Examination of Witness (Questions 660
TUESDAY 11 DECEMBER 2001
660. If you will forgive me saying so, we are
in danger of getting hooked on cannabis. If we are serious about
harm reduction we have to address the drugs which are causing
the most harm. Perhaps heroin would be a good place to start.
Harm comes in two categories: one is harm to the drug user and
the other is the amount of criminality they have to sponsor in
order to feed the habit. Why do we not decriminalise heroin or
move it down? That is the logical step, is it not?
(Mr Trace) It is a very risky step. If we follow the
same sort of argument on heroin as we just have on cannabis, the
main danger is that either through the messages which come from
the authorities or through the actual legal structures they have,
if the message comes through that it is easier and you will have
less attention from the law enforcement authorities to indulge
in the use of a certain drug, then there is the danger that the
prevalence rises as a result and the market increases. With cannabis,
my argument would be that that increase is likely to be marginal,
because we may be near some saturation point already. Even if
there is a marginal increase it is not going to be a very harmful
process to society. With heroin, we cannot be as confident. If
there were any significant increase in heroin use in this country,
then the harms would inevitably follow. The liberalisation of
approach to heroin has much greater risks attached to it.
661. In that case you cannot concentrate on
harm reduction, can you, if you are not willing to address the
drugs which are causing harm for one reason or another?
(Mr Trace) I just said that there are risks attendant
662. What are you saying? Should we, or should
(Mr Trace) Should we what?
663. Should we start moving down the road of
(Mr Trace) No. What we should move down the road of
is harm reduction, good harm reduction practice.
664. I am trying to get from you what constitutes
good harm reduction. Tell us that in relation to heroin, never
(Mr Trace) If we follow that same thought process
with heroin, what we have is a relatively small number of people
who start using heroin but a large proportion of those who become
regular users of heroin. What we do have to be very careful about
is not to increase that overall market. Having said that, when
we have this body of people who use heroin, they are using it
in very harmful ways to themselves and the people around them.
Our first responsibility of the state should be to bring in measures
which protect their health and protect their lives. We have a
situation at the moment where the pattern of use of heroin in
all western countries and actually most other countries as well
now, is entrenched in that way. People use heroin in very risky
ways, primarily by injection, primarily in addictive ways and
it is related to them committing crimes to raise the money, it
is related to losing all contact with the supportive parts of
society we all have. Harm reduction is the first responsibility
we should have as a country. We have a very good harm reduction
policy in this country. People do not recognise this but basically
in the mid-1980s we were all faced in Europe with the first recognition
of this growth in heroin use and the impact it was having on infections,
HIV the most well known, and the impact it was having on death
rates of young people. The response to that in the UK was exemplary.
We introduced very early education for people to avoid risk when
they are using heroin, we were very brave with thatI say
"we" but I was not around at the time myselfbut
the Government were very brave with that at the time and the health
education authorities were very brave at that time and overall,
even more important than all of that, we introduced needle exchanges
when they were seen as a very risky intervention. The fact that
we did that in 1985-86 rather than 1989-90 like other European
countries means we have a much lower rate of HIV prevalence and
probably hepatitis prevalence amongst drug injectors in this country.
That is successful policy and we have been doing that since the
mid-1980s. There are certain issues facing us now about whether
to push those successful policies a little further.
665. Yes, that is what I want you to come to.
(Mr Trace) May I answer case by case because there
is a different argument on each of these suggestions. There is
a case about whether to go to heroin prescribing. There is a case
about whether we should introduce injection rooms. There is a
case about whether we should introduce pill testing for recreational
666. Yes, take them one by one.
(Mr Trace) They are different. First of all injection
rooms. Despite our good harm reduction policy we have a culture
of drug use in this country amongst our street addicts which is
very high risk taking. Street addicts by and large use heroin
and all sorts of other drugs as well. That creates a situation
where overdose is very common. We have high overdose rates and
we have high death rates as a consequence of overdose. This is
the other area where there needs to be a real extra push to policy
at the moment. Broadly we have said that we want to reduce overdose
deaths, but we are not doing enough about it. One of the ways
of reducing overdose deathsand I am not sure it will turn
out to be the most effectiveis to allow the street injectors
to inject in sanitary conditions with first aid on tap so that
if anybody does overdose, first of all they are injecting in broadly
sanitary conditions so there will be less chance of overdose and
secondly, if they do overdose there is a nurse behind the counter
who can deal with that.
667. Are you in favour of that?
(Mr Trace) I am in favour of the concept of it.
668. You cannot have the concept and not the
(Mr Trace) It might not work. The concept is that
you create that situation, but just by creating an injection room,
which I have to say is the situation in Spain at the moment, does
not necessarily mean that all the street addicts will turn up
to it. It does not mean that the practice in that injection room
will be good quality and it does not mean that it will affect
the overall death rate. The idea is good, but you have to implement
it and evaluate it.
669. What would you do?
(Mr Trace) On balance I would introduce some into
the UK on a very controlled action research basis.
670. You would do a pilot to start off with.
(Mr Trace) Yes. It is quite possible also for the
UK to sit back and look at everybody else's pilots. Once again,
they are high risk initiatives and they are very hard to implement.
The Germans, the Australians, the Dutch and the Spanish are doing
them to quite an extensive degree. We could just sit back for
two years and look at their results. Or we could join in that
process and introduce some of our own.
671. Which would you do?
(Mr Trace) I would advise Ministers to have our own
pilot, because it is under our conditions with our drug users
who seem to behave a little differently from European drug users.
I would have our own pilot which runs in parallel with others
on a pilot basis.
672. Now come to the next issue.
(Mr Trace) Pill testing. Broadly once again the idea
has a merit to it.
673. Could you say what pill testing is?
(Mr Trace) Pill testing is to make available to users
of mainly ecstasy but related pills, in night clubs mainly and
night life, the ability to give a sample of a pill they have to
an immediate test kit which will tell them what the constituent
contents are of those pills. That will help them to understand
what they are taking and avoid risk. There is a fundamental problem
with that whole process and that is that most of the harm and
certainly most of the deaths from ecstasy which have occurred
in this country and in Europe would not have been prevented by
pill testing because the fatal reactions we have had to ecstasy
over the years in the UK are totally unpredictable. You could
not say why a certain person had cardiac problems as a result
of taking ecstasy. It was not because they had a particularly
674. So that would not make a significant difference
to harm prevention.
(Mr Trace) Yes, I think so.
675. Are you saying it would not?
(Mr Trace) I am saying I do not have an absolute conclusion
676. It is unlikely to.
(Mr Trace) What I am saying is that even if it worked
well in a UK context, it would not solve the fundamental problem
of people having fatal reactions to pills.
677. Now bring us to heroin prescribing.
(Mr Trace) I am a little surprised why heroin prescribing
is such a political hot potato because we have been prescribing
diamorphine in this country since the 1960s. As a treatment practitioner
I do not think we need to be convinced of diamorphine's possible
use as a substitute prescribing substance; it has pretty much
established itself. The main issue for us, and this is something
related to my role at the National Treatment Agency, is where
in the menu of services we expect to have available in every area
of this country is the place of diamorphine as opposed to methadone
which is the main substance used at the moment. My general view
is that we have been too restrictive on the prescribing of diamorphine,
certainly over the last ten years. The Government does have a
responsibility to ease up their regulation of diamorphine, particularly
through the licensing system. Doctors are only allowed to prescribe
diamorphine if they have a licence from the Home Office. Those
licences have been very hard to get recently. Yes, once again
I very much welcome what Mr Blunkett said. We now have to operationalise
that but we do have to be very careful. Diamorphine is a very
difficult substance to use in operational terms. You have to administer
it several times a day, whereas methadone is once a day. The risks
of diversion onto the black market are very great with powder
diamorphine and it is very expensive.
678. Given that doctors are likely to be reluctant
there is not going to be a great flood of applications from doctors,
(Mr Trace) There will be enough. There are plenty
of doctors out there who would like to prescribe diamorphine but
they have been prevented over previous years.
679. That is what you would start by doing,
(Mr Trace) Yes. Once again you have to go into these
things in terms of pilots. What I should like to see happen now
is that in a number of the high heroin using areas of the country
we would implement pilots where diamorphine was used as part of
a menu of services. The key issue for me is what patients would
benefit from diamorphine under what circumstances as opposed to
patients on other substances.