Drug Abuse

THE INTERNATIONAL JOURNAL OF DRUG POLICY, VOL 7, NO 3,1996

NO TO LEGALISATION, YES TO CONTROLLED

SUPPLY?*

This article was previously published in Dutch in: T Blom, H. de Doelder, D.J. Hessing (1996). Naar een con, sistent drugsbeleid, Gouda Quint, Deventer.

H.F.L. Garretsen',', R. Geurs', V.M. Hendriks' and F. Sturmans',
'Addiction Research Institute Rotterdam IV0), 'Rotterdam Municipal
Health Service, The Netherlands

This paper asks the question: why controlled supply; why not, for example, free supply (legalisation)? A brief review of a few developments in Dutch drugs policy is provided. The problems associated with the illegality of hard drugs are then looked at: the international illegal trade, acquisitive crime and various health problems. The conclusion is that there are major problems but that the same thing is true of legalisation. The drawbacks of legalisation are also discussed and a comparison is made with alcohol. Finally, a number of thoughts concerning controlled supply are reviewed: goals and problems for which solutions are required questions and problems relating to client characteristics, programme characteristics and research characteris tics.



INTRODUCTION

The controlled supply of hard drugs is under discussion. But why controlled supply? Why not, for example, free supply? In particular, the discussion concerning the legalisation of drugs continues to attract attention. Legalisation implies more than controlled supply.'Legalisation'in this article is used to refer to a situation similar to the current Dutch situation relating to alcohol, where consumers can obtain the substance without restrictions, without a prescription and/or medical indication.

Controlled supply certainly does not go this far. In the case of controlled supply, substances are supplied to a particular category of users subject to a number of conditions. Current discussions generally assume supply to a limited group of users after prescription by a doctor. The substance is then prescribed as part of medical treatment. Unlike the situation with free supply, it is therefore an activity that is oriented towards individuals.

The legalisation discussion relates to a variety of substances, both'hard drugs' and 'soft drugs'. Dutch law makes a distinction between'drugs with unacceptable health risks' (hard drugs) and cannabis products, which are believed to involve fewer risks (soft drugs). This article is confined to the legalisation of hard drugs. In part, of course, the same arguments are to be found in the discussion of the legalisation of soft drugs.

SOME DEVELOPMENTS IN DUTCH DRUGS POLICY

Alcohol, coffee and tobacco are substances that are now legal in the Netherlands and that are therefore freely available in many places and commonly used. Many of us think this is a normal situation. Opiates and other substances are now illegal and therefore only available on the black market. By comparison, they are used little. Many people also believe this to be a normal situation.

Nevertheless, this state of affairs should be kept in perspective. How, for example, would one describe the Dutch situation a few centuries ago? One writer states that: 'little alcohol is drunk, there is strong opposition to the drinking of coffee, tobacco smoking is rare. There is an opium trade with J ava'(Garre tsen, 1995a). Variations in the legal status and the use of substances can be found not just between societies but also within societies in the course of time. Throughout history, the same substances have been legal and widely consumed at one time, and prohibited and little used at other times (Garretsen, 1993, 1995a). It is clear, for example, that the effect ofa substance does not play a central role in the questionof whether or not it is legal: potentially dangerous substances such as alcohol and tobacco often have a legal status and, by the same token, stimulants that involve fewer risks are prohibited. The same situation viould seem to prevail in the Netherlands at present.

In addition to legal, freely available substances (alcohol, tobacco) and substances that are not legal but which are tolerated more (soft drugs), Dutch law distinguishes a third category of substances, hard drugs. The supply of this category is not tolerated on other than strictly medical grounds and is prohibited. The use of hard drugs is not a crime ~s such, users tend to be seen more as patients than as criminals. However, trading in these substances is illegal. One of the main corner-stones of Dutch drugs policy is the separation of the soft and hard drugs markets. In addition, there are a lot of initiatives in the field of 'harm reduction'.

It can be stated that public health has been the main focus of Dutch policy in recent decades and that, in this light, the policy has been successful. Compared with other countries, the number of drug users with problems, such as infection with the HIV virus, is relatively small, as is the number of deaths. However, the drugs problem is now being perceived less as a threat to public health and more as a source of nuisance. The tone of the public debate has changed emphatically! The perceived nuisance has started to dominate discussions and tolerance in society as a whole is decreasing (Garretsen, 1995b).

The legalisation discussion also plays a clear role in this public debate. The idea is that if the production and sales of drugs are decriminalised, prices will drop sharply so that, on the one hand, criminal organisations will lose their main source of income and, on the other hand, addicts will no longer perpetrate crimes againstproperty in orderto obtain money for drugs. This last effect would in turn result in a significant reduction in the burdens imposed on the police, the judiciary and the prison system.

At the end of 1995, the government published a policy document on Dutch drugs policy (Het Nederlands Drugsbeleid, Second Chamber, Dutch Parliament Assembly 1995). The government's position in this document was that it did not want any legalisation at all and certainly not ofhard drugs. The principal reasons given were the risks that would be run by more socially-vulnerable young people and international obligations. In what follows here, we will be discussing the legalisation discussion in greater detail and whether this government position merits our support.

ADVANTAGES AND DISADVANTAGES OF THE LEGALISATION OF HARD DRUGS

Why the desire for legalisation? This desire can be based on a'fairness'argument:'why is alcohol legally available and heroin not?' But there are other considerations because the current situation does indeed result in considerable problems.

First of all, there are the problems as described in the policy document: because the substances cannot be produced or sold legally, availability is limited. The resulting increase in prices, in rum, leads to an illegal international trade from which criminal organisations earn large amounts of money, as well as to acquisitive crime among a number of users. The international illegal trade is flourishing. There is no question that major financial interests are at stake. Some economics depend on the cultivation, production and trade in drugs (Engelsman and Wever, 1986). In this regard, the policy document notes that the activities and economic power of the international criminal organisations are increasing to such an extent that they constitute a threat to our democratic system. This, in rum, leads to responses from the government such as the fight against the illegal trade. However, these can also have an escalating effect. Drug seizures can result in the maintenance of high prices. And action directed against, for example, the laundering of drugs money can result in a more professional approach and to even better organised crime syndicates (Schmid, 1992). Criminal organisations try to corrupt the police, the judiciary and banks. It can be concluded that the vicious circle of the drugs trade involves everincreasing social costs (Het Nederlands Drugsbeleid, Second Chamber, Dutch Parl iament Assembly 1995).

In addition, illegality results in acquisitive crime, in crimes against property committed by a number of users in order to obtain money to purchase drugs. An illustration: an'average user'in Rotterdam can easily spend N LG 5 0 on drugs a day for more than 10 years. By that time, users of this kind will have spent approx imately NLG 200 000 on drugs. If this amount vias obtained solely by means of stolen goods, the value of those goods would be more than NLG 800 000. T his drugs-related crime, as well as the situation with regard to the actual sales of drugs, results in a lot of nuisance, usually concentrated in a number of city areas. The extent of drugs-related crime also leads to considerable burdens on the police, the judiciary 2nd the prison system.

However, the current situation erktates more problems than those described above. Selfregulation-controlled use by users-is influenced by, among other things, the rituals and social laws in the user sub-culture and by the availability of ihe drugs: freely available substances can make more controlled use possible (Grund, 1993). Furthermore, illegality has implications for users' daily lives and the way they are structured. At present, users need a lot of time for drugs-related activities. If the substances were to become freely available, they would have more time left for other activities (suchaswork) and their social networks will come to include more contacts that are not drugs-related. A more stable pattern of daily activities with positive consequences for health will become possible.

Another public health problem results from the fact that there is no monitoring of the quality of the drugs that are sold. With alcohol, for example, consumers know exactly what they are buying. Both in terms of the type of drink and in terms of the percentage volume of pure alcohol, there are no surprises. Everything is stated precisely on the bottle. In the case of illegal drugs, consumers do not know all this. There is no quality control and there is no monitoring by a Commodity Inspectorate. It does not need stressing that this can involve health risks as a result of impurities, whichare added to the drugs, andthe genuine risk of inadvertent overdose. The latter is particularly true of foreigners who are used to poorer drugs quality.

In addition to the quality of the drugs, the quality of the devices used is also important: infections resulting from the unhygienic use of syringes are a genuine health problem. The principal causes of death among drug users are deliberate or inadvertent overdoses and complications that result from how the drugs are taken, mparticular injecting (theriskof AIDS, for example).

It can be concluded that the current situation involves many disadvantages. Examples are the international illegal trade and acquisitive crime. These things impose heavy burdens on the police, the judiciary and the prison system. Other examples are the irregular patterns of use that have adverse effects onhealth, as well as the lack of quality control leading to, among other things, overdoses. These drawbacks fuel the legalisation issue. Increasingly, the question that has been raised in recent years is whether legalisation is the solution that will deal with all the problems at a stroke. The question is also being heard in possibly unexpected circles such as the police and the judiciary (De Kort, 1995). However, legalisation, the completely unrestricted supply of harddrugs, also involves major problems!

First of all, the anticipated effects of free supply on the reduction of crime need to be put into perspective. Acquisitive crime will only be reduced. Only a proportion of users turned to crime in order to obtain drugs; some were already involved in criminal activities before they started to use drugs (Bieleman et al., 1989; Grapendaal et al., 1991). In all probability, then, not every criminal user will renounce crime. (It is nevertheless possible that drugs use leads to a longer maintenance of criminal behaviour in some cases.) Inaddition, there would have tobe free supply of all the hard drugs that are in demand. If, for example, only heroin was to become freely available, then acquisitive crime would persist as a by-product of other illegal hard drugs such as cocaine.

Second, there is the question of international obligations. Regardless of the question of the extent to which the Netherlands has obligations based on international treaties ,and conventions, a go-it alone policywould undoubtedly harm international  relations. Legalisation will result in extremely  negative reactions from countries who have declared a 'war on drugs', but probably also from countries that follow less repressive policies.

Another obvious problem is the anticipated additional increase in drugs tourism (a problem that is already considerable). If hard drugs go on sale here legally-and therefore probably at relatively low prices-this will result in a large influx of purchasers from neighbouring countries. And not only from neighbouring countries. Would the Netherlands become the open drugs scene inEurope? Possible measures torestrictdrugs tourism, suchas'secure purchaser passes'for Dutch consumers alone, would not at present appear to be water-t ight, sound solutions. In addition, the image that is projected is important: the news that drugs can be purchased legally would receive niore prominence abroad than reports about how the drugs are supplied and possible restrictive measures.

A less widely-discussed problem enmerges when the comparison with alcohol is made. Researchers into alcohol generally subscribe to the premise that an increased availability of alcohol results in hi:iher levels of consumption, which in turn results in rriore alcohol-related problems (Bruun et at., 197 5; Edwards, 1994). This might also prove to be the case for, currently illegal, hard drugs. It is conceivable that legalisation and free supply will result in greater availability, more use and, in turn, more hard drugsrelated problems.

Problems related to the illegal nature of the substances will be reduced as a result of legalisation. However, other problems may be aggravated, such as problems at work or in traffic. The nature of the problems will change. In this respect, one can make a comparison with the prohibition in the United States that started in 1916. At that time, there was an increase in the problems, such as acquisitive crime and illegal trade-related to the fact that alcohol was not allowed to be served. However, there was a substantial decrease in health problems such as the number of deaths from cirrhosis of the liver (Garretsen, 1993; Goldstein and Kalant, 1990). In short, the situation at the time with respect to alcohol was to some extent comparable to the current situation with respect to hard drugs. And perhaps it does not need to be pointed out that the number of people with alcoholrelated problems is, in absolute terms, much higher than the number of people with hard drugs-related problems. Nevertheless, alcohol consumption is perceived as being a much less serious social problem.

In short, legalisation also has many drawbacks. We believe that the government's decision to reject legalization at this time is a realistic one. In conclusion, no free supply. But to what extent is controlled supply desirable in one form or another?

SOME THOUGHTS WITH REGARD TO CONTROLLED SUPPLY

For the time being, there will be no question of legalisation. But what are the options for controlled supply to a limited group of users? Possibilities here vary from more large-scale ones, such as state-regulated supply for certain categories of users, to very small-scale options. The second possibility is now on the agenda in the Netherlands. More specifically, the prescriptionof herointo severe addicts on medical indication is now being considered. The Health Council of the Netherlands (Health Council, 1995) recently published an advisory report onthis subject. Thegovernment is considering making a similar trial ofamedical kind possible (Second Chamber, Dutch Parliament Assembly, 1995). Is this a desirable development?

The Health Council's advisory report distinguishes between five possible goals of pharmacological intervention in heroin addicts. These are (Gezondheidraad, 1995):

1. the treatment of acute intoxication symptoms;

2. abstinence;

3. the prevention of relapse into the use of heroin or other substances (by means of substitution in the form of quite high maintenance doses of methadone);

4. stabilisation, harm reduction (by means of a relatively low maintenance dose of methadone);

5. palliation, suppression or reduction of symptoms and alleviation of suffering.

Until now, methadone has been used widely. No extensive scientific evaluation of methadone programmes has, however, taken place. Furthermore, the Health Council concludes that there is a wide range of treatment available, which is adequate for a large number of addicts, but that there is a need for additional treatment modalities for a number of addicts. In particular, treatment with heroin is currently under discussion. In the Netherlands, there has been no research into the results of such treatment. Evaluation abroad is not adequate either (Gezondheidraad, 1995, Sturmans, 1995). It would therefore seem to be useful to study the effectiveness and drawbacks of this treatment. The Health Council has recommended a trial for'severe heroin addicts who respond either insufficiently or not at all to the pharmacological interventions currently avaitab V. The aim would be to 'determine whether these addicts can be stabilized by prescribing heroin, whether their bio-psycho-sociat well-being can be enhanced, whether additional use of substances can be reduced and whether they canpossibly be enccuraged to bring an end to their addiction' (Gezondhe idraad, 1995); there is a general consensus that patliative treatment for seriously ill patiqnts with a chronic addiction and a short life expectancy should be made easier in practice.

Preparations are being made for a trial. It is clear that there will be many problems and that many questions wilt need answers before a trial can actuall~ get started (Hendriks et al., 1995; Sturmans, 199 5).

Hendriks et al. (1995) provide an extensive survey of questions and problems that play a part in controlled trials in which the effects of prescribed heroin are compared to those of oral methadone. These questions all require answers before any trials can be started. Hendriks et al. classify the problems in three groups: client characteristics, programme characteristics and research characteristics.

A variety of client characteristics can have an influence on the effect of treatment with heroin. For example, there is a lack of clarity about the rote of additional cocaine use and about the use of methadone in the trial group. In addition, a role is also played by the question of what effect the increase in leisure time wilt have (more use?; an increase in the demand for care?). Programme characteristics under discussion are, for example, the way in \vhich heroin is supplied and the rules concerning supply procedures. Where, how and how often is what given to who? Research characteristics that play a role are, for example, the design Crandomised controlled trial'or'Zelen design'?), including expected compliance among the test subjects, anticipated drop-out rate and the position of informed consent. Other questions relate, for example, to the duration of the trial and the post-trial procedures. In conclusion, it can be stated that the idea of initiating a controlled trial would seem to be opportune and achievable in the Netherlands but that there are many points for discussion with regard to the design and implementation. Prior research is therefore required. Another important question is what the government's response will be to possible positive results of a trial. Would this then mean an extension of the initiatives and possibilities for the prescription of heroin?

HFL Garretesen, Addiction Research Institute, Rotterdam (IVO), Essenlaart 4, 3062 NM Rotterdam, The Netherlands

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