The elusive history of Dutch drug policy: Experiments with Delphi and scenario methods

Dick Osseman, EATI

Introduction
Analysis of Dutch drug policy discussion through the Delphi method
Conclusions from the Delphi study
Recent history of Dutch drug policy
First period: up and until the 1960s
Second period: the fight against cannabis
Third period: late sixties into middle eighties
Mid eighties till 1995
Latter half of the 1990s
From the past into the future: four scenarios
Risk reduction scenario
Drug-free society scenario
Deregulation scenario
Differentiated legalisation scenario
Which scenario will prevail?

Introduction

When preparing this text I read an article by Virginia Berridge entitled "European Drug Policies. The Need for Historical Policy Perspectives"1) . In it, a closer analysis of policymaking dealing with drugs in the light of a historical context was advocated. She mentions a deeper past and the contemporary history of more recent policy developments. In essence, the claim was made (as it can be made often) that an inspection from a historical point of view and taking into account all imaginable influences (national and international, from all layers of society and all professions involved) would enable us to explain how policies developed. The author stated that to her mind little if any of such studies had been performed. She then gave a minute overview of the development of drug policies in the recent past in some European countries, stating that in order to understand these better "we need interviews with policy makers, access to government manuscript documentation, focusing on constructing the real cut and thrust of policy making rather than the bland end-products". Elements that would deserve further research were, in her mind: the role of professionals, volunteer and religious organisations, and the state. Next, the role of fear and crisis (for example, a fear for a cocaine epidemic among British soldiers that turned out to be illusory, but nevertheless allowed wartime regulations to be passed). Then, the role of international and national politics (the developing European Community2) is an example). And finally the study of different models of dealing with drugs (open availability, legal regulation, medical control, public health regulation, to name a few).

The present article does not attempt to be a comprehensive analysis of Dutch drug policy and of the factors that have influenced its development. Rather, it presents two "snapshots" of the policy making process. One of them is based on a study in which the Delphi method was used to shed light on drug policy discussion back in the 1980s. The second one draws on a study published in the late 1990s that examined the development of drug policies over the last decennia and presented a set of alternative scenarios for future drug policy.

Analysis of Dutch drug policy discussion through the Delphi method

In his doctorate thesis "De Hollandse aanpak"3) (The Dutch approach) Dr. Arthur Baanders described his research on the Dutch decision culture. He did this partly because in earlier research he had come to some tentative conclusions, which he wanted to test further. They were:

The societal heroin problem has become impossible to solve.
The magnitude of the problem is to a great extent due to the consumption of heroin being criminalised and medicalised.
The rise in the influence (and number) of the psychotherapeutic professions has "psychologised" the view on the individual and social problems with heroin. Its consumption is looked upon as a psychological derailment that can be corrected with psychological insight.
Nevertheless, the societal heroin problem is so complex that the current psychological approaches do not provide relieve.
The people who make up the group of psychotherapeutic professions are so much put to the test and disoriented by the heroin consumers and the demand they put on these workers, that they do not solve the problem, but rather transform: their interventions become part of the societal problem.
Nevertheless, psychological approaches must be considered to be best, because of the indispensable support given by the psychotherapeutic praxis and because of the hope that is implicitly provided by the psychotherapeutic referential framework.
Secondly the psychotherapeutic theories provide the best basis for the development of strategies to adequately push back the societal heroin problem (better rephrased as poly drug problem).

In order to test his ideas the author interviewed nine people who, at the time, were heavily involved in developing or implementing drug policy.

For this research he made use of the Delphi method. Baanders calls the Delphi method an approach that is best suited for decision making. This does not stop him from using it himself as an instrument to search for (differences in) opinions. He used the method because it enabled him to keep a necessary distance from the decision makers/implementers, and yet allowed him (by means of the feed back process that is part and parcel of the method) to share his findings with these people. He calls his dissertation the final "controlled feedback" of his research.

Probably because this is a thesis the description of the method used is very thorough. Also the interviews that make up most of the book are reported very conscientiously and indeed, as should be the case with a Delphi-method, show the considerations and reflections of the interviewees in response to their fellows contributions. This is indeed an example of a "discussion", as it were, of people who are not in each other's presence and thus are more outspoken than they might have been, had the other discussants been present.

On the other hand, the discussion seems not to lead to a complete reversal of opinions. The second round leads in most cases to a deepening of the views that were given earlier (in some cases it seems more like the second part of a single interview). Occasionally respondents express somewhat more of an agreement with someone the reader might think they would be opposed to, but over all they stay on their starting positions. And in doing so they seem to reflect (with some exceptions, that were known to be exceptional beforehand) their chosen role in life. The judge is strict but benign, the police is repressive, the representative of the dependence treatment facilities is very managerial, and the national policy leader shows all the nuances that the Dutch drug policy is famous for.

Then again, why shouldn't they remain true to their colours? After all, they gravitated towards these professions because this is the role in life they want to play. It would be very dubious if, after one round of Delphi "discussion" they backtracked and changed course.

Some opinions are contrary to scientific knowledge: several respondents spoke about the physical addictive side of cocaine. This flies in the face of most current knowledge (but may reflect the scientific opinion of the period the study was performed, late '80s).

Some opinions seem to be formed on the ground of "common sense", others have a more scientific and logical approach. Some of the spokespeople are willing to develop opinions that are opposed to current policy- and lawmaking, others accept the state of affairs and develop thoughts from that point on. Some are optimistic about the possibility of change, others are more fatalistic.

Because the book is more than a decennium old, some prognoses have been proven wrong, some right. In some occasions a trend that was clear then still continues, in others the pendulum of history has come full swing: experiments with user rooms, that in the 80's had failed and were closing down, were repeated in the late 90's, and then were successful. Some things did change: many respondents call for better registration that nowadays is mostly in place. Similarly the collaboration between such possible partners as police, treatment and rehabilitation services has much improved. What has improved also (and since has gone into a recession) is the economic climate: it is amazing how often reference is made to a "lack of perspective" in the life of prospective drug addicts in the 80's. It was a time of recession in the Netherlands, and so theories that hypothesised a link with feelings of poverty and loss were strong. Later the Dutch economy would explode, and the use of drugs was seen as a result of the luxurious life one could afford. There may be truth in both theories, after all.

Over all the method seems to be related to that of a good reporter who, in preparing for an article, will interview people with contrary opinions, take note of these, maybe ask them if they would like to change their opinion in the light of what spokesperson x or y stated, and then can use the collective interviews to give an overview of "what is going on": not necessarily coming to one opinion, not voting pro or con, but stating what opinions can be heard.

Conclusions from the Delphi study

Baanders concludes that there exists a rather extensive consensus amongst the interviewees in their vision on the course of Dutch drug policy. But there are essential differences.

The big issues

Drug policy has stabilised. After some pioneering years, during which one was overwhelmed by the problem, and during which the approach was piecemeal, the Dutch entered a phase where the approach was more integrated. The problem is nevertheless seen as intractable and to accept this is part of the more realistic approach of "nowadays". The approach is a dual one: on one hand measures in the sphere of the law, on the other measures in the sphere of public health, the latter being the decisive factor. This realism made the Netherlands unique at the time. The law would leave small time users alone (and even, up to a point, small scale dealers) and would go after the big fish. Policing that was too strict would frighten the users away from the addiction services, with all the risks involved for their private and for public health (AIDS et cetera). Thus addiction services are a major - and beneficial - factor in the lives of Dutch drug consumers.

Drug related crime, in a similar vein of realism, was punished harder: tolerance was waning, partly because of the nuisance caused by drug users that was ever more annoying to the citizens. And partly because it was reasoned that a drug user, the addiction notwithstanding, is an adult and responsible person, who could be punished for misdeeds. The accent of the judiciary interventions lay on catching the large scale dealers and importers. And since the money to be made is the main attraction for these operators, a policy was developed to hit them where it hurt: in their bank account. Wherever possible these accounts would be grabbed (and partly used to fight drug-related crime).

The pressure to kick the habit is increasing for repeat offenders. With some Dutch wordplay a distinction is made between dwang and drang (force respectively pressure). Force is out, so compulsory treatment was not considered feasible (motivation would be too low). Pressure is in: a repeat offender might sign a contract that he wanted to (try and) change his habits, and with lots of assistance a change, a way out, was sought. If the "client" prematurely ended the treatment, he would be put in jail. If instead he showed a satisfactory amount of progress, he would remain a free man, and might be helped to find some activities, even a job, and some dwelling, even a house.

The psychotherapeutic "stamp" that marks Dutch addiction policy according to the author can be distinguished clearly. All interviewees refer to "a difficult youth" or "overly problematic adolescence" as a factor leading to addiction. Changes in the general culture and the position of youth are often referred to.

Differences amongst the interviewees

Opinions diverge also, for instance on the effectiveness of information (given at schools) as a means of preventing later problems. Respondents agree youngsters should be informed, but about the "how" they disagree. For one the confrontation with problems is a warning not to start using. For another informing on drugs implies that one has to open the discussion on the paradoxical legal situation of drugs which are forbidden, yet may be bought. A third is of the opinion that drugs should not be put in the spotlight: they should figure as just one issue amongst many in a more general education on health and education.

The role of the addiction services is looked upon quite differently also. Police and justice workers are the most pessimistic about the effectiveness. They tend to doubt statistics that indicate that the amount of addicts is coming down.

The role of the Dutch system is doubted by these parties also. Most outspoken in her doubt is the judge, who considers the Dutch system to be too tolerant and inadequate.

The future of policy

In a next section Baanders focuses on the possible success of the current policy, and its effect on the people who have to translate policy into practice. He quotes an author who wrote: "A insoluble drug problem does not exist, unless we want it to be so. Do we want that? I honestly think we do." Countering that statement Baanders thinks the interviewees do want the problem to be solved. But the effect of policy on the problem is very small, notwithstanding all the exertions of policy makers and policy implementers. The result is frustration at every level.

To design a viable policy in the face of (inter)national opposition and conflicting interests, precludes the policy makers from steering a straight course. Assistance organisations and workers are discredited because of a lack of effectiveness in treatment. The criticism from without causes frictions within. Policy makers, knowing the enormity of the problem, and hearing all the criticism, tend to overstate the effectiveness of the suggested measures, thus creating new frustrations. Aims that are very concrete can often not be reached, and setting such targets should be avoided. But vague goals won't be accepted by society.

In its search for concreteness the addictions sector expects a lot from a (better) registration. The author warns that with new knowledge and changing expected outcomes of interventions new registration systems will always be necessary and outdated by the time they are broadly accepted. So one should not expect too much from them.

The integral nature of the Dutch system, seen as the result of a pioneering phase in policy making that is well behind us, is generally accepted, but has its disadvantages. One is that it will easily lead to self-complacency. Once society accepts the existence of a perennial drugs problem, it may well cut down budgets for drug assistance organisations, and in the end transfer budgets to the juridical rather than the general health organisations. The author speaks of a marriage of convenience, grounded in the knowledge that the system "works" rather than in other reasons. Meanwhile the general policy is one of "don't rock the boat": do not discuss fundamental issues too fundamentally, or the system might topple over.

The new, managerial approach to the drug problem may well detract from the freedom of drug users to the point of being counterproductive. The integrated approach in Amsterdam4) led to a situation where drug users face a solid wall of drug institutions. The author claims that in the old approach a drug user would partake in several, and really different, forms of therapy, and in this process become motivated, by looking at himself from different angles. If only one therapy is offered, this will not motivate enough. The drug assistance organisations should keep in mind that efficiency is too businesslike a thing, leaving out elements like morality and solidarity. Baanders claims that efficiency is not the way to treat people, but that staying-power and patience are of the essence.

But in the final analysis the Dutch levelheaded attitude on the drug issue sets it aside from most other countries, and is to be preferred. It's not a moral system, but a pragmatic one.

Recent history of Dutch drug policy

In an exploratory study on Dutch drug policy that was published approximately ten years after Baanders' study some scenarios are sketched for the years to come.5) As we are already four years farther into the future we can test some of these scenarios for their validity. The book itself does much more: it gives an extensive overview of developments in the spreading of drugs, their consumption, the reaction of the law and society at large, an overview of health- and social problems that are closely linked with drug consumption, a similar overview of Dutch drug assistance organisations and their results, the interplay between drugs and the law, the role of public opinion. In short, it’s a goldmine of information. But since we here try to sketch the development of drug policy, first let's borrow from the historical overview given by the authors.

First period: up and until the 1960s

In 1919 the Opium Law was accepted by the Dutch parliament, a direct result of the 1912 International Conference on Opium. The Opium Law regulated the trade in pharmaceuticals. Opium was primarily used for medical purposes, and addiction was seen as a medical problem. Some recreational use of opium by Chinese immigrants was fought. Drug addiction was not a societal problem.

Second period: the fight against cannabis

After WW2 the consumption of marihuana increased, particularly in the artist milieus. This increase accelerated in the sixties, and the drug was seen as extremely dangerous. It caused much public debate. Penal intervention was deemed necessary. The already existing Medical Consultative Bureaus for Alcoholism were transformed into Consultation Bureaus for Alcohol and Drugs. Drug assistance was generally a penal affair. The commotion was partly due to the fact that the consumption of cannabis was a symbol of the fight against established values. Small amounts in possession led to hard sentences. This repression notwithstanding, consumption spread rapidly. In addition the claim was made that cannabis was not the dangerous drug is was painted to be.

Third period: late sixties into middle eighties

Support for the repression diminishes. Two reports are points along the route that led to a change in the Opium Law in 1976. The Hulsman report focussed on cannabis and did not consider it more dangerous than alcohol or tobacco. Marginalising of users would diminish a transition to heroin consumption. The classical stepping stone theory was repudiated. International treatises, but also a lack of good information and the public opinion stood in the way of legalisation of drugs. The Baan report followed the same line of thinking and advised not to penalise consumption and possession of small quantities of cannabis, to consider small time production and trade in cannabis or the possession of (consumption quantities) of other drugs a misdemeanour, and to punish the trade and production of other drugs. It was suggested that a distinction be made between substances with an acceptable and an unacceptable risk. Both reports concluded that addiction is a health problem, that police and juridical policy should be in tune with the public health policy, and that the secondary risk due to the criminalisation outweighed the primary risk of the consumption itself. Implicit in both reports is the supposition that the international legalisation of cannabis was imminent, and that in due course this would hold for all drugs. This particular thought finds little support in the Dutch population or the international community. Nevertheless the reports led to the distinction between substances with an acceptable and unacceptable risk.

With the acceptance of the revised Opium Law - that brought law up to date with practice - the repressive approach on soft drugs consumption is abandoned. The possession of up to 30 grams is a misdemeanour. Trade and production are punished more severely however. An argument that was originally used, that the social integration of soft drug users is being facilitated by the decriminalisation of soft drugs, has later fallen into oblivion. The argument that everybody nowadays considers decisive is the importance of maintaining a separation between the supply of soft and hard drugs.

Rise of heroin consumption

Starting in the summer of 1972 the consumption of heroin increases steeply. Hard drugs that were used before (amphetamines, opium, LSD) did not lead to the degree of problems that now emerge. Particularly youngsters of foreign extraction with few opportunities finding employment or good schooling fall victim to heroin addiction. Assistance is given by youth assistance organisations working from a social perspective. Assistance with a medical focus continues to put drug users into psychiatric wards to kick the habit until 1974. A new treatment option is methadone treatment, substituting an illegal addiction with a legal one. The first Dutch treatment was started in Amsterdam in 1968. In the beginning methadone is given only to drug users with a strong motivation to become abstinent. Only later will this concept change and methadone will be given to heroin users who continue using heroin. Drugs related crime is seen as the result of an addiction that one cannot fight, so punishment is lenient. This will change in the 80's.

Policy of toleration

In 1977 a new policy option is introduced, that of toleration. This implies that activities that in themselves are punishable by law are nevertheless allowed to continue, if the policy makers decide that this option causes less harm. This will be decided on a local level, in a meeting of the major, chief of the police and the public prosecutor. So called "house dealers" had been dealing cannabis in youth centres in the years before, but now the decision can be made to allow them to do their job. Furthermore, coffee shops emerge, shops that do sell coffee, tea and soft drinks (in some cases alcoholic drinks also), but whose ultimate reason for existence is the sale of cannabis products. These too are generally left alone, unless they violate the regulations that have been established by the local authorities. The status of these regulations is a curious one: they are binding on a local level, but do not have the force of law. The result is that regional differences in policy crop up and continue to exist till today.

As for hard drugs, total abstinence is no longer strived for and the consumers are generally tolerated. Methadone is no longer given primarily to help heroin consumers become abstinent, but to improve their social and medical condition.

Drug policy making in these years was still chaotic. Regionally there were differences in the degree of toleration, as well as in the systems for treatment and care. The drug problem was beyond control, the elements of public nuisance and crime were increasing. Abstinence directed drugs assistance had little success.

Mid eighties till 1995

An interdepartmental working party published a report in 1985, "Drug policy on the move", introducing the term normalisation. This meant that drug consumption had become an element in society that could not be eliminated. An approach similar to that applied to alcohol problems should be considered: addiction is defined as an individual problem, to be dealt with in a businesslike fashion. The addict can be held responsible for his behaviour and will be expected to stick to agreements made with him, in exchange for assistance. The majority of addicts do not lack a sense of responsibility or free will, so some pressure can be put on them to change their behaviour (the distinction between "force and pressure" or in Dutch dwang en drang mentioned before).

The policy towards the coffee shops is formalised in 1991, along the lines that were developed in Amsterdam. Coffee shops are not allowed to advertise their trade, sell hard drugs, be the cause of nuisance, sell to youngsters under 18 (in some municipalities this age is 16) or sell wholesale. What "advertising" means precisely differs from one municipality to the next. In 1994 the criteria are standardised even more: the age limit becomes 18, advertising is better circumscribed. The maximum amount of cannabis that can be sold per customer is set at 30 grams - and dropped to 5 grams in 1996. Local differences still exist in the number of coffee shops allowed and in the sale of alcohol on the premises.

The role played by AIDS

The AIDS-epidemic played an important role in Dutch policy development. In 1985 in turned out that 30% of Amsterdam intravenous drug users had been infected. Preventative measures were quickly implemented. Contrary to what is often stated this did NOT lead to a needle exchange: a needle exchange was already in place, because of the risk of getting hepatitis from shared equipment. The AIDS-epidemic increased the sense that drug use was a life-threatening activity.

The juridical approach

Although the pressure is increasing to put drug users who cause a nuisance or commit drug related crime in jail (responsible as they are for their own deeds), the lack of cells prevents such a measure. In Amsterdam a Street junk project is effected: drug users who under ordinary circumstances might be put in jail, can stay out provided they keep in touch with drug assistance organisations, and make an adequate amount of progress. This has as a by-product an improved co-operation between drug assistance organisations, general social assistance organisations and the police.

Both the ease with which one can buy drugs, as well as the policy towards their consumption, lead to a steady stream of drug tourists, causing problems in the border districts. This calls for urgent regional measures.

Drug assistance organisations as such do become more pragmatic, their attitude moves more into the direction of a harm reduction approach. More attention is given to specific groups, such as inhabitants of foreign extraction, problems of dual iagnosis clients (having an addiction and a psychiatric problem), children of addicted parents, AIDS-related drug assistance.

During the 80's heroin is joined by cocaine as an important drug, in the late eighties ecstasy consumption grows stronger. Addicts use a quantity of drugs consecutively or simultaneously, poly drug use becomes the norm. Alcohol and tobacco are used by most addicts also.

Latter half of the 1990s

In 1995 a policy document is published, "The Dutch drug policy, continuity and change". It describes an essentially unchanged policy, with a strong focus on normalisation and as a result prevention and harm reduction. It is concluded that the policy so far has been successful in relation to health risks, less successful in fighting the problems of nuisance, organised crime and foreign criticism. Because of this adjustments are made. Fighting nuisance will receive extra attention. The move towards synthetic drugs like ecstasy will lead to more prevention measures for recreational drug consumption.

The integration of drug services and co-ordination of activities will continue and increase.

Some experiments, such as a free distribution of heroin amongst hard core users, have been proposed and by now have been finalised and reported on.6)

From the past into the future: four scenarios

From the historical overview, the study on Dutch drug policies moves on to a statistics based comparison of the drugs situation in the Netherlands against that in other countries. The authors state that it would be attractive to extrapolate these statistics to get an impression of what the future has in store, but they decide against it: the number of factors (demographic, economic, cultural) is too large to make such prophesising sensible.

Instead they chose an approach where they used a number of scenarios, descriptions of possible developments in Dutch drug policy. In order to do so, they tested a couple of models of influences on future developments, in the end producing a design where two axes split space into four quadrants:

Formalisation is seen as the strict and forceful regulation of drug trade and consumption, informalisation being the opposite. Moralisation is seen as a view of drug consumption in terms of good and evil: all forms of consumption are frowned upon. Medicalisation focusses attention on socio-medical categorisation of forms of consumption; one thinks in terms of healthy versus sick. Although at any given time the extremes of both factors can be found somewhere in society, society as a whole can be seen to oscillate from one quadrant to another, in other words, from a type of policy making that is mainly under medical and formal influences to another rather under moral and informal influences. Each quadrant leads to a specific policy scenario, the labels used being: Risk reduction, Differentiated legalisation, Drug free society and Deregulation.

The scenarios each describe a possible development, giving an indication of the circumstances that lead to the development in a particular direction, and then describing what happens, once the development is set in motion.

Risk reduction scenario

Broad support is given to a pragmatic attitude towards extreme drug use. Risk should be avoided, so society might strive for a reduction of consumption, but one agrees that a drug-free society is not feasible. Coping with problems is the main issue, diminishing harm to society and the individual. Addiction to (il)legal drugs should be prevented by reducing the number of points of sale of legal drugs, setting age limits for the trade in soft drugs and information campaigns. This in order to reduce the number of users and to improve their medical condition. Great attention is paid to preventive measures. These are diversified, with different targets set for different drugs and consumer groups. Drugs information has a clear position in health campaigns and health education.

Drug assistance aims at reducing the risk of drug consumption, problematic consumers are kept in check as much as possible. Interventions should be evidence based, and tailor made: for every individual client an estimate is made if abstinence is a viable option. If not, a programme of consumption under medical supervision is in place. Drug assistance is handled by distinctive institutions with a clear mission: to reduce the risk to individual and society. They collaborate closely with regular health care, labour market and educational facilities. The police prioritise the tracing of trade in forbidden substances, because of the health risks they present. The judiciary system is linked to the health policy. The number of trade outlets for drugs is kept at a steady level. Projects to put some pressure (part juridical) on problematic consumers to change their behaviour have become part of the assistance.

To fulfil this scenario that fits in well with the policy in the nineties, more statistical material was produced to prove the effectiveness of measures that have so far been instated because of their intuitive appeal. The distinction between hard and soft drugs was proven to be effective and remains a cornerstone of drug policy in the Netherlands. The policy of toleration from the nineties was transferred into clear instructions and rules. A licensing system for soft drug sales was adopted.

Drug-free society scenario

This scenario assumes that several grave incidents will happen, that lead to a fierce discussion on the liberal Dutch drug policy. Some major drug networks are traced, their members arrested, the nuisance caused by consumers aggravates the situation, as does increased drug tourism, conflicts with other European countries flare up, a number of fatal overdoses occur. Thus the ideology emerges that the Netherlands should be a guiding light towards a drug-free society.

The consumption of potentially addictive substances is seen as harmful to the individual and society. So it must be strongly regimented. All substances that can be seen as harmful are controlled by law. Production, trade and consumption all are forbidden. All forces are expected to unite to minimise the consumption of drugs.

Prevention programmes, partly assisted by the EU, receive a strong impulse. The effectiveness of some approaches becomes clear. Strict registration of consumers of illegal drugs increases the insight in (potential) target groups. All potential drug users are targeted with the message that the health of the populace is threatened. Secondary prevention like methadone and needle exchange programmes are aimed only at very small groups of patients that have been declared untreatable. The reduction of nuisance is the aim. The preventive measures are implemented by institutions that are also responsible for treatment. National guidelines rule their every step, and the local leeway for manoeuvring is small. The goal of assistance is abstinence, quickly and effectively, safe use is impossible. Treatment protocols for groups of addicts have been designed. The treatment is provided by the local branches of a number of national organisations with clear, unequivocal targets, aimed at abstinence. Each year the treatment organisations are audited for their effectiveness.

Whenever anybody is found to be a drug user the regional treatment institution and the justice department are notified. The subject will be invited to attend one or more face to face meetings and possibly a treatment program. Declining this offer will lead to registration as untreatable. Criminal or nuisance behaviour will lead to forced treatment or incarceration.

Police and the judiciary system try and prevent the trade and consumption of drugs, sale is punishable by law. Registration and incarceration of repeat offenders follow a first fine. The policy leads first to an increase, but later to a decline in the number of places needed for treatment and cells. The production and trade in hard drugs moves to more lenient countries.

To move into this direction the central government took the initiative towards a radical change in policy. The relative toleration was ended, sales of any amount of any drug were made punishable, coffee shops were closed. Close regional and national co-operation made a speedy about-turn in policy possible. An intensive campaign put the new policy on a solid foundation. The police was given greater latitude in tracing and fighting drug production and trade.

Deregulation scenario

A growing awareness of the limited harmfulness of drugs if not used to extremes, as well as the relatively meagre results of the fight against the trade and consumption of drugs, lead to a growing support for deregulating trade and consumption. The distinction between legal and illegal drugs is no longer deemed sensible by the general public. Each citizen has a responsibility of his own, drugs are seen as giving pleasure also, a pleasant supplement to an evening of entertainment. LSD or ecstasy may trigger valuable emotional, spiritual or religious experiences.

The ban on drugs is seen as an unacceptable infringement of the right of self-determination and a danger to democracy. Most drugs are no more harmful than alcohol or tobacco, rules for consumption or trade should be similar to the ones for those products. Only drugs with a proven very high chance of addiction of health damage will remain restricted by law. Quality control and labelling for all previously forbidden products is implemented. Advice on consumption and specific risk groups is part of the labelling. Preventive measures aim to prevent excessive consumption, essentially along the same lines as campaigns against alcohol and tobacco. For addicts effective programmes have been developed. General information focuses on the quality, effects and side effects of drugs.

The majority of consumers keep consumption under their own control, not causing any trouble. Addiction services have been integrated in regular health care provision and aim in particular at the social problems. Drug addiction is found to be strongly related to psychiatric problems. A variety of services is supplied by the ambulatory mental health services. To increase individual responsibility to consume drugs wisely is the aim.

Police and the judiciary control strictly the quality of drugs. Consumers causing a nuisance are treated equally to other transgressors.

To get here the Netherlands were declared an area for experiment within the European Union. Support to digress from international policies was found. Some products were deregulated following positive results of an experiment with heroin consumption under medical control. Such products became available from chemists shops and similar outlets.

Differentiated legalisation scenario

Political and societal agreement that the consumption of hard drugs is bad has grown. Sensible people know that it may lead to grave addiction. A relatively small number of youngsters and even fewer adults use soft drugs. The overall majority uses drugs sensibly.

Addiction is seen as wrecking the individual and society. Regulations must exits to curtail the harmful effects of alcohol, tobacco and soft drugs. But an all out restriction is neither necessary nor wanted. Measures to regulate these drugs should be tuned to one another. The consequences of hard drugs, including ecstasy, are such that production and trade are forbidden.

Prevention follows these lines, with a clear distinction for hard drugs. Most prevention is through television and general folders that are distributed for free.

Drug addicts can go to regular institutions for assistance. For soft drug addicts a wide array of facilities is available, most of them well integrated in the general ambulatory mental health services. Hard drug addicts that do not react to the regular treatment options are put under more pressure and treated in specialised institutions. Low threshold programmes have been installed for specific hard to reach groups.

The number of drugs that are forbidden has been restricted. Soft drugs are being sold at a number of outlets, where it is forbidden to advertise and the price is relatively high due to tax measures, similar to the ones for alcohol and tobacco. Only small quantities are sold, none to minors. All attention is focussed on the trade of illegal drugs. Buyers of soft drugs have to show identification papers, for control of age and place of residence.

To reach this state the Netherlands started the discussion in international forums, pending the results a state monopoly was instituted. Trade and production of soft drugs were excluded from the open market, to guarantee good quality. All coffee shops (the former places of sale) were closed and instead a small number of outlets were started by the state.

Which scenario will prevail?

The authors wrote their book in an attempt to foresee the future of Dutch drug policy. They state that they are unable to give a specific prognosis, but they do attempt to sketch all elements involved. In their final chapter they treat the major elements.

In trying to evaluate these scenarios the authors state that a continuation of what is seen fit in present day policy is to be expected. That policy has been rather steady over the last 25 years, it has shown elements of the differentiated legalisation and deregulation, but mostly of the risk reduction scenario. Public opinion is partly caused by fear and taboo, partly by pity for the victims. The sudden appearance of a new drug may set the wheels of opinion making and possibly changing in motion, but in general tolerance prevails over repression, the latter coming into play when unacceptable risks are perceived, to health, crime or public order.

The picture society has of drug consumption and consumers

Cannabis is an example of a drug that was first feared, but turned out to be rather harmless, the tolerant attitude of Dutch society leading to the current state of affairs where per capita consumption is lower than in most surrounding countries or in the USA. The public image of cannabis is set by the coffee shops rather than by the consumers. Where these shops exist in poor regions, attracting marginalised youngsters and possibly getting mixed up with crime, the image becomes very negative. This may well reflect on cannabis users in general.

Heroin is an example of another type of drug. It has become clear though that "drug related crime" is not a necessary effect of heroin consumption, but rather is an expression of criminal trends that pre-existed in the addicts-to-be. Nevertheless, long-term heroin users generally are very poor, with a very bad health and poor life expectancy. Many users consume other drugs in the bargain, such as cocaine, alcohol and benzodiazepines. Gradually the image is changing: no longer considered criminals, they can best be seen as therapy resistant patients. Due to this change the general population supports a more lenient attitude; politically an experiment with the medical administration of heroin becomes feasible. For cocaine a similar trend can be expected, with a majority of users steering clear of addiction, a minority of long term users (many also using heroin), and a realisation that the criminal consumer in general was a criminal before getting addicted rather than vice versa.

Prevention

Apart from a discussion that still rages about the effectiveness of prevention, at least prevention workers will have to be knowledgeable about (and able to cope with) new and constantly changing trends, be they national or regional/local. To do this, alliances with such "strange bedfellows" as distributors, traders, organisers of house parties should not be eschewed. Similarly the authors advise that prevention should come up with new and positive images. The consumption and abuse of drugs should be related to more general norms and values. A balance should be struck between elements like self-regulation, norms, information, sanctions and sensible consumption.

New drugs, new users groups and treatments

New drugs may destabilise consumption patterns and treatment orientations. Ecstasy is given as an example: non-deviant users using a non-addictive drug require approaches that are more of a preventive than of a curative nature. New user groups may centre on new drugs, but equally on "old" drugs attracting new consumer groups; for instance heroin (after losing its connotation of being a losers-drug) may attract new marginalised youngsters. New treatments will probably become more prominent, as the knowledge on neurotransmitters and their production, absorption and interactions increases. This may reflect on the relative importance of psychological, sociological and biological interventions.

The authors expect an increase in the informalisation of drug consumption. This would imply that under strict medical control certain hard drugs would become available. Legalisation of hard drugs is not to be expected, so the scenario of differentiated legalisation would be the most probable outcome. Effects of this change would be:

An increase in the number of consumers, who nevertheless would cause less trouble and know better how to handle drugs.
Per capita consumption amongst users would (as it did with cannabis) probably come down, addicts becoming a small and exceptional group.
The relationship between consumption and social disintegration would be less strong.
The demand for specialised drug assistance would come down.

Whatever scenario would prevail, the authors suppose that under all conditions the demand for drugs will remain strong.

1) Derks, J. et al, Current and future drug policy studies in Europe. Max Planck Institut 1999.
2) Boekhout van Solinge, T, Drugs and decision-making in the European Union, CEDRO/Mets en Schilt, Amsterdam 2002. (http://www.cedro-uva.org/lib/boekhout.eu.html)
3) Baanders, A., De Hollandse aanpak. Opvoedingscultuur, Drugsgebruik en het Nederlandse Overheidsbeleid. Uitgeverij Van Gorcum, Assen 1989.
4) Where under political pressure many drug assistance organisations now co-operate, sharing their knowledge about clients, in order to best give them care, but at the same time cutting down their "freedom" to move from one institution to the next.
5) Stichting Toekomstscenario's Gezondheidszorg: Verkenning drugsbeleid in Nederland. Zoetermeer 1998
6) Centrale Commissie Behandeling Heroïneverslaafden (Heroin on medical prescription); edited by van den Brink, W. et al. Utrecht 2002. (http://www.ccbh.nl)