Considered in Grand Committee
My Lords, I beg to move that the draft Misuse of Drugs (Amendment) Order 2021, which was laid before the House on 25 March, be approved.
I am grateful for the advice provided by the Advisory Council on the Misuse of Drugs, which has helped to inform the order before the Committee. The proposed amendment to the Misuse of Drugs Act 1971, which I shall henceforth refer to simply as the 1971 Act, follows the ACMD’s self-commissioned advice published on 29 April last year about benzodiazepines.
The draft order before your Lordships relates specifically to three of those benzodiazepines: flualprazolam, flunitrazolam and norfludiazepam. Due to their potential harm and the evidence of the prevalence of these drugs in the UK, the ACMD recommended controlling all three substances under class C of the 1971 Act. The ACMD also concluded that these three benzodiazepines should be scheduled under Schedule 1 to the Misuse of Drugs Regulations 2001 because, as confirmed by the Medicines and Healthcare products Regulatory Agency, they have no recognised medicinal use in the UK. This is the first proposed addition to control further benzodiazepines under the 1971 Act since the control of 16 benzodiazepines in May 2017, which are also controlled under Class C of the 1971 Act.
Benzodiazepines are associated with a high dependency rate and severe withdrawal symptoms from even short-term use. Furthermore, their combined use with other recreational drugs—in particular opioids and other central nervous system depressants—is associated with an increased risk of mortality and contributes to a significant number of drug-related deaths each year. Data provided by the National Programme on Substance Abuse Deaths showed that in England between 2006 and 2015, there were 5,740 benzodiazepine-related deaths. Of these, just under 4% recorded benzodiazepines as the only compounds implicated in the cause of death, which may indicate the frequency with which they are associated with polydrug use.
I can provide some further background on the three benzodiazepines covered by this order. The first is flualprazolam. The ACMD’s report states that as of March 2020, there have been 12 flualprazolam-associated deaths in the UK recorded by regional statistical agencies. It also states that the European Monitoring Centre for Drug and Drug Addiction issued a report on flualprazolam in March 2019. This detailed deaths with confirmed exposure to the compound in 24 reported cases in Sweden and two in Finland. In eight of these cases, flualprazolam was cited as a contributory or possible contributory factor.
I move on to flunitrazolam. It is likely that the potency of flunitrazolam is greater than that of the already highly potent flunitrazepam, or Rohypnol, which is controlled as a class C drug under the Misuse of Drugs Act 1971. A small number of seizures were made at the UK border between October 2014 and 2019. The ACMD report highlighted that small-scale seizures of a mixture of tablets and powder had also been notified in Germany in 2016 and Denmark in 2017.
I move now to norfludiazepam, which has been identified in the UK twice, both in 2017: once from a police seizure and once by the drug identification provider TICTAC. Small-scale seizures also took place in Germany in 2016, Sweden in 2017 and Norway in 2018. There has also been anecdotal reporting of the use or purchase of norfludiazepam by PostScript 360, a charity that provides treatment for withdrawal from benzodiazepines.
As well as the recommendation for control under the 1971 Act, the ACMD also recommended that the three benzodiazepines be placed in Schedule 1 to the Misuse of Drugs Regulations 2001 and part 1 of Schedule 1 to the Misuse of Drugs (Designation) (England, Wales and Scotland) Order 2015, as these drugs have no known medicinal use in the UK. Subject to the approval of both Houses of Parliament of this draft order, it is intended that a further statutory instrument, subject to the negative resolution procedure, will come into force at the same time as this order, being 28 days after the date the Order in Council is made. This further instrument would make the amendments to the 2001 regulations and the 2015 order.
Parliament’s approval of this order to control flualprazolam, norfludiazepam and flunitrazolam under class C of the 1971 Act, and the scheduling of these under Schedule 1 to the 2001 regulations, as per the recommendations of the ACMD, would make it unlawful to possess, supply, produce, import or export these drugs except under a Home Office licence for research. The maximum sentence for possession of a class C drug is up to two years in prison, an unlimited fine or both, while for supply it is up to 14 years in prison, an unlimited fine or both.
We know that illegal drugs ruin lives and have a corrosive effect on society. It is clear from the advice we have received that these benzodiazepines can cause serious harm, and that is why we are taking this action. I hope I have made the case to control them, even though I have not managed to pronounce them very well, and I commend the order to the Committee.
My Lords, I support this measure and congratulate the Minister on her very clear explanation of the reasons for it, and on her pronunciation, which I will not attempt to follow.
I am pleased to see that the Government have accepted the advice of the Advisory Council on the Misuse of Drugs on this matter. As has just been stated, the arguments in favour of it are straightforward in relation to the potential of these compounds to cause harm, the evidence of their prevalence in the UK and the absence of any clinical need for them. Benzodiazepines all have similar effects, but some—including, the evidence suggests, some of these—are more powerful and addictive than others. There are already more than enough licensed for clinical use and there is no clinical need for more.
As the Minister knows, I shall also take the opportunity as the co-chair of the All-Party Parliamentary Group for Prescribed Drug Dependence to draw attention to the scale and severity of this problem in the UK. These three drugs are obviously very relevant to that matter. In 2018, 11.5 million adults had one or more prescriptions for drugs that can create dependence. Research suggests that at least half experience withdrawal symptoms but only 3% of the population have access to withdrawal services. It is likely that these figures are now higher following the pandemic.
There are large financial as well as personal costs involved. Overprescribing—that is, unnecessary prescribing —of these drugs is estimated to cost between £320 and £642 million annually, and the costs and problems associated with withdrawal probably make that figure much higher. Of course, the personal misery is unmeasurable.
I acknowledge the work of the chief pharmacist Keith Ridge and his team, who are overseeing implementation of the Public Health England recommendations on prescribed drug dependence, but this is going very slowly. We need more urgent and timely action from the Department of Health and Social Care and NHS England given the millions who are taking benzodiazepines and other drugs of dependence beyond what is clinically necessary.
I understand the time and cost it will take to set up new services but recognise that it would be quick and relatively inexpensive to set up the helpline we have recommended. This will benefit patients and clinicians alike and, at last, begin the process of putting appropriate services into place. Will the Government set up the helpline in the near future?
In conclusion, I very much welcome this measure but also note that millions of people are suffering and millions of pounds are being wasted. It is time that the Government acted decisively to stop this. I know that these issues are not the Minister’s responsibility but I would be very interested in her comments and in her addressing these concerns to the Department of Health and Social Care and NHS England.
My Lords, it has taken some time for some very simple action to be taken on benzodiazepines. I first recommended this action in 2003 in the House of Commons and was ignored. I do not want to take issue with the Minister—I hope she does not feel that I am—but there is a concept which she and the noble Lord, Lord Crisp, raised, which I want to disagree with. It is about the unintended consequences of it, and it is not nit-picking, because of where the logic comes from.
Part of the justification for the proposal to the Committee—I entirely endorse the merits of agreeing it today—was that these three benzodiazepines have no identifiable health benefit. That rather misses the point, because even if they had a health benefit, the use of benzodiazepines in the illicit-drug-using and problematic-drug-using communities is prodigious. It can of course take place elsewhere, and there is a huge market for the resale of prescribed drugs; the noble Lord, Lord Crisp, alluded to that. That same market is particularly problematic when it comes to problematic users, by which I mean users whose drug dependency is such that it dominates their entire life and leads them into forms of behaviour that damage others. That is distinct from those who suffer misery by themselves in their own home, which can be through illegal drugs but which is far more often through the misuse of prescribed drugs. That latter category of people do not tend to buy the drugs illegally; they simply get them through perfectly legal prescriptions. However, there is a huge market in the sale of all products, some of which are obtained technically illegally—they are prescribed and then sold on—while others are in the entirely legal market, such as these three particular benzodiazepines.
Part of the dilemma we have and part of the weakness in the system in this country is that the ACMD logic still ties in with what criminal justice sees—and criminal justice still has a tendency not to want too many things to have to regulate and criminalise, because it means more work—as well as with health, and particularly public health, which has had an obsession with the perceived positive benefits of a cocktail of drugs, defined as one drug being used to counteract another drug. That is precisely the kind of use that drug addicts have for benzodiazepines. In my experience, I do not know anyone who has a heroin addiction, for example, who does not also use benzodiazepines. The two go together, although not usually literally together. So the public health input has often been to say, “Things are better out there, because it will help people’s health”. I think that is fundamentally wrong.
Our inability to get on top of drug treatment in this country is partly because criminal justice takes too much of a lead in this. That is not the Minister’s fault, although it is her problem, because she then has a responsibility. I happen to be Lord Mann, of Holbeck Moor in the City of Leeds, and I hope that the Minister will at some stage—I would be happy to accompany her—look at the managed prostitution red light district on Holbeck Moor. It is a health disaster and catastrophe and very unpopular with members of the local community, as I know from listening to them. I in no way purport to represent them; that is for the far more illustrious Members of the Commons. However, the notion of a managed red light district is precisely the kind of problem that has led to so much time being taken to make benzodiazepines illegal.
The Minister is right to bring this forward, but I think we need to knock heads together more, particularly in public health, which is silent too often. It is precisely why usually primary care, although it can be hospitals, has been allowed to overprescribe things that are actually a danger, either through overuse by the individual or misuse by others who get hold of them, sometimes by purchasing them. Benzodiazepines really fit that model in terms of the kinds of markets that are there.
I commend the Minister for this, but there is a great opportunity for this Government to take a leap forward in getting the public health agenda aligned with the criminal justice agenda. For all sorts of reasons, the Government are well positioned to do this in ways that other Governments were more fearful of. I hope that the Minister will look at that. It is not enough simply to make this illegal, because the same people will still be buying it, whether it is legal or illegal. We also need to try to get to the root causes and look at how health does or does not deal with it, and then the country will literally be a healthier place.
My Lords, this SI has been prepared by the Home Office, and this instrument brings three benzodiazepines—forgive me if I cannot pronounce them, but I can send the details—under control as class C drugs under Part 3 of Schedule 2 to the Misuse of Drugs Act 1971, owing to their potential harm and evidence of the prevalence of these drugs in the UK. This order controls these three compounds as class C drugs under the 1971 Act, following advice from the ACMD published on 29 April 2020, owing to the potential for these compounds to create harm and evidence of these drugs in the UK. The Home Office will issue a circular with legislative guidance primarily for the police and courts. The Government will continue to update their messaging on the harms of these substances, including through their information and advisory service online.
Can the Minister explain what fines and prison sentences will be given to individuals who breach these orders?
I call the next speaker, the noble Lord, Lord Paddick. Lord Paddick?
My Lords, I have to get used to Grand Committee not being able to unmute me and having to do it myself, unlike in the Chamber. However, we shall go now.
I thank the Minister for introducing this order, which brings three benzodiazepines under part 3 of Schedule 2 to the Misuse of Drugs Act, owing to their potential harm and prevalence in the UK. The noble Lord, Lord Crisp, quite rightly highlighted the issues associated with similar drugs that are legally overprescribed. As the noble Baroness mentioned, these drugs are related to Rohypnol, the so-called date rape drug, and to Xanax and Valium—well-known anti-anxiety drugs that are highly addictive, or, as the Minister called it, resulting in high dependency. In addition to their potential use to sedate victims by perpetrators of sexual offences, they are respiratory suppressants that can lead to the shutting down of the respiratory system and death, particularly if taken in conjunction with alcohol or similar drugs.
Of course, we on these Benches take a harm-reduction approach to the misuse of drugs, and the fact that one of these drugs has resulted in 12 deaths in the UK is of concern. Can the Minister give any more details of the circumstances of these deaths? Were they people with mental health issues who were self-medicating? Were they people who had taken these drugs in combination with other drugs or alcohol recreationally? Or were they drugged by others?
I ask these questions as there are concerns that the lack of mental health services for those suffering from anxiety and the extended waiting times for people to receive treatment, together with the stigma of suffering from poor mental health, may be driving people to seek substances such as these as a means of immediate relief from their symptoms, without seeking professional medical help. Pushing people into seeking drugs where there is little or no quality control and where the amount of active ingredient contained in each pill can vary enormously can lead to accidental overdose, with disastrous consequences.
Can the Minister point to any research that demonstrates the efficacy of moving psychoactive substances such as these from being covered by the Psychoactive Substances Act 2016 into being included as class C drugs under the Misuse of Drugs Act 1971? How less likely are people to take these drugs as a result of this sort of order? Does the Minister not agree that, as far as most young people in particular are concerned, it makes little difference whether a drug is illegal under the Psychoactive Substances Act or the Misuse of Drugs Act, and that even the classification of the drug under the Misuse of Drugs Act has little impact on the attitudes of those who misuse drugs towards different substances?
Is it not time for an overhaul of the whole approach to the misuse of drugs, adopting a health-based, harm reduction approach based on educating people, particularly the young, as to the effects and dangers of different drugs, rather than an emphasis of police and other criminal justice system resources on criminalising the misuse of drugs that often have only a minimal effect? Diverting resources away from the so-called war on drugs and into effective mental health provision to reduce reliance on drugs, into drug treatment for those addicted, and into education on the effects and dangers of drugs misuse would be a far more effective way of dealing with the issues that this order is intended to deal with.
Is this order no more than rearranging the deckchairs on the Titanic that is the drugs-misuse crisis in the UK? The Government’s failure to have any lasting impact on the supply side of the illegal drugs market surely suggests that the focus should now shift to the demand side, reducing the demand for controlled drugs through adequate mental health provision, education and treatment of addiction. We do not oppose the order, we just ask: what evidence is there that it will be of any benefit?
My Lords, I am very happy to support the order, which, as we have heard, is in response to advice from the Advisory Council on the Misuse of Drugs. Clearly, where drugs cause harm, they must be classified and action taken. As the noble Lord, Lord Paddick, said, these drugs combined with alcohol can prove fatal in many cases because of the effect they have on the body, and can often lead to suicide.
I recall that when my noble friend Lord Mann was in the other place, he did a lot of good work on the issue of drugs in his constituency and many times spoke up about it. To tackle this, it is no good us just adding more drugs to lists, saying that this cannot be done here or that is criminalised there; there must also be the preventive approach, which the noble Lord, Lord Paddick, talked about. We must have both: legislation that says that if you take, sell or use these drugs, those are criminal offences, and, at the same time, a health approach so that people understand. There is an absolute drugs crisis, as my noble friend said, with people taking these drugs with other substances. Unless we can provide people with the support they need to get off drugs, we will not deal with the problem, as with any addiction.
I hope the noble Baroness can respond on that. Does she have any information on what has happened to drug treatment services during the pandemic? What support have we been able to give to people who find themselves in difficulty? The Health and Social Care Select Committee found that funding for treatment had fallen 30% in the three years up to 2019. We must reverse that cut and increase funding. We can say that whatever we like is illegal, but unless we have in place the process to get people off the substances, we will struggle. We have all seen the corrosive effect on individuals, their families and communities—the damage done to them by drugs. As my noble friend Lord Mann said, these are often prescription drugs that are then sold on to other people, but drugs are corrosive.
I will leave it there. I fully support the order but, as many noble Lords have said, there must be another prong to our attack on this process, and that is the health-based proposals many of them talked about.
I thank all noble Lords who have taken part in this debate. It is worth stating at the outset that there are benzodiazepine medicines which can be prescribed by clinicians and have specific uses, but today’s focus is on illicit benzodiazepines.
As the noble Lords, Lord Mann and Lord Crisp, said, this is often about polydrug use. These tend to be drugs used not just in isolation, and deaths tend to occur when polydrug use is being practised. I totally take the point made by the noble Lord, Lord Mann, that the criminal justice system approach to drugs must be aligned to public health. When people have got themselves into illicit drug use, you do not want to criminalise them; you want to get them off the drugs that they are on.
The noble Lord, Lord Mann, made quite an interesting point about managed red light districts not working. I can think of a clear analogy: drug consumption rooms do not work. They are illegal. They exist in Scotland, but they do not work.
The point by the noble Lord, Lord Crisp, about support for those dependent on prescribed medicine is an important one. There is the Talk to FRANK website, which everyone will have heard about. I know that NHS England and NHS Improvement are leading a programme of work in response to the recommendations in Public Health England’s Dependence and Withdrawal Associated With Some Prescribed Medicines: An Evidence Review. The recommendation for a time-limited dedicated national helpline and website has been carefully considered as part of this work. They are also drafting a commissioning framework to help commissioners to optimise the prescribing of dependence-forming medicines, as well as providing support to patients experiencing dependence on prescribed drugs and symptoms of withdrawal. That framework is expected to be published later this year.
Anyone who develops a problem of dependence on medicines should seek help from their GP in the first instance. They might choose to go to a different GP from the one who prescribed the medication, if indeed the medication was prescribed.
The latest prescribing statistics I have are from the ACMD’s 2020 report, which states:
“Prescribing of benzodiazepines by General Practitioners in the UK has been discouraged and has fallen progressively in recent years … from 16.3 million in 2015-16 to 14.9 million in 2018-19”—
that is still huge. It goes on:
“In 2017-18, there were 1.4 million adults in England and Wales who received one or more benzodiazepine prescriptions.”
Public Health England undertook an evidence review of prescribed medicines, which was published in 2019. It concluded:
“Longer-term prescribing is widespread.”
The review covered adults and five classes of medicines, including benzodiazepines, Z-drugs, gabapentinoids, opioids for non-cancer pain and anti-depressants, and some 41 recommendations came out of that.
The noble Lord, Lord Paddick, talked about education. He is absolutely right: education is vital. He asked about reform of the Misuse of Drugs Act 1971. We keep drug controls under review but do not intend to reform the laws on drugs at this point in time. Drug legislation is part of the Government’s wider approach to preventing drug misuse, and education in schools is key to promoting healthy living, treatment and recovery and stopping the supply of certain drugs.
The noble Lord, Lord Paddick, also asked me about the specifics of each case where there was death. I do not have the specifics to hand but, as I said in my opening speech, benzodiazepines are often taken with other drugs and alcohol. With that, I finish and beg to move this statutory instrument.
That completes the business before the Grand Committee this afternoon. I remind Members to sanitise their desks and chairs before leaving the Room.
Committee adjourned at 5.14 pm.