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The drug problem in The Netherlands
0740-5472/M 53.00 + .OO Copyright 0 1984 Pergamon Press Lid
JoumalofSubstanceAbus? Treatment. Vol. 1,pp.12513%1984 Printed in the USA. All tights rcserwd.
INTERNA TIONAL PERSPECTIVES
The Drug Problem in The Netherlands MARTEN KOOYMAN,MD Erasmus Universitdt,
Rotterdam. The Netherlands
INTRODUCTlON
To FOREIGNERS, CURRENT DRUG POUCIES in the Netherlands seem to lack any logic: on one hand, there is political pressure to increase efforts of the police to fight against the illegal sale of heroin; on the other hand, there is pressure from the same politicians to prescribe heroin free to anyone over 16 years old who wants to use this drug. Any (Dutch) heroin addict in Amsterdam can have free methadone, distributed from dispensing centres and even from methadone busses, regardless of his or her continuation of the use of heroin or other illegal drugs. Nevertheless, we are still faced with drug-related crimes and heroin prostitution in Amsterdam. Some social workers who work in prison even think that addicts are able to commit more complicated crimes with the support of methadone since this enables them to prepare a crime in a better way. Another interesting phenomenon is the disappearance of the hashish problem in The Netherlands. From the moment the police tolerated the sale of cannabis in youth centres and coffeeshops, hashish no longer was regarded as a weird, dangerous substance; it was no longer considered a dangerous drug. Apart from a small number of youngsters using hashish daily, it became a recreational drug for some, but lost its attraction to many young people. In order to facilitate the understanding of the present situation in The Netherlands, I will describe the development of the drug scene and treatment policies for addicts in The Netherlands. The Early Days
In The Netherlands, drug addiction started to be a problem in the mid l%Os, when a considerable number of young people became involved in the use of
Requests for reprints should be sent to Martien Kooyman, M.D., Clinical director. Jellinekccntrum, P.O. Box 3907, 1001 AS Amsterdam, The Netherlands.
illicit drugs. Until then, drug abuse in The Netherlands, particularly abuse of opiates, was almost entirely confined to a small group of people working in the health field, such as physicians, nurses and pharmacologists. In The Netherlands, drug addiction was seen as a health care problem; drug addicts were referred to physicians, psychiatrists, mental hospitals and clinics for alcoholics. In the mid l%Ck, cannabis was the drug most commonly used by youngsters, who generally originated from middle class families; a considerable number were students and artists. Some of them started to experiment with LSD, amphetamines and opium. Opium was obtained from the Amsterdam Chinese community, where a small group of addicts used to smoke this drug. Although during some years occasional cannabis users suffering from panic reactions were sent to a psychiatrist, the use of hashish and marihuana was gradually seen as hardly causing any medical problems, contrary to the use of amphetamines. A growing number of people addicted to amphetamines and opium were seen for treatment in outpatient clinics (“konsultatieburos”) which, until then, were only involved in the treatment of alcoholics. For inpatient treatment addicts were sent to psychiatric hospitals, which could not cope with the acting out behaviour of this new kind of patient: the adolescent drug addict. After the news of methadone maintenance programs for opiate addicts reached The Netherlands, similar outpatient programs for opiate addicts were established; the first one in 1%8 by the Jellinekcentrum in Amsterdam, followed by methadone maintenance programs at the “konsultatieburos” in The Hague and in Rotterdam. It. was expected that methadone, being an addictive drug in itself, would block the effects of opium and that daily dispension to addicts would make them independent of the illegal drug scene. Methadone was prescribed to people addicted to opium that they got from the Chinese community in Amsterdam. At that time, heroin was not on the Dutch market yet. 125
126
In the methadone program in The Hague, where I worked in those days, addicts successfully applied for jobs and found places to live with the help of social workers, only to be fired or thrown out of their rooms within a fortnight. We suspected some of our clients used other illegal drugs, despite their denial. After 2 years we decided to implement urine tests. Of the clients in our methadone maintenance program, 100% showed positive tests, even the clients who did not use other drugs (opiates, amphetamines or barbiturates). Apart from that, we noticed that several clients had an alcohol problem, too. In 1969,a residential methadone clinic was founded in the Jellinekcentrum in Amsterdam, where addicts were admitted to be stabilized on methadone maintenance. This clinic had a medical model without sufficient restrictions to the behaviour of its patients. The residents of this clinic continued to use illegal drugs during treatment as they had done after admission to psychiatric hospitals. Up to 1970, I never saw a drug addict who had been able to stay clean after treatment. In that year a group of re+entry residents from the therapeutic community of Daytop Village in New York came to Holland to perform a show that was based on the life of one of the actors. At the end of the show, the actors stepped from the stage reaching out to the audience saying: “Would you love me?” People on the first row regretted not having booked for the balcony. Apparently, drug addicts were human beings! After this show, I started to read about the program of Daytop Village and other therapeutic communities in the United States. In those days, my opinion was that these programs looked more like military camps than treatment centres. However, I liked the idea of starting a therapeutic community in The Netherlands as an alternative to the methadone treatment and admission to psychiatric hospitals. The original plan was different from the American model and was based on the democratic therapeutic communities for psychiatric patients modelled after the Henderson clinic, founded by Maxwell Jones. On 14 February 1972, the plan became reality with the establishment of the Emiliehoeve therapeutic community in The Hague. At the start, the program had a very tolerant atmosphere; we assumed that residents were able to make adult decisions. The first months of the therapeutic community were chaos. This period was very helpful for the staff, because we learned from our mistakes. After the introduction of encounter groups and step by-step establishing structure like the American therapeutic communities with the help of consulting ex-addicts from the United States, the Emiliehoeve program became more and more successful. In the meantime, the outpatient methadone progam of the Jellinekcentrum had grown to more than 400 participants. In 1972, it was believed that we did not have a
M. Kooyman
heroin problem in The Netherlands because of the fact that methadone was easily available. A year later, however, we did have a heroin problem. In 1973, after the Amsterdam police had arrested the suppliers of opium in the Chinese community in Amsterdam, heroin pushers entered the market and addicts changed to a new drug. Amphetamines were less attractive because of the paranoid reactions experienced by many users. As treatment in the Emiliehoeve therapeutic community proved to be successful, the methadone maintenance program in The Hague was changed into a detoxification program. Most of its clients decided to enter into the therapeutic community when given the option. Most of them stayed long enough in treatment to stay clean after treatment. The success of the Emiliehoeve treatment was the first real success in the treatment of drug addicts in The Netherlands. Staff of other treatment centres in Holland attended workshops organized by the staff of the Emiliehoeve therapeutic community. This initiated changes of other treatment centres in The Netherlands; the residential methadone clinic in Rotterdam, where opiate addicts were admitted in order to be stabilized on methadone, was changed into a drug-free therapeutic community. A therapeutic community, belonging to the Hoog Hullen Foundation, changed into a structured drug-free therapeutic community, followed by a neighbouring alcohol clinic of the same organization, which, until then, had been run as a clinic according to the Maxwell Jones’ principles. The residential methadone clinic of the Jellinekcentrum also changed into a therapeutic community. TkIUushmTbatAUAddictsCao& Trented !!hxemfaIly
During the years 1975 and 1976, the positive results of the drug-free therapeutic communities had a lot of publicity. The first ex-addicts were hired by therapeutic communities and by other programs as paid staff members. During those years, methadone programs in Utrecht, Heerlen and Bergen op Zoom were closed, resulting in the disappearance of the addicts from the streets of those cities. Some entered the drug-free treatment programs, but the majority left for cities that were still dispensing methadone. In this period, addicts had to be detoxified in an ambulatory program before admission in the drugfree program of a therapeutic community. As this proved to be too much of a demand of many addicts, clinical detoxification centres were established in the second half of the 1970s. These centres refer addicts to the therapeutic communities. In The Netherlands, therapeutic communities are part of the health system and are officially considered as hospitals for addicts. The detoxification centres are, in most cases,
127
Drug Problem in the Netherlands
part of the same organization, enabling a necessary coordination of the treatment. To some of those detoxification centres a crisis unit is added, where addicts can be admitted during a crisis in their drug career due to outside circumstances. After a maximum’of 4 days they get the option to leave or to be transferred to the detoxification unit of the same centre from where they can be referred to further treatment. In some cases, ambulatory after-care treatment as well as day-care and night-care treatment for those who do not choose for or do not need the intensive treatment in a therapeutic community were established. In The Netherlands the illusion had developed that drug problems could be solved by treatment, which is impossible since the addict who comes into treatment usually caused a lot of problems during a long period before admission. However, many addicts did not go to the treatment centres. The strict structure of the therapeutic communities and the long duration of treatment were not very attractive to most of the addicts, especially if their drug use did not cause too many problems for them. Furthermore, treatment centres modelled after the Emiliehoeve concept, with their strict rules, did not fit in the tolerant and liberal attitudes of the Dutch society towards addicts. Although those treatment programs became more and more successful, or maybe just because of that fact, this treatment system was increasingly criticized, especially by professionals working in centres with liberal policies and by the drug addicts themselves. In that period there was strong political pressure to reach all heroin addicts to make them finally choose treatment. Starting in Amsterdam, low threshold programs were promoted, using methadone to make these programs attractive to addicts. These programs made only few demands of their clients, since staff was afraid to lose contacts with them. In some big cities houses were opened where addicts could meet with each other. After a short while, however, drug dealers as well as “fences” also entered those daycenters. In the areas where these centers were located, addicts created increasing problems to the neighbours, who urged the police to do something to solve the drug problem. The Illusion that Addicts Will Choose Treatment After Contacts with Professionals The assumption that addicts would finally choose for treatment after they had been provided with contacts with social workers and other professionals proved to be another illusion. Before the low threshold centres in Amsterdam had developed, staff of the methadone program of the Jellinekcentrum had made the program more structured: It was decided to discharge residents who continued the use of illegal drugs. A long waiting list
had developed. This resulted in Amsterdam family doctors prescribing methadone to heroin addicts. Those doctors were not prepared for this task and usually were not aware of the fact that addicts collected methadone from different doctors, selling part of it in order to buy heroin. Some doctors saw an opportunity to benefit from this situation and made considerable profits by distributing methadone on a large scale. The Third Illusion: Dispension of Methadone on a Large Scale Will Control the Problem In the main cities of The Netherlands, the problems of the struggle against criminality of heroin addicts increased. It became clear that definitely not all addicts, who were reached by low threshold programs, chose drug free treatment. A third illusion developed, namely the conviction that criminality due to heroin abuse could be considerably reduced by prescribing methadone to as many addicts as possible. Politicians emphasized the importance of establishing large scale methadone programs. In the cities of Utrecht and Heerlen methadone programs were started again without, however, any noticable effect on the increasing criminality. An example of political interference in drug treatment is the start of methadone dispension to addicts in The Hague from busses. In 1978, black heroin addicts, immigrants from Surinarn (a former Dutch colony that became independent that year), squatted a house in The Hague. In this house, drugs were sold not only to Surinam addicts, but also to white addicts. City authorities hesitated to close this house since they were afraid of being accused of racism. In the summer of 1978, the city authorities decided to dispense methadone to the Surinam addicts who lived in that house from a nearby posted bus. Two weeks after this decision, taken without any consultation of staff of existing treatment programs, the bus program started. One week later, the police closed the house and the Surinam addicts squatted another house. Some months later, the city decided to buy that house, changing it into a daycentre with paid staff. In this centre addicts could meet. They were allowed to use their drugs. Within a few weeks this centre became the main market place for illegal drugs and stolen goods in The Hague. After a period of four months, the number of clients of the methadone bus had increased from 70 to 400; one year later, this number was 1,500. Also in Amsterdam and Rotterdam methadone dispensing programs by busses started, together with meeting places where using and dealing drugs was tolerated. These centres provoked a lot of resistance and protests from the neighbours and after a few years most of them were closed.
128
Since 1977, distribution of free heroin as well as enforced treatment have been topics of the discussions. Organizations of parents of drug addicts urged policy makers to do something. From several political sides enforced treatment was proposed, but this idea was dropped as being too inhumane and most probably ineffective. In 1981, the political goals of drug treatment policies started to change. Since it was apparent that not every addict could be persuaded into treatment, the aim was no longer to try to treat all addicts. The new policy was to accept the fact that the problem of drug addiction could not be solved and that society had to learn to accept the addict, including his de viant lifestyle. The focus of the policy was no longer directed at efforts to enable addicts to live a drug free life. In 1981, there was a new element in the discussions: The intention to start dispension of injectable morphine to a small group of addicts in Amsterdam. In Amsterdam, Rotterdam, and several other cities, junkies organized themselves, with or without the assistance of professionals in the field, into pressure groups, the so called “junky unions” (junkiebonden). Their aim was to create dispension of methadone by family doctors without any restrictions. Although in Amsterdam most of the methadone was prescribed by physicians, they had not been involved in prescribing methadone to heroin addicts in other cities in The Netherlands. In 1982, the city of Amsterdam started a large scale experiment: Four regional centres were set up to distribute methadone to drug addicts. These centres did not aim at treatment of addiction, but at controlling the problem by contacting as many addicts as possible. These centres offered medical and social assistance. For those addicts, who only wanted methadone and nothing else, two busses were used to dispense methadone on several sites in the city. To this methadone distribution no restrictions are made: addicts who continue their use of heroin or cocaine can obtain methadone in a dosage they prefer. The underlying philosophy is that the addict, at least, may need a smaller number of illegal drugs and consequently, will steal less and cause fewer problems in society. Part of this policy is that addicts are referred from the city methadone dispension centres to physicians for further methadone prescription as much as possible. A New Solution: Heroin Distribution to All Heroin Addicts
In the summer of 1983, the socialist party of Amsterdam published a proposal for a new drug policy: The city is only responsible for the control of the negative side effects of drug abuse. In this proposal drug
M. Kooyman
abuse is seen as an individual’s choice. Personal problems due to drug abuse are the responsibility of the individual drug user. Social problems are just an alibi for drug abuse. It is said that, contrary to the use of alcohol, the use of heroin is not dangerous for one’s health. In this proposal it is recommended that family doctors prescribe all kind of drugs to any person over 16 years old who asks for it. In case of juvenile heroin prostitution, drugs can be prescribed from the age of 12. It is believed that special therapy and treatment make no sense; if a drug addict needs treatment, this should be given by the family doctor or by existing mental health services. It is also said that prevention is a useless effort. Police action against drug dealers, however, has to be intensified. This proposal does not sound very socialistic. Furthermore, dependence on drugs seems to be ignored. It seems to be an example of naive efforts to solve the problems by actually denying their existence. It also is an example of the fact that many politicians have given up the fight against addiction. This proposal of the Amsterdam socialist party resulted in a plan of the city government to prescribe heroin to those addicts who do not seem to improve through the existing methadone programs. In the fust phase heroin distribution will be limited to a number of 300 addicts. However, in January 1984, the central government denounced the use of heroin as a maintenance drug. In the opinion of the central government, the Amsterdam plans are not in line with the policies in the rest of the country. Another important reason to consider the Amsterdam plans as unacceptable was that their realization would certainly cause strong international opposition. The fact that most heroin addicts are also involved in the use of cocaine seems to deny logic of these plans. Again, we see another illusion: if physicians prescribe heroin to addicts, the problem can be controlled. Opponents of the plan point out the fact that many addicts have been involved in criminal activities before they used their fust drug. In their opinion, the use of heroin and other illegal drugs is part of a deviant lifestyle that will not change through the prescription of heroin. The Pmeat Sitpatios of Dmg Treatment in Tbe Nethlands
During the last two decades new treatment approaches have been developed in The Netherlands, in most cases modelled after the Emiliehoeve program. Seventeen treatment centres were established in various parts of The Netherlands. Some daycare centres were founded, using the principles of a therapeutic comnlunity. During the last two years, several experimental projects with family therapy started. The involve-
129
Drug Problem in the Netherlands
ment of the family and partners of addicts in treatment in therapeutic communities is intensified: Therapeutic communities try to involve relatives before the actual admission of the addict to the therapeutic community. Methadone is used in detoxification programs as well as in maintenance programs. Apart from services aiming at treatment of the addiction, in most cities programs were established to provide care for addicts without the intention of helping them quit their addiction. Here methadone is no longer dispensed as a substitute drug, but more or less as a means to attract addicts to come to the centres. These two goals of intervention by different centres, namely to treat addiction or to make the life of the addict more bearable, can be contradictory. A complication is that an addict often visits both kinds of centres. Staff of treatment centres complain that the help of care centres in making the life of an addict easier may postpone his decision to seek treatment for his addiction.
whether an addict can be turned into a patient; It will also be doubtful whether the black market will disappear when heroin can be distributed by physicians. The negative side effects caused by illegality of drugs can, of course, only be solved through legalizing use and sale of all drugs. Although legalization will probably create problems comparable with those due to alcohol abuse, few people expect this solution to be more than a theoretical possibility, especially in relation with the international complications. The current policy of the central government of The Netherlands is to accept the fact that drug addiction is a problem that cannot be solved and efforts to diminish negative side effects of drug abuse are emphasized. Treatment programs may have a hard time surviving in the coming years. Research is needed to show that positive results of treatment can be attained, if not with all, then at least with a considerable number of addicts.
DISCUSSION
In The Netherlands, the drug problem among adolescents developed as a new phenomenon in the mid 1960s. Without remarkable success, methadone maintenance programs were introduced in 1%8. Drug free treatment in therapeutic communities, developed since 1972, was successful after the first experimental years. This success provoked the illusion that drug related problems could be solved by treatment; low threshold programs, putting few demands on participants, were established to dispense methadone. The illusion was that addicts can be motivated into further treatment if they are brought into contact with professionals. As the addict population kept growing and their street crimes increased in number, Dutch drug policies changed in 1978, using methadone as a means to decrease criminal activities rather than to treat addicts. This also turned out to be an illusion. Currently, there is strong politicial pressure to distribute heroin to addicts to diminish the negative side effects of drug abuse. Dutch drug policies are characterized by the opinion that drug problems cannot be solved and have to be accepted.
Developments of drug policies in The Netherlands show some interesting phenomena. Drug addiction, especially with adolescents, was new and frightening. Panic reactions of the public resulted in a demand from politicians to solve the drug problem. The first successful results of treatment of drug addicts generally considered to be untreatable created the illusion that treatment could solve all drug problems. The fact that addicts caused a lot of problems to themselves and to society before they actually chose treatment was disregarded. Treatment programs that aimed to stop dependence on drugs became more successful after they became more structured. It appeared that addicts need to learn to cope with limits, a capacity they lost or never possessed. Those programs put an increasing demand on their residents and as a result, fewer addicts considered those programs acceptable. In the low threshold programs where methadone is distributed regardless of the continuation of illegal drug use, a large part of the addict population is reached. Only a few of them, however, were successfully referred for treatment of their addiction. Daycentres, where drug use was tolerated, may have made drugs more easily available for experimenting adolescents and may play a role in postponing a decision to stop using or to seek help. In most Dutch cities the emphasis of current drug policies is on the reduction of the negative side effects of drug abuse due to the illegality of drug use. Some people argue that drug addiction will become more acceptable if family doctors will prescribe methadone or even heroin. However, it is doubtful
SUMMARY
REFERENCES Bratter, T.E. & Kooyman, hf. (l!HkO).A structuredenvironment for heroin addicts: The experiences of a community based American methadone clinic and a residential Dutch therapeutic community. lk International Journal of Social Rsychiatty, 19,w-J-203. Jones, M. (1953). The therapeuticcommunity: A new trwtment
method in psych&any. Basic Books, New York. Kooyman, M. (1975). From chaos to a structured therapeutic community: Treatment program on Emiliehoeve. a farm for young addicts. Bulletin on Namotics, 27, 19-X. Overduin, C.M. (1980). The treatment of drug addicts at “The
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Parkwee”. In Readings of tk 5th World Cot@mnce of Therapeutic Commwdties, Samsom Sijthoff, Alphen aan de Rijn. Schaap, G.E. (1978). A new Dutch experiment: Hoog Htillen. a
M. Kooyman drug free therapeutic community for alcohol addicts. l%e Addiction Thempht, 2, 170-180. Sugarman, B. (1974). Daytop Village, a therap& community. Holt. Rinehart & Winston. New York.
JoumalofSubstanceAbus? Treatment. Vol. 1,pp.12513%1984 Printed in the USA. All tights rcserwd.
INTERNA TIONAL PERSPECTIVES
The Drug Problem in The Netherlands MARTEN KOOYMAN,MD Erasmus Universitdt,
Rotterdam. The Netherlands
INTRODUCTlON
To FOREIGNERS, CURRENT DRUG POUCIES in the Netherlands seem to lack any logic: on one hand, there is political pressure to increase efforts of the police to fight against the illegal sale of heroin; on the other hand, there is pressure from the same politicians to prescribe heroin free to anyone over 16 years old who wants to use this drug. Any (Dutch) heroin addict in Amsterdam can have free methadone, distributed from dispensing centres and even from methadone busses, regardless of his or her continuation of the use of heroin or other illegal drugs. Nevertheless, we are still faced with drug-related crimes and heroin prostitution in Amsterdam. Some social workers who work in prison even think that addicts are able to commit more complicated crimes with the support of methadone since this enables them to prepare a crime in a better way. Another interesting phenomenon is the disappearance of the hashish problem in The Netherlands. From the moment the police tolerated the sale of cannabis in youth centres and coffeeshops, hashish no longer was regarded as a weird, dangerous substance; it was no longer considered a dangerous drug. Apart from a small number of youngsters using hashish daily, it became a recreational drug for some, but lost its attraction to many young people. In order to facilitate the understanding of the present situation in The Netherlands, I will describe the development of the drug scene and treatment policies for addicts in The Netherlands. The Early Days
In The Netherlands, drug addiction started to be a problem in the mid l%Os, when a considerable number of young people became involved in the use of
Requests for reprints should be sent to Martien Kooyman, M.D., Clinical director. Jellinekccntrum, P.O. Box 3907, 1001 AS Amsterdam, The Netherlands.
illicit drugs. Until then, drug abuse in The Netherlands, particularly abuse of opiates, was almost entirely confined to a small group of people working in the health field, such as physicians, nurses and pharmacologists. In The Netherlands, drug addiction was seen as a health care problem; drug addicts were referred to physicians, psychiatrists, mental hospitals and clinics for alcoholics. In the mid l%Ck, cannabis was the drug most commonly used by youngsters, who generally originated from middle class families; a considerable number were students and artists. Some of them started to experiment with LSD, amphetamines and opium. Opium was obtained from the Amsterdam Chinese community, where a small group of addicts used to smoke this drug. Although during some years occasional cannabis users suffering from panic reactions were sent to a psychiatrist, the use of hashish and marihuana was gradually seen as hardly causing any medical problems, contrary to the use of amphetamines. A growing number of people addicted to amphetamines and opium were seen for treatment in outpatient clinics (“konsultatieburos”) which, until then, were only involved in the treatment of alcoholics. For inpatient treatment addicts were sent to psychiatric hospitals, which could not cope with the acting out behaviour of this new kind of patient: the adolescent drug addict. After the news of methadone maintenance programs for opiate addicts reached The Netherlands, similar outpatient programs for opiate addicts were established; the first one in 1%8 by the Jellinekcentrum in Amsterdam, followed by methadone maintenance programs at the “konsultatieburos” in The Hague and in Rotterdam. It. was expected that methadone, being an addictive drug in itself, would block the effects of opium and that daily dispension to addicts would make them independent of the illegal drug scene. Methadone was prescribed to people addicted to opium that they got from the Chinese community in Amsterdam. At that time, heroin was not on the Dutch market yet. 125
126
In the methadone program in The Hague, where I worked in those days, addicts successfully applied for jobs and found places to live with the help of social workers, only to be fired or thrown out of their rooms within a fortnight. We suspected some of our clients used other illegal drugs, despite their denial. After 2 years we decided to implement urine tests. Of the clients in our methadone maintenance program, 100% showed positive tests, even the clients who did not use other drugs (opiates, amphetamines or barbiturates). Apart from that, we noticed that several clients had an alcohol problem, too. In 1969,a residential methadone clinic was founded in the Jellinekcentrum in Amsterdam, where addicts were admitted to be stabilized on methadone maintenance. This clinic had a medical model without sufficient restrictions to the behaviour of its patients. The residents of this clinic continued to use illegal drugs during treatment as they had done after admission to psychiatric hospitals. Up to 1970, I never saw a drug addict who had been able to stay clean after treatment. In that year a group of re+entry residents from the therapeutic community of Daytop Village in New York came to Holland to perform a show that was based on the life of one of the actors. At the end of the show, the actors stepped from the stage reaching out to the audience saying: “Would you love me?” People on the first row regretted not having booked for the balcony. Apparently, drug addicts were human beings! After this show, I started to read about the program of Daytop Village and other therapeutic communities in the United States. In those days, my opinion was that these programs looked more like military camps than treatment centres. However, I liked the idea of starting a therapeutic community in The Netherlands as an alternative to the methadone treatment and admission to psychiatric hospitals. The original plan was different from the American model and was based on the democratic therapeutic communities for psychiatric patients modelled after the Henderson clinic, founded by Maxwell Jones. On 14 February 1972, the plan became reality with the establishment of the Emiliehoeve therapeutic community in The Hague. At the start, the program had a very tolerant atmosphere; we assumed that residents were able to make adult decisions. The first months of the therapeutic community were chaos. This period was very helpful for the staff, because we learned from our mistakes. After the introduction of encounter groups and step by-step establishing structure like the American therapeutic communities with the help of consulting ex-addicts from the United States, the Emiliehoeve program became more and more successful. In the meantime, the outpatient methadone progam of the Jellinekcentrum had grown to more than 400 participants. In 1972, it was believed that we did not have a
M. Kooyman
heroin problem in The Netherlands because of the fact that methadone was easily available. A year later, however, we did have a heroin problem. In 1973, after the Amsterdam police had arrested the suppliers of opium in the Chinese community in Amsterdam, heroin pushers entered the market and addicts changed to a new drug. Amphetamines were less attractive because of the paranoid reactions experienced by many users. As treatment in the Emiliehoeve therapeutic community proved to be successful, the methadone maintenance program in The Hague was changed into a detoxification program. Most of its clients decided to enter into the therapeutic community when given the option. Most of them stayed long enough in treatment to stay clean after treatment. The success of the Emiliehoeve treatment was the first real success in the treatment of drug addicts in The Netherlands. Staff of other treatment centres in Holland attended workshops organized by the staff of the Emiliehoeve therapeutic community. This initiated changes of other treatment centres in The Netherlands; the residential methadone clinic in Rotterdam, where opiate addicts were admitted in order to be stabilized on methadone, was changed into a drug-free therapeutic community. A therapeutic community, belonging to the Hoog Hullen Foundation, changed into a structured drug-free therapeutic community, followed by a neighbouring alcohol clinic of the same organization, which, until then, had been run as a clinic according to the Maxwell Jones’ principles. The residential methadone clinic of the Jellinekcentrum also changed into a therapeutic community. TkIUushmTbatAUAddictsCao& Trented !!hxemfaIly
During the years 1975 and 1976, the positive results of the drug-free therapeutic communities had a lot of publicity. The first ex-addicts were hired by therapeutic communities and by other programs as paid staff members. During those years, methadone programs in Utrecht, Heerlen and Bergen op Zoom were closed, resulting in the disappearance of the addicts from the streets of those cities. Some entered the drug-free treatment programs, but the majority left for cities that were still dispensing methadone. In this period, addicts had to be detoxified in an ambulatory program before admission in the drugfree program of a therapeutic community. As this proved to be too much of a demand of many addicts, clinical detoxification centres were established in the second half of the 1970s. These centres refer addicts to the therapeutic communities. In The Netherlands, therapeutic communities are part of the health system and are officially considered as hospitals for addicts. The detoxification centres are, in most cases,
127
Drug Problem in the Netherlands
part of the same organization, enabling a necessary coordination of the treatment. To some of those detoxification centres a crisis unit is added, where addicts can be admitted during a crisis in their drug career due to outside circumstances. After a maximum’of 4 days they get the option to leave or to be transferred to the detoxification unit of the same centre from where they can be referred to further treatment. In some cases, ambulatory after-care treatment as well as day-care and night-care treatment for those who do not choose for or do not need the intensive treatment in a therapeutic community were established. In The Netherlands the illusion had developed that drug problems could be solved by treatment, which is impossible since the addict who comes into treatment usually caused a lot of problems during a long period before admission. However, many addicts did not go to the treatment centres. The strict structure of the therapeutic communities and the long duration of treatment were not very attractive to most of the addicts, especially if their drug use did not cause too many problems for them. Furthermore, treatment centres modelled after the Emiliehoeve concept, with their strict rules, did not fit in the tolerant and liberal attitudes of the Dutch society towards addicts. Although those treatment programs became more and more successful, or maybe just because of that fact, this treatment system was increasingly criticized, especially by professionals working in centres with liberal policies and by the drug addicts themselves. In that period there was strong political pressure to reach all heroin addicts to make them finally choose treatment. Starting in Amsterdam, low threshold programs were promoted, using methadone to make these programs attractive to addicts. These programs made only few demands of their clients, since staff was afraid to lose contacts with them. In some big cities houses were opened where addicts could meet with each other. After a short while, however, drug dealers as well as “fences” also entered those daycenters. In the areas where these centers were located, addicts created increasing problems to the neighbours, who urged the police to do something to solve the drug problem. The Illusion that Addicts Will Choose Treatment After Contacts with Professionals The assumption that addicts would finally choose for treatment after they had been provided with contacts with social workers and other professionals proved to be another illusion. Before the low threshold centres in Amsterdam had developed, staff of the methadone program of the Jellinekcentrum had made the program more structured: It was decided to discharge residents who continued the use of illegal drugs. A long waiting list
had developed. This resulted in Amsterdam family doctors prescribing methadone to heroin addicts. Those doctors were not prepared for this task and usually were not aware of the fact that addicts collected methadone from different doctors, selling part of it in order to buy heroin. Some doctors saw an opportunity to benefit from this situation and made considerable profits by distributing methadone on a large scale. The Third Illusion: Dispension of Methadone on a Large Scale Will Control the Problem In the main cities of The Netherlands, the problems of the struggle against criminality of heroin addicts increased. It became clear that definitely not all addicts, who were reached by low threshold programs, chose drug free treatment. A third illusion developed, namely the conviction that criminality due to heroin abuse could be considerably reduced by prescribing methadone to as many addicts as possible. Politicians emphasized the importance of establishing large scale methadone programs. In the cities of Utrecht and Heerlen methadone programs were started again without, however, any noticable effect on the increasing criminality. An example of political interference in drug treatment is the start of methadone dispension to addicts in The Hague from busses. In 1978, black heroin addicts, immigrants from Surinarn (a former Dutch colony that became independent that year), squatted a house in The Hague. In this house, drugs were sold not only to Surinam addicts, but also to white addicts. City authorities hesitated to close this house since they were afraid of being accused of racism. In the summer of 1978, the city authorities decided to dispense methadone to the Surinam addicts who lived in that house from a nearby posted bus. Two weeks after this decision, taken without any consultation of staff of existing treatment programs, the bus program started. One week later, the police closed the house and the Surinam addicts squatted another house. Some months later, the city decided to buy that house, changing it into a daycentre with paid staff. In this centre addicts could meet. They were allowed to use their drugs. Within a few weeks this centre became the main market place for illegal drugs and stolen goods in The Hague. After a period of four months, the number of clients of the methadone bus had increased from 70 to 400; one year later, this number was 1,500. Also in Amsterdam and Rotterdam methadone dispensing programs by busses started, together with meeting places where using and dealing drugs was tolerated. These centres provoked a lot of resistance and protests from the neighbours and after a few years most of them were closed.
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Since 1977, distribution of free heroin as well as enforced treatment have been topics of the discussions. Organizations of parents of drug addicts urged policy makers to do something. From several political sides enforced treatment was proposed, but this idea was dropped as being too inhumane and most probably ineffective. In 1981, the political goals of drug treatment policies started to change. Since it was apparent that not every addict could be persuaded into treatment, the aim was no longer to try to treat all addicts. The new policy was to accept the fact that the problem of drug addiction could not be solved and that society had to learn to accept the addict, including his de viant lifestyle. The focus of the policy was no longer directed at efforts to enable addicts to live a drug free life. In 1981, there was a new element in the discussions: The intention to start dispension of injectable morphine to a small group of addicts in Amsterdam. In Amsterdam, Rotterdam, and several other cities, junkies organized themselves, with or without the assistance of professionals in the field, into pressure groups, the so called “junky unions” (junkiebonden). Their aim was to create dispension of methadone by family doctors without any restrictions. Although in Amsterdam most of the methadone was prescribed by physicians, they had not been involved in prescribing methadone to heroin addicts in other cities in The Netherlands. In 1982, the city of Amsterdam started a large scale experiment: Four regional centres were set up to distribute methadone to drug addicts. These centres did not aim at treatment of addiction, but at controlling the problem by contacting as many addicts as possible. These centres offered medical and social assistance. For those addicts, who only wanted methadone and nothing else, two busses were used to dispense methadone on several sites in the city. To this methadone distribution no restrictions are made: addicts who continue their use of heroin or cocaine can obtain methadone in a dosage they prefer. The underlying philosophy is that the addict, at least, may need a smaller number of illegal drugs and consequently, will steal less and cause fewer problems in society. Part of this policy is that addicts are referred from the city methadone dispension centres to physicians for further methadone prescription as much as possible. A New Solution: Heroin Distribution to All Heroin Addicts
In the summer of 1983, the socialist party of Amsterdam published a proposal for a new drug policy: The city is only responsible for the control of the negative side effects of drug abuse. In this proposal drug
M. Kooyman
abuse is seen as an individual’s choice. Personal problems due to drug abuse are the responsibility of the individual drug user. Social problems are just an alibi for drug abuse. It is said that, contrary to the use of alcohol, the use of heroin is not dangerous for one’s health. In this proposal it is recommended that family doctors prescribe all kind of drugs to any person over 16 years old who asks for it. In case of juvenile heroin prostitution, drugs can be prescribed from the age of 12. It is believed that special therapy and treatment make no sense; if a drug addict needs treatment, this should be given by the family doctor or by existing mental health services. It is also said that prevention is a useless effort. Police action against drug dealers, however, has to be intensified. This proposal does not sound very socialistic. Furthermore, dependence on drugs seems to be ignored. It seems to be an example of naive efforts to solve the problems by actually denying their existence. It also is an example of the fact that many politicians have given up the fight against addiction. This proposal of the Amsterdam socialist party resulted in a plan of the city government to prescribe heroin to those addicts who do not seem to improve through the existing methadone programs. In the fust phase heroin distribution will be limited to a number of 300 addicts. However, in January 1984, the central government denounced the use of heroin as a maintenance drug. In the opinion of the central government, the Amsterdam plans are not in line with the policies in the rest of the country. Another important reason to consider the Amsterdam plans as unacceptable was that their realization would certainly cause strong international opposition. The fact that most heroin addicts are also involved in the use of cocaine seems to deny logic of these plans. Again, we see another illusion: if physicians prescribe heroin to addicts, the problem can be controlled. Opponents of the plan point out the fact that many addicts have been involved in criminal activities before they used their fust drug. In their opinion, the use of heroin and other illegal drugs is part of a deviant lifestyle that will not change through the prescription of heroin. The Pmeat Sitpatios of Dmg Treatment in Tbe Nethlands
During the last two decades new treatment approaches have been developed in The Netherlands, in most cases modelled after the Emiliehoeve program. Seventeen treatment centres were established in various parts of The Netherlands. Some daycare centres were founded, using the principles of a therapeutic comnlunity. During the last two years, several experimental projects with family therapy started. The involve-
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Drug Problem in the Netherlands
ment of the family and partners of addicts in treatment in therapeutic communities is intensified: Therapeutic communities try to involve relatives before the actual admission of the addict to the therapeutic community. Methadone is used in detoxification programs as well as in maintenance programs. Apart from services aiming at treatment of the addiction, in most cities programs were established to provide care for addicts without the intention of helping them quit their addiction. Here methadone is no longer dispensed as a substitute drug, but more or less as a means to attract addicts to come to the centres. These two goals of intervention by different centres, namely to treat addiction or to make the life of the addict more bearable, can be contradictory. A complication is that an addict often visits both kinds of centres. Staff of treatment centres complain that the help of care centres in making the life of an addict easier may postpone his decision to seek treatment for his addiction.
whether an addict can be turned into a patient; It will also be doubtful whether the black market will disappear when heroin can be distributed by physicians. The negative side effects caused by illegality of drugs can, of course, only be solved through legalizing use and sale of all drugs. Although legalization will probably create problems comparable with those due to alcohol abuse, few people expect this solution to be more than a theoretical possibility, especially in relation with the international complications. The current policy of the central government of The Netherlands is to accept the fact that drug addiction is a problem that cannot be solved and efforts to diminish negative side effects of drug abuse are emphasized. Treatment programs may have a hard time surviving in the coming years. Research is needed to show that positive results of treatment can be attained, if not with all, then at least with a considerable number of addicts.
DISCUSSION
In The Netherlands, the drug problem among adolescents developed as a new phenomenon in the mid 1960s. Without remarkable success, methadone maintenance programs were introduced in 1%8. Drug free treatment in therapeutic communities, developed since 1972, was successful after the first experimental years. This success provoked the illusion that drug related problems could be solved by treatment; low threshold programs, putting few demands on participants, were established to dispense methadone. The illusion was that addicts can be motivated into further treatment if they are brought into contact with professionals. As the addict population kept growing and their street crimes increased in number, Dutch drug policies changed in 1978, using methadone as a means to decrease criminal activities rather than to treat addicts. This also turned out to be an illusion. Currently, there is strong politicial pressure to distribute heroin to addicts to diminish the negative side effects of drug abuse. Dutch drug policies are characterized by the opinion that drug problems cannot be solved and have to be accepted.
Developments of drug policies in The Netherlands show some interesting phenomena. Drug addiction, especially with adolescents, was new and frightening. Panic reactions of the public resulted in a demand from politicians to solve the drug problem. The first successful results of treatment of drug addicts generally considered to be untreatable created the illusion that treatment could solve all drug problems. The fact that addicts caused a lot of problems to themselves and to society before they actually chose treatment was disregarded. Treatment programs that aimed to stop dependence on drugs became more successful after they became more structured. It appeared that addicts need to learn to cope with limits, a capacity they lost or never possessed. Those programs put an increasing demand on their residents and as a result, fewer addicts considered those programs acceptable. In the low threshold programs where methadone is distributed regardless of the continuation of illegal drug use, a large part of the addict population is reached. Only a few of them, however, were successfully referred for treatment of their addiction. Daycentres, where drug use was tolerated, may have made drugs more easily available for experimenting adolescents and may play a role in postponing a decision to stop using or to seek help. In most Dutch cities the emphasis of current drug policies is on the reduction of the negative side effects of drug abuse due to the illegality of drug use. Some people argue that drug addiction will become more acceptable if family doctors will prescribe methadone or even heroin. However, it is doubtful
SUMMARY
REFERENCES Bratter, T.E. & Kooyman, hf. (l!HkO).A structuredenvironment for heroin addicts: The experiences of a community based American methadone clinic and a residential Dutch therapeutic community. lk International Journal of Social Rsychiatty, 19,w-J-203. Jones, M. (1953). The therapeuticcommunity: A new trwtment
method in psych&any. Basic Books, New York. Kooyman, M. (1975). From chaos to a structured therapeutic community: Treatment program on Emiliehoeve. a farm for young addicts. Bulletin on Namotics, 27, 19-X. Overduin, C.M. (1980). The treatment of drug addicts at “The
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Parkwee”. In Readings of tk 5th World Cot@mnce of Therapeutic Commwdties, Samsom Sijthoff, Alphen aan de Rijn. Schaap, G.E. (1978). A new Dutch experiment: Hoog Htillen. a
M. Kooyman drug free therapeutic community for alcohol addicts. l%e Addiction Thempht, 2, 170-180. Sugarman, B. (1974). Daytop Village, a therap& community. Holt. Rinehart & Winston. New York.