Illegal Drugs

BETTER WAYS

If Enforcement Doesn't Work, What Are The Alternatives?

IMPRISONMENT is unlikely to clinch the war against drugs. What other
weapons are there? Education for the young is one possibility, although its
record is discouraging: one recent report complains that "large amounts of
public funds...continue to be allocated to prevention activities whose
effectiveness is unknown or known to be limited." However, for habitual
users, the alternatives are more promising. Drug reformers advocate
projects collectively known as "harm reduction": methadone programmes,
needle-exchange centres, prescription heroin.

One of the most remarkable projects designed to reduce harm is going on in
a clinic two floors up in a side street in Bern, in Switzerland. The clinic
is tidy: no sign, apart from covered bins full of spent syringes, of the
160 patients who come two or three times a day to receive and use
pharmaceutical heroin. This Swiss project grew out of desperation: an
experiment in the late 1980s to allow heroin use in designated sites in
public parks went badly wrong. Bern had its own disagreeable version of
Zurich's more notorious heroin mecca, Platzspitz. In 1994 the city
authorities in Zurich and Bern opened "heroin maintenance" clinics, of
which Bern's KODA clinic is one.

It takes addicts from the bottom of the heap. By law, patients must not
only be local residents: they must be the addicts with the greatest
problems. Christoph Buerki, the young doctor in charge, describes the
typical patient as a 33-year-old man who has been on heroin for 13 years
and made ten previous efforts to stop. Half his patients have been in
psychiatric hospitals, nearly half have attempted suicide, many suffer from
severe depression. Given such difficult raw material, the clinic has been
remarkably successful.

First of all, relatively few drop out of the programme, in contrast to most
other drug-treatment schemes. After a year, 76% are still taking part;
after 18 months, 69%. Of those who drop out, two-thirds move on either to
methadone, a widely used heroin substitute, or to abstinence. Two-thirds of
the patients, stabilised on a regular daily heroin dose, find a job either
in the open market or in state-subsidised schemes. Crime has dropped
sharply. "To organise SFr 100-200 ($57-113) a day of heroin, you need either
prostitution or crime, especially drug-dealing," says Dr Buerki. Yet a
study that checked local police registers for mentions of patients' names
found a fall of 60% in contacts with the police after the addicts started
coming to the clinic. Hardly any patients attempt suicide or contract HIV,
because the clinic sees them daily, monitors their physical and
psychological health, and administers other medicines when they come in for
their heroin.

Interestingly, one side benefit of the programme seems to be to reduce the
use of cocaine. Dr Buerki dislikes the idea of prescribing that drug
because of its unpredictable effects. The vast majority of his patients are
taking it when they first arrive, 56% occasionally and 29% daily. After 18
months of treatment, 41% have stopped using cocaine and 52% use it only
occasionally. Given that there is no equivalent of methadone to wean
cocaine users off their drug, that is a hopeful finding.

Switzerland's experience, says Robert Haemmig, medical director of Bern's
Integrated Drug Services Programme, suggests that abstinence may not be the
right goal for heroin addicts. People can tolerate regular doses of heroin
for long periods, but if they give up for a period and then start again
they run a big risk of overdosing. "It's always hard to tell politicians
that abstinence is quite a risky thing for these people," he says.

Heroin maintenance is still used sparingly in Switzerland, for about 1,000
of the country's estimated 33,000 heroin addicts. Most of those in
treatment get not heroin but methadone. But the programme's success
suggests that there are ways to help even the most "chaotic" drug users, if
governments are willing to be open-minded. Predictably, the Swiss doubt
whether it would work everywhere: "You need a society with well-paid
professionals and a low rate of corruption in the medical profession," says
Thomas Zeltner, the senior official in the federal health ministry. But the
economics of the programme are impressive. It costs much the same as
methadone maintenance, and considerably less than a therapeutic community
or in-patient detoxification. It reaches patients that no other programme
can retain. It reduces crime and legal costs and saves much spending on
psychiatric hospitals.

Market Separation

The Swiss heroin maintenance programme shows what can be achieved when a
country starts to think of drug addiction as a public-health problem rather
than merely a crime. The Netherlands has taken a similarly pragmatic
approach to marijuana for the past quarter of a century. It has aimed to
separate the markets for illegal drugs to keep users of "soft" ones away
from dealers in the harder versions, and to avoid marginalising drug users.
"We have hardly a single youngster who has a criminal record just because
of drug offences," says Mr Keizer, the Dutch health ministry's drug-policy
adviser. "The prevention of marginalisation is the most important aspect of
our policy."

The Dutch Ministry of Health helps to finance a project by the independent
Trimbos Institute of mental health and addiction, to test about 2,500-3,000
ecstasy tablets a year for their users. "When we find substances such as
strychnine in the tablets, we issue a public warning," says Inge Spruit,
head of the institute's department of monitoring and epidemiology.

What makes this approach work is the Dutch principle of expediency, which
has already proved useful in dealing with other morally contentious issues
such as abortion and euthanasia. The activity remains illegal, but under
certain conditions the public prosecutor undertakes not to act. Amsterdam's
famous coffee shops, with their haze of fragrant smoke, are tolerated
provided they sell no hard drugs, do not sell to under-18s, create no
public nuisance, have no more than 500 grams (18 ounces) of cannabis on the
premises and sell no more than 5 grams at a time.

Erik Bortsman, who runs De Dampkring, one of Amsterdam's largest coffee
shops, grumbles that the police (and, worse, the taxmen) raid him two or
three times a year, weighing the stock, checking the accounts and examining
employees' job contracts. Sounding like any other manager of a highly
regulated business, he complains that ordinary cafes that stock cocaine
behind the counter get by with no restraints. He points out, too, that it
does not make sense to allow youngsters to buy tobacco and alcohol at 16
but stop them from buying cannabis until they are 18.

But his main grouse is that, although Dutch police allow the possession of
small amounts of drugs for personal use, he is forbidden to stock more than
500 grams, and his purchases remain technically illegal. This contradiction
is at the heart of Dutch drugs policy. Ed Leuw, a researcher from the Dutch
Ministry of Justice, believes that a majority of Dutch members of
parliament would like to legalise the whole cannabis trade. Why don't they?
Partly because it would further increase the hordes of tourists from
Germany, Belgium and France that come to take advantage of the relaxed
Dutch approach; but mainly because the Dutch have signed the United Nations
convention of 1988, which prevents them from legalising the possession of
and trade in cannabis.

However, Switzerland may have found a way around that obstacle. In a
measure that must still pass through parliament, the government proposes
allowing the growing of, trade in and purchase of marijuana, on condition
that it is sold only to Swiss citizens and that every scrap is accounted
for. All these activities would remain technically illegal, but with formal
exemption from prosecution, in line with Dutch practice. There is no
precedent for this in federal Swiss law. "We wouldn't have done things this
way if we hadn't signed the UN convention," admits Dr Zeltner.

Extending The Model

Could Dutch and Swiss pragmatism be the basis of wiser policies across the
Atlantic? Among lobbyists, the idea that the aim of policy should be to
reduce harm is extremely popular. At the start of June, the Lindesmith
Centre, newly merged with the Drug Policy Foundation, another campaigning
group, held a conference in Albuquerque, New Mexico, where speaker after
speaker argued that current American policies did more harm than good.

A brave minority of politicians agrees, including Gary Johnson, New
Mexico's Republican governor. He is aghast at the lopsided severity of
drugs laws. "Our goals should be the reduction of death, disease and
crime," he says, claiming that many other governors share his views.

For the moment, Mr Johnson is seen as a maverick. "The harm-reduction
approach doesn't sell well in the United States," says John Carnevale,
formerly of the Office of National Drug Control Policy. What is forcing
more debate, he reckons, is a movement among the states to allow the
medical use of marijuana, and perhaps the perceived injustice of
imprisoning so many young black men.

The campaign to allow the use of marijuana for medical treatment recently
received a setback with a ruling by the Supreme Court against the cannabis
buyers' co-operatives that have flourished mainly in California. But public
opinion seems to be cautiously on board: a 1999 Gallup poll found 73% of
Americans in favour of "making marijuana legally available for doctors to
prescribe in order to reduce pain and suffering."

Change, if it comes, will start at state level. But it will come slowly.
Governments everywhere find it hard to liberalise their approach to drugs,
and not just because of the UN convention: any politician who advocates
more liberal drugs laws risks being caricatured as favouring drug-taking.
Still, the same dilemma once held for loosening curbs on divorce, abortion
and homosexuality, on all of which the law and public opinion have shifted.

Public opinion is clearly shifting on drugs, too. When the Runciman Report
in Britain last year advocated a modest relaxation of the laws on
marijuana, the Labour government raced to condemn it. It hastily changed
its tune when most newspapers praised the report. And it is worth recalling
that at the time of America's 1928 election, Prohibition enjoyed solid
support; four years later the mood had swung to overwhelming rejection.

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