Ditte Andersen Research
report
Margaretha Järvinen
Harm reduction –
ideals and paradoxes
ABSTRACT
D. Andersen & M. Järvinen: Harm
reduction – ideals and paradoxes
Aim
The aim of the article is to critically
reflect on the harm reduction approach
used in Danish substance abuse
treatment.
Data
The article is based on qualitative
interviews with staff at treatment
“Who in their right mind could oppose the
notion of reducing harm?” (Nadelmann
1993, 37)
institutions in Copenhagen.
Themes and conclusions
Three themes are addressed. First,
our data indicate that low-threshold
Harm reduction is a term used to describe policies and programmes aimed at reducing the
health-related, social and economic damage
caused by drug use without insisting on total
abstinence (cf. Riley et al. 1999). Harm reduction refers both to concrete practical measures
such as setting up injection rooms, establishing “low threshold” services, giving instruction in good injection techniques, exchanging
syringes and so on, and more generally to an
approach and a way of thinking that focuses
on reducing harm to the drug user him/herself
and to the people in his/her immediate environment, rather than on abstinence.
The purpose of this article is critically to examine the phenomenon of harm reduction as
practised in the Danish treatment system today. We deal with three themes, namely: harm
reduction and abstinence; harm reduction, autonomy and responsibility; and finally, harm
reduction and social integration. Empirically
the article is based on interviews with staff at
outpatient treatment centres in Copenhagen.
methadone treatment is difficult
to combine with a long-term goal
of abstinence. In fact, many harm
reduction proponents among staff are
directly opposed to treatment models
in which abstinence is a goal. Second,
we illustrate how the development of
harm reduction measures is embedded
in a socio-political trend focusing
on a combined “autonomization/
responsibilization” of social clients.
This focus on clients as autonomous
and responsible subjects clashes with
another central conception among staff:
the idea that heroin addicts are slaves to
their substance use and hence cannot
be treated as fully rational human
beings. Third, the article analyses the
relationship between harm reduction
and social integration.
Although social integration of
substance abusers is part of the
rationale behind harm reduction
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
235
Harm reduction – ideals and paradoxes
measures, this goal is
Embarking from these interviews and from the international
difficult to reach with
research literature on harm reduction, we point out a number
a group of clients as
of paradoxes in harm reduction practice. Harm reduction
marginalized as the ones in
measures are in many respects beneficial and necessary, but
focus.
they also entail a number of dilemmas that in our opinion
Keywords
have received far too little attention in the research.
Harm reduction, social
integration, methadone
Social research and harm reduction
treatment, heroin abuse,
Alcohol and drug researchers have in general taken a very
responsibilization
positive view of harm reduction, and in many contexts the
harm reduction paradigm has been presented as a pragmatic, humane and scientific approach to the problems related
to substance use: sometimes, indeed, as the only such approach.
The Australian sociologist Grazyna Zajdow (2005) addresses the question why researchers often take a critical
and satirical view of drug policies aimed at zero tolerance
and control, while they relatively “uncritically” endorse the
harm reduction paradigm. Zajdow believes that, as a group,
sociologists doing research on alcohol and drugs have given
themselves very limited opportunities to respond to public
policies because they adher to a quite rigid (negative) attitude
towards social control. The practical world of drug policies
and treatment is of course complicated. There is considerable ambivalence and lack of clarity regarding what goals
should be chosen for policies and treatment; how these goals
should be reached; which measures are effective in helping
which groups of drug users, etc. Zajdow blames the harm
reduction paradigm – and the proponents of this paradigm
– for ignoring these uncertainties: “Harm minimization, as a
policy response to perceived problems with drug and alcohol use, is an attempt to come to terms with ambivalence by
avoiding the issue altogether”. (p. 186)
Many researchers working within the harm reduction
paradigm would probably be indignant at such accusations
– they hardly regard their approach as unconsidered. Nevertheless, a brief survey of the research literature on harm
reduction makes it clear why Zajdow has raised the issue.
Harm reduction has almost universally been presented as
the “self-evidently correct” approach to the problems associated with drug use, while critical reflections about the paradigm have been very rare. At least this was the case when
236
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
the idea of harm reduction was first intro-
model, whereas abstinence is founded on
duced to the world in the late 1980s and in
medical and religious paternalism. Harm
the decade that followed. In 1989, for ex-
reduction is linked with humanitarianism,
ample, the Dutch sociologist Eddy Engels-
whereas abstinence-oriented approaches
man (1989) presented the concept with the
are associated with repressive policies of
following words: “The Dutch being sober
control. It is not hard to see which drug
and pragmatic people, they opt rather
policy Newcombe himself favours.
for a realistic and practical approach to
A somewhat later example can be taken
the drug problem than for a moralistic or
from the American psychologist and social
over-dramatized one” (p. 212). Engelsman
researcher G. Alan Marlatt. He too gives a
presents harm reduction as the opposite of
very positive account of harm reduction,
a moralistic control policy based on false
writing for example:
premises. According to him, the sensible
“Harm reduction offers a pragmatic
harm reduction approach to drugs in the
yet compassionate set of principles
Netherlands is built on a recognition that
and procedures designed to reduce the
drug-related problems are not a matter for
harmful consequences of addictive be-
the police and the judicial system, but
haviour for both drug consumers and
primarily a question of health and social
for the society in which they live.”
welfare.
(Marlatt 1996, 779)
Another advocate of and leading pio-
Here, again, the relationship between
neer in harm reduction during the period
harm reduction and other approaches is
when the paradigm was being established
presented in either-or terms. Either one
was Russell Newcombe, who is attached
is in favour of harm reduction – in the
to Merseyside . In a collection arising from
shape in which it is presented by the au-
discussions at the Liverpool conference
thors – or one is an opponent of scientific
on harm reduction in 1990, Newcombe
research, common sense, humanitarian-
wrote the seminal article: “The reduction
ism, public health and compassion. And
of drug-related harm: A conceptual frame-
as Nadelmann was quoted as saying in the
work for theory, practice and research.”
epigraph: “Who in their right mind could
Here harm reduction is (again) presented
oppose the notion of reducing harm?” – if
as the sensible alternative to a moralistic
harm reduction is comprehended as a rep-
abstinence-oriented policy:
resentative for all these things?
1
“Harm reduction has its main roots in
The attitude towards harm reduction
the scientific public health model, with
among Danish researchers in the field
deeper roots in humanitarianism and
has been almost unconditionally positive
libertarianism. It therefore contrasts
as well. One of the warmest advocates
with abstentionism, which is rooted
of harm reduction in Denmark is Jørgen
more in the punitive law enforcement
Jepsen, who like many other social re-
model, and in medical and religious
searchers combines a positive view of
paternalism.” (Newcombe 1992, 1)
harm reduction with sharp criticism of
The battlefronts are thus drawn up:
the “repressive policy of control” (Jepsen
harm reduction is based on a scientific
2000; 2001). Jepsen is especially critical of
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
237
Harm reduction – ideals and paradoxes
the USA for its “all-out war on drug use”.
and from individual authors in the field of
“Most peculiar is the American op-
drug research (Miller 2001; Keane 2003;
position to harm reduction measures,
Roe 2005). We will return to these contri-
both in general and in relation to
butions later in the text.
concrete measures such as injection
As a precaution we should make clear
rooms. Thus the USA and its follow-
that our purpose in this article is not to ar-
ers have for many years successfully
gue that harm reduction measures are a bad
kept the term ‘harm reduction’ out of
idea, or that a repressive control policy has
official UN documents, because they
something positive to offer. Rather, we wish
see ‘harm reduction’ as reducing the
to argue for a more considered and nuanced
impact of the all-out war on drug use.”
treatment of the harm reduction approach
(Jepsen 2001, 20)
in drug research, a treatment that is open to
Jepsen also sees the Danish policy of control as a barrier to real and practical harm
discussing the ambivalence, paradoxes and
risks that this approach entails.
reduction, and he thinks that all attempts
In what follows we take a look at the Dan-
to introduce harm-reducing measures will
ish treatment system – and in particular
remain half-hearted so long as the drug
at substitution treatment for opiate users,
field is dominated by “the illusion of an
which is strongly influenced by the con-
all-out condemnation of drug use and drug
cept of harm reduction (whether explicitly
dealing”. (Jepsen 2000, 98-99)
formulated or implicitly assumed). In par-
The above citations exemplify the way
ticular we consider the three themes men-
in which harm reduction has been pre-
tioned in the introduction: harm reduction
sented in drug research. One could have
in relation to abstinence; harm reduction
chosen numerous other examples without
as a means of increasing autonomy and re-
substantially changing the picture. The
sponsibility; and harm reduction and so-
early advocates of harm reduction often
cial integration. Under each of these head-
wrote in direct opposition to what many
ings we will relate the Danish treatment
referred to as repressive control policies,
system, as it is described by practitioners
and in this context harm reduction was
at outpatient centres in Copenhagen, to
presented as an unqualified good. Any
the international research literature on
critical examination of the harm reduc-
harm reduction.
tion principle had obviously to give way
The interviewees in this study come
to a more important cause – a fundamental
from two types of outpatient services in
showdown with the problematic policy of
Copenhagen in 2005–06: “advisory cen-
drug control.
tres” (rådgivningscentre) and “ambulatory
Recently, however, there have been a
centres” (ambulatorier). The advisory cen-
number of contributors to the drug policy
tres (of which there were four in Copen-
debate who take a more nuanced – and
hagen at the time of the interviews2) are
critical – view of the harm reduction para-
the reception units for the drug treatment
digm. These critical interventions come
system, the units through which all drug
both from the general social science litera-
users have to pass before they can be re-
ture on public health and harm reduction
ferred to various forms of treatment. Some
238
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
opiate users receive substitution treatment
all substance users, and where the very
(primarily methadone) at the advisory
term “treatment” tend to be reserved for
centres, while others are referred to the
activities directed towards this goal, while
ambulatory centres (of which there were
other activities are referred to as “care”.
nine in Copenhagen in 2005–06).
Service statistics a total of 13,316 people
Harm reduction and
abstinence
were in treatment for drug abuse in 2005.
One question on which there has been a
Three quarters of the clients were men, and
certain amount of controversy in the in-
the average age was 37. Statistics on the
ternational literature concerns the relation
distribution of various forms of treatment
between harm reduction and abstinence.
show that 82 percent of the clients in Co-
Some authors argue that harm reduction
penhagen were in outpatient treatment in
by definition is aimed neither at abstinence
2005, while only six percent were admitted
nor at a reduction in intake. For others ab-
for inpatient treatment (the proportion of
stinence remains an ideal goal even within
“unknowns” however was relatively high
the harm reduction paradigm – although
– 11 percent). Neither the Health Service
there are other goals (related to the mini-
nor Copenhagen Municipality has infor-
mization of harms) they regard as more
mation on the percentages of opiate users
immediate. A third group sees abstinence
given substitution and drug-free treatment
or intake reduction as a way of reducing
respectively, but the existing treatment
harm, and hence as a means in the harm
statistics suggest that most opiate users are
minimization approach but not as a goal
receiving some form of substitution treat-
in itself.
According to Danish National Health
ment (primarily methadone).
The Canadian sociologist Eric Single
When we, in what follows, analyse the
has come up with a definition that is often
practice of harm reduction at advisory
quoted as a typical example of the first po-
centres and ambulatory centres, we are
sition: i.e. an approach that excludes the
therefore looking at an absolutely key part
goal of abstinence. He defines harm reduc-
of the treatment system for drug users in
tion as follows:
Copenhagen. Substitution treatment on an
“A policy or program directed towards
outpatient basis, accompanied by practi-
decreasing adverse health, social and
cal support from a social worker and con-
economic consequences of drug use
sultations with a contact person, is the
even though the user continues to use
main form of treatment for opiate users
psychoactive drugs at the present time
in Denmark today, while more intensive
[…] abstinence-oriented programs […]
forms of psychosocial treatment aimed at
would not be considered harm reduc-
abstinence (in either an inpatient or an
tion measures.” (Single 1995, 289)
outpatient setting) account for only a min-
G. Alan Marlatt, whom we quoted earli-
imal proportion of client contacts. In this
er, can be seen as an example of the second
respect Denmark deviates from the pattern
position. In Marlatt’s definition of harm re-
in the other Nordic countries, where in
duction the crucial point is that the princi-
general abstinence is the overall goal for
ple recognises abstinence as the ideal goal,
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
239
Harm reduction – ideals and paradoxes
but that a minimization of negative drug
tres, where the interviewee is answering
use consequences is seen as a valuable am-
the question about the goals of his work:
bition too. Marlatt (1996; 1998) describes
Answer: The focus is on the social side,
harm reduction in terms of a continuum,
on the level of functioning. How well
with abstinence at the positive end of the
are [the users] functioning and how
scale and high-risk drug use at the nega-
are they doing? […] It’s not that we’re
tive end. Instead of posing a dichotomy
against it [abstinence]. But we believe
between two extremes (abstinence or a
fundamentally that it’s a question of
focus on harms), Marlatt recommends an
harm reduction and of supporting the
approach that encourages any step in the
drug user on the path he or she wishes
direction of less risky and harmful behav-
to take, for his or her sake […]
iour.
Question: What’s your impression, do
Finally, as mentioned above, abstinence
your drug users want to be drug-free?
or reduced intake can be seen as means
Answer: No, not all of them. Some
of reducing harm without being goals in
do. Some have been trained for years
themselves. The American researchers
to talk about abstinence. I mean, after
Don des Jarlais et al. (1993) express this
years of going through the treatment
position in their definition of harm reduc-
systems they’ve learnt that what you
tion:
have to say when you walk in the door
“Harm reduction simply calls for re-
is “I want to be drug-free” […] And we
ducing the harmful effects of drug use.
spend a lot of time, especially with
If reducing the drug use is the only
new users, on teaching them that that
way in which harmful consequences
doesn’t impress us...
can be reduced, then reduction is nec-
(Interview with a practitioner at an
essary. For many types of drug-related
ambulatory centre).
harm, however, it is possible to reduce
The interviewee in this extract evidently
at least a substantial part of the harm
believes that the majority of the centre’s
without necessarily eliminating (or
clients do not actually want to be drug-free.
even reducing) the drug use itself.”
If they say they do, this is because of their
(Des Jarlais et al. 1993, 424)
previous experience with treatment, i.e. be-
The relationship between harm reduc-
cause they have been socialised to say what
tion and the goals of abstinence or reduced
“the systems” prefer to hear. This concep-
intake has been a central theme in our in-
tion of the users being taught to say they
terviews with representatives of the Dan-
want to be drug free is related to another
ish treatment system. What view does the
widely shared opinion among the staff at
staff at the advisory centres and ambula-
the centres: the idea that abstinence is an
tory centres take of the goal of abstinence
unrealistic goal for the vast majority of opi-
and reduced intake, and is it possible to
ate users, and that drug-free treatment can
combine such goals with – or incorporate
do them more harm than good. One practi-
them into – a harm reduction approach?
tioner made the following statement about
Here is an extract from an interview with a
abstinence-oriented treatment:
representative of one of the outpatient cen240
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
”I really think that you create more
Harm reduction – ideals and paradoxes
failures for the individual user […]
the users have at long last arrived at af-
[Those] who are least well-function-
ter many years’ negative experience with
ing socially have a chance of getting
other forms of treatment. The interviewee
through their treatment – or a risk of
compares the clients’ admission to the
getting through their treatment, as
outpatient centre to the change that takes
I tend to call it – of about five to ten
place in the life of a person on social se-
percent […] And for god’s sake you
curity when he or she is granted an early
shouldn’t give the most down-and-out
retirement pension. Just as the recipient of
people still more defeats […] This also
a pension achieves financial security and
means that the people who make the
is freed from the requirement to seek work
decisions should have nerves of steel...
(or accept retraining and/or comply with
It shouldn’t be a case of drug users com-
other conditions for receiving benefit),
ing in the door at ten o’clock and out
so the outpatient clients get “security of
again and getting a place in outpatient
provision with regard to their drugs” and
treatment at two o’clock. If you do it
escape “well-meaning care workers and
like that, it rarely has much effect. But
people who have become drug-free them-
the dogma [of abstinence] still persists
selves and have just discovered how it all
and it’s kept going by the supporters of
should be done.” (Interview with a practi-
drug-free treatment.”
tioner at an ambulatory centre).
(Interview with a practitioner at an
ambulatory centre).
Thus practitioners at the outpatient centres by and large take the view that drug-
A practitioner from another ambula-
free treatment is pointless for their clients.
tory centre says the following about absti-
A couple of practitioners nevertheless
nence:
make clear that sometimes the centres
“It isn’t our job to motivate people
receive clients “too early”, i.e. clients for
to become drug-free in that way. The
whom abstinence would have been an ap-
idea is to give them a refuge here […]
propriate goal:
With these people what we’re saying
“Sometimes, though, you think, this
is that they should be left in peace to
is unbelievable […] because in actual
have their drugs from now on and till
fact we get people coming in the door
they die, or until they decide that they
who have never received any drug free
don’t want to take drugs any more […]
treatment […] They are sent here from
Because these people – I’d almost say
the advisory centres where care work-
they have been ‘treatment abused’ all
ers and social workers and you-name-
of them.”
it sit and make their decisions.”
(Interview with a practitioner at an
(Interview with a practitioner at an
ambulatory centre).
ambulatory centre).
Thus this interviewee too thinks that
Once the users are sent from the advi-
drug-free treatment is potentially injuri-
sory centres to the ambulatory centres, it
ous to opiate users (cf. the expression
is not easy to “change track” within the
“treatment abused”) and sees the out-
treatment system, according to these prac-
patient centre as a place of freedom that
titioners:
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
241
Harm reduction – ideals and paradoxes
“It’s difficult, because – I mean, the
in the context of harm reduction treat-
whole idea of having them sent here
ment. Harm-reducing treatment is often
‘on a pension’ has far-reaching conse-
based on the premise that drug addiction
quences. When the users have come
is a chronic condition and that abstinence
here, it’s very difficult for us to get
therefore is an illusory goal. Several of
them into drug-free treatment and it’s
the practitioners whom Koutroulis inter-
also difficult to get them into stabilis-
viewed felt that they faced a dilemma if
ing treatment [residential care, where
their clients said that their goal was to be
the goal is not abstinence]. The doors
drug free. The practitioners believed that
tend to close up once people have got
the clients’ desire to stop using drugs was
here, because by then they’ve been
often connected with problems in the here
dumped at the terminus.”
and now (lack of money, difficulties with
(Interview with a practitioner at an
personal relationships, problems with the
ambulatory centre).
police and so on), and that their desire to
If we relate the interviewees’ statements
be drug free was likely to evaporate once
to the international debate on harm reduc-
these acute problems were solved. They
tion vs. abstinence discussed above, we
therefore regarded abstinence as a difficult
can establish the following: the goal of ab-
goal to work with. Koutroulis describes the
stinence is not an integral part of the harm
dilemma as follows: “There is a tension
reduction paradigm at the outpatient cen-
concerning what the client says he or she
tres. To be sure, the practitioners say that
is going to do (abstain), what the clinician
harm reduction can in principle embrace
anticipates the client will do (not abstain),
abstinence as a goal – “the absolutely sev-
and the provision of harm reduction pre-
en-star way of doing it [harm reduction]
vention” (ibid., 7). Despite differences in
is to get the user off drugs altogether”, as
the way harm reduction is practised in an
one of them puts it. It is merely that this
Australian and a Danish treatment context,
goal is irrelevant for their client group. In
both Koutroulis’ and our study encounter
principle they endorse the idea of Mar-
the same paradox when it comes to the
latt’s continuum, in which abstinence is
relationship between harm reduction and
the ideal goal beyond the partial goal of
abstinence: “In theory, harm reduction of-
harm reduction. In practice, however, they
fers choices about drug use (abstinence
obviously work with Single’s approach to
or continued use). In practice, balancing
harm reduction, an approach in which ab-
harm-reduction messages with abstinence
stinence is not a goal, and in which harm
proved to be difficult” (ibid., 15). Many of
reduction is presented as on opposite to
the Danish practitioners we interviewed
drug-free treatment.
are so convinced that abstinence is an im-
These findings accord with those of the
possibility for opiate users – and this ap-
Australian sociologist Glenda Koutroulis
plies not only to the clients at the ambula-
(2000) in her study of the treatment sys-
tory centres but to opiate users in general
tem in Melbourne. It is not easy – and it
(with the exception of the very youngest)
is often considered pointless by the prac-
– that they regard drug-free treatments as ir-
titioners – to include abstinence as a goal
relevant for this group, or even as harmful.
242
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
Harm reduction, autonomy
and responsibility
ladsen & Gruber 1999; Åkerstrøm 2003;
As several researchers have mentioned,
social work in Denmark has consisted not
harm reduction rests on a paradigm that
merely in offering clients the help they
assumes rational behaviour on the part
need and are entitled to, but to a grow-
of individuals who are willing and able
ing extent in fostering the idea of the cli-
to take responsibility for their actions.
ent’s duties and responsibilities (Carstens
The public health researcher Tim Rhodes
1998). In this respect developments in
(2002) uses the British harm reduction
Denmark reflect the international shift
programme for needle exchange as an il-
towards a “combined autonomization/re-
lustration. In public-health-oriented poli-
sponsibilization” of social welfare clients
cies, the drug user is perceived as a “health
(Rose 2000, 1400). Treatment, and social
conscious” citizen capable of taking ra-
work in general, are perceived as an ani-
tional decisions based on public recom-
mating force that is expected to help peo-
mendations concerning risk minimization.
ple take responsibility, monitor risks, and
While formerly, the disease model of drug
act rationally and with forethought (Rose
addiction created a picture of the drug user
2000, 1399, cf. also Foucault 1982). In
as a slave to his/her dependence, incapa-
this new socio-political era it is no longer
ble of taking rational decisions, today, the
the practitioners and social workers who
harm reduction paradigm has inaugurated
are supposed to define the clients’ goals
a very marked shift. Rhodes speaks of an
or to press them to find solutions to their
individualisation of risk behaviour and
problems, because it is believed that this
risk minimization. Individuals who are in-
approach leads to “clientization”. On the
formed about different kinds of risks and
contrary, it is the clients themselves – or
about how to avoid them are also expected
the “users” as they are called in the new
to act on this information (Rhodes 2002).
terminology – who are supposed to set the
The Australian criminologist O’Malley
goals, suggest the means and act in accord-
(1999, 198) describes the shift in thinking
ance with the goals they have chosen.
in these words:
Villadsen 2004). Ever since the late 1980s
In our interviews the discourse of auton-
“In the new discourse, in place of
omization/responsibilization is very prom-
the drug-slave, we have the drug-us-
inent. Hence all interviewees pronounce
ing subject who becomes a consumer
that it is the clients themselves – defined
choosing from a range of drugs, the
as autonomous users (users of drugs; users
risks of which are clearly outlined and
of services) – who should take responsibil-
known […] freedom of choice becomes
ity in relation to their treatment. In the fol-
a dominant theme in descriptions of
lowing extract a practitioner at an advisory
drug users, who, in effect, become
centre explains her view of the client’s role
‘choice-makers’.”
in treatment. The interviewee emphasises
As many researchers have pointed out,
the client’s own initiative, and takes excep-
social work – including social work with
tion to the term “goal”, which she obvious-
drug users – has tended increasingly to
ly regards as something imposed on clients
focus on clients’ “self-management” (Vil-
from outside – and from above:
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
243
Harm reduction – ideals and paradoxes
Question: How would you describe the
(Interview with a practitioner at an ad-
goals you have in relation to the peo-
visory centre).
ple you are contact person for?
Although our interviewees in general
Answer: What do you mean by
regard the new focus on the clients’ auton-
goals? It’s one of those frightfully fine
omy and responsibility as a positive thing,
words that smell of forms with the Co-
some of them point at potential problems
penhagen Municipality logo on […]
in this development. A treatment system
We try as far as possible to be on an
built on the assumption that all initiatives
equal footing with our clients; we ac-
must come from the user him/herself can,
cept that it’s they who are the manag-
according to these interviewees, easily
ing directors in their own lives […]
bring about a situation where social work
We don’t see ourselves as judges or as
comes to revolve around the users who
wiser [than they are] and we don’t set
are most active and demanding. A practi-
out treatment plans that are just fancy
tioner at an advisory centre says: “After all
words on paper […] If it doesn’t come
they have to come and tell us if they want
from inside, it doesn’t come at all […]
something to change, because otherwise
Compassion after all can easily be so
nothing may happen. So they had better
suffocating that it takes away their
be capable of speaking up. And of course
own initiative.
not all of them are capable.” What this
(Interview with a practitioner at an
practitioner suggests, then, is that not all
ambulatory centre).
drug users come and ask for help, either
In the following extract a practitioner at
because they are unable to formulate their
an advisory centre explains the difference
wishes, or (perhaps) because they do not
between responsible drug users and users
know what they want.
who have been “clientized”:
Thus the client’s “goals” are not neces-
”I very much believe that users are
sarily a clearly delimited and easily com-
much more aware of their own respon-
municated phenomenon that the practi-
sibility nowadays, that they want to be
tioner can embark from without further
seen as equal partners in a negotiation
ado. The interviewee above also admits
and I really think many of them are very
that she can easily end up giving priority
focused on this. And then there are oth-
to clients who have clear wishes – at the
ers who – how should I put it – are so
expense of those who are unable to for-
clientized that in principle they virtual-
mulate a goal: “They can easily get a bit
ly can’t wipe their own asses […] They
lost. At any rate they have done so recently
are so socially adapted to the system
when we’ve been rather busy.” On the oth-
that they can’t actually function unless
er hand several practitioners believe – and
the system in one way or another pro-
here we come back to the emphasis on the
vides a very high level of servicing […]
client’s own responsibility – that it is both
And for them it’s a strange thing that
natural and legitimate to prioritise in this
they are supposed to act differently
way. A practitioner at an advisory centre
now when the wind’s blowing in a new
says, for example:
direction”.
244
N O R D IC STUDIES ON ALCOHOL AND DRUGS
“My working hours are organised in
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
such a way that I attend to whoever
conception of the user as strong-willed and
approaches me with a request; all the
enterprising – the users are “the managing
others who do not approach me with
directors in their own lives”, as one of the
a request or whatever, I do nothing
interviewees formulated it above. These
about because that’s the way my time
conceptions, however, are at odds with
has been prioritised […] Those who
the notion that opiate users are forever in
come to me and say they want an ap-
thrall to their craving for drugs, and that
pointment will get an appointment,
any expressed desire on part of the clients
and those who come to me lots of times
to become drug free cannot be taken seri-
will get lots of appointments […] I also
ously. Drug users are thus defined both as
feel it’s somewhat a matter of strategy,
being submitted to the power of drugs, and
that when it comes to intervention, it
therefore as incapable of taking charge of
should be in relation to people who ask
their own lives, and as autonomous indi-
for help, right? […] I do what I should
viduals who are capable of setting plans
do in relation to those who approach
and formulating a request for help. The
me and want help – and beyond that I
decisive point here seems to be whether or
can’t really take responsibility.”
not the users’ plans square with the harm
On a busy working day the interviewee
reduction paradigm. If the users say they
feels that he is doing what can reasonably
want stabilisation, they tend to be regarded
be expected of him by attending to the re-
as reasonable; if they express an interest in
quests that users approach him with. As
becoming drug-free, their plans tend to be
for the users who do not formulate any
regarded as unrealistic and ill-adviced.
goals or do not ask for his help in realising
ity”. The interviewee’s way of reasoning is
Harm reduction and social
integration
a logical outcome of the structure of the
The final point we wish to deal with in
Danish treatment system and of the idea
this article concerns the various (health-
of the autonomous user that the harm-re-
related and social) objectives of the harm
duction approach entails. The problem
reduction approach as it is practiced at the
that should be noted here is that this ra-
outpatient centres in Copenhagen.
their goals, he “cannot take responsibil-
tionale poses considerable and perhaps
A review of the international literature
unrealistic demands on the user. In our
on harm reduction reveals that the health-
interviewees’ understanding, a process
related goals of harm reduction are con-
of change can only be initiated by the us-
siderably more clearly described than the
ers, and it is only the users who can take
social objectives. Among the health-re-
this process further by initiating the staff
lated goals are, for instance reducing the
into their plans; the practitioners can only
number of deaths from overdose, limiting
take action when the users ask them to do
HIV infection, and reducing injury through
so. The interviewees thus operate with a
injection. Broadly speaking there is a pre-
strongly individualistic understanding of
vailing consensus here that a number of
the user, of his/her problems and poten-
harm-reduction measures – including, not
tial for change, and at the same time with a
least, methadone treatment – do in fact reN O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
245
Harm reduction – ideals and paradoxes
duce the number of deaths from overdose,
in the context of concrete treatment? Is
HIV infections and injection injuries, and
harm reduction, for example in the form
this consensus appears to have a well-doc-
of methadone treatment, a permanent so-
umented foundation. (e.g. Coppel 2000;
lution for the clients at the centres, or is
Wolf et al. 2003)
it the first step in a long-term treatment
By contrast the impact of harm reduction measures on the social integration of
scheme involving progressively steppedup objectives aimed at social integration?
drug users is relatively unresearched. In
The answer to the last question is rela-
this area too, however, ambitions are high.
tively clear. A large proportion of the meth-
Once methadone prescription, needle-ex-
adone clients – and this applies especially
change programs, injection rooms and so
to opiate users in the 35–40 age group and
on have ensured an improvement in drug
above – will be on substitution treatment
users’ state of health and a reduction in
for the rest of their lives. The objective
their stress levels, there is an expectation
for these drug users is not to “normalise”
that the long-term social benefits of harm
their situation within various social are-
reduction will begin to appear, in the form
nas (employment and family relations for
of a better integration of drug users in soci-
instance), but to help ensure that their life
ety. And once the drug users do no longer
is made as tolerable as possible. A
���������
practi-
constitute such a big law and order prob-
tioner at an ambulatory centre says:
lem – because they reduce their criminal
“Most of the clients we have here
activities and because they no longer shoot
are not that young, and now they’ve
up in the street and leave syringes in parks
reached a place in their lives where
or on the stairways – they will be met
they’re getting methadone, so they can
with more acceptance and respect from
have a bearable life till they’re put in
their surroundings (Marlatt 1998; Springer
the grave […] But we still have to make
2000; Tammi 2004). As far as its social im-
a plan of action and a treatment plan for
pact is concerned, then, harm reduction is
them, that’s a legal requirement […] So
thought to lead to a “normalisation” of the
we have these plans of action and they
drug users’ situation, increased involve-
can consist of anything from putting
ment in various social arenas (work, fami-
up some curtains to making contact
ly and so on), and a lessening of the extent
with mum and dad […] [but] a treat-
to which drug abusers are stigmatised and
ment plan is a bit more tricky where
shunned by mainstream society.
the older generation is concerned […]
In our study the debate about the various
I know this is a dangerous thing to say,
social objectives of harm reduction leads
but that’s how it is.”
to questions such as these: If abstinence
(Interview with a practitioner at an
is not the goal for (all) opiate users, what
ambulatory centre).
long-term goals is the staff at the outpa-
A practitioner at an advisory centre de-
tient centres actually working with? The
scribes the “older” drug users as follows,
term “social integration” is often used by
and contrasts them with 25-year-old us-
advocates of the harm reduction approach,
ers, for whom the treatment system should
but what does the concept actually mean
have “bigger or different goals”:
246
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
“I mean people who’ve been on the
heads high” and say to the people around
scene […] for years and years […] and
them: “I have been a drug addict for many
have chosen to say, I admit that I’m
years, and now I’m getting methadone,
going to be on methadone for the rest
and I don’t take anything on the side. It’s
of my life […] If they want to totter
just great, and I feel great about it, and
around without having someone get-
that’s how I’m going to live the rest of my
ting at them every other minute […]
life”. However, the same interviewee also
I’m not the one to run after them […]
says that this is unrealistic, because so-
In my opinion one can certainly be a
ciety (and drug users themselves) have a
happy pensioner on methadone […] But
completely different attitude towards drug
if you’re 25 years old and have been
addiction than towards diabetes. She has
through two or three years of drug use
never met a drug user who is proud of be-
it may be that you’ll get […] a couple
ing in methadone treatment, she says, and
of practitioners after you who want to
moreover she doubts that there are any
set some slightly bigger or slightly dif-
“clean” methadone users, i.e. clients who
ferent goals [than methadone mainte-
do not take other drugs on the side. She
nance]. In these cases we expect other
therefore draws the following conclusion
things from them than just keeping
about harm reduction:
their eyes fixed on the medicine cabi-
“On the one hand it’s really, really good
net.”
to help people to improve their quality
(Interview with a practitioner at an ad-
of life. On the other hand I think that
visory centre).
[…] you probably make them remain
The general attitude towards the “older”
in a state of dependency […] I don’t
drug users is that they should be left “in
personally know anyone who has suc-
peace and quiet” (this wording recurs in
ceeded in being stable without periods
many interviews) both in the sense that
of drug abuse on the side.”
they should have a place to live and basic
(Interview with a practitioner at an ad-
economic security, and that they should
visory centre).
be exempt from more ambitious attempts
Here the practitioner is articulating one
at treatment, activation or change in gen-
of the most difficult dilemmas associated
eral. Several interviewees describe drug
with harm reduction – the potential for
addiction as a form of chronic disease,
improved quality of life versus the risk of
which like other diseases requires medi-
persistent or increasing marginalization.
cation (methadone), but which in other
This is a dilemma that demands more at-
respects can easily be combined with a
tention both in research and in practice.
good quality of life. A practitioner at an
advisory
centre
compares
methadone
Conclusion
treatment with insulin treatment for dia-
We will conclude this article by returning
betics, and says she wished that drug users
to the criticisms that have been formulated
could relate as naturally to their illness as
in relation to the harm reduction paradigm.
diabetic patients do to theirs. According to
To begin with, however, let us summarise
her, methadone clients should “hold their
the paradoxes described above.
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
247
Harm reduction – ideals and paradoxes
First, many social researchers and prac-
tendency for the clients to be treated as ra-
titioners consider harm reduction and
tional when their wishes accord with the
the goal of abstinence as fully compatible
harm reduction paradigm and as irrational
– but in practice conflicts arise between
if they express a desire to become drug
the two approaches. Abstinence as a goal
free. This is natural enough, since prac-
is often abandoned in advance at institu-
titioners after all regard opiate addiction
tions adhering to the paradigm of harm re-
as a chronic condition, and long-term/life-
duction, and the work at such institutions
long methadone prescription as the only
is therefore focused on other things than
sensible solution to the problems of addic-
abstinence: stabilisation with the help of
tion.
methadone treatment, and practical assist-
The relationship between harm reduc-
ance in relation to economy and housing.
tion and the combined “autonomization/
In the treatment system in Copenhagen the
responsibilization” approach (Rose 2000,
harm reduction paradigm rests on the idea
1400) thus becomes very complex. On the
that “older” opiate users (people over 35–
one hand the harm reduction paradigm
40 years – but in practice the category also
presupposes that practitioners show re-
includes younger people) neither want to
spect for their clients’ integrity and au-
become, or are capable of becoming, drug-
tonomy, and this indeed seems to happen
free. Measures aiming at abstinence are
both at the advisory centres and at the am-
therefore not an integral part of the work
bulatory centres. Methadone treatment is
at the outpatient centres. Indeed, the op-
administered with a minimum of control
posite is true: many practitioners see it as
and sanctions: the clients have a great deal
their task to treat sceptically any statement
of say in their own treatment (methadone
on part of the clients indicating that they
dosage, other medication, levels of attend-
want to become drug-free, and to persuade
ance and so on) and every attempt is made
them to adopt the more realistic goal of
to avoid “clientization”. On the other hand
stabilisation.
one could maintain that, for certain groups
Second, harm reduction is linked to the
of users, the very strong emphasis on the
perception that all initiatives to change
individual’s responsibility for his/her own
must come from the users themselves,
problems can endanger the client’s digni-
otherwise any attempt at treatment is seen
ty. Contrary to the widespread assumption
as fruitless. At the same time many prac-
that the harm reduction approach almost
titioners say that clients do not always
automatically reduces moral blame, in
come to them and ask for the help they
some cases harm reduction can have the
need. The users’ lives are often so chaotic
very opposite effect: less dignity for drug
that the staff does not expect them to set
users who are unable to formulate their
out realistic plans for the future or formu-
wishes or whose wishes are brushed aside
late wishes that could lead to action. Thus
because they are not regarded as genuine
the interviewees see their clients both as
or realistic, and more moral blame because
autonomous and competent to take deci-
in theory all drug users have access to in-
sions, and as helpless and in thrall to the
formation about the best ways of reduc-
power of drugs. Furthermore, there is a
ing harm and help in realising whatever
248
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Harm reduction – ideals and paradoxes
wishes they may have. Thus failure to act
ers have entered a blind alley where they
on this help and information – and failure
are almost automatically put on long-term
to act in accordance with the principles
methadone treatment without any thor-
defined by the treatment system – may in-
ough discussion of possible alternative
deed be seen as blameworthy.
treatments and of what the actual goals
Third, advocates of the harm reduction
of methadone treatment should be in
paradigm often maintain that harm reduc-
the long run. Methadone treatment has
tion, for example in the form of metha-
thus developed into a “lifetime” treat-
done treatment, allows clients to achieve
ment even for clients who perhaps should
greater social integration. The question is
have been offered alternatives: “ ‘Mature’
whether this is true. Social integration as
medical harm reduction can be seen as a
a phenomenon is not very clearly defined
move from a problematic ‘curative’ model,
at the advisory and ambulatory centres,
through prohibition and treatment, to an
but in practice it appears to mean that
equally problematic ‘palliative’ model”
methadone clients (like all other vulner-
(Roe 2005, 248). Roe also believes that the
able citizens in Denmark) are entitled to
harm reduction paradigm has not replaced
receive social benefits in the form of hous-
the disease model in the drug field, but in-
ing and financial support. In addition they
stead expanded it: “It has also extended
are offered varying levels of contact with
the ‘disease’ model of addiction, labelling
practitioners, and at some of the centres
drug users as permanently disabled by
opportunities to participate in social ac-
their dependence on drugs” (ibid., 247).
tivities (visits to a summer cottage, sports,
According to this argument, harm reduc-
watching films, eating together etc.) All this
tion has led to a medicalization of drug
can contribute to stabilising the client’s life
users’ problems, including problems that
circumstances, but does not necessarily
are fundamentally social in nature, which
lead to social integration in a more ambi-
in practice can mean that any attempt to
tious – some would say traditional – sense.
find long-term solutions to such problems
The interviews give the overwhelming im-
is blocked.
pression that methadone clients are – and
Roe subscribes to the Foucault-inspired
remain so over the years they are enrolled
tradition of research around “governmen-
at the centres – highly marginalized citi-
tality”, a tradition in which one also finds
zens whose lives are marked by loneliness,
other critics of the public health principles
untreated psychological problems, social
on which harm reduction is founded (cf.
rejection, and the tendency to “keep their
Mugford 1993; Miller 2001). These critics
eyes fixed on the medicine cabinet”, as one
do not say that it is problematic in itself
practitioner was quoted as saying above.
to base drug treatment and policy on pub-
The Canadian sociologist Gordon Roe
lic health principles – only that the new
(2005) is of the opinion that in practice
principles are not necessarily as “empow-
harm reduction does not live up to the
ering” and free from moral judgement as
objectives originally set out by advocates
is often claimed. According to Miller and
of the paradigm. According to him, this
Rose (1993), public-health-based policies
approach has meant that many opiate us-
represent part of a neo-liberal developN O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
249
Harm reduction – ideals and paradoxes
ment project that is aimed, to be sure, at
rests on an (explicitly formulated or im-
ridding the system of bureaucracy and ex-
plicit) disease model. The clients’ condi-
cessive mollycoddling of the individual,
tion is regarded as “incurable”, it is often
but at the same time entails new forms of
compared to other chronic diseases (such
control and moral judgement.
as diabetes) and the users are expected to
Petersen and Lupton (1996) describe
need their medicine for the rest of their life
the consequences of the public health per-
in order to be able to function “normally”.
spective for various groups in society, not
This normality, however, does not include
least for those who for one reason or other
social integration in the traditional sense
have problems in living up to the demands
of the word (in relation to work, education
of “responsibility” and rational risk man-
and family).
agement. According to Petersen & Lupton,
The optimistic spirit in which the
the public health perspective is built on
harm reduction approach was original-
a notion of “the entrepreneurial self, that
ly launched should be accompanied by
is, the self who is expected to live life in a
greater attention to these aspects of con-
prudent, calculating way and to be ever-
crete harm-reduction practice. In focus-
vigilant of risks”. The logical consequence
ing on these aspects, however, we should
of this is that an unwillingness on the part
not throw the baby out with the bathwa-
of certain citizens to live up to expecta-
ter. There is a clear justification for harm
tions concerning risk management, or
reduction measures within the treatment
difficulties in doing so, leads to their stig-
system, and a critical discussion of such
matization for “a failure of the self to take
measures should not of course lead to a re-
care of itself” (p.16).
turn to control, restrictions and clientiza-
We agree with Petersen and Lupton in
tion. Nevertheless, in a treatment system
these considerations and with Roe in the
such as Denmark’s, which has undergone
arguments presented above. In Denmark as
radical development in the last fifteen
elsewhere it appears that opiate users are
years, it may be time to pause and reflect
referred for substitution treatment without
on whether the discrepancy between the
any thorough discussion of alternatives or
original ideals of the harm reduction para-
of what the long-term objectives of such
digm, and the reality at actual treatment
treatment should actually be. And in Den-
centres, has become too great.
mark, too, the harm reduction approach
appears to have led to a massive increase
in medical treatment within the field of
drug addiction: methadone prescription
is the dominant form of treatment offered,
and “guaranteed provision” of opiates appears to be the main reason for methadone
clients to come to the outpatient centres
in the first place. In addition, we can see
from our interviews that the practitioners’
understanding of their clients’ problems
250
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Ditte Andersen, Research assistant
The Department of Sociology
University of Copenhagen
Øster Farimagsgade 5
1014 Copenhagen K, Denmark
E-mail: [email protected]
Margaretha Järvinen, Professor
The Department of Sociology & The Danish
National Institute of Social Research (SFI)
Herluf Trolles Gade 11
1052 Copenhagen K, Denmark
E-mail: [email protected]
Harm reduction – ideals and paradoxes
NOTES
1) In 1992 Newcombe became the director
of the “Drugs & HIV Monitoring Unit”
under Mersey Regional Heath Authority in
Liverpool.
2) The article describes the situation in June
2006.
REFERENCES
Carstens, A. (1998): Aktivering, klientsamtaler
og socialpolitik. København: Hans Reitzels
Forlag
Coppel, A. (2000): Drug Policy – the French
Situation. In: Springer, A. & Uhl, A. (eds.):
Illicit Drugs. Patterns of Use – Patterns of
Responses, pp.115–119
Des Jarlais, D.C. & Friedman, S.R. & Ward, T.P.
(1993): Harm reduction: A Public health
Response to the AIDS Epidemic Among
Injecting Drug Users. Annual Review of
Public Health 14, 413–50
Engelsman, E. L. (1989): Dutch Policy on the
Management of Drug-related Problems.
British Journal of Addiction 84: 211–218
Foucault, M. (1982): The Subject of Power.
In: Dreyfus, H.L. & Rabinow, P. (eds.): Michel Foucault: Beyond Structuralism and
Hermeneutics. Brighton: Harvester Press,
208–226
Jepsen, J. (2000): The Danish Harm Reduction
Debate – Actors and Influences. In: Springer, A. & Uhl, A. (eds.): Illicit Drugs. Patterns
of Use – Patterns of Responses, 91–102
Jepsen, J. (2001): Narkotikakrigens ofre.
Afskedsforelæsning. Center for Rusmiddelforskning, Aarhus Universitet
Keane, H. (2003): Critiques of Harm Reduction, Morality and the Promise of Human
Rights. International Journal of Drug Policy
14 (3): 227–232
Koutroulis, G. (2000): That Original Tension.
Negotiating Abstinence in Clinicians’ Accounts of Harm Reduction in Nonresidental
Treatment of Heroin Withdrawal. Journal
of Substance Abuse Treatment 19 (1): 89–98
Marlatt, G. A. (1996): Harm Reduction: Come
as you are. Addictive Behaviors 21 (6):
779–788
Marlatt, G. A. (1998): Harm Reduction. Pragmatic Strategies for Managing Harm-Risk
Behaviors. New York: The Guilford Press
Miller, P. (2001): A Critical Review of the
Harm Minimization Ideology in Australia.
Critical Public Health 11 (2): 167–178
Miller, P. & Rose, N. (1993): Governing
Economic Life. In: Gane, M. & Johnson, T.
(eds): Foucault’s New Domains. London:
Routledge
Mugford, S. (1993): Harm Reduction: Does it
Lead Where its Proponents Imagine? In:
Heather, N. & Wodak, A. & Nadelmann, E.
& O'Hare, P. (eds.): Psychoactive Drugs and
Harm Reduction: From Faith to Science.
London: Whurr Publishers, 21–33
Nadelmann, E. (1993): Progressive Legalizers,
Progressive Prohibitionists and the Reduction of Drug-related Harm. In: Heather, N
& Wodak, A. & Nadelmann, E. & O'Hare,
P. (ed): Psychoactive Drugs and Harm
Reduction: From Faith to Science. London:
Whurr Publishers, 35–48
Newcombe, R. (1992): The Reduction of DrugRelated Harm. In: O’Hare, P. & Newcombe,
R. & Matthews, A. & Buning, E.C. & Drucker, E. (eds.): The Reduction of Drug-Related
Harm. London: Routledge
O’Malley, P. (1999): Consuming Risks: Harm
Minimization and the Government of
“Drug-users”. In: Smandych, R. (ed.): Governable Places: Readings on Governmentality and Crime Control. Brookville: Ashgate
Petersen, A. & Lupton, D. (1996): The New
Public Health. Health and Self in the Age of
Risk. London: Sage
Rhodes, T. (2002): The ’Risk Environment’:
A Framework for Understanding and
Reducing Drug-Related Harm. International
Journal of Drug Policy 13 (2): 85–94
Riley, D. & Sawka, E. & Convey, P. & Hewitt,
D. & Mitic, W. & Poulin, C. & Room, R. &
Single, E. & Topp, J. (1999): Harm Reduction: Concepts and Practice. A Policy Discussion Paper. Substance Use and Abuse 34
(1): 9–24
Roe, G. (2005): Harm Reduction as Paradigm:
Is Better than Bad Good Enough? The
Origins of Harm Reduction. Critical Public
Health 15 (3): 243–250
Rose, N. (2000): Community, Citizenship and
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
251
Harm reduction – ideals and paradoxes
the Third Way. American Behavioral Scientist 43 (9): 1395–1411
Single, E. (1995): Defining Harm Reduction.
Drug and Alcohol Review 14: 287–290
Springer, A. (2000): Harm Reduction in
Vienna. In: Springer, A. & Uhl, A. (eds.):
Illicit Drugs. Patterns of Use – Patterns of
Responses, 103–114
Sundhedsstyrelsen (2006): Stofmisbrugere i
behandling i 2005. Nye
���������������������
tal fra Sundhedsstyrelsen. Årgang 10. juni 2006
Tammi, T. (2004): The Harm Reduction School
of Thought: Three Fractions. Contemporary
Drug Problems 31 (3): 381–400
Villadsen, K. (2004): Det sociale arbejdes genealogi. København: Hans Reitzel
252
N O R D IC STUDIES ON ALCOHOL AND DRUGS
VOL. 24. 2007 . 3
Villadsen, K. & Gruber, T. (1999): Socialpolitiske diskurser – på tværs af sektorer og
organisationer. Roskilde: Roskilde Universitetscenter
Wolf, J. & Linssen, L. & De Graaf, I. (2003):
Drug Consumption Facilities in the
Netherlands. Journal of Drug Issues,
����������������
33 (3):
649–55
Zajdow, G. (2005): What Are We Scared of?
The Absence of Sociology in Current Debates About Drug Treatments and Policies.
Journal of Sociology 41 (2): 185–199
Åkerstrøm Andersen, N. (2003): Borgerens
kontraktliggørelse. København:
����������������
Hans
Reitzel.