• 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.

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. Drug prevention focuses on recreational settings, especially regarding party drugs and the implementation of curricular school-based prevention programmes.

Universal prevention is carried out within schools through the programme ‘the Healthy School and Drugs’ and outside school by the programmes ‘Going Out Alcohol and Drugs’ and ‘Alcohol and Prevention’. ‘The Healthy School and Drugs’ 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. ‘Going Out Alcohol and Drugs’ tries to prevent or reduce drug use among young people in recreational settings. ‘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 parent behaviours and creating a ‘positive’ family atmosphere.

In indicated prevention, it is assumed that disruptive behaviour in middle childhood results in less favourable chances in life, and higher risk 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 behaviour 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. Second, 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 5-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.

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 of prevention in party settings, and the development of drug prevention and counselling via the Internet. Currently, an e-learning module has been developed on alcohol, drugs and driving. The effectiveness of the Digital Alcohol Module is now being evaluated.

Dutch mass media campaigns on cannabis were carried out annually but since 2008 the funding of these campaigns has been stopped.

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Problem drug use

Several national studies have estimated the number of problem opiate users in the Netherlands over the past decade using different methods (treatment multiplier, regression imputation, multiple imputation). However, the most recent estimate dates back to 2001 and might therefore be outdated.

Updated estimates are available on the subnational level. In Amsterdam, there were estimated to be 2 812 (2 648–2 976) problem opioid users in 2007. This corresponds to a rate of 5 (4.7–5.3) problem users per 1 000 inhabitants aged 15–64 years. Problem opiate users were defined as those who have medical and/or judicial problems and/or have difficulties controlling their addiction. Estimates for Amsterdam have been available since 1985, and a comparison shows that the number of Dutch and ethnic Dutch users remained relatively stable throughout the years, while the number of foreign drug users declined, particularly between 1988 and 1997. The national estimate of problem drug users will be updated during 2009.

The EMCDDA defines problem drug use as intravenous drug use (IDU) or long duration/regular drug use of opiates, cocaine and/or amphetamines. Ecstasy and cannabis are not included in this category.

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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. The LADIS contains data from the regular drug treatment services, including probation services, and provides nationwide coverage. In 2007, a total of 150 out of the 160 outpatient units and low-threshold agencies submitted treatment demand data to the LADIS.

In 2007, a total of 8 718 clients entered treatment, out of which 6 078 were first time treatment clients. Data suggest that 37.2 % of all clients entering treatment reported cannabis as their primary drug, followed by 31.8 % for cocaine and 19.7 % for opioids. Among clients entering treatment for the first time, a slightly different distribution was identified with 44.9 % requesting treatment for cannabis followed by 29.1 % for cocaine and 11.8 % for opioids.

Furthermore, in 2007, 36 % of all clients entering treatment were older than 35 years. A lower percentage in age distribution was reported among new treatment clients, with 28 % older than 35 years. The majority (82 %) of all clients entering treatment were males (82 %). A similar gender share was reported for first-time clients with 80 % 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. The HIV prevalence rate in 2007 among injecting drug users (IDUs) is estimated at between 0.8 % and 5 %. 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.

The infection rate among IDUs for the HBV antigen was reported at around 30.6 % in 2007. As regards HCV, no national aggregated data exist for 2007, due to missing data from some services and to the overall change of the registration system.

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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 data base.

In 2007, 99 drug-related deaths were registered (112 in 2006, 122 in 2005). Looking at the distribution by age and sex, the majority of cases were male (79.3%) and the mean age was 39.5 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.

Data on overdoses are also available for Amsterdam from the Municipal Health Service of Amsterdam, which combines data from the Central Methadone Register, the municipal register’s office, coroners’ reports, hospital records and the police. The data also include foreigners that are not included in the population registry. In 2007, there were 25 overdoses which remains within the overall observed trend over last years  (21 in 2006, 29 in 2005 and 22 in 2004). Most of the drug users died from a mixture of drugs, usually involving opiates, cocaine and other substances.

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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. 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. After several years of neglect, 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 and family therapies.

Since 1968, methadone is the most commonly prescribed substitution substance. Heroin-assisted treatment (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 opiate users. Methadone on the other hand, is  available via various outpatient treatment providers, including office-based practitioners and mobile units.

In 2007, a total of 12 715 clients were in opioid subtitution treatment of whom an estimated 12 000 were on methadone maintenance treatment.

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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 user 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 exists 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. The total number of needle exchange programmes in the Netherlands is not known, nor are there national registration data on the number of exchanged syringes or needles. However, data from Amsterdam show that from 1990 to 1993, around one million needles were exchanged. Since 1993, there has been a sharp decline to 200 800 syringes in 2006.

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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 countries from the Netherlands, especially Belgium, France and the UK. 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. In recent years, African countries partly took over this role. In the Netherlands, the role of the maritime trade for cocaine trafficking seems to decrease while trafficking by air is gaining importance.

The Netherlands is an important production country for ecstasy and amphetamines. Most of the amphetamines and ecstasy seized in the EU come from the Netherlands. In 2006, the National Crime Squad carried out 22 investigations into synthetic drugs and 23 production locations were dismantled in 2006, nine of these laboratories were producing amphetamines and five laboratories were producing MDMA. Finally, 52 warehouses of hardware and precursors were dismantled. Most production locations were found in the west and the south of the Netherlands. In 2007, there were a total of 19 196 reports of  drug related offences, out of which 47.6 % were cannabis related offences.

Data on drug seizures in the Netherlands are not registered centrally but instead the National Police Agency annually collects 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). Underreporting and the lack of a uniform registration system hamper the quality of the data collected and thus trends may be influenced by collection strategies and investigation efforts.

The retail price of herbal cannabis in 2007 was EUR 7.7 per gram whereas the retail price for herbal cannabis was EUR 4.3 per gram. Retail prices of other drugs have not changed significantly over the past three years. In 2007, the price of an ecstasy tablet varied between EUR 1 and EUR 5 and the price of cocaine between EUR 10/gram and EUR 20/gram. Amphetamine is much cheaper than cocaine, and costs between EUR 1/gram and EUR 15/gram which is sometimes a reason why it is used as a replacement for cocaine.

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National drug laws

Dutch drug legislation is based upon the principle of the separation of the markets for cannabis and other illegal drugs. Thus, illicit substances, according to the Opium Act, are divided into two lists: substances presenting unacceptable risks (list I) and other substances (list II) such as cannabis, also known under the non-legal terms of ‘hard’ and  ‘soft’ drugs. Penalties for offences involving list II substances are lower than those for list I.

In the Netherlands, the possession of small amounts of drugs for personal use is tolerated in certain cases. However there are situations where the use of drugs is prohibited (i.e. use in schools). The possession of small quantities of drugs for personal use (less than 0.5 grams of hard drugs (list I) and less than five grams for cannabis (list II)) will generally not lead to prosecution, unless it causes public nuisance. Possession of drugs for commercial purposes will be prosecuted and penalties may range from one month imprisonment and/or a fine, to eight years and/or a fine, depending on the quantity and the type of drug. The maximum penalty may be even higher if the crime has been committed more than once. The sale of cannabis in ‘coffeeshops’, while technically illegal, is tolerated under strict conditions.

Within the framework of the Opium Act, importing and exporting of any classified drug is considered a serious offence and can be punished by a penalty ranging from four years of imprisonment and/or a fine to up to 16 years of imprisonment depending on whether a ‘hard drug’ or a ’soft drug’ was involved. In 2001, a special law was introduced which aims to deliver treatment in prison-like institutions to drug users who are ‘prolific’ offenders. In 2004, a new similar act for all prolific offenders came into effect.

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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 2009, 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 Justice is charged with law enforcement, while matters relating to local government and the police fall under the jurisdiction of the Ministry of the Interior and Kingdom Relations.

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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 national focal point maintains a website to disseminate reports on research findings.

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