According to some authors, early identification or early detection (vroegsignalering) of drug abuse or addiction is part of indicated prevention. Other types of indicated preven- tion that are not applied very often in the Netherlands are: a specialised medical office hour for drugs users and an internet drug test (Kleinjan and Engels 2010). In the Nether- lands, early identification of drug use or drug related problems is in many cases part of a more comprehensive (or stepwise) intervention programme. Therefore the difference between these two prevention types is difficult to maintain.
Some selective alcohol and/or drug prevention activities among at risk groups or 'vulner- able groups' exist already for decades, for instance those targeting children of addicted parents (see chapter 12 for details). For other ones, the coverage over time is variable, e.g. youth and young adults in recreational settings, homeless youth or youth from low SES neighbourhoods, prevention among street corner youth. Problems such as home- lessness, psychiatric problems and delinquency, and accumulation of these factors in- crease the risk for the onset of problems considerably (Snoek et al. 2010a; Hosman et al. 2009). Below some available recent publications on this issue are reported.
In 2010 a pilot prevention programme was developed for youth with a slight mental re- tardation (jongeren met een licht verstandelijke beperking) (Hilderink & Bransen, 2010) . This pilot resulted in a preliminary intervention programme that was implemented for parents and their mentally retarded children via the prevention units of four participant regions of addiction care. Some objectives of the foreseen evaluation of the programme (feasibility, client satisfaction and outcomes) were partly realised within the scheduled pilot period. The part focussing on "professional advancement" (deskundigheidsbevorde-
ring) was done by all units, but this part took too much time for satisfactory results. The
"parent meetings" suffered from a low parent motivation and the part focussing on "in- formation and education" for the young people themselves were realised in three regional units in two regions (as intended). The fourth part of the programme, "motivational en- hancement training" could not be realised within the time span of the project. Recom- mendations included: there was a need for more detailed information about more drugs, especially for the somewhat older children; parent meetings should be more integrated in other parent-based interventions; and recruitment of young participants should use in- formal leaders and game-like elements. The results of this pilot imply that the pro- gramme should be adapted substantially before implementing it on a national level.
Street corner youth (hangjongeren) form another vulnerable group. Following rumours at local level about cannabis abuse, this group has been screened by an organisation of ad- diction care (Novadic-Kentron). It appeared that 29% of the boys and 16% of the girls (both younger than 16 years) was smoking cannabis more than once a week. Half of these groups smoked this drug daily. The use of other drugs did not differ from the na- tional average. Several activities, e.g. early identification, information and education, and in some case also referral to addiction care have been suggested to reduce the individual problems of these young people and related societal problems (Akkaya et al. 2011). This suggestions were accepted by the municipality and in 2015 an evaluation will be realised of the effects of these measures (Gemeente Halderberg 2011).
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An e-learning programme for teachers has been introduced on October 3rd 2011 by the
Minister of Education, Culture and Science that should facilitate the development of ex- pertise for the early identification of alcohol- and drug use and related problems among pupils of secondary vocational schools (15-24 year). In schools, alcohol and drug use (predominantly cannabis use) is a risk factor for truancy and drop out. In an earlier study it was concluded that especially secondary vocational schools are in need of support for early detection of alcohol and drug use among students (Ter Bogt et al. 2009). The online programme has two parts. One part is meant for all personnel, including the non- teaching staff of these schools and informs them about substance use and how to detect it. In the additional online course this is elaborated for teachers, a brief training is pre- sented about: (1) how to talk about this habit with their students; (2) criteria for referral to addiction care; and (3) starting a 'drug office hour' at school.1
A group of young people in the Netherlands smokes cannabis without being aware of the risks of doing this at their age. Although there are nowadays special youth programmes in organisations of addiction care, special attention for young drug users who are (still) not in need of help is absent. Therefore a new initiative has been launched at the start of 2011 (Wiet Check) that is based on the Australian Adolescent Cannabis Check-up (ACCU). Young cannabis users (14-21 year) are visited actively to make an appointment for a brief meeting with a professional, for instance in shelters for homeless youth and other groups that were specifically organised. Three times a questionnaire has to be filled in. With one or two incentive-based individual talks (€ 10 per questionnaire) using a non- offending motivational enhancement technique, they are seduced to participate in this preventive intervention and to think about the pros and cons of their cannabis use. The experiment runs in nineteen locations of nine organisations of addiction care. It is funded by the Netherlands Organisation for Health Research and Development (ZonMw) and around 25 professionals are participating. At the same time (2011-2012) an evalua- tion on the effectiveness of this intervention is running that will be reported in 2013.
There appear to be more local initiatives on cannabis use among young people but they are not yet documented except for a proposal for a pilot study submitted to the Nether- lands Organisation for Health Research and Development (ZonMw) named "Smoking cannabis is not normal".2 This pilot aims to prevent cannabis use among young people
from ethnic minorities (originally from Morocco and the Antilles) in two neighbourhoods of the city of Rotterdam by increasing skills of these younger people to resist group pres- sures to use drugs. When proven successful, this approach will be adapted in a broader municipal programme targeted at youth at risk, to reduce public nuisance and enhance talents and competences of young people.
A guideline has been published for professionals who are working with young people in general for the early identification of substance misuse or substance dependence (Snoek et al 2010b). It describes what early identification is and how it should be done. Primary is the collection of information on all persons and organisations that are involved with young people. Cooperation between organisations is considered crucial and subsequent steps of early detection are described, e.g. the choice of a target group, analysis of sub-
1www.signalerenalcoholendrugs.nl
stance use, a valid norm for substance use (e.g. all substance use is problematic when younger than 16 years), determination of problems with a screening card, and motiva- tional enhancement.
The Drugs Information and Monitoring System (DIMS)
During its nearly twenty years of existence, the Drugs Information and Monitoring Sys- tem (DIMS) has monitored the chemical content of more than 100,000 samples of illicit drugs. These drugs are collected directly on the user's level and there is information ex- change between the personnel at the testing facilities and the users. The anonymity of the drug user is guaranteed in order to keep DIMS trustworthy. This enables the collec- tion of data on personal adverse effects and adverse effects experienced by friends, re- gional origin, date, source of purchase, price and reason for testing. The results of two studies suggest that testing drug users are broadly similar to non-testing users (Ben- schop et al. 2002; Korf et al. 2003). Thus, it is reasonable to assume that the DIMS tar- get group is a reflection of all recreational drug users. While DIMS in a strict sense is only a market monitor, the data are fed back to the local organisations of its network to sup- port their activities targeting the prevention of health threatening situations. In 2010, 8,898 drug samples were delivered to DIMS (DIMS, 2011; see § 10.3).
The Monitor Drug-related Emergencies
Since 2009 the Drugs Information and Monitoring System (DIMS) is supplemented by the 'Monitor drug-related emergencies' (Monitor drugsincidenten). Data about drug related emergencies or incidents are collected continuously and anonymously via a number of health-care organisations like hospitals, ambulance services, police medical-services, and first-aid services, in different regions of the country. These services have access to a special website (https://www.drugsincidenten.nl; see also § 6.2 and § 7.1), that enables the exchange of information and supports the professional level of health workers con- cerning interventions targeting these incidents. The data of the Monitor drug-related emergencies are for instance used for feedback to health professionals (e.g. ambulance personnel) and for increasing their drug-related expertise. There were 2,852 unique drug-related incidents registered in 2010 (Vogels and Croes 2011). Almost half of these (46%) took place in the region of Amsterdam and more than one third came from First Aid posts on large-scale festivals and musical events. Some other results show that people from all ages are registered, from a five year old child (that ate by accident an ecstasy pill that was found at home) to an 83 year old man who showed slight intoxication effects from smoking cannabis.
The Drugs Information Line
The 15 year old Drugs Information Line (Drugs InfoLijn) is offering information about drugs to the general public by answering questions asked by phone, e-mail or by chat service. This service is now combining information on drugs and alcohol, but the Alcohol Information line (Alcohol InfoLijn) reports separately its annual statistics. The chat box deals with drugs and safe sex issues for 13 to 16 years old youngsters.
Compared to the past years there is a slight increase in contacts with the Drug Informa- tion Line. In total there were 4,121 contacts for drugs: 2,220 by phone, 1,125 by e-mail, and 176 otherwise. Both information lines have an important referral function. In most cases people were referred to websites (for more information, or e-help), to organisa- tions of addiction care, self help groups or General Practitioners. During the next years a
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quick shift is foreseen from classical media towards new media, e.g. the internet (Publieksinformatie Trimbos-instituut 2011). Especially young people are less inclined to use written documents, telephone or e-mail. Because the threshold for information should remain low, in November 2010 the Trimbos Institute and eleven of the fifteen Dutch organisations of addiction care started an open (free of charge) office hour for in- formation about drugs and alcohol, the national chat service (Bransen and Van der Gouwe 2011). This service is available from 1 to 5 pm via the well known websites www.drugsinfo.nl and www.alcoholinfo.nl, and via the websites of the organisations of addiction care. Information is given by professionals who are regularly trained by the Trimbos Institute. Furthermore, a special LinkedIn group has been started to facilitate the exchange of the most recent information.
All participants of the chat service do their work in rotation (each organisation once per two weeks) in order to reduce the costs per organisation. Hosting and management costs are divided between the organisations. All in all this is a low budget service for informing people with high-quality information about drugs and alcohol (ibid.).
Going Out: Alcohol and Drugs
By ministerial order, the programme "Going Out: Alcohol and Drugs was started in 1998 by the Trimbos Institute in cooperation with several parties in the field of addiction care. It deals predominantly with the prevention of harmful drug use in recreational settings, especially by young people (16-26 year). This project offers preventive instruments (e.g. a quick-scan for detecting drug problems, First Aid courses in case of these problems for personnel of recreational settings, factsheets and a help desk) for several stakeholders, for instance. municipalities, municipal health services, coffee shops and addiction care (Croes and Van Gageldonk, 2009, see also several former national reports).
The Centre for Safe and Healthy Recreation (Centrum Veilig en Gezond Uitgaan) is also part of the programme Going Out: Alcohol and Drugs and was initiated by the Centre for Safety and Prevention of Criminality (Centrum Criminaliteitspreventie) and the Trimbos Institute. The aim of this centre is offering support to municipalities in constructing a local policy (a mix of measures) for increasing safety in recreational settings by reducing drug and alcohol use. It is also a knowledge centre for evidence-based interventions and practice- or experience-based activities in this domain. It disseminates newsletters, info sheets and it organises thematic meetings.1
Interventions targeted at users of GHB
Following signals if an increase in (problematic) use of GHB, the programme Going Out organized an expert meeting to obtain insight in the risks groups and preventive inter- ventions, which were also published in a fact sheet (Horjus and Van Goor 2011). Many organizations are also active now in disentangling the problems related to GHB use, the user groups and treatment van GHB dependence and detoxification (T.K. Aanhangsel- 2535; (see § 5.3.7). On behalf of the Ministry of Health, Welfare and Sports, the Coordi- nation Point Assessment and Monitoring of new drugs (CAM) reassessed the risks of GHB use (Coördinatiepunt Assessment en Monitoring nieuwe drugs 1999; Coördinatiepunt Assessment en Monitoring nieuwe drugs 2011). In its report from 2011, the CAM advised to place this drug on list 1 (hard drugs) of the Opium Act. The Minister wrote to the members of Parliament that she will follow this advice (see also 5.2.7).
An organisation of addiction care (Novadic-Kentron) published a practice-based protocol based on two years of experience with detoxification of GHB users. These ex- periences show substantial differences in the detoxification process among patients. Be- sides, there are different methods for detoxification in use across organisations of addic- tion care (Dijkstra et al. 2010b). Therefore, the Minister of Health, Welfare and Sport also funded an experiment within Novadic-Kentron for determining effective treatment options of GHB addiction. The final target is to publish and disseminate a practice-based guideline. It is funded by the programme Scoring Results (see quality assurance). A re- port is planned at the end of 2012 (Dijkstra et al. 2010b).
The city of Amsterdam has published an Action Plan GHB (GGD Amsterdam 2010). The background of this action plan is the increase in ambulance services caused by GHB use and the addictive nature of GHB when used regularly. GHB users do not seem to be aware of the adverse and possibly also dangerous effects of GHB. The target is to reduce the negative consequences of GHB-use and to support GHB-users and GHB-dependents in relieving the acute problems related to GHB-use. The proposed programme of actions contains: (1) monitoring GHB use in the city to get informed about specific target groups (e.g. via existent and if necessary new monitor activities and via focus groups with rep- resentatives of risk groups within homosexual scenes and dance events); (2) a public campaign targeting these target groups that is also informing about a website with in- formation on this drug and its effects; (3) improving support in case of incidents in rec- reational settings (e.g. a GHB information course for personnel in these settings, for the police and security personnel), and (4) offering low-threshold care for problematic users (based on the results of the current experiments in several organisations of addiction care). A protocol or standard of care is needed for effective help in different situations in case of GHB problems.
Moreover, an exploratory study (telephone interviews and a secondary analysis of na- tional registration data on clients of addiction care, combined with focus groups) is run- ning to analyse characteristics and motives of GHB users, their patterns of use, and re- lated psychosocial or other problems (Hammink and Schrijvers 2011). Targets are to discover user groups, and to give suggestions for prevention of (problematic) use of GHB.