Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 980 - 999)



  980. Yes.
  (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 for GPs?
  (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 options.

Mr Malins

  988. On Naltrexone, where I gather trials in America have proved quite successful, can you just tell me what it does?
  (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, if necessary.

Mr Prosser

  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 my patients?

  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 Dutch experiments.
  (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.

Mr Prosser

  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.

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