9. 1 Integration of drug addicts

In a memorandum from the under-secretary of state for health100 to the
Second Chamber the goals for assistance were adjusted: ending
addiction (abstinence) and improving the physical and social
functioning of the addicts without abstinence being accomplished (17
867, no. 1: 4­8). The assistance modality directed to ending addiction
was in practice coming to be entitled "treatment". The conclusion was
that treatment had been focused too much on abstinence without paying
attention to social background factors leading to addiction, and was
consequently unsuccessful. Expectations about the success of the
assistance system turned out to have been too high. However,
abstinence-oriented assistance should also in the future be part of the
total supply of assistance. The other part should be aimed at users who
were not motivated to end addiction. This form of supporting assistance
includes counselling, dispensing of substitute drugs, material support
and possibilities for social recovery in general (Ibid. 5). Later that year
the under-secretary of state for health, in answers to questions from the
standing committee, mentioned some basic principles that were
practised by assistance and should be leading for local policies on social
recovery:

Assistance facilities strive to an increasing extent to keep the remaining social
contacts (family, neighbourhood) of addicts. Assistance is offered as much as
possible in the social context to which the addict still has a relation. By this, it is
possible to avoid assistance starting only when the addict is totally isolated from
his/her original milieu (17 867, no. 3: 21).

The change of governmental policy meant an adjustment of the first
problem definition and the action programme, especially in the field of
assistance. Undoubtedly the 4-G played a leading role in this process.
They had no time to wait until treatment had turned addicts into drug-
free citizens, since the problem of drug-related nuisance had become
increasingly urgent. In discussions between the government and city
authorities, the approach towards addicts underwent changes.
According to Leon Wever:

Too few of them sought help, and there were too many of them on the streets and in
police cells. They should enter treatment, either voluntarily or under compulsion.
The accessibility of the drug services, and not so much the ready access of
authorities to drug users, was identified as the central question (Wever 1991: 2).

The provision of aid should be adjusted to local needs and the
accessibility of assistance improved. However, pressure from the 4-G
was not the only reason for this policy shift.
In 1982, a study by two criminologists, Jansen and Swierstra,
financed by the Ministry of CRM was published (Jansen and Swierstra
1982). It was a typology of lifestyles based on qualitative interviews of
70 heroin addicts in different social groups, both Dutch and
Surinamese. The study would play an important role in the shift from
abstinence-oriented assistance to "harm reduction". Its importance is
shown by the fact that the under-secretary of state for health ordered a
summary to make its content accessible to a broad public (WVC 1983).
In the preface to the summary, the under-secretary of state mentioned
one conclusion in particular: "The heroin addicts in the study do not
constitute one heterogeneous category; several different types can be
discerned. Each and every type requires a different approach if the drug
and assistance policy is to be adequate" (WVC 1983: 5).
However, this conclusion was not a novelty. As we have seen in the
memorandum on the severely addicted from 1978, the ISD also had
framed four categories of addicts and recommended separate
approaches. The difference lies in the fact that the ISD memorandum
was based on observed behaviour while the results of the study by
Janssen and Swierstra were based on the experiences of addicts as told
by themselves. Some conclusions that were perceived as providing new
perspectives for the drug policy are summarised below.
The different social perspectives of heroin users change in relation to
the development of their existence as a junky and can be explained by
their different social backgrounds. These are the structural conditions.
The lives of heroin users are shaped by the existence of social groups,
i.e. structuring conditions. If the norms and values of a social group
deviate from the dominating norms and values, we can speak of a
subculture. The development of subcultures in which use of heroin is
logical and meaningful can only occur under certain conditions:

· there needs to be an environment in which heroin is available to
youth (culture), i.e. the opportunity structure
· the development of interest groups that profit from the use of heroin,
that have gained a place in society, i.e. the heroin structure: heroin
users have an interest in these groups and the groups have an interest
in the existence of heroin use.

The main finding of Janssen and Swierstra was that the different routes
to heroin lifestyles passes the same kind of cross roads, namely, a youth
subculture that functions as a gate to heroin use.

Figure 4. Different aspects of the heroin problem

In summary, a precondition for the heroin problem is that heroin is
available as well as circles from which reasons can be extracted to start
using heroin. Now this may seem like a trivial conclusion, but there is
more. The heroin structure comprises an illegal branch of big and small
heroin dealers, and a legal branch, i.e. justice and assistance that
unintentionally contribute to the perseverance of the heroin structure.
The heroin user exploits measures by authorities to maintain addiction
and an unchanged lifestyle. For example, imprisonment can be used for
detoxification and recovery, entering treatment to avoid imprisonment,
methadone as a base for daily use of heroin or other drugs. Janssen and
Swierstra called this strategy "re-functionalism".
A consequence for the drug policy and assistance was that the
meaning of heroin use for the addict must guide the kind of intervention
that is chosen. The researchers rejected general solutions like
compulsory care and legalisation of heroin because they were one-sided
actions that did not consider the perspective of the users. Besides, these
measures did not disband the deviant subcultures (17 867, no. 3: 36).
Instead, the researchers proposed a cultural integration of heroin use.
The heroin structure had become an inextricable part of society and the
problems emanating from this structure was a fact. However, additional
problems created by the reaction from society could be prevented by a
cultural integration of the heroin problem (WVC 1983: 30).
The under-secretary of state for health emphasised in the preface to the
summary that he did not share all the conclusions in the report, but it is
obvious that the study influenced discussions on drug policy. The
influence of the study can be illustrated by a quotation from the
memorandum: "It has to be accepted that in the deviant lifestyle of
addicts `the reason' is enclosed in which, seen from the position and
perspective of the addict, use has got a definite function" (17 867, no. 1:
5).
However, the under-secretary of state also emphasised that the shift
from abstinence-oriented assistance to assistance without demanding a
drug-free lifestyle (later called harm reduction) should not be
interpreted as pessimism and giving up the addicts. The approach
should rather be perceived as meeting the problem in a realistic way
(Ibid. 5).
This change of policy had some important implications:

· Assistance agencies should become more "low threshold" through
the fast introduction of methadone maintenance programmes and by
extending street-corner work and drop-in services.
· Government policy was no longer focused on curing dependency
and drug-free treatment only, but also on improving the physical and
social condition of problem drug users who continued to use drugs,
however with abstinence as a long-term goal. Assistance agencies
had to change their "ideological" orientation as well.

Methadone had become the cornerstone of Dutch drug policy.
Abstinence as the only overall goal for treatment was abandoned.


Prevention

The understanding of the reasons why addicts start to use drugs and
most of all why they continue to use drugs and in particular the
processes of deviancy could also add new perspectives to prevention
(Ibid. 8). Information could play a role in the prevention of problematic
drug use. However, its importance should not be overestimated.
Information in schools was to be integrated in the subject of healthy
behaviour in primary and secondary education. This integration would,
however, take many years and in the meantime, organisations like the
FZA, NCA, and People's Union could be involved. The latter two were
remains from the temperance movements (see also Part II) that were
mostly active in information on alcohol issues. The leading principle
would be to strip information of its sensational and emotional character
and bring the image of heroin use and users back to realistic proportions
(Ibid. 9). Emotions, especially when they are paired with anxiety, stood
in the way of a balanced and fruitful exchange of ideas. This was not
only true in family or school situations but also when an assistance
facility is established under the protests of the people in the
neighbourhood (17 867, no. 3: 35). The latter happened, for example, in
Amsterdam in 1983 when angry citizens of a neighbourhood in the
centre occupied the city council chamber and demanded actions against
nuisance. According to the under-secretary of state, normalisation of
information could help to make drug use and most of its related
problems a subject of discussions. It could demythologise and
destigmatise heroin addicts, which were both the goal and the
precondition for the cultural integration of addicts.
Another type of prevention is to highlight problems at an early stage.
A majority of the addicts have developed a socially deviant lifestyle
prior to their drug use. To signal this would be a task for first-line
assistance. Apart from GPs, district nurses, youth workers in youth
centres and clubhouses, local policemen and teachers, could be
involved (Ibid. 37).
The standing committee discussed the policy document with the
government and no motions were filed (UCV 45, 13 June 1983). This
means that all parties accepted the new orientation of the drug policy.
Heroin and heroin users had taken a place in Dutch society and would
do so for an undefined period. This does not mean that that heroin was
accepted but that the heroin user was regarded as a citizen with the
same rights and duties as all others, in spite of his or her heroin habit.

100 In 1982 a Department of Welfare, Health and Culture was established, merging
the departments of CRM and Health.