Chapter 4 Utrecht: A Case Study of Harm Reduction
In this chapter we examine the workings of Dutch drugs policy in close-up, by singling out the example of the city of Utrecht. We shall describe the setting-up, day-to-day working, and the successes and failures of the city's methadone programme.
Heroin use occurs predominately in the larger cities of the country and the city of Utrecht forms no exception to this. Utrecht, situated in the centre of the country, is the smallest of the four major Dutch cities. It has 275,000 inhabitants: the number of addicts is estimated at about 1,500.
The Consultation Centre for Alcohol and Drugs (CAD) runs various methadone programmes for drug addicts. Besides the methadone programmes, there are also various 'alcohol programmes' and departments for probation and after-care service and prevention. The CAD is part of a wider drug-relief circuit that further consists of a programme for immigrants and their children, the day care centre 'Rode Brug' (Red Bridge), a detoxification clinic and the drug-free therapeutic community (DTC) 'Blauwe Huis' (Blue House).
Other institutions involved with care for addicts in Utrecht are the 'Crisis Centre', which provides psychiatric assistance 24 hours a day, 'Release', which has a 'shooting room' where clean syringes have been provided since the early 1980's, and the family doctor service. In Utrecht about 5% of methadone provision is carried out by a small number of family doctors.
The methadone programme
The initiative for starting the Utrecht methadone programme was taken in 1977. Relief care for (heroin) addicts in Utrecht was in a miserable condition. For most of the addicts, the threshold of the existing 'drug team' was too high. A small number of addicts received methadone via the local health authorities or via their family doctor.
Permission by the national government to set up a methadone programme came in September 1978. Because of housing problems, a start could only be made in September 1980: people in the neighbourhood protested against the decision about where to locate the main centre.
Right from the beginning there was a great influx of clients, and the maximum capacity had been exceeded in December 1980. Because of this, there has always been a waiting list of about six weeks between the time of registration and the time that the client can be helped. In the first two years, the total capacity of the programme had risen from roughly 90 to 200 clients. Liquid methadone had to be picked up each day of the week, including weekends, and taken on the spot. Three times a week there was a urine check on 'additional use'. Clients who had not used heroin for two weeks could take their methadone home for the week-end.
To avoid fringe crime, the various dispensing programmes had been limited to 25 clients. In those early years there were nine different programmes at varying times and places during the day, aimed at different 'categories' of addicts. A distinction had been made between 'abstinence' (additional use of illegal drugs prohibited) and 'maintenance' (additional use tolerated), the latter and bigger group divided into intravenous (I.V.) users and others (smokers, sniffers). In addition there were special arrangements for young people still attending school, and for clients with infections (e.g. Hepatitis B).
The scheme of the programmes in 1981 was as follows:
At the outset of the methadone programme the following policy had been formulated:
* There is no exclusive model to explain addiction; it is a social phenomenon that is determined by many factors. Therefore there is no one and only way of treating it
* To provide optimal assistance, a counsellor must accept the addict-client and his/her (deviant) lifestyle.
* The individual addict is entitled to receive both methadone and social (after) care, but will not be forced to enter a detoxification (abstinence) programme. Addict-clients have the right to examine their own files, and also the right to supplement them.
* It is necessary to have the programme assisted and evaluated by a research group.
During the first couple of years, the number of clients in the programme (on a daily basis) increased to an average of 200. The provision of methadone remained an important part of the programme The treatment on offer has been extended, with facilities for acupuncture and family therapy. However, the amount of time available for each client had been drastically reduced, because the increased work-load had not been accompanied by an increase in staff. The time needed for assisting new clients had to be made free by abolishing provision on Sunday, and by restricting the hours of provision on Monday-Friday to between 07.00 and 16.45.
In the course of running the programme, the following policy modifications were made:
* It was thought that the care for addicts is not a primary task for the normal 'first line' services. In this connection, it was considered necessary in a number of cases that the function of the family doctor should be fulfilled by the CAD. The reason for this is that the life-style of the addict (including the unconvential way in which some clients take medicines) often demands a different approach to somatic problems.
* Special emphasis was given to clients with venereal diseases, specially aimed at the group of heroin prostitutes. As in other large cities, attempts have been made to establish a low-threshold 'living room' service for this group,
* The situation of the children of addicted parents was also examined. It appeared that the protocol of the 'Bureau of the Confidential Doctors' with respect to this matter did not function adequately. It was thought that, in many cases, the children of addicted parents are seriously harmed by emotional neglect. In cooperation with the 'Bureau of Confidential Doctors' a working party has been set up in which the Children's Court Magistrate, the Child Welfare Institute, the Children's Hospital, the Medical Kindergarten and the Medical Children's Home, the Guardian Institutes and the CAD are represented. The working party aims to improve the situation for this 'high-risk' group of children.
* Attempts to administer and manage the social benefits of some clients did not succeed because of the refusal of the Social Security Service to transfer the money to another account number, unless this was requested by judicial decree.
* A computer was used to register data from the programme In this way a trend was detected whereby an increasing number of clients were able to function without the use of heroin (on a methadone maintenance basis without the additional use of illicit opiates). Moreover, it was established that there were several groups of clients for which short intensive treatment could be effective. This led to a provisional differentiation between 'treatment clients' on the one hand and 'care clients', for whom the prospect of a drug-free life was less, on the other.
The Utrecht methadone programme works in the following way. An addict who wants to be treated comes to the daily consultation hour at noon. If necessary, an appointment is made for an 'intake' (admission interview). Usually the client is temporarily placed on the waiting list.
The 'intake' has three aims. Firstly, to gain insight into the situation of the client; secondly, to undertake an extensive medical check-up; and thirdly, to discuss the relief care possibilities. The intake procedure is conducted by one of the four fixed intake teams, one of which is especially prepared for the intake of cultural minorities.
To begin with, the (standardized) intake forms are filled in. (Most of the research data, incidentally, originates from these forms). Next, the family doctor involved is notified that his/her patient has been taken up in the programme and the prescribed medication is communicated.
Since the clients change programme so frequently, the initial differences between the programmes (e.g. 'smokers' and 'I.V. users') have gradually diminished. As a rule all clients have to show up to collect their methadone six days a week at a specified time. The methadone for Sunday is handed out on Saturday. During the provision hours there are always two nurses and a social worker present. The client can have a chat and drink a cup of coffee. The atmosphere is usually relaxed.
When urine checks show that a client does not use illicit opiates, he or she only has to collect the methadone three times a week: on Monday, Wednesday and Friday. Individual arrangements can be made for clients with jobs, e.g. once a week and/or via the chemist. Clients from outside town are usually provided for by their family doctor, in consultation with the CAD.
Aggression against staff members results in immediate expulsion from the programme. Up to 1983 this had only occurred twice. Since 1984 there has been more aggression, especially from 'unstable' clients who use a combination of drugs, including alcohol. A number of these receive benzodiazepines as well as methadone. As more and more services are provided by 'first line' health care, this group of problematic drug takers tends to get left out.
We have seen that there are four different teams of professionals for the intake procedure. Two of them are 'care teams'; one is the 'treatment team'. When a client enters a programme, he or she gets a fixed contact person from one of the teams. Contact with a client will vary according to individual needs, from more than once a week to once every three months. Attention can be directed to social as well as psychological problems, but all interventions aim to produce a (structural) change in the life of the client: social rehabilitation and/ or a 'drug-free' life. The 'environment' of the client (partners, family) is increasingly taken into consideration. As a result of this a 'parent group' has been set up. Clients can enter a therapeutic 'day programme' and/or use specific sport facilities. Finally, clients can be referred to a detoxification clinic or a DTC whenever they are ready for it.
The first year
In the first year of the methadone programme (1980-1981), 218 addicts applied for a place; 164 of these entered the programme. In order to give an impression of these clients, we give here some statistical data.
Tables are in percentages. Relatively more females than males enter the programme after applications, i.e. more males drop out in the period immediately after application.
10. Other facts and figures
* 20% had spent (part of) their youth in special institutions.
* 25% had one or more currently or previously addicted brothers and sisters.
* One third of the clients still lived at home with their parents.
* Half of the clients had regular contact with their parents. * There were no waifs or wanderers.
* The client's personal care was mainly reasonable to good.
* Quite a large group (27%) had one or more children living with them.
* Two-thirds of the clients had no job and received social welfare.
*The spending of leisure time was a big problem.
* Many ran into trouble with the law, mainly because of offences, not crimes. *Methadone maintained clients are not 'zombies'.
* The majority seemed scarcely satisfied with their own functioning, but were little motivated to do anything about it.
11. Physical condition
As a consequence of several circumstances (suppression of pain by opiates; the low self-image of the addict) the reluctance to go to the family doctor with somatic complaints is great. One of the biggest advantages of low-threshold methadone programmes is the possibility of improving the physical condition of the addict-clients. The physical condition of the clients is nearly always changed for the better. The appearance of 'dirty' heroin on the street market, however, caused the death of 3% of the clients in 1981 and another 2% in 1982.
Experience with the programme in the early years
In the first two years of the methadone programme (1980-1982), 385 persons applied to join it. The official intake procedure was carried out for 365 of these applicants and 289 (79%) of them finally entered the programme. During this period the 289 clients underwent nearly twenty thousand urine checks to monitor the additional use of heroin. In 69.2% of cases the results were 'positive'. Only 2.7% (N = 7) of all clients never scored 'positive' on the additional use of heroin.
1. Methadone in the 3 months reduction programme
This reduction programme had been set up for small groups (10-20 persons) of 'highly motivated' clients. The additional use of drugs was not allowed and these clients were given the opportunity of intensive guidance.
All clients who applied for this reduction programme and assured the counsellors that they wanted to kick the habit were assigned to it. Counsellors always gave these clients the benefit of the doubt. Unfortunately one cannot conclude that these clients were really 'motivated' to kick their habit. Drug addicts believed that you had to say that you wanted to kick the habit in order to get any methadone at all.
An investigation was carried out to determine how many clients left the programme 'clean' (methadone reduction completed; no use of other illegal drugs during the last 30 days in the programme) within 100 days after the intake procedure. A total number of 27 (9.6% of all clients) met this criterium. Only 3 of these 27 clients had applied for a place in a clinic. However, 19 of the 27 clients started to take illicit drugs again and came back to the programme. As for the remaining 8 persons the situation was unclear (some were extradited, some were heavy alcohol users, and so on). It can be concluded that the success rate of 'permanent' detoxification in an outpatient programme such as the one described is minimal.
2. Methadone in the 'no time-limit' reduction programme ('maintenance')
This programme had been set up to attract drug addicts into a methadone programme and keep in contact with them. The aim of the programme was to combat the harmful consequences of heroin use and to encourage the social rehabilitation of the client.
Three factors are of importance:
a. time span of the contact,
b. continuity and regularity of the contact,
c. status or content of the contact.
a. Time span of the contact
There has been a continuous contact of between half a year and a year with 69 clients (24.5%) and a continuous contact of more than one year with 73 clients (26%). Thus, just over half of the clients (50.5%) have attended the programme for more than half a year.
b. Continuity and regularity of the contact
Percentage of clients who have been away for a continuous period of:
Clients are signed out of the programme if they do not show up during a period of more than one week. After such a period of absence, they have to apply again to enter the programme. This happens in a fair number of cases: 63.3% of all clients in the study were signed out, 35.2% following an absence of longer than one month.
We have just seen that the majority of clients (63.3%; N=178) were signed out of the programme at least once. We shall now examine the time elapsed between 'signing out' and 're-entry' of these clients. Since some addicts are 'revolving door' clients (sometimes more than 10 re-entries), the number of re-entries (441) exceeds the number of clients.
c. Status or content of the contact
Although data on this topic are extremely important, it has not been possible to record and evaluate them systematically within the constraints of the present study. When asked what their impressions of the contact were, the counsellors asserted that:
* clients seldom ask for assistance when they come to get their methadone.
* during this period of the day, clients have a lot of contact with each other.
The counsellors also had the impression that the collective provision of methadone has the following 'fringe benefits' for the clients:
* A fixed and relaxing activity during the day.
* A situation where you do not have to feel hounded. *An occasion to exchange experiences and 'tall stories'.
* An opportunity to prepare illegal activities.
* A comfortable and enjoyable situation.
* A way to experience a feeling of belonging (to the group).
Other remedies may also be prescribed as a substitute for methadone. It is interesting to see what medications are used and why.
Depronal is provided to addicts who have a mild or a slight physical dependence (short-term addicts), or who are in the last phase of their methadone treatment, in order to ease the transition to a 'drug-free' existence. The therapeutic scope is small and the dosage has to be low, otherwise serious side-effects can occur. Depronal cannot alleviate withdrawal symptoms of dosages that are higher than 10 mg. of methadone. One of the doctors calls it 'a chance remedy that does not provide much success'.
Clonidine is applicable to young users who have a short history of addiction and who do not have a poly-drug addiction. It is also suitable for clients who, after methadone maintenance treatment, are sufficiently stabilized and motivated to seek further treatment. It is only practical for a short time because it is ineffective when it is used for a longer time to combat abstinence effects. The doctors note that it might be a good remedy for motivated clients, because the side effects are not pleasant. In fact it is more suitable for intramural use.
* Substances to support abstaining
In Utrecht, a sleeping pill or tranquillizer (only benzodiazepines, certainly no methaqualone) is provided in the case of a strongly decreasing dose of methadone. This is continued after the opiate abstinence process has been completed, because being physically 'clean' does not mean that the addiction problems are over. If the client uses opiates again, the provision is stopped immediately. Antipsychotic drugs are only provided if the client becomes psychotic during reduction in the use of opiates.
Population shifts (1980-1985)
During the years 1980-1985, a total number of 958 clients entered the methadone programme, the male-female ratio being 3:1. The mean age of people in treatment had risen from 24.6 in 1980 to 27.7 in 1985. Each year roughly 100 new clients have entered the programme. The average period between the client's first use of opiates and his/her entrance to the programme was 5 years. This figure has not changed over the years.
The percentage of people living on their own is 40%, including 5% divorced. This figure is growing. 10% are married, another 35% are living with a partner. The status of the remaining 15% is unknown.
Out of all clients, 40% were referred by professionals while 20% were encouraged to come by peers. The percentage of clients entering on their own initiative was 30%. The remaining 10% had other motives for entering.
The average daily methadone dosage is 30 mg., with a minimum of 5 mg. and a maximum of 80 mg. In the first two years of the programme, however, the maximum dosage had been 120 mg.
The percentage of clients leaving the programme 'clean' rose from 15% in 1981 to 25% in 1985. In addition, roughly 10% each year are detoxified before going into prison, and a further 5% before entering a drug-free therapeutic community. Over the same period, the percentage that left without 'success' came down from 46% to 36%. The remaining quarter left for all kinds of other reasons. The latter two groups, together a majority of roughly 65%, mainly consisted of 'revolving-door' clients.
In the following table we give more extensive figures on the clients in the Utrecht methadone programme.
A survey has been conducted into the experiences of 'steady' addict-clients with methadone maintenance care (Verbraeck & van de Wijngaart, 1989). The subjects were interviewed about two main issues:
1. Their experiences during seven years of assistance in the methadone-programme.
2. Their ideas about desirable changes in and alternatives to the routine.
To investigate these two issues in a detailed way, a questionnaire had been developed consisting of 137 items. This questionnaire formed the basis for in-depth interviews with fifteen addict-clients (5 females, 10 males), who had been in the programme since the start (i.e. during seven years) and without substantial breaks, for example for a stay in prison or a therapeutic community. The transcripts have been analysed on the basis of the following subjects:
1. Experiences in the programme
a. social assistance
b. specific projects
c. psychological assistance
d. counselling and additional use of illicit drugs
e. changes in counselling.
2. Suggested improvements
a. individual counselling
d. heroin/morphine maintenance.
1. Experiences in the programme
Asked for their motives for entering the methadone programme, one of the clients responded: 'The majority enter the programme for reasons of comfort'. Others refer to this as 'to feel safe on methadone', 'to feel steady', 'to resist temptation', 'to avoid withdrawal symptoms', 'because it's just convenient', 'to be on the safe side', and 'to avoid early morning withdrawal'.
A few reported had experienced a 'high' in their first period of methadone use. Later all of them developed some kind of methadone dependence. One of them described this vicious circle as follows: 'Every day I take my methadone, because I took it the day before, to avoid withdrawal. I cannot avoid this feeling by taking heroin, I still feel rotten'. Another interviewee responded: 'Some of us are methadone addicts'.
Only a small minority entered the programme with the intention of trying to kick the heroin habit. One of the clients praised the positive social consequences of her step: 'Without methadone I would still have been walking the streets'.
The majority of addict-clients go to the methadone bus each day to collect their methadone. One of the interviewees felt 'addicted to the methadone bus': 'Every day you have to go to that lousy bus. This is a new habit: you go there, you sit down for a moment, and then you go back home again. It is very difficult to stop that.'
At this stage, the clients interviewed do not feel the need to talk with other clients, because 'after all these years you know everything' Another relativised this subject by responding: 'So few people can really offer me something, but they might think the same about me'. Neither do the clients generally associate with the methadone providers: 'The only thing I want to be sure of is my methadone'. However, once in a while clients feel the need to discuss matters with a counsellor. These talks take place in the main office, since there is not enough privacy on the methadone bus.
1a. Social assistance
'My counsellor gave me the information I needed and provided me with information sheets. Another counsellor assisted me in filling out the tax forms. These are matters they can really help you with.'
Clients agree that the counsellors have been able to alleviate acute social needs. They appreciate these forms of social assistance. The counsellors have assisted the clients with various practical matters, such as housing problems. 'Thanks to my counsellor I have been able to keep my house and at the moment I am doing better socially than before. This sort of help is encouraging, but it has no real lasting effects.' Besides housing problems, clients refer to help with borrowing money, settlement of debts and tax affairs, filling out forms, contact with bailiffs, contact with the confidential doctor and with child care providers. One of the clients has been helped with a new passport and a residence permit.
1b. Specific projects
At regular times new 'projects' were set up, such as family therapy, acupuncture, and sport activities. Our group had only experience with acupuncture, but this was not suitable for everybody. Clients on a high methadone dosage could not enter the acupuncture project. Those who have been treated with acupuncture praised the restful impact of acupuncture. 'It was nice and relaxing, but it was stopped when I got pregnant'. The general opinion, however, was that it did not really help you.
1c. Psychological assistance
Clients have varying opinions about individual counselling. Some of them have been helped, especially in their relationships. Others revealed that they had been cheered up. One of the clients said: 'When I was really down in the dumps I went to see my counsellor. These talks have given me relief. Whenever I feel the need, I go to my counsellor'. However, not everybody profits from these consultations. One of the clients stated: 'I don't need any guidance. The counsellors are fine people, but after twelve years of addiction I have found out that no one can help me. You have to do it on your own.' Another client has the same view. 'They are here for the methadone. When I've got problems, I always try to solve them by myself.'
1d. Counselling and additional use of illicit drugs
The clients share the opinion that the additional use of illicit drugs is not influenced by the social and psychological assistance provided. As we have seen above, counsellors are able to help clients with practical matters. These interventions make the clients feel better, but they do not affect the intensity of additional use.
1e. Changes in counselling
The scope of the counsellors is limited. 'They usually act like civil servants. They work from nine to five. You have to leave at five o'clock, even if you're crying.' Individual talks with counsellors have become less and less common because: * 'There is less money, less counsellors and less attention. The quality of counselling has deteriorated.'
* 'They are facing cuts in the budget. Today, they employ a number of agency staff on a temporary basis.'
* 'Today's staff is a new type of counsellor. They have learned everything in school, but they lack fundamental experience.'
Clients experience a growing amount of rules and regulations, but counsellors seem to take fewer responsibilities. At the start of the methadone programme everyone was full of great expectations. Today, counsellors have become 'passive' and 'resigned'.
2. Suggested improvements
The views of clients over the 'ideal' programme, on each of the topics distinguished above, can be summarised as follows:
2a. Individual counselling
'In the ideal programme the approach is strictly individual, because all drug users are different. The counsellors have to find out who someone really is and what he or she really needs, what is the best for that client. That is extremely difficult. The aid given has to be tailored to the needs of the client.'
In the actual situation everyone is lumped together, put in the same category. In the ideal situation a counsellor treats his or her client in a unique way, because everyone is different from each other. A good counsellor takes the trouble to understand and help the client. It is important that counsellor and client are well 'matched' and click with each other. It is very important to know the client really well, because they might talk big and deceive the counsellor. A good counsellor shows signs of interest and expressions of concern to the client. Sometimes it is important to visit the client at home.
It is useless to impose counselling on someone or to force a client into treatment. It could be an advantage to employ former drug users, because they might understand you from their own experience. It is important to separate the 'good guys' from the 'bad guys' and to select the 'motivated' clients for further treatment. Because office hours are from nine to five, one client suggested opening an emergency telephone for clients who want to talk with a counsellor during the other sixteen hours of the day.
'It is important to try out new ideas continually, every useful change is worthwhile. Each morning there are clients who follow the methadone bus to other stops because they want to chat and have a cup of coffee. Among these are some homeless people. They need a 'living room' or a shelter where they can sit down for a while and relax.'
Every interviewee had their own ideas about provisions that might be needed. Priority, however, is given to a provision for drug dependent homeless drifters, who hang around the shopping mall. This would have to provide accommodation without too many rules and regulations, where people don't feel hounded. One of the interviewees opted for accommodation with music and cheap beer. Others think in terms of accommodation where clients could 'really do something', such as sport, and make good intentions. It is important that plans and problems should be discussed with a counsellor. However, clients do not want accommodation to be located in the main office building, because 'such a provision will be annoying for the employees'.
Clients had definite views about the value of activities and new projects. 'It is important to motivate and activate methadone clients. It is not enough to serve coffee or to set up a pinball machine. You have to get them going and make them eager to get to work.'
Generally speaking, methadone clients are not really fond of 'complicated' conversations with counsellors. They prefer being active and creative, like reading books, taking lessons and being retrained, as well as a job or occupational therapy. The counsellors need to visit employers, such as printers, carpenters and garage holders, to create job opportunities for methadone clients and former drug users. The role of the counsellors is very important, because they really could achieve things. 'Employers generally don't like the idea of employing 'ex-users'. For us, it is even difficult to find volunteer work.' One of the interviewees suggested that the methadone clients should change their appearance: they could look and dress up better.
Some of the clients were glad that they had found someone who could help them control their finances (social security benefits or salary). Counsellors could play an intermediary role in fmding a fmancial manager. They could also give examples of how to solve specific problems. 'Some of the clients are like children and you have to treat them accordingly'.
Opinions about the properties of methadone are generally somewhat negative. The most positive remark that we were able to register was that methadone is at least 'cleaner' than other substances. We were told that the large majority of methadone clients take illicit drugs as well. It is a habit and apparently the taking of other substances is not connected with the methadone dosage. 'I can't explain why I do it, because if I knew, I probably wouldn't do it. Today, I am on 15 mg. of methadone, but even if I were on 80 mg. (the current maximum dosage), I would still take heroin'.
Clients agree that methadone acts for less than 24 hours; early morning withdrawal is not uncommon. Although they rather would like to have a 'take home' dosage for the early morning, clients know that they could not handle that situation: they would have nothing left when going to bed.
Some call methadone more addictive than heroin. 'Methadone is a rotten substance. Methadone withdrawal last three long weeks and only after three months do you sleep well again.' This is the reason that the addict-clients like to kick the habit on their own with reducing dosages of heroin.
Reduction of methadone is sometimes accompanied by a psychological 'complex'. 'When I cut back in dosage, I usually get a crisis on 15 mg. of methadone.' Another interviewee reported withdrawal after experiencing certain fears (expecting to be incarcerated). Finally, one of the clients reported that he went 'out of his mind' without methadone.
'If I were employed in the programme, I would give my clients whatever they needed and make no objection if they preferred raising the dosage.'
This is a common feeling among the interviewees. However, they cannot tell how much a given client 'needs'. Moreover, they would be afraid of providing a lethal dosage.
The dispensing of methadone should be separated from counselling. According to the clients these are totally different matters. They prefer, however, to get their methadone in a 'personal' atmosphere (not through a window or a hatch). They usually experience a lack of privacy, because there are too many clients in a programme. Moreover, there is not enough differentiation among clients. It is not good to mix young addicts with 'hard tore' users. 'Stable' clients with a job and a family should get their methadone through the family doctor-pharmacist circuit. Visits to the family doctor are small-scale and more anonymous than visits to the methadone bus. One of the clients added: 'the family doctor treats you as a human being!'
Those interviewed would create special programmes for young drug users ('chronic' addicts are bad role models) and for second generation youth (trying to bridge cultural gaps, finishing school, finding jobs). They also want special attention and care for older addicts: saying 'farewell' to illicit drugs usually means saying 'hello' to alcohol.
Although sugary liquid methadone is dispensed to be consumed on the spot, some of the clients manage to smuggle the methadone outside the bus where it will be injected (or sold to an I.V. user). Why? 'The methadone flash is much better than a heroin flash.' Why shouldn't you give sugarless methadone to those people, you know they inject it, why not play safe?'.
Finally, without exception, everybody praised the facilities for needle exchange.
2d. Heroin/morphine maintenance
Since the majority of methadone clients in the Netherlands take illicit drugs, and (as we have seen above) a small minority inject methadone, we asked the interviewees their opinion about heroin or morphine maintenance. From an earlier (1982) investigation it had emerged that the views of clients were subtle and specific. They took the view that heroin maintenance would have a positive effect on their social functioning. Heroin maintenance would also lead to a disappearance of the black market for heroin and other opiates.
In spite of this rosy picture, one-third of the client population in the 1982 investigation had no desire to enter a heroin maintenance programme. This group, consisting of drug users who had plans to kick the habit or were actually trying to do so, would prefer methadone maintenance. A smaller group would prefer methadone in a 'flexible' programme (no control on additional use) over heroin in a 'tight' regime. Asked for their ideas about which type of clients would enter heroin maintenance, they suggested the long-term users who could not give up the use of heroin.
This picture has not changed over the years. The clients interviewed in this survey did not want heroin maintenance for themselves. They approved of methadone as a good substitute ('I am no longer a junkie, since I'm on methadone maintenance').
We also asked clients for whom heroin maintenance would be a solution. The following 'types' would have been selected:
*Heavy users who take additional drugs;
* Long-term users who do not want to stop their habit;
* Addicts who steal every day and are often in prison;
* Addicts who face the end of their lives.
'You have to be realistic, you can't change people using compulsion and coercion', was the final conclusion of one of the interviewees.
However, clients are quite cautious about the possible success of heroin maintenance programmes. Dealing will perhaps diminish, but drug taking will not. A drug taker is never satisfied, he or she always wants more drugs. Or other drugs, like 'coke', pills or alcohol. Others are also 'hooked' on stealing, hustling and dealing, anything but the monotony of an existence limited by social constraints (cf. Preble & Casey, 1969). 'You won't change that with any type of maintenance'. Besides, 'maintenance is like giving people up', one of the interviewees concluded.
To sum up, the interviews showed that clients profit from psychological and social help, especially in dealing with practical needs, such as debts and housing problems. These forms of assistance, however, do not affect the use of illicit substances. Clients on methadone seldom feel 'normal'. There is unanimous enthusiasm about the facilities for needle exchange.
In the view of the clients, assistance in the ideal programme would be tailored to individual needs after careful selection. Methadone prescribed by family doctors could be a solution for some of the clients. The provision of methadone must be separated from 'real' assistance and counselling.
New alternatives have to be created for clients who continue to inject methadone. The provision of heroin or morphine is not widely supported. Social rehabilitation could be improved by (leisure) projects and employment.