Examination of Witnesses (Questions 900
TUESDAY 18 DECEMBER 2001
900. Could I ask how the treatment is funded?
Is it totally tax funded or if the addict has an income is there
any cost to the addict or is it through health insurance?
(Dr van Santen) It is paid by health insurance. During
the experiment, of course, it is paid by the government out of
health insurance but normally addiction treatment is within health
901. Through the general national health insurance
that people pay via their income if they are in employment?
(Dr van Santen) I think it would be too complicated
to explain to you the Dutch health system.
(Professor Rehm) Switzerland is a more capitalistic
country and we do not have a public health system. There is provision,
however, so that nobody falls between the cracks. But the addicts,
for example, have to pay for certain things like heroin themselves.
902. They pay for the substance?
(Professor Rehm) They pay for the substance but not
for the care.
903. Finally, gentlemen, are either of you familiar
with the Swedish approach to drug addiction?
(Professor Rehm) Sure.
904. They say their objective is to have a totally
drug free country and they believe they are making progress towards
that end. Do you agree with them?
(Professor Rehm) Have you seen a drug free society
in the last 3,000 years?
905. Even they are not pretending that their
country is drug free; they just say that their approach, as I
understand it (and I may be wrong) is that total repression does
(Professor Rehm) Clearly they have a totally different
system. On the other hand, it is true, according to our own calculations,
that every litre of beer drunk in Sweden is causing four-fold
risk of accidents or violence compared to a litre of beer drunk
in Switzerland, France or Italy. It has to do with bingeing and
with certain modes of drug taking and that is one example, alcohol.
I think the question we are trying to solve is not to become a
drug free society but to minimise all the harms to society by
drugs and those are, of course, harms to the user but also harms
to the general public, and looking at the burden from drugs and
illicit drugs and alcohol, it is questionable that they have made
progress in the last ten years. This is a scientific debate and
this is clearly one position within a scientific debate. I go
there quite often, there are lots of discussions on that. I could
name you persons who have a different opinion on that but I think
overall, once you change the perspective to saying "in our
country there are less people using X or Y than your country,"
and you go into how much burden is actually created, Sweden is
not making so much progress, but they are still on a comparatively
low level in Europe. I do not think that is disputed by anybody.
906. Thank you. You have visited Sweden on a
number of occasions?
(Professor Rehm) Yes we have comparative projects
with Sweden and even though we are only an associate to the European
Union we are allowed to get European money for research, and one
of the projects is to compare the drug treatment systems in eight
907. And how do they deal with heroin use? Do
they have any experiments of the sort you have in Holland?
(Professor Rehm) They have methadone and especially
in the Karolinska Institute and the big cities they have methadone,
and then they have a whole system of coercive abstinence-based
treatments. They have certain other drug problems, for example
they have not a lot of cocaine but they have way more amphetamines
and you have to look at the overall picture.
908. Dr van Santen?
(Dr van Santen) I have not much to add to this. What
you see everywhere is when there is a difference in policy you
find first more agreement amongst professionals because they work
with evidence based effective treatment, and the question is can
you withhold from people effective treatment. What you see in
Sweden is that development towards acceptance of these forms of
treatment, which you have seen in Germany also.
909. So you believe the Swedes are moving, despite
their public rhetoric, towards the kind of experiments you are
carrying out in Holland?
(Dr van Santen) Because of the convincing evidence.
(Professor Rehm) They have way too many overdoses
for their estimates of drug users so something must be wrong in
terms of harm. If you have only so many drug users then you cannot
say that so many out of every 100 of them gets into an overdose.
Something must be wrong, either the estimates of the drug users.
The overdose is a hard fact. You can manipulate the definition
but that is pretty hard and that is a death and overall those
indicators are not that good. That is what I am saying about harm
indicators. In professional settings, if you go into the Utrecht
marijuana conference last week the Swedes had a big rhetoric,
"we are against, we are against" but it if you go to
the professionals two days later they say we have opened this,
we have experimented with methadone, we have done this. so it
is a little bit ambiguous.
(Dr van Santen) It is interesting to know that a Swedish
researcher did some investigation on mortality and compared the
mortality from his small methadone programme to mortality among
people on his waiting list and found that it was ten-fold higher.
These are the facts of life which you cannot avoid.
910. You think their figures may not stand up
to scrutiny, their public figures?
(Professor Rehm) No, the waiting list had a ten times
higher mortality. And that is what is driving other professionals
into doing methadone treatment, even though it is against the
Chairman: Thank you very much indeed. That has
been extremely helpful and we are extremely grateful to you for
coming to see us. This session is closed.