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  1. 1. Netherlands National Netherlands National Drug Monitor Drug Monitor NDM Annual Report 2009 In the Netherlands various monitoring organisations follow developments in the area of drugs, alcohol, and tobacco. The Annual Reports of the Netherlands National Drug Monitor (NDM) provide an up-to-date overview of the considerable flow of information on the use of drugs, alcohol, and tobacco. This report combines the most recent data about use and problem use of cannabis, cocaine, opiates, ecstasy and amphetamines, as well as GHB, alcohol, and tobacco. It also presents figures on treatment demand, illness and mortality, as well as supply and market, placing the Netherlands in an international context. The Annual Report also contains data on drug-related crime and drug users in the criminal justice system, and gives details on current punitive measures for applying compulsion and quasi-compulsion to drug addicted criminals. The NDM Annual Report is compiled on behalf of the Ministry of Health, Welfare and Sport, in association with the Ministry of Justice. It aims to provide information to politicians, policy-makers, professionals in the field and other interested parties 20 about the use of drugs, alcohol, and tobacco in the Netherlands. 1 2 3www.trimbos.nl ISBN: 978-90-5253-676-7 20 09 09
  2. 2. Netherlands NationalDrug MonitorNDM Annual Report 2009Trimbos-instituut,Utrecht, 2010
  3. 3. ColophonProject Manager Production ManagerDr. M.W. van Laar Joris StaalEditors Cover Design, Layout and PrintingDr. M.W. van Laar1 Ladenius Communicatie BV 1Dr. A.A.N. CrutsDr. M.M.J. van Ooyen-Houben2 Cover illustrationDrs. R.F. Meijer2 iStockphoto.comDrs. T. Brunt1In association withDr. E.A. Croes1Drs. A.P.M. Ketelaars1Dr. J.E.E. Verdurmen1Ir. J.J. van Dijk21 Trimbos Institute2 WODCTranslationR. de JongISBN: 978-90-5253-676-7This publication can be ordered online www.trimbos.nl/webwinkel, stating article number AF0981.Trimbos-instituutDa Costakade 45Postbus 7253500 AS UtrechtT: + 31 (0)30-297 11 00F: + 31 (0)30-297 11 11© 2010, Trimbos-instituut, Utrecht.All rights reserved. No part of this publication may be copied or publicised in any form or in any way,without prior written permission from the Trimbos Institute.To access this report as a pdf-document:Go to www.trimbos.nlOr go to www.wodc.nl
  4. 4. Members of theNDM Scientific CommitteeProf. dr. H.G. van de Bunt, Erasmus Universiteit RotterdamProf. dr. H.F.L. Garretsen, Universiteit van Tilburg (voorzitter)Prof. dr. R.A. Knibbe, Universiteit MaastrichtDr. M.W.J. Koeter, AIARProf. dr. D.J. Korf, Bonger Institute of Criminology, University of AmsterdamProf. dr. H. van de Mheen, IVODr. C.G. Schoemaker, RIVMA.W. Ouwehand, Stg. IVZObserversMr. R. Muradin, Ministry of JusticeDrs. W.M. de Zwart, Ministry of Health, Welfare and Sport (VWS)Additional RefereesDr. M.C.A. Buster, Municipal Health Service Amsterdam (GGD Amsterdam)Drs. W.G.T. Kuijpers, Stg. IVZDr. M.C. Willemsen, STIVORO Members of the NDM Scientific Committee 3
  5. 5. PrefaceThis is already the tenth Annual Report of the Netherlands National Drug Monitor(NDM).The central task of the NDM is to collect and integrate data on developments insubstance use and drug-related crime. These reports have thus accumulated a wealthof knowledge throughout the years.This tenth report highlights a number of issues. One of these is the steady increase in thenumber of addiction clients with a cannabis problem. Likewise, the number of alcoholand amphetamine clients is increasing, although the latter group remains small. Perhapsa somewhat worrying finding is the fact that juveniles in state care and pupils in theso-called REC-4 schools for special education are using all substances to a (much) greaterextent than pupils in mainstream secondary schools. However, these are relatively smallgroups of youngsters. It is also worth noting that dilutants/mixers are increasingly beingfound in ecstasy and cocaine.As is customary, the 2009 Annual Report has been compiled by Bureau of the NationalDrug Monitor (NDM), which is incorporated in the Trimbos Institute and the ScientificResearch and Documentation Centre (WODC) of the Justice Ministry.Many thanks are due to the staff of these agencies. Once again they have completeda great deal of hard work during the past year. Indeed, the same people produced thedocument entitled “Evaluatie van het Nederlandse drugsbeleid” [Evaluation of Dutchdrug policy] in 2009, which provided a thorough analysis of Dutch policy on drugs since1972. The Scientific Council of the NDM, to which a number of new members havebeen added also acted as advisory committee to this evaluative report and was highlyimpressed by the level of effort undertaken by all the staff involved.Prof. dr. Henk GarretsenChairman, Scientific Committee of the National Drug Monitor Preface 5
  6. 6. Contents List of Abreviations and Acronyms 11 Summary 151 Introduction 272 Cannabis 332.1 Recent Facts and Trends 332.2 Usage: General Population 332.3 Usage: Juveniles and Young Adults 362.4 Problem Use 442.5 Usage: International Comparison 452.6 Treatment Demand 482.7 Illness and Deaths 542.8 Supply and Market 563 Cocaine 593.1 Recent Facts and Trends 593.2 Usage: General Population 603.3 Usage: Juveniles and Young Adults 613.4 Problem Use 663.5 Usage: International Comparison 663.6 Treatment Demand 693.7 Illness and Deaths 743.8 Supply and Market 764 Opiates 794.1 Recent Facts and Trends 794.2 Usage: General Population 804.3 Usage: Juveniles and Young Adults 804.4 Problem Use 824.5 Usage: International Comparison 864.6 Treatment Demand 874.7 Illness and Deaths 915 Ecstasy, Amphetamines and Related Substances 1055.1 Recent Facts and Trends 1055.2 Usage: General Population 1065.3 Usage: Juveniles and Young Adults 108 Contents 7
  7. 7. 5.4 Problem Use 1135.5 Usage: International Comparison 1135.6 Treatment Demand 1175.7 Illness and Deaths 1245.8 Supply and Market 1266 GHB 1336.1 Recent Facts and Trends 1336.2 Usage: General Population 1346.3 Usage: Juveniles and Young Adults 1346.4 Problem Use 1366.5 Usage: International Comparison 1376.6 Treatment Demand 1386.7 Illness and Deaths 1406.8 Supply and Market 1417 Alcohol 1437.1 Recent Facts and Trends 1437.2 Usage: General Population 1447.3 Usage: Juveniles and Young Adults 1457.4 Problem Use 1557.5 Usage: International Comparison 1577.6 Treatment Demand 1607.7 Illness and Deaths 1687.8 Supply and Market 1728 Tobacco 1758.1 Recent Facts and Trends 1758.2 Usage: General Population 1758.3 Usage: Juveniles and Young Adults 1808.4 Usage: International Comparison 1838.5 Treatment Demand 1858.6 Illness and Deaths 1878.7 Supply and Market 1919 Drug-Related Crime 1959.1 Recent Facts and Trends 1969.2 Drug Law Violations and Organised Drug Crime 19710 Drug Users in the Criminal Justice System 21310.1 Recent Facts and Trends 21310.2 Drug use among offenders 21410.3 Interventions for drug users in the criminal justice system 2168 Netherlands National Drug Monitor - NDM Annual Report 2009
  8. 8. Appendix A  Glossary of Terms 223Appendix B  Sources 233Appendix C  Explanation of ICD-9 and ICD-10 codes 243Appendix D  Websites in the area of alcohol and drugs 245Appendix E  Drug use in a number of new EU member states 249Appendix F  Pupils in special and mainstream secondary schools 251References 253 Contents 9
  9. 9. List of abreviations and acronyms2C-B 4-bromo-2,5-dimethoxyphenethylamine4-MTA 4-methylthioamphetamineAIAR Amsterdam Institute for Addiction ResearchAIDS Acquired Immune Deficiency SyndromeAIHW Australian Institute of Health and WelfareBMK Benzyl-methyl-ketonBO Primary EducationBZK Ministry of the Interior (and Kingdom Relations)BZP BenzylpiperazineCAN Swedish Council for Information on Alcohol and Other DrugsCAS Canadian Addiction Survey(CBS) Statistics NetherlandsCEDRO Centre for Drugs ResearchCIV Central Information Centre for Football HooliganismCJIB Central Fine Collection AgencyCMR Central Methadone RegistrationCOPD Chronic Obstructive Pulmonary DiseaseCOR Continuous Research on Smoking HabitsCPA Ambulance Transport CentreCSV Criminal ConsortiumCVA Cerebral Vascular Accident (stroke)CVS Patient Monitoring SystemDBC Diagnosis-Treatment CombinationDHD Dutch Hospital DataDIMS Drugs Information and Monitoring systemDIS DBC Information systemDJI Custodial Institutions Service / Correctional Institutions Service (juve- niles)DMS Drug Monitoring SystemdNRI/OA Research and Analysis Group of the National Criminal Intelligence Service of the National Police AgencyDOB 2,5-dimethoxy-4-bromoamphetamineDSM Diagnostic and Statistical ManualEHBO First AidEMCDDA European Monitoring Centre for Drugs and Drug Addiction Dutch EWDD) (InESPAD European School Survey Project on Alcohol and Other DrugsEU European Union List of abreviations and acronyms 11
  10. 10. EWDD European Monitoring Centre for Drugs and Drug Addiction (inEn glish: EMCDDA)FPD Forensic Psychiatric ServiceGGD Municipal Health ServiceGGGD Community Health ServiceGGZ Netherlands Association for Mental Health CareGHB Gamma hydroxybutyric acidHAART Highly Active Anti-Retroviral TreatmentHAVO General secondary educationHBSC Health Behaviour in School-aged Children (study)HBV Hepatitis B virusHCV Hepatitis C virusHDL-C High density lipoprotein cholesterolHIV Human Immunodeficiency VirusHKS Police Records SystemICD International Classification of DiseasesIDG Intravenous Drug UserIGZ (Public) Health Care InspectorateISD Institution for Prolific OffendersIVO Addiction Research Institute (Rotterdam)IVZ Organization of Care Information SystemsKLPD National Police AgencyKMar Royal Military PoliceLADIS National Alcohol and Drugs Information SystemLIS Injury Information SystemLMR National Medical RegistrationLOM School for children with learning and educational difficultiesLSD d-Lysergic-acid-diethylamideLUMC Leiden University Medical CenterLwoo learning support educationLZI National Hospital Care InformationMBDB N-methyl-1-(3,4-methyleen-dioxyphenyl)-2-butanaminemCPP meta-Chlor-Phenyl-PiperazineMDA Methyleen-dioxyamphetamineMDEA Methyleen-dioxyethylamphetamineMDMA 3,4-methyleen-dioxymethamphetamineMGC Monitor of Organised CrimeMLK School for children with learning difficultiesMMO Social Inclusion MonitorMO/VB region Region for Social Inclusion and Addiction PolicyMSM Men who have sex with menNDM National Drug Monitor12 Netherlands National Drug Monitor - NDM Annual Report 2009
  11. 11. NEMESIS Netherlands Mental Health Survey and Incidence StudyNFU Netherlands Federation of University Medical CentresNIGZ National Institute for Health Promotion and Illness PreventionNMG National Mental Health MonitorNPO National Prevalence SurveyNRI National Criminal Investigation Service/ National Intelligence ServiceNVIC National Poisons Information CentreNWO Netherlands Institute of Scientific ResearchOBJD Research and Policy Database of Criminal RecordsOM Public Prosecutor / Public Prosecution Service / OfficeOPS of wanted persons ListPAAZ Psychiatric Department of a General HospitalPBW Prisons ActPMA ParamethoxyamphetaminePMK Piperonyl-methyl-ketonPMMA ParamethoxymethylamphetaminePOLS General Social SurveyPro practical educationREC-4 RegionalExpertise Centre school for special educationRIAGG Regional Institute for Outpatient Mental Health CareRIBW Regional Organisation for Sheltered AccommodationRISc Risc (of Recidivsm) Assessment ScalesRIVM National Institute of Public Health and the EnvironmentSAMHSA Substance Abuse and Mental Health Services AdministrationSAR Alcohol Research FoundationSEH Emergency First AidSHM HIV Monitoring FoundationSIVZ see: IVZSTD Sexually Transmittable DiseasesSOV Judicial Placement of AddictsSr Criminal CodeSv Code of Criminal ProcedureSVG Addiction and Probation Department of the Netherlands Association for Mental Health CareSRM Monitor of Criminal Law (enforcement)SSI Cigarette industry foundationSWOV Institute for Road Safety ResearchTBS Disposal to be treated on behalf of the State (hospital order)THC TetrahydrocannabinolTNS NIPO The Netherlands Institute of Public Opinion and Market ResearchTRIAS Transaction registration and information processing systemTULP Imposition of restricted freedom sanctions in penitentiary institutions List of abreviations and acronyms 13
  12. 12. UvA University of AmsterdamVBA Drug Counselling Unitv.i. Conditional releaseVIS Early Intervention SystemVMBO Preparatory Secondary Vocational EducationVMBO-p Lower secondary school: practical streamVMBO-t Lower secondary school: theoretical streamVNG Association of Municipalities of the NetherlandsVTV Centre for Public Health StudiesVWO Higher Secondary SchoolVWS Ministry of Health, Education, Welfare and SportWHO World Health OrganisationWODC Scientific Research and Documentation CentreWVMC Abuse of Chemical Substances Prevention ActWvS Code of Criminal LawZMOK School for children with severe educational difficultiesZonMw Netherlands Organisation for Health Research and DevelopmentZorgis Care Information System of the Netherlands Association for Mental Health Care14 Netherlands National Drug Monitor - NDM Annual Report 2009
  13. 13. SummaryBelow is an outline of the most striking developments from the 2009 Annual Report.Tables 1a and 1b give an overview of the most recent figures on substance use anddrug-related crime. The percentage of recent users refers to the percentage that used asubstance during the past year; the percentage of current users refers to the percentagethat has used a substance during the past month.Drugs: usage and treatment demandLarge difference in cannabis use between mainstream and specialeducation, treatment demand continues to riseAmong mainstream secondary school-goers aged 12 to 18 years, the percentage ofcurrent cannabis users declined gradually between 1996 and 2007. This decline wasmost marked among boys. In 2007 8% of this age group were current cannabis users- 6% of girls and 10% of boys. Between 2003 and 2007 the percentage of boys whohad already tried cannabis at a very young age (14) declined from 21% to 13%; among14 year-old girls, the decline in ever use during this period was less marked (down from16% to 12%).By comparison with pupils in mainstream secondary education, cannabis use is morefrequent among the pupils of REC-4 schools for special education. These include pupilsin schools within a Regional Expertise Centre for very problematic children, childrenwith a long-term psychiatric condition, pupils of schools affiliated to a PedagogicalInstitute, pupils in practical education (pro) and pupils of support education schools(lwoo). 41% of 16 year old pupils attending REC-4 schools are current cannabis users,compared to 13% of their peers in mainstream education. The use of other drugs isalso more prevalent among the pupils of REC-4 schools. There is little or no differencein drug use between pupils receiving support education, practical education or main-stream education. Incidentally, the numbers involved in the special schools are low (seeappendix F).Despite the decline trend of the past decade, the percentage of cannabis users amongDutch school-goers in 2007 is relatively high compared to school-goers in other Euro-pean countries. Of the EU-15 only Spain has a higher percentage of current cannabisusers among school-goers in the 15-16 year age group (20%). This is followed by theNetherlands and France (both15%), Italy (13%), Belgium (12%) and the U.K. (11%).In the remaining countries, the percentage of current cannabis users ranges between1% and 10%. Summary 15
  14. 14. As against this declining/stabilising trend in cannabis usage among school-goers, therehas been a steady increase in the number of clients with a cannabis problem seekinghelp from outpatient addiction care. Between 1994 and 2008 the number of primarycannabis clients rose from 1,951 to 8,410. Between 2006 and 2007 there was an increaseof 23% and between 2007 and 2008 a further rise of 5%. This increase took place inall age groups. For years, the percentage of young cannabis clients under the age of 20has remained stable at around 15%. Over half of cannabis clients had problems withone or more other substances as well. Few people are admitted to general hospitals withcannabis problems as the primary diagnosis (57 admissions in 2008). The number ofadmissions citing cannabis misuse and dependence as a secondary diagnosis is higher,(476 in 2008) and shows a rising trend. From 2007 to 2008 there was an increase of19 percent. In a quarter (26%) of the admissions in which cannabis problems weresecondary, psychosis was the main diagnosis.This trend in seeking treatment may be indicative of a rise in the number of problemcannabis users; however, it may equally reflect an improvement in treatment supplyfor cannabis problems, or growing awareness of the addictive properties of cannabis,leading users to seek help earlier. Some 29,000 people in the general population agedbetween 18 and 64 meet a diagnosis of cannabis dependence, and 40,000 people meeta diagnosis of cannabis misuse.No further increase in treatment demand for cocaine useIn the school-going population aged 12-18 in mainstream education, ever use of cocainedeclined slightly from 3% to 1.7% between 1996 and 2007. Current use remainedaround the same level (about 1%). By comparison with their peers from other Europeancountries, Dutch school-goers occupy a mid-range position in this respect.Cocaine, particularly when sniffed or snorted in powder form is relatively commonamong youth and young adults who are frequently ‘out on the town’. However, cocaineis not only used in social settings, but often also at home, both at the weekend andduring the week. It is estimated that 12% of those attending national and regionalparties in 2008/2009 were current cocaine users, and 5% used cocaine on the night.Among frequenters of clubs and discos the rate of current use was somewhat lower,varying between regions from 3% to 6%. The smoked form of cocaine (crack cocaine)is much more common among opiate addicts; however, there are crack users in the harddrugs scene who doe not use opiates. It is not known how many people suffer physical,mental or social problems on account of excessive cocaine use. However, up to 2004the addiction care services registered a sharp increase in the number of primary cocaineclients, from 2,500 in 1994 to 10,000 in 2004. This rising trend did not persist. From2004 to 2008 there were two diverging trends: a slight decline in the number of primarycrack cocaine clients, and a slight rise in the number of clients who snorted cocaine. In2008 the total number of cocaine clients (crack and snorting) was about the same as in2004 (9,686 primary and 7,581 secondary cocaine clients).16 Netherlands National Drug Monitor - NDM Annual Report 2009
  15. 15. The number of hospital admissions citing cocaine misuse or dependence as the maindiagnosis is limited, but has shown a slight rise in recent years. In 2006, 2007 and 2008respectively there were 90, 114 and 131 admissions of this nature. The number ofadmissions citing cocaine problems as a secondary diagnosis is larger. In 2006, 2007 and2008 respectively, there were 514, 607 and 617 cases. Viewed over the longer term,there has been a gradual rise in incidences.Percentage of young opiate users receiving treatment remains limitedHeroin is not popular among the youth. In 2007 0.8% of school-goers aged 12 to 18 inmainstream education had tried this drug, and 0.4% reported past month use. According to the most recent estimate for 2008 there are approximately 17 700problem opiate users in the Netherlands, within a margin of 17 300 to 18 100. Thisis less than a decade ago. The Dutch population of opiate users is in the process ofageing. The proportion of young opiate clients (15-29) receiving treatment for addic-tion declined from 39% in 1994 to 6% in 2005 and 2006, stabilising at 5% in 2007and 2008. Between 2001 and 2004 the total number of clients with a primary opiateproblem declined from almost 18,000 to 14,000, and remained around this level until2007. In 2008 there were 12 711 fewer opiate clients (down by almost 8%) than in2007 and only 5% were new incident addicts. The remainder were already registered fortreatment with the addiction care services. While there was a decline in the number ofadmissions to general hospitals citing opiate problems as a secondary diagnosis between2002 and 2006, the number stagnated in the years following. Between 2006 and 2008 aslight rise (+14%) was evident. The number of hospital admissions with opiate problemsas the main diagnosis remains low (79 in 2008).The number of newly notified cases of HIV and hepatitis B and C among injecting drugusers has been low for years. However, the number of existing infections, particularly ofhepatitis C, is high – at least in municipalities that have data on this. The vast majorityof regions in the Netherlands lack data on the prevalence of hepatitis C among drugusers.Increase in amphetamine clients, but total number remains lowThere is a downward trend in the percentage of ever users and current users of amphe-tamine among school-goers in mainstream education between 1996 and 2007. Thisdecline was most marked between 1996 and 1999. In 2007 1.9% of school-goersaged 12-18 had ever used amphetamine, and 0.8% had used it in the past month.By comparison with other European countries, the percentage of amphetamine usersamong Dutch school-goers is relatively low.Amphetamine is somewhat more popular among juveniles and young adults in thesocial scene (than among school-goers), but considerably less popular than ecstasy. In2008/2009 7% of party-goers at large-scale raves and parties were current users ofamphetamine. Despite indications of the drug’s growing popularity among the provincial Summary 17
  16. 16. youth, the percentage of current amphetamine users among clubbers remains highestin the more urbanized west of the country (5.4%) and lowest in the more rural south(1.7%).Between 2001 and 2007 the number of amphetamine users seeking treatment trebled,and then stabilised in 2008 at 1, 446 addiction care clients. Throughout this period, theshare of amphetamine in treatment demand for drug addiction remained low (between2 and 4%). The number of admissions to general hospitals with a main diagnosis ofmisuse and dependency on amphetamine-like substances (including ecstasy) remainslimited. In 2008 there were 54 such admissions. There was an increase from 2006 to2007 in the number of secondary diagnoses related to misuse and dependency onamphetamine-like substances, from 88 to 136. This rising trend continued at a slowerpace in 2008 (145 admissions). These trends in treatment demand may possibly beassociated with an increase in the number of problem users of amphetamine, but thereis a lack of data to verify this.Ecstasy use seldom a reason for seeking treatmentBetween 1996 and 2007 ecstasy use among the school-going youth showed a down-ward trend. In 2007 2.4% of school-goers aged 12-18 in mainstream education hadever tried ecstasy and 0.8% had used it in the past month.After cannabis, ecstasy remains the most popular illegal drug among juveniles and youngpeople in the social scene. In 2008/2009 a quarter (24%) of the attendees at large-scaleparties and festivals were current ecstasy users. Almost one in five (18%) had usedthe drug that evening, although this percentage varied considerably between venues.Among frequenters of clubs and discos, the percentage of current ecstasy users variedfrom 5% in the more rural north to 12% in the more urban west of the country.It is not known how many people develop problems from ecstasy use. Few ecstasyusers seek treatment from the addiction care services. The number of ecstasy clients asa percentage of all drug clients in addiction care has been low for years, at only 1%, andis declining slightly. In 2008 there were 191 clients with a primary ecstasy problem, andin 2007 there were 239. Three times as many clients cite ecstasy as a secondary problem(571 in 2008). Ecstasy use can cause a disruption to brain function, particularly in theverbal memory. However, the effects tend to be minor, and other factors may possiblyplay a role (overheating, other drugs, pre-existing illnesses and conditions).Increase in GHB incidentsGHB use is rare in the general population and among school-goers in mainstream educa-tion. In 2007 0.6% of school-goers aged 12-18 had ever used GHB. Higher percentagesare found among pupils at special schools and among juveniles in care. 7.1 percent of16 year-olds attending REC-4 schools and 7 percent of juveniles in care had ever triedGHB. Likewise, juveniles and young adults in the social scene have more experience with18 Netherlands National Drug Monitor - NDM Annual Report 2009
  17. 17. GHB. In 2008/2009 4.6 percent of frequenters of large-scale parties and raves reportedpast month use of GHB. Among clubbers and disco-goers, the percentage of currentusers was between one and two percent.GHB use, particularly daily use can lead to dependency, and sudden cessation can resultin rather severe withdrawal symptoms. Treatment demand on account of GHB addictionhas increased in a number of addiction care organisations in recent years, but nationaldata are lacking. GHB is difficult to dose, and there is a high risk of overdose. It isestimated that the number of GHB victims receiving emergency treatment quadrupledbetween 2003 and 2008 to 980. It is unclear how many deaths may be linked to GHB.In 2008 four cases were registered in the Causes of Death Statistics, that were linked toGHB. In 2008 users paid around six euro per 5 ml dose of the drug.Alcohol and tobacco: usage and treatment demandDecline in alcohol use among 12-14 year-olds; rise in treatment demandIn 2008 81 percent of the general population aged over 12 reported ‘sometimes’ drin-king alcohol. This percentage has been stable for some years. Heavy drinking (definedas at least six units of alcohol on one or more days per week) occurs in ten percent ofthe population - 17 percent among males and four percent among females. This meansa total of 1.4 million heavy drinkers. By comparison, in 2001 fourteen percent of thepopulation aged over 12 were heavy drinkers. This slight downward trend is visible in allage groups up to 65 and in both males and females. There are large differences betweenage groups, particular in relation to heavy drinking. In 2008, 37% of males and 12% offemales in the 18-24 year age bracket were heavy drinkers.Alcohol use among school-goers in mainstream secondary education declined between2003 and 2007, but only in the 12-14 year age group. In 2007, 32 percent of thiscohort were current drinkers, compared to 47% in 2003. Alcohol use remained stableamong 15-18 year olds (76% in 2003 and 75% in 2007). There was also a declinein the percentage of school-goers aged 12-14 that had engaged in binge drinkingduring the past month (5 or more units in one session), during the period from 2003to 2007 (28% in 2003 versus 19% in 2007). Binge drinking occurred in 2007 in overhalf of 15-18 year old school-goers, which is the same as in 2003 (57% and 56%respectively). The popularity of alcopops and breezers has declined. While 29 percentof school-goers aged 12-18 drank these weekly in 2003, in 2007 the number was downto 16 percent. Compared to other European countries (EU-15) Dutch school-goers of 15 and 16are ranked among the largest consumers of alcohol. For “drinking alcohol at least tentimes in the past month” only Austria scored higher than the Netherlands (30% and24% respectively). It seems parents tend to underestimate the amount of alcohol theirchild is consuming. Summary 19
  18. 18. Despite a legal ban on selling alcohol to underage customers, youngsters below theage of 16 can still procure alcoholic beverages easily enough, if they attempt to do so.However, their chance of success has declined in off-licence liquor stores. Between 2001and 2007 there was also a decline in the percentage of underage drinkers that reportedactually procuring alcohol (illegally). However, in 2007 half of the youngsters (49%)aged 13-17 had procured alcohol in licensed premises in the month prior to the survey.Only 2% had done so in off-license stores.Only a small percentage (3%) of the circa 1.2 million problem drinkers in the Nether-lands seek treatment from the addiction care services; however this number is growing.In 2008 over 33,000 clients were treated for a primary alcohol problem. This is as manyas in 2007, but 10 percent more than in 2006 and 48 percent more than in 2001. Thepeak age group seeking treatment in 2008 was 40-54. In hospitals, the number ofadmissions for a main diagnosis of alcohol misuse or dependency rose from over 5,600in 2007 to almost 6,000 in 2008 (+6%). Almost twice as many admissions were linkedto a secondary diagnosis involving alcohol, rising from nearly 12,000 to over 13,700(+15%). Among juveniles aged under 17 admitted to hospital for alcohol-relatedreasons, an increase was registered from 263 in 2001 to 711 in 2008 (+170%).No further drop in number of smokers among the youthBetween 2004 and 2007 the percentage of smokers in the Dutch population agedover 15 remained largely unchanged. From 2007 to 2008 there was a slight decline inthe percentage of smokers from 27.5% to 26.7%. There was also a slight drop in thepercentage of heavy smokers (at least 20 cigarettes per day), from 7.2 to 6.7 in thepopulation aged over 12 years.After a sharp drop between 1996 and 2003, the percentage of current smokers amongsecondary school-goers in mainstream education stabilised at 19 percent in 2007. Nodifferences were found between boys and girls in this respect.In 2008 a total of 1.4 million people attempted to quit smoking. Treatment demandfor tobacco addiction consists largely of self-help and GP consultations. The marketfor nicotine replacement products (patches, chewing gum, tablets) expanded furtherbetween 2007 and 2008. Various campaigns were run to encourage people to give upsmoking.For the year 2005 an estimated 90,000 people aged over 35 were admitted to hospitalfor smoking-related illnesses. The decline in smoking among school-goers may ultima-tely yield considerable health gains, particularly in a drop in the number of COPD andlung cancer cases.20 Netherlands National Drug Monitor - NDM Annual Report 2009
  19. 19. DeathsIn the Netherlands, smoking is still the main cause of premature death. In 2008 over19,300 people aged over 20 died as direct consequence of smoking. This was almostthe same number as in 2007. Lung cancer is the main cause of smoking related deaths.The death rate from this disease rose slightly between 2003 and 2008, particularlyamong women. These figures do not reflect deaths due to passive smoking. In 2008alcohol-related conditions were the direct cause of 765 deaths; in almost a furtherthousand cases, alcohol-related conditions were registered as a secondary diagnosis.The rising trend in total deaths from alcohol-related conditions from the early 1990s didnot continue during the period between 2004 and 2008. The death rate from smokingand alcohol-related conditions is many times greater than the death rate due to (hard)drugs. In 2008 129 drugs users died from the consequences of drug overdose, whichwas more than in 2007, when there were 99 deaths. In the past ten years, this numberhas fluctuated between around 100 and 140 cases. Only one in five victims is agedbetween 15 and 34. Ten years ago, as many as 47% of victims were in this young agegroup. By comparison with a number of other EU member states, the rate of acutedrug-related deaths in the Netherlands is low.MarketIncrease in use of mixers in ecstasy and cocaineFor many years, ‘ecstasy tablets’ at consumer level consist mainly of MDMA-likesubstances (in 2007 this was the case in 91% of the tablets tested). However, in late2008 and in the first half of 2009 the was a sharp decline in the proportion of tabletscontaining MDMA, accompanied by a sharp rise in the percentage of tablets containingmore or less comparable pharmaceutical substances (such as mCPP). In the first half of2009 only 70 percent of ecstasy tablets tested contained MDMA. Other pharmaceuti-cals are increasingly being found in cocaine samples, particularly levamisol, a substancethat is no longer registered for human medicinal use. The health risks of snorting orsmoking cocaine that has been mixed with levamisol are not known exactly. In the US,cases of serious blood diseases have been reported.The average THC-content (the main active substance in cannabis) in Dutch-grownweed declined from 20 to 16 percent between 2004 and 2007, stabilising at this levelin the years following. In 2009 the average percentage of THC in Dutch-grown weedwas 15%. The price of Dutch-grown weed has risen slightly in recent years. In 2009 theaverage price was €8.10 per gram for the most popular variety, and €10.50 for the mostpotent variety. There are no indications that cannabis containing lead or glass particlesis reaching the market via the coffee shops. Little is known about the presence of othersubstances such as pesticides in Dutch-grown weed, or about the extent to which thesepose a threat to the health of cannabis users. Summary 21
  20. 20. Offences against the Opium ActInvestigations into serious forms of organised crime are mainlydrug-relatedAs in earlier years, the majority of investigations into more serious forms of organisedcrime in 2007 and 2008 involved drugs. Most cases targeted organisations involvedwith hard drugs, and the most frequently cited drug is cocaine. The percentage ofinvestigations dealing with hard drugs declined in 2008, whereas there was a rise in thepercentage that involved soft drugs only – in particular Dutch-grown weed.Slight drop in new Opium Act offences in the law enforcement chainThe overall picture for 2007 and 2008 shows a (very) slight drop in the number of newdrug offences and the number disposed of. This applies both to the number of suspectscharged by the police and the Royal Marechaussee Constabulary, and to the numberof new drug cases appearing before or disposed of by the public prosecutor and thecourts. 2004 was a ‘peak year’ in terms of drug offences in the law enforcement chain. Sincethen, the trend has been stable, with a recent (very) light decline. The decline is mostmarked in hard drug crimes. The gap between the number of hard drug and soft drugcrimes has been narrowing since 2004. The percentage of both appearing before thepublic prosecutor was virtually identical in 2008. The number of Opium Act offences as a percentage of all crimes has remained fairlyconstant in recent years. It appears that drug offences follow the same trend as crimein general.Summonses and penaltiesSummonses are issued on two thirds of all drug offences. There was a decline in thepercentage of summonses issued for drug offences in 2008 compared to 2007. Asummons is more likely to be issued in cases involving hard drugs and especially thoseinvolving both hard and soft drugs than in cases involving soft drugs only. For the majority of offences, the court imposes a community service order or a partlysuspended prison sentence. In recent years, the percentage of community service ordershas been higher than the number of these detention orders. (Partly) suspended prisonsentences are mainly imposed for smuggling, production or trafficking of hard drugs;community service orders tend to be imposed for smuggling, production or traffickingof soft drugs. The number of detention orders for Opium Act offences has increased inrecent years, but the relative percentage has remained unchanged.22 Netherlands National Drug Monitor - NDM Annual Report 2009
  21. 21. Offences by drug usersDrug users committing fewer property crimes but more violent crimesThe decline in criminality in the Netherlands, in particular the considerable drop inproperty crime appears to be partly related to a reduction in criminality among opiateusers. There has been a decrease in the number of problem drug users with a high levelof criminal recidivism entering the law enforcement system. The decline is particularlymarked among addicts whose primary addiction is heroin, who are mainly responsiblefor property crimes. However, there is a rising trend of violent crime among drug users,which may be explained by an increase in crack cocaine use.No change in the percentage of detainees with a drug problemRecent studies conducted among Dutch detainees found that some 30 to 38 percentwere battling with problem drug use or a drug addiction in the year prior to detention.A large number of problem drug users are found among the very active repeat offendersand those placed in an Institution for Prolific Offenders (ISD).Increasing use of Probation and Aftercare for addictsProbation and Aftercare for addicts is dealing with an ever growing number of clients.In 2007 and 2008 these numbered between 17,000 and over 18,000. The number ofactivities undertaken by Probation and Aftercare for addicts also shows a rising trend.There have been more instances of supervision, and an increase in the number of diag-noses (which also takes account of the reduction of the re-offending risk estimationscales); and a greater number of reports has been issued.Institutions for Prolific Offenders (ISD)In 2007 there were 295 new ISD detainees and in 2008 292. The average per month for2007 was 662 in 2007 and 607 in 2008. Most detainees follow a regime of behaviouralinterventions either inside the penitentiary establishment or outside it. A minority of 21to 24 percent remains in a basic regime without behavioural interventions. Summary 23
  22. 22. Table 1a  Key Data on Substance Use Cannabis Cocaine General Population Usage (2005) -  Percentage of recent users 5.4% 0.6% -  Percentage of current usersI 3.3% 0.3% -  Trend recent use (2001-2005) Stable Stable -  International Comparison Slightly below Below average average Use among juveniles, school-goers 2007) -  Percentage of current users, 12-18 years 8% 0.8% -  Trend 12-18 years (1996-2007) Downward Stable -  International comparison, 15/16 years Above average Average Number of problem users 29 300 Unknown (dependence) 40 200 (misuse) Number of Addiction Care clients (2008) -  Substance as primary problem 8 410 9 686 -  Substance as secondary problem 5 940 7 581 -  Trend (2002-2008) Rising Rising to 2004, thereafter stabilising Number of hospital admissions (2008) -  Misuse/dependence as main diagnosis 57 131 -  Misuse/dependence as secondary diagnosis 476 617 -  Trend (2002 – 2008) Rising Rising Registered deaths (2008)V No primary 22 deaths (primary)I. Recent use: in the past year; current use is in the past month. b = boys, g=girls. II. Between 2003 and2007. III. Estimate from 2003. Some 478,000 people were diagnosed with alcohol use or dependence in2007-2009. IV. Based on heavy smokers (20 or more cigarettes a day)According to new estimation methods.Numbers do not differ significantly from previous estimates. V. Primary death: substance as primary(underlying) cause of death. Secondary death: substance as secondary cause of death (contributory factor orcomplication). VI. Not taking account of road deaths or cancer-related deaths.24 Netherlands National Drug Monitor - NDM Annual Report 2009
  23. 23. Opiates Ecstasy Amphetamine Alcohol Tobacco0.1% 1.2% 0.3% 85% -0.1% 0.4% 0.2% 78% 26.7% (2008)Stable Stable Stable Stable DownwardLow/medium Above average Below average Average Average0.4% 0.8% 0.8% 51% 19%Stable Downward Downward DownwardII DownwardAverage Above average Below average High Average17 300 – 18 100 Unknown Unknown 1 200 000III ±1 000 000IV12 711 191 1 446 33 205 n.a.1 923 571 910 5 528Downward Stable, slightly Rising Rising n.a. downward from 200579 54 5 983 Unknown542 145 13 717Downward Rising Rising Unknown 52 5 765 19 357(primary) (primary)VI (primary+sec.) 1 009 (sec.) Summary 25
  24. 24. Table 1b  Key Figures Drug Crime: Opium Act Offences in the Law Enforcement Chain Phase in the chain Number of police/ No. Of public Convictions/ Custodial Royal Constabu- prosecutor cases dispositions by a sentences 2007 lary suspectsI 2007 2008II court in the first instance 2008 Number of drug offences -  Total 21 477 18 785 11 487 4 165 -  Hard drugs 10 709 9 086 5 835 n.b. -  Soft drugs 7 870 8 977 5 210 n.b. -  Both 2 804 651 436 n.b. -  Update 2006- (Very ) slightly Slightly Downward Downward Downward 2007/2008 downward -  General trend Rising until 2004, Rising until 2004, Fluctuating. Rising until 2002-2007/2008 thereafter stable thereafter declining Decline in hard 2003, thereafter at a relatively high (slightly). drugs since downward level, hard drugs Hard drugs 2003, increase slightly downward downward since in soft drugs to since 2005, soft 2005, soft drugs 2006, thereafter drugs rising reasonably stable downward in 2005, then since 2005, slight declining slightly decline after 2006 % Opium Act 7% 7% 8% 17% offences of total crime - pdate % U Stabilising Stabilising Stabilising Stabilising 2006-2007/2008I. Data available through 2007 on suspects held by police and Royal Constabulary as well as custodialsentences; about cases with the public prosecutor and disposed of by the courts through 2008. Source: HKS,KLPD/DNRI; OMDATA, WODC26 Netherlands National Drug Monitor - NDM Annual Report 2009
  25. 25. 1  IntroductionThe National Drug MonitorIn the Netherlands there are several monitoring organisations that follow developments inthe area of substance abuse. Scientific papers are also frequently published about usagepatterns, prevention and treatment methods. In this veritable sea of information, theNational Drug Monitor (NDM) provides policymakers and professionals working in prac-tice as well as various other target groups with an up-to-date overview of the situation.The primary goal of the NDM is to gather data about developments in substance usein a coordinated and consistent manner on the basis of existing research and registereddata, and to process this information and translate it into a number of core products,such as Annual Reports and thematic reports. This aim is consistent with the currentquest for evidence-based policy and practice.The NDM was set up in 1999 on the initiative of the Minister for Health, Welfare andSport.1 Drug use, however, is not exclusive to the domain of public health but alsoinvolves aspects of criminality and public nuisance. Since 2002, the Ministry of Justicehas also supported the NDM.The NDM embraces the following functions:•  cting as umbrella for and coordinator between the various surveys and registra- A tions in the Netherlands concerning the use of addictive substances (drugs, alcohol, tobacco) and addiction. The NDM aspires towards the improvement and harmonisa- tion of monitoring activities in the Netherlands, while taking account of international guidelines for data collection.•  ynthesising data and reporting to national governments and to international and S national organisations. The international organisations to which the NDM reports include the WHO (World Health Organisation), the UN and the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction).Within the NDM, the collection and integration of data are central. These activities areconducted on the basis of a limited number of key indicators – or barometers of policy –which are agreed by the EU member states within the framework of the EMCDDA. Dataare collected on the following:•  Substance use in the general population•  Problem use and addiction•  Treatment demand from addiction care•  Illness in relation to substance use•  Deaths in relation to substance use. 1  Introduction 27
  26. 26. The thinking behind these five key indicators is that the seriousness of the drugs situ-ation in a country is reflected by the extent of drug use in the general population,the number of problem drug users and addicts, the extent of demand for treatmentand the rate of illness and deaths associated with drug use. However, trends in theseindicators may be influenced by factors other than problem drug use alone. For furtherinformation, see Box 1.Where available, data are recorded on supply and market, such as the price and qualityof drugs. The NDM also reports on registered drug crimes and how law enforcementagencies respond to these crimes. This is also conducted on the basis of a series ofindicators, for which the WODC collects data (Meijer, Aidala, Verrest, Van Panhuis Essers, 2003; Snippe, Hoogeveen Bieleman, 2000). What do the epidemiological key indicators signify? The key indicators of the EMCDDA are intended to reflect the status of drugs problems and to enable improved monitoring of developments. They are also designed to contribute to a broader analysis of policy outcomes, although this remains problematic (Van Laar Van Ooyen, 2009). The EMCDDA has developed protocols for five drug indicators, which the EU member states have to use in the data collection (EMCDDA, 2009). This is aimed at improving inter-country compara- bility at European level of data on drug use and its consequences. Although distinct progress has been made in this respect, the goal has not yet been fully reached. Therefore differences between countries, particularly smaller ones, should still be interpreted with caution. This Annual Report also describes the situation concerning the consumption of alcohol and tobacco within the context of these indicators; with a few exceptions, these data have not been collected in an internationally standardised manner. Substance use in the general population (including school-goers) Population studies on substance use can shed light on the extent of usage and on risk groups. If conducted at regular intervals and in the same way, these studies can also reveal trends. Various groups of users are distinguished, in describing alcohol or drug use. The largest group comprises people who have ever in their lives consumed alcohol and/or drugs – even years previously (ever use). A better indicator of current developments is found in the percentage of people who have lately used a substance - in the past year or month (recent and current use). The way in which the surveys are conducted (e.g. written, by telephone or face- to-face) and the circumstances surrounding the interviews (e.g. the presence of a parent), may influence people’s willingness to ‘admit’ to having used a substance. However, in view of the relatively liberal climate in the Netherlands regarding drug28 Netherlands National Drug Monitor - NDM Annual Report 2009
  27. 27. use, particularly cannabis, under-reporting of drug use is less likely in the Netherlandsthan in countries with a more repressive policy where legal and/or social sanctionsare attached to drug use. At the same time, it is suggested by the National Preva-lence Survey 2005 (NPO) on substance use in the general population, that illegaldrug use is a sensitive topic in the Netherlands too (Rodenburg et al., 2007). Alsoof importance is the extent to which the recruited respondents actually participatein the survey. This can range from less than 50% to almost 100%. A low responserate may undermine the reliability of the findings. Trends in the prevalence of substance use are often difficult to quantify on accountof the numerous interacting factors that may be of influence. Examples are nationaland international policy; effective interventions; the production, availability andaccessibility of drugs and other substances; economic factors (such as income);perceived risks of use; the social environment; and culture, lifestyle and fashions,and the role that substance plays in these.Problem substance useThere is no single prevailing definition of the term ‘problem use’. The EMCDDAdefines problem drug use as injecting drug use or long-term/regular use of opiates,cocaine and/or amphetamines. This is a broad definition which also covers harddrug users who use methadone, for instance, and are able to function well insociety. Throughout the Netherlands, a wide range of definitions is used at local andnational level. Comparisons therefore have to be made very cautiously. For othersubstances, such as cannabis and alcohol, the criteria for misuse and dependence ofinternational classification systems such as the DSM or the ICD are often used. For research on substance use in the general population, respondents are gene-rally selected by random sampling from the population register. This means thatmarginalised groups, such as chronic hard drug users, who are regularly admittedto institutional care or have no fixed address, are greatly under-represented in thistype of research. Therefore, a number of special techniques have been developed,in order to estimate the numbers of hard drug users. Examples are the capture-recapture method and the ‘multiplier’ method. These methods are based on theassumption that a certain percentage of the drug users is known to the police and/or health care services and registered as such. Others have no contact with theseorganisations and are known as the hidden population. Specific statistical techniquesare used to estimate this group as well, in order to arrive at a total estimate of thenumber of problem users. It should be borne in mind that prevalence estimates ofthis kind allow a considerable margin of error and are generally not very accurate.Treatment DemandA certain number of problem users of alcohol or drugs seek treatment from an addic-tion care organisation or are admitted to hospital. Data about the numbers of these 1  Introduction 29
  28. 28. clients and client profiles provide information about (trends in) treatment demand, and are useful in planning and evaluating the care given to alcohol and drug users. These data may also be an indirect indicator of trends in problem use; however other factors, such as the extent and quality of treatment resources, registration problems or changes in the referral system (e.g. increasingly via primary care), may equally impact on the number of registered clients. Significantly too, those who seek treatment may be atypical of addicts in general. There are indications that addicts who seek treatment are in a worse state than those who do not yet look for help. For instance, (comorbid) mental health problems are more common among addiction care clients than among those who battle with addiction on their own. Drug-related infectious diseases The EMCDDA focuses on monitoring the prevalence of HIV infections and hepatitis B and C among injecting drug users. This information is important for establishing priorities for prevention, estimating the (future) illness burden and societal costs, and for monitoring the effects of preventive interventions. This indicator is the least standardised. The information sources available in the EU member states are very diverse, and include random samples of drug users (the gold standard), results of screening of drug users having treatment or in prison, case reports and notified diagnoses of HIV and hepatitis. Furthermore there are large differences in scope (local, regional, national). In an absolute sense, the data of the different countries are therefore not comparable. They do, however, give an indication of develop- ments in the rate of infection. In the Netherlands too, the information is somewhat fragmented. Nonetheless, it does permit cautious conclusions about trends in the problems on the basis of various sources. Deaths related to alcohol and/or drugs Deaths due to overdose or other causes related to substance use are regarded as the most serious and extreme consequence of substance use. Data on the extent and nature of the deaths can be used to monitor trends in problem uses and high risk behaviour (injecting, polydrugs use). In many countries the general cause of death statistics constitute the main source of information on acute drug deaths (‘overdose’). According to the EMCDDA protocol cases are selected on the basis of a pre-ordained range of ICD-9 or ICD-10 codes, which refer to the nature of the death (accidental, deliberate, cause unknown) and the kinds of drugs involved. Countries differ in the procedures followed to establish the cause of death (e.g. whether toxicological analyses are conducted or not). In countries where a post- mortem examination is standard when an unnatural case of death is suspected, there is a greater likelihood of discovering a drug-related death than in countries where this is not the case and/or where the cause of death is established only on the basis of external characteristics and circumstances. And even if toxicological30 Netherlands National Drug Monitor - NDM Annual Report 2009
  29. 29. information is available, this is by no means always used to code the cause of death in the official statistics. Differences like these can impair the comparability of data between countries. Drug users sometimes die from causes other than an overdose. These causes may even be independent of drug use, such as old age, or may be related to it, such as a destructive lifestyle, or infectious diseases from injecting. This total death rate among drug users is charted in longitudinal cohort studies that ‘follow’ drug users throughout the years. There is no standard protocol for alcohol-related deaths. ICD-codes are found in the international that are used to determine deaths related to alcohol use (WHO, 2000; Heale et al., 2002). These codes are used in this Annual Report where alcohol use is explicitly cited as the cause of death. It is virtually certain that the data reflect an underestimation of total alcohol-related deaths, because the role of alcohol use in cause of death is not always recognised.CollaborationsThe NDM relies on the input of many experts. The executors of many local and nationalmonitoring projects, registering bodies and other organisations make their contribu-tion. The quality of the publications is ensured by the NDM Scientific Committee. ThisCommittee evaluates all draft texts and advises on the quality of the monitoring data.The NDM is supported on thematic modules by the study group on prevalence estimatesof problem substance use and the study group on drug-related deaths.Once yearly, the NDM publishes a statistical overview of addiction and substance useand their consequences. This is the NDM Annual Report. This report is included in thedocumentation that is presented to parliament annually.Past and future drug policyIn 2009 drug policy in the Netherlands was subjected to an evaluative review (Van Laarand Van Ooyen, 2009). This review focussed chiefly on drug policy in the 1995-2998period, using data from the NDM Annual Reports. An independent advisory committeesubsequently submitted a recommendation about future drug policy (Drug Policy Advi-sory Committee, 2009). In 2010 a new bill on drugs will be drafted. 1  Introduction 31
  30. 30. 2009 Annual ReportThis is the tenth Annual Report of the NMD. As in previous years, chapters two througheight deal with developments per substance or classes of substances: cannabis, cocaine,opiates, ecstasy and amphetamines, alcohol and tobacco. Because there are signs ofincreasing popularity of GHB, a chapter of this substance has been added. In eachchapter we present a concise report on the most recent data about usage, problem use,treatment demand, illness and deaths, as well as supply and market. The position ofthe Netherlands is placed in an international perspective, but owing to methodologicaldifferences, comparisons between countries should, however, be made with caution.Chapter nine contains data on registered drug-related crime. Central to this is crime asdefined by the Opium Act and the criminal behaviour of drug users in various stages ofthe law enforcement chain (police, Public Prosecutor, judiciary, custody). This chapter alsocontains an up-to-date overview of the possibilities available to law enforcement agenciesfor the compulsory and quasi-compulsory treatment of drug-addicted criminals.Data on substance abuse and drug-related crime can be collected and represented indifferent ways. Appendix A contains information on the terminology used. AppendixB contains a concise overview of the most important sources of information for thisReport.Statistical significanceThis Annual Report describes trends in substance use and differences between groupsof users. In the case of data derived from a random population sample, we refer toan ‘increase’ or ‘decrease’ only when statistically significant. This means that any suchchange is unlikely to be by chance. At the same time, statistical significance is not entirelystraightforward. In very large samples, tiny differences can be significant, but may haveno practical meaning. Significance therefore does not always equate with relevance.Conversely, there may be clear differences in user percentages that are not relevantaccording to statistical analysis. This may be the case where samples are relatively small,with considerable variation within groups. In such cases it could be that a larger sample(for example more respondents) would yield a result that was significant.In this Annual Report we regard statistical significance as guiding principle, but the sizeof the differences is also important.The NDM Annual Report may also be accessed as a pdf document on the followingwebsites: www.trimbos.nl. or www.wodc.nl.32 Netherlands National Drug Monitor - NDM Annual Report 2009
  31. 31. 2  CannabisCannabis (Cannabis Sativa or hemp) contains hashish and weed in various concentra-tions. THC (tetrahydrocannabinol) is the main psychoactive component. Cannabis isgenerally smoked in cigarette form – with or without tobacco – and sometimes througha vaporizer. It is less often eaten in the form of space cake. Users tend to experiencecannabis as calming, relaxing and mind-expanding. In high doses, cannabis can triggeranxiety, panic and psychotic symptoms.The data below apply to both hashish and weed, unless otherwise specified.2.1  Recent facts and trendsIn this chapter, the main facts and trends concerning cannabis are:•  mong school-goers in mainstream secondary education (12-18 years) the percen- A tage of ever and current cannabis users declined gradually between 1996 and 2007, particularly among boys (§ 2.3).•  annabis use among Dutch school-goers aged 15 and 16 is high compared to other C European countries, despite a declining trend (§ 2.5).•  annabis use occurs significantly more often among pupils attending REC-4 schools C for special education, compared to pupils at mainstream schools (§ 2.3).•  y European standards, Dutch adults score slightly below average (in 2005) for recent B cannabis use (§ 2.5).•  n keeping with the rising trend of previous years, the number of cannabis clients of I (outpatient) addiction care increased further in 2007 and 2008 (§ 2.6).•  eneral hospitals again registered a further increase in the number of admissions G involving cannabis use or dependence as a secondary diagnosis between 2007 and 2008 (§ 2.6).•  he average THC content of Dutch-grown weed dropped further between 2006 and T 2007, and stabilised in 2008 and 2009 (§ 2.8).•  etween 2006 and 2009, there was a rise in the average price of Dutch-grown weed B (§ 2.8).2.2  Usage: general populationCannabis is the most widely used of all illegal drugs. In 1997, 2001 and 2005, NationalPrevalence Surveys (NPO) were conducted (NPO, Rodenburg et al., 2007).•  rom 1997 to 2001 the percentage of the population aged from 15 to 64 that had F ever used cannabis remained stable. Between 2001 and 2005 the percentage of ever 2  Cannabis 33
  32. 32. users increased. The total percentage of recent and current users remained at the same level in all three surveys (table 2.1).•  n 2005 over one in five people surveyed reported ever having used cannabis. One in I twenty had used cannabis in the year prior to the interview (recent use), and one in thirty-three had done so in the month before the interview (current use).•  alculated in terms of the population, the number of current cannabis users amounts C to 363,000.•  n 2005 1.3% of the population had used cannabis for the first time ever. The growth I of new users has remained stable throughout the years.Table 2.1  Cannabis use in the Netherlands in the population aged from 15 to 64. Survey years 1997, 2001 and 2005 1997 2001 2005 Ever use 19.1% 19.5% 22.6% -  Male 24.5% 23.6% 29.1% -  Females 13.6% 15.3% 16.1% Recent useI 5.5% 5.5% 5.4% -  Males 7.1% 7.2% 7.8% -  Females 3.8% 3.8% 3.1% Current useII 3.0% 3.4% 3.3% -  Males 4.2% 4.8% 5.2% -  Females 1.8% 1.9% 1.5% First used in the past year 1.4% 1.1% 1.3% I Average age of recent users 27.3 years 28.3 years 30.5 yearsNumber of respondents: 17 590 (1997), 2 312 (2001), 4 516 (2005). I. In the past year. II. In the pastmonth. Source: NPO, IVO.Age and Gender•  ore males than females use cannabis (table 2.1). M•  onsumption of cannabis occurs chiefly among juveniles and young adults (figure 2.1). C - Between 1997 and 2005 the percentage of recent and current users aged 15 to 24 dropped, whereas the percentage of recent and current users in the 25 to 44 year age group increased. This shift took place mainly between 1997 and 2001. - Likewise, the average age of recent cannabis users rose – from 27 to almost 31 (table 2.1). - The age of onset is the age at which a person first used a substance (see also appendix A: age of onset). Among ever users of cannabis, the age of onset for the 15 to 24 year old age group was 16.4 years on average. In the population aged 15 to 64, the age of onset averaged 19.6 years.34 Netherlands National Drug Monitor - NDM Annual Report 2009
  33. 33. Figure 2.1  Cannabis users in the Netherlands by age group. Survey years 1997 and 2005 % Recent % Current16 16 14.314 1412 11.4 1210 10 8 8 7.3 6.4 6 5.2 6 5.3 4.8 4 4 3.1 2 1.1 1.5 2 0.6 0.7 15-24 25-44 45-64 15-24 25-44 45-64 1997 2005 1997 2005Percentage of recent (last year, on left) users and current users (last month, on right) by age group. Source:NPO, IVO.The main citiesThere is more cannabis consumption in urban than in rural areas (Table 2.2).•  n 2005 the percentage of ever and recent cannabis users was approximately three I times greater in highly urban compared to non-urban areas.Table 2.2  Use of cannabis in the four main cities and in non-urban areas among people aged over 15 years. Survey years 1997 and 2005 Ever Use Recent Use Current Use 1997 2005 1997 2005 1997 2005 Very highly urbanI 31.4% 37.5% 10.4% 10.8% 6.2% 7.5% Highly urbanII 21.0% 24.6% 4.8% 5.8% 2.9% 3.2% III Moderately urban 15.5% 20.2% 4.3% 4.3% 2.2% 2.5% IV Semi-rural 15.0% 15.5% 4.5% 3.2% 2.2% 2.0% V Rural 12.8% 13.9% 3.8% 3.0% 1.9% 1.5%Percentage of ever use, recent (last year) and current (last month). No data by urbanisation level for 2001due to small numbers of respondents. I. Definition (Statistics Netherlands, CBS): municipalities with over2,500 addresses per square km. These are: Amsterdam, Rotterdam, Delft, The Hague, Groningen, Haarlem,Leiden, Rijswijk, Schiedam, Utrecht, Vlaardingen and Voorburg. II. Municipalities with 1,500 -2,500addresses per square km. III. Municipalities with 1,000 – 1,500 addresses per square km. IV. Districtswith 500-1,000 addresses per square km. V. Districts with fewer than 500 addresses per square km.Source: NPO, IVO. 2  Cannabis 35
  34. 34. Amount of use•  n 2005 almost a quarter (23.3%) of current users took cannabis (almost) daily. This I is the equivalent of 0.8% of the total population aged between 15 and 64. The percentage was double this (1.6%) among juveniles and young adults in the 15 to 34 age group.•  n population terms, some 85,000 people were using cannabis daily or almost daily I in 2005.2.3  Usage: juvenilesSchool-goers in mainstream educationSince the mid-1980s, the Netherlands Institute of Mental Health and Addiction (TrimbosInstitute) has periodically surveyed the extent of the experience of school-goers aged 12and older at maintream secondary schools with alcohol, tobacco, drugs and gambling.This survey is known as the Dutch National School Survey. The most recent measure-ments were conducted in 2007 (Monshouwer et al., 2007).•  igure 2.2 shows a strong increase in cannabis use among school-goers between F 1988 and 1996. From 1996 to 2007, ever use declined gradually from 22 to 17 percent. During the same period, current use dropped slightly from 11 to 8 percent. This decline took place mostly among boys. Among girls, the percentage differences found between 1996 and 2007 were not significant.•  n 2007 more boys than girls had used cannabis in the month preceding the survey. I The difference between boys and girls for cannabis use varied from one measurement to another.36 Netherlands National Drug Monitor - NDM Annual Report 2009
  35. 35. Figure 2.2  Cannabis use among secondary-school pupils aged 12 to 18 since 1988 % Ever use % Current use30 3025 2520 2015 1510 10 5 5 1988 1992 1996 1999 2003 2007 1988 1992 1996 1999 2003 2007 Boys Girls Total Boys Girls TotalPercentage of ever users (left) and last month (right).Source: Dutch National School Survey, Trimbos Institute.Age•  annabis use increases among school-goers with age. In 2007, few school-goers C aged 12 had tried cannabis – only one in fifty (2%). By the age of 16, almost one in three had ever tried cannabis (30%).•  he age at which school-goers first used cannabis dropped between 1988 and 1996, T after which it stabilised (Monshouwer et al., 2005). The percentage of boys who had already tried cannabis at a very young age (≤14 years) remained stable between 1996 and 2003 (21%) and declined between 2003 and 2007 from 21 to 13 percent. Among 14-year old girls, the decline in ever use of cannabis between 2003 and 2007 was less marked and was not significant (from 16% to 12%).•  he Antenne Monitoring Station in Amsterdam found that the average age of onset T for ever cannabis use among school-goers of western ethnicity rose from 13.5 in 1997 to 14.2 in 2007 (Nabben et al., 2008).•  n early age of onset for cannabis use is associated with an increased risk of later A developing mental health disorders, cannabis dependency, use of hard drugs and possibly cognitive disorders (CAM, 2008). The precise mechanisms involved are not fully known (e.g. effects of cannabis on the developing brain, susceptibility and/or social processes). 2  Cannabis 37
  36. 36. Amount of use•  f the eight percent current school-going users in 2007, over half (55%) had used O cannabis no more than once or twice during the past month. A minority had used cannabis more than ten times (14%): approximately one in five boys (18%) and one in 14 girls (7%) (see Figure 2.3).•  er incident, almost half of the current users smoked less than one joint. 18% of the P boys smoked three or more joints per incident, compared to 11% of girls; but this difference is not statistically significant).Figure 2.3  Frequency of cannabis use among current users. Survey year 2007 Boys Girls 7% 18% 46% 31% 62% 36% 1-2 times 3-10 times 10 times 1-2 times 3-10 times 10 timesPercentage of school-goers who had used cannabis in the month before the survey. Source : Dutch NationalSchool Survey, Trimbos Institute.School level and ethnic background•  here is little difference in the prevalence of cannabis use between the various levels T of education. The percentage of pupils that ever used cannabis and the percentage that used cannabis in the past month is virtually identical in most of the different levels of Dutch secondary schools: VMBO-b (lower secondary, practical) VMBO-t (lower secondary, theoretical), HAVO (middle secondary), while it is slightly lower at VWO (higher secondary, although this difference was not statistically significant.•  here is no strong association between ethnic origin and ever use of cannabis1, with T the exception of Moroccan school-goers who have comparatively less experience of cannabis use, in particular among girls (2%).•  ccording to the Antenne Monitoring Station in Amsterdam, the percentage of ever A users and current users of cannabis is lowest among Moroccan school-goers; but the percentage of users among Turkish and Surinamese school-goers is also lower than among their native Dutch peers (Korf et al., 2003).1 See Appendix A38 Netherlands National Drug Monitor - NDM Annual Report 2009
  37. 37. Cannabis and problem behaviour•  chool-goers who use cannabis exhibit more aggressive and delinquent behaviour and S have more school-related problems (truancy, poor results) than their non-using peers. This association becomes stronger with increasing frequency of use (Monshouwer et al., 2006); Verdurmen et al., 2005b).•  annabis users are more likely to use other substances than non-users (e.g. 5 or more C units of alcohol in the past month, daily smoking, ever use of hard drugs).•  o differences were found for mental health problems, such as withdrawn behaviour, N anxiety or depression.Place of procurement•  n 2007, approximately one third of current users (35%) got their cannabis from I friends, without having to buy it themselves. 40% of current users sometimes bought cannabis in a ‘coffee shop’. 18% sometimes bought cannabis on the street or in a park etc., and 16% from a (home) dealer; one in ten got it at school or near school; and likewise one in ten got it at someone’s house.•  ore girls than boys got cannabis through friends, without having to buy it them- M selves, and boys were more likely than girls to purchase it in or through ‘coffee shops’.•  significant percentage of cannabis-using school-goers aged up to 17 reported A having purchased cannabis in or through a ‘coffee shop’ in 2007. This is remarkable, since the age limit for access to these ‘coffee shops’ is 18. It is not known to what extent these under-age users actually purchased the cannabis themselves, or procured it through third parties.•  he percentage of those who sometimes procured cannabis through a ‘coffee shop’ T was highest among males aged 18. Eight out of ten (82%) of current male users in this age group did so. 2  Cannabis 39
  38. 38. Table 2.3  How do school-goers procure their cannabis? Survey year 2007 Method of procurement 12-15 years 16-17 years 18 years Total B G B G B G B G Total I never buy it 29% 41% 35% 46% 15% 17% 30% 42% 35% Coffee shop 39% 22% 45% 42% 82% 67% 46% 31% 40% From a dealer’s house 24% 11% 18% 6% 14% 35% 20% 10% 16% Someone else’s house 12% 11% 9% 12% 3% 0% 10% 11% 10% At or near school 14% 13% 10% 3% 3% 0% 11% 9% 10% On the street, park etc. 28% 12% 19% 2% 11% 19% 23% 9% 18% Bar 3% 3% 2% 1% 3% 0% 2% 2% 2% Discotheque 4% 2% 3% 1% 3% 0% 3% 2% 3% Youth café or 1% 1% 2% 0% 0% 0% 1% 1% 1% community centre Youth centre 4% 2% 1% 0% 3% 0% 3% 1% 2% Other 1% 1% 1% 1% 0% 0% 1% 1% 1%School-goers aged 12 to 18 of Dutch secondary schools (current users). Respondents could tick more thanone answer. Therefore the percentages do not add up to 100. B = boys; G = girls. Source: Dutch NationalSchool Survey, Trimbos Institute.Schools for special educationIn 2008, The Trimbos Institute, together with the University of Utrecht, conducted a studyon substance use among over 2,600 pupils aged between 12 and 18 attending schoolsfor special education (Kepper et al., 2009). These are schools affiliated to a RegionalExpertise Centre (known as REC-4 schools. Pupils attending these schools may havesevere learning or behavioural difficulties, a long-term illness with psychiatric problems; orthey may be attending schools affiliated to a Pedagogical Institute. Other groups receivepractical education (pro) or support education (lwoo)). The results for the 12-16 year agegroup were compared with those of a 2007 survey conducted in a peer group of pupilsin mainstream secondary schools (vmbo without lwoo; havo and vwo).•  upils attending REC-4 schools have by far the most experience of cannabis use. This P applies to all age groups. Over half of the 16 year olds had ever tried cannabis (table 2.4). Incidentally, pupils attending REC-4 schools account for only one to two percent of all secondary school pupils (see Appendix F).•  mong 12-13 year-olds and 14-15 year-olds in practical education (pro) or support A education (lwoo), the percentages of ever users are comparable to those in main- stream schools. Among 16-year olds, ever use of cannabis is actually lower than in mainstream schools, particularly among pupils in practical education.•  he percentage of current cannabis users is also highest among pupils attending T REC-4 schools. In the other types of education, the differences in use were small.•  n average current cannabis users of both REC-4 and practical schools smoke three O joints per incident. For the lwoo schools the average is two joints, and in mainstream schools it is 1.5 joints among 14-15 year-olds and one joint among 16-year olds.40 Netherlands National Drug Monitor - NDM Annual Report 2009
  39. 39. Table 2.4  Cannabis use among pupils aged 12-16 in special and mainstream schools, by age group Ever Use Current Use 12-13 years 14-15 years 16 years 12-13 years 14-15 years 16 years Special   REC-4I 20% 42% 54% 11% 23% 41%   ProII 5% 15% 19% 2% 6% 10% III   Lwoo 7% 17% 25% 3% 7% 13% Mainstream 4% 17% 30% 2% 9% 13%Percentage of ever and current (past month) users. Survey year for special schools was 2008. Survey year formainstream schools was 2007. I. REC = Regional Expertise Centre. II. Pro = practical education. III. Lwoo =support education. Sources: Trimbos Institute; Trimbos Institute/University of Utrecht.Special groups of young peopleIn certain groups of juveniles and young adults, cannabis use is the rule rather than theexception. Table 2.5 summarises the results of various studies – mostly regional or local.The data are not comparable, on account of differences in age groups and researchmethods. Furthermore, the response rate for surveys among juveniles and young adultsin the social scene is often low. This may lead to a distortion of the results. Trend dataare only available for Amsterdam.Juveniles and young adults in the social scene•  he Antenna-Monitoring Station follows substance use in various groups of young T people in the Amsterdam social scene, such as ‘coffee shops’, bars and fashionable clubs (Benschop et al., 2009). In 2003 and 2008, 39% of the juvenile and young adult attendees at trendy clubs (and parties) in Amsterdam were current cannabis users. In both years, the average number of joints smoked by current users per occasion was about one and a half.•  n 2008/2009 substance use was examined among attendees at eleven national and regi- I onally organised large scale parties (Trimbos Institute/University of Amsterdam 2010). -  Three out of ten of the party-goers were current cannabis users. -  17% of the party-goers had smoked a joint on the evening itself. This varied from 6% to 30% between parties. On average, the revellers smoked 2.4 joints.•  n the same survey in 2008/2009, substance use among clubbers and disco-goers was I studied in large and medium-sized municipalities in five regions of the Netherlands: North (Friesland, Groningen, Drenthe), Oost (Gelderland and Overijssel), Central (Utrecht, Flevo- land), West (Noord- en Zuid-Holland) and South (Noord- Brabant, Zeeland, Limburg). - The percentage of current cannabis users varied between regions and was highest in the regions West (28%), South (24%) and Central (24%) , while it was lowest in the regions North (17%) and East (18%). -  the basis of these data, a national estimate of substance use among clubbers is On being drawn up. These data were not available for this Annual Report, but will be included in the final report of the social scene survey. 2  Cannabis 41
  40. 40. Problem YouthThere are relatively more current cannabis users among young drifters, school dropoutsand juveniles detained in penitentiaries, as well as those in care (between two and eightout of ten).•  lmost half the juveniles in Amsterdam youth care were current cannabis users in A 2006 (Nabben et al., 2007a). Approximately one in three (31%) of these users take cannabis daily, which is 15% of all juveniles in care. The amount and frequency of use is the same for boys as for girls. Over one in ten of current users (11%) have indicated a wish to get help to quit or reduce their use.•  t national level, lower percentages are found in younger age groups among juveniles A in residential care, varying from 18% for 12 and 13 year-olds to 37% for the 16 year-olds (Kepper et al., 2009).42 Netherlands National Drug Monitor - NDM Annual Report 2009
  41. 41. Table 2.5  Current cannabis use in special groups Location Survey year Age (years) Current use Young people in the social scene and young adults -  Frequenters of dance parties, The Hague 2003 15 - 35 37% festivals, city centre -  Bar-goers Zaandam 2006 14 - 44 22% I II -  Bar-goers Amsterdam 2005 Average 27 22% -  Frequenters of bars and sport-hall Noordwijk 2004 Average 23 19% canteen-bars -  Discotheque-goers NijmegenIII 2006 Average 21 12% -  Clubbers Amsterdam 2003 Average 28 39% 2008 Average 25 39% -  Coffee shop frequenters Nijmegen 2005-6 Average 27 84% -  Revellers at parties and festivals NationwideIII 2008/2009 Average 24 30% Problem groups -  Juveniles attending special schools Amsterdam 2003 13 - 16 32% and truancy projects Juvenile detaineesIV -  Regional 2002/2003 14 - 17 59% School drop-outsIV -  Regional 2002/2003 14 - 17 59% Homeless YouthV -  Flevoland 2004 13 - 22 87% -  Street youth Heerlen 2006 15 - 20 35% Juveniles in care VI -  Amsterdam 2006 Average 17 45% -  Juveniles in residential care Nationwide 2008 12-13 18% 14-15 36% 16 37%Percentage of current users, (past month) per group. The figures in this table are not comparable on accountof differences in age groups and research methods. I. Juveniles and young adults in mainstream bars, studentbars, gay bars and hip bars. Therefore not representative of all bar-goers. II. Low response (26%). III. Lowresponse (19%). IV. Research in the provinces of Noord-Holland, Flevoland and Utrecht. Usage amongjuvenile detainees: in the month prior to detention. Drop-outs are juveniles who have missed at least amonth of school during the past year, not counting holidays. V. Young drifters aged up to 23 who have hadno fixed abode for at least three months. VI. Juveniles with behavioural problems, juvenile delinquents,homeless juveniles and juveniles in other care projects. Sources: Parnassia; GGD Zaanstreek-Waterland;Antenne, Bonger Institute for Criminology, University of Amsterdam; GGD Zuid-Holland Noord; Tendens,Iriszorg;Research on the Social Scene, Trimbos-Institute / University of Amsterdam; Mondriaan Zorggroep;EXPLORE, Trimbos Institute /University of Utrecht. 2  Cannabis 43