Policy on drug misuse in Europe

Policies for managing drug misuse among the countries of Europe are characterised by unprincipled variations1 and a dearth of information or analysis that would support systematic decision making. For the past two decades purely political priorities have been the dominant influences in many European nations. The establishment in the European Union of a Monitoring Centre for Drugs and Drug Addiction provides an important opportunity to change this climate so that future management of drug misuse is properly informed by science.

The current lack of information and analysis shows itself in several ways. Radical and interesting changes in policy, such as the removal of criminal sanctions for personal possession of psychoactive drugs in Italy and Spain, have gone unevaluated.2 Few European nations conduct national surveys that would provide the basis for systematic estimates of the prevalence of drug misuse. In the case of France and Italy it has not been possible to identify survey data on drug misuse even at the city or regional level.2 Moreover, in most countries the data that have been collected have remained almost unanalysed beyond official descriptive reports, themselves often buried in obscure publications. Rarely if ever have files been made available for secondary analysis by other scholars. In some nations estimates of the numbers of people dependent on illicit drugs have the precision of medieval estimates of the angel carrying capacity of pinheads. For Britain figures as diverse as 25 000 and 250 000 opiate addicts have been cited, and for Italy figures of 100 000 and 300 000 heroin addicts are equally plausible and equally unfounded.

Unsurprisingly, treatment also varies enormously, with scarcely any reference to a base of research and analysis. In Britain, the United States, and the Netherlands methadone is accepted as the centrepiece of treatment for opiate addicts on the basis of a substantial number of reports of reasonable (though not excellent) quality on the effectiveness of such treatment.3 In some other European nations it is scarcely available at all.4 Greece bans most opiate substitute treatment. France has a total of 52 patients receiving methadone, and Germany had fewer than 1000 patients taking methadone before 1992. In Spain and Britain the availability of substitute treatment varies greatly among regions, and in Italy methadone is mostly limited to short term prescription.4

The continued concern about the prevalence of HIV infection among intravenous drug users is leading to sharp changes in practice, which are not necessarily based on research or evaluation. Thus Germany has developed treatment facilities for 8000 people in the past two years, while French policy makers (after a decade of denial5) and health professionals are finally pushing for a major expansion in the availability of opiate substitute treatment. Pockets of opposing views remain - for example, in Norway and Sweden - but overall there seems to be a swing in favour of prescribing substitutes. On the basis of the available scientific evidence, the United Kingdom Advisory Council on the Misuse of Drugs has recently strongly endorsed the role of structured maintenance treatment with oral methadone in preventing HIV infection.6 Unfortunately, earlier experiences suggest that rapid reactive shifts in attitude may be short lived and not soundly based. The recent Italian laws restricting the consumption of methadone to the confines of treatment centres are an example of reactive decision making inappropriately responding to the problem of methadone diversion.

Different models of mental illness and addiction across Europe also contribute to these sharply divergent responses,7 as do differing systems of health and welfare provision. But the longstanding rejection of methadone in so many countries is symptomatic of the moralism that has characterised drug policy for so long and that makes analysis and research such marginal activities.

The establishment of the European Monitoring Centre for Drugs and Drug Addiction in Portugal during 1994 not only represents a step toward addressing the information and policy gap; it may also provide a battleground for airing national differences. The centre aims to collate, analyse, and disseminate data on drug problems from member states and to facilitate the exchange of information and documents among member states. The centre comes in an era following the Maastricht treaty in which the European Commission seems keen to promote the public health dimension of drug policy. Drug misuse was also one of the subjects singled out for community action by the Health Council in December 1993. Moreover, the Maastricht treaty also commits members states to cooperate over justice and home affairs, including measures to combat the plague of drug misuse. At a recent conference Mr Fortescue, the director responsible for cooperation in justice and home affairs, suggested that such measures might include cooperation among doctors to harmonise the use of certain drugs and to analyse the medical evolution of the treatment of drug addicts.

After decades of fragmentation drug policy in Europe may now be converging, largely as a result of the relation between drugs and HIV infection. The establishment of the European Monitoring Centre for Drugs and Drug Addiction provides at last a facility to promote systematic collection and analysis of data to complement the useful recent work of the Pompidou group.8

Given the dearth of information, the task of the centre remains daunting. Nevertheless, the centre may yet provide the opportunity to put European drug policy on a sound basis, which would allow policy makers and professionals to challenge much of the presently entrenched moralism.