ACCEPTANCE OR ABSTINENCE
HIV and AIDS have caused many countries to re-evaluate their drug information policies. Ralf Gerlach and Wolfgang Schneider offer a commentary on the problematic relationship between the German abstinence, harm reduction and methadone treatment programmes
It is hardly surprising that, compared with international standards, the Federal Republic of Germany holds an exceptional position in the area of policy on aid to drug users. For decades, the majority of so-called 'drug experts' have deliberately ignored the findings of international research and have, often despite their better knowledge, pursued a policy of misinformation which allowed no assimilation to international standards of drug work. This policy is essentially characterised by a rigid adherence to the abstinence paradigm.
THE GERMAN ABSTINENCE PARADIGM
In many Western countries, pluralistically oriented policies on aid to drug addicts are followed in practice. In contrast, during the last 20 years Germany has instituted a drug aid system that is inflexible, rigidly and bureaucratically organised, and undimensional in its abstinence orientation. It is important to stress that, up to the present, no fundamental changes to this system have emerged, despite clear evidence of its inefficiency (Scheerer and Vogt, 1989).
The therapeutic ideal of permanent abstinence for all opiate users has been considered the only valid premise for providing practical survival support and the only valid criterion of success of drug work. Being primarily personality - centred, German drug addiction research has favoured a linear model of addic- I tion. There is thus a uniform and undifferentiated pic-, ture of drug dependence: the dead-end street of heroin automatically leads to dependence, criminality, pover-' ty, and eventually to prison or death. Regarded as deficient personalities, drug users have been subjected to a process of de-individualisation and degraded to helpless victims and objects by being denied any individual responsibility and any right of self-determination.
Long-term therapies, on an inpatient basis, aiming mainly at reconstructing these allegedly deficient personalities, have been proclaimed as the 'Royal Road to Recovery'. If at all possible, cessation from drug involvement is considered to be attainable only' through such treatment.
Practical support to for those drug users whoaFe 1101: motivated to survive needs to address aspects of deteriorations in the physical, psychological and financial state of addicts. This abstinence paradigm has been cemented legislatively by amendments to the Opium Act 1971 and 1982, and cemented practically by establishing the socalled 'coordinated system of drug assistance' (counsell ing/in- patient therapy/after-care) (Kemmesies, 1989).
The consequences of these developments are a sad testimony for the people concerned: 7274 drug deaths between 1970 and 1989, whereas in 1990, no less than, 1480 drug users died. Another result of these developments is that the principle of the voluntary nature of treatment has constantly been undermined by law courts assigning increasing numbers of conditional clients to inpatient treatment centres, in accordance with the 'therapy sections' of the German Opium Act, which were introduced in 1982 tinder the motto'therapy instead of punishment'. As most abstinence therapies are rigidly structured, they could not exist without the 'therapy sectionsy and the growing number of conditional clients.
However, it is generally known that these therapy facilities are often not use(-] to capacity and that involuntary clients already represent up to 80% of all clients, ,,a major percentage of whom do not complete therapy. It should he emphasised that only 20% of drug users who complete therapy continue to live a drug-free life (Hellebrand, 1988). Moreover, it should be pointed out that a large number of drug users consider inpatient treatment to he a worse punishment than prison. Thus, it is not surprising that the number of users in prison has risen rapidly: at the beginning of 1990, more than 5000 drug users were in prison. This figure represents about 5-10 per cent of the estimated total number of drug users in Germany.
CURRENT STATE OF DRUG RESEARCH
Research studies have shown that drug use is a phenomenon with a variety of origin and pattern of use. It has been shown that different patterns of use exist, including variants that are autonomously controlled, ule-oriented, and 'risk-,,iware' (Zinberg, 1984), as well as ,a great variety of cessation attempts which are selfinitiated and maintained without professional assisance (Waldorf, 1983; Biernacki, 1986). These research studies have seldom been reviewed in Germany. Moreover, controlled use as a self- initiated and relatively stable user pattern is not considered to be possible by the majority of 'experts'.
The results of these and other studies have clearly demonstrated that cessation from exclusively drug-associated lifestyles, as well as a transition to controlled use patterns, can often only be achieved after a long-standng period of ups and downs. It is interesting to note that even Alksne et al. (1976) point out that a relapse into drug use should not automatically be equated with a relapse into a status of compulsive drug use. A relapse mayalso achieve a positive effect through initiation of a self-associated cessation of excessive drug use.
Autonomous cessation from a state of physical dependence has to be considered as a dynamic process taking tipa great deal of time, initiated under a variety of differinil conditions (Balkwell, 1983). Consequently, this does not occur 'spontaneously' or 'on one's own'. For this reason, we prefer to characterise this process as an 'autonomously initiated ( ... ) privately organised', and environmentally supported 'process of cessation from the status of compulsive drug use' (Schneider, at al. 1990) instead of speaking of 'spontaneous remission' (Stall et al., 1986) or'natural recovery' (Waldorf, 1983). Thus, we do not exclude autonomously controlled, ruleoriented and risk-aware user patterns.
Apart from the dynamics of development in user behaviour, drug users have to be differentiated by both individual and social criteria. In this respect, there are biographical (age, sex, social background, education, vocation) as well as a multitude of other criteria (including duration of compulsive drug use, extent of integration within the drug scene, mode and intensity of drug-free relationships, length of phases of non-drug and controlled drug use, stability of social support systems, and coping strategies).
Drug users live in different lifestyle contexts in which the use of drugs may be a consequence of selfdirected, subcultural lifestyles, i.e. drug users generally have to be considered as being subject to their own development (Dembo et al., 1986). The research findings outlined above suggest the following:
1. The linear model of addiction so far favoured by German drug experts is no longer valid.
2. There is no single cause for initiating drug use, and no single type of drug user or criterion for diagnosis and prognosis.
3. We should accept that there are people in our society who want to use, or who cannot stop using, illegal drugs.
4. The use of drugs is neither a disease in itself nor the expression of one. So, not every consumer needs treatment in principle.
5. There is no 'Royal Road to Recovery' concerning the treatment of drug users. Therefore, one-sided interpretations and solutions may be little help for a given individual.
6. A one-dimensional drug assistance system ignores the heterogeneity of patterns of drug use and there-' fore does not allow for the needs of most drug users.
NECESSARY PRACTICAL CONSEQUENCES: ACCEPTANCE AND ABSTINENCE?
Experience world wide indicates that drug users voluntarily make use of counselling, health care and treatment services, provided that these services are available and acceptable (Senay, 1988). Because it ignores the principle of voluntariness and free choice of treatment services, as well as the rejection of the notion of drug users as self-responsible and motivated actors, the German drug aid system has only reached a few users who seek support on a voluntary basis. It is dependent to a large extent on the police and legal authorities as suppliers of clients. As a result of the predominant ideal of a drug-free life for all users, more and more users slide into poverty, social disintegration and criminality.
The narrow range and lack of attractiveness of abstinence-oriented services, together with the emergence of AIDS, increasing addict criminality and an increasing mortality rate among drug users, have produced demands for alternative concepts of drug aid work. Meanwhile there is a broad consensus among experts on the necessity of orienting Jrug work to harm-reduction concepts. However, there is little agreement about the means and objectives of this approach, and we can identify two conflicting groups.
Supporters of traditional drug work
This group includes those who feel bound to the abstinence paradigm and consider harm- red uct i on- oriented provisions as a preliminary phase of abstinence - oriented, long-term, inpatient therapies. At first, drug use is accepted so that a relationship of trust can be 'Wstablished between drug users and drug workers; the primary objective here is the facilitation of the user's entry into the standard treatment by increasing its reach and attractiveness. Not surprisingly, this group objects to treatment with substitutes such as methadone or dihydrocodeine. In reality, this approach is nothing more than a concealed expression of the drug-free principle.
Supporters of accepting drug work
This approach is based on die recognition of the criminalisation of drug use, rather than either the drug itself or an addictive personality, as the core of today's drug problem. Contrary to the approach sanctioned by the Opium Act, 'accepting' drug work is oriented towards realistic objectives rather than cherished illusions.
Consequently, the main goal of 'accepting' drug work is not abstinence from drugs - this is only one possible goal - but the reduction of risks associated with drug use. Acceptance implies the following:
The re-individualisation of users and addicts as individuals who are responsible for determining and organising their own lives.
The recognition of drug use as a possible lifestyle.
The granting of human rights and humane living conditions.
Tolerance of illegal drug use.
Furthermore, 'accepting' drug work may be characterised as being subi ect- related, env ironment- oriented (neighbourhood -specific), non-directive, oriented to addict's needs and undemanding.
The leading maxim for this approach is the principlc of absolute voluntariness. As a result of the heterogeneity in individual histories of drug use, this approach mainly involves attendance by and provision of access for drug users through their individual phases of development, without either stipulating preconditions or insisting on changes of behaviour. The resultant health and social stabilisations may themselves foster changes in behaviour, e.g. reduction in use or transition to safe user practices. The approach requires diversified, differentiated and developmentally oriented support services. These might include:
open contactand drop-in centres
access to medical consultation
assistance with finding jobs
access to sterile syringes and needles
provision of free outpatient or inpatient withdrawal services
24-hour phone counselling service
Acceptance-oriented drug work does not aim to displace drug-free intervention strategies but pleads for a diversification of the range of facilities available to drug users. Another essential element within the overall concept of accepting drug work is the methadone programme. Despite the fact that the Federal Republic of Germany has only minimal experience with methadone and despite the initial success of the Northrhine-Westfalian methadone pilot project, a large number of German drug experts are still antagonistic towards substitution treatment with methadone. Thus, there are no methadone programmes, only model projects with limited numbers of clients and fairly rigid terms of admission.
Moreover, the arguments used by the opponents of methadone are seldom based on scientific argument, and often consist of little more than half-truths, e.g. ignoring the fact that there is more than one type of methadone programme (depending upon differing organisations, objectives or client groups), or distortion of scientific data. Such misinformation contributes to upholding an already high level of fear regarding drugs.
In fact, an examination of the scientific literature on methadone programmes shows that the results of such programmes are generally positive (Senary, 1985; Hubbard et al., 1989). The documented benefits of methadone include improvements in health, reduction of criminal activities, illegal drug use and HIV risk-takng behaviours, and a dissociation from the drug scene.
In summary, a drug-free life for all drug users must be recognised as nothing more than an abstract ideal. The present situation calls for a pluralisation and diversificaion of care provisions for drug users based on the notion of acceptance instead of abstinence.
Ralf Gerlach and Wolfgang Schneider
Institute of Sociology and Social Pedagogics, University of Munster, Scharnhorstrasse 1221, 4400 Munster, Germany
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