Stakeholders and content

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Also in countries like Slovenia and Spain the heroin epidemic and the absence of appropriate treatment responses were important factors contributing to the development of OST (Trautmann et al. 2007; Gamella and Jiménez Rodrigo 2004).

4.1.2 Stakeholders and content

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The alternative youth services played an important role in the development of a harm reduction movement in the Netherlands, one element in the counter movements in various European countries of that time, as can be taken from the introduction of the term ‘harm reduction’. It were the people involved in the work of the Merseyside Drug Treatment and Information Centre in Liverpool who started to use this term for needle exchange and other services aimed at reducing the health harm related to drug use, in particular to injecting drugs like heroin. This Merseyside model was developed in response to a heroin epidemic in the early 1980s.

Russell Newcombe, one of the key players involved in the harm reduction development in the UK, summarised the definition as follows: “Harm reduction — also called damage limitation, risk reduction, and harm minimization — is a social policy which prioritizes the aim of decreasing the negative effects of drug use. Harm reduction is becoming the major alternative drug policy to abstentionism, which prioritizes the aim of decreasing the prevalence or incidence of drug use. Harm reduction has its main roots in the scientific public health model, with deeper roots in humanitarianism and libertarianism. It therefore contrasts with abstentionism, which is rooted more in the punitive law enforcement model, and in medical and religious paternalism.” (Newcombe 1987 p1).

This quote summarises the critique from a new player in the drug service field on the establishment, starting bottom-up from local initiatives. It reflects the polarised character of the confrontation between the abstinence and the harm reduction model, two drug treatment paradigms in the drugs field at that time. It is a political statement pervaded by the criticism on the then prevailing abstinence oriented drug treatment. This clash between conflicting views forms an important contextual element in the early years of the process of gradual acceptance of harm reduction services, which started as outsiders gaining wider recognition and finally resulted – at least in some EU Member States – as mainstream approach.

The first initiatives on methadone maintenance treatment in Amsterdam

The development of methadone maintenance treatment in the Netherlands can again serve as example. Methadone was first introduced in the Netherlands as medication to facilitate detoxification of opioid addicts in abstinence oriented drug treatment around 1968. It took some more years till methadone also popped up as maintenance treatment. The first step was taken by a General Practitioner in Amsterdam. One contextual element playing a role in his decision to start with this was that as an amateur painter he was a member of the artist club ‘De Kring’ in Amsterdam where many social critics (writers, poets, movie makers, painters) came together. Drug use was not uncommon among the members. This doctor started prescribing methadone for acquaintances.

More GPs – some of them member of the same circles and even the same club – followed. These GPs also went through the available research literature on methadone maintenance and discussed the approach among themselves. From these small-scale, rather isolated initiatives the development of a national framework for OST started. In one decade, methadone treatment started to change from prescription solely for detoxification purposes to mainly maintenance treatment (De Kort 1995; Blok 2011).

The choice for methadone as OST medication in the Netherlands, and also in other EU countries, was made on the basis of experiences in the US. Methadone was the first well researched OST, apart from some small-scale use of morphine and heroin in the UK in the 1920s. Methadone was applied in the US as early as 1949 to mitigate withdrawal symptoms during the detoxification from heroin.

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Dissatisfaction with the high relapse rate after detoxification led Dole, Nyswander and Kreek to experiment with methadone maintenance as substitution for heroin.

This treatment proved to be successful in terms of retention rates and social stabilisation of clients and in reducing the use of street heroin and heroin use related crime. The treatment approach developed by Dole and Nyswander was the basis for methadone maintenance treatment in the Netherlands (Driessen 2004).

Important stakeholders: local policymakers, politicians, health professionals, charity and drug users In the Netherlands also policymakers and politicians were important stakeholders in initiating and supporting harm reduction services, particularly on local level (Henken 2013). Though also on national level they played an essential role. This does not mean that there was a unanimous view which direction to take. Among others the attitude towards OST signified a divide between policymakers. In his book on the history of drug policy in the Netherlands De Kort (1995) describes that the division between the traditional and alternative drug services at local level in Amsterdam during the 1970s also played a role on national level, between the two responsible ministries. The Ministry of CRM⁹ opposed a criminal law approach and pleaded for a primarily psychosocial care approach for problem drug users, going beyond the limits of medical interventions. A policy brief in 1975 of that Ministry was very much in line with the goals of the "alternative" youth services. They supported a focus on the personal and societal vulnerability of drugs users running into problems.

The Ministry of VOMIL¹⁰ had a different, primarily medical view on the approach of problem use.

To resolve this dichotomy the Dutch government requested the National Health Council to draw up recommendations on care for opioid addicts. These recommendations were more in favour of a mainly medical approach. In the end the government followed these recommendations in 1976, choosing for this mainly medical drug treatment approach, though some elements of the

‘alternative’, psychosocial approach were included as well. In the years that followed, VOMIL primarily chose to focus on the medical aspects of drug treatment such as detoxification programs, while CRM still concentrated on reintegration of addicts into society (Van Laar and Van Ooyen-Houben 2009).

This growing acceptance of OST and other harm reduction services by policymakers and politicians can be taken as example of the processes described by Kingdon in his model. It can be understood as a combined working of the policy and the political stream: policymakers (and politicians) started to see particularly heroin use as a serious problem (the problem stream) requiring a response going beyond the services offered by the available drug treatment programmes. On political level one could see then increasing consensus that OST and other harm reduction services are appropriate responses. The situation then is an example of what Kingdon called a policy window created by the coming together of the problem, policy and political streams window: an opportunity to introduce fundamental changes in drug policy.

The support for these changes was even broader. There were more stakeholders that contributed to it. Also religious and charitable organisations, mainly from protestant origin, helped develop harm reduction services, in particular drop-in centres and night shelters. Various health and social services emerged on the scene, developing, implementing and professionalising a range of harm reduction services, from social support through outreach work to in-patient crisis centres including drug

9 CRM stood for ‘Cultuur, Recreatie en Maatschappelijk Werk’ (Culture, Recreation and Social Work). This Ministry covered the domain of social affairs.

10 VOMIL stood for ‘Volksgezondheid en Milieuhygiëne’ (Public Health and Environmental Protection).

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consumption facilities. Their staff, social workers and other professionals, also played a role in advocating appropriate harm reduction services in the political arena.

Regarding harm reduction advocacy, also groups like the above mentioned MDHG were important. It started simply as a group of people from very different backgrounds (doctors, social workers, parents of heroin users, people living in the neighbourhood of the scene, people simply interested in the drug problem, and of course users and ex-users) concerned about the neglect of the social and health problems of drug users, unhappy with the response of politicians, policymakers and service providers and searching for alternatives (Mol and Trautmann 1991; Henken 2013).

In Slovenia the most important protagonists of harm reduction were health professionals, policymakers and politicians from liberal parties. The debate about substitution treatment resulted in 1994 in the start of a national methadone maintenance treatment programme for problem heroin users under the final responsibility of the Ministry of Health. National guidelines for the treatment of problem heroin users, including methadone maintenance treatment, were adopted by the Health Council at the Ministry of Health in 1994 and methadone maintenance programmes were approved (Kastelic and Kostnapfel-Rihtar 2000). Since then the number of centres providing this treatment has steadily increased (Appendix 3).

In Spain the wider implementation of harm reduction measures like OST started rather late.

According to Gamella and Jiménez Rodrigo, methadone substitution treatment nearly disappeared between 1983, the year in which it formally was permitted by law, and 1991. It took till the early 1990s before the wider implementation of OST started (Gamella and Jiménez Rodrigo 2004 p635).

The most important proponents of OST were health professionals, NGOs and drug users, who underlined the health benefits for the drug users. Politicians and policymakers seemed to be especially concerned with public health, reducing public nuisance and drug use related crime as arguments in favour of introducing OST (Appendix 5).

Researchers and scientists as decisive driving force

There was one more group of stakeholders playing a striking role in the introduction and acceptance of harm reduction in the Netherlands: researchers and scientists. In a time when drug use among young people was an issue of concern on political level, in the media and in public opinion, causing sometimes heated debates, politicians and policymakers called for scientifically sound explanations of and approaches to the drug epidemic. Drug use was a new problem, for which no appropriate solutions were available. The approach to this challenge was a surprisingly rational one. For an appropriate response more, thorough information was needed. This resulted in the formation of two commissions, which were assigned with the task to explore and explain the nature and extent of the problem.

One was the so-called Hulsman Commission (1968-1971), installed by the National Federation of Mental Health Organisations and named after the chair of the Commission, Loek Hulsman, a criminal law professor at the University of Rotterdam. This commission had a diverse membership including law enforcement officials, alcohol treatment experts, psychiatrists, a drug use researcher and a sociologist. The commission’s final report, presented in 1971, provided an extensive analysis of drug use and the social mechanisms behind drug problems providing arguments that prohibition of certain drugs, criminalising the production and use of these drugs is creating instead of solving problems (Stichting Algemeen Centraal Bureau voor de Geestelijke Volksgezondheid 1971).

The other one was the Baan Commission (1968-1972), installed by the government, and named after its chair, Pieter Baan, the Chief Inspector of Mental Health at the Ministry of Health. This commission

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included some members of the Hulsman Commission, as well as officials from the Ministry of Justice, the Amsterdam Chief of Police, and other experts like psychiatrists and sociologists. Its mandate was to explore and explain the nature and extent of the drug problem and come up with recommendations how to deal with it appropriately.

The report of the Commission presented in 1972 came up with a number of interesting findings. It emphasised, among other things, that youth culture is a crucial determinant of drug use. The sometimes unusual behaviour of the cannabis-consuming young people had to be understood as a result of specific subculture norms and ideologies rather than pharmacology (Werkgroep Verdovende Middelen 1972).

These two reports presented the research findings available in their time and were meant as evidence base for the policy decisions to be taken. They defined the points of departure for the Dutch drug policy, as we know it today. The Baan report provided also an overview of risks that were associated with the use of different types of drugs. These risks were divided into physical damage, psychological damage and social damage. The core point in the recommendations of this report was the suggestion to divide drugs into those with ‘inacceptable’ and those with less serious risks for the user, thereby introducing the concepts of ‘soft’ and ‘hard drugs’. The commission defined cannabis as soft drug and other drugs like heroin and amphetamines as hard drugs. Though further research was seen as needed for the final classification of some drugs, the report concluded that cannabis products were relatively benign with limited health risks (Werkgroep Verdovende Middelen 1972).

The report of the Baan Commission was the fundament for the Dutch Drug Law of 1976, in which the distinction between soft drugs and hard drugs was authorised. Its recommendations largely determined the course of the Netherlands’ drug policy, establishing the core features of the Dutch system which are rooted in the concept of harm reduction. It marked the start of a formal drug policy, in which drugs were classified according to their risk, resulting in a separate policy for cannabis products and different legal provisions for hard drugs (Van Laar and Van Ooyen-Houben 2009). The rationale behind this was to separate the markets of soft and hard drugs. According to the Baan Commission’s findings the stepping stone effect, i.e. the step of users from cannabis to hard drugs, has nothing to do with the substance or substance use related issues but with the fact that users can buy different illicit drugs from the same dealer.

It was science that introduced and supported the change from a crime to health paradigm. It was science that helped to create the policy window, by bringing together the problem stream, policy and political streams. Scientists provided the definition of the problem by emphasising that drug use was primarily a health (and social) issue and that it had to be addressed in the first place by health and social policy measures. The Hulsman and the Baan report contributed to the sense of urgency among policymakers and politicians and to a shared understanding among them regarding the appropriate policy choices. In the Netherlands this resulted in the health paradigm taking the lead in drug policy.

The Ministry of Health became – and still is – the leading / coordinating Ministry in drug policy.

The opponents

All these new initiatives met with severe opposition in particular from traditional, abstinence oriented treatment services because of their diverging treatment philosophy. According to the established treatment centres abstinence was the only acceptable and effective option. This is why in the Netherlands the first doctors prescribing methadone met with such fierce opposition.

Substitution treatment was criticised for giving drugs to drug users, perpetuating their addiction by simply replacing one addictive substance by another. Providing syringes to injecting drug users later met with the same criticism: facilitating or encouraging drug use.

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The philosophy of harm reduction, accepting drug using clients as they are, without stating any conditions, was seen as undermining the motivation to get abstinent (Driessen 2004 p3). In the early 1970s there were also representatives of the alternative youth services rejecting methadone treatment.

They saw it as an element of the traditional medical health care approach, defining drug use as disease and the drug users as patient (De Kort 1995 pp241). The same criticism was brought forward by mainly conservative politicians and some media (Blok 2008). Methadone maintenance treatment was expected to lead to a falling number of drug users undergoing drug-free treatment. Though, when these fears did not become true (Driessen 2004 p3), the opposition against OST (and other harm reduction measures) lessened.

In Slovenia the introduction of harm reduction encountered relatively mild opposition, compared with the fierce struggle in other European Member States like Germany and France. Important players in the abstinence-oriented group were conservative politicians, religious organisations and drug-free therapeutic communities. An evaluation of OST in Slovenia found that scientific evidence on the effectiveness of OST – but also of other treatment options – had not much bearing on the debate about drug treatment (Trautmann et al. 2007).

In Spain opponents were again mainly conservative political parties and abstinence-oriented treatment institutions and professionals. In particular the therapeutic communities frequently supported by the Catholic Church played a prominent role here (Appendix 3 and 5). Also here, one prominent argument again was that OST is just replacing one drug by another.