Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 820 - 839)



  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.

Bridget Prentice

  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 effective enough.

  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 participate—this is simplification—and 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 to be.

  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.

  839. Yes.
  (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.

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