ENCOD BULLETIN ON DRUG POLICIES IN EUROPE

JANUARY 2015


Reflections on opiate substitution treatment

In Europe, the war on drugs has gone through several phases – from brute criminalisation of any legitimate use of drugs to acceptance of the “medical use” of certain drugs. The discourse is changing according to expert findings that are often under the clear influence of actual policies as well as public opinion.

Some experts say that the first legal distribution programs of opiate substitution drugs in the early 1990s evolved as a community response due to the emergence of infectious diseases, and on the demand of social workers and the public that wanted to bring down shop-lifting and other activities traditionally related with the prohibition of substances in the neighborhoods of Western Europe.

Opiate substitution programs around the world vary widely. The concrete way of operation of a substitution program depends on a number of factors: the general development of the environment where it is located, the development of the healthcare system, the prevalence rate and last but not least the social-cultural environment together with local traditions.

In the testimony of a former opiate user from Finland that is included in this bulletin, I found that apparently in that country it does not seem unusual if a person who is involved in a substitution program is forced to strip naked in front of the medical staff to show that “the skin surface” is clean of needle punctures. I firmly believe that this is a totally inhumane method. Does this voyeuristic venture takes a minute or two, maybe five? Are the private parts also under scrutiny? No need to ask how that person feels.

It seems that the opiate substitution programs “per se” are at a crossroads. The people-friendly program of Harm Reduction, which was meant to help community lower the tensions amongst its members and help people who need drugs to survive with dignity, now is becoming alienated from its basic mission.

Is opiate substitution a treatment in the true meaning of the word, or is it “just” a form of Harm Reduction? What is drug use – is it a disease or just a pleasurable habit? The answer lies in the observer’s point of view. From my own, the basic problem is the war on drugs and prohibition itself. Opiate substitution programs are important, but they need to be humane. All persons (patients and drug users) in opiate substitution programs must be treated with the same respect, whether they enjoy “forbidden” fruits or not.

By Janko Belin

Experiences of a former opiate user

In order to write this I have not done a lot of research but base the text on my own experiences with having been on prescription opiate substitution treatment medications in a few different countries in Europe. I focus on the issue from a Finnish perspective, as this is where I come from.

Prescribing opiates for heroin substitution purposes by a conventional doctor was extremely rare in Finland in the end of the 90’s. For many users it was much easier to fly to Paris and visit a French doctor who then took care of all their needs regarding opiate substitution medication prescriptions. This was during the pre-Schengen era, so there was no problem in taking the medications legally back to Finland from Paris. To my knowledge, there is no research on this topic but a safe estimate is that at least 20-30 % of the opiate addict population of Finland frequently flew to France to fill their prescription opiate needs and this continued for many years. This type of tourism became known as ”subutex-flights” and was even discussed in the Finnish parliament.

Official state organized substitution treatment programs in Finland started to take in more patients in the beginning of 2000. Before it had been rare enough to have opiate addicts in substitution programs in Finland and those who were in the programs were mostly the ”end of the line junkie-types” e.g. very old of age or patients with HIV. I enrolled into a Finnish program in 2002 at the age of 25 after having relied on French doctors’ prescriptions for a couple of years. At the same time many of my colleagues definitely did not want to enter the Finnish program because of the very strict treatment protocols. I complied to everything in treatment, including the daily (7/7) pick ups of medication for the first 2 years, all the drug screening on demand and stripping naked in search of injection marks. Many of my friends continued to travel to another country to get their monthly prescription medications and did not need to comply to close to none of these possibly demeaning procedures.

At some point in 2002, the legal medical traffic from France to Finland stopped, following a bureaucratic move in the Schengen agreement (see: Schengen Implementing Convention, Article 75). Most of the Finnish ”free-lance” opiate substitution patients now changed the destination of their travels first to Estonia and then to other Baltic countries where they could obtain prescriptions for substitution opiate medications. In most cases this was buprenorphine (of course topped off with benzodiazepines). This eastern medical tourism went on for quite a few years too, until 2007, when the Baltic countries joined the Schengen area.

Thus, many Finnish addicts became international patients due to e.g. the Current Care Guidelines which most doctors obey to even it is stated to be only a recommendation. Today in Finland there is a lot more of the opiate addict population in national substitution programs compared to the situation in early 2000 but it is still a very strict program so there are patients obtaining their opiate substitution treatment from other European countries. There are also patients who have moved abroad only for the sake of getting a more humane substitution treatment protocol to participate in.

The status of a human being differs fundamentally in each country. In France for example opiate substitution patients simply got the prescriptions as any other patient group and went to the pharmacy to obtain the medications. The situation is different in Finnish opiate substitution treatment clinics. For example there is a health care district where a MD working in a methadone program actually calls the treatment ”a procedure of social hygiene”, which is very troubling. It seems that in this district patients enrolling have to agree on having anti-psychotics mixed into their methadone in order to be eligible for the treatment. It would be interesting to compare settings and protocols in all European countries. I know that in many European countries a substitution program patient has a lot more freedom than in Scandinavia. Also the quality of methadone prescribed would be something worth looking into in comparison.

For me the strict protocol did good too. It made me want to stop drugs all together which I finally did after having spent a decade in the strict national program. It is sad that substitution programs are almost a bit too common today and used in so many cases. Today I know it was like having a cling film rolled over my soul forcing me to live mostly in my head to compensate for the obvious lack of feelings and connections to the heart. I assume that patients in substitution do not know of any better state of being alive. I wish there would be some money to be made for the revival of the soul. Then maybe more people would get off those programs all together.

Two Encod representatives will participate in the San Canuto festival at Fuerteventura, Spain, from 16 to 18 January 2015.

Encod wishes you a peaceful and healthy New Year!

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