Drug Abuse

METHADONE COUNTRY REPORT

THE NETHERLANDS

Jan Neeleman, Michael Farrell, Paul Griffiths, Ernst Buning*, Emily Finch, Michael 90ssop and John Strang

The National Addiction Centre, London, UK and *International Bureau of GG&9GD, Amsterdam.

This is an edited part of a report on the delivery of substitution programmes in 11 European Union countries ( Farrell et al., 1996) . The full report on the Netherlands contains a description of three treatment programmes and attempts to describe the practical working of programmes to provide a context for the national overview.

Neither the Commission of the European Communities nor any person acting in the name of the Commission is to be held responsible for the use made of the information contained in this publication.

Unlike most European countries methadone consumption in the Netherlands has remained relatively level (Figure 1).

BACKGROUND

Drug abuse did not emerge as a social problem in the Netherlands until the late 1960s (Wijngaart, 1991). From the early part of the twentieth century opium had been used mainly in the Chinese communities in the harbour quarters in Amsterdam and Rotterdam. In addition there was a small contingent of 'physicians, nurses, pharmacists and artists' who had been opiate users as well as some iatrogenic addicts.

In the summer of 1972, cheap and high quality heroin suddenly became available in Amsterdam and as a result its use spread to new groups. The Suri namese population were recruited to heroin smoking or chasing the dragon ('Chinezen'). It appears that most of the heroin originated from the Golden Triangle until 1979 when Middle Eastern Turkish heroin took over the market.

SCALE OF THE PROBLEM

The total Dutch population is 15 million of who 1.2 million are 'foreigners' and 0.4 million originate from former Dutch colonies. In 1977 the total number of opiate addicts was estimated as 5000 (Wijngaart, 1991), in 1979 as 10 000 (Liefhebber, 1979) in 1982 as 15 000 (Buisman, 1983) and in 1988 24 286 (Driessen, 1990). In 1993 the official estimate of 'hard drug users' was between 21 000 and 25 000, of whom over 50% live in the four largest cities (Zwart and Mensink, 1993). The total number of problem drinkers is estimated at 200 000-400 000 and of pathological gamblers at 40 000-60 000.

DEVELOPMENT OF RESPONSE - GENERAL

Statutory outpatient services
Addiction care in the Netherlands has been the province of a national network of Consultation Bureaux for Alcohol and Drugs (CADs), offering exclusively outpatient ('ambulant') care, treatment, health education and consultation. There are 16 CADs throughout the country with 10 'treatment locations' and approximately 1400staf of whom 950 work directly with clients (IVX 1994b). Since 1991 they work with drug addicts, alcoholics and also with pathological gamblers (Hoekstra and Derks, 1993). The CADs were established from the 1930s as a probation initiative offering a service for alcoholics and funded by the Ministry of Justice.

Municipal public health services
With the growth of drug abuse in the late 1970s some municipal public health department (GG&GDs) in the major conurbations took a major role in the provision of services for chaotic addicts In 1991 five municipal health department (GG&GDs • Amsterdam, Utrecht, Eindhoven, Den Haag, Rotterdam) had methadone dispensing programmes jointly involving approximately 500( clients per year.

Local initiative
In 1991 there were approximately 36 organisations involved in service provision in a total of 45 municipalities (Tweede Kamer,1992), employing a total of 550 staff. These locally subsidised initiatives offer a number of low threshold services (drop ins, street corner work, vocational training and also methadone dispensing on 12 locations in the country) for special groups (e.g. particular ethnic groups or women) (IVV, 1994b). Their number has been decreasing over the years and they are currently in the process of joining up with CADs.

Inpatient services
There are currently 20 'addiction inpatient centres' in the Netherlands. Eleven are part of general psychiatric services while nine are dedicated inpatient services ('categorial psychiatric hospitals') with approximately 36 beds each (Hoekstra and Derks, 1993) which cater for alcoholics, drug addicts and pathological gamblers.

General practitioners
The role of GPs in addiction care is currently limited, although there are geographically some areas, such as Amsterdam, where their involvement is more substantial. There are no legal obstacles to GPs' involvement in the prescribing of methadone.

DEVELOPMENT OF RESPONSE - SUBSTITUTE PRESCRIBING

Exact data on early Dutch experiences with methadone are hard to obtain as general practitioners may have been prescribing well before the first published accounts of methadone treatment appeared (Wijngart, 1991). Methadone was first used systematically in the Amsterdam Jellinek Centre in 1968 (Liefhebber, 1979). According to Noorlander (1987) growing waiting lists and high drop-out problems in outpatient detoxification programmes gave rise to the first methadone programmes with a 'low threshold' description attached to them. Liefhebber (1979), evaluating methadone programmes, found large differences between individual low-threshold programmes and observed that most of them remained oriented to detoxification, especially those organised by the CADs but less so those that had been set up by private initiative or municipal health services. He estimated that, in 1979, there were 10 000 opiate addicts in the country, of whom 68% were in contact with the services and of whom, nationwide,1200receivedmethadone on an outpatient basis, i.e.17% of all treated addicts. However, there were large regional variations in this proportion of methadone treated addicts from 50% in Amsterdam to 396 in some rural areas. The role ot GPs in providing methadone dropped dramatically by 1979 as a result of a recommendation by the Health Council (Gezondheidsraad, 1972) that methadone should not be prescribed without psychosocial care.

Mobile methadone delivery initiatives developed in the main cities as ad hoc emergency responses to crises among ethnic minority drug users; the first buses were used in 1978 in Rotterdam and the Hague (Borger, 1979; Hormann,1979) and in 1979 in Amsterdam (Brussel and Buning,1979) .

In Amsterdam, where the demand was highest, the municipal health service developed a hi« profile in the low threshold care of addicts who were unable to access the statutory ( i .e. CAD) services. As a result, the CAD (Jellinek Centre) in Amsterdam has remained more focused on detoxification than CADs in the remainder of the country which had to take on the longer-term care of addicts themselves in addition to their traditional detoxification activities.

In 1981 the Inspectorate of Health sent a circular (the 'Methadone letter') to all doctors in the Netherlands (Staatstoezicht op de Volksgezondheid, 1981) cautioning general practitioners against taking on addicts for methadone treatment (either for detoxification or for maintenance) without establishing contact with the specialised institutions ( i.e. CADs). It urged GPs to hand out the methadone personally to the patients and cautioned against prescribing through retail pharmacists. It also warned that doctors would be carefully scrutinised in their dealings with addicts and their methadone prescribing behaviour.

Around this time a number cases were heard at the Medisch Tuchtcollege (the Dutch professional disciplinary body) against doctors prescribing opiates too freely to addicts. A result of the 'Methadone letter' was that addiction care (including methadone maintenance) became more or less exclusively the province of the CADs in most parts of the country except Amsterdam where an influential lobby of addiction doctors, GPs and representatives of the CAD and local initiatives emphasised the important role of primary care physicians in the management of straightforward cases. A condition of such GP involvement was that there should be immediate and unconditional access to secondary care and other more specialised services if cases turned out to be unmanageable. Traditionally, such a specialised network supporting GPs has existed in Amsterdam (Amsterdamse Werkgroep,1981). GP prescribing of methadone is negligible in the Netherlands except in Amsterdam where 200 of the 400 GPs prescribe methadone to opiate addicts and where a total number of 1300-1400 opiate addicts are being maintained in primary care.

In 1983 substantial resources were invested in the nationwide expansion of low threshold methadone maintenance programmes.

CURRENT SITUATION - EPIDEMIOLOGICAL INDICATORS

Total addict population
The current figure of 24 000 'hard drug users' is based on 1988 estimates by all outpatient institutions (i.e. CADs, municipal health services and private initiative) of which proportion of all addicts in their catchment they had seen at least once in the previous year (Driessen,1990). For many years, 'hard drug' use was regarded as virtually equivalent to opiate use. How ever, over recent years the pattern has changed with primary opiate dependence being the reason for referral of 25 % of new CAD clients whereas 30% are referred for cocaine and 30% for cannabis related problems (Van den Brink, personal communication).

Routes of administration
The proportions of injecting versus non injecting opiate users is not officially known for the total treated population, let alone for the drug using population at large. Among a random sample (n = 631) of methadone maintained clients (outside the big cities), 33% had injected heroin and 29% cocaine during the previous year (Driessen,1992). In a 1992sample (n = 783) of methadone clients in Amsterdam, 35% of Dutch clients had ever injected and 29% during the previous week (van Brussel,1993)

Mortality
There are few reliable epidemiological data concerning mortality (either overall or cause specific) among drug users (Spruit and Zwart,1993) and the officially published national figures (Table 1) are underestimates as illustrated by the fact that, although the national total death count (non-foreigners) for 1992 was 64, in Amsterdam alone, in that same year the count was 77 (Brussel,1993).

Table 1: Drug related mortality*

*not including foreigners

HIV/AIDS
Of all AIDS diagnoses in the Netherlands 8.5% concern intravenous drug users. It is estimated (Houweling and Jager,1993) that in 1990 there were approximately 9000-12 000 seropositive people in the Netherlands. HIV seroprevalence among intravenous drug users is estimatedat30% in Amsterdam and at less than 3% outside Amsterdam. On 1 July 1991 it was estimated that there were 750-800 seropositive injecting drug users in Amsterdam and outside Amsterdam about 500 (Zwart and Mensink, 1993).

CURRENT SITUATION - POPULATION IN TREATMENT

Outpatient
The national CAD network provides outpatient detoxification and methadone maintenance. In 1992 there were 55 991 clients registered at CADs and 30% (16 797) of these were opiate addicts. In this year there were 24 509 new registrations, 24% (5850) of which concerned opiate addicts (IVV, 1993); 8378 clients received methadone from the CADs in 1992 - it was 6511 in 1988 indicating a steady increase over the years. In addition to the approximately 8378 clients receiving methadone from the CADs, there is an estimated number of 5000 methadone clients in the six municipal public health programmes annually and an estimated 2600 in methadone programmes in private initiatives (Tweede Kamer,1992) . This would indicate a total of 15 978 methadone clients in 1992.

Table 2: Reported AIDS cases

However, it is accepted that there are at least 30% double registrations and hence the actual number of methadone clients would be between 13 581 and 15 978. In 1988,75 % of all methadone clients were on maintenance (Driessen,1990; IVV,1993).

These figures have to be interpreted with some caution because a patient is counted as soon as he picked up methadone even once in the administrative year; this is illustrated by the fact that the mean number of pick ups per methadone maintenance client in 1992 was only 79, indicating very high turnover rates of clients in services or a heavy emphasis on detoxification which is unlikely.

The relative importance of methadone treatment including maintenance in the Netherlands has increased sharply over the past decade and a half. It has been estimated that, in 1979,12% of all outpa tlent contacts were in the context of methadone maintenance (Liefhebber,1979), whereas in 1982 it was 50% (Buisman, 1983) and, in 1988 and 1"92, 72% (Driessen,1990; IW,1993) . The male female ratio is 3.5:1.The mean age of methadone clients has been increasing steadily over the past years indicating the presence of a 'stable', ageing, drug-using population.

Inpatient treatment
In 1991 the number of addiction (alcohol, drugs and gambling) inpatient beds was set at 0.8/1000 population and has recently increased to 1/1000 population (Tweede Kamer,1988; Hoekstra and Derks, 1993) Twenty inpatient services with a total of 1120 places ( i.e.1060 beds and 60 day places) are recognised for the treatment of addiction. Table 3 shows the number of inpatient admissions for drug addiction to any of the 20 institutions since 1988; the bulk of the increase in admission rate may be attributed to increased bed occupancy rates, and decreasing lengths of stay.

FUNDING OF SERVICES

Table 3: Admissions to the inpatient institution for drug addiction

The total annual running costs of the CADs were 145 million guilders in 1993 (IW,1994a).The total costs of the 'local initiatives' (funded through municipal subsidies) was, in 1993, 60 million guilders (Tweede Kamer, 1992). The government contributes 7 million guilders annually to the six municipal health departments which have methadone programmes (and municipalities may add further subsidies) (TweedeKamer,1992).

Funding of outpatient addiction care at the CAD's is currently a source of controversy in the Netherlands. Although inpatient services are funded through Public Health Insurance, the CADs rely on annual subsidies. Originally their funding came from the Department of Justice. From 1969 onward 60%of their funding was paid by the Ministry of Justice and 40% by the Ministry of Welfare, Health and Cultural Affairs (WVC) . Over the years, the relative contribution from the Ministry of Health has increased and currently 83% originates from the Department of Welfare, Health and Cultural Affairs and 17% from the Ministry of Justice (IVV,1994a). However, in 1990 the government decided to decentralise the funding of the CADs and allocate budgets, earmarked for outpatient addiction care, to 23 city councils with responsibility for the organisation of ambulant addiction services in their region (Tjdelijke Financieringsregeling Verslavingszorg = Temporary Financing Arrangement for (Ambulant) Addiction Care). It is now planned to stop earmarked funding for central subsidies in 1997 sothatlocalgovernmentscandecide how much they wish to spend on addiction care (Nationale Raad voor de Volksgezondheid,1994). This planned arrangement (Law Social Renewal), as well as a 10% cut in central government subsidies in 1994, has met with sharp opposition from the CADs, organised nationally in the NEVIV (Dutch Association of Institutes for Addiction Care) .

LEGISLATION (Silvis,1993)

The 'Opium Wet' (Opium Law)
In the 1818 Law on the Practice of Medicine, it is stipulated that

. . . poisons and narcotics may only be delivered by apothecaries, medical doctors, mid wives and surgeons on the basis of a prescription duly signed by a medical doctor, midwife or surgeon. Fine: 100 Dutch guilders.

Following the International Treaty of 1912 the first Dutch Opium Law (1919) was passed in 1919, outlawing the delivery, sale, import, export and manufacture of opium and its derivatives in the Nether lands, although mere possession or use of opioid sub stances was not contrary to the law. The second Opium Law (1928) did outlaw mere possession of the opioid substances. In a 1953 amendment to the 1928 law, the possession of hemp products was also outlawed. In addition, not only the possession but al the use of opiates, cocaine and hemp products became illegal and penal measures became harsher. Although the maximum custodial sentence under the 1928 Law was 1 year, this became 4 years following the 1953 amendments. In 1966 amphetamine were, by amendment, added to the list of Opium Law substances.

The period from 1953 to 1976 has been the only period that drug use as such was a criminal offence in the Netherlands. The spread of cannabis use among large parts of the juvenile population in the late 1960s and early 1970s confronted the authorities with the police's inability to enforce the law. The 1976 0pium Law can be seen as a pragmatic response to this. Its intention was and remains to increase the penal sanctions for use of and trade in 'hard drugs', to reduce the legal sanctions for trade in hemp products, and to reclassify the possession of hemp for personal use from a punishable offence to a punishable 'trespass'. The 1976 Opium Law distinguishes between 'Drugs with unacceptable risk' ('hard drugs') and 'hemp products' (Table 4). *

Heroin and cocaine are not classified as medical drugs and hence may not be prescribed by doctors. Theoretically, dispensation for the prescribing of these substances may be obtained from the Ministry of Health if the prescribing is in the context of scientific research. Methadone may be prescribed by any doctor and prescriptions are periodically checked by the Regional Inspector of Public Health via the dispensing pharmacies. The actual rules of prescribing (writing legibly, maintaining a register, etc.) are covered by the Law on the Provision of Medicines (Wet op de Geneesmiddelen voorziening).

Table 4: List 1 (unacceptable risk) and list 2 (not unacceptable risk) drugs with maximum penalties under the Opium Law, 1976

*Widely seen as an anomally

At different times there have been calls for the prescribing of heroin for addicts, e.g. in Amsterdam in the late 1970s, by the Rotterdam police in 1982, by the Amsterdam City Council in 1984, by the Councillor of Heerlen (see below) in 1994. The discussions about this issue have been heated and the KNMG (the organisation of physicians, compare GMC/BMA) has, during a 1984 discussion initiated by the Amsterdam City Council, indicated its rejection of heroin prescribing by doctors as heroin 'has no valid medical indication in the treatment of addicts'. The KNMG was especially opposed to the idea that doctors in this context could be seen to be used to limit crime rather than use the best medical treatment (Daniels,1984) and this has remained the position of the KNMG until now. However, at the moment of writing the report, the KNMG is moving to a new position allowing medical practitioners treating drug addicts to prescribe not only methadone and morphine but heroin and palfium as well. At present there are firm plans for the initiation of a trial of alternative opiate prescribing programmes which may be located in Rotterdam or Amsterdam.

CRIME
Almost 26% of CAD patients have been referred by the courts; 14% of CAD patients have, during the course of a 'treatment' year, had trouble with the law. Over the years, detected infringements on the Opium Law have increased from 1700/year in 1972 to3500/year in 1992 (Zwart and Mensink,1993). In 1991, 50% of all 21 000 Dutch prisoners were drug addicted (in addition to 10% addicted to alcohol) (NEVIV, 1993).Although during the 1980sdrug policies were mainly geared towards normalisation and limitation of risks for the individual user, the tide has turned to some extent with the publication, in 1988, of the government paper 'Dwang en Drang in de Hulpverlening aan Verslaafden' (Tweede Kamer, 1988) which sets out the desirability of 'diversion from custody schemes' in which the addict is given the choice between either imprisonment or inpatient detoxification for a number of mainly drug related and acquisitive offences. The NEVI5v' (the national organisation of CADs ) has summarised the activities which are taking place in this context (NEVIU 1993). There are 'street junky' projects in three cities now (offering diversion from custody); there are drug free units in 11 prisons. In approximately 10 localities in the Netherlands 'Dwang anc Drang Projects' are running.

CONCLUSION
Distinguishing features of the Dutch addiction treatment system are, among other things, its close integration between alcohol and drug services, and it ability to take responsibility for the treatment of pathological gambling.

Dutch outpatient services (like the Portuguese ones) developed from a probation background whereas inpatient services were established as part of the Health Service. The resulting budgetary split between in and outpatient services may increase the risk of reduced coordination between the two sectors. It is at present uncertain to what extent decentralisation of funding of outpatient services will result in decreased budgets for outpatient care. It is at present unclear who should take the lead the management of dual diagnosis patients. Concern with drug related crime and nuisance has resulted in increased government emphasis on detoxification of criminally involved addicts. Services face the challenge of a new wave of young ethnic minority drug users who are difficult to engage treatment.

A 1988 survey of all methadone dispensing institutions (Driessen, 1990) illustrates the staff shortages in services. The evolution of drug problems and changing social priorities have set a challenge for these services to provide more flexibility and to undergo thorough evaluation to demonstrate their efficacy and their current efficiency and cost effectiveness.

ACKNOWLEDGEMENT

JN is currently supported by a Wellcome Fellowship in Epidemiology. Thanks are also due to Professor Van den Brink and Drs Van Brussel and Van Santen in Amsterdam, for inforrnation and advice . This project was supported by funding from DG5 in the European Commission. The authors take full responsibility for the views expressed

Dr Michael Farrell, National Addiction Centre, 4 Windsor Walk, London SE5 8AF, UK.

REFERENCES

Amsterdamse Werkgroep (1981). Huisarts en hulpverlening bij heroinegebruikers. MedischContact46: 1415-19.

Borger J (1979). Methadon per bus in Den Haag. T. Alc. Drugs 5: 132-3.

Brussel GHA van, Buning EC ( 1979) . Methadon per bus in Amsterdam. T.Alc. Drogs 5: 1397.

Brussel GHA van(1993). Jaarverslag I992 Drugsafdeling. Amsterdam GG&GD.

Buisman WR ( 1983) . De ontwikkeling van de methadonverstrekking inNederland. T. Alc. Drugs 9: 24-9.

Daniels JJHM ( 1984.) Heroineverstrekking zonder meer; zonder meer geen behoorlijk medisch handelen. Medisch Contaa 18 (oKicieel).

Driessen FMHM (1990). Methadonverstrekking in Nederlanl. Utrechc Bureau Driessen.

Driessen FMHM (1992). Methadonclienten in Nederland.Utrecht: Bureau Driessen.

FarrellM,NeelemanJ,Gossop M, Griffiths P, BuningE, Finch

E, Strang J ( 1996) . A Review of the Legislation, Regulunon and Delivery of Methalone in 12 Member States of the European Union, in press. Brussels: European Commission.

Gezondheidsraad ( 1972). Advies inzake de behandeling van versluafden aanopiatenc.q. wekaminen. DenHaag SDU.

Hoekstra MJ, Derks JTM ( 1993 ) . Verslaving en Verslavwingszorg in Nederland. In: Handboek Verslaving. Houten Bohn Stafleu & Van Loghum.

HormannKS (1979). Methadonperbus inRotterdam.T.Alc.Drugs 5: 133-4.

Houweling H, Jager JC ( 1993) . AIDS en HIV infecties. In:VolksgexondheidToekonstVerkenning, degexondheidstoestand van de Nederlanase bevolking in de periode 1950-20I 0. Den Haag. SDU.

IW (1993).LADIS-1992.Utrecht.

IW (1994a). LADIS- I993.Urrecht.

IVV (1994b). Some information and statistical data about the addiction treatment services in the Netherlands. Utrecht.

Liefhebber J ( 1979) . Methadon Verstrekking inNederland. T.Alc. Drugs5: 124-31.

Nationale Raad voor de Volksgezondheid ( 1994).Kwatiteits beleidVerslsingszorg. Zoetermeer: NRV

NEVIV ( 1993) . Drang op Maat; operaaonalisering van dwang en drang met be trekking tot de hulpserlening aan vers laaflen . Utrecht.

Noorlander E (1987). De ontwikkeling van de methadonve strekking in Nederland. Medisch Contact 13: 402-4.

SilvisJ (1993). DeOpiumwet. In:HandboekVerslaving.Houterff BohnStafleu &VanLoghum.

Spruit IP, Zwart WM ( 1993). Druggebruik. In: Volksgezondhei, Tœkonst Verkenning; de gezondheidstoestand van de Neder landseivolkingindeperiodel950-2010.DenHaag:SDU.

Staatstoezichtop de Volksgezondheid ( 1981). Briefaan alleartsen inNederlandbetreffendede ambulante behandelingvan verslaafden aun opiumwetmiddelen. Den Haag: GHI.

Tweede Kamer der Staten Generaal ( 1988) . Dwang en Drang in 0 de Hulpverleningaan Verslaafden. Den Haag: SDU. |

Tweede Kamer der Staten Generaal (1992). Nota Verslavingsproblematiek. Den Haag: SDU. I

Wijngaart GF van de ( l 991 ) . Competing Perspectives on Drug Use. Amsterdam: Swets & Zeitlinger. |

Zwart WM de, Mensink C ( 1993). Alcohol. Tabak, Drugs en Gokken in Cijfers. Utrecht: NIAD. |