Examination of Witnesses (Questions 781
- 799)
TUESDAY 18 DECEMBER 2001
PROFESSOR JUERGEN
REHM AND
DR GERRIT
VAN SANTEN
Chairman
781. Good morning, gentlemen, and thank you
very much for coming so far to see us. As I think you probably
know, we are examining whether British drugs policy works or not
and what changes we might make to it. We are looking at countries
such as Holland and Switzerland to see what lessons we can learn,
and we hope you are going to assist us with that. Could I start
by asking each of you the background to your programme of prescribing
diamorphine to heroin addicts. What is the scale of the problem
and why did you change your approach?
(Dr van Santen) My perspective is the
perspective of the Municipal Institute of Public Health. I am
the responsible Medical Director of this treatment centre. I am
not from the research staff, so I have a practical perspective.
In the City of Amsterdam our Institute has a general responsibility
in providing the necessary care to every Amsterdam citizen, and
in the Department for Mental Health in our Institute we offer
probation care mainly for heroin addicts and we offer outreach
care in 24-hour form. Since the existence of our heroin epidemic
which started in the early 1970s (somewhat later than in England)
we opened up our service and did a lot of experiments with methadone
treatment. Three years ago, when we started with this diamorphine
scientific experience, we knew already what could be done with
methadone dispensation on a low-threshold basis. So we are very
happy with the scientific design. As you know, heroin, or diamorphine,
was never on the Dutch market; we did not have any experience
at all; the only solution was to make a scientific experiment
which was centrally and nationally organised by committee, apart
from our treatment centres. It was a multi-locality study and
one of the six participants is the Amsterdam treatment centre.
We are very lucky that the design was made in such a form that
we could select poor performers among our methadone patients.
So we simply said "Okay, the first choice treatment is methadone
and when it does not work we can try diamorphine". The unanswered
question—until next February—is that it is better
than methadone alone. This was also a limitation because our more
general responsibility is to get in touch with the population
as a whole, because we are not only a treatment facility but we
are also responsible for public nuisance caused by addiction to
heroin. So since this study has proceeded for three-and-a-half
years now, and the conclusion is expected or scheduled next February,
we only have practical results. What I see is that all these poor
performers which were really marginalised people have all stopped
taking heroin.
782. All?
(Dr van Santen) Yes, illegal heroin. We prescribe
plenty for them, legal diamorphine. The other levels of infection
improved to my clinical experience. So this is my perspective.
783. Just help us: how many heroin addicts are
there in Holland?
(Dr van Santen) Twenty-five thousand.
784. How many are the subject of your experiment?
(Dr van Santen) We have been selecting a total of
670 heroin patients all over the country.
785. Can the rest of them get access to prescriptions
or do they have to buy on the black market?
(Dr van Santen) Yes, this is the only scientific experiment
which is running now in Holland, and there is no other place where
you can get prescribed heroin.
786. So you still have a very large black market?
(Dr van Santen) Of course.
787. Illegal market. Are there controlled circumstances
in which heroin addicts who are not on this programme can take
the drugs? For example, in Germany they have shooting galleries,
I think they call them.
(Dr van Santen) Yes, of course, there are. For homeless
people, people who do not have a place to consume their habit
or drugs, we have consuming rooms.
788. Basically, you have been conducting an
experiment for three years to discover whether (and you are only
a little bit further down the road than we are here) prescribing
helps to solve the huge problem which you have. Is that right?
(Dr van Santen) Yes.
789. If I might turn to Professor Rehm, you
are much further down the road in Switzerland. Is that right?
You have changed the policy from 1994 applying to all the heroin
addicts in Switzerland. Is that right?
(Professor Rehm) Please give me permission to tell
the story in, I hope, a very succinct way.
790. Yes, of course.
(Professor Rehm) Basically, in Switzerland we had
in the 1980s a huge increase of the heroin problem which was quite
substantial for a smaller country like Switzerland with 7 million
people. By the beginning of the 1990s we had, in addition, an
open drug market which caused a lot of problems to the general
population, especially in the largest city of Zurich. From the
background of those experiences and from failures of the traditional
treatments in Switzerland, a four-pillar approach was adopted.
The four-pillar approach in Switzerland is repression, prevention,
therapy and harm reduction. The heroin trial, as it is called,
was ordered in 1992 and started in 1994 because it takes quite
a while to pass all the hurdles. Overall, we estimate the number
of drug users in Switzerland to be 30,000. That has not changed
since the beginning of the 1990s.
791. Is that heroin users?
(Professor Rehm) It is both heroin and cocaine dependence.
That is how it is defined. The programme with heroin prescription
was started with 800 in 1994 and now we regularly have places
for about 1,400 people who are in heroin prescription. We are
currently contemplating a trial of heroin tablets. That is because
we have the problem in our inner cities that we have an increasing
number of opiate addicts no longer being checked and who take,
in addition, a lot of other drugs but no injection and they have
failed in methadone treatment to a large degree—some of
them, not all of them. We have persons who are now opiate addicted
but not injecting for at least ten years who have failed so many
methadone programmes and who begin to become a social problem.
So the next step we are contemplating, which is right now being
planned and which will be operating next June, is to do a trial
on heroin tablets versus methadone. Overall, the trial had, in
principle, three phases. The first phase was the feasibility phase,
where we checked things which are considered as usual outcomes.
Those were a mixture since it was not a randomised clinical trial
and we did not have to stick to one outcome. We looked at outcomes
in four areas. The first area was health, and we could show significant
improvements in physical health and no deterioration in those
aspects of health which you cannot improve, like HIV. We could
show that not a lot of new HIV infections happened—in fact,
very, very few—and for people who are on the programme all
the other kinds of infections. The second one is mental health.
We could show that the scores on the mental health instruments
significantly improved. The third one is social integration, which
is a mixture of different indices. The most important for the
public was criminality. There was a very significant reduction
of criminality which can be explained by the fact that it was
no longer necessary to burgle or to do other things to buy the
heroin. The fourth one is by consumption. We did not achieve the
result of the Dutch, we still have about 5 per cent who are using
illegal heroin on top of the legal heroin, for whatever reason.
So it is not 100 per cent success but it is a significant reduction,
of course, because at the beginning of the trial all of them used
illegal heroin and now it is 5 per cent. Overall, the social costs
reduced by all of these behavioural changes because the Swiss
Government paid to initiate this programme. The heroin prescription,
for us, is one treatment in a multitude of health care interventions.
Of our people in drug addiction, we have 18,000 on methadone,
we have another 2,000 on abstinence treatments and we have a smaller
proportion, which is less than 1,000, on buprenorphine. Overall,
the indicators on illicit drugs in Switzerland improved quite
dramatically. We had more than halved the overdose deaths in the
last eight years, we have lots of successes in infectious diseases;
people come to treatment and their rate of hep C, hep B and HIV
has dramatically decreased. We have some other indicators which
show that the overall programme is successful but cannot be causally
attributed to the heroin, the heroin is just one part of it.
792. So there are 1,400 on your programme, at
the moment?
(Professor Rehm) Yes.
793. How were they recruited?
(Professor Rehm) They are basically recruited on their
admission criteria, which defines a last resort treatment, once
the addict or their GP sends them to a specialised treatment centre.
We have 22 specialised treatment centres all over the country,
including in small communities. In Switzerland we do not have
those big cities, the biggest is Zurich. Once they have passed
the admission criteria, which is a minimum age, a certain duration
of addiction—history of addiction—failed treatments
so far, it is a last resort treatment. If they pass that the institution
is sending in a request to the Ministry of Health and once the
Ministry of Health have approved the checks they start treatment.
794. You say you have 30,000 heroin and cocaine
users. How many heroin users do you have?
(Professor Rehm) Probably 95 per cent of them.
795. Ninety-five per cent of them are heroin
users as well as other substances?
(Professor Rehm) A lot of them use both. We have one
of those problems, basically, the use of cocaine and heroin by
injection in the same needle.
796. What are the other many thousands doing?
How are they obtaining their heroin? Those who are not on the
programme?
(Professor Rehm) If you are asking if we still have
illegal heroin in Switzerland, yes, we do. We have recently made
a study where we are trying to look at the untreated heroin addicts
in Zurich. So we went into the places and I saw, basically, two
kinds of untreated addicts. We estimate them around 7,000 to 8,000
in any given area. The large majority of those are addicts who
are not far enough in their career—they do not seek treatment
yet in the first four or five years. We do not find a lot of very,
very young ones, which lets us hope that this is something which
is going to be reduced in future. The second is a smaller group
of not adapted people, who are actually causing lots of problems.
They have a very high frequency of emergency room visits, they
refuse any treatment and they take sometimes methadone in very
low thresholds, but only if it is on an occasional basis—if
it has to be on that day for whatever reason. Those are the kinds
of drug users which cost the most to society, and we are currently
contemplating which measures could be offered to them to get them
into treatment as well. Part of their problem is that they do
not fulfil the criteria of having three failed treatments which
they can actually demonstrate. So we are contemplating, together
with the Germans, who have actually made a randomised trial on
that, to see if we could not specify criteria for people who have
not been in treatment that long before but who have, let us say,
ten years of opiate addiction which they can show, and, also,
give access to heroin even if they do not fail treatment on methadone
before three times.
797. What is the police attitude towards people
possessing heroin?
(Professor Rehm) In most cities—small and large
cities—we have councils which consist of politicians, police
persons, social workers, treaters and, sometimes, researchers.
Overall this strategy is a communal municipal strategy. All the
policies, also, on the police side are discussed together with
our people. The basic attitude of the police is no open drug scenes,
meaning they do not want illegal heroin to be sold in known places
in the cities, and that is not tolerated. Just to give you one
example from Zurich last year, they started to gather in one of
the local parks and it was known then that there was illegal heroin
available in this park, and they stopped that within three months.
So we have a covert drug scene. Overall, the attitude is trying
to separate as much as possible the user from the person who is
only selling. That, of course, is sometimes a problem because
there are lots of users who are also small-scale sellers. The
reality is that the police are trying to go after the big sellers,
keeping in perspective the markets in the cities, because if the
markets are too dry, if it is too expensive, there is more public
nuisance; there are higher rates of burglary and it is uneconomic
behaviour. Overall, what they are trying to do is to go after
the big sellers and try to leave the small-scale sellers alone
as much as possible.
798. Perhaps I could ask Dr van Santen about
the police attitude in Holland. We know you have liberal laws
on cannabis, but does that extend to heroin?
(Dr van Santen) If I may start with the police attitude
to heroin addicts?
799. Yes.
(Dr van Santen) They share the idea that it is a medical
problem, a psychiatric thing, and that primarily medical answers
should be made. What they do with addicts is punish for criminality,
of course, and refer to methadone treatment. As to the substance
heroin, it is illegal. There is some tolerance for possession
by heroin consumers but there is no tolerance at all for large-scale
users.
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