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Sweden and the drugs problem-seen through Dutch eyes

Alderman Mrs G.K.T. Van der Giessen ... chair - Amsterdam City Social Welfare & Health Care
Dr G.H.A. van Brussel ... senior medical officer, drugs unit of the Amsterdam City Health Service
Amsterdam February 1996

1. Introduction

On 14 and 15 February a delegation from Amsterdam made a fact finding visit to Stockholm at the invitation of the city council. The delegation comprised Alderman Mrs Jikkie van der Giessen (who holds the social welfare and healthcare portfolio in the Amsterdam city council), city spokesperson, Mr Richard Lancée, and Dr G.H.A. van Brussel, head of the city medical service's drugs department. The purpose of the visit was to start a constructive dialogue on the two cities' somewhat divergent policies on drugs. The fact finding aspect was designed to ensure the mutual familiarisation and respect which are prerequisites for a meaningful dialogue.

The central question was: what is the nature and extent of the drugs problem in Sweden, what policy is being followed and to what effect.

With this is mind the Amsterdam delegation studied extensive background material provided by the Netherlands Health Ministry and the Amsterdam City Health Department. During this short visit, the delegation exchanged views with many, diverse players including Stockholm councillors, police officers from the drugs squad, and healthcare workers involved in enforced treatment of drugs users and in a closed facility for young users. Last but not least, the Netherlands Embassy was a generous source of hospitality and insights.

This report deals with the following aspects:

a general outline of the country, climate and society
a report on the fact-finding mission
Sweden and the Netherlands: selected healthcare figures
Population research findings on consumption of psychotropic substances in Sweden
an overview of literature on the drugs problem and evaluation data available for Sweden
Brief reflections

Verbal information has been used in the description of many topics. The written sources comprise excellent publications by Sweden's National Institute of Public Health, the Council for information on Alcohol and Other Drugs, and the Health and Social Affairs ministry. Annex 1 provides an overview of the literature consulted.

2. Sweden, general

Sweden is a large but thinly populated country, with 9 million inhabitants. Its rich history goes back to the times of the Vikings whose expansive spirit carries on into the early middle ages. There were regular wars of territorial gain in and around the Baltic, right up to the early 19th century. Norway, Denmark, Schleswig-Holstein, Northern Poland, Finland and parts of Russia all came under Swedish sovereignty at one time or another. However, the country succeeded in staying neutral in both world wars.

Sweden today is a constitutional monarchy with a long tradition of democratic government and a comprehensive welfare network. The country is a great respecter and upholder in international human rights. There are many similarities with the Netherlands. Unemployment and the number of immigrants have both risen recently. Ethnic minorities represent some 20% of Stockholm's population - often they are refugees from Turkey (Kurds), Iran and Iraq. Entry to the European Union two years ago has impacted on the country's relative isolation. One striking example is the threat to the state monopoly on sale of alcoholic beverages - the Bolaget system.

3. Sweden and the Netherlands, selected health statistics

A swift comparison of WHO yearbook statistics for the Netherlands and Sweden shows major similarities. Average life expectancy, deaths from heart-related disorders, cancer etc, are almost identical. The differences that do occur are around male suicides and alcohol related deaths.

Suicides per 100,000 members of the population (1990) Sweden Netherlands males
1,020 (24.1%) 900 (12.3%) females 451 (10.4%) 541 ( 7.2%) Per capita alcohol consumption
in litres (1993) Netherlands 85.2, Sweden 63.2 Death due to cirrhosis of the liver
(1990) per 100,000 Netherlands 4.8, Sweden 7.6

When collated these figures demonstrate that death from liver cirrhosis per litre of alcohol in Sweden is more likely than in the Netherlands by a factor of 2.1. Moreover, it is quite possible - even likely - that the consumption figures based on sales by the state liquor stores are less than totally reliable, as they do not include illegally distilled 'moonshine'.

Drug overdose deaths (ICD 304, 1993) Sweden Netherlands (estimate) per 100,000
pop. 1.6 0.5 total 146 80

Hepatitis C:

In 1990/1994 Sweden had a total of 15,008 reported cases of HCV infection. Of these, 10,000 (or over two thirds) were intravenous drug users (lit.1). It should be borne in mind here that HCV could not be diagnosed before the start of 1990. Dutch estimates also suggest a large number of HCV infected intravenous drugs users. There are no exact figures.

4. The fact-finding mission - a report

4.1 During the two day visit the Amsterdam delegation met and talked with:

a delegation from the Stockholm city council and the director of the ECAD foundation (European cities against drugs)
members of the central Stockholm police drugs squad
the Dutch ambassador
the directors of the Maria Ungdom secure facility for young substance abusers (arrested by the police for a variety of reasons)
a psychiatrist and psychiatric nurse from the secure clinic for women users/abusers committed for enforced treatment under Sweden's LVM legislation.

At all these meetings the Amsterdam party sought additional information material and/or extra detail on information already assembled (shown elsewhere in this report). The aim of a meaningful dialogue was certainly realised, with an even more open and constructive atmosphere than hoped for, throughout all these meetings.

However, it was also very clear that the Swedish and Dutch situations differ radically.

4.2 The city council: Swedish drugs policy

Swedish drugs policy aims to create a drugs-free society. This relatively hardline approach is justified by citing the debacle of the harm reduction models applied in 1965/1967 when medically supervised supply of replacement drugs like morphine and amphetamines and methadone went totally out of control, due to excess consumption, black market dealing etc.

What followed was a policy shift towards total abstinence. The authorities seek to achieve this by reducing both supply and demand; on the supply side this translates as combating all forms of dealing in drugs. And all forms of drug taking are also illegal. Meanwhile, the demand side is targeted via a highly comprehensive network of clinics (voluntary attendance) and 'street corner' social-work programmes. Methadone in its medical/treatment context does not fit in with the abstinence objective. Even so, Stockholm's methadone treatment capacity was quite recently expanded to cope with 450 patients.

In the view of Sweden's policy makers, syringe trade-in projects and low threshold methadone treatment send the wrong message; hence, with the exception of two small-scale syringe trade-in projects in Lund and Malmo, no such facilities exist. In other words - there is nothing in Stockholm - which is home territory for a relatively large number of mainline users.

The LVM Act, which was reinforced in 1986, allows enforced treatment. The authorities are aware of the poor results of enforced treatment (see para 6.3 of this report). When asked why they continued with this very expensive programme, Mr Kohlberg (Stockholm councillor) said that it was part of the prohibition message.

Swedish thinking makes no distinction whatsoever between soft and hard drugs: they treat them all as hard - cannabis included. Cannabis is considered a gateway drug to heroin, and is thought of in relation to serious psycho-pathologic disorders (schizophrenia) in the young. Co-use of amphetamines and cannabis has a bad name in this respect, mainly linked to aggressive incidents. The very low use of cannabis and heroin by the young (according to Swedish studies) is regarded as a success for the prohibition approach, which is duly perpetuated.

The main problem drugs in Sweden are amphetamines, psycho- pharmacopoeia and alcohol. The Swedish anti-drugs community appears to share a dominant fear bordering on certainty that any relaxation along the Dutch road would mean spiralling addiction and related health problems.

Indeed, given the material discussed in the following sections this fear in not unfounded. The consequence of this fear/certainty is that official Dutch differentiation between hard and soft drugs, and the risk-reduction strategy to hard drugs abuse, is viewed as "bizarre". It is as if there were no shared terms of reference, no common "givens".

In fact, what one has here is a difference of visions on how people cope with possible addictive substances, and on internal versus external control. The Swedish authorities regard external control as imperative because the Swedes may lack the necessary self-discipline.

4.3. The drugs squad

Two officers from the Stockholm police drugs squad shared their day-to- day experience of the drugs scene with the Amsterdam delegation. They emphasised the ongoing threat of escalation around young users (under 20 years old). The policy is to get these youngsters into care/treatment programmes as early as possible (see 4.4). It is striking that the starting age for drug abuse is considered to be 15, i.e. very young indeed. The police take a very poor view of cannabis, because of the panic attacks this can cause for young users out on the streets, particularly when combined with alcohol and amphetamines.

The police regularly encounter young OD (overdose) cases. Pill abuse is very common, especially benzodiazepine-type intoxicants like rohypnol and seresta. Also striking is that the users often smoke these tablets, like their Amsterdam counterparts with Mandrax in the 1970s.

The police have wide powers to stop, search and detain suspected users of cannabis, heroin, amphetamines and/or benzodiazapine. Once at the police station, suspects are required to undergo an obligatory urine test, and can be charged with an offense if the result is positive. The courts can impose income-related fines usually of around SK 1,000.-- (NLG 250.--) per offence. All fines are recorded and payment is required as soon as the offender comes in funds, e.g if he/she gets a job. Quite clearly, offenders can accumulate substantial financial penalties in this way.

During the meeting with the police officers, the Amsterdam party was impressed by the high degree of dedication to saving young victims. The police are 100% behind the prohibition policy.

4.4 Maria Ungdom (the Maria Youth Centre Clinic)

This is a major clinic for young users/abusers up to the age of 20. There is a multi-disciplinary staff of 130. Some 1,100 youngsters pass through the facility in a year (1995). One third are admitted under the influence of drugs, having been arrested by the police. Another third are referred by the Social Services, and the remainder seek treatment of their own volition. Ages range from 11 to 21, the average being 17.

Alongside voluntary and enforced treatment, the clinic also provides after- care. Apparently, admission is usually prompted by the abuse of psychotropic substances, often in the street scene.

The spread of admissions per substance in 1995 was as follows:

substance number of people alcohol 743 anabolic steroids 13(?) cannabis 359 amphetamines
171 (inc 12 intrav. users) XTC 41 heroin 79 (inc 15 intav. users) cocaine 33 LSD
52 solvents 68 benzodiazepines 147 others 402 Total number of patients admitted
in 1995 = 1,111.

Quite clearly, there is widespread co-use with hard drugs playing a limited role. The main group are young people with a psycho-pathological profile, exacerbated by substance abuse. Notwithstanding, according to the clinic's director, there has been a serious rise in substance abuse, notably of brown smoking heroin which has recently arrived on the Swedish market, having dominated the scene in the rest of Europe for many years.

4.5 LVM involuntary admissions

We also visited a secure clinic for women admitted as involuntary patients under the LVM Act. The costs of these admissions are retrieved from the Social Services and dedicated funding from the state (i.e. not from health insurance). Negotiations are always difficult.

The clinic is on the site of a major psychiatric hospital outside Stockholm - but there are no organisational links, the clinic is a "guest".

We spoke with a psychiatrist and a psychiatric nurse. On the subject of Fugelstad's study on enforced treatment (1988 - para 6.3), they clearly believed that results had improved somewhat in the meantime, notably due to the longer period of admission; the maximum is six months - in practice four to five months. Rather than treatment, the main objective of the enforced admissions is to motivate the patient to undergo voluntary treatment after release. We were told that no definite evaluation or outflow figures were available right then, but would be mailed to us. The psychiatrist suggested that the figures would be strongly coloured by the fact that patients were invariably drawn from a stringently selected "bad" group.

Of the 20 patients in residence at any one time (60 a year), half are aggressive paranoid schizophrenics. The most common substance involved is heroin, which is used as self-medication for serious psychiatric complaints. Without exception the other patients have serious personality disorders, in some cases they are dangerously psychopathic.

The doctor and nurse cited the following bottlenecks:

The care category here is really "heavy psychiatry", but it is directed by the finance source - Social Services. As previously noted by Fugelstad, this means constant conflict around medication on the principle that "drugs are drugs are drugs, and therefore prohibited and/or undesirable". Given the type of patients, this is a major constraint.

Use of tranquillizers (and certainly methadone) during detoxification is taboo. This results in unnecessarily serious escalations. In one of the isolation cells we were shown, a patient had recently pulled down the ceiling. The only medication used during detoxification is clonidine which acts against hypertension and slightly reduces withdrawal symptoms.

In financing terms this is a very costly facility. Admissions are paid by the patient's local Social Services department. Sweden has problems with public spending. In recent years this has significantly reduced LVM treatment capacity in cities and regions. Our discussion partners were unable to give exact figures, but we were told that several LVM clinics had been closed.

The most important single constraint on the operation of the LVM clinics is that the health problems to be treated are incorrectly designated under the heading of addiction. In fact, the people admitted are very ill psychiatric patients with secondary drug abuse problems. The main body of the psychiatric profession looks down on both the disturbed addicts and the people who treat them within the LVM programme.

5. Psychotropic substances - population research

This paragraph covers data from the two comprehensive reports by the Central Förbundet För Alcohol Narkotika Upplysning and the Fölkhälso Institutet, published in 1993 and 1995 (literature 1 and 2).

5.1 Alcohol

Ground work for the fact-finding mission had included a general look the area around intoxicants. A publication which drew our particular attention was the Swedish health ministry's "Swedish Drugs Policy" whose significant contents merit inclusion in full, in annex 2. In a nutshell, this calls for the continuation of the state import and sales monopoly (Bolaget system), and argues against undesirable interference from Europe (free market forces and harmonised regulation) which would end the monopoly. The brochure draws a dramatic picture of the Swedes' inability to cope with alcohol in the absence of controls, whereby a highly restrictive and limiting sales monopoly is crucial to prevent chaos and widespread public drunkenness. "For centuries Nordic intoxication oriented drinking habits have resulted in extensive social damage" (p.2). The local importance of limiting availability of alcohol is backed up with the report of an experiment in 1967 and 1968 when "strong beer' (i.e. 5% alcohol like Dutch pilsner)) was sold in ordinary food stores. Consumption rose 14-fold, while wine and spirits sales were stable, and the experiment was halted after a few months. Another striking detail is that Saturday closure of the state liquor stores which started in 1981, resulted in a significant fall in public drunkenness and crimes of violence. The brochure closes with a plea that Sweden should be allowed to keep its state monopoly of alcohol sales; as a trade-off, the writers offer to boost sales of imported beverages at the expense of the local schnapps.

The brochure summarised here is something of an eye-opener in evaluating alcohol-related deaths in Sweden: mortality is higher than in the Netherlands, while reported consumption figures are much lower. As noted previously, the figures may be less than comprehensive.

Moreover one has to be 18 to buy and drink alcohol in a bar/pub, 20 to make a purchase in a state liquor store. Drinkers under those ages have to depend on family and older friends, bootleggers and moonshiners (illegal drink dealers and distillers).

The compulsive, get-drunk-at-all-costs drinking pattern is also apparent from a survey of children in grade 9 (15 years of age). This shows that in 1992 almost one in three boys and one in five girls (i.e. 29 and 18 percent) drank the equivalent of 370 ccs of spirits (half a bottle of whisky) in a single session.

Drinking is also common among Dutch youngsters, sometimes to excess, but not to this degree, and not at this early age.

In the last century, widespread alcohol abuse promoted the enforced treatment of alcoholics. This occurred under the aegis of the Temperance Boards organised in local communities. The boards registered alcoholics and incidents of and around public drunkenness. Vagrancy was not tolerated - and certainly not for alcoholics. And if an individual was unable to regulate his or her intake, the community had powers to commit him or her, involuntarily. This and the previously noted links with the local Social Services are striking and recall Holland's pre-war local authority financing of psychiatric hospitalisation. The Swedish system was gradually expanded into the LVM arrangement where by drug abusers can also be confined for treatment in a closed institution. Funding comes from the Social Services and the national government - and not from the health insurers. Admissions pressure local budgets and this has been a factor underlying closure of the highly expensive LVM clinics.

The Temperance Board system, and the registration programme in particular, have enabled excellent longitudinal epidemiological studies into the course of alcoholism and related mortality patterns in Sweden.

5.2 Amphetamines

The Swedes are traditionally vulnerable to amphetamine abuse. This is evidenced by the six million amphetamine tablets (phenedrine and benzedrine) prescribed in 1942. The number of occasional users of these stimulants (one to four times a year) was estimated at 200,000, and 4,000 people took amphetamines once a week. The same 1942 report noted 3,000 people who used 10 to 15 tablets a day! With the exception of Japan and Korea this is a unique world record. Present day users often inject their amphetamines. The current growing supply of very cheap amphetamines is blamed on illegal production and smuggling from Poland and the former Soviet Union.

5.3 Heroin

Leaving alcohol aside, heroin ranks second only to amphetamines as a problem drug in Sweden. The brown, smokeable variety has been on the market for two years now. Heroin is usually injected by co-abusers of amphetamines, alcohol and benzo-diazepines. Alongside the traditional pattern of amphetamine abuse victims who suffer from paranoid schizophrenia and use heroin as a self-medication, recent primary heroin abuse has been most marked among the under-sixteens. So far the street price of heroin in Sweden is very high by European standards.

5.4 Cannabis

Cannabis is considered to be a hard drug in Sweden, and tolerance is zero. Swedish literature frequently refers to the cannabis's psychosis provoking qualities. The young are constantly warned about its dangers. Judging by surveys of school children and young men doing military service, this has borne fruit. The proportion of 20 year old conscripts who had experimented with cannabis and amphetamines fell from 19% in 1980 to 8% in 1993. The statistical tables available do not differentiate between the various types of "narcotics". Neither is it clear in how far the environment of the interviews might have impacted on responses.

5.5 Solvents

Glue or solvent sniffing is almost unknown in the Netherlands, the only exception being a limited outbreak of "tri-sniffing" in the 1960s, and of solvent abuse in the late 1970s. In both cases the abusers were groups of seriously socially disadvantaged youths in a few cities. Solvent abuse is a highly dangerous and damaging practice which can attack both the brain and other internal organs. The practice has always been very widespread in Scandinavia, as well as in the United Kingdom and Ireland.

A recent (1995) survey of 15 to 20 year-olds in Oslo (Norway) showed that 7% had abused solvents at one time or another, while 21% had smoked marihuana. The Swedish picture is similar - at least as far as solvent abuse in concerned.

A 1993 survey showed that 13% of Swedish 15 year old boys had abused solvents at one time or another. By Dutch standards that is an extremely high rate of prevalence - but for Sweden it represents a radical decline: indeed, in 1971 an amazing 27% of 15 year-old boys in Sweden had abused solvents at some time.

5.6 Conclusion

The Swedish leitmotif in dealing with psychotropic substances is the imperative of external control. In fact this means state-enforced limitations on consumption of all such substances. This appears fully justified given the problems around abuse of - in particular - alcohol, amphetamines and solvents. The next paragraph takes a broader look at the issue of drug abuse.

6. The drugs problem - a literature overview

A problem in evaluating the issue of drugs abuse in Sweden is that there is no policy differentiation between the various types of drugs. This is reflected in the descriptions of the drugs problem. Cannabis, amphetamines and heroin are all classified as "narcotics" and all users are addicts, etc. Unlike the Netherlands, Sweden has no total overview of the drugs population in the form of annual reports of city methadone programmes and capture/recapture figures, nor detailed mortality and sickness figures. However, one can glean some insights from sector analyses of, for example, mortality patterns among selected user groupings, published in freely available international medical literature, and a few evaluation reports (all in Swedish). What are involved here are divergent patterns of use and related complications. This section describes a number of high-grade, relevant medical studies and closes with a speculative reconnaissance of the drugs problem in Sweden.

As noted above, amphetamines dominate the hard drugs scene in Sweden. Heroin users form a substantial minority. Alongside amphetamine abusers, Stockholm and Malmo are also home to large concentrations of heroin users. The figures in the various articles relate to the different years and cities, and do not always match up;

Even so, the picture arises of very substantial and sick epidemic of drugs.

6.1 AIDS and drugs

Ljungberg (1991, literature 3) describes the preventative effect on HIV infection, of the local syringe trade-in project involving 182 intravenous users, in Lund (Skane province in southern Sweden). Malmo, also in the south of the country, was the site of another trade-in project. The author estimated the number of "injecting" users in Skane at at least 3,000, out of a population of one million. The average age of the 182 users in the survey was 30 (1991); 80% were men; 70% exclusively used amphetamines; and 98% had been tested for HIV once or more. One percent of Skane's "injecting" users is estimated to be HIV positive; a total of 38 HIV positive users had been identified at the start of 1990, and just over half of these were on heroin. The striking thing about this small number (probably a meaningful picture given Swedish testing policy), is that two-thirds became infected in Stockholm or Denmark. The author contrasts Lund's 1% HIV infected users with the figures for heroin users in Stockholm (1988: 45 to 60 percent).

Lundborg (1989, literature 4) describes the situation around AIDS and drug abuse in Stockholm. According to the author the spread of intravenous use of opiates in Stockholm in the period 1987 to 1988 is 33% amphetamines and 17% heroin; 45% of heroin users being HIV positive with a 0% (?) annual incidence. The prevalence of HIV infection among amphetamine users is 6%, with 1% new infections a year. The total number of HIV infected users is declining due to the high death rate, notably among heroin users.

6.2 Methadone treatment

Gröbladh and Gunne (literature 5 and 6), thoroughly documented Sweden's relatively small-scale methadone programmes. As there is no place for methadone in the country's restrictive drugs policy, it was possible to carrying out a longitudinal comparative coherent study. This contrasted with the fate of clients admitted to a methadone programme with those kept outside when the government put a stop on the intake. This enabled comparative analyses of mortality patterns in the methadone group, the waiting list group, and the category of clients expelled from the programme after discovery of continued abuse.

This is unique material, in that these are the only studies with a control group, out of the very large body of national literature on methadone evaluation.

The groups in the study were;
166 heroin addicts being treated with methadone.
53 of these 166 who were banished from the methadone programme
115 heroin addicts in the waiting list (control) group.

The observations were conducted over five to eight years as from 1979, and hence prior to the AIDS epidemic among users. The annual death rate for the methadone group was 1.4%, with no mortalities from heroin overdoses. Annual deaths in the control group were 7.2%, with three- quarters due to heroin overdoses. It was also striking that deaths among clients banished from the methadone programme rose to 7%, and indeed, the authors call for expansion of methadone treatment.

Fugelstad (1995: literature 7) deals with mortality among 472 HIV positive drug users in the Stockholm region in the period 1966 to 1990. The introduction to the article refers to a study by Byqvist which estimates the total number of intravenous drug users in Stockholm at 4,300 in 1993, with an equal spread of opiate and amphetamine users. Annual deaths among the city's users are calculated at 3% for opiates and 1% for amphetamines.

The 472 HIV positive users followed in the study has a significant, 3.5% annual death rate (whereby the study makes no distinction between amphetamine and heroin users). In most cases the HIV infection dates from the early 1980s (the same period that the virus appeared among Amsterdam users). As it happens, Stockholm does not have a syringe trade-in programme. The Stockholm pattern of fatalities differs from that in Amsterdam. Rather than illness, the majority of deaths among the Swedish HIV cases are due to overdoses (41 of 69 = 60%), or suicide (9 of 69 = 13%). Fugelstad concludes that treatment with methadone offers protection against premature death from an overdose. This conclusion is reinforced by the fact that the non-methadone group comprised an unknown number of amphetamine users, alongside opiate dependants. In Sweden it is assumed (Byqvist) that deaths among amphetamine users is intrinsically low at 1%, compared with 3% for heroin users.

6.3 Results of non-voluntary treatment of drug abusers in Stockholm

Non-voluntary treatment (forced withdrawal) has a high profile in presentation of the Swedish model. Even so, the majority of admissions of addicts for treatment are voluntary in Sweden. In 1993 there were a total of 24,999 voluntary admissions compared with 2,127 legal committals, i.e. 92 versus 8 percent.

The legal committal (non-voluntary) cases were 65% for alcohol, 17% for drugs, 16% for alcohol and drugs, and 2% for other causes.

Fugelstad (literature 8) in 1988 describes the enforced treatment of 152 drug addicts in Stockholm. The study followed them for an average of one year after discharge. The study deals with non-voluntary care and treatment immediately after implementation of the LVM Act in 1986; this legislation enables the detention for non-voluntary treatment of substance abusers who do not respond adequately to voluntary treatment. The group studied was detained for a maximum of two months. Since then, the legislation has been revised to permit a maximum of six months. The LVM provisions are an extension of the Social Services Act. The author describes the chaotic situation, with rampant organisational and harmonisation problems. Mainly involved here is the clash between the medical staff and the people who are in charge of the process - the social workers. The crux of the matter is medical autonomy. In the view of the social workers in charge, all medicines, including anti-psychotica, tranquillizers and anti-depressants are drugs - and thus forbidden. Given that so many of the patients suffer from serious psycho-pathological disorders, this is a major stumbling block; indeed, alongside the short stay, it may well explain the quite disastrous results.

In this study, of the 152 admissions (average age 30), 91 are opiate- dependent (57% HIV positive); another 27 are amphetamine dependent, only one of whom is HIV positive. The other 24 patients are cannabis and solvent users; 12% of this group is HIV positive. The starting age for amphetamine abuse is 15, with users moving to heroin at 18 and 19. During their careers as addicts they are frequently admitted to hospital and to voluntary drugs clinics. The average is ten times. An interesting fact is that after enforced treatment, "care consumption" rises to 4.3 admissions a year.

The follow-up varied per patient, from six months to two-and-a-half years after release. The outcome is dramatic. Of the 152 subjects:
21 died (16 from heroin overdoses)
25 went into methadone programmes
76 were still active users
30 were in prison, or their whereabouts were unknown.

The prior career of those who succeeded in getting into a methadone programme is striking. The author describes then as "the most socially- maladjusted and hopeless LVM clients". Almost all are HIV positive. This is followed by the remark that: "Enormous improvements were noted in the social and addiction situations of all the addicts who underwent methadone treatment."

6.3 Conclusion

The printed material shows a picture of a turbulent hard drugs epidemic whereby there is a heavy incidence of death and illness in the relatively small sub-group of heroin users. It also clear that medical input in drugs care and treatment - particularly in the context of methadone programmes and syringe trade-in projects - is very limited indeed.

The next section deals with the first-hand experiences and discussions around the Swedish approach, during the fact-finding missions.

7. Brief reflections

Sweden's problems around drugs differ from the Dutch situation. The differences come under three general headings:
the substances used
the manner of use
official policy

However, the main thrust is directed at the basic inability to consume any intoxicant with moderation. This social "given" is reflected in the Swedish view of use/consumption of these substances. In turn this translates as policy oriented to external rather than internal checks and controls.

Judging by the material studied, Swedish policy is adequate - in the present context. However, the question arises whether the present situation - that of a relatively prosperous, isolated country, can withstand the probably inevitable social and economic impact of European integration. In the longer run, continuation of the state alcohol monopoly appears unfeasible, while the present unemployment levels and pressures on government spending will also impose policy constraints.

At the same time, changes and improvements are feasible in the area of "harm reduction", notably around syringe trade-in projects and methadone treatment.