Cohen, Peter (1998), Parte la distribuzione di eroina in Olanda: Il caso del pastore Visser di Rotterdam. Il Manifesto, Fuoriluogo, 27-1-1998.
Copyright © 1998 Peter Cohen. All rights reserved.


Heroin maintenance in the Netherlands

The case of the Rev. Visser in Rotterdam

Peter Cohen

In June 1995 the highest Health Advice Council of the Dutch government wrote to the Minister of Health that it would be a good idea if the Netherlands would try to design an experimental heroin maintenance system. The Health Council was responding to a government request made in early 1994 during the former Christian Democratic government of Prime Minister Lubbers.

The Health Council recommended that Mrs Borst, Minister of Health, should nominate a commission that would design a medical heroin experiment.

Following upon the Health Council's letter, the Minister presented the advice to Parliament. In the discussions that ensued, Parliament agreed with the need for further study and went along with the ideas of the Minister. As a result, in December 1996 the Minister of Health created the "Central Commission for Treatment of Heroin Addicts" (CCBH) under the chairmanship of Prof. van Ree, a pharmacologist at the Medical School of Utrecht. In July 1997 the Commission produced a highly detailed design for an experiment consisting of three groups and a total of 750 persons distributed over 8 or 9 different cities.

When the Health Minister followed up her promise to discuss the details of the proposed heroin maintenance plan with Parliament, the religious and Christian parties — none of whom are represented in the present government — voiced strong opposition to the principle of heroin maintenance. They expressed the view that the great evil of drug use dictated that the State should take no part whatever in providing drugs to heavy users. Strangely enough, their arguments were quickly forgotten in the discussions that followed the CCBH plan. But there was yet more opposition to follow.

The Free Market Liberals in Parliament, part of the present centre-left government, feared that the size of the proposed experiment of 750 subjects might overwhelm the ability of the Dutch treatment organisations to handle the resulting problems if the experiment went badly. They also feared that such a large experiment could not be stopped if it encountered serious problems. Their opposition to the plan monopolised the discussions, but they offered approval for an experiment if it were no larger than 50 persons. The opposition of the Free Marketers looked very much like a strategy for attracting votes in the upcoming general elections of 1998.

A conflict then arose in Parliament as the Minister of Health countered the Free Marketers in saying that there was no evidence whatsoever for the claims of the liberals, and she refused to give the green light for the proposed smaller experiment. She would either make a serious and very well documented experiment, or none at all. Finally, the Minister perceived the necessity to strike a deal with the Free Marketers. First she would undertake a pilot experiment with 50 persons only, 25 in Rotterdam and 25 in Amsterdam. If all went well, she would then get the permission of a Parliamentary majority to continue with the original proposal of 750 persons. It was agreed that the pilot experiment of 50 people will start in May 1998.

The following paragraphs describe some details of the plans of the CCBH as published in its July 1997 report. The inclusion criteria to participate in the experiment are 12 in total, of which the most important are that the person is at least 25 years old and still a daily or almost daily heroin user, has a five year career (or more) of heavy heroin use, and has been using methadone for at least 5 years as well. If those conditions are met, and the person is not in a good physical or mental condition and has a score of more than 5 on the ASI scale (Addiction Severity Index), the person will be allowed into the experiment.

The most important of the 15 exclusion criteria are that a person does not fulfil the inclusion criteria, that the person has problems that are contraindications for heroin use or has such severe mental, medical or psychosocial problems that participation in the experiment might be disturbing, and has levels of drug use that are higher than 1000 mg of heroin or 150 mg of methadone per day.

The experiment will have a duration of 14 months, and it will follow three randomly created groups of clients that will be compared. All 3 groups, (A, B and C), will start with 2 months of oral methadone alone, in the dosages that are most used in the Netherlands. The maximum dosage of methadone in the experiment will be 150 mg per day. Group A will receive only methadone during the next 12 months. After the initial 2 month period, group B will receive a combination of oral methadone and heroin for 12 months. Group C will receive 6 months of oral methadone after the initial 2 months, and a combination of methadone and heroin for the last 6 months. Maximum dosage of heroin will be 1000 mg per day, and the offered heroin will be smokeable for heroin smokers, and in injectable form for intravenous users.

The smokeable heroin will have to be made in the Netherlands. In the Netherlands approximately 60% of heavy users smoke heroin from a piece of aluminium foil, and about 16% inject the drug. The remaining group shifts the method of use between smoking and injecting.

In October 1997 some turmoil was caused by a Rotterdam-based priest who is a well known figure in the Dutch treatment system. The Reverend Visser has given over his large church in Rotterdam during the day to a group of heavy drug users who are homeless, or who are too ill to buy drugs on the local street market. In his church he created space where a small group of heroin and cocaine dealers can sell drugs of good quality to the drug users present in the in church. Visser discusses price and quality with these dealers, who are actually respected in his community, considered as responsible people and not treated as criminals. I myself have met these dealers several times, and they are well aware of the fact that Visser makes the rules, not them.

When the Rev. Visser heard about the CCBH plan and all the problems his Christian colleagues had made in Parliament, he announced he would start a heroin experiment on his own. He feared the discussions in Parliament would destroy the experiment, and also that the experiment was open to too few people. Of course the Minister of Justice and the Minister of Health both said that any experiments by the Rev. Visser which competed with the CCBH plan would be suppressed.

I would like to finish this overview with some of my own comments.

I think that the Dutch are doing well in making medical heroin maintenance one of the possible options in treatment.

However, the importance of having this option in the Netherlands should not be exaggerated. It may well be less important than for countries like Switzerland or Italy. In the Netherlands the availability of methadone is extensive and well diffused, so most of the opiate users -- about 26,000 -- have access to some form of methadone maintenance. We need heroin for those few people who are not attracted to this form of maintenance, or who react badly to it. In all types of medicine we see that for a given problem different strategies of medication are available for different types of patients. This principle should be no different for treatment of drug users. Also, we should be very careful that the availability of heroin maintenance will not be the straw-argument behind which much stronger law enforcement will be hidden. Our aim should be to design so many good alternatives to law enforcement that we can start moving drug use out of the sphere of penal law altogether.