Sweden and the
drugs problem-seen through Dutch eyes
The
report of a fact finding mission on 14 and 15 February 1996
Alderman
Mrs G.K.T. Van der Giessen ... chair - Amsterdam City Social
Welfare & Health Care
Dr G.H.A. van Brussel ... senior medical officer, drugs unit
of the Amsterdam City Health Service
Amsterdam February 1996
http://www.ukcia.org/research/sweden.htm
1. Introduction
On 14 and 15
February a delegation from Amsterdam made a fact finding visit
to Stockholm at the invitation of the city council. The
delegation comprised Alderman Mrs Jikkie van der Giessen (who
holds the social welfare and healthcare portfolio in the
Amsterdam city council), city spokesperson, Mr Richard Lancée,
and Dr G.H.A. van Brussel, head of the city medical service's
drugs department. The purpose of the visit was to start a
constructive dialogue on the two cities' somewhat divergent
policies on drugs. The fact finding aspect was designed to
ensure the mutual familiarisation and respect which are
prerequisites for a meaningful dialogue.
The central
question was: what is the nature and extent of the drugs
problem in Sweden, what policy is being followed and to what
effect.
With this is mind
the Amsterdam delegation studied extensive background material
provided by the Netherlands Health Ministry and the Amsterdam
City Health Department. During this short visit, the
delegation exchanged views with many, diverse players
including Stockholm councillors, police officers from the
drugs squad, and healthcare workers involved in enforced
treatment of drugs users and in a closed facility for young
users. Last but not least, the Netherlands Embassy was a
generous source of hospitality and insights.
This report deals
with the following aspects:
Sweden and the Netherlands: selected healthcare figures
Population research findings on consumption of psychotropic
substances in Sweden
an overview of literature on the drugs problem and evaluation
data available for Sweden
Brief reflections
Verbal information
has been used in the description of many topics. The written
sources comprise excellent publications by Sweden's National
Institute of Public Health, the Council for information on
Alcohol and Other Drugs, and the Health and Social Affairs
ministry. Annex
1 provides an overview of the literature
consulted.
2. Sweden, general
Sweden is a large
but thinly populated country, with 9 million inhabitants. Its
rich history goes back to the times of the Vikings whose
expansive spirit carries on into the early middle ages. There
were regular wars of territorial gain in and around the
Baltic, right up to the early 19th century. Norway, Denmark,
Schleswig-Holstein, Northern Poland, Finland and parts of
Russia all came under Swedish sovereignty at one time or
another. However, the country succeeded in staying neutral in
both world wars.
Sweden today is a
constitutional monarchy with a long tradition of democratic
government and a comprehensive welfare network. The country is
a great respecter and upholder in international human rights.
There are many similarities with the Netherlands. Unemployment
and the number of immigrants have both risen recently. Ethnic
minorities represent some 20% of Stockholm's population -
often they are refugees from Turkey (Kurds), Iran and Iraq.
Entry to the European Union two years ago has impacted on the
country's relative isolation. One striking example is the
threat to the state monopoly on sale of alcoholic beverages -
the Bolaget system.
3. Sweden and the
Netherlands, selected health statistics
A swift comparison
of WHO yearbook statistics for the Netherlands and Sweden
shows major similarities. Average life expectancy, deaths from
heart-related disorders, cancer etc, are almost identical. The
differences that do occur are around male suicides and alcohol
related deaths.
Suicides per 100,000 members of the population (1990)
Sweden Netherlands
males 1,020 (24.1%) 900 (12.3%)
females 451 (10.4%) 541 ( 7.2%)
Per capita alcohol consumption in litres (1993)
Netherlands 85.2, Sweden 63.2
Death due to cirrhosis of the liver (1990) per 100,000
Netherlands 4.8, Sweden 7.6
When collated
these figures demonstrate that death from liver cirrhosis per
litre of alcohol in Sweden is more likely than in the
Netherlands by a factor of 2.1. Moreover, it is quite possible
- even likely - that the consumption figures based on sales by
the state liquor stores are less than totally reliable, as
they do not include illegally distilled 'moonshine'.
Drug overdose deaths (ICD 304, 1993)
Sweden Netherlands (estimate)
per 100,000 pop. 1.6 0.5
total 146 80
Hepatitis C:
In 1990/1994
Sweden had a total of 15,008 reported cases of Hepatitis C Virus infection.
Of these, 10,000 (or over two thirds) were intravenous drug
users (lit.1). It should be borne in mind here that Hepatitis C Virus could
not be diagnosed before the start of 1990. Dutch estimates
also suggest a large number of Hepatitis C Virus infected intravenous drugs
users. There are no exact figures.
4. The
fact-finding mission - a report
4.1 During the two
day visit the Amsterdam delegation met and talked with:
a delegation from
the Stockholm city council and the director of the ECAD
foundation (European cities against drugs)
members of the central Stockholm police drugs squad
the Dutch ambassador
the directors of the Maria Ungdom secure facility for young
substance abusers (arrested by the police for a variety of
reasons)
a psychiatrist and psychiatric nurse from the secure clinic
for women users/abusers committed for enforced treatment under
Sweden's LVM legislation.
At all these
meetings the Amsterdam party sought additional information
material and/or extra detail on information already assembled
(shown elsewhere in this report). The aim of a meaningful
dialogue was certainly realised, with an even more open and
constructive atmosphere than hoped for, throughout all these
meetings.
However, it was
also very clear that the Swedish and Dutch situations differ
radically.
4.2 The city
council: Swedish drugs policy
Swedish drugs
policy aims to create a drugs-free society. This relatively
hardline approach is justified by citing the debacle of the
harm reduction models applied in 1965/1967 when medically
supervised supply of replacement drugs like morphine and
amphetamines and methadone went totally out of control, due to
excess consumption, black market dealing etc.
What followed was
a policy shift towards total abstinence. The authorities seek
to achieve this by reducing both supply and demand; on the
supply side this translates as combating all forms of dealing
in drugs. And all forms of drug taking are also illegal.
Meanwhile, the demand side is targeted via a highly
comprehensive network of clinics (voluntary attendance) and
'street corner' social-work programmes. Methadone in its
medical/treatment context does not fit in with the abstinence
objective. Even so, Stockholm's methadone treatment capacity
was quite recently expanded to cope with 450 patients.
In the view of
Sweden's policy makers, syringe trade-in projects and low
threshold methadone treatment send the wrong message; hence,
with the exception of two small-scale syringe trade-in
projects in Lund and Malmo, no such facilities exist. In other
words - there is nothing in Stockholm - which is home
territory for a relatively large number of mainline users.
The LVM Act, which
was reinforced in 1986, allows enforced treatment. The
authorities are aware of the poor results of enforced
treatment (see para 6.3 of this report). When asked why they
continued with this very expensive programme, Mr Kohlberg
(Stockholm councillor) said that it was part of the
prohibition message.
Swedish thinking
makes no distinction whatsoever between soft and hard drugs:
they treat them all as hard - cannabis included. Cannabis is
considered a gateway drug to heroin, and is thought of in
relation to serious psycho-pathologic disorders
(schizophrenia) in the young. Co-use of amphetamines and
cannabis has a bad name in this respect, mainly linked to
aggressive incidents. The very low use of cannabis and heroin
by the young (according to Swedish studies) is regarded as a
success for the prohibition approach, which is duly
perpetuated.
The main problem
drugs in Sweden are amphetamines, psycho- pharmacopoeia and
alcohol. The Swedish anti-drugs community appears to share a
dominant fear bordering on certainty that any relaxation along
the Dutch road would mean spiralling addiction and related
health problems.
Indeed, given the
material discussed in the following sections this fear in not
unfounded. The consequence of this fear/certainty is that
official Dutch differentiation between hard and soft drugs,
and the risk-reduction strategy to hard drugs abuse, is viewed
as "bizarre". It is as if there were no shared terms
of reference, no common "givens".
In fact, what one
has here is a difference of visions on how people cope with
possible addictive substances, and on internal versus external
control. The Swedish authorities regard external control as
imperative because the Swedes may lack the necessary
self-discipline.
4.3. The drugs
squad
Two officers from
the Stockholm police drugs squad shared their day-to- day
experience of the drugs scene with the Amsterdam delegation.
They emphasised the ongoing threat of escalation around young
users (under 20 years old). The policy is to get these
youngsters into care/treatment programmes as early as possible
(see 4.4). It is striking that the starting age for drug abuse
is considered to be 15, i.e. very young indeed. The police
take a very poor view of cannabis, because of the panic
attacks this can cause for young users out on the streets,
particularly when combined with alcohol and amphetamines.
The police
regularly encounter young OD (overdose) cases. Pill abuse is
very common, especially benzodiazepine-type intoxicants like
rohypnol and seresta. Also striking is that the users often
smoke these tablets, like their Amsterdam counterparts with
Mandrax in the 1970s.
The police have
wide powers to stop, search and detain suspected users of
cannabis, heroin, amphetamines and/or benzodiazapine. Once at
the police station, suspects are required to undergo an
obligatory urine test, and can be charged with an offense if
the result is positive. The courts can impose income-related
fines usually of around SK 1,000.-- (NLG 250.--) per offence.
All fines are recorded and payment is required as soon as the
offender comes in funds, e.g if he/she gets a job. Quite
clearly, offenders can accumulate substantial financial
penalties in this way.
During the meeting
with the police officers, the Amsterdam party was impressed by
the high degree of dedication to saving young victims. The
police are 100% behind the prohibition policy.
4.4 Maria Ungdom
(the Maria Youth Centre Clinic)
This is a major
clinic for young users/abusers up to the age of 20. There is a
multi-disciplinary staff of 130. Some 1,100 youngsters pass
through the facility in a year (1995). One third are admitted
under the influence of drugs, having been arrested by the
police. Another third are referred by the Social Services, and
the remainder seek treatment of their own volition. Ages range
from 11 to 21, the average being 17.
Alongside
voluntary and enforced treatment, the clinic also provides
after- care. Apparently, admission is usually prompted by the
abuse of psychotropic substances, often in the street scene.
The spread of
admissions per substance in 1995 was as follows:
substance number of people
alcohol 743
anabolic steroids 13(?)
cannabis 359
amphetamines 171 (inc 12 intrav. users)
XTC 41
heroin 79 (inc 15 intav. users)
cocaine 33
LSD 52
solvents 68
benzodiazepines 147
others 402
Total number of patients admitted in 1995 = 1,111.
Quite clearly,
there is widespread co-use with hard drugs playing a limited
role. The main group are young people with a
psycho-pathological profile, exacerbated by substance abuse.
Notwithstanding, according to the clinic's director, there has
been a serious rise in substance abuse, notably of brown
smoking heroin which has recently arrived on the Swedish
market, having dominated the scene in the rest of Europe for
many years.
4.5 LVM
involuntary admissions
We also visited a
secure clinic for women admitted as involuntary patients under
the LVM Act. The costs of these admissions are retrieved from
the Social Services and dedicated funding from the state (i.e.
not from health insurance). Negotiations are always difficult.
The clinic is on
the site of a major psychiatric hospital outside Stockholm -
but there are no organisational links, the clinic is a
"guest".
We spoke with a
psychiatrist and a psychiatric nurse. On the subject of
Fugelstad's study on enforced treatment (1988 - para 6.3),
they clearly believed that results had improved somewhat in
the meantime, notably due to the longer period of admission;
the maximum is six months - in practice four to five months.
Rather than treatment, the main objective of the enforced
admissions is to motivate the patient to undergo voluntary
treatment after release. We were told that no definite
evaluation or outflow figures were available right then, but
would be mailed to us. The psychiatrist suggested that the
figures would be strongly coloured by the fact that patients
were invariably drawn from a stringently selected
"bad" group.
Of the 20 patients
in residence at any one time (60 a year), half are aggressive
paranoid schizophrenics. The most common substance involved is
heroin, which is used as self-medication for serious
psychiatric complaints. Without exception the other patients
have serious personality disorders, in some cases they are
dangerously psychopathic.
The doctor and
nurse cited the following bottlenecks:
The care category
here is really "heavy psychiatry", but it is
directed by the finance source - Social Services. As
previously noted by Fugelstad, this means constant conflict
around medication on the principle that "drugs are drugs
are drugs, and therefore prohibited and/or undesirable".
Given the type of patients, this is a major constraint.
Use of
tranquillizers (and certainly methadone) during detoxification
is taboo. This results in unnecessarily serious escalations.
In one of the isolation cells we were shown, a patient had
recently pulled down the ceiling. The only medication used
during detoxification is clonidine which acts against
hypertension and slightly reduces withdrawal symptoms.
In financing terms
this is a very costly facility. Admissions are paid by the
patient's local Social Services department. Sweden has
problems with public spending. In recent years this has
significantly reduced LVM treatment capacity in cities and
regions. Our discussion partners were unable to give exact
figures, but we were told that several LVM clinics had been
closed.
The most important
single constraint on the operation of the LVM clinics is that
the health problems to be treated are incorrectly designated
under the heading of addiction. In fact, the people admitted
are very ill psychiatric patients with secondary drug abuse
problems. The main body of the psychiatric profession looks
down on both the disturbed addicts and the people who treat
them within the LVM programme.
5. Psychotropic
substances - population research
This paragraph
covers data from the two comprehensive reports by the Central
Förbundet För Alcohol Narkotika Upplysning and the Fölkhälso
Institutet, published in 1993 and 1995 (literature 1 and 2).5.1 Alcohol
Ground work for
the fact-finding mission had included a general look the area
around intoxicants. A publication which drew our particular
attention was the Swedish health ministry's "Swedish
Drugs Policy" whose significant contents merit inclusion
in full, in annex 2. In a nutshell, this calls for the
continuation of the state import and sales monopoly (Bolaget
system), and argues against undesirable interference from
Europe (free market forces and harmonised regulation) which
would end the monopoly. The brochure draws a dramatic picture
of the Swedes' inability to cope with alcohol in the absence
of controls, whereby a highly restrictive and limiting sales
monopoly is crucial to prevent chaos and widespread public
drunkenness. "For centuries Nordic intoxication oriented
drinking habits have resulted in extensive social damage"
(p.2). The local importance of limiting availability of
alcohol is backed up with the report of an experiment in 1967
and 1968 when "strong beer' (i.e. 5% alcohol like Dutch
pilsner)) was sold in ordinary food stores. Consumption rose
14-fold, while wine and spirits sales were stable, and the
experiment was halted after a few months. Another striking
detail is that Saturday closure of the state liquor stores
which started in 1981, resulted in a significant fall in
public drunkenness and crimes of violence. The brochure closes
with a plea that Sweden should be allowed to keep its state
monopoly of alcohol sales; as a trade-off, the writers offer
to boost sales of imported beverages at the expense of the
local schnapps.
The brochure
summarised here is something of an eye-opener in evaluating
alcohol-related deaths in Sweden: mortality is higher than in
the Netherlands, while reported consumption figures are much
lower. As noted previously, the figures may be less than
comprehensive.
Moreover one has
to be 18 to buy and drink alcohol in a bar/pub, 20 to make a
purchase in a state liquor store. Drinkers under those ages
have to depend on family and older friends, bootleggers and
moonshiners (illegal drink dealers and distillers).
The compulsive,
get-drunk-at-all-costs drinking pattern is also apparent from
a survey of children in grade 9 (15 years of age). This shows
that in 1992 almost one in three boys and one in five girls
(i.e. 29 and 18 percent) drank the equivalent of 370 ccs of
spirits (half a bottle of whisky) in a single session.
Drinking is also
common among Dutch youngsters, sometimes to excess, but not to
this degree, and not at this early age.
In the last
century, widespread alcohol abuse promoted the enforced
treatment of alcoholics. This occurred under the aegis of the
Temperance Boards organised in local communities. The boards
registered alcoholics and incidents of and around public
drunkenness. Vagrancy was not tolerated - and certainly not
for alcoholics. And if an individual was unable to regulate
his or her intake, the community had powers to commit him or
her, involuntarily. This and the previously noted links with
the local Social Services are striking and recall Holland's
pre-war local authority financing of psychiatric
hospitalisation. The Swedish system was gradually expanded
into the LVM arrangement where by drug abusers can also be
confined for treatment in a closed institution. Funding comes
from the Social Services and the national government - and not
from the health insurers. Admissions pressure local budgets
and this has been a factor underlying closure of the highly
expensive LVM clinics.
The Temperance
Board system, and the registration programme in particular,
have enabled excellent longitudinal epidemiological studies
into the course of alcoholism and related mortality patterns
in Sweden.
5.2 Amphetamines
The Swedes are
traditionally vulnerable to amphetamine abuse. This is
evidenced by the six million amphetamine tablets (phenedrine
and benzedrine) prescribed in 1942. The number of occasional
users of these stimulants (one to four times a year) was
estimated at 200,000, and 4,000 people took amphetamines once
a week. The same 1942 report noted 3,000 people who used 10 to
15 tablets a day! With the exception of Japan and Korea this
is a unique world record. Present day users often inject their
amphetamines. The current growing supply of very cheap
amphetamines is blamed on illegal production and smuggling
from Poland and the former Soviet Union.
5.3 Heroin
Leaving alcohol
aside, heroin ranks second only to amphetamines as a problem
drug in Sweden. The brown, smokeable variety has been on the
market for two years now. Heroin is usually injected by
co-abusers of amphetamines, alcohol and benzo-diazepines.
Alongside the traditional pattern of amphetamine abuse victims
who suffer from paranoid schizophrenia and use heroin as a
self-medication, recent primary heroin abuse has been most
marked among the under-sixteens. So far the street price of
heroin in Sweden is very high by European standards.
5.4 Cannabis
Cannabis is
considered to be a hard drug in Sweden, and tolerance is zero.
Swedish literature frequently refers to the cannabis's
psychosis provoking qualities. The young are constantly warned
about its dangers. Judging by surveys of school children and
young men doing military service, this has borne fruit. The
proportion of 20 year old conscripts who had experimented with
cannabis and amphetamines fell from 19% in 1980 to 8% in 1993.
The statistical tables available do not differentiate between
the various types of "narcotics". Neither is it
clear in how far the environment of the interviews might have
impacted on responses.
5.5 Solvents
Glue or solvent
sniffing is almost unknown in the Netherlands, the only
exception being a limited outbreak of "tri-sniffing"
in the 1960s, and of solvent abuse in the late 1970s. In both
cases the abusers were groups of seriously socially
disadvantaged youths in a few cities. Solvent abuse is a
highly dangerous and damaging practice which can attack both
the brain and other internal organs. The practice has always
been very widespread in Scandinavia, as well as in the United
Kingdom and Ireland.
A recent (1995)
survey of 15 to 20 year-olds in Oslo (Norway) showed that 7%
had abused solvents at one time or another, while 21% had
smoked marihuana. The Swedish picture is similar - at least as
far as solvent abuse in concerned.
A 1993 survey
showed that 13% of Swedish 15 year old boys had abused
solvents at one time or another. By Dutch standards that is an
extremely high rate of prevalence - but for Sweden it
represents a radical decline: indeed, in 1971 an amazing 27%
of 15 year-old boys in Sweden had abused solvents at some
time.
5.6 Conclusion
The Swedish
leitmotif in dealing with psychotropic substances is the
imperative of external control. In fact this means
state-enforced limitations on consumption of all such
substances. This appears fully justified given the problems
around abuse of - in particular - alcohol, amphetamines and
solvents. The next paragraph takes a broader look at the issue
of drug abuse.
6. The drugs
problem - a literature overview
A problem in
evaluating the issue of drugs abuse in Sweden is that there is
no policy differentiation between the various types of drugs.
This is reflected in the descriptions of the drugs problem.
Cannabis, amphetamines and heroin are all classified as
"narcotics" and all users are addicts, etc. Unlike
the Netherlands, Sweden has no total overview of the drugs
population in the form of annual reports of city methadone
programmes and capture/recapture figures, nor detailed
mortality and sickness figures. However, one can glean some
insights from sector analyses of, for example, mortality
patterns among selected user groupings, published in freely
available international medical literature, and a few
evaluation reports (all in Swedish). What are involved here
are divergent patterns of use and related complications. This
section describes a number of high-grade, relevant medical
studies and closes with a speculative reconnaissance of the
drugs problem in Sweden.
As noted above,
amphetamines dominate the hard drugs scene in Sweden. Heroin
users form a substantial minority. Alongside amphetamine
abusers, Stockholm and Malmo are also home to large
concentrations of heroin users. The figures in the various
articles relate to the different years and cities, and do not
always match up;
Even so, the
picture arises of very substantial and sick epidemic of drugs.
6.1 AIDS and drugs
Ljungberg (1991,
literature 3) describes the preventative effect on HIV
infection, of the local syringe trade-in project involving 182
intravenous users, in Lund (Skane province in southern
Sweden). Malmo, also in the south of the country, was the site
of another trade-in project. The author estimated the number
of "injecting" users in Skane at at least 3,000, out
of a population of one million. The average age of the 182
users in the survey was 30 (1991); 80% were men; 70%
exclusively used amphetamines; and 98% had been tested for HIV
once or more. One percent of Skane's "injecting"
users is estimated to be HIV positive; a total of 38 HIV
positive users had been identified at the start of 1990, and
just over half of these were on heroin. The striking thing
about this small number (probably a meaningful picture given
Swedish testing policy), is that two-thirds became infected in
Stockholm or Denmark. The author contrasts Lund's 1% HIV
infected users with the figures for heroin users in Stockholm
(1988: 45 to 60 percent).
Lundborg (1989,
literature 4) describes the situation around AIDS and drug
abuse in Stockholm. According to the author the spread of
intravenous use of opiates in Stockholm in the period 1987 to
1988 is 33% amphetamines and 17% heroin; 45% of heroin users
being HIV positive with a 0% (?) annual incidence. The
prevalence of HIV infection among amphetamine users is 6%,
with 1% new infections a year. The total number of HIV
infected users is declining due to the high death rate,
notably among heroin users.
6.2 Methadone
treatment
Gröbladh and
Gunne (literature 5 and 6), thoroughly documented Sweden's
relatively small-scale methadone programmes. As there is no
place for methadone in the country's restrictive drugs policy,
it was possible to carrying out a longitudinal comparative
coherent study. This contrasted with the fate of clients
admitted to a methadone programme with those kept outside when
the government put a stop on the intake. This enabled
comparative analyses of mortality patterns in the methadone
group, the waiting list group, and the category of clients
expelled from the programme after discovery of continued
abuse.
This is unique
material, in that these are the only studies with a control
group, out of the very large body of national literature on
methadone evaluation.
The groups in the
study were;
166 heroin addicts being treated with methadone.
53 of these 166 who were banished from the methadone programme
115 heroin addicts in the waiting list (control) group.
The observations
were conducted over five to eight years as from 1979, and
hence prior to the AIDS epidemic among users. The annual death
rate for the methadone group was 1.4%, with no mortalities
from heroin overdoses. Annual deaths in the control group were
7.2%, with three- quarters due to heroin overdoses. It was
also striking that deaths among clients banished from the
methadone programme rose to 7%, and indeed, the authors call
for expansion of methadone treatment.
Fugelstad (1995:
literature 7) deals with mortality among 472 HIV positive drug
users in the Stockholm region in the period 1966 to 1990. The
introduction to the article refers to a study by Byqvist which
estimates the total number of intravenous drug users in
Stockholm at 4,300 in 1993, with an equal spread of opiate and
amphetamine users. Annual deaths among the city's users are
calculated at 3% for opiates and 1% for amphetamines.
The 472 HIV
positive users followed in the study has a significant, 3.5%
annual death rate (whereby the study makes no distinction
between amphetamine and heroin users). In most cases the HIV
infection dates from the early 1980s (the same period that the
virus appeared among Amsterdam users). As it happens,
Stockholm does not have a syringe trade-in programme. The
Stockholm pattern of fatalities differs from that in
Amsterdam. Rather than illness, the majority of deaths among
the Swedish HIV cases are due to overdoses (41 of 69 = 60%),
or suicide (9 of 69 = 13%). Fugelstad concludes that treatment
with methadone offers protection against premature death from
an overdose. This conclusion is reinforced by the fact that
the non-methadone group comprised an unknown number of
amphetamine users, alongside opiate dependants. In Sweden it
is assumed (Byqvist) that deaths among amphetamine users is
intrinsically low at 1%, compared with 3% for heroin users.
6.3 Results of
non-voluntary treatment of drug abusers in Stockholm
Non-voluntary
treatment (forced withdrawal) has a high profile in
presentation of the Swedish model. Even so, the majority of
admissions of addicts for treatment are voluntary in Sweden.
In 1993 there were a total of 24,999 voluntary admissions
compared with 2,127 legal committals, i.e. 92 versus 8
percent.
The legal
committal (non-voluntary) cases were 65% for alcohol, 17% for
drugs, 16% for alcohol and drugs, and 2% for other causes.
Fugelstad
(literature 8) in 1988 describes the enforced treatment of 152
drug addicts in Stockholm. The study followed them for an
average of one year after discharge. The study deals with
non-voluntary care and treatment immediately after
implementation of the LVM Act in 1986; this legislation
enables the detention for non-voluntary treatment of substance
abusers who do not respond adequately to voluntary treatment.
The group studied was detained for a maximum of two months.
Since then, the legislation has been revised to permit a
maximum of six months. The LVM provisions are an extension of
the Social Services Act. The author describes the chaotic
situation, with rampant organisational and harmonisation
problems. Mainly involved here is the clash between the
medical staff and the people who are in charge of the process
- the social workers. The crux of the matter is medical
autonomy. In the view of the social workers in charge, all
medicines, including anti-psychotica, tranquillizers and
anti-depressants are drugs - and thus forbidden. Given that so
many of the patients suffer from serious psycho-pathological
disorders, this is a major stumbling block; indeed, alongside
the short stay, it may well explain the quite disastrous
results.
In this study, of
the 152 admissions (average age 30), 91 are opiate- dependent
(57% HIV positive); another 27 are amphetamine dependent, only
one of whom is HIV positive. The other 24 patients are
cannabis and solvent users; 12% of this group is HIV positive.
The starting age for amphetamine abuse is 15, with users
moving to heroin at 18 and 19. During their careers as addicts
they are frequently admitted to hospital and to voluntary
drugs clinics. The average is ten times. An interesting fact
is that after enforced treatment, "care consumption"
rises to 4.3 admissions a year.
The follow-up
varied per patient, from six months to two-and-a-half years
after release. The outcome is dramatic. Of the 152 subjects:
21 died (16 from heroin overdoses)
25 went into methadone programmes
76 were still active users
30 were in prison, or their whereabouts were unknown.
The prior career
of those who succeeded in getting into a methadone programme
is striking. The author describes then as "the most
socially- maladjusted and hopeless LVM clients". Almost
all are HIV positive. This is followed by the remark that:
"Enormous improvements were noted in the social and
addiction situations of all the addicts who underwent
methadone treatment."
6.3 Conclusion
The printed
material shows a picture of a turbulent hard drugs epidemic
whereby there is a heavy incidence of death and illness in the
relatively small sub-group of heroin users. It also clear that
medical input in drugs care and treatment - particularly in
the context of methadone programmes and syringe trade-in
projects - is very limited indeed.
The next section
deals with the first-hand experiences and discussions around
the Swedish approach, during the fact-finding missions.
7. Brief
reflections
Sweden's problems
around drugs differ from the Dutch situation. The differences
come under three general headings:
-
the substances used
-
the manner of use
-
official policy
However, the main
thrust is directed at the basic inability to consume any
intoxicant with moderation. This social "given" is
reflected in the Swedish view of use/consumption of these
substances. In turn this translates as policy oriented to
external rather than internal checks and controls.
Judging by the
material studied, Swedish policy is adequate - in the present
context. However, the question arises whether the present
situation - that of a relatively prosperous, isolated country,
can withstand the probably inevitable social and economic
impact of European integration. In the longer run,
continuation of the state alcohol monopoly appears unfeasible,
while the present unemployment levels and pressures on
government spending will also impose policy constraints.
At the same time,
changes and improvements are feasible in the area of
"harm reduction", notably around syringe trade-in
projects and methadone treatment.
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