*

2003

Ed. Henrik Tham

Stockholm University

Department of Criminology

SE-106 91 STOCKHOLM

*The figure on the title page describes number of drug related deaths as underlying or contributory cause of death in absolute numbers, 1969-2000.

Translation:

Dave Shannon

Financial Support:

Contents

Foreword                                                                                                          4

Presentation of the authors                                                                                   5

Drug policy and trends in problematic drug use in Sweden                                                    5

Henrik Tham                                                                                                       

Drug policy and crime control                                                                                                 19

Per Ole Träskman                                                                                                 

The results and consequences of the compulsory treatment system                                    28

Mats Ekendahl                                                                                                    

Sweden and Holland – two drug policy models                                                                     33

Dolf Tops                                                                                                           

Foolish dogmatism kills. On substitution treatment                                                              40

Markus Heilig                                                                                                     

Drug policy and the expansion of the prison system                                                             47

Magnus Hörnqvist                                                                                                

The drug policy relevance of drug related deaths                                                                  53

Leif Lenke and Börje Olsson                                                                                  

The drugs conventions and drug policy of the UN                                                                  64

Henrik Tham                                                                                                       

A drug free Sweden?                                                                                                                71

Henrik Tham                                                                                                       

Foreword

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.

                                                                                                                                                              Ed.

Presentation of the authors

Mats Ekendahl Ph.D. works at the Department of Social Work at Stockholm University

Markus Heilig is Associate Professor at the Karolinska Institutet and is head of the Research, Development and Education unit at the University Hospital at Huddinge

Magnus Hörnqvist is a postgraduate research student at the Department of Criminology at Stockholm University

Leif Lenke is Professor of criminology at Stockholm University

Börje Olsson is Professor of alcohol and drug policy at Stockholm University

Henrik Tham is Professor of criminology at Stockholm University

Dolf Tops Ph.D. works at the Department of Social Work at Lund University

Per Ole Träskman is Professor of penal law at Lund University

Drug policy and trends in problematic drug use in Sweden

Henrik Tham

Developments in the control system

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.”

   Figure 1. Number of police officers working with drug crime 1965-2001.

                        Figure 2. Persons sentenced to prison for drug offences 1975-2001

                Figure 3. Drug users in prison 1968-2002

Trends in drug use

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.

Cannabis as a stepping stone?

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.”

Drug policy and crime control

Per Ole Träskman

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 19^th 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 23^rd May 2001 by comparison with the proposal of the 30^th 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.

The results and consequences of the compulsory treatment system

Mats Ekendahl

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.

Sweden and Holland – two drug policy models

Dolf Tops

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].

Foolish dogmatism kills. On substitution treatment

Markus Heilig

Background

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.

“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 methadone or buprenorfin nor to qualified psychosocial treatment.

One of the challenges facing treatments of this type is that of on the one hand maintaining the ambition of complete abstinence from drugs, and a structure that promotes this goal, but without the treatment being transformed into a means of oppression, with the coveted and quite literally vital pharmaceutical being used as an instrument of domination. The goal, or course, is that with time, the patient will assume responsibility for the treatment. We employed treatment plans that were careful to make it clear that problems during treatment would in the first instance lead to supportive measures – more frequent individual discussions, or, in extreme cases, a short period of hospitalisation. It was important to convey the point that by contrast with the methadone treatment model that had become established in Stockholm, our goal was to do everything to keep the patients in treatment. At the same time, there were explicit rules stating that missed appointments or urine tests that were positive for drugs would lead to patients being discharged if they did not participate in support measures and gradually become stabilised. This combination created a situation of mutual trust and a feeling of being respected among the patients, in a way that is crucial if any form of treatment is to be successful. The results were striking, and at time of writing are about to be published in one of the world’s most prestigious medical journals, The Lancet.[75] Given the requirement of complete abstinence, none of the patients in the control group were able to cope for longer than approximately two months, despite a considerably more intensive programme of psychosocial treatment than is normally available for this group of patients. In the active group, on the other hand, fifteen of twenty patients were still in treatment after a year. On average their urine tests were clean 75% of the time, and their level of accumulated problems had been dramatically reduced, as witnessed by a stable housing situation, substantially lower levels of involvement in crime and a significantly improved employment situation. And we know from Gunne and Grönbladh’s methadone studies that improvements of this kind do not reach a peak until approximately four years after treatment.

The myths

“The French Catastrophe”. Subutex was registered in France over six years ago. The situation in France was distinctive, with heavy restrictions on methadone, and with the majority of patients not receiving treatment. The result was a high and rising level of mortality. When Subutex was registered it was made available without restriction and with no resources being made available for additional components of treatment. General practitioners began issuing a quite phenomenal number of prescriptions. Even given the low level of qualitative treatment involved, there are now approximately 1/5 as many deaths as there were six years ago.[76] Highly qualitative treatment is clearly preferable to a less qualitative alternative. But if the choice is between less qualitative treatment and no treatment at all, it is difficult to see the logic or the morality in opting for the latter. It is in fact Sweden that is witnessing the catastrophe, not France.

“The uncontrolled prescription of Subutex”. A close collaboration between interested treatment workers across Sweden made it possible to count the number of patients receiving structured treatment in accordance with the Maria model, and to make comparisons with the number of patients being prescribed Subutex. For a long time, the difference was negligible. On the other hand, Subutex was available for purchase on the street, for the most part having been smuggled in from Finland. This is unfortunate, but the medical risks involved are limited. The drug-induced euphoria associated with Subutex is limited, and the drug’s pharmacological properties make the risk of overdose extremely remote. In France, in the few cases of deaths where the patient was found to have buprenorfin in the bloodstream, there was also a combination of other substances present, which meant the death could not be tied to Subutex. Irrespective of this, it is not clear that restricting the use of Subutex among conscientious Swedish doctors is the most logical way of resolving the problems associated with the smuggling of this substance from abroad.

“But we don’t want a liberal drug policy”. Presenting oneself or one’s party as the strongest denouncer of drugs has become a competitive and important political sport.  It is difficult to see, however, how drug policy would be made more “liberal”, i.e. more permissive of problematic drug use, by offering effective treatment, in strictly controlled forms, thereby helping the patients to stop taking drugs, to desist from crime and to improve their social situation. I am personally in favour of drug policy being made as stringent as possible. Those who sell drugs should be taken off the streets, and those who deal in drugs without themselves having a dependency should in my opinion be sent to prison – for a long time. But those who are dependent on drugs are not helped by policing measures, and effective treatment constitutes the best way of reducing both the demand and supply of drugs. And this it worth repeating: Effective treatment constitutes one of the cornerstones of a restrictive drug policy. Or it should.

Comprehensive strategy

New forms of treatment may be regarded by their pioneers with an enthusiasm that is every bit as naïve as the opposition. I feel a heavy responsibility to avoid falling into this trap. It is unlikely that Subutex constitutes a treatment that will suddenly prove to be the salvation for all heroin addicts. On the other hand, the treatment does widen the range on offer and helps us together with the patient to choose the method that is best suited to each individual case. It is easy to see the opportunity for a rational, well-balanced strategy that would make treatment available to those patients who need it, whilst at the same time avoiding inferior alternatives. A strategy of this kind was proposed in 2002 by an expert group working on the commission of the National Board of Health and Welfare. Even before this document was made public, a 28 page letter of protest had arrived, comprising a comprehensive sample of all the uninformed reflex reactions that are expressed in the debate in this area. The question is whether we have what it takes for re-orientation. We face a choice between cherished dogmas and the lives of patients.

Drug policy and the expansion of the prison system

Magnus Hörnqvist

Over the past ten to twenty years, the prison population has expanded in virtually all western countries. Drug policy constitutes an important part of the explanation. There is a close correlation between drug policy and the expansion of the prison system. The battle to combat drugs has filled the prisons with drug addicts. This constitutes the single most important reason for the large increase in the prison population in the USA. Drug users sentenced for drug related petty offences comprise the vast majority of prison inmates in the United States. During the 1990s, the number of prison inmates rose by eight per cent per annum, and by the end of the decade, two million Americans sat in the countries’ prisons on any given day. In Europe, too, the numbers of both inmates in general and imprisoned drug addicts are on the increase. There is still a long way to go before we reach the American levels, and in addition it is difficult to know how many of the prison inmates are drug addicts as a result of shifting routines and definitions. One estimation, however, places the number of drug users passing through the prison systems of EU countries at between 180,000 and 600,000 per year. And the trend is towards further increases.[77]

In terms of the social resources they have at their disposal, the drug users among prison inmates constitute a particularly weak group. This weakness is marked not only in relation to the population as a whole, but even by comparison with other inmates. Among those in prison, drug users are more often homeless, more often suffer from financial problems and are more likely to receive no prison visits. Available studies of living conditions among the general population of drug addicts present a picture of a group with a wretched economy, difficulties finding housing, who are in poor condition both physically and psychologically and who lack social contacts with others. Not all are sentenced to prison, however. Are there differences between those addicts who are repeatedly sent to prison and those who find themselves only rarely or never being dealt with by the prison service? Above all, do they constitute a more marginalised group? No surveys have been conducted in Sweden, which makes it difficult to answer this question. Studies from other countries show that police and the courts prioritise poor addicts and immigrants in particular. Once again, the USA provides a very illustrative example. African-American men comprise six per cent of the country’s population and seven per cent of the population of drug users. At the same time African-American men comprise 35 per cent of those arrested for drug offences, and fully 75 per cent of those sentenced to prison for offences of this kind.[78]

Over the last few years, there has been considerable discussion of the over-population of the Swedish prison system. Everything points to an expansion of the prison system, with new prisons being built to provide room for an expanded number of inmates. The alternative would have been decriminalisations or an increased use of alternatives to a prison term such as contractual treatment programmes. Over the next four years, however, there are plans to provide 1500 new prison and remand places. A large proportion of these will probably be filled by drug addicts. In the year 2000, 3,900 individuals, or 43 per cent of those admitted to prison, were heavy drug users.[79]

From this viewpoint, Swedish drug policy is not unique, but rather constitutes part of an international trend. The relevant decisions have nonetheless been taken at the national level. The changes in the Swedish prison population are a consequence of political decisions taken in the Swedish Parliament and of the choice of priorities made by civil servants within the police and prosecution services.

These developments started a little over 30 years ago, when the penal tariff associated with drug offences was increased sharply. Over the following decades, the amount of prison time awarded in connection with drug offences doubled, from 7,000 months per year (during the period 1973 to 1975) to 14,000 months per year (during the period 1990 to 1993). The legislation was tightened successively, with a prison term being included in the sanctioning scale for the mere consumption of drugs in 1993. From this point on, the 1990s saw the police prioritise measures focused on the consumption of drugs, directed at the drug user on the street. This has led to a substantial increase in the number of people convicted of drug offences; between 1993 and 1998 this number increased by over 40 per cent. In 1996, just over half of those convicted exclusively of drug offences were sentenced to prison. The remainder were given other sanctions such as contractual treatment, probation or day-fines. There is a strong correlation between prison sentences for drug offences and drug use at the level of the individual. Nine of ten of the drug addicts admitted to prison have already served a prison term for drug offences relatively recently (during the last five years). As a consequence, the proportion of drug addicts among the prison population has increased over this same period. According to official statistics, a little under half of those admitted to prison over the last three years have been drug users. The increase in the proportion of drug users has been particularly marked among those admitted for a short stay in prison (at most two months); here the proportion of drug users has almost trebled during the 1990s.[80]

Thus if crime policy remains unchanged, a growing proportion of society’s resources will be devoted to locking up drug addicts. Does this seem reasonable? This question is not primarily of an ideological nature. As in any other area of policy, drug policy must be evaluated with respect to its effects. This presentation will focus on some of the concrete effects of drug policy for those serving custodial sentences within the Swedish prison system. The issue of interest is the effect on the individual drug user and the central question is that of the way in which the individual’s chances of desisting from drug use are affected during the time spent in prison.

This requires that we first provide an answer to the question of which effects are relevant. What is required for drug addicts admitted to prison to take the step to a life without criminality and drugs? When these questions are put to the drug users themselves, there are primarily two important factors: the one is an improved social situation, the other motivation on the part of the individual him or herself. If people have not themselves decided to stop using drugs, or to change their lives, the most important condition necessary for effecting change is absent. There is also agreement as to the important role played by the individual’s social situation in relation to the question of continued drug use or desistence. Work, education, housing, keeping drug free company, and participation in leisure activities are crucial to desisting from drug use and remaining free from drugs.[81]

Given this, the question to be examined can be specified more precisely. What effects does current Swedish prison care have on 1) the inmates’ social situation, and 2) their motivation to stop using drugs? To begin with, a custodial sentence in itself has a negative effect on both motivation and the individual’s social situation. Active efforts are therefore required to counteract these negative effects. This insight has also won ground in the legislation in this area. According to the Act on Correctional Treatment in Institutions, the prison authority is charged with counteracting the injury caused by the stay in custody itself. In addition, the inmate’s adjustment to society is to be facilitated. That is to say, at the same time as the state sentences an individual to prison, within the framework of this sanction, those receiving such sentences are to be given a real opportunity to desist from both criminality and drug use.[82]

The social situation. There are no statistics relating to the type of resources made available to drug addicts in prison, nor are there accounts of the forms of assistance that have actually been utilised by inmates in order to improve their social situation. On the other hand, there is comprehensive documentation relating to the existence of this need. There are several studies, for example, showing that prison inmates have significantly poorer resources across the areas of education, finances, health and social relations than the remainder of the population.[83]

The need is thus quite substantial. What do we know about the capacity to meet this need? There are one or two interview surveys of inmates which focus on the forms of assistance provided by the prison service. According to these surveys, a small proportion of inmates report that they have been given forms of assistance relevant to changing their social situation, whilst the majority feel that they have not been given access to help of this kind. Across many different areas, only a minority report that they have received assistance. In a study conducted by the Swedish National Council for Crime Prevention, 95 randomly sampled inmates were interviewed about their situation during the month prior to their release from prison. Of these, 19 per cent reported that they received help with housing, 29 per cent help with employment, 15 per cent help with their financial situation and 17 per cent reported having received help to maintain their network of social contacts. In my own questionnaire survey of 166 drug addicts in prison, a little over ten per cent reported that they were receiving relevant help at the time, with a further fifteen per cent reporting they would be given the opportunity to receive relevant assistance towards the end of their time in prison. Sixty per cent answered that they received no help at all or almost none. This indicates the existence of major deficiencies in the prison service’s capacity to respond to the documented social needs of inmates – either on its own or in collaboration with other agencies. According to the report of the Drugs Inquiry, the trend is on the decline.[84]

Motivation. As is the case with Swedish drug policy in general, the care provided to inmates by the prison service is today based on the assumption that motivation and coercion complement one another. The more difficult it becomes to use drugs, the more people will want to stop doing so. The expanded use of compulsory measures is not regarded as antagonistic towards the reinforcement of motivation, but rather the one is viewed as a prerequisite for the other.[85] But there is reason to question this assumption, which ignores both the harmful effects of compulsion and the influence of the social situation. In an immediate sense, repeated compulsory measures have a destructive effect. This is true across the range of coercive measures – from individual urine tests and body searches to custodial sentences as such. Further, the assumption that the use of compulsion serves a complementary function involves an underestimation of the significance of the social situation for individual motivation. A drug user who is able to see a practicable route to a decent job, a place to live and a functional social network following release from prison will in general be more motivated to stop using drugs than one who does not see such a future, and who is instead confronted by the police, unemployment and further stays in prison. It is important to understand why people continue to use drugs. Having followed the life of the drug user at close hand over a period of several years, Bengt Svensson stated that it involves “wretchedness, treachery, a lack of solidarity, illness, suffering and death, but it also includes other elements – sociability, eventfulness, short-term perspectives, an attitude of it-always-works-out-in-the-end, a feeling of competence, occupation in the form of criminal earning patterns, and the artificial pleasures produced by drugs. This can be contrasted  with what normal life often has to offer them by way of alternative – loneliness, unemployment, poverty, idleness, a sense of being superfluous.”[86]

The motivation to stop using drugs waxes and wanes in the context of a social situation. But in the prison service of today, it is treated as something isolated. Inmates are motivated to stop using drugs by means of special courses aimed at affecting their ways of thinking, their attitudes and their self-image. The objective of these courses is to provide the mental tools needed to cope with life without drugs and criminality, irrespective of an individual’s social situation. But willpower and an improved self-image are resources that are often broken down by setbacks following release. Cognitive programmes may be sufficient to help some, but are unlikely to be enough for the large majority.[87]

Drug users comprise a continuously increasing proportion of the growing prison population. Given the high costs – in both economic and human terms – this course of action ought to be motivated by good arguments. It lies in everyone’s interests at least to ask about its effects, since this constitutes the only means of judging whether or not the project has been a success. The conclusion drawn from the analysis presented here is that the prison service of today appears to be poorly equipped to take care of the group of individuals in question. There are insufficient resources to improve the inmates’ social situation, which also has a negative effect on their motivation to stop using drugs. Given these circumstances, sentencing even more people with drug problems to prison would appear to be highly irrational.

The drug policy relevance of drug related deaths

Leif Lenke and Börje Olsson

Background and objectives

Ever since drug use was exposed to the glare of publicity and defined as a social problem during the 1960s, the greatly heightened mortality rates associated with problematic drug use have constituted one of the main reasons that this issue has continually been awarded a prominent place in both the political arena and the wider social debate. The mystery and drama that have always been associated with drugs have further increased levels of interest, whilst this, in combination with the fact that, in spite of everything, drug use remains an activity of which the majority have no knowledge, has allowed the myths surrounding this phenomenon to flourish. In relative terms, the numbers of drug related deaths are small. At a rough estimate, the number of alcohol related deaths, for example, is approximately 20 to 30 times as high as the number of deaths associated with drug use, without receiving anything like the same amount media attention.

Statistics on drug related mortality have been presented in systematic form since 1956. In part this information has been used as an indicator of the extent of drug use and of trends over time, but it has also served as a source of information on the dangers posed by the various substances and on the hazardous living conditions in which drug users live their lives.

Drug related mortality does not constitute a single uniform concept, but rather includes a variety of different causes of death. Often it is the immediate deaths, such as are caused as a direct consequence of the consumption of narcotic substances, that are emphasised. The most common of these comprises heroin overdoses. There are other causes of drug related deaths, however, such as infections that have arisen in association with injections (including HIV/AIDS), accidents that take place whilst under the influence of drugs or acts of violence taking place between drug users. In addition, the statistics usually differentiate between immediate causes of death and causes that have contributed indirectly to the death. Thus when statistics on drug related mortality are employed for various purposes there is plenty of room for confusion and misunderstanding. For the moment, Swedish authorities and organisations present at least three different statistical series relating to this type of mortality. The pictures of the extent of drug use and of trends over time differ somewhat between these statistical series, and it is clear that the series chosen for presentation and reference in a certain context may depend on the objectives of those presenting the data.

The aim of this article is twofold. The first intention is to clarify the differences between the different types of statistics presented in this area. This will involve amongst other things attempting to describe what the different statistical series show. This is particularly important where comparisons are made with drug related mortality in other countries. The second intention involves an attempt to analyse and understand why these statistics have become the focus of a “political” conflict.

The statistics

National statistics relating to the number of drug related deaths have been published in Sweden for many years. The two oldest series are those presented annually in the publication “Drogutvecklingen i Sverige” (Drug Trends in Sweden) produced by the Swedish Council for Information on Alcohol and other Drugs. These two series are based on Sweden’s official cause of death statistics. The first goes back to 1956 and includes deaths where drug addiction (classified in accordance with the ICD classification system)^[88] was included as the underlying cause of death. According to WHO (the World Health Organization) the term underlying cause of death relates to “the disease or injury that initiated the train of events leading directly to death, or the circumstances of the accident or violence, which produced the fatal injury.”^[89] This means that in principal these statistics reflect deaths – for the most part relating to overdoses – that are immediately associated with the consumption of drugs.

Table 1. Drug related mortality in Sweden.

The statistical series are based on two principles. Those labelled SCB 1 and FHI relate to the “underlying” cause of death. In practice, these series show those cases where death has occurred as a direct consequence of drug use. In this instance, the most common form of such deaths relate to so-called “overdoses” as a result of intravenous heroin use. The series SCB 2 also includes cases were the drug has worked as a so-called “contributory” cause of death. In principle, this latter series describes mortality within the group of drug users at large, i.e. it includes deaths that were not directly related to an overdose.

Diagram 1. Drug related deaths in Sweden 1969-2000.

Diagram 2. Drug related deaths in Sweden 1969-2000. Presented by age.

As can be seen from Diagram 1, the number of drug related deaths has increased dramatically, particularly during the 1990s and in the category where drug use is also included as a contributory cause of death. When the number of deaths is broken down by age, there appears to have been a similarly sharp increase across more or less all age groups (Diagram 2). This means that the increase cannot be explained by reference to an aging cohort of drug users.

Whilst the statistics relating to drug related deaths are subject to a number of problems (including changes to diagnosis codes, changes in the frequency of autopsies etc.), the general picture they provide of the trend over the last 20 years is nonetheless quite unequivocal. The number of drug related deaths (underlying and contributory) is today considerably higher than it has ever been before. In addition, the rate of increase appears to have become steeper over recent years. It is naturally quite correct to demand that the problems associated with these statistics be investigated and that work be conducted to improve them, but this must not be allowed to serve as an excuse for not analysing what implications the increase that can already be observed ought to have for drug policy.

A problem?

To what extent then has particular attention been focused on this problem in the context of the drugs debate? A number of experts have drawn attention to it, amongst others the public health physician and now director general of the National Institute of Public Health, Gunnar Ågren, who put it in the following way in an interview with the tabloid newspaper Expressen (98-11-19):

Mortality among heroin addicts is twice as high in Stockholm as in other European cities. The only treatment method that is reasonably effective, methadone, is held in check by Swedish drug policy.

This is not so self-evident to everyone, however. The website of the Norwegian association the League against Intoxicants^[93], for example, includes an article entitled “Överdosfrågan, en hälsofråga?” (The overdose issue, a question of health?). This article argues against focusing on the problem of drug related deaths. It states that:

270 individuals died of an overdose last year (in Norway). This is serious. But the discussion of the measures that should be taken has to be seen against the background of an international debate on legalisation, in which the overdose problem constitutes a cut-off point.

How should this be understood? To begin with, 270 deaths is indeed a very high number. The number produced headlines in the international press. Few countries show levels of drug related mortality relative to population size that are as high as those of Norway.

But what are we to understand by the use of the phrase “the discussion of these deaths has to be seen against the background of an international debate on legalisation”? Well, according to the organisation itself, which advocates a policy of “zero-tolerance”^[94]like its brother organisations in Sweden – the National Association for a Drug-free Society (RNS), Hassela, and the National Swedish Parents Anti-Narcotics Association (FMN) – focusing on the high mortality among Norwegian drug users is well-suited to the purposes of the so-called “harm reduction” movement.^[95] This movement advocates a view that drug policy must focus on reducing the harms associated with drug use, even if this drug use continues. This movement has also – according to the FMR – “often been seen as constituting a spearhead within the legalisation movement.” Thus focusing on drug related deaths serves to assist the legalisation movement. In the text, this is expressed in terms stating that since many in Norway have agreed to a 10 point programme intended to reduce levels of mortality among drug users,

this shows that the arguments of the legalisation movement have had a major impact.… Whereas analyses show that the proposals will at best have only a marginal effect in preventing overdoses, but will produce crime policy signals that may leave us with a great many more overdose cases to deal with.

Here we have the European drug policy debate in a nutshell. To the extent that you prioritise attempts to reduce the harms caused by drug use, you are helping the “legalisation movement” by “sending the wrong signals”. One of the characteristics of this debate is that those on the “zero-tolerance” side feel that there are no dilemmas in drug policy. They were against the use of methadone programmes because these were viewed as sending out the “wrong signals”. They are against needle exchange programmes for the same reasons, in spite of the fact that such programmes have been recommended by WHO^[96] etc.

The parallels with the alcohol rationing system.

What we are looking at is a classic example of antagonism between absolutist and reformist political theory and practice. The “absolutists” oppose reform because reforms tend to reduce the incitement and the will to achieve the ultimate goal. The same was true of the absolutist temperance movement’s opposition to the system of alcohol rationing. Few today are aware of the fact that the temperance movement was in fact the most outspoken opponent of alcohol rationing and took up the cudgels to abolish this rationing system. (They did so in collaboration with the, often conservative, alcohol liberals). Svante Nycander has illustrated this process very clearly in the book “Svenskarna och spriten”. ^[97]

Given our knowledge of the dramatic increase in levels of various problems that took place following the abolition of alcohol rationing – in the form of substantial increases in mortality, crime and other social problems – one might ask how this could have happened.^[98] It is perhaps not so surprising, however, that those who tend to cover this area – i.e. the temperance movement – have no desire to air this question.

The answer lies nonetheless in the ideology of the temperance movement itself. The Swedish temperance movement – as is the case with the corresponding movements in Finland, Norway, Iceland and North America – are/were based on moral foundations, often with a Free Church connection. Here becoming intoxicated is viewed as immoral because one is then unable to take full responsibility for one’s actions. This leads to the conclusion that an “alcohol-free society” is the only correct line. In today’s terminology, Ivan Bratt – the man who created the alcohol rationing system – was a representative of the “harm reduction” school in the area of alcohol policy. His proposal and his policy led the temperance movement to lose the referendum on a total prohibition of alcohol in 1922. He was never forgiven for this. His policy meant that the state “legalised” alcohol. Bratt sent out the “wrong signals”.

Against this, Bratt argued that the harms associated with alcohol – in all their forms – during the period of alcohol rationing remained at a very low and stable level for several decades, and that a total prohibition could not have been upheld. Mortality rates among alcohol abusers at the time were no higher than among the normal population etc.

This didn’t suit the temperance movement. Its focus lay not on harm and mortality, but instead was more or less exclusively directed at the fact that the number of teetotallers declined during the period of rationing. As did the number of organised teetotallers.

The abolition of alcohol rationing led to a dramatic deterioration in the level of alcohol related harm. It was a success in only one, and that a rather problematical, regard. This related to the fact that the number of persons applying to join the temperance movement underwent a substantial increase. It is difficult to disregard the fact that this increase was a function of the way that alcohol was once again being experienced as – and had once again become – a serious social problem.

On the continent – as in Denmark – the temperance movement chose a different path. These movements were not built on moral, absolutist foundations, but were rather based on a public health perspective. The situation was adjudged such that liquor was deemed to constitute the principal problem and the duty on liquor was therefore increased very substantially. Alcohol consumption fell, and with it levels of alcohol related harm.

The parallels with the drug policy of today are clear. On the continent, this “reformist policy” was regarded as successful, so successful even that in many areas temperance movements ceased to exist altogether. Against this background, today’s drug policies are focused on those drugs that are regarded as constituting the greatest danger.

The “absolutist” temperance movements recovered, however, and continued to promote a policy whereby less potent forms of alcohol were regarded as constituting a “stepping stone” to “heavier” forms of alcohol consumption. During the period of alcohol rationing, it was permitted to purchase liquor, but strong beer was completely prohibited according to the doctrine of the temperance movement. In Iceland, this went so far that as late as in 1989 it was possible to purchase liquor (e.g. “Black Death”) in restaurants, but not strong beer^[99]. The policy was discontinued, but these drinking practices had by then served to put Iceland in first place among the Nordic countries in terms of problematic drinking habits.

Relevance for the Swedish drug debate.

What then is the relevance of the above discussion for the Swedish drug policy debate? The answer is that in Sweden, this debate is still conducted in line with a doctrine similar to that on which the temperance movement was based. With one or two exceptions, the “new temperance movements” that have emerged in the drug policy arena, are founded on the so-called “zero tolerance” principle. These actors oppose all measures that may be regarded as sending out the “wrong signals”. Such measures have included amongst other things both the methadone programme and needle exchanges. In addition, the policy initiatives associated with such actors also assign a central role to the police, not only in relation to trafficking and smuggling etc., but also in relation to the control of users’ consumption of drugs. The express goal of the police, who also work in accordance with the zero tolerance principle, is that “It’s going to be tough to be a drug abuser”.^[100]

Here the rhetoric still looks the same. It took its most recent expression in an article in the national broadsheet Svenska Dagbladet (2002-06-23). There a representative of the Hassela Nordic Network (itself a ZTO), MaLou Lindholm wrote that Sweden is in the process of developing a new form of problematic drug use, namely of the methadone-like substance Subutex. According to Lindholm, this substance had “created 50 thousand drug abusers in France” and was now in the process of being introduced here.

At the same time, no mention at all was made of the fact that the use of Subutex is in fact a treatment method that over recent years has contributed to a reduction of nigh on 80 per cent in the number of drug related deaths in France.^[101]

The zero tolerance organisations instead focus blindly on the fact that the proportion of young people who have tested some kind of drug is lower in Sweden than it is on the continent. No mention is ever made of the fact that the number of heavy drug users in Sweden lies at more or less the same level as on the continent, that Swedish drug users present the highest incidence of hepatitis-C anywhere in Europe,^[102] and so forth.

In addition the Swedish Commission of Inquiry into Drugs was heavily influenced by the ZTOs. It was noted, for example, that drug related mortality was higher in Sweden than in the Netherlands, but no attempt was made to draw any conclusions as to why this might be the case. The Commission commented on the risk-reduction policy in the Netherlands, but did not find that there was anything to be learned from this approach. The dramatic reduction in drug related deaths in France was not even mentioned. Instead, the analysis on drug related mortality was concluded with the statement that “According to the Commission’s assessment, measures directed against problematic drug use in its entirety constitute the only measures that may have a decisive effect on reducing the number of drug related deaths over the longer term” (emphasis added).^[103] The Methadone programme, which all experts consider as having a depressant effect on levels of mortality, was regarded as having “relatively strict rules” which the Commission did not intend to change.

As is usually the case in the Swedish drug policy debate, it is the plan, rather than the reality, that is important. We ignore the fact that the level of mortality among those who fail to get into or are excluded from methadone programmes is approaching ten per cent. Instead we place our faith in cutting mortality by reducing levels of recruitment into heavy drug use.^[104] The problem of course is that even when recruitment declined during the 1980s, this failed to have an impact on levels of drug-related deaths. (See diagrams 1-2 above). But the plan is still applied.

The drugs conventions and drug policy of the UN

Henrik Tham

Swedish drug policy is legitimated in particular by reference to the United Nations drugs conventions. The member states party to these conventions have committed themselves to follow them. The drug policy of the UN is based on three such conventions, from 1961, 1971 and 1988.

The 1961 convention replacing previous conventions on narcotics (The “Single Convention”)

This convention relates to the control of narcotic substances derived from the opium poppy, cocaine leaf and cannabis plant. The convention brought together and unified a number of previous international agreements on the control of narcotics in a single regulatory system, and it applies to over 100 narcotic substances.

The 1971 Convention on Psychotropic Substances

This convention was introduced to control the growing number of psychotropic substances and includes amphetamines and many synthetic substances, i.e. substances produced by chemical means.

The 1988 Narcotics Convention

This convention was primarily established in order to increase control over the international drugs trade. It is also directed at the demand for narcotics, however, through its demand that the purchase and possession of the substances regulated in the two previous conventions be criminalised.

The UN drugs conventions, like other UN conventions, should be viewed as regulatory systems that have emerged in the context of a certain historical situation and that have sometimes been established in a spirit of agreement, sometimes following conflict. When cannabis was introduced into the Single Convention, a number of developing countries unsuccessfully opposed this move, amongst other things because they were afraid it would result in a shift to alcohol consumption.[105]

Within the UN, there has been a tradition of north-south antagonism in relation to the drugs issue. The southern countries, which constitute the poorer producer nations, have a slightly different picture of how control policy should be practised than do the richer, consumer countries. Countries such as Peru do not really understand why poor farmers’ harvests of coca leaf should be eradicated because the U.S.A. has a cocaine problem. The countries responsible for the supply of drugs made demands that the demand for drugs should also be controlled within the consumer countries. These demands led to the criminalisation of possession for personal consumption in the Narcotics Convention of 1988.[106]

There is a further antagonism, this time between different sections of the UN. The World Health Organisation, WHO, has proceeded from a harm reduction perspective in relation to the drugs question. On the basis of its health perspective, this organisation has amongst other things assumed a positive position in relation to needle exchange programmes. Several research projects have also been initiated. The WHO and its expert groups, in opposition to the prevailing control policy, have called attention to alcohol and tobacco as significantly greater problems than drugs and have questioned the harsh criminalisation of softer drugs.[107]

Ongoing discussions within the UN and among its member states also suggest the existence of problems related to the drug conventions and prevailing policy. Despite recurrent, proud declarations about a drug free world, the trends point towards an increase. To the extent that evaluations have been conducted, there has been a tendency to emphasise the process rather than the results. In certain cases, it is possible to point to programmes that have been put into effect, such as the prevention of harvests, for example, but their effects on the number of drug users are conspicuous by their absence. Issues relating to the health problems associated with drug use lead to demands for harm reduction. Several member states are also making demands that they be given more space to deal with the drug problem in ways better adapted to conditions at the local level and are looking for more openness in relation to questions of regulation and decriminalisation. This would also provide more room for the member states to relate to the drug problem on the basis of their own situation.[108]

The UN conventions are also the result of political processes and conflicts. There is a history behind their emergence and they are not of course written in stone but are open to modification and may be changed in different directions. The UN’s report on the world drug situation states that: “Their [the Conventions’] strength derives from the breadth of consensus that inspired them and from their foundation in international law; their weakness stems from their status as a compromise solution for nations of widely diverse historical, cultural and legal traditions, and from their relative difficulty of adaptation to fast-changing conditions.” The UN report also emphasises that: “Laws – and even the international Conventions – are not written in stone; they can be changed when the democratic will of nations so wishes it.”[109]

Amongst other things, the UN conventions have been criticised for forcing into place similar crime policy based solutions where solutions based on medical and social policy would be more appropriate, and for making it more difficult to take national and local conditions into account.

As has been mentioned, however, the member states that have signed the conventions are bound to follow them. At the same time, the conventions leave room for interpretation, which is perhaps understandable given the background of distinctive interests and traditions and of the fact that agreement has been reached only on the basis of compromise. Nor are all the countries agreed on how the conventions are to be understood. Sweden and a number of other countries, for example, argue that the Dutch coffee shops are in conflict with the conventions. For her part, Sweden interprets the conventions very restrictively, by emphasising that all drug use is prohibited according to the United Nations  narcotics convention. Sweden’s official position appears to be that even consumption itself must be criminalised – an interpretation that is shared by few other EU states.

In the context of an analysis of the UN’s narcotics conventions, a group of researchers at the University of Gent in Belgium have made an assessment of what the member states are bound to do, and where there is room for interpretation such that praxis may vary. The group point amongst other things to the fact that the conventions do not require that the consumption of drugs be criminalised, that administrative sanctions may be applied instead of penal sanctions, that waivers of prosecution may be employed, that needle exchange programmes are in breach of the conventions but may be permitted for public health reasons, and that the UN may of course change both the classification of various substances and the way the conventions are to be applied. The general conclusions drawn by the group are as follows:[110]

“1. The United Nations Conventions as an international framework

·        The three United Nations drug Conventions provide an international framework for the control of narcotic and psychotropic substances.

·        The United Nations Conventions adhere a more prohibitionist approach to the drug problem. However, the United Nations “soft law”, the Council of Europe, the European Community and the European Union tone down this prohibitionist approach (e.g. new demand reduction strategies).

·        The United Nations Conventions are not self-executing. Consequently, the implementation of the provision within these Conventions is left to the states themselves. This inevitably involves interpretation.

2. Latitude

Evolving societal phenomena concerning the drug problem result in changing strategies and legal approaches developed by countries.

The room to manoeuvring available to the Parties within the present United Nations Conventions allows them to develop a differentiated national drug policy.

However, this latitude is not unlimited.

In general, the United Nations Conventions require a loyal enforcement by the Parties.

More particularly, the main restriction of the United Nations Conventions is situated at the level of criminalisation. Parties are obliged, to criminalise possession, purchase and cultivation for personal consumption of drugs. Therefore, it is clear that no decriminalisation of these offences is possible.

However, the United Nations Conventions do not oblige the Parties to criminalise the use of drugs.

As stated above, the United Nations Conventions do leave considerable room for Parties to develop a differentiated national drug policy.

-         the imposing of sanctions is a matter within the domestic law of the Party. This means Parties can choose between a penal and an administrative reaction, leaving room for depenalisation of offences by the Parties;

-         the application of penal sanctions leave considerable possibilities to the Parties to differentiate and individualise the reactions;

-         the United Nations Conventions provide for additional and alternative measures (e.g. treatment and social reintegration) for conviction or punishment on all levels of the criminal justice system. Moreover, the necessity of bridges between the criminal justice system and treatment for drug abuse offenders is stressed;

-         at the prosecution level considerable room is left to the Parties to develop a prosecution policy, making use of the expediency principle, as long as the – systematic – use of this principle does not conflict with the spirit of the Conventions;

-         both at the sentencing and at the execution of sanctions levels, the room to manoeuvre and to develop a differentiated national policy is even more apparent, especially for offences related for personal consumption.

For the pursuance of risk reduction strategies:

-         exchange and distribution of needles and syringes violate the United Nations Conventions in theory. However, they are considered to be permitted from a public health point of view;

-         both heroin prescription and methadone maintenance therapy are allowed within the framework of 'medical and scientific purposes';

-         there is no clear guidance in relation to the compatibility of injecting rooms with the United Nations Conventions. Special preconditions will determine whether these strategies resort under the qualification risk reduction;

-         there is no clear guidance in relation to on-the-spot drug testing. However, testing drugs can be argued to resort under the term 'medical and scientific purposes'.

3. Room for reform

When Parties consider the latitude within the Conventions’ provisions insufficient to differentiate their national policies, the Conventions provide options to amend, to modify substances in the Schedules/Tables, to make reservations and to denounce the Conventions. 

Any Party can propose an amendment at any time. An amendment refers to the formal alteration of Convention provisions affecting all the Parties. The three UN Conventions lay down specific requirements with regard to this procedure.

The modification of substances in the Schedules/Tables can be the addition, the deletion, or the transfer of a substance from one schedule to another. The procedures laid down in the three UN Conventions allow changing both the list of classified narcotics and psychotropic substances, and the regime applied to them.

A reservation enables a state to accept a Convention as a whole by giving it the possibility not to apply certain provisions with which it does not want to comply. In addition, any signatory state or contracting state has the option of objecting to a reservation.

These procedures, that have to be made at the time of signature, ratification or accession, are laid down in the 1961 and the 1971 Conventions. The 1988 Convention contains no such provisions. Consequently, the reservation procedure relies on the concerning provision of the 1969 Vienna Convention. 

A denunciation is a declaration by a Party to a Convention by which it purports to opt out of a Convention. The denunciation possibility is included in the three UN Conventions.

One of the consequences of denouncing a Convention can be that the Convention ceases to exist. However, the denunciation without creating an alternative would risk being counterproductive.”  

A drug free Sweden?

Henrik Tham

The goal of Swedish drug policy, i.e. a drug free society, was established a quarter of a century ago. It has clearly not been achieved. Quite the reverse; by comparison with the period when this goal was formulated, the available indicators show that drug consumption has increased.

This increase in the use and abuse of drugs has taken place in spite of a substantial expansion in control measures. Legislation in the areas of both criminal law and compulsory treatment has undergone a continuous expansion. There has also been a continuous increase in the number of police officers working with drugs and in the number of persons given a prison sentence for drug offences. It is difficult to argue that the additional control measures introduced since the 1970s have had a positive effect on levels of drug abuse in Sweden.

At the same time, this policy has involved a high level of costs. A time-honoured, rational and humanist crime policy has been forced to give way in relation to drugs. Legislation has been introduced that provides compulsory care for adults precisely because they use drugs. The battle against drugs has tied up justice system resources. An increasing number of drug users are in prison, and without being given help with their drug abuse. The attitude towards substitution treatment and needle exchange programmes has been so restrictive that we cannot exclude the possibility that Swedish drug policy has contributed to the rising number of drug related deaths.

The official Swedish arguments against a less restrictive policy are that this would “send out the wrong signals”. By punishing the consumption of drugs, by refusing to allow needle exchange programmes, by making complete abstinence a requirement for the provision of housing, the intention is to “emphasise the fact that society will not tolerate drugs”. This policy has been defended by reference to its supposed deterrent effects on the general public. But drug dependency is deterrence enough in itself. Nobody wants to be a drug addict. On the other hand, the policy has entailed a high price, and one that has not been paid by the general public but by the drug users. The policy followed in Sweden leads to a deterioration in the living conditions of drug users and puts their lives and their health at risk. These are already socially excluded individuals who are being refused clean needles, who are not being given the help they need from the social services, and who to a large extent are being made to spend their lives in prison.

The slogan “a drug free Sweden” blocks any insight into the costs involved in Swedish drug policy. All policies involve costs, and these must be weighed against the benefits. This is something that is self-evident in all other policy areas. A total prohibition model does produce benefits, but at a price. During the period of prohibition in the U.S.A., alcohol related liver cirrhosis mortality decreased. At the same time, organised crime and the homicide rate increased dramatically. Sweden chose instead to follow a regulatory model, and managed to bring about a reduction in levels of alcohol related harm without incurring more than moderate control costs.

When faced with poor results, the zero tolerance model has nowhere to go but to demand more zero tolerance. Over the last twenty years, Swedish drug policy has been characterised by constant new demands for tougher sanctions, more controls and expanded police measures. When these measures subsequently show themselves not to produce the desired effects, the conclusion is that even stiffer sanctions and further increases to levels of control are required. Following the substantial increase in the use and abuse of drugs witnessed during the 1990s, political parties and government inquiries are now proposing the use of emetics, the drug testing of minors against the will of their parents and life imprisonment.

Nobody can be sure which form of drug policy is the right one or which methods give the greatest effect on levels of drug abuse whilst at the same time involving the lowest costs. Models such as “a drug free society” or “complete prohibition at any price”, however, reduce the chances of starting any form of unprejudiced debate about an effective and humanist drug policy. A debate of this kind needs to free itself from earlier conceptions and proceed from the idea that drug use constitutes a risk behaviour. The question that presents itself is then: How can we reduce drug related harms for the individual and society without at the same time increasing the harms associated with drugs control?