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Europe leading the way to smarter drug laws: Part one
Addiction rates, deaths, crime plummet when users are no longer considered criminals
The Ottawa Citizen
In November, 1990, officials from four major European cities -- Hamburg, Frankfurt, Zurich and Amsterdam -- declared war on the War on Drugs. "The attempt to eliminate both the supply and the consumption of drugs in our society has failed," city officials declared.
Bruno Schlumberger, The Ottawa Citizen / In Germany, methadone treatment has helped reduce drug-related crimes and drug-related deaths.
Pat McGrath, The Ottawa Citizen / Many Canadians fear that if drugs were made legal, addiction rates would soar. The European experience suggests just the opposite.
Shawn Thew, AFP / Two teenage girls share a joint at a Washington rally in support of the legalization of marijuana. A few European officials have argued for the creation of a legal supply of drugs.
David Lucas, The Canadian Press / 'We've known for a long time that there's no correlation between the type of drug-control regime and the extent of use,' says Benedikt Fischer of the Canadian Centre for Addiction and Mental Health. In fact, 'the tighter the control, the greater the use,' seems to hold true.
Dusan Vranic, The Associated Press / In Holland's 'coffee shops,' marijuana is sold under tightly regulated conditions and police tend to ignore petty street-level dealers.
Pat McGrath, The Ottawa Citizen / Ottawa lawyer Eugene Oscapella, a director of the Canadian Foundation for Drug Policy, says a legal system of drug distribution must be created.
The "Frankfurt Resolution," as the cities' declaration was called, was the beginning of a major movement in Europe. No longer would drug users and addicts be threatened with arrest. No longer would stopping people from using illegal drugs be the obsessive goal of government policy. Now the first priority would be keeping people alive.
The theory behind the Frankfurt Resolution is often called "harm reduction." At its heart, harm reduction accepts that drug use has always existed in society, and always will. The question is how best to minimize the harms of drug use, for both the individual and society.
Harm reduction's first answer to that question is: not with the criminal law. Banning drugs doesn't minimize harms; it maximizes them. As the Frankfurt Resolution noted, existing drug problems "are primarily due to the illegality of drug consumption. Illegality makes drugs impure and expensive, and the dosage is hardly calculable. Illegality is the primary factor causing misery of the addicts, the deaths and the acquisitive crime."
So the resolution called for "a dramatic shift in drug policy." To reduce the "suffering, misery and death" associated with illegal drugs, it said the threat of prosecution must be removed from drug users. Forcing people to give up their drug habits might not be the best way to help them, the resolution added. "Help should not only be aimed at breaking away from dependence, but must also permit a life in dignity with drugs."
What followed the resolution was indeed "a dramatic shift." Major harm reduction policies were implemented, producing astonishing results almost immediately. Others in Europe took notice and followed the pioneers' lead. Now cities and whole countries across the continent are pulling the police out of drug policy, treating drugs as a health issue, not a criminal one. Their success will be increasingly difficult to ignore elsewhere. Europe may be leading the way to a new and better way of dealing with illegal drugs.
If so, it would be ironic, because much of what Europe is doing was inspired by what others did in the past.
Early in the 20th century, as some drugs were banned, black markets formed to supply unmet demand. As always with black markets, the products they sold were painfully expensive and of dubious quality. A new type of drug addict quickly appeared, one that had not been seen before drug prohibition: the young, poor, socially marginalized wretch that is so familiar today.
Prior to the criminalization of drugs, there had been no epidemic of addiction, but there had been addicts. Unlike the frightening spectres who get their drugs from the black market, these addicts tended to be quite ordinary people, with stable lives, families and jobs. If there were a stereotype of an addict in this period, it was a middle-class housewife drinking opium mixed in alcohol to relieve her boredom. As drug prohibition gradually solidified between 1910 and 1920, these addicts were threatened with the loss of the drugs they depended on. They turned to their doctors for help.
Even after prohibition was created, physicians retained the right to prescribe any drug in any form they felt was best for their patients. This included substituting one addictive drug for another, if they felt that the substituted drug was less harmful than the drug the patient was then taking.
The surgeon William Stewart Halsted (1852-1922) successfully applied this technique to himself when he became addicted to cocaine. Dr. Halsted switched to morphine (which is, in effect, a milder form of heroin) and injected himself for the rest of his life, another 40 years. Despite his morphine addiction, Dr. Halsted went on to co-found the Johns Hopkins Hospital and became a renowned physician. His addiction had so little effect on his health and work that it remained secret throughout his life and was only revealed decades after he died.
In addition to drug substitution, doctors could also prescribe the very drug to which a patient was addicted. This was often done to keep the patient's life stable, making the chances of weaning himself off the drug that much better. Sometimes, though, the addiction was never kicked. The prescription was maintained, and the addict would continue to receive the drug in pharmaceutical quality at legal market prices. Many doctors did not consider abstinence the top priority, rather health was. If a person could live a reasonably normal, healthy life while taking a drug, so be it.
In the United States, drugs were gradually criminalized beginning in 1914 and doctors' freedom to prescribe as they saw fit lasted only into the 1920s. Government officials, who saw drug use as a moral taint, did not share the doctors' pragmatic approach. Any continued use of a drug, even if it didn't damage the user's health or relationships, was unacceptable. Federal officials doggedly went after doctors who prescribed banned drugs and finally won several convictions. The doctors surrendered and the drug issue was effectively handed over to the criminal law. Abstaining from all drug use became the highest priority of official policy and the only acceptable goal of drug treatment -- a philosophy the U.S. government exported over the following decades.
In Great Britain, the story was quite different. Physicians steadfastly insisted on the right to prescribe whatever drug they deemed useful. Kicking the addiction was a goal, but not an overriding one. If it didn't happen, the doctors reasoned, it was still better that their patients get clean, tested, labelled drugs rather than the potentially poisonous stuff bought in a black market. The British government's Rolleston Report of 1926 agreed.
For the next 40 years, British doctors prescribed heroin, cocaine, amphetamine and other drugs to addicted patients. The "British system," as it came to be called, was a quiet success. While the average addict in the United States was a poor, haggard and hunted creature, the average British addict was a middle-class, employed citizen. British addicts were in better health, and unlike American addicts, they didn't commonly commit property crimes because they didn't have to pay black market prices for drugs. Most remarkably, the number of addicts in Britain never rose much beyond 1,000, even as the ranks of American addicts swelled.
The "British system" ran into trouble in the mid-1960s, when a worldwide rise in heroin use hit Britain as well. The number of addicts in that country doubled -- from 700 to 1,400. At the time, there were an estimated 20,000 addicts in Manhattan alone, but still the British public was shocked. After 1968, doctors were required to get a special licence to dispense illegal drugs and the "British system" declined. Britain steadily moved toward American approaches, with abstinence as the overriding goal. British rates of drug addiction exploded. By the end of the 1980s, there were approximately 20 times as many addicts as there had been in the 1960s.
For the drafters of the Frankfurt Resolution, the American and British experiences were instructive. So too was Germany's own record of failure.
In the 1980s, then-West Germany waged an aggressive War on Drugs. Police budgets grew. New laws increased punishments. Ever-increasing numbers of drug users and dealers were sent to prison.
Still the country's drug problems spiralled out of control. Heroin addiction rates grew and bedraggled addicts formed ghettos in city centres. Drug-related crime, especially property crime, rose dramatically. Drug-related deaths tripled, to 2,000 a year.
From this failure came the Frankfurt Resolution in 1990. Benedikt Fischer, a research scientist at the Centre for Addiction and Mental Health (formerly the Addiction Research Foundation) and a professor in the departments of public health sciences and criminology at the University of Toronto, tracked the policies that followed. The first change was to remove the threat of punishment by legalizing the possession of small amounts of drugs. "The police don't deal with average illicit drug users anymore," Mr. Fischer says. "If police encounter illicit drug users in many of these jurisdictions, either they just leave them alone, they don't bother them, or they refer them to other social services." This dramatic change was accomplished without legislative reform: The police and prosecutors were simply ordered not to enforce the criminal ban on drug possession, which continues to exist on the books.
With the threat of arrest removed, addicts felt free to use new social services. These included needle exchanges for injection drug users; "safer injection sites," where users could inject themselves under medical supervision; and education that explained how to use drugs in ways that minimize the risks of infection and overdose.
Methadone was another big change. Giving a heroin addict methadone -- a synthetic opiate chemically related to heroin -- has been described as substituting one addiction for another. The German government in the 1980s found that unacceptable and banned methadone. After the Frankfurt Resolution, this was reversed and Germany today has one of the highest per capita rates of methadone treatment for addicts.
The results of Germany's policy shift were clear. "Most of the harms related to illicit drugs were reversed," says Mr. Fischer. No longer fearful of the authorities, far more drug users contacted social services. Needle exchanges and education caused HIV infection rates among injection drug users to drop rapidly, to well below those in other European cities. Drug-related property crimes fell even more spectacularly -- theft from vehicles in Hamburg fell 62 per cent in just two years. Most crucially, drug-related deaths, which had risen rapidly throughout the 1980s, declined as quickly as they had gone up.
Dr. Perry Kendall, British Columbia's provincial health officer and the former president of the Addiction Research Foundation, says the European experience shows that deaths from illegal drug overdoses can be completely eliminated with the right policies. "The injection rooms in Frankfurt have had hundreds of thousands of injections," he notes. But there hasn't been a single overdose death.
The changes in Germany were opposed by many who feared that if the police stopped punishing drug possession, drug use and addiction would soar. It didn't. The rapid rise in use throughout the 1980s stopped, then declined.
Hamburg, one of the cities that most aggressively pursued the new policies, quickly saw a significant drop in heroin use.
Benedikt Fischer says this result wasn't surprising to experts in drug policy. "We've known for a long time that there's no correlation between the type of drug-control regime and the extent of use. Otherwise, the U.S. should have the smallest population of illicit drug users, and the Netherlands should have the largest. But it's completely the opposite."
One thing the German cities didn't try at first, however, was the most controversial element of the "British system": prescribing the very drug to which a person is addicted. Between 1994 and 1997, the Swiss took up that challenge. More than 1,000 addicts who each had made at least two failed attempts at conventional forms of treatment were given clean, pharmaceutical heroin -- a practice sometimes called "heroin maintenance." Again, the results were startling.
There were no overdose deaths. The physical health of addicts greatly improved. The percentage of income from illegal activity fell from 69 to 10 per cent while the number of unemployed fell from 44 to 20 per cent. The percentage who got permanent employment jumped from 14 to 32. Both cocaine and heroin use dropped. Eighty-three people gave up drugs altogether.
The Swiss study confirmed something that has been known for at least a century. While it is very difficult, arguably even impossible, to "cure" an addiction with treatment, a predictable fraction of addicts -- one in 20 per year is a commonly cited figure -- will give up drug use by themselves. The key is to keep them alive and relatively healthy so that can happen. Heroin maintenance does that. And, even for those who never kick their habits, it removes the perpetual hunt for drugs, so addicts are in a stronger position to cope with their addiction.
"You can stabilize their lives," says Dr. Kendall. "They are still addicted to heroin, but they are not overdosing and they're not causing a huge social disruption or criminal issue and their lives can be made better."
Unfortunately, the Swiss project didn't have all the elements of a scientific trial so it can't be said to have conclusively answered key questions. It didn't, for example, show if heroin maintenance is better than methadone treatment. Holland is in the midst of a multi-year study to determine just that. Dr. Kendall says the clinicians running the Dutch project expect to find that while methadone is an effective treatment, there is a hard core of addicts for whom methadone doesn't work as well as heroin maintenance.
Germany is set to launch another study of heroin maintenance next year. Other European countries are formulating their own projects.
The spread of harm reduction policies has been swift, if uneven. While some German cities and states have enthusiastically embraced the movement, more conservative German states such as Bavaria continue to take a punitive approach with all drugs, even marijuana. In the birthplace of the "British system," harm reduction measures such as methadone prescription have spread, even as the Labour government of Tony Blair increasingly embraces policies cribbed from the American War on Drugs.
But several countries have made the shift away from using the criminal law as the main tool of drug policy explicit and uniform. Pragmatism has been the hallmark of Dutch drug policy since the late 1970s, when the possession of drugs was made de facto legal. Switzerland has instituted the full range of harm reduction measures, including heroin maintenance, in most cities -- an approach that has been supported in a popular referendum. Italy and Spain have both embraced harm reduction and "decriminalized" drug possession -- meaning it is punishable by a non-criminal fine or other mild measure, although in practice it's rarely punished at all. Portugal voted in July to follow Spain's lead.
One project that shouldn't be confused with this trend is Zurich's infamous "Needle Park." In the late 1980s, city officials -- spurred on by businesses that wanted addicts out of Zurich's downtown -- allowed drug users and dealers to sell drugs and shoot up in one of the city's parks. It quickly deteriorated into a crime-ridden, unsanitary mess, and was shut down.
Needle Park is often cited as an example of the folly of legalizing drugs. That's wrong. Switzerland didn't legalize drugs, it only ceased to enforce the law within the corners of the park. Inevitably, addicts and dealers from outside Zurich were pushed into the park because of continued punishment elsewhere -- 70 per cent of the 2,000 people in the park each day were not from Zurich. The drug supply continued to come from a black market operated by violent criminals. And addicts continued to have to pay black market prices for drugs of questionable purity, and had to commit crimes to pay those inflated prices. Needle Park was nothing more than a foolish attempt to get the unsightly blemish of addicts off the streets.
Benedikt Fischer insists there are other critical distinctions to make. The "harm reduction" label, he says, is being applied haphazardly to all manner of drug policies. Even the RCMP has used the term. Canada's federal government particularly likes to talk about "harm reduction" and treating illegal drugs as a health issue. "We've heard this rhetoric for a long time in Canada," he says. "But what really matters is the reality on the ground, on the street, in the lives of users. How do we deal with illicit drug users? What do the police do when they encounter them? What is the reality of the response? And here the rhetoric and the reality are very far apart, very different from the European realities."
Canada does have needle exchanges and methadone programs, but they are not nearly as extensive as in much of Europe. More fundamentally, Canada hasn't reined in the criminal law. Punishment continues to be the primary tool of drug policy. Mr. Fischer cites statistics showing that the large majority of drug convictions are for simple possession. Thirteen per cent of possession crimes are punished with incarceration. And more than 70 per cent of all drug crimes involve marijuana. All of these statistics would be unthinkable in European jurisdictions that have adopted the harm reduction approach.
Some Canadian cities have made ad hoc changes in how they enforce the criminal law. Vancouver police, for example, generally do not make arrests for drug possession in the notorious Downtown Eastside. But these arrangements vary from city to city, neighbourhood to neighbourhood, and time to time. Mr. Fischer says this lack of certainty undermines any benefit the changes could make. "The users never know, 'Are they leaving me alone the way they did the last two or three weeks, or are they going to arrest me today?' " The fear of arrest continues -- and so too do the destructive behaviours addicts engage in because of that fear.
The reality of the drug trade further undermines the value of these ad hoc arrangements. When police decide to ease up on users, they often increase resources aimed at dealers. "Cracking down on dealers" is always a politically popular move since, in the public's view, drug dealers are parasites getting rich from the misery of users and addicts.
But the line between users and dealers is often an illusion. Numerous studies have found that most street-level drug dealers are simply drug users trying to make enough money to pay for their own black-market drugs. A 1990 RAND Corporation study of dealers in Washington D.C., for example, found that "the average 'dealer' holds a low-wage job and sells part-time to obtain drugs for his or her own use." So at the same time that the Vancouver police emphasize they're not arresting users, they conduct street sweeps to arrest dealers -- and net the very users they say they're not targeting.
This paradox doesn't just apply to Canada. Even European countries that have effectively legalized drug possession have kept up police attacks on the supply side, aggressively punishing any distribution or sale of drugs. (Holland's "coffee shops," where marijuana is sold under tightly regulated conditions, are an exception. Dutch police also tend to ignore petty street-level dealers.) Many are actually stepping up the war on drug supplies and as a result arresting and punishing users as "dealers."
This is one of many reasons why some harm reduction advocates say that, despite the great changes made in Europe, far more must be done. It's not enough to stop punishing drug possession, they say. A legal system of drug supply must be created.
"People don't like to talk about this," says Eugene Oscapella, an Ottawa lawyer and a director of the Canadian Foundation for Drug Policy. "But the core of prohibition is that we have handed the distribution network of this highly desirable commodity, for some people, over to criminal organizations."
Without a legal drug supply, most of the harms associated with drug prohibition continue, even under a liberalized system of harm reduction. Organized crime continues to profit from the trade and commits violence to control it. Addicts continue to be forced into dealing, prostitution, and property crime to pay black market prices for the drugs they need. And drugs continue to be tainted or poisonous because they are untested and unregulated -- endangering even the great majority of drug users who are not regular users or addicts and whose drug use would generally not otherwise pose major health risks. These and numerous other harms will all continue unless legal drug supplies are permitted.
The Frankfurt Resolution tacitly acknowledged this fact in its list of the woes inflicted by criminalizing drugs, but few European officials have yet argued for the creation of legal supplies. Still, Benedikt Fischer is sure it is "the next step."
"And it will be a big challenge," he adds.
Many models of legalized drug supply have been proposed and studied; what they all have in common is some degree of regulation. "I would never speak of a totally unregulated market in anything that has a potential to harm people," Mr. Oscapella says.
Whether it's mandatory testing and labelling or age restrictions, even the most extreme models of drug legalization include restrictions. No one proposes a return to the free-for-all of the late-19th century, when products containing drugs were sold with false claims and often didn't even mention the presence of drugs on their labels.
Mr. Fischer suggests our long experience regulating the production and sale of alcohol provides a rich source of ideas for how we might legalize and regulate other drugs.
Over the past century and a half, alcohol has been regulated in just about every imaginable way. On the extreme end of that spectrum was the total prohibition of its production, sale or possession. The American "noble experiment," as it was called, was a disaster. Canadian provinces, too, tried alcohol prohibition but most quickly rejected it as unworkable and destructive.
A little less radical is local prohibition, under which municipalities or other local jurisdictions choose to ban alcohol. Before Prohibition, many American municipalities and states went this route. So too did Canadian towns and provinces. Some reserves still have prohibition in Canada. This option has the advantage of reflecting local circumstances and culture but it still creates many of the ills of a black market in the banned drug, although on a lesser scale than full prohibition.
One step back from prohibition is rationing, in which citizens are given coupons to buy only prescribed amounts of liquor from the government. Rationing was mainly used in wartime, but many jurisdictions, including some in Canada, have used it in peacetime as a less restrictive alternative to prohibition. It has the advantage of satisfying casual consumers so they don't add demand to the black market, and it allows government to set a cap on the consumption of problem drinkers. But whatever demand lies above the rationing cap is left unsatisfied, and that causes a black market to form. Not surprisingly, every rationing system has also produced major black markets that, although smaller than those under prohibition, are still very harmful.
The next step in alcohol regulation allowed people to buy and use as much as they wanted, but required them to buy it from government retail outlets. At first, government stores were similar to sterile pharmacies: A customer filled out an order slip, handed it to a clerk who checked the customer's identification to make sure he was old enough to buy, then fetched the order from a back room. Ontario's current liquor stores -- with their products displayed on shelves and glamorously advertised -- are the liberalized descendants of this system.
Ontario has kept government's near-monopoly on alcohol retailing, but other jurisdictions have gone considerably further. Corner stores and gas stations selling beer, wine and spirits are common in most of the Western world. Many western European grocery stores carry a better selection of alcohol than some of Ontario's liquor stores.
With alcohol legalized, many other mechanisms of regulation and control are now available. Producers are inspected, their products are tested, and they are required to print vital information such as alcohol content on their labels. This is why legal alcohol almost never poisons consumers, unlike booze from the black market which does so with terrifying frequency. In many jurisdictions, advertising is restricted or even banned. To be licensed to serve alcohol, bars and restaurants are required to meet specific requirements, such as mandatory server training and restrictions on their hours of operations. Local zoning limits the number of establishments that can sell liquor and where they can be located. Most jurisdictions also forbid public consumption of alcohol, public drunkenness to the point of nuisance, and drinking and driving.