The drugepidemic

The drugepidemic

in Amsterdam,

a public health problem

Giel van Brussel

Medical Doctor

Head of the Drug Department of the Public Health Service in Amsterdam

 

 

 

1. The drugproblem in Amsterdam evolved in a major public health problem due to the following factors:

* public fear:

— will all our children become addicts

— rising crime rates

— international ostracism, Amsterdam as Europe’s drugcapital

* serious health problem for the drugusers and the community

— Aids

— drug related death

— hepatitis C

— TBC.

2. Public health solutions centered round the principle observation:

* There is no curative treatment for (drug)addiction, the addiction tends to resolve in 50% of cases after ten years because natural recovery.

* Therapeutic communities have the following problems on population level:

— selection: psychopathology and serious illnesses are a contraindication

— dropout: 70% or more leave the treatment program

— relapse: 70% of patients graduated from treatment resume use after discharge.

* This means:

From a epidemiological view, the logical thing to do is: harm reduction, especially preventing overdose death by methadone prescription in low threshold programs and needle-exchange.

3. Methadone prescription

This is done by the Amsterdam GP’s (1996: 260 of 400 GP’s) and by the Municipal Health Service. The MHS is responsible for the «difficult» patients with HIV, psychopathology, criminal behaviour etc.

GP’s — 1996: 1160 clients in methadone treatment by 259 GP’s

MHS — 1996: 2200 clients in methadone treatment

4. Needle exchange

Start of system in 1984 because of Hepatitis B epidemic. Peak in 1992 with 1 100 000 needles. Since that time a decrease because of these factors:

— decrease in numbers of foreign addicts: all shooting up

— change to oral use modality

— surplus in mortality among i.v.-drugusers in the last 10 years.

1996: Needle exchange 610 000.

5. Medical problems

Strong association with:

— long term i.v.-use

— long term addiction careers > 20 years mean psychopathology.

So:

Combination of long term addiction, bad physical condition and psychopathology.

Aids:

Preventive efforts in Amsterdam too late: 30%-. HIV among i.v.-drugusers as early as 1985. Since 1985 effective HIV prevention. Inthe rest of Holland HIV-prevention was in time. There is an association between public chaos in open street drugscene and the spread of Aids.

TBC:

Association with homelessness and HIV-infection. Control by obligatory 6 monthly TBC check in methadone programs.

Hepatitis C:

Chronic Hepatitis, livercirrhosis and hepatoma.

Psychopathology:

Up to 10% chronic psychosis among old problematic drugaddicts, personality disorders: 40% depression, 30% etc.

6. Mortality

Overdose mortality is very low among the Amsterdam drugaddicts who are eligible for methadone. Illegal foreign addicts are excluded.

Total mortality is strongly elevated because of:

— long term addiction career

— HIV-infection

— suicide

— accidents.

The Relative Risk, in which drugaddict mortality is compared with the general population adjusted for age is the same through ten years because of the rising age of the addicted population.

7. Essential requisites for an effective public health policy in regard to the drugepidemic are the following:

— Having an open primary care system based on low threshold methadone prescription for all drugaddicts with no waitinglist for those willing to enter methadone treatment.

— A functional decentralised needle-exchange.

— Open hospitals and GP practices. Drugaddicts pose many health problems. Caring for them in the sense of providing normal good quality health care is a means of emancipation and also of destigmatising the population.

— Good cooperation between police and judicial authorities and drug treatment system, without infringing on matters of privacy. The route of information should be from police to treatment system.

— Not to have too many pretensions on what is possible, high hopes produce high levels of frustration and disappointment.

8. Conclusion

Amsterdam has a stabilised drugepidemic: even with a high level of investment by the city in the treatment and prevention system in combination with a stabilised drugproblem the cost in mortality and morbidity is staggering. Because of the fact that there is no effective curative treatment the mean focus should be prevention and harm reduction.