Monday, February 19, 2007

Has the heroin prescribing debate reached a tipping point?

The Independent today reports that the president of ACPO (the Association of Chief Police Officers), Ken Jones, has joined the long list of senior police and public figures calling for heroin (diamorphine) to be prescribed to 'addicts'.

Before considering this potentially significant development it is worth commenting on the Independent's front page which is, in the pursuit of an attention grabbing headline, both misleading and factually incorrect. Firstly, what's with the spoon and powder? Prescribed heroin is provided in liquid form in little glass ampoules, like these:

There is no spoon. And secondly - Heroin is already available on the NHS. It is already given to addicts in the UK (although only about 3-400) , by the NHS, and actually has been since the first world war. It is also given to women during child birth, and extensively used in palliative care and other pain control, including once for me when I had my appendix out. So an interesting 'scoop' for the Independent but slap on the wrist for the stupid sensationalist tabloid front page. I am just about willing to forgive them, however, because today they have also run another in a line of excellent op-eds from Johann Hari on the futility of prohibition which is available on his own website so you can actually read it here - which I strongly recommend you do.

Now back to the actual news.

Unfortunately the Independent isn't available on line after the day of publication (boo-hiss) so here's a link to the same story in the Telegraph. Jones is quoted saying (to the Independent) :

“I was a drugs officer and we have to be realistic. There is a hardcore minority who are not in any way, shape or form anxious to come off drugs. They think 'I am going to go out there and steal, rob burgle and get the money to buy it. We are we going to do - say 'Ok, we are going to try an contain this by normal criminal justice methods’ and fail, or are we going to look at doing something different? Start being a bit more innovative. It is about looking at things in a different way without turning away completely from the current position.”

All good solid thinking, albeit nothing new (slightly oddly, whilst calling for the legal supply of a currently illegal drug for non-medical use he also says "I am not in any shape or form a legaliser" but we will let that semantic conundrum pass). Ken Jones follows a string of senior police who have said the same thing, including Howard Roberts (Chief Constable of Nottinghamshire), Richard Brunstrom (Chief Constable of North Wales), Tom Lloyd (former Chief Constable of Cambridgeshire), Francis Wilkinson (former Chief Constable of Gwent) and ofcourse the late Eddie Ellison (former head of the Met drugs squad). There are many more, some on the record, most still choosing to remain shtum.

We should listen to them. They have been courageous to risk public opproborium by speaking their minds on what remains a highly contentious issue. They undoubtedly know what they are talking about having seen - first hand - the abject failure of using the criminal justice system to try and address a serious and growing public health problem amongst the most vulnerable and marginalised in society. Since heroin prescribing was restricted to few specialist doctors needing a Home Office license in 1967 (since when GP's cannot prescribe heroin as the Telegraph coverage mistakenly claims) the number of heroin users has risen from around 15,000 to around 300,000. Hardly a triumph for a policy aiming to reduce use and ultimately create a drug free society.

Moreover, as the Prime Minsiters own report from the No.10 strategy unit shows in gratuitous detail, the inflated costs of illegal street heroin (due to its non-availability through legal channels) combined with its generally low income problem-user base has led to over 50% of property crime being committed to raise cash to feed an illegal habit.

As discussed on the blog last month the idea of expanding heroin prescribing has been on the table in Government circles for years with very little movement. Everyone in Government knows it's a good idea because they have mountains of evidence from Holland, Germany, Switzerland, Canada, Australia and even the UK telling them so. But since when has evidence of effectiveness had much to do with UK drug policy? Maybe Ken Jones will be the tipping point. Even if they are incapable of doing rational cost benefit analysis in cash terms maybe they can do one with politics. As the crisis in the criminal justice system and prisons continues to spiral out of control, you have to wonder whether the fear of any political costs of expanding heroin prescribing will soon be outweighed by the fear of the political costs of inaction,

On the cash front, one of the hurdles to more heroin prescribing (and the preference for methadone) is that it is widely seen as prohibitively expensive. The figure of £12,000 a year is the one usually quoted, and is roughly correct at today's UK prices, although it will vary from client to client. The Daily Mail covering the Ken Jones story today has somehow turned this into £15,000 a year in the print edition, but then uses the £12,000 figure in its online coverage. Indeed the print edition is full of all manner of classic Daily Mail drug-stat silliness, calculating, for example, that 'making heroin available free to all the country's 200,000 addicts would cost £3 billion.' In the online version the number of addicts is up to 320,000, which is the Home office estimate and probably more realistic. Either way they really don't like the idea of spending money on 'junkies' - apparently oblivious of the far greater cost to every one of leaving them in hands of the illegal market (£16 billion a year in crime costs) or putting them in prison (35K a year each).

In reality heroin prescribing is not going to be the answer for all of the UK problem users, it being just one potential option from a range of possible interventions, decisions that should rightly be being made by agreement between doctor and patient, rather than know-nothing politicians. In the short to medium term at least prescribing is likely to be most useful for the hard core of around 20-30,000 long term relapsing users, who are responsible for the vast majority of drug related offending, and who have failed on other programs. These are the High Harm Causing Users (HHCUs) identified in the Prime Minister's strategy unit report and it is similar criteria to these that have been applied with great success in prescribing regimes in Switzerland and Holland.

Furthermore the cost of diamorphine in the UK is artificially inflated by a huge margin due to the monopoly control of the UK opiates market by Macfarland Smith ltd, investigated as far back as 1989 by the Monopolies and Mergers Commission. This monopoly over-pricing recently led to an investigation by the Office of Fair Trading and then a rather lame report from the DTI which concluded that there was a problem, that they would keep an eye on, but not much else. The upshot of this rarely mentioned scandal is that diamorphine is a whopping six times as expensive in the UK as it is in Holland. Yes, that's a 600% difference - for the exact same pharmaceutical product.

So in true Daily Mail style here's a quick back of the matchbox calculation with the revised 'real world' costs. 20,000 users at £2000 each a year = £40 million. That's without subtracting the cost of prescribing methadone to many of them as we already do. So not quite £3 billion then. But if this £40million made a dent, even a smallish one, in the £16 billion a year in crime that the Home Office estimates is the crime costs to society from fundraising-to-buy-heroin, then it would still be a veritable bargain.

For those who aren't simply hard nosed politicians totting up the pounds or political pros and cons, evidence of heroin prescribing from the 'real world' also shows that:

  • numerous lives would be saved from avoiding dirty street drugs, overdoses and blood borne diseases (The UK consistently has the highest level of drug deaths in Europe)
  • users lives would be stabilised and they would be far more likely to get into treatment and rehabilitation (because they are in more regular contact with services)
  • the number of new young recruits into problematic use would fall dramatically (in Holland the average age of problem heroin users is 40 and rsing, in the UK it is mid-20's and falling)
  • street dealing, drug litter and social nuisance would all fall (re: Zurich, Vancouver)
  • some degree of pressure on the ballooning prison population would be removed (thanks to the massive resulting fall in offending)

Anyway you look at it, its a winner. Small wonder increasing numbers of big names in criminal justice are coming out in favour. Now, what about those big hitters over at the BMA... or even the NTA.....?

Postscript: I had an interesting clash with George Galloway on his TalkSport radio show on this issue on Monday night. You can listen to it here (click on the link and it should open in windows media player - or similar. im afraid theres about 10 minutes of guff before the action starts). I found it odd that Galloway, someone who you would assume to be anti-war generally, and specifically anti US imperialism, aswell as a defender of the marginalised peoples of the world, was an enthusiastic cheerleader for the war on drugs, unable to see beyond his rigid moral view that drugs were bad and therefore should be banned. He had no understanding of harm reduction, the economic realities of illicit production or the long term failure of drug interdiction. Still I gave him a good run for his money, and hopefully some food for thought.


chrisbx515 said...

As one would expect from Transform a blog that highlights the need for sensible evidence based drug laws and treatment options. Unfortunately I notice the Conservatives in Scotland are banging on about methadone being a waste of time and that abstinence based cold turkey rehabs will be their policy for the future and also the BBC highlighting the fact that there is a shortage in the over priced pharmaceutical heroin that you have highlighted.It seems like the illegal opium grown in Afghanistan is not good enough for the prohibitionists to get amongst the growers and make the trade legal to produce the heroin to sort out this shortfall in supply, still no shortage on the streets so no worries there then!

Ian S said...

Just two points to add in to the usual high standard of discussion. The age old split of Government departmental responsibilities for drug misuse is part of this shambles. The NHS has the responsibility to provide treatment but the Home Office licenses the manufacture, wholesaling and retail disribution of Controlled Drugs. I wonder if John Reid knows this? Remember the Home Office is not fit for purpose! It is highly likely to have created an artificial monopoly because its easier to monitor and control.
This takes us straight into the cost of drugs to the NHS and what appears to be an imperative that the taxpayer supports big "british" pharmas and their shareholders.There can't be a shortage of raw opium in the world (Plantations in Tasmania for pharmaceutical opiates) If the shortage of diamorphine is the result of a lack of ampoulising capacity in the UK the normal response in an efficient globalised open market would be to place a contract elsewhere, China?Russia? India? other countries must have freeze drying and ampoulising facilities. Can't all be used to make bird flu vaccine surely!
Tippping point in the debate has probably been passed but unpicking goverment deals and bureacracy is another thing altogether.

Bob said...

I've been mystified by this lack of diamorphine for a while now, it cant still be on licence, so there must be loads of companies wanting to do cheap 'generic' versions of it.

Steve R said...

Bob - i think there are - but they cant because they are not licensed. its a stich up between the home office and the monopoly supplier. A total disgrace and something we will be pushing much harder in the future.