Do projects against ‘drug related nuisance’ undermine harm reduction

Frans H.R. Leenders, Boumanhuis Foundation, Centre for Addiction Care in Rotterdam, The Netherlands

This is a version of a paper presented at the Vlth International Conference on the Reduction of Drug Related Harm in Florence.

In the Netherlands, in the last 2 years discussion has started about how to combat public and individual nuisance resulting from drug use . This discussion was initiated by the media and, shortly after, during the parliamentary elections of 1994 adopted by political parties from the left as well as the rightwing. The then Dutch govemment proactively started up a comprehensive campaign against drug-related nuisance . This campaign has resulted in a variety of projects in nearly a1 the cities of the Netherlands. ‘Sleep In’ projects, various kinds of probation programmes, programmes to approach ‘First offenders’, motivation centres, rehabilitation and resocialisation programmes are examples of this new line of initiatives . The programmes were started as a result of public debate, more specifically public annoyance and frustration, highlighted by the media. As a consequence, these projects could be classified as the result of orthodox conservative mainstream thinking. On the other hand, quite a number of very interesting projects were developed, which, at least potentially address some of the problems and interests of drug users. This article summarises some of these projects and the experiences to date . Some implications for harm-reduction practice and philosophy will be addressed.

Over the past 2 years, a heated debate has developedin the Netherlands on the phenomenon of ‘nuisance’ as a consequence of the use of hard drugs (heroin, cocaine/crack, etc.). The definition of nuisance has tended to be a very broad one, covering very different forms of public and individual nuisance. Although a distinction between subjective nuisance as experienced by citizens and objectively demonstrable components was regularly introduced into the discussion, it has had little effect on the formulation or impact of relevant policy until now. Often, the most common situations were said to involve individuals who were the victims of robbery by users financing their habit in this way, deterioration of homes, streets or even whole neighbourhoods, but also simply the fact that groups of users congregated at certain locations. This last point  was referred to rather ominously and cynically as ‘visual nuisance’.

The nuisance debate formed an essential part of the discussion, which was then under way in the Netherlands, on the possibility of legalising drugs Police officials repeatedly pointed to the uncontrollable side effects of non-legalised drug use. They emphasised, on the one hand, how the international criminal scene really seemed to flourish within a sys-tem of drug prohibition. In addition, they stressed the degenerating and deteriorating living conditions of users, who were more or less forced to resort to crime in order to be able to feed their addiction .

A crucial point in the debate was the question of whether legalisation would contribute towards a fall in drug-related crime among users and a decrease in the related nuisance. Opinion was very divided on this. In the public debate, various spokespeople from the police and drug agencies initially drew a link between legalisation and a corresponding decrease in the nuisance. The proposition, quite plausible in itself if not actually proven, was put forward that expensive, and illegal, drugs could only be paid for through crime, with the good chance that users would ‘automatically’ end up in a degenerating lifestyle and that would be the case more or less for the whole using population.

Drug agencies then added a few nuances to the debate. A number of studies carried out in the major cities had revealed, for example, that between 15 and 20% of registered drug users accounted for 80% of the reported drug-related crime (Grapendaal et al., 1991; Klaassenetal.,1992). The idea, therefore, that a junkie was also by definition a major figure in criminal dealings, turned out to be largely a preconceived idea. Studies also revealed that about half of the people having serious problems with drugs already had a criminal background before becoming addicted. The relationship between nuisance and drug-related crime was therefore very difficult to interpret.

Finally, it was stressed from a number of studies that about two-thirds of users who found themselves in trouble had experienced serious problems in their upbringing and early development (Prins, 1995). Addiction, loosely defined as excessive, compulsive use, can therefore best be characterised as one of the many possible expressions of previously occurring complex problems in the course of a user’s life. Given this complex situation one cannot think that one simple solution to tackling nuisance is available.

In any case, public opinion is primarily affected by emotional, often irrational, processes rather than rational or logical ones. This applies even more to party political discussions, both left and right, particularly at the time of the general election. The media greedily pounced on both the legalisation debate and the nuisance discussion. It became a theme in the election battle of 1994 to see who could promise the most measures to put an end to drug related nuisance. Spokespeople from various groups tried to outdo one another in their proposals and solutions to the nuisance problem, sometimes also pleading in favour of the legalisation of hard drugs. It must be emphasised that both supporters and opponents were more or less equally represented here.

At the end of 1993, the government announced considerable cuts (up to 14%) in the budget for out-patient care for addicts. This budget cuts coincided with a decentralisation of the national to the community level. The call for projects to combat the nuisance were to some extent diametrically opposed to these cuts and were primarily formulated at the community level. One thing and another led, therefore, to the curious situation that in virtually the same week, parliament and the government, on the one hand, announced a budget cut of about Dfll6 000 000 for 1994 and subsequent years, whereas, on the other, the government announced, almost simultaneously, a new policy for combatting nuisance. The resources needed to finance this last operation were expected to amount to an annual sum in the region of Dfl30 000 000 in 1995 rising to about Dfl60 000 000 by 1997. This second amount is more or less half of what is spent on outpatient care for users every year ( including alcohol and gambling), or a quarter of the total annual budget for outpatient and hospital care, therefore representing an attractive bonus for non government organisations (NGOs) and other institutions.

So, the bodies involved in addiction care found themselves in a somewhat schizophrenic situation.

On the one hand, budget cuts had to be set off in organisational terms by creative project development and expansion of nuisance programmes. Moreover, people found themselves in a situation of having to develop these projects quickly on the basis of insights into combatting nuisance which, to put it mildly, offered no clear line of attack. During those days of 1994, there was certain sense of despair and doubting among many a manager involved in care for addicts, as well as workers in the field.

However, one is used to paradoxes in Dutch drugs policy and in the course of 1994andearly 1995 a large number of projects were conceived and put forward for financing. These projects involve both outpatient/outreaching care as well as care for those hospitalised. Many represent a very creative approach to users with a lifestyle in which crime and nuisance play an important part. There is not enough room here to discuss these projects in a way that would do them justice. However, I would like to explain a few general principles in a little more detail.

A large group of projects are of a (secondary or tertiary) preventive nature. These projects are targeting the risk-filled lifestyle of users in the area of drug-related crime and nuisance. The approach in these projects is characterised primarily by the creation of a basis for trust between user and helper, so that direct, pragmatic, but also persistent contact is established. The whole approach is geared towards decreasing wherever possible, and at least stabilising, the risks of nuisance behaviour within the lifestyle. Considering their preventive character, such projects are not always geared towards target groups that already exhibit very intensive nuisance behaviour, but those that could do so in time and for whom nuisance behaviour is probable in the long term.

One example concerns projects geared towards first offenders within the probation system. Also (perhaps outside the probation system) help for users from cultural minorities who are offered day and night care with a maintenance dose of methadone. This form of help has a strong ‘time out’ element, in which guided consideration can be given to follow-up programmes or motivation for this can be increased in a structured way. Structuring the day, conscience clearing and confrontation methods and counselling form important elements of the programme. A second group of projects relates more to the moment at which users actually come into con-tact with the police and judiciary as a result of nuisance behaviour.

In the Netherlands, users often have to be released after conviction, or in many cases even before, because there are inadequate resources or cells to enforce the sentence adequately. Naturally, this gives rise to the critical question of whether or not a conviction, followed by an acquittal, has a lot of effect on chronic users. This idea therefore also plays a role within these projects. The basic principle behind the projects is the ‘drive principle’. Users are presented with the choice between participation in a certain aid project or being put into police or judicial custody. On conviction, users are offered, so to speak, the alternative of putting energy into gaining insight into and reducing those aspects of their lifestyle which ‘cause nuisance’ instead of being put away.

Such an approach is only effective if this choice is a real one. If the programme offered is not chosen, then acquittal should follow. It is striking that a relatively large number of users still choose prison when convicted. Partly as a result of the (sometimes justified) expectation that they will soon be released as a result of a lack of cells, or else because they have no desire to work on their own problems. However, one of these programmes is chosen, and then various activities are offered, all based on a direct, pragmatic and consistent approach.

Within these projects, a great deal of attention is devoted to after-care, resocialisation and ‘social recovery’ activities and, wherever possible, schooling and training. The main problem within the whole aid sector in the Netherlands, as well as the rest of the world, is the lack of placements and placement opportunities where users can create a meaningful existence for drug users following their addiction. In a society with increasing unemployment, the position of addicts is a delicate one. But, as already pointed out, there is not enough room here to go into the concrete details of these projects.

I would, however, like to conclude by touching on a few sensitive ethical issues which are involved in the nuisance programmes as just outlined. Within the Dutch debate, these projects in the beginning appear to have little appeal for many users, or for many a social worker. A lot of them consider the underlying attitude of champions of this approach to be (neo-)conservative and in conflict with a liberalism processed and shaped over many years. Important values such as the acceptance of use and user seem to be undel discussion and some people fear that the coming of the nuisance programmes will usher in a conserv~tive ‘turn around’. Some even fear the possibility that the new ‘drive’ projects are really just the first step towarde pure ‘coercion’ projects. This last standpoint if alsc encountered, unashamedly, in the popular medic (tabloids) and undoubtedly represents a largelpro portion of the general popular attitude ‘Volk-sempfinden’, which is actually nothing new, also in the Netherlands.

Social workers often feel trapped between the two standpoints- the liberal and the (neo)conse rva tive - and try to find an ideological base by mean s oi which they can determine their own attitude towards the nuisance ptojects. On the way, they gradually start to realise that acceptance of use and users can be combined with an assertive rejection of the negative side effects, such as drug-related crime and chronic degeneration. This is even more so if one realises that crime and degeneration cannot be seen as matters of free choice in the lifestylt of the user. The provision of hard drugs would probably only bringlimited improvementhere if one analyses iton a macro level, although further research and experi-ence must be awaited. Provision of hard drugs and anti-nuisance programmes, however, can be com-plementary and may form the beads in the chain against further isolation for the user and a growing rejectionofthe society.

Drug related crime and nuisance behaviour are not aspects that can be ignored within social work, for example, because one is afraid of losing contact with the client. Such phenomena constitute a seri-ous problem for users. Therefore for social workers to ignore them means a failure to take the client seri-ously, to neglecthim orher, and often (subconscious-ly) this may evoke painful experiences related to the (emotional and physical) neglect of users in their childhood or adolescence.

Tolerance insucha positionmaybe an expression of the fear of having to accept unpleasant facts and say unpleasant things to users, which therefore implies, in essence, that the user with whom one is in contact is not taken completely seriously. In my opinion, this is a good angle from which one can cre- | ate a synthesis between the basic principles of a harm-reduction approach and projects set up to combat nuisance.

Frans Leenders, Boumanhuis Addiction Centre, Essenlaan 16, 3024NM, Rotterdam, TheNetherlands.

REFERENCES

Grapendaal M, Leuw E, Nelen JM ( 1991). De econornie van het drugsbesaan, crirninaliteit als expressie van levens Blen loopbaan. Arnhem, Gouda Quint.

KlaasenMPCM, ToetJ, VerveenJ (1992). Schatungherolne ver-slavinginde regio RotterdarrL Boumanhuis.

PrinsE ( 1995). Maturing out: an empirical study of personal hisHtories and processes in hard drug addiction. PhDthesis, University of Rotterdam.