Four Southern European Countries
fifteen years later
Miguel de Andrès
Grup Igia Barcelone
miguel.deandres@retemail.es
A member of the Organising 'Committee for the Barcelona harm reduction conference which took place from 14th. to 16th. November 2001 (www.igia.org/clat)

France, Italy, Portugal and Spain have all adopted their own harm reduction policies in the framework of institutions and traditions which have sometimes seemed rather contradictory. Their respective weaknesses and strengths are summed up here in the hope of putting an end to pointless controversies.

One of the biggest steps forward has been the decision taken in Spain and France to include tobacco-smoking and alcohol in the action plans designed to fight addïctive practices.

Harm reduction first emerged in the 80's in Amsterdam and Rotterdam (Holland) and in the Merseyside area (England). Some particularly innovative schemes were introduced in the former two cities, where a team of medical and social workers started to collaborate with the drug users themselves -and with the police!

In the Merseyside area, the idea was to prescribe injectable opiates and set up syringe replacement schemes, again with the help and support of the police force. These projects certainly yielded results: a very low rate of AIDS infection among the intravenous drug injectors and a decrease in petty crime (1). These two historical examples took the European drug reduction specialists completely by surprise, and many people were quite astounded by the wide range of players involved in these early experiments, which included administrators, political figures at both national and municipal levels, the police force, and the drug users themselves.

In the Southern European States, it was only in the 90's that harm reduction came into being, in the form of syringe replacement programmes. By now in the year 2001, the idea seems to have become generally accepted. Comparisons between the ways in which the present policies have been introduced in the four most southerly European countries, namely Spain, Italy, Portugal and France, can be highly instructive. Rather than just signalling successful results as reflected in the auspicious epidemiological trends, comparisons of this kind also enable us to pinpoint the weaknesses and gaps which need to be remedied if further progress is to be achieved.

As far as opiate agonist treatment is concerned, the model adopted in France involves the prescription of buprenorphine in heavy doses for drug abusers by general practitioners in the framework of their own practices. France is the only one of these four countries where this is possible: in the other three countries, drug abusers are referred to special services for this purposed. In Spain and Italy, methadone is mainly prescribed. Spain is the only country in Europe where methadone is available at all prisons, and since 1999, the replacement of used needles has also been recommended at prisons. In Portugal, methadone programmes have been less widely applied, although this was the first country to authorise the prescription of methadone, back in 1976. Portugal also pioneered the use of LAAM (2) in 1994 (this substance started to be used in Spain in 1997). Medical prescription of heroin has not yet been legalised in any of these four countries, although bills have been drafted in France and Spain on these lines. The latter two countries have both developed lowthreshold* structures on a large scale: there are 34 drug posts in France and 19 Social Emergency centres in Spain.

MOBILISING CIVIL SOLIDARITY GROUPS: WILL THIS SUFFICE?

The NGOs and groups of militants play an important part in these countries. However, since the workers in these groups do not have steady jobs, their projects tend to lack continuity, as they depend on whether or not subsidies will continue to be obtained each year. This weakness tends to reflect the fact that the structures in question are not properly integrated into the public health system's social apparatus.

Thanks to the French Harm Reduction Association (AFR), which brings together a large number of drug users, professionals and supporters, France is way ahead as regards mobilising its civil solidarity resources for the promotion of harm reduction. There exist no movements of this kind in any of the other countries.

The development of an efficient harm reduction system requires a suitable legal framework. Although people have no longer being legally prosecuted in Spain for practising drug abuse in public places since 1992, offenders are still liable to be fined, as in Italy (since 1993) and Portugal (since 2000). Paradoxically, France is the strictest country in this respect, since even simple drug offenders are liable to be sentenced to prison in this country under the 1970 law.

One of the greatest breakthroughs occurred when France and Spain began to use an approach which had already been widely adopted in some English-speaking countries: they have included tobaccosmoking and alcohol in their action plans to combat addiction. This strategy has opened up new perspectives for preventing abuse of all kinds and reducing the harm it does. It has come as a welcome change after struggling in vain for many years to introduce purely preventive measures which not only left the drug abusers themselves completely out of the picture, but also pushed them into choosing between complete abstinence and exclusion from society, which the most vulnerable members of society are often quite incapable of doing.

SELF-SUPPORT SCHEMES MEET WITH ONLY MODERATE SUCCESS.

Drug users' associative movements have developed strongly in France, where they are to be found in most of the large cities. In Spain, the groups of this kind which exist are mainly in Catalonia; they are not very strongly supported by the authorities or by the NGOs; they are practically nonexistent in Italy and Portugal. Whenever drug users have been actually co-operating with field workers, positive and beneficial results have been reported, however, although all attempts to set up joint schemes between local authorities, drug users and administrations have been purely anecdotal.

Only a few groups in France and Spain have been using the so-called drug-testing methods. In Italy, some isolated groups have attended rave parties, giving the participants advice, but this has never been done in Portugal. None of these four countries seem to have adopted any specific large-scale strategies for dealing with these drug abusers. Nor have any preventive educational programmes apparently been developed on the basis of the existing harm reduction theories for use in schools.

The various ways in which harm reduction has developed in these four countries show how flexible these programmes are, since they are able to adapt to various situations and contexts. It seems inappropriate in fact to speak about the type of harm reduction being carried out in a given country, since it is more a question of how various regions and municipalities are tending to adopt practices of one kind or another. Throughout the history of harm reduction, the need has always been felt to promote a spirit of team-work between those responsible in various places, so as to be able to optimise interventions and pool the empirical and scientific knowledge acquired. This is still an essential objective, not only in the case of developing countries but also between neighbouring countries on the same continent.

PUTTING AN END TO FUTILE CONTROVERSIES

One of the snags which has to be overcome in harm reduction is the persistent tendency to assume that its proponents are against complete abstinence. In our opinion, there is no justification for making such a hard and fast distinction. The experience acquired in many cases has shown that it is perfectly feasible to run services of several kinds, some of which promote abstinence for users who have decided to stop taking drugs, usually after a fairly long trajectory, while others focus more on harm reduction, helping the people who have embarked on this trajectory not to take risks with their health and their lives and those of the people around them. One of the strong points of harm reduction is that it sustains not only public health but also law and order. We should not forget that one of the effects of substitutive treatment is that it reduces the number of petty crimes committed. It is therefore particularly important to promote the training of specialised community mediators to act as a link between harm reduction programmes, the community, the local authorities and the drug abusers. One of the main priorities on which the effectiveness of these programmes depends consists of taking steps to help the drug abusers frequenting urban centres and to ensure that the local communities support this undertaking.

1 Pat O'Hare, R. Newcombe, A. Matthews et al (1995). La Reducción de Ins danos relacionados con las drogas. Edición Espanola. Grup Igia.

2 a synthetic opioid agonist with very long-term effects, which can be used as a substitute for heroin at a frequency of only three times a week; whereas methadone has to be taken in daily doses.

Worth consulting:

Centre for the epidemiological monitoring of Aids (1999). Surveillance in Europe. First Half-yearly report 1999.

Observatorio Europeo de la Droga y ]as Toxicomanias. Informe Anual de 2000 sobre el problema de la drogodependencia en la Union Europea. OEDT. Luxembourg.