Statement of Dr Colin Brewer, read into transcript of final hearings of evidence to General Medical Council,  July 2006.

The first point I want to make is that I take full responsibility for the clinical and administrative practices that have led to this hearing. Accordingly, I ask you to deal leniently with Drs Tovey and Kindness. They are unusually caring, compassionate and conscientious clinicians in a field where such qualities are often lacking. Dr Tovey remains Clinical Director of the Stapleford and has, in my view, a very significant contribution to make to the treatment of addiction in this country

You have also heard that over the years, we had a steady trickle of distinguished visitors to the two Stapleford establishments, many of whom were able to observe our prescribing practices. Throughout that time, we also had, as far as we knew, a good relationship with our Home Office inspector and believed that we were well-regarded by her superiors. Especially when we invited by another part of the Home Office to set up, through the charitable Stapleford Trust, a model treatment programme for the prison service. I am proud that we managed to do this and – even more importantly – attract and retain the highly-trained and well-motivated medical and nursing staff, without whom no prison programme, however excellent in theory, can be expected to succeed. Stapleford has provided a range of addiction medicine services that were unique in their diversity and effectiveness. Many of our patients and their family members told us stories of shocking neglect, inefficiency and hostility at the hands of their local NHS units. The people who have given oral or written evidence to you about the many patients that we have probably saved from death or even worse fates are not all wrong or exaggerating.

Over three years ago, I retired from clinical practice and I have had no clinical involvement with the two Stapleford clinics since then. I remain interested in research and writing and in organising the series of Stapleford conferences that continue to attract leading academics and clinicians from many countries. The clinics’ practices have, I know, changed considerably, particularly since the delivery of your findings and a formal system of supervision by established NHS consultants is being arranged. This hearing has at least clarified – for the first time in some areas – what is and what is not acceptable at present and I am confident that new protocols and practices will closely reflect that. 

You have heard evidence that we attract far more than our fair share of challenging patients and that these patients have often – not just occasionally – been rejected by NHS clinics. I am extremely worried and concerned about what will happen to the many patients – both maintenance and implant – whom we have enabled to lead lives that now involve some dignity and stability and who are now staying out of prison. We also treat many quite straightforward patients who simply cannot obtain what ought to be standard NHS care in their area.  In addition, we are the country’s main source of expertise in the field of naltrexone implants. Even if the NHS were willing to take on their care (and you heard from Dr Revill that it is actively unwilling in some areas despite the excellent results from implant treatment that are now being reported in peer-reviewed papers) it would not be able to.

I believe that over the 30 - 40 years in which I specialised in the treatment of alcoholism and other types of drug abuse, I had (and still have) a good reputation as a clinician and as a researcher. Alcohol abuse is a massive problem – far bigger and in many respects far nastier than heroin abuse. For many years, I pointed out the considerable effectiveness of supervised Antabuse (disulfiram). I did this mainly on the basis of the large evidence-base for it in the literature as well as my own clinical experience. Until very recently, the addiction establishment in Britain, based at the National Addiction Centre, denied and occasionally derided this approach, even once suggesting that it was unethical. In 2004, the NAC discreetly removed their anathema in an editorial in ‘Addiction’, without any reference to their prolonged opposition in the face of the evidence. Nevertheless, it remains true that their opposition must have been directly responsible for a large amount of medically preventable alcoholic mischief of various kinds, naturally including numerous alcohol-related deaths. That strikes me as a rather serious indictment of the addiction establishment. Even now, they have not done any research into this important drug, even though it is also one of the few medications known to be helpful in cocaine abuse.

Unfortunately, it is not the only example of lethal policy and educational errors in the face of the evidence. Methadone Maintenance Treatment (MMT) had been quite widely available through the NHS since the mid-1960s, quite often including the prescribing of injectable methadone. Around 1980 – ironically, the year after the publication of the first randomised controlled trial showing the large and specific benefits of MMT – pressure from that same addiction establishment led to the progressive phasing-out of MMT in most areas of Britain. Scotland, in particular, became almost a methadone-free zone, just in time for the introduction of HIV into the Edinburgh addict community in the early 1980s. This pernicious decision probably helped to make it, for a while, the AIDS capital of Europe. All this happened at a time when MMT was being widely introduced in most other Western countries. Around 1995, the NAC finally saw the light but still gave out mixed messages about MMT. That is probably why we have some of the worst MMT in Europe and some of the lowest average doses. This historical attitude to what Prof Strang told the House of Commons had been, throughout, a treatment with ‘a rock solid evidence base’ will in turn have been responsible for many deaths and disasters. By comparison, the sins of omission and commission laid at my door cannot be said to have had these catastrophic effects.

The failure of the NAC to understand the importance of supervision and/or family involvement (or probation linkage) in naltrexone treatment for opiate abuse (as they did with supervised Antabuse treatment) has led to their almost completely ignoring this important alternative to methadone and buprenorphine treatment until very recently. I wish it really were unbelievable that no witness from the NAC – indeed, nobody apart from me - even mentioned naltrexone to the very important 2001-2 Parliamentary committee on drug abuse. It was as if nobody had mentioned condoms in an enquiry about AIDS.  However, a few months ago, and despite his involvement in the current  proceedings, Prof John Strang invited me to the NAC to talk to him and a few senior colleagues about naltrexone implants and the rapid detoxification techniques which, as you have heard, are essential if significant numbers of patients are to reach the point when they can start naltrexone treatment. The current reported 27% completion rate for NAC opiate detoxes is pathetic when close to 100% is routinely achieved at Stapleford and elsewhere, using techniques that have been described and used for over 20 years.

Efficiently and humanely starting patients on NTX treatment is even more important, now because the first licensed depot preparation is available in US. However, its 5-week duration makes it less useful, as you heard from Dr Revill, than the Australian implant, which is able to prevent significant numbers of admissions and – almost certainly – deaths due to opiate overdose following detoxification. It is because of the real benefits of the Australian implants that I feel – as do many patients – that it is justifiable to take some risks in order to get patients to a stage where they can start implant treatment. Clinicians who have not seen the transforming power of naltrexone implants – which is to say, all the GMC expert witnesses - cannot, with respect, comment objectively on the balance of risks involved. That is one major reason why my attitude to certain medications is less restrictive than current guidelines recommend. Bearing in mind that generous MMT was entirely respectable in the 1960s, when I qualified, I hope the committee will not dismiss or deplore certain practices just because they are regarded as old-fashioned by the addiction establishment.

Evidence-based practice is important but so, surely, is practice-based evidence, especially in a field where the unequivocal evidence was officially ignored for so long. We have accumulated a lot of that sort of evidence in areas, such as methadone test-dosing, hair testing, maintenance on unusual drugs and effective detox techniques of which most clinicians have no practical experience. And whereof they do not know, thereof – in some important respects - they cannot speak. It is a pity that a very recent paper, supporting the safety and value of methadone test-dosing and which has been favourably peer-reviewed, comes too late (or possibly too soon) to be presented as evidence. Giving someone only 20-30mg initially and then only small increments for several weeks, when you know they will probably need 90mg, is like deliberately underdosing with antibiotics, insulin, digitalis etc. And of course, most NHS patients having MMT never receive even half of 90mg.

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The only one of the charges against me about which I feel serious regret – and the only one in which any serious harm has been proved – is the death of Grant Smith. I was always aware that his parents lost an only son and I deeply regret that his death reflected failings of management – some unique to this case but some systemic – for which I bear full responsibility. However, given the dreadful state of detoxification services in the NHS (especially in their area – one of the worst in the country, according to NHS ratings) I cannot accept that it was wrong to offer home detoxes, or to involve families, or to use generous sedation to achieve success. Providing low-cost treatment alternatives is very important (and also rather unusual) in private practice, especially because detox often needs to be repeated and that can mean a repeated drain on finances. I really do not believe that 15 years of successful experience with home detoxes is irrelevant. I think the use of Heminevrin in this case was probably a very important factor but when you have seen people successfully completing detox only because Heminevrin was used when less powerful sedatives failed, it is difficult to feel totally wicked simply because it was part of our armoury. If it is a fault to try too hard and not to give up easily, I have that fault and many patients and families are glad that I have it. Incidentally, however dangerous Prof Lader thinks it is, Heminevrin is about the only sedative not covered by new and draconian CD prescribing  regulations.

You have heard quite a lot about an excellent organisation called ‘Detox-5’. I don’t think it was pointed out that it originated in our own use, for several years, of a hospital owned by them for our own detox patients. When the hospital closed, they set up their own similar but longer and more expensive programme elsewhere but they have always acknowledged that we were their original model.

I admit to weaknesses in bureaucratic and monitoring aspects and I regret them, even though consistently positive findings in hair or urine tests shouldn’t necessarily lead to major changes in management - eg regular weekend heroin use in otherwise stable and well-functioning patient. This is similar to an alcoholic who no longer gets drunk but has a weekend beer or two: most clinicians would be delighted with such an improvement. Hair-testing, incidentally, was introduced into Britain by us and I believe I am responsible for its now quite regular use by GMC health and disciplinary committees.

I also admit that I was too trusting at times but given that perfection is impossible, I prefer that to being too untrusting and too dismissive of what patients told me. However, no harm has been shown to result from this attitude, in contrast to the undoubted and large-scale harm which policy decisions by the addiction establishment have caused. I respectfully urge you not to ignore this comparison. We have given large supplies of maintenance medication to internationally known itinerant actors and directors who were obviously very stable and we have insisted on daily supervised pickup for itinerant pop-stars who were internationally famous for being totally unstable and could afford to pay for a personal nurse, responsible to us, to provide the daily supervision. In short, I tried to be flexible. Probably I was too flexible but again, I think that is better than being the opposite.

There are no easy solutions to the ‘drug problem’. In some senses, we are all – society, doctors, drug users, the committee – victims of unthinking Prohibition and the numerous failed ‘wars on drugs’. The Commons select committee said in 2002 that if the drug problem did not improve significantly in a few years, they would have to look again at decriminalisation. It has not improved.

I have no illusions about the sanction that the panel may impose on me. My primary concern, in comparison to which my own fate is of much less importance, is that the future of Stapleford is secured. This is not so that it may constitute some form of legacy of my career but rather because if it does not continue, great disruption, despair and worse will be visited upon those who, through their own efforts and our help, have been able to lead lives which are unrecognisable compared to those they lived when they first came to our door. I repeat that I take full responsibility for the clinical errors that may have been made by my colleagues at the Stapleford.

Signed………………………………….                Dated………………………………