Select Committee on Home Affairs Appendices to the Minutes of Evidence


Additional Evidence from the Home Office for the Home Affairs Committee Enquiry: Comments in Response to Articles by Nick Davies, The Guardian (This is provided in response to a specific request by the Committee to comment on these articles)


  There is strong evidence from a number of research studies to show a clear link between heroin and crack/cocaine misuse and crime—particularly acquisitive crime.

  The New English and Welsh Arrestee Drug Abuse Monitoring (NEW-ADAM) across eight sites reveals that 65 per cent of arrestees tested positive for one or more drugs. Of these 24 per cent tested positive for opiates (including heroin) and 15 per cent for cocaine/crack. Arrestees who are misusers of both heroin and crack/cocaine account for more than half (by value) of acquisitive crime.

  There is also good evidence to show that treatment works and is cost effective in achieving reductions in drug use, offending and improving the health of drug users. For example, the National Treatment Outcomes Research Study (NTORS) showed that for every £1 spent on treatment, £3 is saved on criminal justice spending.

  The criminal justice system provides a unique opportunity to get drug misusers to address their problems and steer them into treatment and away from offending.

  Criminal justice intervention initiatives such as the Arrest Referral schemes and Drug Treatment and Testing Orders (DTTO) are designed to do just that.

  The early pilots for both initiatives showed significant results in terms of reductions in both crime and average expenditure on drugs. For example, the Arrest Referral pilots showed that 31 per cent of offenders were no longer using crack/cocaine, and 28 per cent had stopped using illegal opiates six to eight months after referral. Furthermore, the average expenditure on drugs fell from £375 per week to £70 per week and there were corresponding reductions in the level of crime. The DTTO pilots revealed similar results.

  The Arrest Referral Scheme has also proved successful in getting drug misusers into treatment for the first time—over half (51 per cent) of all those referred had not previously accessed treatment.

  The Arrest Referral and DTTO pilots were rolled out nationally only after careful independent evaluation. In each case this was no less than two years after the pilots began.

  Both initiatives continue to be monitored and evaluated, with a view to building upon the success and spreading best practice.

  Under both initiatives, referral into treatment is done on a voluntary basis. There is no coercive element involved.

  DTTOs are community sentences designed to assist offenders with deeply entrenched drug problems whose record of acquisitive crime might otherwise lead them to a prison sentence. The treatment programmes are challenging and it is disappointing, but not surprising, that some Orders are revoked.

  Those whose Orders were revoked during the pilot stage had not "vanished" or "been thrown out". They would have been breached in accordance with the usual procedures where those on community sentences fail to comply.

  It is not "odd" that, during the DTTO pilots, offenders continued to misuse drugs at the same time that the average expenditure showed a dramatic fall. Reductions in drug misuse are often gradual, and it is not surprising that many offenders were continuing to misuse at an early stage of the Order.


  The adverse physical effects of heroin are limited but the most significant is respiratory depression. Heroin is the addictive drug most commonly involved in "drug-related deaths" due to poisoning (either alone or in combination with other drugs) and is highly dangerous in this regard.

  Heroin is highly dangerous due to the risk of escalating addiction. This is the key to its harm. Regular use of heroin can lead to a deteriorating cycle of escalating use and prioritisation of heroin use over other activities and responsibilities. There is no known upper limit on the dose of heroin to which an individual can become tolerant.

  A drug user on prescribed heroin could still escalate the amount used (with illicit heroin or other opiates) or mix it with other drugs (commonly drugs like cocaine). Risks of injecting would be sustained. Continuing multiple daily use of heroin is liable to reinforce its own and other drug-taking behaviour. This is exactly the nature of addiction and why it can be so destructive. The wider availability of heroin would not only support escalating addiction but could involve new users with different vulnerabilities and patterns of use.

  In addition the routes of use of opiates and other drugs (that will no doubt vary as a matter of fashion if widely available over time) also have well recognised serious dangers.

  There is no question that stimulants can cause death and psychological and psychiatric problems. They are frequently used with opiates. Benzodiazepines and alcohol are also frequently used by drug users to mediate various effects of their drug taking.


  There is no evidence to support this. The licensing requirements exert no influence on prescribing practice with clinicians who make independent decisions about prescribing. The mechanisms for licensing are simple and free and there is no significant barrier to any skilled and reputable practitioner obtaining a license and prescribing heroin. The current system supports good practice based on careful clinical judgement of the needs of the patient. The current limited use of heroin for carefully selected patients has arisen because of decisions, based on the research evidence and experiences of practitioners since the late 1960s. The main reason for this change was the clinical benefit of injectable methadone and then liquid methadone. The difficulty of actually stabilising significant numbers of heroin addicts on injectable heroin (polydrug use, instability and unsafe practices continuing) contributed to the move by clinicians to methadone.

  It is clear that some patients may become relatively stable on injectable heroin and the current British system allows the freedom for experienced clinicians to use that treatment. The evidence and current clinical practice suggests this is not the appropriate treatment for the majority.

  We recognise that there is some inconsistency in prescribing practice around the country and a need to look again at current clinical practice. This is why the Department of Health with the NT and the Home Office have arranged a consensus event in February to bring together a number of prescribing experts, from here and abroad, to review current practice and develop further guidance on the most appropriate use of heroin as a substitution treatment for illicit heroin.


  Most of the evidence for the benefit of treatment of heroin addiction is from the much larger numbers of those prescribed methadone than those prescribed heroin, but it is clear that engagement in such substitution treatments are very effective in reducing a range of personal and social harms.

  There is a large body of evidence to demonstrate the value of the long-acting opiate methadone (particularly liquid methadone taken orally). Methadone allows many drug users in treatment to stabilise their lifestyle. It is easier to return to a stable life on methadone than on injectable heroin because one oral dose is much less intrusive than multiple injections daily. When coming off heroin or methadone most patients require considerable psychological and social support.

  The Advisory Council on the Misuse of Drugs in their Report on Drug Related Deaths and the DH expert document—"Drug misuse and dependence—guidelines on clinical management" both consider the relative benefits of opiate treatments on the basis of the best available evidence. They both conclude on the value and importance of methadone substitution over heroin for the majority of patients in stabilising chaotic lifestyles due to addiction and reducing harm. These works are fully referenced.


  Heroin is actually already available in the UK in addition to other opiate and other treatments. Clinicians moved away from prescribing heroin in favour of oral methadone liquid on clinical grounds (the benefits of which are clearly available in the scientific literature). It is clear that patients on heroin injectable treatments can also be unstable in their drug use and at continuing risk.


  Drugs are already legal for those in treatment for problems with addiction but there are some limitations around issues of individual or public safety. Doctors that are currently prescribing diamorphine have to weight up risks for addicts to whom they prescribe and sometimes refuse on the day to prescribe if the person is intoxicated or there are concerns about driving or currently having a child with them in a state of possible intoxication.

  Given the risks for particular individuals of these drugs (those at risk of psychosis, those with personality disorder and those with a history of abuse or self-harm) availability without assessment of these issues could be highly problematic (and presumably liable to claims of negligence). Because of the dangerousness of these drugs and the ethical responsibilities and duty of care of clinicians and prescribers, it is unlikely that prescribers would be willing to prescribe except for those identified to need the treatment.

  No assessment has been made of the likely impact of making "hard drugs" legal on the types and total numbers that might then use and become addicted. It is quite conceivable that overall harm would escalate. The numbers of people currently using hard drugs is relatively small. With our knowledge of the impact of the current widespread use of harmful legally available drugs, it is highly likely that with legalisation there would be an increase in total use and the harms of escalating addiction. We might then be back to a situation that preceded the International Treaties and the development of the "British System" when widespread harm due to easily available opium and opium dens could no longer be tolerated by Society, and led to its prohibition.

  We are not aware of any evidence that in a legally available market that the total level of injecting and sharing would decline. It is possible that there would be users who would not want to obtain supplies directly which could lead to the development of a secondary market. And it is also possible that for the heavy using adults an illegal market based on price, accessibility, access to novel designer drugs or upper limits to the availability of legally available drugs could develop.

  If the supply of heroin for the treatment of addiction was legalised, it is logical to assume that suppliers of illicit heroin would focus their efforts on recruiting new addicts who could not or would not access the legal supply, particularly young people. Unless all those who ask for heroin, cocaine, ecstasy, methadone and temezepam etc were given their choice of drug, irrespective of prior use, an illicit market will continue to be a problem.

  It is also likely that any opportunity to re-engage into the black market those with access to legally prescribed heroin would be exploited (such as increasing supply of combinations of drugs). This is likely to be particularly successful for those who have not recognised the severity of their addiction (unlike with current treatment populations) and those who have little motivation to change.

  Some regular users will still be involved in an escalating cycle of addiction and may not wish to be involved with state supply. Addiction develops and is sustained by a range of complex factors (biological, psychological and social) so that a legally controlled supply may not fully meet the needs of many of those who have not yet chosen to come in for treatment.

  The provision of such easily available heroin substitution treatment may for some effectively support a longer injecting career or a longer career of heroin and ploydrug use than would otherwise occurred by avoidance of more suitable treatment options.

  The Home Secretary has made it clear that he wants to look closely at current prescribing practice. The consensus event, to be held in February, will address some of the issues around inconsistency of supply and also consider whether or not heroin should be prescribed to more people than are currently receiving it. This is part of a wider harm minimisation approach that will also include an action plan to reduce the number of drug-related deaths and the development of best practice guidance on the treatment of stimulant addiction, including cocaine.

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