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Dutch Drug Policy: A Model for America?
In press for: JOURNAL OF HEALTH & SOCIAL POLICY
David F. Duncan, Dr.P.H., CAS, and Thomas Nicholson, Ph.D
While debates over drug policy in America have focused on choices between demand reduction and supply reduction, the Dutch have pioneered the alternative strategy of harm reduction. The Dutch have built their policy around the principles of separation of markets, low threshold treatment, and normalization of treatment. These policies are worthy of examination as a possible model for drug policy reform in America.
David F. Duncan is a Research Associate at the Center for Alcohol and Addiction Studies, Brown University, Box G, Providence, RI 02912, and is Chairman of the Council on Illicit Drugs of the National Association for Public Health Policy. Thomas Nicholson is Professor of Public Health at Western Kentucky University, Bowling Green, KY 42101 and is Vice-Chairman of the Council on Illicit Drugs.
Dutch Drug Policy: A Model for America?
Drug policies can be developed around a variety of goals and strategies but in America the debate over public policy regarding the currently illicit drugs has been structured around a choice between two competing policy options -- supply reduction and demand reduction.1-2 Supply reduction has been the dominant strategy in American drug policy since enactment of the Harrison Narcotics Act of 1914.2-4 This strategy has concentrated primarily on reducing supplies of illicit drugs through law enforcement, interdiction, and eradication in drug-producing countries. This supply- -side approach assumes that curtailing drug availability will drive up prices, forcing American drug users to stop or seek treatment. In this view, increased prices also deter new users from trying drugs.3
Demand reduction, on the other hand, assumes that as long as there is a demand for drugs, there will be a supply. In the words of Skolnick, "demand generates supply for drugs." Law enforcement successes simply encourage the discovery of new sources and more potent and easily concealed substitute drugs.5 In Reuter's words, "the root of the problem is now seen to be the initiation of new users ... and the failure to provide good quality treatment for addicts."4 Therefore, advocates of this strategy call for an emphasis on primary prevention and treatment on demand.
The demand reduction strategy has only more recently become an active policy alternative and it has clearly been a secondary priority. Federal drug control expenditures over the past dozen years have averaged 70% for supply reduction and 30% for demand reduction. 6 Policy debates have centered on the adequacy of, or need for modifications in, this ratio.
While the debate over these two strategies persists, neither can show much evidence of success. Multi-billion dollar efforts at supply reduction have only marginally driven up the price of drugs and have not reduced access to any detectable degree.3 The federal government estimates that drug law enforcement intercepts only about 15% of the illicit drugs that are transported into this country -- and many critics believe that this estimate is exaggeratedly high. The drug trafficking business has, in fact, expanded since the early 1980's and shows no signs of diminishing.7
Recent history suggests that drug demand may be relatively inelastic as to price while the amount of drugs that traffickers put on the black market varies concomitantly with price.8-10 As a result, increased prices have not reduced demand for the currently illegal drugs but have increased profits for traffickers. As Smart describes the situation, "... the war on drugs therefore functions, in practical fact, as a price support program for the enrichment of drug industrialists."10
It is also apparent that many of our drug problems, such as drug-related crime and the transmission of HIV through needle sharing, are the result of the supply reduction efforts themselves rather than of the actual use of the drugs.11 On the other hand, demand reduction relies on treatment programs which have notoriously low success rates and prevention programs which have an even poorer record of success.
Clearly, there is a need for a third alternative -- a tertium quid. Such a third alternative strategy exists in the harm reduction or harm minimization strategy which has developed in Western Europe and Australia.12-13 "Harm reduction is a policy of preventing the potential harms related to drug use rather than trying to prevent the drug use itself."13 More than one policy critic has suggested that those who are dissatisfied with the current alternatives in the American drug policy debate might look toward these developments overseas.14-15
The Netherlands, and especially the City of Amsterdam, has been in the forefront of the developing harm reduction movement in Europe. Interest in Dutch drug policy has been stimulated in recent years by the HIV epidemic of the past decade.15 The Dutch have held the prevalence of AIDS down to only about 800 cases in the entire country -- 65 of whom are intravenous drug users.
That policy has been described as "a compromise between legalization and the war on drugs" by one of its shapers, Eddy Engelsman, who also states that, It is just an example of the way in which the Dutch try to control or to solve their [social and medical] problems. ... The Dutch being sober and pragmatic people, they opt rather for a realistic and pragmatic approach to the drug problem than for a moralistic and over dramatized one."16
To the consternation of many American critics, the liberal drug policies of the Netherlands have resulted in no increase or a negligibly small increase in drug use. Cannabis use has remained steady in the Netherlands since 1976 while it has increased in the rest of Europe despite vigorous prohibition efforts. Declining numbers of young people are experimenting with drugs. There is only a very small market for cocaine and virtually none for crack. With few new addicts, the population of heroin and cocaine addicts in the Netherlands is now a relatively stable population of about 1,500 aging addicts -- 30-40% of whom are foreign nationals drawn to the Netherlands by the greater safety of drug use there.17-18
The Netherlands is a small country, bounded by the North Sea on the West and North, by Germany on the East and by Belgium on the South. It is about one-fourth the size of the State of New York. More than 14.5 million people, including about 600,000 foreign residents, live within this area of roughly 13,000 square miles, making the Netherlands one of the most densely populated countries in the world.
Contrary to popular impression, the Dutch population is not a homogeneous one of blonde, blue-eyed ice skaters. Large minorities of Indonesians, North Africans and West Indians add to the diversity of the Dutch citizenry. In fact, it is predicted that by the year 2001 a majority of births in the Netherlands will be in these growing minorities. While lacking the extremes of poverty seen in the U.S., the Dutch population does range from rich to poor with a significant minority dependent on public assistance.
THE OPIUM ACT
The legislative basis for Dutch drug policy is the Opium Act as amended in 1976. The Opium Act was originally enacted in 1919 and has been modified a number of times since then. Prosecution of marijuana offenders under the Opium Act began in the 1950's. In the 1960's a growing number of experts and official agencies began to call for a reconsideration of the prosecution policy. They argued the classic Liberal position that protecting people from doing harm to themselves is an insufficient justification for the government to interfere with that person's freedom of choice.
Widespread negative publicity had followed the excessive use of force in the handling of student riots in 1966 by the Amsterdam Police.19 The public backlash, and the resulting resignations of key law enforcement officials, made the Amsterdam Police highly sensitive to public opinion. As a result they adopted more relaxed attitudes toward social issues ranging from the peace movement to drug use. This led to a policy of deemphasizing marijuana possession arrests. The police adopted a policy of not enforcing the drug laws at all in certain youth centers or on a group of abandoned barges that had become young people's "crash pads." This was similar to the practice reported by van de Wijngaart that, "since the early twentieth century there had been small Chinese communities in the cities of Amsterdam and Rotterdam, where the habitual use of opium was tolerated."20
The introduction, largely from West Germany, of a rapidly growing and violently competitive heroin market in the early 1970's nearly overwhelmed the Dutch police forces. This problem was greatest in Amsterdam.
The changing nature of the drug problem and changing views of drug law enforcement led the Dutch government to appoint a Working Party on Drugs composed of experts from various disciplines. The Working Party's recommendations, published under the title Backgrounds and Risks of Drug Use in 1972, largely determined the direction of drug policy over the next two decades. In 1974, the government established an Interministerial Steering Group on Alcohol and Drug Policy to coordinate the activities of the various ministries involved on a national level.
These developments led to the 1976 amendments of the Opium Act. These amendements established two legal classes of drugs: Schedule I drugs -- "drugs presenting unacceptable risks" such as heroin, cocaine, amphetamines and LSD. Schedule II drugs -- marijuana and non-liquid hashish, also known as "traditional hemp products." The possession of up to 30 grams of marijuana is classed as a "petty offence" under the 1976 Act, while all other violations are "crimes."
,P. The amendment also established the "expediency principle" which empowered the Public Prosecutions Department to refrain from instituting criminal proceedings if there were weighty public interests to be considered "on grounds deriving from the general good". In accordance with this principle, Guidelines have therefore been established for detecting and prosecuting offences under the Opium Act. ... The guidelines contain recommendations regarding the penalties to be imposed and set out the priorities to be observed in detecting and prosecuting offences.21
In these guidelines, the Public Prosecutions Department exercised its authority to refrain from prosecuting for possession or sale of small amounts of cannabis. This was in an effort "to avoid a situation in which consumers of cannabis suffer more damage from criminal proceedings than from use of the drug itself" (16). The lifetime prevalence of marijuana use in Amsterdam under these conditions of decriminalization is only 5%, compared to 33% in the U.S..22
The first government policy document focusing on aid to drug addicts appeared in 1977. Since then, six guiding principles of government policy have emerged:
In 1985, the Opium Act was further amended to make it a felony to conspire to traffick in Schedule I drugs. In 1992, the Dutch Parliament expanded asset forfeiture provisions under the Opium Act in order to more effectively combat large scale trafficking organizations.
SEPARATION OF MARKETS
One of the basic principles which has guided the development of Dutch policy toward marijuana has been the principle of "separation of markets." As van Vliet has expressed it, "The decriminalization of the use of and the retail trade in cannabis ... aims at keeping experimenting youngsters away from drugs like heroin, cocaine, etc.."25 This policy has historical precedent in the Netherlands' first drug law which regulated the sale of gin. That law created a separation of markets between places where gin and other distilled spirits might be sold and places where the more traditional beer and wine could be sold.
The guidelines developed by the Public Prosecutions Department provided for toleration of "house dealers" with a visible and controllable business, instead of an underground market. According to the guidelines, the house dealer, "sells hemp products with the trust and protection of the staff of a youth centre, and with the exclusion of others, in that centre."23
The house dealer "as a kind of social worker" envisioned by the Minister in 1976 "hardly exist anymore."26 Buning reports that with the dealer in charge, "the group norm was aimed at maintaining high levels of drug use and criminality." With the appointment of Mayor Ed van Thijn in 1983, these original "cafe-achtige ruimten" were shut down.27
Today, hashish and marijuana are predominantly sold in "coffeehouses" ('Koffiehuis' 'Koffiehuizen') which are subject to Police supervision. Only in exceptional cases is action taken against coffeehouses for selling marijuana, and then only after deliberation by a "triangle committee" composed of the Mayor, the local Head of the Public Prosecution Department and the Chief of Police. Such action might result from such offenses as: loud music, crowds or other nuisances; minors on premises; or heroin or cocaine being sold on premises. Coffeeshops in Amsterdam are no longer allowed to display a marijuana leaf emblem at the store front, as was once the case, because the Public Prosecutions Department has decided that this is a form of advertising which is forbidden under the guidelines.26 We have noted, however, that such emblems are still in use in other Dutch cities.
Amsterdam with 700,000 of the Netherlands 15 million inhabitants, had about half of the nation's 700 coffee houses. More than 100 of these were in the inner city, which is the tourist area of the city, appropriately since "marijuana ranks high up amongst the tourist attractions of Amsterdam"26 More recently the number of coffeehouses in the Amsterdam inner city has been reduced approximately by half.
A British drug educator who had observed this system, concluded that, Although, as previously mentioned, there can be problems involving excessive cannabis use, I was impressed by the positive role coffee shops can play for young people in encouraging less damaging patterns of drug use and providing a welcoming and relaxed facility.26
Our own firsthand observations of the coffeehouses echo this sentiment. Their atmospheres were peaceful, relaxed and friendly, with people quietly drinking tea and coffee. Minors and Schedule I drugs were not observed in the coffeehouses. The shops blended into the surrounding neighborhoods without any of the noise or disturbance of the peace which can accompany some alcohol dispensing establishments.
A BACKLASH AGAINST LIBERALIZATION
Painton reported in Time Magazine that a backlash of public sentiment had developed in the Netherlands against liberal drug policies. This backlash was said to be motivated by middle class perceptions of drug users as an unsightly nuisance.29 Buning, on the other hand, denies the report that neighborhoods are complaining about the nuisance of drug users.27 Our own observation shows that such complaints do occur but are not widespread.
The city officials of Amsterdam, however, do seem to have had some such concerns. In addition to the previously mentioned cutback in the number of coffeehouses, a few years ago the city council enacted the binnenstadverband -- city centre banning order -- which allows drug users who have repeatedly caused public disturbances (including loitering and use of heroin) to be refused entry to a substantial part of the city centre (designated a "distressed area") for a fortnight.
Mol and Trautman pointed out that the serious consequences of such a banning order included the fact that the "distressed area" includes the only syringe exchange open after 5 PM and a "considerable part" of the local drug treatment programs.30 We would add to this the fact that the Amsterdam city centre, like the center of many Dutch towns, serves as the social and cultural hub of the community. Exclusion from these areas can seriously detract from an individual's quality of life. Thus, this penalty imposed a significant degree of punitive isolation without the expense of facilities such as prisons. The Dutch supreme court recently ruled, in a suit brought by the junkies' union, that the banning orders were a violation of human rights and this policy was ended.
Another policy which has been viewed by some as a "crackdown" on Amsterdam's drug users is Project Straatjunks -- street-junkie project -- which began in January, 1989, initially to run for two years. This project was a package of measures aimed at pressuring "extremely problematic drug users" to kick the habit. The project is aimed at a group of 300 to 400 users who repeatedly caused public disturbances in the city centre. Persons who have committed four minor offenses (usually dismissed) within a year -- termed "contaminators of the judicial process" -- are given the choice of imprisonment or going into a drug program. If they enter a program, the prosecution is temporarily suspended. Upon completion of the program it is dismissed; dropping out of the program results in prosecution. No evaluation of this program is available at this time.
LOW THRESHOLD TREATMENT
A key element of the Dutch drug policy has been low threshold treatment. By low threshold the Dutch mean that their should be very few barriers to the person wishing to enter treatment. Treatment programs have been created which have minimal paperwork or other requirements for admission and which make minimal demands on the client. Such programs are intended to encourage as many addicts as possible to enter treatment.
These low threshold programs with their minimal demands serve as funnels directing clients into more demanding programs. For example, an addict may initially enter a methadone program which places no requirements on their clients except that the methadone must be taken on site at the clinic. Later, the addict may wish to transfer to a program which allows take-out dosage for the weekends, but which also requires attendance at weekly group therapy sessions. A subsequent move to a program which allows take-out medication for longer periods to permit travel may require participation in both individual and group therapy and periodical urinalysis.
One of the methadone programs operated by the Amsterdam Municipal Health Service is the "Methadon per Bus" -- methadone by bus -- project. Two mobile clinics cruise the city, stopping at six different locations daily. The liquid methadone is consumed on the spot and clean syringes and condoms are available. The possibility of double prescription is prevented by maintaining a central registry of patients in all the city's methadone programs. Clients who enter through this program can subsequently graduate into one of the higher threshold methadone programs.31
NORMALIZATION OF DRUG ABUSE TREATMENT
One of the more recent concepts to be incorporated into the Dutch drug policy is that of normalization of drug problems. This is a policy which "aims at the integration or encapsulation of drug users in society" 25 in "an attempt to avoid stigmatizing, marginalizing or isolating drug users."28 It is a logical extension of the third and fourth principles for aid to addicts adopted by the government in 1977 -- the social rehabilitation of addicts and the use of nonspecialist treatment services.23-24
The main feature of the normalization policy has been the reintegration of addiction treatment into routine medical practice and the prescribing of methadone by general physicians." The Drugs Department of the Amsterdam Municipal Health Service now operates a network of over 200 general practitioners who prescribe methadone for addicts. This represents over half of all the general practitioners in Amsterdam and the roughly 900 addicts they treat are 40% of all those in methadone treatment in Amsterdam.32
Most of these physicians see four or five addict patients along with their other patients. A few doctors, who are especially interested in treating addictions, have larger caseloads but this is generally discouraged to avoid any concentration of prescribing power in a few physicians. This allows the addicts to obtain their medicine without advertising the fact that they are addicts and discourages the development of a 'junkie' peer group, with drug culture norms, at the treatment site.
The Dutch have made a serious commitment to harm reduction - "a policy of preventing the potential harms related to drug use rather than trying to prevent the drug use itself."13 The harm reduction effort has particularly focused on the prevention of AIDS among intravenous drug users. These efforts have succeeded in keeping the seroprevalence of HIV down to a much lower level than that in the U.S., with only a 4% seroprevalence of HIV among IV drug users in Amsterdam.33
The Dutch were among the first to institute syringe exchange programs where IV drug users could trade in old hypodermic syringes for new sterile syringes. Increasing the supply of sterile syringes was expected to reduce needle sharing and thus slow the transmission of HIV.
Early syringe exchanges were established at methadone clinics. It was a small step to mobile syringe exchanges on the model of the methadone bus. More recently, syringe exchange machines have been introduced to provide twenty-four hour access. These vending machines dispense a new sterile syringe when an old one is inserted into the machine.34
Increasingly, organized addict groups have become actively involved in developing and operating AIDS prevention activities. Peer education about AIDS risk behavior, use of sterile needles and needle cleaning have been particularly successful. Grund, Kaplan, and Adriaans have suggested that the organization of active drug injectors to help themselves and their peers prevent high risk exchange situations is the key to effective AIDS prevention among drug users.35
An ethnographic study of injection behavior among heroin addicts in Rotterdam showed no instances of needle sharing as a planned sequence. Furthermore, unsafe needles were used in less than ten percent of the observed self-injections and new sterile syringes were used in 68%.
In each of the unplanned instances of needle sharing that were observed, the users attempted to clean the syringes between uses. Social norms and rituals of the junkie subculture had clearly been modified by AIDS education.35 These changes in risk behavior have become so widely generalized in the addict population that it is no longer possible to detect behavioral differences between addicts who have participated in AIDS prevention programs and those who have not.36
DRUG EDUCATION AND PRIMARY PREVENTION
Liberalization of drug policies and even the decriminalization of previously illicit drugs does not necessarily imply societal approval of drug use. The Dutch government continues to discourage recreational drug use by means other than arrest and prosecution.
Health education has been a mandatory subject in Dutch primary schools since 1985. Mandated programs of health education include nutrition, safety, dental health, heart disease, cancer, sex education and birth control, in addition to alcohol, tobacco and other drugs. Drug education at the primary level focuses on alcohol & tobacco. In secondary schools illicit drugs are usually included too. The usual message of drug education in the Netherlands is that "'it is best not to do it, but if you do...'"28 In many ways the Dutch model is similar to that which Duncan posits for "post-legalization America.37
THE FUTURE OF DUTCH DRUG POLICY
Despite criticism by the U.S. government and the United Nations, the Dutch government remains firmly committed to the continued pursuit of their course in drug policy. The Dutch policy also seems to have widespread public support. We are not likely to see any change in direction.
Extension of the "expediency principle" to cocaine has been gaining support in the Netherlands' treatment and academic communities but doesn't seem to have gained any public support from government officials yet. A bill to legalize cannabis has been introduced in the Dutch Parliament.38 Dutch opponents of marijuana legalization have argued that The Single Drug Convention requires signatory countries, such as the Netherlands, to outlaw marijuana. The Dutch argue, to the contrary, that The Single Drug Convention actually only requires signatories to cooperate in suppressing unlawful trafficking in drugs and that if they legalize marijuana then legal traffic in marijuana will not be covered by the treaty. At the time of this writing debate over the marijuana legalization measure continues in the Dutch Parliament and it appears likely to most observers that the act will be approved.
Having concluded that, "We simply do not have the resources to use more police to deal with the nuisance caused by drug users," the Rotterdam Police Department has proposed an experiment of distributing heroin legally to a group of "heavy addicts."39 Critics charge that in the contemporary Rotterdam drug scene heavy users of heroin are also heavy users of cocaine and that the distribution of the one free and not the other will produce little change.40 Drug ethnographer J. P. Grund has proposed the alternative of establishing about 20 to 30 "closed clubs", on the model of Perron O, a sanctuary for addicts operated by a Rev. Visser, in which member-users could buy and use both heroin and cocaine without police interference.40
One of the most striking aspects of the Dutch strategy is its compassion. Missing are the rhetoric of a "war" on their own people and massive expenditures on police, prisons and punishment. Their efforts seem to be driven by a genuine concern to prevent further human suffering and disease. Their policies and programs are rational, pragmatic approaches calculated to reduce risk-taking behavior.
How is the effectiveness of the Dutch approach to be judged? It would appear that over time these policies have not led to increased drug use or abuse -- the main argument against harm reduction by drug prohibitionists in this country. This should not be at all surprising given the American experience that decriminalization of marijuana in some states did not lead to noticeable increases in consumption or abuse.41 The Dutch are providing further evidence that the initiation and cessation of drug-taking behavior have much less to do with legislation than with other personal and social influences.
On the positive side, Dutch strategies seem to be mitigating the spread of HIV, reducing the number of IV drug users and keeping the overall prevalence of illicit drug use notably lower than in neighboring countries and far lower than in the United States. All this, while expending less resources on law enforcement and curtailing organized crime and political corruption. Had these results occurred in America, our political leaders would have proclaimed victory in the war on drugs. Nevertheless, prohibitionists in this country seem bent on ignoring or deriding the Dutch model. One is left to wonder about the true motives of these prohibitionists.
Can America learn from the Dutch experience? International comparisons of policy are fraught with difficulties. The Netherlands and the United States are different in many ways. On the other hand, both countries are ethnically diverse, economically developed, capitalist nations. The Dutch experience could serve as a model for American development of our own version of harm reduction.
Former Surgeon General Jocelyn Elders made this very point in noting the success of drug law revisions in various countries and suggesting that it may be time for America to consider new approaches.
The authors believe that there are at least three major lessons that America can learn from the Dutch experience: First, that there are alternatives to the extremes of the war on drugs on one hand and a libertarian free market in drugs on the other hand. Second, that liberalizing drug policies need not lead to increased drug use. Third, that control of the spread of AIDS and reform of our drug policies are highly interrelated.
The authors also believe that there are at least three lessons that drug policy reformers in America can learn from the Dutch experience: First, that reform does not have to begin in the legislature; changes in law may solidify, rather than initiate, reforms adopted by the executive or judicial branches of government. Second, that reforms don't have to begin at the national level; innovations at the local level which prove successful can become national policy. Third, that reform isn't likely to come in a single reform package affecting all the currently illicit drugs; reforms are likely to be incremental with different steps affecting different drugs.
During the 1980's, an estimated 100,000 Americans died as a direct result of our war on drugs -- drug overdoses and AIDS deaths associated with needle-sharing.42 We attribute drug overdose deaths to the War on Drugs because they are primarily a result of uncertainty over the strength and purity of drugs in a black market. Drug-related AIDS deaths are included due to the experience of countries such as Australia and the Netherlands where transmission of HIV via contaminated syringes has been nearly eliminated through harm reduction programs. Maybe it is time for reason and compassion to play more prominent roles in America's struggle with drug abuse too.
Acknowledgement: This research was supported in part by Grant T32AA07459 from the National Institute on Alcohol Abuse and Alcoholism. The views expressed herein are those of the authors and do not necessarily reflect the views of the institutions with which they are affiliated.
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