E C Buning’s research while affiliated with Gemeentelijke Geneeskundige en Gezondheidsdienst and other places

The Amsterdam drug policy is based on prevention, drug-free treatment and harm reduction interventions. This article focusses on the last aspect. Harm reduction is defined as ‘If a drug user is not capable or willing to give up his drug use, he should be assisted in reducing the harm caused to himself and others.’ Two harm reduction interventions are described: the needle exchange schemes and the provision of methadone (low-threshold clinics, methadone bus, police stations and through general practitioners). Besides general indicators, such as estimated number of heroin addicts and their average age, results of more specific evaluation projects are discussed to examine the effects of harm reduction interventions. It is concluded that the policy was effective in managing the drug problem (stable number of addicts, low number of new young drug addicts, low mortality rate), but that effective measures against the HIV epidemic were taken too late. Furthermore, harm reduction interventions have not discouraged drug users from making use of drug-free treatment facilities.

By Septemer 30th 1991, 19579 cases of AIDS among injecting drug users had been reported in Europe. HIV seroprevalence rates among drug injectors vary from less than 5% in some cities to over 50% in others. Since the estimated number of drug injectors in Europe is between 750000 and 1.000000. HIV is a considerable threat to drug injectors, their sex partners and their off-spring, affecting large numbers of citizens in the European region. This paper gives an overview of the magnitude of the drugslAIDS problem, in the European region, and the concrete measures that have been taken to prevent HIV infection among drug users. Data from the evaluation of methadoneprogrammes, needle and syringe exchange schemes and data on sexual behaviour change of drug users are critically reviewed. Limitations of the methods used for the evaluation of prevention activities are also discussed Based on all the material reviewed, the main conclusions are the following. -AIDS is a greater threat to public health than problem drug use. -more accurate and reliable evaluation methods need to be utilized at European Community level. -a combination of prevention measures should be used in ordet to reduce the further spread of HIV infection among injecting drug users.

The needle and syringe exchange in Amsterdam was initiated in 1984 by the Junky Union. To date, ample data are available to support the role of the needle exchange in facilitating drug injectors to use drugs in a safer way: no increase in drug use could be validated, participants of the exchange schemes were less involved in needle sharing, the supply of large quantities of needles to drug users did not lead to an increase in needle stick accidents by the general public, and, finally, the HIV prevalence among drug injectors has remained stable since 1986, while the incidence of acute hepatitis B has gone down.

In this specially commissioned BJA series experienced clinicians will be giving their personal and frontline views as to how the practical business of treating people with substance problems is best handled. One of the methadone programmes of the Amsterdam Municipal Health Service is the ‘methadone by bus’ project. Two mobile clinics cruise the city, stopping at six different locations daily. The liquid methadone is consumed on the spot and clean needles and condoms are available. This project is based on the principles of ‘harm-reduction’, i.e. if it is not (yet) possible to ‘cure’ a hard drug user, one should at least try to minimize the harm they cause to themselves and their environment. As soon as a client refrains from the use of illegal drugs, the client can ‘graduate’ to other methadone programmes with a higher threshold. To prevent double prescription, all Amsterdam methadone programmes participate in the central methadone registration. The Amsterdam Municipal Health Service has contact with over 50% of the drug users. The estimated number of hard drug users has remained stable over the last 5 years, whilst the average age of drug users has increased to 32 years. In the future, increasing the average dosage and the provision of injectable drug users will be discussed to assess their role in further harm reduction.

We interviewed a group of 145 injecting drug users (IDUs) in Amsterdam about their drug use, participation in a needle-exchange programme and needle sharing. Approximately 1 year later 60 IDUs were followed up. IDUs who exchange regularly ('exchangers') are older, inject longer and are more often in contact with methadone programmes. Exchanging is associated neither with an increase in injecting nor with lending needles to other IDUs. The risk level of injecting of the exchangers is much lower than that of the non-exchangers. From this it can be concluded that a needle exchange is an effective prevention programme against the spread of HIV infection. However, efforts have to be made to reach the group of younger short-term injectors and those IDUs who are not in contact with methadone-maintenance programmes. Since there are indications that regular injectors in particular exchange, and since young male injectors are more at risk of borrowing independent of exchanging, it is argued that an exchange programme should be complemented with other prevention approaches, i.e. intensive counselling and the spread of leaflets with information on cleaning used needles with bleach.

In summary, it can be stated that Amsterdam has a wide variety of helping modalities. Approximately 70 percent of the city's 7,000 drug addicts are in contact with this helping system. In The Netherlands, no evidence could be found to support the fear that low-threshold methadone programs keep addicts away from drug-free treatment. Figure 1 shows that the number of addicts entering drug-free treatment doubled in the period 1981-85 (most popular has been the drug-free aftercare). This is even more striking since the estimated number of addicts did not increase in that same period. So, instead of keeping addicts away from treatment, low-threshold programs and outreach activities may have been effective tools in motivating addicts to enter drug-free treatment. Figure 2 shows the rise of the mean age of drug addicts, while figure 3 indicates that the percentage of addicts under 22 years decreases (14.4 percent in 1981 and 5.1 percent in 1986). Since the total number of addicts is quite stable, this may suggest that heroin is becoming less attractive to young people.