The addiction care in the Netherlands consists of a nationwide network of some 200 loca- tions that are part of twelve large regional organizations (see also § 2.3). Addiction care is also organised by judicial institutions and to a lesser extent by some religion-based and private institutions. It is also practiced in general and psychiatric hospitals and by a sub- group of General Practitioners (mostly in the bigger cities). During the past decade there is an increased cooperation between mental health care and addiction care (comorbidity, dual diagnosis patients) and to a somewhat lesser extent also between social work, relief centres and other organisations (e.g. for realising case management, Intensive Communi- ty-based Treatment or Assertive Community Treatment).
In the past years, treatment interventions have been extended with treatment via the in- ternet (e-treatment), with treatment programmes for specific target groups (e.g. young people, people with double diagnosis, people with mild or borderline intellectual disabili- ties, the elderly, and other vulnerable groups) and with treatment interventions for other types of addictions (e.g. gambling and internet addiction).
During the past decade, the addiction care in the Netherlands consolidated its quality as- surance by means of the quality management program Scoring Results (Resultaten Scoren,
http://www.qqznederland.nl/index.php?p=157153). This programme is still running. Dur- ing the same period the funding policy and consequently also the funding system has changed substantially for health care in general. From a more demand-driven funding sys- tem that was paid by the government it was reconstructed towards a more market econ- omy model of competition between health insurance companies and based on quality and efficiency of care. The main guiding principles for funding health care and also addiction care are: a transparent treatment process, demand-driven care, and Routine Outcome Monitoring (ROM). Health care is also increasingly guided by a small number of large com- panies and corporations that have developed from mergers between the more numerous older organizations for health insurance and for addiction care (cf. Van Hoof et al. 2010). Today, the Ministry of Health, Welfare and Sports only funds special projects. One example is the medical prescription of heroin for a specific user group (annually € 17 million) and each one of the 16 municipalities where heroin prescription units are situated additionally funds some 200,000-300,000 euro annually. Other examples are the update of a substitu- tion treatment guideline (RIOB, see National Report 2010) and the development of a treat- ment protocol for GHB addiction.
Another development was the shift of responsibilities in addiction care and drug preven- tion from the government towards municipal level (see also 3).The municipalities are funded for these activities by the ministry. Due to the current economic crisis the annual budget for the municipalities will be cut substantially while in the recent past their respon- sibilities and tasks increased. Therefore the Association for Dutch Municipalities (VNG) complained to the government about this indirect municipal budget cut down. Several institutes of addiction care have already announced a serious number of forced discharges due to the budget cuts.
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Moreover, apart from the capacity cuts implemented by the insurance companies, by January 2012, patients will have to pay a higher financial contribution to cover the costs of addiction care. This has a negative effect on the accessibility of care.
5.2 Strategy/policy
During the past year addiction care in the Netherlands has continued and consolidated several initiatives for quality improvement that were taken during previous decades. New initiatives more specifically target at increasing the cost-effectiveness and efficiency of the addiction care. Moreover, improvements have been made in the care arrangements for chronically drug-dependent persons with complex problems. Pilots are now running for (pharmacological) treatment of cocaine- and GHB-related problems. There are more initia- tives for online therapy and there is more attention for vulnerable groups, especially (but not exclusively) for younger people (see also the National Report 2010). Below some of the- se developments will be briefly elaborated, based on recent publications.
On the 15th of December 2010, the Minister of Health, Welfare and Sport installed an Advi-
sory Committee Vulnerable Youth and Addiction consisting of experts from youth care, the forensic youth psychiatry, and youth addiction care. In April 2011 this committee reported that substance (ab)use by young people is a relative easily changeable determinant of psy- chiatric and social problems at an older age. The group between 12 and 24 years old has not been (but should be) a common target group in drug prevention, addiction care, youth care, and youth mental health care. Available interventions for early detection are still rarely applied, and the capacity (personnel) to implement these interventions in the organ- isations is in many cases insufficient. The common accumulation of risk factors among the aforementioned target groups increases the risk of escalation as well as the risk of the problems becoming chronic (see also chapter 3). Early detection, prevention, and early (in- tegrated) intervention strategies are therefore essential for reducing problems. It is im- portant that the expertise of the addiction care is disseminated towards the organisations for youth care. This can be realised by means of outreach work (Adviescommissie Kwetsbare Jeugd & Verslaving 2011).
Young people are more vulnerable for the risks of alcohol and cannabis use than adults and they are on average unaware of the risks of it. Because the use of these drugs have increased among these young people, the advice of the former Advisory Committee on Drug Policy (Adviescommissie Drugsbeleid 2009) suggested to sharpen the drug policy measures in order to prevent this (see § 1.1). Although the Minister of Health, Welfare and Sport agreed on this advice in her recent drug policy letter, the proposed policy measures do not support specific funding for drug prevention among this group. Instead it calls for more intensive use of existent intervention programmes targeting the early identification
(vroegsignalering) of drug use or problems (T.K. 24077-259).
In daily practice, Dutch addiction care mainly focuses on treatment (cure) and drug pre- vention. Based on professional experience from the past decades, abstinence was and is not the most important target in addiction care. In general it is admitted that not only treatment or detoxification is important for a longer lasting recovery of the client, but also after care, rehabilitation or reintegration.
Several initiatives have been taken during the past decade to ameliorate the most im- portant problems of the drug users. An example is the start of hostels were drug users can live on their own without the daily hassles of living and scoring in the streets (see national report 2008, 9.1).
A second initiative has been the national Strategy Plan for Social Relief (Plan van
Aanpak Maatschappelijke Opvang) for homeless drug users that took these people from
the streets in social relief centres. These are examples of taking care of the basic living conditions of homeless drug users. At the same time these measures reduced public nui- sance in the streets considerably (National Report 2010, § 8.2). Initiatives from client or- ganisations and supported by several legal arrangements, e.g. the Client Participation Act for Organisations of Health Care from 1996 (Wet Medezeggenschap Clienten
Zorginstellingen) and the Social Support Act (Wet Maatschappelijke Ondersteuning) from
2006, recently resulted in a declaration of intent: the national Charter of Maastricht
(Handvest Maastricht). This Charter stresses both the importance and the willingness of
all organisations of addiction care and client organisations (clientenraden) to engage in cooperation toward a more recovery-driven addiction care. Here 'recovery' stands for more than abstinence alone. The target of the intended cooperation between the addiction care and the client organisations is to increase the perspectives and the possibilities for social recovery, rehabilitation, and reintegration, although these last two words are not used in this context (Oude Bos and Rutten, 2010; De Haan and Oude Bos, 2011). It implies also a change in focus from cure to cure plus after care and to increase the quality of life of cli- ents. Partly influenced by client organisations, many institutes for addiction care have already developed activities and interventions for housing, work and daily activities. The Charter represents the common opinion that these initiatives should be extended and strengthened to become successful. To make social recovery a real possibility, knowledge from clients, professionals, and science should be integrated somehow. The addiction care must change from being supply-directed towards being demand-directed, and thus the addiction care should be more individualised and client-directed. The key terms for this change are: empowerment, self management, expertise by experience (ervaringskennis), and resilience. The perspective and the responsibility of the individual client should be broadened. The cooperative road to go has to be designed and constructed during the next two years (see also National Report 2010, § 8.2).
Training and education
Since 2005, a Council for enhancing professionalism in addiction care (Raad voor
Bekwaamheidsontwikkeling) is in operation (see National Report 2008). In 2010, the Coun-
cil has initiated university education on addiction for the medical sciences and psychology. For instance, the Faculty of Medicine of Utrecht University has introduced a curriculum on ad- dition science for 2nd year students. In this 5-week module 35 students participated. The
Faculty of Psychology at the Erasmus University of Rotterdam introduced a similar curricu- lum for 3rd year students, which has been evaluated. The evaluation has resulted in the ad-
vice to include practical skills (e.g. a training in motivational enhancement techniques), and to include more information on treatments. The curriculum will be continued in 2011. In 2010, the Council has furthermore disseminated a manual on studying addiction science for higher vocational education (Buisman 2011). Moreover, the Radboud University Nij- megen (RUN) offers a post-master training in addiction medicine and addiction psycholo- gy. Diverse universities of applied sciences offer a minor training in addiction, for example the Fontys University of Applied Sciences, the HAN University of Applied Sciences, the
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Windesheim University of Applied Sciences, and the Inholland University of Applied Sci- ences.