CRIMINAL JUSTICE ASSOCIATION
Dr HC Raabe, MD
MRCP (UK) MRCGP, General
Practitioner
The Family Practice,
95-97 Railway Road, Leigh, Lancs. WN7
4AD. e-mail: hcraabe@btinternet.com
Dr Linda Stalley, BMBS MRCP (UK) DRCOG, General
Practitioner
Springfield House, New Lane, Eccles, Manchester M30
7JE.
●
The aim of any drug
policy should be to minimise harm caused by the drug to individuals and society.
●
Whether drugs such as
cannabis should be decriminalised is now the subject of intense debate.
●
We are concerned that
the discussion on this issue often neglects the important roles of drug
prevention, education and treatment.
●
Two European countries,
the Netherlands and Sweden adopted completely different drug policies about 25
years ago.
●
In the Netherlands
the use of cannabis has essentially been legalised:
The drug policy has been based on the harm-reduction approach, aiming at
a reduction of health risks, not necessarily at abstinence2.
●
In contrast, Sweden’s
drug policy is based on the goal to create a drug free society:
Drug prevention, education and the criminal justice system are aimed
towards limiting any use of illicit drugs4.
●
The assessment of the
Dutch policy by the United Nations Office for Drug Control and Crime Prevention
finds that:
”the liberal attitude towards cannabis went parallel with relatively high
levels of cannabis consumption… Abuse of almost all other drugs was increasing
strongly in Amsterdam over the last decade. Hard drug use doubled. The
strongest growth was observed for ecstasy.” 2
●
Following the de
facto legalisation cannabis use has increased sharply in the Netherlands:
In the age group 18-20 an increase in the past year cannabis use from 15% in
1984 to 44% in 1996 was observed. In this period, its use did not increase in
countries such as Denmark, Germany, Canada, Australia and the USA7.
●
A 1999 European School
survey found that Cannabis is used far more frequently in Holland than in
Sweden:
14% of Dutch pupils aged 15-16 have used cannabis over the past month versus 2%
in Sweden. 5% of 15-16 year olds have used it more than six times in the past
month in Holland as compared to 0% in Sweden9.
●
The use of other
illicit drugs including cocaine, amphetamines and ecstasy is far higher in the
Netherlands than in Sweden8.
●
The United Nations
Office for Drug Control and Crime Prevention states that:
the Netherlands “is one of the main entry points of drugs into Europe and
the centre of synthetic drug manufacture in Europe, notably ecstasy and
amphetamines. Cannabis cultivation in the Netherlands is among the
largest in Europe.” 2
●
In 1998, 118122 kg
of Cannabis were seized in Holland compared to 496 kg in Sweden. Dutch
seizures of cocaine were 11,452 kg in comparison with 19 kg in Sweden3.
●
It is estimated that 80%
of the Heroin seized in the UK and France has passed through Holland since it
is considered to be “relatively trouble-free from a criminal’s point of view.” 11
●
The outcome of the
Swedish drug policy aimed at creating a drug-free society has, after a quarter
of a century, been far more successful than the liberal “harm-reduction
approach” utilised in the Netherlands.
●
Associated with its
“harm-reduction” policy, the Netherlands has seen a significant rise in drug
abuse and trafficking of cannabis, cocaine, amphetamines and ecstasy. This
exceeds, by far, abuse and trafficking in Sweden.
The starting point of drug policy should be public
health. How can we reduce the harms caused to individuals and society by drugs
in general and cannabis in particular?
To abuse drugs is not primarily an issue of
individual rights since drug taking has adverse consequences for the individual
and society, for example car accidents due to the influence of alcohol and/or
cannabis[1].
From a public health point of view the aim of any
drug policy should be to minimise harm caused by the drug. Legislation and the
criminal justice system play a role in this and whether drugs such as cannabis
should be decriminalised is currently the subject of intense debate. We are
concerned that - over this issue - the current discussion on drugs perhaps neglects
the important roles of prevention, education and treatment.
The success of any policy regarding cannabis and
other illicit drugs can be measured by many factors. We suggest that the main
criterion should be how good this policy is at “producing” a low usage of
illicit drugs.
We have the advantage of being able
to examine two European countries, which, 25 years ago, adopted completely
different drug policies:
In the Netherlands – while officially still illegal –
the use of cannabis has essentially been decriminalised in 1976. Dealing in
small quantities of cannabis has been legalised through coffee shops. The drug
policy has been based on the harm-reduction approach, aiming at a
reduction of health risks, not necessarily at abstinence[2].
This is reflected for example by easy access to needle exchange and methadone
maintenance programmes. A strong distinction is made between “hard drugs” and
“soft drugs”. This is based on the assumption that “hard drugs” such as heroin,
cocaine, LSD and amphetamines pose an unacceptable risk while the risks of
cannabis are considered to be not so great[3].
Another goal of the Dutch policy is to separate the markets for “soft” and
“hard” drugs.
In contrast, Sweden’s drug policy is based on the goal
to create a drug free society. Drug prevention and education is aimed
towards limiting experimental and occasional use. Public opinion strongly
supports this approach[4].
Interestingly enough, Sweden’s drug policy used to be liberal in the 1960s,
basically reflecting a harm reduction approach[5].
However, with the 1968 Narcotic Drugs Act Swedish drug legislation became
restrictive until the goal of a drug free society was officially adopted in
1978. In Sweden all non-medical use of drugs is regarded as drug abuse and no distinction
is made between soft and hard drugs. The Swedish drug policy is formulated
around the gateway hypothesis, i.e. cannabis use is associated with “harder”
drug use. Efforts are focussed on preventing cannabis use since this is
frequently the first illicit drug experimented with. The dangers of cannabis
are strongly emphasised in education. Possession of any illicit drug is
punishable, depending on the amount and the substance by a fine or
imprisonment. The prosecution is essentially bound to prosecute drug offences
and abstaining from prosecution is rare3. The Police have the power
to enforce drug testing if they suspect abuse[6].
3. Trends In
Cannabis Use In The Two Countries
Has the liberal drug policy of the Netherlands led to
an increased use of cannabis?
The assessment of the Dutch policy by the United
Nations Office for Drug Control and Crime Prevention finds that:
“the liberal attitude towards cannabis
went parallel with relatively high levels of cannabis consumption… Abuse of
almost all other drugs was increasing strongly in Amsterdam over the last
decade. The strongest growth was observed for ecstasy and hard drug use
doubled.” 2
Following the de facto legalisation prevalence of
cannabis has increased sharply. In the age group 18-20 an increase in the past
year use of cannabis from 15% in 1984 to 44% in 1996 was observed. The increase
in the past month use over the same period was from 8.5% to 18.5%.
The increase in Dutch prevalence from 1984 to 1992
provide the strongest evidence that Dutch regime might have increased cannabis
use among the young: In this period, use levels were quite flat or declining in
cities such as Oslo, Stockholm, Hamburg, and countries such as Denmark,
Germany, Canada, Australia and the USA[7].
A comparison with the trends of drug abuse for all
drugs in Sweden reveals the following pattern: During the mid 1960s up to the
early 1970s a strong rise of drug abuse was observed among 15-16 year olds. It
may be relevant to note that Sweden’s drug policy used to be liberal in the
1960s, reflecting a harm reduction approach7. However, with the 1968
Narcotic Drugs Act Swedish drug legislation became restrictive3
until in 1978 the goal of a drug free society was officially adopted. Drug
abuse fell in the 70s and up to until 1990. In the 1990s, drug abuse has been
once again on the rise in Sweden as in other European countries, though levels
seem to be still lower than in the early 1970s and – apart from solvents -
lower than in most European countries5. (Table 1):
Table 1: Life-time prevalence of drug
abuse (all drugs) among 15-16 year olds in Sweden 5
|
Early 1960s |
1967 |
1970/71 |
1975 |
1983 |
1990 |
1993 |
1996 |
1999 |
|
Very low |
< 4% |
13% |
7.5% |
5.0% |
3.5% |
5% |
7.6% |
8.0% |
Although data is not
directly comparable in methodologies, the main trends indicated are clear.
How do the Netherlands and Sweden
compare regarding cannabis use?
Table 2.: Life-time prevalence of use of different
illegal drugs among 15-16 year old students in 1999 8
|
|
All illegal drugs |
Cannabis |
Amphetamines |
Ecstasy |
Cocaine |
Heroin |
|
Netherlands |
28.8% |
28.6% |
4.0% |
5.0% |
4.2% |
1.3% |
|
Sweden |
8.0% |
7.0% |
1.0% |
1.0% |
1.0% |
1.0% |
|
|
Ever use |
Last month use |
Six times or more last month |
|
Netherlands |
28% |
14% |
5% |
|
Sweden |
8% |
2% |
0% |
The AIDS incidence related to drug users is low both
for Holland (0.6 per million population) and Sweden (0.9 per Million
population). The prevalence of HIV infection among injecting drug abusers in
the Netherlands is in the range between 0.5% and 25.9%. The figure for Sweden
is 2.6% 8.
The prevalence of ‘problem drug users’ is possibly
higher in Sweden (4.0-5.4 per 1000 population) than in the Netherlands (2.5-2.9
per 1000) 8. However, due to the methodology used there appears to
be some fluctuation of these figures and the figures only a few years ago were
lower in Sweden than in the Netherlands. In the past, problem users in Sweden
mainly injected amphetamines (roughly ¾ of ‘problem users’) whereas only ¼ of
‘problem users’ injected heroin. Heroin use has increased recently. In the
Netherlands, almost all problem drug users use heroin.
An increase in the mean age for people in drug
treatment – as observed in Sweden - indicates a flattening or possible downward
trend as less new (i.e. younger) users are entering the treatment system. This
is usually a positive sign. This trend has also been observed in the almost
every other European country in the late 1990s apart from Holland and
Luxembourg, where the mean age has decreased, i.e. younger users enter the
treatment system[9].
6. Drug Related Deaths
Drug-related deaths do not necessarily support the
Dutch drug policy:
The low numbers of drug-related deaths in the Netherlands
has been put forward as vindicating the Dutch approach. Indeed, in 1998, the
last year for which figures are available for Sweden by the European Monitoring
Centre, there were 85 acute drug-related deaths. In 1999, the last year for
which figures are available for the Netherlands (which has nearly twice the
population of Sweden) there were 76 drug-related deaths8. This would
translate into a drug-related mortality of approximately 5 per million
population for the Netherlands and 10 per million for Sweden using national
definitions.
A higher death rate may reflect a higher age of the
drug using population in Sweden. However, there is the obvious concern that
drug addicts may not seek treatment for fear of criminal charges. This would
certainly be a serious shortcoming of the Swedish drug policy.
It is, however important to note that the above
mentioned figures are based on national definitions which are not identical in
both countries: For example, if a person dies following an accident and the
toxicological analysis reveals the presence of an illicit drug, the death would
be classified as drug-related in Sweden but not in the Netherlands3.
Also, there is a far higher autopsy rate with toxicological analysis for
suspected drug-related deaths in Sweden (up to 90%) than in the Netherlands
(30-40%) which would make the detection of drug-related deaths more likely in
Sweden than in the Netherlands3 .
Furthermore, there is a huge variation between death
rates for the same country according to the definition used. For the year 1995
the number of drug-related deaths in the Netherlands was 33 according to the
national definition, however 70 when using a definition using a European
standard. For the same year, the figures for Sweden range between 41 and 134,
depending on the definition or standard used8 . For this reason, the
claimed low number of deaths per population which has been used to defend the
“Dutch model” may not reflect the real situation.
It may be more relevant to note that there has been
an increase in the number of drug-related deaths in the Netherlands over the
past five years. This is mainly due to an increase in cocaine-related deaths.
During the same period, a decrease was observed in Sweden.
In the assessment by the United Nations Office for
Drug Control and Crime Prevention the Netherlands continue to be the centre of
synthetic drug manufacture in Europe, notably ecstasy and amphetamines.
Cannabis cultivation in the Netherlands is among the largest in Europe. In
terms of trafficking, the Netherlands – notably due to its port of Rotterdam –
is one of the main entry points of drugs into Europe2: In 1998,
118122 kg of Cannabis were seized in Holland compared to 496 kg in Sweden.
Dutch seizures of cocaine significantly increased from 3433 kg in 1992 to 11452
kg in 1998. In contrast, the Swedish cocaine seizures in 1998 were 19 kg. Also,
there are significantly higher seizures for heroin, amphetamines, ecstasy and
LSD in the Netherlands3.
Holland – in the words of senior customs and police
officers in the UK, France and Belgium has become “the drugs capital of
Western Europe” – and not just of cannabis, but also of heroin, cocaine and
now ecstasy. It is estimated that 80% of the Heroin seized in the UK and France
has passed through Holland since it is considered to be “relatively
trouble-free from a criminal’s point of view.” [10]
The Dutch official view is that cannabis use is by no
means risk free, but certainly no more harmful than alcohol and tobacco use3.
This view is outdated: According to recent research, smoking marijuana – as
compared with smoking cigarettes – is associated with nearly fivefold increase
in blood carboxyhaemoglobin level, a threefold increase in the amount of tar
inhaled and retention of one-third more tar[11].
This is likely to lead to an increase in cancer promotion. In fact, there have
been case reports of cancer in the aerodigestive tract in young adults with a
history of heavy cannabis use. Such cancers are unusual in this age group, even
among those who smoke tobacco and drink alcohol[12].
The assumptions of the Dutch drug policy, i.e. that
the harms of cannabis are not considered to be great and that cannabis has a
low potential for dependency are not borne out by recent thorough reviews on
the subject[13] [14].
In a 1995 conference on Marijuana use organised by the US National Institute of
Drug Abuse one of the experts stated that “Studies show that [marijuana] is
more harmful than any of us realized.”[15]
One of the bases of the Swedish drug policy is the
‘gateway’ hypothesis. While discounted by some researchers, there has been
recent pharmacological support for this hypothesis indicating that both
cannabis and heroin may act on the same receptors in the brain[16].
Data from New Zealand also supports this hypothesis. After adjustment for
confounding factors, a 60-fold increased risk of other illicit drug use among
those who used cannabis on more than 50 occasions a year was observed[17].
Adolescents who use marijuana are 104 times more likely to use cocaine compared
with peers who never smoked cannabis[18].
The data on drug prevalence in both countries appears
to vindicate the Swedish approach based on the gateway hypothesis: infrequent
cannabis use in Sweden is associated with a low use of “hard” drugs whereas a
high prevalence of cannabis use in Holland is associated with higher prevalence
of “hard” drug abuse.
Having implemented their different policies for a
quarter of a century, the outcome of the Swedish drug policy aimed at creating
a drug-free society has been far more successful than the liberal
“harm-reduction approach” utilised in the Netherlands. The use of cannabis and
of other illicit drugs including cocaine, amphetamines and ecstasy is far lower
in Sweden than in the Netherlands. Associated with its “harm-reduction” policy,
the Netherlands has seen a significant rise in cannabis, cocaine, amphetamines
and ecstasy use. Furthermore, it has become one of the main drug trafficking
countries in Europe for heroin, cocaine and cannabis and the centre of
synthetic drug manufacture, notably ecstasy and amphetamines. Far more
harm-reduction for the Netherlands and other European countries would ensue if
the Netherlands adopted drug regulations aimed at reducing drug use.
The available evidence therefore strongly favours the
Swedish approach.
10. Lessons To Be Learnt
The Swedish and Dutch experiences
points to the following lessons:
[1] Tutt D et al. Cannabis and road death: an
emerging injury prevention concern. Health Promotion Journal of Australia 2001;
12: 159-62.
[2] United Nations Office for Drug Control and
Crime Prevention 2000: The Netherlands - Country profile on drugs.
[3] European Parliament, Directorate General
for Research 2001: The drug policies of the Netherlands and Sweden: How do they
compare?
[4] Report to the EMCDDA by the Reitox national
focal point of Sweden, Folkhälsoinstitutet. Sweden, Drug Situation 2000.
[5] United Nations Office for Drug Control and
Crime Prevention 1998: Country Drug Profile Sweden.
[6] Boekhout van Solinge T. The Swedish Drug
Control System. Cedro, Amsterdam 1997. Please note that the more negative
conclusion of this Dutch assessment of the Swedish drug policy are not supported
by EMCDDA data
[7] MacCoun R and Reuter P. Evaluating
alternative cannabis regimes. British Journal of Psychiatry 2001. 178: 123-8.
[8] Trimbos Institute Utrecht, quoting European
School Survey Project on Alcohol and Other Drugs ESPAD 1999.
[9] United Nations Office for Drug Control and
Crime Prevention. World Drug Report 2000; p96-7
[10] Collins L. Holland’s half-baked drug
experiment. Foreign Affairs 1999; 78: 82-98.
[11] Wu TC et al. New England Journal of
Medicine 1998; 318: 347-51.
[12] Hall W, Solowij N. Adverse effects of
cannabis. Lancet 1998; 35: 1611-16.
[13] Ashton CH. Adverse effects of cannabis and
cannabinoids. British Journal of Anaesthesia 1999; 83: 637-49.
[14] Johns A. Psychiatric effects of cannabis.
British Journal of Psychiatry 2001; 178: 116-22.
[15] National Institute on Drug Abuse (NIDA),
National Institutes of Health 1995. National Conference on Marijuana Use. p. 38
[16] Tanda G et al. Cannabinoid and Heroin
activation of mesolimbic dopamine transmission by a common mu1 opioid receptor.
Science 1997; 276: 2048-50.
[17] Fergusson DM, Horwood LJ. Does Cannabis use
encourage other forms of illicit drug use? Addiction 2000: 95: 505-20.
[18] The American Academy of Pediatrics.
Marijuana: A continuing concern for Pediatricians. Pediatrics 1999.
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