Annex
Additional Evidence from the Home Office
for the Home Affairs Committee Enquiry: Comments in Response to
Articles by Nick Davies, The Guardian (This is
provided in response to a specific request by the Committee to
comment on these articles)
DRUG TREATMENT
AND TESTING
ORDERS ARE
AN ILLUSTRATION
OF "POLITICS
PERVERTING HEALTHCARE"
There is strong evidence from a number of research
studies to show a clear link between heroin and crack/cocaine
misuse and crime—particularly acquisitive crime.
The New English and Welsh Arrestee Drug Abuse
Monitoring (NEW-ADAM) across eight sites reveals that 65 per cent
of arrestees tested positive for one or more drugs. Of these 24
per cent tested positive for opiates (including heroin) and 15
per cent for cocaine/crack. Arrestees who are misusers of both
heroin and crack/cocaine account for more than half (by value)
of acquisitive crime.
There is also good evidence to show that treatment
works and is cost effective in achieving reductions in drug use,
offending and improving the health of drug users. For example,
the National Treatment Outcomes Research Study (NTORS) showed
that for every £1 spent on treatment, £3 is saved on
criminal justice spending.
The criminal justice system provides a unique
opportunity to get drug misusers to address their problems and
steer them into treatment and away from offending.
Criminal justice intervention initiatives such
as the Arrest Referral schemes and Drug Treatment and Testing
Orders (DTTO) are designed to do just that.
The early pilots for both initiatives showed
significant results in terms of reductions in both crime and average
expenditure on drugs. For example, the Arrest Referral pilots
showed that 31 per cent of offenders were no longer using crack/cocaine,
and 28 per cent had stopped using illegal opiates six to eight
months after referral. Furthermore, the average expenditure on
drugs fell from £375 per week to £70 per week and there
were corresponding reductions in the level of crime. The DTTO
pilots revealed similar results.
The Arrest Referral Scheme has also proved successful
in getting drug misusers into treatment for the first time—over
half (51 per cent) of all those referred had not previously accessed
treatment.
The Arrest Referral and DTTO pilots were rolled
out nationally only after careful independent evaluation. In each
case this was no less than two years after the pilots began.
Both initiatives continue to be monitored and
evaluated, with a view to building upon the success and spreading
best practice.
Under both initiatives, referral into treatment
is done on a voluntary basis. There is no coercive element involved.
DTTOs are community sentences designed to assist
offenders with deeply entrenched drug problems whose record of
acquisitive crime might otherwise lead them to a prison sentence.
The treatment programmes are challenging and it is disappointing,
but not surprising, that some Orders are revoked.
Those whose Orders were revoked during the pilot
stage had not "vanished" or "been thrown out".
They would have been breached in accordance with the usual procedures
where those on community sentences fail to comply.
It is not "odd" that, during the DTTO
pilots, offenders continued to misuse drugs at the same time that
the average expenditure showed a dramatic fall. Reductions in
drug misuse are often gradual, and it is not surprising that many
offenders were continuing to misuse at an early stage of the Order.
HEROIN IS
A RELATIVELY
SAFE DRUG
AND THOSE
PRESCRIBED HEROIN
CAN CONTROL
THEIR USE
WITH LITTLE
DIFFICULTY
The adverse physical effects of heroin are limited
but the most significant is respiratory depression. Heroin is
the addictive drug most commonly involved in "drug-related
deaths" due to poisoning (either alone or in combination
with other drugs) and is highly dangerous in this regard.
Heroin is highly dangerous due to the risk of
escalating addiction. This is the key to its harm. Regular use
of heroin can lead to a deteriorating cycle of escalating use
and prioritisation of heroin use over other activities and responsibilities.
There is no known upper limit on the dose of heroin to which an
individual can become tolerant.
A drug user on prescribed heroin could still
escalate the amount used (with illicit heroin or other opiates)
or mix it with other drugs (commonly drugs like cocaine). Risks
of injecting would be sustained. Continuing multiple daily use
of heroin is liable to reinforce its own and other drug-taking
behaviour. This is exactly the nature of addiction and why it
can be so destructive. The wider availability of heroin would
not only support escalating addiction but could involve new users
with different vulnerabilities and patterns of use.
In addition the routes of use of opiates and
other drugs (that will no doubt vary as a matter of fashion if
widely available over time) also have well recognised serious
dangers.
There is no question that stimulants can cause
death and psychological and psychiatric problems. They are frequently
used with opiates. Benzodiazepines and alcohol are also frequently
used by drug users to mediate various effects of their drug taking.
THE RESTRICTION
OF HEROIN
PRESCRIBING (FOR
ADDICTION) TO
ONLY THOSE
WITH A
LICENCE IS
COMPOUNDED BY
DOCTORS BEING
"OFFICIALLY DISCOURAGED
FROM USING
THE LICENCE"
There is no evidence to support this. The licensing
requirements exert no influence on prescribing practice with clinicians
who make independent decisions about prescribing. The mechanisms
for licensing are simple and free and there is no significant
barrier to any skilled and reputable practitioner obtaining a
license and prescribing heroin. The current system supports good
practice based on careful clinical judgement of the needs of the
patient. The current limited use of heroin for carefully selected
patients has arisen because of decisions, based on the research
evidence and experiences of practitioners since the late 1960s.
The main reason for this change was the clinical benefit of injectable
methadone and then liquid methadone. The difficulty of actually
stabilising significant numbers of heroin addicts on injectable
heroin (polydrug use, instability and unsafe practices continuing)
contributed to the move by clinicians to methadone.
It is clear that some patients may become relatively
stable on injectable heroin and the current British system allows
the freedom for experienced clinicians to use that treatment.
The evidence and current clinical practice suggests this is not
the appropriate treatment for the majority.
We recognise that there is some inconsistency
in prescribing practice around the country and a need to look
again at current clinical practice. This is why the Department
of Health with the NT and the Home Office have arranged a consensus
event in February to bring together a number of prescribing experts,
from here and abroad, to review current practice and develop further
guidance on the most appropriate use of heroin as a substitution
treatment for illicit heroin.
METHADONE IS
MORE DANGEROUS
AND MORE
ADDICTIVE THAN
HEROIN
Most of the evidence for the benefit of treatment
of heroin addiction is from the much larger numbers of those prescribed
methadone than those prescribed heroin, but it is clear that engagement
in such substitution treatments are very effective in reducing
a range of personal and social harms.
There is a large body of evidence to demonstrate
the value of the long-acting opiate methadone (particularly liquid
methadone taken orally). Methadone allows many drug users in treatment
to stabilise their lifestyle. It is easier to return to a stable
life on methadone than on injectable heroin because one oral dose
is much less intrusive than multiple injections daily. When coming
off heroin or methadone most patients require considerable psychological
and social support.
The Advisory Council on the Misuse of Drugs
in their Report on Drug Related Deaths and the DH expert document—"Drug
misuse and dependence—guidelines on clinical management"
both consider the relative benefits of opiate treatments on the
basis of the best available evidence. They both conclude on the
value and importance of methadone substitution over heroin for
the majority of patients in stabilising chaotic lifestyles due
to addiction and reducing harm. These works are fully referenced.
THERE SHOULD
BE A
FREE CONTROLLED
LEGAL SUPPLY
OF HEROIN
Heroin is actually already available in the
UK in addition to other opiate and other treatments. Clinicians
moved away from prescribing heroin in favour of oral methadone
liquid on clinical grounds (the benefits of which are clearly
available in the scientific literature). It is clear that patients
on heroin injectable treatments can also be unstable in their
drug use and at continuing risk.
LEGALISATION OF
HEROIN AND
OTHER CONTROLLED
DRUGS WOULD
OBLITERATE ASSOCIATED
HARMS
Drugs are already legal for those in treatment
for problems with addiction but there are some limitations around
issues of individual or public safety. Doctors that are currently
prescribing diamorphine have to weight up risks for addicts to
whom they prescribe and sometimes refuse on the day to prescribe
if the person is intoxicated or there are concerns about driving
or currently having a child with them in a state of possible intoxication.
Given the risks for particular individuals of
these drugs (those at risk of psychosis, those with personality
disorder and those with a history of abuse or self-harm) availability
without assessment of these issues could be highly problematic
(and presumably liable to claims of negligence). Because of the
dangerousness of these drugs and the ethical responsibilities
and duty of care of clinicians and prescribers, it is unlikely
that prescribers would be willing to prescribe except for those
identified to need the treatment.
No assessment has been made of the likely impact
of making "hard drugs" legal on the types and total
numbers that might then use and become addicted. It is quite conceivable
that overall harm would escalate. The numbers of people currently
using hard drugs is relatively small. With our knowledge of the
impact of the current widespread use of harmful legally available
drugs, it is highly likely that with legalisation there would
be an increase in total use and the harms of escalating addiction.
We might then be back to a situation that preceded the International
Treaties and the development of the "British System"
when widespread harm due to easily available opium and opium dens
could no longer be tolerated by Society, and led to its prohibition.
We are not aware of any evidence that in a legally
available market that the total level of injecting and sharing
would decline. It is possible that there would be users who would
not want to obtain supplies directly which could lead to the development
of a secondary market. And it is also possible that for the heavy
using adults an illegal market based on price, accessibility,
access to novel designer drugs or upper limits to the availability
of legally available drugs could develop.
If the supply of heroin for the treatment of
addiction was legalised, it is logical to assume that suppliers
of illicit heroin would focus their efforts on recruiting new
addicts who could not or would not access the legal supply, particularly
young people. Unless all those who ask for heroin, cocaine, ecstasy,
methadone and temezepam etc were given their choice of drug, irrespective
of prior use, an illicit market will continue to be a problem.
It is also likely that any opportunity to re-engage
into the black market those with access to legally prescribed
heroin would be exploited (such as increasing supply of combinations
of drugs). This is likely to be particularly successful for those
who have not recognised the severity of their addiction (unlike
with current treatment populations) and those who have little
motivation to change.
Some regular users will still be involved in
an escalating cycle of addiction and may not wish to be involved
with state supply. Addiction develops and is sustained by a range
of complex factors (biological, psychological and social) so that
a legally controlled supply may not fully meet the needs of many
of those who have not yet chosen to come in for treatment.
The provision of such easily available heroin
substitution treatment may for some effectively support a longer
injecting career or a longer career of heroin and ploydrug use
than would otherwise occurred by avoidance of more suitable treatment
options.
The Home Secretary has made it clear that he
wants to look closely at current prescribing practice. The consensus
event, to be held in February, will address some of the issues
around inconsistency of supply and also consider whether or not
heroin should be prescribed to more people than are currently
receiving it. This is part of a wider harm minimisation approach
that will also include an action plan to reduce the number of
drug-related deaths and the development of best practice guidance
on the treatment of stimulant addiction, including cocaine.
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