EXPERIENCES WITH HARM REDUCTION POLICIES AND THE RELEVANCE OF THE INTERNATIONAL DRUG CONVENTIONS

Presentation by Fredrick Polak, psychiatrist, Netherlands Drug Policy Foundation, at panel on Harm Reduction at NGO-meeting organized by the Senlis Council, Vienna, 16, 17 April 2003

One of the arguments against ending drug prohibition is that, in many situations, the harm reduction approach has been beneficial. By slowly and carefully moving on, even under continued prohibition, the harms and injustices of this system will disappear.

This seemingly reasonable argument must be disputed. While it is true that in many countries Harm Reduction methods (HR) have contributed greatly to improvements for both drug users and the population as a whole, this will not undo the numerous unintended harmful consequences of drug prohibition. I will discuss a few of the reasons why we should restrict our expectations of the beneficial influence of HR.

One reason is that excessive demands are made on the research to which new HR methods have to be subjected - whereas new repressive drug policies with direct implications for public health are routinely introduced without any scientific evaluation.

After succesful conclusion of research trials, when the results of HR methods are clearly positive on criteria of public health, public order and criminality, regular introduction of these methods is in many cases obstructed or impeded.

When HR methods are implemented, many problematic drug users are excluded, and in general the facilities are strongly restricted and excessively regulated in their daily functioning.

Then there are the limitations of the medical model, on which many HR policies are based.
Doctors can never sufficiently and adequately provide substitution drugs to the people who want to use them, nor does the medical profession want to do so - and rightly so, because it is neither the duty nor the competence of the medical profession to control the consumption of adult users of psychoactive substances.

In addition, for large groups of problematic users there simply is no substitution treatment available. For instance, for those people for whom cocaine is the most important drug.

Even in countries where it is acknowledged that, for large groups of users, abstinence is not a realistic goal of treatment and of drug policy, there is little room for experimenting with methods that aim at moderating drug use, at learning to increase personal control. There is little research on stimulating social and group norms for acceptable, moderate patterns of drug use.

As a consequence, the general societal problem of drug prohibition remains, because under continued drug prohibition there is no acceptance of non-medical drug use, be it recreative or regular heavy use.

As examples of the vicissitudes of HR policies in the Netherlands, I will discuss cannabis policy and the heroin trial.

Cannabis Policy
One of the first harm reduction policies in the Netherlands was the soft drugs policy which was adopted after the Opium Law was changed in 1976. The health risks connected to cannabis were officially seen as "not unacceptable" (which is not quite the same as "acceptable") and small scale sales of cannabis were allowed under strict conditions. This change of policy was meant to create a separation in the markets for cannabis and for the other illegal drugs, and to prevent the incarceration of large numbers of otherwise law-abiding citizens.

In this system, cannabis products have been sold to the general public openly in special outlets. In addition to the small-scale sales of cannabis, these so-called coffeeshops have an important social function, similar to café's and coffeehouses. More than 25 years of experience with this policy can teach us a number of interesting lessons.

In comparison to countries with strictly prohibitive policies, this policy of creating safe spaces for young people to experiment with cannabis does not lead to higher levels of the use of cannabis, nor of the other, still illegal drugs, nor of dependence on these substances.
In fact, the Dutch experience with practically free availability of cannabis provides indications for what could be named the Opposite-Of-The-Stepping-Stone-Theory: Allowing young people to smoke cannabis can lead to a decrease in the use of the other drugs.

On the other hand, it became obvious that decriminalization does not provide for adequate regulation. Large amounts of money are collected in the illegal cannabis market. Law enforcement efforts systematically result in increasing the market share of criminal organizations over small-scale growers. There is no control of misuse of desinfectants by cannabis growers.

In a rational process of political assessment and planning, legislation would have been introduced for the regulation of this system. When in 2001 a parliamentary resolution asked the government to arrange regulation for the coffeeshops, the Netherlands government lacked the political will to stand up for its convictions and refused, referring to the international conventions.

Heroin maintenance research
The second example is the heroin trial. Research on heroin maintenance has been conducted in six cities from July 1998 to December 2001, with clear and positive results. Yet, due to political manoeuvering of the Christian Democrats (the largest political party), this method will not be introduced as a regular treatment modality - which would be the natural and rational thing to do on account of the positive and promising research outcome.
Continuation of heroin maintenance on a small scale could only be ensured by arranging a political compromise in the form of a follow-up research project.

Abandoning human beings to addiction
The reasons why the Christian Democratic Party now wants to to eliminate the coffeeshops and discontinue the heroin project are disguised, of course, as health arguments. but they are fundamentally moral and ideological. In the view of the Christian Democrats treatment should be aimed at abstinence. Heroin maintenance means abandoning human beings to addiction which, they say, is something a society should never do.

There are at least two reactions to this argument.
1. The assumption seems to be that treatment can be so effective that every drug addict can attain abstinence.
This is assumption is false, and starting from this false assumption causes serious misery.

2. It must be asked: what does society do for the much larger numbers of people who are addicted to alcohol?
Of course, voluntary treatment is available, albeit it often on a limited scale, but alcohol addicts can freely buy as much of their drug of choice as they want, of guaranteed quality and at reasonable cost. Aren´t they abandoned by society to their addiction?

The use of this sort of argument shows not only the intellectual weakness of the prohibitionist position, but also its inherent moral flaw: as if it is better to let selected groups of addicts ruin their lives without adequate supply of drugs, than to provide them with drugs so that they can lead reasonably normal lives.

Conclusion
The issue today is to which degree Harm Reduction methods can diminish the catastrophic consequences of international drug prohibition. Words like "drug prohibition" or "war on drugs" suggest that actually a fight against drugs is going on. In reality drug prohibition is a self-perpetuating enterprise which stimulates both the illegal drug trade and unsafe patterns of drug use. In the last century, this so-called fight against drugs has led to an enormous and very lucrative illegal drugs market, to large-scale loss of life due to prohibition-related violence and to AIDS and other mostly avoidable diseases, and to a predominant but false image of drug use as inevitably unsafe.

Adoption of harm reduction methods can effectively diminish some of the harmful effects of drug prohibition. As a consequence, in countries where harm reduction methods are applied, some parts of the damage caused by drug prohibition are smaller than, for instance, in the USA. Even where this is the case, however, such as in a number of European countries, in Australia, Canada, and New Zealand, punitive repression continues the discrimination and mistreatment of drug users both in the medical and in the non-medical field.

The official UN policy is still directed at an illusionary drug free world and restricts the objective of drug treatment to abstinence. This enables many governments to systematically obstruct the adoption and spread of Harm Reduction methods, with an appeal to the International Drug Conventions. These outdated treaties are abused to impede necessary and highly desirable progress of rational and effective drug policies.
The International Drug Conventions are based on early 20th century thinking and do not address the modern world. They should be seen for what they are: the core of the international drug problem.

Fredrick Polak, M.D., psychiatrist
Netherlands Drug Policy Foundation
Vossiusstraat 31
1071 AG Amsterdam
T: +31 (0)20 6624 024
E: fpolak@knmg.nl
www.drugsbeleid.nl