The Dutch Harm Reduction Model of Addiction Treatment
Jana Slovic, Jenny Sager, Jonathan Karademos
Harm reduction focuses on minimizing harmful consequences of drug use for the user and for society. It consists of various levels of control ranging from government policies to services such as needle exchanges and free heroin. Overcoming addiction is incredibly difficult and harm reduction works to keep addicts healthy until they are able to get clean. However, many oppose harm reduction because of the ethical issue of simply regulating their usage or by putting addicts on “less dangerous” drugs instead of actually treating their addiction. We would like to explore the Dutch harm reduction model, and then through a series of interviews, find out whether the efforts to control the population of users gets in the way of actual treatment.
Does the Dutch harm reduction model of addiction care allow for adequate treatment for everyone?
"The Dutch being sober and pragmatic people, they opt for rather a realistic and practical approach to the drug problem than for a moralistic or over dramatized one. The drug abuse problem should not be primarily seen as a social problem of police and justice. It is essentially a matter of health and social well being." -E.M. Englesman (1989) Dutch sociologist.
Harm Reduction Methods arose in the Netherlands in the 1970's as a response to growing drug problems. Out of fear that cracking down on drug use would only drive it underground where quality and price of drugs could be dangerous to both users and society, the government took a different approach. This approach involved the new concept of "Harm Reduction" instead of the zero-tolerance approach to drug use that had previously been in place. The reality of drug use was recognized, and in efforts to protect the well-being of users and the public, a system was set up that tolerated regulated drug use. This included the start of the first needle exchange programs, and efforts to help drug users find stability in their lives instead of criminalizing them. As time progressed, changes in policy advanced the development of the harm reduction system.
- 1972: Narcotics Working Party called for drug policy based on the risk level of each specific narcotic
- 1976: Dutch Opium Act made a distinction between soft drugs (marijuana and hashish) and hard, or high risk drugs. This paved the way for the separation of the soft and hard drug markets.
- 1981: “Harm Reduction” is defined, providing a basis for the current Dutch harm reduction model. It stated that the government’s first efforts would not necessarily be to punish or end addiction, but rather to improve the health and well-being of the addict in efforts to “help them to function in society” (Marlatt, 32)
- 1985: Normalization Policy
With the growing spread of AIDS in the 1980's, many countries around the world adopted some of the idealogies of the Dutch harm reduction model. Government regulation of safe usage of intraveinous drugs became the main method of reducing the spread of HIV within the user population. These methods included needle exchanges, educational programs, and in some countries like Britain, the medical prescription of heroin.
Over the past 20 years, great increases in substance based programs grounded in the principles of harm reduction have greatly altered the range of treatment services available to the population of drug users in the Netherlands. The treatment system in the Netherlands has expanded from a zero tolerance model to a multi-option approach, ranging from programs such as methadone maintenance to programs such as drug-free therapy.
Harm Reduction is a complex concept, and thus there have been several attempts to define the main prinicples. Below are two examples:
Principles of Harm Reduction (Copyright 1996 by the Harm Reduction Coalition, pg.3-5):
- 1.) Accepts, for better or for worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore and condemn them.
- 2.) Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them, and both affirms and seeks to strengthen that capacity of people who use drugs to reduce the various harms associated with their drug use.
- 3.) Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
- 4.) Establishes quality of individual and community life and well-being – not necessarily cessation of all drug use – as the criteria for successful interventions and policies.
- 5.) Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harms.
- 6.) Recognizes that the realities of poverty, class, racism, social isolations, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harms.
- 7.) Does not attempt to minimize or ignore the many real and tragic harms and dangers association with licit and illicit drug use.
Harm Reduction Principles:
- 1.) Abstinence should not be the only object of services to drug users, because it excludes a large proportion of people who are committed to long-term drug use.
- 2.) Abstinence from drug use should be the final goal in a series of harm reduction objectives designed to reduce harmful consequences.
- 3.) Harm reduction programs should offer user-friendly services to attract and make contact with drug users, and to empower them to change their behavior and develop suitable intermediate objectives for change.
- 4.) Harm reduction should be multidisciplinary and should include health care providers, police, drug treatment and prevention workers, and others who work with drug users.
- 5.) Harm reduction should include four areas of service: treatment, care, control and education.
Context: With the three of us being science majors, looking at a health issue was of great interest. There are many health issues that we looked at, including immigrant health care, elderly care and drug addiction treatment. After researching all of these topics on some level, drug addiction treatment stood out the most due to its deviance from what we were familiar with in the United States. In the U.S., zero-tolerance 12 step programs are common, and while there are needle exchanges and methadone clinics, the existence of such programs is not based on harm reduction. Furthermore, in the United States, drug addiction is often presented as a moral problem instead of a health problem. In the Netherlands, addiction is thought to be a health problem, so drug addiction treatment is covered by basic health insurance. Because of these differences, we were interested in learning more about the harm reduction model of addiction care and looking at how it works, who it reaches, and what the limitations are.
- GGD Website (Municipal Health Service, Amsterdam Branch)- Government statement and view on drug addiction treatment. States goals and policies relating to treatment options for addicts in Amsterdam who are legal and working citizens with health care.
- Jellenik Clinic Website: Manifesto and Aim of Government Endorsed Clinic. This site listed the various treatment options available, medications used, and aftercare options. However, the sight was mostly in Dutch and the English version was heavily condensed.
- Smith and Jones Center: Goals and aims of the private 12- step clinic not included in the national healthcare system. The site outlines treatment options and goals, and also highlights the differences between the Smith and Jones and government sponsored clinics.
- Trimbos Institute: A wide variety of publications on drug policy and education/prevention programs.
- Jellinek Clinic (from Harm Reduction) - Over the past 20 years, there has been a great increase in low-threshold, or substance-based, programs based on the principles of harm reduction. Such programs have greatly altered the range of treatment services available to the Dutch population of drug users. The treatment system in the Netherlands has expanded from a mainly abstinence-oriented model to a multiple-option approach, which has treatments ranging from low-threshold (i.e. methadone maintenance) to high-threshold (i.e. drug-free therapeutic communities) programs, attempting to make treatments accessible to a majority of addicts.
- Smith and Jones Wild Horses Center - The first 12 Step based treatment center in the Netherlands. This center provides a different opinion on how drug addiction should be treated and will be a valuable asset to our research.
Problems: The largest problem that we had was narrowing down the topic. At first, we wanted to look at immigration, yet we were quickly overwhelmed by the amount of information present on this topic in both the US and the Netherlands. Knowing we needed to narrow the topic down, we chose to focus on immigration and the health care due to our backgrounds in microbiology and our interests in health care. Once again, we found that there was just too much information. So in narrowing down our topic once again we decided to focus on addiction treatment, and how immigrants go about learning of treatment options and gaining access to care. However, we were still faced with a lot of obstacles. Upon arriving in Amsterdam, our plan was to spend a week seeing how difficult it would be to find information about and/or locate treatment facilities as a non-dutch speaking individual unfamiliar with Amsterdam. It was indeed extremely hard, and when we met with Mirjam about our project we realized that we had hit a dead end and needed to go in a new direction. Because of the new immigration policies, every legal immigrant to the Netherlands speaks Dutch fairly well, so the language barrier we wished to explore in relation to seeking care proved to not be barrier at all. Then we learned that because addiction treatment falls under health care, everyone's care is paid for by health insurance. So the affordability aspect was not an issue either. So two weeks before our final presentation, we decide to change direction completely, and with Mirjam's help we were able to come up with a new and exciting topic: looking at the harm reduction model of addiction care. Yet even though we had collected a significant amount of information pertaining to addiction services and the Dutch health care system, we had been focusing on publications regarding immigrant issues so we had to gather new information.
After this realization, we went into a rapid data-gathering mode where we split up to gather as much information as possible in our new shortened time frame. Of course, more problems did occur. The Jellinek website: www.jellinek.nl, had very little information in English resulting in a large language barrier that required help from Mirjam to overcome. Another issue was obtaining an interview with a Jellinek representative. While we did have an interview scheduled with a representative of Jellinek, the interview ultimately fell through. In order to present our findings in the most effective way possible, we decided to construct a website for the final presentation. We faced problems with HTML coding when we attempted to embed our audio and video as well as in attempting to format the pages across a variety of servers.
The following was our proposed method before we had our topic change. We are keeping the old method in here in order to show our progression of thought, and because some of the methods still apply to our new project.
In order to complete our project, a few different methods must be employed. During the course of our time in the Netherlands, we will go through many days of “role play”, interviews, conducting surveys and doing internet research. Through extensive use of these three methods, we should be able to attain the information to answer our research question. Through role play, we will take on the role of an immigrant entering the Netherlands. Without speaking Dutch or knowing our way around, we will likely face problems simmilar to those immigrants face immigrants in learning about heroin addiction treatment options as well as accessing care. Through interviews we will be able to gain insight into how providers percieve the accessibility, affordability and availability of heroin addiction treatment to non-natives. We can then compare to opinions of patients that we obtain through surveys. Of course the internet will be our primary mode of contact with our sources as well as an important tool in researching any issues that become of interest to us along the way.
However, there are limitations to our methods. “Role playing” will give us an idea of the types of problems immigrants may face in trying to find treatment, yet this method also brings in our own personal backgrounds and skills that do not apply to the immigrant population as a whole. We do not speak Dutch while many immigrants have to learn at least a certain amount of Dutch in order to immigrate. We may not have navigation skills that are equal to an average individual. Also, we are not heroin addicts, and thus we do not belong to a community of individuals that may have experience with/ knowledge of treatment options and locations. Interviews also have limitations. Interviewing the directors of these clinics may be a problem due to the fact that August is a holiday month, and they may not be in Amsterdam at all. Also, we are coming into this project with our own biases, and we can only get as much out of an interview as we bring in, so if we stick to one narrow scope of questions we will only get one narrow scope of answers. It is important that in interviewing we try to address all viewpoints, and possibly ask questions a bit off topic in order to gain a greater understanding of the context of our research. Gaining access to patient opinons is extremely limiting because of doctor/patient confidentiality, the sensitivity of the topic of addiction, and legal issues surrounding heroin use. To overcome this, we have come up with the idea of an anonymous survey which would enable us to gain feedback from many patients regarding the ease of access, quality and affordability of care. Then there is the question of how to distribute the survey. Currently we are hoping that we can get in contact with clinics that will be willing the distribute the surveys to willing patients, but this may be overly optimistic. The biggest limitation with internet research comes with the language barrier. A lot of the clinic websites are in Dutch, and a lot of those seeking addiction treatment may not have internet access so it may not be the best tool to investigate quality and accessibility of care.
With all social research questions, it can be very hard not to show a bias in the research. A few biases that we are bringing to our project are that we assume that immigrants have problems accessing addiction treatment and that many immigrants do not have health insurance to compensate for the cost of treatment.
What follows is an updated method section which addresses our new research question.
The most beneficial part of this whole research experience has been to choose a topic, narrow it down, and then through the process of research, change it to focus in on answering the question our data was heading towards. Besides online and offline literature-based research, the bulk of our field data was gathered through in-depth interviews. The following individuals were willing to share their first hand experiences and expertise in the field of drug addiction treatment in the Netherlands:
- Keith Bakker, director and founder of Smith and Jones Clinic, which focuses on the abstinence-based “12 Step Minnesota model" of drug treatment.
- Government employed child psychologist who works with children who have been removed from their parents’ custody due to parental drug use. (Has chosen to remain anonymous)
- Self- indentified addict and ex-user, who was a former patient of Jellinek and current patient of Smith and Jones. (Has chosen to remain anonymous)
During the interview process, we came in with a few open-ended questions that we wanted to ask. These questions allowed for lengthy responses rather than a simple yes or no. As the interviews progressed, we asked unplanned questions pertaining to the interviewee's responses, yet we made sure to transition back to our planned questions eventually so as to get responses relevant to our research question. Though critical to our research, interviews were not without limitations. We recognize that information gathered during interviews is effected by assumptions held by both the interviewer and the interviewee. They do not present the experiences of an entire population, but instead only those of a single individual. Also, because we were only able to set up interviews with individuals critical of the harm reduction model, the information we gathered was one-sided.
In addition to these interviews, we were able to sit in on an “Open Group” meeting that was held at the Smith and Jones clinic. While identity of individuals that shared their experiences and thoughts with us will remain anonymous, their opinions and statements regarding the Dutch addiction treatment options will be considered in our findings.
Due to the fact that we were not able to interview an official Jellinek representative, internet research on the Jellinek website using a translator was essential to gaining an understanding of harm reduction from inside the system. Without Mirjam as a translator, we would not have been able to access a significant portion of information available on the site pertaining to the harm reduction system. However, even with Mirjam's help, it was impossible to have the entire website translated, so it is likely that valuable information was missed.
Further limitations in our project arose from our own personal biases and assumptions. Upon landing in Amsterdam, we we under the assumption that not every immigrant spoke Dutch and that the resulting language barrier would pose a problem in finding health care. This, however, is not the case since Dutch language profficiency is required for immigration to the Netherlands. We also assumed that affordabiity of addiction treatment may be an issue for those new to the country, yet we soon found that all legal, working people in the Netherlands are entitled to free health insurance, which covers addiction care. The realization that our original assumptions were false was the reason why we changed our research question. With respect to the harm reduction system, we brought with us the bias that the dutch system was ideal in that it found a way to accomodate everyone seeking treatment. This assumption was mostly based in our skeptical view of the American system and the resulting interest in a different way of approaching addiction care. Initially, these biases were present in our research questions, and it was not until our interviews with experts and meetings with Mirjam that we recognized their presence and adjusted our analysis accordingly.
- Hine, Christine. Virtual Methods and the Sociology of Cyber-Scientific Knowldege.
- Howard, Dr. Philip N. Organizing an In-Depth Interview.
- Lynch, Kevin. A Walk Around the Block.
- Van Maanen. In the Field: On Writing Ethnography. Universtiy of Chicago Press; Chicago.
We carried out a cultural exploration, and thus did not need to obtain IRB approval. However, because we questioned individuals about discuss sensitive topics, we made sure to be incredibly aware of ethical boundaries. We worked with Mirjam Schieveld from the summer institute to collect names of clinics and individuals of interest to us in Amsterdam. Before leaving, we contacted clinic directors to set up formal interviews. We also obtained information from patients about the accessibility, and quality of care available, and potential problems with the system. In order to gain this information, we met with the director of a clinic, who then invited us to a users meeting where we were put in contact with individuals willing to share their experiences. While conducting interviews we began by asking our subjects what level of anonymity they wished to retain, and were respectful of this. At times, this required us to never write down names and other personal information or simply using one’s position (i.e. child psychologist, addict and ex-user) as the only identifier.
In terms of measures taken to maintain anonymity, we have taken many steps. Video was only taken with expressed consent, and any other identifiers (other than the subjects face) were edited out from both this wiki and the website. All audio clips and quotations were used with permission and any requests for anonymity were honored to the fullest.
From our literature-based research, we learned about the various levels of prevention and treatment in the harm reduction system including but not limited to:
1. Prevention programs for non users, specifically children and adolescents. These programs encourage non-users to abstain by placing drugs, NOT users in a bad light.
2. Safe Use programs for users who are not necessarily in need of addiction care. Such programs are focused on keeping users healthy, and also help to save hospitals and prisons money. An example of such a program would be the extablishment of user rooms, which provide a safe place off the streets where users can use their drugs under supervision.
3. Detox is available for addicts who have undergone and initial interview process and have been found to meet the requirements. Detox can be either drug free or can involve "less harmful" substitutes. For most hard drugs, detox almost always involves alternative substances, just as in methadone maintenance of heroin addicts.
4. Prescription of illegal drugs is sometimes available to addicts who have undergone every other treatment option without success. Examples of this within the Netherlands incude the free heroin program.
5. Mental and Social Care are available for patients who need extra help integrating back into society.
We also conducted a series of Interviews, which are explained below:
1.) The Interview with Keith Bakker, director and founder of the Smith and Jones Center, which is a 12 step abstinence program. This interview provided us with a critical look at the government-sponsored harm reduction system from someone who had experienced it as a patient and later decided to create another treatment option. (See below for transcript of interview).
Interview with Keith Bakker, founder and director of Smith and Jones Treatment Clinic, Amsterdam, August 13th, 2007. Transcribed with permission.
Keith: Basically, what happens is that the Dutch healthcare system is split up. It’s all about quantity. Now the health care system what they have, they have, they were trying to figure out how they were going to pay for addictions care and what they decided to do is that they made something called the A W B Zed which is a big pot of money which different health care organizations can apply to a sort of governing people over that money and they can ask for money for different projects. Now addiction falls under there. Because of this system how it’s put together, you have what’s called contracted health care, so for the last 30 years addiction care has only been provided by one organization for every region in Holland. And the policy for those the umbrella organizations for all these different regions is harm reduction. And because of the health care system, the way it's put together, there’s no competition. So, no one can come in, or you can come in and apply for that money as well. We have 60 hoops to jump through and its all subsidized health care so you don’t really have a chance to compete with them. So you couldn’t come in with something else because it’s just the way the system was built.
Now, it’s very interesting, I wanted to open a clinic in 1992 but the health care system because there was a Chinese wall built around the health care system I couldn’t even get through. Then European Law came along, the EU law, so I started fighting my battles based on common market law. And my point was that based on EU law, is that everyone has a choice it says in European Law. That if a certain medical treatment is not available in an EU member state, country so, and there is not a treatment available here but it is available in England or if there is a long waiting list here and there is no waiting list in England then I, as an EU citizen, have the right to go to England to get treatment. So what I did was I started eight, nine years ago with fighting the government and I won. I beat them. And now I’ve got 16 Dutch, English treatment centers that provide abstinence based treatment admitted into the Dutch healthcare system. So now hundreds and hundreds of people have gone to England to get treatment because of the work I did to get the clinics admitted into the health care system. So that is how I started. So I’m all for treatment choices. So you see. So abstinence based treatment needs be part of a package for people to choose. And then eventually I had my own places and now we’re… its huge.
Jana: So when you did open your place, you chose an abstinence run facility?
Keith: Well we detox, we do indeed do detox but it has always been a dilemma of how do you pay for treatment because what kind of problem is it? Is it a medical problem? Or what is it?
Jana: Well don’t the Dutch view it as a medical problem, whereas in the US they view it as a moral issue?
Keith: Well, it’s still paid for by health insurance over there in America:
Keith: Once, I mean you get one round of treatment and then they say you’re screwed but in general…but over here it’s paid for by medical. But is it a matter of, I think it’s only a medical problem while you are detoxing. Because after you detox there is no more physical problem. You’re all set. Then it’s an issue and it has nothing, definitely doesn’t have to do with a moral issue, it has to do with there is something wrong between my ears that says it’s ok to hurt myself. Now, do you understand? The same thing is if a woman or a man sitting in front of a pot of Hagen Daaz Ice cream knowing you’re going to get fat, knowing that they’re going to feel guilty, and doing it anyway. The same thing is a cocaine addict with a gram of coke snorting that line of coke. So there is something wrong in their mind, so there’s, I don’t know if its mental illness. Now what’s happening is that they are saying it’s psychiatrics so they are doing a duel diagnosis thing so they are, you know, in order to get treated now, in order to get money, because they pulled again the money from within Holland for health care, for addiction here. So now you have to have a psychiatric diagnosis to get treatment. So now every addict in the country is being diagnosed with some kind of psychiatric disorder. So it’s always been an issue of who pays for this? Do you understand? So the church says they are going to open a treatment center but then they don’t do the physical part, they don’t do the medical part. So then the psychiatrists they come along and say were going to do it, but they don’t do the life issues part. So that is why we do a holistic approach. So we deal with all three. So we have psychiatrists that work here. A psychologist and we have a medical doctor. So we’ve got it all. So that’s pretty much a big difference then how we were.
Jenny: Well we just haven’t gotten an actual view from outside the government institutions, so we don’t have a good understanding of the problems people face in the harm reduction system.
Keith: Basically the harm is about how they don’t want somebody to break into your car and take somebody’s radio. That’s what harm reduction is about. That’s why it’s called harm reduction. The harm doesn’t mean harm to the person…well it could mean harm reduction to the person as well, but what they try and do is that their motto is “lets stabilize them so we put them on medication that comes from the government and then we’ll stabilize them on that and then we’ll get them a house, we’ll get their lives together, and we’ll help them get stabilized in all areas. And then we will maybe eventually treat them.” But the problem is they never treat them.
Jana: But they state that abstinence is their goal.
Keith: That’s what they claim, but what they claim or do are two entirely different things. And the problem is that with harm reduction, you see that the illness of addiction is two fold. You have a physical aspect which is an allergy of the body and you have the mental aspect which is of course allowing myself to hurt myself. You know, continuing behavior. The allergy of the body and this is where the key with what addiction is all about is that there is an allergic reaction in the body. I’m an alcoholic, I don’t drink, but if I have a drink, there’s an allergic reaction in my body that produces a craving for more. I can’t just have one drink, it’s an allergy. It’s absolutely impossible. So for me I know that, but for a hundred years when I was drinking I thought, damn, why can’t I drink like normal people? So what happens is you have, and it is very important to do a good diagnosis, if somebody is an addict because they are rebellious, then harm reduction could conceivably work and help them get their life back together. Then they can eat and drink just like normal people. So I think it has been built for people like that. Harm reduction is not built for people who have the illness of addiction because if they take methadone or if they take some kind of medication, all its going to do is pour gasoline on the fire. And then they are going to use more on top of it. That’s why harm reduction actually doesn’t work for me or those people, because they take the pills they get from the government and then the allergy kicks in and they need more. So they are always using more than they actually get from the government. Do you understand? It doesn’t work. For some people it will.
Jana: So can you say that the zero tolerance policy should be everyone’s treatment?
Keith: No, that’s the other side. See there is no perfect system. I don’t agree with the American system either. You see, there is no perfect system. To be honest with you, now that we are here the system is much healthier. Well, I don’t know if that’s true.
Jenny: So there are more options?
Keith: Yeah, there are more treatment options. But having said that, it's not because people have to pay money to come to us we are still having a hard time getting into the system…that’s bullshit, I don’t even want to be in the system. People pay to come here. But there are now sorta these regular healthcare organizations are all now starting to open up these units like mine: 12 step, abstinence based treatment. And that wasn’t happening five years ago. So I have put a huge amount of pressure on them, I’m on TV all the time on this and that. I’m quite well known in this country so there is…the pressure has certainly changed things. So now there are more treatment choices coming. SO if you look at decriminalization if you look at legalization, you can buy dope at a coffee shop here no problem. Now what happens is that…I agree with that, I think it’s a good thing because…well wait I shouldn’t have said that…I think what’s good about it is that it gives the police officer a choice, it gives him more options as to what he’s going to do with this guy. If he finds a junky and he’s shooting up, in America he’s going to jail. In Holland the cop would say “finish your shot and get the hell out of here.” Because he knows the guy is going to steal more money anyway. Do you understand? So rather…it gives people a little more freedom to choose. Do you understand? But my goal with Smith and Jones is…I don’t ever want to be covered by health insurance. We are setting up the chart right now where we have a million buildings in the city and we’re actually quite big. But what we do is sorta run a Robin Hood organization that 3 quarters of the people pay and a quarter don’t. So the problem with the company is actually going in to help the people who don’t have any money.
Jana: What are your reasons for not wanting to be in the healthcare system?
Keith: Because then I have to play by their rules. Then it’s about systems as opposed to the client. You see? And then we are not able to do the things that we do.
Jana: They would have their regulations that you would have to follow?
Keith: Well now, you see its getting better because we have been established now for four years, and we’ve made such a big splash. We have a lot of regular healthcare providers that are sending us patients. We are getting quite accepted…everyone knows who we are but there’s sort of a…I’m a bit of a controversial character as well, because I am a weird guy. But I’m really passionate about what I do. And I don’t care about what they think. Because I was a drug addict and I was in their system and it almost killed me because every time I went in, I was taking more and more of their methadone. I would go in there and say this isn’t working and told me “well you need to take more.” And I said I don’t need to take more and they said “well you have to, to stabilize you.” So then I would take more, and for some reason I wanted to use more. So I was in Hell. The only thing that works for people who are born with the illness of addiction is to stop. It’s the only thing that helps. It doesn’t help to substitute something. It’s like giving a crack addict a joint instead. What are you doing? Do you understand?
Jenny: Do you think that’s why the free heroin pilot program was started?
Keith: They wanted me to do that. They were throwing up their hands, they didn’t know what to do anymore. They had no idea what to do anymore. They’re screwed. They’ve got all these people who are all (change of memory card).
Jenny: It seems like they have taken the view that they can’t get people to stop, so why not stabilize them and reduce the harm toward society.
Keith: Well yeah, so they don’t get their bike stollen. What harm reduction is all about really is all about control. It’s all about if you put a junky on methadone he has to get his methadone everyday because he is terribly addicted. And do you know where he has to get it? He has to get it from you. And you’re the government. So if you want to control the junky, the best thing you can do is, get him hooked on your dope. So he’s got to be there at 11 every morning at that methadone bus, and you know what, they know exactly where you are. And then you’ve got the ones who are really causing trouble, and you think well, lets give them some heroin, and now there saying they want to give them coke as well. And you want to know why, because they want to have all these people under control in central locations. That’s why there is this whole thing about…I don’t know the English word, but they have this room where people go use.
Jenny: User room?
Keith: Yes. And you know what that is…they know where they are all the time. Because they are in there and not out in front of my house. And the tax payers are having no trouble because of the junkies. You know how much money they earn on drugs and drug tourism and drug everything in this country? I mean it’s been going on since the 1500s.
Jana: Do you think it’s feasible to cure all the addicts of addiction rather than…?
Keith: No because I’m not…you see…on one hand I’m not against the heroin project because there are some people that if they want to do that for the rest of your life, you should be able to. If you really want to take drugs…the problem is unless you give someone an alternative and say…well look…it’s a law in this country if you go to the doctor, the doctor has to say “this is what I can offer you, but I can also offer you this.” Do you understand? The doctor can’t say this is the only thing that I can do for you. He has to say here is an option. And in drug treatment policies, there are no options. They say go take heroin. Ok great…I say to the guy…the doctor said to me. He said you need to take heroin, and you need to take it from us. I don’t want to take heroin I want to get clean. He said you can’t there is nothing for you here. And that’s when I decided…I stood there and talked to him and said I’m going to start a clinic. And I did. So, once again there is no perfect system. Harm reduction has worked for maybe…I have met a couple people that it worked for. But in general, it doesn’t work.
Jenny: When you were trying to get clean, did you do it here or did you go somewhere?
Keith: I went to England. I went to England and got clean in a hospital for 14 weeks. Oh I was a mess. A nice white kid from West Port, Connecticut, man I was in trouble.
Jana: How long had you been using?
Keith: Well I used twice. I used…well I’ve used my whole life. But the heroin, the real stuff I was doing that at 25 until I was 28. And then I stayed clean for six and a half years, and used again for a year and a half between ’96 and ’98. And that’s when they said you should do heroin…during those years.
Jana: Here? The government?
Keith: Yeah in Holland. Amsterdam. I’m from America, I have my whole drug history over there. Not in Heroin or anything, but I’ve got smuggling. I got arrested by the DEA. You know…crazy shit. Crazy life.
Jenny: How is your clinic different than the 12-step programs in the U.S.?
Keith: I think what we have is a core basis of 12 step. Every treatment center has its own flavor. And we work a lot with young people. And I have my own television show called Brat Camp. I don’t know if you know what it is? They give me the worst kids they can find and I take them for 35 days and last year I took them to Africa, to Kenya, I had the 7 worst little gangsters they could give me. So at the end of the 35 days they climbed the highest mountain in Kenya…together. And that’s what I do. So I have my own show every year and I have another show which I do for young people…it’s a talk show. So I do all this stuff. So we get a lot of kids. And there is a certain flavor here, it’s quite different we are very much focused on life skills and things like that. What the Jellinek and what the Dutch Health Care system is really good at is that they can get you a house, they can get you a bicycle, they can get you a place to work, they can take care of your money for you. They do that stuff really well. A lot better than I can, because they’ve been doing it for many years. But what they don’t do is take out the terrorists. It’s like in Afghanistan. The American smart. They go over to Afghanistan and they run around there for a while and say ok the Taliban is gone. And what happens is five years later they come back and blow them up. And that’s exactly what addictions do. That’s what we call addiction, we call it a terrorist. Because the terrorist is waiting. And the terrorist talks to you all day. The Taliban uses bombs. My terrorist waits until I am alone and says “go ahead and have one drink. Don’t worry” Last time he was telling me “mushrooms aren’t drugs.”
Jana: Because they are really prevalent here (referring to Jellinik clinic).
Keith: Well yeah, they are the ones I am suing and I beat them again.
Jana: Suing them for…?
Keith: Yeah, they keep on playing games and they…I had 14 lawsuits running against them at one point. And there’s a big television thing going on right now about methadone, because they were putting people on…they were doing an experiment and put people on huge pieces of methadone because they wanted to see if they put them up two or three hundred milligrams of methadone to see if that might help the cravings, but what it did was kill about 8 of them. And I had one of them here. And so I keep hammering these guys. And now, they, they, you know what they did, they had a little bit of an ego issue and they thought that they were, you know, hot shit and doing everything right. I don’t believe there is a perfect system, they are good for a group of people. But I also love the idea of, look, if I’m a heroin addict and I want to be that…you know in America like what is it 80% of the people in prison in the US are there for some sort of drug related or alcohol related crime.
Jana: And they don’t get treatment..
Keith: It doesn’t help, you know you get a junky and he screws up and he sticks somebody with a knife when he’s drunk. You know that’s not necessarily the answer either. You see, it depends on who you are. You know that’s not the right answer either. You know it’s like anything, finding balance. So I love that we have the opportunity here to do what we do.
Jana: Are there other places here that do the 12 step program?
Keith: One is already open. Two. But all the big (clinics) are now trying to hurry up and train people to open a unit. Even the Jellinek is now opening a unit- 12 Step. They want to open in a couple years.
Jana: 12 Step, like abstinence?
Keith: Yeah. And they said in the newspapers three years ago that I, they said that 12 step programs were outdated and now all of a sudden they are like…
Jenny: Yeah on their website it says that as well.
Keith: Says that it’s outdated? Yeah it’s unbelievable, and like two pages later it says that they’re going to open a place. It’s completely crazy.
Jana: So does the government want your clinic as a part of their system?
Keith: They were getting a lot of press because the politicians like me a lot. Politicians love me. And they’re getting a lot of pressure from them. Politicians now, and insurance companies. They are seeing that there probably is another way. The problem, you see, with addiction is that people really don’t care. That generally, people aren’t junkies. And for many years the Jellinek had convinced people that they were dealing with it. But meanwhile, millions and millions and millions of Euros had been thrown away by keeping them…now what harm reduction does is it doesn’t provide a solution; I mean there is no illusion in this. I mean its not called solutions, its called harm reduction. I mean just the fact that someone would invest in harm reduction. Its like the house is on fire and I’m only going to put half of it out. That’s what harm reduction is. Well that’s a good picture isn’t it?
Jana: So what about an individual who would want to come here but most likely can’t afford it?
Keith: Well we have beds for them…we take people in.
Jana: For detox?
Keith: Yes. If somebody really wants it. I’ll do an intake and if somebody doesn’t have the possibility of paying and the person wants it more than anything, I’ll take them in. But that’s why Smith and Jones as a company has never made any money. It’s never earned any money. WE have huge turnover, but every month we are at zero…because we give away so much. But that’s why I do this; I don’t do this to make money. I love my job.
Jana: Well, what role do you play?
Keith: I’m the director of the whole thing. The whole organization.
Jana: Is it just here in Holland?
Keith: Yes. Well, it seems like we are in England now as well. And were getting a new unit outside of Amsterdam, 40 beds.
MEMORY CARD CHANGE
Jenny: Is Smith and Jones involved in any educational or preventative programs?
Keith: I do it personally sometimes I will go to schools or something like that. For example, I am speaking in a big festival for kids on Saturday. I’m doing basically just treatment. You know that’s what my personal goal is eventually; I’d like to set up charity…a big charity support from my friends in rock and roll. And set up youth programs in places where they don’t have any money…like Russia. You know, there are huge problems all over the place. We’re lucky we live in the western world where we can afford it. So eventually maybe make a training center here that can train up people to go work in their own country
(end of recording)
2.) Interview with ex-user, past patient of the Jellinek Clinic and current outpatient of the Smith and Jones clinic. (has chosen to remain anonymous).
3.) Interview and talk with a government employee-child psychologist who’s cases are mostly made up of children who have been removed from their parent’s homes and care due to parental drug use. (has chosen to remain anonymous).
Statements by child psychologist regarding the system of Dutch health care in general:
- “The system is based on social control.”
- “The state’s aim is to help, sure, but abstinence and sobriety are never reached.”
- “Control is based on their drugs (i.e. methadone or free heroin) so they get them to where they want them, and the addicts become dependent on them.”
- “It’s a difficult and complicated situation because, without a hard focus on sobriety, addicts can remain addicts, while the state still reserves the right to take their children away. “
- “Harm reduction has been very effective in what the government had hoped, but I can’t say that addicts have truly been helped.”
4.) Jellinek Website Translations
- The aim of treatment is determined on a patient-specific basis. This is done so as to ensure that the best conceivable guidance, treatment and care is provided to addicts. It is not a program that focuses only on abstinence. Instead, adapted, controlled use is most common because it is “feasible and comfortable”.
- Treatment at Jellinek always begins with the lightest treatment, which may yield results. The seriousness of the addiction can determine “how heavy” treatment is. Many clients are helped with four consultations, which is Jellinek’s lightest program. Often, more consultations are necessary.
Maps and Media
External link to map of safe use sites
External link to map of Amsterdam schools
External link to Hospitals
External link to all our research sites
- For more media, see our website soon at http://www.geocities.com/dutchharmreduction/
For the purposes of clarifying our idea of “treatment” in this project, we defined treatment as a means of care preferred by an individual.
Based on our research on the harm reduction model of addiction care, we recognize the broad scope of treatment options available through government sponsored clinics like the Jellinek. Starting out with the actual prevention of drug use all the way to prescribing illegal drugs, the harm reduction system works incredibly well in promoting the health of the individual user and the safety of society. It also works to integrate problem drug users back into society by physically stabilizing them and providing them with mental or housing assistance as needed. At first glance, this system appeared to us to be ideal, but once we ventured away from government websites and publications, we realized that it has its limits.
Through interviews with a Keith Bakker, addicts, and a child psychologist, we became aware of some of the limitations of the harm reduction system. Despite the broad scope of programs offered at government clinics, the common complaint was that it was not broad enough. This is due to the fact that 12 step programs are currently not available within the Netherlands in government clinics. While clinics such as the Jellinek claim that the long term goal of treatment is abstinence, patients are generally started on the lowest-threshhold programs, which are generally drug-dependent. Not until much later, after going through many low-threshold steps, do patients sometimes have the option of entering a high- threshold drug-free treatment program. Unfortunately, according to our interviewees, by the point at which abstinence becomes an option, most patients desiring that form of treatment have droped out.
For patients who desire a zero-tolerance, abstinence program, frustrations with the harm reduction system often drive them to seek care through 12 step clincs like the Smith and Jones. Unfortunately, 12 step clincs are not sponsored by the government and thus health insurance can not be used, so care is consequentely very expensive. The high cost restricts 12 step programs to the small percentage of addicts that can afford it. Those without the money for private clinics are forced to return to the Jellinek.
Considering our definition of treatment as being a means of care preferred by an individual, does the Dutch harm reducation model of addiction care allow for adequate treatment for everyone?
Based on our findings, we would have to argue that in order for the harm reduction system to provide treatment for everyone, diversification of programs is necessary. This may include the creation of 12 step programs, or simply the incorporation of current 12 step programs into the government-funded system.
Regarding future directions, we would like to interview representatives of the Jellinek and the Municipal Health Service inorder to understand the viewpoint of those in support of the harm reduction model. Also, we recently learned that in coming years, 12 step programs are going to be started in government sponsored clinics. We would be interested in looking into how this change in sponsorship came about and what does that mean for private clinics?
References and Contacts
- Netherlands Institute of Mental Health and Addiction
Trimbos-instituut Da Costakade 45 Postbus 725 3500 AS Utrecht T: 030 297 11 00
- The Netherlands Organization for Health Research and Development – Pieter-Jan Carpentier, Corresponding author.
Tel.: +31 010 408 8712
- Janhuib Blans - Drug Policy in the Netherlands
- Mirjam Schieveld Addiction Institute
Summer Institute International School for the Humanities and Social Sciences Universiteit van Amsterdam Courier and Visiting address Prins Hendrikkade 189-B 1011 TD Amsterdam The Netherlands Email: SummerInstituteemail@example.com http://www.ishss.uva.nl/Summer.html
- Keith Bakker - Director, Smith and Jones Wild Horses Center
Sint Nicolaasstraat 16 1012 NK Amsterdam Tel: +31 (0)20 5286371 Tel :+31 (0)20 4278370 Email: firstname.lastname@example.org http://www.smithandjones.nl
• Access. The ACCESS Guide to HEALTH CARE in the Netherlands. The Netherlands: Stimuka, 2005.
• "AD Ziekenhuis Top 100." ad.nl. July 2006. www.ad.nl. 10 May 2007 <http://www.ad.nl/ziekenhuistop100/>.
• “AMOC DHV” 10 August 2007. < http://www.amoc-dhv.org/imige/1.jpg>
• Bakker, Keith. “Smith and Jones Wild Horses Center” 31 July 2007 <http://www.smithandjones.nl>
• “Dutch Drug Policy: A Model for America?” Journal of Health & Social Policy. 10 August 2007. < http://www.druglibrary.org/schaffer/other/dutch.htm>
• "Guidelines on Harm Reduction." Journal for Drug and Alcoholism. 3(2000) 01 June 2007 < publications/dacp/journal/2000_3/j%20xxiii%202000_3%20e xtracomunitari_en.pdf>>.
• “Harm Reduction Coalition” 5 August 2007. http://www.harmreduction.org/index.php
• “Harm Reduction Psychotherapy and Training Associates”. 8 August 2007. http://www.harmreductioncounseling.com/index.html
• "Health Care: The Medical System in the Netherlands." justlanded.com. 2007. Just Landed. 12 May 2007 <http://www.justlanded.com/english/netherlands/tools/just_landed_guide/health/healthcare>.
• Janssen, Otto “Normalization of the drugs problem: an outline of the Dutch drugs policy”. 10 August 2007. http://www.druglibrary.org/schaffer/MISC/nethnorm.htm
• Marlatt, Alan G. Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors. New York: Guilford, 1998.
• “Needle Exchange Programs for the Prevention of Human Immunodeficiency Virus Infection: Epidemiology and Policy”. American Journal of Epidemiology, Vol. 154, No. 12. 10 August 2007 <http://aje.oxfordjournals.org/cgi/reprint/154/12/S70.pdf>.
• "Part I: History of Federal and State Involvement in Narcotic Treatment." Treatment Improvement Exchange. 11 July 2002. Treatment Improvement Exchange. 11 Jun 2007 <http://www.treatment.org/taps/tap12/tap12part1.html>.
• “Psychiatric Services” 8 August 2007. http://www.psychservices.psychiatryonline.org/cgi/content/full/50/6/843
• Smit, F, J. Toet, H. Van Driel, E. Van Ameijden, J. Verdurmen. "Under-utilisation of Addiction Treatment Services by Heroin users from Ethnic Minorities: Results from a Cohort Study Over Four Years." Addiction Research and Theory 12 no.3(2004): 285-298.
• “The Harm Reduction Model: Pragmatic Approaches to Drug Use from the Area between Intolerance and Neglect”. Dr. Diane Riley, Canadian Centre on Substance Abuse, 1993. 5 August 2007 <http://www.ccsa.ca/pdf/ccsa-004011-1993.pdf>.
• “The impact of harm-reduction-based methadone treatment on mortality among heroin users.” American Journal of Publich Health, Vol 91, Issue 5 774-780. < http://www.ajph.org/cgi/content/abstract/91/5/774>
• "“U.S. – Netherlands Addiction Workshop and Binational Symposium on Drug Abuse, Addiction Research and Innovation”." NIDA: National Institute of Drug Abuse 20 10 2007 08 May 2007 <www.drugabuse.gov/MeetSum/International/netherlands.html>
• "The Netherlands and the United States: A Comparison." Drug War Facts. 29 May 2007. Common Sense for Drug Policy. 15 May 2007 <http://www.drugwarfacts.org/thenethe.htm>.
• "Trimbos Institute, Netherlands Institute of Mental Health and Addiction." KNAW. 01 June 2007. Onderzoek Informataie. 08 May 2007 <http://www.onderzoekinformatie.nl/en/oi/nod/organisatie/ORG1236731/>.