Hvordan kan et dansk heroinforsøg udformes og hvad vil man opnå ved det, spørger centerleder Jørgen Jepsen fra Center for Rusmiddelforskning bl.a. i denne opsummering af heroindebatten.

Efter publiceringen af WHO’s moderate vurdering af de schweiziske heroinforsøg er diskussionen om et eventuelt dansk

heroinforsøg blusset op igen. Desværre bærer mange af debatindlæggene og medieomtalerne præg af forvirrede og kategoriske opfattelser og udtalelser, f.eks. at det drejer sig om “fri heroin”, “heroin til unge” osv., osv.. Der er i dag behov for en afklaring af, hvad diskussionen bør dreje sig om, hvad meningen med et dansk heroinforsøg i det hele taget kunne være og hvordan det kunne tilrettelægges bedst muligt. Det følgende er et personligt forsøg på at udrede nogle af trådene og lægge op til en mere omtænksom afgørelse, uden på forhånd at tage absolut stilling den ene eller anden vej.

Resultater fra Schweiz

De schweiziske forsøg har vist, at det har været muligt at uddele heroin til hårdt ramte opiatmisbrugere uden problemer for omverdenen og med et etisk og praktisk forsvarligt arrangement. Ifølge forsøgsrapporterne har de deltagere, der er blevet i forsøget, opnået bedre fysisk og psykisk helbred, en bedre social situation (bolig- og arbejdsmæssigt og mht. økonomi), reduceret deres kriminalitet og nedsat forbruget af nogle illegale stoffer. De har også i betydelig grad afviklet deres kontakter med stofmiljøet – men ikke fået nye, positive omgangskredse uden for dette.

Disse resultater – der anerkendes af WHO og de fleste nuancerede eksperter – er baseret på de pågældendes egne oplysninger, men de er i et vist omfang – f.eks. mht. kriminalitet – støttet på uafhængige undersøgelser. Men der er en hel del problemer i den bredere tolkning og vurdering af disse resultater.

Allerførst: Den ønskede reduktion i dødeligheden blandt de stofmisbrugere, der deltog i forsøget, er ikke klart bevist, omend den er sandsynliggjort. Den er på ca. 2 pct. – hvad der stort set svarer til f.eks. den danske dødelighed blandt narkomaner, i og uden for behandling – 2.4 pct. (Sundhedsstyrelsen, 1999). En del af dem, der døde i forsøgsperioden, var i øvrigt forinden smittet med HIV. Men intet forsøg af den størrelsesorden, der har været tale om – og som kunne komme på tale i et dansk forsøg – kan med rimelig sikkerhed bevise en reduktion i dødeligheden. Dertil er tallene for små og den statistiske usikkerhed følgelig for høj.

Heri ligger også uundgåelige begrænsninger for et evt. dansk heroinforsøg.

Det må erkendes, at det ikke lykkedes i de schweiziske heroinforsøg at fastholde en del af de allerdårligste misbrugere. Dette gjaldt især dem, der havde det dårligst psykisk og nogle personer med et højt sideforbrug af kokain. Men andre af dem, der forlod forsøget, gik over til mere traditionelle former for behandling, heriblandt metadon(støttet) behandling eller stoffri do.. En del har formentlig ikke kunnet eller ikke villet deltage i den psykologiske behandling, der var en del af forsøget som en forudsætning for at være med overhovedet. (I øvrigt så det ud til, at de ‘dårlige’ misbrugere i de schweiziske forsøg ikke gennemsnitligt var så dårlige, som den dårligste gruppe af danske stofmisbrugere).

For det andet: Det er usikkert, i hvilket omfang de opnåede resultater skyldes heroinen som sådan eller den ledsagende psyko-sociale behandling. Det er i dag en udbredt opfattelse blandt eksperter, både de schweiziske og udenlandske i øvrigt (fremgik f.eks. af et møde i Bern i marts 1999), at det ikke med det anvendte design er muligt at påvise årsagen. Men det vil det næppe heller være med noget andet, anvendeligt design. Spørgsmålet er formentlig forkert stillet. Realiteten synes at være, at heroin fungerer som ‘lokkemad’, der får folk ind i og i nogen grad fastholder dem i behandlingen, således at de øvrige tiltag kan få en chance for at fungere. Disses nærmere karakter og omfang er imidlertid utilstrækkeligt belyst i de schweiziske rapporter.

Men principielt er det den gamle historie om ægget og hønen.

Forsøgsdesign og videnskabelighed

Problemet i den forbindelse handler afgørende om, hvilken form for videnskabelighed, man mener er nødvendig i forbindelse med sådanne forsøg. De schweiziske forsøg blev kritiseret for, at de ikke anvendte det traditionelle bio-medicinske design (der normalt anvendes ved afprøvning af lægemidler og andre stoffer) med en eksperimentalgruppe og en kontrolgruppe og med statistisk tilfældig (“randomiseret”) placering i den ene eller den anden gruppe. Gerne i øvrigt sådan, at man anvender to forskellige behandlingsmåder/stoffer – f.eks. metadon og heroin – samtidig med at en tredje gruppe får ‘placebo’, dvs. et uvirksomt stof (f.eks. kalktabletter), således at man kan kontrollere for effekten af dette, at personer blot får opmærksomhed i forbindelse med, at de deltager i et forsøg (noget der erfaringsmæssigt i sig selv kan give en vis positiv virkning – den såkaldte “Hawthorne-effekt”).

Et sådan design blev delvist anvendt i nogle mindre, isolerede dele af de schweiziske forsøg, især for at måle forskelle imellem heroin og morfin. Men denne del af forsøgene gik skævt – hvilket imidlertid ikke rokker ved de øvrige resultater.

Resten af de schweiziske resultater blev søgt belyst gennem et andet design, nemlig med en efterfølgende opstilling af sammenligningsgrupper. Her viste det sig, at de schweiziske resultater med heroin var bedre end i sammenligningsgrupperne med metadon. Disse sammenligninger kan konkret kritiseres på metodologisk grundlag, men at man anvender denne metode er ikke i sig selv kritisabelt – det er faktisk i denne forbindelse det eneste realistiske design, omend man kan lave sammenligninger fra starten af et evt. forsøg, i stedet for efterfølgende. Man kan så gøre mest muligt for at sikre sig, at grupperne ligner hinanden i de væsentlige henseender – men helt sammenlignelige som ved et egentligt experimentelt design kan de aldrig blive. Selv kritikere af de schweiziske forsøg – som f.eks. Dorrit Schmidt i en kritisk artikel i bladet “Stof” nr. 4, jan. 1998 – anvender denne sammenligningsmetode. D.S. sammenligner i stedet blot med en gruppe metadonbehandlede i Hamborg, der viste bedre eller lige så gode resultater som i det schweiziske forsøg. Men heller ikke her var der tale om helt sammenlignelige grupper. Og i øvrigt nåede gruppen, der analyserede forsøgene i Hamborg, frem til, at heroin ville være et ønskeligt supplement til metadon-behandlingen for visse grupper.

Det er også bemærkelsesværdigt, at man i Danmark har iværksat forsøg med substitutionsstofferne LAAM og Buprenorphin (i stedet for metadon), uden at man har fulgt det experimentelle design, de samme sundhedspersoner ellers kritiserer de schweiziske forsøg for at mangle.

En del af forskellen hænger sammen med, at heroinforsøgene går ud fra en intravenøs brug af heroinen. Da denne har en kort halveringstid, må der indsprøjtninger til flere gange om dagen for at holde abstinenserne væk. Kritikere finder dette meget betænkeligt. Men de glemmer, at man taler om personer, der – uden forsøget – alligevel ville sprøjte sig flere gange om dagen, blot under meget mere betænkelige omstændigheder: usterilt, på gaden, jagtet af politiet og med stof af ukendt styrke i sprøjten. Heroinforsøgene er i den forbindelse et klart skadesreducerende tiltag, uagtet om folk holder op eller ej, og rent faktisk viste det sig, at en del af forsøgsdeltagerne nedsatte antallet af daglige fremmøder til indsprøjtning fra tre til to eller en enkelt gang – i nogle tilfælde fik de så metadon med hjem for at kunne klare sig indtil de mødte næste gang. Igen et praktisk orienteret, skadesreducerende tiltag. Det ødelagde måske det strikte bio-medicinske experimental-design – men det virkede.

Heroinforsøg i Danmark

Der er herefter to grundlæggende spørgsmål i forbindelse med et evt. dansk heroin-forsøg: Hvilket forsøgsdesign skal der bruges – og hvad er det man vil opnå?

Det sidste spørgsmål er egentlig det væsentligste, men har været stort set forsømt i den danske debat. I stedet har denne været reduceret til et simplistisk ‘for eller imod’. Men for eller imod hvad?

Der henstår en række spørgsmål efter de schweiziske (og de nystartede hollandske) forsøg. WHO peger således på, at man ikke uden videre kan anvende de schweiziske resultater i andre lande og kulturelle sammenhænge, hvorfor man anbefaler forsøg i andre lande (!). Men man må også kunne stille andre, væsentlige og mere præcise spørgsmål end i de andre forsøg.

Opnåelse af målsætningen at reducere dødeligheden vil man ikke kunne bevise i evt. et dansk forsøg, selvom man lagde det op på et (højt) niveau på f.eks. 1000 deltagere. Men om man kunne “få fat på” en meget tung gruppe og fastholde denne med fornøden indsats var vel værd at undersøge. At forsøgene vil kunne udføres i praksis og være etisk forsvarlige anser selv WHO for at være godtgjort af de schweiziske forsøg.

Men hvem skal forsøget rettes imod? Hvis det kun er en lille gruppe, meget ringe stillede, bør der vies særlig opmærksomhed til rekruttering og fastholdelse – noget man ikke gjorde så meget ud af i Schweiz. Man fandt i øvrigt, at det blev i stigende grad vanskeligt at finde egnede forsøgsdeltagere, så vi behøver ikke at være bange for, at et dansk forsøg – med de fornødne krav om deltagelse i psyko-social behandling – skal virke som en magnet på danske stofmisbrugere og rykke dem væk fra den stoffri behandling.

Men skal man evt. gå ned i graderne og søge at inddrage misbrugere, som endnu ikke er nået alt for langt i deres karriere – og derfor kan inddrages i en behandling på et tidligere tidspunkt, hvis man kan få fat på dem? Dette er en politisk og etisk afgørelse, der ikke er noget videnskabeligt svar på på forhånd.

Mht. undersøgelsesdesign forekommer det, at et egentligt kontrolleret eksperiment hverken er etisk forsvarligt eller praktisk gennemførligt. Hvis nogle deltagere skal have metadon, hvor de i stedet havde håbet på heroin – som andre får – vil de stemme med fødderne, og dermed invalidere forsøget. Nogle kritikere hævder, at stofmisbrugerne ikke kan kende forskel på, om de får metadon eller heroin. Men de selv hævder, at der er klare forskelle, og de fleste foretrækker heroin. Men ikke alle. En nyligt rapporteret, canadisk undersøgelse viste, at 34% af en gruppe misbrugere, som fik tilbudt valget mellem heroin eller et andet substitutionsstof (for det meste metadon), valgte heroinen fra.

Dersom man vil forlange et klassisk forsøgsdesign som grundlag for et dansk forsøg, kan man lige så vel opgive på forhånd. Det vil simpelthen ikke virke, eventuelle slutninger fra det ville være begrænsede, og der vil være store etiske problemer i det. Men der er andre anvendelige designs. Problemet er, at debatten hidtil hovedsagelig har drejet sig om dette design, uanset om det er uegnet i andre sammenhænge end dem, hvortil de er udviklet (se dog kritik mv. i: Netværk for Samfundsvidenskabelig Sygdomsforskning, 1996). Det er altså en usikkerhed om den rette videnskabelige model. Et forsøg baseret på på forhånd opstillede, videst muligt sammenlignelige grupper vil være mere relevant. Men ingen af designene giver “videnskabelig vished”,

kun en vis sandsynlighedsgrad inden for hver deres forudsætninger. Den, der kræver vandtæt bevis, har på forhånd afskåret sig fra videre overvejelser og viderebragt en illusion om videnskabelighed.

Vil vi overveje et dansk heroinforsøg, må man derfor først afgøre de nævnte spørgsmål om målgruppe og design. Man kan ud fra en etisk betragtning sige, at man først bør udbygge systemet med en adækvat anvendelse af de behandlingsmuligheder, vi allerede kender. Samstemmende beretninger tyder på, at vi ikke for alvor i Danmark har afprøvet og gennemført en metadon-understøttet behandling med fuldt tilstrækkelige, supplerende tilbud om psykologisk og social støtte. Det burde man måske gøre, inden man går videre. Når denne behandling er tilstrækkeligt udbygget landet over, kan man så bedre forsvare evt. at gå videre med eventuel heroinunderstøttet behandling.

Men man kunne også – da det lige opstillede mål næppe vil blive realiseret inden for en overskuelig tid – lave et heroinforsøg baseret på sammenligningsmetoden.

Stofmisbrugernes valg

Man kunne vælge i ét område at tilbyde heroin med krav til deltagerne om, at de samtidig indgår i en intensiv psyko-social behandling – og til behandlere, administratorer og politikere om, at de stiller denne behandling til rådighed. Samtidig kunne man i et andet område tilbyde tilsvarende intensiv behandling, men knyttet til metadon som substitutionsstof i stedet for heroin. Og endelig kunne man finde et tredje område, med “gængs”, ringe eller ingen supplerende psykosocial behandling, men blot metadon som hovedstof. En sammenligning mellem sådanne tre modaliteter kunne give os en betydeligt større indsigt. De tre områder bør været klart geografisk adskilt, og kun misbrugere med bopæl inden for det pågældende område bør kunne deltage i det lokale forsøg. Det vil være et problem, at de kulturelle rammer og de ikke-institutionelle faktorer vil være forskellige, og dette bør man drage særlig omsorg for at belyse.

I virkeligheden er det egentlige spørgsmål, hvilken behandling den enkelte stofmisbruger vil foretrække, og her er der ikke på forhånd nogle sikre svar. Nogle vil vælge det ene, andre det andet. Og det ville vel være godt nok, hvis ikke vi kom med rigide krav om bevis for noget, der ikke kan bevises. Men hvad vil der være etisk og politisk galt med at lade misbrugerne selv vælge, hvilken behandlingsform de vil foretrække? Ligesom andre patienter i princippet har frit sygehusvalg og kan være medbestemmende om valget af behandlingsform.

Når mange er modstandere af heroinforsøg, er det tildels udtryk for en puritanistisk holdning, at folk ikke skal have, hvad de ønsker. Man vil f.eks. ikke give gratis alkohol til alkoholikere. Rent bortset fra, at vi tillader alkoholikere at bruge bistandshjælpen til alkohol, er der den væsentlige forskel, at alkohol er et yderst giftigt stof, medens man kan indtage heroin i årevis og føre en rimeligt normal tilværelse, hvis man ikke er udsat for de risici og den forfølgelse fra omgivelsernes side, der følger af stoffets illegale status og kontrolsystemet.

Repræsentanter for den stoffri behandling er stærke modstandere af et heroin-forsøg, fordi de mener, dette vil afholde misbrugere fra at søge stoffri behandling. De skal “finde deres bund”, som man så smukt kalder det – “helt ned med nakken”, siger andre mere bramfrit. Men i betragtning af, at kun 34-36 pct. af personer, der har påbegyndt en stoffri behandling, gennemfører denne (se Mads Uffe Pedersen, CRF, 1998 og 1999), og at kun 40-60 af disse er stoffri et år efter udskrivningen – altså en total successrate på max 20 pct. (mindre for de helt unge og for dem over 40), kan man ikke påstå, at den stoffri behandling er svaret for alle. De økonomiske og ideologiske interesser, der præger dette område, har imidlertid ført til voldsomme udfald mod anderledes tænkende.

Økonomi og politik

Et sidste synspunkt går ud på, at et heroinforsøg vil være dyrt og trække ressourcer fra de øvrige, hårdt tiltrængte indsatser på stofmisbrugsområdet. Det er rigtigt, at det vil koste udlæg af en ikke ubetydelig størrelsesorden og stille en række prioriteringskrav til systemerne. Derfor bør Folketinget ikke iværksætte heroinforsøg, hvis man ikke er indstillet på at bevilge de fornødne, særskilte midler hertil. Noget andet er, at man kunne overveje at lade forsøgsdeltagerne betale for den heroin, de får i forsøget. Hvorfor ikke – når alkoholikerne kan betale for deres alkohol? Gør man det – det drejer sig om ca. 250 kr. om dagen, siger man i Schweiz – vil der for samfundet være en nettobesparelse som følge af mindre kriminalitet fra denne gruppe med færre belastninger af rets- og fængselssystemet. Men man får ikke en massiv afskaffelse af kriminalitet på denne måde. Penge er trods alt et af de allermest afhængighedsskabende stoffer.

Problemet med at inddrage denne besparelse er i virkeligheden rent bevillingsteknisk – at overføre penge fra Justitsministeriets område til social- og sundhedssektoren. Og dette er måske et af de politisk vanskeligste – men en besparelse er jo en besparelse, uanset hvor den posteres på finansloven. Hovedopgaven er altså at bevilge de penge til forsøget, som skal til, uden smålig nedskæring på området i øvrigt. Til gengæld kan man så mere rationelt undersøge, hvad man egentlig får for de penge, man investerer på stofmisbrugsområdet. Udredningen heraf er først begyndt for nylig og politikerne står famlende over for opgaven: At blive mere rationelle.

Den hidtidige form for heroindiskussion har desværre gjort det vanskeligt at træffe sådanne rationelle valg. Politikerne må derfor overveje mål og midler mere grundigt, inden de træffer en afgørelse. Der er ingen lette svar, hverken den ene eller den anden vej.

F:

Bern: International Symposium: Heroin assised treatment for dependent drug users: State of the art and new research perspectives, (Bern, 10-12. March, 1999)

Netværk for Samfundsvidenskabelig Sygdomsforskning (1996): Kontrollerede Kliniske Undersøgelser – forsvar, kritik og refleksioner (Dorte Gannik og Laila Launsøe, red.)

Pedersen, Mads Uffe (1999): Stofmisbrugere efter behandling. Rapport nr. 5, CRF, Aarhus (1998): Stofmisbrugere i døgnbehandling. Delrapport nr. 3, CRF, Aarhus

Schmidt, Dorrit (1999): Heroinforsøgene i Schweiz – alternativ til hvad? Narkotikarådets blad “Stof” nr.4, jan. s.4-10.

Sundhedsstyrelsen (1999): Nye tal fra Sundhedsstyrelsen, 3/3: Dødelighed og dødsårsager blandt stofmisbrugere indskrevet i behandling i Danmark. Skøn over antal dødsfald blandt stofmisbrugere og over antal stofmisbrugere i Danmark

Harry J. AnslingerDirector of the Federal Bureau of Narcotics

1930 – 1967General References to Anslinger

The History of the Marijuana Laws in the United States by Charles Whitebread – A Speech to the California Judges Association 1995 annual conference An excellent, and funny history of how we got our current drug laws.

The Forbidden Fruit and the Tree of Knowledge: An Inquiry into the Legal History of American Marijuana Prohibition by Professor Richard J. Bonnie & Professor Charles H. Whitebread, II — The first major study ever done of the legal history of the marihuana laws.

The History of the Marihuana Tax Act of 1937 by David F. Musto, MD

From the National Commission on Marihuana and Drug Abuse, 1972

· History of Marihuana Legislation
From The Marihuana Tax Act Page
· Conference on Cannabis Sativa L. January 14, 1937 — Room 81 Treasury Building, 10:30 AM
· Statement of H. J. Anslinger, Commissioner of Narcotics, Bureau of Narcotics, Department of the Treasury.
· Additional statement of H. J. Anslinger (includes “Marihuana as a Developer of Criminals”, by Eugene Stanley, district attorney, parish of Orleans, New Orleans, La.)
· Statement of H. J. Anslinger, Commissioner of Narcotics, Bureau of Narcotics of the Treasury Department
· Marihuana Conference of 1938
Correspondence about the legal status of hemp 1930 – 1938
· Letter from Harry Anslinger – September 29, 1936
· Letter from Elizabeth Bass – September 30, 1936
· Letter from Elizabeth Bass – October 6, 1936
· Letter from Harry Anslinger – November 2, 1936
· Letter from Elizabeth Bass – November 3, 1936
· Letter from Elizabeth Bass – November 5, 1936
· Letter from Elizabeth Bass – November 6, 1936
· Report of the Marihuana Investigation – Summer, 1937
· Letter from H. W. Bellrose, October 12, 1937
· Letter from H. W. Bellrose – October 12, 1937
· Letter from H. W. Bellrose – October 14, 1937
· Letter from Brien McMahon – October 26, 1937
· Letter from Will S. Wood – November 6, 1937
· Letter from Frank Ridgway – January 21, 1938
· Letter from Elizabeth Bass – March 5, 1938
· Letter from Elizabeth Bass – March 5, 1938
· Letter from Elizabeth Bass – March 10, 1938
· Report of Survey Commercialized Hemp Crop (1934-35 Crop) in the State of Minnesota, by H.T. Nugent, Federal Bureau of Narcotics, Field Supervisor, October 22, 1938
Hemp Around Their Necks — Chapter 3 of Harry Anslinger’s 1961 book “The Murderers”. – Among other things he tells how the La Guardia Committee Report gave children a signal to light up as many reefers as they want.

STATEMENT OF H. J. ANSLINGER,

COMMISSIONER OF NARCOTICS, BUREAU OF NARCOTICS OF THE TREASURY DEPARTMENT

MR. ANSLINGER: Mr. Chairman and distinguished members of the committee, we are having a great deal of difficulty. Last year there were 338 seizures of marihuana in some 31 states involving several hundred tons of growing plants, bulk marihuana, and cigarettes.
The states are asking for our help. We are trying to give it to them, but we are rather limited in our ability at the present time.
I have made a statement before the Ways and Means Committee, which is in the record, but since that time I want to point out to the committee an incident which occurred on June 28, at Abingdon, Va. There was a marihuana farm at that point, and the man who was growing those plants had been connected with a family that was engaged in smuggling narcotic drugs into Atlanta penitentiary some years ago. When we heard Dewey Doss was engaged in the production of marihuana, we went after him, and we got the state officers to make a case against him. We could not do anything about that, although the information came to us first.
A month or so ago, down in Texas, a man was arrested on a Missouri Pacific train going north with a quantity of cannabis, and another man was arrested in the vicinity of this place, called Raymondsville, Texas. They had both stripped the plants on a hemp farm.
SENATOR BROWN: You mean they had taken the leaves off?
MR. ANSLINGER: They had taken the leaves off and the flowering tops.
I received this letter from an attorney at Houston, Texas, just the other day. This case involves a murder in which he alleges that his client, a boy 19 years old, had been addicted to the use of marihuana.
SENATOR BROWN: Shall we read this into the record?
MR. ANSLINGER: Yes, sir; I shall be very glad if you will.
(The letter is as follows:)
Houston, Tex., July 7, 1937
H. J. Anslinger
United States Commissioner of Narcotics
Washington, DC
Dear sir:
Your article on Marihuana appearing in the July issue of the American is very useful as well as interesting.
this subject strikes close to home because of a client II have who not so long ago murdered in a brutal way a man who had befriended him in giving him a ride. This client is a boy 20 years of age and he explained to me he has been smoking marihuana for several years. I would like to have about 1 copies of your article and will gladly pay any necessary charges. I would appreciate an early reply.
Yours Truly,
Sidney Benbow
MR. ANSLINGER: I have another letter from the prosecutor at a place in New Jersey.
It is as follows:
The Interstate Commission on Crime
March 18, 1937
Charles Schwarz, Washington, DC
My Dear Mr. Schwarz:
That I fully appreciate the need for action, you may judge from the fact that last January I tried a murder case for several days, of a particularly brutal character in which one colored young man killed another, literally smashing his face and head to a pulp, as the enclosed photograph demonstrates. One of the defenses was that the defendant’s intellect was so prostrated from his smoking marihuana cigarettes that he did not know what he was doing. The defendant was found guilty and sentenced to a long term of years. I am convinced that marihuana had been indulged in, that the smoking had occurred, and the brutality of the murder was accounted for by the narcotic, though the defendant’s intellect had not been totally prostrate, so the verdict was legally correct. It seems to me that this instance might be of value to you in your campaign.
Sincerely yours,
Richard Hartshorne
Mr. Hartshorne is a member of the Interstate Commission on Crime. We have many cases of this kind.
SENATOR BROWN: It affects them that way?
MR. ANSLINGER: Yes.
SENATOR DAVIS: (viewing a photograph presented by Mr. Anslinger) Was there in this case a blood or skin disease caused by marihuana?
MR. ANSLINGER: No; this is a photograph of the murdered man, Senator. It shows the fury of the murderer.
SENATOR BROWN: That is terrible.
MR. ANSLINGER: That is one of the worst cases that has come to my attention, and it is to show you its relation to crime that I am putting those two letters in the record.
SENATOR BROWN: The first letter is also very interesting.
MR. ANSLINGER: This first letter was from an attorney at Houston. In June of this year, at Geneva, an international committee of experts in going over the reports received from all over the world said that the reports thus far indicate that the medical value of cannabis derivatives is very doubtful. There is another report here from Dr. Paul Nicholas Leech.
SENATOR BROWN: That is, to make perfectly clear, its medical value is not very great, and there are many other drugs that may be used in place of it that are fully as good if not better?
MR. ANSLINGER: Yes, sir; it is not indispensable.
SENATOR BROWN: I think some medical men say that if we had no such drug at all the medical profession would not be very greatly handicapped. That is, medical science would not be very greatly handicapped.
MR. ANSLINGER: I think they are pretty generally in agreement that its use could be abandoned without any suffering.
I have a few cases here that I would like to tell the committee about. In Alamosa, Colorado, they seem to be having a lot of difficulty. The citizens petitioned Congress for help, in addition to the help that is given them under state law. In Kansas and New Mexico also we have had a great deal of trouble.
Here is a typical illustration: A 15-year-old boy, found mentally deranged from smoking marihuana cigarettes, furnished enough information to police officers to lead to the seizure of 15 pounds of marihuana. That was seized in a garage in an Ohio town. These boys had been getting marihuana at a playground, and the supervisors there had been peddling it to children, but they got rather alarmed when they saw these boys were developing the habit, and particularly when this boy began to go insane.
In Florida some years ago we had the case of a 20-year-old boy who killed his brothers, a sister, and his parents while under the influence of marihuana.
Recently, in Ohio, there was a gang of very young men, all under 20 years of age, every one of whom had confessed that they had committed some 38 holdups while under the influence of the drug.
In another place in Ohio, a young man shot the hotel clerk while trying to hold him up. His defense was that he was under the influence of marihuana.
SENATOR BROWN: When a person smokes the cigarette, how long does the influence of the drug continue?
MR. ANSLINGER: From reports coming to me, I think it might last as long as 48 hours before the effects of the drug fully wear off.
SENATOR BROWN: I do not know whether it was your article I read, or an article from some other source, but I understand that experiments have been conducted, in which the persons smoking the marihuana have been kept under control after taking the drug. Do you know whether or not that demonstrated how long the effect would be felt?
MR. ANLSINGER: As I remember it, the effects in those cases were something like 48 hours, before they fully returned to their normal senses.
Here is a case in Baltimore, where a young man committed rape while under the influence of marihuana. He was hanged for it. Last fall, about September, we uncovered a field of several acres, growing right outside the city limits of Baltimore. Those men were selling it to New York, sending it all over the country, at $20 a pound.
SENATOR DAVIS: And how many pounds to the acre?
MR. ANSLINGER: That would depend, Senator. If they just took the flowering tops the yield would not be so big, but some of them strip off the leaves and the flowering tops and grind them up.
SENATOR DAVIS: Do the leaves have the same effect as the flowering tops?
MR. ANSLINGER: Yes, sir; one of the Treasury’s chemists is here who can verify that, sir. It has been proved by experts in other countries who have analyzed the leaves. They find that the resin is also present in the leaf. Our experiments have not shown the presence of any drug in the mature stalks, though. A one time we thought that the dangerous principle was only in the flowering top, but that is not true. What led us to the study as to whether there was resin in the leaves was the fact that we had seen so much of this stuff rolled up. In some cases only the leaves had been crushed, and they seemed to be giving the effect. In New Mexico, officers sent us about 4 or 5 pounds of nothing but leaves, and some of that particular shipment had been the cause of the killing of a police officer, and also the killing of a man within the ring. Every day we have such seizures, reports.
SENATOR BROWN: Is the cigarette that is made form the flowering top more potent than the one made from the leaves?
MR. ANSLINGER: Yes, sir, it would be, because the tops have the resin concentrated.
SENATOR BROWN: Do I understand that the seed is ground up, too. and used to any extent?
MR. ANSLINGER: Well, we have heard of them smoking the seed..
SENATOR BROWN: Does it produce the same effect?
MR. ANSLINGER: I am not qualified to say. We have not made any experiments as to that, but we do know that the seed has been smoked. I think that the proposition of the seed people sterilizing the seed by heat and moisture will certainly do a lot to kill this traffic. I think that that one thing might cut this traffic in half, because much of the trouble we encounter is due to the trafficker going to a feed store and buying the birdseed and planting cannabis, and all due to the birdseed being scattered during the winter. Hempseed is thrown out in the garden or in the vacant lot. The following year you have a growth of cannabis. That is what happened in Baltimore, and particularly in Philadelphia. I know of a case there where the State officers got over 200,000 pounds of growing plants, as the result of dissemination by birdseeds. A lot of that growth was being used illicitly. The traffickers knew where to get it. The plant reseeded itself.
The action that will be taken under this bill by the birdseed people in sterilizing the seed should have a remarkable effect in killing the traffic.
SENATOR BROWN: The sterilized seed will not reproduce?
MR. ANSLINGER: It will re-seed itself.
SENATOR BROWN: I am referring to the birdseed. What are they going to do to the birdseed?
MR.ANSLINGER: They are going to kill the germinating power.
SENATOR BROWN: When the seed is then thrown out, what will happen?
MR. ANSLINGER: Nothing will happen.
SENATOR DAVIS: Will it be of any use as a birdseed?
MR. ANSLINGER: Oh, yes. It will still have food properties.
SENATOR BROWN: The birds will sing just the same?
MR. ANSLINGER: There is some question about that. Sterilization is a voluntary act by the birdseed people.
SENATOR BROWN: That is not in this bill?
MR. ANSLINGER: It is not in there. They voluntarily agreed to do that under this act.
MR. HESTER: Yes, it is in the bill.
SENATOR BROWN: I wan to bring out one fact that you have not touched upon yet. As I understand it marihuana is not a habit-producing drug, at least to the same extent that opium is, for instance. It is somewhat easier to break the habit in the case of marihuana than it is in the case of opium smoking?
MR. ANSLINGER: Yes, you have stated that correctly, Senator. It is a very difficult matter to break the opium habit. However, this habit can be broken. There is some evidence that it is habit-forming. The experts have not gone very far on that.
SENATOR BROWN: There is the impression that it is stimulating to a certain extent? It is used by criminals when they want too go out and perform some deed that they would not commit in their ordinary frame of mind?
MR. ANSLINGER: That was demonstrated by these seven boys, who said they did not know what they were doing after they smoked marihuana. They conceived the series of crimes while in a state of marihuana intoxication.
SENATOR DAVIS: How many cigarettes would you have to smoke before you got this vicious mental attitude toward your neighbor?
MR. ANSLINGER: I believe in some cases on cigarette might develop a homicidal mania, probably to kill his brother. It depends on the physical characteristics of the individual. Every individual reacts differently to the drug. It stimulates some and others it depresses. It is impossible to say just what the action of the drug will be on a given individual, of the amount. Probably some people could smoke five before it would take that effect, but all the experts agree that the continued use leads to insanity. There are many cases of insanity.
SENATOR HERRING: Is it every type off hemp that contains this drug, or is it just some particular type?
MR. ANSLIINGER: Yes, sir; there are different forms, but only one species.
SENATOR BROWN: This thought has impressed me: I read with care the supplemental statement which you placed in the record before the Ways and Means Committee, in which you brought out quite clearly that the use, which will be “illicit” if we may describe it that way, in the event this bill becomes a law, has been known to the peoples of Europe and Mexico and the United States for centuries.
MR. ANSLINGER: That is right.
SENATOR BROWN: Do you think that the recent great increase in the use of it that has taken place in the United States is probably due to the heavy hand of the law, in its effect upon the use of other drugs, and that persons who desire a stimulant are turning to this because of the enforcement of the Harrison Narcotics Act and the State laws?
MR. ANSLINGER: We do not know of any cases where the opium user has transferred to marihuana. there is an entirely new class of people using marihuana. The opium user is around 35 to 40 years old. These users are 20 years old, and know nothing of heroin or morphine.
SENATOR BROWN: What has happened to the new dissemination of it? We did not hear anything of it until the last year or so.
MR. ANSLINGER: I do not think that the way against opium has very much bearing upon the situation. That same question has been discussed in other countries; in Egypt particularly, where a great deal of hasheesh is used, they tried to show that the marihuana user went to heroin, and when heroin got short he jumped back to hasheesh, but that is not true. This is an entirely different class.
I do not know just why the abuse of marihuana has spread like wildfire in the last 4 or 5 years.
SENATOR BROWN: Could you give us any estimate of the number of persons that are engaged in this illicit traffic? Please state that as nearly as you can.
MR. ANSLINGER: I can only give you what our records show, Senator. There were about 400 arrests throughout the States in the year.
SENATOR BROWN: That is for violations of State law?
MR. ANSLINGER: For violations of State law. That would not include the arrests in California, where I understand they have several hundred a year; but the figure I am giving you of 400 arrests would be about the average number that are being picked up now, under just a noncoordinated enforcement policy , every State doing its own work, and bringing us in occasionally. When they run into “dope” work, and bringing it to us occasionally. When they run into “dope” we down and say, “It is marihuana and you take the case.”
The state of Ohio recently seized what we call a “plant”. It was a seizure of marihuana. These people had a mailing list of 6,000 customers scattered throughout the States.
SENATOR DAVIS: How were they dispensing it?
MR. ANSLINGER: They were selling it in lots from a pound down, just selling it by mail.
SENATOR BROWN: There was nothing in the law to prevent a man in Columbus, Ohio, using the mail in selling it to a person in Louisville, Kentucky?
MR. ANSLINGER: No, they are doing it every day.
SENATOR DAVIS: Is there anything in the present bill to prevent them using the mail?
MR. ANSLINGER: Under this bill it would have to be tax-paid, and all of that would be illicit, sir.
SENATOR HERRING: You say there are several hundred arrests in California alone, and about that same number throughout the rest of the United States?
MR. ANSLNGER: There are about the same number in the rest of the United States.
SENATOR HERRING: How do you account for that? Is it because of their state law?
MR. ANSLINGER: It is because they have a state enforcement agency there. They vigorously enforce the law. I might say that Pennsylvania is doing important work also.
SENATOR HERRING: It might be just as prevalent in other states; but for the fact that we do not have the law enforced as efficiently?
MR. ANSLINGER: I would not say it is as prevalent, but certainly the use has increased in the last few years. In Pennsylvania the enforcement people are very active today, particularly in Pittsburgh and Philadelphia, and the are constantly calling upon us.
SENATOR DAVIS: Are they endorsing the Harrison Narcotics Act in manner satisfactory to you?
MR. ANSLINGER: Yes, sir; that is satisfactory, but they are asking us for help every now and then when they run into a rather large situation.
SENATOR BROWN: I think that while you are on that point you had better make clear the need for Federal legislation. You say the States have asked you to do that. I presume it is because of the freedom of interstate traffic that the States require this legislation?
MR. ANSLINGER: We have had requests from states to step in because they claimed it was not growing in that state, but that it was coming in from another state.
SENATOR BROWN: And they could not touch that?
MR. ANSLINGER: And they could not touch it and we could not touch it.
There is need for coordinated effort. We are required to report ot the League of Nations, under a treaty arrangement, all of the seizures of marihuana made throughout the United States. It is rather difficult to get, I would say, half of them. One particular reason and one primary reason for this is — usually these complaints come to us first — that there is “dope” being used in a certain place, and that there is a supply of it on a certain street. Our men go and investigate it, and they find that it is marihuana. Well, we have to call in the state officers and there is a lot of lost effort. Very often by the time the state officer comes the case is gone. I would say in most of these cases we get the information first and turn it over to the state officer. Now, we want to coordinate all of that work throughout the states. By state and Federal cooperation we can make a good dent in this traffic.
For instance, all states had narcotics laws before the enactment of the Harrison Narcotics Act, but until the Federal Government stepped in no substantial progress was made.
SENATOR BROWN: What have you to say about the extent of the production of hemp? May it be produced in practically any state in the Union?
MR. ANSLINGER: Yes, sir, it can be produced.
SENATOR BROWN: There is climatically no reason why it could not be produced everywhere in the United States?
MR. ANSLINGER: No.
SENATOR BROWN: Growing as a weed could take place anywhere?
MR. ANSLINGER: Anywhere; yes, sir. That has been demonstrated.
SENATOR DAVIS: A moment ago I asked you what was the yield per acre, and you then told me so much of the flower and so much of the leaves. What is the combined yield per acre of both the flower and the leaves?
MR. ANSLINGER: I would not be able to say that, sir. That would be impossible.
SENATOR DAVIS: Is there any way of getting that information?
MR. ANSLINGER: We are growing an experimental crop over here on the Agricultural Farm. We can find out that way, or we can take a plant and strip the leaves and the flowers, and find out how many plants there are in an acre and multiply it. I think that would give a reasonably accurate estimate. I think I can find that out.
SENATOR DAVIS: I wish you would.
SENATOR BROWN: Now, Commissioner Anslinger, I do not know whether you are the best man to answer this question, or Mr. Hester. What dangers, if any, does this bill have for the persons engaged in the legitimate uses of the hemp plant?
MR. ANSLINGER: I would say that they are not only amply protected under this act, but they can go ahead and raise hemp just as they have always done it.
SENATOR BROWN: It has been represented to me that the farmer might hesitate to grow hemp when he is not only subjected to a $5 tax but also to the supervision by the Government, or what you might call the “nosing” of the Government into his business. What have you to say to this proposition?
MR. ANSLINGER: Well, I would say the answer to that is the fact that they are already controlled under state legislation.
SENATOR BROWN: In practically every state in the Union.
MR. ANSLINGER: Not all the states, but certainly in a lot hemp-growing states they are controlled. In most of the states cultivation is prohibited but in some states they are regulated by license.
SENATOR BROWN: Administratively, it seems you have charge of the administration of the tax and the collection of the tax?
MR. ANSLINGER: Yes, sir.
SENATOR BROWN: Just what would happen? We will take a farmer living the other side of Alexandria, over in Virginia. Just what would happen to him if he wanted to grow 2 acres of hemp? What would he have to do?
MR. ANSLINGER: He would go down to the collector of internal revenue and put down his $5 and get a registration, a stamp tax. That would permit him to grow under the act, and at the end of year —-
SENATOR BROWN: That is a stamp tax similar to the one a doctor gets who uses a narcotic?
MR. ANSLINGER: Yes, sir, the same kind of tax.
SENATOR BROWN: He would hang that up in his house?
MR. ANSLINGER: Yes, sir. At the end of the year we would just ask how much he grew.
SENATOR BROWN: Would you not go down and look his field over, to ascertain whether he was making any illicit use of the otherwise worthless byproduct? As I understand it, there is no legislation about the use of the petals or the flowers or of these leaves.
MR. ANSLINGER: So far very few of these hemp people have been involved. Well, they have not been involved in the illicit traffic at all.. This case in Texas is the only case I know of. We were not going to supervise his crop. It would be impossible.
SENATOR BROWN: I do not mean that, but suppose that some fellow come along and says, “I will give you $100 to let me go in and strip your leaves and top flowers from your hemp crop.” How would you ever cover that? How would you meet a situation of that kind?
MR. ANSLINGER: Certainly under the act, if the farmer agreed ot that, they would both be guilty of conspiracy to violate the act.
SENATOR BROWN: But you would exercise no particular supervision over the growing of that crop?
MR. ANSLINGER: The exercise would be in this way: If we see Mr. Dewey Doss, the photograph of whose place I showed you, go in and pay $5 to the collector, we would watch that. We would be very careful to see what disposition he made of that, but we would certainly know the sheep from the goats without any close general supervision.
SENATOR BROWN: I do not think that you would have any trouble with legitimate manufacturers, because they are dealing with the Government; but the farmer himself might be a little disposed not to grow the hemp, knowing the illicit use that might be made of a part of his crop.
MR. ANSLINGER: It is just an information return. That is all we would be interested in, unless he would conspire with someone else to have the crop stripped. But one saving feature about this whole thing so far as the farmer is concerned is that the crop is cut before the resin reaches the nth state.
SENATOR BROWN: Before it reaches its greatest potency?
MR. ANSLINGER: In other words, before it reaches its greatest potency. There is some resin that comes up through the plant, but if he is a legitimate hemp producer he will cut it down before the resin makes its appearance.
SENATOR BROWN: You had before the Ways and Means Committee two samples of the plant. Do you happen to have any of those samples here?
MR. HESTER: We do not have them here this morning. We can get those samples for you.
MR. ANSLINGER: The plant which I have in my hand now can be easily distinguished as you go along the road.
SENATOR DAVIS. You can see that along all the highways of the country.
MR. ANSLINGER: Well, Senator Davis, that will grow up 16 feet.
SENATOR DAVIS: How high?
MR. ANSLINGER: Sixteen feet.
SENATOR DAVIS: Sixteen feet?
MR. ANSLINGER: Sixteen feet. Of course when they are small like that you cannot distinguish them.
SENATOR BROWN: At what height are they usually harvested?
MR. ANSLINGER: About 14 or 16 feet.
SENATOR BROWN: At that height?
MR. ANSLINGER: Not for hemp production. That is for resin.
SENATOR BROWN: I mean for hemp production.
MR. ANSLINGER: Oh, for hemp production, I would say around 10, 12, 14 feet. But it is certainly before the resin gets up there to do the damage.
SENATOR BROWN: Are there any other questions that any member wants to ask Mr. Anslinger?
MR. ANSLINGER (sic): What is the return to the farmer per acre?
MR. ANSLINGER: I do not know. The hemp people here could tell you what the return is, but I understand it is around $30.
SENATOR BROWN: Does it require intense cultivation?
MR. ANSLINGER: I do not think so.
SENATOR HERRING: It is a weed that will grow, is it not?
MR. ANSLINGER: It will grow without any trouble. In fact, a lot of these illicit traffickers will try to hide their field with corn. They will grow corn all around it. Well, the hemp will shoot right up above the corn and will grow 4 or 5 feet higher.
MR. HESTER: Before we complete our case I think we ought to say one word on the regulations, if I may?
SENATOR BROWN: Yes; we shall be glad to have that.
MR. HESTER: From time immemorial it has been the policy of Congress in imposing taxes and in providing exemptions under certain conditions from the imposition of certain taxes, to provide that the exemption will be made under regulations to be prescribed by the Commissioner of Internal Revenue.
Take for example in this particular case, in the Revenue Act of 1932 they provided that automobile parts and accessories should be exempt from taxes if the manufacturer sells them to a manufacturer who is going to make a complete automobile or truck.
In order to get that exemption the manufacturer who is going to sell that part of an automobile or truck to the other manufacturer, who is going to make a completed truck, cannot get that exemption except under regulations to be prescribed by the Commissioner of Internal Revenue.
The Commissioner merely requires him to obtain a certificate from the other manufacturer that this part is to be used in the manufacture of a completed truck.
In this particular we have exactly the same situation here, and we are simply following the practice, I say, that Congress has followed from time immemorial in revenue acts. The farmer here will not even have to go to the Collector’s office. All he will have to do will be merely to mail in his five dollars, and they will send him the stamp tax and the registration. At the end of the year he will make an information return as to how much land he has under cultivation and what disposition he has made of it.
When he wants to sell his crop off seeds all he will have to do under the regulations of the Treasury Department will be to obtain some evidence from the person to whom he sells it, that that person is entitled to the exemption.
That is the situation with respect to the seed, which is the important item involved here so far as the domestic interests are concerned. Of course, the fiber products are entirely out of the bill.
That completes our case.
SENATOR BROWN: Mr. Hester, what are you going to do with respect to the large number of farmers who are not going to know about this law in its earlier stages of enforcement? It seems to me that with the lack of dissemination of information, a great many of them are going to engage perhaps in a legitimate production of it, not knowing of this law. Are you rather harsh toward those fellows, or can you be reasonable and generous toward them?
MR. HESTER: No, the bill will not become effective for 60 days, and there are not a great many of the hemp producers in the United Sates. Of course the Treasury Department would do everything it possibly could to notify these people. There would be no hardship imposed upon them. This would be administered exactly as any other revenue act is administered, and frequently there are excise taxes imposed where the individual does not know anything about it.
SENATOR BROWN: What legitimate uses are now made of the hemp plant in the United States. That is, what causes the farmer to raise it?
MR. HESTER: Some raise it for seeds.
SENATOR BROWN: Do you mean birdseeds?
MR. HESTER: Yes. They raise the seeds for use in the manufacture of birdseed. They make oil out of it. Most of the seed, however, that is used in the manufacture of oil is imported from Manchuria, but it may develop in this country.
Then after the seed is used for the making of oil, they take that seed and crush it, and make meal and meal cake, and that is sold to cattle raisers.
The oil is used in the manufacture of varnish and paint and soap and linoleum, and then in the case of the mature stalk they use that for making fiber and fiber products. Of course, they are entirely outside the bill.
SENATOR DAVIS: While primarily you are placing a tax, it is for the sole purpose of getting and enforcement of the law, and getting a plan for enforcing it?
MR. HESTER: That is correct.
SENATOR DAVIS: If it should be one dollar, what difference would that make?
MR, HESTER: Well, the situation is simply this: ——-
SENATOR DAVIS: I am only talking from the farmer’s point of view, of charging him one dollar instead of five dollars.
MR, HESTER: I am glad you raised that point, Senator Davis,. When the Harrison Act was first before the Supreme Court the occupational tax was only one dollar, and the vote was 5 to 4. In other words the Supreme Court said, “This is a revenue measure”, although the tax was only one dollar. But the vote was five to four. After that Congress raised the occupational tax and then when the case came before the Supreme Court, the vote was six to three. and the Court said, “We now have more reason to sustain the constitutionality of this act that we had before, because it is more of a revenue act than it was then.”
In the case of the producers, under the Harrison Narcotics Act, although there are no poppies grown in this country, if they could develop it so that they could raise poppies, so that they could get opium from it, the farmer would have to pay $24, but in this case the producer only pays five dollars.
We have left the practicioner at one dollar, because that was the situation of the Harrison Narcotics Act, and that is the real reason why the figures are set in this bill at $24, $5, $3, and one dollar, so that we can have a real revenue raising measure.
SENATOR DAVIS: You charge five dollars an acre under this?
MR, HESTER: Oh no, a year.
SENATOR DAVIS: I meant to say this: You charge five dollars whether he produces on one acre of on one thousand acres?
MR, HESTER: That is right.
Senator Brown: Have you worked out the Canal Zone matter with the Department?
MR, HESTER: We have. They wish to be exempted, and they have agreed not to propose their amendment providing for direct regulation of marihuana in the zone because as I pointed out to you the other day it might indicate on the face of the bill that it is a regulatory measure, but they wish to be exempted, and we have no objection. We are preparing to change that.
SENATOR BROWN: Just one or two more matters. Why should they be exempted?
MR, HESTER: There is no legitimate business in the Canal Zone, and they say they have sufficient control over the marihuana problem in the zone at this time under existing legislation, and they object to general legislation being applied.
SENATOR BROWN: It would probably be considerable duplication of effort down there.
MR, HESTER: There might be some. The Harrison Narcotics Act applies to the Canal Zone, and that is the reason why it was included in this bill. But the Treasury Department has no objection if the Canal Zone goes out.
SENATOR BROWN: Will this entail any considerable increase in personnel of the Department?
MR, HESTER: No, I do not think so.
MR. ANSLINGER: No, sir.
SENATOR BROWN: I understand this measure has the approval of the Treasury Department.
MR, HESTER: Yes, oh, yes. it is strongly recommended by the Treasury Department.
SENATOR BROWN: Is there anything further from the ‘government? Do you desire to have a chemist testify?
MR, HESTER: I think we have finished our case.
SENATOR BROWN: Very well, Thank you, Mr. Hester and Commissioner Anslinger.
The next witness on my list is Mr. Rens of the Rens Hemp Coo. of Brandon, Wis. We would be glad to hear from him.

erfaringer fra Schweiz
Anja Dobler Mikola og Beat Kaufmann, Institut für Suchtforschung, Zürich.
Den 21.februar 1991 blev der i Schweiz vedtaget en lovpakke med det formål at formindske problemerne med narkotika. På denne baggrund blev der udviklet en række videnskabelige undersøgelser af ordination af narkotika til afhængige og herunder også et projekt med kontrolleret uddeling af opiater til indsatte. Projektet blev kaldt KOST og begyndte i 1994.
Det bliver nu evalueret og det følgende er bygget på data fra halvvejsevalueringen.

Oberschöngrün Fængsel ønskede ved hjælp af kontrolleret tildeling af narkotika at tage aktivt del i rehabiliteringen af opiatafhængige indsatte ved at give dem muligheden for at stabilisere sig mentalt og fysisk uden at lide under det stress det er, at skulle skaffe stofferne illegalt.

Fængslet, der er åbent, er det største i sin kanton og har plads til 75 indsatte. Betingelsen for at afsone der er, at man ikke er til fare for andre og ikke skønnes at ville flygte.

Målgruppen for KOST projektet var opiatafhængige indsatte, hvis kriminalitet havde forbindelse med stofafhængigheden. I betragtning af deres fortsatte afvigende adfærd var integration i det almindelige fængselssystem vanskelig.
Alle som tog del i eksperimentet gjorde det frivilligt.
De blev ikke tvunget eller presset, men simpelt hen informeret om muligheden.

Under forsøget blev deltagerne anbragt i separat “fængsel” på et landbrug, der ligger 3 km fra Oberschöngrün. Der højst 8 deltagere i projektet ad gangen og de bor og lever i næsten total isolation fra de øvrige indsatte. Landbruget er baseret på blandet drift med både kvæg og korndyrkning samt bolig for de indsatte.

De indsatte får heroin tre gange om dagen og de injicerer selv stoffet i et kliniklignende lokale, der er specielt indrettet til det.
Der er en sygeplejerske til stede, når heroinen deles ud sammen med en sikkerhedsvagt, der har ansvaret for sikkerheden.
Der er blevet ansat sygeplejersker specielt på grund af heroinbehandlingen. De øvrige ansatte er fra den almindelige fængselstab.

De indsatte er primært beskæftigede med arbejde ved landbruget. De bliver instrueret og superviseret af deres foresatte.
Arbejdstiden strækker sig over alle syv af ugens dage, som det er typisk for landbrugsarbejde.

Arbejdet begynder kl. 5.30, to timer før den første tildeling af heroin.

De første resultater:
Her er kun plads til en kort opsummering af de første resultater, men en mere detaljeret beskrivelse kan findes i halvvejsevalueringen, der er baseret på fokuserede interviews med indsatte og personalet, der blev udført i perioden mellem september 1995 og marts 1996.

Forsøget blev startet den 8. september 1995. Fra september til november blev der gennemført en tre måneders pilotfase med fire indsatte.

Efter introduktionsperioden, hvor alle involverede vænnede sig til den usædvanlige forsyningssituation, fortsatte tildelingen af heroin indtil marts 1996. Der var en enkelt episode med medicinske implikationer, som blev klaret uden alvorlige følger for projektet.

De indsatte var i hovedsagen beskæftiget med landbruget. I begyndelsen kneb det med at få udført det nødvendige arbejde, fordi ikke alle arbejdede effektivt. Ineffektiviteten skyldtes både den sedative effekt af heroinen og det forhold, at de færreste havde lært at arbejde ordentligt, fordi de ikke havde nogen faglig uddannelse og kun i beskedent omfang havde været i arbejde. Efter nogle få uger forbedredes arbejdsindsatsen så meget, at det nødvendige arbejde blev udført uden nogen problemer.

Før forsøget begyndte blev det ofte betvivlet, om indsatte, der fik heroin, overhovedet kunne arbejde effektivt. Man frygtede, at de ville være så stærkt sederede, at de ville være passive og umotiverede for at arbejde på samme måde som andre indsatte. Det er bemærkelsesværdigt, at man med forsøget har kunnet vise, at der ikke er nogen grund til at betvivle, at man kan arbejde normalt, selv om man er i heroinbehandling.
I Oberschöngrün er man ikke i tvivl om, at de heroinbehandlede indsatte arbejder lige så effektivt som andre indsatte, så længe heroindispenseringen ikke resulterer i mærkbar sedation eller fører til abstinenser.

I indkvarteringsområdet havde alle de interviewede i begyndelsen af projektet noteret alvorlige akutte og kroniske konflikter mellem de indsatte.
Konflikterne var typiske fængselskonflikter, som blev intensiveret af forsøget.
Det viste sig afgørende, at forsøget blev udført i et afgrænset område adskilt fra det øvrige fængsel, og at de indsatte slap for det stress, der kommer af at skulle skaffe stofferne illegalt.
Endelig var sammensætningen af gruppen vigtig for udfaldet af eksperimentet, men det var tydeligt, at de indsatte havde svært ved at håndtere deres konflikter konstruktivt.

I et forsøg på at bedre dette blev omsorgen forbedret og der blev givet bedre mulighed for at de indsatte kunne være lidt for sig selv.

Selve uddelingen af heroin var stort set problemfri, efter at den første usikkerhed var overstået. De indsattes adfærd i forhold til sygeplejerskerne var præget af behov for nærhed og regrediering. Det ser ud til at en vellykket tildeling af heroin i fængsel afhænger af et tæt og tillidsfuldt samarbejde mellem sygeplejersker og sikkerhedsvagter.
Kun hvis det er tilstede, kan der gives tilstrækkelig omsorg, uden at sætte nogen af de ansattes sikkerhed på spil.

Spørgsmålet om, hvorvidt det er muligt at give heroinbehandling i fængsler, må besvares med et ja….men. KOSTprojektet har bevist, at det kan organiseres og implementeres, men institutionen har måtte betale dyrt for det.
Adskillige af de ansatte i fængslet forholdt sig meget kritiske til projektet. De, der var involveret i det, var travlt beskæftiget blandt andet fordi der blev fokuseret meget på dem fra organisationens side. Uforudsete begivenheder i pilotprojektet krævede fleksibilitet i forhold til de oprindelige planer, og noget af personalet klagede over mangel på regulering og forudsigelighed i projektet.

For de indsatte forsvandt belastningen med at skaffe heroin. Dette beskrev og vurderede alle som et positivt resultat. Alt i alt var deres fængselsophold blevet betydeligt mere tåleligt på grund af tildelingen af heroin. Og det er et signifikant skridt mod skadesminimering, der blev defineret som hovedmålsætningen.

Ovenstående indlæg, der med forfatternes tilladelse er oversat fra engelsk af redaktionen, blev afleveret som oplæg ved en konference i Amsterdam først i 1997.

Evalueringsrapporten kan rekvireres hos Institut für Suchtforschung, Konradstrasse 32, Zürich 8005, Schweitz. Tlf. 0041 1 273 40 24, Fax. 0041 1 273 40 64.

Af Keld Broksø
En række klare anbefalinger til eventuelt kommende, danske forsøg med heroin, opfordrer Center for Rusmiddelforskning nu til, at forsøg med heroinudlevering skal have sideløbende, sammenlignelige forsøg med metadon, personalet skal være robust, og danske heroinforsøg skal supplere og ikke træde i stedet for andre behandlinger.

Anbefalingerne kommer fra centerleder Jørgen Jepsen, som er tilhænger af heroinforsøg og medforfatter til en rapport som Socialministeriet modtog denne uge om de schweiziske forsøg med heroinuddeling.

Rapporten, som blev til i et samarbejde med Københavns Universitet, endte dog som en såkaldt ikkerapport: Anbefalingerne for eller imod danske forsøg mangler fordi de schweiziske resultater har statistiske mangler, der gjorde det umuligt at konkludere noget.

Personligt bilag.
Jørgen Jepsen har derfor leveret et personligt bilag til rapporten.
Bilaget indeholder blandt andet hans egne indtryk fra forsøget i Schweiz.
I Socialministeriet gør man dog opmærksom på, at det havde man ikke bedt om, og man vil derfor se helt bort fra Jørgen Jepsens egen udlægning af de schwejziske heroinforsøg.

Jørgen Jepsen understreger imidlertid en lang række ting, som bliver aktuelle ved en evt. forberedelse af danske heroinforsøg:
i. Et dansk forsøg skal specialdesignes fordi de schweiziske erfaringer ikke kan overføres direkte.
ii. Danske forsøg bør holde sig til heroin fordi der ikke er så gode erfaringer med kokaincigaretter, morfin m.m.
iii. Heroinforsøg er kun aktuelt for en lille gruppe hårdt belastede narkomaner.
iv. Man må være indstillet på store omkostninger i begyndelsesfasen, men det vil senere give besparelser på grund af mindre kriminalitet.
v. Endelig understrege Jørgen Jepsen. at heroinudlevering ikke løser narko problemet det reducerer kun skadevirkningerne.

Mens danske politikere fortsat mangler en rapport fra Sundhedsstyrelsen, der kan fuldende beslutningsgrundlaget om danske heroinforsøg, har FN i mellemtiden vendt på en tallerken: Generaldirektøren for FNs Narkotikakontrol program, Pino Arlacci, har rost de schweiziske forsøger fordi de var under streng viden skabelig kontrol.

Dermed står Lægeforeningen, Formanden for Folketingets retsudvalg Bjørn Elmquist, formanden for Narkotikarådet, Preben Brandt, og Center for Rusmiddelforskning ikke længere alene i anbefalingen af de schweiziske forsøg og som inspirationskilde til danske forsøg.

Nanna W. Gotfredsen

Efterspørgslen er prisufølsom og en hårdere indsats mod narkotikahandlen vil medføre mere og ikke mindre kriminalitet.
Af Gunnar Thorlund Jepsen, Professor
En forstærket politimæssig og strafferetlig indsats mod narkohandel og stofmisbrug fører blot til højere priser og større omsætning på dette illegale marked. Vejen frem er derfor at underminere markedet – ikke hverken at forstærke indsatsen eller det modsatte: At legalisere stofmisbrug.

Dette er efter min opfattelse den uundgåelige konklusion efter at have lœst og vurderet internationale analyser af problemet og efter at have afprøvet en økonomisk model på narkotikamarkedet.1 Ved narkotika forstås i denne artikel såkaldt hårde stoffer som heroin, kokain og amfetamin. Disse stoffer har i nutidens samfund følgende karakteristika:

De efterspørges af en bestemt kundekreds – såkaldte misbrugere – ikke af alle.

De er vanedannende, dvs. de giver en tilvænning, der er vanskelig at komme ud af, og hvor ophør af forbrug endda kan give stærke abstinenssymptomer.

Import af og anden handel med disse stoffer er forbudt, hvorfor markedet for disse stoffer er illegalt.

Der er bivirkninger for brugerne i form af social deroute, HIV-risiko, leverbetændelse m.v.

Der er bivirkninger for andre i form af sociale og andre offentlige udgifter, kriminalitet som berigelsesforbrydelser for at skaffe midler til stoffer samt eventuelle ‘krige’ mellem organiserede bander om markedet.

Disse karakteristika er for nogles vedkommende tilsyneladende en følge af, at markedet er illegalt. I en interessant artikel: »The price elasticity of hard drugs: The case of opium in the Dutch East India 1923-38« i Journal of Political Economy, vol. 103, no.2, 1995 demonstreres, at i et – nœsten – legaliseret marked er kundekredsen større og består også af brugere, der kan ‘styre’ deres forbrug af opium (casual users). Derimod viser undersøgelser, at selvom andelen af befolkningen, der bruger narkotika, falder, så falder forbruget ikke vœsentligt. De nœvnte karakteristika synes derfor at have vœsentlige implikationer for narkotikamarkedets natur.

Efterspørgslen er prisufølsom.
For det første er efterspørgslen meget lidt prisfølsom. Narkotikamisbrugerne står for den helt væsentlige del af efterspørgslen og finansierer den fortrinsvis ved kriminalitet. Deres daglige stofforbrug skal opfyldes på den ene eller den anden måde og det uanset markedsprisen og uanset konsekvenserne ved anskaffelsesmåden.

Økonomer taler om efterspørgselselasticiteten, der udtrykker, hvor meget efterspørgslen falder ved prisstigninger. For markedet for narkotika vurderes den til at vœre lav – nœr nul i de industrialiserede lande. Det skyldes, at markedet er illegalt, og at der er meget få ikke-misbrugere blandt efterspørgerne.2 Den anden side af markedet er udbuddet. Her taler man om den såkaldte udbudskurve, der viser hvilke priser, udbyderne vil have for at sœlge. Udbudsprisen synes at vœre ret uafhœngig af, hvor risikabelt i form af anholdelse og straf det er at handle på det pågœldende marked. Risikoen for at blive anholdt og få en hård straf indkalkuleres i prisen som en slags ‘risikoprœmie’. Således skriver Miron og Zwiebel (jf. note 1): »Perhaps the most incontrovertible effect of prohibition is an upward shift in the supply curve for drugs«.

Alt afhœngig af indsatsen mod narkotikamisbrug og straframmerne varierer denne ‘risikoprœmie’ fra land til land, hvorfor også priserne gør det. I Aloyz Prinz artikel (ligeledes note 1) er gennemsnitspriserne for udvalgte lande angivet for heroin og kokain. Samtidig angives koefficienten for prisens variation, der synes at vise, at de varierer meget lidt, hvor priserne er lave.

I øvrigt betyder kriminaliseringen også, at begrebet kundeloyalitet bliver af stor betydning. Det er vigtigt for pusherne at kende deres købere, så de ikke blivet ‘stukket’. Det er også af betydning for mellemhandlere og bagmœnd. Forbrugerloyaliteten sikres ved konstant kvalitet og sikre leverancer til afgrœnsede grupper, men hindrer ikke, at ‘risikoprœmien’ må betales af den endelige forbruger: Narkotikamisbrugeren.

Større politiindsats – større kriminalitet
Efterspørgslen er altså prisuelastisk. Udbuddet er derimod altid til stede, hvis ‘risikoprœmien’ – og en rimelig avance – betales. I fig. 1 og fig. 2 på næste side er vist to skematiserede eksempler på, hvorledes narkotikapriser dannes på to markeder – et marked med en lempelig narkopolitik (små straffe, lille politiindsats ) og et marked med en stram narkotikapolitik (høje straffe, stor politiindsats ). Figurerne er naturligvis teoretiske, eller om man vil, postulerede, men bygger på den vurdering, at efterspørgslen ikke er sœrlig elastisk, og at udbuddet isœr er følsomt over for narkotikapolitikken – forhold der synes empirisk veldokumenteret. Af figurerne ses, at prisen er vœsentligt højere på markedet med en stram narkopolitik, fordi ‘risikoprœmien’ her er høj.

Da narkotikamarkedet er illegalt, og stofmisbrugere i det vœsentlige skaffer pengene kriminelt, kan man tilnœrmelsesvist måle kriminalitetsomfanget ved at se på den mœngde penge, der omsœttes på narkotikamarkedet. Det er vist skraveret i fig. 1 og fig. 2. Set fra en økonomisk synsvinkel er der således intet som helst paradoks i, at en hårdere indsats mod narkotikahandelen medfører mere – og ikke mindre – kriminalitet.

Markedet søges opretholdt
Et andet karakteristikum ved markedet er det tidsmœssige aspekt. Markedet vil dø ud, hvis der ikke hele tiden sikres en tilgang af nye afhœngige. Under den forudsœtning vil de interesserede parter derfor i deres ønske om profit forsøge at bevare markedet intakt ved hele tiden at lokke nye kunder ind ‘i butikken’. Til dette formål vil narkotikahandlerne (både de små: pusherne og de store: bagmœndene) anvende pris- og ‘marketing’politik. En strammere narkotikabekœmpelsespolitik vil øge bestrœbelserne på at bevare markedet med stœrkere konsumentloyalitet.3 Hertil kommer, at fordi narkotikamisbruget er mest latent i kriminelle og asociale kredse, vil en større kriminalisering øge tilgangen af misbrugere. F.eks. skaber fœngselsmiljøet tilsyneladende i sig selv misbrugere.

Man kan nu spørge, hvilke implikationer narkotikamarkedets sœrlige natur må have for narkotikapolitikken.

Det vil vœre en for hastig konklusion, at man afkriminaliserer markedet. For dette vil medføre, at efterspørgsels- og udbudsforholdene vil œndres. Priserne vil falde, og man vil få et større narkotikaforbrug uden for egentlige misbrugskredse. Formentlig vil man få de samme problemer som på markedet for spiritus – måske bortset fra, at spiritus fysisk er et mere farligt stof end f.eks. opiater.

Eliminér den illegale efterspørgsel

I stedet for at sœtte ind på udbudssiden af markedet, f.eks. ved at gøre salg straffrit, kunne man forsøge at eliminere efterspørgselssiden. Hvis man på én gang fandt en mirakelkur, hvor man kunne motivere alle stofmisbrugere til afvœnning, ville der ikke mere vœre nogen efterspørgsel af betydning på det illegale marked.

Det ville dø ud.

Følgevirkningerne heraf ville vœre, at narkotikakriminaliteten, forstået som den kriminalitet der er en direkte følge af narkotikamisbruget, ville falde vœk. Det ville påvirke tilgangen af nye stofmisbrugere, der ville blive mindre, fordi den netop er betinget af det asociale og kriminelle narkomiljø. Det ville også vœre et vœsentligt modtrœk mod alle de andre negative aspekter ved narkotikamisbruget (HIV-spredning og andre sygdomsrisici, kriminalitet, bandedannelse mv.).

Indfør legal dosering
Er det muligt at eliminere den illegale efterspørgsel? Måske ikke fuldstœndigt. Men hvis man i København indrettede klinikker, hvor f.eks. heroinmisbrugere under lœgekontrol kunne få deres doser, ville mange vœlge dette frem for en stadig kriminel jagt på penge til stoffet. Samtidigt ville man komme i kontakt med misbrugerne og få mulighed for at motivere dem til behandling. Forslaget er altså ikke at give markedet frit. Tvœrtimod ville chancen for at ødelœgge det illegale marked og lokke stofmisbrugerne i behandling fortsat vœre størst, jo mere stressende det er at skaffe sig midler til stoffer på det illegale marked. Så tilbuddene om kontrolleret legal narkotikadosering kunne udmœrket ledsages af en hårdere jagt på stofmisbrugere og pushere på det illegale marked.

Effekten af en sådan ‘pisk- og gulerodspolitik’ må ikke bedømmes kortsigtet. Den risiko, den gratis heroin kan medføre ved at lokke nye misbrugere til, er nok til stede, selvom lœgekontrollen kan modvirke den. Men den må vurderes i lyset af det – formentlig langt større antal – misbrugere, man undgår ved, at det illegale narkotikamarked og miljøet deromkring forsvinder. De forsøg med gratis heroindosering, der for tiden foregår i f.eks. Schweiz, kan, alene fordi de kun omfatter en lille delmœngde af misbrugerne, ikke bruges som eksempler på, hvad en total eliminering af det illegale marked vil betyde. De økonomiske mekanismer, der styrer markedet, er generelle.

Begynd i fœngslerne
Det er dog et område, hvor man eventuelt kan foretage et økonomisk eksperiment – nemlig fœngslerne. I stedet for forsøg på at isolere sœlgerne, dvs. de såkaldt stœrke fanger, kunne man ødelœgge deres forretning ved gratis under lœgekontrol at give deres kunder de stoffer og med tiden den behandling, de måtte ønske.

Det er hyklerisk at acceptere en nœrmest monopolagtig udnyttelse af fœngslede misbrugere, når dette monopol på en gang kan knuses ved at dosere stofmisbrugerne det stof, de i alle tilfœlde vil købe via de stœrke fanger. Doseringen skal følges af behandlingtilbud – naturligvis.

At det selv i et så isoleret miljø som fœngselsmiljøet volder modstand at ødelœgge det illegale narkotikamarked ved legal dosering viser imidlertid, at der er nogle psykologiske barrierer – ikke mindst hos vore politikere – der skal overvindes, før man erkender, at vejen frem er ved legal dosering at lokke stofmisbrugerne i behandling og ud af narkotikakriminaliteten. Det er ellers min opfattelse, at en sådan politik på lœngere sigt kan bringe os tilbage til Danmark før 1960′ erne – Danmark uden illegal narkotika og uden narkotikamisbrug af betydning.

Note 1: For nœrmere vurdering af det europœiske narkotikamarked kan jeg henvise til Aloys Prinz: »Do European Drug Policies Matter?« i »Economic Policy – A European Forum«, oktober 1997, hvor der findes en indgående empirisk baseret beskrivelse af narkotikamarkederne og narkotikapolitikken i de europœiske lande samt en artikel af J.A. Miron og J. Zwoebel i Journal of Economic Perspectives, 1995. »The Economic Case against Drug Prohibition«.

Note 2: En undersøgelse af disse forhold er vanskelig, fordi markedet netop er illegalt, men der kan henvises til f.eks. M. Grapendahl: »Economic Behaviours of Amsterdam Opiate Users«, the International Journal of Addictions, 1992.

Note 3: For en teoretisk behandling af dette forhold henvises til: Gunnar Thorlund Jepsen og Peter Skott: »On the Effects of Drug Policy« (Working Paper no. 1997-15), Institut for Økonomi, Aarhus Universitet.

Gunnar Thorlund Jepsen, professor ved institut for Økonomi, Aarhus Universitet

- Final Report on Injecting Rooms in SwitzerlandBy Kate Dolan and Alex Wodak. Unpublished Manuscript, 26 July 1996.

Summary

This report describes injecting rooms in three Swiss cities (Zurich, Basel and Bern) based on a visit which took place in February 1996.

The first injecting room in Switzerland was established a decade ago with the intention of reducing the public nuisance caused by injecting in public areas (toilets, parks) and public health problems such as HIV transmission and overdose. Injecting rooms are now generally well accepted by the Swiss public although opposition had arisen initially when some injecting rooms were located in residential areas. Injecting rooms also operate in some Germany cities. Injecting rooms are planned for some Austrian cities. There are virtually no publications in English on injecting rooms.

The Centres visited differed in strictness of operation and many other organisational details but were similar in many respects. All have medically trained staff who supervise all injections on the premises and revive clients who have taken an overdose. Staff were able to control the number of clients who entered the premises and the actual room where injecting takes place. All Centres were well patronised and provided free injecting equipment and advice on injecting. No staff assisted IDUs to inject. At least 100 clients visit each Centre daily. Tens of thousands of injections have been supervised and thousands of abscesses treated annually. No overdose deaths have occurred in any Centre.

The main benefits of injecting rooms have been reduction of public nuisance and improvement of health in a very vulnerable and unhealthy group of IDUs. Injecting rooms have enabled the adoption of less hazardous injecting practices, reduced the number of overdose deaths, minimised the nuisance to the community of injecting in public places and probably reduced HIV transmission. The Centres are well tolerated in Swiss communities. Some IDUs have entered treatment as a result of attending injecting rooms. Legal problems surrounding the operation of injecting rooms have been overcome. Police work with the staff of injecting rooms.

The annual cost of running a centre was about $300,000. Behaviour of some IDUs has been problematic. The Centres, apart from the actual injecting rooms, were heavily polluted with cigarette smoke.

Injecting rooms are only needed in areas of cities with particular characteristics, such as frequent public injection. It is relatively easy to demonstrate success in reducing public injection. Evaluation is technically quite difficult. Staff believe that risk behaviour has been reduced because of interactions between IDUs and staff. It seems clear that the benefits of injecting rooms in Switzerland have outweighed the costs but the ratio of benefits to costs is not as dramatic as with, say, needle exchange or methadone maintenance

Introduction

This report describes a visit to injecting rooms in three Swiss cities (Zurich, Basel and Bern) in February 1996 and reports on discussions with health workers and researchers who have worked in or evaluated these injecting rooms in Switzerland (appendix a).

The main aims of operating injecting rooms in Switzerland are to reduce the public health risks and the public nuisance associated with drug injecting. These health risks include death from overdose and infection with blood borne viruses (HIV, HBV and HCV) from the shared use of injecting equipment. The Centres are also important points of contact for IDUs not in treatment. Medically trained staff are available at all times to resuscitate clients who experience a drug overdose on the premises.

The context within which these injecting room exist should be noted. Switzerland has implemented a number of innovative HIV prevention programs which have rarely been adopted elsewhere. Examples include `needle parks’ or open drug scenes where IDU buy, sell and use drugs, a trial of provision of heroin which includes current prisoners) and syringe exchange schemes for prisoners. Some of these initiatives have been more successful than others. The distinguishing characteristic of Swiss authorities is the acknowledgment that existing policies have been ineffective (and often counterproductive) and a preparedness to experiment to identify more effective measures. Switzerland has a surprising high number of IDUs. Because of housing shortages, they are very visible in the streets. HIV prevalence among IDUs was already high, up to 50 percent in some cities, when HIV /AIDS was first recognised. Switzerland now provides excellent needle exchange and methadone programs.

The first injecting room in Switzerland was established in Bern in 1986. Health workers had noticed IDUs had become marginalised from mainstream society and were being shunned from cafes and restaurants. These health workers proposed establishing a special cafe for IDUs which could also be used as a convenient point of contact with IDUs who did not utilise health services. IDUs then began injecting in these cafes. The workers soon realised that this provided an excellent opportunity to monitor and modify IDUs risk behaviour to reduce harms associated with injecting. Initially, some injecting rooms were placed in settings later found to be unsuitable. These rooms had to be relocated. Community opposition in Basel decreased after concerned residents attended an open day at the Centre. Another factor was the desire to reduce public nuisance resulting from IDUs injecting in parks and public toilets.

Descriptions of the Centres and the injecting rooms

In Zurich, Centres with injecting rooms are funded by the Department of Welfare. Non government organisations operate injecting rooms in the other cities. The injecting rooms are housed within Centres which also contain a cafe, a counselling room and a clinic for primary medical care. The injecting rooms are discrete rooms within the Centres. These two terms `the Centre’ and `the injecting room’ will be used to distinguish between the two levels of intervention.

In Zurich, door-men are employed to manage the flow of clients into the Centre. They ensure that only residents of Zurich enter the Centre and also prevent clients from congregating outside.

The actual injecting rooms are small and have a `sterile ambience’. All injecting rooms contained two or three tables where clients sit to prepare and inject their drugs. The three rooms visited had spaces at tables for six, six and twelve clients to sit and inject. Injecting paraphernalia – such as needles and syringes, a candle, sterile water and spoons – were placed at each position at the tables where the clients sat. There were also paper towels, cotton pads, bandaids and rubbish bins nearby. The walls of the injecting room were tiled up to a height of approximately two metres. The tables tops were made of stainless steel which enabled the surfaces to be cleaned easily.

An overwhelming impression of all the Centres visited was the constant in and out movement of clients. Movement in and out of the injecting rooms was less common as IDUs generally stayed inside for up to half an hour. Once clients were inside the Centre, most appeared content to wait for their turn to inject. Many preferred to remain in the Centre for some time after injecting.

Access to the injecting rooms

In Zurich, clients were required to show evidence of residence in that city before entering the Centre. This restriction was imposed in response to the Centres being inundated with IDUs from other cities. Staff must verify that clients are at least 16 years old and have a history of injecting before they are allowed to use the injecting rooms. The order in which clients enter the injecting room was regulated by a queuing system in two cities. In Zurich, clients took a number and entered the injecting room when their number was called. In Basel, clients were required to sit in chairs forming a queue just outside the room. However, this system sometimes resulted in disputes about who was next in line as clients would often leave their seats. In Zurich, clients’ first names were recorded on a diagram which depicted where they were sitting in the room. This allowed staff to know who each client was in case of an overdose.

Most Centres had a maximum capacity limit. When this limit was reached, clients were only admitted when others left the Centre. In Bern, the door to the Centre was only opened every half hour for five to ten minutes. Clients could only enter or leave the Centre during this time. It would be almost impossible to enter the Centre, visit the injecting room, inject and leave the Centre within the brief period that the door was opened. This meant that clients had to remain in the Bern Centre for at least half an hour, making the Centre more crowded than perhaps it needed to be. The Centre in Bern originally provided clients with identity cards which had to be shown to gain entry. This system has been abandoned as clients tended to loose the cards.

Rules

In addition to rules which are common in most drug agencies (such as no violence or drug dealing), there were specific rules for the injecting rooms. Clients must wash their hands on entering the injecting room and clean their own place at the table after injecting. Clients were not allowed to smoke in the injecting rooms. Most Centres had a maximum time limit (30 or 60 minutes) that a client could spend in the injecting room. Clients are only allowed to prepare their own drugs in the injecting room. In some injecting rooms, clients were allowed only one injection per visit to the room. Staff were not permitted to help clients inject in any Centre. Breaking the rules resulted in clients being barred from the Centre for a few days or up to a few weeks depending on the nature of the infringement.

Staff and operation

All Centres had at least one staff member present in the injecting rooms at all times. This staff member changed every hour or so as extended periods in the injecting room were considered to be too taxing. All staff have been trained to resuscitate clients if they overdose, although one staff member had the prime responsibility for this duty.

Most Centres opened for approximately seven hours a day. Some Centres are closed for one or two days a week. Centres usually operated at full capacity. In cities with a number of Centres, operating times were staggered to increase the number of hours per day that IDUs could inject safely. Some Centres have allocated specific times for female injectors to inject drugs. There were usually three or four staff on each shift. In Basel the Centre was initially closed on Sundays. Demand has been as high that the Centre is now open every day. Doctors were employed on a sessional basis to visit the Centre for a few hours a week. The cafe areas were filled with cigarette smoke. The Centres preferred to employ smokers as these conditions are often difficult for non smokers. One Centre had a light indicating when the toilet was occupied. The toilets could be opened from the outside in case of an overdose. Some Centres had direct phone lines to the police and ambulance service.

In the event of an overdose

When a client collapses, the worker in the injecting room calls another worker to assist. A small bottle of oxygen is taken to the client and administered via a face mask and simple resuscitation bag until the client regains consciousness. If the client was unable to resume breathing within ten minutes, an ambulance is called. Naloxone, a narcotic antagonist, is not used to revive clients in any Centre.

Clientele

Most IDUs in Switzerland inject a cocktail of cocaine and heroin. There are an estimated 6,000 IDUs in Zurich and 2,000 in Basel. Most clients have had hepatitis. Clients were generally older than the average IDU, although one Centre did have a predominantly younger clientele.

Other Services

A safe injecting environment is just one of several services offered by the Centres. Counselling, referral, free soup, tea and coffee and cheap fruit and vegetables were provided in the Centres. In Zurich, clients volunteered to work in the cafe and to collect discarded syringes in the vicinity of the Centre. So many clients volunteer to help that work is allocated by a lottery system.

Research into injecting rooms

Research evaluation of the injecting rooms includes monitoring the number of needles and syringes distributed and returned, number of injections, overdoses, abscesses and the number of times an ambulance has been called. Approximately 100 clients a day visit the Centres in Zurich and Basel. In three centres in Zurich, there were an estimated 68,000 injections, 3,000 abscesses treated, 22 clients resuscitated and ten calls for an ambulance to attend in a one year period.

A comparison of clients surveyed in Bern in 1990 and 1995 was undertaken. Clients were mainly (70%) males and aged about 30 years. Most (73%) had a history of imprisonment. The mean age clients started injecting was 19 years. There had been a significant increase in the proportion of clients reporting that their first injection occurred with a sterile needle and syringe over the study period. Reuse of injecting equipment decreased significantly during the study. Self reported HIV positive status was 12 and 16 percent in 1990 and 1995 respectively. There has been a strong resistance to testing IDUs for research purposes in Switzerland. Therefore, most HIV data are based on self report.

The main reasons given for attending injecting rooms in 1995 were: to inject in peace (86%), to obtain free injecting equipment (33%) and because medical attention was available. Approximately half of the clients reported injecting several times a day. There have been no deaths in any injecting rooms in Switzerland to date. Workers in Basel believe that the number of deaths due to overdose in the community has decreased as a result of injecting rooms. In Bern, workers believe they have made the injecting ritual less dangerous by moving clients from 2 ml to 1 ml syringes which carry less risk of blood borne infection.

According to the Report “Evaluation der Gassenzimmer I, II, und III in Basel”, injecting rooms have provided drug users with hygienic and controlled conditions, prevented infection through the provision of sterile syringes, needles and condoms and gave access to medical care and opportunities for intervention with possible emergencies such as overdoses. The demonstration project was overwhelmingly welcomed by all key parties: the evaluation team called for the continuance of the strategy, so as to provide a stable environment for Basel IDUs.

Injecting equipment

Three different methods were used to distribute injecting equipment in the three cities visited. In Zurich, staff provided equipment to clients as they entered the injecting room and there was a strong emphasis on exchange. In Bern, clients were provided with a free syringe and charged a small fee for additional syringes. Clients in Basel helped themselves to injecting equipment from a dispensing tray on the wall. No Centres provided butterfly infusion sets. Only one Centre provided 5 and 10 ml syringes which clients use for the injection of methadone syrup. One brand of syringes available in Switzerland has detachable filters that are removed after drugs are drawn into the syringe. Samples of these syringes were obtained.

Conclusions

Experience over the years suggest that injecting rooms have probably not been as successful as syringe exchange or methadone programs in reducing HIV infection, but the benefits clearly outweigh the costs. Injecting rooms seem very likely to continue in Switzerland. Injecting rooms only seem to be needed under particular circumstances and in certain locations.

fax: 0011 41 21 314 7373