Examination of Witnesses (Questions 563
- 579)
TUESDAY 27 NOVEMBER 2001
DR COLIN
BREWER, BILL
NELLES, LORD
ADEBOWALE, CBE, AND
PROFESSOR JOHN
STRANG
Chairman: Gentlemen, welcome. I think most of
you heard the previous session, so you probably understand the
line we are likely to want to follow. We are going to follow the
same order of business, that is to say ask whether government
policy is working, what changes you would like to see and discuss
the practical implications of decriminalisation. Who wants to
start the ball rolling?
Mrs Dean
563. I think most of you were in for the last
session. In answering whether you believe government policy is
working, could you also address the issue of whether the strategy
is having an impact on the morbidity and mortality rates related
to the following substances, as measured by acute health problems,
long-term health problems, addiction problems and problems due
to route of use. Could you take each substance: cannabis, cocaine,
crack cocaine, heroin and ecstasy?
(Dr Brewer) Most of us do not see cannabis as very
much of a health problem, certainly in comparison with alcohol,
which should be our point of reference for all drug problems.
Alcohol is our biggest drug problem, always has been and probably
always will be. In comparison, cannabis is a very minor problem.
All drugs have toxic effects, cannabis included, and it may well
have some toxic effects we do not yet know about because there
need to be long-term studies, but low down on the list and low
in addictive potential. Cocaine, yes, a problem but still in comparison
with alcohol quite small. Professor Henry mentioned a total of
87 acute cocaine-related deaths. If you look at the number of
acute alcohol-related deaths, you will find that there are many
times more than that. Even allowing for the fact that far more
people drink alcohol than use cocaine, I think alcohol still wins
hands down. Crack is probably more of a problem than ordinary
cocaine, but only in the sense that distilled alcohol is more
of a problem than non-distilled alcohol. Presumably the amount
of damage you could do to yourself by drinking in the days of
mead and beer and wine was rather less until the Islamic world,
ironically, invented distilling round about the tenth century.
You are bound to have progress in these fields. If you have motor
cars you get more people killed by motor cars than killed by galloping
horses. We cannot disinvent these technical advances. Heroin,
yes addictive but probably somewhat less addictive than nicotine
in the sense that the percentage of people who ever use heroin
who become addicted is probably rather less than the percentage
of people who ever use nicotine and become addicted.
564. Is the Government's policy having an impact
on the morbidity and mortality rates?
(Dr Brewer) Not very much. It could do a lot better.
Government policy cannot work in the field of supply, because
however much you confiscate, the smuggler always seems able to
get through. You get occasional successes, but where you are dealing
with what comes into the category of crimes without victims, at
any rate as seen by the people who use the drugs, it is always
going to be fairly easy, barring some major technological development,
for smuggling to continue. The amount of stuff which is actually
interdicted is tiny. Although drug fashions come and go, certainly
it does not look as though we are having much effect on the amount
of cocaine that comes in judging by the increasing number of people
who use it. If you wipe out a plantation somewhere in Colombia
it will sprout up somewhere else. As far as the effect on the
prison population is concerned, clearly a failure. I presume that
the announcement yesterday of a need for more prisons for women
has something to do with an increase in the number of women addicts.
It seems unlikely that women are suddenly becoming more violent.
Chairman
565. It probably has to do with the fact that
more women are being used as mules from countries which produce
the drugs.
(Dr Brewer) I doubt very much that accounts for the
increase in prisoners. The number of women users is quite large;
the number of mules is relatively small. It could be a factor.
It does not seem to be discouraging use amongst the young. Illicit
drug taking remains common. The big problem is that people are
talking about drugs and alcohol as though they were somehow different.
I do feel that alcohol should be our point of reference. It is
only in this century that the curious idea has grown up that it
is all right to intoxicate yourself with some drugs but not with
others. Until 1916 you could intoxicate yourself with whatever
you liked. You could go to hell in your own handcart, but at least
the law did not interfere. Personally I feel rather strongly we
should go back to that set of Victorian values.
(Professor Strang) May I make the suggestion that
we could probably tell you where we thought we had a particular
contribution to make. The danger is that each one of us would
love to have you exclusively for an entire day to cover all sorts
of territories. My own view is that across the panel here you
have a particular expertise across treatment and rehabilitation
type areas and if you did not grill us heavily about that you
and we would miss out. Within that I would have thought the balance
between psycho-social elements or rehabilitation elements and
the prescribing debate were the two bits.
Chairman: You are absolutely right.
Mrs Dean
566. May I suggest that you initially answer
the question in your own way? Is government policy working? Then
perhaps colleagues will move on.
(Lord Adebowale) Government policy is not working
really. If you look at the current statistics which were produced
on Monday in terms of the number of deaths across the European
Union, half of the deaths from overdoses of illegal drugs took
place in this country. Clearly that would indicate that government
policy is not working. The major emphasis on criminal justice
as opposed to health or lack of equal emphasis on health is a
major problem in that we are not actually treating people, we
are punishing them in that access to treatment in some cases can
only be gained through committing a crime. I have certainly met
people who have taken that route. If I were being honest, as the
question is quite general, I should have to come to the conclusion
that it is not working.
Chairman
567. Turning Point is the largest provider of
treatment services to drug users in the country, but we have heard
it said that it still takes a very long time to get treatment
if you need it. How long does it take to get onto one of your
courses? Does that vary from one part of the country to another?
(Lord Adebowale) It depends on where you are. The
first thing to say is that we are a social care charity. We do
not just provide a substance misuse service, we also work with
people with mental health problems and with learning difficulties.
Last year we saw about 90,000 people and we currently have live
in our files about 36,000 substance misuse cases. Part of the
problem is that it does depend on where you are and the substance
you are misusing or addicted to. There is a major problem with
access to treatment. The waiting lists for the most needy are
often the longest and in places where addiction is prevalent those
are the people who often have to wait the longest. Six to nine
months for access to treatment is not unusual and in fact you
would probably be doing quite well. For young people there is
a cycle of recovery where people contemplate getting information
about treatment. They need that information quickly, they need
to access information quickly; if they do not, then they will
continue using. For Turning Point lack of access to treatment
or lack of education and information about treatment availability
is a major problem.
568. Would you say it comes down to resources?
(Lord Adebowale) Resource is a major area. I would
argue the Government are not spending nearly enough on treatment
and education focused on young people. It has been said that treatment
needs to be made fashionable if young people are going to be able
to access it and it certainly needs to be made available.
569. Do you have any estimate of the increase
which would be necessary in resources?
(Lord Adebowale) If it difficult for me. I do not
have figures for the amount. I am sure that we could come up with
estimates, but I do not think enough emphasis has been placed
on treatment full stop in government policy.
570. Where would you take it away from? Is there
some area where we are spending too much money? The trouble in
Government is that everybody under every heading comes to you
demanding more resources for their particular speciality, whatever
it happens to be. The job of Government is to try to arbitrate
between those conflicting demands.
(Lord Adebowale) I do not have access to the kind
of information which would be needed to answer that question fully
because it is clear from my experience, both at Turning Point
and at the alcohol recovery project where I spent some considerable
time, that spending money on treatment would save some considerable
money further down the line. The fact of the matter is that if
you go to any A&E Department you will find the results of
alcohol misuse before you. We spend very little on alcohol treatment
compared with other areas of drug misuse. The cost benefit is
fairly obvious but we still refuse to spend the money on treatment
and on prevention and the same formula applies to drugs. In some
ways, without wishing to be impertinent, it is not really for
me to say to the Government where to take money from in order
to spend it on this area. I simply say you are not spending enough
and I know that the money could be found. It is a matter of priorities.
571. You say it is a matter of priorities. We
were hoping to offer some suggestions as to what should be prioritised
and what should not.
(Lord Adebowale) You are spending £1 million
per month keeping the dome up. You might want to think about that
for a start.
572. There would be a lot of support for that
suggestion. Professor Strang?
(Professor Strang) I shall try to come back more specifically.
I imagine there is a broad consensus that the Government, or you,
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. I would then come
in and argue from a health care perspective that there are additionally
a further group of people who need treatment for which society
must pay a cost, as with all other considerations. That is part
of what our Government is for, it is to pay money even if the
treatment does not pay for itself. But at least do the first part.
I draw your attention to this book which I hope you have all had
as compulsory reading, but if you have not, you should all be
given it. The Royal College of Physicians and Royal College of
Psychiatrists published a book for you—I do not suppose
they knew they were writing it for you—which came out last
year and it was aimed at what in the old days would have been
a new society-type general public readership. It is called "Drugs
dilemmas and choices". In this, pages 120-121, they compare
our expenditure with the American expenditure. The American expenditure
is massively greater than ours but it is still possible to look
at how they cut up their cake. They cut up a much bigger chunk
of their bigger cake into the treatment and rehabilitation area.
They spend 19 per cent of their cake on treatment and rehabilitation
compared with our 12 per cent. A 50 per cent increase in the proportion,
whatever the size of your cake, going into treatment puts us on
a par with the States and the USA is not famous for having a welfare-oriented
approach, they are more famous for the control-oriented gunboat-type
strategy. The other area I would probably take it away from, which
is hugely controversial, is that I would question the amount of
expenditure in the primary education area. Everybody instinctively
feels it must be a good thing. I have to tell you that there is
an incredibly flimsy evidence base for whether it is an investment
which is worthwhile. It may be unacceptable to the public to take
too much of it away, but if the cold light of scrutiny were put
upon that it would be a desperately disappointing area and I would
shift that type of prevention work at least to secondary prevention—so
preventing the harm amongst those already involved.
573. You will have heard one of our previous
witnesses saying he thought we should spend more on education.
(Professor Strang) I did hear that.
574. It only goes to show that you get a rich,
wide range of responses to a Committee of this sort. Just be specific
about this education which is not working. What are you saying?
That it is not producing results?
(Professor Strang) What I am saying is that I think
you need a businesslike approach to this whole area. You want
to work out where the personal and societal costs are occurring
and also where you and we think you have any influence upon it.
That is why treatment becomes interesting. Treatment has a big
influence on some of those harms with some types of problems.
Not all types of problems, just some selected types. You then
say with your prevention stuff you are willing to spend any amount
on prevention—provided it prevents. But if it does not,
if it just means you have a more knowledgeable population of schoolkids,
who are just as likely to use, then I would say that was not the
objective and a profoundly disappointing result. I would want
evidence that it reduced their use or reduced the harm which resulted
from their use. And that is largely missing.
575. So you would withdraw any drugs education
in schools.
(Professor Strang) What have we done in this country
to study prevention strategies? Project Charlie is constantly
quoted and the evaluation of Project Charlie. If I remember correctly—you
would need to check the figures—the follow-up sample, the
number of kids followed up, was 45. I do not regard that as the
kind of strong solid evidence we should be seeking. If you look
at the big studies that have been done overseas, yes, you have
better quality evidence, but it does not show the promised benefits.
We want to make a real difference. Just wanting to do good is
not good enough, is it?
576. Does it have the opposite effect and spread
knowledge to kids who would not otherwise have it?
(Professor Strang) I am not arguing against for that
reason. I am really arguing that it should be exposed to scrutiny
in a way that all sorts of areas of the drugs policy should be
exposed to scrutiny. I would want customs and interdiction. If
you want customs and interdiction to make drugs less available,
then measure whether they are less available and measure where
the price goes up and purity goes down. It does not. In fact,
it mostly goes in the opposite direction over recent years.
(Lord Adebowale) May I come back? You asked for more
specific facts on costs and cost benefit analysis. I just note
that the National Treatment Outcome Research Study, NTORS, indicated
that treatment works and that for every one pound spent on treatment
three pounds are saved on criminal justice. Perhaps that might
give an indication of where you might take money from.
Chairman: We shall come to that aspect of things
in a moment. It is very controversial, as you have probably gathered.
Mr Cameron
577. Having these experts in treatment here,
it would be a shame if we did not ask them for their views. We
all agree treatment should be expanded but how would you go about
it? I was going to pursue that line of questioning. That is the
key question. Within that there are some subsidiary ones which
perhaps you could all pick up on. Would you like to see a massive
expansion of method and replacement or prescribing heroin?
(Mr Nelles) As someone from the Methadone Alliance,
perhaps it would be appropriate for me to speak on this particular
issue. One of the problems is that methadone treatment is actually
not universally available in this country, so we do not actually
have the standard intervention for long-term opiate drug use available
to everybody in this country. There is also a serious lack of
consensus amongst professionals as to what should be done. This
is very difficult for drug users who are frankly caught in the
middle. I feel some responsibility today, because I am a drug
user myself and I am not sure that this Committee has heard from
very many drug users. It is very important that our voice is heard.
There is certainly a real problem with a lack of resources, there
is a real problem with a system which makes people wait for several
weeks if not months before they can get help. These things need
to be addressed and changed. Certainly we need an expansion of
methadone treatment, however, methadone alone is not enough of
an answer. It does not help the people who have problems with
drugs other than opiates and they need to have their needs addressed,
but also methadone does not seem to attract and hold people into
treatment as well as perhaps other forms of prescribing could.
I have been to visit Holland and I have been to visit the pilot
programme which was referred to in the previous hearing. I was
very struck there by the successes they were having with their
patients who were receiving diamorphine under supervision. I have
to say I am not a great fan of injectable drug use. I think it
is important that it is something which is minimised, but I do
think we have to be realistic and recognise that if we base our
clinics only on oral methadone, which is certainly the case in
many part of this country, we exclude valuable interventions we
know save lives and reduce harm. I have seen people who have been
maintained on heroin, who have a high quality of life and who
are almost indistinguishable from other individuals. I have also
seen people maintained on heroin who have not done so well and
that is why it is important that we do have lots of different
interventions. One of the great fears we have is that the history
of this country, which is one of plenary engagements, means that
we dumb things down to an oral methadone state. It is very important
that we understand that oral methadone has a marvellous track
record, it is a very good treatment. It has an evidence base that
is extremely strong, but it is not enough in and of itself. However,
we certainly do need to be able to get it in all parts of the
country and that is not the case at the moment. I have worked
in Bristol with advocacy clients who have not been able to receive
basic standard oral methadone in Bristol and the person who spoke
earlier was absolutely right, in Bristol you cannot get into methadone
treatment programmes unless you have some other serious problem.
That seems to be the position at the moment. I think that is scandalous.
I know it is not what the providers in Bristol want to have happen,
but it seems to be what comes about.
578. Dr Brewer, I can see you nodding. Would
you agree with that?
(Dr Brewer) Yes. I would add that if you repealed
the whole crazy set of moral panic, First World War legislation
which got us into this mess, largely under American pressure,
you would not need organised methadone maintenance programmes
because we would go back to the Victorian system where people
maintained themselves very happily just as my alcoholic patients,
until they come for treatment, maintain themselves quite happily
on alcohol which they can buy at a large number of outlets. If
you went back to that system—I am not suggesting exactly
the same as Victorian society because society is not the same—people
would maintain themselves on things like laudanum and perhaps
even on methadone which they could buy with some sort of fairly
simple licensing system. Then that would not solve all problems
but many people who find themselves, to their annoyance perhaps
dependent on heroin and therefore having to do frightful things
in order to raise enough money to buy it, would either not need
to commit crime or would commit far fewer crimes, like impoverished
alcoholic patients. You do not have to rob many banks to buy a
bottle of vodka a day. You can almost do it on social security;
in fact quite a few of my patients do. Yes, any attempts to reduce
the waiting lists in the NHS generally are obviously important.
I cannot speak for the rest of the services, but they have clearly
failed in methadone. There are many areas, even in the South East
where services are perhaps slightly better than other areas where
you cannot get an appointment for many months. If you do get an
appointment you may not get any methadone, assuming it is a suitable
case for methadone, for many months after that. Then the doses
are absurdly small. The average methadone dose in this country,
according to a paper of which John Strang was one of the authors
recently, is 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.
Even where you can get methadone, there are very few places which
will give you more than 80mg and they usually push you off that
as quickly as they can. The whole thing is crazy.
579. Would you agree that the priority in terms
of treatment is to make sure that this methadone replacement treatment
is available more quickly to everyone? Is that priority number
one rather than expanding residential care and other things?
(Dr Brewer) Residential care has a massive drop-out
rate. It is fine for the people who stay but something like 80
per cent of them have disappeared within a few months of going
there. They are supposed to stay for long periods. It is far too
expensive. It has a place, but it is a small place. I do not think
we should think of methadone as the only opiate substitute. Methadone
is actually quite a good drug. It has a bad name amongst addicts.
I spend quite a lot of time persuading my patients it is not as
bad as it is painted, but we have a number of other drugs, including
morphine itself. It does not currently have a licence for that
but it does not stop one prescribing it.
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