Examination of Witnesses (Questions 820
TUESDAY 18 DECEMBER 2001
820. I am surprised to hear you say that.
(Dr van Santen) You should not think of consumption
of cannabis as something which happens on a large scale, it is
far much less than tobacco smoking.
821. So the drug is more carcinogenic but the
quantities that are smoked are less?
(Professor Rehm) Those response slopes are much higher
for cannabis but you will not find in our society lots of cannabis
smokers who smoke 20 cigarettes of cannabis per day. Basically,
0.00 per cent. You will still find in our society that at least
15 per cent of adult males who smoke smoke 20 cigarettes a day.
So even if you have a dose response slope which is much higher,
the overall burden of disease is much lower which is attributed
to cannabis. If you look at the burden of disease in our societies,
I can tell you that for Switzerland because we made those calculations
in terms of economic costs, we have first tobacco, then alcohol
and then a gap, and another gap and a third gap, and then we have
the so-called illegal drugs. Even if you count all the policing
and all the things which we do, the overall costs are only relevant
to substances which are very prevalent in the overall society.
Even if you legalise cannabis, you do not have a huge prevalence
like in Holland of 50-year-olds who regularly continue to smoke
cannabis. There are some but it is not the public health problem
compared to tobacco. Nobody is diminishing the effects on the
individual level; somebody who would smoke a lot of cannabis every
day of course has more health risks than somebody smoking the
same amount of cigarettes every day.
822. Good morning, gentlemen. Can I ask Dr van
Santen, first of all, you say your experiment is of 670 addicts
and that is the only place where prescribed heroin is available.
It is quite a small experiment, I wonder if you would be able
to tell us whether you have any specific evidence on the effects
say on acquisitive crime, whether your heroin addicts are less
likely to commit crime than those who are not on prescription,
their own health and also on anti-social behaviour generally?
(Dr van Santen) Yes. I must disappoint you because
I am not from the experiment itself, I am just one of the treatment
providers who is participating in this experiment. The scientific
result is going to be published next February. I want to assure
you that all of the questions that you put are being asked. In
my opinion it is a pretty well designed study with controlled
groups and finally we will find out whether all your questions
can be answered and will give us reasons to continue and open
it up to larger groups, because that is the objective. We could
not do anything else than this small-scale experiment. It was
against the background that we knew that methadone alone was not
823. What has been the response of the general
public, how did they respond to the experiment itself and, indeed,
what is their response to heroin addicts generally?
(Dr van Santen) It has been in every newspaper and
strongly in Parliament. It has become, in my opinion, too much
a political problem, because on the one hand if you have consensus
on the notion that it is a medical problem why should the public
and the politicians interfere. The professionals are the first
to propose these kind of treatments. In fact there was a proposal
in 1981 which was stopped by the government and we as professionals
in some form are dependent on politicians, and as a result of
that it has resulted in a very well designed scientific study
in the hope that scientific evidence will convince politicians
than it is an effective treatment. In essence we are dealing with
morality, the public is afraid and it is a relatively new phenomenon,
newer in Holland than it is in England. If you ask the public
with experience, with victims in their families, they want good
treatment, that is what they want, they want good care. We did
not find any resistance among neighbourhoods, public and politicians.
It is just the question of morality, are we able to create a consensus
on the nature of this phenomenon, which is a psychiatric problem,
an acquired disease.
824. Obviously because the report is not published
until February are you able to give us any indication of what
you think the successes or failures of the experiment are so far?
(Dr van Santen) What I see, when I visit the clinic
we run, as a clinical worker I see positive results, of course,
as I told you. They all stop consuming illegal heroin and they
improve in all of the fields you have just mentioned. All the
doctors agree and the whole professional team agrees on that.
We would be very much surprised if the result was negative. I
have confidence that it will come out positive. It will also give
us more details to improve treatment. Originally it was a scientific
experiment and a clinical trial of heroin and medicine. It also
has to do with the setting in which it is prescribed. It is not
only prescribing it is also the treatment, the other interventions
combined with prescribing. What we see in the heroin experiment
is that the staff to patient ratio is much lower than in a normal
patient case and that they can achieve much more intensive treatment
for other problems and diseases which come together with addiction.
As you know, there is no addict who does not have other psychiatric
problems or other social problems, it effects functioning in every
field, so it is also the intensity and the quality of the other
interventions which go together with the prevention of heroin.
825. Do some of the addicts in the experiment
hold down jobs?
(Dr van Santen) Yes, sure. Employment is an important
issue. Rehabilitation is paramount because it has to do with social
exclusion. These are people who lost the ability to participate
in society and once you prescribe, it is such a simple form of
treatment, you simply prescribe the desired drugs until the craving
is diminished and a normal person is able to work and to participatethis
is simplificationand stop some of the anti-social behaviour.
826. I take it then that you hope that this
experiment is so successful, and you are convinced it will be,
that you will able to convince the politicians to allow it?
(Dr van Santen) It is not my job to convince them,
it is the evidence which will convince them and the politicians
will allow us to continue and open it up to other people and expand
the programme. I think the power of the prescribing of heroin
lies not among those poor performers on methadone but on those
people not reached yet by services, by necessary care.
827. Professor Rehm, you said earlier that amongst
the things within your experiment, which seems larger than the
Holland one, the social benefits outweigh the costs and you also
said that overdose deaths have been more than halved.
(Professor Rehm) In Switzerland, yes.
828. What other benefits have there been and
have there been any failures in the system so far?
(Professor Rehm) In the treatment itself the overall
success rate was significant for physical health, mental health,
social inclusion, exclusion, including criminality and consumption.
The failure within those parameters, which we have to face, is
that we had some improvement in the unemployment rate but we did
not succeed to have employment for more than 40 per cent, that
is one of the problems which we are still working on. Clearly
employment is an indicator in our society for social inclusion
and exclusion and we have not been as successful as we wished
829. Why do you think that is the case?
(Professor Rehm) I think basically some of what is
happening is happening to a lot of older people who are now 45
years old or 50 years old, who do not have good employment history,
to say the least, and who are basically not the most well trained
and who do not get jobs. The Swiss society is not a paradise which
is a totally different island from all of the other societies,
we have unemployment and our unemployment rates are the highest
for those kind of people I have just described to you, 45, 50
and over, not good training and a bad employment history. If you
have been on drugs for 15 or 20 years you have a bad employment
history, even if you worked sometimes sporadically it is not the
references that the usual person in the job office of an employer
wants to see. We have refrained from doing social programmes,
meaning state paid jobs created just for that group of people
because that would not be a fair trial. There has been a suggestion
to create some jobs with the government where those people could
be employed, open those up for every body, but you cannot say
this is a successful trial. What I am showing you is those are
the numbers who are in the normal labour market, and they have
been round the 40 per cent, that means 60 per cent are still unemployed.
830. I accept what you are saying about the
combination of age and lack of skills, and so on, that effects
everyone whichever country they live in. I wanted to know whether
it was the addicts themselves who were interested in going into
employment or whether the problem was coming from else where,
it is partly obviously from else where.
(Professor Rehm) Most of them were interested at least
in trying jobs. Some of them failed, and some of those failures
have to do with the requirement of treatment. Basically if you
are on heroin treatment and if you are supervised, as right now
we are doing, because we do not want any diversion, people have
to shoot themselves in front of the nurse, there can be no take
home or take away medication in any way. That basically means
that they go to the treatment agency three times a day and this
is very disruptive for a normal job. Of course we have people
who tell us, look I could have a job if you give me take home
medication. That, of course, creates all kind of dilemmas. At
this point we are still at the stage where we do not want any
heroin from the state being divulged on to the street. In some
ways we have acted against them. It is a consideration of values.
831. Sure. Some of my colleagues will ask you
all about the connection with street heroin. One final very quick
point, you have already talked to us about the fact that in Switzerland
much of this will be decided by referenda and on the whole so
far it has been positive. Can you give us anything specific on
crime levels? Have you any indication on the reduction in crime
levels as a result of the experiment?
(Professor Rehm) Yes, first the referendum, it was
a three phase referendum, the first was, should we offer this
kind of treatment, more or less, which was positive. The second
one was, could you globally classify its legalisers. They wanted
to legalise all heroin based on a market approach, the school
of freedom, and they were turned down dramatically 80/20. The
third referendum was a referendum mainly by people who said, this
drug policy of Switzerland is the beginning of the end, it is
way too liberal, we have to strengthen it, we should abolish heroin
treatment. The outer part of this referendum, which was not in
the referendum itself, was we should abolish methadone treatment
and we should go back to abstinence treatment. They were turned
down by a very high rate. The kind of policy which is right there
seems to be supported both by referenda and by the public opinion
polls. We can only speculate on why this is the case because when
people vote they do not give us the reasons. It has been widely
published that the rate of burglary in our patients has gone down
dramatically. What has happened is the following, one of the conditions
to get heroin and to come into treatment is that you give up your
right of police records not to be seen by others. Research, under
certain circumstances, can scrutinise your police records. That
means, of course, anonymous for us, we get a number and the police
get a number. Part of their consent form was that we are actually
not bound to what they report to us about criminal behaviour but
to what are the police records. In those police records we saw
a dramatic reduction. We do not only have self reports but we
know that by police records the rate of burglaries went down dramatically.
This is the single biggest improvement in percentage terms of
the heroin trial. The single biggest thing is heroin itself, but
I think it is trivial, having no illegal heroin or less illegal
heroin is pretty trivial when you give it for free. Out of all
of the other indicators this is the largest percentage reduction.
That was widely publicised. In a society like Switzerland, where
overall it is quite a conservative society, this was one of the
main drivers of this public support for this kind of treatment.
832. It is fairly interesting, from the debates
we have been having recently about civil liberties, that people
were prepared to give up liberty records in that way?
(Professor Rehm) It is the one thing which has been
disputed and which has gone to Athens, at least three times, back
and forth. It was basically an evaluation of research saying,
look, if we go with self reports this is the only trial which
has been done so far and if we report self reports nobody will
believe us, they will say those addicts do not give correct responses.
We need some kind of confirmation and then the evaluation overall.
There is no other study where we could get this information from,
overall what it can bring to the public, it is the giving up of
some civil liberties for the person being treated, we opt for
this one, but do not come to us for the next study. That was basically
in a nutshell the evidence.
833. Does the Dutch experiment have any crime
figures as well?
(Dr van Santen) Sure, sure. We also have the police
records, but they are not to be translated into individuals themselves.
834. Does it show the same as the Swiss experiment?
(Dr van Santen) The results will be there in February.
835. Before our conclusions, I hope.
(Dr van Santen) The decriminalising effect was demonstrated
already for methadone alone. I would expect the same to apply.
836. Thank you. Professor Rehm, are you familiar
with the paper by a Dr Aeschbach, a Swiss national at the Department
of Psychiatry at Yale University?
(Dr van Santen) Yes, Aeschbach.
837. Excuse my pronunciation.
(Professor Rehm) I am sorry.
838. He suggests that the Swiss trials of supervised
heroin prescriptions do not withstand scientific scrutiny?
(Professor Rehm) Let us put it this way, we recently
published in the Lancet, which is usually considered as
one of the highest scientific scrutiny. I think what happened
there is a misunderstanding of a lot of the scientific endeavour.
Basically in Switzerland what we had to show in the beginning
was general feasibility of the trial and that there can be effects
under quite good circumstances. Of course our rate of personnel
to patient is also quite low, 1.7 for a doctor and 1.7 for social
workers, for about seven or eight we have one accompanying person.
(Professor Rehm) The second one is that in Switzerland
we did not have enough knowledge to actually conduct a randomised
controlled clinical trial, it was the first study. The second
study in the Netherlands did a randomised controlled clinical
trial of course which elevates all of points that Aeschbach is
making. The third one now is in Hamburg and it is widening the
randomised clinical trial, meaning they actually have a design
where they say, look we want to see into the black box, we no
longer want to see heroin versus methadone, we want to see heroin
in combination with certain psycho social intervention, which
we also randomise, and we want to see that not only for treatment
failures, the Swiss has shown that to a certain degree, we want
to see can they attract non-treatment goers in our society, which
is way more a problem in Switzerland. Overall I see the scientific
endeavour in a way that not one study can solve it all. There
is a basis for the feasibility for first results, there is something
in the treatment and I would never say there is any proof or anything.
The second one is the randomised control clinical trial who have
very strict designs. The third one is widening. If you try to
put standards to any one single study to solve everything you
will always have to say it fails.