Report on Visit to Drug Programs in
Amsterdam, Netherlands and Frankfurt, Germany

by Councillor Jennifer Clarke

September 2000

CONTEXT

In July of 2000 I visited the cities of Amsterdam and Frankfurt to see their programs for drug addicts in operation and to talk to drug helping professionals, police and city council representatives to learn their perceptions of these programs. I discovered that the approaches in the two cities are different from each other although there are some common components and that their programs and laws have changed over the years to respond to changing perceptions about how they are working.

To understand the context for what these two cities have been able to do it's important to know they each have the legal jurisdiction and budget for what we in Vancouver would see as a combination of provincial and city functions. Amsterdam has an annual budget of NLG 7.5 Billion (Cdn $ 4.3 Billion which is 7 times the city of Vancouver budget) for its population of 727,000. From its council of 45 elected members 8 aldermen are chosen to form the college of aldermen chaired by a mayor appointed by the monarch. The college is responsible for the day to day business of the city with each alderman having a portfolio of responsibilities akin to a provincial minister's. The mayor is responsible for the police and public order. The alderman responsible for health has the power together with the mayor to act in the area of drug policy for example to put in a safe injection site over neighbourhood objection. The city spends about NLG 10 million (Cdn.$ 5.75 million) directly on its drug programs annually. Other components are financed through the other departments.

Frankfurt has an annual operating budget of DM 4.8 Billion (equivalent of Cdn.$3.1 Billion which is 5 times the city of Vancouver's budget) for its population of 650,000 people. Annually the city spends about DM 10 million (Cdn $ 6.5 million) on their drug programs which is supplemented by a DM 5.5 million (Cdn$ 3.6 million )contribution from the surrounding state of Hessen. This does not include the cost of methadone, detox and treatment paid for from state health insurance. Taxes are derived 50/50 from a business tax and a city income tax. The 9 councillors chosen from the Frankfurt parliament of 93 members each functions as a minister of the crown over such areas as transportation, energy, social welfare, housing and health. Together with the mayor they form a council of 10 which has the legal, financial and organizational capacity to make decisions and create programs which are not currently within the city of Vancouver's power to do alone.

In Amsterdam I met with Dr. Gerrit van Santen, Chief Physician of the City of Amsterdam's Department of Mental Health who oversees the city's medical approach to drug addicts; Mr. Theo Sluijs who oversees the city's outreach and comprehensive care program for addicts; and Police Commissioner Jules Somers who is responsible for law enforcement activities inAmsterdam related to illegal drugs and addicts. I also visited the city's scientific heroin trial unit and clinics where addicts are treated.

In Frankfurt I met with Mr. Gerd Furst, deputy director of Frankfurt's drug policy office; Mr. Nicolas Burggraf, Frankfurt's Councillor for Health under whose jurisdiction the drug programs fall; Deputy Chief of Police Michael Hallstein who is responsible for drug related law enforcement activities and the staff at several of Frankfurt's drug crisis centers and safe injection rooms.

AMSTERDAM

Amsterdam's approach to drug addiction is that it is a mental health problem best addressed through harm reduction measures that stabilize the addict medically and socially and substitute a legal drug such as methadone for an illegal drug such as heroin. The mental health branch of Amsterdam's public health department has developed an integrated system of response to addiction which coordinates the actions of health clinics, hospitals, the police, social housing and social service to what until recently has been primarily a heroin oriented population of addicts.

Only recently has cocaine become a factor. There are 5000 - 6000 known addicts living in Amsterdam. While the health professionals articulated the point of view that all human beings whether legally or illegally in the country have a right to public health access without discrimination, the city has taken steps to be accountable to the neighbourhoods with regard to addict behaviour and most recently the Dutch Parliament has passed tough new laws for mandatory treatment for the addict repeat criminal offenders. The views expressed as to how the program is working were different between the helping professionals and the police. These issues are still controversial in the neighbourhoods according to all with whom I spoke.

Amsterdam's open drug scene, according to Theo Sluijs, started in 1975 after the former Dutch colony of Surinam achieved its independence. Holland was flooded by Surinamese colonials who were disillusioned with their new home and turned to drugs. Many had relationships with prostitutes.* Consequently problems related to drug addiction grew with the spread of HIV and other sexually transmitted diseases. The first service was a methadone bus begun in 1979. In the 1980's the open drug scene (centered around the Dam Square and the Nieumarkt area of downtown) spun out of control. The mayor and police declared the area a state of emergency giving police the power to arrest anyone who displayed nuisance or disorderly behaviour in that area which still exists today (see section on legal sanctions). At the same time the city began developing its integrated approach to drug addiction and the police began referring patients.

PROGRAMS

Dr. Gerritt van Santen, chief physician for the mental health branch of the city's health department, says his department's specialty is "offering care for care avoiding people." He believes that it is essential to understand addiction as a "mental disorder characterized by aninability to put intention into action. This is a consensus you need before you can develop any policy." He said in the 1980's the city first tried to refer addicts to traditional psychiatrists who did not want to get involved. Eventually the city gave up on this approach and set up its own system of shared care with the local general practitioners (physicians) who see the more stable addicts while the public system of integrated care sees the more difficult clients that can't be handled by the G.P.s. Only classic dual diagnosis patients are referred to psychiatrists (i.e. schizophrenia and drug addiction). A high proportion of addicts are mental patients or have multiple illness.

Today, three units of the city's mental health department deal with various aspects of the addict's behaviour and care. The Ambulant Medical Team under the direction of Theo Sluijs does outreach, acts as an intermediary between drug users and hospitals, runs boarding houses and shelter beds for homeless addicts, and provides medical service and methadone in the jails for addicts at the daily request of the police. It also runs projects to provide care for addicts illegally in the country and to respond to addicts who create a noise or disturbance on the streets. The Care Coordination Unit deals with hard to handle addicts who cause problems in the community such as those who are mentally ill, refuse treatment or have multiple medical problems. This unit is "responsible to neighbours not just the patient," according to Theo Sluijs. When neighbours call the police, for example, this unit's responsibility is to coordinate with the police and treatment providers to develop a program to deal with the individual's problem within three months. The third unit includes the five outpatient clinics, needle exchange program, seven safe consumption rooms and the scientific medical heroin trial program.

TREATMENT

The approach to treatment is one primarily of low threshold substitution rather than abstinence-oriented programs. Van Santen said, "effective treatment is not detox and inpatient treatment but is long-term pharmacotherapy ... [to] reduce criminal behaviour, public nuisance and disorder." Methadone is the first choice for substitution and is available on demand. He said it shows good results for heroin users with a rate of 60% remission after one year. This statistic means that users are not cut off methadone if they test positive for continuing use of heroin or cocaine. The goal is to find a sufficient dose over a length of time that will reduce at first and ultimately eliminate the need for illegal narcotic use. The health department believes this approach reduces the harm to the community as the need to steal to finance the drug habit is reduced and reduces the harm to the addict from the threat of disease and overdose associated with illegal narcotic use. About 2700 addicts are annually treated with pharmacotherapy by the department. Most receive methadone while others, particularly cocaine addicts receive another substitution drug such as benzodiazepine, librium , valium or ritalin for cocaine use.

He said there are 14 detox beds in the city with a maximum stay of five days used primarily to stabilize addicts. There are very few beds for inpatient abstinence oriented treatment. He said it is a very expensive approach that can handle very few people at a time. Their experience isonly 5% are clean and sober two years after discharge. Many of their addict population have been repeatedly through this type of treatment without success. For the younger addict who has been using for under one year he believes it can work with an intense, highly individualized program but for the older or long-term addict he believes drug use is part of a lifestyle that must be changed before abstinence based treatment will work. He said substitution deals with the craving for the drug but then you still have to deal with "the patient's lifestyle and retarded development" and social de-integration. It is the lifestyle that the coordinated response seeks to build up so that through the combination of substitution and support the patient is less harm to himself and the surrounding community in terms of his public behaviour and criminal activity.(Further details and statistics on Amsterdam's approach in Attachment 1)

Van Santen said most of the addicts seen in Amsterdam are heroin users with most cocaine users also using heroin so the treatment approach focuses on heroin addiction. He said many of their heroin users began as cocaine addicts and he is not sure that cocaine use is really a separate type of serious addiction. He said the average age of the city's addicts is 40 years old and that they are not attracting new young addicts into the scene because of their highly medicalized approach and the image promoted through their education and prevention school programs that drugs are for losers. There is much greater concern about the alarming rise in alcohol use by young people. Sluijs contradicted this somewhat by saying he is alarmed at the skyrocketing trend to crack cocaine which their present treatment methods aren't set up to deal with.

There have been problems in making the integrated approach of medical - social support coupled with policing and judicial sanctions work said Sluijs, particularly for the 400 to 600 hardest to handle addicts. He said just this year an agreement was made between justice, the aldermen, the police and helping organizations to work better together to avoid territoriality, duplication and the gaps of the past. In January 2000 the city began a project for the most intractable 400 - 600 addicts whose goal is not treatment or abstinence but support in five basic areas to prevent this group from public nuisance and criminality. The five areas are access to shelter, social welfare income, health insurance and care, safe consumption room and structured daytime activities to keep them off the street. The way it works is that when the police identify a candidate they fax the information to the care coordination unit of the mental health branch. The unit in turn assigns a "mentor" for the addict either from the public or private health system or from one of the social service or religious organizations that work with addicts. The mentor does up an individual plan for the client. The plan is put into a database to which all the cooperating agencies have access so that if the plan isn't followed appropriate action can be taken to try to get the client back on track. The police in turn have immediate access to the health system through this arrangement to support them in their job of maintaining public order.

LEGAL SANCTIONS

The Netherlands distinguishes between soft drugs like cannabis which are not illegal and are sold in coffee shops and hard drugs like heroin and cocaine which are not illegal to consume butare illegal to possess or consume publicly. In Amsterdam, if you are caught publicly consuming by the police, you are immediately issued an eight hour "no go" order for the area, usually the downtown where the addict has bought and wants to quickly consume. If that is violated the addict gets a 14 day "no go" for the area and if that is violated the penalty is three months in jail. Sluijs said 80% of addicts have experience with the judicial system but most eventually comply. The new project for intractable addicts allows this information to be entered on the client's file and the mentor to take the appropriate steps to help the client become compliant.

For some years judges have been allowed to offer addicts convicted of crimes related to their addiction drug treatment instead of jail. Many choose jail. Police Commissioner Jules Somers said that although the drug helping system and the harm reduction approach has succeeded for many addicts there is still an intractable group who cause the most trouble. He said, "The harm reduction policy is working for the addict but not working to solve crime. The health condition of these people is good but they still commit crime... . For a certain group the methadone and health approach doesn't work. For those that it does work, that's O.K. for me."

He said that a recent survey of crime in Amsterdam showed that 36,000 people committed 267,000 crimes over the past three years but 1200 of those people were responsible for 42,000 crimes in the inner city where the drug addicts are concentrated. In other words, less than two tenths of one percent (.15%) of the city population is responsible for 16% of all crime. He said because of the problems associated with this group of intractable addicts the Dutch Parliament recently passed a law to be proclaimed this fall called "SOV" (Skufrechterlijhe Ofrang Verslaufden) which means "Penal Addiction Treatment Centre". It will force addicts who have been convicted of five or more offences in a year related to their addiction and who refuse voluntary drug treatment to go to a special prison for mandatory abstinence oriented drug treatment for two years. Somers said SOV will apply to about 5% of addicts. The police, he said, wanted it to apply to a bigger group but that it was contrary to the Dutch harm reduction policy so the criteria of five convictions and refusal of treatment was established. He said, "The way to this decision has taken a long time." He said despite their problems he does not believe their policies have increased the number of addicts or attracted them from elsewhere.

Somers said the police concentrate their efforts on the drug dealers and there are strict penalties for dealing with sentences ranging from several months to several years in jail. Addicts found in possession of more than a small amount also get convictions and sentences, he said.

Commissioner Somers described a pilot treatment project for addicted women prostitutes who commit the most crimes called "the top ten women project." It identifies the worst repeat offenders and, during sentencing, offers them a choice of jail or treatment in a drug clinic where they will get rehabilitation and training in regular work. They will evaluate the success of the project after six months, he said

SAFE CONSUMPTION ROOMS

There are 7 safe consumption rooms in Amsterdam with another 7 planned. The existing rooms see approximately 30% injectors and 70% non-injectors who smoke/sniff heroin or cocaine. Their purpose is to prevent open consumption and overdose and other medical problems amongst the addicts. The first 2 or 3 were established in conjunction with the boarding houses which provided shelter beds to the addicts downtown near the center of the drug scene. As most of the drug dealing is downtown the three safe consumption rooms downtown are used frequently, the four in the neighbourhoods are not, according to Sluijs. He also said that this issue is controversial because neighbourhoods find it difficult to accept these facilities so 7 more are planned to disperse their impact even though the authorities feel they are unlikely to be used as they're too far from the downtown where addicts buy drugs. He said addicts don't like to move very far between the buy and consumption. Neighbours object to the rooms being located near them so council recently passed an ordinance allowing the mayor and the alderman for health the power to override local objection on the placement of consumption rooms.

He said several decades ago they tried different ways of using a house dealer associated with these rooms but stopped because it caused all kinds of problems (increased crime, fights and lack of control). He said dealers do not congregate at the consumption rooms because the police and staff won't permit it but that they're not far away. Police Commissioner Somers confirmed this saying that although dealers aren't allowed inside it's very difficult to prevent them congregating nearby.

Van Santen said you have to offer the neighbourhood something if you want to open up a drug facility. The police first measure the base nuisance level before opening and measure it thereafter monthly reporting their findings to the neighbourhood council. He said the city also offers the neighbourhood increased services such as more street cleaning, police surveillance and better lighting to cope with the possible problems. Addicts sign agreements agreeing not to loiter or hang around the facilities and not to litter.

Amsterdam is one of several Dutch cities with safe consumption rooms. In others such as the Hague they are controversial and not permitted.

HEROIN TRIAL

Amsterdam is in year two of a four year medical heroin trial looking at whether prescription heroin might be a useful medication for addicts who repeatedly fail on methadone. The federal government sponsored study has 120 addicts divided into three groups of forty who each get a different regime of drug and all of whom agree to certain conditions like regular drug testing, HIV testing, access to their police, housing and jobs records to see if one group does better than the other in terms of health, social stability and criminal or nuisance behaviour. Criteria for participation is that they were poor performers on methadone. One group gets heroin from the start of the trial, the next must wait to get heroin for six months while the third group must wait twelve months before getting heroin, each of the latter groups receiving methadone in the meantime. Heroin receiving patients come to the heroin trial unit three times daily Mondayto Friday to inject or smoke heroin (most smoke) and are given methadone for the weekends. Methadone receiving patients are dispensed methadone three times a week at the unit and given methadone to take home in between. Dr. van Santen says the Swiss heroin trial was done without control groups and participation in data collection was voluntary so the information from it is inconclusive in determining whether some methadone intractable patients would do better on heroin.

Establishing the unit, Van Santen said, was highly controversial as the people who lived and worked on this mixed use street, as well as the parents of the school, there were very opposed. There was a huge public meeting attended by the aldermen. The city committed to control the behaviour of the addicts as they came to and from the unit and told the addicts they'd be cut off the list of those to receive heroin if they misbehaved or loitered in the area. The addicts were recruited to sweep the street several times weekly, remove graffiti and litter and have behaved very well. In turn the street has "adopted" the addicts and considers the heroin program "theirs" according to the program coordinators. I visited the unit, observed there was no congregating of addicts before the hour for their heroin dose, and that addicts were orderly when they came, consumed their drug on site in a supervised setting and then departed.

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* Note: There are currently 8,000 to 10,000 registered prostitutes who work in city sanctioned bordellos in the red light district. A branch of the city health department is responsible for licencing and checking the bordellos to ensure the women are over aged 18 and checked for STDs. Van Santen said some cocaine using prostitutes are stable and healthy working in this scene. Those that become addicted to heroin usually become unable to work in the bordellos and are forced onto the street. A separate unit of the health department which I visited does outreach and care for 160 of these heroin addicted street prostitutes.

FRANKFURT

The approach taken to drug addicts in Frankfurt is called "help and suppression". It incorporates a number of harm reduction components borrowed from Amsterdam. Beginning in 1992 the city created five drug "crisis" centers where addicts can get a meal, use showers and washrooms, and get a shelter bed. Each center has social workers and public health professionals who provide addicts with basic medical care and advice, counseling and referral to either methadone maintenance or detox and treatment. Between 1994 and 1996 safe injection rooms were added to the centers. This was coupled with a policing strategy that did not tolerate open consumption and moved the addicts to the centers to either inject indoors or get treatment. There is a drug court component to the judicial-legal system.

Like a number of other cities in Europe by the late 1980's Frankfurt had developed a large, open, primarily injection drug scene that the city was unable to tolerate or cope with. Two-thirds of the addicts were not residents of Frankfurt but daily came from all over Germany to buy drugs and shoot up. During the civic elections of 1989 the Green Party, which subsequently came to power in a coalition government, called for a drug strategy based on a harm reductionapproach. Margareta Nimsche became the councillor for health and spearheaded the creation of the drug help system but it was not until 1992 that significant action was taken. At that time the new European Central Bank was looking at Frankfurt as one of three cities in which to locate but only if Frankfurt could get rid of the open drug scene which was right next to the banking district. The bank and the business community pledged money to help, money they continue to contribute up to this day. The city seconded Dr. Gerrit van Santen from Amsterdam for a year to set up its first methadone program.

The mayor established a date, dubbed "doomsday," for the shutdown of the open drug scene and notified the surrounding municipalities that their addicts were going to be sent home as of that date. Four months prior to doomsday the first crisis center, Eastend, was set up in an old gasworks building in an industrial district 15 minutes from the train station area's Taunusalge Park where the drug scene was concentrated. It included a methadone clinic. The date for "doomsday" was widely publicized in advance and when it arrived the police went into the area. Anyone who could not prove they had lived in Frankfurt for the previous 12 months was taken to the train station to return home. Addicts still openly consuming were taken by police in vans to Eastend for help. Later, other crisis centers were opened in the vicinity of the train station area because the first one was too far away. Deputy director for drug policy Mr. Gerd Furst says the police cooperation was key and it was they who suggested alternatives be established before they would agree to go in to clear out Taunusalge Park.

Between 1992 when this program started and 1999, open drug injection dropped from 1500 people a day to fewer than 50, the number of addicts dropped from 10,000 to between 3,000 and 6,000 (police estimate is lower than health professionals'), the number of dealers known to the police dropped from 5,000 to 1,400, crime typically committed by addicts dropped by at least 50%, and the number of non-resident addicts dropped from 65% to 20%. Addicts are no longer flooding in from other communities to buy and consume drugs in Frankfurt. Because of these results the current councillor for Health, Mr. Nicolaus Burggraf, says the program "has broad public support" although components of it like the safe injection rooms are not very popular.

The reduction in the number of addicts and resulting crime rates is the result of two things, according to Furst: the widespread availability of low threshold methadone (which is a higher threshold than Amsterdam's) and the policing strategy that moves addicts consuming publicly indoors and targets those coming from outside Frankfurt, particularly dealers. He does not feel they attract more addicts because of their programs. The current worry is that the drug scene is shifting from primarily heroin use to 50% cocaine use for which they don't have as effective a strategy.

TREATMENT

Treatment focuses on substitution of primarily methadone for heroin although they have found methadone useful in stabilizing some cocaine users as well. As mentioned above, Amsterdam's Dr. van Santen was recruited in 1991 to set up a methadone program as German doctors wereunwilling to do so because of the stigma attached to methadone use for other than life threatening situations. 1000 slots of low threshold methadone were opened up for addicts who could prove they'd been residents of Frankfurt for 12 months or longer.

Methadone is administered by doctors paid through health insurance so it is not available to Frankfurt non-residents including illegal immigrants. This is a growing problem as they form the highest proportion (65%)of those now using the safe injection rooms. Councillor Burggraf said, "When we widened our program we agreed only to open methadone and other treatment to residents of Frankfurt and on the other hand to force other communities to take responsibility for their own addicts. They have responded differently. Some well, some not."

Although addicts are not supposed to use illegal drugs while taking methadone there is some tolerance until they are stabilized with the right dosage and other support. Even if the addict continues to use occasionally the fact that most of his craving is supplied by methadone means there is less harm to him and the community from which he no longer needs to steal as often. Methadone has been used with some success to help stabilize cocaine users although there is no specific treatment for them. They can take part in the therapy available for heroin users and there is a special inpatient therapy unit in Berlin, a pilot project of the federal government, which seems "quite effective" said Furst. The fact that 50% of the addicts seen by the crisis centers are using cocaine makes the drug scene in Frankfurt right now very rough and makes the lack of effective treatment a very serious problem according to all of the staff members with whom I spoke.

In-patient abstinence-oriented treatment is primarily focused towards youth and very new addicts. For adults the success of abstinence oriented treatment, defined as completing a one and one half to two year program, is about 25% according to Furst but there is no long term follow up to see how well they do following discharge. The adult treatment model offers a ratio of one therapist/counsellor to 20 plus patients. For youth under 21 years the success rate is 70%, he said, offering an intense one to one ratio of therapist to addict on an inpatient basis for those under 18 years and subject to availability for those up to 21 years.

A person found by the authorities to be using cocaine or heroin before his or her 16^th birthday is placed by a judge in a mandatory one to one program above. Between the ages of 16 and 18 years the mandatory treatment is at the discretion of a judge, and over 18 it must be voluntary but the one-to-one model can be requested if available up to 21 years. Furst said this is expensive but shows such a good rate of success that treatment money is focussed here. For longer term older addicts the focus is on substitution and social support. Annually there are about 100 users under 18 years, 90% female victims of sexual abuse, and 150-200 between the ages of 18 and 25 years, the majority of addicts being 25-40 years old. The average age of addicts is 30.8 years and rising, he said, as fewer young people are attracted to the drug scene.

Residential detox and treatment are offered by the state government of Hessen and paid for through the individual's state health insurance which means it is not available to illegal immigrants (unlike Amsterdam). There are 610 residential treatment beds and 150 detox bedsin the state of Hessen of which 50 are in Frankfurt. The philosophy of treatment is that the treatment beds should be outside Frankfurt far away from the drug scene which could pull the patient back into the lifestyle. After 6 months of inpatient treatment, the addict moves on to counselling and drug free housing and one of the state's job training programs open to anyone. There is also a school for methadone and post treatment patients to complete their primary and secondary schooling.

Although there is no move towards compulsory treatment as in the Netherlands with SOV there is a form of drug court. Judges can give addicts convicted of crimes with sentences of less than two years the choice of jail or drug treatment. Furst said that although the success rate for residential treatment is generally low it is better with this form of mandatory treatment. In long term follow up, he said these court sentenced treatment outcomes are better but they don't know why.

DEVELOPMENT OF THE CRISIS CENTERS

The five crisis centers mentioned above were established beginning in 1992. I visited two, Eastend which was the first one established in an industrial area and La Strada established later closer to the center of the downtown drug scene so more addicts would use it. La Strada sees about 200 addicts a day. It has a small contact cafÈ open 8:30 to 19:30h Monday to Friday where addicts can get a cup of coffee or smoke a cigarette and talk to a social worker and, three days a week, get a meal for about Cdn $1.00. Addicts can also use the shower and toilets and the clothes exchange on the first floor. There are 6 day beds for sick addicts. Counseling is available until midnight. Upstairs there are 22 sleeping rooms available for homeless addicts on an `in by 8 p.m out by 11:00 a.m.' basis for up to four weeks. (After four weeks the addict can move to another crisis center's sleeping rooms on the same basis) Staff at La Strada said there were enough beds for the demand. There is phone service to the hospital for overdoses and referrals to detox , treatment and other medical help from La Strada staff. The centre is staffed by 40 people around the clock: days, 1 site supervisor ( team leader), 1 housekeeper, 9 social workers and 20 social work students and, nights, 10 students. It also has a safe injection room. (See below) The cost of running La Strada is DM 2 million (Cdn $1.3 million per year).

A pilot program called the "Crack Project" operates out of La Strada. It does outreach to crack users in the down town core with a team of three composed of a youth social worker, an adult social worker and a physician who go out three times weekly. Their goal is to make contact with crack users, help them take care of basic needs such as food and shelter, court and medical appointments and to integrate them into the drug help or youth help system. They have used methadone to try to stabilize users by having them come in once daily for methadone, food and medical care and thus to establish a diurnal rhythm in those who have lost feeling for time. Gradually they introduce detox and treatment. The program has been more effective than anyone thought. In the two years since it began they've introduced 200 of the estimated 400 crack users to methadone and about 60 crack users to detox and treatment of whom only 2 are back on the street.

Eastend is a much larger facility that incorporates the same components as La Strada but also includes a methadone and medical clinic open at 5 p.m. daily, a long term shelter for addicts who are stable enough to graduate from the overnight beds to a room for six months and a series of workshops in which to train and accustom recovering addicts to the world of work. It sees about 120 methadone patients and 100 cafÈ patrons daily , has 71 shelter beds, and about 60 addicts in its work programs which include a garden, a laundry, a woodworking shop and a print shop.The addicts who work can do so for up to 60 hours a month for about Cdn $ 5.00/hour before graduating to a regular one year state job training program. Eastend operates with 20-30 staff and about 50 students.

SAFE INJECTION ROOMS

According to Furst and the team leaders at both La Strada and Eastend, the crisis centers opened without safe injection rooms but addicts were found in the shower and in the toilets etc. shooting up. This was felt to be a health risk for staff at the crisis centers so Frankfurt pressed for the legal ability to have injections supervised in one room, in house, primarily in order to protect staff health. In 1994 the attorney general of the state of Hessen issued a legal opinion that such a room would not be incompatible with German drug laws against illegal narcotics. The first such room was opened at Eastend in December 1994 but few addicts used it as it was so far from where the drugs are sold. There was no neighbourhood controversy as it was located in a decaying industrial district.

When Frankfurt decided to open the second injection room, "Druckraum", at the center of the area where drugs are sold there was huge controversy. The poor residents of the red light district in which it was to be located were opposed as was the influential business community in the immediately adjacent banking district. There was a heated public meeting attended by up to 400 people according to Josch Steinmetz, team leader of the Druckraum, including council members, police, the drug policy office, business and community representatives. Citizens were frightened this would make the situation on the street worse. The city committed that the police would ensure addicts could not shoot up publicly but would have to come indoors to inject and that they would try it for six weeks. If the situation worsened the city committed to shut the room down. Six weeks later the city held a second public meeting but only five people attended said Steinmetz because the situation on the street had improved. There are now 6 injection rooms, most located in the crisis centers. The business community has private security to help mitigate the situation on the street, said Furst, and contributes money towards specific projects of the drug help program.

Druckraum is a stand alone injection room and the largest facility of its kind in Germany. It is a glassed-in, tiled room with 12 places for injecting (no smoking or sniffing is allowed in these rooms) at a stainless steel counter. Addicts are supplied with a stainless steel kidney basin with everything necessary to inject but the drug which they supply themselves. The room and its clients are supervised by two staff at all times. Druckraum sees about 200 people and 400 injections a day, 600 different people a week, some in suit and tie with briefcase. It has low threshold medical care twice weekly and methadone counselling once weekly but refers clientsto other crisis centers such as La Strada three blocks away for follow up. It attracts clients living or working within a one half kilometer radius.

Steinmetz and Furst said dealers are kept from the door by police and staff but remain in the area because the addicts, their clients, are there. Steinmetz said that the district had been a rundown area for drugs and crime for the previous 50 years and the center of the drug scene for 25 years. He said there were legal bordellos and freelancing prostitutes in the houses and apartments of the surrounding district. He said the crisis centers are located here because the addicts are and have been for a long time. He did not believe addicts would walk even three or four blocks from where they buy to where they would consume. He believes the dealers will move closer to the consumption facility and therefore this would move the focus of the drug scene. His opinion was that addicts and the dealers associated with them will move to where a crisis center or consumption facility is located and that even with extraordinary police pressure dealers will remain in the vicinity. Furst and Police Deputy Chief of Special Forces Michael Hallstein said, however, that separating the addicts and dealers had allowed the police to focus on the dealers with the result that the number has dropped 75% in the last 8 years.

Everyone with whom I spoke said they felt the safe injection rooms while unpopular have contributed to the break up of the open drug scene, drug litter and helped to bring addicts into contact with medical help and treatment. They did not believe the rooms cut down on the criminal behaviour of the addicts because they still have to get their drugs (they believe methadone has reduced the demand for the drugs and therefore criminal behaviour such as stealing) but they believe in combination with the crisis centers they have reduced the public nuisance, disorder and detritus of the open drug scene by forcing it indoors. Deputy chief Hallstein said police insist addicts use the rooms. If one is full the user is referred to another one. Councillor Burggraf said, "The general perception is that addicts are sick people so we need to be humanitarian but the open scene affects businesses and shops. If you can get them [addicts] off the street it helps because addicts prevent clients from coming to the shop."

In total 800-900 addicts inject in Frankfurt's 5 safe injection rooms daily. Furst said several small rooms are better than one big one. There has never been an overdose death in the rooms although there are 5-6 incidents daily. These are handled with ambulance and hospital for backup. 50% of those using the rooms inject heroin, the other 50% cocaine. These latter clients create the most difficulty in the rooms for staff with their volatile, aggressive behaviour. "Safe injection rooms alone doesn't make sense," said Furst, "but integrated into the drug helping system it is very useful." Because they don't allow heroin or cocaine smoking in the rooms there are still about 300 people who smoke outside in the open.

HEROIN TRIAL

Frankfurt will participate in a seven city German government sponsored 3 year scientific heroin trial beginning in 2001. Of the 200 addicts from Frankfurt, 100 will take heroin with a control group of 100 on methadone. Criteria are now being developed with the goal of finding out whether prescription heroin would be a better medication for some long term addicts whorepeatedly respond neither to methadone or other forms of treatment. The study will also look at what forms of psycho-social support are the most effective. The heroin program will be located about 5 km away from the red light district where the other drug help programs are located.

POLICING

The Frankfurt regional police have 3500 officers of which there are about 600 in the special forces branch that includes drug law enforcement. There are 120 officers in the drug unit with another 30 to 50 seconded from the Hessen state police. They police the red light drug area 24 hours a day in uniform and have a plainclothes group that targets the dealers and traffickers. Deputy chief of special forces Michael Hallstein said "We arrest them if we catch them and . . . 75% of those charged are convicted with a jail term." He said possession of an illegal drug is a criminal offense but consumption is not therefore small quantities for personal use are not prosecuted. He said a large portion of the dealers they see are illegal immigrants or asylum claimants (like refugee claimants here) who are unable to work in Germany and turn to dealing and using. Gerd Furst said, "When I first started working here 11 years ago I wouldn't have known I would say that the excellent cooperation with police has been a vital component of the success of the drug helping scene. It is vital to have the police involved to control the scene."

CRIME

"You cannot say the crime being conducted by addicts is down. What you can say is that the typical crime conducted by addicts such as car break-ins, shoplifting, muggings and such is down." said Gerd Furst. " Is it because of our drug aid program or because the market is flooded with car radios and better car alarms . . . ? Whether these crimes are down 80% or 30% due to our programs no one can say." But, whatever the cause, they are down.

From 1991, the year before the open drug street scene was shut down, and 1999 street muggings fell from 1223 to 629, about 50%, and car break-ins in the city centre where the drug scene is fell from 7825 to 3148, more than 60%. The number of dealers fell from 5000 to 1400 with a commensurate drop in offenses against German drug laws in Frankfurt. (See Attachment 2, Frankfurt police department statistics).

Overall the people in Frankfurt with whom I spoke felt the programs that they had put together by trial and error had improved their drug problem. They believe more adjustments are necessary to cope with increased cocaine use and to provide inpatient treatment for new or very young addicts.

GENERAL OBSERVATIONS

… Each of these cities has a highly developed "help system" for addicts which they believe has generally helped improve addict health, social stability and behaviour. This systemis coupled with specifically targeted regulations and laws regarding open drug consumption and disorderly or criminal behaviour and has a policing strategy to enforce them. Both said police cooperation was key.

… Each city has had to modify its approach based on experience. For example, Holland is now taking a harder legal approach to criminal behaviour for those addicts who refuse to accept help from the drug and social help system. And, programs that were originally set up to deal with heroin are less effective now that the addicts' preference is shifting heavily towards cocaine for which there is no proven treatment.

… Neither city thought it had solutions, only management strategies and tools, and I felt neither was "selling a solution".

… Both cities said the single most effective and cost effective thing they did was to introduce low threshold methadone as it stabilized many addicts and decreased criminal and nuisance behaviour. Neither city emphasizes abstinence based treatment except for new or adolescent addicts.

… Safe consumption rooms were established in Amsterdam as part of harm reduction for addicts and moving consumption indoors; in Frankfurt to protect workers from health risks of indiscriminate needle use and to break up the open drug scene. Both cities felt it worked to break up the open drug scene and improve addict health but, by itself, did not reduce criminality. Treatment with methadone and other methods did.

… Both cities are participants in larger federally sponsored heroin trials in their own countries to see if heroin prescription would be suitable for a small population of long term intractable addicts for whom other treatment had failed.

… In both cities the addict population and the programs for them have been controversial, particularly safe injection/consumption rooms.

… The programs cost significantly and are paid for out of city budgets that have primary responsibility for health and social welfare which in Canada come from provincial not city budgets.

… Our city does not have available some of the legal tools these two cities did such as drug court-like programs, penalties for open consumption, and mandatory drug treatment for addicted repeat criminal offenders.

… Both cities balanced harm reduction measures for the addict with harm reduction for the surrounding communities and heavily involve them in implementation.

Report on Visit to Drug Programs in Amsterdam, Netherlands and Frankfurt, Germany

by councillor jennifer clarke September 2000

List of Attachments

Attachment #1
Cover Page from Care for the Future . Opiate Addicts in Amsterdam. Trends and Figures 1996-1998. GG and GD; Municipal Health Service Amsterdam.

A copy of the full report is available through either the City Clerk's office or the Councillors' Secretariat.

Attachment #2
Graph: Car Break-ins in Central District, Frankfurt
Graph: Street Muggings in Central District, Frankfurt
(On file in the City Clerk's Office)

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