Drug Use as a Social Ritual. Chapter 18b

Revitalization of Dutch Drug Policy

a. Transforming the Leading Policy Incentive: Towards a Controlled Availability of Drugs

There is thus a clear need to adjust the policy. When the Netherlands wants to maintain its position on the innovative frontier of the international discussion on drug policy, it must pursue new ways and approaches to counter the above discussed problems. Goldstein and Kalant recently wrote that "the practical aim of drug policy should be to minimize the extent of use, and thus to minimize the harm." (56) Most attempts to reduce the extent of use have relied on prohibition based supply reduction strategies. Not only have these strategies failed to check the use of drugs in countries with a tradition of illicit drug use, but (injecting) drug use is increasingly spreading to new regions. This spread may even be the result of drug prohibition as this has provided the economic incentive for the illicit drug industry, and spreading patterns often follow the routes of illicit drug trafficking. (84) Likewise, prohibition of one drug may induce the emergence of other, more potent drugs and more efficient drug administration rituals. Within months after the establishment of anti opium laws in Hong Kong, Laos and Thailand heroin use appeared suddenly and injecting came up. (85) Equally important is that these conventional strategies have introduced a plethora of secondary harm (see chapter ten). While Goldstein and Kalant seemingly refer to primary harm --harm directly related to the use of a certain substance, e.g. deteriorated tissue integrity of the nasal septum, due to frequent intranasal cocaine use or fetal alcohol syndrome in babies born from alcoholic mothers--, this may well be exceeded by the magnitude of secondary harm (harm related to drug policy), in particular since the advent of the AIDS epidemic. Minimization of harm associated with drug use, therefore, should be the practical aim of drug policy. Reduction of the extent of use may well be part of the strategy, but prohibition has proven to be unsuitable for this purpose, as it has resulted in the almost total absence of government control over the chain between producer and consumer. By criminalizing the drug trade, control has been handed over to illegal enterprise, resulting in an uncontrolled availability of drugs.

Recently one of the architects of the normalization policy, Eddy Engelsman, contemplated on a drug policy outside of criminal law. (86) Abandoning criminal law as the (dominant) policy instrument does, of course, not imply abandoning all control. Drugs are and have always been key commodities. Just as any other key commodity (food, housing, legal drugs), these need to be regulated. But by abandoning criminal law the chain between producer and consumer can be regulated more efficiently by simpler enforceable regulation systems. While this would be a preferable situation, it would be contra-indicated to change the law abruptly and legalize all drugs from one day to the other. This would disturb the natural progression of the described cultural transition process. Both users and mainstream culture need the time to adapt to increased availability of drugs.

Instead, the Dutch normalization policy should be revitalized --from containment of problematic drug use and management of drug related problems, the leading policy incentive should be shifted towards actively influencing the nature of drug use and directing drug using cultures towards less harmful patterns of use. The above explained cultural transition process of the heroin culture should be more actively influenced --its orientation at survival lessened while encouraging a transition towards progress. Likewise, the social controls that communicate safe use patterns in the XTC culture must be stimulated. The results of the present study suggest that such interventions are certainly feasible, especially in the Netherlands. But this will require sophisticated strategies and innovative interventions focussed on the drug culture(s) and its determinants. A step-by-step decriminalization of the various drugs --leading to, what one might term, a controlled availability-- should be part of the policy instruments, but is not the only one available. In the broader perspective of current Dutch social policy thinking, such a development would, in fact, offer a meaningful example of social renewal. Evidently, these activities should be monitored closely by research.

b. Increased Drug Availability and Prevalence of Use

It is often argued that increased drug availability will result in increased use. (56) Drugs themselves are considered to have such powerful reinforcing properties that mere availability will lead to (uncontrolled) use. Animal experiments are often presented to support this thesis. (87) However, Rhesus monkeys given four hours of daily access to cocaine during which drug delivery resulted from each lever press regulated their intake to a remarkable degree and showed stability in their daily cocaine use over periods of months. (88) In contrast, increasingly restrictive experimental regimes result in higher responding rates (and thus use levels). For example, monkeys in a progressive ratio schedule (89) would vigorously press the lever up to 12.800 times in order to get a shot of cocaine, depending on the dose. (90) In as much the drug taking behavior of these caged animals can be compared with that of humans in their natural setting, these experimental regimes more likely measure factors which resemble different aspects of prohibition in a highly stressful social setting, than a single pharmacological drug effect. Furthermore, in laboratory experiments with two rat colonies --one in a conventional experimental environment, the other in a simulated natural environment, a rat park-- affinity for opiate drugs could be established only under restricted conditions. (91)

Another argument often put forward is that of the per capita higher prevalence of use and addiction among physicians and other medical professionals, who have easy access to drugs. (56) These professions, however, are often very stressful with long working hours. More importantly, drug taking medical professionals risk heavy sanctioning, such as loss of professional license and criminal prosecution. Because of this threat and the social stigma involved with the use of illegal drugs, these drug using professionals are almost without exception solitary covert users. They are highly secretive about their use and do not associate (knowingly) with other drug using professionals. (92) This seriously hampers the formation of controlling rituals and rules as there is no exchange of information between, nor support or pressure from, (drug using) peers.

The rising prevalence of illicit drug use in production regions or the prevalence of opiate use in nineteenth century Europe and North America is likewise presented to support the thesis that increased availability will result in increased prevalence of drug use. However, table 18.1 indicated that in the Netherlands the use of drugs has stabilized, despite their relatively high availability. In addition to what was said above about the role of prohibition in the current spread of drug use, it can be argued that today's socio-economic conditions do not compare to those of the previous century, in which many drugs furthermore were rather indiscriminately promoted. Nowadays knowledge of and experience with drug use has increased greatly --not only of the pharmacology of the substances, but, more importantly, also of the social (learning) processes involved in drug taking. Likewise, prevention and education has become a science. Anti-tobacco and alcohol moderation campaigns indicate that lower use levels and self-regulation can well be established within a lawful context.

c. A Demand for Positive Rules

Negative rules deny the pertinence of behavior (thou shall not!) without offering acceptable alternative models of conduct. Almost all current drug laws are negative rules which do not make sense to those who use drugs and thus brake them by definition. Therefore negative rules are difficult to enforce. In every situation where people are subjected to rules, which they do not agree with or see the rationale of, they will look for and create channels to evade these rules and protect their interests. Thus, in every closed institution (prison, boot camp, psychiatric clinic) one will find an informal/underground communication and exchange system that distributes restricted information and commodities (e.g. food, electronics, (bootlegged) alcohol and other drugs). (93) Likewise, many people disagree with speed restrictions on multiple lane highways --not only do they break them, but they also try to circumvent enforcement with radar warning devices. Positive rules, at the other hand, make sense even to those who break them and thus are easier to enforce. Traffic lights and way of passage rules, for example, are ubiquitously accepted. (94) But, illustrations of positive rules can be found in all social groups. Figure 18.5 depicts an example of a positive rule regulating tobacco smoking on a birthday. The text translates into: "We would prefer that you did not smoke in this living room until our daughter Tessa Fairy is in dreamland and we give you the sign."

Figure 18.5

The implementation process of a controlled availability of drugs must be accompanied by education and prevention activities aimed at strengthening the social determinants of self- regulation. While a certain extent of ritualization around drug use is a positive requirement of self-regulation processes --in particular some re-ritualization around alcohol use may be beneficial to users and society as a whole-- the use of illicit drugs should be de-ritualized. The symbolic power of sharing a dose of heroin should be weakened as well as the current status of heroin use as a key indicator of subcultural identity. The strong reliance on, often (group) idiosyncratic, rituals should be superseded by more general applicable rules. These should take the form of positive rules that sanction socially acceptable patterns of use.

d. Social Policy and Life Structure

In general, the life structure of drug users is not a specific target of drug policy, but rather the subject of general socio-economic policy. Unfinished education, unemployment, lack of perspective and other (psycho-social) life stressors have all been associated with problematic drug use. (95 96 97 98) In that respect, socio-economic destitute is perhaps the main determinant of increasing prevalence of (uncontrolled) drug use in and around the poverty stricken production regions. This emphasizes the multi-dimensionality of the proposed model. It may be a rather moth-eaten phrase, but drug policy must be embedded in a broader framework of socio-economic policy that aims to provide citizens with the skills and chances to pursue a satisfactory life. The potential role of drug treatment in this area will be addressed further below.

e. Availability of Cannabis and XTC

Actually, the time for adjustment of the cannabis policy is riper than ever. While there are no availability problems at the consumer level, in the current twilight zone situation the cannabis trade seems to be increasingly controlled by non-legal enterprise. The number of coffee shops is growing and some are apparently less willing to comply with the --typical Dutch-- implicit rules, for example regarding nuisance, advertisement and availability of other (il)licit drugs. Completely unrestricted opening hours, furthermore, result in a --quite undesirable-- unregulated availability. Further decriminalization, --which may imply legalization-- would allow for a controlled availability through effective regulation of (domestic) cultivation, geographical spread of sales outlets, opening hours, product range, advertisement, quality testing, etc. (99) New drugs, such as XTC could be subjected to an experimental period, in which their controlled availability through regulated channels should be guaranteed. Such a strategy would probably not only eliminate the fast developing black market, but prevent considerable potential harm when supported by well considered and targeted information campaigns. Political ignorance and fear of foreign critique, however, result in indecisiveness and procrastination. Even worse, proposals for a more repressive approach of cannabis have recently surfaced. Likewise, while the Rotterdam drug squad is unhappy with the illicit status of XTC and complains about the recent pollution of the XTC market, (100) this development is very likely the result of the targeted actions of inter-regional organized crime squads (IRTs), picking an easy mark. (101) The prolonged criminalization of these drugs can be considered a serious crime against public health.

f. Strengthening Rituals and Rules of Users of Cannabis and XTC

In the domain of life structure users of cannabis and/or XTC probably need not be targeted as a distinct population, as their lives are fairly integrated in non drug dominated networks. In contrast, the formation of rituals and rules directed at moderation and safe controlled use of these drugs will require extra attention, especially in the case of XTC. In addition to mainstream media --school, public service announcements similar to the national alcohol moderation campaign-- subcultural channels may also be utilized, for example to distribute information on how to handle in case of adverse effects of drug use. A good example of this approach is a recent flyer from MDTIC in Liverpool on how to prevent, and handle in case of, heatstroke. This glossy party flyer-like folder uses lay-out, style symbols and argot of the English rave culture to present a life-saving message and is distributed via subcultural networks, such as certain records and clothing stores. (44) Not only can these media be used to strengthen and transfer existing, but also to feed new cultural norms. Gay Men's Health Crisis' billboard advertisement campaign in the U.S. stating that "9 out of every 10 gay men use condoms" in a time that perhaps one out of 10 actually did so, provides a good example. The key issue is to go beyond simplistic don't do this, don't do that messages and provide positive identification models, non-judgmental advice, and practical examples of safe conduct. When such valuable information is introduced into the community it will be disseminated by users themselves utilizing natural network links and peer pressure. (102)

g. Availability of Heroin

The real challenge, however, is to be found in the heroin culture. Self-regulation processes in this community are seriously hampered by two decades of repression. Policy must be directed in ways which empower users, stimulate self-regulation, and make it possible for them to take responsibility for their lives in general and drug use in particular. Medical dispension of heroin or injectable drugs is perhaps beneficial for a subgroup of users, for example those with serious stages of HIV disease, but will not have a significant impact on the heroin culture as a whole. It does not take away craving for cocaine, nor does it stimulate self-control, as control over the use level remains in the hands of an outside force --the doctor who writes the script. Therefore, enlarging drug availability must be organized outside the realm of drug treatment or care. As explained before, instant legalization is likewise not advised. Instead, heroin and cocaine should gradually become easier available, and, applying the expediency principle, consumer transactions should no longer be prosecuted.

A lot can be learned from the decriminalization of cannabis and the current policy towards house addresses in Rotterdam. Future policy must be a logical elaboration of, and thus be grounded in, the current street practice of tolerated house addresses where drugs are sold and used. This implicates an important role for the police. The police must extend its tolerant approach to a more active, regulating one. Use and vending of drugs at house addresses or in certain cafes should no longer be a reason for intervention, unless it involves inadmissible nuisance or other unlawful activities (e.g. fencing). An alternative or complementary possibility is the creation or endorsement of low key members only club houses, which can best be envisaged as a hybrid of the coffee shop and the opium den, (103) where drugs can be purchased for reasonable prices and used in a relaxed atmosphere. In addition to tolerating these venues, the police should actively explain this policy to the people that run them. When use and consumer sales are no longer reasons for intervention, and when given the proper support, users will be more than willing to cooperate with the authorities to control nuisance.

An interesting example of this proposed policy --apparently practice precedes policy again-- is provided by the recent off-the-record cooperation of a police precinct, a neighborhood social safety project (a positive exception) and a house address in the west of Rotterdam. In contrast with the rather repressive social control approach sketched above, drug use itself is accepted to a certain degree in this neighborhood and provisions are taken to reduce the harm for both the neighborhood and the users. For example, a steel sharpsafe has been installed in a park where injecting happens regularly and a space has been provided to a group of users. This tolerated house address offers both smokers and injectors a place to use. While clean needles are supplied, the provisions for smokers are, however, more favorable. The place has distributed a newsletter among its visitors issuing the house rules, information about health issues and other significant topics. HIV prevention materials are supplied by a local outreach team while health workers have access to the place. Its visitors have been active in removing abandoned needles off the streets and parks in the neighborhood and the side walk in front of the place is frequently swept. Police officers visit the place several times a week to discuss the state of affairs and to provide practical advise to visitors. This regulatory approach is being extended to several dealing addresses while simultaneously, a number of really vexatious addresses have been closed down, leading to a decrease of nuisance in the neighborhood.

In general, these places should discourage injecting by offering limited provisions for injecting (however, without stimulating unintended unsafe situations) and make more moderate modes of administration, such as smoking more attractive. Perhaps a few separate venues for injecting should be created. Quality control would become feasible and new, milder, smokable products (e.g. heroin reefers) can be introduced at lower prices than injectables. Coca tea or "Cokee" may be served free as there are some indications that this may reduce cocaine craving. (7 104)

h. Changing the Rituals and Rules of the Heroin Culture

The proposed controlled availability policy will induce a gradual adaptation of rituals and rules. However, when left to its own virtue it will take some time before these cultural changes become apparent. One should not forget that most of the current rituals and rules have been developed over a period of two decades and during that period they have proved highly functional. Merely feeding the culture with information is insufficient for establishing rapid change. But, in light of the HIV epidemic among IDUs rapid speed is of the essence. Such fast interventions cannot be expected from the established treatment agencies. A view which is apparently shared by the authorities as a recent government report doubts the effectivity of the current efforts. (105) The report considers merely providing leaflets and syringes insufficient. It states that prevention policy needs to be stronger and more innovative in relation to methods of approach. The report recommends to involve (ex) users in approaching out-of-treatment populations and employing drug users as para-professionals. Institutions are suggested to encourage self-organization of drug users and offer them facilities to do so. (105) There is thus a recognized need for immediate action directed at changing the rituals and rules of the heroin culture regarding HIV related behaviors.

Only few peer support initiatives have been undertaken in the Netherlands. One Rotterdam outreach program cooperated with active IDUs to distribute clean works via established network relations (described in chapter fourteen). In the Deventer No-Risk project active and former drug users were recruited to educate out-of-treatment users. They supplied prevention materials (needles, condoms, etc.) and provided HIV prevention trainings to other users urging them to subsequently pass on the information in their networks. (106) Another pilot project in Nijmegen worked with two former sex workers to provide peer education. (107) While all of these projects suggest that involving drug users in prevention activities is feasible and promising, they also revealed some obstacles in the realm of continuity, status problems, cooperation with other professional organizations, credibility, training and support, etc. (107 108) Very similar problems are described by Broadhead and colleagues, who studied the San Francisco NIDA outreach demonstration project. (102 109) They referred to these problems as agency problems, which can occur in any bureaucratic organization. A major problem of the Dutch peer support projects has been the lack of sufficient funding, in particularly for proper scientific evaluation. As a result, it is not possible to adequately assess their contribution. Likewise, these projects have a rather weak theoretical basis. Nevertheless, peer support/pressure seems an important method for HIV prevention. The current challenge is to operationalize the concept in ways that preclude or overcome the indicated problems.

Recent sociological research offers interesting perspectives on the formation and enforcement of norms, valuable for the concept of peer based HIV prevention. (110 111) In general, emergence of norms is dependent on three factors: 1) inclinations or actors' preferences regarding their own behavior; 2) regulatory interests or actors' preferences regarding the behavior of others; and 3) enforcement resources or measures for enforcing norms, for example access to sanctions and information. Most studies of norm emergence have focussed on inclinations or enforcement resources, but these recent studies emphasize the role of regulatory interests. (111) Regulatory interests create the demand for norms, while contradictory inclinations determine the supply cost of normative compliance, giving the emergence of norms a market-like quality. Social norms can only emerge when the regulatory interests that order cooperation outweigh the contradictory inclinations that lean toward defection. (102)

As knowledge of the AIDS epidemic diffused into the IDU community, new regulatory interests to reduce high risk behaviors emerged. But, while IDUs share these regulatory interests in preventing HIV infections, there are numerous contradictory inclinations resulting from the recurrent risks inherent to survival in the heroin culture (police harassment or arrest, overdose, rip offs and violence). The reduction of these conventional risks often relied on strategies that entail risks for HIV infection (not carrying works, use of shooting galleries, using with a partner and needle sharing). (112) Nonetheless, as chapter twelve explained, new safe use norms have emerged. The aim of future interventions must thus be to strengthen already existing risk-reduction norms and where necessary stimulate their adoption.

Based on Heckathorn's theory of group-mediated social control, (110 111) Broadhead and Heckathorn have designed a model to harness the potential contributions of IDUs' peer support, which, they claim, will preclude the discussed agency problems. (113) This model, "termed client-driven intervention (CDI) is based on two design principles. First, to preclude agency problems, IDUs are provided with modest, but direct incentives to take over the functions traditionally performed by outreach workers. Second, to foster the creation of risk- reduction norms or bolster already existing norms, [the program relies] on secondary rather than primary incentives. [T]he aim is not merely to affect the behavior of individual IDUs, but to alter the manner in which IDUs exercise influence over one another." (102) (emphasis in original) In this design IDUs will receive a modest payment or primary incentive for their participation in an interview-test-education session. Ensuing they will be receiving additional payments for recruiting peers, educating them and distributing prevention materials. These latter payments will be provided afterwards and are secondary incentives as they reward measured changes in their peers' behavior. In their proposed study Broadhead and Heckathorn will compare a CDI with a traditional outreach design.

The CDI model seems also promising for utilization in the Netherlands. The socio-political conditions may even be superior compared to the USA. The possibilities of more formal forms of drug users' self-organization, at the other hand, have not yet been sufficiently examined in the Netherlands. Both the success of the Dutch Junkiebonden (junkie unions) during the 1980s (114) and the current Australian practice of engaging drug user self-organizations in HIV prevention (115 116) suggest an important reservoir. It will be highly interesting to assess the validity of the two models for the Dutch situation. A comparative study is currently being planned. (117)

i. Improving the Life Structure of Marginalized Users

When drugs become normally available the need to spend much time on drug related activities and with other drug users diminishes. Many users will be able to pick up conventional activities and responsibilities (such as work) again, and their social network will gradually consist of less drug related connections. On the other hand, persistent involvement in illicit drug use limited the feasibility of developing legal professional skills and made the development and maintenance of criminal skills useful and opportune. Criminal activities not infrequently developed prior to or simultaneously to the drug use career (66) and a considerable number of people have never been legally employed. The informal job market (drug dealing, acquisition crime, prostitution) provides meaning and structure to the lives of many people with little chances of legal employment. (73) These factors may seriously hamper the normalization of the life structures of many users. This will be exacerbated by the high level of stigmatization and the resulting impaired self-concept. Furthermore, as was discussed in 18.3, for many marginalized users drugs are only one of the many problems. Homelessness, a complete lack of perspective, psycho-social problems and an impaired health status (HIV) are among the problems that will further frustrate making changes.

These are among the problems to be addressed by future treatment and care policy. Mindful of the discussion in 18.3, however, it is doubtful if the established treatment and care system -- with its large emphasis on maintaining or curing opiate addiction-- is equipped to take on these new challenges. It appears too much to be a one size fits all approach with little tailoring towards needs and potentials of individual clients. (86) Therefore, revitalization and reorganization of the treatment and care system is an important element of future policy. Old dogmas and structures should be reconsidered and examined on their significance in the context of the new policies. New objectives need to be formulated and perhaps new organizational frameworks established, that cut through existing barriers. Without making any pretensions to comprehensiveness, the following paragraphs will discuss some of the areas to be considered.

Drug users have the same right to health care as any other citizen in the Netherlands. Their treatment and care needs should be met by appropriate approaches, whether these are provided by general or specialized (psycho-social) health care organizations, including drug treatment programs. Drug use in itself may not be a ground for refusal. Independent intensive case management, which matches clients' needs with the services offered can make an important contribution to this aim. These cost-effective case managers can be envisaged as a type of consumer brokers, who can work to help clients negotiate the multiple and complex systems of existing institutions and further serve as advocates on behalf of marginalized clients who are not accustomed to doing so for themselves. Case management can help marginalized users to regain some control over their lives again and prevent others' slipping into (further) marginalization. It will also lead to a more efficient utilization of the existing service capacity. Perhaps the provision of services to drug users should obtain more of a free market quality. In New Zealand, for example, the introduction of free market health care has seemingly had a positive effect on the empowerment of users, as they gained the same status as consumers of any other health care provision. (118)

Financial management (e.g. benefits, bills, debts) can prevent many of the currently typical problems, such as evictions from housing. In Rotterdam, a low threshold SRO (single room occupancy) would meet the needs of many currently homeless users. In that way, they would also be much easier to approach by other service providers and become more responsive to public health interventions, such as HIV prevention or TB campaigns, as it has been established that homelessness and the resulting inability to plan and organize is associated with enduring risk behavior and positive serostatus. (119)

One of the main determinants of life structure is a steady pattern of daily activities. It is almost undisputed that work fulfills an important role, both in respect to daily patterning and in terms of social status and self-respect. So called re-socialization programs which offer skills and job training have been in function for quite a while, but their results are not always clear, as little evaluation has been conducted. Often these projects are part of the same organization that runs the methadone program and only clients qualify. One can wonder whether a certificate from a drug re-socialization program is an advantage in a job interview. Often programs are rather inflexible without exploring and developing personal skills and talents. A skillful con man may well be trained to be a successful insurance salesman. It can furthermore be questioned whether the activities many of these programs offer match the demands of the labor market. It is therefore advisable that these specialized projects are incorporated by, or form solid referral agreements with general job training programs. The goal must be to help people get real jobs. Experiments in this direction are currently underway and seem promising. (120 121) Currently, most projects are open only to ex-users, or persons who only use methadone. It is advisable to relax this criterium to stabilized users. Likewise, methadone programs should be more flexible to working schedules of employed clients.

Additional (illegal) drug use is often a ground for expulsion from treatment. It is a truly bizarre phenomenon that upon discovery of use --whether this entails an occasion of recreational use or a relapse into symptomatic behavior-- people are debarred from treatment. Wouldn't it be equally or more justifiable to intensify the treatment? After all, in many cases problematic drug use has been the reason for seeking treatment in the first place.

Methadone dispension should be separated more from other services. Treatment is now often polluted by all sorts of power games around this synthetic substitution drug. By separating the two, treatment goals become clearer and trusting relationships between client and therapist are better possible. Methadone dispension schedules could be personalized. For some clients it is best to pick up their methadone seven days a week, for others once a week suffices. In Rotterdam the methadone dispension has recently been computerized. Perhaps providing clients with a PIN-code card should be considered, so that they themselves can choose the time of pick up, resulting in a more even spread over the day. This would decrease their dependence on the system and limit the scene function of the methadone programs. Many clients would be better served if they could get their methadone from their general practitioner, guaranteed that the GP receives the proper support. (122 123) One can imagine that when drugs become easier available, the demand for methadone would be reduced anyway. Its function would probably also change as it would less frequent be used as a maintenance and more as a crisis or reduction drug.

A seriously under-developed area in the Dutch drug services field is health maintenance. The need for a health maintenance approach will grow with concerns about HIV infection, but it would be erroneous to limit such an approach to HIV care or AIDS prevention. Currently, licenced nurses invest the majority of their time in methadone dispension --an incredible waist of human resource and training, which decreases job satisfaction and contributes to the negative image many have of their clients. With the right additional training, their skills can be utilized in helping their clients learn to maintain their own health, given the resources available to them.

The policy changes and interventions discussed in this section, while not a panacea and certainly necessitating the same scrutiny as any other well intentioned advice, are logical extensions of the current normalization policy. It is expected that they will gradually reduce the problematic nature of illicit drug use to its genuine proportions and allow users as well as society at large to deal with the effects of drugs in a more rational manner. As has been put forward before, the proposed changes must be carefully monitored by research. Therefore, the final section of this chapter will consider some research issues.

Considerations for Future Research

The studies reported in this thesis all considered certain aspects of drug use behavior in its natural environment. Little detail is yet known about the behaviors of drug users outside treatment institutions, in particular in Europe. Some epidemiological studies are available, but these explain little of the drug taking behavior itself, nor of its functions and meanings. As explained before, this lack of knowledge has been the reason for choosing ethnography as the principle methodology of the project. (124) This approach has been highly fruitful, as many different aspects of drug use could be described and interrelated in a wider context. The lack of existing knowledge was likewise the reason for the rather general initial research questions. The resulting wide scope allowed for the formulation of several hypotheses along the research process --of which some have subsequently been assessed in a quantitative manner-- and the serendipitous discovery of frontloading.

In particular in the rather virgin field of AIDS and drug use there is still much to discover for which we may be blind when merely relying on standardized measurements. As Turnbull wrote: "It is too easy to go into a field situation expecting or hoping to find this or that, for invariably you come out having found what you wanted. Selectivity can do great things in blinding one to a wider reality." (125) The need for studies which add to our basic knowledge of drug use, its relations with HIV and the factors that obstruct or promote safer and controlled drug use is obvious and urgent. Exactly here, ethnography has much to offer as it has a rich and fruitful history in exploring and explaining drug use behaviors. It is a large and precious reservoir of theoretical and practical knowledge, which can be drawn from in designing AIDS and drugs studies.

In addition to this open focus ethnography, there is a clear need for controlled field intervention studies which develop simple, practical methods and strategies for checking the spread of HIV in the drug user community, grounded in its cultural traditions. In that respect, it is of crucial importance to contact those populations that are currently unreached. In order to generate reliable and valid data, such studies --consider the name Experimental Comparative Ethnography-- must include multiple research sites and experiment with new methodologies that refine ethnographic techniques for intensive case-finding and description, for example randomized snowball sampling, (126) network analysis (127) and Experience Sampling. (64 128) The urgency of the AIDS pandemic underlines the necessity of cooperation between, and integration of, qualitative and quantitative approaches, in particular in search of innovative methodologies. Attempts in this direction are e.g. undertaken in some of the American NIDA demonstration projects. (129) Unfortunately, in many of these projects the ethnographic component has been made subservient to the collection of large statistically analyzable data bases. Instead, ethnographers should take an active role in designing multimethod studies, that are driven by ethnographic analysis. Ethnography is especially suited to give direction to such multidisciplinary projects as it can build bridges between policy and hidden populations (130) which are essential for successful drugs and AIDS policies. Ethnography provides the information, skills and experience required for working with indigenous research collaborators and, above all, it can generate the theoretical framework and testable hypotheses for subsequent quantification. Thus, ethnography provides not only the eyes and ears of the research but also its thriving analytical power. An interesting example of such an inventive cooperation is provided by the above discussed CDI design. (113)

In this thesis a theoretical model has been presented for explaining self-regulation processes in human drug taking. In the previous chapter the model was used to explain the paradoxical cocaine/heroin patterns of the study subjects. But application is not limited to this population. It may equally be applied to other populations and other drugs. The model seems suitable for application in qualitative, quantitative and mixed designs. It can be utilized in cross-cultural comparisons of drug policies and different populations or subcultures using the same drug. The model may likewise be used in longitudinal and evaluation studies. An important future task will be to operationalize and refine the model and its determinants. The following variables can then be considered for inclusion:

• Demographic and background statistics
• General and personal socio-economic circumstances
• Drug use variables (type, dose, frequency)
• Social network variables
• Individual and social ritualization processes (e.g. the nature of rituals; the intensity of ritualization)
• Nature and power of rules
• Drug users' subjective experiences and time patterning regarding their drug use
• Psycho-social health
• Physical health
• Treatment history
• Drug availability, both at the general and the personal level.
• Legal and social status of drugs
• Parameters of subculture (e.g. argot, sign language, style symbols)

Another matter in need of further study is the apparent graduality and multidimensionality of self-regulation processes and their relevance in the development of comprehensive definitions. As was explained in chapter three, the development of valid definitions of drug use related states has been a long and unrewarding task. Feeling a need for a concise definition of, for example, controlled drug use, one may be tempted to define such a notion in terms of quantifiable measures. But beyond the extreme examples, sheer quantity is an insufficient measurement. Quality of use --operationalized in the factors that constitute the feedback model-- should therefore play an important role in attempts to define these issues. (131)

Future drug use research in the Netherlands should concentrate on the factors that determine self-regulation processes. As this has recently also been suggested in a position paper on research of the Dutch ministry of health, (132) this should have consequences for funding. Utilizing the feedback model several studies can be suggested, for example:

• An Experimental Comparative Ethnography of XTC use in selected cities in the Netherlands (e.g. Rotterdam or Amsterdam), the United Kingdom (London, Manchester or Liverpool) and the USA (New York or Chicago) for example, will provide significant information on this comparably new and unpolluted drug phenomenon.
• Another study might focus on the suggestion that new groups of heroin users (e.g. young Moroccans in Amsterdam) are seemingly able to regulate their use of this substance in ways that avoid loss of control.

Finally, two research issues, significant to the prevention of HIV need to be addressed. First, as the HIV infection potential of Syringe Mediated Drug Sharing techniques has been recently established, (133) the prevalence, circumstances, and possibilities for prevention of HIV transmission through these techniques need to be studied. Secondly, as ammonia is almost ubiquitously available on dealing addresses, it is worthwhile to assess its potential as a viricide in needle cleaning simulations. (134) If this agent would prove effective it could be promoted among IDUs in the Netherlands. As it is a familiar product in the heroin/cocaine scene, acceptation as a simple disinfectant may be much easier than when bleach would be promoted as such.

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