BELGIUM - Psychotherapist involved in the treatment of drug addicts in Belgium. He was Director of two rehabilitation centres for youth and adolescent and, for twelve years was Assistant Professor at the School of Public Health of Brussels University.

ABSTRACT: Given the inherent danger of heroin, the present prohibition policy is certainly justified, as long as it is applied with a policy involving the use of methadone. This would tend to "break" the black market and allow for medical follow-up and psychotherapeutic treatment of users.

("THE COST OF PROHIBITION ON DRUGS", Papers of the International

Anti-prohibitionism Forum, Brussels 28th september - 1st october 1988; Ed. Radical Party)

In response to the generally-held ideas of international experts in the field advocating the lifting of the prohibition of the drugs presently considered illegal, I should like to present my clinical experience with drug addicts.

Obviously, it will not be easy in the space of a quarter of an hour to expound on the lessons learned and results obtained from a psychotherapeutic practice with drug addicts which goes back to 1978.

Marco Taradash's invitation has prompted me to talk on a theme intimately related to my professional experience. Thus, although I have also had contact with addicts who had taken drugs excessively prior to their treatment, or were still taking them (amphetamines, cocaine, hashish, codeine, and a wide array of benzoic acids or other psychotropic drugs), I shall limit my talk to the subject of heroin addiction and forego offering any suggestions as regards the other illegal drugs, as regards the campaign against drug prohibition.

I have, since 1978, treated a good 400 addicts. The combined treatment of oral or intravenous administration of methadone and a long-range support therapy resulted in preventing for the first fifty months the deaths of those patients who remained in treatment. During that period, 3% of these patients who had - against my advice - either left treatment or, suffering excessively from brutal withdrawal symptoms, upon their dismissal from hospital or jail, died from massive overdoses. A point for comparison is the annual mortality rate (l.6%) of heroin addicts in the United Kingdom. (1)

Looking back on my medical experience, I believe I could say that the positive therapeutic results achieved can be attributed to a combination of the following:

1. Methadone, which over time limits the craving for heroin;

2. An intense supportive psychotherapy which encouraged the addict to live and manage his daily stress, gradually overcoming that depressive state which would result in the lengthening of the period of addiction to heroin, re-establishing the will to go on, creating those living conditions which could make giving up drugs possible.

As the participants of this reunion envisage the legalisation of drugs, I should like to explain a bit more in detail what effects heroin can have on the human psyche. For ten years, I have been in a position to observe the psychic, moral, intellectual, affective, and social havoc wreaked on the individual who uses heroin, as well as the damage inflicted daily on his relationships with partner and family.

In the opinion of some, hard drug-related crime is the result of the prohibitive cost of obtaining that drug. In all truth, an infinity of harm is caused by the psychic effects of heroin itself. The heroin addict (pharmaco-dependent) experiences inexplicable changes of mood; he is overly sensitive, egocentric, lacking in will power and tends to misconstrue. He is passive and very often lacks interest in anything beyond procuring his next fix. With time, heroin alters his moral sense; he becomes utterly insensitive to the sentiments and actions of others; he lives for himself alone. For some, the drug destroys all initiative or desire to work. After a few years of addiction, some become social derelicts, having lost all contact with normal society, their only 'friends' being "junkies" who like themselves are suicidal depressives. During therapy, dialogue with a "broken" heroin addict is difficult, because his train of though is chaotic and he understands with great difficulty the sense of what his interloc

utor is saying. He changes the subject constantly, does not retain what has been said, even finding it difficult to remember what he said or did the previous evening. He neglects his person, and his deteriorating relationships are exacerbated by his unrelenting craving for the drug.

Heroin dulls his self-perception and his affections, and at the same time reduces or annihilates his perception of the affections or the desires of others. I know of no worse poison to man or anything more destructive to human relationships.

Those psychic, intellectual and affective effects of heroin, combined with the indisputable damage done to the heroin addict's quality of life, which becomes progressively worse (due to the criminal acts "made necessary" by the prohibitive cost of drugs, an asocial and unproductive life, imprisonment and the relative consequences) deepen his social alienation.

The reasons for which Great Britain has for half a century provided for legal administering of heroin for therapeutic purposes are historical. According to A. Hamid Ghodse (2), opium addicts in the 1920s numbered in the hundreds, consisting for the most part of physicians or medical personnel addicted to morphine. In 1926, the Rolleston Committee recommended that heroin or morphine be prescribed for those patients on two conditions: that their being deprived of the drug would not provoke symptoms which could not be satisfactorily treated, or that it did not prevent them from living useful and reasonably normal lives.

During the 1960s, the number of known drug addicts doubled on the average of every two years, to the point that in 1968 Home Office statistics estimated their number at 2,782. One important reason for that increase was the excess of prescriptions issued by certain physicians, some of which were destined to the black market. This happened because the clinicians at the London Drug Dependence Clinics attempted to stabilise addicts by prescribing heroin. At that time, the first encouraging results were being reported in the United States for methadone treatment. As a result, in the 1970s, London physicians gradually abandoned heroin and began to prescribe methadone, administered by injection or orally (the latter became more widely practised during the 1980s).

At present, orally-administered methadone is preferred by most European practitioners. For various reasons, France, Belgium, West Germany and Greece still resist applying this therapeutic method, which not only permits a prolonged ambulatory treatment - which is less expensive for the addict - -but also causes a reduction in illegal heroin trafficking (3) and all drug-related crime.

The most spectacular results have been obtained in the Netherlands. According to the mayor of Amsterdam, since 1986, 75% of national addiction has been stabilised with oral methadone treatment. The remaining 25% are inveterate heroin addicts, considered beyond saving. An experimental programme has been conceived (although, to my knowledge, never put into operation) for the provision of "uncut" heroin (in the interests of individual and public well-being). My personal experience (1978-1983) in the use of methadone intravenously administered to some two hundred patients very dependent on opiates, but even more so on the hypodermic needle, led me to conclude that this treatment permitted the stabilisation of the patient with a dose adequate to reduce or suspend totally the injection of heroin, preventing the addict from continuously increasing doses of heroin which would eventually result in his hitting bottom.

After intensive support psychotherapy, combined with intensive social assistance, injected methadone can be substituted with orally-administered methadone. Set-backs are inevitable, but after 3 or 4 years modest results are possible. Stimmel (4), wrote in 1978 that, after an average of 3.5 years of treatment, 57% of his patients abstained (the medical record on the average covered a period of three years after the withdrawal of methadone).

Why substitute methadone for heroin? Because methadone stabilises to a remarkable degree the mood of overly-sensitive, apathetic or particularly aggressive heroin addicts going through withdrawal.

Because it permits the existence of couple relationships which hitherto had been hellish and impossible. Because it reduces the addict's suicidal tendencies, also normalising his mood, behaviour and intellectual functioning to such a degree that even the most observant clinician can be convinced that the patient is living without substitute "drugs".

In my practice, I insist (as Deylon in Geneva and the English do) on the conjunction of living conditions and medical treatment in the "healing process of the heroin addict".(5) More often than not, "the heroin addict does not abandon all drug dependence unless he stops living alone; unless he has established a stable relationship and if he is active in a non-marginal professional activity".(6)

In conclusion, I should like to point out that these results demonstrate the necessity of avoiding or remedying the negative effects with heroin - either legal or illegal. After the discovery twenty-five years ago of the universal benefits of methadone, I do not believe that therapists should any longer assume the responsibility of prescribing medically-controlled heroin. Who would risk following that now-abandoned non-therapeutic practice? What physician will still attempt to justify it?

The clinician in me suffered sufficiently when witnessing the psychic, social, family and physical decay of heroin addicts condemned to lives of crime in order to pay the prohibitive prices of illegal drugs. However, I absolutely cannot agree to an antiprohibitionist policy which would, covertly, medically perpetuate the deleterious psychic effects of a newly-legal heroin.

The methadone cure has been known to the European medical profession for twenty years now. I believe that the essential steps to be taken now - on a European level - are the following (with your permission, I quote a conclusion from my L'Amour Condamne' (Love Condemned), which was published in 1987).

"What are the immediate actions to be taken? Attempt to destroy the offer of illegal heroin by satisfying the demand of the drug addicts by providing methadone under medical supervision; "destroy the market" and at the same time treat the addicts. Could there be a simpler operational objective, a more humanitarian, more relevant or less costly one? Could there be a solution better answering the requirements of all - the afflicted and their families, the physicians, parliamentarians (...) everyone, that is except the drug traffickers?" (7)

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(1) Ghodse, A. H.; Sheehan, M.; Tylor C. and G. Edwards, "Death of Drug Addicts in the United Kingdom, 1967-1981", The British Medical Journal, 1985, pp. 290 and 425-428.

(2) Ghodse, A. H., "Treatment of Drug Addiction in London", The Lancel, 1983, pp. 636-639.

(3) cf. the pilot experiments in Chicago by Patrick H. Hughes, "Behind the Wall of Respect - Community Experiments in Heroin Addiction Control - 1977".

(4) Stimmel and coll,. "Detoxification from Methadone Maintenance", Ann. New York Academy of Sciences, 311 (1978), pp. 173=180.

(5) "Les Problemes de la drogue dans leur contexte socioculturel", Cahier de Sante' Publique de l'OMS, No. 73, Geneva, 1982.

(6) Badour, J., "Rapport a la Commission de la Drogue (19851986) du Parlement europeen".

(7) Baudour, J., "L'amour condamne' - esquisse d'une psychotherapie des toxicomanes", Liege-Brussels, P. Marvaga Editions, 1987.