Examination of Witnesses (Questions 980
TUESDAY 15 JANUARY 2002
(Dr Gerada) I am probably the most specialist GP in
England in terms of drug misuse and I do not have a diamorphine
Home Office licence. I do not want one and I would never see the
need for having one. I am sure if I applied I would get one but
I do not think it is a necessary aspect of care for primary care.
I think it is a very expensive form of treatment. We have methadone
ampoules if you want to go down the injectable route, which only
need to be given once a day instead of three times a day for diamorphine.
We have costs of £15,000 to £20,000 per year per patient
for diamorphine verses £2,000 for methadone. A specialist
GP, if they so wish, could apply for a diamorphine licence but
I would never apply and would never see the need for one.
981. We have had evidence from drug misusers
who say that they do not think methadone is the right treatment
and they need heroin prescribed.
(Dr Gerada) If they really think that, they can get
heroin prescribed from specialist services. If we go down that
route, we are colluding and creating life long addicts. I saw
a patient this morning. I was on the radio this morning talking
about this issue and a drug user came to me and I asked him what
he thought about it. I have never met him before. He said, "Yeah,
if I had heroin I do not think I would come off." It has
taken him five years but he is now in work; he is being supported.
I think we are colluding in a life of addiction. If you look at
the evidence for methadone ampoules, there is very little movement
from methadone amps to methadone linctus and then on to nothing.
If we think that is going to be any better with diamorphine where
you get a rush then we are naive, to be absolutely honest. I have
read the evidence. I have seen the Swiss and Dutch studies with
highly controlled, supervised ingestion. That means somebody watching
somebody inject three to four times a day. If we can afford that,
if we want that route, so be it, but I would be in disagreement
except for an exceptionally few number of users.
982. I heard you on the radio this morning.
Did you say that you had treated something in the region of 12,000?
(Dr Gerada) No. I have treated about 1,200 drug users.
I have only once asked the question, "Would this patient
need heroin as a prescription?" I referred the patient to
a local specialist colleague with some specific questions. The
patient got severely depressed every time they stopped and, after
the specialist had assessed the patient, the decision was that
he did not need heroin. Once in 12 years have I even considered
it as a treatment for my patients. I work in south east London
in an area that has five times the level of drug misuse and I
get all sorts of people coming in off the street. I do not necessarily
see just the simple end of drug misuse.
983. You obviously think that more doctors should
not obtain licences. You do not think there is any need for licensing
(Dr Gerada) No, I do not. There might be exceptions.
One never says never in medicine so I could never say never for
ever. There might be a GP working as a specialist who wants to
run a special service for injecting drug users at the extreme
end but overall I see no requirement.
984. Do any of the others feel strongly in the
opposite direction and do you not think licensing is necessary?
(Dr Barnett) From my own limited experience locally,
no. I would support everything that has been said in respect of
patients who are injectable methadone. Trying to shift them from
that treatment is very difficult and it is something that GPs
will not touch either. I could not imagine a situation at the
present time where GPs would want such licences.
985. Is there any guidance available to GPs
about prescribing diamorphine?
(Dr Gerada) The only guidance is this (Clinical Guidelines)
and it says very little. It is about a page. I know that the Department
of Health has set up a working group to look at the whole area
of diamorphine prescribing. There is very little guidance. It
is empirical. Even if you ask specialists, which I am sure you
have, it is empirical. It is for someone that has failed every
other treatment and the benefits must outweigh the risks.
986. Are you suggesting that there is a principal
policy difference between the Department of Health and the Home
Office, given that the Home Secretary is suggesting wider availability
of diamorphine prescribing? Is that the impression you have?
(Dr Gerada) Yes.
987. One of our previous witnesses, a medical
person, mentioned Naltrexone as a possible drug to treat drug
abusers with. Do any of you have experience of that?
(Dr Gerada) I have limited experience of it and it
is a very good relapse prevention treatment which the clinical
guidelines do not recommend as a GP form of treatment but, as
it becomes more widely used, it could be used in a general practice
setting. The other drug is Buprenorphine which we have missed
out completely. We always preface treatment with methadone and
I think we should stop doing this. I do not think the two are
the same. Treatment equals treatment and there is a range of treatment
988. On Naltrexone, where I gather trials in
America have proved quite successful, can you just tell me what
(Dr Gerada) It is a tablet but there are some implants.
We do not have the implants here.
(Mrs Glover) The implants are coming.
(Dr Gerada) It basically blocks the effects. If you
were to take an opiate on top of that, you would fee very ill.
It is a bit like antabuse, if any of you know antabuse in terms
of alcohol. Essentially, you would get no rush from taking additional
heroin or methadone or anything else like that.
989. It would take away the need to take it?
(Dr Gerada) Yes. It is not a panacea. None of these
things is a panacea. You need to take it three times a week as
a very long action. It works in well motivated patients.
(Mrs Glover) You do need to know they have taken it.
Maybe you need to supervise them taking it three times a week.
If they have not taken it, it is not going to work.
990. Is it an expensive option?
(Dr Gerada) About £60 a month.
991. It is a cheaper option than the others?
(Dr Gerada) I can get you the figures. It is an expensive
option if you think of NHS drugs treatment, full stop. It is complicated
to get somebody on to Naltrexone from a drug free state. Once
you have got them on to it, it is very easy to maintain.
992. How long do you have to remain on it?
(Dr Gerada) You have to have a space between being
off opiates and starting Naltrexone of about a week. A lot of
places, in particular Northern Ireland, will automatically start
you on Naltrexone before you leave your treatment service. Again,
it is not a panacea but it is part of the treatment option.
993. How long would you have to go on prescribing?
(Dr Gerada) For as long as you felt the urge, the
craving. Think of cigarette smoking. Most people who give up cigarettes
crave them for the rest of their days.
994. You are not saying it would be necessary
to prescribe that for the rest of their days?
(Dr Gerada) No, but you are looking for other significant
changes to the reasons why they use drugs. Maybe a few years,
995. You have given us your very strong views
about the use of diamorphine and the Chairman introduced the session
by mentioning the conflict of views we have had during this inquiry.
You have very much added to that conflict. I am not saying that
as a criticism but as a comment. For my part, it makes my task
hugely difficult. I was getting to the position where I was supporting
the idea of prescribing diamorphine or even heroin to manage people's
cases and as a means of harm prevention, to take away the chaotic
lifestyle, to reduce criminality etc. One of the strong bits of
evidence we had was from an addict who was receiving prescribed
doses and was living a normal life, carrying on his professional
duties and from people who were prescribing him those drugs, giving
a very comfortable view of the way they manage them in crisis.
We heard evidence from someone whose close friend was an addict
of heroin and was receiving heroin by hook or by crook on a regular
basis. Again, they were living a normal life with all the responsibilities.
You are an expert in this field and it is the core of your professional
life. Your evidence has flown in the face of that. What sort of
discussion do you have when you sit down with people on the other
side of the fence?
(Dr Gerada) What sort of discussion do I have with
996. No; with the other experts and people involved
in these matters who have such diametrically opposite views.
(Dr Gerada) A lot of the views in favour of diamorphine
are coming from the criminal justice end. The health end are saying
there is a place for very limited, highly supervised prescriptions
of diamorphine but we need blanket coverage. We need injecting
rooms etc. I am seeing this through a treatment setting. I would
ask the question: how can you lead a normal life if you are having
to inject three to four times a day, even if it is not supervised,
even if you do not have to go to a clinic, police station or pharmacy
or a GP practice? How can you lead a normal life taking that sort
of treatment when you have methadone? Do you want to inject? Methadone
has a half life of 18 hours. You do not need to inject it every
day. You do not get the high. Those are the sort of questions
I would pose to the people who advocate it. We have had diamorphine
since 1920 in this country. GPs prescribed this, remember, up
to about 1965 and they were removed from prescribing it because
there was total chaos on the street, with unregulated diamorphine
being prescribed in bucket loads. What I am worried about is that
we are suggesting that we go back to the situation we had in the
1960s, before methadone appeared, of having free for all diamorphine.
997. I do not think anybody is suggesting that.
They are suggesting that it should be made available in totally
controlled circumstances. That is the burden of the Swiss and
(Dr Gerada) It is available at the moment in controlled
circumstances. I have not seen any evidence, even from the Dutch
or Swiss studies, that we need to have any more.
998. The Home Secretary has announced that he
wants to increase the number of heroin addicts being treated with
diamorphine. You do not support that?
(Dr Gerada) No.
999. Could I ask the other witnesses?
(Dr Thompson) I would agree with Dr Gerada in a treatment
setting. The problem you have is that you are hearing evidence
from people who are advocating giving heroin virtually on demand,
but the Home Secretary is looking at burdening already over-stretched
treatment services with a very labour intensive, so-called treatment
which does not have any evidence to support its use as a treatment.
If you are looking at wanting to collapse the black market by
providing heroin legally, do that but do not call it treatment
and do not over-stretch the primary health care resources by doing
that. Do it another way.