Anyone responsible for caring for sick people will pose the question as to how this care can be achieved meaningfully and efficiently. This applies in particular to the difficult care of drug addicts.

How to reach and ensure care for drug addicts is an essential question of my daily work and I am especially honoured and pleased to be able to invited to speak about such an important topic for me here today.
If you want to help, the right help must be provided, whoever wants to help effectively has to know more.; to know more, for example , as to how those needing help have got into their specific trouble, what help is required and in what way this help can be provided.

As a doctor, it is no difficult matter for me to talk about this theme, for I take as my point of departure the necessity of helping the sick, which as a doctor I am prepared to do without reservation.
However, my standpoint is obviously not shared by the majority, as is borne out by the fierce discussions in many places concerning the care of drug addicts. Quite the contrary – I even dare to maintain that the title question for many is not even a question at all.

Everyone is in agreement that serious drug addicts have to be reached. But do they really have to be helped?
A widely held view is that drug addicts are a relatively small societal group, causing enormous harm to society through procurement of criminality, which makes people insecure, endangering children through the pollution of playgrounds with infectious syringes and representing a catastrophic negative image for our youth through the fact that drug addicts maintain and beef up the dangerous drug market through their own addiction and dealing. Drug addicts disturb public security.
Many decision-makers in drug policy are therefore of the opinion when posing the question : ”How can we help them?” of in fact :” How can we get rid of them?”!

Ladies and gentlemen, please do understand me correctly: I share the standpoint of public security without reservation. Neither do I want any of my members of staff at the Health Office to again be knocked down in broad daylight and her hadbag stolen just for a few euros to buy heroin.
What I find fault with and what I offer proof against is the concealed mixture of contradictory viewpoints under one banner, for it distorts the discussion and means an impediment for us seeking real solutions.
For me myself it is easy to answer the question as to why help is to be provided for drug addicts and why specific and particular kinds of assistance must be granted.

In any European city, the victims of the addiction industry are to be seen in the most varied stages of their social and physical neglect, victims of themselves, yet alsovictims of the state`s powerlessness.
At the end of March this year, I recieved a letter from a young prisoner asking for a slot in a therapeutic programme offered by the health authorities of the City of Duesseldorf which is recognised by the judicial authorities as aprogramme where therapy instead of punishment may be practised.
This letter shows a frequent career with a socially negative burden starting in childhood, with the social decline through the father`s imprisonment, the ensuing failures at school, attendance at special shcools, the professional training failing, drifting into the drug scene, falling to heroin and cocain consumption, procurement criminality, custody, first suspended prison sentences ensuing and – never a therapy that is far-reaching.

I am strating with this letter to show you what in most cases has already happened when we attempt to help drug addicts, the victims of a disastrous life story and tale of woe.
Addiction is not a rare fate nowadays. In drug consumption, above all, in alcohol, tobacco and cannabis, Germany leads the pack world-wide. Addictive conduct, including non-substance related ones such as gambling addiction, is widely-spread in Germany.
The individual and economic subsequent costs, incurred as aresult of consumption of addictive drugs and addictive conduct, are high.
According to a report from the Federal Medical Chamber concerning the status at the end of 2003, the following is to be expected for the 81 milllion inhabitants of Germany:

9.3 million with risky alcoholoc consumption
2.7 million with deleterious alcoholoic consumption
1.7 million alcoholics
1.5 million medical drug addicts
290, 000 drug addicts, of whom
180,000 injecting drug-addicted.

According to the projected latest data of EMCDDA, of AIDS-Hilfe Deutschald and DHS. (Deutsche Hauptstelle für Suchtfragen e.V. – Main German Office for Questions of Addiction), of the approx. 180,000 injecting drug addicts to be anticipated are up to
170,000 hepatitis C infected
120,000 hepatitis B infected or anti-body positive
40,000 HIV infected.

Despite the currently approx. 30,000 therapeutic places for addicts and methadone substitution of approx. 50,000 drug addicts, the healthcare and social problems continue to increase.
Considered seriously drug-addicted in Germany is anyone who has lost his or her own flat adn is thus homeless. Up to 15% of injecting drug addicts in Germany are estimated not to have their own flat any more, corresponding to 25,000 to 30,000 people.
According to EMCDDA and DROBS figures 45,000 of all drug addicts do not have any schooling completed ; 120,000 do not have an apprenticeship/vocational traning.

The Reitox figures indicate that taking drugs in Germany is are ¼ of all adults some time or other every 14-th in the last 12 months, every 25-th in the last 30 days.
For young persons , the figures are clearly higher:
With the 15-18 year-old schollochildren every third one
has taken drugs sometime,
Every 4-th one in the last 12 months
Every 6-th within the last 30 days.
Here, the health situation of drug addicts is alarming.

In Germany, every 14-th newly HIV infected person is in contanct with the drug scene, 18%of the new AIDS patients are injectin drug users,
13% of the newly reported hepatitis B cases are drug addicts and
51% of the newly reported hepatitis C cases are addicts.

We all know that our cities are full of illegal drugs, that they are sold and consumed largely without hindrance. Anyone therefore easily imagines the financial and moral harm thus incurred.
The conditions of the street and scene have their upshot in the increased morbidity and the high degree of mortality of the addicts.
Faced with this terrible reality, many declare trhat the facts have to be accepted and that fighting sich a development by society as awhole will not bear the fruits of any success.

This view of the issues naturally simplifies the task, since it makes the discussion with the causes superfluous, because radical changes to what is happening do not appear possible anyway.
What`s worse – it only permits superficial help – help in the best instance oriented on symptoms.
Fighting diseases from the cause seems to me like therapy of an infectious desease where what is valid is to reduce the epidemic mass, to cut down on the virulence of the cause and to block its channels of transmission, i.e. analogous to drug addicts:
- to prevent the commencement of consumption when possible
- if consumption is not preventable, to put off commencement as long as possible, i.e. to delay the commencement of consumption,
- to reduce the quantity of consumption in those already consuming and to minimise secondary damage.

Help must, however, always be oriented on the individual him- or herself. The supreme order of the day in the medical sense is the ”nil nocere” – the ”non-harmful”.
In other words, help for the individual should not involve harm for the community.

Some critics of the help measures, however, fear harm from practically any kind of help for drug addicts.
I maintain that effective help for unhappy persons can never result in non-acceptable harm. Help is not only imperative for the doctor, but is charged to us all belonging to the Christian culture group arising from the ethical/humanitarian duty of Christian charity for all people.
How can harm be caused and to whom, when we make food, clothing and a place of abode available to drug addicts? Harm might only be brought about if we accept the wrong action. Providing the necessary help to drug addicts does not mean accepting their wrong actions.
Accepting a drug addict as a human being does not denote acceptance of his or her actions.
I firmly believe that this clarity in relations with drug addicts is a necessity, and that clarity and truth must distinguish our own actions.

Dismantling threshholds and enhancing availability cannot be brought about by assuming the scene lingo or by the therapist visually merging into the addicts`scene by wearing similar clothing as their patients.
For me in my relations with drug addicts, the syringe always remains the syringe, it never turns into ”gear”, as I much too often hear in drug advisory sessions. Heroin remains heroin for me, it does not turn into ”dope”.
Any addict knows that I do not use drugs. Any drug addict must also be aware of this, othewise I do not represent any kind of real orientation assistance.

Meaningful care of sich drug addicts goes further that purely superficial risk minimalisation.
Caring must see causes, must minimise losses and should provide the drug addict with the emotional and social competence requisite for living in the community in the long term.

The discussion about help for drug addicts, about injection rooms and heroin allocation is, in the meantime, dominated ideologically almost everywhere and hardly does justice to the demands of reality.
Almost 20 years ago there was a similar situation with methadone substitution, which today – when executed meaningfully - is no longer controversial in specialist circles.
Methadone substitution must have an unequivocal therapeutic goal, serving the addicts` psychic and social stabilisation to return to legality with the unequivocal goal of definitive abstinence.
In Duesseldorf, we from the public health authority have been maintaining methadone substitution points since 1987, currently at three locations with an average of 200 patients a day. It has been verified that a plurality of our patients has attained abstinence in the long term. In addition, we have started a low-threshold programme, the methadone immediate programme. Demonstrated here is that a high degree of attachment to the facility is acieved through methadone and thus further therpeutic goals are attainable in the long term.
In my opinion, what is important in methadone substitution - as in any treatment of drug addicts – is the honesty and clarity of the doctors in charge, adequate psychological care of the addicts and sufficient control of accessory consumption. Without effective control, methadone substitution turns into a “basic high” for addicts and attains nothing in the long haul.

Similarly intense and passionate as the discussion was about the indication for methadone substitution 20 years ago, views are today expressed about injection rooms on a politically ideological level. Scientifically there is no evidence to date that the infection risk for drug patients can be effectively reduced with regard to HIV, hepatitis C and hepatitis B, any inoculation campaign would certainly be superior. Even a roof over the addict’s head only for the time of fixing is not a meaningful help.
Meaningful is, however, the task of caring for such people including sick people who are not as yet abstinent and who in the course of daily care must take a fix some time to prevent withdrawal symptoms appearing.
Our neighbouring city Cologne initiated just such a facility operated with good success by the Social Service of Catholic Men. What is decisive here is that people get the opportunity not only for 20 minutes to inject heroin, but that a facility is available, in which those who are not yet abstinent can spend their day under care, and that it is accepted that drugs are also injected, this restricted in time.

Anyone going for a walk through our cities sees the victims of the drug industry and has to recognise the necessity of meaningful help. Going hand in hand with the honesty of action is the serious discussion for the necessary help and the clear decision for the suffering people.

There are opponents to any measure, opponents to life-saving help.
After recognising the necessity to help a person, the requisite help measures must be executed without risks for others being calculated. Doctors have helped in epidemics, even for example risking getting sick themselves.
It is deeply unethical to deny help for a sick person, because possibly risk for others occurs. Everyone in our society must be able to rely on society helping him or her – just as he of she is also obliged to intercede for society.
This is not a question of mathematical calculation, but of a fundamental ethical requirement of a functioning social community.

Help measures for drug addicts must also be able to be gauged as to how they affect mental trauma. A patriarch of addict therapy, Prof. Jellinek, explained that the valley of suffering has to be passed through, before sufficient interventive pressure for therapy can be built up.
This used to apply and certainly still does today to alcoholics. Drug addicts mostly become addicted as youths in the vulnerable phase of their psychic development.
The development of the alcoholic right up to social decompensation runs for decades on end, in the case of young drug addicts it isa frequently attained in a matter of but a few years. This is why timely and swift help is essential in order not to allow too strong a deprivation of the personality to emerge which makes causal help almost impossible.

From the therapists` helplessness, investigation of even unusual methods becomes understandable, such as heroin allocation. However, general heroin allocation would be suitable to change the general attitude of our young people towards drugs and would thus endanger adolescents.

In Germany, possession of small quantities of cannabis, cocaine and heroin for self-consumption is no longer prosecuted, it does, however, continue to remain prohibited. When youths are asked today about the legal relevance of possession of small quantities of drugs, they generally consider them permissible. Adolescents do not differentiate between “permissible” and “prohibited, but not prosecuted”. This is precisely the reason why unequivocal demarcation is requisite. The young teachers in my time at school who felt themselves to be friends of the pupils, perhaps even were these, were regarded by us with disapproval. Those teachers, who were strict but fair, clear and true, were an orientation aid for us.

Effective ad radical help for drug addicts is not restricted to giving succour to the worst destitution; it must also contain specific offers.
As an example, the health authorities in Duesseldorf maintain residential groups for pregnant women and young mothers. There are also offers for providing schooling facilities and occupational training.
Help must also reach the drug addicts in jail, for if punishment is to have rehabilitative significance, then the period of imprisonment must e utilised for therapy for drug addicts. I am a member of the advisory board of a major prison in North –Rhine Westphalia and have asked the Minister of Justice of our state why there is not any far-reaching therapeutic offer in the jails.
His explanation was that the penal system has no provision for this. If you are aware of the utter boring everyday life in jail, and of the availability of narcotics in jail, then you will appreciate that jail cannot have a social rehabilitative effect for drug addicts. Those calling for needle exchange in jail does not act irresponsibly because they offer needles, but because as a result of resignation there is no further therapy offered, which above all else the restriction of heroin offered in jail belongs to.

Currently, the health authorities in Duesseldorf are opening a day hospital for drug addicts – supplementary to what is being affered in the way of rehabilitative measures. We are often asked why precisely seriously ill drug addicts turn to us, patients, who are allegedly difficult to reach. My daily work bears out that almost anyone in distress will accept honest help.
Our help is certainly more attractive thatn the conditions of the street and the scene. Communication within the scene is best, each member of the scene knowing what`s what in a city and knowing exactly what is to be expected from the individual offers. Not each offer will be equally effective for all those needing help. This is why helpers and help are to be developed in the plural, no specific measures offered reaching all, no individual helper being able to reach all.
What is decisive is therefore a supplementary network of help. Orientation of everything that is offered must be: What does the drug addict need – not what does he or she wants. Hardly anyone suffering from appendicitis will welcome the appendix being operated on and removed; nevertheless, it is correct and required measure.
As a doctor, one finds oneself frequently in the situation of having to motivate patients to subject themselves to burdening therapies. The ability to communicate and the capability to teach motivation development form the basis for initiating a meaningful therapeutic process for drug addicts.
One of the essential prerequisites is therefore the multi-professionalism of a team of helpers who are thus able to introduce supplementary qualifications to the help process.

Youths are frequently more difficult to reach than adults, 75% of drug addicts being psychiatrically relevantly ill as well. For this reason, medicine takes on such significance in the predominantly psychological/pedagogical process of abstinence development.

What does make many help measures fundamentally more difficult in the drug scene is the dearth of orientation in many youths. The regulated world, where we grew up, which we are discussing here, is not the world where present youth is living.
Where are youths supposed to find orientation today, when politicians are engaged in serious discussions about whether one should have a right for a high, including a drug high.
The Federal German Constitutional Court in Karlsruhe issued a current decision in all seriousness that this is not a constitutional right. Youths are not to be positively influenced by popularity, but through positive models, through exemplary action.
In Duesseldorf I know a Dominican monk and a Franciscan monk, both being concerned with the homeless and drug addicts. The scene accepts the help of both of them without reservation. Granting aid may be a question of religion, its acceptance - certainly not.

Help for drug addicts must be oriented on what has to be done for them and what can be reached with them and that without any return.
Help for the seriously ill must be help without any expectancy. Such help is to be granted from the fundamental ethical /moral and Christian motivation. Subsequent, therapeutic interventions with drug addicts must attain the necessary social and emotional reintegration of the drug addicts into a therapeutic process. Drug addicts must learn basic social attitudes, in particular they must learn to leave the primary regressive basic pattern of drug addiction, that others care for them and this without any return consideration.

However, development of the socially requisite system of rights and obligations cannot be the prerequisite for granting elementary help.

I do not wish society as it is today; I hope I have not been a contributory cause as to how it is presented today. When I was young, we talked of violent crimes in low voice, when children were around. Nowadays, anyone can experience violence superabundantly, for example, in the “soul-searching striptease” of a criminal on television, or on the other hand in a so-called show also offering children “entertainment”, for example, as to whether three lovers are better for a lonely suburban housewife than two.
We are constantly evolving a world with a dearth in orientation, with egocentric leanings and lack of helpfulness. True, many may donate record sums for tsunami victims, however, people in cities carry on regardless when passers-by are beaten up or the homeless freeze to death in a back alley.

Each of us may know that serious help reaches those in need, that meaningful help alleviates harm, that help is – naturally – not only a state mission, but a demand made on each of us individually as well.

A human being is God’s creation, the cities - not. They have turned into what we have made of them, what we permitted, what we perhaps have not yet changed. Sven Hedin said many years ago: “ It is never too late to do what is right.”

Acting correctly means providing honest help for the needy, naturally for needy drug addicts as well. Requisite help includes a roof over your head, food and provision of elementary needs this as a Christian precept; further meaningful help must include intervention against addiction, as combating the cause of the drug addicts` suffering.

Drug addicts are to be reached through honesty and meaningful offers without restrictions and direct demands. Here, workable relations are to be evolved in order to accompany addicts in intervention to a life in liberty without addiction.
Only they are really free who are also free of addiction.

Thank you very much for your kind attention!

 
[< Back]