2007 Netherlands National Drug Monitor

The Annual Report also contains data on beloop registered drug crime and Voor meer informatie over het ontstaan, en behan­ deling gives details onstoornissen current punitive forwww.trimbos.nl, applying compulsion and van psychische kunt umeasures terecht op quasi-compulsion drug criminals. en in de jaarboekentovan deaddicted Nationale Monitor Geestelijke Gezondheid. The NDM Annual Report is compiled on behalf of the Ministry of Health, Welfare Sport, (Netherlands in associationMental with the Ministry of Justice. De studieand NEMESIS Health Survey and It aims to provide information toeerste politicians, policy-makers, professionals in the field Incidence Study) is het landelijke onderzoek naar de geesand other interested with information the use of drugs, alcohol telijke gezondheid vanparties de algemene bevolkingabout in Nederland. Het and tobacco the Netherlands uitgevoerd in de jaren 1996werd door hetinTrimbos-instituut 1999. Het leverde in de loop van de tijd zeer veel gegevens op, waar tot op de dag van vandaag beleidsmakers, professionals en universitaire onderzoekers gebruik van maken.

The Netherlands National Drug Monitor 2007

In theuNetherlands monitoring follow Heeft vragen over various het vóórkomen vanorganisations psychische stoornissen developments in the area of drugs, alcohol and tobacco. vrouwen, bij specifieke bevolkingsgroepen, zoals hoger opgeleide The Annual Reports of the National Drug Monitor (NDM) an jonge mannen, werkenden en alleenstaanden? Dan vindtprovide u in up-to-date overview of the flow of information on the dit boek de antwoorden. Hetconsiderable bevat epidemiologische informatie use of drugs, and tobacco. maar ook kennis over psy­ afkomstig vanalcohol de NEMESIS-studie, chische stoornissen uit de jaarboeken van de Nationale Monitor This reportGezondheid combines the most data about use problem use of Geestelijke van hetrecent Trimbos-instituut. Ditand maakt cannabis, cocaine, ecstasy voor and amphetamines, assnel well as alcohol het boek uniek, en opiates, dus onmisbaar iedereen die zich and tobacco.in It het alsovóór­ presents figures on treatment and en adequaat komen van een psychischedemand, stoornis illness bij deaths as doelgroepen well as supplywil and market, placing the Netherlands in an specifieke verdiepen. Deze uitgave is praktisch international en toepasbaar.context. Geschikt voor iedere professional.

ND M

NDM

NDM

The Netherlands National Drug Monitor Annual Report 2007

NDM Annual Report 2007

Trimbos Institute, Utrecht, 2008

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Colophon Editors Dr. M.W. van Laar1 Dr. A.A.N. Cruts1 Dr. J.E.E. Verdurmen1 Dr. M.M.J. van Ooyen-Houben2 Drs. R.F. Meijer2 In association with Dr. E.A. Croes1 Drs. A.P.M. Ketelaars1 P.P.J. Groen2 J.J. van Dijk2 1 2

Trimbos Institute (Netherlands Institute of Mental Health and Addiction) WODC

Production Frédéric Zolnet Lay-out Gerda Hellwich Ellen van Oerle Design cover and print Ladenius Communicatie BV, Houten

This publication can be ordered online at www.trimbos.nl. Article number AF0837. You will receive an invoice for payment. ISBN 978-90-5253-621-7

© 2008 Trimbos Institute, Utrecht All rights reserved. No part of this publication may be copied or publicised in any form or in any way, without prior written permission from the Trimbos Institute To access this report as a pdf. document: Go to www.trimbos.nl. Or go to www.wodc.nl.

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Members of the NDM Scientific Committee

Prof. dr. H.G. van de Bunt, Erasmus Universiteit Rotterdam Prof. dr. H.F.L. Garretsen, Tilburg University (President) Prof. dr. R.A. Knibbe, Universiteit Maastricht Dr. M.W.J. Koeter, AIAR Dr. D.J. Korf, Bonger Institute of Criminology, University of Amsterdam Prof. dr. H. van de Mheen, IVO Prof. dr. J.A.M. van Oers, RIVM, Tilburg University A.W. Ouwehand, Stg. IVZ Drs. A. de Vos, Netherlands Association for Mental Health Care (GGZ Nederland) Observers mr. R. Muradin, Ministry of Justice Drs. W.M. de Zwart, Ministry of Health, Welfare and Sport (VWS) Additional referees Dr. M.C.A. Buster, Municipal Health Service Amsterdam (GGD Amsterdam) Ms. A. Hoekstra, Ministry of Justice R. Mathijssen, SWOV Drs. W.G.T. Kuijpers, Stg. IVZ Dr. M.C. Willemsen, STIVORO

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Contents PREFACE

7

LIST OF ABREVIATIONS AND ACRONYMS

9

SUMMARY

13

1

INTRODUCTION

21

2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

CANNABIS RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION USAGE: JUVENILES PROBLEM USE USAGE: INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS SUPPLY AND MARKET

25 25 25 27 32 33 36 41 41

3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

COCAINE RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION USAGE: JUVENILES AND YOUNG ADULTS PROBLEM USE USAGE: INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS SUPPLY AND MARKET

45 45 45 47 50 50 52 56 57

4 4.1 4.2 4.3 4.4 4.5 4.6 4.7

OPIATES RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION USAGE: JUVENILES PROBLEM USE USAGE: INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS

59 59 59 60 61 64 65 70

5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8

ECSTASY, AMPHETAMINES AND RELATED SUBSTANCES RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION USAGE: JUVENILES AND YOUNG ADULTS PROBLEM USE USAGE: INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS SUPPLY AND MARKET

81 81 82 83 86 87 89 95 96

6 6.1 6.2

ALCOHOL RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION

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101 101 102

5

6.3 6.4 6.5 6.6 6.7 6.8

USAGE: JUVENILES AND YOUNG ADULTS PROBLEM USERS USAGE: INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS SUPPLY AND MARKET

104 110 112 115 123 127

7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

TOBACCO RECENT FACTS AND TRENDS USAGE: GENERAL POPULATION USAGE: JUVENILES AND YOUNG ADULTS PROBLEM USE INTERNATIONAL COMPARISON TREATMENT DEMAND ILLNESS AND DEATHS SUPPLY AND MARKET

130 130 130 133 135 136 139 140 143

8 8.1 8.2 8.3

DRUG-RELATED CRIME RECENT FACTS AND TRENDS DRUG LAW VIOLATIONS DRUG USERS IN THE CRIMINAL JUSTICE SYSTEM

147 148 148 167

Appendix A Glossary of Terms

175

Appendix B Sources

184

Appendix C Explanation of ICD-9 and ICD-10 codes

193

Appendix D Websites in the area of alcohol and drugs

195

Appendix E Drug use in a number of new EU member states

199

REFERENCES

201

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PREFACE As is customary, the 2007 Annual Report has been compiled by the Bureau of the National Drug Monitor (NDM), which is incorporated in the Trimbos Institute and the Scientific Research and Documentation Centre (WODC) of the Justice Ministry. This Report contains a great deal of information, covering topics such as substance use and treatment demand, deaths, markets and drug law offences. The 2007 Annual Report clearly shows, for instance, that treatment demand for cannabis use continues to rise, that the THC content in Dutch-grown weed has further declined and that the Dutch school-going population drink a lot, by comparison with other European countries. The publication of the Annual Report makes a lot of important and (policy-) relevant information available. Thanks to a relatively high quality data supply system, developments in the area of substance use and drug-related crime can be charted on an annual basis. At the same time, the Annual Report also identifies (potential) gaps in knowledge, which will be the focus of attention in the coming years. The Scientific Council of the National Drug Monitor is indebted to the staff of the NDM Bureau and of the WODC for the hard work they have done. Many thanks are also due to all individuals and organisations that submitted data for the report. Prof. Dr. Henk Garretsen Chairman Scientific Committee of the National Drug Monitor.

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LIST OF ABREVIATIONS AND ACRONYMS 2C-B 4-MTA AIAR AIDS AIHW BMK BO BZK BZP CAN (CBS) CEDRO CJIB CMR COPD CPA CSV CVA CVS DBC DIMS DIS DJI DMS dNRI/O&A DOB DSM EHBO EMCDDA ESPAD EU FPD GGD GG&GD GGZ GHB HAART HAVO HBSC HBV HCV HDL-C HIV HKS ICD IDG IGZ ISD

4-bromo-2,5-dimethoxyphenethylamine 4-methylthioamphetamine Amsterdam Institute for Addiction Research Acquired Immune Deficiency Syndrome Australian Institute of Health and Welfare Benzyl-methyl-keton Primary Education Ministry of the Interior (and Kingdom Relations) Benzylpiperazine Swedish Council for Information on Alcohol and Other Drugs Statistics Netherlands Centre for Drugs Research Central Fine Collection Agency Central Methadone Registration Chronic Obstructive Pulmonary Disease Central Post for Ambulance Transports Criminal Consortium Cerebral Vascular Accident (stroke) Patient Monitoring System Diagnosis-Treatment Combination Drugs Information and Monitoring System DBC Information system Custodial Institutions Service / Correctional Institutions Service (juveniles) Drug Monitoring System Research and Analysis Group of the National Criminal Intelligence Service of the National Police Agency 2,5-dimethoxy-4-bromoamphetamine Diagnostic and Statistical Manual First Aid European Monitoring Centre for Drugs and Drug Addiction European School Survey Project on Alcohol and Other Drugs European Union Forensic Psychiatric Service Municipal Health Service Community Health Service Netherlands Association for Mental Health Care Gamma hydroxybutyric acid Highly Active Anti-Retroviral Treatment General secondary education Health Behaviour in School-aged Children (study) Hepatitis B virus Hepatitis C virus High density lipoprotein cholesterol Human Immunodeficiency Virus Police Records System International Classification of Diseases Intravenous Drug User (Public) Health Care Inspectorate Institution for Prolific Offenders

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IVO Addiction Research Institute (Rotterdam) IVZ Organization of Care Information Systems KLPD National Police Agency KMar Royal Military Police LADIS National Alcohol and Drugs Information System LIS Injury Information System LMR National Medical Registration LOM School for children with learning and educational difficulties LSD d-Lysergic-acid-diethylamide LUMC Leiden University Medical Center LZI National Hospital Care Information MBDB N-methyl-1-(3,4-methyleen-dioxyphenyl)-2-butanamine mCPP meta-Chlor-Phenyl-Piperazine MDA Methyleen-dioxyamphetamine MDEA Methyleen-dioxyethylamphetamine MDMA 3,4-methyleen-dioxymethamphetamine MGC Monitor of Organised Crime MLK School for children with learning difficulties MMO Social Inclusion Monitor MO/VB region Region for Social Inclusion and Addiction Policy MSM Men who have sex with men NDM National Drug Monitor NEMESIS Netherlands Mental Health Survey and Incidence Study NFU Netherlands Federation of University Medical Centres NIGZ National Institute for Health Promotion and Illness Prevention NMG National Mental Health Monitor NPO National Prevalence Survey NRI National Criminal Investigation Service/ National Intelligence Service NVIC National Poisons Information Centre NWO Netherlands Institute of Scientific Research OBJD Research and Policy Database of Criminal Records OM Public Prosecutor / Public Prosecution Service / Office OPS List of wanted persons PAAZ Psychiatric Department of a General Hospital PBW Prisons Act PMA Paramethoxyamphetamine PMK Piperonyl-methyl-keton PMMA Paramethoxymethylamphetamine POLS General Social Survey RIAGG Regional Institute for Outpatient Mental Health Care RIBW Regional Organisation for Sheltered Accommodation RISc Risc (of Recidivsm) Assessment Scales RIVM National Institute of Public Health and the Environment SAMHSA Substance Abuse and Mental Health Services Administration SHM HIV Monitoring Foundation SIVZ see: IVZ STD Sexually Transmittable Diseases SOV Judicial Placement of Addicts Sr Criminal Code Sv Code of Criminal Procedure SVG Addiction and Probation Department of the Netherlands Association for Mental Health Care

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SRM SSI SWOV TBS THC TNS NIPO TRIAS TULP UvA VBA v.i. VIS VMBO-p VMBO-t VNG VTV VWO VWS WHO WODC WVMC WvS ZMOK ZonMw Zorgis

Monitor of Criminal Law (enforcement) cigarette industry foundation Institute for Road Safety Research Disposal to be treated on behalf of the State (hospital order) Tetrahydrocannabinol The Netherlands Institute of Public Opinion and Market Research Transaction registration and information processing system Imposition of restricted freedom sanctions in penitentiary institutions University of Amsterdam Drug Counselling Unit Conditional release Early Intervention System Lower secondary school: practical stream Lower secondary school: theoretical stream Association of Municipalities of the Netherlands Centre for Public Health Studies Higher Secondary School Ministry of Health, Education, Welfare and Sport World Health Organisation Scientific Research and Documentation Centre Abuse of Chemical Substances Prevention Act Code of Criminal Law School for children with severe educational difficulties Netherlands Organisation for Health Research and Development Care Information System of the Netherlands Association for Mental Health Care

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SUMMARY Tables 1a and 1b give an overview of the most recent figures on substance use and drugrelated crime. Below is an outline of the most striking developments from the 2007 Annual Report. The percentage of recent users refers to the percentage that used a substance during the past year; the percentage of current users refers to the percentage that has used a substance during the past month.

Drugs: use and treatment demand Treatment demand for cannabis use continues to rise In the general population of 15 to 64 years, the percentage of current cannabis users remained stable between 2001 and 2005. In 2005, 3.3% of the population were current users the equivalent of 363,000 users in absolute terms. As against this stable trend for usage, there has been a steady increase in the number of clients with a cannabis problem seeking help from outpatient addiction care. Between 1994 and 2006 the number of primary cannabis clients rose from 1,951 to 6,544. Between 2005 and 2006 there was an increase of seven percent. Almost two thirds of cannabis clients (63%) are aged 25 or older. Few people are admitted to general hospitals with cannabis problems as the primary diagnosis (54 admissions in 2006). The number of admissions citing cannabis misuse and dependence as a secondary diagnosis is higher, and rose from 299 in 2005 to 377 in 2006 – an increase of 26%. This trend may be indicative of a rise in the number of problem cannabis users; however, it may equally reflect an improvement in treatment supply for cannabis problems, or growing awareness of the addictive properties of cannabis, leading users to seek help earlier. No further increase in treatment demand for cocaine use In the population aged 15 to 64, the percentage of current cocaine users remained stable between 2001 and 2005 (in 2005: 0.3% or 32,000 users). Among young people in social settings and young adults, cocaine use (particularly snorting) is considerably more prevalent than in the general population (3-19% current users, depending on the group). Use is not confined to the social scene, but often occurs at home, both at the weekend and during the week. The popularity of the drug has spread throughout the entire country, although following Amsterdam, its use seems to have reached saturation point. However, there may still be a rising trend among rural youth. Cocaine combined with alcohol is the drug of choice. Among hard drug addicts, cocaine in the form of crack which is smoked and therefore more addictive, is part of the standard drugs repertoire. Use of crack is relatively low among problem youth (who favour cannabis instead). It is not known how many people suffer physical, mental or social problems on account of excessive cocaine use. Data from outpatient addiction care registered a sharp rise in the number of primary cocaine clients from 2,500 in 1994 to ten thousand in 2004. However, this trend did not continue in 2005 or 2006. In fact, there was a drop of two percent in the number of cocaine clients to 9,599, between 2005 and 2006. This drop can be chiefly attributed to a reduction in the number of clients with a primary crack problem. The number of hospital admissions involving cocaine rose until 2002, after which it fluctuated around the same level. In 2006, a total of 514 admissions were registered stating cocaine misuse and dependency as a secondary diagnosis. There are far fewer cases of cocaine problems as the main diagnosis (90 admissions in 2006).

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Increase in amphetamine clients but numbers remain low In the general population of 15-64 years, the percentage of amphetamine users is fairly low and remains stable. In 2005 0.2% of the population were current amphetamine users. In population terms this accounts for 21,000 persons. However, the number of amphetamine users seeking help from outpatient addiction care more than doubled from 482 in 2001 to 1,215 in 2006. Between 2005 and 2006 there was an increase of 9 percent. The share of amphetamine in all treatment requests from outpatient addiction care for drug-related problems remains minor (4% in 2006) The number of general hospital admissions related to amphetamine(-like) substances is limited, although there was a discernible increase in 2004 of the number of secondary diagnoses involving amphetamine misuse and dependency (63 in 2003, 108 in 2004 and 88 in 2006). These trends in treatment demand may possibly reflect a growing number of problem amphetamine users; however, there is a lack of data to confirm this theory. In the social and nightlife scene, amphetamine plays only a modest role compared to cocaine and ecstasy. Key observers have, however, identified increased usage in certain parts of the country (north and south) and among specific groups of adolescents, particularly local (native Dutch) village youth. These youngsters sometimes use this substance as a cheaper alternative to cocaine. Ecstasy use still widespread, but seldom a reason for seeking treatment The percentage of current ecstasy users in the general population remained stable between 2001 and 2005 (in 2005: 0.4% or 40,000 users). In the nightlife scene, ecstasy is still a much-used drug, particularly at raves and dance parties. Key observers in the scene have identified a moderation of ecstasy use, particularly among the older revellers. However, among younger, more recently initiated users, excessive consumption has been observed more often, although there are no trend data available. The number of people with a primary ecstasy problem seeking treatment from outpatient addiction care has remained limited for years, and dropped from 293 in 2005to 228 in 2006. Over three times this number report ecstasy as a secondary problem (715 in 2006). Various studies have shown that frequent ecstasy use causes changes to the serotonin-receptors in the brain. Clinical effects of frequent ecstasy use have also been reported, such as memory loss and an increase in symptoms of depression. On the basis of recent research it cannot be concluded that even occasional ecstasy use is safe, although the effects of use in low doses on brain function are said to be subtle. Number of opiate users registered with outpatient addiction care and hospitals continues to drop According to the most recent estimates which date from 2001, there were between 24,000 and 46,000 problem opiate users in the Netherlands. Of the EU-15 member states, the Netherlands together with Greece and Germany has the lowest number of problem users per thousand inhabitants aged between 15 and 64 (2-3 users compared to 8-9 in Italy and Spain and 10 in the U.K.). The average age profile of Dutch opiate users has grown older throughout the years. The percentage of young opiate clients (15-29 years) receiving outpatient addiction care dropped from 39% 1994 to 6% in 2005, stabilising at this level in 2006. Between 2001 and 2006 there was also a drop in the total number of primary opiate clients, from almost 18 thousand to 13 thousand (-22%). Between 2005 and 2006 there was a drop of seven percent. Of opiate clients seeking treatment for their addiction, only 4% were first-time clients in 2006. The remainder were already registered with outpatient addiction care. There was also a drop in the number of admissions to general hospitals involving opiates as a secondary diagnosis. In 2005 and 2006 there were 594 and 476 such admissions respectively – a drop of 20%. The remaining group of opiate clients is growing older and often has to contend with

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physical and mental problems. The decline in the percentage of current injectors among opiate clients of outpatient addiction care has stagnated, and in 2005 and 2006 remained at ten percent. New HIV infections among injecting hard drug users are now rare. Nonetheless, injecting remains a significant risk factor for Hepatitis C infection. The rate of this infection is particularly high among registered HIV positive injecting drug users.

Alcohol and Tobacco: usage and treatment demand Slight rise in number of alcohol-related hospital admissions The number of recent and current consumers of alcohol in the population aged 15 to 64 remained stable between 2001 and 2005 (in 2005: recent 85%, current 78%). The percentage of people who consumed six or more units of alcohol in one day on at least on occasion during the past six months dropped during this period from 40 to 35 percent. There are considerable differences among the age groups, particularly where more heavy alcohol use is concerned. Males aged between 18 and 24 score highest for heavy and problem drinking. In 2007, 38% of males and 14% of females in this age group were heavy drinkers (defined as consuming at least six units of alcohol on one or more days per week). This is less than in 2002 (42% of males and 18% of females aged between 18 and 24) but slightly more than in 2006 (36% for males and 10% for females in the same age group). Alcohol use among juveniles has also attracted a lot of attention in recent years. The proportion of school-goers using alcohol at a young age increased between 1999 and 2003. They often start to drink when they are between eleven and fourteen years old. However, among 12 year olds there was a slight drop in the percentage of current users between 2003 and 2005. Alcohol appears to be inextricably linked to going out. Particularly among younger underage drinkers, there has been a marked increase in pre-drinking at home before going out to socialise. Cutting costs plays a part in this. Binge drinking among young people socialising now appears to be the norm. Despite a statutory ban on selling alcohol to juveniles aged under 16, they apparently have no problem procuring alcoholic beverages. In 2006, one fifth of 12 to 16 year olds reported having ever purchased alcohol. Of the approximately 1.2 million problem drinkers in the Netherlands, only a small number seek treatment from outpatient addiction care. In 2006, over 30,000 clients were treated for a primary alcohol problem. This represents a slight drop of 3%, which followed a rise of 39% between 2001 and 2005. In hospitals we saw an increase in the number of admissions for a primary diagnosis of alcohol abuse and dependence, from 3,900 in 2001 to 4,500 in 2004. Between 2004 and 2005, the number of hospital admissions remained fairly stable (4,533); however, from 2005 to 2006, there was a further slight rise of 7% (4,855). The number of juveniles aged 16 or under admitted for an alcohol-related problem rose (massively) by over 80% between 2001 and 2006. Slight drop in the number of smokers The percentage of smokers in the population aged 15 or older showed a slight decline from 28.2% in 2006 to 27.5% in 2007. Among those aged 12 and older, the percentage of heavy smokers declined from 7.2% to 6.7%. In the case of tobacco addiction, treatment demand chiefly involves self-help and GP consultations. In 2006 an estimated 42,800 males and 42,100 females consulted their GP about quitting smoking. This is 24% less than in 2005. The market for nicotine replacement therapies (patches, gum, tablets) rose between 2006 and 2007. Various anti-smoking campaigns are in place.

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Deaths Smoking remains the most important cause of death In the Netherlands, smoking is still the main reason for premature deaths, even if the trend is slightly downward. In 2006 19,366 people aged over 20 died as a direct consequence of smoking, which was seven percent less than in 2000. In 2006 alcohol-related conditions were the direct cause of over 700 deaths; in a further thousand or so cases, alcohol-related conditions were listed as a secondary cause of death. The rise in total alcohol-related deaths, evident from the early 1990s, has not continued since 2004. Deaths from alcohol-related conditions and tobacco are many times those caused by (hard) drug abuse. In 2006, 112 direct drug-related deaths (overdose) were registered – slightly fewer than in 2005 (122). During the past ten years, this number has fluctuated between 103 and 144 cases. By comparison with a number of other European countries, the death rate from drugs remains low in the Netherlands.

Market Further drop in TCH-content of Dutch-grown weed The Drugs Information and Monitoring System (DIMS) monitors the composition of recreational drugs and cannabis. It has been found that for years most pills sold as ecstasy tablets contain true MDMA or a related substance. However, one in ten ecstasy tablets in 2007 was found to also contain the substance metachlorpiperazine (mCPP). This substance can induce unpleasant effects. The number of pills found to have a relatively high dose of MDMA (over 105 mg) rose from 20% in 2006 to 30% in 2007. The average THC content (the main active ingredient in cannabis) of Dutch-grown weed declined further between 2006 and 2007 from 17.5% to 16%. The average price per gram of Dutch-grown weed rose during this period from €6.20 to €7.30. There are no indications that cannabis mixed with lead beads or glass particles is reaching the market via the coffee shops.

Offences against the Opium Act The majority of criminal investigations into serious forms of organised crime involve drugs In 2006, three-quarters of the more than 300 investigations into serious forms of organised crime were aimed at drug trafficking or production. Most cases concerned hard drugs: cocaine, synthetic drugs and heroin. In the case of soft drugs, the investigations mainly centred on the cultivation or trafficking of Dutch-grown weed. Stabilisation of new Opium Act offences in the law enforcement chain in 2006 Over 22,000 individuals are registered with the police and Royal Military Police as suspects of drugs offences – about the same number as in 2004 and 2005. Some 20,000 cases have proceeded to the Public Prosecutor; 2004 was a peak year in this respect; in 2005/2006, the number stabilised at relatively high level. The percentage of Opium Act offences has remained fairly consistent in recent years at seven to eight percent. Apparently drug crimes follow the same trend as the total of all crimes. Drop in hard drug offences, but soft drug crimes on the rise This trend was particularly marked in 2005 and 2006. This is likely to be a consequence of the clampdown on hemp cultivation. There is little difference between the number of

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hard drug cases and soft drug cases before the Public Prosecutor or the courts. However, hard drug crime still accounts for the majority of cases overall, and for the bulk of sentences handed down as well as number of detention years. More Opium Act offences disposed of and fewer (partly) unconditional prison sentences handed down by the courts The courts disposed of some 13,000 Opium Act cases in the first instance. In 2006, the number of community service orders declined slightly compared to 2005, but is still relatively high. Between 2000 and 2005 there had been a steady increase. In 2006, the courts imposed fewer (partly) unconditional prison sentences than in 2005; the number of detention years was also lower. This decline was already to be seen in 2004, and generally applies to all types of crime. Drug cases are part of this general downward trend. However, the percentage of drug crimes has increased somewhat, implying that these crimes are declining less markedly than the other types. Drug crimes are relatively likely to progress through the entire law enforcement chain. The percentage of Opium Act offences in all crimes registered with the police/Royal Military Police and the Public Prosecutor fluctuates between six and eight percent. The percentage before the courts is higher, at seven to nine percent. Drug offences account for 12-13% of all custodial sentences (2000-2006) and for between 27 and 33 percent of total detention years imposed for crimes. This means that the ratio of drug crime increases as it progresses along the chain. In 2006, offences against the Opium Act had a relatively high likelihood of ending up in court and leading to a relatively long custodial sentence.

Crimes committed by users A large proportion of the prison population have problems with substance use or gambling. 60% of detainees report problem use of alcohol or drugs, or a gambling problem in the year prior to detention. 30% are problem drinkers, 33% are problem cannabis users; 24% are addicted to hard drugs – especially cocaine and heroin. And 6% have a gambling habit.

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Tabel 1a

Key Data on Substance Use Cannabis

Cocaine

Opiates

Ecstasy

Amphetamine

Alcohol

Tobacco

5.4% 3.3%

0.6% 0.3%

0% 0%

1.2% 0.3%

0.3% 0.2%

85% 78%

27.5% (2007)

Stable

Stable

Stable

Stable

Downward

Slightly below average

Below average

Low

Above average

Below average

Average

Average

9%

0.8%

0.5%

1.2%

0.8%

58%

20%

Downward (b) Stable (g)

Stable

Stable

Downward

Downward

Stable (b) Upward (g)II

Downward

Average

Average

Average

Below average

Below average

High (>10 times last month)

Average

UnknownIII

Unknown

24,000-46, 000IV

Unknown

Unknown

1 200 000

>1 000 000V

6,544 5,167

9,599 7,829

13,180 2,043

228 715

1,215 760

30,210 5,208

Unknown

Downward

Stable, slight drop in 2006

Upward

Upward until 2005, slight drop in 2006

n.a.

General Population Usage (2005) -

Percentage of recent usersI - Percentage of current usersI - Trend recent use (2001-2005) - International comparison

Stable

Stable

Use among juveniles, school-goers (2003) - Percentage of current users, 12-18 yrs - Trend 12-18 yrs (1996-2003) - International comparison, 15/16 yrs Number of problem users

Number of Outpatient Addiction Care clients (2006) - Substance as primary problem - Substance as secondary problem

- Trend (2002 – 2006)

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Upward

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Upward until 2004, then a slight drop

Number of hospital admissions (2006) - Misuse/dependence as primary diagnosis - Misuse/dependence as secondary diagnosis - Trend (2002 – 2006)

54 377

90 514

78 476

39 88

4,855 11,689

Unknown

Upward

Stable

Downward

Slightly upward

Slightly upward

Unknown

No primary deaths

21 (primary)

44 (primary)

<10

1,009 (sec.)VII 733 (primary.)

19,366 (primary+sec.)

Registered Deaths (2006)VI

<10

I. Recent use: in the past year; current use is in the past month. b = boys, g=girls. II. Between 1999 and 2003. III. 50,000 in 1996 according to cannabis dependence diagnosis. IV. According to new estimation methods. Numbers do not differ significantly from previous estimates. V. Based on heavy smokers (20 or more cigarettes a day). VI. Primary death: substance as primary (underlying) cause of death. Secondary death: substance as secondary cause of death (contributory factor or complication). VII. Not taking account of road deaths or cancer-related deaths.

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Table 1b

Drug crime: Key Figures; Opium Act offences in the law enforcement chain Number of police/KMar suspectsI

Number of Public Prosecutor cases

Convictions by a court in the first instance

Custodial sentences

Detention years

- Total

22 145

20 193

13 076

4 133

2 243

- Hard drugs

11 090

9 870

6 538

3 317

1 884

- Soft drugs

8 127

9 461

5 942

573

199

- Both

2 487

804

577

243

160

- Update 2005-2006

Stable

Stable

Increase

Reduction

Reduction

Increase until 2004, then stable at a relatively high level

Increase until 2004; 2005 and 2006 somewhat lower. Decline in hard drugs (since 2004); increase in soft drugs

Decline in hard drugs (since 2003); increase in hard drugs

Increase until 2004; then a decline

Increase until 2003; then a decline

Phase in the chain Number of offences

- Global trend 2000-2006

% Opium Act offences of totalII - Update of % 2005-2006

7%

7.5%

8%

16%

26%

Stable

Stable

Slight increase

Slight increase

Slight increase

I. Provisional figures 2006. Sources: HKS, KLPD/DNRI; OMDATA, WODC; OBJD, WODC

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1

INTRODUCTION

The National Drug Monitor In the Netherlands there are several monitoring organisations that follow developments in the area of substance abuse. Scientific papers are also frequently published about usage patterns, prevention and treatment methods. In this veritable sea of information, the National Drug Monitor (NDM) provides policymakers and professionals working in practice as well as various other target groups with an up-to-date overview of the situation. The primary goal of the NDM is to gather data about developments in substance use in a coordinated and consistent manner on the basis of existing research and registered data, and to process this information and translate it into a number of core products, such as Annual Reports, thematic reports and fact sheets. This aim is consistent with the current quest for evidence-based policy and practice. The NDM was set up in 1999 on the initiative of the Minister for Health, Welfare and Sport.1 Drug use, however, is not exclusive to the domain of public health but also comes within the remit of the Justice Ministry. Since 2002, the Ministry of Justice has also supported the NDM. The NDM embraces the following functions: • Acting as umbrella for and coordinator between the various surveys and registrations in the Netherlands concerning the use of addictive substances (drugs, alcohol, tobacco) and addiction. The NDM aspires towards the improvement and harmonisation of monitoring activities in the Netherlands, while taking account of international guidelines for data collection. • Synthesising data and reporting to national governments and to international and national organisations. The international organisations to which the NDM reports include the WHO (World Health Organisation), the UN and the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction). Within the NDM, the collection and integration of data are central. These activities are conducted on the basis of a limited number of key indicators – or barometers of policy – which are agreed by the EU member states within the framework of the EMCDDA. Data are collected on the following: • Substance use in the general population • Problem use and addiction • Treatment demand from addiction care • Illness in relation to substance use • Deaths in relation to substance use. Where available, data are recorded on supply and market, such as the price and quality of drugs. The NDM also reports on registered drug crimes and how law enforcement agencies respond to these crimes. This is also conducted on the basis of a series of indicators, for which the WODC collects data.2 NDM reports consist mainly of statistical data that are based on quantitative research. Sometimes the Annual Report also contains data that are based on qualitative research. These are often derived from the observations of key persons in specific settings. Because these feedback reports may provide indicators for potential new trends in sub-

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stance use, they are sometimes included in the Annual Report. These indications may form the basis for further statistical substantiation.

Collaborations The NDM relies on the input of many experts. The executors of many local and national monitoring projects make their contribution. The quality of the publications is ensured by the NDM Scientific Committee. This Committee evaluates all draft texts and advises on the quality of the monitoring data. The NDM is supported on thematic modules by the study group on prevalence estimates of problem substance use and the study group on drug-related deaths. Once yearly, the NDM publishes a statistical overview of addiction and substance use and their consequences. This is the NDM Annual Report. This report is included in the documentation that is presented to parliament annually.

2007 Annual Report This is the ninth Annual Report of the NMD. Chapters two through seven deal with developments per substance or classes of substances: cannabis, cocaine, opiates, ecstasy and amphetamines, alcohol and tobacco. In each chapter we present a concise report on the most recent data about use, problem use, treatment demand, (illness) and deaths, as well as supply and market. The position of the Netherlands is placed in an international perspective. Owing to differences in age group categories, definitions of usage and methods, the differences between countries should, however, be interpreted with caution. Chapter eight contains data on registered drug-related crime. Central to this is crime as defined by the Opium Act and the criminal behaviour of drug users in various stages of the law enforcement chain (police, Public Prosecutor, judiciary, custody). This chapter also contains an up-to-date overview of the possibilities available to law enforcement agencies for the compulsory and quasi-compulsory treatment of drug-addicted criminals. Data on substance abuse and drug-related crime can be collected and represented in different ways. Appendix A contains information on the terminology used. Appendix B contains a concise overview of the most important sources of information for this Report. The NDM Annual Report may also be accessed as a pdf document on the following websites: • www.trimbos.nl. • or www.wodc.nl.

Information Gaps During the compilation of the Annual Reports, it has transpired that some essential data may be missing, considerably out of date or of inadequate quality. The gaps identified by the NDM Scientific Committee include the following in particular: • The number of problem users of cannabis and cocaine is unknown. • There are no recent data on the prevalence of HIV and Hepatitis B and C among local groups of (injecting) hard drug users. • In a more general sense, we are losing sight of developments in risk behaviour and problems (mental, social and health-related) in the population of problem hard drug

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• •

• •

users. This is due to a reduction in the number of periodic, quantitative field studies in this population. There is no national database of trends in (risk) substance use among the at-risk group of youngsters in social settings. There is still insufficient information on users who seek help from private addiction clinics and from regular addiction clinics who have not yet merged with outpatient addiction care. There is an incomplete picture of those who obtain an offer of help for addiction problems by means of an E-health intervention. There is still incomplete registration of the results of treatment and care in respect of outpatient and inpatient addiction care.

The chapter on drug-related crime reports chiefly on registered crime. There is little data available on non-registered drug-related crime. Any data that are available are reported here. Significant gaps in the registration data are: • The registration of drug seizures is incomplete and inconsistent. • Data on drug-using convicted offenders are incomplete or of inadequate quality. Action has already been taken to address a number of these deficiencies. For the three main cities, Amsterdam, Rotterdam and The Hague, an estimate is to be calculated of the number of users of crack, the smokeable form of cocaine. This is to be conducted within the framework of the ZonMw programme on risk behaviour and dependency. Furthermore, in 2009, the NEMESIS population study on mental health (Netherlands Mental Health Survey and Incidence Study, Nemesis II), will generate national data on the number of cannabis-dependent people in the general population aged 18 to 64. In addition, the Public heath Inspectorate (IGZ) aims to establish a complete overview of all private addiction clinics in 2008. Besides this, E-health interventions in the form of prevention, early intervention and self-help are generally not registered with the National Alcohol and Drugs Information System (LADIS). There are only occasional databases at regional level on these interventions. Only E-health interventions that are included as part of actual treatment for addiction problems, are registered with LADIS. Funding of E-health by insurers is likely to be one of the reasons for having this kind of treatment fully registered as standard. With regard to gaps in law enforcement data, the WODC conducted a survey in 2006-2007 on the number of dismantled cannabis plantations, and on the incidence of problem alcohol and drug users and gambling addicts in the prison system. 3;4 The information from these studies has been included in this Annual Report. In addition, it is important that in future, all organisations for addiction care should participate in the nationwide registration of the Diagnosis Treatment Combinations (DCBs), and that this information is delivered to the national DBC Information System (DIS).To this end it is important that all addiction care organisations should participate in the DIS. Some organisations will do so as an addiction care division within an integrated organisation for mental health care. The DIS may well succeed in reducing some of the information gaps during the coming years. But to date, the DBC registration has not yet met the requirements for charting the scale of alcohol and drug addiction. For other gaps, a short-term solution may not be feasible. During the coming years, the issue of improving the quality of monitoring data will therefore remain under scrutiny. For as long as new registration systems , such as the DIS, are unable to take on the functions of the existing systems, it remains altogether of great importance that the existing registration systems such as the Dutch Hospital Registration (LMR) and the National Alcohol and Drugs Information System (LADIS) should remain in place. On behalf of the NVZ hospitals association and the Netherlands federation of university medical centres (NFU), a working group

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has now been set up for the LMR which aims to maintain the further development of the LMR in the form of the National Hospital Information System (LZI).

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CANNABIS

Cannabis (Cannabis Sativa or hemp) contains hashish and weed in various concentrations. THC (tetrahydrocannabinil) is the main psychoactive component. Cannabis is generally smoked in cigarette form – with or without tobacco – and sometimes through a vaporizer. It is less often eaten in the form of space cake. Users tend to experience cannabis as calming, relaxing and mind-expanding. In high doses, cannabis can trigger anxiety, panic and psychotic symptoms. The data below apply to both hashish and weed, unless otherwise specified.

2.1 RECENT FACTS AND TRENDS In this chapter, the main facts and trends concerning cannabis are: • The percentage of recent and current cannabis users in the population aged between 15 and 64 remained stable between 2001 and 2005. (§ 2.2). • Among school-goers (12-18 years) the percentage of current cannabis users dropped slightly between 1996 and 2003. Data from 2005 show that cannabis use among school-goers has stabilised (§ 2.3). • Cannabis use occurs relatively frequently among ‘problem juveniles’ (§ 2.4). • By European standards, Dutch adults score around or slightly below average for recent and current cannabis use (§ 2.5). • In keeping with the rising trend of previous years, the number of cannabis clients of (outpatient) addiction care increased further in 2006 (§ 2.6). • General hospitals registered an increase in the number of admissions involving cannabis use or dependence as a secondary diagnosis between 2005 and 2006 (§ 2.6). • The average THC content of Dutch-grown weed dropped further between 2006 and 2007 (§ 2.8). • Between 2006 and 2007, there was a rise in the average price of Dutch-grown weed (§ 2.8).

2.2 USAGE: GENERAL POPULATION Cannabis is the most widely used of all illegal drugs. In 1997, 2001 and 2005, National Prevalence Surveys (NPO) were conducted5. • From 1997 to 2001 the percentage of the population aged from 15 to 64 that had ever used cannabis remained stable. Between 2001 and 2005 the percentage of ever users increased. The total percentage of recent and current users remained at the same level in all three surveys (table 2.1). • In 2005 over one in five people surveyed reported ever having used cannabis. One in twenty had used cannabis in the year prior to the interview (recent use), and one in thirty-three had done so in the month before the interview (current use). • Calculated in terms of the population, the number of current cannabis users amounts to 363,000. • In 2005 1.3% of the population had used cannabis for the first time ever. The growth of new users has remained stable throughout the years.

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Table 2.1

Cannabis use in the Netherlands in the population aged from 15 to 64. Survey years 1997, 2001 and 2005 1997

2001

2005

19.1% 24.5% 13.6%

19.5% 23.6% 15.3%

22.6% 29.1% 16.1%

5.5% 7.1% 3.8%

5.5% 7.2% 3.8%

5.4% 7.8% 3.1%

3.0% 4.2% 1.8%

3.4% 4.8% 1.9%

3.3% 5.2% 1.5%

1.4%

1.1%

1.3%

27.3 years

28.3 years

30.5 years

Ever use

• Male • Females Recent useI

• Males • Females Current useII

• Males • Females First used in the past year I

Average age of recent users

Number of respondents: 17 590 (1997), 2 312 (2001), 4 516 (2005). I. In the past year. II. In the past month. Source: NPO, IVO.5

Age and Gender • More males than females use cannabis (table 2.1). • Consumption of cannabis occurs chiefly among juveniles and young adults (figure 2.1). Between 1997 and 2005 the percentage of recent and current users aged 15 to 24 dropped, whereas the percentage of recent and current users in the 25 to 44 year age group increased. This shift took place mainly between 1997 and 2001. - Likewise, the average age of recent cannabis users rose – from 27 to almost 31 (table 2.1). - The age of onset is the age at which a person first used a substance (see also appendix A: age of onset). Among ever users of cannabis, the age of onset for the 15 to 24 year old age group was 16.4 years on average. In the population aged 15 to 64, the age of onset averaged 19.6 years.

-

Figure 2.1

Cannabis users in the Netherlands by age group. Survey years 1997 and 2005

%

%

Recent

16

16

14

14

12

12

10

10

8

8

6

6

4

4

2

2

Current

0

0 15-24 years

25-44 years 1997

45-64 years

15-24 years

25-44 years 1997

2005

45-64 years

2005

Percentage of recent (last year, on left) users and current users (last month, on right) by age group. Source: NPO, IVO.5

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The main cities There is more cannabis consumption in urban than in rural areas (Table 2.2). • In 2005 the percentage of ever and recent cannabis users was approximately three times greater in urban than in non-urban areas.

Table 2.2

Use of cannabis in the four main cities and in non-urban areas among people aged over 15 years. Survey years 1997 and 2005 Ever Use

Recent Use

Current Use

1997

2005

1997

2005

1997

2005

Very highly urbanI

31.4%

37.5%

10.4%

10.8%

6.2%

7.5%

Highly urbanII

21.0%

24.6%

4.8%

5.8%

2.9%

3.2%

15.5%

20.2%

4.3%

4.3%

2.2%

2.5%

Semi-ruralIV

15.0%

15.5%

4.5%

3.2%

2.2%

2.0%

V

12.8%

13.9%

3.8%

3.0%

1.9%

1.5%

Moderately banIII Rural

ur-

Percentage of ever use, recent (last year) and current (last month). No data by urbanisation level for 2001 due to small numbers of respondents. I. Definition (Statistics Netherlands, CBS): municipalities with over 2,500 addresses per square km. These are: Amsterdam, Rotterdam, Delft, The Hague, Groningen, Haarlem, Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. II. Municipalities with 1,500 -2,500 addresses per square km. III. Municipalities with 1,000 – 1,500 addresses per square km. IV. Districts with 500-1,000 addresses per square km. V. Districts with fewer than 500 addresses per square km. Source: NPO, IVO.5

Amount of use • In 2005 almost a quarter (23.3%) of current users took cannabis (almost) daily. In population terms, this amounts to 85 thousand people.

Special groups In certain groups of adults, cannabis use occurs considerably more frequently than in the general population. • In 2002 more than half (52%) of the homeless people in 20 Dutch municipalities were current cannabis users.6. • In 2006, 32% of the homeless surveyed in the Rotterdam shelters for the homeless used cannabis (almost) daily.7 • Cannabis use is also more prevalent among people with a (specific) mood, anxiety or alcohol disorder than among people without these disorders.4

2.3 USAGE: JUVENILES School-goers Since the early 1980s, the Netherlands Institute of Mental Health and Addiction (Trimbos Institute) has conducted surveys to establish the extent of the experience of schoolgoers aged 12 and older at regular secondary schools with alcohol, tobacco, drugs and

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gambling. This survey is known as the Dutch National School Survey. The most recent measurements were conducted in 2007; the results will be available in mid-2008. • Figure 2.2 shows a strong increase in cannabis use among school-goers between 1988 and 1996.9 • After 1999, the percentage of ever use stabilised and stayed at about the same level as in 1996. Current use dropped significantly between 1996 and 2003. This decline took place mostly among boys. Among girls, the percentage of current cannabis users remained more or less the same between 1996 and 2003. - A comparison with data from the national Health Behaviour of School-aged Children (HBSC) study in 2005 shows that recent cannabis use remained stable between 2003 and 2005.10 In 2003, 12.5 percent of school-goers aged between 12 and 16 had used cannabis in the past year; in 2005 this figure was 11.7%. • The surveys conducted up to and including 1999 found that more boys than girls used cannabis. In 2003 for the first time there was no difference between boys and girls for ever use. The difference between boys and girls for current use was also less marked, but still statistically significant.

Figure 2.2

Cannabis use among school-goers aged 12 to 18 from 1988 Current Use

Ever Use %

%

30

16 25

25 19

20 15 10 5

22 15 12

10

18

14

14

23 20 19 17

20

12

12

10

10

9

8

16

6

9

4

7

2

11 7

5 4

8

9

9 7

7

4

2

0

0 1988

1992 Boys

1996 Girls

1999

2003 Total

1988

1992 Boys

1996 Girls

1999

2003

Total

Percentage of ever users (left) and last month(right). Source: Dutch National School Survey, Trimbos Institute.

Age • Cannabis use increases among school-goers with age. In 2003, few school-goers aged

•

•

28

12 had tried cannabis – only one in fifty (2%). By the age of 16, one in three had ever tried cannabis (34%). The age at which school-goers first used cannabis dropped between 1988 and 1996.11 Some cannabis users smoked their first joint at the age of 13 or younger. The number of these among ever users doubled during this period from 21% to 40%. Between 1996 and 2003 the age of onset remained unchanged. Research among twins conducted by the University of Amsterdam has shown that juveniles who start to use cannabis before age 18 are more likely to use hard drugs later.12 This is not because of a genetic link or family circumstances. Social factors are

TRIMBOS-INSTITUUT

•

•

more likely to play a part, with early cannabis use an expression of a tendency towards anti-conventional behaviour. This explanation is in line with results of research among 16 year old school-goers in six European countries (Belgium, Czech Republic, France, Ireland, Poland and Greece). This study found that juveniles who had started using cannabis at a very young age (< 13), compared to those who started at 14 or 15 had a grater chance of frequent cannabis use as well as other risk behaviour, such as early smoking (< 13),drunkenness and early sexual activity (< 13). 13 Similar correlations are found for early smoking and alcohol use. 14

Amount of use • Of the nine percent current school-going users in 2003, almost half had used cannabis

•

•

no more than once or twice during the past month. A minority had used cannabis more than ten times (17%): one in five boys and over one in ten girls (see Figure 2.3). Per incident, almost half of the current users smoked less than one joint (46%). It is probable that they smoke together with others and share a joint. Almost one in three smoked between one and two joints per incident (32%), and almost a quarter smoked more than three joints per incident (23%). There is also a link between frequency and amount. Of the users who smoked between three and ten times a month, a quarter (27%) smoked three or more joints each time. Of those who used cannabis more than ten times a month, two-thirds (67%) smoked three or more joints each time. The latter group incurs a relatively high risk of developing problems.

Figure 2.3

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-goers who had used cannabis in the month before the survey. Source : Dutch National 9 School Survey, Trimbos Institute.

School level and ethnic background • In 2003 there was little or no difference in the percentage of ever users and current users in the different levels of Dutch secondary schools VMBO-p (lower secondary, practical) VMBO-t (lower secondary, theoretical), HAVO (middle secondary) and VWO (higher secondary). Nor was there much difference in frequency of use in the past month. However, the percentage of school-goers that smoked three or more joints on

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•

•

average per incident was considerably higher at VMBO level than at the higher VWO level (30% versus 8%). Current cannabis use was less frequent among Moroccan than among Dutch girls (0% versus 7%). No difference was found between Moroccan and Dutch boys. Antillean/Aruban (12%), Surinamese (8%) or Turkish (5%) pupils did not differ significantly on this measure from their native Dutch peers.a According to the Antenna-monitor in Amsterdam, the percentage of ever users and current users of cannabis is lowest among Moroccan school-goers; the percentage of users among Turkish and Surinamese school-goers is also lower than among native Dutch schoolchildren.15

Cannabis and problem behaviour • School-goers who use cannabis exhibit more aggressive and delinquent behaviour and

• •

have more school-related problems (truancy, poor results) than their non-using peers. This association becomes stronger with increasing frequency of use. 16;17 Cannabis users are more likely to use other substances than non-users (5 or more units of alcohol in the past month, daily smoking, ever use of hard drugs). No differences were found for psychiatric problems, such as withdrawn behaviour, anxiety or depression.

Place of procurement • In 2003 two out of three current users got their cannabis from friends, and one in

• •

•

three (also) bought it in or through ‘coffee shops’ (Table 2.3). Over one in ten bought cannabis from a (home) dealer and one in ten got it ‘through others’. More girls than boys got cannabis through friends, and boys were more likely than girls to purchase it in or through ‘coffee shops’. A significant percentage of cannabis-using school-goers aged up to 17 reported having purchased cannabis in or through a ‘coffee shop’ in 2003. This is remarkable, since the age limit for access to these ‘coffee shops’ is 18. It is not known to what extent these under-age users actually purchased the cannabis themselves, or procured it through third parties. Males aged 18 buy most of their cannabis from ‘coffee shops’. Eight out of ten of these current male users did so.

Table 2.3

How do school-goers procure their cannabis? Survey year 2003 12-15 yrs B

16-17 yrs

G

B

G

18 yrs B

Total G

B

G

Total

From friends

60%

78%

64%

77%

40%

69%

60%

78%

67%

Purchased in or through coffee shops

22%

22%

57%

37%

81%

56%

40%

27%

35%

Bought from a dealer

17%

6%

15%

12%

9%

0%

16%

7%

12%

Through others

16%

9%

6%

2%

0%

0%

11%

6%

9%

7%

6%

2%

8%

4%

0%

5%

6%

6%

Other

School-goers aged 12 to 18 of Dutch secondary schools (current users). Respondents could tick more than one answer. Therefore the percentages do not add up to 100. B = boys; G = girls. Source: Dutch National School 9 Survey, Trimbos Institute. a

See appendix A for the definition of native and ethnic/immigrant.

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A comparative study of school-goers aged 14 to 18 shows that there is little difference between Dutch and French school-goers for perceived availability of cannabis, despite the differences in drugs policy in the two countries.18 • In both countries, the percentage of juveniles that indicates being able to procure cannabis (fairly) easily increases with age. • There is a correlation between perceived availability and cannabis use and problem use. Use and problem use increase according as the juveniles report greater ease in procuring cannabis.

Special groups of young people In certain groups of juveniles and young adults, cannabis use is the rule rather than the exception. Table 2.4 summarises the results of various studies – mostly regional or local. The data are not comparable, on account of differences in age groups and research methods. Trend data are only available for Amsterdam. • There are relatively more current cannabis users among young drifters, school dropouts and juveniles detained in penitentiaries, as well as those in care (between three and eight out of ten). - Almost half the juveniles in Amsterdam youth care are current cannabis users.19 Approximately one in three (31%) of these users take cannabis daily, which is 15% of all juveniles in care. The amount and frequency of use is the same for boys as for girls. Over one in ten of current users (11%) have indicated a wish to get help to quit or reduce their use. • The Antenna-monitor follows substance use in various groups of young people in the Amsterdam social scene, such as ‘coffee shops’, bars and fashionable clubs. - According to a survey conducted among ‘coffee shop’ frequenters in 2001, two thirds of current users smoke a joint every day. Per incident, current users smoke four joints on average. Daily users smoke an average of five joints each time.20 - Between 1998 and 2003 the percentage of current cannabis users among socialising juveniles and young adults in fashionable clubs (and parties) in Amsterdam dropped from 52% to 39%. The average number of joints smoked by current users each time also dropped from two to one and a half.15 This trend is also evident in Amsterdam for most other drugs. - Key observers in the Amsterdam social scene report a continuing decline in drug use in 2006. The use of cannabis appears to be following the trend set by increasing numbers of people who are giving up smoking tobacco for health reasons. 19 - Among pub-goers, however, cannabis use remained stable between 2000 and 2005. 21 Smoking joints is prohibited in many clubs and pubs, although the rules vary. - It is not known how cannabis trends are currently developing in other parts of the country. Key observers report that the declining trend in Amsterdam is not perceptible on a nationwide basis. In the south, in particular, there appears to be a slight increase in cannabis use. However, cannabis is generally little used in social and entertainment settings, with the exception of coffee shops. 22 • Young socialisers often use more than one substance, and these are frequently used together. The combination of choice is cannabis with alcohol, followed by cannabis with ecstasy.22 23-25

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Table 2.4

Current cannabis use in special groups Location

Survey year

Age (years)

Current use

Frequenters of dance parties, festivals, city centre

The Hague

2003

15 - 35

37%

Bar-goers

Zaandam

2006

14 - 44

22%

2000

Average 25

24%

2005

Average 27

22%

Young people in the social scene and young adults

I

II

Bar-goers

Amsterdam

Frequenters of bars and sport-hall canteenbars

Noordwijk

2004

Average 23

19%

Discotheque-goers

NijmegenIII

2006

Average 21

12%

Clubbers

Amsterdam

1998

Average 26

52%

2003

Average 28

39%

Coffee shop frequenters

AmsterdamIV

2001

Average 25

88%

Nijmegen

2005-6

Average 27

84%

13 - 16

32% 37%

Problem groups Juveniles attending truancy projects

special

schools

and

Amsterdam

Marginalised youthV

The Hague

2000/2001

16 - 25

Juvenile detaineesVI

Regional

2002/2003

14 - 17

School drop-outsVI

Regional

2002/2003

14 - 17

Homeless YouthVII

Flevoland

2004

13 - 22

87%

Amsterdam

2006

Average 17

45%

Heerlen

2006

15-20

35%

Juveniles in care

VIII

Street youth

59% 55%

Percentage of current users, (past month) per group. The figures in this table are not comparable on account of differences in age groups and research methods. I. Juveniles and young adults in mainstream bars, student bars, gay bars and hip bars. Therefore not representative of all bar-goers. II. Low response (26%). III. Low response (19%). IV. Low response (15%). V. Young people who do not receive sufficient care and/or are insufficiently able to meet their own living needs. Surveyed at locations for the homeless youth, low-threshold day and night centres and (other) temporary accommodation facilities. VI. Research in the provinces of Noord-Holland, Flevoland and Utrecht. Usage among juvenile detainees: in the month prior to detention. Drop-outs are juveniles who have missed at least a month of school during the past year, not counting holidays. VII. Young drifters aged up to 23 who have had no fixed abode for at least three months. VIII Juveniles with behavioural problems, juvenile delinquents, homeless juveniles and juveniles in other care projects. References: 19;19-21; 26-35

2.4 PROBLEM USE It is not known exactly how many people develop problems related to cannabis use. Problem use involves a diagnosis of cannabis dependence based on the DSM international psychiatric classification system. By comparison with nicotine, heroin and alcohol, cannabis is not very addictive. However, the risk of dependence increases with long-term frequent use and is often accompanied by dependence on other substances. Younger people are more susceptible to this than older people.36 • There are no recent figures available on the number of people who are dependent on cannabis. According to NEMESIS data from 1996, between 0.3% and 0.8% of the population aged between 18 and 64 met the criteria for a diagnosis of cannabis de-

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• •

•

•

pendence (DSM 3rd revised edition). In population terms, this amounted to between 30,000 and 80,000 people. The majority were aged under 23.8 New data will come onstream in 2009. As stated in §2.3 (frequent) cannabis use is linked to problem behaviour, such as aggressive and criminal behaviour, use of other drugs and problems at school. This is not to say that cannabis use is the cause of these problems. Often cannabis use is preceded by behavioural problems, or both may be part of a broader pattern of deviant behaviour. Another possibility is an overlap of risk factors that lead to both cannabis use and deviant behaviour.36;37 In 2006/2007 as in previous years, key observers from the Amsterdam Antenna Monitor identified excessive cannabis use among some neighbourhood and problem youth.19 Elsewhere, key observers recorded excessive cannabis use among street youth in Den Bosch38 and Heerlen26, among street youth and problem youth in Gelderland39 among at-risk juveniles in Eindhoven40, problem youth in Tilburg41 and young mothers receiving social inclusion care in Maastricht.42 However, hard data about cannabis use in these groups are lacking.

2.5 USAGE: INTERNATIONAL COMPARISON General population Data about drugs use in EU member states and Norway emanate from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Institutes in the US, Canada and Australia also regularly publish the findings of surveys on drugs use in the population. • It is difficult to conduct a precise comparison of the data, owing to differences in survey years, measuring methods and sampling. The age group is the main variable. Table 2.5a shows usage data that have been (re)calculated according to the standard age group of the EMCDDA (15 to 64 years). Data for the other countries are contained in Table 2.5b. For Europe, only the EU-15 and Norway have been included. Appendix E shows usage figures for the other EU member states, in so far as these are available. • Between 8% and 45% of people in the general western population have ever used cannabis (tables 2.5a and 2.5b). The lowest percentages are found in Greece and Portugal. In Canada and the US, almost one in two people have ever tried cannabis. Of all 26 countries in the EU-27 for which data are available, Romania, Malta and Bulgaria are exceptions at the lower end with 2%-4%. Denmark tops the list with 37%, but has an average score for the measures ‘recent’ and ‘current’ use. • An estimated 7% of all EU member state inhabitants, or 23 million people, have used cannabis during the past year. At 5%, the Netherlands is ranked somewhat below this European average. • For the measure ‘recent use’, however, the percentages differ greatly. Of the EU-27 for which data are available, the percentage of recent users is lowest in Malta (1%). Italy and Spain have the highest rate at 11%, followed by the U.K. at 10%. Internationally, Canada tops the list at 14%. • For current use, Spain stands out in front (9%). The lowest percentages are found in Sweden and Greece (1%). At 3%, the Netherlands is close to the European average of 4%.

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33

Table 2.5a

Cannabis use in the general population of a number of EU-15 member states and Norway: age group 15 to 64 years

Country

Year

Ever use

Recent use

Current use

France

2005

31%

9%

5%

Spain

2005/6

29%

11%

9%

Italy

2005

29%

11%

6%

The Netherlands

2005

23%

5%

3%

Austria

2004

20%

8%

4%

Ireland

2002/2003

17%

5%

3%

Norway

2004

16%

5%

2%

Finland

2004

13%

3%

2%

Belium

2004

13%

5%

3%

Greece

2004

9%

2%

1%

Portugal

2001

8%

3%

2%

A precise comparison between countries is hampered by differences in survey year, measuring methods and sampling. Percentage of ever users, recent (past year) and current (past month). - = not measured. 43 References:

Table 2.5b

Cannabis use in the general population of a number of EU- 15 member states and Canada, the US and Australia: other age groupsI Ever use

Recent use

Current use

15 +

45%

14%

-

2006

12 +

40%

10%

6%

Denmark

2005

16-64

37%

5%

3%

Australia

2004

14+

34%

11%

7%

U.K.

2004

?

30%

10%

6%

Germany

2003

18 – 59

25%

7%

3%

Italy

2003

15 – 54

22%

7%

5%

Sweden

2006

16 – 64

12%

2%

1%

Country

Year

Age (yrs)

Canada

2004

United States

A precise comparison between countries is hampered by differences in survey year, measuring methods and sampling. Percentage of ever users, recent (past year) and current (past month). I. Drug use is relatively low in the youngest (12-15) and oldest age groups (>64). Consumption figures in studies with respondents younger and/or older than the EMCDDA standard may be lower than figures in studies that do use the EMCDDAstandard. The opposite is true for studies with a more limited age span. - = not measured. References: 43-47;47

Trends It is difficult to determine the trends in cannabis use on account of a lack of repeat and comparable measurements in and between countries. • According to the EMCDDA, cannabis use in the 1990s increased in the majority of EU countries, particularly among juveniles and young adults. In recent years this trend appears to have stabilised, particularly in countries with a high degree of prevalence. France and the U.K. even report a slight decrease among young people in the 16-34 age group. By contrast, in Italy, the percentage of recent users has surged (from 7%

34

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• •

in 2003 to 11% in 2005). Finland and Sweden also report a slight increase; however in these countries the percentage of cannabis users remains well below the level of countries such as the U.K. and Italy.43 In the Netherlands, cannabis use remained stable between 1997 and 2005 in the population aged between 15 and 64. There are no comparable figures for usage prior to 1997. In Canada the percentage of ever users rose sharply between 1994 and 2004 from 28% to 45%. The percentage of recent users doubled in this period from 7% to 14%. The findings of repeated surveys in the US suggest that cannabis use has stabilised since 2000.44

Juveniles The data from ESPAD, the European School Survey Project on Alcohol and Other Drugs lend themselves better to comparison. In 1999, 2003 and 2007, surveys were conducted among fifteen and sixteen year old secondary school pupils.48 The results of the most recent wave will be made available during the course of 2008. Table 2.6 shows cannabis use in a number of EU countries and Norway. Belgium, Germany and Austria only took part in 2003. The US did not take part in the ESPAD but conducted similar research. • The percentage of school-goers that had ever used cannabis in 2003 was highest in Ireland, followed closely by France, the U.K. and the US. Belgian school-goers were in fourth place, and the Dutch in fifth place. • France topped the list for current use, followed by the US, the U.K. and Ireland. These were followed by the Netherlands and Italy. • In the U.K. and Portugal, the percentage of current users in 2003 was 4 and 3 percentage points higher respectively than in 1999. In other countries, differences of two percentage points or less were found. • The percentage of school-goers that had used cannabis six times or more in the past month was lowest in the Scandinavian countries and highest in France, the US and the UK. Dutch school-goers occupied fourth place together with their Irish and Italian peers. • In most countries, ever use of cannabis was associated with degree of truancy, lack of parental control and having older siblings who used cannabis.

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Table 2.6

Cannabis use among school-goers aged 15 and 16 in a number of EU member states, Norway and the US. Survey years 1999 and 2003. Ever use

Country

Current use

Six or more times past month

1999

2003

1999

2003

1999

2003

United States

41%

36%

19%

17%

9%

8%

Ireland

32%

39%

15%

17%

5%

6%

France

35%

38%

22%

22%

9%

9%

U.K.

35%

38%

16%

20%

6%

8%

Belgium

-

32%

-

17%

-

7%

28%

28%

14%

13%

5%

6%

-

27%

-

12%

-

4%

Italy

25%

27%

14%

15%

4%

6%

Denmark

24%

23%

8%

8%

1%

2%

-

21%

-

10%

-

3%

Portugal

8%

15%

5%

8%

2%

3%

Finland

10%

11%

2%

3%

1%

0%

Norway

12%

9%

4%

3%

1%

1%

Sweden

8%

7%

2%

1%

0%

0%

Greece

9%

6%

4%

2%

2%

1%

Netherlands Germany

Austria

I

Percentage of ever use, current use (past month) and six times or more in the past month. I. Six of sixteen member states. - = not measured. The US did not participate in the ESPAD, but conducted comparable research. Source: ESPAD. 48

2.6 TREATMENT DEMAND Outpatient addiction care The National Alcohol and Drugs Information System (LADIS) registers the number of people who seek treatment from outpatient addiction care, including rehabilitation programmes and the addiction clinics that are merged with the outpatient addiction care services49 (see in appendix A: LADIS client) • The number of clients registered on account of a primary cannabis problem tripled between 1994 and 2004 (Figure 2.4). From 2005 to 2006 there was a further increase of 7%. • Per 100,000 inhabitants aged 15 and over, the number of primary clients rose from 16 in 1994 to 49 in 2006. • The role of cannabis in all requests for treatment also rose – from 10% in 1994 to 20% in 2006. • In 2006 over a third of primary cannabis clients were newcomers (36%). These had not previously been registered with the (outpatient) addiction care services for a drug-related problem. • For 49% of primary clients, cannabis was the only problem; 51% reported problems with another substance as well. • The number of (outpatient) addiction care clients citing cannabis as a secondary problem also rose between 1994 and 2006 (Figure 2.4). For this group, alcohol (46%), cocaine or crack (32%), heroin (10%) or amphetamine (6%) was the primary problem.

36

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Figure 2.4

Number of (outpatient) addiction care clients with primary or secondary cannabis problems, from 1994 Number

6000 5000 4000 3000 2000 1000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Primary

1951 2274 2659 3264 3291 3281 3443 3432 3701 4485 5456 6100

Secondary 2846 2668 2718 2820 2844 3063 3144 3300 3697 4291 4630 5057 Source: LADIS, IVZ.

49

Age and gender • In 2006 the majority of primary cannabis clients were male (81%). The ratio of fe• •

males fluctuated during the period 1994 to 2006 between 15% and 19%. In 2006 almost two-thirds of cannabis clients were aged over 25. The average age was 29. The peak age group was 20 to 29 (Figure 2.5). In absolute terms the number of young clients aged between 15 and 29 doubled from 1,531 in 1994 to 3,729 in 2006. However, relative to the other age groups, their ratio in this period dropped from 79% to 57%.

Regional trends • The Netherlands is divided into 43 regions for social inclusion care and addiction policy

•

(MO/VB regions). In the 2002-2006 period, the demand for treatment on account of cannabis per 10,000 inhabitants aged 15 and older was greatest in the MO/VB regions of Den Helder, Alkmaar, The Hague, Rotterdam and Deventer (between 5.9 and 6.5 cannabis clients).50 During the period 2002-2006, the number of primary cannabis clients rose by 52% compared to 1997-2001. This increase took place in almost all regions of the Netherlands. In only two regions was there a drop in the number of cannabis clients. These were the regions of Amersfoort (-27%) and Ede (-2%). The four regions with the sharpest rise are: Almelo (216%), Leiden (172%), Den Helder (154%) and Enschede (137%).50

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37

Figure 2.5

Age distribution of primary cannabis clients of (outpatient) addiction care. Survey year 2006

% 30% 25%

23%

22%

20% 15%

17% 14% 11%

10%

7%

5%

3%

2%

1%

45-49

50-54

>54

0% 15-19

20-24

25-29

30-34

35-39

Percentage of clients per age group. Source: LADIS, IVZ.

40-44

Age

49

Internet-based Interventions A number of organisations for addiction care offer help through the internet for problem cannabis use. One of these is ‘Brijder Verslavingzorg’, which offers help on www.cannabisondercontrole.nl, and the Jellinek and Tactus organisations which offer self-help on the websites www.jellinek.nl and www.zelfulpvoorverslaafden.nl respectively. So far data about the number of treatment requests from (outpatient) addiction care do not contain information about self-help via the internet. However, in the near future, actual internet interventions that are given as part of treatment and are funded by a health insurer will be registered as standard treatment and will then be visible in the data on treatment demand.

General Hospitals; incidents In 2006, the Dutch Hospital Registration (LMR) recorded almost 1.7 million clinical admissions to general hospitals. Drug-related problems did not figure strongly in these numbers. There were 525 cases of drug abuse and drug addiction as the primary diagnosis and 1,876 cases as a secondary diagnosis. • In 10% of the main diagnoses the drug involved was cannabis (figure 2.6). Misuse of cannabis was more often to blame than dependence (56% versus 44%). It is not known what the symptoms were that led to the hospital admission (mental or physical). The number of main diagnoses related to cannabis misuse or dependence has been low for years, although there appears to have been a slight increase between 2002 and 2005. • As a secondary diagnosis, cannabis plays a more prominent role. In 2006 there were 377 secondary diagnoses involving cannabis (29% dependence, 71% misuse). In recent years there has been a rise in this respect, albeit with fluctuations. Between 2005 and 2006 the number of cannabis secondary diagnoses rose by 26%.

38

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• In 2006 the most common main diagnoses that accompanied the secondary diagnoses were: - psychoses (27%) - injury due to accidents (11%, such as fractures, cuts, concussion) - misuse or dependence on alcohol and drugs (16%, mainly alcohol: 13%) - poisoning (4%, by drugs, alcohol, medication) - respiratory tract illnesses and symptoms (6%) - cardio-vascular illnesses (5%) - other diagnoses (33%). • In these figures, the same person may be admitted more than once per year. In addition, more than one secondary diagnosis may be made per case. In 2006, corrected for duplication, the total amounted to 381 persons who were admitted at least once with cannabis misuse or dependence as the main or secondary diagnosis. Their average age was 31, and 77% were male. • In 2006 cannabis problems were also recorded as primary or secondary diagnosis in 25 day-care treatments. This is somewhat less than in 2005 (45 day care treatments). • In addition, the LMR recorded 15 admissions in 2006 for which “accidental poisoning with hallucinogens” was cited as secondary diagnosis (ICD-9 code: E854.1). From 2001 to 2005, there were 15, 8, 16 15 and 14 cases respectively. These may have involved cannabis, but equally LSD or magic mushrooms.

Figure 2.6

Clinical admissions to general hospitals, related to cannabis misuse and dependence, from 1994

Number 450 377

400 322

350 300

200

249

247

250

193 160

184

195

26

29

230

299

246

193

154

150 100 50

21

39

38

29

24

38

33

46

56

62

54

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Cannabis as main diagnosis

Cannabis as secondary diagnosis

Number of diagnoses, not corrected for duplication of persons or for more than one secondary diagnosis per admission. ICD-9 codes: 304.3, 305.2 (Appendix C). Source: LMR, Prismant.

According to the injury information system (LIS) of the Consumer Safety Institute51 an average of 3,200 people are treated annually at the accident and emergency departments of hospitals on account of an accident, violent incident or self-mutilation related to drug use (henceforth called ‘accidents’). The drugs meant here are cocaine, heroin, can-

TRIMBOS-INSTITUUT

39

nabis, ecstasy, magic mushrooms and speed. The data have been averaged over the period from 2002 through 2006. • After cocaine, cannabis is the most frequently cited drug. Almost one in five (18%) victims of an accident involving drugs indicates having used cannabis. If we count only the cases where the drug is known (68%), then cannabis accounts for 25% of all drug-related emergency room treatment. • These figures are likely to be an under-estimate of the true number of drug-related accidents. At the Ambulance Transport Centre (CPA), The Amsterdam Municipal Health Service (GGD Amsterdam) keeps a log of the number of requests for emergency treatment related to drug use. • In 2006 cannabis use played a part in 461 cases – a rise of 35% compared to 2005 (Table 2.7). • In approximately one out of three cases (34%), an ambulance was needed for admission to hospital. The remainder were treatable at the scene. • The rise in cannabis incidents may possibly be linked to the increase in drug tourism in Amsterdam.

Table 2.7

Cannabis incidents registered by the GGD Amsterdam, from 1995 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Smoking Cannabis Eating space cake Total

130

137

165

211

107

118

106

243

226

196

258

281

347

34

73

58

47

28

21

35

46

59

61

62

61

114

164

210

223

258

135

139

141

289

285

257

320

342

461

Number of incidents per annum. Source: CPA, GGD Amsterdam.

In recent years, the National Poison Information Centre (NVIC) of the National Institute of Public Health and the Environment (RIVM) has registered an increase in requests for information from doctors, pharmacists and government bodies with regard to cannabis use (table 2.8).52 • The number of information requests concerning cannabis trebled between 2000 and 2005. This trend came to an end in 2006 and 2007. • These data do not provide a picture of the absolute number of intoxications, because these are not notifiable. According as doctors become more familiar with the symptoms and treatment of an intoxication with a particular drug, the likelihood of consulting the NVIC is reduced.

Table 2.8

Cannabis

Requests for information concerning cannabis use from the National Poisons Information Centre from 2000 2000

2001

2002

2003

2004

2005

2006

71

129

141

144

191

202

186

Annual number of information requests via the NVIC 24-hour telephone line. Requests via the website www.vergiftigingen.info (online since April 2007) are not included for 2007. Source: NVIC, RIVM.

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2.7 ILLNESS AND DEATHS Increasingly, cannabis use is associated with mental problems. • Evidence is mounting that cannabis use increases the risk of later psychotic disorders.53-56 • The risk increases with the frequency of use. • Individuals with a prior history of psychotic symptoms are at greater risk of developing psychosis following cannabis use than those without a prior history. • It is possible that genetic factors play a role in this. There are indications that people with a certain variant (Val/Val) of the COMT-gene, which is involved in the breakdown of the receptor dopamine in the brain are extra susceptible to developing a psychosis, particularly if they have commenced cannabis use at a young age.57 • Research into the relationship between cannabis use and the onset of other mental problems, such as anxiety disorders depression, has yielded a less consistent picture.58 The role of the increasing concentration of THC, detected until recently in Dutch-grown weed, in relation to acute or long-term (health) problems is unclear. • In 2005, the RIVM conducted research into the acute effects of strong cannabis (joints with 33, 51 and 70 mg of THC). The results showed an increase in heart rate, a drop in blood pressure and a decline in cognitive functions and motor function. The effects increased with higher THC doses.59 Young, healthy people can usually tolerate these effects without suffering any health complications. However, people with cardiovascular illness incur a risk. • Research conducted among ‘coffee shop’ frequenters shows that there is a specific group of – mainly young – users with a clear preference for ‘strong weed’.60-61 They use the drug relatively often and in large quantities and run an increased risk of dependence. It is not known how large this group of users is. • In the US a slight increase has been found over time in the percentage of people dependent on or abusing cannabis, while the number of users (without a disorder) remained the same.62 This increase was found to run parallel with a slight rise in the THC concentration in cannabis, and was independent of frequency or amount of use. This could indicate a causal relationship. However, the researchers were unable to explain why the increase in cannabis-related disorders occurred only among ethnic minorities and not among the white population. The toxicity of cannabis is low.63 • For the past 20 years, Statistics Netherlands (CBS) has not recorded a single case of death directly related to the intake of cannabis on its cause of death registration forms. • No direct deaths attributable only to cannabis are known from other countries.

2.8 SUPPLY AND MARKET Coffee shops and other points of sale • Since 1997 the number of coffee shops has declined (table 2.9).64;65 The sharpest drop took place between 1997 and 1999, particularly in the smaller municipalities and in Rotterdam. During this period, the number of coffee shops dropped by 28 percent.

TRIMBOS-INSTITUUT

41

After 1999 the annual decrease was less pronounced. Between 2004 and 2005 the number of coffee shops dropped by only one percent. Table 2.9

Number of coffee shops in the Netherlands by municipality, from 1997

Municipalities by number of inhabitants < 20 000 inhabitants

1997I

1999

2000

2001

2002

2003

2004

2005

± 50

14

13

11

12

12

10

10

20-50 000 inhabitants

± 170

84

81

86

79

73

77

75

50-100 000 inhabitants

± 120

±115

109

112

106

104

101

103

100-200 000 inhabitants

211

190

168

167

174

168

166

161

> 200 000 inhabitants:

628

443

442

429

411

394

383

380

- Amsterdam

340

288

283

280

270

258

249

246

- Rotterdam

180

65

63

61

62

62

62

62

- The Hague

87

70

62

55

46

41

40

40

- Utrecht

21

20

18

17

18

18

17

17

16

16

15

15

15

15

813

805

782

754III

737

729

II

- Eindhoven Total

± 1179

846

I. Estimate. II. Fewer than 200 000 inhabitants up to 1999. III. In 2003 three coffee shops were not listed by municipality size. Source: Intraval 65

• In late 2005 there were 729 officially sanctioned coffee shops in the Netherlands; ap-

• •

•

•

proximately half (52%) of these were in the main cities with over 200 thousand inhabitants. In 2005, 78 percent of municipalities had no coffee shop. The University of Amsterdam has conducted research into the purchasing of cannabis. In municipalities with officially tolerated coffee shops, an estimated 70% of local cannabis is purchased directly in the coffee shop.66 The greater the number of coffee shops per 100 000 inhabitants, the greater the share of the local coffee shops in local cannabis sales. On a national scale, (excluding the main cities, and municipalities without coffee shops) it is estimated that there are several thousand non-sanctioned cannabis suppliers. These operate from fixed points of sale such as their homes or on an underthe-counter basis in food and drink establishments as well as through mobile sales such as home delivery after telephone orders or dealing on the street. These sellers account for an estimated 30% of local sales.

Quality and price The Trimbos Institute gathers information about the strength of cannabis, i.e. the concentration of active components, especially THC (tetrahydrocannabinol). Since 2000, samples of various cannabis products have been purchased and submitted for chemical analysis.67 • In all tests, Dutch-grown weed was found on average to contain higher concentrations of THC than imported varieties. • Figure 2.7 shows that there was a strong increase in the average THC content of Dutch-grown weed samples between 2000 and 2004. In 2005 the average THC con-

42

TRIMBOS-INSTITUUT

• •

•

centration dropped from 20 to 18 percent, levelling off in 2006. In 2007, the average percentage dropped further to 16%. The percentage of THC in foreign weed has fluctuated in recent years at around six percent. The percentage of THC in imported hashish was around the same as in Dutch-grown weed for years. However, between 2006 and 2007 the average percentage of THC in imported hashish dropped sharply from 18.7% to 13.3%. Dutch-grown weed largely originates from intensive and professional domestic cultivation, which by comparison with foreign cultivation, produces weed with a higher THC content.

In 2007, further research was conducted on the quality of Dutch-grown weed. 67,68 This was prompted by suspicions that the weed was increasingly being mixed with substances such as glass beads, sand, lead or liquids to make the weed look better (more glossy) and to boost its weight artificially. • Microscopic testing of 100 samples from coffee shops showed virtually no contamination with sand or glass particles. It is not known to what extent other substances, such as liquid mixing agents, may have been added. • Powdered glass and chalk have, however, been found in a number of other samples handed into the DIMS as ‘suspicious’, but these were not procured via the coffee shops. Figure 2.7

Average THC percentage in cannabis products % 25% 20% 15% 10% 5% 0%

2000

2001

2002

2003

2004

2005

2006

2007

Dutch-grown weed

8,6%

11,3%

15,1%

18,1%

20,4%

17,7%

17,5%

16,0%

Foreign weed

5,0%

5,3%

6,6%

6,2%

7,0%

6,7%

5,5%

6,0%

Foreign hashish

11,0%

12,1%

17,5%

16,6%

18,2%

16,9%

18,7%

13,3%

The percentages relate to samples that were collected in December/January. The years cited refer to the year in which samples were collected in the month of January. Source: DIMS, Trimbos Institute.67

Table 2.10 shows the average prices for a gram of cannabis purchased in coffee shops. • In 2007 the average price of Dutch-grown weed was over a euro higher than in 2006. This price rise may be linked to the intensified efforts to combat (large-scale) cannabis production. Besides, the hot summer of 2006, when a lot of crops failed, may have contributed to this increase.3 • In 2007, the price of foreign hashish was slightly higher than in 2006, however, not significantly so. The price of a gram of imported weed remained the same.

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43

Table 2.10

Average price (€) per gram of cannabis product in coffee shops 2000

2001

2002

2003

2004

2005

2006

2007

Dutch-grown weed

5.83

5.86

6.28

6.45

5.97

6.22

6.20

7.30

Foreign weed

3.87

3.80

4.16

4.32

4.86

4.11

4.40

4.30

Foreign hash

6.29

6.36

7.14

7.56

6.46

6.78

7.30

7.70

The prices relate to samples collected in December/January. The years cited refer to the year in which the month of January falls. Source: DIMS, Trimbos-instituut.67

44

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3

COCAINE

Cocaine works as a stimulant. Many cocaine users are able to fit cocaine into their lives without developing problems; they use cocaine for recreational purposes. However, the drug can lead to addiction. Cocaine can be used in a variety of forms.69 In powder form, (cocaine hydrochloride) cocaine is usually snorted in the Netherlands, and rarely injected. Occasionally it is smoked like a cigarette. Street names for this kind of cocaine include ‘coke’, ‘flake’, ‘candy’, ‘nose candy’ ‘o.k.’, ‘okey doke’, ‘AKA’, ‘Vitamin C’, ‘white lady’ and ‘coca puffs’. Among problem hard drug users, the base form of cocaine (‘crack cocaine’) is the most popular. Base cocaine is obtained by heating a solution of cocaine powder and a base substance, such as natrium bicarbonate or ammonia. It is smoked in a little pipe or tube or inhaled from aluminium foil. Both methods are known in this study as smoking, unless stated otherwise. Crack owes its name to the crackling sound it emits during the heating process. In the 1980s the users made their own base cocaine. Nowadays it is sold ready for use on the streets. The data below apply to all forms of cocaine, unless stated otherwise.

3.1 RECENT FACTS AND TRENDS The main facts and trends concerning cocaine in this chapter are: • Between 2001 and 2005 ever use of cocaine in the general population increased. The percentage of recent and current cocaine users remained stable during this period. (§ 3.2). • The increase in the number of new cocaine users in the general population dropped between 2001 and 2005 (§ 3.2). • With regard to recent use of cocaine, the Dutch score slightly below average compared to other European member states (§ 3.5). • Cocaine has become increasingly popular among juveniles and young adults in the social scene (and at home) through the country, although the user market now appears to be saturated. There are signs that cocaine use is still on the rise among rural youth (§ 3.3). • There was a slight drop between 2005 and 2006 in the percentage of clients seeking treatment from addiction care for cocaine use (§ 3.6). This decline was chiefly among clients with a crack problem. • The number of registered acute deaths from cocaine use is low, and remained stable between 2004 and 2006 (§ 3.7). • In recent years, powder cocaine used by consumers has been relatively often found to be mixed with medicines (§ 3.8).

3.2 USAGE: GENERAL POPULATION • Between 2001 and 2005 there was an increase in the number of people in the Netherlands aged between 15 and 64 who had experience with cocaine (table 3.1). The difference between 1997 and 2001 was not significant. 5

TRIMBOS-INSTITUUT

45

• The percentage of recent and current users remained at the same level in all three

•

•

surveys. The percentage of current users was the same in the 1997 and 2005 surveys. The decline recorded in 2001 was not significant. In absolute figures, there were an estimated 32 thousand current users of cocaine in the Netherlands in 2005. These figures are virtually certain to be an underestimation, because problem users of hard drugs are under-represented in population surveys, such as the NPO. The annual increase in first-time users of cocaine dropped from 0.4% in 2001 to 0.1% in 2005. These figures could be indicative of a decline in the new use of cocaine.

Table 3.1

Cocaine use in the Netherlands in the population aged 15 to 64. Survey years 1997, 2001 and 2005 1997

2001

2005

Ever use

2.6%

2.1%

3.4%

Recent useI

0.7%

0.7%

0.6%

Current use

0.3%

0.1%

0.3%

Used for the first time in the past year

0.3%

0.4%

0.1%

27.7

26.7

31.9

II

I

Average age of the recent users

Number of respondents: 17 590 (1997), 2 312 (2001), 4 516 (2005). I. In the past year. II. In the past month. 5 Source: NPO, IVO.

Age, gender and urbanisation level • Ever use of cocaine occurs mainly among males (5.2%, versus 1.6% among females)

•

• • •

and in the age group 25 to 44 years (5.3%, versus 2.8% among 15-24 year olds and 1.6% in the 45-64 age bracket). Cocaine use occurs mainly in the big cities. 7.6% of the population in very highly urbanised areas have used cocaine. This compares with only 0.7% of the population in non-urban areas. The numbers of recent and current users are too small to permit a further breakdown by age, gender and urbanisation level. Between 2001 and 2005 there was a rise in the average age of recent users. The age of onset is the age at which an individual first used a substance (see also appendix A: age of onset). Among ever users of cocaine, the age of onset was 17.6 on average for the 15 to 24 year age group. In the population aged 15 to 64, the average age of onset is 23.1 years.

Special groups Compared to the average population, cocaine use is relatively high among homeless people, drifters and prisoners. • In 2002 nearly half (47%) of all the homeless and drifters in 20 Dutch municipalities had used crack in the past month; one in ten snorted cocaine 10%).6 • In 2006, 29% of the homeless at the day and night shelters in Rotterdam used cocaine (almost) daily. 7 • In 2002 a third (32%) of male detainees in eight Remand centres used cocaine/crack on a daily basis in the six months prior to detention.70 See §8.3 for more figures on drug use among detainees.

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3.3 USAGE: JUVENILES AND YOUNG ADULTS School-goers According to the Dutch National School Survey, considerably fewer secondary school students use hard drugs, such as cocaine than cannabis.9 • From 1988 to 1996 there was, however, an increase in use. • This trend was no longer found in the measurements of 1999 and 2003. The percentage of pupils that had ever or recently used this drug appeared to drop slightly between 1996 and 2003, but these differences are not significant (Figure 3.1). • More boys than girls have ever or recently used cocaine. • The percentages of cocaine users seem somewhat lower among pupils attending a higher level school (VWO, HAVO) compared to their peers who attend a lower level school (VMBO); however these differences are not statistically significant.

Figure 3.1

3.5

Use of cocaine among school-goers aged 12 to 18 from 1988

%

3 3

2.8

2.5 2.2

2

1.6 1.2

1.5 1

0.4

0.5

1.1

1.2 0.8

0.4

0 1988

1992

1996

Ever use (%)

1999

2003

Current use (%)

Percentage of ever users and recent users (past month). Source: Dutch National School Survey, Trimbos Institute.

Special groups In certain groups of juveniles and young adults, the rate of cocaine use is high. Table 3.2 contains a summary of the results of various, often local, studies. The data are not easy to compare, on account of differences in age groups and research methods. Trend data are available only for Amsterdam. • Cocaine is relatively popular among juveniles and young adults in the social scene. In Amsterdam, the percentage of current cocaine users among clubbers dropped between 1998 and 2003 from 24 to 14 percent.15 This drop chiefly concerned snorting

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47

• •

•

•

48

cocaine. However, key observers in the Amsterdam social scene reported a stabilisation or even slight increase in use, which appears to be less and less restricted to the weekends.19 In so far as data are available, current cocaine uses among socialising juveniles and young adults in other cities varies from three to ten percent (table 3.2). According to qualitative panel studies involving key observers in social settings, cocaine has penetrated society to a broad and varied extent. - In 2006/2007 key observers reported that cocaine use throughout the whole country had reached saturation point, with possible slight upsurges in use in Amsterdam and Rotterdam. 22 - However, rising popularity of cocaine has been observed among (employed) rural youth. It is also particularly popular among students, soccer fans and bar staff. 2271 - According to key observers, cocaine is used as much at home as in social settings. 22 In the social scene, cocaine is often consumed together with alcohol25 The excessive use of alcohol by revellers is often quoted as one of the reasons for the popularity of cocaine22 . This is because cocaine is said to have a sobering effect, permitting the user to drink more and for longer. 72 In so far as data are available, crack is not widely consumed among problem youth (table 3.2). Young drifters in Flevoland have the most experience of this drug. One in five have tried crack, and one in eighteen are current users. 73 According to recent research among juveniles in Amsterdam youth care, the substance is used little in this group. 19 Nonetheless, key observers have identified a rise in crack use among problem youth in Gelderland35 , street kids in Den Bosch38 , marginalised youngsters in Eindhoven40, Maastricht42 and Parkstad Limburg. 74 However, trend data are not available.

TRIMBOS-INSTITUUT

Table 3.2

Cocaine use in special groups Location

Survey year

Age (yrs)

Ever use

Current use

Frequenters of dance parties, festivals, city centre

The Hague

2003

15 - 35

23%

10%

Pub-goers

Zaandam

2006

14 - 44

13%

4%

Pub-goersI

AmsterdamII

2000

Average 25

26%

9%

2005

Average 27

26%

8%

2005

14 - 34

20%

6%

20%

8%

Juveniles and young adults in the social scene

Visitors to restaurants, hotels, pubs

Eindhoven

Frequenters of bars and sport hall canteen-bars

Noordwijk

2004

Average 23

Discotheque-goers

NijmegenIII

2006

Average 21

11%

3%

Clubbers

Amsterdam

1998

Average 26

49%

24%

2003

Average 28

39%

14%

AmsterdamIV

2001

Average 25

52%

19%

Nijmegen

2005-6

Average 27

33%

10%

Marginalised youthV

The Hague

2000/2001

16 - 25

23%

9%

Juvenile detaineesVI

Regional

2002/2003

14 - 17

“Coffee shop” clients

Problem youth 16% VIII

5% IX 10% School drop-outsVI

Regional

2002/2003

14 - 17

VIII

4% IX

6% VIII 2% IX 2% VIII 1% IX

VII

Young drifters

Flevoland

2004

13 - 22

29%VIII IX

19% Juveniles in care

Amsterdam

2006

Avge. 17

8% VIII 4% IX

10%VIII 6%IX 2% VIII 1% IX

Percentage of current users (last month) per group. The figures in this Table were not comparable on account of differences in age groups and research methods. I. Juveniles and young adults from mainstream bars, student bars, gay and hip bars. Therefore not representative of all bar-goers. II. Low response rate (26%). III. Low response rate (19%). IV. Low response rate (15%). V. Juveniles who do not receive sufficient care and/or are insufficiently able to meet their own living needs. Surveyed at locations for homeless young people, low-threshold day and night centres and (other) temporary accommodation facilities. VI. Research in the provinces of Noord-Holland, Flevoland and Utrecht. Use among juvenile detainees: in the month prior to detention. School drop-outs are youngsters who have failed to attend school for at least one month during the past 12 month, not counting holidays. VII. Young people aged up to 23 who have had no fixed abode for at least three months. VIII. Snortable cocaine in powder form. IX. Smokeable cocaine in the form of crack. X Juveniles with behavioural problems, juvenile delinquents, homeless juveniles 19-21; 27-29; 31-35; 75;76 and juveniles in other care projects References:

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3.4 PROBLEM USE • There are no reliable estimates of the total number of problem cocaine users. According to field studies and registration data, there are basically three groups of users. • The first group consists of problem users of opiates (see § 4.4), who nowadays almost all use cocaine as well, usually the ready-to-smoke type of crack.77;78 Partly because it takes effect so quickly, crack use leads to more rapid compulsive behaviour and addiction than snortable cocaine.79-81 For many opiate addicts, cocaine is now the drug of choice. They have great difficulty in cutting down or quitting and have a full-time job in procuring the substance.82 Use of crack may accelerate the marginalisation of problem opiate users and make the drugs scene more extreme.83 • In the hard drugs scene there are also problem users who frequently use cocaine, especially crack, without using heroin as well. It is not known how big this group is. - Field studies have shown that this accounts for some 10 to 15 percent of the total population of problem hard drug users. 82;84 - Local studies conducted earlier this decade show that crack users without a prior history of heroin use comprise mainly immigrant and homeless juveniles and young adults as well as street prostitutes.80;85 - According to research in Rotterdam, crack use can, in particular in the case of juveniles, act as a catalyst for a process of marginalisation, separating young people more and more from family, work and healthcare services.86 • The third group consists of users who started off snorting cocaine for recreational purposes, but then developed problem use (derailed snorters). By comparison with crack smokers, they generally started to snort coke from a more socially integrated position. The number of these problem users is not known. Field studies among the first two groups of users have shown that self-injecting of cocaine (or heroin) declined sharply during the 1990s, and with it the risk of infection. By contrast, smoking cocaine (and heroin) has increased, although recent data are unavailable. • For example, the number of ‘pure injectors’ of cocaine in Parkstad-Limburg as a percentage of total problem cocaine (and other hard drug) users dropped from 40% in 1996 to 4% in 1999. The number of problem users that both injected and smoked cocaine dropped from 30% to 17%. Between 1999 and 2002 this situation remained more or less stable.79;80;85 • According to the most recent figures from Rotterdam (2003), Utrecht (1999) and Parkstad-Limburg (2002), smoking cocaine is the usual method for between seven and nine out of every ten problem users of hard drugs.

3.5 USAGE: INTERNATIONAL COMPARISON 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 who use cannabis. • Differences in survey year, measuring methods and sampling make it difficult to conduct a precise comparison. The age group is the main factor of influence. Table 3.3a contains usage figures that have been (re)calculated according to the standard age group of the EMCDDA (15 to 64 years). Data for the other countries are shown in Ta-

50

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•

•

ble 3.3b. For Europe, only countries from the EU-15 and Norway have been included. Appendix E contains usage figures for the other EU member states, where available. The percentage of people aged up to 60 or 70 who have experienced cocaine is by far the greatest in the US and Canada. In the EU-15 the percentage of ever users varies from less than one per cent to seven percent. The highest rates are reported in the U.K. and Spain (approx. 7%).In the remaining EU member states (appendix E), the percentage of ever users does not exceed 1.2%. In the Netherlands, over 3% of the population aged between 15 and 64 has ever used cocaine, which is less than the European average of 4%.43 In most EU-15 and EU-27 countries, no more than about one percent of the population reports past year use of cocaine. Exceptions are the U.K. and Spain, with two and three percent respectively. In the US and Canada, the percentage of recent users is also higher. The Netherlands has a rate of recent cocaine use of 0.6%, which is below the European average of 1.3%.43

Table 3.3a

Cocaine use in the general population of a number of EU-15 member states and Norway: age group 15 to 64 years

Country

Year

Ever use

Recent Use

Spain

2005/2006

7.0%

3.0%

Netherlands

2005

3.4%

0.6%

Ireland

2002/2003

3.1%

1.1%

Norway

2004

2.7%

0.8%

France

2005

2.6%

0.6%

Austria

2004

2.3%

0.9%

Finland

2004

1.2%

0.3%

Portugal

2001

0.9%

0.3%

Greece

2004

0.7%

0.1%

Differences in survey year, measuring methods and sampling hamper a precise comparison between countries. 43 Percentage of ever users and recent users (past year). - = not measured. References:

Table 3.4b

Cocaine use in the general population of a number of EU-15 member states, the US, Canada and Australia: other age groupsI

Country

Year

Age (years)

Ever use

Recent use

US

2006

12 and older

14.3%

2.5%

Canada

2004

15 and older

10.6%

1.9%

United Kingdom

2004

?

6.5%

2.3%

Australia

2004

14 and older

4.7%

1.0%

Italy

2003

15 – 54

4.6%

1.2%

Germany

2003

18 – 59

3.2%

1.0%

Denmark

2005

16 – 64

4.0%

1.0%

Sweden

2000

16 – 64

0.7%

0.0%

Differences in survey year, measuring methods and sampling hamper a precise comparison between countries. Percentage of ever use and recent use (past year). I. Drug use is relatively lowest in the youngest (12-15) and older age groups (>64). Usage figures in studies with respondents who are younger and/or older than the EMCDDA standard may be lower than in studies using the EMCDDA standard. The opposite is the case for studies 43;45;87 with a more limited age range. References:

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51

Juveniles and young adults In de ESPAD survey of fifteen and sixteen year old school-goers in Europe conducted in 1999 and 2003, respondents were asked if they had ever used cocaine. In 2003 they were also asked about recent use. The data from this project are easier to compare than data from the general population. • Table 3.4 shows cocaine use in a number of EU countries and Norway. The US did not take part in ESPAD but conducted comparable research. • In the US, school-goers have more frequent experience of cocaine than their peers in the EU, notwithstanding the drop in the percentage of ever users between 1999 and 2003. • Italy and the UK were top of the list for ever use in 2003 (4%). The Netherlands, Belgium, France, Ireland and Portugal were above average at three percent, but the differences compared to other countries are slight. • Italy, the UK and the US have relatively the greatest number of recent users, at 3%. In the remaining countries, no more than one to two percent of school-goers had used cocaine recently. In the Netherlands, the figure is 1%.

Table 3.4

Cocaine use among school-goers aged 15 and 16 in a number of EU member states, Norway and the US. Survey years 1999 and 2003 1999

2003

Ever use

Ever use

Recent use

US

8%

5%

3%

Italy

2%

4%

3%

UK

3%

4%

3%

-

3%

1%

France

2%

3%

-

Ireland

2%

3%

1%

The Netherlands

3%

3%

1%

Portugal

1%

3%

2%

Denmark

1%

2%

2%

-

2%

2%

Greece

1%

1%

1%

Norway

1%

1%

1%

Sweden

1%

1%

0%

Finland

1%

0%

0%

Belgium

Germany

I

Percentage of ever users and (2003) in the past year (recent). I. Six of sixteen federal states. - = not meas48 ured. The US did not participate in the ESPAD, but conducted comparable. Source: ESPAD.

3.6 TREATMENT DEMAND Outpatient Addiction Care The National Alcohol and Drugs Information System (LADIS) registers the number of people who seek treatment from the (outpatient) addiction care services, which include the addiction probation and aftercare service and addiction clinics that are merged with the outpatient addiction care services49 (See appendix A: LADIS clients).

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• The number of clients with cocaine as a primary problem quadrupled between 1994

•

• •

• •

• •

and 2004. Between 2004 and 2005 a first small drop of two percent was registered and between 2005 and 2006 there was a further 2% drop (figure 3.2). Per 100 000 inhabitants aged 15 and older, the number of primary cocaine clients rose from 20 in 1994 to 76 in 2004, and dropped slightly to 74 in 2005 and 72 in 2006. The ratio of cocaine clients to all clients with a drug problem also grew, viz., from 13% in 1994 to 30% in 2006. In 2006 about one in six (18%) primary cocaine clients were newcomers. These clients had not been registered before with the (outpatient) addiction care services for a drug problem. For over half of primary cocaine clients (54%), smoking (crack) is the main method of use, and for four out of ten (41%) it is snorting. Only one percent inject cocaine. The drop between 2004 and 2006 in the number of primary cocaine clients can be attributed to a reduction in the number of crack users. During this period, the percentage of crack users among primary cocaine clients declined from 61 to 54 percent. Most primary cocaine clients (74%) also had problems with another substance, mainly alcohol, cannabis and heroin. For a quarter (26%), cocaine was the only problem. Cocaine was also often cited as a secondary problem (Figure 3.2). In this group, the primary problem was heroin (53%), alcohol (33%), or cannabis (7%). Between 2005 and 2006, there was a slight decline (-4%) in number of clients with secondary cocaine problems.

Figure 3.2

Number of (outpatient) addiction care clients with primary or secondary cocaine problems from 1994I

Number 11000 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 Primary

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2468 2928 3349 4137 4607 5689 6103 6647 7774 9216 9999 9824

Secondary 6020 6391 6503 7015 6699 6932 7111 8426 8281 8388 8393 8157 I. The rise in secondary cocaine clients from 2000 to 2001 is partly due to the provision of opiate client data (since 2001) by the GGD Amsterdam. For 2005, the Jellinek data have been extrapolated. Source: LADIS, 49 IVZ.

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53

Age and gender • In 2006 over eight out of ten primary cocaine clients were male (82%). The ratio of female clients has risen somewhat since 1999 (16% in 1994-1999, 17% in 2000 and 18% in 2001-2006). • In 2006 the average age was 35. This means that primary cocaine clients are younger than opiate and alcohol clients, but older than cannabis, ecstasy and amphetamine clients. • Figure 3.3 shows that 59% of primary cocaine clients are aged between 25 and 39. The ratio of young cocaine clients aged 15 to 29 has dropped over time from 56% in 1994 to 31% in 2006.

Figure 3.3

Age distribution of primary cocaine clients of (outpatient) addiction care. Survey year 2006

% 25 19

20

20

20

15

13 11

9

10

4

5 1

2

0 15-19

20-24

25-29

30-34

35-39

Percentage of clients per age group. Source: LADIS, IVZ.

40-44

45-49

50-54

>54

Age

49

Regional trends • The Netherlands is divided into 43 regions for Social Welfare and Addiction Policy (MO/VB regions). Between 2002 and 2006, treatment demand per 10 thousand inhabitants over the age of 15 was greatest in the MO/VB region of Rotterdam (20.4 cocaine clients), followed by the MO/VB region of Zaanstad (14.6 cocaine clients). 50 • During the period 2002-2006 the number of primary cocaine clients increased by an average of 63% compared with 1997-2001. This growth took place in all regions of the Netherlands. The sharpest rise was registered in seven regions in the north-east of the country: Deventer (160%), Enschede (159%), Friesland (158%), Assen (156%), Apeldoorn (143%), Zwolle (139%) and Almelo (122%).50

General hospitals; incidents In general hospitals, cocaine misuse and dependence are not often recorded as the primary diagnosis for clinical admissions. • In 2006 there were 90 cases, of which 61% were due to cocaine misuse and 39% to cocaine dependence (Figure 3.4).

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• Cocaine related problems are more often recorded as a secondary diagnosis. Between 1996 and 2002 there was a rise in the number of admissions with cocaine misuse or dependence as a secondary diagnosis. Between 2004 and 2006, the number of secondary diagnoses fluctuated around the same level, with a slight drop between 2005 and 2006 (6%). • In 2006 the most frequently occurring categories of primary diagnoses which had cocaine misuse or dependence registered as a secondary diagnosis were: - diseases and symptoms of the respiratory system (18%) - injury through accidents (14%, such as fractures, cuts, concussion) - poisoning (13%) - misuse of or dependence on alcohol or (other) drugs (11%) - diseases of the cardio-vascular system (9%) - psychotic disorders (5%).

Figure 3.4

700

Admissions to general hospitals related to cocaine misuse and dependence, from 1994

Number 562

600

547

514

451

500 371

363

383

377

55

50

65

67

81

84

80

89

101

53

90

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

400 300

551 506

285

246

200 100

24

0 1995

Cocaine as main diagnosis

Cocaine as secondary diagnosis

Number of diagnoses, not corrected for duplication of persons or of more than one secondary diagnosis per admission. ICD-9 codes: 304.2, 305.6 (appendix C). Source: LMR, Prismant.

• The same person may be admitted more than once per year. In addition, more than

•

one secondary diagnosis may be made per case. In 2006, corrected for duplication, the total amounted to 514 persons who were admitted at least once with cocaine misuse or dependence as the primary or secondary diagnosis. Their average age was 35, and 74% were male. The LMR registered no cases of ‘accidental poisoning with cocaine’ as the secondary diagnosis in 2006 (ICD-9 code E855.2)

According to the injury information system (LIS)51 of the Consumer Safety Institute, on average 3,200 people are treated annually at the accident and emergency departments of hospitals on account of an accident, violent incident or self-mutilation related to drug use. The drugs in question are cocaine, heroin, cannabis, ecstasy, magic mushrooms and

TRIMBOS-INSTITUUT

55

speed. The data have been averaged for the period from 2002 to 2006, and consist of estimates for the entire country, based on data from a representative sample of hospitals. • Cocaine is the most frequently cited drug. Approximately one in three (34%) drug victims indicates having used cocaine. If we count only the cases where the drug is known (68%), then cocaine accounts for 46% of all drug-related emergency room treatment. • Approximately twelve percent of drug victims (400 cases) are treated for complications caused by a foreign body. In most cases, these involve pellet swallowers. • These figures are likely to be an under-estimate of the true number of drug-related accidents. The National Poison Information Centre of the National Institute of Public Health and the Environment (RIVM) registers the number of requests for information from doctors, pharmacists and government organisations about (potentially) acute poisoning by foreign bodies such as drugs.52 • The number of information requests for cocaine rose steadily between 2000 and 2003 and fluctuated in the years following. From 2006 to 2007 there was a slight rise in the number of requests (table 3.5) • A trend in the number of information requests does not necessarily equate with a trend in the number of intoxications. Increasing familiarity among professionals with the symptoms and treatment of drug poisoning cases may reduce the need for information requests from the NVIC.

Table 3.5

Cocaine

Information requests concerning cocaine use from the National Poisons Information Centre (NVIC) from 2000

2000

2001

2002

2003

2004

2005

2006

150

184

217

247

227

254

211

Number of information requests annually via the NVIC 24 telephone helpline. Requests via the website www.vergiftigingen.info (online since April 2007) are not included in the data. Source: NVIC, RIVM.

3.7 ILLNESS AND DEATHS • Cocaine induced health problems, particularly from frequent crack smoking include

•

lung complications (coke lung), exhaustion and reduced immunity, anxiety and paranoia69. Heavy coke users also have more difficulty in keeping their aggression under control. Juveniles and young adults in the social scene who have used cocaine excessively and for prolonged periods exhibit paranoid, uptight and egotistical behaviour as well as introvertedness.22 Constant tiredness is also cited as an effect of frequent cocaine use.21 And the nostrils can become damaged from frequent snorting. 88;89

The Netherlands Cause-of-death statistics of Statistics Netherlands (CBS) still lists few (acute) deaths that could be attributed to cocaine. • Nonetheless, there is evidence of an increase between 1997 and 2002, after which cocaine deaths declined in 2003 and stabilised between 2004 and 2006. From 1996 through 2006 there was a total of 201 cases (Figure 4.7 in chapter 4).

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• Figure 3.5 shows a breakdown by age group of all cocaine deaths in the period 2001

•

•

through 2006. Almost two-thirds (64%) of the deceased were aged over 35. The peak is found in the age group of 30 to 39 years. Approximately eight out of ten cocaine victims were male (83%). Deaths in which cocaine has played a contributory part are sometimes recorded under natural causes, such as heart failure. Consequently, it is difficult to determine the number of cases in which cocaine use has contributed to death. The total number of deaths among ‘mules’ who have swallowed pellets of cocaine is unknown. This is partly because the cause-of-death statistics excludes persons who are not registered in the Netherlands. The Amsterdam Municipal Health Service (GGD) registered between three and eight cases annually in the period from 2002 to 2006 (7 in 2006).

Figure 3.5

25

Age distribution of cocaine deaths from 2000 to 2006

%

21

21

20 15

15

16

11 9

10

4

5 1

1

<15

15-19

2

0 20-24

25-29

30-34

35-39

40-44

45-49

50-54

>54

Age

Percentage of deaths 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).

International Comparison According to the EMCDDA, the EU member states registered a total of 400 deaths related to cocaine use in 2005 and 2006. 90 However, in many cases it is not clear if cocaine poisoning is the primary cause of death. Cases in which the death can be attributed to a combination of substances, including cocaine, may also be included in these figures. This also applies to deaths in which cocaine use triggers an existing condition, and is actually a secondary cause of death. Under-reporting may also play a part.

3.8 SUPPLY AND MARKET Composition of cocaine samples The Drugs Information and Monitoring System (DIMS) monitors the market for illegal drugs. To this end, it uses analyses of drug samples submitted by users in addiction care

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57

centres to establish which substances are in the drugs. Some of these samples are identified by the care centre itself. Samples containing unknown substances and all samples in powder form, such as cocaine, are forwarded to the laboratory for chemical analysis. In 2007, 709 powder samples were presented, that had been bought by users as cocaine. • In 2007 92.5% of all powder samples bought as cocaine did in fact contain that drug (mainly hydrochloride). The concentration varied from 1% to 92%, with an average of 57% (in terms of weight). In 2006, the average was 53 percent. • 6.4% of the powder samples sold as cocaine contained one or more other psychoactive substances, and 1.1% contained no psychoactive substance whatever. • As was the case in 2004 and 2005, DIMS again (twice) found atropine in cocaine in 2007. Shortly before this contaminated cocaine was discovered, a national alert had been issued (Red Alert), because cocaine contaminated with atropine had been found in the vicinity of a dead cocaine user. In recent years, powder samples that were sold as cocaine have increasingly been found to (also) contain medicines • One in three (36%) samples analysed in 2007 were found to contain phenacetine. In 2005 and 2006 the percentages were 37% and 45% respectively. Phenacetine is a substance that was registered until 1984 as a painkiller, but because of possible carcinogenic effects, it was removed from circulation. The concentrations of phenacetine that are used as a mixing agent are far lower than the therapeutic doses which were feared to induce damaging side-effects. • In 2007 cocaine samples were also relatively often found to contain the pharmaceutical drugs diltiazem and levamisol. Twelve percent of cocaine samples sold as cocaine contained diltiazem (2006: 6%); and eleven percent contained levamisol (2006: 4%). Diltiazem is prescribed for high blood pressure and angina pectoris; levamisol is an anti-cancer drug.

Prices Figures from the national Trendwatch-monitor, the Antenne Monitor and the DIMSproject give an indication of the price paid by consumers for a gram of cocaine. • According to key observers, socialising juveniles and young adults who purchased cocaine in 2006/2007, paid on average 50 euro per gram, although prices vary from 35 to 60 euro per gram. In Amsterdam exceptions of up to 70 euro are reported. 22 According to users, this cocaine is of very high quality. 19 • These figures tally with the prices paid by users in 2007 for cocaine samples submitted to the DIMS-project (25 euro minimum and 75 euro maximum per gram of cocaine powder, with an average price of 45 euro per gram). These prices are the same as those reported in 2006.

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4

OPIATES

The drug class of opiates comprises many substances. Some of these are known for their illegal use, such as heroin. Other opiates are heroin substitutes, such as methadone and buprenorphine, or are used therapeutically in medicine, such as morphine and codeine. This chapter is concerned chiefly with heroin and methadone. Opiates can induce euphoria, but may also have the opposite effect. Heroin can be taken in various forms. Currently the most common way to take heroin in the Netherlands is to smoke it (chasing from tinfoil). Injecting the drug is now less common in the Netherlands. Opiate users whose habit has got out of control often use other substances (polydrug use), in a way that is not compatible with ‘normal’ life. Where the collective term ‘hard drugs’ is referred to in this chapter, we usually mean at least one opiate - mainly cocaine.

4.1 RECENT FACTS AND TRENDS The main facts and trends concerning opiates in this chapter are: • Heroin use is low in the general population (§ 4.2). • Heroin has little popularity among school-goers and socialising juveniles (§ 4.3). • The number of opiate addicts in the Netherlands is low compared to other European countries (§ 4.5). • The number of opiate clients in (outpatient) addiction care declined further between 2005 and 2006 (§ 4.6). • In the same period there was also a drop in the number of hospital admissions involving opiates (§ 4.6). • The number of newly diagnosed HIV-infections among injecting drug users remains low (§ 4.7). • The percentage of Hepatitis C infections among HIV-positive injecting drug users is high (§ 4.7). • The acute death rate from drug use remains low in the Netherlands. Between 2005 and 2006 there was a slight decline. (§ 4.7).

4.2 USAGE: GENERAL POPULATION Heroin use is low in the general population. • According to the 2005 NPO survey, 0.6% of the Dutch population aged between 15 and 64 had ever experienced heroin. This is more than the surveys of 1997 and 2001 (0.3% and 0.2% respectively).5 • In all survey years, the percentage of recent and current users was zero, with the exception of recent users in 1997 (0.1%). • These figures are likely to be an under-estimate, because problem users of hard drugs are under-represented in the NPO surveys. Many users of illegal opiates or methadone clients are not reached through random sampling, because they may be homeless, in prison, or otherwise out of the picture. To a certain extent, they may yet be included in statistics by means of other research methods (see § 4.3).

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Special groups Among certain groups of adults, heroin use is more prevalent than in the general population. • In 2002 one in five male detainees (21%) in eight Remand Centres had used heroin in the six months prior to detention.70 • In the same year, 40% of the homeless in 20 Dutch municipalities had used this drug in the month prior to being surveyed.6 • In 2006, 29 percent of the homeless in Rotterdam day and night shelters had used heroin (almost) daily. 7 These groups may overlap with problem users as described in § 4.3.

4.3 USAGE: JUVENILES Heroin is not popular among secondary school-goers aged 12 and older (Table 4.1).9 • In 2003 there were more boys than girls who had ever used heroin (ever use: 1.5% versus 0.7%; current use: 0.8% versus 0.3%). • The percentage of ever users has fluctuated around one percent since 1988. Since then, no more than half of that group was currently using heroin.

Table 4.1

Heroin use among school-goers aged 12 to 18 from 1988 1988

1992

1996

1999

2003

Ever use

0.7%

0.7%

1.1%

0.8%

1.1%

Current use

0.3%

0.2%

0.5%

0.4%

0.5%

Percentage of ever use and current use (past month). Source: Dutch National School Survey, Trimbos Institute.

Special Groups In some at-risk groups, there is a higher rate of heroin use, but this does not apply to all at-risk groups. • In certain circles, a small minority experiments with heroin (Table 4.2). For instance, in 2001 almost one in ten ‘coffee shop’ frequenters in Amsterdam had ever tried heroin.20 • Among frequenters of fashionable clubs in Amsterdam, the percentage of ever users dropped from 6% in 1998 to 2% in 2003. Current use is rare in the social scene.15;25 • In 2000/2001 the highest percentages of users was reported among the marginalised youth in The Hague. Thirteen percent had experienced heroin, and seven percent were current users. 31 • Lower percentages were found among young drifters in the province of Flevoland in 2004. Eight percent had ever used heroin, and two percent were current users. 28 • In Amsterdam heroin use is virtually negligible among juveniles in care, school dropouts and even the most deviant group of juvenile detainees.19;75 In 2006, key observers in Amsterdam reported that heroin use is virtually non-existent among the mainly immigrant street kids and various groups of problem juveniles, such as boyprostitutes, homeless youth and drifters. 19

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• Key observers in the Den Bosch region reported in 2005, however,

that some younger hard drug users who had started with crack, were now also using heroin.38

Table 4.2

Heroin use in special groups Location

Survey year

Age

Ever use

Current use

Bar-goersI

Amsterdam

2000

Average 25

1%

0.2%

Clubbers

Amsterdam

2005

Average 27

1.5%

0%

1998

Average 26

6%

Coffee-shop frequentersII

Amsterdam

2003

Average 28

2%

0%

2001

Average 25

9%

0.9%

School drop-outsIII

Regional

2002/2003

14 - 17

1.1%

0.5%

Juvenile detaineesIII

Regional

2002/2003

14 - 17

The Hague

2000/2001

16 - 25

13%

7%

Homeless youthV

Flevoland

2004

13 – 22

8%

2%

Juveniles in careVI

Amsterdam

2006

Average 17

1%

0%

Juveniles and young adults in the social scene

Problem groups

Marginalised pleIV

young

peo-

3.4%

0.5%

Percentage of ever users and current users (past month) per group. The figures in this Table are not mutually comparable on account of differences in age groups and research methods. I. Selective sample of juveniles and young adults from mainstream bars, student bars, gay bars and hip bars; therefore not representative of all bar-goers. II Low response (15%). III. Research in the provinces of Noord-Holland, Flevoland and Utrecht. Drop-outs are juveniles who have not attended school for at least one month during the past 12 months, not counting holidays. Usage among juvenile detainees: in the month prior to detention. IV. Young people who receive insufficient care or are insufficiently able to meet their own living needs. Surveyed at locations for homeless youth, low-threshold day and night centres and (other) temporary accommodation facilities. V. Young people up to age 23 who have had no fixed abode for at least three months. VI. Juveniles with behavioural 19;20;27problems, juvenile delinquents, homeless youth and juveniles in other care settings. References: 29;31;32;75

4.4 PROBLEM USE The available estimates tend not to draw a clear distinction between problem users of opiates and of other hard drugs.a The estimated figures in Table 4.3 refer mainly to regular users of illegal opiates or of methadone, who generally also take other substances such as cocaine, alcohol and sleeping pills or tranquillizers. According to the most recent available estimates (2001), there are about 33,500 problem users of hard drugs in the Netherlands. This figure is couched in a rather large margin of uncertainty, varying from some 24,000 to over 46,000 problem users. By comparison with estimates dating from 1999, no significant change had taken place. • In 2001, the Netherlands had about three problem users of hard drugs per thousand inhabitants aged between 15 and 64. • Per thousand inhabitants, the greatest proportion of problem users is found in Rotterdam and The Hague (Figure 4.1). However, the differences between the various cities should be interpreted with caution on account of discrepancies in definitions and calculation methods. For example, the estimates for Amsterdam include opiate users a

See Appendix A for a definition of problem use.

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who often use other substances as well. In The Hague and Rotterdam, a wider group of problem hard drug users was taken into account. If a wider definition were used for Amsterdam, this city would possibly be in line with The Hague and Rotterdam. According to a stricter definition, there were an estimated 3,000 problem hard drug users in Rotterdam in 2003 who used hard drugs (almost) daily and as such engaged in criminal activity, caused trouble or were homeless. This amounts to 7.5 persons per thousand inhabitants aged between 15 and 64.

•

Table 4.3

Estimates of the number of problem users of hard drugs

Area

Year

Number

Nationwide

2001

33 500 (23 800 – 46 500)I

Rotterdam

2003

5 051 (4 804 – 5 298) I

Amsterdam

2006

3 297

The Hague

2000-2002

3 200 (per annum)

Parkstad Limburg

2002

800

Enschede

2005

607

Apeldoorn

2005

223

Leeuwarden

2001

389

Almelo

2004

229

Hengelo

2004

191

Owing to differences in definitions and methods, the figures should be interpreted with caution. In Amsterdam, Groningen, Apeldoorn, Friesland, Almelo and the urban triangle, the estimates of problem users involve opiates (as well). In Rotterdam, The Hague, Enschede, Hengelo and Zuid-Limburg, the figures relate to hard drug users in a broader sense. I. Average (and the upper and lower limit) of different estimates. References:91-99

Figure 4.1

Estimates of the number of problem users of hard drugs per 1,000 inhabitants aged from 15 to 64

Number per 1,000 inhabitants 15-64 years 14

12.4

12 10.1 10 8

4

6.3

5.9

6

5.7 4.7

4.7

4.5 3.6

3.1

2 0 National (2001)

Rotterdam (2003)

The Hague (2000-2003)

Amsterdam (2006

Leeuwarden (2001)

Enschede (2005)

Almelo (2004)

Apeldoorn (2005)

Parkstad Limburg (2002)

Hengelo (2004)

Average of highest and lowest estimates (where applicable). Owing to differences in definitions and methods, the differences between the various cities should be interpreted with caution. References: see Table 4.3.

Figure 4.2 shows the development of a number of problem opiate users in Amsterdam according to estimates by the GGD Amsterdam.

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• The number in this group peaked in 1988 at 8,800 problem users and subsequently

•

declined. The decline was largely due to reduction in the number of foreigners, especially Germans and Italians. In recent years, however, a decline has been observed in all groups. In 2006 Amsterdam still had an estimated 3,300 problem users of opiates. Of these, 47% were born in the Netherlands, 26% in Surinam, the Netherlands Antilles, Morocco or Turkey and 27% were born elsewhere.

Figure 4.2

Problem users of opiates in Amsterdam, from 1985

Number

10000

8000

6000

4000

2000

0 1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Born in the Netherlands Born in Surinam, the Netherlands Antilles, Morocco or Turkey Born elsewhere Total Source: GGD Amsterdam.

Age The population of heroin users is getting older. • In Amsterdam the average age of methadone clients has risen from 32 in 1989 to 47 in 2006 (Source: GGD Amsterdam). In Rotterdam and Parkstad Limburg the average age of problem hard drug users rose from 37 in 1998 to 39 in 2002/2003.85;100 • The ageing of heroin users is accompanied by an increasing number of health problems (see § 4.7).

Manner of use The use of opiates poses a particularly high health risk when the drugs are injected. Over time, the injecting of drugs has declined among opiate users.

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63

• Accordingly, the number of injectors of heroin in Parkstad Limburg dropped from 33%

• •

•

•

•

of all heroin users in 1996 to 13% in 1999. This trend did not continue between 1999 and 2002.85 In Rotterdam the ratio of injectors dropped from 15% in 1999 to 10% in 2003.100 Among drug users participating in the Amsterdam Cohort Studies on HIV/AIDS, the number who reported having injected opiates since the previous survey dropped from 57% in 1985 to 21% in 2004.101 The decline in the number of needles and syringes that are exchanged in needle exchange programmes in Amsterdam and Rotterdam is also an indication of a drop in the practice of injecting opiates (see § 4.7). In 2006 10% of opiate clients of (outpatient) addiction care were registered as injectors, and 71% as smokers – the same number as in 2005. The remainder took the drugs in a different way.49 In 1994, 16% of users were injecting, and in 2001 12%. The total number of injecting drug users in the Netherlands can be estimated on the basis of the percentage of injectors among hard drug clients of the addiction care services as well as an estimate of the total number of problem hard drug users in the country. In 2005, this calculation resulted in an estimate of about 3,100 injecting drug users, within a margin of at least 2,200 and at most 4,300 cases.

4.5 USAGE: INTERNATIONAL COMPARISON Use among school-goers • According to the ESPAD survey in 2003 the percentage of 15 and 16 year olds in

•

Europe who had ever used heroin did not exceed two percent. An exception to this was Italy where the figure was 4%. In the Netherlands, one percent of school-goers had ever used heroin.48 The percentage of recent users was less than 1%, with the exception of Italy (3%).

Problem use • The EU has an estimated 1.3 to 2.7 million problem users of hard drugs, i.e. between

•

•

•

•

64

four and five per thousand inhabitants aged between 15 and 64. In most EU countries the hard drugs in question are (also) mainly opiates.87 The estimates are calculated using different statistical methods. Table 4.4 shows the lowest and the highest figures per country. Owing to differences in definitions and methods, the data should be interpreted with caution. In the twelve member states of EU-15 for which national estimates are available, the numbers vary from an average of two to ten problem users per thousand inhabitants aged between 15 and 64. Germany, Greece and the Netherlands are at the bottom of this list, with the U.K. at the top. Of the new member states, the number of problem users varies from less than two per thousand inhabitants aged 15 to 64 (Cyprus, Latvia, Poland), to five or more in Malta, Slovenia and Slovakia. Trend data are available for only eight member states. These show a stable picture, with the exception of Austria, which reports a clear rise in the number of problem opiate users. In Italy too, there are signs of an upward trend. There appears to be an increase in (injecting) use of buprenorphine in France, the Czech Republic, Belgium and Finland. 43

TRIMBOS-INSTITUUT

Table 4.4

Problem users of hard drugs in 12 EU member states

Country

Year

Number per thousand inhabitants from 15 to 64 years Lower limit – upper limitI

Central estimateII

U.K.

2005

10.1 – 10.7

10.2

Spain

2002

7.1 – 9.9

8.5

Italy

2005

7.2 – 8.6

7.9

Denmark

2005

7.1 – 8.0

7.5

Portugal

2000

6.8 – 8.5

7.1

Austria

2004

5.0 – 5.7

5.4

Ireland

2001

5.2 – 6.1

5.7

Finland

2002

4.6 – 6.1

5.3

Sweden

2003

4.5

4.5

Germany

2005

3.0 – 3.5

3.3

The Netherlands

2001

2.2 – 4.3

3.1

Greece

2005

2.3 – 3.0

2.6

According to the EMCDDA definition of problem use: long-term/regular use of opiates, cocaine and/or amphetamines. Owing to differences in methods, the data should be interpreted with caution. Recent estimates for France are lacking (in 1999: 4.4 per 1,000 inhabitants aged between 15 and 64). For most countries the estimates refer to opiate users, with the exception of Sweden and Finland, where amphetamine users are in the majority. In the Czech Republic (not included in the table), both opiate and methamphetamine users are counted. I. Maximum values based on 95% confidence intervals or sensitivity analysis. II. In countries with a number of estimates, the average of these is used. Source: EMCDDA. 43

4.6 TREATMENT DEMAND Outpatient addiction care The National Alcohol and Drugs Information System (LADIS) registers the volume of people seeking treatment from (outpatient) addiction care (including probationary addiction care and the addiction clinics that have merged with outpatient addiction care (See appendix A: LADIS Clients).49 • The number of clients with a primary opium problem rose slightly up to 1997 (Figure 4.3). This increase was partly real and partly a distortion of the figures, following the affiliation of a number of drug addiction care organisations to LADIS. The number of opiate clients remained fairly stable between 1997 and 2000. The increase in 2001 can be largely attributed to the affiliation of GGD Amsterdam to LADIS.b • Between 2001 and 2004 the number of opiate clients dropped. After a slight rise of 2% between 2004 and 2005 there was further drop of seven percent between 2005 and 2006. • The percentage of opiates involved in all drug-related requests for treatment dropped from 71% in 1994 to 44% in 2005, declining further to 41% in 2006. This is partly due to the rise in recent years in the number of clients with another drug problem, such as cocaine and cannabis.

b

In 2001, GGD Amsterdam passed on the data of 1,869 clients with a primary heroin problem; 1,304 of these were not known to the other organizations that participate in LADIS.

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65

• The majority of clients had already sought treatment from (outpatient) addiction care

•

•

for a drugs problem. Only 4% were first-time clients in 2006 and had not been registered before with (outpatient) addiction care for a drug problem. In 2002 as many as 22% were newcomers. The majority (72%) of primary opiate clients also had problems with another substance – mainly cocaine. Approximately three out of ten primary opiate clients (28%) reported no secondary substance. Opiates are less likely to be reported as a secondary problem (figure 4.3). When they are, the primary problem is cocaine or crack (67%), alcohol (26%), or cannabis (2%).

Figure 4.3

Number of clients of (outpatient) addiction care with primary or secondary opiate problems from 1994I Number

20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Primary Secondary

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

14002 14936 15247 15865 15491 15606 15544 17786 16043 15195 13929 14176 13180 804

913

985

1112

1101

1313

1387

1761

1912

2056

2252

2023

2043

I. The rise in the number of persons between 2000 and 2001 is due to inclusion for the first time of data from GGD Amsterdam. Source: LADIS, IVZ. 49

Age and gender • In 2006 80% of primary opiate clients were male. Over time this percentage has fluctuated between 78% and 80%.

• In 2006 the average age was 42 – considerably higher than that of cannabis and cocaine clients. 63% of opiate clients were older than 39 (Figure 4.4).

• The percentage of young opiate clients (age 15 to 29) dropped between 1994 and 2005 from 39% to 6%. In 2006, the number stabilised at six percent.

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Figure 4.4

25

Age distribution of primary opiate clients of (outpatient) addiction care. Survey year 2006

% 23

21

20

20

15

13 11

10 4

5

4 2

1 0 20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

>59

Age

Percentage of clients per age group. Source: LADIS, IVZ. 49

Regional trends • The Netherlands is divided into 43 regions for Social Care and Addiction Policy (MO/VB

•

Regions). During the period 2002-2006, treatment demand for opiate use was greatest in the MO/VB regions of Groningen, Amsterdam, The Hague and Rotterdam (between17.6 and 31.7 opiate clients).50 From 2002 to 2006, the number of primary opiate clients dropped by an average of sixteen percent compared to 1997-2001. This decline occurred in most regions in the Netherlands and was most pronounced in the regions of Utrecht (-56%), Helmond (45%), Zaanstad (-40%) and ’s-Hertogenbosch (-38%). In the urban belt (Randstad), the number of opiate clients rose, but this can be attributed to an expansion of the number organisations in this region that now participate in LADIS. 50

Methadone The main dispensers of methadone are (outpatient) addiction care, GGD Amsterdam, GPs and other physicians. National data are available through LADIS for (outpatient) addiction care, including GGD Amsterdam.49 • The number of methadone clients of (outpatient) addiction care rose slightly up to 2002 (Table 4.5). This was partly a real increase and partly due to the expansion of the number of organisations that participate in LADIS.

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67

Table 4.5

Methadone dispensing in (outpatient) addiction care, from 1994

Year

Number of persons

Average dose per intake (milligrams)

1994

8 882

46

1995

8 817

37

1996

9 068

38

1997

9 838

40

1998

9 754

42

1999

10 666

45

2000

10 805

48

I

12 538

54I

2002

12 805

57

2003

12 048

57

2001

I

2004

12 493

56

2005II

12 564II

54II

2006III

12 000III

62III

I. The rise in the number of persons compared to 2000 is due to the first-time inclusion of data from GGD Amsterdam. The increased average methadone dose may also be (partly) due to this. II. In 2005, 10,362 methadone clients were registered out of an estimated 12,564 methadone clients. The average dose of 54 mg is an under-registration. The actual dose is higher. III. In 2006, 9,811 methadone clients were registered out of an estimated total of 12,000 methadone clients. Source: LADIS, IVZ. 49

• Methadone is generally prescribed as a maintenance treatment. In a minority of cases it is used for coming off heroin.

• The average methadone dose per intake day rose between 1995 and 2003, (table

•

4.5). Because of breaks in trend in the registration data, no definite conclusions can be drawn about recent developments in the average methadone dose for recent years. Data available for 2006 show that 43% of clients received a dose of at least 60 mg methadone. The average therapeutic dose is between 60 and 120 mg. 102 The amount of methadone received by a client each time depends on the methadone policy of the organisation or practitioner in question.

General hospitals; incidents Misuse of and dependence on opiates are rarely stated as the primary diagnosis in general hospitals. In 2006 the LMR listed 78 admissions with this primary diagnosis (69% dependence and 31% misuse, Figure 4.5). • More frequently, opiate misuse and dependence are cited as a secondary diagnosis (476 in 2006; 76% dependence, 24% misuse). Between 2005 and 2006 the number of secondary diagnoses for opiate problems dropped by 20%. The primary diagnoses accompanying these secondary diagnoses vary considerably. The most common in 2006 were: - diseases and symptoms of the respiratory tract (25%) - injury through accidents (12%; fractures, cuts, concussion) - digestive system disorders (10%) - poisoning (7%) - misuse of or dependence on alcohol or drugs (7%) - skin ailments (2%).

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TRIMBOS-INSTITUUT

Figure 4.5

Admissions to general hospitals related to opiate misuse and dependence from 1994

Number 900 800

751

700

742 627

607

596

634

627

674 606

558

600

556

594 476

500 400 300 200 100

74

71

71

71

76

79

75

81

88

51

57

61

78

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Opiates as main diagnosis

Opiates as secondary diagnosis

Number of diagnoses, not corrected for duplication of persons or more than one secondary diagnosis per admission. ICD-9 codes: 304.0, 304.7, 305.5 (see appendix C). Source: LMR, Prismant.

• The same person may be admitted more than once per year. In addition, more than

•

one secondary diagnosis may be made per case. In 2006, corrected for duplication, the total amounted to 439 persons who were admitted at least once with opiate misuse or dependence as the main or secondary diagnosis. Their average age was 43, and 72% were male. In 2006, the LMR registered no cases of accidental poisoning with opiates as a secondary diagnosis (ICD-9 codes E850.0 through E850.2).

In 2006, the Ambulance Transport Centre (CPA) of GGD Amsterdam registered 234 emergency requests for ambulances for presumed non-fatal overdoses of hard drugs. In 67% of the cases, transport to hospital was deemed necessary. • Most cases involved opiates and cocaine, with or without other substances. • The number of hard drug-related ambulance journeys dropped from 307 in 1997 to 188 in 2000 and subsequently rose slightly, but appears to have stabilised in recent years. According to the Injury Information System (LIS) of the Consumer Safety Institute51, an average of 3,200 persons are treated annually in the emergency department of hospitals, following an accident, violent incident or self-mutilation related to drug use. The drugs involved are cocaine, heroin, cannabis, ecstasy, magic mushrooms and speed. The data have been averaged over the period from 2002 through 2006 and relate to estimates for the entire country, based on data from a representative sample of hospitals. • Heroin is cited in only four percent of cases. If we count only the cases where the drug is known (68%), then heroin accounts for 5% of all drug-related emergency room treatment.

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69

• These figures are likely to be an under-estimate of the true number of drug-related accidents. 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 doctors, pharmacists and government organisations about (potentially) acute poisoning by foreign bodies such as drugs.52 • The number of information requests for opiates doubled between 2000 and 2003, and rose by 15% between 2004 and 2005 from 112 to 129 requests (table 4.6) • The drop in the number of information requests in 2006 is related to a discontinuation of listing methadone among the drugs. From that year on, methadone is listed among medicines. • These figures do not really give a complete picture of the absolute number of drug intoxications, because intoxications are not strictly notifiable by doctors. In addition, increasing familiarity among doctors with the symptoms of poisoning by a certain drug and of the required treatment may reduce the likelihood of information requests from the NVIC.

Table 4.6

Opiates

Information requests concerning opiate use from the National Poisons Information Centre (NVIC), from 2000 2000

2001

2002

2003

2004

2005

2006

2007

51

42

95

112

112

129

32

47

Number of information requests per annum via de 24-hour NVIC helpline. Requests via the website www.vergiftigingen.info (online since April 2007) have not been included for 2007. Source: NVIC, RIVM.

4.7 ILLNESS AND DEATHS • The population ageing taking place among opiate addicts is accompanied by prema-

•

•

•

70

ture age-related illnesses such as diabetes and cancer. Lung diseases caused by longterm heavy tobacco use and smoking heroin and cocaine are also on the increase in this group.84 Key observers in the Eindhoven region have reported that some ageing heroin users have partly switched to alcohol. This enables them to live in a permanently drugged state.40 Likewise, in the Maastricht area, there are reports that older heroin addicts frequently have a secondary alcohol addiction, which is accompanied by physical exhaustion.42 According to observers in Parkstad Limburg, the switch to alcohol by this group has compounded their physical problems.74 In addition to their drug addiction, many heroin users are also battling with mental health problems. Research conducted in 2005 among over 200 methadone clients in the province of Noord-Brabant shows that 34% currently suffered from depression, in addition to the existing drug addiction. Thirty percent had ever experienced a manic episode. Of anxiety disorders, a current generalised anxiety disorder was the most common (31%). Nine percent had a current psychotic disorder and over one third (39%) had ever suffered one.103 The GGD Amsterdam also reports that some ten percent of opiate-addicted clients experiences a psychotic episode annually.84 GGD Amsterdam reports an increase in psychopathology among addicts since the early years of the drugs epidemic. Various explanations are put forward for this:

TRIMBOS-INSTITUUT

-

self-selection, because addicts with an accompanying mental disorder are less likely to recover from their addiction than those without a mental disorder; the damaging consequences of a long-term existence on the street; interruption of methadone treatment, for example during imprisonment; increase in crack cocaine use, which, without the calming effect of heroin can lead to an exacerbation of mental problems.

HIV By injecting with contaminated needles or by engaging in unprotected sex, hard drug users incur a risk of becoming infected with HIV, the virus that causes AIDS. There are currently three sources of information in which recent monitoring data concerning HIV among injecting drug users is gathered. These are the National HIV/AIDS registration of the HIV Monitoring Foundation (SHM); the National STI monitoring data on sexually transmitted illnesses; and the Amsterdam Cohort Study, a longitudinal research project in Amsterdam. The data gleaned from these three sources indicate that the rise in new HIV infections among (ever) injecting drug users remains slight. The HIV Monitoring Foundation collects longitudinal data from all HIV infected persons who are registered with the HIV treatment centres. Data from this Foundation show that of all registered new HIV infections in the Netherlands, approximately one to two percent can be attributed to injecting drug use. • In 2006, injecting drug use was found to be the most likely cause of infection in 8 (one percent) of the 871 newly registered HIV infected persons).104 • In previous years, the absolute number of new HIV infections among injecting drug users was somewhat higher, viz. 18 (2001); 15 (2002); 23 (2003); 10 (2004) and 10 (2005).105 • In June 2007, injecting drug use was the most probable transmission route for 617 (5 percent) of the total group of 13,086 registered HIV infected persons.104 The majority of injecting drug users (62%) were infected before 1996, and only 16% from 2000 on. 105 Figure 4.6 shows that the proportion of drug users in the total group of HIV positive patients has declined since 1998. • Three-quarters (73%) of the 617 HIV-positive drug users are male. The largest group is aged between 30 and 39 (43%).104 • The vast majority of HIV positive injecting drug users are of Dutch origin (65%) and other Western European countries (17%).104 • Almost half (47%) of registered drug users live in the Amsterdam region. A quarter live in other regions in the West of the Netherlands. 104 • Deaths among HIV-positive people have been considerably reduced since the introduction of the highly effective treatment, HAART (highly active antiretroviral treatment). Nonetheless, compared to other transmission routes, HIV infection through injecting drug use remains a strong predictor of a fatal outcome. One reason for this is co-infection with Hepatitis C and lifestyle factors, such as excessive alcohol use.105

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Figure 4.6:

Percentage of registered HIV infections by injecting drug use, sexual contact between men and heterosexual contact 70

%

60 50 40 30 20 10 0

?1998

1999

2000

2001

2002

2003

2004

2005

2006

Injecting drug users

9

3

2

2

1

2

1

1

0.9

MSM

58

51

44

45

45

43

49

52

59

Heterosexual contact

23

37

46

42

43

44

40

38

33

MSM = men who have sex with men. Source: HIV Monitoring Foundation.104

The second source of information on HIV among injecting drug users comes from national STI monitoring data on sexually transmitted infections. STI monitoring was officially introduced and consists of eight regional STI centres with a nationwide distribution. National STI monitoring has replaced the monitoring conducted by the STI sentinel stations. • In 2006, 68,977 new visits to an STI centre were recorded. Past-six-month injecting drug use was reported by 90 clients (0.2%); however data from Amsterdam are lacking. Ever injecting drug use was reported by 147 individuals (0.3%).104 • In 2006, a total of 256 new HIV-positive diagnoses were made via the STI centres. Because information on injecting drug use from the GGD Amsterdam is lacking, it is only known for 126 clients who tested positive for HIV whether they were drug injectors. Of these, one person reported having injected during the past six months, and one individual had ever injected. The third source of data on HIV is the Amsterdam Cohort Study. In this longitudinal study, a sharp drop has been found over the past 20 years in the percentage of HIVpositive young drug users (< 30 years old when in included in the study). • The incidence of new HIV diagnoses among ever injectors has dropped from 8.5 per 100 person years in 1986 to around 0 since 2000, with a slight rise in 2005, when two injecting drug users tested positive. In 2006, no new HIV infections were recorded. 106 • The cohort study also shows that a substantial proportion of HIV-positive drug users who are eligible for treatment do not receive this treatment. 107 • It is known that some drug users continue to inject drugs despite receiving methadone replacement therapy. An interesting finding of this study is that injecting drug users who participate fully in both methadone treatment and needle exchange pro-

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grammes incur a lower risk of infection with HIV and Hepatitis C than injecting drug users who do not participate in these programmes. 108 In addition to these three sources, data are available from surveys conducted by the RIVM between 1994 and 2003, among samples of injecting drug users. A total of some 3,500 injecting hard drug users participated, in nine regions of the Netherlands. 109 The main results have been described in earlier editions of the NDM Annual Report. • Summarized briefly, these surveys showed considerable regional differences in HIV infection among ever injectors, ranging from 1 percent (Groningen, Arnhem) to 26% (Amsterdam). Besides methodological considerations, these differences can be largely attributed to actual differences in regional rates of infection. • In cities where repeat measurements were conducted, the percentage of HIV-positive injecting drug users was found to be fairly stable. An exception was Heerlen, where the number doubled from 11% in 1994 to 22% in 1999. • In 2007 a decision was taken by the RIVM to discontinue these surveys, unless in the future other sources – such as those described above – should disclose specific areas of concern, justifying more in-depth study. 104 International comparison The European Monitoring Centre for Drugs and Drug Addiction provides data on the prevalence of HIV infection among injecting drug users in EU member states. The data are derived from a variety of sources and differ in range. Furthermore, within a given country, the situation at local level may diverge strongly from the general national picture. The data are therefore not easily comparable and merely reflect an indication of the degree of contamination.43 • Percentages of HIV positive injecting drug users vary from less than one percent in Cyprus, Finland, Greece, Hungary, Malta, Slovenia and the Czech Republic, to 2540% in Spain (data from 2004 to 2006).110 In a number of countries, such as the Netherlands, there is considerable regional or local concentration of HIV infection. • In most European countries, as in the Netherlands, the number of new HIV infections among injecting drug users was low in 2005 (the year for which the most recent data are available). However, recent registration data are missing for a number of countries that have relatively high percentages of HIV-positive injecting drug users (Estonia, Spain, Italy, Austria). 43 - In 19 member states, the number of newly registered HIV-positive injecting drug users remained below five per million inhabitants. - Higher rates of newly registered infection were reported by Ireland (16 new cases per million inhabitants) and Luxembourg (15 new cases per million inhabitants). - Portugal has the highest number of new HIV diagnoses among injecting drug users, with 85 new cases per million inhabitants in 2005. However, this figure represents a stabilisation of the situation seen in previous years, when a strong upsurge was recorded. - In Latvia, where there were HIV outbreaks among injecting drug users in 2001 and 2002, the number of new diagnoses has declined (from 283 new cases per million inhabitants in 2001, to 49 in 2005). The same is true for Lithuania, where the rate dropped from 109 per million in 2002 to 25 in 2005, and probably also for Estonia.

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• It is estimated that there are between 100 thousand and 200 thousand ever drug users in the EU who are infected with HIV. 43 The number of new diagnoses in the EU is thought to be some 3,500 annually.

Hepatitis B and C A chronic hepatitis B or hepatitis C infection can cause serious forms of liver inflammation. Hepatitis C can virtually only be transmitted by direct blood to blood contact and is much more contagious than HIV. It can also be transmitted by sharing other contaminated (injecting) materials besides needles. The Hepatitis B virus is transmitted by blood contact, for example by intravenous injecting with used needles, or through unprotected sexual contact. Data about Hepatitis C and Hepatitis B among injecting hard drug users are not collected systematically in the Netherlands. • Injecting hard drug use is relatively often the source of new Hepatitis C infection. • In a longitudinal study in Amsterdam, the percentage of HCV infections among ever injecting drug users was found to be 65 percent in 2005. Women were found to be more likely to have a HCV infection (four-fifths of the women tested, as opposed to half the men), as were older drug users and users who had started injecting the furthest back in time. 111 • Data from GGD Amsterdam show a high percentage of hepatitis C infection among injecting drug users attending methadone dispensaries. In 2006, 70% (38 of the 54) of patients tested were carriers of the hepatitis C virus (Source: GGD Amsterdam). • Data from the HIV Monitoring Foundation show that 11 percent of the total of 8,581 HIV positive patients in active follow-up care were also infected with hepatitis C. There is a particularly high rate of Hepatitis C infection among HIV-positive injecting drug users: 94%. Infection among other HIV risk groups is less than 10%.105 • An acute Hepatitis C infection is a notifiable disease. Of the 30 cases of acute or recent Hepatitis C infection reported to the RIVM in 2006, the transmission route was known in 26 cases; in 8 cases (31%) of these the route was injecting drug use (source: RIVM). Chronic HCV infection among drug users is no longer notifiable since 2003; consequently there is a lack of data from this source on the prevalence of this infection among drug users. • Injecting drug use is less often the reason for hepatitis B infections. In 2006 the RIVM) registered 240 new cases of acute Hepatitis B infection. The cause of infection was known in 181 of these. In only one case (0.6%) was the infection caused by injecting drug use.104 The total number of chronic hepatitis B infections in 2006 was 1,482; For 1,071 cases the transmission route was known. In only 12 cases (1.1%) was injecting drug use the most likely transmission route (source RIVM). Since 1998, drug users and other risk groups are offered a vaccination against Hepatitis B. 112;113 According to data from GGD Nederland, over 12,700 drug users had availed of this up to September 2007. This group comprises ever and recent injectors as well as never injectors. Of the total group almost one percent were chronic Hepatitis B carriers. Almost 15% had ever contracted hepatitis B and were now immune. International Comparison Data on Hepatitis C are not easily comparable between countries on account of differences in sources and methods of data collection. The data only give an indication of the

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rate of infection. EMCDDA figures indicate that in the EU member states, Hepatitis C infection occurs very frequently among injecting drug users.43 • In 17 countries (of the 22 for which data are available), a Hepatitis C infection rate of over 60% is found among injecting drug users. The infection rate reported above, of 65 to 70 percent of ever injecting drug users in Amsterdam, is in keeping with this trend. Only five countries report research results that show a Hepatitis C rate of less than 25% among injecting drug users. • In seven countries high rates of HCV infection have also been found among young injectors. This indicates that in some European countries, young drug users continue to exhibit at-risk behaviour. 43 • It is estimated that approximately one million people in the EU are infected with Hepatitis C from ever injecting drugs.43 • Among European countries, the variation in the rate of Hepatitis B infection is greater than for hepatitis C.43 This may possibly be due to factors such as different vaccination strategies (universal versus risk groups). The most complete data available concern having previously had a Hepatitis B infection. In Germany, Italy, Norway, Poland and the U.K., it was reported that over 40 percent of injecting drug users had ever been infected with hepatitis B. 110 These figures indicate that in some countries Hepatitis B is still very prevalent among injecting drug users. This is a cause for concern, given the serious consequences of the infection. • By and large, the proportion of injecting drug users in all reported cases of Hepatitis B has declined in Europe, possible as a consequence of vaccination programmes.43

High-Risk Behaviour Since the 1990s there has been a strong decline in the use of borrowed syringes among injecting drug users. As such, injecting drugs is also less common (see also § 4.3). • Recent data are lacking however, for most cities and regions. According to the most recent surveys, between 8% and 30% of injectors sometimes borrow needles or syringes.114 • In recent years there has been a sharp drop in the number of needles and syringes that are exchanged in needle exchange programmes in Amsterdam and Rotterdam. In the early 1990’s about one million needles were exchanged annually in Amsterdam. By 2006 this had dropped to 200,800 (GGD Amsterdam). In Rotterdam the number of syringes exchanged between 2000 and 2006 more than halved from 422,000 to 180,000 (GGD Rotterdam). Both GGD organisations attribute this drop in exchanges to a decline in injecting. • Apart from used syringes, other contaminated materials are borrowed when injecting drugs; these include spoons, swabs, filters or water used for rinsing.

High-risk sexual activity remains widespread, however. • The number of visits to the GGD by drug users who participated in the Amsterdam

•

Cohort Studies on HIV/AIDS, in which drug users indicated having had unprotected sex, dropped from 52% in 1990 to 40% in 1996. In the period following (from19962004), this percentage remained stable.101 However, few recent (national) data are available. According to the most recent measurements taken among injecting drug users in various cities, failure to use condoms occurred most frequently among long-term partners (76-96%), followed by casual partners (39-73%) and clients (13-50%).114

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AIDS The annual number of AIDS notifications (all transmission routes) to the Public Health Inspectorate (through 1999) and to the HIV Monitoring Foundation (SHM) (from 2000) rose from 325 in 1988 to 533 in 1995, and subsequently dropped to between 230 and 316 cases in more recent years.104 This decline is partly due to the availability of effective anti-retroviral drugs (HAART). These delay or prevent the onset of AIDS in HIV-positive patients. • The number of notified AIDS cases caused by injecting drug use in the Netherlands has remained limited throughout the years. • Of the 7,278 registered AIDS patients (up to and including June 2006), 659 were injecting drug users (9%). This means that the role of injecting drug use in the development of AIDS is on average higher than for contracting HIV. • After peaking at fourteen percent in 1995, there has been a drop in number of injecting drug users among HIV-positive patients who developed full-blown AIDS. In 2005, 6% (20 instances) of notified AIDS cases involved an injecting drug user. Data for 2006 are not complete: up to and including June 2006, AIDS was diagnosed in 9 injecting drug users (4%).104 International Comparison Since the introduction of effective anti-retroviral drugs, the number of new AIDS patients has become a less reliable measure of the transmission of the HIV virus. Nonetheless, notifications of new AIDS cases still serve as an indication of the size of the problem. They are also an indication of the availability of anti-retroviral treatment for drug users. • In the whole of Europe, the country with the highest percentages of new AIDS diagnoses among drug users in 2005 was Portugal, with 36 new cases per million inhabitants. This constituted an increase on previous years. Other European countries with a high percentage of new AIDS diagnoses among drug users in 2005 are Latvia, Spain and Italy. In Estonia, a rise was reported between 2003 and 2004 (of up to 13 new AIDS diagnoses among injecting drug user per million inhabitants); however there are no data for 2005. The Netherlands is one of the countries with a low number of new AIDS cases among drug users.43;110 • There are no data on the availability of HAART for drug users. However, according to WHO estimates, the rate of access to HAART medication is over 75% everywhere in the EU member states. 43

Deaths Direct deaths According to the cause of death statistics of Statistics Netherlands (CBS) the death rate from the direct consequences of opiate use is low in the Netherlands. Direct deaths are those following an overdose, i.e. intoxication from a lethal dose of a drug. According to the EMCDDA standard for calculating direct drug deaths, both accidental and nonaccidental overdoses (suicide) are included, as well as cases where it has not been determined whether the poisoning was accidental or not.43;115-117 Between the mid-1990s and 2001, there was a rise across the spectrum – not only for opiates - in the number of registered deaths from drug overdose (Figure 4.7).

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Figure 4.7

Deaths from drug overdose in the Netherlands from 1986 Number

160 140 120 100 80 60 40 20 0

19 86 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Total

68

54

51

56

70

80

75

75

87

70

108

108

110

115

131

144

103

104

12 7

122

112

Opi ates

67

49

47

54

62

76

72

68

77

56

81

71

71

63

68

75

37

53

52

60

44

Cocaine

1

3

2

1

3

1

2

3

2

6

10

8

11

12

19

26

34

17

20

23

21

Other

0

2

2

1

5

3

1

4

8

8

17

29

28

40

44

43

32

34

55

39

47

Number of deaths. From 1986-1995 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 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 an explanation of the codes: see appendix C. Source: Cause of death statistics, Statistics Netherlands (CBS).

• This trend can be partly attributed to an increase in cocaine-related deaths (see § •

•

• •

3.7). The transition from classification system ICD-9 to ICD-10 in 1996 also plays a part in the increase. A greater number of cases may possibly be counted as drugs deaths since 1996 according to the ICD-10 classification, than was formerly the case with the ICD-9 classification. Drug deaths are more easily recognisable in the ICD-10 classification than in the ICD-9 classification. Between 1996 and 2001 there was also a rise in the number of cases of “poisoning by other or unspecified narcotics” and “poisoning by other or unspecified psychodysleptics”. These cases often involve (combinations) of hard drugs, with or without other substances, and sometimes also (combinations of) medicines and/or alcohol. In 2002 there was a drop in the number of deaths; this was followed by a rise in 2004 which declined again slightly in 2005 and 2006. This number only relates to deaths among inhabitants who were officially registered in the population register. In 2006, a further 28 cases were registered with Statistics Netherlands (CBS) of drug deaths among people who were in the Netherlands at the time of death, but were not registered in the population register as residents.

The number of registered deaths by opiate overdose is low in the Netherlands. • Until 2001 this number fluctuated between 47 and 77 cases per annum. The initial drop in 2002 and 2003 did not continue in the two subsequent years, but resumed again in 2005 and 2006. • As is the case with opiate users in general, overdose victims are also getting older. From 1985 through 1989, only 16% of these were older than 34, compared to 69% between 2000 and 2006 (Figure 4.8).

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Figure 4.8

Age distribution of deaths from overdose of opiates in the periods 19851989, 1990-1994, 1995-1999 and 2000-2006

% 100% 80% 60% 40% 20% 0%

1985-1989

1990-1994

1995-1999

2000-2006

>=65

1

4

3

7

35-64

15

35

50

62

15-34

82

61

47

31

0-14

1

0

0

0

Percentage of deaths per age group. Source: Cause of Death Statistics, CBS.

Total deaths The EMCDDA protocol charts only the volume of acute (overdose) deaths. Drug users may also die of other causes, such as accidents and illnesses incurred by injecting drugs (indirect drug-related deaths). In addition, drug users may die of causes that are neither directly nor indirectly related to their drug habit (age-dependent basic death rate) These three components – overdose deaths, indirect deaths and basic death rate – constitute the total death rate among drug users. • By means of data on deaths among drug users in Amsterdam (see following paragraph) and an estimation of the total number of problem hard drug users in the Netherlands, an estimate can be made of the total death rate. • An estimated 480 problem hard drug users died in the Netherlands in 2001. This figure lies within margins of at least 340 and at most 660 deaths. • Of these total deaths, it is estimated that 11% can be attributed to the basic death rate that is not related to drugs; an estimated 23% of the deaths are related directly to drugs and 66% related indirectly to drug use.118 Amsterdam GGD Amsterdam reports the number of deaths among drug users on an annual basis (Figure 4.9). Unlike the national cause of death figures of Statistics Netherlands (CBS) the overdose deaths registered in Amsterdam also include deaths among illegal immigrants and tourists. The GGD report also takes account of registered opiate users in Amsterdam who died of causes other than an overdose. • In 2006, 21 drug users in Amsterdam died following an ‘overdose’ of drugs - often opiates, with or without other substances. • Deceased opiate clients have usually died of causes other than an overdose such as endocarditis, sepsis, lung disease, liver cirrhosis, suicide, accidents, violence or AIDS.

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As they grow older, opiate users are more likely die of underlying conditions such as diseases of the lungs, liver or heart. - The drop in the number of deaths registered in the early 1990s did not continue through the mid-1990s. After a sharp rise in 2004 in the category ‘other causes of death’, the number in this category rose in 2005, but dropped again in 2006 (figure 4.9).

Figure 4.9

Deaths among drug users in Amsterdam from overdose and other causes, from 1992I Number 160 140 120 100 80 60 40 20 0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Overdose

52

37

39

26

26

22

25

27

31

32

29

21

22

29

21

Other causes

83

102

86

92

90

76

67

73

76

112

96

128

61

84

58

T otal

135

139

125

118

116

98

92

100

107

144

125

149

83

113

79

Number of deaths among people ever registered as opiate users with GGD Amsterdam. I. Other causes of death (such as endocarditis, sepsis, lung disease, liver cirrhosis, suicide, accidents, violence, AIDS) of persons registered with the GGD Amsterdam as ever having used opiates. Source: GGD Amsterdam.

International Comparison • Annually, between seven and over nine thousand people in the EU die following a drug overdose, often involving opiates in combination with other substances. This can be seen as the minimum number, since not all cases of drug-related deaths are registered.43 • International comparison of the number of ‘drug deaths’ is hampered by discrepancies in the definition of this term. - Figure 4.10 shows the number of deaths per 100,000 inhabitants directly related to drug use for six EU member states and Norway. In the case of these countries it was possible to use virtually the same ICD-10 codes, thus removing a major source of disparity between the countries. 110 - The codes refer to opiates, hallucinogens, cocaine, amphetamines and cannabis. The majority of cases (also) include opiates. 110 - According to these figures, Norway and Denmark top the list, although a sharp downward trend has been visible in Norway since 2001. According to these calculations, the Netherlands has the lowest number of ‘drug deaths’. 110

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Figure 4.10

Acute deaths from taking drugs: a comparison of six EU member states plus Norway based on the same ICD codes

9

Number per 100,000 inhabitants

8 7 6 5 4 3 2 1 0

1994 1995

1996 1997

1998

1999 5.0

4.3

3.9

5.9

4.6

4.8

4.5

United Kingdom

2.4

2.5

2.8

Finland

2.1

Norway Denmark

5.5

4.1

Sweden 0.7

2001

2002

2003

2004

6.0

4.9

5

3.1

2.4

2.8 2.6

2.4

0.8

0.7

7.7

8.2

4.5

4.5

3.3

3.1

1.9

1.7

2.3

2.6

2.1

1.9

1.9

1.5

1.6

1.8

2.2

1.9

1.8

1.7

1.6

1.6

1.8

1.5

1.4

1.4

0.7

0.7

0.8

0.9

0.6

0.6

Germany Netherlands

3.0

2000

0.7

2005

Number of deaths per 100 thousand inhabitants. 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. Deaths with the codes X61 and X62 are missing for Norway. For better comparability, T40.4 is not counted in Sweden. Source: EMCDDA. 110

Data from the EMCDDA show that the number of acute deaths due to drugs at European level rose from the early ’90s until 2000. In the new EU member states, this rise occurred chiefly among young drug users (aged under 25). From 2000 a general downward trend is evident, however, this has not continued since 2003. 43

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5

ECSTASY, AMPHETAMINES AND RELATED SUBSTANCES

The official name for Ecstasy is 3,4-methylenedioxymethamphetamine (MDMA). Other substances that are chemically similar to MDMA – or indeed substances that bear no resemblance to it - are also sold as Ecstasy without the user being aware of the difference. These include MDA, MDEA, MBDB and amphetamines. In this chapter, unless otherwise indicated, ‘Ecstasy’ is understood to mean substances that are experienced or passed off as Ecstasy. By amphetamines we mean both ‘ordinary’ amphetamine - and methamphetamine, the stronger variant - unless otherwise indicated. Ecstasy has a stimulating and entactogenic effect. An entactogenic effect means that people feel drawn to each other and make contact more easily. This combination of qualities has contributed to Ecstasy’s reputation as a party or dance drug. The addictive effect is thought to be low. Ecstasy is generally swallowed in the form of tablets. Sometimes it is dissolved as a powder in a drink and then taken. Street names for Ecstasy tablets are often derived from the logo stamped on the pills, such as “mitsubishi”, “lover boy” or “superman’. High does pills are sometimes called “Super X” or “triple stacks”. Other street names include “E”, “Rolls”, “Adam”, “Hug Drug”, “Disco biscuits”, “White Doves” “New Yorkers”, “sweeties” and “wafers”. 22 Amphetamine also has a stimulating effect, stronger than Ecstasy, but has no entactogenic effect. Amphetamine is used socially, but also by opiate or polydrug addicts. Frequent use can lead to dependence. This risk is greater for methamphetamine than for ordinary amphetamine. The street name for amphetamine is “speed”. Street names for methamphetamine are “crystal”, “ice”, “tina”, “yaba” and “meth”. 22 In the Netherlands, amphetamines are generally swallowed or snorted, and sometimes injected. Methamphetamine is sometimes smoked. Among rural youth, amphetamine is sometimes used as a cheaper alternative to cocaine. Used in this way, amphetamine is known in Dutch as ‘farmer’s coke’.119

5.1 RECENT FACTS AND TRENDS The most important facts and trends about Ecstasy and amphetamines in this chapter are: • The percentage of ever users and recent users of Ecstasy in the general population rose between 2001 and 2005. The percentage of current Ecstasy users remained stable (§ 5.2). • Amphetamines are less popular than Ecstasy. Between 2001 and 2005 the use of this substance in the general population remained stable (§ 5.2). • Compared to a number of other EU member states, the percentage of recent Ecstasy users in the Netherlands is on the high side (§ 5.5). • At national level, Ecstasy remains an important drug among socialising adolescents and young adults. While there are signs of a moderation in use, excessive use is still observed in certain groups (§ 5.3). • Amphetamine is considerably less popular than Ecstasy in the social scene. There are signs that amphetamine use has increased among the rural youth (§ 5.3). • The number of primary Ecstasy clients seeking treatment from (outpatient) addiction care is small, and dropped between 2005 and 2006 (§ 5.6).

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• The rise in the number of clients with a primary amphetamine problem continued between 2005 and 2006 (§ 5.6). • The number of admissions to general hospitals with a primary diagnosis of misuse of or dependency on amphetamine(-like substances) is low, and remained stable between 2005 and 2006 (§ 5.6). • Nowadays, Ecstasy pills almost always contain an MDMA-like substance. However, one in ten Ecstasy tablets (also) contains the substance mCPP (§ 5.8). • The percentage of Ecstasy pills with a high dose of MDMA rose between 2006 and 2007(§ 5.8).

5.2 USAGE: GENERAL POPULATION • The number of people in the Dutch population aged between 15 and 64 that had ever

• • •

•

used Ecstasy increased between 2001 and 2005 (table 5.1). The percentage of recent and current users remained stable during this period.5 Considerably fewer people have ever or recently used amphetamines. Their numbers remained stable between 2001 and 2005. The percentage of current users for both Ecstasy and amphetamines remained well below one percent. In absolute terms, the number of current Ecstasy users in 2005 amounted to 40,000, while there were 21,000 current amphetamine users. These estimates are probably on the low side, because problem users of hard drugs were under-represented in the survey in question. The annual increase in new Ecstasy users remained stable between 2001 and 2005. For amphetamines, the drop between 2001 and 2005 is significant. This may be an indication of a slight loss of popularity of this substance.

Table 5.1

Use of Ecstasy and amphetamines among people aged between 15 and 64 in the Netherlands. Survey years 1997, 2001 and 2005 Ecstasy

Amphetamine

1997

2001

2005

1997

2001

2005

Ever use

2.3%

3.2%

4.3%

2.2%

2.0%

2.1%

Recent useI

0.8%

1.1%

1.2%

0.4%

0.4%

0.3%

Current useII

0.3%

0.3%

0.4%

0.1%

0.0%

0.2%

Used for the first time in the past year

0.5%

0.5%

0.3%

0.2%

0.2%

0.1%

Average age of recent users I

25.1

26.6

28.1

25.8

27.0

25.9

Number of respondents: 17 590 (1997), 2 312 (2001), 4 516 (2005). I. In the past year. II. In the past month. 5 Source: NPO, IVO.

Age, Gender and Urbanisation Level • For both Ecstasy and amphetamines, the percentage of ever users is three times

•

82

higher in males than in females. The figures for 2005 are 6.6% and 1.2% for Ecstasy and 3.2% and 1.0% for amphetamines respectively.5 Ever use of Ecstasy occurs most in very highly urbanised areas (9.6%) and least in non-urban areas (2.0%). For amphetamines, the differences are less pronounced but

TRIMBOS-INSTITUUT

•

• •

•

the same pattern is visible (4.1% in very highly urbanised areas, versus 1.3% in nonurban areas. People in the 25 to 44 year age group have the most experience with Ecstasy (7.1% versus 5.1% among 15-24 year olds and 0.9% among 45-64 year olds). For amphetamines, there are no differences in ever use between the age groups. The number of recent and current Ecstasy and amphetamine users is too small for a breakdown by age, gender and urbanisation. The average age of recent Ecstasy users has risen from 25 in 1997 to 28 in 2005. The difference between 2001 and 2005 was not significant. For amphetamines, no differences have been found over the years. The age of onset is the age at which an individual first used a substance (see also appendix A: age of onset). Among ever users in the 15 to 24 age group, the age of onset averaged 17.3 years for Ecstasy and 17.4 years for amphetamines. In the population aged15 to 64, the age of onset averaged 22.2 for Ecstasy and 21.6 for amphetamines.

5.3 USAGE: JUVENILES AND YOUNG ADULTS School-goers • From 1992 to 1996 there was a rise in the percentage of Ecstasy and amphetamine • •

users among pupils in mainstream secondary schools.9 For both drugs, the percentage of ever users dropped more rapidly between 1996 and 1999 than between 1999 and 2003. The percentage of current users of Ecstasy and amphetamines dropped between 1996 and 1999 and subsequently stabilised between 1999 and 2003 (Figure 5.1).

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Figure 5.1

Use of Ecstasy and amphetamines among school-goers aged 12 to 18 from 1992

%

Ecstasy

7 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

1.2

1.0

2.2

1.9 1.1

1

0.8

0.6 0

0 1992

1996

Ever

1999

2003

Current

1992

1996

Ever

1999

2003

Current

Percentage of ever users and current users (past month). Source: Dutch National School Survey, Trimbos Institute.

Special groups In certain groups of young people there are relatively more users of Ecstasy and amphetamines. Table 5.2 contains a summary of the results of various studies. The figures are not mutually comparable because of differences in age groups and research methods. Trend data are only available for Amsterdam. After cannabis, Ecstasy remains the illegal drug of choice for young people in the social scene, particularly at ‘raves’, albeit with signs of levelling off. In recent years, this drug has also encountered competition from cocaine and amphetamine. • By far the highest percentage of Ecstasy users in 2001-2002 was reported among frequenters of rave parties.120 • Among frequenters of mainstream bars, student bars, gay bars and hip bars in Amsterdam, the percentage of current Ecstasy users remained stable between 2000 and 2005 (7% and10% respectively, i.e. not a significant difference).21 In the hip bars and gay bars, the percentage of Ecstasy users is twice as high as in mainstream and student bars. • Among frequenters of fashionable clubs in Amsterdam the percentage of current users halved from 41% in 1998 to 19% in 2003. 15 In 2006, key observers in Amsterdam identified a further stabilisation of Ecstasy use and a trend towards less frequent and more cautious use. 19 However, in the ‘urban’ music scene, a slight increase in Ecstasy use was observed. The drug is still sometimes used heavily at large-scale parties. Incidental bingeing with multiple pills has also been seen. • Trend data are not available for other regions. However, key observers say that Ecstasy use was found to be evenly spread throughout the country in 2006/2007, and

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•

•

has stabilised at a somewhat lower level than was the case a few years ago. 22 Older revellers in particular, are reported to be behaving more ‘sensibly’ with Ecstasy. It seems they are experiencing a certain degree of Ecstasy fatigue. Nonetheless, excesses are seen among certain groups of beginning users. At the same time, the experience or expectation of negative physical or emotional consequences of using Ecstasy such as headache, dizziness, anxiety or depression appears to be deterring some young people from using Ecstasy.19;120;121 In nightlife settings, Ecstasy is often taken with other substances, such as alcohol, cannabis and amphetamines. Ecstasy taken together with alcohol is particularly popular.22

Amphetamines are less popular among young people out on the town than Ecstasy. However, there are indications of increased interest in this substance in certain parts of the country. • Among frequenters of mainstream bars, student bars, gay bars and hip bars in Amsterdam, the percentage of ever users of this drug stabilised at 17% between 2000 and 2005. The percentage of current users stabilised during this period at 2%.21 • Although there are no trend data concerning amphetamine use in other regions, key observers in the social scene are of the opinion that amphetamine use has increased slightly, particularly in rural areas and in the north of the country.22 - Amphetamine use is particularly noticeable among native Dutch ‘village youth’, particularly those hanging around and those with behavioural problems. In these a groups, usage is often not confined to the weekend. - In the north of the country, amphetamine is sometimes known as ‘farmer’s coke’, because it is used by the rural youth as an alternative to cocaine on account of its lower price. - In the trendier scene, the substance often has a negative image. However, at hardcore gatherings and in certain (alternative) scenes, amphetamine use is somewhat more prevalent (punk, electro, trance, underground, rock and techno) than in fashionable clubs. • DIMS data (see (§ 5.8) and qualitative data from the Trendwatch Monitor22 suggest that methamphetamine is not particularly popular in the Netherlands. At the same time, Trendwatch has identified a slight increase in interest in this substance in 2006/2007 among gay networks in Amsterdam and among so-called psychonauts, who experiment a lot with hallucinogenic substances and other drugs.

a

According to the 2006 Antenna Monitor in Amsterdam, amphetamine does not appear to play a role among problem youth and 19 juveniles in care. This is probably due to the high number of migrant juveniles in these groups.

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Table 5.2

Use of Ecstasy and amphetamine in special groups Location

Survey year

Age (years)

Socialising juveniles and young adults

Ecstasy

Amphetamine

Ever

Current

Ever

Current

Attending dance parties, outdoor music festivals, city centre

The Hague

2003

15 - 35

35%

17%

-

-

Attending Raves

Four raves distributed throughout the country

2001-2

14 - 43 Avge. 22

76%

65%

-

-

Bar-goers

Zaandam

2006

14 - 44

17%

7%

7%

2%

Bar-goersI

AmsterdamII

2000

Avge. 25

34%

10%

17%

2%

2005

Avge. 27

32%

7%

17%

2%

Frequenters of bars and sports canteens

Noordwijk

2004

Avge. 23

20%

6%

-

-

Disco-goers

NijmegenIII

2006

Avge. 21

17%

5%

7%

3%

Clubbers

Amsterdam

1998

Avge. 26

66%

41%

45%

13%

2003

Avge. 26

33%

19%

34%

7%

AmsterdamIV

2001

Avge. 25

63%

23%

39%

5%

Nijmegen

2005-6

Avge. 27

40%

13%

25%

6%

Regional

2002/2003

14 - 17

23%

9%

10%

3%

Regional

2002/2003

14 - 17

19%

6%

13%

2%

Flevoland

2004

13 - 22

38%

8%

26%

2%

2006

Avge. 17

14%

2%

7%

1%

Coffee shop clients

Problem youth Juvenile detaineesV V

School drop-outs

VI

Homeless youth

Juveniles in careVII

Amsterdam

Percentage of ever users and current users (last month) per group. The figures in this table are not mutually comparable because of differences in age group and research methods. b = boy; g = girl. I. Juveniles and young adults from mainstream bars, student bars, gay bars and hip bars. Therefore not representative of all bar-goers. II. Low response (26%). III. Low response (19%). IV. Low response (15%). V. Research in the provinces of Noord-Holland, Flevoland and Utrecht. Use among juvenile detainees: in the month prior to detention. School drop-outs are juveniles who have not attended school for at least one month during the past 12 months, not counting holidays. VI. Young people aged up to 23 who have had no fixed abode for at least three months. VII Juveniles with behavioural problems, juvenile delinquents, homeless youth and juveniles in other care projects. References: 19-21;27-29;31-35;75;76;120

5.4 PROBLEM USE • It is not known how many problem users of Ecstasy and amphetamines there are, i.e. people who are impeded in their daily functioning by their drug use or even become addicted. However we do know how many seek treatment (see § 5.6).

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5.5 USAGE: INTERNATIONAL COMPARISON General population Table 5.3 presents data on the use of Ecstasy and amphetamines in a number of EU member states, Norway, Australia, Canada and the US. • Differences in survey year, measuring methods and sampling hamper a precise comparison. The main factor of influence is the age group. Table 5.3a shows usage figures that have been (re)calculated according to the standard age category of the EMCDDA (15 to 64). Figures for the other countries are contained in Table 5.3b. For Europe only countries in the EU-15 plus Norway are included. Appendix F shows usage figures for the other EU member states, where available.

Table 5.3a

Use of amphetamines and Ecstasy in the general population of a number of EU-15 member states and Norway: age group 15 to 64

Country

Year

Ecstasy

Amphetamines

Ever

Recent

Ever

Recent

Spain

2005/2006

4.4%

1.2%

3.4%

0.7%

The Netherlands

2005

4.3%

1.2%

2.1%

0.3%

Ireland

2002/2003

3.8%

1.1%

3.0%

0.4%

Austria

2004

3.0%

0.9%

2.4%

0.8%

Italy

2005

2.5%

0.5%

2.4%

0.4%

France

2005

2.0%

0.4%

1.4%

0.1%

Norway

2004

1.8%

0.5%

3.6%

1.1%

Finland

2004

1.4%

0.5%

1.9%

0.6%

Portugal

2001

0.7%

0.4%

0.5%

0.1%

Greece

2004

0.4%

0.2%

0.1%

0.0%

Belgium

2001

-

-

2.1%

-

Differences in survey year, measuring methods and sampling hamper a precise comparison between countries. 43 Percentage of ever users and recent users (past year) - = not measured. References:

Table 5.3b

Country

Ecstasy and amphetamine use in the general population of a number of EU-15 member states, the US, Canada and Australia: other age groupsI Year

Age

Ecstasy

Amphetamines

Ever

Recent

Ever

Recent

Australia

2004

14 +

7.5%

3.4%

9.1%

3.2%

The U.K.

2004

?

6.7%

1.9%

11.7%

1.5%

US

2006

12 +

5.0%

0.9%

8.2%

1.4%

Canada

2004

15 +

4.1%

1.1%

6.4%

0.8%

Germany

2003

18 - 59

2.4%

0.8%

3.4%

0.9%

Denmark

2005

16 - 64

1.8%

0.3%

6.9%

0.7%

Sweden

2000

16 - 64

0.2%

0.2%

1.9%

0.2%

Differences in survey year, measuring methods and sampling hamper a precise comparison between countries. Percentage of ever use and recent use (past year). I. Drug use is relatively low in the youngest age groups (12-15) and in the oldest age groups (>64). Usage figures in studies with respondents who are younger and/or older than the EMCDDA-standard may be lower than in studies that use the EMCDDA-standard. The opposite 43-47;47 will be true for studies using a more restricted age range. References:

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87

• With regard to ever use of Ecstasy, Australia and the U.K. top the list with values of

•

•

•

almost seven percent or higher. In the Netherlands, over 4% have ever used Ecstasy. In Portugal, Greece and Sweden the percentage of ever users does not exceed one percent. Of the new member states, the Czech Republic stands out with a rate of seven percent (appendix E). The percentage of ever users of amphetamines ranges from less than 1% in Portugal and Greece to 9% in Australia, with a high of 12% in the U.K. 2% of people in the Netherlands have ever used amphetamines. In the new member states, ever use of amphetamines remains below 3% (appendix E). Of the countries shown in Tables 5.3a and 5.3b, the percentage of recent users is highest for both substances in Australia, at over 3%. In the EU-15 member states, the figures for recent Ecstasy use range from almost zero to two percent. Of the new member states, the Czech Republic tops the list with 3.5% for recent Ecstasy use (appendix E). In the Netherlands, the percentage of recent Ecstasy users (1.2%) is above the European average of 0.9%. For recent amphetamine use, the Dutch percentage of 0.3% is below the European average of 0.7%.

Juveniles and young adults The data from the ESPAD-study on school-goers aged 15 and 16 in European countries lend themselves better to comparison. Table 5.4 shows the use of Ecstasy and amphetamines in a number of EU states and Norway. Belgium, Germany and Austria only participated in the 2003 wave of the survey. The US did not take part in ESPAD but conducted comparable research.48

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Table 5.4

Ecstasy and amphetamine use among school-goers aged 15 and 16 in a number of EU member states, Norway and the US. Survey years 1999 and 2003 Ecstasy

US

Amphetamine

1999

2003

2003

1999

2003

2003

Ever

Ever

Recent

Ever

Ever

Recent

6%

6%

3%

16%

13%

9%

Austria

-

3%

2%

-

4%

4%

Ireland

5%

5%

2%

3%

1%

0%

Belgium

-

4%

3%

-

2%

1%

The Netherlands

4%

5%

3%

2%

1%

1%

United Kingdom

3%

5%

3%

8%

3%

2%

France

3%

4%

-

2%

3%

-

Germany

-

3%

2%

-

5%

3%

Denmark

3%

2%

2%

4%

4%

3%

Norway

3%

2%

1%

3%

2%

1%

Italy

2%

3%

2%

2%

3%

2%

Greece

2%

2%

2%

1%

0%

0%

Portugal

2%

4%

2%

3%

3%

2%

Finland

1%

1%

1%

1%

1%

0%

Sweden

1%

2%

1%

1%

1%

1%

Percentage of ever users and past year users (recent). The US did not take part in the ESPAD, but conducted comparable research. - = not measured. Source: ESPAD.

• In 2003, the percentage of school-goers that had ever taken Ecstasy was lowest in

•

Finland, Greece, Denmark, Norway and Sweden (2% or less). The US topped the list with 6%, followed by the Netherlands, Ireland and the UK with five percent. The percentage of recent users varied between one percent in Finland, Sweden and Norway, to three percent in the Netherlands, Belgium, the U.K. and the US. Of the countries listed in Table 5.4, the US scored by far the highest for recent amphetamine use (13%), followed by Germany, Austria and Denmark (4% - 5%). The Netherlands together with Finland, Greece, Ireland and Sweden occupied the lowest position. The percentage for recent use was highest in the US (9%). In the other countries in table 5.4 between 0 and 4% of school-goers had used amphetamines in the past year.

5.6 TREATMENT DEMAND Outpatient addiction care The National Alcohol and Drugs Information System (LADIS) registers the number of people seeking treatment from (outpatient) addiction care services, including the addiction probation and aftercare services and the addiction clinics that are merged with the outpatient addiction care services. 49 (See Appendix A: LADIS clients.)

TRIMBOS-INSTITUUT

89

Ecstasy • The number of (outpatient) addiction care client with Ecstasy as a primary problem rose until 1997 (Figure 5.2). This increase was partly due to the expansion of possibilities for addiction care services to register problem Ecstasy use. After 1997 the number dropped until 1999, when it levelled off. Between 2005 and 2006 the number of primary Ecstasy clients dropped by 22%.

Figure 5.2

Numbers registered with (outpatient) addiction care for primary or secondary Ecstasy problems from 1994I Number

1000 900 800 700 600 500 400 300 200 100 0

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Primary

29

208

398

457

340

252

241

225

250

277

291

293

228

Secondary

32

321

552

672

607

549

573

563

622

655

750

781

715

I. In 1994 the registration of Ecstasy problems was not yet complete. Source: LADIS, IVZ.

49

• Per 100,000 inhabitants aged 15 and older, LADIS registered approximately two pri-

• •

• •

mary Ecstasy clients in 2006 – considerably fewer than for most other drugs (49 for cannabis, 72 for cocaine, 99 for opiates). The rate of Ecstasy problems in the entire treatment demand for drugs problems has remained low in recent years: below 1%. In 2006 nearly one third of primary Ecstasy clients (31%) were newcomers. They were registered for the first time in 2006, and had not been registered previously with (outpatient) addiction care for a drugs problem. The majority of Ecstasy clients also had problems with another substance (83%). There are more clients who cite Ecstasy as a secondary problem than as a primary problem. After a drop between 1997 and 1999 the number of these clients rose again between 2001 and 2005. Between 2005 and 2006 this number dropped again by 8%. In 2006 the primary problem for these secondary Ecstasy clients was mainly cocaine or crack (36%), followed by cannabis (24%), amphetamines (20%) or alcohol (16%).

Amphetamines • The number of clients with amphetamines as the primary problem rose until 1998, followed by a drop, but rose again from 2001. Between 2005 and 2006 the number of amphetamine clients increased by 9% (Figure 5.3).

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• The percentage of amphetamines in the entire treatment demand for drug problems • • • •

remained low throughout the years under review (between 2% and 4%). Per 100,000 inhabitants aged 15 and older, LADIS registered nine primary amphetamine clients in 2006 - more than in 1994 or in 2001 (4 in both years). In 2006, one third (33%) of primary amphetamine clients were first-time clients of (outpatient) addiction care for a drugs problem. The majority of clients with a primary amphetamine problem also reported problems with other substances (79%). For over seven hundred clients amphetamines were a secondary problem in 2006. This represents an increase of 4% compared to 2005. For this group, the primary problem was cocaine or crack (31%), alcohol (23%), cannabis (26%), heroin (9%), or Ecstasy (5%).

Figure 5.3

Numbers registered with (outpatient) addiction care for primary or secondary amphetamine problems from 1994 Number

1400 1200 1000 800 600 400 200 0

1994 1995 1996 1997 1998

1999

2000

2001

2002

2003 2004 2005 2006

Primary

497

566

667

794

870

810

623

482

543

735

954

1118 1215

Secondary

489

566

558

610

590

560

498

474

481

552

645

728

Source LADIS, IVZ.

760

49

Age and Gender Ecstasy • In 2006 seven out of ten (70%) of primary Ecstasy clients were male. The ratio of female clients is greater than for cannabis, cocaine or opiates (18-20%). Between 2000 and 2006 the percentage of female clients rose from 19 to 30 percent. • The average age of primary Ecstasy clients was 26. Accordingly, they are the youngest of all drugs clients. The peak age group is 20-24 (see Figure 5.4). Amphetamines • In 2006 three quarters of primary amphetamine clients were male (77%). The percentage of female clients rose slightly from 21% in 2000 to 23% in 2006. • The average age is 28, somewhat older than Ecstasy clients, and slightly higher than the average age in 2005, when it was 26. Here too, the peak age is 20-24 (Figure 5.4).

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Figure 5.4

45

Age distribution of primary Ecstasy and amphetamine clients of (outpatient) addiction care. Survey year 2006

%

40

Amphetamine Ecstasy

36

35 29

30 25 20

22 16

18

17

15

14 15 9

10

6

5

5 4

2 2

2 1

1 0

45-49

50-54

55-59

0 15-19

20-24

25-29

30-34

Percentage per age group. Source: LADIS, IVZ.

35-39

40-44

Age

49

Regional Trends • The Netherlands is divided into 43 regions for Social Care and Addiction Policy (MO/VB Regions). From 2002-2006, treatment demand on account of amphetamine was greatest in the MO/VB regions of Leeuwarden, Assen, Vlaardingen, Dordrecht, Breda, Bergen op Zoom and Heerlen (between 1.0 and 3.2 amphetamine clients per 10,000 inhabitants aged 15 and older). 50 • During the 2002-2006 period, the number of primary amphetamine clients increased by 20% on average, compared to 1997-2001. This increase occurred in most regions in the Netherlands and was most pronounced in the regions of Flevoland (217%) and Zwolle (173%).50

General hospitals; incidents The Dutch Hospital Registration (LMR) registers few annual admissions to general hospitals, with amphetamine problems - including other psycho-stimulants such as Ecstasy as the primary diagnosis (Figure 5.5). • In 2006 there were 39 admissions, which accounts for 7% of all admissions with drugs as the primary diagnosis. 34 cases were related to amphetamine misuse; 5 cases were diagnosed as dependent on amphetamines. • There were somewhat more numerous occurrences of secondary diagnosis involving amphetamines: 88 in 2006, about the same as in 2005. The main illnesses or disorders accompanied by secondary diagnoses of amphetamine misuse or dependence were very diverse. The most common main diagnoses were:

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- psychosis (21%) - misuse or dependence on drugs (11%) - poisoning (11%) - cardio-vascular diseases (11%) - misuse or dependence on alcohol (9%) - accidents (8%) - diseases of the respiratory tract (4%). • The same person may be admitted more than once per year. In addition, more than one secondary diagnosis may be made per case. In 2006, corrected for duplication, the total amounted to 119 persons who were admitted at least once during the year with amphetamine misuse or dependence as the main or secondary diagnosis. Their average age was 29, and 74% were male. • In 2006 the LMR registered no cases of accidental poisoning, with amphetamines as a secondary diagnosis (ICD-9 code E854.2).

Figure 5.5

Admissions to general hospitals related to amphetamine misuse and dependence from 1994

Number 120

108

100

82

80 80

69

60 40 20

66

70 61

58

63

46 33

24

40

45

39

30

29 23

88

29

33

25

21

29

36

29

0 1994

1995

1996

1997

1998

1999

Amphetamine as main diagnosis

2000

2001

2002

2003

2004

2005

2006

Amphetamine as secondary diagnosis

Number of diagnoses, not corrected for duplication of persons or more than one secondary diagnosis per admission. ICD-9 codes: 304.4, 305.7 (appendix C). Ecstasy and amphetamines are registered under the same codes. Source: LMR, Prismant.

GGD Amsterdam registers the number of requests for emergency treatment from the Ambulance Transport Centre (CPA). • In 2006 there were 53 Ecstasy-related requests for treatment, 16% less than in 2005 (table 5.5). • In about three-quarters of the Ecstasy cases (72%), removal to hospital was necessary; this is more than in the case of cannabis incidents (34%). • In 2006, amphetamines were the reason for a request for treatment from the CPA in Amsterdam in only thirteen cases.

TRIMBOS-INSTITUUT

93

Table 5.5

Drug-related incidents involving amphetamines and Ecstasy, registered by GGD Amsterdam, from 1995

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Amphetamine

6

1

7

7

7

30

6

5

7

8

3

13

Ecstasy

38

66

41

35

43

36

42

39

39

59

63

53

Number of incidents (persons) per year. Source: CPA, GGD Amsterdam.

According to the national Injury Information System (LIS) of the consumer safety association51 some 3,200 people annually receive emergency treatment in a hospital for injury caused by an accident, violence or self-mutilation incident involving drugs use. The drugs involved are cocaine, heroin, cannabis, Ecstasy, magic mushrooms and speed. The data have been averaged for the period from 2002 through 2006 and are based on estimates for the whole country derived from data from a representative sample of hospitals. • Ten percent of drug victims report having used Ecstasy. If we count only those cases for which the drug is known (68%), then Ecstasy accounts for 14% of all drug-related cases treated in hospital emergency departments. • These figures are probably an under-estimate of the true number of drug-related incidents. The National Poison Information Centre (NVIC) of the RIVM registers the number of information requests from doctors, pharmacists and government organisations concerning (potentially) acute intoxication by poisonous substances such as drugs.52 • There are more requests for information concerning Ecstasy than concerning amphetamines (table 5.6). The number of information requests for Ecstasy rose until 2004 and dropped slightly in the years 2005 to 2007.

Table 5.6

Ecstasy Amphetamine

Requests for information on account of Ecstasy and amphetamine use from the National Poisons Information Centre from 2000 2000

2001

2002

2003

2004

2005

2006

2007

164

194

184

208

246

217

183

171

42

39

39

47

51

128

106

88

Number of information requests per year received via the NVIC 24-hour helpline. Requests made via the website www.vergiftigingen.info (online since April 2007) are not included in the table. Source: NVIC, RIVM.

• The number of requests for information on amphetamines trebled between 2000 and

•

94

2005. Most of the requests related to patients who had used amphetamines at parties, both singly and in combination with other drugs or alcohol. In 2006 and 2007, there was a slight drop in the number of information requests involving amphetamines. These figures do not give a picture of the absolute number of intoxications, because these are not notifiable. The increasing familiarity of doctors with the symptoms and treatment of a certain drug overdose may play a part, as this reduces the need to seek information from the NVIC.

TRIMBOS-INSTITUUT

5.7 ILLNESS AND DEATHS Illnesses • According to the latest scientific evidence, Ecstasy use can cause long-term disruption • •

•

•

•

of brain function, particularly the memory, concentration and mood.122;123 This disruption can last longer than a year after the drug use has been discontinued. It is unknown whether there is a return to full recovery. These changes are probably due to damage to serotonergic nerves in the brain; The effects can be attributed to Ecstasy use; however, taking substances other than Ecstasy, such as amphetamine may also play a role. 124 Tests on laboratory animals have shown that the risk of brain damage increases if there is a rise in body temperature after using MDMA. In humans this is also likely to be the case. The risk of overheating and consequently (long-term brain damage) increases if a user takes large doses of MDMA in a warm environment (over 18-20 degrees Celsius). The exact dose that leads to damage is not known. It is presumed that taking high-dose pills containing two to three times the potency of average pills would be enough. The average tablet contains between 75 and 80 mg of MDMA (see § 5.8). The results of research conducted by the University of Amsterdam and the University of Utrecht, do not suggest that short-term or one-off use might cause serious damage to and impairment of brain function in the long term.125;126 At the same time it cannot simply be concluded that a low dose of Ecstasy is safe. - Research participants took an average of 1.8 to 6 Ecstasy tablets and were tested on average 8 to 19 weeks after their last dose. - The results showed a narrowing of the arteries in some parts of the brain.125 - Performance for memory and concentration tasks or in brain activity during the performance of these tasks remained more or less unchanged126 , although one study showed a reduction in verbal retention. 127 - Indications of possible damage to nerve endings were also found, as well as an increased need for sensation seeking. No effect on depression or impulsiveness was found.125 - It is not known whether the artery narrowing and memory reduction is permanent. The clinical relevance of these effects would appear to be small, for the time being at least.

Deaths The exact number of deaths due to use of amphetamines and Ecstasy is unknown. • According to the cause of death statistics of Statistics Netherlands (CBS), these substances are not often the primary cause of death. In the period 1996 - 2002 there was a maximum of four acute deaths per year. In 2003 Statistics Netherlands registered seven cases, in 2004 five cases and both in 2005 and 2006 four cases (ICD-10 code F15 and ICD-10 codes X41, X61 and Y11, all three codes in combination with code T43.6; for an explanation of the codes, see appendix C). These codes not only refer to amphetamines and MDMA (-like substances), but also to other stimulants such as caffeine, ephedrine and khat. According to the EMCDDA, in other European countries, Ecstasy and amphetamine play a subordinate role in drugs death, at least in so far as figures are available.43

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95

• In 2006, throughout the entire EU, 78 deaths were reported in which Ecstasy played a •

•

role. Ecstasy was often not the only substance involved. Other factors which may have played a part in these deaths are over-heating, water intoxication or an underlying illness. A relatively large number of deaths due to methamphetamine – the extra strong variant of amphetamine – were reported in the Czech Republic; 16 cases in 2004 and 14 in 2005. Finland reported 65 cases in which amphetamine may possibly have had fatal consequences.

5.8 SUPPLY AND MARKET The Drugs Information and Monitoring System (DIMS) tests drug samples submitted by users in addiction care centres, to establish which substances are in the drugs. Some of these samples (tablets) are identified by the care centre itself by certain features such as logo, weight and diameter. Samples containing unknown substances and all samples in powder form are forwarded to the laboratory for chemical analysis. In addition to drug samples submitted by consumers, the DIMS also analyses drugs that are seized by security staff at clubs and discos. The results of these tests are comparable to those for the consumer samples.

Composition of Ecstasy tablets In 2007, consumers submitted a total of 3,506 tablets for analysis. One in three of these was identified on the basis of external features. The remainder (2,385) were sent on to the laboratory for further chemical analysis. Of these, the majority (97.2%) had been purchased by the consumer as Ecstasy. Table 5.7 shows the percentage of the ‘Ecstasy’ tablets analysed that were found to contain MDMA and/or another substance. The table only shows pills that were purchased by the consumer as Ecstasy, irrespective of the actual composition. • In 2007, 80% of the pills contained only an MDMA-like substance (= MDMA, MDA, MDEA or MBDB), compared to 77% in 2006. Most MDMA-like pills contain only MDMA. • Over one in ten (11%) Ecstasy tablets contains one or more pharmacologically active substances in addition to an MDMA-like substance. The psycho-active substances that were found together with an MDMA-like substance in 2007 were mainly caffeine (5.5%) and mCPP (3.4%, see ‘other substances’). In 2006, 3.3% of Ecstasy pills in this category contained mCPP. • In 2007, 6.1% of pills contained only mCPP as a psychoactive agent (category ‘other pharmacologically active substance’). This compares to 5.4% in 2006. The total percentage of Ecstasy pills containing mCPP, whether in combination with MDMA-like substances or not, was 9.5% in 2007. This is approximately the same as in 2006 (8.7%). • Since the late 1990s there has been a sharp drop in the percentage of Ecstasy tablets containing only amphetamine or methamphetamine. In 2007, the figure was only 0.7%. In most cases the dose was low (on average 9.2 mg amphetamine or 11.5 mg methamphetamine per pill). • The average amount of MDMA in ecstasy pills rose from 74 mg in 2006 to 82 mg in 2007. The highest measurement found in 2007 was 199mg (compared to 173 mg in 2006.

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• Figure 5.6 shows that the proportion of high-dose Ecstasy pills (more than 105 mg MDMA) has increased from 20 percent in 2006 to 30 percent in 2007. This increase can be chiefly attributed to the rise in the proportion of pills containing between 105 mg and 140 mg MDMA. The percentage of tablets containing more than 140 mg MDMA (5%) remained below that of 2004 and 2005.

Table 5.7

Number and composition of ‘Ecstasy’tablets submitted to DIMS that were analysed in the lab, from 1997

Substances (% of the tablets)

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Total number of tablets analysed

2 344

2 578

1.805

2 462

2 359

2 130

2 177

1 985

2 134

2 523

2 319

MDMA

44.3%

74.4%

83.7%

87.6%

86.1%

84.9%

85.4%

85.6%

76.0%

75.4%

78.8%

MDEA

7.8%

1.1%

1.6%

0.8%

0.7%

0.4%

0.5%

0.1%

0.3%

0.2%

0.4%

MDA

1.1%

2.1%

2.4%

1.9%

0.6%

1.4%

0.9%

1.9%

2.9%

0.4%

0.0%

MDBD

1.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

Combination of Ecstacy-like substancesI

6.1%

1.7%

1.0%

2.7%

2.5%

1.5%

2.2%

4.4%

5.2%

0.8%

0.9%

Combination of Ecstacy-like substances + other pharmacologic active substanceII

10.8%

8.3%

5.1%

4.1%

7.4%

8.2%

8.3%

5.4%

7.8%

13.0%

11.0%

(Meth)amphetamine

14.6%

6.0%

3.0%

0.7%

0.7%

1.7%

1.0%

0.3%

3.9%

0.9%

0.4%

(Meth)amphetamine + other pharmacologic active substance

1.2%

0.7%

0.5%

0.2%

0.3%

0.2%

0.2%

0.0%

0.1%

0.9%

0.3%

Other pharmacologic active substanceI

11.6%

4.7%

2.2%

1.4%

1.1%

0.8%

0.6%

1.7%

3.2%

7.1%

7.3%

No pharmacologic active substance

1.6%

1.0%

0.6%

0.6%

0.6%

0.8%

0.8%

0.7%

0.7%

1.2%

0.8%

Percentage of tablets containing a particular substance or combination of substances. Categories are mutually exclusive and add up to 100 percent. I. Ecstasy-like means MDMA, MDEA, MDA or MBDB . II. For instance caffeine, mCPP, etc. Source: Drugs Information and Monitoring System (DIMS).

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Figure 5.6

Concentration of MDMA in ‘Ecstasy’ tablets submitted to the DIMS %

100% 80% 60% 40% 20% 0%

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

>140 mg

1

1

1

2

4

4

6

10

9

3

5

106-140 mg

6

5

6

9

14

11

12

12

13

17

25

71-105 mg

36

27

29

35

49

42

38

34

28

30

28

36-70 mg

39

53

52

45

28

39

38

39

36

37

33

1-35 mg

17

15

11

9

5

5

7

5

13

13

9

Percentage of tablets with a certain percentage of MDMA. These are tablets that were tested in the lab and were found to contain at least 1 mg MDMA. Source: DIMS, Trimbos Institute.

Other substances Table 5.8 indicates the number of samples found by DIMS (Ecstasy tablets, powders, liquids or other) containing substances that are undergoing continuous monitoring within the context of the European Early Warning System (EWS), or otherwise pose a possible threat to public health. • In 2007, substances such as 4-MTA, DOB, MBDB and PMA/PMMA were scarcely if at all found on the Dutch market. • The hallucinogen 2C-B, which was often found in the mid-nineties, particularly in Ecstasy pills, was found 21 times in drug samples in 2007. Few of these involved Ecstasy. • In 2007, more samples of the former anaesthetic GHB were submitted to the DIMS than in previous years. Key observers with Trendwatch Monitor identified a slight increase in GHB use in Amsterdam and some rural areas, in 2006/2007, although well below that of other (party) drugs such as Ecstasy and cocaine.22 • In 2007, ketamine was also found more often than in previous years. There appears to be increasing interest in this substance too in certain networks and in certain parts of the country, although no definite figures are available. 22

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Table 5.8 2C-B 4-MTA

Number of samples containing other psychoactive substances 1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

317

12

25

12

11

2

15

5

9

18

21

9

16

8

6

1

5

0

1

0

0

0

128

52

0

1

0

0

0

3

5

0

2

-

-

1

0

0

0

3

3

0

13

4

50

16

24

36

102

72

72

98

114

142

203

1

15

26

5

5

0

0

2

9

13

0

0

16

1

2

1

2

3

19

17

50

80

113

12

0

0

0

0

0

1

1

0

0

mCPP

-

-

-

-

13

92

256

323

PMA/(PMMA)I

1

8

0

0

0

0

0

0

Strychnine

1

0

0

Atropine BZP GHB/GBL DOB Ketamine MBDB

Total 3.734 4.478 4.363 4.065 3.798 3.445 I. Tablets containing more than 1 mg. Source: DIMS, Trimbos.

0

0

0

0

0

3.510

3.604

4.095

4.580

4 727

• In late 2004 the substance meta-Chloro-Phenyl-Piperazine (mCPP) appeared on the Dutch Ecstasy market. mCPP, like MDMA works on serotonergenic brain cells, but has scarcely any stimulative effect. Users report many negative effects. - In 2007, the total share of samples containing mCPP in all samples registered by DIMS was 6.8%, which is higher than in 2006 (5.6%). It was decided at European level not to conduct a risk evaluation for this substance. However, since 2006 it is actively monitored within the context of the European Early Warning System. • Another piperazine that has been found in Ecstasy tablets since 2003 is benzylpiperazine (BZP). In contrast to certain other European countries, BZP does not appear to enjoy great popularity in the Netherlands. Accordingly it was scarcely found at all by DIMS in 2007. - At European level, a risk evaluation for BZP was conducted in 2007. Following the ensuing recommendations, it was decided on 3 March 2008 that BZP should be brought under the control of national drugs legislation in the member states. - In the Netherlands, mCPP and BZP have always been regarded as non-registered drugs that are covered by the Medicines Act (GW), formerly known as the WoG. Unlicensed trade in mCPP or BZP is illegal.

Composition of (meth)amphetamine samples DIMS also receives samples of powders that are sold as ‘speed’ (in addition to the pills sold as Ecstasy that contained amphetamine). In 2007 770 speed samples were analysed in the lab – more than in 2006 (553). • The vast majority of the samples (97%) contained amphetamine; the concentration of amphetamine varied from 1 to 73 percent, with an average of 34%. This average is virtually the same as that in preceding years. • Only 0.4% of the samples sold as ‘speed’ contained only methamphetamine. This variant of amphetamine is not very popular in the Netherlands, in contrast to the US, for example. • As in previous years, most of the samples contained caffeine (60%) in addition to amphetamine.

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Prices The national Trendwatch Monitor the Antenna Monitor and the DIMS project give some indication of the price paid by consumers for an Ecstasy tablet or a gram of amphetamine. Amphetamine • According to key observers in the social scene, young revellers paid €7.50 on average in 2006/2007 for a gram of amphetamine; however, the prices ranged from 2 to 15 euro per gram. In Amsterdam the average price is higher, at between 10 and 20 euro. This may be related to the small and relatively inaccessible market for speed in Amsterdam. 22 • Consumers who had drug samples tested with DIMS in 2007 paid an average of 2 to 20 euro per gram of amphetamine (average 6 euro), which was about the same as in 2006. Ecstasy • According to key observers in the social scene, the price of Ecstasy in 2006/2007varied between 2 and five euro per tablet. This is less than in 2004/2005, when it was between 3 and 8 euro per tablet). The price drops according as quantities purchased increase, and rises for higher concentrations of the active substance. 22 • Consumers who had Ecstasy tablets tested with DIMS in 2007 paid an average of €2.75 per pill, ranging from 50 cent to 10 euro.

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6

ALCOHOL

Alcohol is made from fermenting grains or fruits. It is drunk in the form of beer, wine or spirits. One glass of wine, beer or a measure of spirits contains approximately the same amount of alcohol. This is because the size of the glass used is reduced according as the alcohol content of the drink is higher. In social situations, drinkers experience alcohol as relaxing and convivial. In less sociable situations, alcohol can exacerbate an aggressive mood. Excessive use (even where incidental) can result in accidents – at work, at home and in traffic. Alcohol is an addictive substance. With regular use, habit and tolerance are increased. Excessive use of alcohol can lead to a number of illnesses, particularly diseases of the liver and the cardiovascular system as well as cancer.

6.1 RECENT FACTS AND TRENDS The main facts and trends concerning alcohol in this chapter are: • According to sales figures, the consumption of alcohol per head of the population in the Netherlands remained stable in 2006 (§ 6.2). • The number of recent and current alcohol users in the population aged 15-64 remained stable between 2001 and 2005. The percentage of binge drinkers (six or more units of alcohol in one day) dropped in this period, particularly in the 15-24 age group. • Alcohol use among school-goers increased between 1999 and 2003, most markedly among young girls aged between 12 and 14. Since 2003 there have been signs of a slight drop in this age group (§ 6.3). • In the total group of school-goers, binge drinking remained stable between 2003 and 2005, but appears to be on the increase among past month drinkers (§ 6.3). • By comparison with other countries, alcohol consumption among school-goers in the Netherlands is high (§ 6.5). • Despite a legal ban, juveniles aged under 16 are easily able to procure alcoholic beverages (§ 6.8). • Ten percent of the Dutch population aged 16 - 69 are problem drinkers (§ 6.4). • Heavy drinking, problem drinking and alcohol misuse and dependence are relatively more prevalent among young men aged 18 to 24 (§ 6.4). • The rise in the number of alcohol clients of (outpatient) addiction care between 2001 and 2005 did not continue in 2006 (§ 6.6). • The registration data of general hospitals show a slight increase between 2005 and 2006 in the number of admissions involving an alcohol-related condition. The number of children and juveniles up to age 16 admitted for alcohol-related reasons also rose (§ 6.6). • The number of road deaths and injuries caused by alcohol use has dropped further in recent years. After a drop in the preceding years, the percentage of drink-driving motorists stabilised between 2005 and 2006 (§ 6.6). • Total deaths from alcohol-related conditions (primary and secondary causes of death together) have remained stable since 2004 (§ 6.7).

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6.2 USAGE: GENERAL POPULATION Alcohol use is widespread in Dutch society. • According to the findings of National Prevalence Surveys (NPO), the percentage of people in the population aged 15 to 64 that used alcohol in the past year dropped slightly from 87% in 1997 to 85% in 2001.5 This drop was most marked among females and among respondents in the 25-44 age group. • Between 2001 and 2005 the percentage of recent drinkers remained stable at 85%. • The number of people who had taken alcohol in the past month remained stable throughout the years at around 78%. • The percentage of drinkers who had consumed six or more drinks in one day during the past six months (binge drinking) dropped from 40% in 2001 to 35% in 2005. This decline took place both among males and females and particularly among respondents aged from 15 to 24. • The age of onset is the age at which an individual first uses a substance (see also appendix A: age of onset). Among recent users of alcohol, the age of onset in the 15 to 24 age group was 14.6 years on average. In the population aged 15 to 64 the age of onset averaged at 16.5. According to a survey conducted by Statistics Netherlands (CBS) in 2007, over four out of five people (81%) aged 12 and older ‘sometimes drink alcohol’. In 2001 the figure was 82%. The percentage of drinkers has remained fairly stable for years. Sales figures give an indication of the amount of alcohol consumed annually per head of the population (Table 6.1).

Table 6.1

Beer, wine and spirits per capita (in litres of pure alcohol), from 1960

Year

Beer

Wine

Spirits

Total

1960

1.2

0.2

1.1

2.6

1965

1.9

0.5

1.9

4.2

1970

2.9

0.8

2.0

5.7

1975

4.0

1.5

3.4

8.9

1980

4.8

1.4

2.7

8.9

1985

4.2

2.0

2.2

8.5

1990

4.1

1.9

2.0

8.1

1995

4.1

2.2

1.7

8.0

2000

4.1

2.3

1.7

8.2

2001

4.0

2.3

1.7

8.1

2002

4.0

2.3

1.7

8.0

2003

4.0

2.5

1.5

7.9

2004

3.9

2.6

1.4

7.9

2005

3.9

2.7

1.3

7.9

2006

3.9

2.8

1.3

7.9

Source: Drinks Product Board; Wine Product Board.128;129

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• Alcohol consumption was highest in the Netherlands during the second half of the

• • •

•

•

1970s and in the 1980s. Then followed a slight decline, which did not continue from the early 1990s. In 2006, 7.9 litres of pure alcohol were consumed per capita – the same amount as in 2005. The consumption of spirits and beer remained unchanged in 2006 and wine drinking rose slightly from 21.3 litres in 2005 to 21.5 litres in 2006. After a sharp drop in 2003 (minus one third compared to 2002) sales of ready-mixed drinks (‘alcopops’) stabilised in 2004. However, in 2005 there was another sharp drop (by 31% compared to 2004). This decline continued in 2006 (down a further 19%). Accordingly the consumption of these drinks has plummeted by more than two-thirds since 2002 to 114,746 hectolitres. In contrast to this downward trend in alcopops, there has been a rise in the sales of liqueurettes (liqueur-like products with an alcohol content of under 15 percent). The sale of these drinks rose from 36 812 hectolitres in 2005 to 42 442 hectolitres in 2006 – an increase of 15 percent. In 2006, a total of 78 litres of beer, 22 litres of wine and four litres of spirits per person were imbibed.

Special groups In certain groups within the adult population, alcohol consumption may be significantly higher or lower than average. • Research conducted in Amsterdam (2004) 130 shows that far fewer people of Moroccan or Turkish origin drink alcohol than native Dutch people. a - There are three times as many drinkers among the native Dutch population as in the Turkish Amsterdam community and six times as many as in the Moroccan community in Amsterdam. - Between 1999/2000 and 2004 the percentage of drinkers among Turks dropped by over 6%, whereas it increased among Moroccans by almost 7%. • A Rotterdam-based study (2004) shows that in second-generation Turkish people (1630 years) there are fewer drinkers than among Dutch people of the same age.131 - Among Turkish people aged 16-30, 36% had drunk alcohol during the past six months, compared to 94% of their native Dutch peers. - There is also less excessive drinking in the Turkish group. Six percent of this age group drinks excessively, compared to fourteen percent in the Dutch cohort. - When only regular drinkers are compared (defined as an average of at least one drink per week), the difference found in excessive drinking disappears. • Both religious and cultural factors appear to be related to alcohol use among second generation Turkish and Moroccan drinkers. Socio-cognitive factors, such as the influence of family and Turkish/Moroccan friends, as well as expectations of behaviour towards alcohol are more important as predictors of alcohol use in this group.132 • Over a third (35%) of the homeless in twenty Dutch municipalities were found to be high-risk drinkers in 2002 (defined here as more than 25 units of alcohol weekly); 23% drank more than 56 units a week, and 13% more than 112 units weekly.6 • In 2006, 21% of the Rotterdam homeless had drunk six or more units of alcohol (for females four+) daily or almost daily during the past 12 months. 18% drank at least eight units daily or almost daily (females at least six). 7

a

The Municipal Health Service (GGD) Amsterdam applies the definition of BZK/VNG for ethnic background, see appendix A.

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• According to measurements taken in 2006/2007, problem alcohol use was found in 30% of detainees in remand centres. Average consumption was 50 units weekly (see §8.3). 4 • Of the alcohol-drinking working population, in 2002 some four percent sometimes drank alcohol just before or during work: one percent did so at least once weekly.133 - 38% sometimes drink alcohol straight after work; 12% do so weekly. The catering sector has the greatest number of workers drinking after work (31% weekly); the healthcare sector and the civil service have the least (5% and 4% respectively, weekly).133 • It can be concluded from the National Sport Survey of 2004 that people who play sports generally drink alcohol more often (in moderation) than those who do not participate in sports. 134 - 15% of the sports participants were teetotallers, compared to 29% of the nonparticipants - Sports participants are more likely than non-participants to drink more than five units of alcohol per week (38% compared to 26%); however, they are less likely to consume two or more units on all days of the week (7% compared to 9%). - This difference remains in place if account is taken of differences between sports participants and non-participants in terms of gender, age and education level.

6.3 USAGE: JUVENILES AND YOUNG ADULTS School-goers Since the mid-1980s, the Trimbos Institute has monitored the extent to which pupils aged from 12 to 18 attending mainstream secondary schools have experience with alcohol, tobacco, drugs and gambling. This takes place within the context of the Dutch National School Survey. The most recent results date from 2003. • In 2003, 85% of pupils attending mainstream secondary schools had ever used alcohol. This was an increase on 1999 when the figure was 74%. However, the percentage fluctuated somewhat over a fifteen-year period. (Figure 6.1).9 • In 2003, 58% of pupils interviewed had drunk alcohol in the month before the survey, which was about the same as in 1999.

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Figure 6.1

90

Alcohol consumption among school-goers aged 12 to 18, from 1988

% 85

80

79

79 74

70 69 60

58 54

54

55

50 45

40 1988

1992

1996

Ever

Current

1999

2003

Percentage of ever drinkers and in the month before the survey (current). Source: Dutch National School Survey, Trimbos Institute.9

Age and gender • Particularly among young girls aged 12 to 14, ever use and current (past month) use of alcohol increased between 1999 and 2003 (Figure 6.2). - In 1999, 57% of girls aged 12-14 had ever drunk alcohol; in 2003 this had risen to 78%. - In 1999, 32% of this group had drunk alcohol in the past month; in 2003 the figure was 44%. • Fifteen percent of the school-goers reported having taken their first drink at the age of ten or younger; almost twice as many of these were boys (19%) as girls (10%). The majority of pupils who drink, started between the age of 11 and 14. • In 2003 there was no difference in the percentage of boys and girls that had ever or recently taken alcohol. However differences were found in drinking patterns. Boys drank alcohol more often than girls, and in greater quantities. This difference was most marked among older boys: - Of the 16-year old boys who had consumed alcohol during the past month, 29% had drunk on more than ten occasions in the month, compared to 19% of girls. - Likewise, 29% of 16-year old boys drank more than ten units on average on a weekend day, whereas for girls, the figure was 9%. • In 2003 almost half of school-goers (47%) had already taken an alcoholic drink by age 12; by age 15, 52% are drinking on a weekly basis.

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Figure 6.2

Trends in ever alcohol use in secondary school pupils by age and gender from 1992 Boys

%

Girls

%

100

100

80

80

60

60

40

40

20

20 0

0 1992

1996 12

1999 13

2003

1992

1996 12

14

1999 13

2003 14

Percentage of ever drinkers. Source: Dutch National School Survey, Trimbos Institute.9

A comparison of data from the national Health Behaviour of School-aged Children (HBSC) study in 2005 shows that both ever and past month use of alcohol in the entire cohort of school-goers aged 12 to 16 remained stable between 2003 and 2005.10 • Among the youngest age groups, however, alcohol use declined somewhat between 2003 and 2005. In 2003, 71 percent of 12 year olds had ever drunk alcohol; in 2005 this had dropped to 61 percent. A similar drop was found among 13 year olds – from 80% in 2003 to 70% in 2005. Likewise, the percentage of 12 year olds who had consumed alcohol in the past month dropped (from 31% to 23%). • The percentage of school-goers that had drunk five or more units of alcohol on at least one occasion in the past four weeks (binge drinking), remained stable between 2003 and 2005 (35% and 37% respectively). • There was an increase in binge drinking among school-goers who drink. Of those who report having consumed alcohol in the past month, 75% drank five or more units of alcohol on a single occasion in 2005, compared to 64% in 2003. • Nonetheless, according to NPO data, binge drinking in the 15-24 age group declined between 2001 and 2005 – from 53% to 40%. These figures refer to people who on at least one occasion consumed six or more units of alcohol in a single day during the past half year. This definition differs somewhat from that in the HBSC study; therefore the results are not mutually comparable.5 Alcopops are still particularly popular among girls.10 • In 2005, 55% of girls who had consumed alcohol during the past month reported drinking alcopops or breezers at least every month. These drinks are the most popular among girls, followed by mixes (32%) and beer (27%). • Among boys, beer is the most popular: 53% of current drinkers drink beer every month, followed by alcopops/breezers (44%) and mixes (27%). • It is unclear how these figures can be reconciled with the declining sales figures for premixed drinks.

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Parents Parents can play an important role in the education of their child regarding alcohol. • Various studies have shown that establishing rules in relation to alcohol (forbidding alcohol use) can delay alcohol onset and reduce the likelihood of problem drinking. 135;136

• However, as children get older, many parents quickly become more tolerant. -

In the final year of primary school, only 3% of pupils report being allowed to have an alcoholic drink at home if a parent is present (2005 survey). Around a quarter of parents of juveniles aged 12 to 16 allow their adolescent to drink one glass of alcohol at home. From around age 16 on, over half of adolescents say they are allowed to drink at home. 10

Ethnic background • Among school-goers with a Moroccan or Turkish background aged 12 to 16, current alcohol use is significantly lower than among native Dutch pupils (8% and 15% versus 63%). Pupils with a Surinamese background occupy an intermediate position (47%).9 • The quantity taken per occasion does not, however, differ between ethnic groups.137 Alcohol and problem behaviour

• Pupils aged 12-16 who drink on a weekly basis exhibit more delinquent and aggres-

•

sive behaviour than those who do not drink every week. There is no difference between boys and girls in this respect, but the association is stronger among the younger age groups.138 Among juveniles of 12 and 13, weekly alcohol use is linked to somatic symptoms and feelings of anxiety and depression.

Special groups of young people In certain groups of juveniles and young adults alcohol use may occur more frequently. Alcohol consumption among socialising youngsters, young holiday-makers and problem youth is discussed below. Socialising juveniles and young adults Many young people drink when they are out socialising. Table 6.2 summarises the results of a number of studies conducted among young people in the social scene. The figures are not mutually comparable on account of differences in age groups and research methods. • In 2005 one fifth of young socialisers aged 13 drank alcohol while out, as did nearly two-thirds of fourteen and fifteen year olds and almost nine out of ten sixteen and seventeen year olds. These figures are comparable with those from 2003.139 • Nine out of ten socialisers in The Hague in the 15-35 age bracket had drunk alcohol during the past month and six out of ten during the past week.29 • Alcohol consumption is lower among fans of Hip-hop/Rap/R&B than among fans of Pop/Rock or Dance/House/Techno. This may be associated with the preference of young Moroccans for the former, since alcohol use is lower among Morroccans.29 • In Amsterdam one third of bar-goers, coffee-shop clients and frequenters of fashionable clubs use alcohol daily or a few times a week, and consume at least four or five drinks on each occasion. Half the bar-goers drink alcohol a few times a week and 7%

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•

consume alcohol daily. The percentage of bar-goers that consume alcohol daily appears to have remained the same since 2000.15;15-20;21;21 The percentage of binge drinkers (6 or more drinks) among young people going out ranges in various studies from 49% to 64%.21;33;33,34,34

Table 6.2

Alcohol use in the social youth scene

Population

Location

Young people socialising in general

Nationwide

Survey year

Age

Percentage

Past year

13 14-15 16-17

19% 62% 87% 88% 60%

Measure useI

for

alcohol

2005

Attending raves, outdoor festivals, city centre

The Hague

2003

Past month Past week

15-35

Bar-goers

Zaandam

2006

Binge drinking: Six drinks or more Ten drinks or more

14-44 Average 21

Frequenters of bars and sports club canteens

Noordwijk

2004

Binge drinking: more than 6 drinks more than 10 drinks

Average 23

Disco-goers

Nijmegen

2005

Binge drinking: 10 or more drinks

15-40 Average 21

2005

Past month Daily or a few times weekly, at least four or five drinks per occasion Binge drinking: Six drinks or more

Average 26

Bar-goers

Amsterdam

64% 50% 61% 32% 29% 97% 33%

49%

Coffee shop clients

Amsterdam

2001

Daily or a few times weekly, at least four or five drinks per occasion

Average 25

30%

Clubbers

Amsterdam

2003

Daily or a few times weekly, at least four or five drinks per occasion

Average 28

33%

The figures in this table are not mutually comparable on account of differences in age groups and research 35;139 methods. I. The following definitions of binge drinking are used: Zaandam: 6/10 drinks or more on an average night out; Noordwijk: on average more than 6/10 drinks on a weekend night out; Nijmegen: 10 or more drinks on the 15;20;21;33-35;139;141 evening of the survey; Amsterdam: 6/10 drinks when out on the town. References:

Pre-drinking According to reports from key observers in the social scene, “pre-drinking” has been on the increase in recent years.140 This can take place at home, on the street, in a ‘hangout’ , at a friend’s place, or indeed increasingly in bars themselves (encouraged by special offers). In general it appears to be mainly teenagers who engage in pre-drinking before a night out, in order to save money. • A survey conducted in 2005 among teenagers out socialising (aged 13-17) found that half of those who drink sometimes do so before going out. They pre-drink mainly at home (61%) or at a friend’s house (65%).139 The percentages of pre-drinkers vary per age group:

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-

A quarter (26%) of 13 year old socialising drinkers (or 1.5% of all 13 year olds). 41% of 14/15 year old socialising drinkers (or 12% of all 14/15 year olds). 56% of 16/17 year old socialising drinkers (or 39% of all 16/17 year olds).

Hangouts In recent years there has been increasing focus on alcohol use among youngsters in ‘hangouts’. A hangout is a collective name for an informal place, such as hut or a den where young people meet up in their free time. The phenomenon of spending time in hangouts has been researched in various studies. Some of the findings are contradictory, which may be related to different definitions of hangouts and different methods. For this reason it is currently not possible to provide an accurate estimate of the extent of alcohol consumption in hangouts. According to the national monitor on alcohol availability among youngsters in 2005, 11% of adolescents aged 13-17 sometimes go to a hangout.139 In the Netherlands there are estimated to be some 1 500 such hangouts.142 • 8% of 13 year olds report sometimes going to a hangout, as well as 15% of 14-15 year olds and 12% of 16-17 year olds.139 • It is mostly older groups who drink while frequenting the hangouts. Of the 16-17 year olds who go there, 82% drink alcohol there. Of the 14-15 year olds and 13 year olds, 65% and 26% respectively report drinking alcohol in these dens. • On average, five alcoholic drinks are consumed. The 2005 HBSC study – also a national study - found much higher figures for hangouts. According to this study, 40% of juveniles aged twelve to sixteen had frequented a hangout in the past month. A third of these reported having drunk alcohol there. 10 • Young people in rural areas are more likely to visit a hangout. Around one third of city juveniles sometimes go to a hangout, compared to over half of village youth. • In cities, 22% of juveniles say they drink alcohol in a hangout, compared to 41% in the villages. In a recent study (2007) of hangouts in the region of Twente, 30% of fourth year students (average age 15.8 years) reported having sometimes visited a hangout. 143 • Most of those who frequent a hangout are attending a VMBO lower secondary school (36%), followed by HAVO middle secondary school (25%) and VWO higher secondary school (20%) • Youngsters who go to hangouts consume more alcohol than those who don’t – even after correcting for gender and education level. Hangout frequenters consume on average 15 alcohol units per week, compared to seven for those who do not go to hangouts. • On a typical hangout evening in the weekend, young people take an average of nine alcoholic drinks. Holiday-makers • Research conducted at youth camp sites in 2003 (average age 17.4), has shown that over 80% of the boys and nearly half the girls drink alcohol every day during the holiday. Boys consume an average of 17 drinks per day, and girls take seven drinks a day.144 Problem Youth Alcohol use is often common among certain groups of problem youth.

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• Juveniles attending a truancy project in Amsterdam are more likely to be current drinkers (over 50%) than their non-truant peers who attend school regularly (40%).15 • Pupils attending schools for children with severe educational difficulties (ZMOK) do not differ significantly in terms of frequency and intensity of alcohol use from their peers in mainstream schools. However, when only the native Dutch pupils are compared, the ZMOK school pupils do drink more and more often.145 • Research conducted among young people in care in Amsterdam (age 14-25); average age 17.5) shows that 54 percent consumed alcohol during the past month (current drinkers). 19 - The vast majority of the current drinkers only drink occasionally (86%); a mere 2% consume alcohol on a daily basis. - The current drinkers take five drinks on each occasion, on average. - Six percent of those in Amsterdam youth care meet the definition for risk drinking. This is defined as consuming at least four drinks per session daily or several times a week (up to age 19) or five drinks per occasion (young people over 19). - The above data on the proportion of current drinkers, the average number of drinks and risk drinking among young people in the Amsterdam youth care are similar to the findings from an earlier study conducted among school-goers in Amsterdam. - Girls and boys are equally likely to be current drinkers, drink the same amount per session and are equally likely to be risk drinkers. - Differences were however found between boys of western and non-western origin. Among those of western origin, the percentage of current drinkers (74%) and risk drinkers (12%) is much higher than among non-western boys (46% and 3% respectively). When they drink, however, both groups consume the same number of units per occasion. - Juvenile delinquents are less often current drinkers (40%) than juveniles with behaviour problems (59%) or homeless youth (61%). • Research from 2002/2003 among 14-17 year old detainees and drop-outs (defined as juveniles who had missed school for at least one month during the past year, excluding holidays) measured past month alcohol use and binge drinking (5 or more units at one session the past month): 146 - It was found that alcohol use among juvenile detainees and drop-outs was comparable: 63% of the juvenile detainees and 64% of the drop-outs had drunk alcohol in the past month, and 48% and 47% respectively had been binge drinking in the past month. - These percentages are also comparable with those for 14 to 17 year old schoolgoers in the sentinel station project.

6.4 PROBLEM USERS The extent of alcohol problems depends on the definition used. Researchers distinguish between heavy drinking, problem drinking, irresponsible drinking and dependence on or misuse of alcohol.

Heavy drinking According to Statistics Netherlands (CBS) ‘heavy drinking’ means consuming at least six units of alcohol on one or more days per week.

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• Based on this definition, 11% of the Dutch population aged 12 and over were heavy

• •

drinkers in 2007. In recent years the percentage of heavy drinkers has remained fairly stable: 14 percent in 2001, 12 percent in 2002, 11 percent in 2003, 12 percent in 2004 and 11 percent in both 2005 and 2006. In 2007 there were four and a half times more male heavy drinkers than female. Young people aged between 18 and 24 scored highest on this measure. In 2007 the percentage of heavy drinkers among young men was 38% and 14% among young women (Figure 6.3). This is lower than in 2002, when 42% of males aged 18 to 24 were heavy drinkers and 18% of the females; however it is slightly more than 2006 (36% of males and 10% of females aged 18 to 24).

Figure 6.3

45

Heavy drinkers by gender and age among people aged 12 and older. Survey year 2007

% 38

40 35 30

25

25

19

20 14

15 10 5

Male Female Total

25

7

14

18

16

18

12

11

9 4 5

11

11 6

4

3

4

3

2

2 1 1

25-34

35-44

45-54

55-64

65-74

>74

4

0 12-17

18-24

Total

Age

Percentage of people who drink six units of alcohol on one or more days per week. Source: POLS, Statistics Netherlands (CBS).

Problem drinking Problem drinkers are people who not only drink above a certain level, but also experience problems caused by their alcohol consumption. • In 2003 10% of the Dutch population aged between 16 and 69 were problem drinkers, with more male problem drinkers (17%) than female (4%).147 • Problem drinking is most prevalent in the 16-24 age group, where 34% of males and 9% of females are problem drinkers (Figure 6.4). • Of the problem drinkers recorded in 2003, a year later almost half (46%) were still problem drinkers. This means that over half of this group no longer meet the criteria for problem drinking.148 • The severity of the alcohol-related problems as well as age and gender are the main factors which determine whether problem drinkers are still categorised as such after one year. The likelihood of remaining a problem drinker increases with the severity of the problems and is greatest among younger age groups and males.

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Figure 6.4 40 35

Percentage of problem drinkers by age and gender. Survey year 2003

% 34

30 25 19

20

Male Female

15 10

13 9

8 4

5

3

3

0 16-24 years

25-34 years

Source: University of Maastricht

35-54 years

55-69 years

147

• Of those measured who were not problem drinkers in 2003, two percent had developed a problem with alcohol by 2004.

Alcohol misuse and dependence • Recent data on alcohol misuse and dependence are missing. According to data from

•

the 1996 Nemesis study, 8% of the Dutch population aged between 18 and 64 fulfilled the diagnostic criteria for alcohol misuse (4.6%) or dependence (3.7%).149 New data are expected in 2009. Alcohol misuse and dependence are most common among young men aged between 18 and 25; In 1996, 18% of this age group met the criteria for alcohol misuse and 13% for alcohol dependence.150

Within the general population, a large proportion of people who at some stage meet the criteria for alcohol misuse or dependence will recover over time.151 • Of those with alcohol misuse, 85% recover over a three-year period. • Of those with alcohol dependence 74% recover over a three-year period. • Of those who recover, only a small percentage relapse into their drinking habits. 14% again meet the criteria for alcohol dependence two years after recovery, and 10% the criteria for alcohol misuse.

6.5 USAGE: INTERNATIONAL COMPARISON General Population • In 2003, alcohol consumption in Western Europe varied from 4.9 to 12.6 litres per head of population (Figure 6.5). By comparison with the other Western European countries, the Netherlands appears to occupy an intermediate position.

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• These data do not allow for the consumption of unregistered alcohol, such as alcohol obtained through home brewing, smuggling, cross-border purchase and use of ‘surrogate’ alcohol, made for industrial, technical or medical purposes. - In the Netherlands this unregistered use, as in Belgium, is thought to be rather small-scale: 0.5 litres per inhabitant in the population aged over 15. 152 - By comparison, in Denmark, Sweden and Finland, consumption is approximately two litres per inhabitant in the population aged over 12. - Considerably larger quantities of unregistered alcohol use are reported in Eastern Europe, particularly in the Baltic States, Bulgaria, Poland and Slovenia (five litres per inhabitant aged over 15). - More recent figures are currently unavailable.

Figure 6.5

Extent of per capita alcohol consumption in a number of EU member states, measured in litres of pure alcohol. Survey year 2003

Luxembourg

12.6 10.8

Ireland Germany

10.2 10

Spain Portugal

9.6

United Kingdom

9.6

Denmark

9.5

France

9.3

Austria

9.3

Belgium

8.8

The Netherlands

7.9

Finland

7.9

Greece

7.7

Italy

6.9

Sweden

4.9 0

2

4

6

8

10

12

14

16

Litres per capita Source: Drinks Product Board, Distillers Commission.

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Juveniles Data from ESPAD, the European School Survey Project on Alcohol and Other Drugs are more easily comparable. The most recent measurements were taken in 1999 and 2003, among fifteen and sixteen year old school-goers attending secondary schools. 48 Table 6.3 displays alcohol use in a number of EU countries and Norway. Belgium, Germany and Austria participated only in 2003. The US did not take part in the ESPAD survey, but conducted comparable research. The ESPAD study surveyed the use of alcohol and frequency of drunkenness. • In 2003 the Netherlands scored in the higher echelons for the measure ‘having taken alcohol at least 40 times in my entire life’. • The Netherlands topped the list for the measure ‘having taken alcohol at least ten times in the month prior to the survey’. • For the measure ‘drunkenness’, Dutch school-goers scored considerably less highly. Approximately one in seventeen reported having been drunk at least twenty times in their lives. • Between 1999 and 2003 the percentage of pupils that had drunk alcohol on ten or more occasions increased in the Netherlands and Italy, whereas it dropped in Denmark. • In 2003, the percentage for 20 or more occasions of intoxication dropped only in Denmark; in the remaining countries, it remained stable.

Table 6.3

Alcohol use and drunkenness among school-goers aged 15 and 16 in a number of EU member states, Norway and the US. Survey year 2003

Country

Denmark Austria

Consumption: 40 times or more in lifetime

Consumption: 10 times or more in past month

Intoxication: 20 times or more in lifetime

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%

Germany

-

37%

-

11%

-

12%

Belgium

-

36%

-

20%

-

7%

Greece

42%

35%

13%

13%

4%

3%

Italy

17%

24%

7%

12%

2%

5%

France

20%

22%

8%

7%

4%

3%

Finland

20%

20%

1%

2%

28%

26%

Sweden

19%

17%

2%

1%

19%

17%

Norway

16%

15%

3%

3%

16%

14%

Portugal

15%

14%

6%

7%

4%

3%

US

16%

12%

5%

4%

11%

7%

The Netherlands UK Ireland

Percentage of school-goers. - = not measured. The US did not participate in ESPAD, but conducted comparable research. Source: ESPAD. 48

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A study which compared the reported availability and use of alcohol among school-goers aged between 14 and 17 in the Netherlands and France found the following:18;153;153 • Dutch juveniles find it easier to procure alcohol than their French peers; 72% of the Dutch and 59% of the French juveniles find it easy to procure alcohol. • In France it is more likely that peers and/or older people will criticise teenagers’ drinking habits, even before negative consequences appear. Informal social control on adolescent drinking is stricter in France than in the Netherlands. • In both countries there is an association between perceived availability and alcohol use; teenagers who find it easy to get alcohol drink more often and they more frequently take five or more drinks per occasion. • Perceived availability has more impact on use in the Netherlands than in France.

6.6 TREATMENT DEMAND Outpatient addiction care The National Alcohol and Drugs Information System (LADIS) registers the number of people seeking treatment from (outpatient) addiction care, including the probation and aftercare services and the addiction clinics that are merged with outpatient addiction care. 49 (See in appendix A:LADIS Client.) • In 2006, 31,210 people were registered with (outpatient) addiction care with alcohol use as the primary problem. This represents an estimated three percent of problem drinkers. • The absolute number of clients with a primary alcohol problem in (outpatient) addiction care increased by 48% between 1996 and 2005 (Figure 6.6). From 2005 to 2006 there was a slight reduction of 3%. • Per 10,000 inhabitants over the age of 15 in the Netherlands, the number of primary clients rose from 17 in 1996 to 26 in 2006. • Between 1994 and 2000, the percentage of alcohol in all requests for treatment from outpatient addiction care varied from 37% to 40%. Thereafter there was a distinct increase from 41% in 2001 to 47% in 2005. The percentage stabilised at 46% in 2006. • In 2006 over a fifth (22%) of primary clients were newcomers. They had not been registered before with (outpatient) addiction care on account of an alcohol problem. This is similar to the percentage of first-time clients in 2005 (21%). • In the case of two-thirds of primary alcohol clients, alcohol was the only problem substance (67%). One third reported a secondary substance (33%). In 2005, a quarter reported using an additional substance as well. • The number of (outpatient) addiction care clients who cite alcohol as a secondary problem also rose between 1995 and 2005 (Figure 6.6). In 2006 the number of secondary alcohol clients stabilised. For this group, cocaine (43%), cannabis (24%) or heroin (16%) were the most prevalent primary problems.

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Figure 6.6

Number of clients of (outpatient) addiction care with primary or secondary alcohol problems, from 1996 Number

35000 30000 25000 20000 15000 10000 5000 0

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Primary

20939 21134 22378 22554 22365 22388 23849 26874 29518 31073 30210

Secondary

2465

2622

2718

2847

3007

3945

4121

4631

4987

5261

5208

Source: LADIS, IVZ. 49

Age and gender • In 2006 the majority of primary alcohol clients were male (75%). The ratio of female clients fluctuated in 1994-2006 between 23 and 27 percent. • The average age in 2006 was 45. The peak age group for primary alcohol clients was 40-54 (Figure 6.7). Between 1997 and 2006 there was an increase in the percentage of older people seeking treatment.154 • In 2006, 20% of outpatient alcohol clients were over 55. In 1997, the figure was only 13%. • Since 1997 the ratio of over 55s seeking treatment for alcohol has increased by 78% (corrected for population ageing). Among clients aged under 55, there was a 35% increase. • In 2006 almost one third (31%) of the over 55s seeking treatment were female. Among the under-55 age group, the ratio of females was 24%. • The number of females over 55 seeking treatment for alcohol has grown faster than the male cohort. The number of women has doubled since 1997, while the increase among men is 64%.

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Figure 6.7

20

Age distribution of primary alcohol clients of the (outpatient) addiction care services. Survey year 2006

%

18

17 16

16

15

13

14 12

8

6

6

6 4

3

4 2

10

9

10

1

0 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>64

Age

Percentage of clients per age group. Source: LADIS, IVZ. 49

Internet-based interventions Recent years have seen a surge in the amount of prevention and treatment programmes available through the internet in the Netherlands. A programming study in 2007 listed 18 e-mental health interventions (both prevention and treatment) that target problem alcohol use. 155 • Almost half of the interventions listed are aimed exclusively at problem alcohol use. The remaining interventions integrate these with interventions aimed at problem drug use. • Four of the eighteen interventions involve treatment; the remainder are preventive interventions. • Considerable use is made of the treatment interventions.

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-

-

-

-

In 2005, 578 clients were treated through the programme “alcoholdebaas.nl” [mastering alcohol]. Between September 2003 and July 2005, over 3,300 log-in identities were created for the Jellinek self-help module for problem drinkers156 Some 65% visitors to the site did not return to the self-help module after creating a user name. Over 30% returned at least one more time, but did not complete the module. Only a small group – 5% - completed the module. As yet no annual figures are available for other online treatments (e.g. annazorg.nl and brijder.nl). For some providers it is not feasible to treat the number of people online who register for online treatment for alcohol problems. Registration for online treatment through the websites ‘alcoholdebaas.nl’ and ‘brijder.nl’ is regularly shut down on account of capacity problems. In August 2006, there were 1,200 people on the waiting list for ‘alcoholdebaas.nl’. The above-cited LADIS registration data contains registration details of clients who avail of recognised internet treatments. This is not the case for preventive or selfhelp modules. A study conducted in the Netherlands has shown that internet treatments are more likely to be used by women, well-educated people, employed people and older people. These are groups that are difficult to reach through face-to-face therapies. 157

General hospitals and incidents The LMR (Dutch Hospital Registration) registered some 1.7 million clinical admissions to general hospitals in 2006. • In 2006 there were 4,855 admissions with an alcohol-related condition as the primary diagnosis. The most frequent diagnoses were: - alcohol misuse (32%) - alcoholic liver disease (28%) - alcohol dependence (15%) - intoxication and toxic effects of alcohol (15%) - alcohol-induced psychoses (8%). • Alcohol problems are far more often involved in secondary diagnoses. In 2006, 11,689 alcohol-related secondary diagnoses were registered. In order of occurrence these were alcohol misuse (44%), alcohol dependence (21%), intoxication and toxic effects of alcohol (14%) alcoholic liver disease (13%), and alcohol-induced psychoses (7%). The primary diagnoses accompanying these secondary diagnoses were: - accidents (other than poisoning; 31%) - gastric disorders (16%) - poisoning (14%) - diseases of the cardio-vascular system (6%) - illnesses and symptoms of the respiratory tract (5%) - psychoses (3%). • The number of admissions to general hospitals with an alcohol-related condition as the primary diagnosis increased by a third (32%) from 1996 to 2004 (Figure 6.8). From 2004 to 2005 the number of admissions remained more or less stable, but from 2005 to 2006 there was another slight rise (7%). • Between 1996 and 2004 there was a rise in the number of secondary diagnoses (figure 6.7). From 2003 to 2004 these rose by 14%, followed by a slight drop in 2005. The number of alcohol-related secondary diagnoses stabilised in 2006.

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Figure 6.8

Admissions to general hospitals for alcohol-related problems, from 1996 Number 14000 12000 10000 8000 6000 4000 2000 0

1996

1997 1998 1999 2000 2001

2002

2003

2004 2005 2006

Alcohol as main diagnosis

3406

4011 4076 4079 3923 3880

4254

4239

4501 4553 4855

Alcohol as secondary diagnosis

8513

9973 9822 9652 10116 9949 10291 10899 11991 11546 11689

Number of admissions, not corrected for duplication 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 admitted if 980.0-1 is reported as a complication.). For an explanation of the codes: see appendix C. The figures refer to all alcohol-related secondary diagnoses. More than one secondary diagnosis is possible per admission. Source: LMR, Prismant.

• The same person may be admitted more than once per year. In addition, more than

•

•

one secondary diagnosis may be made per case. In 2006, corrected for duplication, the total amounted to 12,013 persons who were admitted at least once with one (or more) alcohol-related condition(s) as the main or secondary diagnosis. Their average age was 47, and 69% were male. These figures are probably an under-representation of the true situation, since the role of alcohol is by no means always identified and registered in hospitals as the cause of an illness. In 2006, 353 day-care admissions were also registered as an alcohol-related primary diagnosis. In 2005 there were 357 and in 2004, 415.

Figure 6.9 shows the number of children and juveniles aged under 17 who were admitted to hospital for alcohol-related reasons. • In 2006 482 juveniles aged under 17 were admitted to hospital for an alcohol-related problem. Of these the majority (287) were boys and 195 were girls. • This represents a sharp increase of 83% compared to figures from 2001 when the total number of juveniles admitted on account of alcohol was 263. • The increase is relatively greater among girls than among boys. Among girls, the number of admissions has more than doubled since 2001 (a rise of 135%); the number of boys increased by more than half (59%).

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Figure 6.9

Clinical admissions (main or secondary diagnosis) of juveniles aged under 17 for alcohol-related reasons, from 2001 Number

600 500 400 300 200 100 0

2001

2002

2003

2004

2005

2006

Boys

180

204

227

238

244

287

Girls

83

121

134

176

180

195

Total

263

325

361

414

424

482

Number of admissions, not corrected for duplication of persons. The data include both hospital admissions and day-care treatment. 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 admitted if 980.0-1 is reported as a complication.). For an explanation of the codes: see appendix C. Source: LMR, Prismant.

At the Ambulance Transport Centre (CPA), the Amsterdam Municipal Health Service (GGD Amsterdam) keeps a log of the number of requests for emergency treatment related to alcohol use. • In 2006 the CPA Amsterdam registered 2,132 alcohol-related ambulance journeys. • The number of alcohol-related ambulance journeys dropped slightly between 2001 and 2003 (1,957 in 2001; 1,887 in 2002; 1,733 in 2003) and has been rising since then (1,825 in 2004; 2,056 in 2005; 2,132 in 2006). • By comparison with 2005, this represents a rise of 4%. • Over half of the patients (52%) were transported to the emergency room in a hospital. In the other half of cases, the ambulance staff provided first aid at the scene. According to the injury information system (LIS) of the consumer safety association some 13,000 people annually receive emergency treatment in a hospital for injury caused by an accident, violence or self-harm involving alcohol (Table 6.4).51 The data are estimates for the whole country, based on figures from a representative sample of hospitals. • The number of emergency room admissions resulting from accidents, violent incidents or self-harming in which alcohol was involved increased by 18% from 2002 to 2006. The remaining LIS data have been averaged over the period from 2002 through 2006. • Nearly three-quarters of all victims are male (71%; 9,500). • 13% are aged between 0 and 19 years (which means 1,800 children annually); 25% are aged 20 to 29 and 39% are in the 30-49 age group. • The likelihood of emergency room treatment is greatest in the 20-24 age group (15% of all cases), followed by age 15-19 (12%). Each week an average of 39 victims aged

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•

•

•

•

•

20 to 24 are treated in a hospital emergency room for the consequences of alcohol use. Over half of the accidents take place in private circumstances (Table 6.5), such as a fall when intoxicated, or alcohol poisoning. In second place are road accidents (particularly falls from bicycles), followed by self-harm (often involving a combination of alcohol and drugs and/or medicines) and injury through violence. Half (50%;6,700) of the victims of an accident involving alcohol had fallen – often from a bicycle, moped or motorcycle (18%; 2,400). Almost a third (32%); 4,300 had suffered alcohol poisoning. One in ten victims were injured after contact with an object (10%; 1,300). Thirty percent of the cases involve alcohol poisoning, either with or without other substances. Over one in three victims were admitted to hospital (37%). The percentage of people admitted to hospital following an accident involving hospital is relatively high. This is an indication that accidents involving alcohol are serious. By contrast, for the average accident in private circumstances, the admission rate is 10%, 17% for road traffic accidents and 59% for self-harming. In approximately 980 admissions annually, drugs had been used in addition to alcohol. Self-harm occurs relatively frequently in a combination of alcohol and drugs (27% of cases, compared to 17% of cases involving only alcohol and 16% involving only drugs). These figures are probably an under-representation of the true scale of alcohol-related accidents.

Table 6.4

Type of alcohol-related incidents that were treated in the emergency department in Dutch hospitals (annual average for 2002-2006)

Type of incident

Number

Percentage

Private circumstances

7 300

54%

Road accident

3 100

23%

2 200

17%

780

6%

±13 000

100%

I

Self-harm

Injury through violence Total I

Such as suicide attempts by using alcohol and medicines. Source: (LIS). 51

In 2004 a survey was conducted on alcohol use among 5,500 people attending the Emergency Room in four hospitals in the Netherlands (Rotterdam, Maastricht, Emmen, Amersfoort).158 • Approximately 15% had consumed alcohol in the six hours prior to treatment • Compared to non-users, those who had taken alcohol were more likely to be treated between 12 midnight and 8.00 a.m. and were more likely to have been brought to hospital by ambulance. They had also consumed relatively more illegal drugs in the 24 hours prior to treatment and were more often frequent and heavy drinkers. The National Poison Information Centre (NVIC) of the RIVM provides doctors, pharmacists and government organizations with information about poisoning. • In 2007 there were 1,979 information requests about poisoning with alcoholic drinks, which was 19% more than in 2006 (table 6.5) 52. • These figures do not provide a clear picture of the absolute number of intoxications, however, because alcohol poisoning is not a notifiable condition. Moreover, doctors

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• •

are generally familiar with the symptoms of alcohol use and overdose. The more familiar doctors are with the symptoms and treatment of intoxication with a particular substance, the less likely they are to consult the NVIC. Some three-quarters of the cases involved a combination of alcohol and medicines. The number of information requests for alcohol poisoning involving juveniles aged between 13 and 17 has increased in recent years from about 4% in 2002 to 8% in 2005. No further rise has been registered since 2005. Alcohol poisoning among juveniles is mostly the result of drinking spirits with friends.

Table 6.5

Requests for information on account of alcohol poisoning from the National Poisons Information Centre (NVIC) from 2000

Total - % in 13-17 age group

2000

2001

2002

2003

2004

2005

2006

2007

1 372

1 247

1 403

1 709

1 817

1 780

1 658

1979

4%

5%

4%

5%

7%

8%

8%

8%

77%

75%

68%

72%

73%

75%

- % alcohol and medicines

Number of information requests annually submitted via the NVIC 24-hour helpline. Requests via the website 52 www.vergiftigingen.info (online since April 2007) have not been included for 2007. Source: NVIC,RIVM.

Driving under the Influence The percentage of drink-drivers remained stable in 2006.159 • Sobriety tests conducted during weekend nights in 2006 showed that 3.0% of the tested motorists had more than 0.5 pro mille of alcohol in their blood. This is not a significant difference compared to 2005 (2.8%). However, compared to 2001, a decline has taken place (4.1% in 2001). • In 2006 there were more male than female drink-drivers (3.5% versus 1.8%). • After reductions in earlier years among both males and females, the percentage of offences remained stable in 2006 in both groups. • The highest percentage of drink-drivers among males is in the 25-34 age group (4.1%) followed by the 35-49 age group (3.9%); among females it is in the 35-49 age group (2.7%). • The percentage of drink-drivers is highest between 2.00 and 4.00 a.m. Alcohol and drug use in traffic increases the risk of serious injury.160 • Research conducted among motorists in the Tilburg region shows that 35% of serious injuries among drivers are related to alcohol and/or illegal drug use (particularly alcohol per mille rates of 1.3 and upwards, drug/alcohol combinations (particularly with alcohol per mille rates of 0.8 and upwards) and drug/drug combinations. • This research also shows that driving when under the influence of cannabis – with or without alcohol – is more common than driving under the influence of alcohol (4.5% versus 2.1%), while driving while using benzodiazepines – with or without alcohol – is equally common (2.1%). Since 1 January 2006, the maximum permitted blood-alcohol count for newly licensed drivers (holding a license for less than 5 years) has been reduced from 0.5 to 0.2‰.161 • A similar reduction in the legal alcohol limit for newly licensed drivers had already been introduced in a number of North-American states as well as Australia and Austria. This reduction appears to have had a positive effect on road traffic safety.

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• In Austria, for instance, the number serious traffic accidents involving newly licensed •

drivers dropped by almost 17% in a five-year period. The Institute for Road Safety Research (SWOV), has estimated that the reduction in the legal alcohol limit in the Netherlands can cut road deaths by ten and serious injuries by 150 per annum. This is based on an expected 5% decline in alcohol-related accidents.

According to the Ministry of Transport, Public Works and Water Management, there were an estimated 2,400 road deaths plus hospital admissions due to alcohol use in 2006 (table 6.6) 2 • The total number of alcohol-related hospital admissions and deaths has dropped since 1997 (Table 6.6). • The percentage of alcohol-related traffic-accident deaths and hospital admissions in this period has also dropped in relation to the total number of traffic-accident deaths and hospital admissions. - In 1996 19% of traffic-accident deaths and hospital admissions were alcoholrelated; in 2006 this was 14%.

Table 6.6

Estimated number of injuries and deaths in traffic accidents involving alcohol use, from 1997

Deaths Hospital admissions

1997

1998

1999

2000

2001

2002

2003

2004

2005

225

225

210

200

180

170

170

135

115

2006 100

3 700

3 600

3 300

3 300

3 100

3 000

2 900

2 800

2 600

2 300

Source: Ministry of Transport, Public Works and Water Management (DVS), 2007.

6.7 ILLNESS AND DEATHS Illnesses Light and moderate alcohol consumption In general, low alcohol consumption is said to reduce the risk of cardio-vascular illnesses. It is unclear whether this applies to all population groups. The exact degree of risk reduction and the amount of alcohol required to maximise this risk reduction are also still being debated.162 • There are indications that compared to teetotallers on the one hand, and heavy drinkers on the other hand, moderate drinkers have a lower rate of coronary heart disease. It is thought that this may be due to an increase in ‘good’ cholesterol, HDL-C (high-density lipoprotein cholesterol).163;164;164 • Moderate drinkers also have less risk of ischemic stroke. Among the over 55s, moderate alcohol use may also reduce the risk of vascular dementia - caused by problems with blood circulation in the brain.165 • The greatest reduction in risk for cardio-vascular diseases appears to be reached by drinking one standard glass every two days. If more than two drinks per day are taken, this actually increases the risk of these diseases.162 • In recent Dutch research it was found that moderate alcohol consumption before the age of 45 has no effect on cardio-vascular illness after that age. This study did find a b

Data overlap partly with those of LIS, Consumer and Safety.

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•

slightly reduced risk of premature death or a diagnosis of cardio-vascular illness among people aged 45 and older who consume alcohol in moderation. However, the extent of the association depends partly on the alcohol questionnaire used and on including other factors in the results, such as lifestyle.166 Moderate alcohol consumption also reduces the risk of age-related diabetes. 167 This may be caused by an increased concentration of the protein adiponectine. This protein is instrumental in the body’s insulin sensitivity. 168

There are indications that light to moderate drinkers are less likely to die prematurely than non-drinkers or heavy drinkers. • These associations appear only to apply to people who have a regular moderate drinking pattern, without episodes of heavy drinking.169 • In a recent meta-analysis of the association between moderate alcohol use and death, it was concluded that the positive effects of moderate alcohol use were grossly overestimated in the past. A major reason for this is that studies often listed people who had given up alcohol as non-drinkers. Giving up drink is also related to having poor health. Taking only those studies without this mistake, no significant difference in deaths was found between non-drinkers and moderate drinkers.170 Excessive alcohol use The injurious effects of excessive alcohol use are numerous.162;171-173 • Alcohol use is related to over 60 medical conditions. For most of these, risk increases according as more alcohol is consumed.162;169 • Globally, alcohol use causes almost as many deaths and illnesses as smoking and high blood pressure. The global illness burden from alcohol has been calculated to be four percent. For smoking the figure is 4.1% and for high blood pressure, it is 4.4%.169 - In the Netherlands, excessive alcohol use contributes 4.5% to the national illness burden, chiefly on account of alcohol dependence.174 - This puts the burden of illness from alcohol (dependence) in fourth place in the Netherlands among lifestyle factors (after smoking, overweight and high blood pressure) and in eighth place among the top ten illnesses. Excessive alcohol use increases the risk of certain types of cancer.173 • Drinking two or more units of alcohol daily increases the risk of cancer of the mouth and throat, as well as a certain type of oesophageal cancer. The risk is further exacerbated for those who smoke as well. • There are clear indications, that alcohol consumption is accompanied by a slightly increased risk of breast cancer, viz. 7% to 9% with each unit of alcohol per day. • There are very clear indications of an increased risk of colon cancer, however only if three or more units per day are consumed. • For liver cancer, there are also clear indications of an increased risk from alcohol, but only after cirrhosis has first developed. Excessive alcohol use also increases the risk of cardio-vascular disease and damage to the brain and nervous system.171;175 • Daily consumption of five or more drinks increases the risk of coronary artery disease. • Daily consumption of more than two drinks increases the risk of hemorrhagic strokes. This is only true for hemorrhagic strokes. • Long-term and excessive alcohol consumption (more than 8 units per day) may damage the nervous system (polyneuropathy), shrink the brain and damage cognitive functioning (learning, memory, concentration etc.).

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• Binge-drinking increases the risk of coronary vascular disease, acute kidney failure and brain damage. In its advice on alcohol use in relation to conception, pregnancy and breast-feeding, the Health Board concluded that it is impossible to set a safe limit for alcohol use by either men or women prior to conception and for women during pregnancy and breastfeeding.176 • There are indications that one standard glass or possibly even less of alcohol per day before conception may affect a woman’s fertility, and increase the risk of miscarriage and foetal death. The latter two risks are also increased by alcohol consumption by the father. • An average alcohol consumption of less than one standard glass per day during pregnancy may increase the risks of miscarriage, foetal death and premature birth. It may also have a negative impact on the child’s psychomotor development after birth. The effects are exacerbated by a higher average consumption. Consumption of six or more standard drinks per day increases the risk that the child will be born with defects and the typical facial characteristics of Foetal Alcohol Syndrome. • During breastfeeding, after consumption of one to two glasses of alcohol by the mother, infants have shown much less inclination to feed during the three hours afterwards and have a disturbed sleep-waking pattern. Long-term heavy alcohol use in adolescence has been linked with damaging effects on the (development) of the brain. 177 • Research especially shows negative effects on learning and memory function. • In juveniles with a diagnosis of alcohol misuse or dependence, damage has been found to the structure and volume of the brain, compared to their peers without alcohol problems. • On the basis of current research, it cannot be concluded with certainty, whether alcohol use is the (only) cause. However, the results of animal experiments do point to a causal association. In its recently published ‘Healthy Eating Guidelines’, the Health Board issues the following advice with regard to alcohol use:178 • No more than two standard measures of alcohol daily for men • No more than one standard measure of alcohol daily for women • Alcohol consumption is not advised below the age of 18. • Women who are or want to become pregnant or who are breastfeeding are also advised to abstain from alcohol.

Deaths The number of alcohol-related deaths showed a rising trend from 1996 through 2003. In 2004 there was evidence of a slight decline, and the number of alcohol-related deaths has remained stable since then. • According to the Causes of Death Statistics of Statistics Netherlands, in 2006 almost 1,742 people died of causes linked specifically to alcohol, 25% more than in 1996 (Figure 6.10). • In 2006, alcohol was stated to be the primary cause of death in 42% of all alcoholrelated deaths; in the remaining 58%, alcohol use was the secondary cause of death. • In 2006, dependence and other mental disorders caused by alcohol use were the main causes of alcohol-related death (61%), followed by alcoholic liver disease (34%).

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• Alcohol-related deaths were most prevalent in the age group from 50 to 70 (Figure 6.11). Most of those who died were male (on average 74%). • The role of alcohol use in deaths is not always identified. Therefore these figures do not fully reflect the true situation. - On the basis of epidemiological research it is thought that between four and six percent of cancer deaths are linked to chronic excessive alcohol use. This would mean that in 2002, between 1,500 and 2,300 alcohol-related cancer deaths took place instead of the 150 registered cases.179;180 - It may also be assumed that deaths caused by alcohol-related accidents and alcohol-related aggression are not included fully in these figures.

Figure 6.10

Deaths from alcohol-related conditions, from 1996 Number

2000 1800 1600 1400 1200 1000 800 600 400

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Secondary

705

710

750

774

809

888

928

1090

1029

1003

1009

Primary

690

686

744

783

820

906

826

796

722

771

733

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 stated as complication T51.0-1). For an explanation of the codes: see appendix C. Source: Cause of Deaths Statistics, Statistics Netherlands (CBS). Primary cause of death: the illness or the event which started the started the process leading to death. This is known as the underlying illness. Secondary cause of death: consequences or complications of the primary cause of death, like other illnesses that were present at the time of death and may have contributed to the death.

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Figure 6.11

Deaths from alcohol use (primary and secondary) in men and women by age group. Survey year 2006

Number 300 250 200 150 100 50 0

<40

40-45

45-50

50-55

55-60

60-65

65-70

70-75

75+

Female

10

25

40

71

60

66

56

47

81

Male

45

59

120

177

216

201

183

113

172

Age

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 stated as complication T51.0-1). For an explanation of the codes: see appendix C. Source: Cause of death statistics, Statistics Netherlands (CBS)

6.8 SUPPLY AND MARKET Alcohol is widely available in grocery stores, liquor stores and in pubs and restaurants. According to the Licensing and Catering Act, it is not permitted to sell drinks containing alcohol to juveniles aged under 16. For spirits, the age limit is 18. • In 2005, 7% of 13-15 year olds had purchased alcohol in bars in the past month. Likewise 7% percent purchased alcohol from a liquor store and one percent from a grocery store (table 6.7).139 • According to a survey from 2006, 21% of boys aged 12 to 16 have sometimes purchased alcohol. 136 Boys are more likely to buy beer, alcopops and liqueurs. These data cannot be compared with those from the 2005 study because of differences in the questions asked. In 2006, the question concerned ‘alcohol purchased in the last month’, whereas in 2005 it was ‘sometimes purchased alcohol’. • Between 2001 and 2005 there was a decline in the percentage of youngsters aged under 16 who purchase low-alcohol beverages. This decline can be seen in bars (from 14% to 7%), in liquor stores (from 4% to 1%) and in grocery stores (from 13% to 7%). • Spirits are less likely to be purchased than other alcohol types. Of 16-17 year olds, five percent had purchased spirits in a bar and 8% in a liquor store in 2005. Youngsters aged under 16 rarely buy spirits. • Since 2001 there has been a decline in the percentage of juveniles that purchase spirits in bars (from 4% to 2%). The drop registered at liquor stores is not significant (from 4% to 3%).

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Table 6.7

Percentage of legally underage juveniles that bought weak or strong alcoholic beverages in the past month from various sales outlets. Survey 2005

Age Weak alcoholic beverage Strong alcoholic beverage

13 y

14 -15 y

16 -17 y

total

Bars etc.

1

13

-

7

Liquor store

0

2

-

1

Grocery store

2

11

-

7

Bars etc.

0

1

5

2

Liquor store

0

0.5

8

3

Source:139

There are few obstacles preventing youngsters from purchasing alcohol. In 2005 compliance with the age limits in Dutch supermarkets and liquor stores was measured for the first time by means of the ‘mystery shopping’ method. For this experiment, adolescents aged 15 and 17 attempted to purchase alcohol in a total of 150 supermarkets and 150 liquor stores.181 • 86% of all attempts were successful. • In the case of low alcoholic beverages, 88% of attempts by 15 year olds to make supermarket purchases were successful. In liquor stores, 77% of attempts were successful for this age group. • In purchasing spirits, 89% of 17 year olds were successful. • Girls have more success than boys (93% versus 78%). • One in seven adolescents (14%), who sometimes or regularly participate in the social scene, uses or has used a fake ID to purchase alcohol. 182 These are usually ID papers that have been faked or that belong to an older acquaintance. Alcohol is often offered for sale at a cut-price rate. In 2006, price reductions were found in one third (31%) of over 200 bars surveyed in five cities. 183 • Almost half of the special offers were for beer (48%), followed by happy hours (11%) and reduced prices for cocktails (10%). Special offers for shooters, spirits and wine were less common. • Notices concerning special offers were found on a quarter of bar websites. • A survey conducted among 14 and 15 year olds found that juveniles who frequent bars often choose the venue on the basis of the special offers available. Research conducted in a test bar situation among eighty young subjects (average age 21.5), showed that both looking at alcohol advertising and looking at films showing alcohol consumption led to increased alcohol use. 184 • Subjects watching a film in which alcohol was consumed drank over half a glass more per hour than those who watched a film that did not show alcohol use. • Those who had viewed alcohol advertising during the breaks drank almost threequarters of a glass more per hour than those who have viewed a neutral set of commercials. • Subjects who viewed the film showing alcohol consumption as well as the commercials containing alcohol ads drank even twice as much per hour as those who had viewed both the neutral film and the neutral ads. In 2005, three quarter of secondary schools provided alcohol at school parties.185 • Schools that provide alcohol at school parties almost without exception operate a policy that alcohol may not be given to pupils aged under 16. • Half of the pupils who are not yet sixteen (51%) drank alcohol at school parties.

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• Almost two-thirds of this group (64%) reported having been able to purchase alcohol •

themselves at a school party. Over one in three (39%) of the pupils attending a school party reported having drunk between five and ten alcoholic drinks; 12% (chiefly boys) take more than ten drinks at a school party.

Excise • The 18% increase of excise duty on spirits that was introduced on 1 January 2003

• • • •

• •

was reversed on 1 January 2006. This means the excise per litre of pure alcohol is now 15.04 euro. Accordingly, a bottle of spirits has become 1.00 to 1.5 Euro cheaper.186 In July 2007, the excise on a litre of spirits (35% alcohol) was €5.26, on a litre of wine €0.59 and on a litre of beer, €0.25 (Table 6.8). For a glass of beer of 0.25 litres, this means €0.06, for a glass of wine of 0.1 litres it is also €0.06 and for a measure of spirits (0.035 litres) it is €0.18. EU member states have different excise policies, with widely disparate rates of tax. In Italy, the tax on a litre of spirits with 35 volume percent alcohol is three euro compared to 19 euro in Sweden (Table 6.8). Seven wine producing countries impose no excise duty at all on wine. Table 6.9 shows that the Dutch excise rates are in the mid-range.

Table 6.8

Excise duty on alcoholic beverages in a number of EU member states. Survey dates March-July 2007 BeerI

WineII

SpiritsIII

Sweden

79

237

1 885

Ireland

99

273

1 374

Member state

U.K.

101

263

1 015

Finland

97

212

989

Denmark

34

82

704

Belgium

21

47

613

The Netherlands

25

59

526

France

13

3

508

9

0

456

Greece

14

0

397

Luxembourg

10

0

364

Austria

24

0

350

Portugal

17

0

328

Spain

11

0

291

Italy

28

0

280

Germany

Amounts in Euros per hectolitre of consumption. I. 5% alcohol by volume, survey date July 2007. II. 11% alcohol by volume; survey date July 2007. III. 35% alcohol by volume; survey date March 2007. Sources: Alcohol Product Board, Wine Product Board, European Commission.

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7

TOBACCO

Tobacco is made from the dried leaves of the tobacco plant (Nicotiana). It is generally smoked in the form of a cigarette, cigar or pipe, and more rarely taken as snuff or chewed. Users experience tobacco as stimulating (improves concentration) and calming. Nicotine, its most important psychoactive component, is an addictive substance. Regular use is habit forming and increases tolerance. When tobacco smoke is inhaled, various substances are released, such as nicotine, tar and carbon monoxide, as well as number other chemicals that are harmful to the health.

7.1 RECENT FACTS AND TRENDS In this chapter, the main facts and trends concerning tobacco are: • Between 2006 and 2007, there was a slight drop in the percentage of smokers in the general population. (§ 7.2). • Between 2005 and 2006, there was a rise in the average tobacco sales per smoker (§ 7.2). • The percentage of school-goers that had ever smoked declined between 2003 and 2005. The percentage of daily smokers remained stable in this period. (§ 7.3). • Eight percent of smokers expressed a wish to stop smoking within a month (§ 7.4). • The Netherlands occupies an intermediate position in the EU with regard to smoking among school-goers (§ 7.5). • Non-smoking is increasingly the social norm among young people (§ 7.6). • There has been a slight reduction in total smoking-related deaths in recent years (§ 7.7). • Until recently, deaths from lung cancer were dropping for men, but continue to rise for women (§ 7.7).

7.2 USAGE: GENERAL POPULATION In the 1960s and 1970s smoking was the norm, particularly among men. From the late 1960s until the early 1990s, the percentage of smokers declined sharply. This decline subsequently became less marked. Various surveys have measured the percentage of smokers in the population. • Surveys by TNS NIPO point to a stabilising decline in the number of smokers between 2004 and 2007 (Table 7.1).187

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-

Between 2006 and 2007 there was a further slight decline in smoking in the population aged 15 and older from 28.2% to 27.5%.188 In 2006 30% of the population in this age group were ex-smokers whereas 42% had never smoked. 187 In terms of the whole population, there are 3.7 million smokers in the Netherlands. The gap between male and female smokers has shrunk (Table 7.1). Female smokers now smoke virtually as much as male smokers. Female smokers smoke on average 14 cigarettes daily, and male smokers smoke on average 15 cigarettes (or roll-ups). The highest percentage of smokers is found in the age group from 30 to 34. (Figure 7.1).187

-

-

Table 7.1

Male and female smokers in the Netherlands aged 15 and older, from 1970

Year

Male

Female

Total

1970

75%

42%

59%

1975

66%

40%

53%

1980

52%

34%

43%

1985

43%

34%

39%

1990

39%

31%

35%

1995

39%

31%

35%

1996

39%

32%

35%

1997I

36.7%

30.3%

33.4%

1998

37.4%

30.1%

33.7%

1999

37.2%

30.6%

33.9%

36.8%

29.3%

32.9%

2000

33.2%

27.2%

30.2%II

2002

34.0%

27.6%

30.7%

2003

32.8%

27.2%

29.9%

2004

30.8%

25.2%

27.9%

2005

31.1%

24.5%

27.7%

2006

31.4%

25.0%

28.2%

2007

30.5%

24.5%

27.5%

2001

II

II

II

Percentage of smokers. I. From 1997, percentages are available with one digit after the decimal point. II In 2001, the research method was changed: instead of a face-to-face interview at home, the survey is conducted via the Internet. This change may have affected the outcomes. Source: STIVORO, TNS NIPO.187;188

• The NPO (National Prevalence Research) conducted surveys on substance use in 1997, 2001 and 2005. According to the NPO, the percentage of the population aged 15 to 64 that ever smoked dropped from 70% in 1997 to 62% in 2005. The drop was most marked between 2001 and 2005. - The number of daily smokers dropped between 2001 and 2005 from 34% to 27%. These data deviate somewhat from those of the TNS NIPO measurements.5 • A downward trend can be seen in smoking among women during pregnancy. In 2003 11% smoked, compared to 21% in 1996. 189 • The National Anti-Smoking Programme 2006-2010 has set the target to reduce the number of smokers in Dutch society from 28% in 2005 to 20% in 2010.190 -

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Figure 7.1 Percentage of smokers in the Netherlands by age group and gender. Survey year 2006 I % 50

40 32 30

33

34 31

32

33

33 28

28

21 20

15 10

10

0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-74

>74

Age

I. Figures for 2007 are not yet available. Source: STIVORO, TNS NIPO. 187

By contrast with the reduction in the number of smokers, there was an increase in the 1970s in the amount of tobacco used per smoker. Since the 1980s, the average number of cigarettes or roll-ups smoked daily has been estimated at around the twenty mark. 187 • In 2006 some 28 billion cigarettes or roll-ups were smoked in the Netherlands – a rise of over 3 billion compared to 2005 (Table 7.2). 187 • Rolling tobacco has declined in popularity since 1990 by comparison with cigarettes.187

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Table 7.2

Use of cigarettes and rolling tobacco in the Netherlands, since 1967

Year

Cigarettes (billion)

Roll-ups (billion)

Total (billion)

Average daily sales per smokerI

1967

16.6

9.1

25.7

12.9

1970

18.7

9.9

28.6

14.0

1975

23.9

13.1

37.0

18.6

1980

23.0

13.9

36.9

21.3

1985

16.3

17.8

34.1

20.7

1990

17.3

16.6

33.4

22.4

1995

17.2

14.4

31.6

20.1

2000

16.7

13.7

30.4

19.9

2001

16.3

12.4

28.7

20.1

2002

16.9

13.2

30.1

20.5

2003

17.0

13.1

30.1

20.9

2004

14.8

12.1

26.9

20.0

2005

13.5

11.1

24.6

18.3

2006

17.1

10.9

28.0

20.4

I. Average number of cigarettes or roll-ups. Source: STIVORO, Statistics Netherlands (CBS), Ministry of Finance.

187

Heavy smoking According to Statistics Netherlands (CBS), there has been a decline in recent years in the percentage of heavy smokers. However, in 2006 and 2007 the decline was only slight. • In 2007, 6.7% of the population aged 12 and older smoked 20 or more cigarettes a day (7.5% of males and 5.6% of females). In 2006, the figure was 7.2%; in 2005 7.7%; and in 2001 9.8%.191 • In 2005 over a quarter of all smokers were heavy smokers (26%). This figure dropped to 25% in 2006 and 24% in 2007. This compares with 35% in 2000.

7.3 USAGE: JUVENILES AND YOUNG ADULTS The percentage of young smokers has dropped in recent years. • According to the Dutch National School Survey, there was drop between 1999 and 2003 in the percentage of school-goers who had ever smoked and in those who had smoked during the past month (Figure 7.2). 9 • Data from the TNS NIPO-survey show that the percentage of current smokers among those aged 10 to 19 remained stable from 1992 through 2002 (between 27% and 31%). In 2004, the percentage of current smokers in this age group dropped to 23%. In 2005, it remained stable, but dropped further to 21% in 2006, followed by a rise to 22% in 2007.193

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Figure 7.2

Smoking among school-goers aged 12 to 18, from 1988

% 65 59 55

55

55 55

45 45

35

30 27

26 23

25

20 Ever

Current

15 1988

1992

1996

1999

2003

Percentage of lifetime smokers (ever) and in the last month before the survey (current). Source: Dutch National School Survey, Trimbos Institute. 9

Smokers start young.9 • In 2003 11% of pupils in the two most senior years of primary school had ever smoked. Of pupils attending mainstream secondary schools, 45% had ever smoked. These figures reflect the average; the percentage rises with age (Figure 7.3). Figure 7.3 70

Smoking in school-goers aged 10 and older, by age. 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 current (past month) and lifetime (ever). PE = primary education Source: Dutch National School Survey, Trimbos Institute. 9

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• A fifth (20%) of secondary school pupils had smoked in the past month; 9% smoked every day.

• These percentages, too, increase as the pupils get older. In the oldest age group

•

(16+), nearly one third were current smokers, compared to 6% of 12 year olds and 12% of thirteen year olds. Almost the same number of boys (18%) as girls (22%) had smoked in the past month.

Extent of smoking • Current smokers among school-goers smoke the following amount per day on aver-

•

age: One third (34%) smoke less than one cigarette daily, and a quarter smoke more than ten a day.9 Nine percent of school-goers smoke daily. Over a third of this group (36%) smoke more than ten a day.9

A comparison with data from the national Health Behaviour in School-aged Children (HBSC) study in 2005 suggests that the percentage of school-goers that ever smoked underwent a further decline between 2003 and 2005.10 • In 2003, 43% of school-goers aged 12 to 16 had ever smoked; in 2005 this was 33%. • The percentage of daily smokers remained unchanged, however, during this period (8.6% in 2003; 8.4% in 2005).

Special groups Smoking is considerably more common among juveniles in the social scene, young adults and juveniles in care than among school-goers. • In 2006, 63% of juveniles with behavioural and developmental problems (average age 17) in youth care programmes in Amsterdam were smokers. Of this group, 69% were daily smokers. 19 In so far as trend data are available, socialisers show a decline in smoking as well as the general population. • Among frequenters of Amsterdam bars the percentage of daily smokers dropped from 46% in 2000 to 31% in 2005. The number of heavy smokers (at least 20 cigarettes or roll-ups per day) declined from one quarter in 2000 to 18% in 2005.21 • Between 1998 and 2003 the percentage of clubbers that had smoked in the past month dropped from 67% to 55%.15 • In 2006, key observers in the Amsterdam social scene reported a decline in smoking, and that many socialisers were trying to cut down or quit smoking altogether. 19

7.4 PROBLEM USE A clear indication of the extent to which smokers find their use of tobacco problematic is their desire to stop smoking. • In 2006, 8% of smokers said they wanted to stop smoking within a month, 9% wanted to stop within six months, a further 9% within a year, and 24% said they wanted to quit at some time in the future, but not within a year.194

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In scientific circles, the term ‘nicotine dependence’ is sometimes favoured above ‘tobacco addiction’. Nicotine dependence can be measured on different scales: the Fagerström Test for Nicotine Dependence, a scale which runs from zero to ten (highly addicted); the DSM-IV, the Cigarette Dependence Scale, the Nicotine Dependence Syndrome Scale and the Winsconsin Inventory.195 In 2000, the Fagerström Test for Nicotine Dependence was conducted among twins from the Dutch Register of Twins.196 • Nicotine dependence is linked to the number of cigarettes that are smoked. • Male smokers have a higher average score for nicotine dependence than female smokers: 3.02 versus 2.77. • Attempts to quit smoking are more likely to be successful, the less one is dependent on nicotine.

7.5 INTERNATIONAL COMPARISON The percentage of smokers in the population of different EU member states varies considerably. However, the comparability of the figures may be questionable. For instance, there are discrepancies in how smoking is defined and in the age groups (Table 7.3). In many countries the data concern daily smokers; in the Netherlands smokers are people who smoke ‘daily or sometimes’. 197 • Of the countries that measured daily smoking, Greece had the most smokers (38%) and Sweden the fewest (16%). • With the exception of Ireland and Sweden there are more male than female smokers. In Portugal, where only ten percent of the female population smoke daily or sometimes, this gender difference was the greatest.

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Table 7.3

Smokers in the adult population in a number of EU member states plus Norway and SwitzerlandI Male

Female

Total

Criterion for smoking

18+

30%

25%

27%

Daily

20022005

15+

28%

23%

25%

Daily

France

20022005

15+

33%

27%

30%

Daily

Greece

19992001

15+

47%

29%

38%

Daily

Ireland

20022005

15+

24%

24%

24%

Daily

Italy

20022005

15+

31%

17%

24%

Daily

Luxembourg

20022005

15+

39%

26%

33%

Daily

Norway

20022005

16-74

27%

25%

26%

Daily

Spain

20022005

16+

34%

22%

28%

Daily

Sweden

20022005

16-84

14%

19%

16%

Daily

Switzerland

20022005

14-65

24%

20%

22%

Daily

The Netherlands

2005

15+

31%

25%

28%

Daily or sometimes

Austria

20022005

15+

48%

47%

47%

Daily or sometimes

Portugal

19992001

15+

33%

10%

21%

Daily or sometimes

Finland

20022005

15-64

27%

20%

23%

Current smokers

UK

20022005

16+

28%

24%

26%

Current smokers

Germany

20022005

18-54

37%

31%

34%

Past 30 days

Country

Year

Belgium

20022005

Denmark

Age

Percentage of smokers per year or average per year. I. Differences in survey year, measuring methods and definitions hamper a precise comparison between countries. Source: WHO. 197

With ESPAD (see appendix B) it is possible to compare the smoking behaviour of 15 and 16 year old pupils in secondary schools. Figure 7.4 shows data for the percentage of school-goers that had smoked during the past month in 2003. 48 • Of the countries under review, Austria had the most and Sweden the fewest smokers among secondary school students. • The Netherlands occupies an intermediate position. • In most of the countries, more girls smoke than boys.

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Figure 7.4 Smokers among secondary school pupils aged 15 and 16 in a number of EU member states plus Norway and Switzerland. Survey year 2003 49

Austria

48

Germany

43 38

Finland

38 35

45 46

41

35

Italy

56

40

34 34 33

Switzerland

33

France

36

31 33

Ireland

37

28 32 33 32

Belgium

31 31 32

The Netherlands

30

Denmark

27

32

29

United Kingdom

34

25 28

Greece

27

30

28

Norway

32

24 28 27 28

Portugal

27

Spain

22 23

Sweden

20

0

10

20

31

26

%

30 Boys

Girls

Percentage that had smoked in the past month. Source: ESPAD.

40

50

60

Total 48

• Over a quarter of Dutch school-goers (27%) report having smoked more than forty times in their lives. In the other countries, this percentage varies from 18% in Portugal to 42% in Austria.

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7.6 TREATMENT DEMAND Treatment demand for tobacco addiction mainly involves self-help and requests for treatment from the GP. Addiction Care sometimes provides cessation programmes, but not on a large scale. • Almost two-thirds (63%) of smokers who attempt to quit, do so without any external help. The remainder attend courses, consult their GP, use nicotine replacement therapies (patches, chewing gum or Zyban®) or Champix®, have acupuncture or hypnosis, or try a different method. The most common reason for giving up smoking is smokers’ concern about their own health.198 • The use of nicotine replacement therapies has increased. Sales in patches, chewing gum and tablets rose between November 2006 and November 2007 from 13.2 million euro to 14.3 million euro.199 In 2006, Zyban® was only issued 45,000 times, a drop of over 6% compared to 2005.170 The new anti-smoking medication, Champix®, was dispensed over 14,000 times in the first three quarters of 2007.200 • People who want to give up smoking can go to their GP for advice. In 2006 an estimated 42,800 males and 42,100 females consulted their GP about quitting smoking. In total, this is 24% less than in 2005. The majority of quitters are aged between 40 and 60.201 • The Minimal Intervention Strategy (MIS) has proved to be an effective instrument which GPs, nurses and cardiologists can use to encourage patients to give up smoking.202 The application of the MIS intervention my midwives can lead to a significant reduction in smoking among pregnant women.203 Its adoption and implementation by the nursing departments of cardiology and obstetrics could be significantly improved. 204

• In late 2004, an official guideline for treating tobacco addiction was published by the

•

Dutch Institute for Healthcare Improvement (CBO). This guideline contains strategies for dealing with patients who smoke and describes the effectiveness of various treatments. 205;206 In 2007, the NHG Guideline on giving u smoking was published. This guideline for general practices is a reworking of the CBO Guideline and builds on the MIS intervention on giving up smoking for general practice (H-MIS). 207

The STIVORO advisory centre also provides support to people who want to give up smoking. • In 2006, 707 people signed up for Telephone Coaching, and over 6,000 coaching sessions took place.187 The new intervention for problematic quitters, ‘personal coaching for giving up smoking’ has shown good results. 208 • In January 2006, STIVORO launched the Guideline for Tobacco Prevention in Local Healthcare Policy. This guideline was developed in order to support municipalities and municipal health services (GGDs) in implementing local policies for discouraging smoking.209 • The campaign ‘Smokers deserve a reward’ was launched on 2 November 2006. Its aim was to motivate as many smokers as possible from lower socio-economic classes to try to stop smoking for 24 hours. More than half of the 12,272 participants succeeded in abstaining for 24 hours.210 This campaign was repeated in November 2007. • The campaign ‘You can learn how to quit’ was run from mid-December 2006 to midJanuary 2007. During this time, the campaign website received 120,000 hits. During the first quarter of 2007, 31% of people who availed of support for quitting used a form of support with proven effectiveness. 211

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• The youth campaigns were aimed at preventing youngsters from taking up smok-

ing.212 The emphasis was on improving the image of non-smokers and putting nonsmoking forward as the social norm. Between 2001 and 2005, the non-smoker did indeed acquire a more positive image. The percentage of youngsters that felt that friends wanted them not to smoke rose from 19% to 25% between 2004 and 2005.213

Another issue is the demand on the health care system for conditions caused or exacerbated by smoking. The number of hospital admissions associated with smoking amounted to nearly 100,000 in the early 1990s.214 More recent figures are not yet available.

7.7 ILLNESS AND DEATHS In the Netherlands, smoking is the most important cause of premature death. • There is evidence of a slight downward trend in smoking-related deaths. In 2006 over 19,000 people aged 20 and older in the Netherlands died from the direct consequences of smoking (table 7.4). Compared to 2000 when there were 20,718 deaths , this represents a drop of 6.5% percent.215 Per 100,000 inhabitants aged 20 and older, total deaths from smoking dropped from 173 in 2000 to 157 in 2006 – a decline of nine percent. • Of all deaths in the Netherlands among people aged 20 and older, nearly 15% were directly attributable to smoking in 2006 (21% for men and 8% for women).215 Smoking is linked to cardio-vascular disease, lung diseases and cancer. • Table 7.4 shows that lung cancer, COPD, oesophageal concern and oral cancer are caused overwhelmingly by smoking. In 2006 91% of lung cancer cases among men and 73% among women were caused by smoking. • Recently clear indications have emerged that smoking increases the risk of dementia. 216

• Research in the Dutch male population has shown that an average smoker has a reduced life expectancy almost seven years and a heavy smoker of almost nine years. Furthermore, smoking cigarettes causes almost six years of illness. 217 • The true death rate from smoking is higher, because the effect of passive smoking has not been factored in. Passive smoking can cause a variety of illnesses. - People who do not smoke themselves, but are regularly exposed to passive smoking from a partner who smokes have an increased risk of developing lung cancer. In the case of passive smoking women, the increased risk is 20% and among passive smoking men, the elevated risk of lung cancer is 30%.218 - Besides lung cancer, passive smoking also increases the risk of diseases of the respiratory tract, such as asthma and bronchitis. There is furthermore an elevated risk of cardio-vascular diseases and brain haemorrhage. 219 The risk of an acute coronary incident increases by 15% from more than one hour of passive smoking weekly. 220 - Children have a higher risk of developing infections of the respiratory tract and middle-ear infection from passive smoking. Babies whose mother smokes have a higher risk of complications during pregnancy, as well as premature birth, low birth weight, higher blood pressure and higher cholesterol.221-224 Passive smoking by the mother during pregnancy can also result in a lower birth weight. 224 - Annual deaths from passive smoking are estimated at several thousand cases due to heart conditions, several hundred cases from lung cancer and about a dozen instances of cot death. 225

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Table 7.4

Deaths due to a number of conditions among men and women aged 20 and older. Survey year 2006I Total deaths

Condition

Deaths from smoking

Men

Women

Lung cancer

6 254

3 171

5 711 (91.3%)

2 325 (73.3%)

COPD

3 634

2 645

3 066 (84.4%)

1 815 (68.6%)

7 182

5 307

2 030 (28.3%)

660 (12.4%)

Stroke (CVA)

3 922

6 047

803 (20.5%)

578

(9.6%)

Heart failure

2 472

3 967

439 (17.8%)

219

(5.5%)

Oesophageal cancer

1 062

391

843 (79.4%)

244 (62.4%)

Cancer of the larynx

189

49

151 (79.9%)

40 (81.6%)

Coronary easeII

heart

Oral cavity cancer TotalI

dis-

Men

Women

372

175

343 (92.2%)

99 (56.6%)

25 087

21 676

13 386 (53.4%)

5 980 (27.6%)

I. Per condition, first rounded to whole numbers and then added up. II In 2006, deviating from the 2005 report, includes “other coronary heart diseases”. Source: RIVM, Statistics Netherlands (CBS). 215

Thanks to the fall-off in smoking among men between 1960 and 1990, male deaths from lung cancer have dropped since the mid 1980s. Among women, however, who have taken up smoking in greater numbers, the trend is reversed (Table 7.5). • The upward trend in lung cancer deaths among women will continue for some decades.226 • The decline among men until 2003 did not continue in subsequent years. • The opposite trends for men and women balance each other out. Consequently, total deaths from lung cancer have remained fairly stable for some years.

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Table 7.5 Year

Deaths from lung cancer as the primary cause of death among people aged 15 and older from 1985. Deaths per 100,000 inhabitants Males

Females

Total

1985

127

16

71

1986

130

17

72

1987

127

17

71

1988

128

19

72

1989

123

20

70

1990

117

20

67

1991

118

20

68

1992

117

22

69

1993

115

24

69

1994

113

26

68

1995

112

27

69

1996

109

28

68

1997

108

29

68

1998

106

30

68

1999

105

33

68

2000

99

34

66

2001

100

35

67

2002

96

39

68

2003

95

40

67

2004

99

42

70

2005

97

45

71

2006

95

47

71

1985-1996: ICD-9 code 162, from 1996: ICD-10 codes C33-34 (see appendix C). Source: Cause of death statistics, Statistics Netherlands (CBS).

Not only have deaths from smoking-related lung cancer stabilised in recent years: • Deaths from smoking-related COPD and other conditions have also stabilised (figure 7.5). • There is a downward trend in the death rate from smoking-related coronary heart disease and stroke.

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Figure 7.5 Deaths from a number of smoking related conditions in the population aged over 20, from 2000 Number

9000 8000 7000 6000 5000 4000 3000 2000 1000 0

2000

2001

2002

2003

2004

2005

2006

Lung cancer

7442

7596

7726

7629

8033

8053

8036

COPD

5282

4983

4925

5083

4477

5006

4881

Coronary heart disease

3963

3667

3526

3442

3068

2912

2690

Stroke (CVA)

1810

1763

1823

1662

1578

1465

1382

Other

2222

2096

2176

2324

2258

2332

2378

Number of deaths from smoking. Other conditions are: oral cavity cancer, cancer of the larynx, oesophageal cancer and heart failure. Source: RIVM, Statistics Netherlands (CBS).

7.8 SUPPLY AND MARKET Availability of tobacco The market share of the various sales outlets varies for cigarettes, cigars, rolling tobacco and pipe tobacco. 227 • In 2006 37% of cigarettes were purchased in supermarkets, 27% at petrol stations, 21% in tobacconists and convenience stores, 5% in bars etc. and 9% from other outlets. 227 • In the same year, the percentages for cigars were: 36% purchased in petrol stations, 31% in tobacconists and convenience stores, 22% purchased in supermarkets, 2% in bars etc., 9% from other outlets.227 • The percentages for rolling tobacco and pipe tobacco were: 50% in supermarkets, 20% in tobacconists and convenience stores, 20% at petrol stations, 4% in bars etc., and 6% from other outlets. 227 Since 1 January 2003 it is no longer permitted under the amended tobacco laws, to sell tobacco products to juveniles aged under 16. • The number of juveniles aged between 13 and 15 who have bought tobacco products dropped between 1999 and 2005 from 26% to 6%.228 • Of the minors who had purchased tobacco, 57% indicated having made the purchase themselves in 2005, whereas in 1999 this was 43%.228 • Youngsters purchase tobacco products from four different kinds of retail outlets: tobacconist (40%), grocery store (49%), petrol station (43%), cigarette machines (23%). The trend is moving away from grocery stores and cigarette machines.228

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• The likelihood that a juvenile aged under 16 will succeed in purchasing tobacco products is at least 90%, which is the same as in 1999, 2001 and 2003. Nonetheless, 93% of retailers claim that they never sell tobacco to children aged under 16.228 On 1 January 2004, an article was added to the Tobacco Act to the effect that employers are obliged to protect employees from the tobacco smoke of others. 229 • The percentage of companies that say they have correctly implemented the smoking ban rose from 76% to 81% between 2004 and 2006. 229 • During this period, the percentage of companies that experienced problems in the introduction of the smoking ban declined from 23% to 13%.229 • During the same period, the percentage of companies that experienced problems in maintaining the smoking ban dropped from 15% to 5%.229

Excise duty • On 1 July, 2007, a packet of 19 cigarettes in the most popular price bracket cost 3.80 euro. This converts to 5 euro for 25 cigarettes, of which €2.85 is excise tax and €0.80 is VAT (table 7.6). A packet of rolling tobacco weighing 50 grams also cost 5 euro, of which €2.25 is excise duty and €0.80 is VAT (Table 7.6).230-232

Table 7.6

Cigarette prices and taxes from 1970. Survey date July 2007

Year

Price

Taxes

Taxes in %

1970

0.86

0.60

69%

1975

1.02

0.68

67%

1980

1.36

0.98

72%

1985

1.88

1.35

72%

1990

1.97

1.37

70%

1995

2.56

1.84

72%

1996

2.61

1.87

72%

1997

2.79

2.01

72%

1998

2.93

2.11

72%

1999

3.04

2.19

72%

2000

3.15

2.27

72%

2001

3.43

2.50

73%

2002

3.54

2.58

73%

2003

3.54

2.63

74%

2004

4.60

3.36

73%

2005

4.60

3.36

73%

2006

5.00

3.65

73%

2007

5.00

3.65

73%

Price and taxes in Euro per pack of 25 (converted). Tax includes excise duty and VAT. Source: European Commission. 231

International Comparison The taxes imposed on tobacco products differ considerably among EU member states. • In the EU-15 the excise duty is highest in the UK and lowest in Austria (Table 7.7). The Netherlands occupies an intermediate position.231

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• In 2003 the World Bank published an overview of six cost-effective interventions de-

•

signed to discourage the use of tobacco. These interventions are: increasing the price of tobacco products; introducing a smoking ban in public places and the work place; increase the budget for smoking deterrent policy; impose a ban on tobacco advertising; place warnings on tobacco products; and offering treatments for support in quitting smoking. In particular, if they are introduced in tandem, these anti-smoking measures have the potential to reduce illness and deaths from tobacco use. In 2004, experts in 28 European countries rated the degree of implementation of these interventions. In 2004 the Netherlands was placed 7th out of 28 countries.233 In 2005, 30 European countries were rated and the Netherlands dropped to tenth place.234 In 2007, the Netherlands dropped to a shared 14th place. 235

Table 7.7

Cigarette prices and taxes in a number of EU member states. Survey date July 2007

Country

Price

Excise duty

VAT

Excise + VAT

U.K.

10.03

6.21

1.49

7.71

Sweden

5.89

3.06

1.18

4.24

Spain

3.00

1.91

0.41

2.33

Portugal

3.75

2.32

0.65

2.97

Netherlands

5.00

2.85

0.80

3.65

Luxembourg

3.80

2.20

0.50

2.70

Italy

4.25

2.49

0.71

3.19

Ireland

8.81

5.35

1.53

6.88

Greece

3.50

2.01

0.56

2.57

Germany

5.88

3.52

0.94

4.46

France

6.25

4.00

1.02

5.02

Finland

5.25

3.00

0.95

3.95

Denmark

5.36

2.86

1.07

3.94

Belgium

4.71

2.86

0.82

3.68

Austria

4.25

2.49

0.71

3.20

Price, excise duty and VAT expressed in euros per pack of 25 cigarettes (converted). Source: European Commission. 231

• In 2007 the Netherlands received the following scores compared to the other Euro-

pean countries for the six cost-effective anti-smoking measures: price of tobacco products: below average smoking bans in public places and workplace: below average amount of national budget allocated to anti-smoking policy: above average ban on advertising tobacco products: above average warnings on tobacco packaging: average.

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8

DRUG-RELATED CRIME

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defines drug related crime as four kinds of criminality236: 1) crimes committed in violation of drug legislations; 2) psychopharmacological crime: crimes committed under the influence of a psychoactive substance as a result of its acute or chronic use (e.g. violent crimes); 3) economic-compulsive crimes: crimes committed in order to obtain money (or) drugs to support drug use (for example, theft, forging prescriptions, fraud); 4) systemic crimes: crimes committed within the functioning of illicit drug markets as part of the business of drug supply, distribution and use (for example violent acts in the drugs trade/gangland killings, corruption). This chapter deals with the following issues:

• Drug law crime: crime as described in Dutch legislation on drugs (Opium Act, Abuse of Chemical Substances Prevention Act (WVMC) or crime that is related to these drug laws (organised crime), as well as driving under the influence of legal and illegal substances (crimes described in the Road Traffic Act). • Drug users in the criminal justice system and the measures and interventions available to deal with them. There is no systematic information available about specific psychopharmacological or economic-compulsive felonies or about systemic criminality. The data in this chapter refer mainly to violations of the Opium Act. This legislation prohibits the smuggling, production, cultivation, trafficking, and possession of drugs. Use of drugs is not punishable under the Opium Act, and possession of small amounts for own use is not pursued. If an individual is in possession of a small amount of drugs, these are seized. For large amounts, a booking and prosecution may follow. The Public Prosecutor does not define what is meant by ‘large quantities’ in its policy rules. 237 The Opium Act makes a distinction between soft drugs and hard drugs. There are different penalties and prosecution guidelines for these categories. The illicit drugs that come under the Opium Act are contained in List I (Hard drugs) and List II of the law. The trafficking and production of drugs are accorded greater priority in criminal investigations than possession; and there are more severe penalties for hard drug offences than for soft drug offences. In June 2006, the maximum penalty for the production, trafficking and possession of large quantities of soft drugs was raised from four to six years of imprisonment or payment of a specific fine (article 11 of the Opium Act). The data are chiefly derived from the registries of law enforcement agencies. This includes both crimes that are registered when a suspect is arrested and booked (registered and solved crimes) and crimes that are registered but not solved (such as investigations into organised drug crime and drugs that have been seized without a suspect). The data cannot be generalised to total drug crime – including non-registered crime. The figures also reflect the crime-solving priorities and capacity of the law enforcement authorities, as well as the leeway afforded them in providing information. This calls for a certain degree of caution in interpreting the data and in drawing conclusions about trends. Furthermore, registration systems are not static: they are regularly updated and improved, which means later versions may differ from earlier ones. Information on crime related to drug use and perpetrated by drug users is very limited, because information on drug use is not systematically sought by the law enforcement agencies.

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Despite these limitations, the information contained in this chapter provides a picture of what is currently known about drug-related crime in the Netherlands. In addition to registration data, use is made of the findings of recent research publications. Paragraph 8.1 describes the most important results from 2006.In §8.2, we provide data on drug law crime in the criminal justice chain. §8.3 contains information on the crimes committed by drug users, and the interventions that are applied to these in the criminal justice system.

8.1 RECENT FACTS AND TRENDS • The majority of criminal investigations conducted into the more serious forms of organised crime were again aimed at drugs, in 2006.

• The number of new Opium Act offences in the law enforcement chain has stabilised.

• • • •

• •

Until 2004, there was a rising trend, and 2004 was a peak year in this respect. In 2005 and 2006 the trend evened out. The percentage of Opium Act offences in the law enforcement chain has been fairly stable since 2003/2004. There has been a decline in the percentage of hard drug offences in the law enforcement chain, whereas the percentage of soft drugs cases is rising. Hard drug crimes still account for the majority of crimes and represent the bulk of prison sentences as well as number of detention years imposed. There has been a drop in the number of (partially) unconditional custodial sentences imposed for drug offences. This decline has been ongoing since 2004 and reflects an overall declining trend in prison sentences, not only in relation to drug crimes. Drug law offenders are relatively more likely to receive a comparatively long prison sentence. A large percentage of detainees in the Netherlands are problem substance users (alcohol or drugs) or gamblers. The majority of these addicts are serving sentences for property crimes, violations of the Opium Act and violent crimes.

8.2 DRUG LAW VIOLATIONS The following developments are linked to high-priority criminal investigations in 2006 and are relevant to the context of the data: • The intensified efforts within the drug courier policy at Schiphol airport to reduce the imports of cocaine by pellet swallowers and body packers were incorporated into a permanent strategy in 2006. 238;239 • Cocaine-related organised crime has been defined as a serious threat to Dutch society. Combating this serious or organised cocaine-related crime has been one of the six priorities in the approach to organised crime since 2005. The same applies to heroin smuggling via the so-called Balkan route. 240 • A special programme targeting ecstasy was conducted from 2001 through 2006. These measures were also made permanent, in 2007. The production of and trafficking in synthetic drugs are also considered serious threats to society and are contained in the six policy priorities. 240 • The intensification of activities aimed at combating the production of cannabis is ongoing. 241-243 An integrated approach, involving the collaboration of police, electrical companies and housing corporations is being applied in many regions. 3;3;224 Meas-

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ures to tackle organised hemp cultivation are part of the ‘programme to intensify action against organised crime’. 245

Drug seizures The National Criminal Intelligence Service of the National Police Agency (KLPD), reports annually on the quantities of drugs seized. For the 2006 report, information was collected from the police agencies, the Royal Military Police, customs and the Inland Revenue Intelligence and Investigations Department (FIOD-ECD). Registration methods differ per police region.3 For the 2006 report, 26 of the 29 police regions supplied complete data on their drug seizures. 246 The data presented in Table 8.1 below are therefore not complete and probably reflect minimum quantities.

Table 8.1

Seizures of different kinds of drugs in 2006I

Type of drug

2006

Hashish

+ 4 600 kilos

Marihuana/Dutch-grown weed

+ 6 600 kilos II

Hemp plants (including shoots)

+ 1 650 500

Heroin

+ 1 000 kilos

Cocaine

+ 10 600 kilos

Amphetamine

+ 600 kilos, + 38 100 tablets and + 3 kilos of paste

Ecstasy (MDMA/MDA/MDEA)

+ 700 kilos, + 4 118 300 tablets and + 100 litres

LSD

+ 22 600 tabs and + 2 500 tablets

GHB

+ 2 000 tablets and + 58 litres

Methadone

+ 11,600 tablets

Magic Mushrooms

+ 150 kilos

BMK

+ 170 litres

PMK

+ 100 litre

I. Figures are rounded and seizures of less than 10 kg/litres are not listed. II. According to Wouters et al. (2007) the estimated total was 2 800 000 in 2006 and 2 700 000 in 2005.3

Data from additional sources give further information: • The limited quantities seized of amphetamine precursor, benzyl-methyl-keton (BMK) and of ecstasy precursor, piperonyl-methyl-keton (PMK), does not mean that the production of synthetic drugs has been successfully undermined. There are indications that the traffickers have changed their smuggling routes as a result of large-scale seizures in 2003 and 2004, and that there has been a shift from the seizure of tablets to powder. 247 • New synthetic drugs were seized in 2006: mCPP (approximately 380,000 tablets), methamphetamine (about 5,000 tablets) and other forms of MDMA (‘Original 69’ and ‘Explosion’). • Some 6,000 hemp plantations were dismantled – both in 2006 and in 2005. 3 • Large hauls of cocaine (+9,000 kilos) were seized by customs officials: 3,200 kg during passenger checks, 1,200 kg during controls of air freight and package mail at Schiphol airport and 4,500 kg during shipping checks. 248 • 23 production plants for synthetic drugs were dismantled; nine of these were producing amphetamine and fourteen were producing ecstasy. The number of ecstasy pro-

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duction locations has declined since its peak in 2002, although an increase was reported between 2005 and 2006. 248;248;249 The production plants discovered in 2006 were very sizeable, and police report that the producers make every effort to conceal them. Labs were chiefly found in the west and south of the country. This is also where most dumped waste products were found (42 instances in 2006). It appears that ecstasy is still widely available. According to the Expertise Centre, production now (also) takes place in other countries. In general, production processes have been halted by the intensified combating efforts; but criminal networks involved in ecstasy are fairly solid and impossible to eradicate completely. 250 At most their activities can be curbed.

Organised crime in relation to drugs For the purpose of Europol’s Organised Crime Threat Assessment (OCTA), the Research and Analysis Group of the National Criminal Intelligence Service of the National Police Agency (KLPD), annually records the criminal investigations conducted by the Dutch police into organised crime. All 25 Dutch police regions, as well as the National Police Research and Analysis Group and special criminal investigation departments report on both their ongoing and completed investigations that meet the EU criteria for organised crime (table 8.2). Because of changes in registration methods, the data cannot be directly compared throughout the years. The data from before 2002 can not be directly compared to data from later ; and data for 2005 does not cover the entire calendar year. In 2006, a broader data collection took place, which made the total number for 2006 significantly higher than for previous years. This is particularly marked in the higher number of investigations into trafficking in soft drugs. For this reason, long-term trend data are not supplied. Table 8.2

Criminal investigations into more serious forms of organised crime, drug law crime and hard and soft drugs, 2000-2006I 2000

2001

2002

2003

2004

2005

2006

Total number of investigations

148

146

185

221

289

176

333

- % targeting drugs

53%

62%

63%

66%

69%

72%

75%

78

90

117

146

200

127

250

- % involving hard drugs

82%

83%

83%

83%

84%

85%

79%

- % involving soft drugs

55%

41%

45%

39%

27%

41%

60%

- % involving only hard drugs

45%

59%

55%

61%

69%

59%

40%

- % involving only soft drugs

18%

17%

17%

17%

11%

15%

21%

- % involving hard and soft drugs

37%

24%

28%

22%

16%

26%

39%

64

75

97

121

168

108

198

- % cocaine

60%

57%

54%

68%

- % synthetic drugs

54%

39%

44%

43%

- % heroin

17%

18%

29%

29%

Number of investigations targeting drugs

Number of investigations involving hard drugs

I. Single investigation may involve trafficking in or production of several types of drug. Percentages therefore do not add up to 100%. There were breaks with trend between 2002 and 2003, between 2004 and 2005, and

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between 2005 and 2006 as a result of changed registration methods. Source: KLPD/DNRI, Research and Analysis Group.

• In 2006, the bulk of criminal investigations (75%) was aimed at trafficking in or pro• •

duction of drugs. The majority of these involved hard drugs. Cases involving only hard or soft drugs are more common that cases involving a combination of hard and soft drugs. Trafficking of cocaine is the most frequently occurring subject of investigation. This is followed by synthetic drugs (production and trafficking) and then heroin trade. Investigations into soft drug cases are chiefly aimed at trafficking and/or cultivation of Dutch-grown weed (72%), followed by trade in hashish (not in table).

Under Article 140 of the Dutch Penal Code, participation in a criminal organisation is a criminal offence, punishable under the law. An Opium Act violation, in combination with an offence under Article 140 indicates that the perpetrators belong to a criminal organisation. • In 2006, the Public Prosecutor disposed of 415 cases involving this combination (table 8.3). • This number has increased steadily for the past three years.

Table 8.3

Opium Act cases combined with Article 140 disposed of by the Public Prosecutor, 2000-2006

Number of cases

2000

2001

2002

2003

2004

2005

2006

362

426

361

354

384

405

415

Source: OMDATA. Data processing by WODC.

Research was conducted recently on (organised0) criminal structures underlying cannabis cultivation in the south of the Netherlands (the provinces of Limburg, Brabant and Zeeland). 244 The research involved analysing the files relating to Opium Act offences from 2000 to 2005, and interviewing cannabis growers in 2006/2007. The main results are: • Cannabis cultivation appears to be widespread. It is fairly easy to procure materials, knowledge and skills. Growshops play a (partly legal) facilitating role in this. • Four types of organisation within cannabis cultivation can be distinguished: (1) small and medium-sized independent home growers with between 100 and 1,000 plants; (2) growers or cultivators with large cultivations in industrial premises; (3) developers with between five and ten plantations in houses and (4) criminal collaborations that purchase cannabis on a large scale, then process and trade it, particularly for export; sometimes they have their own plantations as well. • Use of coercion or force against small-scale growers was not found; however there are indications of ‘horizontal’ violence between organisations and of rip-offs of plantations. • There are signs that criminal-based organisations and cultivation in non-urban areas are becoming more important in general cannabis cultivation, at the expense of the smaller (often more ideologically-based) growers. 3;244;251

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Drug Crime Suspects The number of people suspected of an offence against the Opium Act that were booked by the regular police or Royal Military Police has stabilised (figure 8.1). • In 2006 there were over 22 thousand suspects. The trend was upward until 2004, after which it stabilised at a relatively high level. • Most cases involve hard drug crimes: 11,000 in 2006, which is about the same as in 2005, but less than in 2004.Hard drug offences account for half of all drug offences. The share of these offences is declining. • There were 8,000 soft drug offences. From 2000 to 2005, there was a steady rise in the number of people held on suspicion of a soft drug offence; this stabilised in 2006. Soft drug offences now account for 37% of all offences against the Opium Act. This percentage has been increasing throughout the years. • There were almost 2,500 offences in 2006 involving hard and soft drugs. A continuously rising trend is perceptible for this. In terms of share in total drug crime, these offences account for only 11%, but this rate has been rising in recent years. • Opium Act suspects account for 7% of all suspects registered with the police and Royal Military Police. This number rose between 2000 and 2004 from five percent to eight percent; since then it is between seven and eight percent. Figure 8.1

Number of drug crime suspects registered by police and Royal Military Police, by hard and soft drugs, 2000-2006I,II Number 25000

20000

15000

10000

5000

0

2000

2001

2002

2003

2004

2005

2006

Total public prosecutor

9958

12736

15810

18921

22301

21963

22145

Hard drugs

5871

7437

9357

10881

12057

11122

11090

Soft drugs

2694

3578

4595

5915

7439

8294

8127

Both

947

1160

1222

1392

2106

2166

2487

I. Unit of calculation is the number of times that a suspect is booked for an Opium Act offence is registered in the HKS. II. Data for 2006 are provisional . Source: HKS, KLPD/DNRI.

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• The majority of Opium Act suspects are male (table 8.4). Between 2001 and 2006 the percentage of female suspects increased, but still remains well below the number of males. Females are relatively more often involved in soft drugs offences. Males are relatively more often involved in hard drugs offences. Table 8.4

Characteristics of suspects of Opium Act violations by hard and soft drugs, 2006I Hard drugs

Soft drugs

Both

Total

10 259

7 772

2 431

20 866II

Male

87%

81%

84%

84%

Female

13%

19%

16%

16%

1

41%

44%

43%

42%

2

11%

14%

12%

12%

3-4

12%

14%

13%

13%

5-10

16%

16%

17%

16%

11-20

10%

8%

10%

9%

21-50

8%

4%

4%

6%

> 51

3%

1%

1%

2%

12-17 yrs

3%

4%

4%

4%

18-24 yrs

29%

18%

22%

24%

25-34 yrs

32%

30%

32%

31%

35-44 yrs

22%

28%

26%

25%

45-54 yrs

11%

14%

12%

12%

55-64 yrs

2%

5%

3%

3%

≥ 65 yrs

0%

1%

1%

1%

Total number Gender Number of offencesIII

previous

Age at registration of last crime

I. The Table shows suspects of single crimes; each accused is represented only once in the table, even if a suspect is booked for Opium Act offences more than once in year. The figures are provisional. II in 404 cases the type of drug is unknown. This category has not been included here. III A previous offence is when police have booked a suspect for one or more offences; previous offences from the entire criminal history are meant. Source: HKS, KLPD/DNRI.

• Drug crime suspects may come from smaller communities and medium-sized towns,

•

•

but the majority of suspects living in the Netherlands are resident in cities of over 100,000 inhabitants (not in table). 18% live outside the Netherlands. Hard drugs suspects are relatively more likely to live in a big city or abroad. Soft drug suspects are more likely to live in medium-sized and smaller towns. A considerable percentage of Opium Act suspects have a number of previous offences on record. One third have five or more, and 17% have more than ten. Suspects of offences involving hard drugs have the greatest number of previous convictions. The majority of suspects are aged between 18 and 44. Few are younger than 18. The average age of drug offenders increased from 31 in 2001 to 33 in 2006. Soft drugs offenders tend to be older than hard drug suspects.

Registration of Opium Act cases at the Public Prosecutions Department Official reports of drug law violations are forwarded by the police to the offices of the Public Prosecutor. Not all incidents are registered with the Public Prosecutor. Offences are

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153

filtered first by the police on the basis of likelihood of successful prosecution. Cases that are deemed ‘unprosecutable’ are not forwarded to the offices of the Public Prosecutor.

• Figure 8.2 shows that the numbers of cases reported to the Public Prosecutor follows

•

•

•

the same line as for the police and the Royal Military Police. Up to 2004 the trend was rising, with 2004 being a peak year; this was followed by a slight drop in 2005 which stabilised in 2006 at a rather high level. Of the 20,000 drug cases, the majority (67%) involve preparation, production and smuggling/trafficking of drugs. The remainder concerns possession. The number of possession cases is increasing: from 29% in 2004 to 33% in 2006 (not in table). The share of drug law offences (expressed as a percentage of total cases) increased between 2000 and 2004 and has stabilised since 2004 (table 8.5). The lower number registered by the Public Prosecutor in 2005 and 2006 reflects a trend across the board and does not only apply to offences against the Opium Act. 252 In 2006 slightly fewer hard drug cases were registered than in 2005. These cases have been on the decline since 2004. This drop concerns the preparation, production and smuggling/trafficking of hard drugs and not possession. There are still more hard drug cases than other types.

Figure 8.2

Number of Opium Act cases registered with the Public Prosecutor, by hard and soft drugsII, 2000-2006 Number 25000

20000

15000

10000

5000

0

2000

2001

2002

2003

2004

2005

2006

11677

13945

16619

18232

21940

20159

20193

Hard drugs

6676

7894

9504

10305

11967

9910

9870

Soft drugs

4560

5522

6613

7283

9246

9475

9461

Both

402

459

455

613

695

714

804

Opium Act total

I. More than one case may be registered per accused. II. A small number of Opium Act cases cannot be allocated to any of the categories. These cases have not been included in the figures. Source: OMDATA, WODC.

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Table 8.5

Drug law cases (in %) registered with the Public Prosecution Department, by hard and soft drugs, 2000-2006I 2000

2001

2002

2003

2004

2005

2006

Total criminal offences (against all laws)

238 832

238 092

254 300

273 642

275 367

268 513

269 015

Percentage Opium Act offences

5%

6%

7%

7%

8%

8%

8%

- Hard drugs

57%

57%

57%

57%

55%

49%

49%

- Soft drugs

39%

40%

40%

40%

42%

47%

47%

Opium Act offences by drug type

- Hard and soft drugs

3%

3%

3%

3%

3%

4%

4%

100%

99%

100%

100%

100%

100%

100%

I. More than one case may be registered per accused. Source: OMDATA, WODC.

• There were some 9,400 soft drug cases, and these account for 47% of all Opium act

•

•

•

•

cases. The long-term trend is rising for both number and share of soft drug cases. This relates to the preparation, production and smuggling/trafficking of soft drugs, in contrast to the trend for hard drugs (mainly possession). This is probably a consequence of the stepping up of actions against cannabis cultivation. 3 Between 2004 and 2005 the picture changed: in 2004, cases involving the preparation, production, smuggling and trafficking of drugs still mainly concerned hard drugs; in 2005 (and 2006) the majority of this type of cases involved soft drugs (not in table). Where drug possession is concerned, most criminal cases relate to hard drugs. The share of hard drugs in total cases is increasing (from 62% in 2004 to 70% in 2006; not in table). Analyses of cases in 2004 shows that many hard drug cases involve cocaine (40%, mostly import), followed by ecstasy (11%, mainly possession), opiates (9%, mainly trade) and amphetamine (3%, mostly possession), and lastly, other hard drugs such as LSD and GHB, both 0.4%. 253 35% of drug cases involve Dutch-grown weed, especially in relation to production. Most cases involve cannabis farms with a fairly professional structure, including timed artificial lighting, centrally regulated watering systems and external ventilation; they are usually contained in separate, concealed and heated constructions. 253

Disposals of Opium Act cases by the Public Prosecutor. • The bulk (66%) of the ca. 21,000 cases disposed of are heard in court (following a • •

summons; figure 8.3). 20% of Opium Act cases culminate in a financial order. This rate has fluctuated in recent years between eighteen and twenty percent. The number of dismissals on policy grounds accounts for 6% of cases. In 2004 the number was relatively higher. This was due to the drug courier policy at Schiphol air-

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155

porta. Since 2005, the percentage of dismissals on policy grounds has been declining, but is still higher than prior to 2004. Figure 8.3

80

Opium Act cases disposed of by the Public Prosecutor (in %), 2000-2006

% 73

71

72

70

70

66

65

61

60 50 40 30 20 10

19

15 10 5

9

4

3

7

20

18

10 3

3 5 3

3 5 3

20

19 7

2

8 6

2

6 5

2

0 2000 Summons

2001 Fines

2002

Policy dismissals

2003 Technical dismissals

2004

2005

2006

Joinders

Source: OMDATA, WODC.

• Dismissals on technical grounds account for between five and six percent of cases •

•

• •

a

Joinders rarely occur. Opium Act offences constitute 8% of the total number of cases disposed of by the Public Prosecutor in 2006, which is the same as in 2004 and 2005. In previous years (2000-2003), the number rose from five to seven percent. 68% of hard drug cases are heard in court and 63% of soft drug cases. 83% of cases involving both soft and hard drugs are brought before the court (figure 8.4 a-c). The latter cases clearly less often result in a financial order or dismissal. Financial orders are most common in soft drug cases. However, since 2004 the trend has been downward. Dismissals are most common in cases involving only hard drugs (15%). Nine percent are dismissals on policy grounds. Fewer cases involving soft drugs are dismissed (8%); 3% are policy dismissals. The lowest number of dismissals occurs in cases involving both hard and soft drugs: five percent, of which two percent are on policy grounds.

Hard drug couriers without a criminal record and with only a small amount of drugs were not prosecuted, but were deported after seizure of the drugs; they were then blacklisted to prevent future travel to the Netherlands.

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Figure 8.4

Opium Act cases disposed of by the Public Prosecutor by type of decision, 2000-2006, (a) hard drugs, (b) soft drugs, (c) hard and soft drugs (a) Hard drugs

% 90 80

80

79

78

80

70

68

64

61

60 50 40 30 20 4 6

10

9 3

64 8 3

8

2001

2002

3

6

9 3

3 53

17 10 10

1313 7

3

9 9 3

6

2

0 2000 Summons

Fines

Policy dismissals

2004

Technical dismissals

2005

2006

Joinders

(b) Soft drugs

% 70

2003

64

64 58

60

59

55

63

58

50 40

35

30 20 10

34

31

30

27

26

18 5

8 3

45 3

3 52

34 2

2 42

34 2

3 5 2

0 2000 Summons

2001 Fines

2002 Policy dismissals

2003

2004

Technical dismissals

TRIMBOS-INSTITUUT

2005

2006

Joinders

157

100 90

%

(c) Hard and soft drugs

86

87

85

86

86

86

83

80 70 60 50 40 30 20 10

3 1

7

2 3

2

8

4

1

1

5

8

2

2 31

8 1

4

6

1

24 2

10 2 32

0 2000 Summons

2001 Fines

2002

2003

Policy dismissals

2004

Technical dismissals

2005

2006

Joinders

Source: OMDATA, WODC.

• Table 8.6 shows the number of cases relating to the Abuse of Chemical Substances Prevention Act (WVMC). In 2006 36 WVMC cases were disposed of by the Public Prosecutor. These cases relate to precursors for the manufacture of synthetic drugs. The number varies considerably from year to year: 2005 was low, whereas 2006 was higher. Most of these were WVMC cases in combination with Opium Act cases, and always involved hard drugs.

Table 8.6

Number of disposals of WVMC cases, 2000-2006 2000

2001

2002

2003

2004

2005

2006

7

16

6

7

2

5

7

WVMC and Opium Act

34

64

48

47

38

16

29

Total

41

80

54

54

40

21

36

Only WVMC

Source: OMDATA. Data processing: WODC.

Disposals by the courts (in the first instance) • In 2006, there was a rise in the number of Opium Act cases disposed of by the courts,

• • • •

compared to previous years. Compared to 2005, the number rose by 7% (figure 8.5; table 8.7). There was a slight rise in hard drug cases vis à vis 2005. The number of soft drug cases rose by a substantial twelve percent. The number of cases involving both hard and soft drugs has risen continuously between 2001 and 2006. In 2006, the number was over 60% higher than in 2001. Violations of the Opium Act accounted for nine percent of the total number of cases disposed of in court in 2006. There was a decline in the share of hard drug cases, accompanied by an increase in the percentage of soft drug cases.

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TRIMBOS-INSTITUUT

Figure 8.5

Number of cases disposed of by the courts by hard and soft drugs, 20002006I Number 14000 12000 10000 8000 6000 4000 2000 0

2000

2001

2002

2003

2004

2005

2006

Total Public Prosecutor

8054

8841

10708

12716

12157

12220

13076

Hard drugs

4895

5543

7061

8315

7016

6374

6538

Soft drugs

2857

2974

3288

3998

4665

5315

5942

Both

296

314

334

398

467

524

577

I. More than one case may be registered per accused. Source: OMDATA, WODC.

Table 8.7

Percentage of cases disposed of in court in the first instance, by hard and soft drugs, 2000-2006I 2000

2001

2002

2003

2004

2005

2006

122 733

121 924

128 777

148 189

145 928

145 261

146 860

8 054

8 841

10 708

12 716

12 157

12 220

13 076

7%

7%

8%

9%

8%

8%

9%

- Hard drugs

61%

63%

66%

65%

58%

52%

50%

- Soft drugs

35%

34%

31%

31%

38%

43%

45%

4%

4%

3%

3%

4%

4%

4%

Total cases (all laws) Opium Act cases % Opium Act of total Opium type

Act

by

drug

- Hard and soft drugs

I. More than one case may be registered per accused. Source: OMDATA, WODC.

Penalties imposed in drug law cases • Figure 8.6 shows the number of penalties imposed by the court in the first instance: community orders, (partial) unconditional custodial sentences and fines, and the

TRIMBOS-INSTITUUT

159

•

• •

•

•

number of cases disposed of by the Public Prosecutor with a financial ordera In 2006 over 4,900 community service orders were imposed. The number of community service orders increased steadily between 2000 and 2005. This rising trend came to an end in 2006. There has been some decline in the average number of community service days imposed since 2004 (table 8.8). Almost 4,400 (partially) unconditional prison sentences were handed down. This is a clear drop since 2003. There was a further drop in 2006. In this respect, sentences for drug offences are following a general pattern, viz. a decline in the overall number of prison sentences for all crimes. In 2005 and 2006 more community service orders than prison sentences were imposed. This is a reversal of previous trends. For a drug offence, the average duration of a prison sentence is over nine months. There has been a decline in this respect since 2002, when the average was about 14 months (table 8.8) The percentage of drug crimes within all prison sentences is increasing. This means that by comparison with other offences, drug crimes are increasingly more likely to be punished with a prison sentence. In 2006, over 1,600 fines were imposed. This number has been declining since 2004. The median amount of a fine fluctuates between €470 and €500 (see table 8.9). Financial orders (Public Prosecutor) are least common for Opium Act offences. The median amount has fluctuated since 2003 between €250 and €270 (table 8.9).

Figure 8.6

Sanctions in Opium Act cases, 2000-2006 Number 7000 6000 5000 4000 3000 2000 1000 0

2000

2001

2002

2003

2004

2005

2006

Community service orders

2521

2701

3053

3868

4390

5096

4919

Detention

3478

4414

5767

6413

5399

4811

4392

Fines

1518

1645

1813

1864

2110

1815

1620

Financial orders

202

699

993

1117

1316

1171

994

Source: OMDATA. Data processing: WODC.

a

The number of dispossessions cannot be retrieved in a reliable way from OMDATA and is therefore not listed.

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TRIMBOS-INSTITUUT

Table 8.8

Average duration (days) of community service orders and unconditional custodial sentences imposed for Opium Act violations, 2000-2005 2000

2001

2002

2003

2004

2005

2006

Community service order

118

124

120

128

117

112

114

Unconditional custodial sentence

400

408

431

390

378

331

296

Source: OMDATA, data processing, WODC.

Table 8.9

Amount (median, in euros) of fines and financial penalties in Opium Act cases, 2000-2006 2000

2001

2002

2003

2004

2005

2006

Find

454

500

500

500

480

500

470

Financial penalty

113

182

220

250

250

270

250

Source: OMDATA, Data processing: WODC.

Custodial sentences under the Opium Act • In 2006, over 4,000 drug offenders ended up in prison (Table 8.10). • The percentage of Opium Act cases in all custodial sentences has been fairly stable • •

since 2002 (16-17%). Perpetrators of hard drug offences are much more likely to receive an unconditional custodial sentence than soft drug offenders. The ratio of detention years for drug crimes is around 30%. By far the most detention years are for hard drug crimes, although the share for soft drug offences has increased.

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161

Table 8.10

Unsuspended custodial sentences and detention years in Opium Act cases, by hard and soft drugs, 2000-2006I 2000

2001

2002

2003

2004

2005

2006

Total custodial sentences (all laws)

26 152

27 770

31 774

35 757

32 443

28 713

23 658

Total Opium Act

3 114

3 786

5 070

5 862

5 130

4 508

4 133

Percentage Opium Act

12%

14%

16%

16%

16%

16%

17%

- hard drugs

10%

12%

14%

14%

13%

13%

14%

- soft drugs

1%

1%

1%

1%

2%

2%

2%

- hard and soft drugs

1%

1%

1%

1%

1%

1%

1%

Total detention years

8 873

9 904

11 993

13 070

12 766

10 799

7 842

Total Opium Act

2 294

2 880

3 987

4 252

3 774

2 972

2 243

Percentage Opium Act

26%

29%

33%

33%

30%

28%

29%

- hard drugs

22%

26%

30%

30%

26%

23%

24%

- soft drugs

2%

1%

1%

2%

2%

3%

3%

- hard and soft drugs

2%

2%

2%

1%

2%

2%

2%

I. Excluding juveniles. II A case involving a hard drugs offence as well as a soft drugs offence is classified under hard drugs. III. Detention years are calculated by adding up the unconditional part of the prison term, and subtracting first the part that is not completed on the basis of the regulation on parole release (v.i.). Source: OBJD, WODC

• Dutch citizens are also in custody abroad for drug-related crimes. In 2006, there were

•

over 2,000, which accounts for 83% of all Dutch nationals held in custody abroad. 254 This is a large number, by comparison with neighbouring countries such as Belgium, Germany, the U.K. or France. Half of these detainees are being held for smuggling or trafficking in cocaine.

Recidivism among drug offenders • Within one year, some 22% of drug offenders have been convicted of a new offence

• •

(general recidivism, defined as all new criminal cases, except those that end in an acquittal, dismissal on technical grounds or other technical judgement, table 8.11). 255 After eight to nine years, general recidivism rises to 52%. Within one year, some 18% of convicted felons have a new conviction for a serious offence. This is defined as a criminal case arising from an offence that carries a sentence of at least four years. After eight to nine years, this serious recidivism rises to 42% (not in table).

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TRIMBOS-INSTITUUT

Table 8.11 Observation riod

Prevalence of general recidivism for four successive cohortsI of drug offenders pe-

1 yr

2 yrs

3 yrs

4 yrs

5 yrs

6 yrs

7 yrs

8 yrs

9 yrs

Cohort 1997

23%

32%

37%

41%

44%

47%

49%

51%

52%

Cohort 1998

22%

31%

37%

42%

45%

48%

50%

52%

Cohort 1999

23%

33%

40%

44%

48%

51%

54%

Cohort 2000

23%

34%

41%

46%

49%

52%

I. Cohort: individuals who in a specific year have been convicted of at least one Opium Act offence. It was ascertained whether they faced new criminal proceedings within the period under review. The data have been corrected for factors including time spent in detention. Cohort 1997: n = 8 300, cohort 1998: n = 9 020, cohort 2000: n = 8 869, cohort 2001: n = 8 505.Source: WODC-Recidivemonitor, 2007

Within one year, eight percent are involved in new criminal proceedings on account of an Opium Act offence (table 8.12). After eight to nine years, this has risen to 25%. In later cohorts there is a greater degree of recidivism, for general, serious and specific Opium Act violations.

Table 8.12

Prevalence of new criminal proceedings for an Opium Act offence for four successive cohorts of drug offenders

Observation period

1 yr

2 yrs

3 yrs

4 yrs

5 yrs

6 yrs

7 yrs

8 yrs

9 yrs

Cohort 1997

8%

12%

15%

17%

19%

21%

22%

24%

25%

Cohort 1998

7%

11%

15%

17%

20%

22%

24%

25%

Cohort 1999

8%

13%

16%

19%

22%

24%

26%

Cohort 2000

8%

13%

16%

20%

22%

24%

Source: WODC-Recidivemonitor, 2007.

Drug crime in the law enforcement chain • The proportion of drug crimes increases as we look further along the chain (table

•

• •

8.13). Although the data have been derived from various sources and the association should be interpreted with caution, it may be asserted that drug offenders are brought before the court relatively often and receive relatively long prison sentences. This is true for the entire period of 2001 to 2006 (not in table). The percentage of drug cases with the police and the Public Prosecutor fluctuates between six and eight percent; before the courts the rate is between seven and nine percent; of (partially) unconditional custodial sentences drug cases account for between 12 and 13 percent, and finally of detention years, the rate is 27 to 33 percent. In the later phases of the chain, crimes involving hard drugs are predominant. The percentage of soft drug cases increased throughout the entire law enforcement chain during the period 2001 to 2006.

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Table 8.13

Opium Act offences in the law enforcement chain: suspects, convicted offenders, custodial sentences and detention years, by hard and soft drugs, 2006 Public Prosecutor

Court 1st instance

Custodial sentences

Detention years

22 145

20 193

13 076

4 133

2 243

11 090

9 870

6 538

3 317

1 884

Soft drugs

8 127

9 461

5 942

573

199

Both

2 928

862

596

243

160

7%

8%

9%

17%

29%

Hard drugs

50%

49%

50%

80%

84%

Soft drugs

37%

47%

45%

14%

9%

Both

13%

4%

5%

6%

7%

Phase in chain

Police

Total Opium Act offences Hard drugs

% Opium Act of totalII

I

% hard drugs-soft drugs

I. There are 502 police suspects (6%) for ‘other Opium Act violations’ included in ‘both’. II. Total = total number of cases III. A case involving both a hard drugs offence and a soft drugs offence is classified here under hard drugs. Sources: HKS, KLPD/DNRI; OMDATA, WODC; OBJD, WODC.

• Within the prison population, the number of drug offenders fluctuates at around one in five (figure 8.7). The majority of prisoners are serving sentences for violent crimes. Opium act offenders constitute the only category of offenders that increased in 2006 (not in figure).

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Figure 8.7

Percentage of Opium Act offenders in the prison systemI compared with five other offender groups, survey date 30 September 2006 Road traffic Vandalism offences /public order 1% 5% Other 27%

Property crimes 17%

Opium Act 20%

Violent crimes 30% I. Including convicted offenders placed extramurally. Extramural prisoners (subjected to electronic tagging and penitentiary programs) are included, as are places occupied under the Temporary Special Facilities Directorate (TDBV) by drug couriers and illegal immigrants. Source: Criminaliteit en Rechtshandhaving [Crime and law enforcement], WODC.

Driving under the influence (DUI) • Driving under the influence of both legal and illegal substances is a punishable offence

• •

under article 8, paragraph 1 of the 1994 Road Traffic Act, (art. 8, par. 1 and 3) The legal limit for alcohol is set a blood-alcohol level of 0.5‰ or a breath-alcohol level of 235 µg/l. Since January 2006, the legal limit for newly qualified drivers (holding a license for less than five years) is lower: 0.2‰, or 88 µg/l. There is no objective measure for psycho-active medicines or for (illegal) drugs. These come under a general ban contained in article 8 paragraph 1. Large-scale screening for drugs is currently not feasible, due to a lack of suitable instruments.256 Since October 2006, research has been conducted in this area within the European project “Driving under the Influence of Alcohol, Drugs and Medicines” (DRUID)257 This project will end in 2010. In practice, the police will only screen for medicines or drugs if a motorist is seen driving in an aberrant way, and/ or if a motorist involved in a traffic accident is suspected of driving under the influence of a substance, on the basis of physical symptoms. If alcohol is found to be present, then usually no further screening is conducted to detect other substances.

The advisory service of the Department of Public Works conducts research annually on driving under the influence of alcohol159 In collaboration with the police, breath tests are conducted among a random sample of motorists (n=27,000-30,000) on Friday and Sat-

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urday nights in 73 areas within the 25 police regions. In 2006 a total of 29,355 drivers were tested. • Three percent of the motorists were in breach of the drink-driving limit. This is approximately the same rate as in 2005. Viewed over a longer period – 2001 through 2006 – a decline is perceptible. • The number of offenders with a blood-alcohol level of over 1.3‰ dropped from 0.6%in 2005 to 0.4% in 2006 (not significant). • The west of the Netherlands has the highest percentage of offenders (3.5%); the north of the country has the lowest, at 1.8%. Offenders were mainly detected in municipalities of over 100,000 inhabitants. • There are more male offenders than female : 3.5% compared to 1.8%. Male offenders are most frequently in the 24-35 age bracket, whereas females are mainly aged 35 to 49. This picture has not changed vis à vis 2005. • The percentage of offenders is highest between 02.00 and 04.00 in the night, as was the case in all previous years investigated. • According to data from Statistics Netherlands (CBS), in 2006, the police interviewed over 61 people suspected of drink-driving. Between 2000 and 2006 the number rose sharply. • The police are authorized on behalf of the Public Prosecutor to propose payment of a fine for first-time offenders whose blood-alcohol level is not above 1.3‰. Fines can range from €220 to €480. Since 2000, the Central Fine Collection Agency (CJIB) processes these transactions. If the offender pays the fine, the case is concluded without any intervention by the Public Prosecutor. If no payment is made, the case is then sent to the Office of the Public Prosecutor. Cases which are not eligible to be settled through the CJIB are sent on directly. Cases dealt with by the CJIB therefore overlap to a certain extent with the number processed by the Public Prosecutor’s office. • In 2006, the option of paying a standard fine was proposed in 28,000 cases (table 8.14). This is slightly fewer than in 2005, which is remarkable, since in 2006, police powers were expanded under the law. • 92% of the cases involve drivers of motorised vehicles.

Table 8.14

Number of standard transactions for drink-driving processed by the CJIB, by driver and blood alcohol content (BAC) 2002-2006I

Number

2002

2003

2004

2005

2006

Total

11 355

12 488

25 329

28 666

28 220

Drivers of motorised vehicles

10 355

11 374

23 478

26 262

25 837

Of which: - BAC 0.2‰ to 0.53‰ I

-

-

-

-

2 709

- BAC 0.54‰ to 0.80‰

7 859

8 680

11 692

12 418

11 669

- BAC 0.81‰ to 1.30‰

2 496

2 694

11 205

13 058

10.731

-

-

545

735

621

- BAC > 1.31‰ - BAC unknown

1

36

48

51

107

Drivers of moped/ motor scooter

851

969

1 622

2 105

2105

Cyclists

149

145

229

299

278

I. Only new licence-holders (since 1-1-2006) and drivers without a driving licence (since 1-10-2006). Source: CJIB. Data processing, WODC.

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• In over 15,000 cases, payment was received by the CJIB in 2006. Of the unpaid fines,

•

a large percentage – over 12,600 cases - were sent on to the office of the Public Prosecutor. In 2006, 37 796 DUI cases were registered with the Public Prosecutor. 83% of these involved the driver of a passenger car or motor cycle who was above the alcohol limit.

8.3 DRUG USERS IN THE CRIMINAL JUSTICE SYSTEM There is only limited information available on drug users within the criminal justice system. This is because data on drug or alcohol use is not registered in a systematic way by the police Public Prosecutor, the courts or the prisons. The data in this report are derived from police registration systems and from recently completed research.

Drug-users in police files In the police records system (HKS), suspects may be registered as ‘drug users’. This is a so-called a danger classification. A suspect is registered as a ‘drug user’ if there are reasons to believe that he or she poses a threat to the law enforcement officer on account of the drug use. Suspects may also be registered as ‘drug users’ on the basis of information they have supplied themselves, e.g. to the effect that they have a drug problem or because they have requested methadone. There is always a possibility that a suspect may be drug user, but is not registered as such in the HKS, because the police are not aware of this or do not recognise the fact. It is likely that the figures are a considerable underestimate. In addition, there are regional differences in the registration practice with regard to this category. • Up to 2004, between 9,000 and 10,000 suspects were categorised annually as ‘drug users’. In 2005 the number was 9,700 and in 2006 it was 8,600. • Over 90% of suspects categorised as drug users are male. This has been the case for years. • The average age is rising, and in 2006 it was 39. • Between 2000 and 2006 the percentage of individuals in this category living in large cities (250,000 or more inhabitants) declined from 45% to 40%. • Over 70 percent had come into contact with the police for an offence on more than 10 previous occasions; one in five even had over 50 previous encounters • Non-violent property crimes are the most common offences. These are followed by violent crimes (not involving property) and Opium Act violations (table 8.15). • There is a decline in the number of drug users that are accused of having committed property crimes. • The percentage accused of other violent acts and of Opium Act offences is increasing.

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Table 8.15:

Type of offence by suspects classified by police as drug users, 2000-2006 2000

2001

2002

2003

2004

2005

2006

Property crimes without violence

63%

63%

63%

58%

56%

53%

50%

Property crime with violence/extortion

11%

11%

12%

11%

10%

8%

8%

Other violent crime

19%

20%

22%

23%

24%

25%

25%

Opium Act offence

18%

18%

19%

22%

22%

24%

25%

Vandalism/ public order offence

20%

21%

23%

23%

23%

22%

22%

Road Traffic Offences

10%

10%

10%

10%

11%

11%

11%

1%

1%

1%

1%

1%

1%

1%

10%

10%

10%

11%

11%

11%

10%

Sex crimes Other crimes

I. Suspects may be accused of more than one type of crime. Source: HKS, KLPD/DNRI.

Drug and alcohol use among detainees In 2006/2007, research was conducted among 637 detainees who were screened for problem alcohol and drug use and problem gambling in the year prior to detention. 4 Screening took place in the first weeks after arrival in a remand centre. This may have affected the ascertainment of psychiatric symptoms, in view of the fairly sudden abstinence situation. More in-depth interviews were conducted with a number (n=161) of the group with problems (n=383). During these interviews, the extent of the problems was recorded. Use was also made of data from police and prison records. Groups that are somewhat overrepresented in the sample include females, minors, people of Dutch origin and detainees with a legal status.

Table 8.16 Prevalence of problem substance use and gamblingI (%) among detainees in the past year (n=637) Percentage Alcohol

30.0%

Cannabis

33.2%

Opiates

11.9%

Cocaine

18.7%

Stimulants

4.3%

Ecstasy

1.9% II

Sedatives

15.1%

Gambling

6.0%

I. More than one answer possible. II. Not prescribed by a doctor. Source: Oliemeulen et al. (2007) 4

• 60% of the detainees report problem use of alcohol or drugs and/or a gambling problem. Problem alcohol and cannabis use are the most common (table 8.16).

• Problem alcohol users are found mainly in the 25 to 44 age bracket. The have an av-

•

erage of twenty previous offences each. The (relatively) most common offences are drug offences and property crimes (including violent ones), followed by murder/manslaughter. Problem cannabis users tend to be mainly young males. They have a relatively high rate of Opium Act offences, property offences (some violent), violence to persons and murder/manslaughter. In police records, this group was found to have an average of 28 previous offences on file.

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• Problem opiate users have a high rate of non-violent property crimes as well as drug • •

• •

•

•

law offences. On average they have a criminal record of 58 previous offences. Problem cocaine users have a high percentage of property crimes and drug law offences. On average they have 47 previous offences, according to police files. Problem use of (non-prescribed) sedatives mainly occurs in combination with problem use of other drugs. These problem users are mainly found in the age group of 25 to 44 years. They have a high rate of Opium Act offences, and an average of 44 previous offences according to police registration. Offenders with a gambling problem commit a relatively large share of property crimes. 47% of problem users or gamblers have problems with a single substance; 27% have problems with two substances (including gambling) and 26% have problems with three or more substances. The group with two or more substance problems report more symptoms of dependency, misuse and craving. There is a high instance of psychological and psychiatric problems. More than half report personality problems; anxiety disorders and psychotic symptoms are also common. Physical health is generally poor, particularly among users of opiates and sedatives. Drug use does occur during detention, but the availability of drugs is said to vary from one institution to another. 258 Injecting opiates and stimulants occurs rarely within penitentiary establishments.

Interventions for drug users in the criminal justice system In this paragraph the following are discussed: • The clients and activities within probationary aftercare • Behavioural interventions during detention • Treatment as an alternative to prosecution and sanctions • SOV and ISD The data were derived from the following sources: • Patient Monitoring System (CVS) of (Addict) Probation and Aftercare. This was integrated in the National Alcohol and Drugs Information System (LADIS). • The Custodial Institutions Service (DJI) (of the Justice Ministry) has provided information on Drug Counselling Units (VBAs) in penitentiary institutions, cf. article 43, par. 3, SOV and ISD. • Reports of research findings. Probation and Aftercare of addicts Probationary aftercare is offered to addict offenders in some 50 locations by 15 organisations for addiction care. that are certified for probationary rehabilitation. Probation and aftercare of addicts consists of 12 core activities conducted on behalf of law enforcement agencies.259 In 2006, probation and aftercare of addicts had 16,385 clients – which was more than in previous years (table 8.17). The picture is more or less the same as in 2005: • The average age is 36.5. The biggest group (26%) are aged 40 to 49. • 91 percent are male • 72 percent are of Dutch origin. 28% are employed; 48% have completed primary school at most; 53% live alone (not in table). • For 74% of the group, the addiction problems are long-term i.e., longer than five years.

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• The primary substance problem in most cases is alcohol use. This percentage is rising. • Of the drug using group, most have problems with cocaine/crack. Opiates and cannabis are less often the primary problem. The percentages of opiate users is declining.

Table 8.17:

Clients of probation and aftercare for addicts 2002-2006I

Clients: Total number Average age

2002

2003

2004

2005

2006

12 399

14 579

14 875

15 574

16 385

35

35.3

35.6

36.1

36.5

Number of males

92%

92%

92%

92%

91%

Primary problem alcohol

38%

40%

43%

46%

47%

Primary problem opiate use

25%

21%

18%

16%

24%

Primary problem crack/cocaine

26%

27%

25%

24%

15%

Primary problem cannabis Addicts with alternating treatment and probationary aftercare

6%

6%

7%

8%

8%

7 794 (63%)

8 501 (58%)

8 489 (57%)

8 734 (56%)

9 457 (58%)

I. Data from a large organisation for addiction care are missing; dummy figures have been imputed. Source: LADIS, SIVZ, 2007.

• Most of the activities pertaining to probationary aftercare of addicts show a rising • •

trend (table 8.18). Only the activities ‘diagnoses’ and ‘behavioural interventions’ showed a drop in 2006. Diagnostic activities are the most frequently conducted. This involves conducting a probationary rehabilitation test, using both earlier procedures and the new standard instruments Quick Scan and RISC (risk evaluation scales), in order to select clients more stringently for participation in programs.260;261

Table 8.18

Number of times that Probation and Aftercare conducted core activities, 2002-2006I, II

ActivitiesIII

2002

2003

2004

2005

2006

Early intervention visits

3 629

4 305

4 110

3 962

4 400

995

922

889

1 152

1 494

Early intervention report IV

Project Supervision

10 048

9 156

1 028

-

-

Referral to treatment

1 568

2 115

2 254

2 081

3 226

Monitoring

2 407

3 726

4 919

5 454

7 880

Behavioural interventions

1 696

2 566

2 929

2 806

2 624

Work orders

3 382

4 098

4 650

4 904

5 293

Education orders ReportsV

139

217

241

286

360

7 587

8 746

8 369

8 454

8 931

10 615

10 605

11 504

9 935

43 900

39 994

40 603

44 143

DiagnosesVI Total

31 451

No data available at client level or specified by type of substance. II. Data from 2001 not included as figures deviate because patient monitoring system (CVS) was implemented in that year. III. Figures show number of activities after auditing. IV. Discontinued since 2004. V. Information reports, advisory reports and evaluative reports. VI Including RISc (conducted 3,664 times in 2006). Source: SVG, 2007.

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Behavioural interventions during detention • While serving a custodial sentence, problem drug users may be placed voluntarily in special Drug Counselling Units (VBAs). Currently there are 15 VBAs in various prisons, with a formal capacity of 308 places. In late 2006, 280 VBA cells were occupied (not only by addicts); this accounts for some 90% of total VBA capacity, and is about the same as in 2005. • Detained addicts can participate in behavioural intervention programs if they are serving a long-term sentence and if improvement can be expected. The interventions are required to have (provisional) accreditation. Specifically available for convicted problem users are the lifestyle training program and the relapse prevention program. The community service order relating to alcohol delinquency is also available (see: www.justitie.nl/recidivie). • Methadone dispensing during detention varies in practice. New guidelines are in the process of being drawn up. 262 Treatment as an alternative to prosecution and sanctions

• Since the 1990s the policy of the criminal justice system has been to (“coercively”) direct criminal drug users to treatment programs as an alternative to prosecution and sanctions, when the nature of the crime permits this. Most cases involve participation in a treatment program as a specific condition for the suspension of temporary custody (art. 80 Sv) or a conditional sanction (art. 14a and 14c Sr). Treatment in specially designated institutions is also offered as a substitute to detention (art. 43 of the Prisons Act (Pbw)). Table 8.19

Referrals to care by addiction and probation services, by type of treatment program, 2002-2006I

Type of care program

2002

2003

2004

2005

2006

Non-clinical treatment for addicts (outpatient and part-time)

474

725

796

765

1 194

Clinical treatment for addicts

650

863

926

732

934

Social inclusion care

126

170

196

174

345

Non-clinical psychiatric treatment

44

83

113

153

284

Psychiatric outpatient clinic

20

35

32

53

105

Part-time psychiatric treatment

28

50

48

42

100

123

75

52

54

79

RIBW [Regional Institute for Protective Housing] care

5

11

9

18

44

RIAGG [Regional Outpatient Mental Health] treatment

8

18

12

12

30

22

24

22

22

29

Psychiatric treatment in a general psychiatric hospital

Hostels for the homeless Psychotherapy

8

18

23

22

28

Social bed and breakfast accommodation

24

23

18

16

26

24 hour crisis help

19

19

19

10

21

Other facilities

17

10

5

8

15

1 568

2 124

2 267

2 081

3 234

Total

1. No figures available at client level, not specified by type of substance. II. Including 24 activities which have not shown evidence of output. Source: SVG (www.svg.nl).

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• In 2006, problem users were directed to treatment over 3,000 times; this mainly in• •

volved outpatient or semi-residential addiction care (table 8.19). There has been a distinct increase in referrals to social work care and psychiatric treatment In 2006, 137 clients were placed in detention-substitute treatment (art. 43, par 3 Pb). The remained in a clinic for an average of 74 days.

The Judicial Placement of Addicts and the Institutions for Prolific Offenders • The Judicial Placement of Addicts (SOV) was launched in 2001 and discontinued as an autonomous measure in 2004. It has since been incorporated as a module in the measure ‘Placement in an Institution for Prolific Offenders Act’ (ISD). • The ISD took effect on October 2004.263;264 • Both SOV and ISD orders are made by the courts. Offenders who receive these orders are placed in a penitentiary institution. Behavioural interventions take place both inside and outside the institution. • Differences between SOV and ISD are as follows: 265;266 - The ISD reaches a wider target group, including women, non-drug addicts and offenders with serious psychiatric problems. - The ISD has greater capacity: 1,000 places in 2007, of which 874 in penitentiary institutions and 126 in external treatment centres - The ISD does not consist of a set program. - There is more stringent screening and selection for behavioural interventions. - Case discussions aimed at intervention planning take place prior to ISD placement, when a potential participant enters the criminal justice system. • The number of SOV participants is being phased out, whereas the number of ISD participants is increasing (figure 8.8). The average monthly number of ISD participants in 2006 was 448 – more than in 2005. Of these, an average of 140 underwent the basic regime monthly, 264 participated in a behavioural intervention within the penitentiary institution, and 44 participated in a treatment programme outside the institution. • An estimated 95% of ISD participants are problem hard drug users/addicts.

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Figure 8.8

700

Number of SOV and ISD participants monthly, 2006 Number

600 500 400 300 200 100 0

Jan

Feb

Mar Apr

May June July Aug Sep Oct

Nov Dec

ISD

307

344

381

392

408

438

438

476

499

535

572

574

SOV

87

87

86

87

80

71

72

54

47

38

22

18

Source: Custodial Institutions Service (DJI), 2006.

The following facts are known about the effectiveness of the SOV: 267 • SOV participants are chiefly chronic opiate addicts. They have a history of repeat treatment and have a long criminal history, mainly involving property offences. • Soon after placement in the SOV, they experience an improvement in their physical and mental health. • A large percentage of them does not complete all phases of the SOV. Half do not progress beyond phase one, 21% stop at phase 2 and 32% proceed to phase 3. • After completing the programme, more than 40% of the participants can be broadly regarded as a success. They may still commit crimes, but to a lesser extent or they use less drugs (but still methadone) or they function better socially (are employed or occupied, don’t run up new debts and have a stable living situation). • If a stricter definition of success is used, such as ‘improvements in criminal recidivism and addiction’, then the success rate is lower: between 12 and 28 percent (depending on the exact definition). • If an even stricter definition of success is used, to include the above plus social functioning, then the success rate is between 12 and 21 percent. • The success rate declines over time: one year after completing the SOV, between seven and 22 percent can still be considered a success (according to the broad definition). • SOV is more effective than regular detention. • SOV is equally as effective as regular quasi-compulsory behavioural interventions. • If we take account of the fact that SOV participants have a longer history of treatment and crimes than problem users who are participating in a quasi-compulsory treatment programme, then this means that the SOV has reached a more problematic group. Seen in this light, outcomes for the SOV are more positive.

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The following facts are known about the implementation of the ISD. 265;268;269 • A greater number of offenders receive an ISD order than was formerly the case with the SOV (on account of the greater capacity). However, the ISD capacity is not fully used. • Screening is conducted systematically with the RISc risk assessment instrument. • ISD participants have far more serious mental health problems, sometimes in combination with limited intellectual capabilities. • The introduction of the ISD was rushed and poorly prepared. • The rate of progression to treatment is lower than envisaged; the transition from detention to care is far from smooth. • Collaboration between law enforcers, health care bodies and local actors has improved. Case discussions are progressing well, according to those involved; however problems still need to be ironed out with regard to the distribution of responsibilities and tasks and also in relation to finances and capacity.

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Appendix A Glossary of Terms

This appendix consists of two parts. In the first part terms are explained that relate to substance use and addiction. The second part explains the terminology used in connection with drug-related crime.

I. SUBSTANCE USE AND ADDICTION Addiction Problem use of a substance, involving dependence. As a rule, this Annual Report means the clinical diagnosis of dependence. Hover, it is not possible for judicial monitoring organisations to establish clinical diagnoses. Judicial monitors register for example addition danger from drug use or ‘clear indications of addiction’ (see §8.3.2., SRM). The clinical diagnosis of dependence is established via classification systems as the DSM and the ICD. Characteristics of dependence are: frequent use of large amounts or prolonged periods of use, needing increasing quantities of the substance to induce the desired effect (habituation), withdrawal symptoms, using the substance to counteract withdrawal symptoms, wanting to quit without success, devoting considerable time to acquire the substance or to recover from use, neglecting important activities at home, at school at work or in leisure time and continuing with use despite the realization that it causes many problems. Age of onset The age at which an individual first used a substance, depending on the group to which it is applied. Age of onset may apply to ever users (ever lifetime use), recent users (in the past year) and current users (past month). The age of onset may also be determined for different age groups. For example, in 2005, the average age of onset for cannabis users in the 15 to 24 age group was 16.4 years. In the population aged 15 to 64 it was 19.6 years. In a younger age group, the average age of onset may be lower than in a broader population, because some ‘late’ substance users may not be included in the calculations. However, at a later age there may be distorted recall about the age at which a substance was first used. Data on age of onset should therefore be interpreted with caution. Chasing (the dragon) Smoking heroin from tinfoil. Buprenorphine Like methadone, buprenorphine is a substitute for heroin and is used as medication for treating heroin addiction. Advantages of buprenorphine over methadone are that overdose has fewer side effects, the withdrawal effects after stopping use are less severe, and the risk of misuse and addiction is lower. Clinical admission Admission to a hospital during which the patient stays for one or more nights in the hospital. Convenience stores See: Tobacconist and convenience store.

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Current Use The use of a substance in the past month, irrespective of frequency (from once to daily). Current users are automatically counted with recent users (past year), who in turn are automatically counted with ever users (lifetime use). Day care Admission to a hospital for a maximum of one day, without an overnight stay. Dependence See: Addiction. DSM DSM stands for Diagnostic and Statistical Manual of Mental Disorders. DSM forms a guide for determining which mental disorder a person has. According to the DSM, addiction is one of the mental disorders. DSM-III-r is the third (revised) version, and DSM-IV is the fourth version. Dutch-grown weed Weed (a cannabis product) which is produced in the Netherlands. Ever use The use of a substance ever in one’s lifetime, irrespective of frequency (from once to daily). Ever use does not say anything about recent or current use. If someone once tried a substance a long time ago that was popular in those days, this counts as ever use for life. Hallucination Sensory experience (seeing, hearing or feeling) that someone has, but is not shared by others. Hallucinations may be a symptom of a mental disorder, but are induced deliberately by some through drugs. Hallucinogens Substances that induce hallucinations, such as magic mushrooms and LSD. These are also known as psychodysleptic drugs. Cannabis can sometimes cause hallucinations. Hardcore Heavy form of music at raves. Hard drugs Drugs on list I of the Opium Act. These drugs constitute an unacceptable public health risk. Hard drugs include, for instance, heroin, cocaine, crack, ecstasy and amphetamine. Hepatitis A highly contagious disease in which the liver is damaged by the hepatitis virus. The hepatitis virus occurs in various forms: hepatitis A, hepatitis B and hepatitis C. HBV is the hepatitis B virus, and HCV is the hepatitis C virus.

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ICD International Classification of Diseases. The ICD is the diagnostic classification system of the World Health Organisation (WHO) for somatic illnesses, accidents and mental disorders. Causes of death are also registered in ICD codes. The ICD-9 is the ninth and the ICD-10 is the tenth version. See also appendix C. Immigrant, foreign, ethnic Owing to differences in definitions, figures on non-nationals are not always comparable. Some definitions are: According to the Ministry of the Interior, the Association of Municipalities of the Netherlands (VNG), the Dutch National School Survey, the Antenna-monitor and the most common definition in this Annual Report (unless otherwise indicated), “immigrant” means an inhabitant of the Netherlands who was born abroad, or at least one of whose parents was born abroad. According to Statistics Netherlands (CBS): "immigrant" is an inhabitant of the Netherlands, at least one of whose parents was born abroad, despite the country of birth of the person himself or herself. According to GGD Amsterdam: "immigrants" are inhabitants who were themselves born abroad. According to LADIS: "immigrants" are clients who in their own experience have a cultural origin that is outside the Netherlands. Inpatient addiction care Addiction care for which the client is admitted to an institution. LADIS Client Client of (outpatient) addiction care some of whose data about background, treatment demand and treatment received are registered anonymously with LADIS, the National Alcohol and Drugs Information System. Clients are registered with addiction care for many kinds of help varying from therapeutic treatment to support in the form of debt restructuring, obtaining methadone, probation and aftercare or monitored access to a users’ area. Clients who no longer avail of the treatment after some time are automatically deleted and are no longer included in the list of clients. The Ladis system corrects for duplication. Each person is included only once in the list of clients. Mellow Type of music at raves that is more melodious and less heavy than hardcore music. Misuse Problematic use of a substance that does not (yet) constitute addiction. Misuse is established by diagnostic classification systems such as the DSM and the ICD. Characteristics of misuse are: neglect of duties at home, at school or at work, use in dangerous situations (such as driving under the influence), coming into contact with the law and continuing with use despite the problems that it induces. Narcotics General, collective term for drugs.

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Native Dutch According to the Ministry of the Interior, the Association of Municipalities of the Netherlands (VNG), the Dutch National School Survey, the Antenna-monitor and the most common definition in this Annual Report (unless otherwise indicated), “native Dutch” means someone who was born in the Netherlands and both of whose parents were born in the Netherlands. Outpatient addiction care Addiction care for which the client is not admitted to an institution. For inpatient addiction care, the client is admitted to an institution. Parkstad Limburg The conglomeration of South Limburg municipalities of Brunssum, Heerlen, Kerkrade, Landgraaf, Nuth, Onderbanken, Simpelveld and Voerendaal. (The municipality of Nuth has since withdrawn from the collaboration). Party drugs Drugs used by some revellers at parties and raves, such as ecstasy, amphetamines, cannabis, GHB and LSD. Polydrug use Use of several drugs by a drug user, such as heroin and cocaine. Primary diagnosis The main illness for which a patient is admitted to hospital. Primary problem If someone has problems with two (or more) substances, then the primary problem is the substance that causes the most problems. The other substance is the secondary problem. Primary cause of death The direct cause of someone’s death. If someone dies directly from an overdose of drugs, then this is the primary cause of death. If someone dies from an accident that occurred under the influence of a drug, the accident is the primary cause of death. The drug is a secondary cause. Problem use The use of a substance in such a way that physical, mental or social problems arise, or that a nuisance to a society arises. Problem use is not always addiction. “Misuse” is a form of problem use that does not mean addiction. Psychodysleptic drugs See: Hallucinogens Psychonauts A psychonaut is literally someone who goes on a journey within the mind. Psychonauts use drugs to stimulate their mental journey of discovery. Some use only natural drugs such as magic mushrooms and cacti. Others also use synthetic drugs for their trip. Psychonauts can exchange their experiences on the website www.psychonaut.com

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Psychosis Mental disorder involving hallucinations, i.e. sensory experience (seeing, hearing or feeling) that someone has, but is not shared by others. If the disorder does not last longer than a month, then it is called a temporary psychotic disorder. Recent use The use of a substance in the past year, irrespective of the frequency (from once to daily). Recent users are automatically included with ever users (use ever in one’s life). Recreational use Use of a substance (generally in the user’s leisure time), without problem use (misuse or addiction). Schizophrenia Mental disorder involving hallucinations, i.e. sensory experience (seeing, hearing or feeling) that someone has, but is not shared by others People suffering from this disorder function poorly at school at work and in the family. The disorder is only known as schizophrenia if the disorder has lasted for at least six months. Secondary cause of death A cause that has contributed indirectly to death. If someone died from an accident that took place while he or she was under the influence of a drug, the drug is a secondary cause of death. Secondary diagnosis A secondary or underlying illness, in addition to the main illness (primary diagnosis) for which a person has been admitted to hospital. Secondary problem If a user has a problem with two (or more) substances, the secondary problem is the substance that causes relatively the least problems. The other substance is the primary problem. Soft drugs Drugs on list II of the Opium Act, particularly cannabis. These are drugs that constitute a less great public health hazard than the hard drugs on list I of the Opium Act. Special secondary education Education for children with learning difficulties (MLK), education for children with learning and educational difficulties (LOM) and education for children with severe educational difficulties (ZMOK). THC Tetrahydrocannabinol, the main psycho-active ingredient of cannabis. Tobacconists and convenience stores Shops that generally sell products such as tobacco products, (cigarettes, cigars, rolling tobacco), smokers requisites (pipes, lighters) and magazines, newspapers, greeting cards, snacks, sweets and lottery tickets and scratch cards.

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Use / Usage The use of a substance ever in one’s life (ever use or lifetime use), in the past year (recent use) or in the past month (current use). Current users are automatically included with recent users (past year), who in turn are automatically included with ever users.

II.

DRUGS CRIME

a

Acquittal Verdict by the judge when it is deemed not proven that the charges laid against the accused have been committed by the accused. See also: case dismissal, verdict of guilt. Adult suspect / offender Suspects who are 18 or older at the time of committing a punishable offence. Appeal Legal instrument permissible to anyone against whom a judgment was pronounced. Case dismissal Decision by the public prosecutor not to prosecute an established punishable offence on policy or technical grounds; See also: Dismissal on policy grounds. Dismissal on technical grounds. Case inadmissible Final judgment in which the judge refuses the request or demand of a party or denies the Public Prosecutor permission to prosecute on grounds that lie outside the case itself (such as a procedural error). Charge Written record by an investigating officer about facts or circumstances observed by him or her. Compulsion Compulsion means the user is given no choice. He can be admitted without his consent. See also: Quasi-compulsion. Crime / felony More severe punishable act, defined as such in the law; the division of punishable acts into crimes and offences is of importance in procedural law (absolute competence and legal remedies) and penalization; trials in the first instance are mainly held before the court as opposed to an offence, which is less severe. Criminal Case Charges against a suspect registered with an office of the public prosecutor.

a

Source: Statistics Netherlands (CBS), Voorburg/Heerlen, 2003; edited by WODC.

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Criminal record/prior offence A criminal record / prior offence refers to a contact with the police in which charges were made relating to one or more offences. Custody Principal- : detention for a maximum of one year and four months; this is a lighter sentence than a prison sentence and is generally sat out in a remand centre. Subsidiary- : detention on the grounds of not or not fully paying a fine. Discharge from (further) prosecution Decision by the judge, despite evidence supporting the case of the Public Prosecutor, based on the opinion that the offence or the accused is not punishable. See also: Verdict of guilt, Acquittal. Dismissal on policy grounds Decision by the public prosecutor not to prosecute a suspect for an established offence on the grounds of public interest. See also: Dismissal. Dismissal on technical grounds Decision by the public prosecutor not to prosecute for a punishable act on the grounds that prosecution cannot lead to a conviction (for example because there is insufficient evidence or because the suspect cannot be sentenced. Disposal by the court Final judgment, whether conviction, acquittal, dismissal of charges or other verdicts. Disposal by the Public Prosecutor Final decision about a case registered with the office of public prosecutions, e.g. whether to drop charges, create a joinder, offer a transaction or submit to the courts for trial. Early release Statutory early release from penitentiary institutions of prisoners sentenced to long-term detention. Final judgment Verdict by a judge that concludes a civil case which started with a summons. Financial order / transaction Under certain circumstances, payment of one or more penalties (usually a fine) as decreed by the investigating officer or public prosecutor who then forfeits the right to prosecute. In the first instance Primary judicial body before which a case is heard. See also: appeal.

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Joinder ad informandum Presentation by the public prosecutor of a case not being prosecuted to another case being heard by the judge, with the intention that the judge will take account of the joinder case in determining the sentence. See also: Disposal by public prosecutor. Joinder of causes of action Joining together by the public prosecutor of a number of registered cases, with the intention that the judge will dispose of these cases together with a single sentence. See Disposal by public prosecutor. Joinder of session Joining together by the judge of a number of different cases registered with the office of the public prosecutor with the intention of dealing with these as a single case. See Disposal by the court Juvenile suspect / offender Suspects who are under 18 at the time of committing a punishable offence. More straightforward juvenile cases are usually dealt with by Halt agencies. NB. No-one can be prosecuted for an offence committed before the age of 12. Offence Punishable act of a less serious nature, defined as such in the law. the division of punishable acts into crimes and offences is of importance in procedural law (absolute competence and legal remedies) and penalization; disposal usually occurs with a settlement/financial order via the Public Prosecutor or are heard before a district court. See also: crime/felon Ordinary case before the courts Criminal case in the first instance that is heard before the courts, with the exception of tax fraud and economic offences. Percentage of solved crimes The total number of crimes solved during a specific period in relation to the total number of charges pressed by the police during the same period for similar crimes, expressed in percentages. Placed in remand / remanded in custody Detention in police custody for a maximum of four days on the order of the (assistant) public prosecutor, if the normal time permitted for questioning a suspect (six hours) is not enough. Pre-trial detention / temporary custody Detention in a Remand centre pending trial, generally when there is suspicion of a serious crime (crime carrying a prison sentence of at least four years) or of absconding and/or of a danger to society. Prison sentence Detention, for life or for a limited period, with a maximum of 20 years, generally sat out in a prison. See also: custody.

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Probation and aftercare service Organisation that aims by its efforts to make a demonstrable contribution towards the reintegration and rehabilitation of offenders into society. Accordingly, an important aim is to prevent the repetition of punishable offences. To this end, the organisation conducts examinations and drafts reports with regard to the character and circumstances of the suspect or convicted offender; it devises plans of action to achieve its goals, conducts supervision and monitoring of the accused and of task orders. Only in cases that promise distinct possibilities of changed behaviour and the likelihood of success is deemed considerable, are intensive programs undertaken with these goals in mind. Public Prosecutor Government agency charged with the following tasks: enforcing laws, detecting and prosecuting punishable offences, issuing sentences and informing the judge insofar as prescribed by law. Quasi-compulsion Using quasi-compulsion, the authorities try to steer a user who is also a repeat offender in the direction of a care program. The user has the choice between a care program and a judicial punishment. The choice is influenced as follows: if the user opts for a care program, not only can he or she improve their situation, but any further prosecution and sanction will be dismissed or adjourned. If not, or if he does not comply with the conditions put forward, then the judicial sanction will be imposed. Sentence / Verdict Binding decision explained by the judge in a case submitted to the court for judgment. Solved crimes Crimes for which at least one suspect /offender is known to the police, even if he or she is at large or denies having committed the act. Summons Official document (writ) that requires a person to appear in court at a certain time in connection with a punishable offence. Suspect The person against whom, prior to the start of prosecution, there is a reasonable assumption of guilt of committing a punishable offence on the grounds of facts or circumstances; then known as ‘the accused’ once prosecution commences. Unconditional judgment Decision by the judge without leave to appeal (by a regular legal instrument). Verdict of guilt Judgment by the judge, after the charges put forward by the public prosecutor have been deemed proven and punishable and the suspect is deemed to be punishable.

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Appendix B Sources

This appendix contains a schematic overview of the main sources used by the National Drug Monitor (NDM) for (I) use and problem use and (II) treatment demand and treatment, (III) illness and death, (IV) market information and (V) crime and law enforcement. For a more detailed description of the sources used see: www.trimbos.nl/monitors, or www.ivo.nl, or www.zonmw.nl.

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I. USE AND PROBLEM USE

Source

Dutch National School Survey

Target group

Substances

School-goers aged 10-18 in the last two years in primary schools and in mainstream secondary schools: VMBO, HAVO and VWO; sometimes programs at special schools

Alcohol, drugs, tobacco

1984, 1988, 1992, 1996, 1999, 2003 Special schools, projects: 1990, 1997

Organisation responsible / Homepage

Trimbos Institute www.trimbos.nl

Annually since 1993, with varying target groups

Bonger Institute of Criminology, University of Amsterdam in collaboration with Jellinek Preventie www.jur.uva.nl www.jellinek.nl/

Alcohol, drugs, tobacco

1995, 1999, 2003, 2007

CAN, Pompidou Group, For the Netherlands, Trimbos Institute www.can.se/

Alcohol, drugs

2002, 2003, 2007

MORE www.denhaag.nl/

School-goers and socialising young people in Amsterdam

Alcohol, drugs, tobacco

ESPAD

School-goers aged 15 and 16 in 35 European countries

Market research on the social scene in The Hague

Participants in the social scene aged 16-35 in The Hague

Antenne

Measurements

HBSC

School-goers aged 11-17

Alcohol, cannabis, tobacco

2001, 2005

WHO, for the Netherlands: Trimbos Institute, Radboud University Nijmegen and Utrecht University www.hbsc.org www.trimbos.nl

Local and regional monitoring organisations

General population and/or juveniles depending on location and region;

Alcohol, drugs, tobacco, depending on location and region.

Generally annually, varies per location and region.

Local GGDs in liaison with GGD Nederland, municipal and private research agencies www.ggd.nl

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Source National Institute for public opinion and market research (TNS NIPO) National Prevalence Survey (NPO)

NEMESIS (Netherlands Mental Health Survey and Incidence Study Permanent research on home life situation (POLS)

186

Target group

Substances

Measurements

Organisation responsible / Homepage

National population aged 15 and older

Tobacco

Annual

STIVORO www.stivoro.nl

Alcohol, drugs, tobacco

1997, 2001, 2005

CEDRO, University of Amsterdam (1997, 2001) www.cedro-uva.org IVO (2005) www.ivo.nl

Alcohol, drugs

NEMESIS I; 1996 and follow-up in 1997 and 1999; NEMESIS II: 2007 to 2015

Trimbos Institute www.trimbos.nl

Alcohol, tobacco, for the youth module, also drugs

Annual (alcohol, tobacco); 2001 (drugs)

Statistics Netherlands (CBS) www.Statistics Netherlands (CBS).nl

National population aged 12 and older (1997, 2001) or 15-64 years (2005)

National population aged 16 to 64

National population aged 12 and older, Juveniles and young adults aged 12-29 years.

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II. TREATMENT DEMAND AND TREATMENT Measurements

Organisation responsible / Homepage

Methadone

Annual

GGD(Community Health Service) Amsterdam www.ggd.amsterdam.nl

Clients of (outpatient) addiction care

Alcohol, drugs

Annual

IVZ, Houten www.sivz.nl

National Medical Registration (LMR)

Hospital patients

Alcohol, drugs

Annual

Prismant www.prismant.nl

Injury Information System (LIS)

Patients who receive emergency treatment following an accident (data are extrapolated).

Alcohol, drugs

Annual

The Consumer Safety Institute www.veiligheid.nl

Source

Target group

Central Methadone Registration (CMR)

Methadone clients in the Amsterdam region

National Alcohol and Drugs Information System (LADIS)

Substances

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III.

Illness and Deaths

Source

Target group/subject

Substances

Measurements

Organization responsible / Homepage

Amsterdam cohort study and monitor of drugs-related deaths

Causes of death among methadone clients and recreational drug users in Amsterdam

Hard drugs, recreational drugs

Annually from 1976

GGD (Municipal Health Service) Amsterdam www.ggd.amsterdam.nl

Central Post for Ambulance Transports (CPA)

Ambulance journeys for the population of Amsterdam and surrounding area

Alcohol, drugs

Annual

GGD Amsterdam www.ggd.amsterdam.nl

Cause of death statistics

Causes of death for inhabitants of the Netherlands registered in the population register, and law court records

Alcohol, drugs, tobacco

Annual

Statistics Netherlands (CBS) www.Statistics Netherlands (CBS).nl

HIV/AIDSregistration

HIV-infected and AIDS patients among intravenous drug users

Hard drugs

Half yearly

IGZ, SHM, RIVM www.hiv-monitoring.nl

HIV-monitoring among risk groups including drug users

Intravenous drug users in various cities

Hard drugs

From 1991 various measurements in various cities

RIVM and GGDs www.rivm.nl/

Alcohol

Annually, from 1970

AVV, Ministry of Road Traffic and Public Works www.rws-avv.nl

DUI (Driving under the influence) monitor

188

Motorists

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IV. MARKET INFORMATION

Source

Target group/subject

Substances

Measurements

Responsible organisation / Homepage

Drugs Information and Monitoring System (DIMS)

Social scene drugs by recreational users

Social scene drugs

Continuous; annual report

Trimbos Institute www.trimbos.nl

Monitor of official coffee shops

Number of officially sanctioned coffee shops; coffee shop policy of municipalities plus enforcement policy

Cannabis

1997, 1999, annually from 20002005, then every two years.

THC-monitor

THC concentrations and price of cannabis samples from coffee shops

Cannabis

Twice yearly; annual report

TRIMBOS-INSTITUUT

WODC www.wodc.nl/

Trimbos Institute www.trimbos.nl

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V. CRIME AND LAW ENFORCEMENT

Source

Patient monitoring system (CVS)

Measurements

Organisation responsible / Homepage

Daily files

Addiction and Probation department of the GGZ (SVG) in collaboration with Dutch Probation and the Youth Care, Probation and after care of the Salvation Army www.ggznederland.nl

Summonses arising from charges; Charges made against suspects; registered criminal record of suspects

Danger classification ‘drug users’ or ‘alcohol dependent’; drugs offences divided into hard and soft drugs

Updating at the end of the first quarter of the entire previous year; also extraction of definite figures for previous year (because of processing lag)

Research and Analysis Group of the National Criminal Intelligence Service of the National Police Agency (O&A/dNRI/KLPD), in collaboration with the police regions; The Scientific Research and Documentation Centre (WODC) of the Justice Ministry has a copy www.politie.nl/KLPD/ www.wodc.nl/

Drug seizures; number of criminal investigations; dismantled hemp farms; uncovered production locations of synthetic drugs

All substances, divided into type of drug

Continuous registration, annual report

Target group/subject

Sources

Output data of addiction rehabilitation and probation, clients of addiction rehabilitation and probation and aftercare

Police Records System (HKS)

Drug seizures

190

All substances, no breakdown into type

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K&O/O&A/dNRI/KLPD, in collaboration with police regions www.politie.nl/KLPD/

Source

Target group/Subject

Substances

Measurements

Organisation responsible / Homepage

Research and Policy database of Criminal Records (OBJD)

Policy information on criminal law enforcement; anonymous copy of the database of the Criminal Records (OBJD)

Drug offences, subdivided into hard and soft drugs

Updated four times yearly

WODC www.wodc.nl/

Public Prosecutor data (OMDATA)

National database of the national public prosecution department containing data about prosecutions and judgements in the first instance

Drug offences, subdivided into hard and soft drugs

Updated three times yearly

Public Prosecutor and Council for the Judiciary. The Office of the Public Prosecutor collects and manages the data. The WODC has a copy www.wodc.nl/

National Investigation Information Services

Criminal investigations by the Dutch police of more serious forms of organised crime; offenders against laws that include the Opium Act who act in collaboration

Sub-divided into hard and soft drugs

Enforcement of penalties involving detention and measures in penitentiary (TULP)

Characteristics of detainees, offences, length of sentences and characteristics of the penal institutions; juvenile penitentiaries (TULP/JJI) and TBS-institutions are registered separately

Continuous registration

WODC-Monitor of Recidivism

Longitudinal research project with standardised recidivism measurements among various groups of convicted offenders.

Reports on the basis of the OBJD

Data base of Central Fine Collection Agency (TRIAS)

Data on financial penalties offered by the police and district courts. These are recorded and relayed afterwards.

TRIMBOS-INSTITUUT

Annual report

Continuous registration

K&O/O&A/dNRI/KLPD, in cooperation with the police regions www.politie.nl/KLPD/

Custodial Institutions Service (DJI of the Justice Ministry www.dji.nl/

WODC www.wodc.nl/

Central Fine Collection Agency (CJIB); administrative organization of the Justice Ministry. www.cjib.nl/

191

Appendix C Explanation of ICD-9 and ICD-10 codes

Explanation of ICD-9 codes ICD-9 code

Explanation

162

Malignant neoplasm of trachea, bronchus and lungs

291

Alcohol psychoses

292

Drug psychoses

303

Alcohol dependence syndrome

304

Drug dependence

304.0

Opioid type dependence

304.2

Cocaine dependence

304.3

Cannabis addiction

304.4

Amphetamine and other psychostimulant dependence

304.7

Combinations of opioid type drug with any other

305

Non-dependent abuse of drugs or other substances

305.0

Alcohol abuse

305.2

Cannabis abuse

305.3

Hallucinogen abuse

305.4

Sedative, hypnotic or anxiolytic abuse

305.5

Opioid abuse

305.6

Cocaine abuse

305.7

Amphetamine or related acting sympathicomimetic abuse

305.8

Anti-depressant type abuse

305.9

Other, mixed, or unspecified drug abuse

357.5

Alcoholic polyneuropathy

425.5

Alcoholic cardio-myopathy

535.3

Alcoholic gastritis

571.0

Alcoholic fatty liver

571.1

Acute alcohol hepatitis

571.2

Alcoholic liver cirrhosis

571.3

Unspecified alcoholic liver damage

980.0-1

Toxic effect of alcohol

E850

Accidental poisoning by analgesics, antipyretics and antirheumatics

E850.0

Accidental poisoning by heroin

E854.1

Accidental poisoning by psychodysleptics (hallucinogens)

E854.2

Accidental poisoning by psycho-stimulants

E855.2

Accidental poisoning by local anaesthetics (including cocaine)

E860.0-2

Accidental poisoning by alcoholic drinks (ethanol/methanol)

E950.9*

Suicide by poisoning through solid substances or liquids

E980.9*

Poisoning by solid substances or liquids, undetermined intent

* Only included if registered as complication 980.0-1.

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Explanation of ICD-10 codes ICD-10 code

Explanation

C33

Malignant neoplasm of trachea

C34

Malignant neoplasm of bronchus and lung

F10

Mental and behavioural disorders due to use of alcohol

F11

Mental and behavioural disorders due to use of opiates

F12

Mental and behavioural disorders due to use of cannabinoids

F13

Mental and behavioural disorders due to use of sedatives or hypnotics

F14

Mental and behavioural disorders due to use of cocaine

F15

Mental and behavioural disorders due to use of other stimulants

F18

Mental and behavioural disorders due to use of volatile solvents

F19

Mental disorders and behavioural disorders due to multiple drug use and use of other psychoactive substances

G31.2

Degeneration of nervous system due to alcohol

G62.1

Alcoholic polyneuropathy

I42.6

Alcoholic cardio-myopathy

K29.2

Alcoholic gastritis

K70.0

Alcoholic fatty liver

K70.1

Alcoholic hepatitis

K70.2

Alcoholic fibrosis and sclerosis of liver

K70.3

Alcoholic liver cirrhosis

K70.4

Alcoholic hepatic failure

K70.9

Alcoholic liver disease, 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*

Accidental poisoning by and exposure to alcohol

X61 + T43.6

Suicide by psychostimulants

X65*

Intentional poisoning by and exposure to alcohol

Y11 + T43.6

Poisoning by psychostimulants, undetermined intent

Y15*

Poisoning by and exposure to alcohol, undetermined intent

*Only included if stated as complication T51.0-1.

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Appendix D Websites in the area of alcohol and drugs

Australian Institute of Health and Welfare (AIHW) http://www.aihw.gov.au/ Bouman GGZ http://www.boumanggz.nl/ Brijder Verslavingszorg http://www.brijder.nl/ CEDRO Centrum voor Drugsonderzoek (UvA) http://www.cedro-uva.org/ Centraal Bureau voor de Statistiek (STATISTICS NETHERLANDS (CBS)) http://www.Statistics Netherlands (CBS).nl/ Centrum Maliebaan http://www.centrummaliebaan.nl/ De Hoop http://www.dehoop.nl/ DeltaBouman http://www.deltabouman.nl/ Emergis Verslavingszorg http://www.emergis.nl/verslavingszorg/ European Centre for the Epidemiological Monitoring of AIDS http://www.eurohiv.org/sida.htm European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) http://www.emcdda.org/ European Commission, Taxation and Customs Union http://europa.eu.int/comm/taxation_customs/publications/info_doc/info_doc.htm# Excises Europol http://www.europol.eu.int/home.htm GGD Amsterdam http://www.ggd.amsterdam.nl/

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GGD Nederland http://www.ggd.nl/ GGZ Noord- en Midden Limburg/Verslavingszorg (GGZ NML) http://www.ggz-groepnmlimburg.nl/ GGZ Nederland http://www.ggznederland.nl Inspectie voor de Gezondheidszorg http://www.igz.nl/productie/indexie.html Instituut voor Onderzoek naar Leefwijzen & Verslaving (IVO) http://www.ivo.nl/ Intraval. Bureau voor onderzoek en advies http://www.intraval.nl/ IrisZorg http://www.iriszorg.nl/ Jellinek kliniek (Amsterdam) http://www.jellinek.nl/ Korps Landelijke Politiediensten (KLPD) http://www.klpd.nl/ Ministry for Justice http://www.justitie.nl/ Ministry for Health, Welfare and Sport http://www.minvws.nl/index.html Mondriaan Zorggroep/Verslavingszorg http://www.mondriaanzorggroep.nl/ Nationaal Instituut voor Gezondheidsbevordering en Ziektepreventie (NIGZ) http://www.nigz.nl/ Novadic-Kentron, netwerk voor verslavingszorg http://www.novadic-kentron.nl/ Openbaar Ministerie http://www.openbaarministerie.nl/ Parnassia, Psycho-Medisch Centrum http://www.parnassia.nl/ Police http://www.politie.nl/

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Prismant http://www.prismant.nl/index.htm Rijksinstituut voor Volksgezondheid en Milieu (RIVM) http://www.rivm.nl/ Rijks-Kwaliteitsinstituut voor land- en tuinbouwprodukten www.rikilt.dlo.nl/ Stichting Consument en Veiligheid http://www.consument-en-veiligheid.nl/ Stichting Informatievoorziening Zorg (IVZ) http://www.ivv.nl/ http://www.sivz.nl/ STIVORO, voor een rookvrije toekomst http://www.stivoro.nl/ Substance Abuse & Mental Health Service Administration (SAMHSA) http://www.samhsa.gov/ SWOV-Stichting Wetenschappelijk Onderzoek Verkeersveiligheid http://www.swov.nl TACTUS, Instelling voor verslavingszorg http://www.tactus.nl/ Trimbos Institute http://www.trimbos.nl/ Vereniging GGZ Nederland http://www.ggznederland.nl/ Verslavingszorg Noord Nederland http://www.verslavingszorgnoordnederland.nl/ Wetenschappelijk Onderzoek- en Documentatiecentrum (WODC) http://www.wodc.nl/ World Health Organisation (WHO) http://www.who.int/en/ ZonMw http://www.zonmw.nl/

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Appendix E Drug use in a number of new EU member states

Use of cannabis, cocaine, ecstasy and amphetamine in the general population of a number of new EU member states

I

Cannabis

Cocaine

Ecstasy

Amphetamine

Country

Year

Age

Ever

Recent

Ever

Recent

Ever

Recent

Ever

Recent

Cyprus

2006

15 - 64

6.6%

2.1%

1.1%

0.6%

1.6%

1.0%

0.8%

0.3%

Estonia

2003

15 - 69

-

4.6%

-

0.6%

-

1.7%

-

1.3%

Hungary

2003

18 - 54

9.8%

3.9%

1.0%

0.4%

3.1%

1.4%

2.5%

1.0%

Latvia

2003

15 - 64

10.6%

3.8%

1.2%

0.2%

2.4%

0.8%

2.6%

1.1%

Lithunia

2004

15 - 64

7.6%

2.2%

0.4%

0.3%

1.0%

0.4%

1.1%

0.3%

Malta

2001

18 – 64

3.5%

0.8%

0.4%

0.3%

0.7%

0.2%

0.4%

0%

Poland

2002

16 – 64

7.7%

2.8%

0.8%

0.5%

0.7%

0.2%

1.9%

0.7%

Slovakia

2004

15 - 64

15.6%

3.6%

1.1%

0.6%

4.0%

0.8%

1.5%

0.2%

Czech Rep.

2004

18 – 64

20.6%

9.3%

1.1%

0.2%

7.1%

3.5%

2.5%

0.7%

Romania

2004

15 - 64

1.7%

-

-

-

-

-

-

Bulgaria

2005

18 - 60

4.4%

1.5%

1.1%

0.3%

1.3%

0.5%

1.4%

0.4%

Percentage of ever users and recent users (past year). I. Drug use is relatively low in the youngest (12-15) and older age groups (>64). Usage figures in studies with respondents who are younger and/or older than the EMCDDA-standard (15-64) may be lower than in studies that apply the EMCDDA-standard. The opposite is true for studies with a more limited age range. - = not measured. Source: EMCDDA.

TRIMBOS-INSTITUUT

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