The NSW Users & AIDS Association

We lost Tim to an overdose the other day. Many, many people will remember him as generous, kind hearted and quick to smile, and many people will weep, as I did. A lot of people are angry, like I am, that there wasn’t more support for Tim; that he didn’t have to die like he did.

I am angry at government policy and public attitudes that say assisting people to do safely what they are going to do anyway is just encouraging them. I am angry at the attitude that says if you make choices “they” don’t agree with, you deserve everything you get.

A civilised society doesn’t abandon people when it disagrees with their choices. I don’t smoke, but I don’t want to see smokers left to die in agony because they should have known the health consequences.

Tim would be here to smile at me for many years to come if only the angry, ignorant voices of some people didn’t drown out the sound of care and compassion.

Smile on Tim, you’re in a better place.

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In May this year, the German parliament voted a resounding “yes” to prescription synthetic heroin for “severely dependent heroin users” over the age of 23 years who had made at least two previous treatment attempts. Almost two in three German parliamentarians decided it was a good idea to help people who still wanted assistance. But what was the vibe like before then?

It’s 2006 and Northern Germany is freezing from autumn onwards. Hamburg is a working port city just like Sydney – although the sky and water aren’t quite as sparkly. Oh, and it rains most days just to kick you when you’re down. Sunlight drops from an average of three hours per day in October to just one hour per day in November. I asked Dr Marc Armbruster what it’s like to never see sunlight when you work inside all day, “Oh, it’s normal, you don’t notice it,” he reckons. Marc works at St Georg Hospital as a skin doctor, and some of his patients are people who inject drugs in need of repair work to wounds that won’t heal.

I’m loitering around the main train station trying to find “Drob Inn” to make my 2pm appointment. Are Germans precise with time? Does the German Pope wear a dress? Drob Inn is a one-stop-shop for people who inject drugs, opening in 1987 as part of a larger health and welfare service. You can go there to take drugs safely, have a shower or talk to a counsellor to help you find a place to live. Another good thing about Drob Inn is that their doctors are paid for by the government, and clients can see them for free throughout the day. This means asylum seekers and “illegal” immigrants are covered for one of the most basic human rights. (I think health is listed in Article 25 of The Universal Declaration of Human Rights, isn’t it?) Having free doctors also makes it easier if you’re homeless and you’ve lost all your ID cards.

No-one around the station knows where Drob Inn is, so I start asking strangers, using its other name: Wüstenrot Haus. Ironically, “desert red house” is the literal translation, so I picture a fiery colour to guide me through the grim weather. It turns out Wüstenrot Haus was the name of a bank, and I am guided towards a deserted park. Here looms an old office block, but now the 50 to 80 investors are buying and selling drugs or waiting for the centre to open. A cop car loiters in the background, and I later discover they are keeping the clients safe as drugs and money circulate around the crowd. The drugs of choice here are heroin and crack; its personal havoc is carved deep into the faces and teeth of today’s customers.

Peter Möller greets me at the door and we move into a spacious empty lounge and café area. Peter is the coordinator and he leads me into what looks like a huge fish tank. This is one of the drug consumption rooms. Laughing, he points at the ceiling explaining how it used to be painted white. But, like a Datsun 180B, all the cigarette (and other) smoke has coated the ceiling a solid 1970s yellow-caramel colour. (The rest of the Drob Inn went tobacco smoke-free in October 2007 which, amazingly, was three months before anti-smoking laws came into force throughout Hamburg.) They have a total of 15 rooms for taking drugs; three rooms for smoking or inhaling drugs, seven to inject drugs and 10 to ingest drugs. Alcohol and cannabis, however, are not permitted.

Now, this is a six storey building and Peter leads me into the stairwell and up we clamber. “The higher we go the more intensive the service,” he says as he waves towards the five bedrooms for crack users who need respite for 24 hours, as well as the private consultation rooms for psychological or welfare counselling. Another door hides a clothing room with second-hand items to spruce up your wardrobe. Drob Inn receives between 300 and 400 clients per day so a large workforce, and a bevy of university interns, strive to meet the clients’ needs.

Downstairs again life is stirring around the kitchen where vats of pasta bubble away for the clients trickling inside. Pungent parmesan cheese wafts through the expectant throng. One of the odd things I mull over is that the doors open during the week at 9am except for today, when they open at 2.30pm. The drug consumption rooms close at 5am, while the medical services finish at 7pm. Even stranger is the needle exchange hours which are just 2pm to 7pm. I can see a bit of a mismatch here. You can score a spag bol but no sterile needle, and when you have a needle, odds are there’s no medical supervision because the medical staff have gone home at 7pm. But you can wash your clothes in their laundry after midnight.

I press Peter on the clients’ needs a little more because I notice many aren’t from Germany, and there’s no multilingual posters or pamphlets around. In Australia, we are lucky to have information resources in different languages (I like to decipher the different words when bored and waiting in a doctor’s lounge). “Your clients come from other countries, can your staff speak their languages?” I ask hopefully. “No, there was one who could speak a little French with an Arabic client once,” he answers. Hmmm, perhaps there’s room to encourage a few bilingual volunteers or internships at Drob Inn, I wonder. In this city, one in seven residents was born outside Germany, and Hamburg is also home to Europe’s largest Afghani community.

To me, the strangest feature of Drob Inn is that they will ban their clients for a few days if they deal drugs inside. The café and lounge area is set up as a social hangout and I can imagine clients will relax and forget the rules sometimes. What is worse, the ban can be extended even longer if they sneak back pretending to be someone else. Drob Inn has a card system to keep track of who’s in and who’s not. I left the centre with a feeling of ambivalence towards the centre because of this practice.

Hamburg is a city of almost 1.8 million people and hosts five drug consumption centres. In 2006, there were a further 20 of these centres across the rest of Germany. Drob Inn is the largest service in Hamburg and the police department contributes towards its funding because, I was told, it makes it “easier for everyone” to have this centrally-located one-stop-shop.

If you’re in the know it’s easy to find Drob Inn. Just go through the bus terminal, and then down into the quiet park away from everything.

Grant Mistler is a member of the NUAA Board of Governance

Photograph by Grant Mistler

Europe has several drug consumption centres in various countries, including 13 in Germany, 17 in Switzerland, 16 in the Netherlands and one each in Norway and Copenhagen. Unlike the Medically Supervised Injecting Centre (MSIC) in Kings Cross, there is no constant medical supervision in the injecting rooms and users can take drugs in other ways other than injecting. They also act as drop in centres, offering food, medical assistance and even shelter during the winter.

Outside of Europe and Australia, Canada is the only country to have a legal centre for drug usage. Unsurprisingly, there are currently no announced plans to explore such a scheme in the United States.

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The term “dual diagnosis” or “comorbidity” is used when a person experiences two physical or mental illnesses at the same time and is commonly used to describe people with mental health problems who are also drug users or drinkers. The term does not describe a particular illness or a consistent set of symptoms, but covers a wide range of patterns commonly experienced by people with mental health problems who use drugs and/or alcohol. The relationship between drug and alcohol use and mental health issues is complex; unfortunately, it is often reduced to negative assumptions and stereotypes, especially by providers of mental health services.

The mental health aspect of dual diagnosis has largely been defined as the presence of a “functional psychotic illness”, for example bipolar disorder or delusional disorder, and generally identifies any substance use as problematic and negative. I argue that this definition is excessively narrow and judgemental. For a start it shuts out people with conditions such as personality disorders, depressive illnesses, anxiety disorders or eating disorders - known as non-psychotic mental health problems - from the potential benefits of specialist help or intervention that is currently available to those people with psychotic illnesses who use drugs. This is critical since the presence of these mental health problems among people with substance use issues is common.

Current mental health practices and services often reflect general community attitudes toward people who use drugs as dangerous and bad, despite little evidence to support these attitudes. The commonly held view is that even small amounts of alcohol or drugs worsen the mental illness of someone with dual diagnosis. This view exists despite the fact that little research has been done to explore either the reasons for drug use, or the potential positive effects of drug use for some people with mental health problems. This approach completely ignores the experience of many drug users who have found that using drugs has been helpful or therapeutic, both in managing symptoms and in dealing with the daily experience of living with mental health problems in hostile communities – communities which tend to stigmatise such people rather than attempt to understand them.

It has been suggested that people who experience both mental illness and problematic substance use often present different problems to those who experience only one. The condition of dual diagnosis has been linked to a number of specific problems and symptoms. Some research, largely from North America, links dual diagnosis with a range of poor outcomes including relapse or exacerbation of mental illness, poor compliance in taking medication, increased contact with the criminal justice system, increased risk of contracting hepatitis C or HIV, and increased incidence of suicide.

In the UK, the National Health Service has responded to the traditional lack of understanding amongst mental health workers of substance use problems by issuing “good practice guidance” in the care and management of people with dual diagnosis. This good practice guidance recognises that mental health services and drug treatment services in the UK have evolved separately, both philosophically and practically. The guidance, known as “mainstreaming”, recommends that those with dual diagnosis be treated and managed largely by adult mental health services. The idea behind mainstreaming is to reduce the number of health services that people living with dual diagnosis have to deal with.

Research indicates that the more agencies a person has to deal with, the less well they do. Recognising this, good practice guidance recommends that outreach team workers be “trained and equipped to work with dual diagnosis”, and that in-patient service staff, community mental health teams, crisis resolution teams and early intervention teams be suitably trained.

Australia has effectively taken the opposite approach to the UK’s mainstreaming into mental health services by putting most of its dual diagnosis investment ($18 million between 2003-2010) into the alcohol and drug sector. At the same time, the Network of Alcohol and Other Drugs (NADA), in partnership with the Mental Health Coordinating Council (MHCC), has developed the “No wrong door” approach. “No wrong door” is designed to respond to users of the community mental health sector who have drug and alcohol problems. The project is based on the principle that all consumers, regardless of which service they go to, should be able to receive care that covers the full range of their mental health and substance use issues and difficulties. In other words, there is no wrong door!

According to international studies, cannabis and alcohol are the substances most frequently used by people with mental health problems. In the past five years, research on cannabis use and mental health problems has taken a new direction and has been picked up by governments, the popular media and the medical establishment. Following a period of relatively liberal cannabis policy in the UK and other European countries, it is now not at all unusual to read coverage of “killer skunk”, “addicted teenagers” and ”cannabis psychosis”.

During this period it has been demonstrated that drug laws regarding cannabis have nothing to do with harms and everything to do with governments wishing to seem “tough on drugs”. In the UK, after lobbying from the Advisory Committee on the Misuse of Drugs, cannabis was reclassified downwards from class B to C, removing the possibility of arrest for personal use. The Brown Labour government then classified it up again. Cannabis use, and the psychosis it allegedly causes, has been implicated in everything from knife crime to the war on terrorism. This is far from accurate, and totally fails to recognise that cannabis can and does help many people with mental health problems, pain and other health issues.

There is a general agreement that cannabis can trigger a serious but temporary psychotic reaction in otherwise healthy people. However, how this happens, or how often, is completely unknown. It is also unclear what doses or types of cannabis are involved, whether somebody is a heavy, regular or infrequent user, and whether reports of these reactions are anything other than clinicians’ opinion. However, the current evidence suggests it is extremely unlikely that cannabis use can independently cause a persistent chronic psychotic illness such as schizophrenia, even if its role as a risk factor in the onset of schizophrenia remains unclear and controversial. The question of which comes first between cannabis use and schizophrenia also remains greatly disputed. There have been studies that suggest mental illness is often preceded by cannabis use, but the methods used in these studies are often demonstrated as flawed. Furthermore, the notion that cannabis use causes mental illness is undermined by an important statistical fact: while cannabis use is increasing, there is no commensurate increase in the incidence of mental illnesses, schizophrenia in particular. The debate remains about whether cannabis use is harmful to people living with schizophrenia, and current thinking is fractured with various studies producing significantly different findings. It is, however, certainly probable that some people with schizophrenia who use cannabis experience worsened or lengthened psychotic symptoms – just as it is also probable that for some people cannabis use relieves negative symptoms, unpleasant affective states and counters the side effects of anti-psychotic medicines.

The last 15 years have been both “the best of times and the worst of times” for people living with dual diagnosis – the best of times in that research, policy development, funding and training have led to direct provision of services that are in a much more advanced place to offer actual help; and the worst of times in that abstinence is still promoted as the only approach to drug use. In promoting abstinence we fail to realise that what we are doing is asking people who are often stigmatised, vulnerable, frightened and in poor mental health to stop doing the only thing that makes them feel any better! Eleven years ago I wrote in the International Journal of Drug Policy pleading the case for the sensitive provision of harm reduction-focused services for people with dual diagnosis, believing it was only a matter of time until the only approach we knew that worked, harm reduction, was adopted for people with dual diagnosis. Sadly, more than a decade later, I could write the very same paper. As I said then, insisting on abstinence means you might never see them again.

Peter Phillips is a Senior Lecturer in Substance Use & Addiction at the School of Community & Health Sciences at the City University in London

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