National Report on the Drug Situation in The Netherlands 2001 Draft Final version December 2001 © Netherlands Focal Point Part I (Henk Rigter, Toine Ketelaars) Part II (Margriet van Laar) Part III (André van Gageldonk) Part IV (André van Gageldonk, Margriet van Laar) 2001 Trimbos Institute Netherlands Focal Point PO Box 725 3500 AS Utrecht The Netherlands phone: +31-30-2971100 fax: +31-30-2971111 2 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 AWBZ General Act on Special Disease Management CAD Consultation Agency for Alcohol and Drugs CAM Coordination Centre for the Assessment and Monitoring of NewDrugs CBS Statistics Netherlands CEDRO Centre for Drug Research CIDI Composite International Diagnostic Interview CIT Community Intervention Trial CMR Central Methadone Registration CVS Client Monitoring System CVZ Health 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 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 HBV Hepatitis B HCV Hepatitis C HIV Human Immune Deficiency Virus HKS Defendant Recognition System (of the Police) ICD International Classification of Diseases IDUs Intravenous Drug Users IGZ Health Care Inspectorate IMC Inpatient Motivation Centres 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 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 Drug Prevention 3 LTP LifeTime Prevalence LMP Last Month Prevalence LYP Last Year Prevalance MAD Local Monitor 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 NDM National Drug Monitor NEMESIS Netherlands Mental Health Survey and Incidence Study NIGZ National Institute for Health Promotion and Illness Prevention NPO National Drug Use Survey PiGGz Inpatient Register Mental Health Care PMA Paramethoxyamphetamine PREFFI Prevention Effectiveness Instrument RCT Randomised Controlled Trial RGO Health Research Council RIKILT State Institute for Quality Control of Agricultural Products RIVM National Institute for Health Promotion and Illness Prevention RODIS Rotterdam Drugs Information System RVZ National Council for Public Health and Care SAMHSA Substance Abuse and Mental Health Services Administration SCP National Institute for SocioCultural Studies SOV Penal Placement of Addicts in a Penitentiary Treatment Institution 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 Care Information System 4 INDEX LIST OF ABBREVIATIONS 3 EXECUTIVE SUMMARY 7 PART 1 NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS 1 Developments in drug policy and responses 15 1.1 Political framework in the drug field 15 1.2 Policy implementation, legal framework and prosecution 18 1.3 Developments in public attitudes and debates 24 1.4 Budget and funding arrangements 27 PART II EPIDEMIOLOGICAL SITUATION 2 Prevalence, patterns and developments in drug use 33 2.1 Main developments and emerging trends 33 2.2 Drug use in the population 34 2.3 Problem drug use 46 3 Health consequences 51 3.1 Drug treatment demand 52 3.2 Drug-related mortality 63 3.3 Drug-related infectious diseases 67 3.4 Other drug-related morbidity 74 4 Social and legal correlates and consequences 77 4.1 Social problems 77 4.2 Drug offences and drug-related crime 82 4.3 Social and economic costs of drug consumption 84 5 Drug markets 85 5.1 Availability 85 5.2 Sources of supply and drug seizures 86 5.3 Price/purity 88 6 Main facts and trends per drug 91 7 Discussion 92 7.1 Consistency between indicators 92 7.2 Implications for policy and interventions 93 7.3 Methodological limitations and data quality 94 5 PART III DEMAND REDUCTION INTERVENTIONS 8 Strategies in demand reduction at national level 99 8.1 Major strategies and activities 107 8.2 Approaches and new developments 108 9 Intervention areas 118 9.1 Primary prevention 120 9.2 Reduction of drug-related harm 132 9.3 Treatments 140 9.4 After-care and re-integration 148 9.5 Interventions in the criminal justice system 149 9.6 Specific targets and settings 154 10 Quality assurance 163 10.1 Quality assurance procedures 165 10.2 Evaluation 165 10.3 Research 166 10.4 Training for professionals 167 PART IV KEY ISSUES 11 Poly drug use: drug set and setting 173 11.1 Patterns and users groups 173 11.2 Health and social consequences 177 11.3 Risk assessment and local market 178 11.4 Specific approaches to the interventions 178 11.5 Methodological issues 179 12 Success treatment: the effectiveness of the interventions 180 12.1 The approaches to treatments and the related concepts of success 180 12.2 Evaluation of the treatments 184 12.3 Methodological issues 179 13 Drug users in prison 188 13.1 Epidemiological situation 188 13.2 Availability and supply 191 13.3 Contextual information 191 13.4 Demand reduction policy in prison 199 13.5 Evaluation of drug users treatments in prison 197 13.6 Methodological issues 197 APPENDIX: ADDITIONAL TABLES 199 REFERENCES 205 6 7 EXECUTIVE SUMMARY PART I NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS Drug policy Realising that drugs are here to stay, the government of the Netherlands stresses the importance of prevention, treatment and harm reduction for the individual, his environment, and for society as a whole. Drug policy in the Netherlands has four objectives: 1. prevention and treatment 2. harm reduction in drug users 3. reduction in the supply of drugs 4. maintenance of public order. Legislation The Dutch Opium Act is a penal law. A distinction is made between hard and soft drugs. The maximum penalties for the import or export of a hard drug, for manufacture, transportation or sale, and for possession or storage are specified in the Opium Act. Since the end of the 1980s, legal measures to reduce the public nuisance caused by drug users have received greater emphasis. 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. National legislation is implemented at both the regional and local level by the courts, the police and municipalities. Organisational framework As public health interests are the cornerstone of drug policy in the Netherlands, the Minister of Health, Welfare and Sport is responsible for coordinating activities. Other important key players are the Minister of the Interior, the Minister of Justice, the Synthetic Drugs Unit, the Association of Netherlands Municipalities, and the Organization Information Systems on Addiction Care and Treatment. Policy implementation is to a large extent in the hands of local and regional authorities and organisations. Recent developments Measures to reduce the public nuisance caused by drug use and trafficking are high on the political agenda in the Netherlands. ♦ In 1997, the policy to close down those coffee shops which cause public nuisance or fail to adhere to the guidelines of the National Public Prosecution Department was tightened, resulting in a decrease in the number of coffee shops. One of the conclusions of the evaluation (in 2001) of this tightening of guidelines was that the flow of cannabis tourists to the Netherlands has not diminished. But the national government still believes coffee shops are essential in keeping youngsters away from hard drugs. ♦ In 1999 an article called Damocles was added to the Opium Act. This regulation expanded the legal armament of municipalities to redress unwanted developments such as an unchecked increase in the number of coffee shops. 8 ♦ In 2001, an Act (Penal Placement of Addicts in a Penitentiary Treatment Institution, Wet strafrechtelijke opvang verslaafden) came into effect to admit substance users into a penitentiary institution with ‘treatment’ facilities if they continue to cause serious nuisance in the form of criminal recidivism. ♦ In 2001, the government announced a series of measures to intensify actions against the production, sale and use of ecstasy. Other developments in policies and legislation ♦ In 2000, 4-MTA was added to list I of the Opium Act. ♦ Psilocine and psylocybine