Examination of Witnesses (Questions 580
- 599)
TUESDAY 27 NOVEMBER 2001
DR COLIN
BREWER, BILL
NELLES, LORD
ADEBOWALE, CBE, AND
PROFESSOR JOHN
STRANG
580. Should it be licensed?
(Dr Brewer) I am sorry, I should have said it does
not have a product licence. You do not need a medical licence
to prescribe it. Even though I do not have a licence to prescribe
heroin I do have one patient who is maintained because he has
an underlying painful condition for which I am allowed to prescribe.
He functions perfectly well. He works hard despite his medical
condition. If you were standing next to him on the Tube, you would
not know he was any different from anyone else. He has about 400mg
or 500mg of heroin daily which he actually injects intramuscularly
and he buys it as heroin powder, which is not officially approved
of, but it makes it about one tenth of the price. It costs him,
on a private prescription, about £30 per week, which is something
many people could afford. It is cigarette money.
581. It sounds as though the message you are
giving us is that for different forms of treatment you need different
things. There is a sort of "Let a thousand flowers bloom".
For some people it is methadone replacement; there ought to be
more diamorphine prescribing. Is that a right message for us to
be taking away?
(Dr Brewer) As well as maintenance prescribing with
opiates, we are seriously deficient in this country in the polar
opposite of maintenance prescribing which is a drug called naltrexone,
which is a heroin blocking drug. Once you are maintained on naltrexone
you stop using heroin. In fact if I could have done, I would have
brought a patient here to demonstrate. I was hoping I could inject
him with a vast dose of heroin in front of you to show that when
someone has swallowed naltrexone heroin has no effect.
582. It has none of the pleasurable effects.
(Dr Brewer) No effect at all. It just blocks it completely.
It is very under-used here. In many other countries, particularly
more in southern Europe, it is a standard part of the range of
treatments. An addiction clinic should be rather like—
583. This is a new one on me and I think on
all of us. Can we just understand this? This is a drug which—
(Dr Brewer) You have to be detoxified first.
584. So you are no longer feeling the need for
heroin.
(Dr Brewer) On the contrary, you are feeling the need
very much when you have been detoxified which is why most detoxified
people relapse within a very short period of being detoxified.
If you are taking naltrexone, and that means encouraging people
to take it and usually involving the family in seeing that it
is taken regularly, it is a great help as shown in several proper
randomised trials, and it does help people resist the temptation.
You go out of a hospital, out of rehab, usually back to your old
environments with the same sights and sounds and smells and the
dealers sometimes literally knocking on the door saying, "Hi.
Welcome back. You've come out of rehab. I've got some really good
stuff for you". It is asking rather a lot of human nature
for people to say they will be strong, at least all the time.
Naltrexone is not a miracle cure, I do not believe in miracle
cures, but it is a very helpful alternative. I think that 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.
Chairman
585. Is naltrexone very expensive?
(Dr Brewer) No; about £2 per day.
Mr Cameron
586. In that context, any comments about the
National Treatment Agency? If the theory is that we should be
letting a thousand flowers bloom, does it make sense to have a
National Treatment Agency trying to impose?
(Lord Adebowale) On the question of methadone replacement,
clearly it is one treatment in a whole plethora of other treatments.
You have to get access to it and doctors are generally reluctant
to work with people with addictions and there is an issue about
access to appropriate equipment. The Hungerford project, which
is a Turning Point project in Soho, relatively new, has been very
busy. In the last eight months we have had over 25,000 contacts,
an average of 150 a day and have seen approximately 1,500 different
individuals. It comes back to the point, and it is worth making
the point over and over again, that unless people have appropriate
access to treatment, no matter how effective it is, it will not
work. We have been working with something called locality prescribing,
which is run in partnership with GPs which has helped gain access
to methadone users. We prescribe in accordance with Department
of Health guidelines. This particular method has been very popular
with both GPs and users because the clinic is in familiar settings
which are less intimidating that doctors' surgeries and drug users
are accepted and their situation and needs are known by drug workers
who work in partnership with the GPs. There are methods which
do work and have been shown to work and are popular with drug
users and GPs but they are not available everywhere. They are
not available in those areas where they are needed most. May I
just touch on the NTA and then on others? Turning Point is in
full support of the NTA and indeed the response to the suggestion
to let a thousand flowers grow is that the NTA is there to stop
us from wasting a lot of fertiliser. That is why they are there.
A lot of work and a lot of money needs to be spent on finding
out what works. What we do know is that different people respond
to different treatments and this is across both alcohol and other
drugs. The NTA is a welcome resource for capturing what works
and then spending appropriate sums on spreading the good work.
(Mr Nelles) The example of shared care, which is what
this process has become known as, where doctors work in alliance
with local drug services, is very much the way forward. I speak
as someone who started the first GP prescribing programme in Reading
some 20 years ago. It is extremely important to bring GPs in,
however they need training and they need assistance. We cannot
expect GPs, very busy as they are, to carry the sort of case loads
we would expect. What we need are people to work with the GPs
and assist them, but we also need better training for GPs because
while some do a very good job prescribing, others can cause harm
through their initiatives. This is an important point that we
need to make. Some of the harm which comes from drug use is to
do with the drugs themselves and some is to do with the criminalisation
process. We need to help people to manage their drug dependency
in a way which we used to much more in the 1960s and I am afraid
we have rather gone away from, because we feel that to help people
learn to manage their dependency is somehow condoning and approving
of the practice. This is very ill judged logic The important thing
is that the treatment accepts that for some people abstinence
is not realistic and they need the assistance and care which can
come from prolonged contact with people who may provide them with
clean and sterile supplies of the drugs. One thing I should also
like to mention is that heroin does not have to be very expensive
as a treatment. The way it is currently prescribed in glass ampoules
is certainly expensive, but if we returned to the principle of
having hypodermic tablets, for instance, which could be used quite
safely, we would get a lot less expensive heroin programmes when
we cost them. I do not want to say that heroin is the answer,
because I do not think that it is, but it is one of the answers.
(Professor Strang) I have another angle on the let
a thousand flowers bloom. The whole point about it is that you
then have to strip some of them out when you discover they are
weeds or that others are doing better. You were obviously wanting
to check out this issue of heroin prescribing. I would encourage
you, if I might be so bold, to think more widely. The real issue
is injectable prescribing of which heroin is the most famous.
It may possibly be the most attractive but it is not the only
one and in this country a far more common practice is injectable
methadone prescribing. At least in your consideration, the big
controversial practice which goes on in this country is injectable
prescribing, whether it is heroin or methadone. In this area,
it is injectable prescribing which sets this country apart from
the rest of the world.
587. Could you explain that in a bit more detail?
At the moment most people who take methadone in this country are
taking it orally.
(Professor Strang) Yes. I would suggest that you should
consider injectable methadone as if it was an altogether different
drug from oral methadone. I know it is chemically the same drug,
but in terms of its appeal and its contribution, it has something
much closer to heroin in terms of—
588. You get a more immediate high when you
take it.
(Professor Strang) Yes. I am not saying it is the
same, but it is closer to heroin in its experience; and hence
the injectable methadone debate is closer to the heroin debate.
And, furthermore, injectable methadone debate, like injectable
heroin, is there on your doorstep.
589. Is your feeling that if addicts were allowed
to have injectable methadone, they would find that closer to heroin
and therefore would not buy street heroin? Is that what you are
saying?
(Professor Strang) Without question that is true.
Whether that is the right choice or whether heroin might be a
better choice or whether none of them would be a better choice
is a different matter. But it is definitely true that in the continuum
it is between the two and in my view it is one hell of a sight
closer to the injectable heroin than oral methadone.
590. Professor Strang, you obviously have strong
views. What would you change if you were writing our report on
the heroin front; heroin prescribing, methadone prescribing, oral,
injectable? Where do you think policy should end up?
(Professor Strang) I would probably go scurrying along
to someone like Bill Nelles and ask his advice. You could be hard
pushed to do much better. What you are wanting is a layered system.
Let us look at an example first. Many people have heart disease.
You do not say everybody has to have a heart transplant. You have
the idea that, of 1,000 people with heart disease, you hope to
be able to manage 750 of them in a straightforward way in a GP
setting, another 100 might need something more specialist locally
and only perhaps five or whatever might need the most expensive
controversial treatment. Your equivalent in this field would be
to ensure universal prompt availability of methadone maintenance
treatment which would not be the sub-optimal treatment that we
have, but would be good quality, proper doses, good psycho-social
care. That would be universally available and it has an international
stamp of evidence to support it. You then move on to more unorthodox
less commonly prescribed treatments which might be more specialist
and I would see injectable maintenance as being in that category
and I would probably create a bit of a hierarchy within the injectable
maintenance with injectable methadone being the next step in this
pyramid and injectable heroin being the next level up. You can
add as many levels as you want if it gives a better fit to the
model. It would be absurd to be seeing heroin as your treatment
response to early cases or first cases. But if we tried to implement
this layered system today, we immediately encounter a problem.
The problem is you do not have the capacity and you do not have
the training infrastructure for that pyramid. For example, at
the Maudsley we have a small supervised injecting clinic like
the Swiss or Dutch one, very small. Our bid to the drug czar's
treatment fund or ADCU's treatment fund was short-listed but that
is not much use when it is then not funded. Our bid to local funders
fails to get an increased capacity. We get other projects supported
such as liaison workers but we do not get an increased straightforward
treatment capacity.
591. In order for you to produce this pyramid
of treatments so you can have the right treatment for the right
sort of addict which is going to help them eventually get off
the drug, what has actually got to change in the Government's
drug strategy?
(Lord Adebowale) I am not sure whether your question
is just referring to heroin and injecting users.
592. On opiate users to start.
(Lord Adebowale) Opiates. Firstly, what you have heard
and what we would agree with, what I would agree with is that
injecting treatments do have a place and the only objection to
them is based on a kind of prurience and what the press might
say. That is the first thing. We need to say it works. The second
thing is that GPs need to be given the tools to get on with it
and indeed they need to be encouraged to do it because there is
evidence that GPs are reluctant not only to treat any person who
has a substance misuse problem, whatever the substance, because
they are concerned about the effect on their reputation professionally.
That is a real problem. The third thing you heard and you will
certainly hear it from me is that the barriers to providing shared
care arrangements with GPs are not real. In other words, there
are methods—my colleague has called it shared care, we call
it locality prescribing—which deal with the potential for
disruption within clinics, which have a controlled but appropriate
group of clients which is managed in partnership with organisations
like mine and we know that these prescribing regimes can also
engage other medical professionals like nurses. There is a model
there. There is a model, it works and it requires GPs to be appropriately
trained, to be encouraged to use it and it needs to be made widely
available. That only deals with a certain type of substance misuser
and we must not see that as the only answer. May I very quickly
respond to Dr Brewer's comments about residential services because
I would not want that to lie as an answer simply because we provide
a lot of residential services and because my own background tells
me that 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.
Chairman
593. Is Dr Brewer right that there is an 80
per cent drop-out?
(Lord Adebowale) On some programmes I am sure there
is a high drop-out rate, on others there is a significant retention.
It all depends on the treatment programme which is attached to
the residential service which is provided and how good that residential
service is. Certainly that is not the case at Turning Point.
Mr Cameron
594. One point I did not quite understand about
what you said which was otherwise extremely clear and very, very
helpful. Are you saying that GPs should be trained and it should
be GPs who would be providing the injectable or oral or whatever,
or would you see expansion of your own sector, the voluntary sector
as being perhaps the provider of those services? You have all
sorts of problems with GPs, their regular clients being worried
about sharing surgeries and addicts etcetera.
(Lord Adebowale) I am saying both things are the case.
There is a general problem with GPs, if you talk to the Social
Exclusion Unit, and the Department of Health would back this up,
and that is first of all the recruitment of GPs and the reluctance
of those GPs to work in areas where they are most needed. If you
look at any one of the 88 worst estates in the neighbourhood renewal
strategy you will see we have a problem with GPs generally. What
we would argue for is better training of GPs. They are obviously
a major resource and it is where people go when they have medical
problems, but GPs themselves need to be supported with additional
resources which the voluntary sector can provide. It is both.
(Mr Nelles) They also need to be financed. One of
the problems is that providing care to drug users is not what
is called a core medical service for general practitioners. This
is a real problem because general practitioners are expected to
do a great deal on the budget they have. In my experience, one
of the things which has encouraged GPs to become involved is paying
them specific sums to set up specific treatment programmes for
drug users. This is a very important point that we must not overlook.
Chairman
595. This is something which could be done by
practice nurses rather than GPs.
(Mr Nelles) Yes.
596. If you look at Sunderland, part of which
I represent, we have a chronic shortage of GPs.
(Lord Adebowale) May I support that in that there
are more nurses working in the substance misuse field than doctors
and nurse prescribing is something we would certainly encourage.
It needs to be properly evaluated of course and the training needs
to be made available. It seems to me that the full panoply of
health professionals needs to be brought to bear on what is a
serious health problem. I find it astonishing that there is no
incentive process to encourage GPs to work in areas where there
is obviously greatest need and to work with those clients who
have the most severe problems. Some of those will be substance
misusers.
597. Part of the problem is that all the doctors
in the world really would like to work in California, is it not?
(Lord Adebowale) So would most chief executives of
charities.
(Dr Brewer) One of the problems, I am sorry to say,
is that most GPs hate addicts and wish they would all go and quietly
die somewhere. That is not much of an exaggeration. They do not
even like alcoholics, even though doctors being reasonably fond
of a drop themselves can empathise rather more with alcoholic
patients than with patients whose taste is for other drugs. It
is not just a question as in the case of alcoholic patients of
"I'm a doctor, I'm educated and middle class and you perhaps
as an alcoholic patient are not, but at least we know what a glass
of whisky tastes like", but with drugs it is a question of
mainly middle class, middle aged, doctors completely unable to
penetrate the culture which is a couple of generations removed
from them of predominantly youngish working class, quite a few
unemployed, but many employed, heroin addicts who work very hard
to support their habit. It is like family planning. There are
many doctors who would not prescribe the pill when it came out
because like addiction it has a moral dimension. This is the great
problem. It is not just a medical issue it is a moral and political
one. You just have to find a way, as we did with family planning,
of saying if they did not like prescribing the pill, fine, but
they should not pretend they were a general practitioner in the
fullest sense. You either pay people, you bribe people as in the
case of family planning when we said if they provided a contraceptive
service they would receive more money, so how about that, maybe
that would change their minds, or we set up easily accessible
clinics without much of a waiting list, staffed by people who
either have a positive or at least a neutral attitude to the issue.
That is the secret, because you are never going to persuade people
who think that addicts should be shot to learn to love them. It
is pointless to try.
(Professor Strang) I very much agree with Dr Brewer's
point about there being a major problem of GP reluctance. Part
of the unit I run is a research unit as well as the treatment
side. We have recently completed a national survey of GPs and
50 per cent of them would not prescribe methadone under any circumstances.
Whether you regard the 50 per cent as good news or bad news is
that old joke of whether you are an optimist or pessimist. The
cautionary note I would add about the huge enthusiasm we have
in this country for pushing it out to GPs is that it is rather
like community care and psychiatry and mental health services:
what was initially a good idea gets embraced by the accountant
as being a good way of shifting costs with a complete disregard
for the quality of what is then provided. Referring you back to
what I know is now going to be your compulsive reading, page 227
of "Drugs dilemmas and choices", this gives you snippets
of the key bits of information. Page 227 describes a very elegant
study from the States comparing basic methadone maintenance treatment
(with nothing much more, like the legally minimum extras of the
social care), with a standard programme (with all the ancillary
care) and then thirdly a deluxe treatment (like the Hilton equivalent).
The drug is the same in all three of those and when they followed
them up: just the drug on its own, 71 per cent of their people
are still using drugs a year later; the standard treatment, only
53 per cent are still using; the deluxe treatment is hardly any
better, 51 per cent. Going from just a methadone prescription
to your broader social programme you are almost doubling the proportion
who have managed to give up street drugs. The problem we have
in this country is that, however much we might pretend otherwise,
virtually everything we have in this country is what they had
difficulty getting ethical approval for over there, because it
is just the bare prescribing with virtually nothing added. We
need to bring it up to that basic standard of care as a universal
part of what is provided. It is not the drug bits, it is the broader
social programme with quite active engagement of people in building
those other aspects of their lives. The other issue about injectable
prescribing where we have to be cautious about it is that unlike
oral methadone maintenance, where there is a rock solid evidence
base and because it was controversial fortunes have been ploughed
into getting a good evidence base in the States so that it would
be thrown out if it was no good, we have scarcely a single study
of injectable maintenance. Indeed, it was only recently that,
at the National Addiction Centre, we recently undertook and published
the first ever controlled trial of oral versus injectable methadone.
Why did it take us 40 years in this country to do it? Because
there is no investment in the research side of the treatment process.
Addiction research in this country still depended on us saying
"To hell with it. We shall just try to do it in our spare
time". That is a real problem for the future because decisions
will be made in this sort of setting and five years from now we
still will not know whether it was the right choice or not.
598. Do other countries not have research we
can draw on?
(Professor Strang) They have not had injectable prescribing
and we are at this moment being overtaken by the Dutch. It is
really good news that we will have the results from the Dutch
experiment. However, I hope collectively Government and society
feel pretty ashamed of the fact that we could not be bothered
to make that investment to find out for ourselves whether what
we were doing was worthwhile. It shows a disregard for the subject
as though we do not care about whether the treatment works.
(Mr Nelles) I should like to make one important point
about oral methadone and that is that it does tend to polarise
the outcome of treatment more than prescribing heroin. The Mitcheson
and Hartnoll paper in the 1970s represents a significant point
at which practitioners decided to move away from managing addiction
to trying to cure addiction because there was this evidence that
if oral methadone only was provided, some people did better because
they had an incentive to move forward, whereas a lot of people
had harm because they dropped out of treatment because the oral
methadone was not acceptable. I do think Professor Strang's point
that the issue is about injectable prescribing is extremely important.
There are some benefits to the prescription of methadone by injection.
There are some problems but the big one is that people need to
inject far less. Injectable methadone is usually one dose a day
and one dose a day will hold people. Injectable heroin involves
more injection episodes and even the best addicts with the best
injection technique will eventually collapse their veins and have
problems. It is at that sort of point that we are not very good
at having interventions which will help people at that sort of
stage.
Angela Watkinson
599. I should like to ask what you perceive
as the purpose or the aim of having a prescribing policy? Is it
simply to maintain the habit of the addict for as long as they
want on the dose they require, or is it to assume a reducing dose
with the eventual aim of cure? Are drug addicts similar to alcoholics
in that they have to make the decision before that sort of treatment
could be successful? If they are not co-operating, would they
then return to their habit when the course of treatment finished?
(Dr Brewer) The word "cure" is one we rarely
use in the addiction field. "Management" certainly and
yes, some of our patients do oblige us eventually for a variety
of reasons, sometimes to our surprise, by remaining free either
completely of the use of the particular drug which caused them
problems or they reduce it to a rate which does not really cause
many problems. With alcoholics, if they are physically dependent
on alcohol, in the sense that they are very uncomfortable if they
do not have it, and they get the shakes in the morning and start
seeing pink elephants, they can maintain themselves quite easily
by just buying the stuff legally and there are many tens of thousands
of alcoholics who do this. They are more obvious than the heroin
addicts because they smell of alcohol, but otherwise their behaviour
may be relatively straightforward, provided their blood alcohol
level does not fall. With heroin, if you are not yet ready to
contemplate giving it up, you either have to stick with your illegal
source, which is the cause of so much crime and other problems,
or you have to go for a maintenance prescription. I am sure John
Strang will back me up, but the research shows that if you push
people off a steady-state maintenance prescription before they
are ready for it, it nearly always ends in tears; they usually
go back to their drug of choice. Therefore the idea of maintaining
people on a steady dose, sometimes for years, as a harm reduction
or harm minimisation technique is quite acceptable. This is not
controversial in most academic areas, but it goes against the
grain at a kind of moral level for lots of people. I sometimes
wonder whether one way of dealing with this is really to ask the
addicts to pay for their methadone in whole or in part. It is
not an expensive drug. My alcoholics pay for their alcohol when
they are maintaining themselves, so why not methadone patients?
Another analogy is that methadone treatment is just like nicotine
treatment for smoking except that the current advice is that you
should tail off the nicotine patches over a period of a few months,
although there are quite a few studies which suggest you should
stay on it for as long as you need. If you banned cigarettes,
but said don't worry you can have all the nicotine patches you
like, you would have a large riot on your hands because there
are people who for various reasons have a habit of smoking. If
they do not get their nicotine that way it is not the same. That
is the analogy with injecting. It may seem a weird habit, but
we cannot disinvent the syringe and some people, for a mixture
of psychological, pharmacological even slightly sexual reasons,
get so much out of the process of injection that they are just
very, very reluctant to give it up. As long as they do it in private,
I actually think it is less antisocial than smoking. At least
they do not leave a ghastly trail of unpleasant smells behind
them.
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