the use of illicit drugs other than heroin may be reduced...In addition, through the prescription of heroin, medical and social care may be initiated and efforts may be undertaken to help these addicts to structure their lives, and—for some addicts—to achieve abstinence from drugs. For example, 10% of the patients admitted to the Swiss heroin program (22% of all discharges) left the program to start abstinence oriented treatment."[180]

190.  We conclude that the Dutch and Swiss evidence provides a strong basis on which to conduct a pilot here in Britain of highly structured heroin prescribing to addicts. We recommend that a pilot along the lines of the Swiss or Dutch model is conducted in the UK. Should such a pilot generate the positive results which one would expect from the Dutch and Swiss experience, we recommend that such a system should supersede the little-used "British system" of licensing.

191.  We recommend that a pilot offering prescribed diamorphine to heroin addicts is targeted, in the first instance, at chronic addicts who are prolific offenders.

Diamorphine for persistent addicts who have not yet accessed treatment

192.  Professor Rehm and Dr Van Santen told the Committee that the Swiss and Dutch programmes to provide diamorphine to addicts were only to open to persistent addicts who had tried, and failed, to comply with other treatments such as methadone, over a period of some years. They emphasised, however, that this did not necessarily allow the most problematic group to be accessed, who were described as:

193.  The suggestion is that diamorphine on prescription may offer a way of encouraging these people, too, to enter treatment. Dr Van Santen said: "I think the power of the prescribing of heroin lies not among those poor performers on methadone but on those people not reached yet by services, by necessary care".[182] Professor Rehm too described this as potentially a much more important role for diamorphine prescription than that explored by the trials: "we want to see can they attract non-treatment goers in our society, which is way more a problem in Switzerland".[183] He referred to a trial about to begin in Germany, run by Hamburg University, in which the criteria for admission to the scheme will be widened slightly to include not only those who have failed on an alternative treatment but also those who have not accessed any treatment for at least the past six months.[184]

194.  We recommend that the Government commissions a further trial to look at the prescription of diamorphine to addicts who have not yet, or are not currently accessing any treatment, despite having a long history of heroin addiction.

195.  It has been emphasised to us that diamorphine prescription should be used as a complement to already existing treatments which are backed up by strong evidence, such as methadone treatment. If diamorphine treatment could be offered to all problematic users who do not successfully access other treatments, we believe it could play a useful part in managing the social problems generated by this group of people.

151   Q. 106. Back

152   Q. 494. Back

153   Reducing Drug Related Deaths, p. 58. Back

154   Professor Nutt, Q492-3. Back

155   NTORS at one year: The National Treatment Outcome Research Study:Changes in Substance Use, Health and Criminal Behaviour One Year after Intake, Michael Gossop, John Marsden and Duncan Stewart, Department of Health, 1998 (hereafter "NTORS at one year"). Back

156   Bill Nelles, General Secretary of the Methadone Alliance, Q. 577. Back

157   Q. 572. Back

158   Q. 578. Back

159   Q. 584. Back

160   Q. 616. Back

161   Q. 1387. Back

162   Q. 592. Back

163   Dr Andy Thompson, NHS Alliance, Q. 1034. Back

164   Q. 1301. Back

165   Q. 1034. Back

166   Fifth Report of the Home Affairs Committee, 1998-99, Drugs and Prisons, HC 363-I, p. xlix. Back

167   Survey of doctors prescribing diamorphine (heroin) to opiate dependent drug users in the United Kingdom, Nicky Metrebian, Tom Carnwath, Gerry V Stimson, Thomas Storz, accepted for publication by Addiction magazine. Back

168   Feasibility, safety and efficacy of injectable heroin prescription for refractory opiod addicts: a follow-up study, Jürgen Rehm, Patrick Gschwend, Thomas Steffen, Felix Gutzwiller, Anja Dobler-Mikola, Ambros Uchtenhagen, The Lancet Vol. 358 No. 9291, 27 October 2001. Back

169   Medical co-prescription of heroin: two randomised controlled trials, Central Committee on the treatment of heroin addicts, Wim van den Brink, Vincent M. Hendriks, Peter Blanken, Ineke A. Huijsman, Jan M. van Ree, 2002 (hereafter "Medical Co-prescription of heroin"). Back

170   QQ. 882; 883. Back

171   Q. 1298. Back

172   Vol III, Ev 227. Back

173   Q. 1458. Back

174   A Review of Drugs Policy and Proposals for the Future, The Association of Chief Police Officers, Drugs Committee, April 2002, p. 16. Back

175   Q. 981. Back

176   Q. 1564. Back

177   Q. 1568. Back

178   Q. 1577; Q. 1578. Back

179   Q. 1466. Back

180   Medical co-prescription of heroin, Section 2.8.1. Back

181   Professor Rehm, Q. 796. Back

182   Q. 826. Back

183   Q. 839. Back

184   The German project of heroin assisted treatment of opiate dependent patients: a multicentre, randomised, controlled clinical trial, Principal Investigator: Prof. Dr. Michael Krausz, Deputy Director of the Centre of Psycho social Medicine, Psychiatry and Psychotherapy, Director of the Centre for interdisciplinary Addiction Research of Hamburg University. Back

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