Examination of Witness (Questions 1560
- 1579)
TUESDAY 19 MARCH 2002
MR RALF
LÖFSTEDT
1560. What about hepatitis C? As a key health
issue, the figures we have, from an article you were provided
with, state that 90 per cent of injecting drug users in Sweden
have hepatitis C, which is by far the highest in Europe. Again,
is this because you have not had harm reduction as a big enough
part of your strategy or is it something else?
(Mr Löfstedt) I do not know. The problem is that
in our needle exchange programme in the southern part of Sweden
there is the same rate of hepatitis C in that area as elsewhere
in the country. On the other hand, it does not seem as though
the needle exchange programme should have any impact on hepatis
C and B. I cannot give a reason. One theory is that we have succeeded
in reducing new incidents of HIV, not because we are giving drug
addicts clean needles but more because we have tested people.
That was very controversial in the beginning, in the mid-Eighties.
It means that drug addicts are taking care and responsibility
for themselves and for others. They still share needles, and we
can see that by looking, for instance, at the hepatitis rates,
but they are not sharing needles with HIV sufferers or else the
HIV-positive person uses the needle last in the chain. I cannot
see any other explanation for this.
1561. Do you have a target for reducing the
number of drug-related deaths in your national plan?
(Mr Löfstedt) We do not have the figures. The
target, of course, is to reduce drug-related deaths. In the action
plan there are no figures on reducing the number of drug addicts
by 5, 10 or 20 per cent.
1562. Does it worry you that in 1998 there were
85 acute drug-related deaths in Sweden?
(Mr Löfstedt) Yes, it worries us.
1563. That is a big figure, is it not? Do you
feel that the strategy has held you back from dealing enough with
that issue of harm, death, HIV and hepatitis C or not?
(Mr Löfstedt) I do not think so. When you are
creating a drug policy for society, you must see the whole thing
in context. Whatever you do, you make sure that more harm will
not be done than is solved. Of course we are concerned about the
high figures. We are concerned about the health of drug addicts.
We are concerned about social life and we put a lot effort in
to helping but we think that the best way of helping drug addicts
is to provide treatment and make sure that they can live a drug-free
life, instead of focussing on technical solutions that may help
them to continue their addiction or drug use but with a little
less risk.
Mr Cameron: I was coming to that. When it comes
to treatment, we have had witnesses from Switzerland and Holland
who have talked about heroin prescribing for addicts who have
a very strong addiction to heroin, who are not yet ready to kick
the habit. They said that the most important thing is to get these
people a stable, clean supply of heroin so that they stop stealing,
they do not overdose, do not inject themselves with impure drugs
and they do not die. The evidence would seem to be that they have
reduced the number of drug-related deaths through doing that.
What do you think about prescribing heroin in extreme circumstances?
Chairman
1564. But strictly controlled circumstances,
so there is no leakage.
(Mr Löfstedt) I have thought about that a great
deal but, to be brief, it was not long ago that we saw methadone
as the final solution to the drug problem. After a while, we found
it was not the answer. Now it is heroin prescription that is the
final solution to the drug problem. We will probably find in a
couple of years that that is not the answer either. What is the
difference between methadone and heroin? You get a kick from heroin
but you do not have that from methadone. The problem I see is
that you lose the borders. The Swiss are talking about a project
with 1,000 of their hardest heroin addicts but what would we do
with the rest? How does a project like that affect society if,
instead of 1,000 we have 30,000? The Swiss are saying that is
the number of heroin addicts in Switzerland. What shall we do
with those who take amphetamines, cocaine or morphine? We keep
widening the borders. If we do that, I think we should be clear
about what we are doing. We are now talking about pilot projects,
as is happening in Switzerland, the Netherlands and elsewhere.
I do not think we should discuss this in terms of pilot projects.
If you start a project like that, it is impossible to stop and
go backwards. What will you do with the persons to whom you give
heroin for a year or a number of years? You cannot kick them back
on to the streets again. Before we stop, I think we should be
very careful to analyse the effects, not only on the individuals
but also on the families and society as a whole. One problem,
as I see it, is that we only look at these projects from the perspective
of the individual. We say, "We have this individual; he has
been on heroin for ten years. It is unlikely that he will succeed
in treatment". That is the first problem, saying that people
are hopeless. I am an old social worker, and I know that no one
is hopeless but treatment takes time. You have to work for many
years perhaps to succeed. I have seen people who after three,
four or five treatments finally return to a drug-free life. What
will the effect on society be if we take more and more people
directly from drug addiction into another type of drug addiction,
but one sponsored by society?
Mr Cameron
1565. We are doing that, are we not, with methadone
and the Swedish are doing it with methadone as well. We have had
people coming to us saying, "You need different forms of
treatment for various sorts of people". We had some witnesses
last week whose children had died from drug abuse. The child of
one of them could not take methadone because it gave him nightmares
but there was no clean supply of heroin available. Do you have
a specific objection? If you are going to start giving methadone
to drug addicts, do you have a specific objection to stabilising
some addicts in some cases with diamorphine and heroin? Is it
because of the society point or is there something else?
(Mr Löfstedt) It is mainly the society point.
Also, there is no discussion about heroin prescriptions in Sweden.
That should not be possible from a political point of view. Personally,
I do not think that is successful.
1566. What do the majority of your addicts do?
I think you said earlier you have 17,000 heroin addicts and somewhere
we saw that you have 600 to 800 methadone treatment places.
(Mr Löfstedt) Yes.
1567. What do the rest do? Where do they go?
Where does an addict go when he comes in for treatment?
(Mr Löfstedt) Basically the main drugs in Sweden
are amphetamines. We cannot solve that problem with methadone.
We have strict rules concerning methadone. For the same reason,
we see methadone as part of a comprehensive treatment programme;
it is not the methadone itself but the methadone could be used
in a treatment programme. Then again, how do we do that for the
people in most need without that affecting the drug-free treatment?
We see in other countries that if you start with more or less
free methadone, that will affect the whole treatment system. In
some countries you cannot find any drug-free treatment facility
today. In Sweden the main focus is on drug-free treatment.
1568. Are those residential programmes?
(Mr Löfstedt) They are both residential and open
care. The rule concerning methadone is just to find people in
need and no one else; the methadone should be a part of the treatment
programme, which includes social and psychiatric care and whatever
the person needs. We do not want to see a development whereby
a drug addict just goes to his general practitioner and receives
methadone and then goes back on the street again. That is not
our view. The next problem, as you indicate, is: what do we do
with people who do not fit within the programme? We have rules.
That is a problem. We have to take care of that in a different
way. To be on a methadone programme, you have to follow the rules
and, if you do not, you will be thrown out. You are welcome to
come back but for a while you will leave the programme. It is
up to the social authorities to help that person in another way
and try to take care of him one way or another. In some countries
we see developing, low threshold methadone programmes. What effect
does that have on the rest of the addict group? Some might say,
"Why should I go through a strictly controlled methadone
programme if I could go on to a low threshold methadone programme
and still use my heroin?"
1569. Do you think you get addicts off heroin
by pushing them into a form of treatment that they may not respond
to?
(Mr Löfstedt) It depends what you mean by "push".
The basic idea is that society has the responsibility to push
or motivate people from drug addiction into treatment. We are
not just sitting waiting for drug addicts to say, "Hey, I
want to go into treatment and now I am ready". We think it
is important to influence drug addicts as early as possible and
also to motivate them to enter treatment. Our problem is not people
who want to enter treatment. Our problem is people who do not
want to go into treatment and our efforts to put them into treatment.
Mr Russell
1570. If the United Kingdom liberalised its
current drug policy, would that have any impact at all on Sweden?
(Mr Löfstedt) Probably. Drug policy is very natural
and we need to co-operate on an international level. Last week
I attended a meeting of the UN Drugs Control Committee. There
was a huge debate on cannabis. I do not know if you know about
IZB, the European Board for Narcotic Drugs. Every year they present
a report. The theme of this year's report was cannabis. The conclusion
is that there is a number of problems with cannabis. For instance,
is cannabis harmless or not? The IZB said that there are routines
and rules to show a substance to be harmless. People who have
that kind of evidence should put it to the World Health Organisation,
which will scrutinise it and arrive at a decision. It is impossible
to withdraw drugs if they are shown to be harmless from the UN
lists. Another problem was also discussed in an international
perspective. For a number of years we have been telling the developing
countries that they should put a lot of effort into reducing these
crops. Now the rich countries are saying that they cannot afford
to fight the demand, so they do not care; they do not think there
is a problem with cannabis and they tolerate cannabis. That means
that we are saying to developing countries that they can go on
producing cannabis because of the liberalisation and that it is
tolerated in Europe. That also means that supplies will increase.
1571. That is to Sweden as well.
(Mr Löfstedt) To Sweden as well, and to all countries.
1572. If you have the harshest drug regime in
Europe, which I believe is the case, why is it then that you should
be concerned that liberalising it in this country would have a
negative effect on Sweden? People are more likely to come to the
United Kingdom rather than to go to Sweden.
(Mr Löfstedt) No, it is not so directly towards
Sweden but of course it is a problem for Sweden that other countries
in Europe are saying cannabis is not problematic. If we are saying
you should not use cannabis and others are saying it is all right,
that sends a double message, which will weaken our message. That
is the problem.
1573. If taking the drug in Sweden is going
to be a criminal offence and if taking it in other European countries
is not, why would foreign nationals wish to go to Sweden to take
drugs? Equally, is there not a temptation for Sweden to export
its drug addicts to other countries?
(Mr Löfstedt) I do not think I see that as a
major problem. Of course, young people today are travelling around.
If we say they should not use cannabis because it is harmful to
them, and they go to another country and are told it is all right,
it is free and society will provide them with cannabis, then of
course we will have a problem when they come back to explain why
it is dangerous in Sweden and not in the Netherlands. This is
a problem. Also, the message is conveyed in films, music and other
media.
Chairman
1574. Is cannabis allowed for medicinal use
in Sweden?
(Mr Löfstedt) No.
1575. Not at all?
(Mr Löfstedt) No.
1576. It is not allowed for pain relief in terminally
ill people?
(Mr Löfstedt) No. If there is scientific evidence
that cannabis has any medicinal use, I do not see that as a policy
problem, as long as we use the same rules for cannabis as for
any other agents, those authorised by competent bodies, scientific
evidence and so on.
1577. Just going back to the experiments in
the Netherlands and Switzerland with heroin users, you were saying
that this may not work and it is a very expensive way of maintaining
a heroin addict for life in some cases. I think that is what you
are saying, is it not? There is one respect of course in which
it might make a difference and that is that it will stop them
committing crimes in order to fund their habit. Since in this
country 40 per cent of acquisitive crime is drug-related, that
would have an impact, would it not?
(Mr Löfstedt) Certainly, and our experience in
the Seventies with an amphetamine prescribing project showed that.
I do not want to compare that with the Swiss experiment, which
is different. I think that the Swiss experiment is better controlled
than the Swedish one and it was for an elderly group; in Sweden
a young group was used. It showed that criminality increased during
the period; that is, not drug crimes but other types of crime
increased. I am not sure, but one solution might be that normally
you are both a criminal and a drug addict; you have both identities.
It is not so easy to say you are just a criminal because you need
money for drugs. If you receive the drugs free, it is not certain
that you will stop your criminal behaviour. If you do not have
to look for drugs, you have more time for crime. That is one idea
behind the result in Stockholm. I think it is bit different with
the Swiss experiment because that was with an older group. We
also know that people reduce their criminal activities after their
thirties. If we have heroin addicts of around 40, they will probably
reduce their criminal activities.
1578. I do not think anybody is suggesting that
it should be just for people over 40. The point that is being
made is at the moment in this country (and it must be true in
most others) if you are a heroin addict, unless you happen to
be wealthy, almost the only way you can fund your habit is by
crime, there is no other way forward.
(Mr Löfstedt) But how do you do that without
affecting the prevalence of new drug addicts? That is the main
problem. If we make drugs more easily available I think that will
affect the number of drug addicts.
1579. You would obviously have to lay down some
criteria, ie, it would only apply to chronic heroin addicts who
had been taking heroin for two years, something like that. If
you said only those over 40 you would be rather undermining the
original object?
(Mr Löfstedt) That is my point. It is very difficult
to find criteria which do not interfere in a negative way in the
policy. If you say, "You have to have been using drugs for
at least two years", you would certainly have a number of
people using drugs for two years just to be able to go into the
programme. So in one way or another you will affect the whole
system and my advice is to be very careful when thinking and analysing
and taking decisions because any decision will affect the system.
One problem that we could see in Europe is we only think from
the individual perspective, we very seldom think from the perspective
of society. I think that the heroin project is one example of
that. You look at individuals and you see that an individual has
changed his health and his social life or whatever, but the evaluation
does not look at what happened to the families, what happened
to their working life, what happened to society as a whole, and
the next step, what will happen if we increased the number of
heroin addicts.
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