Drug use: A tale of two industrialized continents

On a summer morning in Bonn, Germany, a city on the Rhine River, drug addicts congregate in a lively, sun-filled cafe steps away from the main train station.

Together they drink fifty-cent coffee, chat and smoke cigarettes. Some read newspapers inside while others sit at picnic tables on the terrace. Many know each other and come every day to eat and shower.

If at any point they want to take their drugs — which are usually heroin, cocaine, amphetamines and pills — they are allowed to in a designated, sterile room in the backyard of the cafe. Afterward, they're under no obligation to stick around if they don't want to and will not be reported to the police.

Employees such as Maik Schutte, the Contact Cafe's coordinator, joke with them. It's a fun job for Schutte, who's worked at the cafe for ten years. It's a comfortable environment for interesting people, he says, and he knows he's helping. The cafe is one of Germany's 24 safe injection sites.

At lunchtime, many eat the warm 50-cent meals served daily; today's is soup and bread. If they don't like what's being offered, they are free to go to a similar cafe operated by a different organization for drug addicts in Bonn. They have options.

Read more: Drug-filled rivers aiding resistance to antibiotics

Europe and drugs today

This year's European Drug Report, published on Thursday, tells the comparatively tame story of drug addiction in Europe in 2018. Although overdose deaths rose slightly — some 8,200 people died from an overdose last year, around 300 more than in 2017 — heroin use is decreasing and the spread of HIV has decreased by 40% over the past decade.

Most statistics are stable in comparison with last year's. Researchers say the number of deaths could be 20% to 30% higher due to potential underreporting by member states.

Marijuana is the most-used drug and cocaine use is on the rise. The report, presented by the European Monitoring Centre for Drugs and Drug Addiction, notes the "Uberization" of the cocaine trade, where users and dealers use mobile phone apps to obtain the drug.

But most of the 8,200 overdoses that occurred in 2018 were not due to cocaine or other drugs, but rather opioids, which made up 78% of all deaths. Of these 78%, around 80% of the deaths were likely heroin-induced, according to Julian Vicente, a researcher of the epidemiology of drugs who took part in the report.

Many opioids are safe in small and controlled quantities when prescribed by doctors but can become highly addictive if abused, as illustrated by the current situation in the United States, where opioids largely derived from fentanyl killed around 70,000 people in 2017.

These varieties haven't reached Europe in high volume, but the report warns that it could happen if the bloc's drug situation isn't kept under close watch.

Read more: Britain's opioid crisis takes on US dimension

History of drug policy in Europe

Policymakers around the world took a hard look at how to regulate drugs when the HIV/AIDs epidemic spread from parts of Africa to New York City in the 1970s.

The idea for safe injection rooms such as Bonn's Contact Cafe were born in Switzerland at the height of the epidemic and spread somewhat hesitantly throughout Europe afterwards.

Researcher Henrik Jungaberle said despite appearances, Germany isn't known for spearheading the progressive drug movement and copied most of its policies from the four-pronged Swiss model.

The model — centered on prevention, therapy, damage control, and control and repression — was introduced in the early 1990s, when the wealthy country known for the Alps, chocolate and offshore banking, also found itself toting around the unsavory distinction of "highest rates of HIV in Western Europe."

In a move criticized by conservative populations worldwide, Zurich introduced as part of its policy a tolerance zone in a space widely known as "Needle Park," where addicts could shoot up in public with clean needles. Over 1,000 addicts crowded the park each day, and although it was disbanded in 1992, the idea of a safe, clean drug injection point stuck.

Jungaberle said he thinks Switzerland was able to lead the way in what he calls "pragmatic drug prevention policy" because the country's government was not looking to become a political global power.

He illustrates his point using modern-day Germany as an example, which now hosts some of the highest numbers of safe injection rooms in Europe. None of the major political parties have made drug consumption a main policy issue in their campaigns, he said.

"If Merkel had formulated the policy that the CDU is pro-drug consumption, I think that the CDU would be against that," he said, discussing German Chancellor Angela Merkel's Christian Democratic Union, the country's main center-right party.

Instead, the German parties in government installed policies quietly, depoliticizing the issue, he said.

Read more: Europol smashes major European crime gang 

A tale of two industrialized countries

Now, most of Europe follows policies similar to Switzerland's. Although countries in the bloc, such as Portugal, have experienced drug epidemics rivaling the current situation in the United States, most have made attempts to clean up the mess over the years. 

When Portuguese lawmakers realized the extent of the epidemic — their own children were dying of drug overdoses, according to Jungaberle — they launched a radical drug policy decriminalizing all drugs. Their efforts prior to decriminalization were similar to today's efforts in the United States: Criminalization and incarceration. 

Now, the country's overdose rate is back on par with the rest of Europe.

These ideas of depoliticization and pragmatic harm reduction directly contrast the way the United States government dealt with the AIDs epidemic.

While much of Europe followed Switzerland's "pragmatic" approach to drug prevention policy, places like the United States and Russia took a more ideological approach, equating drug consumption with moral sin, Jungaberle said.

Recent research published in the journal Population and Development Review supports this theory. They explain that in the 1980s in the United States, where the HIV epidemic was most rampant, drug policies were "abstinence"-based, or focused on eliminating drugs entirely through methods such as incarceration.

European countries focused more on harm reduction through safe injection rooms, similar to those at the Contact Cafe, and needle and syringe programs where addicts could obtain free supplies to inject drugs to halt the spread of HIV, the study said.

The study also attributes the United States' fentanyl addiction — and Europe's lack thereof — to lax prescription regulations in U.S. clinics, a higher preference in Europe for morphine as a form of pain relief than oxycodone, the main painkiller of choice in the United States, and financial incentives from pharmaceutical companies.

"In the US, physicians have stated that their patient satisfaction scores — as well as their paychecks — are negatively affected when they refuse patient demands for prescription painkillers," the study said.

Read more: Landmark US opioid trial begins in Oklahoma