A HARM-REDUCTION EDUCATIONAL STRATEGY TOWARDS ECSTASY (MDMA).

Erik Fromberg (Dutch Institute for Alcohol and Drugs, Utrecht, the Netherlands), paper presented at the 1^st International Conference on the Reduction of Drug-related Harm, Liverpool, *-maart 1990

Introduction.

The use of XTC is spreading in the Netherlands since 1985. First supplies came from the U.S.A., but production of the drug in the Netherlands is presumed to have started in 1987.

In general, the first producers sold their product only to friends and relations, so the nature of these relationships more ore less guaranteed the quality of their product. The chain producer-consumer was short, the production local.

In 1988 XTC was brought under the Dutch Narcotic Law on list I as are heroin, cocaine etc. As a result many small producers stopped their production. However, at the same time the popularity of XTC increased logarithmically. This discrepancy between supply and demand resulted in the provision of more dangerous "impostors", such as LSD, MDA, but particularly amphetamine.

The increasing popularity of this "new" drug and the wide-spread presence of impostor-drugs necessitated an educational strategy.

Goals and methods.

It is selfevident that the essence of our advice can be formulated as: reduction of the harmful effects of the druguse which is in accordance with the central purport of the dutch drugpolicy. Harm reduction is a preventive goal. In this respect we will refer to the three prevention levels of Caplan. When we, be it reluctantly, acknowledge that the primary aim of the narcotic laws is prevention, we also have to acknowledge that these laws have failed completely: drugs are and will be used, notwithstanding laws. In the case of XTC: since it has been placed under the narcotic law

the demand for it has increased enormously. One might state that the law has resulted in a reduction of the availability of the drug, however, this is not the whole story. The demand is met with the supply of more dangerous drugs. The crux of the problem lies in the fact that narcotic laws take away the responsability for individual behaviour from the individual and places it in the hands of the government. The availability of all sorts of illegal drugs makes clear that governments are not able to bear this responsability.

In our educational strategy we emphasize the individual’s responsability, in a way which can best be compared with "safe use" AIDS-campaigns. This implies that we neither want to moralize, nor assume a missionary point of view. Starting point is the supposition that everybody is capable to act with responsability with regard to himself, as long as no impediments exist such as lack of information etc. The existence of a small number of innate irresponsible people has never been an argument to prohibit car-driving or other potentially dangerous activities.

In the Dutch drugpolicy the spreading of factual information has always been an important part of our prevention strategies. In contrast to some other countries where information on drugs and their effects is often considered propaganda and punished as such, people in Holland can freely discuss and write about drugs. One who acknowledges that drugs as such are neither good nor bad and that drugs of which the use is legally considered as entailing "unacceptable" risks under certain circumstances can even have more positive than negative effects, has never been prosecuted because of alleged drug-propaganda. In the Dutch drugpolicy the relativity of "unacceptable" is taken into account.

As a result the dutch public is relatively well-informed about drugs compared with the public abroad. Thus, a second aspect of our educational strategy is that we make use of and rely on already existing knowledge of the (candidate)user.

However, information as such is not sufficient. Education is not the same as information. Education implies that the information is being placed in a normative frame of reference. Occasionally establishing norms is confused with moralizing. In such cases it is stated that the use of a drug is bad, with an implicit argumentation on ethical considerations. It has to be stated emphatically that ethical considerations have their own value, but are subjective.

In short the goal of our education is harm reduction by giving factual information offered in a normative frame, without moralizing, taking into account the responsability of the individual and his existing knowledge on drugs pretext.

The targetgroup.

The targetgroup for our eduction are those who use XTC, because there exists a lack of information among them , furthermore we also expect to reach also those who are considering whether or not to use XTC.

This expectation is based on considerations regarding:

The properties of XTC.

The most important property in this respect is the fact that XTC is characterized as a "drug for social occasions". Next in importance is the fact that XTC has a low "entering threshold". This threshold is determined by pharmacological and sociological factors.

Pharmacological factors are:

• the soft action, when compared with the real hallucinogens like LSD;
• the "practical" duration of action, not as short as cocaine, not as long as LSD;
• the drug is relatively easy to combine with other drugs;
• the drug is easily dosed, also with regard to its differential effects;
• the user can function socially;
• the drug is not addictive.

Relevant sociological factors are:

• the reinforcement of feelings of togetherness;
• the "light"-trend; XTC is being preferred above "hard" drugs as LSD, and more important above speed or cocaine. The old drugs are being rejected or being used more pragmatically;
• the "varia"-trend in consumption patterns of legal as well as illegal drugs;
• the revival of the "Sixties";
• the feel of personal stardom: with your head in the clouds, but with your feet solid on the ground.

This low entering threshold is the main cause of the quickly growing popularity of this drug, but also causes a remarkable openness about the use of it.

The properties of the drug and the form in which it is supplied also entails on consumer-level there are no means to check whether the product offered indeed contains the drug, something which is possible with a drug like Cannabis.

The structure of the market.

New drugs are always introduced by a small group of people who have a relationship that had already been established. From this group which usually belongs to the toplayer of the community the use spreads to the bottom. When this happens with an addictive drug the relationship between users becomes more obscure as it spreads to the bottom. The spread of cocaine use is a good example.

The same process occurs with non-addictive drugs like Cannabis and LSD, with the difference that the intrinsic criminal structure, which is so characteristic for the heroin and amphetamine trade, never developed, in spite of the illegality of these drugs. The differences between the Cannabis-market and the LSD-market can be explained by the difference in entering thresholds, being low in Cannabis and high in LSD. Due to the low threshold of Cannabis this drug is attractive to many, while the high threshold of LSD limits its use to a small group. The cohesion within this group ensured that as soon as sufficient information on LSD was present within this group its use gave no more problems. In this sense the selfcorrecting capacity of this market was and is large.

Up till now the market structure of XTC can best be compared with that of LSD and Cannabis. The structure is characterized by:

• a quick spread among a relatively large number of people;
• the selfcorrecting capacity of the market is in principle strong enough to limit possible dangers of the use of the drug;
• there is only a weak coupling to specific groupcharacteristics: XTC use persists, while for example the acidhouse musical trend passed its zenith and, while the use spreads to the bottom it does not diminish in the top group.

The local character of the market.

XTC is not a product that is traded by way of a world-wide network as is the case with cannabis and heroin. The production doesnot require a high degree of technical expertise nor a large financial investment. It is a drug that can be produced relatively cheaply in a small laboratory from base materials that can be obtained legally. The entering threshold is not only low for the consumer but also for the producer. This resulted in a number of producers supplying a small local market. The chain between producer and consumer is short.

Within the local group of consumers relations exist that go further than the use of the drug. As a result the use is strongly determined by friendship-relations, in contrast with heroin where commercial interests play a very important role, not only on the level of international smuggling but as well on the consumer level: trade to finance one’s own use.

This means in the case of XTC information about the drug is spread in the bying and selling process.

Although the popularity of XTC has a number of aspects that can be compared with the emergence of Cannabis and LSD in the Sixties and early Seventies, there exist remarkable differences too. The most important one is the "pulverization of the scene". While in the Sixties the binding forces between the scenes were stronger than the dividing forces, now the reversal is true: the youth culture is pulverized. In the Sixties the hippy subculture was characterized by a strong feeling of togetherness, the binding factor being a lifestyle, a valuesystem, in which the use of Cannabis was not only a binding factor, but a symbol of those binding values. AD 1990 we see a multitude of different groups, having few mutual affinities, and which do not consider the use of XTC as a binding factor. Acid-house and jazz-pop fans, older and neo-hippies, New Age-groups, motorclubs and yuppies: each group has its own goals, values and life styles. These groups seem to have nothing in common, however, they do have some common characteristics:

• musical interest,
• outgoing,
• looking out for something special,
• acceptation of druguse i.c. of cannabis and being relatively well informed about drugs,
• rejecting the pragmatization, the no-nonsense of the Eighties, contiguous with the revival of the Sixties,
• a rather strong collectivity within the group, not being drug-oriented,
• strong indifference to the government and politics.

To illustrate this last point: most XTC-users we talked to did not even know the drug had been brought under the narcotics law.

Goal of the education.

The goal of the education is on the level of the primary prevention:

• emphasizing the considerable chance that what one uses may not be XTC but a more dangerous drug, because what is offered as XTC often is adulterated or contains other drugs (i.c. amphetamine or LSD);
• giving the aspirant consumer more tools for decision-making about whether or not to use the drug;
• prevention of over-identification by avoiding scene-words;

With regard to secondary prevention:

• the building of knowledge and experience among user groups;
• reinforce the selfcorrecting capacity of usergroups and the market. Even on the black market standardization is possible as we see with LSD.

With regard to tertiairy prevention:

• stimulation of self help, teaching people what to do when they are confronted with problems in others.

The information and the spread of it.

The problem is how to reach these different groups, especially while the differences between the groups are so large that media specially directed at these groups do not exist in contrast to the underground press in the Sixties.

So two approaches are possible:

high key: a broad campaign directed at the general public reaching everybody, but having the danger that such a campaing evokes interest in the drug that did not exist beforehand.

low key: spreading by way of many different channels, directed to all special groups.

We handled both approaches in the following way:

High key: a publicity campaign around a conference on XTC in which not the drug XTC was central but the "market pollution", the general risk of all black market products not being what they are supposed to be, due to lack of control of the products. This is information that is relevant to all people, consumers as well as potential consumers of nearly all illegal drugs and is supposed to have a demand reduction effect.

Low key: aimed at the different groups of (potential) users with specific information on XTC contiguous on the high key approach. The chosen media were a folder and, as an experiment, a public service-telephone number.

The most important consideration was that it was necessary to give a lot of factual information since, the media-hype on XTC notwithstanding, the main facts on XTC were not available. Both our folder and the telephone message try to give these facts and can be used as the basis for further information.

We had to fulfill two requirements:

The editing of the folder.

As mentioned before, we have chosen for a very factual approach due to the heterogeneity of the targetgroup. We have chosen the style of the package insert as enclosed with medical drugs. With regard to the contents we chose for the next order:

• the actions of the drug, by which we hope to reduce the influence of malafide sellers
• the market pollution: one never knows what one is buying. This makes an appeal to the responsability of the potential user and connects to the high key campaign.
• the risks of the use, if one has proper XTC: acute poisoning and long term effects.
• combinations with other drugs. We answered the question whether specific combinations should be discussed by only mentioning them in general terms. Combinations that are used only in small circles (as XTC with poppers) we did not mention, while we considered the risk involved in drawing attention to such combinations as heavier than the lack of information. We consider making smaller leaflets on such topics to be spread among relevant circles.
• contra-indications.

The question whether or not to give an indication for a price was answered with a clear no.

The public service phone number.

We prepared a tape recording with the same information for use on a public service telephone. The number was advertised in several national newspapers and in the first month over 400 people dialled the number, for which they are charged 50 cents per minute by way of their telephone account. We consider this a success and are discussing how to extend the use of this medium in the future.

Final remarks.

It is clear that this information is just one part of a prevention strategy. The prosecution policy is also playing an important role. Since the local market structure implies a selfcorrecting capacity which is absent in large scale production and selling. Therefore prosecution should be directed at large scale operations and leave local production and comsumption more or less unhampered. We consider a balanced dismissal policy an important matter, which mainly serves the harm reduction policy by barring adulterated drugs and limiting the use to local markets.

The judicial powers as well as the police have so far followed such a subtle policy.

We have since noticed a clear reduction of impostor drugs on the XTC market and consider this a first sucsess for our policy.