Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Professor David Hannay (DP004)

Attached is a memorandum I wrote in 2007 for circulation to all political parties at the time of an election.

I am a retired GP who qualified in London, worked for 16 years in Glasgow, then 10 years in Sheffield as Professor of General Practice, before returning to South West Scotland as a rural GP.

The figures in the memorandum are out of date, but the situation is if anything worse and the arguments for a change in policy remain.

THE HEROIN HOLOCAUST—A DRUG DISASTER
(The need to medicalize heroin addiction)

Background

Introduction

The word drug is used for substances that alter mood, of which some are legal such as alcohol and tobacco, whereas others are illegal such as heroin, cocaine and cannabis. Amongst illegal drugs some like heroin are called hard drugs because they cause high dependence, and others like cannabis are considered as soft drugs because they are less addictive. As well as the extent to which they cause dependence, the harm which drugs cause may be short-term or long-term.

Legal Drugs

Whether drugs are legal or not, depends as much on social and cultural norms as on the amount of harm they cause. For instance, cigarette smoking causes little dose related harm in the short term beyond the irritation of tobacco smoke, but the long term cumulative effects are devastating. It has taken a generation for us to realise that cigarette smoking kills thousands of people a year through lung cancer, respiratory disease and heart attacks. But nicotine is addictive and in spite of price rises and health warnings, many find it difficult to stop smoking.

The other legalized drug of alcohol has a different profile of harm. Unlike nicotine the short term effects of excess alcohol are dramatic behavioural change with loss of control and drunkenness, which in turn leads to violent crime and road deaths. Unlike cigarettes, the long term effects of alcohol in moderation may be beneficial to health, but a minority will develop a compulsive dependence causing long term social and physical harm such as liver cirrhosis, which is increasing.

Because of their harmful effects, there are controls on legal drugs, such as prohibition on selling to children, licensing laws, and the recent ban on smoking in public places. But huge industries have grown up for the production, supply, and retail of the legalized drugs of tobacco and alcohol.

Illegal drugs

The same considerations of harm and dependency apply to other mood altering substances which have been deemed illegal and are controlled by the Misuse of Drugs Act 1971. This classifies illegal drugs into three classes with a graduation of penalties for their supply and possession. Those viewed as the most dangerous and harmful are in Class A (eg Heroin and Cocaine); in class B those seen as less serious (eg. Amphetamine and Codeine) and the remainder in Class C as the least harmful (eg Benzodiazapines and Cannabis). The act makes it unlawful to posses or supply these drugs unless prescribed by a doctor, and makes provision for the notification of addicts and the establishment of special clinics.

Of these drugs Cannabis was reclassified from Class B to Class C in 2002, which caused the then “Drugs Tsar” to resign in protest. The medical use of cannabis has also been contentious. But it is Class A drugs which cause the most harm. The use of Cocaine has grown dramatically with increasing seizures and a lowering of price. In 2000 there were 4 deaths in Scotland due to Cocaine but in 2005 this had grown to 44, approximately 15% of all drug deaths. However, by far the greatest harm done to individuals and society is caused by heroin and society’s reactions to it.

Results of the Holocaust

Prevalence

The proportion of addicts reporting heroin use has grown annually since 1975 with increasing numbers injecting. Heroin costs one third of the price 10 years ago. Every day in Scotland, 100 people are caught in possession of illegal substances, a 7% increase on the previous year. In the UK there are now about 350,000 registered heroin addicts of whom 60,000 are in Scotland, which is twice the proportion south of the border. In addition, it is estimated that 50,000 children in Scotland have one or more parents addicted to heroin. However, the number of registered addicts considerably underestimates the true prevalence. Nor is this just a problem of inner cities. One of the most affected areas is Dumfries and Galloway, where heroin addiction started to rise in the 1980s and it is estimated that 7% of 15–25 year olds are now addicted, with 1,000 users in Dumfries alone. This is in spite of the success of the local police force in seizing supplies and jailing dealers. The number of people seeking help in the region is 14% above the national average with 89% new users being teenagers. But there is a three-month waiting list for the local NHS clinic.

Deaths

The number of deaths due to heroin in Scotland rose from 84 in 1996 to 225 in 2004. In Edinburgh alone there were 40 more deaths from heroin than the previous year. In Dumfries & Galloway the average age of death from heroin addiction is 29 with a range from 17–42 years. As well as having twice the rate of heroin addiction, Scotland has twice the suicide rate of England, with many suicides being drug related.

Crime

Over the past five years there has been a steady rise in drug related crime. Over the same period, violent crime in woman has risen by 50%, mainly due to stealing and prostitution caused by drug use. It costs on average £40 a day to maintain a heroin habit or £280 a week. Of this £80 may come from state benefits leaving £200 a week or £10,000 a year to be found mainly from stealing, low level dealing, and prostitution. In the UK retailers lose £2.1 billion from shoplifting, much of it drug related. It has been estimated that 90% of prostitutes do so to afford their heroin addiction. Most of the prostitutes recently killed in Glasgow and Ipswich were heroin addicts, many on methadone.

As a result, Scottish jails are awash with heroin and have been called drugs supermarkets. There are now 7,200 in Scottish jails of which 70% suffer from drug addiction, which is not surprising as it is drug related crime that has led to their imprisonment. The prisons are overcrowded and we will soon need 1,000 extra places with a new prison costing £160 million. 45% of prisoners are re-convicted within two years, about half for drug offences.

Costs

The annual cost to the state of one young heroin addict is estimated to be £26,000. As the average length of addiction is 13 years, this comes to a staggering £325,000 per addict. The annual cost does not take into account the value of stolen goods and is made up as follows: Prison four months—£12,000; State benefits eight months—£3,000; Housing benefit—£3,000; Probation/Social work—£2,000; Methadone—£2,000; Legal aid, Court costs, Police costs, Council tax benefits—£1,000 each.

Reactions to the Holocaust

Control and Treatment

The emphasis of society’s response has been to try to control heroin addiction and to care for addicts with a combination of legal penalties and treatment. The mainstay of treatment is methadone, usually prescribed in special clinics. It is highly addictive, but can be taken by mouth once a day, instead of heroin which has a shorter half life. There are 20,000 addicts in Scotland on methadone which costs £2,000 a year, or a total of £40 million a year and the number of prescriptions are rising. There is evidence that methadone reduces mortality and criminality, but it also de-motivates and only 3% come off the programme.

Methadone is also a method of control with supervised consumption in pharmacies and urine tests for other illegal substances which may lead to suspension from clinics. To this humiliation is the added fact that often the dose of methadone is insufficient to prevent the additional use of illegal drugs. It may also take three to eight months to get an appointment. The debate continues between harm reduction and withdrawal to abstinence, for which other drugs such as dihydrocodeine and naltrexane have been used and even low level electric stimulation.

There have been recent attempts to improve treatment facilities with £60 million voted by the Scottish Parliament last year to increase rehabilitation facilities. At the same time, others advocate more controls such as contraception prescribed with methadone and on the spot fines for possession. The former suggestion ignores human rights and the latter would only increase crime to pay for the fines.

Some politicians advocate drug free prisons with mandatory drug testing, but the majority of prisoners are there as a result of addiction mainly to heroin. Even on-the-spot fines have been opposed on the basis that anyone possessing heroin should be prosecuted through the courts. A more constructive approach has been to replace prison sentences with Drug Treatment and Testing Orders, which have been shown to cut reconviction rates.

However, none of these approaches addresses the fundamental problem which is that the present legal basis of criminalizing possession of a highly addictive drug such as heroin inevitably creates a flourishing black market, so that users are driven to criminal activity in order to fund their craving. And yet all the official responses have ignored this fundamental fact and concentrated on control, with the language of conflict such as “a war on drugs” and the appointment of “drug tsars”.

In 1999 the Scottish Drug Enforcement Agency was launched, followed in 2001 by the Scottish Executive’s Effective Intervention Unit with guidance on shared care arrangements, all essentially about control. In the same year Dumfries & Galloway published a glossy multi-agency Alcohol and Drugs Strategy with an emphasis on harm reduction, which now involves multiple stake holders such as the Police, Social Work, Health Professionals, and the Voluntary Sector.

At the same time the Royal College of General Practitioners were promoting a “Certificate in the Management of Drug Misuse”, again with the emphasis on control. Last year’s annual report from the Scottish Drug Forum, which co-ordinates policy and information for the voluntary sector, described policy developments and initiatives in training, support and research. But nowhere were questions raised about the legal basis of our current response to heroin addiction.

New Directions

Fortunately there have been voices in authority speaking out against the present situation. Scotland’s drug tsar, Tom Wood, has stated that the war on drugs is being lost. “The current system has a limited impact on reducing the massive crime, health and social harm caused”. Two years ago Lord McCluskey, a former high court judge, called for the legalization or rather medicalization of heroin which the previous year had accounted for two thirds of the 56 drug related deaths with methadone involved in one fifth. In the 1970s there were no such deaths but the figure is now more than one a day.

Other countries have adopted new approaches to the problem of heroin addiction, and moved away from reliance on methadone alone. In Australia and Canada they have started supervised injection clinics. In Holland the co-prescription of heroin with methadone has been found to be cost effective compared to methadone alone for chronic heroin addicts. Unlike the UK, the Dutch spend more on services and less on enforcement. In Switzerland they have medicalized heroin by providing it on prescription, which has resulted in a 60% reduction in drug related crime, and a drop of 70% in the prison population. However, a referendum showed that the majority were against legalizing the drug as opposed to medicalizing it.

Last year the Parliamentary Science and Technology Committee criticized the Advisory Council on the Misuse of Drugs, and called for a major overhaul of the present system of classifying drugs, so that alcohol and tobacco would be included to reflect the harm they cause compared to illegal drugs. Alcohol is half as expensive as it was 25 years ago during which time drink related deaths have more than trebled. The maternal use of tobacco results in a greater reduction in birth weight than heroin. Together alcohol and tobacco cause about 40 times the total number of deaths than all illegal drugs combined.

The recent multi-disciplinary report from the Royal Society of Arts, recommended that the Misuse of drugs Act 1971, should be replaced by a new Misuse of Substances Act which ranked all drugs, both legal and illegal, according to the harm they caused. On this scale alcohol and tobacco were more dangerous than cannabis, but the most harmful of all was heroin

Conclusions

The problem

A holocaust is defined as wholesale sacrifice and destruction. As a society we are sacrificing lives on the altar of our prejudices at enormous cost to the state, and in the process destroying the life chances of thousands of mainly young people. The problem with criminalizing a highly addictive drug like heroin is that inevitably a black market is created so that users are driven to crime, prostitution or low level dealing to fund their craving. Indeed, it is difficult to think of a better way of encouraging crime or creating pyramid selling.

The problem is not so much illegal drugs as illegal drug money. This is not to say that suppliers should not be pursued with the full force of the law and their assets seized, but there would be little need for dealers, if heroin was available for those who needed it. This need arises because users soon become mentally and physically distressed if they can not get the drug. Given this fact it is extraordinary that we still use the language of confrontation and control to table the problems. On the one hand we stigmatize addicts as criminals, and on the other hand provide clinics, mainly based on methadone which may be as addictive as heroin but can conveniently be taken orally once a day. Such clinics are often difficult to access and tend to be highly controlling.

Solutions

There are no easy solutions, but it is clear the present policies are a failure by any standard, let alone harm reduction. In the early 1970s when the Misuse of drugs Act was passed there were less than 500 known heroin users. Four decades later there are something like 500,000 addicts and an estimated £10 billion a year going into the pockets of criminals. This is madness on a massive scale. Disastrous failures require drastic remedies.

Firstly, the possession and use of heroin should cease to be a criminal offence. Decriminalizing possession would remove large numbers of offenders from the courts and prison.

Secondly, heroin should be prescribed on the NHS for those who want it. This would require the establishment of injecting clinics in each locality, with help for those who wanted to come off heroin which most addicts do. Such facilities would destroy the need for a black market.

These two measures alone would transform the situation, but would require a sea change in attitudes for the law, police and the medical and caring professions. As drug policy in Scotland is reserved to Westminster, the change in law would have to be UK wide, quite apart from the fact that decriminalizing possession in only one part of the UK would tend to attract users from other parts.

The prescription of heroin on the NHS would require a change in the medical approach, so that it became more caring and less controlling. If heroin addiction were considered a disease then it would not be acceptable to suspend patients from clinics for taking other drugs tested in urine, any more than it would be acceptable to stop treating diseases caused by smoking if patients continued to smoke. The new general practice contract has given doctors more free time and more pay, which should make it feasible to base such clinics in primary care.

Recently some addicts met farmers from Afghanistan from where 80% of heroin in the UK originates. If this were purchased by the government for prescription by the NHS, then one source of funding for terrorism in Afghanistan would also be undermined.

It is important to emphasize that it is not suggested that heroin should be legalized which would start an unstoppable industry as has happened with tobacco. Nor is it suggested that illegal suppliers should not be rigorously pursued and prosecuted. Rather this is a plea that heroin possession and use should be medicalized rather than criminalized. Such a change in law would greatly reduce crime and pressures on the police and prison services. It would also require doctors to treat addicts as patients with an illness, rather than as deviants who need to be controlled.

April 2007

Prepared 8th December 2012