Examination of Witnesses (Questions 880
TUESDAY 18 DECEMBER 2001
880. So there is no serious problem that security
is required for staff?
(Professor Rehm) No.
(Dr van Santen) You need professionalism. Of course,
some of our patients show behaviour problems, but treatment deals
with a commitment to the patient, making deals with the patient.
The addiction itself is not a cognitive disorder, it is not trouble
with cognition, if you understand what I am saying. It is a disorder
and the controlling of an obsessive disorder. And so it is possible
to get in contact and communicate with those patients and make
agreements. If it is professionally done it is respected. We have
had practically no incidents.
881. It is interesting that your experience
from both countries is that is not a serious problem. You mentioned
earlier, Dr van Santen, that 600 or 700 people in Holland are
legally prescribed heroin amongst the many thousands that take
it illegally so how do you prevent leakage of the legal heroin
onto the black market?
(Dr van Santen) Does the Committee ever travel? You
are invited to see how this works. You cannot give a 100 per cent
guarantee but people are being massively controlled to take their
prescribed heroin on the spot.
882. So there is limited knowledge that you
have of any leakage in Holland?
(Dr van Santen) There is no leakage.
Bob Russell: I have seen the coffee shops but
of course that is not for heroin. Finally, gentlemen, the treatment
883. Shall we check with Professor Rehm that
there is no leakage in Switzerland.
(Professor Rehm) There is no leakage of injectable
heroin in Switzerland. The people are injecting on the spot under
supervision and I see no way how they could get that back out
of their blood. There has been very, very, very limited leakage
of tablets. Usually tablets have to be broken under eyesight supervision
and overall we speak about quantities of less than ten in the
last six years which have been on the illegal market. The police
are instructed to immediately inform us if there is any of this
heroin on the black-market, specifically because it is such a
touchy issue, and I think basically we can say we have no leakage.
884. We have heard that some people who are
drug addicts trying to come off treatment require several doses
a day, so how is that physically administered? Do the people have
to come in time after time or are they placed in the same place
for the whole day?
(Dr van Santen) The heroin clinic is open seven days
a week and has a dispensing service three times daily. So if you
are a client you can come and consume your heroin three times
a day. We have stabilised patients who only show at night after
work four times a week, so that is also possible and, furthermore,
they take methadone.
885. And the Swiss experience?
(Professor Rehm) Exactly the same. The clinics are
open three times a day seven times a week. Once people are stabilised,
they prefer to take methadone for the time that they are working
because that allows them to work and some of them come in three
or four times a week for nights or for the weekends, but overall
this is how it is controlled and this is why we can say there
is no reversion. It has a positive and negative side.
886. So the treatment centres in both examples
are very successful?
(Dr van Santen) In terms of feasibility, yes.
887. Would you gentlemen like to see it expanded
in Holland? You have said that only 600 or 700 heroin addicts
are being treated in this way.
(Dr van Santen) I hope that the result of the experiment
will be positive and the next step will be that we can offer this
treatment modality to more patients.
888. Is it an expensive programme?
(Dr van Santen) Expensive? Methadone treatment would
cost you 2,500 euro a year and heroin treatment will cost you
889. What I am thinking that is the salaries
to maintain these clinics 365 days a year, especially for a limited
number of patients, is presumably quite an expensive option?
(Dr van Santen) Yes, but we are trying to find the
(Professor Rehm) The question which has not been answered
yet is cost-effectiveness. By just looking at the modalities of
treatment, it is very clear that heroin will cost you about three
times as much as methadone. That is why it is not the standard
treatment, that is why overall we still say at the end of the
day we believe in the current system. There could be 50 per cent
on methadone who are doing quite well on methadone and we will
not switch them to heroin. What we are talking about is those
additional ten per cent who currently are not doing well in any
system and who cost us more. So it is clearly more costly but
the question which is scientifically now open is is it more cost
effective than methadone? That is something we could not do because
you need a randomised clinical trial for that. You will have some
results there in Holland.
890. It is injectable heroin that is the most
expensive form, the powder is cheaper; is that not right?
(Dr van Santen) The price of the substance itself
is not worth mentioning.
891. It is the salaries.
(Professor Rehm) It is the salaries of the staff who
are there seven times a week. That is what is costing our society.
892. Do those staff perform other functions
as well beside dealing with heroin addicts? Are they providing
a service to any other clientele in Holland?
(Dr van Santen) Yes. The staff is a multi-disciplinary
team consisting of nurses, which is the core profession in the
team practice, and they have a caseload and they make treatment
plans and do case management. Doctors are there for a diagnosis
and treatment and social workers are also there.
893. Yes, but what I am asking is are these
staff also assisting other clients as well besides the heroin
users in your clinic?
(Dr van Santen) In our situation we have a service
with five clinics and one of them is a heroin clinic so staff
shift from one clinic to another. Is that what you mean?
894. You are saying there are five clinics;
do they deal solely with heroin users or do they deal with others?
(Dr van Santen) Within the experiment of the heroin
clinic only heroin, that is for sure.
895. That is one of the clinics, but the others?
(Dr van Santen) They dispense no heroin but methadone
and other substitute medication.
896. So they are all dealing with drug consumers?
(Dr van Santen) And normal psychiatric patients.
897. Is that the same in Switzerland?
(Professor Rehm) We have a more normal situation where
we strongly encourage new centres to at least deal with methadone,
and what I think will happen in the future is that it would be
a more an addiction clinic. We also do have some inclusion of
psychiatry to see some specialists there who would mainly deal
with other psychiatric diseases but come in for the specific treatment
898. One of the objections that some of our
general practitioners have is that they do not want their surgeries
full of heroin addicts. Obviously that does not happen in your
country, but it could do if the whole programme were made nationwide?
(Dr van Santen) This is an important issue. It is
a public health issue, I think. The insight is that the response
to an epidemic is that it cannot be managed by one party, so you
need co-operation, especially with general practitioners. Within
the shared care you organise with general practitioners, they
take the better cases and the clinic takes the severe cases.
899. That is what you do in Switzerland too?
(Professor Rehm) Exactly. We see a role for the specialised
centres in the beginning because there is a lot of social care
which you do not usually get at a GPs and with crisis intervention
when something does not function. The GPs get the stable cases
which are not a real problem with the other patients.
Chairman: I understand that.