Plenary 2: Healthy Clubbing: A joint agenda for research, policy and practice
c) Monitoring and health: A national policy framework to reduce substance use related health risks
Marcel de Kort
Welfare and Sport Ministry of Health, Directorate for Mental Health and Addiction Policy, PO Box 20350, Den Haag 2500, The Netherlands.
Phone no: +(31 70) 340 69 40 Fax no: +(31 70) 340 78 58
History of drug use
In June 1970 a three-day ball was held in Rotterdam, a kind of Dutch version of the famous American ‘Woodstock’. This was an important event. Instead of an oppressive approach aimed at eliminating all drug use and drug dealing, the police tolerated the use and sale of drugs. The health service and the drugs information agency Release, still existing in the UK, organised a special drug team to inform the public and to give first aid. The objective of the authorities was to avoid problems by means of prevention and assistance rather than hard repression; this was a successful and controversial approach. The police officers, disguised as hippies, concluded that there was no violence, no crime, no serious health risks and that the visitors had great trust in the drug scene so it was a great success.
So what has changed in the Netherlands since 1970? Acceptance of cannabis is not being tolerated anymore; health protection still takes priority when it comes to drug use in the nightlife circuit and it is a corner stone of our drug policy. The role of the Ministry of Health in eliminating the health risks associated with drug use in the nightlife circuit is mainly in allowing scope for innovative approaches, co-ordinating different initiatives and encouraging research and monitoring. Research is essential in order to develop policy and enable monitoring, because the Netherlands policy is based on facts, not on ideologies or dogmas.
Changes in drug use
The drug problem in the Netherlands was relatively straightforward until the end of the 1980s. Putting it simply, there was recreational use of cannabis and cocaine which led to few social problems as a general rule and there were poly-drug users; amongst them heroin users formed the core of the drug problem. Those were uncomplicated times for drug policy makers, health care and drug prevention. However the introduction of ecstasy totally disrupted this relative calm. Whereas different user groups could easily be identified and the risks of drug use were well known in the 1980s, the early 1990s were characterised by great uncertainty about the substances, the user groups and the risks involved.
These new substances involved different effects and new risks from those associated with traditional substances but the characteristics of the users also differed significantly. Users of synthetic drugs were not marginalised; these were young people whose lifestyle revolved around drug use. Ecstasy was used on a recreational basis mostly, that is occasional use usually at dance parties. In fact, the only similarity with the period before 1985 was that you were dealing with psychoactive substances. Drug set and setting all changed in a very short time. These swift changes raised entirely new questions for drug policy, prevention and care. For example, what are the risks of the different types of substances? Who uses these drugs? What patterns of use exist? How can you limit these risks? The answers we had in the 1980s were not very useful in the 1990s so at the start of the 1990s three task forces were asked to tackle these questions. The first task force focused on prevention and public information, the second on formulated guidelines for local policy and the third on research, monitoring and registration.
The efforts of the second task force resulted in guidelines for limiting the health risks at large-scale dance parties. These guidelines stated that, in order to get a licence for a large-scale dance party, first aid facilities should be available, there must be adequate ventilation, drinking water, chill out rooms, transportation, entry checks, emergency exit routes and also pill testing, although that was not compulsory.
Task force three strongly emphasises interdisciplinary research projects. At first, research concentrated on the acute risks of ecstasy, and now there is more concern about the neurotoxicity. Thus pharmacological and biomedical research was undertaken on the neurotoxicity of ecstasy, which has been continued on the bases of the results.
Research and monitoring
In 1998 there was a study of ecstasy use in nightlife places. Interestingly, large-scale rave parties are not that popular anymore in Holland and most ecstasy use takes place in discos and at home. About 65% of the visitors at large-scale rave parties have used ecstasy or thought that they had used ecstasy. Combined use was especially with cannabis, amphetamines or alcohol. 6% use ecstasy excessively, 49% regularly and 42% use it recreationally.
The research project also looked at the effectiveness of pill testing, and registration systems were set up to record incidents reported by hospitals or first aid staff at rave parties, although the results were delayed because there were not enough incidents or admissions at the hospitals to get valid results. The number of incidents at parties is low and the number of clinical incidents was limited, so there are very few serious problems. Another study shows that, of the hospital admissions, the people who had taken ecstasy had done so mostly at home or in discos and not at rave parties. Maybe this is a sign of the decreasing popularity of ecstasy and of large-scale rave parties in Holland, although party people were the source for this research programme.
The most important results of the foregoing studies were a number of specific interventions which were developed over the years, particularly in the area of prevention. The clubbing and drugs project is a broad based integrated project that focuses on alcohol and drug use in the nightlife circuit, coffee shops, clubs, discos and at large-scale parties. This project was set up by the Trimbos Instituut in cooperation with the Ministry of Health and it included participants from different sectors such as health authorities, the police, youth care, advertising businesses, the club and bar circuit and the media. This was based on the idea that to be most effective, preventative activities should take place in all areas of young people’s lives. This project not only focuses on schools but also on young people’s own nightlife environment.
Another project is the Drugs Information and Monitoring System (DIMS). The essence of this project is that consumers are given the option of knowing the composition and dosage of their drugs. DIMS is not only important from the viewpoint of prevention but also gives policymakers in particular a good understanding of the unstable synthetic drug market. It cannot be denied that testing pills for consumers is a controversial activity; critics argue that this testing gives out the wrong signals and may actually encourage use. We are highly conscious of this dilemma in the Netherlands, so it is important to realise that for the most part our preventative effort is to discourage drug use. Of course, it is also the government’s responsibility to limit the risks run by users of synthetic drugs as far as possible, bearing in mind specific risks of synthetic drugs such as their unknown dosage and composition. It is also important to monitor the supply side of this market so that high risk substances can be spotted at an early stage.
From the viewpoint of health protection, it is essential to be aware of the appearance of high-risk substances on the market and to take quick, preventative action. Various warning campaigns have therefore been run under the auspices of DIMS. There have been quite a number of warning campaigns ranging from very low level campaigns just informing emergency departments in the hospital or first aid personnel at rave parties, to nationwide campaigns. New substances bring about new risks and effects. Scientifically very little is known and they are constantly appearing on the market. This does not only apply to synthetic drugs but also to ‘smart products’ and ‘eco drugs’ whose popularity has grown rapidly.
‘Smart drugs’
Smart products and drugs are generally sold in outlets known as smart shops. Besides hallucinogenic mushrooms these shops sell many other products. A number of products have a clear psychoactive effect like that of the mushrooms such as products containing ephedrine. Certain other products have such a limited psychoactive effect that it is highly debatable whether or not they can be described as drugs, whilst other products are not psychoactive at all, such as vitamins and minerals. The smart shops and the products sold in the shops lie within the borderland between the drug policy, public health policy, protecting the health and safety of the consumers of food and drink products, and policies in respect of the supply of medicines.
The clear distinction between foods, medicines and illicit drugs is disappearing, especially for the users themselves. They do not think any differently about drugs, vitamins, minerals, food or medicines, and it becomes rather difficult to make distinctions between them, which leaves us facing a rather complex problem. In 1997, a working group was set up by the Ministry of Health. The working group carried out a risk assessment that explicitly took the social risks of psychoactive smart drugs and eco drugs into account as well. This working group recommended that the present policy focusing primarily on health protection should be continued. According to the working group, these products do not pose unacceptable risks in terms of damage to the individual or to society. However, it was concluded that in the case of a few acutely toxic substances a ban on sales would be appropriate on the grounds of the Commodities Act. The ban avoids criminalising users since possession for personal use is not an offence, and moreover this approach does not reinforce the drug image of these products.
Despite the complexity of the problem, our experiences with the smart shops show that the principles of Dutch drug policy fully enable us to respond flexibly to new developments beyond all the boundaries of traditional drug policies. Our policy in respect of psychoactive smart products and eco drugs aims to limit the risks to the individual, his or her immediate environment and society at large. Health protection by means of information, monitoring and research is still priority, and there is extensive monitoring in the area of smart products and eco drugs. Our policy is not based on the present moral outcry about drug shops or ideological arguments, but on a rational evaluation of the risks. There is large scope for modifying the policy to take new developments of the problem into account.
By definition the national government must be taken over by events when it comes to reacting quickly to new developments. That is a pity but it does prevent the government from reacting to every hype as rumours and stories are continually arising in the drug sector. It is the government’s job to respond as quickly as possible. Reliable facts, monitoring and research are indispensable for this purpose.
To enable us to respond swiftly to the appearance of new substances the ‘Co-ordination Centre’ for assessment and monitoring of new drugs was set up at the beginning of 1999. This centre provides facilities for carrying out risk analysis for new substances, at very short notice if necessary. It is able to carry out the risk analysis that the Netherlands have been using for years at high speed and in this centre all relevant parties are involved, like the DIMS, drug agencies, the police and the unit for synthetic drugs in the Netherlands, medical doctors, toxicologists and others. Various steps can be taken based on the results of this sort of risk analysis including monitoring, preventative activities and legal measures.
The role of field workers
It should be emphasised that local government and particularly the people working in the field, such as outreach workers, police, first aid workers, the party organisers, and club owners, play a far more important role in developing new interventions than the national government does. Trends in nightlife and trends in drug use are followed closely and field workers are ideally placed to develop innovative approaches and to find proof that preventive actions are working. They are also usually more familiar with specific circumstances than policymakers at a national level. The best initiatives come from the bottom up and it is a job for national government to encourage and facilitate those innovations. In the Netherlands we have been quite successful in allowing scope for innovative approaches from a bottom up approach.
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