Dan Gardner is the New York Times best-selling author of Risk, Future Babble, Superforecasting (co-authored with Philip E. Tetlock), and How Big Things Get Done (co-authored with Bent Flyvbjerg). His books have been published in 26 countries and 20 languages. Prior to becoming an author, Gardner was an award-winning investigative journalist. More >

Needles, Heroin, and Politics

AMSTERDAM -- "The biggest problem is finding the vein," Karsten mutters as he jams the needle into his right arm, over and over, like a robin digging for worms. Nothing. He jams it in a few more times. No luck. He switches hands and hunts in his left arm for the elusive worm. Watching this through my camera lens, I feel the warm glow of nausea. My stomach clenches and my mouth goes dry. I hate needles. Just the thought of a sliver of steel sliding beneath skin makes me shrivel. I lower the camera, roll my eyes, and look at the ceiling. Deep breath, deep breath. I raise the camera again and try to keep Karsten in the frame without looking at the darting little creature in the centre. It's a silly thing to do, I know. The needle is what it's all about. Neil Young got it right. We fear the heroin Karsten is trying to inject into his body. We blame it for the damage done. But far more than the heroin, it's the needle that makes every junkie like a setting sun. We have to look at the needle. So I do, and my stomach lurches again. Fortunately it only takes Karsten a few more jabs before he finds what he's after. He pushes the plunger and slips the needle out. A slug trail of blood slides down his arm. He's lucky; some junkies damage so many veins they have to shoot into a finger, the neck, or even the femoral vein in the groin. He puts the messy tool on a silver tray and leans back in his chair. Holding a cotton ball to the crook of his arm, he looks as relaxed as a lawyer finishing the day with a nice glass of scotch. Karsten doesn't have to hide the evidence of his crime or scurry to a hiding place because this drug den is officially approved and paid for by the city of Amsterdam. Despite its exotic function, the room is not much to look at. There are two tables, a pair of black faux-leather couches, a glass-topped coffee table and a sleeping cat. Outside, there's a patio and a little garden. It could be a suburban rec room if everything weren't so clean and orderly. There are no scowling criminals, no whacked-out whores, no filth, fear or fighting -- none of the drug-culture cliches that have terrified and titillated the middle-class for decades. There are only half a dozen people chatting and laughing while they consume heroin and cocaine as casually as a book club sampling the latest Starbucks dark roast. In North America, this is a cutting-edge idea. A similar facility is set to open in Vancouver and others are being considered by many Canadian cities. We call them safe-injection sites. But in Western Europe, where they've existed for years, they are "consumption sites," "health rooms," or just "user rooms." The name underscores a critical fact: In some Western European countries, far fewer addicts inject than in Canada. On one of the couches, Steve leans across the coffee table and consumes heroin the way most junkies do in Holland. In one hand, he has a strip of aluminum foil holding a tiny brown ball of heroin; in the other, a lighter. In his mouth is a straw. He flicks the lighter and puts the flame beneath the foil, reducing the heroin to a hissing liquid that sends a thin tail of smoke up through the straw. He tilts the foil, the heroin runs, the smoky tail shifts, and the straw follows - "chasing the dragon," as this technique is called. Steve leans back in the couch, holding the smoke in his lungs as long as he can, then lets go with a gasp. Almost immediately, he begins to brighten. When he came in this morning he was bedraggled, his eyes drooping and nose running, a junkie on the edge of withdrawal. The heroin has set him right again. Steve has been using smack for 28 years and it stopped getting him high long ago. Now, he needs it to feel normal, like a hardcore coffee drinker who needs a morning cup to stop his head from throbbing. "For me anyway, heroin is a necessity," he says in a working-class English accent. "Cocaine is a luxury. If I make enough, I buy the cocaine. If not, I only buy the heroin." Like Karsten, who is German, Steve is a foreigner. This user room is run by AMOC, a social service agency that helps foreign addicts survive in Amsterdam and arranges for them to return home. There are eight more users' rooms scattered throughout the city. Steve came to Amsterdam in the 1970s when the city was Europe's San Francisco, the Mecca of counterculture. He is an original hippie, which he proudly demonstrates by taking off his woollen hat and wagging his long ponytail. He's homeless now but he wasn't always. "I was with a Dutch girl for 18 years. We had a flat and everything like normal life. Two dogs, four cats, washing machine, television, all that sort of shit. She died six years ago. But not from drugs. She died from cancer. Since then, I don't care anymore." Like all citizens of European Union countries, Steve has the right to live and work in Amsterdam but not to collect welfare. His life is a 24/7 hustle for money, drugs and a place to sleep and it shows on his haggard face. He looks a decade older than his 46 years but still, for a hardcore addict living on the streets, just being alive at his age is an accomplishment. "The reason I reached 46," he says with perfect certainty, "is I don't shoot." Only 15 per cent of addicts in the Netherlands inject, the lowest rate in Europe, and it shows in all the statistics. The proportion of Dutch AIDS cases caused by injection drug use -- 11 per cent -- is one of the lowest on the continent. The number of drug-related deaths, at 0.5 per 100,000 inhabitants, is also among the lowest -- far lower than that of Germany (1.3) and the United Kingdom (2.7). It's also much better than the death rate in Sweden (1.9), a nation that takes an almost American-style hardline on drugs and often savages the Netherlands for its liberal policies. (The United States itself fares badly when its drug-related death rate is compared to that of the European Union as a whole. A report by the European Monitoring Centre on Drugs and Drug Addiction notes: "The number of (drug-related deaths) in the E.U. countries, with 376 million inhabitants, amounts to roughly half of those recorded in the United States, with 270 million inhabitants. In recent years, the number of cases in the E.U. has fluctuated between 7,000 and 8,000, whereas the United States appears to present an upward trend from 13,000 to 16,000 in the same period.") Not only are fewer Dutch addicts dying, very few young Dutch people are joining their ranks. The rate of heroin use is so low officials can hardly measure it. And for more than a decade it has been flat -- unlike the United States, which saw a substantial rise in heroin use in the 1990s. As a result, Holland's addict population stabilized more than a decade ago and the average addict is now much older than 40. Increasingly, health officials working with addicts deal with the ills of aging, not drug abuse. The Dutch have even discussed the problem of housing senior-citizen addicts -- which is not a problem elsewhere, but a fantasy. Dutch successes are all the more astonishing given that this tiny trading nation, with its highly developed international transport network, is flooded with drugs. Heroin is cheaper and purer in the Netherlands than just about anywhere in the western world. Cocaine is more expensive than in North America but it's very cheap by European standards. Synthetic drugs such as Ecstasy are everywhere. And marijuana is sold openly in more than 800 shops. Canada, of course, does not have marijuana shops. Nor does Canada have the cheap and potent drugs found in the Netherlands. Canada does, however, have far more despair, disease and death. In 1995, the latest year for which data are available, the rate of deaths due to illicit drugs in Canada was 2.6 per 100,000. That's more than five times the Dutch rate. The key difference is the needle: Injection is the standard method of using hard drugs in Canada. Whether it's heroin, cocaine or a combination of the two -- a "speedball" -- there's usually a needle involved. One-third of new HIV cases in Canada in 1999 were the result of injection drug use. Of 250,000 Canadians with hepatitis C, 70 per cent are current or former injectors and almost two-thirds of new hep C infections, and one-third of new hep B infections, are caused by needle use. Those infected will pay with their health. Some will pay with their lives. But all Canadians will pay with dollars: The lifetime cost of treating just one person with HIV is estimated at $150,000, while the cost of a liver transplant for a hepatitis C patient is $250,000, suggesting that the bill for existing infections alone will be many hundreds of millions of dollars. Grim as this is, the situation could get worse. An estimated 100,000 Canadians are currently injecting illicit drugs and they are increasingly switching from shooting heroin to cocaine, or both. Because cocaine's effects are much briefer than heroin's, users have to inject far more frequently -- some shoot up as many as 20 times a day. More injection means more infection, overdose and death. "The problems associated with the use of drugs by injection are reaching crisis proportions in many communities in Canada," declared a federal/provincial task force in September, 2001. Among many recommendations for reform, the task force called for a study of user rooms -- or "safe injection sites" -- like AMOC's in Amsterdam. So did an all-party committee of the House of Commons last December. The hope is that, combined with needle exchanges, safe-injection sites will help public health officials at least contain the carnage. Whether that will work is an important question increasingly discussed by politicians, the media and the public. But there is a more basic question that is almost never asked. Why do users inject drugs in the first place? Heroin and cocaine can be smoked, as Steve does. In powder form, they can be snorted. As liquids or solids, they can be swallowed. So why do addicts take drugs by sticking steel slivers into their arms, legs, fingers, groins and necks? Why, in the age of AIDS, do they take up that hideous little device and go hunting for veins? In the 19th century, when all drugs were legal and often sold as casually as soda pop, cannabis, opium, morphine and, later, cocaine and heroin, were all available in many forms. Patent medicines -- loaded with drugs that often weren't mentioned on the labels -- usually came in the form of liquids but there were also lozenges, syrups, ointments and many others. Opium was often mixed with alcohol, a drink called "laudanum." It was also taken as a syrup, or in the Asian fashion -- smoked in pipes. Athletes chewed coca leaves to gain stamina from cocaine. Coca tea was common. Cocaine spiced up wine and, most famously, Coca Cola. Cocaine powder was also sniffed, as was heroin -- a more-potent refinement of morphine -- after it came on the market in 1898. But the needle was also a fixture of the Victorian age, usually in tandem with morphine, the more-potent derivative of opium. (Opium, morphine, heroin and codeine are all derived from the opium poppy. They are known collectively as "opiates." Along with many synthetic cousins like methadone and Demerol, they are known as "opioids.") When syringe injections were perfected in the 1850s, morphine shots became a staple of medicine. Some recreational users picked up the practice and made it fashionable: In the late 19th-century, chic ladies and gentlemen carried ornate injection kits much like the silver cigarette cases that would be popular among a later generation. But this was not injection as Karsten and most junkies know it. Nineteenth-century users gave themselves hypodermic injections only. The needle never touched a vein. "No one seems to have injected morphine intravenously until the 20th century," writes historian Richard Davenport-Hines in The Pursuit of Oblivion: A Global History of Narcotics. The earliest known account of intravenous drug use dates from 1925, in Terre Haute, Indiana. From there, the practice spread like the plague. By 1935, almost half the addicts admitted to an American drug-treatment hospital were shooting into their veins. By the early 1950s, injection had become so routine that when a heroin panic swept North America -- immortalized by Frank Sinatra in The Man With The Golden Arm -- the needle symbolized the terrifying threat. By the time Neil Young came along, needles, veins and drugs were inextricably intertwined. Intravenous injection wasn't the only revolution in drug-taking during the 1920s. The drug-laced lozenges, liquors, tinctures and potions all vanished. So did coca leaves, tea and wine -- leaving pure powder as the only form of cocaine available. Opium smoking also began to rapidly diminish in western countries, even in the Chinatowns of major cities where the practice had a long history, so that by the 1950s opium smoking and even opium itself had disappeared in Canada. Even non-medical morphine use began to drop steadily in the 1920s, leaving heroin the reigning opiate. Historians point to a number of factors that contributed to these radical changes in drug use, including a growing urban underclass attracted to the escapist thrill of more potent drug forms and methods. But the really critical change was the law. In Canada, the United States and elsewhere, drug prohibition was phased in between 1910 and 1920. Smugglers, not pharmaceutical companies, supplied the new black markets and smugglers, for obvious professional reasons, prefer shipping small items to large. That means they favour more potent drugs over less -- an envelope of powder cocaine instead of a bushel of coca leaves, heroin instead of opium. Alcohol prohibition in the United States had exactly the same effect in the same decade: The availability of beer and wine fell while that of spirits, particularly super-potent booze, soared. Banning drugs also reduced total drug supplies, and that had two huge consequences. First, the purity of drugs at the street level plummeted because black-market dealers diluted their drugs confident that customers had no choice but to buy from them. Instead of high-purity, pharmaceutical quality drugs, users got talcum powder, baking soda or whatever else the dealer found at hand -- and a tiny amount of the drug itself. In theory, users could overcome this simply by buying and using much more. In reality, that was impossible because prices on the black market were 10 times higher, or more, than they had been in the legal market. Extremely expensive, weak drugs left users with only one option: Switch to more efficient, cost-effective methods of use. Don't drink or eat the drug because processing it in the stomach is inefficient and wasteful, particularly with heroin. Sniffing is much more effective. Smoking is better still. But by far the most efficient method is intravenous injection. On top of this, opiate users develop tolerance over time, forcing them to use more to get the same effect. Faced with rising tolerance, ballooning prices and plummeting purity, addicts had little choice but to start shooting drugs into their veins. In Creating the American Junkie, historian Caroline Jean Acker unearthed the words of drug users who lived through the transition from the laissez-faire drug markets before the First World War to the black markets of the 1920s. A pattern appeared time and again, as in the case of James Martin, an American user. Martin noted that before opium importation was banned in the United States in 1909, "a can of hop was only $4," but "when the government made that law, it jumped up to $50 a can." So he switched to sniffing heroin, which wouldn't be banned for several more years. When that, too, was prohibited, he started shooting up "to get a better kick out of it." An entire generation of drug users followed the same path. The era of needles hunting for veins dawned and the damage was done. None of this is ancient history because drugs are still banned. Milder forms of drugs are still unavailable. Prices are still inflated, purity is still cut, and users are still pushed toward intravenous injection. "In theory and in practice," writes Michael Gossop, a leading British addictions researcher, "heroin users may change their main route of administration between snorting, chasing and injecting. However, the likelihood of such transitions are biased toward more efficient, and more risky, routes of administration. In a study of such transitions among heroin users in south London, we found that users were twice as likely to switch from snorting to chasing or to injecting as to make the reverse transition. Similarly, chasers were twice as likely to move on to injecting as to switch back to chasing." The drug-taking revolution of the 1920s is also very much a pressing issue in countries that have until recently escaped the war on drugs. Diane Riley points to Central Asia, where she has worked on drug-related projects for UN AIDS, the UN's anti-AIDS agency. "Traditionally, it's a region that has used marijuana and syrup and poppy from opium poppy. Opium smoking is traditional as well." But the United Nations, at the urging of the United States, has steadily pressed Central Asian governments to attack all drug use. "So they're cracking down on marijuana and poppy with as much vehemence as they are on heroin." The result is exactly what happened in North America in the 1920s: Traditional drugs and methods are being replaced by the intravenous injection of heroin. Still, users in a few countries have actually gone the other way and given up the needle. During the 1990s, most Spanish heroin addicts stopped injecting and took up smoking. Holland went through the same transition in the 1980s. Both countries have reaped enormous health benefits as a result. Why have some bucked the trend? Culture and habit are critical. Users learn methods from other users and they invest their techniques with ritual and meaning. A user's choice of method is not strictly rational and calculated, just as a vodka drinker's preference for martinis over screwdrivers likely does not simply reflect a desire for greater drinking efficiency. But culture is not static, as Holland's experience shows. During the late 1970s, a wave of Surinamese immigrants came to the Netherlands. Many failed to integrate and took to heroin to ease the misery of dislocation. But needles were alien to the Surinamese and they loathed injection. They smoked heroin instead. The new demand increased the black market's efforts to supply the form of heroin that can be smoked. With smokeable heroin more widely available, AIDS a horrifying new threat, and experienced users around to encourage and teach others how to chase the dragon, Dutch addicts abandoned the needle. The switch from needles is also helped along when addicts are treated as people in need of help, not criminals who deserve punishment. That's the case in both Holland and Spain. Under Dutch law, possession of a small amount of hard drugs is still formally a crime but it's not really enforced. In Spain, possession has been decriminalized since 1992. As a result, addicts in both countries are in closer contact with health authorities. And they are freer to go through the slow, elaborate procedure of chasing the dragon instead of taking the quick hit of injection and scurrying away. Price and purity have also had a hand. Drugs in both Holland and Spain are relatively inexpensive and both countries experienced dramatic declines in price -- and rises in purity -- at the same time their users gave up the needle. In other words, the effects of drug prohibition, including the pressure to inject, were eased somewhat by the abject failure of law enforcement to stop more and more drug shipments from being produced and smuggled into these countries. And not only these countries. In the United States, between 1980 and 2000, the price of heroin at the street level fell by one-third while the average purity rose from four per cent to 25 per cent. Most of these dramatic changes occurred in the 1990s -- which is also when significant numbers of American heroin users started sniffing instead of shooting. It was the first time since heroin had been banned that sniffing had appeared in a big way. In Canada, the trend in drug prices has been, as it has throughout the western world, downward. But the declines in this country haven't been as steep as in Holland or even the United States. And drugs remain far more expensive in Canada than in the Netherlands. According to data from the RCMP and the Trimbos Institute, a Dutch agency, a gram of heroin on Canadian streets costs $200 to $400 while a gram in Holland is worth just $50 to $57. A gram of cocaine in Canada is $80 to $150, compared to $50 to $78 in Holland. The connection between high prices and the needle is something Dutch addicts understand. "It's terrible. You see it yourself in Canada. Everybody's fixing there because the price is so high. Here we can smoke it because the prices are lower," Guido Vandervet, told me in an Amsterdam drop-in centre. Vandervet has been a junkie for decades but for the last several years he hasn't had to hustle for heroin. He's a patient in an experimental Dutch program which prescribes minimum doses of heroin to addicts in an effort to stabilize their lives. Marion, 43, is another patient in the program and she credits the free heroin with her decision to give up injection after 20 years of shooting up. The program, she says, "was the only place that I got enough heroin, and such a good quality, that I could switch. Outside, I could never make enough money to go over to smoking. Because you need a lot more for smoking. It's a lot more efficient to inject." Perhaps it should be called the Dutch paradox: Less expensive drugs promote less dangerous forms of drug use. Of course the idea that cheap drugs can save lives is raw heresy in law enforcement circles. The whole point of fighting the drug trade is to reduce the drug supply and success is demonstrated by rising prices and falling purities. This is what every narcotics officer works hard for. It's what the War on Drugs is all about. Unfortunately, that means that if the "Dutch paradox" is correct, it has an ugly flipside: The very thing police officers work so hard to accomplish is what pushes addicts to stick needles in their veins. Diane Riley, for one, is convinced this is the case. "This is one of the reasons why I am very much opposed" to the War on Drugs, she says. The first danger of needles is the simplest: They puncture the skin, which is the body's frontline against infection. Every puncture is a potential infection site. Fill the needle with untested, impure junk and the risk soars. Put that needle in the hands of a frightened, run-down, mentally unstable junkie living in squalor and there will almost certainly be a tragedy. Collapsed veins are common. So are blood poisoning and endocarditis, an infection of the heart valves. In May, 2000, 30 addicts in Britain and Ireland died when they injected heroin that had been tainted by a common bacterium; smoking the drugs would have killed the bacterium and saved their lives. Injection also boosts the risk of overdose by slamming a large dose of the drug into the brain at top speed. Smoking delivers the drug as quickly as injection but only a relatively small amount can be inhaled at one go -- an effective safety mechanism. In his 28 years of heroin use, Steve has seen many overdoses but he's not worried, he says, because he smokes his drugs and "if I smoke too much, before I take enough to kill me I'm going to crash out." In a survey of London junkies, Michael Gossop found that just two per cent of heroin smokers had experienced a non-fatal overdose compared to 31 per cent of injectors. Police compound the risk of overdose when they jail junkies for a few days or weeks, as they so often do. That's just enough time for the addict's tolerance to decline so that when he returns to the street the dose he's used to taking is now overwhelming. And junkies are notoriously reluctant to call for help when someone overdoses, fearing they will be arrested: One American study found that in only 14 per cent of overdoses was an ambulance called right away, while in half the cases an ambulance was never called. The most notorious risk of injection is catching a blood-borne disease. The explosion of HIV in the 1980s, and hepatitis C in the 1990s, drilled this danger into public consciousness but it is far from a new threat: In 1933, a wave of malaria swept through heroin injectors in New York City. Injection alone doesn't spread these diseases, of course. It happens because junkies share needles, rinse water, cotton or other paraphernalia. For that, too, the law is primarily responsible. In many places, including some American states, possessing drug paraphernalia is a crime. In others, possession isn't a crime but can be used as evidence of related crimes such as possession or trafficking. Often the law bans the sale of clean syringes. In every case, however, the rule is the same: The tighter the restrictions, the more needles are shared. In Edinburgh, Scotland, in the early 1980s, "there was a shortage of syringes because the chief medical officer for Scotland was a strict puritan and didn't believe that people should shoot up drugs. Whether they did or not, they shouldn't," recalls Cindy Fazey, a professor of drug policy at the University of Liverpool and formerly a top official with a United Nations drug agency. Under Scottish law, "selling paraphernalia for drug use was a criminal offence (and) there were no syringes to be had." Shooting galleries where users gathered and shared needles sprang up. "And then you had someone come over who was HIV positive. And it whizzed through the addict population, from zero to about 60 per cent in an incredibly short time." Similar, eruptions took place all over the world. In Canada, the proportion of HIV infections caused by injection peaked at almost one-half in 1996, while in 1999, the latest year for which numbers are available, needles were the cause of one-third of new infections. In the United States, 28 per cent of new HIV cases in 2001 could be blamed on injection drug use. So could more than one-third of all AIDS deaths during the 1990s. Outside North America, only the African AIDS epidemic has little connection with intravenous drug use. "In Asia and central and Eastern Europe, the majority of cases are through injection and that's getting it into the general population," says Riley. Horrifying as the epidemic is, it's likely going to get much worse. "What we're seeing is just the very, very tip of the iceberg," says Diane Riley. Rates of injection drug use are exploding in Asia, especially in the former Soviet Bloc. Governments are responding with increased repression, which promotes needle sharing which is spreading HIV faster than the rats that brought the Black Death to Europe. "The epidemic isn't going to peak for 10 to 20 years." When HIV hit Edinburgh, recalls Cindy Fazey, "there was a panic and a realization that we must stop this. And the way to stop it was with needle exchanges." Britain was one of the first countries to widely distribute clean needles to addicts, a move that particularly benefited England and Wales since they had never banned needles as Scotland had. Today, England and Wales have the lowest rate of HIV infection among injection drug users in Europe "at about six per cent. Compare that with France or Italy, where they're around 60 or 70 per cent." In Canada, HIV infection rates vary widely from city to city. One of the highest is in Ottawa, where surveys have found that more than 20 per cent of injectors have HIV or AIDS. Needle exchanges started to appear widely in Canada in the early 1990s, prompting furious debate. Supporters argued they reduced infections without increasing drug use. Opponents pointed to research by Dr. Martin Schechter, a University of British Columbia AIDS researcher, showing that addicts who used some Canadian needle exchanges had a higher rate of HIV infection -- suggesting that needle exchanges were actually fostering infection. Dr. Schechter himself supports needle exchanges and has pointed out -- loudly and often -- that the critics are wrong. His research showed that higher-risk individuals were more likely to use the exchanges, and that was the real cause of the higher infection rate among clients. But this is an old controversy, at least in medical circles. Today, Dr. Schechter says, "there's no debate among public health people." Even the top drug official in Sweden -- a country fiercely opposed to liberal drug policies -- recently declared that Swedish pilot projects have succeeded; he called for needle exchange to expand nationwide. "The only debate now is at the political level," says Dr. Schechter. Many officials in both the U.S. government and the UN drug agencies continue to fight needle exchange. "It's kind of on ideological grounds," says Dr. Schechter. "But they continue to cite articles such as ours and put out the misconception that needle exchange is harmful." Outside of hard-line political circles, the AIDS epidemic shook up policy makers by demonstrating that there were far worse dangers than drugs. A new way of thinking sprang up, one that focussed on reducing harm overall rather than the narrow obsession of driving down drug use. The "harm reduction" movement was born. User rooms -- or "safe injection sites" -- were one of the first inventions of the new movement. Germany, Switzerland, Holland, Spain and Australia all have facilities where users can take drugs without fear of arrest. The idea is simple: Stop addicts from shooting up in filthy alleys, flophouses and parks by providing them with hygienic rooms, sterile equipment, clean water and staff who can call for help if something goes wrong. There are no systematic evaluations yet but the research that has been done is hopeful. In Frankfurt, Germany, where the first user rooms were introduced during the early 1990s, the number of fatal overdoses fell from 147 in 1991 to 22 in 1997, a time when the total number of overdose deaths in Germany held steady. And none of those 22 deaths in 1997 occurred in the user room. In fact, according to a report by Australian researcher Alex Wodak, "there has not been a single death in a (user room) in Europe." Many are not impressed. The International Narcotics Control Board, a UN agency, claims users' rooms violate international drug treaties. John Walters, the White House's "drug czar," has denounced them as "state-sponsored suicide." And the Canadian Alliance has opposed the introduction of users' rooms in Canada. Kevin Sorenson, a Canadian Alliance MP and member of a recent House of Commons committee that studied illicit drug issues, insists that users' rooms are "not something that people will use to the degree that it's going to alleviate any problems." The committee visited a site in Germany, he says. "There was four blocks before you got to the safe shoot-up site where they were laying all over the sidewalk shooting up regardless. The culture of drug use is you shoot up wherever, whenever." Thomas Kerr, research co-ordinator with British Columbia Centre for Excellence in HIV/AIDS, says that Sorenson and other critics of safe injection sites are ignoring the evidence. Kerr studied the issue with colleagues, he says, and "our review of 18 safe injection sites in four different countries suggested that people who injected in public places will make the transition to injecting in safe injection sites." What Sorenson saw has to be put in context, says Mr. Kerr. "If Mr. Sorenson had been in Frankfurt in the early 90s, he could have gone to a particular city park and seen thousands of people injecting outdoors, as opposed to the maybe dozen he saw on his recent trip. There were numerous overdoses in that park every day, multiple visits from ambulances. If you go to that park now, it is empty. There isn't a single person there. Yes there are still some people who inject in public but to suggest that the open drug scene in Frankfurt has not been diminished is completely erroneous. It's minuscule compared to what it once was." The critics seem to be losing the fight, at least within Canada. The House of Commons committee ignored the Alliance opposition and recommended last December that pilot projects proceed. So did a federal-provincial task force. Even the RCMP supports the idea, provided the rooms are set up as part of a continuum with treatment and rehabilitation. Outside the AMOC user room in Amsterdam, there are no broken-down junkies languishing on the sidewalks, no rubbish, dirt or disorder. It's an ordinary street and aligned with ordinary Dutch canal houses -- one of which happens to have a room where addicts use drugs. Like the rest of central Amsterdam, even the notoriously rowdy red-light district, everything is scrupulously tidy. Squint and you might think you're in Switzerland. Amsterdam wasn't always so Swiss. In the 1980s, the city was internationally notorious for the addicts who flooded its parks and neighbourhoods. Hardliners blamed the mess on Holland's liberal drug policies. In reality, says Eberhard Schatz, program co-ordinator of AMOC, the war on drugs itself was to blame. Until the early 1990s, none of Holland's neighbours shared its liberal views on drugs. Germany, in particular, took a very strict line, even forbidding methadone treatment. German addicts -- who, like all European Union residents, have the right to live in any EU country -- fled across the Dutch border. And instead of hiding in basements, alleyways and derelict buildings as they would in countries like the United States that still toss junkies in jail, the foreign addicts lived and used drugs openly. Hence, the appearance of chaos. Germany's war on drugs accomplished less than nothing: Addiction and AIDS soared. Finally, in the late 1980s, Germany began to abandon repression and follow the Dutch lead. "At the end of the 1980s, really major changes were made in Germany," says Schatz, a German social worker who has lived in Amsterdam for 13 years. "Fewer people needed to come here because of better facilities in Germany. So, in the beginning of the 1990s, we saw a major reduction in the number (of addicts) coming to Amsterdam." User rooms have also contributed to Amsterdam's new civility, by "getting people off the streets into safe circumstances," says Schatz. Amsterdam has nine rooms "and they're spread out so it doesn't concentrate the activity." Officially, that's as far as the Dutch experiment has gone. Unofficially, some user rooms have taken one more giant step: Dealers with a reputation for honesty and providing untainted drugs are permitted to quietly work in the user rooms. Schatz says that's vital because even with the user rooms, "addicts still have to buy the stuff they are using out on the street." That means more rip-offs, beatings and poisonings for addicts and more disorder for neighbourhoods. "So we should have house dealers who serve the people on the spot." In 2003, it might sound like Schatz is dreaming. But then, 20 years ago, who would have imagined a group of addicts using drugs without fear of arrest in a government-sanctioned facility? Who would have imagined junkies -- the leering, diseased, demons of 20th-century mythology -- sitting around a tidy suburban rec room, relaxing, talking and laughing like ordinary human beings? Diane Riley is pleased by the success of Europe's experiments with harm reduction but she is worried that many reformers, in Europe and in Canada, aren't nearly bold enough in their thinking or their demands for change. "My mind is to go beyond harm reduction. When I got involved with it, which is now 20 years ago, I saw it just as a stepping-stone, a band-aid. And I'm rather perturbed to see the way it has become the goal in and of itself, rather than being a stepping stone to major drug policy reform -- decriminalization and eventually legalization." With legalization, Riley says, drugs and drug use could be effectively regulated and controlled by governments. The milder, safer forms of drugs that disappeared in the 1920s could return. So could the much less dangerous methods of use ousted by the needle. This time, it could be the needle that is thrown in the dustbin of history. No more needles digging veins like worms. No more AIDS, hepatitis, and overdose. No more junkies like setting suns, no more damage done. It's a vision that would mark Riley as a radical even in Amsterdam, and she knows it. "These are things I think we should be pursuing but if you talk about them, it's like, oh, this woman is promoting exotic forms of drug use. But obviously we're going to use drugs, and we need to use drugs. I think that's part of the human condition for a lot of people. So why can't we use them more safely?"