My name is Massimo Barra. I’m a medical doctor. Since 35 years I am involved in the field of substance abuse. In 1976 I created Villa Maraini which is an antidrug institu-tion in Rome that since then took care of about 35.000 drug users. I’ve only 15 minutes to speak about the most controversial aspects of the treatment of a drug user. In my opinion, there are four steps in the relationship between an individual and the substance he takes, that we can call “intoxication scale”: the use of a substance, the abuse of a substance, the dependency from a substance and the obsession for a substance.
Those who develop a dependence or an obsession, also known as craving, are not healthy persons anymore. Not recognizing and not treating this sickness, at the same level in which any other disease is treated, not only is a mistake, but is a wicked action the world of healthy people does to the world of drug users. It is also a masochistic choice by the society in its whole: a drug user who is treated is dangerous for himself and for the others, but a drug user who is non treated or not even recognized as a sick person is as twice as dangerous. It is even worst when “the others” start to stigmatize and give moralistic judgments, that become a form of violence and discrimination against drug users. And our daily experience tells us that violence always bring violence. In reality, nobody can oblige anybody else to feel good and to stay well, and the knife of well-being or discomfort is always in the drug user’s hands, not in those of the doctor or the family. Forcing the hand to the nature of a disease often causes artificial damages that are provoked without a necessary cause.
A forced detoxication that is not shared with and not asked for by the drug user can lead to irreparable damages, such as an overdose, because it contributes to remove the protective shield of tolerance. Many drug users die of overdose after a forced stay in prison or in a therapeutic community. The life of a drug user is marked by easy detoxications, but it is even more marked by easier relapses. The starting point of each therapy has to always be a clear rela-tionship between the therapist and the patient, in which no judgment has to be done. As our Lord said, ”Do not judge if you do not want to be judged, do not con-demn if you do not want to be condemned”. The first, immediate objective of each therapy is to improve a drug user’s quality of life, and to avoid that a drug users kills himself or does not harm himself too much. We call this “Harm reduction”.
These two words, Harm reduction, have been in the last two decades at the centre of strong debates all over the world, as they have taken an ideological and political meaning, which goes well beyond their semantic meaning: the clear, self-evident truth that reducing harm to individuals and to the society is better than increasing them, and that no health policy can wish to increase the harm caused by a morbid event. But logics, even if it based on scientific evidence, is not enough to explain political choices. Would it be so, scientists would have the full control over Governments, thing that has never happened. Appealing to evidence in order to influence the political debate is not enough if on the other side there are pre-judgments that are not based on logic but on irrationali-ty and emotion, illogicality and instinct. And we do know how much these can influ-ence a man’s action, often even more than logic. Should it be driven by the light of science and evidence Mankind would not go to war or kill. The promotion or the denial of Harm reduction have become the symbol of the op-position between two different ways of intending the problems linked to substance abuse, as if it was a barrier between two opposite extremisms.
On the one hand, the prohibitionists “without if and without but”, those for whom drugs are evil, drug users are criminals or sinners to be redeemed; the supporters of strong anti-drug policies, of the Zero-tolerance; those who are for the savage beha-vioral strategy of the carrot and stick; those who justify any violation of a drug user’s human rights, should it help him to quit; those who clap people with bad reputation and origins if they manage authoritarian therapeutic communities using punishment as a forced step to redemption; those who think that a drug user has to touch the bottom in order to rise again and do their best as therapeutists, parents and friends to worsen a drug user’s quality of life, to accelerate the moment in which he will regret his crime, ask for forgiveness and accept any kind of punishment in order to get rid of drugs; those who having a budget at their disposal, spend it all on repression, police, customs.
On the other hand are the non prohibitionists, those who consider drug users as sick persons and not as sinners; those who consider punishment and prison as counter-productive, who think that public health interventions based on scientific evidence represent the best way to fight the negative effects drugs have on both individuals and the society; who think that a drug free world is unrealistic and unfeasible, who consider the sanctionary system as a source of stigma and discrimination towards drug users, as it creates more harm than substances (Stigma kills!), up to those who ask for liberalization of any substance, for the end of prohibitionism, abolition of in-ternational treaties up to the full liberty to take drugs as a mean to expand a per-son’s knowledge and conscience.
It is self evident that a synthesis between these opposite and extreme positions can not be done without a major, common effort that tries to get the debate out of the boundaries of emotion and irrational. Having said that, let me say that I am a strong supporter of Harm reduction, a strat-egy that has not valid alternatives. Harm reduction is the first objective of any therapeutic intervention, as it tries to avoid the irreparable and the point of no return for an individual and to prevent some of the social damages linked to the phenomenon.
There is no magic treatment or simple answer in the field of substance abuse. But a treatment that works is a treatment that we can adapt to the special circumstances of any individual. It is like there were two different and completely opposite strategies, one totally against drugs and drug users, the other one more flexible, and in my opinion realis-tic, with the consequence that supporters of the first approach consider supporters of harm reduction as facilitators and partners in crime with consumers. It is now time for listening to the voices of the most vulnerable ones and to advocate a new way, beyond prohibition and even harm reduction. A new global approach based on humanitarian principles that empowers people to make healthy choices. But what exactly is a harm reduction strategy, in reality?
A harm reduction strategy is the opposite of a harm increase strategy, which humiliates, mortifies, criminalizes and stigmatizes drug users, producing negative effects both at the individual and public health levels, as well as at the social one. There is no other field in medicine in which doctors have the objective to increase the harm of patients. Many people think, in good faith, that associating a form of harm, or punishment, or violence, to the action of taking drugs could help “uncondi-tionate” the positive conditioned reflex associating drugs with pleasure. According to this point of view, if the memory of pleasure makes it easier to contin-ue taking drugs, the memory of sorrow and grief should act as a deterrent.
On the contrary, the more an individual is treated with violence, the more he looks for sub-stances that can give him comfort, that can help him, that can give him back serenity and calm, that can love him. Many drug users could not revive from the evil consequences of sadistic and unqua-lified therapeutic treatments, which have increased, and not decreased, the damag-es related to drug consumption. Harm increase is as dangerous as substances, and a harm increase approach implies and justifies stigma and discriminations of drug users. Everywhere in the world, even in countries that uphold human rights, drug users are still denied basic citizen rights. Drug users are humiliated, bullied, discriminated and treated more as criminals than as sick people. Public opinion and well thinking people are often accomplices of this stigmatization.
If this is the situation in the world today, we have to consider it as one of the major problems to face from the humanitarian point of view. And that justifies the inter-vention of the International Movement of the Red Cross and Red Crescent, which has always been in the frontline against any kind of human suffering. The Red Cross “makes no discrimination as to nationality, race, religious beliefs, class or political opinions”. It bases its anti-drugs activities on the Principle of Humanity and on scien-tific evidence. A few years ago, we took a strong position in favor of Harm reduction, with a publi-cation that you can find on the web of the International Federation, under the name “Spreading the light of Science”. Shortly after we involved Red Cross and Red Cres-cent National Societies from all the continents into an initiative called “The Rome Consensus for a humanitarian drug policy”.
The Rome Consensus, that today counts 118 member National Societies, advocates to Governments for anti-drug policies that are respectful of fundamental human rights and are not violent and punitive. We are currently waiting for the new anti-drugs policy of the Obama administration, for which opening to scientific evidence should be easier than publically denouncing the previous administration for violating fundamental human rights by torturing prisoners of war. On this subject, it is also important to mention the common and precise position of the European Union. Even the UN system, with the UNODC and WHO Joint Initiative, is improving its strategy. I want to read you, in this regard, two statements made by UNODC Execu-tive Director, Antonio Maria Costa, who said that “ Scientific evidence shows that drug addiction is an illness that can and must be traited.
There are no ideological debates about curing cancer or diabetes. Left and right are not divided on the need for treating tuberculosis or HIV. So why are there political contraposition about drugs?” and that “Drug control has an image problem: too much drug-related crime; too many people in prison, and too few in health services; too few resources for prevention, treatment and rehabilitation; too much eradication of drug crop, and not enough eradication of poverty” and finally “although drug kills, I don’t believe we need to kill because of drugs”. Even the UN Secretary General, Ban Ki-Mon, who by the way has been an active vo-lunteer of the Korean Red Cross Youth and who spent one month in the USA invited by the American Red Cross, being received by President John Fitzgerald Kennedy, in its speech on the occasion of the 2008 World Day against drugs, used new and un-usual words for the UN bureaucracy, saying that “No one should be stigmatized or discriminated against because of their dependence on drugs”.
All these factors and considerations, ranging from the position of the International Movement of the Red Cross and Red Crescent and the European Union, up to the recent opening signals from the United Nations, together what we could now expect from the United States, makes me feeling slightly optimist for the future, and think that the worst and repressive aspects that have transformed the fight against drugs into the fight against drug users could finally give the way to reason and evidence, for a global action based on compassion and therapy, far from prejudice, violence, stigma and discrimination.