Swiss and Dutch research
180. Persuasive evidence of the effectiveness
of diamorphine prescribing does, however, exist elsewhere in Europe.
We took evidence from Professor Juergen Rehm, Director and Chief
Executive, Addiction Research Institute, Zurich, Switzerland,
and Senior Scientist, Centre for Addiction and Mental Health,
Toronto, Canada, and from Dr Gerrit Van Santen, from Amsterdam
Municipal Public Health Laboratory, both of whom have been involved
with pilots of diamorphine prescribing to heroin addicts, in Switzerland
and The Netherlands respectively.
181. Professor Rehm's study found that treatment
of heroin addicts in Switzerland with prescribed heroin was often
successful, with many patients going on to methadone treatment
or abstinence therapy after being treated with prescribed heroin.
Results from the Dutch trial were also positive. The study found
that the treatment led to improvements in patients' physical and
mental health, and significant reductions in illegal activities
amongst the patients. The researchers found that they were able
to deliver the treatment programme without serious health risks
for the treatment staff or the patients. Nor were there serious
public order and controllability problems for the treatment staff
or the neighbourhood.
Both Professor Rehm and Dr Van Santen also told us that the programmes
were set up in such a way that there was no leakage of pharmaceutical
heroin from the clinics onto the black market.
The drugs were only dispensed under strict supervision. The Swiss
study also found that the heroin prescribing programmes saved
money for society. While the programmes were expensive to run,
the reduced criminality of patients and improved health meant
that, overall, savings were made to the criminal justice and health
182. The Home Secretary has indicated that he
is looking at the possible expansion of heroin prescription to
addicts, and has set up a team of experts to consider the issue.
Mr Ainsworth explained:
"What we are worried about is that the current
guidance has led us to be a little too restrictive as to where
we are prepared to offer heroin as a form of treatment and that
there are situations where people are not being allowed access
to that treatment where it may well be appropriate and that is
in part because, or we believe it is in part because, of the guidance
that we have given and the effective restriction of the guidance
which has been given".
183. The group of experts is expected to report
back with their conclusions by the end of 2002. We do not think
that it is enough for the Government simply to expand the number
of doctors licensed to prescribe diamorphine to heroin addicts.
184. It has been persuasively argued to us that
the legalisation and regulation of heroin would collapse the criminal
market, drastically reduce the level of acquisitive crime and
make addiction easier to treat. For reasons already given (see
paragraph 65 above) we do not propose to go down this road. We
do, however, accept that there is a strong case for bringing heroin
use above ground, so that those who wish to be helped can be,
and those who do not wish to be helped can at least indulge their
habit at a minimum risk to their own health and that of the public.
The obvious first step is the introduction of safe injecting houses
(so-called "shooting galleries") of the sort that exist
elsewhere in Europe. At their most basic these are places where
addicts can go without fear of arrest to inject illegally purchased
heroin and where practical advice is available as to the safest
means of injection and the safe disposal of needles. The Home
Office told us that "the current government position is that
injecting rooms for illicit drugs should not be introduced in
this country whilst we have no evaluations of those developed
in other European countries".
185. We believe that such facilities may offer
potential to reduce harm. As well as helping users to reduce the
risks to their health, safe injecting premises could make a significant
impact on the nuisance caused to others by illicit injecting.
All members of the Committee have heard from constituents about
the problem of discarded needles and other paraphernalia in the
street posing a health and safety risk, particularly to children.
If injecting users could be directed to safe premises, needles
could be disposed of in a safe way and the problem contained.
186. We recommend that an evaluated pilot
programme of safe injecting houses for heroin users is established
without delay and that if, as we expect, this is successful, the
programme is extended across the country.
187. We go further. As we have seen, a number
of other European countries have established carefully controlled
programmes for the treatment of heroin users which involve making
clean heroin (or diamorphine) legally available to users together
with sanitary equipment and sound advice on dosage and injecting
techniques. The aim is to help addicts manage their habit and
in due course to wean them off their addiction. It also has the
additional benefit for society as a whole that they no longer
have to rely on acquisitive crime to fund their habit. As Mrs
Tina Williams, whose son is addicted to heroin, put it to us "if
you are treating the user with what they need to keep them well
why would they go to the black market?".
The Association of Chief Police Officers said recently:
"There is a compelling case to explore further
the merits of prescribing drugs of addiction to patients with
entrenched dependency problems who have not responded to other
forms of therapy...this should include the wider use of heroin
within a menu of treatments".
188. Opinion, however, is far from unanimous.
Dr Claire Gerada, of the Royal College of General Practitioners,
told us that providing diamorphine to addicts would mean "colluding
and creating life long addicts".
We asked Mr Ralf Löfstedt, Deputy Director of the Swedish
Ministry of Health and Social Affairs, for his opinion of heroin
prescribing, given Sweden's more restrictive approach to drugs
policy. He told us that providing prescribed heroin implied that
some patients were "uncurable" and warned that society
would be sending out inconsistent messages: "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?".
He also suggested that it might be harder to motivate addicts
to take up treatment such as methadone and drug-free programmes
if they were able to access clean heroin.
He told us that the reductions in crime which had been seen in
the Swiss and Dutch programmes might not be sustained and suggested
further that heroin treatment programmes might cause a rise in
the numbers of new users.
189. Mrs Williams told us that "on humanitarian
grounds to prescribe controlled diamorphine to people that are
really sick and need it is not a signal to encourage people to
The Dutch report addressed many of the objections to diamorphine
"It should be emphasised that drug users
are not 'given up' when prescribing heroin, nor that it is accepted
that these persons will remain addicted for the rest of their
lives. Heroin prescription may be a new hold for heroin addicts
for whom there has been no adequate treatment so far. By enabling
drug users to return to their original intoxication through medically
prescribed heroin, also the use of illicit drugs other than heroin
may be reduced...In addition, through the prescription of heroin,
medical and social care may be initiated and efforts may be undertaken
to help these addicts to structure their lives, andfor
some addictsto achieve abstinence from drugs. For example,
10% of the patients admitted to the Swiss heroin program (22%
of all discharges) left the program to start abstinence oriented
190. We conclude that the Dutch and Swiss
evidence provides a strong basis on which to conduct a pilot here
in Britain of highly structured heroin prescribing to addicts.
We recommend that a pilot along the lines of the Swiss or Dutch
model is conducted in the UK. Should such a pilot generate the
positive results which one would expect from the Dutch and Swiss
experience, we recommend that such a system should supersede the
little-used "British system" of licensing.
191. We recommend that a pilot offering prescribed
diamorphine to heroin addicts is targeted, in the first instance,
at chronic addicts who are prolific offenders.
Diamorphine for persistent addicts
who have not yet accessed treatment
192. Professor Rehm and Dr Van Santen told the
Committee that the Swiss and Dutch programmes to provide diamorphine
to addicts were only to open to persistent addicts who had tried,
and failed, to comply with other treatments such as methadone,
over a period of some years. They emphasised, however, that this
did not necessarily allow the most problematic group to be accessed,
who were described as:
"a smaller group of not adapted people,
who are actually causing lots of problems. They have a very high
frequency of emergency room visits, they refuse any treatment
and they take sometimes methadone in very low thresholds, but
only if it is on an occasional basisif it has to be on
that day for whatever reason. Those are the kinds of drug users
which cost the most to society".
193. The suggestion is that diamorphine on prescription
may offer a way of encouraging these people, too, to enter treatment.
Dr Van Santen said: "I think the power of the prescribing
of heroin lies not among those poor performers on methadone but
on those people not reached yet by services, by necessary care".
Professor Rehm too described this as potentially a much more important
role for diamorphine prescription than that explored by the trials:
"we want to see can they attract non-treatment goers in our
society, which is way more a problem in Switzerland".
He referred to a trial about to begin in Germany, run by Hamburg
University, in which the criteria for admission to the scheme
will be widened slightly to include not only those who have failed
on an alternative treatment but also those who have not accessed
any treatment for at least the past six months.
194. We recommend that the Government commissions
a further trial to look at the prescription of diamorphine to
addicts who have not yet, or are not currently accessing any treatment,
despite having a long history of heroin addiction.
195. It has been emphasised to us that diamorphine
prescription should be used as a complement to already existing
treatments which are backed up by strong evidence, such as methadone
treatment. If diamorphine treatment could be offered to all problematic
users who do not successfully access other treatments, we believe
it could play a useful part in managing the social problems generated
by this group of people.
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