The Dutch Approach: Normalization of Drug Problems

Abstract

Dutch drug policy has received widespread but mostly critical attention. Criticisms arise in part from a misunderstanding of the policy, which is perceived to be more permissive than it actually is. In fact, Dutch drug laws are similar to those of other western countries, although they are enforced with more flexibility in order to minimize harmful effects on drug users. Dutch policy relies heavily on prevention, as well as treatment of drug problems. Although available statistics suggest that these policies are relatively successful in the Netherlands, careful consideration must be given to situational variables in any attempts to adopt them elsewhere.

Since1976 the Dutch have operated under a differentiated enforcement policy toward drugs, in which distinctions are made between substances presenting different degrees of risk, and between drug users and suppliers. This article examines the Dutch experience and attempts to evaluate its success from the perspectives of both enforcement and prevention. In doing so, it seeks lessons from the Dutch experience that might be applied to other nations.

Dutch policy has been for some time the object of widespread and mostly critical attention. While some Dutch initiatives such as preliminary plans for heroin maintenance programs in the city of Amsterdam have appeared to be provocative and ill-conceived, other programs such as the rather successful AIDS campaign in the Netherlands and the opening of needle-exchange programs have led to a more positive interest in the Dutch model (van Brussel and Buning 1988; van de Wijngaart 1987).

Caution is required, however, in accurately describing Dutch policy and interpreting its outcomes. One course of error is the essential nature of the policy. Dutch policy aims at the "normalization" of drug problems. However, this policy is far from complete normalization of drug use. The basis of the "normalization of use" view is that individuals, and cultures, can learn to handle drugs in a relatively safe way (which may include a decision to say "no" to using them). However, international treaties such as the 1961 Single Convention have made it virtually impossible for people to get acquainted with illicit drugs, so there has been little opportunity for this learning to take place. Current Dutch law forbids the possession or presence of illicit drugs, so drug use may lead to criminal prosecution. The fact that criminal consequences can arise in the Netherlands for the use of most drugs (other than cannabis) shows that the country's drug policy does not completely conform to the normalization of use model.

Before the amendment of the Opium Act in 1976, Dutch policy was virtually indistinguishable from that of other nations. However, since that year "drugs presenting unacceptable risks," such as heroin, cocaine, amphetamines, LSD and hash oil (liquid hashish), have been distinguished from "traditional hemp products" such as hashish and marijuana. According to the Dutch government

... the Act also reflects the view that criminal law plays only a minor part in preventing individual drug abuse. Although the risk to society must of course be taken into account, every possible effort must be made to ensure that users are not caused more harm by criminal proceedings than by the use of the drug itself (Ministry of Welfare, Health and Cultural Affairs 1985:1).

In the Netherlands, distinctions are also made between formal requirements of the law and what the public prosecutor prescribes as policy for implementing the law (sometimes referred to as pseudo law making). It is the public prosecutor who actually governs prosecution policy. The prosecution policy pursued in implementing the Opium Act also reflects the view that differing risks incurred by drug abuse should be considered.

One of the basic premises of Dutch criminal procedure is the expediency principle laid down in the Code of Criminal Procedure whereby the Public Prosecutions department is empowered to refrain from bringing criminal proceedings if there are weighty public interests to be considered ( "on grounds deriving from the general good"). Guidelines have therefore been established for detecting and prosecuting offenses under the Opium Act. Similar guidelines also exist for other offenses such as the illegal possession of arms, pirate broadcasting, and exceeding the speed limit. The guidelines contain recommendations regarding the penalties to be exacted and set out the priorities to be observed in detecting and prosecuting offenses. The scale of properties adopted corresponds to the distinction made in the Opium Act. Accordingly, detecting the import and export of "drugs presenting unacceptable risks" takes the highest priority, whilst detecting the possession of "hemp products" for personal use takes the lowest priority. Special police officers and customs officials take specific action to detect the import and export of, and large-scale trafficking in, all drugs (including hemp products).

The application of the expediency principle in the Netherlands may be seen as part of a pragmatic prosecution policy. In cases involving low-priority offenses, the Public Prosecutions Department may decide not to prosecute. The law thus steps aside, as it were, in cases where prosecution would have no beneficial effect in reducing the risks involved. This may be the case for example, if criminal proceedings against users of hemp products would create more problems from them than would be solved (Ministry of Welfare, Health and Cultural Affairs 1985:1-2).

Some of the differences between the Netherlands and other countries can be explained by this distinction between legal requirements and decisions made under enforcement policy.

A problem in making any clear statement about the success or failure of Dutch policy is that such statements necessarily make assumptions about what would have happened if the policy had not been adopted. Yet we have no means of knowing, for example, what the current rate of marijuana use in the Netherlands would be if the country had all along adopted the same policies for this substance as England or the United States. It is interesting, nonetheless, to contemplate the effects of Dutch law regarding cannabis. Since 1976 the amended Opium Act and prosecution policy have created a de facto decriminalization of the use of help products, but have not led to an increase in their use. According to the Dutch government:

"In 1976, 3% of young people aged 15-16 and 10% of the 17-18 age group had occasionally used hashish or marijuana. In 1985 these figures were 2% and 6% respectively" (Ministry of Welfare, Health and Cultural Affairs 1985:2).

Other sources of data also indicate that a decreasing number of adolescents smoke hashish and marijuana. A survey by Sijlbing (1984; Sijlbing and Persoon 1985) showed that twelve percent of high school students in the Netherlands used cannabis at least once in their lifetime, considerably less than the fifty-nine percent found for the same group in the United States (Johnston et al. 1984). Current use (monthly prevalence) in the same population is also lower in the Netherlands than in the United States: five percent (Sijlbing 1984) as compared with twenty-nine percent (Johnston et al. 1984).

In the Netherlands today, cannabis products are generally seen as substances that do not cause unacceptable risks. Recent research (Husain and Khan 1985; Mechoulam 1984) indicates that the use of cannabis is not without risks, and that these risks might have been underestimated in the past. On the other hand, these risks should not be exaggerated (Lasagna 1986). From time to time the story of new, allegedly stronger and more dangerous marijuana re-emerges. Recently, this story has been demythologized by Mikuriya and Aldrich (1988). They have argued that the range of potencies available in the mid-1970s was approximately the same (averaging two percent to five percent THC) as that reported in the second half of the 1980s. Moreover, the old medical cannabis extracts were apparently stronger than most of the forms now available.

To sum up, the use of cannabis in the Netherlands has been decriminalized to a certain extent, as illustrated by the undisturbed sale in so-called coffee shops where the use of alcohol and "hard drugs" is not allowed. It has also been normalized through "recreative use" by the generation of the sixties and others, domestication of use, and, in public areas, passive acceptance by the general public. Yet little cannabis is used. De facto decriminalization of cannabis does not appear to produce more cannabis use, and does appear to be successful.

However, the number of drug users is not the most important factor in evaluating the success of the policy. There are more important questions we need to ask. In what conditions do the users live? Are they socially marginalized, or accessible to programs of help and able to five a normal life? What is the quality of life for the population as a whole? Are drug users under constant surveillance, or do they enjoy the feeling that they are - within reasonable limits - free to choose their own lifestyle?

In terms of these questions, there can be no doubt that Dutch policy is very successful compared to others. Foreign visitors may be shaken about the "junkies" that they encounter in the shopping areas or entertainment centers of Amsterdam, but the fact that they can encounter them there is one of the triumphs of the policy. In other countries, drug users are forced - sometimes literally - to "go underground," i.e., to five in conditions comparable to those of an escaped convict. This increases health risks and vulnerability to exploitation enormously. In the words of the Dutch Minister of Justice Korthals Ades (1987)

In the Netherlands we give high priority to services directed primarily at improving the health and social functioning of the addict, without necessarily ending addiction, because a lot of addicts are not, or not yet, capable of kicking the habit. Addiction involves a lifestyle which cannot be changed easily and quickly.

We note that the majority of addicts have some contact with medical and social services which we appreciate as a very positive development. It is a fact that there are few depraved addicts, the junky-type addicts, and the death rate among addicts is only 0.5%, which is low in comparison with other countries. This approach may be characterized as harm reduction.

These very circumstances, in fact, explain the presence in the Netherlands, especially in Amsterdam, of a considerable number of drug users who are escaping from repressive policies of other countries. An estimated thirty percent of all drug addicts in Amsterdam are foreigners. Most of these are Germans, followed by Italians (who exceed the number of Germans in the summer months) and English. Thus, to an extent the failures of other countries' policies are being wrongly charged to the Dutch account.

As far as the total number of regular (dependent) hard drug (i.e., other than marijuana or hashish) users is concerned, the indications are that the level of use is slightly lower than in other countries, and has stabilized with few new cases being reported (de Zwart 1989). Figures per 100,000 inhabitants are Netherlands, 100-130; Federal Republic of Germany, 130; Great Britain, 107-143; Den-mark, 120-160; Norway, 125; Sweden, 125-175; and Italy, 140. In the Netherlands, the condition of these users is better, however, in terms of both social integration and access to welfare services.

Data about drug users give us only one side of the story. Like other "normalizing" strategies, Dutch policy is not only directed at "problem cases," but is also a long-term policy of prevention. The Dutch government has recognized that activities which try to control the demand for drugs are preferable to those which try to control the supply of drugs.

It is generally recognized that experimenting with drugs does not automatically lead to regular or excessive use. The number of experimenters Who subsequently give up the use of these substances, or the occasional users (so-called chippers) is several times greater than the number who ultimately become addicts (Zinberg 1984). Consequently, preventing drug-related problems may receive more emphasis than preventing drug use.

Research into lifestyles of heroin addicts in the Netherlands, stimulated by the government, has shown that from the point of view of the addicts, the use of drugs has a certain functional significance. It is by using drugs that they are able to cope with difficulties, conflicts, contradictions and other problems they encounter in society. This finding has broadened understanding of the reasons for turning to drug addiction and makes clear that current measures of prevention are not necessarily the most appropriate solution. New approaches toward prevention, aimed at both demand reduction and harm reduction, are emerging (Janssen and Swierstra 1983).

The Dutch government takes the view (Ministry of Welfare, Health and Cultural Affairs 1985) that the significance of information as a means of preventing drug abuse should not be overestimated. Studies by de Haes and Schuurman (1975) and others have shown that publicity is ineffective in preventing problems of drug abuse, particularly where it has the effect of sensationalizing the dangers of drugs. It may even encourage the onset of drug use (cf. Nowlis 1980). Publicity of this kind is likely to be one-sided and is, therefore, not used by the Dutch government.

However, it has also been shown that non-sensational drug/health education projects which have been embedded in the school curricula do have positive effects on the attitudes (knowledge, opinion, and concrete behavior) of school children (van de Wijngaart and Vendelbosch 1989). Long-term projects show better results than single interventions. Nevertheless, one should not expect miracles from school-based education programs. The example set by parents and other role models in the social and cultural context has been found to be of greater influence.

Good prevention policy also encompasses the treatment of users who have become addicted and who are asking for help. Those who are not quite ready to stop the use of illegal substances might enter methadone maintenance care, which includes provision of methadone, tolerance of additional use of other substances, basic care and social security benefits. This approach is typical of Dutch assistance aimed at harm reduction (van de Wijngaart 1988). Others might enter drug-free treatment programs because they wish to kick the habit and become socialized into a new way of life. Treatment is directed toward meeting friends outside the drug scene, finishing school or vocational training, and developing a new lifestyle.

Entering the job market and acquiring a position of one's own is difficult in the Netherlands because of the unfavorable unemployment rate and the inflexible job market. Money has been invested in treatment without the necessary funding for actual rehabilitation. Without a reasonable alternative, relapse into addiction is likely, making treatment a vicious circle, a dead-end street without reward for the client and a burnout for the counselor or therapist. Unfortunately, successful work projects have been scarce in the Netherlands until now, and the Dutch could learn in this respect from experiences in Denmark and the United States.

The lack of (re)habilitation opportunities is not the only weak feature of the Dutch model. Recently, the head of the national Alcohol, Drugs and Tobacco branch of the Ministry of Health expressed the view that the demand for public order rather than the actual needs of drug addicts increasingly seems to be the basis for relief work. In 1988, a memorandum was sent to parliament about "compulsion and pressure in the treatment of addicts." Although no new legal proposals have been made, both the judiciary and the treatment system were urged to make more creative use of existing legal possibilities to pressure addicts into treatment (Engelsman 1988 and 1989). Moreover, cutbacks in governmental. expenditure are beginning to lead to signs of deterioration in the aid-giving system (Verbraeck and van de Wijngaart 1989).

To what extent can insights gained from the Dutch experience be applied in other countries, as has been recommended by Trebach (1987), Nadelmann (1988), Wisotsky (1988) and others? Our studies have emphasized understanding drug use in the context of its specific cultural and historical situation. By its very nature, this understanding cannot simply be extrapolated to other social contexts. One must be cautious in attempting to generalize insights from one setting to problems confronting other lands. The case of psychiatric policy in northern Italy provides a relevant example. There a radical normalizing policy was implemented across a whole range of psychiatric services. However, when similar ventures were undertaken in France, Great Britain and the United States, the cultural and historical context of these lands was so different from that of northern Italy that few of the same results were effected (Ingleby 1980).

In the same way, there is absolutely no guarantee that attempts to follow Dutch drug policy in other countries would meet with success. Like the Italian "democratic psychiatry," the policy depends strongly for its success on public as well as professional support. Crucial elements of the Dutch context would appear to be a strong belief in equal rights, belief in the possibility and legitimacy of social intervention, and a sound system of welfare and health care provisions. On the other hand, the Dutch context does not include other factors which seem to be important elements of the "drug problem" in the United States. The existence of strong social polarities, the lack of adequate welfare provisions, and the sheer geographical size of the country. Draper (1987) has argued that it is hardly possible to isolate drug policy from foreign, economic and social policy. He concluded that, while good social policy is not a panacea for drug problems, it can contribute to their solution.

It is clear from the above considerations that application of insights from the Dutch experience of normalization to the problems of other lands is a complex matter. However, it is tempting to summarize a few viable features.

First, in order to develop a realistic and pragmatic approach to drugs, it must first be recognized that throughout history people in different cultures have used substances that have the potential to make life more comfortable, less tiring and more attractive. The substances, people and circumstances have varied from culture to culture. Drug use, like all behavior, always occurs in a complex social and cultural context which often gives meaning to the behavior. No simple relationships exist between cause and effect. Patterns of drug use are influenced by many factors such as family, school, church, community, peer groups and the media.

Most people learn to deal with these substances without getting into trouble: one could speak of nonproblematic or controlled use. A minority might find itself in a situation where experience with drugs could lead to problematic use. This is essentially a matter of health and social well-being. That is why a differentiated system of welfare and health care provisions is required, tailored to the individual needs of the addict-client. Moreover, there are people who may not be (yet) willing or able to give up drug use. For these, easy access to low-threshold care facilities is required. Health education in general and the promotion of "safe" drug use and "safe" sex techniques in particular are essential. These are closely connected to the availability of new sterile syringes and condoms.

Further strategies from the Dutch experience might also be applied in other contexts. For example, the interests of drug users could be generally promoted by a union-like organization such as the Dutch Junkiebond (Junkie League). Drug users themselves might play an important role in peer education, as well as in counseling seropositive buddies. Differentiation between various substances could prove successful, as it has between cannabis and illicit substances in the Netherlands. Last but not least, one could study the effects of a non- criminalizing approach to "new" substances.

In containing drug problems it is important to recognize that the criminal status of drug use is a major factor in causing problems for addicts and the community in general. However, we agree with Alexander (1988) that the transition from the present situation to a more measured response to drugs should be a gentle one. It would seem unwise to make too many new drugs publicly available in a short time, because time is required for society to "domesticate" new drugs for general usage and to adapt to a new way of thinking (van de Wijngaart in press).

Good counsel is never out of date, and it is at least encouraging to note that, in the context of regular international congresses and policy studies, a frank exchange of viewpoints is under way. For example, a recent meeting of experts from different European countries and the United States concluded:

Legal and illegal drugs have several basic similarities. The distinctions drawn between them today are a result of various historical conditions. The distinctions are not based on the innate character of the various substances.

The results of the system of prohibition and of severe penal measures against the totally forbidden substances, are poor compared to the costs. The "control costs" are mounting and threaten internal peace and the preservation of central values of human rights in many countries. Examples of "control costs" are: consolidation of organized crime, the undermining of the principles of legality and due process and the diversion of scarce law enforcement resources. The huge amount of money circulating in the drugs trade threatens international economic and political stability.

In view of this situation, the participants of the seminar are of the opinion that the international community must commence now the work of analyzing the possibilities for bringing the total prohibition within this field to an end and create instead control systems similar to those used vis a vis other potentially harmful substances. Emphasis ought instead to be put on prevention through general health education and the encouraging of a sound lifestyle.

As an interim step the group would suggest a considerable reduction in the punishment level. The use of capital punishment for drug dealing ought immediately to be brought to a stop. Personal use and the possession for that use should not be punished (Wisotsky 1988).

Far-reaching steps like the ones mentioned above require a lot of discussion, and solutions will differ across cultures, especially in the time needed to introduce them. The Netherlands has recognized that there is no ideal solution. Fortunately, both politicians and experts from different disciplines are prepared to listen to each other and consider with open mind policies that may be suited to the Dutch situation.

In these efforts, the biggest problem may be to find solutions that will be respected by neighboring countries. However, cooperation should not have to mean giving up one's special qualities and achievements. Engelsman (1989) has stated that the present attempts in the United Nations to merge national drug policies into a single global approach are bound to prove counterproductive for many countries, since such a universal approach neglects cultural, economic and legal differences among all member countries.

Finally, as the Scottish poet Robert Burns observed, "the best-laid schemes of mice and men gang aft agley." Nowhere is the discrepancy between good intentions and actual consequences greater than in the field of social policy. Drug policy - as the War on Drugs dramatically shows - is no exception to this rule. A more enlightened and vigorous policy, if we seriously want it to have a better chance of success, will have to be systematically based on empirical studies which do justice to the complexity of the problem. Good policy is based on facts, not on myths and propaganda.

Alexander, B.K.
1988 Alternatives to the war on drugs. In The cost of prohibition on Drugs, Radical Party and CO.R.A. (eds.) 200-209. Rome: Coordinamento Radicale Antiproibizionista.

Brussel, G. van and Buning, E.
1988 Public health management of AIDS and drugs in Amsterdam. In Problems of drug dependence, L.S. Harris (ed.). NIDA Research Monograph 90. 295-301

Draper, R.
1987 Balancing of supply and demand. 16th ICAA Int'l. Institute on the Prevention and Treatment of Drug Dependence. Lausanne, Switzerland.

Engelsman, E.L.
1988 Het Nederlands drugsbeleid in West-Europees perspectief (Dutch drug policy in a Western-European perspective). International Conference on Drug Policy. Tilburg: KUB (3 June).

Engelsman, E.L.
1989 Dutch policy on the management of drug-related problems. Brit. J. Addiction 84(2):211-218.

Haes, W. de and J. Schuurman
1975 Results of an evaluation study of three drug education methods. Int. J. Health Education 18(4):suppl.

Husain, S. and 1. Khan
1985 An update on cannabis research. Bulletin on Narcotics 37(4):3-13.

Ingleby, J.D. (ed.)
1980 Critical psychiatry: The politics of mental health. New York: Pantheon.

Janssen, O. and K. Swierstra
1983 On defining "hard core addicts. " Groningen, Sweden: Institute of Criminology.

Johnston, L.D., P.M. O'Malley and J.G. Bachman
1984 Highlights from Drugs and American high school students, 1975-1983. Washington, D.C.: NIDA.

Korthals Altes, F.
1987 Address by the Minister of Justice of the Kingdom of the Netherlands. International Conference on Drug Abuse and Illicit Trafficking. Vienna: United Nations (General Debate, 19 June).

Lasagna, L.
1986 Is the social use of marijuana dangerous or addicting? Controversies in alcoholism and substance abuse 77-81.

Mechoulam, R.
1984 Research on cannabis: An overview. Impact of science on society 133:23-33.

Mikuriya, T.H. and M.R. Aldrich
1988 Cannabis 1988 - Old drug, new dangers: The potency question. J. Psychoactive Drugs 20(1):47-55.

Ministry of Welfare, Health and Cultural Affairs
1985 Policy on drug users (Fact Sheet 19).

Nadelmann, E.A.
1988 The case for legalization. The Public Interest 92:3-31.

Nowlis, H.
1980 Drug demystified. Paris: Unesco/United Nations.

Sijlbing, G.
1984 The use of drugs and alcohol by Dutch youth. 14th International Institute on the Prevention and Treatment of Drug Dependence. Athens, Greece.

Sijlbing' G. and J.M.G. Persoon
1985 Cannabis use among youth in the Netherlands. Bulletin on Narcotics 37(4):51-60.

Trebach, A.S.
1987 The great drug war. New York: Macmillan.

Verbraeck, H. and G.F. van de Wijngaart
1989 Ervaringen van clienten met methadonverstrekking (Clients' experiences with methadone programs). Tijdschrift voor Alcohol, Drugs en andere Psychotrope stoffen 15(4).

Wijngaart, G.F. van de
1987 AIDS prevention policies among drug users. International Conference on Drug Abuse and Illicit Trafficking. Vienna: United Nations (NGO - Forum).

Wijngaart, G.F. van de
1988 Methadone in the Netherlands: An evaluation. Int. J. Addiction 23(9):913-925.

Wijngaart, G.F. van de
in press Competing perspectives on drug use - the Dutch experience. London: Routledge.

Wijngaart, G.F. van de and H. Vendelbosch
1989 Evaluation of the NCA school program on alcohol and tobacco. In Proceedings of the 35th Int'l. Congress on Alcoholism and Drug Dependence, R.B. Waahlberg (ed.) Vol. IV: 712-716.

Wisotsky, S.
1988 Recent developments in the American War on Drugs. International Conference on Drug Policy. Tilburg: KUB.

Zinberg, N.
1984 Drug, set and setting. New Haven and London: Yale University Press.

Zwart, W.M. de
1989 Alcohol, tabak en drugs in cijfers. Utrecht: NIAD.