"Harm reduction"

Almost all drug liberals in Western Europe says they are supporters of the ideas about the so called "harm reduction". This idea is playing an increasingly bigger role in the international drug debate. There are being arranged a great number of conferences, seminars and symposiums on a global level, on European level, on EU level, and on national, regional and local level about "harm reduction" policy.

No reduction in use - no reduction in demand

"Harm reduction" ought to mean a decrease of harm, of damage. But this expression is not used to describe a policy that primarily seeks to decrease drug consumption on individual og society level. They are not talking about "use reduction". Neither does it include a policy of reducing the demand for drugs, "demand reduction". Furthermore does not "harm reduction" include any wish to use police or other authorities for repressive measures. These are the only conclusions that can be drawn from the West European debate about "harm reduction".

A dim definition

There are in other words no established definition on what "harm reduction" really means. Every debating person og conference leader uses the definition that suits his or her goals in the debate.

Many drug policy proposals, speeches, explanations and arguments are using the expression "harm reduction" from completely different points of view. And even if the proposals, the contributions in discussions, explanations and arguments often are very much in conflict with each other, they all refer to the same notion; "harm reduction".

Three practical main directions

The drug liberals want a development in the direction of a more liberal interpretation of the drug legislature. There does not, however, exist any general agreement on what that would consist of. Nevertheless there are three main directions in the drug liberal arguments and proposals.

  1. Increased use of legal prescription of drugs. Within this mainstream there are again other platforms. Some want a small scale, strictly controlled legal prescription. Others want a liberally used legal presciption . The legal precriptions can either have a "gradual reduction" goal, or follow the "maintenance" principle.
  2. Other groups are spokesmen for decriminalizing. Also within this group there are different directions. Some want to have a "pragmatic" decriminalizing, just to avoid having to use the police force when it is not strictly neccesary. Others are much more liberal, and want a wide range decriminalizing of all kinds of drugs.
  3. A third main group is working for legalizing: That drugs are to be defined as a legal trade object. Also within these there are those who only want to legalize cannabis, and those who want to legalize all drugs.

Two completing lines

To be able to attain "harm reduction" as a result of one of the three main policies, there are two completing lines to be seen. The first consists of sosial help measures in a "harm reduction" spirit. The other is what the drug liberals calls "prevention and information", with "harm reduction" as a goal.

Legal prescription

Legal prescription of drug can be done in different ways. Generally inherent in all "Legal Prescription Programmes" is that a doctor prescribes drugs to drug addicts, either by the way of addicts coming to a clinic to fetch or being given the drug, or via prescriptions, with which the addict can get the drug from a drug store. No matter which way it is done, it is the taxpayers that meets the bill.

Some of the ways in which the Legal Prescription Programmes are carried out in Western Europe, are not being used in Norway or Sweden. An accurate description of these are therefore in place.

In Norway and Sweden drugs are only prescribed with the goal of gradual reduction. In many West European countries the most common is "maintenance" prescripitions. These are two quite different ways to try to cope with abuse, with different effects and different goals.

"Substitutes"

Those who are getting methadon or other drugs, legally prescribed, as a substitute for heroin, are often spoken of as "substitutes" in West European debate. A "substitute" therefore, is a person who are taking part of a Legal Prescription Programme.

"Gradual reduction"

Gradual reduction is a method used to help the addict to a gradually decrease in consumption, with the aim to make the person totally drugfree. Concerning the opiats (opium, morfin, heroin etc.) the motives for a gradual reduction are both of a medical and a rehabilitating order, because the opiates gives very strong physical abstinence symptoms. The doctors will then prescribe smaller and smaller doses, and after a few weeks they are down to zero. The common substitute drug is methadon, a syntetic drug, which gives milder abstinence symptoms than heroin.

The gradual reduction is accomplished in a controlled way. The intake of metadon is always done under the supervision of trained nurses.

Other types of drugs, like cannabis, cocain, amphetamine, LSD, ecstacy, crack etc. does not instill physical dependence, and therefore rarely gives any serious physical abstinence symptoms. When it does happen, it is not nearly as painful as the symptoms caused by opiats. Those who want to stop using these kinds of drugs should therefore be able to do so without experiencing any great physical problems, and should not need any gradual reduction programme at all. The phase of gradual reduction is usually followed by a rehabilitation programme. Gradual reduction is only used on a very small scale in the West European countries.

Maintenance

The most common way of legal prescription in Western Europe is the "maintenance" principle.

Maintenance means that one tries to stabilize the consumption on a certain level, and the addict will thereafter be prescribed that dose each day,week after week, year after year. In some West European countries one can find people who have been on a maintenance programme for more than twenty years. In most maintenance programmes the addict himself is given the opportunity to decide the level of the drug dose.

Some of the maintenance programmes are more restrictive and under severe control. In those the methadon is given only in a clinic or in a so called "methadon bus", under supervision of av nurse. No one is allowed to bring with him methadon out of the place.

Other methadon programmes gives out rations of methadon for a shorter or longer periode, in order that the addict can take it either at home or in other places. This may be so both when the drug is handed out in clinics, and when prescribed by private practitioners.

Those who are getting methadon prescriptions from private practitioners is a third group. The prescription is valid for a shorter or longer period, usually about two weeks. The addict gets his drug at the drug store, and decides himself where and when he will take it.

The maintenance progammes do not try to convince the addict to try scaling down or stopping the abuse. It is up to each addict to decide whether he or she will try a gradual reduction, or continue being prescribed maintenance doses.

Why maintenance doses?

The aim of the maintenance programmes is to get the abuser off a "chaotic" life, into a more stable existence. In chaotic periods the abuser will from time to time have problems getting hold of the kind of drug he prefers. This leads to abuse of several different drugs, or that he mixes different types of drugs, that the doses goes up and down, uncertainty about the purity and concentration of the drugs, what additional substances might be added, uncertainty about whether one will have money for the next dose etc.

When they get drugs legally prescribed, they can stabilize their existence. The supply of methadon is regular, the doses stable, the concentration likewise, and there is no fear of harmful additives, the financing is no problem etc. Even if the abuser continues taking drugs, one views this as a way to achieve "harm reduction". (1)

Comparison with alcohol.

Nobody has proposed that one does the same for alcoholics: Daily handout of free alcohol (financed by the taxpayers). One should think that such a measure also would stabilize their situation. No money problems, no bad "moonshine" or methanol, no harmful additives or uncertain concentrations etc. "Harm reduction". But here also one has to accept that the person is still drinking, as long as the legal prescription programme lasts.

Free syringes.

The legal prescription programme is often combined with programmes for dispensing syringes. Some times the syringes are distributed at clinics in a controlled way, where one gives out a new syringe and gets a used one in exchange. At other places it is conducted in a much more liberal way, where one can get as many syringes as one wishes, without having to hand over an equal number of used ones. There are also places where on can get the syringes from automats, with no control whatsoever.

There exist many projects with distribution of free syringes in Western Europe. The goal is to minimize the problems created by several people using the same syringe. Sharing of syringes leads to spreading of diseases like hepatitis or HIV. The fact that free distribution of syringes can increase the number of drug users, are in most West European countries deemed as secondary to the value of the programmes in the struggle against HIV and hepatitis.

In certain cities an unbelievable number of syringes are distributed. In Zurich it is estimated that about 14000 syringes are distributed every day, that equals about five million syringes a year. And in Liverpool there are distributed even more. (2,3)

Which drugs are being prescribed?

Which drugs are prescribed varies from country to country. The most commonly prescribed preparats are methadon and similar synthetic substitutes for heroin. More than half of the prescribed preparats are methadon and similar drugs. However, precription of heroin is becoming more and more common. In Great Britain, Holland, Switzerland and Italy heroin is prescribed to quite a number of abusers.

In some countries pain killing drugs, like codein, are prescribed. In Great Britain and a few other countries amphetamine is being prescribed to elderly people. In a few cases even cocaine and crack are being prescribed in Great Britain. Prescription of sedatives and sleeping drugs, like for instance Rohypnol, is very common in most of the West European countries.(4,5,6)

Who receives prescribed drugs?

The Prescription Programmes have very different goals and target groups in the different countries. In some countries drugs are primarily prescribed to abusers who have unsuccessfully undergone all other kinds of treatments and rehabilitation programmes available in the country.

In other countries it is performed in a much more liberal way, with prescription of drugs to a large number of abusers. The government of Ireland has as a confirmed goal for their Legal Prescription Programmes, that they eventually shall include all the drug abusers in the country. (7,8)

Pregnant women.

In many of the West European countries there is no hesitation in prescribing drugs to pregnant women. One does not try to persuade them to end the abuse, and it is said that methadon is harmless for the foetus. One considers it "better" for the child that the mother is given stable doses throughout the pregnancy, than risk the mother involved try to get the methadon on the street.

When the baby is born, it has to enter a gradual reduction programme with methadon in smaller and smaller doses, until they are down to nil. One is not concerned about the baby getting the drug through suckling its mother. Methadon is being considered harmless for the child.

Many spokesmen for the Legal Prescription Programmes asserts that it is wrong to try to convince a pregnant woman to scale down and stop taking drugs through the pregnancy. One considers it most probable that the mother then will stay drugfree for a short periode, and then she will take to the streets again and end up in the same "chaotic" abuse, with varying doses and the use of different drugs, both separately and mixed.

One concludes that it is more harmful to the foetus hassling the mother about abstinence during the pregnancy, than if the she is alowed to live in peace with her "stable abuse". (9,10,11,12,13)

How is the prescription conducted?

Here also there are great differences in the different West European countries. In the most controlled programmes the drug is given in liquid form, and taken under supervision at a clinic.

In other countries the prescription is so extensive that the methadon is being handed out from special methadon buses. Here also the distribution is under control. In the most liberal programmes there is a majority of prescription from General Practitioners. The abuser gets a prescription valid for from a week up to a month, and gets his drug in liquid form, so it can be either drunk or injected.

There are also examples of drugs being given to abusers at socalled "crisis stations" or something equal. Here the abusers even can get help to inject the drug, if their hands are too shaky or they have problems finding a suitabe vein. In some countries a solution with drugs from automats is being discussed. (14,15,16,17,18)

How extensive are the Legal Prescription Programmes?

The countries usually have a fairily good control of the numbers of abusers who are receiving drugs legally through the different clinic programmes. On the other hand they do not have an equally good control of the number of abusers who get their legal doses prescribed by General Practitioners. In addition there is a grey zone consisting of certain drug store keepers who are selling methadon and other preparats black, without prescriptions. Many of the socalled "substitutes" can tell about that.

As no one has made any exact survey on how many people are getting drugs legally prescribed in Western Europe, all estimates will be more or less well qualified guesses.

If one takes the different reports as a basis, there seems to be about 100.000 persons, probably more, that are taking part of a Legal Prescription Programme. Maybe even up to 200.000.

There is, however, one thing one can be sure of: The number will increase dramatically. All reports points to a very steep escalation:

  • The number of countries starting up Legal Prescription Programmes are increasing
  • The number of projects within each country is increasing
  • The general trend is that the number of "maintenance doses" is increasing
  • In addition there is a gradual transition from strictly controlled to more liberal programmes.

Decriminalizing

Decriminalizing of certain forms of trafficking with drugs are quite common in Western Europe.

Some countries have decriminalized the use and possesion of smaller quantities of cannabis for personal use. Other countries have also decriminalized the use and possesion of ecstasy, and others again have decriminalized dealing with certain types of amphetamine. A few countries have even gone further, and have decriminalized more than just the possession and use of different types of drugs.

Prohibited by law.

In spite of the decriminalizing of all trafficking with drugs, it is still prohibited by law. One has, however, removed the punishment for certain sides of dealing with drugs, usually use and possesion of smaller quantities for personal use. It has become a question of how the authorities interpret the legislation. The law itself, including the prohibition, still exists.

Two components

The decriminalizing consists of two components. One component is that the police still reacts to violation of the drug legislation, but that the councel for the prosecution and the court of justice thereafter decide withdrawal of the charge. In Great Britain the number of withdrawals of the charge have increased severely concerning cannabis offences. Five years ago only 1 % got a withtdrawal of the charge, today about 45 % are getting it in connection with cannabis offences.

The other component consists of that the police and other authorities refrain from acting on such matters. Some times they give oral warnings or confiscate the drug. Usually they neither give warnings nor confiscate the drug, at least not when it concerns only small quantities.

What is being decriminalized?

In many countries the use of drug is decriminalized. In some countries the possesion and personal use of small quantities of drugs is decriminalized. In some countries also the growing, production and sale of certain drugs is decriminalized. Likewise, import of smaller quantities of certain types of drugs, and transit through the country is decriminalized.

Different quantities

In Amsterdam and Schleeswig Holstein all dealing with up to 30 grammes of cannabis, 5 grams of cocaine and amfetamine, and 1 gram of heroin is decriminalized. In other areas and countries there are different weight limits for the decriminalizing. The decriminalizing is in other words differently practitioned in different countries, but different practice can also exist between different areas in the same country.

The German Constitutional Court of Justice.

The German Constitutional Court of Justice has gone farthest in Europe in decriminalizing the use of drugs. The Court of justice resolved on the 28th April 1994, to decriminalize the use, possesion, sale, growth and production of cannabis for personal use. Also import of cannabis for personal use, and bringing cannabis on transit through the country was decriminalized.

What is new here, compared to other countries, is that import of small quantities and bringing cannabis in your luggage on transit through the country was decriminalized. Now it is up to each =delstat= to decide the quantity limit of decriminalizing. It will probably differentiate from state to state, with Schleswig Holstein as the most liberal and probably Bayern as the most restrictive.

A big city phenomenon

In several countries local and regional authorities takes part in deciding the rules for the police work in practice. Therefore several big cities have decriminalized trafficking with drugs, while the rural areas still have a more restrictive view on the interpretation of the drug legislation.

"Soft drugs" - "hard drugs"

Some of the West European countries have introduced a sharp diffence in the penalty reactions between so called "soft drugs" and "hard drugs". Usually cannabis, that is hashish and marihuana, is viewed as "soft drugs". In some countries ecstasy also is included in the "soft drugs" group.

No legal trade article

No matter what, the decriminalizing of drugs does not turn them into a legal trade article. The penalty reactions are removed for certain parts of the drug traffic, but it is still forbidden by law to deal even with small amounts of drugs.

Legalizing

A legal trade article

To legalize drugs means to make drugs a legal trade article.

No European country has yet gone as far as to legalize all kinds of drugs, but certain parts of the drug traffic in several West European countries is legalized. Kath for instance, is not classified as a drug in other countries than Norway, Sweden and Denmark.

In many of the countries amphetamine is a common ingredient in different slimming preparats, without these being classified as drugs. In Great Britain amphetamine is solely classified as a drug, class A, when it is dissolved and ready for injection. In tablet form it is classified at the same level as Valium and other tranquilizers. If drugs in any form ever should be classified as a legal trade article, on must be observant of the rules in the Rome Treaty concerning free movement of trade articles within the European Union.

What should be legalized?

The ones who appears as spokesmen for legalizing, have very different notions about which drugs should be legalized. Many opinion leaders move that only the socalled "soft drugs" should be legalized. They are usually talking about cannabis, hashish and marihuana, but in Spain is already ecstasy classified as a "soft drug".

Other debaters propose legalizing of coca and its derivatives in addition to cannabis. As cocaine is a derivative of coca, this means that they also include cocain in the group of legalized drugs.

Other people again propose that all drugs should be legalized, including the "hard drugs". This point of view is not commonly shared, but is promoted by two of the real "big ones" i the legalizing debate. Marco Taradesh, member of the EU Parliament and Secretary General of International Prohibitionist League (IAL), and Margarethe Nimsch, City Councellor in Frankfurt, and leader of the Big City Movement for Legalizing of Drugs, are both well known and important supporters of full legalizing.

How to accomplish legalizing

The most eager liberalitionists proposes a free and unrestricted market for drugs as for any other legal trade article. Other propose that the sale should take place in Government controlled shops with a special license for such trade. Then it should be possible to maintain an age limit for the buyers, and there can also be a firm control with price and quality etc. Some proposes salesplaces modelled after the governmental Wine Monopolies in Norway and Sweden. Many proposes that the sale should take place at the common drug stores. Some of these offers that a prescription from a doctor should be needed, while others want it to be an unrestricted sale.

It is a widely spread view that a free, but controlled sale will bring a lot of money to the government, as one then can add taxes to the prices. Certain debaters, on the other hand, move that the government should subsidize the drugs, and so keep the prices low. That way it will be easier to defeate the black drug market which exists today.

Sales promotion

Certain drug liberals goes as far as to propose that sales promotion for drugs should be permitted. Others think that sales promotion should be permitted only with the same restrictions as goes for medicines. A third group thinks that the sales promotion should follow the same rules as those for alcohol and tobacco. Others again think that sales promotion should be permitted for "soft drugs", but not for "hard drugs". There are also those among the drug liberals who says that no sales promotion for drugs should be permitted.

Social measures in "harm reduction" spirit

The majority of those who wants an increased effort on legal prescription and decriminalizing or legalizing of drugs, also suggests an increased effort on social help measures. Some of them suggest increased efforts on rehabilitation programmes for abusers, more "first aid" institutions, and increased resources to medical support programmes. Others suggest increased efforts on general society programmes. All of it in true "harm reduction" spirit.

"Harm reduction" goals.

Very few of the social programmes aimed at drug addicts have as their goal that the addict shold stop using drugs. In other words: They are not primarily aiming at rehabilitation. Most of the programmes aims at stabilizing the abusers' situation, and accept continued abuse of drugs. Here one can see the counterpart of the alcohol industry's motto of "sensible drinking": The users shall be trained to tackle their drug abuse, and learn to live with it. This they should do with a redused risk, and without suffering unneccesarily great harm. It is a kind of "moderation thinking" for drug addicts.

The social help programmes will at their best only be a following up and support of the legal prescription, the decriminalisation or the legalization programmes.

Prevention and information

"Harm reduction" goals

The information programmes about drugs in Western Europe, apart from Sweden, Norway, Finland and Iceland, very often include the same ideas: The drug is here to stay. Therefore it is unrealistic to go out and try to encourage the youth not to use drugs. If you do, you lose credibility and no one will be interested in what you have to say. The realistic, pragmatic and flexible way, is to inform on how to use drugs without suffering too much harm, a kind of encouragement to temperate drug use. This is tackling reality, and it does not shut its eyes to the positive sides of drug use. Such information helps reduce unneccesary fright for drugs. It is credible, and is important to those who are "just experimenting" with drugs, but do not use it on a regular basis.

Drug liberalism?

The main content of the West European drug liberalism can be summed up i three points: Legal prescription, decriminalizing and legalizing of drugs. The content of the three points is supported by the contents of the social programmes for drug abusers and the information programmes about drugs i Western Europe, - programmes in true "harm reduction" spirit.

Is legal prescription a result of drug liberalism?

The strictly controlled gradual reduction programmes can hardly be described as drug liberalistic. The goal here is to make the drug addict stop his abuse. One may question the programmes, but not because they can be viewed as a result of a drug liberal policy.

When venturing in on the strictly controlled maintenance programmes, one is on more uncertain ground. These programmes may be termed drug liberal, in the sense that they accept use of drugs. In addition the participants of these programmes take part of a sub culture that has impact on others, and spread an accepting attitude to drugs. The maintenance programmes where the abuser brings the drug home, can definitely be termed as drug liberal. From such programmes prescribed drugs leak into the black market. There can be no doubt that so liberal programmes are a contributor to further spreading of drugs in the society.

This is even more clear if one takes a look at the programmes where the abuser gets a prescription, which he then takes to a drug store to get the drug; especially in the cases where private practitioners are issuing the drug prescriptions. From these programmes there is a big leakage to the black market. These programmes are also contributing to an increase of the problems mentioned above, the creation of sub cultures of people going on maintenance doses. Sub cultures that influence others, and which spread an accepting attitude towards drugs. Therefore these programmes ar drug liberal.

Are the syringe programmes a result of drug liberalism?

The syringe programmes are not implemented out of drug policy motivation. They are carried out to reduce the spreading of HIV/AIDS and hepatitis. The programmes are to be dobted for several reasons, one of them being that there is very little evidence that they actually lead to their stated goal.

When the abuser is about to inject the drug, he is usually in a state when the question of clean syringes is a minor detail. They are often shaky and ill from abstinence. They feel the urge for a new dose, and are very eager to set the fix. Often they are also influenced by alcohol or other drugs. They are therefore willing to use any syringe, no matter how many clean syringes they have access to. They simply choose what is at hand there and then. The effect of the syringe programmes are therefore doubtful, concerning the spreading of both HIV/AIDS and hepatitis.

Losing the control

In several cities the syringe programmes have grown to such proportions that one has partly or wholly lost control. Used syringes are thrown away and are littering the environment to such a degree that there is a great chance that anybody can sting oneself accidentally, and be infected by them.

For instance, in Liverpool the government has been forced to implement an information campaign aimed at children and parents in neighbourhoods where one knows that children are playing with syringes they find in the streets. The campaign was set in motion after several children had been HIV-infected after having played with syringes they had found. In such situations the syringe programmes are creating new problems.

If it is difficult to get hold of syringes, that will be a barrier against drug use in general, and especially a hindrance to pass from smoking, drinking or taking the drugs in tablet form, into injecting it. To distribute a lot of syringes about also implies lowering the threshold, making it easier to abuse drugs, and it simplifies the crossover to needle addiction.

Conclusion: The syringe programmes are drug liberal.

Is decriminalizing a result of drug liberalism?

That the society still punishes the use of small quantities of drugs, is a signal that one does not accept any form or quantity of drug abuse. To remove the penalty for using drugs, is to give a signal that one tolerates such use. Removing the penalty for use, possesion, sale, production and smaller amounts of drugs implies that the society accepts drug trafficing. Therefore one may say that decriminalizing is a result of drug liberalism.

Are social "harm reduction" programmes a result of drug liberalism?

To implement treatment- and rehabilitation programmes that accept the use of drugs, and where one wishes to teach the addict how to live with his drug abuse, means that one is introducing a liberal view on drugs. This kind of programmes are therefore significant results of drug liberalism. The treatment- and rehabilitation programmes that aims at gradual reduction or at making the abuser stop his abuse, are not results of drug liberalism.

Legalizing = drug liberalism?

Legalizing includes liberalizing the laws and rules concerning all trafficing with drugs. Therefore legalizing is a clear result of drug liberalism.

Good or bad?

Whether drug liberalism is good or bad is the topic of this article.

NOTES:

  1. Report from the Harm Reduction Conference in Rotterdam 1993.
  2. IAL Newsletter 20.04.1994.
  3. Interviews with Andrew Bennett and Janet Holcombe in Liverpool 22.01.1994.
  4. See note 2.
  5. ECDP report 1993.
  6. EIGDU report 1992.
  7. See note 2.
  8. Interview with John O'Connor, National Drug Treatment Centre, Dublin, 25.01.1994
  9. See note 2.
  10. See note 9.
  11. Interview with Noel Towe at Local Governments Drugs Forum, London 20.01.1994. 1
  12. Interview with Margaretha Nimsch, City Councellor in Frankfurt, 09.05.1994.
  13. Interview with Susanne Schard, Chief Coordinator for European Cities on Drug Policy, Frankfurt 09.05.1994.
  14. See note 2.
  15. See note 4.
  16. See note 6.
  17. See note 7.
  18. See note 14.