From fix to foil: The Dutch experience in promoting transition away from injecting drug use, 1991 - 2010

This article by John-Peter Kools describes the transformation in route of drug administration away from injecting in The Netherlands. It describes the Dutch drug setting in the early 90s, autonomous drug trends in drug using communities, and range of health interventions to promote 'route transition'. How an entire generation of injectors switched to non-injecting.

In the early 90s, the Dutch heroin epidemic was at its peak. Starting in the 70s, initially in the main cities, it had spread rapidly among young people all over the Holland, leading to an estimated population of 25,000 opiate users [1].

Large scale low threshold drug treatment and harm reduction services (as methadone programs and needle exchange programs) were initiated at an early stage. HIV prevalence among injectors, however stabilized after the alarming onset of the HIV epidemic in the mid 80s, was still a considered a serious public health problem, showing regional differences, from 26% in Amsterdam, 14% in Heerlen/Maastricht (the area bordering Germany and Belgium) to 1% in some other areas (Groningen, Arnhem) [2].

A substantial percentage (around 30%-40%) of the Amsterdam drug using population preferred injection [3]. Big differences in injecting behaviour were recorded according to (ethnic) background: 40% among Dutch drug users injected, 5% among drug users of ethnic origin (mainly coming from Suriname or the Dutch Antilles) and 70% among drug users from other European countries like Germany or Italy. The main drug injected at that time was heroin, but cocaine and amphetamine were also injected. Whether drug users preferred injecting or other routes of administration was very clear, there was a distinct watershed between those who injected and those who didn’t. The route of administration was part of a specific drug user identity. Non-injectors who preferred smoking on foil, known locally as ‘chinezen’ or ‘chasing’, were often regarded as ‘sissies, or not ‘real drug users’. For injectors, injecting was thought to be the only effective and satisfying way of drug consumption, the best way to get ‘bangs for your buck’. They did not consider non-injecting ways of drug use as realistic alternatives routes of administration.

An Amsterdam study [4] based on epidemiological data from 1985 to 1992 describes high and stable rates of initiation of injection (30% of non-injectors started to inject within a period of 5 years, and 70% of those who once tried injecting, also started with injecting), suggesting that “a substantial number of the 60-70 percent of drug users in Amsterdam who do not inject can be expected to start injecting in the future”. The paper stresses the importance of prevention and cessation of injection, but also raises questions on the feasibility of these health interventions.

‘Top quality aluminium foil’
The Amsterdam-based harm reduction organization Mainline working on HIV prevention among drug users addressed both injectors and non-injectors. In order to reach non-injectors with HIV prevention messages, the third issue of their health promotion magazine, April 1992, had a cover story on smoking heroin, [5]. “Two-thirds of all [Dutch] heroin users ‘chase the dragon’. Yet little is know about it.” The article described various technical details of chasing, useful practices, and drug users described benefits of smoking drugs. “I get more pleasure from my dope ... I‘m also more sociable.” The article was very well received and subjects on health promotion and non-injecting featured more frequently in outreach conversations. The main aim was to provide health information to non-injecters, rather than direct promotion of a transition to non-injecting.

In order to increase opportunities for outreach workers to discuss non-injecting, a sheet of aluminum foil was enclosed in all 9000 copies of the October 1992 issue. The cover text mentioned: ‘Top quality aluminum foil’. The response was overwhelming. The foil in the magazine excited much interest amongst drug users. Non-injectors regarded the availability of foil as a sign that their drug use and health were being taken seriously. And as an unexpected effect injectors started discussing the pros and cons of the various drug consumption techniques.

Shifting patterns
Around the same time, (the winter of 1992) a Mainline outreach worker reported the first observation of long-term injectors to have stopped injecting: ‘Bumped into Red Harry. Grinning from ear to ear. He said he stopped injecting. After 27 years! Started smoking in prison.... “Which suits me fine. More relaxed.... You wouldn’t think it possible that I can do that. After so may years.” [6] More similar observations followed, first in Amsterdam, and later in other Dutch cities, indicating a shift in consumption patterns. More and more drug injectors seemed to be re-evaluating their method of administration through injecting (e.g. vein damage, abscesses, viral infections) and considering smoking on foil as a realistic alternative. Even long-term injectors mentioned the possibilities and potential benefits of ‘chinezen’.

In the middle of the Dutch heroin and HIV epidemic and major efforts to reduce HIV prevention, an endogenous process of transition to non-injecting seemed to be spreading among drug using populations.

Enforcing and accelerating this transition became an important HIV prevention and general health promotion objective for Mainline in the coming years.

A leading article in the Mainline magazine from November 1993 was entirely dedicated to route transition and and ‘The Switch’ was prominently mentioned on the cover [7]. The article contained interviews with two well know peer leaders in the Amsterdam drug scene. One of them was prominent in a couple of pictures, ‘chasing the dragon’ in the intimacy of his own kitchen. The message of the article and the accompanying outreach campaign was more straightforward: ‘Chasing is cool, more healthy, social and any injector can do it.’
A set of post cards was included in this issue, introducing non-injecting and ‘chasing’ as an HIV prevention measure.

The health campaigns culminated in a special edition of the magazine on ‘Chasing’ in 1995 [8]. A 6-page article elaborately described the technical aspects of chasing heroin, pharmaceutical processes, health benefits over injecting and testimonies on ‘switching’. Once again, a strip of thick aluminum foil was included in the magazine. The 12,000 magazines, funded and supported by the Dutch Ministry of Health, were distributed nationally by outreach workers, through a peer network and were also made available in prisons.

Various needle exchange programs, initially in Amsterdam and Rotterdam, started to offer and sell non-injecting paraphernalia, such as foil, as part of the total package of drug paraphernalia that they distributed.

Field research
Mainline outreach workers conducted a field study on route transition in 1995 [9]. 106 Injectors and former injectors in the Amsterdam region were questioned on their methods of consumption. The results were beyond expectations: nearly half of the respondents considered themselves to no longer be ‘an injector’ and had switched to non-injecting (47%). The majority of those who considered themselves ‘injectors’ (73%) also regularly used their drugs through non-injecting routes of administration. The majority of ‘switchers’ had changed quite recently, (over the preceding 5 years).
Injectors main reasons for switching were:
  • Health issues (like fear of transmission of viral infections) or specific health problems that hampered injecting, in particular vein problems. 70% of those who switched reported ‘health’ as the major drive for transition;
  • Decreased satisfaction with IV injection: “Even a decent fix doesn’t get me over the roof, so in that case I prefer I prefer chasing;
  • The process of transition was often not planned, but the result of practical short-term choices (e.g. no clean syringes available, poor veins).
  • Steady availability of drugs (stable purity, lowered cost) and a base-form of drugs that can be easily vaporized.
  • Presence of non-injecting fellow users and peer leaders.

The biggest unforeseen benefits of switching were reported to be social. Non-injectors mentioned that they felt chasing drugs was embedded in a culture of sharing and socializing, rather than individual consumption. “Compare it with someone who sits sociably at the bar and treats everybody to a round. That’s totally different from someone sitting in the toilet and tossing back the contents of a hip-flask. I don’t think of myself as a junkie any more, but as a user.” [5]

The main conclusion of the field research was that the distinct watershed between injectors and non-injectors was disappearing and that non-injecting had become a realistic alternative. Transition to non-injecting often turned out to be a significant step in increasing user’s self-management and coping strategies around their drug consumption.

In the mid 90s the trend towards transition away from injecting became much more visible. This development was further accelerated by the arrival of cocaine base. At that time smokeable cocaine base (‘gekookte coke’ in Dutch, or ‘bori’ in Surinamese) took over a large part of Dutch cocaine street market. ‘Bori’ was ready-made, very cheap (a couple of coins for a small lump), with an instant ‘flash’ and no injecting needed. First reported in the Rotterdam in the early 90s [10], the sale and use of cocaine base swept over Holland within a year. By 1997, most cities in Holland reported that cocaine base had become both the main and preferred drug among drug users [11]. The introduction of ready-to-smoke-cocaine almost certainly had an additional accelerating effect on the existing trends towards non-injecting. Who needed the hassle with a syringe when smoking ‘bori’ brought an even better feeling?

The transition towards non-injecting use of heroin and cocaine was reported by drug workers, community field workers in major Dutch cities and peer networks all over Holland. Field research among young injectors in Amsterdam in 1997 showed an impressively low number of young injectors; 8 (eight!) respondents younger than 26 had been detected in an extensive network search [12]. Five of them were from Eastern Europe and only recently in Amsterdam. No major influx of new injectors was found; injecting was becoming ‘old-school’.

From the second half of the 90s, the switching trend also started to show up in epidemiological data. An open cohort study, including more than one thousand Amsterdam drug users, clearly demonstrated significant risk reduction behavior. The percentage of injectors that injected frequently (over two times a day) halved during the period of the study 1986-1997 (to 27% among HIV negative DUs, and 22% for HIV positive DUs). [13].

National campaigns
In 1997 and 1998 Mainline conducting a series of peer support campaigns to promote route transition in various Dutch regions. A mobile outreach facility frequented 20 cities during the campaign promoting a ‘Switch-programme’. This intervention consisted of the presentation of a video, group discussions, individual consultation and provision of educational and risk reduction materials, including aluminum foil. The 20-minute video contained 10 testimonials of former injectors reflecting on their transition process. The campaigns also paid attention to potential relapse and non-injecting related health risks. Although non-injecting drug use is not associated with such serious health risks as blood-borne viruses, sepsis, overdoses, endocarditis and abscesses, smoking is obviously not completely without harm. Smoking drugs (cocaine basing or heroin chasing) can sometimes lead to serious respiratory problems. The positive response to the Switch campaigns underlined the significant nationwide trends of transition found earlier, with the exception of a few of cities (e.g. Groningen) with more stable populations of injectors [14].

A range of skills-building workshops for local drug workers were also conducted in order inform workers of the benefits and opportunities of ‘switching’ and to train frontline workers in supporting drug users to move away from injecting. A series of 2-day workshops were held in 9 regions all over Holland.
Both the peer support campaigns and the drug worker workshops were funded by the Dutch Ministry of Health.

By the end of the decade the development seemed to be complete. Within a couple of years an entire generation of drug users in Holland changed their rituals and habits and moved away from injecting.

International exposure
Mainline’s extensive national campaigns on promoting ‘the Switch’ ended in 1999. Selected articles on the issues of ‘chasing’ and ‘the Switch’ have been published in English compilations of the Mainline magazine, issued on specific occasions (1992 AIDS conference, 1997 International Harm Reduction Conference).

The concept of the ‘The Switch’ trend in The Netherlands and the experience gained in promoting transition were presented the International Harm Reduction Conference in 1997 [15].

The wider concept of dovetailing health interventions into drug users’ self management strategies was also the subject of an international project. The results of the various activities are compiled in the handbook on strengthening existing drug users’ control strategies [6].

Recent trends
An Amsterdam study at the Municipal Health Service on injecting drug use, part of the open cohort study, confirms the huge changes in injecting behavior over the years [16]. The data illustrate severe declines in injecting prevalence (from 66% in 1986, to 36% in 1998). Injecting initiation decreased markedly (4.1% to 0.7%), injecting cessation nearly doubled (10.0% to 17.1%) and relapse nearly halved (21.3 to 11.8%). Environmental factors, such as changes in the drug use culture (e.g. ‘injecting is for losers’ and the role of the non-injecting Surinamese drug users community) and the stable drug market (e.g. availability of cocaine base and low prices -30 and 60 euro for 1/1 gram of heroin/cocaine-) are mentioned as important explanatory factors. Another significant factor in transition is the availability of low threshold substitution treatment. Increasing methadone dosages is mentioned as supportive in the process of giving up injecting [17].

Qualitative research among young drug users underlines the earlier findings that, notwithstanding pockets of injecting drug use, non-injecting has become the mainstream mode of administration and injecting is increasingly regarded as a ‘dead end street’ [18]. Transition away from injecting is often initiated by users’ individual health concerns and aspirations to get a better grip on their dependency. Transition away from injecting is mentioned to be a step in ‘maturing out’ of problematic drug use towards less frequent drug use or even abstinence.

Currently, more than 15 years after the first signs of transition in the Dutch drug using community, the trends have continued. Injecting has become uncommon, and it has lost its ‘sex appeal’. Only relatively small groups (e.g. long-term injectors, migrants/tourists from e.g. Eastern Europe) continue to inject. The latest available national data from 2005 indicates that around 10% of the estimated 33,500 problem users in Holland were using their drugs intravenously [19]. Also the number of exchanged syringes in Rotterdam and Amsterdam continued to decline in over the years (from over a million in Amsterdam in 1993 to 210,000 in 2007 and from 400,000 in 2000 to 170,000 in 2007 in Rotterdam [20]). The ongoing trend of declining injecting prevalence seems to be is clearly illustrated by recent findings from Amsterdam where only 4% of problematic users report current injection and 20% report ‘ever injected’ [21]. The number of injectors in Rotterdam, Holland’s second biggest city with over half a million of inhabitants, has dropped to an estimated 325 people.

Although the overall public health impact of the ‘transition away from injecting’ is overall absolutely valued positively, other health complaints like respiratory problems are regularly witnessed and individual cases are known of some former injectors with severe respiratory problems who have been given advice to consider taking up injecting again [22].

It is impossible to say what the final effect of the various health campaigns has been, from the first health promotion activites in 1992 about the technique of chasing to the full-blown promotion campaigns to switch to non-injecting a few years later. However, it seems evident that these interventions significantly contributed to a major shift away from injecting. Health was obviously an important consideration for drug users, and autonomous processes in drug using communities were likely strengthened by tailored health promotion campaigns: monitoring and recognizing the existing early developments, re-enforcing them with clear-cut technical information and re-distributing them community-wide through peer support work.

Availability of foil
The availability of aluminum foil seems to have played a significant role in the transition process. Aluminum foil is not subjected to any drug law in Holland. Neither the Opium Act nor any general municipal ordinance mentions drug using paraphernalia. There are also no separate drug paraphernalia laws in the Netherlands. Any service that is willing to provide foil in order to stimulate or facilitate (transition to) non-injecting is able to do so.

Most of the 150 needle and syringe exchange projects in the Netherlands have aluminum foil available for sale or at no cost. Foil is also often available in consumption rooms (around 40 facilities all over the country) or at local drug treatment facilities.

January 2010
John-Peter Kools, The Netherlands
Independent consultant on drugs, HIV and harm reduction

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