Prevention Philosophy
One of the premises of drug prevention policy and education is that information should be
presented in a realistic and non-moralistic manner, emphasising a personal responsibility
for one's health.
Information and education activities for young people,
have been around for years. Initially, they consisted primarily of a transfer of
knowledge, combined with warnings and cautions. But research showed that this had no
effect or even a negative effect. What is more, young people have a natural need to
experiment and much experimental use does stop eventually. These days, a key premise is
that it is better to steer the inevitable experiments in the right direction by means of
credible information and education. Which is why these have to be backed up with facts and
any exaggeration of the risks has to be avoided. Alcohol and drug use have been stripped
of their taboo image and of the sensational and emotional tone of voice that did in fact
act as an attraction. What has to be prevented, however, are any permanent harmful effects
due to experimenting, whether or not this is the result of pressure from peers or others.
Research showed that education increases knowledge and changes attitudes but has
insufficient effect on actual behaviour. Broader-based prevention programmes are therefore
considered more important in the Netherlands. In addition to offering knowledge, therefore
also promote behavioural skills, such as increasing the resistance of young people,
teaching them to deal with peer pressure and improving their decisiveness.
The difference between primary and secondary prevention is
getting smaller and smaller. For both, risk reduction is the main focus. The message in
prevention is: use sensibly.
Structure of Prevention Activities
The Dutch government creates the conditions for the development, implementation and
evaluation of prevention, information and education. The implementation occurs in a
variety of institutions such as schools, local and regional addict care organisations, The
Municipal Health Services, the police and several national bodies.
The National Prevention Support Centre
The National Support Centre on Drug Prevention (Landelijke Steunfunctie Preventie -
verslaving en middelengebruik), which is subsidised by the Ministry of VWS, co-ordinates
and supervises the prevention efforts. Programmes of work are co-ordinated in consultation
with the heads of prevention departments and priorities are specified for development,
standardisation and research. Next to this task the LSP offers a help desk for the
institutions offering assistance with information provision, the promotion of expertise,
and innovation. The LSP ensures that there is a coherent relationship with prevention
activities in the field of mental care and therefore it is structurally linked with the
National Prevention Support centre for the Mental Health Care sector. The programmes of
these bodies are co-ordinated and priorities set during primary consultations and half
yearly meetings to discuss their schedule of work. These priorities include the
improvement of quality , collaboration in connection with the internet and the
consolidation of secondary prevention. The LSP also works together with the prevention
development centre within the context of the programme ‘Achieving Results’ .
Amongst other things this centre is involved in developing an Electronic Prevention
Project File,(EPPD). This tool will make a major contribution to daily operations and will
also promote the standardisation of preventive intervention and the potential for
evaluation.
Primary prevention, Examples of National Primary
Prevention Activities
National Campaign: Drugs Do Not Be Fooled !
The Trimbos Institute in collaboration with over 60 regional addict care
institutions and Municipal medical and Health Services organised a campaign in 2000 and
2001 entitled: ‘Drugs do not be fooled’( Drugs, laat je niks wijsmaken !). Its
aim was to encourage and to improve the communication about drugs between young people and
their parents, and to influence the information seeking behaviour of young people.
The Drugs Information Telephone Line
In 1996, the Drugs Information Telephone Line was launched to improve the provision of
information and education activities relating to drugs. This project is part of the
Trimbos Institute and is aimed at meeting the demand from the general public for factual
and reliable information. Intermediary groups, the public and the media can use it as a
source of information. National and local institutes and government authorities are
supported with services and products, such as improving the quality of products,
distributing information materials and conducting information and education campaigns.
There is a database with existing information and education materials, and information is
provided via the Internet. The telephone line is open 24 hours a day. They can choose to
be sent printed information about drugs or to have personal talk with a member of the Drug
Information Line’s staff. The callers can also be referred to a regional institute
for further assistance.
In 2001 34% (11.017) opted for a personal call compared to
28 % (9.816) in 2000. The drugs about which the largest numbers of questions are asked
were cannabis,; these were followed by XTC and then cocaine. Most of the questions were
about the risks of use. The peak number of calls was connected with the afore mentioned
campaign "drugs, do not be fooled’. The number of the Drug Information line
appeared prominently in all the publicity of the campaign.
Healthy Schools and Stimulants
The project 'Healthy schools and substances' (gezonde school en genotmiddelen),
specifically aimed at secondary school pupils, was launched in 1991. The project is a
co-operative effort on the part of the Trimbos Institute, the out-patient facilities for
addiction care and local public health services, together with local authorities. The
project provides information on tobacco, alcohol, cannabis and gambling, aimed
specifically at the ages at which students generally have their first contacts with the
substance in question or with gambling. For cannabis this is usually around 15 years old.
Besides providing information, the project is also aimed at establishing regulations (no
substance use in schools), detection and guidance. By mid 1996, 30% of schools were
implementing this project on a structural basis. In 2001 the number of participating
secondary schools had increased to 75%.
The ResCon research centre evaluated the project over the
period 1995-1998 . It reveals that its combination of an informative approach with an
individual-oriented approach is producing an effect. Students in schools where this
project was carried out show greater awareness in their dealings with tobacco, alcohol and
cannabis, and are better informed about these substances. Different groups of school
students also showed a lower frequency of use, and their intention to use drugs appeared
to be lower than in schools where the project was not carried out.. In addition students
attending schools participating in the project know better than their counterparts at
other schools whom they can approach about problems connected with drug use.
The project has recently been updated and its scope has
been expanded. Various new interventions have also been added. One example of these is
’No deal!’, which provides schools and support institutions withguidelines for
collaborating with the police to combat drug dealing in and around
schools. Another project is ’Active Pupils’
[Actieve leerlingen], which fits in with the trend towards the use of pupil-mentor
relationships in the education sector.
For information on primary prevention activities and XTC
see: prevention policy on XTC
Secondary Prevention: Harm Reduction
Harm reduction can be defined as follows:
If a drug user (man or woman) is not capable or
willing to give op his drug use, he should be assisted in reducing the harm caused to
himself and others.
In this definition, the type of drug is unspecified,
inferring that any drug, be it legal or illegal, can either be used in a ‘hard’
or ‘soft’ manner. It speaks about ‘user’ rather than
‘addict’ or ‘abuser’, implying that irregular use of drugs could also
cause harm (for example overdose taken by inexperienced user). The definition refrains
from moralism, and assumes that, if someone continues to use drugs, this should be
accepted as a fact. However, this should not be interpreted as defeatism, since the
definition clearly speaks about ‘should be assisted in reducing the harm.....’ ,
which indicates that society and helping agencies have an obligation to do something. The
definition sees a modest role for the helping agencies (‘assisted’) and trusts
in self-regulation and self-determination of drug users. Furthermore, it talks about
‘reducing’ and not about ‘elimination’ of drug related harm. Finally,
‘harm’ is defined as harm drug users cause to themselves as well as to others.
Harm Reduction in Practice
Assistance to drug addicts, who are either unwilling or unable to give up drug use, is
aimed at the reduction of health risks and the improvement of the addict's quality of
life. In order to reach as many addicts as possible harm reduction activities are usually
incorporated in low-threshold programs. These activities can be: the provision of
methadone, sterile needles, food, medical care user rooms, accommodation etc.
Secondary Prevention Activities
Methadone Programmes
One of the key elements of assistance to drug addicts in
the Netherlands is the supply of methadone to replace heroin. From the LADIS report
2000 it appears that a total of 13.500 hard drug users participated in a methadone program
of one of the participating institutions.
Methadone is a synthetic opiate, and also addictive, but
it has some advantages over heroin. Dosages, in tablet or liquid form, can be measured
precisely, and it can be taken orally. It is effective for 12 to 24 hours, while heroin
only works for 3 to 6 hours. Methadone is usually supplied on a maintenance basis
(continuous supply of the same dose) or on a reduction basis (gradually downgrading within
1 to 6 months). In reduction programs methadone is supplied to reduce opiate withdrawal
symptoms in order to achieve complete abstinence. However, cutting down methadone seems
difficult to achieve. Therefore, over three-fourths of the methadone programs is based on
maintenance. The primary objectives of methadone maintenance programs are: the prevention
of progressive health deterioration, and to keep in touch with drug users. This makes
medical supervision possible. This is important regarding the prevention of a further
spread of infectious diseases such as AIDS, TBC, hepatitis B and C. Supplying methadone
may also enable heroin addicts to live a structured life, that - in turn - may increase
their chances of successful social integration and, in the long run, a drug-free
existence.
The main prerequisite for placement in the methadone
programs is heroin dependence. A medical examination takes place upon admittance, followed
by regular check-ups. In most methadone maintenance programs, simultaneous use of drugs,
alcohol or psychoactive medicine is permitted, if used at moderation. Methadone is mainly
dispensed by CAD's. In some cases other institutions operate methadone programs (the
Municipal Health Service in Amsterdam, Triton in Den Helder, Symbion in Rotterdam).
Methadone is being supplied in departments of the institutes, or in buses that follow
certain routes along different locations in some of the major cities. In some cities
general practitioners and other physicians prescribe methadone, particularly to older,
relatively well functioning heroin addicts. In some cases, it is possible to receive
methadone in some of the detention houses, prisons or police offices.
Evaluation of methadone programmes
Evaluation studies of methadone programs revealed positive results regarding the health of
drug addicts. Over a third of the clients are able to control their drug addiction and
hardly use other drugs. About a fourth are well integrated into society in terms of social
contacts, work, education, housing and keeping their appointments. However, the majority
are marginally integrated into society and continue to use other drugs such as heroin and
cocaine. For one fourth of the opiate addicts methadone has either slight or no positive
effects. These extremely problematic users are characterised by uncontrolled drug use,
poor health and criminal behaviour.
Methadone in High Doses
Comparatively Low doses of methadone (averaging 40 mg/day) have traditionally been
dispensed in the Netherlands, even in maintenance programs. Promising results have been
achieved in the United States with the dispensation of high doses (>60 mg/day) for
maintenance purposes. Additional use of heroin decreases, the psychiatric and social
situation of the addict improves and there is a decline in crime. An experiment has been
started in the Netherlands to find out if the Dutch situation can be improved in a similar
way.
The Dutch study into the effects of large doses of
methadone has demonstrated that addicts who received a large dose of methadone (more than
85 mg) were using less heroin two years later and were also in better health and felt
better mentally than addicts who received a small dose. The treatment does not produce any
clear social benefits; it has a favourable effect on the addict’s social network, but
not on criminal behaviour, housing or participation in work. The treatment with large
doses of methadone fits in with the regular treatment of heroin addicts. Although large
doses of methadone clearly produce better results, the treatment is not completely
risk-free. Near-accidents, such as near overdoses, were slightly more common in the
experimental group. Because of
this, the researchers’ made recommendations
concerning protocol development and a
monitoring system to prevent (near) accidents. This year
the addict care sector will work within the framework of the ’Achieving Results’
[Resultaten Scoren] programme to review the methadone programmes and develop protocols in
this area. The recommendations of the study on large
doses of methadone will be incorporated into these
protocols.
Needle Exchange
Sharing needles/syringes increases the risk of infection with HIV/AIDS and hepatitis B and
C. Therefore, several syringe exchange programs have been developed in the eighties that
enable injecting drug users to obtain free sterile syringes after returning used ones.
When the first needle exchange was started in Amsterdam, in the summer of 1984 (initiated
by the Junky Union), its goal was to prevent Hepatitis B infection. Soon after that, the
necessity of Aids prevention arose. In 1985 other institutions took over the initiative.
In other cities in the Netherlands, needle exchange programmes were also started. Soon
other countries in Europe and Australia followed.
Syringe exchange facilities are located at Municipal
Health Services, addiction care services, private locations, change machines, mobile
exchange centres or at pharmacies. Sometimes drug users can also buy injecting equipment
such as alcohol swabs and ascorbic acid. In 60 different cities in the Netherlands, 130
syringe exchange programs are being run. In most of the cases these services are part of a
methadone program.
Evaluation of the Amsterdam needle and syringe exchange
program showed that no increase in drug use could be validated, participants of the
exchange schemes were less involved in needle sharing, the supply of large quantities of
needles to hard drug users did not lead to an increase in needle stick accidents by the
general public, and, finally, the HIV prevalence among drug injectors remained stable
since 1986, while the incidence of acute hepatitis B had gone down.
Prevention of Infectious Diseases
In the context of prevention of infectious diseases, information is provided to drug
users. Regarding HIV prevention, several projects have been developed based on the premise
that information given to drug users ('safer sex and safer use') is most effective when
provided by drug users themselves. This type of peer support is particularly effective for
drug users who are hard to reach by the regular addiction treatment and assistance system.
Moreover, measures such as the methadone and syringe exchange programs have a preventive
value also with respect to drug-related diseases and the harmful effects of drug use on
society.
Hepatitis B Vaccination Program
Research has been going on since October 1998 into the feasibility and penetration of a
hepatitis B vaccination program, aimed at different risk groups (such as people who use
hard drugs). So far it has become clear that the willingness of the group of hard drug
users to participate in the program is high. More than 200 users have been vaccinated so
far.
HIV/AIDS Prevention
In the Netherlands, only 13% of the hard drug users inject their drugs. A large majority
of 75% smoke the drug. The number of intravenous drug users remains low in comparison with
surrounding countries. The percentage of intravenous drug users as a percentage of HIV is
10, 5 %
Aids prevention among hard drug users consists of very
many different activities. For example Information is given to drug users about safer sex
and safer drug use, condoms are made available, clean needles are provided through needle
exchange schemes.
User Rooms
Some cities have opened special centres to deal with the problems that homeless hard drug
users cause in the streets. In these centres, hard drug addicts can take their daily
dosages and receive assistance from care workers. The centres are not allowed to sell or
supply drugs. Local residents support this initiative, and take part in consultations on
the running of the centres.
The Public Prosecutions Service has imposed a number of
conditions for the introduction of user rooms. They must be part of the municipality's
integrated policy on drugs, and public health and safety must be safeguarded.
Evaluation User Rooms
User rooms were studied by the Trimbos Institute in 2002.
They reviewed various studies and concluded that all studies indicate that user rooms have
a positive effect on the state of health of those using them, that they lead to a
reduction in nuisance and that they increase the reach of the addict care services.
However, in some cases drug dealing in close vicinity of the user rooms was observed. This
is why it would be important not to concentrate facilities in one area.
Heroin Treatment Heroin experiment
To improve the treatment of heroin addicts political approval of the heroin experiment was
obtained in 1999.
The objective of the heroin experiment was that
participants improve their mental and physical health and ameliorate their social
functioning. In case the social functioning improves, criminal behaviour will reduce, as
well as public nuisance caused by drug addicts
It was clear from the experiences in Amsterdam and
Rotterdam, that the first two treatment units were not experiencing any significant
problems in the areas of safety, manageability and public order. As of August 1999, 100
participants have been involved in the study in Amsterdam. There are 92 participants in
Rotterdam. The experiment was expanded to various other cities in the beginning of 2000.
In Amsterdam, a second treatment unit was opened. In February 2002, the results were
presented to the Minister of Health (Minister Borst). The main conclusions were:
Conclusion 1.
The study was conducted and analyzed successfully.
Conclusion 2.
Supervised co-prescription of heroin to chronic,
treatment-resistant heroin dependent and methadone treated patients is more effective than
the continuation of methadone alone.
Conclusion 3.
Supervised co-prescription of heroin to chronic,
treatment-resistant heroin dependent and methadone treated patients yields clinically
relevant health benefits.
Conclusion 4.
The beneficial effects of supervised co-prescription of
heroin are linked to the continuation of treatment.
Conclusion 5.
Supervised medical co-prescription of heroin is
practicable with no excess of serious medical adverse events and with a limited number of
controllable public order problems.
Conclusion 6.
The costs of the medical prescription of heroin are
dependent on the type of treatment implementation.
Deterioration of condition of patients after the heroin
experiment
80% of patients were significantly deteriorated 2 months
after ending the heroine programme and the gains in terms of health improvement perished.
This does not mean that this treatment has to be carried out for life. The experiment
foresees in a treatment period of 12 months. This is due to the research protocol. In the
future, a decision will be made based on a individual assessment of the patient to see for
how long prescription of heroin is desirable and justified. Based on –yet to develop-
criteria, treatment with heroin will be evaluated individually. This means that it will
not be a treatment with an open end, but limited between various evaluations. Switzerland
has this form of treatment since 1994. There, the average duration of treatment is 3,3
years. Yearly, 20-30% moves from the heroin programme to a detoxification programme and
about 33% moves on to a methadone programme
Present policy regarding the prescription of heroin
In 2002, the Minister of Health (VWS) has installed a
committee to advice him regarding the implementation of treatment with heroin. This
committee advised to set up 15 units. The new government has agreed that after evaluation
of the present projects in Amsterdam, Rotterdam, the Hague, Utrecht, Heerlen and
Groningen, a decision will be made. The results of the evaluation are expected in the
beginning of 2004.
Until a decision has been made, the present situation
continues, which means that the prescription of heroin is part of a scientific experiment.
For this experiment, 5 million Euros is available yearly for a total of 300 places.
EDOCRA/detoxification under anaesthetic
Another study was undertaken to improve the treatment of
heroin addicts: detoxification with the aid
of naltrexon,
In the EDOCRA study high-speed detoxification was carried
out with the aid of the opiate antagonist naltrexon. A general anaesthetic was also
administered to the control group in a general hospital. After this, both groups received
10 months of outpatient treatment. The study will continue, but the short-term results
indicate that detoxification with naltrexon under anaesthetic is no more effective than
detoxification with naltrexon alone; however, it is more expensive and slightly less safe.
Next year it will become clear whether this effect is also evident in the long term.