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The Drug Information and Monitoring System (DIMS) in the Netherlands: Implementation, results, and international comparison


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The Ministry of Health in the Netherlands has made illicit drug testing for drug users possible since the 1990s, in order to prevent serious health hazards associated with unexpected dangerous substances. This system of illicit drug testing is called the Drug Information and Monitoring System (DIMS). In nearly two decades, more than 100 000 drug samples have been handed in at DIMS testing facilities. This review describes the DIMS methodology and overviews results of the three main psychostimulant drug markets that have been monitored, i.e. ecstasy, amphetamine (speed), and cocaine. Additionally, monitoring results of hallucinogens are also described for the first time. For comparison, alternative international monitoring systems are described briefly alongside some of their results. Finally, drug monitoring is discussed from the perspectives of policy, prevention, and the drug users themselves.
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Drug Testing
and Analysis
Received: 12 September 2010 Revised: 18 November 2010 Accepted: 23 May 2011 Published online in Wiley Online Library:
( DOI 10.1002/dta.323
The Drug Information and Monitoring System
(DIMS) in the Netherlands: Implementation,
results, and international comparison
Tibor M. Bruntand Raymond J.M. Niesink
The Ministry of Health in the Netherlands has made illicit drug testing for drug users possible since the 1990s, in order to prevent
serious health hazards associated with unexpected dangerous substances. This system of illicit drug testing is called the Drug
Information and Monitoring System (DIMS). In nearly two decades, more than 100 000 drug samples have been handed in at
DIMS testing facilities. This review describes the DIMS methodology and overviews results of the three main psychostimulant
drug markets that have been monitored, i.e. ecstasy, amphetamine (speed), and cocaine. Additionally, monitoring results of
hallucinogens are also described for the first time. For comparison, alternative international monitoring systems are described
briefly alongside some of their results. Finally, drug monitoring is discussed from the perspectives of policy, prevention, and
the drug users themselves. Copyright c
2011 John Wiley & Sons, Ltd.
Keywords: drug monitoring; cocaine; Ecstasy; MDMA; amphetamine
Introduction: Dutch drug policy
From a historical point of view, drug policy and legislation on drug
use in the Netherlands is substantially different from that in many
other countries. The aim of Dutch policy is to reduce both the
demand for and the supply of drugs, and to limit the risks of drug
use. One of the main features of Dutch policy on drugs is harm
reduction, i.e. preventing drug use and limiting risks and harm
to users and the people with whom they associate. This policy
is based on the recognition of the fact that, in an open society,
drugs are quite simply available, and therefore (problematic) drug
use is also unavoidable.[1] In the Netherlands, it is an offence to
produce, possess, sell, and import or export drugs, although it
is not considered an offence to use them. Preventive strategies
are aimed to reduce the demand for drugs, while professional
care limits the harm they cause to users and the people they
associate with. To cut off supplies, the authorities are cracking
down on organized crime. Because in the Netherlands drugs
are primarily regarded as a health issue, the Minister of Health
is responsible for the overall coordination of policy on drugs.
The central objective of the Dutch drug policy was formulated in
the 1970s. As in many Western countries, the drug problem
in the Netherlands underwent a fundamental change at the
end of the 1980s, and the beginning of the 1990s. In the slipstream
of the increasingly popular rave scene, the popularity of synthetic
drugs such as Ecstasy grew rapidly. Ecstasy became popular due
to its non-addictive properties and euphoric effect.
The Dutch drug policy in 1990s was characterized by great
uncertainty about the substances being used, the user groups, and
the risks.[2,3] Use of the new synthetic drugs involved effects and
risks that were different from those associated with the traditional
substances of abuse. Instead of addiction, the most important
risks became acute and chronic damage to the user’s health.
However, the risks that these new substances posed to health
varied considerably, depending on their contents, the settings in
which they were taken, and individual factors. The characteristics
of the new drug users were also very different from those of
the traditional drug addicts.[4] Users of synthetic drugs were not
marginalized, deviant young people who had adapted lifestyles
revolving around drug use. The new psychotropic substances were
consumed on an incidental, recreational basis by young people
who did not differ from non-users in most respects. In fact, the
only similarity with the previous decade was that the drugs being
used were also psychoactive substances.
During the 1990s and at present, besides using new synthetic
drugs, new generations of recreational drug users also started
to embrace more traditionally abused drugs, like cocaine.[5]
Because of its psychostimulant properties, not that different
from amphetamines, it had an image of an associated successful
and prosperous lifestyle. Because cocaine use poses its own
unique array of health risks, especially when as casually used
by recreational users as synthetic drugs, and is a traditionally
adulterated substance with various pharmacological compounds,
its widespread use has added an additional concern for the health
authorities in the Netherlands.
The Ministry of Health developed information material aimed
at discouraging young people from using Ecstasy and other drugs
associated with the nightlife settings.[3] Specific measures were
propagated to prevent or deal with problems caused by drug use
at dance venues, raves, and clubs, such as good ventilation, the
presence of first aid teams and availability of free drinking water.[6]
The scale in which they were used and the specific risks that
the range of new recreational drugs brought about, such as the
lack of certainty about their dosage and composition, made the
Correspondence to: Tibor M. Brunt, Trimbos Institute (Netherlands Institute of
Mental Health and Addiction), PO Box 725, 3500 VJ, Utrecht, the Netherlands.
Drug Information and Monitoring System, Netherlands Institute of Mental
Health and Addiction (Trimbos Institute), Utrecht, the Netherlands
Drug Test. Analysis (2011)Copyright c
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
government decide to monitor this market adequately.[3,7] Illicit
drug market monitoring was deemed necessary for surveillance,
in order to detect acutely hazardous substances, dosages, or
situations at an early stage of appearance on the drug market.
The Drug Information and Monitoring System
From the viewpoint of harm reduction and prevention, it was
essential to gain knowledge about the appearance of new risky
substances on the drug market and to take decisive preventive
action. To enable the adequate monitoring of the rapid changes
on the market for recreational drugs, testing services were set
up where users could have the composition and dosage of
their XTC tablets and other drugs tested. These testing services,
provided within the framework of the national Drug Information
and Monitoring System (DIMS), offer valuable insights into the
dynamic recreational drug market, particularly for policymakers.
Additionally, it enables prevention activities to be expanded
towards a group of drug users that would normally not be reached.
The testing facilities of the DIMS network are usually embedded
in the prevention departments of institutions for the care of
addicts. Traditionally, these departments have much experience
in prevention activities on the very problematic level of drug
addicts; recreational drug users were not seen by these institutions.
Since the foundation of DIMS, users are frequently warned
about the health risks associated with recreational substances.
The authorities act immediately when dangerous drugs are in
circulation. Depending on the severity of circumstances, the
network of testing facilities is alerted, flyers are distributed at
clubs and rave venues and/or warnings are published in the
regional or national press.[7]
A nationwide network of test facilities at drug prevention insti-
tutions in different places in the Netherlands takes part in DIMS.
Drug users hand in Ecstasy tablets or other preparations anony-
mously for a test. The personnel working at these testing facilities
are health and prevention professionals; they communicate about
the effects of the particular substances and their associated risks.
A few of the participating institutions are merely receiving sta-
tions and directly send all the samples they receive to the DIMS
Bureau at the Trimbos Institute and do not offer the opportunity
for identifying any tablets at their own offices. However, most of
the testing facilities are able to identify some of the tablets the
moment they are handed in by the drug user. This is referred to as
‘office testing’.
Office testing
First, the outward characteristics of tablets are registered, including
diameter, thickness, weight, colour, presence of a groove, light or
dark speckling (if present), and any logo visible (and its design).
Second, a Marquis reagent test is performed to find out whether
a tablet contains any Ecstasy-like substances, amphetamine, a
hallucinogenic compound, or none of these. The next step is
to determine whether information is already available about the
specific tablet based on these external characteristics and results
of the Marquis test. This is done with the help of an online
electronic database which is updated weekly by the DIMS Bureau.
The database contains features of all (Ecstasy) tablets that have
recently been analyzed in a laboratory. Because of this weekly
input of information on tablets and because of the fact that Ecstasy
tablets are usually produced in large batches, certain tablets can be
determined and recognized through this specially developed and
weekly updated database on the DIMS website, the ‘recognition
list’. The average MDMA (3,4-methylenedioxymetamphetamine)
content and the variation of the tablet are then known, and the
tablet does not have to be analyzed necessarily in the laboratory.
When the consumer decides to have the tablet analyzed in the
laboratory anyway, its analysis results can be used for validation
of the recognition list. This has shown a 99% reliability of the
recognition list. Therefore, this ‘office testing’ recognition system
provides the testing facilities throughout the country with a tool
to give the drug consumer an immediate and accurate test result,
without having to hand over the actual tablet. On average, 30% of
tablets are determined this way.
Tablets that are not recognized by this online determination
system and those about which doubt exists together with
other drugs samples such as powders, capsules, and liquids are
forwarded to the DIMS Bureau at the Trimbos Institute. When
possible, additional information, such as the place of purchase,
the price that was paid, and the consumer’s knowledge and
opinion of the product is added. Finally, at the testing facility,
a unique individual number is given to the drug consumer by
which he or she is able to communicate regarding the particular
drug sample’s test result one week later. At the DIMS Bureau
itself, all samples received are registered, and details are carefully
re-examined for possible re-assessment of the determination that
was done by the testing facilities. Basically, all samples received
by the DIMS Bureau are then coded, packaged, and transported to
the laboratory for full chemical analysis (Figure 1).
Laboratory analyses
Qualitative and quantitative analyses of the drugs samples
that have been sent to the DIMS Bureau were performed
in the laboratory of the Delta Psychiatric Hospital (Deltalab,
Poortugaal, the Netherlands), which specializes in analyzing drug
samples. A set of robust analytical methods was used to identify
known and unknown components, to quantify and classify them.
After crushing and homogenizing the sample, three separate
analytical techniques were used. First, thin layer chromatography
(ToxilabA) was performed for identification. Therefore, a small
part of the sample (approximately 2 mg) was concentrated on a
Toxidisc, placed in the chromatogram and developed according
to the ToxilabA procedure. The analytes were identified by
relating their position (RF) and colour to standards through
four stages of detection: a colouring stage I (Marquis reagent),
a washing stage II, an UV fluorescence stage III, and finally a
colouring stage IV with Dragendorff’s reagents. The Toxilab
methodology including three reference samples provides a robust
identification.[8] An extensive library enables the chromatographer
to check on correct location of spots as well as the identification
of new substances.
Subsequently, the quantification of the main compo-
nents (e.g. amphetamine, metamphetamine, 3,4-methylene-di-
oxyamphetamine (MDA), 3,4-methylene-dioxyethylamphetamine
(MDEA), N-methyl-a-(1,3-benzodixol-5-yl)-2-butamine (MBDB),
caffeine, cocaine and heroin) was performed with gas chro-
matography - nitrogen- phosphorous detection (GC-NPD). The
samples were pretreated: after being crushed, 25 mg sample
was ultrasonified in 0.01 M HCl. An internal standard was added Copyright c
2011 John Wiley & Sons, Ltd. Drug Test. Analysis (2011)
DIMS: Implementation, results, and international comparison
Drug Testing
and Analysis
Figure 1. A schematic representation of the DIMS system.
Figure 2. A flowchart representing the procedure of clarification of substances by the laboratory.
(Chirald, Sigma-Aldrich, Zwijndrecht, the Netherlands); there-
after a liquid-liquid extraction was performed with ToxitubeA,
a diluted sample of the extract was used for the cold-on-
column injection on the GC-column (WCOT-CP-Sil-8-CB, length
25 m, id 0.32 mm df 0.25 µm). The total runtime was 12– 28 min
on a programmed time– temperature scale (75 –280 C) with
nitrogen-phosphor-detector and helium as carrier gas. The
two methods were running independently and were used
as a mutual confirmation. In case of any discrepancies, or
trace amounts requiring quantification, a gas chromatography-
mass spectrometry (GC-MS) method was introduced as the
tiebreaker. This generally needed to be done in approximately
10% of the samples. GC-MS (Varian Saturn 4D, Varian Medi-
cal Systems, Houten, the Netherlands) conditions were similar
to GC-NPD and substances were identified full scan (EI) with
the NIST-library. GC-MS was also used for quantification of
certain uncommon substances (e.g. γ-hydroxybutyrate (GHB),
γ-butyrolactone (GBL), para-methoxyamphetamine (PMA), para-
methoxymethamphetamine (PMMA), ephedrine, ketamine and
lysergic acid diethylamide (LSD)). In exceptional cases, iden-
tification was performed using advanced GC-MS and nuclear
magnetic resonance (NMR) spectroscopy structural analysis (e.g.
2,5-dimethoxy-4-bromophenethylamine (2C-B), 2,5-dimethoxy-
4-bromoamphetamine (DOB) and 4-methylthioamphetamine
(4-MTA)). Combining different routes for clarification and
quantification leads to a growing list of identified compounds
in illicit drugs found over the years (Figure 2).
Drugs users
An important difference between DIMS and other ways of
collecting toxicochemical data on drug samples, such as drug
seizures by the police, is the fact that data are collected directly on
the user’s level and there is contact with the user. With DIMS, this
means there is an information exchange between the personnel
at the testing facilities and the users. Most important information,
such as personal adverse effects, or adverse effects experienced
by friends, with the drug sample in question is recorded and saved
in the DIMS database. Other important inputs in the database are
regional origin, date, source of purchase, price, and reason for
testing. Other relevant information may be added by the testing
personnel, but anonymity of the drug user is always guaranteed,
one of the main conditions of keeping the DIMS system trustworthy
for drug users. The information supplied by the users is often crucial
in determining which substance is associated with unexpected
risks and in which part of the country these risks may possibly
occur. From the perspective of the institutions for addiction and
mental healthcare that provide the testing facilities, it is important
to have one-on-one contact with young, recreational drug users
to target their prevention and harm reduction activities.
There have been at least two studies that attempted to describe
the users that utilize DIMS as a test facility for their drugs.[9,10] These
suggested that users utilizing testing systems are broadly similar
to non-testing users. We can therefore consider the target group of
the DIMS system as a reasonable reflection of all recreational drug
Drug Test. Analysis (2011)Copyright
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
users. The vast majority of drug users who visit the DIMS testing
services are youths or men with an ethnic Dutch background
who are engaged in paid employment or study. The group
includes both experienced users who take Ecstasy every week
and less experienced ones who just take it occasionally. As well as
taking Ecstasy, they report considerable experience with alcohol,
tobacco, and cannabis, and to a lesser extent also with cocaine
and other drugs. Most of them have no experience with heroin
or basecoke. The most common lifetime pattern of Ecstasy use
involves increasing amounts taken up to a peak of use, followed
by a decline to a somewhat lower level. The average dose is
two tablets per occasion. If Ecstasy is taken in combination with
another substance, it is usually alcohol, and, to a lesser extent,
cannabis. Tablets are usually bought from a friend or a known
dealer some time before a night out. When buying Ecstasy,
knowing the dealer is considered far more important than
obtaining tablets with a familiar logo or colour. Visitors to the
test facilities were also asked about the main reason why they
have their drugs tested. The majority answered health concerns,
followed by curiosity about the results, and circulated warnings
about dangerous drugs. With regard to the attitude towards
prevention and harm reduction, the testing systems were seen as
a very reliable source of information and users also appreciated
this way of contact with prevention organizations.[9,10]
The DIMS results are not, by definition, an exact representation
of the Ecstasy market in the Netherlands. The DIMS monitoring
system depends on drug samples handed in by users, and will
therefore not be an exact reflection of the use and availability
of drugs on the market. However, DIMS is a qualitative monitor
that does not focus on the precise number (quantity) of specific
tablets or other drugs on the market, but on the contents (quality -
chemically and toxicologically) of drug samples. However, a study
comparing drug samples as delivered at DIMS with those obtained
from police seizures at dance venues and rave parties, showed
that the DIMS results in fact provide a fairly accurate picture of the
total Dutch Ecstasy market at consumer level.[11]
Monitoring results
Since DIMS was set up in 1992, the Dutch illicit drug market has
now been monitored for almost two decades. In particular, DIMS
follows movements of Ecstasy, amphetamines, and cocaine and
to a lesser extent, of synthetic hallucinogens on the market.
Cannabis products, hallucinogenic mushrooms, and doping-
related substances such as anabolic steroids are not systematically
monitored. For cannabis-related products, DIMS has a different
monitoring system.[12] Here we will discuss the DIMS results of the
contents of Ecstasy, amphetamine, cocaine, and LSD drug samples
over the past 18 years. More specific details for Ecstasy may be
found in Spruit,[7] and Vogels et al.,[11] and for amphetamine and
cocaine in Brunt et al.[13,14]
It is well-known that the Netherlands has been an important
country for the illegal production of amphetamines and Ecstasy
for many years,[15] and it seems reasonable to assume that
most Ecstasy and amphetamines on the Dutch consumer market
come directly from this illegal production. This contrasts with
cocaine, which is exclusively obtained through illegal imports.
Large changes in the composition of amphetamines and Ecstasy
are therefore often a direct reflection of changes in production
processes, such as shortages of precursors or other chemicals. In
contrast, changes in the composition of cocaine could be explained
by law-enforcement activities affecting export and import.
As for the overall results of the monitor, a combined total of
more than 100 000 drug samples have been handed in at DIMS
between 1992 and July 2010. The vast majority of these samples
were tablets, falling into the categories ‘recognized’ or ‘analyzed
by the laboratory’ (Figure 3). Figure 4 shows the proportion of
tablets, powders, and other drugs (liquids, capsules, papertrips)
that have been analyzed in the laboratory between 1993 and 2010.
Powders make up the largest part of the rest of the drug samples;
these comprise mainly MDMA, speed, or cocaine powders. Liquids,
capsules, or miscellaneous forms of drug samples only make up a
very small percentage of the total.
There is a difference between what in pharmacological literature
is defined as Ecstasy and what is called Ecstasy by drug users.
Pharmacological and chemical scientific literature defines Ecstasy
as 3,4-methylenedioxy-N-methylamphetamine (MDMA).[16] When
epidemiological or socio-scientific research refers to Ecstasy,
preparations are meant that are known to the interviewees by
that name. By no means everything that is sold as Ecstasy
is MDMA.[11,17] At the beginning of the 1990s, MDMA, MDEA,
and MDA were the substances most frequently found in
tablets bought as Ecstasy (Figure 5). MDMA, MDEA, and MDA,
often referred to as Ecstasy-like substances, are substituted
methylenedioxyphenethylamines, a chemical class of derivatives
of the phenetylamine group, to which group also amphetamine
belongs. MBDB or ‘Eden’ is another substance that belongs to the
group of methylenedioxyphenethylamines (Figure 6).
The use of MDMA in the Netherlands was first reported in
1985.[18] MDMA induces the so-called entactogenic effect.[19]
MDMA and MDEA hardly exert any hallucinogenic effects and
MDA causes nothing more than light illusory perceptions and
distorted images. MDA has a stronger stimulating effect than
MDEA and MDMA, but a weaker entactogenic effect.
The most common form of MDMA incorporated in Ecstasy
tablets is the hydrochloride salt. It is a white powder that is
easily soluble in water. Ecstasy products on the market are seen
typically as tablets with a characteristic logo, less commonly as
powders, capsules, liquids, or crystals. A typical Ecstasy tablet
contains between 80 and 100 mg of MDMA. From the literature,
it may be concluded that people take anything from half a tablet
to several tablets per evening or weekend.[20,21] If these figures
are used as a reference mark, the recreational doses taken by
users amount to 0.54 mg/kg, distributed over many hours and
sometimes several days. In some cases, peak use can be as high as
10 mg/kg. What people take and how much they take depends,
however, on factors such as the effects they want to achieve, their
degree of experience, and the actual, often unknown, composition
of the tablets.
Figure 5 summarizes the composition of tablets sold as Ecstasy
as analyzed by DIMS in the laboratory throughout 1993 2010.
The picture shows that there have been two periods during which
many tablets contained other substances in addition to or instead
of MDMA. In and around 1997, many Ecstasy tablets contained
amphetamines and in and around 2009 many tablets contained
meta-chlorophenylpiperazine (mCPP) instead of or in addition to
MDMA. At the peak of the shortage of MDMA, in October 1997, only
30% of the Ecstasy tablets handed in at DIMS contained MDMA
or a MDMA-like substance. The peak of shortage of MDMA in
2009 was in March, with only 40% of all Ecstasy tablets containing Copyright c
2011 John Wiley & Sons, Ltd. Drug Test. Analysis (2011)
DIMS: Implementation, results, and international comparison
Drug Testing
and Analysis
Figure 3. Number of drug samples per year delivered at DIMS between 1992 and 2010. Data reflect pharmaceutical appearance.
Figure 4. Relative contribution of tablets, amphetamine, cocaine, XTC powders and other drugs delivered at DIMS between 1992 and 2010 that have
been analyzed in the laboratory.
MDMA. Between 1996 and 2001, less than 50% of the Ecstasy
tablets contained more than 70 mg MDMA; the same applies for
2009, when only 42% of the tablets sold as Ecstasy contained more
than 70 mg MDMA per tablet. Before 1997 and between 2000 and
2009, more than 50% of the Ecstasy tablets contained more than
70 mg MDMA per tablet.
MDEA and MDA, which were present in about 30% of the
Ecstasy tablets before 1997, have virtually disappeared from the
Ecstasy market; MDEA and MDA were never present in substantial
amounts, since 1997. Sporadically, nowadays, only small amounts
of MDEA and MDA are found, often in combination with MDMA,
in tablets. Apart from the marked decline in the number of tablets
containing MDMA-like substances, the periods around 1997 and
2009 are characterized by the appearance of other psychoactive
substances in tablets sold as Ecstasy, e.g. MBDB, 2C-B, atropine,
4-MTA, PMA around 1997, and mCPP and mephedrone around
2009 (Figure 5). The appearance of PMA was accompanied with
a national warning campaign in the Netherlands, since this is a
much more hazardous substance as any MDMA-like substance,
with a steep dose-response curve.[22] In the late 1990s, PMA
appearedin Ecstasy tablets allover theworld andcaused numerous
emergencies and even deaths.[23 – 27]
Drug Test. Analysis (2011)Copyright
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
Figure 5. Composition of tablets sold and bought as Ecstasy handed in at DIMS per year, a number of novel substances found are given at the top of the
figure, in order of appearance through time.
Figure 6. Chemical structures of the methylenedioxyphenethylamines
In the 1930s, amphetamine was marketed as a nasal inhaler to
shrink mucous membranes under the trade name Benzedrine.
Early users of the Benzedrine inhaler discovered that it had a
euphoric stimulant effect, which resulted in it becoming one
of the earliest synthetic stimulants widely used for non-medical
(recreational) purposes.[28]
Speed and pep are the street names for amphetamine, like
XTC and Ecstasy are street names for MDMA. In the Netherlands,
amphetamine has been a controlled substance since 1976.[29] The
proportion of the people in the Netherlands that have recently
used amphetamine, as well as the lifetime prevalence of the
general population of twelve years and older, is quite low and
relatively stable, in 2005 0.3% and 2.1%, respectively.[30] In the
mid-1990s, there was a temporary increase of amphetamine
abuse. In that period, speed became especially popular among
certain subgroups of partygoers. They often distinguished them-
selves from others by music preference (hardcore trance) and
dress.[31,32] Because amphetamine (speed) is much cheaper than
cocaine (coke), it was previously also known as ‘coke for the poor’.
Methamphetamine is closely related to amphetamine. In Thailand,
tablets containing methamphetamine are sold as Yaba.[33] Yaba
is much stronger and is much longer acting than amphetamine.
In the Netherlands, recreational use of amphetamine is much
more common than abuse of methamphetamine; in fact,
methamphetamine use is very uncommon.
Unlike MDMA, amphetamine has no entactogenic properties.
The recreational user of amphetamine seeks the mental and
physical stimulation which it produces. The desired effects usually
last up to four hours and as the effects begin to wear off may be Copyright c
2011 John Wiley & Sons, Ltd. Drug Test. Analysis (2011)
DIMS: Implementation, results, and international comparison
Drug Testing
and Analysis
Figure 7. Mean percentage of amphetamine and caffeine in speed powders per year(q uartiles indicated by scaling lines on axis). Only powders containing
quantifiable amounts of amphetamine (>1%) have been included.
succeeded by a period of restlessness, anxiety, fatigue, disinterest,
or tiredness.[28] Some users seek the stimulating properties
of amphetamine for other purposes. Those in monotonous
occupations may abuse amphetamine in the workplace and
students may use the drug to decrease tiredness, enabling
studying for long periods of time.[28]
Amphetamine is a member of the phenethylamine family. As an
illicit drug, amphetamine is mostly found as a sulfate salt, which is
a white powder, easily soluble in water. Although amphetamine
appears in tablets with logos similar to Ecstasy, on the street
amphetamine is mostly sold in powder form and like cocaine, it is
often snorted.[30] When snorted or ingested, a dose may vary from
several tens to several hundreds of milligrams depending on the
purity and the individual tolerance for the drug.
Between 1992 and July 2010, 8239 powder samples bought as
speed were handed in at DIMS. In about 85% of these samples,
the amount of amphetamine was high enough for quantification.
Between 1997 and 2001, the percentage of samples that did not
contain quantifiable amounts of amphetamine was over 20%,
reaching a peak of over 40% in 1999. Until 1996, the number
of speed samples delivered to DIMS was hardly high enough to
describe the speed market. Since 1996, the number of samples
increased to over 10 samples per month from 1996 until 1999, and
since 2000, on average more than 20 samples per month were
handed in. In 2008 and 2009, more than 60 samples per month
were received at DIMS.
The analyzed speed powders that were handed in between
1995 and 2010, with detectable amounts of amphetamine,
contained on average 30% pure amphetamine (30.2±0.2%;
mean ±SEM). Between July 1998 and April 2001, the mean
amount of amphetamine decreased to less than 20%. In January
2000 the mean amount of amphetamine decreased to less than
5% (Figure 7). This phenomenon reoccurred in 2008/2009, with
an absolute low in December 2008, with a mean percentage
of amphetamine of 18%. Simultaneously with the decrease in
amphetamine concentration, the amount of caffeine in speed
powders increased (Figure 7). The purity of speed, expressed
as the mean percentage of amphetamine, seems to follow an
inverse relationship with the percentage of caffeine over time,
with the mean percentage of amphetamine in a powder being
high, the percentage of caffeine being low and vice versa.The
amount of samples handed in did not drop in both instances of
amphetamine shortage, and neither did the percentage of samples
not containing quantifiable amounts of amphetamine.
The most common route of synthesis for amphetamine is by
the Leuckart method.[28] This method uses benzylmethylketone
(BMK, 1-phenyl-propanone) as a precursor. Around 1999, and
in 2008 and 2009, there were shortages of this amphetamine
precursor on the illegal drug production circuit. Therefore,
it became extremely difficult to produce amphetamine. The
available speed powders hardly contained amphetamine and
were cut much more with caffeine. Caffeine is often added to
amphetamine at the production source, whereas other cutting
agents, such as glucose and other sugars, are usually added
elsewhere.[15] Unlike MDMA, a shortage of amphetamine on the
illegal drug market does not seem to cause the appearance of
‘new’ psychoactive compounds in speed powders. However, the
transient shortage of amphetamine in 2008/2009 caused the
appearance (and disappearance) of two psychoactive substances:
4-fluoroamphetamine and 4-methylamphetamine (not to be
confused with methamphetamine), substances that had not been
seen in speed powders before (Figure 8).
Cocaine is a natural product extracted from the leaves of Erythrox-
ylon coca. Cocaine has a psychomotor stimulant effect similar to
that of amphetamine. Cocaine base and the hydrochloride salt are
white powders.[34] In recreational use, cocaine is typically snorted
whereby it is absorbed through the nasal mucosa.
Since 1993, DIMS received cocaine powders; in the early
1990s, on average between 5 and 10 samples per month, but
in subsequent years numbers quickly increased. Since 2004,
more than 50 samples per month were handed in. Of the
powders that were sold as cocaine, an average of 10% did not
contain quantifiable amounts of cocaine. The remaining powders
contained 56 ±0.3% (mean ±SEM) pure cocaine. From 1993
to 1999, the average purity was higher than in the past decade
Drug Test. Analysis (2011)Copyright
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
Figure 8. Chemical structures of amphetamine, methamphetamine, 4-
fluoroamphetamine and 4-methylamphetamine.
(2000– 2010), 66.3±0.7% (mean ±SEM) versus 54.9±0.8% (mean
±SEM), respectively.
Often adulterants are added to increase weight, and sometimes
other, mainly less costly substances are added to make up for lost
potency.[35] Alternatively, adulterants are added to camouflage
the decrease in potency of the cut-up cocaine, usually other
local anesthetics, which produce the same numbness to the
gums as cocaine, thereby creating the false impression to
handed in at DIMS were cut with a variety of substances: inert
compounds (mannitol, maltose, inositol, flour, starch), synthetic
local anesthetics (lidocaine, benzocaine, procaine, tetracaine) and
other pharmacologically active substances (caffeine, phenacetine,
levamisole, hydroxyzine, diltiazem).[13]
Approximately 10% of all cocaine samples contained a synthetic
local anesthetic. The average amount of pure cocaine in these
samples (44.6±0.9%; mean ±SEM) was significantly lower
than in the samples not containing synthetic local anesthetics
(57.0±0.3%; mean ±SEM). Similarly, cocaine cut with other
pharmacologically active substances also contained less pure
cocaine (38.8±0.4%; mean ±SEM) than cocaine powders that did
not contain these substances (62.1±0.3%; mean ±SEM) (Figure 9).
Apparently, all of these adulterants were added for compensatory
purposes as already mentioned. Table 1 summarizes the major
pharmacologically active substances found in DIMS cocaine
powders during the last five years (2005– 2009). Atropine was
Table 1. Psychoactive compounds most commonly found in DIMS
cocaine powders (2005–2009)
Present in % of samples Mean ±S.E.M.
Phenacetin 38 25.5±1.3 (n=956)
Levamisole 21 7.4±0.3 (n=338)(1)
Caffeine 15 9.0±2.6 (n=502)
Lidocaine 8 n.q.
Procaine 7 n.q.
Diltiazem 6 n.q.
Hydroxyzine 3 n.q.
Benzocaine 0.4 n.q.
Diphenhydramine 0.1 n.q.
Tetracaine 0 n.q.
Atropine 0 2.0±3.0 (n=5)
N.q., not quantified; n, number of samples quantified; (1) Data from
found in 2005, and again in 2007. The presence of atropine in
cocaine was accompanied by several hospitalizations and even
fatalities in both occasions, in the Netherlands and across the
border (Italy, France, Germany, Belgium).[36,37] In situations such
as these, it is a vital part of the surveillance function of DIMS to
immediately orchestrate a national mass media warning to warn
the (potential) users and furthermore, to alert the international
network of early warning systems throughout the EU.
LSD and other hallucinogens
Of all hallucinogens, lysergic acid diethylamide (LSD or ‘acid’) is
the most prevalent handed in at DIMS. LSD samples are usually
papertrips, taken from greater formats of colourfully decorated
paper. The LSD is impregnated into the paper at a certain
concentration, which does not have to be equally spread among
individual papertrips taken from one original sheet of paper. The
other form in which LSD is handed in at DIMS is as microdot. This is
a minute tablet, usually weighing less than 10 mg, without logo or
much other specific characteristics. Most microdots are coloured
uniformly black.
Figure 9. Mean percentage of cocaine (purity) in cocaine powders containing pharmacologically active adulterants and not containing pharmacologically
active adulterants. Only powders containing quantifiable amounts of cocaine have been included. Copyright c
2011 John Wiley & Sons, Ltd. Drug Test. Analysis (2011)
DIMS: Implementation, results, and international comparison
Drug Testing
and Analysis
Figure 10. Percentage of samples containing LSD of all samples that were sold as LSD and the average concentration of LSD per unit (papertrip or
microdot), three substances found in samples sold as LSD are given at the top of the figure, in order of appearance trough time.
In the Netherlands, LSD is used by small subpopulations of users
and in other settings as the mainstream clubs or events where
Ecstasy or cocaine are used. One subpopulation is often referred
to as the ‘psychonauts’; the experimental drug users that are
interested in exploring new psychological avenues in the brain as
well as going out and listening to dance music.[38] This dance music
is often another style (e.g. psytrance, a psychedelic type of dance
music) than the more mainstream dance music played at big clubs
or events.[5] Because LSD is used in the busy and noisy setting of a
dance party, the dosages used nowadays tend to be considerably
lower (20– 125 µg) than the dosages that were reported in the
1960s and 1970s (3002000 µg[39]). This reduces the risk of a
negative mental experience or ‘bad trip’, while undergoing LSD’s
specific effects.
At DIMS, first numbers of LSD samples were seen around 1999.
In that year, only six samples were handed in that were sold as LSD.
This increased to 10 samples in 2000 and 12 in 2001. From 2002
and onwards the number of LSD samples at DIMS became more
and more substantial, with a peak of 99 samples in 2003 and 66
samples for the first six months of 2010. Based on these numbers,
something can be said about the LSD market, at least on an annual
basis. Around 80% of the samples that were sold as LSD contained
the hallucinogenic substance (Figure 10). An exception was 2002,
when only 26% of all LSD samples contained the hallucinogen;
in the rest of the samples the concentration was either not
quantifiable or traces of other compounds were found, such as
methamphetamine or DOB. In 2007, some papertrips were handed
in containing fentanyl, a very potent synthetic opioid, which led
to a special warning campaign, directed at the small target group
of LSD users. The average concentration of LSD ranged from
20 µgto96µg/unit (unit meaning either papertrip or a microdot)
(Figure 10). However, the variation in LSD concentration was
substantial: from 1 –500 µg/unit. This widespread concentration
between units probably represents two extremes of the market:
the low dosages, probably being used at nightlife settings, such
as dance parties and raves, whereas the higher dosages might
come from the more experienced users who take LSD in a more
secluded, private setting.[40]
There were only a few other hallucinogens handed in at DIMS
with 2C-B being the most prevalent one after LSD. Initially
2C-B was sold as small tablets, with concentrations between
115 mg 2C-B per tablet. During the second half of the 2000s,
2C-B was frequently found in tablets sold as Ecstasy and these
tablets highly resembled Ecstasy tablets, with similar logos,
shapes, and colours. Recently, 2C-B was also encountered in LSD
papertrips (Figure 10). Concentrations 2C-B rarely exceeded 5 mg
per sample (tablet or papertrip). Other hallucinogens that have
been found by DIMS were on sporadic basis and comprised 2,5-
dimethoxy-4-ethylthiophenethylamine (2C-T-2 and 2C-T-7), N,N-
dimethyltryptamine (DMT), 5-methoxy-diisopropyltryptamine (5-
MeO-DiPT) and dextromethorfan (DXM), among others.
Other drug markets and monitors
Illicit drug testing in order to gain insight into certain drug markets
for health or even law enforcement purposes is nothing new.
Usually, information concerning the contents of illicit street drugs
comes from the various national forensic institutes that are situated
in most countries. These forensic institutes often receive parties
of drugs that have been seized by the police, either at customs,
clandestine production facilities, or from consumers at local events.
This is no different from the situation in the Netherlands, were
the National Forensic Institute provides important information
about the drug market in addition to the DIMS system. The
presence of two independent systems offering quantitative and
qualitative information about the state of the illicit drug market
creates an ideal situation to compare and validate results. It
also adds to a more complete picture of the illicit drug market
and allows for the specification of which batches of drugs were
distributed domestically and which were probably meant for
export. Regardless of the advantages, most countries do not have
Drug Test. Analysis (2011)Copyright
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
an additional direct costumer-derived information source of the
illicit drug market, besides the seized samples.
However, besides the Netherlands, there are other nations
assembling illicit drug market data from additional sources than
the forensic institutes, like the French National Identification
System for Drugs and Other Substances (SINTES), a combination of
police and customs seizures and samples obtained directly from
the consumers by social field workers.[41] TICTAC,intheUnited
Kingdom, utilizes amnesty bins from large clubs and venues in
some major British cities to describe the chemo-analytical contents
ofthe drugs inthese bins.[42,43] Thereis the ‘on-the-spot’ dancefloor
high performance liquid chromatography (HPLC) analysis by the
Check-It team from Vienna, Austria, and in Switzerland there
is the Safer Party c
initiative, collecting samples from the users
directly through fieldwork contacts.[44,45] Their analysis procedure
is based on an automated HPLC for the separation process.[45]
These HPLC systems are equipped with DAD/UV-Vis Spectrometers
(DAD=Diode Array Detector) and autosamplers and analysis
results can be obtained within 20 min, making it useful for testing
on the dancefloor.
In the United States, there is the DanceSafe initiative; it tests
drugs and makes the test results public to the potential consumer
audience.[46,47] It more or less seems to work according to the way
the DIMS recognition list works, with the exception that the drug
consumer has to do the colouring test him-/herself and combine
the result of this test with the tablet characteristics given on the
website. Finally, the National Drug and Alcohol Research Centre
in Australia provides a very elaborate system of monitoring illicit
drug markets, and besides using the laboratory analysis informa-
tion provided by the Australian Crime Commission, it uses a wide
network of drug users for information on ‘perceived drug purity’
for instance, collectively referred to as the Illicit Drug Reporting
System (IDRS) and the Ecstasy and Related Drugs Reporting System
(EDRS).[48,49] Whereas these initiatives have all contributed to the
knowledge of the composition of the illicit drug markets through-
out the world, by far, most international chemo-analytical data
were reported by the different national forensic institutes.[50 – 54]
Because of the large differences in types of drug sample
monitoring methodologies between the various countries around
the world, it is virtually impossible to make a one-on-one
comparison between countries on market variables, such as purity,
price, or content. Large organizations, such as the European
Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
and the United Nations Office on Drugs and Crime (UNODC),
provide some insight into the variety of the different global
illicit drug markets,[55,56] but the quantity of samples and
extent of national coverage still differs considerably between
countries. Nonetheless, Figure 11 aims to provide some insight
into international comparison between the three main illicit drug
markets previously discussed in this review, i.e. Ecstasy, cocaine,
and amphetamine. Important to bear in mind is that not all
countries provided information on every substance; for instance,
amphetamine is barely monitored outside of Western Europe, but
methamphetamine is. Also, the analytical methods of the different
international laboratories might differ considerably, which of
course impacts on the results as well. Therefore, the results are
more indicative of global trends than they are exact comparisons.
Comparing the different monitoring results to those of DIMS in
recent years, it is evident that every country shows its own unique
drug market composition and dynamic (Figure 11). Roughly, and
not surprisingly, the different Western European Ecstasy markets
show more resemblance to each other as to Eastern Europe or
Western Australia, for instance. The different Western European
‘speed’ markets also show a resemblance, but the amphetamine
purity in all of them is considerably lower than it is in the
Netherlands. In contrast to the Ecstasy markets, the different
cocaine markets show a less clear pattern of resemblance between
Western European countries. The markets in the USA and Western
Australia are in fact very comparable with many European markets
(Figure 11). This makes sense, since the source of cocaine (Latin
America) is the same in all considered countries.
Additionally, new psychoactive additives are also reported by
many countries, providing an alternative source of comparison
between drug markets (Table 2). To keep matters simple, only the
cocaine and Ecstasy markets are compared, since these two mar-
kets are most known for emerging new substances/adulterations
anyway. The United States are compared to two major Western
European countries, France and Germany, to provide some degree
of cross-Atlantic comparison. As is shown, the Ecstasy markets
show a lot of similarities between these countries divided by
the Atlantic. However, the United States seems to have its own
specific compounds appearing in Ecstasy tablets, such as dex-
tromethorphan (DXM) or phentermine for instance. On the other
hand, phenethylamines like MBDB or 3,4-methylenedioxy– N-(2-
hydroxyethyl)amphetamine (MDHOET) were not seen in the US
Ecstasy market. As for cocaine adulterants, there is once again
a more uniform spread among all three countries, confirming
cocaine as the import product it is to all these countries.[55] Inter-
estingly, from a global diversion point of view, however, are the
different time-points that the adulterants arose in the different
countries. As with the purity data, it is important to bear in mind
that the drug testing systems between these countries probably
differ in a number of aspects.
Illicit drug market monitoring is recognized as a surveillance tool
for the benefit of public health,[63,64] somewhat analogous to
agencies concerned with inspecting product quality of foods or
medicine, that are well-spread throughout all countries in the
world. Similar to warnings about food poisonings, drug monitors
try to keep track of acutely hazardous substances found in illicit
drugs and issue warnings to take a rapid course of action. The
monitoring results of DIMS have provided valuable qualitative
information on changes in the content of drug samples in the
Netherlands throughout the years. The DIMS results were used for
national and international risk assessments and major warning and
prevention activities. In this capacity, it functions almost directly
at the level of the potential drug consumers and this ensures
quick delivery of the prevention message. Secondly, it attempts to
accurately follow drug market processes in time. This is in contrast
to the forensic institutes which do not generally aim at public
health related matters, nor strive to monitor processes through
During nearly two decades of monitoring street drugs, DIMS
has shown that the different psychostimulant markets are very
dynamic and new psychoactive substances and additives are
emerging frequently. Interestingly, the rise of new substances
often co-occurs with the shortage of a specific illicit drug of
abuse. This applied to amphetamine, 4-MTA and PMA, found
in Ecstasy tablets, during the 1990s or mephedrone and mCPP
during the last couple of years. Mephedrone, actually, is rather
a special case as recent literature has made clear.[65 – 69] It was Copyright c
2011 John Wiley & Sons, Ltd. Drug Test. Analysis (2011)
DIMS: Implementation, results, and international comparison
Drug Testing
and Analysis
Figure 11. Percentage of analyzed tablets containing MDMA-like substances in six countries between 2004 and 2008.[47,57] Average content of MDMA
in mg/tablet in five countries between 2004 and 2008.[58,59] Average amphetamine purity in five countries between 2004 and 2008.[58] Average cocaine
purity in eight countries between 2004 and 2008.[58 – 60] In Western Australia average MDMA content was expressed as percentage/tablet.
sold through various websites, as plant fertilizer, especially in the
UK.[70] Although in the Netherlands it was found as a replacement
for MDMA in Ecstasy tablets, mephedrone seems to be a part of
a far more greater whole: ‘legal highs’, referring to drugs sold
through the Internet that mostly do not have a legally controlled
status. This phenomenon seems to be persistent, because, after the
ban of mephedrone in a number of countries, a new generation
of post-mephedrone products was already signalled.[67] These
products can be produced in laboratories anywhere around the
world and their sale via the Internet will make legislation more
complex, thereby changing the face of drug trade radically. Besides
these new psychoactive substances, also novel adulterants, such
as levamisole, could provide new challenges for healthcare and
policymaking.[71 –74]
astir that it wasbanned earlier in2010.[75] It isbanned in manyother
EU member states at the moment and a risk assessment procedure
has already been conducted by the EMCDDA,[76] which may
possibly lead to a ban in the remainder of the EU member states.
Following the continuing rise of new psychoactive substances
on the drug markets, described in this review, such collective
European efforts to ban substances seem to have increased in
frequency over time. Other substances that underwent the same
fate and were banned include benzylpiperazine (BZP), 4-MTA, PMA,
and MBDB, among others.[56,77] But it is the monitoring systems
that are at the core of these Pan-European policy initiatives.
Whereas the special drug policy of the Netherlands makes
a system like DIMS possible, other countries have made great
efforts of their own to create intelligible insights into their
drug markets. Some of these efforts resulted in similar systems
like DIMS, whereas others derive drug market information in
a different way.[41– 43,46,48,78 – 80] As suggested in this review,
analytical testing procedures for drug samples probably differ
between many countries, reflecting on the results. Several factors
could be of importance: ways of extraction, measuring to the
base or salt form, purity definitions, quantification method used,
etc. Nevertheless, on various drugs of abuse, very similar results
over time were reported by different countries.[55,56] This provides
interesting avenues of investigation, such as import, export, routes
of dispersion, or sources of adulteration, for example.
Recently, perhaps one of the most striking new chemo-analytical
methods of measuring drug market information that has been
reported by several research groups is the detection of drugs
of abuse, their metabolites, and their adulterants in public
wastewater by HPLC-tandem mass spectrometry.[81 – 86] In this
way, drug markets can be monitored without the involvement of
anyone participating in the illicit drug circuit; for example, users
or producers. But this method rather measures consumption itself
and is better developed for large, non-specified, bulk analyses from
certain areas. User-specific or sample-specific data are impossible
to gain by this method. This method might be useful in assessing
the scale of temporal and spatial illicit drug use in the future.
Drug Test. Analysis (2011)Copyright
2011 John Wiley & Sons, Ltd.
Drug Testing
and Analysis T. M. Brunt and R. J. M. Niesink
Table 2. New psychoactive substances detected on the Ecstasy and cocaine markets in 2004–2009 in Germany, United States and France
2004 2005 2006 2007 2008 2009
Ecstasy market 2C-I, MBDB Ephedrine, MBDB BZP mCPP mCPP, BZP Mephedrone, PMA
Cocaine market Lidocaine,
caffeine, procaine
United States
Ecstasy market Ephedrine, DXM, BZP,
TFMPP, creatine
Ephedrine, DXM,
fentanyl, mCPP,
Ephedrine, DXM,
mCPP, modafinil,
procaine, BZP
mCPP, 2C-B, BZP,
ketamine, DXM, FPP,
Cocaine market Diltiazem,
Caffeine, levamisole,
Ecstasy market MBDB, 5-Meo-Dipt mCPP, MDHOET 4-MTA, ketamine,
BZP, ketamine,
mCPP, BZP 4-fluoroamphetamine,
Cocaine market Phenacetin,
MBDB, N-methyl-1-(1,3-benzodioxol-5-yl)-2-butanamine; TFMPP, 1-(3-trifluoromethylphenyl)-piperazine; BZP, benzylpiperazine; MDDMA, 3,4-
methylenedioxydimethylamphetamine; DXM, dextrometorphan; MDHOET, 3,4-methylenedioxy N-(2-hydroxyethyl)amphetamine; 4-MTA, 4-
methylthioamphetamine; 2C-I, 2,5-dimethoxy-4-iodophenethylamine.
Detected in drugs obtained from intoxicated hospitalized patients Sources USA.[47,61] Sources France & Germany.[57,62]
Finally, there is the question of the benefit of a monitoring
system for the drug users themselves. Despite the fact that many
recreational drug users are relatively well-informed about the
risks, they are often willing to accept them nonetheless.[87– 89] So
how could a system like DIMS possibly aid in prevention or harm
reduction? There are at least two arguments to be made in favour
of a drug analysis and testing system in this context. First, it has
been suggested that individual, directed, harm-reduction advice
serves the needs of existing users better than simply promoting
abstention.[87] In this sense, the one-on-one contacts the users
have with the personnel at the DIMS testing offices, combined
with factual information concerning their drug purchase and
other drugs circulating the streets largely meets the information
needs of drug users. Additionally, young drug users often dismiss
government messages as tendentious and untrustworthy and are
better persuaded by personal contact with well-informed peers
or professionals.[87,88,90– 92] It has to be noted, however, that the
reach of a drug testing system such as DIMS is limited to a fraction
of all (potential) drug users.
Monitoring the market of illicit drugs creates a platform on which
to base policymaking and public health preventive activities, as
well as for research purposes. This review of DIMS and other drug
testing systems has made clear that the market for psychoactive
substances of abuse is continuously moving, underlining the
necessity to continue the systematic monitoring of this market.
Future challenges for DIMS could lie in developing ways to monitor
the Internet market and doping drug market, as these seem to
be developing rapidly and good insights into these markets are
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... Drugs of concern included fentanyl and analogues, as well as other drugs identified as causing health harms by included studies. Nine studies reported the detection of fentanyl or analogues by DCS in Canada [24,41,53,54], Slovenia [86] and Spain [56,76,87] from 2016 to 2019 and in the Netherlands in 2011 [58]. Six of the studies reported that fentanyl or analogues were detected in samples expected to be other drugs [24,41,54,58,76,87] and none reported fentanyl or analogues as expected. ...
... Nine studies reported the detection of fentanyl or analogues by DCS in Canada [24,41,53,54], Slovenia [86] and Spain [56,76,87] from 2016 to 2019 and in the Netherlands in 2011 [58]. Six of the studies reported that fentanyl or analogues were detected in samples expected to be other drugs [24,41,54,58,76,87] and none reported fentanyl or analogues as expected. Other drugs of concern reported in five or more studies included atropine, DOx, levamisole and para-methoxy(meth) amphetamine (P(M)MA); these were detected in Europe [43, 55-58, 61, 63, 66-68, 88, 89], the United States [44,65] and Canada [53]. ...
... These concordance measures were reported in 61.1%of studies (n = 55). Seven studies assessed concordance among multiple drug classes, including psychedelics, stimulants and depressants[40,[53][54][55][56][57][58]; 11 studies focused exclusively on MDMA[44,[59][60][61][62][63][64][65][66][67][68]. ...
Full-text available
Background and aims: Drug checking services provide people who use drugs with chemical analysis results of their drug samples, while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) influence of drug checking services on behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services. Methods: Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science, and Dissertations & Theses Global. Eligible studies were peer-reviewed articles and conference abstracts, or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools. Results: We screened 2,463 titles and abstracts and 156 full-texts, with 90 studies meeting inclusion criteria. Most (n=65, 72.2%) were from Europe and used cross-sectional designs (n=79, 87.7%). Monitoring of drug markets by drug checking services (n=63, 70%) was the most reported domain, followed by influence of drug checking services on behaviour (n=31, 34.4%) including intent to use, actual use, and disposal of the drug, and outcomes related to models of drug checking services (n=17, 18.9%). The most common outcome measures were detection of unexpected substances (n=50, 55.6%), expected substances (n=44, 48.9%), new psychoactive substances (n=40, 44.4%), and drugs of concern (n=32, 36.5%) by drug checking services. Conclusions: Drug checking services appear to influence behavioural intentions and behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe and increasingly in North America. Concerns about drug contents and negative health consequences facilitate use of drug checking services; lack of concern, trust in drug sellers, lack of accessibility of drug checking services, and legal and privacy concerns are barriers to use.
... Since the Dutch Drug Information and Monitoring System (DIMS) was established in 1992 (Brunt and Niesink 2011), numerous DCS have established themselves worldwide. Barratt et al. (2018b) comprehensively outlined 31 DCS active in 20 different countries. ...
... Other methods used by services in Europe and Australia include Thin Layer Chromatography, GC-MS, HPLC, and Fourier Transform Infrared Spectroscopy (Barratt and Ezard 2016;Brunt and Niesink 2011;Fornero et al. 2017). To obtain the most accurate results, many services such as DIMS, CheckIT, and services in the UK, use a mixed-methods approach (Rusmiddelforskning, C.f 2019;TEDI 2012a). ...
... At the UK's first on-site DCS, 94.8% of patrons had never contacted drug or alcohol services before (Measham 2020). Brunt and Niesink (2011) suggest that since young PWUD frequently dismiss government messaging as untrustworthy, individualized HR messaging through informed peers and professionals may better meet their needs and affect HR behaviors. ...
Drug-checking services (DCS) provide people who use drugs (PWUD) the opportunity to have their substances tested before consumption. Though some suggest they may have adverse consequences, DCS have been introduced as a harm reduction (HR) strategy. A systematized review of the literature regarding drug checking (DC) methods and testing locations, advantages and disadvantages, and legal frameworks with an emphasis on HR was conducted referencing PRISMA guidelines. The primary search of PsychInfo, PubMed, Medline, CINHAL, CORE, and Web of Science was conducted between the 4th and 10th of September 2020, and 51 literature pieces were included in the final article. Most of the literature focuses on the benefits of currently available DCS. The services identified varied significantly in terms of testing methods, location of operation, primary goal, and the surrounding legal framework. The results suggest using multiple DC methods to be most beneficial. Further, DCS and the personalized interventions they provide can positively influence behavior change, minimize harm, and reduce mortality. DCS are a viable public health intervention that requires cross-sector support beyond the legal frameworks and testing methods. Services will need to be tailored to meet the needs of their chosen setting, local drug market, and target audience.
... Det første systemet for rusmiddeltesting, DIMS -Drug Information and Monitoring System -ble etablert i Nederland av det nederlandske helsedepartementet tidlig på 1990-tallet (tabell 1). Et landsomfattende system for laboratoriebasert testing ble etablert for å overvåke rusmiddelmarkedene og kvantifisere sammensetningen i ulike rusmidler i et forsøk på å redusere alvorlige helseskader forbundet med forekomster av uventede stoffer i rusmidlene (Brunt & Niesink, 2011). Mer enn 100 000 prøver har blitt analysert de siste 20 årene, primaert i forbindelse med markedene for ecstasy, amfetamin og kokain (Brunt & Niesink, 2011). ...
... Et landsomfattende system for laboratoriebasert testing ble etablert for å overvåke rusmiddelmarkedene og kvantifisere sammensetningen i ulike rusmidler i et forsøk på å redusere alvorlige helseskader forbundet med forekomster av uventede stoffer i rusmidlene (Brunt & Niesink, 2011). Mer enn 100 000 prøver har blitt analysert de siste 20 årene, primaert i forbindelse med markedene for ecstasy, amfetamin og kokain (Brunt & Niesink, 2011). Siden har flere andre systemer for rusmiddeltesting og mobile klinikker/fasiliteter blitt etablert i en rekke land, mange av dem som følge av statlige tiltak (tabell 1) (Brunt, 2017 Nord-og Sør-Amerika (Barratt, Kowalski, Maier, & Ritter, 2018). ...
... These services can also be crucial for issuing preventative warnings (in case of dangerous adulterants), helping to avoid further harm. Nevertheless, drug checking alone might not be sufficient: in particular, people who use ATS less frequently may require education about adulteration and drug checking, and referral to support services and drug education are important facilitators of harm reduction intentions [59]. ...
Full-text available
Background Amphetamine-type stimulants (ATS) are globally widely used. Scientific literature generally defines four phases of substance use (initiation, continuation, increase and decrease); however, there is limited understanding of what influences these different phases of ATS use. The ATTUNE study investigated which factors shape individual phases of use, or ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use. Methods Qualitative, semi-structured interviews ( n = 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily. Results Amphetamine and MDMA were the most commonly used ATS. Yet, types of ATS used differed between the countries. We found that people who use ATS have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation, decrease and sometimes dependence. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of ATS, phase or country. Conclusions These findings demonstrate that tailor-made interventions are needed for the diverse types of people who use ATS and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.
... This approach generates knowledge about drug markets that can be further enhanced when used in combination with alternative information (e.g., circumstantial, specimen weight or wastewater related). 3,5,67 Ultimately, it contributes to improve our understanding of illicit drug markets and better target resources in this area. ...
In the area of illicit drugs, forensic case data has proven effective at detecting links between seizures and providing greater insights into illicit drug markets. This research explored the application of mathematical and statistical techniques to several chemical profiles of Australian methylamphetamine seizures. The main aim was to create and deliver a method that would expand the use of illicit drug profiling for strategic intelligence purposes, contributing to the fight against illicit drug trafficking. The use of comparison metrics and clustering analysis to determine links between existing illicit drug specimens and subsequent new specimens was evaluated and automated. Relational, temporal and spatial analyses were subsequently used to gain an insight into illicit drug markets. Relational analysis identified clusters of seizures central to the network. Temporal analysis then provided insights into the behaviour of distribution markets, specifically the emergence and extinction of certain clusters of seizures over time. Spatial analysis aided the understanding of the inter‐jurisdictional nature of illicit drug markets. These analyses allowed for the generation of strategic intelligence relating to when and where the Australian methylamphetamine illicit drug market was the most active. Additionally, the strategic level trends identified clusters of seizures which were worth investigating further. These clusters were explored through a case study, which exploited additional chemical profiling data to provide drug market knowledge at an operational level. In turn, the intelligence produced at various levels could allow relevant law enforcement agencies to take necessary measures in disrupting markets.
... These services can also be crucial for issuing preventative warnings (in case of dangerous adulterants), helping to avoid further harm. Nevertheless, drug checking alone might not be su cient: especially less frequent users may require education about adulteration and drug-checking, and referral to support services and drug education are important facilitators of harm reduction intentions (Brunt & Niesink, 2011). ...
Full-text available
Background: Amphetamine Type Stimulants (ATS) are globally widely used. However, there is limited understanding of what influences different phases of ATS use, as well as whether this varies by type of ATS user (groups). The ATTUNE study investigated which factors shape individual ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use. Methods: Qualitative, semi-structured interviews (n= 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily. Results: Most ATS users consumed amphetamine only (28%), followed by amphetamine and MDMA (17%). Yet, types of ATS used differed between the countries. We found that that ATS users have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation and decrease. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of user, phase or country. Conclusions: These findings demonstrate that tailor-made interventions are needed for the diverse user types and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.
... Given the opportunity, such services can access new Table 5 Attitudes towards drug checking services user populations that would otherwise not be in reach [14]. Moreover, such services have been integral in reducing harm by detecting adulterants and alerting festival attendees and medical and support personnel, as well as informing existing national early warning systems [22]. Murphy et al. 2021 highlight how friends are most likely to influence the utilisation a drug checking service, illustrating the significance of peers in influencing norms, practices and behaviours [13]. ...
Full-text available
Background Festival drug-related deaths are a growing public health concern. Aim To examine drug use and related harm-reduction practices and attitudes towards utilisation of drug safety testing services. Methods Data collection took place over the 2019 festival season (June–October). The questionnaire was self-reported. Data was gathered via the online survey, which was promoted through online and social media platforms and outlets. Social media communication methods were used to reach the targeted population more effectively. Results A total of 1193 Irish festival attendees over the age of 18 completed an anonymous online survey. Alcohol, MDMA powder/crystals, ecstasy pills and cocaine were the highest reported drugs used by Irish festival attendees. The vast majority of participants reported polysubstance use (86.8%/ n = 1036). Forty percent of participants (39.98%/ n = 477) reported having had sex following the use of a drug at a festival; of these, 66% ( n = 316) said that the sex was unprotected. Most participants (84.0%/ n = 1003) engaged in some form of harm reduction when taking drugs at festivals. Overwhelmingly, participants reported a willingness to engage with drug-checking services. The vast majority (96.3%; n = 1149) and would use drug checking services more than three-quarters (75.1%/ n = 897) reported that they would use an ‘amnesty bin’ for drugs if it were part of an alert system to notify if dangerous drugs are in circulation. A chi-square test of Independence was conducted to examine whether age and utilisation of drug safety testing service a festival were independent. Moreover, when all cases are taken together, the difference between testing modalities (onsite, offsite and amnesty bin) shows a significant difference p < 001 between those who would use onsite and offsite drug testing facilities. Conclusion The evidence from this survey indicates that those young people who use drugs at festivals would be prepared to utilise drug checking services and amnesty bins should help inform the public health response to this important area.
Technical Report
Full-text available
The Norwegian Directorate of Health is currently considering the possibility of establishing a national warning system for overdoses. Such a system would connect data collection and risk analysis with planned methods to communicate warnings of particularly potent or dangerous drugs to users. We conducted a single health technology assessment. Our first aim was to map the research assessing effectiveness of overdose warning systems. Our second aim was to map qualitative research on users’ experiences and perspectives on such systems. The systematic literature search identified 4493 references, eleven studies met the inclusion criteria. Machine learning was used throughout the study identification and selection processes. The main findings were: • Studies reported heterogenous systems that met our definition, although none called these “overdose warning systems”. These systems added monitoring functions to existing harm reduction services, or added communication to existing monitoring systems. Communication was primarily to harm reduction groups, not users themselves. • It was not possible to measure the effect of these systems, largely because the systems explored were embedded in other harm reduction programs and were responding to overdose spikes. • Regarding user experiences and preferences of warnings, users reported preferring numbers and facts, receiving warnings from other users or from harm reduction groups, and compassionate and nonjudgemental messaging.
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The findings in this thesis show that drug monitoring can be used to resolve some health issues and that it can also be applied to gain insights for the development of drug policy. Through all layers of drug politics, nationally or internationally, the DIMS is consulted for information updates. The data in this thesis show that the illicit psychostimulant markets in The Netherlands are very dynamic and continuously changing. When the purity of certain psychostimulants dropped, the probability of new psychoactive substances or new adulterants appearing on the market increased. Also, the market dynamics of illicit drugs showed remarkable similarities with that of regular consumer products. With regard to prevention activities, timely monitoring by DIMS has repeatedly resulted in timely mass media 172 warnings and through the DIMS network the communication was specifically directed at the groups at risk and maintained at a level of professionalism appreciated by these specific groups. The results in this thesis support the awareness of drug users about the drugs they consume and show the increasing awareness about the option of drug testing. Coupling the chemical data of the DIMS to the information that was communicated by the drug consumers yielded many new insights into the different effects of the expected, but mainly unexpected, psychostimulants and other substances in the drug samples. These examples can be seen as a basis for more refined research. Finally, with some notes on future directions, promising new avenues for assembling drug data are underway, like drug monitoring through the analysis of public wastewater for example. Especially, combining different sources of drug data and more frequent reports would hold promise for optimal data for interpretation and creating timely drug policies. Furthermore, while warranting anonymity, enriching the DIMS database in the future with new items, like dose, route of administration, age, gender etc., would greatly increase the scientific value of the DIMS data, leaving less room for speculation or misinterpretation of effects.
Full-text available
Significant changes in British recreational drug use were seen throughout 2009, with the emergence and rapid growth in the availability and use of substituted cathinones or ‘M-Cats’ (most notably mephedrone and methylone), a group of psychoactive drugs not currently controlled under the Misuse of Drugs Act 1971 (HM Government, 1971), with similar effects to ecstasy, cocaine and amphetamines. The reasons for the appearance and appeal of this group of so-called ‘legal highs’ are explored here in relation to availability, purity, legality and convenience. The authors argue that a reduction in the availability (and thus purity) of illegal drugs such as ecstasy and cocaine and resultant disillusionment among users was a key motivation for displacement to substituted cathinones, conveniently and legally purchased online. Finally, we explore policy considerations around the likely criminalisation of substituted cathinones and the challenge of providing rapid yet considered harm reduction responses to emergent drug trends in the face of a minimal scientific evidence base and eager press demonisation.
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A large number of cathinone derivatives have shown a wide range of bioactive properties, attracting great interest from communities associated with pharmaceutical research. Some of these derivatives have gained popularity as so-called recreational 'legal highs' due to their availability on the Internet and high street shops. A previous study described the qualitative analysis of 24 'legal high' Energy-1 (NRG-1) and NRG-2 products obtained from 18 websites following the ban on mephedrone and derivatives in April 2010. The majority of these products contained a mixture of cathinones just carrying a new label. Here, three additional cathinone products have been detected; two from an NRG-1 sample and one from an NRG-3 sample. This report describes their identification. NRG-1 sample 1 consisted of a mixture of 4 cathinones namely 4-fluoromethcathinone (1), 1-(3,4-methylenedioxyphenyl)-2-(methylamino)pentan-1-one (pentylone, 2), 3,4-methylenedioxy-α-pyrrolidinobutyrophenone (MDPBP, 3) and 3,4-methylenedioxypyrovalerone (MDPV, 4). The sample labelled as NRG-3 (mislabelled with the chemical structure of mephedrone) consisted of a mixture of 4-methyl-α-pyrrolidinopropiophenone (MPPP, 5) and (2), whereas the remaining NRG-1 sample 2 (also mislabelled with the chemical structure of mephedrone) consisted of a mixture of (2) and (3). Qualitative analyses were carried out by GC-(EI/CI)-MS, NMR spectroscopy and confirmation by preparation of standards. The preparation of brominated precursors carrying the 3,4-methylenedioxyphenyl nucleus revealed extensive α,α-dibromination: the mass spectral and NMR data of these intermediates are also presented and discussed.
Uppers. Crank. Bennies. Dexies. Greenies. Black Beauties. Purple Hearts. Crystal. Ice. And, of course, Speed. Whatever their street names at the moment, amphetamines have been an insistent force in American life since they were marketed as the original antidepressants in the 1930s. On Speed tells the remarkable story of their rise, their fall, and their surprising resurgence. Along the way, it discusses the influence of pharmaceutical marketing on medicine, the evolving scientific understanding of how the human brain works, the role of drugs in maintaining the social order, and the centrality of pills in American life. Above all, however, this is a highly readable biography of a very popular drug. And it is a riveting story. Incorporating extensive new research, On Speed describes the ups and downs (fittingly, there are mostly ups) in the history of amphetamines, and their remarkable pervasiveness. For example, at the same time that amphetamines were becoming part of the diet of many GIs in World War II, an amphetamine-abusing counterculture began to flourish among civilians. In the 1950s, psychiatrists and family doctors alike prescribed amphetamines for a wide variety of ailments, from mental disorders to obesity to emotional distress. By the late 1960s, speed had become a fixture in everyday life: up to ten percent of Americans were thought to be using amphetamines at least occasionally. Although their use was regulated in the 1970s, it didn't take long for amphetamines to make a major comeback, with the discovery of Attention Deficit Disorder and the role that one drug in the amphetamine family-Ritalin-could play in treating it. Today's most popular diet-assistance drugs differ little from the diet pills of years gone by, still speed at their core. And some of our most popular recreational drugs-including the "mellow" drug, Ecstasy-are also amphetamines. Whether we want to admit it or not, writes Rasmussen, we're still a nation on speed.
The Netherlands' policy on drugs is the plaything of reformers and prohibitionists in the ideological debate about drugs. The Dutch approach is either presented as a seductive and successful alternative to the American policy of zero tolerance or as an out-and-out disaster. In this article, we outline the principles and objectives on which the Netherlands' policy is based and then describe how they are implemented in practice. We conclude that the principles and objectives of Dutch drug policy are diametrically opposed to the ideologically and politically colored debate.
British Government policy on drugs primary prevention is outlined and principal recommendations are identified. The review is organized under the four main providers: police, teachers, peers and parents. Current methods are reviewed within a British policy framework with a focus on British programmes which have been evaluated. Most programmes use a combination of information, resistance or life skills training and normative education. Evaluative research suggests these methods are generally most effective. The police have achieved a community-wide approach, teachers have managed to integrate drug education into the National Curriculum, peer approaches have considered the needs of their target audience and parent approaches have recruited influential educators. However, more evaluative research is required before we can identify which particular programmes are most effective in reducing drug use.
This article describes an investigation of illicit drugs at street level in six selected police districts in different regions of Denmark. The investigation was carried out during a 6-year period from 1995 to 2000. During the period, a total of 1244 samples were examined, as about 200 samples were seized each year. A total of 94% of the seized samples were familiar drugs: heroin base, heroin hydrochloride, cocaine hydrochloride and amphetamine sulphate. Only 2% of the samples contained designer drugs. From having constituted 53% of the samples in 1995, the frequency of heroin base fell during the period to 27% of the samples in 2000. The frequency of heroin hydrochloride was unchanged. In the same period, the frequency of cocaine hydrochloride increased from 10% of the samples in 1995 to about 25% of the samples in 2000. Apart from a few exceptions, cocaine had the same extension in all regions of Denmark after 1996. Amphetamine was more frequent in the west of Denmark, while heroin hydrochloride was more frequent in central Denmark. The purity of heroin base was lower in the period 1997–1999 than in the other years. During the entire period, the purity of cocaine hydrochloride and amphetamine sulphate fell, while the purity of heroin hydrochloride was unchanged. No significant differences between the various regions of Denmark were detected during the period in the purity of heroin hydrochloride, heroin base, cocaine hydrochloride or amphetamine sulphate. MDMA was the most frequent designer drug, but other types of designer drugs such as MDA and MDE and the less common PMA, PMMA and MBDB were also found.
Since the recent ban on mephedrone,1 2several alternative products have been introduced on internet websites. One of the most prominently discussed second generation products is Energy 1 (NRG-1), also advertised as naphyrone (naphthylpyrovalerone, O-2482), which originated from a group of compounds previously described in the medicinal chemistry literature.3These products are offered as legal substitutes for the recently criminalised “legal highs,” the mephedrone derivatives. One of the earlier studies exploring the motivation for using these drugs suggested that consumers think that they are more likely to be of higher purity than street drugs, carry a lower risk of physical harm, and not be liable for the criminal sanctions associated with drugs controlled under the Misuse of Drugs Act.4To obtain an initial snapshot of the post-ban situation, we purchased 17 products online from 12 UK based websites over the six weeks after the ban on mephedrone in mid-April 2010. Chemical analysis was carried out by established procedures (table 1⇓).5 View this table:View PopupView InlineNRG-1 and NRG-2 products purchased online from UK based websites in the 6 weeks after the ban on mephedroneMost of the NRG-type products were recently banned cathinones that just carried a new label; this suggests that both consumers and online sellers are, most likely without knowledge, at risk of criminalisation and potential harm. This has important health and criminal justice consequences that will require carefully thought out responses and further investigation.NotesCite this as: BMJ 2010;341:c3564FootnotesCompeting interests: None declared.References↵Morris K. UK places generic ban on mephedrone drug family. Lancet2010;375:1333-4.OpenUrlCrossRefMedlineWeb of Science↵Winstock AR, Marsden J, Mitcheson L. What should be done about mephedrone? BMJ 2010;340:c1605. (23 March.)OpenUrlFREE Full Text↵Meltzer PC, Butler D, Deschamps JR, Madras BK. 1-(4-methylphenyl)-2-pyrrolidin-1-yl-pentan-1-one (pyrovalerone) analogues: a promising class of monoamine uptake inhibitors. J Med Chem2006;49:1420-32.OpenUrlCrossRefMedlineWeb of Science↵Measham F, Moore K, Newcombe R, Welch Z. Tweaking, bombing, dabbing and stockpiling: the emergence of mephedrone and the perversity of prohibition. Drugs Alcohol Today2010;10:14-21.OpenUrl↵Martins CPB, Freeman S, Alder JF, Passie T, Brandt SD. Profiling psychoactive tryptamine-drug synthesis by focusing on detection using mass spectrometry. Trends Anal Chem2010;29:285-96.OpenUrlCrossRef
A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality, and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.
During the last 25 yrs, the Netherlands has attempted to achieve a balanced, two-track, public health and justice policy on drugs. This paper considers the implementation of that policy for ecstasy, a drug that has gained popularity throughout Europe during this decade. Prevention is the Dutch government's primary policy aim. Research, monitoring, and registration are important foundations for the public health aspects of Dutch policy. Important policy instruments include the development of regulations directed towards reductions in the environmental risks posed by house parties and efforts to educate users and non-users about the drug. The justice elements of Dutch ecstasy policy include the outlawing of compounds (since 1988), passing new criminal legislation, and enhancing national and ordained that all drugs had to be criminally investigated and prosecuted along the same lines. Some public health and criminal justice elements of the national policy reinforce each other but others are conflicting. Policy efforts are directed towards the continuing process of maintaining a balance between these approaches and the control of conflicting interests. (PsycINFO Database Record (c) 2002 APA, all rights reserved)