Netherlands

"Cannabis is the most common illicit substance used by the Dutch adult general population aged 15-64 years, followed at a distance by MDMA/ecstasy and cocaine. The gender gap regarding cannabis use remains: last year prevalence of cannabis use among young adults was approximately twice as high among males as among females. The use of all illicit drugs is concentrated among young adults aged 15-34 years.

"The increasing trend in ecstasy use seems to have halted, at least in the general population, but prevalence rates remain high among young adults. In school-age children, the use of ecstasy decreased between 2015 and 2017. Available data suggest an increase in recent years in cocaine and amphetamine use among young adults in particular and in cocaine use among the general population. There is also some evidence that rates of cocaine use increased among Amsterdam clubgoers.

"Studies among other sub-groups of young people indicate that the use of illicit substances is more common in recreational settings, especially in clubs and at festivals. Moreover, some new psychoactive substances (NPS), such as 4-fluoroamphetamine (4-FA), have gained popularity among this sub-group, although use of other NPS remains low.

"Wastewater analyses can complement the results from population surveys, by providing data on drug use at a municipal level, based on the levels of illicit drugs and their metabolites found in wastewater. As part of the Europe-wide Sewage Analysis Core Group Europe (SCORE) analyses, analysis of wastewater in Eindhoven indicates that cocaine use remained stable between 2017 and 2018. In contrast, the results for Amsterdam point to an increase in cocaine use. The use of MDMA and cocaine seems to be more common in Amsterdam and Eindhoven than in Utrecht."

"Since 1976, it has been a basic principle of Dutch drug policy to pursue the separation of the markets for ‘soft’ and ‘hard’ drugs. The Opium Act Directive states that the ‘Dutch drugs policy aims to discourage and reduce drug use, certainly in so far as it causes damage to health and to society, and to prevent and reduce the damage associated with drug use, drug production and the drugs trade’ (Stc 2011-11134). The 1995 white paper ‘Drug policy: continuity and change’ sets out comprehensively the principles of the Dutch illicit drugs policy. Taking a balanced approach, it recognises the distinction between ‘soft’ (Schedule I) and ‘hard’ (Schedule II) drugs. It outlines four major objectives: (i) to prevent drug use and treat and rehabilitate drug users; (ii) to reduce harm to users; (iii) to diminish public nuisance caused by drug users; and (iv) to combat the production and trafficking of drugs.

"Since 1995, other aspects of Dutch drug policy have been elaborated in a number of issue-specific strategies and policy notes or letters to parliament. These have included the white paper ‘A combined effort to combat ecstasy’ (2001), the ‘Plan to combat drug trafficking at Schiphol airport’ (2002), the ‘Cannabis policy document’ (2004), the ‘Medical prescription of heroin’ (2009), the ‘Police and the Public Prosecution Office policy letter’ (2008-12 and 2012-16) targeting drugs and organised crime, and a policy view on drug prevention addressing young people and nightlife (2015).

"Dutch cannabis policy has been elaborated in a series of policy letters. The ‘Letter outlining the new Dutch policy’ (2009) placed an increased emphasis on prevention and use reduction, and it amended the ‘coffee shop’ policy. The expediency principle holds that the public prosecutor has the discretionary power to refrain from prosecuting a criminal offence if this is judged to be in the public interest. This approach provides the basis for the ‘coffee shop’ policy, which allows users to buy cannabis in coffee shops, preventing them from coming into contact with hard drugs. Since 1996, the sale of small quantities has been tolerated if coffee shops adhere to the following criteria: no advertising, no sale of hard drugs, no public nuisance in and around the coffee shop, no admittance of or sale to minors, no sale of large quantities per transaction (maximum 5 g) and a maximum in-store stock for sale of 500 g. In 2013, another criterion was added: admittance to coffee shops and sales are limited to residents of the Netherlands, although local adjustments in the implementation of this criterion are allowed.

"Like other European countries, the Netherlands regularly monitors and evaluates its drug policy and specific issues using routine indicator monitoring and specific research projects. Long-standing monitoring systems include the Drug Information and Monitoring System (drug composition), the tetrahydrocannabinol (THC) monitor (cannabis potency) and drug-related emergencies monitoring (presentations at festival first aid stations and medical services in eight Dutch regions). In 2009, an external evaluation of the 1995 white paper was carried out by the Trimbos Institute.

"The Netherlands Opium Act is the basis for the current drug legislation. It defines drug trafficking, cultivation and production and dealing in and possession of drugs as criminal acts. The Act and its amendments confirm the distinction between Schedule I drugs (e.g. heroin, cocaine, MDMA/ecstasy, amphetamines) and Schedule II drugs (e.g. cannabis, hallucinogenic mushrooms). The Opium Act is implemented by the national Opium Act Directive to prosecutors, which is periodically revised; for example, since 2018, prosecutors have been asked, when appropriate, to consider (partially) replacing community service and prison sentences with a fine. New psychoactive substances are regulated through amendments to relevant schedules of the Opium Act.

"Drug use itself is not specified as a crime, though there are situations when the use of drugs is prohibited at the local level for reasons of public order or to protect the health of young people, such as at schools and on public transport. It is up to the responsible authorities — not the national government — to regulate this. The possession of small quantities of drugs for personal use is punishable by imprisonment, but, in practice, it is not subject to targeted investigation by the police. Anyone found in possession of a small amount of drugs for personal use will generally not be prosecuted, though the police will confiscate the drugs; prosecution is considered only to refer an individual to a care agency. The threshold amount for cannabis is set at 5 g. Since 2012, the Opium Act Directive has left open the possibility of arresting and prosecuting individuals in possession of less than 5 g of cannabis in certain circumstances.

"People who use drugs can be convicted when they have committed a crime such as selling drugs, theft or burglary. Since 2004, a special law — the Placement in an Institution for Prolific Offenders Law — has enabled the treatment of persistent offenders, of whom problem drug users constitute a major proportion. The measure consists of a combination of imprisonment and behavioural interventions and treatment, which are mostly carried out in care institutions outside prison.

"The Opium Act states that supplying drugs (possession, cultivation or manufacture, import or export) is a crime punishable by up to 12 years’ imprisonment, depending on the quantity and type of the drug involved. However, the Opium Act Directive also sets out strict conditions under which cannabis sales and consumption outlets, known as ‘coffee shops’, may be tolerated by local authorities. In March 2017, there were 567 ‘coffee shops’ in the Netherlands."

"Data on the use of illicit substances among students aged 15-16 are reported in the European School Survey Project on Alcohol and Other Drugs (ESPAD). This survey has been carried out regularly in the Netherlands since 1999 and the most recent data are from 2015. The ESPAD studies indicate a decreasing trend in lifetime cannabis use among school-age children over the period 1999-2015. Nevertheless, in 2015, lifetime use of cannabis among students in the Netherlands was notably higher than the ESPAD average (based on data from 35 countries). However, lifetime use of illicit drugs other than cannabis and lifetime use of NPS were more or less in line with the ESPAD average. Data from the 2017 Health Behaviour in School-aged Children (HBSC) study also showed a decrease in lifetime prevalence of cannabis use among students aged 12-16 years from 16.5 % in 2003 to 9.2 % in 2017."

"In the Netherlands, harm reduction activities are implemented through outreach work, low-threshold facilities and centres for ‘social addiction care’, the main goal of which is to establish and maintain contact with difficult-to-reach drug users.

"Most outreach work is carried out by low-threshold services in outpatient care facilities. Drug consumption rooms offer the possibility of hygienic and supervised consumption. In 2018, there were 24 drug consumption rooms across 19 Dutch cities servicing people who inject drugs and those who smoke or inhale. At some Regional Institutes for Protected Living, the use of drugs is also tolerated. Outreach activities also feature in programmes for reducing drug-related public nuisance, which are a collaborative venture between treatment and care facilities, the police and civil groups.

NSPs [Needle and Syringe Exchange Programs] were established in the Netherlands over 30 years ago and are available in all major cities. These programmes are mainly implemented by addiction care and some municipal health services, and syringes are available through street drug workers and at treatment centres. There is no national monitoring of the number of syringes and needles distributed. Available local data from Amsterdam and Rotterdam indicate a continuous decline in syringe provision between 2002 and 2017 to one fifth of the original number; the decline is attributed to a reduction in heroin use and injecting in general and an increase in the inhalant use of other substances such as crack cocaine.

"In 2015, the new oral interferon-free direct-acting antiretroviral treatments for hepatitis C virus (HCV) infection became reimbursable. Such treatment is offered to all HCV patients, irrespective of the level of fibrosis. A comprehensive hepatitis plan was launched in 2016, and the Health Council advised that people who use drugs should actively be offered hepatitis B virus and HCV testing. Addiction care institutions were identified as the main players responsible for case finding in this risk group.

"Several projects implement chain of care pathways to lead HCV-positive drug users into treatment in hospital centres. In addition, retrieval projects in several parts of the country aim to find patients previously diagnosed with chronic HCV, including people who use drugs, to offer them treatment with direct-acting antiretroviral drugs."

"Studies reporting estimates of high-risk drug use can help to identify the extent of the more entrenched drug use problems, while data on first-time entrants to specialised drug treatment centres, when considered alongside other indicators, can inform an understanding of the nature of and trends in high-risk drug use.

"In the Netherlands, high-risk drug use is mainly linked to use of heroin or crack cocaine. There are also reports of dependent gamma-hydroxybutyrate (GHB) users, but their total number is unknown. The most recent estimate suggested that there were 14,000 high-risk opioid users in the country in 2012 (1.3 per 1 000 inhabitants aged 15-64 years). Available data indicate a decline in the estimated number of opioid users in the last decade. Based on a study in the three largest cities, the prevalence of crack cocaine use ranged between 1.6 and 2.2 per 1,000 inhabitants aged 15-64 years in 2013. Many high-risk drug users, including opioid users, also use crack cocaine and a range of other licit and illicit substances. In 2016, a general population survey estimated that 1.4 % of people older than 18 years in the Netherlands were high-risk cannabis users.

"Data from specialised treatment centres indicate that the number of new treatment entrants has remained stable in recent years, following an increase during the period 2006-11. In 2015, the largest group of first-time drug-treatment entrants comprised those who required treatment for cannabis use. Cocaine (crack) is the second most commonly reported primary substance among first-time clients, although the trend indicates a decline from 2008.

"The number of primary heroin users requiring treatment for the first time has declined since 2007 and has remained relatively stable since 2012. Overall, heroin users entering treatment are older than other treatment clients. Injecting drug use is rare among those entering treatment."

"Since 1988, substance use is monitored every four years among pupils of primary education (7th and 8th grade) and all grades of ‘mainstream’ secondary education. The most recent survey was conducted in 2011. Among pupils from primary education, questions on illegal drug use were restricted to cannabis. Methodological details have been described in the 2012 National Report and in ST.
"The results showed that primary-school children (7th and 8th grade) had little experience of cannabis. In 2011 only 0.3% of them had ever smoked a joint.
"• Table 2.3.1 shows the trends in lifetime prevalence and table 2.3.2 the last month prevalence of drug use rates among pupils of secondary education of 12-18 years (see also ST02).
"• The percentage of last month cannabis users declined gradually between 1996 and 2003, and remained stable in 2007 and 2011.
"• Both lifetime and last month use was higher among boys than girls (lifetime 20.7% and 13.9%, respectively; last month: 10.5% and 4.8%, respectively). No differences were found between the various school levels.
"• Overall, prevalence rates of the other drugs peaked in 1996, decreased afterwards and remained stable between 2007 and 2011. Lifetime use of ecstasy remained highest and use of heroin remained lowest over all years (2.6% and 0.6%, respectively in 2011)."

Percentage of People In the Netherlands Aged 18 and Over In The General Population Reporting Last-Month Use Of:

• Marijuana: 4.6%
• Cocaine: 0.7%
• Opiates: "Hardly any"
• Ecstasy: 1.1%
• Amphetamine: 0.5%
• GHB: 0.2%
• Sedatives and Tranquilizers: 6.5%

Percentage of People In the Netherlands Aged 18 and Over In The General Population Reporting Last-Year Use Of:

• Marijuana: 7.5%
• Cocaine: 1.6%
• Opiates: "Hardly any"
• Ecstasy: 2.8%
• Amphetamine: 1.1%
• GHB: 0.4%
• Sedatives and Tranquilizers: 10.2%

"Police and Public Prosecutor give low priority to the investigation of possession of small amounts of a drug for own use. The Opium Act Directive of the Public Prosecutor state that, if the offence concerns possession of small amounts for own use of a hard drug, the drugs will be seized, but normally there will be no custody or prosecution. Diversion to care is the primary aim of custody or prosecution in cases of possession of hard drugs (Directive Opium Act 2011A021 2012, www.om.nl). ‘Small amounts’ of a hard drug are defined as one tablet, ample, wrapple or ball of the drug and in any case an amount of no more than 0,5 grams. With regards to cannabis (categorized as ‘soft drug’) small amounts are defined as no more than 5 grams and no more than 5 cannabis plants – under the condition that there is no professional or commercial cultivation of the plants (Stc. 2011 – 22936). For hallucinogenic mushrooms, also categorized as soft drugs, the small amounts for own use are defined as 0,5 grams (dried mushrooms) and 5 grams (fresh ones). In cases of possession of small amounts of soft drugs, the drugs will be seized but a dismissal by the police will normally (‘in principle’) follow, without custody or prosecution."

Table: Drug Use and Crime Indicators, Comparison Between The US and The Netherlands

"All recent policy documents state that the Dutch drug policy has two cornerstones - and this was confirmed by the Minister of Health, Welfare and Sport during the major drug debate in the House of Representatives in March 2012: to protect public health and to combat public nuisance and drug-related crime (TK 24077-259; TK Handelingen 69-28 maart 2012). In the current Opium Act Directive the objective of the drug policy is described as: 'The [new] Dutch drugs policy is aimed to discourage and reduce drug use, certainly in so far as it causes damage to health and to society, and to prevent and reduce the damage associated with drug use, drug production and the drugs trade' (Stc 2011-11134)."

"From April 2009 until December 2009 the general population survey also included questions on problems related to cannabis use. These questions were derived from the DSM IV criteria for cannabis dependence and may be considered as a proxy measure of problem cannabis but they do not yield a clinical diagnosis of dependence. As these questions were introduced in the second quarter of 2009, the net sample was slightly lower (n=4,638 instead of 5,769), but prevalence rates of cannabis use were virtually the same (e.g. last year prevalence was 7.0% in the full sample and 7.1% in the reduced sample). Questions on problems related to cannabis use were only completed by respondents who had used cannabis at least five times in the past 12 months. Table 2.1.2 shows the percentages of cannabis users fulfilling the criteria. Almost one quarter (23%) responded positive to three or more 'symptoms', which can be indicative of problem use."

"Figure 2.2.1 shows that cannabis use strongly increases with age.
"• At age 12 only few pupils have ever used cannabis, less than 1%. At age 16, one in five girls and one in three boys had ever tried cannabis.
"• While boys have overall more ever and current experience with cannabis, gender differences are only significant for current use and only at age 16.
"• While the Dutch National School Surveys on Substance use have shown a strong increase in the age of first cannabis use between 1988 and 1996, the HBSC studies showed that lifetime prevalence among 14 year old pupils decreased from 20% in 2011 to 11% in 2009.
"Frequency of cannabis use
"• Nine percent of the pupils of 12-16 years had used cannabis in the past year. Of this group, 42% had smoked cannabis only 1 time, 49% smoked between 2 and 39 times and 10% was a relatively heavy user (40 times or more in the past year).
"Cannabis use: school level and ethnicity
"• There were no significant differences between school types in the percentages of recent and current cannabis users.
"• There were also no major differences in prevalence rates between Dutch and other ethnic groups, except for a lower rate of recent use among Moroccan pupils (4% against 10% among Dutch pupils). This difference remains significant after correcting for differences in school type and family situation between Dutch and Moroccan pupils."

"The Netherlands is a significant transit country for illicit drugs, especially cocaine from South America entering through the Port of Rotterdam and destined for European markets. Customs officials announced in January that authorities confiscated 38 tons of cocaine in the Port of Rotterdam in 2019, an increase of 50 percent from 2018. Officials announced in July that authorities intercepted twice as much cocaine in the ports of Rotterdam and Vlissingen in the first half of 2020 as in the same period in 2019.  The Netherlands is one of the largest sources of synthetic drugs for international markets and has identified an increase in the number of methamphetamine laboratories where Mexican nationals were accomplices. A typical methamphetamine lab seizure in 2018 yielded 22 kilograms (kg), but in 2019, the average seizure was over 400 kg.  
 
"The Dutch Opium Act prohibits the possession, commercial distribution, production, import, and export of all illicit drugs.  The act distinguishes between “hard” drugs (e.g., heroin, cocaine), and 'soft' drugs (cannabis products).  Sales of less than five grams of cannabis products are 'tolerated' (i.e., illegal but not prosecuted) in regulated establishments called 'coffee shops.'

"Drug traffickers increasingly use legitimate postage companies to distribute narcotics to global customers. Authorities report that dealers send over 100,000 packages containing cocaine, ecstasy, or methamphetamines to foreign countries each year."

"The most recent survey on drug use in the general population was conducted in 2009. However, due to methodological changes, the data are not comparable with those of previous surveys (1997, 2001 and 2005). Hence, recent trends cannot be described. In 2009 last year prevalence of cannabis use in the population of 15-64 years was 7.0% and last month prevalence was 4.2%. Almost one-third (30%) of the last month users had used cannabis daily or almost daily in the past month. The percentage of recent users of cocaine and ecstasy was almost the same (1.2% and 1.4%, respectively). Amphetamine remained least popular with 0.4% recent users.

"Cannabis use among pupils (12-16 years) from regular secondary schools showed a decreasing trend between 2001 and 2009. In 2009, 9% of the pupils had used cannabis in the past year against 14% in 2001. Four in ten recent users had used only once in the past year, and a minority was a frequent blower (40 times or more).

"Prevalence rates of drug use are appreciably higher in (local) studies among various subpopulations, including pubgoers and nightlifers (cannabis, ecstasy, cocaine), neighbourhood and hang-around youth (cannabis, ecstasy, cocaine) and men who have sex with men (ecstasy, cocaine, GHB). However, no higher levels but even lower levels of drug use (cannabis, ecstasy, cocaine) were found among first-year students.

"Various indicators strongly point at an increase in the (problem) use of GHB in some subpopulations both in and outside the nightlife scene. In 2009, 0.4% of the population between 15 and 64 years had used GHB and 0.2% reported use in the past month. These figures are comparable to those of amphetamine but much lower compared to ecstasy and cocaine. Higher percentages of GHB users are found among populations in the nightlife scene, although GHB is not by definition a club drug and use at home is also commonly reported."

"In 2018, approximately 1.02 million Dutch people aged 18 and older had used cannabis in the past year (7.5% of this age group). Last-year use is highest among people aged between 18-19 and 20-24, (21.4% and 23.7%). The figure for last-month use among people aged 18 and older is 4.6%. More than a third (35.0%) of the last-month users smoked dope (almost) every day.

"The percentages of people who had ever smoked dope (23.7%) and those who smoked dope (almost) every day (1.6%) were higher in 2018 than in previous years (21.1% and 1.2% in 2015), but it is still too early to speak of a trend.

"The percentage of last-year cannabis users among 15-64-year-olds in the Netherlands was, at 9.6%, higher than the European average (7.4%).

"Of cannabis users aged 18 and older, 83.5% used cannabis recreationally, 5.8% used cannabis only for medical reasons, and 10.7% used cannabis both as a medicine and recreationally. Of those who (also) used cannabis as a medicine, 90.6% did so without a doctor's prescription.

"Among secondary school pupils between 12 and 16 years old, there was a fall in last-year use between 2003 and 2015 (from 13.1% to 8.2%), but last-year use remained at the same level in 2017 (7.9%)."

"• There is an increase in the total number of police reports of Opium Act offences in 2011.
"• There is an increase in both hard and soft drugs reports compared to 2010. The increase in soft drugs exceeds the increase in hard drugs offences. The number of reports of combinations of both hard and soft drugs has decreased. This type of cases forms a minority.
"• The proportion of hard drugs and soft drugs offences remained more or less constant compared to 2010. In 2011, there are almost as many hard drugs as soft drugs reports. There is an increase in the proportion of soft drugs offences since 2009. This increase is confirmed by the Netherlands Police Agency, who assume that the increase is a result of the intensified enforcement efforts directed at cannabis production (Nationaal Netwerk Drugsexpertise 2012).
"• 7% of all the police reports concern Opium Act offences in 2011. This proportion increased compared to 2010.
"• Most arrestees for Opium Act offences are male. Most of the arrestees have more than one criminal report. For 42%, the 2011 offence is the first registered offence (of all possible offences, not only Opium Act offences; not in table)."

"The next phase in the criminal justice chain is the Public Prosecutor. Note that a police report is a different administrative unit than a case registration of the Public Prosecutor.
"• In 2011 the number of Opium Act cases increased compared to 2010, especially soft drug cases. The increase is substantial.
"• The percentage of soft drug cases increased in 2011, while that of hard drug cases decreased. More than half of the cases (53%) concerns soft drugs now.
"• The majority of the Opium Act cases (60%) concerns production, trafficking or dealing of drugs, 40% concerns possession of drugs (not in table). It is not known from the figures what the quantity of drugs was in the cases of ‘possession of drugs’. The general guideline for prosecution states that, if possession concerns ‘small amounts for own use’ police dismissal or prosecution aimed at diversion to care can follow. The drugs will always be seized. But if someone possesses more of a drug than the small amount that is considered ‘for own use’ – and which might be meant for dealing – or if there is also another, more serious offence involved, arrest and prosecution are the rule. The available data do not allow a distinction between possession of small amounts for personal use or larger amounts which might be meant for supply.
"• In cases of hard drugs, 44% concerns production or trafficking and 46% concerns possession of hard drugs in 2011 (not in table). For soft drugs, these fractions are different: 74% concerns production or trafficking and 26% possession (not in table).
"• The percentage of Opium Act cases of all cases in 2011 is 7.6%. This is the first increase since 2005."

Problem Drug Use

"The previous estimate of the total number of problem opiates users in the Netherlands pertained to the period 2008-2009. For that previous period, it was estimated that there were about 17,700 more or less problematic opiates users (Cruts and Van Laar 2010). This estimate has now been updated for the year 2012. It is estimated that in this year there were about 14,000 more or less problematic opiates users, a decrease of about 21% compared to 2008-2009 (Cruts, Van Laar, and Buster 2013). This updated estimate has been reported to the EMCDDA by means of the Standard Table ST7_2013_NL_01.
"For both estimates, the method of the treatment multiplier was applied. From February until June 2013, a total of 401 more problematic opiates users were recruited in five Dutch cities to obtain the field sample required to perform the treatment multiplier. The 401 respondents were recruited in the cities of Amsterdam (100 respondents), Rotterdam (100 respondents), Utrecht (71 respondents), Eindhoven (70 respondents), and Haarlem (60 respondents). Their mean age was 47.7 years within a range of 23 to 74 years, 86% was male and 14% was female. These more problematic opiates users were contacted, recruited, and interviewed by experienced field workers who applied a structured questionnaire (Schaap and Kools 2013). The respondents used heroin (81.8%) or methadone (88.8%), or both substances."

"The national HIV/ AIDS registration of the HIV Monitoring Foundation (SHM) was appointed by the Dutch Ministry of Health Welfare and Sport as the executive organisation for the monitoring of HIV in the Netherlands in 2002. This registration contains data on HIV-infected patients who are seen regularly by HIV/ AIDS treating physicians in one of the 26 collaborative HIV treatment centres throughout the country. It also includes data from a prior project on HIV positive patients treated between 1998 and 2001 (the AIDS Therapy Evaluation Netherlands, or ATHENA, cohort). The longitudinal, anonymous data are used to monitor changes in the HIV epidemic, the natural history of HIV and the effects of treatment (www.hiv-monitoring.nl). The latest available report of the SHM shows again that men who have sex with men (MSM) still account for the largest number of HIV diagnoses annually (Van Sighem et al., 2012). The number of new diagnoses is still increasing in MSM of 55 years or older. A steady decline, though, is now seen in younger MSM and in patients infected through heterosexual contact, which is attributable to the reduction of immigration from HIV-endemic countries. Since several years, the contribution of injecting drug users to new HIV diagnoses is less than 1%.
"• In 2012, 843 new HIV diagnoses were reported in the treatment centres. In 4 men and 0 women injecting drug use was the most likely route of transmission (table 6.2.1) (Soetens et al., 2013).
"• Up to December 2012 a cumulative total of 20,528 HIV-infected individuals were registered by the treatment centres and the HIV Monitoring Foundation (Soetens et al., 2013). The percentage of patients infected with HIV through injecting drug use is 3.6 (737 patients). Up to 2000, 8% of all new HIV-diagnoses was associated with injecting drug use, but since 2000 this has declined sharply. The main route of HIV-transmission in the Netherlands is sexual: through MSM contact in 57% of cases and through heterosexual contact in 31%.
"• 72% of HIV-positive IDUs originated from the Netherlands and 23% from other Western European countries."

"Until 2001, AIDS cases meeting WHO criteria were registered in the national Information System on AIDS Statistics, maintained by the Health Care Inspectorate (IGZ). In 2002 this AIDS registration was replaced by the HIV/ AIDS registration of the SHM mentioned above. As the IGZ data appeared to be incomplete since 2000, the data below are based on the IGZ registration until 1999 and the SHM data from 2000 onwards. The year of AIDS diagnosis refers to the date of the first CDC-C diagnosis (classification C according to the Centres for Disease Control).
"• Up to December 2012, the cumulative total of reported AIDS diagnoses was 8,875 and 5,442 HIV infected individuals had died (Soetens et al., 2013). The annual number of new AIDS diagnoses peaked in the first half of the nineties (around 500 cases per year) and then gradually dropped, to 154 cases in 2012 (Soetens et al., 2013). The observed decrease since 1996 is related to the availability of HAART, which slowed progression from HIV to AIDS.
"• Of the 154 new AIDS diagnoses in 2012, 3 (1.9%) were among injecting drug users (table 6.2.2). In the same year, 131 AIDS patients died, among whom were 16 (12.2%) injecting drug users. Note that the data for 2012 are incomplete due to reporting delay (Soetens et al., 2013).
"• Up until December 2012, 720 registered AIDS patients (8.1% of the total AIDS diagnoses) belonged to the transmission risk group of injecting drug users. The number of diagnosed AIDS cases related to injecting drug use peaked in 1995 (74), but remained at or below 15 cases per year since 1999, with the exception of 2005 (24 cases).
"• Note that the percentage of IDUs among the total population of AIDS patients (8.1% over all years) is higher than the percentage of IDUs in the total population of HIV patients (3.6%), but that the percentage of IDUs among the AIDS deaths is even higher: 11% or over in the last decade (except for 9.4% in 2011). This indicates that the disease course in injecting drug users is less favourable than in other risk groups."

"• The PIENTER-2 study found a weighted national HCV seroprevalence of 0.30% (95% CI 0.05-0.55%) (Vriend et al., 2012).
"• The study described that most HCV-positive persons (70%) were born in a HCV endemic country. Eight of the 6386 participating individuals reported having injected drugs and three of eight ever injectors were HCV-positive. However, the study concludes that 'limited information was obtained on the HCV prevalence among high-risk groups like IDU and HIV-positive MSM. Despite the high number of total participants, the number of HIV-positive MSM and of participants reporting IDU was very small. Moreover, information on (former) IDU and HIV status was missing in 3-10% of the total study population. A possible underrepresentation of these groups could have resulted in an underestimation of the national HCV seroprevalence.' (Vriend et al., 2012)
"• Based on the HCV prevalence from the PIENTER studies and recent HCV data from specific risk groups (migrants, MSM and IDUs), a new HCV estimation was made using mathematical modelling, which took into account the changes in HCV dynamics in several risk groups (lower numbers of HCV infection in the “usual” HCV risk groups: IDUs and haemophilia patients; and more acute HCV infections in MSM) (Vriend et al., 2013). The estimated national HCV seroprevalence was 0.22% (min 0.07%; max 0.37%), equivalent to 28,100 HCV infected individuals (min n=9,600; max n= 48,000)."

"Between 1996 and 2012, the total number of recorded drug-related deaths among residents fluctuated between a minimum of only 94 cases in 2010 and a maximum of 144 cases in 2001.
"Despite some fluctuations over the years, the total number of drug-related deaths in the Netherlands has remained relatively low. This might be explained by a low number of socially marginalized problem drug users, successful harm reduction measures among the problem drug users, and protective factors, such as the nationwide availability of methadone-maintenance treatment, heroin-assisted treatment, and a low rate of intravenous drug use.
"Opiates and cocaine
"Cases of 'opiates' and 'cocaine' refer to cases in which these substances were explicitly stated as the primary cause of death on the death certificate. From 1996 up to including 2001, opiate intoxications were the most common causes of drug-related death recorded among Dutch residents. In this period, the casualty rate fluctuated between 81 and 75 cases. In 2002, the number of opiate deaths decreased and reached about the same level as the number of acute cocaine deaths, which had slowly increased since the late nineties. Since 2003 these trends have diverged again and each year there were more opiates deaths than cocaine deaths. However, in 2012 the number of opiate cases (28) came close again to the number of cocaine cases (22).
"Psychostimulants
"In 2012, there were only 3 cases that were coded to poisoning by psychostimulants (other than cocaine), compared to just four cases in 2009, two cases in 2008 and 2011, and only one case in 2007 and 2010. Whether these fatal intoxications concerned amphetamines, MDMA, or other psychostimulants is not known."

Treatment

"There are no major changes in the substitution treatment in the Netherlands. Methadone substitution treatment is still the standard option. From 2001 to 2010, the number of methadone clients decreased with 13% from 11,597 to 10,085 clients (Ouwehand et al. 2011). However, the proportion of opiates clients receiving methadone treatment increased in this period from 69% to 82%. Buprenorphine is used in one organization of addiction care and elsewhere incidentally."

"In 2012 there are still 740 treatment places for medical heroin prescription operational at 18 units in 16 different municipalities (Regulation Heroin Treatment). Since 15 October 2009 heroin (diamorphine) can be prescribed by physicians working at municipal treatment units for treatment resistant heroin addicts to addicts who are registered at that units. For this reason the Opium Act Decision was complemented with Appendix 2 (Stb 2009-348). Medical heroin prescription is legal on the condition that strict requirements are met. A 4-year follow-up study concluded that the physical and psychological condition of the patients who received heroin treatment was far better and they caused much less public nuisance than the heroin users who withdrew from the treatment (Blanken et al. 2010)."

Harm Reduction

"Estimates from Mainline (a grassroots organisation for drug users in Amsterdam) and the Trimbos Institute suggest that there are approximately 150 needle/syringe exchange programs in the Netherlands. This is a rough estimate because for some cities it has been reported that pharmacists are also exchanging syringes. There are also reports of merging of several sites as well as closure, which may cut down the estimated number, however, new estimates are not available. In Amsterdam and Rotterdam trend data on the numbers of syringes that were exchanged are available from the municipal health services. In both cities, a decreasing trend in the number of exchanged syringes is observed since many years (see figure 7.3.1). The small and unexplained increase observed in 2008 was not continued afterwards."

"• In Amsterdam, figures are available since 1990. After a steady increase until 1993 (1,082,880 syringes were exchanged in that year), the number of exchanged syringes declined and slightly fluctuates below 200,000 syringes per year since 2007 (146,000 in 2012) (source: M. Buster, GGD Amsterdam).
"• In Rotterdam, figures are available since 2000. The number of syringes ordered by the local distribution centres was reduced between 2000 and 2012 from 422,400 to 91,400 (source: R.A. Wolter, GGD Rotterdam). Data for 2011 are not available due to a change in the registration system. It is noteworthy that in Rotterdam during evening and nightly hours drug users can exchange needles and syringes at several police stations.
"• The decline during many years in the number of syringes exchanged can be explained by several factors: a reduction of injecting heroin users in general; a reduction of drug users, often injectors, from neighbouring countries; a reduced popularity of injecting resulting from experienced health problems, in combination with an increase in the use of crack; and mortality among injectors. It is assumed that the far majority of drug users in need of clean needles are being reached with the current efforts.
"• The municipal health service of Rotterdam also collects information on the distribution of other (clean) paraphernalia and condoms. In 2012, they distributed 25,000 condoms, 900 pocket containers (for needle and syringe disposal) and 10,550 stericups. Based on the assumption that the average drug users exchanges 10 syringes a week, this comes to a total of 176 injecting drug users reached (and probably present) in Rotterdam, a steady decline from the estimated 812 injecting drug users in 2000 (source: R.A. Wolter, GGD Rotterdam)."

"The first formal drug consumption room in the Netherlands opened in 1994 and since the beginning of this century the number has rapidly increased. An inventory in 2010 among a network of infectious disease experts in all addiction care institutions in the Netherlands identified 37 drug consumption rooms, located in over 25 cities in the Netherlands (Havinga and Van der Poel 2012). In the last decade, due to several developments, the organisation of these locations and the population using them changed. A major impact has had the decrease in homeless drug users. The majority of them is now living in social housing projects, which has reduced drug use on the street and the associated nuisance, including that of drugs dealing. Another important factor has been the decrease in injecting drug use, which further reduced the population using the drug consumption rooms. While in 2003 the average number of visitors per drug consumption room was 36, this has decreased to 22 in 2010 (Havinga and Van der Poel 2012). Since 2010, the number of drug consumption rooms has further decreased, but there is no new overview of the current number. Personal communications point to a shift towards an organisation of the consumption rooms more based on security and less on medical support. An increasing number of consumption rooms have an entrance guarded by security personal behind a glass wall, with whom it is not easy to discuss medical problems. For further information on the organisation of drug consumption rooms: see our National Report 2012."

"Twenty years ago the Ministry of Health, Welfare, and Sport (VWS) founded the Drugs Information and Monitoring System (DIMS). The DIMS explores the chemical content of drugs, the health risks, and monitors trends. The drugs are collected by means of those users who bring their drugs for control to an organisation affiliated with the DIMS. These organisations have weekly office hours. This method of collecting drugs brings along the possibility to exchange information between the personnel at the testing facilities and the users. The user is informed about the composition of the delivered drugs and is warned about the risks. The data that are collected this way are used for education, prevention, and drug policy. Next to this, the data are used to inform the network of organisations participating in the DIMS.
"Acute health risks for users can occur, for example in case extra harmful substances are detected in the drugs. In case of such acute health risks, the DIMS will start a national or a regional warning campaign, a Red Alert. In 2011, the DIMS warned two times at a national level. The first national warning targeted the risks of using ecstasy pills contaminated with PMMA [Para-Methoxymethamphetamine], and the second national warning targeted pills with a high dose of MDMA. During the first six months of 2012, about 4,000 people visited the consulting hours of the DIMS-facilities, about 160 people every week. In total 4,421 samples were delivered, about 176 samples weekly (DIMS 2012) (see also § 10.3).
"At the request of the present Cabinet, the DIMS has increased its tasks with regard to the "Reporting Desk New Drugs" (Meldpunt Nieuwe Drugs, MND). The MND monitors the new psychoactive drugs which appear frequently on the market, like mephedrone, 4-MEC, or MDPV. These new drugs raise questions about who are the users and about the (health) risks. At a special website (www.meldpuntnd.nl/) the users can report new drugs anonymously and eventually can describe their experiences with these drugs."

Economics

"Moolenaar, Nauta, and Van Tulder (2013) report on expenditures for prevention, investigation, prosecution, sentencing and support of offenders of different types of offences in 2011. The types of offences are categorized on the basis of the most serious offence. Opium Act offences are one of the categories, differentiated according to Schedule I drug offences (hard drugs) and Schedule II drug offences (soft drugs) (table 9.1.6). Figures for 2011 are preliminary.
"• Expenditures for Opium Act offences in 2011 are estimated at € 395,0 million (in nominal amounts), of which € 287,9 million is spent on hard drugs and € 107,2 million on soft drugs.
"• Expenditures for Opium Act offences account for 3.1% of the total of expenditures for all offences. Of all 8 types of offences, Opium Act offences rank seventh in amount of expenditures (see table 9.1.7).
"• € 8,3 million is used for prevention activities, € 81,8 million for investigation, € 44,6 million for prosecution, € 16,0 million for sentencing, € 205,3 million for the execution of sentences, and € 38,9 million for support of offenders and other kinds of support and activities (not in table).
"• Soft drugs expenditures are highest in the stage of prevention and investigation, but hard drugs are higher in all the other activities (not in table). From all drug expenditures, the execution of sentences for hard drug offences rank highest (its estimated costs are € 175,3 million)."

"In the Netherlands, an institute for addiction care and/or mental health care is financed in a complex way by several sources. As a rule, regular institutes receive their funding from the Ministry of Health, Welfare, and Sport; the Ministry of Social Affairs and Employment; the Ministry of Security and Justice; the provinces; the municipalities; the health insurance companies; additional temporary funds; and some private funding.
"Table 1.3.1 gives an overview of the expenditures of the institutes during the fiscal years 2010 and 2011. From this table it can be estimated that the annual expenditures of the main regular institutes for addiction care, together with the institutes for integrated addiction care and mental health care, in 2010 amounted to 1,545,241,886 euro, which increased with 4.4% to a total of 1,612,533,820 euro in 2011. Given a general inflation of 2.3% in 2011 (www.cbs.nl), this implies a real net increase of the expenditures by 2%. Unfortunately, it is not directly clear which part of the amounts is spent on treating addiction, let alone drug addiction, and which amount is still missing from the non-merged mental health care.
"With regard to the annual growth of the mental health care (including the addiction care), the Minister of Health, Welfare, and Sport in June 2012 signed an agreement with the mental health care that in 2013 and 2014 the annual growth will be reduced from 5% to 2.5% (www.psy.nl, 18-06-2012)."

"Differences in cannabis smoking behaviour may also represent different risks for cannabis dependence independently of total THC exposure. Similar to cigarette smokers [16,21–24], cannabis smokers typically gradually decrease the puff volume and puff duration during the course of one joint, whereas puff velocity and interpuff interval gradually increase [20]. Interestingly, in a 2-year prospective study, nicotine dependence has been shown to develop more rapidly in tobacco smokers who smoke with stable or increasing puff volume and increasing puff duration ('atypical' smoking) [16]. One interpretation of this finding is that the risk of becoming nicotine-dependent is lower in smokers who reach nicotine saturation before the cigarette is finished and decrease their pace of smoking. If this mechanism also applies to cannabis smoking, one may expect that the risk for and the severity of cannabis dependence is associated with 'atypical' cannabis smoking."

"This study among 98 experienced cannabis smokers is the first naturalistic study to examine whether users of cannabis with high THC concentration titrate the psychoactive effects by using lower doses and/or by reduced inhalation, and whether cannabis smoking behaviour (topography) predicts cannabis dependence severity independently of total THC exposure.
"In contrast to our hypothesis, there was a positive association between cannabis THC concentration and cannabis dose, indicating that users of stronger cannabis generally used larger amounts of cannabis to prepare their regular joint. However, in line with our hypothesis, the negative association between THC concentration of joints and total inhaled smoke volume indicates that users of stronger joints inhaled smaller smoke volumes, thus resulting in partial titration of the total THC exposure. Overall, as exemplified by the comparison of the average user with the user with the maximum THC concentration, users of high-potency cannabis will generally be exposed to higher total doses of THC (at least in this sample). This is in line with Cappell et al.’s observations through a one-way mirror experiment in 1973 where users only partly adapted their intake [14]. Indeed, increased THC concentrations of cannabis have recently been linked to increased internal THC exposure assessed in blood [28]."

"Although experienced young adult cannabis users with a preference for stronger joints titrated their THC exposure to some extent by inhaling less smoke, in general more potent cannabis was used in higher dosages leading to a higher THC exposure compared to users preferring lower potency cannabis. None the less, in our population of frequent cannabis users, total THC exposure was only a weak predictor of dependence severity, and did not remain significant after adjustment for baseline dependence severity. However, cannabis smoking behaviours predicted cannabis dependence severity independently of baseline THC exposure and baseline cannabis dependence severity. As the amount of explained variance was low, due possibly to the multifactorial aetiology of dependence, future studies should include other predictors, such as genetic variations, early traumatic experiences and — most importantly — time-dependent variables representing the dynamic nature of personal and dependence development. Meanwhile, smoking variables, such as smoking topography and completely finishing high-dose/high-potent joints in one smoking session, may be helpful to identify people at risk of escalating cannabis dependence severity."

"The Dutch harm reduction policy postulates a distinction between drugs with acceptable and unacceptable health risks. This policy is
laid down in the so-called ‘Opium Act’. The Opium Act of 1976 regulates the status of a large number of substances. The law has a dual listing of substances it declares as ‘illicit’ for use, production or distribution. Schedule I contains all the substance drugs with ‘unacceptable risks’ (including hash oil). Schedule II was created for cannabis products such as hashish and marijuana. Both categories are illicit, but priority for criminal investigation and prosecution is given to the first. Maximum penalties for trafficking drugs with ‘unacceptable risks’ were raised in 1976, and penalties for possession of cannabis for personal use in amounts up to 30 grams were lowered, with possession constituting a misdemeanour (Korf, 1995). In October 1996 this amount was revised to 5 grams for personal use, and 500 grams for coffee shop owners. At the same time, magic mushrooms were added to Schedule II. (Public Prosecution Service, regarding guidelines for criminal offences against the Opium Act¹).

"Hashish and marihuana (cannabis) are drugs with acceptable risks and their sale is tolerated in coffee shops. Conditions are laid down by the government as well as by local policy-makers. Coffee shop owners can possess up to 500 grams. If they have more in stock or if they do not obey other regulations, the local police may intervene, depending on the nuisance caused and the local policy. The government has drawn up directives, which coffee shops have to follow in order to be tolerated. These rules are the Ahojg directives. They stand for: No advertising (A); No sale of hard drugs (although ‘hard drugs’ is not an official term, it is mentioned in the directives, referring to Schedule I drugs) (H); No nuisance (O); No sale of drugs to youths under 18 years of age and no admission of youths to coffee shops (J); No sale of large quantities (max 5 grams per transaction) (G)."

"All recent policy documents state that the Dutch drug policy has two cornerstones - and this was confirmed by the Minister of Health, Welfare and Sport during the major drug debate in the House of Representatives in March 2012: to protect public health and to combat public nuisance and drug-related crime (TK 24077-259; TK Handelingen 69-28 maart 2012). In the current Opium Act Directive the objective of the drug policy is described as: 'The [new] Dutch drugs policy is aimed to discourage and reduce drug use, certainly in so far as it causes damage to health and to society, and to prevent and reduce the damage associated with drug use, drug production and the drugs trade' (Stc 2012-26938)."

"The most important act with regard to drug law offences is the Opium Act, which defines the trafficking, production, cultivation, dealing and possession of illegal drugs as criminal acts, when these activities take place outside of the conditions mentioned in the Opium Act Decision and the Regulation Opium Act Exemptions. The drugs in question are named in schedule I (‘hard drugs’ like heroin, cocaine, amphetamines or ecstasy) and schedule II (‘soft drugs’ like cannabis or hallucinogenic mushrooms) of the Opium Act. The possession of drugs is a criminal act and therefore theoretically the use of drugs may be a criminal act as well. This reasoning was part of a verdict of the Council of State (Raad van State 201009884/I/H3 2011). The Prosecutor, however will never prosecute consumption of drugs per se.
"Preparative activities for the illegal production, sale or export of hard drugs are also criminal acts according to the Opium Act (article 10a). These imply also possession of substances which are meant to be used for the illegal production of hard drugs (see for instance LJN: BW8614 2012).
"The Prevention of Abuse of Chemicals Act is also of importance for the combat of drug-related crime, especially with regard to precursors of synthetic drugs. In addition, administrative law plays an increasing role in the combat of drug-related crime on the local and regional level."

"Police and Public Prosecutor give low priority to the investigation of possession of small amounts of a drug for own use. The Opium Act Directive of the Public Prosecutor state that, if the offence concerns possession of small amounts for own use of a hard drug, the drugs will be seized, but normally there will be no custody or prosecution. Diversion to care is the primary aim of custody or prosecution in cases of possession of hard drugs (Directive Opium Act 2011A021 2012, www.om.nl). ‘Small amounts’ of a hard drug are defined as one tablet, ample, wrapple or ball of the drug and in any case an amount of no more than 0,5 grams. With regards to cannabis (categorized as ‘soft drug’) small amounts are defined as no more than 5 grams and no more than 5 cannabis plants – under the condition that there is no professional or commercial cultivation of the plants (Stc. 2011 – 22936). For hallucinogenic mushrooms, also categorized as soft drugs, the small amounts for own use are defined as 0,5 grams (dried mushrooms) and 5 grams (fresh ones). In cases of possession of small amounts of soft drugs, the drugs will be seized but a dismissal by the police will normally (‘in principle’) follow, without custody or prosecution."

"Dutch coffee shop policy became more restrictive on 1 January 2012. Two new criteria coffee shops must adhere to in order for them to be tolerated were added to the Opium Act Directive for the Public Prosecutor: the private club [B] criterion and the residence [I] criterion. The new criteria were formally enforced in the three southern provinces of Limburg, Noord-Brabant and Zeeland between 1 May 2012 and 19 November 2012.

"The B-criterion stipulated that coffee shops could only permit access to, and sell to, registered coffee shop members. The members had to be documented in a verifiable membership list. The I-criterion stipulated that only residents of the Netherlands would be allowed to become coffee shop members and hence to enter the Dutch coffee shops. These criteria were an addition to the existing AHOJG-drug tolerance criteria for coffee shops ([A] no advertising, [H] no hard drugs, [O] no nuisance, [J] no minors and [G] sale and stock of only limited quantities of cannabis in the coffee shop, which were already part of the Opium Act Directive. The new criteria were intended to counter nuisance and (organized) crime related to coffee shops and the trade in narcotics, to reduce the attraction of the Dutch drug policy on users from abroad and to make an end to the previous ‘open-door-policy’ of the coffee shops, making them smaller and more manageable."

"Considerable changes have taken place on the cannabis consumer market in the south of the Netherlands between 1 May (the start of the enforcement of the B- and I-criteria) and October-November 2012:
"• Drug tourists mostly disappeared.
"• The number of visits to coffee shops decreased drastically (Nijkamp & Bieleman, 2013).
"• Cannabis users were purchasing their cannabis on the illegal market significantly more often. The cannabis users in the sample of the street survey purchased their cannabis less often from coffee shops and more often from mobile phone dealers, dealers selling from the street or buildings other than coffee shops and from or through friends (Korf, Benschop & Wouters, 2013).
"• The degree and frequency of the nuisance experienced by people living in the direct vicinity of coffee shops changed little, but there was a shift in the nature of the nuisance. Prior to 1 May 2012, local residents attributed the nuisance they experienced mostly to the coffee shops. After six months, the nature had shifted to nuisance due to drug dealing on the streets (Snippe & Bieleman, 2013). These changes became apparent quickly in the southern provinces after the implementation of the new criteria, but were not observed in the comparison group."

"The Bureau Medicinal Cannabis (BMC) only delivers the raw material, there is still no official 'cannabis medication' produced and registered by a pharmaceutical company. The BMC could be exploited cost-effective in 2010. In 2010, 102 kilograms of medicinal cannabis were delivered to pharmacies and it is estimated that about 558 patients were using it with an average of 0.5 gram per day per each person. Some Dutch health insurance companies reimburse medicinal cannabis in certain circumstances (TK Aanhangsel-2461). According to the Dutch Foundation for Pharmaceutical Statistics was medicinal cannabis in 2010 6,700 times supplied to 1,300 different patients. Every year there is an increase of about 10 per cent.²"

"According to a European study, the prevalence in the Netherlands of the use of alcohol by car drivers is 2.2%, compared to 3.5% average in Europe. The use of cannabis by car drivers (1.7%) is above the European average of 1.3% (SWOV factsheet 2011). According to the Road Traffic Act it is forbidden to drive under the influence of a (illegal) substance affecting one's driving ability. The Ministers of Security and Justice and Transport are preparing a bill to change this Act in order to be better able to detect these drivers. Part of the bill is to give police investigators the authority to use an oral fluid screener as pre-selection method to detect drug use of traffic participants. The legal evidence will remain a blood test. The use of GHB is only detectable with a blood test. Like with driving under the influence of alcohol, threshold values will be defined for driving under the influence of drugs (e.g. 50 microgram per litre for amphetamine and cocaine and 3 microgram per litre for THC). A special commission has proposed limiting blood values per drug in accordance with international practices. Because some substances are occurring in the body and measuring instruments are not sensitive enough, zero limits are not feasible. The present bill uses behaviour-related limits, meaning that a limit is set above which driving skills are affected. There are fewer traffic casualties due to the use of drugs and medicines than to alcohol consumption (T.K. 29398-236; T.K. 32859-3; TK32859-7)."

"In the city of Venlo (province of Limburg), on the Dutch-German border, the Hektor Project to combat drug-related crime and nuisance at the local level, started in 2001 and was extended several times, first by a combined contribution of the central and municipal government, but since 2010 Hektor is only financed by the local government. Its purpose was to diminish public nuisance mostly caused by German drug tourists. The project operated on three levels. One level aimed at diminishing public nuisance by tracking down and closing non-tolerated points of sale (administrative enforcement) and step up action against drug-related crime. The second level had to do with the redevelopment of parts of the city centre to make it more attractive to new investment. The third level of the project concentrated on redefining the local coffee shop policy. In 2007 three illegal drug trade venues were closed. The experienced drug related nuisance diminished significantly in the centre of the town since two coffee shops were relocated in 2005. Because the illegal drug trade shifted to other parts of the town, it was decided in 2007 to extend the Hektor-approach to all parts of the town of Venlo. The municipal authorities, the police, the Public Prosecution Service and the Tax and Customs are cooperating to tackle illegal drug trade and public nuisance caused by drug tourists. According to the third evaluation of the Hektor project, which was carried out before the introduction of new Dutch coffee shop policy, it is possible to diminish illegal street trade and drug related public nuisance in a Dutch border town by the approach chosen in Hektor (Snippe 2012).
"Another project to combat drug related nuisance, which started as a pilot project but was continued since 2003, is the Courage Project of the municipalities of Roosendaal and Bergen op Zoom near the border with Belgium in the province of North Brabant. One of the results of this project was that the mayors of both municipalities decided in September 2009 to close down the four tolerated coffee shops. However, the Courage Project was continued among others with a monitor called the Drugsscan, in order to follow the developments. Since the closure of the coffee shops 95 per cent of the drug tourists disappeared from the street scene. The Courage Team shifted the emphasis from drug related public nuisance to investigating drug related criminality. In 2011 narcotics for the amount of 7 million euro were confiscated and dispossessions for the amount of 600,000 euro were collected (Courage 2012; www.courage.nu)."

"There is no evidence that the depenalization component of the 1976 policy, per se, increased levels of cannabis use. On the other hand, the later growth in commercial access to cannabis, after de facto legalization, was accompanied by steep increases in use, even among youth. In interpreting that association, three points deserve emphasis. First, the association may not be causal; we have already seen that recent increases occurred in the United States and Oslo despite very different policies. Second, throughout most of the first two decades of the 1976 policy, Dutch use levels have remained at or below those in the United States. And third, it remains to be seen whether prevalence levels will drop again in response to the reduction to a 5-g limit, and to recent government efforts to close down coffee shops and more aggressively enforce the regulations."

"According to a survey of 400 physicians, both general practitioners and specialists in the Netherlands, which was performed just before the legal introduction of medicinal cannabis, only 6% said that they were under no condition willing to prescribe medicinal cannabis, while 60% to 70% regarded medicinal cannabis sufficiently socially accepted and would prescribe it if asked for by a patient.⁴⁶"

"Recently, a survey performed on 200 patients who were using medicinal cannabis during the first months after its introduction in the Netherlands was published.⁴⁹ The survey showed that most of the respondents had previous experiences with cannabis use for medicinal purposes or with synthetic cannabinoids such as dronabinol, whereas a minority of 40% were “new” users. Most patients were satisfied using medicinal cannabis; only 10% of patients reported moderate to more severe transitory adverse effects. In about half of the users, the patients themselves took the initiative to suggest medicinal cannabis to their treating physicians as a therapeutic option, whereas in about 30% of users the initiative was taken by the involved general practitioner or medical specialist. In the remaining 20% of users, it was a joint initiative of both patient and clinician."