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 33yearold 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 inpatient 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 publichealth 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 2,5003,000
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 under18s, 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 tax men) 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' cooperatives 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 drugtaking. 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.