Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 540 - 559)



Bob Russell

  540. That leads on quite neatly to what the effect would be of decriminalisation or legalisation of drugs. All four of you said that government policy is not working so the crux of our inquiry is whether we leave things not working or move on. I just wondered whether you could perhaps separate cannabis and other drugs in your answer as to what the effect of decriminalisation or legalisation of drugs would be if cannabis were okay and the prevalence of drug use and the number of addicts.
  (Professor Nutt) I need to be clear what you mean by decriminalisation. Do you mean selling it, encouraging it, marketing it, as tobacco currently is?

  541. I do not think anybody is talking about encouraging it—at least I am unaware of that—but it being legally available through some sort of controlled outlet like a pharmacist or something.
  (Professor Nutt) I imagine it would have very little impact on use. I think the market for cannabis is getting close to saturation at present.

  542. Professor Henry said earlier that nine per cent of the population use cannabis and we have just been told that is a declining figure. Is it nine per cent of the entire population or certain categories?
  (Professor Henry) Yes. This is the European figure which is nine per cent of the UK population. Obviously there will be certain age groups where it will be much more widely used and I would suspect those are the younger age groups.

  543. So four to five million people and if Parliament is representative of the community, 60 MPs, are taking cannabis which is illegal. What would happen if it were decriminalised or legalised? Purely cannabis. Do you think those figures would go up, remain static or possibly with greater education and the drug being taxed, one assumes, would that fall?
  (Professor Henry) I think there would be a rise in cannabis use. It might not be a massive rise, but I cannot see it going down, because a lot of people find it very difficult to get hold of the stuff. I do not know how. If it were available from recognised outlets for sale, for example, I am sure there would be more people trying it and more people using it.

  544. I believe your earlier evidence was that cannabis is not as addictive as cigarettes.
  (Professor Henry) Very true. It is not as addictive as cigarettes and so many people are using it there must be compensatory perceived benefits in users.

  545. If there were an increase in cannabis use, which I think you are saying there probably would be, would that then lead on to an increase in so-called hard drugs?
  (Professor Henry) There is evidence that prior utilisation of any substance is associated with a higher incidence. Although many people will not go on to use a further substance, the concept of gateway applies. If somebody has tried one substance, then they are probably more likely to try a further substance and so on. Not that any specific substance can be regarded as a gateway.
  (Professor Nutt) That is quite a difficult question because one natural experiment we have was the Dutch experiment where they in a sense have gone partly down that route. There the evidence is the other way round, which is that if people get cannabis in a controlled environment, they are less likely to take heroin, because they are less likely to go into the heroin market. While John is right, there may be a chemical effect to encourage you to take other drugs, that may be overridden by the separation of the market effects.

  546. I am grateful for that last contribution because that is in fact my next question. Having been to Holland and seen two or three of the coffee shops, the evidence which has been given is exactly that, that allowing free use of cannabis has led to a reduction in hard drug use. Would you accept that argument?
  (Professor Henry) I accept that argument. The illicit drug market almost certainly operates cohesively to a degree. If one manages to separate out one of those substances, then you might get a decrease in use. I accept that.

  547. Do you think there is a case to be made for saying that cannabis should be separated from other drugs in terms of criminalisation and what is legal and what should be illegal?
  (Mr Hickman) Yes. In terms of Amsterdam, I should not have thought they would say that separating cannabis has resulted in a decline in heroin use, because I do not know what evidence they have for that. They are separate epidemics and I do not agree with a gateway hypothesis either. Making it legal would not have any effect on the heroin using population.

  548. As a professional would you feel that separating cannabis from the other drugs in the eyes of the law is a step forward or a step back?
  (Mr Hickman) It is a step forward, if it comes attached to a health education campaign. The most important thing is to reduce the levels of drug use. Having it legal or illegal does not do that at all. In order to reduce drug use you have to spend some money on health education.

  549. If there is a free-for-all either of cannabis or all drugs being decriminalised, surely that would have an adverse effect on the National Health Service and all the health problems that go with it?
  (Mr Hickman) What? Legalising would have an adverse effect?

  550. If there is an increased uptake in drug use, then leading on to hard drug use.
  (Professor Nutt) If. It is a complicated equation because what you have to put into it are the health consequences of illicit drug use and this is where epidemics like AIDS in America and like hepatitis C here, have huge health costs which are often not thought about in relation to drug use. There is a cohort of hepatitis C positive patients now in this country and other countries who will become a huge burden on the Health Service in the next ten years as their livers slowly decay. It may well be that if you made drugs more available in a way which avoided infection, you would not have hepatitis C, in which case the health costs of the way drugs are used now may actually be greater than the extra costs incurred by extra addiction. It is a complicated equation. I would not necessarily say that making drugs more available would increase health costs. It would certainly increase psychiatric costs, but that might be offset by the savings in other areas of medicine.

  Chairman: I hope you are going to pursue the decriminalisation of heroin.

Bob Russell

  551. I did give our witnesses the opportunity but I am looking at the clock and the time allocated. I am quite happy to pursue that.
  (Professor Nutt) The heroin issue is an important one. May I just say a few things about it? Heroin is not illegal, doctors and addiction specialists prescribe heroin and with some success. The question at present is whether it should be prescribed more or more often. That is a health economic argument and I should be interested in what my colleagues here say. Heroin is significantly more expensive than methadone and if the limiting factor in methadone availability is cost, then, if the budget stays the same, you are going to get fewer people treated if heroin is prescribed than are currently treated with methadone. The other point is that there is a major controlled trial of heroin prescribing going on in Holland at present. It will be the first proper trial which would meet the criteria for licensing a drug, that is it is a double blind study which compares the intervention of prescribed heroin against normal treatment. That is nearing completion now, we should have the data from that study in the middle of next year and that would greatly inform the debate as to whether prescribing heroin is both effective medically and also cost effective.


  552. I think you know something about the Swiss experience.
  (Professor Nutt) The Swiss experience is an open study where they thought it would make sense to take people off the streets and allow them to self-administer heroin in controlled environments. Clearly that was effective in terms of reducing deaths and stabilising people who had very disorganised lives. It was not a controlled experiment. The Dutch one is the first properly controlled experiment.

  553. Does your instinct tell you that that is the way to go here?
  (Professor Nutt) No, I am not sure about that. The health economic argument is a complex one and it may be that if we have extra investment it might be better to invest it in methadone and other treatments like buprenorphin, rather than prescribing heroin. I have a very open mind on that at present.
  (Professor Stimson) I conducted one study where we gave patients the choice of heroin to inject or methadone to inject. I can make the paper available to the Committee. We are just finishing another study where we are looking at heroin prescribers in the United Kingdom; how many there are and how many patients they are prescribing for. The answer is that there are very few people who prescribe heroin. In fact the Home Office does not have very good records. The Home Office list of the licensed doctors does not correspond to what we found when we wrote to them because many of them claimed they did not have licences or they had moved away from the address where the licence was held and so on. There are about 40 or 50 heroin prescribers in the UK and around 450 patients who are receiving heroin on prescription.

  554. That is a tiny sample of the whole.
  (Professor Stimson) Yes. We were interested in why there was not more, because in a sense this should be the country where there would be more of it. We asked both the doctors who hold licences why they did not prescribe more and the doctors in drug clinics who did not have licences why they did not prescribe more. The main arguments against prescribing would be resources and cost, because heroin is more expensive than methadone, lack of a research base, lack of research evidence for its effectiveness.

  555. Presumably the fact that they do not want their surgeries cluttered up by chaotic heroin users.
  (Professor Stimson) Heroin users may not be chaotic. I have done two studies, one of heroin users from 1968 whom we followed eventually for 20 years and many of them were not chaotic, though some were. In a small study I conducted where we gave people a choice of heroin or methadone for their prescription and then followed them for a year, these were long-standing people who were resistant to the idea of giving up injecting drugs, they had had several failed methadone treatments, they were older, but there were health gains and the treatment retention was very high. Some of them were chaotic but for the most part they were helped to lead a slightly better life. I would not say it works for everybody. To jump ahead a bit, there is probably a place for more heroin prescribing, but it is not the single simple solution. It is within the panoply of treatments which should be available.

  556. The other argument against was leakage as well, was it not?
  (Professor Stimson) In the trials which are going on in Holland and in Switzerland the people had to sit in this room and be observed to be injecting, which may prevent leakage, but was not very nice for the patients. In the trial we did we asked for the ampoules to be returned and there was a very high return rate on the ampoules. We also did some street interviewing to check how easily available ampoules were and what their price was on the market. Ampoules of heroin are very rare. They are like gold dust and if people get them, they want to keep them for themselves for the most part. That might change if there were more heroin prescribing but for the most part, if you get NHS heroin you do not want to let anybody else have it.

  557. It would be very useful if you would make those two papers available to the Committee. The major argument which is being put to us for much wider prescription of heroin is that you collapse the criminal drug market. I appreciate this does not relate to making the health of the patient better or worse, but there must be some truth in that, must there not?
  (Professor Stimson) There might be. This was an argument when the drug clinics were first introduced: doctors talked about competitive prescribing to drive out the drug market by supplying a sufficient quantity of heroin but not too much. If you supply too much, you are creating the black market itself. Very difficult to know. I would abstain on the answer to that.

  558. We are not allowed to abstain.
  (Professor Stimson) I am.

  559. If this Committee were to recommend a much wider prescription of heroin. . .
  (Professor Stimson) We should not be against that. It would bring in another population. You would have to be careful whom you recommended it for, but different treatment modalities attract different people at different stages in their drug using life. More heroin prescribing would help a group of people, but it is not the only solution.
  (Mr Hickman) I would recommend a trial first. Most criteria for people going onto heroin include that they failed on methadone and they are a bit older. These are not the people who are committing all the drug related crimes, who are younger. You probably have people at different careers, different trajectories and you want to get people who are committing the drug-related crime into treatment early. I do not know whether heroin is going to have a role in being able to do that. It would be interesting to do a trial at least.
  (Professor Henry) My comments would not be an expert opinion.

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