REPORT TO THE EMCDDA by the Reitox National Focal Point

THE NETHERLANDS DRUG SITUATION 2002

FINAL VERSION

REITOX This file at the Trimbos Institute:

Written by

Part I (T. Ketelaars) Part II (M.W. van Laar) Part III (A. van Gageldonk) Part IV (A.A.N. Cruts, A. van Gageldonk) November 2002

© NDM/Netherlands Focal Point

2002 Trimbos Institute NDM/Netherlands Focal Point PO Box 725 3500 AS Utrecht The Netherlands phone: +31-30-2971100 fax: +31-30-2971111 Members of the Epidemiology Working Group Epidemiology of the National Drug Monitor

Members of the Study Group Epidemiology of the NDM

Mr. A.A.N. Cruts, Trimbos Institute Mr. H.F.L. Garretsen, Tilburg University Mrs. C.A.M. van Gorp, M.A., Ministry of Health, Welfare and Sport (Observer) Mr. R.A. Knibbe, Universiteit Maastricht Mr. M.W.J. Koeter, Amsterdam Institute for Addiction Research (AIAR) Mr. D.J. Korf, Criminological Institute Bonger, University of Amsterdam Mrs. M.W. van Laar, Trimbos Institute Mr. R.F. Meijer, Research and Documentation Centre (WODC), Ministry of Justice Mrs. H. van de Mheen, Addiction Research Institute Foundation (IVO) Mr. A. Mol, Care Information Systems Foundation (IVZ) Mr. J.A.M. van Oers, National Institute for Health Promotion and Illness Prevention (RIVM) Mrs. E.L.M. Op de Coul, National Institute for Health Promotion and Illness Prevention (RIVM) Mr. A.W. Ouwehand, Care Information Systems Foundation (IVZ) Mr. H.G.M. Rigter, Trimbos Institute Mr. Th.A. Sluijs, Municipal Health Service Amsterdam (GG&GD Amsterdam) Mrs. J.E.E. Verdurmen, Trimbos Institute Mr. G.C.G. Verweij, Statistics Netherlands (CBS) Mr. P.P. de Vrijer, Ministry of Justice (Observer) Mrs. W.M. de Zwart, Ministry of Health Welfare and Sport (Observer)

Additional consultants Mr. M.C.A. Buster, Municipal Health Service Amsterdam (GG&GD Amsterdam) Mr. A.W.M. van der Heijden, National Police Agency (KLPD) Mrs. E.H.B.M.A. Hoekstra, Ministry of Justice, Directorate of Sanctions, Rehabilitation and Victim Care (DGPJS) Mrs. A.J.J. Slotboom, National Office of the Public Prosecution Service Mr. M.C. Willemsen, DEFACTO, voor een rookvrije toekomst (Institute for Public Health and Smoking) INDEX

SUMMARY MAIN TRENDS AND DEVELOPMENTS 7

PART 1 NATIONAL STRATEGIES: INSTITUTIONAL & LEGAL FRAMEWORK 11

1. Developments in drug policy and responses 13

1.1 Political framework in the drug field 13 1.2 Legal framework 16 1.3 Laws implementation 20 1.4 Developments in public attitudes and debates 21 1.5 Budget and funding arrangements 24

______

PART 2 EPIDEMIOLOGICAL SITUATION 25

2. Prevalence, patterns and developments in drug use 27

2.1 Main developments and emerging trends 27 2.2 Drug use in the population 28 2.3 Problem drug use 36

3. Health consequences 42

3.1 Drug treatment demand 42 3.2 Drug-related mortality 49 3.3 Drug-related infectious diseases 53 3.4 Other drug-related morbidity 56

4. Social and legal correlates and consequences 59

4.1 Social problems 59 4.2 Drug offences and drug-related crime 61 4.3 Social and economic costs of drug consumption 66

5. Drug markets 66

5.1 Availability and supply 66 5.2 Sources of supply and drug seizures 67 5.3 Price/purity 68 6. Main facts and trends per drug 70

7. Discussion 72

7.1 Consistency between indicators 72 7.2 Methodological limitations and data quality 72 ______PART 3 DEMAND REDUCTION INTERVENTIONS 76

8. Strategies in Demand Reduction at National Level 78

8.1 Major strategies and activities 78 8.2 Approaches and new developments 78

9. Prevention 81

9.1 School programmes 81 9.2 Youth programmes outside school 83 9.3 Family and childhood 83 9.4 Other programmes 85

10. Reduction of drug related harm 87

10.1 Description of interventions 93 10.2 Standards and evaluation 98

11. Treatment 100

11.1 “Drug-free” treatment and health care at national level 102 11.2 Substitution and maintenance programmes 103 11.3 After-care and re-integration 105

12 Interventions in the Criminal Justice System 106

12.1 Assistance to drug users in prisons 106 12.2 Alternatives to prison for drug dependent offenders 108 12.3 Evaluation and training 108

13.Quality Assurance 111 ______

PART 4 KEY ISSUES 114

14. Demand reduction expenditures on drugs in 1999 116 14.1 Concepts and definitions 116 14.2 Financial mechanisms, responsibilities and accountability 116 14.3 Expenditures at national level 118 14.4 Expenditures of specialised drug treatment centres 120 14.5 Conclusions 121 14.6 Methodological information 121 15. Drug and alcohol use among young people aged 12-18 123 15.1 Prevalence, trends and patterns of use 123 15.2 Health and social consequences 128 15.3 Demand and harm reduction responses 129 15.4 Methodological information 132

16. Social exclusion and reintegration 134 16.1 Definitions and concepts 134 16.2 Drug use patterns and consequences observed among socially excluded population 135 16.3 Relationship between social exclusion and drug use 137 16.4 Political issues and reintegration programmes 138 16.5 Methodological information 140

REFERENCES 145

ÿ Bibliography 145 ÿ Data Bases/Software/Internet addresses 174

ANNEXES 178

ÿ Annex 1: Drug monitoring systems and data sources 178 ÿ Annex 2: Additional tables 180 ÿ Annex 3: List of abbreviations 185 ÿ Annex 4: List of tables 187 ÿ Annex 5: List of graphs 189 ÿ Annex 6: Map of the Netherlands, provinces and cities 190 SUMMARY: MAIN TRENDS AND DEVELOPMENTS

Annual reports of the drug situation in the Netherlands are commissioned by the European Monitoring Centre for Drugs and Drug Addiction and the Ministry of Health, Welfare and Sport. The reports concentrate on illegal drugs and give an overview of developments on the following subjects: drug policy, drug use, and drug demand reduction. Each year, three special issues are dealt with. In 2002, these issues were expenditures on demand reduction, drug and alcohol use among youngsters and social exclusion and re-integration.

Developments in legal, political and organisational framework

Drug policy in the Netherlands has four major objectives: (1) prevention of drug use and treatment and rehabilitation of addicts; (2) reduction of harm to drug users; (3) diminishing public nuisance caused by drug users (i.e. disturbance of public order and safety in the neighbourhood); and combating the production and trafficking of drugs. The Ministry of Health, Welfare and Sport (VWS) co-ordinates overall drug policy and treatment and prevention policy. The Ministry of Justice is charged with law enforcement related to the judicial aspects of drugs. Drug-related matters concerning the local level and the police fall under the jurisdiction of the Ministry of the Interior and Kingdom Relations. Actually, policy in the Netherlands is highly decentralised. Within the limits of the law, the local authorities have extensive responsibilities in addressing the drug problem. A bill has been accepted in 2002 to amend the Opium Act to allow the cultivation and use of cannabis for medical and scientific purposes. A governmental agency can grant permission to grow cannabis after checking the integrity of potential growers. The agency also sees to the quality control and standardisation of medicines produced from cannabis. In October 2002, the Dutch government decided that physicians may prescribe cannabis to patients and that pharmacies are allowed to supply the drug for medical reasons. Approved cannabis will not be available before Summer 2003. Legal arrangements to meet the EU directive on money laundering render it more difficult for criminal organisations to retain the proceeds of their illegal activities. New is the Act for the Promotion of Integrity Assessments by the Public Administration. A new agency investigates the background of organisations that apply for subsidies and permits. Aim is to counter attempts of criminal organisations to take advantage of public money. The number of drug couriers who swallow small packages of drugs increased to unprecedented levels in 2002. This caused stagnation in the criminal law chain. A special Act went into effect on 6 March 2002 enabling to place a number of detainees together in one cell in special emergency detention facilities. On the request of Parliament the Minister of Health, Welfare and Sport decided to forbid the testing of XTC-pills at most (house) parties. She ordered to examine other methods of monitoring drug markets. Intensifying legal measures against the production, sale and use of ecstasy are meant to counterweight the increase of trade of synthetic drugs and its precursors via Dutch harbours and airports. The judiciary and the police gear up joint efforts for an annual € 18.6 million (2003-2006). The Synthetic Drugs Unit (USD) has a pivotal role in the implementation of these efforts and international contacts with countries that are important in the trafficking of ecstasy are intensified. In July 2002, the new government of the Netherlands did not formulate a new drug policy. In stead a few intentions were formulated: to combat more firmly the production and trafficking of drugs, to force recidivist criminal addicts to submit to detoxification and to after care for two years, to close 'coffee shops' near schools and the Dutch frontiers, and to stop pill testing at parties. Because the cabinet stepped down in October 2002 and new elections will be held in January 2003, it is uncertain what will happen in the near future.

Developments in the drug situation in the Netherlands

7 Drug use in the general population of the Netherlands has increased from 1997 onwards, but remained stable among young people. The level of cannabis consumption in the Netherlands is an average one, compared to other European Union countries, and above average when we look at cocaine and ecstasy use. A growing number of cocaine users, particularly of crack cocaine, seek help from drug treatment services. The club drug GHB has gained in popularity among partygoers. Drug trafficking and drug-related (‘acquisitive’) petty crime claim a considerable amount of resources from the police and the criminal justice system. The number of recent (last month) cannabis users in the Dutch population has increased between 1997 and 2001 from approximately 326,000 to 408,000. The largest increase is reported among adolescents aged 20–24, while use among the age group 12–15 years remains limited and practically unchanged since 1997. The sharp decline in the number of coffee shops between 1997 and 2000 (from 1179 to 813) has levelled off in 2001 (presently 805 coffee shops). Cannabis is not exclusively purchased in coffee shops, but also to a large extent from (older) friends and to a far lesser extent from a home dealers, in cafes or smart shops,or other recreational settings (NDM 2002). Cocaine has gained in popularity. Between 1997 and 2001, the percentage of recent users in the general population has doubled from 0.2 to 0.4 percent, which makes the Netherlands the fourth leading country in the European Union with regard to recent cocaine use, and the second leading country with regard to ever use of cocaine. Crack, the smokeable and most addictive form of cocaine, has become the main drug for many problem hard drug users. Statistics from drug treatment services show a sharp increase in the number of people seeking help for cocaine problems (representing an increase of 450% between 1994 and 2000). Two in three people seeking help for cocaine problems are crack cocaine users. The number of opiate addicts in the Netherlands — between 26,000 and 30,000 — is stable, and low compared to other EU countries (2.6 per 1,000 inhabitants in the Netherlands; 4.3 per 1,000 inhabitants in France; and 6.7 per 1,000 inhabitants in the United Kingdom). On average, the methadone maintenance doses prescribed for the treatment of opiate addicts are being raised (from 37 mg in 1995 to 48 mg in 2000) and higher dosages appeared to be more effective. Mortality from opiate overdose among Dutch people remains low (between 30 and 50 deaths per year), while the average age of the victims increases. The percentage of recent ecstasy users in the general population increased from 0.3% to 0.5% between 1997 and 2001. This increase was mainly caused by women. Ecstasy is still popular among young partygoers, although there are signs of a moderation in use particularly among frequent users. The party drug GHB, originally an anaesthetic, seems a new trend in club culture in spite of the fact that the line between ingesting the required GHB dose and one that may cause unconsciousness is very thin. Two in three users report that they have fallen unconscious after the use of GHB. In general, GHB use seems to have no harmful health consequences, unless it is used in combination with other substances. GHB has been linked to sex offences, road traffic accidents and deaths, but the number of serious incidents seems quite limited in proportion to the overall levels of consumption.

Developments in demand and harm reduction

Several reports refer to a stagnation in addiction care due to: 1) an ageing drug addict population remaining in care; 2) an ineffective co-operation between addiction care and mental health care or general practitioners, and 3) to ineffective referrals to addiction care from other care sectors. Registration data also point at the ageing of professionals in the addiction care. The combat against this stagnation is focussed on other care regimes for ‘revolving-door’ clients. Studies on medical heroin co-prescription, rapid detoxification with naltrexone with or without anaesthesia, and higher doses of methadone maintenance treatment were published. Also other types of treatment were tried out. An important example is farm work for the most problematic group of addicts. Working at the farm appear to reduce

8 problems substantially. These results pave the way to introduce new treatments for these problem groups, thus enabling more efforts of regular addiction care directed at new groups of drug users. Contrary to former decades, the emphasis on pharmacological treatment (drug treatment) of addiction problems is growing. This shift might be part of a broader shift, namely the increasing focus on neurosciences and pharmacotherapies. Public support for a more repressive drug policy seems to grow, partly because of a call for ‘zero tolerance’. This has not yet led to major changes in drug policy. New elections will be held in January 2003. During the past year the policy programme “Getting Results” (1998-2003) to improve the quality of addiction care and drug prevention resulted in several publications and guidelines, for instance on social addiction care, user rooms, and casemanagement for chronic addicts. The evaluation results of this programme are to be published in 2004. Important subprojects of Getting Results are initiation of facilities for education of professionals in addiction care to enlarge or to bring update their competence or expertise, improving and integrating information systems in addiction, monitoring, and co-ordination of funding and planning of outpatient addiction care. Family-based interventions are underdeveloped and should be developed and evaluated as components of broader programmes. A pilot study on the coverage of a free of charge hepatitis B vaccination programme for high- risk groups was successful, especially when combined with personal advice for less educated groups. Dual diagnosis clients are considered most problematic in addiction care, partly due to the separation of treatment and care for addiction problems and mental health problems. New types of integrated care, or rather ‘co-ordinated care’, are being developed to circumvent these barriers. Drug-dependent offenders are offered treatment modalities from the first phase of police custody to incarceration and even after detention. Most programmes are voluntary or coercive (participation as an alternative to penalties and detention). Since Spring 2001 penal law enforcement can be used for frequently re-offending addicts. There are no formal requirements for quality assurance in mental health care including addiction care. This may probably the reason for the slow development of quality systems in addiction care.

Key issue: expenditures on demand reduction

Information on costs of addiction care is not readily available. First, the structure of the flows of money to addiction care is complex and partly unclear. Second, different analysis strategies result in different outcomes. Third, addiction care is – partly due to mergers in mental health care - often considered as a part of a broader system, for instance mental health care or psychogical/psychiatric problems (depending on the analysis strategy). Fourth, treatment of alcohol and drug problems are never separated in Dutch cost data, thus cost information on treatment of illicit drugs is not feasible. Recent studies and activities show that reducing the complexity of funding Dutch addiction care might become a political issue for the next future. When this would be pursued, the consequence will be that several laws have to be changed.

Key issue: drug and alcohol use among young people aged 12-18 year

The use of illegal drugs is still low among this age group. Cannabis scores highest, but the use of hard drugs and synthetic drugs is almost non-existent in this age group and deaths and overdoses are rare. Cannabis use increased steeply from 1988 to 1996, but lifetime and last month prevalence stabilised afterwards (until 1999) at 19% and 15%. Boys are more frequent users than girls. The first experimental drugs for young people are predominantly

9 tobacco and alcohol. This pattern remained stable over the last five years or even tended to decrease. Young alcohol users also use cannabis and tobacco more frequently. During the past years, several mass media campaigns were launched targeting drugs and drug use among young people. The ten-year-old prevention programme The Healthy School and Drugs is still in operation and evaluated as well as other school-based projects. However, drugs are mostly used during weekends and several preventive activities were set out in different settings (youth pubs, coffeeshops, etc.). Furthermore, family-based prevention is done to stimulate parents in low SES neighbourhoods in talking about drug issues with their kids. A special treatment unit for the small group of very young drug addicts was evaluated. Youth media are a rich source of information for detecting, tracking and understanding emerging drug trends also among this early age group. This is especially valid for the internet. However the sheer quantity and transitoriness of websites hampers a clear overview. The number of calls and visits to the Drugs Info Line and its website illustrate the need for objective information on effects and risks of drug use.

Special issue: social exclusion and reintegration

Vulnerable for social exclusion are the lowly educated, the unemployed, the homeless, and immigrants from Moluccan, Turkish, Moroccan, Surinamese, Antillean, and other origins. Due to incomplete data, it is not yet certain whether immigrants and Dutch natives differ in drug use. Social exclusion and reintegration are targets of organisations with a broader view, including mental health, homelessness, or poverty. The recently initiated National Monitor on Homelessness (MMO) covers this sector. One of its targets is to report valid national data on these subjects. Valid statistics are rare and variations in outcomes are considerable. Estimations of the percentage of homeless having drug problems range from 20% to 58%. Local data exist for some big cities. The Poverty Monitor uses the following broad indicators for social exclusion: a marginal educational level; illiteracy; bad command of the Dutch language; and a marginal position on the labour market. Addiction certainly adds to social isolation. In the Netherlands, especially outpatient addiction care is historically deeply rooted in social work, targeting at keeping clients integrated with society as much as possible. Treating the addiction problem goes hand in hand with social reintegration programmes, support for financial debts, housing, and social skills training for maintaining social contacts and finding and keeping an appropriate job. Many specific programmes exist(ed) to reach these general goals. In 2003 it will be evaluated to what extent the goals of the National Action Plan for combating social exclusion have been reached.

10 PART 1

National strategies: Institutional and legal frameworks

11 12 1 Developments in drug policy and responses

1.1 Political framework in the drug field

1.1.1 Main objectives of the national drug policy

The national drug policy in the Netherlands has four major objectives: • To prevent drug use and to treat and rehabilitate drug users. • To reduce harm to users. • To diminish public nuisance by drug users (the disturbance of public order and safety in the neighbourhood). • To combat the production and trafficking of drugs.

This policy is carried out in close collaboration with municipalities, health care and social care professionals and institutions, criminal justice authorities and the police. The main policy instruments are: • a sharp separation of the markets for soft and hard drugs • partial decriminalisation of soft drugs • monitoring of changes in the use of drugs and in the consequences of drug use • establishing and maintaining a highly diversified and extensive professional network of health care and social institutions offering help to drug users • prevention of (problematic) drug use through information and education targeted at both the general public and at special groups • social reintegration of (former) drug users • reconciling the interests of crime control with those of public order, public health and welfare • tackling the trafficking of hard drugs and larger quantities of soft drugs by using the full weight of the criminal law • financing research into the effectiveness and efficiency of addiction care services and of prevention programmes.

Dutch drug policy gives priority to a public health approach. In some cases, this resulted in a certain degree of tolerance and non-prosecution, instead of strict law enforcement. We give some examples: • The Drugs Information and Monitoring System (DIMS): this service co-ordinates pill testing at special test locations (not at parties) to determine health risks, to get insight in available new drugs and in trends in substance use (see also 10). Participants of DIMS will not be prosecuted (Staatscourant 2000, nr.250). • Safe Injection Rooms/User Rooms: in some municipalities hard drug users can use drugs in protected rooms, specially created for them by the local authority (see also 10). Drug dealing in or around user rooms is forbidden (Staatscourant 2000, nr.250). • Coffee-shop policy: Coffee shops are alcohol free outlets resembling bars, pubs or cafés, where adults – eighteen years or older – may individually purchase cannabis up to five grams (Staatscourant 2000, nr.250). Yet, suppressing large-scale commercial production of cannabis is a high law enforcement priority.

13 1.1.2 Basic elements of drug policy at the national level

Importance is given to a balanced and integrated approach of the drugs issue. This is reflected in the division of policy domains and tasks of the various ministries involved. The Ministry of Health, Welfare and Sport (VWS) (www.minvws.nl) is responsible for co-ordinating drug policy, and also has substantial responsibility for treatment and prevention of drug problems. The Ministry of Justice (www.justitie.nl) is charged with legislation, law enforcement and other matters related to the judicial aspects of drugs, while drug-related matters on a local level and the police fall under the jurisdiction of the Ministry of the Interior and Kingdom Relations (www.minbzk.nl)

1.1.3 Co-ordination

Collaboration and co-ordination between ministries and between ministries and (government) agencies is currently realised within a number of formalised and non-formalised structures.

• The most important co-ordination body at the administrative level is the Official Working Group on Drug Policy Implementation (AWUD). All sorts of policy questions and issues related to drugs are discussed here at a strategic level. Every month a meeting is arranged in which the ministries of Health, Welfare and Sport, Justice, Interior and Kingdom Relations, Foreign Affairs and Finance participate. All other ministries can participate whenever issues are put on the agenda that call for their attention.

• At operational level the Co-ordination Centre for Assessment and Monitoring of new drugs (CAM) was set up within the Health Care Inspectorate as part of the National Drugs Monitor. It carries out multi-disciplinary risk assessments on all new drugs, new combinations of drugs or new applications of existing substances. It covers both health and public order and safety dimensions. Participants in the CAM are: the ministries of Health and Justice and the Synthetic Drugs Unit (see below).

• The National Co-ordination Committee Precursors was established in 1999 as a co- ordination structure between ministries (Finance, Health, Justice, Foreign Affairs) and state bodies involved in the execution of various tasks (Economic Surveillance Department, Customs, Unit Synthetic Drugs). The committee discusses all topics involving precursors. The secretariat lies with the Ministry of Finance. It is the Committee’s task to reach consensus on the Dutch position in the international arena with regard to precursor-related issues.

• The Synthetic Drugs Unit (USD) was formed in 1997 in an effort to fight the production and trafficking of XTC, amphetamine and other synthetic drugs. The USD consists of all possible law enforcement bodies. The Public Prosecution Service, the police, Customs, the Royal Netherlands Military Constabulary, the Fiscal Intelligence and Investigation Department/Economic Surveillance Department, the National (Criminal) Investigation and Information Department of the Central Police Services (Korps Landelijke Politiediensten), the Central Import and Export Office and the National Transport Inspectorate, all participate in this unit. The unit is led by a specially appointed Public Prosecutor and a Chief of Police. The USD’s main task is to carry out criminal investigations of national or international character, either independently or in collaboration with others, and to

14 prosecute offenders of the drug laws. The USD can also suggest new policy initiatives in the area of synthetic drugs.

• The National Drug Monitor (NDM) was set up by the ministers of Health and Justice, but the secretariat is located at the Trimbos-institute. The creation of the NDM in 1999 confirms the importance of an effective monitoring of drugs and drug-related problems. One of its tasks is the production of an authoritative annual report on a broad range of drug-related issues.

• The Steering Group International Information (Stuurgroep Voorlichting Buitenland) is made up of representatives of the ministry of Health, Welfare and Sport, the ministry of Foreign Affairs, the ministry of Justice and the ministry of Interior and Kingdom Relations. This Steering Group was set up to discuss the way of giving information about the Dutch drug policy to policy makers, politicians, media, and citizens in foreign countries. The meetings of the Steering group take place once a month.

• Within each ministry co-ordination mechanisms are set up. The ministry of Health, Welfare and Sport has structural meetings regarding substance use (legal and illegal) with all directorates involved. Every month, topics such as policy on alcohol, tobacco and illegal drugs and legislation are being discussed.

• The Drugs Bureau (Bureau Coördinatie Drugsbeleid) and the Law Enforcement Directorate General (DGRh) of the ministry of Justice is responsible for different aspects of the judicial side of drug policy. Formalised meetings take place between both directorates to co-ordinate and to promote co-operation in drug related files. Both departments stay in close contact with the National Board of Prosecutors General, head of the Public Prosecution and appointed with the task – under the responsibility of the Minister of Justice - for setting the law enforcement and prosecution guidelines

• Communication lines exist with the Central Police Services (Korps Landelijke Politiediensten) and the National Expert Network on Drugs (Nationaal Netwerk Drugsexpertise), which consists of police officials working in the field of narcotics.

1.1.4 Basic elements of drug policy at the regional and local level

Policy in the Netherlands is highly decentralised. Local authorities have their own responsibilities in addressing the drug problem, though within the limits of national drug laws. • Dealing with the drug issue at the local level: 'tripartite consultations' between the mayor, the police commissioner and the public prosecutor take place regularly on a structural basis. These three parties jointly execute the local drug policy on the basis of their institutional responsibilities and powers. The national Support and Information Point Drugs and Safety (SIDV) (www.sidv.nl) provides information and support to municipalities in developing local drug policy (see 9.4). • Addiction care and prevention: national government creates the condition for the development , implementation and evaluation of prevention, information and education. The implementation is largely in hands of intermediary organisations, such as those in the field of education, youth care, sport and socio-cultural work, and addiction care organisations.

15 • Prevention: a National Support Centre for Prevention (LSP) has been set up to strengthen the collaboration between the many prevention units in addiction care.

1.2 Legal framework

The use of drugs is not penalised in the Netherlands, in contrast to the production, trafficking and possession of drugs. (Article 2 and 3 of the Opium Act) The framework for prosecuting unlawful activities, especially the production and trafficking of drugs, and for sentencing criminal drug users has been gradually expanded in the past decade and now involves an extensive set of laws and other legal instruments (see hereafter).

1.2.1 The Opium Act

Dutch legislation is consistent with the provisions of all the international agreements the Netherlands has signed, i.e. the UN Conventions of 1961, 1971 and 1988, and other bilateral and multilateral agreements on drugs. The Dutch Opium Act (1928), or Narcotics Act, is a penal law. It was fundamentally changed in 1976. Since then, the Opium Act has been amended repeatedly but its basic structure has been maintained. The new Act distinguished drugs presenting unacceptable risks (hard drugs) and “other drugs” (e.g. cannabis), which were seen as less dangerous (soft drugs). In an appendix to the Act several substances, including opiates, cocaine, amphetamine and LSD, were listed in Schedule I under the heading ‘drugs presenting unacceptable risks’. In Schedule IIb only cannabis was listed, without the qualification of unacceptability. In 1993, the Netherlands ratified the1971 Convention of the United Nations on Psychotropic Substances. As a result, many other substances had to be added to the two Schedules of the Opium Act. This included MDMA (ecstasy). New substances continue to be placed on the lists. In 2000, 4-MTA, an analogue of MDMA. was placed on Schedule I. In 2001, the Co-ordination Centre for the Assessment and Monitoring of New Drugs (CAM) has published a risk assessment of GHB (gamma-hydroxybutyric acid). CAM recommended that the use of GHB should be monitored and that a new risk assessment should be carried out as soon as monitoring data call for a re-assessment. In 2002, however, GHB and Zolpidem were placed on Schedule IIa of the Opium Act, and PMMA on Schedule I, because these substances were placed on the lists of the UN Convention on Psychotropic Substances.

In 2002, the Opium Act was amended in relation to the medical use of cannabis (Staatsblad 2002, 520). In the amendment the cultivation of cannabis for medical and scientific purposes is regulated. A governmental agency, the Bureau for Medical Cannabis (BMC), can grant permission to qualified growers to cultivate cannabis. It has to check the integrity of applicant cannabis growers. The BMC also sees to the quality and the standardisation of medicines produced from cannabis. At the moment, the cannabis products used in practice for medical reasons are of uncertain composition and are not subject to rigid quality control. In October 2002, the Dutch government decided that physicians may prescribe cannabis to patients and that pharmacies are allowed to supply this drug. The first approved medicinal preparations of cannabis will not be available at the pharmacies before Summer 2003 (T.K. 27.874, nr.9).

16 In the 150 to 200 "smart shops" in the Netherlands mushrooms with psychedelic properties can be bought. The active ingredients psilocybine and psilocyne are listed in Schedule I, but until recently it was not clear if the Opium Act also applies to the fresh or dried mushrooms themselves. At issue was whether drying these products should be considered ‘processing’ in the sense of the Opium Act. According to a regional Court of Justice, the Opium Act extends to psychedelic mushrooms that have been dried or processed into any other form - for example, waffles -, but not to fresh mushrooms. The Supreme Court of the Netherlands confirmed the sentence in this case on 5 November 2002.

1.2.2 Sanctions

The maximum penalty in the Opium Act for the import or export of a hard drug is twelve years of imprisonment or a fine of €45,000. For manufacture, transportation or sale, eight years; and for possession or storage four years or €45,000 (Article 10 of the Opium Act). The maximum penalties for cannabis in the Opium Act are four years of imprisonment or a fine of € 45,000 for import or export. And four years or € 45,000 for manufacture including cultivation of hemp and for transportation, sale or storage. All commercial cultivation of cannabis in glasshouses or domestically is forbidden unless a license has been granted. Open-air cultivation is permitted only for cannabis fibre varieties with clear-cut agricultural applicability as defined by national or European Union regulations. The maximum penalty for the possession of maximum 30 grams of cannabis amounts to one-month imprisonment (or € 2250) (Article 11 of the Opium Act). Habitual offenders against the Opium Act are likely to be sentenced to higher penalties than are people without a criminal track record. The maximum penalty for repeated violation of the Opium Act with regard to hard drugs is sixteen years of imprisonment or a fine of € 450,000. The offender may be subject to confiscation of any assets gained from the offence.

In 1999, an article called ‘Damocles’ was added to the Opium Act (Article 13b). This article allows mayors to act against coffee shops, pubs, shops and other public places if these create drug-related nuisance or trespass against the Opium Act or the Opium Act Directive. Measures to be taken under this article include closure of the premises and seizure of any drug stock.

In 2001, the Medicines Act and the Economic Offences Act were changed. Illegal trafficking in all kinds of medicines or drugs were characterised as an economic offence and can be punished as such (maximum 6 years of imprisonment). The purpose of this amendment was to create more judicial possibilities to combat dope in sports and the abuse of GHB.

1.2.3 Chemical precursors

In 1995, the Abuse of Chemical Substances Prevention Act (Wet Voorkoming Misbruik Chemicaliën), came into force. This Act deals with the trafficking in chemical substances that may be used in the production of drugs, and addresses international regulations. For the manufacture and the trafficking of substances registered in category 1 of Appendix I of the Act, a licence issued by the Minister of Health, Welfare and Sport is required. The Economic Surveillance Department of the Ministry of Economic Affairs oversees the implementation of the Act. A breach of this law constitutes an economic offence. Profits thus acquired may be confiscated.

17 The investigation of these illegal transactions will be intensified. Data on the seizures of precursors are sent to the International Narcotics Control Board (INCB) and the exporting countries. A special policy guide line has been established this year for providing some data to China (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a). From 1996 to 2000 about twenty cases were settled, but in 2001 there was a steep rise: 39 offences of this law were brought before justice (Bureau NDM, 2002, p.159).

1.2.4 Money laundering

The Netherlands has introduced or changed laws to meet the EU directive on money laundering, making it more difficult for criminal organisations to retain the proceeds of their illegal activities. The most recent legal action of the Dutch government to get a grip on money laundering is the Act for the Promotion of Integrity Assessments by the Public Administration (Wet bevordering integriteitsbeoordelingen door het openbaar bestuur or Wet Bibob). By creating an Investigation Agency, that checks background data of organisations that apply for subsidies and permits, the Dutch government attempts to prevent criminal organisations from taking advantage of public money or laundering money with the unintentional assistance of the Public Administration. The Agency can only investigate when asked to do so by governing bodies. This act came into effect on 20 June 2002. Within three years the efficacy of this act will be evaluated (Staatsblad 2002, 347).

1.2.5 Other important laws

The Prisons Act (Penitentiaire beginselenwet -1998) contains the basic principles of the Dutch prison system. The most important principle is to prepare prisoners to return to the society. Detainees who have been sentenced to an unconditional prison term of more than one year may enter a so-called penitentiary programme of at most six months duration. The aim of the penitentiary programme is to facilitate the social reintegration of offenders by helping them to gain job experience outside the prison walls. Violating the rules of the penitentiary programme will result in the mandatory completion of the remainder of the prison sentence. Penitentiary programmes are not accessible by addicts who are sentenced under the Compulsory Treatment Order (Penitentiaire beginselenwet, Article 2). On 1 April 2001 the Judicial Treatment of Addicts (Strafrechtelijke Opvang Verslaafden-SOV) was introduced. It allows the courts to commit addicted habitual offenders to a special institution for up to two years. The alternative is a prison sentence. The act is set up as an experiment. Further implementation of the law must await the outcomes of a stringent evaluation for three to four years. The experiment will run in four institutions – in Amsterdam, Rotterdam, Utrecht and the ‘Southern municipalities’ -, totalling 288 admission ‘lots’. All the institutions have commenced operation and in June 2002 more than 120 inmates had been ordered there (Bureau NDM, 2002)(see 9.5). In 2001, the number of drug couriers who swallow small packages of drugs increased to unprecedented levels at the Dutch national airport Schiphol. The limits of the criminal law chain were reached by the end of that year. A special Act was drawn up: Act Temporary Measures for Penitentiary Capacity for Drug Couriers (Tijdelijke Wet Noodcapaciteit Drugskoeriers). This went into effect on 6 March 2002 (Staatsblad 2002, 124). This Act is unique as it is specially made for one kind of offender. The temporary measures enable law enforcement agencies to place detainees together in one cell in special emergency detention

18 facilities - contrary to the Prisons Act. The regime in these emergency facilities is severely restricted but complies with the relevant minimum international requirements (see 1.4.4 ).

1.2.6 Addressing drug-related public nuisance

Since the end of the 1980s legal measures have been taken to reduce the public nuisance caused by drug users. The Damocles Regulation has expanded the legal armament of municipalities to redress unwanted developments such as an unchecked increase in the number of coffee shops or to sanction infractions to national or local drug policy. These legal instruments stem from either public health or public order concerns, or both. Another tool is the Closing Drug Premises Act, or Victoria Act (Wet sluiting drugspanden), which came into effect in 1997. This law added an article to the Municipality Act (Gemeentewet, article 174a). It allows mayors of municipalities to close down premises where drug use or trafficking causes public nuisance. Initial experience with the Victoria Act has been favourable but also illustrative of the legal difficulties local government may face when it tries to deprive citizens of access to their property. Municipalities can create additional means of intervention by formulating a coffee shop policy and by introducing bylaws. In 2002, the use and usefulness of both the Damocles Regulation and the Victoria Act were evaluated. Most mayors regard these legal instruments as effective law enforcement tools to reduce public nuisance (Smits and Smallenbroek, 2002). The shutdown of buildings and especially the nailing up of houses may adversely affect the appearance and social structure of a street or neighbourhood. Two members of Parliament have drafted a bill – for the so-called Victor Act - to allow municipalities to give a new destination to closed premises, such as permitting new tenants to move in. The Victor Act went into effect on 29 May 2002 (Staatsblad 2002, 348).

An important pilot project to combat drug-related crime and nuisance at the local level is the Hektor Project in the city of Venlo. The purpose is to diminish the nuisance caused by many German drug tourists who buy cannabis mostly at ‘illegal’ coffee shops, i.e. coffee shops not tolerated by the local authorities. The project has a three-line approach: 1. Low tolerance towards nuisance in the public space; 2. Revision of the coffee shop policy; 3. To combat the infiltration of the real estate market by organised crime. By creating special teams the local government, the regional police, the Public Prosecution Service and the Fiscal Intelligence and Investigation Department (FIOD), succeeded in closing many drug dealing premises and illegal coffee shops. Also, substantial amounts of black money could be confiscated. The Hektor Project runs from 2001 to 2005 and will be evaluated (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a).

1.2.7 Important new initatives

Pill testing Following the wish of the majority of the Lower House, the Minister of Health, Welfare and Sport decided to forbid the testing of XTC-pills at (house) parties. At the same time, the Minister ordered to examine other methods of monitoring the drug markets. The final decision on monitoring activities will be taken in January 2003 (Ministerie van Volksgezondheid, Welzijn en Sport, 2002b).

19 District bans for addicts In July 2002, the mayor of Rotterdam imposed a personal ban for six months on about 50 drug addicts to linger around in the Rotterdam borough of Delfshaven during daytime. These addicts caused much drug-related nuisance for the local residents. The ban is based on Article 172 of the Municipality Act (Gemeentewet) which gives the mayor the power to restore public order. A pressure group of addicts (de Junkiebond) brought the case to the Regional Court, that decided that the mayor is entitled to combat nuisance, but also that the ban of six months is too long and not well motivated (Steun- & Informatiepunt Drugs & Veiligheid, 2002). The city of Rotterdam will continue this banning policy.

1.3 Law implementation

1.3.1 Opium Act Directive

In the Netherlands, criminal investigation and prosecution operate under the so-called ‘expediency principle’ or principle of discretionary powers (opportuniteitsbeginsel). The Dutch Public Prosecution Service has full authority to decide whether or not to prosecute and may also issue guidelines. The most recent set of comprehensive guidelines for enforcing the Opium Act was the Opium Act Directive of 2000, which is valid from 2001 until 2005 (Staatscourant 2000, nr.250). The Opium Act Directive stipulates when the maximum penalty or a lesser sanction is required. Decision criteria are the amount of drug, the kind of drug, the place where the drug was sold, and occasional versus long-term dealing. The Polaris Tables (2001) give a very detailed elaboration of this principle. The sale of cannabis is illegal, yet coffee shops are allowed to maintain a stock of 500 grams and to sell up to 5 grams to a customer. In 2002, a feasibility study started to find a method for counting not tolerated outlets of cannabis sales (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p.16). Cultivation of cannabis is forbidden, but growth of five or less plants for personal use has a low prosecution priority. Also, in the Opium Act Directive the AHOJ-G criteria to which coffee shops must adhere are clearly described: ‘A’ stands for no Advertising of any drug ‘H’ for no Hard drug sale ‘J’ for not selling cannabis to Young persons (under 18); up to 1996 the age limit was 16. ‘O’ for no public nuisance, and ‘G’ for no large quantities (more than 5 grams cannabis) per transaction. Up to 1996 the limit was 30 grams. In recent years, the government policy has been to reduce the number of coffee shops. The estimated number went down from almost 1200 in 1997 to 805 in 2001 (see 4.1.1). It is unclear yet if this has resulted in increased supply of cannabis through channels outside coffee shops. Most of the Dutch municipalities do not have a coffee shop. High prosecution priority is given to professional and commercial cannabis cultivation. The indicators for professional dealing with regard to cannabis cultivation are listed in great detail in the Opium Act Directive. In 2001, 1973 large-scale cannabis growers were apprehended (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a).

1.3.2 Prosecution priorities

The relative prosecution priorities (high to lower) in the Netherlands are:

20 • offences involving hard drugs rather than soft drugs • the production or trafficking of any drug rather than the possession for personal use (lowest priority: possession of a hard drug [heroin] up to 0,5 grams and possession of cannabis up to five grams) • offences committed by recidivists rather than first-time offences • large-scale cultivation or sale of cannabis • the sale of cannabis outside coffee shops through street dealers, couriers, the Internet, pubs, shops and so on, rather than sale in coffee shops.

In January 2002, the Code of Criminal Procedure was changed. Besides investigations ‘on the body’ of suspects, including rectal and vaginal searching, which were already legal, more intrusive methods - investigations 'in the body' - such as the use of X-rays and ultra- sound scans are permitted, as long as a physician applies these techniques. (Staatsblad 2002, 66). These additional methods may be used for instance in persons suspected of having swallowed small packages of drugs or having pushed packed drugs into body orifices (body packing).

1.3.3 Intensified actions against ecstasy

In 2001, the national government announced measures against the production, sale and use of ecstasy (Ministerie van Justitie, 2001). The Public Prosecution Service will intensify investigations into the manufacture and sale of ecstasy. The Ministry of Justice and the police will gear up their joint efforts. Actions from 2002 to 2006 also include mass medial health promotion campaigns highlighting the adverse effects of ecstasy. This action plan costs € 18.6 million each year and will be evaluated in 2006. The Synthetic Drugs Unit (USD) has a pivotal role in the implementation of these efforts and five special XTC-teams will be created by the regional police forces. The contacts with countries that are important in the trafficking of ecstasy will be intensified ( Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p.24-25).

1.4 Developments in public attitudes and debates

1.4.1 Public attitudes

There are no recent general surveys or opinion polls focusing on attitudes towards the drug problem (see National Report 2001 and 8.2.3). However, in 1996, 1997, 1998, 2000 and 2002 drug-related nuisance was surveyed by interviewing 19,000 persons in underprivileged neighbourhoods in 13 municipalities (the Integral Security Report- Integrale Veiligheidsrapportage) (see 4.1.1). From 1996 to 2000 the experienced drug-related nuisance was decreased significantly in these neighbourhoods, but this trend did not continue after 2000. Instead, it stabilised at the same level. Five kinds of nuisance were considered. Not all of these had the same trend: concerns with regards to the annexation of the public space by drug addicts and street-walking decreased, whereas the subjective nuisance caused by drug dealing activities, pollution of the public space by addicts and nuisance caused by coffee shops increased (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p.19).

1.4.2 Drug policy of the new government

21 In July 2002, the new government presented its coalition agreement. No new drug policy was formulated, but a few intentions were announced: • To combat more firmly the production and trafficking of drugs. • To mandate recidivist criminal addicts to detoxification. • To close 'coffee shops' near schools and the Dutch frontiers. • To stop pill testing at parties. As the government stepped down in October 2002, it is at this moment uncertain what will happen in the near future. In January 2003 there will be new elections

1.4.3 Public debate

Increased public debates on drug issues in Parliament illustrate the strong public interest in these issues. We already mentioned combating drug-related crime and the reduction of drug- related nuisance, including mandating criminal addicts into treatment or guidance (see above and 11.3.3). In 2002, public opinion was pressing for stricter law enforcement in general, but also regarding drug-related nuisance. Some issues featuring in public debates are presented below.

1.4.4 Drug trafficking

• A recurrent theme in the public debate is fear of ‘alienation’ from drug policies in other countries concerning drug trafficking. There is general consensus that international collaboration should be sought. In 2001 and 2002, the collaboration with France was intensified in the field of exchanging information on law enforcement issues, but also in the field of treatment and prevention. The A-teams of police forces of France, Belgium, Luxembourg and the Netherlands concentrate on cross-border drug tourism by checking motorway traffic and passengers in international trains. These teams appear to be very successful. In one year 1271 drug runners were caught. Therefore the investigation services of France and the Netherlands decided to collaborate more systematically (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p. 33). • In November 2001, a special Collaborative Investigation Team was installed (Recherchesamenwerkingsteam), in which special forces of the Netherlands, the Netherlands Antilles and Aruba join activities to combat organised crime (in most cases related to drug trade). • The increase in the number of people arrested at Schiphol Airport for carrying swallowed pellets of drugs (cocaine) resulted in an overload of criminal cases, thus the limits of the criminal law chain were reached. This problem was frequently discussed in the mass media. The regional courts are hardly able to handle this extra case load and it became highly problematic to find prison cells for the arrested couriers (see 1.2.5). In January 2002 the government accepted the "Plan of Action for Drug Trafficking at Schiphol", which intends to intensify the existing two-line approach (TK 2001-2002, 28192, nr.1). The first line comprises measures to prevent drug transports from the Netherlands Antilles to the Netherlands. The second is directed at ensuring that intercepted drugs are confiscated and judicial intervention against couriers will follow. New measures regarding the supply of drugs, drug control, criminal policy and penitentiary capacity did not lead to a substantial decrease in the number of drug couriers. One of these measures is pre-flight control. In 2001, 1233 drug couriers were arrested at Schiphol Airport. From January to September 2002, 1311 drug couriers of

22 whom 503 swallowed pellets of drugs, were arrested at the airport and more than 3600 kilograms of drugs were seized (see 5.2 ) The suggestion to exclusively confiscate the drugs seized and not prosecuting the couriers immediately, in order to relieve the criminal law chain, is still a subject for debate. • A report on organised crime in the Netherlands, concluded that bribing of Dutch custom officers by cocaine smugglers at the port of Rotterdam is not extensive, because the efforts of the smugglers are directed to skirt customs (Kleemans et al, 2002, p. 92).

1.4.5 Extradition of alleged ecstasy smugglers

The USA perceive the Netherlands as an important "source country" of ecstasy pills. There is growing collaboration between US and Dutch authorities to fight the production and trafficking of ecstasy-like drugs. Requests for extradition of alleged smugglers have been honoured by Dutch judges in 2001 and 2002. Prominent Dutch lawyers are questioning this change of policy of the Ducth authorities (Husken and Vuijst, 2002).

1.4.6 Cannabis policy

The Dutch cannabis policy is exemplary of a more general pragmatic political position of the Netherlands: forbidding something but at the same time tolerating to some extent its existence. The government increasingly seeks the international debate. In December 2001, an international conference on municipal cannabis policies was organised by the Dutch Minister of Justice. This Cities Conference in Utrecht was attended by 120 participants from 50 European cities from 20 countries. It was concluded that in many of these cities a de facto policy of decriminalisation of the possession of small amounts of cannabis has taken place. Thus, the gap between official policy and practice is widening (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p.17-18). In February 2002, a scientific cannabis meeting jointly organised by the Ministers of Health of Belgium, France, Germany, the Netherlands and Switzerland took place in Brussels. The proceedings of the Scientific Cannabis Conference can be found at: http://www.trimbos.nl/trimbos/Cannabis2002%20Report.pdf

1.4.7 Drugs and the Internet

In 2001, the project ‘Drugs and the Internet’ was started, trying to gather knowledge on the varieties of using the Internet as a source for promoting and selling soft and synthetic drugs. The main purpose was to assess the adequacy of present policies derived from the Opium Act and the Public Prosecution Service guidelines. In May 2002 a 'quick scan' of advertising activities regarding soft drugs and synthetic drugs was completed. No evidence was found of a large-scale trade of synthetic drugs via the Internet, but precursors of synthetic drugs where offered in large quantities. At the 103 web sites of Dutch 'coffee shops' no cannabis products were advertised, which may indicate that these outlets adhere satisfactorily to the already mentioned AHOJ-G criteria (Ministerie van Volksgezondheid, Welzijn en Sport, 2002a, p. 24).

1.4.8 Medical prescription of heroin

23 The government decided to continue the medical prescription experiment of heroin for chronic treatment refractory opiate addicts at the present treatment units. In the near future a decision will be taken whether or not this treatment will be extended to other cities. A special committee has been installed to study the possibility of implementation of medical prescription of heroin in the Netherlands (see 10.2.2).

1.5 Budget and funding arrangements

No new general data (see for relevant data our National Report 2001 and chapter 14).

24 Part 2

Epidemiological Situation

25 26 2 Prevalence, patterns and developments in drug use

2.1 Main developments and emerging trends

A main development concerns the slight increase in lifetime and last month drug use in the general population from 1997 to 2001 (Abraham et al., 2002). Similar to other Western countries, cannabis remained by far the most popular illicit drug in the Netherlands. The number of current users in the population increased on average from 326,000 to 408,000. Lifetime use of hard drugs, such as ecstasy, amphetamines, cocaine and hallucinogenic mushrooms, was much lower but also showed an increase since 1997. The number of recent users of cocaine and ecstasy almost doubled. For ecstasy, the increase was most prominent among women. In 2001, lifetime and last month prevalence of drug use was generally highest among young people of 20-24 years. The increase since 1997 was also highest in this age group. This age pattern might be associated with the active participation of these young people in the nightlife scene (e.g. visiting cafés, pubs and parties). In contrast, drug use remained at a low level among 12 to 15-year-olds. This stabilisation is corroborated by findings from a series of school surveys (De Zwart et al., 2000; Ter Bogt et al., 2002). It is difficult to explain this trend. It might reflect the influence of (school) prevention programmes or a just ‘ceiling or saturation’ effect in drug use. Ecstasy and cocaine are still popular among young people visiting raves and clubs and to a lesser extent among pubgoers and visitors of coffee shops, at least in Amsterdam (Korf et al. 2002a). However, according to observational and anecdotal data, ecstasy seems less common than a few years ago, especially in club networks and among (former) frequent users. Adverse (after) effects and increasing amounts of time to recover mentally and physically after ecstasy use seem to contribute to this trend. A clear development concerns the increasing popularity of a former narcotic drug, GHB, in the nightlife scene and other networks. In contrast to how users of ecstasy perceive ecstasy, GHB is perceived by its users as a fairly harmless drug with many pleasurable effects, few side effects and a clear head on the morning after (Korf et al., 2002b). Yet, the majority of users report having lost consciousness (‘passing out’) at least once while on GHB. The use of this drug has also been associated with traffic accidents, sexual offences and death but precise figures are lacking. Cocaine has gained popularity in different populations and this trend paralleled an increasing treatment demand. This pertains especially to the ready-to-smoke preparation of cocaine, cocaine-base or crack: two out of three cocaine users applying for help today have a crack problem. Yet, treatment demand among cocaine sniffers has increased as well, especially among those persons who also have a combined alcohol problem. Finally, the number of problem users of harddrugs in the Netherlands seems to be stable and is, relative to the population size, among the lowest of the Member States of the European Union.

27 2.2 Drug use in the population

2.2.1 General Population

The first National Prevalence (drug use) Survey was carried out in 1997 among 22, 000 persons in the Dutch population of 12 years and older using a computer-assisted personal interview (Abraham et al., 1999). The second survey was held in 2001 among 17,655 persons of 12 years and older (response rate 47%). This time both a computer assisted personal interview (CAPI) and multi-method approach were used, which required respondents to fill in a paper and pencil questionnaire or to respond to the questions by computer (a diskette based questionnaire or a webversion). The multi-method was introduced mainly because it was almost impossible to recruit CAPI interviewers.

Table 2.1: Drug use (%) in the Dutch population of 12 years and older in 1997 and 2001 Lifetime prevalence Last month prevalence 1997 2001 1997 2001 Cannabis 15.6 17.0* 2.5 3.0* Cocaine 2.1 2.9* 0.2 0.4* Ecstasy 1.9 2.9* 0.3 0.5* Amphetamine 1.9 2.6* 0.1 0.2 Hallucinogensa 1.8 1.3 0.0 0.0 LSD 1.2 1.0 -- -- Halluc. Mushrooms 1.6 2.6* 0.1 0.1 Heroin 0.3 0.4 0.0 0.1 a. Hallucinogens, including LSD, mescaline, psilocybin, 2CB, ayahuasca, and excluding mushrooms. * Significant change from 1997 to 2001. Source: National Prevalence Survey, CEDRO (Abraham et al., 2002).

Table 2.1 shows that in both surveys, cannabis was the most popular illicit drug both in terms of lifetime or ‘ever use’ and last month or ‘current use’. The percentage of users of other drugs was many times lower. Significant increases in lifetime prevalence were found for cannabis, cocaine, ecstasy, amphetamine and hallucinogenic mushrooms. For for the first three drugs the last month prevalence also showed an increase since 1997.

Prevalence rates for cannabis use were roughly twice as high among men than women (in 2001: LTP 21.3% vs. 12.8%; LMP 4.3% vs. 1.8%). This also applied to the percentage of users who ever tried hard drugs1 (LTP: 6.2% vs. 3.7%). However, there was no gender difference for the percentage of current users of hard drugs (LMP: 0.8%). Increases in use between 1997 and 2001 were evident both among men and women. Yet, the change in last month prevalence of ecstasy use was largely due to women (0.1% in 1997 and 0.5% in 2001).

If we extrapolate prevalence rates of last-month use to the general population of 12 years and older, we obtain a lower bound estimate of the number of users (table 2.2). It is called ‘lower bound’ because various groups of drug users are likely to be underrepresented in the survey, such as homeless youth, prisoners, opiate addicts and frequent visitors of coffee shops. This applies especially to users of hard drugs, such as cocaine and heroin. Moreover,

1 cocaine, amphetamines, ecstasy, hallucinogens (excl. mushrooms) and heroin

28 the surveys are based on self-reported drug use, which may cause an underestimation of the actual consumption.

Table 2.2: Minimum estimates of the number of current drug users in the Netherlands in 2001* Average 95% CI Cannabis 408,000 375,000 - 443,500 Cocaine 55,000 43,300 – 68,900 Ecstasy 67,000 54,400 – 82,700 Amphetamine 30,000 21,700 – 40,700 Hallucinogensa 2,600 900 – 7,600 LSD 1,200 300 – 5,800 Hallucinogenic mushrooms 11,300 6,800 – 18,800 * Extrapolated from last month prevalence rates to the Dutch population of 12 years and older. a. Hallucinogens, including LSD, mescaline, psilocybin, 2CB, ayahuasca, and excluding mushrooms. Source: National Prevalence Survey, CEDRO (Abraham et al., 2002).

Population density and drug use Drug use is generally higher in urbanised regions with a high population density compared with non-urban regions with a low population density. Figure 2.1 shows that Amsterdam peaked on most measures of cannabis and cocaine use, supporting the notion that drug use in Amsterdam is not at all representative of the Netherlands as a whole2. Yet, increases in drug use between 1997 and 2001 were fairly modest in Amsterdam compared to Rotterdam and other highly urbanised regions. Differences in drug use between the big cities can not be explained by differences in population density, which are comparable. Possibly, differences in lifestyle (e.g. the frequency of visiting bars, clubs or disco’s), experimental behaviour and local policies may play a role (Abraham et al., 1999).

Figure 2.1 Prevalence of cannabis use (upper figure) and cocaine use (lower figure) in big cities and non-urban regions among the Dutch population of 12 years and older, in 1997 and 2001

Cannabis % 45 38,1 40 36,7 35 30 26,3 25 22,4 23,0 20 18,5

15 10,5 11,4 8,1 7,8 10 5,0 3,3 4,1 4,8 5 1,5 1,7 0 Amsterdam Rotterdam Other highly urbanised Non-urban regions regions

LTP 1997 LTP 2001 LMP 1997 LMP 2001

2 LTP for hard drugs together (2001): Amsterdam (15.5%), Rotterdam (7.3%), other highly urbanised regions (8.4%), non urbanised regions (2.5%). LMP for hard drugs together (2001): Amsterdam (2.1%), Rotterdam (1.5%), other highly urbanised regions (1.7%), non urbanised regions (0.5%).

29 Cocaine % 12 10,0 10 9,4 8 6 5,2 5,4 4 3,4 3,3 1,6 2 1,0 1,2 0,9 0,9 1,0 0,4 0,4 0,1 0,3 0 Amsterdam Rotterdam Other highly urbanised Non-urban regions regions

LTP 1997 LTP 2001 LMP 1997 LMP 2001

Other highly urbanised regions: Municipalities with over 2,500 adresses on average per square kilometre, Amsterdam and Rotterdam excluded. Non-urban regions: Municipalities with less than 500 adresses on average per square kilometre. Source: National Prevalence Survey, CEDRO (Abraham et al., 2002).

Age distribution Figure 2.2 presents the age distribution of cannabis users. Current use (as indicated by the last month prevalence) is relatively low among people of 12-15 years, peaks between 16 and 24- year-olds and declines again after age 30. The increase in cannabis use between 1997 and 2001 was highest in age group 20-24 years and remained at about the same level among young people of 12-15 years. A similar pattern was found for hard drugs (cocaine, amphetamine, ecstasy, hallucinogens excl. mushrooms and heroin together). The stabilisation in the lowest age group is corroborated by findings of surveys among students (see 2.2.2).

Figure 2.2: Prevalence of cannabis use (%) across age groups in the general population in the Netherlands of 12 years and older

45

40

35

30

25

20

15

10

5

0 12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69 >=70

LTP 1997 7.5 27.5 31.7 30.6 21.7 20.5 16.8 6.7 1.9 0.5 LTP 2001 5.9 28.4 41.9 33.8 25.9 21.9 18.5 8.3 1.2 0.4 LMP 1997 2.0 8.3 7.1 4.7 2.1 3.6 1.5 0.5 0.0 0.0 LMP 2001 2.2 8.6 11.2 6.6 3.6 2.7 1.7 0.9 0.0 0.0

30 Intensity of use Roughly two-thirds of all persons who have ever tried cannabis, cocaine, ecstasy or amphetamines did not use these drugs more than 25 times in their life (table 2.3). However, since 1997, the percentage of experienced users of cocaine and ecstasy has clearly increased. Mushrooms, with a very low dependence potential, are hardly used more than 25 times in a life. This may also be related to the relatively recent (re)introduction of these drugs on the market.

Table 2.3: Experienced drug use among ever users ( 25 times or more) in the Netherlands in 1997 and 2001 Proportion of of lifetime users 1997 2001 Cannabis 33% 34% Cocaine 23% 29% Ecstasy 25% 30% Amphetamines 33% 34% Mushrooms 5% 7% Source: National Prevalence Survey, CEDRO (Abraham et al., 2002).

Table 2.4 presents data on the intensity of cannabis use, expressed as the number of days of use in the past month. In 2001, half of the current users consumed cannabis once a week or less, on average. One out of five current users belonged to the almost daily users. This group may be at risk of developing a problematic pattern of use. Compared with 1997, this group became somewhat smaller, at least at the national level. In Amsterdam and Rotterdam, the percentage of frequent users had slightly increased, from 23% to 25% and from 21% to 26%, respectively.

Table 2.4: Consumption of cannabis among current users in the Netherlands in 1997 and 2001 Number of days of use in the last month Proportion of current usersa 1997 2001 1 – 4 45% 51% 5 – 8 14% 12% 9 – 20 15% 18% < 20 days 26% 19% a. Current use (last month prevalence). Source: National Prevalence Survey, CEDRO (Abraham et al., 2002).

2.2.2 School and youth population

The National Youth Health Survey gives insight into the development of drug use among secondary school students of 12-18 years from 1988 –1999 (see table A1 and A2, annex 2). In 2001, another survey was held in the framework of a WHO study, the Health Behaviour in School-aged Children (2001/2002)3. It assessed the lifetime and last year prevalence of cannabis use (and smoking and alcohol consumption) among 7,556 students of 11-17 years (Ter Bogt et al., 2002). In order to establish recent trends, data on cannabis use from the 1992, 1996 and 1999 surveys have been re-analysed for secondary school students in age

3 This survey was comparable as far as questions on cannabis use are concerned.

31 group 12-17 years (n=5,730). Questions of lifetime prevalence have been included only in the 1999 and 2001 surveys.

Cannabis Cannabis is the most popular illicit drug among students. • Figure 2.3 shows that the lifetime prevalence of cannabis among students of 12-17 years increased between 1996 and 1999, but levelled off since then. In our previous National Report we have shown that the increasing trend was already evident from1988 to 1999. Moreover, last year prevalence did not change between 1999 and 2001, supporting the conclusion that cannabis use stabilised since 1996. Note also that these findings are in line with those of the National Prevalence Surveys in 1997 and 2001 revealing generally stable prevalence rates of cannabis among youg people between 12-15 years (see 2.2.1). • Frequent use is not common: 2.5% of all students had smoked cannabis more than 40 times in the past year, which is one of every six last years users. However, such frequent use is much more common among boys than girls and in the older age groups (e.g. 12% of the 16-17 year old boys against 6% among girls).

Figure 2.3: Development of cannabis use (%) among students of 12-17 years at secondary schools

% 25 20.1 18.8 20 18

15 13.6 15.3 15.1

10

5

0 1992 1996 1999 2001

Lifetime prevalence Last year prevalence

Sources: National Youth Health Survey and Health Behaviour in School-aged Children, Trimbos Institute.

Other illicit drugs4 The use of other drugs, such as ecstasy, amphetamine, cocaine and mushrooms, is much lower among students, while heroin use is almost non-existent (LMP in 1999: 1.4%, 1.1%, 1.2%, 1.2% and 0.4%, respectively). Prevalence rates increased since 1988 and also stabilised from 1996 to 1999. The data are given in table A1 and A2 (annex 2). Statistical

4 Data refer to age group 12-18 years.

32 analysis even revealed a significant decrease in the lifetime prevalence of ecstasy and amphetamine use.

It is hard to explain such trends. Changes in policy might play a role. For example, measures to reduce the number of coffee shops, which resulted in a 32% decrease from almost 1200 in 1997 to 805 in 2001 (Bieleman and Goeree, 2002). Or the increase in the minimum age from 16 to 18 years (implemented in 1996) at which people are ‘allowed’ to buy cannabis in coffee shops. Whether such measures influence the availability of cannabis can be questioned. According to Korf et al. (2000), increasing the minimum age influences the way young people obtain cannabis, i.e. buying less often in coffee shops, while having negligible effects on the availability or level of cannabis use. This would be consistent with the finding that young people (secondary school students) tend to buy cannabis less often in coffee shops (41% in 1996, 32% in 1999) and more often through friends (41% in 1996, 47% in 1999) (De Zwart et al., 2000). Moreover, Korf et al. (2002) showed that in 2001, 7% of the visitors of coffee shops in Amsterdam was below 18 years. This percentage was twice as low as in 1994 (14%).

Students from special schools and truancy projects According to a survey held in 1997, drug use is appreciably higher among students of secondary schools for special education, i.e. youth with learning and/or education problems, and among young dropouts attending truancy projects (Stam et al., 1998). (see table A3 and A4 in annex 2).

2.2.3 Drug use in nightlife scenes

Since drug use is highly associated with a pleasure-seeking and outgoing lifestyle, visitors of coffee shops, café’s, discotheques and raves have usually more experience than the average population. Table 2.5 shows prevalence rates of drug use among three different samples studied in the Antenne monitor among Amsterdam youth: 1) visitors of coffee shops (2001), 2) pubgoers (2000) and 3) visitors of trendy clubs and (house) parties (1998). Respondents were 25-26 years on average. The response rates were fairly low: about 23- 25% for the pubgoers and clubbers/ravers and 15% for the coffee shop visitors. In addition to the quantitative data, the Antenne monitor also includes qualitative data on new developments in drugs markets and the nightlife scene, obtained from a panel of insiders recruited in a wide range of youth scenes (Korf et al., 2002).

33 Table 2.5: Drug use (%) among visitors of coffee shops, pubgoers and clubbers/ravers in Amsterdam Visitors of coffee shops Pubgoers Visitors of clubs and 2001 (N=203) 2000 (N=504) parties 1998 (N=456) Lifetime Last month Lifetime Last month Lifetime Last month Cannabis 79 88 75 24 85 52 Cocaine 52 19 26 9 48 24 Ecstasy 63 23 34 10 66 41 Amphetamine 39 5 17 2 45 13 Mushrooms 60 6 25 2 45 8 LSD 29 2 8 <0.5 21 1 Poppers 37 7 23 6 39 11 Ketamine 9 2 3 <0.5 4 n.r. Heroin 9 1 1 <0.5 GHB 12 3 7 1 10 2 Non-Dutch men were underrepresented and Duth women were overrepresented in the sample of visitors of coffee shops. The proportion of non-Western respondents in the three samples was 26, 7 and 18, respectively. The proportion of females was 36, 65 and 40 respectively. Source: Antenna monitor Amsterdam (Korf et al., 2002). N.r.=not recorded.

Some comments on table 2.5: • Coffee shop-goers had a more or less similar pattern of drug use as clubbers and ravers (except for cannabis), while prevalence rates were clearly lower among pubgoers. • Compared to a similar survey in 1990 and 1994, ecstasy use appeared to be much higher among coffee shop-goers than in 2001. In contrast, cocaine use remained at about the same level. Among clubbers and ravers, cocaine use increased from 1995 to 1998 (LMP: 14% and 24%, respectively). • The percentage of cocaine users was quite high among visitors of coffee shops and clubs and parties but did not exceed prevalence rates of ecstasy. • The consumption of the ‘new’ synthetic drug GHB has spread across the country among different populations of users. Yet, quantitative data are only available from the Antenne monitor. In all three samples listed in table 2.5, experience with GHB was fairly common. Current use was highest among coffee shopgoers but this might also be related to the recent upsurge in popularity of this drug (and subsequently higher use rates in the most recent survey).

In addition to the quantitative data, the qualitative panel study of the 2001 Antenne survey further indicated the following: • Ecstasy seems still to be widely used as a party and rave drug. However, its popularity seems to decrease among clubgoers. According to the panel members, there seems to be a tendency towards moderation, i.e. less frequent use and lower doses at a time. Regular users seem to be less inclined to accept the adverse (after) effects, such as irritability, lack of energy and general malaise, or the increasing amount of time to recover physically and mentally. • The revival of cocaine since the late nineties now seems rooted. Cocaine is seen as a social lubricant, especially in relaxed environments where one can sniff it without sneaking around. The formerly separated networks of cocaine and pill users have mixed. Despite the positive reports on cocaine, panel members also observe an increasing

34 number of obsessive users running into problems (behavioural, financial). Some of them have applied for help. • Taking drugs in combination seems the rule rather than the exception. Popular combinations are cocaine and alcohol, or GHB and MDMA (to neutralise the sedative effect of GHB). • Viagra seems to be gradually more common in the nightlife scene to facilitate erection after the consumption of stimulants. • Ketamine (still) seems to play a rather minor role in the nightlife scene compared to other drugs. However, interest in ketamine has been observed in some party and club networks but the scarce supply may limit its use. These indications from qualitative research still require validation from quantitative research.

GHB users Signs of an increasing popularity of GHB and related health incidents have prompted the Ministry of Health to commission research on the characteristis of GHB use. The study included field observations and in-depth interviews among 72 regular GHB users and other key persons, such as prevention workers, police officials and drug producers (Korf et al., 2002). The sample included only GHB users that had taken GHB 5 times or more, and at least in the past year. The main results are as follows: • The sample was a fairly mixed group of persons from various ethnic and educational backgrounds. However, generally speaking, the typical GHB user is a western (mainly Dutch), employed male between 20-30 years, who likes the nightlife scene (visiting pubs, parties, discotheques). He likes alcohol, smokes, is commonly a blower and has ample experience with a wide range of psychoactive substances. He prefers stimulants, like cocaine and ecstasy. • Almost half of the respondents took GHB at least once a week in the past month. The average intake was one vial (about 5 ml), usually split into several doses per evening or day (see also figure 2.4). Consumption took place both in the nightlife scene and in private settings.

Figure 2.4: Pattern of GHB use in the past month among regular experienced GHB users

Frequency of GHB use in past month Dose per occasion % % 35 32.1 40 28.3 30 35 33.4 33.4 25 30 27.5 20.8 20 25

15 20 11.3 15 10 7.5 10 5 3.9 0 5 2 0 0 daily 4 - 6 2 - 3 1 day per few days 1 day per days per days per week per month <1 vial 1 - 2 2 - 5 5 - 10 >-10 week week month vials vials vials vials

35 One vial contains about 5 ml. Source: Korf et al., 2002. N=72

• GHB was often combined with ecstasy, followed by cannabis, amphetamine and alcohol. The main reasons to combine GHB with ecstasy were the more intense high and the fact that ecstasy somehow neutralised the sedative effects of GHB, which reduced the risk to pass out. • The main reasons to use GHB were the pleasant high, positive social effects and lack of a negative hangover. In fact, most users reported to feel refreshed on the morning after use. • Negative self-reported and (ever) self-experienced effects included: vomiting (73%), sudden collapses (25%), twitching of limbs and face (37%) and respiratory problems (16%). Passing out (loosing consciousness) was a fairly common event reported by 64% of the respondents (ever experienced); 10% reported a frequency of at least 10 times. • The association of GHB with sexual offences has been debated. This study indicated that GHB indeed can be used for such purposes. Some (mainly female) users reported having been harassed (21%), groped (13%) or having had sex against their will (3%) while under the influence of GHB. Sexual abuse seems to occur mainly by people already known by the victim, although they may have just met each other during a night out.

2.2.4 Other samples

Compared to the general population, drug use is high among the homeless youth (Korf et al., 1999; National Report 2001), persons who have been arrested by the police (Van den Broek et al., 2000; National Report 2001, 4.2) and prisoners. About 30 to 44% of the population in the prisons of Amsterdam and Scheveningen is dependent on drugs (Koeter and Luhrman, 1998; Schoemaker and Van Zessen, 1997). (see 4.2).

2.3 Problem drug use

2.3.1 Cannabis

Little is known about the percentage of persons in the population who run into problems by using cannabis. This is partly due to the lack of an unambiguous definition of ‘problematic use’ • According to the Netherlands Mental Health Survey and Incidence Study (Nemesis) in the Dutch population between 18-64 years, 0.5% [95% CI: 0.3-0.8] of the respondents fulfilled a DSM-III-r diagnosis of cannabis dependence in the year before the interview. (Bijl et al., 1998). In absolute numbers, this accounts for some 30,000-80,000 persons (1- year prevalence).5 • In another survey among the population between 16-50 years in the central part of the Netherlands, 0.5% of the respondents fulfilled criteria for ‘problematic cannabis use’ in the month before the interview (Van der Poel and Van der Mheen, 2001). The latter was defined as the consumption of cannabis on at least 15 days during the month prior to the

5 High-risk groups, such as youth delinquents, homeless and poly-drug addicts, are likely to be underrepresented.

36 interview and having psychological, social or financial problems associated with cannabis use. • Using an adapted version of the DSM-IV criteria for cannabis dependence, 27% of a sample of current blowers recruited in Amsterdam coffee shops fulfilled a diagnosis of cannabis dependence (Korf et al., 2002). Note that officially this diagnosis is assigned only if someone fulfils at least three of seven criteria, while in this study three of five criteria were used (two criteria were excluded: tolerance and withdrawal). Further, users who visit coffee shops frequently and spend a sizeable amount of time at these locations are more likely to be captured in the sample than occasional visitors. Corrected for this selection bias, 8% of the current blowers would qualify as cannabis dependent. Finally, it has been suggested that a subject’s mental health is only (seriously) compromised if someone complies with all five criteria (Soellner, 2000). This happened to be the case for only 0.3% (also corrected for selection bias) of the current blowers visiting coffee shops.

2.3.2 Ecstasy, amphetamines and cocaine

The number of problematic users of these drugs is not known. Ecstasy has no strong dependence potential. In spite of this, a minority of persons has a compulsive use pattern with associated psychological and somatic problems. The number of ecstasy and amphetamine users applying for help at treatment centres is fairly low. However, there is no information on the ‘hidden’ part of the population of problem users of these drugs staying out of the reach of treatment services.

2.3.3 Cocaine

The number of problem users of cocaine is not known. There are basically two groups of users: those who primarily sniff cocaine (the HCL preparation) for recreational purposes and those who smoke the drug (basecoke or crack) alone or in combination with opiates. Uncontrolled, obsessive use occurs more frequently and easily on basecoke. However, according to treatment demand figures (see 3) and observational data (Korf et al., 2002), heavy cocaine sniffers also increasingly run into problems. • According to field studies, 70% to 90% of all problem users of opiates also seem to consume basecoke. Taking the estimate of the number of problem users of opiates into account (see 2.3.4), this means that there may be some 18,000 – 27,000 problem users of basecoke. This estimate excludes primary basecoke users, who do not consume opiates, as well as an unknown number of problematic cocaine sniffers. • According to field studies, about 10% to 15% of the marginalised problem users of harddrugs seem to consume cocaine (basecoke) without using opiates (Van de Mheen, 2000; De Graaf et al., 2000; Coumans et al., 2000). • Daily use of basecoke seems especially evident among homeless youth, street prostitutes and young people from ethnic minorities (Vermeulen et al., 2001; Korf et al., 2002). A seemingly new group of problem users – asylum seekers from Somalia, Ethiopia, Russia and Yugoslavia – seems to concentrate in the centre of Amsterdam (Korf et al., 2002). They behave fairly aggressive and often seem to combine basecoke with alcohol. • Injecting cocaine (and heroin) has decreased and smoking increased, since the mid- ninieties. In street samples of problem users of harddrugs, cocaine was always smoked by 79% to 86% of the respondents, while 5% or less always injected the drug. The

37 remainder combined both routes of administration (Van de Mheen, 2000; De Graaf et al., 2000; Coumans et al., 2000). • Frequent smoking of basecoke is associated with a variety of health problems, such as physical exhaustion, respiratory problems and paranoia. • There are some signals that heavy basecoke use might promote sexual risk behaviour. The results of a study including this issue will be available in 2003.

2.3.4 Opiates

Most household or other population surveys do not yield accurate estimates of regular use of opiates and other hard drugs. The samples are either too small to include enough hard drug users for that sort of calculations, or are biased due to under-representation of these persons. Common methods of estimating the number of these ‘hard to reach’ opiate and/or poly drug users are capture-recapture, nominative techniques and extrapolation from registration data.

The number of problematic opiate users in the Netherlands has been estimated several times in the past years (table 2.6). The most recent estimate arrives at between 26,000 – 30,000 problem users of (also) opiates, which seems to be fairly well in the range of previous estimates. In 2003, the National working group on Prevalence estimates will investigate the feasibility of implementing new estimation methods, including a 1, 2 and 3-sample capture- recapture at the national level (Smit et al., 2002). Table 2.6 also gives an overview of the methods and outcomes of estimates of the number of problem hard drug users in different Dutch cities and regions. Figure 2.5 shows that the highest concentrations of problem hard drug users per 1000 inhabitants are found in Amsterdam, Rotterdam, The Hague, and Parkstad-Limburg.

Table 2.6: National and local estimates of the number of problem hard drug users Site Year Method Estimate Source National 1993 Multiple 28,000 Bieleman et al., 1995 National 1996 Multiplier (treatment data) 25,000-29,000 Toet, 1999 Multivariate social indicator 27,000 National 1999 Multiplier (treatment data) 25,970-30,298 Smit and Toet, 2001 Multivariate social indicator 29,213 Amsterdam 2001 2-sample C-RC 5,045 GG&GD Amsterdam Rotterdam 1994 Truncated Poisson 3,500 – 4,000 Smit et al., 1997 Den Haag 1998 2-sample C-RC 2,586 – 2,740 Burger and Struber, 2001 Utrecht* 1999 Treatment multiplier 950 Ten Den et al., 1995 570 De Graaf et al., 2000 Parkstad- 1999 Multiple*** 800 Coumans et al., 2000 Limburg*/** (average) Estimates concern users of opiates, who usually also consume other substances, unless mentioned otherwise. C- RC=capture-recapture. * Problematic, almost daily users of heroin, cocaine and/or other drugs; may also include primary cocaine users. ** Parkstad-Limburg involves Heerlen and seven smaller towns. *** Also including a 3- sample capture-recapture: 883 problem users of hard drugs [95% CI: 774-1022]

38 Figure 2.5: Estimated number of problem users of harddrugs (mainly opiates) per 1000 inhabitants in the Netherlands

12.0

9.5 9.4 10.0 9.0

8.0

6.0 4.9

4.0 3.4 2.6 2.0

0.0 National Amsterdam Rotterdam The Hague P-Limburg Utrecht 1999 1999 2001 1994 1998 1999

Average values of lowest and highest estimates. Sources and definitions: see table 2.6.

Declining number of opiate addicts in Amsterdam Estimates for Amsterdam are available since 1984. Figure 2.6 shows the estimated number of (problem) opiate addicts broken down by country of origin. The declining trend since 1988 is especially evident among foreign drug users (Italians and Germans), whereas the number of Dutch and ethnic-Dutch users remained relatively stable. • In 2001, the number of opiate addicts was estimated at 5,054, including 36% persons who were born in the Netherlands, 24% persons in Surinam, the Netherlands Antilles, Morocco and Turkey and 41% elsewhere. The first and second subgroup generally has a residence permit and maximal access to (methadone) treatment. The size of the third group is probably overestimated, because the opiate addicts that are born elsewhere are not part of a 'closed population'. • Buster et al. (2002) also applied a 3-sample capture-recapture method to 1997 registration data (police, hospital, low-threshold treatment), which has some advantages above the 2-sample-capture-recapture method (less violation of independence assumption). Moreover, violation of the the closed-population assumption was minimised by restricting the data sampling period to 3 months instead of 1 year. Using this method the number of problematic opiate users (e.g. those who have medical and/or judicial problems and/or have difficulties controlling their addiction) was estimated at 4,069. This is lower than the ‘old’ estimate (figure 2.6) of 5,177, which seems to be largely due to the restricted sampling period.

39 Figure 2.6: Estimated number of opiate addicts in Amsterdam by country of origin

Aantal 10000

9000

8000

7000

6000

5000

4000

3000

2000

1000

0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Born in the Netherlands Born in Surinam, Dutch Antilles, Morocco, Turkey Born elswhere Total

Estimates based on 2-sample capture-recapture applied to data from the Central Methadone Register (CMR). Source: Municipal Health Service Amsterdam.

2.3.5 Characteristics of problem hard drug users

• Most problem hard drug users are poly-substance users consuming heroin, methadone, cocaine, cannabis, alcohol and psychoactive medicines. The large majority of opiate users also regularly consume cocaine (base-coke or crack) and for a minority crack is the main drug (see 2.3.2). • Smoking (chinesing or basing) is the most common route of heroin administration among hard drug users in the Netherlands. In street samples of problem users of harddrugs, heroin was always smoked by 58% to 65% of the respondents, while 5%-15% always injected the drug. The remainder combined both routes of administration (Van de Mheen, 2000; De Graaf et al., 2000; Coumans et al., 2000)6. Injection may be slightly more common among youg drug users (see below). • Depending on the definition, about 30% to 50% of the opiate or poly-substance users suffers from psychiatric co-morbidity (dual diagnosis) (Schrijvers et al., 1997 and Eland, 1997). • Most addicts are male (some 80%) and there is an ageing trend. The municipal health service in Amsterdam recorded an increase in average age of opiate users in methadone treatment from 32 years in 1989 to 39 years in 1998 (Van Brussel and Buster, 1999). Field studies in Utrecht, Rotterdam and Parkstad-Limburg among problem hard drug

6 Drug injection rates are very low among ethnic, e.g. Surinamese, drug users, and relatively high among foreign drug users (e.g. from Germany, Italy).

40 users also revealed an average age of 37 years (Van de Mheen, 2000; De Graaf et al., 2000; Coumans et al., 2000). • “Allochtonous” drug users were overrepresented in Utrecht (45%) and Rotterdam (42%), including in particular Surinamese, Moroccan and Antillian persons. In Parkstad-Limburg 24% of the problematic drug users was allochtonous, with a relatively high proportion of Germans. The average age of Surinamese drug users is higher than that of the other drug users, which is probably related to the low injection rate and subsequent lower mortality risk (Van Brussel and Buster, 1999; Van de Mheen, 2000).

2.3.6 Risk behaviour

Low rate of injecting drug use Injecting behaviour among drug users in the Netherlands has decreased in the past decades. • From 1986 to 1998 the prevalence of injecting among drug users recruited in the Amsterdam cohort on HIV and AIDS declined from 66% to 36% (Van Ameijden & Coutinho, in press). This is largely due to increased injection cessation rates and reduced relapse into injection.7 • According to a recent cross-sectional study among young problem drug users in Amsterdam (mean age 25 years), 39% had ever injected drugs and 22% was a current injector (Welp et al., 2002). Compared to a sample of young drug users from the Amsterdam cohort study recruited between 1985 and 1989, a history of injecting had declined from 83% (1985-1989) to 56% (1998). • According to LADIS (2000) 13% of the opiate users in treatment was an injector.

For explaining these relatively low rates and the declining trend in the past decade, various cultural and drug market factors may play a role (Witteveen et al., Van Brussel and Buster, 1999). For example, drug users may cease injecting because of major health problems, inability to inject (damaged veins), social networks and pressure of important others, severe dependence and cultural disapproval. Moreover, there was an increase in the availability of non-injection cocaine, i.e. basecoke, while at the same time the availability of injectable cocaine (and heroin) decreased.

Unsafe injecting behaviour and unsafe sex According to various regional or local cross-sectional surveys, some 10% to 17% of the injecting drug users have recently borrowed used syringes from fellow drug users. A slightly higher percentage found in The Hague and a substantially higher percentage in Twente. The last figure should be interpreted with some caution since the number of drug users included in the study was low (n=79, against some 200 in most other regions). • It has been suggested that drug users with persistent high injecting risk behaviour are more apt to trivialize these risks and to be more likely to inject unsafely with a drug using partner (Haks et al., 2001). • In cities where repeated surveys have been carried out (Amsterdam, Rotterdam and Arnhem, the prevalence of borrowing syringes has decreased). • Unsafe sexual behaviour, i.e. not using condoms especially with stable partners, remains high in most cities. If HIV prevalence is rather high and sexual partners are no drug

7 These prevalence figures of injection should not be taken as representative of drug users in general because in the Amsterdam Cohort Study on HIV and AIDS injecting drug users are clearly over- represented.

41 users, there is a theoretical risk of transmission of HIV to the general population. • A large proportion of current injectors (about 40%) shares paraphernalia, such as spoons, rinse water to clean syringes, colanders or ‘cooking attributes’. The risk of HIV transmission is limited by this behaviour but it could contribute to a spread of HCV and HBV.

In the cross-sectional study among young problem drug users described above (Welp et al., 2002), the lack of a recent steady partner appeared to be an important risk factor for a positive HIV status among injectors in 1998, while borrowing used syringes was no longer a risk factor.

3. Health consequences

3.1 Drug treatment demand

We will describe trends in treatment demand at the following institutes: 1) Specialised outpatient drug treatment centres, based on the National Alcohol and Drugs Information System (LADIS). 2) Specialised inpatient drug treatment centres, based on the Inpatient Register Mental Health Care (PiGGz). 3) General hospitals, based on the National Information System on Hospital Care and Day Nursing (LMR).

In the Netherlands people with drug addiction problems are seen most in specialised outpatient centres, and to a lesser extent in specialised inpatient clinics or general hospitals. Data are given in Table A5 through A8 (appendix).

Some remarks on these registration systems: • The three registers (LADIS, PiGGz, and LMR) are independent. Therefore, a person may be recorded in each of these registers within the same year. The figures can not be added up without running the risk of double-counting of persons. • Trends in inpatient treatment data are available untill 1996. Since 1997 the data set is incomplete because the number of services supplying data has dropped sharply. The Netherlands Association for Mental Health Care (GGZ Nederland) has developed a new registration system, the Care Information System (Zorg Informatie Systeem – ZORGIS), in order to replace the PiGGz. The system will be fully operational in 2003 at the earliest. • No new outpatient and inpatient data could be presented for the registration year 2001. This is due to the implementation of a new client monitoring system (Cliëntvolgsysteem – CVS) of the Netherlands Probation Foundation, which is not (yet) compatible with the LADIS. This caused a (temporary) loss of information on rehabilitation activitities by the outpatient drug treatment services, which will be solved by the end of 2002, when special technical arrangements will have been made to link data from both systems. We will present, however, new insights into treatment demand by cocaine users based on secondary trend analyses on data from 1994-2000.

42 • The LMR (and also PiGGz) is an episode register. The basic unit of registration is a (discharge) diagnosis. For 2001, we have also applied a correction for double counting of persons due to multiple admissions in the registration year and multiple secondary drug- related diagnoses per admission.

3.1.1 Outpatient treatment demand8

The development of all drug client registrations (not corrected for double counting of persons) since 1990 is shown in figure 3.1. The number of drug client registrations doubled from about 19,000 in 1990 to 38,000 in 1999 and seems to level off slightly in 2000. This decrease is, however, is not paralleled by a similar decline in unique drug clients. Part of the increase in drug client registrations was not due to treatment demand but was rather due to an expansion of LADIS coverage.

Table 3.1: Number of unique clients registered at outpatient services

1994 1995 1996 1997 1998 1999 2000 NUMBER OF CLIENT REGISTRATIONS Drugs 24 409 25 726 28 050 32 788 34 226 37 974 36 658 Alcohol 22 170 21 891 22 966 23 637 25 584 25 843 25 510 All (incl. gambling) 56 938 55 184 56 833 62 467 65 622 69 528 67 262

NUMBER OF UNIQUE CLIENTS Drugs 20 375 21 641 23 025 25 202 25 261 26 333 26 605 Alcohol 20 237 20 204 20 939 21 134 22 378 22 554 22 365 All (incl. gambling) 50 053 48 835 49 319 51 783 52 744 53 863 53 428

Source: LADIS, IVZ.

As shown in table 3.1, correcting for double counting has a greater effect on drug registrations than alcohol registrations. Drug registrations reduce from 36 658 registrations to 26 605 unique clients. Alcohol registrations reduce less: from 25 510 registrations to 22 365 unique clients. This difference is due to the higher number of ‘repeated registrations’ for drug clients (in particular opiate clients) within one registration year ('revolving-door clients', in Dutch: ‘draaideurclienten’).

8 The definition of ‘treatment’ according to the key figures of IVZ – as reported here - is slightly different from the definition in the TDI protocol. The standard key figures concern all administrative registrations of persons at an outpatient treatment service, while the TDI definition is restricted to persons who have actually had at least one face-to-face contact.

43 Figure 3.1: Development of the number of drug registrations at outpatient addiction centres (LADIS). See also table A5.

40.000

35.000

30.000 opiates cocaine 25.000 amphetamines cannabis 20.000 medicines

15.000 XTC others 10.000 total

5.000

0 90 91 92 93 94 95 96 97 98 99 2000

Source: LADIS, IVZ.

According to table 3.2 and figure 3.1, most drug clients report to have a primary problem related to opiate use, followed at some distance by cocaine and cannabis. Users of ecstasy and amphetamine rarely apply for treatment. • The number of opiate client registrations rose until 1999 and slightly decreased since then. Yet, the number of unique opiate clients remained fairly stable in the past five years. The number of client registrations for cannabis increased sharply until 1997 and levelled off since then. The number of ‘primary’ cocaine clients (and registrations) showed the most remarkable increase since the early nineties (details follow hereafter). Part of this increase might be related to the growing number of clients reporting cocaine as their primary rather than secondary problem drug. The number of amphetamine and ecstasy clients has decreased since 1998 and 1997, respectively. • Clients with a primary opiate problem are on average the oldest clients, followed by primary cocaine clients. Ecstasy clients are on average the youngest clients. • The gender distribution is fairly similar for all drugs: four out of every five drug clients is male. • The number of clients applying for help at an outpatient centre for the first time is the highest among cannabis and ecstasy clients.

44 Table 3.2: Drug clients at outpatient addiction centres in 2000 cannabis cocaine opiates ecstasy amphet. Total number of client registrations 3974 8241 22658 281 747 Total number of persons with primary drug problem* 3443 6103 15544 241 623 • Percentage of all drug clients 13% 23% 58% 1% 2% • Mean age (years) 28 years 32 years 37 years 25 years 28 years • Percentage males 81% 83% 80% 81% 79% Number of persons applying for treatment in 2000** 1850 3323 5230 109 199 • Percentage of first treatments*** 69% 44% 22% 73% 61% Total number of persons with secondary drug 3 144 7111 1387 573 498 problem* * Corrected for double counting of persons. Includes both persons who applied for treatment in 2000 and persons who were also registered in adjacent previous years. Whether a given substance is reported as a primary or secondary problem depends upon the perception of the client. ** Unique persons who applied for treatment in 2000 and were not continued treatments from the previous year. *** Concerns persons who have never been registered in LADIS before (since 1994). Source: LADIS, IVZ.

Developments in cocaine treatment demand In 2001, the Ministry of Health commissioned a study to carry out an in-depth analysis of data on outpatient treatment demand for cocaine use in order to improve insight into the cahracteristics of these clients. For this purpose, IVZ analysed registration data for the time period 1994-2000 (Mol et al., 2002). The main findings were as follows: • In 2000, some 14,600 clients applied for help because of a primary of secondary problem related to cocaine use. • Between 1994 and 2000, cocaine treatment demand increased with 59%. • In this period, the role of cocaine as a primary drug (as perceived by the clients) increased from 29% to 44%. • In 2000, two out of every three cocaine clients had a problem with the smoking of ‘basecoke’ (crack) against one out of three clienst who had problems with snorting cocaine HCL. Moreover, treatment demand related to basecoke increased from 57% in 1994 to 65% in 2000.

Table 3.3: Characteristics of outpatient treatment demand for cocaine use Client profile: problem drugs Number % of all Average Increase Average of clients cocaine age since number of in 2000* clients* 1994 treatment days Cocaine (snorting) 870 5.9 29 years 113% 159 Cannabis ánd cocaine (snorting) 832 5.7 27 years 117% 166 Alcohol ánd cocaine (snorting) 1833 12.5 32 years 140% 181 Cocaine-base/crack, excl. Heroin 2940 20.1 30 years 184% 171 Cocaine** ánd heroin 8118 55.6 36 years 26% 325 * Concerns both primary and secundary drug problems. ** mostly basecoke/crack. Source: LADIS, IVZ (Mol et al., 2002).

The analysis revealed five types of cocaine clients. Some characteristics are given in table 3.3. Other characteristics (not shown), included cultural origin, source of income, civil status, education, professional history, living conditions and referral by the criminal justice system. • Generally speaking, cocaine snorters were the most socially integrated clients, as regards, among others, living status, source of income, working experience and having children. Snorters who had problems with both cocaine and alcohol were older than those

45 who had problems with cannabis in addition to cocaine. The former combination seems to be most risky. • The largest group of cocaine clients consisted of basecoke/crack smokers. They were less socially integrated than cocaine snorters and were more often from ‘allochtonous origin’9. Most of them had problems with both basecoke/crack and heroin. However, treatment demand had increased most strongly among primary basecoke/crack users, who did not consume heroin. This group was on average younger than the heroin/cocaine clients and was relatively more commonly referred by the criminal justice system (38% against 19%).

3.1.2 Methadone treatment demand

Methadone supply is one of the key elements of assistance to opiate users in the Netherlands. Some key figures on methadone supply through outpatient centres taking part in the LADIS registration is given in table 3.4. In 2000, LADIS recorded almost 11,000 methadone clients. About 96% of these clients joined a methadone maintenance programme and the others took methadone on a reduction basis for detoxification.

Table 3.4: Characteristics of methadone supply at outpatient centres Number of persons Average dose (mg)* 1995 8,817 37 1996 9,068 38 1997 9,838 40 1998 9,754 42 1999 10,666 45 2000 10,805 48 * Per portion. Source: LADIS, IVZ.

Figure 3.2: Methadone consumption (gramme) per person per year

12

10

8

6

4

2

0 1994 1995 1996 1997 1998 1999 2000 maintenance 5,6 6,6 7,8 7,9 9,2 10,0 11,0 detoxification 4,8 5,5 5,8 6,4 8,0 8,2 7,4

9 ‘Cultural origin’ in LADIS is based on a client’s nationality (as indicated in his or her passport) or self- identification of a client with an ethnic group. Most ‘allochtonous’ clients are born in Eastern Europe, Africa, Asia, and Latin-America.

46 Source: LADIS/IVZ. Table 3.4 also shows that the average methadone dose per treatment day increased over the years. In 2000, 45% of all ‘portions’ consisted of a ‘therapeutic’ dose of 50 mg or more. Figure 3.2 also shows that between 1994 and 2000, the average consumption of methadone per person per year in methadone maintenance treatment increased from 5.6 gram to 11 gram. This trend is due to an increase in metahdone dose per treatment day on the one hand, and an increase patient compliance on the other hand10.

LADIS coverage of methadone clients in the Netherlands is not complete. Data are (still) missing from the Municipal Health Service Amsterdam, general practitioners, prisons and police stations. Part of these data is recorded in the Amsterdam CMR. Data from the national Health Care Insurance Board (CVZ) can be used to estimate outpatient prescriptions of methadone by GPs and specialists. Van Alem and Mol (2001) made the following calculation based on 1999 data:

Table 3.5: Estimate of the number of methadone clients in the Netherlands Source Number of clients LADIS 10,666 CMR, not included in LADIS 2,000 CVZ, not included in LADIS/ CMR 900 Total About 13,500 Source: IVZ, Van Alem and Mol (2001).

Table 3.6 gives some characteristics of methadone supply in Amsterdam, as recorded in the CMR. The average dose of methadone generally increased over the years. Moreover, the total number of clients and the new clients (first treatments) recorded in the CMR generally decreased since the late eighties. This trend can be attributed in part to the decreasing number of foreign clients, in particular German and Italian clients. Since 1989, the city of Amsterdam has taken measures to discourage foreign users from coming to Amsterdam, for example by tightening entrance criteria to a methadone programme. At the same time the improvement of drug treatment facilities abroad (e.g. methadone programmes in Germany) may have encouraged foreign drug users to return home.

Table 3.6: Methadone supply in Amsterdam in 1989 and 1998-2001 1989 1998 2000 2001 Total number of clients* 4,765 3,881 3,705 3,708 Number of first registrations 978 454 480 523 Average age (year) 32 39 40 41 Average methadone dose (mg) 37 53 55 52 * Municipal Health Service and Jellinek, including short term supply at police office. Source: CMR, Municipal Health Service Amsterdam (M. Buster).

3.1.3 Inpatient treatment

Inpatient services include addiction clinics and specialised addiction units in general psychiatric hospitals. Treatment demand for drug use problems is much lower at inpatient

10 Increased patient compliance is evident from an increased number of methadone ‘portions’ consumed per person/year and an increased (average) treatment duration per person/year.

47 centres (largely aiming at detoxification) compared with outpatient centres (various programmes) but shows a similar increase over the past decade.

The total count of drug-related inpatient admissions increased from almost 2700 in 1990 to about 4900 in 1996 (figure 3.3). These cases refer to ICD-9 codes for nondependent drug abuse (305.2-9) and drug dependence (304). The large majority of admissions are related to opiate dependence. The registration is incomplete since 1997. Therefore this trend does not (necessarily) reflect a diminishing treatment demand. See also table A6.

Figure 3.3: Number of admissions to inpatient addiction services because of drug dependence or nondependent drug abuse (ICD-9 codes 304 and 305.2-9).

5000 4500 4000 opiates 3500 cocaine 3000 cannabis 2500 amphetamines 2000 hallucinogens other 1500 total 1000 500 0 1990 1991 1992 1993 1994 1995 1996

The registration is incomplete since 1997, and therefore only the figures from 1990 through 1996 are included. Source: PiGGz, Prismant.

3.1.4 General hospital admissions

Figure 3.4 shows the number of admissions to general hospitals because of drug dependence or abuse. It is clear that these disorders are counted much more often as a secondary diagnosis than a primary diagnosis. However, the overall number of admissions related to illicit drugs is still relatively low and stable over the years. In 2001 the LMR recorded a total of 1.5 million hospital admissions. Drug dependence an drug abuse were counted 454 times as a primary diagnosis and 1,926 as a secondary diagnosis. Half of the drug-related cases counted as primary diagnoses were due to the use of psychoactive medicines (e.g. benzodiazepines). Table 3.7 gives some more details about admissions related to the main drugs of abuse. For cases in which opiates, cocaine and cannabis abuse or dependence were the secondary diagnoses, it has been examined which were the accompanying main reasons (primary diagnoses) for admission. • For opiates the main reasons were respiratory diseases (26%), injuries due to accidents (16%), gastro-intestinal diseases (7%) and cardiovascular diseases (6%). • For cocaine the main reasons were injuries due to accidents (18%), respiratory diseases (17%), cardiovascular diseases (8%) and drug poisoning (8%; especially benzodiazepines).

48 • For cannabis the main reasons were a schizophrenic disorder (22%), alcohol abuse and dependence (10%) and paranoïd behaviour (8%).

Figure 3.4: Number of admissions to general hospitals because of a primary (left) or secondary (right) diagnosis drug dependence or nondependent drug abuse (ICD-9 codes 304 and 305.2-9). See also table A7 and A8.

2200 Opiates 2000 Other drugs 1800 Medicines 1600 Total 1400 1200 1000 800 600 400 200 0 1996 1997 1998 1999 2000 2001 1996 1997 1998 1999 2000 2001

Source: LMR, Prismant.

Table 3.7: Hospital admissions related to drug abuse and drug dependence in 2001 cannabis cocaine opiates amphetamines Number of primary diagnoses (%)** 38 (53%) 81 (69%) 81 (22%) 36 (86%) Number of secondary diagnoses (%)** 249 (79%) 451(53%) 634 (19%) 58 (71%) Number of persons*** 251 456 541 90 • Average age (years) 28 years 34 years 39 30 • Percentage male 80% 79% 68% 69% * ICD-9 codes: cannabis 304.3, 305.2; cocaine 304.2, 305.6; opiates 304.0, 304.7, 305.5; amphetamines 304.4, 305.7. These ICD-9 codes are not 100% specific with regard to the drugs in question. ** Absolute number and proportion of admissions due to drug abuse from the total of drug abuse ánd drug dependence. *** Number of persons who were admitted at least once because of a drug-related disorder assigned as a primary or secondary diagnosis. Source: LMR, Prismant.

3.2 Drug-related mortality

3.2.1 General Mortality Register

The main source providing the official Dutch statistics on drug-related deaths is the General Mortality Register (GMR) or Causes of Death Statistics held by Statistics Netherlands – CBS – (Bonte et al. 1985.) Causes of death are classified according to the International Classification of Diseases, Injuries and Causes of Death (ICD). The 9th edition was used from 1979 through 1995, until the implementation of the 10th edition in 1996. This register has national coverage, includes only residents of the Netherlands and provides data especially on acute mortality due to drug use. Cases refer mainly to direct or acute deaths (drug ‘overdose’). The GMR data do not offer a distinction between experimental and habitual drug

49 users, and are not suitable to trace deaths due to rare toxicological substances (e.g. various synthetic drugs).

Figure 3.5: Drug-related deaths in the Netherlands in 2000 according to selection B recommended by the EMCDDA

90 80 77 70 60 50 40 30 30 18 20 10 6 0 Disorders Accidental Intentional Poisoning poisoning poisoning undetermined intent

Selection B (ICD-10): F11-F12, F14-F16, F19; and X42, X41, X62, X61, Y12, Y11 (combined with T40.0-9, T43.6).

In the current National Report, we have switched from presenting (trend) data according to our national selection of ICD codes to count the number of drug-related deaths to the EMCDDA standard. The main distinction between both standards concerns the inclusion of intentional drug poisoning (suicide) and drug poisoning with undetermined intent, which were not taken into account in the national selection (see figure 3.5). Therefore, the EMCDDA standard results in higher absolute figures than the national standard. However, there is a perfect match with regard to the trends in mortality.

Figure 3.6 shows the number of cases recorded from 1985 through 1999 according to the EMCDDA selections of ICD-codes. • Opiate intoxications were the most common causes of death recorded among Dutch residents and the casualty rate has fluctuated slightly over the years. • The total number of (registered) drug-related deaths slightly increased in the past years. This can be attributed to various factors, such as the change from ICD-9 to ICD-10 in 1996 and the slight increase in acute cocaine intoxications. In fact, the recent increase is mainly due to ‘accidental poisoning by other and unspecified dysleptics’, followed by ‘poisoning by other and unspecified narcotics’. It is not clear which drugs were involved in these deaths. • In 2000, 80% of all recorded deceased were male; 64% were between 25 and 44 years. • In spite of the recent increase, the number of drug-related deaths in the Netherlands is still relatively low, which might be explained by protective factors, such as the nationwide availability of methadone maintenance treatment and the low frequency of intravenous

50 drug use in the Netherlands. There are, however, some indications that not all cases of drug-related deaths are recognised in the GMR (De Zwart and Wieman, 2001).

Figure 3.6: Number of acute drug-related deaths in the Netherlands according to the EMCDDA selection of ICD-9 codes (1985-1995) and ICD-10 codes (1996- 1998). See also table A9.

140

120

100

80

60

40

20

0 1985 1986 1987 1989 1990 1991 1992 1994 1995 1996 1997 1999 2000 Total ICD-9 57 68 54 56 70 80 75 87 70 Total ICD-10 108 108 115 131 Opiates a.o. 51 67 49 54 62 76 72 77 56 77 67 61 66 Cocaine 3 1 3 1 3 1 2 2 6 10 8 12 19

ICD-9: 292, 304.0, 304.2-9, 305.2-3, 305.5-7, 305.9, E850.0, E850.8, E854.1-2, E855.2, and E858.8, E950.0, E950.4, E980.0, E980.4 (combined with N965.0, N968.5, N969.6 or N969.7). ICD-10: F11-F12, F14-F16, F19; and X42, X41, X62, X61, Y12, Y11 (combined with T40.0-9, T43.6). Source: National Causes of Death Statistics, Statistics Netherlands.

3.2.2 Registration of drug-related deaths in Amsterdam

Each year the Municipal Health Service of Amsterdam traces drug-related deaths by combining data from the Central Methadone Register, the municipal registrar’s office, the municipal coroners, hospital records, and the police. Data on overdoses from Amsterdam coroners also concern foreigners not included in the Population Registry. This is in contrast to the GMR, which only includes Dutch residents. Toxicological screening is performed in about 20% of the suspected overdose cases. In spite of this, most fatal overdoses among users known in the Central Methadone Register are likely caused by a toxic combination of substances or MDMA in combination with dehydration.

It should be noted that the registration includes deaths among all drug users ‘ever’ known to the Municipal Health Service, without having accurate information on their actual status as a ‘drug user’. If the inclusion criteria are restricted to drug users recorded in the past five years, the number of deaths appears to be lower (see table 3.8).

51 Table 3.8: Number of deaths among drug users in Amsterdam Cause 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Overdose 52 37 39 26 26 22 25 27 31 32 Other causes* 83 102 86 92 90 76 67 73 76** 112** Total 135 139 125 118 116 98 92 100 107 144 * Including infectious diseases, violent deaths, accidents, suicide. ** If only persons would be included who were recorded as a drug user in the past five year, the number of deaths by ‘other causes’ drops to 59 and 80, respectively. Source: Municipal Health Service Amsterdam (personal communication M. Buster; T. Sluijs).

Characteristics of the cases recorded in 2001 are as follows: • 56% of the deceased were Dutch and 44% were born abroad. • Four out of every five overdose deaths were caused by heroin and/or methadone, often injected and taken in combination with cocaine, alcohol or medicines; cocaine without heroin was involved in three cases; MDMA was also found in three cases. • Dutch overdose victims were on average older than their fellows who were born abroad (44 against 36 years). The contribution of other pathology, such as respiratory, liver and cardiac diseases in establishing overdose deaths is increasing with the ageing of the population of drug users.

The Municipal Health Service also investigates mortality rates among methadone clients (data provided by Marcel Buster). In order to have a proper follow-up of drug users, only methadone clients who were likely to stay in Amsterdam are included (i.e. who had a known address in the city and were born in the Netherlands, Surinam, Netherlands Antilles, Turkey or Morocco). Figure 3.7 shows that the overall mortality has increased since the eighties. This might be partly related to the ageing of the population. The overdose mortality remained low, which might be related to the low rate of injection. The main increase is seen in the category ‘other causes of death’, including aids, livercirrhosis, cancer, respiratory diseases, endocarditis, suicide, and violence.

Figure 3.7: Mortality per 1,000 person years among Amsterdam methadone clients

25 Other mortality Overdose mortality 20 Baseline mortality

15 16,6 13,6 10 13,3 7,9 mortality/ 1000 py 4,9 5 2,0 2,2 3,3 2,9 1,4 1,2 1,6 2,2 2,7 3,3 0 1985-1988 1989-1992 1993-1996 1997-2000 2001

Source: Municipal Health Service Amsterdam (M. Buster).

52 In a recent study, Buster et al. (2002) investigated whether starting and temporarily discontinuing methadone treatment was related to an increased risk in overdose mortality. The results showed that between 1986 and 1998, the overall overdose mortality rate was 2.3/1000 py. During the first two weeks after (re)entering treatment, a modest increase was observed (2.9/1000 py). Possible explanations include accumulation of methadone, inadequate assessment of tolerance of ‘new’ clients and concurrent periods of stress or extreme heroin use when entering treatment.

3.2.3 Deaths related to the use of ecstasy, GHB or other (synthetic) drugs

The number of persons who died after using ecstasy or other synthetic drugs is not known since there is no central registration of these cases. Moreover, full toxicology (and autopsy) is required to identify the precise cause of death. However, this is no routine procedure in the Netherlands. • In 2001, the national Health Care Inspectorate (IGZ) counted five persons who died after using MDMA (four men and one woman between 16 and 31 years). However, it is not clear whether MDMA was the underlying cause of death. One case concerned a combination of substances and in two cases an existing heart disease might have contributed to death. • Between 1999 and 2001, the Netherlands Forensic Science Institute (NFI) reported 13 deaths in which toxicological analyses had revealed an increased GHB concentration in blood or urine (i.e. above the normal endogenous threshold). In four cases GHB was the oly substance and in 9 cases GHB was mixed with other drugs (and/or alcohol). However, the precise cause of death can not be reliably established only on ground of toxicological findings.

3.3 Drug-related infectious diseases

Drug injectors may share needles and other equipment, increasing the risk of spreading blood-blood transmittable diseases, such as HIV and hepatitis B and C (HBV, HCV). Injecting drug users may also spread these diseases if they engage in unprotected sexual activities. However, this route of transmission is considered less important than drug injection as far as hepatitis C is concerned. Information on infectious diseases and risk behaviour among drug users is mainly obtained from cross-sectional surveys in different locations in the Netherlands (sentinel surveillance). A longitudinal cohort study in Amsterdam (started in 1985) has provided additional information about incidence and risk factors. We have reported in detail about the results in previous national reports. Finally, a cross-sectional study was carried out in 1998 on patterns of use and health risks among young problem drug users in Amsterdam. The results will be reported here.

3.3.1 HIV prevalence

HIV Surveillance Table 3.9 summarises findings from the Dutch HIV surveillance of the National Institute of Public Health and the Environment (RIVM), using repeated surveys among drug users in 4 fixed (Amsterdam, Rotterdam, Heerlen/Maastricht en Arnhem) and 2 optional cities. Following an advice of the RGO (Health Research Council), the frequency has been reduced

53 to one survey per year since 2001. That means, a survey once per five years instead of two years in four the main regions. In other regions a survey should be held only if needed.

Table 3.9: HIV-prevalence and risk behaviour among injecting drug users* Year HIV prevalence (%) Borrowing used syringes (%)** Amsterdam 1993 30 18 1996 26 18 1998 26 12 Arnhem 1991/1992 2 42 1995/1996 2 39 1997 1 16 Brabant*** 1999 5 17 Deventer 1991/1992 0 3 Goningen 1997/1998 1 11 Rotterdam 1994 12 18 1997 9 11 The Hague 2000 2 21 Twente# 2000 3 30 Utrecht 1996 5 17 Zuid-Limburg& 1994 10 19 1996 12 17 1999 14 14 * Injecting 1 time or more in lifetime ánd using hard drugs on at least one day per week in the past 6 months. ** 1 time or more in past 6 months (current injectors). *** Eindhoven, Helmond, Den Bosch. # Almelo, Hengelo, Enschede. & Heerlen: 11% (1994), 16% (1999), 22% (1999) and Maastricht: 8% (1994) 3% (1996), 5% (1999).

In these surveys, frequent hard drug users (heroin, cocaine, methadone, amphetamines) were recruited in methadone centres and on the street. Apart from collecting saliva (and blood) samples to test for HIV antibodies, self-reported risk behaviour was assessed in face- to-face interviews (Wiessing et al., 1996). The results show that the pattern of HIV prevalence and injecting risk behaviour among drug injectors across the Netherlands is quite heterogeneous. • HIV prevalence is highest among drug injectors in Amsterdam, followed by Heerlen and Rotterdam. Of the big cities, the Hague scores lowest, followed by Utrecht. • In most cities where repeated surveys have been held, HIV prevalence is fairly stable. • However, in Heerlen, a town in the South of the Netherlands, HIV prevalence had doubled between 1994 and 1999 (from 11 to 22%). A straightforward explanation is lacking (Beuker et al., 2001).

In a cross-sectional study among 282 young problem drug users11 in Amsterdam (mean age 25 years), 7.4% were infected with HIV. Among those who had ever injected drugs, HIV prevalence was 16.2% against 1.8% among those who had never injected drugs (Welp et al., 2002).

11 Using heroin, cocaine, methadone and/or amphetamine at least 3 days/week); age <30 years.

54 3.3.2 Hepatitis B and C

In contrast to HIV and hepatitis B, the main route of hepatitis C transmission is through blood - blood contact, not through sexual activities. It is therefore seen as a more reliable indicator of unsafe injecting than HIV or hepatitis B. • Seroprevalences of anti-HBV and -HCV among drug users recruited from the Amsterdam cohort (December 1985-September 1989) were quite high: 68% and 65%, respectively. For drug users who had ever injected (88% of sample), the figures increased to 74% and 73%, respectively whereas considerably lower rates were obtained among never injectors (19% and 11%, respectively12) (Van Ameijden et al., 1993). • The HIV surveillance of the RIVM now and then includes hepatitis B and/or C data, but systematic data collection on these infectious diseases is lacking. Table 3.10 shows seroprevalences of HCV and HBV in the cities of Rotterdam, Heerlen/Maastricht and The Hague.

Table 3.10: Seroprevalence of HBV and HCV (%) among (injecting) drug users* 13 Year HBV-positivea HCV-positive Rotterdam 1994 56% IDU 79% IDU 27% non-IDU 13% non-IDU Heerlen/Maastricht 1996 63% IDU 74% IDU 1998/1999b 67% IDU Den Haag 2000c 35% IDU 47% IDU * IDU=in jecting drug users (definition: see table 30). a. posive for anti-HBc. b. 7 per cent tested positive for HbsAg, indicating current infection with hepatitis B. c. In the Hague, 3 per cent tested positive for HbsAg.

3.3.3 AIDS

Ever since the first drug injector in the Netherlands was diagnosed with AIDS in 1985, the disease has joined overdose as a major cause of death in this group of users. AIDS cases meeting WHO criteria were until 1999 registered in the national Information System on AIDS Statistics, maintained by the Health Care Inspectorate (IGZ). Since 2000 the National Institute of Public Health and the Environment (Infectious Diseases Surveillance Information System, ISIS) reports on these data.

Between 1985 and 2001, a total of 5,229 reports of AIDS have been recorded in the Netherlands, including 564 injecting drug users (11%). Homosexual and bisexual men are the largest risk group. AIDS incidence assumedly decreased because of the availability of improved pre-AIDS treatment, which was introduced in 1996 and leads to a longer incubation period. Because of these developments, monitoring the HIV/AIDS epidemic in the Netherlands will depend more and more on HIV status surveillance instead of on registration

12 Blood samples were analysed with a less reliable first generation test for HCV. The prevalence of HCV among never-injectors is probably overestimated. 13 A positive test to antibodies to HBV is a marker for a previous or current infection (anti-HBc). A positive test for HbsAg without anti-HBc points to an acute infection. Samples testing positive for both anti-HBs and HbsAg indicate a chronic active disease and a chronic carrier state. These cases are at risk of developing serious complications and infecting other people. Chronic hepatitis develops in about 80% of all cases of infection with HCV. For 20-30%% the outcome may be lethal due to liver cirrhosis or liver cancer.

55 of new AIDS cases (Termorshuizen and Houweling, 1997). Therefore, the AIDS surveillance is replaced by a HIV/AIDS registration since the beginning of 2002 (see also 3.3.2).

Figure 3.8: Number of reported AIDS cases by year of diagnosis for the total group and for injecting drug users (IDUs) separately.

600

500

400

300

200

100

0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1999 2000 2001

total 122 136 243 325 392 419 447 512 480 488 538 457 340 179 106 45 IDU 1 6 16 34 34 41 43 56 61 63 79 49 44 24 9 4 Source: IGZ, RIVM.

3.3.4 Respiratory diseases

Long term smoking heroin and base coke may cause severe lung diseases. Inhaling the hot smoke damages lung tissue, which has usually also suffered from long term tobacco use. As shown in §3.1.3, 26% and 17% of the hospital admissions, in which dependence or abuse of opiates and cocaine, respectively, were the secondary diagnoses, were related to respiratory disorders. In Parkstad-Limburg respiratory problems were reported by 74% of the hard drug users who consumed cocaine against 40% who used other drugs (Coumans et al., 2000). The number of drug users presenting at the Municipal Health Service of Amsterdam with a Chronic Obstructive Pulmonary Disease is rising (Van Brussel & Buster, 1999). This condition may finally result in lung emphysema and, in the absence of adequate treatment, in death.

3.4 Other drug-related morbidity

3.4.1 Non-fatal drug emergencies

There is no national registration system for recording drug-related non-fatal emergencies. At local level the Municipal Health Service of Amsterdam keeps a record of nonfatal emergencies brought to their attention, some of which require transportation to the hospital by ambulance. The link with drug use has been based on anamnestic and circumstantial data.

56 Figure 3.9: Number of non-fatal emergencies due to drug overdose recorded in Amsterdam*.

400

350 308 294 300 287 271 258 250 208 196 200 188

150 1994 1995 1996 1997 1998 1999 2000 2001

* Includes heroin, cocaine (and psychoactive medicines). Source: Municipal Health Service Amsterdam.

• Between 1994 and 2001 a total of 2010 non-fatal drug overdoses were recorded (see figure 3.9). These cases probably involved opiates and/or cocaine, in combination with other substances, but details about toxicology are not available. In 2001, two out of three cases had to be transported to a hospital. • In 2001, 289 incidents were reported due to the consumption of cannabis, which may sometimes lead to panic attacks and other untoward reactions, particularly in inexperienced users (figure 3.10).

Figure 3.10: Number of non-fatal emergencies in Amsterdam related to the use of cannabis

300 46 250 47

200 58 73 150 34 28 21 35 243 211 100 40 165 130 137 107 118 106 50 82 11 40 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

smoking hashish eating spacecake

Source: Municipal Health Service Amsterdam.

The number of cannabis emergencies increased from 1993 to 1997 and decreased since then. In 2001, the number of recorded cannabis emergencies was twice as high as in the year before. Some 57% of the cases concerned tourists from abroad. The precise reason is

57 not known. According to the Municipal Health Service (Th. Sluijs), the increase might be due to the growing number of English drug tourists in Amsterdam, who often tend to combine cannabis with alcohol. Symptoms associated with cannabis emergencies are usually not severe (Elshove-Bolk et al., 2002).

Table 3.11: Number of non-fatal emergencies* recorded by the Municipal Health Service of Amsterdam in 2001 Amphet. Cannabis Mushr. Ecstasy LSD GHB Other Transported 2 108 20 24 1 61 23 Not transported 4 181 29 18 2 8 14 Total 6 289 49 42 3 69 37 % 1 58 10 8 1 14 7 * Transported to a hospital or treated at the spot. Source: Municipal Health Service Amsterdam.

Educare is an organisation which offers first aid at large-scale (house) parties. Among less than 1% of 650,000 visitors of parties in 2000 and 2001, Educare recorded health-related emergencies. One out of every three emergencies had been associated with alcohol or drug use, of which half were assumed to be related to ecstasy. This is one out of every five health- related emergencies (22% in 2000 and 20% in 2001) (Van Laar et al., 2002).

GHB The growing popularity of GHB has been associated with an increasing number of emergencies, although precise figures are lacking. • The number of nonfatal emergencies recorded by the Municipa Health Service of Amsterdam has increased from 25 in 2000 to 69 in 2001 (see table 3.11). Most users had to be transported to a hospital because they had lost consciousness. • In 2000 and 2001, the National Toxicology Information Centre (NVIC) received 91 and 172, information requests from hospitals, respectively. In 2001, 26 cases concerned persons who lost consciousness in association with GHB use. In the first half of 2002, there were 85 information requests, including 21 comatose patients. • Between 1999 and 2001, the Netherlands Forensic Science Institute has recorded 162 requests for toxicological analyses on GHB. Thirty-nine% of the cases tested positive. In several cases, a link was suggested between GHB use and traffic accidents, sexual offences or death (see also 3.2.3). GHB was often used in combination with other substances. However, precise information on the extent of GHB related incidents, and its causal involvement, is lacking.14 • Temporary loss of consciousness seems to be a frequent ‘side effect’ of GHB. In a survey among experienced users (see 2.2.3), 64% had passed out one time or more ever in their life and 10% did so 10 times or more (Korf et al., 2002).

3.4.2 Drug-related traffic accidents

A pilot study in the Netherlands suggests that drug use in traffic is fairly common and has increased in the past years (Mathijsen et al., 2002). In 1997/1998, about 5.5 percent of the

14 There are no adequate national registration systems for recording such events. Moreover, toxicological analyses are rarely carried out to verify the use of GHB (e.g. in emergency rooms in hospitals). Even if such analyses are performed, there may be problems in interpreting the results due to the usually low levels of GHB in

58 urine samples of drivers in nine selected research areas on Friday and Saturday nights tested positive for drugs. In a subsequent study in 2000/2001 at one site (Tilburg), 11% of the urine or blood samples of weekend drivers were positive for drugs. Three out of four concerned cannabis and the remainder cocaine and ecstasy, often combined with cannabis15. Most drug users were males younger than 35 years.

However, if drugs are detected in bodily fluids or are found in the clothes of drivers involved in accidents, this does not necessarily mean that there is a causal relationship between the accident and the substances found. In a related case-control study, no significant increase in injury risk could be found for single-use of cannabis, cocaine, ecstasy/amphetamines, opiates or low blood alcohol concentrations (BAC, 20-50 mg/ml). However, the relative risk increased for benzodiazepines (4.4), combinations of different drugs (8.8) and a BAC above 50 mg/ml (6.1-48). Highest injury risk was found for the combined use of alcohol and drugs (458). However, it should be noted that not all persons who tested only positive for cannabinoids (THCCOOH) were actually under the influence while driving. In fact, only 13% of them reported to have blowed less than four hours before (Mathijsen et al., 2002). Other studies have revealed a modest increase in accident risk for cannabis alone, if the analysis is restricted to cases which could be assumed to be under the influence of the drug while driving (Ramaekers et al., 2002).

4. Social and legal correlates and consequences

4.1 Social problems

4.1.1 Social exclusion

This topic is addressed in detail in chapter 16.

That drug users may be at a social disadvantage can be tentatively inferred from treatment statistics, such as those of LADIS. In 2000, almost one-third has a paid job (depending on main drug) - the majority receiving some form of social benefit – and the same proportion is an immigrants (table 4.1). These percentages deviate from those of society at large but that in itself is not proof of excessive social problems.

blood/urine (possibly due to a delay between consumption and sampling), which are hard to discriminate from concentrations related to endogenous GHB production. 15 The methodogical differences between the two studies were assumed to have little impact on the comparability of the data.

59 Table 4.1: Social characteristics of drug clients at outpatient centres in 2000 Cocaine, incl. Ampheta- Cannabis Opiates crack mines All drugs Allochtonous* 19% 29% 28% 5% 27% Secondary or higher 65% 62% 55% 58% 71% education Employed 42% 22% 39% 42% 29% Cohabitation 63% 51% 55% 63% 55% Total number 3,443 15,544 6,103 623 26,605 * Allochtonous according to a client's self-identification with an ethnic group.

Surveys of the Region and City Monitor on Alcohol and Drugs (MAD) among field samples of hard drug users indicate that few users have income from a legal job, about one-third is homeless and often have financial problems (debts) (Van de Mheen, 2000; De Graaf et al., 2000; Coumans et al., 2000).

People from ethnic minorities are apparently overrepresented among problematic drug users16, although precise figures are lacking because not all problematic drug users are in treatment or reached by field samples. They also seem to be less well reached by the addiction care and treatment services than autochthonous drug clients and have a relative high treatment dropout rate: 60% for Dutch clients against 70% for Moroccan, 67% for Surinamese and 65% for Antillean clients (Vrieling et al., 2000).

A key of the Dutch drugs policy is to reduce drug-related nuisance, such as disturbances of public order, property crime, aggression and violence, deviant behaviour, pollution and neglect of drug-premises, feelings of a lack of safety and threats to health, fear and irritation related to violence. A small proportion of hard drug addicts is responsible for the majority of the nuisance problems, particularly in the cities. However, other (socially marginalised) groups may also contribute, such as alcohol addicts, homeless people and psychiatric patients are also responsible for nuisance problems.

In 1996 the Ministry of the Interior has established a system to monitor developments in drug-related nuisance experienced by residents, carried out by research institute Intraval (Snippe et al., 2000). Neighbourhoods were selected, mainly in disadvantaged areas, in 16 municipalities scattered across the country. Overall, residents in 30 neighbourhoods were surveyed four times in five years as part of this process (in 1996, 1997, 1998 and 2000). All the municipalities in question were experiencing considerable drug-related nuisance. Not only were larger municipalities involved, so were smaller ones which had to contend with an influx of drug tourists. • In general, drug-related nuisance has slightly decreased since 1996, with some fluctuations depending on the specific type of nuisance. • A decrease has been observed especially for perceived nuisance related to coffee shops (since 1997) annexation and pollution of public spaces by drug addicts (since 1998). • However, there has been no substantial change in the lack of safety experienced by residents and their assessment of the liveability of their neighbourhood in the period, 1996-2000. The same applies to the number of victims and crimes involving property or violence.

16 Substance use itself is not necessarily higher, or may actually be lower among ethnic minorities (see §2.2.3).

60 Coffee shops From 1995 onwards, Dutch policy has focused on controlling the problems associated with coffee shops. As a result of strict enforcement and various administrative and judicial measures, the number of coffee shops has diminished in the past years (table 4.2). • The decrease was most pronounced between 1997 and 1999 (28%) and tended to stabilise since 2000. • In 2001, 51% of all coffee shops were located in the four big cities. • The large majority (79%) of all Dutch municipalities does not have any coffee shop at all.

Table 4.2: Number of coffee shops in the Netherlands Number of inhabitants 1997a 1999 2000 2001 < 20,000 ±50 14 13 11 20-50,000 ±170 84 81 86 50-100,000 ±120 ±115 109 112 100-200,000 211 190 184 183 >200,000: - Amsterdam 340 288 283 280 - Rotterdam 180 64 63 61 - The Hague 87 70 62 55 - Utrecht 21 20 18 17 Total 1179 913 813 805 a. estimated number of coffee shops. Source: Bureau Intraval (Bieleman and Goeree, 2001).

• Besides coffee shops, (other) illegal sales outlets do exist in a number of these municipalities, such as private homes, courier services and so forth. The Ministry of Justice has commissioned a pilot study to investigate these illegal outlets. Results of this pilot study are not yet available.

4.2 Drug offences and other drug-related crime

In 2002, the Ministry of Justice has contributed for the first time to the National Drug Monitor (NDM), which was established in 1999 by the Minister of Health. A preparatory study has shown that the availability and quality of data on drug-related criminality is not yet sufficient and will require extensive efforts of police and justice in the years to come. Recognising these limitations, a baseline document has been drafted containing a detailed overview of currently available statistics on solved drug-related crime, i.e. drug (law) crimes and crimes among drug users (Meijer et al., 2002). The figures in this paragraph are largely based on this document.

4.2.1 Offences against the Opium Act

Various sources give information on the (registered) number of offences against the Opium Act. In previous years we have presented data from Statistics Netherlands on the number of solved cases by the police, involving one or more suspects. For this reason and because of underreporting of police data, two other sources are assumed to give a better picture of the number of registered offences against the Opium Act. The first involves the number of unique

61 suspects recorded in the registration system of the police (HKS, HerKenningsdienst Systemen). Suspects are included if the police have made a report of the offence. The second source involves the number of Opium Act cases by irrevocable judgements recorded at the Public Prosecution Service. Note that more than one case may be recorded per suspect. Therefore, data from these two sources can not be directly compared. • In the past years, the number of suspected Opium Act offenders fluctuated between 8,000 and 10,000 (table 4.3). The number of suspects of hard drug offences is about 1,5 to 2 times as high as the number of suspects of soft drug offences. • Between 1996 and 2001, suspects of hard drug offences make up about 3 to 4% of the total number of suspects. The proportion of suspects of soft drug offences varies between 2 and 3 %.

A detailed analysis of the profile of the suspected Opium Act offenders in 2001 shows the following: • 88% is male (soft drugs: 85%, hard drugs 90%) • about one out of three (35%) is between 25-34 years (average age: 31 years) • about 20% lives abroad or has an unknown place of residence • some 60% of the soft drug offenders is born in the Netherlands against 40% for the hard drug offenders • hard drug offenders are more likely to live in the big cities while soft drug offenders concentrate in medium-sized cities • a quarter of the hard drug offenders is also a known drug user against some four per cent of the soft drug offenders • one out of five Opium Act offenders is also suspected for a property crime (Meijer et al., 2002).

Table 4.3: Offences against the Opium Act reported by the police or Public Prosecutor Number of suspected Opium Cases against the Opium Act Act offenders* recorded by the Public Prosecution Service** 1996 9629 1997 10210 10761 1998 10264 11611 1999 9153 11132 2000 8273 10546 2001 9168 11143 * Unique persons. ** More than one case may be recorded per suspect. Sources: HKS, OBDJ (Meijer et al., 2002).

• Of all criminal cases recorded at the Public Prosecution Service, 5% can be attributed to Opium Act offences. • The percentage softdrug cases increased from 31 in 1997 to 39% in 2001. The percentage of hard drug cases in the period slightly decreased from 63 to 57%. Moreover, some 2 to 3% of the cases concern both hard and soft drug offences.

It is quite difficult to explain trends in the registered number of offences. Many factors may play a role, such as variations in investigational efforts of the police, changes in policies or registration artefacts.

62 Registration data on the precise nature of Opium Act offences are not available. Some inferences on the type of offences (e.g. production, transportation) and substances involved (e.g. cocaine, ecstasy, heroin, cannabis) can be drawn from the Criminal Justice Monitor (SRM) of the WODC, which was based on a detailed analysis of a random selection of files of criminal cases settled by the Public Prosecutor and at court (NDM 2002). The data were obtained from cases recorded in 1993 and 1995 and may not be up-to-date anymore. Moreover, the sample was restricted and the law enforcement practice may have changed. The following figures are therefore just indicative and should be interpreted with great caution. • As shown in figure 4.1, four out of ten cases are related to drug trafficking and dealing. Possession of drugs for personal use takes a second position. Production of drugs is the least often involved in Opium Act cases.17 • Most Opium Act offences are related to cannabis (24%) and cocaine and heroin (23%), followed by heroin only (20%), cocaine only (17%), ecstasy/amphetamine (5%), methadone (2%), other (4%) or unknown drugs (4%). As regards the production of drugs, cannabis scored highest (74%), followed by ecstasy/amphetamine (22%).

Figure 4.1: Nature of criminal cases involving offences against the Opium Act

Proportion of criminal cases

0,4% 5,8% Production 18,8% 35,0% Transportation

Trafficking/dealing

Possession for personal use Unknown

40,0%

Source: SRM/WODC (Meijer et al., 2002).

4.2.2 Convictions and court sentences for drug offences

A special database of the Ministry of Justice (OBJD) gives information on the number of criminal cases recorded at the Public Prosecution Service and how cases were settled. Some figures are as follows: • In 2001, a total of 11,143 offences against the Opium Act were recorded at the Public Prosecution Service (see also the right column in table 4.3). • Some 67% (7,447) cases were taken to court (hard drug offences more often than soft drug offences). Between 1997 and 2000, these percentages were 64, 66, 72 and 71%, respectively.

17 Whether this still holds today is not known given the growing production of synthetic drugs in the late nineties.

63 • Among all Opium Act cases dealt with by the courts, 99% resulted in a verdict of guilty. This percentage remained stable from 1997 to 2001. Table 4.4 gives a breakdown by sentence imposed to Opium Act cases following a verdict of guilty.

Table 4.4: Number of irrevocable sentences in Opium Act cases imposed by the courts 1997 1998 1999 2000 2001 Task sentences* 1 441 1 853 2 129 2 138 1 120* Unconditional prison sentence 3 522 3 676 3 578 3 341 3 523 Financial transaction 1 101 1 157 911 838 1 568 Fixed penalty 1 287 1 476 1 634 1 350 1 393 Dispossession 90 91 74 73 46 * If the court imposes a sentence, it has the option of imposing a task sentence. This applies to relatively minor offences punishable by a maximum non-suspended prison sentence of six months. A task sentence can consist of work, treatment, education or a combination of these. The figure for 2001 is probably a registration artefact (underreporting). Souce: OBJD, WODC.

• Each year, some 3,500 unconditional prison sentences are imposed. In 2001, the mean duration was about one year: 364 days for hard drug offences (88% of the cases), 184 days for soft drug offences (8% of the cases) and 458 days for offences concerning both hard and soft drug offences (5% of the cases) (Meijer et al., 2002).

4.2.3 Prison data

Data on the population of penitentiary institutions are stored in TULP, the automated registration system of the prison service, and processed by Statistics Netherlands. Information on drug dependence is not recorded in this system. TULP gives information on the number of registered offenders against the Opium Act at a specific point of time (point prevalence) (see NDM 2002, Annex B). • Between 1994 and 2001, the total number of detainees increased with 42% (figure 4.2). In 2001, the large majority of detainees was male (94%). • The percentage of Opium Act offenders grew from 16% in 1994 to 19% in 2001. The large majority (87%) was male. • Opium Act offences are the most common offences among detained women (37%, against 17% for men).

64 Figure 4.2: Total number of detainees and detained Opium Act offenders

14000

12000

10000

8000

6000

4000

2000

0 1994 1995 1996 1997 1998 1999 2000 2001 Total 8735 10330 11930 11770 11760 11870 11760 12410 Opium Act 1355 1590 1805 1980 1990 1965 1965 2320

Source: Statistics Netherlands.

4.2.4 Crimes by drug users

The qualification ‘drug user’ or ‘drug addict’ is often not very accurate in police statistics. However, some sources give a rough indication of the group of criminal ‘drug users’. Due to a possible underreporting, the data are most meaningful in describing a profile of the ‘criminal drug user’ rather than drawing conclusions about absolute figures.18

The registration system HKS (see 4.2.1) of the police includes a classification ‘drug user’. This notification is made when the suspect may constitute a danger to others due to his or her drug use. • In 2001, the HKS recorded 8,730 suspected (hard) drug users, which probably is an underestimation. • 9% were females and the average age was 36 years. These figures deviate from those pertaining to the total population of suspects (14% females; average age 32 years). • Most drug users were suspected of a property crime without violence (see table 4.5). • Almost half of them lived in one of the four big cities (47%). • Some 37% committed his or her first crime before the age of 17. • The rate of recidivism is high: three-quarters of the registered drug users had 11 or more records of an offence in his or her total criminal career.

18 Just for illustration, in 2000, some 6% of the suspects of criminal offences was registered as a problem drug (or drug + alcohol) user. This is quite certainly a minimum estimate.

65 Table 4.5: Offences among suspects registered by the police as a drug user in 2001 Type of offence Percentage* Sexual offence 1% Violence (against other persons) 19% Property crimes with violence 11% Property crimes without violence 63% Vandalism, disturbance public order 19% Traffic offence 10% Opium Act offences 17% Other 19% * Total number of cases is 8,730. Source: HKS (Meijer et al., 2002).

4.3 Social and economic costs of drug consumption

There are no recent estimates of the social and economic costs of drug use. In 1995, the total annual social costs of drug addiction have been estimated at some 3 billion guilders (€1.4 billion), covering judicial costs, property crimes, specialised and general health costs, productivity loss, traffic accidents, social welfare expenditures, debts and devaluation of immovable property (Ernste & Bouwmeester, 1996). For comparison, the total costs for alcoholism were estimated at some 6 billion guilder (€ 2.7 billion). A more recent estimate has been made for costs related to alcohol use but not to drug use.

More details are given in chapter 1 and 14.

5 Drug markets

5.1 Availability

In the Netherlands, cannabis and hallucinogenic mushrooms are available through a system of ‘tolerated distribution’ (Abraham, 1999). That is, cannabis can be bought in coffee shops while mushrooms and other eco- and smart drugs can be obtained in some 150-200 smart shops. In 2001 the National Prevalence Survey included questions about the places of purchase of cannabis, mushrooms, and hard drugs (table 4.6). A distinction is made between drug users between 12 and 17 years and drug users older than 18 years. The former group is not allowed to buy cannabis in coffee shops (see 1), and smart shops usually also do not allow entrance of people below 18 years (Abraham, 1999). Because the number of young users (12-17 years) of hard drugs was very low, only places of purchase of cannabis were included for this age group.

66 Table 4.6: Places where last-year users (12-17 years, ≥18 years) purchased their drugs in 2001* relatives, coffee- café, home smart- Total Last year friends shops pub dealer% shops answers users (n) % % % % (n) 12-17 years Cannabis 46 37 2 3 2 390 253 ≥ 18 years Cannabis 37 47 2 2 2 1,517 1,028 Cocaine 55 2 5 17 0 284 217 Amphetamine 57 2 3 12 4 130 95 Ecstasy 65 2 3 10 1 355 274 Mushrooms 26 6 0 0 64 124 109 * More than one answer (location) per drug was possible. Source: National Drug Use Survey (Abraham et al., 1999).

• These results show that relatives and friends play a major role in obtaining drugs. • Coffee shops are the most important place of purchasing cannabis for people of 18 years and older while relatives and friends are more important for younger people.

5.2 Sources of supply and drug seizures

The Netherlands takes up an important position as a market and transit country of cocaine and heroin. This may be in part related to the great volume and concentration of maritime and land trade in the Netherlands, which are the most trafficking modus operandi for traffickers (Farrell, 1998). The Netherlands is also an important production country of synthetic drugs, like ecstasy, and cannabis. One way to gain insight into the size of the supply is from drug seizures. • There is no central registration of drug confiscations in the Netherlands. Each year, some data are collected from 26 regional police departments, including the National Police Agency (KLPD), Customs, the Royal Netherlands Military Constabulary (Dutch police with military status) and the Synthetic Drugs Unit (Bijkerk and Van der Werf, 2002). • Table A10 (annex 2) shows that the quantities of registered seized drugs fluctuated strong over the years. In 2001, the total number of seizures was 14,353 and the number of recorded investigations was 4,701. But these figures must be interpreted with great caution. • Caution is warranted in interpreting trends since the data are neither complete nor comparable from year to year. Although the response from the data sources was fairly good (86% in 1998, 97% in 2000, and 100% in 2001), not all police regions appeared to deliver adequate data. Therefore, the figures in table A10 are almost certainly lower bound estimates of the total amount of drugs seized. • Further, trends may be due to changes in efforts of investigation services, variations in the drugs markets as well as registration artefacts and new investigation methods.

The Synthetic Drugs Unit (USD) provides some more detailed information on seizures of synthetic drugs (Witteveen & Reijnders, 2002; see table 5.1). • In 2001, the USD has recorded a total of 678 seizures of synthetic drugs (20% in the Netherlands and 80% abroad but related to the Netherlands).

67 • From the Dutch-related tablets seized abroad, most MDMA tablets were seized in the United Kingdom (over 6 million), followed by Germany (4.3 million) and the United States (4 million). • The amount of seized amphetamine was higher in 2001 compared with 2000, which is consistent with an increase in amphetamine production locations and seizures of the precursor BMK.

Table 5.1: Amount of confiscated ecstasy tablets, attributed to the Netherlands

1998 1999 2000 2001 Amphetamines Seized abroad* 1,569 kg 990 kg 1,251 kg 530 tablets, 731 kg Seized in the Netherlands 1,450 kg 853 kg 293 kg 20,592 tablets 242,000 tablets 450,000 tablets 514 kg Ecstasy Seized abroad* 2.4 million tablets 9.7 million tablets 16.2 million tablets 22.1 million tablets 9 kg 16 kg Seized in the Netherlands 1.1 million tablets 3.6 million tablets 5.5 million tablets 3.6 million tablets 54 kg 405 kg 632 kg 113 kg

Number of tablets and kilograms of powder. Only registered if seizure exceeded 500 tablets and/or 500 kg of powder. * Related to the Netherlands. Source: USD.

Investigational efforts at Schiphol Airport have been intensified in the past years, especially to combat cocaine smuggling. Between January and September 2002, a total of 1,311 drug couriers have been arrested, including 503 ‘pellet swallowers’ (body packers). From January - July 2002, over 3,600 kg cocaine had been seized. In 2000 and 2001, the number of arrests was 800 and 1,223, respectively.

5.3 Price/purity

The Drugs Information Monitoring System (DIMS) provides detailed information on the quality of ‘ecstasy’ pills on the Dutch market and since 1999 also on the THC content and prices of cannabis samples sold in coffee shops (THC-monitor). Information on prices of synthetic drugs are obtained from the Synthetic Drugs Unit (USD). Note that methods to collect these data are different.

5.3.1 Content of ‘ecstasy’ pills

Table 5.2 shows that the proportion of ‘ecstasy’pills containing MDMA as main component strongly increased over the years, while pills containing amphetamine, the most common ‘contaminator’ decreased (DIMS, 2002). • Currently, 9 in 10 tested ecstasy tablets mainly contain MDMA. • The percentage of tablets in the category ‘other active substances’ has decreased. • The MDMA content per tablet is on average 83 mg, slightly higher than in previous years (70 mg). In 2001, 66% of the tested pills contained more than 70 mg MDMA against 49% in 2000 and 42% in 1999. • In 2001, the detection of tablets containing a dangerous concentration of PMA has led to a health warning campaign.

Table 5.2: Percentage of pills tested by DIMS by main component, since 1997

68 1997 1998 1999 2000 2001 MDMA 34 72 86 89 92 MDEA 7 1 1 1 1 MDA <1 1 2 2 <1 Combination1 4 1 1 3 2 Amphetamines2 32 11 6 2 2 Other psychoactive substances3 9 6 2 1 1 Other/unknown4 11 7 2 3 2 Total number tested 7,009 6,268 4,751 3,961 3,549

Percentage of tested tablets. a) In 2000 and 2001 DIMS registered another 952 and 603 ecstasy-like pills, respectively, which were not analysed by the lab. Source: DIMS. 1 Combination of MDA, MDEA and/or MDMA. 2 Amphetamine and/or methamphetamine, either or not in combination with other substances. 3 See table 5.3. 4 Caffeine, yohimbine, ephedrine, medicines (paracetamol, quinine, etc).

Table 5.3 shows the content of pills (or fluids: GHB) in the category ‘other psychoactive substances’. In 2001, an increase was seen in the number of fluids containing GHB.

Table 5.3: Number of samples by main component classified as “other psychoactive substances” 1997 1998 1999 2000 2001 2C-B 317 12 25 12 11 DOB 1 15 26 5 5 Atropine 128 52 0 1 0 MBDB 113 12 0 0 0 Ketamine 0 16 1 2 1 4-MTA 9 16 8 6 1 Strychnine 1 0 GHB 50 16 24 36 102 PMA/(PMMA) 1 8 Source: DIMS, Trimbos Institute.

69 5.3.2 Cannabis: THC content

Between 1999 and 2001, samples of different cannabis products (about 1 gram each) were procured from coffee shops and chemically analysed (Niesink 2001; Niesink et al. 2001). • Dutch marijuana and hashish contain more THC on average than foreign varieties (table 5.4). • Of the analysed cannabis products the THC content was found to be highest in Dutch hashish. However, this concerns a small number of samples of a type of hashish not often sold. • The health consequences of cannabis with higher percentages THC are not known.

Table 5.4: Average THC percentage in cannabis products

1999/2000 2000/2001 THC No. of THC No. of content samples content samples Dutch marihuana 9% 126 11% 131 Foreign marihuana 5% 56 5% 49 Dutch hashish 21% 18 16% 18 Foreign hashish 11% 90 12% 96

Source: THC-monitor, Trimbos Institute (Niesink et al., 2002).

5.3.3 Prices

According to the THC-monitor (see above), the average street price of a gram of Dutch as well as foreign marijuana remained stable over the years (table 5.5).

Table 5.5: Average price per gram of cannabis products (in €)

1999/2000 2000/2001 Dutch marijuana 5.83 5.86 Foreign marijuana 3.87 3.80 Dutch hashish 8.85 7.11 Foreign hashish 6.29 6.36

Source: Niesink (2001).

According to the USD, the retail price of a MDMA-tablet was 4 to 5 euro (March 2002).

6 Main facts and trends per drug

This paragraph summarises the main facts and trends related to the consumption of cannabis, ecstasy/amphetamine, cocaine, opiates, and other drugs. Possible explanations and factors underlying trends have been mentioned in the corresponding paragraphs.

70 Cannabis

• The percentage of cannabis users in the general population increased between 1997 and 2001, especially among adolescents aged 20-24. The estimated number of current users increased from 326,000 to 408,000. • Use among the age group 12–15 years (including students) remains limited and practically unchanged in the past years. • Treatment demand related to problems with cannabis use has increased in the past decade until 1997, and levelled off since then. • The sharp decline in the number of coffee shops between 1997 and 2000 has levelled off in 2001. • The THC content of Dutch marihuana bought in coffee shops is higher than of foreign marihuana.

Ecstasy, amphetamines and other synthetic drugs

• The use of ecstasy and amphetamine in the general population is low, but increased between 1997 and 2001. Current use of ecstasy increased especially among women. • Ecstasy is still popular among visitors of (dance)parties, discotheques and clubs. • GHB has gained popularity in special (local) networks of users. Its use has been associated with sexual offences, road traffic accidents and deaths, but precise figures are lacking. • Treatment demand for ecstasy and amphetamine is low and decreasing. • The number of registered fatal ecstasy intoxications is relatively low. • The average percentage of MDMA in ecstasy pills has slightly increased.

Opiates

• The number of problem users of opiates is estimated between 26,000 and 30,000. • Most problem opiate users also use cocaine (basecoke or crack). • The average age of opiate users is increasing. • The number of opiate overdoses registered at national level is stable, but the total number of acute drug-related deaths has increased in the past years. This may be partly due to a change in registration procedures. • Overall mortality among drug users (methadone clients) in Amsterdam has increased since the eighties. • The number of hard drug users injecting drugs intravenously is relatively low. • Sexual risk behaviour remains worrisome. • Crimes among hard drug users and drug law crimes draw heavily on the resources of the police and the criminal justice system.

Cocaine

• The percentage of current cocaine users in the general population remained low but doubled between 1997 and 2001. • Cocaine sniffing is fairly popular among visitors of coffee shops, pubgoers and clubbers/ravers in Amsterdam; no information is available for the Netherlands in general. • Cocaine is very popular among hard drug addicts, especially basecoke/crack.

71 • Use of basecoke/crack as a primary drug increases, especially among (young) problem drug users. • There are increasing health problems related to cocaine (and heroin) smoking. • Treatment demand for cocaine has increased by 59% since 1994. Today, the majority of treatment demands concerns basecoke/crack. • The number of registered acute cocaine deaths is low but slightly increased in the past years.

Multiple use

Users of the licit and illicit drugs often have experience with multiple substances, e.g. almost all consumers of cannabis also smoke tobacco, and the large majority also uses alcohol. Combined use of various substances is also a common phenomenon, especially among (young) people with an outgoing lifestyle (visiting bars, discotheques and parties) and among regular hard drug users.

7 Discussion

7.1 Consistency between indicators

The increase in drug use in the general population, especially in age group 20-24 years, is difficult to explain. Young adolescents in this age group are relatively frequent visitors of cafés and dancings and the link between drug use and an ‘outgoing’ lifestyle has been established repeatedly. The stabilisation of drug use among young people (12-15 years and secondary students aged 12-18 years) is difficult to explain either. As far as cannabis is concerned, a change in policy might have played a role (increase of age limit for buying cannabis in coffee shops) or the influence of prevention activities or a general ‘ceiling or saturation’ effect in drug use. Other indicators, e.g. increase in cannabis treatment demand until 1997, which levelled off since then, and the reduction in the number of coffee shops since 1997, seem to be at odds with the slight overall increase in cannabis use.

Cocaine (sniffing) has increased in the general population (again most clearly in age group 20-24 years) and is fairly popular among young visitors of party- or clubgoers (in Amsterdam). Moreover, in the past decade the consumption of basecoke/crack among problem users of hard drugs has sharply increased. This trend is consistent with the growing number of cocaine users seeking assistance at drug treatment services. Moreover, the number of registered acute cocaine deaths tends to increase in the past years. The increased efforts to combat cocaine (and ecstasy) trafficking do not seem to have influenced drug use rates so far.

7.2 Methodological limitations and data quality

The National Epidemiology Working Group evaluates all output generated by the Bureau of the National Drug Monitor (NDM). The NDM integrates the function of the Dutch operational Focal Point. As such, the implementation of the five EMCDDA Key Indicators had high priority. Different expert groups have been established to support this work. In 2002, the Bureau NDM, together with the national experts, has developed a general research

72 programme to improve the quality of data on these five key indicators (Van Laar et al., 2002). Specific grants are needed to realise the different proposals. Briefly, the state-of implementation of the key indicators is as follows:

General population surveys We have a fairly good picture on the prevalence of drug use in the general population owing to the National Prevalence Surveys in 1997 and 2001. The response rates were fairly low (about 50% and 47%, respectively) although common for such surveys. The questionnaire is largely compatible with the EMCDDA model questionnaire and most core variables are available. However, it remains to be seen whether the two surveys were fully comparable given the different methods of questioning (e.g. CAPI against multi-method). Information on drug use among students is obtained from the National Youth Health Surveys, which are compatible with the ESPAD and are carried out about every four years. The school surveys do not provide reliable data on drug use among youth above the obligatory school age (16 years) and among drop-outs. However, the impact of the last group is assumed to be limited since this group only constitutes 5% of the students at the most (Smit et al. 2002). Further, ethnic minorities are captured fairly well. Differences between schoolgoing and non- schoolgoing youth will be studied in 2003 by secondary analayses on data from the general population and school surveys. Further, the methodology of the HBSC study (see 2.2) will be refined to be fully comparable with the National Youth Health Surveys. This means that in the future we will have prevalence data on drug use among students every two years.

Prevalence estimates The number of hard drug users has been estimated in various Dutch cities and at the national level. In order to develop and implement an improved, reliable and efficient monitoring instrument on prevalence estimates, the NDM sub working-group on prevalence estimates has developed a project poposal (Smit, Van Laar, Meijer, and Mol, 2002). This proposal focuses on testing the feasibilty of 1-,2- and 3-sample capture-recapture methods by using different data sources, e.g. on treatment demand and of the police or criminal justice system. It is also intended to discriminate between opiate (or poly) drug users and primary cocaine users. A secondary objective is to enhance insight into the group of drug users entering the criminal justice system.

Treatment demand

With regard to its data-storage facilities, the LADIS now meets the demands of the TDI protocol. Recently added items are "age of first use" and "self-reported first treatment". Current activities focus on improving the quality of the registration (data input, output). Special attention is also paid to maintain the coverage of LADIS, which was compromised recently by the implementation of a client monitoring system (cliëntvolgsysteem – CVS) by the Netherlands Probation Foundation (Stichting Reclassering Nederland). Further, because LADIS covers only outpatient centres, initiatives are required to ensure that the new system on inpatient treatment demand (ZORGIS) is also compatible with the TDI protocol.

73 Drug-related deaths

Data from the General Mortality Register (supplied by Statistics Netherlands) meet the requirements of the EMCDDA protocol for collecting data on drug-related deaths. There are, however, indications that these data underestimate the true number of drug-related deaths (De Zwart et al., 2001). Moreover, data on mortality among drug users obtained from the Municipal Health Service Amsterdam do not fully comply with the EMCDDA protocol on mortality cohort studies. Therefore, the NDM sub working-group on Drug-related deaths (which met 4 times in 2002), has developed a project proposal to improve both national statistics on drug-related deaths and local systems on monitoring drug-related mortality (Van Laar et al., 2002).

Infectious diseases

HIV prevalence data are available from repeated serosurveys among street samples of drug users at different locations in the Netherlands. The method is largely compatible with the (proposed) EMCDDA standard for collecting data on infectious diseases. However, the measurement density of the current HIV surveillance in the Netherlands has been decreased recently (see 3.3). Moreover, there is no systematic data collection on the prevalence of hepatitis C (and B) among drug users, which is the main focus of the EMCDDA infectious diseases indicator. The Netherlands Focal Point has recently nominated a new expert to examine the feasibility of implementing a protocol on routine screening of infectious diseases at drug treatment locations (based on a model of the Municipal Health Service Amsterdam) and to implement assessments of infectious diseases in the Drug Monitoring System of the Region and City Monitor on Alcohol and Drugs (MAD).

Criminal justice and law enforcement data

Finally, the EMCDDA is strengthening data collection in the field of criminal justice and law enforcement. Further to this, the Dutch Ministry of Justice has started activities to develop and improve data collection systems on this topic (see 4.2). Although the quality of some statistics is still questionable, a first overview of the solved drug-related crime has been given in the 2002 Annual Report of the National Drug Monitor. Working relationships have been established between the NDM/Focal Point and the Research and Documentation Centre (WODC) of the Ministry of Justice.

74 75 PART 3

Demand Reduction Interventions

76 77 8 Strategies in demand reduction at national level

8.1 Major strategies and activities

Demand and harm reduction have been prominent in Dutch drug policy during the past 25 years with emphasis on education and persuasion to (potential) users and on reducing feelings of danger, and nuisance to the public. Judicial action (prosecution and imprisonment) is mainly reserved for possession, trade and trafficking of hard drugs (National Report 2001, see also 1.2.3). The government is steering and funding most organisations and activities aimed at development, implementation and evaluation of demand and harm reduction. Organisations of addiction care initiate, develop and guide drug treatments, after care and reintegration at local and regional level. Funding of development and evaluation of drug prevention is done by Municipal Health Services and intermediares such as the National Institute for Health Promotion and Disease Control (NIGZ) and the Netherlands Institute of Mental Health and Addiction (the Trimbos Institute). Advice and monitoring of drug prevention is the task of the National Support Center for Drug Prevention (LSP). For a list of intermediary organisations at national level, see National Report 2001.

8.2 Approaches and new developments

8.2.1 New and innovative approaches

During the past few years more emphasis has been put on pharmacological treatment (drug treatment, i.e. withdrawal treatment) of addiction instead of on social work and psychotherapy was done in former decades. Though this shift might be part of a broader shift with a focus on neurosciences and pharmacotherapies, the effectiveness of these therapies should be determined in more detail and in combination with drug-free treatments (Van den Brink and Geerlings, 1999a; 1999b; Van den Brink, 2002).

Enhancing the quality of drug prevention and addiction care The five-year policy programme (1998-2003) for improving the quality of addiction care and drug prevention (Resultaten Scoren or ‘Getting Results’) is still running. The total programme costs are more than € 2,7 million. The evaluation results of this programme are to be published in 2004. Important subprojects of Getting Results are: • Initiation of facilities for education of professionals in addiction care to enlarge or to update their competence or expertise; • Improving and integrating information systems in addiction; • Monitoring; • Co-ordination of funding and planning of outpatient addiction care.

Two other activities were mentioned in our former national report: the initiation of national monitoring and (more fundamental) registration activities. Monitoring drug-related data has now been introduced in two ways: the annual report of the National Drug Monitor (NDM) and the chapter on addiction care in the annual Branch Report (new style) for mental health. The NDM annual report focusses on legal and illegal drugs. It presents drug-specific data on use (general population and youth), problematic use, treatment demand in inpatient and outpatient care, international comparisons, health risks,

78 societal burden and from 2002 also the Ministry of Justice co-participates with information on registered criminality and criminal prosecution. In future reports, information on judicial measures against drug-related criminality wil also be taken into account (NDM, 2002). Publication of hard cover fact sheets will probably be ended and replaced by website information because of its easy updating possibilities. An English translation of data of the latest NDM-report is available on the internet site of the Trimbos Institute (www.trimbos.nl). It has been proposed to include drug prevention and drug treatment and information about evidence-based practice in the next years. Annual branch reports (new style) have been published on several policy domains (health, mental health, social support, etc.) and are meant for national policy making and all other stakeholders. Data in these reports are systematically covering five subjects: demand of care (treatment, etc.); supply and capacity of care; use of care, funding; and quality of care (for additional information about registration systems, see National Report 2001, 8). Various (collaborating) agencies in the Netherlands (cf. paragraph 8) collect data on addiction and substance use but none is national in its scope (National Report 2001). Both the Ministry of Health, Welfare and Sport and the judicial authorities want to invest in improving data collection. A new registration system in under way that combines data on inpatient and outpatient care (ZORG-IS). The Ministry of Justice has commissioned a study on the feasibility of a new registration system on the production, distribution and use of drugs (Snippe et al., 2000).

A monitoring report of the Municipal Health Service has noticed a stagnation in the process of addiction care in Rotterdam. Especially the proportion of new drug using clients has decreasing since 1990 from some 800 to 300 per year (Wierdsma and Van Driel, 2000). More than three quarters of the drug clients is already known and covered by local addiction care. This stagnation has been partly explained by the aging of drug addicts who remain in care (the ‘hard core’ or ‘revolving-door clients’) for instance methadone clients and the homeless or dual diagnosis group (see 8, 10, 11). Their permanent or repeted presence in addiction care causes a reduced availability of supply of care for new (younger) clients. Other explanations are an ineffective co-operation between addiction care and mental health care or general practitioners, and ineffective referrals to addiction care from other care sectors. The same trend has been registrated in other big cities (CBZ, 2002). Finally, registration data point at the aging of professionals in the addiction care field (Hesseling and Prins, 2002). Though this may also indicate a stagnation in treatment habits, no empirical data are available to explore and confirm this hypothesis. The combat against stagnation of addiction care is mainly focussed on other care regimes for the group of aging addicts (10, 11.2), thus saving time and money to be directed to new treatments for new target groups.

8.2.2 Socio-cultural developments relevant to demand reduction

The historical background and context of attitudes and opinions on drug use have been described in our former report. It was concluded that these variables cannot be used for a straightforward explanation of drug policies.

8.2.3 Developments in public opinion

Attitudes toward formerly tabooed subjects such as sexuality, and the use of (soft) drugs became much more permissive during the sixties and seventies. Many idealistic and experimental tendencies concerning drug use during these decades are perceived as too

79 extreme nowadays (SCP, 2000). Besides, the national and local political issues of drug supplies and drug use is connected to the issue of public safety and criminality. Presently, there may be a change favouring more repression, or at least stricter enforcement of existing laws. However, in the absence of data from reliable opinion polls, it is hard to say whether this represents a new trend.

8.2.4 New research findings

Fundamental problems arise for practice and research due to comorbidity or dual diagnosis. Research has pointed at the high correlates between psychiatric problems and addiction problems. The attention for this subject is increasing and the state of the art in daily practice has been reported (Meeuwissen et al., 2001). It has for instance been estimated that ADHD is manifest among some 10% of the addicted in treatment. The Trimbos Institute is developing and testing protocols for diagnosis and treatment of this type of dual diagnosis patients (Eland and Van de Glind, 2001a; 2001b). Subsequently, a symposium on this subject will be organised by the Trimbos Institute in 2003. A current research project aims at psychometric evaluation of checklists and clinical judgement for psychiatric disorder in addiction care and to evaluate a stepped assessment procedure in daily practice of addiction treatment (de Jong, 2001). Another study is determining the effects of pharmacotherapy (methylphenidate) for patients with Attention- Deficit/Hyperactivity Disorder (ADHD) and addiction (De Jong and Carpentier, 2001). ADHD patients with addiction problems are also the subject of a third study (Vitale and Van den Eijnden, 2002) that focusses on the bottlenecks of implementing integrated care for these patients (see 11). At the same time symposia have been organised on cannabis use among schizophrenia patients and its effects (Polak, 2002).

Other new research findings are described in chapters 9 to 12.

8.2.5 Specific events during the reporting year

NO INFORMATION AVAILABLE

80 9 Prevention

Two surveys (Wychgel, 1998; Warmenhoven, 1998) revealed that school-based prevention is the core of prevention in the Dutch addiction care system. It is generally considered a necessary condition for proper evaluation, to specify what is done for who and how, in order to enable measurement of effectiveness, ‘quality of care’ and ‘good practice’. However, in most cases descriptions of prevention are in general terms, pointing at (parts of) prevention programmes. Another problem is that many prevention activities consist of programmes that combine several interventions (packages) at the same time or sequentially (ketenbenadering, interventiepakketten or ‘stepped care’). Combinations are assumed to be more effective, but it is far more difficult to evaluate the effects of combinations of interventions in a methodologically sound way.

National strategy

There is no explicite national strategy to enhance an evaluation culture in drug prevention in the Netherlands. Instead, a five-year programme on drug prevention policy (‘Getting Results’) is aiming at quality improvement at a national level and will be evaluated the coming years (National Report 2001).

Organisation and co-ordination within national structures

Drug prevention has not been organised nor co-ordinated at a national level. This is related to the Dutch funding system. Nearly all bigger organisations of addiction care include small departments (five to eight persons) for drug prevention but their funding stems mainly from municipal authorities (9c, 14).

Expenditures on prevention in Member States

In the Netherlands, the municipalities are paying drug prevention activities (see 14). The mean annual expenditures on drug prevention in the bigger organisations of addiction care (the Jellinek, Novadic and others) are approximately € 450.000 (one million guilders). Smaller ones receive smaller amounts of money but specified cost data are absent.

9.1 School programmes

The nation wide programme The Healthy School and Drugs was initially funded by the Dutch Health Research and Development Council (ZON/Mw). In 2003 it was co-funded by the Ministry of.Health, Welfare and Sport. Continuation after 2003 is undecided yet.

9.1.1 Specificities of policies

In the Netherlands, schools are required by law to provide students with information on health issues in general but not on drug issues specifically.

9.1.2 Models of school prevention

81 The most common type of school-based drug prevention is the national programme The Healthy School and Drugs, directed at teachers and parents as intermediary target groups. This programme exists already for more than ten years and has been evaluated in 1999 (Jonkers et al., 1999; National Report 2001, 9.1.2). Activities for the Healthy School and Drugs are the responsiblility of school personnel and support is given by professionals from Municipal Health Services and organisations of addiction care. The Trimbos Institute takes care of advice, consultation, training, education, and publishes and disseminates printed and audiovisual materials. Recently a manual became available for setting up and maintaining this type of drug prevention at schools.

Besides this long-term school-based programme, there are some short-term regional or local initiatives that are not evaluated up to now (see 15.3.1).

9.1.3 Prevention programmes available in the country There are 33 registrated local applications of the Healthy School and Drugs and some other loose schoolprojects for instance with police officers that have not been evaluated (see 15.3.1).

9.1.4 Evaluation studies and results

The Healthy School and Drugs has been evaluated nationally in 1999 (see above). In general the (experimental) use of tobacco, alcohol and cannabis increased within two years after the start of the programme at schools. Measured effects should be understood as less increase of substance use compared with non-participating schools (Rescon, 1999). After two year students in the participating schools showed significant but small effects for alcohol and cannabis use, but after three years these effects on cannabis use had disappeared. At 12-15 years most students start to experiment with (legal) drugs and are susceptible to group pressures. This type of school-based prevention is able to delay this initial legal drug use. Unexpectedly, cannabis use became somewhat more frequent after the intervention among those who used it. Results of an old Dutch study show that this effect may be temporary (De Haes & Schuurman, 1975). Based on results from American meta-analyses it was recommended in another study to involve students more actively with prevention activities in contrast to teacher led prevention lessons, to focus on peer pressure resistence training and to add interventions directed at the environment (family and neighbourhood) of the students to school-based prevention (Cuijpers, 2002a; 2002b; Engels, 2002).

9.1.5 Research projects

Recently two updated systematic research reviews on the effectiveness of school-based drug prevention have been published. The first one, a meta-analysis of twelve studies on peer-led versus adult-led programmes, showed that in general peer-led programmes were somewhat more effective, but studies differed considerably in characteristics and results. It was concluded that the effectiveness of a prevention programme is determined by several characteristics of the programmes (Cuijpers, 2002a). The second review determines effective ingredients of school-based programmes. Its basic assumption is that most programmes are not effective because effectiveness could not be proven for these programmes in general. Based on three meta-analyses, six studies examining significant mediating variables of interventions and 21 studies directly comparing prevention programmes with or without

82 specific characteristics (four on booster sessions, twelve on peer-led versus adult-led programmes and five on adding community interventions to school programmes). Seven evidence-based quality criteria appeared to be important for increasing the effectiveness: interactive delivery of activities (with strong commitment of the students); the ‘social influence model’ as a leading theory; focus on norms (commitment not to use and intentions not to use; adding community interventions; use of peer leaders and life skills (Cuijpers, 2002b).

9.2 Youth programmes outside schools

The bulk of current drug use by youngsters in the Netherlands can be characterised as recreative drug use, mainly during weekends.

9.2.1 Definitions used

The website of the Support and Information Point Drugs and Safety (SIDV) defines recreational settings as “large-scale dance events”, clarified as dance events organised on locations or spots that are unusual for regular catering services (sporting halls, exhibition halls, football stadiums, or just in the open air). The number of visitors varies enormously. Sporting halls can accomodate 1000-1500 visitors, other locations 45.000 (www.sidv.nl). Besides these large-scale dance events, drugs are also regularly used in pubs, discotheques and the like.

9.2.2 Types and characteristics of interventions outside school

A number of on-the-spot activities were organised at places where youngsters spend their free time. Examples are: Public campaigns, the Drugs Info Line (telephone information line), First Aid services, and pill testing facilities during large-scale dance parties. Pill testing is nowadays only done in specialised centres (1.4.5)

9.2.3 Statistics and evaluation results

NO INFORMATION AVAILABLE

9.2.4 Specific training for professionals and peers in this field

In 2002, the Trimbos Institute organised two train-the-trainer courses in First Aid for drugs incidents in recreational settings (Trimbos Instituut, 2002). The courses include knowledge about recreational drugs, possible health consequences, and adequate First Aid activities. Pill testing professionals are trained in chromatography and spectometry, First Aid professionals paramedically and training of trend watchers or trend spotters concentrates on unobtrusively observation of dance scene activities and (changing) drug habits.

9.3 Family and childhood

In general, evaluation of preventive activities or care for children of addicted parents is still rare (National Report 2001, 9.6b). In fact the family is neglected in drug prevention. This conclusion was confirmed in a key note address during the Forum of Alcohol and Drug Researchers (FADO) held in Utrecht on November 7th 2002. The main message of the key

83 note speaker was that prevention of substance use in the Netherlands is still concentrated on individual users, school-based prevention and peers. The family, an important socialising factor, did not attract much attention during the last ten-fifteen years. Some projects were realised but few evaluations have been done. This omission should be compensated to increase effectiveness of drug prevention in the future (Engels, 2002). A recent systematic review of the international literature concluded that family-based prevention to increase parent influence on their children’s drug use is a developing work field. This situation does not allow a broad implementation of specific interventions because the effectiveness is still unknown (Cuijpers and Bolier, 2001). In short, family prevention is a challenging new field. A more specific publication presents a literature review and a survey of current practice of case management for children with addicted parents (Bool, 2002). The author present prerequisites for effective case management (it preassumes for instance motivated participants and an adequate coverage among families). He further concludes that it remains unclear which types of case management are most effective, although some studies indicate that Assertive Community Treatment is promising. A second option is the Strength Model approach which actively supports and uses positive qualities or skills of parents. Another publication deals with parent meetings on drug use. This study focussed on the effects of four experimental parent meetings (during evenings) on communicative behaviour towards their children and its influence on the relation between this behaviour and education style. The study was conducted as part of the project Healthy School and Drugs (see 9.1). All 172 parents filled in a questionnaire before the meeting and were requested to send back a second questionnaire after a month. This was done by 95 parents (55%). The main conclusions were that parents did not talk more often with their children about drugs and their possible drug use then a month earlier, nor did their parenting style correlates with it (Panka, 1999).

9.3.1 Definitions used

NO INFORMATION AVAILABLE

9.3.2 Types and characteristics of intervention with family and childhood

An increasing number of the organisations of outpatient addiction care offer free of charge courses on drugs and drug use to parents. These courses (mostly two meetings) are either part of a community approach or simply a separate family intervention for interested parents. Parents who think that their children (might be prone to) experiment with cannabis, are invited to attend. During the sessions, information is given on parenting techniques and on the risks of drug use. A considerable amount of time is spent on emotional debriefing of experiences with drug use of their children. However, these activities are not systematically developed and evaluated.

9.3.3 Research projects and evaluation results

Evaluation of the public campaign ‘Drugs, don't fool yourself’ aims at determining coverage and appreciation of this campaign, and finally stimulates seeking information about drugs and drug addiction among parents and their older children (see 15.3). The new campaign has been started on October 28th (Dijkhuis, 2002).

84 9.4 Other programmes

Peer-to-peer approaches

Peer support for parents in low SES neighbourhoods to prevent child drug problems targets parents to talk with other parents in a trustful, informal environment. Participation rates for parent meetings in low SES neighbourhoods are expected to be small. It was assumed that low threshold peer meetings may be effective in reaching and stimulating parents for participation ('the tupperware strategy'). The 'home-party' (a meeting in the living room of a neighbourhood peer) is assumed to be the most effective approach for increasing the coverage rate, their knowledge about drug use and their (subjective) parenting skills. Twelve house parties were organised in four neighbourhoods of three different cities. Pre-selected mothers (hostess and peer) invited other parents from children of 8-16 years (mostly family members, friends, acquaintances) to participate in a home-party for exchanging thoughts about parenting problems and drug related child problems. Parents are also encouraged to talk with their children about these problems and invited to become a hostess for future parties (snowball procedure). The number of participating parents was 106, five fathers included. Baseline data on knowledge, attitudes, and drug use were measured and discussed. Pictural representations were used as well as video recordings of difficult parenting situations. A booklet with exercises at home served as a basis for information and discussion in the family situation. The authors stress that parenting skills should be discussed in a humorous and light-hearted manner. The adagium was 'keep talking with the kids'. Other organisations take care of the implementation of the booklet's tools and strategies amongst parents in other neighbourhoods. Peer prevention with homeparties can be implemented separately or as a part of community-based projects.

Another initiative was prevention of infectious diseases among (mostly illegal) North African drug users in Rotterdam (see also 10.1.2). This approach proved to be unsuccessful (National Report 2001). Three-quarter never contacted regular addiction care. In most cases peers adviced about safe sex and distributed syringes and condoms. Specific information about these peer contacts (how and what) was not available. Due to cultural barriers it was impossible (and sometimes even dangerous) to train female peers for this purpose. Repeated contacts were mainly informal but the social status of distributing peers (syringes, condoms, etc.) appeared to be higher in the perception of receiving peers. Therefore, these were no longer peer education talks, thus not registrated as such. It was concluded that the distribution of materials was accepted as more important than peer education. Drug users rather receive syringes from ‘peers’ than from professionals. In general it may be that the peer approach for (illegal) immigrants does not work because of divergent perceptions of social status (the cultural factor).

Telephone help lines

Talking freely about drugs and drug use is still uncommon. On February 1996 the Dutch Minister of Health officially opened the National Drugs Information Line. This telephone service offers neutral, objective information, free leaflets and a counselling service. Later a web site was made with the same objective. The growing use of this Information Line shows a need for neutral, objective drug-related information. The telephone line is open to the public

85 and anonymous. Nowadays a fixed expert team is operating the Infoline and they are assisted by several volunteers. From 1996 to 2001 the number of telephone calls increased from more than 26.000 (the initial target was set at 25.000 calls) to more than 35.000 in 2000 (a hundred calls a day). In 2001 this number declined to 32 000, probably due to the success rate of the website. In the same period visits increased from 26.500 to 115.600 (2000) and 179.318 in 2001. The number of personal telephone talks increased during the past year from 9.816 to 11.017 (Kok et al., 2001). More than a quarter is drug user. Students also frequently use the Infoline. Others less frequent users are parents, family and friends of drug users. In general women are using the Drug Information Line more often than men, and asked more questions about drug use of others. Drug users and students were most frequently calling. Most telephone calls take less than five minutes (66%), only 5% of the calls last longer than 20 minutes. In 1999 this situation was the same. Most questions were about drugs in general. Second are questions about hash and weed, followed by XTC and cocaine. Risks of drug use are most frequently asked for. Questions about problems with doping were more often asked than in 2000. In 1999 co- operation has started between the Netherlands Centre for Doping Issues and the Trimbos Institute. An experimental Doping Information Line has been started.

Community programmes

Most preventive activities are combinations of activities realised in local communities (municipalities, neighbourhoods). Few are regional and sound effect evaluations are absent. In almost all cases, community-approach prevention exist of several activities (often a mix of drug-specific or health-specific school lessons, games, educational meetings, lectures, educational theatre for children, etc.). They do not exclusively target drug use but in most cases also alcohol and tobacco use and sometimes gambling. Activities take place on several levels in the community (municipal, neighbourhood, school, family), with several participants (neighbourhood police officers, organisation of addiction care, Municipal Health Service, peers) and they are meant for (intermediary and final) target groups, for instance local policy makers, coffee shop owners, camp site owners, teachers, parents, children. In some cases booklets, posters, youth magazines, exhibitions or preliminary guidelines (draaiboeken) are also involved.

Mass media campaigns

In the past six years several mass media campaigns have been organised and evaluated (National Report 2001). At this moment the use of these campaigns is critised in the media because they are not considered cost-effective. This consideration is not only based on daily experience but also on a host of empirical data ranging from the fifties to now (Hornik et al., 2002). Therefore mass media campaigns may only be effective if embedded in broader prevention strategies. Yet, these are still separately funded by the government.

Internet

Today there are many sites to be visited on drugs. We restrict this paragraph to a few examples.

86 At this moment the site of the Trimbos Institute (www.trimbos.nl) gives access to the Drug Information Line (see 9.4.1), eight English fact sheets about drugs, drug notes, and information about the Healthy School and Drugs (see 9.1). The site of the Drug Information Line contains general information on drugs and answers to frequently asked questions. Fact sheets give quick information about addiction care and assistance, and about Dutch drug policy in general and specifically aimed at cannabis, hard drugs, public drug-related nuisance, and education. This site also gives access to other organisations in the Netherlands and abroad that focus on drugs. An internet site of the National Drug Monitor is being developed to enable everyone to gain access to a nationally integrated database on drugs, on demand and harm reduction, on effectiveness of prevention and treatments, and on the EDDRA database of the EMCDDA. Most regional organisations of addiction care (see National Report 2001, 8) have their own sites to inform the public about their work, and some also deal with drug research. The site of the Jellinek (www.jellinek.nl) also answers commonly asked questions about drugs and recently an on line drug treatment service was started (for drug sites see 15.1.5). An ambitious internet project is the national monitoring project on Public Health and Care in the broadest sense: the National Health Compass (Nationaal Kompas Volksgezondheid) developed by the National Institute for Public Health and the Environment (RIVM). This site (www.nationaalkompas.nl) is meant to inform about health issues in general including mental health and drugs (Van Oers, 1999). The National Health Compass also includes addiction and addiction care. The client directed summary for addiction care ‘Briefly and to the point’ (Beknopt) has already been inserted. Other more elaborate parts of addiction and addiction care in the Netherlands will be inserted during the coming years. The website of the Support and Information Point Drugs and Safety (Steun en Informatiepunt Drugs & Veiligheid) presents concise information (www.sidv.nl) about cannabis, recreational drugs, smart drugs, national policy, local policy, examples from practice, jurisdiction, publications).

9.4.1 Research projects and evaluation results

See our National Report 2001.

9.4.2 Specific training

In 2002, the Trimbos Institute organised several training courses for addiction care, both on a basic level and more in-depth (Trimbos-instituut, 2002). Other courses deal with dual diagnosis (both for professionals in addiction care and mental health care) or prevention in coffee shops (both for personnel and for visitors of coffee shops).

10 Reduction of drug-related harm

Role of harm reduction within national drug policy

Harm reduction has been one of the pivotal aspects of our national drug policy during the past 25 years (see 8), and this is consistent with our perception of drug addiction mainly from a health perspective. Healthy behaviour should be endorsed and unhealthy behaviour is difficult to enforce. This contrasts with the punitive-judicial view on drugs and drug addiction.

87 Definition and priority

Defining clear differences between outreach work, low-threshold services, harm reduction activities, and the newest term ‘social addiction care’ is hazardous. Actually, all four deal with seducing difficult to reach drug users to participate in some action to prevent a worsening of the situation (individual and/or social). Some years ago a new concept was coined: ‘social addiction care’. It is one of the pilars of the five-year policy programme ‘Getting Results’ (see 8.2, 9). This concept is conceived in broader sense, setting idealistic and more long-term goals (see below).

Most outreach work is carried out by low threshold services in outpatient care facilities (National Report 2001). These services are active in street corner work offering daytime shelter in drop-in centres for street junkies, living room projects for drug-using prostitutes and user rooms for chronic hard drug users. Other target groups of these services are injecting drug users, extremely problematic drug users, and drug users from foreign countries (these are evidently not permanent residents). Outreach activities also feature in programmes for reducing drug-related public nuisance, which are often a joint venture between treatment and care facilities, police and civic groups. A new type of outreach work today is education ‘on the spot’ (i.e. where young people meet) applying peer-support techniques. Another one is developed at this moment and aimes at drug using people who have been sentenced to stay a few months in prison (Mainline, 2000; National Report 2001 hereafter).

Recent policy trends

No changes compared to former years (National Report 2001, 8).

Current public/professional discussion

In Amsterdam. local politicians considered possibilities for a special building in a suburb (junkenflat) where in general many addicts are staying, but this plan was not approved by the municipality. Besides user rooms, there are nowadays ‘supported housing projects’ for addicts and a night relief center (24 beds).

Harm reduction practice

Social addiction care Social addiction care is not concentrated on treatment but on minimalisation of the effects of addiction for the client (care instead of cure) or on improvement of daily performances of the client. Harm reduction is considered a minimal model of social addiction care (Broekman et al., 2002). Social addiction care is meant to improve the quality of life and the re-integration of addicts.

Relief centres for homeless Many cities have relief centres for homeless people, sometimes these are only opened for the night, in most cases however a 24 hours service is offered for homeless (addicted or not). The most important objective is to reduce public nuisance (‘visual’ nuisance by their appearance or by litter (beer cans, bottles, paper ware) that has been left behind, and drug- related criminality).

Pill testing Targeting at prevention of health damage from overdose or toxicity after use of synthetical drugs by people (not only youth) in recreational settings). Sixty testers are working in the field, eight collaborators in the DIMS-office and four lab analists (all university or higher vocational level education)

88 Needle exchange Targeting injecting use of hard drugs (a minority of the group of hard drug users) to reduce needle sharing, infections, infectious diseases and to reduce leaving used needles on the streets. The activities are mainly done by street workers, workers of organisations of addiction care, pharmacists, workers of public cleansing departments.

Time out rooms for addicted prostitutes Giving the opportunity to addicted prostitutes to have some rest in a trustful environment, to talk about their problems, to find some preliminary solutions for these. The actual work is done by specialised women care workers (vrouwenhulpverlening).

Farm work Giving the opportunity to (ex)addicts (after detoxification) to participate in supported farm work in order to structured day activities, stimulate social contacts, reduce relapses and stabilising their lives. This programme was carried out by a programme co-ordinator, management of regional addiction care organisations, and participating farmers (see Range of services).

Living unit for older addicts A living unit for a small group of older methadone and cocaine users to reduce drug-related nuisance and stabilising their drug use. Living units should be operated by experienced and trained professionals (not specified).

Case management The term case management (also called ‘interfering care’ or bemoeizorg) as an intervention for chronic addicts often with dual diagnosis, stems from psychiatry. A definition was not formulated but an important part of case management is co-ordination of activities and therapies in order to enable stepped care or care packages for individual clients. In most cases case management is realised on a one-to-one (client-manager) basis. The ideal caseload of each manager is considered 15 to 20 clients in order to stay effective and avoid burnout. The actual amount of casemanagers is not known.

Range of services

Self help groups Self help groups have already been mentioned in our National Report 2001 (see 9.6.6).

Mainline The Mainline foundation (www.mainline.org) is an independent non governmental organisation, striving to improve the health and quality of life of drug users. Mainline workers accept drug use. Direct contact with drug users enables Mainline to point out and analyse new developments in the drug scene at an early stage. Targeted harm reduction activities are possible, as well as health education, consultancy and training of social workers. Established in 1990 as a small fieldwork organisation for AIDS prevention in Amsterdam, over the years Mianline has grown into a professional harm reduction organisation. Attention is paid to (new) health problems, drugs, techniques, and target groups. Through its key task, i.e., health education and prevention for drug users on the street, Mainline has gained a great deal of knowledge on developments surrounding substance use, substance users, and health risks. This knowledge is used in field work, education material, training, policy (-consultancy), and research. An increasing number of

89 organisations and research institutes call on the expertise and experience of Mainline, which consequently results in regular collaborations.

Inpatient Motivation Centres (IMCs) (See National Report 2001, 9.2.1).

A living unit for older addicts Empirical data refute the common wisdom that harddrug addicts cannot grow older than fifty. Today, a growing part of the chronic heroine addict population illustrate this. Problems with their need of care are partly comparable to problems of the elderly in general. Specific problems are that aging drug users are less able to get their daily drug regime and suffer a high risk for personal neglect. Maintaining a minimal standard of living requires support. An experimental living unit for seven methadone and cocaine using ‘seniors’ (older than 55 years) was funded by the Municipal Health Service in the city of Rotterdam. It started in 1999 and was evaluated a year later (Heijman and Verveen, 2000). The seniors were not extremely problematic. A maximum size of ten addicts was recommended to avoid anonymity of group members, to ensure care and to maintain the support of the neighbourhood. The relationship between professionals and neighbours were good and no public nuisance was detected during the evaluated year. Clients were satisfied with this type of supported living condition, could manage financially, and were able to withdraw from excessive cocaine use, due to the support of the professionals.

The agricultural link! Farm work for dual diagnosis patients A recent two-year experiment with working on the farm for (ex)addicts also showed many positive results (Cool, 2002). Initially this project was meant for drug-users who caused public nuisance but the co-operating organisations of addiction care referred exclusively treatment refractory clients (multiproblem clients, most of them with dual diagnosis). The co- operating farmers were able to handle these clients quite well and the clients themselves appeared to be satisfied with their work. It structured their life and they had rewarding social contacts. Talking with colleague workers with other problems reduced the seriousness of their own problem perception. Furthermore, in contrast to the attitudes of the outside world, they felt accepted in these contacts. Finally, their drug use decreased or stopped entirely. However, their lack of problem solving capacity appeared to be unchanged. At the start of this experimental pilot, the participating organisations of addiction care were cautious about the effects but after some months the effects were surprising. Co-operation between farmers and management of regional organisations of addiction care remained stiff. Addiction care did not involve in formal arrangements to enlarge or prolonge this co-operation. Aftercare and further rehabilitation were inadequately organised. Rather, the implicite assumption was that farmer work could be an end station for participating clients (the highly problematic group of dual diagnosis clients). Funds for continuation of this project are still quite uncertain.

Enhancing vocational opportunities for addicts In Brabant (a Southern part of the Netherlands) co-operation between an addiction care organisation (Novadic) and the Weener Group has been agreed upon. The Weener Group targets at offering paid work and vocational support to persons with different kinds of disabilities. They do so to implement several legal arrangements for increasing participation of these groups at the labour market (GGZ Nederland, 2002).

Health rooms

90 Current health care or addiction care is not accessible for addicted prostitutes. Most of the addicted prostitutes also have other problems and feel uneasy or unsafe in these locations. In Rotterdam, social work service for addicted prostitutes in the streets was organised (PMW, 1999). Fixed consulting hours and regular visits facilitated to contact these women and to motivate and support them for changing their lives. In 1998 48 addicted prostitutes participated, some with dual diagnosis or polydrug use. Most of them (38) had contact with specialised addiction care (a ‘living room’) situated near their ‘work spot’. A third of this target group used methadone. The impression is that these contacts are last resort contacts (avoiding to ‘get lost’ entirely). At best, contacts with regular addiction care facilities are short-term and mostly occur during crises. Supporting this target group in trying to resocialise is crucial: i.e. mediating between clients and guardians, renewing contacts with their children, and maybe later referring them to regular addiction care. Another project (Time out) specifically meant for addicted prostitutes offers a regular and direct accessible day-and-night supportive care facility. Its targets are: keeping contact with this target group, offering solutions for acute problems, and working on a more continuous care provision (National Report 2001, 9.2.1).

Street work in general The grass roots organisation of street workers Mainline Amsterdam is old but still existent. Mainline street workers actively seek contact and try to maintain contact with drug users. In informal contacts they avoid being (too) demanding to drug users. Contacts are primarily meant to give support by loosely giving information about drugs, watching for trends in drug use, and trying to enhance abilities for self-help. Mainline established a prevention project specifically for female drug users (Mainline 2000). Their drop-in centre offers specific services for this user group (hairdressing, workshops on safe sex, overdose training and counselling on contraception). In another project two street workers offer assistance to drug users who are temporary in prison. The first results show much enthusiasm to contact these workers during hours that prisoners are free of obligatory activities. The target is also to maintain these contacts after release from prison.

Pill testing Since 1992, information on the composition (dose, ingredients) of synthetic drug preparations such as XTC pills has been produced by the Drugs Information and Monitoring System (National Report 2001 10f). DIMS tries to answer the following questions: “What substances are appearing on the drug market?”, “What are the health risk of these substances?” and “What are the trends in substance use?” DIMS studies toxico-epidemiological effects of drugs. Drug samples are sent in or collected from fieldwork organisations and drug users or DIMS-participants. At this moment 16 participants are active in 26 cities. The pills are tested at affiliated offices or in a specialised hospital laboratory. Pills containing particularly dangerous ingredients, for example, XTC pills with high dosages of MDMA, have led to successfull warning campaigns aimed at potential users. ‘Danger’ is determined by several predetermined factors such as characteristics, toxicity, dosages found, noticeable effects or dissemination of the samples. In case of dangerous substances other parties are also warned, for instance the Ministry of Health, Welfare and Sport, the Health Inspection, the National Toxicology Information Centre, First Aid Services, etc. (Planije et al., 2001).

User rooms

91 User rooms for chronic hard drug users that are not motivated for treatment. These rooms give the opportunity to use drugs without having to stay in the hectic street scene, avoiding the use of used syringes. User rooms are also initiated to reduce drug-related nuisance. Access is often reserved for users with an identity card. These measures are meant to keep others who can be motivated for treatment away from these rooms. Professionals are looking after the health situation of users by offering food and drinks, toilets and showers, informing them, giving advice, or taking care of clean syringes, condoms, etcetera.

Effects of medical co-prescription of heroin Recently medical co-prescription of heroin for treatment refractory chronic addicts was evaluated (CCBH, 2002). It was concluded that adding heroin to methadone maintenance treatment was feasible, beneficial and safe for this target group. It yielded clinically relevant health effects and criminality was reduced during the full 12-month period. A protocol will be made for prolonging prescription for individual addicts who participated in the experiment. The Mayors of cities that participated in the experiment suggested that heroin co-prescription should be part of regular addiction care. This has not yet resulted in national decision making (cf Van Dam et al., 2002).

Needle exchange Facilities for needle exchange or syringe exchange exist already more than ten years. In all major Dutch cities such exchange services are available. However, most younger opiate addicts do not inject their drugs. These facilities differ in type of drug users, exchange system (one-to-one or otherwise), the organisation (Municipal Health Centres, on streetcorners, etc.), syringe prices, cleaning fluids, bleach, etc.). A structural co-operation between Aids prevention organisations and syringe exchange does not exist. Of primary importance for the use of syringe exchange facilities are privacy or anonymity, low thresholds and no top-down perceived rules, clear-cut constant opening hours, and accessibility.

Case management Case management for chronic addicts with dual diagnosis consist of offering practical and psychological help, supplemented by co-ordination of different care activities for individual clients. Referral to inpatient addiction care may also be part of these activities to reduce escalations or dangerous situations (Wolf et al., 2002). The international literature shows that an effective model of case management is most probably Assertive Community Treatment. This model can be characterised by several criteria: structural (caseload, teamwork, co- operation with other health professionals, etc.), organisational (explicite inclusion criteria, slow admittance of new clients, a 24-hour crisis intervention facility, etc.) and content (support and care is provided in daily client situations, an active approach or interference, high frequency of contacts, etc.). The study of Wolf et al. gives guidelines. The amount of case management interventions for this client group is still unknown.

Alternative medicine For Surinamese drug addicts the pros and cons of implementation of traditional cure done by ‘witch doctors’ (Winti) in regular addiction care has been pondered (Leenders et al., 2001). In several organisations Winti has already been used for specific addicts and their families. Evaluation has not been done and general implementation is not realised up to now.

Networking between HR professionals

92 We know only of informal networking among harm reduction professionals. People know each other from conferences, other meetings or incidental co-operation. Formal networks do not exist. This can be a limiting factor for case management, because a coherent network of addiction care facilities is crucial for success (Wolf et al., 2002). Casemanagers do not have the authority to enforce co-operation among different organisations. This problem does not seem to be exclusively Dutch, nor is it exclusively limited to the world of addiction care. In general inter-staff rivalries will kill necessary collaboration in non-commercial organisations (cf McLellan et al., 1999). The important question remains, what conditions might avoid or reduce these rivalries.

Co-ordination of national policies and local practice Local practice is mainly left to local strategies. This is probably due to our complex and stratified financing system (see 14).

Expenditures on specific harm reduction projects Expenditures on specific harm reduction projects are only partly known. This is probably also due to our complex and stratified financing system (see again for details, chapter 14).

10.1 Description of interventions (in recreational settings, prevention of drug related overdoses and user rooms)

10.1.1 Outreach work in recreational settings

First aid services Safe dance parties do not exist and a prohibition of these events - when drug use is involved - is not effective, because these events would be continued underground. A preferable approach is assumed to be a combination of prevention and cure by monitoring and testing new drugs and offering professional First Aid in case of emergencies (Bruin et al., 1999). Regular monitoring and testing of drugs can quickly prevent the continuation of disastrous effects of pills with dangerous components. The effectiveness of First Aid services at big dance parties has been evaluated. Small teams that are well trained are more effective than bigger teams with a moralistic approach and insufficient knowledge of the possible effects of several drugs.

10.1.2 Prevention of infectious diseases

Dissemination of information/education material

The grass roots organisation Mainline Amsterdam distributes leaflets to drug users and intermediares about the following subjects: tuberculosis, HIV tests, viral load and CD4, safe injecting, hepatitis A to G, and condom use (www.mainline.org).

Safer use training

NO INFORMATION AVAILABLE

93 Outreach to problem drug users, groups at risk

Drug use of immigrants The risk of infectious diseases among North African drug users is high. In North African cultures one is not supposed to talk about drug use and sexual contacts. Preventive activities for these groups are rarely initiated. This is probably because these people are difficult to reach. Many are illegal immigrants. In an experimental peer support project eight male peers were coached by field workers who had contacts with 595 male drug users afterwards. Most contacts with this target group were once-only and the content of this contact remained unknown (see 9.4).

HIV tests HIV counseling and testing for drug users is expensive, but widely available. These interventions require patient compliance. The Amsterdam cohort study showed that the percentage of injecting drug users that was tested for HIV increased from 29% (1989) to 50% (1998). Current policy formulation toward HIV counseling and testing has become more active. Still, regular addiciton care organisations and municipal health services appear to be insufficiently equipped for active HIV testing among (ex)injecting drug users and their families. Pilot projects were recommended (Tiemeijer and Kramer, 2001).

HIV treatment In Amsterdam approximately 30% of the infected users are or were treated (HAART or Highly Active Anti-Retroviral Treatment). Some 50% who started this treatment dropped out, and 50% complained about the treatment regimen. Thus, coverage for this service is highly selective.

Hepatitis B vaccination A free of charge hepatitis B vaccination programme was implemented for drug users and other risk groups (homosexuals and heterosexuals with multiple sexual contacts, included prostitutes). From the intial 14.000 representatives of these target groups, more than half complied to the whole vaccination programme (Steenbergen et al., 2001). For most of them this was done in a specific out patient health care setting of the Amsterdam Municipal Health service. When vaccination was supplemented by personal advice, participation increased considerably (1026 versus 303 participants). Vaccination without personal advice resulted in an increase of participants that were better informed, easy to reach, and motivated homosexual men. Based on these results the Ministry of Health, Welfare and Sport has funded a nation wide implementation of vaccination of high-risk groups that will be evaluated. This project started at November 1st 2002 and will end in june 2006 (GGD Nederland, 2001; Trimbos-instituut, 2002).

Hepatitis C tests Hepatitis C is far more infectious and more than 80% of the infected do not recover from this disease. Approximately 30% will have cirrhosis after 2-30 years. Standard treatment for this disease is Interferon, injected three times a week for six months, with severe side effects and a recovery rate of 25%. Here, patient compliance is generally difficult to maintain. Though the amount of injecting drug use is lowering in the Netherlands, the slumbering long-term effects of this habit among older drug users might become manifest in due course.

94 Prophylactic vaccination of early stage syphilis among (drug using) street prostitutes Addicted street prostitutes in Rotterdam were considered to be an important source of syphilis infection in 1996-1997 by local medical care. Some 75 percent of the prostitutes were hard drug addicts trying to gain money for buying drugs. Streetworkers affirmed that prostitutes that were screened positive for syphilis would not be inclined to engage in a vaccination programme. To shortcut the rapid increase of syphilis it was decided that during one month, a prophylactic vaccination of early stage syphilis (one high-dose injection of benzylpenicilline) among all street prostitutes should be executed, irrespective of the screening results. Co-operation was financially rewarded (11,35 Euro). Screening results indicated that early stage syphilis was most prominent among South American and North African prostitutes (37 and 67 percent). Analysis showed a strong relationship between drug use and syphilis infection. At the end of 1997 no new cases of syphilis infection have been registrated (Bosman et al., 1999).

Reduction of drug-related infectious diseases in prisons Recently the Trimbos Institute published a manual for raising awareness of health problems connected to drug use and drug-related infectious diseases in prisons. Primary target groups are professionals in health services in or outside prison but also social workers, prison officers, peer leaders or inmates can use this book as a source of practical information. At this moment an English and a Russian version are available and a German version is forthcoming.

Peer-outreach

NO INFORMATION AVAILABLE

Secondary Needle Exchange through user networks

NO INFORMATION AVAILABLE

Others

NO INFORMATION AVAILABLE

10.1.3 Prevention of drug related overdoses

Examples of ‘policies’ in overdose-prevention

User rooms are one of the aspects of harm reduction policy and these are (amongst other targets) meant to prevent overdoses.

A research proposal has been sent to the Dutch Health Research and Development Council (ZON/Mw). This study is meant for tracing environments and co-variates of drug overdoses in order to support prevention activities in the future (G. Cruts, personal communication).

95 Examples of specific projects

In former years the Safe Use Kit was successfully distributed and this kit contained a small note “in case of overdose call 06-11” (the central number of the ambulance service). See further user rooms (10).

Projects in high-risk settings

NO INFORMATION AVAILABLE

Documentation, evaluation results, research

The cocaine experiment in Rotterdam This current experiment builds on an earlier project in Rotterdam and its surroundings (‘Take Five’) for motivated cocaine users (Henskens, 1999). It is meant to motivate the group that lives under very bad conditions on the street, the multiproblem crack users. The question is: “Is it possible to motivate these extremely problematic crack users for treatment and to keep them in treatment for a year thus improving their health situation and reducing public nuisance?” The Dutch Health Research and Development Council funded this controlled experiment with 170 treatment-refractory crack users. This target group will be approached by intensive fieldwork. Half of this group will be randomly assigned to motivation treatment and the other 85 receive standard treatment from a separate research team.The control group will be told that they participate in an evaluation of the addiction care in Rotterdam to aviod turmoil. Both interventions last eight to eleven months depending on the time out period. Measurement takes place before treatment, and four and eight months later.The results of this experiment are not available yet.

A study of the Municipal Health Services in Amsterdam searched for explanations of overdoses. One of the main factors appeared to be the risk of periods of abstinence. Habituation of the body to the drug has been reduced. Some relapsing (ex)users take the old dose and this might be fatal (Buster, et al., 2002).

10.1.4 User rooms or safe injection rooms

Definitions and delivery of services

Three types of user room are mentioned in a recent review study (Linssen et al., 2002a): integrated rooms (thirteen of the twenty user rooms in november 2000) with easier access to regular addiction care, seven independent rooms (for users who do not want to be in regular care) and self regulated user rooms (illegal rooms run by the users and co-operating dealers). One integrated room co-operates with the neighbouring methadone distribution point. For the first and second type a maximum capacity is recommended of eight users for the actual user room and fifty for the living room (the get some rest, watch TV, have some food or drinks, etc.) where drug use is forbidden (De Jong, 1996). Separate rooms are sometimes present for staff and for voluntarily isolation (reducing stimuli for reducing side effects of cocaine misuse).

96 Home rules are common. Prohibited are agression, theft, walking to and fro, mutual drugs dealing, and alcohol use. An identity card is compulsory and will be delivered after initial screening. This enables control and punishment possibilies by simple withdrawal of the card (the principle of the stick and the carrot). In many living rooms coffee, tea, sandwiches are supplied, but also free of charge syringes, sterile water, tinfoil, etc.

State of the situation Self regulated user rooms (the so called ‘basements’ in Rotterdam) existed for several years because public nuisance was reduced. Most shut their doors deliberately caused by publicity in the mass media and consequently public arousal. In November 2000 twenty user rooms of the first and second type existed in the Netherlands.

List all services Specified data on all existing individual user rooms are not available. Examples are: De Verwijsplek in the city of Apeldoorn; De Buren and Spanjaardstraat, both in Rotterdam; and De Daeke in Venlo. Some were evaluated.

Key-objectives Being acceptable for hard drug users, reducing drug-related public nuisance, improving harm reduction (health promotion, stimulating safe and controlled drug use, prevention of overdoses and infectious diseases), and improving physical health and psychological well- being of users (Linssen et al., 2002a; 2000b).

User profile Hard drug users who live in the streets. Usually the physical and psychological condition of this group is miserable and they often cause nuisance.

Staffing, budgets In most cases professionals (nursing, social work) but volunteers are also common. The psychological distance between users and health professionals is generally considered to be large. Training in First Aid knowledge is highly recommended. A minimal additional staffing rate (for a capacity of eight users and maximal fifty visitors) is recommended of two controllers, one observer (support and medical care) and one warden.

Documentation, evaluation results, research studies In 1994 two large cities gave the start by deciding to support drug consumption rooms or user rooms (gebruiksruimten) (Meijer et al., 2001). Although opening hours, admittance criteria and surveillance during actual drug use may be different, most user rooms are open all day and select drug users that are registered as resistent to treatment. Access is reserved for drug users with an identity card, thus enabling to keep others who are motivated for treatment away from these facilities. Professionals of regular organisations of addiction care have an important role in these rooms. They are offering food and drinks, toilets and showers, taking care of clean syringes, condoms, etcetera.. They are also prone to inform them or giving them some advice. Users often have a specific caregiver (Biesma, Bieleman and Visser, 1998). Drug dealing is prohibited. The pros and cons of these facilities have been discussed and their utility defended and doubted (De Jong 2000; Fromberg and Linssen, 2000). Several evaluation reports have been published indicating that in general user rooms

97 meet their purpose (Biesma and Bieleman, 1998a; 1998b; 1998c; Biesma, Bieleman and Visser, 1998; Meijer et al., 2001). We give a short description of the results of a recently published systematic review of eight studies of user rooms, both of national (five studies) and foreign origine (Linssen et al., 2002a). All studies were of unsufficient methodological quality: none of these used a control group, pretest-posttest periods were very short or the number of participants was very small. All studies scored on three outcome measures: health, public nuisance and coverage of participants by regular addiction care. All five Dutch studies scored positive on public nuisance reduction, three on improved health (in two other studies this could not be determined) and addicts in two facilities had contacts with regular addiction care (in two other cases this was unclear and in one no contacts existed). By and large this indicates that user rooms might have positive effects on nuisance and probably also on health and regular care contacts.

10.2 Standards and evaluations

10.2.1 Existence of professional standards on HR interventions

Some professional standards for harm reduction activities are developed at this moment, for instance standards for medical heroin co-prescription and for rapid detoxification. Recently guidelines are published for the organisation and design of user rooms (Linssen et al., 2002), for patient placement matching, and for choice of (the route of addiction) care (De Wildt et al., 2002). Both guidelines are products of the five-year policy programme Getting Results (see 8.2, 9).

10.2.2 Evaluation studies on HR measures

Pill testing (see 10)

The Dutch Heroin Trial (effects of medical co-prescription of heroin) Medical co-prescription of heroine for methadone refractory addicts is assumed to improve the quality of life of opiate addicts and to reduce drug related nuisance caused by them. Outcomes were assessed by a Randomised Clinical Trial (RCT) with one year follow-up (CCBH, 2002). Outcome measures were physical health, psychological and social well- being, criminality, nuisance rates, and satisfaction. For heroine smokers the overall index score of successful treatment was 23% higher than for the only-methadone-group. Among injecting users this effect was 25%. Adding heroine to methadone treatment yielded clinically relevant health benefits. Medical heroine prescription appears to be a feasible and safe (no adverse effects) for chronic treatment-refractory addicts. For injectors and inhalers, successful treatment outcomes occur within the first two months of treatment. Injectors responded faster (a maximum success rate within two months) while inhalers improved during the full 12-month period. The majority (81-87%) of the drop outs in the experimental condition deteriorated substantially following discontinuation of the heroin prescription. Two months after discontinuation, mean outcome scores returned to equal dysfunctional levels measured just before starting the experiment. Thus benefits are linked to continuation of treatment (prescription of heroin).

98 A protocol will be developed for prolonged medical prescription to the drug users who participated in the experiment.

Needle exchange

NO INFORMATION AVAILABLE (National Report 2001, 9.2.3)

User rooms The study of Linssen et al. (2002b) also gives guidelines for the organisation and design of user rooms, for selection and admission of members of the target group (by addiction care professionals, the police and neighbourhood inhabitants), house rules (no drinking, no dealing, etc.), personnel (a mix of different professionals when possible), anticipation of relationship with the neighbourhood (explicite agreements, complaint procedures, commitment), safety and hygiene (preventive measures: First Aid attributes, syringes, tinfoil, condoms, etc.) and liability (signing liability contracts by participants).

Needle exchange

NO INFORMATION AVAILABLE (For other examples, see 10)

10.2.3 Training of staff in HR techniques: organisation, access, target groups for training

See 10d, staffing (nurses, social workers). No officially regulated specific training in harm reduction available.

10.2.4 Major research projects on HR topics carried out in the past 5 years

Subjects or main projects (National Report 2001, EDDRA database): • Methadon in maintenance treatment (two-year effects, higher doses) • Immediate detoxification with naltrexone under anaesthesia • Medical heroin co-prescription • Vaccination programmes to prevent infectious diseases • Integrated care, farm work or psychiatric home care for dual diagnosis patients • The Drugs Information Line • The Drug Information and Monitoring System (DIMS) • Parent oriented work to stimulate talking about drugs (‘home parties’, etc.) • The Healthy School and Drugs • Peer education for immigrant users (Moroccan, North African, Moluccan) • Effects of compulsory treatment (Triple-Ex, SOV)

Amount of public research funding available in 2002

NO INFORMATION PUBLISHED

99 11 Treatment

Dual diagnosis

The number of dual diagnosis patients is assumed to be large. Authors in mental health care in the United States report percentages ranging from 20 to 50 and for addiction care the range goes from 60 to 80 (Kessler et al., 1999). In the Netherlands comparable percentages are mentioned (Geerlings and van den Brink, 1995; De Jong et al., 1996). In several regional centres projects are initiated to take care of this target group (Noorlander, 1997; Huygen, Janson, Korteweg Verbeeke, 1997; van Weeghel et al., 1997; Lohuis Bosma, 1998; Nes, 1999; Polstra et al., 1999). Spotting dual diagnosis patients in psychiatric or addiction care is still sub-optimal. The responsibility for these patients is insufficiently recognised by both fields. Patients are often moved to and fro between psychiatry and addiction care, thus rarely meeting sufficient care for their problems. Continuity of care is absent but at the same time there is a growing awareness that “monotherapies” (treating addiction and psychiatric problems separately) are insufficient for helping these people. Besides profesionals in addiction care should be careful with addictive drug therapies (benzodiazepines) for hard drug addicts or high-risks for negative interactions with the drugs taken (MAO-inhibitors) (Van den Brink and Geerlings, 1999a). Co-operation of mental health care and addiction care will be necessary to develop integrated care for this dual diagnosis group (Meeuwesen and Kroon, 2000). Mental health workers are inclined to send people with dual diagnosis to addiction care and workers in addiction care promptly send them back because they cannot handle psychiatric problems (cf the experience with working on a farm, see 10). Existent frontiers between the systems of addiction care and mental health are still difficult to bridge. However slowly, these domains begin to co-operate. Although in all Dutch regions convenants were signed to improve the co-operation between mental helath care and addiction care for dual diagnosis patients, more than half of this patient group thinks that this did not result in improved care Van Rooijen, 2001). Today two wards for inpatient treatment for dual diagnosis exist, offering integrated care, one in the region of Dordrecht, the other in Utrecht. The clinic in the Dordrecht region (Portugaal) opened in 1999. After half a year, workers in this ward were able to categorise these clients (Noorlander, 2000). Most of them are long-term addicts (15 years and more), 70% suffer from severe mental disorders (psychosis, affective disorders, anxiety disorders, ADHD, posttraumatic stress disorder, neurological disorder or Korsakov syndrome). Thirty percent had a personality disorder. Most of the clients had a history of long neglected physical problems (venereal diseases, Hepatitis B and C, HIV, and other illnesses). Many have financial problems, are homeless, or without meaningful relationships. Almost all women and some of the men had experience with prostitution. Some 85% of the clients came voluntarily to this special ward. These people were not admitted to regular settings because specialised diagnostic and treatment knowledge was not available, compulsory admission targeting abstinence or time out and stabilisation was necessary but impossible to organise, family care was absent, or care professionals were plagued by burnout. In short, the absence of offering adequate help for these clients destined them to this ward.

The second clinic (Roosenburg) opened also around 1999 in Den Dolder in the Utrecht region. It is offering twelve beds for a three months stay. The first phase is to observe each client during several weeks during different activities to enable a valid diagnosis. Cure

100 and care is taken care of by professional therapists, a psychiatrist, a physician specialised in addiction problems, and psychiatric nurses. What needs to be treated first is important (mental illness or addiction problems). In most cases it is clear within six weeks which treatment path could best be chosen. Longer detoxification periods are tolerated and relapses are not punished but talked about and treated. (Van Rooijen, 2001).

Recently a systematic review study is published that gives an overview of types of case management for chronic addicts and the effectiveness of this interventions (Wolf et al., 2000). Case management is meant for multiproblem clients such as those in the Rotterdam hospital ward (see above). The report offers a typology of case management and conditions for effectiveness (based on international publications). The scope of this study is broader than dual diagnosis patients and covers also exclusively addicted clients, homeless addicts, and drug use during pregnancy. The results of five effect studies (four with control groups) for dual diagnosis show that case management has small positive effects on patients satisfaction, drug use, psychiatric symptoms, social skills, and utilisation of care.

In an older experimental project for dual diagnosis patients (Hofman et al., 1997) most patients were very difficult to treat in regular psychiatric care and/or they were not accepted. This group existed of deprived persons (no education, partner or job and in several cases also a judicial career). It was assumed that they were in need for after care at home. Of the 26 clients, 24 had earlier psychiatric treatment. The frequency of contacts over the study period was different. 24 clients had less than 100 contacts and two more than 300. Half of these contacts were realised within the care organisation, the other half outside. During this study ten of these dual diagnosis patients were deregistered. Four of them were referred to regular psychiatric or addiction care. This experimental special care was continued as a regular care module in the Northern region.

Private outpatient addiction treatment For already ten years a promising private (outpatient) addiction care unit (“Consistent”) exists in Haarlem delivering care for addicts and their environment, with garantees for anonymity (Elkerbout and Helsloot, 2002). It is the only private ‘clinic’ (or rather an ‘addiction care practice’ of three therapists) in our country, and includes treatment of addiction of all substances and gambling. Individual care, family interventions, brief interventions in small groups and educational meetings on addiction are possible. On request, individual treatment can also be done by e-mail or telephone. During the past ten years 454 clients were treated, 331 had problems with alcohol, 23 with gambling, 12 smoked too much, 8 had eating problems, 6 were addicted to medicines, 25 for polydrug use, 19 came for problematic cocaine use and 4 for cannabis. Twenty-six clients were scored ‘otherwise’. More than half of them were men. Half of the group was 40-60 years old. The education and income level were not reported. Results in the jubilee publication point at the important role of primary health care professionals (general practitioners and psychologists) for treating addicted people, especially for both sides of the continuum, the less problematic and chronic addicts. Care can start within one week after a first contact because precisely at that moment clients are most prone to change their substance use. It is delivered by a co-operative effort of the three professionals. The basic assumption is that this will be more effective than each one working on its own with individual clients. The jubilee book also presents the results from a client evaluation. Unfortunately only a quarter responded to this request.

101 Immediate detoxification of opiates with naltrexone under anaesthetics (EDOCRA) At best standard detoxification programmes cause a temporary reduction of drug use. Non compliance is often substantial and relapses sooner or later occur. Methadone detoxification works slower and increases these risks. Results of some international studies suggest that naltrexone might decrease opiate use quickly but withdrawal symptoms remain a problem. High quality studies are needed to determine the effectiveness of immediate detoxification for Dutch target groups.The Dutch EDOCRA-experiment (a Randomised Clinical Trial) compares the effects of two naltrexone detoxification methods (one with anaesthesia, the other without) followed by (outpatient) standardised aftercare with lower dosages of naltrexone (De Jong et al., 2002). What is the cost-effectiveness of both methods? There appear to be no short-term (one-month) differences in effectiveness of rapid detoxification with naltrexone under anaesthesia and without anaesthesia. Furthermore, detox under anaesthesia is a less safer method and more expensive, Eighty percent of the anaesthesia-group did not use opiates during the first month after treatment. For the non- anaesthesia-group this percentage was 77. Longer-term effects are still under study. Because of the small differences in effectiveness and because anaesthesia is less safe and more expensive. The government has decided that this experiment with rapid detoxification can be continued (total follow-up of 16 months) but without anaesthesia. Final results will be expected at the end of 2003. Therefore, regular addiction care dropped anaesthesia from this type of care. Rapid detoxification under anaesthesia is still a possibility in a private clinic, Miroya. The most prominent argument: addicts are scared of the withdrawal symptoms, thus anaesthesia is a welcome solution for to overcome this barrier (www.miroya.nl).

11.1 Drug-free treatment and health care at a national level

In most cases drug-free treatments (including types of psychosocial support) are part of pharmacological treatments, they complement these (Van den Brink and Geerlings, 1999a; 1999b). The current scientific literature shows that (cognitive) behavioural techniques (i.e. brief interventions such as motivational interviewing in groups or individual) might be most effective (see below). A new development is the start of ‘virtual’ drug free addiction treatment without being part of pharmological treatment. This development is part of the movement to a more client- centered addiction care. The Jellinek in Amsterdam started on its website an online addiction treatment at October 2nd 2002. Everybody can ask questions about reducing drug use or alcohol use on work days 12.00 to 14.00 and from 15.00 to 17.00 p.m., when a professional offers his e-consult (Schoemaker, 2002).

11.1.1 Objectives and definitions of drug-free treatment

The main objective is to complement drug treatments in order to increase the duration of effects and reduce relapse rates. In addiction care, motivational interviewing in (less than) twelve steps is directed at improving patient compliance because compliance is usually quite low (Schippers and De Jonge, 2002).

11.1.2 Criteria of admission to drug-free treatment

102 Specific criteria are not used for drug-free treatments. Drug treatment should be complemented as much as possible with drug-free treatments. If possible, partners and/or family members should be involved, dependent on the phase of addiction of the client and the objectives agreed upon (Van den Brink, 1999b).

11.1.3 Availability, financing, organisation and delivery of drug-free treatment services

NO INFORMATION AVAILABLE

11.1.4 Evaluation results, statistics, research and training

See 11. Guidelines for carrying out motivation interviewing were published earlier (Broothaerts et al., 1999).

11.2 Substitution and maintenance programmes

11.2.1 Objectives for substitution treatment

Stabilisation of the situation of the client, i.e. reducing heroin use, drug-related nuisance, and infectious diseases. Improving physical and psychological health. To stay in contact with hard drug users (Driessen, 1999).

11.2.2 Criteria of admission to substitution treatment

During the past decades the admission criteria for methadone programmes are never specified. Being addicted to heroin for more than six months was enough for entering the programme.

11.2.3 Availability, financing, organisation and delivery of substitution treatment services

Since 1997, methadone distribution has been financed by temporary grants from the Medical Insurance Board (Ziekenfondsraad) covered by the Welfare Act that stems from 1994. This arrangement has been prolonged. The Minister of Health, Welfare and Sport prefers to address a structural financing system as part of the wider problem of expenditures of medication and laboratory tests prescribed by specialised physicians in outpatient facilities. Until that time, temporary subsidies are given to methadone prescription (see 14). The Health Care Assurance Board has evaluated former subsidy regulations for methadone prescription (CVZ, 2001). The Board recommended to end the existing financing system for opiate addicts and to initiate one integrated financing system for addiction care, including the costs of social care and support (housing, work, school, recreational), psychosocial care, health care and prevention, and the costst of combatting nuisance and criminality. Meanwhile the subsidy for methadone prescription for 2003 should be higher in order to be correspondent with the real costs, according to the Board. Finally, under specified conditions the prescription of other medication than methadone should also be funded (ibid.).

Methadone programmes are nowadays offered in all outpatient addiction care institutions and by some municipal health services. Approaches are different in different regions and in the larger cities (National Report 2001, 9.3.2).

103 11.2.4 Substitution drugs and mode of application

In the Netherlands, it has long been common practice to distribute small doses of methadone (an average of 40 mg a day) in maintenance programmes. In Amsterdam during 1985-1998 the mean dosage increased from 41 to 50 mg/day (Langendam, 2000). In the United States, higher doses are common (more than 60 mg a day) in maintenance programmes that had favourable results. Other evidence from a prospective cohort study among 498 injecting harddrug users in Amsterdam suggest that overdose mortality is reduced by low-threshold methadone maintenance programmes but that programmes with higher dosages (more than 55 mg daily) may be more effective (Van Ameijden et al., 1999). For the results of an experiment (see 11.2.7)

11.2.5 Psycho-social counseling

NO INFORMATION AVAILABLE

11.2.6 Diversion of substitution drugs

In former years other substitution drugs have been tried out (LAAM, clonidine and palfium) but these were not successful. The present situation of methadone distribution is not substantially different from the situation in the 1980s, except the current move to high doses.

11.2.7 Evaluation results, statistics, research and training

A recent evaluation of registration data on participants of Dutch outpatient methadone programmes shows that, compared to other drug users, methadone users are ‘poor performers’ and ‘very problematic drug users’ (Van Alem et al., 2001). Methadone users are older than non methadone using opiate users, they stay much longer in care and occupy a relative large proportion of the available care capacity. Methadon users score much lower on some indicators for the assessment of care: still having complaints, still using opiates and still not satisfied. This confirms already published conclusions on this subgroup (Driessen, 1999; Zorg voor de Toekomst, 1999). For other evaluation reports we refer to our National Report 2001 (9.3.2)

Effects of high doses in methadone maintenance treatment In the US higher doses of methadone in maintenance treatment were successful. A Dutch evaluation of high doses of methadone was recently reported (Driessen, 2002). The 247 participants of maintenance treatment on nine spots were random assigned to a high dosage group (more than 84 mg p/day, gradual dosis increase in consultation with the client to a maximum of 160 mg p/day). The second group continued with the usual doses (less than 85 mg p/day). After 22 months, the high dosage group used less opiates than the low dosage group. The first group also scores better for physical and psychological health. Addiction is better manageable with higher doses. Heroin use reduces and the use of other substances stabilises. There are no changes in the social situation. Yet, the chance of serious incidents (suicide attempts and overdoses) is bigger than for the lower dosage group. It is concluded that in the Dutch situation high dosdes of methadone are more effective than the usual lower doses, but preventive activities should be implemented to avoid undesirable incidents. In short, in the Netherlands, higher doses methadone in maintenance treatment also appear to

104 be more effective than low doses. Opiate use is reducing and other drugs are not substituted, thus addiction becomes more manageable. However, additional activities to prevent undesired incidents should be supplemented. The physical situation is much better after 24 months. Their psychological situation improved somewhat less and the social situation did not change.

11.3 After-care and re-integration

Forensic after care A Forensic Addiction Clinic was opened in 1998, intended for imprisoned drug-using recidivists resisting regular care and treatment (IVON, 1998). The treatment programme distinguishes three subsequent stages: an intramural, a semimural and a resocialisation stage. The last stage is similar to ‘supported living’: clients are supported in learning to live independently again after release from prison. Thus it is a long-term programme (National Report 2001, 9.5).

11.3.1 Links with national strategy and legislation

NO INFORMATION AVAILABLE

11.3.2 Objectives, definitions and concepts of reintegration

NO INFORMATION AVAILABLE

11.3.3 Accessibility for different target groups

The accessibility of provisions for after-care is diverse, institution-specific provisions and an overview have not been published, except for one measure, namely Judicial Treatment of Addicts (SOV), formerly named ‘Penal Placement of Addicts in a Penitentiary Treatment Institution’ (National Report 2001). The SOV is meant for chronically criminal addicts (‘revolving-door clients’) . In another (pilot) project, farm work for addicts was initially accessible for nuisance causing addicts, but during the project only addicts were referred to these farms with dual diagnosis that could not be treated in the referring organisations of addiction care (see 10).

11.3.4 Organisation, financing, managing, availability and delivery of services

There is no formal organisation, financing, management or delivery of after-care for addicted people. After-care is in most cases part of broader programmes of addiction care, for instance of the Judicial Treatment of Addicts (SOV).

11.3.5 Statistics, research and evaluation results

Few evaluation studies on after-care are published. Some examples cover vocational rehabilitation (National Report 2001).

105 11.3.6 Training

In 1999 a manual was published for professionals to guide the process of vocational rehabilitation of (former) drug users that highlights important aspects of working at vocational rehabilitation (Ten Cate and Hexspoor, 1999).

12 Interventions in the criminal justice system

According to the National Health Council, national statistics on the percentage of drug users among prisoners are not available. Research in some penitentiary institutions reveal that one third of this population is drug dependent and one third of this group has severe addiction problems and/or polydrug user (mostly heroin and cocaine). The severe group amounts to 10.000-15.000 people (Gezondheidsraad, 2002). The mean length of detention among the addicted is shorter than the total detention population. Drug-related criminality of addicts (‘acquisitive’ criminality) is in general less serious. Half of the addicted detainees is released within two months and three quarter within four months. More than half have been born in the Netherlands and few are female. For assumptions and viewpoints on interventions for drug users in the criminal justice system we refer to our National Report 2001.

12.1 Assistence to drug users in prisons

Drug treatment within the criminal justice system • Re-integration of drug-dependent offenders is an important goal of the judiciary. • Drug-dependent offenders are stimulated to get into treatment, both to improve their own situation as well as to reduce criminality and nuisance. Increasing use is made of the (coercive) authority of the penal law. • Table 12.1 provides an overview of the differentiated treatment options for drug- dependent offenders in custody (both less and more severe options).

106 Table 12.1 Treatment options available to drug-dependent detainees according to phase in the custody chain

Phase in custody Options available to drug-dependent detainees: chain: Pre-detention • Voluntary: Arrest referral schemes While in police custody

Bringing before court Coercive: and • Suspension of pre-trial detention for drug treatment or During court hearing counselling (under special conditions) via pre-trial intervention by delegated judge. • Suspension of court proceedings for a certain period to allow the suspect to access treatment or counselling. • Awarding of a (partly) suspended sentence with the condition to enter a particular treatment or program, specified during the hearing. Mandatory: • Judicial Treatment of Addicts (SOV) During detention Coercive: • Placement in a drug guidance unit • Placement (in a residential clinic) in the framework of Section 43 PBW (Prisons Act) • Participation in a penitentiary program Post-detention • Voluntary: Treatment, counselling and support

• From the moment of arrest until the execution of the sentence, the addict in the criminal justice system can access (voluntary) drug treatment and counselling, take part in programs and courses, and receive support and care. • Drug-dependent offenders are fully encouraged to undergo treatment voluntarily, for example through arrest referral schemes. Since the 1990’s, increasing use is also being made of the coercive measures in the penal law to mandate dependent offenders to enter drug treatment or programs. Participation in a treatment program, for example, forms an alternative to penalties and detention.

The Early Intervention for justiciable addicts (VroeghulpInterventie Aanpak or VIA) and Addiction Guidance Departments (Verslavings Begeleidings Afdelingen or VBAs) are types of assistence for justifiable addicts that recently have been evaluated (see below). The SOV is being evaluated during the coming years. The use of these arrangements has been less than initially expected. This may be caused predominantly by a lack of co-operation of the different organisations that participate in these measures (police, judiciary, organisations for addiction care, and probation). A policy group is active to initiate and support activities to reduce these difficulties (development of a diagnostic instrument, improving the effectiveness of treatments and garanteeing the supply of a wide range of treatments and care).

12.1.1 Abstinence oriented treatments

107 Though all treatment programmes in prison are abstinence directed (National Report 2001) it is recommended for Addiction Guidance Departments to include harm reduction measures as well as to make these departments more attractable for addicts. This would also introduce a shift in current practice of regular addiction care, namely a more practical down-to-earth approach including housing, solving financial debts, social skills training, brief behavioural interventions, and re-integration (Health Council, 2002). Below we shortly describe evaluations of the early intervention approach for justifiable addicts on criminal and addictive behaviour and the long-term effects of drug-free detention programmes (12.3.1).

12.1.2 Substitution treatment

All programmes for justifiable addicts are abstinence directed although guidelines from the Ministry of Justice tolerate methadone treatment for short-term detainees when these already used methadone before imprisonment. In daily practice however, many prison physicians reduce and end methadone treatments. In fact the variations in these treatments in prisons are manyfold, a fact that the Health Council considers undesirable. Consensus driven guidelines are necessary (Gezondheidsraad, 2002).

12.1.3 Harm reduction measures

For Aids prevention within prison walls (see National Report 2001). Prisons have their own medical staff but this is in most cases not concerned with harm reduction activities for drug users (see also above).

12.1.4 Community links

NO INFORMATION AVAILABLE

12.2 Alternatives to prison for drug dependent offenders

See above.

12.2.1 Objectives, organisation, funding and professional resources

See above (for expenditures, see 14).

12.2.2 Accessibility to alternative measures: principles, criteria for admission

See above.

12.2.3 Information strategies

NO INFORMATION AVAILABLE

12.3 Evaluation and training

108 12.3.1 Evaluation results

Early intervention approach Evidently, imprisonment of criminal drug users partly solves public nuisance or criminal acts immediately, but in most cases criminal recidivism occurs after release from prison. Is early intervention (outpatient and inpatient) a solution for this recidivism? Is the stick an effective instrument? Will early intervention increase client compliance? Unfortunately, participation appeared to be low. At follow-up no differences in drug-related nuisance appear between those who participated in early intervention and those who did not participate. The criminality rate remains high. Two third of the participants took part in treatments but did not comply to an entire treatment programme. Usually, outpatient treatment is ended very quickly, and most clinical treatment after a month. More than 75% of these clinical treatments end against the advice of the professionals. Low participation rates imply that the societal effects of early interventions are negligeable.

Long-term effects of drug-free detention programmes Data were compared of 86 male inmates who voluntarily participated in a drug-free detention programme and 42 other drug using detainees from other wings of the same prison not entering this programme. One to two years after release or transfer, this detention programme did not have any positive effect on drug use, recidivism, physical, psychological or social functioning. Drug use and criminal recidivism decreased in both groups (participants and non-participants). Physical, psychological or social functioning did not change substantially in both groups in the same period. On the other hand, participants in a drug-free detention programme were significantly more active in seeking treatment after release from prison. The authors conclude that the significantly higher treatment seeking behaviour in the participant group possibly reflects the high motivation rate of participants (they themselves decided to participate in this drug-free detention programme). Furthermore, it might be questioned if the programme staff was sufficiently equipped to treat the severe and multiple problems of this group.

Judicial Treatment of Addicts (SOV) It has become legally possible to mandate drug-dependent offenders to treatment in a residential facility. The “Judicial Treatment of Addicts” (SOV) Order is presently implemented as a temporary experiment in specially equipped correctional facilities. The SOV is the most severe measure in the entire range of orders that can be imposed on criminal drug users in the justice system. • The order is imposed by a panel of three judges on the request of the public prosecutor, if the suspect: - is a Dutch male; - has committed a crime; - is drug-dependent; - has been sentenced to a prison term at least 3 times in the five years prior to the current offence; - has participated without success in drug treatment in the past; - does not suffer from any serious psychiatric disorders.

109 • The Judicial Treatment of Addicts order has a mandatory term of two years, and three phases: a closed phase of six months, a transitional phase of six to nine months, and a final, open phase outside the facility (after care). • The mandatory treatment of addicts in the criminal justice system (SOV) started in 2001 as a trial project in four different areas: In Rotterdam (start date 1 April 2001, first intake from 1 July 2001, 96 cells); in Amsterdam (start date September 2001, 96 cells); in Utrecht (start date October 2001, capacity 48 cells); and in the South (Arnhem, Nijmegen, Den Bosch, Eindhoven, Maastricht and Heerlen; start date October 2001, capacity 48 cells) (NDM 2002).

Table 12.2 Number of offenders in mandatory drug treatment (SOV) in correctional institutions by status and location. Survey date 26 March, 21 May, and 31 August 2002

Amsterdama Rotterdama Utrechtb Southb Total Mar May Aug Mar May Aug Mar May Aug Mar May Aug Mar May Aug In mandated 27 46 54 19c 25 33 9 15 20 3d 6 14 58 92 121 SOV treatment In SOV 9 0 0 23 0 5 12 0 0 15 0 0 59 0 5 placement & selection phase Total 36 46 54 42 25 38 21 15 20d 18 6 14 117 92 126 a) Cell capacity is 96: 48 for the closed phase, 24 each for the transitional and open phases. b) Cell capacity is 48: 24 cells for the closed phase and 12 cells each for transitional and open phases. c) Two cases are in appeal, one case is in appeal with the Supreme Court. d) One in Arnhem, two in Maastricht.

(Source: NDM 2002)

• The total capacity for SOV consists of 288 cells. • One year after the introduction of the SOV measure (March/April 2002), 58 offenders followed mandatory drug treatment, whilst 59 were in the placement and selection phase. In May and August 2002, the number of mandated SOV offenders has increased. • At present, fewer individuals are in the placement and selection phase of the SOV; most of these persons are detained elsewhere. • At the end of August 2002, 95 participants are in phase 1, and 25 in phase 2. So far, no participants have reached phase 3 of the program. • The effectiveness of this mandatory drug treatment order is still unknown. In September 2001, process evaluation of the SOV started and results will be available in 2004. Final results of the effect evaluation (started in June 2002) are expected in late 2006.

12.3.2 Statistics and research

NO NEW INFORMATION AVAILABLE (National Report 2001, 13)

12.3.3 Training

NO INFORMATION AVAILABLE

110 13 Quality assurance

Quality assurance of health care in general (including addiction care) was settled by enabling legislation (Kaderwet) in 1996, leaving the responsibilities for realisation of quality assurance measures mainly to the addiction care system itself (the principle of self regulation). The most important parts of this legislation are: evidence-based care, specified care policy, a quality assurance system and an annual quality report. After several years improvements appear to require more time than expected (National Report 2001). Evaluators concluded that during the past years quality instruments and procedures were developed, but far less attention has been given to evaluate the effectiveness of the process, the outcomes and costs. The importance of the perspectives and interests of clients is still underrated and the commitment of client organisations is still low. Tasks and responsibilities of both client organisations and assurance companies remain unclear (T.K., 28.439, nr.1). In the field of drug prevention, quality assurance is separately stimulated by the five-year policy programme “Getting Results” (see 8.2, 9). However, legal pressures or sanctions (the National Inspectorate of Health Care) are absent or low. The Ministry decided to start monitoring quality assurance within the health care system (ibid.).

13.1 Description of new trends and developments

NO FURTHER INFORMATION AVAILABLE (see above)

13.2 Formal requirements for quality assurance

There are no formal requirements for quality assurance in addiction care (see “enabling legislation” above).

13.3 Criteria and instruments applied in quality assurance

No specific instruments are used to determine the rate of quality care except training. Training to increase knowledge about quality of (addiction) care for general health professionals is underdeveloped. Training of professionals was probably more frequently realised (National Report 2001). Up to now, the attention paid on addiction issues during basic professional training for physicians, nurses, social workers, psychiatrists and psychologists is insufficient. Possibilities for specific addiction care training courses at university level curriculi have increased somewhat for students in health care. A (new) facultative course in addiction and addiction care for medical students at the University of Nijmegen has been set up and several research institutes and teaching commitments at universities are explicitely directed at evidence-based addiction care and implementation of effective interventions in addiction care. Together with the National Support Centre for Prevention (LSP), the Netherlands Focal Point are organising training sessions for drug prevention professionals in 2003 for the third time.

13.4 Application of quality assurance procedures and results

111 Publications of explicite quality assurance procedures or evaluations are still rare. Recently a guideline was published for intake, patient placement matching, and choice of (route of addiction) care (De Wildt et al., 2002). The objective is to give a checklist for structuring the first phases of client care, matching it to clients needs, client problems, and the appropriate care or route of care. In another study, client satisfaction of outpatient addiction care was determined by interviews (Luijting, 2002). Some conclusions are directed at improvement of: 1) information supply about what clients can expect from cure and care; 2) possibilities for syringe exchange during maintenance treatment delivery, and 3) attention of general practitioners or nurses for physical and psychological health of drug using patients.

Some other activities on a national level are also meant to support quality assurance. Quality assurance in health care is annually monitored as a part of the branch report on mental health. Branch reports are meant to deliver short cut information for Parliament, other policy makers and other stakeholders. These reports cover the following subjects: demand of care, supply and capacity of care, use and productivity of care, funding of care and quality of care. The Trimbos Institute is responsible for the subjects Mental Health (including addiction care) and Homelessness and Social Exclusion (Maatschappelijk Opvang). A new registration system (ZORG-IS) is currently constructed, enlarging possibilities for regular reports of essential data on addiction care in a systematic way. The funds for developing another instrument for improving registration data in addiction care (Analyse Instrument Kwaliteit in Samenhang or AIKIS (National Report 2001) were not continued. Guidelines or protocols to standardise care or prevention activities are not commonly applied and existing protocols or monitoring practices are rarely tested and improved (Instituut voor Gebruikersparticipatie en Beleid, 1999). The Amsterdam Institute of Addiction Research (AIAR) is developing criteria and indicators for a monitoring system for addiction care services. The target is to improve the effectiveness and efficiency of addiction prevention and treatment programmes. Annual reporting about quality management has already been institutionalised in the Jellinek Clinic (National Report 2001).

112 113 PART 4

Key Issues

114 115 14 Demand reduction expenditures in 1999

14.1 Concepts and definitions

In the literature on costs and cost-effectiveness, in general two main types of costs are discerned: direct and indirect costs (cf. Hakkaart-van Roijen, 1998). Direct costs are the costs of the organisation of treatment, care, and drug prevention (personnel, buildings, etc.). In general these costs are relatively easy to trace, calculate or estimate. Indirect costs are in general considered as the costs of losses of economic productivity, caused by mental or physical absenteeism or by mortality. These costs are rarely calculable in a valid way and less easy to estimate. A third type – most difficult to calculate - has been studied for alcohol use in the Netherlands, namely the societal costs or social costs (KPMG, 2001). Examples of three types of social costs are: 1) the costs of criminality, violations of legal regulations or public nuisance (damage to individuals or the environment caused by drug users or by criminals who are engaged in synthetic drugs supplies, the reduced value of real estate near meeting points of drug users, costs of driving under the influence traffic accidents, judicial and health care costs for victims); 2) general health care costs (admissions to hospital or GP care for drug users); and 3) the costs of reduced capacity for daily work (losses of economic productivity caused by drugs, absenteeism and illness, mortality, insurance costs for inabilities to work). Thus, the existent dimensions are not mutually exclusive. Societal costs include the indirect costs that are often mentioned but rarely studied in economic studies. In this paragraph we exclude societal costs (and indirect costs) of drug use because no Dutch reports have been published on this subject (except for alcohol use). It would be interesting however, to compare the societal costs of alcohol and drugs. Second, we excluded the expenditures on activities for reducing drug supplies or the supply of precursors for synthetic drugs. These activities are carried out by the judiciary, the police force, etcetera (see 1.3.3). We focus on direct expenditures or direct costs of treatment, addiction care and drug prevention.

In Dutch publications of costs or expenditures three types of analyses are known: 1) budget analysis on different levels (seldomly done on a sub-national level); 2) analysis of the flow of money from the national budget to activities of cure, care and prevention (see 14.2.1) and 3) estimation of costs based on allocation of money to specific diagnoses (for instance based on the International Classification of Diseases). Budget data on a national level of addiction care are published by the Ministry of Health, Welfare and Sport in the annual report on health care (Zorgnota, 2002). The complex flow of money was presented by the Council of Public Health and Health Care a few years ago (RVZ, 1999) and an analysis of the third type has recently been updated (Polder et al., 2002).

14.2 Financial mechanisms, responsibilities and accountability

14.2.1 Organisation and delivery of drug demand reduction expenditures during the year

Together with the Advisory Report “Regauging Addiction Care” two background studies were published in 1999 by the Council of Public Health and Care. One background study paid attention to the complexity of the ‘flow of money’ (from national, via intermediary to regional

116 or local levels). In figure 14.1 we give a short description of the Dutch financing system.Though the data are from 1997 and 1998, the main picture of this report largely remained unchanged.

Figure 14.1: Flow of governmental expenditures to addiction care: 1997-1998 From national level to intermediary From intermediary to addiction care in million € General Act on Special Disease Management (AWBZ) 59,1 from AWBZ to Regional Care to independent clinics Office 15 from AWBZ to Regional Care to authorised General Psychiatric Hospitals (APZ) Office 2,3 from AWBZ to Regional Care to Consultation Bureaus for Alcohol and Drugs or Office Organisations of Addiction Care for methadone maintenance treatment ? according to the National Health to GPs and pharmacists in Amsterdam for Service Act, via health care methadone maintenance treatment (‘regular assurance companies to GPs and medicine prescription’) Municipal Health Services Municipal targetpayment (Gemeentelijke doeluitkering verslavingsbeleid) 50,9 according to Public Welfare Act to local and regional organisations of addiction 1994, from Ministry budget (VWS) care to selected municipalities for local or regional addiction policy 7,5 Specific funds for reducing public to outpatient addiction care drug-related nuisance Probation 18,4 Ministry budget (Justice) via the to outpatient addiction care National Probation Foundation and the Netherlands Mental Health Organisation 2,3 for the Educational Enactment to outpatient addiction care for execution of the Alcohol to the Foundation for Educational Enactment Alcohol (General Traffic Addiction Funds of the Act) Netherlands Mental Health Organisation ? Other Direct funding by the Ministry of national organisations (the Trimbos Institute, Defacto, the Jellinek clinic) for research and experiments and separate municipal budget funds. Source: RVZ (1999).

It should be noted that these data do not discriminate between expenditures for drugs and for other substances.

The most important sources of funding addiction care are the General Act on Special Disease Management (de Algemene Wet Bijzondere Ziektekosten), the special fund for municipal addiction policy (gemeentelijke doeluitkering verslavingsbeleid), and the probation funds (reclasseringsgelden).

117 Approximately half of the traceable expenditures (more than € 76 million) flows from the cashbox of the General Act on Special Disease Management (AWBZ) to the Regional Care Offices and than to addiction clinics (dependent or independent). From this € 76 million, € 2,3 million flows to organisations of addiction care (formerly Consultation Bureaus of Alcohol and Drugs). Finally an unknown amount is meant for Municipal Health Services for methadone maintenance treatment or for the same purpose, due to the National Health Service Act (Ziekenfondswet), via the health care insurance companies to general practitioners in Amsterdam. A second source of expenditures flows from the budget of the Ministry of Health, Welfare and Sport (based on the Public Welfare Act from 1994) to selected municipalities (Centrumgemeenten) for financing local addiction care activities, social support and crisis teams for women (the special fund for municipal addiction policy). According to the Council of Public Health and Health Care (RVZ) € 58 million of this flow was meant for outpatient addiction care (former Consultation Bureaus of Alcohol and Drugs and other organisations). Furthermore, specific legal regulations resulted in extra expenditures for 24-hour support for fulnerable groups of people (homeless, addicted, neglected). This total of some € 150 million, comes from the Ministry of the Interior and Kingdom Relations, and from the Ministery of Health, Welfare and Sport. It originally targeted social integration and public safety. Today, most of this money is actually spent on homeless addicts (LeClerc and Kornalijnslijper, 2002). Probation money of the Ministry of Justice (more than € 18,4 million) is meant for organisations of the National Probation Foundation and € 2,3 million flows via the Foundation for Addiction Funds of the Netherlands Mental Health Organisation to probation activities. The Educational Enactment Alcohol is also paid with part of this budget.

14.2.1 Interaction between public and private expenditures

NO INFORMATION AVAILABLE

14.2.2 Financial sources and responsibilities

See 14.2.1

14.3 Expenditures at national level (geographical extension)

A second study used the method of cost estimation based on allocation of money to specific diagnoses (International Classification of Diseases). This type of analysis does not discriminate for expenditures of specific ministries but deals with the direct costs of health care (a dutch website gives information on several breakdowns of these data: www.kostenvanziekten.nl). In this analysis the category “alcohol and drug problems” are part of the broader category “psychological problems”. Thus these data do not discriminate between expenditures for drugs and for other substances (Polder et al., 2002). Data are presented for age groups and sex. Table 14.1 gives an example

According to this study the total costs of care for people with drug or alcohol problems were more than € 285 million in 1999. It should be noted that these data do not discriminate between specialised addiction care and care for people with addiction problems in mental

118 health care organisations. Three quarters of this money (some € 215 million) was spent in mental health care, inclusive addiction care. Fourteen percent in nursing and care (i.e. Korsakow), another 6,8% in general hospitals and for medical specialists, 2,8 percent on medication. Other expenditures were small (i.e. 0,7 percent was meant for primary health care.

Table 14.1: Costs of care for alcohol and drugs problems (in € million) Age group Male Female Total 1-14 0,1 0,0 0,1 15-24 11,4 2,8 14,2 25-44 108,5 28,4 136,9 45-64 64,3 26,6 91,0 65-74 17,0 10,2 27,2 75-84 6,4 6,4 12,8 85+ 1,3 1,6 2,9 Total 209,0 76,1 285,1

The annual publication of national health budget data does not give a clear specification of expenditures on addiction care either. Table 14.2 shows expenditures on mental health care, addiction care and social relief activities for the homeless and social excluded (maatschappelijke opvang). For instance, most psychiatric hospitals also include some types of (inpatient) addiction care but the costs are not specified (VWS, 2002). From 1998-1999 the expenditures for addiction care increased with € 2. In 2000 the increase was € 4, a year later € 10 million and € 16 million in 2002. The government decided to enlarge the expenditures on low-threshold outpatient care for alcohol problems with € 2,3 million in 2001, and with an annual € 7,7 million afterwards. Expenditures (in € million) of the Ministry of Health, Welfare and Sport on organisations of addiction care were from 1998 to 2002: 68,9, 74,2, 107,5 and 113,4 (NDM, 2002).

The same table 14.2 from this report shows that systematic data (on cure and care for drug and alcohol problems) are only published for independent addiction clinics. The expenditures in the first and third row are only for a small part valid for addiction care. Thus, these systematic data are insufficient for a valid indication of the costs of addiction care per type of organisation.

Table 14.2: Developments in expenditures addiction care in € million (VWS, 2002) 2001 2002 2003 2004 2005 General Psychiatric 1.646,3 1.693,0 1.762,6 1.794,5 1.805.5 Hospitals Independent Addiction 85,1 89,5 93,1 94,9 94,9 Clinics Organisations of Addiction 252,4 257,7 257,7 257,8 257,8 Care, social relief activities and crisis centres for women

119 Since 1997, methadone distribution has been financed by temporary grants from the Medical Insurance Board (Ziekenfondsraad) covered by the Welfare Act. The Minister of Health, Welfare and Sport prefers to address a structural financing system as part of the wider problem of expenditures of medication and laboratory tests prescribed by specialised physicians in outpatient facilities. Until that time, temporary subsidies are given to methadone prescription. The Health Care Assurance Board has evaluated former subsidy regulations for methadone prescription (CVZ, 2001). The Board recommended to end the existing financing system for opiate addicts and to initiate one integrated financing system for addiction care, including the costs of social care and support (housing, work, school, recreational), psychosocial care, health care and prevention, and the costs of combatting nuisance and criminality. Meanwhile the subsidy for methadone prescription for 2003 should be higher in order to correspond with the real costs. This will reduce the chance that the prescribing organisations choose the cheapest prescription methods. Cheapest does not neccessarily equals most cost-effective. Finally, under specified conditions the prescription of other medication than methadone should also be funded, according to the Board (ibid.).

Between 1994 and 1998 € 96,4 million was spent for reducing drug-related nuisance in 26 municipalities (Bröer and Noyon, 1999).

The total costs of the five-year programme Getting Results (see 8.2, 9) are more than € 2,7 million.

In the Netherlands, drug prevention activities are paid by the municipalities. The annual expenditures on drug prevention activities in the bigger organisations of addiction care (the Jellinek, Novadic and others) are approximately € 450.000 (one million guilders). Smaller ones receive smaller amounts of money. Specified insights in these amounts are absent.

In short, expenditures on addiction care do not fit in a simple system and insight from all sources is difficult to grasp (NDM, 2002; VWS, 2002b). The reported amounts of money show unexplained differences and we lack a general systematic registration. At this moment the Netherlands Court of Audit (Algemene Rekenkamer) is preparing a study on the structure of expenditures in addiction care, but the realisation of it still has to be decided.

14.4 Expenditures of specialised drug treatment centres

A specified overview of the expenditures of specialised treatment centres does not exist and requires a separate study. Annual reports of these organisations often do not publish cost data. Accounting data are not sufficient to gather insights in the total costs. Gathering this data will further be hampered by several restrictions. For instance, due to the many mergers in the past five years, many treatment centres are part of a bigger organisation, often including mental health care organisations. Financial data are not specified for separate treatment centres in the annual reports but restricted to the (merged) organisation as a whole.

The activities of one private addiction clinic (all substances) have been published recently (Elkerbout and Helsloot, 2002) but no budget data were given.

120 Medical co-prescription of heroin was subject to a cost analysis, covering the direct medical costs of this palliative treatment. The estimates are based on the costs of three treatment centres. Overhead costs (charged by the organisations where co-prescription activities were realised) were excluded. Possible cost savings as a result of the medical co-prescription of heroin, and an investigation of the balance between costs and effects will be the subject of future reports (CCBH, 2002). Table 14.3 shows the estimated annual costs devided in costs of personnel (professionals, security and administration), material costs (rent, rebuilding, cleaning, energy and maintenance) and patient-related material costs (heroin or other medical supplies) for three categories of treatment unit size.

Table 14.3: Estimated annual costs (€) of medical heroin prescription treatment units 25 patients unit 50 patients unit 75 patients unit personnel 500.348 712.356 780.513 material 104.500 138.500 172.500 patient-related 65.00 130.000 195.000 total costs 669.848 980.856 1.148.013 total costs per patient 26.794 19.617 15.307

14.5 Conclusions

14.5.1 Problems on information and research related to drug expenditures, gaps and suggestions for future directions in our country

Information on costs of addiction care is not readily available and available cost data are not easy to aggregate and interprete reliably. First, the structure of the flow of money to addiction care is complex and partly unclear. There is growing concern on a reduction of this complexity. Second, different analysis strategies result in different outcomes. Third, addiction care is – partly due to recent mergers in mental health care - often considered as a part of the much broader system of mental health care. Fourth, treatment of alcohol and drug problems are never separated in Dutch cost data, thus cost information on treatment of illicit drugs is not feasible. Recent reports show that reducing the complexity of funding Dutch addiction care might become a political issue for the next future. Pursuing this would imply that several laws will have to be changed (the National Health Service Act and the Public Welfare Act).

14.5.2 Global estimation of ‘Demand reduction expenditures on drugs’

See 14.2.1

14.6 Methodological information

Cost analysis is a separate profession, especially fine-grained cost analyses. The literature shows huge quantities of publications with analyses that might be used for it (i.e. cost of illness studies, cost-benefit studies, etcetera., each with deviant types of analyses).

14.6.1 Limits in data available

121 See 14.2.1

14.6.2 Main studies and research

See 14.2.1

14.6.3 Bibliographical references

Bröer, Ch., and Noyon R. (1999). Over last en beleid. Evaluatie Nota Overlast en vijf jaar SVO-beleid tegen overlast van harddruggebruikers. Amsterdam, Regioplan Stad en Land. Central Committee on the Treatment of Heroin Addicts. (2002). Medical co-prescription of heroin. Two randomised controlled trials. Utrecht, Central Committee on the Treatment of Heroin Addicts (CCBH). CVZ (2001). Evaluatie subsidieregelingen methadonverstrekking 1997-2000. Amstelveen, College voor Zorgverzekeringen (CVZ). Hakkaart-van Roijen, L. (1998). Societal perspective on the costs of illness. Leiden, University of Leyden (published dissertation). KPMG (2001). Kosten en baten van alcoholzorg en –preventie. Eindrapport. Hoofddorp, KPMG Bureau voor Economische Argumentatie. Polder, J.J., Takken, J., Meerding, W.J., Kommer G.J., and Stokx L.J. (2002). Kosten van ziekten in Nederland. De zorgeuro ontrafeld. Bilthoven/Rotterdam, Rijksinstituut voor Volksgezondheid en Milieu (RIVM)/Erasmus Universiteit (EUR). RVZ (1999). Dossier verslaving en verslavingszorg. Achtergrondstudie bij het advies Verslavingszorg herijkt. Zoetermeer, Raad voor de Volksgezondheid en Zorg (RVZ). VWS (2002a). Zorgnota 2002. Den Haag, Ministry of Health, Welfare and Sport (VWS).

122 15 Drug and alcohol use among young people aged 12-18

15.1 Prevalence, trends and patterns of use

15.1.1 General population surveys

The first experimental drugs for young people are legal, tobacco and alcohol. A smaller proportion is going to use cannabis. A small part of these cannabis users also tries other drugs somewhat later. This does not imply that cannabis is an stepping stone to hard drugs (Rigter et al., 2002).

General population Data of the National Prevalence Surveys in 1997 and 2001 have been re-analysed for age groups 12-14 years and 15-17 years, as was requested in the EMCDDA Guidelines (see tables 15.1, 15.2).

Table 15.1: Lifetime prevalence of drug use among young people in 2001 12-14 years 15-17 years boys Girls Total boys girls Total Cannabis 3.7 1.2 2.5 22.5 17.0 19.8 Cocaine 0.0 0.0 0.0 2.3 0.5 1.4 Amphetamine 0.0 0.0 0.0 2.0 1.1 1.6 Ecstasy 0.1 0.0 0.1 3.7 1.7 2.7 LSD 0.0 0.0 0.0 0.1 0.4 0.2 Mushrooms 0.3 0.0 0.2 3.8 1.4 2.6 Tobacco 21.2 20.9 21.0 46.0 50.1 48.0 Alcohol 57.5 50.9 54.3 88.7 87.4 88.1 Source: National Prevalence Survey, CEDRO

Table 15.2: Last month prevalence of drug use among young people in 2001 12-14 years 15-17 years boys Girls Total boys girls Total Cannabis 1.7 0.5 1.1 9.3 3.0 6.2 Cocaine 0.0 0.0 0.0 0.4 0.0 0.2 Amphetamine 0.0 0.0 0.0 0.9 0.1 0.5 Ecstasy 0.0 0.0 0.0 0.9 0.7 0.8 LSD 0.0 0.0 0.0 0.0 0.0 0.0 Mushrooms 0.0 0.0 0.0 0.5 0.2 0.4 Tobacco 6.4 7.5 6.9 24.7 27.0 25.8 Alcohol 28.2 24.6 26.5 74.6 68.3 71.5 Source: National Prevalence Survey, CEDRO

• It is clear from these tables that the use of illegal drugs is fairly low among young people between 12 and 14 years. As expected, cannabis scores highest but hard drug use is almost non-existent. • The percentage of illegal drug users increases steep in age group 15-17 years, but again most users only seem to prefer cannabis. • As expected, alcohol use is much more common in both age groups. The percentage of current users of alcohol was about three times as high among age group 15-17 than age group 12-14.

123 • Compared with the 1997 survey, drug use has remained rather stable in these age group (or even tended to decrease), which contrasts with the increase seen in the other age groups in the general population, especially adolescents of 20-24 years (see 2.2). Figure 15.1 illustrates this trend with regard to cannabis use.

Figure 15.1: Prevalence of cannabis use among young people in 1997 and 2001

cannabis % 25 22,4 19,8 20 12- 14 years 15-17 years

15

10 7,1 6,2 4,3 5 2,5 1,2 1,1 0 LTP 1997 LTP 2001 LMP 1997 LMP2001

Source: National Prevalence Survey, CEDRO

Combined use of illegal drugs and alcohol in the past month Among those young people who had consumed alcohol in the last month, a higher percentage had also consumed cannabis (12-14: 3.1%; 15-17: 8.2%) and tobacco (12-14: 15.2%; 15-17: 31%) in comparison with peers who had not consumed alcohol (cannabis 12- 14: 0.4%; 15-17: 0.8%; tobacco 12-14: 4%; 15-17: 12%).

Students The National Youth Health Survey gives statistics on drug use among young people, mainly on secondary school students aged 12-18 (table A1, 2.2). Comparisons with former surveys show that cannabis use increased steeply from 1988 to 1996. After that year (untill 1999) both lifetime and last month prevalence of cannabis use stabilised at 19% and 15%. The use of other drugs (cocaine, ecstasy, amphetamine) did not show a further increase as well. These data converge with those found in the National Prevalence Survey mentioned above.

Table 15.3 gives an overview of the current (last month) use of alcohol, tobacco and different drugs among students in general and among those who had also consumed cannabis in the last month. It is clear that, both legal and illegal drug use is higher among current cannabis users than students in general.

124 Table 15.3 Last-month use of alcohol, tobacco and drugs among secondary school students of 12-16 yearsa in 1999 All students Current cannabis usersa Alcohol 49,8% 93,0% Tobacco 25,9% 86,0% Cannabis 7,9% 100% Ecstasy 1,2% 11,8% Cocaine 1,1% 10,1% Amphetamine 0,9% 8,4% Heroin 0,3% 2,3% a. Use in the past month. Source: Youth health Survey, Trimbos Institute (Smit et al., 2002).

Another more recent survey confirmed this trend among 12-17 year old students (see chapter 2.2; Ter Bogt et al., 2001). Boys are more frequently users than girls.

A quarter of the students who used cannabis during the last month, used it ten times more or more often. These students purchase cannabis mainly in coffee shops or they get it from friends, but buying cannabis in coffee shop has decreased from 1996 to 1999 since the minimum age had changed from 16 to 18 years in 1996.

Table 15.4: Where do students (12-18 years) usually purchase cannabis? 1996 1999 from friends 41 47 in coffee shops 41 32 from dealers 11 11 from others 5 8 at school 3 1 home cultivation - 2 Percentage of last month users. Source: National Youth Health Surveys

Cannabis consumers often use other (legal) drugs as well (De Zwart et al., 2000). Nine out of ten students who used cannabis during the past month also drank alcohol. This is considerably more than among all students (five out of ten). Consumer rates are correlated with other factors like going out, friends that also use cannabis, truancy, and delinquency (stealing, vandalism, or dodge fare).

Special groups Drug use is higher among students in special schools for secondary education and in truancy support projects (tables A3 and A4 in Annex 2) and among young people visiting bars and dancings. Data on the prevalence of drug use among Amsterdam youth in the nightlife scene is given in table 2.5 of chapter 2. However, most respondents in these surveys were older than 18 years (average age 25 years). Table 15.5 also illustrates that drug use is fairly high among the homeless youth.

125 Table 15.5: Drug use (%) among homeless youth (N=91; 1999)* Drug Lifetime Last month Last 24 hours (daily) Cannabis 96 76 (43) Cocaine 66 36 18 Ecstasy 55 18 1 Mushrooms 50 18 1 Amphetamine 47 10 0 LSD 26 2 1 Heroin 21 11 7 * Young people below 23 years of age who have been homeless for at least three months at the time of the survey and who had slept in at least three different places during that period. Source: Korf et al., 1999

15.1.2 Qualitative research

The European project “Emerging trends in drug use” is meant to develop an “early identification function” for emerging drug phenomena to improve the sensitivity of existing drug information systems of participating countries. As part of this project, youth media, music and the Internet are being explored as potential sources of information. The EMCDDA has a summary of the feasibility study on its website, entitled 'Monitoring youth media as a new source of information for detecting, tracking, and understanding emerging drug trends'.

15.1.3 Perceptions about risks, benefits and image of specific drugs

Perceptions about risks and benefits Dutch data on perceptions of young people of risks and benefits of drug use are rare. Rough indications can be found in some news paper articles. The common belief nowadays is that heroin is for loosers and snorting cocaine for winners. XTC has become normal in recreational settings though users know they should pay attention for misuse because of brain damage risk (NDM, 2002). It is generally conceived (not only among young people) that there is a need of knowing the risks of drug use (see 9.4, the results of the telephone help line). Benefits are probably strongly correlated with targets for use, motives to use, intention to use, actual use, popularity and image (see below). Common motives to use may be rather universal among youth. They cover different reasons, i.e. to forget problems, for pleasure, to satisfy curiosity (experimentation), to be “cool”, to relax, to ‘expand your mind’, or enlarging the chance of being accepted in the peer group (Korf et al., 2002).

Perceptions about the image of drugs Actual drug use is considered an indicator of popularity and in its turn popularity is an indicator of image. Changes in the popularity of specific drugs are difficult to explain. Causal explanations of changes in drug use need specific and expensive research designs. We can only give some data about changes in popularity of specific drugs. Heroin is unpopular in youth culture nowadays. Cocaine was ‘cool’ for a long period and its status seem to be rising together with XTC and GHB use in private environments, clubs, party settings, etcetera (Korf et al., 2002). Recently the European Union Opinion Research Group (EORG) published a report on attitudes and opinions of young people in the Union on drugs (EORG, 2002). This survey covers several subjects, for instance personal use, motivation for trying drugs and difficulties in stopping using them, consequences of drug use, dangers of different substances, sources of information on drugs, and management of drug-related problems. One of the conclusions

126 is that nearly 70% of Dutch youth (15-24 years) is able to purchase cannabis in the vicinity of their home address (The United Kingdom, Spain and Ireland score higher on this subject) whilst young people in most other EU countries buy cannabis at other places. Compared to other countries, curiosity and expected effects was mentioned most frequently (more than 75%) by young people in the Netherlands as a reason for experimenting with drugs. Other countries scored higher on peer pressure, thrill seeking and problems at home. Looking at consequences of drug use, Dutch youth thinks considerably less frequent than their peers in other countries of problems with the law and communicable diseases. They score highest on relief from pain or stress and moderate on mental problems and dependence. Heroin is thought of as the most dangerous drug, compared to ecstasy and cannabis. However, the percentage who thinks drug use “very dangerous” is one of the lowest on heroin (80%), by far the lowest for cannabis (7%), and below the mean (50%) for ecstasy. Finally, the internet and friends are more popular as sources of information on drugs among Dutch youth than specialised drug centres and health professionals. Almost all other EU countries score much higher on the last two sources.

15.1.4 Trends in recent years

See above.

15.1.5 New alternative information sources

In the Netherlands and abroad there are probably hunderds of websites giving information on drugs and drug related matters (personal communication with colleagues in the Trimbos Institute). First, the sites of organisations of addiction care or drug prevention are active on drug education. Second, commercial sites offer (for instance) do-it-yourself kits (tips and tools). Third, myriads of party sites and chatting clubs exist. Many sites offer drug-related information as part of a more general package of subjects. Most sites exist for a short time, disappear or become non-communicative because the hype is over. New ones emerge that are considered “good” among peers and visited frequently. It is not feasible to cover all these sites and even trying to list them is not fruitfull. They might be outdated already. Updated information can be searched by common search machines (i.e. Google). In short, new sites are not always the best ones, or they are the best for a short time (like musical top hits nowadays) because they are initiated and visited by younger people themselves and it is not feasible to predict their course of life (good, fashionable or cool, well known, etc.). An example of a site with many links on different drug-related subjects is the subsite plants & drugs from www.erowid.org. A second example is www.totse.com. An example of a Dutch (sub)site is “drugs”in the site of the Youth Information Point (Jongeren Informatiepunt) (www.jip.org).

The investigators of a recent study on GHB (see 2.2.3) have followed discussions on this “narcotic” drug on one website and registered the most important themes: GHB and alcohol, consequences of dosages, and “What to do in case of a bad trip?”. Unpopular are moral messages or pushing prevention messages, and clearly commercially-based information. Results of a survey (structured interviews) among 72 regular users (at least five times and at least once during the past year) in four regions indicate, that most GHB-users participate in

127 parties, clubs, lounges and afterparties. Though they also do this within their own region they also go quite often to other parts of the country. This indicates that GHB-users are for a large part traveling partygoers. They are a dynamid and nomadic partygroup. (Korf et al., 2002).

15.2 Health and social consequences

15.2.1 Deaths and overdoses

Drug-related deaths among young people aged 12-18 seem to be rare. In 2000, Statistics Netherlands recorded four males between 15 and 19 years, who died from accidental poisoning by heroin (1x) or other unspecified psychodysleptic drugs (1x), or poisoning of undetermined intent by other and unspecified dysleptics (1x) or cocaine (1x).

15.2.2 Hospital emergencies

The Municipal Health Service in Amsterdam registers the number of non-fatal drug-related emergencies. As far as recreational drugs (cannabis, ecstasy etc.) are concerned, the youngest person who became unwell in 2001 was 21 years. Published data from the Dutch Hospital Registration (Landelijke Medische Registratie) are not age-specific, thus this would require a separate study.

15.2.3 Driving accidents

The legal age for driving in the Netherlands is 18 years so this age group falls outside the target group.

15.2.4 Demand for treatment

A small-scale clinic (Bauhuus) for young addicts (13-18 years) is targeting at individualised intensive care for this target group (Strijker et al., 2001). The results of a programme evaluation of Bauhuus are published. Addiction is a contraindication for admission, both in youth care and in mental health care or psychiatry. And conversely, psychiatric problems are a contraindication for admission in addiction care facilities. Furthermore, clients in regular addiction care are in most cases adults. Thus young addicts are by-passed in youth care and psychiatry when addiction is an important problem. At the same time they are by-passed in addiction care when psychiatric problems are involved. The mean period of stay in Bauhuus is three months. The mean age at admission is lower than in former years (1993-2000) and the number of admissions increased over this period. Treatment in Bauhuus has three phases. First, structuring and appeasing daily client life. In this phase the degree of freedom is reduced and clients are checked on drug use by urinalysis, and on other problems (individual, family, friends). A multidisciplinary team takes care of treatment modalities (adolescent psychiaty, family therapist, and others). Clients have individual tutors. Risk factors for drug use are reduced (truncy, unemployment, recreational activities). In the second phase, clients are enabled to exercise with more freedom and responsibilities. Targets are: going to school, having daily work and supporting social contacts outside scenes, and family support. Thirdly, clients co-operate in a detachment plan

128 and in determining the needed type of after care. During all phases crisisintervention (time out) is possible. The programme evaluation answered four questions. 1. Coverage: What are the characteristics of the target group and are these congruent with client group characteristics? A wide range of problems were measured among clients and their parents with validated instruments (CIDI, SCL-90, CBCL, ASI and other instruments) covering addiction, family relations, behaviour, psychological complaints, personality, and psychiatric problems. The outcomes were compared with measurement values of norm groups, clinical groups, and youth in organisations for judicial treatment. In general the client group appear to equal largely the target group, i.e. youth with a serious problems on different levels. 2. Needs of specialised care: What are the characteristics of the organisation and do these differ from the other regional organisations? Data were used on the history of the client (addiction, problems), supply of different types of care in three provinces (including many more regions), and a questionnaire survey about treatment centres. The results indicated that existent organisations did not cover adequately the needs of this client group and that Bauhuus could have an important function in these regions. 3. Client and parent satisfaction: What kind of treatments and care are involved? Do these satisfy clients and parents? After discharge, parents were satisfied of the quality of the programme, but their children judged moderately positive about their stay in Bauhuus and the treatments. The drop out rate was comparable to that of regular addiction care treatment facilities. During a follow-up measurement their mean judgement scores declined to ‘neutral’. Their mean scores on school or work situation had improved compared with the discharge date, and they used less or no drugs. Behaviour problems were also reduced. The Bauhuus is an “open” inpatient youth care organisation situated in an ordinary quarter of the city. To combat the drop out rate, the authors recommend to change it in a more close setting, thus reducing the stimuli coming from the city and that might be seducing. Finally, a follow-up study should use a control group to assess the effectiveness of this treatment programme (ibid.).

For additional information about effectiveness of treatment services for young people with drug problems we refer to a recent international review study (Burniston et al., 2002).

15.3 Demand and harm reduction responses

15.3.1 prevention programmes and campaigns

A serial on TV was specifically meant for young people and drug use (‘Out of your mind’). One objective was to correct prejudice against drug use among young people. There still is considerable attention for extreme users while the majority of young people only use drugs incidentally during weekends. Mass media messages often cause prejudiced views of drugs and drug use among TV watchers, especially parents. The serial did not aim at propagating drug use nor did it want to be paternalistic in its approach. The target was rather to give honest information about the pros and cons, thus trying to break the sheer negative myth on drug use and to stimulate young people and parents to talk about this subject. At the end of each TV session the telephone number of the Drugs Information Line is presented.

129 In February 2000 the Minister of Health started a nation wide new mass media campaign (Slik!?) to prevent substance abuse among youngsters and adolescents. This campaign was advertised by radiocommercials (popular youth channels), several journals and newspapers. Leaflets were spread over all schools and several other organisations. At the same time a video (undertitled in English) accompanied by an implementation letter for teachers was available. The first publicity peak lasted a few weeks and was accompanied by interviews and comments on radio and TV and in the printed press. These activities have enabled a new agenda setting of substance abuse among young people. However, additional local and regional activities in- and outside school, and in the family remain necessary to stimulate behaviour change (National Report 2001, 9.1.6).

Evaluation of the public campaign ‘Drugs, don't fool yourself’ (Drugs, laat je niks wijsmaken) was aimed at determining coverage and appreciation of this campaign, and finally stimulating seeking information about drugs and drug addiction among parents and their older children (see 9.3.3). The ultimate aim was to improve parenting skills and family discussions about these subjects. More than 40% of the youngsters saw at least one of the TV spots and a quarter had heard one of the radio spots. One third of the parents had heard about this campaign via TV or radio. More than 90% of the parents and the youngsters thought it a good initiative, and knowledge about drugs is important for 85-90% of them. A quarter of the parents wants more information. Two thirds of the parents and 60% of the youngsters will call the Drug Info Line when they want to know more about drugs. More than half of the youngsters did not know in advance where to go for this information and 1,3% of them have actually called the Drug Info Line. The second round of this campaign started on October 28th (Dijkhuis, 2002).

Another parent-directed type of prevention programme is peer support for parents in low SES neighbourhoods to prevent child drug problems (see 9.4). Low threshold peer meetings using the ‘tupperware strategy' are held in living rooms of neighbourhood peers with large neighbour networks, to improve their knowledge about drugs and drug use and to enlarge parenting skills.

In some bigger cities school-based prevention projects have been set up under auspicien of the local police (National Report 2001, 9.1c). Some programmes are directed exclusively at children in the highest grades of primary schools in different cities (e.g. the project ‘Doe effe normaal’ in Rotterdam), others at students of primary and secondary schools in Amsterdam. These educational interventions have not been systematically evaluated. Yet, the content of the message of the first prevention program has been adapted recently because it aroused too much fear in children.

The most common type of school-based drug prevention is the national programme The Healthy School and Drugs (see 9.1.2). This programme exists already for more than ten years and has been evaluated in 1998 (National Report 2001, 9.1.2). Some short-term regional or local school-based initiatives exist that are not evaluated up to now. One of these small scale programme types is Safety at School (Veiligheid op School). It organises one-day workshops for students who start secondary school, resulting in the creation of a prevention poster. Participants are the police, the municipal health service (GGD), prevention workers of the regional organisation of addiction care and specific youth care. A second variant is The Safe School (De veilige School) in which the municipality, the police and schools co-operate

130 in offering prevention of drug use and drug-related criminality. Each school has a school consultant (teacher) with three day training who is a contact person for the other organisations in order to start preventive initiatives (not specified) and to initiate local policy measures. In many regional and local programmes the police force or specific (neighbourhood) police officers also participate but it remains unclear what specific activities are delegated to them or done by them (9.4).

The bulk of current drug use by youngsters in the Netherlands can be characterised as recreative drug use, mainly during weekends (10.1). A number of on-the-spot activities were organised at places where youngsters spend their free time. In 1998, the Trimbos Institute developed a comprehensive approach and launched a working plan called ‘Going out and drugs’ (National Report 2001, 9.1.3). In co-operation with the Ministry of Health, Welfare and Sport and a number of regional organisations, a plan was developed to structure demand reduction activities by developing effective activities for different settings outside school where youngsters use drugs, such as coffee shops, discotheques, parties and clubs, and places where major musical events are organised. Activities are to be adjusted to the local situation and ought to keep pace with the dynamics of youth culture and current hypes in drug use. Three life spheres are assumed to be highly influencial in youth: school, outside school (peers and leisure) and the family. Twenty activities are part of this comprehensive programme. Those meant for outside school are: a convenant with coffee shops, meant to commit the owners to drug prevention activities, prevention educational course for personnel of coffee shops, preventive activities in coffee shops, prevention policy for youth work, development of preventive methods for children of immigrants, and region-specific public campaigns. Meant for use in school are: supporting coherence between the school activities, drug prevention lessons, methods for spotting drug users and guiding them, implementing general agreements on drug use at school, stimulating parent participation, and participation of trusted students, social resistance training, and approaching premature school-leavers. Furthermore there are parent courses in ‘talking about drugs with your kids’, support for immigrant parents, educational materials and preventive activities for inpatient youth care.

The National Support Centre for Prevention (LSP) has twice coordinated drug prevention activities during annual Youth Exhibitions (Megafestatie). This exhibition covers very diverse aspects of youth life and attracted some 150,000 to 200,000 youngsters (National Report 2001, 9.1.3). Participants in peer projects contacted young visitors of the exhibition. Prevention workers both from regular organisations and ‘street workers’ were informing interested visitors. Computer games on subjects such as XTC or alcohol and electronic tests of knowledge on drug-related subjects were used. In 1998, around 18,000 young people visited the information stand, talked to consultants, gathered information materials and played educational games. More than 2,500 completed a questionnaire. In 1999, an Internet site related to the exhibition was visited by 1,800 youngsters. This year no drug prevention activities were undertaken at the Megafestatie.

A three-step experimental neighbourhood-based programme has been evaluated (National Report 2001, 9.1.4.). Target groups (and interventions) in this project are: 1) youngsters of 16-20 years who regularly visit a youth joint in the neighbourhood (target: peer produced video-show on the risks of alcohol and drug abuse); 2) intermediaries, i.e. youth workers, volunteers, the municipal police, the neighbourhood council, and other stakeholders (target: training course on attitudes to alcohol and drugs and skills in observing abuse); 3) local residents (target: a special information day co-organised and performed by youngsters). It

131 was expected that co-operation between organisations that have interests in youth problems would be enhanced. Unfortunately the quality of this programme was insufficient to determine effects. Afterwards it was concluded that targets were insufficiently specified and only a small part of the neighbourhood youth was reached (i.e. visited the video-construction sessons). Training courses were followed by all youth workers who unanimously affirmed the importance of the methods and content. Effects on the young residents on, knowledge and attitudes of alcohol and drug abuse, could not be determined validly due to a considerable drop out rate. The effects on expertise of the intermediaries also remained unknown.

15.3.2 Specific harm reduction interventions in parties, including pill testing

(see 10.1)

15.3.3 Other demand reduction responses

NO INFORMATION AVAILABLE

15.4 Methodological information

15.4.1 Limits in data available

Several information systems do not report data in age groups, for instance the data base on drug related deaths or overdoses. Age group-specific data sometimes require a separate analysis of existent data systems. See further 15.1.5.

15.4.2 Bibliographical references

Abraham, M.D., Cohen, P.D.A., Kaal, H.L. (2002). Licit and illicit drug use in the Netherlands, 2001. Amsterdam, Mets. Bogt, T. ter, Van Dorsselaer, S., Vollebergh, w. (2001). Roken, drinken en blowen door Nederlandse scholieren (11 t/m 17 jaar). Kerngegevens middelengebruik uit het Nederlandse HBSC-onderzoek. Utrecht, Trimbos-instituut. Burniston, S., Dodd, M., Elliott, L., Orr, L., and Watson. L. (2002). Drug treatment services for young people: A research review. Scottish Executive Drug Misuse Research Programme, Effective interventions unit. (downloadable from: www.isdscotland.org/goodpractice/effectiveunit.htm) Korf, D.J., Nabben, T., Leenders, F.R.J., Benschop, A. (2002). GHB. Tussen extase en narcose. Amsterdam, Rozenberg Publishers. NDM (2002). Nationale DrugMonitor. Jaarbericht 2002. Utrecht, Bureau NDM. Rigter, H., Van Laar, M., Rigter, S., and Kilmer, B. (2002). Cannabis: feiten en cijfers anno 2002. Utrecht, Nationale DrugMonitor (Backgroundstudy Cannabis). Strijker, J., Boersma, C.J., Zandberg, Tj., Rink J.E. (2001). Jong en verslaafd. Onderzoek naar nut en noodzaak van intersectorale behandeling voor verslaafde jongeren in het Bauhuus. Groningen, Rijksuniversiteit Groningen (RUG), PPSW. Zwart, W.M. de, Monshouwer, K., and Smit, F. (2000). Jeugd en riskant gedrag. Kerngegevens 1999. Roken drinken, drugsgebruik en gokken onder scholieren vanaf tien jaar. Utrecht, Trimbos-instituut.

132 133 16 Social exclusion and reintegration

16.1 Definitions and concepts

16.1.1 Concepts and definitions

The Social and Cultural Planning Office of the Netherlands (SCP) monitors social exclusion by means of the Poverty Monitor. The Poverty Monitor not only covers financial discrimination, but also non-financial discrimination (Uunk and Vrooman 2001). • Financial discrimination manifests itself in bad situations with regard to work, health, housing, and social contacts, more modest means, and lower life satisfaction. • Examples of non-financial discrimination are discrimination due to ethnicity, old age, and physical or mental health problems.

In the Netherlands, social exclusion is not exclusively defined as financial discrimination. Instead, the focus is on non-financial discrimination.

16.1.2 Arisen issues

The Netherlands have a long historical tradition of being tolerant for different cultural groups. Within the 'pillarized society' of the fifties and before, each cultural group was allowed its own 'pillar'. With regard to immigrants, the Netherlands, just like the United Kingdom and Sweden, are an example of "civic pluralism". In a country with civic pluralism, "new citizens are allowed to retain their cultural identities and express them and the interests related to them in the public sphere, including core institutions". Moreover, in the Netherlands, within the historical "Dutch tradition of pillarization, the government's policies provided for a large degree of autonomy for 'ethnic minorities' in the cultural sphere, incorporated minority elites into the policy process through subsidization of representative organizations and their inclusion in the policy deliberation and implementation processes" (Koopmans and Statham, 2001).

The traditional Dutch policy of giving each cultural group its own place in a 'pillarized multicultural society' was expected to combat social exclusion. During the past years, however, the critical issue has arisen that this policy may have had an adverse effect for new immigrants. Giving each cultural group its own place may not have prevented social exclusion, but may even have reinforced it. Koopmans and Statham (2001) signal that in the 1990s "the realism set in that maintaining group diversity could also mean structuring disadvantage for those groups". Duyvené de Wit and Koopmans (2001) conclude that the Dutch experience shows that too strong an emphasis on cultural differences goes at the cost of reintegration. The Netherlands currently experience a growing public opinion stating that, for a proper social integration, all citizens and inhabitants should at least adhere to some Dutch core values and standards (in Dutch: waarden en normen). What those essential values and standards are, is still under discussion.

134 16.1.3 Vulnerable groups

Vulnerable for social exclusion are the lowly educated, the unemployed, the homeless, and immigrants from Moluccan, Turkish, Moroccan, Surinamese, Antillean, and other origins.

16.2 Drug use patterns

16.2.1 Prevalence of drug use

Due to incomplete data, it is not yet certain whether immigrants and Dutch natives differ in drug use. Only for cannabis, the National Prevalence Survey (NPO) in 1997 found a slightly higher last-month prevalence among immigrants: 4.1% for immigrants compared to 2.2% for native Dutch (Eland and Rigter 2001). Nonetheless, the Council for Public Health and Health Care (RVZ 2000a) signals a high prevalence of addiction problems among different ethnic groups. Conversely, the proportion of immigrants among drug addicts is higher than the proportion of immigrants among the total population (RVZ 2000b). Table 16.1 shows these proportions. Moreover, the numbers of immigrants who register with outpatient drug services are greater than the numbers that could be expected based on the proportion of the population (Eland and Rigter 2001). Probably, immigrants in general less frequently use drugs, but if an immigrant does use drugs, there is a greater chance to become addicted.

Table 16.1: Proportion of immigrants and native Dutch among the total population and among drug addicts Proportion among the total Proportion among drug Ethnic origin* population addicts Moluccan 0.3% 3.6% Antillean 0.6% 6% Moroccan 1.3% 11.2% Turkish 1.6% 5.6% Surinamese 1.7% 16% Native Dutch 93% 50% *Ethnic origin according to country of birth or country of birth of parent(s). Source: RVZ (2000b).

For the period from 1994 through 1998, a cohort study was conducted to compare immigrant and native clients in outpatient addiction care (Vrieling at al. 2000). At the start of the cohort study it was found that Moluccans, Surinamese and Moroccans show an above average problem with heroin. Antilleans show an above average problem with cocaine and Moroccans with cannabis (Eland and Rigter 2001). For example, 53% of the Moluccan clients registered for a primary problem with heroin, compared to 13% of the native Dutch clients. Table 16.2 shows these percentages for the specific ethnic groups and the specific addiction problems.

135 Table 16.2: Distribution of primary addiction problem of immigrants and native Dutch over alcohol-, heroin-, cocaine-, cannabis-, and gambling addiction* Primary addiction problem Ethnic origin** Alcohol Heroin Cocaine Cannabis Gambling Moluccan 9% 53% 9% 2% 23% Antillean 26% 24% 34% 6% 7% Moroccan 15% 41% 10% 12% 20% Turkish 26% 20% 9% 8% 36% Surinamese 22% 41% 14% 4% 15% Native Dutch 51% 13% 5% 6% 19% *Medicines and some drugs are not reported, and therefor the total is less than 100%. **Ethnic origin according to self-identification with an ethnic group. Source: LADIS cohort study 1994-1998, IVV/IVO (Vrieling et al. 2000).

The National Monitor on Homelessness (MMO) covers the sector for homelessness and social inclusion. The MMO monitors, inter alia, addiction problems among the homeless. Including addiction to alcohol and gambling, it was found that from the homeless leaving a relief centre in 1999, 25% had entered with addiction problems. From the homeless entering a relief centre in 2000, 19% had addiction problems (again including addiction to alcohol and gambling). Estimations of the percentage of homeless having drug problems range from 20 to 58% (Wolf et al. 2000; Wolf 2001). The city of The Hague was monitored from November 2000 until March 2001. For homeless people that were sometimes not sheltered in a relief centre but out on the streets, the last-month prevalence of drug addiction was 53%. For homeless people that were not out on the streets but sheltered in a relief centre, this prevalence was only 4% (Reinking et al. 2001). Table 16.3 gives further figures.

Table 16.3: Prevalence of dependence or abuse among the total population of the Netherlands and the homeless in The Hague Substance of Total population of Homeless people out Homeless people in dependence or abuse the Netherlands on the street a relief centre Life-time prevalence Alcohol 28.3% 47.4% 43.0% Drugs 4.1% 68.0% 19.4% Alcohol and/or drugs 78.4% 52.7% Last-month prevalence Alcohol 8.5% 21.6% 15.1% Drugs 1.2% 52.6% 4.3% Alcohol and/or drugs 65.0% 17.2% Sources: Nemesis; City of The Hague, Reinking et al. 2001.

16.2.2 Patterns of use

For the homeless people in The Hague that are actually out on the streets, the following last- month prevalences were found: 59% for heroin, methadone, or cocaine; 35% for cannabis; and 31% for other drugs like amphetamines, hallucinogens, solvents, pills, and medicines. For the homeless that were not out on the streets but sheltered in a relief centre, the last- month prevalences were lower: 4% for heroin, methadone, or cocaine; 13% for cannabis;

136 and 22% for other drugs like amphetamines, hallucinogens, solvents, pills, and medicines (Reinking et al. 2001). Table 16.4 gives the figures for drugs as well as alcohol.

Table 16.4: Prevalence of substance use among the homeless in The Hague Homeless people out on the street Homeless people in a relief centre Life-time Last-month Life-time Last-month Substance use prevalence prevalence prevalence prevalence Alcohol (any amount) 59.8% 35.1% 66.7% 32.3% Alcohol (>5 consumptions) 49.5% 25.8% 49.5% 18.3% Heroin, methadone, cocaine 71.1% 58.7% 20.6% 4.3% Cannabis 54.6% 35.1% 32.3% 12.9% Other drugs* 50.5% 30.9% 33.3% 21.5% Combination** 74.2% 56.7% 23.7% 8.6% *Other drugs are: amphetamines, hallucinogens, solvents, pills, medicines. **Combination excludes alcohol any amount. Sources: City of The Hague, Reinking et al. 2001.

16.3 Relationship between social exclusion and drug use

16.3.1 Indicators of social exclusion

The Poverty Monitor applies the following indicators for social exclusion (Uunk and Vrooman 2001): • a marginal educational level: • illiteracy • bad command of the Dutch language • a marginal position on the labour market • social isolation • geographical isolation in stigmatised neighbourhoods • no admission to social key-institutions for care, social security, and welfare • deviation from the mainstream culture with regard to work ethic.

16.3.2 Data from research

On the different indicators of social exclusion, the following results have been found (Uunk and Vrooman 2001): • Educational level: compared to native Dutch, ethnic minorities more often have only finished primary education. • Language command: among the Turks 37% and among the Moroccans 27% often have difficulty to carry on a conversation in the Dutch language. • Labour market: vulnerable for marginal positions are women, youngsters, people with low education, and non-western immigrants. • Social isolation: vulnerable for social isolation are people with a low income (especially the unemployed), and the elderly.

137 • Geographical isolation: compared to native Dutch, Turks, Moroccans, Surinamese, and Antilleans more often live in stigmatised neighbourhoods. • No admission to social key-institutions: vulnerable for no admission are the homeless, among which people with debts, the unemployed, drug- and alcohol addicts, and young drifters. • Cultural exclusion: vulnerable for a deviating work ethic are people above 50 years, inhabitants of the four large cities (Amsterdam, Rotterdam, The Hague, and Utrecht), immigrants, singles, and single parents.

To explain homelessness, Wolf (2002) stresses that social as well as individual factors are involved. Homelessness may, for example, result from too complex a society on the one hand, and an individual's vulnerability for addiction on the other hand. Exclusion and self- exclusion reinforce one another, that is social and psychological factors interact during the process of "settling out" (in Dutch: "uitburgeren"). Conversely, social exclusion may lead to problematic drug use, but conversely problematic drug use may lead to social exclusion. Since a causal link in both directions is plausible, it would be very difficult to establish precisely to what extent social exclusion has evoked problem drug use and to what extent problem drug use has led to social exclusion. Nonetheless, given the fact of a certain amount of social exclusion of vulnerable groups like immigrants and the homeless, social exclusion will partly explain problematic drug use among those vulnerable groups.

As reviewed above, an indicator for social exclusion is "no admission to social key- institutions", like health and welfare institutions. In institutes for outpatient addiction-care, immigrants show a higher percentage of dropouts. From the Turkish clients, for example, 71% drop out, compared to 'only' 53% from the native Dutch clients (Eland and Rigter 2001). This indicates that immigrants have problems to consolidate their admission to health institutes like institutes for addiction care. Table 16.x gives the dropout rates for specific groups.

Table 16.5: Dropout rate of immigrants and native Dutch in outpatient addiction care Ethnic origin* Percentage dropout Moluccan 58% Antillean 66% Moroccan 74% Turkish 71% Surinamese 77% Native Dutch 53% *Ethnic origin according to self-identification with an ethnic group. Source: LADIS cohort study 1994- 1998, IVV/IVO (Vrieling et al. 2000).

16.4 Political issues and reintegration programmes

16.4.1 Policies

As a member of the European Union, the Netherlands are committed to establish a National Action Plan (NAP) to combat social exclusion. The first NAP was set up in June 2001. Groups that are vulnerable for drug abuse are, among others, school dropouts, unemployed

138 ethnic minorities, homeless persons, and inhabitants of vulnerable neighbourhoods in the large cities. Among others, the NAP has planned to halve the number of school dropouts in 2010, to halve the difference in unemployment between ethnic minorities and native Dutch, to diminish the number of homeless persons, especially young drifters, and to strengthen the social infrastructure in the vulnerable neighbourhoods in the large cities (Uunk and Vrooman 2001).

16.4.2 Elements of treatment

In the Netherlands, especially the outpatient addiction care is deeply rooted in social work. A major goal of outpatient addiction care has always been to keep clients integrated with society as much as possible (Van der Stel 1995). Treating the addiction problem goes hand in hand with social reintegration programmes with regard to financial reconstruction, debt restructuring, housing, and practising social skills for maintaining social contacts and finding and keeping an appropriate job.

16.4.3 Specific reintegration programmes

In the Netherlands there is a broad supply of programmes for problem drug users and their social environment to prevent further social exclusion and to support social reintegration. Some salient programmes are the following: • In social boarding houses for homeless addicts, social reintegration is stimulated by appealing to their own responsibility for keeping their boarding houses in good repair (Huijbregts 1999). • Providers of personal e-mail addresses for homeless addicts support that they remain in contact with municipal and social-welfare institutes (Langelaan 2000). • Safe user rooms for homeless addicts prevent further social exclusion by stimulating them to use their drugs in a way that is more acceptable for their fellow men living or working in the same neighbourhood (Van Rooijen 1999). A guidebook has been established for organising a safe user room (Linssen et al. 2002). • Specialised old people's homes for drug addicts that are aged 55 and over, stimulate the social integration of ageing drug addicts within a common neighbourhood (De Wit 1999). • Specialised addiction clinics in which drug clients are treated together with their children, keep these drug clients in contact with their children and prevent further social exclusion of these children (Bakker 1999). • Cooperations between employer's federations, job centres, municipalities, and institutes for addiction care create suitable work for urban addicts, and stimulate their social reintegration (Hemels 1999). Other work programmes for addicts are established on the countryside, in rural estates or at farms (zorgboerderijen) (Prins 2000). Such work programmes at the countryside can be the last stage of a Judicial Treatment of Addicts (SOV) (Schoemaker 2000). The Netherlands Association for Mental Health Care (GGZ Nederland 1999) has established a guidebook to support counsellors in finding suitable work for addicts. Some institutes for addiction care cooperate with organisations that are specialised in labour reintegration (Langelaan 2002a). • For addicts that have committed crimes, there are special work programmes (Hofman 2001). There are also special work programmes for addicts that cannot yet take the responsibility for a structural job. As day labourers, those addicts can apply for low- threshold jobs that only last one day (Langelaan 2002b).

139 • Relief centres for addicted prostitutes not only offer a time out for a few weeks of rest, but also support starting a new life (Maatjes 2000). • Institutes that apply the Liberman Modules for double trouble clients, who not only suffer from addiction but also from psychosis, prevent their further social exclusion (Langelaan 2001). Moreover, some clinics are specialised in treating clients that have dual diagnoses (Van Rooijen 2001). • Special courses for imams about drugs and addiction care are meant to prevent that the Islamic community remains isolated from institutes on addiction care (Schoemaker, 2002a).

16.4.4 Results from outcome evaluation

In 2003 it will be evaluated to what extent the goals of the National Action Plan (NAP) have been reached (Uunk and Vrooman 2001).

The last phase of the Judicial Treatment of Addicts (SOV) is a reintegration programme, for example a work programme. The Trimbos Institute currently evaluates the SOV.

During the spring of 2001, 52 case-management projects were counted that co-ordinated addiction care and social service for chronic addicts with multiple problems. In the coming years, the National Monitor on Homelessness (MMO) will evaluate some of these case- management projects (Wolf et al. in press).

The work programme "Baanberekenend" reached 136 clients with severe addiction problems and separated from the labour market. Results of an outcome evaluation showed that almost a quarter of the clients has found a paid job. From the remaining clients, almost half improved their perspective on the labour market (Michon et al. 2000).

The learn and work programme "Triple-Ex" targets at addicts that have committed crimes. A total of 116 former clients of Triple-Ex participated in an outcome evaluation. It was found that, after leaving the programme, almost half of the clients has had a job, and 87% did not have problems with regard to labour (Vermeulen et al. 2000).

Five Dutch studies have been conducted on the effects of safe user rooms. Given the methodological limitations of these studies, no hard conclusions can be drawn yet. Nonetheless, there are indications that safe user rooms promote contact between addicts and institutes for addiction care, reduce public nuisance from addicts, and thus reduce social exclusion. However, it is assumed that safe user rooms are only effective when public support is garanteed (Linssen et al. 2000).

16.5 Methodological information

16.5.1 Limits in data available

Eland and Rigter (2001) notice the following limitations in the available data about immigrants:

140 • The various definitions of the term 'immigrant' hamper a comparison of the sparse data from research and registration systems. • Various registration systems (monitors) require improvement or expansion of mapping the problem of immigrant drug users. More targeted surveys are needed to uncover groups of immigrants, with varying drug use patterns. • Inpatient registration systems are incomplete because not all institutes participate, and apply a narrow, limited definition of 'immigrant'. • Insight into the addiction and drug treatment 'careers' of both native Dutch and immigrant users is still lacking.

16.5.2 Main studies and research

In general, the Poverty Monitor of the Social and Cultural Planning Office of the Netherlands (SCP) covers social exclusion on all indicators for all vulnerable groups. It will also be evaluated to what extent the National Action Plan (NAP) has reduced social exclusion (Uunk and Vrooman 2001).

More specifically, it is common for some organizations that supply data to the National Drug Monitor to collect data on indicators of social exclusion. It is common practice to investigate drug use among socially excluded groups. Van Laar et al. (2001) give an overview of the "main projects for monitoring addiction and substance use in the Netherlands from a public health perspective". The following projects pay special attention to indicators of social exclusion: • the National Prevalence Survey (NPO) • the Region and City Monitor on Alcohol and Drugs (MAD) • the National Youth Health School Survey • the Antenne Monitor • the Netherlands Mental Health Survey and Incidence Study (Nemesis) • the Central Methadone Registration (CMR) • the National Alcohol and Drugs Information System (LADIS).

The newly developed system "Zorgis" for inpatient addiction care, will also collect data on ethnic origin (Van Rooijen 2002; GGZ Nederland 2002).

For the homeless, the National Monitor on Homelessness (MMO) covers drug use and addiction problems (Wolf et al. 2000).

16.5.3 References

Bakker, H. (1999). De Herberg; Verslaafde ouder met kind in behandeling. Psy, 3, (5), 10-13. Coumans, A.M., Neve, R.J.M., and Van de Mheen, H. (2000). Het proces van marginalisering en verharding in de drugscene van Parkstad Limburg. IVO, Rotterdam. De Wit, R. (1999). Opvanghuis oudere verslaafden in startblokken. Psy, 3, (1), 5. Duyvené de Wit, Th., and Koopmans, R. (2001). Die politisch-kulturelle Integration ethnischer Minderheiten in den Niederlanden und Deutschland. Forschungsjournal Neue Soziale Bewegungen, 14, (1), 26-41. Eland, A., and Rigter, H. (2001). Immigrants and drug treatment; Background study National Drug Monitor. Bureau NDM, Utrecht.

141 GGZ Nederland (1999). Handleiding arbeidstoeleiding van verslaafden; Hoofdlijnen, achtergronden en details. GGZ Nederland, Utrecht. GGZ Nederland (2002). GGZ-Zorggegevensset 2003. GGZ Nederland, Utrecht. Hemels, I. (1999). Banen in Heerlen; Ondernemers in actie voor drugsverslaafden. Psy, 3, (7), 28-29. Hofman, O. (2001). Normaal leven; Werkzame drang voor verslaafden. Psy, 5, (6), 14-16. Huijbregts, V. (1999). Dak- en thuislozen; Zelfbeheer als therapie. Psy, 3, (8), 28-30. Koopmans, R., and Statham, P. (2001). How national citizenship shapes transnationalism. A comparative analysis of migrant claims-making in Germany, Great Britain and the Netherlands. Revue Européenne des Migrations Internationales, 17, 63-100. Langelaan, M. (2000). E-mail voor zwervers. Psy, 4, (12), 4. Langelaan, M. (2001). Nee tegen alcohol en drugs. Psy, 5, (8), 6. Langelaan, M. (2002a). Verslaafden aan het werk. Psy, 6, (7), 20. Langelaan, M. (2002b). Ondernemer Van Strien: 'Zonder euro's geen inhoud'. Psy, 6, (9), 12- 16. Linssen, L., De Graaf, I., and Wolf, J. (2002). Gebruiksruimten in beeld; Handreiking bij de organisatie en inrichting. Ontwikkelcentrum Sociaal Verslavingsbeleid/GGZ Nederland, Utrecht. Linssen, L., De Jong, W., and Wolf, J. (2000). Gebruiksruimten; Een systematisch overzicht van de voorziening en de effecten ervan. Trimbos-instituut/Ontwikkelcentrum Sociaal Verslavingsbeleid, Utrecht. Maatjes, H. (2000). Vrouwenopvang Hera; Rusthuis voor heroïneprostituees. Psy, 4, (9), 29- 31. Michon, H., Rondez, M., and Van Weeghel, J. (2000). Een werkend middel; Evaluatie van Baanberekenend; Arbeidstoeleidingsproject voor mensen met een verslavingsachtergrond. Trimbos-instituut, Utrecht. Prins, E. (2000). Zorgboerderij; 'Ze brengen een hoop gezelligheid'. Psy, 4, (11), 31-35. Reinking, D., Nicholas, S., Van Leiden, I., Van Bakel, H., Zwikker, M., and Wolf, J. (2001). Daklozen in Den Haag; Onderzoek naar omvang en kenmerken van de daklozenpopulatie. Trimbos-instituut, Utrecht. RVZ (Raad voor de Volksgezondheid en Zorg) (2000a). Interculturalisatie van de gezondheidszorg. RVZ, Zoetermeer. RVZ (Raad voor de Volksgezondheid en Zorg) (2000b). Allochtone cliënten en geestelijke gezondheidszorg. RVZ, Zoetermeer. Schoemaker, B. (2000). Strafrechtelijke Opvang van Verslaafden; Resocialiseren op een landgoed. Psy, 4, (2), 16-19. Schoemaker, B. (2002a). Praten over drank en drugs in de moskee; Cursus voor imams. Psy, 6, (10), 9-11. Uunk, W.J.G., and Vrooman, J.C. (2001). Sociale uitsluiting. In Armoedemonitor 2001, pp. 139-162. SCP/CBS, Den Haag. Van der Stel, J.C. (1995). Drinken, drank en dronkenschap: Vijf eeuwen drankbestrijding en alcoholhulpverlening in Nederland; Een historisch-sociologische studie. Verloren, Hilversum. Van Laar, M., De Zwart, W., Rigter, H., Van Alem, V., Cruts, G., Knibbe, R., Korf, D., and Willemsen, M. (ed.) (2001). 2000 Annual Report NDM. Bureau NDM, Utrecht. Van Rooijen, M. (1999). Gebruiksruimten; Keurig snuiven en spuiten. Psy, 3, (9), 17-19. Van Rooijen, M. (2001). Dubbele diagnose kliniek: Zendingswerk. Psy, 5, (14), 24-29. Van Rooijen, M. (2002). Allochtone cliënten apart registreren. Psy, 6, (4), 11.

142 Verdurmen, J.E.E., Toet, J., and Spruit, I.P. (2000). Alcohol- en druggebruik in de gemeente Utrecht. Trimbos-instituut, Utrecht. Vermeulen, K.T., Hendriks, V.M., and Zomerveld, R. (2000). Drangbehandeling in Den Haag; Evaluatieonderzoek naar de effectiviteit van het behandelprogramma Triple-Ex voor justitiabele verslaafden. Den Haag, Parnassia Addiction Research Centre (PARC). Vrieling, I., Van Alem, V.C.M., and Van de Mheen, H. (2000). Drop-out onder allochtonen in de ambulante verslavingszorg 1994-1998. Houten/Rotterdam: IVV/IVO. Wolf, J. (2001). Monitor Maatschappelijke Opvang; Jaarbericht 2001. Trimbos-instituut, Utrecht. Wolf, J.R.L.M. (2002). Een kwestie van uitburgering. SWP, Amsterdam. Wolf, J., Elling, A., and De Graaf, I. (2000). Monitor Maatschappelijke Opvang; Deelmonitoren Vraag, Aanbod en Gemeentelijk beleid. Trimbos-instituut, Utrecht. Wolf, J., Planije, M., and Thuijls, M. (in press). Case management voor langdurig verslaafden met meervoudige problemen.

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Data Bases/Software/Internet addresses

Databases/Software

See Annexes (1st columns of the tables)

Internet addresses in the Netherlands or mentioned in this report (* = also information in English)

Government bodies

Ministry of Health, Welfare and Sport* http://www.minvws.nl/

Ministry of Justice* http://www.justitie.nl/

Minstry of the Interior and Kingdom Relations* http://www.minbzk.nl/

174 Ministry of Foreign Affairs* http://www.minbuza.nl/

Question & Answers Drugs 2002 (full text document): http://www.minbuza.nl/default.asp?CMS_TCP=tcpAsset&id=00C5B06F1D8A4A788A330B9F 87D0FB02

Support and Information Point Drugs and Safety (SIDV) http://www.sidv.nl/ Research institutes

Trimbos Institute. Netherlands Institute of Mental Health and Addiction* http://www.trimbos.nl/

2002 Cannabis Report (full text document): http://www.trimbos.nl/trimbos/Cannabis2002 Report.pdf

CEDRO. Centre for Drug Research* http://www.cedro-uva.org/

IVO. Instituut voor Onderzoek naar Leefwijzen & Verslaving* http://www.ivo.nl/

RIVM. National Institute for Public Health and the Environment* http://www.rivm.nl/

National Health Compas http://www.nationaalkompas.nl/

Information on Drugs

DrugsInfo http://www.drugsinfo.nl/

De Jellinek http://www.jellinek.nl/

Mainline* http://www.mainline.org/

Jongeren Informatie Punt (JIP) http://www.jip.org/

Information on drug treatment www.miroya.nl

International

Erowid http://www.erowid.org/index.shtml

175 Totse.com http://www.totse.com/

Drug Misuse in Scotland: Good practices http://www.isdscotland.org/goodpractice/effectiveunit.htm

176 177 ANNEXES

ANNEX 1: Drug monitoring systems and data sources

The main sources of information on drug use in the Netherlands are given below.

Monitoring drug use Survey Scope Measurements Organisation National Drug Use National, Dutch 1997, 2000/2001 CEDRO, University of Survey (NPO) population of 12 years Amsterdam, with Statistics and older Netherlands Local Monitor Alcohol Population of Utrecht, 1999 (first round) Trimbos Institute, IVO and and Drugs (MAD) Rotterdam, Parkstad- University of Maastricht Limburg 16-69 years; sites will be expanded National Youth Health National, students of 1984, 1988, 1992, 1996 Trimbos Institute, with Survey primary and secondary and 1999* municipal health services schools (10-18+ years) National Youth Health National, students of 1990, 1997 Trimbos Institute, with Survey ‘Special’ special schools and municipal health services participants in truancy and committees of school projects truancy projects Antenna Survey Amsterdam youth, incl. annual since 1993, but Institute Bonger, students and frequency depends on University of Amsterdam occasionally other target group and Jellinek Prevention groups * In 2001, the HBSC-study provided (comparable) data on the use of cannabis

Monitoring treatment demand Information system Scope Population Organisation Last reporting year LADIS. National alcohol & National Outpatients of specialised IVV/IVZ 2000 drugs information system addiction care and treatment centres PiGGz. Inpatient register National Inpatients of mental health care Prismant 1999* mental health care institutions, incl. addiction clinics. ICD-9 diagnosis LMR. National Information National Inpatients of general hospitals Prismant 2001 System on Hospital Care ICD-9 diagnoses and Day Nursing CMR. Central methadone Amsterdam Methadone clients Municipal Health 2001 register region Service of Amsterdam * Since 1997 the data are not complete. Trends in inpatient treatment demand are therefore not reliable. System will be replaced by another system (ZORG-IS).

178 Monitoring diseases and mortality Information system Target group and scope Organisations responsible

HIV monitoring Injecting drug users in different RIVM towns AIDS registrationa Injecting drug users IGZ Cause of Death Statisticsb National, people listed in the CBS population register a) Will be replaced in 2002 by an HIV/AIDS registration system. b) Mortality among Amsterdam drug users is recorded yearly by the Amsterdam GG&GD.

Monitoring the drugs market Project ‘Target group’ Report Organisations responsible Drugs Information and Composition of party Yearly Trimbos Institute, with Monitoring System (DIMS) drugs offered by drug treatment consumers agencies THC Monitor THC content and price Yearly Trimbos Institute of cannabis samples from coffees shops.

179 Annex 2: Additional tables

Table A1: Lifetime use of drugs among students of 12-18 years at secondary schools cannabis Ecstasy amphetamine Cocaine heroin mushrooms 1988 8 - - 1 - - 1992 15 3.3 2.1 1.5 0.7 - 1996 21 5.6 5.1 2.9 1.1 4.3 1999 20 3.8 2.8 2.8 0.8 3.8 -: not measured. Source: National Youth Health Survey (De Zwart et al., 2000).

Table A2: Last-month use of drugs among students of 12-18 years at secondary schools cannabis ecstasy amphetamine cocaine heroin Mushrooms 1988 3 - - 0.4 - - 1992 7 1 0.6 0.4 0.2 1996 11 2.2 1.9 1.1 0.5 1.5 1999 9 1.4 1.1 1.2 0.4 1.2 -: not measured. Source: National Youth Health Survey (De Zwart et al., 2000).

Table A3: Use of drugs among students of 12-18+ years at special schools in 1997 cannabis ecstasy amphetamine cocaine heroin Mushrooms LTP 24 9 7 4 2 8 LMP 14 4 3 2 1 3 LTP = lifetime prevalence. LMP = last month prevalence. Source: Stam et al., 1998.

Table A4: Use of drugs among youth participating in truancy projects in 1997 cannabis ecstasy amphetamine cocaine heroin Mushrooms LTP 56 30 25 14 4 18 LMP 35 15 9 5 1 7 LTP = lifetime prevalence. LMP = last month prevalence. Source: Stam et al., 1998.

Table A5: Number of drug client registrations at outpatient addiction centres Year opiates cocaine ampheta- cannabis medicines ecstasy others total mines 90 15282 1498 244 913 798 315 19050 91 16171 1743 271 1174 833 322 20514 92 16645 2015 395 1533 844 283 21715 93 17171 2240 519 1749 696 162 22537 94 17748 3026 588 2157 690 29 168 24409 95 18062 3555 649 2465 607 228 118 25726 96 19102 4066 739 2941 601 428 173 28050 97 21645 5231 934 3678 623 514 163 32788

180 98 22300 5998 1043 3739 598 392 156 34226 99 24017 8028 997 3804 675 306 147 37974 00 22658 8241 747 3947 659 281 125 36658

Table A6: Number of admissions to inpatient addiction services ICD-9 codes 1990 1991 1992 1993 1994 1995 1996 1997** Opiates 304.0, 304.7, 305.5 2089 2455 2495 2672 2774 3128 3055 1493 Cocaine 304.2, 305.6 106 123 151 168 236 323 364 387 Cannabis 304.3, 305.2 71 82 141 149 177 291 309 323 Amphetamines 304.4, 305.7 21 29 43 46 30 54 58 47 Hallucinogens 304.5, 305.3 9 4 10 8 9 8 3 4 Other* see below 472 475 636 671 650 703 798 523 Total 304, 305.2-9 2768 3168 3476 3714 3876 4507 4587 2777

(continued) ICD-9 codes 1998** 1999** Opiates 304.0, 304.7, 305.5 1236 688 Cocaine 304.2, 305.6 374 388 Cannabis 304.3, 305.2 177 160 Amphetamines 304.4, 305.7 39 25 Hallucinogens 304.5, 305.3 18 0 Other* see below 198 246 *Other = Dependence on barbiturate type medicines (304.1), other drugs (304.6), combination excluding morphine-type drug (304.8), unspecified drugs (304.9), and nondependent abuse of barbiturates and tranquillisers (305.4), antidepressants (305.8), other, mixed or unspecified drugs (305.9). **incomplete data. Inpatient services include addiction clinics and specialised departments of general psychiatric hospitals. Source: PiGGz, Prismant

Table A7: Number of admissions to general hospitals for main diagnosis Substance(s) ICD-9 codes 1996 1997 1998 1999 2000 2001 Opiates 304.0, 304.7, 305.5 71 71 76 79 75 81 Cocaine 304.2, 305.6 53 55 50 65 67 81 Cannabis 304.3, 305.2 38 26 29 29 24 38 Amphetamines 304.4, 305.7 29 33 25 21 29 36 Hallucinogens 304.5, 305.3 15 21 27 7 16 23 Other* See below 200 195 188 221 245 195 Total 304, 305.2-9 406 401 395 422 456 454 Source: Dutch Information System on Hospital Care and Day Nursing (LMR), Prismant (former SIG/NZi).

181 Table A8: Number of admissions to general hospitals for secondary diagnosis Substance(s) ICD-9 codes 1996 1997 1998 1999 2000 2001 Opiates 304.0, 304.7, 305.5 607 742 596 627 558 634 Cocaine 304.2, 305.6 246 371 363 383 377 451 Cannabis 304.3, 305.2 154 184 195 247 193 249 Amphetamines 304.4, 305.7 46 80 69 66 61 58 Hallucinogens 304.5, 305.3 22 28 23 26 22 27 Other* See below 555 557 521 499 499 507 Total 304, 305.2-9 1630 1962 1767 1848 1710 1926 *Other = Dependence on barbiturate type medicines (304.1), other drugs (304.6), combination excluding morphine-type drug (304.8), unspecified drugs (304.9), and nondependent abuse of barbiturates and tranquillisers (305.4), antidepressants (305.8), other, mixed or unspecified drugs (305.9). Source: Dutch Information System on Hospital Care and Day Nursing (LMR), Prismant.

Table A9: Number of acute drug-related deaths in the Netherlands according to EMCDDA standard* Males Females Total 1985 46 11 57 1986 55 13 68 1987 42 12 54 1988 46 5 51 1989 46 10 56 1990 60 10 70 1991 70 10 80 1992 60 15 75 1993 60 15 75 1994 67 20 87 1995 51 19 70 1996 83 25 108 1997 88 20 108 1998 94 16 110 1999 95 20 115 2000 104 27 131 * See 3.2.1 for the selections of codes. Source: Causes of Death Statistics, Statistics Netherlands (CBS).

182 Table A10: Summary of drug seizures in the Netherlands in 1995-2001* 1995 1996 1997 1998** Quantity Quantity Number Quantity Number Quantity Cannabis – kg 332 086 102 951 1 790 65 587 2 781 126 159 Nederwiet – plants 549 337 1 272 526 296 553 135 299 353 178 Cocaine – kg 4 851 9 222 1 005 11 495 1 232 8 998 Heroin – kg 351 516 812 999 835 784 MDMA – tablets* 48 418 1 498 940 310 847 052 583 1 163 514 MDMA - kg* 277 703 1 506 MDMA – liters* 32 250 MDEA – tablets - 800 636 41 23 627 * * Amphetam.- tablets 850 1 025 225 102 240 242 409 Amphetam. - kg 45 324 225 815 1 450 LSD- trips 305 32 320 29 27 594 15 35 964

Table A10 (continued): Summary of drug seizures in the Netherlands in 1999- 2001* 1999* 2000 2001 Number Quantity Number Quantity Number Quantity Cannabis – kg 14 909 110 341 9 243 39 920 33 419 Nederwiet – plants 582 588 661 851 884 609 Cocaine – kg 3 391 10 361 2 676 6 472 8 389 Heroin – kg 1 552 770 1 833 896 739 MDMA – tablets* 154 3 663 608 125 5 500 000 125 3 684 505 MDMA - kg* 50 632 113 MDMA – liters* 445 MDEA – tablets * * Amphetam.- tablets 45 847 20 592 Amphetam. - kg 853 293 579 LSD- trips 2 667 9 972 28 731 Total 14,535 *Figures of drug seizures must be interpreted with great caution, because only registered seizures are included, some regions are missing, and the reliability and validity of the data are uncertain. Trends may not be inferred from these data. ** Since 1998 and 1999 MDA, MDMA, PMA, 2-CB and MDE have been taken together under ”MDMA”.

Other facts reported for 2001: • The USD detected 35 production locations of synthetic drugs • In 2001, the number of dismantled marijuana plantations was 2,012 • The largest amount of cocaine (68%) was seized by the Customs and Netherlands Military Constabulary.

183 Table A11: Population* of the Netherlands on the 1st of January 2001 Males Females Total Age group (times 1000) (times 1000) (times 1000) 00-04 years 512 489 1001 05-09 years 509 487 996 10-14 years 501 479 981 15-19 years 477 454 931 20-24 years 487 476 963 25-29 years 564 555 1119 30-34 years 672 646 1318 35-39 years 677 651 1328 40-44 years 626 610 1235 45-49 years 578 564 1143 50-54 years 601 581 1182 55-59 years 444 431 875 60-64 years 369 374 743 65-69 years 306 337 644 70-74 years 248 310 559 75-79 years 181 275 455 80-84 years 99 189 288 85-89 years 44 114 158 90-94 years 13 45 58 >= 95 years 2 10 13 Total 7910 8077 15987 *Population times 1000 inhabitants. Source: Statistics Netherlands (CBS).

184 ANNEX 3: LIST OF ABBREVIATIONS

2C-B 4-bromo-2,5-dimethoxyphenethylamine 4-MTA 4-methylthioamphetamine ADAM Arrestee Drug Abuse Monitoring system ADHD Attention-Deficit/Hyperactivity Disorder AIAR Amsterdam Institute for Addiction Research AIDS Acquired Immune Deficiency Syndrome APZ General Psychiatric Hospital ASI Addiction Severity Index AWBZ General Act on Special Disease Management BMC Bureau for Medical Cannabis CAD Consultation Agency for Alcohol and Drugs CAM Coordination Centre for the Assessment and Monitoring of NewDrugs CAPI Computer Assisted Personal Interview CBCL Child Behaviour CheckList CBS Statistics Netherlands CCBH Central Committee on the Treatment of Heroin Addicts CEDRO Centre for Drug Research CIDI Composite International Diagnostic Interview CIT Community Intervention Trial CMR Central Methadone Registration CVS Client Monitoring System CVZ Health Care Insurance Board DIMS Drugs Information and Monitoring System DMS Drugs Monitoring System DOB 2,5-dimethoxy-4-bromoamphetamine DSM Diagnostic and Statistical Manual of Mental Disorders EMCDDA European Monitoring Centre for Drugs and Drug Addiction EU European Union FADO Forum of Alcohol and Drug Researchers FIOD Fiscal Intelligence and Investigation Department GGD Municipal Health Service GG&GD Area Health Authority GGZ Nederland Netherlands Association for Mental Health Care GHB Gamma-hydroxy-butyrate GMR General Mortality Register HAART Highly Active Anti-Retroviral Treatment HBV Hepatitis B HCV Hepatitis C HIV Human Immune Deficiency Virus HKS Defendant Recognition System (of the Police) ICD International Classification of Diseases, Injuries and Causes of Death IDUs Intravenous Drug Users IGZ Health Care Inspectorate IMC Inpatient Motivation Centres INC International Narcotics Control Board IPSER Institute for Psycho-Social and Social-Ecological Research IVO Addiction Research Institute Foundation IVV Foundation of Information on Addiction Care IVZ Care Information Systems Foundation KLPD National Police Agency

185 LCI National Co-ordination Team for Infectious Diseases LADIS National Alcohol and Drugs Information System LMR National Information System on Hospital Care and Day Nursing LSD D-Lysergic acid diethylamide LSP National Support Centre for Prevention LTP LifeTime Prevalence LMP Last Month Prevalence LYP Last Year Prevalence MAD Region and City Monitor on Alcohol and Drugs MBDB N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine MDA Methylene-dioxyamphetamine MDEA Methylene-dioxyethylamphetamine MDMA 3,4-methylene-dioxymethamphetamine MEK Minimal Evaluation Kit MMO National Monitor on Homelessness NAP National Action Plan NDM National Drug Monitor NEMESIS Netherlands Mental Health Survey and Incidence Study NFI Netherlands Forensic Science Institute NIGZ National Institute for Health Promotion and Disease Control NPO National Drug Use Survey/National Prevalence Survey PiGGz Inpatient Register Mental Health Care PMA Paramethoxyamphetamine PREFFI Prevention Effectiveness Instrument RCT Randomised Controlled Trial/Randomised Clinical Trial RGO Health Research Council RIKILT State Institute for Quality Control of Agricultural Products RIVM National Institute for Public Health and the Environment RODIS Rotterdam Drugs Information System RVZ National Council for Public Health and Care SAMHSA Substance Abuse and Mental Health Services Administration SES SocioEconomic Status SIDV Support and Information Point Drugs and Safety SCL Symptom CheckList SCP National Institute for SocioCultural Studies SOV Judicial Treatment of Addicts SVO Steering Committee for the Reduction of Nuisance TBC Tuberculosis THC Tetrahydrocannabinol UNRAB University of Nijmegen Research Group on Addictive Behaviours USD Synthetic Drugs Unit VBA (Drug-free) Addiction Guidance Departments VBD Drugs Information Bureau VNG Association of Netherlands Municipalities VTV Centre for Public Health Studies VWS Ministry of Public Health, Welfare and Sports WHO World Health Organisation WODC Research and Documentation Centre of the Dutch Ministry of Justice XTC Ecstasy ZON/MW Dutch Health Research and Development Council/Medical Sciences ZORGIS Registration System on Mental Health Care

186 ANNEX 4: LIST OF TABLES

Table 2.1: Drug use (%) in the Dutch population of 12 years and older in 1997 and 2001 Table 2.2: Minimum estimates of the number of current drug users in the Netherlands in 2001 Table 2.3: Experienced drug use among ever users (25 times or more) in the Netherlands in 1997 and 2001 Table 2.4: Consumption of cannabis among current users in the Netherlands in 1997 and 2001 Table 2.5: Drug use (%) among visitors of coffee shops, pubgoers and clubbers/ravers in Amsterdam Table 2.6: National and local estimates of the number of problem hard drug users Table 3.1: Number of unique clients registered at outpatient services Table 3.2: Drug clients at outpatient addiction centres in 2000 Table 3.3: Characteristics of outpatient treatment demand for cocaine use Table 3.4: Characteristics of methadone supply at outpatient centres Table 3.5: Estimate of the number of methadone clients in the Netherlands Table 3.6: Methadone supply in Amsterdam in 1989 and 1998-2001 Table 3.7: Hospital admissions related to drug abuse and drug dependence in 2001 Table 3.8: Number of deaths among drug users in Amsterdam Table 3.9: HIV-prevalence and risk behaviour among injecting drug users Table 3.10: Seroprevalence of HBV and HCV (%) among (injecting) drug users Table 3.11: Number of non-fatal emergencies recorded by the Municipal Health Service of Amsterdam in 2001 Table 4.1: Social characteristics of drug clients at outpatient centres in 2000 Table 4.2: Number of coffee shops in the Netherlands Table 4.3: Offences against the Opium Act reported by the police or Public Prosecutor Table 4.4: Number of irrevocable sentences in Opium Act cases imposed by the courts Table 4.5: Offences among suspects registered by the police as a drug user in 2001 Table 4.6: Places where last-year users (12-17 years, >=18 years) purchased their drugs in 2001 Table 5.1: Amount of confiscated ecstasy tablets, attributed to the Netherlands Table 5.2: Percentage of pills tested by DIMS by main component, since 1997 Table 5.3: Number of samples by main component classified as "other psychoactive substances" Table 5.4: Average THC percentage in cannabis products Table 5.5: Average price per gram of cannabis products (in €) Table 12.1 Treatment options available to drug-dependent detainees according to stage in custody chain Table 12.2 Number of offenders in mandatory drug treatment (SOV) in correctional institutions by status and location. Survey date 26 March, 21 May, and 31 August 2002 Table 14.1: Costs of care for alcohol and drugs problems (in € million) Table 14.2: Developments in expenditures addiction care in € million Table 14.3: Estimated annual costs (€) of medical heroin prescription treatment units Table 15.1: Lifetime prevalence of drug use among young people in 2001 Table 15.2: Last month prevalence of drug use among young people in 2001 Table 15.3: Last-month use of alcohol, tobacco and drugs among secondary school students of 12-16 years in 1999 Table 15.4: Where do students (12-18 years) usually purchase cannabis? Table 15.5: Drug use (%) among homeless youth (N=91; 1999) Table 16.1: Proportion of immigrants and native Dutch among the total population and among drug addicts

187 Table 16.2: Distribution of primary addiction problem of immigrants and native Dutch over alcohol-, heroin-, cocaine-, cannabis-, and gambling addiction Table 16.3: Prevalence of dependence or abuse among the total population of the Netherlands and the homeless in The Hague Table 16.4: Prevalence of substance use among the homeless in The Hague Table 16.5: Dropout rate of immigrants and native Dutch in outpatient addiction care Table A1: Lifetime use of drugs among students of 12-18 years at secondary schools Table A2: Last-month use of drugs among students of 12-18 years at secondary schools Table A3: Use of drugs among students of 12-18+ years at special schools in 1997 Table A4: Use of drugs among youth participating in truancy projects in 1997 Table A5: Number of drug client registrations at outpatient addiction centres Table A6: Number of admissions to inpatient addiction services Table A7: Number of admissions to general hospitals for main diagnosis Table A8: Number of admissions to general hospitals for secondary diagnosis Table A9: Number of acute drug-related deaths in the Netherlands according to EMCDDA standard Table A10: Summary of drug seizures in the Netherlands in 1995-2001 Table A10 (continued): Summary of drug seizures in the Netherlands in 1999-2001 Table A11: Population of the Netherlands on the 1st of January 2001

188 ANNEX 5: LIST OF FIGURES AND GRAPHS

Figure 2.1: Prevalence of cannabis use (upper figure) and cocaine use (lower figure) in big cities and non-urban regions among the Dutch population of 12 years and older, in 1997 and 2001 Figure 2.2: Prevalence of cannabis use (%) across age groups in the general population in the Netherlands of 12 years and older Figure 2.3: Development of cannabis use (%) among students of 12-17 years at secondary schools Figure 2.4: Pattern of GHB use in the past month among regular experienced GHB users Figure 2.5: Estimated number of problem users of harddrugs (mainly opiates) per 1000 inhabitants in the Netherlands Figure 2.6: Estimated number of opiate addicts in Amsterdam by country of origin Figure 3.1: Development of the number of drug clients at outpatient addiction centres (LADIS) Figure 3.2: Methadone consumption (gramme) per person per year Figure 3.3: Number of admissions to inpatient addiction services because of drug dependence or nondependent drug abuse (ICD-9 codes 304 and 305.2-9) Figure 3.4: Number of admissions to general hospitals because of a primary (left) or secondary (right) diagnosis drug dependence or nondependent drug abuse (ICD-9 codes 304 and 305.2-9) Figure 3.5: Drug-related deaths in the Netherlands in 2000 according to selection B recommended by the EMCDDA Figure 3.6: Number of acute drug-related deaths in the Netherlands according to the EMCDDA selection of ICD-9 codes (1985-1995) and ICD-10 codes (1996- 1998) Figure 3.7: Mortality per 1,000 person years among Amsterdam methadone clients Figure 3.8: Number of reported AIDS cases by year of diagnosis for the total group and for injecting drug users (IDUs) separately Figure 3.9: Number of non-fatal emergencies due to drug overdose recorded in Amsterdam Figure 3.10: Number of non-fatal emergencies in Amsterdam related to the use of cannabis Figure 4.1: Nature of criminal cases involving offences against the Opium Act Figure 4.2: Total number of detainees and detained Opium Act offenders Figure 14.1: Flows of governmental expenditures to addiction care: 1997-1998 Figure 15.1: Prevalence of cannabis use among young people in 1997 and 2001

189 ANNEX 6:

Map: Overview of Dutch provinces and some important cities

190