By Ernest Drucker Director of the Drug Treatment Program and Professor of Epidemiology and Social Medicine

at Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx

On the European Front

On leave for a couple of months from the American drug wars, visiting the drug policy, research and treatment networks in Great Britain, France, The Netherlands and Germany. Often I was hot on the heels of delegations of the US Drug Enforcement Agency and Willam Bennett's crew who are waging an aggressive campaign to persuade NATO partners to shift their priorities from the war against communism to the war against drugs. And with some success too. Mitterrand in France and Kohl in West Germany have both made public statements supporting the US position. In Italy, Craxi has put together a tough drug law mandating strict penalties for possession for even minute quantities of drugs for personal use - a marked shift in Italian policy which heretofore exempted personal use from prosecution. But it is the British political leadership that has jumped into the US camp with the greatest zeal - despite the fact that this approach contradicts most of current British practice on drugs and AIDS, e.g., the ACMD reports and their wide

impact on transforming assumptions and practice in the UK drug field. Still Margaret Thatcher's great media nonevent - the World Ministerial Drug Summit, held in London in April (at exactly the same time as the First International Conference on the Reduction of Drug Related Harm in Liverpool) drew hundreds of state representatives who received slick press packets but little else. (See Mike Ashton's report on the Drug Summit in IJDP No. 6). It was, ultimately, set up as a show of support for America, whose leadership is otherwise definitely on the decline in Europe. Of course taking a lead from America in drug policy is a bit like taking a lead from the USSR in agriculture or industrial development. But the Drug Wars (at least at this lofty level) are fought in the land of hyperbole and rhetoric - reality seems to matter little - indeed that is their deeper emotional appeal and exactly what makes drugs such a serviceable political issue.

But "on the ground" in Europe, the specifics suggest a far more positive picture - especially in regard to the development of drug treatment services and their linkage to AIDS. What follows is a quick overview to be followed in future issues of this Journal with more in-depth reports on current policy and practice in several European countries.

Is Paris learning? ("One never encounters a North African face in any of the key social positions...")

After more than a decade of dithering about methadone and its application to the treatment of heroin addiction, the French seem to be moving towards the establishment of some limited access to methadone treatment. Driven by an appropriate concern about AIDS spread, (France has 50-100,000 heroin injectors, 20%-40% of them infected with HIV) and prodded by the human rights group, Médecins du Monde, the French may be on the verge of opening some methadone clinics. In Paris I met with Dr Claude Olievinstein, to discuss the past and future of French drug treatment (a full report on this interview will appear this winter in IJDP). Dr Olievinstein, a psychiatrist and director of France's largest and longest running drug treatment service at Marmatton Hospital in Paris, is the dean of French drug experts.

In France, psychiatrists have absolute control over methadone's use in drug treatment. Pharmacists can't even legally provide it to any but those psychiatrists authorized to dispense it Dr Olievinstein being one of the very few that are. He, like many French psychiatrists, is opposed at a gut level to the use of methadone believing that support of continued drug use (even methadone) is wrong. His best selling 1977 book is called 'There Are No Happy Drug Users'.

I am constantly amazed by the vehemence of anti-methadone feeling among a small but influential group of French psychiatrists and drug-free program workers. As the French can do so well, they construct a labyrinth of philosophical objectives that deal mainly in abstractions about methadone without data or personal experience to guide them. And they forestall action indefinitely. Therein lies the danger. But now, because of AIDS, Dr Olievinstein, and many others in France, have reconsidered their position. "I don't like methadone" he says "but the AIDS epidemic is a more serious threat than drugs, and methadone may help. It is the correct moral choice at this time".

Yet, even quite recently in France, this "moral" choice has been politically dangerous. Dr Leon Schwarzenberger, appointed Health Minister in 1989 by the Mitterrand government when it regained full control of the national government after two years of power sharing ("cohabitation") with Chirac's Conservatives, set out his program and mentioned methadone and drug law reform in his first public address. Three days later he was out of a job, replaced by an interim Health Minister (Dr. Evin) who, not surprisingly, has studiously avoided the drug issue.

There is some thaw now though driven by continued concern about AIDS - and several prominent health leaders are pushing again for methadone treatment. Among them are Dr Michelle Barzac, former Health Minister of the Republic and now Chirac's Health Commissioner for Paris and Dr Bernard Kouchner, founder of M.D.M., now Mitterrand's Minister for Humanitarian Action and, possibly, the next Health Minister. Sensing these political winds, Evin has indicated tacit approval of methadone programs on a pilot basis.

All of this has an important and somewhat sinister political spin related to the resurgent French Right. In addition to all the usual problems with drug policy there is, in France, a powerful association between the large North African immigrant community, drug traffic and, increasingly, heroin and cocaine use. One never encounters a North African face in any of the key social positions, no street level worker and certainly no culturally attuned drug treatment services directed toward immigrant drug use. So this trend remains invisible to health officials outside the criminal justice system. But there is great fear that this association may fuel a reaction by Jean-Marie Le Pen's anti-immigrant forces and the National Front, so the French tend to look the other way and delay decisive action. This matter is a political bombshell waiting to explode not only in France, but throughout much of Western Europe, whose large immigrant and "guest worker" population (many from Southern Europe and Africa) face new threats of displacement associated with the open borders of the new EEC and the likely incorporation of more Eastern European workers into their economy. So it is very easy to wed "drugs" to any other social or political conflict and inflame passions for violent solutions to deeply rooted problems. As Romanian "miners" beat on the heads of students in Bucharest this Spring, they told foreign reporters that "the students were all on drugs".

While both the Netherlands and Great Britain (especially the Merseyside region) have received much attention for their liberal and pragmatic drug treatment policies and AIDS prevention approaches, in both places there is another quiet revolution taking place: namely the reintegration of addiction treatment into routine medical practice and the prescribing of controlled drugs by general physicians. In Oxfordshire, England, Ailsa Duncan, working out of the Regional Health Authority's AIDS Program, has organized more than 30 General Practitioners into a network treating about 100 local drug users. Each GP has 4-5 patients as part of their panel. They prescribe maintenance drugs - mostly oral methadone - and, in some cases, injectables. The Regional Authority and Duncan's team provide supplemental social services for these patients to help meet their special needs and to offset some of the problems that often make local practitioners dread treating drug users. In the past in office-based practices. But the Oxfordshire program suggests that these problems may be more a function of the scarcity and antagonistic quality of existing drug treatment services than anything inherent in this particular corner of medical practice. At least that's the theory. With additional involvement of trained drug specialist it seems, after all, quite possible to maintain a few patients in a practice (Duncan's article in IJDP to follow soon).

Nowhere is the potential of this approach more evident than in the Netherlands - always the leader in the development of pragmatic and humane approaches to drug problems. Dr. Gerret van Senden and G.H.A. van Brussel of the Drugs Department, Municipal Health Service in Amsterdam, operate a very large network of 200 General Practitioners who treat over 900 patients - 40% of all those in methadone treatment in Amsterdam. This group of practitioners constitutes over half of all of Amsterdam's GP's - a landmark in the conception and practice of drug treatment. As in Great Britain, most of these clinicians see 4-5 patients. Some doctors, who are especially interested, have larger caseloads but this is generally discouraged to avoid a concentration of prescribing power in a few general doctors. Also, because of the ready availability of both lower and higher threshold drug treatment services in Amsterdam, i.e., the two methadone buses with almost 1,000 patients and the "full-service" clinics with 200-300 patients. And, of course, these services are well integrated with HIV-related care for the 90-100 HIV symptomatic patients that have been seen so far in Amsterdam. (A fuller report on this program is in preparation in Amsterdam .)

These considerations virtually assure increased use of drugs in the population of East Germany - with the particular patterns of use evident today in West Germany as the best predictor for what will happen. Faced with this likely development, what drug policy should be adopted in the new Germany? What would be the goals and objectives of such a policy? How would it be implemented? And what outcomes might be monitored to evaluate its effectiveness?

Any policy addressing the likely development of IV drug use and the risk of AIDS that it carries with it should be based on an objective assessment of current drug policies in other West European nations - especially their effectiveness (or lack thereof) for dealing with the spread of AIDS in this important group. And, in the case of a united Germany, such policies should not automatically consist of a simple extension of current practices and policies of West Germany to East Germany - although this is the plan for all criminal law.

More crucial is the character of West Germany's attitude toward drug addiction. German law is quite literal and includes compulsory prosecution of drug users. As is common in societies with repressive prohibitionist policies, treatment services are minimal and stunted in their form. Despite having a core population of heroin users, methadone has been generally scorned in West Germany. Indeed it is illegal for doctors to maintain patients on methadone and several have been imprisoned for doing so. AIDS has brought some loosening of this approach, but only in a few cities and only very recently and the German medical community is still deadset against drug maintenance approaches.

But now the dubious efficacy of West German drug policies and practices to date (given the severity and prevalence of drug problems in West Germany), and the self-evident problem faced by East Germany suggest the need for a fundamental reassessment.

First, East Germany is starting from a base of no hard drug use, no IV use, and none of the identifiable social or public health consequence associated with IV drug use in the rest of Europe especially AIDS. Second, there is no precedent for the rapid merger of one drug-using Western society with another in which no such use occurs (although alcohol and the American Indians provide an ominous precedent). Further, there are no precedents for preventing the extension of general consumer patterns of Western society to new populations - indeed all the pressure is to mimic them in every aspect. Finally, there is no modern instance where any nation's drug policy will be so decisively tested in application as will be the case in Germany (with the possible disastrous example of alcohol prohibition in the U.S.). Whatever is done or not done the results will be readily apparent in short order.

A rational drug policy for Germany should be based on its likely public health consequences and its efficacy should be measured by the achievement of (or failure to achieve) some specified public health objectives -minimisation of health problems especially drug related deaths and AIDS, and the limitation of adverse social consequences-for the drug users, their families and for the wider society. The-total elimination (or absolute prevention) of drug use per se is not a feasible policy goal and should not determine specific objective strategies or tactics. As the Netherlands has demonstrated, even quite substantial levels of drug use are not inconsistent with the public health objectives outlined above.

Still, the rapid introduction of hard drugs and the development of a pattern of drug use in a previously non-drug using population within Europe carries certain hazards. Many of these stem from the fact that no experienced drug using population exists, e.g., poor judgement based on the ignorance of new users, no role models for "safe" or "controlled" drug use, and, (of special importance) no trained or experienced cadre of drug abuse-prevention or treatment personnel. But, nonetheless, it should be possible to limit the severity of all the adverse consequences outlined above and to prevent the development of an HIV epidemic among drug users, their sexual partners and infants in East Germany.

All of Germany should adopt the harm minimisation strategy gaining increasing popularity in other European countries (e.g., Netherlands, Great Britain, Switzerland), including:

• early identification of problem users and a policy where police and courts "steer" users to treatment or counselling, rather than incarcerating them

• training of general doctors to see addicts in their practices

• drug training for personnel of health clinics, hospitals and emergency rooms

• development of a range of treatment options including low threshold services with easy access and no barriers

• a full spectrum of clinical services: methadone maintenance, detoxification, and drug free residential care

• the use of drug problems to identify and assist those families most damaged by the social transformations already underway.

It is possible that this inevitable increase in drug use in East Germany is a one-time phenomenon (per Heroin in the 1 970's in the rest of Europe) and will stabilize after the first shock of integration with the West has passed. The question is how to get through this phase with a minimum of damage to drug users and to the rest of the society? (This will be the subject of a forthcoming IJDP paper with Henner Hess of Frankfurt).

Back now in New York City - just over a brief love-fest sparked by Nelson Mandela's visit but, in actuality, mired in an increasingly nasty and racially polarized drug debate. By comparison Europe seems extraordinarily in control of its destiny. Perhaps it's the absence of a large multi-generational underclass, festering ghettos and cruelly indifferent national government. But Europe is on the threshold of a great period in its history and should be able to get past the drug issue (and AIDS) if some of the positive trends and fresh opportunities I've noted are grasped and developed.