AN OVERVIEW OF THE CONCLUSIONS

1. The ingestion of heroin and/or cocaine by way of smoking (primarily chasing and to a lesser extent basing) and injecting fulfill the conditions for ritualization. The behavioral sequences are highly standardized and stylized, and of special meaning to the performers. They are highly functional in the process of getting high. (Ch. 4 and 5; R.Q. 1.1)
2. The drug administration rituals of the observed drug users are, in general, rather stable. Transitions between smoking (primarily chasing) and injecting rituals were only infrequently observed. When occurring, these were associated with availability, (loosing or regaining) control over drug use, social pressure, or hedonistic motives. (Ch. 6; R.Q. 1.2)
3. Cocaine has become the engine of the former heroin scene. It is used in varying combinations with heroin. The addition of cocaine has resulted in a large number of (psycho- social) problems in the study population, and is associated with initiation into injecting. Basing may be a precursor for cocaine injecting. These problems are for a large part related to the low 'subjective' availability of the drug. Cocaine has disturbed rather controlled heroin(/methadone) use patterns. Its use has been nested in rituals developed for heroin use and taken over its function of primary source of pleasure. As a result, a functional relationship between heroin and cocaine has been established. Heroin use has become almost completely intertwined with and subservient to cocaine use. It is mainly used to modulate the effects of cocaine, in particular to ameliorate cocaine's disturbing side effects. (Ch. 5 and 7; R.Q. 1.1, 1.2, 1.5 and 1.7)
4. Both the smoking and the injecting ritual fulfill important instrumental functions, such as maximizing the yield of a given dose of drugs; controlling the level of drug use and managing positive and negative effects of the drugs; and preventing secondary problems. These instrumental functions are represented in the construction of the paraphernalia, as well as by the behavioral sequences themselves. (Ch. 4, 5 and 7; R.Q. 1.5 and 1.7)
5. Both administration rituals contain elements of symbolic elaboration. The construction and use of certain paraphernalia, certain ritual cues, parts of the sequence, and the order of the sequence can obtain a power beyond the instrumental functionality --they can for example invoke the start of a ritual sequence (getting high), enhance the experience of the drug effect, and reduce anxiety. The data suggests that symbolic elaboration is stronger among IDUs. (Ch. 8; R.Q. 1.5 and 1.6)
6. The social functions of the drug administration rituals are most obvious in the recurrent sharing of drugs. Drug sharing includes instrumental functions, e.g. preventing withdrawal, but is also an important means to socialize, establish and reinforce relationships and is ultimately aimed at maintaining the social network/subculture. The sharing ritual is subjected to several rules, e.g. regarding reciprocity. Drug sharing is not unique for illegal drug users, but resembles a fundamental and normal human behavior. (Ch. 9; R.Q. 1.3, 1.4, 1.5, 1.6 and 1.7)
7. In terms of the risks of overdose, physical harm, and communicable diseases it is clear that, given the current conditions of prohibition, the smoking ritual entails less health risks than injecting. (Ch. 10; R.Q. 2.1)
8. Syringe mediated drug sharing techniques, such as frontloading and backloading can transmit HIV and other microbiological infections when unsterile syringes are used. In the Netherlands frontloading may well be a major route of HIV infection. Drug sharing situations often entail multiple possibilities of transmission. (Ch. 11, 12; R.Q. 2.2)
9. Needle sharing is primarily determined by the structural or situational availability of needles, while drug craving and inexperience with the injecting ritual are important additional factors. Because of a lack of knowledge, other injection paraphernalia are often casually shared. (Ch. 12; R.Q. 2.3)
10. The thesis that needle sharing is a ritual cannot be supported by substantial evidence in the scientific literature. In general, needle sharing cannot be considered a ritualized behavior pattern, as the behavioral sequence does not fulfill the requirements of the relevant definitions. (Ch. 13; R.Q. 2.4)
11. Engaging active IDU's in HIV prevention activities is an necessary and feasible approach. They have access to places and populations which are not accessible for traditional service providers and can utilyze their natural information and exchange networks. (Ch. 14; R.Q. 3.2)
12. As a general rule, crack is not available in the Netherlands. Dutch cocaine (and heroin) smokers prefer to prepare the cocaine base themselves, and economic pressure towards preprocessed cocaine base is absent. Only under the specific ecological and socio-political conditions of the Rotterdam Central Railway Station a preprocessed product, 'cooked cocaine' has emerged. Currently, this phenomenon is well contained. However, (local) policy changes affecting the availability of cocaine as well as the time and space allocations of drug users -- that is, when they are pressured into the streets--, may result in entrepreneurial adaptations towards middle market level distribution of base cocaine (a.k.a. crack). (Ch. 15; R.Q. 3.1)
13. Cross cultural comparisons of patterns of drug use produce interesting data about the influence of the social context of use and drug policy, on the construction of drug problems, and about the extent to which these factors impact on the risk for HIV transmission. (Ch. 16; R.Q. 3.1)
14. Whether drug use is controlled or uncontrolled depends on the application of rituals and rules, which constrain and regulate use patterns. The nature of these rituals and rules is determined by the availability of drugs. A sufficient availability allows for the formation of a set of rituals and rules aimed at safe and controlled use. A high life structure provides the incentive and the structure to maintain a 'controlled' availability and apply regulating rituals and rules. Strict enforcement of drug prohibition has a negative impact on all three factors, hampers effective self-regulation processes and induces a survival oriented subculture. (Ch. 17 and 18; R.Q. 1.7, 1.8, 1.9 and 3.1)
15. The Dutch normalization policy is in need of revitalization. The leading policy incentive should be shifted from containment of problematic drug use and management of drug related problems, towards actively influencing the nature of drug use and directing drug using cultures towards less harmful patterns of use. This new policy must allow for a controlled availability of drugs through a wider application of the expediency principle; by way of culturally sensitive intervention studies stimulate the formation of safe use norms; and adapt the existing service system to make it more responsive to the needs of consumers, change the belief systems of current problematic drug users so as to instill a sense of entitlement and belonging to the community at large, and, by so doing, induce the concrete quality of life improvements by which they can improve their own life structure. (Ch. 18; R.Q. 3.2 and 3.3)
16. Future drug use research in the Netherlands should concentrate on the factors that determine self-regulation processes. Developing and evaluating effective community based interventions to curb the spread of HIV constitutes an equally important research priority. (Ch. 18; R.Q. 3.3)
17. The preponderant influence (drug) availability plays in the daily lives of the study participants is perhaps the most conspicuous and consistent finding of this study. (all chapters; R.Q. 1.2, 1.3, 1.8, 1.9, 2.3, 2.4 and 3.1)