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This article describes the increasing trend of cocaine and crack use among marginalized polydrug users in Rotterdam since the end of the 1980s, based on quantitative data and ethnographic monitoring. This trend is subsequently placed within the context of developing supply structures as well as local drug policy developments including care and law enforcement strategies. The results show the dynamic relationship between illicit drug demand and supply and policy interventions. Given that the use of psychoactive substances will most likely continue, the challenge for local drug policy may lie not only in repression and providing care facilities but also in regulating the settings where demand and supply meet. The latter, in order to decrease the potential harm of drug use for both the users and the local population.

Background/Aims: Crack users in the Netherlands are an ageing and diverse population with longstanding criminal careers. Our aim was to assess factors associated with current criminal involvement and specialization in selling drugs, property crime and violence. Method: A sample of 1,039 frequent crack users was recruited in three major Dutch cities, combining respondent-driven sampling with random institutional sampling. Bivariate and logistic regression analyses were performed to find factors associated with current criminality. Results: A total of 431 participants (41.5%) had engaged in crime in the past 30 days, mostly selling drugs (68.9%), followed by property crimes (34.4%) and a few cases of violent crime (9.7%). Younger age, homelessness, heavier patterns of use and a more prolific criminal justice history were associated with current criminality. Those receiving welfare benefits tended to be more likely to specialize only in selling drugs as opposed to (also) property crimes. Conclusion: Reducing drug use among criminally involved crack users and addressing their housing conditions could have a significant impact on reducing drug-related crime. Welfare benefits might act as protective factor against committing property crimes but not against the selling of drugs.

In a recent randomized controlled trial (Hendriks et al., 2011), multidimensional family therapy (MDFT) and cognitive behavioral therapy (CBT) were equally effective in reducing cannabis use in adolescents (13-18 years old) with a cannabis use disorder (n=109). In a secondary analysis of the trial data, we investigated which pretreatment patient characteristics differentially predicted treatment effect in MDFT and CBT, in order to generate hypotheses for future patient-treatment matching.The predictive value of twenty patient characteristics, in the area of demographic background, substance use, substance-related problems, delinquency, treatment history, psychopathology, family functioning and school or work related problems, was investigated in bivariate and subsequent multivariate linear regression analyses, with baseline to month 12 reductions in cannabis use days and smoked joints as dependent variables.Older adolescents (17-18 years old) benefited considerably more from CBT, and younger adolescents considerably more from MDFT (p0.01). Similarly, adolescents with a past year conduct or oppositional defiant disorder, and those with internalizing problems achieved considerably better results in MDFT, while those without these coexisting psychiatric problems benefited much more from CBT (p0.01, and p=0.02, respectively).The current study strongly suggests that age, disruptive behavior disorders and internalizing problems are important treatment effect moderators of MDFT and CBT in adolescents with a cannabis use disorder. If replicated, this finding suggests directions for future patient-treatment matching in adolescent substance abuse treatment.

Background Cocaine, particularly in its base form ('crack'), has become one of the drugs of most concern in the Netherlands, being associated with a wide range of medical, psychiatric and social problems for the individual, and with significant public order consequences for society. Available treatment options for cocaine dependent users are limited, and a substantial part of the cocaine dependent population is not reached by the addiction treatment system. Psychosocial interventions for cocaine dependence generally show modest results, and there are no registered pharmacological treatments to date, despite the wide range of medications tested for this type of dependence. The present study (Cocaine Addiction Treatments to improve Control and reduce Harm; CATCH) investigates the possibilities and problems associated with new pharmacological treatments for crack dependent patients. Methods/Design The CATCH-study consists of three separate randomised controlled, open-label, parallel-group feasibility trials, conducted at three separate addiction treatment institutes in the Netherlands. Patients are either new referrals or patients already in treatment. A total of 216 eligible outpatients are randomised using pre-randomisation double-consent design and receive either 12 weeks treatment with oral topiramate (n = 36; Brijder Addiction Treatment, The Hague), oral modafinil (n = 36; Arkin, Amsterdam), or oral dexamphetamine sustained-release (n = 36; Bouman GGZ, Rotterdam) as an add-on to cognitive behavioural therapy (CBT), or receive a 12-week CBT only (controls: n = 3 × 36). Primary outcome in these feasibility trials is retention in the underlying psychosocial treatment (CBT). Secondary outcomes are acceptance and compliance with the study medication, safety, changes in cocaine (and other drug) use, physical and mental health, social functioning, and patient satisfaction. Discussion To date, the CATCH-study is the first study in the Netherlands that explores new treatment options for crack-cocaine dependence focusing on both abstinence and harm minimisation. It is expected that the study will contribute to the development of new treatments for one of the most problematic substance use disorders. Trial Registration The Netherlands National Trial Register NTR2576 The European Union Drug Regulating Authorities Clinical Trials EudraCT2009-010584-16

This monograph describes the history, findings and international context of heroin-assisted treatment (HAT) in the Netherlands. The monograph consists of (1) a short introduction and seven paragraphs describing the following aspects of HAT in the Netherlands: (2) history of HAT studies and implementation of routine HAT in the Netherlands; (3) main findings on efficacy, safety and cost-effectiveness from the two randomized controlled HAT trials in the Netherland; (4) new findings from a large cohort study on the effectiveness of HAT in routine clinical practice in the Netherlands; (5) unique data on the patients perspective of HAT; (6) data on the pharmacological and pharmaceutical basis for HAT in the Netherlands; (7) description of the registration process; and (8) account of the international context of HAT. Together, these data show that HAT can now be considered a safe and proven-effective intervention for the treatment of chronic, treatment-resistant heroin dependent patients. (C) 2010 Elsevier B.V. and ECNP. All rights reserved

Aims To describe 4-year treatment retention and treatment response among chronic, treatment-resistant heroin-dependent patients offered long-term heroin-assisted treatment (HAT) in the Netherlands. Design Observational cohort study. Setting and intervention Out-patient treatment in specialized heroin treatment centres in six cities in the Netherlands, with methadone plus injectable or inhalable heroin offered 7 days per week, three times per day. Prescription of methadone plus heroin was supplemented with individually tailored psychosocial and medical support. Participants Heroin-dependent patients who had responded positively to HAT in two randomized controlled trials and were eligible for long-term heroin-assisted treatment (n = 149). Measurements Primary outcome measures were treatment retention after 4 years and treatment response on a dichotomous, multi-domain response index, comprising physical, mental and social health and illicit substance use. Findings Four-year retention was 55.7% [95% confidence interval (CI): 47.6–63.8%]. Treatment Response was significantly better for patients continuing 4 years of HAT compared to patients who discontinued treatment: 90.4% versus 21.2% [difference 69.2%; odds ratio (OR) = 48.4, 95% CI: 17.6–159.1]. Continued HAT treatment was also associated with an increasing proportion of patients without health problems and who had stopped illicit drug and excessive alcohol use: from 12% after the first year to 25% after 4 years of HAT. Conclusions Long-term HAT is an effective treatment for chronic heroin addicts who have failed to benefit from methadone maintenance treatment. Four years of HAT is associated with stable physical, mental and social health and with absence of illicit heroin use and substantial reductions in cocaine use. HAT should be continued as long as there is no compelling reason to stop treatment.

Needle exchange is a practical and important part of the Dutch prevention strategy to check the spread of HIV among injecting drug users (IDUs). However, needle-exchange programs are often tied to drug treatment programs that only reach a limited number of IDUs. To overcome this limitation, alternative designs are considered and initiated. This article describes a community-based approach to needle exchange that is built on empowerment of, and intense participation by, known IDUs to target unknown IDUs for delivery of clean needles. The needle-exchange patterns of the IDUs participating in this collective scheme are compared to those of other users who exchanged needles on an individual basis. It was found that this approach extended the reach of the program to a great degree and that it was well received in the IDU community. However, the results were negatively influenced by police activities aimed at closing down places where drugs were used and sold. It is concluded that engaging IDUs in peer-group-directed prevention efforts is both feasible and promising.

Aims Previous studies have shown that abstinent heroin addicts exhibit an attentional bias to heroin-related stimuli. It has been suggested that attentional bias may represent a vulnerability to relapse into drug use. In the present study, the predictive value of pre-treatment attentional bias on relapse was examined in a population of abstinent heroin addicts. Further, the effect of cue exposure therapy (CET) on attentional bias was studied. Design Participants were assigned randomly to receive nine sessions of CET or placebo psychotherapy. Setting An in-patient drug abuse treatment setting. Participants Abstinent heroin-dependent patients. Measurements Participants completed the emotional Stroop task both before and after completing treatment. Findings Pre-treatment attentional bias predicted relapse at 3-month follow-up, even when controlling for self-reported cravings at the test session. Further, attentional bias was reduced in both groups after therapy, independent of treatment condition. Conclusions Attentional bias may tap an important component of drug dependence as it is a predictor of opiate relapse. However, CET does not specifically reduce attentional bias.

Objective To determine the cost utility of medical co-prescription of heroin compared with methadone maintenance treatment for chronic, treatment resistant heroin addicts. Design Cost utility analysis of two pooled open label randomised controlled trials. Setting Methadone maintenance programmes in six cities in the Netherlands. Participants 430 heroin addicts. Interventions Inhalable or injectable heroin prescribed over 12 months. Methadone (maximum 150 mg a day) plus heroin (maximum 1000 mg a day) compared with methadone alone (maximum 150 mg a day). Psychosocial treatment was offered throughout. Main outcome measures One year costs estimated from a societal perspective. Quality adjusted life years (QALYs) based on responses to the EuroQol EQ-5D at baseline and during the treatment period. Results Co-prescription of heroin was associated with 0.058 more QALYs per patient per year (95% confidence interval 0.016 to 0.099) and a mean saving of €12 793 (£8793, $16 122) (€1083 to €25 229) per patient per year. The higher programme costs (€16 222; lower 95% confidence limit €15 084) were compensated for by lower costs of law enforcement (- €4129; upper 95% confidence limit - €486) and damage to victims of crime (- €25 374; upper 95% confidence limit - €16 625). The results were robust for the use of national EQ-5D tariffs and for the exclusion of the initial implementation costs of heroin treatment. Completion of treatment is essential; having participated in any abstinence treatment in the past is not. Conclusions Co-prescription of heroin is cost effective compared with treatment with methadone alone for chronic, treatment resistant heroin addicts.

OBJECTIVE: To determine whether supervised medical prescription of heroin can successfully treat addicts who do not sufficiently benefit from methadone maintenance treatment. DESIGN: Two open label randomised controlled trials. SETTING: Methadone maintenance programmes in six cities in the Netherlands. PARTICIPANTS: 549 heroin addicts. INTERVENTIONS: Inhalable heroin (n = 375) or injectable heroin (n = 174) prescribed over 12 months. Heroin (maximum 1000 mg per day) plus methadone (maximum 150 mg per day) compared with methadone alone (maximum 150 mg per day). Psychosocial treatment was offered throughout. MAIN OUTCOME MEASURES: Dichotomous, multidomain response index, including validated indicators of physical health, mental status, and social functioning. RESULTS: Adherence was excellent with 12 month outcome data available for 94% of the randomised participants. With intention to treat analysis, 12 month treatment with heroin plus methadone was significantly more effective than treatment with methadone alone in the trial of inhalable heroin (response rate 49.7% v 26.9%; difference 22.8%, 95% confidence interval 11.0% to 34.6%) and in the trial of injectable heroin (55.5% v 31.2%; difference 24.3%, 9.6% to 39.0%). Discontinuation of the coprescribed heroin resulted in a rapid deterioration in 82% (94/115) of those who responded to the coprescribed heroin. The incidence of serious adverse events was similar across treatment conditions. CONCLUSIONS: Supervised coprescription of heroin is feasible, more effective, and probably as safe as methadone alone in reducing the many physical, mental, and social problems of treatment resistant heroin addicts

Injecting drug users may now be the largest group at risk for contracting HIV, mainly through the sharing of drug injection equipment (including lending, borrowing, and renting). This article presents the results of an ongoing ethnographic study into the drug-taking rituals of heroin addicts. A possible additional route of HIV contamination is presented, namely the ritual sharing of drugs through a practice termed “frontloading,” which is embedded in a broader pattern of the sharing of resources among addicts. It is hypothesized that in the Netherlands this practice may be responsible for a substantial proportion of HIV spread among injecting drug users.

Editor—Dehue thinks that our study was a nerve racking test for the patients because considerable sanctions were connected with participants' treatment responses. This is based on the false assumptions that patients would be expelled from the experiment if they deteriorated while receiving heroin and that patients in the control condition would lose their opportunity to enter heroin assisted treatment if they improved during the treatment with methadone alone. Measures on illicit drug use and criminal activities showed excellent agreement with urine analysis and police register data, indicating that patients in the trial were accurate and reliable in their reporting. Reed et al assume that patients were required to be in continuous methadone maintenance treatment for only four weeks in the previous five years. Study participants were in methadone treatment for around 12 years on average and were using methadone 28 days in the month before the start of the trial. At the end of the trial the methadone dosage in the experimental groups was on average about 10 mg lower than in the control groups, but this difference was neither significant nor clinically relevant. Therefore a difference in methadone dosage between the treatment conditions is unlikely to have accounted for the observed efficacy of medically prescribed heroin. Craighead finds it disappointing that 45-88% (actual data 45-78) of the participants did not respond to co-prescribed heroin. We believe that 22-55% response in a chronic, treatment resistant population of heroin addicts with very few assets, serious health problems, and massive social impairments is a substantial effect. We disagree with Caplehorn's conclusion that the study data favour continuation of methadone treatment in this population. Although treatment retention is often a prerequisite for treatment effectiveness, retention can never replace effectiveness data (response) in establishing efficacy. Additional analyses show that the observed efficacy of heroin prescription is not due to some Hawthorn or Honeymoon effect (www.ccbh.nl). Voth and Aeschbach question the validity and clinical relevance of the primary outcome variable of the study. In the trial, similar results in favour of the heroin assisted treatment were obtained with various other response definitions, including definitions that did not allow any deterioration or increase in cocaine use. Heroin prescription resulted in modest reductions in cocaine use and large reductions in criminality. With regard to their final statement, we refer to Rehm et al, who showed that after five years only 34% of the patients were still in heroin assisted treatment and that most of the patients who left the heroin programme started another treatment, generally methadone maintenance or abstinence treatment.1 The view that heroin assisted treatment furthers the addiction and enslavement of suffering addicts is therefore not supported by the data. In contrast, the findings indicate that heroin assisted treatment can be a useful addition to the treatment armature available for these suffering, chronically impaired patients.

A low association between self-reported craving and physiological measures of craving is often found. Social desirability might influence this relation between subjective and physiological reactivity. Subjects were seventy-six in-patient abstinent heroin abusers. Social desirability, general craving scores and difference scores of physiological and subjective heroin craving, measured after exposure to a neutral and heroin cue were assessed. Cue reactivity, both subjective and physiological was found to be enhanced after exposure to a heroin-related cue. In line with earlier studies, a modest relation was found between subjective and physiological cue reactivity. Contrary to earlier research, however, high social desirability scores were associated with lower craving scores, but not with physiological scores. It can be concluded that, among other subject-related variables, social desirability influences self-reported craving but does not influence physiological reactivity in a clinical population. No significant moderation effect of social desirability on the relation between subjective and physiological reactivity was found.