Specific training

In 2002, the Trimbos Institute organised several training courses for addiction care, both on a basic level and more in-depth (Trimbos-instituut, 2002). Other courses deal with dual

diagnosis (both for professionals in addiction care and mental health care) or prevention in coffee shops (both for personnel and for visitors of coffee shops).

10

Reduction of drug-related harm

Role of harm reduction within national drug policy

Harm reduction has been one of the pivotal aspects of our national drug policy during the past 25 years (see 8), and this is consistent with our perception of drug addiction mainly from a health perspective. Healthy behaviour should be endorsed and unhealthy behaviour is difficult to enforce. This contrasts with the punitive-judicial view on drugs and drug addiction.

Definition and priority

Defining clear differences between outreach work, low-threshold services, harm reduction activities, and the newest term ‘social addiction care’ is hazardous. Actually, all four deal with seducing difficult to reach drug users to participate in some action to prevent a worsening of the situation (individual and/or social). Some years ago a new concept was coined: ‘social addiction care’. It is one of the pilars of the five-year policy programme ‘Getting Results’ (see 8.2, 9). This concept is conceived in broader sense, setting idealistic and more long-term goals (see below).

Most outreach work is carried out by low threshold services in outpatient care facilities (National Report 2001). These services are active in street corner work offering daytime shelter in drop-in centres for street junkies, living room projects for drug-using prostitutes and user rooms for chronic hard drug users. Other target groups of these services are injecting drug users, extremely problematic drug users, and drug users from foreign countries (these are evidently not permanent residents). Outreach activities also feature in programmes for reducing drug-related public nuisance, which are often a joint venture between treatment and care facilities, police and civic groups. A new type of outreach work today is education ‘on the spot’ (i.e. where young people meet) applying peer-support techniques. Another one is developed at this moment and aimes at drug using people who have been sentenced to stay a few months in prison (Mainline, 2000; National Report 2001 hereafter).

Recent policy trends

No changes compared to former years (National Report 2001, 8). Current public/professional discussion

In Amsterdam. local politicians considered possibilities for a special building in a suburb (junkenflat) where in general many addicts are staying, but this plan was not approved by the municipality. Besides user rooms, there are nowadays ‘supported housing projects’ for addicts and a night relief center (24 beds).

Harm reduction practice

Social addiction care

Social addiction care is not concentrated on treatment but on minimalisation of the effects of addiction for the client (care instead of cure) or on improvement of daily performances of the client. Harm reduction is considered a minimal model of social addiction care (Broekman et al., 2002). Social addiction care is meant to improve the quality of life and the re-integration of addicts.

Relief centres for homeless

Many cities have relief centres for homeless people, sometimes these are only opened for the night, in most cases however a 24 hours service is offered for homeless (addicted or not). The most important objective is to reduce public nuisance (‘visual’ nuisance by their appearance or by litter (beer cans, bottles, paper ware) that has been left behind, and drug- related criminality).

Pill testing

Targeting at prevention of health damage from overdose or toxicity after use of synthetical drugs by people (not only youth) in recreational settings). Sixty testers are working in the field, eight collaborators in the DIMS-office and four lab analists (all university or higher vocational level education)

Needle exchange

Targeting injecting use of hard drugs (a minority of the group of hard drug users) to reduce needle sharing, infections, infectious diseases and to reduce leaving used needles on the streets. The activities are mainly done by street workers, workers of organisations of addiction care, pharmacists, workers of public cleansing departments.

Time out rooms for addicted prostitutes

Giving the opportunity to addicted prostitutes to have some rest in a trustful environment, to talk about their problems, to find some preliminary solutions for these. The actual work is done by specialised women care workers (vrouwenhulpverlening).

Farm work

Giving the opportunity to (ex)addicts (after detoxification) to participate in supported farm work in order to structured day activities, stimulate social contacts, reduce relapses and stabilising their lives. This programme was carried out by a programme co-ordinator,

management of regional addiction care organisations, and participating farmers (see Range of services).

Living unit for older addicts

A living unit for a small group of older methadone and cocaine users to reduce drug-related nuisance and stabilising their drug use. Living units should be operated by experienced and trained professionals (not specified).

Case management

The term case management (also called ‘interfering care’ or bemoeizorg) as an intervention for chronic addicts often with dual diagnosis, stems from psychiatry. A definition was not formulated but an important part of case management is co-ordination of activities and therapies in order to enable stepped care or care packages for individual clients. In most cases case management is realised on a one-to-one (client-manager) basis. The ideal caseload of each manager is considered 15 to 20 clients in order to stay effective and avoid burnout. The actual amount of casemanagers is not known.

Range of services

Self help groups

Self help groups have already been mentioned in our National Report 2001 (see 9.6.6).

Mainline

The Mainline foundation (www.mainline.org) is an independent non governmental

organisation, striving to improve the health and quality of life of drug users. Mainline workers accept drug use. Direct contact with drug users enables Mainline to point out and analyse new developments in the drug scene at an early stage. Targeted harm reduction activities are possible, as well as health education, consultancy and training of social workers.

Established in 1990 as a small fieldwork organisation for AIDS prevention in Amsterdam, over the years Mianline has grown into a professional harm reduction organisation. Attention is paid to (new) health problems, drugs, techniques, and target groups. Through its key task, i.e., health education and prevention for drug users on the street, Mainline has gained a great deal of knowledge on developments surrounding substance use, substance users, and health risks. This knowledge is used in field work, education material, training, policy (-consultancy), and research

.

organisations and research institutes call on the expertise and experience of Mainline, which consequently results in regular collaborations.

Inpatient Motivation Centres (IMCs)

(See National Report 2001, 9.2.1).

A living unit for older addicts

Empirical data refute the common wisdom that harddrug addicts cannot grow older than fifty. Today, a growing part of the chronic heroine addict population illustrate this. Problems with their need of care are partly comparable to problems of the elderly in general. Specific problems are that aging drug users are less able to get their daily drug regime and suffer a high risk for personal neglect. Maintaining a minimal standard of living requires support. An experimental living unit for seven methadone and cocaine using ‘seniors’ (older than 55 years) was funded by the Municipal Health Service in the city of Rotterdam. It started in 1999 and was evaluated a year later (Heijman and Verveen, 2000). The seniors were not

extremely problematic. A maximum size of ten addicts was recommended to avoid anonymity of group members, to ensure care and to maintain the support of the

neighbourhood. The relationship between professionals and neighbours were good and no public nuisance was detected during the evaluated year. Clients were satisfied with this type of supported living condition, could manage financially, and were able to withdraw from excessive cocaine use, due to the support of the professionals.

The agricultural link! Farm work for dual diagnosis patients

A recent two-year experiment with working on the farm for (ex)addicts also showed many positive results (Cool, 2002). Initially this project was meant for drug-users who caused public nuisance but the co-operating organisations of addiction care referred exclusively treatment refractory clients (multiproblem clients, most of them with dual diagnosis). The co- operating farmers were able to handle these clients quite well and the clients themselves appeared to be satisfied with their work. It structured their life and they had rewarding social contacts. Talking with colleague workers with other problems reduced the seriousness of their own problem perception. Furthermore, in contrast to the attitudes of the outside world, they felt accepted in these contacts. Finally, their drug use decreased or stopped entirely. However, their lack of problem solving capacity appeared to be unchanged. At the start of this experimental pilot, the participating organisations of addiction care were cautious about the effects but after some months the effects were surprising. Co-operation between farmers and management of regional organisations of addiction care remained stiff. Addiction care did not involve in formal arrangements to enlarge or prolonge this co-operation. Aftercare and further rehabilitation were inadequately organised. Rather, the implicite assumption was that farmer work could be an end station for participating clients (the highly problematic group of dual diagnosis clients). Funds for continuation of this project are still quite uncertain.

Enhancing vocational opportunities for addicts

In Brabant (a Southern part of the Netherlands) co-operation between an addiction care organisation (Novadic) and the Weener Group has been agreed upon. The Weener Group targets at offering paid work and vocational support to persons with different kinds of

disabilities. They do so to implement several legal arrangements for increasing participation of these groups at the labour market (GGZ Nederland, 2002).

Current health care or addiction care is not accessible for addicted prostitutes. Most of the addicted prostitutes also have other problems and feel uneasy or unsafe in these locations. In Rotterdam, social work service for addicted prostitutes in the streets was organised (PMW, 1999). Fixed consulting hours and regular visits facilitated to contact these women and to motivate and support them for changing their lives. In 1998 48 addicted prostitutes participated, some with dual diagnosis or polydrug use. Most of them (38) had contact with specialised addiction care (a ‘living room’) situated near their ‘work spot’. A third of this target group used methadone. The impression is that these contacts are last resort contacts (avoiding to ‘get lost’ entirely). At best, contacts with regular addiction care facilities are short-term and mostly occur during crises. Supporting this target group in trying to resocialise is crucial: i.e. mediating between clients and guardians, renewing contacts with their children, and maybe later referring them to regular addiction care.

Another project (Time out) specifically meant for addicted prostitutes offers a regular and direct accessible day-and-night supportive care facility. Its targets are: keeping contact with this target group, offering solutions for acute problems, and working on a more

continuous care provision (National Report 2001, 9.2.1).

Street work in general

The grass roots organisation of street workers Mainline Amsterdam is old but still existent. Mainline street workers actively seek contact and try to maintain contact with drug users. In informal contacts they avoid being (too) demanding to drug users. Contacts are primarily meant to give support by loosely giving information about drugs, watching for trends in drug use, and trying to enhance abilities for self-help. Mainline established a prevention project specifically for female drug users (Mainline 2000). Their drop-in centre offers specific services for this user group (hairdressing, workshops on safe sex, overdose training and counselling on contraception). In another project two street workers offer assistance to drug users who are temporary in prison. The first results show much enthusiasm to contact these workers during hours that prisoners are free of obligatory activities. The target is also to maintain these contacts after release from prison.

Pill testing

Since 1992, information on the composition (dose, ingredients) of synthetic drug preparations such as XTC pills has been produced by the Drugs Information and Monitoring System (National Report 2001 10f). DIMS tries to answer the following questions: “What substances are appearing on the drug market?”, “What are the health risk of these substances?” and “What are the trends in substance use?” DIMS studies toxico-epidemiological effects of drugs. Drug samples are sent in or collected from fieldwork organisations and drug users or DIMS-participants. At this moment 16 participants are active in 26 cities. The pills are tested at affiliated offices or in a specialised hospital laboratory. Pills containing particularly

dangerous ingredients, for example, XTC pills with high dosages of MDMA, have led to successfull warning campaigns aimed at potential users. ‘Danger’ is determined by several predetermined factors such as characteristics, toxicity, dosages found, noticeable effects or dissemination of the samples. In case of dangerous substances other parties are also warned, for instance the Ministry of Health, Welfare and Sport, the Health Inspection, the National Toxicology Information Centre, First Aid Services, etc. (Planije et al., 2001).

User rooms for chronic hard drug users that are not motivated for treatment. These rooms give the opportunity to use drugs without having to stay in the hectic street scene, avoiding the use of used syringes. User rooms are also initiated to reduce drug-related nuisance. Access is often reserved for users with an identity card. These measures are meant to keep others who can be motivated for treatment away from these rooms. Professionals are looking after the health situation of users by offering food and drinks, toilets and showers, informing them, giving advice, or taking care of clean syringes, condoms, etcetera.

Effects of medical co-prescription of heroin

Recently medical co-prescription of heroin for treatment refractory chronic addicts was evaluated (CCBH, 2002). It was concluded that adding heroin to methadone maintenance treatment was feasible, beneficial and safe for this target group. It yielded clinically relevant health effects and criminality was reduced during the full 12-month period. A protocol will be made for prolonging prescription for individual addicts who participated in the experiment. The Mayors of cities that participated in the experiment suggested that heroin co-prescription should be part of regular addiction care. This has not yet resulted in national decision making (cf Van Dam et al., 2002).

Needle exchange

Facilities for needle exchange or syringe exchange exist already more than ten years. In all major Dutch cities such exchange services are available. However, most younger opiate addicts do not inject their drugs. These facilities differ in type of drug users, exchange system (one-to-one or otherwise), the organisation (Municipal Health Centres, on streetcorners, etc.), syringe prices, cleaning fluids, bleach, etc.). A structural co-operation between Aids prevention organisations and syringe exchange does not exist. Of primary importance for the use of syringe exchange facilities are privacy or anonymity, low thresholds and no top-down perceived rules, clear-cut constant opening hours, and accessibility.

Case management

Case management for chronic addicts with dual diagnosis consist of offering practical and psychological help, supplemented by co-ordination of different care activities for individual clients. Referral to inpatient addiction care may also be part of these activities to reduce escalations or dangerous situations (Wolf et al., 2002). The international literature shows that an effective model of case management is most probably Assertive Community Treatment. This model can be characterised by several criteria: structural (caseload, teamwork, co- operation with other health professionals, etc.), organisational (explicite inclusion criteria, slow admittance of new clients, a 24-hour crisis intervention facility, etc.) and content (support and care is provided in daily client situations, an active approach or interference, high frequency of contacts, etc.). The study of Wolf et al. gives guidelines. The amount of case management interventions for this client group is still unknown.

Alternative medicine

For Surinamese drug addicts the pros and cons of implementation of traditional cure done by ‘witch doctors’ (Winti) in regular addiction care has been pondered (Leenders et al., 2001). In several organisations Winti has already been used for specific addicts and their families. Evaluation has not been done and general implementation is not realised up to now. Networking between HR professionals

We know only of informal networking among harm reduction professionals. People know each other from conferences, other meetings or incidental co-operation. Formal networks do not exist. This can be a limiting factor for case management, because a coherent network of addiction care facilities is crucial for success (Wolf et al., 2002). Casemanagers do not have the authority to enforce co-operation among different organisations. This problem does not seem to be exclusively Dutch, nor is it exclusively limited to the world of addiction care. In general inter-staff rivalries will kill necessary collaboration in non-commercial organisations (cf McLellan et al., 1999). The important question remains, what conditions might avoid or reduce these rivalries.

Co-ordination of national policies and local practice

Local practice is mainly left to local strategies. This is probably due to our complex and stratified financing system (see 14).

Expenditures on specific harm reduction projects

Expenditures on specific harm reduction projects are only partly known. This is probably also due to our complex and stratified financing system (see again for details, chapter 14).

10.1 Description of interventions (in recreational settings, prevention of drug