Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 840 - 859)



  840. You are saying that is what Professor Aeschbach did?
  (Professor Rehm) Yes.

  841. Dr van Santen, are you familiar with Professor Aeschbach's paper?
  (Dr van Santen) I am not a researcher.

Mrs Dean

  842. Professor Rehm, is the main aim of the programme to help people out of their addiction or to manage their addiction and improve their general health and well being?
  (Professor Rehm) What we are trying to do is have a succession of goals. The long-term goal is still abstinence. We say that we can show this long-term goal only by intermediate steps of helping them in their day-to-day lives. I think the most convincing figure we have is that if people stay in heroin assisted treatment for longer than three years those who leave treatment have about a 30 per cent chance of going into abstinence treatment. When we said that at the beginning, that this is a long-term goal, they said, okay, are you speaking from both sides of your mouth. You can say a lot about long-term treatments, we will no longer be there, you will no longer be there. The longer the people stay in treatment the more chances there are to go even to abstinence or methadone treatment, try it again. The question is, of course, how much is enough. The question is, when should we make more effort to actually make them go rather than them deciding by themselves that they have to fight for six years. We currently have a big debate within the treatment community and between researchers and the treatment community on measures, how to actually move those long term people out into whatever, usually abstinence. I think long term you do have success. We have only done six years of programming. Most of the people who started six years ago are out, lots of them tried abstinence treatment. We have people who go into abstinence treatment, make the first step, withdraw completely but that does not mean they have long term success. Any kind of treatment in the addiction field cannot guarantee long term success, at least it is a positive indication.

  843. Do you have figures for how many are drug free and correspondingly do you have figures of how many relapsed?
  (Professor Rehm) That is a very difficult undertaking. Overall after two years it was the same addiction still, that is one of the problems of comparing those different things.

  844. In the journal, in the Lancet it talks about one, two and three admissions and treatments, could you explain a little bit more of how people are admitted and how they then finish on that one treatment session and come back. Do they instigate that or do you?
  (Professor Rehm) There are rules and if they violate the rules they are kicked out of the treatment. Non violence is probably the strictest rule. Clearly if one of the drug addicts is causing harm or threatening to cause harm verbally to staff they are kicked out of the programme. Those happenings usually come pretty early, those people are terminated within six months to one year, sometimes even earlier. Then there are treatments where basically it is an interaction between the treatment, persons and their client, meaning they facilitate, they say, you have been stable now we have your word, why are you still coming here three times a day, would it not be better to go on methadone you can take home or go to abstinence. This kind of interaction is the usual case I would say. Then there are terminations of the people by themselves without any facilitation, even sometimes against the councillor, those would be for people who would say, I was HIV-positive when I came in here, all I want to do is die now, I want to go out, that is it. That happened in some individual cases. People were saying by themselves, look you do not believe I can do abstinence but I am trying abstinence.

  845. People would also be counted as coming off the treatment if they went into abstinence treatment.
  (Professor Rehm) Of course if they went into abstinence treatment they would get medical withdrawal, that is their right. They are phased out and they start their abstinence treatment. All of our abstinence treatment in Switzerland have a requirement that you have come in be abstinent and after withdrawal.

  846. Can I turn to Doctor van Santen, it is basically the same question I am asking, the aim of the programme as far as you see it, whether it is to try and get people off drugs or to improve their life-style?
  (Dr van Santen) The issue of abstinence, by that you many even without any medication.

  847. Yes. Either.
  (Dr van Santen) It has to do with the selection of patients. We have a public service and we concentrate ourselves on the severe cases which have become very chronic and difficult to reverse. The issue here is a selection of patients, I think. There is a network development of addiction. Studies show the longer the duration the more difficult it is to reverse an addiction. If you select patients with a short history the chances of abstinence and the reversion of the addiction are good and in chronic cases are very difficult. In this discussion I think we missed the nature of addiction itself, because it is a common thing, especially for us because we have severe cases. We talk about success and the consumption of illegal substances has stopped during medication, so our aim, first of all, lies in that direction, then on medication and in complete remission of consuming drugs, which means that your craving is completely under control and your rehabilitation is successful. Yes, detoxification or medication is an issue, too often leading to relapse. In my field, in my experience, I am talking about patients where the disease has become very irreversible, and I think the constant pressure on them not only from their environment but also from within, from themselves, to combat abstinence against their biological disturbances that is not professional.

  848. You are saying they are safer on prescribed heroin than they are on coming off the drug and relapse, is that what you are saying?
  (Dr van Santen) If you withdraw from medication too early or too quickly then withdrawal itself is the cause of the relapse, that is what I am saying.

  849. Do you have any figures on the numbers you treated who have come off heroin?
  (Dr van Santen) In a methadone outpatient clinic substitution treatment shows five per cent of people becoming abstinent from medication. If you look at the design of heroin experimentees amongst participants in some cases we have some case become abstinence while on heroin treatment. We are lucky that the natural history of this disease that when the patients get older their craving for drugs and loss of control improve, we are helped by the nature of this disease.

Mr Malins

  850. Could I ask you both about something called naltrexone, the heroin blocking drug, could I ask if you used it? Am I right in saying that if I was heroin addict and I took naltrexone it would simply block out the need for it? What do you both say?
  (Dr van Santen) Naltrexone is a classic antagonist of heroin and methadone. The studies which have been done internationally, mainly in the United States, and also currently in Holland, where people are detoxified very rapidly and put on naltrexone can be positive. In my experience you need an array of services and you need different situations of treatment, this is one of them. Technically it is very simple to integrate this treatment in your treatment programme. In our clinics we cannot sell it so very good.

  851. You cannot? Do you use it?
  (Dr van Santen) We cannot sell it. People do not accept it. They need to go through withdrawal and the research which is being done now in Holland, there is a programme where people are hospitalised for a few days for rapid detoxification and put on naltrexone afterwards. This is being published mid 2002.

  852. Right. Dealing with your treatment options for addiction, is diamorphine offered as one choice out of a menu of treatment options?
  (Dr van Santen) I think so, yes.

  853. It is. Are they given their choice on request?
  (Dr van Santen) You need professionalism in between. I think that a professional team, which is a multi disciplinary team, can in its assessment make indications for the different treatments modalities, yes.
  (Professor Rehm) Can I just go back to naltrexone, I think naltrexone was the one medication which has been scientifically supported the most in terms of money and resources although the are overall results of naltrexone trials are not that strong.

  854. All right.
  (Professor Rehm) Especially over the long term. If you look it is used now in almost all countries as part of the rapid detoxification part. It is sometimes used as support and sometimes used for very specific case.

  855. Let me ask you this question arising out of that, is there any research going on anywhere and is there ever going to be a possibility that we will discover a drug which will, so to speak, overnight, stop the need for heroin? What does the future hold on wonderful cures, any prospect?
  (Professor Rehm) There is research going on very clearly there are some hopes with regard to genetic research.

  856. Genetics.
  (Professor Rehm) Genetically produced drugs. There is more research going on worldwide, financed mainly by the National Institute of Health in the US and thereby NIDA, the National Institute of Drug Abuse on cocaine than on heroin. The problem overall is that whenever you do genetic research on drugs you come to the conclusion that it is not one gene which is responsible for it but it is a multitude of different interactions. That means that while nobody will exclude that such a medication sometimes may be possible it is not round the corner and we will have decades in order to solve the problem otherwise.

  857. Decades? Many years?
  (Professor Rehm) Yes. Lots of societies have problems now and while genetic research is fully supported for long range goals we need to have short-term fixes.

  858. I understand. Finally, the programmes to which you have been referring, do they require patients to take their diamorphine in a particular way, injecting orally or are there any other problems with this?
  (Dr van Santen) One of the differences between Holland and Switzerland is the percentage of people who do not inject is much higher, the majority inhale heroin. In the design they also offer heroin for inhalation and most of the participants of the experiment with the experiment are only inhaling. Diamorphine is being offered in an injectable form and in a form for inhaling. Can I add something on the issue of pharmacotherapy and addiction where you ask for future discoveries. I am not saying that I am quite satisfied with the existing possibilities but I want to make a little comparison between the pharmacotherapy for depression compared to opiate addiction. With existing medications the results for opiate addiction are better than for depression, so it is all very relative, I think. Why should we wait for a magical cure for addiction, where there is effective treatment, pharmacotherapy and not use it, whereas for depression, for instance, there is no such reluctance.

  859. Thank you both very much.
  (Professor Rehm) What we are doing right now, our agency which is controlling medication clearly stated that evaporated heroin used in Holland would not get their approval, no medication would get their approval. For those people not injecting we are using different forms of tablets.

  Mr Malins: Thank you very much.

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