DOES EUROPE DO IT BETTER?

LESSONS FROM HOLLAND, BRITAIN AND SWITZERLAND

Listen to a debate among drug policy advocates and you're likely to hear
impassioned claims about the brilliant success (or dismal failure) of more
"liberal" approaches in certain European countries. Frequently, however,
such claims are based on false assumptions. For example, we are told that
marijuana has been legalized in the Netherlands. Or that addicts receive
heroin by prescription in Great Britain.

Pruned of erroneous or excessive claims, the experience in Europe points to
both the feasibility of successful reform of US drug laws and the drawbacks
of radical change. What follows are descriptions of some innovative
approaches being tried over there, with judgements of their applicability
over here. They fall into three broad categories: eliminating user sanctions
(decriminalization), allowing commercial sales (legalization) and medical
provision of heroin to addicts (maintenance).

Decriminalizing Marijuana: The Case of the Dutch Coffee Shops

Dutch cannabis policy and its effects are routinely mischaracterized by both
sides in the US drug debate. Much of the confusion hinges on a failure to
distinguish between two very different eras in Dutch policy. In compliance
with international treaty obligations, Dutch law states unequivocally that
cannabis is illegal. Yet in 1976 the Dutch adopted a formal written policy
of nonenforcement for violations involving possession or sale of up to
thirty grams (five grams since 1995) of cannabis--a sizable quantity, since
one gram is sufficient for two joints. Police and prosecutors were forbidden
to act against users, and officials adopted a set of rules that effectively
allowed the technically illicit sale of small amounts in licensed coffee
shops and nightclubs. The Dutch implemented this system to avoid excessive
punishment of casual users and to weaken the link between the soft and hard
drug markets; the coffee shops would allow marijuana users to avoid street
dealers, who may also traffic in other drugs. Despite some recent
tightenings in response to domestic and international pressure (particularly
from the hard-line French), the Dutch have shown little intention of
abandoning their course.

In the initial decriminalization phase, which lasted from the mid-seventies
to the mid-eighties, marijuana was not very accessible, sold in a few
out-of-the-way places. Surveys show no increase in the number of Dutch
marijuana smokers from 1976 to about 1984. Likewise, in the United States
during the seventies, twelve US states removed criminal penalties for
possession of small amounts of marijuana, and studies indicate that this
change had at most a very limited effect on the number of users. More recent
evidence from South Australia suggests the same.

>From the mid-eighties Dutch policy evolved from the simple
decriminalization of cannabis to the active commercialization of it. Between
1980 and 1988, the number of coffee shops selling cannabis in Amsterdam
increased tenfold; the shops spread to more prominent and accessible
locations in the central city and began to promote the drug more openly.
Today, somewhere between 1,200 and 1,500 coffee shops (about one per 12,000
inhabitants) sell cannabis products in the Netherlands; much of their
business involves tourists. Coffee shops account for perhaps a third of all
cannabis purchases among minors and supply most of the adult market.

As commercial access and promotion increased in the eighties, the
Netherlands saw rapid growth in the number of cannabis users, an increase
not mirrored in other nations. Whereas in 1984 15 percent of 18- to
20-year-olds reported having used marijuana at some point in their life, the
figure had more than doubled to 33 percent in 1992, essentially identical to
the US figure. That increase might have been coincidental, but it is
certainly consistent with other evidence (from alcohol, tobacco and legal
gambling markets) that commercial promotion of such activities increases
consumption. Since 1992 the Dutch figure has continued to rise, but that
growth is paralleled in the United States and most other rich Western
nations despite very different drug policies--apparently the result of
shifts in global youth culture.

The rise in marijuana use has not led to a worsening of the Dutch heroin
problem. Although the Netherlands had an epidemic of heroin use in the early
seventies, there has been little growth in the addict population since 1976;
indeed, the heroin problem is now largely one of managing the health
problems of aging (but still criminally active) addicts. Cocaine use is not
particularly high by European standards, and a smaller fraction of marijuana
users go on to use cocaine or heroin in the Netherlands than in the United
States. Even cannabis commercialization does not seem to increase other drug
problems.

Treating Heroin Addicts in Britain

The British experience in allowing doctors to prescribe heroin for
maintenance has been criticized for more than two decades in the United
States. In a 1926 British report, the blue-ribbon Rolleston Committee
concluded that "morphine and heroin addiction must be regarded as a
manifestation of disease and not as a mere form of vicious indulgence," and
hence that "the indefinitely prolonged administration of morphine and
heroin" might be necessary for such patients. This perspective--already
quite distinct from US views in the twenties--led Britain to adopt, or at
least formalize, a system in which physicians could prescribe heroin to
addicted patients for maintenance purposes. With a small population of
several hundred patients, most of whom became addicted while under medical
treatment, the system muddled along for four decades with few problems.
Then, in the early sixties, a handful of physicians began to prescribe
irresponsibly and a few heroin users began taking the drug purely for
recreational purposes, recruiting others like themselves. What followed was
a sharp relative increase in heroin addiction in the mid-sixties, though the
problem remained small in absolute numbers (about 1,500 known addicts in
1967).

In response to the increase, the Dangerous Drugs Act of 1967 greatly
curtailed access to heroin maintenance, limiting long-term prescriptions to
a small number of specially licensed drug-treatment specialists. At the same
time, oral methadone became available as an alternative maintenance drug. By
1975, just 12 percent of maintained opiate addicts were receiving heroin;
today, fewer than 1 percent of maintenance clients receive heroin.
Specialists are still allowed to maintain their addicted patients on heroin
if they wish; most choose not to do so--in part because the government
reimbursement for heroin maintenance is low, but also because of a
widespread reluctance to take on a role that is difficult to reconcile with
traditional norms of medical practice. Thus, one can hardly claim that
heroin maintenance was a failure in Britain. When it was the primary mode of
treatment, the heroin problem was small. The problem grew larger even as
there was a sharp decline in heroin maintenance, for many reasons unrelated
to the policy.

'Heroin-Assisted Treatment': The Swiss Experience

What the British dropped, the Swiss took up. Although less widely known, the
Swiss experience is in fact more informative. By the mid-eighties it was
clear that Switzerland had a major heroin problem, compounded by a very high
rate of HIV infection. A generally tough policy, with arrest rates
approaching those in the United States, was seen as a failure. The first
response was from Zurich, which opened a "zone of tolerance" for addicts at
the so-called "Needle Park" (the Platzspitz) in 1987. This area, in which
police permitted the open buying and selling of small quantities of drugs,
attracted many users and sellers, and was regarded by the citizens of Zurich
as unsightly and embarrassing. The Platzspitz was closed in 1992.

Then in January 1994 Swiss authorities opened the first heroin maintenance
clinics, part of a three-year national trial of heroin maintenance as a
supplement to the large methadone maintenance program that had been
operating for more than a decade. The motivation for these trials was
complex. They were an obvious next step in combating AIDS, but they also
represented an effort to reduce the unsightliness of the drug scene and to
forestall a strong legalization movement. The program worked as follows:
Each addict could choose the amount he or she wanted and inject it in the
clinic under the care of a nurse up to three times a day, seven days a week.
The drug could not be taken out of the clinic. Sixteen small clinics were
scattered around the country, including one in a prison. Patients had to be
over 18, have injected heroin for two years and have failed at least two
treatment episodes. In fact, most of them had more than ten years of heroin
addiction and many treatment failures. They were among the most troubled
heroin addicts with the most chaotic lives.

By the end of the trials, more than 800 patients had received heroin on a
regular basis without any leakage into the illicit market. No overdoses were
reported among participants while they stayed in the program. A large
majority of participants had maintained the regime of daily attendance at
the clinic; 69 percent were in treatment eighteen months after admission.
This was a high rate relative to those found in methadone programs. About
half of the "dropouts" switched to other forms of treatment, some choosing
methadone and others abstinence-based therapies. The crime rate among all
patients dropped over the course of treatment, use of nonprescribed heroin
dipped sharply and unemployment fell from 44 to 20 percent. Cocaine use
remained high. The prospect of free, easily obtainable heroin would seem to
be wondrously attractive to addicts who spend much of their days hustling
for a fix, but initially the trial program had trouble recruiting patients.
Some addicts saw it as a recourse for losers who were unable to make their
own way on the street. For some participants the discovery that a ready
supply of heroin did not make life wonderful led to a new interest in
sobriety.

Critics, such as an independent review panel of the World Health
Organization (also based in Switzerland), reasonably asked whether the
claimed success was a result of the heroin or the many additional services
provided to trial participants. And the evaluation relied primarily on the
patients' own reports, with few objective measures. Nevertheless, despite
the methodological weaknesses, the results of the Swiss trials provide
evidence of the feasibility and effectiveness of this approach. In late 1997
the Swiss government approved a large-scale expansion of the program,
potentially accommodating 15 percent of the nation's estimated 30,000 heroin
addicts.

Americans are loath to learn from other nations. This is but another symptom
of "American exceptionalism." Yet European drug-policy experiences have a
lot to offer. The Dutch experience with decriminalization provides support
for those who want to lift US criminal penalties for marijuana possession.
It is hard to identify differences between the United States and the
Netherlands that would make marijuana decriminalization more dangerous here
than there. Because the Dutch went further with decriminalization than the
few states in this country that tried it--lifting even civil penalties--the
burden is on US drug hawks to show what this nation could possibly gain from
continuing a policy that results in 700,000 marijuana arrests annually.
Marijuana is not harmless, but surely it is less damaging than arrest and a
possible jail sentence; claims that reduced penalties would "send the wrong
message" ring hollow if in fact levels of pot use are unlikely to escalate
and use of cocaine and heroin are unaffected.

The Swiss heroin trials are perhaps even more important. American heroin
addicts, even though most are over 35, continue to be the source of much
crime and disease. A lot would be gained if heroin maintenance would lead,
say, the 10 percent who cause the most harm to more stable and socially
integrated lives. Swiss addicts may be different from those in the United
States, and the trials there are not enough of a basis for implementing
heroin maintenance here. But the Swiss experience does provide grounds for
thinking about similar tests in the United States.

Much is dysfunctional about other social policies in this country, compared
with Europe--the schools are unequal, the rate of violent crime is high and
many people are deprived of adequate access to health services. But we are
quick to draw broad conclusions from apparent failures of social programs in
Europe (for example, that the cost of an elaborate social safety net is
prohibitive), while we are all too ready to attribute their successes to
some characteristic of their population or traditions that we could not
achieve or would not want--a homogeneous population, more conformity, more
intrusive government and the like. It's time we rose above such
provincialism.

The benefits of Europe's drug policy innovations are by no means decisively
demonstrated, not for Europe and surely not for the United States. But the
results thus far show the plausibility of a wide range of variations--both
inside and at the edges of a prohibition framework--that merit more serious
consideration in this country.

Note:
Robert J. MacCoun is a professor in the Goldman School of Public Policy and
Boalt Hall Law School at the University of California, Berkeley. Peter
Reuter is a professor in the School of Public Affairs and the department of
criminology at the University of Maryland. This work was supported by a
grant from the Alfred P. Sloan Foundation to RAND's Drug Policy Research
Center.
http://www.rand.org/centers/dprc/