lion for improving methadone maintenance distribution in 2008. He also informed Parliament to increase this budget to € 15 million annually during later years (Ministerie van Volksgezondheid 2008b).
Medical heroin prescription
Experimental medical heroin prescription is continued. By the end of 2008, 17 units in 15 differ- ent municipalities, with a total of 715 places will be operational. National funding is on average € 16,500 per place. Municipalities have to compensate the total costs which will be on average around € 10,000 per place. Formally, heroin prescription is still an experimental project (see also §1.2).
5.4 Research
The new research programme Addiction (Risk Behavior and Dependency) of the Dutch Health Research and Development Council (ZonMw) is currently funding fifteen studies on addiction. Five of these cover treatment issues. The first one deals with effectiveness of intensive commu- nity-based care (bemoeizorg) for persons with complex addiction problems and focus on the contribution of specific programme components to drug use reduction and other outcomes. A second study compares the difference in effectiveness of antipsychotics (clozapine versus risperidone) on craving in persons with schizophrenia and problematic cannabis use. The third study focuses on treatment needs of chronic crack users and investigates the therapeutic effi- cacy of three new medically assisted treatments (rimonabant, modafinil and dexamphetamine). The fourth study examines the effects of two long-term medically assisted treatments (rimona- bant and varenicline) on the dopaminergic system, impulse control, and other outcomes. This study also tries to determine the predictive value of these treatments for relapse in cocaine abuse. A fifth study is done in collaboration with NIDA/University of Pittsburg and covers the outcomes of rimonabant for cocaine users in a double-blind placebo controlled randomised trial (Dutch Council of Health Research and Development (ZonMw) 2007).
Two projects from the former ZonMw programme Addiction are still running. One is planned to offer information materials, a strategy and handbook on ultra rapid detoxification with naltrexone. This experiment was already described in EDDRA and the National Report 2004). The result of the other study is a module for addiction care education (Bachelor and Masters level) ( (ZonMw 2008). A spin-off activity of this experiment is also an evaluation of the psychometric properties of the Dutch version of the 16-item Subjective Opiate Withdrawal Scale (SOWS) during different stages of withdrawal of patients who participated in this rapid detoxification experiment. SOWS is one of several instruments for measuring withdrawal symptoms. None of these instruments is widely accepted. Exploratory factor analysis of the measurement outcomes resulted in exclusion of three items. After this, four factors could be identified that satisfactorily represented the most important detoxification symptoms. The final 13-item SOWS shows high internal consistency, high test-retest reliability and good validity at different stages of withdrawal (Dijkstra et al. 2007b).
65 It is often assumed that naltrexone reduces craving. A follow-up study (baseline, 1-, 5-, and 10- months after rapid detoxification treatment) measured craving with three pre-existing instru- ments. Based on the results of urinanalysis, patients were divided over three conditions: 1) ab- stinent + taking naltrexone, 2) abstinent without taking naltrexone, and 3) relapsed in opiate use. It shows that people who took naltrexone, did not experience significantly less craving than those in the two conditions who did not. Thus the initial intuition-driven assumption is refuted. The study was funded by the Dutch Health Research and Development Council (ZonMw) (Dijkstra et al. 2007a).
6
Health Correlates and Consequences
6.1 Drug-related deaths and mortality among drug users
General Mortality Register: direct deaths
In the Netherlands, statistics on drug-related deaths are available from the General Mortality Register (GMR), or Causes of Death Statistics, held by Statistics Netherlands (CBS) (Van Laar et al. 2006). In this register the causes of death are classified according to the International Classification of Diseases, Injuries and Causes of Death (ICD). The 9th edition of the ICD was used from 1979 through 1995, and the 10th edition of the ICD has been in use since 1996. The register has national coverage, but in standard form only includes deceased residents of the Netherlands who were registered at a municipal register. However, data on drug-related deaths among non-residents are available from an additional database.
The General Mortality Register (GMR) specifically provides data on acute mortality due to drug use, that is poisoning by drugs, or drug 'overdose'. These are the cases in which death is directly related to drugs. The GMR data do not make a distinction between experimental and habitual drug users, and are not suitable for tracing deaths due to rare toxicological substances like vari- ous synthetic drugs. Nonetheless, the registered cases can be selected according to the EM- CDDA definition of acute drug-related death as reported in the Standard Tables ST05 and ST06.
Overall trend
• Figure 6.1 shows the number of cases recorded from 1987 through 2007 according to the EMCDDA selection of ICD-codes (ST05, ST06). The figure only includes cases from resi- dents that were registered at a municipal register. Among non-residents, an additional 30 cases were registered in 2007 in a separate database (Deerenberg, Statistics Netherlands, personal communication, 30-07-2008). The total number of recorded drug-related deaths among residents increased between 1995 and 2001; it decreased in 2002 and 2003, rose in 2004, and declined ever since. The rising trend until 2001 can be attributed to various fac- tors, such as the change from ICD-9 to ICD-10 in 1996, since ICD-10 includes more cases. It can also be attributed to the rise in acute cocaine deaths, which appears to parallel an in- crease in the problem use of this substance.
• Of the 99 cases in 2007, a total of 42 cases were coded to unspecified substances, com- pared to 47 cases in the 2006 registration year. Although the specific substances are not known, an inquiry at Statistics Netherlands (CBS) revealed that these cases are mostly re- lated to hard drugs and to polydrugs, and are therefore rightly included in the group of drug- related deaths. The number of unspecified cases ranges from 18 in 1996 to 53 in 2004.
Substance specific trends
• 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. Between 1985 and 2001, opi- ate intoxications were the most common causes of drug-related death recorded among Dutch residents. In this period, the casualty rate fluctuated between 47 and 77 cases. In
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