Doctors have played an important role in the problematization and medicalization of drug use. Medical arguments have been applied for the justification of drug prohibition. The monopo-ly of the prescription of opiates, which doctors obtained through drug prohibition, helped the medical profession in the establishment of their professional status. Many of their patients however, became dependent on the prescribed opiates (and later barbiturates and benzodiazepines).
Two factors have changed since the start of drug prohibition:
This applies to all aspects of health that are involved:
dependence, toxicity and negative consequences on third per-sons. The health dimensions of the drug problem show a drama-tic increase since drug prohibition was enforced internation-ally. Of course, in itself this is no proof of cause, but the economic laws of the illegal drug market stimulate unsafe drug use and illegal drug trade. On the other hand, once drug use has reached a certain plateau, relaxation of repression does not result in a serious increase in the number of problematic users.
The medical profession has not reacted to the continuing misuse of medical arguments in the debate on drug policy. The official, often tacit, support by medical organizations has been crucial to the continuation of drug prohibition. This paper focuses on the role of doctors (individuals and organisations) in the public and scientific debate on drug policy. It is illustrated with a short survey of developments in the Netherlands.
by Freek Polak, psychiatrist, Amsterdam1
This paper about the position of the medical profession in the drug problem does not address the treatment system, but the role doctors can play in the public and scientific debate on drug policy. It focuses on the situation in the Netherlands, but many of its themes seem relevant for physicians in other countries as well.2 Historically, doctors have played an important role in the problematization and subsequent medicalization of substance use, of which opiates were the most potent. The monopoly of the prescription of opiates, which doctors obtained through drug prohibition, helped the medical profession in the establishment of their professional identity and status. For many of their patients however, this meant getting dependent on the prescribed opiates or on other psychotropic substances (barbiturates, amphetamines and benzodiazepines), instead of being prevented by their doctor from developing dependence. The official, often tacit, support by medical organizations has been crucial to the continuation of drug prohibition. Whereas it is becoming clearer and clearer that drug prohibition is a failed sociomedical policy, based on mistaken ideas about drug use, the medical profession has not reacted to the confusion and sometimes even the misuse of medical arguments in the debate on drug policy.
Two factors, however, have changed since the beginning of drug prohibition.
These two changes open an opportunity for doctors who no longer want to stand apart from this issue. In the coming period in which we have to face the difficult but rewarding task of getting rid of drug prohibition, many doctors will be happy to assist their patients and society in learning better how to handle drugs and dependence.
When doctors free themselves of prejudices and give serious consideration to the epidemiology of illicit drug use, they will have to face the evidence and recognize that the main effects of drug prohibition have been harmful.3 When we leave the harmful effects of drug prohibition on society apart and restrict ourselves to the field of health, we observe that the health dimensions of the drug problem have shown a dramatic increase since drug prohibition was enforced internationally in the early 20th century. This applies to dependence as well as to toxicity and negative consequences on third persons. Of course, in itself this is no proof of cause, but few econom-ists dispute that the economic laws of the illegal drug market stimulate unsafe drug use and illegal drug trade. Finally, numerous data show that once drug use and abuse have reached a certain plateau, relaxation of repression does not result in a serious increase in the number of problematic users. In the Netherlands for example, where access to cannabis is free, most users smoke incidentally and the number of people who seek treatment for problematic cannabis use has remained small in relation to the large number of cannabis users.4 Doctors are best suited to explain that the basic reason why drugs should be legalized and regulated is not that they are harmless - because they are not. The argument is the opposite:
Drugs should be legalized, because the health risks they carry can be better controlled by some sort of legal regulation.
Associations of doctors and medical institutions can convey the message that health arguments are being misused in the drug policy debate. Individual doctors can be of great value in the daily personal contact with their patients, giving information and advice, disproving misconceptions and myths. With the right attitude and with sufficient knowledge of psychoactive substances they can become "advisors on the use of drugs", just as they are in other socio-medical matters.
Not all medicalization is progress, however. In the actual situation there is a tendency to medicalize all illegal drug use - not only when it is problematic. As a consequence, under prohibition drug users are considered pathological who would be within the range of normality in a system that accepts some patterns of usage.
Medicalization leads to political pressure for forced treatment, even when this method has been shown to have little effect on the course of dependence. And on the other side of the ideological spectre there is a plea for the harm reduction approach, a central method of which is medical distribution of illegal drugs (to users willing to register as addicts). While many doctors are willing to contribute by providing access to controlled substances, their attitude towards taking responsibility for other people's drug use is ambivalent, because they understand that this will go on for the rest of their professional lives, if the repressive system continues unchanged. In another paper I concluded that medical provision of illegal psychoactive drugs is an artefact of drug prohibition and that, apart from emergency situations, this method is only acceptable in the course of the transition to general legalization.5
Doctors are in the position to point to a number of little known facts about drug use.3
For them the situation should be made as bearable as possible.
However, many doctors are not aware of these facts. How can we explain that despite their scientific training and clinical experience doctors often have the same prejudices on drugs as the general population? There are two main reasons for this, of which one is specific for doctors. I will discuss it under the heading 'the Clinician's Illusion'. First the other reason: doctors experience the drug problem in the existing situation of prohibition and they are, like everyone else, liable to confuse consequences of drug prohibition with psychopharmacological effects of the forbidden substances. For example, the violence that accompanies (part of the) illegal drug transactions is easily seen as a property of cocaine.
During their training doctors learn to trust their own experiences. They form their opinion on the drug problem on the basis of the cases they see. But they are usually unaware of an epidemiological problem that Patricia and Jacob Cohen have named the 'Clinician's Illusion'.6 They have described how clinical impressions easily lead to misconceptions about the duration and severity of chronic illnesses. From their selective exposure doctors form a distorted image of drug use. They see a disproportionally large number of serious and chronic cases, because they only see users in search of treatment, or via the police and the judiciary. On the other hand, doctors know little or nothing about normal, unproblematic use, or about people for whom dependence is a less serious problem, which is solved relatively quickly and without treatment.
The concept of the Clinician's Illusion is so important, because it tells doctors that they are not stupid when they fear drug legalization. On the basis of their clinical impres-sions they are bound to get these ideas. Yet, it may be expected of doctors to understand that there is a difference between clinical impressions and epidemiological data. In other words, that personal experience does not automatically offer a sound image of the world as a whole. So, when a doctor does not know people who have learned to control their drug use, this does not mean that controlled drug use does not exist. It may even mean that there is a lot of controlled use, of which doctors are not aware. Doctors just are not in a position to know these things.
The least that doctors should do is explain that drug prohibition has been harmful to public health and has promoted drug abuse. What did the war on drugs accomplish? In every country that applies the international drug conventions illegal trade and drug abuse have increased. People who have problems in their selfcontrol are marginalized, criminalized, detained, denied their rights as citizens, parents, owners of property, whereas many of those people who can control their use refrain from it because of prohibition, and are thus denied the use of something that can be worthwhile to them. In many countries traditional patterns of usage have been replaced by unsafe methods. So what does this mean? It seems a classic Popperian case of falsification of the assumptions on which drug prohibition was and is based. The theory was that drug prohibition would diminish drug abuse, but there is little evidence to support this.
Doctors should explain to the public in general and to politicians that there really is no reason to treat the illicit drugs differently than alcohol and tobacco. Of course, it will not be easy to abolish drug prohibition and to repair the harm it has caused. But it can be done, with careful preparation and a good scenario.7
In their basic training all doctors have learned to distinguish clinical impressions from epidemiological findings, so they should be able to convey correct information on illegal drugs to the general public.
Unfortunately, the distorted image most doctors have of illegal drug use coincides with the image the general public gets from the media and most doctors are not aware that their conceptions of drug use are distorted as a consequence of the combined effects of the Clinician's Illusion and of drug prohibition.
It is the collusion of these two selective views (of the medical profession and the general public), together with the emotionality of the debate, that obstructs efforts for a rational discussion and that helps support drug prohibition, despite the evidence of its failure and inhumanity.
The drug debate thus far has been dominated by emotions and ideologies, and not by rationality and scientific evidence. This makes the drug debate almost futile. TV-programmes and articles in the press tend to reinforce existing fears and superstition.
The question then is how to get a rational debate started. This is where doctors as a professional group can be influent-ial. A remarkable example of this possibiblity occurred recently at the time of the Dutch parliamentary debate on drug policy. Repeated attacks on Dutch drug policy by the French President triggered a French-Dutch diplomatic scuffle in which one of Chiracs political allies called the Netherlands a 'narco-state'. Some Dutch political observers suggested that the only way to cure Chirac of his drugs 'obsession' was to have him consult Dutch Health Minister Els Borst, a former professor of medicine and director of the Academic Hospital of the University of Utrecht. It is a pity that sessions with such therapeutic potential will probably never take place. She is one of the few persons capable of convincing Chirac that his son in law, who according to undenied rumors died of an overdose, would have had better chances of staying alive in Holland. The same goes for President Clinton who is convinced his brother would have died if drugs had been legalized. A doctor, aware of the actual situation in countries with different drug policies, could explain to Clinton and Chirac that the chances for their drug dependent relatives keeping good health are definitely better in the Netherlands than in France or the USA. Tragic experiences with drug dependence do not provide evidence for continuing drug prohibition, but on the contrary, they support arguments for legal regulation. Els Borst could also explain to Chirac that it is understand-able that he believes the myths about the dangers of cannabis, because he has been misinformed by people like Gabriel Nahas, who has worked for United Nations and Columbia University. Hence the importance of the article by Christie and Chesher on the unreliability of Nahas,8 and of the recent libel cases of Nahas against Mischka (a journalist) and Lebeau (a doctor) in Paris. On the merit of this article Nahas now is openly called a scientific fraud. This is an important step in adjusting people to the thought that what doctors and professors are saying on drugs is not always the truth. The next step is more serious. The public will inevitably find out that what govern-ments have been telling them on the subject of drugs is mostly lies or nonsense, and that the scientific community largely has remained silent (or has supported this disinformation.)
It is an absurd situation that we still have to discuss canna-bis legalization. The debate on cannabis functions as a smoke screen that keeps us from the real debate: on the legalization of the so-called hard drugs. Sensible people who want to end cannabis prohibition find themselves in a position where they feel obliged to say that cannabis should be legalized, because it is harmless, but that hard drugs are so terrible and harm-ful that they should be repressed even harder - and both statements are incorrect.
If cannabis were totally harmless, it would need no more regu-lation than tea. Doctors should explain that, fortunately, cannabis carries so little health risks that only minimal regulation is needed. The health risks associated with the other illicit drugs are somewhat, or seriously, larger. To minimize these risks appropriate regulations can be devised. But if cannabis were proven to be very toxic - which is not the case, but suppose - should that be a reason to prohibit cannabis? No, this should be even more reason for an adequate legal regulation for cannabis, exactly as in the case of alcohol, tobacco, heroin, cocaine, amphetamine and the pre-scription drugs.
The harm reduction approach is an integral part of Dutch drug policy since the beginning of the tolerant soft drug policy in 1976. Periodically, since the early eighties, discussions of heroin distribution have flared up, but no fundamental change in drug policy was envisioned.
The Royal Dutch Medical Association (KNMG, the umbrella orga-nisation for the medical profession) had always opposed heroin distribution for the following reasons:
1.Medical provision of illegal substances to addicts is inade-quate medical practice.
3.The medical profession has no task in securing public order or containing criminality.
In 1994, largely because of positive reports on the Swiss heroin project, the KNMG unexpectedly adopted the position that heroin prescription to opiate addicts can be appropriate medical practice, provided it is being done on an individual basis. This means that heroin provision by doctors can not be a socio-medical measure for groups of drug users. Following this, on the initiative of the Dutch Psychiatric Association, the KNMG has established a commission on the drug problem, to describe the role of doctors in drug policy and in the treatment of dependency. It is explicitly stated that this will include the application of health considerations and arguments in the policy debate. Nobody can be sure of the outcome of this, but it seems clear that the KNMG is beginning to acknowledge that it has a responsibility in the search for a better drug policy.
In the fall of 1995 the government issued its long awaited drug policy report,9 nicknamed the 'purple report' (because the government consists of a mixture of red and blue: social-democrats and liberals, whereas the religious parties are in the opposition, for the first time this century). The commen-tary on this report from the board of the KNMG included some critical remarks, of which three are the most interesting:
In the parliamentary debate on the purple report, Health Minister Els Borst defended the government position that the Dutch soft drug policy has proven its worth and that increase of repression, in an effort to reduce the nuisance in border regions and in poor sections of large cities, would be harmful to public health. She then made a statement which in my view is very important, but which remained almost unnoticed:
'The arguments against a more repressive policy are even stronger when it concerns reducing the harm to the health of hard drug users.'10
This shows that Minister Borst understands the dynamics of drug prohibition. The quiet and self-assured way in which she defended Dutch drug policy in parliament encourage my optimism that rationality is gaining ground. The lively discussions of the report and the debate in Belgium, England, France and Germany did not produce only stereotypical attacks on coffeeshops, but also support for our drug policy from health authorities in Germany and from first rate medical periodicals, like the Lancet and British Medical Journal.11
One of the dilemmas in the Netherlands is how to make progress with the repressive system still functioning. For instance, some people think we can tolerate the sale of small quantities of hard drugs, like we did twenty years ago with cannabis. But this half-way solution will probably lead to the same problems 'at the back door' we have with cannabis, and strengthen the black market. Moreover, this option would create some serious additional risks, for instance of media exploitation of fatal accidents with young drug users - even when their occurrence diminishes, as may be expected.
In my view, the decisive argument should be the potential of a measure to improve the image of drug use that will be projec-ted by the media. We should introduce only those changes in drug policy of which we are convinced that they will lead to an improvement of the public image of drug use. For instance, the Swiss experience has confirmed that medical provision of heroin is a safe way to ameliorate the health and social conditions of long time hard drug addicts. Another positive development is the increasing acceptance of 'users rooms', guarded spaces where people can use (smoke or inject) illegal drugs without being bothered by the police. Earlier, in Holland we have had some bad experiences with users rooms, because they were insufficiently guarded and became unmanageable. More recently there have been encouraging reports about users rooms (in Rotterdam, in the church run by the Reverend Hans Visser, and in other Dutch cities) and from Germany and Switzerland. Health Minister Borst expressed support for the idea of a new kind of social pensions for homeless addicts, including users rooms that will be reserved for the tenants.
IRRATIONAL SUPPORT OF DRUG PROHIBITION For politicians who have defended drug prohibition the real problem is to save their face. Must they admit they were totally wrong in their views on drugs and in the policies they chose? They will never do that unless they have the full support of the scientific forum. In this difficult process they will dearly need not just the silent support but the active encouragement and advice of the medical profession. Doctors can help politicians to save face. Not only can they convey the idea that the public has been subjected to incor-rect information on drugs, they can also explain how this happened, because they themselves have believed most of these myths as well. That is why the concept of the Clinician's Illusion is so useful.
A few words on Thomas Szasz, whose work on the drug question of more than twenty years ago is too little known. His thesis12 that the choice of which drugs are forbidden and which are legal is a moral and political decision, but not a scientific one, has been confirmed by the French State Committee on Ethics and the Life Sciences in their 1994 report (without mentioning Szasz):
'These findings show that the distinction between legal and illegal drugs has no scientific basis of any kind.'13
Szasz' most famous book, the Myth of Mental Illness, took such a radical position in the complex and vogue-ridden field of psychiatry that he was harder hit than other writers of that period by the swing to biological psychiatry that took place since. This has produced a negative halo effect on his other work. In order to discredit a certain point of view in American psychiatry, it is sufficient nowadays to mention that Szasz thought it twenty years ago.
In my view his opinions on mental illness are still important, although their scope is more limited than was thought at the time. Since the biological substrate of much of schizophrenia has been demonstrated convincingly, his objections to the medicalization of personal behavior and of deviancy may be considered off the mark in the case of that disorder. But with respect to drug use and the medicalization of the drug problem his views have retained their relevance.
So we have a problem. In the scientific community it is consi-dered unethical not to mention the originator of certain ideas one mentions. But doing so in the case of Szasz may diminish the chances of the acceptance of what one wants to say.
DISTRIBUTION OF HEROIN SHOULD NOT BE REFERRED TO AS 'FREE'.
In the media, medical provision of heroin is frequently refer-red to as 'free' distribution. Anyone who says that, is igno-rant or against such policies. Nobody proposes free distrib-ution. In Switzerland the fixed price of the prescribed heroin is 10 Franks (about 8 US dollars) per day, independent of the quantity. In Holland there is preference for a system in which the client pays a proportional price and not a fixed fee. The Swiss system has a strong binding effect on its clients. It does not seem right to let people pay for the maximum daily amount, and not pay less when they use less. It seems questionable whether this will help users develop a sense of mastery of their drug use.
When we look at this period as the final phase of drug prohibition (as Reinarman and Levine do14), it should be noted that national governments currently seem to pay no attention to what would happen if the credibility of drug prohibition and respect for the law in general reached such depths that drug prohibition could no longer be carried through. In that case a chaotic situation will arise, with unpredictable risks for public health, unless specific regulations for that purpose have been prepared beforehand. Doctors (and others) should be working on recommendations and proposals now.7
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