2004 Netherlands National Drug Monitor
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Annual Report NDM 2004
Editorial Board 1 Dr. M.W. van Laar 1 Dr. A.A.N. Cruts 1 Dr. J.E.E. Verdurmen 2 Dr. M.M.J. van Ooyen With the cooperation of 1 Dr. A.P.M. Ketelaars 1 Dr. P. van Gelder 1 2
Trimbos Institute WODC
This publication can be ordered through www.trimbos.nl, or directly from the Trimbos Institute, Order Department, P.O. Box 725, 3500 AS Utrecht, the Netherlands, tel.: 030-297 11 80; fax: 030-297 11 11; e-mail: [email protected]. article number AU0290. An invoice will be sent to you for payment. ISBN 90-5253-487-X © 2005 Trimbos Institute, Utrecht All rights reserved. Nothing from this publication may be copied and or otherwise distributed without the prior written permission of the Trimbos Institute.
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MEMBERS OF THE SCIENTIFIC COUNCIL OF THE NDM Prof. H.G. van de Bunt, Erasmus University Rotterdam Prof. H.F.L. Garretsen, University of Tilburg (Chairman) Prof. R.A. Knibbe, University of Maastricht Dr. M.W.J. Koeter, Amsterdam Institute for Addiction Research (AIAR) Dr. D.J. Korf, Criminological Institute Bonger, University of Amsterdam Dr. H. van de Mheen, Addiction Research Institute Foundation (IVO) Prof. J.A.M. van Oers, Addiction Research Institute Foundation (IVO), University of Tilburg Mr. A.W. Ouwehand, Organisation for Care Information Systems (IVZ) Dr. A. de Vos, Mental Health Service (GGZ Netherlands) Observers Mr. P.P. de Vrijer, Ministry of Justice Dr. W.M. de Zwart, Ministry of Public Health, Welfare and Sports Additional consultants Ms. M. Brouwers, Research and Documentation Centre (WODC), Ministry of Justice Dr. M.C.A. Buster, Amsterdam Area Health Authority (GG&GD Amsterdam) Ms. E.H.B.M.A. Hoekstra, Ministry of Justice Dr. R.F. Meijer, Research and Documentation Centre (WODC), Ministry of Justice Dr. ir. E.L.M. Op de Coul, National Institute of Public Health and the Environment (RIVM) Mr. Th.A. Sluijs MPH, Amsterdam Area Health Authority (GG&GD Amsterdam) Dr. M.C. Willemsen, STIVORO
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TABLE OF CONTENTS Preface List of abbreviations Summary 1
Introduction
2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
Cannabis Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Supply and the market
3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Cocaine Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Market
4 4.1 4.2 4.3 4.4 4.5 4.6 4.7
Opiates Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality
5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8
Ecstasy, amphetamines and related substances Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality Supply and the market
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6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8
Alcohol Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality Supply and the market
7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8
Tobacco Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Supply and the market
8 8.1 8.2 8.3 8.4
Recorded drug crime Latest facts and trends Recorded drug crime Criminal drug users Help for problem users in the criminal system
Appendices A B C D E F
Glossary of Terms Sources Definition of ICD-9 and ICD-10 codes Overview of the products of the Netherlands (Drug) Rehabilitation Foundation and coercive treatment processes Internet addresses with information on alcohol and drugs Data youth monitors and youth surveys
References
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PREFACE In the last decade, the number of cocaine users in the (outpatient) care organisations for drug addicts has quadrupled. This increase was especially apparent in recent years. Alcohol consumption is on the increase, particularly among young girls. In 1999, 57 percent of girls aged 12-14 had drunk alcohol ever in their lifetime; in 2003 this had increased to 78 percent. And Dutch pupils topped the list in respect of alcohol consumption. The chance for a person younger than sixteen to succeed in buying alcohol and/or tobacco is 90 percent or higher. In the period 1997-2003, the number of coffee shops dropped from nearly 1,200 to 754. This drop may affect control of drug trafficking and the separation of markets for soft drugs and hard drugs. In addition, Opium Act offences add increasingly to the workload of the criminal system. The increase is partly a result of cocaine couriers. These are some of the disturbing figures from the Annual Report 2004 of the National Drug Monitor (NDM) before you. With a view to the provision of care and the undertaking of preventive activities, it is important to be informed of such developments annually. In this framework, much attention is often paid to negative developments. Fortunately, many positive developments can also be reported. The percentage of pupils using drugs remains stable or decreases. The size of the group of opiate addicts is stable, while the average age of the group is rising. The number of heavy smokers is down. A favourable development is also that intravenous use of cocaine and heroin decreases. The NDM relies on the contribution of a multitude of national and local monitoring projects and experts. Many thanks are owed to the organisations and institutions that provided data for the Annual Report. Thanks are also owed to the Bureau of the NDM. The Bureau composes the annual reports with great care. This gives the Netherlands a prominent position in the information collection and provision. Prof. Henk Garretsen Chairman of the Scientific Council of the National Drug Monitor
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LIST OF ABBREVIATIONS 2C-B 4-MTA AIAR AIDS AIHW APZ BiZa BO BVT CAM CAN CBS CEDRO CMR COPD CPA CSV CVA CVS DIMS DJI DMS dNRI/O&A DOB DSM EHBO EMCDDA ESPAD EU FPD GGD GG&GD GGZ GHB HAVO HBSC HBV HCV HDL-C HIV HKS ICD IDG IGZ IVO IVV IVZ
4-bromo-2,5-dimethoxyphenethylamine 4-methylthioamphetamine Amsterdam Institute for Addiction Research Acquired Immune Deficiency Syndrome Australian Institute of Health and Welfare General Psychiatric Hospital Ministry of the Interior Primary Education Tobacco Information Agency (Bureau Voorlichting Tabak) Coordination Agency for the Assessment and Monitoring of New Drugs Swedish Council for Information on Alcohol and Other Drugs Statistics Netherlands Centre for Drug Research Central Methadone Registration Chronic Obstructive Pulmonary Disease Central Ambulance Station Criminal Organisation Cerebrovascular Disorders Client Follow-up System Drugs Information and Monitoring System National Agency of Correctional Institutions Drugs Monitoring System National Criminal Intelligence Service of the National Police Agency, Research & Analysis Group 2,5-dimethoxy-4-bromoamphetamine Diagnostic and Statistical Manual First Aid / Casualty Ward European Monitoring Centre for Drugs and Drug Addiction (in Dutch: EWDD) European School Survey Project on Alcohol and Other Drugs European Union Forensic Drug Treatment Clinic Municipal Health Service Municipal Medical & Health Service/Area Health Authority Mental Health Service Gamma-hydroxy-butyrate Higher General Secondary Education Health Behaviour in School-aged Children (study) Hepatitis B virus Hepatitis C virus High density lipoprotein cholesterol Human Immune Deficiency Virus Police Records System International Classification of Diseases. Intravenous Drug User Health Care Inspectorate Addiction Research Institute Foundation Organisation Information Systems on Addiction Care and Treatment Organisation Care Information Systems
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KLPD KMar LADIS LIS LMR LOM LUMC MAD MBDB MDA MDEA MDMA MGC MLK MMO NDM Nemesis NIGZ NMG NPO NRI NVIC NWO OBJD OM OPS PBW PiGGz PMA PMMA POLS RIKILT RISc RIVM SAMHSA SHM SOA SOV Sr Sv SVG SRM SSI SWOV TBS THC TNS NIPO TULP USD UvA VBA v.i.
National Police Agency Royal Military Police National Information System on Alcohol and Drugs Injury Information System Dutch Hospital Registration Special School for Children with Learning and Behavioural Difficulties Leiden University Medical Center Regions and Towns Monitor for Alcohol and Drugs N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine Methylene-dioxyamphetamine Methylene-dioxyamphetamine 3,4-methylene-dioxymethamphetamine Organised Crime Monitor Special School for Children with Learning Difficulties Social Inclusion Monitor National Drug Monitor Netherlands Mental Health Survey and Incidence Study National Institute for Health and Prevention National Monitor Mental Health Care National Prevalence Research National Criminal Intelligence Service National Poison Information Centre Netherlands Organisation for Scientific Research Justice Documentation Research Database Public Prosecutions Department List of wanted persons Prisons Act Register of Inpatient Mental Health Care Paramethoxyamphetamine Paramethoxymethylamphetamine Permanent Survey on Living Conditions Institute of Food Safety Risk Assessment Scales National Institute of Public Health and the Environment Substance Abuse and Mental Health Services Administration HIV Monitoring Foundation Sexually Transmittable Diseases Judicial Treatment of Addicts Criminal Law Netherlands Code of Criminal Procedure Netherlands Rehabilitation Foundation Criminal Justice Monitor Tobacco Manufacturers’ Association Netherlands Institute for Road Safety Research Detention under a hospital order Tetrahydrocannabinol Dutch Institute for Public Opinion and Market Research Enforcement of custodial measures in correctional institutions Synthetic Drugs Investigation Unit University of Amsterdam Drug-free Unit conditional release (on parole)
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VIS VMBO-p VMBO-t VNG VTV VWO VWS WHO WODC WVMC WvS ZMOK ZONMW Zorgis
Arrest Referral Scheme (Vroeghulp Interventie Systematiek) Prevocational secondary education – theoretical stream Prevocational secondary education – practice-oriented stream Association of Netherlands Municipalities Centre for Public Health Studies Pre-University Education Ministry of Public Health, Welfare and Sports World Health Organisation Research and Documentation Centre of the Ministry of Justice Abuse of Chemical Substances Prevention Act Criminal Code Special School for Children with Severe Behavioural Learning Problems Netherlands Organisation for Health Research and Development Care information system GGZ
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SUMMARY Use of substances: general In the Netherlands, the number of people that had used drugs ever or in the past month rose between 1997 and 2001, peaking among young people between the age of 20 and 24. Among secondary school pupils drug consumption stabilised between 1996 and 2003, or was down slightly. However, alcohol consumption increased, particularly among girls younger than 15. In some groups — such as pupils with behavioural or learning problems, truants, detainees, psychiatric patients, homeless people, or individuals who are vulnerable and marginalised in other ways – the use of alcohol and drugs is considerably more prevalent than in the general population. In general, these groups are often struggling with (additional) behavioural, psychological and social problems. Young people associated with trendy clubs are quite often found to experiment with (new) drugs and alcohol. In Amsterdam, drug consumption in trendy clubs decreased nevertheless between 1998 and 2003. However, alcohol consumption increased and remained by far the main stimulant during clubbing. Often several substances are either consumed simultaneously or in short succession each time. Furthermore, poly use is the rule rather than the exception among problem users. Compared to the use of drugs in the general population of other western countries, the Netherlands rated around or somewhat above average. On indicators of problem use of hard drugs, the Netherlands scored proportionally positively (relatively few problem users, small percentage of injecting drug users, low drug-related mortality). The following developments have been observed and are listed for each drug: Cannabis Cannabis remains by far the most popular of all illicit drugs. The number of current cannabis users in the Dutch population rose between 1997 and 2001 from 2.5 to 3 percent. Extrapolated over the entire population, the number of users increased from 326,000 to 408,000, an increase of 25 percent. The proportion of current cannabis users among secondary school pupils dropped slightly between 1996 and 2003, from 11 to 9 percent. This decrease must be attributed mainly to the boys (from 14% to 10%). Compared to their peers in the old EU Member States, cannabis use of Dutch pupils can be considered average. Among young people and young adolescents in Amsterdam trendy clubs, the number of current users of cannabis decreased also, from 52 percent in 1998 to 39 percent in 2003. One in five current users consumes cannabis daily of almost daily. Consumers with intensive use patterns can become dependent on cannabis. Young people with an outspoken preference for ‘strong’ cannabis have a good chance of becoming dependent. The total number of people concerned is not known. The number of clients of the (outpatient) care organisations for drug addicts with a primary cannabis problem continued to increase slightly. From 2002 to 2003 an increase of 21 percent was recorded. Between 1994 and 2004 their number doubled from 1,951 to 4,485. The number of clients who named cannabis as a secondary problem increased from 2,846 to 4,291. The number of admissions into general hospitals with cannabis abuse or dependency as primary diagnosis was low (46 in 2003). A slight increase is observed in the number of admissions with these problems as secondary diagnosis (246 in 2003). The number of coffee shops fell in 2003 by four percent, from 782 in 2002 to 754. In 1997 there were still nearly 1,200 coffee shops. The average THC content in Dutch-grown marijuana (Nederwiet) rose further between 2002/2003 and 2003/2004, from 18 to 20 percent. In 1999/2000 the THC content was half of that (9%). It is not known whether this increase has health-related consequences, but there is increasing scientific evidence that cannabis can induce psychotic symptoms, particularly in heavy users with a
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predisposition for psychoses. The question of cause and effect, however, is still subject of discussion. More research is needed to demonstrate the causality. Cocaine The use of cocaine in the general population is limited. However, the percentage of ever users of cocaine did increase from 2.1 percent in 1997 to 2.9 percent in 2001. The percentage of current users increased from 0.2% to 0.4 percent. Among secondary pupils the use remained stable in the past few years. In 2003, two percent of them had had experience with cocaine. The use of cocaine showed a large increase in the last decade in special groups of the population, such as problem hard drug users. These users mainly use crack, the smokable and most addictive form of cocaine. Seven to nine out of ten opiate addicts also use cocaine, which by now has become the main drug for many hard drug users. Cocaine, especially sniffed coke, has become popular among the partying youth and young adolescents. In Amsterdam, between 1998 and 2003, a decrease in the percentage of current users of sniffed coke took place among visitors of trendy clubs, from 24 to 14 percent, but compared to ecstasy, cocaine has grown in popularity. Figures from (outpatient) care organisations for drug addicts show a strong increase in the number of people seeking help for cocaine-related problems. From 2002 to 2003 an increase of 19 percent was recorded. In 2003, the number of clients with a primary cocaine problem was even four times larger than in 1994 (9,216 and 2,468, respectively). The number of clients with cocaine as a secondary problem increased also in this period, from 6,020 to 8,388. Two in three help-seeking cocaine users have a crack problem. They struggle with physical and psychological complaints, such as lung problems, exhaustion, aggression and paranoia. Data about admissions into hospitals and about mortality suggest also an increase in cocaine problems until 2002, but this trend did not continue in 2003. The number of cocaine users admitted to general hospitals as a result of (crack) cocaine-related problems rose from 246 in 1996 to 562 in 2002, after which it decreased slightly to 506 in 2003. Acute mortality as a result of cocaine use – as far as recorded – fluctuated until the mid-nineties between one and three cases per year. In the years 2000, 2001 and 2002, 19, 26 and 34 cases, respectively, were recorded. In 2003, 17 cases were recorded. Opiates Heroin, the most frequently used illicit opiate, is not popular among the general population (0.1% current users in 2001). The number of problem users of (also) opiates is stable in the Netherlands, with an estimated figure of 32,000 (ranging between 22,000 and 42,000). Per thousand inhabitants, the Netherlands has three hard drug problem users. This is low compared to other (old) EU Member States, such as the United Kingdom, Italy, Portugal and Denmark, which have between seven and nine cases per thousand inhabitants. The treatment demand of opiate addicts in (outpatient) care organisations for addicts decreased slightly between 2001 and 2003, from 17,786 to 15,195 clients. Corresponding with the decreasing number of young heroin users, the proportion of young opiate clients also showed a downward tendency. About 12,000 opiate addicts are registered in methadone programs, generally as clients on maintenance basis. Currently, they receive a higher dose of methadone on average than ten years ago (57 versus 46 mg), but only one third of them receives a (therapeutic) dos of 60 mg or more. The average age of the group of opiate addicts is rising. In 1989, the average age of the methadone clients in Amsterdam was 32; in 2003, it was 44 years. In Rotterdam and Parkstad Limburg, the average age of problem uses rose from 37 to 39 between 1998 and 2003. Long-term opiate dependence often is accompanied by considerable harm to the health of the user, owing to the use of the substance itself, but also as a result of the unhealthy lifestyle and the route of administration. The proportion of opiate addicts injecting the drug decreased strongly in the last decade and is now estimated at 10 to 20 percent. Heroin is now mostly smoked. Since opiate addict
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often also smoke a large quantity of tobacco, lung disorders are more prevalent. A large proportion of former IDUs is infected with hepatitis C (47-79%) and hepatitis B (35-67%). The proportion of IDUs infected with HIV varies from 1 percent in Groningen and Arnhem to 22 percent in Heerlen and 26 percent in Amsterdam. Needle sharing decreased in the past ten years, but between 8 and 30 percent of IDUs still (occasionally) share needles. Sexual risk behaviour (practising sex without condoms) is still widespread. As a result, the risk of transfer of contamination with HIV and hepatitis B is still considerable in a number of regions. From 1996 to 2001 incl., recorded opiate-related mortality fluctuated between sixty and eighty cases per year. In the last few years, a slight decrease was evident (37 in 2002 and 53 in 2003). Ecstasy and amphetamines The percentage of current ecstasy users in the general population between 1997 and 2001 rose from 0.3 to 0.5 percent. This increase occurred mainly among women. The percentage of current amphetamine users remained low (0.1% in 1997 and 0.2% in 2001). Among secondary pupils, the percentage of ever users and current users of both substances decreased between 1996 and 2003. In 2003, three percent had had experience with ecstasy and two percent with amphetamines. Ecstasy is still popular among young clubbers, although the use is showing signs of moderation. An increasing number of young people seem to handle this substance intelligently and to be aware of the risks. Among visitors of trendy clubs in Amsterdam, the percentage of current ecstasy users halved from 41 percent in 1998 to 19 percent in 2003. The use of amphetamine, a considerably less popular substance in party life, also showed a decrease, from 13 to 7 percent. Compared to other hard drugs, problem use of ecstasy did not occur often. Since 1999, the treatment demand in outpatient care organisations for addicts primarily for ecstasy is low compared to other drugs and relatively stable. In 2003, 277 clients were recorded with ecstasy as a primary problem and 655 clients for whom ecstasy was a secondary problem. The number of primary amphetamine clients increased slightly from 482 in 2001 to 735 in 2003. In 2003, 552 clients named amphetamines as a secondary problem. The acute health risks from ecstasy intoxication can be considerable, but it is not known how often such intoxications occur. The number of ecstasy-related incidents at parties dropped. This may be connected with the stable composition of ecstasy pills. In the last few years, more than nine in ten ecstasy pills that consumers handed in for testing at care organisations for addicts contained only MDMA or an MDMA-like substance. However, the percentage of pills with a high MDMA content of more than 140 milligrams per pill increased slightly, from one percent in 1999 to six percent in 2003. According to the latest scientific insights, the use of ecstasy may lead to long-term memory problems, to problems with the capacity to concentrate and mood problems. The risk of brain damage depends on the dose and the temperature at which ecstasy is used. The exact number of people who have died as a result of ecstasy use is not known. The Cause of Death Statistics Agency recorded seven cases in 2003. Alcohol Alcohol consumption is widespread in Dutch society. Of the population aged 16 and over, 85% drink alcohol ‘occasionally’. This percentage has been stable in the last few years. Sales figures, however, show a slight decrease in the total per capita consumption of alcohol in 2003. This decrease is due to the decrease in the consumption of distilled spirits, which dropped by nearly ten percent in 2003 compared to the year before. Heavy drinking – six glasses or more on at least one day a week – was prevalent in eleven percent of the population aged 12 and over, a slight decrease compared to 2001. Proportionally, heavy drinking is most prevalent among young men aged 18 to 24 incl. This age group also accounts for a relatively high number of traffic accidents in which alcohol is involved. Ten percent of the Dutch population aged 16 to 69 are problem drinkers.
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Alcohol consumption among secondary pupils increased between 1999 and 2003. In 1999, 74 percent of the pupils had experience with alcohol, in 2003 this was 85 percent. The increase was especially noticeable among young girls, aged 12 -14. In 2003, there was no difference in the percentage of boys or girls who had a drink in the month prior to the survey. There were however differences in drinking pattern. Boys drank alcohol more frequently than girls. They also drank larger quantities than girls, particularly older boys. Compared to pupils in other countries, Dutch pupils drank frequently. In 2003, 26,874 persons were treated at the (outpatient) care organisations for drug addicts with alcohol use as primary problem. This is thirteen percent more than in 2002. Many people were also admitted into general hospitals as a result of alcohol consumption; in 2003, 4,239 were admitted with an alcohol-related disorder as primary diagnosis and 10,899 with an alcohol-related secondary diagnosis. The number of recorded dead and injured in traffic as a result of alcohol consumption dropped slightly since 1997. In 2003, their number was nearly 2,700. Total alcohol-related mortality, however, has risen in the past few years. In 2003, nearly 1,900 people died from causes in which alcohol was named explicitly, seven percent more than in 2002 and over forty percent more than in 1995. Tobacco In 2003, the Netherlands had over four million smokers; slightly more men than women (33% versus 27%). While in the early eighties as many as 52 percent of the men and 35 percent of the women smoked cigarettes, the percentage of heavy smokers has fallen over the past years. In 2000, ten percent of the population aged 12 and over smoked at least twenty cigarettes a day and in 2003 this dropped to eight percent. Among pupils aged 12 and over, the percentage of ever users decreased from 55 to 45 percent. The percentage of pupils who had smoked in the month before the survey dropped in that same period from 27 to 20 percent. In 2003, over 20,000 people died from the direct consequences of smoking. Per 100,000 inhabitants, 67 people died from lung cancer, the main cause of death from smoking. While mortality from this illness is decreasing among men, it is rising among women. Recorded drug-related crime Offences under the Opium Act put a heavier strain on the resources of the criminal system in 2003 than in 2002; this also applied to all the phases of the criminal process. In 2003 more suspects were booked for Opium Act offences than in 2002. Most of those offences were still related to hard drugs. Of the investigations into organised crime 66 percent concerns Opium Act offences. This is more or less the same as in 2002, when this proportion was 63 percent. The number of Opium Act cases taken in by the Public Prosecutions Department continued to increase, although the increase by 8 percent in 2003 was somewhat less than in the two previous years. The Court dealt with over 12,000 Opium Act cases, more than in 2002 when over 10,000 cases were dealt with. The number of imposed community sentences and confiscation orders in cases under the Opium Act increased strongly in 2003. The number of unsuspended custodial sentences in Opium Act cases increased also in 2003. In 2003, these made up 15 percent of the total number of custodial sentences. The increase was due to the hard drug cases, which made up 14 percent of the total in 2003. The proportion of soft drug cases remained stable, being 1 percent of the total. One in three sentences involving prison years was drugrelated, which is more than before; 28 percent concerned hard drugs. In 2003, a quarter of the prison population were detained because of Opium Act offences. Offenders under the Opium Act repeated the offence more often than other offenders. In 2003, criminal drug users put an approximately the same burden on the criminal system as in 2002. That same year, the police recorded over 10,000 suspects as 'drug users'.. These suspects mainly committed property offences in 2003 as well. Offences involving violence and Opium Act offences were somewhat more frequent in 2003 than in the previous years. Three in four drug-using suspects
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had eleven or more crime-related police reports in his/her criminal history. More than 70 percent of the ‘very high rate’ frequent offenders are regular drug users. In 2003, in general more activities of the Netherlands (Drug) Rehabilitation Foundation were recorded in the criminal system. The number of addicts entering the Judicial Treatment of Addicts (SOV) rose also steadily in 2003. End 2003 there were 192 participants. The degree of capacity utilisation increased compared to 2002 and was 85 percent end 2003. From April 2003, the regular outflow of participants started.
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1
INTRODUCTION
The National Drug Monitor In the Netherlands, numerous monitors record developments in the field of substance use. In addition, frequently research is published about patterns of use, prevention of substance use and treatments. To policymakers and professionals in the field and to other target groups the National Drug Monitor (NDM) provides an updated overview in this large data flow. The NDM aims primarily to collect data about developments in substance use in a coordinated and consistent manner based on existing research and records and to combine and convert this knowledge into a number of basic products, such as annual reports, thematic reports and fact sheets. This objective is in line with the current social pursuit of a policy and practice based on facts. The NDM was established in 1999 on the initiative of the Minister of Public Health, Welfare and Sports 1 (VWS). However, drug use is not only within the focus of public health, but also of the judicial system. Since 2002, the NDM has also been supported by the Ministry of Justice. The NDM promotes the following functions: • Acting as a coordinating body for currently ongoing surveys in the Netherlands and for registering data on substance use (drugs, alcohol, tobacco) and dependence. The NDM strives for an improved harmonisation of monitoring activities in the Netherlands, taking international data collection guidelines into account. • Achieving a synthesis of the compiled data, and reporting to national authorities and international and domestic organisations. The international organisations that receive reports from the NDM include the WHO (World Health Organisation), the United Nations and the EMCDDA (the European Monitoring Centre for Drugs and Drug Addiction). At the centre of the NDM’s work is the collection and integration of figures. To that end a limited number of key indicators or ‘policy barometers’ are used, which were agreed upon by the Member States of the European Union in the framework of the United Nations and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). This involves information on: • substance use in the general population • problem use and dependence • the use of professional services • illness • and drug-related mortality. The NDM also reports on recorded drug crime and penal response. Here too, a series of key indicators are used, which are collected by the Research and Documentation Centre of the Ministry of 2;3 Justice (WODC). To that end, the Ministry of Justice in 1999 initiated a developmental program.
Collaboration The NDM relies on the contribution of a multitude of experts. Implementing organisations of numerous local and national monitoring projects supply the building blocks. The quality of the publications is warranted by the Scientific Council of the NDM. This Council evaluates all written concepts and offers advice on the quality of monitored data. Three work groups - – the work group Prevalence Estimates
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of Problem Substance Use, the work group Drug-related Mortality, and the workgroup Effectiveness in the Treatment of the Drug Problem – support the NDM on thematic sub(fields). Each year the NDM publishes a statistical overview of addiction and substance use and its consequences: the Annual Report. This report is part of the annual documentation submitted to Parliament.
Annual Report 2004 This is the sixth Annual Report of the NDM. Chapters two to seven incl. describe developments per substance or classes of substances: cannabis, cocaine, opiates, ecstasy and amphetamines, alcohol and tobacco. Per chapter we briefly and concisely present the most recent figures pertaining to the use, problem use, treatment demand, (illness and) mortality and finally supply and the market. The situation in the Netherlands is (carefully) placed in an international context. In Chapter 8 the information on recorded drug crime is presented, with the focus on narcotics offences (violations of the Dutch Opium Act) and drug crime by users in the different sections of the penal chain (police, Public Prosecutor’s Office, justice system, detention). This chapter also provides a current overview of the penal options in terms of mandatory and coercive measures for criminal drug addicts. Figures on substance use and drug crime can be measured and reflected in various ways. Appendix A contains information about the terminology used. In Appendix B we give a concise overview of the main sources of the information in this Annual Report. The Annual Report can also be accessed via internet: http://www.trimbos.nl/Downloads/Producten/NDM%202004.pdf
Other information • • •
Key figures about the addiction care sector can be found in the Brancherapport [Mental Health 4 Sector Report] GGZ-MZ 2000-2003. The NDM background study ‘Hulp bij Probleemgebruik van Drugs’ [Treatment for Problem Use of 5 Drugs] gives a detailed overview of effective treatments of drug addiction. For more details about the results and gaps of monitor systems in the field of alcohol and drugs 6 we refer to the report ‘Monitoring van alcohol en drugs onder the loep’ [Monitoring of alcohol and drugs under the microscope], which can also be found on internet (www.trimbos.nl/ndm of www.ivo.nl). A detailed overview of recording systems and research in the Netherlands about the monitoring of alcohol and drugs can be found on the website of the Trimbos Institute, the Research Institute Foundation (IVO) and the Netherlands Organization for Health Research and Development (ZonMw) (www.trimbos.nl/monitors of www.ivo.nl of www.zonmw.nl).
Earlier publications of NDM are: 7 • ‘Fact sheet Drugsbeleid’ [Fact sheet on drug policy], briefly outlining information on drug policy, drug use, addiction care, drug education and prevention and public nuisance, drug-related crime and drug trafficking. 8 • ‘Bovenmatig drinken in Nederland’ [Excessive drinking in the Netherlands], a report based on the outcomes of the Nemesis household survey. 9 • ‘Cannabis. Feiten en cijfers 2003’ [Cannabis. Facts and figures in 2003], a background study of the state of science on cannabis.
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In addition to the NDM the Trimbos Institute oversees the coordination of two other national monitors, resulting in cooperation with: the Netherlands Mental Health Monitor (NMG) and the Homelessness and Social Inclusion Monitor (Monitor Maatschappelijke Opvang – MMO). • Annual reports and other reports produced by these monitors can be found on the website of the Trimbos Institute (www.trimbos.nl).
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2
CANNABIS
Cannabis (Cannabis Sativa or hemp) comprises hashish and pot in various preparations. THC (tetrahydrocannabinol) is the main psychoactive ingredient. Cannabis is usually smoked in cigarettes, whether or not in combination with tobacco, and sometimes via an evaporator. Eating it – in the form of space cake – also occurs. Consumers experience cannabis as having a calming, relaxing and psychedelic effect. At a high dose, cannabis may cause fear, panic and psychotic symptoms. The below data apply to hashish and pot together, unless stated otherwise.
2.1
LATEST FACTS AND TRENDS
The main facts and trends regarding cannabis in this chapter are: • The percentage of users of cannabis in the general population increased between 1997 and 2001. The proportion of (almost) daily consumers among recent users decreased in this period (Chapter 2.2). • The percentage of recent users among school-aged children (12-18 years) decreased slightly between 1996 and 2003. The credit of this decrease goes to the boys; among the girls the consumption remained the same (Chapter 2.3). • Compared with their peers in a number of other Member States of the European Union, in respect of cannabis use, Dutch pupils are in the middle range (Chapter 2.5). • Among visitors of trendy clubs in Amsterdam the use of cannabis decreased between 1998 and 2003 (Chapter 2.3). • Just as in previous years, the number of cannabis patients who sought help from the (outpatient) care organisations increased between 2002 and 2003 (Chapter 2.6). • The number of coffee shops fell slightly between 2002 and 2003 (Chapter 2.8). • The average THC content in Dutch-grown cannabis rose further between 2002/2003 and 2003/2004 (Chapter 2.8).
2.2
USE IN THE GENERAL POPULATION
Of all drugs, cannabis is the most commonly used substance. In 1997 and 2001, National Prevalence 10 Surveys (NPO) were conducted by the Amsterdam drug research institute CEDRO. Between 1997 and 2001 a slight rise in the use of cannabis was noted in the Netherlands. Key figures are as follows: • In 2001, one in six respondents aged 12 and over had ever used cannabis (see Table 2.1). • One in 33 respondents had used cannabis in the month prior to the interview (current use). • Extrapolated over the entire population, in absolute numbers, this represents an increase from 326,000 to 408,000 in current cannabis users over these four years (1997 – 2001); a rise of 25 percent. • Cannabis consumption is most prevalent among young people and adolescents (see Figure 2.1). - The rise in both ever use and current use figures was found to be highest in the age group 20 to 24 years incl. (see Figure 2.1). - Ever use figures dropped slightly among young people aged 12 to 15 incl. (see Chapter 2.3 for comparison). • Cannabis use is more prevalent among men than among women (see Table 2.1).
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Table 2.1
Cannabis use in the Netherlands among people aged 12 and over. Survey years 1997 and 2001
Has ever used • Men • Women I Used currently • Men • Women First use in the past year Average age of current users
1997 15.6% 20.6% 10.8%
2001 17.0% 21.3% 12.8%
2.5% 3.5% 1.4%
3.0% 4.3% 1.8%
1.3% 28 years
1.0% 28 years
I. In the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 2.1 Cannabis users in the Netherlands by age group. Survey years 1997 and 2001
% 50 40 30 20 10 0
12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69 >=70
Ever 1997
7.5
27.5
31.7
30.6
21.7
20.5
16.8
6.7
1.9
0.5
Ever 2001
5.9
28.4
41.9
33.8
25.9
21.9
18.5
8.3
1.2
0.4
Current 1997
2.0
8.3
7.1
4.7
2.1
3.6
1.5
0.5
0.0
0.0
Current 2001
2.2
8.6
11.2
6.6
3.6
2.7
1.7
0.9
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
24
The large cities Consumption of cannabis is more prevalent in cities than in rural areas (see Table 2.2. Table 2.2
Cannabis use in the four large cities and in rural areas among people aged 12 and over. Survey years 1997 and 2001 Ever use
Amsterdam Rotterdam Other primarily urban I municipalities II Utrecht II The Hague III Rural municipalities
Current use
1997 36.7% 18.5% 23.0%
2001 38.1% 22.4% 26.3%
1997 8.1% 3.3% 4.1%
2001 7.8% 5.0% 4.8%
27.3% 20.1% 10.5%
11.4%
4.2% 4.2% 1.5%
1.7%
Percentage of ever (lifetime) and current (last month) users. I. Definition: municipalities with more than 2,500 addresses per square kilometre with the exception of Amsterdam and Rotterdam. These are: Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. II. Utrecht and The Hague were not listed separately in the 2001 survey. III. Definition (Statistics Netherlands - CBS): towns with fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Level of consumption The frequency of cannabis use among current users varies strongly. • In 2001, almost half of all current users in the Netherlands used cannabis less than once a week 10 (see Figure 2.2).
•
Approximately one fifth of this group used cannabis (almost) daily. Extrapolated over the entire population this amounts to nearly 78,000 people; fewer than in 1997 (over 83,000 people). This decline did not occur evenly across the Netherlands. In Amsterdam and Rotterdam the percentage of heavy users rather seemed to increase.
25
Figure 2.2 Cannabis consumption levels in the Netherlands among current users aged 12 and over. Survey years 1997 and 2001 60
% 51
50
45
40 30
1997
26
20
14
12
15
2001 19
18
10 0 1-4
5-8
9-20
>20
Number of days in last month
Percentage among current users. Number of days on which cannabis was used in the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Sources of procurement Cannabis users procure cannabis mainly in coffee shops or obtain it through friends and acquaintances (see Table 2.3). • Young people between the age of 12 and 17 are more likely to obtain cannabis through friends and acquaintances than from coffee shops. The opposite is true for cannabis users aged 18 and over. I
Cannabis procurement sources of recent users? Survey year 2001
Table 2.3
Users aged 12 to 17 incl.
Users aged 18 and over
from coffee shops
46% 37%
37% 47%
from a ‘house dealer’
3%
2%
in a pub
2%
2%
in a smart shop
2%
2%
at another public nightlife location
4%
2%
through growing it themselves
3%
4%
4%
4%
They obtain their cannabis - through friends and acquaintances
-
Other
II
I. The percentage of cannabis procurement sources of recent users in the last year. A respondent may have more than one source. II. Through youth clubs, dealer delivery services, strangers on the street, etc. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
26
Special groups In certain groups of adults a considerably higher prevalence of cannabis use was noted than in the general population. 11 • In 2002, over half (52%) of the homeless in 20 Dutch towns were current cannabis users. a
• In the same year, one in three (33%) male detainees in eight penitentiaries stated to have used cannabis daily in the last six month prior to detention. Detainees with serious psychological 12 disorders or prison-imposed restrictions (contact ban) were not represented in the sample. • There are indications that cannabis use is very common among certain groups of psychiatric 13;14 patients, such as people with schizophrenia or borderline disorder. Hard figures are scarce. According to older data by Nemesis (from 1996) cannabis use is more prevalent among people with mood disorders and combined anxiety/mood disorders than among people without these disorders (7%, 9% and 3% recent users, respectively). As regards patients with anxiety problems alone, no (significant) difference was observed.
2.3 USE AMONG YOUNG PEOPLE To classify the use of cannabis among young people, figures from the National Prevalence Research are available, as mentioned in Chapter § 2.1. In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F we give an overview of recent figures concerning the use of cannabis among young people in 29 municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of the difference in cannabis use between the various municipalities. The percentage of young people aged 19 to 23, for example, who ever tried cannabis is remarkably low in Urk (16%) compared to Almere and Lelystad (50%). The ever use in the lastmentioned cities seems also to be higher than the national average (see Figure 2.1). In this paragraph we also present the data of the Dutch National School Survey and data from (often local) surveys among special groups of young people.
Pupils Since the mid-eighties the Trimbos Institute has monitored the extent to which secondary school pupils aged 12 and over have experience with alcohol, tobacco, drugs and gambling. This is done in, what is called, the Dutch National School Survey. • Figure 2.3 shows that the percentage of cannabis users among school-aged youth increased 15 significantly between 1988 and 1996. • After 1999 the ever use stabilised and remained at approximately the same level as in 1996. The current use decreased significantly between 1996 and 2003. The credit of this decrease goes mainly to the boys. Among girls, the percentage of current users of cannabis remained more or less the same between 1996 and 2003.
a
In Arnhem, Den Bosch, Breda, Grave and 4 remand prisons in Rotterdam.
27
•
In the measurements of up to 1999 incl., more boys than girls used cannabis. In 2003, for the first time, the ever use was the same for boys and girls. The difference of actual use between boys and girls decreased also, but remained statistically significant.
Figure 2.3
Use of cannabis among school-aged youths aged 12 and over, from 1988 Current use (%)
Ever use (%) 16
30
23 19
20
18 15 10
10 5
22 20
15
14
14
25
25
20 19 17
12
12
10
10
9
11 9
8
16
6
12 9
4
7
2
7
5 4
8 7
9 7
4
2
0
0 1988
1992 Boys
1996 Girls
1999 Total
2003
1988
1992 Boys
1996 Girls
1999
2003
Total
Percentage of ever users (on the left) and current users (on the right). Source: Dutch National School Survey, 16 Trimbos Institute.
Age • •
The use of cannabis increases with age. Only few twelve-year olds have experience with cannabis: one in fifty (2%). At age sixteen, one in three pupils ever used cannabis (34%). The age on which school-aged youth used cannabis for the first time dropped between 1988 and 186 1996. The percentage of ever users of cannabis who smoked their first joint at the age of thirteen or younger doubled in this period from 21 to 40 percent. Between 1996 and 2003 the first-use age remained the same.
Level of consumption •
•
•
Of the nine percent current users in 2003, nearly half had used cannabis not more than once or twice in the past month. A minority blew more than ten times (17%): one in five boys and more than one in ten girls (see Figure 2.4). Per occasion nearly half the current users smoked less than one joint (46%). They probably smoke together with others, sharing a joint. Nearly one in three smoked one or two joints per occasion (32%) and nearly a quarter smoked more than three joints per occasion (23%). There is also a correlation between frequency and quantity. Of those who blow three to ten times a month, a quarter (27%) smoke three or more joints per occasion. Of those who blow more than ten times a month, two-thirds (67%) smoke three or more joints per occasion. This last group runs a relative large risk of getting into problems.
28
Figure 2.4
Frequency of cannabis use among current users. Survey year 2003 girls
boys 11%
20%
43% 51% 38% 37%
1-2 times
3-10 times
> 10 times
1-2 times
3-10 times
> 10 times
Percentage of school-aged youth who had used cannabis in the month before the survey. Source: Dutch National 16 School Survey, Trimbos Institute.
School level and ethnic origin •
• •
The percentage of ever users and current users among pupils of VMBO-t (pre-vocational secondary education - theoretical stream), HAVO (senior general secondary education), VWO (pre-university education) and VMBO-p (pre-vocational secondary education - practical stream) is about the same. The frequency of use in the last month does not differ much either between the school levels. However, the percentage of pupils who smoke three or more joints on average per time is significantly higher at VMBO than at VWO (30% versus 8%). Current use of cannabis is less common among Moroccan than native Dutch girls (0% versus 7%). No difference is found between Moroccan and native boys. Antillian/Aruban (12%), b Surinamese (8%) or Turkish (5%) pupils do not differ significantly in this from native pupils. According to data from the Antenne Monitor, in Amsterdam the percentage of ever users and current users of cannabis is lowest among Moroccan pupils but also the percentage of users among Turkish and Surinamese pupils is lower than among native Dutch pupils.
Sources of procurement •
• •
•
b
Two in three current users receive cannabis from friends and one in three buys it (also) in coffee shops (see Table 2.4). More than one in ten buy cannabis from a ‘house dealer’ and one in ten receives it ‘in a roundabout way’. More girls than boys obtain cannabis through friends; boys buy in coffee shops more often than girls. A considerable part of the blowing pupils of up to 17 years incl. buy cannabis in a coffee shop. This is remarkable, because the legal minimum age for access to a coffee shop is 18 years. It is unknown to what extent these young people themselves actually bought cannabis in a coffee shop or had others by it for them. Boys aged 18 are used to buying cannabis mostly in coffee shops. Eight in ten current users among boys buy their cannabis there.
For the definition of native Dutch and immigrant: see Appendix A.
29
Table 2.4
Cannabis procurement sources of school-aged youth? Survey year 2003 12-15 years b g
Through friends Buy in coffee shops Buy from dealer In a roundabout way Otherwise
60% 22% 17% 16% 7%
78% 22% 6% 9% 6%
16-17 years b g
64% 57% 15% 6% 2%
77% 37% 12% 2% 8%
b
18 years g
b
Total m
Total
40% 81% 9% 0% 4%
69% 56% 0% 0% 0%
60% 40% 16% 11% 5%
78% 27% 7% 6% 6%
67% 35% 12% 9% 6%
Secondary school pupils aged 12 and over (current users). The pupils were allowed to check multiple answers. Therefore, the percentages do not add up to 100%. b = boys, g = girls. Source: Dutch National School Survey, 16 Trimbos Institute.
Special groups of young people The use of cannabis in certain groups of young adolescents is the rule rather than the exception. Table 2.5 summarises the results of a broad spectrum of studies. The figures in this table are not comparable due to differences in age categories and research methods. • Among young people in special schools and participants in truancy projects relatively many current users are found. • The Antenne-monitor monitors the use of substances in various groups of young people in the Amsterdam club scene, such as coffee shops, pubs and trendy clubs. - According to a survey among visitors of coffee shops, two thirds of the current blowers use cannabis daily. Current blowers smoke four joints on average per occasion. Daily blowers 17 smoke five joints on average per occasion. - In 2001, the number of Amsterdam coffee shop visitors under the age of 18 was 50 percent c lower than in 1994 (7% and 14% respectively). This may be connected with the raise of the legal minimum age from sixteen to eighteen years for the sale of cannabis to young people by coffee shops. - Between 1998 and 2003, the percentage of cannabis users among young people and adolescents who visit trendy clubs (and parties) in Amsterdam dropped from 52 to 39 percent. The average number of joints smoked by current users per time dropped also, from two to one 18 and half. This trend, which also applies to most of the other drugs, is in line with the phase of the ‘new level-headedness’ and the observed tendency to more prudent use. • Young people who visit clubs and pubs often also have experience with other substances. Table 2.6 shows the percentage of young people visiting clubs and pubs in The Hague who used both cannabis and another substance in the month prior to the interview. Often these substances are used simultaneously. Favourite combinations are cannabis with alcohol and cannabis with 19-21 ecstasy. • The use of cannabis (and other substances) is common among young homeless people. Four in 22 ten young homeless people in the Netherlands are (almost) daily users. In 2004, 87% of the 23 young homeless people in Flevoland were current users of cannabis.
c
Coffee shop visitors up to the age of 25 only, were included in the comparison between 1994 and 2001.
30
Table 2.5
Current cannabis use in special groups Location I
Young people in special education II Pub visitors Young people in truancy programs III Marginalised young people Young clubbers Visitors of trendy clubs Young people in special education and truancy projects IV Young homeless people V
Coffee shop clientele
Nationwide Amsterdam Nationwide The Hague The Hague Amsterdam Amsterdam
Survey year 1997 2000 1997 2000/2001 2003 2003 2003
Age (year) 12 - 18 Mean age 25 12 - 18 16 - 25 15 - 35 Mean age 28 13 - 16
Current use 14% 24% 35% 37% 37% 39% 32%
Nationwide Flevoland Amsterdam
1999 2004 2001
15 - 22 13 - 22 Mean age 25
76% 87% 88%
Percentage of current (last month) users by group. The figures in this table are not comparable owing to differences in age groups and research methods. I. Special schools for children with learning and/or behavioural difficulties (MLK, LOM, ZMOK). II. Young people and adolescents visiting mainstream, student, gay, and trendy pubs. The sample is therefore not representative for all pub visitors. III. Young people receiving inadequate care and/or cannot provide sufficiently in their own livelihood. Recruited at locations for young homeless people, lowthreshold day- and night shelters and (other) temporary living accommodations. V. Young people up to 23 years 17;22;24-26 23 . of age without a fixed address for three months or longer. References:
Table 2.6
Poly-consumption of cannabis and other substances among young clubbers in The Hague. Survey year 2003
Combination Cannabis with alcohol Cannabis with ecstasy Cannabis with cocaine Cannabis, cocaine and ecstasy
Percentage of recent users. 34% 14% 8% 6%
The same person may occur in several categories. I. Number of respondents: 634. Source: Survey of clubbers in 21 The Hague.
2.4
PROBLEM USE
The precise number of people experiencing problems as a result of cannabis use is not known, nor is there a generally accepted definition of problem cannabis use. The addictive potential of cannabis is minimal compared to that of nicotine, heroin and alcohol. However, the risk of dependence does increase with prolonged and frequent use and often is associated with an additional dependence on 27 other substances. Young people are more vulnerable to becoming dependent than older people. • The Nemesis study provides information about the prevalence of cannabis dependence according rd to the psychiatric classification system Diagnostic and Statistical Manual (DSM) (3 amended edition). In 1996, between 0.3 and 0.8 percent of the population aged 18 to 64 incl. showed the symptom criteria for this diagnosis in the year prior to the study. Extrapolated over the entire population this amounted to between approx. 30,000 and 80,000 people. The majority of these 28 cannabis users was not older than 22 years. • Problem cannabis use is very common in certain groups of young people, such as youths who end up in juvenile correctional facilities, play truant on a frequent basis and display delinquent behaviour (see Table 2.7).
31
Table 2.7
Problem cannabis use in different groups
Group
Year
General population in the Netherlands General population in Midden-Holland
1996
Age (year) 18 – 64
1999
16 – 50
Youths in juvenile correctional facilities
1998/ 1999
12 – 18 (mean age16)
High-risk juveniles (truancy and delinquent behaviour) in Rotterdam
1998
14 – 17 (mean age16)
Definition of problem use DSM-III-r diagnosis cannabis dependence in the last year Cannabis use on a minimum of 15 days in the last month and presence of the psychological, social and financial problems related to the use DSM-III-r diagnosis cannabis dependence in the last 6 months prior to detention Cannabis use on a minimum of 11 days in the last month and presence of userelated problems
I. Average of 0.5%. DSM-III-r=Diagnostic and Statistical Manual, 3rd edition. References:
13;28-30
Percentage of problem users I 0.3% - 0.8% in the last year 0.5% in the last month
30% in the last 6 months 20% in the last month
.
Cannabis use is increasingly associated with psychological problems. 31 • There is growing evidence that cannabis increases the risk of a psychotic disorder later in life. 32;33 • The risk increases with the frequency of cannabis use. • People with a history of psychotic symptoms are particularly vulnerable. • It is not known to what extent other vulnerability factors increase the risk of psychosis. • Studies are currently underway regarding the connection between cannabis use and the 34;35 development of depression. The role of the increasing concentration of THC in Nederwiet (Dutch-grown cannabis) in the occurrence of (health) problems is not clear. • Recent research among coffee shop clientele, however, has shown that there is a specific group 36 of especially young users with a clear preference for ‘strong cannabis’. They use it relatively often and in large quantities and run a large risk of becoming dependent.
2.5
USE: INTERNATIONAL COMPARISONS
General population Data on drug use in the EU Member States are provided by the European Monitoring Centre for Drugs 37;38 and Drug Addiction (EMCDDA). Organisations in the United States (USA) and Australia also 39;40 publish outcomes of surveys on drug use on a regular basis. • Differences in survey year, research methods and sampling complicate precise data comparisons. Of particular influence is the age group. Table 2.8a shows consumption figures (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data on the other countries are listed in Table 2.8b. • The percentage of recent cannabis users in the general population is lowest in Finland, Portugal and Sweden and highest in Canada, England and Wales, the United States and Australia. Of the EU countries stated in Tables 2.8a and 2.8b, the Netherlands seems to take a position around the middle or slightly higher.
32
Table 2.8a
Cannabis use in the general population of various EU Member States and Norway: age group from 15 to 64 years incl.
Country Spain France The Netherlands Ireland Northern Ireland Norway Greece Luxembourg Sweden Finland Belgium Portugal
Year 2001 2000 2001 2002/2003 2002/2003 1999 1998 1998 2000 2002 2001 2001
Ever use 25% 23% 21% 18% 17% 11% 13% 13% 13% 13% 11% 8%
Percentage of ever and recent (last year) users. - = not measured. References:
Table 2.8b
Recent use 10% 8% 6% 5% 5% 5% 4% 1% 3% 3% 37;38
Cannabis use in the general population of various EU Member States, the United I States and Australia: other age groups
Country Canada United States Australia Denmark England and Wales Italy Germany
Year 2002 2003 2001 2000 2002/2003 2001 2000
Age (year) 15 and over 12 and over 14 and over 16 - 64 16 – 59 15 – 44 18 – 59
Ever use 41% 41% 33% 31% 31% 22% 19%
Recent use 12% 11% 13% 6% 11% 6% 6%
Percentage of ever in lifetime and recent (last year) users. I. Drug use is proportionally low in the youngest (1215 years) and the older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. The opposite is true for studies 37-42 with a more limited age range .
Young people Better suited for comparison are the figures from the European School Survey Project on Alcohol and Other Drugs (ESPAD). The last surveys were conducted in 1999 and 2003 among secondary school 43 pupils aged 15 and 16. • Table 2.9 portrays the consumption of cannabis in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in the ESPAD, but conducted comparable research. • The percentage of pupils that had ever used cannabis in 2003 was highest in Ireland, closely followed by France, the United Kingdom and the United States. Belgian pupils took the fourth and Dutch pupils the fifth place. • France had the highest current use figures, followed by the United States, the United Kingdom and Ireland. The Netherlands and Italy came next. • In the United Kingdom and Portugal the percentage of current users rose by four and three percentage points, respectively, in 2003 compared with 1999. Elsewhere differences of two or fewer percentage points were found.
33
•
•
The percentage of pupils who had used cannabis six times or more in the last month was lowest in the Scandinavian countries and highest in France, the United States and the United Kingdom. Dutch pupils shared a fourth place with their Irish and Italian peers. In most of the countries there was a correlation between ever use of cannabis and the degree of truancy, lack of parental control and the presence of older brothers or sisters who used cannabis.
Table 2.9
Cocaine consumption among pupils aged 15 and 16 in EU Member States, Norway and the United States. Survey years 1999 and 2003
Country
Ever use
United States Ireland France United Kingdom Belgium The Netherlands I Germany Italy Denmark Austria Portugal Finland Norway Sweden Greece
1999 41% 32% 35% 35% 28% 25% 24% 8% 10% 12% 8% 9%
2003 36% 39% 38% 38% 32% 28% 27% 27% 23% 21% 15% 11% 9% 7% 6%
Current use 1999 19% 15% 22% 16% 14% 14% 8% 5% 2% 4% 2% 4%
2003 17% 17% 22% 20% 17% 13% 12% 15% 8% 10% 8% 3% 3% 1% 2%
Six times or more in the last month 1999 2003 9% 8% 5% 6% 9% 9% 6% 8% 7% 5% 6% 4% 4% 6% 1% 2% 3% 2% 3% 1% 0% 1% 1% 0% 0% 2% 1%
Percentage of ever in lifetime users, current (last month) users and six times or more in the last month users. I. Six of sixteen Member States. - = not measured. The United States did not take part in the ESPAD, but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
2.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records the number of people seeking assistance from (outpatient) care organisations for addicts, including the probation and after-care services. (See in Appendix A: Client LADIS.) • The number of clients registered for a primary cannabis problem more than doubled between 1994 and 2003 (see Figure 2.5). Between 2002 and 2003 the increase was 21 percent. • The proportion of cannabis in all drug-related registrations increased also, from 10 percent in 1994 to 15 percent in 2003. • Characteristics of the primary ecstasy clients in 2003: - The majority was male (83%); the proportion of women increased somewhat, from 15 percent in 1994 to 17 percent in 2003. - The average age was 28. Most of these clients were in the age group 20-24 years (see Figure 2.6). - Four in ten were new clients (40%). They had not sought drug-related help from (outpatient) care organisations for addicts before. • The number of clients in (outpatient) care organisations for addicts who mentioned cannabis as a secondary problem increased also between 1994 and 2003 (see Figure 2.5).
34
• For this group, alcohol (40%), cocaine or crack (36%), or heroin (14%) was the primary problem.
Figure 2.5
Number of clients in (outpatient) care organisations for addicts with primary or secondary cocaine problems, from 1994 5000
4000
3000
2000
1000 Primary
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 1951 2274 2659 3264 3291 3281 3443 3432 3701 4485
Secundary 2846 2668 2718 2820 2844 3063 3144 3300 3697 4291 Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Figure 2.6
Age distribution of clients in (outpatient) care organisations for addicts with cannabis as primary problem. Survey year 2003
30% 25% 25% 21% 18%
20% 15%
14% 10%
10% 6% 5%
3%
2%
45-49
50-54
1%
0% 15-19
20-24
25-29
30-34
35-39
40-44
55-59
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
35
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • The number of admissions for cannabis abuse and dependence rose from 71 in 1990 to 309 in 1996 (ICD-9 codes: 304.3, 305.2; see Appendix C). • The proportion of cannabis in all drug-related admissions rose slightly between 1990 and 1996, from three to seven percent. • The situation since then is not really known, because record keeping has been incomplete from 1997 (see Appendix B).
General hospitals; incidents In 2003, the National Medical Registration (LMR) recorded nearly 1.6 million clinical admissions in general hospitals. Drug problems hardly played a role in these admissions. In that year, drug abuse and drug addiction were determined 402 times to be the primary diagnosis and 1,986 times as the secondary diagnosis. • Eleven percent of the primary diagnoses involved cannabis (37% dependence, 63% abuse; see Figure 2.7). It is not known whether the complaints that led to the admission were psychological or physical in nature. • Cannabis-related problems played a greater role in terms of secondary diagnoses (30% dependence, 70% abuse). The slight rise until 1999 did not continue in the last few years. • In 2003, these secondary diagnoses were mostly associated with the following primary diagnoses: - psychoses (29%) - accident-related injuries (13%, e.g. fractures, wounds, concussion) - abuse or dependence on alcohol and drugs (13%, mainly alcohol) - poisoning (10%, by drugs, alcohol, prescription drugs) - respiratory illnesses and symptoms (8%) - heart and vascular diseases (7%)
36
Figure 2.7 Clinical admissions in general hospitals related to cannabis abuse and dependence, from 1994
300 249
247
250 193
200
246 230
160
184
195
193
154
150 100 39
50
38 26
21
29
29
38 24
46 33
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Main diagnosis - clinical
Secondary diagnosis - clinical
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.3, 305.2 (Appendix C). Source: National Medical Registration (LMR), Prismant.
• A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 262 patients were admitted in 2003. They were admitted at least once this year with cannabis abuse or dependence diagnosed as primary or secondary problem. The average age was 29 years and 79 percent were male. • In 2003, cannabis-related problems also played a role as primary or secondary diagnoses in 69 day-treatment admissions. In addition, in 2003, the National Medical Registration (LMR) recorded 16 admissions with “accidental poisoning with hallucinogens” as secondary diagnosis (ICD-9 code: E854.1). In 2001 and 2002, there were 15 and 8 such cases respectively. This may involve cannabis, but also LSD or magic mushrooms. The Central Ambulance Service of the Amsterdam Area Health Authority (GG&GD Amsterdam) keeps a record of the number of drug-related emergency calls. • Cannabis use was involved in 257 cases. That is somewhat less than in the two previous years, but represents twice the number compared to the years 1998 up to 2000 incl. (see Table 2.10). • More than one in three (35%) cannabis cases required transport to hospital casualty. The rest could be treated on-site. Table 2.10
Cannabis incidents recorded by the Amsterdam Area Health Authority (GG&GD Amsterdam), from 1992
Smoking cannabis Eating space cake
1992 82 40
1993 40 11
1994 130 34
1995 137 73
1996 165 58
1997 211 47
1998 107 28
1999 118 21
2000 106 35
2001 243 46
2002 226 59
Number of annual incidents. Source: Central Ambulance Station (CPA), Amsterdam Area Health Authority (GG&GD Amsterdam).
37
2003 196 61
Most of the complaints of the people arriving in Casualty with a cannabis-related problem are not serious. • In 2000, Onze Lieve Vrouwengasthuis in Amsterdam mostly registered patients feeling unwell and 44 anxious (44%), with heart palpitations (20%), or nausea (15%). • Psychotic complaints were observed in four percent of cannabis patients. • Injuries as a result of a slip/fall accident were noted in 14 percent of the cases. These accidents may be connected with the (lowering) effect of cannabis on the blood pressure and motor coordination.
2.7
MORTALITY 45
The toxicity of cannabis is minimal. • In the past twenty years, the Statistics Netherlands (CBS) has not recorded one single death directly related to the consumption of cannabis. • No such directly related deaths are known in other countries.
2.8
SUPPLY AND THE MARKET
Coffee shops The number of coffee shops in the Netherlands has decreased (see Table 2.11).
• •
46
Between 1997 and 1999, Bureau Intraval registered a decrease of 28 percent , with the most significant decrease in the smaller towns and in Rotterdam. Since 1999, the annual decrease was less significant: four percent between 1999 and 2000, one percent between 2000 and 2001, three percent between 2001 and 2002 and four percent between 47 2002 and 2003.
•
In late 2003, the Netherlands had 754 officially ‘tolerated’ coffee shops, about half of which (52%) are located in the large cities with more than 200,000 inhabitants.
•
In 2003, of the 489 Dutch municipalities, 79 percent had no coffee shop at all. Three quarters (78%) of the municipalities maintained a ‘zero tolerance’ policy, meaning that coffee shops are not permitted. Nearly a quarter (23%) of the municipalities maintained a ‘maximum policy’, meaning that a limit has been set to the number of coffee shops that are tolerated.
•
•
Other ‘sales sources’ such as deal houses and street dealers are not included in the last two surveys.
38
Table 2.11
Number of coffee shops in the Netherlands by municipality, from 1997
Municipalities by number of inhabitants < 20,000 inhabitants 20-50,000 inhabitants 50-100,000 inhabitants 100-200,000 inhabitants > 200,000 inhabitants - Amsterdam - Rotterdam - The Hague - Utrecht II - Eindhoven Total
I
1997
1999
2000
2001
2002
2003
± 50 ± 170 ± 120 211
14 84 115 190
13 81 109 168
11 86 112 167
12 79 106 174
12 73 104 168
340 180 87 21
288 65 70 20
283 63 62 18 16
280 61 55 17 16
270 62 46 18 15
258 62 41 18 15
± 1 179
846
813
805
782
754
I. An estimate. II. Fewer than 200,000 inhabitants up to 1999. Source: Tilburg Institute for Social Policy Research and Consultancy (IVA), University of Tilburg.48
THC content and price The Trimbos Institute gathers information about the potency of cannabis, i.e., the concentration of the active substances, particularly THC (tetrahydrocannabinol). Since 1999, samples of different cannabis 49;50 products have been bought regularly in coffee shops and chemically analysed. • All surveys showed that Dutch-grown marihuana contained more THC on average than imported varieties. • Figure 2.8 shows that the average THC content in Nederwiet (Dutch-grown marijuana) has strongly risen since 1999. • The percentage of THC in imported hashish rose until 2001/2002. In the years thereafter no further increase was measured. The percentage of THC in imported weed increased slightly over the years. • Most of the Nederwiet originates from the intensive and professional indoor cultivation, which, compared to outdoor cultivation, results in weed with a higher THC percentage. 37 • In so far as data are available, no significant increase is noticeable in other European countries. However, it is hard to compare international figures, due to the large differences in research methods.
39
Figure 2.8
Average percentage of THC in cannabis products 25% 20% 15% 10% 5% 0%
1999/2000
2000/2001
2001/2002
2002/2003
2003/2004
Nederwiet
9%
11%
15%
18%
20%
Imported weed
5%
5%
7%
6%
7%
Imported hash
11%
12%
18%
17%
18%
Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
51
The price of one gram of Nederwiet or one gram of imported weed fluctuated slightly in the past years. • In 2002/2003 the price of Nederwiet was somewhat higher than in 1999/2000 and 2000/2001, but this trend did not continue in the last measurement. • Imported weed was somewhat more expensive in 2003/2004 than in 1999/2000 and 2000/2001. • Imported hashish was more expensive in 2000/2001 than in 2002/2002 and dropped again somewhat in the period from 2002/2003 to 2003/2004 (see Table 2.12).
Table 2.12
Price (€) per gram of cannabis product
Nederwiet Imported marijuana Imported hashish
1999/2000 5.83 3.87
2000/2001 5.86 3.80
2001/2002 6.28 4.16
2002/2003 6.45 4.32
2003/2004 5.97 4.86
6.29
6.36
7.14
7.56
6.46
Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
•
Marijuana growers in the Netherlands sometimes use pesticides to protect the plants against diseases. There are no current data about the presence of these substances in Nederwiet. Chemical analyses done in 1999 found pesticide residues in half of the Nederwiet samples. 52 However, the concentrations were so low that they did not pose a health risk.
40
3
COCAINE
Cocaine has a stimulating effect. Many cocaine users are able to combine this drug with a ‘normal’ lifestyle without getting into problems. They use cocaine for recreational purposes. Nonetheless, cocaine use can lead to dependence. Moreover, cocaine may manifest itself as part of a problematic use pattern involving the simultaneous use of several drugs. 53 Cocaine can be administered in various forms. Cocaine in salt form (hydrochloride powder) is mostly sniffed but rarely injected in the Netherlands. Every once in a while powder cocaine is smoked in a cigarette. Freebase or crack cocaine is particularly popular among problem users of hard drug. Freebase or crack is obtained by heating a solution consisting of cocaine powder, sodium bicarbonate (baking soda) or ammonia, and water. Crack cocaine is smoked in a small (crack) pipe or placed on aluminium foil and inhaled through a tube. Crack is impure crack cocaine with residues of sodium bicarbonate. It gets its name from the cracking sound of the ‘rock’ when smoked. In the eighties, crack was prepared by the consumers themselves. Nowadays it is mainly sold on the street in the form of ready-to-use ‘rocks’. The information below pertains to all forms of cocaine unless indicated otherwise.
3.1
LATEST FACTS AND TRENDS
The main facts and trends about cocaine in this chapter are: • The number of current cocaine users in the general population doubled between 1997 and 2001. The largest increase was noted in adolescents aged 20-24 (see Chapter 3.2). • Among school-aged youngsters (12-18 years) the percentage of cocaine users remained stable between 1996 and 2003 (see Chapter 3.3). • Dutch pupils score average on cocaine use compared to their peers in many other EU Member States (see Chapter 3.5). • Sniffed cocaine is fairly popular among young clubbers, in particular in trendy clubs, discos and pubs. • Among young people in trendy clubs in Amsterdam, consumption dropped between 1998 and 2003 (see Chapter 3.3). • Cocaine – especially in the form of crack cocaine – enjoys great popularity among problem opiate users (see Chapter 3.4). • The strong increase in the number of cocaine users in (outpatient) care organisations for addicts continued between 2002 and 2003 (see Chapter 3.6). • The number of admissions in general hospitals for cocaine-related problems increased between 1996 and 2002, but did not rise further in 2003 (see Chapter 3.6). • The rising trend in the number of registered acute deaths from cocaine use between the midnineties and 2001 did not continue in 2002 and 2003 (see Chapter 3.7). • In 2003, cocaine powder of consumers had often been mixed with phenacetin (see Chapter 3.8).
3.2
USE IN THE GENERAL POPULATION
According to the NPO the number of Dutch people aged 12 and above with cocaine experience rose 10 between 1997 and 2001 (see Table 3.1). • The percentage of ever users who have consumed cocaine 25 times or more in their lifetime – i.e. experienced users – grew; from 23 percent in 1997 to 29 percent in 2001. • The percentage of current users doubled in the same period but remained far below one percent. In absolute figures this represents an increase from nearly 28,000 to 55,000 current cocaine users.
41
However, these figures most certainly are an underestimation, as problem hard drug users are a
underrepresented in the National Prevalence Survey (NPO). • Cocaine is used mostly by adolescents aged 20 to 24. This same age group showed the highest increase in users between 1997 and 2001 (see Figure 3.1). • The number of current users who used cocaine (almost) daily rose from 1.8 percent in 1997 to 4.5 percent in 2001. • Men outnumbered women in both survey years as regards experience with cocaine. Furthermore, more men than women were current users in 1997, but female users had caught up by 2001 (see Table 3.1).
Table 3.1
Cocaine use in the Netherlands among people aged 12 and above. Survey years 1997 and 2001
Has used ever in lifetime • Men • Women I Used currently • Men • Women Used for the first time in the past year Mean age of current users
1997 2.1% 2.9% 1.3%
2001 2.9% 3.9% 1.9%
0.2% 0.3% 0.1%
0.4% 0.4% 0.4%
0.3% 29 years
0.3% 29 years
I. In the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 3.1
Cocaine users in the Netherlands by age group. Survey years 1997 and 2001 10
%
8 6 4 2 0 12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69 >69 Ever 1997
0.1
2.3
3.9
4.8
3.6
3.1
2.4
0.5
0.4
0.0
Ever 2001
0.1
2.7
8.6
4.6
5.0
4.2
3.8
1.2
0.1
0.0
Current 1997
0.0
0.3
0.7
0.7
0.1
0.2
0.2
0.0
0.0
0.0
Current 2001
0.1
0.9
1.6
0.8
0.6
0.2
0.3
0.2
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
a
The number of problem users of opiates in the Netherlands is estimated at 32,000 on average. Field studies show that 70% to 90% of them also uses cocaine (mainly crack) (see Chapter 3.4). In absolute numbers it concerns therefore between 22,000 and 29,000 cocaine users in this group. The degree of overlap between these figures and those of the NPO is unknown.
42
The large cities Cocaine use is not spread out evenly across the Netherlands (see Figure 3.2). • In 2001, the percentage of current users was four times higher in Amsterdam than in rural areas. • In other, highly urbanised areas including Rotterdam, the proportion of current cocaine users was three times higher than in rural areas. • The rise in the percentage of ever and current cocaine users occurred all across the country but was moderate in Amsterdam.
Figure 3.2
12 10
Cocaine use in large cities and rural areas among people aged 12 and above. Survey years 1997 and 2001
% 9.4
10
8 6
5.4
5.2
4
3.3
3.4
2
1 1.2
1.6 0.4
0.9
0.4
0.9
1 0.1 0.3
0 Amsterdam
Ever 1997
Rotterdam
Ever 2001
Highly urban, other Current 1997
Rural
Current 2001
Percentage of ever (lifetime) and current (last month) users. Definition (Statistics Netherlands (CBS)): Other highly urbanised municipalities: more than 2,500 addresses per square kilometre, with the exception of Amsterdam and Rotterdam, namely Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. Definition of rural municipalities: fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Special groups Compared with the average population, cocaine use frequently occurs among the homeless and detainees. • In 2002, nearly half (47%) of the homeless in twenty Dutch municipalities had smoked crack in the 11 last month; one in five (20%) sniffed cocaine. • In 2002, one in three male detainees (32%) in eight penitentiaries used cocaine/crack daily in the 12 last six months prior to detention.
43
3.3
USE AMONG YOUNG PEOPLE
To categorise the use of cocaine among young people, figures from the National Prevalence Research are available, as stated in Chapter 3.2. In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F you will find an overview of recent figures concerning the use of cocaine among young people in nine municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. However, methodological differences, in particular in respect of age groups, complicate comparison of the figures. The number of municipalities and regions for which information is available is considerably smaller than for cannabis, because the use of hard drugs is often included in one single question, due to which differentiation by substance is not possible. In this paragraph we also present the data of the Dutch National School Survey and data from (often local) surveys among special groups of young people.
Pupils According to the National Representative School Survey conducted by the Trimbos Institute, 15 considerably fewer secondary school pupils use hard drugs, such as cocaine, than cannabis. • Between 1988 and 1996, however, this number increased. • The 1999 measurement showed a stabilisation in the percentage of pupils with ever or current cocaine experience (see Figure 3.3). This stabilisation continued in 2003b. • More boys than girls were ever or current users of cocaine. • The percentages of cocaine users seem slightly lower among pupils of a higher school level (preuniversity education - VWO, senior general secondary education - HAVO) compared to peers of a lower school level (pre-vocational secondary education - VMBO), but these differences are not statistically significant.
b
The decrease in ever use observed in Figure 3.3 was not significant.
44
Figure 3.3
3.5
Cocaine use among pupils aged 12 and above, from 1988
%
3 3
2.8
2.5 2.2 2
1.6 1.2
1.5
1.1
1.2
1 0.4
0.5
0.8
0.4
0 1988
1992
1996
Ever use (%)
1999
2003
Current use (%)
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
Special groups In certain groups of young people cocaine use occurs quite often. Table 3.2 summarises the result of various studies. The figures are not suitable for comparison due to differences in age groups and research methods.
• According to data from the Antenne Monitor, the numbers of current cocaine users among club, party and disco-goers in Amsterdam rose from 14 to 24 percent between 1995 and 1998. This 54 mainly involved cocaine sniffing. Between 1998 and 2003, current use of cocaine dropped again to the level of 1995 (14%). • The Hague doe not signal a decreasing popularity of cocaine among young people visiting clubs 21;24 and parties, but there are no hard trend data. According to observations of key persons, cocaine is on the up and up elsewhere in the country as well, particularly in trendy clubs, discos 20 and pubs. 19-21 • In the clubbing circuit, cocaine is often used together with alcohol. • In other countries, such as Austria, Belgium, France and the United Kingdom, visitors of raves have 55 considerably more experience with cocaine than the average population. • Young homeless people have the highest rate of cocaine use (see Table 3.2). A survey among young people without fixed address in five Dutch municipalities showed that one in three had used cocaine just recently. The most common route of administration was sniffing or smoking (crack) 22 cocaine; (current smokers: 32%, sniffers: 11%, IDUs: 1%). Among young homeless people in 23 Flevoland, lower percentages were found in 2004 (see Table 3.2).
45
Table 3.2
Use of cocaine in special groups Location I
Young people in special education Young people in truancy programs III Marginalised young people Young clubbers III Pub visitors Visitors of trendy clubs IV Coffee shop visitors V Young homeless people
Nationwide Nationwide The Hague The Hague Amsterdam Amsterdam Amsterdam Nationwide Flevoland
Survey year 1997 1997 2000/2001 2003 2000 2003 2001 1999 2004
Age (year) 12 - 18 12 - 18 16 - 25 15 - 35 Mean age 25 Mean age 28 Mean age 25 15 - 22 13 - 22
Ever use 4% 14% 23% 23% 26% 39% 52% 66% VI 29% VII 19%
Current use 2% 5% 9% 10% 9% 14% 19% 36% VI 10% VII 6%
Percentage of ever users (in lifetime) and recent users (last month) per group. The figures in this table are not comparable due to differences in age groups and research methods. I. MLK, LOM, ZMOK. II. Young people with insufficient care and or unable to sustain in their own existence. Recruited in places for young homeless people, low-threshold day and night shelters and (other) temporary living accommodations. III. Select samples of young people and adolescents visiting mainstream, student, gay and trendy pubs, so not representative for all pub visitors. III. Little response (15%). V. Young people up to 23 years without a fixed address for three months or 17;18;22;24longer. VI. Snortable cocaine in powder form. VII. Smokable cocaine in the form of crack. References: 26 21;23 .
3.4
PROBLEM USE
Reliable estimates of the number of problem users of cocaine are not available. • Seven to nine in ten opiate addicts also use cocaine, often in the form of crack. Freebase (or crack) c 56-58
• • • • •
• •
c
leads to compulsory behaviour and addiction faster than sniffed cocaine. For many hard drug users cocaine meanwhile is the most important drug. They have quite a hard 59 time to stop or reduce their use and their whole day is filled with procuring the drug. Nearly 10 to 15 percent consume cocaine without the additional use of heroin. In Utrecht this group 59 is mostly composed of young Antilleans and Moroccan users without a prior history of heroin use. Frequent cocaine use, especially crack, is being observed in certain groups of hard drug users, 57;58 such as among the (young) homeless, immigrants and street prostitutes. Intravenous use of cocaine (and heroin) has decreased strongly in the last few years and with it the risk of infections. Smoking of cocaine (and heroin) on the other hand has increased. The percentage of ‘hard core’ cocaine injectors of all problem hard drug users in Parkstad Limburg decreased from 40 percent in 1996 to 4 percent in 1999. The percentage of problem users who both injected and smoked cocaine fell from 30 to 17 percent. Between 1999 and 2003 this situation 56-58 showed no significant change. At present, for seven to nine in ten problem users of hard drugs, the most current use of cocaine is smoking (see Table 3.3). Health problems, especially as a result of frequent freebasing, are lung complications, exhaustion 53 and a weakened immune system, extra strain of the feet, anxiety and paranoia. Heavy coke users also find it more difficult to keep their aggression under control.
However, users of shiff cocaine can also get into problems (see Chapter 3.6.1).
46
Table 3.3
Route of administration of cocaine by problem hard drug users
Route of administration Always injects Smokes and injects Always smokes
Rotterdam 2003 4% 10% 86%
Utrecht 1999 1% 10% 86%
Parkstad Limburg 2003 7% 19% 71%
Percentage of problem users by route of administration in the last 6 months. The figures in the columns do not add up to 100 percent entirely; the disparity represents other methods of consumption (sniffing). Source: Regions and Towns Monitor for Alcohol and Drugs (MAD).
3.5
USE: INTERNATIONAL COMPARISONS
General population In the general population of Western countries the number of people using hard drugs such as cocaine is considerably lower than the number of people using cannabis. • Differences in survey year, methods of measurement and random samples make precise comparison difficult. Of particular influence is the age group. Table 3.4a shows consumption figures for cocaine which are (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data on the other countries are listed in Table 3.4b. • The percentage of people up to the age of 60 or 70 who have experience with cocaine is by far the highest in de Unites States. • In the oldest Member States of the European Union the ever use varies from nearly zero percent to six percent, with the highest percentages in England and Wales and in Spain. In the Netherlands, nearly four percent of the population aged 15 to 64 years incl. has ever used cocaine. • Of the above EU Member States, Sweden has proportionally the lowest number of recent cocaine users (0%) and Spain the highest (2.6%). In the Netherlands over one percent used cocaine in the past year.
47
Table 3.4a
Use of cocaine in the general population of several EU Member States and Norway: age group from 15 to 64 years incl.
Country
Spain The Netherlands Ireland Norway Northern Ireland France Greece Sweden Portugal Finland Luxembourg
Year
Ever use
Recent use
2001 2001 2002/2003 1999 2002/2003 2000 1998 2000 2001 2002 1998
4.9% 3.6% 3.1% 1.2% 1.7% 1.6% 1.3% 0.7% 0.9% 0.7% 0.2%
2.6% 1.1% 1.1% 0.6% 0.4% 0.2% 0.5% 0.0% 0.3% 0.3% -
Percentage of ever in lifetime and recent (last year) users. - = not measured. References:
Table 3.4b
37;38
Use of cocaine in the general population of several EU member states, the I United States, Canada and Australia: other age groups
Country United States Canada England and Wales Australia Italy Denmark Germany
Year 2003 2002 2002/2003 2001 2001 2000 2000
Age (year) 12 and over 15 and over 16 – 59 14 and above 15 – 44 16 – 64 18 – 59
Ever use 14.7% 8.0% 6.2% 4.4%
Recent use 2.5% 1.3% 2.1% 1.3%
3.4% 2.5% 2.3%
1.1% 0.8% 0.9%
Percentage of ever in lifetime and recent (last year) users. ? = unknown. I. Drug use is proportionally low in the youngest group (12-15 years) and older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. For studies with a more 37-41 limited age range the reverse applies. References: .
Young people and adolescents In the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 1999 and 2003 among pupils aged 15 and 16, the respondents were interviewed about the ever use of cocaine. In 2003 they were also interviewed as to their recent use. The figures from this survey can be compared better than the figures from surveys among the general population. • Table 3.5 portrays the consumption of cocaine in a number of EU countries and Norway. The United States did not take part in the ESPAD, but conducted comparable research. • American pupils have more often experience with cocaine than their peers in the EU, despite the drop in the percentage of ever users between 1999 and 2003.
• Italy and the United Kingdom scored highest in ever use in 2003 (4%). With 3 percent, the Netherlands, Belgium, France, Ireland and Portugal rated above the middle, but the differences with other countries are small.
• In Italy, the United Kingdom and the United States, proportionally most recent users are found (3%). In the other countries, not more than 1 to 2 percent of the pupils had recently used cocaine.
48
Table 3.5
Cocaine consumption among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey years 1999 and 2003
United States Italy United Kingdom Belgium France Ireland The Netherlands Portugal Denmark I Germany Greece Norway Sweden Finland
1999 Ever use 8% 2% 3% 2% 2% 3% 1% 1% 1% 1% 1% 1%
2003 Ever use 5% 4% 4% 3% 3% 3% 3% 3% 2% 2% 1% 1% 1% 0%
Recent use 3% 3% 3% 1% 1% 1% 2% 2% 2% 1% 1% 0% 0%
Percentage of ever in lifetime and recent (last year - 2003) users. I. Six of sixteen Member States. - = not measured. The United States did not take part in the ESPAD, but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).43
3.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) • The number of recorded admissions with cocaine as primary problem increased nearly four-fold between 1994 and 2003. Between 2002 and 2003 the increase was 19 percent (see Figure 3.4). • The proportion of cocaine users among all the drug users seeking assistance from outpatient care organisations rose also considerably, from 13 percent in 1994 to 30 percent in 2003. • The increase in the cocaine-related treatment demand occurred in the entire country, but was strongest in the regions of Eindhoven, Twente, the Achterhoek and the IJsselmeerpolders. • Characteristics of the primary cocaine clients in 2003: - Most of them are men (82%). - The average age is 33. Nearly half the primary cocaine clients are between 25 and 34 years old (see Figure 3.5). - A quarter (24%) consisted of new clients, so they had never before been registered with the (outpatient) care organisations for addicts because of a drug problem. - Most of the cocaine clients smoke or sniff the drug (see below). • Cocaine was also indicated often as a secondary problem (see Figure 3.4). - For this group the primary problem is heroin (67%), alcohol (22%), or cannabis (5%). - Between 1994 and 2001 the number of clients with secondary cocaine problems increased. The increase between 2000 and 2001 is partly due to the fact that the figures of the Amsterdam Area Health Authority (GG&GD) were included for the first time.
49
Figure 3.4
Number of clients of (outpatient) care organisations for addicts with primary or secondary cocaine problems, from 1994
10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 Primary
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2468 2928 3349 4137 4607 5689 6103 6647 7774 9216
Secundary 6020 6391 6503 7015 6699 6932 7111 8426 8281 8388 The increase in secondary cocaine clients between 2000 and 2001 is partly due to the supply (since 2001) of data of opiate clients of the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ). 60
An analysis of LADIS data up to 2000 incl. gives the following picture: • For two in three ‘primary’ cocaine clients crack (smoking) is the main means of use and for one in three ‘sniff cocaine’. • The proportion of crack users among the cocaine clients grew from 57% percent in 1994 to 65% in 2000. • More than half the cocaine clients - primary and secondary problems together - have problems with both cocaine (usually crack) and heroin (56%). Next are problem users of only crack without opiates (20%), of both sniff cocaine and alcohol (13%), of both sniff cocaine and cannabis (6%) or only of sniff cocaine (6%).
50
Figure 3.5
Age categories of primary cocaine clients in the (outpatient) care organisations for addicts. Survey year 2003
% 25
21
23
20
17 14
15
11 10
6 5
3
2 1
0 15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
Age
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • In 1990 there were 106 admissions and in 1996 there were 364 (ICD-9 codes 304.2 and 305.6; Appendix C). • The percentage of cocaine-related problems in all drug-related admissions rose also in this period, from 4 to 8 percent. • The situation since then is not known, because record keeping has been incomplete from 1997 (see Appendix B).
General hospitals; incidents In general hospitals, upon admission, cocaine abuse and dependence abuse are often not recorded as the main diagnosis. • In 2003, eighty cases were counted, 70 percent of which for cocaine abuse and 30 percent for cocaine dependence (see Figure 3.6). • These cocaine problems more often play a part as a secondary diagnosis. Between 1996 and 2002 the number of admissions with cocaine abuse or dependence as secondary diagnosis increased. This trend seems to have come to a stop in 2003. • The most commonly diagnosed problems that were registered in 2003 in case of cocaine abuse or dependence as secondary diagnosis were: - accident-related injuries (21%, e.g. fractures, wounds, concussion)
51
-
respiratory illnesses and symptoms (16%) poisoning (12%) heart and vascular diseases (9%) abuse or dependence on alcohol and (other) drugs (6%) psychoses (5%)
Figure 3.6
Clinical admissions in general hospitals for cocaine abuse and dependence, from 1994
700 562
600
506 451
500 400
352
371
363
55
50
383
377
65
67
285
300
246
200 100
38
24
53
81
84
80
0 1994 1995
1996 1997 1998
Cocaine as primary diagnosis
1999 2000
2001 2002 2003
Cocaine as secondary diagnosis
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.2, 305.6 (Appendix C). Source: National Medical Registration (LMR), Prismant.
• A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 550 patients were admitted in 2002. They were admitted at least once that year with cocaine abuse or dependence diagnosed as primary or secondary problem. The average age was 34 years and 73 percent were male. • In 2003, the National Medical Registration (LMR) counted also 16 cases of unintentional poisoning with local anaesthetics (mainly cocaine) as secondary diagnosis (ICD-9 code E855.2). Exact figures about the number of persons who become unwell after the use of cocaine are not known. According to the Injury Information System of the Consumer and Safety Foundation, annually 2,300 people on average are treated at emergency first-aid departments of hospitals after an accident, violence or self-harm related to the use of drugs (comp. 14,000 because of alcohol, Chapter 6).d • Nearly one in three (32%) drug victims reports to have used cocaine, more than one in five cannabis (22%) and one in eight ecstasy (12%). Of over a quarter (27%) of the cases it is not known which drug(s) is/are involved.
• These figures probably are an underestimation of the real number of drug-related accidents.
d
The drugs concerned are cocaine, heroin, cannabis, ecstasy, paddo's and speed. The data are the averages over the period 1999 to 2003 inc.
52
The National Poison Information Centre (NVIC) of the National Institute of Public Health and the Environment (RIVM) registers the number of requests for information from physicians, pharmacists and governmental institutions about (potential) acute poisoning due to antigens, such as drugs. • The number of reported drug-related incidents rose from 656 in 2000 to 1,210 in 2003. For cocaine an increase from 150 to 247 incidents was registered. • However, these figures do not provide an insight in the absolute number of intoxications.
3.7
MORTALITY
The Cause of Death Statistics of Statistics Netherlands (CBS) still counts very few (acute) deaths that are — believed to be — directly attributable to cocaine. • However, there does appear to be an increase. From 1985 to 1994 incl., the total number of cocaine-related deaths was 21, compared with 143 from 1995 to 2003 incl. (see Figure 4.9). • The rising line from 1996 to 2001 incl. (10 and 26 cases, respectively) did not continue in 2002 and 2003 (34 and 17 cases, respectively). • Figure 3.7 shows that most of the deceased were between 25 and 49 years old. Nearly three in ten were women. • Fatalities in which cocaine plays a role are sometimes recorded under the code of deaths from natural causes, for example heart problems. This makes it difficult to establish the number of cases in which cocaine has actually contributed to the person’s death. • The total number of deceased 'drug mules' is not known, one of the reasons being that the Cause of Death Statistics Agency does not include deceased persons who are not listed in the Dutch population registration system. In 2002 and 2003, the Amsterdam Area Health Authority (GG&GD Amsterdam) recorded 8 and 3 cases, respectively.
Figure 3.7 25
Age categories associated with cocaine-related deaths from 1996 to 2001 incl.
% 19
20
17 15 15
14
13
10
9
5 5 1
3
2
1
1
0 <15
15-19
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
>64
age (years) Percentage of deceased per age group. ICD-10 codes primary causes of death: F14 and X42*, X62*, Y12* (* in combination with code T40.5). Source: Cause of Death Statistics, Statistics Netherlands (CBS).
53
3.8
MARKET
Composition of cocaine samples The Drugs Information and Monitoring System (DIMS) examines the substances in drug samples that are turned in by consumers to care organisations for addicts. Part of these samples are identified by the services. Samples of unknown composition and all the samples in powder form are forwarded to the laboratory for chemical analysis. • In 2003, 229 powders were supplied that were bought by the consumer as cocaine. Of those, 217 (95%) contained actually cocaine (mainly hydrochloride) with a concentration of 65% on average (by weight). • Amphetamine was found twice, caffeine ten times and heroin once. Two powders did not contain any psychoactive substance. • Most of the powders also contained cocaine-related residual products, which are included when cocaine is extracted from the plant, such as tropacaine and norcocaine (87%). • The percentage of powders that (also) contained phenacetin nearly doubled from 9 percent in 2002 to 16 percent in 2003. Phenacetin is a substance that, until 1984, was registered as a painkiller, but was withdrawn from the market because of its possible carcinogenic characteristics. The quantities of phenacetin that are used as a cutting agent are many times smaller than the therapeutic quantities. However, the risks of phenacetin as a cutting agent of cocaine, such as the effects of heating when ‘smoking’ crack, are not known.
Prices Trend data about the prices paid by consumers for a gram of cocaine are not available. Recent figures from the Antenne Monitor and the Drugs Information and Monitoring System (DIMS) project, however, give an indication of the current situation. • Clubbing young people and adolescents in Amsterdam, who bought cocaine in 2003, paid between 46 and 52 euros per gram on average, depending on the type of dealer (house dealer or dealer in the clubbing circuit).
• These data correspond with the price that consumers paid in 2003 for cocaine samples supplied to the DIMS project (minimum 40 and maximum 50 euros per gram, with an average of 45 euros per gram).
54
4
OPIATES
The category of opiates includes many drugs. Some, such as heroin, are known for their illegal use. Others, such as methadone, function as replacements of heroin or are (also) otherwise applied in medicine: morphine, codeine and the like. This chapter deals mainly with heroin and methadone. Opiates may cause a high, but may also have a subduing effect. Heroin is administered in many manners. At present the most current use in the Netherlands is smoking (‘Chinese-style’, smoking from aluminium foil). Less often, heroin is injected. People whose opiate use has gotten out of hand often use additional drugs (polydrug use) in a way that is hard to combine with a ‘normal’ lifestyle. The collective term ‘hard drugs’ used in this chapter mainly refers to at least one type of opiate, as well as mainly to cocaine.
4.1
LATEST FACTS AND TRENDS
The main facts and trends regarding opiates in this chapter are: • The use of heroin is not very frequent in the general population (see Chapter 4.2). • Heroin is still not very popular among pupils and young people who visit clubs and pubs (see Chapter 4.3). • The number of opiate addicts in the Netherlands remains stable and is low compared with other European countries (See Chapter 4.4 and Chapter 4.5). • Intravenous injection of opiates has decreased. Opiates are now mostly smoked (see Chapter 4.4). • The number of opiate clients of the (outpatient) care organisations for addicts decreased slightly between 2001 and 2003. The proportion of young opiate clients decreased further (see Chapter 4.6). • The average methadone dose increased over the years, but still a minority of the methadone clients receives (therapeutic) doses of 60 mg or more (see Chapter 4.6) • The percentage of injecting drug users contaminated with HIV remained fairly stable in Amsterdam (1993-1998), Rotterdam (1994-2002/03), Maastricht (1994-1999) and Arnhem (1991/92-1997). In Heerlen their percentage increased between 1994 and 1999 (see Chapter 4.7). • The majority of injecting drug users in Rotterdam and Heerlen/Maastricht are contaminated with hepatitis B and C. For The Hague the figures are somewhat more positive (see Chapter 4.7). • Needle sharing among injecting drug users was less and less common, but in some regions (The Hague and Twente) this is still done often. Sexual risk behaviour remains a problem (see Chapter 4.7). • Acute death (‘overdose’) due to opiate use decreased slightly between 2001 and 2003 (see Chapter 4.7). • Acute death due to drug use is low in the Netherlands compared to other countries (see Chapter 4.7).
55
4.2
USE IN THE GENERAL POPULATION
The use of heroin is not widespread in the general population. • According to the National Prevalence Survey (NPO) conducted in 2001, 0.4 percent of the Dutch 10 population aged 12 and over had experience with heroin. In 1997 this was 0.3 percent.
• •
In 2001 the percentage of current users was 0.1 percent. These figures are probably an underestimation, as problem hard drug users are underrepresented in the National Prevalence Survey (NPO). Many illegal opiate users and methadone clients are not included in general population surveys, because they have no fixed address (homelessness), are detained, or are inaccessible for other reasons. However, they can be charted to a certain degree through other research methods (see Chapter 4.3).
Special groups Among certain adults the use of heroin is more current than in the general population. • In 2002, one in five male detainees (21%) in eight remand centres used heroin daily in the six 12 months prior to detention. • In that same year, 40 percent of the homeless in twenty Dutch municipalities had used this drug in 11 the month previous to the survey. These groups may show an overlap with the problem users described in Chapter 4.4.
4.3
USE IN THE YOUNG PEOPLE
Heroin is unpopular among secondary school pupils of secondary school aged twelve years and 15 above (see Table 4.1). • In 2003 more boys than girls had ever or currently used heroin (ever: 1.5% versus 0.7%; current: 0.8% versus 0.3%). • Since 1988, the percentage of ever users fluctuated around one percent. In all those years, not more than half of them had currently used heroin.
Table 4.1
Heroin use among pupils aged 12 and over, from 1988
Has used ever in lifetime Used currently
1988 0.7% 0.3%
1992 0.7% 0.2%
1996 1.1% 0.5%
1999 0.8% 0.4%
2003 1.1% 0.5%
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
• According to somewhat older figures, the percentage of current heroin users is higher among young people in special education and participants in truancy programs, than among pupils in ‘regular’ education, but even this higher percentage remains below 1 percent (see Table 4.2). • A number of recent local and regional studies show also that heroin has not advanced very much among young people. In Almelo, Apeldoorn, Drente, Groningen and South-Holland North the percentage of ever users remains under one percent (see Appendix F). • In certain circles, a minority of young people experiment with heroin (see Table 4.2). In 2001, for 17 example, nearly one in ten coffee shop visitors had ever tried heroin. • Among visitors of trendy clubs in Amsterdam the percentage of ever users dropped from six 18;21 percent in 1998 to two percent 2003. Current use is not (very) frequent in the clubbing circuit. • A 1999 survey among young homeless people in five municipalities (Amsterdam, Breda, Hilversum, Tilburg and Zaanstad) shows that this group had experience with heroin relatively often.
56
More than one in ten young homeless people were current users of this drug. The most common 22 route of administration in this group was smoking (current smokers: 11%, IDUs: 1%, sniffers: 0%). In 2004 lower percentages were found among young homeless people in Flevoland, eight percent 23 had ever used heroin and two percent were current users.
Table 4.2
Heroin use in special groups
I
Pub visitors Young people in special II education Visitors of trendy clubs Young people in truancy programs III Coffee shop visitors IV Marginalised young people V Young homeless people
Location
Survey year
Ever use
2000 1997
Age (year) Mean age 25 12 - 18
1% 2%
Current use 0,2% 0,8%
Amsterdam Nationwide Amsterdam Nationwide
2003 1997
Mean age 28 12 - 18
2% 4%
0% 0,9%
Amsterdam The Hague Nationwide Flevoland
2001 2000/2001 1999 2004
Mean age 25 16 - 25 15 - 22 13 - 22
9% 13% 21% 8%
0,9% 7% 11% 2%
Percentage of ever users (in lifetime) and current (last month) per group. The figures in this table cannot be compared with each other because of differences in age groups and research methods. < means ‘less than’. I. A selective sample of young people and adolescents visiting mainstream, student, gay and trendy pubs. This sample is therefore not representative for all pub visitors. II. Special School for Children with Learning Difficulties (MLK), Special School for Children with Learning and Behavioural Difficulties (LOM), Special School for Children with Severe Behavioural Learning Problems (ZMOK). III. Low response (15%). IV. Young people receiving inadequate care and/or cannot provide sufficiently in their own livelihood. Recruited at locations for young homeless people, low-threshold day- and night accommodation and (other) temporary accommodation. V. Young people up to 23 years of age without a fixed address (homeless) for three months or longer. 17;22;23;25;26 . References:
4.4
PROBLEM USE
The available estimates usually do not allow us to make a clear distinction between problem opiate a
users on the one hand and other hard drug users on the other hand. The estimates in Table 4.3, therefore, refer to problem users of illegal opiates, or methadone, who usually use additional substances, such as (crack) cocaine, alcohol, and sleeping tablets or tranquillisers. • According to the latest estimates, the number of problem users of hard drugs amounts to approx. 32,000. This number is accompanied by a fairly large margin of uncertainty, varying from approx. 22,000 to 42,000 problem users. Compared with earlier years, no significant change has taken place. • The Netherlands has approximately three problem hard drug users per thousand inhabitants aged 15 to 64 years incl. • Per thousand inhabitants, most of the problem users are located in Amsterdam, Rotterdam and The Hague (see Table 4.1).
a b
For the definition of problem user: see Appendix A. In 2001 the Amsterdam Municipal Medical & Health Service (GG&GD Amsterdam) brought in 1,869 clients with a primary heroin problem, 1,304 clients of whom were not known to other bodies participating in the National Information System on Alcohol and Drugs (LADIS).
57
Table 4.3
Estimates of the number of problem hard drug users
Scope Nationwide Nationwide Nationwide Nationwide Amsterdam Rotterdam The Hague Parkstad Limburg Leeuwarden Enschede Utrecht
Year 1993 1996 1999 2001 2003 1994 1998 2002 2001 2003 1999
Number 28,000 I 25,000 – 29,000 I 26,000 -30,000 II 32,000 (22,000 – 42,000) 4,530 3,500 – 4,000 2,600 – 2,700 800 389 600 570
I. Based on different estimation methods. II. Average (and 95% reliability interval) of two methods. References: 57;61-66
Figure 4.1
Estimates of the number of problem hard drug users per 1,000 inhabitants aged 15 to 64 incl.
12.0 9.4
10.0 8.5
8.9
8.0 6.3 5.7
6.0 4.5 4.0
3.4
3.0
2.0 0.0 Nationw ide (2001)
Amsterdam (2003)
Rotterdam (1994)
The Hague (1998)
Utrecht (1999)
Parkstad Limburg (2002)
Leeuw arden (2001)
Enschede (2003)
Average of highest and lowest estimates (if applicable). References: see Table 4.3.
Figure 4.2 portrays the development in the number of problem opiate users in Amsterdam according to estimates of the Amsterdam Area Health Authority (GG&GD Amsterdam). • The size of this group peaked in 1988 (8,800) and then decreased. This decline was mainly attributable to foreigners, especially Italians and Germans, leaving Amsterdam. The decline levelled off since 1998. • In 2003, Amsterdam still had an estimated 4,500 problem opiate users. 38 percent were born in the Netherlands, 25 percent in Surinam, the Netherlands Antilles, Morocco or Turkey and 37 percent originated from elsewhere.
58
Figure 4.2
Problem opiate users in Amsterdam, from 1985
Number
10000
8000
6000
4000
2000
0 1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
Born in the Netherlands Born in Surinam, the Netherlands Antilles, Morocco, or Turkey Born elsewhere Total Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
Opiate use is particularly precarious when injected intravenously. • In the course of the years, users of opiates injected the drug less frequently (see Table 4.4). The percentage of ‘hard core’ heroin injectors of all problem hard drug users in Parkstad Limburg decreased from 33 percent in 1996 to 13 percent in 1999. This trend did not continue between 1999 and 2003. In Rotterdam the proportion of hard core injectors dropped from 15 percent in 56-58 1999 to 10 percent in 2003. • In 2003, 10 percent of the opiate clients of (outpatient) care organisations for addicts were known to inject and 72 percent to smoke. The rest used other routes of administration. In 1994, 16 percent still injected the drug. The population of heroin users is becoming old and has to cope increasingly with health problems. • In Amsterdam, the average age of methadone clients increased from 32 in 1989 to 44 in 2003. In Rotterdam and Parkstad Limburg, the average age of problem hard drug users rose from 37 to 39 61;67 years between 1998 and 2003.
• •
Many opiate users have to cope with both drug addiction and (another) mental disorder, such as social phobias or depression (‘dual diagnosis’). According to somewhat older estimates of the mid68;69 nineties, this pertains to between 30 and 50 percent of the opiate users. According to the Amsterdam Area Health Authority (GG&GD Amsterdam), the ageing process is accompanied by the occurrence of old age diseases, such as diabetes and cancer. Pulmonary diseases due to sustained heavy tobacco consumption and heroin smoking are becoming 70 increasingly frequent.
59
Table 4.4
Route of administration of heroin by problem hard drug users
Route of administration Always injects Smokes and injects Always smokes
Rotterdam
Utrecht
Parkstad Limburg
2003 10% 10% 80%
1999 1% 10% 86%
2003 19% 16% 63%
Percentage of problem users by route of administration in the last 6 months. The figures in the columns do not add up to 100 percent entirely; the disparity represents other methods of consumption (such as sniffing). Source: Regions and Towns Monitor for Alcohol and Drugs (MAD).
4.5
USE: INTERNATIONAL COMPARISONS
Use by pupils •
•
According to the European School Survey Project on Alcohol and Other Drugs (ESPAD), in 2003 the percentage of ever users of heroin among pupils aged 15 and 16 in Europe did not exceed two 43 percent. An exception was Sweden where four percent of the pupils had experience with heroin. The percentage of recent users was not higher than one percent, except in Italy (3%).
Problem use • •
•
The old EU Member States have an estimated 1.5 million problem hard drug users, or three to ten 37;38 per thousand inhabitants aged 15 to 64 incl. It involves mainly (also) opiates. The estimates are calculated with different statistical methods. Table 4.5 shows the lowest and highest figures per country. Because of differences in definitions and methods, the data should be interpreted with caution. This is particularly true for Luxembourg for which the estimates vary widely. With two to three problem hard drug users per thousand inhabitants, Greece, the Netherlands and Germany are at the bottom of the list of all the old EU Member States.
60
Table 4.5 Country Luxembourg United Kingdom Italy Portugal Denmark Austria Ireland Spain Sweden France I Belgium Finland Germany The Netherlands Greece
Problem hard drug users in several EU Member States and in Norway Year 2000 2000/2001 2002 2000 2001 2002 2001 2000 1998 1999 1997 1999 2000 2001 2002
Number per thousand inhabitants aged 15 to 64 incl. Lowest – highest estimate Average 6.2 – 13.6 9.9 9.0 – 9.8 9.4 6.7 – 8.4 7.5 6.0 – 8.5 7.3 6.7 – 7.7 7.2 5.4 – 6.2 5.8 5.2 – 6.1 5.6 5.3 5.3 4.2 – 4.8 4.5 3.9 – 4.8 4.3 3.5 – 4.2 3.9 3.1 – 4.1 3.6 2.7 – 3.5 3.1 2.0 – 3.9 3.0 2.1 – 2.9 2.5
Because of differences in definitions and methods, the data should be interpreted with caution. The estimates relate in most countries to opiate users, with the exception of Sweden, where amphetamine injectors are in the majority (at any rate in the early nineties). I. Figures for Belgium relate only to intravenous drug users and are an underestimation of the actual number of problem hard drug users. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
4.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) • The number of clients with primarily opiate-related problems increased slightly until 1997 (see Figure 4.3). This increase was partly real and partly a misrepresentation, as more drug services joined the National Information System on Alcohol and Drugs (LADIS). From 1997 to 2000 incl. the number of opiate clients remained fairly stable. The increase in 2001 is mainly due to the entry of b
the Amsterdam Area Health Authority (GG&GD Amsterdam) into LADIS.
• Since 2001 the number of opiate clients has decreased. Between 2002 and 2003 the decrease was five percent. • The proportion of opiates in all the requests for drug-related aid decreased from 71 percent in 1994 to 30 percent in 2003. This is mainly due to the increase in the number of clients with another drug problem, such as cocaine and cannabis. • Characteristics of the primary opiate clients in 2003 are: - Most of them (80%) are men. - The average age is 40, considerably higher compared to the cannabis and cocaine clients. Eight in ten opiate clients are aged between 30 and 49 years (see Figure 4.4). - Most of the clients appealed before to the (outpatient) care organisations for addicts because of a drug problem. One in twenty (5%) was a newcomer. - Opiates are not often mentioned as a secondary problem (see Figure 4.3). For this group the primary problem is cocaine or crack (69%), alcohol (26%), or cannabis (2%).
61
•
The proportion of young opiate clients decreased further. In 2002, 13 percent of the primary opiate clients were aged between 15 and 29 years, in 2003 this was 9 percent. In comparison: in 1994, this age group contained 39 percent of the opiate clients.
Figure 4.3
Number of clients of (outpatient) care organisations for addicts with primary or secondary opiate problems, from 1994
20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Primary Secundary
1994 1995 1996
1997 1998 1999 2000 2001
2002 2003
14002 14936 15247 15865 15491 15606 15544 17786 16043 15195 804
913
985
1112 1101 1313 1387 1761
1912 2056
I. The increase in the number of people in 2001 compared to 2000 is due to the first supply of data from the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
62
Figure 4.4 Age group categories of primary opiate clients in the (outpatient) care organisations for addicts. Survey year 2003 % 25
22 20
17
23
17
15
10
7 5
2
8
2 1
0 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64
Age
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
An estimated 13,500 opiate-dependent persons in the Netherlands receive methadone. The main providers of methadone are the (outpatient) care organisations for addicts, the Amsterdam Area c71 Health Authority (GG&GD Amsterdam), GPs and medical specialists. • The number of methadone clients of the (outpatient) care organisations for addicts increased slightly until 2002 (see Table 4.6). Besides due to an actual increase, this is also due to the larger number of institutions that take part in the LADIS. • Methadone is prescribed as maintenance treatment in over 97 percent of the cases. In the other cases, it is used for heroin detoxification purposes. 72 • The average daily methadone dose increased since 1995 (see Table 4.6). In 2003, 37 percent of the clients received a (therapeutic) dose of 60 mg methadone or more. The amount of methadone prescribed to a client per time largely depends on the methadone policy of the respective drug service/GP, or on the case worker.
c
GPs and specialists provide an estimated 2,750 persons with methadone, 900 of whom do not appear in the 71 National Information System on Alcohol and Drugs (LADIS).
63
Table 4.6 Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Methadone distribution by the (outpatient) care organisations for addicts, from 1994 Number of people 8 882 8 817 9 068 9 838 9 754 10 666 10 805 I 12 538 12 805 12 048
Daily averaged dose (milligrams) 46 37 38 40 42 45 48 I 54 57 57
I. The increase in the number of people as compared with 2000 is due to the first supply of data from the Amsterdam Area Health Authority (GG&GD Amsterdam). The increase in the average methadone dose may also be (partially) related to this. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. Of all drugs, opiates make up the majority of admissions in the inpatient care organisations for addicts (Patients Admission Tracking System for Inpatient Mental Health Care (PiGGz), Mental Health Service (GGZ Netherlands)/Prismant).
• • •
The number of admissions for opiate addiction and opiate abuse rose in the first half of the nineties from 2,089 in 1990 to 3,128 in 1995 and decreased slightly, namely to 3,055 admissions in 1996 (ICD-9 codes: 304.0, 304.7, 305.5, Appendix C). The proportion of opiate patients in the total of the inpatient care organisations for addicts decreased from 75 percent in 1990 and 77 percent in 1991 to 67 percent in 1996. Due to the absence of recorded information after 1996, developments with respect to the treatment demand can no longer be reflected reliably.
General hospitals; incidents Opiate abuse and dependence are rarely diagnosed as the primary problem in general hospitals. In 2003 Dutch Hospital Registration (LMR) recorded 51 admissions (63% dependency and 37% abuse, see Figure 4.5). • These conditions are more often diagnosed as secondary problems (85% dependence, 15% abuse). The main diagnoses of these secondary problems differ widely. In 2003, the principal problems in secondary diagnoses were given as: - respiratory illnesses and symptoms (26%) - accident-related injury (16%; fractures, wounds, concussion) - digestive system diseases (8%) - poisoning (8%; especially benzodiazepines) - skin diseases (6%; abscesses).
64
•
•
A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 533 patients were admitted in 2003. They were admitted at least once this year with opiate abuse or dependence diagnosed as primary or secondary problem. Their average age was 39 and seven in ten were men (69%). Three in ten patients came from the four big cities: Amsterdam (21%), Rotterdam (6%), The Hague (5%) and Utrecht (3%). Accidental opiate intoxication was recorded as a secondary diagnosis in 26 hospital admissions. 11 such admissions involved methadone.
Figure 4.5
Clinical admissions in general hospitals for opiate abuse and dependence, from 1994 900 800
751
700
742 627
607
596
634
627
674 606
558
600 500 400 300 200 100
74
71
71
71
76
79
75
81
88
1994
1995
1996
1997
1998
1999
2000
2001
2002
51
0
Opiates as primary diagnosis
2003
Opiates as secondary diagnosis
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.0, 304.7, 305.5 (Appendix C). Source: National Medical Registration (LMR), Prismant.
In 2003, the Central Ambulance Station of the Amsterdam Area Health Authority (GG&GD 73 Amsterdam) recorded 226 emergency calls for suspected non-fatal hard drug overdoses. • Emergency calls mainly involved opiate and cocaine use, sometimes in combination with other substances. • More than three-quarters (79%) of the above cases required transportation to a hospital. This is a considerably higher percentage than for ambulance calls involving cannabis (35%).
4.7
ILLNESS AND MORTALITY
HIV Needle-sharing or practising unsafe sex puts hard drug users at risk of infection with HIV, the virus that causes AIDS. Between 1994 and 2003, the National Institute of Public Health and the Environment (RIVM) conducted sixteen surveys among injecting hard drug users in nine regions in the Netherlands. Figure 4.6 shows the most recent figures. • There are large regional differences in HIV infection among drug users who ever injected the drug.
65
• • • •
74
Of the big cities, Amsterdam leads. The Hague has the lowest percentage. In most cities participating more than once in the survey, the percentage of HIV-infected IDUs (intravenous drug users) remained stable. Heerlen is an exception. In this city this proportion doubled from 11 percent in 1994 to 22 percent 75;76 in 1999. In a long-term survey in Amsterdam, the number of new HIV infections among IDUs dropped from 9 percent in 1986 to 1-2 percent in 1999. Between 1999 and 2002, the number of new cases 68;69 fluctuated between zero and 0.2 percent annually. In 2003 not a single new case of HIV 77;78 infection was found.
Figure 4.6
HIV infection among injecting drug users
30% 26% 25%
20% 14%
15%
10% 10% 5%
5%
5%
3%
2%
1%
1%
Arnhem 1997
Groningen 1997/1998
0% Amsterdam 1998
SouthLimburg 1999
Rotterdam 2002/2003
Utrecht 1996
Brabant 1999
Twente 2000
The Hague 2000
Percentage of ever injecting hard drug users infected with HIV. An ever injecting hard drug user is a person who has intravenously injected a drug once or more times in his or her life and used hard drugs at least once a week in the past 6 months. Percentages in previous surveys: Amsterdam 26% in 1993 and 1996; Rotterdam 11% in 1994; Arnhem: 2% in 1991/1992 and 1995/1996; South-Limburg 10% in 1994 and 12% in 1996 (in Maastricht: 8% in 1994, 3% in 1996, 5% in 1999); in Heerlen, 11%, 17% en 22% respectively. Brabant includes Eindhoven, Helmond, Den Bosch. Twente includes Almelo, Hengelo, Enschede. Source: the National Institute of Public 74;76 Health and the Environment (RIVM).
Statistics about HIV infection in a number of EU Member States originate from diverse sources and differ with respect to their degree of coverage. The figures are therefore not suitable for comparison 37 and provide only an indication of the degree of infection. • Figure 4.7 shows that percentages of HIV-infected injecting drug users vary from approx. 1 percent or less in Finland (data from needle exchange programmes) and from 10 to 35 percent in Spain (data from the care organisations for drug addicts, the centres for HIV screening and clinics for sexually transmitted diseases (SOA)). • In Italy and Portugal, just as in the Netherlands, there is a considerable regional or local dispersion of HIV infection. • According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the available figures suggest that the percentage of injecting HIV-injected drug users is stable or going down, at any rate in the old EU Member States. In a number of new Member States and their neighbouring countries, such as Estonia, Latvia, Russia and the Ukraine, there are indications of a fast growing HIV epidemic, with a peak in Estonia and Latvia in 2001. However, in many countries
66
no reliable trend data are available and the situation at a local level may differ strongly from the general domestic picture.
Figure 4.7
Percentage of injecting drug users (IDUs) infected with HIV in several EU Member States and Norway
The data originate from several sources (samples, treatment centres, prisons, needle exchange). The percentages between brackets refer to local sources. The colours indicate the degree of infection in accordance with the average of the highest and lowest measured value. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
Hepatitis B and C Hepatitis B and C are serious forms of liver infection caused by the hepatitis B or C virus, HBV and HCV respectively. HBV is transmitted through blood contact, for example as a result of an intravenous injection with used needles, or through unsafe sexual contact. HCV can practically only be transmitted
67
by direct blood-blood contact. HCV is much more contagious than HIV and can also be transmitted via contaminated (injection) utensils other than needles. • Data about HCV and HBV among injecting hard drug users are not systematically collected in the Netherlands. Information is available for a number of locations. • At the latest examination, approximately three quarters of IDUs in Rotterdam and Heerlen/Maastricht appeared to be infected with hepatitis HCV and a slightly lower percentage 79;80 with HBV (see Table 4.7). 81 • The picture in The Hague was better. There is no immediate explanation for this.
Table 4.7
Hepatitis B and C infections among samples of hard drug users in Rotterdam, Heerlen/Maastricht and The Hague
Rotterdam Heerlen/Maastricht The Hague
I
Year 1994 1996 II 1998/1999 2000
HBV-positive 56% of the IDUs 27% of the non-IDUs 63% of the IDUs 67% of the IDUs 35% of the IDUs
HCV-positive 79% of the IDUs 13% of the non-IDUs 74% of the IDUs 47% of the IDUs
IDG = ever injecting hard drug users, recruited on the street and at the aid organisations. HBV = Hepatitis B virus. HCV = Hepatitis C virus. I. positive for anti-HBc, a marker for an earlier or current infection with hepatitis B. II. Seven percent were positive for HbsAg, indicative for a current hepatitis B infection. Source: National Institute of Public Health and the Environment (RIVM).
For Amsterdam data are available of 116 clients of a methadone centre who were screened in 2002 82 for contagious diseases. • Table 4.8 shows the percentages of infections with HBV and HCV by injection status. About eight in ten currently injecting methadone clients were (ever) infected with HBV and or HCV. A slightly lower percentage of HBV infections was found among clients who had ever injected, but did not do so any longer at the moment of measurement. • More than a quarter (27%) of those who had never injected were infected with HBV. This indicates sexual risk behaviour. • One in ten drug users who, so they said, had never injected had ever been infected with HCV. 83 This figure corresponds with an earlier survey in Amsterdam and Rotterdam (see Table 4.7). This finding may indicate non-reporting of the injection of drugs and or another manner of infection, like via attributes that are used for smoking cocaine.
Table 4.8 Hepatitis B and C infections among methadone clients in Amsterdam. Survey year 2002
HBV HCV
Ever injected, not currently 55% 90%
Currently injecting
Never injected
85% 77%
27% 10%
It concerns here percentages of users who were ever infected with HBV or HCV, so both old, chronic and current 82 cases. Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
•
•
In the old EU Member States, HCV infection is common among IDUs. According to various sources, the percentage of HCV infections varies between 40 and 80 percent, with an average of 65 percent. 37 Figures for HBV infection show much variation - between 17 and 85 percent.
68
Risk behaviour •
•
•
Needle-sharing among drug users has decreased compared to five to ten years ago. In most of the cities and areas about which information is available report occasional needle-sharing by 8 to 84 30 percent of IDUs (see Table 4.9). In addition to sharing used needles, other used utensils, such as spoons, swabs, filters, or water for rinsing syringes are also shared occasionally. An estimated one in four IDUs do this. Sharing these utensils increases the risk of infection with hepatitis B and C, but not with HIV. Sexual risk behaviour remains widespread. Practising sex without condoms is most found among permanent partners (76-96%), followed by casual partners (39-73%) and customers (13-50%, see Table 4.9).
Table 4.9 Region
Amsterdam Rotterdam
SouthIII Limburg Utrecht Arnhem
Groningen IV Brabant The Hague V Twente
Needle sharing and sexual risk behaviour among IDUs Survey year Needle or No condom No condom II lI syringe use use I permanent casual sharing partner partner 1996 18% 76% 40% 1998 12% 85% 47% 1994 18% 91% 47% 1997 10% 84% 54% 2002/2003 8% 85% 43% 1994 19% 86% 61% 1996 17% 87% 39% 1999 10% 89% 49% 1996 17% 84% 45% 1991/1992 42% 1995/1996 39% 90% 51% 1997 16% 96% 53% 1997/1998 11% 89% 57% 1999 17% 88% 61% 2000 21% 84% 73% 2000 30% 92% 68%
No condom lI use customers 30% 29% 20% 31% 32% 13% 17% 25% 17% 40% 21% 22% 24% 17% 40% 50%
I. Percentage of ever injecting hard drug users who had borrowed syringes or needles from others in the last 6 months. II. Had not always used condoms in the last 6 months. III. Heerlen and Maastricht. IV. Eindhoven, Helmond, Den Bosch. V. Almelo, Hengelo, Enschede. = unknown. Source: National Institute of Public Health and 85 the Environment (RIVM).
AIDS •
•
•
The number of AIDS cases reported to the Health Care Inspectorate (up to 1999 incl.) and the HIV Monitoring Foundation (from 2000) rose from 325 in 1988 to 533 in 1995 and fell since to between 230 and 280 cases in the past few years. One of the reasons of this is the introduction of effective anti-viral licit drugs. These prevent fewer HIV cases from turning into AIDS or delay the onset. Intravenous drug injection as a contributing factor to AIDS in the Netherlands remained moderate throughout all these years; expressed in percentages: an average of 10%, with a peak of 14% in 1995. In 2003 three percent (8 cases) of the reported aids cases concerned IDUs. The number of reported AIDS cases differs in the old EU Member States. Figure 4.8 shows the development for countries that in any year reported more than ten new cases of AIDS among IDUs per million of inhabitants. In Belgium, Denmark, Germany, Greece, the Netherlands, Austria,
69
Finland, Sweden and the United Kingdom the number of cases did not exceed ten per million of inhabitants annually. In the mid-nineties, Spain and Italy reported by far the highest numbers. In the following years, these numbers reportedly fell sharply in those two countries. In Portugal the number of reported AIDS cases rose from the early nineties onwards, but did not increase in 2000. These three Member States comparatively have the highest numbers of IDUs infected with AIDS.
•
Figure 4.8
New cases of AIDS among IDUs per million of inhabitants in a number of EU Member States, from 1985
140
Spain 120
Italy Portugal
100
France Ireland
80
Luxembourg
60
40
20
0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Numbers of new cases per diagnosis year per million of inhabitants, adjusted in respect of previous years because of delays in reporting. The figures reported until 31 December 2003 incl. Figures for 2003 are incomplete for Spain and Italy. Trends are only reflected for the old EU Member States that reported more than ten new cases per million of inhabitants in any year. Source: The European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), Statistical Office of the European Communities (Eurostat).
Mortality According to the Cause of Death Statistics of Statistics Netherlands (CBS), few people in the Netherlands die annually as a direct result of opiate consumption. When death does occur, it is mostly the result of a drug overdose. In accordance with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard for the calculation of the acute death from drug use, these figures include all the cases of unintentional and intentional (suicide) poisoning and poisoning that may or 86;87 may not have been intentional. Between the mid-nineties and 2001 the number of registered deaths from all kinds of overdoses showed a rising trend, so not just for opiates (see Figure 4.9). • This trend is partially due to the increase in death from cocaine (see Chapter 3.7). • In addition, due to the transition of the classification system ICD-9 to ICD-10, more cases may have been included in the ICD-10 system from 1996 than in earlier years in the ICD-9 system. • Between 1996 and 2001, the number of cases of "poisoning by other non-specified narcotics" and “poisoning by other or non-specified psychodysleptics” increased. It concerns here often
70
(combinations of) hard drugs, whether or not together with other substances, but sometimes also (combinations of) prescription drugs and/or alcohol. The number of registered deaths due to an overdose of opiates is low in the Netherlands. • Until 2001 this number of deaths varied from 47 to 77 cases annually. The two following years showed a decrease. • Just as the heroin users, the overdose victims are increasingly older. In the years 1985 up to 1989 incl., only 16 percent of the deceased were older than 35 years, compared to 63 percent in the years 2000 up to 2003 incl. (see Figure 4.10).
Figure 4.9
Deaths from drug overdoses in the Netherlands, from 1985
160 140 120 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Totaal
57
68
54
51
56
70
80
75
75
87
70
108 108 110 115 131
144 103 104
Opiates
51
67
49
47
54
62
76
72
68
77
56
81
71
71
63
68
75
37
53
Cocaine
3
1
3
2
1
3
1
2
3
2
6
10
8
11
12
19
26
34
17
Number of deaths. From 1985 to 1996 ICD-9 codes: 292, 304.0, 304.2-9, 305.2-3, 305.5-7, 305.9, E850.0, E850.8*, E854.1-2, E855.2, E858.8*, E950.0*, E950.4*, E980.0*, E980.4* (*In combination with codes N965.0 and/or N968.5 and/or N969.6 and/or N969.7). From 1996 to 2002 ICD-10 codes: F11-F12, F14-F16, F19, X42*, X41*, X62*, X61*, Y12*, Y11* (*In combination with the T-codes T40.0-9, T43.6). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
71
Figure 4.10
Age group categories involved in death from an opiate overdose between the periods 1985-1989, 1995-1994, 1995-1999 and 2000-2003
100% 80% 60% 40% 20% 0%
1985-1989
1990-1994
1995-1999
2000-2003
>=65
1
4
3
5
35-64
15
35
50
58
15-34
82
61
47
37
0-14
1
0
0
0
Death percentage per age group. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
Amsterdam The Amsterdam Area Health Authority (GG&GD Amsterdam) publishes annual reports on the number of deaths among drug users (see Figure 4.11). These mortality figures for death due to an overdose differ from those published by the Cause of Death Statistics of Statistics Netherlands (CBS), as the Amsterdam Area Health Authority also includes drug-related deaths of illegal immigrants and tourists. The Area Health Authority ( also records the number of opiate users in Amsterdam who died from other causes. • In 2003, 21 drug users in Amsterdam died after taking a drug ‘overdose’, often opiates whether or not in combination with other substances. Once ecstasy (MDMA) was involved. Nine of the overdose victims were Dutch and twelve were foreigners. • Opiate clients usually died from other causes than an overdose (see caption Figure 4.11). Twenty-one deceased drug users were infected with HIV, but this did not necessarily contribute to their deaths. • The average age of the deceased drug users (all causes) who were born in the Netherlands was 51 years. The average age of the drug users born abroad was 43 years. • The decrease in the number of recorded deaths at the beginning of the nineties did not continue in the mid-nineties. From 2001, there was a slight increase in the category of ‘other’ causes of death (see Figure 4.11). With the increasing age of opiate users, underlying problems such as pulmonary, liver and heart diseases play a larger role in these deaths.
72
Figure 4.11
Mortality among drug users in Amsterdam, from 1992
160 140 120 100 80 60 40 20 0
1992
Overdose Other causes Total
I
1993 1994 1995
1996 1997
1998 1999
2000
2001 2002 2003
52
37
39
26
26
22
25
27
31
32
29
21
83
102
86
92
90
76
67
73
76
112
96
126
135
139
125
118
116
98
92
100
107
144
125
147
I Other causes of death (such as endocarditis, sepsis, pulmonary disorders, cirrhosis of the liver, suicide, accidents, violence, AIDS) involving opiate users who were ever registered as clients of the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
International comparisons • Annually, between eight thousand and nine thousand people in the old EU Member States die from a drug overdose; often from opiates in combination with other substances. This is a lower 37;38 limit, because not all cases of death from drug use are recorded. • International comparisons of the number of ‘drug deaths’ are made more difficult due to differences in the definition of the term ‘drug death’. • Figure 4.12 shows the proportion of deaths directly related to drug use for five EU Member States and Norway per 100,000 inhabitants. The same ICD-10 codes were used here. Included are opiates, hallucinogens, cocaine, amphetamine and cannabis. The majority of cases (also) 87 involved opiates. • According to these calculations, Norway and Denmark head the list. The Netherlands are at the bottom. • According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), since 2000 a modest decrease in the number of acute drug-related deaths is noticeable at a European level.
73
Figure 4.12
Acute deaths from drug consumption: a comparison between five EU Member States and Norway Number per 100,000 inhabitants 9 8 7 6 5 4 3 2 1 0 1994
1995
Norway Denmark Finland
5.5
4.1
1996
1997
1998
1999
2000
2001
2002
4.3
3.9
5.9
5.0
7.7
8.2
6.0
4.6
4.8
4.5
4.5
4.5
2.1
1.9
1.7
2.3
2.6
2.1
1.9
1.5
1.6
1.8
2.2
1.9
1.8
1.6
1.6
1.8
1.5
1.4
0.7
0.7
0.8
0.9
0.6
Sweden* Germany The Netherlands
0.7
0.7
2003
1.9
0.6
ICD-10 codes: F11-F12, F14-F16, F19, X42*, X41*, X62*, X61*, Y12*, Y11* (*In combination with the T-codes T40.0-9, T43.6). I. With a view to better comparability, T40.4 is not taken into account in Sweden. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
74
5
ECSTASY, AMPHETAMINES AND RELATED SUBSTANCES
The official name for ecstasy is 3,4-methylenedioxymethamphetamine (MDMA). Substances with a chemical composition similar to that of MDMA — such as MDA, MDEA, MBDB and amphetamines, — a are also sold as ‘ecstasy’, quite often without the user being aware of the difference. Unless stated otherwise, by ‘ecstasy’ we refer in this chapter to substances that are experienced or recommended as ecstasy. By amphetamine we refer to 'ordinary' amphetamine and methamphetamine, the stronger version, unless stated otherwise. Ecstasy has a stimulating and entactogen effect. As a result of the entactogen effect of ecstasy, people feel connected with one another and they find it easier to make contact. This combination of characteristics contributes to the reputation of ecstasy as a party drug. The addictive effect is probably light. Ecstasy is usually taken in the form of pills. Amphetamine has a stimulating effect, stronger than ecstasy, without having an entactogen effect. Amphetamine is also used in trendy clubs, but also used by opiate or polydrug addicts. When used frequently, it may result in dependence. This risk is higher for methamphetamine than for ‘ordinary’ amphetamine. In the Netherlands, amphetamine is usually swallowed or sniffed and sometimes injected or smoked.
5.1
LATEST FACTS AND TRENDS
The main facts and trends regarding ecstasy and amphetamine in this chapter are: • The percentage of ever use of ecstasy and amphetamine in the general population rose between 1997 and 2001. Current use of ecstasy increased particularly among women (see Chapter 5.2). • Between 1996 and 2003 the percentage of pupils who have experience with these substances fell slightly. The percentage of current users decreased also (see Chapter 5.3). • Current use of ecstasy and amphetamine among Dutch pupils is not higher than that of other European peers (see Chapter 5.5). • Ecstasy is still popular among young clubbers, although the use is showing signs of moderation. In Amsterdam, the percentage of users among visitors of trendy clubs dropped (see Chapter 5.3). • The number of ecstasy users seeking help from the (outpatient) care organisations for addicts is low and has been stable in the past four years. The number of primary amphetamine clients is also small, but increased between 2001 and 2003 (see Chapter 5.6). • Health problems at house parties as a result of ecstasy and amphetamine use have been less and less frequent since 1996 (see Chapter 5.6). • The number of recorded acute deaths as a result of ecstasy and amphetamine use is low (see Chapter 5.7). • The use of ecstasy may have a long-term negative effect on brain functions, in particular of the memory, the capacity to concentrate and mood (see Chapter 5.7). • Ecstasy tablets nowadays almost always contain MDMA. The proportion of ecstasy tablets with a high dose of MDMA increased slightly between 2000 and 2003 (see Chapter 5.8).
5.2 • •
a
USE: GENERAL POPULATION The number of Dutch people aged 12 and over with experience of ecstasy or amphetamines (ever 10 use) rose between 1997 and 2001 (see Table 5.1). The percentage of current users remained far below one percent for both substances combined.
Substances that are not similar to MDMA at all are also recommended as ecstasy.
75
•
In absolute figures, the number of current users of ecstasy was 67,000 and the number of current users of amphetamine was 30,000. These estimates are probably rather low, because problem users of hard drugs were underrepresented in that particular survey.
Table 5.1
Ecstasy and amphetamine use in the Netherlands among people aged 12 and over. Survey years 1997 and 2001
Has used ever in lifetime • Men • Women I Used just recently • Men • Women First use in the past year Mean age of current users
Ecstasy 1997 2001 1.9% 2.9% 2.7% 3.7% 1.0% 2.1%
Amphetamines 1997 2001 1.9% 2.6% 2.7% 3.4% 1.1% 1.8%
0.3% 0.4% 0.1%
0.5% 0.5% 0.5%
0.1% 0.2% 0.1%
0.2% 0.2% 0.3%
0.4% 25 years
0.5% 26 years
0.2% 30 years
0.2% -
I. In the last month. - = Not sufficient users for a reliable estimate of the average age. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 5.1
Ecstasy and amphetamine users in the Netherlands by age group. Survey year 2001 % 15
10
5
0
12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69
>=70
Ecstasy ever
0.5
5.5
13.6
7.1
5.0
2.6
1.0
0.6
0.0
0.0
Amphetamines ever
0.2
3.9
9.5
4.2
3.8
3.1
2.2
1.1
0.5
0.5
Ecstasy current
0.2
1.6
2.5
0.8
0.7
0.3
0.1
0.2
0.0
0.0
Amphetamines current
0.2
0.7
0.9
0.2
0.4
0.1
0.1
0.2
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
•
•
Ecstasy is especially popular among adolescents aged 20 to 24 incl. (see Figure 5.1). The increase in the proportion of ever users was also largest in this group: from six percent in 1997 to thirteen percent in 2001. Current use rose from more than one to nearly three percent. The percentage of current users also doubled among young people aged 16 to 19 incl. (an increase of 0.8% to 1.6%). The percentage of amphetamine users also peaked among young adolescents aged 20 to 24 incl. (see Figure 5.1). In this group, ever use rose from four percent in 1997 to nearly ten percent in 2001. Current use rose in this period from 0.3 to 0.9 percent.
76
• •
The increase in current users of ecstasy and amphetamines was larger among women than among men. In 2001 nearly as many women were current consumers as men. In 2001, nearly one in three (30%) ever users aged twelve and above had used ecstasy 25 times 10 or more in life. In 1997 this was 25 percent.
The large cities Large cities and other primarily urban areas have a comparatively higher percentage of ecstasy and amphetamine use than the rest of the Netherlands. Amsterdam leads in both survey years (see Figure 5.2).
Figure 5.2
Use of ecstasy (figure above) and amphetamines (figure below) in large cities and rural areas among people aged 12 and over. Survey years 1997 and 2001 ecstasy
% 10 8.7
8
7.0
6
5.3 4.3
4 2.6
2.2
2
1.1 1.1
1.0
0.5
0.1
0.9
1.2 1.4 0.1 0.3
0 Amsterdam
%
Rotterdam
Highly urbanised, other
Non-urbanised
amphetamines
10 8 6.6 6.0
6 4.2
3.8
4
2.8
2.7
2 0.3 0.3
1.1
0.2
0.3
0.1
0.2
1.4 0.1 0.2
0 Amsterdam Ever 1997
Rotterdam Ever 2001
Highly Non-urbanised urbanised, other
Current 1997
Current 2001
Percentage of ever (lifetime) and current (last month) users. Definition (Statistics Netherlands (CBS)): Other highly urbanised municipalities: more than 2,500 addresses per square kilometre, with the exception of Amsterdam and Rotterdam, namely Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. Definition of rural municipalities: fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
77
5.3
USE: YOUNG PEOPLE
Figures about the use of ecstasy and amphetamines among young people are shown in Figure 5.1, in which the percentage of users among the general population, resulting from the National Prevalence Research, has been classified by age group. In the last few years, information about the use of substances has also become available from numerous local and regional youth monitors carried out for cities and towns. For amphetamine and ecstasy the information is more limited than for cannabis and legal substances, because questions about the use of ‘hard drugs’ are often not classified by substance. The tables in Appendix F show the results for eight (amphetamine) and eleven (ecstasy) municipalities or regions. It is difficult to compare the figures due to methodological differences, such as the manner of measuring use and age groups. In addition to these general data, information is available from the Dutch National School Survey and (often local) surveys among special groups, such as visitors of clubs and pubs. These data will be described below.
Pupils • • •
The percentage of ecstasy and amphetamine users among secondary school pupils increased 16 between 1992 and 1996. The percentage of ever users of the two drugs decreased by fifty percent between 1996 and 2003. The decrease took place in particular between1996 and 1999. The percentage of current users of ecstasy and amphetamine dropped also between 1996 and 2003 (see Figure 5.3).
Figure 5.3 7
Ecstasy and amphetamine use among pupils aged 12 and over, from 1992
%
Ecstasy
6
7
Amphetamines
%
6
5.8
5.3
5
5 4
4
3.8 3.4
3
2.9 2.3
2
3 2
2.8 2.2
1.4 1
1
1.0
2.2
1.9 1.1
1
0.8 0.6
0
0 1992
1996 Ever
1999 Current
2003
1992
1996 Ever
1999
2003
Current
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
78
Special groups In certain groups of young people, proportionately more users of ecstasy and amphetamines are found. Table 5.2 summarises the results of a broad spectrum of studies. The figures in this table cannot be compared with one another because of differences in age groups and research methods.
•
According to less recent data, ecstasy and amphetamine use is more frequent among pupils in special education and participants in truancy programs than among 'regular' pupils (see Table 5.2). However, the figures should be interpreted with caution in view of the recent decrease in 25 (ever) use among ‘regular’ pupils and young clubbers (see below).
Table 5.2
Ecstasy and amphetamine use in special groups
Young people in special I education Young people in truancy programs Visitors of trendy clubs II Pub visitors Young clubbers III Young homeless people Coffee shop visitors
IV
Location
Survey year
Age (year)
Ecstasy
Amphetamines
Nationwide
1997
12 - 18
Ever 9%
Current 4%
Ever 7%
Current 3%
Nationwide
1997
12 - 18
30%
15%
25%
9%
Amsterdam Amsterdam The Hague Nationwide Flevoland Amsterdam
2003 2000 2003 1999 2004 2001
Mean age 26 Mean age 25 15 - 35 15 - 22 13 - 22 Mean age 25
33% 34% 35% 55% 38% 63%
19% 10% 17% 18% 8% 23%
34% 17% 47% 26% 39%
7% 2% 10% 2% 5%
Percentage of ever users (in lifetime) and current (last month) per group. The figures in this table cannot be compared with one another because of differences in age groups and research methods. - = not measured. I. Special School for Children with Learning Difficulties (MLK), Special School for Children with Learning and Behavioural Difficulties (LOM), Special School for Children with Severe Behavioural Learning Problems (ZMOK). II. A selective sample of young people and adolescents visiting mainstream, student, gay and trendy pubs. This sample is therefore not representative for all pub visitors. III. Young people of up to 23 years without a fixed 17;22-25 . address for three months or longer. IV. Low response (15%). References:
Ecstasy continues to be (after cannabis) the main illegal drug for young people in the clubbing circuit, in particular parties, although there are indications of a tendency to moderate the use. • According to the Amsterdam Antenne Monitor the percentage or current ecstasy users among 18 visitors of trendy clubs dropped from 41 percent in 1998 to 19 percent in 2003. The proportion of users during the night out dropped from 27 to 8 percent. In 2003, they took 1.9 pills per night: this does not differ (significantly) from 1998 (2.4 pills per night). • In The Hague the percentage of ecstasy users among young clubbers was at the same level as in 21 Amsterdam. • Elsewhere in the country, key figures in the partying circuit also noted that young clubbers handled ecstasy ‘more prudently’ and were better informed of the risks. Visitors of discotheques in rural 20 areas in the eastern part of the country do not seem to be an exception. • The experience or expectation of negative physical and emotional effects of ecstasy use, such as headaches, dizziness, feelings of anxiety or depression, seem to discourage the use of it by young 188 people. Amphetamines are less popular among young clubbers than ecstasy. • In Amsterdam the percentage of visitors of trendy clubs who had ever used this drug dropped from 45 percent in 1998 to 34 percent in 2003. The percentage of current users dropped from 13 percent to 7 percent.
79
• At hardcore parties and in certain (alternative) scenes, amphetamines are used somewhat more 20 frequently (punk, electro, trance, underground, rock and techno) than in trendy clubs.
5.4 •
5.5
PROBLEM USE The number of problem users of ecstasy and amphetamines — i.e. people whose drug use leads to role limitations or even dependence — is not known. However, the number of individuals who seek drug treatment or counselling is known (see Chapter 5.6).
USE: INTERNATIONAL COMPARISONS
General population Table 5.3 presents information about the use of ecstasy and amphetamines in a number of EU Member States, Norway, Australia, Canada and the United States.
•
Differences in survey year, methods of measurement and random samples make precise comparison difficult. Of particular influence is the age group. Table 5.3a shows consumption figures (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data for the other countries can be found in Table 5.3b.
•
As regards ever use of ecstasy, England & Wales, Australia and Ireland beat them all with values over five percent. In Denmark, France, Portugal, Greece and Sweden, the percentage of ever users does not exceed one percent.
•
The percentage of people who ever used amphetamines varies from less than one percent in Portugal and Greece to nine percent in Australia and the United States, while England and Wales peak with twelve percent. Australia tops the list of the countries shown in Tables 5.3a and 5.3b with the highest percentage of recent users of both drugs. The Netherlands takes one of the highest positions for use of ecstasy.
•
80
Table 5.3a
Amphetamine and ecstasy use in the general population of several EU Member States and Norway: age group from 15 to 64 years incl.
Country
Northern Ireland Spain Ireland The Netherlands Finland Norway Belgium Luxembourg France Portugal Greece Sweden
Year
Ecstasy Ever Recent 5.9% 1.7% 4.2% 1.9% 3.8% 1.1% 3.6% 1.5% 1.4% 0.5% 2.4% 0.7% 1.2% 0.9% 0.2% 0.7% 0.4% 0.3% 0.1% 0.2% 0.2%
2002/2003 2001 2002/2003 2001 2002 1999 2001 1998 2000 2001 1998 2000
Amphetamines Ever Recent 3.9% 0.8% 3.0% 1.2% 3.0% 0.4% 3.1% 0.6% 2.2% 0.5% 2.6% 1.2% 2.1% 1.5% 0.2% 0.5% 0.1% 0.6% 0.0% 1.9% 0.2%
Percentage of ever in lifetime and recent (last year) users. - = not measured. References:
37;38
Table 5.3b Ecstasy and amphetamine use in the general population of several EU Member I States, the United States, Canada and Australia: other age groups Country England and Wales Australia
Year
Age
2002/2003 2001
16 - 59 14 and above 12 and above 15 and above 15 - 44 18 - 59 16 - 64
United States
2003
Canada
2002
Italy Germany (‘West’) Denmark
2001 2000 2000
Ecstasy Ever Recent 6.6% 2.0% 6.1% 2.9%
Amphetamines Ever Recent 12.3% 1.6% 8.9% 3.4%
4.6%
0.9%
8.8%
1.2%
2.9%
0.8%
4.6%
0.5%
1.8% 1.6% 1.0%
0.2% 0.7% 0.5%
1.5% 2.3% 5.9%
0.1% 0.6% 1.3%
Percentage of ever in lifetime and recent (last year) users. I. Drug use is proportionally low in the youngest (12-15 years) and the older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. For studies with a more limited age range 37-41 the reverse applies. References:
Young people Better comparable are the data of the European School Survey Project on Alcohol and Other Drugs (ESPAD) among pupils aged 15 and 16 in European countries. Table 5.4 portrays ecstasy and amphetamine use in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in the ESPAD, but conducted comparable 43 research.
81
•
•
The number of pupils who tried ecstasy in 2003 was lowest in Finland, Greece, Denmark, Norway and Sweden (2% or less). The United States topped the list with six percent, followed closely by the Netherlands, Ireland and the United Kingdom with five percent. In none of the countries current use of pupils exceeded two percent. Of the countries listed in Table 5.4, Germany, Austria and Denmark scored highest for current use of amphetamines (4 - 5%). The United States scored exceptionally higher with 13 percent. The Netherlands shared the lowest position with Finland, Greece, Ireland and Sweden. In most of the countries, maximum one percent of the pupils recently used amphetamines, with the exception of the United States (2%), Austria (3%) and Spain (2%).
Table 5.4
Ecstasy and amphetamine use among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey years 1999 and 2003
Country United States Austria Ireland Belgium The Netherlands United Kingdom France Germany Denmark Norway Italy Greece Portugal Finland Sweden
Ever use ecstasy 1999 2003 6% 6% 3% 5% 5% 4% 4% 5% 3% 5% 3% 4% 3% 3% 2% 3% 2% 2% 3% 2% 2% 2% 4% 1% 1% 1% 2%
Ever use amphetamines 1999 2003 16% 13% 4% 3% 1% 2% 2% 1% 8% 3% 2% 3% 5% 4% 4% 3% 2% 2% 3% 1% 0% 3% 3% 1% 1% 1% 1%
Percentage of ever users (in lifetime). The United States did not take part in the ESPAD, but conducted comparable research. - = not measured. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
5.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.)
Ecstasy •
• •
The number of recorded admissions in the (outpatient) care organisations for addicts primarily for ecstasy rose until 1997(see Figure 5.4). This was partly due to an improved registration system. From 1997 this number started to decline, followed by a stabilisation from 1999. Between 2002 88 and 2003 the number increased by eleven percent. With one percent, ecstasy problems accounted for a small proportion of the total number of requests for drug treatment or counselling. Characteristics of the primary ecstasy clients in 2003 were: - About three quarters (74%) were men.
82
•
- The average age was 25. - Over one-third (38%) were new clients of the (outpatient) care organisations for addicts. There were more clients stating ecstasy as a secondary than as a primary problem. - The primary problem for this group of secondary ecstasy clients was cocaine (42%), cannabis (25%), alcohol (15%), or amphetamines (14%).
Figure 5.4
Number of recorded admissions in the (outpatient) care organisations for I addicts because of primary or secondary ecstasy problems, from 1994
1000 900 800 700 600 500 400 300 200 100 0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Primary
29
208
398
457
340
252
241
225
250
277
Secundary
32
321
552
672
607
549
573
563
622
655
I. In 1994, not all the ecstasy-related problems were fully recorded yet.
Amphetamines •
•
•
•
The number of admissions primarily for amphetamine-related problems increased until 1998 but declined again from 2001. Between 2002 and 2003, the number of amphetamine clients increased by 35 percent (see Figure 5.5). With three percent of the total of drug-related treatment requests in 1999 and two percent in 2000 to 2003 incl., amphetamine-related problems remained all those years below the treatment requests of other drugs. Characteristics of the primary amphetamine clients in 2003 were: - Over three quarters (78%) were men. - The average age was 28, slightly higher than that of the ecstasy clients. - About a third (37%) of amphetamine clients who sought help from the (outpatient) care organisations for addicts were new clients. Amphetamines were a secondary problem for over six hundred clients. - The primary problem for this group was cocaine (35%), alcohol (20%), heroin (18%), cannabis (17%), or ecstasy (6%).
83
Figure 5.5
Number of recorded admissions in the (outpatient) care organisations for addicts because of primary or secondary amphetamine problems, from 1994
1000 900 800 700 600 500 400 300 200 100 0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 497
566
667
794
870
810
623
482
543
735
Secundary 489
566
558
610
590
560
498
474
481
552
Primary
Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • This dated information shows that the use of ecstasy or amphetamine rarely leads to admission in a drug treatment clinic or general psychiatric hospital. • Between 1996 and 1999, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded 58, 51, 39 and 25 admissions respectively for ecstasy and amphetamines combined (ICD-9 codes 304.4 and 305.7; see Appendix C).
General hospitals; incidents The National Medical Registration (LMR) registers few admissions annually in general hospitals for amphetamine-related problems, including ecstasy (See Figure 5.6). • In 2003, it concerned ten percent of all primary diagnoses for drugs. Most of the admissions (87%) related to abuse; 13 percent related to dependence of amphetamines. • The percentage of admissions in which these disorders were diagnosed as secondary problem was slightly higher. The main disorders diagnosed — where amphetamine abuse and dependence were diagnosed as secondary problem — were very diverse. A quarter of the admissions in 2003 involved alcohol abuse and dependence. • A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 89 patients were admitted in
84
•
2003. They were admitted at least once this year with amphetamine abuse or dependence diagnosed as primary or secondary problem. The average age was 30 years and 72 percent were male. Accidental amphetamine overdose was listed as secondary diagnosis (ICD-9 code E854.2) in 25 hospital admissions.
Figure 5.6 Clinical admissions in general hospitals for amphetamine abuse and dependence, from 1994
100
Number 80
80
69
70
66 61
63 58
60 46
40
33
30
29 29
20
24
33
29 25
23
36 29
21
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Amphetamines as primary diagnosis Amphetamines as secondary diagnosis The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.4, 305.7 (Appendix C). Ecstasy and amphetamine are recorded under the same codes. Source: National Medical Registration (LMR), Prismant.
The Amsterdam Area Health Authority (GG&GD Amsterdam) records the number of calls for emergency aid received by the Central Ambulance Service. • In 2003, calls for emergency aid were 39 times ecstasy-related, approximately the same as in the previous years. Exceptionally high was 1996, with 66 calls (see Table 5.5). • In 2003, twenty-five ecstasy users (64%) required transportation to hospitals. • The most common complaints in ecstasy-related incidents noted by the Amsterdam hospital Onze Lieve Vrouwengasthuis were heart palpitations and fainting, ‘feeling unwell’ and anxiety. Fainting 44 only occurred in people who had consumed ecstasy in combination with alcohol and/or GHB.
Table 5.5
Amphetamine- and ecstasy-related drug incidents recorded by the Amsterdam Area Health Authority (GG&GD Amsterdam), from 1995
Amphetamines Ecstasy
1995 6 38
1996 1 66
1997 7 41
1998 7 35
1999 7 43
2000 30 36
2001 6 42
2002 5 39
2003 7 39
Number of incidents (people) per year. Source: Central Ambulance Station (CPA), Amsterdam Area Health Authority (GG&GD Amsterdam).
According to Stichting Educare, an organisation that provides first aid at house parties in the Netherlands, the number of acute health problems as a result of drug use is relatively small and is 89 decreasing.
85
• • •
• •
From 1996 to 2002 incl., Stichting Educare provided care to 15,000 people in total at 134 parties. The number of visitors who sought assistance for health problems from the First Aid decreased from 1.2 to 0.8 percent in this period. In the course of years, amphetamines and ecstasy were increasingly less involved in these incidents and alcohol increasingly more. - The proportion of amphetamine-related incidents in all substances-related incidents decreased from 17 percent in 1996 to 2 percent in 2002. - For ecstasy, Stichting Educare recorded a decrease from 47 percent to 20 percent. - As distinct from this downward trend for drugs, an increase in alcohol-related health problems from 4 to 17 percent was recorded. In the case of both ecstasy and amphetamine users, mainly light complaints were reported, such as feeling unwell, headaches, nausea and dizziness. Recent observations by health workers who are active at parties confirm the downward trend of 20 ecstasy-related incidents.
5.7
ILLNESS AND MORTALITY
Illness The latest state of the art indicates that ecstasy use may cause long-term brain function disorders, in 90 particular of the memory, the capacity to concentrate and moods. • This disorder may continue for more than a year after discontinuation of the use. It is unknown whether full recovery is made. • These changes are probably connected with damage to serotonergic nerves in the brain, but the use of other substances in addition to ecstasy may also come into it. • In laboratory animals the chance of brain damage increases with an increase in body temperature after MDMA use. It is assumed that the same is true for human beings. • The chance of overheating, resulting in (long-term) brain damage increases, if a consumer takes larger quantities of MDMA in a warm environment (over 18-20 degrees). It is not known which quantity exactly results in damage. It is assumed that damage is already done in case of intake of highly dosed pills containing twice to three times the average dose. • Research at the University of Amsterdam will show in due course whether short-term use may also cause damage to and a decrease of brain functions.
Mortality The exact number of deaths caused as a result of amphetamine or ecstasy use is not known. • According to the Cause of Death Statistics of Statistics Netherlands (CBS), use of these substances is not often the primary cause of death. In the period 1996 - 2002, a maximum of four acute deaths annually were recorded. In 2003, Statistics Netherlands (CBS) recorded seven cases (ICD-10 codes F15, X41*, X61*, Y11* [* together with code T43.6]; for an explanation of the codes see Appendix C). These codes do not only include amphetamines and MDMA(-like) substances, but also other stimulants, such as caffeine, ephedrine and khat. • In 2002, the Amsterdam Area Health Authority (GG&GD Amsterdam) reported two deaths in which MDMA may have been involved. There is no national survey. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), ecstasy plays a minor part in drug-related deaths in other European countries as well, at least in so far as 37;18 information is available.
86
• •
• •
5.8
An exception seems to be the United Kingdom, where an increase in ecstasy-related deaths was 91 recorded from 12 cases in 1996 (from August) and 1997 to 72 cases in 2001 to April 2002. In the United Kingdom, from August 1996 to April 2002 incl., a total of 202 deaths were recorded that were allegedly ecstasy-related. In seventeen percent of the cases, only MDMA or an MDMAlike substance was found in a toxicological examination. In the other cases, other substances were also found, in particular opiates, alcohol, cocaine and amphetamine. Other factors that may have contributed to these deaths are overheating, water intoxication or an underlying decease. The increase between 1996 and 2002 may also have resulted from a changed registration practice. Autopsists are said to report ecstasy increasingly as possible cause of death.
SUPPLY AND THE MARKET
The Drugs Information and Monitoring System (DIMS) examines the substances in drug samples that are turned in to care organisations for addicts. Part of these samples (pills) is identified by the organisation itself on the basis of characteristics like logo, weight and diameter. Samples of unknown composition and all the samples in powder form are forwarded to the laboratory for chemical analysis. The number of samples that consumers hand to DIMS annually has strongly decreased since 1997. This is probably connected with the discontinuation of participation of the Safe House Campaign at parties (Drug Consultation Bureau - Stichting Adviesburo Drugs), the increased consumer confidence in the fairly stable composition of pills and a reduction of the number of pills that a user can have 89 tested each time.
Composition of ecstasy pills The number of pills sold as ecstasy that were recognised at test locations dropped from 4,320 in 1997 to 688 in 2003. The number of ‘ecstasy’ pills that were analysed in the laboratory remained fairly stable. Table 5.6 shows the percentage of the analysed pills containing MDMA and or another substance. • In the last few years, the proportion of pills containing only MDMA or a MDMA-like substance increased strongly, whereas the proportion of pills containing (also) another psychoactive substance, such as amphetamine, decreased. • In 2003, over 95 percent of the 'ecstasy’ pills actually contained MDMA, MDEA or MDA, or a combination of these substances. • In that year, the average concentration of MDMA in ecstasy pills was 78 mg, approximately the same as in the previous years. Figure 5.7 shows, however, that the proportion of ecstasy pills with a high quantity of MDMA (more than 140 mg) rose slightly from one percent in 1997 and 1998 to six percent in 2003. The highest measured quantity in 2003 was 215 mg.
87
Table 5.6
Number and composition of (ecstasy) pills handed to the Drugs Information and Monitoring System (DIMS), from 1997
Substances (% of pills) MDMA MDEA MDA Combination of MDMA, MDA and or MDMA Combination of MDMA, MDA and or another I psychoactive substance Pills without MDMA, MDEA and or MDA: II Amphetamine Methamphetamine I Another psychoactive substance No psychoactive substance Total number of analysed pills
1997 44.6% 8.2% 1.5% 2.6% 9.0%
1998 75.2% 1.3% 2.2% 1.6% 4.3%
1999 82.0% 1.4% 2.8% 1.0% 3.3%
2000 89.5% 0.9% 2.0% 3.0% 1.2%
2001 91.4% 1.2% 0.7% 3.0% 0.9%
2002 88.7% 0.4% 1.4% 1.7% 3.7%
2003 91.2% 0.5% 0.9% 2.1% 2.1%
15.5%
6.5%
3.9%
0.9%
1.0%
14.7% 3.9% 2,434
4.5% 4.3% 2,713
2.7% 2.9% 2,306
1.6% 0.8% 2,497
1.2% 0.5% 2,402
1.7% 0.3% 1.3% 0.8% 2,149
1.0% 0.3% 0.7% 0.8% 2,187
Percentage of pills that contain a specific substance or combination of substances. Categories are mutually exclusive. I. E.g. 2-CB, MBDM, DOB, PMA, caffeine, ephedrine etc. II. Until 2002 no distinction was made between amphetamine and methamphetamine. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Figure 5.7
Concentration of MDMA in ‘ecstasy’ pills handed to DIMS
100% 80% 60% 40% 20% 0%
1997
1998
1999
2000
2001
2002
2003
>140 mg
1
1
1
2
4
4
6
106-140 mg
6
5
6
9
14
11
12
71-105 mg
36
27
29
35
49
42
38
36-70 mg
39
53
52
45
28
39
38
1- 35 mg
17
15
11
9
5
5
7
Percentage of pills with a certain quantity of MDMA. It relates to pills that were tested in the laboratory and contain at least 1 mg MDMA. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Other substances Table 5.7 shows the number of samples (ecstasy pills, powders or otherwise) found by DIMS to contain substances that are continuously examined in a European framework and or may be a danger to public health.
88
• •
• •
b
Most of the substances in Table 5.7 had virtually disappeared from the market by 2003 . The presence of pills containing atropine and DOB led to health warning campaigns in 1997/1998 and 1999. In 2000, a health warning campaign was launched in response to pills with harmful levels of strychnine. Another campaign was launched in 2001, after a pill with dangerous levels of PMA was found (over 50 milligrams). The former anaesthetic agent GHB is also regularly handed to DIMS. In 2001 it concerned 102 samples (usually liquids) and, in 2002 and 2003, 72 samples were involved annually. In the last few years, GHB has become popular in certain circles. Meanwhile the use seems to have stabilised and in Amsterdam there are indications that the interest in this substance is decreasing 18;20 again.
Table 5.7 2C-B 4-MTA Atropine DOB Ketamine MBDB I PMA/(PMMA) Strychnine
Number of samples with other psychoactive substances 1997 317 9 128 1 0 113
1998 12 16 52 15 16 12
1999 25 8 0 26 1 0
2000 12 6 1 5 2 0 1 1
2001 11 1 0 5 1 0 8 0
2002 2 5 0 0 2 0 0 0
2003 2 0 0 0 3 0 0 0
I. Pills containing more than 1 milligram. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Composition of (meth)amphetamine samples DIMS receives also samples (mainly powders) that were sold as ‘speed’. In 2003, it involved 393 samples. • Most of them (85%) contained (also) amphetamine; three percent contained both amphetamine and methamphetamine and three percent contained only methamphetamine. Methamphetamine is stronger and has a more prolonged effect than amphetamine. • The average percentage of amphetamine was 33 (by weight). • The proportion of samples in which caffeine was found rose from 32 percent in 2002 to 54 percent in 2003.
Prices The prices paid by consumers for ecstasy and amphetamine are not systematically recorded. Trends in prices can therefore not be reported. Recent figures from the Antenne Monitor and the Drugs Information and Monitoring System (DIMS) project, however, give an indication of the current situation. • In 2003, young clubbers in Amsterdam paid over three euros on average per pill when buying 18 several pills in one time from a house dealer. Per single pill the price was somewhat higher: 4.25 euros on average. Dealers in the clubbing circuit demand higher prices: 5.52 euros on average per pill when buying one.
b
End 2004 cocaine samples were found to have been mixed with harmful quantities of atropine. In the Netherlands a warning campaign was started after people had been hospitalised in various places - also in Italy, Belgium and France - with cocaine/atropine intoxication.
89
•
Consumers who had pills tested by DIMS paid in 2003 between 1 and 7.5 euros per pill with an average of 3.50 euros.
90
6
ALCOHOL
Alcohol is produced through the yeasting of grains and grapes. Alcohol is drunk as beer, wine or distilled spirits. A glass of beer, a glass of wine and a glass of distilled spirits contain each approximately the same amount of alcohol. In social situations, consumers experience alcohol as having a relaxing effect and promoting a good mood. In less social situations, alcohol may increase an aggressive mood. Alcohol is an addictive substance. Regular use results in habituation and tolerance. Excessive use of alcohol may lead to several diseases, in particular liver diseases, cardiovascular diseases and cancer.
6.1
LATEST FACTS AND TRENDS
The main facts and trends regarding alcohol in this chapter are: • Sales figures indicate that the per capita consumption of alcohol dropped slightly in 2003. This drop can be attributed to the drop in the consumption of distilled spirits (see Chapter 6.2). • Alcohol use among pupils increased between 1999 and 2003, particularly among young girls aged between 12 and 14. • Compared to pupils in other countries, Dutch pupils are frequent drinkers. (See chapter 6.5). • In spite of a legal ban, it is relatively easy for young people under the age of 16 to purchase alcoholic beverages, particularly in hotel and catering establishments, supermarkets and groceries but also in off licences (see Chapter 6.3). • Heavy drinking is proportionally more prevalent among male adolescents aged 18 to 24 incl. Adolescent males relatively often are involved in traffic accidents, in which alcohol is a contributing factor or the cause (see Chapter 6.4). • Ten percent of the Dutch population aged 16 to 69 are problem drinkers. • Between 2001 and 2003, the number of recorded admissions in the (outpatient) care organisations for addicts for alcohol problems increased (see Chapter 6.6). • The number of traffic-related fatalities and injuries caused by alcohol use fell slightly in the last few years (see Chapter 6.6). • Total mortality due to alcohol-related disorders (primary and secondary causes of death together) increased slightly between 2001 and 2003 (see Chapter 6.7). • Excessive alcohol consumption is the main determinant of loss of quality of life (see Chapter 6.7).
6.2
USE: GENERAL POPULATION
Alcohol consumption is widespread in Dutch society. • According to a Statistics Netherlands (CBS) survey of 2003, 85 percent of the population aged 16 and over has ‘the occasional drink’. This represents an increase compared to the middle of the nineties, when only 79 percent of the population consumed alcohol. In the last few years, 92 however, this percentage has been fairly stable. • National Prevalence Surveys (see Appendix B) confirm the use of alcohol in all segments of Dutch 10 society. - In 2001, 92 percent of the Dutch population aged 12 and over had ever used alcohol and 75 percent had used alcohol recently (in the last month). 20 percent of the recent consumers drank (almost) daily. - In 1997, 90 percent had ever consumed alcohol and 73 percent had used alcohol recently. 24 percent of the recent consumers drank alcohol every day.
91
•
a
Research conducted in The Hague (2001) and Amsterdam (1999/2000) suggests that alcohol use b 93;94
is considerably lower among Moroccan and Turkish people than among native Dutchmen. - The percentage of alcohol consumers among Moroccan and Turkish men was between 6 and 12 and between 23 and 28 percent respectively. The percentage of men of Dutch descent was between 82 and 88 percent in both cities. - The percentage of alcohol consumers among Moroccan and Turkish women was between zero and two percent and between two and eleven percent respectively. Among women of Dutch descent this was 70 to 71 percent. Sales figures give an indication of the annual per capita alcohol consumption (see Table 6.1). • Alcohol consumption in the Netherlands was highest in the second half of the seventies and in the eighties. This was followed by a slight decline, which trend discontinued from the early nineties. However, from 2001 a slight decrease in alcohol consumption is apparent. • In 2003, the per capita consumption was 7.9 litre of pure alcohol. This was 0.1 litre less than in 2002. • This drop can be attributed to the drop in the consumption of distilled spirits. This dropped in 2003 by nearly ten percent compared to the previous year. This may be connected with the increase in excise duty on distilled spirits per 1 January 2003 (see Chapter 6.8). • The sale of premixes decreased in 2003 to over 200,000 hectolitres, a drop of one third compared to 2002. • Per person the Dutch drank 79 litres of beer, 20 litres of wine and 4 litres of distilled spirits.
Table 6.1 Year 1960 1965 1970 1975 1980 1985 1990 1995 2000 2001 2002 2003
Beer, wine and distilled spirits per capita (in litres of pure alcohol), from 1960 Beer 1.2 1.9 2.9 4.0 4.8 4.2 4.1 4.1 4.1 4.0 4.0 4.0
Wine 0.2 0.5 0.8 1.5 1.4 2.0 1.9 2.2 2.3 2.3 2.3 2.4
Distilled spirits 1.1 1.9 2.0 3.4 2.7 2.2 2.0 1.7 1.7 1.7 1.7 1.5
Source: Commodity Board for Distilled Spirits (PGD) 2002; Commodity Board for Wine.
Total 2.6 4.2 5.7 8.9 8.9 8.5 8.1 8.0 8.2 8.1 8.0 7.9
95;96
a
The Amsterdam figures only refer to Moroccan and Turkish persons aged 35 and over. Because of the absence of an adequate number of younger respondents, reliable figures could not be presented. The percentages of alcohol consumers most likely are higher among the younger Moroccan and Turkish persons. b For the definition of ethnic backgrounds, the Amsterdam Area Health Authority (GG&GD Amsterdam) follows the definition of the Ministry of the Interior / Association of Dutch Municipalities (VNG): see Appendix A.
92
Special groups •
•
6.3
In 2002, over one-third (35%) of the homeless in twenty Dutch municipalities were risk drinkers (defined here as consuming more than 25 glasses per week); 23 percent drank more than 56 11 glasses per week and 13 percent drank more than 112 glasses per week. Approximately 4 percent of the drinking working labour force drinks alcohol sometimes just before 97 or during work: one percent does this at least once a week. - 38 percent consume sometimes alcohol immediately after work and 12 percent do this weekly. In the hotel and catering business the proportion of those drinking immediately after work is highest (31% weekly), in health care and public welfare work and in public administration this 97 is lowest (5% and 4% weekly).
USE: YOUNG PEOPLE
For the classification of alcohol consumption among pupils aged twelve and over, figures are available from the National Representative School Survey (see Appendix B). In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F an overview is given of recent figures concerning the use of alcohol among young people in 29 municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of difference in alcohol use between the various municipalities. In this paragraph we shall also present the data from (often local) surveys among special groups of young people.
Pupils Since the mid-eighties the Trimbos Institute has monitored the extent to which secondary school pupils aged 12 and over have experience with alcohol, tobacco, drugs and gambling. This is done in, what is called, the Dutch National School Survey. • In 2003, 85 percent of the pupils of ‘regular’ secondary schools had experience with alcohol. That was more than in 1999, when still 74 percent had experience with alcohol. However, this 16 percentage fluctuated over the past fifteen years (see Figure 6.1). • In 2003, 58 percent of all interviewed pupils had consumed alcohol in the month prior to the survey, about the same as in 1999. • Among young girls aged 12 to 14 incl. in particular, an increase in ever and previous month use was apparent compared to 1999. - In 1999, 57 percent of the girls aged 12-14 had ever drunk alcohol, in 2003 this had risen to 78 percent. - In 1999, 32 percent had used alcohol in the last month, in 2003 this was 44 percent. • Fifteen percent of the pupils reported they consumed their first alcoholic drink at age 10 or younger, nearly twice as many boys (19%) as girls (10%). Most pupils start drinking between the age of 11 and 14.
93
Figure 6.1
Alcohol consumption among pupils aged 12 and over, from 1988 90
% 85
80
79
79 74
70 69 60
58 54
54
55
50 45
Ever
Current
1999
2003
40 1988
1992
1996
The percentage of consumers who ever used alcohol (in their lifetime) and in the month before the survey 16 (recent). Source: Dutch National School Survey, Trimbos Institute.
•
• •
In 2003 the percentages of boys and girls who ever or currently consumed alcohol did not differ. There are differences, however, in drinking patterns. Boys drink alcohol more frequently than girls. They also drink larger quantities than girls. All this concerns in particular older boys: - Of the boys aged 16 who drank in the past month, 29 percent did this more then ten times in that month compared to 19 percent of the girls. - Also 29 percent of these drinking boys aged 16 drink more than ten glasses on average on a weekend day. For the girls this is 9 percent. In 2003, nearly half the pupils (47%) aged 12 had already once drunk an alcoholic drink, while those aged 15 consumed alcohol weekly (52%). Among pupils of Moroccan descent (aged 12-16) current alcohol consumption is significantly lower c
•
than among pupils of Dutch descent (8% versus 63%). Pupils of Turkish or Surinam descent take 16 an intermediate position, with 15% and 47% respectively. However, there is no difference 98 between ethnic groups with respect to the quantity that is consumed per occasion. Alcohol use is often combined with smoking cigarettes. In 1999, one quarter (26%) of all the pupils (12-16 years) had smoked cigarettes in the past month. Among drinking pupils this was 42 99 percent. 16
Among secondary school pupils, beer and breezers/premixes are most popular. • Among boys, beer is the most popular drink: of the boys who used alcohol in the past month, 42 percent report they drink beer weekly. • Among girls breezers are most popular: of the girls who had used alcohol in the past month, 30 percent drink breezers weekly.
Special groups of young people In certain groups of young people and adolescents alcohol use is widespread.
c
For the definition of ethnic background: see Appendix A.
94
•
•
• • •
University or college students drink more alcohol than other young people. In 1999, these students consumed an average of 16 glasses per week (men 20 and women 8 glasses). Members of student’s associations averaged 23 glasses per week (men 27 and women 12 glasses). Young people of comparable ages consumed an average of 10 glasses per week (men 13 and women 7 glasses)0.100 Holiday periods in particular are times in which much alcohol is consumed. A survey at youth camp sites (average age 17.4) shows that more than 80 percent of the boys and nearly half the girls use alcohol every day of the holiday. Boys drink daily seventeen glasses and girls seven on 101 average. Young people in a truancy program in Amsterdam are more often current drinkers (over 50%) than 18 their peers who do not play truant but go to school (40%). A survey in five municipalities in the Netherlands (Amsterdam, Breda, Hilversum, Tilburg and 22 Zaanstad) shows that one in ten young homeless drinks alcohol daily. Young people at ZMOK schools (special education for children with severe behavioural learning problems) do not differ significantly in respect of frequency and intensity of alcohol use from young people in regular education. When only young people of Dutch descent are compared, however, 102 young people at ZMOK schools drink more frequently and in larger quantities.
Many young people drink when they go out. Table 6.2 summarises the results of a number of surveys among young clubbers. The figures in this table are not comparable due to differences in age categories and research methods. • In 2003, one fifth of the young clubbers aged 13 consumed alcoholic drinks when going out on the town, two thirds of those aged 14 and 15 and nine in ten of those aged 16 and 17. These 103 percentages are lower for those aged 13 up to 15 incl. than in 2001. • Nine in ten young people in The Hague (aged 15-35) who visit clubs and pubs consumed alcohol 21 in the past month and six in ten in the past week. • Among fans of Hiphop/Rap/+R&B, alcohol consumption is lower than among fans of Pop/Rock or Dance/House/Techno. This may be connected with the preference of Moroccan young people for 21 this type of music. Alcohol use is less common among Moroccans • In Amsterdam, one third of both pub visitors, coffee shop visitors and the visitors of trendy clubs 17;18;104 drink alcohol daily or at least four or five glasses several times a week.
95
Table 6.2
Alcohol consumption among young clubbers
Population Young clubbers general
Location Nationwide
I
Survey year 2003
Measurement for alcohol consumption in the past year
2001
Young clubbers general
The Hague
II
2003
Hiphop/Rap/R&B Pop/Rock Dance/House/Techno Pub visitors
The Hague
II
2003
Amsterdam
III
2000
Coffee shop visitors
Amsterdam
IV
2001
Visitors of trendy clubs
Amsterdam
V
2003
in the past month in the past week in the past month
at least four or five glasses daily or several times a week at least four or five glasses daily or several times a week at least four or five glasses daily or several times a week
Age (year) 13 14-15 16-17 13 14-15 16-17 15-35 15-35
25 years on average
Percentage 18 64 89 39 74 91 88 60 75 88 92 33
25 years on average
30
28 years on average
33
The figures in this table cannot be compared with one another because of differences in age groups and research 103 21 104 methods. I. Source: Intraval. II. Source: Survey of clubbers in The Hague. III. Source: Antenne. . IV. Source: 17 18 Antenne. V. Source: Antenne.
6.4
PROBLEM USE
The scope of the alcohol problem depends on the applied definition. Research sometimes differentiates between heavy drinking, problem drinking, irresponsible drinking and alcohol dependence or alcohol abuse.
Heavy drinking Statistics Netherlands (CBS) defines heavy drinking as consuming at least six glasses of alcohol on one or more days per week. • According to this definition, eleven percent of the population aged 12 and over consisted of heavy drinkers in 2003. This is the same percentage as ten years ago. Since 2001, however, the percentage of heavy drinkers has slightly decreased (see Figure 6.2). • In 2003, four times more men than women were heavy drinkers. • Young people aged 18–24 lead in the measurement heavy drinking. In 2003, the percentage of heavy drinkers among adolescent men and women was 39% and 12% respectively (see Table 6.3). • This is slightly lower than in 2002. Then 42 percent of the young adolescent men and 18 percent of the adolescent women appeared to be heavy drinkers.
96
Figure 6.2
Percentage of heavy drinkers of alcohol among people aged 12 and over, from 2000 16 14
14 13 12
12
11
10 8 6 4 2 0 2000
2001
2002
2003
Source: Permanent Survey on Living Conditions (POLS), Statistics Netherlands (CBS).
Table 6.3
Heavy drinkers among people aged 12 and over by gender and age. Survey year 2003
12-17 years 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 years and over Total: 12 years and over
Men 6% 39% 25% 16% 24% 14% 7% 4% 19%
Women 6% 12% 4% 4% 3% 4% 1% 0% 4%
Total 6% 25% 14% 10% 14% 9% 4% 2% 11%
The percentage of people consuming six or more glasses of alcohol on one or more days per week. Source: Permanent Survey on Living Conditions (POLS), Statistics Netherlands (CBS).
Problem drinking Problem drinkers are people whose alcohol consumption exceeds a certain threshold value, and who report all kinds of effects of alcohol consumption. • Ten percent of the Dutch population aged 16 to 69 are problem drinkers, more men (17%) than women (4%).
Alcohol abuse and alcohol dependence •
According to dated data from the 1996 Netherlands Mental Health Survey and Incidence Study (Nemesis), eight percent of the Dutch population aged 18–64 met the diagnostic criteria for alcohol dependence or alcohol abuse (alcohol abuse 4.6% and alcohol dependence 3.7%). In
97
•
6.5
absolute numbers, 820,000 people annually were involved, approximately 4.5 times more men 28 than women. Alcohol abuse and dependence is most found among young men aged between 18 and 25; in 1996, eighteen percent met the criteria for alcohol abuse and thirteen percent met the criteria for alcohol dependence.8
USE: INTERNATIONAL COMPARISONS
General population •
•
In 2002, alcohol consumption in Western Europe varied from 4.9 to 11.9 litre per capita (see Figure 6.3). Compared with the other Western European countries, the Netherlands seems to take a low middle position. Per capita alcohol consumption here is determined on the basis of alcohol sales figures. There are considerable differences between individual countries as regards ‘unrecorded’ consumption, such as private import, ‘duty-free’ purchases, and homebrewn alcohol products. Consequently, the 105 figures cannot be compared completely.
Figure 6.3
Alcohol consumption levels in a number of EU Member States, measured per capita and in litres of pure alcohol. Survey year 2002
Luxembourg
11.9 10.8
Ireland Germany
10.4
France
10.3
Portugal
9.7
Spain
9.6 9.6
United Kingdom Denmark
9.5 9.2
Austria The Netherlands
8
Belgium
7.9 7.8
Greece Finland
7.7
Italy
7.4
Sweden
4.9
0
2
4
6
8
10
12
14
16
Source: Commodity Board for Distilled Spirits (PGD), Spirits Committee.
98
Young people The European School Survey Project on Alcohol and Other Drugs (ESPAD) carried out among pupils 43 aged 15–16 included questions about the level of alcohol use and the frequency of intoxication. • Table 6.4 portrays the consumption of alcohol in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in ESPAD, but conducted comparable research. • In 2003, the Netherlands was in the top section of the list in the measurement 'consumed alcohol forty times or more ever in life’. • The Netherlands had a leading position in the measurement 'consumed alcohol at least ten times in the month prior to the survey'. • Dutch figures on pupils were significantly lower in the measurement ‘intoxication’. Approximately one in eight pupils reported having been drunk at least twenty times ever in life. • Between 1999 and 2003, the percentage of pupils who had consumed alcohol 10 times or more increased in the Netherlands and Italy. This percentage decreased in Denmark. • Twenty times or more drunkenness ever in life only decreased in Denmark in 2003, whereas it remained stable in the other countries.
Table 6.4
Alcohol consumption and drunkenness among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey year 2003
Country
Denmark Austria The Netherlands United Kingdom Ireland Germany Belgium Greece Italy France Finland Sweden Norway Portugal United States
Consumption: 40 Consumption: 10 Drunkenness: 20 times or more in times or more in times or more in life the last month life 1999 2003 1999 2003 1999 2003 59% 50% 18% 13% 41% 36% 48% 21% 21% 37% 45% 20% 25% 8% 6% 47% 43% 16% 17% 29% 27% 40% 39% 16% 16% 25% 30% 37% 11% 12% 36% 20% 7% 42% 35% 13% 13% 4% 3% 17% 24% 7% 12% 2% 5% 20% 22% 8% 7% 4% 3% 20% 20% 1% 2% 28% 26% 19% 17% 2% 1% 19% 17% 16% 15% 3% 3% 16% 14% 15% 14% 6% 7% 4% 3% 16% 12% 5% 4% 11% 7%
Percentage of the pupils. - = not measured. The United States did not participate in the European School Survey Project on Alcohol and Other Drugs (ESPAD), but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
99
6.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) In 2003, 26,874 persons were registered at the (outpatient) care organisations for drug addicts with alcohol use as 106 primary problem. This is an estimated three percent of all the people showing alcohol abuse or alcohol dependence. • The absolute number of clients with a primary alcohol problem in the (outpatient) care organisations for drug addicts increased between 1994 and 1999 by twelve percent and stabilised in 2000 and 2001. After 2001, however, an increase is apparent (see Figure 6.4). In 2002, the number increased by seven percent and in 2003 by thirteen percent compared to 2001 and 2002, respectively. This increase may be the effect of the Alcohol Action Plan of the care organisations 107 for drug addicts of the Mental Health Service (GGZ Netherlands). • Characteristics of these clients in 2003 were: Most of them were men (75%). The percentage of women increased slightly in the last few years. The average age was 44. Two thirds of the alcohol clients were aged forty or over. This made the alcohol clients older than the drugs clients (see Figure 6.5). - A quarter of the registered clients in 2003 were newcomers, i.e. they had not been registered before for an alcohol-related problem at the (outpatient) care organisations for drug addicts. - Only ten percent were immigrants (for the definition see Appendix A). • Alcohol was indicated less often as a secondary problem. - For this group the primary problem was cocaine (43%), heroin (23%), or cannabis (17%). - The number of secondary alcohol clients has risen since 1997. In 2003, the number of secondary alcohol clients increased by twelve percent compared to the year 2002. • When comparing the period 2000-2003 to the period 1996-1999, an increase of the number of alcohol clients is apparent in Brabant, Limburg and the northern half of the Netherlands. The other regions show a decrease.
Figure 6.4
Number of clients in the (outpatient) care organisations for addicts for primary or secondary alcohol problems, from 1994
30000 25000 20000 15000 10000 5000 0 Primary
1994 1995
1996 1997 1998
1999 2000 2001 2002
2003
20085 20175 20939 21134 22378 22554 22365 22388 23849 26874
Secundary 2441 2473
2465 2622 2718
2847 3007 3945 4121
4631
Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
100
Figure 6.5
20
Age categories of primary alcohol clients in the (outpatient) care organisations for addicts. Survey year 2003
% 17 16 14
15
13 10
10
10 6 5 4
5
4
1 0 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64
>64
age (years) Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Self-help via internet On 23 November 2004, on www.MinderDrinken.nl a self-help site started for adult problem drinkers (18+) who wish to lower their alcohol consumption independently. In two weeks’ time, 11,000 unique visitors visited the site. Of those, 2,150 registered for the self-help program and 1,230 persons 108 effectively started using the interactive self-help module.
Inpatient care organisations for addicts There are no recent nationwide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • In 1996, the Register of Inpatient Mental Health Care (PiGGz) recorded nearly 6,200 admissions for problematic alcohol use, approximately the same order of magnitude as in the previous four years. • Alcohol dependence was diagnosed as the primary problem in over eight of ten admissions. Ten percent of the admissions occurred as a result of alcohol abuse and six percent because of alcohol psychosis, including Korsakov’s syndrome. • Treatment in which patients participate in inpatient programs of a hospital/clinic as outpatients (partial admissions) was limited, yet did increase until 1996.
101
General hospitals and incidents •
The number of clinical admissions in general hospitals with an alcohol-related disorder as primary diagnosis rose slightly between 1994 and 2003 (see Figure 6.6).
•
In 2003, 4,239 admissions took place with an alcohol-related disorder as primary diagnosis. The most common diagnoses related to: - alcoholic-related liver disease (29%, 1,245 admissions) - alcohol abuse (27%, 1,151 admissions) - alcohol dependence (17%, 719 admissions) - alcohol poisoning and toxic consequences of alcohol (14%, 610 admissions) - alcohol psychoses (10%, 412 admissions) Alcohol-related problems are more often diagnosed as a secondary problem. Between 1994 and 2003 the number of times that alcohol figured in secondary diagnoses rose (see Figure 6.6). In 2003, 10,899 alcohol-related problems were diagnosed as a secondary problem. In order of prevalence it concerned alcohol abuse (44%), alcohol dependence (23%), alcohol-related liver disease (14%), alcohol poisoning and toxic consequence of alcohol (9%) and alcohol psychoses (7%). The primary problems diagnosed for these secondary problems were: - accidents (other than poisonings, 26%) - digestive disorders (17%) - poisoning (15%) - heart and vascular diseases (7%) - respiratory illnesses and symptoms (5%) - psychoses (4%) A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 11,255 patients were admitted in 2003. They were admitted at least once that year with one (or more) alcohol-related problem(s) as primary or secondary diagnosis. The average age of these patients was 47 years, and 70 percent were men. It is probable that these figures are an underestimation, as hospitals quite often fail to recognise and record the role of alcohol as cause or the particular illness.
• •
•
•
•
d
d
In 2003, 415 day-treatment admissions for a primary alcohol diagnosis were also recorded.
102
Figure 6.6
Clinical admissions in general hospitals with an alcohol-related problem, from 1994 12000 10000 8000 6000 4000 2000 0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
3378
3531
3406
4011
4076
4079
3923
3880
4254
4239
Alcohol as secondary 7867 diagnosis
8677
8513
9973
9822
9652 10116 9949 10291 10899
Alcohol as primary diagnosis
Number of admissions, not adjusted for double counting of persons. ICD-9 codes: 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-3, 980.0-1, E860.0-2, E950.0*, E980.9* (*only included if 980.0-1 has been mentioned as complication.). For a definition of the codes: see Appendix C. The figures refer to alcohol-related secondary diagnoses. More than one secondary diagnosis per admission can be made. Source: National Medical Registration (LMR), Prismant.
The Central Ambulance Service of the Amsterdam Area Health Authority (GG&GD Amsterdam) keeps a record of the number of alcohol-related emergency calls. • In 2003, the ambulance services in Amsterdam recorded 1,733 alcohol-related trips, a decrease of 109 nine percent compared to 2002. - This was seven percent of all the urgent calls in Amsterdam. - Most of the persons were men (71%). - Over half the trips (54%) was for persons aged between 15 and 44. - Approximately half the patients (49%) were transported to a hospital emergency ward. In the other 51 percent of the cases, the ambulance staff gave first aid on the spot. e
According to the Injuries Information System (LIS) of Consumer and Safety , approximately 13,000 people receive emergency treatment in a hospital annually for injuries sustained in an accident, or as 110 a result of violence or self-harm involving alcohol (see Table 6.5). • Of the recorded victims 74 percent were men. • Ten percent were aged between 15 and 19 (which means 1,300 children annually), 27 percent were in the age group 20-29 and 41 percent were in the age group 30-49. Most of the treatments are in the age category 20-24 (15%). • Half the accidents occur in the private sphere, such as falling down under the influence of alcohol or due to alcohol poisoning. Traffic accidents account for the second largest number of injuries (particularly bicycle crashes). Next is self-harm, often involving a combination of alcohol with drugs and/or medicines (see Table 6.5). e
These figures are estimates for the entire country, based on data from a representative sample of hospitals.
103
• • • • •
Many victims sustain head injuries (40%). Other conditions requiring treatment are alcohol poisoning (26%), and shoulder, arm, or hand injuries (17%). Nearly one in three victims was hospitalised (32%). This is a higher percentage than that for all types of accidents combined (8%). Annually, approximately 40 victims die who received emergency aid for an alcohol-related accident. The direct costs of accidents involving alcohol amount to 22 million euros annually on average. These figures probably are an underestimation of the real number of alcohol-related accidents.
Table 6.5
Types of alcohol-related accidents treated in hospital emergency wards in the Netherlands (average figures over the years 1999 -2003)
Type of accident Private accident Traffic accident I Self-harm Act of violence Total
Number 6 400 3 100 2 200 800 ±13 000
Percentage 51 24 18 6 100
I. Such as suicide attempts with alcohol and licit drugs. Source: Injuries Information System of Consumer and Safety (LIS).
The LIS data show that annually approximately 1,300 children receive emergency aid after an accident involving alcohol. At the Leiden University Medical Center (LUMC) and at three hospitals in The Hague, all the patients were selected who, in the period 1999-2001, were younger than seventeen and who had been examined because of a blood alcohol concentration of at least 1.00 111 promille. • It concerned in total 88 children, 58 boys and 30 girls, with an average age of 15.4. • In 2001 it concerned 51 children. This number was higher than in previous years (19 and 18 in 1999 and 2000, respectively). In 2003, the Institute for Road Safety Research (SWOV) counted nearly 2,700 recorded casualties, f
both the hospitalised injured and outpatients, in which alcohol was involved (see Table 6.6). • The total number of alcohol victims in traffic has fallen slightly from 1997 onwards, both as regards fatalities and injuries (see Table 6.6). • In 2002, over eight in ten of the seriously injured (hospitalised) or dead were men. Nearly a quarter (23%) of these victims were men aged 18 to 24 incl.
Table 6.6
Number of traffic injuries and deaths as a result of alcohol use, from 1996
Severity of injury Death I Hospital II Emergency first aid III Lightly injured Total
1996
1997
1998
1999
2000
2001
2002
2003
97 1 204 1 048 1 064 3 413
103 1 188 1 012 1 106 3 409
83 1 154 962 1 127 3 326
92 1 166 939 1 152 3 349
87 1 129 911 1 113 3 240
72 1 036 876 1 000 2 984
97 1 096 702 945 2 840
71 1 028 596 992 2 687
I. Hospitalisations. II. Transported to a hospital, but received emergency help only. III. Not transported to a hospital. Source: Institute for Road Safety Research (SWOV) / Transport Research Centre (AVV).
•
f
The figures in Table 6.6 are an underestimation of the real figures, because not near enough all traffic accidents are recorded. In addition, the police often does not carry out alcohol breathalyser Figures overlap partly with those of the Injury Information System (LIS), Consumer and Safety.
104
•
•
tests when accidents have occurred. The Institute for Road Safety Research (SWOV) estimates that the actual number is nearly three times higher, caused by DUI. Provisional figures of the SWOV show that of all injured drivers who are hospitalised 35% had used alcohol and/or drugs: 13 percent consumed alcohol, 11 percent used several drugs and 11 112 percent of the drivers were found to have used a mix of alcohol and drugs. The percentage of DUI drivers decreased in 2003. Alcohol tests showed that 3.9 percent of the checked drivers had a blood alcohol level of over 0.5 promille. In 2002, this percentage was still 4.3. The largest proportion of offenders is found among those aged 25 and over. Noticeable is the decrease for men aged 18-24: from 4.1 percent in 2002 to 3.5 percent in 2003. However, women 113 aged 18-24 showed a slight increase compared to 2002 (from 0.5% to 0.8%).
The National Vaccine Information Centre (NVIC) of the RIVM provides information to physicians and 114 care providers about poisoning. • In 2003, approximately 1,700 requests for information were made in respect of alcohol intoxication, mostly through alcoholic drinks. • In most of the cases adults aged 18 to 65 incl. were involved. • In 76% of the cases it concerned a combination of alcohol with medicines, often intentional autointoxication. • The number of requests for information about alcohol intoxications in young people aged 13 to 17 incl. increased by 63%, from 57 requests in 2002 to 93 in 2003. Alcohol intoxications in young 111 people are usually the result of drinking distilled spirits with friends.
6.7
ILLNESS AND MORTALITY
Illness One to two units of alcohol per day for women and two to three units per day for men usually do not 115-118 present a risk for one’s health. • Moderate alcohol consumers are less likely to contract coronary heart disease than complete abstainers or heavy drinkers. This may be linked with an increase in the 'healthy' cholesterol type HDL-C (high density lipoprotein cholesterol). • Moderate alcohol consumers also are less likely to suffer a cerebral infarct. Among people aged over 55, moderate alcohol consumption may reduce the risk of dementia due to blood circulation in the brain. • There are indications that premature deaths are less likely to occur among light to moderate alcohol users than among abstainers or heavy drinkers. Moreover, moderate alcohol users feel 119 healthier. 115;116;120
However, the harmful consequences of excessive alcohol use are plentiful. • Life style factors may lead to a considerable number of years spent without good health, resulting in loss of quality of life. Excessive alcohol consumption is the main determinant of loss of quality of 121 life. • Nearly 12.5 percent of the burden of disease for men and 2.3 percent of the burden of disease for women may be blamed on excessive use of alcohol. 120
Excessive alcohol consumption increases the risk of various forms of cancer. • The consumption of two or more glasses of alcohol a day increases the risk of oral and throat cancer and a specific type of cancer of the oesophagus. The combination of drinking and smoking increases this risk.
105
• • •
There are very clear indications that the consumption of alcohol leads to a slight increase in the risk of breast cancer, i.e. 7 to 9 percent with each glass of alcohol per day. There are clear indications for an increase in the risk of intestinal cancer, but only in case of consumption of three or more glasses a day. There are also clear indications that alcohol consumption increases the risk, but only after cirrhosis of the liver had already been caused.
Excessive alcohol consumption also increases the risk of cardiovascular diseases and damage to the 115;116 brain and the nerves. • Daily alcohol consumption of five glasses or more increases the risk of damaging the coronary arteries. • The consumption of more than two glasses daily also increases the risk of strokes or cerebral infarctions. This only applies to so-called ‘hemorrhagic’ cerebral infarctions. • Prolonged and excessive alcohol use (more than eight units per day) may cause polyneuropathy (damage to motor nerves, sensory nerves or both), brain shrinkage, and damage cognitive functions (learning, memory, concentration and so forth). • Binge drinking, i.e. consuming large amounts of alcohol in a short period, increases the risk of heart and vascular diseases, acute kidney failure and brain damage.
Mortality The number of alcohol-related deaths has increased slightly over the past years. • According to the Cause of Death Statistics of Statistics Netherlands (CBS), nearly 1,900 people died in 2003 from causes in which alcohol was explicitly stated, over forty percent more than in 1995 (see Figure 6.6). • Between 2001 and 2003, the number of deaths for which alcohol was stated as primary cause of death decreased somewhat and the number of deaths for which alcohol was stated as secondary cause of death increased slightly. In total the number of cases increased by 5 percent in this period. • Dependency and other mental disorders due to the use of alcohol were the leading causes of death: 61 percent, followed by alcohol-related liver diseases, 33 percent. • The highest number of deaths as a result of the use of alcohol occurred in the age group 50-65 (see Figure 6.8). Most of the deceased were men (75% on average). • Alcohol use as a contributing factor to the death is not always recognised. Consequently, these figures do not reflect reality entirely. • Based on epidemiological research, for example, 4 to 6 percent of cancer-related deaths is estimated to be connected with chronically excessive alcohol consumption. This would mean that there were between 1,500 and 2,300 alcohol-related deaths associated with cancer in 2002, 122;123 instead of the 150 cases recorded. • In 2003, 71 traffic deaths involving alcohol were recorded (see Table 6.6). However, the real number of alcohol-related traffic deaths is estimated at 250. • Alcohol is the fourth leading cause of death of all 'lifestyle factors', after smoking, physical inactivity 124 and bad eating habits.
106
Figure 6.7
Alcohol-related mortality, from 1995 Numberl
2000 1800 1600 1400 1200 1000 800 600 400 secundary primary
1995 1996 1997 1998 1999 2000 2001 2002 2003 669 663
705 690
710 686
750 744
774 783
809 820
888 906
928 826
1090 796
Number of deaths. 1995: ICD-9 codes 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-3, 980.0-1, E860.0-2, E950.9*, E980.9* (* only included if 980.0-1 has been mentioned as complication .) From 1996-2003: ICD-10 codes F10, G31.2, G62.1, I42.6, K29.2, K70.0-4, K70.9, K86.0, X45*, X65*, Y15*, T51.0-1 (* only included if T51.0-1 has been mentioned as complication). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
107
Figure 6.8
Alcohol-related mortality among males and females by age category. Survey year 2003
350
300
250
200
150
100
50
0
<40
40-45
45-50
50-55
55-60
60-65
65-70
70-75
75+
female
20
28
55
81
78
61
48
40
66
male
54
89
145
214
206
214
172
128
187
Number of deaths. ICD-10 codes: F10, G31.2, G62.1, I42.6, K29.2, K70.0-4, K70.9, K86.0, X45*, X65*, Y15*, T51.0-1 (* only included if T51.0-1 has been mentioned as complication). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
6.8
SUPPLY AND THE MARKET
Alcohol can be easily obtained in groceries, supermarkets, off licences and hotel and catering establishments. The (Dutch) Licensing and Catering Act prohibits the sale of low alcohol beverages to young people under the age of sixteen. For high alcohol beverages, the minimum age limit is eighteen years. A 2003 survey shows that, despite these legal provisions, pupils have no problem in buying 103 alcohol. ). . • In the past month, 18 percent of young people aged 14 and 15 bought low alcohol beverages in hotels or catering establishments and 12 percent in groceries or supermarkets (see Table 6.7). • Strong alcoholic beverages are bought less often. In the past month, 8 percent of the group aged 16 and 17 bought strong alcoholic beverages in hotels or catering establishments and another 8 percent in off licences. • The probability that young people under the age of sixteen succeed in buying alcoholic beverages turns out to be 90 percent or higher in both hotels and catering establishments and in groceries and supermarkets. Nevertheless, approximately 90 percent report they always observe the age limits.
108
Table 6.7
Percentage of young people who succeeded in buying weak and strong alcoholic beverages at various sales outlets in the past month. aged 13
Weak alcoholic beverages
Strong alcoholic beverages Source: Intraval.
•
hotel and catering establishments off-licence grocery and supermarket hotel and catering establishments off-licence
1.8
aged 14 and 15 18.4
aged 16 and 17 -
0.6 4.1
2.6 12.2
-
0.4
1.3
7.9
0.1
1.5
8.1
103
At ten percent of the workplaces of the labour force, alcohol is for sale in the canteen or the company restaurant. Thirty-four percent report that alcohol is occasionally available otherwise at the workplace, e.g. in the refrigerator or brought by a colleague. Eleven percent report that at least 97 once a week a gathering is organised where alcohol is served.
Excise duty • • • • •
• •
Effective 1 April 2002, the excise duty on beer was raised by eighteen percent and that on wine by 125 21 percent. The proceeds were used for lowering excise duties on soft drinks by 39 percent. Effective 1 January 2003, the excise duty on distilled spirits was also raised by eighteen 126 percent. Excise duty on one litre of distilled spirits (35 percent proof) is 6.2 euros, on a litre of wine 59 euro 95;96 cents and on a litre of beer 25 euro cents (see Table 6.8). This represents an increase of six euro cents for a 0.25 litre glass of beer or a 0.1 litre glass of wine, and 22 euro cents for a 0.035 glass of distilled spirits. EU Member States have different tax policies. Tariffs vary considerably between individual countries. For example, on a litre of distilled spirits (35 percent proof) an excise duty of three euros is levied in Italy, compared with nineteen euros in Sweden (see Table 6.8). Seven wine-producing countries levy no duties at all on wine. Table 6.8 shows that Dutch excise duty tariffs are in the medium range.
109
Table 6.8
Excise duty tariffs on alcoholic beverages in a number of EU Member States per hectolitre. Survey date December 2003 - spring 2004.
Member State Sweden Ireland Finland United Kingdom Denmark The Netherlands Belgium France Germany Luxembourg Austria Greece Portugal Spain Italy
Beer 81 99 143 97 47 25 21 13 9 10 25 14 15 10 17
I
II
Wine 242 273 235 253 95 59 47 3 0 0 0 0 0 0 0
Distilled spirits 1 932 1 374 989 972 707 621 581 508 456 364 350 331 314 259 256
III
Amounts in euros per hectolitre consumption. I. 5 volume percent alcohol; survey date December 2003. II. 11 volume percent alcohol; survey date December 2003. III. 35 volume percent alcohol; survey date spring 2004. Sources: Commodity Board for Distilled Spirits (PGD), Commodity Board for Wine, Central Brewery Agency, European Commission.
110
7
TOBACCO
Tobacco is made of the dried leaves of the tobacco plant (Nicotiana). Tobacco is usually smoked in the form of a cigarette or cigar or in a pipe and rarely sniffed or chewed. Consumers experience tobacco as having a stimulating (improvement of capacity to concentrate) and calming effect. Nicotine, the main psychoactive ingredient, is addictive. Regular use results in habituation and tolerance. During inhalation of tobacco smoke various substances are released, such as nicotine, tar and carbon monoxide, and many more products that are harmful to one’s health.
7.1
LATEST FACTS AND TRENDS
The main facts and trends regarding tobacco in this chapter are: • The percentage of smokers in the general population fell slightly from the early nineties to 2001. Between 2001 and 2003, the percentage of smokers remained stable (see Chapter 7.2). • The percentage of heavy smokers decreased between 2000 and 2003 (see Chapter 7.2). • The proportion of smokers among pupils dropped between 1999 and 2003 (see Chapter 7.3). • In respect of smoking among pupils, the Netherlands were in the middle range in the EU (see Chapter 7.5). • Lung cancer mortality was still declining among men, but continued rising among women (see Chapter 7.6).
7.2
USE: GENERAL POPULATION
Smoking — particularly among men — was quite common in the sixties and seventies. This was followed by a considerable decline in the late sixties that lasted up until the early nineties. Since then, this decline has levelled off. • Surveys of the Dutch Institute for Public Opinion and Market Research (TNS NIPO) may point at a decrease in the number of smokers from 2000 (see Table 7.1), but because of a change in the 127 manner of research, this is not certain. • The TNS NIPO figures indicate a decrease in smoking conduct from 30 percent in 2003 to 28 128 percent in 2004. Figures of the National Prevalence Research also show a downward trend. In 1997, 33 percent of the Dutch population aged 12 and over had smoked in the month prior to the 10 survey. In 2001 this had dropped to 30 percent. • According to the TNS NIPO, in 2003, 30 percent of Dutchmen aged 15 and over were smokers. In 127 that year, 29 percent were ex-smokers and 41 had never smoked. • Extrapolated over the entire population, nearly four million people smoked. - The gap between men and women narrowed (see Table 7.1). Nevertheless, there were still differences in the smoking behaviour of men and women. Women smoked fewer cigarettes per day than men. They preferred light filter cigarettes to hand-rolled cigarettes. - Smoking was highest in the group aged 35 to 49 incl. (see Figure 7.1). • Approximately 1.6 percent of the population quit smoking each year. An equal number of people started smoking. These new smokers included a relatively high number of young people under the age of 19, people with a low level of education, and women aged 30 to 34. This latter group included women who stopped smoking during pregnancy and took it up again after the 129 pregnancy.
111
Table 7.1 Actual smokers in the Netherlands among men and women aged 15 and over, from 1970 Year 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 I 2001 2002 2003
Men 75% 66% 52% 43% 39% 39% 39% 37% 37% 37% 37% 33% 34% 33%
Women 42% 40% 34% 34% 31% 31% 32% 30% 30% 31% 29% 27% 28% 27%
Total 59% 53% 43% 39% 35% 35% 35% 33% 34% 34% 33% 30% 31% 30%
Percentage of smokers. I. In 2001, the research method was changed: from a personal interview with a poll-taker at home, to completing a questionnaire via a modem or the internet. This change may affect the outcomes. Source: Defacto, for a smoke-free future (previously STIVORO), the Dutch Institute for Public Opinion and Market Research (TNS NIPO).
Figure 7.1
50
Percentage of smokers in the Netherlands by age group and gender. Survey year 2003
% men 40
37
40
31 30
women 34
26 26
31 25
20
16 15
10 0 15-19
20-34
35-49
50-64
>64
age (years) Source: Defacto, for a smoke-free future (previously STIVORO), the Dutch Institute for Public Opinion and Market Research (TNS NIPO).
According to Statistics Netherlands (CBS), the percentage of heavy smokers has decreased over the past years. • In 2003, eight percent of the population aged 12 and over smoked at least twenty cigarettes on average per day (9.6% of men and 6.9% of women). In 2000 this was still ten percent (10,4% of the 92 men and 8.7% of the women).
112
• Relatively many heavy smokers live in North-Brabant and the four big cities, with exceptionally 130 many living in and around the regions The Hague, Nieuwe Waterweg North and Eindhoven. Although the number of smokers had decreased in the seventies, an increase in the level of tobacco consumption per smoker was noted. Since the eighties, the average number of cigarettes or handrolled cigarettes smoked per day fluctuated around 20. • In 2003, almost 30 billion cigarettes and hand-rolled cigarettes in the Netherlands literally went up in smoke (see Table 7.2). 127 • Hand-rolled cigarettes dropped in popularity since 1990, compared to manufactured cigarettes.
Table 7.2
Consumption of manufactured and hand-rolled cigarettes in the Netherlands, from 1967
Year
Cigarettes (billion)
1967 1970 1975 1980 1985 1990 1995 2000 2001 2002 2003
16.6 18.7 23.9 23.0 16.3 17.3 17.2 16.7 16.3 16.9 17.0
Hand-rolled cigarettes (billion) 9.1 9.9 13.1 13.9 17.8 16.6 14.4 13.7 12.4 13.2 13.1
Total (billion) 25.7 28.6 37.0 36.9 34.1 33.4 31.6 30.4 28.7 30.1 30.1
Average tobacco sales per smoker per I day 12.9 14.0 18.6 21.3 20.7 22.4 20.1 19.9 20.1 20.5 20.9
I. Average number of cigarettes or hand-rolled cigarettes. Source: Defacto, for a smoke-free future.
7.3
USE: YOUNG PEOPLE
The percentage of young people who smoke has dropped in the last few years. • According to the Dutch National School Survey, the percentage of pupils that had ever smoked en the percentage that had smoked in the past month dropped between 1999 and 2003 (see Figure 7.2). • The figures of the TNS NIPO survey show that the percentage of recent smokers among young people aged 10-19 was stable from 1992 to 2002 incl. (between 27% and 31%). In 2003 the 127 percentage of recent smokers in this group of young people dropped to 24%.
113
Figure 7.2
Smoking among school-aged youths aged 12 and over, from 1988
% 65 59 55
55
55
55 45 45
35
30 27
26 25
23 20 Ever
Current
15 1988
1992
1996
1999
2003
The percentage of smokers ever in their lifetime and in the month before the survey (current). Source: National Representative School Survey, Trimbos Institute.
People begin to smoke at an early age. • In 2003, eleven percent of the pupils in the two highest groups of elementary school had smoked ever in their lives. Of pupils of ‘regular’ secondary schools, 45 percent had smoked ever in their lives. These figures are an average: the percentage increases with the age of the pupils (see 16 Figure 7.3).
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Figure 7.3
70
Smoking according to age among pupils aged 10 and over. Survey year 2003
% 63
60
60
55 49
50 40
35
32
30
28
30
23
20
20 12
11 6
10
ever
1
current
0 PE
12 yr
13 yr
14 yr
15 yr
16 yr
17-18 yr
Percentage of smokers ever (in lifetime) and current (last month). PE = primary education. Source: National Representative School Survey, Trimbos Institute.
• •
•
One fifth (20%) of secondary school pupils had smoked as recently as in the last month, while nine percent smoked daily. These percentages also increase with age. Nearly one third in the highest age group (16 years and over) were current smokers, compared to six percent in the group aged 12 and twelve percent of the group aged 13. Approximately an equal numbers of boys (18%) and girls (22%) had smoked in the past month.
Level of smoking •
•
It is known how much the current smokers among pupils smoked on average per day. For one third (34%) it was less than one cigarette and for a quarter of this group it was more than ten cigarettes per day. Nine percent of the pupils smoked daily. More than one third of this group (36%) smoked over ten cigarettes per day.
Regional dispersion In the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F we give an overview of recent figures concerning the use of tobacco among young people in 28 towns, cities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of the difference in tobacco use between the various towns and cities. In the age group of 18 to 23 incl., for example, 17 percent in Leiden smoked daily compared to 35 percent in Almelo.
115
Availability of tobacco Since 1 January 2003, pursuant to the amended Tobacco Act it has been forbidden to sell tobacco products to young people younger than 16. • The number of young people aged 13-15 who sometimes buy tobacco products dropped between 131 1999 and 2003 from 26 to 9 percent. • Of those who sometimes buy tobacco products, 56 percent reported in 2003 that they bought the products for themselves, whereas this was still 43 percent in 1999. • They bought the tobacco products in four kinds of sales outlets: specialised tobacco shops (46%), groceries or supermarkets (50%), petrol stations (42%) and hotels or catering establishments (31%). The trend is to buy more in shops for tobacco products. • The chance for a person younger than 16 to succeed in buying tobacco products was, just as in 1999 and 2001, 90 percent or higher. Nevertheless 93 percent of the outlets claimed never to sell 131 tobacco products to people younger than 16. Another survey found that, after the implementation of the amended Tobacco Act that forbids this, 84% of the smokers under the age of 16 personally bought cigarettes at least once. Only 13% of them were asked for their age or a 132 remark was made to them about it by the salespeople.
Special groups Smoking was considerably more prevalent among young clubbers and adolescents than among 17;18;104 pupils. • 46, 37 and 70 percent of the visitors of Amsterdam pubs (2000), trendy clubs (2003) and coffee shops (2001), respectively, were daily smokers. • The daily smokers among the visitors of pubs and coffee shops smoked an average of 14 to 16 manufactured or hand-rolled cigarettes per day; 20 to 36 percent smoked more than one pack a day (at least 20 manufactured or hand-rolled cigarettes). • Between 1995 and 2003, the percentage of visitors of trendy clubs that ever smoked remained stable (87% in 2003). The percentage that had smoked in the past year dropped from 77% in 1998 to 68% in 2003. The percentage that had smoked in the past month in this period dropped from 67% to 55%.
7.4 •
•
PROBLEM USE A clear indication of the extent to which smokers consider their use problematic is the desire to quit smoking. In 2003, 8% of the smokers in the Netherlands stated they wanted to stop smoking within a month, 9% within six months, 8% within a year and 14% said they wanted to stop smoking 133 at one time in the future. In scientific circles, the term ‘nicotine dependence’ is sometimes preferred to ‘tobacco addiction’. The level of dependence can be measured with the Fagerström Test for Nicotine Dependence, a scale ranging from zero to ten (10 = severe nicotine dependence). – Research showed that, in 1997, the result for Dutch smokers on this scale was 3.0 on average, 134 compared to 4.3 for American smokers. – Men scored higher on average than women. – Smokers who sought help with smoking cessation were more successful on average than smokers who did not seek assistance.
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7.5
USE: INTERNATIONAL COMPARISONS
The proportion of smokers among the population of EU Member States varies greatly, although the comparability of the figures is doubtful. For example, some countries define the term ‘smoker’ and age groups differently (see Table 7.3). Many countries understand this to mean daily smokers, whereas the Netherlands defines ‘smokers’ as people who ‘smoke daily or occasionally’. • According to the most recent figures, of the compared countries, Portugal had the lowest number of smokers, and Greece — together with Germany — the highest number. • With the exception of Sweden and Norway, more men than women smoked. In Portugal this difference was largest.
Table 7.3
Smokers among adults in several EU Member States, Norway and Switzerland
Country
Year
Men
Women
Total
Criterion for smoking
2000 2002 2000 2002 2000 2000 2002
Age (year) 18+ 15+ 20-54 15-64 18+ 18+
Belgium Denmark Germany Finland France Greece Ireland
36% 31% 40% 27% 33% 47% 28%
26% 27% 32% 20% 21% 29% 26%
31% 28% 36% 23% 27% 38% 27%
Italy Luxembourg The Netherlands Norway Austria Portugal
1999 2000 2003 2001/2002 2000 1995/1996
14-65 15+ 15+ 16-74 19+
32% 34% 33% 30% 29%
17% 27% 27% 30% 6%
25% 32% 30% 30% 29% 17%
Spain United Kingdom Sweden Switzerland
2001 2002 2000/2001 2000
16+ 16+ 16-84 14-65
39% 27% 17% 37%
25% 25% 21% 29%
32% 26% 19% 32%
daily daily daily or regularly daily regularly or occasionally daily regularly daily daily or occasionally daily daily in the past two weeks daily current smokers daily regularly or occasionally
Percentage of smokers. - = not measured/unknown. Source: World Health Organisation (WHO) 127 Netherlands: Defacto, for a smoke-free future (previously STIVORO).
135
, for the
The European School Survey Project on Alcohol and Other Drugs (ESPAD) (see Appendix B) enables comparison of the smoking behaviour of secondary school pupils aged thirteen and sixteen. Figure 7.4 43 gives figures for the percentage of pupils who smoked in the past month. • Of the compared countries, Austria had the highest number of smokers among secondary school pupils and Sweden the lowest. 132 • The Netherlands were in the middle range. • In most of the countries, more girls smoked than boys.
117
Figure 7.4
Smokers among secondary school pupils aged 15 and 16 in several EU Member States, Norway and Switzerland. Survey year 2003
49
Austria
48
56
45 46
Germany
43 38
Finland
35
Italy
35
41
38 40
34 34 33
Switzerland
33
France
31
36
33
Ireland
28
37
32 33 32
Belgium
31 31 32
The Netherlands Denmark
27
30 32
29
United Kingdom
34
25 28
Greece
27
30
28
Norway
24
32
28 27 28
Portugal
27
Spain
22 23
Sweden
20
0
10
20 Boys
31
26
%
30 Girls
40
50
60
Total
Percentage that smoked in the past month. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
• •
More than a quarter of Dutch pupils (27%) reported to have smoked more than forty times in their lives. This percentage varied from 18% in Portugal to 42% in Austria. In October 2004, the European Network for Smoking Prevention (ENSP) published a report about 136 the effects of the Tobacco Control Policy in 28 European countries. This report showed how each country scored on six cost-effective interventions that may lead to a reduction of tobacco consumption: the price of tobacco articles, a smoking ban in public spaces and placed of work, the height of the budget for the Tobacco Control Policy, a prohibition of advertisements for tobacco articles, warnings on tobacco articles and the availability of treatments to stop smoking. For the six interventions taken together, the Netherlands reached the seventh place among these 28 European countries. The date of this survey is 1 January 2004.
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7.6
TREATMENT DEMAND
Treatment mainly involves self-help and seeking help from the general practitioner. The care organisations for addicts occasionally offer smoking cessation programs, albeit not on a large scale. • Approximately two thirds of all smokers who attempt to stop smoking do so without any means of help. The remainder attend courses, seek advice from their GP, use nicotine substitutes (plasters, chewing gum, lozenges), undergo acupuncture or hypnosis, etc.. The main reason for attempting 137 to stop smoking is for health reasons. • In the recent past, the antidepressant bupropion (Zyban®) was registered in the Netherlands as a non-nicotine aid for smoking cessation. According to IMS Health, in 2001, 2002 and 2003, bupropion was prescribed 80,000, 70,000 and 73,000 times by physicians. This adds up to a total of 3.0, 2.7 and 2.7 million tablets, respectively. The demand seems to be stabilising. • The market of nicotine substitutes – plasters, chewing gum and lozenges – doubled in 2004 compared to 2003 to a total turnover of 16.7 million euros. This indicates a considerable increase in attempts to stop smoking. • People who wish to stop smoking can ask their general practitioner for advice. In 2003, an estimated 65,000 men and 65,000 women consulted their GP about how to stop smoking. Most of 138 them were aged 40-60. The Minimal Intervention Strategy (MIS) has proven an effective protocol for general practitioners, nurses and cardiologists to stimulate smoking patients to stop 139 smoking. • The Counselling Centre of STIVORO also supports people who wish to stop smoking. In 2003, 1,118 people registered for coaching by phone and more than 8,000 coaching discussions took 127 place. • Towards the year 2004, STIVORO held an intensive stopping campaign called ‘Nederland Start Met Stoppen’ [The Netherlands Starts Stopping]. This campaign contributed to the attempts of over 1 million smokers to stop smoking around 1 January 2004. In December 2004, 24 percent of 128 these people had not returned to smoking. Usually, five to ten percent of those who have 140 stopped persevere a year in doing that. As most important reason to stop is given the increase in excise duty on tobacco. In 2003, besides a nationwide campaign, STIVORO conducted also a 127 campaign about passive smoking and smoking at the workplace. • End 2004, an official guideline of the Dutch Institute for Health Care Improvement (CBO) for the treatment of tobacco addiction was published. In this guideline, the approach of smoking patients 141;142 in medical practice is discussed and the effectiveness of various treatments is descibed. The demand on the health care system for problems caused or aggravated by smoking is of entirely different proportions. The number of hospital admissions for illnesses related to smoking amounted to 143 nearly 100,000 in the early nineties. Recent figures are not available.
7.7 • • • • •
MORTALITY Smoking is the leading cause of premature death in the Netherlands. In 2003, over 20,000 people died in the Netherlands from the direct consequences of smoking. In 2002, the direct mortality from smoking was estimated at 20,175 and in 2003 at 20,141 deaths. 144 In 2000, this number was still 20,718 deaths. Of all deaths in the Netherlands in 2003, approximately 14 percent was due to smoking (20% of the men and 8% of the women). Smoking is connected with cardiovascular diseases, pulmonary diseases and cancer. Table 7.4 shows that lung cancer is mainly caused by smoking: in 74 percent (women) to 91 percent (men) of all the cases in 2003.
119
•
The actual mortality from smoking may be higher, because the effects of passive smoking were 145;146 not taken into account. It is unclear, however, to what extent passive smoking leads to death.
Table 7.4
Mortality from a number of illnesses among men and women aged 20 and over. Survey year 2003
Illness Lung cancer Chronic obstructive pulmonary disease (COPD) Coronary heart disease Stroke (cerebrovascular disorder) Heart failure Oesophageal cancer Cancer of the larynx Cancer of the oral cavity Total
Total mortality Men 6 156 3 870
Women 2 706 2 661
Mortality from smoking Men Women 5 627 2 002 3 264 1 819
8 895 4 529
6 638 7 053
2 577 958
865 704
2 538 971 200 358
3 849 376 39 202
461 771 157 330
224 235 32 115
27 517
23 524
14 145
I
5 996
I
I. Per disorder first rounded off to whole numbers and subsequently added up. Source: National Institute of Public Health and the Environment (RIVM), Statistics Netherlands (CBS).
As a result of the decline in smoking among men between 1960 and 1990, lung cancer mortality in men has dropped. However, this trend is reversed in women who have started to smoke more. In 2000 and 2002, fewer deaths from lung cancer in men were reported than in previous years (see Table 7.5). • The rising curve in the number of deaths from lung cancer in women is bound to continue for 147 several decades to come. • The opposing trends in men and women balance each other out. As a result, the total number of deaths from lung cancer has remained stable for years.
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Table 7.5 Year 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Mortality with lung cancer as primary cause of death among people aged 15 and over, from 1985. Deaths per 100,000 inhabitants Men 127 130 127 128 123 117 118 117 115 113 112 109 108 106 105 99 100 96 95
Women 16 17 17 19 20 20 20 22 24 26 27 28 29 30 33 34 35 39 40
Total 71 72 71 72 70 67 68 69 69 68 69 68 68 68 68 66 67 68 67
1985-1996: ICD-9 code 162, from1996: ICD-10 codes C33-34 (see Appendix C). Source: Cause of Death Statistics, Statistics Netherlands (CBS).
7.8 • •
•
SUPPLY AND THE MARKET
From 1 January 2004, employers have been obliged to guarantee their staff a non-smoking 148 workplace. From that date it has also been forbidden to smoke in public transport. In 2003, 46% of the rolling tobacco was sold in the general groceries and supermarkets, 22% in specialised tobacco shops, 21% in petrol stations, 5% in hotels or catering establishments and 6% elsewhere. Of the cigarettes 36% were sold via the general groceries and supermarkets, 6% via hotels or catering establishments, 25% via specialised tobacco shops, 24% via petrol stations and 149 9% via other channels. This does not include sales from cigarette vending machines. From 1 February 2004, the price of a pack of cigarettes in the most popular price class has been € 4.60, including € 2.63 excise duty and € 0.73 VAT. A 50-gram pack of rolling tobacco costs also 149 € 4.60, including € 2.08 excise duty and € 0.73 VAT (see Table 7.6).
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Table 7.6
Price of cigarettes and tax burden, from 1970. Survey date: February 2004
Year 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Price 0.86 1.02 1.36 1.88 1.97 2.56 2.61 2.79 2.93 3.04 3.15 3.43 3.54 3.54 4.60
Tax burden 0.60 0.68 0.98 1.35 1.37 1.84 1.87 2.01 2.11 2.19 2.27 2.50 2.58 2.63 3.36
Tax burden in % 69% 67% 72% 72% 70% 72% 72% 72% 72% 72% 72% 73% 73% 74% 73%
Price and tax burden in euros per pack of 25 cigarettes. Tax burden includes excise duty and VAT. Source: Tobacco Manufacturers’ Association Netherlands (SSI).
The excise duty imposed on tobacco products varies considerably between individual Member States of the European Union. • In the 15 old EU Member States the excise duty is highest in the United Kingdom and lowest in Spain (see Table 7.7). In the 15 old EU Member States the excise duty is highest in the United Kingdom and lowest in Spain (see Table 7.7).
Table 7.7
Prices on cigarettes and tax burden in several EU Member States. Survey date 1 May 2004
Country United Kingdom Ireland France Sweden Finland Denmark Germany The Netherlands Belgium Austria Greece Luxembourg Portugal Italy Spain
Price 8.25 7.65 6.25 5.16 5.00 4.97 4.74 4.60 4.45 3.75 3.13 3.10 2.75 2.58 2.44
Excise 5.35 4.74 4.00 2.57 2.88 2.70 2.86 2.63 2.54 2.14 2.82 1.81 1.70 1.50 1.41
VAT 1.23 1.33 1.02 1.03 0.90 0.99 0.65 0.73 0.77 0.63 0.48 0.33 0.44 0.43 0.34
Excise+VAT 6.58 6.06 5.02 3.60 3.78 3.69 3.52 3.36 3.31 2.76 3.30 2.14 2.14 1.93 1.75
Price, tax burden and VAT in euros per pack of 25 cigarettes. Source: European Committee.
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8
RECORDED DRUG CRIME
At the heart of the Dutch drug policy is the public health aspect. In addition, the Dutch drug policy aims also to reduce the harm caused to society by substance abuse: nuisance, crime and public order problems. The Minister of Justice is responsible for criminal enforcement and the social rehabilitation of offenders. The supply of drugs is combated by means of investigation, prosecution, and the adjudication of the suspects involved in the production, (international) drug trafficking, and possession of drugs. Drug treatment and counselling is made available for drug using offenders while in detention with the aim to improve their situation and therefore reduce crime and nuisance. This chapter provides a statistical overview of the nature and scope of the recorded drugs crime and the penal response. Drug crime is made up of two components:
•
Drug law violations: as set out in the respective drug laws (Opium Act, Misuse of Chemicals Prevention Act), or offences connected with drug law violations (e.g. organised crime, money laundering, etc.).
•
Crimes by drug users: crimes committed by drug users. It should be noted that there is no persuasive evidence of a causal connection between drug use or addiction and crime: drug use or addiction need not necessarily precede crime. When drug users violate drug laws, an overlap between both crime components is involved. In this chapter we shall report about recorded drug crime, to be exact: the crime recorded when a suspect is arrested and booked. This is the crime that has been recorded and solved. The ratio of drug crime in the volume of all recorded crime (in addition to solved crime, this also included crime that has been recorded but has not been solved) and in the volume of all crime (both recorded and unrecorded) is not examined here. Results can therefore not just be applied to the volume of total drug crimes. The figures in this chapter express to some degree the efforts of the police and the criminal justice system in fighting drug crime. The data cover the years 1999 to 2003 incl. as much as possible. Where possible, a distinction is a
made between hard and soft drug cases. Appendix B contains a list of sources used in this chapter. For further information we refer to www.trimbos.nl/monitors. Not all the data are of a good quality. This problem has been discussed 2;3 151;152 before. Especially data about seized drugs must be interpreted with caution. In addition, based on the current data, the existence of addiction of individuals cannot be determined exactly in files of the police and the criminal justice system. In this chapter we use, therefore, the term “drug user” or 3 “problem user of drugs” to indicate a possible addiction problem with the persons concerned. In the text, details about the quality of the used sources are specified.
a
Most figures relate to drugs as defined in the Opium Act, which means: not to alcohol and tobacco. An exception is formed by the figures of the probation and after-care service, in which the type of substance has not been specified.
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8.1
LATEST FACTS AND TRENDS
The main facts and trends regarding drug crime in this chapter are:
•
•
• •
8.2
Offences under the Opium Act added more to the workload of the criminal system in 2003 than in 2002; this also applied to all the phases of the criminal process. - In 2003 more suspects were booked for offences under the Opium Act than in 2002. Most of those offences were still related to hard drugs (see Chapter 8.2.1). - Two thirds of the number of investigations into organised crime concerned violations under the Opium Act: this is more or less the same as in 2002 (see Chapter 8.2.2). - The number of cases taken in by the Public Prosecutions Department continued to increase (see Chapter 8.2.2). - In 2003, the Courts handled significantly more cases of violations under the Opium Act than in 2002 (see Chapter 8.2.5). - The number of imposed community sentences and confiscation orders in cases under the Opium Act increased strongly in 2003 (see Chapter 8.2.6). - The number of unsuspended custodial sentences in Opium Act cases increased also in 2003. This increase was due to hard drug cases (see Chapter 8.2.7). - In terms of detention years, of the custodial sentences imposed in criminal cases, an increasing proportion concerned drug cases (see Chapter 8.2.7). - Offenders under the Opium Act repeated the offence more often than other offenders (see Chapter 8.2.8). Criminal drug users increased the work load of the criminal system to about the same extent as in 2002. - In 2003, the police recorded over ten thousand suspects as “drug users”. Of this group more than 70 percent had a criminal record showing over ten offences (see Chapter 8.3.1). - Over 70% of the ‘very high rate’ frequent offenders are regular hard drug users (see Chapter 8.3.2). In 2003, in general more activities of the Netherlands (Drug) Rehabilitation Foundation were recorded in the criminal system (see Chapter 8.4.1). The number of compulsory admissions in the Judicial Treatment of Addicts (SOV) rose steadily in 2003 (see Chapter 8.4.3).
RECORDED DRUG CRIME
In this paragraph we shall describe the nature and volume of the recorded drug law violations specifically with respect to the Opium Act - and the profile of the drug offenders. This is done along the criminal law chain. First the data from the police will be discussed: the number of booked suspects, criminal investigations into criminal cooperation networks and confiscated drugs. Then the number of cases and the manner of disposal by the Public Prosecutions Department will be discussed. In the end, part of these cases found their way to Court. Figures will be provided of the number of cases in which the Court pronounced sentence and of which sentences were passed. Finally, data will be given about detention because of offences under the Opium Act and repeat offences by the offenders.
8.2.1 Suspects under the Opium Act Table 8.1 shows the number of suspects against whom a police report was drawn up because of a violation of the Opium Act (production, transport, trafficking and/or possession of drugs). This is based on the number of suspects against whom a police report was drawn up once or more times in a
124
specific year because of a violation of the Opium Act. If the violation of the Opium Act involves hard drugs, we shall refer to this hereafter as "hard drug offences". If soft drugs are involved, we shall speak of ‘soft drug offences’. • The (still provisional) figures for 2003 indicate that the police booked more than 14,000 suspects because of offences under the Opium Act, more than in 2002. • The increase is apparent for hard drugs and for soft drugs, as well as for the combination of both. • In 2003, most of these offences still concerned hard drugs: more than half the suspects were booked for hard drug offences. The proportion of suspects of soft drug offences was 38 percent. This was slightly higher in 2003 than in the previous years.
Table 8.1 Number Total
• • •
I
Number of unique suspects of Opium Act offences booked by the police by type of drug, from 1999 II
Hard drugs
1999 9 091 5 228
2000 8 171 4 619
2001 10 139 5 558
2002 12 114 6 777
2003 14 299 7 744
Soft drugs
3 022
2 784
3 726
4 347
5 495
841
768
855
990
1 060
Hard drugs
57%
57%
55%
56%
54%
Soft drugs
33%
34%
37%
36%
38%
9%
9%
8%
8%
7%
Both
%
• • •
Both
I. Unique suspects: each suspect has been counted only once per year in the table, even if he/she was booked more often than once in a year for violation of the Opium Act. II. Provisional figures. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
Besides the police, the Royal Military Police also makes arrests for violations under the Opium Act. Although the Royal Military Police also handles other cases (e.g. of Dutch military abroad), most of the cases concern suspects arrested at Schiphol Airport. Table 8.2 gives an overview of the number of suspects who have not also been recorded by the police in the Police Records System (HKS).
Table 8.2 Number Total
• • •
I
Number of unique suspects of Opium Act offences booked by the Royal Military Police by type of drug, from 1999 1999 486 384
2000 516 464
2001 910 870
2002 1 477 1 419
2003 1 640 1 491
Soft drugs
87
43
35
52
137
Both
15
9
5
6
12
Hard drugs
79%
90%
96%
96%
91%
Soft drugs
18%
8%
4%
4%
8%
3%
2%
0.5%
0%
1%
Hard drugs
%
• • •
Both
I. Unique suspects: each suspect has been counted only once per year in the table, even if he/she was booked more often than once in a year for violation of the Opium Act. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
It is apparent from Table 8.2 that in 2003 this concerned 1,640 suspects, mainly of hard drug offences. The number of hard drug offences increased in the past five years, particularly in 2002 and 2003. The number of soft drug offences increased especially in 2002 and 2003. The increase in the last two
125
years may be largely because, otherwise than in previous years, in 2002 and 2003 all reports at Schiphol were drawn up and recorded exclusively by the Royal Military Police. Hard drug offences always made up by far the larger part. Table 8.3 shows the profiles of the suspects booked by the police for Opium Act offences in 2003. • Most of them are men. Most suspects are aged 25 to 35.
• •
•
•
b
b
The soft drug suspects are the least frequently recorded as drug users and have relatively few criminal records. The hard drug suspects live more often in the large cities, are younger and have more criminal records than the soft drug suspects. Twenty percent have more than ten. Approximately a quarter of the suspects of a hard drug offence are known as drug users. Suspects of both hard and soft drugs are usually well known by the police: nearly half of them have more than ten criminal records. Compared to suspects of only a hard drug or soft drug offence, they are more represented in the age group of 35-45 and more often men. They usually live in middle-sized towns and relatively infrequently abroad. They are most often recorded at the police as drug users. The profile of the suspects arrested by the Royal Military Police is different. Sixty percent of them lives abroad, nearly half (46%) originate from the Netherlands Antilles. Most of the suspects have only one criminal record (87%) and are relatively young: 35 percent is in the age group 18-24, 32 percent is aged between 25 and 34.
See for the restrictions of this classification of drug using suspects the remark to Chapter 8.3.1.
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Table 8.3
Profiles of suspects of offences under the Opium Act by type of drug. Survey year 2003
Total number
Soft drugs 5 495
Hard drugs Both 7 744 1 060
Gender
Men Women
83% 17%
88% 12%
93% 7%
Municipality by I number of inhabitants
Unknown under 10 000 10 000 – 20 000 20 000 – 50 000 50 000 - 100 000 100 000 - 150 000 150 000 - 250 000 250 000 and over (four largest cities) Abroad
3% 1% 8% 20% 19% 10% 11% 14%
5% 1% 5% 14% 12% 10% 8% 32%
4% 1% 7% 20% 23% 12% 9% 19%
14%
13%
5%
Alcohol Drugs Otherwise
1% 1% 2%
2% 23% 6%
3% 28% 9%
1
46%
36%
10%
2 3–4 5 – 10 11 – 20 21 or over
12% 13% 16% 8% 5%
12% 14% 17% 10% 10%
5% 12% 24% 23% 25%
12-17 18-24 25-34 35-44 45 and above
3% 20% 33% 26% 18%
4% 32% 33% 20% 11%
1% 14% 34% 33% 18%
II
Danger classification addiction
III
Number of criminal records in the total recorded criminal history
Age upon recording of latest offence
I. The offences may have been committed in another town or city than where the suspect lives. II. See remarks to Chapter 8.3.1. III. A criminal record is a police contact during which a report of one or more crimes was drawn up. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
8.2.2 Investigations into organised crime The National Criminal Information service of the National Police Services Agency (KLPD), Research and Analysis group, lists the investigations annually undertaken by the Dutch police in the field of c
organised crime. Two comments to the figures should be given: In the first place, the data about the investigations are not directly comparable from 2002 to those from the previous years. This is due to the new recording method that the National Police Services Agency (KLPD) started to use in 2002. The data of all the regional investigations are now requested through a new form, the “Criminal c
This listing is done commissioned by the EU Justice and Home Affairs Council (JBZ Raad). Only investigations that satisfy the criteria set for organised crime by the Council are included.
127
Cooperation (CSV) – manager”. On the basis of this form, the criminal cooperation from the listed investigations are described. The registration of criminal cooperation is expected to be more complete from 2002 than in the previous years. Investigation priorities, capacity and the possibilities of the investigation services are here also important factors in the height of the numbers. For that reason, the number of recorded investigations may fluctuate strongly from year to year. One single criminal investigation may involve several types of drugs and various activities in the field of drugs. Table 8.4 gives the figures in respect of the criminal investigations. • In 2003 more criminal investigations were recorded than in 2002. • Two thirds (66%) of the criminal investigations focused on drugs. That percentage is about the same as that of the previous year. • Forty percent of all the investigations focused only on hard drugs, 11 percent only on soft drugs and 14 percent on both hard drugs and soft drugs. • In 62 percent (91) of the criminal investigations into drugs only one type of drug was involved. In the other criminal investigations, several types of drugs were involved. • Cocaine figured in 60 percent of the criminal investigations into hard drugs. Fifty-four percent of these criminal investigations concerned synthetic drugs and 17 percent heroin. The number of criminal investigations into cocaine increased strongly compared to 2002. This may be connected with more intensive inspections at Schiphol Airport. • The criminal investigations into soft drugs were mainly focused on Dutch-grown cannabis (53%) or hashish (39%). In the case of criminal investigations into Dutch-grown cannabis, not just trade was concerned but also production. • Figures from 1998 to 2002 incl. show that more than half the criminal investigations dealt with various activities in the field of drugs. The investigated criminal groups dealt more often with transport and trade than with production. In 2003 the division by production, transport and trade could no longer be made.
Table 8.4
Criminal investigations into more serious forms of organised crime: proportion of drug crime by type of drug, from 1999
Number of criminal investigations Involving drug crime
• Hard drugs • Soft drugs • Hard and soft drugs
1999 118 100%
2000 148 100%
2001 146 100%
2002 185 100%
2003 221 100%
75 24
64% 20%
78 35
53% 24%
90 53
62% 36%
117 64
63% 35%
146 89
66% 40%
9
8%
14
9%
15
10%
20
11%
25
11%
42
36%
29
20%
22
15%
33
18%
32
14%
Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
8.2.3 Confiscated drugs The National Criminal Information service of the National Police Services Agency (KLPD), Research and Analysis group reports annually about the quantity of confiscated drugs. This is done based on reports from the police forces, core teams, customs and the Royal Military Police. The below overview must be considered with a critical eye. Recording of seizure is not centrally organised within the police forces and other investigation bodies, often it is not uniform and sometimes no records are made at 151;152 all. In the interpretation of the data one must take into account that the figures only indicate a 152;153 minimum limit of the total number of seized drugs. Moreover, the differences between the types of drugs and between the years are not systematic to such an extent that it is very difficult to interpret them. It is impossible to gather trends from them. The quantities of confiscated drugs may vary in
128
proportion to the investigation efforts, the number of cases that had to be dealt with, changes in the market and/or accuracy in reporting. Seven of the 25 regional police departments have not supplied data. De Miranda and Van der Werf, who prepared the 2003 overview, have calculated an indication of the seizures for those lacking 152 regional police departments. To that end they consulted the Drug Seizure file of the National Investigations Information Service (NRI). This file contains the seizures from a specific minimum quantity. Table 8.5 includes the thus achieved 2003 figures. The authors (De Miranda and Van der Werf, 2004) outline the following picture: • “Heroin: the reported quantity of seized heroin was less in 2003 than in the previous years. In 2003 more than 417 kilograms of heroin were reported, whereas this was more than 1,000 kilograms in 2002, a decrease of 63 percent. The quantity of heroin that was confiscated in 2003 was the lowest since 1996. The number of seizures of heroin reported by the criminal investigation bodies was 533. • Cocaine: in respect of cocaine there was an increase compared to previous years. In 2003, more than 17,000 kilograms of this drug were reportedly seized; an increase of over 120 percent compared to 2002. The number of seizures reported is 3,917. Most of the seizures were carried out by the Royal Military Police in collaboration with customs. • Amphetamines: criminal investigation bodies reported to have seized more amphetamines in 2003 than in 2002, i.e. 843 kilograms and, in addition, 14,000 pills. Furthermore, for the first time the seizure of amphetamines in fluid form was reported, i.e. 37 litres. The number of seizures reported was 219. • Ecstasy (MDMA): in the information of the criminal investigation bodies a decrease was noticeable in the quantity of XTC seized in the Netherlands. In 2003, 435 kilograms of MDMA (powder and paste) were seized, a fifty percent decrease compared to 2002. The quantity of seized tablets also showed a decrease. The records mention more than 5.4 million of tablets in 2003, a decrease of 20 percent compared to 2002. The number of seizures is not mentioned. • LSD: The figures for 2003 are not sensational. 1,642 tablets were seized. The number of seizures was nine. • Cannabis: Compared to the previous year, 2003 showed a decrease in the reported quantity of seized cannabis products, such as (foreign) hashish, marihuana and Dutch-grown cannabis. In 2003, 19,103 kilograms of cannabis were seized, a significant decrease compared to the 46,675 kilograms confiscated in 2002. The number of reported seizures of cannabis products was 2,199."
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Table 8.5
I
Quantities of seized drugs in the Netherlands, from 1999
Kind of drug 1999 2000 2001 2002 2003 Heroin Kilogram Kilogram 770 896 739 1 122 417 Cocaine Kilogram 10 361 6 472 8 389 7 968 17 560 Amphetamines Kilogram 853 293 579 481 843 Tablets 45 847 II. 20 592 1 028 14 000 Litres 37 XTC (MDMA) Kilogram *** 632 113 849 435 Tablets 3 663 608 5 500 000 3 684 505 6 787 167 5 420 033 Discovered production places 36 37 35 43 37 LSD Trips 244 9 829 28 731 355 Tablets 2 423 143 1 642 Methadone Kilogram 50 16 1 4 Tablets 186 437 5 543 8 968 9 446 57 430 Litres 0,57 Cannabis Hashish Kilogram 61 226 29 590 10 972 32 717 10 719 Marihuana Kilogram 47 039 9 629 21 139 9 958 7 067 Dutch-grown cannabis Kilogram 2 076 701 1 308 1 179 Hemp plants 582 588 661 851 884 609 900 381 1 111 855 Total weight cannabis 110 341 39 920 33 419 42 675 19 103 Rounded-up hemp farms 1 091 1 372 2 012 1 574 1 867 Number of seizures 14 909 9 243 14 353 18 823 5 752 I. Not included: hashish oil (1 litre in 1999); paddo’s (278 kilograms in 2003); mescaline (1 kilogram in 2003) and 152 opium (0.1 kilogram in 2003). II. Indicates that there are no seizures or none are known.
8.2.4 Intake and disposal of Opium Act cases by the Public Prosecutions Department The police send the police reports in respect of violations of the Opium Act to the Public Prosecutions Department (OM). Not all the police reports are registered at the Public Prosecutions Department (OM). Criminal cases, after all, are already ‘screened’ by the police, meaning that those cases that in all likelihood cannot be prosecuted are already filtered out. Such cases do not always end up in the records of the Public Prosecutions Department. Table 8.6 shows the numbers of cases taken in by the Public Prosecutions Department for each type of drug. • The number of cases taken in by the Public Prosecutions Department continued to increase, although the increase by 8 percent in 2003 was somewhat less than in the two previous years. An increase was apparent in hard drug and soft drug cases, and also in the category hard and soft drugs. • The proportion of hard and soft drug cases remained virtually the same in those past five years. • A closer analysis of the recent increase in the number of Opium Act cases shows that half the increase was caused by the increase at the Haarlem district. In 1999 this district handled 12 percent of the total number of hard drug cases in the Netherlands. In 2002 and 2003 this more than doubled (26%). Schiphol cases are dealt with by the Haarlem district; for a considerable part, the increase will concern cases against drug couriers, including ‘drug swallowers’.
130
Table 8.6
Opium Act cases taken in by the Public Prosecutions Department by type of drug, from 1999
Hard drugs Soft drugs Hard and soft drugs Total
1999 6 407 4 380 888 11 675
2000 6 397 4 324 792 11 513
2001 7 672 5 059 827 13 558
2002 9 246 5 832 770 15 848
2003 9 989 6 156 942 17 087
Hard drugs Soft drugs Hard and soft drugs Total
55% 38% 8% 100%
56% 38% 7% 100%
57% 37% 6% 100%
58% 37% 5% 100%
58% 36% 6% 100%
Source: Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC).
Table 8.7 shows what the decision of the Public Prosecutions Department was in Opium Act cases that were disposed in final and conclusive judgment between 1999 and 2003. • In 2003, the number of criminal cases under the Opium Act was nearly 15,000. Compared to 2002, this is an increase of 13 percent. • The Public Prosecutions Department issues a summons in the majority of drug cases. This means that most drug cases are brought before the Court. In those last five years a slight drop in the percentage of summons was apparent. The proportion of out-of-court settlements increased in that period of five years, particularly in soft drug cases. • In cases involving both hard and soft drugs, a summons was issued relatively often.
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Table 8.7
Criminal cases disposed in final and conclusive judgement for Opium Act offences by decision of the Public Prosecution Department and type of drug, from 1999
1999 2000 2001 2002 2003 Total number of Opium Act cases 11 132 10 546 11 143 13 206 14 943 72% 71% 67% 67% 68% • Summons 9% 9% 16% 18% 17% • Out-of-court settlement 6% 6% 6% 5% 5% • Discretionary dismissal 8% 9% 7% 6% 5% • Dismissal by reasons of likeliness of nonconviction 5% 5% 5% 4% 5% • Joinder Hard drugs 75% 76% 74% 75% 74% • Summons 4% 4% 7% 10% 11% • Out-of-court settlement 7% 7% 6% 4% 4% • Discretionary dismissal 9% 9% 8% 6% 5% • Dismissal by reasons of likeliness of nonconviction 5% 5% 5% 5% 5% • Joinder Soft drugs 68% 64% 56% 53% 57% • Summons 16% 17% 29% 33% 29% • Out-of-court settlement 5% 6% 5% 5% 5% • Discretionary dismissal 7% 8% 6% 5% 5% • Dismissal by reasons of likeliness of nonconviction 5% 4% 4% 3% 4% • Joinder Hard and soft drugs 89% 84% 78% 81% 80% • Summons 2% 3% 3% 3% 7% • Out-of-court settlement 2% 2% 7% 4% 5% • Discretionary dismissal 4% 8% 9% 9% 5% • Dismissal by reasons of likeliness of nonconviction 3% 3% 3% 3% 3% • Joinder Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
In respect of the Misuse of Chemicals Prevention Act (WVMC) the following appears. • In the period between 1999 and 2003, annually some thirty cases involved offences against the WVMC, usually in combination with hard drug offences. In 2003, 22 cases with such a combination of offences were recorded; six cases only concerned an offence under the WVMC (see Table 8.8).
Table 8.8
Number of final and conclusive judgments in cases concerning an offence under the WVMC, from 1999
Only WVMC WVMC and Opium Act Total
1999 3 20 23
2000 7 18 25
2001 12 27 39
2002 3 29 32
2003 6 22 28
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
•
More than 200 times a year, besides an offence under the Opium Act, charges also include participation in a criminal organisation (Section 140, Netherlands Criminal Code). In 2003 this happened 223 times (see Table 8.9).
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Table 8.9
Number of final and conclusive judgments in respect of Section 140 Netherlands CC, from 1999 1999 292
Number of cases Section 140
2000 230
2001 215
2002 132
2003 223
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.5 Disposal by the Court As shown in Chapter 8.2.4, most of the Opium Act cases are brought before the Court. Table 8.10 shows the number of cases disposed by the Court. • In 2003, the Courts disposed of over twelve thousand Opium Act cases. This is an increase of 21 compared to 2002. This increase was already shown for a number of years in respect of both hard drug and soft drug cases, as well as in respect of cases with hard and soft drugs combined. This picture is in step with the figures of intake and of disposed cases of the Public Prosecutions d
•
Department (OM). Most of the cases here also concerned hard drugs. The proportion of hard drug cases steadily increased since 1999: from 54 percent in 1999 to 64 percent in 2003. The proportion of soft drug cases dropped since 1999 from 38 to 30 percent.
Table 8.10
Criminal cases disposed by the Court in first instance by type of drug, from 1999
Hard drugs Soft drugs Hard and soft drugs Total
1999 4 558 3 223 664 8 445
2000 4 720 2 744 609 8 073
2001 5 321 2 858 658 8 837
2002 6 543 3 078 581 10 202
2003 7 883 3 675 766 12 324
Hard drugs Soft drugs Hard and soft drugs Total
54% 38% 8% 100%
58% 34% 8% 100%
60% 32% 7% 100%
64% 30% 6% 100%
64% 30% 6% 100%
Source: Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.6 Penalties in Opium Act cases Table 8.11 describes the penalty probability and the types of penalties: financial out-of-court settlements by the Public Prosecutions Department and the orders for community service, unsuspended custodial sentences, fines and confiscations imposed by the Court. I. The penalty probability shows the likelihood whether or not an offender under the Opium Act will actually be e penalised.
d
The figures of the Public Prosecutions Department (OM) in Table 8.7 and the Court in Table 8.10 cannot be compared just like that: there is a time difference between the moment of intake of a case, the disposal by the Public Prosecutions Department (OM) and the moment of judgment by the court; the figures of the Public Prosecutions Department in Table 8.7 relate to cases disposed in final and conclusive judgment, those of the court in Table 8.10 relate to cases disposed in first instance. e The penalty probability is defined as the sum of all out-of-court settlements and guilty verdicts with penalties, divided by the total number of disposed cases (excluding joinder of charges and transfer of criminal proceedings).
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•
•
• •
The penalty probability increased slightly: from 86 percent in 2001 to 89 percent in 2002 and 2003. This means that a penalty was imposed in 89 out of 100 cases. The remainder of the suspects had their cases dismissed of had their cases acquitted. The increase may partly be due to "screening" by the police. Criminal cases are presently assessed by the police for the probability of prosecution. Such filtered cases do not always end up in the records of the Public Prosecutions Department (OM). The number of imposed community sentences rose again strongly in 2002 (+34%). The number of unsuspended prison sentences also continued to rise (+11%), although somewhat less strongly than in 2002. The increase in the number of unsuspended prison sentences was probably to a considerable extent due to the drug couriers arrested at Schiphol Airport (including what are called “drug swallowers”) (see also Chapter 8.2.7). The number of out-of-court settlements and fines did not change. The number of confiscations, though relatively low in absolute numbers, increased strongly in 2003.
Table 8.11
Penalty probability and number of unsuspended penalties in Opium Act cases, from 1999 1999 86%
2000 85%
2001 86%
2002 89%
2003 89%
Community service orders
2 129
2 138
2 382
2 985
4 008
Unsuspended custodial sentences
3 578
3 341
3 523
4 641
5 155
911
838
1 568
1 884
1 797
1 634
1 350
1 393
1 522
1 547
74
73
46
58
105
Penalty probability Kind of penalty
• • • • •
Financial out-ofcourt settlements Fines Confiscation orders
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
•
•
The average length of the imposed community sentences remained more or less the same throughout the years (see Table 8.12). In 2003, the average length of a community service sentence was 119 days. The average length of the unsuspended custodial sentences was relatively high in 2002 and again somewhat lower in 2003. In 2003, the length of imposed custodial sentences was 357 days on average.
Table 8.12
Average length (in days) of community service orders and unsuspended custodial sentences in Opium Act cases, from 1999
1999 Community service 124 orders Unsuspended custodial 369 sentences
2000 122
2001 121
2002 114
2003 119
348
356
382
357
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
134
•
• •
The amount of the imposed financial out-of-court settlements has increased in the course of years. f In 2003, the median amount was 320 euros (see Table 8.13). The highest amount of a financial out-of-court settlement in 2003 was 50,000 euros. The amount of fines increased in 2002 and 2003. In 2003 the median amount was 500 euros. The highest fine in 2003 was 900,000 euros. The amounts involved in confiscation orders varied considerably per year.
Table 8.13
Median amount in euros of financial out-of-court settlements and confiscation orders in Opium Act cases, from 1999
Financial out-of-court settlements Fines Confiscation orders
1999 183
2000 163
2001 214
2002 293
2003 320
459 4 018
459 3 511
458 6 112
509 619
500 2 616
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.7 Custodial sentences Opium Act As a result of custodial sentences imposed, a number of offenders end up in prison. Table 8.14 describes the number and length of the (partly) unsuspended custodial sentences imposed because of violation of the Opium Act.
• • •
In 2003, 15 percent of the total number of custodial sentences were custodial sentences for violations of the Opium Act. Since 1999, this number grew steadily. The increase is due to hard drug cases. In 2003 these made up 14 percent of the total number of custodial sentences. The proportion of soft drug cases remained stable. Of the detention years, 29 percent could be attributed to drug cases, 28 percent of which for hard drug cases, an increase compared to 2002. This increase in prison capacity requirement was caused largely by the increased focus on drug couriers at Schiphol. This is evident from the number of years of detention imposed for violations of the Opium Act in Haarlem, where these cases are handled. In 2003, 14 percent of all the detention years imposed in the Netherlands were related to drug cases in Haarlem.
f
The median is the value associated with the middle number in a set of ordered data (ascending or descending).The median is less sensitive to extremely high or low values than the arithmetical mean.
135
Table 8.14 Imposed unsuspended custodial sentences under the Opium Act by number and percentage of custodial sentences and length in years of detention, from 1999 Number of custodial sentences Total of Opium Act cases I hard drugs soft drugs Other criminal cases
1999 26 313 12% 11% 1% 88%
2000 27 021 11% 10% 1% 89%
2001 28 940 12% 11% 1% 88%
2002 32 849 14% 13% 1% 86%
2003 34 381 15% 14% 1% 85%
9 441 26% 24% 2% 74%
9 442 23% 22% 1% 77%
10 517 23% 22% 1% 77%
12 512 27% 26% 1% 73%
12 235 29% 28% 1% 71%
II
Years of detention Total of Opium Act cases I hard drugs soft drugs Other criminal cases
I. A case in which charges of a soft drug offence are brought, besides a hard drug offence, is classified under hard drugs. II. The number of years of detention is calculated by deducting the suspended part (that does not have to be served as a result of parole regulations) from the unsuspended prison sentence in each case. Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
In 2003, over 14,000 persons were detained in total, part of them because of violations of the Opium Act (see Table 8.15). • A quarter of the prison population was made up of offenders under the Opium Act in 2003. Compared to 2002 this is a decrease, whereas, over the period between 1999 and 2003, there was in increase of 21 to 25.
Table 8.15
1999 8 789 1%
2000 10 300 1%
2001 11 399 1%
2002 II 11 960 1%
2003 II 14 191 1%
Vandalism/disturbance of the public order
3%
2%
4%
4%
4%
Property offences
22%
20%
20%
19%
20%
Offences against the Opium Act
21%
21%
24%
27%
25%
Violent offences
43%
43%
42%
42%
43%
Unknown/other offences
11%
12%
9%
8%
7%
101%
99%
100%
101%
100%
Total number
• • • • • • •
I
Number of persons in penal institutions by type of offence, from 1999
Traffic offences
III
Total
I. The figures do not include detention of aliens. II. 2002 does not include detainees in detention centres, 2003 does include these. III. Not always exactly 100% due to rounding differences. Source: Enforcement of custodial measures in correctional institutions (TULP), National Agency of Correctional Institutions (DJI).
8.2.8 Recidivism of Opium Act offenders Despite having been sentenced, part of the Opium Act offenders came into renewed contact with the law. To get a picture of their recidivism, from the WODC Recidivist Monitor (see Appendix B) a selection was made of all the people who had been at least once in contact with the law in 1997 for
136
g
violation of the Opium Act. This resulted in a group of 8,708 Opium Act offenders. Of these people, the entire criminal record was subsequently requested. It was researched whether they came into renewed contact with the law in 1997 and if so, after how much time. In this respect, three types of recidivism have been distinguished. For the determination of the general recidivism, all the new contacts with the criminal justice system are counted, with the exception of matters ending in acquittal, dismissal by reason of likeliness of nonconviction or another technical judgment. We speak of serious recidivism in the case of new contacts with the criminal justice system for offences that carry a minimum sentence of four years. For the determination of the special recidivism of drug offenders, only new contacts with the criminal justice system because of a violation of the Opium Act are counted. Table 8.16 provides an overview of the percentage of Opium Act offenders who were in renewed contact with the criminal justice system within a period of one to five years. For purposes of comparison, the recidivism in the entire population of perpetrators has been stated.
•
• • • • •
h
The general picture is that drug offenders repeated an offence somewhat more often when compared to their proportion in the total offender population, that is to say all the offenders added up. Within one year after release, a quarter of all those convicted for drug offences against the Opium Act came into renewed contact with the law. Within five years this increased to 45 percent. Counting only cases of serious offences, the percentage of frequent offenders for violations of the Opium Act was 15 percent within one year, going up to 29 percent within five years. The proportion of frequent offenders under the Opium Act within five years (what is called special recidivism) was 22 percent. These data prove that Opium Act offenders did not just repeat the violations of the Opium Act, but also engaged in other forms of criminality. Male offenders under the Opium Act repeated the offence more often generally than female offenders (not included in the table). The criminal past played an important role. For individuals who had contacts with the criminal justice system for serious drug offences, the probability of recidivism after the initial case was higher. Moreover, the younger the perpetrator was at the first contact with the law, the larger the probability of recidivism at a later stage.
Table 8.14
Percentage of frequent offenders after having violated the Opium Act, cumulatively over a period of five years
• •
OA 45%
5 years II total 42%
General
OA 25%
1 year II total 22%
Serious
15%
14%
21%
19%
25%
23%
28%
25%
29%
26%
Special
10%
-
15%
-
18%
-
20%
-
22%
-
Type of repeat offence
•
O b s e r v a t i on P e r i o d 2 years 3 years 4 years I II I II I II OA total OA total OA total 34% 31% 40% 36% 43% 39%
I
I
I. Perpetrators who were in contact with the law in 1997 for a violation of the Opium Act (OA). II. All the perpetrators who were in contact with the law in 1997. Source: Recidivism Monitor, Research and Documentation Centre of the Ministry of Justice (WODC).
Table 8.17 provides an outline of numbers of Opium Act offences in the distinguished phases of the criminal law chain in 2003. The figures are based on various sources and their mutual relationship
g
Including 7 (0.1%) offences under the Misuse of Chemicals Prevention Act (WVMC). Determination of the special recidivism or recidivism in the framework of the Opium Act is not meaningful, because the nature of the initial cases of the perpetrators varies widely. This contrary to the initial cases of drug offenders, which always concern a violation of the Opium Act or of the Abuse of Chemical Substances Prevention Act (WVMC). h
137
must be interpreted with caution. It is apparent once more that hard drug offences occurred more often in all the phases than soft drug offences. This difference increased as we progress in the chain.
Table 8.17
Number of suspects at the police, Royal Military Police (KMar) and Public Prosecutions Department (OM), persons sentences by the Court, prison sentences and years of detention for Opium Act offences by phase in the criminal law chain and hard and/or soft drugs, 2003 Phase in chain Police KMar OM Court in first Custodial I instance sentences Total Opium Act 14 299 1 640 17 087 12 324 5 137 7 744 1 491 9 989 7 883 4 618 • Hard drugs 5 495 137 6 156 3 675 370 • Soft drugs 1 060 12 942 766 149 • Both % 54% 91% 58% 64% 90% • Hard drugs 38% 8% 36% 30% 7% • Soft drugs 7% 1% 6% 6% 3% • Both
Years of detention 3 600 3 298 145 157 92% 4% 4%
I. Eighteen sentences and years of detention are missing: these cannot be categorised by kind of drug or the duration of the sentence is unknown. Sources: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service (DNRI); Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC); Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.3
CRIMINAL DRUG USERS
8.3.1 Profiles of drug using suspects Tables 8.18 and 8.19 display characteristics of suspects recorded as “drug users” in the Police Records System (HKS). In the HKS, addiction of use of drugs is not recorded as such. Nevertheless a rough description can be given of the group of suspected drug users by using what is called the ‘danger classification’ in the HKS. If it has become known that a suspect is a problem user of drugs, or if the suspect has indicated this, that suspect is recorded in the system as “drug user” in what is called “danger classifications”. The extent of drug addiction cannot be accurately established on the basis of the available data. There are doubts about the completeness of the recording of drug use; it is 3 assumed that it concerns a minimum indication.
138
Table 8.18
Profiles of suspects recorded as “drug users”, from 1999
Number of suspects Gender
Men Women
Town or city by number Under 20 000 I of inhabitants 20 000 – 50 000 50 000 – 100 000 100 000 – 150 000 150 000 – 250 000 250 000 and over Abroad Unknown Danger classification
Alcohol Drugs Otherwise
II
1999 9 972 90% 10%
2000 9 251 90% 10%
2001 2002 2003 9 947 10 525 10 247 91% 90% 90% 9% 10% 10%
4%
4%
4%
4%
4%
11% 12% 10% 9% 46% 6% 2%
11% 12% 10% 10% 47% 5% 2%
11% 12% 10% 10% 45% 5% 4%
10% 12% 11% 10% 45% 5% 3%
10% 11% 11% 10% 44% 4% 6%
11% 100% 19%
11% 100% 20%
12% 100% 20%
11% 100% 20%
11% 100% 21%
Age upon recording of 12-17 latest offence 18-24 25-34 35-44 45-54 55 years and over
0%
0%
0%
0%
0%
9% 43% 37% 9% 1%
9% 41% 39% 10% 1%
8% 38% 40% 12% 1%
8% 36% 41% 14% 1%
7% 33% 42% 16% 2%
Average age (year)
34.4
34.8
35.4
36.3
36.8
I. Last known domicile or residence. II. Provisional figures: HKS data of the last year are retrieved once more after a year. We know from experience that there will be an addition of approximately 6%. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
• •
• •
•
Nine in ten suspects recorded as drug users were men. This proportion remained constant over the years. The distribution of drug using suspects by size of the towns or cities in which the drug using suspects live, also remained practically constant: nearly half the suspects (44%) lived in cities of 250,000 or more inhabitants. Of these drug using suspects, 11 percent were also recorded as addicted to alcohol and 21 percents also as addicted to other substances (such as licit drugs). Often the suspects who are classified as drug users got in contact with the police for the first time at a young age: in 2003, nearly half (45%) were younger than 18 years at the time the first offence was recorded, three-quarters (77%) were younger than 25 (not shown in the table). The average age at the most recent offence was slightly higher in 2003 than in 2002 and was about 37.
139
Table 8.19
Characteristics of offences by suspects recorded as “drug users”, from 1999 I
1 2 3-4 5-10 11-20 21-50 >50
II
Sexual assault Other violence Theft with violence / extortion Property offences Vandalism, disturbance of the public order / authorities Traffic offences Offences against the Opium Act Other offences
Criminal record
Type of offence
1999 3% 3% 5% 16% 20% 31% 21%
2000 3% 3% 5% 15% 20% 32% 22%
2001 4% 3% 5% 15% 20% 32% 22%
2002 4% 3% 6% 16% 21% 32% 20%
2003 3% 2% 5% 15% 20% 32% 20%
1% 19% 12% 63% 20%
2% 20% 12% 63% 21%
1% 20% 12% 63% 21%
1% 22% 12% 63% 22%
1% 23% 11% 58% 22%
10% 20%
11% 18%
11% 19%
10% 19%
10% 22%
10%
11%
10%
10%
10%
I. Total number of criminal records in the entire prior criminal history. II. Suspects may have committed more than one type of offence; consequently, the percentages should not be added up. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
• •
Against the vast majority of the suspects classified as drug users an earlier police record was drawn up because of a criminal offence and 72% has more than ten earlier criminal records. Nearly six out of ten suspects were booked for a property offence. In 2003, this percentage was lower than in 2002. The category "other offences" was slightly higher than in earlier years, as was the category ‘Opium Act’.
8.3.2 Proportion of drug users in the population of frequent offenders on judicial level A recent WODC report shows that the judicial system has to deal with a group of more than 6000 'very 154 high rate frequent' offenders. These are offenders who had more than ten valid penal cases in the previous period of five years. The authors did additional analyses based on information, recorded in i
the criminal files. • An estimated 70 percent of the very high rate frequent offenders were regular users of hard drugs and more than 10 percent had to cope with alcohol problems (see Table 8.20). This analysis shows that the group of frequent offenders, at any rate the most active, corresponded to a large extent with the group of regular hard drug users.
i
Sample from the Criminal Justice Monitor (SRM) (see Appendix B).
140
Table 8.20
Profile of frequent offenders on judicial level in the years 1993, 1995 and 1999
Number Regular hard drug use Alcohol problems
Low rate frequent offenders
High rate frequent offenders
Very high rate frequent offenders
Total group of offenders
252
248
145
2 480
17% 7%
36% 10%
71% 12%
14% 4%
Source: Criminal Justice Monitor (SRM)/Recidivism Monitor of the Research and Documentation 155 Centre of the Ministry of Justice (WODC).
8.4
HELP FOR PROBLEM USERS IN THE CRIMINAL SYSTEM
Problem users of drugs in the criminal system can receive support and help in respect of their (addiction) problems in several manners. The Netherlands (Drug) Rehabilitation Foundation offers possibilities and, inter alia, contacts suspected or convicted users and prepares reports for the Public Prosecutions Department and the Court about the possibilities for an individual care program. In addition, there are possibilities for users to participate in a care program as an alternative to prosecution and penalties. Programs in detention prepare users in a placement and selection phase. Since 2001, it has become legally possible for the Courts to mandate drug users to undergo treatment: Judicial Treatment of Addicts (SOV). In this paragraph we shall describe which help was available in 2003 and how often problem users made use of it: • the Netherlands (Drug) Rehabilitation Foundation (see Chapter 8.4.1) • alternatives for prosecution and penalties and placement and selection phase (see Chapter 8.4.2) • intake in the Judicial Treatment of Addicts (SOV) (see Chapter 8.4.3). The figures are based on the following sources: • The Client Follow-up System (CVS) of the (addiction) probation service implemented in 2001 (see 156 Appendix B). This system does not give complete nationwide information about the nature of the addiction of the clients (alcohol, drugs, gambling, etc.) or about the type of drug (heroin, j
cocaine, etc.). The figures have therefore not been specified by type of addiction. Figures on k
•
•
client level are not available either. It is not known how reliable the figures are. The National Agency of Correctional Institutions has provided information about Drug-free Units (VBAs) in penitentiaries. Figures about the intake in and outflow from the Judicial Treatment of Addicts (SOV) are based on data from the SOV locations and have been obtained via the Trimbos Institute.
j
Data from the National Information System on Alcohol and Drugs (LADIS) of before 2001 show that drug addicts make up approx. 60% of the clients of the probation service for addicts. The second large category is made up of clients with alcohol-related problems as a primary diagnosis. The drug clients were mainly users of hard drug: opiates, psychoanaleptic drugs (including cocaine) and poly-drug use. The trend was in the direction of fewer opiates and more psychoanaleptic drugs. k In the annual accounts 2003 the remark is made that the retrieval of overviews is very time-consuming and that there is doubt about the reliability of the overviews.
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8.4.1 The Netherlands (Drug) Rehabilitation Foundation The Netherlands (Drug) Rehabilitation Foundation offers users in the criminal system various forms of support, within budgetary and policy-related limits. It forms a bridge between the judicial authorities and the care organisations. • From the approx. 50 establishments, 15 care organisations for addicts recognised in the 138 framework of the Netherlands (Drug) Rehabilitation Foundation are active. These form a nationwide network. • In 2002, 44 percent of the clients of the Netherlands (Drug) Rehabilitation Foundation were in predetention, 41 percent served a prison sentence. No figures are available for 2003. In 2003, the Netherlands (Drug) Rehabilitation Foundation carried out twelve key activities for 156;158 justiciable individuals. Table 8.21 shows how often these activities have been carried out. The numbers relate to all kinds of problems (drugs, alcohol, gambling, etc). In 2003, the activity “diagnosis” l
was defined anew. This was related to the implementation of a standard instrument - the RISC - that was implemented in the framework of the judicial program Terugdringen Recidive [Reducing Recidivism] and that must be applied and recorded by the Netherlands (Drug) Rehabilitation Foundation and staff in penitentiaries.
Table 8.21
Number of times that the Netherlands (Drug) Rehabilitation Foundation carried I, II out key activities in 2002 and 2003 III Products 2002 2003 Visit for early assessment of needs 3 629 4 305 Early assessment intervention report 995 922 Counselling for treatment 10 048 9 156 IV Diagnosis 10 615 Placement and selection phase 1 568 2 115 Supervision 2 407 3 726 Reintegration program 1 696 2 566 Community service order 3 382 4 098 Training order 139 217 Social inquiry report 4 423 4 254 Recommendation report 2 989 4 408 Nonpunitive order report 175 84 I. No figures on client level or specified by the type of substance are available. II. Figures 2001 not given, figures different, implementation process Client Follow-up System (CVS) took place that year. III. The figures relate to established production after accounting audit. IV. Newly defined in 2003. Source: Netherlands (Drug) 140 Rehabilitation Foundation (SVG).
•
Visits to make an early assessment of needs were made more than 4,000 times in 2003, which is more often than in 2002. It concerns the first visit to a detainee, a suspect taken into police custody or placed in a detention centre, more specifically on detainees who are actually expected to be taken in by the care organisations. In the last few years, the number of visits to make an early assessment of needs was between 3,600 and 4,000.
l
The RISC (Risk Assessment Scales) is an instrument for rehabilitation services and the prison service; it is used to achieve an assessment of the chance of recidivism and to make the correct choice of intervention for the client. Diagnostics through RISC makes an assessment possible of the risk of recidivism and of the danger that a client poses for himself/herself and others. Moreover, it shows in which areas of life the client has needs or deficiencies and which possibilities of lack thereof someone has to participate in specific interventions.
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•
In the case of early assessment intervention, a report is submitted to the Court recommending whether or not the pre-trial detention should continue (and the manner in which). In 2003, this type of intervention was carried out more than 900 times. This number hardly differs from that in 2002.
•
Part of the counselling for treatment is the ‘systematic approach that is used for drawing up, coordinating and evaluating a plan of action based on examination’. In 2003, counselling for treatment took place more than 9,000 times, which is less often than in 2002.
•
Diagnoses were recorded as such for the first time in 2003. Redefining and the new manner of recording have to do with the development of a new diagnostic instrument (the RISC), which is to be the standard in the future. In 2003, the number of diagnoses made by the Netherlands (Drug) Rehabilitation Foundation was over 10,000.
•
In the placement and selection phase it concerns the effort required to place a client in a care institution. The placement and selection phase may take place at any stage of the criminal process: from the stay in a police cell or the remand centre up to and including the stage of 159 detention. In 2003, more than 2,000 efforts for placement and selection were carried out, more than in 2002.
•
The Netherlands (Drug) Rehabilitation Foundation supervises clients in the framework of a judicial decision in all the phases of the criminal process. In 2003, more than 3,700 supervision records were made.
•
In reintegration programmes, the Netherlands (Drug) Rehabilitation Foundation provides training to teach clients insight and/or skills in the field of living, work, education, finances, behaviour, relationships, etc. The activities within the Drug-Free Units (VBAs) in penitentiaries are part of this. In 2003, activities in this framework took place more than 2,500 times, an increase compared to 2002.
•
In 2003, the Netherlands (Drug) Rehabilitation Foundation was more than 4,000 times involved in the execution of a community service order or training order. This is also more than in 2002.
The Netherlands (Drug) Rehabilitation Foundation prepares various kinds of reports: social inquiry, recommendation and nonpunitive order reports (see Table 8.22). • Social inquiry reports give written information to the Court in respect of the decision about prosecution, adjudication or the enforcement of a sentence and/or (punitive) order. Social inquiry reports are prepared during police custody, remand in custody or pre-trial detention. The number of social inquiry reports, which are usually requested by the judicial authorities, fluctuated around 4,000 over the years.
•
A recommendation report is a limited, written manner of giving information about the client to a (judicial) authority in respect of a specific question or a decision to be taken Recommendation reports are prepared throughout the entire judicial process. In 2003, the number of recommendation reports increased by nearly 50 percent to more than 4,000.
•
Nonpunitive order reports concern written information to the Ministry of Justice, the Forensic Psychiatric Service (FPD), institution in the framework of a hospital order (TBS) and/or the Court in respect of decisions about a nonpunitive order. These reports relate, inter alia, to the Judicial Treatment of Addicts (SOV). In 2003, 84 reports were prepared.
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Table 8.22
Number of reports prepared by the Netherlands (Drug) Rehabilitation Foundation, from 1999
Year
Social inquiry reports
Recommendation reports
1999 2000 2001 2002 2003
4 427 4 113 3 303 4 423 4 254
2 269 2 555 2 292 2 989 4 408
Nonpunitive order reports 175 84
Source: Netherlands (Drug) Rehabilitation Foundation (SVG).
8.4.2 Treatment processes as an alternative for prosecution and penalties Since the nineties, judicial policy has focused explicitly on leading criminal drug users to treatment 160 processes as an alternative for prosecution and penalties. This aims to improve the situation of the user via a treatment process and - as a result - to reduce nuisance and criminal recidivism. In all the phases of the criminal process, from the arrest up to their detention, there are possibilities to be received into a treatment process. In the initial phase and the final phase, intake occurs only on a voluntary basis. From remand in custody to detention, coercion is possible. In the case of coercion, users have the choice between participation in a treatment process, on the one hand, and prosecution or a penalty (often detention), on the other hand. The choice is not without commitment: if the user does not satisfy the conditions and agreements, further prosecution, conviction or execution of penalties is bound to take place. This is the coercion, the big stick. There are various judicial options for intake in treatment processes from the criminal system (see Table 8.23). The table also includes the compulsory measure of Judicial Treatment of Addicts (SOV). • During the police phase, there are no options for coercion. Users may approach the treatment service at their own initiative. • During pre-trial detention, there is the option of (conditional) dismissal and suspension of the detention under conditions, the condition being participation in a treatment process. • While brought before the public prosecutor and during court hearing, the proceedings may be stayed or a suspended sentence may be imposed under the condition of participation in a treatment process. • Since April 2001, it has been possible to impose the nonpunitive order Judicial Treatment of Addicts (SOV), placing a drug user in a special custodial institution. • During detention, it is possible to participate in detention replacing treatment pursuant to Section 43 of the Prisons Act (PBW). This section provides the possibility to transfer detainees to a treatment facility, possibly outside of the penitentiary institution. • At the last stage of detention, participation in a Penitentiary Program outside of the penitentiary institution is possible. This program provides guided use of facilities outside of the penitentiary institution, while the detainee may also participate in social activities without the care organisations. • At the end of the chain, at the end of the detention, any intake in the treatment services is on a voluntary basis. • In 2003, no changes were made to the criminal options compared to 2002.
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Table 8.23
Criminal options for intake in treatment processes for drug users by phase in the custody chain, situation 2003
Phase in custody chain During police custody and remand in custody without extension (police phase) During pre-trial custody
Judicial option
• •
•
While brought before the public prosecutor and during court hearing
•
•
•
During detention
•
• Post-detention
•
Coercion or compulsion No coercion possible; intake in None treatment process on a voluntary basis (Conditional) dismissal by the Public Intake in treatment process under coercion; agreement of addict Prosecutions Department (OM) (Section 167 of the Netherlands Code required of Criminal Procedure) Conditional suspension of pre-trial detention (Section 80 of the Netherlands Code of Criminal Procedure) Staying of the court hearing/deferment of sentencing (Sections 281 and 346 of the Netherlands Code of Criminal Procedure)
Intake in treatment process under coercion; agreement of addict required
Awarding of a (partly) suspended sentence with the condition to enter a particular treatment or care program, specified during the hearing (Sections 14a and 14c of the Netherlands Code of Criminal Procedure) Imposing of nonpunitive order Judicial Treatment of Addicts (SOV) (Section 38m of the Netherlands Code of Criminal Procedure)
Compulsion, nonpunitive order may be imposed without the agreement of the addict
Participation in treatment process, if necessary outside of the penitentiary institution in a residential clinic (Section 43 Prisons Act)
Intake in treatment process under coercion; agreement of addict required
Participation in a penitentiary program (Section 4 Prisons Act) None
No coercion possible; intake in treatment process on a voluntary basis
Source: Research and Documentation Centre of the Ministry of Justice (WODC).
•
•
• •
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In penitentiary institutions, detained problem users receive the possibility to be placed in the DrugFree Units (VBAs) on a voluntary basis. VBAs are meant as a placement and selection program to a treatment process. In 2003 there were 12 VBAs with 325 places. In 2002, drug users participated 758 times in a VBA compared to 680 in 2003. No figures are known about the use of the distinguished judicial options by problem users of drugs. The application of coercion and the effectiveness of the treatment processes that the 161 judicial authorities use towards the care organisations appear capable of improvement. In 2003, 2,115 efforts for placement and selection were carried out (see Table 8.24). Not all the efforts for placement and selection that were started in 2003 have been realised. Figures from the Netherlands (Drug) Rehabilitation Foundation show that of the over 3,000 efforts for placement and selection that were started two thirds (67%) were actually realised according to plan. In one-third of the cases the placement and selection phase for treatment was not completed
145
•
as planned. In these cases the process was broken off prematurely for one reason or other (e.g. by the addict or by the care organisation). These figures are the same as in 2002. The various possible treatment processes are not specifically related to one of the (above described) judicial modality. From the judicial system, a user may go to many possible facilities that are not financed by the Ministry of Justice, as long as the decisive authority (usually the judge or the selection official) finds this an appropriate and acceptable process.
•
The influx from the judicial system into treatment processes takes place mainly into clinical, outpatient and part-time facilities in the addiction care that are not financed by the Ministry of Justice (see Table 8.23).
•
The categories of clinical, outpatient and part-time care organisations for addicts comprise services with various objectives and target groups (see Appendix D).
Table 8.24
Placement and selection efforts to treatment by the Netherlands (Drug) I Rehabilitation Foundation by type of treatment process in 2002 and 2003
Type of treatment process: Clinical treatment of addicts Outpatient and part-time treatment of addicts Social care Psychiatric care by a General Psychiatric Hospital (APZ) Non-clinical psychiatric care Psychiatric part-time treatment Social pensions Homes for the homeless Psychiatric outpatient clinic Crisis shelter 24 hours Other facilities Total
II
2002 650 474
42% 30%
2003 889 41% 726 34%
126 123
8% 8%
171 76
8% 4%
44 28 24 22 20 19 38 1 568
3% 2% 2% 1% 1% 1% 2% 100%
83 50 23 25 35 19 56 2 153
4% 2% 1% 1% 2% 1% 3% 101%
I. No figures available on client level, not specified by type of substance. II. Figures 2003 calculated based on production overview 31-05-2004, production figures not yet audited. This is the reason for differences with Table 8.20. Source: Netherlands (Drug) Rehabilitation Foundation (SVG).
8.4.3 The Judicial Treatment of Addicts (SOV) With effect of 1 April 2001, it has become legally possible for the courts to mandate criminal problem users of drugs to undergo treatment in a special custodial facility with a partly inpatient and partly outpatient program. The “Judicial Treatment of Addicts” (SOV) Order is presently implemented as a temporary experiment in specially equipped correctional facilities.
•
The order is imposed by a three-judge criminal section of the court at the request of the Public Prosecutions Department, if the suspect has committed a crime that is subject to pre-trial detention, is drug-dependent, has been sentenced to a custodial punishment at least three times in the five years prior to the current offence, has participated without success in compulsory drug treatment in the past and does not suffer from a serious psychiatric disorder. The SOV is only meant for men who have the Dutch nationality.
•
The Judicial Treatment of Addicts order has a mandatory term of two years. The Judicial Treatment of Addicts program has a phased system with a closed phase, a half-open phase and an open phase outside of the institution. The duration of each phase is six to nine months. The order includes a "unit 4". There those persons are placed who do not (or temporarily not) wish to cooperate with the program provided in the framework of the order. They will undergo minimum treatment.
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•
The Judicial Treatment of Addicts (SOV) started in 2001 in four different locations: Rotterdam (start date 1 April 2001), Amsterdam (start date 1 May 2001), Utrecht (start date October 2001) and in the South (Arnhem, Nijmegen, Den Bosch, Eindhoven, Maastricht and Heerlen; start date October 2001). The first participant was accepted in June 2001. The total capacity is 219 places.
•
The number of participants in the SOV increased steadily in 1003, as it did in 2002: from 157 in January 2003 to 178 in June and 192 end December 2003. Between July and November 2003 the number was more or less stable (see Figure 8.1).
Figure 8.1
Number of participants in the Judicial Treatment of Addicts (SOV) per month in 2003
250
192
200 163
165
174
157
170
178
Jan
Feb
Mar
Apr
May
Jun
183
184
181
183
184
Jul
Aug
Sep
Oct
Nov
150
100
50
0 Dec
Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
The degree of capacity utilisation increased also. In 2003 the degree of capacity utilisation increased from 71 percent in January to 78 percent in June and subsequently to 85 percent in December. End 2003, 15 percent of the available (inpatient) places were still empty (see Table 8.25). End 2002 this was still 32 percent.
•
The degree of capacity utilisation varied per location. In December 2003, the degree of capacity utilisation in Amsterdam was 94%, in Rotterdam 85 percent, in Utrecht 91 percent and in the South (Arnhem, Nijmegen, Den Bosch, Eindhoven, Maastricht and Heerlen) 65%.
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Table 8.25
Number of participants and degree of utilisation of the Judicial Treatment of Addicts (SOV) by location Survey dates 31 January, 30 June and 32 December I 2003 II
Amsterdam Rotterdam Utrecht South Total Jan Jun Dec Jan Jun Dec Jan Jun Dec Jan Jun Dec Jan Jun Dec 65 69 68 47 54 61 23 25 32 20 22 26 155 170 187
Number of participants Degree of capacity utilisation (%)
90
96
94
65
75
85
66
71
91
50
55
65
71
78
85
I. Counted exclusive of participants in phase 3. II. South in December 2003: Arnhem: 6, Nijmegen: 2, Heerlen: 5, Den Bosch: 5, Eindhoven: 6, Maastricht: 2. Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
End December 2003, 90 participants were in phase 1, 61 in phase 2 and 5 in phase 3; 28 participants were staying in unit 4 and 7 participants underwent treatment in another facility while retaining their SOV status. Eight persons were already in the Judicial Treatment for Addicts (SOV) before it was imposed (preventives or pre-SOVs; see Table 8.26).
Table 8.26
Participants in the Judicial Treatment for Addicts (SOV) by phase, stay in unit 4 and in another facility. Survey date 31 December 2003
Phase/unit Preventive or pre-SOV Phase 1 Phase 2 Phase 3 Unit 4 In another facility while retaining SOV status Total
Number of participants 8 90 61 5 28 7 I 200
I. Included: one participant who is a fugitive. Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
In 2003, the outflow started on a regular basis, that is to say the outflow of drug addicts who had completed the SOV program. On 22 April 2003, the first participant completed this treatment and left. In December 2003, 22 participants completed the treatment and left. The Judicial Treatment for Addicts (SOV) was ended seven times prematurely by the Court.
•
Information about the processes and effectiveness of this drug treatment order is not yet available. In September 2001, the process evaluation of the SOV commenced. The results will become available at the beginning of 2005. The effect evaluation commenced in June 2002, with the final results expected in late 2006.
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Appendix A
Glossary of Terms
This appendix consists of two parts. In the first part, concepts in the field of the use of substances and addiction are explained. In the second part, concepts in the field of drug crime are explained. I.
USE OF SUBSTANCES AND ADDICTION
Abuse A form of problematic use of a substance, whereas there is no addiction (yet). Abuse is established via diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Characteristics of abuse are: nonfulfilment of obligations at home, at school or at work, use in dangerous situations (for example, driving under the influence), being in contact with the criminal judicial system and continued use despite the problems created by this. Addiction Problematic use of a substance while there is dependence. As a rule, in this Annual Report, by "addiction" is understood the clinical diagnosis of dependence. However, for judicial monitors it is not possible to make clinical diagnoses. Judicial monitors record, for example, additional danger because of drug use or ‘clear indications for addiction’ (see Chapter 8.3.2., Criminal Justice Monitor (SRM)). The clinical diagnosis of dependence is made via classification systems as the Diagnostic and Statistic Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Characteristics of dependence are: frequent use of large quantities or for a longer period of time, the need of ever increasing quantities of the substance to cause the desired effect (habituation), withdrawal symptoms, use of the substance against withdrawal symptoms, wanting to stop while not succeeding, spending much time to obtain the substance or to recover from it, dropping important activities at home, at school, at work or during leisure time and continuing the use in spite of the realisation that this causes many problems. Client LADIS Client of the (inpatient) care organisations of drug addicts, of whom some details about his/her background, treatment demand and received treatment are recorded anonymously in the LADIS, the National Information System on Alcohol and Drugs. Clients are registered with the care organisations for many forms of help, from a therapeutic treatment to help in the form of debt rescheduling, methadone provision, social rehabilitation or controlled access to a users’ room. Clients who do no longer use the aid organisation after some time are deregistered automatically and are no longer included in the number of clients. Clinical admission Admission in a hospital while the patient stays for one or more nights in the hospital. Current use The use of a substance in the last month, irrespective of the frequency (from one-time to daily). Current users are included automatically as part of the recent users (use in the past year), who are again included automatically as part of the ever users (use ever in life). Day-treatment admission Admission in a hospital for maximum one day, while the patient does not stay overnight in the hospital. Dependence See: Addiction.
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DSM DSM stands for Diagnostic and Statistical Manual of Mental Disorders. The DSM is a manual to determine from which mental disorder somebody suffers. According to the DSM, addiction is one of the mental disorders. The DSM-III-r is the third revised version and the DSM-IV is the fourth version. Ever use The use of a substance ever in a life-time, irrespective of the frequency (from one-time to daily). Hallucination Perception (seeing, hearing or feeling) that someone has, but that is not shared by other people. Hallucinations may be a symptom of a mental disorder, but are called up intentionally by some people via hallucinogens. Hallucinogens Substances calling up hallucinations, such as paddo's and LSD. Are also called psychodysleptics. Cannabis may also cause hallucinations sometimes. Hardcore Hard form of music at house parties. Hard drugs Drugs appearing in list I of the Opium Act. These drugs create an unacceptable risk to public health. Hard drugs include heroin, cocaine, crack, ecstasy and amphetamine. Hepatitis A highly contagious disease in which the liver is affected by the hepatitis virus. The hepatitis virus appears in various forms: the hepatitis A, the hepatitis B and the hepatitis C virus. HBV is the hepatitis B virus and HCV is the hepatitis C virus. ICD International Classification of Diseases. The ICD is the diagnostic classification system of the World Health Organisation (WHO) for physical diseases, accidents and mental disorders. Causes of death are also recorded in ICD codes. The ICD-9 is the ninth and the ICD-10 is the tenth version. See also Appendix C. Immigrant, foreign, ethnic Due to different definitions, figures about immigrants are not always comparable. Some definitions are: According to the Ministry of Home Affairs, the Association of Dutch Municipalities, the National Representative School Survey, the Antenne Monitor and as generally used in this Annual Report (unless stated otherwise): "immigrant" is an inhabitant of the Netherlands who was born abroad, or an inhabitant with at least one parent who was born abroad. According to Statistics Netherlands (CBS): "immigrant" is an inhabitant of the Netherlands with at least one parent who was born abroad, irrespective of the country of birth of the person himself/herself. According to the Amsterdam Area Health Authority (GG&GD Amsterdam): "foreigner" is an inhabitant who was born abroad. According to National Information System on Alcohol and Drugs (LADIS): "immigrant" is a client who in his own perception has a cultural origin from outside of the Netherlands. Inpatient care organisations for addicts Care of addicts in which the client is not admitted in a facility.
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Mellow Form of music at house parties that is melodious and less hard than hardcore music. Narcotics Drugs. General collective term for narcotic drugs. Native Dutch According to the Ministry of Home Affairs, the Association of Dutch Municipalities, the National Representative School Survey, the Antenne Monitor and as generally used in this Annual Report (unless stated otherwise): "native Dutch" is a person who was born in the Netherlands while both parents were also born in the Netherlands. Nederwiet Weed (a cannabis product) grown in the Netherlands. Outpatient care organisations for addicts Care of addicts in which the client is not admitted in a facility. In the case of inpatient care of addicts, the client is admitted in a facility. Parkstad Limburg The cooperation between the South-Limburg municipalities of Brunssum, Heerlen, Kerkrade, Landgraaf, Nuth, Onderbanken, Simpelveld and Voerendaal. (The municipality of Nuth has meanwhile left the cooperation.) Party drugs Drugs used by some party-goers at parties, such as ecstasy, amphetamines, cannabis, GHB and LSD. Poly drug use The use of various drugs one after the other, for example heroin and cocaine. Primary cause of death The direct cause of somebody’s death. If someone dies directly as a result of a drug overdose, then this is the primary cause of death. If somebody dies as a result of an accident that took place while he or she was under the influence of a drug, then the accident is the primary cause of death. The drug is then a secondary cause of death. Primary diagnosis The primary disease for which someone is admitted in a hospital. Primary problem If someone has a problem with two (or more) substances, the primary problem is the substance causing the largest problem. The other substance is then the secondary problem. Problematic use The use of a substance in such a manner that it causes physical, mental or social problems or in such a manner that it causes social nuisance. Problematic use does not always mean addiction. "Abuse" is a form of problematic use, whereas there is no addiction. Psychodysleptics See: Hallucinogens.
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Psychosis Mental disorder in which someone has hallucinations, i.e. sees, hears or feels things that are not perceived by other people. If the disorder lasts less than one month, it is called a short term psychotic disorder. Smoking Chinese-style Smoking of heroin from aluminium foil. Secondary diagnosis An additional or underlying disease for which someone is admitted in hospital in addition to the primary disease (primary diagnosis). Recent use The use of a substance in the last year, irrespective of the frequency (from one-time to daily). Recent users are included automatically as part of the ever users (use ever in lifetime). Recreational use Use of a substance (usually during leisure time) in which the substance is enjoyed without a question of problematic use (abuse or addiction). Schizophrenia Mental disorder in which someone has hallucinations, i.e. sees, hears or feels things that are not perceived by other people. As a result of this disorder, one's functioning at school, work and in the family is affected. The disorder is only called schizophrenia if it lasts at least six months. Secondary cause of death A cause that contributed indirectly to the death. If somebody dies as a result of an accident that took place when he or she was under the influence of a drug, then the drug is a secondary cause of death. Special education Special education for children with learning difficulties (MLK), special education for children with learning and behavioural difficulties (LOM) and special education for children with severe behavioural learning problems (ZMOK). Secondary problem If someone has a problem with two (or more) substances, the secondary problem is the substance causing relatively the smallest problem. The other substance is then the primary problem. Soft drugs Drugs in list II of the Opium Act, such as cannabis and paddo's. Drugs with less risk for public health than the hard drugs in list I of the Opium Act. THC Tetrahydrocannabinol, the main psychoactive ingredient of cannabis. Use The use of a substance ever in lifetime (ever use), in the past year (recent use), or in the past month (current use). Current users are included automatically as part of the recent users, who are again included automatically as part of the ever users.
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II.
DRUG CRIME
a
Acquittal Judgment by the court in which the court does not consider it proved that the charge made by the public prosecutor was committed by the suspect. See also: Discharge from further prosecution, Conviction. Appeal Ordinary legal remedy granted to any party which appeared in the first instance and which was partially or entirely unsuccessful; the reason for the proceedings is the judgment pronounced in the first instance. Bar to the prosecution Final decision in which the court rejects the request or claim of a party or denies the right of the Public Prosecutions Department to prosecute based on a ground that is not part of the case itself (for example, a procedural error). Coercion Coercion means that a user who is dealt with by the criminal system because of the umpteenth offence is ‘pushed' in the direction of a treatment process. The user has the choice between a treatment process and a penal sanction. The choice has consequences: if the user opts for a treatment process, not only can he improve his situation, but also further prosecution and penalty will be suspended. If he does not opt for that, or if he does not satisfy the conditions of the judicial authorities, execution of the penal sanction will follow. See also: Compulsion.
Compulsion Contrary to “coercion”, in the case of compulsion the user has no choice. He can be admitted without his consent. In the case of repeat criminal offenders among hard drug users this can be done by imposition of the nonpunitive order Judicial Treatment of Addicts (SOV). See also: Coercion.
Conviction Judgment by the court in which the court considers the fact charged by the Public Prosecutions Department proved, considers it an offence and is of the opinion that the suspect is punishable. Court of law Court of justice that takes cognizance in the first instance of all the cases for which no other court has been designated. There are 19 courts of law. N.B. As of 1 January 2002 the subdistrict courts have become part of the organisation of the courts of law. Crime Heavy kind of offence, named thus in criminal law; categorising offences as crimes and minor offences is pertinent to procedural law (absolute competence and legal remedies) and to the penalization; disposal in the first instance is usually carried out by the court a
Source of list of concepts: Statistics Netherlands (CBS), Voorburg/Heerlen, 2003; Research and Documentation Centre of the Ministry of Justice (WODC)
153
See also: Minor offence.
Criminal record A criminal record is a police contact during which a report of one or more crimes was drawn up. Criminal case The police report in respect of one suspect that is registered at a public prosecutor’s office for prosecution. Custodial sentence Prison sentence, for life or for a period of maximum twenty years, usually served in a prison. See also: Detention. Detention Principal detention: custodial sentence for a period of maximum 1 year and 4 months, of a lighter nature than imprisonment and usually served in a remand centre Alternative imprisonment: custodial sentence because of non-payment or only partial payment of a fine. Discharge from (any) further prosecution Judgment of the court in which, on the one hand, the court considers the fact charged by the public prosecutor proved, but, on the other hand, is of the opinion that the fact or the suspect is not punishable. See also: Conviction, Acquittal. Discretionary dismissal Decision of the Public Prosecutions Department waiving prosecution of an established offence in the public interest. See also: Dismissal. Dismissal Decision of the Public Prosecutions Department waiving prosecution of an established offence on policy-related or technical grounds. See also: Discretionary dismissal, Dismissal by reasons of likeliness of nonconviction. Dismissal by reasons of likeliness of nonconviction Decision of the Public Prosecutions Department to waive prosecution of an offence, as the Department is of the opinion that prosecution will not lead to a conviction (for example, because there is not sufficient proof or because the offence or the suspect is not punishable). Disposal by the court Final judgment, by conviction, acquittal, discharge from further prosecution or one of the other final judgments. Disposal by the Public Prosecutions Department Final judgment with respect to a police report registered with the public prosecutor’s office by dismissal, joinder without charge, joinder with charge, out-of-court settlement or transfer to the court cases department of a different public prosecutor’s office. Early release The early release in principle, by virtue of the law, from the penitentiary of persons convicted to a longterm prison sentence.
154
Final judgement Sentence by the court definitely ending a civil matter that started with a summons for a certain instance. See also: Interlocutory judgment. First instance, (in the -) Primary judicial authority where a case is disposed. See also: Appeal.
Irrevocable judgment Judgment of a court of law against which no (ordinary) remedy is available anymore. Joinder in the hearing Joining by the court of criminal cases that are registered under different public prosecutor’s office numbers, with the objective of disposing these cases as one criminal case. See : Disposal by the court Joinder with charge Joining by the Public Prosecutions Department of registered criminal cases with the objective of having the court dispose several cases simultaneously in one sentence. See: Disposal by the Public Prosecutions Department. Joinder without charge Joining by the Public Prosecutions Department of a criminal case without charge to another case that is submitted to the court, with the objective of having the court take the joined case into account when determining the punishment. See also: Disposal by the Public Prosecutions Department Minor offence Light kind of offence, named thus in criminal law; categorising offences as crimes and minor offences is pertinent to procedural law (absolute competence and legal remedies) and to the penalization; disposal is usually through a settlement/out-of-court settlement via the Public Prosecutions Department or disposal in the first instance by the subdistrict court. See also: Crime. Netherlands Rehabilitation Foundation (SVG) Organisation aiming to make an effort and contribute demonstrably to the reintegration of the rehabilitation clients into society. The aim is also to prevent a repetition of the punishable behaviour. It does so by investigating and reporting the person and circumstances of the suspect or the convicted person, drawing up action plans to achieve the objectives set, providing counselling and supervision during the execution thereof and the supervision of the execution of community service. Only in those cases in which there are clear starting points for behavioural change and the chance of success seems to be considerable, intensive programmes will be used to this end. Ordinary criminal action courts Criminal case that is, in the first instance, within the competence of the court, except for fiscal and financial offences.
155
Out-of-court settlement Fulfilment, in certain circumstances, to prevent prosecution, of one or more conditions set by the investigating officer (police) or the Public Prosecutions Department (public prosecutor), such as payment of an amount of money (‘fine’), cancelling the right of prosecution. Percentage of solved crimes The total number of crimes solved in a certain period as compared to the total number of police report drawn up in that same period in respect of the same or similar crimes, expressed in percentage. Police custody Deprivation of liberty for maximum four days at the instruction of the assistant public prosecutor, if the period (six hours) that a suspect may be detained for questioning is not sufficient. Police report Written report drawn up by an investigating officer about the facts or circumstances noted by him/her. Pre-trial detention Deprivation of liberty in remand centre prior to disposal in court, generally applied upon suspicion of a serious offence (criminal offence carrying a jail sentence of four years or more), because of a serious risk of escape and/or for serious cause of public safety, for example, fear of repetition. Public Prosecutions Department (OM) Public authority with the following assignments: maintenance of the law, investigation and prosecution of criminal offences, execution of sentences and informing the court insofar as the law prescribes thus. Sentence Reasoned binding judgment of the court in an action brought it. See also: Judgment, Interlocutory judgment. Solved crime A crime in which at least one of the suspects became known to the police, even if he/she is a fugitive or denies to have committed the (criminal) offence. Summons Official writ (bailiff’s notification) calling someone to appear at a certain time before the court in connection with the prosecution of an offence charged to the person summoned (law of criminal procedure). Suspect Before the commencement of the prosecution, this is the person who, based on facts or circumstances, is reasonably supposed to be guilty of an offence, after which the suspect is the person against whom the prosecution is directed. Suspect who is a minor Someone who is under 18 year of age at the time of committing an offence. Disposal of (juvenile) cases of a simple nature takes usually place via Halt (Bureaus). N.B. Nobody may be prosecuted for an offence committed before reaching the age of 12. Suspect who is of age Someone who is 18 year of age or older at the time of committing an offence.
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Appendix B
Sources
This appendix provides an overview of the main sources of the National Drug Monitor (NDM) for, successively, (I.) use and problem use, (II.) treatment demand and treatment, (III.) disease and mortality, (IV.) market information and (V.) judicial data. For a more detailed description of the sources: see www.trimbos.nl/monitors, or www.ivo.nl, or www.zonmw.nl.
I.
USE AND PROBLEM USE
Source
Target Group
Substances
Antenne
Pupils and young clubbers in Amsterdam
Alcohol, drugs, tobacco
ESPAD
Secondary school pupils aged 15 and 16 in 35 European countries
Alcohol, drugs, tobacco
Survey of clubbers in The Hague
Clubbers aged 16-35 in The Hague
Alcohol, drugs
Health Behaviour in Schoolaged Children (HBSC)
Pupils aged 11-17
Alcohol, cannabis, tobacco
Measurements
Responsible organisation/ Homepage Annually since 1993, the Bonger Institute for Criminology with varying choice of of the University of Amsterdam target group (UvA) and Jellinek Prevention and Consultancy www.jur.uva.nl www.jellinek.nl/ 1995, 1999, 2003 the Swedish Council for Information on Alcohol and Other Drugs (CAN), the Pompidou Group, for the Netherlands the Trimbos Institute www.can.se/ Annually from 2002 Research Committee Monitoring & Registration of Addiction Problems (MORE) www.denhaag.nl/ Four-yearly since 2001 World Health Organisation (WHO), for the Netherlands: Trimbos Institute, Radboud University Nijmegen and Utrecht University www.hbsc.org www.trimbos.nl.
Source
Target Group
Substances
Measurements
Local and regional monitors
General population and/or young people depending on location and region, for young people: see also Appendix F
Alcohol, drugs, tobacco, depending on location and region
Usually annually, varies by location and region
The Dutch Institute for Public Opinion and Market Research (TNS NIPO) National Prevalence Research (NPO)
National population aged fifteen and over
Tobacco
Annually
National population aged 12 and over
Alcohol, drugs, tobacco
1997, 2001, possibly also 2005
National population aged 16 to 64 incl.
Alcohol, drugs
1996, 1997, 1999
Pupils aged 10-18 in the two highest groups of the primary schools and the 'regular' secondary schools: first form secondary school, pre-vocational secondary education (VMBO), higher general secondary education (HAVO) and pre-university education (VWO), sometimes projects at special schools National population aged 12 and over young people aged 12-29
Alcohol, drugs, tobacco
1984, 1988, 1992, 1996, 1999, 2003
Netherlands Mental Health Survey and Incidence Study (Nemesis) National Representative School Survey
Permanent Survey on Living Conditions (POLS)
Responsible organisation/ Homepage Municipal Health Services (GGDs) in coordination with the GGD Netherlands, municipal and private research bureaus www.ggd.nl Defacto, for a smoke-free future (previously STIVORO) www.stivoro.nl Centre for Drug Research (CEDRO), University of Amsterdam; in conjunction with Statistics Netherlands (CBS) www.cedro-uva.org Trimbos Institute www.trimbos.nl. Trimbos Institute www.trimbos.nl.
Special schools, projects: 1990, 1997
Alcohol, tobacco, for the young people module also drugs
Annually
Statistics Netherlands (CBS) www.cbs.nl
158
II.
TREATMENT DEMAND AND TREATMENT
Source
Target Group
Substances
Measurements
Central Methadone Registration (CMR)
Methadone clients in the Amsterdam region
Methadone
Annually
Educare monitor
Those requesting treatment at first aid stations of dance events
Alcohol, drugs
Annually from 1996
National Information System on Alcohol and Drugs (LADIS)
Clients of the (outpatient) care organisations for addicts. In 2003, the origin of the clients was as follows: 49% outpatient, 6% clinical, 30% hospital outpatient, 16% probation and after-care services. Hospital patients
Alcohol, drugs
Annually
Alcohol, drugs
Annually
Alcohol, drugs
Annually
Alcohol, drugs
Annually, complete up to and including 1996
National Medical Registration (LMR) Injury Information System (LIS) Register of Inpatient Mental Health Care (PiGGz). Is replaced by Zorgis.
III.
Patients who receive emergency treatment after an accident Clients of the inpatient care organisations for addicts
Responsible organisation/ Homepage Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl Educare Ambulant, Stichting Nursing & Education Consultancy www.educaregroningen.nl Organisation Care Information Systems (IVZ), Houten www.sivz.nl
Prismant www.prismant.nl Consumer Safety Institute www.veiligheid.nl Mental Health Service (GGZ Netherlands), Prismant www.ggznederland.nl www.prismant.nl
ILLNESS AND MORTALITY
Source
Target Group/Subject
Substances
Measurements
Cohort study Amsterdam en monitor drug-related mortality
Causes of death among methadone clients and recreational drug users in Amsterdam Ambulance trips for the population of Amsterdam and surrounding area
Opiates, recreational drugs
Annually from 1976
Alcohol, drugs
Annually
Causes of death of registered inhabitants of the Netherlands
Alcohol, drugs, tobacco
Annually
Central Ambulance Service (CPA) Causes of Death Statistics
Responsible organisation/ Homepage Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl CBS www.cbs.nl
159
Source
Target Group/Subject
Substances
Measurements
HIV/AIDS recording
People infected with HIV and aids patients among injecting drug users
Opiates
Half-yearly
HIV surveillance among drug users
Injecting drug users in various cities
Opiates
Since 1991 various measurements in various cities
ROI monitor
Drivers
Alcohol
Annually from 1970
IV.
Responsible organisation/ Homepage Health Care Inspectorate (IGZ), HIV Monitoring Foundation (SHM), National Institute of Public Health and the Environment (RIVM) www.hiv-monitoring.nl National Institute of Public Health and the Environment (RIVM) and Municipal Health Services (GGDs) www.rivm.nl/ Transport Research Centre (AVV), Ministry of Transport, Public Works and Water Management www.rws-avv.nl
MARKET INFORMATION
Source
Target Group/Subject
Substances
Measurements
Drugs Information and Monitoring System (DIMS) Coffee shop monitor
Party drugs of recreational users
Party drugs
Annually
Coffee shop policy of municipalities and enforcement policy
Cannabis
Annually
Monitor tolerated coffee shops
Officially tolerated coffee shops
Cannabis
THC Monitor
THC content and price of cannabis samples from coffee shops
Cannabis
1997, 1999, annually since 2000 Annually
Responsible organisation/ Homepage Trimbos Institute www.trimbos.nl. Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/ Bureau Intraval www.intraval.nl/ Trimbos Institute www.trimbos.nl.
160
V.
JUDICIAL
Source
Target Group/Subject
Substances
Measurements
Client Follow-up System (CVS)
Production figures of the Netherlands (Drug) Rehabilitation Foundation and their clients
All substances, no classification
Daily file creation
Police Records System (HKS)
Police reports of complaints; police records drawn up against suspects; recorded criminal history of suspects
Danger classification ‘drug user’ or ‘addicted to alcohol’; Opium Act offences classifiable by hard and soft drugs
Update end first quarter of the entire previous calendar year; also extraction of final figures for the year before that (because of processing backlogs)
Seizures of drugs
Seizures of drugs; number of investigations, ‘rounded up’ cannabis nurseries; discovered production places of synthetic drugs
All substances, classification by type of drug
Continuous recording, annual report
Responsible organisation/ Homepage Foundation of Addiction Probation Services (SVG) in collaboration with Netherlands Rehabilitation Foundation and probation and after-care services of the Salvation Army www.ggznederland.nl The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD, in collaboration with the regional police departments; the Research and Documentation Centre of the Ministry of Justice (WODC) has a copy at its disposal http://www.politie.nl/KLPD/ www.wodc.nl/ The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD), in collaboration with the regional police departments http://www.politie.nl/KLPD/
161
Source
Target Group/Subject
Substances
Measurements
Locations Judicial Treatment of Addicts (SOV).
Figures about admissions in the SOV, drug-dependent offenders who are accepted for participation in the SOV process Policy information about the criminal procedure; anonymised copy of the Justice Documentation System
All substances
Monthly
Opium Act offences classifiable by hard and soft drugs
Four time per year before update
Public Prosecutions Department Data (OMDATA)
National database of the National Office of the Public Prosecutions Department with data on prosecution and disposal in first instance.
Opium Act offences classifiable by hard and soft drugs
Three time per year before update
Investigations into Organised Crime
Investigations by the Dutch police into more serious forms of organised crime; offenders of, inter alia, the Opium Act who work together in a criminal organisation
Classification by hard and soft drugs
Annual report
Enforcement of custodial measures in correctional institutions (TULP)
Profiles of detainees, length of imposed penalties and profiles of the institutions; judicial institutions for juvenile persons (TULP/JJI) and institutions in the framework of a hospital order (TBS) are recorded separately
Opium Act offences classifiable by hard and soft drugs
Continuous recording
Justice Documentation Research Database (OBJD)
Responsible organisation/ Homepage Locations Judicial Treatment of Addicts (SOV) www.trimbos.nl. Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/ Public Prosecutions Department and Council for the Administration of Justice; the National Office of the Public Prosecution Service collects and manages the data; Research and Documentation Centre of the Ministry of Justice (WODC) has a copy at its disposal www.wodc.nl/ The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD), in collaboration with the regional police departments http://www.politie.nl/KLPD/
National Agency of Correctional Institutions (DJI) of the Ministry of Justice www.dji.nl/
162
Source
Target Group/Subject
Substances
Measurements
WODC Recidivist Monitor
Long-term research project with standardised recidivist measurements among different groups of justiciable individuals
Opium Act offences classifiable by hard and soft drugs
Reports based on Justice Documentation Research Database (OBJD)
Responsible organisation/ Homepage Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/
163
Appendix C
Definition of ICD-9 and ICD-10 codes
Definition of ICD-9 codes ICD-9 code 162 291 292 303 304 304.0 304.2 304.3 304.4 304.7 305 305.0 305.2 305.3 305.4 305.5 305.6 305.7 305.8 305.9 357.5 425.5 535.3 571.0 571.1 571.2 571.3 980.0-1 E850 E850.0 E854.1 E854.2 E855.2 E860.0-2 E950.9* E980.9*
Definition Malignant neoplasms of trachea, bronchus and lung Alcoholic psychoses Drug psychoses Alcohol dependence syndrome Drug dependence Dependence to opiates and related substances Cocaine dependence Cannabis dependence Dependence to amphetamines and other psychostimulants Dependence to combinations of opiates with other substances Non-dependent abuse of drugs or other substances Alcohol abuse Cannabis abuse Hallucinogen abuse Barbiturate and similarly acting sedative or hypnotic abuse Opiate abuse Cocaine abuse Amphetamine or related acting sympathomimetic abuse Antidepressant type abuse Other, mixed, or unspecified drug abuse Alcoholic polyneuropathy Alcoholic cardiomyopathy Alcoholic gastritis Alcoholic fatty liver Acute alcoholic hepatitis Alcoholic cirrhosis of the liver Alcoholic liver damage, unspecified Toxic effect of alcohol Accidental poisoning by analgesics, antipyretics, and antirheumatics Accidental poisoning by heroin Accidental poisoning by psychodysleptics (hallucinogens) Accidental poisoning by psychostimulants Accidental poisoning by local anaesthetics (including cocaine) Unintentional poisoning by alcoholic beverages (ethanol/methanol) Suicide through self-inflicted poisoning by solid or liquid substances Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted * Only included if 980.0-1 has been mentioned as complication.
Definition of ICD-10 codes ICD-10 code C33 C34 F10 F11 F12 F13 F14 F15 F18 F19
Definition Malignant neoplasms of trachea Malignant neoplasms of bronchus and lung Mental and behavioural disorders due to use of alcohol Mental and behavioural disorders due to use of opiates Mental and behavioural disorders due to use of cannabis Mental and behavioural disorders due to use of sedatives or hypnotics Mental and behavioural disorders due to use of cocaine Mental and behavioural disorders due to use of other stimulants Mental and behavioural disorders due to use of volatile solvents Mental and behavioural disorders due to poly drug use and use of other psychoactive substances G31.2 Degeneration of the nervous system due to alcohol consumption G62.1 Alcoholic polyneuropathy I42.6 Alcoholic cardiomyopathy K29.2 Alcoholic gastritis K70.0 Alcoholic fatty liver K70.1 Alcoholic hepatitis K70.2 Alcoholic fibrosis and cirrhosis of the liver K70.3 Alcoholic cirrhosis of the liver K70.4 Alcoholic hepatic failure K70.9 Alcohol-induced liver diseases, unspecified K86.0 Alcohol-induced chronic pancreatitis T51.0-1 Toxic effect of alcohol, ethanol and methanol (only as secondary code) X41 + T43.6 Accidental poisoning by psychostimulants X42 Accidental poisoning by narcotics and psychodysleptics [hallucinogens], not classified elsewhere X42 + T40.5 Accidental poisoning by cocaine X45* Intentional poisoning by and exposure to alcohol X61 + T43.6 Suicide through psychostimulants X65* Intentional auto-intoxication by alcohol Y11 + T43.6 Poisoning by psychostimulants, undetermined whether accidentally or purposely inflicted Y15* Poisoning by and exposure to alcohol- undetermined whether purposely inflicted * Only included if complication T51.01 has been mentioned.
165
Appendix D Overview of products Netherlands (Drug) Rehabilitation Foundation and coercive treatment processes Current treatment processes as alternative for prosecution and detention Type of treatment process: Drug treatment clinic
Characterisation by objective:
Inpatient Motivation Centre
Low-threshold facility, aimed to motivate clients to undergo follow-up treatment or to improvement of welfare and well-being. Not aimed at abstinence and therapy. Length of stay 3-4 months.
Long-term phased programmes (SOV coercion, Triple-Ex)
Aimed at reintegration (work/training, leisure time, living, finances, social relationships), abstinence and reduction of nuisance and crime by the participants. Phased setup: closed - half-open - open phase, duration 16-18 months.
Forensic drug treatment clinic
Clinic with national function. Phased setup. Strong security in the first closed phase. Aimed at abstinence, social stability and better functioning, Therapeutic. Duration 6-18 months.
Living projects under guidance
Small-scale projects in which clients are trained and guided in living, learning and working. The objective is to guide addicts towards (the highest possible degree of) living independently. Often in combination with learning/work processes.
Aimed at abstinence and stability in psychological and social functioning. Therapeutic, also crisis intervention.
Outpatient and part-time Aimed at improvement or stabilisation of the situation of clients treatment of addicts through guidance and counselling. Source: 144.
Appendix E
Internet addresses with information on alcohol and drugs
Addiction Research Institute Foundation (IVO) http://www.ivo.nl/ Addiction Treatment Centre North Netherlands http://www.verslavingszorgnoordnederland.nl/ Amsterdam Area Health Authority http://www.gggd.amsterdam.nl/ Australian Institute of Health and Welfare (AIHW) http://www.aihw.gov.au/ Brijder Addiction Treatment Centre http://www.brijder.nl/ CEDRO Centre for Drug Research (University of Amsterdam) http://www.cedro-uva.org/ Consumer Safety Institute http://www.consument-en-veiligheid.nl/ De Grift http://www.degrift.nl/ DeltaBouman http://www.deltabouman.nl/ Dutch Association for Mental Health Care (GGZ) http://www.ggznederland.nl Emergis Addiction Treatment Centre http://www.emergis.nl/verslavingszorg/ European Centre for the Epidemiological Monitoring of AIDS http://www.eurohiv.org/sida.htm European Commission - Taxation and Customs Union http://europa.eu.int/comm/taxation_customs/publications/info_doc/info_doc.htm#Excises European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) http://www.emcdda.org/ Europol http://www.europol.eu.int/home.htm GGZ Group North and Central Limburg/Addiction Treatment Centre http://www.ggz-groepnmlimburg.nl/
Health Care Inspectorate http://www.igz.nl/productie/indexie.html Institute of Food Safety (RIKILT) http://www.rikilt.dlo.nl/ Intraval. Bureau for Research and Consultancy http://www.intraval.nl/ Jellinek Centre (Amsterdam) http://www.jellinek.nl/ Maliebaan Centre http://www.centrummaliebaan.nl/ Mental Health Service Netherlands http://www.ggznederland.nl Ministry of Justice http://www.justitie.nl/ Ministry of Public Health, Welfare and Sports (VWS) http://www.minvws.nl/index.html Mondriaan Care Group/Addiction Treatment Centre http://www.mondriaanzorggroep.nl/ Municipal Health Service Netherlands http://www.ggd.nl/ National Institute for Health and Prevention (NIGZ) http://www.nigz.nl/ National Institute of Public Health and the Environment (RIVM) http://www.rivm.nl/ National Police Agency (KLPD) http://www.klpd.nl/ Novadic-Kentron, network for addiction treatment http://www.novadic-kentron.nl/ Organisation for Care Information Systems (IVZ) http://www.ivv.nl/ http://www.sivz.nl/ Parnassia, Psycho-Medical Centre http://www.parnassia.nl/ Police http://www.politie.nl/
170
Prismant http://www.prismant.nl/ Public Prosecutions Department http://www.openbaarministerie.nl/ Research and Documentation Centre (WODC) http://www.wodc.nl/ STIVORO, for a smoke-free future http://www.stivoro.nl/ Statistics Netherlands (CBS) http://www.cbs.nl/ Substance Abuse & Mental Health Service Administration (SAMHSA) http://www.samhsa.gov/ SWOV-Institute for Road Safety Research http://www.swov.nl/ TACTUS, Institution for addiction treatment http://www.tactus.nl/ Trimbos Institute http://www.trimbos.nl/ World Health Organisation (WHO) http://www.who.int/en/
171
Appendix F
Data youth monitors and youth surveys
The percentages of the use of drugs, alcohol and tabak are based on reports of local youth monitors or youth surveys in towns, cities, regions or provinces, throughout the Netherlands. Most of the young people who are the subject of these surveys were selected via a representative sample taken from the Municipal Personal Records Databse (GBA) or the Population Register. Most of the times these young people were sent a written questionaire with the request to complete and return it. Sometimes the possibility was provided to answer the questions via the internet. With a view to comparability, the following critera were applied for the selection of the data. In the first place, the maximum age margin was limited to young people aged 10 to 26 incl. Whenever youth monitors also related to children below the age of 10, those data have therefore not been included. In the second place, the overview has been limited to youth monitors that were carried out after 1-12002. Thirdly, the results of all the youth monitors in which the sample consisted of specific secondary school classes have not been included. This is the case, inter alia, in pupil surveys and in, what are called, E-MOVO surveys (Electronic Monitoring and Information). In the overview tables some distortion may have occurred. This is due to the varying use of the term ‘occasionally’ in the questions asked about alcohol, tobacco and drugs. The question Have you smoked occasionally? is understood here as: Have you ever smoked? The question Do you smoke occasionally? leaves the young people most room for their own interpretation. In the absence of a subsequent question about the regularity of the use (in the past four weeks, the past week or daily), this second variant of ‘occasionally’ has been equated with smoking in the past four weeks. The same has been done with questions like Do you smoke occasionally? and Do you smoke? In nearly all youth monitors, separate questions are asked about the use of soft drugs/cannabis. However, regularly ‘hard drugs’ (ecstasy, cocaine, heroin, LSD, paddo’s and amphetaminen) are combined in one single question. In case of absence of the separate ‘hard drugs’ percentages in a report, these data have not been included in the overview tables.
CANNABIS Town or city/Region/ Province 162 Almelo
Year
Net number of respondents
Age youngsters
Ever
Recent
2002
511
18-23 years
32%
Almere
2002
2.080
16% 50% 30%
Alphen a/d 164 Rijn 165 Amersfoort
2003
512
12-18 years 19-23 years 12-23 years 12-26 years
2004
1.292
16-18 years
166
2003
7.085
2003
900
2% 20% 32% 37% 18%
1% 6% 8% 5%
167
12-14 years 15-17 years 18-21 years 22-24 years 12-22 years
2002
1.234
19-23 years
38%
8%
39% 38% 39% 29%
15% 5% 9% 6%
163
8% 9%
19-22 years Apeldoorn
Dordrecht
168
Drenthe of which: - Assen - Coevorden - Emmen - Hoogeveen
9%
Current/ occasionally 4%
14%
173
- Meppel 163 Dronten
Ede
169
Eindhoven Flevoland
170
163
Gooi and Vecht 171 Region Groningen 172 (city) 173 Heerhugowaard ‘s-Hertogenbosch 163 Lelystad
Leiden
175
Maasbracht
176
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) Nijmegen
178
179
Schiedam Tilburg
Urk
180
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
174
57% 14% 38% 23%
2002
603
2003
1.750
2002 2002
664 508 6.087
End 2001
1.025
12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 18-20 years 21-24 years 12-17 years 18-24 years 12-18 years 19-23 years 12-23 years 12-18 years
2002
1.801
12-17 years
2002
556
14-21 years
2002 2002
825 2.171
2003
1.023
2002
478
18-24 years 12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 12-17 years 18-23 years 24-26 years 12-17 years
2003
12.297
12-17 years
2002
665
2003
1.600
12-18 years 19-23 years 12-23 years 12-17 years
12% 35% 20% 16%
2003
1.005
12-23 years
24%
2003
1.938
2002
285
2002
256
12-13 years 16-17 years 12-17 years 19-23 years 12-23 years 12-18 years
2003
6.862
12-17 years
2002
?
12-17 years
14%
2002
337
14% 39% 21%
2003
3.697
12-18 years 19-23 years 12-23 years 12-14 years
7%
1% 10% 14% 10% 5% 14% 16% 45% 27% 18%
8% 8%
12,5% 29%
5% 8% 12%
17% 50% 32% 5% 8% 6% 11% 11% 3% 5%
8%
1% 11% 5%
7% 16% 9%
12% 4% 5%
2%
15-17 years
7%
12-17 years
5%
18-23 years 24-26 years 12-26 years
10% 10% 8%
174
COCAINE Town or city / Province Almelo
Year
162
Apeldoorn
Drenthe
166
168
Eindhoven Flevoland
170
163
Groningen 172 (city) 173 Heerhugowaard Nijmegen
178
179
Schiedam
Net number of respondents
Age youngsters
Ever
2002
489
18-23 years
2,3%
2003
7.085
2002
1.234
12-14 years 15-17 years 18-21 years 22-24 years 19-23 years
2002 2002
664 508 6.061
12-17 years 18-24 years 12-23 years
2002
1.801
12-17 years
2002
556
14-21 years
2%
2003
1.600
12-17 years
1%
2003
1.005
12-23 years
3%
Recent
1%
Current/ occasionally 0,4%
< 1% < 1% 4% 7% 3% 1,1 2,1 < 1% 0,2%
<1%
HEROIN Town or city / Province 162 Almelo
Year
Net number of respondents
Age youngsters
Ever
2002
480
18-23 years
0%
2003
7.085
168
2002
1.234
12-17 years 18-24 years 19-23 years
< 1% < 1% < 1%
Groningen 172 (city) SouthHolland 184 North
2002
1.801
12-17 years
2003
3.697
12-26 years
Apeldoorn Drenthe
166
Recent
0%
Current/ occasionally 0%
0,1 % 0%
ECSTASY Town or city / Province Almelo
Age youngsters
2002
Net number of respondents 490
166
2003
7.085
167
2003
900
12-14 years 15-17 years 18-21 years 22-24 years 12-24 years
<1% 2% 7% 10% 3%
2002
1.234
19-23 years
4%
2002
664 508 6.061
12-17 years 18-24 years 12-23 years
162
Apeldoorn
Dordrecht Drenthe
168
Eindhoven Flevoland
170
163
Year
2002
18-23 years
Ever
3,2%
Recent
1,4%
Current/ occasionally < 1%
2,8% 5,1% 1,6%
175
Groningen 172 (city) 173 Heerhugowaard Nijmegen
178
179
Schiedam
West-Friesland
183
2002
1.801
12-17 years
0,5%
2002
556
14-21 years
4%
2003
1.600
12-17 years
1,5%
2003
1.005
12-23 years
6%
2002
?
12-23 years
< 1%
1%
AMPHETAMINES/SPEED Town or city / Province 162 Almelo
Year
Age youngsters
Ever
2002
Net number of respondents 488
18-23 years
3%
2003
7.085
2002
1.234
12-14 years 15-17 years 18-21 years 22-24 years 19-23 years
< 1% 1% 3% 6% 2%
2002
508
18-24 years
163
2002
6.061
12-23 years
Groningen 172 (city) Heerhugowa 173 ard
2002
1.801
12-17 years
2002
556
14-21 years
3%
179
2003
1.005
12-23 years
3%
Apeldoorn
Drenthe
166
168
Eindhoven Flevoland
170
Schiedam
Recent
Current/ occasionally
< 1%
< 1%
1,3% < 1% 0,1%
ALCOHOL Town or city/Region/Provinc e 162 Almelo
Net number of respondents
Age youngsters
Ever
Current/ occasionally
2002
528
18-23 years
83%
2002
2.080
12-23 years
82%
78%
2003
512
12-26 years
74%
68%
2004
1.292
166
2003
7.085
12-17 years 10-22 years 12-14 years 18-21 years 12-24 years
55% 55% 38% 84% 71%
167
2003
900
12-22 years
62%
163
Almere
Alphen a/d Rijn Amersfoort Apeldoorn
Dordrecht
Year
165
164
Drenthe
168
2002
1.234
19-23 years
86%
Dronten
163
2002
603
12-23 years
82%
2003
1.750
12-24 years
75%
2002
664 508 6.083
12-17 years 18-24 years 12-23 years
50% 85% 79%
Ede
169
Eindhoven Flevoland
170
163
2002
81%
Weekly
29%
82%
176
Gooi and Vecht 171 Region Groningen 172 (city)
End 2001
Lelystad Leiden
12-18 years
67%
2003
640 616 545 700
12-13 years 14-15 years 16-17 years 18-24 years
23% 62% 84% 70-80%
2002
556
14 years 15-16 years 17-21 years 14-21 years 12-23 years
2002
Haarlemmermeer Heerhugowaard
1.025
185
173
163
175
2002
2.171
2003
1.023
80%
93% 81%
22% 66% 43%
18-23 years
82%
12-26 years
Maasbracht
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) 178 Nijmegen
179
Schiedam Tilburg Urk
180
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
66%
79%
12-14 years 15-17 years 12-17 years 24-26 years
176
20% 80% 90%
82% 76%
70%
2002
478
2003
12.297
12-14 years 15-17 years 12-17 years 12-17 years
29% 81% 53% 59%
2002
665
12-23 years
82%
2003
1.600
10-11 years
13%
6%
12-17 years
54%
42%
81%
?
18-24 years
2003
1.005
12-16 years
47%
17-23 years
74%
2003
1.938
12-17 years
51%
2002
285
12-23 years
75%
2002
256
12-18 years
39%
2003
6.862
12-13 years
20%
14-15 years
60%
16-17 years
80%
12-17 years
53%
12-17 years 12-23 years 12-23 years
80%
66% 77% 79%
12-14 years 15-17 years 12-17 years 18-23 years 24-26 years 18-26 years
30% 82% 56% 90% 88% 90%
24% 77% 50% 87% 82% 85%
2002
?
2002
337
2003
3.697
88%
70%
177
TOBACCO Town or city/Region/ Province 162 Almelo
Year
Age youngsters
Ever
70%
2002
528
18-23 years
2002
2.080
2003
512
12-18 years 19-23 years 12-23 years 12-26 years
166
2003
7.085
167
2003
900
12-14 years 15-17 years 18-21 years 22-24 years 12-22 years
163
Almere
Alphen a/d Rijn Apeldoorn
Dordrecht
Net number of respondents
164
Current/ occasionally 9%
52% 53%
25%
27% 56% 67% 71%
3% 8% 9% 9%
3% 17% 25% 28% 15% 33%
168
2002
1.234
19-23 years
11%
Dronten
163
2002
603
16% 48%
2003
1.750
12-18 years 19-23 years 12-23 years 12-24 years
2002 2002
664 508 6.086
End 2001
1.025
12-17 years 18-24 years 12-18 years 19-23 years 12-23 years 12-18 years
2003
845 640 616 545 700
9-11 years 12-13 years 14-15 years 16-17 years 19-24 years
2002
556
14-21 years
2003
1.023
169
Eindhoven Flevoland
170
163
Gooi and Vecht 171 Region Groningen 172 (city)
2002
Haarlemmermeer Heerhugowaard Leiden
185
173
175
163
Maasbracht
176
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) Nijmegen
178
179
Schiedam Tilburg
180
2002
2.171
2002
478
2003
12.297
2002
665
2003
1.600
2003
? 1.005
2003
1.938
54%
19% 16%
21%
33% 15% 40% 17% 43% 54% 46%
9%
20% 12%
2% 3% 18% 30% 32% 11%
18%
12-14 years 15-17 years 18-23 years
7% 20% 26%
1% 13% 17%
24-26 years
37%
20%
25%
15%
12-26 years
Lelystad
35%
15% 39%
Drenthe
Ede
Daily
12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 12-17 years 12-18 years 19-23 years 12-23 years 10-11 years 12-17 years 18-24 years 12-16 years 17-23 years 12-13 years 14-15 years 16-17 years
65%
57%
17% 44% 56%
22%
21%
7% 29% 4%
8%
18% 46% 55% 7%
20%
10% 25% 64%
24% 3% 9% 1% 13% 25%
5% 26%
178
Urk
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
36%
259
12-17 years 12-18 years 19-23 years 12-23 years 12-18 years
2003
6.862
12-17 years
37%
2002
?
12-17 years 12-23 years 12-18 years 19-23 years 12-23 years 12-26 years
2002
285
2002
2002
337
2003
3.697
13,2% 28% 44%
69%
9%
21%
24% 11%
5%
9% 17% 27%
39%
18% 38% 50% 51%
25%
18% 8%
179
180
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Editorial Board 1 Dr. M.W. van Laar 1 Dr. A.A.N. Cruts 1 Dr. J.E.E. Verdurmen 2 Dr. M.M.J. van Ooyen With the cooperation of 1 Dr. A.P.M. Ketelaars 1 Dr. P. van Gelder 1 2
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MEMBERS OF THE SCIENTIFIC COUNCIL OF THE NDM Prof. H.G. van de Bunt, Erasmus University Rotterdam Prof. H.F.L. Garretsen, University of Tilburg (Chairman) Prof. R.A. Knibbe, University of Maastricht Dr. M.W.J. Koeter, Amsterdam Institute for Addiction Research (AIAR) Dr. D.J. Korf, Criminological Institute Bonger, University of Amsterdam Dr. H. van de Mheen, Addiction Research Institute Foundation (IVO) Prof. J.A.M. van Oers, Addiction Research Institute Foundation (IVO), University of Tilburg Mr. A.W. Ouwehand, Organisation for Care Information Systems (IVZ) Dr. A. de Vos, Mental Health Service (GGZ Netherlands) Observers Mr. P.P. de Vrijer, Ministry of Justice Dr. W.M. de Zwart, Ministry of Public Health, Welfare and Sports Additional consultants Ms. M. Brouwers, Research and Documentation Centre (WODC), Ministry of Justice Dr. M.C.A. Buster, Amsterdam Area Health Authority (GG&GD Amsterdam) Ms. E.H.B.M.A. Hoekstra, Ministry of Justice Dr. R.F. Meijer, Research and Documentation Centre (WODC), Ministry of Justice Dr. ir. E.L.M. Op de Coul, National Institute of Public Health and the Environment (RIVM) Mr. Th.A. Sluijs MPH, Amsterdam Area Health Authority (GG&GD Amsterdam) Dr. M.C. Willemsen, STIVORO
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TABLE OF CONTENTS Preface List of abbreviations Summary 1
Introduction
2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
Cannabis Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Supply and the market
3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Cocaine Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Market
4 4.1 4.2 4.3 4.4 4.5 4.6 4.7
Opiates Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality
5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8
Ecstasy, amphetamines and related substances Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality Supply and the market
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6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8
Alcohol Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Illness and mortality Supply and the market
7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8
Tobacco Latest facts and trends Use in the general population Use among young people Problem use Use: international comparisons Treatment demand Mortality Supply and the market
8 8.1 8.2 8.3 8.4
Recorded drug crime Latest facts and trends Recorded drug crime Criminal drug users Help for problem users in the criminal system
Appendices A B C D E F
Glossary of Terms Sources Definition of ICD-9 and ICD-10 codes Overview of the products of the Netherlands (Drug) Rehabilitation Foundation and coercive treatment processes Internet addresses with information on alcohol and drugs Data youth monitors and youth surveys
References
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PREFACE In the last decade, the number of cocaine users in the (outpatient) care organisations for drug addicts has quadrupled. This increase was especially apparent in recent years. Alcohol consumption is on the increase, particularly among young girls. In 1999, 57 percent of girls aged 12-14 had drunk alcohol ever in their lifetime; in 2003 this had increased to 78 percent. And Dutch pupils topped the list in respect of alcohol consumption. The chance for a person younger than sixteen to succeed in buying alcohol and/or tobacco is 90 percent or higher. In the period 1997-2003, the number of coffee shops dropped from nearly 1,200 to 754. This drop may affect control of drug trafficking and the separation of markets for soft drugs and hard drugs. In addition, Opium Act offences add increasingly to the workload of the criminal system. The increase is partly a result of cocaine couriers. These are some of the disturbing figures from the Annual Report 2004 of the National Drug Monitor (NDM) before you. With a view to the provision of care and the undertaking of preventive activities, it is important to be informed of such developments annually. In this framework, much attention is often paid to negative developments. Fortunately, many positive developments can also be reported. The percentage of pupils using drugs remains stable or decreases. The size of the group of opiate addicts is stable, while the average age of the group is rising. The number of heavy smokers is down. A favourable development is also that intravenous use of cocaine and heroin decreases. The NDM relies on the contribution of a multitude of national and local monitoring projects and experts. Many thanks are owed to the organisations and institutions that provided data for the Annual Report. Thanks are also owed to the Bureau of the NDM. The Bureau composes the annual reports with great care. This gives the Netherlands a prominent position in the information collection and provision. Prof. Henk Garretsen Chairman of the Scientific Council of the National Drug Monitor
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LIST OF ABBREVIATIONS 2C-B 4-MTA AIAR AIDS AIHW APZ BiZa BO BVT CAM CAN CBS CEDRO CMR COPD CPA CSV CVA CVS DIMS DJI DMS dNRI/O&A DOB DSM EHBO EMCDDA ESPAD EU FPD GGD GG&GD GGZ GHB HAVO HBSC HBV HCV HDL-C HIV HKS ICD IDG IGZ IVO IVV IVZ
4-bromo-2,5-dimethoxyphenethylamine 4-methylthioamphetamine Amsterdam Institute for Addiction Research Acquired Immune Deficiency Syndrome Australian Institute of Health and Welfare General Psychiatric Hospital Ministry of the Interior Primary Education Tobacco Information Agency (Bureau Voorlichting Tabak) Coordination Agency for the Assessment and Monitoring of New Drugs Swedish Council for Information on Alcohol and Other Drugs Statistics Netherlands Centre for Drug Research Central Methadone Registration Chronic Obstructive Pulmonary Disease Central Ambulance Station Criminal Organisation Cerebrovascular Disorders Client Follow-up System Drugs Information and Monitoring System National Agency of Correctional Institutions Drugs Monitoring System National Criminal Intelligence Service of the National Police Agency, Research & Analysis Group 2,5-dimethoxy-4-bromoamphetamine Diagnostic and Statistical Manual First Aid / Casualty Ward European Monitoring Centre for Drugs and Drug Addiction (in Dutch: EWDD) European School Survey Project on Alcohol and Other Drugs European Union Forensic Drug Treatment Clinic Municipal Health Service Municipal Medical & Health Service/Area Health Authority Mental Health Service Gamma-hydroxy-butyrate Higher General Secondary Education Health Behaviour in School-aged Children (study) Hepatitis B virus Hepatitis C virus High density lipoprotein cholesterol Human Immune Deficiency Virus Police Records System International Classification of Diseases. Intravenous Drug User Health Care Inspectorate Addiction Research Institute Foundation Organisation Information Systems on Addiction Care and Treatment Organisation Care Information Systems
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KLPD KMar LADIS LIS LMR LOM LUMC MAD MBDB MDA MDEA MDMA MGC MLK MMO NDM Nemesis NIGZ NMG NPO NRI NVIC NWO OBJD OM OPS PBW PiGGz PMA PMMA POLS RIKILT RISc RIVM SAMHSA SHM SOA SOV Sr Sv SVG SRM SSI SWOV TBS THC TNS NIPO TULP USD UvA VBA v.i.
National Police Agency Royal Military Police National Information System on Alcohol and Drugs Injury Information System Dutch Hospital Registration Special School for Children with Learning and Behavioural Difficulties Leiden University Medical Center Regions and Towns Monitor for Alcohol and Drugs N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine Methylene-dioxyamphetamine Methylene-dioxyamphetamine 3,4-methylene-dioxymethamphetamine Organised Crime Monitor Special School for Children with Learning Difficulties Social Inclusion Monitor National Drug Monitor Netherlands Mental Health Survey and Incidence Study National Institute for Health and Prevention National Monitor Mental Health Care National Prevalence Research National Criminal Intelligence Service National Poison Information Centre Netherlands Organisation for Scientific Research Justice Documentation Research Database Public Prosecutions Department List of wanted persons Prisons Act Register of Inpatient Mental Health Care Paramethoxyamphetamine Paramethoxymethylamphetamine Permanent Survey on Living Conditions Institute of Food Safety Risk Assessment Scales National Institute of Public Health and the Environment Substance Abuse and Mental Health Services Administration HIV Monitoring Foundation Sexually Transmittable Diseases Judicial Treatment of Addicts Criminal Law Netherlands Code of Criminal Procedure Netherlands Rehabilitation Foundation Criminal Justice Monitor Tobacco Manufacturers’ Association Netherlands Institute for Road Safety Research Detention under a hospital order Tetrahydrocannabinol Dutch Institute for Public Opinion and Market Research Enforcement of custodial measures in correctional institutions Synthetic Drugs Investigation Unit University of Amsterdam Drug-free Unit conditional release (on parole)
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VIS VMBO-p VMBO-t VNG VTV VWO VWS WHO WODC WVMC WvS ZMOK ZONMW Zorgis
Arrest Referral Scheme (Vroeghulp Interventie Systematiek) Prevocational secondary education – theoretical stream Prevocational secondary education – practice-oriented stream Association of Netherlands Municipalities Centre for Public Health Studies Pre-University Education Ministry of Public Health, Welfare and Sports World Health Organisation Research and Documentation Centre of the Ministry of Justice Abuse of Chemical Substances Prevention Act Criminal Code Special School for Children with Severe Behavioural Learning Problems Netherlands Organisation for Health Research and Development Care information system GGZ
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SUMMARY Use of substances: general In the Netherlands, the number of people that had used drugs ever or in the past month rose between 1997 and 2001, peaking among young people between the age of 20 and 24. Among secondary school pupils drug consumption stabilised between 1996 and 2003, or was down slightly. However, alcohol consumption increased, particularly among girls younger than 15. In some groups — such as pupils with behavioural or learning problems, truants, detainees, psychiatric patients, homeless people, or individuals who are vulnerable and marginalised in other ways – the use of alcohol and drugs is considerably more prevalent than in the general population. In general, these groups are often struggling with (additional) behavioural, psychological and social problems. Young people associated with trendy clubs are quite often found to experiment with (new) drugs and alcohol. In Amsterdam, drug consumption in trendy clubs decreased nevertheless between 1998 and 2003. However, alcohol consumption increased and remained by far the main stimulant during clubbing. Often several substances are either consumed simultaneously or in short succession each time. Furthermore, poly use is the rule rather than the exception among problem users. Compared to the use of drugs in the general population of other western countries, the Netherlands rated around or somewhat above average. On indicators of problem use of hard drugs, the Netherlands scored proportionally positively (relatively few problem users, small percentage of injecting drug users, low drug-related mortality). The following developments have been observed and are listed for each drug: Cannabis Cannabis remains by far the most popular of all illicit drugs. The number of current cannabis users in the Dutch population rose between 1997 and 2001 from 2.5 to 3 percent. Extrapolated over the entire population, the number of users increased from 326,000 to 408,000, an increase of 25 percent. The proportion of current cannabis users among secondary school pupils dropped slightly between 1996 and 2003, from 11 to 9 percent. This decrease must be attributed mainly to the boys (from 14% to 10%). Compared to their peers in the old EU Member States, cannabis use of Dutch pupils can be considered average. Among young people and young adolescents in Amsterdam trendy clubs, the number of current users of cannabis decreased also, from 52 percent in 1998 to 39 percent in 2003. One in five current users consumes cannabis daily of almost daily. Consumers with intensive use patterns can become dependent on cannabis. Young people with an outspoken preference for ‘strong’ cannabis have a good chance of becoming dependent. The total number of people concerned is not known. The number of clients of the (outpatient) care organisations for drug addicts with a primary cannabis problem continued to increase slightly. From 2002 to 2003 an increase of 21 percent was recorded. Between 1994 and 2004 their number doubled from 1,951 to 4,485. The number of clients who named cannabis as a secondary problem increased from 2,846 to 4,291. The number of admissions into general hospitals with cannabis abuse or dependency as primary diagnosis was low (46 in 2003). A slight increase is observed in the number of admissions with these problems as secondary diagnosis (246 in 2003). The number of coffee shops fell in 2003 by four percent, from 782 in 2002 to 754. In 1997 there were still nearly 1,200 coffee shops. The average THC content in Dutch-grown marijuana (Nederwiet) rose further between 2002/2003 and 2003/2004, from 18 to 20 percent. In 1999/2000 the THC content was half of that (9%). It is not known whether this increase has health-related consequences, but there is increasing scientific evidence that cannabis can induce psychotic symptoms, particularly in heavy users with a
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predisposition for psychoses. The question of cause and effect, however, is still subject of discussion. More research is needed to demonstrate the causality. Cocaine The use of cocaine in the general population is limited. However, the percentage of ever users of cocaine did increase from 2.1 percent in 1997 to 2.9 percent in 2001. The percentage of current users increased from 0.2% to 0.4 percent. Among secondary pupils the use remained stable in the past few years. In 2003, two percent of them had had experience with cocaine. The use of cocaine showed a large increase in the last decade in special groups of the population, such as problem hard drug users. These users mainly use crack, the smokable and most addictive form of cocaine. Seven to nine out of ten opiate addicts also use cocaine, which by now has become the main drug for many hard drug users. Cocaine, especially sniffed coke, has become popular among the partying youth and young adolescents. In Amsterdam, between 1998 and 2003, a decrease in the percentage of current users of sniffed coke took place among visitors of trendy clubs, from 24 to 14 percent, but compared to ecstasy, cocaine has grown in popularity. Figures from (outpatient) care organisations for drug addicts show a strong increase in the number of people seeking help for cocaine-related problems. From 2002 to 2003 an increase of 19 percent was recorded. In 2003, the number of clients with a primary cocaine problem was even four times larger than in 1994 (9,216 and 2,468, respectively). The number of clients with cocaine as a secondary problem increased also in this period, from 6,020 to 8,388. Two in three help-seeking cocaine users have a crack problem. They struggle with physical and psychological complaints, such as lung problems, exhaustion, aggression and paranoia. Data about admissions into hospitals and about mortality suggest also an increase in cocaine problems until 2002, but this trend did not continue in 2003. The number of cocaine users admitted to general hospitals as a result of (crack) cocaine-related problems rose from 246 in 1996 to 562 in 2002, after which it decreased slightly to 506 in 2003. Acute mortality as a result of cocaine use – as far as recorded – fluctuated until the mid-nineties between one and three cases per year. In the years 2000, 2001 and 2002, 19, 26 and 34 cases, respectively, were recorded. In 2003, 17 cases were recorded. Opiates Heroin, the most frequently used illicit opiate, is not popular among the general population (0.1% current users in 2001). The number of problem users of (also) opiates is stable in the Netherlands, with an estimated figure of 32,000 (ranging between 22,000 and 42,000). Per thousand inhabitants, the Netherlands has three hard drug problem users. This is low compared to other (old) EU Member States, such as the United Kingdom, Italy, Portugal and Denmark, which have between seven and nine cases per thousand inhabitants. The treatment demand of opiate addicts in (outpatient) care organisations for addicts decreased slightly between 2001 and 2003, from 17,786 to 15,195 clients. Corresponding with the decreasing number of young heroin users, the proportion of young opiate clients also showed a downward tendency. About 12,000 opiate addicts are registered in methadone programs, generally as clients on maintenance basis. Currently, they receive a higher dose of methadone on average than ten years ago (57 versus 46 mg), but only one third of them receives a (therapeutic) dos of 60 mg or more. The average age of the group of opiate addicts is rising. In 1989, the average age of the methadone clients in Amsterdam was 32; in 2003, it was 44 years. In Rotterdam and Parkstad Limburg, the average age of problem uses rose from 37 to 39 between 1998 and 2003. Long-term opiate dependence often is accompanied by considerable harm to the health of the user, owing to the use of the substance itself, but also as a result of the unhealthy lifestyle and the route of administration. The proportion of opiate addicts injecting the drug decreased strongly in the last decade and is now estimated at 10 to 20 percent. Heroin is now mostly smoked. Since opiate addict
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often also smoke a large quantity of tobacco, lung disorders are more prevalent. A large proportion of former IDUs is infected with hepatitis C (47-79%) and hepatitis B (35-67%). The proportion of IDUs infected with HIV varies from 1 percent in Groningen and Arnhem to 22 percent in Heerlen and 26 percent in Amsterdam. Needle sharing decreased in the past ten years, but between 8 and 30 percent of IDUs still (occasionally) share needles. Sexual risk behaviour (practising sex without condoms) is still widespread. As a result, the risk of transfer of contamination with HIV and hepatitis B is still considerable in a number of regions. From 1996 to 2001 incl., recorded opiate-related mortality fluctuated between sixty and eighty cases per year. In the last few years, a slight decrease was evident (37 in 2002 and 53 in 2003). Ecstasy and amphetamines The percentage of current ecstasy users in the general population between 1997 and 2001 rose from 0.3 to 0.5 percent. This increase occurred mainly among women. The percentage of current amphetamine users remained low (0.1% in 1997 and 0.2% in 2001). Among secondary pupils, the percentage of ever users and current users of both substances decreased between 1996 and 2003. In 2003, three percent had had experience with ecstasy and two percent with amphetamines. Ecstasy is still popular among young clubbers, although the use is showing signs of moderation. An increasing number of young people seem to handle this substance intelligently and to be aware of the risks. Among visitors of trendy clubs in Amsterdam, the percentage of current ecstasy users halved from 41 percent in 1998 to 19 percent in 2003. The use of amphetamine, a considerably less popular substance in party life, also showed a decrease, from 13 to 7 percent. Compared to other hard drugs, problem use of ecstasy did not occur often. Since 1999, the treatment demand in outpatient care organisations for addicts primarily for ecstasy is low compared to other drugs and relatively stable. In 2003, 277 clients were recorded with ecstasy as a primary problem and 655 clients for whom ecstasy was a secondary problem. The number of primary amphetamine clients increased slightly from 482 in 2001 to 735 in 2003. In 2003, 552 clients named amphetamines as a secondary problem. The acute health risks from ecstasy intoxication can be considerable, but it is not known how often such intoxications occur. The number of ecstasy-related incidents at parties dropped. This may be connected with the stable composition of ecstasy pills. In the last few years, more than nine in ten ecstasy pills that consumers handed in for testing at care organisations for addicts contained only MDMA or an MDMA-like substance. However, the percentage of pills with a high MDMA content of more than 140 milligrams per pill increased slightly, from one percent in 1999 to six percent in 2003. According to the latest scientific insights, the use of ecstasy may lead to long-term memory problems, to problems with the capacity to concentrate and mood problems. The risk of brain damage depends on the dose and the temperature at which ecstasy is used. The exact number of people who have died as a result of ecstasy use is not known. The Cause of Death Statistics Agency recorded seven cases in 2003. Alcohol Alcohol consumption is widespread in Dutch society. Of the population aged 16 and over, 85% drink alcohol ‘occasionally’. This percentage has been stable in the last few years. Sales figures, however, show a slight decrease in the total per capita consumption of alcohol in 2003. This decrease is due to the decrease in the consumption of distilled spirits, which dropped by nearly ten percent in 2003 compared to the year before. Heavy drinking – six glasses or more on at least one day a week – was prevalent in eleven percent of the population aged 12 and over, a slight decrease compared to 2001. Proportionally, heavy drinking is most prevalent among young men aged 18 to 24 incl. This age group also accounts for a relatively high number of traffic accidents in which alcohol is involved. Ten percent of the Dutch population aged 16 to 69 are problem drinkers.
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Alcohol consumption among secondary pupils increased between 1999 and 2003. In 1999, 74 percent of the pupils had experience with alcohol, in 2003 this was 85 percent. The increase was especially noticeable among young girls, aged 12 -14. In 2003, there was no difference in the percentage of boys or girls who had a drink in the month prior to the survey. There were however differences in drinking pattern. Boys drank alcohol more frequently than girls. They also drank larger quantities than girls, particularly older boys. Compared to pupils in other countries, Dutch pupils drank frequently. In 2003, 26,874 persons were treated at the (outpatient) care organisations for drug addicts with alcohol use as primary problem. This is thirteen percent more than in 2002. Many people were also admitted into general hospitals as a result of alcohol consumption; in 2003, 4,239 were admitted with an alcohol-related disorder as primary diagnosis and 10,899 with an alcohol-related secondary diagnosis. The number of recorded dead and injured in traffic as a result of alcohol consumption dropped slightly since 1997. In 2003, their number was nearly 2,700. Total alcohol-related mortality, however, has risen in the past few years. In 2003, nearly 1,900 people died from causes in which alcohol was named explicitly, seven percent more than in 2002 and over forty percent more than in 1995. Tobacco In 2003, the Netherlands had over four million smokers; slightly more men than women (33% versus 27%). While in the early eighties as many as 52 percent of the men and 35 percent of the women smoked cigarettes, the percentage of heavy smokers has fallen over the past years. In 2000, ten percent of the population aged 12 and over smoked at least twenty cigarettes a day and in 2003 this dropped to eight percent. Among pupils aged 12 and over, the percentage of ever users decreased from 55 to 45 percent. The percentage of pupils who had smoked in the month before the survey dropped in that same period from 27 to 20 percent. In 2003, over 20,000 people died from the direct consequences of smoking. Per 100,000 inhabitants, 67 people died from lung cancer, the main cause of death from smoking. While mortality from this illness is decreasing among men, it is rising among women. Recorded drug-related crime Offences under the Opium Act put a heavier strain on the resources of the criminal system in 2003 than in 2002; this also applied to all the phases of the criminal process. In 2003 more suspects were booked for Opium Act offences than in 2002. Most of those offences were still related to hard drugs. Of the investigations into organised crime 66 percent concerns Opium Act offences. This is more or less the same as in 2002, when this proportion was 63 percent. The number of Opium Act cases taken in by the Public Prosecutions Department continued to increase, although the increase by 8 percent in 2003 was somewhat less than in the two previous years. The Court dealt with over 12,000 Opium Act cases, more than in 2002 when over 10,000 cases were dealt with. The number of imposed community sentences and confiscation orders in cases under the Opium Act increased strongly in 2003. The number of unsuspended custodial sentences in Opium Act cases increased also in 2003. In 2003, these made up 15 percent of the total number of custodial sentences. The increase was due to the hard drug cases, which made up 14 percent of the total in 2003. The proportion of soft drug cases remained stable, being 1 percent of the total. One in three sentences involving prison years was drugrelated, which is more than before; 28 percent concerned hard drugs. In 2003, a quarter of the prison population were detained because of Opium Act offences. Offenders under the Opium Act repeated the offence more often than other offenders. In 2003, criminal drug users put an approximately the same burden on the criminal system as in 2002. That same year, the police recorded over 10,000 suspects as 'drug users'.. These suspects mainly committed property offences in 2003 as well. Offences involving violence and Opium Act offences were somewhat more frequent in 2003 than in the previous years. Three in four drug-using suspects
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had eleven or more crime-related police reports in his/her criminal history. More than 70 percent of the ‘very high rate’ frequent offenders are regular drug users. In 2003, in general more activities of the Netherlands (Drug) Rehabilitation Foundation were recorded in the criminal system. The number of addicts entering the Judicial Treatment of Addicts (SOV) rose also steadily in 2003. End 2003 there were 192 participants. The degree of capacity utilisation increased compared to 2002 and was 85 percent end 2003. From April 2003, the regular outflow of participants started.
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1
INTRODUCTION
The National Drug Monitor In the Netherlands, numerous monitors record developments in the field of substance use. In addition, frequently research is published about patterns of use, prevention of substance use and treatments. To policymakers and professionals in the field and to other target groups the National Drug Monitor (NDM) provides an updated overview in this large data flow. The NDM aims primarily to collect data about developments in substance use in a coordinated and consistent manner based on existing research and records and to combine and convert this knowledge into a number of basic products, such as annual reports, thematic reports and fact sheets. This objective is in line with the current social pursuit of a policy and practice based on facts. The NDM was established in 1999 on the initiative of the Minister of Public Health, Welfare and Sports 1 (VWS). However, drug use is not only within the focus of public health, but also of the judicial system. Since 2002, the NDM has also been supported by the Ministry of Justice. The NDM promotes the following functions: • Acting as a coordinating body for currently ongoing surveys in the Netherlands and for registering data on substance use (drugs, alcohol, tobacco) and dependence. The NDM strives for an improved harmonisation of monitoring activities in the Netherlands, taking international data collection guidelines into account. • Achieving a synthesis of the compiled data, and reporting to national authorities and international and domestic organisations. The international organisations that receive reports from the NDM include the WHO (World Health Organisation), the United Nations and the EMCDDA (the European Monitoring Centre for Drugs and Drug Addiction). At the centre of the NDM’s work is the collection and integration of figures. To that end a limited number of key indicators or ‘policy barometers’ are used, which were agreed upon by the Member States of the European Union in the framework of the United Nations and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). This involves information on: • substance use in the general population • problem use and dependence • the use of professional services • illness • and drug-related mortality. The NDM also reports on recorded drug crime and penal response. Here too, a series of key indicators are used, which are collected by the Research and Documentation Centre of the Ministry of 2;3 Justice (WODC). To that end, the Ministry of Justice in 1999 initiated a developmental program.
Collaboration The NDM relies on the contribution of a multitude of experts. Implementing organisations of numerous local and national monitoring projects supply the building blocks. The quality of the publications is warranted by the Scientific Council of the NDM. This Council evaluates all written concepts and offers advice on the quality of monitored data. Three work groups - – the work group Prevalence Estimates
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of Problem Substance Use, the work group Drug-related Mortality, and the workgroup Effectiveness in the Treatment of the Drug Problem – support the NDM on thematic sub(fields). Each year the NDM publishes a statistical overview of addiction and substance use and its consequences: the Annual Report. This report is part of the annual documentation submitted to Parliament.
Annual Report 2004 This is the sixth Annual Report of the NDM. Chapters two to seven incl. describe developments per substance or classes of substances: cannabis, cocaine, opiates, ecstasy and amphetamines, alcohol and tobacco. Per chapter we briefly and concisely present the most recent figures pertaining to the use, problem use, treatment demand, (illness and) mortality and finally supply and the market. The situation in the Netherlands is (carefully) placed in an international context. In Chapter 8 the information on recorded drug crime is presented, with the focus on narcotics offences (violations of the Dutch Opium Act) and drug crime by users in the different sections of the penal chain (police, Public Prosecutor’s Office, justice system, detention). This chapter also provides a current overview of the penal options in terms of mandatory and coercive measures for criminal drug addicts. Figures on substance use and drug crime can be measured and reflected in various ways. Appendix A contains information about the terminology used. In Appendix B we give a concise overview of the main sources of the information in this Annual Report. The Annual Report can also be accessed via internet: http://www.trimbos.nl/Downloads/Producten/NDM%202004.pdf
Other information • • •
Key figures about the addiction care sector can be found in the Brancherapport [Mental Health 4 Sector Report] GGZ-MZ 2000-2003. The NDM background study ‘Hulp bij Probleemgebruik van Drugs’ [Treatment for Problem Use of 5 Drugs] gives a detailed overview of effective treatments of drug addiction. For more details about the results and gaps of monitor systems in the field of alcohol and drugs 6 we refer to the report ‘Monitoring van alcohol en drugs onder the loep’ [Monitoring of alcohol and drugs under the microscope], which can also be found on internet (www.trimbos.nl/ndm of www.ivo.nl). A detailed overview of recording systems and research in the Netherlands about the monitoring of alcohol and drugs can be found on the website of the Trimbos Institute, the Research Institute Foundation (IVO) and the Netherlands Organization for Health Research and Development (ZonMw) (www.trimbos.nl/monitors of www.ivo.nl of www.zonmw.nl).
Earlier publications of NDM are: 7 • ‘Fact sheet Drugsbeleid’ [Fact sheet on drug policy], briefly outlining information on drug policy, drug use, addiction care, drug education and prevention and public nuisance, drug-related crime and drug trafficking. 8 • ‘Bovenmatig drinken in Nederland’ [Excessive drinking in the Netherlands], a report based on the outcomes of the Nemesis household survey. 9 • ‘Cannabis. Feiten en cijfers 2003’ [Cannabis. Facts and figures in 2003], a background study of the state of science on cannabis.
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In addition to the NDM the Trimbos Institute oversees the coordination of two other national monitors, resulting in cooperation with: the Netherlands Mental Health Monitor (NMG) and the Homelessness and Social Inclusion Monitor (Monitor Maatschappelijke Opvang – MMO). • Annual reports and other reports produced by these monitors can be found on the website of the Trimbos Institute (www.trimbos.nl).
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2
CANNABIS
Cannabis (Cannabis Sativa or hemp) comprises hashish and pot in various preparations. THC (tetrahydrocannabinol) is the main psychoactive ingredient. Cannabis is usually smoked in cigarettes, whether or not in combination with tobacco, and sometimes via an evaporator. Eating it – in the form of space cake – also occurs. Consumers experience cannabis as having a calming, relaxing and psychedelic effect. At a high dose, cannabis may cause fear, panic and psychotic symptoms. The below data apply to hashish and pot together, unless stated otherwise.
2.1
LATEST FACTS AND TRENDS
The main facts and trends regarding cannabis in this chapter are: • The percentage of users of cannabis in the general population increased between 1997 and 2001. The proportion of (almost) daily consumers among recent users decreased in this period (Chapter 2.2). • The percentage of recent users among school-aged children (12-18 years) decreased slightly between 1996 and 2003. The credit of this decrease goes to the boys; among the girls the consumption remained the same (Chapter 2.3). • Compared with their peers in a number of other Member States of the European Union, in respect of cannabis use, Dutch pupils are in the middle range (Chapter 2.5). • Among visitors of trendy clubs in Amsterdam the use of cannabis decreased between 1998 and 2003 (Chapter 2.3). • Just as in previous years, the number of cannabis patients who sought help from the (outpatient) care organisations increased between 2002 and 2003 (Chapter 2.6). • The number of coffee shops fell slightly between 2002 and 2003 (Chapter 2.8). • The average THC content in Dutch-grown cannabis rose further between 2002/2003 and 2003/2004 (Chapter 2.8).
2.2
USE IN THE GENERAL POPULATION
Of all drugs, cannabis is the most commonly used substance. In 1997 and 2001, National Prevalence 10 Surveys (NPO) were conducted by the Amsterdam drug research institute CEDRO. Between 1997 and 2001 a slight rise in the use of cannabis was noted in the Netherlands. Key figures are as follows: • In 2001, one in six respondents aged 12 and over had ever used cannabis (see Table 2.1). • One in 33 respondents had used cannabis in the month prior to the interview (current use). • Extrapolated over the entire population, in absolute numbers, this represents an increase from 326,000 to 408,000 in current cannabis users over these four years (1997 – 2001); a rise of 25 percent. • Cannabis consumption is most prevalent among young people and adolescents (see Figure 2.1). - The rise in both ever use and current use figures was found to be highest in the age group 20 to 24 years incl. (see Figure 2.1). - Ever use figures dropped slightly among young people aged 12 to 15 incl. (see Chapter 2.3 for comparison). • Cannabis use is more prevalent among men than among women (see Table 2.1).
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Table 2.1
Cannabis use in the Netherlands among people aged 12 and over. Survey years 1997 and 2001
Has ever used • Men • Women I Used currently • Men • Women First use in the past year Average age of current users
1997 15.6% 20.6% 10.8%
2001 17.0% 21.3% 12.8%
2.5% 3.5% 1.4%
3.0% 4.3% 1.8%
1.3% 28 years
1.0% 28 years
I. In the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 2.1 Cannabis users in the Netherlands by age group. Survey years 1997 and 2001
% 50 40 30 20 10 0
12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69 >=70
Ever 1997
7.5
27.5
31.7
30.6
21.7
20.5
16.8
6.7
1.9
0.5
Ever 2001
5.9
28.4
41.9
33.8
25.9
21.9
18.5
8.3
1.2
0.4
Current 1997
2.0
8.3
7.1
4.7
2.1
3.6
1.5
0.5
0.0
0.0
Current 2001
2.2
8.6
11.2
6.6
3.6
2.7
1.7
0.9
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
24
The large cities Consumption of cannabis is more prevalent in cities than in rural areas (see Table 2.2. Table 2.2
Cannabis use in the four large cities and in rural areas among people aged 12 and over. Survey years 1997 and 2001 Ever use
Amsterdam Rotterdam Other primarily urban I municipalities II Utrecht II The Hague III Rural municipalities
Current use
1997 36.7% 18.5% 23.0%
2001 38.1% 22.4% 26.3%
1997 8.1% 3.3% 4.1%
2001 7.8% 5.0% 4.8%
27.3% 20.1% 10.5%
11.4%
4.2% 4.2% 1.5%
1.7%
Percentage of ever (lifetime) and current (last month) users. I. Definition: municipalities with more than 2,500 addresses per square kilometre with the exception of Amsterdam and Rotterdam. These are: Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. II. Utrecht and The Hague were not listed separately in the 2001 survey. III. Definition (Statistics Netherlands - CBS): towns with fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Level of consumption The frequency of cannabis use among current users varies strongly. • In 2001, almost half of all current users in the Netherlands used cannabis less than once a week 10 (see Figure 2.2).
•
Approximately one fifth of this group used cannabis (almost) daily. Extrapolated over the entire population this amounts to nearly 78,000 people; fewer than in 1997 (over 83,000 people). This decline did not occur evenly across the Netherlands. In Amsterdam and Rotterdam the percentage of heavy users rather seemed to increase.
25
Figure 2.2 Cannabis consumption levels in the Netherlands among current users aged 12 and over. Survey years 1997 and 2001 60
% 51
50
45
40 30
1997
26
20
14
12
15
2001 19
18
10 0 1-4
5-8
9-20
>20
Number of days in last month
Percentage among current users. Number of days on which cannabis was used in the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Sources of procurement Cannabis users procure cannabis mainly in coffee shops or obtain it through friends and acquaintances (see Table 2.3). • Young people between the age of 12 and 17 are more likely to obtain cannabis through friends and acquaintances than from coffee shops. The opposite is true for cannabis users aged 18 and over. I
Cannabis procurement sources of recent users? Survey year 2001
Table 2.3
Users aged 12 to 17 incl.
Users aged 18 and over
from coffee shops
46% 37%
37% 47%
from a ‘house dealer’
3%
2%
in a pub
2%
2%
in a smart shop
2%
2%
at another public nightlife location
4%
2%
through growing it themselves
3%
4%
4%
4%
They obtain their cannabis - through friends and acquaintances
-
Other
II
I. The percentage of cannabis procurement sources of recent users in the last year. A respondent may have more than one source. II. Through youth clubs, dealer delivery services, strangers on the street, etc. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
26
Special groups In certain groups of adults a considerably higher prevalence of cannabis use was noted than in the general population. 11 • In 2002, over half (52%) of the homeless in 20 Dutch towns were current cannabis users. a
• In the same year, one in three (33%) male detainees in eight penitentiaries stated to have used cannabis daily in the last six month prior to detention. Detainees with serious psychological 12 disorders or prison-imposed restrictions (contact ban) were not represented in the sample. • There are indications that cannabis use is very common among certain groups of psychiatric 13;14 patients, such as people with schizophrenia or borderline disorder. Hard figures are scarce. According to older data by Nemesis (from 1996) cannabis use is more prevalent among people with mood disorders and combined anxiety/mood disorders than among people without these disorders (7%, 9% and 3% recent users, respectively). As regards patients with anxiety problems alone, no (significant) difference was observed.
2.3 USE AMONG YOUNG PEOPLE To classify the use of cannabis among young people, figures from the National Prevalence Research are available, as mentioned in Chapter § 2.1. In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F we give an overview of recent figures concerning the use of cannabis among young people in 29 municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of the difference in cannabis use between the various municipalities. The percentage of young people aged 19 to 23, for example, who ever tried cannabis is remarkably low in Urk (16%) compared to Almere and Lelystad (50%). The ever use in the lastmentioned cities seems also to be higher than the national average (see Figure 2.1). In this paragraph we also present the data of the Dutch National School Survey and data from (often local) surveys among special groups of young people.
Pupils Since the mid-eighties the Trimbos Institute has monitored the extent to which secondary school pupils aged 12 and over have experience with alcohol, tobacco, drugs and gambling. This is done in, what is called, the Dutch National School Survey. • Figure 2.3 shows that the percentage of cannabis users among school-aged youth increased 15 significantly between 1988 and 1996. • After 1999 the ever use stabilised and remained at approximately the same level as in 1996. The current use decreased significantly between 1996 and 2003. The credit of this decrease goes mainly to the boys. Among girls, the percentage of current users of cannabis remained more or less the same between 1996 and 2003.
a
In Arnhem, Den Bosch, Breda, Grave and 4 remand prisons in Rotterdam.
27
•
In the measurements of up to 1999 incl., more boys than girls used cannabis. In 2003, for the first time, the ever use was the same for boys and girls. The difference of actual use between boys and girls decreased also, but remained statistically significant.
Figure 2.3
Use of cannabis among school-aged youths aged 12 and over, from 1988 Current use (%)
Ever use (%) 16
30
23 19
20
18 15 10
10 5
22 20
15
14
14
25
25
20 19 17
12
12
10
10
9
11 9
8
16
6
12 9
4
7
2
7
5 4
8 7
9 7
4
2
0
0 1988
1992 Boys
1996 Girls
1999 Total
2003
1988
1992 Boys
1996 Girls
1999
2003
Total
Percentage of ever users (on the left) and current users (on the right). Source: Dutch National School Survey, 16 Trimbos Institute.
Age • •
The use of cannabis increases with age. Only few twelve-year olds have experience with cannabis: one in fifty (2%). At age sixteen, one in three pupils ever used cannabis (34%). The age on which school-aged youth used cannabis for the first time dropped between 1988 and 186 1996. The percentage of ever users of cannabis who smoked their first joint at the age of thirteen or younger doubled in this period from 21 to 40 percent. Between 1996 and 2003 the first-use age remained the same.
Level of consumption •
•
•
Of the nine percent current users in 2003, nearly half had used cannabis not more than once or twice in the past month. A minority blew more than ten times (17%): one in five boys and more than one in ten girls (see Figure 2.4). Per occasion nearly half the current users smoked less than one joint (46%). They probably smoke together with others, sharing a joint. Nearly one in three smoked one or two joints per occasion (32%) and nearly a quarter smoked more than three joints per occasion (23%). There is also a correlation between frequency and quantity. Of those who blow three to ten times a month, a quarter (27%) smoke three or more joints per occasion. Of those who blow more than ten times a month, two-thirds (67%) smoke three or more joints per occasion. This last group runs a relative large risk of getting into problems.
28
Figure 2.4
Frequency of cannabis use among current users. Survey year 2003 girls
boys 11%
20%
43% 51% 38% 37%
1-2 times
3-10 times
> 10 times
1-2 times
3-10 times
> 10 times
Percentage of school-aged youth who had used cannabis in the month before the survey. Source: Dutch National 16 School Survey, Trimbos Institute.
School level and ethnic origin •
• •
The percentage of ever users and current users among pupils of VMBO-t (pre-vocational secondary education - theoretical stream), HAVO (senior general secondary education), VWO (pre-university education) and VMBO-p (pre-vocational secondary education - practical stream) is about the same. The frequency of use in the last month does not differ much either between the school levels. However, the percentage of pupils who smoke three or more joints on average per time is significantly higher at VMBO than at VWO (30% versus 8%). Current use of cannabis is less common among Moroccan than native Dutch girls (0% versus 7%). No difference is found between Moroccan and native boys. Antillian/Aruban (12%), b Surinamese (8%) or Turkish (5%) pupils do not differ significantly in this from native pupils. According to data from the Antenne Monitor, in Amsterdam the percentage of ever users and current users of cannabis is lowest among Moroccan pupils but also the percentage of users among Turkish and Surinamese pupils is lower than among native Dutch pupils.
Sources of procurement •
• •
•
b
Two in three current users receive cannabis from friends and one in three buys it (also) in coffee shops (see Table 2.4). More than one in ten buy cannabis from a ‘house dealer’ and one in ten receives it ‘in a roundabout way’. More girls than boys obtain cannabis through friends; boys buy in coffee shops more often than girls. A considerable part of the blowing pupils of up to 17 years incl. buy cannabis in a coffee shop. This is remarkable, because the legal minimum age for access to a coffee shop is 18 years. It is unknown to what extent these young people themselves actually bought cannabis in a coffee shop or had others by it for them. Boys aged 18 are used to buying cannabis mostly in coffee shops. Eight in ten current users among boys buy their cannabis there.
For the definition of native Dutch and immigrant: see Appendix A.
29
Table 2.4
Cannabis procurement sources of school-aged youth? Survey year 2003 12-15 years b g
Through friends Buy in coffee shops Buy from dealer In a roundabout way Otherwise
60% 22% 17% 16% 7%
78% 22% 6% 9% 6%
16-17 years b g
64% 57% 15% 6% 2%
77% 37% 12% 2% 8%
b
18 years g
b
Total m
Total
40% 81% 9% 0% 4%
69% 56% 0% 0% 0%
60% 40% 16% 11% 5%
78% 27% 7% 6% 6%
67% 35% 12% 9% 6%
Secondary school pupils aged 12 and over (current users). The pupils were allowed to check multiple answers. Therefore, the percentages do not add up to 100%. b = boys, g = girls. Source: Dutch National School Survey, 16 Trimbos Institute.
Special groups of young people The use of cannabis in certain groups of young adolescents is the rule rather than the exception. Table 2.5 summarises the results of a broad spectrum of studies. The figures in this table are not comparable due to differences in age categories and research methods. • Among young people in special schools and participants in truancy projects relatively many current users are found. • The Antenne-monitor monitors the use of substances in various groups of young people in the Amsterdam club scene, such as coffee shops, pubs and trendy clubs. - According to a survey among visitors of coffee shops, two thirds of the current blowers use cannabis daily. Current blowers smoke four joints on average per occasion. Daily blowers 17 smoke five joints on average per occasion. - In 2001, the number of Amsterdam coffee shop visitors under the age of 18 was 50 percent c lower than in 1994 (7% and 14% respectively). This may be connected with the raise of the legal minimum age from sixteen to eighteen years for the sale of cannabis to young people by coffee shops. - Between 1998 and 2003, the percentage of cannabis users among young people and adolescents who visit trendy clubs (and parties) in Amsterdam dropped from 52 to 39 percent. The average number of joints smoked by current users per time dropped also, from two to one 18 and half. This trend, which also applies to most of the other drugs, is in line with the phase of the ‘new level-headedness’ and the observed tendency to more prudent use. • Young people who visit clubs and pubs often also have experience with other substances. Table 2.6 shows the percentage of young people visiting clubs and pubs in The Hague who used both cannabis and another substance in the month prior to the interview. Often these substances are used simultaneously. Favourite combinations are cannabis with alcohol and cannabis with 19-21 ecstasy. • The use of cannabis (and other substances) is common among young homeless people. Four in 22 ten young homeless people in the Netherlands are (almost) daily users. In 2004, 87% of the 23 young homeless people in Flevoland were current users of cannabis.
c
Coffee shop visitors up to the age of 25 only, were included in the comparison between 1994 and 2001.
30
Table 2.5
Current cannabis use in special groups Location I
Young people in special education II Pub visitors Young people in truancy programs III Marginalised young people Young clubbers Visitors of trendy clubs Young people in special education and truancy projects IV Young homeless people V
Coffee shop clientele
Nationwide Amsterdam Nationwide The Hague The Hague Amsterdam Amsterdam
Survey year 1997 2000 1997 2000/2001 2003 2003 2003
Age (year) 12 - 18 Mean age 25 12 - 18 16 - 25 15 - 35 Mean age 28 13 - 16
Current use 14% 24% 35% 37% 37% 39% 32%
Nationwide Flevoland Amsterdam
1999 2004 2001
15 - 22 13 - 22 Mean age 25
76% 87% 88%
Percentage of current (last month) users by group. The figures in this table are not comparable owing to differences in age groups and research methods. I. Special schools for children with learning and/or behavioural difficulties (MLK, LOM, ZMOK). II. Young people and adolescents visiting mainstream, student, gay, and trendy pubs. The sample is therefore not representative for all pub visitors. III. Young people receiving inadequate care and/or cannot provide sufficiently in their own livelihood. Recruited at locations for young homeless people, lowthreshold day- and night shelters and (other) temporary living accommodations. V. Young people up to 23 years 17;22;24-26 23 . of age without a fixed address for three months or longer. References:
Table 2.6
Poly-consumption of cannabis and other substances among young clubbers in The Hague. Survey year 2003
Combination Cannabis with alcohol Cannabis with ecstasy Cannabis with cocaine Cannabis, cocaine and ecstasy
Percentage of recent users. 34% 14% 8% 6%
The same person may occur in several categories. I. Number of respondents: 634. Source: Survey of clubbers in 21 The Hague.
2.4
PROBLEM USE
The precise number of people experiencing problems as a result of cannabis use is not known, nor is there a generally accepted definition of problem cannabis use. The addictive potential of cannabis is minimal compared to that of nicotine, heroin and alcohol. However, the risk of dependence does increase with prolonged and frequent use and often is associated with an additional dependence on 27 other substances. Young people are more vulnerable to becoming dependent than older people. • The Nemesis study provides information about the prevalence of cannabis dependence according rd to the psychiatric classification system Diagnostic and Statistical Manual (DSM) (3 amended edition). In 1996, between 0.3 and 0.8 percent of the population aged 18 to 64 incl. showed the symptom criteria for this diagnosis in the year prior to the study. Extrapolated over the entire population this amounted to between approx. 30,000 and 80,000 people. The majority of these 28 cannabis users was not older than 22 years. • Problem cannabis use is very common in certain groups of young people, such as youths who end up in juvenile correctional facilities, play truant on a frequent basis and display delinquent behaviour (see Table 2.7).
31
Table 2.7
Problem cannabis use in different groups
Group
Year
General population in the Netherlands General population in Midden-Holland
1996
Age (year) 18 – 64
1999
16 – 50
Youths in juvenile correctional facilities
1998/ 1999
12 – 18 (mean age16)
High-risk juveniles (truancy and delinquent behaviour) in Rotterdam
1998
14 – 17 (mean age16)
Definition of problem use DSM-III-r diagnosis cannabis dependence in the last year Cannabis use on a minimum of 15 days in the last month and presence of the psychological, social and financial problems related to the use DSM-III-r diagnosis cannabis dependence in the last 6 months prior to detention Cannabis use on a minimum of 11 days in the last month and presence of userelated problems
I. Average of 0.5%. DSM-III-r=Diagnostic and Statistical Manual, 3rd edition. References:
13;28-30
Percentage of problem users I 0.3% - 0.8% in the last year 0.5% in the last month
30% in the last 6 months 20% in the last month
.
Cannabis use is increasingly associated with psychological problems. 31 • There is growing evidence that cannabis increases the risk of a psychotic disorder later in life. 32;33 • The risk increases with the frequency of cannabis use. • People with a history of psychotic symptoms are particularly vulnerable. • It is not known to what extent other vulnerability factors increase the risk of psychosis. • Studies are currently underway regarding the connection between cannabis use and the 34;35 development of depression. The role of the increasing concentration of THC in Nederwiet (Dutch-grown cannabis) in the occurrence of (health) problems is not clear. • Recent research among coffee shop clientele, however, has shown that there is a specific group 36 of especially young users with a clear preference for ‘strong cannabis’. They use it relatively often and in large quantities and run a large risk of becoming dependent.
2.5
USE: INTERNATIONAL COMPARISONS
General population Data on drug use in the EU Member States are provided by the European Monitoring Centre for Drugs 37;38 and Drug Addiction (EMCDDA). Organisations in the United States (USA) and Australia also 39;40 publish outcomes of surveys on drug use on a regular basis. • Differences in survey year, research methods and sampling complicate precise data comparisons. Of particular influence is the age group. Table 2.8a shows consumption figures (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data on the other countries are listed in Table 2.8b. • The percentage of recent cannabis users in the general population is lowest in Finland, Portugal and Sweden and highest in Canada, England and Wales, the United States and Australia. Of the EU countries stated in Tables 2.8a and 2.8b, the Netherlands seems to take a position around the middle or slightly higher.
32
Table 2.8a
Cannabis use in the general population of various EU Member States and Norway: age group from 15 to 64 years incl.
Country Spain France The Netherlands Ireland Northern Ireland Norway Greece Luxembourg Sweden Finland Belgium Portugal
Year 2001 2000 2001 2002/2003 2002/2003 1999 1998 1998 2000 2002 2001 2001
Ever use 25% 23% 21% 18% 17% 11% 13% 13% 13% 13% 11% 8%
Percentage of ever and recent (last year) users. - = not measured. References:
Table 2.8b
Recent use 10% 8% 6% 5% 5% 5% 4% 1% 3% 3% 37;38
Cannabis use in the general population of various EU Member States, the United I States and Australia: other age groups
Country Canada United States Australia Denmark England and Wales Italy Germany
Year 2002 2003 2001 2000 2002/2003 2001 2000
Age (year) 15 and over 12 and over 14 and over 16 - 64 16 – 59 15 – 44 18 – 59
Ever use 41% 41% 33% 31% 31% 22% 19%
Recent use 12% 11% 13% 6% 11% 6% 6%
Percentage of ever in lifetime and recent (last year) users. I. Drug use is proportionally low in the youngest (1215 years) and the older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. The opposite is true for studies 37-42 with a more limited age range .
Young people Better suited for comparison are the figures from the European School Survey Project on Alcohol and Other Drugs (ESPAD). The last surveys were conducted in 1999 and 2003 among secondary school 43 pupils aged 15 and 16. • Table 2.9 portrays the consumption of cannabis in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in the ESPAD, but conducted comparable research. • The percentage of pupils that had ever used cannabis in 2003 was highest in Ireland, closely followed by France, the United Kingdom and the United States. Belgian pupils took the fourth and Dutch pupils the fifth place. • France had the highest current use figures, followed by the United States, the United Kingdom and Ireland. The Netherlands and Italy came next. • In the United Kingdom and Portugal the percentage of current users rose by four and three percentage points, respectively, in 2003 compared with 1999. Elsewhere differences of two or fewer percentage points were found.
33
•
•
The percentage of pupils who had used cannabis six times or more in the last month was lowest in the Scandinavian countries and highest in France, the United States and the United Kingdom. Dutch pupils shared a fourth place with their Irish and Italian peers. In most of the countries there was a correlation between ever use of cannabis and the degree of truancy, lack of parental control and the presence of older brothers or sisters who used cannabis.
Table 2.9
Cocaine consumption among pupils aged 15 and 16 in EU Member States, Norway and the United States. Survey years 1999 and 2003
Country
Ever use
United States Ireland France United Kingdom Belgium The Netherlands I Germany Italy Denmark Austria Portugal Finland Norway Sweden Greece
1999 41% 32% 35% 35% 28% 25% 24% 8% 10% 12% 8% 9%
2003 36% 39% 38% 38% 32% 28% 27% 27% 23% 21% 15% 11% 9% 7% 6%
Current use 1999 19% 15% 22% 16% 14% 14% 8% 5% 2% 4% 2% 4%
2003 17% 17% 22% 20% 17% 13% 12% 15% 8% 10% 8% 3% 3% 1% 2%
Six times or more in the last month 1999 2003 9% 8% 5% 6% 9% 9% 6% 8% 7% 5% 6% 4% 4% 6% 1% 2% 3% 2% 3% 1% 0% 1% 1% 0% 0% 2% 1%
Percentage of ever in lifetime users, current (last month) users and six times or more in the last month users. I. Six of sixteen Member States. - = not measured. The United States did not take part in the ESPAD, but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
2.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records the number of people seeking assistance from (outpatient) care organisations for addicts, including the probation and after-care services. (See in Appendix A: Client LADIS.) • The number of clients registered for a primary cannabis problem more than doubled between 1994 and 2003 (see Figure 2.5). Between 2002 and 2003 the increase was 21 percent. • The proportion of cannabis in all drug-related registrations increased also, from 10 percent in 1994 to 15 percent in 2003. • Characteristics of the primary ecstasy clients in 2003: - The majority was male (83%); the proportion of women increased somewhat, from 15 percent in 1994 to 17 percent in 2003. - The average age was 28. Most of these clients were in the age group 20-24 years (see Figure 2.6). - Four in ten were new clients (40%). They had not sought drug-related help from (outpatient) care organisations for addicts before. • The number of clients in (outpatient) care organisations for addicts who mentioned cannabis as a secondary problem increased also between 1994 and 2003 (see Figure 2.5).
34
• For this group, alcohol (40%), cocaine or crack (36%), or heroin (14%) was the primary problem.
Figure 2.5
Number of clients in (outpatient) care organisations for addicts with primary or secondary cocaine problems, from 1994 5000
4000
3000
2000
1000 Primary
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 1951 2274 2659 3264 3291 3281 3443 3432 3701 4485
Secundary 2846 2668 2718 2820 2844 3063 3144 3300 3697 4291 Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Figure 2.6
Age distribution of clients in (outpatient) care organisations for addicts with cannabis as primary problem. Survey year 2003
30% 25% 25% 21% 18%
20% 15%
14% 10%
10% 6% 5%
3%
2%
45-49
50-54
1%
0% 15-19
20-24
25-29
30-34
35-39
40-44
55-59
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
35
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • The number of admissions for cannabis abuse and dependence rose from 71 in 1990 to 309 in 1996 (ICD-9 codes: 304.3, 305.2; see Appendix C). • The proportion of cannabis in all drug-related admissions rose slightly between 1990 and 1996, from three to seven percent. • The situation since then is not really known, because record keeping has been incomplete from 1997 (see Appendix B).
General hospitals; incidents In 2003, the National Medical Registration (LMR) recorded nearly 1.6 million clinical admissions in general hospitals. Drug problems hardly played a role in these admissions. In that year, drug abuse and drug addiction were determined 402 times to be the primary diagnosis and 1,986 times as the secondary diagnosis. • Eleven percent of the primary diagnoses involved cannabis (37% dependence, 63% abuse; see Figure 2.7). It is not known whether the complaints that led to the admission were psychological or physical in nature. • Cannabis-related problems played a greater role in terms of secondary diagnoses (30% dependence, 70% abuse). The slight rise until 1999 did not continue in the last few years. • In 2003, these secondary diagnoses were mostly associated with the following primary diagnoses: - psychoses (29%) - accident-related injuries (13%, e.g. fractures, wounds, concussion) - abuse or dependence on alcohol and drugs (13%, mainly alcohol) - poisoning (10%, by drugs, alcohol, prescription drugs) - respiratory illnesses and symptoms (8%) - heart and vascular diseases (7%)
36
Figure 2.7 Clinical admissions in general hospitals related to cannabis abuse and dependence, from 1994
300 249
247
250 193
200
246 230
160
184
195
193
154
150 100 39
50
38 26
21
29
29
38 24
46 33
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Main diagnosis - clinical
Secondary diagnosis - clinical
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.3, 305.2 (Appendix C). Source: National Medical Registration (LMR), Prismant.
• A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 262 patients were admitted in 2003. They were admitted at least once this year with cannabis abuse or dependence diagnosed as primary or secondary problem. The average age was 29 years and 79 percent were male. • In 2003, cannabis-related problems also played a role as primary or secondary diagnoses in 69 day-treatment admissions. In addition, in 2003, the National Medical Registration (LMR) recorded 16 admissions with “accidental poisoning with hallucinogens” as secondary diagnosis (ICD-9 code: E854.1). In 2001 and 2002, there were 15 and 8 such cases respectively. This may involve cannabis, but also LSD or magic mushrooms. The Central Ambulance Service of the Amsterdam Area Health Authority (GG&GD Amsterdam) keeps a record of the number of drug-related emergency calls. • Cannabis use was involved in 257 cases. That is somewhat less than in the two previous years, but represents twice the number compared to the years 1998 up to 2000 incl. (see Table 2.10). • More than one in three (35%) cannabis cases required transport to hospital casualty. The rest could be treated on-site. Table 2.10
Cannabis incidents recorded by the Amsterdam Area Health Authority (GG&GD Amsterdam), from 1992
Smoking cannabis Eating space cake
1992 82 40
1993 40 11
1994 130 34
1995 137 73
1996 165 58
1997 211 47
1998 107 28
1999 118 21
2000 106 35
2001 243 46
2002 226 59
Number of annual incidents. Source: Central Ambulance Station (CPA), Amsterdam Area Health Authority (GG&GD Amsterdam).
37
2003 196 61
Most of the complaints of the people arriving in Casualty with a cannabis-related problem are not serious. • In 2000, Onze Lieve Vrouwengasthuis in Amsterdam mostly registered patients feeling unwell and 44 anxious (44%), with heart palpitations (20%), or nausea (15%). • Psychotic complaints were observed in four percent of cannabis patients. • Injuries as a result of a slip/fall accident were noted in 14 percent of the cases. These accidents may be connected with the (lowering) effect of cannabis on the blood pressure and motor coordination.
2.7
MORTALITY 45
The toxicity of cannabis is minimal. • In the past twenty years, the Statistics Netherlands (CBS) has not recorded one single death directly related to the consumption of cannabis. • No such directly related deaths are known in other countries.
2.8
SUPPLY AND THE MARKET
Coffee shops The number of coffee shops in the Netherlands has decreased (see Table 2.11).
• •
46
Between 1997 and 1999, Bureau Intraval registered a decrease of 28 percent , with the most significant decrease in the smaller towns and in Rotterdam. Since 1999, the annual decrease was less significant: four percent between 1999 and 2000, one percent between 2000 and 2001, three percent between 2001 and 2002 and four percent between 47 2002 and 2003.
•
In late 2003, the Netherlands had 754 officially ‘tolerated’ coffee shops, about half of which (52%) are located in the large cities with more than 200,000 inhabitants.
•
In 2003, of the 489 Dutch municipalities, 79 percent had no coffee shop at all. Three quarters (78%) of the municipalities maintained a ‘zero tolerance’ policy, meaning that coffee shops are not permitted. Nearly a quarter (23%) of the municipalities maintained a ‘maximum policy’, meaning that a limit has been set to the number of coffee shops that are tolerated.
•
•
Other ‘sales sources’ such as deal houses and street dealers are not included in the last two surveys.
38
Table 2.11
Number of coffee shops in the Netherlands by municipality, from 1997
Municipalities by number of inhabitants < 20,000 inhabitants 20-50,000 inhabitants 50-100,000 inhabitants 100-200,000 inhabitants > 200,000 inhabitants - Amsterdam - Rotterdam - The Hague - Utrecht II - Eindhoven Total
I
1997
1999
2000
2001
2002
2003
± 50 ± 170 ± 120 211
14 84 115 190
13 81 109 168
11 86 112 167
12 79 106 174
12 73 104 168
340 180 87 21
288 65 70 20
283 63 62 18 16
280 61 55 17 16
270 62 46 18 15
258 62 41 18 15
± 1 179
846
813
805
782
754
I. An estimate. II. Fewer than 200,000 inhabitants up to 1999. Source: Tilburg Institute for Social Policy Research and Consultancy (IVA), University of Tilburg.48
THC content and price The Trimbos Institute gathers information about the potency of cannabis, i.e., the concentration of the active substances, particularly THC (tetrahydrocannabinol). Since 1999, samples of different cannabis 49;50 products have been bought regularly in coffee shops and chemically analysed. • All surveys showed that Dutch-grown marihuana contained more THC on average than imported varieties. • Figure 2.8 shows that the average THC content in Nederwiet (Dutch-grown marijuana) has strongly risen since 1999. • The percentage of THC in imported hashish rose until 2001/2002. In the years thereafter no further increase was measured. The percentage of THC in imported weed increased slightly over the years. • Most of the Nederwiet originates from the intensive and professional indoor cultivation, which, compared to outdoor cultivation, results in weed with a higher THC percentage. 37 • In so far as data are available, no significant increase is noticeable in other European countries. However, it is hard to compare international figures, due to the large differences in research methods.
39
Figure 2.8
Average percentage of THC in cannabis products 25% 20% 15% 10% 5% 0%
1999/2000
2000/2001
2001/2002
2002/2003
2003/2004
Nederwiet
9%
11%
15%
18%
20%
Imported weed
5%
5%
7%
6%
7%
Imported hash
11%
12%
18%
17%
18%
Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
51
The price of one gram of Nederwiet or one gram of imported weed fluctuated slightly in the past years. • In 2002/2003 the price of Nederwiet was somewhat higher than in 1999/2000 and 2000/2001, but this trend did not continue in the last measurement. • Imported weed was somewhat more expensive in 2003/2004 than in 1999/2000 and 2000/2001. • Imported hashish was more expensive in 2000/2001 than in 2002/2002 and dropped again somewhat in the period from 2002/2003 to 2003/2004 (see Table 2.12).
Table 2.12
Price (€) per gram of cannabis product
Nederwiet Imported marijuana Imported hashish
1999/2000 5.83 3.87
2000/2001 5.86 3.80
2001/2002 6.28 4.16
2002/2003 6.45 4.32
2003/2004 5.97 4.86
6.29
6.36
7.14
7.56
6.46
Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
•
Marijuana growers in the Netherlands sometimes use pesticides to protect the plants against diseases. There are no current data about the presence of these substances in Nederwiet. Chemical analyses done in 1999 found pesticide residues in half of the Nederwiet samples. 52 However, the concentrations were so low that they did not pose a health risk.
40
3
COCAINE
Cocaine has a stimulating effect. Many cocaine users are able to combine this drug with a ‘normal’ lifestyle without getting into problems. They use cocaine for recreational purposes. Nonetheless, cocaine use can lead to dependence. Moreover, cocaine may manifest itself as part of a problematic use pattern involving the simultaneous use of several drugs. 53 Cocaine can be administered in various forms. Cocaine in salt form (hydrochloride powder) is mostly sniffed but rarely injected in the Netherlands. Every once in a while powder cocaine is smoked in a cigarette. Freebase or crack cocaine is particularly popular among problem users of hard drug. Freebase or crack is obtained by heating a solution consisting of cocaine powder, sodium bicarbonate (baking soda) or ammonia, and water. Crack cocaine is smoked in a small (crack) pipe or placed on aluminium foil and inhaled through a tube. Crack is impure crack cocaine with residues of sodium bicarbonate. It gets its name from the cracking sound of the ‘rock’ when smoked. In the eighties, crack was prepared by the consumers themselves. Nowadays it is mainly sold on the street in the form of ready-to-use ‘rocks’. The information below pertains to all forms of cocaine unless indicated otherwise.
3.1
LATEST FACTS AND TRENDS
The main facts and trends about cocaine in this chapter are: • The number of current cocaine users in the general population doubled between 1997 and 2001. The largest increase was noted in adolescents aged 20-24 (see Chapter 3.2). • Among school-aged youngsters (12-18 years) the percentage of cocaine users remained stable between 1996 and 2003 (see Chapter 3.3). • Dutch pupils score average on cocaine use compared to their peers in many other EU Member States (see Chapter 3.5). • Sniffed cocaine is fairly popular among young clubbers, in particular in trendy clubs, discos and pubs. • Among young people in trendy clubs in Amsterdam, consumption dropped between 1998 and 2003 (see Chapter 3.3). • Cocaine – especially in the form of crack cocaine – enjoys great popularity among problem opiate users (see Chapter 3.4). • The strong increase in the number of cocaine users in (outpatient) care organisations for addicts continued between 2002 and 2003 (see Chapter 3.6). • The number of admissions in general hospitals for cocaine-related problems increased between 1996 and 2002, but did not rise further in 2003 (see Chapter 3.6). • The rising trend in the number of registered acute deaths from cocaine use between the midnineties and 2001 did not continue in 2002 and 2003 (see Chapter 3.7). • In 2003, cocaine powder of consumers had often been mixed with phenacetin (see Chapter 3.8).
3.2
USE IN THE GENERAL POPULATION
According to the NPO the number of Dutch people aged 12 and above with cocaine experience rose 10 between 1997 and 2001 (see Table 3.1). • The percentage of ever users who have consumed cocaine 25 times or more in their lifetime – i.e. experienced users – grew; from 23 percent in 1997 to 29 percent in 2001. • The percentage of current users doubled in the same period but remained far below one percent. In absolute figures this represents an increase from nearly 28,000 to 55,000 current cocaine users.
41
However, these figures most certainly are an underestimation, as problem hard drug users are a
underrepresented in the National Prevalence Survey (NPO). • Cocaine is used mostly by adolescents aged 20 to 24. This same age group showed the highest increase in users between 1997 and 2001 (see Figure 3.1). • The number of current users who used cocaine (almost) daily rose from 1.8 percent in 1997 to 4.5 percent in 2001. • Men outnumbered women in both survey years as regards experience with cocaine. Furthermore, more men than women were current users in 1997, but female users had caught up by 2001 (see Table 3.1).
Table 3.1
Cocaine use in the Netherlands among people aged 12 and above. Survey years 1997 and 2001
Has used ever in lifetime • Men • Women I Used currently • Men • Women Used for the first time in the past year Mean age of current users
1997 2.1% 2.9% 1.3%
2001 2.9% 3.9% 1.9%
0.2% 0.3% 0.1%
0.4% 0.4% 0.4%
0.3% 29 years
0.3% 29 years
I. In the last month. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 3.1
Cocaine users in the Netherlands by age group. Survey years 1997 and 2001 10
%
8 6 4 2 0 12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69 >69 Ever 1997
0.1
2.3
3.9
4.8
3.6
3.1
2.4
0.5
0.4
0.0
Ever 2001
0.1
2.7
8.6
4.6
5.0
4.2
3.8
1.2
0.1
0.0
Current 1997
0.0
0.3
0.7
0.7
0.1
0.2
0.2
0.0
0.0
0.0
Current 2001
0.1
0.9
1.6
0.8
0.6
0.2
0.3
0.2
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
a
The number of problem users of opiates in the Netherlands is estimated at 32,000 on average. Field studies show that 70% to 90% of them also uses cocaine (mainly crack) (see Chapter 3.4). In absolute numbers it concerns therefore between 22,000 and 29,000 cocaine users in this group. The degree of overlap between these figures and those of the NPO is unknown.
42
The large cities Cocaine use is not spread out evenly across the Netherlands (see Figure 3.2). • In 2001, the percentage of current users was four times higher in Amsterdam than in rural areas. • In other, highly urbanised areas including Rotterdam, the proportion of current cocaine users was three times higher than in rural areas. • The rise in the percentage of ever and current cocaine users occurred all across the country but was moderate in Amsterdam.
Figure 3.2
12 10
Cocaine use in large cities and rural areas among people aged 12 and above. Survey years 1997 and 2001
% 9.4
10
8 6
5.4
5.2
4
3.3
3.4
2
1 1.2
1.6 0.4
0.9
0.4
0.9
1 0.1 0.3
0 Amsterdam
Ever 1997
Rotterdam
Ever 2001
Highly urban, other Current 1997
Rural
Current 2001
Percentage of ever (lifetime) and current (last month) users. Definition (Statistics Netherlands (CBS)): Other highly urbanised municipalities: more than 2,500 addresses per square kilometre, with the exception of Amsterdam and Rotterdam, namely Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. Definition of rural municipalities: fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Special groups Compared with the average population, cocaine use frequently occurs among the homeless and detainees. • In 2002, nearly half (47%) of the homeless in twenty Dutch municipalities had smoked crack in the 11 last month; one in five (20%) sniffed cocaine. • In 2002, one in three male detainees (32%) in eight penitentiaries used cocaine/crack daily in the 12 last six months prior to detention.
43
3.3
USE AMONG YOUNG PEOPLE
To categorise the use of cocaine among young people, figures from the National Prevalence Research are available, as stated in Chapter 3.2. In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F you will find an overview of recent figures concerning the use of cocaine among young people in nine municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. However, methodological differences, in particular in respect of age groups, complicate comparison of the figures. The number of municipalities and regions for which information is available is considerably smaller than for cannabis, because the use of hard drugs is often included in one single question, due to which differentiation by substance is not possible. In this paragraph we also present the data of the Dutch National School Survey and data from (often local) surveys among special groups of young people.
Pupils According to the National Representative School Survey conducted by the Trimbos Institute, 15 considerably fewer secondary school pupils use hard drugs, such as cocaine, than cannabis. • Between 1988 and 1996, however, this number increased. • The 1999 measurement showed a stabilisation in the percentage of pupils with ever or current cocaine experience (see Figure 3.3). This stabilisation continued in 2003b. • More boys than girls were ever or current users of cocaine. • The percentages of cocaine users seem slightly lower among pupils of a higher school level (preuniversity education - VWO, senior general secondary education - HAVO) compared to peers of a lower school level (pre-vocational secondary education - VMBO), but these differences are not statistically significant.
b
The decrease in ever use observed in Figure 3.3 was not significant.
44
Figure 3.3
3.5
Cocaine use among pupils aged 12 and above, from 1988
%
3 3
2.8
2.5 2.2 2
1.6 1.2
1.5
1.1
1.2
1 0.4
0.5
0.8
0.4
0 1988
1992
1996
Ever use (%)
1999
2003
Current use (%)
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
Special groups In certain groups of young people cocaine use occurs quite often. Table 3.2 summarises the result of various studies. The figures are not suitable for comparison due to differences in age groups and research methods.
• According to data from the Antenne Monitor, the numbers of current cocaine users among club, party and disco-goers in Amsterdam rose from 14 to 24 percent between 1995 and 1998. This 54 mainly involved cocaine sniffing. Between 1998 and 2003, current use of cocaine dropped again to the level of 1995 (14%). • The Hague doe not signal a decreasing popularity of cocaine among young people visiting clubs 21;24 and parties, but there are no hard trend data. According to observations of key persons, cocaine is on the up and up elsewhere in the country as well, particularly in trendy clubs, discos 20 and pubs. 19-21 • In the clubbing circuit, cocaine is often used together with alcohol. • In other countries, such as Austria, Belgium, France and the United Kingdom, visitors of raves have 55 considerably more experience with cocaine than the average population. • Young homeless people have the highest rate of cocaine use (see Table 3.2). A survey among young people without fixed address in five Dutch municipalities showed that one in three had used cocaine just recently. The most common route of administration was sniffing or smoking (crack) 22 cocaine; (current smokers: 32%, sniffers: 11%, IDUs: 1%). Among young homeless people in 23 Flevoland, lower percentages were found in 2004 (see Table 3.2).
45
Table 3.2
Use of cocaine in special groups Location I
Young people in special education Young people in truancy programs III Marginalised young people Young clubbers III Pub visitors Visitors of trendy clubs IV Coffee shop visitors V Young homeless people
Nationwide Nationwide The Hague The Hague Amsterdam Amsterdam Amsterdam Nationwide Flevoland
Survey year 1997 1997 2000/2001 2003 2000 2003 2001 1999 2004
Age (year) 12 - 18 12 - 18 16 - 25 15 - 35 Mean age 25 Mean age 28 Mean age 25 15 - 22 13 - 22
Ever use 4% 14% 23% 23% 26% 39% 52% 66% VI 29% VII 19%
Current use 2% 5% 9% 10% 9% 14% 19% 36% VI 10% VII 6%
Percentage of ever users (in lifetime) and recent users (last month) per group. The figures in this table are not comparable due to differences in age groups and research methods. I. MLK, LOM, ZMOK. II. Young people with insufficient care and or unable to sustain in their own existence. Recruited in places for young homeless people, low-threshold day and night shelters and (other) temporary living accommodations. III. Select samples of young people and adolescents visiting mainstream, student, gay and trendy pubs, so not representative for all pub visitors. III. Little response (15%). V. Young people up to 23 years without a fixed address for three months or 17;18;22;24longer. VI. Snortable cocaine in powder form. VII. Smokable cocaine in the form of crack. References: 26 21;23 .
3.4
PROBLEM USE
Reliable estimates of the number of problem users of cocaine are not available. • Seven to nine in ten opiate addicts also use cocaine, often in the form of crack. Freebase (or crack) c 56-58
• • • • •
• •
c
leads to compulsory behaviour and addiction faster than sniffed cocaine. For many hard drug users cocaine meanwhile is the most important drug. They have quite a hard 59 time to stop or reduce their use and their whole day is filled with procuring the drug. Nearly 10 to 15 percent consume cocaine without the additional use of heroin. In Utrecht this group 59 is mostly composed of young Antilleans and Moroccan users without a prior history of heroin use. Frequent cocaine use, especially crack, is being observed in certain groups of hard drug users, 57;58 such as among the (young) homeless, immigrants and street prostitutes. Intravenous use of cocaine (and heroin) has decreased strongly in the last few years and with it the risk of infections. Smoking of cocaine (and heroin) on the other hand has increased. The percentage of ‘hard core’ cocaine injectors of all problem hard drug users in Parkstad Limburg decreased from 40 percent in 1996 to 4 percent in 1999. The percentage of problem users who both injected and smoked cocaine fell from 30 to 17 percent. Between 1999 and 2003 this situation 56-58 showed no significant change. At present, for seven to nine in ten problem users of hard drugs, the most current use of cocaine is smoking (see Table 3.3). Health problems, especially as a result of frequent freebasing, are lung complications, exhaustion 53 and a weakened immune system, extra strain of the feet, anxiety and paranoia. Heavy coke users also find it more difficult to keep their aggression under control.
However, users of shiff cocaine can also get into problems (see Chapter 3.6.1).
46
Table 3.3
Route of administration of cocaine by problem hard drug users
Route of administration Always injects Smokes and injects Always smokes
Rotterdam 2003 4% 10% 86%
Utrecht 1999 1% 10% 86%
Parkstad Limburg 2003 7% 19% 71%
Percentage of problem users by route of administration in the last 6 months. The figures in the columns do not add up to 100 percent entirely; the disparity represents other methods of consumption (sniffing). Source: Regions and Towns Monitor for Alcohol and Drugs (MAD).
3.5
USE: INTERNATIONAL COMPARISONS
General population In the general population of Western countries the number of people using hard drugs such as cocaine is considerably lower than the number of people using cannabis. • Differences in survey year, methods of measurement and random samples make precise comparison difficult. Of particular influence is the age group. Table 3.4a shows consumption figures for cocaine which are (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data on the other countries are listed in Table 3.4b. • The percentage of people up to the age of 60 or 70 who have experience with cocaine is by far the highest in de Unites States. • In the oldest Member States of the European Union the ever use varies from nearly zero percent to six percent, with the highest percentages in England and Wales and in Spain. In the Netherlands, nearly four percent of the population aged 15 to 64 years incl. has ever used cocaine. • Of the above EU Member States, Sweden has proportionally the lowest number of recent cocaine users (0%) and Spain the highest (2.6%). In the Netherlands over one percent used cocaine in the past year.
47
Table 3.4a
Use of cocaine in the general population of several EU Member States and Norway: age group from 15 to 64 years incl.
Country
Spain The Netherlands Ireland Norway Northern Ireland France Greece Sweden Portugal Finland Luxembourg
Year
Ever use
Recent use
2001 2001 2002/2003 1999 2002/2003 2000 1998 2000 2001 2002 1998
4.9% 3.6% 3.1% 1.2% 1.7% 1.6% 1.3% 0.7% 0.9% 0.7% 0.2%
2.6% 1.1% 1.1% 0.6% 0.4% 0.2% 0.5% 0.0% 0.3% 0.3% -
Percentage of ever in lifetime and recent (last year) users. - = not measured. References:
Table 3.4b
37;38
Use of cocaine in the general population of several EU member states, the I United States, Canada and Australia: other age groups
Country United States Canada England and Wales Australia Italy Denmark Germany
Year 2003 2002 2002/2003 2001 2001 2000 2000
Age (year) 12 and over 15 and over 16 – 59 14 and above 15 – 44 16 – 64 18 – 59
Ever use 14.7% 8.0% 6.2% 4.4%
Recent use 2.5% 1.3% 2.1% 1.3%
3.4% 2.5% 2.3%
1.1% 0.8% 0.9%
Percentage of ever in lifetime and recent (last year) users. ? = unknown. I. Drug use is proportionally low in the youngest group (12-15 years) and older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. For studies with a more 37-41 limited age range the reverse applies. References: .
Young people and adolescents In the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 1999 and 2003 among pupils aged 15 and 16, the respondents were interviewed about the ever use of cocaine. In 2003 they were also interviewed as to their recent use. The figures from this survey can be compared better than the figures from surveys among the general population. • Table 3.5 portrays the consumption of cocaine in a number of EU countries and Norway. The United States did not take part in the ESPAD, but conducted comparable research. • American pupils have more often experience with cocaine than their peers in the EU, despite the drop in the percentage of ever users between 1999 and 2003.
• Italy and the United Kingdom scored highest in ever use in 2003 (4%). With 3 percent, the Netherlands, Belgium, France, Ireland and Portugal rated above the middle, but the differences with other countries are small.
• In Italy, the United Kingdom and the United States, proportionally most recent users are found (3%). In the other countries, not more than 1 to 2 percent of the pupils had recently used cocaine.
48
Table 3.5
Cocaine consumption among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey years 1999 and 2003
United States Italy United Kingdom Belgium France Ireland The Netherlands Portugal Denmark I Germany Greece Norway Sweden Finland
1999 Ever use 8% 2% 3% 2% 2% 3% 1% 1% 1% 1% 1% 1%
2003 Ever use 5% 4% 4% 3% 3% 3% 3% 3% 2% 2% 1% 1% 1% 0%
Recent use 3% 3% 3% 1% 1% 1% 2% 2% 2% 1% 1% 0% 0%
Percentage of ever in lifetime and recent (last year - 2003) users. I. Six of sixteen Member States. - = not measured. The United States did not take part in the ESPAD, but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).43
3.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) • The number of recorded admissions with cocaine as primary problem increased nearly four-fold between 1994 and 2003. Between 2002 and 2003 the increase was 19 percent (see Figure 3.4). • The proportion of cocaine users among all the drug users seeking assistance from outpatient care organisations rose also considerably, from 13 percent in 1994 to 30 percent in 2003. • The increase in the cocaine-related treatment demand occurred in the entire country, but was strongest in the regions of Eindhoven, Twente, the Achterhoek and the IJsselmeerpolders. • Characteristics of the primary cocaine clients in 2003: - Most of them are men (82%). - The average age is 33. Nearly half the primary cocaine clients are between 25 and 34 years old (see Figure 3.5). - A quarter (24%) consisted of new clients, so they had never before been registered with the (outpatient) care organisations for addicts because of a drug problem. - Most of the cocaine clients smoke or sniff the drug (see below). • Cocaine was also indicated often as a secondary problem (see Figure 3.4). - For this group the primary problem is heroin (67%), alcohol (22%), or cannabis (5%). - Between 1994 and 2001 the number of clients with secondary cocaine problems increased. The increase between 2000 and 2001 is partly due to the fact that the figures of the Amsterdam Area Health Authority (GG&GD) were included for the first time.
49
Figure 3.4
Number of clients of (outpatient) care organisations for addicts with primary or secondary cocaine problems, from 1994
10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 Primary
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2468 2928 3349 4137 4607 5689 6103 6647 7774 9216
Secundary 6020 6391 6503 7015 6699 6932 7111 8426 8281 8388 The increase in secondary cocaine clients between 2000 and 2001 is partly due to the supply (since 2001) of data of opiate clients of the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ). 60
An analysis of LADIS data up to 2000 incl. gives the following picture: • For two in three ‘primary’ cocaine clients crack (smoking) is the main means of use and for one in three ‘sniff cocaine’. • The proportion of crack users among the cocaine clients grew from 57% percent in 1994 to 65% in 2000. • More than half the cocaine clients - primary and secondary problems together - have problems with both cocaine (usually crack) and heroin (56%). Next are problem users of only crack without opiates (20%), of both sniff cocaine and alcohol (13%), of both sniff cocaine and cannabis (6%) or only of sniff cocaine (6%).
50
Figure 3.5
Age categories of primary cocaine clients in the (outpatient) care organisations for addicts. Survey year 2003
% 25
21
23
20
17 14
15
11 10
6 5
3
2 1
0 15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
Age
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • In 1990 there were 106 admissions and in 1996 there were 364 (ICD-9 codes 304.2 and 305.6; Appendix C). • The percentage of cocaine-related problems in all drug-related admissions rose also in this period, from 4 to 8 percent. • The situation since then is not known, because record keeping has been incomplete from 1997 (see Appendix B).
General hospitals; incidents In general hospitals, upon admission, cocaine abuse and dependence abuse are often not recorded as the main diagnosis. • In 2003, eighty cases were counted, 70 percent of which for cocaine abuse and 30 percent for cocaine dependence (see Figure 3.6). • These cocaine problems more often play a part as a secondary diagnosis. Between 1996 and 2002 the number of admissions with cocaine abuse or dependence as secondary diagnosis increased. This trend seems to have come to a stop in 2003. • The most commonly diagnosed problems that were registered in 2003 in case of cocaine abuse or dependence as secondary diagnosis were: - accident-related injuries (21%, e.g. fractures, wounds, concussion)
51
-
respiratory illnesses and symptoms (16%) poisoning (12%) heart and vascular diseases (9%) abuse or dependence on alcohol and (other) drugs (6%) psychoses (5%)
Figure 3.6
Clinical admissions in general hospitals for cocaine abuse and dependence, from 1994
700 562
600
506 451
500 400
352
371
363
55
50
383
377
65
67
285
300
246
200 100
38
24
53
81
84
80
0 1994 1995
1996 1997 1998
Cocaine as primary diagnosis
1999 2000
2001 2002 2003
Cocaine as secondary diagnosis
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.2, 305.6 (Appendix C). Source: National Medical Registration (LMR), Prismant.
• A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 550 patients were admitted in 2002. They were admitted at least once that year with cocaine abuse or dependence diagnosed as primary or secondary problem. The average age was 34 years and 73 percent were male. • In 2003, the National Medical Registration (LMR) counted also 16 cases of unintentional poisoning with local anaesthetics (mainly cocaine) as secondary diagnosis (ICD-9 code E855.2). Exact figures about the number of persons who become unwell after the use of cocaine are not known. According to the Injury Information System of the Consumer and Safety Foundation, annually 2,300 people on average are treated at emergency first-aid departments of hospitals after an accident, violence or self-harm related to the use of drugs (comp. 14,000 because of alcohol, Chapter 6).d • Nearly one in three (32%) drug victims reports to have used cocaine, more than one in five cannabis (22%) and one in eight ecstasy (12%). Of over a quarter (27%) of the cases it is not known which drug(s) is/are involved.
• These figures probably are an underestimation of the real number of drug-related accidents.
d
The drugs concerned are cocaine, heroin, cannabis, ecstasy, paddo's and speed. The data are the averages over the period 1999 to 2003 inc.
52
The National Poison Information Centre (NVIC) of the National Institute of Public Health and the Environment (RIVM) registers the number of requests for information from physicians, pharmacists and governmental institutions about (potential) acute poisoning due to antigens, such as drugs. • The number of reported drug-related incidents rose from 656 in 2000 to 1,210 in 2003. For cocaine an increase from 150 to 247 incidents was registered. • However, these figures do not provide an insight in the absolute number of intoxications.
3.7
MORTALITY
The Cause of Death Statistics of Statistics Netherlands (CBS) still counts very few (acute) deaths that are — believed to be — directly attributable to cocaine. • However, there does appear to be an increase. From 1985 to 1994 incl., the total number of cocaine-related deaths was 21, compared with 143 from 1995 to 2003 incl. (see Figure 4.9). • The rising line from 1996 to 2001 incl. (10 and 26 cases, respectively) did not continue in 2002 and 2003 (34 and 17 cases, respectively). • Figure 3.7 shows that most of the deceased were between 25 and 49 years old. Nearly three in ten were women. • Fatalities in which cocaine plays a role are sometimes recorded under the code of deaths from natural causes, for example heart problems. This makes it difficult to establish the number of cases in which cocaine has actually contributed to the person’s death. • The total number of deceased 'drug mules' is not known, one of the reasons being that the Cause of Death Statistics Agency does not include deceased persons who are not listed in the Dutch population registration system. In 2002 and 2003, the Amsterdam Area Health Authority (GG&GD Amsterdam) recorded 8 and 3 cases, respectively.
Figure 3.7 25
Age categories associated with cocaine-related deaths from 1996 to 2001 incl.
% 19
20
17 15 15
14
13
10
9
5 5 1
3
2
1
1
0 <15
15-19
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
>64
age (years) Percentage of deceased per age group. ICD-10 codes primary causes of death: F14 and X42*, X62*, Y12* (* in combination with code T40.5). Source: Cause of Death Statistics, Statistics Netherlands (CBS).
53
3.8
MARKET
Composition of cocaine samples The Drugs Information and Monitoring System (DIMS) examines the substances in drug samples that are turned in by consumers to care organisations for addicts. Part of these samples are identified by the services. Samples of unknown composition and all the samples in powder form are forwarded to the laboratory for chemical analysis. • In 2003, 229 powders were supplied that were bought by the consumer as cocaine. Of those, 217 (95%) contained actually cocaine (mainly hydrochloride) with a concentration of 65% on average (by weight). • Amphetamine was found twice, caffeine ten times and heroin once. Two powders did not contain any psychoactive substance. • Most of the powders also contained cocaine-related residual products, which are included when cocaine is extracted from the plant, such as tropacaine and norcocaine (87%). • The percentage of powders that (also) contained phenacetin nearly doubled from 9 percent in 2002 to 16 percent in 2003. Phenacetin is a substance that, until 1984, was registered as a painkiller, but was withdrawn from the market because of its possible carcinogenic characteristics. The quantities of phenacetin that are used as a cutting agent are many times smaller than the therapeutic quantities. However, the risks of phenacetin as a cutting agent of cocaine, such as the effects of heating when ‘smoking’ crack, are not known.
Prices Trend data about the prices paid by consumers for a gram of cocaine are not available. Recent figures from the Antenne Monitor and the Drugs Information and Monitoring System (DIMS) project, however, give an indication of the current situation. • Clubbing young people and adolescents in Amsterdam, who bought cocaine in 2003, paid between 46 and 52 euros per gram on average, depending on the type of dealer (house dealer or dealer in the clubbing circuit).
• These data correspond with the price that consumers paid in 2003 for cocaine samples supplied to the DIMS project (minimum 40 and maximum 50 euros per gram, with an average of 45 euros per gram).
54
4
OPIATES
The category of opiates includes many drugs. Some, such as heroin, are known for their illegal use. Others, such as methadone, function as replacements of heroin or are (also) otherwise applied in medicine: morphine, codeine and the like. This chapter deals mainly with heroin and methadone. Opiates may cause a high, but may also have a subduing effect. Heroin is administered in many manners. At present the most current use in the Netherlands is smoking (‘Chinese-style’, smoking from aluminium foil). Less often, heroin is injected. People whose opiate use has gotten out of hand often use additional drugs (polydrug use) in a way that is hard to combine with a ‘normal’ lifestyle. The collective term ‘hard drugs’ used in this chapter mainly refers to at least one type of opiate, as well as mainly to cocaine.
4.1
LATEST FACTS AND TRENDS
The main facts and trends regarding opiates in this chapter are: • The use of heroin is not very frequent in the general population (see Chapter 4.2). • Heroin is still not very popular among pupils and young people who visit clubs and pubs (see Chapter 4.3). • The number of opiate addicts in the Netherlands remains stable and is low compared with other European countries (See Chapter 4.4 and Chapter 4.5). • Intravenous injection of opiates has decreased. Opiates are now mostly smoked (see Chapter 4.4). • The number of opiate clients of the (outpatient) care organisations for addicts decreased slightly between 2001 and 2003. The proportion of young opiate clients decreased further (see Chapter 4.6). • The average methadone dose increased over the years, but still a minority of the methadone clients receives (therapeutic) doses of 60 mg or more (see Chapter 4.6) • The percentage of injecting drug users contaminated with HIV remained fairly stable in Amsterdam (1993-1998), Rotterdam (1994-2002/03), Maastricht (1994-1999) and Arnhem (1991/92-1997). In Heerlen their percentage increased between 1994 and 1999 (see Chapter 4.7). • The majority of injecting drug users in Rotterdam and Heerlen/Maastricht are contaminated with hepatitis B and C. For The Hague the figures are somewhat more positive (see Chapter 4.7). • Needle sharing among injecting drug users was less and less common, but in some regions (The Hague and Twente) this is still done often. Sexual risk behaviour remains a problem (see Chapter 4.7). • Acute death (‘overdose’) due to opiate use decreased slightly between 2001 and 2003 (see Chapter 4.7). • Acute death due to drug use is low in the Netherlands compared to other countries (see Chapter 4.7).
55
4.2
USE IN THE GENERAL POPULATION
The use of heroin is not widespread in the general population. • According to the National Prevalence Survey (NPO) conducted in 2001, 0.4 percent of the Dutch 10 population aged 12 and over had experience with heroin. In 1997 this was 0.3 percent.
• •
In 2001 the percentage of current users was 0.1 percent. These figures are probably an underestimation, as problem hard drug users are underrepresented in the National Prevalence Survey (NPO). Many illegal opiate users and methadone clients are not included in general population surveys, because they have no fixed address (homelessness), are detained, or are inaccessible for other reasons. However, they can be charted to a certain degree through other research methods (see Chapter 4.3).
Special groups Among certain adults the use of heroin is more current than in the general population. • In 2002, one in five male detainees (21%) in eight remand centres used heroin daily in the six 12 months prior to detention. • In that same year, 40 percent of the homeless in twenty Dutch municipalities had used this drug in 11 the month previous to the survey. These groups may show an overlap with the problem users described in Chapter 4.4.
4.3
USE IN THE YOUNG PEOPLE
Heroin is unpopular among secondary school pupils of secondary school aged twelve years and 15 above (see Table 4.1). • In 2003 more boys than girls had ever or currently used heroin (ever: 1.5% versus 0.7%; current: 0.8% versus 0.3%). • Since 1988, the percentage of ever users fluctuated around one percent. In all those years, not more than half of them had currently used heroin.
Table 4.1
Heroin use among pupils aged 12 and over, from 1988
Has used ever in lifetime Used currently
1988 0.7% 0.3%
1992 0.7% 0.2%
1996 1.1% 0.5%
1999 0.8% 0.4%
2003 1.1% 0.5%
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
• According to somewhat older figures, the percentage of current heroin users is higher among young people in special education and participants in truancy programs, than among pupils in ‘regular’ education, but even this higher percentage remains below 1 percent (see Table 4.2). • A number of recent local and regional studies show also that heroin has not advanced very much among young people. In Almelo, Apeldoorn, Drente, Groningen and South-Holland North the percentage of ever users remains under one percent (see Appendix F). • In certain circles, a minority of young people experiment with heroin (see Table 4.2). In 2001, for 17 example, nearly one in ten coffee shop visitors had ever tried heroin. • Among visitors of trendy clubs in Amsterdam the percentage of ever users dropped from six 18;21 percent in 1998 to two percent 2003. Current use is not (very) frequent in the clubbing circuit. • A 1999 survey among young homeless people in five municipalities (Amsterdam, Breda, Hilversum, Tilburg and Zaanstad) shows that this group had experience with heroin relatively often.
56
More than one in ten young homeless people were current users of this drug. The most common 22 route of administration in this group was smoking (current smokers: 11%, IDUs: 1%, sniffers: 0%). In 2004 lower percentages were found among young homeless people in Flevoland, eight percent 23 had ever used heroin and two percent were current users.
Table 4.2
Heroin use in special groups
I
Pub visitors Young people in special II education Visitors of trendy clubs Young people in truancy programs III Coffee shop visitors IV Marginalised young people V Young homeless people
Location
Survey year
Ever use
2000 1997
Age (year) Mean age 25 12 - 18
1% 2%
Current use 0,2% 0,8%
Amsterdam Nationwide Amsterdam Nationwide
2003 1997
Mean age 28 12 - 18
2% 4%
0% 0,9%
Amsterdam The Hague Nationwide Flevoland
2001 2000/2001 1999 2004
Mean age 25 16 - 25 15 - 22 13 - 22
9% 13% 21% 8%
0,9% 7% 11% 2%
Percentage of ever users (in lifetime) and current (last month) per group. The figures in this table cannot be compared with each other because of differences in age groups and research methods. < means ‘less than’. I. A selective sample of young people and adolescents visiting mainstream, student, gay and trendy pubs. This sample is therefore not representative for all pub visitors. II. Special School for Children with Learning Difficulties (MLK), Special School for Children with Learning and Behavioural Difficulties (LOM), Special School for Children with Severe Behavioural Learning Problems (ZMOK). III. Low response (15%). IV. Young people receiving inadequate care and/or cannot provide sufficiently in their own livelihood. Recruited at locations for young homeless people, low-threshold day- and night accommodation and (other) temporary accommodation. V. Young people up to 23 years of age without a fixed address (homeless) for three months or longer. 17;22;23;25;26 . References:
4.4
PROBLEM USE
The available estimates usually do not allow us to make a clear distinction between problem opiate a
users on the one hand and other hard drug users on the other hand. The estimates in Table 4.3, therefore, refer to problem users of illegal opiates, or methadone, who usually use additional substances, such as (crack) cocaine, alcohol, and sleeping tablets or tranquillisers. • According to the latest estimates, the number of problem users of hard drugs amounts to approx. 32,000. This number is accompanied by a fairly large margin of uncertainty, varying from approx. 22,000 to 42,000 problem users. Compared with earlier years, no significant change has taken place. • The Netherlands has approximately three problem hard drug users per thousand inhabitants aged 15 to 64 years incl. • Per thousand inhabitants, most of the problem users are located in Amsterdam, Rotterdam and The Hague (see Table 4.1).
a b
For the definition of problem user: see Appendix A. In 2001 the Amsterdam Municipal Medical & Health Service (GG&GD Amsterdam) brought in 1,869 clients with a primary heroin problem, 1,304 clients of whom were not known to other bodies participating in the National Information System on Alcohol and Drugs (LADIS).
57
Table 4.3
Estimates of the number of problem hard drug users
Scope Nationwide Nationwide Nationwide Nationwide Amsterdam Rotterdam The Hague Parkstad Limburg Leeuwarden Enschede Utrecht
Year 1993 1996 1999 2001 2003 1994 1998 2002 2001 2003 1999
Number 28,000 I 25,000 – 29,000 I 26,000 -30,000 II 32,000 (22,000 – 42,000) 4,530 3,500 – 4,000 2,600 – 2,700 800 389 600 570
I. Based on different estimation methods. II. Average (and 95% reliability interval) of two methods. References: 57;61-66
Figure 4.1
Estimates of the number of problem hard drug users per 1,000 inhabitants aged 15 to 64 incl.
12.0 9.4
10.0 8.5
8.9
8.0 6.3 5.7
6.0 4.5 4.0
3.4
3.0
2.0 0.0 Nationw ide (2001)
Amsterdam (2003)
Rotterdam (1994)
The Hague (1998)
Utrecht (1999)
Parkstad Limburg (2002)
Leeuw arden (2001)
Enschede (2003)
Average of highest and lowest estimates (if applicable). References: see Table 4.3.
Figure 4.2 portrays the development in the number of problem opiate users in Amsterdam according to estimates of the Amsterdam Area Health Authority (GG&GD Amsterdam). • The size of this group peaked in 1988 (8,800) and then decreased. This decline was mainly attributable to foreigners, especially Italians and Germans, leaving Amsterdam. The decline levelled off since 1998. • In 2003, Amsterdam still had an estimated 4,500 problem opiate users. 38 percent were born in the Netherlands, 25 percent in Surinam, the Netherlands Antilles, Morocco or Turkey and 37 percent originated from elsewhere.
58
Figure 4.2
Problem opiate users in Amsterdam, from 1985
Number
10000
8000
6000
4000
2000
0 1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
Born in the Netherlands Born in Surinam, the Netherlands Antilles, Morocco, or Turkey Born elsewhere Total Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
Opiate use is particularly precarious when injected intravenously. • In the course of the years, users of opiates injected the drug less frequently (see Table 4.4). The percentage of ‘hard core’ heroin injectors of all problem hard drug users in Parkstad Limburg decreased from 33 percent in 1996 to 13 percent in 1999. This trend did not continue between 1999 and 2003. In Rotterdam the proportion of hard core injectors dropped from 15 percent in 56-58 1999 to 10 percent in 2003. • In 2003, 10 percent of the opiate clients of (outpatient) care organisations for addicts were known to inject and 72 percent to smoke. The rest used other routes of administration. In 1994, 16 percent still injected the drug. The population of heroin users is becoming old and has to cope increasingly with health problems. • In Amsterdam, the average age of methadone clients increased from 32 in 1989 to 44 in 2003. In Rotterdam and Parkstad Limburg, the average age of problem hard drug users rose from 37 to 39 61;67 years between 1998 and 2003.
• •
Many opiate users have to cope with both drug addiction and (another) mental disorder, such as social phobias or depression (‘dual diagnosis’). According to somewhat older estimates of the mid68;69 nineties, this pertains to between 30 and 50 percent of the opiate users. According to the Amsterdam Area Health Authority (GG&GD Amsterdam), the ageing process is accompanied by the occurrence of old age diseases, such as diabetes and cancer. Pulmonary diseases due to sustained heavy tobacco consumption and heroin smoking are becoming 70 increasingly frequent.
59
Table 4.4
Route of administration of heroin by problem hard drug users
Route of administration Always injects Smokes and injects Always smokes
Rotterdam
Utrecht
Parkstad Limburg
2003 10% 10% 80%
1999 1% 10% 86%
2003 19% 16% 63%
Percentage of problem users by route of administration in the last 6 months. The figures in the columns do not add up to 100 percent entirely; the disparity represents other methods of consumption (such as sniffing). Source: Regions and Towns Monitor for Alcohol and Drugs (MAD).
4.5
USE: INTERNATIONAL COMPARISONS
Use by pupils •
•
According to the European School Survey Project on Alcohol and Other Drugs (ESPAD), in 2003 the percentage of ever users of heroin among pupils aged 15 and 16 in Europe did not exceed two 43 percent. An exception was Sweden where four percent of the pupils had experience with heroin. The percentage of recent users was not higher than one percent, except in Italy (3%).
Problem use • •
•
The old EU Member States have an estimated 1.5 million problem hard drug users, or three to ten 37;38 per thousand inhabitants aged 15 to 64 incl. It involves mainly (also) opiates. The estimates are calculated with different statistical methods. Table 4.5 shows the lowest and highest figures per country. Because of differences in definitions and methods, the data should be interpreted with caution. This is particularly true for Luxembourg for which the estimates vary widely. With two to three problem hard drug users per thousand inhabitants, Greece, the Netherlands and Germany are at the bottom of the list of all the old EU Member States.
60
Table 4.5 Country Luxembourg United Kingdom Italy Portugal Denmark Austria Ireland Spain Sweden France I Belgium Finland Germany The Netherlands Greece
Problem hard drug users in several EU Member States and in Norway Year 2000 2000/2001 2002 2000 2001 2002 2001 2000 1998 1999 1997 1999 2000 2001 2002
Number per thousand inhabitants aged 15 to 64 incl. Lowest – highest estimate Average 6.2 – 13.6 9.9 9.0 – 9.8 9.4 6.7 – 8.4 7.5 6.0 – 8.5 7.3 6.7 – 7.7 7.2 5.4 – 6.2 5.8 5.2 – 6.1 5.6 5.3 5.3 4.2 – 4.8 4.5 3.9 – 4.8 4.3 3.5 – 4.2 3.9 3.1 – 4.1 3.6 2.7 – 3.5 3.1 2.0 – 3.9 3.0 2.1 – 2.9 2.5
Because of differences in definitions and methods, the data should be interpreted with caution. The estimates relate in most countries to opiate users, with the exception of Sweden, where amphetamine injectors are in the majority (at any rate in the early nineties). I. Figures for Belgium relate only to intravenous drug users and are an underestimation of the actual number of problem hard drug users. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
4.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) • The number of clients with primarily opiate-related problems increased slightly until 1997 (see Figure 4.3). This increase was partly real and partly a misrepresentation, as more drug services joined the National Information System on Alcohol and Drugs (LADIS). From 1997 to 2000 incl. the number of opiate clients remained fairly stable. The increase in 2001 is mainly due to the entry of b
the Amsterdam Area Health Authority (GG&GD Amsterdam) into LADIS.
• Since 2001 the number of opiate clients has decreased. Between 2002 and 2003 the decrease was five percent. • The proportion of opiates in all the requests for drug-related aid decreased from 71 percent in 1994 to 30 percent in 2003. This is mainly due to the increase in the number of clients with another drug problem, such as cocaine and cannabis. • Characteristics of the primary opiate clients in 2003 are: - Most of them (80%) are men. - The average age is 40, considerably higher compared to the cannabis and cocaine clients. Eight in ten opiate clients are aged between 30 and 49 years (see Figure 4.4). - Most of the clients appealed before to the (outpatient) care organisations for addicts because of a drug problem. One in twenty (5%) was a newcomer. - Opiates are not often mentioned as a secondary problem (see Figure 4.3). For this group the primary problem is cocaine or crack (69%), alcohol (26%), or cannabis (2%).
61
•
The proportion of young opiate clients decreased further. In 2002, 13 percent of the primary opiate clients were aged between 15 and 29 years, in 2003 this was 9 percent. In comparison: in 1994, this age group contained 39 percent of the opiate clients.
Figure 4.3
Number of clients of (outpatient) care organisations for addicts with primary or secondary opiate problems, from 1994
20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Primary Secundary
1994 1995 1996
1997 1998 1999 2000 2001
2002 2003
14002 14936 15247 15865 15491 15606 15544 17786 16043 15195 804
913
985
1112 1101 1313 1387 1761
1912 2056
I. The increase in the number of people in 2001 compared to 2000 is due to the first supply of data from the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
62
Figure 4.4 Age group categories of primary opiate clients in the (outpatient) care organisations for addicts. Survey year 2003 % 25
22 20
17
23
17
15
10
7 5
2
8
2 1
0 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64
Age
Percentage of clients by age group. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
An estimated 13,500 opiate-dependent persons in the Netherlands receive methadone. The main providers of methadone are the (outpatient) care organisations for addicts, the Amsterdam Area c71 Health Authority (GG&GD Amsterdam), GPs and medical specialists. • The number of methadone clients of the (outpatient) care organisations for addicts increased slightly until 2002 (see Table 4.6). Besides due to an actual increase, this is also due to the larger number of institutions that take part in the LADIS. • Methadone is prescribed as maintenance treatment in over 97 percent of the cases. In the other cases, it is used for heroin detoxification purposes. 72 • The average daily methadone dose increased since 1995 (see Table 4.6). In 2003, 37 percent of the clients received a (therapeutic) dose of 60 mg methadone or more. The amount of methadone prescribed to a client per time largely depends on the methadone policy of the respective drug service/GP, or on the case worker.
c
GPs and specialists provide an estimated 2,750 persons with methadone, 900 of whom do not appear in the 71 National Information System on Alcohol and Drugs (LADIS).
63
Table 4.6 Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Methadone distribution by the (outpatient) care organisations for addicts, from 1994 Number of people 8 882 8 817 9 068 9 838 9 754 10 666 10 805 I 12 538 12 805 12 048
Daily averaged dose (milligrams) 46 37 38 40 42 45 48 I 54 57 57
I. The increase in the number of people as compared with 2000 is due to the first supply of data from the Amsterdam Area Health Authority (GG&GD Amsterdam). The increase in the average methadone dose may also be (partially) related to this. Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. Of all drugs, opiates make up the majority of admissions in the inpatient care organisations for addicts (Patients Admission Tracking System for Inpatient Mental Health Care (PiGGz), Mental Health Service (GGZ Netherlands)/Prismant).
• • •
The number of admissions for opiate addiction and opiate abuse rose in the first half of the nineties from 2,089 in 1990 to 3,128 in 1995 and decreased slightly, namely to 3,055 admissions in 1996 (ICD-9 codes: 304.0, 304.7, 305.5, Appendix C). The proportion of opiate patients in the total of the inpatient care organisations for addicts decreased from 75 percent in 1990 and 77 percent in 1991 to 67 percent in 1996. Due to the absence of recorded information after 1996, developments with respect to the treatment demand can no longer be reflected reliably.
General hospitals; incidents Opiate abuse and dependence are rarely diagnosed as the primary problem in general hospitals. In 2003 Dutch Hospital Registration (LMR) recorded 51 admissions (63% dependency and 37% abuse, see Figure 4.5). • These conditions are more often diagnosed as secondary problems (85% dependence, 15% abuse). The main diagnoses of these secondary problems differ widely. In 2003, the principal problems in secondary diagnoses were given as: - respiratory illnesses and symptoms (26%) - accident-related injury (16%; fractures, wounds, concussion) - digestive system diseases (8%) - poisoning (8%; especially benzodiazepines) - skin diseases (6%; abscesses).
64
•
•
A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 533 patients were admitted in 2003. They were admitted at least once this year with opiate abuse or dependence diagnosed as primary or secondary problem. Their average age was 39 and seven in ten were men (69%). Three in ten patients came from the four big cities: Amsterdam (21%), Rotterdam (6%), The Hague (5%) and Utrecht (3%). Accidental opiate intoxication was recorded as a secondary diagnosis in 26 hospital admissions. 11 such admissions involved methadone.
Figure 4.5
Clinical admissions in general hospitals for opiate abuse and dependence, from 1994 900 800
751
700
742 627
607
596
634
627
674 606
558
600 500 400 300 200 100
74
71
71
71
76
79
75
81
88
1994
1995
1996
1997
1998
1999
2000
2001
2002
51
0
Opiates as primary diagnosis
2003
Opiates as secondary diagnosis
The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.0, 304.7, 305.5 (Appendix C). Source: National Medical Registration (LMR), Prismant.
In 2003, the Central Ambulance Station of the Amsterdam Area Health Authority (GG&GD 73 Amsterdam) recorded 226 emergency calls for suspected non-fatal hard drug overdoses. • Emergency calls mainly involved opiate and cocaine use, sometimes in combination with other substances. • More than three-quarters (79%) of the above cases required transportation to a hospital. This is a considerably higher percentage than for ambulance calls involving cannabis (35%).
4.7
ILLNESS AND MORTALITY
HIV Needle-sharing or practising unsafe sex puts hard drug users at risk of infection with HIV, the virus that causes AIDS. Between 1994 and 2003, the National Institute of Public Health and the Environment (RIVM) conducted sixteen surveys among injecting hard drug users in nine regions in the Netherlands. Figure 4.6 shows the most recent figures. • There are large regional differences in HIV infection among drug users who ever injected the drug.
65
• • • •
74
Of the big cities, Amsterdam leads. The Hague has the lowest percentage. In most cities participating more than once in the survey, the percentage of HIV-infected IDUs (intravenous drug users) remained stable. Heerlen is an exception. In this city this proportion doubled from 11 percent in 1994 to 22 percent 75;76 in 1999. In a long-term survey in Amsterdam, the number of new HIV infections among IDUs dropped from 9 percent in 1986 to 1-2 percent in 1999. Between 1999 and 2002, the number of new cases 68;69 fluctuated between zero and 0.2 percent annually. In 2003 not a single new case of HIV 77;78 infection was found.
Figure 4.6
HIV infection among injecting drug users
30% 26% 25%
20% 14%
15%
10% 10% 5%
5%
5%
3%
2%
1%
1%
Arnhem 1997
Groningen 1997/1998
0% Amsterdam 1998
SouthLimburg 1999
Rotterdam 2002/2003
Utrecht 1996
Brabant 1999
Twente 2000
The Hague 2000
Percentage of ever injecting hard drug users infected with HIV. An ever injecting hard drug user is a person who has intravenously injected a drug once or more times in his or her life and used hard drugs at least once a week in the past 6 months. Percentages in previous surveys: Amsterdam 26% in 1993 and 1996; Rotterdam 11% in 1994; Arnhem: 2% in 1991/1992 and 1995/1996; South-Limburg 10% in 1994 and 12% in 1996 (in Maastricht: 8% in 1994, 3% in 1996, 5% in 1999); in Heerlen, 11%, 17% en 22% respectively. Brabant includes Eindhoven, Helmond, Den Bosch. Twente includes Almelo, Hengelo, Enschede. Source: the National Institute of Public 74;76 Health and the Environment (RIVM).
Statistics about HIV infection in a number of EU Member States originate from diverse sources and differ with respect to their degree of coverage. The figures are therefore not suitable for comparison 37 and provide only an indication of the degree of infection. • Figure 4.7 shows that percentages of HIV-infected injecting drug users vary from approx. 1 percent or less in Finland (data from needle exchange programmes) and from 10 to 35 percent in Spain (data from the care organisations for drug addicts, the centres for HIV screening and clinics for sexually transmitted diseases (SOA)). • In Italy and Portugal, just as in the Netherlands, there is a considerable regional or local dispersion of HIV infection. • According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the available figures suggest that the percentage of injecting HIV-injected drug users is stable or going down, at any rate in the old EU Member States. In a number of new Member States and their neighbouring countries, such as Estonia, Latvia, Russia and the Ukraine, there are indications of a fast growing HIV epidemic, with a peak in Estonia and Latvia in 2001. However, in many countries
66
no reliable trend data are available and the situation at a local level may differ strongly from the general domestic picture.
Figure 4.7
Percentage of injecting drug users (IDUs) infected with HIV in several EU Member States and Norway
The data originate from several sources (samples, treatment centres, prisons, needle exchange). The percentages between brackets refer to local sources. The colours indicate the degree of infection in accordance with the average of the highest and lowest measured value. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
Hepatitis B and C Hepatitis B and C are serious forms of liver infection caused by the hepatitis B or C virus, HBV and HCV respectively. HBV is transmitted through blood contact, for example as a result of an intravenous injection with used needles, or through unsafe sexual contact. HCV can practically only be transmitted
67
by direct blood-blood contact. HCV is much more contagious than HIV and can also be transmitted via contaminated (injection) utensils other than needles. • Data about HCV and HBV among injecting hard drug users are not systematically collected in the Netherlands. Information is available for a number of locations. • At the latest examination, approximately three quarters of IDUs in Rotterdam and Heerlen/Maastricht appeared to be infected with hepatitis HCV and a slightly lower percentage 79;80 with HBV (see Table 4.7). 81 • The picture in The Hague was better. There is no immediate explanation for this.
Table 4.7
Hepatitis B and C infections among samples of hard drug users in Rotterdam, Heerlen/Maastricht and The Hague
Rotterdam Heerlen/Maastricht The Hague
I
Year 1994 1996 II 1998/1999 2000
HBV-positive 56% of the IDUs 27% of the non-IDUs 63% of the IDUs 67% of the IDUs 35% of the IDUs
HCV-positive 79% of the IDUs 13% of the non-IDUs 74% of the IDUs 47% of the IDUs
IDG = ever injecting hard drug users, recruited on the street and at the aid organisations. HBV = Hepatitis B virus. HCV = Hepatitis C virus. I. positive for anti-HBc, a marker for an earlier or current infection with hepatitis B. II. Seven percent were positive for HbsAg, indicative for a current hepatitis B infection. Source: National Institute of Public Health and the Environment (RIVM).
For Amsterdam data are available of 116 clients of a methadone centre who were screened in 2002 82 for contagious diseases. • Table 4.8 shows the percentages of infections with HBV and HCV by injection status. About eight in ten currently injecting methadone clients were (ever) infected with HBV and or HCV. A slightly lower percentage of HBV infections was found among clients who had ever injected, but did not do so any longer at the moment of measurement. • More than a quarter (27%) of those who had never injected were infected with HBV. This indicates sexual risk behaviour. • One in ten drug users who, so they said, had never injected had ever been infected with HCV. 83 This figure corresponds with an earlier survey in Amsterdam and Rotterdam (see Table 4.7). This finding may indicate non-reporting of the injection of drugs and or another manner of infection, like via attributes that are used for smoking cocaine.
Table 4.8 Hepatitis B and C infections among methadone clients in Amsterdam. Survey year 2002
HBV HCV
Ever injected, not currently 55% 90%
Currently injecting
Never injected
85% 77%
27% 10%
It concerns here percentages of users who were ever infected with HBV or HCV, so both old, chronic and current 82 cases. Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
•
•
In the old EU Member States, HCV infection is common among IDUs. According to various sources, the percentage of HCV infections varies between 40 and 80 percent, with an average of 65 percent. 37 Figures for HBV infection show much variation - between 17 and 85 percent.
68
Risk behaviour •
•
•
Needle-sharing among drug users has decreased compared to five to ten years ago. In most of the cities and areas about which information is available report occasional needle-sharing by 8 to 84 30 percent of IDUs (see Table 4.9). In addition to sharing used needles, other used utensils, such as spoons, swabs, filters, or water for rinsing syringes are also shared occasionally. An estimated one in four IDUs do this. Sharing these utensils increases the risk of infection with hepatitis B and C, but not with HIV. Sexual risk behaviour remains widespread. Practising sex without condoms is most found among permanent partners (76-96%), followed by casual partners (39-73%) and customers (13-50%, see Table 4.9).
Table 4.9 Region
Amsterdam Rotterdam
SouthIII Limburg Utrecht Arnhem
Groningen IV Brabant The Hague V Twente
Needle sharing and sexual risk behaviour among IDUs Survey year Needle or No condom No condom II lI syringe use use I permanent casual sharing partner partner 1996 18% 76% 40% 1998 12% 85% 47% 1994 18% 91% 47% 1997 10% 84% 54% 2002/2003 8% 85% 43% 1994 19% 86% 61% 1996 17% 87% 39% 1999 10% 89% 49% 1996 17% 84% 45% 1991/1992 42% 1995/1996 39% 90% 51% 1997 16% 96% 53% 1997/1998 11% 89% 57% 1999 17% 88% 61% 2000 21% 84% 73% 2000 30% 92% 68%
No condom lI use customers 30% 29% 20% 31% 32% 13% 17% 25% 17% 40% 21% 22% 24% 17% 40% 50%
I. Percentage of ever injecting hard drug users who had borrowed syringes or needles from others in the last 6 months. II. Had not always used condoms in the last 6 months. III. Heerlen and Maastricht. IV. Eindhoven, Helmond, Den Bosch. V. Almelo, Hengelo, Enschede. = unknown. Source: National Institute of Public Health and 85 the Environment (RIVM).
AIDS •
•
•
The number of AIDS cases reported to the Health Care Inspectorate (up to 1999 incl.) and the HIV Monitoring Foundation (from 2000) rose from 325 in 1988 to 533 in 1995 and fell since to between 230 and 280 cases in the past few years. One of the reasons of this is the introduction of effective anti-viral licit drugs. These prevent fewer HIV cases from turning into AIDS or delay the onset. Intravenous drug injection as a contributing factor to AIDS in the Netherlands remained moderate throughout all these years; expressed in percentages: an average of 10%, with a peak of 14% in 1995. In 2003 three percent (8 cases) of the reported aids cases concerned IDUs. The number of reported AIDS cases differs in the old EU Member States. Figure 4.8 shows the development for countries that in any year reported more than ten new cases of AIDS among IDUs per million of inhabitants. In Belgium, Denmark, Germany, Greece, the Netherlands, Austria,
69
Finland, Sweden and the United Kingdom the number of cases did not exceed ten per million of inhabitants annually. In the mid-nineties, Spain and Italy reported by far the highest numbers. In the following years, these numbers reportedly fell sharply in those two countries. In Portugal the number of reported AIDS cases rose from the early nineties onwards, but did not increase in 2000. These three Member States comparatively have the highest numbers of IDUs infected with AIDS.
•
Figure 4.8
New cases of AIDS among IDUs per million of inhabitants in a number of EU Member States, from 1985
140
Spain 120
Italy Portugal
100
France Ireland
80
Luxembourg
60
40
20
0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Numbers of new cases per diagnosis year per million of inhabitants, adjusted in respect of previous years because of delays in reporting. The figures reported until 31 December 2003 incl. Figures for 2003 are incomplete for Spain and Italy. Trends are only reflected for the old EU Member States that reported more than ten new cases per million of inhabitants in any year. Source: The European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), Statistical Office of the European Communities (Eurostat).
Mortality According to the Cause of Death Statistics of Statistics Netherlands (CBS), few people in the Netherlands die annually as a direct result of opiate consumption. When death does occur, it is mostly the result of a drug overdose. In accordance with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard for the calculation of the acute death from drug use, these figures include all the cases of unintentional and intentional (suicide) poisoning and poisoning that may or 86;87 may not have been intentional. Between the mid-nineties and 2001 the number of registered deaths from all kinds of overdoses showed a rising trend, so not just for opiates (see Figure 4.9). • This trend is partially due to the increase in death from cocaine (see Chapter 3.7). • In addition, due to the transition of the classification system ICD-9 to ICD-10, more cases may have been included in the ICD-10 system from 1996 than in earlier years in the ICD-9 system. • Between 1996 and 2001, the number of cases of "poisoning by other non-specified narcotics" and “poisoning by other or non-specified psychodysleptics” increased. It concerns here often
70
(combinations of) hard drugs, whether or not together with other substances, but sometimes also (combinations of) prescription drugs and/or alcohol. The number of registered deaths due to an overdose of opiates is low in the Netherlands. • Until 2001 this number of deaths varied from 47 to 77 cases annually. The two following years showed a decrease. • Just as the heroin users, the overdose victims are increasingly older. In the years 1985 up to 1989 incl., only 16 percent of the deceased were older than 35 years, compared to 63 percent in the years 2000 up to 2003 incl. (see Figure 4.10).
Figure 4.9
Deaths from drug overdoses in the Netherlands, from 1985
160 140 120 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Totaal
57
68
54
51
56
70
80
75
75
87
70
108 108 110 115 131
144 103 104
Opiates
51
67
49
47
54
62
76
72
68
77
56
81
71
71
63
68
75
37
53
Cocaine
3
1
3
2
1
3
1
2
3
2
6
10
8
11
12
19
26
34
17
Number of deaths. From 1985 to 1996 ICD-9 codes: 292, 304.0, 304.2-9, 305.2-3, 305.5-7, 305.9, E850.0, E850.8*, E854.1-2, E855.2, E858.8*, E950.0*, E950.4*, E980.0*, E980.4* (*In combination with codes N965.0 and/or N968.5 and/or N969.6 and/or N969.7). From 1996 to 2002 ICD-10 codes: F11-F12, F14-F16, F19, X42*, X41*, X62*, X61*, Y12*, Y11* (*In combination with the T-codes T40.0-9, T43.6). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
71
Figure 4.10
Age group categories involved in death from an opiate overdose between the periods 1985-1989, 1995-1994, 1995-1999 and 2000-2003
100% 80% 60% 40% 20% 0%
1985-1989
1990-1994
1995-1999
2000-2003
>=65
1
4
3
5
35-64
15
35
50
58
15-34
82
61
47
37
0-14
1
0
0
0
Death percentage per age group. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
Amsterdam The Amsterdam Area Health Authority (GG&GD Amsterdam) publishes annual reports on the number of deaths among drug users (see Figure 4.11). These mortality figures for death due to an overdose differ from those published by the Cause of Death Statistics of Statistics Netherlands (CBS), as the Amsterdam Area Health Authority also includes drug-related deaths of illegal immigrants and tourists. The Area Health Authority ( also records the number of opiate users in Amsterdam who died from other causes. • In 2003, 21 drug users in Amsterdam died after taking a drug ‘overdose’, often opiates whether or not in combination with other substances. Once ecstasy (MDMA) was involved. Nine of the overdose victims were Dutch and twelve were foreigners. • Opiate clients usually died from other causes than an overdose (see caption Figure 4.11). Twenty-one deceased drug users were infected with HIV, but this did not necessarily contribute to their deaths. • The average age of the deceased drug users (all causes) who were born in the Netherlands was 51 years. The average age of the drug users born abroad was 43 years. • The decrease in the number of recorded deaths at the beginning of the nineties did not continue in the mid-nineties. From 2001, there was a slight increase in the category of ‘other’ causes of death (see Figure 4.11). With the increasing age of opiate users, underlying problems such as pulmonary, liver and heart diseases play a larger role in these deaths.
72
Figure 4.11
Mortality among drug users in Amsterdam, from 1992
160 140 120 100 80 60 40 20 0
1992
Overdose Other causes Total
I
1993 1994 1995
1996 1997
1998 1999
2000
2001 2002 2003
52
37
39
26
26
22
25
27
31
32
29
21
83
102
86
92
90
76
67
73
76
112
96
126
135
139
125
118
116
98
92
100
107
144
125
147
I Other causes of death (such as endocarditis, sepsis, pulmonary disorders, cirrhosis of the liver, suicide, accidents, violence, AIDS) involving opiate users who were ever registered as clients of the Amsterdam Area Health Authority (GG&GD Amsterdam). Source: Amsterdam Area Health Authority (GG&GD Amsterdam).
International comparisons • Annually, between eight thousand and nine thousand people in the old EU Member States die from a drug overdose; often from opiates in combination with other substances. This is a lower 37;38 limit, because not all cases of death from drug use are recorded. • International comparisons of the number of ‘drug deaths’ are made more difficult due to differences in the definition of the term ‘drug death’. • Figure 4.12 shows the proportion of deaths directly related to drug use for five EU Member States and Norway per 100,000 inhabitants. The same ICD-10 codes were used here. Included are opiates, hallucinogens, cocaine, amphetamine and cannabis. The majority of cases (also) 87 involved opiates. • According to these calculations, Norway and Denmark head the list. The Netherlands are at the bottom. • According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), since 2000 a modest decrease in the number of acute drug-related deaths is noticeable at a European level.
73
Figure 4.12
Acute deaths from drug consumption: a comparison between five EU Member States and Norway Number per 100,000 inhabitants 9 8 7 6 5 4 3 2 1 0 1994
1995
Norway Denmark Finland
5.5
4.1
1996
1997
1998
1999
2000
2001
2002
4.3
3.9
5.9
5.0
7.7
8.2
6.0
4.6
4.8
4.5
4.5
4.5
2.1
1.9
1.7
2.3
2.6
2.1
1.9
1.5
1.6
1.8
2.2
1.9
1.8
1.6
1.6
1.8
1.5
1.4
0.7
0.7
0.8
0.9
0.6
Sweden* Germany The Netherlands
0.7
0.7
2003
1.9
0.6
ICD-10 codes: F11-F12, F14-F16, F19, X42*, X41*, X62*, X61*, Y12*, Y11* (*In combination with the T-codes T40.0-9, T43.6). I. With a view to better comparability, T40.4 is not taken into account in Sweden. Source: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
74
5
ECSTASY, AMPHETAMINES AND RELATED SUBSTANCES
The official name for ecstasy is 3,4-methylenedioxymethamphetamine (MDMA). Substances with a chemical composition similar to that of MDMA — such as MDA, MDEA, MBDB and amphetamines, — a are also sold as ‘ecstasy’, quite often without the user being aware of the difference. Unless stated otherwise, by ‘ecstasy’ we refer in this chapter to substances that are experienced or recommended as ecstasy. By amphetamine we refer to 'ordinary' amphetamine and methamphetamine, the stronger version, unless stated otherwise. Ecstasy has a stimulating and entactogen effect. As a result of the entactogen effect of ecstasy, people feel connected with one another and they find it easier to make contact. This combination of characteristics contributes to the reputation of ecstasy as a party drug. The addictive effect is probably light. Ecstasy is usually taken in the form of pills. Amphetamine has a stimulating effect, stronger than ecstasy, without having an entactogen effect. Amphetamine is also used in trendy clubs, but also used by opiate or polydrug addicts. When used frequently, it may result in dependence. This risk is higher for methamphetamine than for ‘ordinary’ amphetamine. In the Netherlands, amphetamine is usually swallowed or sniffed and sometimes injected or smoked.
5.1
LATEST FACTS AND TRENDS
The main facts and trends regarding ecstasy and amphetamine in this chapter are: • The percentage of ever use of ecstasy and amphetamine in the general population rose between 1997 and 2001. Current use of ecstasy increased particularly among women (see Chapter 5.2). • Between 1996 and 2003 the percentage of pupils who have experience with these substances fell slightly. The percentage of current users decreased also (see Chapter 5.3). • Current use of ecstasy and amphetamine among Dutch pupils is not higher than that of other European peers (see Chapter 5.5). • Ecstasy is still popular among young clubbers, although the use is showing signs of moderation. In Amsterdam, the percentage of users among visitors of trendy clubs dropped (see Chapter 5.3). • The number of ecstasy users seeking help from the (outpatient) care organisations for addicts is low and has been stable in the past four years. The number of primary amphetamine clients is also small, but increased between 2001 and 2003 (see Chapter 5.6). • Health problems at house parties as a result of ecstasy and amphetamine use have been less and less frequent since 1996 (see Chapter 5.6). • The number of recorded acute deaths as a result of ecstasy and amphetamine use is low (see Chapter 5.7). • The use of ecstasy may have a long-term negative effect on brain functions, in particular of the memory, the capacity to concentrate and mood (see Chapter 5.7). • Ecstasy tablets nowadays almost always contain MDMA. The proportion of ecstasy tablets with a high dose of MDMA increased slightly between 2000 and 2003 (see Chapter 5.8).
5.2 • •
a
USE: GENERAL POPULATION The number of Dutch people aged 12 and over with experience of ecstasy or amphetamines (ever 10 use) rose between 1997 and 2001 (see Table 5.1). The percentage of current users remained far below one percent for both substances combined.
Substances that are not similar to MDMA at all are also recommended as ecstasy.
75
•
In absolute figures, the number of current users of ecstasy was 67,000 and the number of current users of amphetamine was 30,000. These estimates are probably rather low, because problem users of hard drugs were underrepresented in that particular survey.
Table 5.1
Ecstasy and amphetamine use in the Netherlands among people aged 12 and over. Survey years 1997 and 2001
Has used ever in lifetime • Men • Women I Used just recently • Men • Women First use in the past year Mean age of current users
Ecstasy 1997 2001 1.9% 2.9% 2.7% 3.7% 1.0% 2.1%
Amphetamines 1997 2001 1.9% 2.6% 2.7% 3.4% 1.1% 1.8%
0.3% 0.4% 0.1%
0.5% 0.5% 0.5%
0.1% 0.2% 0.1%
0.2% 0.2% 0.3%
0.4% 25 years
0.5% 26 years
0.2% 30 years
0.2% -
I. In the last month. - = Not sufficient users for a reliable estimate of the average age. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
Figure 5.1
Ecstasy and amphetamine users in the Netherlands by age group. Survey year 2001 % 15
10
5
0
12-15 16-19 20-24 25-29 30-34 35-39 40-49 50-59 60-69
>=70
Ecstasy ever
0.5
5.5
13.6
7.1
5.0
2.6
1.0
0.6
0.0
0.0
Amphetamines ever
0.2
3.9
9.5
4.2
3.8
3.1
2.2
1.1
0.5
0.5
Ecstasy current
0.2
1.6
2.5
0.8
0.7
0.3
0.1
0.2
0.0
0.0
Amphetamines current
0.2
0.7
0.9
0.2
0.4
0.1
0.1
0.2
0.0
0.0
Age
Percentage of ever and current (last month) users per age group. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
•
•
Ecstasy is especially popular among adolescents aged 20 to 24 incl. (see Figure 5.1). The increase in the proportion of ever users was also largest in this group: from six percent in 1997 to thirteen percent in 2001. Current use rose from more than one to nearly three percent. The percentage of current users also doubled among young people aged 16 to 19 incl. (an increase of 0.8% to 1.6%). The percentage of amphetamine users also peaked among young adolescents aged 20 to 24 incl. (see Figure 5.1). In this group, ever use rose from four percent in 1997 to nearly ten percent in 2001. Current use rose in this period from 0.3 to 0.9 percent.
76
• •
The increase in current users of ecstasy and amphetamines was larger among women than among men. In 2001 nearly as many women were current consumers as men. In 2001, nearly one in three (30%) ever users aged twelve and above had used ecstasy 25 times 10 or more in life. In 1997 this was 25 percent.
The large cities Large cities and other primarily urban areas have a comparatively higher percentage of ecstasy and amphetamine use than the rest of the Netherlands. Amsterdam leads in both survey years (see Figure 5.2).
Figure 5.2
Use of ecstasy (figure above) and amphetamines (figure below) in large cities and rural areas among people aged 12 and over. Survey years 1997 and 2001 ecstasy
% 10 8.7
8
7.0
6
5.3 4.3
4 2.6
2.2
2
1.1 1.1
1.0
0.5
0.1
0.9
1.2 1.4 0.1 0.3
0 Amsterdam
%
Rotterdam
Highly urbanised, other
Non-urbanised
amphetamines
10 8 6.6 6.0
6 4.2
3.8
4
2.8
2.7
2 0.3 0.3
1.1
0.2
0.3
0.1
0.2
1.4 0.1 0.2
0 Amsterdam Ever 1997
Rotterdam Ever 2001
Highly Non-urbanised urbanised, other
Current 1997
Current 2001
Percentage of ever (lifetime) and current (last month) users. Definition (Statistics Netherlands (CBS)): Other highly urbanised municipalities: more than 2,500 addresses per square kilometre, with the exception of Amsterdam and Rotterdam, namely Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. Definition of rural municipalities: fewer than 500 addresses per square kilometre. Source: National Prevalence Research (NPO), Centre for Drug Research (CEDRO).
77
5.3
USE: YOUNG PEOPLE
Figures about the use of ecstasy and amphetamines among young people are shown in Figure 5.1, in which the percentage of users among the general population, resulting from the National Prevalence Research, has been classified by age group. In the last few years, information about the use of substances has also become available from numerous local and regional youth monitors carried out for cities and towns. For amphetamine and ecstasy the information is more limited than for cannabis and legal substances, because questions about the use of ‘hard drugs’ are often not classified by substance. The tables in Appendix F show the results for eight (amphetamine) and eleven (ecstasy) municipalities or regions. It is difficult to compare the figures due to methodological differences, such as the manner of measuring use and age groups. In addition to these general data, information is available from the Dutch National School Survey and (often local) surveys among special groups, such as visitors of clubs and pubs. These data will be described below.
Pupils • • •
The percentage of ecstasy and amphetamine users among secondary school pupils increased 16 between 1992 and 1996. The percentage of ever users of the two drugs decreased by fifty percent between 1996 and 2003. The decrease took place in particular between1996 and 1999. The percentage of current users of ecstasy and amphetamine dropped also between 1996 and 2003 (see Figure 5.3).
Figure 5.3 7
Ecstasy and amphetamine use among pupils aged 12 and over, from 1992
%
Ecstasy
6
7
Amphetamines
%
6
5.8
5.3
5
5 4
4
3.8 3.4
3
2.9 2.3
2
3 2
2.8 2.2
1.4 1
1
1.0
2.2
1.9 1.1
1
0.8 0.6
0
0 1992
1996 Ever
1999 Current
2003
1992
1996 Ever
1999
2003
Current
Percentage of ever (lifetime) and current (last month) users. Source: National Representative School Survey, Trimbos Institute.
78
Special groups In certain groups of young people, proportionately more users of ecstasy and amphetamines are found. Table 5.2 summarises the results of a broad spectrum of studies. The figures in this table cannot be compared with one another because of differences in age groups and research methods.
•
According to less recent data, ecstasy and amphetamine use is more frequent among pupils in special education and participants in truancy programs than among 'regular' pupils (see Table 5.2). However, the figures should be interpreted with caution in view of the recent decrease in 25 (ever) use among ‘regular’ pupils and young clubbers (see below).
Table 5.2
Ecstasy and amphetamine use in special groups
Young people in special I education Young people in truancy programs Visitors of trendy clubs II Pub visitors Young clubbers III Young homeless people Coffee shop visitors
IV
Location
Survey year
Age (year)
Ecstasy
Amphetamines
Nationwide
1997
12 - 18
Ever 9%
Current 4%
Ever 7%
Current 3%
Nationwide
1997
12 - 18
30%
15%
25%
9%
Amsterdam Amsterdam The Hague Nationwide Flevoland Amsterdam
2003 2000 2003 1999 2004 2001
Mean age 26 Mean age 25 15 - 35 15 - 22 13 - 22 Mean age 25
33% 34% 35% 55% 38% 63%
19% 10% 17% 18% 8% 23%
34% 17% 47% 26% 39%
7% 2% 10% 2% 5%
Percentage of ever users (in lifetime) and current (last month) per group. The figures in this table cannot be compared with one another because of differences in age groups and research methods. - = not measured. I. Special School for Children with Learning Difficulties (MLK), Special School for Children with Learning and Behavioural Difficulties (LOM), Special School for Children with Severe Behavioural Learning Problems (ZMOK). II. A selective sample of young people and adolescents visiting mainstream, student, gay and trendy pubs. This sample is therefore not representative for all pub visitors. III. Young people of up to 23 years without a fixed 17;22-25 . address for three months or longer. IV. Low response (15%). References:
Ecstasy continues to be (after cannabis) the main illegal drug for young people in the clubbing circuit, in particular parties, although there are indications of a tendency to moderate the use. • According to the Amsterdam Antenne Monitor the percentage or current ecstasy users among 18 visitors of trendy clubs dropped from 41 percent in 1998 to 19 percent in 2003. The proportion of users during the night out dropped from 27 to 8 percent. In 2003, they took 1.9 pills per night: this does not differ (significantly) from 1998 (2.4 pills per night). • In The Hague the percentage of ecstasy users among young clubbers was at the same level as in 21 Amsterdam. • Elsewhere in the country, key figures in the partying circuit also noted that young clubbers handled ecstasy ‘more prudently’ and were better informed of the risks. Visitors of discotheques in rural 20 areas in the eastern part of the country do not seem to be an exception. • The experience or expectation of negative physical and emotional effects of ecstasy use, such as headaches, dizziness, feelings of anxiety or depression, seem to discourage the use of it by young 188 people. Amphetamines are less popular among young clubbers than ecstasy. • In Amsterdam the percentage of visitors of trendy clubs who had ever used this drug dropped from 45 percent in 1998 to 34 percent in 2003. The percentage of current users dropped from 13 percent to 7 percent.
79
• At hardcore parties and in certain (alternative) scenes, amphetamines are used somewhat more 20 frequently (punk, electro, trance, underground, rock and techno) than in trendy clubs.
5.4 •
5.5
PROBLEM USE The number of problem users of ecstasy and amphetamines — i.e. people whose drug use leads to role limitations or even dependence — is not known. However, the number of individuals who seek drug treatment or counselling is known (see Chapter 5.6).
USE: INTERNATIONAL COMPARISONS
General population Table 5.3 presents information about the use of ecstasy and amphetamines in a number of EU Member States, Norway, Australia, Canada and the United States.
•
Differences in survey year, methods of measurement and random samples make precise comparison difficult. Of particular influence is the age group. Table 5.3a shows consumption figures (re)calculated in accordance with the standard age group of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (15 to 64 years incl.). Data for the other countries can be found in Table 5.3b.
•
As regards ever use of ecstasy, England & Wales, Australia and Ireland beat them all with values over five percent. In Denmark, France, Portugal, Greece and Sweden, the percentage of ever users does not exceed one percent.
•
The percentage of people who ever used amphetamines varies from less than one percent in Portugal and Greece to nine percent in Australia and the United States, while England and Wales peak with twelve percent. Australia tops the list of the countries shown in Tables 5.3a and 5.3b with the highest percentage of recent users of both drugs. The Netherlands takes one of the highest positions for use of ecstasy.
•
80
Table 5.3a
Amphetamine and ecstasy use in the general population of several EU Member States and Norway: age group from 15 to 64 years incl.
Country
Northern Ireland Spain Ireland The Netherlands Finland Norway Belgium Luxembourg France Portugal Greece Sweden
Year
Ecstasy Ever Recent 5.9% 1.7% 4.2% 1.9% 3.8% 1.1% 3.6% 1.5% 1.4% 0.5% 2.4% 0.7% 1.2% 0.9% 0.2% 0.7% 0.4% 0.3% 0.1% 0.2% 0.2%
2002/2003 2001 2002/2003 2001 2002 1999 2001 1998 2000 2001 1998 2000
Amphetamines Ever Recent 3.9% 0.8% 3.0% 1.2% 3.0% 0.4% 3.1% 0.6% 2.2% 0.5% 2.6% 1.2% 2.1% 1.5% 0.2% 0.5% 0.1% 0.6% 0.0% 1.9% 0.2%
Percentage of ever in lifetime and recent (last year) users. - = not measured. References:
37;38
Table 5.3b Ecstasy and amphetamine use in the general population of several EU Member I States, the United States, Canada and Australia: other age groups Country England and Wales Australia
Year
Age
2002/2003 2001
16 - 59 14 and above 12 and above 15 and above 15 - 44 18 - 59 16 - 64
United States
2003
Canada
2002
Italy Germany (‘West’) Denmark
2001 2000 2000
Ecstasy Ever Recent 6.6% 2.0% 6.1% 2.9%
Amphetamines Ever Recent 12.3% 1.6% 8.9% 3.4%
4.6%
0.9%
8.8%
1.2%
2.9%
0.8%
4.6%
0.5%
1.8% 1.6% 1.0%
0.2% 0.7% 0.5%
1.5% 2.3% 5.9%
0.1% 0.6% 1.3%
Percentage of ever in lifetime and recent (last year) users. I. Drug use is proportionally low in the youngest (12-15 years) and the older age groups (>64 years). Consumption figures in studies with respondents who are younger and or older than the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standard may turn out lower than the figures in studies applying the EMCDDA standard. For studies with a more limited age range 37-41 the reverse applies. References:
Young people Better comparable are the data of the European School Survey Project on Alcohol and Other Drugs (ESPAD) among pupils aged 15 and 16 in European countries. Table 5.4 portrays ecstasy and amphetamine use in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in the ESPAD, but conducted comparable 43 research.
81
•
•
The number of pupils who tried ecstasy in 2003 was lowest in Finland, Greece, Denmark, Norway and Sweden (2% or less). The United States topped the list with six percent, followed closely by the Netherlands, Ireland and the United Kingdom with five percent. In none of the countries current use of pupils exceeded two percent. Of the countries listed in Table 5.4, Germany, Austria and Denmark scored highest for current use of amphetamines (4 - 5%). The United States scored exceptionally higher with 13 percent. The Netherlands shared the lowest position with Finland, Greece, Ireland and Sweden. In most of the countries, maximum one percent of the pupils recently used amphetamines, with the exception of the United States (2%), Austria (3%) and Spain (2%).
Table 5.4
Ecstasy and amphetamine use among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey years 1999 and 2003
Country United States Austria Ireland Belgium The Netherlands United Kingdom France Germany Denmark Norway Italy Greece Portugal Finland Sweden
Ever use ecstasy 1999 2003 6% 6% 3% 5% 5% 4% 4% 5% 3% 5% 3% 4% 3% 3% 2% 3% 2% 2% 3% 2% 2% 2% 4% 1% 1% 1% 2%
Ever use amphetamines 1999 2003 16% 13% 4% 3% 1% 2% 2% 1% 8% 3% 2% 3% 5% 4% 4% 3% 2% 2% 3% 1% 0% 3% 3% 1% 1% 1% 1%
Percentage of ever users (in lifetime). The United States did not take part in the ESPAD, but conducted comparable research. - = not measured. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
5.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.)
Ecstasy •
• •
The number of recorded admissions in the (outpatient) care organisations for addicts primarily for ecstasy rose until 1997(see Figure 5.4). This was partly due to an improved registration system. From 1997 this number started to decline, followed by a stabilisation from 1999. Between 2002 88 and 2003 the number increased by eleven percent. With one percent, ecstasy problems accounted for a small proportion of the total number of requests for drug treatment or counselling. Characteristics of the primary ecstasy clients in 2003 were: - About three quarters (74%) were men.
82
•
- The average age was 25. - Over one-third (38%) were new clients of the (outpatient) care organisations for addicts. There were more clients stating ecstasy as a secondary than as a primary problem. - The primary problem for this group of secondary ecstasy clients was cocaine (42%), cannabis (25%), alcohol (15%), or amphetamines (14%).
Figure 5.4
Number of recorded admissions in the (outpatient) care organisations for I addicts because of primary or secondary ecstasy problems, from 1994
1000 900 800 700 600 500 400 300 200 100 0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Primary
29
208
398
457
340
252
241
225
250
277
Secundary
32
321
552
672
607
549
573
563
622
655
I. In 1994, not all the ecstasy-related problems were fully recorded yet.
Amphetamines •
•
•
•
The number of admissions primarily for amphetamine-related problems increased until 1998 but declined again from 2001. Between 2002 and 2003, the number of amphetamine clients increased by 35 percent (see Figure 5.5). With three percent of the total of drug-related treatment requests in 1999 and two percent in 2000 to 2003 incl., amphetamine-related problems remained all those years below the treatment requests of other drugs. Characteristics of the primary amphetamine clients in 2003 were: - Over three quarters (78%) were men. - The average age was 28, slightly higher than that of the ecstasy clients. - About a third (37%) of amphetamine clients who sought help from the (outpatient) care organisations for addicts were new clients. Amphetamines were a secondary problem for over six hundred clients. - The primary problem for this group was cocaine (35%), alcohol (20%), heroin (18%), cannabis (17%), or ecstasy (6%).
83
Figure 5.5
Number of recorded admissions in the (outpatient) care organisations for addicts because of primary or secondary amphetamine problems, from 1994
1000 900 800 700 600 500 400 300 200 100 0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 497
566
667
794
870
810
623
482
543
735
Secundary 489
566
558
610
590
560
498
474
481
552
Primary
Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Inpatient care organisations for addicts There are no recent countrywide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • This dated information shows that the use of ecstasy or amphetamine rarely leads to admission in a drug treatment clinic or general psychiatric hospital. • Between 1996 and 1999, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded 58, 51, 39 and 25 admissions respectively for ecstasy and amphetamines combined (ICD-9 codes 304.4 and 305.7; see Appendix C).
General hospitals; incidents The National Medical Registration (LMR) registers few admissions annually in general hospitals for amphetamine-related problems, including ecstasy (See Figure 5.6). • In 2003, it concerned ten percent of all primary diagnoses for drugs. Most of the admissions (87%) related to abuse; 13 percent related to dependence of amphetamines. • The percentage of admissions in which these disorders were diagnosed as secondary problem was slightly higher. The main disorders diagnosed — where amphetamine abuse and dependence were diagnosed as secondary problem — were very diverse. A quarter of the admissions in 2003 involved alcohol abuse and dependence. • A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 89 patients were admitted in
84
•
2003. They were admitted at least once this year with amphetamine abuse or dependence diagnosed as primary or secondary problem. The average age was 30 years and 72 percent were male. Accidental amphetamine overdose was listed as secondary diagnosis (ICD-9 code E854.2) in 25 hospital admissions.
Figure 5.6 Clinical admissions in general hospitals for amphetamine abuse and dependence, from 1994
100
Number 80
80
69
70
66 61
63 58
60 46
40
33
30
29 29
20
24
33
29 25
23
36 29
21
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Amphetamines as primary diagnosis Amphetamines as secondary diagnosis The number of diagnoses, not adjusted for double patient counts or more than one secondary diagnosis per admission. ICD-9 codes: 304.4, 305.7 (Appendix C). Ecstasy and amphetamine are recorded under the same codes. Source: National Medical Registration (LMR), Prismant.
The Amsterdam Area Health Authority (GG&GD Amsterdam) records the number of calls for emergency aid received by the Central Ambulance Service. • In 2003, calls for emergency aid were 39 times ecstasy-related, approximately the same as in the previous years. Exceptionally high was 1996, with 66 calls (see Table 5.5). • In 2003, twenty-five ecstasy users (64%) required transportation to hospitals. • The most common complaints in ecstasy-related incidents noted by the Amsterdam hospital Onze Lieve Vrouwengasthuis were heart palpitations and fainting, ‘feeling unwell’ and anxiety. Fainting 44 only occurred in people who had consumed ecstasy in combination with alcohol and/or GHB.
Table 5.5
Amphetamine- and ecstasy-related drug incidents recorded by the Amsterdam Area Health Authority (GG&GD Amsterdam), from 1995
Amphetamines Ecstasy
1995 6 38
1996 1 66
1997 7 41
1998 7 35
1999 7 43
2000 30 36
2001 6 42
2002 5 39
2003 7 39
Number of incidents (people) per year. Source: Central Ambulance Station (CPA), Amsterdam Area Health Authority (GG&GD Amsterdam).
According to Stichting Educare, an organisation that provides first aid at house parties in the Netherlands, the number of acute health problems as a result of drug use is relatively small and is 89 decreasing.
85
• • •
• •
From 1996 to 2002 incl., Stichting Educare provided care to 15,000 people in total at 134 parties. The number of visitors who sought assistance for health problems from the First Aid decreased from 1.2 to 0.8 percent in this period. In the course of years, amphetamines and ecstasy were increasingly less involved in these incidents and alcohol increasingly more. - The proportion of amphetamine-related incidents in all substances-related incidents decreased from 17 percent in 1996 to 2 percent in 2002. - For ecstasy, Stichting Educare recorded a decrease from 47 percent to 20 percent. - As distinct from this downward trend for drugs, an increase in alcohol-related health problems from 4 to 17 percent was recorded. In the case of both ecstasy and amphetamine users, mainly light complaints were reported, such as feeling unwell, headaches, nausea and dizziness. Recent observations by health workers who are active at parties confirm the downward trend of 20 ecstasy-related incidents.
5.7
ILLNESS AND MORTALITY
Illness The latest state of the art indicates that ecstasy use may cause long-term brain function disorders, in 90 particular of the memory, the capacity to concentrate and moods. • This disorder may continue for more than a year after discontinuation of the use. It is unknown whether full recovery is made. • These changes are probably connected with damage to serotonergic nerves in the brain, but the use of other substances in addition to ecstasy may also come into it. • In laboratory animals the chance of brain damage increases with an increase in body temperature after MDMA use. It is assumed that the same is true for human beings. • The chance of overheating, resulting in (long-term) brain damage increases, if a consumer takes larger quantities of MDMA in a warm environment (over 18-20 degrees). It is not known which quantity exactly results in damage. It is assumed that damage is already done in case of intake of highly dosed pills containing twice to three times the average dose. • Research at the University of Amsterdam will show in due course whether short-term use may also cause damage to and a decrease of brain functions.
Mortality The exact number of deaths caused as a result of amphetamine or ecstasy use is not known. • According to the Cause of Death Statistics of Statistics Netherlands (CBS), use of these substances is not often the primary cause of death. In the period 1996 - 2002, a maximum of four acute deaths annually were recorded. In 2003, Statistics Netherlands (CBS) recorded seven cases (ICD-10 codes F15, X41*, X61*, Y11* [* together with code T43.6]; for an explanation of the codes see Appendix C). These codes do not only include amphetamines and MDMA(-like) substances, but also other stimulants, such as caffeine, ephedrine and khat. • In 2002, the Amsterdam Area Health Authority (GG&GD Amsterdam) reported two deaths in which MDMA may have been involved. There is no national survey. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), ecstasy plays a minor part in drug-related deaths in other European countries as well, at least in so far as 37;18 information is available.
86
• •
• •
5.8
An exception seems to be the United Kingdom, where an increase in ecstasy-related deaths was 91 recorded from 12 cases in 1996 (from August) and 1997 to 72 cases in 2001 to April 2002. In the United Kingdom, from August 1996 to April 2002 incl., a total of 202 deaths were recorded that were allegedly ecstasy-related. In seventeen percent of the cases, only MDMA or an MDMAlike substance was found in a toxicological examination. In the other cases, other substances were also found, in particular opiates, alcohol, cocaine and amphetamine. Other factors that may have contributed to these deaths are overheating, water intoxication or an underlying decease. The increase between 1996 and 2002 may also have resulted from a changed registration practice. Autopsists are said to report ecstasy increasingly as possible cause of death.
SUPPLY AND THE MARKET
The Drugs Information and Monitoring System (DIMS) examines the substances in drug samples that are turned in to care organisations for addicts. Part of these samples (pills) is identified by the organisation itself on the basis of characteristics like logo, weight and diameter. Samples of unknown composition and all the samples in powder form are forwarded to the laboratory for chemical analysis. The number of samples that consumers hand to DIMS annually has strongly decreased since 1997. This is probably connected with the discontinuation of participation of the Safe House Campaign at parties (Drug Consultation Bureau - Stichting Adviesburo Drugs), the increased consumer confidence in the fairly stable composition of pills and a reduction of the number of pills that a user can have 89 tested each time.
Composition of ecstasy pills The number of pills sold as ecstasy that were recognised at test locations dropped from 4,320 in 1997 to 688 in 2003. The number of ‘ecstasy’ pills that were analysed in the laboratory remained fairly stable. Table 5.6 shows the percentage of the analysed pills containing MDMA and or another substance. • In the last few years, the proportion of pills containing only MDMA or a MDMA-like substance increased strongly, whereas the proportion of pills containing (also) another psychoactive substance, such as amphetamine, decreased. • In 2003, over 95 percent of the 'ecstasy’ pills actually contained MDMA, MDEA or MDA, or a combination of these substances. • In that year, the average concentration of MDMA in ecstasy pills was 78 mg, approximately the same as in the previous years. Figure 5.7 shows, however, that the proportion of ecstasy pills with a high quantity of MDMA (more than 140 mg) rose slightly from one percent in 1997 and 1998 to six percent in 2003. The highest measured quantity in 2003 was 215 mg.
87
Table 5.6
Number and composition of (ecstasy) pills handed to the Drugs Information and Monitoring System (DIMS), from 1997
Substances (% of pills) MDMA MDEA MDA Combination of MDMA, MDA and or MDMA Combination of MDMA, MDA and or another I psychoactive substance Pills without MDMA, MDEA and or MDA: II Amphetamine Methamphetamine I Another psychoactive substance No psychoactive substance Total number of analysed pills
1997 44.6% 8.2% 1.5% 2.6% 9.0%
1998 75.2% 1.3% 2.2% 1.6% 4.3%
1999 82.0% 1.4% 2.8% 1.0% 3.3%
2000 89.5% 0.9% 2.0% 3.0% 1.2%
2001 91.4% 1.2% 0.7% 3.0% 0.9%
2002 88.7% 0.4% 1.4% 1.7% 3.7%
2003 91.2% 0.5% 0.9% 2.1% 2.1%
15.5%
6.5%
3.9%
0.9%
1.0%
14.7% 3.9% 2,434
4.5% 4.3% 2,713
2.7% 2.9% 2,306
1.6% 0.8% 2,497
1.2% 0.5% 2,402
1.7% 0.3% 1.3% 0.8% 2,149
1.0% 0.3% 0.7% 0.8% 2,187
Percentage of pills that contain a specific substance or combination of substances. Categories are mutually exclusive. I. E.g. 2-CB, MBDM, DOB, PMA, caffeine, ephedrine etc. II. Until 2002 no distinction was made between amphetamine and methamphetamine. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Figure 5.7
Concentration of MDMA in ‘ecstasy’ pills handed to DIMS
100% 80% 60% 40% 20% 0%
1997
1998
1999
2000
2001
2002
2003
>140 mg
1
1
1
2
4
4
6
106-140 mg
6
5
6
9
14
11
12
71-105 mg
36
27
29
35
49
42
38
36-70 mg
39
53
52
45
28
39
38
1- 35 mg
17
15
11
9
5
5
7
Percentage of pills with a certain quantity of MDMA. It relates to pills that were tested in the laboratory and contain at least 1 mg MDMA. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Other substances Table 5.7 shows the number of samples (ecstasy pills, powders or otherwise) found by DIMS to contain substances that are continuously examined in a European framework and or may be a danger to public health.
88
• •
• •
b
Most of the substances in Table 5.7 had virtually disappeared from the market by 2003 . The presence of pills containing atropine and DOB led to health warning campaigns in 1997/1998 and 1999. In 2000, a health warning campaign was launched in response to pills with harmful levels of strychnine. Another campaign was launched in 2001, after a pill with dangerous levels of PMA was found (over 50 milligrams). The former anaesthetic agent GHB is also regularly handed to DIMS. In 2001 it concerned 102 samples (usually liquids) and, in 2002 and 2003, 72 samples were involved annually. In the last few years, GHB has become popular in certain circles. Meanwhile the use seems to have stabilised and in Amsterdam there are indications that the interest in this substance is decreasing 18;20 again.
Table 5.7 2C-B 4-MTA Atropine DOB Ketamine MBDB I PMA/(PMMA) Strychnine
Number of samples with other psychoactive substances 1997 317 9 128 1 0 113
1998 12 16 52 15 16 12
1999 25 8 0 26 1 0
2000 12 6 1 5 2 0 1 1
2001 11 1 0 5 1 0 8 0
2002 2 5 0 0 2 0 0 0
2003 2 0 0 0 3 0 0 0
I. Pills containing more than 1 milligram. Source: Drugs Information and Monitoring System (DIMS), Trimbos Institute.
Composition of (meth)amphetamine samples DIMS receives also samples (mainly powders) that were sold as ‘speed’. In 2003, it involved 393 samples. • Most of them (85%) contained (also) amphetamine; three percent contained both amphetamine and methamphetamine and three percent contained only methamphetamine. Methamphetamine is stronger and has a more prolonged effect than amphetamine. • The average percentage of amphetamine was 33 (by weight). • The proportion of samples in which caffeine was found rose from 32 percent in 2002 to 54 percent in 2003.
Prices The prices paid by consumers for ecstasy and amphetamine are not systematically recorded. Trends in prices can therefore not be reported. Recent figures from the Antenne Monitor and the Drugs Information and Monitoring System (DIMS) project, however, give an indication of the current situation. • In 2003, young clubbers in Amsterdam paid over three euros on average per pill when buying 18 several pills in one time from a house dealer. Per single pill the price was somewhat higher: 4.25 euros on average. Dealers in the clubbing circuit demand higher prices: 5.52 euros on average per pill when buying one.
b
End 2004 cocaine samples were found to have been mixed with harmful quantities of atropine. In the Netherlands a warning campaign was started after people had been hospitalised in various places - also in Italy, Belgium and France - with cocaine/atropine intoxication.
89
•
Consumers who had pills tested by DIMS paid in 2003 between 1 and 7.5 euros per pill with an average of 3.50 euros.
90
6
ALCOHOL
Alcohol is produced through the yeasting of grains and grapes. Alcohol is drunk as beer, wine or distilled spirits. A glass of beer, a glass of wine and a glass of distilled spirits contain each approximately the same amount of alcohol. In social situations, consumers experience alcohol as having a relaxing effect and promoting a good mood. In less social situations, alcohol may increase an aggressive mood. Alcohol is an addictive substance. Regular use results in habituation and tolerance. Excessive use of alcohol may lead to several diseases, in particular liver diseases, cardiovascular diseases and cancer.
6.1
LATEST FACTS AND TRENDS
The main facts and trends regarding alcohol in this chapter are: • Sales figures indicate that the per capita consumption of alcohol dropped slightly in 2003. This drop can be attributed to the drop in the consumption of distilled spirits (see Chapter 6.2). • Alcohol use among pupils increased between 1999 and 2003, particularly among young girls aged between 12 and 14. • Compared to pupils in other countries, Dutch pupils are frequent drinkers. (See chapter 6.5). • In spite of a legal ban, it is relatively easy for young people under the age of 16 to purchase alcoholic beverages, particularly in hotel and catering establishments, supermarkets and groceries but also in off licences (see Chapter 6.3). • Heavy drinking is proportionally more prevalent among male adolescents aged 18 to 24 incl. Adolescent males relatively often are involved in traffic accidents, in which alcohol is a contributing factor or the cause (see Chapter 6.4). • Ten percent of the Dutch population aged 16 to 69 are problem drinkers. • Between 2001 and 2003, the number of recorded admissions in the (outpatient) care organisations for addicts for alcohol problems increased (see Chapter 6.6). • The number of traffic-related fatalities and injuries caused by alcohol use fell slightly in the last few years (see Chapter 6.6). • Total mortality due to alcohol-related disorders (primary and secondary causes of death together) increased slightly between 2001 and 2003 (see Chapter 6.7). • Excessive alcohol consumption is the main determinant of loss of quality of life (see Chapter 6.7).
6.2
USE: GENERAL POPULATION
Alcohol consumption is widespread in Dutch society. • According to a Statistics Netherlands (CBS) survey of 2003, 85 percent of the population aged 16 and over has ‘the occasional drink’. This represents an increase compared to the middle of the nineties, when only 79 percent of the population consumed alcohol. In the last few years, 92 however, this percentage has been fairly stable. • National Prevalence Surveys (see Appendix B) confirm the use of alcohol in all segments of Dutch 10 society. - In 2001, 92 percent of the Dutch population aged 12 and over had ever used alcohol and 75 percent had used alcohol recently (in the last month). 20 percent of the recent consumers drank (almost) daily. - In 1997, 90 percent had ever consumed alcohol and 73 percent had used alcohol recently. 24 percent of the recent consumers drank alcohol every day.
91
•
a
Research conducted in The Hague (2001) and Amsterdam (1999/2000) suggests that alcohol use b 93;94
is considerably lower among Moroccan and Turkish people than among native Dutchmen. - The percentage of alcohol consumers among Moroccan and Turkish men was between 6 and 12 and between 23 and 28 percent respectively. The percentage of men of Dutch descent was between 82 and 88 percent in both cities. - The percentage of alcohol consumers among Moroccan and Turkish women was between zero and two percent and between two and eleven percent respectively. Among women of Dutch descent this was 70 to 71 percent. Sales figures give an indication of the annual per capita alcohol consumption (see Table 6.1). • Alcohol consumption in the Netherlands was highest in the second half of the seventies and in the eighties. This was followed by a slight decline, which trend discontinued from the early nineties. However, from 2001 a slight decrease in alcohol consumption is apparent. • In 2003, the per capita consumption was 7.9 litre of pure alcohol. This was 0.1 litre less than in 2002. • This drop can be attributed to the drop in the consumption of distilled spirits. This dropped in 2003 by nearly ten percent compared to the previous year. This may be connected with the increase in excise duty on distilled spirits per 1 January 2003 (see Chapter 6.8). • The sale of premixes decreased in 2003 to over 200,000 hectolitres, a drop of one third compared to 2002. • Per person the Dutch drank 79 litres of beer, 20 litres of wine and 4 litres of distilled spirits.
Table 6.1 Year 1960 1965 1970 1975 1980 1985 1990 1995 2000 2001 2002 2003
Beer, wine and distilled spirits per capita (in litres of pure alcohol), from 1960 Beer 1.2 1.9 2.9 4.0 4.8 4.2 4.1 4.1 4.1 4.0 4.0 4.0
Wine 0.2 0.5 0.8 1.5 1.4 2.0 1.9 2.2 2.3 2.3 2.3 2.4
Distilled spirits 1.1 1.9 2.0 3.4 2.7 2.2 2.0 1.7 1.7 1.7 1.7 1.5
Source: Commodity Board for Distilled Spirits (PGD) 2002; Commodity Board for Wine.
Total 2.6 4.2 5.7 8.9 8.9 8.5 8.1 8.0 8.2 8.1 8.0 7.9
95;96
a
The Amsterdam figures only refer to Moroccan and Turkish persons aged 35 and over. Because of the absence of an adequate number of younger respondents, reliable figures could not be presented. The percentages of alcohol consumers most likely are higher among the younger Moroccan and Turkish persons. b For the definition of ethnic backgrounds, the Amsterdam Area Health Authority (GG&GD Amsterdam) follows the definition of the Ministry of the Interior / Association of Dutch Municipalities (VNG): see Appendix A.
92
Special groups •
•
6.3
In 2002, over one-third (35%) of the homeless in twenty Dutch municipalities were risk drinkers (defined here as consuming more than 25 glasses per week); 23 percent drank more than 56 11 glasses per week and 13 percent drank more than 112 glasses per week. Approximately 4 percent of the drinking working labour force drinks alcohol sometimes just before 97 or during work: one percent does this at least once a week. - 38 percent consume sometimes alcohol immediately after work and 12 percent do this weekly. In the hotel and catering business the proportion of those drinking immediately after work is highest (31% weekly), in health care and public welfare work and in public administration this 97 is lowest (5% and 4% weekly).
USE: YOUNG PEOPLE
For the classification of alcohol consumption among pupils aged twelve and over, figures are available from the National Representative School Survey (see Appendix B). In addition, in the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F an overview is given of recent figures concerning the use of alcohol among young people in 29 municipalities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of difference in alcohol use between the various municipalities. In this paragraph we shall also present the data from (often local) surveys among special groups of young people.
Pupils Since the mid-eighties the Trimbos Institute has monitored the extent to which secondary school pupils aged 12 and over have experience with alcohol, tobacco, drugs and gambling. This is done in, what is called, the Dutch National School Survey. • In 2003, 85 percent of the pupils of ‘regular’ secondary schools had experience with alcohol. That was more than in 1999, when still 74 percent had experience with alcohol. However, this 16 percentage fluctuated over the past fifteen years (see Figure 6.1). • In 2003, 58 percent of all interviewed pupils had consumed alcohol in the month prior to the survey, about the same as in 1999. • Among young girls aged 12 to 14 incl. in particular, an increase in ever and previous month use was apparent compared to 1999. - In 1999, 57 percent of the girls aged 12-14 had ever drunk alcohol, in 2003 this had risen to 78 percent. - In 1999, 32 percent had used alcohol in the last month, in 2003 this was 44 percent. • Fifteen percent of the pupils reported they consumed their first alcoholic drink at age 10 or younger, nearly twice as many boys (19%) as girls (10%). Most pupils start drinking between the age of 11 and 14.
93
Figure 6.1
Alcohol consumption among pupils aged 12 and over, from 1988 90
% 85
80
79
79 74
70 69 60
58 54
54
55
50 45
Ever
Current
1999
2003
40 1988
1992
1996
The percentage of consumers who ever used alcohol (in their lifetime) and in the month before the survey 16 (recent). Source: Dutch National School Survey, Trimbos Institute.
•
• •
In 2003 the percentages of boys and girls who ever or currently consumed alcohol did not differ. There are differences, however, in drinking patterns. Boys drink alcohol more frequently than girls. They also drink larger quantities than girls. All this concerns in particular older boys: - Of the boys aged 16 who drank in the past month, 29 percent did this more then ten times in that month compared to 19 percent of the girls. - Also 29 percent of these drinking boys aged 16 drink more than ten glasses on average on a weekend day. For the girls this is 9 percent. In 2003, nearly half the pupils (47%) aged 12 had already once drunk an alcoholic drink, while those aged 15 consumed alcohol weekly (52%). Among pupils of Moroccan descent (aged 12-16) current alcohol consumption is significantly lower c
•
than among pupils of Dutch descent (8% versus 63%). Pupils of Turkish or Surinam descent take 16 an intermediate position, with 15% and 47% respectively. However, there is no difference 98 between ethnic groups with respect to the quantity that is consumed per occasion. Alcohol use is often combined with smoking cigarettes. In 1999, one quarter (26%) of all the pupils (12-16 years) had smoked cigarettes in the past month. Among drinking pupils this was 42 99 percent. 16
Among secondary school pupils, beer and breezers/premixes are most popular. • Among boys, beer is the most popular drink: of the boys who used alcohol in the past month, 42 percent report they drink beer weekly. • Among girls breezers are most popular: of the girls who had used alcohol in the past month, 30 percent drink breezers weekly.
Special groups of young people In certain groups of young people and adolescents alcohol use is widespread.
c
For the definition of ethnic background: see Appendix A.
94
•
•
• • •
University or college students drink more alcohol than other young people. In 1999, these students consumed an average of 16 glasses per week (men 20 and women 8 glasses). Members of student’s associations averaged 23 glasses per week (men 27 and women 12 glasses). Young people of comparable ages consumed an average of 10 glasses per week (men 13 and women 7 glasses)0.100 Holiday periods in particular are times in which much alcohol is consumed. A survey at youth camp sites (average age 17.4) shows that more than 80 percent of the boys and nearly half the girls use alcohol every day of the holiday. Boys drink daily seventeen glasses and girls seven on 101 average. Young people in a truancy program in Amsterdam are more often current drinkers (over 50%) than 18 their peers who do not play truant but go to school (40%). A survey in five municipalities in the Netherlands (Amsterdam, Breda, Hilversum, Tilburg and 22 Zaanstad) shows that one in ten young homeless drinks alcohol daily. Young people at ZMOK schools (special education for children with severe behavioural learning problems) do not differ significantly in respect of frequency and intensity of alcohol use from young people in regular education. When only young people of Dutch descent are compared, however, 102 young people at ZMOK schools drink more frequently and in larger quantities.
Many young people drink when they go out. Table 6.2 summarises the results of a number of surveys among young clubbers. The figures in this table are not comparable due to differences in age categories and research methods. • In 2003, one fifth of the young clubbers aged 13 consumed alcoholic drinks when going out on the town, two thirds of those aged 14 and 15 and nine in ten of those aged 16 and 17. These 103 percentages are lower for those aged 13 up to 15 incl. than in 2001. • Nine in ten young people in The Hague (aged 15-35) who visit clubs and pubs consumed alcohol 21 in the past month and six in ten in the past week. • Among fans of Hiphop/Rap/+R&B, alcohol consumption is lower than among fans of Pop/Rock or Dance/House/Techno. This may be connected with the preference of Moroccan young people for 21 this type of music. Alcohol use is less common among Moroccans • In Amsterdam, one third of both pub visitors, coffee shop visitors and the visitors of trendy clubs 17;18;104 drink alcohol daily or at least four or five glasses several times a week.
95
Table 6.2
Alcohol consumption among young clubbers
Population Young clubbers general
Location Nationwide
I
Survey year 2003
Measurement for alcohol consumption in the past year
2001
Young clubbers general
The Hague
II
2003
Hiphop/Rap/R&B Pop/Rock Dance/House/Techno Pub visitors
The Hague
II
2003
Amsterdam
III
2000
Coffee shop visitors
Amsterdam
IV
2001
Visitors of trendy clubs
Amsterdam
V
2003
in the past month in the past week in the past month
at least four or five glasses daily or several times a week at least four or five glasses daily or several times a week at least four or five glasses daily or several times a week
Age (year) 13 14-15 16-17 13 14-15 16-17 15-35 15-35
25 years on average
Percentage 18 64 89 39 74 91 88 60 75 88 92 33
25 years on average
30
28 years on average
33
The figures in this table cannot be compared with one another because of differences in age groups and research 103 21 104 methods. I. Source: Intraval. II. Source: Survey of clubbers in The Hague. III. Source: Antenne. . IV. Source: 17 18 Antenne. V. Source: Antenne.
6.4
PROBLEM USE
The scope of the alcohol problem depends on the applied definition. Research sometimes differentiates between heavy drinking, problem drinking, irresponsible drinking and alcohol dependence or alcohol abuse.
Heavy drinking Statistics Netherlands (CBS) defines heavy drinking as consuming at least six glasses of alcohol on one or more days per week. • According to this definition, eleven percent of the population aged 12 and over consisted of heavy drinkers in 2003. This is the same percentage as ten years ago. Since 2001, however, the percentage of heavy drinkers has slightly decreased (see Figure 6.2). • In 2003, four times more men than women were heavy drinkers. • Young people aged 18–24 lead in the measurement heavy drinking. In 2003, the percentage of heavy drinkers among adolescent men and women was 39% and 12% respectively (see Table 6.3). • This is slightly lower than in 2002. Then 42 percent of the young adolescent men and 18 percent of the adolescent women appeared to be heavy drinkers.
96
Figure 6.2
Percentage of heavy drinkers of alcohol among people aged 12 and over, from 2000 16 14
14 13 12
12
11
10 8 6 4 2 0 2000
2001
2002
2003
Source: Permanent Survey on Living Conditions (POLS), Statistics Netherlands (CBS).
Table 6.3
Heavy drinkers among people aged 12 and over by gender and age. Survey year 2003
12-17 years 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 years and over Total: 12 years and over
Men 6% 39% 25% 16% 24% 14% 7% 4% 19%
Women 6% 12% 4% 4% 3% 4% 1% 0% 4%
Total 6% 25% 14% 10% 14% 9% 4% 2% 11%
The percentage of people consuming six or more glasses of alcohol on one or more days per week. Source: Permanent Survey on Living Conditions (POLS), Statistics Netherlands (CBS).
Problem drinking Problem drinkers are people whose alcohol consumption exceeds a certain threshold value, and who report all kinds of effects of alcohol consumption. • Ten percent of the Dutch population aged 16 to 69 are problem drinkers, more men (17%) than women (4%).
Alcohol abuse and alcohol dependence •
According to dated data from the 1996 Netherlands Mental Health Survey and Incidence Study (Nemesis), eight percent of the Dutch population aged 18–64 met the diagnostic criteria for alcohol dependence or alcohol abuse (alcohol abuse 4.6% and alcohol dependence 3.7%). In
97
•
6.5
absolute numbers, 820,000 people annually were involved, approximately 4.5 times more men 28 than women. Alcohol abuse and dependence is most found among young men aged between 18 and 25; in 1996, eighteen percent met the criteria for alcohol abuse and thirteen percent met the criteria for alcohol dependence.8
USE: INTERNATIONAL COMPARISONS
General population •
•
In 2002, alcohol consumption in Western Europe varied from 4.9 to 11.9 litre per capita (see Figure 6.3). Compared with the other Western European countries, the Netherlands seems to take a low middle position. Per capita alcohol consumption here is determined on the basis of alcohol sales figures. There are considerable differences between individual countries as regards ‘unrecorded’ consumption, such as private import, ‘duty-free’ purchases, and homebrewn alcohol products. Consequently, the 105 figures cannot be compared completely.
Figure 6.3
Alcohol consumption levels in a number of EU Member States, measured per capita and in litres of pure alcohol. Survey year 2002
Luxembourg
11.9 10.8
Ireland Germany
10.4
France
10.3
Portugal
9.7
Spain
9.6 9.6
United Kingdom Denmark
9.5 9.2
Austria The Netherlands
8
Belgium
7.9 7.8
Greece Finland
7.7
Italy
7.4
Sweden
4.9
0
2
4
6
8
10
12
14
16
Source: Commodity Board for Distilled Spirits (PGD), Spirits Committee.
98
Young people The European School Survey Project on Alcohol and Other Drugs (ESPAD) carried out among pupils 43 aged 15–16 included questions about the level of alcohol use and the frequency of intoxication. • Table 6.4 portrays the consumption of alcohol in a number of EU countries and Norway. Belgium, Germany and Austria only participated in 2003. The United States did not take part in ESPAD, but conducted comparable research. • In 2003, the Netherlands was in the top section of the list in the measurement 'consumed alcohol forty times or more ever in life’. • The Netherlands had a leading position in the measurement 'consumed alcohol at least ten times in the month prior to the survey'. • Dutch figures on pupils were significantly lower in the measurement ‘intoxication’. Approximately one in eight pupils reported having been drunk at least twenty times ever in life. • Between 1999 and 2003, the percentage of pupils who had consumed alcohol 10 times or more increased in the Netherlands and Italy. This percentage decreased in Denmark. • Twenty times or more drunkenness ever in life only decreased in Denmark in 2003, whereas it remained stable in the other countries.
Table 6.4
Alcohol consumption and drunkenness among pupils aged 15 and 16 in a number of EU Member States, Norway and the United States. Survey year 2003
Country
Denmark Austria The Netherlands United Kingdom Ireland Germany Belgium Greece Italy France Finland Sweden Norway Portugal United States
Consumption: 40 Consumption: 10 Drunkenness: 20 times or more in times or more in times or more in life the last month life 1999 2003 1999 2003 1999 2003 59% 50% 18% 13% 41% 36% 48% 21% 21% 37% 45% 20% 25% 8% 6% 47% 43% 16% 17% 29% 27% 40% 39% 16% 16% 25% 30% 37% 11% 12% 36% 20% 7% 42% 35% 13% 13% 4% 3% 17% 24% 7% 12% 2% 5% 20% 22% 8% 7% 4% 3% 20% 20% 1% 2% 28% 26% 19% 17% 2% 1% 19% 17% 16% 15% 3% 3% 16% 14% 15% 14% 6% 7% 4% 3% 16% 12% 5% 4% 11% 7%
Percentage of the pupils. - = not measured. The United States did not participate in the European School Survey Project on Alcohol and Other Drugs (ESPAD), but conducted comparable research. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
99
6.6
TREATMENT DEMAND
Outpatient care organisations for addicts The National Information System on Alcohol and Drugs (LADIS) records how often people seek help from (outpatient) care organisations for addicts. (See in Appendix A: Client LADIS.) In 2003, 26,874 persons were registered at the (outpatient) care organisations for drug addicts with alcohol use as 106 primary problem. This is an estimated three percent of all the people showing alcohol abuse or alcohol dependence. • The absolute number of clients with a primary alcohol problem in the (outpatient) care organisations for drug addicts increased between 1994 and 1999 by twelve percent and stabilised in 2000 and 2001. After 2001, however, an increase is apparent (see Figure 6.4). In 2002, the number increased by seven percent and in 2003 by thirteen percent compared to 2001 and 2002, respectively. This increase may be the effect of the Alcohol Action Plan of the care organisations 107 for drug addicts of the Mental Health Service (GGZ Netherlands). • Characteristics of these clients in 2003 were: Most of them were men (75%). The percentage of women increased slightly in the last few years. The average age was 44. Two thirds of the alcohol clients were aged forty or over. This made the alcohol clients older than the drugs clients (see Figure 6.5). - A quarter of the registered clients in 2003 were newcomers, i.e. they had not been registered before for an alcohol-related problem at the (outpatient) care organisations for drug addicts. - Only ten percent were immigrants (for the definition see Appendix A). • Alcohol was indicated less often as a secondary problem. - For this group the primary problem was cocaine (43%), heroin (23%), or cannabis (17%). - The number of secondary alcohol clients has risen since 1997. In 2003, the number of secondary alcohol clients increased by twelve percent compared to the year 2002. • When comparing the period 2000-2003 to the period 1996-1999, an increase of the number of alcohol clients is apparent in Brabant, Limburg and the northern half of the Netherlands. The other regions show a decrease.
Figure 6.4
Number of clients in the (outpatient) care organisations for addicts for primary or secondary alcohol problems, from 1994
30000 25000 20000 15000 10000 5000 0 Primary
1994 1995
1996 1997 1998
1999 2000 2001 2002
2003
20085 20175 20939 21134 22378 22554 22365 22388 23849 26874
Secundary 2441 2473
2465 2622 2718
2847 3007 3945 4121
4631
Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
100
Figure 6.5
20
Age categories of primary alcohol clients in the (outpatient) care organisations for addicts. Survey year 2003
% 17 16 14
15
13 10
10
10 6 5 4
5
4
1 0 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64
>64
age (years) Source: National Information System on Alcohol and Drugs (LADIS), Organisation Care Information Systems (IVZ).
Self-help via internet On 23 November 2004, on www.MinderDrinken.nl a self-help site started for adult problem drinkers (18+) who wish to lower their alcohol consumption independently. In two weeks’ time, 11,000 unique visitors visited the site. Of those, 2,150 registered for the self-help program and 1,230 persons 108 effectively started using the interactive self-help module.
Inpatient care organisations for addicts There are no recent nationwide data about the treatment demand at the inpatient care organisations for addicts. In the near future these data will become available from Zorgis, the new information system for the umbrella organisation Netherlands Association for Mental Care (GGZ). Until 1997, the old registration system, the Patients Admission Tracking System for Intramural Mental Health Care (PiGGz) recorded the annual drug-related admissions in drug treatment clinics and drug units of psychiatric hospitals. • In 1996, the Register of Inpatient Mental Health Care (PiGGz) recorded nearly 6,200 admissions for problematic alcohol use, approximately the same order of magnitude as in the previous four years. • Alcohol dependence was diagnosed as the primary problem in over eight of ten admissions. Ten percent of the admissions occurred as a result of alcohol abuse and six percent because of alcohol psychosis, including Korsakov’s syndrome. • Treatment in which patients participate in inpatient programs of a hospital/clinic as outpatients (partial admissions) was limited, yet did increase until 1996.
101
General hospitals and incidents •
The number of clinical admissions in general hospitals with an alcohol-related disorder as primary diagnosis rose slightly between 1994 and 2003 (see Figure 6.6).
•
In 2003, 4,239 admissions took place with an alcohol-related disorder as primary diagnosis. The most common diagnoses related to: - alcoholic-related liver disease (29%, 1,245 admissions) - alcohol abuse (27%, 1,151 admissions) - alcohol dependence (17%, 719 admissions) - alcohol poisoning and toxic consequences of alcohol (14%, 610 admissions) - alcohol psychoses (10%, 412 admissions) Alcohol-related problems are more often diagnosed as a secondary problem. Between 1994 and 2003 the number of times that alcohol figured in secondary diagnoses rose (see Figure 6.6). In 2003, 10,899 alcohol-related problems were diagnosed as a secondary problem. In order of prevalence it concerned alcohol abuse (44%), alcohol dependence (23%), alcohol-related liver disease (14%), alcohol poisoning and toxic consequence of alcohol (9%) and alcohol psychoses (7%). The primary problems diagnosed for these secondary problems were: - accidents (other than poisonings, 26%) - digestive disorders (17%) - poisoning (15%) - heart and vascular diseases (7%) - respiratory illnesses and symptoms (5%) - psychoses (4%) A person can be admitted more than once in a given year. Moreover, more than one secondary diagnosis can be made per admission. Adjusted for double counts, 11,255 patients were admitted in 2003. They were admitted at least once that year with one (or more) alcohol-related problem(s) as primary or secondary diagnosis. The average age of these patients was 47 years, and 70 percent were men. It is probable that these figures are an underestimation, as hospitals quite often fail to recognise and record the role of alcohol as cause or the particular illness.
• •
•
•
•
d
d
In 2003, 415 day-treatment admissions for a primary alcohol diagnosis were also recorded.
102
Figure 6.6
Clinical admissions in general hospitals with an alcohol-related problem, from 1994 12000 10000 8000 6000 4000 2000 0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
3378
3531
3406
4011
4076
4079
3923
3880
4254
4239
Alcohol as secondary 7867 diagnosis
8677
8513
9973
9822
9652 10116 9949 10291 10899
Alcohol as primary diagnosis
Number of admissions, not adjusted for double counting of persons. ICD-9 codes: 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-3, 980.0-1, E860.0-2, E950.0*, E980.9* (*only included if 980.0-1 has been mentioned as complication.). For a definition of the codes: see Appendix C. The figures refer to alcohol-related secondary diagnoses. More than one secondary diagnosis per admission can be made. Source: National Medical Registration (LMR), Prismant.
The Central Ambulance Service of the Amsterdam Area Health Authority (GG&GD Amsterdam) keeps a record of the number of alcohol-related emergency calls. • In 2003, the ambulance services in Amsterdam recorded 1,733 alcohol-related trips, a decrease of 109 nine percent compared to 2002. - This was seven percent of all the urgent calls in Amsterdam. - Most of the persons were men (71%). - Over half the trips (54%) was for persons aged between 15 and 44. - Approximately half the patients (49%) were transported to a hospital emergency ward. In the other 51 percent of the cases, the ambulance staff gave first aid on the spot. e
According to the Injuries Information System (LIS) of Consumer and Safety , approximately 13,000 people receive emergency treatment in a hospital annually for injuries sustained in an accident, or as 110 a result of violence or self-harm involving alcohol (see Table 6.5). • Of the recorded victims 74 percent were men. • Ten percent were aged between 15 and 19 (which means 1,300 children annually), 27 percent were in the age group 20-29 and 41 percent were in the age group 30-49. Most of the treatments are in the age category 20-24 (15%). • Half the accidents occur in the private sphere, such as falling down under the influence of alcohol or due to alcohol poisoning. Traffic accidents account for the second largest number of injuries (particularly bicycle crashes). Next is self-harm, often involving a combination of alcohol with drugs and/or medicines (see Table 6.5). e
These figures are estimates for the entire country, based on data from a representative sample of hospitals.
103
• • • • •
Many victims sustain head injuries (40%). Other conditions requiring treatment are alcohol poisoning (26%), and shoulder, arm, or hand injuries (17%). Nearly one in three victims was hospitalised (32%). This is a higher percentage than that for all types of accidents combined (8%). Annually, approximately 40 victims die who received emergency aid for an alcohol-related accident. The direct costs of accidents involving alcohol amount to 22 million euros annually on average. These figures probably are an underestimation of the real number of alcohol-related accidents.
Table 6.5
Types of alcohol-related accidents treated in hospital emergency wards in the Netherlands (average figures over the years 1999 -2003)
Type of accident Private accident Traffic accident I Self-harm Act of violence Total
Number 6 400 3 100 2 200 800 ±13 000
Percentage 51 24 18 6 100
I. Such as suicide attempts with alcohol and licit drugs. Source: Injuries Information System of Consumer and Safety (LIS).
The LIS data show that annually approximately 1,300 children receive emergency aid after an accident involving alcohol. At the Leiden University Medical Center (LUMC) and at three hospitals in The Hague, all the patients were selected who, in the period 1999-2001, were younger than seventeen and who had been examined because of a blood alcohol concentration of at least 1.00 111 promille. • It concerned in total 88 children, 58 boys and 30 girls, with an average age of 15.4. • In 2001 it concerned 51 children. This number was higher than in previous years (19 and 18 in 1999 and 2000, respectively). In 2003, the Institute for Road Safety Research (SWOV) counted nearly 2,700 recorded casualties, f
both the hospitalised injured and outpatients, in which alcohol was involved (see Table 6.6). • The total number of alcohol victims in traffic has fallen slightly from 1997 onwards, both as regards fatalities and injuries (see Table 6.6). • In 2002, over eight in ten of the seriously injured (hospitalised) or dead were men. Nearly a quarter (23%) of these victims were men aged 18 to 24 incl.
Table 6.6
Number of traffic injuries and deaths as a result of alcohol use, from 1996
Severity of injury Death I Hospital II Emergency first aid III Lightly injured Total
1996
1997
1998
1999
2000
2001
2002
2003
97 1 204 1 048 1 064 3 413
103 1 188 1 012 1 106 3 409
83 1 154 962 1 127 3 326
92 1 166 939 1 152 3 349
87 1 129 911 1 113 3 240
72 1 036 876 1 000 2 984
97 1 096 702 945 2 840
71 1 028 596 992 2 687
I. Hospitalisations. II. Transported to a hospital, but received emergency help only. III. Not transported to a hospital. Source: Institute for Road Safety Research (SWOV) / Transport Research Centre (AVV).
•
f
The figures in Table 6.6 are an underestimation of the real figures, because not near enough all traffic accidents are recorded. In addition, the police often does not carry out alcohol breathalyser Figures overlap partly with those of the Injury Information System (LIS), Consumer and Safety.
104
•
•
tests when accidents have occurred. The Institute for Road Safety Research (SWOV) estimates that the actual number is nearly three times higher, caused by DUI. Provisional figures of the SWOV show that of all injured drivers who are hospitalised 35% had used alcohol and/or drugs: 13 percent consumed alcohol, 11 percent used several drugs and 11 112 percent of the drivers were found to have used a mix of alcohol and drugs. The percentage of DUI drivers decreased in 2003. Alcohol tests showed that 3.9 percent of the checked drivers had a blood alcohol level of over 0.5 promille. In 2002, this percentage was still 4.3. The largest proportion of offenders is found among those aged 25 and over. Noticeable is the decrease for men aged 18-24: from 4.1 percent in 2002 to 3.5 percent in 2003. However, women 113 aged 18-24 showed a slight increase compared to 2002 (from 0.5% to 0.8%).
The National Vaccine Information Centre (NVIC) of the RIVM provides information to physicians and 114 care providers about poisoning. • In 2003, approximately 1,700 requests for information were made in respect of alcohol intoxication, mostly through alcoholic drinks. • In most of the cases adults aged 18 to 65 incl. were involved. • In 76% of the cases it concerned a combination of alcohol with medicines, often intentional autointoxication. • The number of requests for information about alcohol intoxications in young people aged 13 to 17 incl. increased by 63%, from 57 requests in 2002 to 93 in 2003. Alcohol intoxications in young 111 people are usually the result of drinking distilled spirits with friends.
6.7
ILLNESS AND MORTALITY
Illness One to two units of alcohol per day for women and two to three units per day for men usually do not 115-118 present a risk for one’s health. • Moderate alcohol consumers are less likely to contract coronary heart disease than complete abstainers or heavy drinkers. This may be linked with an increase in the 'healthy' cholesterol type HDL-C (high density lipoprotein cholesterol). • Moderate alcohol consumers also are less likely to suffer a cerebral infarct. Among people aged over 55, moderate alcohol consumption may reduce the risk of dementia due to blood circulation in the brain. • There are indications that premature deaths are less likely to occur among light to moderate alcohol users than among abstainers or heavy drinkers. Moreover, moderate alcohol users feel 119 healthier. 115;116;120
However, the harmful consequences of excessive alcohol use are plentiful. • Life style factors may lead to a considerable number of years spent without good health, resulting in loss of quality of life. Excessive alcohol consumption is the main determinant of loss of quality of 121 life. • Nearly 12.5 percent of the burden of disease for men and 2.3 percent of the burden of disease for women may be blamed on excessive use of alcohol. 120
Excessive alcohol consumption increases the risk of various forms of cancer. • The consumption of two or more glasses of alcohol a day increases the risk of oral and throat cancer and a specific type of cancer of the oesophagus. The combination of drinking and smoking increases this risk.
105
• • •
There are very clear indications that the consumption of alcohol leads to a slight increase in the risk of breast cancer, i.e. 7 to 9 percent with each glass of alcohol per day. There are clear indications for an increase in the risk of intestinal cancer, but only in case of consumption of three or more glasses a day. There are also clear indications that alcohol consumption increases the risk, but only after cirrhosis of the liver had already been caused.
Excessive alcohol consumption also increases the risk of cardiovascular diseases and damage to the 115;116 brain and the nerves. • Daily alcohol consumption of five glasses or more increases the risk of damaging the coronary arteries. • The consumption of more than two glasses daily also increases the risk of strokes or cerebral infarctions. This only applies to so-called ‘hemorrhagic’ cerebral infarctions. • Prolonged and excessive alcohol use (more than eight units per day) may cause polyneuropathy (damage to motor nerves, sensory nerves or both), brain shrinkage, and damage cognitive functions (learning, memory, concentration and so forth). • Binge drinking, i.e. consuming large amounts of alcohol in a short period, increases the risk of heart and vascular diseases, acute kidney failure and brain damage.
Mortality The number of alcohol-related deaths has increased slightly over the past years. • According to the Cause of Death Statistics of Statistics Netherlands (CBS), nearly 1,900 people died in 2003 from causes in which alcohol was explicitly stated, over forty percent more than in 1995 (see Figure 6.6). • Between 2001 and 2003, the number of deaths for which alcohol was stated as primary cause of death decreased somewhat and the number of deaths for which alcohol was stated as secondary cause of death increased slightly. In total the number of cases increased by 5 percent in this period. • Dependency and other mental disorders due to the use of alcohol were the leading causes of death: 61 percent, followed by alcohol-related liver diseases, 33 percent. • The highest number of deaths as a result of the use of alcohol occurred in the age group 50-65 (see Figure 6.8). Most of the deceased were men (75% on average). • Alcohol use as a contributing factor to the death is not always recognised. Consequently, these figures do not reflect reality entirely. • Based on epidemiological research, for example, 4 to 6 percent of cancer-related deaths is estimated to be connected with chronically excessive alcohol consumption. This would mean that there were between 1,500 and 2,300 alcohol-related deaths associated with cancer in 2002, 122;123 instead of the 150 cases recorded. • In 2003, 71 traffic deaths involving alcohol were recorded (see Table 6.6). However, the real number of alcohol-related traffic deaths is estimated at 250. • Alcohol is the fourth leading cause of death of all 'lifestyle factors', after smoking, physical inactivity 124 and bad eating habits.
106
Figure 6.7
Alcohol-related mortality, from 1995 Numberl
2000 1800 1600 1400 1200 1000 800 600 400 secundary primary
1995 1996 1997 1998 1999 2000 2001 2002 2003 669 663
705 690
710 686
750 744
774 783
809 820
888 906
928 826
1090 796
Number of deaths. 1995: ICD-9 codes 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-3, 980.0-1, E860.0-2, E950.9*, E980.9* (* only included if 980.0-1 has been mentioned as complication .) From 1996-2003: ICD-10 codes F10, G31.2, G62.1, I42.6, K29.2, K70.0-4, K70.9, K86.0, X45*, X65*, Y15*, T51.0-1 (* only included if T51.0-1 has been mentioned as complication). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
107
Figure 6.8
Alcohol-related mortality among males and females by age category. Survey year 2003
350
300
250
200
150
100
50
0
<40
40-45
45-50
50-55
55-60
60-65
65-70
70-75
75+
female
20
28
55
81
78
61
48
40
66
male
54
89
145
214
206
214
172
128
187
Number of deaths. ICD-10 codes: F10, G31.2, G62.1, I42.6, K29.2, K70.0-4, K70.9, K86.0, X45*, X65*, Y15*, T51.0-1 (* only included if T51.0-1 has been mentioned as complication). For a definition of the codes: see Appendix C. Source: Cause of Death Statistics, Statistics Netherlands (CBS).
6.8
SUPPLY AND THE MARKET
Alcohol can be easily obtained in groceries, supermarkets, off licences and hotel and catering establishments. The (Dutch) Licensing and Catering Act prohibits the sale of low alcohol beverages to young people under the age of sixteen. For high alcohol beverages, the minimum age limit is eighteen years. A 2003 survey shows that, despite these legal provisions, pupils have no problem in buying 103 alcohol. ). . • In the past month, 18 percent of young people aged 14 and 15 bought low alcohol beverages in hotels or catering establishments and 12 percent in groceries or supermarkets (see Table 6.7). • Strong alcoholic beverages are bought less often. In the past month, 8 percent of the group aged 16 and 17 bought strong alcoholic beverages in hotels or catering establishments and another 8 percent in off licences. • The probability that young people under the age of sixteen succeed in buying alcoholic beverages turns out to be 90 percent or higher in both hotels and catering establishments and in groceries and supermarkets. Nevertheless, approximately 90 percent report they always observe the age limits.
108
Table 6.7
Percentage of young people who succeeded in buying weak and strong alcoholic beverages at various sales outlets in the past month. aged 13
Weak alcoholic beverages
Strong alcoholic beverages Source: Intraval.
•
hotel and catering establishments off-licence grocery and supermarket hotel and catering establishments off-licence
1.8
aged 14 and 15 18.4
aged 16 and 17 -
0.6 4.1
2.6 12.2
-
0.4
1.3
7.9
0.1
1.5
8.1
103
At ten percent of the workplaces of the labour force, alcohol is for sale in the canteen or the company restaurant. Thirty-four percent report that alcohol is occasionally available otherwise at the workplace, e.g. in the refrigerator or brought by a colleague. Eleven percent report that at least 97 once a week a gathering is organised where alcohol is served.
Excise duty • • • • •
• •
Effective 1 April 2002, the excise duty on beer was raised by eighteen percent and that on wine by 125 21 percent. The proceeds were used for lowering excise duties on soft drinks by 39 percent. Effective 1 January 2003, the excise duty on distilled spirits was also raised by eighteen 126 percent. Excise duty on one litre of distilled spirits (35 percent proof) is 6.2 euros, on a litre of wine 59 euro 95;96 cents and on a litre of beer 25 euro cents (see Table 6.8). This represents an increase of six euro cents for a 0.25 litre glass of beer or a 0.1 litre glass of wine, and 22 euro cents for a 0.035 glass of distilled spirits. EU Member States have different tax policies. Tariffs vary considerably between individual countries. For example, on a litre of distilled spirits (35 percent proof) an excise duty of three euros is levied in Italy, compared with nineteen euros in Sweden (see Table 6.8). Seven wine-producing countries levy no duties at all on wine. Table 6.8 shows that Dutch excise duty tariffs are in the medium range.
109
Table 6.8
Excise duty tariffs on alcoholic beverages in a number of EU Member States per hectolitre. Survey date December 2003 - spring 2004.
Member State Sweden Ireland Finland United Kingdom Denmark The Netherlands Belgium France Germany Luxembourg Austria Greece Portugal Spain Italy
Beer 81 99 143 97 47 25 21 13 9 10 25 14 15 10 17
I
II
Wine 242 273 235 253 95 59 47 3 0 0 0 0 0 0 0
Distilled spirits 1 932 1 374 989 972 707 621 581 508 456 364 350 331 314 259 256
III
Amounts in euros per hectolitre consumption. I. 5 volume percent alcohol; survey date December 2003. II. 11 volume percent alcohol; survey date December 2003. III. 35 volume percent alcohol; survey date spring 2004. Sources: Commodity Board for Distilled Spirits (PGD), Commodity Board for Wine, Central Brewery Agency, European Commission.
110
7
TOBACCO
Tobacco is made of the dried leaves of the tobacco plant (Nicotiana). Tobacco is usually smoked in the form of a cigarette or cigar or in a pipe and rarely sniffed or chewed. Consumers experience tobacco as having a stimulating (improvement of capacity to concentrate) and calming effect. Nicotine, the main psychoactive ingredient, is addictive. Regular use results in habituation and tolerance. During inhalation of tobacco smoke various substances are released, such as nicotine, tar and carbon monoxide, and many more products that are harmful to one’s health.
7.1
LATEST FACTS AND TRENDS
The main facts and trends regarding tobacco in this chapter are: • The percentage of smokers in the general population fell slightly from the early nineties to 2001. Between 2001 and 2003, the percentage of smokers remained stable (see Chapter 7.2). • The percentage of heavy smokers decreased between 2000 and 2003 (see Chapter 7.2). • The proportion of smokers among pupils dropped between 1999 and 2003 (see Chapter 7.3). • In respect of smoking among pupils, the Netherlands were in the middle range in the EU (see Chapter 7.5). • Lung cancer mortality was still declining among men, but continued rising among women (see Chapter 7.6).
7.2
USE: GENERAL POPULATION
Smoking — particularly among men — was quite common in the sixties and seventies. This was followed by a considerable decline in the late sixties that lasted up until the early nineties. Since then, this decline has levelled off. • Surveys of the Dutch Institute for Public Opinion and Market Research (TNS NIPO) may point at a decrease in the number of smokers from 2000 (see Table 7.1), but because of a change in the 127 manner of research, this is not certain. • The TNS NIPO figures indicate a decrease in smoking conduct from 30 percent in 2003 to 28 128 percent in 2004. Figures of the National Prevalence Research also show a downward trend. In 1997, 33 percent of the Dutch population aged 12 and over had smoked in the month prior to the 10 survey. In 2001 this had dropped to 30 percent. • According to the TNS NIPO, in 2003, 30 percent of Dutchmen aged 15 and over were smokers. In 127 that year, 29 percent were ex-smokers and 41 had never smoked. • Extrapolated over the entire population, nearly four million people smoked. - The gap between men and women narrowed (see Table 7.1). Nevertheless, there were still differences in the smoking behaviour of men and women. Women smoked fewer cigarettes per day than men. They preferred light filter cigarettes to hand-rolled cigarettes. - Smoking was highest in the group aged 35 to 49 incl. (see Figure 7.1). • Approximately 1.6 percent of the population quit smoking each year. An equal number of people started smoking. These new smokers included a relatively high number of young people under the age of 19, people with a low level of education, and women aged 30 to 34. This latter group included women who stopped smoking during pregnancy and took it up again after the 129 pregnancy.
111
Table 7.1 Actual smokers in the Netherlands among men and women aged 15 and over, from 1970 Year 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 I 2001 2002 2003
Men 75% 66% 52% 43% 39% 39% 39% 37% 37% 37% 37% 33% 34% 33%
Women 42% 40% 34% 34% 31% 31% 32% 30% 30% 31% 29% 27% 28% 27%
Total 59% 53% 43% 39% 35% 35% 35% 33% 34% 34% 33% 30% 31% 30%
Percentage of smokers. I. In 2001, the research method was changed: from a personal interview with a poll-taker at home, to completing a questionnaire via a modem or the internet. This change may affect the outcomes. Source: Defacto, for a smoke-free future (previously STIVORO), the Dutch Institute for Public Opinion and Market Research (TNS NIPO).
Figure 7.1
50
Percentage of smokers in the Netherlands by age group and gender. Survey year 2003
% men 40
37
40
31 30
women 34
26 26
31 25
20
16 15
10 0 15-19
20-34
35-49
50-64
>64
age (years) Source: Defacto, for a smoke-free future (previously STIVORO), the Dutch Institute for Public Opinion and Market Research (TNS NIPO).
According to Statistics Netherlands (CBS), the percentage of heavy smokers has decreased over the past years. • In 2003, eight percent of the population aged 12 and over smoked at least twenty cigarettes on average per day (9.6% of men and 6.9% of women). In 2000 this was still ten percent (10,4% of the 92 men and 8.7% of the women).
112
• Relatively many heavy smokers live in North-Brabant and the four big cities, with exceptionally 130 many living in and around the regions The Hague, Nieuwe Waterweg North and Eindhoven. Although the number of smokers had decreased in the seventies, an increase in the level of tobacco consumption per smoker was noted. Since the eighties, the average number of cigarettes or handrolled cigarettes smoked per day fluctuated around 20. • In 2003, almost 30 billion cigarettes and hand-rolled cigarettes in the Netherlands literally went up in smoke (see Table 7.2). 127 • Hand-rolled cigarettes dropped in popularity since 1990, compared to manufactured cigarettes.
Table 7.2
Consumption of manufactured and hand-rolled cigarettes in the Netherlands, from 1967
Year
Cigarettes (billion)
1967 1970 1975 1980 1985 1990 1995 2000 2001 2002 2003
16.6 18.7 23.9 23.0 16.3 17.3 17.2 16.7 16.3 16.9 17.0
Hand-rolled cigarettes (billion) 9.1 9.9 13.1 13.9 17.8 16.6 14.4 13.7 12.4 13.2 13.1
Total (billion) 25.7 28.6 37.0 36.9 34.1 33.4 31.6 30.4 28.7 30.1 30.1
Average tobacco sales per smoker per I day 12.9 14.0 18.6 21.3 20.7 22.4 20.1 19.9 20.1 20.5 20.9
I. Average number of cigarettes or hand-rolled cigarettes. Source: Defacto, for a smoke-free future.
7.3
USE: YOUNG PEOPLE
The percentage of young people who smoke has dropped in the last few years. • According to the Dutch National School Survey, the percentage of pupils that had ever smoked en the percentage that had smoked in the past month dropped between 1999 and 2003 (see Figure 7.2). • The figures of the TNS NIPO survey show that the percentage of recent smokers among young people aged 10-19 was stable from 1992 to 2002 incl. (between 27% and 31%). In 2003 the 127 percentage of recent smokers in this group of young people dropped to 24%.
113
Figure 7.2
Smoking among school-aged youths aged 12 and over, from 1988
% 65 59 55
55
55
55 45 45
35
30 27
26 25
23 20 Ever
Current
15 1988
1992
1996
1999
2003
The percentage of smokers ever in their lifetime and in the month before the survey (current). Source: National Representative School Survey, Trimbos Institute.
People begin to smoke at an early age. • In 2003, eleven percent of the pupils in the two highest groups of elementary school had smoked ever in their lives. Of pupils of ‘regular’ secondary schools, 45 percent had smoked ever in their lives. These figures are an average: the percentage increases with the age of the pupils (see 16 Figure 7.3).
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Figure 7.3
70
Smoking according to age among pupils aged 10 and over. Survey year 2003
% 63
60
60
55 49
50 40
35
32
30
28
30
23
20
20 12
11 6
10
ever
1
current
0 PE
12 yr
13 yr
14 yr
15 yr
16 yr
17-18 yr
Percentage of smokers ever (in lifetime) and current (last month). PE = primary education. Source: National Representative School Survey, Trimbos Institute.
• •
•
One fifth (20%) of secondary school pupils had smoked as recently as in the last month, while nine percent smoked daily. These percentages also increase with age. Nearly one third in the highest age group (16 years and over) were current smokers, compared to six percent in the group aged 12 and twelve percent of the group aged 13. Approximately an equal numbers of boys (18%) and girls (22%) had smoked in the past month.
Level of smoking •
•
It is known how much the current smokers among pupils smoked on average per day. For one third (34%) it was less than one cigarette and for a quarter of this group it was more than ten cigarettes per day. Nine percent of the pupils smoked daily. More than one third of this group (36%) smoked over ten cigarettes per day.
Regional dispersion In the last few years, numerous local and regional surveys have been conducted commissioned by municipalities. In Appendix F we give an overview of recent figures concerning the use of tobacco among young people in 28 towns, cities or regions in the Netherlands based on representative samples from the population. These figures provide a picture of the surveys that are conducted throughout the country. Due to methodological differences, in particular in age groups, it is complicated to make comparisons, but, nevertheless, the figures give an impression of the difference in tobacco use between the various towns and cities. In the age group of 18 to 23 incl., for example, 17 percent in Leiden smoked daily compared to 35 percent in Almelo.
115
Availability of tobacco Since 1 January 2003, pursuant to the amended Tobacco Act it has been forbidden to sell tobacco products to young people younger than 16. • The number of young people aged 13-15 who sometimes buy tobacco products dropped between 131 1999 and 2003 from 26 to 9 percent. • Of those who sometimes buy tobacco products, 56 percent reported in 2003 that they bought the products for themselves, whereas this was still 43 percent in 1999. • They bought the tobacco products in four kinds of sales outlets: specialised tobacco shops (46%), groceries or supermarkets (50%), petrol stations (42%) and hotels or catering establishments (31%). The trend is to buy more in shops for tobacco products. • The chance for a person younger than 16 to succeed in buying tobacco products was, just as in 1999 and 2001, 90 percent or higher. Nevertheless 93 percent of the outlets claimed never to sell 131 tobacco products to people younger than 16. Another survey found that, after the implementation of the amended Tobacco Act that forbids this, 84% of the smokers under the age of 16 personally bought cigarettes at least once. Only 13% of them were asked for their age or a 132 remark was made to them about it by the salespeople.
Special groups Smoking was considerably more prevalent among young clubbers and adolescents than among 17;18;104 pupils. • 46, 37 and 70 percent of the visitors of Amsterdam pubs (2000), trendy clubs (2003) and coffee shops (2001), respectively, were daily smokers. • The daily smokers among the visitors of pubs and coffee shops smoked an average of 14 to 16 manufactured or hand-rolled cigarettes per day; 20 to 36 percent smoked more than one pack a day (at least 20 manufactured or hand-rolled cigarettes). • Between 1995 and 2003, the percentage of visitors of trendy clubs that ever smoked remained stable (87% in 2003). The percentage that had smoked in the past year dropped from 77% in 1998 to 68% in 2003. The percentage that had smoked in the past month in this period dropped from 67% to 55%.
7.4 •
•
PROBLEM USE A clear indication of the extent to which smokers consider their use problematic is the desire to quit smoking. In 2003, 8% of the smokers in the Netherlands stated they wanted to stop smoking within a month, 9% within six months, 8% within a year and 14% said they wanted to stop smoking 133 at one time in the future. In scientific circles, the term ‘nicotine dependence’ is sometimes preferred to ‘tobacco addiction’. The level of dependence can be measured with the Fagerström Test for Nicotine Dependence, a scale ranging from zero to ten (10 = severe nicotine dependence). – Research showed that, in 1997, the result for Dutch smokers on this scale was 3.0 on average, 134 compared to 4.3 for American smokers. – Men scored higher on average than women. – Smokers who sought help with smoking cessation were more successful on average than smokers who did not seek assistance.
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7.5
USE: INTERNATIONAL COMPARISONS
The proportion of smokers among the population of EU Member States varies greatly, although the comparability of the figures is doubtful. For example, some countries define the term ‘smoker’ and age groups differently (see Table 7.3). Many countries understand this to mean daily smokers, whereas the Netherlands defines ‘smokers’ as people who ‘smoke daily or occasionally’. • According to the most recent figures, of the compared countries, Portugal had the lowest number of smokers, and Greece — together with Germany — the highest number. • With the exception of Sweden and Norway, more men than women smoked. In Portugal this difference was largest.
Table 7.3
Smokers among adults in several EU Member States, Norway and Switzerland
Country
Year
Men
Women
Total
Criterion for smoking
2000 2002 2000 2002 2000 2000 2002
Age (year) 18+ 15+ 20-54 15-64 18+ 18+
Belgium Denmark Germany Finland France Greece Ireland
36% 31% 40% 27% 33% 47% 28%
26% 27% 32% 20% 21% 29% 26%
31% 28% 36% 23% 27% 38% 27%
Italy Luxembourg The Netherlands Norway Austria Portugal
1999 2000 2003 2001/2002 2000 1995/1996
14-65 15+ 15+ 16-74 19+
32% 34% 33% 30% 29%
17% 27% 27% 30% 6%
25% 32% 30% 30% 29% 17%
Spain United Kingdom Sweden Switzerland
2001 2002 2000/2001 2000
16+ 16+ 16-84 14-65
39% 27% 17% 37%
25% 25% 21% 29%
32% 26% 19% 32%
daily daily daily or regularly daily regularly or occasionally daily regularly daily daily or occasionally daily daily in the past two weeks daily current smokers daily regularly or occasionally
Percentage of smokers. - = not measured/unknown. Source: World Health Organisation (WHO) 127 Netherlands: Defacto, for a smoke-free future (previously STIVORO).
135
, for the
The European School Survey Project on Alcohol and Other Drugs (ESPAD) (see Appendix B) enables comparison of the smoking behaviour of secondary school pupils aged thirteen and sixteen. Figure 7.4 43 gives figures for the percentage of pupils who smoked in the past month. • Of the compared countries, Austria had the highest number of smokers among secondary school pupils and Sweden the lowest. 132 • The Netherlands were in the middle range. • In most of the countries, more girls smoked than boys.
117
Figure 7.4
Smokers among secondary school pupils aged 15 and 16 in several EU Member States, Norway and Switzerland. Survey year 2003
49
Austria
48
56
45 46
Germany
43 38
Finland
35
Italy
35
41
38 40
34 34 33
Switzerland
33
France
31
36
33
Ireland
28
37
32 33 32
Belgium
31 31 32
The Netherlands Denmark
27
30 32
29
United Kingdom
34
25 28
Greece
27
30
28
Norway
24
32
28 27 28
Portugal
27
Spain
22 23
Sweden
20
0
10
20 Boys
31
26
%
30 Girls
40
50
60
Total
Percentage that smoked in the past month. Source: European School Survey Project on Alcohol and Other Drugs (ESPAD).
• •
More than a quarter of Dutch pupils (27%) reported to have smoked more than forty times in their lives. This percentage varied from 18% in Portugal to 42% in Austria. In October 2004, the European Network for Smoking Prevention (ENSP) published a report about 136 the effects of the Tobacco Control Policy in 28 European countries. This report showed how each country scored on six cost-effective interventions that may lead to a reduction of tobacco consumption: the price of tobacco articles, a smoking ban in public spaces and placed of work, the height of the budget for the Tobacco Control Policy, a prohibition of advertisements for tobacco articles, warnings on tobacco articles and the availability of treatments to stop smoking. For the six interventions taken together, the Netherlands reached the seventh place among these 28 European countries. The date of this survey is 1 January 2004.
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7.6
TREATMENT DEMAND
Treatment mainly involves self-help and seeking help from the general practitioner. The care organisations for addicts occasionally offer smoking cessation programs, albeit not on a large scale. • Approximately two thirds of all smokers who attempt to stop smoking do so without any means of help. The remainder attend courses, seek advice from their GP, use nicotine substitutes (plasters, chewing gum, lozenges), undergo acupuncture or hypnosis, etc.. The main reason for attempting 137 to stop smoking is for health reasons. • In the recent past, the antidepressant bupropion (Zyban®) was registered in the Netherlands as a non-nicotine aid for smoking cessation. According to IMS Health, in 2001, 2002 and 2003, bupropion was prescribed 80,000, 70,000 and 73,000 times by physicians. This adds up to a total of 3.0, 2.7 and 2.7 million tablets, respectively. The demand seems to be stabilising. • The market of nicotine substitutes – plasters, chewing gum and lozenges – doubled in 2004 compared to 2003 to a total turnover of 16.7 million euros. This indicates a considerable increase in attempts to stop smoking. • People who wish to stop smoking can ask their general practitioner for advice. In 2003, an estimated 65,000 men and 65,000 women consulted their GP about how to stop smoking. Most of 138 them were aged 40-60. The Minimal Intervention Strategy (MIS) has proven an effective protocol for general practitioners, nurses and cardiologists to stimulate smoking patients to stop 139 smoking. • The Counselling Centre of STIVORO also supports people who wish to stop smoking. In 2003, 1,118 people registered for coaching by phone and more than 8,000 coaching discussions took 127 place. • Towards the year 2004, STIVORO held an intensive stopping campaign called ‘Nederland Start Met Stoppen’ [The Netherlands Starts Stopping]. This campaign contributed to the attempts of over 1 million smokers to stop smoking around 1 January 2004. In December 2004, 24 percent of 128 these people had not returned to smoking. Usually, five to ten percent of those who have 140 stopped persevere a year in doing that. As most important reason to stop is given the increase in excise duty on tobacco. In 2003, besides a nationwide campaign, STIVORO conducted also a 127 campaign about passive smoking and smoking at the workplace. • End 2004, an official guideline of the Dutch Institute for Health Care Improvement (CBO) for the treatment of tobacco addiction was published. In this guideline, the approach of smoking patients 141;142 in medical practice is discussed and the effectiveness of various treatments is descibed. The demand on the health care system for problems caused or aggravated by smoking is of entirely different proportions. The number of hospital admissions for illnesses related to smoking amounted to 143 nearly 100,000 in the early nineties. Recent figures are not available.
7.7 • • • • •
MORTALITY Smoking is the leading cause of premature death in the Netherlands. In 2003, over 20,000 people died in the Netherlands from the direct consequences of smoking. In 2002, the direct mortality from smoking was estimated at 20,175 and in 2003 at 20,141 deaths. 144 In 2000, this number was still 20,718 deaths. Of all deaths in the Netherlands in 2003, approximately 14 percent was due to smoking (20% of the men and 8% of the women). Smoking is connected with cardiovascular diseases, pulmonary diseases and cancer. Table 7.4 shows that lung cancer is mainly caused by smoking: in 74 percent (women) to 91 percent (men) of all the cases in 2003.
119
•
The actual mortality from smoking may be higher, because the effects of passive smoking were 145;146 not taken into account. It is unclear, however, to what extent passive smoking leads to death.
Table 7.4
Mortality from a number of illnesses among men and women aged 20 and over. Survey year 2003
Illness Lung cancer Chronic obstructive pulmonary disease (COPD) Coronary heart disease Stroke (cerebrovascular disorder) Heart failure Oesophageal cancer Cancer of the larynx Cancer of the oral cavity Total
Total mortality Men 6 156 3 870
Women 2 706 2 661
Mortality from smoking Men Women 5 627 2 002 3 264 1 819
8 895 4 529
6 638 7 053
2 577 958
865 704
2 538 971 200 358
3 849 376 39 202
461 771 157 330
224 235 32 115
27 517
23 524
14 145
I
5 996
I
I. Per disorder first rounded off to whole numbers and subsequently added up. Source: National Institute of Public Health and the Environment (RIVM), Statistics Netherlands (CBS).
As a result of the decline in smoking among men between 1960 and 1990, lung cancer mortality in men has dropped. However, this trend is reversed in women who have started to smoke more. In 2000 and 2002, fewer deaths from lung cancer in men were reported than in previous years (see Table 7.5). • The rising curve in the number of deaths from lung cancer in women is bound to continue for 147 several decades to come. • The opposing trends in men and women balance each other out. As a result, the total number of deaths from lung cancer has remained stable for years.
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Table 7.5 Year 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Mortality with lung cancer as primary cause of death among people aged 15 and over, from 1985. Deaths per 100,000 inhabitants Men 127 130 127 128 123 117 118 117 115 113 112 109 108 106 105 99 100 96 95
Women 16 17 17 19 20 20 20 22 24 26 27 28 29 30 33 34 35 39 40
Total 71 72 71 72 70 67 68 69 69 68 69 68 68 68 68 66 67 68 67
1985-1996: ICD-9 code 162, from1996: ICD-10 codes C33-34 (see Appendix C). Source: Cause of Death Statistics, Statistics Netherlands (CBS).
7.8 • •
•
SUPPLY AND THE MARKET
From 1 January 2004, employers have been obliged to guarantee their staff a non-smoking 148 workplace. From that date it has also been forbidden to smoke in public transport. In 2003, 46% of the rolling tobacco was sold in the general groceries and supermarkets, 22% in specialised tobacco shops, 21% in petrol stations, 5% in hotels or catering establishments and 6% elsewhere. Of the cigarettes 36% were sold via the general groceries and supermarkets, 6% via hotels or catering establishments, 25% via specialised tobacco shops, 24% via petrol stations and 149 9% via other channels. This does not include sales from cigarette vending machines. From 1 February 2004, the price of a pack of cigarettes in the most popular price class has been € 4.60, including € 2.63 excise duty and € 0.73 VAT. A 50-gram pack of rolling tobacco costs also 149 € 4.60, including € 2.08 excise duty and € 0.73 VAT (see Table 7.6).
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Table 7.6
Price of cigarettes and tax burden, from 1970. Survey date: February 2004
Year 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Price 0.86 1.02 1.36 1.88 1.97 2.56 2.61 2.79 2.93 3.04 3.15 3.43 3.54 3.54 4.60
Tax burden 0.60 0.68 0.98 1.35 1.37 1.84 1.87 2.01 2.11 2.19 2.27 2.50 2.58 2.63 3.36
Tax burden in % 69% 67% 72% 72% 70% 72% 72% 72% 72% 72% 72% 73% 73% 74% 73%
Price and tax burden in euros per pack of 25 cigarettes. Tax burden includes excise duty and VAT. Source: Tobacco Manufacturers’ Association Netherlands (SSI).
The excise duty imposed on tobacco products varies considerably between individual Member States of the European Union. • In the 15 old EU Member States the excise duty is highest in the United Kingdom and lowest in Spain (see Table 7.7). In the 15 old EU Member States the excise duty is highest in the United Kingdom and lowest in Spain (see Table 7.7).
Table 7.7
Prices on cigarettes and tax burden in several EU Member States. Survey date 1 May 2004
Country United Kingdom Ireland France Sweden Finland Denmark Germany The Netherlands Belgium Austria Greece Luxembourg Portugal Italy Spain
Price 8.25 7.65 6.25 5.16 5.00 4.97 4.74 4.60 4.45 3.75 3.13 3.10 2.75 2.58 2.44
Excise 5.35 4.74 4.00 2.57 2.88 2.70 2.86 2.63 2.54 2.14 2.82 1.81 1.70 1.50 1.41
VAT 1.23 1.33 1.02 1.03 0.90 0.99 0.65 0.73 0.77 0.63 0.48 0.33 0.44 0.43 0.34
Excise+VAT 6.58 6.06 5.02 3.60 3.78 3.69 3.52 3.36 3.31 2.76 3.30 2.14 2.14 1.93 1.75
Price, tax burden and VAT in euros per pack of 25 cigarettes. Source: European Committee.
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8
RECORDED DRUG CRIME
At the heart of the Dutch drug policy is the public health aspect. In addition, the Dutch drug policy aims also to reduce the harm caused to society by substance abuse: nuisance, crime and public order problems. The Minister of Justice is responsible for criminal enforcement and the social rehabilitation of offenders. The supply of drugs is combated by means of investigation, prosecution, and the adjudication of the suspects involved in the production, (international) drug trafficking, and possession of drugs. Drug treatment and counselling is made available for drug using offenders while in detention with the aim to improve their situation and therefore reduce crime and nuisance. This chapter provides a statistical overview of the nature and scope of the recorded drugs crime and the penal response. Drug crime is made up of two components:
•
Drug law violations: as set out in the respective drug laws (Opium Act, Misuse of Chemicals Prevention Act), or offences connected with drug law violations (e.g. organised crime, money laundering, etc.).
•
Crimes by drug users: crimes committed by drug users. It should be noted that there is no persuasive evidence of a causal connection between drug use or addiction and crime: drug use or addiction need not necessarily precede crime. When drug users violate drug laws, an overlap between both crime components is involved. In this chapter we shall report about recorded drug crime, to be exact: the crime recorded when a suspect is arrested and booked. This is the crime that has been recorded and solved. The ratio of drug crime in the volume of all recorded crime (in addition to solved crime, this also included crime that has been recorded but has not been solved) and in the volume of all crime (both recorded and unrecorded) is not examined here. Results can therefore not just be applied to the volume of total drug crimes. The figures in this chapter express to some degree the efforts of the police and the criminal justice system in fighting drug crime. The data cover the years 1999 to 2003 incl. as much as possible. Where possible, a distinction is a
made between hard and soft drug cases. Appendix B contains a list of sources used in this chapter. For further information we refer to www.trimbos.nl/monitors. Not all the data are of a good quality. This problem has been discussed 2;3 151;152 before. Especially data about seized drugs must be interpreted with caution. In addition, based on the current data, the existence of addiction of individuals cannot be determined exactly in files of the police and the criminal justice system. In this chapter we use, therefore, the term “drug user” or 3 “problem user of drugs” to indicate a possible addiction problem with the persons concerned. In the text, details about the quality of the used sources are specified.
a
Most figures relate to drugs as defined in the Opium Act, which means: not to alcohol and tobacco. An exception is formed by the figures of the probation and after-care service, in which the type of substance has not been specified.
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8.1
LATEST FACTS AND TRENDS
The main facts and trends regarding drug crime in this chapter are:
•
•
• •
8.2
Offences under the Opium Act added more to the workload of the criminal system in 2003 than in 2002; this also applied to all the phases of the criminal process. - In 2003 more suspects were booked for offences under the Opium Act than in 2002. Most of those offences were still related to hard drugs (see Chapter 8.2.1). - Two thirds of the number of investigations into organised crime concerned violations under the Opium Act: this is more or less the same as in 2002 (see Chapter 8.2.2). - The number of cases taken in by the Public Prosecutions Department continued to increase (see Chapter 8.2.2). - In 2003, the Courts handled significantly more cases of violations under the Opium Act than in 2002 (see Chapter 8.2.5). - The number of imposed community sentences and confiscation orders in cases under the Opium Act increased strongly in 2003 (see Chapter 8.2.6). - The number of unsuspended custodial sentences in Opium Act cases increased also in 2003. This increase was due to hard drug cases (see Chapter 8.2.7). - In terms of detention years, of the custodial sentences imposed in criminal cases, an increasing proportion concerned drug cases (see Chapter 8.2.7). - Offenders under the Opium Act repeated the offence more often than other offenders (see Chapter 8.2.8). Criminal drug users increased the work load of the criminal system to about the same extent as in 2002. - In 2003, the police recorded over ten thousand suspects as “drug users”. Of this group more than 70 percent had a criminal record showing over ten offences (see Chapter 8.3.1). - Over 70% of the ‘very high rate’ frequent offenders are regular hard drug users (see Chapter 8.3.2). In 2003, in general more activities of the Netherlands (Drug) Rehabilitation Foundation were recorded in the criminal system (see Chapter 8.4.1). The number of compulsory admissions in the Judicial Treatment of Addicts (SOV) rose steadily in 2003 (see Chapter 8.4.3).
RECORDED DRUG CRIME
In this paragraph we shall describe the nature and volume of the recorded drug law violations specifically with respect to the Opium Act - and the profile of the drug offenders. This is done along the criminal law chain. First the data from the police will be discussed: the number of booked suspects, criminal investigations into criminal cooperation networks and confiscated drugs. Then the number of cases and the manner of disposal by the Public Prosecutions Department will be discussed. In the end, part of these cases found their way to Court. Figures will be provided of the number of cases in which the Court pronounced sentence and of which sentences were passed. Finally, data will be given about detention because of offences under the Opium Act and repeat offences by the offenders.
8.2.1 Suspects under the Opium Act Table 8.1 shows the number of suspects against whom a police report was drawn up because of a violation of the Opium Act (production, transport, trafficking and/or possession of drugs). This is based on the number of suspects against whom a police report was drawn up once or more times in a
124
specific year because of a violation of the Opium Act. If the violation of the Opium Act involves hard drugs, we shall refer to this hereafter as "hard drug offences". If soft drugs are involved, we shall speak of ‘soft drug offences’. • The (still provisional) figures for 2003 indicate that the police booked more than 14,000 suspects because of offences under the Opium Act, more than in 2002. • The increase is apparent for hard drugs and for soft drugs, as well as for the combination of both. • In 2003, most of these offences still concerned hard drugs: more than half the suspects were booked for hard drug offences. The proportion of suspects of soft drug offences was 38 percent. This was slightly higher in 2003 than in the previous years.
Table 8.1 Number Total
• • •
I
Number of unique suspects of Opium Act offences booked by the police by type of drug, from 1999 II
Hard drugs
1999 9 091 5 228
2000 8 171 4 619
2001 10 139 5 558
2002 12 114 6 777
2003 14 299 7 744
Soft drugs
3 022
2 784
3 726
4 347
5 495
841
768
855
990
1 060
Hard drugs
57%
57%
55%
56%
54%
Soft drugs
33%
34%
37%
36%
38%
9%
9%
8%
8%
7%
Both
%
• • •
Both
I. Unique suspects: each suspect has been counted only once per year in the table, even if he/she was booked more often than once in a year for violation of the Opium Act. II. Provisional figures. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
Besides the police, the Royal Military Police also makes arrests for violations under the Opium Act. Although the Royal Military Police also handles other cases (e.g. of Dutch military abroad), most of the cases concern suspects arrested at Schiphol Airport. Table 8.2 gives an overview of the number of suspects who have not also been recorded by the police in the Police Records System (HKS).
Table 8.2 Number Total
• • •
I
Number of unique suspects of Opium Act offences booked by the Royal Military Police by type of drug, from 1999 1999 486 384
2000 516 464
2001 910 870
2002 1 477 1 419
2003 1 640 1 491
Soft drugs
87
43
35
52
137
Both
15
9
5
6
12
Hard drugs
79%
90%
96%
96%
91%
Soft drugs
18%
8%
4%
4%
8%
3%
2%
0.5%
0%
1%
Hard drugs
%
• • •
Both
I. Unique suspects: each suspect has been counted only once per year in the table, even if he/she was booked more often than once in a year for violation of the Opium Act. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
It is apparent from Table 8.2 that in 2003 this concerned 1,640 suspects, mainly of hard drug offences. The number of hard drug offences increased in the past five years, particularly in 2002 and 2003. The number of soft drug offences increased especially in 2002 and 2003. The increase in the last two
125
years may be largely because, otherwise than in previous years, in 2002 and 2003 all reports at Schiphol were drawn up and recorded exclusively by the Royal Military Police. Hard drug offences always made up by far the larger part. Table 8.3 shows the profiles of the suspects booked by the police for Opium Act offences in 2003. • Most of them are men. Most suspects are aged 25 to 35.
• •
•
•
b
b
The soft drug suspects are the least frequently recorded as drug users and have relatively few criminal records. The hard drug suspects live more often in the large cities, are younger and have more criminal records than the soft drug suspects. Twenty percent have more than ten. Approximately a quarter of the suspects of a hard drug offence are known as drug users. Suspects of both hard and soft drugs are usually well known by the police: nearly half of them have more than ten criminal records. Compared to suspects of only a hard drug or soft drug offence, they are more represented in the age group of 35-45 and more often men. They usually live in middle-sized towns and relatively infrequently abroad. They are most often recorded at the police as drug users. The profile of the suspects arrested by the Royal Military Police is different. Sixty percent of them lives abroad, nearly half (46%) originate from the Netherlands Antilles. Most of the suspects have only one criminal record (87%) and are relatively young: 35 percent is in the age group 18-24, 32 percent is aged between 25 and 34.
See for the restrictions of this classification of drug using suspects the remark to Chapter 8.3.1.
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Table 8.3
Profiles of suspects of offences under the Opium Act by type of drug. Survey year 2003
Total number
Soft drugs 5 495
Hard drugs Both 7 744 1 060
Gender
Men Women
83% 17%
88% 12%
93% 7%
Municipality by I number of inhabitants
Unknown under 10 000 10 000 – 20 000 20 000 – 50 000 50 000 - 100 000 100 000 - 150 000 150 000 - 250 000 250 000 and over (four largest cities) Abroad
3% 1% 8% 20% 19% 10% 11% 14%
5% 1% 5% 14% 12% 10% 8% 32%
4% 1% 7% 20% 23% 12% 9% 19%
14%
13%
5%
Alcohol Drugs Otherwise
1% 1% 2%
2% 23% 6%
3% 28% 9%
1
46%
36%
10%
2 3–4 5 – 10 11 – 20 21 or over
12% 13% 16% 8% 5%
12% 14% 17% 10% 10%
5% 12% 24% 23% 25%
12-17 18-24 25-34 35-44 45 and above
3% 20% 33% 26% 18%
4% 32% 33% 20% 11%
1% 14% 34% 33% 18%
II
Danger classification addiction
III
Number of criminal records in the total recorded criminal history
Age upon recording of latest offence
I. The offences may have been committed in another town or city than where the suspect lives. II. See remarks to Chapter 8.3.1. III. A criminal record is a police contact during which a report of one or more crimes was drawn up. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
8.2.2 Investigations into organised crime The National Criminal Information service of the National Police Services Agency (KLPD), Research and Analysis group, lists the investigations annually undertaken by the Dutch police in the field of c
organised crime. Two comments to the figures should be given: In the first place, the data about the investigations are not directly comparable from 2002 to those from the previous years. This is due to the new recording method that the National Police Services Agency (KLPD) started to use in 2002. The data of all the regional investigations are now requested through a new form, the “Criminal c
This listing is done commissioned by the EU Justice and Home Affairs Council (JBZ Raad). Only investigations that satisfy the criteria set for organised crime by the Council are included.
127
Cooperation (CSV) – manager”. On the basis of this form, the criminal cooperation from the listed investigations are described. The registration of criminal cooperation is expected to be more complete from 2002 than in the previous years. Investigation priorities, capacity and the possibilities of the investigation services are here also important factors in the height of the numbers. For that reason, the number of recorded investigations may fluctuate strongly from year to year. One single criminal investigation may involve several types of drugs and various activities in the field of drugs. Table 8.4 gives the figures in respect of the criminal investigations. • In 2003 more criminal investigations were recorded than in 2002. • Two thirds (66%) of the criminal investigations focused on drugs. That percentage is about the same as that of the previous year. • Forty percent of all the investigations focused only on hard drugs, 11 percent only on soft drugs and 14 percent on both hard drugs and soft drugs. • In 62 percent (91) of the criminal investigations into drugs only one type of drug was involved. In the other criminal investigations, several types of drugs were involved. • Cocaine figured in 60 percent of the criminal investigations into hard drugs. Fifty-four percent of these criminal investigations concerned synthetic drugs and 17 percent heroin. The number of criminal investigations into cocaine increased strongly compared to 2002. This may be connected with more intensive inspections at Schiphol Airport. • The criminal investigations into soft drugs were mainly focused on Dutch-grown cannabis (53%) or hashish (39%). In the case of criminal investigations into Dutch-grown cannabis, not just trade was concerned but also production. • Figures from 1998 to 2002 incl. show that more than half the criminal investigations dealt with various activities in the field of drugs. The investigated criminal groups dealt more often with transport and trade than with production. In 2003 the division by production, transport and trade could no longer be made.
Table 8.4
Criminal investigations into more serious forms of organised crime: proportion of drug crime by type of drug, from 1999
Number of criminal investigations Involving drug crime
• Hard drugs • Soft drugs • Hard and soft drugs
1999 118 100%
2000 148 100%
2001 146 100%
2002 185 100%
2003 221 100%
75 24
64% 20%
78 35
53% 24%
90 53
62% 36%
117 64
63% 35%
146 89
66% 40%
9
8%
14
9%
15
10%
20
11%
25
11%
42
36%
29
20%
22
15%
33
18%
32
14%
Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
8.2.3 Confiscated drugs The National Criminal Information service of the National Police Services Agency (KLPD), Research and Analysis group reports annually about the quantity of confiscated drugs. This is done based on reports from the police forces, core teams, customs and the Royal Military Police. The below overview must be considered with a critical eye. Recording of seizure is not centrally organised within the police forces and other investigation bodies, often it is not uniform and sometimes no records are made at 151;152 all. In the interpretation of the data one must take into account that the figures only indicate a 152;153 minimum limit of the total number of seized drugs. Moreover, the differences between the types of drugs and between the years are not systematic to such an extent that it is very difficult to interpret them. It is impossible to gather trends from them. The quantities of confiscated drugs may vary in
128
proportion to the investigation efforts, the number of cases that had to be dealt with, changes in the market and/or accuracy in reporting. Seven of the 25 regional police departments have not supplied data. De Miranda and Van der Werf, who prepared the 2003 overview, have calculated an indication of the seizures for those lacking 152 regional police departments. To that end they consulted the Drug Seizure file of the National Investigations Information Service (NRI). This file contains the seizures from a specific minimum quantity. Table 8.5 includes the thus achieved 2003 figures. The authors (De Miranda and Van der Werf, 2004) outline the following picture: • “Heroin: the reported quantity of seized heroin was less in 2003 than in the previous years. In 2003 more than 417 kilograms of heroin were reported, whereas this was more than 1,000 kilograms in 2002, a decrease of 63 percent. The quantity of heroin that was confiscated in 2003 was the lowest since 1996. The number of seizures of heroin reported by the criminal investigation bodies was 533. • Cocaine: in respect of cocaine there was an increase compared to previous years. In 2003, more than 17,000 kilograms of this drug were reportedly seized; an increase of over 120 percent compared to 2002. The number of seizures reported is 3,917. Most of the seizures were carried out by the Royal Military Police in collaboration with customs. • Amphetamines: criminal investigation bodies reported to have seized more amphetamines in 2003 than in 2002, i.e. 843 kilograms and, in addition, 14,000 pills. Furthermore, for the first time the seizure of amphetamines in fluid form was reported, i.e. 37 litres. The number of seizures reported was 219. • Ecstasy (MDMA): in the information of the criminal investigation bodies a decrease was noticeable in the quantity of XTC seized in the Netherlands. In 2003, 435 kilograms of MDMA (powder and paste) were seized, a fifty percent decrease compared to 2002. The quantity of seized tablets also showed a decrease. The records mention more than 5.4 million of tablets in 2003, a decrease of 20 percent compared to 2002. The number of seizures is not mentioned. • LSD: The figures for 2003 are not sensational. 1,642 tablets were seized. The number of seizures was nine. • Cannabis: Compared to the previous year, 2003 showed a decrease in the reported quantity of seized cannabis products, such as (foreign) hashish, marihuana and Dutch-grown cannabis. In 2003, 19,103 kilograms of cannabis were seized, a significant decrease compared to the 46,675 kilograms confiscated in 2002. The number of reported seizures of cannabis products was 2,199."
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Table 8.5
I
Quantities of seized drugs in the Netherlands, from 1999
Kind of drug 1999 2000 2001 2002 2003 Heroin Kilogram Kilogram 770 896 739 1 122 417 Cocaine Kilogram 10 361 6 472 8 389 7 968 17 560 Amphetamines Kilogram 853 293 579 481 843 Tablets 45 847 II. 20 592 1 028 14 000 Litres 37 XTC (MDMA) Kilogram *** 632 113 849 435 Tablets 3 663 608 5 500 000 3 684 505 6 787 167 5 420 033 Discovered production places 36 37 35 43 37 LSD Trips 244 9 829 28 731 355 Tablets 2 423 143 1 642 Methadone Kilogram 50 16 1 4 Tablets 186 437 5 543 8 968 9 446 57 430 Litres 0,57 Cannabis Hashish Kilogram 61 226 29 590 10 972 32 717 10 719 Marihuana Kilogram 47 039 9 629 21 139 9 958 7 067 Dutch-grown cannabis Kilogram 2 076 701 1 308 1 179 Hemp plants 582 588 661 851 884 609 900 381 1 111 855 Total weight cannabis 110 341 39 920 33 419 42 675 19 103 Rounded-up hemp farms 1 091 1 372 2 012 1 574 1 867 Number of seizures 14 909 9 243 14 353 18 823 5 752 I. Not included: hashish oil (1 litre in 1999); paddo’s (278 kilograms in 2003); mescaline (1 kilogram in 2003) and 152 opium (0.1 kilogram in 2003). II. Indicates that there are no seizures or none are known.
8.2.4 Intake and disposal of Opium Act cases by the Public Prosecutions Department The police send the police reports in respect of violations of the Opium Act to the Public Prosecutions Department (OM). Not all the police reports are registered at the Public Prosecutions Department (OM). Criminal cases, after all, are already ‘screened’ by the police, meaning that those cases that in all likelihood cannot be prosecuted are already filtered out. Such cases do not always end up in the records of the Public Prosecutions Department. Table 8.6 shows the numbers of cases taken in by the Public Prosecutions Department for each type of drug. • The number of cases taken in by the Public Prosecutions Department continued to increase, although the increase by 8 percent in 2003 was somewhat less than in the two previous years. An increase was apparent in hard drug and soft drug cases, and also in the category hard and soft drugs. • The proportion of hard and soft drug cases remained virtually the same in those past five years. • A closer analysis of the recent increase in the number of Opium Act cases shows that half the increase was caused by the increase at the Haarlem district. In 1999 this district handled 12 percent of the total number of hard drug cases in the Netherlands. In 2002 and 2003 this more than doubled (26%). Schiphol cases are dealt with by the Haarlem district; for a considerable part, the increase will concern cases against drug couriers, including ‘drug swallowers’.
130
Table 8.6
Opium Act cases taken in by the Public Prosecutions Department by type of drug, from 1999
Hard drugs Soft drugs Hard and soft drugs Total
1999 6 407 4 380 888 11 675
2000 6 397 4 324 792 11 513
2001 7 672 5 059 827 13 558
2002 9 246 5 832 770 15 848
2003 9 989 6 156 942 17 087
Hard drugs Soft drugs Hard and soft drugs Total
55% 38% 8% 100%
56% 38% 7% 100%
57% 37% 6% 100%
58% 37% 5% 100%
58% 36% 6% 100%
Source: Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC).
Table 8.7 shows what the decision of the Public Prosecutions Department was in Opium Act cases that were disposed in final and conclusive judgment between 1999 and 2003. • In 2003, the number of criminal cases under the Opium Act was nearly 15,000. Compared to 2002, this is an increase of 13 percent. • The Public Prosecutions Department issues a summons in the majority of drug cases. This means that most drug cases are brought before the Court. In those last five years a slight drop in the percentage of summons was apparent. The proportion of out-of-court settlements increased in that period of five years, particularly in soft drug cases. • In cases involving both hard and soft drugs, a summons was issued relatively often.
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Table 8.7
Criminal cases disposed in final and conclusive judgement for Opium Act offences by decision of the Public Prosecution Department and type of drug, from 1999
1999 2000 2001 2002 2003 Total number of Opium Act cases 11 132 10 546 11 143 13 206 14 943 72% 71% 67% 67% 68% • Summons 9% 9% 16% 18% 17% • Out-of-court settlement 6% 6% 6% 5% 5% • Discretionary dismissal 8% 9% 7% 6% 5% • Dismissal by reasons of likeliness of nonconviction 5% 5% 5% 4% 5% • Joinder Hard drugs 75% 76% 74% 75% 74% • Summons 4% 4% 7% 10% 11% • Out-of-court settlement 7% 7% 6% 4% 4% • Discretionary dismissal 9% 9% 8% 6% 5% • Dismissal by reasons of likeliness of nonconviction 5% 5% 5% 5% 5% • Joinder Soft drugs 68% 64% 56% 53% 57% • Summons 16% 17% 29% 33% 29% • Out-of-court settlement 5% 6% 5% 5% 5% • Discretionary dismissal 7% 8% 6% 5% 5% • Dismissal by reasons of likeliness of nonconviction 5% 4% 4% 3% 4% • Joinder Hard and soft drugs 89% 84% 78% 81% 80% • Summons 2% 3% 3% 3% 7% • Out-of-court settlement 2% 2% 7% 4% 5% • Discretionary dismissal 4% 8% 9% 9% 5% • Dismissal by reasons of likeliness of nonconviction 3% 3% 3% 3% 3% • Joinder Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
In respect of the Misuse of Chemicals Prevention Act (WVMC) the following appears. • In the period between 1999 and 2003, annually some thirty cases involved offences against the WVMC, usually in combination with hard drug offences. In 2003, 22 cases with such a combination of offences were recorded; six cases only concerned an offence under the WVMC (see Table 8.8).
Table 8.8
Number of final and conclusive judgments in cases concerning an offence under the WVMC, from 1999
Only WVMC WVMC and Opium Act Total
1999 3 20 23
2000 7 18 25
2001 12 27 39
2002 3 29 32
2003 6 22 28
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
•
More than 200 times a year, besides an offence under the Opium Act, charges also include participation in a criminal organisation (Section 140, Netherlands Criminal Code). In 2003 this happened 223 times (see Table 8.9).
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Table 8.9
Number of final and conclusive judgments in respect of Section 140 Netherlands CC, from 1999 1999 292
Number of cases Section 140
2000 230
2001 215
2002 132
2003 223
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.5 Disposal by the Court As shown in Chapter 8.2.4, most of the Opium Act cases are brought before the Court. Table 8.10 shows the number of cases disposed by the Court. • In 2003, the Courts disposed of over twelve thousand Opium Act cases. This is an increase of 21 compared to 2002. This increase was already shown for a number of years in respect of both hard drug and soft drug cases, as well as in respect of cases with hard and soft drugs combined. This picture is in step with the figures of intake and of disposed cases of the Public Prosecutions d
•
Department (OM). Most of the cases here also concerned hard drugs. The proportion of hard drug cases steadily increased since 1999: from 54 percent in 1999 to 64 percent in 2003. The proportion of soft drug cases dropped since 1999 from 38 to 30 percent.
Table 8.10
Criminal cases disposed by the Court in first instance by type of drug, from 1999
Hard drugs Soft drugs Hard and soft drugs Total
1999 4 558 3 223 664 8 445
2000 4 720 2 744 609 8 073
2001 5 321 2 858 658 8 837
2002 6 543 3 078 581 10 202
2003 7 883 3 675 766 12 324
Hard drugs Soft drugs Hard and soft drugs Total
54% 38% 8% 100%
58% 34% 8% 100%
60% 32% 7% 100%
64% 30% 6% 100%
64% 30% 6% 100%
Source: Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.6 Penalties in Opium Act cases Table 8.11 describes the penalty probability and the types of penalties: financial out-of-court settlements by the Public Prosecutions Department and the orders for community service, unsuspended custodial sentences, fines and confiscations imposed by the Court. I. The penalty probability shows the likelihood whether or not an offender under the Opium Act will actually be e penalised.
d
The figures of the Public Prosecutions Department (OM) in Table 8.7 and the Court in Table 8.10 cannot be compared just like that: there is a time difference between the moment of intake of a case, the disposal by the Public Prosecutions Department (OM) and the moment of judgment by the court; the figures of the Public Prosecutions Department in Table 8.7 relate to cases disposed in final and conclusive judgment, those of the court in Table 8.10 relate to cases disposed in first instance. e The penalty probability is defined as the sum of all out-of-court settlements and guilty verdicts with penalties, divided by the total number of disposed cases (excluding joinder of charges and transfer of criminal proceedings).
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•
•
• •
The penalty probability increased slightly: from 86 percent in 2001 to 89 percent in 2002 and 2003. This means that a penalty was imposed in 89 out of 100 cases. The remainder of the suspects had their cases dismissed of had their cases acquitted. The increase may partly be due to "screening" by the police. Criminal cases are presently assessed by the police for the probability of prosecution. Such filtered cases do not always end up in the records of the Public Prosecutions Department (OM). The number of imposed community sentences rose again strongly in 2002 (+34%). The number of unsuspended prison sentences also continued to rise (+11%), although somewhat less strongly than in 2002. The increase in the number of unsuspended prison sentences was probably to a considerable extent due to the drug couriers arrested at Schiphol Airport (including what are called “drug swallowers”) (see also Chapter 8.2.7). The number of out-of-court settlements and fines did not change. The number of confiscations, though relatively low in absolute numbers, increased strongly in 2003.
Table 8.11
Penalty probability and number of unsuspended penalties in Opium Act cases, from 1999 1999 86%
2000 85%
2001 86%
2002 89%
2003 89%
Community service orders
2 129
2 138
2 382
2 985
4 008
Unsuspended custodial sentences
3 578
3 341
3 523
4 641
5 155
911
838
1 568
1 884
1 797
1 634
1 350
1 393
1 522
1 547
74
73
46
58
105
Penalty probability Kind of penalty
• • • • •
Financial out-ofcourt settlements Fines Confiscation orders
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
•
•
The average length of the imposed community sentences remained more or less the same throughout the years (see Table 8.12). In 2003, the average length of a community service sentence was 119 days. The average length of the unsuspended custodial sentences was relatively high in 2002 and again somewhat lower in 2003. In 2003, the length of imposed custodial sentences was 357 days on average.
Table 8.12
Average length (in days) of community service orders and unsuspended custodial sentences in Opium Act cases, from 1999
1999 Community service 124 orders Unsuspended custodial 369 sentences
2000 122
2001 121
2002 114
2003 119
348
356
382
357
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
134
•
• •
The amount of the imposed financial out-of-court settlements has increased in the course of years. f In 2003, the median amount was 320 euros (see Table 8.13). The highest amount of a financial out-of-court settlement in 2003 was 50,000 euros. The amount of fines increased in 2002 and 2003. In 2003 the median amount was 500 euros. The highest fine in 2003 was 900,000 euros. The amounts involved in confiscation orders varied considerably per year.
Table 8.13
Median amount in euros of financial out-of-court settlements and confiscation orders in Opium Act cases, from 1999
Financial out-of-court settlements Fines Confiscation orders
1999 183
2000 163
2001 214
2002 293
2003 320
459 4 018
459 3 511
458 6 112
509 619
500 2 616
Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.2.7 Custodial sentences Opium Act As a result of custodial sentences imposed, a number of offenders end up in prison. Table 8.14 describes the number and length of the (partly) unsuspended custodial sentences imposed because of violation of the Opium Act.
• • •
In 2003, 15 percent of the total number of custodial sentences were custodial sentences for violations of the Opium Act. Since 1999, this number grew steadily. The increase is due to hard drug cases. In 2003 these made up 14 percent of the total number of custodial sentences. The proportion of soft drug cases remained stable. Of the detention years, 29 percent could be attributed to drug cases, 28 percent of which for hard drug cases, an increase compared to 2002. This increase in prison capacity requirement was caused largely by the increased focus on drug couriers at Schiphol. This is evident from the number of years of detention imposed for violations of the Opium Act in Haarlem, where these cases are handled. In 2003, 14 percent of all the detention years imposed in the Netherlands were related to drug cases in Haarlem.
f
The median is the value associated with the middle number in a set of ordered data (ascending or descending).The median is less sensitive to extremely high or low values than the arithmetical mean.
135
Table 8.14 Imposed unsuspended custodial sentences under the Opium Act by number and percentage of custodial sentences and length in years of detention, from 1999 Number of custodial sentences Total of Opium Act cases I hard drugs soft drugs Other criminal cases
1999 26 313 12% 11% 1% 88%
2000 27 021 11% 10% 1% 89%
2001 28 940 12% 11% 1% 88%
2002 32 849 14% 13% 1% 86%
2003 34 381 15% 14% 1% 85%
9 441 26% 24% 2% 74%
9 442 23% 22% 1% 77%
10 517 23% 22% 1% 77%
12 512 27% 26% 1% 73%
12 235 29% 28% 1% 71%
II
Years of detention Total of Opium Act cases I hard drugs soft drugs Other criminal cases
I. A case in which charges of a soft drug offence are brought, besides a hard drug offence, is classified under hard drugs. II. The number of years of detention is calculated by deducting the suspended part (that does not have to be served as a result of parole regulations) from the unsuspended prison sentence in each case. Source: Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
In 2003, over 14,000 persons were detained in total, part of them because of violations of the Opium Act (see Table 8.15). • A quarter of the prison population was made up of offenders under the Opium Act in 2003. Compared to 2002 this is a decrease, whereas, over the period between 1999 and 2003, there was in increase of 21 to 25.
Table 8.15
1999 8 789 1%
2000 10 300 1%
2001 11 399 1%
2002 II 11 960 1%
2003 II 14 191 1%
Vandalism/disturbance of the public order
3%
2%
4%
4%
4%
Property offences
22%
20%
20%
19%
20%
Offences against the Opium Act
21%
21%
24%
27%
25%
Violent offences
43%
43%
42%
42%
43%
Unknown/other offences
11%
12%
9%
8%
7%
101%
99%
100%
101%
100%
Total number
• • • • • • •
I
Number of persons in penal institutions by type of offence, from 1999
Traffic offences
III
Total
I. The figures do not include detention of aliens. II. 2002 does not include detainees in detention centres, 2003 does include these. III. Not always exactly 100% due to rounding differences. Source: Enforcement of custodial measures in correctional institutions (TULP), National Agency of Correctional Institutions (DJI).
8.2.8 Recidivism of Opium Act offenders Despite having been sentenced, part of the Opium Act offenders came into renewed contact with the law. To get a picture of their recidivism, from the WODC Recidivist Monitor (see Appendix B) a selection was made of all the people who had been at least once in contact with the law in 1997 for
136
g
violation of the Opium Act. This resulted in a group of 8,708 Opium Act offenders. Of these people, the entire criminal record was subsequently requested. It was researched whether they came into renewed contact with the law in 1997 and if so, after how much time. In this respect, three types of recidivism have been distinguished. For the determination of the general recidivism, all the new contacts with the criminal justice system are counted, with the exception of matters ending in acquittal, dismissal by reason of likeliness of nonconviction or another technical judgment. We speak of serious recidivism in the case of new contacts with the criminal justice system for offences that carry a minimum sentence of four years. For the determination of the special recidivism of drug offenders, only new contacts with the criminal justice system because of a violation of the Opium Act are counted. Table 8.16 provides an overview of the percentage of Opium Act offenders who were in renewed contact with the criminal justice system within a period of one to five years. For purposes of comparison, the recidivism in the entire population of perpetrators has been stated.
•
• • • • •
h
The general picture is that drug offenders repeated an offence somewhat more often when compared to their proportion in the total offender population, that is to say all the offenders added up. Within one year after release, a quarter of all those convicted for drug offences against the Opium Act came into renewed contact with the law. Within five years this increased to 45 percent. Counting only cases of serious offences, the percentage of frequent offenders for violations of the Opium Act was 15 percent within one year, going up to 29 percent within five years. The proportion of frequent offenders under the Opium Act within five years (what is called special recidivism) was 22 percent. These data prove that Opium Act offenders did not just repeat the violations of the Opium Act, but also engaged in other forms of criminality. Male offenders under the Opium Act repeated the offence more often generally than female offenders (not included in the table). The criminal past played an important role. For individuals who had contacts with the criminal justice system for serious drug offences, the probability of recidivism after the initial case was higher. Moreover, the younger the perpetrator was at the first contact with the law, the larger the probability of recidivism at a later stage.
Table 8.14
Percentage of frequent offenders after having violated the Opium Act, cumulatively over a period of five years
• •
OA 45%
5 years II total 42%
General
OA 25%
1 year II total 22%
Serious
15%
14%
21%
19%
25%
23%
28%
25%
29%
26%
Special
10%
-
15%
-
18%
-
20%
-
22%
-
Type of repeat offence
•
O b s e r v a t i on P e r i o d 2 years 3 years 4 years I II I II I II OA total OA total OA total 34% 31% 40% 36% 43% 39%
I
I
I. Perpetrators who were in contact with the law in 1997 for a violation of the Opium Act (OA). II. All the perpetrators who were in contact with the law in 1997. Source: Recidivism Monitor, Research and Documentation Centre of the Ministry of Justice (WODC).
Table 8.17 provides an outline of numbers of Opium Act offences in the distinguished phases of the criminal law chain in 2003. The figures are based on various sources and their mutual relationship
g
Including 7 (0.1%) offences under the Misuse of Chemicals Prevention Act (WVMC). Determination of the special recidivism or recidivism in the framework of the Opium Act is not meaningful, because the nature of the initial cases of the perpetrators varies widely. This contrary to the initial cases of drug offenders, which always concern a violation of the Opium Act or of the Abuse of Chemical Substances Prevention Act (WVMC). h
137
must be interpreted with caution. It is apparent once more that hard drug offences occurred more often in all the phases than soft drug offences. This difference increased as we progress in the chain.
Table 8.17
Number of suspects at the police, Royal Military Police (KMar) and Public Prosecutions Department (OM), persons sentences by the Court, prison sentences and years of detention for Opium Act offences by phase in the criminal law chain and hard and/or soft drugs, 2003 Phase in chain Police KMar OM Court in first Custodial I instance sentences Total Opium Act 14 299 1 640 17 087 12 324 5 137 7 744 1 491 9 989 7 883 4 618 • Hard drugs 5 495 137 6 156 3 675 370 • Soft drugs 1 060 12 942 766 149 • Both % 54% 91% 58% 64% 90% • Hard drugs 38% 8% 36% 30% 7% • Soft drugs 7% 1% 6% 6% 3% • Both
Years of detention 3 600 3 298 145 157 92% 4% 4%
I. Eighteen sentences and years of detention are missing: these cannot be categorised by kind of drug or the duration of the sentence is unknown. Sources: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service (DNRI); Public Prosecutions Department Database (OMDATA), Research and Documentation Centre of the Ministry of Justice (WODC); Justice Documentation Research Database (OBJD), Research and Documentation Centre of the Ministry of Justice (WODC).
8.3
CRIMINAL DRUG USERS
8.3.1 Profiles of drug using suspects Tables 8.18 and 8.19 display characteristics of suspects recorded as “drug users” in the Police Records System (HKS). In the HKS, addiction of use of drugs is not recorded as such. Nevertheless a rough description can be given of the group of suspected drug users by using what is called the ‘danger classification’ in the HKS. If it has become known that a suspect is a problem user of drugs, or if the suspect has indicated this, that suspect is recorded in the system as “drug user” in what is called “danger classifications”. The extent of drug addiction cannot be accurately established on the basis of the available data. There are doubts about the completeness of the recording of drug use; it is 3 assumed that it concerns a minimum indication.
138
Table 8.18
Profiles of suspects recorded as “drug users”, from 1999
Number of suspects Gender
Men Women
Town or city by number Under 20 000 I of inhabitants 20 000 – 50 000 50 000 – 100 000 100 000 – 150 000 150 000 – 250 000 250 000 and over Abroad Unknown Danger classification
Alcohol Drugs Otherwise
II
1999 9 972 90% 10%
2000 9 251 90% 10%
2001 2002 2003 9 947 10 525 10 247 91% 90% 90% 9% 10% 10%
4%
4%
4%
4%
4%
11% 12% 10% 9% 46% 6% 2%
11% 12% 10% 10% 47% 5% 2%
11% 12% 10% 10% 45% 5% 4%
10% 12% 11% 10% 45% 5% 3%
10% 11% 11% 10% 44% 4% 6%
11% 100% 19%
11% 100% 20%
12% 100% 20%
11% 100% 20%
11% 100% 21%
Age upon recording of 12-17 latest offence 18-24 25-34 35-44 45-54 55 years and over
0%
0%
0%
0%
0%
9% 43% 37% 9% 1%
9% 41% 39% 10% 1%
8% 38% 40% 12% 1%
8% 36% 41% 14% 1%
7% 33% 42% 16% 2%
Average age (year)
34.4
34.8
35.4
36.3
36.8
I. Last known domicile or residence. II. Provisional figures: HKS data of the last year are retrieved once more after a year. We know from experience that there will be an addition of approximately 6%. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
• •
• •
•
Nine in ten suspects recorded as drug users were men. This proportion remained constant over the years. The distribution of drug using suspects by size of the towns or cities in which the drug using suspects live, also remained practically constant: nearly half the suspects (44%) lived in cities of 250,000 or more inhabitants. Of these drug using suspects, 11 percent were also recorded as addicted to alcohol and 21 percents also as addicted to other substances (such as licit drugs). Often the suspects who are classified as drug users got in contact with the police for the first time at a young age: in 2003, nearly half (45%) were younger than 18 years at the time the first offence was recorded, three-quarters (77%) were younger than 25 (not shown in the table). The average age at the most recent offence was slightly higher in 2003 than in 2002 and was about 37.
139
Table 8.19
Characteristics of offences by suspects recorded as “drug users”, from 1999 I
1 2 3-4 5-10 11-20 21-50 >50
II
Sexual assault Other violence Theft with violence / extortion Property offences Vandalism, disturbance of the public order / authorities Traffic offences Offences against the Opium Act Other offences
Criminal record
Type of offence
1999 3% 3% 5% 16% 20% 31% 21%
2000 3% 3% 5% 15% 20% 32% 22%
2001 4% 3% 5% 15% 20% 32% 22%
2002 4% 3% 6% 16% 21% 32% 20%
2003 3% 2% 5% 15% 20% 32% 20%
1% 19% 12% 63% 20%
2% 20% 12% 63% 21%
1% 20% 12% 63% 21%
1% 22% 12% 63% 22%
1% 23% 11% 58% 22%
10% 20%
11% 18%
11% 19%
10% 19%
10% 22%
10%
11%
10%
10%
10%
I. Total number of criminal records in the entire prior criminal history. II. Suspects may have committed more than one type of offence; consequently, the percentages should not be added up. Source: Police Records System (HKS), National Police Agency (KLPD)/National Criminal Intelligence Service of the National Police Agency (DNRI), Research & Analysis group.
• •
Against the vast majority of the suspects classified as drug users an earlier police record was drawn up because of a criminal offence and 72% has more than ten earlier criminal records. Nearly six out of ten suspects were booked for a property offence. In 2003, this percentage was lower than in 2002. The category "other offences" was slightly higher than in earlier years, as was the category ‘Opium Act’.
8.3.2 Proportion of drug users in the population of frequent offenders on judicial level A recent WODC report shows that the judicial system has to deal with a group of more than 6000 'very 154 high rate frequent' offenders. These are offenders who had more than ten valid penal cases in the previous period of five years. The authors did additional analyses based on information, recorded in i
the criminal files. • An estimated 70 percent of the very high rate frequent offenders were regular users of hard drugs and more than 10 percent had to cope with alcohol problems (see Table 8.20). This analysis shows that the group of frequent offenders, at any rate the most active, corresponded to a large extent with the group of regular hard drug users.
i
Sample from the Criminal Justice Monitor (SRM) (see Appendix B).
140
Table 8.20
Profile of frequent offenders on judicial level in the years 1993, 1995 and 1999
Number Regular hard drug use Alcohol problems
Low rate frequent offenders
High rate frequent offenders
Very high rate frequent offenders
Total group of offenders
252
248
145
2 480
17% 7%
36% 10%
71% 12%
14% 4%
Source: Criminal Justice Monitor (SRM)/Recidivism Monitor of the Research and Documentation 155 Centre of the Ministry of Justice (WODC).
8.4
HELP FOR PROBLEM USERS IN THE CRIMINAL SYSTEM
Problem users of drugs in the criminal system can receive support and help in respect of their (addiction) problems in several manners. The Netherlands (Drug) Rehabilitation Foundation offers possibilities and, inter alia, contacts suspected or convicted users and prepares reports for the Public Prosecutions Department and the Court about the possibilities for an individual care program. In addition, there are possibilities for users to participate in a care program as an alternative to prosecution and penalties. Programs in detention prepare users in a placement and selection phase. Since 2001, it has become legally possible for the Courts to mandate drug users to undergo treatment: Judicial Treatment of Addicts (SOV). In this paragraph we shall describe which help was available in 2003 and how often problem users made use of it: • the Netherlands (Drug) Rehabilitation Foundation (see Chapter 8.4.1) • alternatives for prosecution and penalties and placement and selection phase (see Chapter 8.4.2) • intake in the Judicial Treatment of Addicts (SOV) (see Chapter 8.4.3). The figures are based on the following sources: • The Client Follow-up System (CVS) of the (addiction) probation service implemented in 2001 (see 156 Appendix B). This system does not give complete nationwide information about the nature of the addiction of the clients (alcohol, drugs, gambling, etc.) or about the type of drug (heroin, j
cocaine, etc.). The figures have therefore not been specified by type of addiction. Figures on k
•
•
client level are not available either. It is not known how reliable the figures are. The National Agency of Correctional Institutions has provided information about Drug-free Units (VBAs) in penitentiaries. Figures about the intake in and outflow from the Judicial Treatment of Addicts (SOV) are based on data from the SOV locations and have been obtained via the Trimbos Institute.
j
Data from the National Information System on Alcohol and Drugs (LADIS) of before 2001 show that drug addicts make up approx. 60% of the clients of the probation service for addicts. The second large category is made up of clients with alcohol-related problems as a primary diagnosis. The drug clients were mainly users of hard drug: opiates, psychoanaleptic drugs (including cocaine) and poly-drug use. The trend was in the direction of fewer opiates and more psychoanaleptic drugs. k In the annual accounts 2003 the remark is made that the retrieval of overviews is very time-consuming and that there is doubt about the reliability of the overviews.
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8.4.1 The Netherlands (Drug) Rehabilitation Foundation The Netherlands (Drug) Rehabilitation Foundation offers users in the criminal system various forms of support, within budgetary and policy-related limits. It forms a bridge between the judicial authorities and the care organisations. • From the approx. 50 establishments, 15 care organisations for addicts recognised in the 138 framework of the Netherlands (Drug) Rehabilitation Foundation are active. These form a nationwide network. • In 2002, 44 percent of the clients of the Netherlands (Drug) Rehabilitation Foundation were in predetention, 41 percent served a prison sentence. No figures are available for 2003. In 2003, the Netherlands (Drug) Rehabilitation Foundation carried out twelve key activities for 156;158 justiciable individuals. Table 8.21 shows how often these activities have been carried out. The numbers relate to all kinds of problems (drugs, alcohol, gambling, etc). In 2003, the activity “diagnosis” l
was defined anew. This was related to the implementation of a standard instrument - the RISC - that was implemented in the framework of the judicial program Terugdringen Recidive [Reducing Recidivism] and that must be applied and recorded by the Netherlands (Drug) Rehabilitation Foundation and staff in penitentiaries.
Table 8.21
Number of times that the Netherlands (Drug) Rehabilitation Foundation carried I, II out key activities in 2002 and 2003 III Products 2002 2003 Visit for early assessment of needs 3 629 4 305 Early assessment intervention report 995 922 Counselling for treatment 10 048 9 156 IV Diagnosis 10 615 Placement and selection phase 1 568 2 115 Supervision 2 407 3 726 Reintegration program 1 696 2 566 Community service order 3 382 4 098 Training order 139 217 Social inquiry report 4 423 4 254 Recommendation report 2 989 4 408 Nonpunitive order report 175 84 I. No figures on client level or specified by the type of substance are available. II. Figures 2001 not given, figures different, implementation process Client Follow-up System (CVS) took place that year. III. The figures relate to established production after accounting audit. IV. Newly defined in 2003. Source: Netherlands (Drug) 140 Rehabilitation Foundation (SVG).
•
Visits to make an early assessment of needs were made more than 4,000 times in 2003, which is more often than in 2002. It concerns the first visit to a detainee, a suspect taken into police custody or placed in a detention centre, more specifically on detainees who are actually expected to be taken in by the care organisations. In the last few years, the number of visits to make an early assessment of needs was between 3,600 and 4,000.
l
The RISC (Risk Assessment Scales) is an instrument for rehabilitation services and the prison service; it is used to achieve an assessment of the chance of recidivism and to make the correct choice of intervention for the client. Diagnostics through RISC makes an assessment possible of the risk of recidivism and of the danger that a client poses for himself/herself and others. Moreover, it shows in which areas of life the client has needs or deficiencies and which possibilities of lack thereof someone has to participate in specific interventions.
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•
In the case of early assessment intervention, a report is submitted to the Court recommending whether or not the pre-trial detention should continue (and the manner in which). In 2003, this type of intervention was carried out more than 900 times. This number hardly differs from that in 2002.
•
Part of the counselling for treatment is the ‘systematic approach that is used for drawing up, coordinating and evaluating a plan of action based on examination’. In 2003, counselling for treatment took place more than 9,000 times, which is less often than in 2002.
•
Diagnoses were recorded as such for the first time in 2003. Redefining and the new manner of recording have to do with the development of a new diagnostic instrument (the RISC), which is to be the standard in the future. In 2003, the number of diagnoses made by the Netherlands (Drug) Rehabilitation Foundation was over 10,000.
•
In the placement and selection phase it concerns the effort required to place a client in a care institution. The placement and selection phase may take place at any stage of the criminal process: from the stay in a police cell or the remand centre up to and including the stage of 159 detention. In 2003, more than 2,000 efforts for placement and selection were carried out, more than in 2002.
•
The Netherlands (Drug) Rehabilitation Foundation supervises clients in the framework of a judicial decision in all the phases of the criminal process. In 2003, more than 3,700 supervision records were made.
•
In reintegration programmes, the Netherlands (Drug) Rehabilitation Foundation provides training to teach clients insight and/or skills in the field of living, work, education, finances, behaviour, relationships, etc. The activities within the Drug-Free Units (VBAs) in penitentiaries are part of this. In 2003, activities in this framework took place more than 2,500 times, an increase compared to 2002.
•
In 2003, the Netherlands (Drug) Rehabilitation Foundation was more than 4,000 times involved in the execution of a community service order or training order. This is also more than in 2002.
The Netherlands (Drug) Rehabilitation Foundation prepares various kinds of reports: social inquiry, recommendation and nonpunitive order reports (see Table 8.22). • Social inquiry reports give written information to the Court in respect of the decision about prosecution, adjudication or the enforcement of a sentence and/or (punitive) order. Social inquiry reports are prepared during police custody, remand in custody or pre-trial detention. The number of social inquiry reports, which are usually requested by the judicial authorities, fluctuated around 4,000 over the years.
•
A recommendation report is a limited, written manner of giving information about the client to a (judicial) authority in respect of a specific question or a decision to be taken Recommendation reports are prepared throughout the entire judicial process. In 2003, the number of recommendation reports increased by nearly 50 percent to more than 4,000.
•
Nonpunitive order reports concern written information to the Ministry of Justice, the Forensic Psychiatric Service (FPD), institution in the framework of a hospital order (TBS) and/or the Court in respect of decisions about a nonpunitive order. These reports relate, inter alia, to the Judicial Treatment of Addicts (SOV). In 2003, 84 reports were prepared.
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Table 8.22
Number of reports prepared by the Netherlands (Drug) Rehabilitation Foundation, from 1999
Year
Social inquiry reports
Recommendation reports
1999 2000 2001 2002 2003
4 427 4 113 3 303 4 423 4 254
2 269 2 555 2 292 2 989 4 408
Nonpunitive order reports 175 84
Source: Netherlands (Drug) Rehabilitation Foundation (SVG).
8.4.2 Treatment processes as an alternative for prosecution and penalties Since the nineties, judicial policy has focused explicitly on leading criminal drug users to treatment 160 processes as an alternative for prosecution and penalties. This aims to improve the situation of the user via a treatment process and - as a result - to reduce nuisance and criminal recidivism. In all the phases of the criminal process, from the arrest up to their detention, there are possibilities to be received into a treatment process. In the initial phase and the final phase, intake occurs only on a voluntary basis. From remand in custody to detention, coercion is possible. In the case of coercion, users have the choice between participation in a treatment process, on the one hand, and prosecution or a penalty (often detention), on the other hand. The choice is not without commitment: if the user does not satisfy the conditions and agreements, further prosecution, conviction or execution of penalties is bound to take place. This is the coercion, the big stick. There are various judicial options for intake in treatment processes from the criminal system (see Table 8.23). The table also includes the compulsory measure of Judicial Treatment of Addicts (SOV). • During the police phase, there are no options for coercion. Users may approach the treatment service at their own initiative. • During pre-trial detention, there is the option of (conditional) dismissal and suspension of the detention under conditions, the condition being participation in a treatment process. • While brought before the public prosecutor and during court hearing, the proceedings may be stayed or a suspended sentence may be imposed under the condition of participation in a treatment process. • Since April 2001, it has been possible to impose the nonpunitive order Judicial Treatment of Addicts (SOV), placing a drug user in a special custodial institution. • During detention, it is possible to participate in detention replacing treatment pursuant to Section 43 of the Prisons Act (PBW). This section provides the possibility to transfer detainees to a treatment facility, possibly outside of the penitentiary institution. • At the last stage of detention, participation in a Penitentiary Program outside of the penitentiary institution is possible. This program provides guided use of facilities outside of the penitentiary institution, while the detainee may also participate in social activities without the care organisations. • At the end of the chain, at the end of the detention, any intake in the treatment services is on a voluntary basis. • In 2003, no changes were made to the criminal options compared to 2002.
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Table 8.23
Criminal options for intake in treatment processes for drug users by phase in the custody chain, situation 2003
Phase in custody chain During police custody and remand in custody without extension (police phase) During pre-trial custody
Judicial option
• •
•
While brought before the public prosecutor and during court hearing
•
•
•
During detention
•
• Post-detention
•
Coercion or compulsion No coercion possible; intake in None treatment process on a voluntary basis (Conditional) dismissal by the Public Intake in treatment process under coercion; agreement of addict Prosecutions Department (OM) (Section 167 of the Netherlands Code required of Criminal Procedure) Conditional suspension of pre-trial detention (Section 80 of the Netherlands Code of Criminal Procedure) Staying of the court hearing/deferment of sentencing (Sections 281 and 346 of the Netherlands Code of Criminal Procedure)
Intake in treatment process under coercion; agreement of addict required
Awarding of a (partly) suspended sentence with the condition to enter a particular treatment or care program, specified during the hearing (Sections 14a and 14c of the Netherlands Code of Criminal Procedure) Imposing of nonpunitive order Judicial Treatment of Addicts (SOV) (Section 38m of the Netherlands Code of Criminal Procedure)
Compulsion, nonpunitive order may be imposed without the agreement of the addict
Participation in treatment process, if necessary outside of the penitentiary institution in a residential clinic (Section 43 Prisons Act)
Intake in treatment process under coercion; agreement of addict required
Participation in a penitentiary program (Section 4 Prisons Act) None
No coercion possible; intake in treatment process on a voluntary basis
Source: Research and Documentation Centre of the Ministry of Justice (WODC).
•
•
• •
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In penitentiary institutions, detained problem users receive the possibility to be placed in the DrugFree Units (VBAs) on a voluntary basis. VBAs are meant as a placement and selection program to a treatment process. In 2003 there were 12 VBAs with 325 places. In 2002, drug users participated 758 times in a VBA compared to 680 in 2003. No figures are known about the use of the distinguished judicial options by problem users of drugs. The application of coercion and the effectiveness of the treatment processes that the 161 judicial authorities use towards the care organisations appear capable of improvement. In 2003, 2,115 efforts for placement and selection were carried out (see Table 8.24). Not all the efforts for placement and selection that were started in 2003 have been realised. Figures from the Netherlands (Drug) Rehabilitation Foundation show that of the over 3,000 efforts for placement and selection that were started two thirds (67%) were actually realised according to plan. In one-third of the cases the placement and selection phase for treatment was not completed
145
•
as planned. In these cases the process was broken off prematurely for one reason or other (e.g. by the addict or by the care organisation). These figures are the same as in 2002. The various possible treatment processes are not specifically related to one of the (above described) judicial modality. From the judicial system, a user may go to many possible facilities that are not financed by the Ministry of Justice, as long as the decisive authority (usually the judge or the selection official) finds this an appropriate and acceptable process.
•
The influx from the judicial system into treatment processes takes place mainly into clinical, outpatient and part-time facilities in the addiction care that are not financed by the Ministry of Justice (see Table 8.23).
•
The categories of clinical, outpatient and part-time care organisations for addicts comprise services with various objectives and target groups (see Appendix D).
Table 8.24
Placement and selection efforts to treatment by the Netherlands (Drug) I Rehabilitation Foundation by type of treatment process in 2002 and 2003
Type of treatment process: Clinical treatment of addicts Outpatient and part-time treatment of addicts Social care Psychiatric care by a General Psychiatric Hospital (APZ) Non-clinical psychiatric care Psychiatric part-time treatment Social pensions Homes for the homeless Psychiatric outpatient clinic Crisis shelter 24 hours Other facilities Total
II
2002 650 474
42% 30%
2003 889 41% 726 34%
126 123
8% 8%
171 76
8% 4%
44 28 24 22 20 19 38 1 568
3% 2% 2% 1% 1% 1% 2% 100%
83 50 23 25 35 19 56 2 153
4% 2% 1% 1% 2% 1% 3% 101%
I. No figures available on client level, not specified by type of substance. II. Figures 2003 calculated based on production overview 31-05-2004, production figures not yet audited. This is the reason for differences with Table 8.20. Source: Netherlands (Drug) Rehabilitation Foundation (SVG).
8.4.3 The Judicial Treatment of Addicts (SOV) With effect of 1 April 2001, it has become legally possible for the courts to mandate criminal problem users of drugs to undergo treatment in a special custodial facility with a partly inpatient and partly outpatient program. The “Judicial Treatment of Addicts” (SOV) Order is presently implemented as a temporary experiment in specially equipped correctional facilities.
•
The order is imposed by a three-judge criminal section of the court at the request of the Public Prosecutions Department, if the suspect has committed a crime that is subject to pre-trial detention, is drug-dependent, has been sentenced to a custodial punishment at least three times in the five years prior to the current offence, has participated without success in compulsory drug treatment in the past and does not suffer from a serious psychiatric disorder. The SOV is only meant for men who have the Dutch nationality.
•
The Judicial Treatment of Addicts order has a mandatory term of two years. The Judicial Treatment of Addicts program has a phased system with a closed phase, a half-open phase and an open phase outside of the institution. The duration of each phase is six to nine months. The order includes a "unit 4". There those persons are placed who do not (or temporarily not) wish to cooperate with the program provided in the framework of the order. They will undergo minimum treatment.
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•
The Judicial Treatment of Addicts (SOV) started in 2001 in four different locations: Rotterdam (start date 1 April 2001), Amsterdam (start date 1 May 2001), Utrecht (start date October 2001) and in the South (Arnhem, Nijmegen, Den Bosch, Eindhoven, Maastricht and Heerlen; start date October 2001). The first participant was accepted in June 2001. The total capacity is 219 places.
•
The number of participants in the SOV increased steadily in 1003, as it did in 2002: from 157 in January 2003 to 178 in June and 192 end December 2003. Between July and November 2003 the number was more or less stable (see Figure 8.1).
Figure 8.1
Number of participants in the Judicial Treatment of Addicts (SOV) per month in 2003
250
192
200 163
165
174
157
170
178
Jan
Feb
Mar
Apr
May
Jun
183
184
181
183
184
Jul
Aug
Sep
Oct
Nov
150
100
50
0 Dec
Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
The degree of capacity utilisation increased also. In 2003 the degree of capacity utilisation increased from 71 percent in January to 78 percent in June and subsequently to 85 percent in December. End 2003, 15 percent of the available (inpatient) places were still empty (see Table 8.25). End 2002 this was still 32 percent.
•
The degree of capacity utilisation varied per location. In December 2003, the degree of capacity utilisation in Amsterdam was 94%, in Rotterdam 85 percent, in Utrecht 91 percent and in the South (Arnhem, Nijmegen, Den Bosch, Eindhoven, Maastricht and Heerlen) 65%.
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Table 8.25
Number of participants and degree of utilisation of the Judicial Treatment of Addicts (SOV) by location Survey dates 31 January, 30 June and 32 December I 2003 II
Amsterdam Rotterdam Utrecht South Total Jan Jun Dec Jan Jun Dec Jan Jun Dec Jan Jun Dec Jan Jun Dec 65 69 68 47 54 61 23 25 32 20 22 26 155 170 187
Number of participants Degree of capacity utilisation (%)
90
96
94
65
75
85
66
71
91
50
55
65
71
78
85
I. Counted exclusive of participants in phase 3. II. South in December 2003: Arnhem: 6, Nijmegen: 2, Heerlen: 5, Den Bosch: 5, Eindhoven: 6, Maastricht: 2. Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
End December 2003, 90 participants were in phase 1, 61 in phase 2 and 5 in phase 3; 28 participants were staying in unit 4 and 7 participants underwent treatment in another facility while retaining their SOV status. Eight persons were already in the Judicial Treatment for Addicts (SOV) before it was imposed (preventives or pre-SOVs; see Table 8.26).
Table 8.26
Participants in the Judicial Treatment for Addicts (SOV) by phase, stay in unit 4 and in another facility. Survey date 31 December 2003
Phase/unit Preventive or pre-SOV Phase 1 Phase 2 Phase 3 Unit 4 In another facility while retaining SOV status Total
Number of participants 8 90 61 5 28 7 I 200
I. Included: one participant who is a fugitive. Source: Judicial Treatment of Addicts (SOV) locations, Trimbos Institute.
•
In 2003, the outflow started on a regular basis, that is to say the outflow of drug addicts who had completed the SOV program. On 22 April 2003, the first participant completed this treatment and left. In December 2003, 22 participants completed the treatment and left. The Judicial Treatment for Addicts (SOV) was ended seven times prematurely by the Court.
•
Information about the processes and effectiveness of this drug treatment order is not yet available. In September 2001, the process evaluation of the SOV commenced. The results will become available at the beginning of 2005. The effect evaluation commenced in June 2002, with the final results expected in late 2006.
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Appendix A
Glossary of Terms
This appendix consists of two parts. In the first part, concepts in the field of the use of substances and addiction are explained. In the second part, concepts in the field of drug crime are explained. I.
USE OF SUBSTANCES AND ADDICTION
Abuse A form of problematic use of a substance, whereas there is no addiction (yet). Abuse is established via diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Characteristics of abuse are: nonfulfilment of obligations at home, at school or at work, use in dangerous situations (for example, driving under the influence), being in contact with the criminal judicial system and continued use despite the problems created by this. Addiction Problematic use of a substance while there is dependence. As a rule, in this Annual Report, by "addiction" is understood the clinical diagnosis of dependence. However, for judicial monitors it is not possible to make clinical diagnoses. Judicial monitors record, for example, additional danger because of drug use or ‘clear indications for addiction’ (see Chapter 8.3.2., Criminal Justice Monitor (SRM)). The clinical diagnosis of dependence is made via classification systems as the Diagnostic and Statistic Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Characteristics of dependence are: frequent use of large quantities or for a longer period of time, the need of ever increasing quantities of the substance to cause the desired effect (habituation), withdrawal symptoms, use of the substance against withdrawal symptoms, wanting to stop while not succeeding, spending much time to obtain the substance or to recover from it, dropping important activities at home, at school, at work or during leisure time and continuing the use in spite of the realisation that this causes many problems. Client LADIS Client of the (inpatient) care organisations of drug addicts, of whom some details about his/her background, treatment demand and received treatment are recorded anonymously in the LADIS, the National Information System on Alcohol and Drugs. Clients are registered with the care organisations for many forms of help, from a therapeutic treatment to help in the form of debt rescheduling, methadone provision, social rehabilitation or controlled access to a users’ room. Clients who do no longer use the aid organisation after some time are deregistered automatically and are no longer included in the number of clients. Clinical admission Admission in a hospital while the patient stays for one or more nights in the hospital. Current use The use of a substance in the last month, irrespective of the frequency (from one-time to daily). Current users are included automatically as part of the recent users (use in the past year), who are again included automatically as part of the ever users (use ever in life). Day-treatment admission Admission in a hospital for maximum one day, while the patient does not stay overnight in the hospital. Dependence See: Addiction.
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DSM DSM stands for Diagnostic and Statistical Manual of Mental Disorders. The DSM is a manual to determine from which mental disorder somebody suffers. According to the DSM, addiction is one of the mental disorders. The DSM-III-r is the third revised version and the DSM-IV is the fourth version. Ever use The use of a substance ever in a life-time, irrespective of the frequency (from one-time to daily). Hallucination Perception (seeing, hearing or feeling) that someone has, but that is not shared by other people. Hallucinations may be a symptom of a mental disorder, but are called up intentionally by some people via hallucinogens. Hallucinogens Substances calling up hallucinations, such as paddo's and LSD. Are also called psychodysleptics. Cannabis may also cause hallucinations sometimes. Hardcore Hard form of music at house parties. Hard drugs Drugs appearing in list I of the Opium Act. These drugs create an unacceptable risk to public health. Hard drugs include heroin, cocaine, crack, ecstasy and amphetamine. Hepatitis A highly contagious disease in which the liver is affected by the hepatitis virus. The hepatitis virus appears in various forms: the hepatitis A, the hepatitis B and the hepatitis C virus. HBV is the hepatitis B virus and HCV is the hepatitis C virus. ICD International Classification of Diseases. The ICD is the diagnostic classification system of the World Health Organisation (WHO) for physical diseases, accidents and mental disorders. Causes of death are also recorded in ICD codes. The ICD-9 is the ninth and the ICD-10 is the tenth version. See also Appendix C. Immigrant, foreign, ethnic Due to different definitions, figures about immigrants are not always comparable. Some definitions are: According to the Ministry of Home Affairs, the Association of Dutch Municipalities, the National Representative School Survey, the Antenne Monitor and as generally used in this Annual Report (unless stated otherwise): "immigrant" is an inhabitant of the Netherlands who was born abroad, or an inhabitant with at least one parent who was born abroad. According to Statistics Netherlands (CBS): "immigrant" is an inhabitant of the Netherlands with at least one parent who was born abroad, irrespective of the country of birth of the person himself/herself. According to the Amsterdam Area Health Authority (GG&GD Amsterdam): "foreigner" is an inhabitant who was born abroad. According to National Information System on Alcohol and Drugs (LADIS): "immigrant" is a client who in his own perception has a cultural origin from outside of the Netherlands. Inpatient care organisations for addicts Care of addicts in which the client is not admitted in a facility.
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Mellow Form of music at house parties that is melodious and less hard than hardcore music. Narcotics Drugs. General collective term for narcotic drugs. Native Dutch According to the Ministry of Home Affairs, the Association of Dutch Municipalities, the National Representative School Survey, the Antenne Monitor and as generally used in this Annual Report (unless stated otherwise): "native Dutch" is a person who was born in the Netherlands while both parents were also born in the Netherlands. Nederwiet Weed (a cannabis product) grown in the Netherlands. Outpatient care organisations for addicts Care of addicts in which the client is not admitted in a facility. In the case of inpatient care of addicts, the client is admitted in a facility. Parkstad Limburg The cooperation between the South-Limburg municipalities of Brunssum, Heerlen, Kerkrade, Landgraaf, Nuth, Onderbanken, Simpelveld and Voerendaal. (The municipality of Nuth has meanwhile left the cooperation.) Party drugs Drugs used by some party-goers at parties, such as ecstasy, amphetamines, cannabis, GHB and LSD. Poly drug use The use of various drugs one after the other, for example heroin and cocaine. Primary cause of death The direct cause of somebody’s death. If someone dies directly as a result of a drug overdose, then this is the primary cause of death. If somebody dies as a result of an accident that took place while he or she was under the influence of a drug, then the accident is the primary cause of death. The drug is then a secondary cause of death. Primary diagnosis The primary disease for which someone is admitted in a hospital. Primary problem If someone has a problem with two (or more) substances, the primary problem is the substance causing the largest problem. The other substance is then the secondary problem. Problematic use The use of a substance in such a manner that it causes physical, mental or social problems or in such a manner that it causes social nuisance. Problematic use does not always mean addiction. "Abuse" is a form of problematic use, whereas there is no addiction. Psychodysleptics See: Hallucinogens.
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Psychosis Mental disorder in which someone has hallucinations, i.e. sees, hears or feels things that are not perceived by other people. If the disorder lasts less than one month, it is called a short term psychotic disorder. Smoking Chinese-style Smoking of heroin from aluminium foil. Secondary diagnosis An additional or underlying disease for which someone is admitted in hospital in addition to the primary disease (primary diagnosis). Recent use The use of a substance in the last year, irrespective of the frequency (from one-time to daily). Recent users are included automatically as part of the ever users (use ever in lifetime). Recreational use Use of a substance (usually during leisure time) in which the substance is enjoyed without a question of problematic use (abuse or addiction). Schizophrenia Mental disorder in which someone has hallucinations, i.e. sees, hears or feels things that are not perceived by other people. As a result of this disorder, one's functioning at school, work and in the family is affected. The disorder is only called schizophrenia if it lasts at least six months. Secondary cause of death A cause that contributed indirectly to the death. If somebody dies as a result of an accident that took place when he or she was under the influence of a drug, then the drug is a secondary cause of death. Special education Special education for children with learning difficulties (MLK), special education for children with learning and behavioural difficulties (LOM) and special education for children with severe behavioural learning problems (ZMOK). Secondary problem If someone has a problem with two (or more) substances, the secondary problem is the substance causing relatively the smallest problem. The other substance is then the primary problem. Soft drugs Drugs in list II of the Opium Act, such as cannabis and paddo's. Drugs with less risk for public health than the hard drugs in list I of the Opium Act. THC Tetrahydrocannabinol, the main psychoactive ingredient of cannabis. Use The use of a substance ever in lifetime (ever use), in the past year (recent use), or in the past month (current use). Current users are included automatically as part of the recent users, who are again included automatically as part of the ever users.
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II.
DRUG CRIME
a
Acquittal Judgment by the court in which the court does not consider it proved that the charge made by the public prosecutor was committed by the suspect. See also: Discharge from further prosecution, Conviction. Appeal Ordinary legal remedy granted to any party which appeared in the first instance and which was partially or entirely unsuccessful; the reason for the proceedings is the judgment pronounced in the first instance. Bar to the prosecution Final decision in which the court rejects the request or claim of a party or denies the right of the Public Prosecutions Department to prosecute based on a ground that is not part of the case itself (for example, a procedural error). Coercion Coercion means that a user who is dealt with by the criminal system because of the umpteenth offence is ‘pushed' in the direction of a treatment process. The user has the choice between a treatment process and a penal sanction. The choice has consequences: if the user opts for a treatment process, not only can he improve his situation, but also further prosecution and penalty will be suspended. If he does not opt for that, or if he does not satisfy the conditions of the judicial authorities, execution of the penal sanction will follow. See also: Compulsion.
Compulsion Contrary to “coercion”, in the case of compulsion the user has no choice. He can be admitted without his consent. In the case of repeat criminal offenders among hard drug users this can be done by imposition of the nonpunitive order Judicial Treatment of Addicts (SOV). See also: Coercion.
Conviction Judgment by the court in which the court considers the fact charged by the Public Prosecutions Department proved, considers it an offence and is of the opinion that the suspect is punishable. Court of law Court of justice that takes cognizance in the first instance of all the cases for which no other court has been designated. There are 19 courts of law. N.B. As of 1 January 2002 the subdistrict courts have become part of the organisation of the courts of law. Crime Heavy kind of offence, named thus in criminal law; categorising offences as crimes and minor offences is pertinent to procedural law (absolute competence and legal remedies) and to the penalization; disposal in the first instance is usually carried out by the court a
Source of list of concepts: Statistics Netherlands (CBS), Voorburg/Heerlen, 2003; Research and Documentation Centre of the Ministry of Justice (WODC)
153
See also: Minor offence.
Criminal record A criminal record is a police contact during which a report of one or more crimes was drawn up. Criminal case The police report in respect of one suspect that is registered at a public prosecutor’s office for prosecution. Custodial sentence Prison sentence, for life or for a period of maximum twenty years, usually served in a prison. See also: Detention. Detention Principal detention: custodial sentence for a period of maximum 1 year and 4 months, of a lighter nature than imprisonment and usually served in a remand centre Alternative imprisonment: custodial sentence because of non-payment or only partial payment of a fine. Discharge from (any) further prosecution Judgment of the court in which, on the one hand, the court considers the fact charged by the public prosecutor proved, but, on the other hand, is of the opinion that the fact or the suspect is not punishable. See also: Conviction, Acquittal. Discretionary dismissal Decision of the Public Prosecutions Department waiving prosecution of an established offence in the public interest. See also: Dismissal. Dismissal Decision of the Public Prosecutions Department waiving prosecution of an established offence on policy-related or technical grounds. See also: Discretionary dismissal, Dismissal by reasons of likeliness of nonconviction. Dismissal by reasons of likeliness of nonconviction Decision of the Public Prosecutions Department to waive prosecution of an offence, as the Department is of the opinion that prosecution will not lead to a conviction (for example, because there is not sufficient proof or because the offence or the suspect is not punishable). Disposal by the court Final judgment, by conviction, acquittal, discharge from further prosecution or one of the other final judgments. Disposal by the Public Prosecutions Department Final judgment with respect to a police report registered with the public prosecutor’s office by dismissal, joinder without charge, joinder with charge, out-of-court settlement or transfer to the court cases department of a different public prosecutor’s office. Early release The early release in principle, by virtue of the law, from the penitentiary of persons convicted to a longterm prison sentence.
154
Final judgement Sentence by the court definitely ending a civil matter that started with a summons for a certain instance. See also: Interlocutory judgment. First instance, (in the -) Primary judicial authority where a case is disposed. See also: Appeal.
Irrevocable judgment Judgment of a court of law against which no (ordinary) remedy is available anymore. Joinder in the hearing Joining by the court of criminal cases that are registered under different public prosecutor’s office numbers, with the objective of disposing these cases as one criminal case. See : Disposal by the court Joinder with charge Joining by the Public Prosecutions Department of registered criminal cases with the objective of having the court dispose several cases simultaneously in one sentence. See: Disposal by the Public Prosecutions Department. Joinder without charge Joining by the Public Prosecutions Department of a criminal case without charge to another case that is submitted to the court, with the objective of having the court take the joined case into account when determining the punishment. See also: Disposal by the Public Prosecutions Department Minor offence Light kind of offence, named thus in criminal law; categorising offences as crimes and minor offences is pertinent to procedural law (absolute competence and legal remedies) and to the penalization; disposal is usually through a settlement/out-of-court settlement via the Public Prosecutions Department or disposal in the first instance by the subdistrict court. See also: Crime. Netherlands Rehabilitation Foundation (SVG) Organisation aiming to make an effort and contribute demonstrably to the reintegration of the rehabilitation clients into society. The aim is also to prevent a repetition of the punishable behaviour. It does so by investigating and reporting the person and circumstances of the suspect or the convicted person, drawing up action plans to achieve the objectives set, providing counselling and supervision during the execution thereof and the supervision of the execution of community service. Only in those cases in which there are clear starting points for behavioural change and the chance of success seems to be considerable, intensive programmes will be used to this end. Ordinary criminal action courts Criminal case that is, in the first instance, within the competence of the court, except for fiscal and financial offences.
155
Out-of-court settlement Fulfilment, in certain circumstances, to prevent prosecution, of one or more conditions set by the investigating officer (police) or the Public Prosecutions Department (public prosecutor), such as payment of an amount of money (‘fine’), cancelling the right of prosecution. Percentage of solved crimes The total number of crimes solved in a certain period as compared to the total number of police report drawn up in that same period in respect of the same or similar crimes, expressed in percentage. Police custody Deprivation of liberty for maximum four days at the instruction of the assistant public prosecutor, if the period (six hours) that a suspect may be detained for questioning is not sufficient. Police report Written report drawn up by an investigating officer about the facts or circumstances noted by him/her. Pre-trial detention Deprivation of liberty in remand centre prior to disposal in court, generally applied upon suspicion of a serious offence (criminal offence carrying a jail sentence of four years or more), because of a serious risk of escape and/or for serious cause of public safety, for example, fear of repetition. Public Prosecutions Department (OM) Public authority with the following assignments: maintenance of the law, investigation and prosecution of criminal offences, execution of sentences and informing the court insofar as the law prescribes thus. Sentence Reasoned binding judgment of the court in an action brought it. See also: Judgment, Interlocutory judgment. Solved crime A crime in which at least one of the suspects became known to the police, even if he/she is a fugitive or denies to have committed the (criminal) offence. Summons Official writ (bailiff’s notification) calling someone to appear at a certain time before the court in connection with the prosecution of an offence charged to the person summoned (law of criminal procedure). Suspect Before the commencement of the prosecution, this is the person who, based on facts or circumstances, is reasonably supposed to be guilty of an offence, after which the suspect is the person against whom the prosecution is directed. Suspect who is a minor Someone who is under 18 year of age at the time of committing an offence. Disposal of (juvenile) cases of a simple nature takes usually place via Halt (Bureaus). N.B. Nobody may be prosecuted for an offence committed before reaching the age of 12. Suspect who is of age Someone who is 18 year of age or older at the time of committing an offence.
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Appendix B
Sources
This appendix provides an overview of the main sources of the National Drug Monitor (NDM) for, successively, (I.) use and problem use, (II.) treatment demand and treatment, (III.) disease and mortality, (IV.) market information and (V.) judicial data. For a more detailed description of the sources: see www.trimbos.nl/monitors, or www.ivo.nl, or www.zonmw.nl.
I.
USE AND PROBLEM USE
Source
Target Group
Substances
Antenne
Pupils and young clubbers in Amsterdam
Alcohol, drugs, tobacco
ESPAD
Secondary school pupils aged 15 and 16 in 35 European countries
Alcohol, drugs, tobacco
Survey of clubbers in The Hague
Clubbers aged 16-35 in The Hague
Alcohol, drugs
Health Behaviour in Schoolaged Children (HBSC)
Pupils aged 11-17
Alcohol, cannabis, tobacco
Measurements
Responsible organisation/ Homepage Annually since 1993, the Bonger Institute for Criminology with varying choice of of the University of Amsterdam target group (UvA) and Jellinek Prevention and Consultancy www.jur.uva.nl www.jellinek.nl/ 1995, 1999, 2003 the Swedish Council for Information on Alcohol and Other Drugs (CAN), the Pompidou Group, for the Netherlands the Trimbos Institute www.can.se/ Annually from 2002 Research Committee Monitoring & Registration of Addiction Problems (MORE) www.denhaag.nl/ Four-yearly since 2001 World Health Organisation (WHO), for the Netherlands: Trimbos Institute, Radboud University Nijmegen and Utrecht University www.hbsc.org www.trimbos.nl.
Source
Target Group
Substances
Measurements
Local and regional monitors
General population and/or young people depending on location and region, for young people: see also Appendix F
Alcohol, drugs, tobacco, depending on location and region
Usually annually, varies by location and region
The Dutch Institute for Public Opinion and Market Research (TNS NIPO) National Prevalence Research (NPO)
National population aged fifteen and over
Tobacco
Annually
National population aged 12 and over
Alcohol, drugs, tobacco
1997, 2001, possibly also 2005
National population aged 16 to 64 incl.
Alcohol, drugs
1996, 1997, 1999
Pupils aged 10-18 in the two highest groups of the primary schools and the 'regular' secondary schools: first form secondary school, pre-vocational secondary education (VMBO), higher general secondary education (HAVO) and pre-university education (VWO), sometimes projects at special schools National population aged 12 and over young people aged 12-29
Alcohol, drugs, tobacco
1984, 1988, 1992, 1996, 1999, 2003
Netherlands Mental Health Survey and Incidence Study (Nemesis) National Representative School Survey
Permanent Survey on Living Conditions (POLS)
Responsible organisation/ Homepage Municipal Health Services (GGDs) in coordination with the GGD Netherlands, municipal and private research bureaus www.ggd.nl Defacto, for a smoke-free future (previously STIVORO) www.stivoro.nl Centre for Drug Research (CEDRO), University of Amsterdam; in conjunction with Statistics Netherlands (CBS) www.cedro-uva.org Trimbos Institute www.trimbos.nl. Trimbos Institute www.trimbos.nl.
Special schools, projects: 1990, 1997
Alcohol, tobacco, for the young people module also drugs
Annually
Statistics Netherlands (CBS) www.cbs.nl
158
II.
TREATMENT DEMAND AND TREATMENT
Source
Target Group
Substances
Measurements
Central Methadone Registration (CMR)
Methadone clients in the Amsterdam region
Methadone
Annually
Educare monitor
Those requesting treatment at first aid stations of dance events
Alcohol, drugs
Annually from 1996
National Information System on Alcohol and Drugs (LADIS)
Clients of the (outpatient) care organisations for addicts. In 2003, the origin of the clients was as follows: 49% outpatient, 6% clinical, 30% hospital outpatient, 16% probation and after-care services. Hospital patients
Alcohol, drugs
Annually
Alcohol, drugs
Annually
Alcohol, drugs
Annually
Alcohol, drugs
Annually, complete up to and including 1996
National Medical Registration (LMR) Injury Information System (LIS) Register of Inpatient Mental Health Care (PiGGz). Is replaced by Zorgis.
III.
Patients who receive emergency treatment after an accident Clients of the inpatient care organisations for addicts
Responsible organisation/ Homepage Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl Educare Ambulant, Stichting Nursing & Education Consultancy www.educaregroningen.nl Organisation Care Information Systems (IVZ), Houten www.sivz.nl
Prismant www.prismant.nl Consumer Safety Institute www.veiligheid.nl Mental Health Service (GGZ Netherlands), Prismant www.ggznederland.nl www.prismant.nl
ILLNESS AND MORTALITY
Source
Target Group/Subject
Substances
Measurements
Cohort study Amsterdam en monitor drug-related mortality
Causes of death among methadone clients and recreational drug users in Amsterdam Ambulance trips for the population of Amsterdam and surrounding area
Opiates, recreational drugs
Annually from 1976
Alcohol, drugs
Annually
Causes of death of registered inhabitants of the Netherlands
Alcohol, drugs, tobacco
Annually
Central Ambulance Service (CPA) Causes of Death Statistics
Responsible organisation/ Homepage Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl Amsterdam Area Health Authority (GG&GD) www.gggd.amsterdam.nl CBS www.cbs.nl
159
Source
Target Group/Subject
Substances
Measurements
HIV/AIDS recording
People infected with HIV and aids patients among injecting drug users
Opiates
Half-yearly
HIV surveillance among drug users
Injecting drug users in various cities
Opiates
Since 1991 various measurements in various cities
ROI monitor
Drivers
Alcohol
Annually from 1970
IV.
Responsible organisation/ Homepage Health Care Inspectorate (IGZ), HIV Monitoring Foundation (SHM), National Institute of Public Health and the Environment (RIVM) www.hiv-monitoring.nl National Institute of Public Health and the Environment (RIVM) and Municipal Health Services (GGDs) www.rivm.nl/ Transport Research Centre (AVV), Ministry of Transport, Public Works and Water Management www.rws-avv.nl
MARKET INFORMATION
Source
Target Group/Subject
Substances
Measurements
Drugs Information and Monitoring System (DIMS) Coffee shop monitor
Party drugs of recreational users
Party drugs
Annually
Coffee shop policy of municipalities and enforcement policy
Cannabis
Annually
Monitor tolerated coffee shops
Officially tolerated coffee shops
Cannabis
THC Monitor
THC content and price of cannabis samples from coffee shops
Cannabis
1997, 1999, annually since 2000 Annually
Responsible organisation/ Homepage Trimbos Institute www.trimbos.nl. Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/ Bureau Intraval www.intraval.nl/ Trimbos Institute www.trimbos.nl.
160
V.
JUDICIAL
Source
Target Group/Subject
Substances
Measurements
Client Follow-up System (CVS)
Production figures of the Netherlands (Drug) Rehabilitation Foundation and their clients
All substances, no classification
Daily file creation
Police Records System (HKS)
Police reports of complaints; police records drawn up against suspects; recorded criminal history of suspects
Danger classification ‘drug user’ or ‘addicted to alcohol’; Opium Act offences classifiable by hard and soft drugs
Update end first quarter of the entire previous calendar year; also extraction of final figures for the year before that (because of processing backlogs)
Seizures of drugs
Seizures of drugs; number of investigations, ‘rounded up’ cannabis nurseries; discovered production places of synthetic drugs
All substances, classification by type of drug
Continuous recording, annual report
Responsible organisation/ Homepage Foundation of Addiction Probation Services (SVG) in collaboration with Netherlands Rehabilitation Foundation and probation and after-care services of the Salvation Army www.ggznederland.nl The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD, in collaboration with the regional police departments; the Research and Documentation Centre of the Ministry of Justice (WODC) has a copy at its disposal http://www.politie.nl/KLPD/ www.wodc.nl/ The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD), in collaboration with the regional police departments http://www.politie.nl/KLPD/
161
Source
Target Group/Subject
Substances
Measurements
Locations Judicial Treatment of Addicts (SOV).
Figures about admissions in the SOV, drug-dependent offenders who are accepted for participation in the SOV process Policy information about the criminal procedure; anonymised copy of the Justice Documentation System
All substances
Monthly
Opium Act offences classifiable by hard and soft drugs
Four time per year before update
Public Prosecutions Department Data (OMDATA)
National database of the National Office of the Public Prosecutions Department with data on prosecution and disposal in first instance.
Opium Act offences classifiable by hard and soft drugs
Three time per year before update
Investigations into Organised Crime
Investigations by the Dutch police into more serious forms of organised crime; offenders of, inter alia, the Opium Act who work together in a criminal organisation
Classification by hard and soft drugs
Annual report
Enforcement of custodial measures in correctional institutions (TULP)
Profiles of detainees, length of imposed penalties and profiles of the institutions; judicial institutions for juvenile persons (TULP/JJI) and institutions in the framework of a hospital order (TBS) are recorded separately
Opium Act offences classifiable by hard and soft drugs
Continuous recording
Justice Documentation Research Database (OBJD)
Responsible organisation/ Homepage Locations Judicial Treatment of Addicts (SOV) www.trimbos.nl. Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/ Public Prosecutions Department and Council for the Administration of Justice; the National Office of the Public Prosecution Service collects and manages the data; Research and Documentation Centre of the Ministry of Justice (WODC) has a copy at its disposal www.wodc.nl/ The unit Knowledge and Development, department Research and Analysis of the National Criminal Information service of the National Police Agencies (K&O/O&A/dNRI/KLPD), in collaboration with the regional police departments http://www.politie.nl/KLPD/
National Agency of Correctional Institutions (DJI) of the Ministry of Justice www.dji.nl/
162
Source
Target Group/Subject
Substances
Measurements
WODC Recidivist Monitor
Long-term research project with standardised recidivist measurements among different groups of justiciable individuals
Opium Act offences classifiable by hard and soft drugs
Reports based on Justice Documentation Research Database (OBJD)
Responsible organisation/ Homepage Research and Documentation Centre of the Ministry of Justice (WODC). www.wodc.nl/
163
Appendix C
Definition of ICD-9 and ICD-10 codes
Definition of ICD-9 codes ICD-9 code 162 291 292 303 304 304.0 304.2 304.3 304.4 304.7 305 305.0 305.2 305.3 305.4 305.5 305.6 305.7 305.8 305.9 357.5 425.5 535.3 571.0 571.1 571.2 571.3 980.0-1 E850 E850.0 E854.1 E854.2 E855.2 E860.0-2 E950.9* E980.9*
Definition Malignant neoplasms of trachea, bronchus and lung Alcoholic psychoses Drug psychoses Alcohol dependence syndrome Drug dependence Dependence to opiates and related substances Cocaine dependence Cannabis dependence Dependence to amphetamines and other psychostimulants Dependence to combinations of opiates with other substances Non-dependent abuse of drugs or other substances Alcohol abuse Cannabis abuse Hallucinogen abuse Barbiturate and similarly acting sedative or hypnotic abuse Opiate abuse Cocaine abuse Amphetamine or related acting sympathomimetic abuse Antidepressant type abuse Other, mixed, or unspecified drug abuse Alcoholic polyneuropathy Alcoholic cardiomyopathy Alcoholic gastritis Alcoholic fatty liver Acute alcoholic hepatitis Alcoholic cirrhosis of the liver Alcoholic liver damage, unspecified Toxic effect of alcohol Accidental poisoning by analgesics, antipyretics, and antirheumatics Accidental poisoning by heroin Accidental poisoning by psychodysleptics (hallucinogens) Accidental poisoning by psychostimulants Accidental poisoning by local anaesthetics (including cocaine) Unintentional poisoning by alcoholic beverages (ethanol/methanol) Suicide through self-inflicted poisoning by solid or liquid substances Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted * Only included if 980.0-1 has been mentioned as complication.
Definition of ICD-10 codes ICD-10 code C33 C34 F10 F11 F12 F13 F14 F15 F18 F19
Definition Malignant neoplasms of trachea Malignant neoplasms of bronchus and lung Mental and behavioural disorders due to use of alcohol Mental and behavioural disorders due to use of opiates Mental and behavioural disorders due to use of cannabis Mental and behavioural disorders due to use of sedatives or hypnotics Mental and behavioural disorders due to use of cocaine Mental and behavioural disorders due to use of other stimulants Mental and behavioural disorders due to use of volatile solvents Mental and behavioural disorders due to poly drug use and use of other psychoactive substances G31.2 Degeneration of the nervous system due to alcohol consumption G62.1 Alcoholic polyneuropathy I42.6 Alcoholic cardiomyopathy K29.2 Alcoholic gastritis K70.0 Alcoholic fatty liver K70.1 Alcoholic hepatitis K70.2 Alcoholic fibrosis and cirrhosis of the liver K70.3 Alcoholic cirrhosis of the liver K70.4 Alcoholic hepatic failure K70.9 Alcohol-induced liver diseases, unspecified K86.0 Alcohol-induced chronic pancreatitis T51.0-1 Toxic effect of alcohol, ethanol and methanol (only as secondary code) X41 + T43.6 Accidental poisoning by psychostimulants X42 Accidental poisoning by narcotics and psychodysleptics [hallucinogens], not classified elsewhere X42 + T40.5 Accidental poisoning by cocaine X45* Intentional poisoning by and exposure to alcohol X61 + T43.6 Suicide through psychostimulants X65* Intentional auto-intoxication by alcohol Y11 + T43.6 Poisoning by psychostimulants, undetermined whether accidentally or purposely inflicted Y15* Poisoning by and exposure to alcohol- undetermined whether purposely inflicted * Only included if complication T51.01 has been mentioned.
165
Appendix D Overview of products Netherlands (Drug) Rehabilitation Foundation and coercive treatment processes Current treatment processes as alternative for prosecution and detention Type of treatment process: Drug treatment clinic
Characterisation by objective:
Inpatient Motivation Centre
Low-threshold facility, aimed to motivate clients to undergo follow-up treatment or to improvement of welfare and well-being. Not aimed at abstinence and therapy. Length of stay 3-4 months.
Long-term phased programmes (SOV coercion, Triple-Ex)
Aimed at reintegration (work/training, leisure time, living, finances, social relationships), abstinence and reduction of nuisance and crime by the participants. Phased setup: closed - half-open - open phase, duration 16-18 months.
Forensic drug treatment clinic
Clinic with national function. Phased setup. Strong security in the first closed phase. Aimed at abstinence, social stability and better functioning, Therapeutic. Duration 6-18 months.
Living projects under guidance
Small-scale projects in which clients are trained and guided in living, learning and working. The objective is to guide addicts towards (the highest possible degree of) living independently. Often in combination with learning/work processes.
Aimed at abstinence and stability in psychological and social functioning. Therapeutic, also crisis intervention.
Outpatient and part-time Aimed at improvement or stabilisation of the situation of clients treatment of addicts through guidance and counselling. Source: 144.
Appendix E
Internet addresses with information on alcohol and drugs
Addiction Research Institute Foundation (IVO) http://www.ivo.nl/ Addiction Treatment Centre North Netherlands http://www.verslavingszorgnoordnederland.nl/ Amsterdam Area Health Authority http://www.gggd.amsterdam.nl/ Australian Institute of Health and Welfare (AIHW) http://www.aihw.gov.au/ Brijder Addiction Treatment Centre http://www.brijder.nl/ CEDRO Centre for Drug Research (University of Amsterdam) http://www.cedro-uva.org/ Consumer Safety Institute http://www.consument-en-veiligheid.nl/ De Grift http://www.degrift.nl/ DeltaBouman http://www.deltabouman.nl/ Dutch Association for Mental Health Care (GGZ) http://www.ggznederland.nl Emergis Addiction Treatment Centre http://www.emergis.nl/verslavingszorg/ European Centre for the Epidemiological Monitoring of AIDS http://www.eurohiv.org/sida.htm European Commission - Taxation and Customs Union http://europa.eu.int/comm/taxation_customs/publications/info_doc/info_doc.htm#Excises European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) http://www.emcdda.org/ Europol http://www.europol.eu.int/home.htm GGZ Group North and Central Limburg/Addiction Treatment Centre http://www.ggz-groepnmlimburg.nl/
Health Care Inspectorate http://www.igz.nl/productie/indexie.html Institute of Food Safety (RIKILT) http://www.rikilt.dlo.nl/ Intraval. Bureau for Research and Consultancy http://www.intraval.nl/ Jellinek Centre (Amsterdam) http://www.jellinek.nl/ Maliebaan Centre http://www.centrummaliebaan.nl/ Mental Health Service Netherlands http://www.ggznederland.nl Ministry of Justice http://www.justitie.nl/ Ministry of Public Health, Welfare and Sports (VWS) http://www.minvws.nl/index.html Mondriaan Care Group/Addiction Treatment Centre http://www.mondriaanzorggroep.nl/ Municipal Health Service Netherlands http://www.ggd.nl/ National Institute for Health and Prevention (NIGZ) http://www.nigz.nl/ National Institute of Public Health and the Environment (RIVM) http://www.rivm.nl/ National Police Agency (KLPD) http://www.klpd.nl/ Novadic-Kentron, network for addiction treatment http://www.novadic-kentron.nl/ Organisation for Care Information Systems (IVZ) http://www.ivv.nl/ http://www.sivz.nl/ Parnassia, Psycho-Medical Centre http://www.parnassia.nl/ Police http://www.politie.nl/
170
Prismant http://www.prismant.nl/ Public Prosecutions Department http://www.openbaarministerie.nl/ Research and Documentation Centre (WODC) http://www.wodc.nl/ STIVORO, for a smoke-free future http://www.stivoro.nl/ Statistics Netherlands (CBS) http://www.cbs.nl/ Substance Abuse & Mental Health Service Administration (SAMHSA) http://www.samhsa.gov/ SWOV-Institute for Road Safety Research http://www.swov.nl/ TACTUS, Institution for addiction treatment http://www.tactus.nl/ Trimbos Institute http://www.trimbos.nl/ World Health Organisation (WHO) http://www.who.int/en/
171
Appendix F
Data youth monitors and youth surveys
The percentages of the use of drugs, alcohol and tabak are based on reports of local youth monitors or youth surveys in towns, cities, regions or provinces, throughout the Netherlands. Most of the young people who are the subject of these surveys were selected via a representative sample taken from the Municipal Personal Records Databse (GBA) or the Population Register. Most of the times these young people were sent a written questionaire with the request to complete and return it. Sometimes the possibility was provided to answer the questions via the internet. With a view to comparability, the following critera were applied for the selection of the data. In the first place, the maximum age margin was limited to young people aged 10 to 26 incl. Whenever youth monitors also related to children below the age of 10, those data have therefore not been included. In the second place, the overview has been limited to youth monitors that were carried out after 1-12002. Thirdly, the results of all the youth monitors in which the sample consisted of specific secondary school classes have not been included. This is the case, inter alia, in pupil surveys and in, what are called, E-MOVO surveys (Electronic Monitoring and Information). In the overview tables some distortion may have occurred. This is due to the varying use of the term ‘occasionally’ in the questions asked about alcohol, tobacco and drugs. The question Have you smoked occasionally? is understood here as: Have you ever smoked? The question Do you smoke occasionally? leaves the young people most room for their own interpretation. In the absence of a subsequent question about the regularity of the use (in the past four weeks, the past week or daily), this second variant of ‘occasionally’ has been equated with smoking in the past four weeks. The same has been done with questions like Do you smoke occasionally? and Do you smoke? In nearly all youth monitors, separate questions are asked about the use of soft drugs/cannabis. However, regularly ‘hard drugs’ (ecstasy, cocaine, heroin, LSD, paddo’s and amphetaminen) are combined in one single question. In case of absence of the separate ‘hard drugs’ percentages in a report, these data have not been included in the overview tables.
CANNABIS Town or city/Region/ Province 162 Almelo
Year
Net number of respondents
Age youngsters
Ever
Recent
2002
511
18-23 years
32%
Almere
2002
2.080
16% 50% 30%
Alphen a/d 164 Rijn 165 Amersfoort
2003
512
12-18 years 19-23 years 12-23 years 12-26 years
2004
1.292
16-18 years
166
2003
7.085
2003
900
2% 20% 32% 37% 18%
1% 6% 8% 5%
167
12-14 years 15-17 years 18-21 years 22-24 years 12-22 years
2002
1.234
19-23 years
38%
8%
39% 38% 39% 29%
15% 5% 9% 6%
163
8% 9%
19-22 years Apeldoorn
Dordrecht
168
Drenthe of which: - Assen - Coevorden - Emmen - Hoogeveen
9%
Current/ occasionally 4%
14%
173
- Meppel 163 Dronten
Ede
169
Eindhoven Flevoland
170
163
Gooi and Vecht 171 Region Groningen 172 (city) 173 Heerhugowaard ‘s-Hertogenbosch 163 Lelystad
Leiden
175
Maasbracht
176
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) Nijmegen
178
179
Schiedam Tilburg
Urk
180
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
174
57% 14% 38% 23%
2002
603
2003
1.750
2002 2002
664 508 6.087
End 2001
1.025
12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 18-20 years 21-24 years 12-17 years 18-24 years 12-18 years 19-23 years 12-23 years 12-18 years
2002
1.801
12-17 years
2002
556
14-21 years
2002 2002
825 2.171
2003
1.023
2002
478
18-24 years 12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 12-17 years 18-23 years 24-26 years 12-17 years
2003
12.297
12-17 years
2002
665
2003
1.600
12-18 years 19-23 years 12-23 years 12-17 years
12% 35% 20% 16%
2003
1.005
12-23 years
24%
2003
1.938
2002
285
2002
256
12-13 years 16-17 years 12-17 years 19-23 years 12-23 years 12-18 years
2003
6.862
12-17 years
2002
?
12-17 years
14%
2002
337
14% 39% 21%
2003
3.697
12-18 years 19-23 years 12-23 years 12-14 years
7%
1% 10% 14% 10% 5% 14% 16% 45% 27% 18%
8% 8%
12,5% 29%
5% 8% 12%
17% 50% 32% 5% 8% 6% 11% 11% 3% 5%
8%
1% 11% 5%
7% 16% 9%
12% 4% 5%
2%
15-17 years
7%
12-17 years
5%
18-23 years 24-26 years 12-26 years
10% 10% 8%
174
COCAINE Town or city / Province Almelo
Year
162
Apeldoorn
Drenthe
166
168
Eindhoven Flevoland
170
163
Groningen 172 (city) 173 Heerhugowaard Nijmegen
178
179
Schiedam
Net number of respondents
Age youngsters
Ever
2002
489
18-23 years
2,3%
2003
7.085
2002
1.234
12-14 years 15-17 years 18-21 years 22-24 years 19-23 years
2002 2002
664 508 6.061
12-17 years 18-24 years 12-23 years
2002
1.801
12-17 years
2002
556
14-21 years
2%
2003
1.600
12-17 years
1%
2003
1.005
12-23 years
3%
Recent
1%
Current/ occasionally 0,4%
< 1% < 1% 4% 7% 3% 1,1 2,1 < 1% 0,2%
<1%
HEROIN Town or city / Province 162 Almelo
Year
Net number of respondents
Age youngsters
Ever
2002
480
18-23 years
0%
2003
7.085
168
2002
1.234
12-17 years 18-24 years 19-23 years
< 1% < 1% < 1%
Groningen 172 (city) SouthHolland 184 North
2002
1.801
12-17 years
2003
3.697
12-26 years
Apeldoorn Drenthe
166
Recent
0%
Current/ occasionally 0%
0,1 % 0%
ECSTASY Town or city / Province Almelo
Age youngsters
2002
Net number of respondents 490
166
2003
7.085
167
2003
900
12-14 years 15-17 years 18-21 years 22-24 years 12-24 years
<1% 2% 7% 10% 3%
2002
1.234
19-23 years
4%
2002
664 508 6.061
12-17 years 18-24 years 12-23 years
162
Apeldoorn
Dordrecht Drenthe
168
Eindhoven Flevoland
170
163
Year
2002
18-23 years
Ever
3,2%
Recent
1,4%
Current/ occasionally < 1%
2,8% 5,1% 1,6%
175
Groningen 172 (city) 173 Heerhugowaard Nijmegen
178
179
Schiedam
West-Friesland
183
2002
1.801
12-17 years
0,5%
2002
556
14-21 years
4%
2003
1.600
12-17 years
1,5%
2003
1.005
12-23 years
6%
2002
?
12-23 years
< 1%
1%
AMPHETAMINES/SPEED Town or city / Province 162 Almelo
Year
Age youngsters
Ever
2002
Net number of respondents 488
18-23 years
3%
2003
7.085
2002
1.234
12-14 years 15-17 years 18-21 years 22-24 years 19-23 years
< 1% 1% 3% 6% 2%
2002
508
18-24 years
163
2002
6.061
12-23 years
Groningen 172 (city) Heerhugowa 173 ard
2002
1.801
12-17 years
2002
556
14-21 years
3%
179
2003
1.005
12-23 years
3%
Apeldoorn
Drenthe
166
168
Eindhoven Flevoland
170
Schiedam
Recent
Current/ occasionally
< 1%
< 1%
1,3% < 1% 0,1%
ALCOHOL Town or city/Region/Provinc e 162 Almelo
Net number of respondents
Age youngsters
Ever
Current/ occasionally
2002
528
18-23 years
83%
2002
2.080
12-23 years
82%
78%
2003
512
12-26 years
74%
68%
2004
1.292
166
2003
7.085
12-17 years 10-22 years 12-14 years 18-21 years 12-24 years
55% 55% 38% 84% 71%
167
2003
900
12-22 years
62%
163
Almere
Alphen a/d Rijn Amersfoort Apeldoorn
Dordrecht
Year
165
164
Drenthe
168
2002
1.234
19-23 years
86%
Dronten
163
2002
603
12-23 years
82%
2003
1.750
12-24 years
75%
2002
664 508 6.083
12-17 years 18-24 years 12-23 years
50% 85% 79%
Ede
169
Eindhoven Flevoland
170
163
2002
81%
Weekly
29%
82%
176
Gooi and Vecht 171 Region Groningen 172 (city)
End 2001
Lelystad Leiden
12-18 years
67%
2003
640 616 545 700
12-13 years 14-15 years 16-17 years 18-24 years
23% 62% 84% 70-80%
2002
556
14 years 15-16 years 17-21 years 14-21 years 12-23 years
2002
Haarlemmermeer Heerhugowaard
1.025
185
173
163
175
2002
2.171
2003
1.023
80%
93% 81%
22% 66% 43%
18-23 years
82%
12-26 years
Maasbracht
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) 178 Nijmegen
179
Schiedam Tilburg Urk
180
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
66%
79%
12-14 years 15-17 years 12-17 years 24-26 years
176
20% 80% 90%
82% 76%
70%
2002
478
2003
12.297
12-14 years 15-17 years 12-17 years 12-17 years
29% 81% 53% 59%
2002
665
12-23 years
82%
2003
1.600
10-11 years
13%
6%
12-17 years
54%
42%
81%
?
18-24 years
2003
1.005
12-16 years
47%
17-23 years
74%
2003
1.938
12-17 years
51%
2002
285
12-23 years
75%
2002
256
12-18 years
39%
2003
6.862
12-13 years
20%
14-15 years
60%
16-17 years
80%
12-17 years
53%
12-17 years 12-23 years 12-23 years
80%
66% 77% 79%
12-14 years 15-17 years 12-17 years 18-23 years 24-26 years 18-26 years
30% 82% 56% 90% 88% 90%
24% 77% 50% 87% 82% 85%
2002
?
2002
337
2003
3.697
88%
70%
177
TOBACCO Town or city/Region/ Province 162 Almelo
Year
Age youngsters
Ever
70%
2002
528
18-23 years
2002
2.080
2003
512
12-18 years 19-23 years 12-23 years 12-26 years
166
2003
7.085
167
2003
900
12-14 years 15-17 years 18-21 years 22-24 years 12-22 years
163
Almere
Alphen a/d Rijn Apeldoorn
Dordrecht
Net number of respondents
164
Current/ occasionally 9%
52% 53%
25%
27% 56% 67% 71%
3% 8% 9% 9%
3% 17% 25% 28% 15% 33%
168
2002
1.234
19-23 years
11%
Dronten
163
2002
603
16% 48%
2003
1.750
12-18 years 19-23 years 12-23 years 12-24 years
2002 2002
664 508 6.086
End 2001
1.025
12-17 years 18-24 years 12-18 years 19-23 years 12-23 years 12-18 years
2003
845 640 616 545 700
9-11 years 12-13 years 14-15 years 16-17 years 19-24 years
2002
556
14-21 years
2003
1.023
169
Eindhoven Flevoland
170
163
Gooi and Vecht 171 Region Groningen 172 (city)
2002
Haarlemmermeer Heerhugowaard Leiden
185
173
175
163
Maasbracht
176
Northeast and 177 Middle Brabant Northeast Polder 163 (NOP) Nijmegen
178
179
Schiedam Tilburg
180
2002
2.171
2002
478
2003
12.297
2002
665
2003
1.600
2003
? 1.005
2003
1.938
54%
19% 16%
21%
33% 15% 40% 17% 43% 54% 46%
9%
20% 12%
2% 3% 18% 30% 32% 11%
18%
12-14 years 15-17 years 18-23 years
7% 20% 26%
1% 13% 17%
24-26 years
37%
20%
25%
15%
12-26 years
Lelystad
35%
15% 39%
Drenthe
Ede
Daily
12-18 years 19-23 years 12-23 years 12-14 years 15-17 years 12-17 years 12-18 years 19-23 years 12-23 years 10-11 years 12-17 years 18-24 years 12-16 years 17-23 years 12-13 years 14-15 years 16-17 years
65%
57%
17% 44% 56%
22%
21%
7% 29% 4%
8%
18% 46% 55% 7%
20%
10% 25% 64%
24% 3% 9% 1% 13% 25%
5% 26%
178
Urk
163
Utrecht
181
182
West-Brabant
West-Friesland Zeewolde
163
South-Holland 184 North
183
36%
259
12-17 years 12-18 years 19-23 years 12-23 years 12-18 years
2003
6.862
12-17 years
37%
2002
?
12-17 years 12-23 years 12-18 years 19-23 years 12-23 years 12-26 years
2002
285
2002
2002
337
2003
3.697
13,2% 28% 44%
69%
9%
21%
24% 11%
5%
9% 17% 27%
39%
18% 38% 50% 51%
25%
18% 8%
179
180
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