Examination of Witnesses (Questions 600
- 619)
TUESDAY 27 NOVEMBER 2001
DR COLIN
BREWER, BILL
NELLES, LORD
ADEBOWALE, CBE, AND
PROFESSOR JOHN
STRANG
600. So an analysis of that is that you cannot
impose a reducing dose unless the person wishes.
(Dr Brewer) It is unwise. You can encourage, do a
little gentle arm twisting and you can also offer people various
ways of withdrawing. A lot of the people I have on maintenance
are actually quite keen at some stage to withdraw, but it is quite
difficult. There is a number of techniques which are increasingly
used in various countries which make it virtually certain that
once you have started a detoxification you will complete it and
in somewhat less discomfort than is usual with conventional methods.
It is a pity that the standard response to an 18, 19, 20-year-old
who has started to use heroin is not usually withdrawal, even
though quite a few of them would quite like to be withdrawn before
they get too deeply into it. The waiting lists for withdrawal
are truly a national disgrace. They are much worse even than the
waiting lists for methadone. People wait months or years to get
in and that is really bad.
(Professor Strang) This issue about coercion. I would
not want you to go away thinking that there was not benefit to
coercion. It all depends on what you mean by it. Some degree of
nudging or coaxing or pointing out to people the implications
of their behaviour is a crucial part. It is what we want GPs to
do with their patients about their smoking and their drinking
and similarly their injecting. All of us, I am sure, virtually
everybody we are seeing, is in treatment under coercion. It may
be family pressure, it may be the courts, but it would be a mistake
to disregard the healthy side of this pressure. Your question
about the objectives, I think they have to be health gains. The
only legitimate justification for treatment is that the patient
benefits from the treatment. There are then spin-off benefits
which are a huge bargain for the rest of us. There are public
health gains of less injecting, less HIV, less hepatitis C, there
are criminal justice benefits and they are huge. But the real
legitimacy of the treatment is that the patients themselves derive
benefit. They achieve stability, they get physically better, they
are less likely to overdose. Once you are in a methadone programme,
your likelihood of dying of an overdose is massively reduced.
Incidentally, on the subject of overdose, we do not pay attention
to overdose properly. Dying of overdoses clearly gets missed by
what we have addressed as key issues. It has become a big issue
in the last year.
601. Presumably you have to have the co-operation
of the addict, otherwise they would go and supplement their supply
illegally.
(Professor Strang) Yes, but that is what you are dealing
with. Part of what you are working with is that coercion. There
is one aspect about overdose which I hope you might pick up which
is a slightly different one. There is a controversy at the moment
about how acceptable it is to engage addicts, users, their family
and the wider public in teaching resuscitation, training to resuscitate
each other. And also a key issue about whether naloxone, which
is an opiate "antidote" should be available. We have
recently started introducing it in a few places in this country
but there are also concerns being voiced that this is condoning
the behaviour. I would have thought it would be very legitimate
for you to look at the rights and wrongs of it and I should be
delighted if you formed a view on it. The argument is that it
is a complete reversal; rather like Dr Brewer's naltrexone, this
is a rapid, short acting, antidote. It is what gets given in the
casualty department or in the ambulance. The proposal has been
to go one step further: why should the parent or the partner or
the user themselves not have that antidote? Personally I think
the arguments are overwhelming. I cannot see a logic for not doing
so. But it has to be said that opinion is divided and other people
think this is condoning the behaviour and sending a mixed message.
It probably is but I believe that if it is saving a life, then
I can cope with the odd mixed message.
(Mr Nelles) I have to say that in my experience coercion
is rarely successful in helping drug users to abandon their drug
use. The factors which lead people to decide to stop are many
and varied. If you have a system—and indeed we had a system
in this country in the late 1970s and early 1980s—where
you really abandon providing maintenance treatment and you go
over to short detox because you feel it is important that people
come off the drugs, it is of course important that we give people
every assistance to come off when they want to, but we have to
recognise that, particularly with opiate use, this is something
which is physiologically reinforced by the chemistry of the brain
and the way that the brain changes when someone takes opiates
for a long period of time. Opiates are very benign drugs on the
body but they do cause a significant change in brain chemistry,
in the endorphin system. In some people this is very hard to return
to normal and we are getting more evidence now of what we mean
when we say that. We now have the ability to look inside some
of these very delicate systems in the brain. We have to understand
that some people cannot exercise a choice over whether or not
they give up opiates; it is not something they can do. What they
can do is live and manage that dependency. We should recognise
that this is perhaps our greatest obligation to drug users: to
help them stay alive.
Chairman
602. Given that we think coercion does not really
work, would you say the Drug Abstinence Order which the courts
now have the power to impose is not a good idea?
(Mr Nelles) Drug treatment orders are possibly a good
idea. To have abstinence as the end goal is probably mistaken.
(Dr Brewer) There is one situation where
coercion is very valuable and that is when you are treating someone
in the context of a probation order in a judicial setting. As
you will gather, I do not particularly mind whether people cease
their anti-social behaviour by a good methadone programme or a
good naltrexone programme, but if people are having adequate doses
of oral methadone, perhaps even of injectable methadone and they
still are offending in order to get heroin, you have to say to
them that clearly they have to try something else, at least unless
heroin prescribing were available, which might in that case be
quite useful. If it is not available and if people are still offending,
you cannot suddenly change the law and the way it is enforced
in order to suit them. A probation order is an ideal setting because
quite a few people are coming into a probation order having been
in prison and if they are lucky having been detoxified in prison.
It is an ideal situation for using naltrexone as a condition of
probation. During the Government's much trumpeted trial of drug
treatment and testing orders, which most of us in the business
think were actually not very much of a success, not because it
could not succeed, but because it was badly planned, badly executed,
the total number of people treated with naltrexone was one. That
seems to me to be a terrible lost opportunity. We know from good
controlled studies that if you take it as a condition of probation,
it massively reduces the amount of heroin people use and reduces
the amount of time they need to spend in prison. That seems to
be an enormous goal and well worth having.
Bridget Prentice
603. To some extent some of you have answered
some of the points I wanted to raise. Mr Nelles said two things
in his last comment which I should like to take up again, when
he talked about taking addicts off when they want. What happens
if the addicts do not want? You also said that we have an obligation
to drug users. Why? Why do we have an obligation to them?
(Mr Nelles) Because they are human beings, they are
our brothers, they are our sisters, they are our family, they
are part of the fabric of our nation. They may have made a choice
which was mistaken and they will pay for that choice in many cases,
but I certainly do not think that we should abandon our commitment
to these people as human beings and as people who need the best
treatment and the best interventions we can give them.
604. Is it not an argument that if they have
made that choice, they should be allowed to get on with it?
(Mr Nelles) If everyone were punished for the choices
they make we would have a very, very different world. I am sorry,
human nature being what it is . . . My own case would be illustrative
here. I started using opiates when I was studying to be a nurse.
I was someone who it could be said certainly had an intellectual
understanding of the problems which would come from continuing
to use these substances. But because the effects of the drugs
were pleasurable and because I managed very well because I was
able to get clean, sterile drugs, it was not really until I came
back to Britain and found that the treatment system refused to
prescribe injectable drugs that I really started to run into problems.
I did very well on oral methadone eventually, but I sustained
a lot of harm in the meantime and that is why I do feel that injectable
prescribing is very important. To go back to your other point,
I can understand the concern that people feel, the general public
feel, at the idea of drug users dying, at the idea that young
peoples' lives are taking different directions and they do not
realise their potential, but I feel what we need is a compassionate
and caring approach which encourages people to make contact with
treatment providers and does not blame them overly—we should
not applaud it but we should not blame them overly—for a
mistake which people made often when they were younger and for
which they pay for many years.
605. I have no disagreement with what you are
saying personally. On the other hand, a lot of the evidence we
have been given would suggest that a lot of these drugs, as Nick
Davies of The Guardian said, harm neither body nor mind.
(Mr Nelles) I would not agree with that. Heroin does
harm people in the sense that they fail to reach their potential.
We should not encourage people to use it but we have to be realistic
and accept that at this point in our culture, heroin is very available;
we do not seem to be able to do anything to stop that. I have
seen so many occasions when we have been told we are going to
get harder on this, we are going to deal with it in a more robust
way and I do not see things changing. What I do see changing is
the situation in countries like the Netherlands and Switzerland
where they have perhaps been more canny and started to realise
that by helping addicts to manage their dependency, they then
actually get a lot of benefits back for society in reduced crime,
reduced acquisitive crime. These sorts of benefits would have
their impact on public opinion in this country. If you ask people
in Holland what they think of drug users, the public opinion is
much more ameliorated than it is in this country because in this
country there are no good facilities, therefore many heroin users
are a problem.
606. I want to go back to the business of the
GPs. You gave me the example of Holland and Switzerland and that
drug management actually makes people generally more tolerant
and co-operative with drug users. I have to say quite frankly
I am appalled by what you tell us about GPs. I suspect that this
afternoon the Chancellor of the Exchequer is going to pour yet
more money into the National Health Service and I am beginning
to wonder what the point is if the GPs are simply refusing to
treat people. Can you give me one other example of where GPs refuse
to treat a class of people?
(Dr Brewer) Abortion, at one time, not now.
(Lord Adebowale) Poor people.
(Professor Strang) One of our papers was entitled
Discrimination on Grounds of Diagnosis. That is essentially what
you have.
(Lord Adebowale) Homeless people, poor people, to
go back to what I was saying about the 88 worst estates and access
to GPs. Services are very poor in those areas.
607. You are making the case for GPs even worse
than I first thought.
(Lord Adebowale) I am a bit concerned and I hope that
we move onto other areas of substance misuse because the focus
on injecting heroin can give a distorted picture Certainly the
use of crack cocaine is something we should be as concerned about
and the use of stimulants simply because the use of those drugs
is attracting members of the community who are particularly young,
particularly members from minority ethnic communities. It is my
view that we have an opportunity to put strategy in place to deal
with stimulant misuse if we are brave enough, which is not to
say we should ignore or indeed—
Chairman
608. Yes, by all means move onto these other
areas briefly, bearing in mind that we have had a lot of witnesses
and many of them have dealt with these areas already. If you want
to touch on them we should be very grateful.
(Lord Adebowale) I feel a lot has gone on and may
I just comment quickly on the answer to your question. I am a
pragmatist so perhaps I will give a pragmatic answer to "Why
bother?". First of all, four million people take illegal
drugs in this country, far more imbibe alcohol, which is a drug,
to the point where it is a danger to themselves and others. It
would seem to me that many of those people pay taxes and we should
therefore provide a service for that reason if for no other. You
asked four questions.
609. You wanted to talk about crack cocaine.
(Lord Adebowale) At Turning Point what we have seen
is a gradual increase in the numbers of people we see who have
crack cocaine problems. Five years ago one per cent of the users
in the southern region were crack cocaine users; it is now 12
per cent. We are seeing a rapid increase. There does not appear
to be a huge body of evidence about what we do with crack cocaine
users in this country. There is no methadone prescription, there
is nothing. The debate about prescribing and injecting heroin
seems to me to revolve around a moral issue when the practical
solutions are staring us in the face. Fine, we can have an interesting
debate about that, but it seems to me that is getting into the
area of angels and needles. The fact of the matter is that there
is a solution. Crack cocaine however is a far more problematic
issue because there is no ready off-the-shelf solution. We are
still in the area of experimentation. It is a highly addictive
drug and we are now seeing the assumptions about crack cocaine
being smashed on a daily basis, that is the assumptions that it
is an inner city drug, generally used by black people. We are
now seeing professionals starting to use crack cocaine, it is
increasing in use and we do not appear to have an approach other
than a criminal justice one. It seems to me that the use of crack
cocaine is not known to be as widely used as heroin although there
is some evidence that crack cocaine users also use heroin.
610. Do you have a suggestion?
(Lord Adebowale) Firstly, there is not enough treatment—funnily
enough I come back to that point again—for crack cocaine
and stimulant users. Secondly, we have not started fully looking
at the research base in terms of what works for crack cocaine
users. Enough work is not being done on poly drug misuse. One
of the issues which was raised earlier about motivation and accessing
services for heroin users assumes that is all they are using.
Many heroin users are also using alcohol and using stimulants—
611. Including crack cocaine.
(Lord Adebowale) Exactly, including crack cocaine.
Turning Point has been using some alternative interventions, acupuncture
and massage, to try to attract crack misusers into our services
and that appears to be having some effect. I suppose what I am
calling for is a rapid increase in the attention given to crack
and research into what works and the rolling out of what works
and a national crack strategy. That is going to be the next problem.
612. Anybody got any suggestions for this national
crack strategy beyond the ones we have just heard?
(Mr Nelles) It is very important that there are residential
rehabilitation places which can take people for fairly short periods
of time. In my experience crack cocaine is something one recovers
from reasonably quickly if one can abstain from it; when I say
"reasonably quickly" I mean the physical addiction is
not as powerful a problem to detoxify from as opiates. It is very
addictive though and people should be gently separated from the
drug in places which are very caring, very quiet. The idea of
respite care is important here. The idea of giving people a break
from cocaine use, being able to eat well, sleep, get all the things
we know will build people back up.
613. That is no good if they go back to the
environment from which they came, is it? As Dr Brewer said earlier,
somebody knocks on the door on the day they return, do they not?
(Mr Nelles) This is a real problem. I am not sure
I think dealers are quite so hard-nosed. I have met a great many
dealers in my time and whilst many of them want to sell their
product, to say that they have no concerns for their clients is
perhaps an over-statement. That is not to say they are the kindest
people either. I have seen two bids put in for residential respite
houses for crack, both of which do not seem to have got anywhere.
That is a great shame because that is exactly the sort of thing
which should be piloted. I sit on the board of City Roads, a well-known
London agency and we certainly want to take that forward. It is
very hard to find the money and the facilities to do it.
(Dr Brewer) There are several companies working on
a kind of naltrexone for cocaine. In principle you can now make
a blocking agent, an anti-body, an antidote to almost any drug
of abuse. This is one of the benefits of the new genetics. We
hope that within a few years we shall actually have some drugs
of this kind and that there is a reasonable chance they can be
tailor-made for any drug of abuse with the possible exception
of alcohol, simply because alcohol is such a weak drug you have
to take it in tens of grams. I do think one thing the Government
can do is push a lot more money into basic research of the kind
David Nutt does. We punch well below our weight in research in
this area. Generally in medicine Britain punches above its weight,
but in this field of fundamental research into brain processes,
the amount spent is probably rather small.
(Professor Strang) With regard to cocaine, the most
honest answer we can give you is that there is nothing very special
we can tell you and that there are no very special treatments.
It is not that it does not matter, but I feel a bit like a cancer
specialist coming to you saying we can do great things around
better quality treatment for breast cancer and you asking why
we cannot do the same for lung cancer. The plain answer is that
it is just much worse news to have lung cancer. The message I
hope we get across to you is that there are some types of addiction
problems where it can make a massive difference with very specific
types of treatments and there are others where we are reliant
on general principles such as you outlined, like getting somebody
to change the environment they are in, what might be known as
"doing a geographical" and those things. They are important,
but they are not so much the subject of debate.
614. One of the arguments made by those who
argue for a liberalisation of the heroin regime is that that would
then free criminal justice resources to focus on the most damaging
drugs for which there are no medical solutions, to wit crack.
(Professor Strang) I should have thought it was irrelevant
either way. People are arguing that from both ends of the divide.
I suspect it would be completely neutral.
(Lord Adebowale) You mentioned the environment in
which people come from. It is important to emphasise that it is
connected to the issue of resources. We have a £1 billion
neighbourhood renewal programme currently in place. It is supposed
to focus on the 88 worst estates in which you will find the whole
range of drug problems. If you look at that strategy, and I bear
some responsibility for some pages of that, those bits which refer
to young people, you will find little reference to the spend on
drug treatment. I think it would be scandalous for us to go off
and do this exercise without emphasising the need for those neighbourhood
renewal programmes to provide treatment for those people who most
need it in the areas where they are most needed. People are far
wiser, certain drug misusers are far wiser, than we have given
them credit and people are perfectly capable of staying away from
the dealer if they are given access to the treatment. I do not
go along with Professor Strang's last statement simply because
the amount of time wasted in debating the issue of injecting or
not injecting and the paraphernalia around that debate takes our
minds away from what we should be focusing on, which are areas
like crack misuse and cocaine misuse which we know very little
about and which tend to affect those clients, young, minority
ethnic young people, the population of which is going to soar
over the next 20 years. We need to be paying much more attention
to that area.
Mr Prosser
615. On the theme of the thousand flowers blooming
and all the various treatments for various people's needs, is
it not right that even taking into account the pyramid effect
for injectable or prescribed drugs and the various types of residential
and abstention treatments, we are really getting down to two basic
principles: abstention or prescription? I think that is almost
self-evident. If that is the case, can you give us a feel, I have
no idea at all, even in your own personal experiences, how that
breaks down, 50 per cent would require one or something else?
(Mr Nelles) There is no contradiction in having both
approaches working together, but it is difficult to do them in
the same agency or in the same department. It is very important
that we have harm reduction initiatives and prescribing approaches
for people who are not able to give up and we have rehabilitation
and detoxification approaches for people who do want to give up.
That is incredibly important.
616. On the issue of residential care, Dr Brewer
told us about 80 per cent are re-offending and coming back, re-using
and retaining a problem. I have a private centre in my constituency,
Northbourne, and they assure me that their figures are the opposite
and that 80 per cent do not go back to drugs.
(Mr Nelles) I have to say that the NTORS study evidence
is really quite strong on this, that 51 per cent of people are
drug free after a significant number of years after attending
residential rehab. It is important to understand that residential
rehab is very important. It changed my life. Without a doubt,
by going into residential rehab at the time I did, I learnt essential
principles of self-discipline which kept me alive and that is
why it is very valuable. I do not think we can say that it works
for everybody and the best places do not seem to get a result
of much more than about 55 to 60 per cent, in fact I think that
is a slight exaggeration.
(Lord Adebowale) Two points. The first is that Turning
Point does not subscribe to abstention or management; we provide
both. It is true that it is horses for course. One person who
might start with abstention in mind might end up managing and
vice-versa. You have to provide the appropriate opportunities
for the individual. I understood, and perhaps Professor Strang
will tell me I am wrong here, but there is something called the
Prochaska and di Clemente's, a cycle of recovery, which is, and
I believe this to be true, that people generally do not give up
and walk away and never come back. Some do, but generally people
relapse; that is what they do. They do on alcohol and they do
on most other drugs. Part of the problem we have—and I have
talked to many civil servants and Ministers—is that they
do not apply the same rules to everyone else which are apparent
in their own lives. The expectation that someone who has a life-long
addiction to a very addictive drug, be it cigarettes or alcohol
or any of the others, has three months in a residential facility
and then they just stop can be unrealistic. What you have to do
is provide the basis on which we understand that relapse is part
of the recovery process for some people and that they will relapse
and that you require a treatment regime which enables them to
come back when they relapse and that they are held by that treatment
regime and that they do not fail. Having invested the time and
the money to get them to the point where they are even at a pre-contemplative
stage or contemplating recovery, or indeed having experienced
recovery, to then abandon them because they relapse, seems to
me to be a complete waste. That is part of the problem in talking
about 80 per cent dropping out. They might do, but many come back.
(Mr Nelles) And many will have benefits from the period
of time they have spent in residential rehabilitation. That is
important to bear in mind.
(Professor Strang) NTORS has been mentioned to you
and I am now concerned that you have not even come across their
reports. For example, I hope you have had copies of the NTORS
publications because it is one of the very few bits of substantial
research done in this country and it addresses not all but quite
a number of the issues you have raised. I am also delighted that
such a setting gives you such educational opportunities as Prochaska
di Clemente's, cycle of recovery. What Victor has said is an excellent
summary. All sorts of things in health care give a health gain
and you come back again and that goes for chronic bronchitis,
athletes' foot, anything you can think of. Looking at substantial
health gain while you are doing it, you are aware that there is
a risk it might relapse but if so you want then to treat it faster.
There is nothing very special about the addiction field from that
point of view.
617. If we were to find ourselves making recommendations
to government to decriminalise or legalise drug use and provide
prescriptions, could Dr Brewer give us some advice, three or four
points on the stages we should recommend to move from where we
are now to where you would like us to arrive, the return to Victorian
values? How would you do that?
(Dr Brewer) First of all I should get you to read
Professor Berridge. This is written by our leading historian of
legislation and opiate use, Opium and the People by Virginia Berridge.
Some of the final chapters give a very good explanation—it
would be quite funny were it not so tragic—of the arguments
which went on in 1916 and how really America inflicted a sort
of pharmacological colonialism on the rest of the world. That
is what happened. Nobody else was terribly concerned about banning
opiates. It was an American initiative. Perhaps there are some
resonances for today. I should start by reading that and realise
that actually when you could buy the stuff fairly freely in a
chemist's shop the British Empire did not grind to a halt. I would
make one change, which is that I suspect that quite a lot of the
Victorian opiate users were not teenagers and adolescents; the
teens perhaps started earlier and ended earlier in those days.
You have to do something in the way of testing in schools to identify
those people still under some sort of tutelage and supervision
who are starting to use drugs early, starting with nicotine. Early
smoking is one of the best predictors of later disaster. It is
very rare for me to come across a heroin addict who does not smoke
and never has smoked. You have to monitor what goes on in schools
and perhaps introduce some sort of sanctions while you have them
up to the age of 16 in a situation where you can actually do a
bit of insisting. After that I would experiment with the less
controversial drugs, of which cannabis obviously heads the list.
Ecstasy, in terms of its abilities to cause serious harm and more
importantly serious anti-social behaviour, is really quite small
beer. We have to return to the idea that people have a right to
make mistakes, provided those mistakes do not impinge unduly on
the rest of society. We do not dispute the right of people to
drink alcohol and to get drunk on alcohol, even though that regularly
causes catastrophic damage for families and individuals and for
society. I really cannot for the life of me see the difference
in principle between getting intoxicated on alcohol, getting intoxicated
on cocaine and getting intoxicated on heroin except that heroin
addicts, if they have too much, generally just fall asleep somewhere
quietly and do not disturb. I would look very seriously at the
history of this. After all it started across the road in Parliament
presumably. It seems to have been passed on the nod like other
important legislation. According to Professor Berridge, at one
important stage of the debate there was barely a quorum in the
House. We got into this mess unthinkingly and here we still are
80 years later.
(Professor Strang) That is a pretty wide-ranging response.
I would come at it from the other end. I would look at where we
are now and whether a change in one direction or another direction
would be a change for the better or worse. Personally I think
you should first charge us or charge whoever else you can charge,
charge the Government, with making sure there is universal access
to good quality oral methadone maintenance. Here is a treatment
on which we now have a worldwide evidence base. Within our NHS
it is scandalous that there is not prompt access to bog standard
good quality oral methadone maintenance treatment. My next objective
would then be to ensure that we had some extra treatments for
more unusual cases or people who do not benefit from the treatment
at the first level or layer. That is where I bring my injectables
in as the next layer up. You would need to work out what it is
that warrants your need to move up to the next level of treatment.
It would not be very difficult to work it out, and you would need
a working percentage, maybe ten per cent of the people in treatment
would need to go up to that next level of injectables. With that
are security implications. How would you do that in a way which
did not just leak out onto the streets? Some of them are commonsense
measures like returning ampoules which you have heard about today.
(Mr Nelles) Not giving people too large a supply at
one time.
(Professor Strang) We should look very carefully at—both
the Swiss and the Dutch have set them up—supervised injecting
rooms as one measure, not as a universal necessary requirement
but as part of that. I would see those as tinkering with what
we have to make what we have work better.
618. What would you say to those who say legalise
heroin, make it available.
(Professor Strang) I would get them to remind me how
many people it is, what percentage of this country currently who
have gone down the pathway of ever using heroin: something like
one per cent, probably less.
619. A lot less than that.
(Professor Strang) A pretty small proportion. There
is a mistaken belief that the rest of the general public just
would not. If you want the most extreme other end, that if circumstances
get bad or you feel they are bad what proportion of honourable
and upright citizens might get caught up in a heroin addiction
problem, I realise it is a very different situation, but clean-cut
American kids were sent off to Vietnam and over 40 per cent of
them got involved in heroin addiction out there.
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