• Drug use among the general population and young people
• Prevention
• Problem drug use
• Treatment demand
• Drug-related infectious diseases
• Drug-related deaths
• Treatment responses
• Harm reduction responses
• Drug markets and drug-related offences
• National drug laws
• National drug strategy
• Coordination mechanism in the field of drugs
• Drug-related research

Drug use among the general population and young people

National prevalence surveys on drug use were carried out in the Netherlands in 1997, 2001 and 2005 among the general population, 15–64 years. In 2005, 22.6 % of respondents reported lifetime prevalence of cannabis (compared to 19.5 % in 2001 and 15.6 % in 1997). In the most recent survey, the gender gap regarding cannabis use seemed to be broadening: last year prevalence of cannabis was about 2.5 times higher among men than women, compared to almost 2:1 in the previous year. Lifetime prevalence of ecstasy use (4.3 %) increased significantly compared to previous years, and last year prevalence of ecstasy increased as well. Lifetime prevalence of cocaine increased compared to 1997.

Several national and local studies among other things inquiring also about cannabis use were carried out in the period from 2005–09 among the general population. The results are available from the report on the Netherlands drug situation 2010 and also 2011.

ESPAD surveys among students aged 15–16 have been carried out regularly for many years. The results concerning illegal drug use show an increasing trend for cannabis use since 1988, which stabilised between 1996 and 2003. In 2007, the lifetime prevalence rate of cannabis use was 28 % which is a similar result as in 2003. The percentage of students using other drugs such as ecstasy, amphetamines, cocaine or heroin is much lower. Inhalants were the most popular, with lifetime prevalence reported at 6 %, followed by ecstasy (4 %), cocaine and LSD (3 %), amphetamines (2 %) and heroin (1 %). Results indicated 25 % for the last year prevalence of cannabis use (23 % in 2003), 15 % for the last month prevalence of cannabis (13 % in 2003). In addition, the reported lifetime prevalence of cannabis use among males was 31 % and 26 % among females.

The results of the HBSC 2005 among those aged 12–16 years indicate a lifetime prevalence of cannabis use of 14.3 %, last year prevalence 11.7 % and the last month prevalence of 7 %. Differences between boys and girls were not significant. The trend for last year prevalence of cannabis has not changed significantly during recent years.

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Prevention

The main feature of the Dutch prevention policy is a strong focus on health promotion in general. The prevention activities are funded mainly by the Ministry of Health, Welfare and Sport. However, local municipalities are responsible for carrying out the prevention programmes in close cooperation with the schools and national entities involved in health promotion and substance prevention. Health prevention activities are mainly directed at the general public, but the focus is shifting gradually towards young people and people with low socioeconomic status, likewise activities in recreational settings, especially regarding party drugs, are of high priority.

Universal prevention is carried out within schools through the programme ‘the Healthy School and Drugs’ and outside school by the ‘Going Out, Alcohol and Drugs’ and ‘Alcohol and Prevention’ programmes. ‘The Healthy School and Drugs’ programme was established more than 10 years ago and remains the leading school-based prevention programme in the Netherlands. The programme comprises several lectures in secondary school on alcohol, tobacco and cannabis. Recently, the programme was amended by several new e-learning modules for lower vocational education and on driving under the influence. ‘Going out, alcohol and drugs’ tries to prevent or reduce health and safety problems related to drug use among young people in recreational settings. The project ‘Alcohol and education’ provides advice and supports parents of children aged under 16, to prevent alcohol misuse outside school. A new type of prevention at home is the Home Clinic that can be contacted by parents who are suspicious about their children’s or their partner’s drug-related behaviour. On request, an anti-drug and alcohol team will visit the parent(s) at home for training them in recognising drug use and acting against it. Due to the costs of these courses (EUR 4 500 — for the total course), parents are advised to start a course together with other parents.

Selective prevention is mostly targeted at youths on the streets and in party settings, and is carried out by NGOs in cooperation with government services. These programmes focus on the implementation of safe clubbing regulations and person-to-person interventions in club premises. The Dutch Strengthening Families Programme focuses on (children of) parents with substance abuse problems. It is based on the principles of the Australian evidence-based Triple P-programme (Positive Parenting Programme). The aim is to improve mental health of both children and parents by changing parental behaviours and creating a ‘positive’ family atmosphere. In 2010, the Centre on Safe and Healthy Nightlife, was opened within a framework of the EU-funded project mainly focusing on collection and dissemination of best practices to reduce substance abuse in recreational settings and providing tools for professionals.

In indicated prevention, it is assumed that disruptive behaviour in middle childhood results in less favourable chances in life, and higher risks of substance abuse and criminality in adolescence. Two Dutch projects are based on these insights. The first project, the Parent Management Training Oregon (PTMO), is gradually implemented in the Netherlands for parents of children (4–12 years) with disruptive behavior disorder. It encourages new behaviours, reinforcement of good behaviour and discouraging wrong behaviour, keeping track of the child, finding solutions for problems raised, encouraging to stick to agreements and to stay engaged. Secondly, the experimental Coping Power programme offers cognitive behavioural therapies for children and manualised behavioural interventions for parents to improve parenting behaviour and reduce disruptive child behaviours. A five-year follow-up among 61 of the initial 77 participants when compared to a matched healthy control group, showed significantly better results on delinquency and substance use for the intervention group when compared to both the care-as-usual group and the matched healthy control group.

In 2010, a two-years long national mass media campaign `Smoking, alcohol and cannabis education: advice and support to parents` was initiated to target parents with children of 10 to 16 years of age.

Special characteristics of the prevention culture in the Netherlands within the European context are: the delivery of universal prevention through one national prevention programme, a high degree of development and research on prevention in party settings, and the development of drug prevention and counselling via the Internet.

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Problem drug use

Several national studies have estimated the number of problem opiate users in the Netherlands over the past 20 years using different methods (treatment multiplier, regression imputation, multiple imputation). In 2008, the most recent estimate was calculated by means of treatment multiplier and suggests a total of 17 700 opiate users in the Netherlands (95 % confidence interval from 17 300 to 18 100). Available data indicate a decline in the estimated number of opiate users since the beginning of the century. Ageing of the opiate users and low popularity of opiates among younger drug user groups are suggested as reasons for the trend.

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Treatment demand

The National Alcohol and Drugs Information System (LADIS) is the most comprehensive information system on treatment demand clients in the Netherlands. LADIS contains data from the regular drug treatment services, including probation services, and provides nationwide coverage. In 2009, a total of 201 out of the 212 outpatient and inpatient units and low-threshold agencies submitted treatment demand data to LADIS.

In 2009, a total of 11 650 clients entered treatment, out of which 6 196 were first time treatment clients. Data suggest that 38.4 % of all clients entering treatment reported cannabis as their primary drug, followed by 31.4 % for cocaine and 18.2 % for opioids. Among clients entering treatment for the first time, a slightly different distribution was identified with 50.4 % requesting treatment for cannabis followed by 26.8 % for cocaine and 7.9 % for opioids.

Furthermore, in 2009, 42 % of all clients entering treatment were older than 35 years. A lower percentage in age distribution was reported among new treatment clients, with 31 % older than 35 years. The majority (81 %) of all clients entering treatment were males. A similar gender share was reported for first-time clients with 77 % for males.

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Drug-related infectious diseases

The Dutch HIV surveillance within the National Institute of Public Health and the Environment uses repeated surveys among drug users in four fixed cities (Amsterdam, Rotterdam, Heerlen-Maastricht and Arnhem) and two optional cities. Since 2001, one fixed city has been studied per year. In these surveys, hard drug users of heroin, cocaine, methadone and amphetamines are recruited in methadone centres and on the street.

Three sources of surveillance data with regard to HIV among injecting drug users are currently providing data on newly-diagnosed HIV infections. In 2009, 692 new HIV diagnoses were reported in the treatment centres. In one case (0.1 %), injecting drug use was the most likely route of transmission. Injecting drug users were defined as those who injected once or more in their lifetime and who have used hard drugs on at least one day per week in the past six months.

In Amsterdam, none out of the 46 injecting drug users in methadone substitution treatment tested in 2009 were HIV positive.

The last notifications on acute hepatitis B infection in injecting drug users were received in 2007, when two cases were reported. In 2009, six out of 1 251 chronic hepatitis B infections were linked to injecting drug use. About 47 acute hepatitis C infection cases were reported in 2009, however, only 38 had a known transmission route. For three cases, injection drug use was reported as the likely transmission route. Available data from the Amsterdam Municipal Health Service suggests hepatitis C prevalence rates of 54.3 % among 35 tested injecting drug users.

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Drug-related deaths

The main source providing the official Dutch statistics on drug-related deaths is the General Mortality Register or Causes of Deaths Statistics managed by Statistics Netherlands (CBS). The register has national coverage and includes only residents of the Netherlands. Cases are classified according to ICD-10 and refer mainly to direct or acute deaths (drug overdoses). Data about drug-related deaths among non-residents are available from a separate database.

In 2009, 139 drug-related deaths were registered (129 in 2008, 99 in 2007, 112 in 2006, 122 in 2005). Looking at the distribution by age and sex, the majority of cases were male (79.8 %) and the mean age was 40.8 years.

The total number of drug-related deaths increased from 1996 to 2001. This rise may be partly due to the switchover of ICD-9 to ICD-10 in 1996, and to the increasing number of cocaine intoxications. Following this increase, DRDs decreased anew to 103–104 cases in 2002–03, followed by a new upward trend observed in 2004 (127 cases), before the consecutive falls in 2005 and 2007. In 2008–09, a new upward trend was observed.

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Treatment responses

In the Netherlands, the responsibility for the organisation, implementation and coordination of addiction care is delegated to regional and local authorities. Drug treatment is mainly delivered by non-governmental organisations on a regional level, followed by private organisations including physicians, hospitals and private clinics. Drug treatment is also provided in regional public hospitals. In the past decade, however, the number of addiction service providers has reduced considerably due to many mergers which took place in the Dutch mental healthcare and addiction care, for economic reasons. In 2009, addiction care was provided at 13 regional organisations. Additional organisations that take care of addicted persons are the municipal health services, general psychiatric hospitals, several religious organisations, and some 10 private clinics. The private clinics and the addiction units in general psychiatric hospitals do not participate yet in the National Alcohol and Drugs Information System (LADIS).

Funding for drug treatment is mainly provided by the public budget at national and local level. Detoxification and residential treatment is funded by health insurance.

Possibilities for drug treatment interventions in the Netherlands are diverse. Outpatient substitution treatment is dominant for opiate dependence. Psychosocial interventions are again more frequently provided to complement substitution treatment in order to attain longer term effectiveness and to reduce relapses and to promote social reintegration.

Types of frequently-used psychosocial treatments in drug treatment centres are motivational interviewing, relapse prevention techniques, cognitive-behavioural therapies, family, community and home-based treatment therapies.

Since 1968, methadone is the most commonly prescribed substitution substance. Heroin-assisted treatment (HAT, introduced in 1998) and high-dosage buprenorphine treatment (introduced in 1999) are also available. HAT is only provided in specialised treatment centres and is meant for a restricted and controlled group of treatment-resistant opiate users. Methadone, on the other hand, is available via various outpatient treatment providers, including office-based practitioners and mobile units.

According to the latest available data (2009), a total of 10 624 clients were in opioid subtitution treatment, of whom an estimated 9 909 were on methadone maintenance treatment, including 715 clients receiving diamorphine prescriptions.

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Harm reduction responses

In the Netherlands, the difference between outreach work, low-threshold services, harm reduction activities, and the term ‘social addiction care’ is hard to define. The first target is to get in contact and maintain contacts with hidden populations. All four deal with motivating difficult-to-reach drug users (hidden populations) to participate in some kind of treatment to prevent a worsening of their life situation (individual and/or social). If this is not feasible, support is given to these drug users for reducing drug-related harm.

Most outreach work is carried out by low-threshold services in outpatient care facilities. These services are active in ‘street corner work’ offering daytime shelter in drop-in centres for street problem drug users, ‘living room’ projects for drug-using prostitutes and drug consumption rooms for chronic hard drug users. Other target groups of these services are injecting drug users, extremely problematic drug users, and drug users from foreign countries. Outreach activities also feature in programmes for reducing drug-related public nuisance, which are often a joint venture between treatment and care facilities, police and civil groups. Outreach work today is often education ‘on the spot’ (i.e. where young people meet) applying peer-support techniques. Another one is targeting drug users who have been sentenced to prison, e.g. pre-release counselling.

Facilities for needle exchange or syringe exchange exist for more than 20 years in the Netherlands and are available in all major Dutch cities. Needle exchange programmes are mainly implemented by street workers, workers of institutes for addiction care and, to a much lesser extent, by pharmacists. Around 175 fixed needle and syringe programmes are known in the Netherlands (150 in specialist agencies and 25 pharmacy-based needle and syringe exchange programmes). There is no national registration data on the number of exchanged syringes or needles. However, data from Amsterdam show that from 1990 to 1993, approximately one million needles were exchanged. Since 1993, there has been a sharp decline to 283 000 syringes in 2009.

Since 2002, the national hepatitis B vaccination campaign targeting behavioural risk groups has been implemented. This campaign offers screening for hepatitis B infection and following vaccination of susceptible persons. Approximately 17 500 IDUs have been benefiting from the programme since its inception. The screening and vaccination of drug users usually takes place in addiction care institutions or by the municipal outreach services.

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Drug markets and drug-related offences

The Netherlands has a pivotal position within international trade, and thus plays a major role as a drug market and, more importantly, as a transit country for heroin and cocaine. The supply of heroin to Europe, including the Netherlands, is mainly dependent on the production of opium in Afghanistan. The Netherlands is an endpoint of the Balkan route, and heroin is distributed to other western European countries from the Netherlands. Cocaine is supplied from Latin America to Europe. The Caribbean countries, in particular the former Dutch colonies, played a major role in the trafficking of cocaine. However, in recent years, African countries partly took over this role.

In 2009, the National Crime Squad dismantled 24 synthetic drugs production locations while in 2008, 21 of these facilities were seized. The increase is mainly due to the number of amphetamine production sites, which was three times higher than that in 2008, and the production of so-called `designer drugs`.

Data on drug seizures in the Netherlands are registered centrally by the National Police Agency. The registration concerns data from the regional police departments, customs, the Royal Military Police, as well as from the Synthetic Drugs Unit (now part of the National Police Force). Under-reporting and the lack of a uniform registration system hamper the quality of the data collected and thus trends cannot be reported.

In 2009, the total number of 17 032 offences against the Opium Act were reported, which is less than when compared with the number of the reports in 2008 (18 849). More than two thirds of reported cases are supply-related offences and slightly more than half of all reports are linked to cannabis.

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National drug laws

The Netherlands Opium Act which came into force in 1928 and was fundamentally amended in 1976, is the basis for the present drug legislation. It defines drug trafficking, cultivation and production, dealing and possession of drugs as criminal acts. The act and its amendments confirm the distinction between 'hard' (like cannabis or hallucinogenic mushrooms) and 'soft' drugs (heroin, cocaine, ecstasy, amphetamines). This distinction is determined by a 'risk scale', based on medical, pharmacological, sociological and psychological properties of a substance.

Drug use does not constitute a crime in legal terms. However, there are situations when the use of drugs is prohibited, such as for instance schools and public transportation. It is up to the responsible authorities — which is not the national government — to regulate this.

The possession of small quantities of drugs for personal use is accorded a much lower priority. Anyone found in possession of less than 0.5 grams of Schedule I (i.e. 'hard') drugs will generally not be prosecuted, though the police will confiscate the drugs and consult a care agency. As for cannabis, a maximum of 5 grams will not lead to investigation or prosecution.

Drug users are convicted when they have committed a crime such as selling, theft, robbery or burglary. A special law — Placement in an Institution for Prolific Offenders (ISD) — was introduced in 2004, meant for the treatment of criminal drug users in prison-like institutions.

Importing and exporting of any classified drug is considered a serious offence. The penalty for hard drug trafficking can run up to 12 to 16 years.

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National drug strategy

The Netherlands’ 1995 white paper ‘Drug policy: continuity and change’ formulated the basic principles of the Dutch drug policy: a distinction between ‘soft’ and ‘hard’ drugs; a balanced and integrated approach; and four major objectives. These are: (i) to prevent drug use and to treat and rehabilitate drug users; (ii) to reduce harm to users; (iii) to diminish public nuisance caused by drug users; and (iv) to combat the production and trafficking of drugs. This White paper, which addresses only illegal drugs, was complemented in subsequent years by several specific strategies in the supply reduction field: dismantling ecstasy production locations (2001); stopping cocaine trafficking by drug couriers using airplanes, especially body-packers (2002); and dismantling large-scale cannabis cultivation (2004). During 2010/2011, the drug policy will be updated.

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Coordination mechanism in the field of drugs

The responsibility for Dutch drug policy is shared between several ministries. The Minister of Health, Welfare and Sport is responsible for coordinating the drug policy, and the Ministry of Security and Justice is charged with law enforcement and matters relating to local government and the police.

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Drug-related research

Drug research in the Netherlands is extensive and covers many domains. Public funding of drug-related research is to a large extent delegated to intermediary agencies, although ministries and municipalities also directly fund a considerable amount of research projects. Many academic institutions are involved in drug research, sometimes together with researchers from institutes for addiction care. A national meeting is organised annually for drug researchers to stay informed about recent developments. The number of publications in national and international scientific journals is extensive. The development and implementation of multidisciplinary evidence-based guidelines, protocols and training materials are the most important dissemination channels for drug-related research findings from the scientific community to practitioners and decision makers. The Netherlands national focal point maintains part of the website of the Trimbos Institute to disseminate reports on research findings. Recent drug-related studies mentioned in the 2010 Dutch National report mainly focused on aspects related to responses to the drug situation, consequences of drug use and experimental drug treatment methods.

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