'Tailor-made' provision of methadone in Amsterdam
by Ernst Buning
This article describes the provision of methadone in Amsterdam. In the 1970's, a small scale and high threshold methadone programme was developed by the Jellinek Centre. Because of the limited scope of this programme, general practitioners (GP's) and the Amsterdam Municipal Health Service (GG&GD) developed a differentiated system in the 1980's. Currently, methadone is provided in a 'tailor-made' way, ranging from weekly take home dosages prescribed by GP's, to regular attendance at an low-threshold harm-reduction outpatient clinic or participation in a psycho-therapeutic methadone programme.
We estimate that in Amsterdam we have about 5,000 to 6,000 people on heroin (The total number in The Netherlands is estimated about 25,000, so about 25% live in Amsterdam). In Amsterdam, about 60% of the heroin addicts are not injecting. They are chasing the dragon. Among the 40% who inject the heroin (about 2,500), about 30% are HIV positive (about 800 persons).
Amsterdam heroin addicts who want to stop using drugs can go to outpatient and inpatient facilities which are offered by the Amsterdam Jellinek Centre.
For those who are not in touch with the drug free helping system, so called ‘harm reduction’ facilities are offered. In Amsterdam harm reduction is defined as follows: 'If a drug user (male or female) is not capable or willing to give up his drug use, he should be assisted in reducing the harm he is causing to himself and his environment'.
One of the tools in a harm reduction strategy is methadone. In Amsterdam methadone is used in three ways:
The Amsterdam Municipal Health Service (GG&GD) operates a number of different methadone programmes:
The GG&GD employs a special team which is in touch with the general hospitals. They visit wards where drug users are admitted and they speak with the staff and the patient. The aim of this intervention is to enable normal medical treatment of drug addicts who are admitted to a hospital for a medical reason. We have experienced that hospital staff have a tendency to show an extreme attitude towards drug addicts: they either ‘pamper’ them or they ‘hate all those criminal junkies’. Such extreme attitudes sometimes hinder the continuity of medical care and can lead to patients premature departure.
If clients are doing very well in one of the programmes, we might contact the general practitioner and ask him/her to continue the maintenance treatment. About 200 of the 400 GP’s in Amsterdam prescribe methadone. Normally, this means that the patient sees the GP once a week. The GP gives a prescription, which the patient takes to the pharmacist.
If a patient needs psycho-therapeutic assistance, the patient might be referred to one of the programmes in the Jellinek Centre. This centre also provides methadone. This is done in a very strict manner (urine samples, no tolerance of use of illegal drugs, mandatory contact with counsellor etc.)
Data collected in the period that we expanded the low-threshold methadone programme (1981-1988) show that in that same period the number of clients making use of drug free treatment also increased. This means that the assumption that harm-reduction programmes discourage drug users to make use of drug free treatment turned out to be untrue in the Amsterdam situation.
Overall, the Amsterdam helping system is in touch with about 70 to 80% of the drugs users. Since 1984, the number of drug users who die after an overdose has declined to about 30 a year. Compared to other Western European cities, this number is very low. The average age of Amsterdam drug users has consistently increased to about 37 in 1996, whilst at the same time the percentage of young drug users has declined. This means that Amsterdam has a rather stable chronic group of addicts, with hardly any ‘newcomers’.
In conclusion it can be said that the policy which Amsterdam has developed in the last two decades seems to have been rather effective, but not ideal: we still have a group of drug addicts which presents considerable problems. However, we can be a little optimistic, since we do not have many new heroin addicts, and youngsters do not seem to want to drop out in the drug scene as much as they did in the 1970's. Fundamental in both prevention, treatment and harm reduction is our aim not to marginalize drug use and drug users, since we believe that if we expect drug users to behave in a responsible manner, society should not reject and exclude drug users, but rather stay on speaking terms with them and listen to them.