THE HARM REDUCTION APPROACH TO DRUG CONTROL:

INTERNATIONAL PROGRESS

by Ethan Nadelmann, Peter Cohen, Ernest Drucker, Ueli Locher,

Gerry Stimson and Alex Wodak

April 1994

Prospects for victory in the "war on drugs" in.the United States seem no better today than when the war was declared during the mid-1980s. The number of Americans behind bars for drug law violations has risen dramatically to unprecedented levels,l yet drug-related problems in most urban ghettos have not diminished. A majority of new AIDS cases in U.S. cities, and among African Americans and Latinos, are attributed to illicit drug misuse and related behavior. Most of the approximately twenty million Americans who violate the drug laws each year2 are moderate or controlled drug users. Between 1.1 and 1.5 million, however, are injecting drug usersS-many of whom find it difficult to control their use. Many others consume heroin, cocaine, amphetamine and other illicit drugs in ways that cause harm to themselves and others. Most Americans appear at a loss for what to do about this persistent problem. 4

New approaches to our drug problems are needed. During the past decade, municipal, state and national governments in Europe and Australia have responded to local drug problems with a variety of initiatives that merit close examination in the United States. Based on the evolving notion of "harm reduction," these initiatives focus on reducing the adverse consequences of both psychoactive drug use and drug control policies without eliminating drug consumption.6 Our objectives in this-article are to describe and analyze these initiatives and the lessons they suggest for improving drug policies in the United States.

"Harm reduction" approaches generally view abstinence as the most effective means of avoiding drug-related problems-but not as the only solution for drug users. They reject as unachievable the oft-stated objective of creating a "drug-free society," emphasizing instead the need to design policies that acknowledge the ubiquity of psychoactive drug use in virtually all societies and seek to minimize the harms that result. Clear distinctions are drawn between drug misuse and controlled use of drugs .6 Notions of "zero tolerance" are seen as antithetical to public health, civil liberties and human rights as well as unnecessarily burdensome to the criminal justice system. Illicit drug users are regarded not as animals, devils or traitors but as human beings who use and sometimes misuse drugs. Interventions focus not on isolating drug users but on integrating or reintegrating them into the community. Priority is placed on maximizing the proportion of drug users in contact with drug treatment, outreach and public health services. Drug laws are regarded not as moral absolutes to be enforced indiscriminately, but as part and parcel of broader public health and social welfare policies which emphasize pragmatism and inclusiveness.

Harm reduction approaches focus on the following questions: How can we reduce the risks that drug users will acquire infections such as HIV, hepatitis B and C and tuberculosis, suffer an overdose, or develop dangerous abscesses? How can we reduce the likelihood that drug users will engage in criminal and other undesireable activities that harm others? How can we increase the chances that drug users will act responsibly toward others, take care of their families, complete their education or training and engage in legal employment? How can we increase the likelihood of rehabilitation for drug users who have opted to change their lives? And how, more generally, do we ensure that drug control policies not cause more harm to drug users and society at large than drug use itself?

When questions such as these were asked a generation ago, one response was the introduction of oral methadone maintenance programs. Introduced first in the United States during the 1960s,7 the practice of methadone maintenance has since been adopted in dozens of countries. Its central ingredient is the provision of methadone-a relatively long-acting opiate-to heroin users who are unable or unwilling to abstain from opiate use altogether. Methadone maintenance programs confronted (and continue to confront) many obstacles: accusations that they tolerate, perpetuate and condone drug addiction, embarrassments when programs are poorly run and depicted unfavorably in the media, and "NIMBY" (not in my backyard) protests from local neighborhoods .8 Nonetheless, their efficacy in reducing drugrelated morbidity, mortality and criminality, and in facilitating legal employment, better family circumstances and a general improvement in quality of life are well established.9 A vast body of medical evidence indicates that there are few negative health consequences of long-term methadone maintenance.l°

Responding to the problems of illicit drug use today requires pragmatic innovations comparable to the introduction of oral methadone maintenance programs in past decades. These include rapid expansion of the number, variety and quality of oral methadone maintenance programs, repeal of drug paraphernalia

laws and prohibitions on the sale and possession of syringes, expansion of needle exchange schemes, research and development of drug maintenance programs involving drugs other than oral methadone, reform of cannabis policy, toleration of "street rooms" where drugs can be injected in relative safety under the supervision of medical staff, creation of organizations to represent the interests of drug users, integration of police activities with harm reduction programs, and other initiatives directed at reducing crime and disease. Most of these innovations share an underlying assumption that it is better for both society and the individual to concentrate on reducing the risks and harms of drug use than to focus entirely on making people drug-free.

Harm reduction is a new name for an old concept. During the nineteenth and early twentieth centuries, when potent new drugs became available, drug control efforts focused less on prohibiting opiates and other drugs and more on ensuring quality, purity and safe dose levels.1l In the United Kingdom, the influential Rolleston Report of 1926 formalized the policy of allowing (mainly middle class) opiate users to obtain their drugs from their physicians. 12 Morphine maintenance programs in the United States early this century similarly reflected harm reduction precepts, as did efforts to persuade drug misusers to switch to safer drugs.1s The movement to decriminalize marijuana during the 1970s was driven by the realization that criminal sanctions created greater harm than marijuana use itself. Other evidence can be found wherever governments viewed drug abstinence as either unrealistic or impolitic and sought instead to reduce the harms associated with drug use.

Contemporary harm reduction notions first emerged in the formulation of Dutch drug policy during the late 1970s-and early 1980s. The singular event that subsequently catapulted harm reduction thinking into official drug policy in the United Kingdom, Australia, Switzerland and elsewhere was the recognition (during the mid-1980s) of the link between injection drug use and the AIDS epidemic. In each country, government health officials declared that AIDS presented a great threat to public health, and that henceforth AIDS prevention efforts should take precedence over anti-drug efforts. 14 These policy declarations stood in stark contrast to official drug control policy in the United States, where comparable recommendations by the National Academy of Science and other scientific and political advisory.bodies were rejected by most political leaders at every level of government.

The role of local and state governments and officials in promoting and implementing harm reduction policies cannot be overestimated. This is especially true in Germany, where harm reduction initiatives in Bremen, Frankfurt, Hamburg and other cities have met with opposition from the central government. Obliged to respond directly to rapidly growing drug abuse problems during the 1980s, city officials were quick to realize the limits and undesireable consequences of relying primarily on criminal justice tactics and institutions. In 1990, the governments of Amsterdam, Hamburg, Zurich and Frankfurt created a transgovernmental alliance-the European Cities on Drug Policy (ECDP) -- and drafted and signed a "Frankfurt Resolution" calling for a transition to harm reduction policies. By 1993, the membership of the ECDP included Arnhem, Basel, Hannover, Luzern, Rotterdam, Zagreb and other cities, and its annual meeting drew representatives from 58 cities from 14 countries.15 Efforts are also underway to expand the alliance to North America.16

In the United States, the debate over drug legalization-re-ignited in late 1993 by Surgeon General Joycelyn Elder's comments calling for study of policy alternatives-has proven useful in increasing awareness of the relationship between drug prohibition and most drug-related problems. But it also has contributed to an unfortunate polarization of the broader debate over drug policy alternatives .17 A growing number of federal, state and local officials are now expressing interest in less punitive and more public health-oriented drug control policies that eschew both the "war on drugs" approach and outright legalization. But consideration of realistic alternatives has been limited by widespread ignorance of harm reduction initiatives abroad.

THREE CAVEATS

Any analysis of harm reduction efforts must be qualified by three important caveats. First, the scope and progress of harm reduction efforts in most countries has been almost overshadowed by the global scale and intensification of the war on drugs. The international drug prohibition regime promoted by

the United States since the early l900s is now firmly established throughout the world. 18 It was consolidated in 1988 with the signing of the United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychoactive Substances-now ratified by over one hundred governments. Many drug enforcement tactics and sanctions developed and refined in the United States-including undercover operations, extensive employment of paid informants and electronic surveillance, asset forfeiture laws, far-reaching conspiracy statutes, drug testing programs and mandatory minimum and long-term prison sentences-have been adopted in many countries.l9 The amount and proportion of police resources and prison space devoted to drug law enforcement have increased dramatically in virtually every country. Even in Britain, Australia, Switzerland and the Netherlands, advances in harm reduction have proceeded in tandem with tougher and more extensive efforts against drug traffickers. It is in this, largely hostile, environment that harm reduction programs currently operate.

The second caveat concerns the methodological limitations encountered in evaluating different drug control policies and problems. 20 Data collection and analysis regarding illicit behavior, and particularly drug dealing and other consensual crimes, are inherently difficult given the generally hidden nature of the activities and the strong disincentives for participants to disclose their involvement. Even in the United States, where data collection on illicit drug consumption and related behavior has advanced much further than elsewhere, informed analysts often differ widely in their estimations and analyses. Comparative analysis among countries presents further complications. Governments vary in how they collect and categorize data on illicit drug use and related public health and criminal justice information. Substantial variations within countries-such as among the 26 cantons in Switzerland, the six states and two territories in Australia, or the many cities and counties of the United Kingdom-render cross-national comparisons exceedingly difficult and problematic. Transnational movements of illicit drugs and drug users complicate efforts to assess the impact of national and local drug control policies. The same is true of intranational movements of illicit drug users, such as from rural, suburban and small urban areas to metropolitan cities such as Zurich, Amsterdam and London. Most importantly, illicit drug use and drug-related behavior are shaped by so many societal influences, ranging from cultural norms to broader social welfare policies, that it is extremely difficult, and sometimes impossible, to determine the precise impact of specific drug control policies on drug-related behavior.

The third caveat concerns the adaptability and potential efficacy of foreign innovations in the United States. Most of the countries in which harm reduction policies are being implemented have much in common with the United States. They are advanced industrialized democracies, shaped by Judaeo-Christian ideals and traditions, populated principally by Caucasians of European origin but with growing ethnic and racial minorities, troubled by rising levels of crime and social deprivation, and increasingly hard pressed to sustain government support for social welfare services. They resemble one another and differ from the United States, however, in at least five respects. First, none has witnessed an explosion in "crack" cocaine use comparable to that which has occurred in the United States (although some must contend with extensive use of injectable amphetamine). Second, none exhibit the magnitude and intensity of urban poverty, violence and social dislocation found in many U.S. cities. Third, none possess ethnic and racial minorities comparable to African Americans in the United States in terms of their share of both the overall population and the population of those most negatively affected by illicit drug use and drug control policies. Fourth, each has demonstrated a commitment to universal access to health care and provision of social services far beyond that found in the U. S. Fifth, each has proven more effective than the U.S. in balancing popular sentiments regarding the immorality of drug use and other deviant behavior with public health and broader social welfare concerns. None of these differences undermine the relevance of harm reduction precepts and policies to the United States-but they do suggest that both the prospects and the efficacy of harm reduction initiatives in the United States will be influenced by the peculiar American context.

AVAILABILITY OF NEEDLES AND SYRINGES

Needle exchange programs and other initiatives to make needles and syringes legally and readily available to drug injectors epitomize the notion of harm reduction. They proliferated in most Western countries during the late 1980s as governments sought to stem the relationship between intravenous drug use and the transmission of HIV. Such programs are predicated on the assumption that most people who can not or will not stop injecting drugs will nonetheless take precautionary measures to reduce the likelihood of contracting HIV. This assumption has since been well substantiated. 21 By the late 1980s, virtually all developed countries except the United States had made legal access to sterile injection equipment-through needle exchanges, over-the-counter sales, or both-a primary component of AIDS prevention for intravenous druq users .22

The availability of clean needles to illicit drug injectors varies substantially depending on local laws, policies, attitudes and the personal situations of drug users .23 Local laws may prohibit the sale of needles without a prescription, as is the case in Washington, D.C. and ten states-including those where the vast majority of illicit drug injectors live.24 Even where over-the-counter (or behind-the-counter) sale is permitted, pharmacists may be prohibited or discouraged from selling needles to anyone they suspect of illicit drug use. Drug paraphernalia laws may prohibit posesssion of needles without a prescription, thereby making drug injectors highly vulnerable to arrest. And even where no laws prohibit the sale and possession of needles, they may not be readily available to drug users leading impoverished, disorganized and itinerant lives on the streets. The contrast with Europe, Canada and Oceania is striking. Few of these countries ever enacted prescription or paraphernalia laws, and two that did-France26 and Austria-revoked them during the mid-1980s. 26

Efforts to discourage needle sharing among drug injectors have focused on repealing restrictions on the sale and possession of needles and otherwise expanding the infrastructure for needle distribution. Other efforts have focused on distributing containers of bleach,27 encouraging drug injectors to sterilize their "works," and otherwise educating drug users in harm reduction methods .28 Most public health authorities agree that these efforts must be complemented by more active needle exchange efforts that maximize the availability of sterile needles to injectors, minimize the circulation of used needles, and reach as many drug injectors as possible. Availability is enhanced by both making the needles available at little or no cost and increasing the number of locations where they can be obtained. Circulation of used needles is minimized by encouraging or requiring drug injectors to return used needles for clean ones.

The first needle exchange programs started in the Netherlands in the early 1980s, in response not to AIDS but to a hepatitis B epidemic among drug injectors. 29 These programs were rapidly expanded shortly thereafter in response to the threat of HIV.> In Britain, political support for needle exchange arose in 1986 in response to strong evidence from Scotland that a shortage of needles had facilitated the spread of AIDS. Needle exchange quickly emerged as the cornerstone of HIV prevention among drug injectors. Over 200 needle exchange programs now operate in England, and two-thirds of all drug agencies maintain some needle distribution scheme.3l In Australia, needle exchange programs began in 1986 and quickly spread throughout the country.32 By 1992, seven of Australia's eight jurisdictions provided both needle exchange and methadone. In Switzerland, needle exchange is commonplace in most cities-even though regions differ with regard to the means of distribution. The city with the largest needle exchange program in the world is Zurich, where between 10,000 and 15,000 needles are exchanged each day. 3S Needle exchanges also operate in most large cities in Germany as well as Vienna, Madrid, Bologna, Dublin, Oslo and many smaller cities.34 In Lisbon, Copenhagen, Strasbourg, Florence, Milan and Turin, where no needle exchanges have been established, needles are readily available in pharmacies.35

Most programs have many features in common. They are strongly supported by political and government officials at the national and local level, and by a substantial majority of public opinion. Most law enforcement officials are also supportive. These programs provide not only needles but also alcohol swabs, sharpsafe containers, medicative ointments and sterile water. Although injectors are strongly encouraged to return used needles, the 1:1 requirement is not strictly enforced. Condoms are usually provided. Many programs also provide primary health services and more generic advice on maintaining good health. The ethos is sympathetic to users. Drug injectors are not harassed about their drug use, although they are informed of, and on request referred to, drug treatment programs and other alternatives. They may be shown how to inject less hazardously so as to avoid local complications such as abscesses, septicaemia (a blood disease) and renal thrombosis. Some programs also provide detached or outreach services-such as mobile vans and pedestrian distributors-to deliver needles more directly to drug injectors' homes and drug taking venues. In Zurich, sterile syringes can be obtained around the clock via a network of distribution points that include contact centers for drug users, a "needle van," mobile medical teams, pharmacies and vending machines. S6 In Vienna, needles are exchanged in a mobile Ganslwirt bus, which reaches about 10-25% of all injectors.37 In Amsterdam, police stations will provide clean needles in return for dirty ones.38 Many pharmacists now participate in needle exchange efforts as well.39 In Liverpool, for instance, over fifty pharmacists sell injecting equipment and twenty operate free needle exchanges.40 In New Zealand, 16% of all retail pharmacies were involved in needle distribution and exchange by 1990 .41

Debates over needle exchange in these countries focus not on whether they are desirable or necessary but on particular tactics and methods. Automated needle exchange machines-which deliver a clean needle when a used needle is deposited-can now be found in more than a dozen European and Australian cities42 These machines are relatively inexpensive, available twenty-four hours a day, and generally recognized as a useful complement to regular needle exchange programs.43 Some public health officials, however, worry that such machines decrease personal contact between drug injectors and health workers, and that public opinion and hard pressed public health budgets may ultimately favor vending machines over staffed programs. Also controversial is the role that drug users play in needle exchange .44 Some drug injectors collect large numbers of dirty syringes (from open drug scenes, the streets, other drug users, and so on), exchange these for clean ones, and then sell the new syringes to other drug users. Some critics have objected to the fact that syringes distributed at no cost are then sold at a profit. But others have pointed out that these de facto needle exchangers provide an important service by collecting dirty needles and making clean needles available to less accessible drug injectors and at night and other times when official programs are closed.

Although the efficacy of needle exchange programs in reducing HIV transmission has not been proven categorically, abundant evidence points to the effectiveness of these programs and related efforts in disseminating information on HIV/AIDS risks, reducing needle sharing, disposing of used needles, and ultimately reducing the transmission of HIV and other infections by and among drug injectors.45 The popular assumption (common in the United States) that drug injectors will not alter their behavior to reduce the risks of contracting HIV and other infections has consistently been refuted.46 Surveys of drug

injectors indicate that substantial and increasing proportions of drug injectors participate in needle exchange programs and only use sterile needles. In most cities, the rate of HIV infection among those who began injecting drugs since the mid-1980s is dramatically lower than among those who were injecting before needle exchange programs and AIDS prevention programs began. In Australia and much of the United Kingdom, where needle exchange programs were instituted quickly and widely in the mid-1980s, rates of HIV infection among drug injectors have remained lower than in most other countries .47 Fears that increased needle availability would encourage illicit drug injection among new users have proven unfounded.48 Indeed, the trend in many countries, including the United States, is away from injection toward oral and nasal means of consumption-a result both of greater AIDS awareness and the availability of increasingly potent and inexpensive heroin. 49

WORKING WITH DRUG USERS

The influence of harm reduction precepts are most readily found in outreach efforts directed at HIV prevention.50 Although these efforts often aim to lure drug users into treatment, they focus most of their energies on minimizing drug-related harms outside formal treatment settings. 51 Outreach projects may engage drug users in local drug scenes or visit them at their homes and other gathering places. Some employ vans or buses. Others make use of drop-in centers. They offer information about safer drug use and safe sex, provide a link between drug users and social/medical services, often distribute needles and condoms, and can prove indispendable in collecting information about recent developments in the drug scene.52

The most graphic representations of harm reduction can be found in drug education initiatives targeted at current drug users. The antecedents of these initiatives date back to the underground literature of the 1960s and early 1970s, when nongovernmental organizations and publications provided guidelines on how to minimize the risks associated with drug use. When drug prevention campaigns failed to stem rising solvent abuse in Britain during the late 1970s, the Institute for the Study of Drug Dependence published a guide for minimizing the dangers associated with solvent sniffing.53 During the late 1980s, the Lifeline Project in Manchester, England began publishing Smack in the Eve, a comic book targeted at current opiate users which provided harm minimization information in a "user friendly" style and language.54 In 1990, it initiated a second comic book series, Peanut Pete, directed at young people engaged in recreational use of stimulants, hallucinogens and other "party drugs." Similar publications are produced in the Netherlands, Australia and Germany.55 They contain information on druginduced paranoia, the dangers of particular types of drug use, and services of particular interest to drug users. Such publications appear to have been successful in reaching and educating substantial numbers of drug users in the reduction of drug-related harm.

Harm reduction efforts also seek to reduce the harms that result from the unknown purity and potency of illicit drugs. Drug users can be taught to recognize and minimize certain dangers-but most users lack the expertise and resources to analyze the drugs they purchase. In the Netherlands, public health authorities recognized that one of the greatest dangers associated with the sudden expansion of the "rave scene" (dance clubs and other gatherings where young people consume MDMA and other stimulants and hallucinogens and dance to high-energy rave music) was the sale of adulterated and unexpectedly high potency drugs. They responded by employing drug analysis units at raves where drugs purchased illicitly could be tested prior to consumption. 56 Such initiatives resemble the Analysis Anonymous public drug testing service created by PharmChem Laboratories, Inc., in 1972, which provided a similar service to illicit drug users who mailed in samples for analysis .67

Organized and subsidized self-help groups of illicit drug users play a modest but important role in the formulation and implementation of drug control policies in the Netherlands, Germany and Australia, and have begun to exercise some influence in Switzerland and the United States . 58 The "junkie union" in Amsterdam was decisive in initiating free needle exchange programs in 1983-1984 after a major pharmacist in the central inner city "copping" area refused to sell needles to drug users. Similar groups in Canberra, Rotterdam, Groningen, Basel, Bern, Bremen and a few other German cities have worked with local public health officials on needle exchange programs and other harm reduction initiatives.S9 Most of these groups produce publications targeted at illicit drug users that contain useful information on reducing drug-related harms, kicking the habit, and identifying drug treatment alternatives. Although these groups tend to be short-lived and highly dependent upon one or two highly motivated individuals, they play an important role in articulating the sentiments and perceptions of precisely those citizens who are most affected by local policies. They also offer valuable conduits between local governments and underground populations.

INFORMAL ZONING

Another innovation involves official toleration and even sponsorship of low-threshold facilities known as "contact centers," "street-rooms," "harm reduction centers" and so on. These are places where drug users can meet, obtain injection equipment and condoms as well as simple medical care, advice, help with domestic problems and sometimes a place to sleep. Most facilities allow drug users to remain anonymous. Many have qualified medical staff present.60 And some provide a room where drug injectors can consume illicit drugs in a relatively hygienic environment. 61 These are regarded as preferable to the two most likely alternatives: open injection of illicit drugs in public places, which is widely regarded as distasteful and unsettling to most urban residents; or consumption of drugs in unsanctioned "shooting galleries" that are often dirty, sometimes violent and frequently controlled by drug dealers, and where needle sharing

is often the norm. A few "street rooms" were quietly tolerated within drug agencies in England during the 1960s. During the late 1970s, a number of "drug cafes" for heroin users were established in Amsterdam-but later shut down when drug dealers effectively displaced social workers from control of the daily course of events.62 In Switzerland, the first Gassenzimmer were established by private organizations in Bern and Basel during the late 1980s.6S By late 1993, eight were in operation, with most under the direct supervision of city officials: two in Bern, two in Basel, one in Luzern (in City Hall), and three in Zurich.64 A number of smaller cities in the German-speaking parts of the country plan to follow suit during 1994. An evaluation of the three Gassenzimmer in Zurich after their first year of operation concluded that they had proven effective in reducing the transmission of HIV and the risk of overdose. 65

During the 1980s, open drug scenes emerged in many European cities, often in central areas near train stations, commercial areas, public parks and tourist attractions. No consensus has yet emerged on whether these scenes should be suppressed and dispersed or tolerated and even regulated. The city of Zurich attracted international notoriety during the late 1980s and early l990s for its official toleration of an open drug scene in a public park, the Platzspitz, which became known as Needle Park. The initial congregation of illicit drug injectors in the park during the mid-1980s was regarded by most city officials and residents, including the police, as an improvement after years of chasing drug users around the city. The

concentration of drug users facilitated the provision of needle exchange, emergency first aid and other medical and social services .

During the early l990s, public and official sentiment changed. City residents became upset by the growing numbers of drug injectors flocking to Zurich from elsewhere in Switzerland-about 70% of the approximately 2000 people entering the park each day were not city residents66 -- and by increases in the number of robberies and car break-ins in the vicinity of the park. Within the park, competition among drug dealers generated rising levels of violence, and general social and sanitary conditions deteriorated. The Platzspitz was closed in February 1992. The open drug scene then flowed into different neighborhoods near the Platzspitz, frustrating police and angering city residents, until city authorities agreed to let it settle on the site of a closed train station a few hundred meters from the Platzspitz. There it remains, still serviced by health and social welfare workers working out of a "contact center," and policed regularly by law enforcement officials.67

No consensus has emerged regarding the lessons of Needle Park. Some police officials believe that the lesson is to adopt more punitive approaches and make Zurich less hospitable to illicit drug users. Proponents of legalization see thb failure of Needle Park as evidence of the limits of liberalization within the broader context of drug prohibition. The principal problems in the park, they point out, were all a result of prohibition: the violent behavior and destructive impact of illicit drug dealers; overdoses and other adverse health effects from illicitly produced drugs of unknown potency and purity; robberies and other criminal activities committed by drug users requiring substantial sums of money to buy drugs at prices inflated by prohibition; and the unnatural congregation of many of.the country's illicit opiate users in one place as a result of more severe drug policies elsewhere in Switzerland. Still others, including many of the city's public health and social welfare workers, reject the conclusion that Needle Park was a failure. They regard it instead as an experience that made the needs, and the misery, of drug users visible to everyone, thereby generating support for rapid implementation of needle exchange programs and other harm reduction measures.

Zurich was not the only city to tolerate and attempt to regulate an open drug scene. A much smaller scene-in Bern's Kocherpark-evolved along much the same lines until it too was closed in 1992. In Basle, the open drug scene centered along the river in a smaller version of the situation in Zurich after Needle Park. As in Zurlch, these scenes attracted significant numbers of young drug users from neighboring towns and generated strong opposition among local communities, which led to the dispersal of the scenes.68 In Rotterdam, an open drug scene, known as Platform Zero, can be found at the Rotterdam railroad station, where it is closely supervised by local police. Needle exchange services and a mobile methadone unit are readily available.

In Frankfurt, Germany, open heroin scenes emerged during the 1970s and ended up during the mid-1980s in two adjacent parks, the Gallusanlage and Taunusanlage, when top police officials decided that their decade-long efforts to suppress the local drug scenes had failed to halt their growth and merely shifted them from one neighborhood to another.69 Working in tandem with Zurich officials, local authorities in Frankfurt established three crisis centers in the vicinity of the drug scenes, stationed a mobile ambulance to provide needle exchange services and emergency medical assistance, offered first aid courses to junkies, and provided another bus for drug using prostitutes. Other services were provided in the vicinity of the main train station, where a "pill scene" consisting of a few hundred speed users had formed. The police continued their efforts to apprehend drug dealers but initiated a policy of tolerating an open scene within strictly defined borders within the Taunusanlage Park. These initiatives were combined with efforts to lure drug users away from the drug scene by providing night-lodgings, daytime residences and methadone treatment centers in neighborhoods removed from the city center. In late 1992, following the successful implementation of these measures, the open drug scene in the park was shut down. The entire policy was coordinated and overseen by the "Monday Group"-a group of top city officials, including police, medical, public health, drug policy and political officials that met each Monday to assess local drug-related developments. By 1993, the new policy was believed responsible for significantly reducing the number of homeless drug users, drug-related robberies, and drug-related deaths in the city. 70

one other innovation worth noting is the "apartment dealer" arrangement, adopted informally in Rotterdam, whereby police and prosecutors refrain from arresting and prosecuting apartment dealers-including sellers of heroin and cocaine -so long as they do not cause problems for their neighbors. 71 Both this arrangement and Platform Zero are viewed as part and parcel of broader "safe neighborhood" plans in which police and residents collaborate to keep neighborhoods safe, clean and free of nuissances 72

Toleration and regulation of open drug scenes and apartment dealers both represent forms of informal zoning controls similar to those employed to regulate illegal prostitution .73 They also are consistent with the underlying philosophy of community policing in the United States. Law enforcement authorities recognize that they are unable to effectively suppress most illicit drug use and dealing, and that chasing users and dealers from one neighborhood to another is costly and often counterproductive. Local residents express concern primarily with the safety and orderliness of their neighborhoods, not with illicit drug use per se. And public health and social welfare officials find it easier to provide essential services when drug scenes are relatively stable and easily accessible. The challenges of maintaining control of such scenes are considerable given both the illegality of the market and the social maladjustment of many hardcore drug users-but no more so than the quite different challenges of more repressive policies. The greatest challenges, in this domain of harm reduction as in others, primarily involve popular perceptions, media dePictions and public relations.

METHADONE

Drug maintenance and substitution programs play an important role in harm reduction efforts in most countries. Methadone maintenance programs-most of which provide counseling and other medical and social services in addition to the substitute drug-have proven effective in reducing heroin and other illicit drug consumption, drug-related criminality and the transmission of HIV and other infectious diseases.74 Oral methadone is now dispensed in dozens of countries-including every member of the European Union except Greece-although a few, notably France,75 are only now beginning to reverse strident anti-methadone policies. The number of methadone recipients and dispensers has increased quickly in recent years-although the need for methadone maintenance programs continues to exceed the

supply in most localities.76

Although the United States pioneered methadone maintenance, it has fallen far behind developments in some other countries. The number of people receiving methadone rose rapidly during the late 1960s and early 1970s, but has remained relatively stable-at about 115,000 -- for more than a decade.77 In the United States, methadone is the most tightly regulated drug in the pharmacopoeia. With few exceptions, it may only be dispensed in licensed "programs" subject to strict federal and state regulations regarding dosage levels, pick-up times and locations, and other matters typically left to the discretion of physicians where other medications are concerned .78 Methadone maintenance programs in the United States are relatively expensive,79 often punitive, and generally "userunfriendly. ,,80 In many states, methadone regulations are clearly in conflict with sound medical treatment practices. 81

By contrast, all of the countries which have adopted harm reduction approaches have liberalized methadone availability in recent years. Each has taken steps to attract and retain a higher proportion of illicit opiate users in treatment, in part by better adapting methadone programs to the particular needs of clients. Stringent restrictions on methadone dosage levels -which are unsupported by any empirical data, but nevertheless remain the rule among most American programs-have been eased in the face of undisputed evidence that such limits undermine the efficacy of methadone treatment .82 There is also widespread support for the view that methadone maintenance need not be directed towards a goal of abstinence, and that a "drug-free" therapeutic objective is neither universally desirable or appropriate. Tens of thousands of former heroin addicts on methadone for a decade or more now lead healthy and socially productive lives83 -- and tens of thousands of others have used methadone as a route to becoming drug-free altogether. Many view their "dependence" on methadone as practically and ethically indistinguishable from the diabetic's "dependence" on insulin.

The principal objective of methadone treatment within a harm reduction framework is "to reduce the individual and social harm associated with illicit opioid use. ,,84 Abstinence from illicit drug use is regarded as a desirable, but clearly secondary, objective-although it is worth observing that there is no evidence that entry to methadone maintenance reduces the likelihood of eventual stable abstinence from drugs.85 Priority is placed on maintaining contact between illicit drug users and health care providers. By contrast, in the United States most methadone programs expel clients who continue to use heroin or other drugs illegally. Harm reduction programs generally oppose such a policy given evidence that methadone recipients who continue to use drugs illicitly generally fare better in terms of health and welfare than do other illicit drug users who have been discharged from or denied entry into programs. In the Netherlands, United Kingdom and some Australian programs, syringe exchanges are integrated or run in conjunction with many methadone programs, and clients need not submit their urine for examination.

Harm reduction efforts in many countries include "low threshold" programs which make oral methadone readily available with minimal conditions, and often minimal ancillary services, to heroin addicts. These programs are generally opposed in the United States and elsewhere on three grounds: that they are less effective than more "comprehensive" methadone programs in reducing illicit drug use and other undesireable drug-related behavior:86 that their availability offers a less demanding option for heroin addicts who would be better served by more comprehensive programs; and that their dramatically lower cost will undermine political support for traditional full-service programs. Support for "low threshold" programs, on the other hand, is based on their relatively low cost, which greatly increases the number of people who can be provided with care; the premise that many recipients of methadone do not need and receive no apparent benefit from more comprehensive (and expensive) programs; their.proven success in establishing contact with illicit drug users put off by the more rigorous requirements and intrusiveness of more comprehensive programs; and the fact that their clients typically fare better than do illicit drug users not enrolled in any programs ;87 "Low threshold" programs now operate in Barcelona, 88 several cities in Switzerland, 89 Germany, Australia and Hong Kong as well as most cities in the . Netherlands. In the United States, the principal experience with "low threshold" programs is the "interim" methadone maintenance clinic created in New York to provide methadone and limited services to addicts awaiting treatment in standard comprehensive methadone maintenance programs. Initial evaluations of the interim program have been favorable, with significant reductions in heroin use90 and rates of patient retention in treatment a~proximately the same as those in more comprehensive programs.9

Efforts to expand the availability of methadone in some countries have proceeded in tandem with initiatives to better integrate drug users into mainstream society-what the Dutch call "normalization" of deviant opiate users.92 Many methadone programs require clients-particularly those in the early stages of enrollment-to consume their doses at the program site. This requirement may have temporary benefits but often proves onerous to clients who must attend the clinic seven days a week, who do not live within easy access to the site, and whose time is limited given job and family responsibilities. Numerous measures have been taken to alleviate this inconvenience. The Dutch pioneered in the deployment of "methadone buses"-mobile facilities that dispense methadone and related services at designated times and locations each day.93 This innovation has recently been adopted in Frankfurt and Barcelona as well as in Baltimore, Boston and a few other U.S. cities. In the Netherlands and, to a lesser extent, Switzerland, methadone is also available in public health clinics and other government facilities. Some programs, including a few in the United States, deliver methadone to the homes of clients with AIDS and other immobilizing diseases.

What most distinguishes methadone maintenance in the United States from approaches abroad is the role of general practicioners and pharmacists in the provision of methadone and supervision of clients. In the United States, general practicioners and pharmacists are virtually barred by federal regulations from playing any role in methadone maintenance; the only exceptions involve a few "medical maintenance" experiments that permitted long-term methadone recipients to transfer from traditional methadone clinics to hospital-based physicians or a health maintenance organization.94 By contrast, in many foreign

cities and countries, -- including Australia,95 the United Kingdom, Switzerland,96 the Netherlands, Austria, Germany97 and Hong Kong-general practicioners play a leading role in methadone maintenance. Some work closely with methadone maintenance clinics, while others are more independent. Most limit the number of methadone clients to no more than a dozen or two. Methadone prescriptions typically are filled at local pharmacies, where clients-especially new ones-may be required to consume the methadone on the spot. Thousands of general practicioners throughout Europe and Australia are now involved in methadone maintenance. In Britain, this is the principal means of distribution. These developments, as well as other initiatives to diversify and normalize methadone availability, offer numerous benefits. They make methadone available to heroin addicts who live far from methadone clinics, and reduce the amount of time and energy that methadone recipients must devote to obtaining their prescribed drug. They alleviate the powerful stigma associated with participation in methadone programs. They defuse and circumvent the "NIMBY" protests and zoning problems that often defeat efforts to establish new methadone clinics. And they play an important role in involving the medical community in the treatment of.drug addiction.

The use of methadone in jails and prisons has generally been restricted to brief heroin detoxification programs. In Copenhagen, methadone is available at police stations for addicts who have been arrested. 98 More recently, discreet and quite limited initiatives have been taken in Australia, Switzerland and the Netherlands to provide methadone to jail and prison inmates. 99 An evaluation of the methadone maintenance program initiated in January 1991 in two jails in Basel reported that it had drastically reduced illicit drug use among inmates receiving methadone.100 The largest in-jail methadone maintenance program in the world, with 3000 admissions per year, is the Key Extended Entry Program (KEEP) in New York City. Created in 1987 to provide maintenance doses of methadone to heroin and methadone users who had been arrested on misdemeanor charges and jailed at the Rikers Island jail facilities, it has proven effective in increasing the proportion of inmates who apply for and remain in drug treatment after release.l°l It remains the only such program in the United States.

Opponents to relaxed controls on methadone typically focus on the illicit sale or diversion of the drug by legal recipients. Although methadone diversion is not uncommon, its negative consequences have been overestimated. There are extremely few reports of people initiating illicit opiate use with diverted methadone. The principal consumers of diverted methadone are heroin users not currently enrolled in methadone programs, who use it to detoxify from heroin and as a heroin substitute .102 The most common and vigorous objections involve neighborhood complaints regarding conspicuous methadone dealing in the vicinity of methadone clinics-but liberalization efforts that displace methadone distribRtion from centralized locations to more numerous and discreet distributors generally alleviate this problem. Indeed, much of the criticism of methadone diversion focuses on public perceptions rather than any undesireable public health or criminogenic consequences. The optimal solution to methadone diversion is to increase the availablity of methadone to those who require it.

BEYOND ORAL METHADONE

Despite their successes, oral methadone programs in most cities reach only a modest proportion of illicit opiate users and exert at best a modest impact on their cocaine and multiple drug use. Most legal recipients of oral methadone report that they miss the "high" associated with the consumption of opiates by injection and other means of rapid delivery. The result is that substantial proportions of those who enter oral methadone maintenance programs either quit or continue to use illicit drugs while still receiving oral methadone. Some also illegally inject the methadone-a potentially dangerous practice since most methadone prepared for oral consumption is not suitable for injection. Accordingly, proposals have been made to expand drug maintenance programs and practices beyond oral methadone to include injectable methadone and other drugs in oral, injectable and smokable form.

Expansion of drug maintenance programs beyond oral methadone offers the possibility of luring many more illicit drug users away from the illicit market and into contact with drug treatment and other social services, and of sustaining those injected heroin, and presents relatively few undesireable side effects on health. Two other opiates that are even more long acting-buprenorphine and levo-alpha-acetylmethadyl (LAAM) -have been studied as well and are now being considered for wider use. Injectable methadone, heroin and other opiates similarly present relatively few negative health consequences, but may present greater difficulties in achieving stable maintenance regimens. Far less is known about the prospects of achieving effective maintenance with stimulants (amphetamine, cocaine, etc.) either alone or in combination with opiates and/or sedatives.

Within the United States, dozens of narcotics maintenance clinics provided maintenance doses of morphine and other narcotics, including in some cases heroin, to thousands of addicts between 1912 and 1923.1°S Some of these-particularly one in Shreveport, Louisiana-proved successful both in normalizing the lives of opiate addicts and in virtually eliminating illicit local drug markets.106 In much of Asia during the latter half of the nineteenth century and the first half of the twentieth, governments restricted the sale of opium and other opiates but authorized the sale of opium to addicts, often local Chinese, through licensed outlets.t07 These too often accomplished similar objectives. During the 1970s, numerous proposals to prescribe heroin to addicts were advanced in the United Statesl08: one proposed the prescription of heroin as a lure and stepping stone to oral methadone maintenance; 109 another as a supplement to oral methadone:1l0 and Yet another as a distinct program to attract heroin addicts unwilling to enter oral methadone or drugfree treatment programs.1ll None of these proposals, however, were implemented.

In the United Kingdom, physicians have always retained the freedom to prescribe heroin, cocaine and most other drugs. This flexibility represents the core of what has long been known as the "British System." 112 Opiate addiction represented a relatively minor problem in Britain from the 1920s to the 1960s. The number of addicts at any one time was never much more than a thousand. Most were middle class. And most were prescribed their drugs of c:hoice-including heroin, morphine, pethidine, dipipanone, cyclimorph, dicanol, cocaine and amphetamine in oral and injectable forms-by physicians who perceived legal maintenance as preferable to illegal maintenance with drugs purchased from illegal sources.113 This began to change -particularly in London-during the mid-1960s, when the number of addicts began to increase and their age and social stature changed. The increase was blamed in part on a handful of physicians accused of writing grossly excessive prescriptions -although broader social, economic and cultural trends were also to blame (as in the United States).114 During the following decade, the "British system'2 evolved into one somewhat similar to that in the United States. In 1968, the British government announced that physicians would henceforth require a license to prescribe heroin and cocaine (although not methadone) to addicts. Oral methadone gradually replaced heroin, morphine and injectable methadone as the principal drug prescribed to addicts, and a more confrontational, abstinence-driven approach to treatment replaced the older tradition of normalization of addict lives with maintenance doses.

The switch to oral methadone could not be neatly justified by reference to scientific studies. The principal controlled study of heroin maintenance-in which ninety-six confirmed heroin addicts requesting a heroin maintenance prescription were randomly allocated to treatment with injectable heroin or oral methadone-found that "refusal to prescribe heroin is...associated with a considerably higher abstinence rate, but at the expense of an increased arrest rate and a higher level of illicit drug involvement and criminal activity among those who did not become abstinent." 115 Most British clinicians, frustrated and tired with both the theory and practice of providing addicts with drugs they otherwise would obtain on the streets, chose to interpret this study as justification for focussing on abstinence and relying only on oral methadone. 116 This policy eased the task of dealing with drug addicts, but at the cost of excluding others for whom abstinence and oral methadone were unacceptable. The British treatment system was thus poorly prepared to compete with the black market and attract illicit drug users when heroin use rose dramatically in Britain during the 1980s-to about tenfold the number of users in the mid-1960s. The proportion of opiate addicts^seeking treatment dropped-according to one estimate-from at least 50% in the early 1970s to io-25% in the mid-1980s. 117 What Americans often describe as the failure of the "British system" is more accurately characterized as evidence of the failure of the American system in Britain.

The "British system" never entirely disappeared. Even during the 1970s and 1980s, a few physicians continued to prescribe heroin, morphine and many other drugs to a small number of older, mostly middle class, addicts.1l8 During the late 1980s, largely in response to the spread of HIV, a few physicians began advocating a return to more flexible prescription practices. This was endorsed by the ministerial Advisory Council on the Misuse of Drugs.1l9 British physicians and clinics still rely primarily on oral methadone, but about ten percent of all methadone prescriptions are for injectable methadone,120 and a few physicians and clinics prescribe pharmaceutical versiohs of many of the drugs sold on the streets, including heroin, cocaine and amphetamine.121 One physician in Merseyside, John Marks, has gained international attention for his outspoken advocacy of more liberal prescribing practices, which include prescription of heroin and cocaine in smokable form to a small number of patients.122 In Warrington, one clinic has prescribed maintenance doses of cocaine in injectable ampoules, nasal sprays, and ''reefers.@|123 Physicians in Exeter, Portsmouth, Plymouth and Cheltenham have prescribed amphetamine in oral form to injecting amphetamine users. Initial reports suggest that the practice is associated with significant reductions in iIlicit drug use and HIV risk, as well as considerable progress in stabilizing employment, accommodation and legal status.124 Many physicians also prescribe heroin and other drugs to the occasional addict when methadone fails to accomplish desired treatment objectives-but most do so discreetly, preferring not to attract attention from either heroin users or the media. More flexible prescribing practices also emerged in Edinburgh in 1988 -- a few years after local authorities realized that the prevalence of HIV infection among resident heroin users was, at over 50%, the highest in the United Kingdom. 125 Local physicians responded with more liberal prescription of methadone as well as oral versions of dihydrocodeine, diazepam and temazepam-all drugs desired by addicts-although drug users were warned to steer clear of temazepam .126 This policy-combined with the rapid expansion of needle distribution and exchange-is believed to have played an important role in reducing needle use and sharing, the rate of new HIV infections, and drug-related criminality. 127 Local law enforcement authorities generally support harm reduction objectives and policies, and regard the diversion of prescribed drugs to black markets as a minor problem. 128

In Switzerland, the federal government recently approved a scientific study to prescribe drugs other than oral methadone-including injectable or smokable heroin, injectable morphine, injectable methadone and smokable cocaine-to 700 addicts.l29 Participation in the study is limited to drug users at least twenty years of age who have used heroin intensively for at least two years and dropped out of treatment programs at least twice. The study is thus targeted specifically at those drug users who failed to respond to other efforts to coerce or lure them away from the black market. The study, based on fourteen projects in

eight cities, employs a variety of research designs, with some based on random assignment of addicts and drugs and others based on evaluation of individual needs and drug use patterns. The scientific program evaluation will examine the physiological effects of the prescribed drugs, compliance with program requirements, and the impact on drug consumption, physical health, quality of life and criminality. 130

In the Netherlands, a small morphine maintenance program was initiated on an experimental basis in Amsterdam 1983. Designed to manage a special group of thirty-seven "extremely problematic addicts," the program provided a baseline dose of oral methadone, a dose of injectable morphine, and in some cases benzodiazepines and antipsychotics. Evaluated in a 2-3 year follow-up, the program was deemed modestly successful in improving the health and functioning of most of the addicts and reducing their involvement in criminal activities. 131 More recently, the Municipal Health Department in Amsterdam has begun prescribing injectable methadone and palfium-an opiate that can be taken orally-to a group of long-term heavy opiate users.132 In Italy during the late 1970s, a number of physicians dissatisfied with the quality of care for heroin addicts began providing addicts with injectable morphine on an out-patient basis. The Italian government legalized thevprescribing experiment in 1980 -- but approval was abruptly withdrawn a few years later. No scientific evaluation of the program was ever conducted-although an estimated 1-4,000 addicts were participatinq in 1982.133 In Austria, private physicians have

always been free to prescribe any legally available drug to addicts. Approximately a dozen addicts currently receive prescriptions for injectable morphine or methadone, with many others receiving prescriptions for codeine and other synthetic opiates.l34 In Australia until the 1960s, physicians prescribed maintenance doses of opiates, principally morphine, to small numbers of white, middle-class addicts and aging Chinese opium smokers.l35 In Queensland, a small injectable methadone program has operated for decades.136 In 1991, the Legislative Assembly of the Australian Capital Territory recommended consideration of a legal program for the controlled availability of heroin, and the Australian National University then sponsored the most thorough feasibility study of heroin maintenance ever undertaken. 1S7 It is now considering initiating an experimental program to prescribe heroin to addicts in the Australian Capital Territory. 138 Both in these and other countries, moreover, physicians often exercise greater latitude in prescribing maintenance doses of opiates to addicts suffering from AIDS (and hence entitled to opiates for pain relief).

Although opiate maintenance programs can prove highly effective in reducing illicit heroin and other opiate consumption, their impact on consumption of non-opiates such as amphetamine and cocaine is likely to be modest at best. This is an increasingly important limitation given the dramatic growth since the late 1970s in cocaine and multi-drug consumption -notably "crack" cocaine and combinations of cocaine and heroin known as "cocktails" or "speedballs." In the United States and most other countries, the notion of legally maintaining addicts with cocaine, amphetamine and other stimulants, either alone or in combination with opiates, is rejected. Almost no effort has been made to investigate the feasibility of such a regimen.139 In Britain, where some physicians reason that legal maintenance with this combination is preferable to illegal "maintenance," the practice of prescribing maintenance doses of cocaine, typically in combination with heroin and/or methadone, has persisted for decades-although the number of recipients declined from approximately 80 in 1969 to about 25 in 1974 and has remained in that range since. 140 An initiative in Britain to prescribe injectable amphetamine to injecting amphetamine users during the amphetamine epidemic of 1968 was deemed a failure.141 More recent initiatives to prescribe oral amphetamines, however, appear more successful.142 Anecdotal accounts of cocaine prescribing in Merseyside suggest the same.143 There are also reports from Peru and the United States that coca tea and other low potency cocaine-based beverages seem to prove useful in drug treatment programs.144 The Swiss experimental program, which allows for prescription of cocaine in smokable form, offers a rare opportunity to assess the feasibility of including stimulants in maintenance programs.

CANNABIS

Harm reduction principles have also influenced policies regarding cannabis. Although national drug commissions in many countries during the 1970s recommended the decriminalization of

cannabis,145 only the Netherlands followed through at the national level. The Baan Commission expressed the harm reduction sentiment that drug laws should not be more damaging to an individual than the use of the drug itself.146 It also argued that the tendency of some cannabis users to move on to illicit opiate use could be reduced by separating the "soft-drug" and "hard-drug" markets. In 1976, the Opium Law was revised to increase penalties for heroin and cocaine trafficking and decrease penalties for the sale and consumption of smail amounts of cannabis to misdemeanor offenses. Prosecutorial and police guidelines were also revised to de-emphasize enforcement of the cannabis laws. The result was the creation of a relatively normalized, essentially non-criminal, and easily accessible cannabis distribution system in most Dutch cities.

Cannabis can be bought in hundreds of Dutch "coffee shops"-some of which are bars serving alcoholic beverages and food as well.147 Most coffee shops offer a selection of ten or more types of marijuana and hashish at prices somewhat less than current U.S. prices. Advertising is prohibited, open display discouraged, and sales to minors prohibited. The police monitor these shops closely, make no effort to disturb buyers and sellers, and will investigate crimes against house dealers. If police detect sales of heroin or cocaine, they will warn the owner once before ordering the shop closed. The same practice applies to coffee shops that become centers of fencing, late night noise and hideouts for illegal immigrants.

The Dutch policy appears to have accomplished its objectives. Cannabis consumption among young people has remained relatively low. A national survey in 1989 reported that 17.7% of Dutch 17-18 year-olds had smoked cannabis at least once and 4.6% within the last month-approximately half to one-third the rates in the United States .148 Even in Amsterdam, the respective rates of consumption were 24.5% and 12.6% .149 Rates of cocaine and heroin consumption among Dutch citizens are similarly modest-although the relatively high quality and low price of the drugs have attracted "drug tourists" from elsewhere in Europe.l50 Dutch authorities express some concern about organized criminal involvement in wholesale production and sales of cannabis, and they must contend with frequent complaints from authorities in neighboring Germany and Belgium, but by and large the policy is regarded favorably by most Dutch law enforcement and other officials involved in drug control.

In 1987, the South Australian government introduced a Cannabis Expiation Notice system which allows individuals apprehended with small quantities of cannabis (up to 100 grams) to have their offense discharged-with no record of a criminal conviction-upon payment of a fine. 151 A similar scheme was introduced in the Australian Capital Territory in 1992. An analysis of the first two years of the expiation system by the South Australian Office of Crime Statisticsvfound little evidence of any impact on the number or type of people detected using cannabis.1s2 Its principal recommendation was that steps be taken to ensure that notice recipients pay their fines promptly to avoid court appearances.

In August 1991, the Federal High Court of Switzerland decided-in a case involving the sale of eight kilograms of hashish-that penalties for dealing cannabis were unduly harsh and needed to be revised given increasing evidence that the health hazards of cannabis consumption were relatively modest.153 A number of lower courts in Germany have ruled similarly, finding cannabis prohibition laws in conflict with the German constitution. 164

In the United States, eleven states decriminalized marijuana during the 1970s, effectively reducing legal sanctions for possession of small amounts to sanctions other than imprisonment. The impact on marijuana consumption was negligiblel55 -- although a recent study concluded that marijuana decriminalization was associated with an increase in the number of emergency room marijuana episodes and a decrease in the number of mentions of other drugs.156 Decriminalization did, however, reduce the number of arrests and prosecutions for marijuana offenses. An eRamination of marijuana law enforcement costs in California estimated that the state saved one billion dollars in the decade following the 1976 Moscone Act decriminalizing 157 marijuana.

HARM REDUCTION AND NICOTINE

Much (but not all) of the opposition to harm reduction initiatives fades when the drugs involved are legal. No government now favors outright prohibition of the production, sale and consumption of cigarettes despite their dangers. They rely instead on high taxes, warning labels, restrictions on times and places of sale and consumption, public information campaigns and numerous other measures to regulate and deter tobacco consumption. These measures have proven successful both in encouraging smokers to quit and discouraging many young people from starting to smoke, particularly in those countries-such as Canada-where they have been employed most aggressively.

Efforts are also devoted to reducing the harms associated with tobacco consumption among those who are unable or unwilling to stop. These focus on devising means of consumption that satisfy the craving for nicotine but reduce or eliminate associated tars and other harmful substances. The introduction of filter-tips and changes in tobacco processing methods beginning in the 1950s appear to have been successful in halving lung cancer rates among smokers.158 Subsequent efforts to reduce health risks by encouraging smokers to smoke less and marketing low-tar, low-nicotine cigarettes proved relatively unsuccessful because smokers responded by puffing harder, inhaling more deeply, and smoking to a shorter butt.159 In 1983, the Independent Scientific Committee on Smoking and Health in Britain recommended the development of low-tar cigarettes with slightly enhanced nicotine yields to reduce compensatory increases in smoking behavior and improve acceptability to smokers. 160 Nicotine chewing gum, developed in Sweden during the early 1970s, has proven effective in relieving nicotine withdrawal symptoms and helping people to quit smoking, particularly when accompanied by intensive counselling and support.lsl Other nicotine delivery systems are now emerging: skin patches, nasal sprays and vapour puffers and inhalers. Harm reduction precepts also suggest that the European Community's efforts to ban smokeless tobacco and the successful campaign by anti-tobacco forces in the United States to prohibit over-the-counter sale of the virtually tar-free "cigarettes" designed by R. J. Reynolds may have been counterproductive.

Alternative nicotine delivery systems share much in common with methadone programs. Both provide a highly addictive drug-albeit one that poses only mild health risks-in a form designed to reduce associated harms to consumers and others. Both have proven effective in reducing more dangerous forms of drug consumption. Both were designed primarily as a short-term aid to help people stop consuming a drug, but are now used by many people for long-term maintenance. Both are readily integrated with most living styles. Consumed in the form of oral methadone, chewing gums or skin patches, neither provides consumers with much of the effect on mood or cognition experienced with injected heroin or smoked cigarettes. But both are potentially available in other forms-injectable, smokable, nasal spray and vapour puffer and inhaler-that provide more of the "rush" desired by addicts. And both are opposed by some on

the grounds that they perpetuate addictive behavior and reduce incentives to quit entirely.

The differences between the two systems are also worth noting. Alternative nicotine delivery systems are designed to substitute for tobacco products that pose great health risks despite their legal availability. Most of the dangers associated with heroin, by contrast, stem from its illegality. Alternative nicotine delivery systems also pose slightly greater health risks (such as heart disease and oral cancer) than methadone and other opiates. But whereas many tobacco substitutes can be purchased either over-the-counter or with easily obtained prescriptions, methadone remains relatively difficult to obtain. Although both are relatively inexpensive to produce, the legal and administrative costs of most methadone programs substantially inflate the effective price of methadone.

CONCLUSION

Why has harm reduction emerged as a guiding principle of drug control policy in some countries and cities but not in most of the United States and other advanced industrialized democracies? The reasons vary from one country to another -although citizens of each boast of powerful strains of pragmatism and sensibility in their national character. These countries, particularly Australia and the Netherlands, are less receptive to the highly emotional, polarized and longstanding conflicts not only over drugs but abortion, homosexuality, prostitution, gambling, euthanasia and other issues that arouse such sustained

moralistic fervor in the United States. Public health precepts tend to prevail over contrary moralistic impulses. People worry less about "sending the wrong message" with policies that attempt to minimize the harmful consequences of illegal and undesireble behavior. Even when they seek to legislate morality, they tend not to favor vigorous enforcement of such laws. And few favor increasing levels of incarceration to those found in the United States.

Drug policy experts in these countries also explain their divergent drug policies in terms of particular national characteristics. Australians often point to their geographic isolation. Swiss emphasize their long tradition of neutrality, their persistence in resisting the homogenizing influences of European integration, their wealth, and the absence of urban ghettos-which make it impossible to hide deviant behavior in neighborhoods where tourists and good citizens do not venture. British point to the long tradition of physician independence in clinical decisions, but they also note the rapid growth of non-medical drug agencies staffed by social workers and nurses, who are less encumbered than physicians with traditional medical views on treatment of drug abuse. The Dutch pride themselves on their pragmatic and non-moralistic approaches to most domains of social policy. And urban officials stress that they have no choice but to devise effective harm reduction strategies given the concentration of drug-related problems in urban areas. They can not afford, in their view, the more moralistic approaches advocated in less urbanized areas.

Growing numbers of Americans recognize the need for new approaches to America's drug problems. Federal, state and local officials increasingly speak of de-emphasizing criminal justice approaches in favor of more drug treatment and prevention. Sorely lacking, however, has been any coherent philosophy or framework for re-directing drug control policies in the United States. Harm reduction precepts offer no panacea, but they do provide an alternative philosophy and framework that promises to reduce the negative consequences of both drug use and drug policies.

Harm reduction is not an alien philosophy unsuited to the United States. Its basic precepts can be discerned in the early history of U.S. drug control, in the institutionalization of methadone maintenance programs since the 1960s, in the decriminalization of marijuana during the 1970s, and in recent efforts to reduce the harms associated with alcohol and tobacco consumption. Both the philosophy and the language of harm reduction can be heard and seen in the recent proliferation of needle exchange programs in more than three dozen U.S. cities, in recent experiments with "interim" methadone maintenance and the employment of methadone buses in a few cities, in the creation of a methadone maintenance program in New York City's jaii system, and in outreach efforts and other local initiatives to reduce the spread of HIV among illicit drug users. In late 1993, the Working Group on Drug Policy Reform created by Baltimore Mayor Kurt Schmoke issued a report designed to provide a model harm reduction drug policy for Baltimore and other American cities.162

Among its recommendations were the consideration and adoption of many of the initiatives described in this article. 16S

Harm reduction, it must be stressed, neither celebrates nor legitimates psychoactive drug use, but rather acknowledges that it cannot be eliminated. Harm reduction does not disavow abstinence but rather recognizes that there are other ways to reduce the harms of drug use. It does not repudiate government's responsibility to "send the right message'~ but rather insists that government rhetoric and policy demonstrate concern for the health and welfare even of those who continue to use drugs illicitly. And it demands not that police abstain from drug enforcement but that they collaborate with public health officials and even drug users to reduce drug-related harms. There is not, and cannot be, any simple or ultimate solution to America's drug problems. What harm reduction offers is a pragmatic and humane approach for reducing the damage associated with drug use and ineffective drug control policies.