CONTENTS
©html 1995 drugtext foundation
With some 700.000 residents, Amsterdam - though it is the capital of the Netherlands - is still not a metropolis comparable to Berlin, London or Paris. It can howver boast of many big city features: its social and cultural climate, the commercial role it plays, and the multicultural composition of its population
The darker sides of the urban picture are evident in Amsterdam as well. The city is faced with all the problems drug addiction entails. The crime rate and deviant behaviour of drug addicts affects city residents and visitors alike. In addition, the spread of AIDS by drug addicts is a menace to public health.
More than sufficient reason for city authorities to do all they can to alleviate the situation. In the course of time, innovation, experimentation and consultation with all the parties involved has enabled Amsterdam to develop a pragmatic policy. A policy that sets the priorities where the city authorities feel they belong. The institutions involved, city authorities, police, courts, public health care and social work agencies have joined forces to implement the measures apt to have the best effects.
What the city policy basically amounts to is combatting the trade in drugs, fighting drug-related crime, and preventing and deterring the use of drugs.The aim is to minimize the detrimental effects for society as a whole. Via rehabilitation programmes, every effort is made to help addicts stop taking drugs. If it does not work, efforts are made to reduce the psychological and physical harm to the individual. Halting the spread of AIDS is another important aspect.
One of the reasons the City of Amsterdam has opted for this approach is that the "tougher" methods applied in other countries have not yielded any solutions to the drug problem. What is more, a less subtle, more uncompromising approach would not be in keeping with the Dutch way of thinking, and certainly not with the Amsterdam mentality. The drug problem is a social problem and we have learned from experience that social problems can not be solved or eliminated by violence. This is why Amsterdam has opted for "the third road" not a total war against drug addicts, not a paradise for drug addicts, but an all-out campaign to reduce the harm caused by drug addicts to society and to help addicts who want to be helped. We cannot just wave a magic wand and make the problem disappear. The problem is too complex for that, and there are aspects that can never be solved. But the approach does seem to have helped. There has been a gradual fall in the number of addicts, and the number of HIV positive addicts has not mushroomed. In other words, we may not have solved the drug problem but we have got it "under control."
In the Netherlands, with a total population of 15,000.000, the number of hard drug addicts has stabilized at about 15,000 to 20,000. Approximately 6,200 of them live in Amsterdam, another 30 % live in Rotterdam, The Hague and Utrecht, and the rest are spread out over about 60 smaller towns. Amsterdam differs from the other three large cities in the size of the problem and the early formulation and application of a specific integral approach.
When we use the term "addicts" in this pages we are referring to heroin addicts. We have the following facts about addicts in Amsterdam. Approximately 1,500 of them come from Surinam, the Netherlands Antilles or Morocco. Another 2,500 come from the European continent, mainly Germany or Italy, about 1,000 of whom have a completely legal status. The other addicts are Dutch. In the course of time, addicts have been apt to use more and more substances side by side, combining cocaine, alcohol or tranquilizers with heroin. There has been a rise in the average age of addicts from 26 in 1981 to more than 32 in 1991, and a fall in the percentage of addicts younger than 22 from 14.4% in 1981 to 2.5% in 1991. This is because fewer and fewer youngsters start using hard drugs. By far the majority of the addicts are male: 70% of the white addicts and no less than 90% of the addicts from the ethnic minorities.
Heroin is used in various ways. Aproximately 40% of the addicts inject it and the other 60% smoke it in cigarettes or inhale it from silver foil (chasing the dragon). These methods have to do with where they come from. Addicts from the ethnic minorities hardly use needles, but 40% of the Dutch addicts and 70% of the addicts from other European countries do.
Injecting heroin is risky business. Using a needle someone else has used is particularly dangerous because it can lead to HIV infection and a serious liver ailment caused by the hepatitis virus. Ever since December 1985, an anonymous epidemiological study has been conducted among addicts. Extremely cautious estimates have it that approximately 30% of the total number of addicts who inject heroin are HIV-positive. This percentage has remained stable for the past few years.
This stability is a positive point, though it is certainly no reason to rejoice. HIV infection leads to illness and death. In an effort to minimize the further spread of the virus, facilities have been provided for addicts to exchange their used needles for new ones and many addicts take advantage of them.
In June 1991, there were 1,737 registered AIDS patients in the Netherlands, 135 of whom were addicts. There was a sharp reduction in cases of acute hepatitis B among addicts: 26 in 1984 and only 5 in 1989. Unfortunately this number increased to 34 in 1990.
In the course of time, there has also been a reduction in the number of addicts who died of an overdose. Fatalities of this kind are particularly prevalent among European foreigners and to a somewhat lesser degree among Dutch addicts. Addicts from the ethnic minorities tend to smoke heroin, which is less dangerous in this respect.
In 1990, 39 addicts died in Amsterdam of an overdose: 24 European foreigners, 13 Dutch and 2 addicts from the ethnic minorities. In 1988, 1989 and 1990, the number of overdose fatalities was more or less the same: 40, 42 and 39. In the period from 1983 to 1987, this figure had been considerably higher: an annual average of 60.
3. DUTCH DRUG POLICY POINTS OF DEPARTURE
The main principles of the Amsterdam drug policy have been adopted in other cities as well and have exerted considerable influence on the national policy. Though the emphases and instruments may differ, every Dutch city that is confronted with relatively large-scale drug use adheres to the same principles.
The policy is twofold: the enforcement of the Opium Law regulating the criminal aspects of the drug trade, and the implementation of preventive, public health and social measures. The point of departure is to minimize the hazards of drug use for the user as well as for society as a whole. The pragmatic approach is focussed on maximum effectiveness. An emotional and dogmatic approach would not be in keeping with the Dutch culture and traditions and has proved elsewhere to create more problems than it solves.
Ever since 1976, the Dutch approach, which differs on several points from those adhered in other countries, has been stipulated in the Opium Law. A fundamental feature of this law is that a distinction is drawn between soft drugs and hard drugs, i.e. drugs involving an "unacceptable risk." To avoid any misunderstandings here, soft drugs are cannabis products such as hashish and marijuana and in the Netherlands the term hard drugs is mainly used to refer to heroin, cocaine, LSD, amphetamines and XTC.
The Opium Law also draws a clear distinction between drug dealing and drug use. The possession of drugs for one' own use is not punished as severely as possession for purposes of trade. This distinction is designed to keep addicts from being treated as hardened criminals.
There are severe punishments, long-term prison sentences and/or high fines, for dealing or possessing large quantities of either hard drugs or soft drugs, in other words more than one is apt to need for peronal use. The import or export of hard drugs is viewed as the most serious criminal offence and is punishable by a maximum of twelve years of imprisonment and/or a fine of up to 100 000. The sale, transport and production of hard drugs are punishable by up to eight years imprisonment.
The maximum sentence for the import or export of cannabis products is four years imprisonment. The possession of a small quantity of soft drugs for personal use (less than 30 grams) is classified as a misdemeanour rather than a criminal offence and is punishable by a prison term of one month. Howver an individual who has hard drugs in his or her possession for personal use is committing a criminal offense according to the law and can be sentenced to a prison term of up to one year
On the grounds of these legal stipulations, guidelines have been drawn up for the detection and prosecution of these punishable offences. Dictated by the interests of society, priorities have been set and choices have been made. Investigations activities are focused on the activities that can harm society the most. In other words, people who smpke marijuana now and then are not the target of an all-out witch hunt, but every effort is made to minimize the trade in soft as well as hard drugs.
Investigation and prosecution policies are drawn up in the course of regular consultations attended by the Mayor, the Public Prosecutor and the Police Commissioner. In the Netherlands the Mayor is responsible for the maintenace of law and order and the general command of the police force in the city. The Public Prosecutor falls under the Minister of Justice and is responsible for the investigation and prosecution of punishable offences. Maintaining law and order and investigating punishable offences are also police tasks. This means the Police Commissioner is accountable to the Mayor as well as to the Public Prosecutor. For optimal coordination, the Mayor, the Public Prosecutor and the Police Commissioner regularly discuss all the aspects involved in what have come to be referred to as "triad consultations."
In the Netherlands, no express efforts are made to detect the possession or sale of less than 30 grams of soft drugs, so one might say these acts are "tolerated." In a number of cities including Amsterdam, these small quantities are openly sold in coffee shops. The aim of this "tolerant" guideline is to prevent users of relatively less dangerous soft drugs from having to rely on the illegal circuits. This would be apt to move them towars the edge of mainstream society and put them into contact with dealers in hard drugs, with all the risks this would entail. Studies have demonstrated that in the present situation, very few users move from soft to hard drugs.
Besides maintaining law and order, social and public health
care facilities and prevention are also important elements in the
Dutch policy on drugs.
The major points of departure are:
- On the local or regional level, there should be a network of
medical and social facilities for addicts.
- Addicts should have easy access to this kind of help.
- The social rehabilitation of addicts and ex-addicts should be
promoted.
This pragmatic approach, with a cooordinated packet of
measures and cooperation among the various agencies involved, is
characteristic of the Amsterdam policy on drugs. It is a
realistic policy. The problem is there and it does not seem
probable it will ever be completely solved. This is why it would
be better to make every effort to minimize the hazards and
detrimental effects for the rest of society than to wage a futile
war against everything that has anything to do with hard drugs.
It has been demonstrated in the United States how pointless and
indeed counter-productive this kind of battle can be. The only
effect it has is that addicts land in the illegal circuit, can no
longer be reached by preventive, social or public health
measures, and are far more apt to turn to criminal behaviour to
get the drugs they need. In view of these considerations,
Amsterdam has developed a number of help programmes for addicts
providing alternative substances (e.g. the methadone program).
Experiments are started with both palfium and heroin maintenance.
This line of action certainly does not imply that Amsterdam is a paradise for addicts where everyone can freely use and deal drugs, where heroin is distributed free of charge and every addict is eligible to sign up for help. On the contrary, prevention and deterrence are the major components of the Amsterdam attitude. Every effort is made to combat the drug trade and restrict the harmful effects for society.
Up to the early eighties, the Amsterdam policy was characterized by virtually unbounded tolerance toward addicts. This is what made Amsterdam so attractive to addicts from abroad, which in turn resulted in mushrooming problems.
There was a growing awareness of the need to put a halt to this devlopment, and of the fact that drug use is not only a public health problem but also a civil order one. In 1984, backed by a widespread political consensus, a new policy was introduced that is still being implemented.
This policy is characterized by the following elements:
The methadone programme and checking the spread of AIDS have come to play such a central role in the Amsterdam policy on drugs that they both merit special attention here.
Methadone is a synthetic narcotic that was first developed as a pain killer in Germany in 1941 and was used in the United States in the sixties for the treatment of heroin addicts. It is an addictive substance that can be administred in exact quantities as a tablet or in liquid form. Whereas heroin is only active for a few hours, the effect of methadone does not wear off for more than 24 hours.In the Netherlands, methadone is used to reach heroin addicts and help them stabilize their drug use and ease the withdrawal symptoms.
The methadone programme is nationally and internationally renowned but controversial. Experience has shown that providing replacement substances is an effective way to keep the drug problem from getting totally out of control, restrict the nuisance aspects and protect addicts from disease or death. Virtually all the Dutch municipalities confronted with drug-related problems have put a methadone programme in effect.
The Amsterdam methadone programme dates back to 1979 and was initially designed for addicts of Surinamese descent. Materially, mentally and physically, they were in a far worse state at the time than many other addicts. In particular, their health was cause for concern. The city of Amsterdam decided to expand the existing facilities for this group and start up a methadone programme.
The methadone programme fell under the auspicies of the Municipal and Public Health Department. It was felt that a Public Health Department with a medical and nursing staff at hand, a good organization capacity and operating under the responsibility of the city would be the best basis for a programme of this kind. Dutch legeislation allows for methadone distribution, and physicians can precribe it. What is more, everyone in Amsterdam is so familiar with the Municipal Health and Public Health Department that the threshold is low.
Like the needle exchange project, at the start the methadone programme also led to heated discussion on political and ethical principles. It is an indisputtable fact that people on methadone continue to be addicted and that in essence, physicians help them go on being addicted, whereas according to their professional code of ethics, they should be "curing" them. But at the same time, city authorities were realistic enough to realize that it takes a lot of time for people to get to the point where they are willing and able to stop taking drugs altogether, and this is a point many of them never get to. So one again, the point of departure is a pragmatic one: distributing methadone enables people who are not (yet) willing or able to stop taking drugs to lead a more or less "normal" life. In 1982, the City of Amsterdam decided to expand the programme and open it to other addicts as well. This was the beginning of the system still in effect today, with daily doses of methadone distributed free of charge. Distribution takes place via neighbourhood aid stations and two mobile methadone busses that drive past a number of fixed spots in or near the drug scene every day.
The procedure is as follows. Drug users report to one of the four neighbourhood aid stations and are examined there to see whether they are really addicted. The methadone dosage is set and this information is given to the staff on the methadone bus. There the drug user receives a bottle of methadone every day with his or her name on it.
Not everyone is eligible for this programme. Ther are the following requirements:
In order to keep the distribution as easily accesible as possible, ther are no further requirements such as urine tests to see whether clients are still also taking illegal drugs, or obligatory contact with a social worker. On the whole, clients do go on taking illegal drugs as well, but the methadone means they need far smaller quantities of them. They do not have to resort to crime just to pay for their daily dose.
There are rather strict requirements for drug users who want to be treated at one of the four neighbourhood aid stations. The purpose of these aid stations, where approximately 2,000 drug users receive medical treatment without being admitted to hospital, is to reduce drug use to an acceptable minimum. Drug users are given methadone in pills, and there is thus much more personal responsibility involved than in the case of clients who get their liquid dose at the methadone bus. Clients are not permitted to use any illegal drugs in addition to the methadone, and this is checked by urine tests. Clients who violate this rule are no longer treated at the aid station and have to go back to the methadone bus.
Efforts are made to gradually reduce the dosage so that clients are slowly but surely ready stop taking drugs altogether, although this is frequently still too difficult a step to take. Clients are however often able to reduce their drug use to an acceptable level. Once individuals start functioning reasonably well and are able to take proper care of themselves, there is often the desire to leave the aid station and be treated by their own general practitioner. This breaks the last tie with the drug circuit.
There are a number of general physicians in Amsterdam who distribute methadone. They treat a total of approximately 1,400 patients, about ten a piece. They work in close conjunction with the Municipal Medical and Public Health Department, which is immediately prepared to take the patient back into its own methadone programme if there are any problems. This close cooperation between general practitioners and the Municipal Medical and Public Health Department is unique and generally works extremely satisfactorily.
Of the estimated 6,000 to 6,500 addicts in Amsterdam, approximately 4,600 are reached via the methadone programme. The distribution of methadone has a number of clearly positive effects. Since the Municipal Medical and Public Health Department has regular contact with most of the addicts this way, it is easy to reach them with information about other important matters, particularly regarding AIDS prevention. Ever since 1986, the methadone busses also distribute clean syringes, needles and condoms. Methadone distribution has not led to a rise in demand. On the contrary, there is a steady decrease in the number of clients, though they do generally remain under treatment for lenghtier periods of time.
In addition, the regular contact provides opportunities for further help in stopping drug use altogether, rehabilitation programmes and social assistance. As a result, the number of addicts who have signed up for detoxification and rehabilitation treatment has doubled since the introduction of the busses and the needle exchange project.
Another positive effect is that autorities have better insight into the number of addicts and their situation. These figures help them decide on whatever adjustments might have to be made. Methadone distribution also plays an essential role as regards another Amsterdam drug policy aim, minimizing the nuisance aspect for the rest of society. The methadone programme enables drug users to function within society in a more or less normal manner. Without it, the detrmental effects for the city and the people of the city would be far greater, since addicts would have to resort to whatever methods they could find to get money for their daily dose of drugs.
6. CHECKING THE SPREAD OF AIDS
The main aim of the Aids and drug policy is to prevent the further spread of HIV among addicts. The care for addicts who are already HIV-positive or have AIDS is organized as well as possible. This care is provided by existing medical facilities and is focused on keeping this group of patients from sinking into even greater social isolation. The distribution of methadone is only one of the efforts mafe to keep the lives of addicts with AIDS from becoming totally unbearable.
In the field of AIDS and drugs, a national policy has been formulated by the Ministry of Welfare, Public Health and Culture. It is also the goal of this policy to prevent the further spread of HIV via blood and sperm. Instruments to restrict the risks include safe sex, safe drug use and more general changes in behaviour.
If it is not possible to get sufficient numbers of addicts to stop taking drugs altogether, then it is only logical to focus efforts on getting them to adopt safer techniques for drug use. Attention is also focused on promoting safe sex techiques and the use of condoms. But even where safe techniques for drug use are concerned, the policy is still pragmatic. If you cannot get addicts to stop taking drugs, you have to provide them with safe equipment: sterile needles. Approximately 30% of the Amsterdam addicts who use the injection method are HIV-positive. This pertains to a group of about 800 addicts, about half of whom are of Dutch descent and a quarter from other European countries. The number has stabilized, but the fact still remains that this is a matter of grave concern. Despite recent advances in medical science, sooner or later AIDS is fatal.
The virus is not only transmitted by unsafe sexual contact, but also by injection needles. Many addits share their needles. In 1984 an arrangement was set up enabling addicts to exchange their needles for clean ones. The request for this kind of facility was first expressed by the League of Junkies, their own organization which was set up to promote their interests at the time. The League of Junkies, backed by people working in the field, advocated setting up this kind of arrangements when a local pharmacy stopped selling needles to about 200 addicts in the summer of 1984. The League of Junkies was afraid this would lead to an epidemic of acute hepatitis B among addicts.
The municipal Medical and Public Health Department and the city authorities initially had certain reservations. One of the objections was that the arrangement would encourage people to use the injection method and remove any stimulus to stop taking drugs altogether. However, the advantages of sterile needles were so obvious that the City of Amsterdam nonetheless decided to launch a limited experiment. It was also in the general interest that contaminated needles not wind up sticking out of plastic garbage bags or discarded in parks or playgrounds.
The Municipal Medical and Public Health Department purchased large quantities of new needles delivered them once a week to the League of Junkies and took back the used ones. At the beginning, approximately a thousand needles a week were exchanged this way. When AIDS began to be a cause for concern in 1985, other institutions decided to inytroduce this kind of arrangement as well. Ample use has been made of these arrangements, with approximately 100,000 needles exchanged in 1985, 700,000 in 1987 and no fewer than a million in 1991.
The needle exchange project was evaluated. Studies showed that general drug use had not increased and that addicts who used the arrangements shared their needles less frequently with other addicts. Only 29% of the addits who used the needle exchange facilities indicated that they had used more drugs in the past six months, and 38% said they had used less drugs. Sequel studies yielded comparable results. Only 9% of the addicts who used the needle exchange facilities said they had shared needles with other addicts in the past month, wheras 22% of the addicts who did not use the facilities said they had done so.
The Aids prevention policy is also focused on changing behaviour. An important instrument in this respect is of course information. By reaching as many addicts as possible and giving them information about safe drug use and safe sex, efforts are made to make it clear to them how important it is to change their behaviour. In addition to sterile needles, condoms are also distributed either free of charge or at an extremely low price.
A stitch in time saves nine, which is why it is never too early to teach children about the dangers of drug use. At primary schools, children between the ages of 4 and 12 are taught about how to live a healthy life, and learn about the harm caused by smoking, drinking or taking drugs. In recent years, the Amsterdam police force has set up a drug prevention campaign for older primary school pupils. Teachers can come to the police station with these pupils and talk to addicts there. Of course lessons of this kind have to be accompanied by information on all kinds of addiction. The lessons are optional and require the permission of parents, addicts and whatever other persons involved. At secondary schools and youth centers, there are also intensive information campaigns on the risks of drug use.
Another prevention policy aim is to keep youngsters swithching from relatively less dangerous soft drugs such as hashish or marijuana to hard drugs. For this purpose, a clear distinction is drawn in the Netherlands between the approach to soft drugs and to hard drugs. In coffeeshops and youth centers, under the condition that no nuisance is caused for other people in the vicinity, the buyers are not under the age of 18 and there are no conspicuous advertisements for the merchandise, the police generally do not take any steps against the possession and sale of small quantities (less than 30 grams) of soft drugs.
Of course these activities are carefully scrutinized. If the neighbours complain, if large quantities of soft drugs are sold or if hard drugs are sold, the police immediately intervene and in the name of the Mayor od Amsterdam, the premises can be closed. By "turning a blind eye" to the use and sale of small quantities of soft drugs, the authorities keep users from resorting to the illegal circuits, where hard drugs are also on sale.
Another element in the Amsterdam approach to the drug problem is deterrence in the interest of people in the vicinity, for whom drug use often causes a considerable nuisance, as well as of additcs themselves. To a certain extent, the detrrence aspect is a question of keeping addicts from disturbing the peace. Of course combatting crime is also instrumental.
The trade in drugs is actively combatted by a special police unit, the Narcotics Brigade. The police also take action against addicts who engage in muggings, burglaries, shoplifting or other crimes in order to be able to pay for their daily dose of drugs.
One of the major goals of the Amsterdam police, stipulated at the triad consultations attended by the Mayor, the Public Prosecutor and the Police Commissioner, is to minimize the nuisance caused by addicts and reduce the trade in drugs. By way of permanent surveillance, thorough observation and arrests, district police teams can keep the drug trade under control and reduce the crime rate. In this framework, cafés where hard drugs are sold are regularly closed down. The approach has been effective in that the crime rate fell in 1987 and 1988 and has remained stable ever since.
Another aspects is the Amsterdam attitude to addicts from abroad. Approximately 20 to 30% of the addicts in Amsterdam come from other countries in Europe, mainly from Germany. Many of them come to the Dutch capital because they cannot get the help they want in their own country. This group has settled more or less permanently in Amsterdam. In addition, there are the "drug tourists" who come to Amsterdam for a short period of time. It is only logical that Amsterdam is not happy about this influx of foreigners. The city has already got enough problems of its own.
In order to discourage foreign addicts from coming to Amsterdam, the city decided not to offer them the same help other drug users get. This means they are not eligible for the regular methadone distribution. However, the approach remains humane; if foreign addicts are in extremely poor physical condition, they can go to a special Municipal Medical and Public Health Department consultation hour. They can receive crisis assistance there and are given sterile needles, condoms and if necessary, methadone for a limited period of time. This help is only meant to tide them over until they can go back to their own country one or two weeks later.
Foreign addicts, in particular the ones from Germany, are helped to return to their own country. In the past few years, the Dutch autorities and various social work and public health agencies have contacted the authorities in the surrounding countries. The aim is to develop aid programmes to enable addicts to return to their own countries and receive the help they need there. This only pertains to addicts who have not committed any criminal offense in the Netherlands. If and when they break a law here, they are deported. In delivering deported addicts into custody, the Dutch authorities work in close conjunction with the authorities in the surrounding countries.
Due to measures like these and the general deterrence policy, Amsterdam is no longer a Mecca for European drug users. Foreign addicts are fortunately starting to understand this, and there has been a sharp reduction in drug tourism.
In order to implement a reasonaby succesful drug policy, of course it is of the utmost importance to reach as many addicts as possible. If they do not ask for help of their own accord, they have to be reached through other channels. One of the ways these cahnnels are maintained in Amsterdam is via street workers who frequent the drug scene, are familiar with everything that is happening there, provide oral and written information about AIDS and make every effort to serve as a bridge between the addicts and the social wok and public health agencies set up to help. Specially trained street workers approach prostitutes addicted to heroin.
Twice a day, physicians from the Municipal Medical and Public Health Department stop at police stations to examine addicts who have been arrested . Every year about 1,500 addicts pass through the police stations for one reason or another. The physicians give them basic medical aid including methadone and useful information about treatment options, the needle exchange project and other matters related to AIDS.
The social and medical aid provided this way has two aims: to help the addicts themselves and to minimize the nuisance for other people. Social aid means addicts are helped to solve housing, financial or legal problems. Medical aid, as has been noted in this booklet, includes regular medical examinations, methadone, sterile needles, condoms and hospital referrals.
Amsterdam also runs a wide variety of specific projects, a number of which are decribed below.
In Amsterdam there are 300 to 400 "extremely problematic" drug addicts. They generally have no fixed address, no visible maens of support, and spend most of their time in the downtown area. Most of them try to get money for drugs by breaking into cars or homes or mugging people on the street, thus making the entire area a dangerous one.
Since this group is generally out of reach of existing aid programmes and continues to exhibit criminal conducts, a harder approach has been opted for. As soon as criminal addicts have been in trouble with the police four times within a year, they are given a choice: they can either serve their entire sentence with no time off for probation or enter a rehabilitation clinic. They have to complete the entire drug rehabilitation treatment, otherwise they still go to prison.
This project was started in 1989 and is carried out in close conjunction with the national authorities. Of course extra facilities had to be craeted: accomodations at rehabilitation clinics as well as prison cells. Ever since 1990, the street addict project has been completely operational. Approximately half of the 250 street addicts who were eligible did indeed opt for the drug rehabilitation clinic. The others were not admitted to the clinic because there were no openings at the time, because the court failed to give permission for treatment, or because they had language or psychiatric problems or were not willing to attend the appropriate treatment program.
Many drug addicts are admitted to general hospitals that are not well-equipped to deal with their specific problems. The hospital project was set up to give drug addicts the help they need. A specialized team of social psychiatric nurese visits the addicts in the hospital, advises the medical staff and coordinates the treatment. The aim is to see to it that these patients receive normal medical treatment combined with the necessary doses of methadone.
The people who work on this project are apt to come into contact with addicts who develop AIDS. Since the care of AIDS patients is often poorly coordinated, the hospital project staff continues to be responsible for the treatment of addicted AIDS patients. They try to make the lives of addicted AIDS patients as bearable as possible, and one of the ways they do this is by administring methadone. They act in close cooperation with hospital specialists, social work and public health agencies outside the hospital, the patients' relatives and general practitioners.
With increasing frequency, social work and public health agencies are confronted with addicts who have considerable psychiatric problems. Since facilities for addicts are not equipped to deal with psychiatric problems and psychiatric facilities are not equipped to deal with drug-related problems, these patients have nowhere to turn to. This is why various institutions have worked together to provide a special kind of psychiatric help for this group. The aim is to gain insight into what is ailing the individual and to provide assistance and treatment geared toward the psychiatric problems of the specific addict (individualized help). The diagnosis can be made at the Drug Ward of the Municipal Medical and Public Health Department, where a psychiatrist has been on the staff for the past six years. Treatment can then be given at other institutions including drug rehabilitation clinics. Within the Regional Institute for Outpatient Mental Haelth Care (RIAGG), preparations are being made for a Drugs and Psychiatry working group, which is to play an important platform function.
There are several hundred prostitutes on heroin working in Amsterdam. Although they are only a small minority of the total group of prostitutes in the city, they present a considerable problem which is not easy to solve. Approximately 50% of these women are HIV-positive and many have venereal diseases as well.
Addicted prostitutes are viewed as a social problem that cannot be solved by police or court intervention. This means the police do not hound the prostitutes, but proceed with caution, particularly if they do not cause too much of a nuisance. Arrests and imprisonment would ony mean the prostitutes would disperse over the entire city and be completely out of reach for any form of help whatsoever. The help they receive is not only in their own interest, it is also in the interest of their unfortunately inevitable circle of clients and thus of public health in general.
Facilities for these prostitutes include a special clinic for venereal diseases, a separate consultation hour, possibilities for admission to a crisis center and a large number of specific arrangements including a living room project where the women can come in the evening or at night. Streetworkers try to contact these women at night. In order to curb the further spread of HIV, condoms are distributed free of charge and information is provided about AIDS. Efforts are also made to encourage the prostitutes to come to the special consultation hour.
9. WITHDRAWAL, TREATMENT AND REHABILITATION
Withdrawal treatment is mainly given at the Amsterdam Jellinek Centre, the largest institution specialized in drug addiction in the Netherlands. The Center also treats addiction to alcohol, pharmaceuticals and gambling, but we confine ourselves here to drug addiction. The Jellinek Center's activities are threefold: prevention, treatment and after-care.
The key concept is "made-to-measure" and all the activities are geared as much as possible to the needs of individual clients. The central aim is to reduce health risks and enable clients to function better in society.
The prevention Institute of the Jellinek Center gives oral and written information about everything that has to do with drug addiction and provides documentary material and courses for groups. The friends and relatives of people with drug problems can also come to the Center.
Drug addicts can be admitted to one of the Jellinek Center clinics, where group and family treatment is also available. A much larger number of addicts receive outpatient treatment, which means they have regular contact with a staff member at one of the fifteen treatment branches all across the city. Methadone is prescribed there as a therapeutic instrument. Outpatient treatment is provided free of charge, but for admission to one of the clinics, the addict has to have medical insurance.
The lenght of time that addicts remain at a clinic varies from several weeks to nine months. They are often first admitted to the detoxification unit. An important element in all of the treatment programs is that addicts learn to deal with their own feelings, with other people, and with social situations without resorting to drugs.
In order to keep people from falling back into their old behavior paterns afterwards, the Jellinek Center has a comeback program. This after-care is an essential link between the treatment and the return to society. Clients can attend weekly meetings or spend some time at a special halfway house.
10. RESEARCH AND INTERNATIONAL COOPERATION
In order to gain insight into the dimensions and nature of the drug problem and assess the effectiveness of various measures, studies have to be conducted. Ever since 1984, the City Council of Amsterdam has been promoting research of this kind, and this has led in turn to a large number of publ;ications. The data presented in these publications play an important role in the evaluation of existing policies and the formulation of new ones. Research and registration are mainly implemented by the Municipal Medical and Public Health Department and the two Amsterdam universities. Some of the results of this research have been incorporated into this booklet.
Amsterdam is only too willing to explain its policy on drugs and is very interested in the experiences of other cities in other countries. Precisely because the policy is of such a pragmatic nature, the Amsterdam approach is open to influence by foreign experiences and activities, and the exchange of know-how and skills is highly valued. On a number of fronts, the City of Amsterdam works together with the national authorities, with other Dutch municipalities and with such international organizations as the European Community, the World Health Organization and the Pompidou Committee appointed by the Council of Europe.
Every year any number of colleagues come to Amsterdam to learn more about its approach to drugs and AIDS. In early 1989, the City of Amsterdam received a subsidy from the European Community to help accommodate the people arriving for this purpose and improve the informative quality of their visits. This led to the foundation of an international network among various European cities to exchange information on the relation between AIDS and drugs. Seminars are organized in this framework and people who work in the field of drugs and AIDS can receive a grant from the European Community for informative visits to other European cities in the network.
Amsterdam also takes part in a wide variety of European study programmes and projects. One of these study projects is coordinated by the World Health Organization to prevent the spread of HIV infection among hard drug users in various European cities. The European Division of the World Health Organization has two interesting programmes in the field of drugs: one to prevent the abuse of psycho-active drugs and a regional one on AIDS. The City of Amsterdam plays an active role in both of these programs. The two Amsterdam universities take part in the studies conducted by the Council of Europe in the field of drug use and social and medical care.
To what extent has the Amsterdam policy been succesful? Ther are figures available, some of which have already been referred to in this booklet. Social work and public health agencies maintain contact with 85% of the addicts in the city. The percentage of addicts who are HIV-positive or have hepatitis B is much lower than in other cities in Europe and North America. Compared with the large cities in other countries, very few serious criminal offences are committed by addicts in Amsterdam. The desire to stop taking drugs altogether and undergo treatment for this purpose has become more widespread in recent years. There has been a gradual fall in the number of addicts, particularly among the younger age groups.
The University of Amsterdam has been commissioned by the city to evaluate the facilities set up to help addicts in Amsterdam. The first report was published in 1990 and was focussed on the experiences of addicts themselves. The City of Amsterdam formulated its reaction to the research results. All things considered, the following picture has emerged.
The general impression is that the effects of the policy have been positive. The drug epidemic has entered a stable stage, the researchers feel, and they thus confirm the conclusions of the Municipal Medical and Public Health Departmet. The policy is pluriform in that it provides for various forms of care and help varying from intensive assistance to facilities for drug users who can take more responsibility for their own actions. This pluriformity functions well and the help reaches a large segment of the drug users and this contributes toward reducing the nuisance they cause.
One positive effect of the methadone program is that its clients need less heroin and are thus far less apt to commit crimes or disturb the peace. The other side of the coin is that addicts continue to be isolated from mainstream society and remain in the drug scene. Together with the way the police and the courts have acted, the distribution of methadone has contributed toward the reduction of drug-related crime and its stablization ever since 1989. The efforts of social work and public health agencies and the police have also helped reduce the visible nuisance caused by drug users in the neighbourhoods where they congregate.
The researchers also concluded that via the distribution of methadone, social and medical workers have been able to maintain contact with most of the drug users. This has provided a good basis for measures in the field of AIDS prevention.
However, in a number of ways the situation is still a cause for concern. There has been a rise in the average age of addicts and there is now a group of older drug users who are not adequately reached via the existing social and medical channels and are not willing or able to reduce their drug use or stop taking drugs altogether. These addicts have any number of medical and psychiatric problems. Some of them are HIV-positive and are consequently certain to fall ill soon.
The prostitutes who are on heroin constitute another problem group. Since they often do not have a legal residence permit, they tend to steer clear of the social work and public haelth agencies. This is all the more worrying because they are generally in extremely poor physical condition and often have veneral diseases. Estimates have it that 50% of the prostitutes on heroin are HIV-positivew. A number of them come to the special consultation hour at the Municipal Medical and Public Health Department to be treated for veneral diseases. Despite the risks to their own helath as well as the health of others, however, many of them still remain impossible to reach.
It should be clear by now that the Amsterdam policy on drugs is not a sure cure for "all evils." There are still numerous problems to be solved. It can nonetheless definitely be concluded that the policy has not led to an enormous drug problem that is totally out of control, as foreigners often assume exists based on what they know of the approach in the past. On the contrary. The Amsterdam authorities, police and medical and social workers are all convinced they are moving in the right direction.