Examination of Witnesses (Questions 1
- 19)
TUESDAY 9 JUNE 2009
PROFESSOR JOHN
STRANG
Q1 Chairman: May I bring this session
of the Select Committee to order and tell those present that this
is the first session of our inquiry into the drugs trade, in particular
to investigate the trends in cocaine use in the United Kingdom
and the progress in tackling the cocaine trade in terms of both
action on reducing supply and demand reduction in the United Kingdom.
Professor Strang, thank you very much for coming to give evidence
at this very first session. There have been a number of newspaper
reports which have suggested that recently there have been a number
of cases of young people in their 20s and 30s who have suffered
heart attacks as a result of using cocaine in combination with
alcohol. Is this a new phenomenon? Has this increased in recent
years and what concerns do you have about what appears to be an
increase in the use of cocaine in this way?
Professor Strang: It has long
been recognised that there is an association between cocaine overdose
and cardiovascular problems, stress to the heart, because essentially
cocaine is a powerful stimulant and has some cardio toxic qualities.
That includes accident-and-emergency-type health crises such as
you are describing. I would only know those indirectly because
it is probably best to view my area of practice or competence
as one foot in the treatment sector and the other in the research
and policy side and that treatment bit will be a more planned
treatment rather than emergency treatment. I would hear about
it but I would not be the doctor who was rolling up my sleeves
in A&E; not so dramatic. That has increased. If I might be
so bold, what is difficult for all of us and for you as a Committee
is to get a sense of what weight to attach to a change like that
which occurs. You do have, from the health point of view, increasing
numbers of people presenting to treatment, increasing numbers
with complications and yet you also need to keep an eye on the
bigger picture of what is happening with total presentations for
different types of drug problems and where this fits in that bigger
picture. Media reports will tend to be that there has been a 50%
increase, but if it goes from 3% to 4.5% that is not the same
as if it goes from 20% to 30%.
Q2 Chairman: We are keen to know
whether this is a new phenomenon or whether this is something
which has always happened with a drug like cocaine.
Professor Strang: It is not a
new phenomenon; it is something that is greater not only as you
get more cocaine use but more heavy cocaine use.
Q3 Chairman: Is it on the increase?
Professor Strang: My understanding
is that it is on the increase but those are not data which I have.
I am giving you second-hand reports.
Q4 Chairman: Where is the best place
to get the data?
Professor Strang: Probably from
accident and emergency departments. There is an association, I
cannot remember the name, of consultants of accident and emergency
department and they have a Journal of Emergency Medical Services.
I imagine they collate those data and could give you a response.
St Mary's Hospital often collected that in the past.
Chairman: Thank you, we will pursue that.
Q5 Ms Buck: Do we know anything about
the differential impact in terms of a range of factors including
health impact of different groups of users and different variations
of the drug?
Professor Strang: I think I follow
your question but can you just repeat it so I can make sure I
have understood? There are different types of cocaine.
Q6 Ms Buck: Yes, different types
of cocaine consumed in different ways. Do we know anything about
whether the consumption patterns affect the health outcomes of
users? Do we know anything about whether different groups of users
more inclined to take the drug in different ways are affected
particularly badly?
Professor Strang: I can deal with
your first question and I will have a go at your second one. On
the different groups of use, one would have snorting of cocaine,
one would have smoking it, which would mean using it as crack
cocaine, or one would have injecting cocaine. Yes, you are right,
there are different health implications, there are different dependents,
in terms of the likelihood of getting into a mess with it and
those go in the way that you would anticipate. The slower effect
of snorting the drug versus either injecting it or smoking it
would have fewer psychiatric complications and fewer cardiovascular
complications, fewer of the general complications. The rapid effect
of intravenous use, and you could reasonably assume that crack
smoking was very close to intravenous use as it is like intravenous
use without the needle and syringe in terms of its speed of effect,
those two would be very close to each other. You also asked about
the different groups of people who might use it.
Q7 Ms Buck: Yes. Some of the interesting
elements here are that there are those people, I think of Charles
Murray, the author of The Bell Curve, an American sociologist
and others, who kind of make the argument that we should not worry
too much about a bit of middle class consumption of a joint or
a line or cocaine. What we really need to worry about frankly
are poor people taking drugs, the estates, the ghettoes, that
sort of language. To what extent do you think there is an argument
there? To what extent is it true that the drug consumption behaviour
of different groups of people, by vulnerability really, is something
we should be more concerned about than simply this top line question
of legalisation?
Professor Strang: I think you
are raising a hugely important point. I need to declare at the
outset that I am primarily a doctor, so you are leading me onto
territory which was not my primary expertise but it is one in
which I have become quite interested. If I may give advance notice,
during the course of your work there are reports coming out from
an organisation called UKDPC, UK Drug Policy Commission, looking
at the influence of market forces on problems. There is also an
international group bringing out a book by the end of the year
about drug policy and the public good which looks at issues like
public availability and which bits of the social strata get hit
hardest or least. On the whole, even though it is an illegal commodity,
you are talking about a commodity which obeys rules of the marketplace.
Higher levels of use mean that you get wider patterns of distribution
and larger levels of people with problems. We have studied this
very well and we know it well with alcohol and tobacco and presumably
with cornflakes and Levi jeans I imagine though I have not read
those papers. Those same laws apply to the illicit field and the
greater manifestation of those problems will be those who have
other indices of disadvantage, but it is not the sole preserve
of that group. There is sometimes a dangerous notion that problems
only affect those with other disadvantages, as your population
level of consumption gets greater, you get more dependence problems,
you get more health and other sequelae as well; you have shifted
the curve.
Q8 Patrick Mercer: What are the main
health concerns which arise from the current rash of cocaine taking?
Professor Strang: One very obvious
one which comes in my direction is that group of individuals who
get profoundly dependent on it and the associated personal family,
societal, criminal sequelae which come from that. Those will be
greater with the more intense forms of cocaine use so when cocaine
injecting was widespread that would be more associated and in
particular, when crack cocaine came to be more widely used, that
led to a greater proportion getting into those more extreme situations
than had been the case with cocaine snorting. In a way, one of
the difficulties for having any policy around drugs such as cocaine
is that its impact is partly influenced by the pattern, the way
in which the consumer group chooses to use it, even when the drug
stays the same. So snorted cocaine, having some aspects of a chic
quality in the 1980s, the Hollywood stars, is actually exactly
the same drug as the crack cocaine that was then being used in
ghettoes in US cities. The drug is actually the same; it has just
been slightly altered to be able to use it to give a much more
rapid effect, which does make it quite challenging then to work
out what your policy is when the substance was originally the
same.
Q9 Patrick Mercer: Are the health
ramifications of this distinctly different for crack as opposed
to cocaine powder?
Professor Strang: Yes, they are.
With cocaine, as with the other drugs that you have to grapple
with in your rolling programme, part of those are to do with the
substance, part of them are to do with the way in which the drug
is used, in particular any drug which is ever taken by injection
or has any association with sexual behaviour has huge health implications
in terms of HIV and hepatitis C, the most obvious viral ones and
immediate overdose crises and deaths as an immediate response
versus the long-term health responses.
Q10 Chairman: Can you name those
drugs? Which drugs do you have in mind?
Professor Strang: The most obviously
injected ones would be heroin and then cocaine would be the next
one. Anything taken by injection takes you into that category
of having problems where the drug happens to be the reason that
the health hazard has occurred. It is an obvious point but it
obviously changes fundamentally when the pattern of use changes.
Q11 Mrs Dean: The British Crime Survey
has shown a steady increase in the use of cocaine powder over
the last ten years, while crack use has remained static. Have
you seen an increase in health problems over the last ten years?
Professor Strang: There is an
increase and I imagine you also have the data from NDTMS, the
National Drug Treatment Monitoring System, showing how many people
are presenting and those are typically reported about whether
somebody is presenting with cocaine in either of those forms,
either as their primary problem or as a secondary problem. The
difference is probably obvious but it is important to grasp the
difference. A drug appearing as a secondary problem is partly
influenced by just what is going on out there and it is difficult
for you to work out whether that meant it was a problem or not.
There would be a very high prevalence of cigarette smoking in
those but you are charting the other drugs which are used, whereas
the primary problem would be the problem that somebody had presented
to the service saying I am in a mess and this is the main reason
I am in a mess. Both of them would be of interest to you but,
in terms of treatment need and response, the primary drug declared
would be the main one. In fact in the last report I have from
NDTMS from last year they have a figure showing which drugs people
were presenting with and about 75% of people are presenting with
a heroin-related problem and, eyeballing it, it looks about 15%
with a cocaine problem. A lot of that cocaine is as a secondary
problem. We are certainly seeing a lot of that but somebody presenting
with their primary heroin problem will have an additional complication
of the cocaine use on top, but it does not displace the fact that
the heroin problem is probably the main driver for them seeking
treatment and a smaller group, about one third of those, where
cocaine is the primary problem.
Q12 Bob Russell: Following on that
last line of questioning, I must stress I have no personal knowledge
of this but I have been told that cocaine use has now overtaken
heroin use in the UK and your last answer suggests that is not
the case. What are the health consequences of this likely to be
if in fact that is true?
Professor Strang: This is a real
case of lies, damn lies and statistics. I can hopefully clear
up some of that. In terms of prevalence of use, the two different
data sets which I have brought with me in case you were going
to quiz me on exact numbers are the Home Office's statistical
bulletin about the British Crime Survey which is a household survey
which tells you about prevalence of use, call it drug misuse declared,
what is declared about what people are using; then there is the
treatment system about who is presenting seeking help for treatment
and the picture is different. In the prevalence of use, what you
have, if you look at adults, you are definitely correct. Cocaine
strongly trumps heroin in the opiates; you are talking of many
times more people have used cocaine in the last year than heroin.
However, if you are talking about people presenting for treatment,
it turns round the other way. Both of those are correct; they
are just asking different questions.
Q13 Bob Russell: Are there going
to be increasingly worrying health consequences with cocaine use
having overtaken heroin use?
Professor Strang: As cocaine use
has become more widespread, there will be. One of the worries
I would have, in so far as I do not know how much a committee
such as yours is allowed to change its brief as it evolves, I
imagine you are allowed to look at other aspects, is that it would
be a pity if your interest in cocaine meant that you took your
eye off the ball from a treatment point of view to do with the
heroin problem. The challenge of the heroin treatment need remains
larger than the challenge of the cocaine treatment need. I know
the patterns of use of cocaine for many years now have been ahead
of heroin, but the treatment need for seeking treatment has not
followed that.
Q14 Bob Russell: So is heroin more
worrying to society than cocaine?
Professor Strang: The number of
people who seek treatment because of it is more with heroin than
cocaine. We have not followed the American pattern of cocaine
having swamped treatment services. We have what seems to me to
be a growing heroin problem with a growing treatment response,
which is still the major challenge, whilst also paying proper
attention to the cocaine bit. I am not trying to trivialise it.
Q15 David T C Davies: Could you clarify
that for me? My understanding is that crack cocaine is a harder
addiction to beat than even heroin. Therefore, the numbers might
be smaller but the needs of those who are suffering crack addiction
are possibly even greater than those suffering heroin addiction.
Is that right?
Professor Strang: I would urge
caution about trying to rank which are the greater addictive drugs
and which are harder to come off. It smacks more of tabloid newspaper
coverage than the sort of real issues one is trying to deal with.
If you look at somebody who has become addicted to crack cocaine
or addicted to heroin, they are both major challenges, they have
to break that addiction. To be honest, it depends hugely on the
individual and their circumstances. The other bit which I think
you do need to bear in mind is that there is a large population
out there who do not hit the health issues. You can actually get
this from the British Crime Survey data. They ask three questions
about whether you have ever used, whether you have used in the
last year and whether you have used in the last month. Let us
presume the last month is the one which is closest as a figure
to someone who might have a problem. If someone had used in the
last year and not the last month then that seems quite a long
way away from the group one is talking about. You get a clear
gradation down. With your cocaine use you will have 5% of young
people who will report having used it in the last year and you
can then look at what the equivalent is. In the last month it
will be half that figure and the last year will be twice that
figure.
Q16 David T C Davies: But my understanding
is that it actually takes quite a while to get addicted to heroin
but if you try crack cocaine once that is pretty much it and you
will be hooked.
Professor Strang: That is what
the newspapers tell you and me. It does not actually fit. If you
look at the data from the British Crime Survey you have data on
the percentage who will have used crack cocaine ever, will have
used crack cocaine in the last year and in the last month and
it does not show that inevitability. You see a similar gradation
across a number of drugs, with, if anything, heroin having more
of a dangerous stickiness to it. Certainly it would not fit that
tabloid coverage.
Q17 Martin Salter: If ever there
was a war which cannot be won it is the war on drugs. If ever
there was a more inappropriate phrase to summarise a drug policy
I would suggest that is it. I would be interested in your comments.
It has always seemed to me that any sensible drugs policy needs
education, enforcement and treatment as its three strands.
Professor Strang: Yes.
Q18 Martin Salter: I am interested
in what is available for the various forms of cocaine addiction.
I understand for heroin that we have alternative substances which
people can be weaned onto like Subutex or methadone, but they
have their own problems. With cocaine it is considerably more
labour intensive, is it not? I have heard stories about cognitive
behaviour therapy for crack cocaine addicts but what are the treatments
which are out there and what are the success rates of the various
forms of treatment for cocaine addiction?
Professor Strang: Your opening
statement is enormously important and I hope it gets placed in
bold in your conclusions. You do need each of those aspects. You
need a public control policy; you need something around the general
public and their attitudes to it and you need a treatment system
and it is absurd to think you could possibly go with one or the
other. The war rhetoric and the war metaphor have real dangers.
One of the very encouraging statements in the last month was from
the new drugs tsar in the US who says that he thinks the drug
war metaphor can do more damage than good.
Q19 Martin Salter: Forgive me for
interrupting. This started with Nancy Reagan's search for sound
bites, did it not?
Professor Strang: I think it predates
that but I do not want to get into personalities. I have been
able to live with the war rhetoric because from a health point
of view you might have a war on disease or war on poverty but
you do not send tanks and troops in, you send ambulance crews
and social workers in. From that point of view it is useful, if
you think of it as wanting to harness the resources you have,
to look for different levers you might have that affect the problems
in society. If you think of it as therefore meaning that it is
gunboats and interdiction, then that really is dangerous from
a drug point of view. You are absolutely right. One thing which
is exasperating for many of us is that we do not have the equivalent
of methadone and buprenorphine in the cocaine field so there is
no medication basis to it. Nevertheless that does not mean you
do not have anything. You do. You are working with people to tide
them through the immediate coming off but also the rebuilding
of their lives and work around getting back into the workplace
and the family place, work around more controversial work with
building incentive schemes towards people both achieving abstinence
and rebuilding their lives has got quite encouraging results.
Contingency management is the buzz phrase and is probably a better
buzz phrase than the cognitive behavioural phrase you were using.
There is a literature on that.
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