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RES E A R C H A R T I C L E Open Access
Open drug scenes: responses of five European
cities
Helge Waal
1,2*
, Thomas Clausen
1
, Linn Gjersing
3
and Michael Gossop
1,4
Abstract
Background: Open drug scenes are gatherings of drug users who publicly consume and deal drugs. The authors
conducted a study of five European cities that have met such scenes constructively. The aim was to investigate
shared and non-shared interventions and strategies in order to increase the understanding of this type of problem.
Methods: First a description was made for the cities of Amsterdam, Frankfurt, Vienna, Zürich and Lisbon. These
descriptions were sent to contact persons in each city prior to visit by the researchers. The methods and strategies
in each city were discussed and core choices and efforts extracted. A report was sent to the contact group for
corrections and clarifications. The paper analyses shared and non-shared traits and strategies.
Results: All of the cities had initially a period with conflict between liberal and restrictive policies. A political
consensus seems to be a prerequisite for effective action. A core shared characteristic was that drug dependence
was met as a health problem and drug use behaviour as a public nuisance problem. Low th reshold health services
including opioid maintenance treatment were combined with outreach social work and effective policing.
Conclusion: Prevention, harm reduction and treatment should be combined with law enforcement based on
cooperation between police, health care and social services. The aim should be “coexistence” between society and
users of illegal substance s and the strategy based on several years planning and conjoint efforts. The solutions are
found in appropriate combinations of harm reduction and restrictive measures.
Keywords: Drug use area, Public nuisance, Harm reduction, Urban drug policy
Background
When drug users congregate to sell and use drugs in pub-
lic spaces, this phenomenon is referred to as an open drug
scene [1]. The phenomenon was studied in a cross-
national project in the early 1990’sthatfocussedonnine
European cities. The study was financed by European
Monitoring Centre for Drugs and Drug Addiction
(EMCDDA) [2]. According to the authors there was
neither a generally accepted definition of a “drug scene”
nor an agreement on what was meant by “open”.The
study therefore developed an operational concept defining
open drug scenes as all situations where citizens are pub-
licly confronted with drug use and drug dealing [2]. These
scenes vary in visibility, size and site and might be
categorized as concentrated open scenes, dispersed open
scenes, and hidden scenes. The advantages and disadvan-
tages of dispersed drug use areas versus concentrated
scenes have been discussed [3,4]. Some observers have ad-
vocated that the concentrated scenes might ease control
and monitoring of an illegal drug market. The effective-
ness of harm reduction measures such as outreach ser-
vices, dispersion of sterile utensils and location of user
rooms might also be increased as they could be provided
in the same area [5-8]. However, low drug prices, lack of
law enforcement and lack of social control seem to attract
drug users towards the open drug scene and the increase
in problems appears to have been more rapid than the in-
crease in the population of addicts [9].
This paper focuses upon the concentrated open scenes
where users meet and use drugs in ways that are visible to
the public. The scenes are often found in city centres, par-
ticularly in central railway stations and city park areas.
The users may be in poor physical and mental condition
* Correspondence: helge.waal@medisin.uio.no
1
Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo,
Norway
2
Clinic for Psychiatry and Addiction, Oslo University Hospital, Kirkevn 166,
0450 Oslo, Norway
Full list of author information is available at the end of the article
© 2014 Waal et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Waal et al. BMC Public Health 2014, 14:853
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and the locations will often serve as a focal point for drug
dealing. This situation might grow out of police control as
has previously happened in European cities such as Zurich
and Frankfurt [1,2,9,10]. Also, the scenes are often feared
to attract new users and antisocial groups and individuals.
The stigma and negative image seem mostly to discourage
well integrated adolescents from approaching the scenes
[11], but a mixture of push and pull-factors might attract
less socially stable adolescents [12,13], displaced persons,
asylum seekers and others who have problems fitting into
the societal structures. Homelessness is often prevalent as
different types of dysfunctions are prevalent [14,15] and
increased rates of crime may be found in the neighbour-
hood. For such reasons, the scenes are regarded as a pub-
lic nuisance and the usual consensus is that an open
concentrated drugs scene is a problematic phenomenon.
However, there have been different views on how to re-
duce or prevent the drug scenes. In their study Bless and
colleagues [2] state that the cities adhered differently to
preventive and corrective strategies often influenced by
ideological concepts where “prohibitionists” confronted
adherents of “harm reduction”. Closure by repressive mea-
sures might increase drug related difficulties [1,16,17], but
although harm reduction measures might decrease the so-
cial and health harms [8], they do not seem to decrease
the size and seriousness of the open drugs scenes. Closure
might increase the propensity of users stuck in the scenes
to seek treatment noted as increased demand for metha-
done maintenance [18] but might also increase user des-
peration and destructive patterns of drug use. These
experiences are relevant for discussions on drug policies.
Open drug scenes have been described in cities such
as Vancouver and Montreal in Canada, New York and
San Francisco in the US, and Amsterdam, Rotterdam,
Frankfurt, Hamburg, Zürich, Vienna and Copenhagen
and Oslo in Europe. In 2004 the Pompidou group
launched a series of seminars to study drug scenes and
the different national policies and prepared a list of rec-
ommendations [19]. With this as background the au-
thors performed a stud y of the interventions applied in
European cities known for successful reduction of open
drug scenes. The aim was to investigate the core inter-
ventions and strategies and describe the evidence for ef-
fectivene ss. The study was commissioned as a part of
planning preventive interventions to address the prob-
lem of an open drug scene in Oslo in 2009.
Methods
This study built on earlier involvement by the first au-
thor with a seminar in the Pompidou group on urban
security [20]. An interdisciplinary study group was estab-
lished; in addition to researchers this included persons
with expertise on addiction, urban city policies and po-
lice strategies; a specialist in psychiatry and addiction
medicine, the head of the clinical substance user services
in Oslo, a high ranking police officer and two researchers.
Five cities that were well known for their responses to
open drug scenes, were selected; Amsterdam, Frankfurt,
Zürich, Vienna and Lisbon. As the study of interventions
in different social setting does not lend itself to experi-
mental or controlled investigation, a method combining
qualitative and quantitative observations was chosen in
accordance with the Qualitative research review guidelines
– RATS [21].
The report to the Pompidou group was supplemented
with national reports from the EMCDDA on the drug
problems in selected countries. In addition an unsystem-
atic literature search was performed in Medline, Pub Med,
Psychlit and Sociological Abstracts with the search words
“open drug scenes”. As the period studied stretched from
changes in Amsterdam in late 1970’s to changes in Vienna
and Lisbon up to the time of the study, the search had no
pre-specified time limit. The first author selected the pa-
pers found relevant on basis of abstract before reading in
full text. All papers dealing with description of drugs
scenes in the core cities and the measures taken in the cit-
ies were included. Papers primarily focussing HIV or
HCV prevention in general were excluded as were papers
focussing trials with heroin assisted treatment. Papers fo-
cussing aspects such as gender problems on the scenes
and other cultural aspects were likewise found outside the
scope of the study. The available evidence describing the
development in each city was concentrated to specific city
descriptions focussing upon the characteristics of the open
drug scenes and the city responses and core strategies.
The information was discussed and organized in descrip-
tions according to the groups knowledge of the cities.
These descriptions are based on consensus in the group.
A public office or authority with coordinating or plan-
ning responsibilities in the cities was then approached
with a request for a contact person. The city descriptions
were sent to the contact person in each city for input
and corrections. The contact persons arranged for meet-
ings between the visiting group and the core city plan-
ning office, addiction treatment experts and core police
officers in order to have discussions on relevance and im-
portance of chosen methods. In addition the group visited
the former open drug scenes. The cities’ interventions and
the visiting group’s understanding were discussed in meet-
ings with researchers, police, social workers and addiction
medicine specialists. The resultant observations are
therefore based on a consensus developed from different
sources.
On this basis, a description and analysis of the mea-
sures and strategies were prepared for each city. The
analyses were discussed in the group and then sent to
the contact person in each city for final comments. This
final revision serves as the basis for findings of shared
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and non- shared experiences and core interventions in
this paper. Each city was visited for 2–3 days. As we
were dependent on meetings with professionals that
mostly have heavy workloads and busy schedules, the
meetings were adjusted to their possibilities. Each meet-
ing lasted from one to two hours. The main focus were
on the preformed city descriptions, the correctness and
relevance of interventions described and relative import-
ance of the interventions and the experiences. The
agenda was open to allow for the focus and judgement
of the partaking professionals both from the visiting
group and the city representatives. More detailed de-
scriptions of the development of drug problems in the
cities, the chosen contact persons, details of the visits
and on relevant socioe conomic city characteristics can
be found in the report to the municipality of Oslo [22].
Ethics
Health research in Norway is regulated through the Act
on medical and health research that covers research that
include health indicators or personal information of any
type concerning individuals or treatment that can be
traced bac k to individuals. Studies on general treatment
quality and on effectiveness of economic or other regula-
tions are outside the scope of the statute that regulate
applications to ethical boards [23]. As the study con-
cerns city policies on the general phenomenon of open
drug scenes, application to research ethical board wa s
judged unnecessary.
Results
Amsterdam - “the introduction of harm reduction”
Description was based on Bless [2], Bless [24], Buning
&van Brussel [25], Buster [26], Kalmthout [27], Reinaas
[10], Waal [20], van der Meer [28], EMCDDA national
report [29].
Open drug scenes
Problems in Amsterdam were first eviden t with the de-
velopment from cannabis use integrated in an anti-
establishment culture towards increasing use of heroin
among disadvantaged groups. Initially in the late 1970’s
these problems were met with measures of prevention
and repression. In spite of these measures, the number
of drug users in the city with problematic and self-
destructive behaviours increased. Open drugs scenes ap-
peared early. A well-known example is the development
of the problem in the Zeedijk area, a deprived city area
with slum characteristics.
Responses
After initial discussions and shifts in policy, the
Amsterdam City Council asked the Amsterdam Munici-
pal He alth Service to develop stra tegies to reach the
“unmotivated drug users”. The aim was a public health
approach both to contain the “drug epidemic” and to
meet the specific needs of this group. This can be seen
as the o rigins of harm reduction as a systematic policy.
One characteristic feature was the attempt to separate
“soft drugs” (i.e. cannabis) from “hard drugs” (in
particular heroin) [25,27]. Drug use wa s not seen as a
crime while professional dealing was. Dependence was
regarded as a disease to be met by health care measures.
Another feature was heavy investment in low thresh-
old methadone dispensing from the Municipal Health
Service [25]. Mobile dispensing from buses was started
in order to reach marginalised groups and to overcome
resistance from unwilling neighbourhoods. Methadone
dispensing from police stations was initiated to reach de-
viant and antisocial groups and to enable continuation
of treatment after arrest and imprisonment. Needle dis-
pensing was also initiated, as were shelters and con tact
centres. The main purpose was a systematic policy of
harm reduction and health care policies. After the turn
of the century this was supplemented with heroin
assisted treatment, compulsory treatment within mental
health systems and quasi-compulsory treatment in spe-
cial prison s.
Core strategies
Open drug scenes were, from the beginning, systematic-
ally met with policing and an extensive rede velopment
programme in affected areas [2]. As the drug scenes be-
came more prominent, the policy emphasis increasingly
focused on dispersion of scenes, urban safety pro-
grammes and compulsory interventions aimed at street
addicts who were not responding to helping measures.
Any public gathering of more than four to five addicts
was to be interrupted by the police backed by adminis-
trative laws that authorised fines. If the users did not pay
their fines, this could result in the issuing of court orders
followed by arrests. The courts could also impose anti-
social behaviour orders.
The cultural attitude of tolerance towards deviant be-
haviour is also relevant. The Dutch tradition seems to
contain a high tolerance for self-determination provided
there is no public nuisance. The police have traditions for
making of alliances with deviant groups and to find com-
promises so that the law is practised leniently or adapted
to situations where non-action might be sensible.
Observations
Bless [2] noted that the Amsterdam experience suggests
that a consistent approach along these lines can be quite
effective to keep the scene on the move and prevent
major concentration of drug users. On one hand, treat-
ment and harm reduction centres are readily accessible.
On the other hand, drug users that cause nuisance might
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be subjected to compulsory means, including choice be-
tween prison and treatment. The system is presently re-
ported to meet with broad satisfaction by the community.
Present situation
At the time of the present study, there was no noticeable
open drug scene. The combination of a harm reduction
strategy and syste matic prevention of public nuisance
had been effective in keeping the problems to tolerable
levels. Open scenes were present but only in a dispersed
form and not publicly noticeable. The main current em-
phasis wa s to develop the heroin assisted treatment pro-
grammes, to increase integration with the psychiatric
treatment system, particularly with assertive community
teams, to strengthen comprehensive treatment for those
with co-morbi d problems, to strengthen treatment
within prisons, and, more generally, to integrate health
system based addiction services, social service systems
and mental health systems.
Frankfurt Am Main -”taunusanlage and user rooms ”
City description was based on Bless [2], Hedrich [7],
Kemmesies [17,30], Reinaas [10], Waal [20], EMCDDA
national report 2009 [31], Schard [32].
Open drug scenes
Problems in Frankfurt began with cannabis smoking and
gatherings in parks. These were initially met with
abstinence-oriented treatment and police repression. Such
responses were largely ineffective and were followed by in-
creasingly destructive drug use. The latter half of the
1980’s brought development of a large and destructive
drug scene in the “Taun usanlage”, a park area between the
old and new opera, and with large bank buildings on both
sides. The scene grew until more than one thousand users
met daily with open dealing and injecting drug use, obvi-
ous mental and physical problems, and public nuisance.
Responses
An initial policy of abstinence-oriented treatment was
gradually changed towards harm reduction with contact
centres and methadone places, outreach services, and ser-
vices offering basic medical assistance. Periodically the po-
lice would disperse the scenes and arrest users and dealers
in an inconsistent policy with shifts between liberal and
restrictive measures. This situation was seen as unsatisfac-
tory, and in 1987 the city established a coordinating com-
mittee, and in 1989 a city coordination office.
Core strategies
In 1992 the Mayor decided that the open drug scene in
the Taunusanlage could no longer be tolerated. Low
threshold methadone programmes were enlarged and
decentralized. A large shelter with a contact centre, cafe
and a methadone outpatient clinic opened in former in-
dustrial buildings out side the city centre. Then a massive
police intervention was implemented. Drug users not
resident in Frankfurt were expelled from the city. Help-
ing facilities were at the same time established in the
home communities. Users in the city centre and at the
scenes were taken by bus to the contact centre in the
periphery. The first safe injection room was established
in 1994 and three more in 1996.
Observations
According to our contact group the present treatment
system is well received both by the public and the polit-
ical system. Shelters we re closed in daytime, the rules
for conduct were explicit and exceptions were only ac-
cepted i n very special cases. The system with a com-
bined re liance upon harm reduction for users and zero
tolerance for public nuisance seemed to be integrated in
the city. There was a strong emphas is on social integra -
tion of users, but also an expe ctation of compliance.
However, the original system of removing non-resident
users to their home locations was often ineffective and
was e a sily counteracted by a return ticket to F rankfurt.
Present situation
The current policy decisions and measures were origin-
ally met with opposition and demonstrations, but at the
time of the study open drug scenes were not seen as a
significant problem by the respondents. Although there
has been a continuous establishment of new drug
scenes, these have been kept und er control by outreach
social services in cooperation with city police. There are
approximately 200 to 300 users who belong to a drug
scene around the central train station in Frankfurt’s red-
light district. Here a small group of 30 to 50 persons are
“causing trouble and are viewed as unruly and with no
respect for the police”. The capacity in the health system
and social services is relatively satisfactory and there are
no waiting lists in methadone maintenance programmes
or shelters. However, capacity for long term rehabilita-
tion is unclear, and there is a high level of homelessness
and unemployment. Users who neglect the rules of the
shelters are often asked to leave, if necessary with the as-
sistance of the police. Difficult and violent users are sub-
jected to court proceedings according to possible crimes,
and might also be handled with in-house sanctions (e.g.
problematic individuals may be denied admission for a
time). The mental health system is exp ected to take care
of addicts with psychiatric disorders. The heroin assisted
treatment programme in its current form was not struc-
tured to treat the most problematic users and was there-
fore not relevant to most of the users in the open drug
scenes.
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In general, the situation was reported to be acceptable,
and it was intended that the policy should continue along
the established lines. Respondents stated that a certain
level of problems should be expected and integrated in a
city the size of Frankfurt. The need for a long term per-
spective was especially emphasized with no quick solu-
tions. Several years’ perspective is necessary to deal with
open drug scenes with continuing efforts to prevent recur-
rence. Coordination of control and harm reduction sec-
tors is a core element as is continued focus on problem
solving and monitoring.
Zürich - the city of heroin treatment
City description was based on Bless [2], Uchtenhagen
[33-35], Klingemann [36], Falcato [18], Fuchs [5], Huber
[9], Stohler [37,38], Hertzig [39], Conolly [19], Waal [20].
Open drug scene
Users began to congregate in parks and open places dur-
ing the late 1970’s and the problems increased through
the next decade. Repressive measures and helping mea-
sures were both advocated and tried. The situation was
characterized by political controversies and shifting deci-
sions. Finally a large open drug scene developed in the
“Platzspitze” (needle-park) in central Zurich. Several
thousand drug users gathered daily, selling and openly
injecting drugs. Many supportive services were provided
at the scene an d these helped to alleviate some of the
problems, but the scene expanded regardless. A massive
closure initiative merely caused the scene to move to a
nearby unused railway station, the Letten, with a subse-
quent increase in problems.
Responses
The situation in the early 1990’s was experienced as cata-
strophic. In response to this situation the leading political
parties developed a shared policy platform, and this en-
abled the national authorities to develop a national plan
with four pillars; prevention, treatment, controls, and
harm reduction. The plan was based on coordination at
the municipal, canton and national levels, with the co-
operation of police, treatment system and social author-
ities. Outreach services cooperated with the police and
interventions could include police detaining users against
their will. Methadone treatment provision was massively
enlarged and later supplemented with heroin assisted
treatment. Harm reduction was promoted as the primary
aim with treatments adapted to the needs of the user. No-
body was excluded for drug use or non-compliance. How-
ever, retention was often limited, with many users leaving
treatment though many might return again at a later stage.
Also, users who continued public nuisance behaviour
might be brought to “relocation centres”, possibly leading
to quasi-compulsory treatment. Violent users were judged
to be a shared responsibility for control and treatment
sector. Mentally ill users were regarded as the responsibil-
ity of the public mental health system with well-developed
traditions for opioid maintenance treatment.
Core strategies
The Platzspitze was closed in 1992, and the Letten scene
in 1994. All users were approached with offers of treat-
ment, and these were linked to control measures and re-
pression of the drug scenes with users eventually
compelled to return to their home municipalities. As
open drug scenes tend to recur, a continuous joint effort
was established. Our respondent s empha sized that the
police initially def ined the drug scenes as social prob-
lems while the social workers tended to view the scenes
as a public order problem. What was needed, according
Zürich respondents was a shared understanding of a
joint responsibility. This is best developed through daily
meetings between police, social and health care workers.
A core concept is “Urban compatibility” (Stadtverträ-
glichkeit) with the aim to integrate marginalized individ-
uals. Homeles sness is defined as unacceptable, and
Zürich has 1500 housing places for different target
groups, about hundred places in temporary shelters and
about 400 low threshold places for drug users and other
socially marginalized individuals. There is zero tolerance
for certain types of behaviour such as drug dealing and
for large gatherings of users which is seen as “destructive
to co-existence” in public places. In addition Zürich has
created a specific approach termed “SIP” (Se curity, inter-
vention, prevention). This involves outreach social ser-
vices working in close cooperation with the police with
shared information systems. The intention is to educate
marginalized people to social behaviour and the aim is
co-existence.
Observations
The Zürich situation may be understood in terms of re-
sponses to a national and local crisis with an unprece-
dented rapid increase in heroin use, large open drugs
scenes and related criminality and mortality. This crisis
seems to have ended several years of conflict between
liberal and conservative parties advocating different
measures with treatme nt and survival measures versus
repressive control measures. Repeated shifts of policy
were replaced by a long-term systematic policy integrat-
ing prevention, harm reduction, treatment and control.
During our discussions it was repeatedly emphasized
that all pillars have equal importance. The integration of
control measures with treatment and harm reduction
was especially prominent. Another important aspect was
the overall coordinat ion of national, cantonal, and muni-
cipal policies. Today the policies have bro ad general ac-
ceptance in the general population and the political
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parties accept and support the policies included the dif-
ferent harm reduction aspects, with exception of a right
wing extremist party.
Present situation
Open drug scenes have now largely disappeared in Swiss
cities. Drug dealing typically occurs in private apartments.
Drug injecting in public places is infrequent. Used needles
and syringes in public places are reported to be a minor
problem. Also, user satisfaction is reported to be high, par-
ticularly in projects using heroin assisted treatment. Con-
trol measures are reported as being integrated with
treatment, health care and social services. The capacity of
health and social services is reported to be sufficient with
well-developed systems of quality control. Involuntary and
quasi compulsory treatment is accepted. Treatment in
prisons is well developed with differing models.
Vienna- ”zusammenleben” and “zones of tolerance”
City description was based on Bless [2,24], Springer [40],
Uhl [41], Waal [20], EMCDDA annual report Austria [42].
Open drug scene
A growing drug problem during the late 1980s increased
greatly during the nineties. Open drug scenes and their
associated features caused heated public debate. The re-
sult was a high level political decision to appoint a drug
coordinator and a coordinating body. A policy of
“zusammenleben” was formulated to contain the prob-
lems and reduce the harms and nuisances. The basic
policy element was to confront user areas with diversion
and “zones of toleran ce”. Originally several small satellite
drug scen es existed. But gradually the treatment system
was increased and the scenes prevented by repressive
measures. The last such zone was in the park at Karl-
platz where 40–50 users were tolerated at one time.
Roughly 1000 users belonged to the scene. Outside the
zone no more than four to five persons were allowed to
gather, particularly not in the Metro. If more than 10
users gathered outside the zone, they would be asked by
the police to move and to disperse, or to go to the zone.
The zone was under police surveillanc e and outreach so-
cial workers worked in the area. Apart from this, there
were no other services at the scene: this was the result
of a deliberate strategy not to increase the attractiveness
of the scene in a precarious balance between too much
control and restrictions (repression) and too little (too
much tolerance). The main problems with Karlplatz, ac-
cording to our informants, were the visibility of drugs
and intoxication. There were no injections on the scene,
but nearby toilets were used as injection rooms. It was
also a difficult place to oversee, and included food stalls,
shopping malls and a centre for several Metro lines and
buses. The social concerns increased.
Responses
Austria initially developed a strategy of treatment and
containment. Methadone maintenance treatment, and
subsequently maintenance with slow release morphine
was made available both by general practitioners and from
public programmes. A publicly funded social organisation
was developed to provide social support systems with
meeting places and help. Vocational training programmes
had been an important part of the city response together
with a large housing programme as the city has a large
number of public apartments. There was a consensus that
addiction is an illness and that users are primarily the re-
sponsibility of the health care and social care system. The
principle is treatment for addicts and repression for
dealers. Users are generally not imprisoned. Maintenance
treatment should be available, if necessary on demand
with a low threshold. A high emphasis is placed on out-
reach and low threshold services.
Core strategies
From the turn of the century, pressures on smaller open
drug scenes increased until Karlplatz remained as the only
remaining scene. In 2010 it was decided that this should
also be closed. Reconstruction of the bus station offered
an opportunity. Social services increased the availability of
counselling and shelters, and cooperation between social
services and the police was strengthened. The number of
staff in the contact centres was increased and two new
places for needle exchange established. The capacity of
the night shelter was doubled. The contact centre and
needle exchange at Karlplatz were moved from the area
while the street worker contact group remained. The sur-
rounding park was reconstructed with increased visibility.
Then the drug scene was closed down by police interven-
tions. When the study group visited the scene there were
almost no drug users present and the closure was viewed
as having succeeded. However, it was stated that continu-
ing intervention to prevent the re-establishment of the
drug scene was necessary. At least two police officers were
always to be in sight and the intention was to prevent the
re-emergence of any open scene: this policy was to be
continued for at least two to three more years. The goal
was to get drug users into the treatment system and to
avoid users having to buy drugs illegally on the black
market.
Observations
Most users can presently find treatment or harm
reduction measures i n a variety of therapeutic settings,
counselling centres, GPs , and inpatient treatment. Only
a minority of users are outside the treatment system.
User satisfaction is reported to be high, but more psy-
chiatric help is needed for co-morbid users. A high level
of health a nd social care is a priority of the syste m. It is
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stated as a goal that no drug user should be without a
home and the homeless care services are well developed.
Nearly 100% of all drug users are covered by the health
care system and social insurance. According to the city
sources, there are only minor problems with difficult
users. Users who sell drugs on premises, use violence
against other clients or threaten personnel will be
excluded: however, they can find treatment in any other
institution. Continuing drug use is not seen as a reason
for exclusion from treatment. Violent users are very few
and dealt with individually. As a last measure police are
called in. It is an intention to engage more psychiatrists in
drug institutions and to develop psychiatric treatments
specifically to meet the needs of mentally ill users.
Present situation
The Vienna system seems to be a functioning well without
heroin dispensing and injection room facilities. The sys-
tem offers a high level social and health care system oper-
ating on a harm reduction model together with an
emphasis on the prevention of public nuisance. The earlier
policy of zones of tolerance, rules of conduct and conflict
management has been modified and the zones have been
closed. The level of overdose mortality is viewed as within
acceptable limits even though maintenance drugs appear
to be the main opioid involved in these deaths. Open drug
scenes are presently prevented through continued police
surveillance and outreach social service interventions. A
decentralized system of opioid maintenance treatment,
largely in primary care settings, with different types of opi-
oid agonists is provided.
Lisbon – decriminalization as a solution?
Description was based on Bless [24], Greenwald [43],
Hughes [44], EMCDDA Annual report Portugal.
Open drug scenes
Before downfall of the dictatorial regime of Salazar in 1974
the army and the navy had an important place in Portu-
guese society and large neighbourhoods were dependent on
navy activities. The political changes brought hardship, and
drug trafficking became a possibility to supplement income.
Three large areas/neighbourhoods in Lisbon developed into
open drug scenes termed “supermarkets ”. Casal Ventoso,
the largest “supermarket ”, had approximately 5000 “visi-
tors” every day. 2000 people lived in the area and whole
families were i nvolved in trafficking. In this area there were
large numbers of individuals in poor health and conspicu-
ous deprivation, openly injecting drugs.
Responses
A general change of policy was formulated by the “Com-
mission for a National Drug Strategy” which regarded
drug use as a health problem. Drug use was largely
decriminalized, and individuals were permitted to carry
user doses for 10 days without charges. Selling remained
criminalized. At the same time Portugal established a
specific system based on administrative sanctions, the
“Commissions for the Dissuasion of Drug Addiction”
(CDT). Police and other authorities were able to refer
users to these regional bodies that have psychologists, and
social workers. The CDT functions as a sort of court,
informing the user, listens to them and decides on re-
sponses. The user is also entered in a national register sep-
arate from the criminal register. This system is intended
for non-dependent users. Addicts should be referred to
treatment. Civil behaviour orders are also issued. The
CDT system should be understood as a part of a compre-
hensive treatment system that is intended to function
without waiting lists and with outreach social services that
might support motivation and problem solving among
users.
Core strategies
The emergency responses were developed in collaboration
with the municipality. The open drug scene (“supermar-
ket”) areas were literally destroyed and rebuilt with EU
grants. At the same time treatment availability was in-
creased and low threshold opioid maintenance treatment
services such as methadone buses were established. At
present, open drugs scenes are constantly met with a po-
lice presence, and the police can refer users to the CDT
system. The police have the authority to search users on
the street and to control areas with obvious open drug
scenes.
Observations
Initially, these responses prompted a heated debate and
strong negative predictions about future increases in
problems. However, the city informants stated that the
level of problems had diminished, and at the time of the
study, drug use was not seen as a major public problem.
The realities are difficult to evaluate. It seems clear that
the system presently is well accepted. It seems also clear
that most users are positive about the CDT system as an
alternative to court proceedings. The system is, however,
not in any way a form of legalization. On the contrary,
in several ways this type of decriminalization might be
seen as relatively strict societal response.
Present situation
The former, large open drug scenes seem to have disap-
peared. However, drug use in cafes and on the party scene
is prevalent, and drug selling, at least of cannabis, is not
uncommon in Lisbon. The number of users in treatment
has increased while the growth of drug problems
has stalled or diminished. The CDT system is mostly
respected by users, but repeated use and repeated referrals
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might increase levels of sanctions. Mental health problems
should, at least in theory, be diagnosed and followed up
within mental health services, and city informants report
that the drug treatment services are part of or work in
close cooperation with psychiatry.
Shared and non-shared interventions and strategies
Table 1 gives an overview of the city interventions and
strategies. As can be seen all the cities have shared policy
decisions with strategies for coordination of different mea-
sures and of communication between control sector and
social sector. Further, all have well-known harm reduction
interventions although user rooms are only found in three
of the cities. Heroin assisted treatment is well developed
in two and on a small scale in one. All have well developed
system of shelters, and housing is mostly available as is
contact centres. The control sector interventions are less
shared but all share dispersing tactics. Some form of social
behaviour order is found in four out of five. Strategies to
discourage or send out non-residents are also usual. For-
mal decriminalization of substance use is only found in
Lisbon while informal is also found in Amsterdam and
Zurich as long as it does not occur in public. All cities
have zero tolerance for public nuisance (not shown in
table).
Discussion
The cities in this study were chosen primarily because
they have been successful reducing open drug scenes. In
Amsterdam, Zurich and Lisbon, the city strategy was
embedded in national drug policy and strategy reforms
but all were in consort with drug policy development.
Amsterdam chose early a policy of harm reduction to
counteract growing problems, but as the study demon-
strates, these are combined with systematic control mea-
sures. This seems to be a shared trait. All the cities
describe open drug scenes that tended to grow out of con-
trol. These scenes were regarded as destructive to individ-
ual drug users and as a problematic nuisance to society.
Then the cities applied a range of harm reduction mea-
sures combined with systematic control strategies in order
to tackle the problems. None of the cities succeeded by
treatment and medical and social support measures alone.
Provision of increased helping measures alone seems to
have been unsuccessful and when provided within the
open drug scenes, may even have increased their attrac-
tion. Equally, the provision of repressive methods alone
has not been successful, even when an increase in control
measures was combined with crisis intervention and
coercive interventions. Only when the cities developed a
comprehensive policy that integrated and coordinated
Table 1 Shared and non-shared interventions and strategies
Amsterdam Zurich Frankfurt Vienna Lisbon
Shared political and social consensus + + + + +
City coordinating system + + + + +
System for shared information + + + + +
Low threshold OPIOID MAINTENANCE TREATMENT + + + + +
Needle dispensing + + + + +
Health rooms/user rooms + + + - -
Heroin assisted treatment (HAT) + + (+) -* -
Housing projects + + - + +
Shelters + + + + +
Contact centre and café + + + + -
Outreach social work services + + + + +
Compulsory treatment + (+) - - -
Reconstruction projects + - - + +
Shared policing and social services patrolling + + - + -
Zones of tolerance - - - + -
Detention centre - + - - -
Police dispersing tactics (compulsory) + + + + +
Social behaviour orders + + + - **
Treatment within criminal justice + + - - -
Decriminalization of personal use (−)(−)- -+
Expulsion/discouragement of non-residents (+) + + + -
*Vienna offers maintenance treatment with slow release morphine.
**Commission for Dissuasion of Drug Addiction (CDT).
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treatment and helping measures with control measure
were they able to successfully alleviate their situation. It
might seem that the all have met the precondition of over-
coming the controversy between prohibitionist and harm
reduction ideologies as observed to be important by Bless
and co-authors [2]. As pointed out by Csete [45] in
discussing the case of Zürich, a pragmatic approach shows
the usefulness of different harm reduction elements within
a comprehensive urban policy. This is also reported from
Rotterdam where “tolerance zones” and comprehensive
helping measures did not prevent troublesome presence
in the streets of homeless and addicts. “Silence in the
streets” was attained only when the city developed a “pro-
active” policy combining control measures with care for
the client [46].
The comprehensive and integrated policies share cer-
tain core features. One is that problematic substance
use and dependence are defined as health c are prob-
lems. At the sa me time, drug taking is seen a s a social
behaviour that is subject to ordinary social rules. The
user ha s no right to be of nuisance to others, but the
user has the same inborn right to integration in society
and the same set of individual rights as others in the
general population. Social stigmatization and isolation
should be avoided. It is also accepted that mental health
problems are often a key feature of problematic drug
use and that these conditions should be d iagnosed and
treated effectively. Nevertheless , problematic behaviour
should be controlled and prevented, and rele vant mea-
sures have t o be shared across different professions and
ser vice systems. Therefore shared responsibility should
be accepted with a commitment to cooperation between
the p olice, the social services and the he alth care ser-
vices. This commitment has to be binding and anchored
at a high political le vel. A common observation was that
where t here had been political and professional dis-
agreements and conflicts, these obstructed the imple-
mentation of any effective policy. A common theme wa s
that on-going political and ideological conflicts seem to
have prevented solutions and effective measures for sev-
eral years. Only when consensus had been reached at
sufficiently high political and administrative levels , ha s
real progress been achieved. Another importa nt aspect
was long term policies. The cities all emphasized a time
perspective of se veral y ears for the implementation of
both helping and control mea sures. There are no quick
fixes. In particular; election periods were seen a s too
short a time perspective, meaning that a consensus be-
tween the major political parties is esse ntial.
A conspicuous feature is that harm reduction has been
adopted as a central strategy in all the studied cities.
There were differences in how this strategy was imple-
mented but the common features were a free-of-charge,
low threshold public health service, often at city service
level. All the cities established easy access to low thresh-
old opioid maintenance treatment without or with short
waiting periods. This is most likely a precondition for
closure of drug scenes that up to closure have secured
availability of heroin.
Another feature is that all the cities developed specific
strategies to contact and attract ”hard to reach” users, if
necessary by combined outreach social service cooperat-
ing with police patrol or officers. A shared element in this
was the provision of easily available contact and crisis cen-
tres that offered a range of social services, often incorpor-
ating needle dispensing, and in some cities, user rooms.
Homelessness was addressed through a varied system of
shelters and hostels, but the services presupposed appro-
priate behaviour and required the services’ premises to be
respected by users. The dominant drug used in all the cit-
ies was heroin, and a high level use of injections often in
public caused societal reactions and concerns in relation
to epidemics of HIV and HCV. Overdoses and problem-
atic overdose mortality both on scenes and in the neigh-
bourhoods increased the need for interventions. This also
made the available alternatives such as injection rooms
and in particular low threshold methadone dispensing the
obvious choices. Other drugs were also used, but the focus
was on heroin.
One shared theme is that assertive social services seem
to be a prerequisite of an effective response. Typically
the cities have created active and assertive outreach ser-
vices to contact and engage with drug using individuals
on the street. This response was coordinated with or
conjoint with police patrols or officers, in particu lar to
prevent the development of drug scenes. The cities also
provided a range of services such as night shelters and
other housing opportunities, contact centres as a place
to be during the day, and opportunity for cheap food,
washing, needle dispensing etc. The service also served
as a gateway to low thre shold health services and main-
tenance programmes. But at the same time it was agreed
that open drug scenes are destructive, and that the
provision of services should not increase the attraction
of the drug scenes and not be offered on scene.
The organization of health services in the cities varied
but, again, some shared aspects were evident. One was an
emphasis that services should also be available for the most
behaviourally problematic users. The services tended not
to operate with written referrals and timed appointments,
but to be available on demand. Waiting lists and waiting
times were reduced as far as possible and were regarded in
principle as not acceptable. The substance use treatment
service should be comprehensive and include low thresh-
old methadone maintenance, rehabilitation oriented main-
tenance therapy (high threshold), crisis intervention, and
detoxification within a longitudinal treatment perspective.
The choice of abstinence oriented treatment and treatment
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in therapeutic communities was optional. Communication
and coordination was strongly emphasized, either through
coordination boards of high level commissioners. Informa-
tion was to a large degree shared between controlling and
helping offices,.
Some elements were found in some but not in all of the
cities (Table 1). User rooms were integrated within the re-
sponses of Amsterdam, Frankfurt and Zürich. Respon-
dents reported that these supported the social integration
of users, particularly those without their own housing.
The facilities were also seen as reducing public nuisance
in local areas with a high prevalence of drug use. Heroin
assisted treatment was a particular feature of the city re-
sponses of Zürich and Amsterdam while playing a more
limited role in Frankfurt. Heroin assisted treatment was
not seen as an essential response for the prevention of
open drug scenes in any of the cities. Low threshold
methadone treatment was emphasized in all cities, but a
mobile service with dispensing in buses was only operative
in Amsterdam and Lisbon. Slow release morphine (Substi-
tol) was only used in Vienna where it was the main agon-
ist medication, and was valued by doctors and users, but
seen as problematic by the police. Reports suggested that
slow release morphine was diverted and misused on a
relatively large scale, and that more than half of the over-
dose deaths were found to be associated with this
medication.
Limitations
The f indings relate to extremely complex e vent s w hich
took place in changing social, political and economic
circumstances and often over relatively prolonged pe-
riods of time. The findings are largely based upon evi-
dence given by individuals or groups with close access
to event s in each of the cities, but the expressed views
are always subject t o personal opinions about those
event s. In Amsterdam, we did not succeed in convening
an inter-professional and interdisciplinary group and
were dependent on information from and discussion
with core researchers. In the other cities the use of mul-
tiple informants and multiple information sources was
intended to reduce biases due to incomplete accounts
or unrepresentative views, though this does not elimin-
ate the problem of shared but inaccurate beliefs. Also,
the biases or inaccuracies of the investigators were
counterbalanced by the process of repeated feedback
from respondents.
The focus on heroin as problematic drug might limit
the usefulness for cities in which other types of drug are
most strongly linked to open drug scenes. Use of crack
cocaine has increased in Europe and has for many years
been a major problem in some South American coun-
tries and some US city centers. On problematic aspect is
the lack of evidence based low threshold services for
these types of problems limiting the direct relevance
when cocaine and amphetamine are the main drugs.
However, the problems of policy disagreement and the
need for coordinated interventions combining res tricting
and helping measures are in our opinion of clear
relevance.
It should also be acknowledged that the investigation
of complex social events such as the waxing and waning
of open drug scenes is not amenable to traditional ex-
perimental designs, and “objective data” about the evolu-
tion of such events is extremely difficult (and sometimes
impossible) to obtain. Provided that the limitations of
the study methods are taken into account , we believe
that the findings may be useful and informative.
Conclusion
The cities in our study have all responded to open drug
scenes through a combination of prevention, enforce-
ment, harm reduction, and treatment mea sures as rec-
ommended by Bless [2]. They have also developed
systems for active cooperation between police, health
care and social services. They provided ready access to
and availability of low threshold maintenance treatment,
most often by methadone. A s a consequence they ap-
pear to have effe ctively closed the existing open drug
scenes and have continued to implement active mea-
sures to prevent any recurrence of the scenes. Under-
lying these measures has been a ba sic acceptance of
drug users including those who have been unable or un-
willing t o stop the use of illegal drugs, but this was com-
bined with a policy not to permit the continuation of
destructive be haviour in terms of public nuisan ce. The
cities established policies of “no tolerance” for public
nuisance but nevertheless developed appeasement, and
found approaches to “coexistence” between society and
users of illegal substances. This helped to end unfruitful
controversies between liberal and conservative ideologies
and policies. The solutions are found in appropriate com-
binations of harm reduction and restrictive measures.
Abbreviations
EMCDDA: European monitoring centre for drugs and drug addictions;
SIP: Security, intervention, prevention; CDT: Commissions for dissuasion of
drug addiction.
Competing interest
No competing interests. No external funding.
Authors’ contribution
HW: design and head of project, contact with collaborators on cities, main
author. TC and LG: Participation in project and discussions in cities,
observations and analyses, contributions to and acceptance of paper. MG:
Discussion of project, analyses of observations, main adviser to, supervising
of and contribution to paper. All authors have contributed to several
revisions and have endorsed the final version. All authors read and approved
the final manuscript.
Waal et al. BMC Public Health 2014, 14:853 Page 10 of 12
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Authors’ information
HW: Professor emeritus psychiatry and addiction medicine, University of Oslo,
Norwegian Centre for Addiction Research and consultant at Oslo University
Hospital, Clinic for psychiatry and addiction, Centre for substance abuse
treatment. HW has been central in the development of opioid maintenance
treatment and addiction treatment and research in Norway.
TC: Dr med, Professor of addiction medicine, SERAF, Norwegian Centre for
Addiction Research, University of Oslo. Core interest: Norwegian cohort
studies on opoid maintenance treatment, overdose mortality epidemiology
and prevention and international alcohol dependency studies.
LG: PhD from Oslo University, Norwegian Centre for Addiction Research.
Thesis on opioid maintenance treatment programs. Presently: Researcher at
Norwegian Institute of Alcohol and Drug Research.
MG: Professor Kings College London, National Addiction Centre, UK. Wide
international experience from different types of addiction research. Presently
visiting professor at Norwegian Centre for Addiction Research, University of
Oslo.
Acknowledgements
The authors are grateful for cooperation with city officials and social and
health care professionals in the collaborating cities.
Amsterdam: Professor Wim van den Brink and Senior researcher Marcel
Buster.
Frankfurt: Drug coordinator J Weimer, heads of public prosecution office: M
Bechtel and Buchhold and Police Commissioner Thomas Zosel.
Zürich: Prof Rudolf.Stohler and Michael Liebrenz, administrator A. Feller,
Captain Beat Rhyner Criminal Investigation division, Major Felix Lengwieler
High Crime Areas division: Researcher A. Moldovanyi.
Vienna: Professor A Springer and Dr med Hans A Haltmeyer from Verein
Wiener Sozialprojekte (Viennese social projects), Drug Coordinator Michael
Dressel, Drug commissioner of Vienna, Dr Alexander David and project
coordinator Angelina Zenta from Such und Drogenkoordination Stadt Wien,
Major Dietmar Berger and police officers from Karlplatz police station,
managing director Mag. Robert Öllinger, Viennese social projects.
Lisbon: Dr. João Goulão, President of IDT and National Coordinator on Drugs
and Ana Sofia Santos IDT and Paula Vale de Andrade IDT, Nadia Cardoso
Simões, Lisbon Dissuasion Commission, Paul Griffiths, Dagmar Hedrich,
Ignacio Vázquez Moliní, Klaudia Palczak, Jane Mounteney, Roland Simon
from EMCDDA, dr Miguel Vasconcelos and Antonio Costa, Centro das Taipas.
Author details
1
Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo,
Norway.
2
Clinic for Psychiatry and Addiction, Oslo University Hospital, Kirkevn
166, 0450 Oslo, Norway.
3
Norwegian Institute of Alcohol and Drug Research,
Oslo, Norway.
4
Kings College London, National Addiction Centre, London,
UK.
Received: 14 January 2014 Accepted: 29 July 2014
Published: 16 August 2014
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doi:10.1186/1471-2458-14-853
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Waal et al. BMC Public Health 2014, 14:853 Page 12 of 12
http://www.biomedcentral.com/1471-2458/14/853