Drug Abuse

Drugs policy in the Netherlands: The importance of the renewal of care

3. Prevention and the care and treatment of addicts

3.1. The importance of the renewal of care

The number of hard drug addicts in the Netherlands is stable and relatively low (cf. annex I). The average age of heroin addicts is over thirty and rising*. There is therefore no reason to assume that the policy on soft drugs has resulted in a large increase in hard drug addicts. The fact that according to various statistics, including those of the Amsterdam Municipal Health Service, young people in the Netherlands rarely start using hard drugs such as heroin or cocaine before the age of 20 rather suggests the opposite in fact*.

The fact that there are virtually no young people under 20 using heroin or cocaine in the Netherlands is extremely gratifying, especially as experience shows that the later in life a person starts using a drug the greater the chance of their overcoming their addiction at some stage.

Care providers are now facing new developments, however.

As already described above, the nuisance caused by some addicts has increased. Secondly, care workers are having to deal with an increasingly large variety of extremely problematic target groups, all of whom need to be approached in a different way. Examples include mentally disturbed addicts, addicts whose lifestyles involve a lot of crime and/or aggression, addicts who are homeless and young addicts with no fixed address, foreign addicts and multiple drug users. What links these groups is the fact that their addiction is not an isolated problem but often bound up with other problems, such as psychiatric disorders and problems of lifestyle and/or social deprivation. Diseases such as TB and certain forms of hepatitis are increasingly common among addicts. Many of the addicts in these target groups are in a poor physical and mental condition, partly as a result of the long-term use of drugs and their chance of recovery is therefore small*.

Dutch policy on hard drug addicts has for a long time been based on the principle that addicts should be treated as patients requiring treatment for their addiction, that treatment being geared to ensuring their abstinence from drugs in future. However, there are few scientifically sound, broad-based evaluations of the effectiveness of such treatment programmes in the somewhat longer term but what studies there are reveal that they have only a limited effect on the progress of the addiction process*,*.

Care aimed at limiting the damage caused while a person is addicted is reasonably successful, however. As a result, the health of Dutch addicts is relatively good, one current sign of which is the growing number of older addicts. Some Dutch addicts are also relatively well integrated in the community.

The disappointing results of some treatments aimed only at abstinence, and the emergence of new groups of addicts, whose addiction is only one component of a whole range of problems, mean that adjustments need to be made in the types of preventive work carried out and care provided. The government believes that the following innovations should have the highest priority:

• innovations in prevention;
• greater coordination of the various forms of care;
• differentiation of the range of residential care available;
• better coordination of residential and out-patient care with that provided in penal institutions (compulsion and dissuasion projects);
• experimental provision of heroin on medical grounds.

The innovations involved concern the care provided to all drug addicts and the prevention work aimed at vulnerable groups who are at risk of addiction. At the same time, particular attention will be paid to problematic addicts, who are often those involved in crime.

Each of the above-mentioned priorities in the renewal of care is discussed briefly below.

Drugs policy in the Netherlands: The renewal of care and prevention

3.2. The renewal of care and prevention

The nature of the drugs problem is constantly changing. This has consequences for the care provided and for prevention work. New drugs, changing patterns of use and new risk groups impose considerable demands on prevention workers and require a dynamic approach. For example, the emergence of ecstasy and other similar drugs demands a different attitude and approach from the traditional activities engaged in in the past. Prevention can no longer be limited to traditional target groups, such as schoolchildren and, in respect of secondary prevention, the users of heroin. As regards its ability to respond appropriately to new developments, prevention work needs to be improved. The activities concerned still do not reach new risk groups and hidden users enough, as illustrated by the fact that it is frequently organisations other than the traditional institutions which are most active in visiting young people who go to discos, coffee shops and raves and use drugs there. The traditional institutions too will be expected to adopt an active approach to new user groups and to the visiting of places where drugs are used.

As regards prevention, it is difficult to say what specific results the various activities of recent years have had because insufficient evaluation has been carried out. Precisely because the field to be covered by both primary and secondary prevention activities is becoming broader, it must be clear what is effective and what is not. Research into the effectiveness and efficiency of prevention work will therefore be promoted, as will the monitoring of developments in the nature and extent of drug use. An understanding of the latter is absolutely essential if we are to respond properly to new trends. Market surveys through a monitoring system are extremely important for prevention work and for those providing care. They enable prevention workers to understand sooner and better social trends which may affect the drugs problem. Monitoring is also important for those providing, allowing them, for example, to develop at an early stage new strategies to limit damage. The government has reserved funds for proper monitoring.

The conclusion was drawn above that problematic drug use is closely linked to social deprivation. In order to be able to reach new risk groups at an early stage, prevention work will have to focus its attention on a broader front and bear such social deprivation in mind more. In order to reach groups such as young people with no fixed address, truants and marginalised groups of both Dutch and foreign origin, there will also have to be cooperation with other institutions, such as the youth services. Policy on the big cities provides for an integrated approach to the dangers of large numbers of young people in the cities becoming marginalised. This year the authorities in the big cities are to draw up concrete plans of action to tackle this problem, working in conjunction with the Public Prosecutions Department and the police.

Policy should be based on the "facet approach", which involves taking the various angles of the problem into account as much as possible. We would refer in this connection to the policy document on health from 1995 to 1998 ("Gezond en Wel, kader van het volksgezondheidsbeleid 1995-1998") (Lower House 1994-95, no. 24126) and to the policy document entitled "Regie in de Jeugdzorg" (Management in youth services)*.

In the case of drug addiction the old adage that prevention is better than cure is particularly true. Research has shown that the decisive preventive factor for young people is a sufficient awareness of the risks. For some years now the NIAD has been carrying out a considerable number of information activities aimed at young people, in collaboration with municipal health service departments and schools. It is expected that a freephone information number will be started up in autumn 1995, dealing with questions on alcohol, drugs, tobacco and gambling. As part of the integrated approach to youth problems in the big cities, which forms an important part of the policy on the big cities, and in other contexts too, we will encourage a new drive to provide good quality, realistic information in schools on the use and misuse of alcohol, nicotine and drugs, geared specifically to problem groups as well as to pupils in general. At the suggestion of the Public Prosecutions Department, for example, the Alcohol and Drug Clinic (CAD) in Drenthe has followed the example of a successful German initiative and produced video clips on the risks of drug use which can be used to provide information in discos etc. The opportunities for carrying out public information activities in coffee shops will also be better exploited. To complete the picture as regards prevention, drug dealers who operate in or near schools or who use pupils to deal for them must be punished severely. The Minister of Justice will request the Public Prosecutions Department to bear this in mind in its investigation and prosecution policy. The sale of hard drugs to young people will meet with particularly severe penalties.

The increase in the use of designer drugs such as ecstasy requires a new approach. The problem from the point of view of prevention is that in general these drugs do not result in physical dependency, though they can cause serious damage to health. The fact that pills of inferior quality are put on the market is an additional problem. The above-mentioned monitoring system will cover the quality of these drugs too. Policy is also geared to developing new methods of communication and a national working party is currently preparing activities in this area. Greater attention can also be devoted to prevention through administration. As stated above, the Minister of Health, Welfare and Sport has recently sent a memorandum to the municipalities containing guidelines for the development of a policy on large- scale events (Stadhuis en House, 1995).

Executive agencies in particular have noted a lack of national support for prevention work in the form of information, the promotion of expertise and innovation. This is not a desirable situation, since there is insufficient opportunity for spotting both duplication and gaps in the prevention work being carried out. Nor is there sufficient information on how the care of addicts ties in with the activities of the police and judicial authorities.

In the near future we will enable a national support body for standards in prevention work to be established to meet these needs.

Drugs policy in the Netherlands: Greater coordination of care for addicts

3.3. Greater coordination of care for addicts

The variety of requests for assistance and the increase in the number of target groups mean that care can no longer comprise a standard range of treatments but that the agencies concerned must provide "tailor-made" care. Essentially this entails a shift from care involving little differentiation to a demand-oriented approach which also allows aspects such as social deprivation, housing and the residential environment, and social skills to be taken into account. Appropriate care programmes will have to be developed in which the care process is geared to specific individuals, where the initial and ultimate objectives are set out and in the course of which all the various elements which may go to make up a request for assistance can be addressed. Such an approach will also help to avoid addicts having to deal with various organisations between which there is no coordination. This will mean that if clients are referred to other institutions in the course of their treatment, information will have to be transferred and agreements made monitored. Those responsible for a client at the various institutions should keep one another informed through client files, standard records, standard protocols and personal communication. Case management is of crucial importance to this kind of integrated care programme.

There are two key concepts which are central to the provision of care: responsibility and reciprocity. Addicts must accept responsibility for their own behaviour. The fact that they are addicts is no excuse for causing a nuisance to other people. The second concept, reciprocity, means that addicts are expected to keep to agreements made with care workers in return for the help they receive. The programmes to be developed as part of the renewal of care will have to help achieve these objectives. If a demand-oriented approach results in a care programme geared to individual needs and wishes, the ideas of responsibility and reciprocity will mean more to clients. It will then be easier to remind addicts of their obligations to society, which are a reasonable quid pro quo for their care.

Most methadone substitution programmes are carried out by the non-residential care sector. Many addicts lead lives which are reasonably socially integrated, partly as a result of these programmes. Nevertheless, in many cases they do not go on from these programmes to treatment and training, employment and accommodation projects. Methadone programmes, treatment programmes and social rehabilitation projects should be complementary and in the years ahead this is an aspect which must be worked on. Improved coordination with other care institutions for drug addicts, general social service institutions, including those which help people get into employment, the police and judicial authorities, and the probation service, would be a positive contribution. The Inter-administrative Task Force on Public Safety and the Care of Addicts will be responsible for promoting this.

Drugs policy in the Netherlands: Differentiation in residential care

3.4. Differentiation in residential care

Apart from a few beds for acute emergencies involving overdoses (crisis detoxification), residential care is almost entirely geared to achieving abstinence. There is a problem in that there are certain categories of users who need residential care but are not in a position in which abstinence can be regarded as a realistic objective. At the time such users are admitted to residential care their situation is usually so bad that no considered plans for the future can be made. Their only real need at that point is often rest and the chance to recover. If they are then told that the aim of admitting them is to ensure their future abstinence from drugs, practical experience shows that a very large number of clients will refuse admission immediately or give up the treatment at an early stage. For this reason residential care should also be more differentiated than in the past as regards the aims and exact content of the treatment it provides.

In addition to treatment aimed at achieving abstinence, residential care will also provide programmes where the aim of treatment is not so radical - stabilising and improving the situation of the individual addict, for example. As things stand, clients can only choose between various programmes aimed at abstinence, most of which are lengthy. There are far too few short or part-time programmes which are not aimed directly at total recovery but at stabilisation and improvement. The establishment of the Residential Motivation Centre (Intramuraal Motivatie Centrum) in Amsterdam is a start. The first task there is to create a stable, safe environment; from there consideration can be given to what kind of follow-up treatment (residential or otherwise) is appropriate. The development of suitable programmes for use in such a setting will increase the chance that addicts who have been difficult if not impossible to reach to date will come into and remain in contact with the care services. This will be promoted by ensuring that greater attention is paid from the start in residential care to aspects related to social rehabilitation. Trials involving sheltered accommodation and work experience experiments (both forming part of an integrated package of care ) are a practical example of such a multi- facetted approach. We will encourage those involved in residential care to set up their own projects of this kind, geared to social rehabilitation.

Drugs policy in the Netherlands: Management and financing structure of non-residential care for addicts

3.5. Management and financing structure of non-residential care for addicts

Most non-residential care for addicts is concentrated in approximately 45 larger municipalities. Until 1994 such care was funded under the Temporary Subsidy Scheme for the Care of Addicts (TFV), which had a budget of over NLG 110 million per annum. The main feature of the scheme was that financing was channelled through 23 "central" municipalities which were then responsible for organising non-residential care for addicts in their region, in consultation with the other municipalities concerned. The joint distribution of the regional budget among the various institutions and municipalities concerned was thus assured. This partly decentralised management system and financing structure operated satisfactorily.

As part of the policy on social renewal, non-residential care for addicts was incorporated, subject to conditions, in the Temporary Act for the Promotion of Social Renewal (TWSSV). The above- mentioned system involving 23 central municipalities managing care in the region was retained. An obligation to provide care and information and to establish appropriate consultations with other relevant parties in the region was also imposed on those municipalities.

In view of the temporary nature of the TWSSV, the intention is that as of 1997 the total TWSSV budget will be transferred to the Municipalities Fund. As it is not possible to require one municipality to transfer funding from this source to another, this means that the budget for non-residential care for addicts will be split and spread among all municipalities. The link between administrative responsibility, the obligation to provide care, and the ability to procure the necessary funds will thus come to an end.

The Dutch Association of Care Organisations for Addicts (NeVIV) and a number of municipal authorities have pointed out the dangers of fragmentation. The government is of the opinion that the duty of the municipalities concerned to cooperate with other relevant parties and to provide information in the provision of non-residential care for addicts should be laid down in law. This could be done by amending the Welfare Act (section 12 in particular), for example.

In consultation with the parties concerned ways are being sought of establishing a financing structure before 1997 which will in essence allow the present system to continue. It is crucial that the link between administrative responsibility and the availability of the budget to carry out that responsibility should be maintained. There is an instrument which can be used by the Municipalities Fund temporarily to allocate funds to specific municipalities. The funds would then remain the same but would be channelled through the Municipalities Fund. This could continue for up to four years, a period which would be used to improve the necessary regional cooperation. Such cooperation will then enable the resources to be distributed in the ordinary way.

Drugs policy in the Netherlands: Compulsion and dissuasion in the care of addicts

3.6. Compulsion and dissuasion in the care of addicts

The policy being pursued is based on the above-mentioned policy document on the reduction of nuisance (Lower House 1992-94, 22684, no. 12). A crucial part of this is the "compulsion or dissuasion" approach, whereby certain addicts who have been arrested on account of criminal offences are given a choice between entering into a period of supervision and treatment with some prospect of being integrated in society and ending their life of crime, or remaining in custody.

As stated above, an inter-ministerial Steering Committee for the Reduction of Nuisance (SVO) has been set up to implement the policy set out in the policy document.

In consultation with the relevant parties in the municipalities which are responsible for reducing nuisance and providing non- residential care for addicts the SVO has drawn up integrated project plans. After all, primary responsibility for local policy lies with the municipalities. In 1994 it was possible to provide nine municipalities with grants. The policy on large cities was borne in mind in selecting the total of 25 municipalities which were eligible for such a grant from 1995. One of the criteria on which the distribution of funds was based was that the approach adopted should be an integrated one, devoting attention to prevention, care, detention and rehabilitation alike. It also had to be clear that the various parties, such as those providing care for addicts (residential and non-residential), the police, the judicial authorities, the probation service, municipal agencies and penal institutions had all bore accepted responsibility for bringing about a reduction in nuisance.

In addition to these local projects grants are also being provided to a number of national initiatives, such as the "Made to measure dissuasion" project being run by NeVIV, increasing the number of social services bed and breakfast establishments, the expansion of early intervention projects (VIPs), the development of work and training orders for addicts, the expansion of the number of drug-free units in penal institutions and the establishment of a forensic addiction clinic (FVK). The latter, in which addicts will pass through closed and open stages of treatment, is expected to become operational early in 1996. The clinic's target group will comprise addicts who have committed criminal offences and who can be treated, but the nature of whose addiction, the seriousness of whose offences, whose personality structure and whose history of care are such that admission to open residential care would not be appropriate. Addicts will therefore enter the clinic and undergo treatment in a closed setting, the duration of which will vary from one person to another. Once they have completed the closed stage they will move on to the open stage, which will take place in a special community providing accommodation and work and/or work experience, in a rural setting. This is a new form of care for addicts which is being started as a trial; a certain amount of time will be needed before it can be fully operational. This is why a start will be made with the closed stage, and on a small scale. Ultimately, a maximum of 70 places will be available.

In accordance with the estimate given in the policy document on the reduction of nuisance caused by addicts, we will increase the budget of the Steering Committee for the Reduction of Nuisance (SVO) for 1996 by NLG 12.5 million. As stated above, the SVO will be merged with the task force on nuisance caused by drugs to form the Inter-administrative Task Force on Public Safety and the Care of Addicts.

The government attaches considerable value to increasing the number of places available in compulsion and dissuasion projects. The 200 additional cells where inmates follow a simple regime, most of which will become available in 1995, have been reserved for the four biggest cities as part of the policy on the big cities. More cells and cells of different types are needed for the dissuasion projects. In consultation with the Public Prosecutions Department 500 of the additional cells which the government has decided to provide in 1996 will be reserved for the detention of addicts who have committed serious offences. This will provide sufficient extra capacity for this category of offender.

As part of the "Effective Detention" initiative, drug-free units have been created within penal institutions. The capacity of these units, which have a modified regime, is approximately 300. It is planned that this should be increased to 620 by 1997. The intention is that these places will enable suitably motivated addicts to spend some or all of their time in detention in drug- free units and actively prepare themselves for actual treatment and social rehabilitation. Offenders will leave the units either to go into treatment (under article 47 of the Prison Rules) or because the period of detention has come to an end, in which case they will have the option of continued supervision by an organisation concerned with the care of addicts and/or the probation services.

Order under the criminal law for the care of addicts

Current compulsion and dissuasion projects are intended for addicts who have committed relatively serious offences. As a rule, they are admitted to a drug rehabilitation clinic when discharged from the penal institution. As stated above, current thinking is that in the case of a great many addicts it is not realistic to expect them to achieve abstinence in the short term and that it would be better to seek an improvement in their way of life and integration in society. To this end, various forms of non-residential care are provided, in which the emphasis is on undergoing training or work experience. A number of towns and cities, including Dordrecht and Den Bosch, have had some success with offering training and employment, under strict conditions, to systematic offenders, including addicts*.

Within the framework of the policy on the big cities, talks have been held with the four big cities on the possibility of setting up a trial involving addicts who have committed a series of less serious criminal offences participating in forms of care in a closed setting. The most that can be expected of a large proportion of such addicts is an improvement in lifestyle. This can be achieved by placing them in care, in a closed setting, where their social rehabilitation can be pursued through training and work experience. The legal grounds for these new forms of care for problematic addicts who have committed offences can, for the time being, include the suspension of a custodial sentence subject to special conditions. This means that addicts are placed in a closed establishment on a voluntary basis as an alternative to spending a period of detention in a remand centre or prison. If they leave the programme early they will be arrested and sent to a remand centre. The municipality is responsible for providing treatment, training and work experience, both during the placement and once an addict has been discharged. Ideally, some prospect of actual employment at the end of it all should also be provided, and to this end the Ministry of Social Affairs and Employment is involved in the preparation of the experiment.

Making placement in care a condition for the suspension of a custodial sentence is not ideal. Placement takes the place of relatively short period of detention can thus also only be for a short time. It is desirable that ways be found of placing addicts in care on a compulsory basis when they cause a serious nuisance, by committing a series of minor offences and/or engaging in aggressive behaviour, for example. A specific legal basis must be created. The Minister of Justice is therefore to submit a bill on the introduction of an order under the criminal law for the care of addicts, analogous in part to the measure which used to be taken to place tramps, beggars and pimps in a state labour institution (article 432, Netherlands Criminal Code). Justification for placing addicts who continue to commit offences with great regularity in care lies not in the seriousness of the individual offences they have committed but rather in the nuisance to the community their crimes cause and in the fact that it is important that drug addicts receive integrated treatment and training in a closed setting. For this reason the maximum length of such a placement will exceed the usual tariff for property offences, extending from a minimum of three months to a maximum of one or two years.

The municipal authorities in the four biggest cities have said that they are willing to cooperate in setting up one or more trials. A survey is to be conducted in the very near future to determine, among other things, the precise size of the target group. The municipalities of Rotterdam and Amsterdam have said that they are prepared to help finance the trial and we are prepared to commit funds from the big cities policy budget.

It has been agreed with the big cities that the above-mentioned Inter-administrative Task Force on Public Safety and the Care of Addicts will set up a joint working party to prepare and supervise the survey, followed by one or, if possible, a number of trials. It is hoped that a trial will begin in Rotterdam as early as 1996, involving approximately 100 addicts who cause a nuisance. The Task Force will develop proposals for the expansion of the trials to include at least 300 places, at least 100 of which will be made available to the municipality of Amsterdam.

We anticipate that, partly on account of the limited numbers of highly active recidivist addicts per city, increasing the number of places in coercion and dissuasion projects plus increasing normal cell capacity will result in a substantial reduction in the amount of nuisance caused by problematic criminal addicts.

Drugs policy in the Netherlands: Provision of heroin on medical grounds

3.7. Provision of heroin on medical grounds

The nature of the problem of seriously degenerate and sometimes seriously ill addicts is different again. The constant presence of such addicts means that new methods of intervention are needed, especially in the Netherlands, where the average age of addicts is relatively high. There are those who advocate that such addicts should be admitted to clinics for treatment on a compulsory basis (on medical grounds) and there are others who believe that they should undergo compulsory treatment in prison on account of the drug-related crime they commit.

Experts consider that it would only be possible to admit a very small number of addicts to clinics under the terms of the Psychiatric Hospitals (Compulsory Admission) Act (BOPZ). Addiction in itself is not a mental illness. Most addicts could not be diagnosed as mentally ill on valid grounds. However, there is a relatively large number of psychiatric patients among the most degenerate addicts. On the other hand, mentally ill people who have been heavily addicted to drugs for a long time are usually difficult if not impossible to treat. The options for admitting more addicts to closed clinics for treatment are therefore extremely limited.

The amount and nature of the crime such people commit are not so serious as to warrant placement in a forensic addiction clinic or the coercion and dissuasion approach on the grounds of the criminal nuisance they cause.

On 7 June 1995 the Vice-chair of the Health Council presented a report to the Minister of Health, Welfare and Sport on prescribing heroin for addicts; the report was brought to the attention of the Lower House. The Committee on the Use of Medicines in Drug Addiction, which drew up the report, concluded that, in view of the fact that insufficient scientific data was available on the effectiveness/harmfulness of prescribing heroin on medical grounds to any type of addict within the current heroin addict population, it was desirable for research on the subject involving a medical trial to be conducted in the Netherlands. The Committee believed that addicts who were seriously addicted to heroin and who did not respond adequately if at all to the medicinal treatments currently available should be eligible to participate in such a trial. They did not believe the length of time a person had been addicted to be of decisive importance, though addicts wishing to take part should have participated repeatedly and without success in treatment programmes aimed at using medication to stabilise their condition and prevent them relapsing into addiction. The aim of the trial would be to examine whether such addicts can be stabilised through the prescription of heroin, whether their physical and psychosocial wellbeing can be improved, whether their use of additional drugs can be reduced and whether they can perhaps be motivated to give up their addiction.

The Committee advised that the medicinal use of heroin should be compared with the currently most common form of medication, oral administration of methadone. If desired, the heroin to be prescribed can be combined with oral methadone. The trial should involve both injectable and non-injectable heroin. This means that the research project must be structured in such a way that in interpreting the results account can be taken of the different forms of administration and the differences in the euphoria arising from them. Naturally, the trial must meet all the requirements of good clinical research.

The Committee recommended that the trial should be conducted by the existing care organisations. Consideration could be given to carrying out the research in a number of locations at the same time, and not only in the big cities; in principle, it would then be possible for the protocols to differ in parts one from another. Too many locations should be avoided to ensure that the project does not become unmanageable. Scientific evaluation of the trial should be carried out by an independent research organisation. The Committee considered it advisable that the research protocol should be submitted not only to a committee on medical ethics but also to an international committee of experts. In view of the importance of such a study and the need for coordination, the Committee also recommended the establishment of a national monitoring committee.

The Committee advised against giving addicts the heroin prescribed to take away with them and stressed that ceasing to prescribe the drug upon termination of the study could present problems. Experience had shown, the Committee added, that such problems could largely be avoided if a contract were concluded with each participant in the trial stating the purpose of the trial and its duration, plus the rights, obligations and responsibilities of both the patient and those treating him or her. The Committee also advised that research should be conducted into the possibilities that other opiates producing euphoria might offer in the treatment of heroin addicts, particularly those which are available or can be made available in a form which is easy to administer.

We share the Committee's basic idea, that a medical trial into the effectiveness and harmfulness of prescribing heroin to heroin addicts is desirable, given that insufficient scientific data on the subject is available.

We are also able to agree in principle with the target group for such a trial, as formulated by the Committee, namely individuals who are seriously addicted to heroin and who do not respond adequately if at all to the medicinal treatments currently available. Partly in view of the undoubtedly strong attractions of participation in such a project for addicts, we do consider, however, that it should in the first instance be reserved for older addicts who have a long history of addiction and whose psychosocial situation is beyond remedy. On this point we therefore disagree with the Committee's standpoint that the length of time that an addict has been addicted is not of decisive importance.

We also endorse the objective of such a trial, namely to see whether the condition of the kind of addicts involved can be stabilised by the prescription of heroin, whether their physical and psychosocial wellbeing can be improved, whether their use of additional substances can be reduced and whether they can perhaps be motivated to give up their addiction. The three aspects of wellbeing - physical, mental and social - are functionally linked, and measuring them will require different objective criteria for each. The multiplicity of factors which will affect the outcome of treatment - the Committee mentions the medication used, the dose and method of administration, the personality of the person treating the addicts, the setting in which treatment occurs, the rituals surrounding treatment, the expectations and the intentions of the person carrying out the treatment, the expectations, hopes and receptiveness of the patient and, finally, the interaction which occurs between the two in the course of the treatment - explains in part the Committee's view that trials should be conducted at a number of locations and that over a hundred addicts should be involved at each of them.

We believe that a trial period is necessary before an answer can be given to these practical, medical and organisational questions and a better estimate of the costs involved made. Such a period is also required in order to draw up a realistic research protocol and test its feasibility in practice. What is needed is a preliminary study, involving no more than 50 addicts. An initial period of six months might be involved, terminating with an evaluation, followed by another six months spent in drafting a strict medical protocol. Evaluation of that should in turn produce a definitive protocol structure for the medical trials to be carried out. Addicts such as described above should participate in the preliminary study and the criteria for their selection should be worked out carefully.

As already indicated, the provision of heroin in this way is intended to improve the physical and psychosocial situation of the addicts concerned. This measure is not intended to reduce nuisance to others, though attention should be devoted to both nuisance and crime in the protocol on the data to be collected and in the evaluation study. What must be clear from the outset is that heroin can no longer be prescribed to addicts who have been placed in custody on account of having committed offences.

The Minister of Health, Welfare and Sport will enter into consultations with the municipal authorities which have already submitted proposals for the provision of heroin to addicts, in order to establish where the preliminary study described above can be held. If the preliminary study proves successful a decision will be taken on the definitive medical trial. One condition will be that some form of co-financing must be involved to meet additional material costs, such as the costs of heroin preparations and medical reports and evaluation. The municipal health services could in principle be primarily responsible for the implementation of the trial.

The Minister of Health, Welfare and Sport has asked the General Chief Inspector of Health to draw up a report on the subject.

The use of heroin for experimental/therapeutic purposes during the preliminary study and the medical trials can be authorised by the first of the undersigned granting permission for the drug to be used for scientific purposes, in accordance with section 6 of the Opium Act. The necessary peer review of the medical activities involved can also be arranged in this context. The Public Health Supervisory Service would have to be responsible for supervising the project. Reports assessing experience to date could be submitted to the Minister of Health, Welfare and Sport and to the Lower House in the form of an annual report from the Supervisory Service.

In the meantime, the trials involving the prescription of heroin which are currently being carried out in Switzerland and which are being evaluated by the World Health Organisation, among others, can be examined to see whether they have yielded any information which could be of value to policy in the Netherlands in the future. At the moment, seven hundred addicts in Switzerland are being provided with heroin. Experience to date, it is believed, has been mainly positive. The Public Health Supervisory Service has been asked to follow the progress of these projects and to report on them in due course to the Minister of Health, Welfare and Sport. The report will be brought to the attention of the Lower House.

Under the provisions of article 12, in conjunction with article 19, of the Single Convention, full details must be given to the International Narcotics Control Board in Vienna, so that the current estimate of heroin consumption can be increased to the level required for the implementation of the prescription plans. This means that that level will have to be determined in cooperation between the medical services responsible for implementing the plans and the Public Health Supervisory Service.

Separately from the above, the Committee recommended making it easier in practice to provide heroin or other opiates equivalent to heroin, by way of a palliative, to seriously ill patients who have been permanently addicted to heroin for a long time and are expected to have only a short time to live. The Committee's recommendation was not accompanied by an explanation of the existing technical difficulties. The Public Health Supervisory Service has therefore been asked to set up a study on the subject and to present more detailed proposals on making such treatment easier. The availability of medicines containing heroin will in any event be a problem, as they are not registered in the Netherlands. The criteria by which patients should be selected for such treatment must be formulated carefully. The Minister of Health, Welfare and Sport is prepared to consider this aspect of the Committee's report more closely and to discuss it with the Lower House.

Drugs policy in the Netherlands: Guarantee of standards, and evaluation

3.8. Guarantee of standards, and evaluation

On the one hand, the range of preventive and curative facilities on offer should be constantly renewed in response to newly emerging problems and questions but on the other the relevant budget must be kept under control. Choices will always have to be made within the range available. A proper understanding of the costs and benefits of the various options is essential for the development of policy in this area. Up to now insufficient attention has been devoted to the effectiveness of both residential and non-residential care for addicts in the Netherlands. As part of the renewal of care and the policy on the big cities, greater emphasis will be placed on monitoring and evaluation. A considerable contribution can already be made in fact if national registration systems are developed further and if the institutions' annual reports include more statistical information on the addicts treated, drop-outs, and clients who have completed courses of treatment, and how their lives have progressed since, if known. Studies evaluating preventive measures are also still being conducted in a less systematic manner than might be desired and the Minister of Health, Welfare and Sport will encourage improvements in this area.

Institutions involved in the care of addicts have now started developing a policy on standards. For example, an assessment framework has been drawn up, product standardisation projects have been started, and research has been conducted into how satisfied clients are with services. The Organisation for Future Scenarios in Health Care has been asked to draw up future scenarios for the addiction problem as well*.

 

 

 

 

 

 

 

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