Drug Consumption Room: Different Harm Reduction Approach An Overview Between Holland And Italy

FIRST CHAPTER  
1.1 Drugs 
What do you mean when you say Drug? According to the Oxford Dictionary the definition of 
drug is: “A medicine or other substance which has a physiological effect when ingested or 
otherwise introduced into the body.”  
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But for everyone drug has different meaning. Now we can try to understand something about 
drugs and why the humans use drugs in their life.  
A drug can have many names. The chemical name describes the molecule. The generic name 
is a shorter, simpler name that assigned to the substance by conventional agreement. The 
official name is the trademark for drug registered by the company that produces it, and if 
often varies between countries because of the local law. Finally, the drugs can have popular or 
street name which differs among people, places and times.  
The origin of drugs use is quiet simple. Humans are inquisitive creature. If something can be 
done, somebody will try to do it. If a substance can be eaten, it is certain that somebody will 
try to eat it (Gahlinger P.M., 2004). 
Psychoactive drugs have always been closely associated with religion. In early relief system, 
any substance that had the ability to prevent or cure disease was considered sacred. For 
psychoactive drugs, social and religious rituals arose as a way of controlling their use. By 
allowing these drugs to be used only on certain occasions or by certain people, the general 
population could be protected for harm.  
According to pharmacological science, a drug is defined as “a chemical substance used in the 
treatment, cure, prevention, or diagnosis of disease or used to otherwise enhance physical or 
mental well-being” (Random House, 1998). In more common usage, a drug is any substance 
that in small amounts produces noticeable changes in the body or mind.  
In the past, if a drug helps the body, it was considered a medicine. If it injuries the body, it 
was called a poison.  
Illegal drugs are not necessarily those that are considered the most dangerous, but those that 
result in other hazards such as addiction or inappropriate behaviour. If a drug causes someone 
https://en.oxforddictionaries.com/definition/drug;
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to act in ways that are offensive to others, it represents a threat not only to the individual but 
to the whole society.  
In the past a lot of drugs were used as a medicine or in surgery, like heroin or cocaine. After 
we understand the risk of addiction with these drugs, most of those became illegal.   
1.1.1 Different Type Of Drugs  
All drugs can be identified by their name and classified regarding different criteria, such as:  
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Their way of action;  
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Their indications;  
- Their chemical structure.  
We will focus on the classification of the drugs regarding their effects on the metabolism of 
the drug users.  
There are two clear categories of drugs: the downers and the uppers; and all the others are 
called trippers (Inaba D.S., Cohen, W.E:, Holstein, M.E., 1997). 
The consequences of downers on the metabolism are: slow down breathing rhythm, slow 
down the heartbeat, etc. For example some downers are: Opiate, Ketamine, Benzodiazepine 
etc. (Inaba D.S., Cohen, W.E:, Holstein, M.E., 1997). 
The consequences of uppers on the metabolism are: accelerate the breathing rhythm, 
accelerate the heartbeat, etc. For example some uppers are: Cocaine, Crack, Speed, etc. (Inaba 
D.S., Cohen, W.E:, Holstein, M.E., 1997). 
The consequence of trippers on the metabolism are not as clear as the other two categories. In 
general, those substances have different impacts on the metabolism based on the amount used 
and the predisposition of the user’s metabolism. For example, a couple of shot of gin tend to 
bring the user in an euphoric state of mind and an excitement similar to an upper but if the use 
increases, the effect of the alcohol on the metabolism will be similar to a downer, slowing 
down the breathing rhythm, and giving other “downers” effects. For example some trippers 
are: Cannabis, MDMA, LSD, etc. (Inaba D.S., Cohen, W.E:, Holstein, M.E., 1997). 
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1.1.2 Drug Use, Abuse And Addiction  
Before speak about use, abuse and addiction we need to explain something.  
In order to have the psychoactive drugs to be effective, they must enter into the blood stream 
and get to the brain. More quickly the drugs reach the brain the more dramatic the effects will 
be.  
There are only five common methods of use drugs. These are arranged here based on the 
speed with which the drugs will reach the brain and begin to have an effect (Gahlinger P.M., 
2004). 
Smoking: Smoked or inhaled drugs enter the lungs and are quickly absorbed by the 
bloodstream throughout tiny vessel lining the air sacs. Smoke is created when a material is 
vaporised under heat to form a gas. As a gas spreads into the cooler surrounding air, it 
condenses into microscopic liquid droplets. These droplets catch the light and appear as 
visible smoke. Because of the very small size of the droplets inhaled, the smoke continues all 
the way to the lung air sacs where it contacts the bloodstream and is quickly absorbed. Blood 
from the lungs continues to the heart and some of it is pumped directly to the brain. Generally 
it takers 7-10 seconds to get to the brain (Gahlinger P.M., 2004). 
Injecting: This is the most direct way to take drug but surprising, is not as fast as smoking. 
There are several methods of sing a needle to inject a drug. It my be injecting into a vein,  a 
muscle, or deep into the skin. If the drug is injected into a vein, the blood first return to the 
right side of the heart. It is than pumped to the lungs, returned to the left side of the heart, and 
then pumped to the brain. The other types of injection spread the drug in to other tissues. 
Blood bathing these tissues will eventually pick up the drug, return it to the heart, lungs, and 
heart again, and then carry it to the brain. Generally the time that the drug needs to get to the 
brain is 15-30 seconds if injected into a vein and 3-5minutes if injected ito a muscle or skin.  
Snorting: Snorting is an expression used in the illegal drug trade meaning to sniff a drug. It 
comes from the sound made with a quick, sound sniff, like a snorting horse. Drug sniffed by 
the noise are absorbed by blood vessels in the mucous membranes of the nasal passages. 
Although these blood vessels are very close to the brain, the drug-laden blood first return to 
the heart, and then some of it is pumped back to reach the brain. Generally it takes 3-5 
minutes to the brain (Gahlinger P.M., 2004). 
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Contact: Some drugs can be absorbed directly through the skin, or mucous membranes in the 
eyes, mouth, vagina, or anus. Historically some drugs were taken after first cutting or burning 
the skin and then applying a drug paste. Today, prisoners use occasionally this method, even if 
it is painful and inefficient.  
Fentanyl is marketed in an adhesive patch that provide a steady release of the drug for several 
days. Some illicit users of cocaine rub it on a mucous membrane, especially in the vagina or 
penis. Tiny LSD blotters are sometimes dropped into the space behind the lower eyelid, where 
the drug is rapidly absorbed. Generally time to reach the brain is 3-5 minutes for the eye and 
15-30 minutes for the skin and other areas (Gahlinger P.M., 2004). 
Ingesting: A drug that is eaten, drunk, or taken as a pill first passes down the esophagus to the 
stomach, where it is mixed with gastric fluids. It than moves on the small intestine, where it is 
absorbed into the tiny blood vessels lining the walls. Intestinal blood goes to the liver, where 
the drug may be filtered out or altered. Blood from the liver then reaches the heart and is 
pumped to the brain. At any steps along the way, the drug may be metabolised or degraded, 
making this method either the safest and the slowest and less efficient way to take a drug. 
Generally the time to brain is 20-30 minutes (Gahlinger P.M., 2004). 
Now we can start to understand what it means use, abuse and addiction.  
Substance abuse has a different meaning in the legal sense from psychiatric sense. Legally, 
abuse refers to substance that are used for non-medical or non-legitimate purpose. Using a 
drug just for fun is therefore considered abuse of a drug.  
The psychiatric meaning of abuse considers the outcome rather than the purpose of use. 
According to the definition taken from the American Psychiatric Association in their 
Diagnostic and Statistical Manual of Mental Disorders (DSM-V , 2013) substance use 
disorders is: “A problematic pattern of substance use leading to clinically significant 
impairment or distress, as manifested by at least two of the following, occurring within a 12-
month period:  
- Substance are often taken in large amount or over a lounge period than was intended;  
- There is a persistent desire or unsuccessful efforts to cut down or control substances use;  
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A great deal of time is spent in activities that are necessary to obtain the substances, use the 
substances, or recover form its effects; 
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Craving, or a strong desire or urge to use substances; 
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Recurrent substances use resulting in a failure to fulfil major role obligations at work, 
school, or home; 
- Continue substance use despite having persistent or recurrent social or interpersonal 
problems caused or exacerbated by the effects of substances; 
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Important social, occupational, or recreational activities are given up or reduced because of 
substances use;  
- Recurrent substances use in situations in which it is physically hazardous; 
- Continued substance use despite knowledge of having a persistent or recurrent physical or 
psychological problem that is likely to have been caused or exacerbated by the substances;  
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Tolerance symtoms;  
- Withdrawal symptoms.   
In short, abuse is defined as “the continued use of a drug despite negative 
consequence” (Inaba D.S., Cohen, W.E:, Holstein, M.E., 1997). 
But, when this drug use became abuse? Typically, people do not start to use drugs with the 
intention of disrupting their lives or becoming addicted. Drug use usually begins with 
curiosity, encouragement by friends or a desire to find relief from boredom, pain, anxiety, or 
depression. Use shades into abuse when drug activity starts to cause problems in the person’s 
life. Illegal drug use can be considered to fail into one of the following categories, where any 
level of use may progress to the next:  
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Experimental use: This is short-term, random use of one or more drugs. It usually occurs 
out of curiosity, encouragement by friends, or a desire to reach an altered state of mind; 
- Recreational use: This occurs most often with friends who get together occasionally to 
take the drug, either out of interest or pleasure; 
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Circumstantial use: By this point, the drug is used for a specific purpose: the cope with a 
problem or achieve a certain mood. The users may take the drug with friends, with 
acquaintances, with strangers, or alone. They may take it in binges, backing off when they 
need less or when problems from using the drug overcome the benefit;  
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Compulsive use: This is drug addiction. The user’s life is dominated by getting and using 
the drug. Everything else is less important Addicts may be able to function quite well as 
long as they have access to the drug and use it in a regulated way, but their can easily 
become uncontrollable and lead to physical, social, and legal problems.  
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In medical studies, “substance dependence” is the term used for addiction. There are two 
types of substance dependence: phycological dependence and physical dependence. 
Psychological dependence is a craving for the drug, so that the user is desperate to get more. 
Physical dependence means that there are physical symptoms of withdrawal when the person 
stops using the drugs, such as hangover, body aches, or a flu-like feeling. Addiction is 
generally considered to be a condition of psychological dependence with or without 
accompanying physical dependence. A drug user can be addicted even though there are no 
withdrawal symptoms (Gahlinger P.M., 2004). 
According to the DSM-V , substance dependence is defined as a maladaptive pattern of 
substance use leading to impairment or distress, with at least three of following:  
- Tolerance: A need for increasing amounts of the substance to achieve the desired effects, 
or a diminished effects with the same amount; 
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Withdrawal: A syndrome of impairment or distress the occurs when use of the substance 
is stopped, and relieved when it is taken again; 
- Increasing amounts: The substance is taken in large amounts or over large period then 
was intended;  
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Attempts to stop use: There is a persistent desire or unsuccessful effort to cut down or 
control the use of substance;  
- Drug-seeking behaviour: A great deal of time is spent in activities necessary to obtain the 
substance, or recover from its effects; 
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Neglecting other activities: Important social, occupational, or recreational activities are 
given up or reduced because of the substance use;  
- Drug Problems: The person continues to use the substance even though he or she knows 
that it is causing physical or psychological problems.  
Not all drugs cause a withdrawal syndrome when the user stop taking them. Those that do 
generally produce withdrawal effects that are opposite from the effects of the drug. For most 
drugs, withdrawal is usually just uncomfortable, but for some drugs it can br hazardous or 
even fatal.  
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1.1.3 Cocaine  
For thousands of years, native of the Andes chews or brewed coca leaves into a tea for 
refreshment and to relieve fatigue, similar to modern customs of chewing tobacco and 
drinking tea or coffee. The Indians considered the leaf to be sacred and essential to life. When 
the Spaniards conquered the Inca Empire in the 16th century, they attempted to ban coca 
chewing. They relented when they discovered that Indians working in the silver mines would 
work harder if given their daily allotment of coca. Coca leaf chewing remains even now an 
important part of traditional Andean culture and nutrition.  
The coca bush can grow to the height of nine meters but is usually pruned down to about two 
meters for easy collection of the leaves. Leaves are usually harvested three time a years, up to 
six time in some areas.  
Soon after its refinement in the 19th century, cocaine was prescribed for almost any illness. If 
effectively became a recreational drug, as much of its early medical use was more likely a 
matter of abuse or addiction. Cocaine wines and cocaine soft drinks became extremely 
popular. When its addictive potential was realised, cocaine was made illegal. Now, only 
cocaine hydrochloride remain medically available for very restricted use.  
Illegal cocaine is usually distributed as white crystalline powder or as an off-white chunky 
material. The powder, cocaine hydrochloride, is often diluted with variety of substance, the 
most common being sugars such as lactose, inositol, or mannitol, and local anaesthetics such 
as lidocaine. This adulteration increases the volume and therefore multiples profits. Powder 
cocaine is generally snorted or dissolved in water and injected.  
Powder cocaine surged in popularity in the 1970s. It was called the champagne of drugs 
because it was expensive and thought to have no serious consequence. It was also known as 
the yuppie drugs because it appealed to young urban professionals.  
Powder cocaine is usually snorted, with the fine powder absorbed by the mucosal members of 
the nasal passages. This is much more effective than simply ingesting cocaine. The absorption 
of snorted cocaine is still not as fast as smoking it, however, because the small nasal blood 
vessels are constricted by the drug. But powder cocaine cannot be smoked because it is 
destroyed by the high temperature of combustion. In order to make a smokeable cocaine from 
of cocaine, it was chemically modified in to a substance called freebase.  
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Freebase cocaine is made by heating cocaine hydrochloride in water and adding a base, 
usually sodium bicarbonate of buffered ammonia. This base “free” the cocaine from the 
hydrochloric acid used in its initial production. An organic solvent is than added and the 
solution is shaken vigorously. The liquid separates into two layers, with cocaine dissolved in 
the top of the layer. This can be drawn off with an eye dropper and placed into a dish to 
evaporate, leaving almost pure cocaine crystals. The result is an alkaloid which is both 
resistant to heat and is also very fat-soluble, meaning that it can enter the brain easily. Since 
ether is extremely flammable, freebase users must be careful to wait until all the ether has 
evaporated before smoking the crystals to avoid explosive burns.  
Freebase cocaine was developed around 1976 and caused another upset in cocaine abuse. It 
was purer, and therefore more potent, than the typical powder cocaine, and it could be 
smoked, allowing a large amount of cocaine to quickly enter the bloodstream from the lungs 
and go directly to the brain. The effects of freebase were faster and more potent, making 
freebase more highly addictive than powder cocaine.  
Until the mid-1980s, freebasing grew in popularity to the extent that about 10 to 20 percent of 
all cocaine was used in this way.  
The danger of using extremely flammable chemicals such as ether presents a major problem 
in making freebase. The solution is a technique that is simpler than freebase, called “dirty 
basing”. Rather than extracting pure cocaine, the crude power is simply dissolved in baking 
soda and water. The mixture is than boiled or put in a microwave oven to speed up the 
chemical reaction, after which it is removed and called quickly by putting it into a refrigerator 
or pan of ice water. The solid settles out at the bottom and is removed and dried. The results is 
yellowish-white material hat looks like pieces of soap or plaster. These can be broken into 
smaller chunks, usually about one-tenth to one-half of a gram. When these “rocks” are heated, 
they make popping, cracking sound-hence the name, crack.  
Crack appeared in 1985 as a simple, much cheaper way to get benefits of freebase cocaine.  
Until crack came along, hard drugs use was limited by its high cost and risk of disease. The 
public has always tolerated a limited amount of drug abuse, especially when it is largely 
restricted to the eccentric, wealthy, or politically well-connected. But crack pushed the limits 
of this tolerance, it was too close to the home. It was cheap, did not require needle injection, 
did not use flammable liquids such as ether, and it could be hidden or stored. Crack was a 
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low-cost, highly addictive form cocaine and it spreads most rapidly into the inner city and 
minority neighbourhoods. 
The intensity of the psychological effects of cocaine depends on how quickly, and how much 
of, the drug reaches to the brain. Snorted cocaine reaches the brain in one to three minutes and 
produces a high that lasts for half and hour or so. Intravenous injection of cocaine takes only 
15 to 30 seconds to produce its effects, which pack in 3 to 5 minutes and lasts for 15 to 20 
minutes. Smoking is even faster, producing and effects within 10 seconds and peak in 3 to 5 
minutes, which lasts about 15 minutes. Because the high of smoked cocaine is so short and 
intense, it is especially addictive.  
Cocaine has both euphoric and stimulating properties, much like the amphetamine, but they 
do not last long. There is increased alertness, excitation, and a feeling of confidence and well-
being. There is also an increased pulse rate and blood pressure, insomnia, and a loss of 
appetite. The euphoric effect is often followed by a dysphoric - a disagreeable felling of 
fatigue, depression, and anxiety. To avoid this, another dose is usually taken; and the cycle 
continues until the supply of cocaine is used up.  
When cocaine and alcohol are used together, a new chemical, cocaethylene is formed in the 
liver. This compound crosses the blood-brain barrier and produces a longer and more 
intensely euphoric high.  
Like all stimulants, the longer cocaine is used, the more the user needs to achieve the same 
level of excitement and euphoria. The meantime, the unpleasant effects of anxiety, insomnia, 
and overall discomfort begin to accumulate. Long-term users say that although cocaine no 
longer produces much of a “high”, they still cannot stay away from it. There is a persistent, 
unsettling sense of craving the drug.  
Withdrawal from cocaine produces the opposite of the high. After a cocaine binge, the user 
has feelings of apathy, irritability, depression, and disorientation. He or she may sleep for long 
periods, be lethargic and drowsy, ravenously hungry, and have vivid dreams. These symptoms 
usually abate in a few days or weeks.  
Physical signs of withdrawal include muscular aches, abdominal pain, chills, tremors, and 
complete exhaustion. Abrupt withdrawal from a long binge can cause the “Cocaine Washout 
Syndrome”- a state of decreased consciousness to the extent that the users can be aroused only 
after vigorous stimulation, and even then may be too exhausted even to speak or make any 
movement (Roberts J., Greenberg M., 2000).  
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An overdose of cocaine may cause seizure, respiratory failure, stroke, cerebral haemorrhage 
or heart failure. Death can result from any of these. There is no specific antidote for cocaine 
overdose.  
It is impossible to determinate the amount of cocaine needed for an overdose; it can be caused 
by snorting as little as one-fiftieth of gram. Between 2 and 10 precent to those taken to the 
hospital for a cocaine overdose have seizures, which can occur as long as 12 hours later. 
Seizures can happen at any time, with the first use, the twentieth, or the hundredth, and will 
eventually strike most users (Inaba D.S., Cohen, W.E:, Holstein, M.E., 1997). 
Cocaine is sometimes used in combination with heroin or other opiates, because the edginess 
caused by the first is mellowed by the dreamy effects of the second. The combination can be 
especially dangerous. People who are taking cocaine normally back off on their use when the 
jitteriness gets too great, but in the presence of heroin the shaky feelings are not so obvious 
and they tend to take more cocaine, increasing the risk of an overdose. On the other hand, 
heroin users who would normally back of when they feel they have had enough sedan might 
take more because of the stimulation form cocaine, resulting in a heroine overdose.  
Generally the physical signs of overdose are: Fever, rapid or irregular heartbeat, enlarged 
pupils, dry mouth, etc. And the mental signs of overdose are: confusion, agitation, paranoia, 
hyperactivity, etc.  
With any sign of cocaine oversee, the user should be taken immediately to a hospital. 
Monitoring may be required even the person appears to have recovered, since seizures can 
occur hours later.  
1.1.4 Heroin 
The poppy flower Papaver somnifierum was coltivated in the Mediterranean region as early 
as 5000 BC. It matures in about 90 days and grows to a height of about one meter. After 
maturity, the flowers petals fall, leaving the 2,5- to 7,5-centimetre-wide green seen pod. When 
cut, the walls of this seed pod will ooze a milky fluid. For thousands of years, this fluid was 
scraped by hand and dried to a gummy substance known as opium.  
The cultivation of opium poppies spread throughout Asia and North Africa where from 
ancient time until the present, opium has ben used to numb the body and mind. Opiate drugs 
eventually became popular throughout the world both for their medicinal value and for 
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recreational use. Today, the many derivatives of opium are among the most addictive drugs 
known (Gahlinger P.M., 2004). 
Raw opium is made by collecting the sap from the poppy to produce a brown, tarry substance. 
This material may be dried and rolled into a ball (gum opium), or crushed to a powder 
(powder opium). The prices of collecting gum opium from poppies is very labor intensive. A 
more modern and efficient method uses machines to harvest the entire mature plant and cut it 
to poppy straw, which is dried and processed to a fine brownish powder. Most opium powder 
is produced this way, on specially licensed farms on contract to pharmaceutical companies.  
Poppies are grown in Australia, Turkey, France and Spain for the production of poppy straw. 
Farmers plants crops in spring or fall. Brightly coloured flowers appear about three months 
later. After fertilisation, the petals drop from the flowers and expose the seed pod, a bulb 
about the size of a walnut. Opium is produced in the root system and distributed to all parts of 
the planet, but the majority collects in the thin wall of the seed pod. When the pod is cut, the 
milky white opium slowly bleeds from the incision, changing the color to brown as it dries. 
This gummy material is shaped of and collecting the following day. Pods may be incised up fo 
five or six times before the opium is depleted.  
Morphine is the primary constituent of opium and the first pure drug ever extracted form a 
plant. When raw opium was dissolver in hot water, adding lime brought morphine to the 
surface as a white suspension while the other solids settled to the bottom. It was discovered 
that here is a wide range of morphine concentration in the natural pant. Now, commercial 
opium is standardised to contain 10 percent morphine.  
Morphine is one of the most effective drugs known for relief of pain and remains the standard 
against which new pain-relieving medication are measured. It also has a number of medical 
application beyond pain relief, with important use in emergency medicine. Morphine is 
available in oral solution, sustained-release tablets, suppositories, and injectable preparation. 
The injectable form can be given subcutaneously, intramuscularly, and intravenously.  
Heroin, diacetylmorphine, was discovered in 1874 by combining morphine and acetic acid. 
Commercial production began in 1898. This new narcotic was synthesised from morphine in a 
search for pain reliever that was less addictive. Its discoverers could not have been more 
wrong. Within a few years, it became apparent that heroin was being widely abused. The 
illegal production of heroin begins when a farmer sells gum opium to nearby processor. This 
material is then placed in boiling water, stirred into a mixture, and lime is added to leach out 
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the morphine as calcium morphenate. This is filtered out and ammonium chloride is added, 
causing the morphine base to settle to the bottom. Activated charcoal and hydrochloric acid 
are than added to produce morphine hydrochloride, which is dried and pressed into brick for 
shipment to a heroin lab. The dried morphine base is often called heroin #1. It can be smoked, 
but is usually made into heroin #2. First, the morphine base is pulverised and mixed with 
acetic anhydride. Water and activated charcoal and than sodium bicarbonate are added, casein 
the heroin base to settle out. The mixture is filtered and the heroin base dried, producing 
heroin #2. This crude heron is treated with hydrochloric acid to produce heroin hydrochloride, 
for final sale.  
Heroin is usually injected, snorted, or smoked. When the injected into a vein, the onset of 
euphoria occurs in seven to ten seconds. Intramuscular injecting is slower, taking about five to 
eight minutes, and snorting is slower yet, taking about ten to fifteen minutes, and does not 
produced as intense a “rush” ad other methods. Despite the slower onset, many users now 
prefer to snort or smoke heroin because of concern about injection-related illness.  
Morphine was the first opiate molecule to be analysed, and it sill the standard by which the 
others are measured. Heroin is made by combining morphine with acetic anhydride. Heroin is 
not really a different drug from morphine. It is more potent then morphine because it is more 
soluble in fat, and therefore enters the brain faster. Once in the brain, however, it is converted 
back to morphine and has the same effects.  
Of the illegal opiates, heroin is the most prominent. It has a cyclical popularity, going in and 
out of fashion for reason that are not well understood. Until the 1980s, the most common way 
of using heroin was injecting it. In part because of worries of hepatitis or HIV and the fear and 
disgust associated with needles, heroin use declined. A decade later, heroin returned to 
popularity as a purer drug that could be snorted or smoked. Heroin is usually smoked by 
placing a small amount on aluminium foil and heating it from below by a match, called 
“chasing the dragon”. Heroin also joined cocaine in a highly addictive combination that 
allowed the user to take more of both drugs.  
Taking a small amount of an opiate results in a short-lived feeling of euphoria leading to 
several hours of physical and mental relaxation. Many other effects may be present, varying 
with the user, the amount taken, and the type of drug. Although opiates different widely in 
their action, most include the following signs and symptoms. 
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