The goal of Swedish drug policy is “a drug free society”. By setting
this objective,
Sweden has assumed a unique position
among European nations, adopting a total prohibition model and emphasising a
restrictive approach. At the official level, Swedish policy has been presented
as a success both in relation to the less restrictive policy previously followed
in
Sweden, and to the policies of other
countries.
The drugs question has once again become topical since levels of drug
use have risen sharply following an earlier decline. The Government has
appointed a special co-ordinator on drugs issues, who is now working under the
banner “Mobilisation against drugs”. The Government is also expected to furnish
a large amount of money for this mobilisation.
A number of academics and researchers have long been critical of
various aspects of Swedish drug policy. At the same time, the debate surrounding
this issue has been polarised and in a state of deadlock, which has made it very
difficult for those with alternative viewpoints to make themselves heard. In the
context of the new and more open situation prevailing at the present time, some
researchers wish here to present their views on Swedish drug policy. The authors
are wholly responsible for their own sections of the text.
Mats Ekendahl Ph.D. works at the Department of Social Work at
StockholmUniversity
Markus Heilig is Associate Professor at the Karolinska
Institutet and is head of the Research, Development and Education unit at the
UniversityHospital at
Huddinge
Magnus Hörnqvist is a postgraduate research student at the Department of Criminology
at
StockholmUniversity
Leif Lenke is Professor of criminology at
StockholmUniversity
Börje Olsson is Professor of alcohol and drug policy at
StockholmUniversity
Henrik Tham is Professor of criminology at
StockholmUniversity
Dolf Tops Ph.D. works at the Department of Social Work at
LundUniversity
Per Ole Träskman is Professor of penal law at
LundUniversity
Swedish drug policy has been successful in reducing levels of
problematic drug use both over time and relative to that of other countries.
This is the official picture presented in political statements, government
inquiries, and the informational publications of public sector agencies.
According to these official statements, Swedish drug policy is successful as a
result of its restrictiveness. The term is used to refer to an intensive policy
agenda involving informational, treatment and control measures across a broad
front.
The success of drug policy has been questioned in relation to the
resources devoted to informational campaigns and treatment programmes. These do
not constitute the most controversial areas of drug policy however. Most of the
criticism directed against the drug policy practised in
Sweden has been
focused on the area of control, since here drug policy involves the use of
sanctioning and compulsion. Police interventions, prison sanctions and
compulsory treatment all constitute departures from the basic civil rights and
freedoms outlined in
Sweden’s Constitution. Interventions
of this kind against citizens, constituting as they do exceptions to the
freedoms and rights enjoyed by all, must therefore be specially authorised by
law. Compulsory measures might be justified if they were to clearly reduce the
risks for serious consequences that would otherwise affect the individual and
society. The compulsory measures employed in the context of drug policy must
therefore be assessed in relation to their effects on problematic drug use and
its consequences.
Since the end of the 1960s, there has been a substantial tightening
of the control related aspects of drug policy. Tableau 1 presents important
legislative changes that have taken place since the Drug Offences Act came into
force in 1968. The area covered by the criminal law has expanded throughout this
period. In addition, the application of the law has been tightened successively.
The number of police officers whose work is focused on drugs has increased
(Figure 1), the number of persons sentenced to a prison term for drug offences
has risen (Figure 2) and the proportion of drug users among those admitted to
prisons has also increased (Figure 3).[1]
The years around 1980 constituted a watershed for Swedish drug
policy. From this point, the objective became “a drug free
Sweden” and the
focus of drug policy shifted from the manufacturer and the dealer to the
individual drug user. The Prosecutor General introduced massive restrictions on
the opportunities available to prosecutors to issue cautions rather than to
prosecute for possessing drugs for personal use and the police began to focus
special resources on street-level operations under the slogan “it’s going to be
tough to be a drug abuser.”
Tableau 1. The evolution of drugs
legislation
1968 Prison
term for serious offences raised from 2 to max. 4 years
1969 Prison
term for serious offences raised to max. 6 years
Telephone taps allowed in connection with serious
offences
1972 Prison
term for serious offences raised to max. 10 years
1980
Tightening of praxis in relation to prosecutorial
cautions
1981 Prison
term for non-serious offences raised from 2 to max. 3 years
Prison term for serious offences raised from min. 1 to min. 2 years
1982 Act on
the Compulsory Treatment of Adult Drug Abusers
1983 Extension
of area covered by penal law
1985 Prison
term for minor drug offences raised to max. 6 months
1988
Criminalisation of personal consumption, max. sanction
fines
1989 Extension
of Care of Young Persons Act in relation to drug abusers
1993 Prison
term max. 6 months for personal consumption
1999 Extension
of criminalisation of synthetic drugs
Extension of Care
of Young Persons Act in relation to drug abusers
Zero limit for drugs while driving
Figure 1. Number of police officers working
with drug crime 1965-2001.
Figure 2. Persons sentenced to prison for drug offences
1975-2001
Any assessment of the effects of Swedish drug policy must be based on
a number of measures of drug use. It is possible by means of such measures to
study pattern changes and also to make comparisons with other countries. The
indicators of the extent of drug use employed in analyses of the situation in
Sweden are self-reported drug use among school pupils and national service
conscripts, drug related illness and mortality, arrestees with needle marks,
estimates made by various public sector agencies of numbers of drug users, drug
seizures made by the police and customs services, persons convicted[2] of drug offences and numbers of
drug users in prison system institutions. These different indicators measure
somewhat different things and are of varying reliability. The indicators that
serve as direct measures of drug use may be regarded as more reliable than those
that describe responses to drug use, such as police and court data for example.
In combination, however, the various measures may provide a rough picture of the
relevant trends.
Since 1971, annual questionnaire surveys have been conducted among pupils in year 9 (aged 15). Figure 4
presents trends in the proportion of girls and boys respectively who report
having tried drugs, primarily cannabis.[3] The trend shows a gradual
reduction in the numbers trying drugs during the 1970s and through the early
1980s, with these numbers bottoming out between the mid 1980s and the beginning
of the 1990s. Thereafter there was a marked increase. Measuring drug use during
the last month provides a rather more sophisticated indicator than measures of
ever having tried drugs. The trend shown by this indicator is more or less the
same, however.
Figure 4. Proportion of youths in year nine who have used drugs
1971-2001,
by gender
One measure of the trends in drug use, available from as early as the
1960s, is based on the needle marks found for the first time among those
admitted to
Stockholm’s remand centre.[4] Following a substantial increase,
the number presenting needle marks fell sharply between the end of the 1960s and
the mid 1970s. Thereafter this number lay at a relatively stable level until the
beginning of the 1990s (after which point there are no longer data available).
Another characteristic of the trend in drug use in
Sweden is that
unlike the majority of countries, where heroin use came to dominate trends in
heavy drug use,
Sweden developed an amphetamines
problem. Heroin arrived on the scene in
Sweden in the mid 1970s. Since then
its use has increased and at the end of the century, the use of heroin and
amphetamines lay at similar levels as the dominant drugs used by heavy drug
users.
The use of measures based on the societal response to drug use, such
as the numbers convicted of drug offences, for example, may be misleading. First
and foremost, this measure may be regarded as reflecting the work the justice
system. Measures of this kind may however be used to study whether trends have
varied across different groups of drug users. The picture of persons convicted
of drug offences shows a fall in the number of young people being convicted,
aged between fifteen and twenty, from the early 1970s until the beginning of the
1990s (Figure 5).[5] At the same time, the number of
older individuals, aged 30 to 39, being convicted increases. Given that it seems
unlikely that the police should have decided to reduce their focus on young
people, the trends indicate a decrease in the number of young drug users over
time. This builds on the assumption that in general those who commit drug
offences are also drug users, and that drug use starts relatively early in the
life course. From the beginning of the 1990s, however, the number of young
people convicted of drug offences underwent a sharp increase whereas the upward
trend among the older group was broken.
Figure 5. Persons convicted of drug offences
1968-2001,
by age groups 15-20
and 30-39 years
Indicators of first time drug users should be kept separate from
those measuring the number of drug users in the population at a given time.
National estimates of the number of drug users show that numbers of heavy drug
users (intravenous users or those who use cannabis on a near daily basis)
increased from 15,000 in 1979, to 19,000 in 1992 and 26,000 in 1998.[6] Thus the increase here has been
substantial, and was particularly marked during the 1990s. In part this trend
reflects that fact that people who started using drugs when they were young have
continued to do so as they have grown older. Between 1979 and 1992, the average
age of drug users increased, and the influx of young persons into this group was
reduced. During the 1990s, however, it was not only the number of older drug
users that increased but also the number of younger ones. Trends in drug related
mortality also follow those in the number of heavy drug users (see Lenke &
Olsson in this volume).
Figure 6. Numbers of heavy drug users 1979,
1992 and 1998,
in total and aged 24 or
under
In summary, the number of individuals using drugs for the first time
increased dramatically during the 1960s only to decline during the 1970s,
reaching its lowest level during the 1980s. From the beginning of the 1990s, the number of
first time users once again increased. The number of heavy drug users in
Sweden has increased successively
since measures were first produced at the end of the 1970s. Despite this
increase at the aggregate level, the number of younger heavy users fell up to
the beginning of the 1990s. From this point on, however, the number of young
persons presenting heavy drug use has also increased.
The control system and trends in drug use
One might then pose the question: Do the available indicators of
trends in drug use suggest that Swedish drug policy, and in particular the
control measures employed, has been successful?
The dramatic increase in the number of drug users during the 1960s
can also be seen in several other countries, and thus has nothing to do with
Swedish drug policy. An experiment conducted with legal prescriptions in
Stockholm
between 1965-67 is of interest in relation to the drug policy debate of the
time. The experiment, which involved doctors providing a small group of drug
users with generous access to amphetamines, has since been put forward
repeatedly as a reason why Swedish drug policy cannot be liberalised.[7] Critics regarded the legal
prescription of amphetamines as catastrophic, in particular because the
prescribed drugs were spread extensively to persons not included in the
experiment. A closer analysis of the experiment does not, however, indicate that
it had any directly negative consequences. Levels of crime did not increase
among those included in the experiment, and levels of mortality were no
different from those among other drug users. The sharp increase in the number of
intravenous drug users in
Stockholm began several years prior to the
start of the experiment. The number of prescriptions for amphetamines was also
far too low to have had any major impact on the number of drug users in
Stockholm.[8]
During the years 1968 to 1972, the severity of sanctions for serious
drug offences was increased dramatically. The other chief characteristic of drug
policy during the 1970s was that the drug user was not to be punished.
Possession of small amounts for personal consumption led to a caution issued by
the prosecutor, whilst heavy drug users were offered treatment. Despite the
absence of more intrusive measures, the available indicators suggest that the
numbers of people starting to use drugs fell over the course of this decade –
the number of fifteen year olds who had tried drugs was halved, and the number
of young people convicted of drug offences dropped even more steeply.
In the context of the wider debate, however, the 1970s came to be
characterised as the all-too-liberal decade, where a “laissez-faire” policy saw
drug use spreading to ever younger groups of users, and to an increasingly large
part of the country. The leading critic of the time, who would also come to have
a major influence on the direction drug policy was to take, claimed that drug
use was spreading like an epidemic and that the “ultra-liberal policy”
constituted a “Swedish tragedy”.[9]
As has been mentioned, from the end of the 1970s drug policy was
given a new direction with the goal now being the complete elimination of drug
use. Praxis shifted away from the issuance of cautions for minor drug offences,
and the number of police officers working with drug offences was increased at
the same time as the focus of resources was shifted towards the drug user on the
street.
The immediate effect of this tighter drug policy was that the number
of young people being convicted of drug offences increased for a couple of years
(see Figure 5). Thereafter, the decrease that had been witnessed since the 1970s
continued, but at a slower rate. The reduction in the number of young persons
convicted of drug offences was mirrored by a reduction in the number of young
heavy drug users included in the national estimates (see Figure 6). The figures
from the questionnaire surveys of fifteen year old and national service
conscripts also show a further drop in the numbers reporting having tried drugs.
The trends of the 1980s may be interpreted as indicating that the
more restrictive drug policy had an effect on the number of young people
starting to take drugs. For the most part, however, the decrease constitutes a
continuation of the trends witnessed during the “ultra-liberal 1970s”. At the
same time, the falling drug use among young people witnessed during the 1980s
mirrors a drop in levels of drunkenness in this same group. It is highly
unlikely that this trend has anything to do with drug policy. On the other hand,
it does coincide with alcohol policy measures introduced with the objective of
restricting drinking among young people. When drug use among youths increases
again during the 1990s, it is once again mirroring the trend in levels of
drunkenness.[10] This correlation might be
interpreted in different ways. Research clearly shows however that the use and
abuse of drugs is often preceded by excessive levels of alcohol consumption,
whilst the reverse is more uncommon.
During the 1980s, sanctioning levels were also increased in relation
to non-serious drug offences. The use of compulsory treatment was extended among
both young people and adults. The consumption of illicit drugs was criminalised
in 1988. The sanctioning scale for the consumption of drugs was extended to
include prison sentences in 1993, which also gave police the right to conduct
compulsory testing of bodily fluids. The objective of stiffening the sanctioning
system in 1993 was to give the police the “opportunity to intervene at an early
stage in order to forcefully prevent young people becoming hooked on drugs”.
Since the sanctions were stiffened, approximately 10,000 blood and urine samples
have been taken annually. The number of drug officers within the police force
has almost doubled during the 1990s (see Figure 1).
The intense focus on the use of criminal justice based measures
during the 1990s did not however lead to any reduction in the extent of drug
use. The various measures of drug trends instead indicate marked increases – the
number of fifteen year olds who have tried drugs, the number of young people
convicted of drug offences and the number of heavy users among young people
according to the counts conducted in 1992 and 1998. In addition, the police have
lowered the priority of measures focused on serious drug offences and
trafficking in relation to personal use. One third of the blood and urine
samples drawn from young people tested negative. An evaluation of the change in
the legislation conducted by the Swedish National Council for Crime Prevention
emphasised the problems associated with the violations of personal integrity
that young people are subjected to by this kind of drug testing.[11]
The total number of heavy drug users presents a somewhat different
trend to that among first time drug users and abusers. The size of this group
has increased successively over the course of the 1980s and 1990s. Established
drug users do not seem to have been deterred by police or sanctions. Nor do the
substantial resources devoted to treatment programmes appear to have been able
to put a stop to the increase. The number of heavy drug users also increased
during the 1980s in spite of massive treatment efforts intended to meet the
threat posed by HIV.
It has been claimed both in a government inquiry and in the wider
debate that the substantial increase in the number of drug users witnessed
during the 1990s may in part be a result of a reduction in the level of
resources devoted to care and treatment measures.[12] There is no real evidence that
such a contraction in resources has in fact taken place, however. It is true
that an evaluation conducted by National Board of Health and Welfare indicates
that many local authorities appear to have made cut-backs within the drug
treatment sector at the beginning of the 1990s. The time spent in treatment also
appears to have become somewhat shorter. On the other hand, the costs incurred
by local authorities in relation to treatment programmes remained constant
during the mid 1990s. Institutional care programmes have been cut back, but
non-institutional programmes have been extended. In addition, the cuts in levels
of institutional care have for the most part been felt in relation to the
treatment of alcoholism.[13]
Even if there have been some cut backs in the level of care provision
for drug users, the question remains as to whether this can in fact explain the
increase in the number of heavy drug users witnessed during the 1990s. Cut backs
in the level of compulsory treatment are unlikely to have had any effect, since
they have not shown themselves to reduce levels of relapse into drug use.[14] One might also question the
existence of any form of treatment effect within the drug treatment sector.
According to a review of the research conducted by the National Board of Health
and Welfare, scientific follow-ups have not found evidence of any long term
treatment effects.[15]
This does not constitute an argument against treatment. It has a
major value in its own right as a means of care provision. Individual drug users
have been helped – and should continue to be given help – to stop using drugs.
Certain programmes have produced positive effects, others seem promising, and
the objective must of course be the development of effective methods of
treatment. The findings from research conducted to date, however, suggest that
the expectations we have of treatment approaches as a means of reducing levels
of relapse into problematic drug use should not be particularly high. Above all,
it seems unlikely that even extensive care resources would be able to have a
significant effect on the level of drug use and related trends over time.
Thus there do not appear to be any clearly identifiable links in
Sweden between changes in drug-related control measures and changes in patterns
of drug use. Levels of drug use and problematic drug use appear to have
developed relatively independently of penal and compulsory care based
legislation, levels of police resources, prison sentences and treatment efforts.
One might still argue that drug policy has been successful in that
the proportion of young people trying drugs has been and remains low in relation
to other western countries,[16] and that it is therefore
important to maintain the existing control focus in all areas of drug policy.
Having tried drugs, most commonly cannabis, is not in itself serious
nor does it constitute a social problem among young people. Occasional use is
said to be a serious matter, however, since it constitutes a stepping stone on
the way to heavy drug use. This assertion is one that deserves to be taken
seriously and also one that may be tested against the data. The background to
this hypothesis, which is widely held to be true in Sweden, is to be found inter alia in Swedish alcohol policy,
where the control of alcohol use has also had an effect on levels of alcohol
abuse. Sweden has been able to restrict the extent of alcohol related harms by
means of a restrictive alcohol policy, which employs age limits on the purchase
of alcohol, a state monopoly on alcohol sales, limited opening times, the
control of the bar and restaurant trade, high taxes and so forth. The positive
effects on levels of violence[17] and liver cirrhosis mortality
have been established both in a historical perspective and in relation to other
countries.
Unlike drugs, however, Sweden has never prohibited the use of
alcohol. The two markets are therefore quite different. The likelihood of moving
from having tried drugs to becoming a heavy drug user or from smoking cannabis
to the intravenous use of heroin or amphetamines is also subject to substantial
variations. In the
Netherlands, a significantly larger
proportion of young people have tried drugs and many more smoke cannabis than is
the case in
Sweden. The intravenous use of heavy
drugs is no more extensive in the Netherlands than in Sweden, however.[18] Very few of those who have tried
cannabis go on to try heroin too – in
Amsterdam and the USA, the proportion who do so has been reported to lie
at three and four per cent respectively.[19]
Even if occasional consumption did involve an increased risk for
heavy drug use, it is difficult to know how such occasional consumption might be
controlled. By devoting resources to testing urine samples and through a
dramatic increase in the number of convictions, attempts were made during the
1990s to prevent young people from starting to use drugs. In spite of these
efforts, however, both the proportion of young people who have tried drugs and
the proportion adjudged to be heavy drug users underwent substantial increases
during this same period.
The trends followed by heavy drug use are founded on other factors
than the numbers who have tried or who consume drugs on an occasional basis.
Heavy drug use is in essence tied to marginalisation and extreme hardship. This
is true at both the individual and societal levels. Studies have time and again
shown that heavy drug users to a much greater extent than others come from
impoverished homes, have experienced family conflicts, have had physical and
psychological health problems and have had done poorly in school – and all this
prior to their drug use.[20] Nor has there been a lack of
early interventions, inter alia in
the form of being taken into care and placements outside of the family home.[21] From a broader European
perspective, heavy drug use is also particularly extensive in countries
presenting high levels of unemployment.[22] In
Sweden, trends
in drug use among the young follow trends in levels of youth unemployment.[23]
Trends in heavy drug use are for the most part determined by the same
factors that give rise to alcohol abuse and criminal recidivism. Thus there are
no major differences between the measures required to deal with these different
phenomena. From a historical perspective, and by comparison with other
countries, penal sanctions and the use of compulsion do not appear to be methods
that have produced results; or as it has been expressed in an important book on
drug policy in
Scandinavia, Den Gode Fiende (The suitable enemy):
“We cannot punish our way out of major social problems. Collective solutions do
not sit very well in the shadow of
penal law. The war is lost. What is important now is that we do not
lose civilised society.”
Historical developments have led to a situation where drug policy and
crime policy have become interwoven. Ever since the 1960s, drug policy has been
characterised by a tough criminal law approach. Criminalisation and the use of
stiff penalties have constituted the primary means of controlling anything that
might be labelled “narcotics”. Any examination of drug policy must therefore
include an analysis of crime policy.
In
Scandinavia, sensible crime
policy – and as a part of this, sensible criminal justice policy – has often
been characterised using words such as “rational”, “homogenous” and “humanist”.
What the words rationality and homogeneity are intended to emphasise
is above all the requirement that all decisions must be based on a solid
fundament of fact (both empirical and legal) and must be subject to thorough
deliberation. All legislation takes as its point of departure the identification
and acknowledgement of a social problem. To justify attempting to resolve the
problem by means of the law, the problem must be both sufficiently serious, and
sufficiently difficult to resolve that informal solutions or decisions taken by
authorities at the executive level would not be adequate to the task. Thus
before legislative measures are taken, the nature of the problem must be
established and specified, and various possible alternative solutions must be
determined.[24] In the case of penal
legislation, there must in addition be very good grounds for criminalisation.
Criminalisation and penal sanctions can only constitute a justifiable solution
when other options are not sufficient.[25]
The requirement of humanism refers first and foremost to
the norms that apply to a trial in the criminal court, with the requirement of a
fair trial, including all the minimum guarantees for criminal court cases that
are implicit in internationally established human rights. But the demand for
humanism also presumes that the norms of the criminal justice system are non
discriminatory, and that the sanctioning system is not formulated so that
control by means of the criminal law causes more suffering than is absolutely
necessary. Above all else, this means that the necessary sanctioning level be
subject to careful consideration. There must be a reasonable balance between the
requirement of effectiveness and the requirements that follow from the fact that
the criminal law shall only be used as “ultima ratio” and then only to the
extent and in such a way as may be derived from a sanctioning ideology based on
justice.[26]
Penal legislation is therefore always tied to three questions: should
a certain act be criminalised at all? How should the act being criminalised be
described and defined? And how severely should the criminalised act be
sanctioned?
When it comes to the criminalisation of drugs, the answers to these
three questions are often taken for granted. Criminalisation should always be
used, the criminalisation should be applied sufficiently broadly as to encompass
the handling of drugs in any and all its forms, and the sanctions should be
severe. But how well does this in fact correspond to the requirements of good
crime policy? Let us begin by taking a brief look at historical developments.
Up until the 1960s, drug use was chiefly defined as an individual
problem, which was somewhat more concentrated within certain social groups.[27] This all changed radically
during the 1960s, leading to amongst other things a specific Penal Law on
Narcotics (1968:64). The Law had two primary objectives. The first was to
emphasise the seriousness of drug use and to make it clear that it constituted
an unwelcome problem that would be aggressively opposed. The second was to
differentiate between those who trafficked in and distributed drugs on the one
hand and those who used them on the other. The Law was not intended to hit the
drug users, but rather the idea was to reduce the supply of narcotics by means
of intensive, criminal law based controls focused on those who supplied and
distributed drugs. The maximum tariff for drug offences was fixed at four years
imprisonment, and this maximum level (which was regarded as being on the high
side) was motivated by reference to a putative
preventive effect on serious drug crime and drug trafficking. After only
a year, however, this maximum tariff was increased to six years imprisonment.[28]
The maximum sanction was increased again just a few years later. This
occurred in connection with a “Nordic merry-go-round” of similar measures.
Between 1970 and 1972, the drugs legislation was tightened in
Finland,
Norway and
Sweden. In the process, the maximum
penal tariff for serious drug offences in
Finland was
raised to ten years imprisonment. The motivations included reference to the fact
that plans were afoot in both
Norway and
Sweden to raise
the maximum sanction to just this level. Not long afterwards, the maximum
sentences were increased to ten years imprisonment in both
Norway and
Sweden. Here the motivation was that
these countries could not have a lower maximum tariff than that in effect in
Finland.[29]
Drug controls were tightened further at the end of the 1970s. From
this point on, the official objective of the control policy was to bring about a
“drug free society”. Of the agencies, parties or organisations active in this
area, there is hardly a one that has not employed this goal formulation. The
objective is still defined in this way today[30], although the Government has
stated in a paper to Parliament that this general and visionary objective may be
broken down into three measurable components: reducing the level of recruitment
into drug use, increasing the numbers desisting from drug use and restricting
the supply of narcotics.[31]
One thing that may be said to distinguish Swedish drug control is the
way a choice has been made to take a “tough” line at all levels. The war on
drugs is to be won by means of a straight, uncomplicated and resolute battle. No
reason is seen for differentiating between softer and harder drugs. The risks
associated with softer drugs have even been regarded as greater than those of
the harder substances, since softer drugs are perceived as a stepping stone
towards heavy drug use.[32]
One essential element in the battle against drugs is the
criminalisation of the consumption of drugs. Drugs have been compared with a
virus that can strike anyone, and this virus must therefore be stopped using any
and all available means, but above all through severe criminal justice
measures.[33]
Until the 1980s, the application of the drugs legislation was
intended to avoid obstructing or preventing drug users from entering treatment.
Control efforts were to be focused on producers, suppliers etc. During the
1980s, this approach started to be called into question in the context of a
heated debate. Should control measures primarily be focused on more serious drug
crimes or on the drug user?[34] A decisive step towards this
latter alternative, i.e. focusing control on the drug users, was taken when the
personal consumption of drugs was criminalised in 1988. The relevant Bill
emphasised that drug policy had to be formulated in such a way as to make it
clear that society takes a negative view of drugs and drug use. In addition, it
was felt that criminalising personal consumption would have a preventive effect,
particularly among youths. Further emphasis was placed on the importance of
adopting a uniform approach within the Nordic countries. And the personal
consumption of drugs was already sanctionable according to Norwegian and Finnish
legislation.[35]
In the preliminary work conducted in association with the legislative
change that criminalised personal consumption in 1988, three principal arguments
against criminalisation were discussed: penalising an action directed against
the perpetrator’s own person conflicts with a liberal Swedish tradition (where
not even suicide or assisting suicide are criminalised); the effective
enforcement of the criminalisation would require a level of resources not
available to the police (the questions of the police’s right to take urine and
blood samples when there was a suspicion of drug use, and the question of the
evidentiary value of such samples, were particularly sensitive); the fear of
punishment might lead drug users to avoid seeking treatment. This last issue was
resolved by means of a special freedom from liability clause whereby a drug user
could avoid criminal responsibility if he or she submitted to treatment for
their drug dependency.[36] In 1988 the penalty for personal
consumption was fixed at a fine.
The controversial aspects of criminalising personal consumption and
of the possibility of allowing for urine testing where there is a suspicion of
drug use have been described by the Supreme Court Justice Staffan Vängby in the
following way:
I can take a couple of examples from my own experience as an
investigator [of evidentiary difficulties that will arise in connection with a
new criminalisation]. The one related to the criminalisation of the consumption
of drugs. In the Drugs Inquiry of 1982 we coined the phrase that if drug
consumption was criminalised we would be up to our knees in urine. The
politicians failed to resist the pressure of public opinion and we ended up with
what we’d anticipated. It became a means for the police to show their
effectiveness by arresting known drug users without this having the slightest
practical effect as far as I can understand. Quite the reverse, such simple
police measures take resources away from areas that may have a real significance
in relation to drugs, including amongst other things the investigation of
trafficking on the streets.[37]
In 1993, the severity of the sanction for personal consumption of
drugs was raised with the inclusion of a prison term of up to six months in the
sanctioning scale. The objective was to “provide opportunities to intervene at
an early stage in order to forcefully prevent young people getting caught in
drug use, and to improve the treatment of drug users serving sentences.”[38] The arguments for increasing the
severity of sanctions were primarily the following: The penal tariff for
personal consumption (a fine) was too low by comparison with other minor drug
offences, particularly possession. With the introduction of a prison term into
the sanctioning scale, the police were given the opportunity to conduct body
searches in the form of urine and blood tests, when there was a reasonable
suspicion of drug use. The introduction of a prison term into the sanctioning
scale also made it possible for treatment based sentences to be passed in
connection with drug use. This improved the treatment opportunities available to
drug users. At the same time, however, the special freedom from liability rule
for drug users voluntarily seeking treatment was revoked. The general rules
relating to waivers of prosecution were deemed to be sufficient in such cases.[39]
In connection with the criminalisation of personal consumption, the
police were given extended powers of control besides those relating to body
searches. All these increased police resources were in fact to a large extent a
result of the police’s own political activity. Prior to the raising of the penal
tariff, which allowed the police to take urine and blood samples where there was
good reason to suspect a person to be under the influence of drugs, the police
had requested that they be given this power on a number of occasions. Without
the ability to take urine and blood samples, they claimed, the evidence required
to make a criminalisation of personal consumption effective would not be
forthcoming. The demand for increased control opportunities was one of the
points made in the drugs manifesto produced by the National Police Board in
1989. One of the mottoes of this manifesto, which was repeated in several other
contexts as well, was that it should be “tough to be a drug user”. The
opportunity to take urine and blood samples when a person was suspected of
having taken drugs was something that would be used precisely to make things
tough in this way.
The effects of the extended powers granted to the police are
described in a report produced by the Swedish National Council for Crime
Prevention on the efforts made by the justice system to combat personal drug
use. The report clearly shows the way that this particular type of anti-drugs
activity has been given an ever higher priority:
Slightly over 70 per cent of all police authorities report that
measures to combat drug use are one of the goals in the area of drug crime.
Almost half reported having specified goals relating to a certain number of
urine and blood tests being taken. Measures against serious drug offences do not
appear as often as prioritised goals …, despite the fact that the countywide
units, which primarily focus on combating serious drug crime, are included in
the presentation. One third of the police authorities report that their
objectives include taking measures to combat serious drug offences. Only two
police authorities have specified productivity targets relating to how may
serious drug offences should be investigated.[40]
The report summarised the trend in the number of recorded drug
offences in the following way:
The number of reported drug offences has increased dramatically since
the mid 1970s. As a result of changes to prosecutorial praxis and intensified
measures against street trafficking at the beginning of the 1980s, there was an
increase in the number of reported offences relating to possession and
consumption. The substantial increase in the number of reported drug offences
after 1993 may be explained by the increased opportunities made available to the
police to apply the legislation against the consumption of drugs. Judging by the
trend in reported drug offences, police measures have become more focused than
they were before on possession and personal consumption. In 1999, the personal
consumption category accounted for slightly over 40 per cent of the total number
of reported drug offences. A similarly large proportion related to possession.
Transfers of drugs comprised approximately fifteen per cent.[41]
The conclusions drawn by the report of the National Council for Crime
Prevention can be summarised in a few short sentences.
Over recent years the police have increasingly clearly prioritised
minor drug offences, of which personal consumption offences constitute a
substantial proportion. Urine and blood testing has comprised an essential part
of these control activities, with these tests being focused increasingly often
on younger individuals. This has also resulted in a substantial increase in the
number of persons convicted of minor drug offences.
This short description of the trends in drug controls also allow us
to present a picture of the situation as it stands at present. This picture is
completely dominated by the criminalisation of the personal consumption of
drugs, of severe sanctions, i.e. usually a prison term for all drug offences
with the exception of personal consumption and the possession of small amounts
of drugs[42] and an “aggressive” approach by
the police. The police efforts directed against drug users in particular are
based on the use of trite scare-tactics, with the extensive use of urine and
blood testing constituting an essential component to this end. The personal
integrity of individuals is interfered with deliberately with a “punitive
objective” in mind. The question then arises: is this kind of drug policy
sensible, and does it represent a crime policy approach that might be
characterised using the words rational, homogenous and humanist? In a Government
Bill aimed at improving the effectiveness of the way in which criminal cases are
processed (prop. 1994/95:23) the Government made the following
assessment:
Criminalisation as a means of attempting to prevent the breach of
various societal norms should be employed with caution. The justice system
should not be encumbered with such behaviours as are not regarded as being
particularly reprehensible. Neither is criminalisation the only, nor always the
most effective means of combating unwanted behaviours. The public resources
devoted to combating crime should be concentrated on forms of conduct that may
give rise to significant injury or danger and that cannot be dealt with by other
means.
Much of the activity related to the handling of drugs is clearly
deserving of punishment. This is also something that is clearly manifested in
the international conventions on narcotics, particularly in the UN’s convention
on drug offences (United Nations Convention against Illicit Traffic in Narcotic
Drugs and Psychotropic Substances, adopted on December 19th 1988).
But this need not include everything. It need not for example include the
personal consumption of drugs, or possession for personal
use.
Different countries have resolved the issue of criminalising the use
of drugs in different ways. This is true even within
Scandinavia, where
Denmark has
consciously chosen not to penalise personal consumption. It is difficult to
build a picture of the international situation, inter alia because in certain countries,
whilst personal consumption does not constitute a crime, the user may still be sentenced for possession,
whereas in other countries personal consumption may be sanctionable by law, but
is not prosecuted in practice.[43] Within the EU, joint legislative
measures to criminalise the personal consumption of drugs have not been deemed
necessary. In the proposal for a Framework Decision that the Commission has
produced relating to the minimum rules for criminal acts in connection with
illicit drugs trading and associated sanctions, acts exclusively committed in
connection with personal drug use have been expressly excluded (proposed Article
2 paragraph 2, in the proposal of the 23rd May 2001 by comparison
with the proposal of the 30th November 2002).
There are several arguments that might be put forward against the
criminalisation of the personal consumption of drugs.[44] There are also certain arguments
that might be adduced in favour of such a course of action. It is certain,
however, that progress could be made towards a more rational and humane drug and
crime policy by decriminalising personal consumption, including the possession
of small amounts for personal consumption.
Decriminalisation may be motivated by reference to rationality: drug abuse problems cannot
be resolved effectively by means of penal law; the focus of the existing control
structure has gone astray and it is not particularly effective. Control measures
other than penal sanctions would be more effective over the long term in dealing
with the health and order-related problems related to the personal consumption
of drugs. Decriminalisation can also be motivated by reference to homogeneity: in liberal societies there
is very little room for the criminalisation of self-destructive behaviours or of
behaviours that are in fact merely a manifestation of something that is
perceived as immoral by certain people. But the foremost motivation for
decriminalisation relates to its humanity. Drug users should not be
placed under stress and treated like people from an alien and unwanted world. As
Professor Johs. Andenaes, who is also an advocate of decriminalisation, has put
it “amongst other things, it’s a question of justice and humanity in relation to
a group of people with major problems”.[45] The Swedish policy of
pressurising drug users is not in the least bit just. It is therefore not worthy
of anybody’s support.
I made the following assessment of penal drug policy in a different
context:
Penal drug policy does not correspond … to the form of crime policy
that has otherwise officially been accepted as correct. When formulating penal
drug policy, people have either neglected to carry out an honest analysis of the
harm and reprehensibility of the different drug-related activities, or have
alternatively neglected to accept and respect the results produced by such
analyses. Nor has anyone openly weighed alternative models of action against one
another in order to choose the one that appears most sensible. What has been
done, on the other hand, is to clearly formulate a political objective (“a drug
free society”), and at the same time to declare that this objective will be
achieved by means of criminal justice measures. This means that no attention has
been paid to the limitations of the criminal justice based control system. A
decision has been taken to reach an objective using means that are not
realistic, and the correctness of this decision has then been stubbornly
maintained.[46]
I still stand by this assessment. A new assessment would first
require a shift in drug controls and thereby also a shift in the crime policy
being pursued in the drugs arena. A good first move in this direction would be
to decriminalise the personal consumption of drugs, including possession for
personal consumption.
In
Sweden, the Care of Abusers (Special
Provisions) Act (1988:870), also known as LVM, has been in force since the
beginning of the 1980s. The Act decrees that substance abusers may be compelled
against their will to spend time at specific LVM institutions for a maximum of
six months. The objectives of such compulsory interventions are to ensure the
individual’s survival by interrupting acute forms of drug abuse and motivating
the individual to continue into voluntary treatment, and to promote long term
rehabilitation.
Since the mid 1990s, the number of persons being placed in care in
accordance with the LVM Act has fallen continuously.[47] This lead legislators to
establish a commission of inquiry in 2002 with the task of investigating the
causes underlying the change in the way the law is applied.[48] The Inquiry’s conclusions are
expected to be published in 2003. Recently, the Parliamentary Auditors also
published the findings from an independent inquiry into the way in which the
National Board of Institutional Care (SiS) carries out its task as the agency
responsible for the compulsory institutional care of both drug abusers and
youths. The report criticises SiS for a lack of external supervision, for not
conducting adequate follow-ups of its work and for employing treatment methods
whose effectiveness may be called into question.[49]
Thus at present, a discussion is being conducted, primarily at the
political level, as to whether LVM works and is being used in the way that was
intended when the Act was formulated. One thing that is conspicuous only by its
absence, not only in governmental inquiries, but also in the directives issued
to relevant committees and in the media statements made by those in power, is
the willingness to question whether compulsory treatment constitutes a necessary
and valuable component in society’s management of the drug dependency problem.
Instead, the reduction in the number of LVM-decisions witnessed over recent
years is usually taken as an indication that substance abusers are being left to
their fate and are not receiving the care they have a right to.
If as a rule compulsory care in accordance with LVM fulfilled the
objectives described above, then the shift in legal praxis would of course
constitute a problem from the point of view both of care ideology and of the
safeguarding of individuals’ legal rights. However, there is no reliable
knowledge as to the treatment effects that are achieved with the help of LVM. No
effect studies that might provide information of this kind have been conducted
in this area. One obvious reason for this is that such studies would require
ethically indefensible experimental designs whereby comparable subjects were
randomised into either compulsory or voluntary treatment groups, or into a group
receiving no treatment at all. In the absence of research of this kind, the
question of the treatment effects of the compulsory treatment legislation must
be answered in a different way.
An examination of the smaller follow-up studies that have been
conducted shows that compulsory treatment at LVM institutions and voluntary
institutional care in general, often give rise to a similar improvement rate.
Irrespective of how treatment has been initiated, approximately one in ten
individuals remains free from drug abuse, and the condition of one in three has
improved in some way, after approximately one to two years.[50] Data of this kind cannot be
employed to draw conclusions as to possible treatment effects, however. Drug
users may be expected to pendulate between better and worse life conditions, and
may sometimes even desist from drug use even though they refuse to participate
in formally organised treatment.[51]
Furthermore, drug users in compulsory care are themselves doubtful as
to whether a stay of several months at an LVM institution has any useful effect
in terms of lasting rehabilitation.[52] As is the case with social
workers who have experience of LVM cases, the users themselves question whether
compulsion and potential violations of personal integrity can in any way
function as an introduction to effective treatment.[53] On the other hand, the majority
of both drug users and case-workers from the social services appear to have a
positive attitude towards the use of short term, compulsory detoxification. This
may help drug users to survive in really acute situations and may enable them,
in a sober/drug-free condition, to decide whether they wish to continue
receiving treatment on a voluntary basis.
It is not at all certain, however, that these scientific insights
will help to bring about any kind of revision or repeal of the legislation
forcing drug users into compulsory care. Firstly, Swedish society has a long
tradition of providing help even for those drug users who do not ask for
assistance from the authorities. It was decreed as early as in the Alcoholics
Act of 1913, that persons judged to lack the capacity to put their own lives in
order should be compelled to change by means of internment and compulsory work.
The paternalistic element in the welfare system is thus nothing new, but is
rather based on, and constitutes a development of, an idea that has been
practised for over ninety years. When Swedish authorities are faced with people
who are ruining their own or other people’s lives through drug abuse, the
country’s historical tradition means that the logical question is not simply
“Would you like some help?” but rather “Would you like some help, or are we
going to have to force it on you?”.
Secondly, the use of compulsory institutionalisation within the drug
treatment sector is based on a number of fundamental propositions that are taken
for granted and which in themselves constitute a justification for the LVM Act.
These include the conception that the problems experienced by society as a
result of drug use are substantial, that drugs and drug use are entirely
hazardous and pointless, that drug users are the victims of circumstances beyond
their own control and that treatment constitutes an adequate solution for the
problems experienced by different individuals.[54]
Additional propositions underlying the legislation are that drug use
is defined as a social and not a private problem and that people should not be
given the right to take their own lives by means of drug use. In addition there
is a strong conviction that the consumption of certain chemical substances (and
above all heroin) is highly addictive. This is regarded as having a debilitating
effect on the individual’s capacity to make rational choices.
Against the background of these fundamental ideas, it is entirely
consistent that public sector agencies be given the opportunity to temporarily
take into care those who are unable to cope with their lives in a socially
acceptable and constructive manner. Society may be said to be doing the “unfit
drug users” a service by preventing them from doing what they are assumed
actually not to want to do. This benevolent foundation underlying the
legislation is further reinforced by the fact that the LVM Act has a righteous
objective and that there exists a belief in society that the drug treatment
sector can contribute to the rehabilitation of drug users.
Irrespective of the results produced by treatment over the longer
term, the compulsory care sector can do no wrong; it is doomed to succeed, so to
speak. There are a number of factors that point to this. The first of these is
the fact that the goal of abstinence is achieved by definition through the
initial confinement of the drug user to a detoxification ward. The second is
that the goal of motivation is regarded as having been achieved once the drug
user agrees to being transferred to a more open form of treatment. According to
the legislation, this is something that should occur at the latest after three
months in an LVM institution, but it does not mean that the individual has
accepted voluntary treatment or that the possibility of returning him/her to
compulsory care has been eliminated. The third is that the legislation holds all
the trumps, since in purely human terms, it may seem better to do anything at
all rather than simply allowing drug users to take their lives in
peace.
In practice, compulsory treatment in accordance with the LVM Act has
three consequences that are of symbolic importance for the Swedish welfare
state: 1) it ensures that a substantial amount of resources are allotted to the
treatment of drug use, since LVM cannot be prioritised away even when available
budgets are tight; 2) it stands as a guarantee that society’s “unfortunates”
will be given assistance and will survive; and 3) it constitutes the basis of a
strong social services sector which has the opportunity to help even those
people who appear to lack the capacity to bring about changes on their
own.
If we look at these points from the opposite angle, however, we see
that being required to make savings will force local authorities to reserve
institutional care resources for LVM cases, instead of providing them to people
who are prepared voluntarily to seek the assistance of the treatment sector. It
might similarly be argued that LVM involves society’s “unfortunates” being
locked up and forced to accept treatment whose positive results are rather
dubious. In addition, a “strong social services sector” with the authority to
compel people into treatment may lead people to avoid turning to it for help out
of fear that they will be placed in care.
All in all, LVM’s time as a pilot project and “pioneering measure”[55] may now be seen as having come
to an end. The legislation has been in use for over twenty years and there is
still no evidence that compulsory treatment results in any kind of
rehabilitation over the long term for heavy drug users who lack the incentive to
change on their own. The reduction in the number of LVM decisions witnessed over
recent years has been viewed as indicating that local authorities make use of
the legislation primarily to save lives and to get people into detoxification.
Since both the preliminary work conducted in connection with the legislation and
the text of the legislation itself state that compulsory treatment is intended
also to lead to motivational work and long term rehabilitation, applying the law
in acute situations of this type is of course open to criticism. Looking to
expected treatment results, however, short term compulsory detoxification
appears to constitute the only form of LVM intervention that finds support in
the scientific literature and that appears rational from the point of view of
rehabilitation.
It is a well known fact that since the 1960s,
Sweden and
Holland have
developed completely different types of drug policy. But there are a number of
misconceptions as to what the differences consist in and how they have arisen.
My contribution to this anthology involves elucidating these differences[56].
In the context of international discussions of drug policy, the
policies followed by
Sweden and
Holland are regarded as
being completely antithetical. Swedish policy is described as restrictive,
meaning that measures are directed at preventing the population coming into
contact with illegal narcotic substances. The basic assumption is that all
non-medical use of drugs constitutes abuse. The underlying motive is that this
is done for the people’s best and that it is the job of the state to shield the
population from danger. Dutch policy is described as liberal, i.e. the state
should not interfere in people’s private lives as long as this does not cause
injury to a third party. This also extends to behaviours regarded by the
majority as undesirable, e.g. illegal drug use. In the following, I will be
restricting myself to what I regard as the essential elements that distinguish
the two countries’ drug policies from one another.
Social problems
One way of studying the development of a certain drug policy is to
employ a social constructionist perspective. This term is used to indicate that
social problems such as drug use, for example, are constructed in a process in
which a large number of actors participate. One important aspect of this process
involves arriving at a definition of the problem that everyone is more or less
agreed upon. The causes of the problem, how it spreads, the measures suitable to
combat the problem, and who should assume responsibility for what, are all
factors that are determined by the way a problem is defined[57]. This process results in an
integrated strategy, a drugs policy. Against this backdrop, it is important to
see how this new social problem has been defined in the two countries. When drug
use among young people became the focus of an increasing amount of attention
during the 1960s, both countries appointed committees of experts, giving them
the task of charting the problem and proposing counter measures. As a point of
departure, the text now turns to a discussion of the composition of these
committees, which is important because it gives an indication of what
politicians perceived to be the nature of the problem. The committees’
conclusions to a large extent then laid the foundations for the way in which the
problem would be perceived, and set the course that the development of drug
policy has since followed.
Sweden
The Swedish Drug Treatment Committee (1965 - 1968) was dominated by
representatives of the medical disciplines, which may be understood as a result
of the fact that intravenous amphetamine abuse was regarded as constituting the
major drug problem in
Sweden. Since the Second World War,
amphetamines had been used pharmaceutically on a large scale and the medical
profession were experts in this area. The doctors’ influence, not only on the
committee, but also within the general debate, certainly contributed to the
establishment of one of the central points of departure for Swedish drug policy,
namely that the drug problem could be compared to an epidemic. Although the
committee made the point that the comparison only related to the extent of drug
use and not to the programme of countermeasures, the metaphor came to have a
major impact on the formulation of Swedish drug policy[58]. The strategy to combat
epidemics is described by Nils Bejerot [59] in the following
way:
1. The agent itself must as far as possible be eliminated (the drug)
2. Control must be exercised over the means of distributing the
hazardous agent (by blocking illegal
production, importation and sales)
3. There should be preventive measures focused on susceptible and at
risk, but as yet uninfected, groups among the population (the provision of instructions, information,
and the conduct of preventive activities)
4. Those already affected should be given
treatment
5. Those who are highly contagious should be isolated and given long
term care (compulsory treatment).
One requirement for the use of a control strategy of this kind is
that the epidemic be presented as constituting a threat for a large proportion
of (youths) or of the entire population. The threat should also be presented as
being so immediate that possible disadvantages become subordinate to the
expected advantages. A classic demagogic device was employed in order to win
support for the programme of measures. Asplin, for example, the Minister of
Health and Social Affairs, emphasised the importance of uniting all the forces
of good in the battle against drugs[60]. A distinction was thus made
between the forces of good and evil. The forces of good were comprised of all
those engaged in the battle against drugs. The forces of evil included
unprincipled pharmaceuticals producers and of course those who smuggled drugs
into
Sweden, the “drugs sharks”. Those
whose views deviated from the official definition of the problem were also
counted among the forces of evil, and a few years later, this group came to be
labelled “drug liberals”.
In 1978, the Swedish parliament stipulated that the goal was to be
the elimination of drugs (the “agent”) in
Sweden. These
were never to be allowed to become a part of Swedish culture[61]. With this, a new element was
introduced into the discussion surrounding drugs. Drug use was unSwedish. This
served to further strengthen a trend that had existed since the 1960s, namely
that drugs constituted an epidemic from abroad. The placing of the cause of the
drug problem outside
Sweden has been a distinctive
characteristic of Swedish drug policy. The conduct of the battle was not solely
the task of the authorities, but was also something for citizens in schools and
residential neighbourhoods. United, the Swedish people constituted the force of
good, battling against an evil coming in from abroad, and in 1984, Ingvar
Carlsson stated that the only acceptable goal was a drug free society[62].
A model was developed based on the simple idea that if there are no
drugs in society, then there can be no drug problem either. In order to arrive
at this situation, three principal lines of attack were required, which will be
recognised from the epidemiological model described above. Firstly, the supply
of the agent (drugs) to
Sweden was to be cut off, and the
customs service were to play a crucial role in this regard. Secondly, demand was
to be obstructed by preventing those who had not yet been affected from coming
into contact with drugs. This constitutes one of the central tasks of the police
patrols focused on street level drug dealing. Another preventive measure
consists in using informational and educational measures and influencing public
opinion in order to affect people’s attitudes and behaviour so that they have no
desire even to experiment with drugs. The mass media have a decisive role to
play here. Thirdly, a drug care sector is required to provide treatment for the
carriers of the disease (the drug users) pushing them towards a drug free life,
under compulsion if necessary (isolating the contagious).
Holland
The committee of experts established in
Holland (1966-1972)
comprised a broad group of lawyers, social scientists and medical professionals.
One of the direct reasons for the establishment of the committee was the harsh
criticism directed at the repressive approach to illegal drug use employed in
Holland during
the 1950s and until the latter part of the 1960s. By contrast with the situation
in
Sweden, cannabis was the focus of
attention in
Holland. This was a substance with no medical
connection and about which there was little or no detailed knowledge. It was
primarily regarded as a youth cultural phenomenon that could not be resolved by
means of criminal justice measures. Cannabis was one part of the powerful
cultural changes that were affecting the whole of society. The epidemic concept
was not used by the Dutch committee at all. Instead it referred to diffusion
theory, which has been used to explain the dissemination of innovations within a
population. The underlying assumption is that new phenomena begin by spreading
quickly, but that they then subside and settle at a lower saturation point.
There were differing views as to what constituted suitable measures,
but politicians gradually came to agree that Dutch drug policy would be based on
an assessment of the risks that the use of various psychoactive substances
involved both for the user him/herself and for society. In the context of this
risk assessment, cannabis involved fewer risks than LSD, amphetamines and
opiates, for example. Measures would be focused on those substances associated
with the greatest risks. One important point of departure was that not all drug
use was defined as abuse per se, but
rather that socially integrated drug use was both possible and did occur. Drug
policy measures were viewed as having the potential to exacerbate the problems,
and thereby also constituted a risk factor that was to be included in the
context of risk assessment. This led to strategies aimed at reducing the risks
associated with the use of cannabis that were distinct from those associated
with other substances[63].
The definition employed by the committee and its conceptualisation of
risk came to constitute the major elements in the drug policy adopted by the
Dutch parliament in 1976[64]. These factors had assumed a
special relevance in 1972, when heroin arrived and spread quickly, particularly
among marginalised youth groups. It is important to note that the causes of the
problem were sought in social conditions within Dutch society, and not outside
Holland. The
possibility of cutting off the supply of drugs was not discussed as a realistic
alternative. The openness of the Dutch economy and the country’s reliance on
transit trade with its enormous inflows and outflows of goods made this
impossible. The occurrence of drug use was viewed as a worrying development but
also as being part of a trend that could not be controlled by politics. Besides
the geographical and economic conditions, it would have demanded measures that
were irreconcilable with the country’s liberal tradition on the issue of the
relationship between state and citizens.
The assumption was made that drugs would constitute an (illegal) part
of the supply of other means of pleasure promotion for a considerable time to
come, and that they were something that society would be forced to live with. A
model was developed that would separate the market for cannabis from that of
other drugs associated with an unacceptable level of risk. As regards cannabis,
tolerating coffee shops was intended to keep this substance out of the criminal
sphere, whilst a more repressive strategy was developed in relation to other
substances (heroin, cocaine), with the police and customs being given a central
role. Preventive measures in the form of informational and educational
activities were focused primarily on establishing a dialogue between youths and
parents on how to behave in relation to drugs in general. To begin with, the
treatment of drug addicts had the goal of inducing complete abstinence from
drugs. When this turned out to be unrealistic, different goals were specified,
complete abstinence or controlled drug use, depending on the conditions present
in the case of a specific individual. Among the most important distinguishing
features of Dutch drug policy, then, are the way it differentiates between
substances and target groups, and the way measures are focused on the goal of
risk reduction.
Comparison
The fundamental points of departure for drug policy were formulated
during the first two decades of the modern drug problem. Later developments have
primarily served to cement these points of departure. What similarities and
differences can be identified then between the two
countries?
In
Sweden, the problem was defined as
constituting a major threat to the people, and in
Holland as part of a society undergoing a
process of change. In
Sweden, all non-medical drug use was
regarded as abuse, whilst socially integrated drug use was regarded as a
possibility in
Holland. In
Sweden, there is
a unified front against drugs, which would be irreconcilable with the Dutch
policy on differentiated measures based on risk assessment. In
Sweden, the forces of good and evil
were identified and distinguished from one another, in
Holland it was different
substances and ways of using them. By extension, the principal objective of
Swedish drug policy may be said to consist in shielding the population from
drugs. In
Holland, drug policy is focused on shielding
individuals and society against different types of risk that may arise as a
result of drug use.
One similarity between the two countries is that they both identify
three areas as central to drug policy: the control system, preventive efforts
and treatment. As has been described above, however, these areas have been
associated with very different goals and have been given a different content,
since the points of departure are completely different.
Finally, one may ask whether the drug situation in the two countries,
following slightly over thirty years of completely dissimilar forms of drug
policy, is also radically different? Shouldn’t the number of heavy drug addicts
be substantially higher in
Holland, as well as the proportion of the
population who have tried cannabis? Isn’t the number of drug related deaths much
lower in Sweden?
According to estimates published in the annual report of the European
Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in 2002, this is not the
case. The number of heavy drug addicts is approximately the same across the two
countries, and is in fact much higher in Sweden if the count is presented in
terms of the number per 1000 of population, 4.7 by comparison with 2.6[65]. In Holland, 19.1 per cent of
the population have used cannabis at some point, as compared with 13 per cent in
Sweden[66]. In relation to mortality rates,
too, Holland appears to have fewer cases of acute drug related deaths among drug
addicts than Sweden, despite having a larger number of opiate abusers[67].
In Sweden, there is a widely held belief that we are a leading light
in the field of drug policy and treatment. The reality on the street is very
different. And for myself as a researcher, physician and human being, it is
completely unbearable. This is clearest in relation to patients with heroin
dependency, for whom there is a treatment which international and Swedish
meta-analyses agree improves the situation of patients, reducing levels of problematic drug use, improving social
functionality – including the reduction of criminality – and perhaps most
importantly, reducing mortality. Psychologically based treatment methods have no
such effect, unless they are provided in addition to an effective
pharmacological treatment; and even as part of a combination of this kind, the
treatment method most commonly offered in Sweden, i.e. non-specific support,
shows no effect.[68] In spite of the clarity of these
data, which in some cases have been available for approximately twenty years,
the “Swedish model” continues to withhold effective treatment from the majority,
i.e. approximately 90 per cent, of patients with heroin dependency, for
ideological reasons. Even among the minority of patients who are granted access
to treatment, this occurs in a spirit of policing rather than one of medical
provision. As a result, drug related mortality in Sweden has now been increasing
steeply for almost a decade, whilst other countries – such as France and Norway,
for example – have been able to break corresponding trends. A large part of this
mortality in Sweden occurs in direct association with patients being
compulsorily discharged from methadone treatment (MMT) as a result of sometimes
quite trivial infractions, and sometimes having undergone several years of
successful treatment.
Even if methadone and similar pharmaceuticals are effective for those
who have already developed heroin dependency, this effectiveness must be weighed
against the risk of leakage, and of new recruitment into problematic drug use.
Concerns over developments of this kind are at best based on ignorance, however.
Primary methadone dependency is a rarity even in countries where access to
methadone is largely unrestricted – methadone abuse does of course occur, but
only among persons who already have a well-developed drug dependency, namely on
heroin. What is more important is to realise that every active drug addict
constitutes a source for the dissemination of drugs, since dealing constitutes
part of the syndrome. Every addict that can be removed from the street by means
effective treatment contributes to a reduction in the accessibility of drugs.
There are no medical, general preventive or economic arguments that serve to
support the line adopted in Sweden. The position taken on this issue is the
result of the political needs of the actors involved, and not of the medical
needs of the patients.
A conceptual framework for the treatment of heroin
dependency
People do not take drugs because they want to die from AIDS or an
overdose. Addicts want to achieve the same positive goals in life as everybody
else. The difference is that the patients fail in this time and time again.
Relapses intervene and disrupt their lives, so that they constantly find
themselves back at square one. This constitutes a failure of “self-efficacy”,
i.e. the capacity to “self-regulate” behaviour in order to achieve one’s goals.
Today our knowledge of the processes within the central nervous system that lie
behind this phenomenon is relatively good.[69] Behavioural choices are normally
made through the continuous weighing of contradictory factors against one
another. Shall I go over to the computer and finish this article, or stay
sitting on the sofa? Shall I have children, wonderful creatures, but such hard
work too? The everyday requirements of self-regulation are difficult enough. In
a patient with drug dependency, the available choices are more restricted, and
are determined by the balance between normal motivational forces and factors
associated with the dependency. Among these latter factors, heroin euphoria is
important to begin with, but over time the focus shifts to holding one’s own
against a painful craving, and overcoming bad habits. Relapse occurs when the
individual is unable to get this balance to weigh in favour of the behaviours
that lead to the goals he or she is seeking to achieve: keeping a job, a partner
or maybe a place to live.[70]
Failure leads to a process of negative learning, which lowers the
patients’ expectations of their ability to cope when they are faced with choices
in the future. These expectations are integrated into thought patterns which in
time become automatic. There is a myth that drug users have to have “had enough
of drugs” before they can open up to the effects of treatment, but the only
thing an addict learns from failure is – how to fail. The most important task of
treatment is to help the patient break this cycle, and to help him experience
being successful. In the context of this work any method that shifts the
motivational balance in favour of “healthy” behavioural choices is of use. Such
interventions can be accomplished with both pharmacological and psychological
tools.[71]
The role of the pharmaceuticals - methadone and
buprenorfin
For over 30 years, ideologically motivated social commentators have
repeated the same misapprehensions: treatments employing methadone and other
similar substances amount to “legal narcotics”, which at best serve to keep the
patient off the street. In actual fact, the substances at issue have been
produced in such a way as to minimise the extent to which they provide the
feelings of euphoria produced by the illicit drugs for which they serve as
substitutes. Even if this has not been completely successful, the potential for
dependency is much lower by comparison with the drugs available on the street,
in line with our knowledge of the fundamental pharmacological properties of
these substances.[72] The mechanisms by means of which
these pharmaceuticals may shift the motivational balance in the right direction
are also well known (Table 1).
Table 1. The clinical effect profile of pharmaceuticals that may be
relevant for the pharmacological treatment of heroin dependency.
Type of pharmaceutical
Inhibition of craving for drug
Inhibition of heroin-euphoria
Full opiat receptor agonist
(e.g. methadone)
Yes
Incomplete
Partial agonist
(e.g. buprenorfin)
Yes
Yes
Pure antagonist
(e.g. naltrexon)
No
Yes
“Agonist” is the pharmacological term given to a substance that binds
a receptor and activates it. An “antagonist” on the other hand binds the
receptor with no accompanying activation taking place, whereby the effect of
other activating substances – such as the heroin – is smothered and fails to
materialise. “Partial agonists” fall between these two - binding is followed by
a certain, but limited receptor activation. If there are no other receptor
activating substances in the system, then there will be a certain level of
opiate-like clinical effect. In the presence of other, more potent opiates, this
effect is instead transformed into antagonism.
Among the suitable pharmaceuticals, methadone is the one with far and
away the best evidentiary support. Methadone reduces levels of mortality and
morbidity, and improves social functioning. From a medical perspective, the only
reasonable conclusion is that patients who are not helped by other means must be
afforded the right to be given this form of treatment. This is exactly what was
established by the federal guidelines laid down in 1998 by the American National
Institutes of Health.[73] There are however disadvantages
associated with Methadone that limit its usefulness; above all a certain
potential for overdoses and leakage into street level drug use. In the majority
of cases the treatment must continue for several years. Strategies are also
needed, therefore, that would constitute a “first line of defence” before the
step is taken to methadone treatment. This need is particularly great in
relation to young patients, and patients at an early stage in the development of
a dependency. In this regard the partial
opiate receptor agonist buprenorfin (Subutex) has an interesting
pharma-cological profile, indicating a
lower dependency potential and lower toxicity. The use of buprenorfin therefore
suggests itself as an attractive option for creating the conditions for modern
psychological treatment.
The development of the Maria model
In 1999, at the Maria Clinic in
Stockholm, we organised a project to develop
integrated, Subutex-assisted treatment. Daily medication with Subutex was
combined with group treatment employing cognitive behavioural therapy. This
therapy focused on preventing relapse in accordance with a manual-based
methodology for which there was good empirical support.[74] Other components included
individual conversational support, and strict controls that the patient is not
taking drugs. Based on a small series of successful pilot patients, we began a
controlled study of the model in the spring of 2000. All were given the
intensive psychosocial treatment package; half were in addition randomised to
receive buprenorfin treatment and half to a placebo group. It is important to
point out that these patients, as is the case with approximately 90 per cent of
Swedish heroin users, would otherwise not have had access to either
