Reframing Dutch drug policies: a new era for harm reduction

Abstract

In this article the authors offer their perspective on the changes in the Dutch harm reduction field. From the 1970s to the 1990s, the Netherlands emerged as a leader in harm reduction services, driven by grassroots movements like the Medisch-sociale Dienst Heroïne Gebruikers (MDHG) (Medisch-sociale Dienst Heroïne Gebruikers (MDHG) translates to Medical-Social Service Heroin Users in English) in Amsterdam and Junkiebond in Rotterdam. These organisations advocated for health-centred policies, initiated needle exchange programmes, and created safe consumption spaces. Their efforts led to significant public health improvements and policy shifts towards harm reduction, reducing HIV and hepatitis rates among people who use drugs. By the 1980s, harm reduction became institutionalised within local health and social care systems, leading to notable declines in drug-related harm and crime. However, from the 2000s, a shift towards security and crime prevention emerged, influenced by socio-political changes. Increased criminal justice measures and budget cuts for harm reduction services strained the system, making it harder to address emerging drug trends and the complex needs of people who use drugs. Despite challenges, there is renewed momentum for reform, particularly at the local level, advocating for the responsible regulation of psychoactive substances. Amsterdam Mayor Femke Halsema's 2024 conference on drug regulation exemplifies this shift, calling for policies that address prohibition failures and centre harm reduction. International bodies like the UN High Commissioner for Human Rights support this approach, emphasising a health and rights-based framework. As the Netherlands navigates these evolving dynamics, there is a pressing need to reinvest in harm reduction infrastructure, ensuring it meets diverse community needs and reaffirms its foundational rights-affirming principles.

Introduction

In this article, the authors—all seasoned harm reduction workers—offer their perspective on the changes in the Dutch harm reduction field. The claims in this article are based on historic as well as novel academic and grey literature that support the more subjective experiences of the authors. This article is a commentary and not intended as an academic paper.

The origins of harm reduction in the Netherlands (1970–1990)

Starting in the 1970s and continuing throughout the 1980s and 1990s, the Netherlands emerged as a pioneer in developing and implementing harm reduction services, even though these interventions were not labelled as such at that time. The pragmatic and practical approach towards drug use for which the Dutch became famous was not the result of a grand strategy. Rather, harm reduction interventions and concepts grew organically and from the bottom up, responding to the emerging harms associated with injecting drug use [1]. Political support followed gradually due to a shared sense of urgency [2].

The central role of the drug user movement

In the early 1980s, larger cities in the Netherlands were faced with a number of challenges, including fatal overdoses, high prevalence rates of HIV, viral hepatitis B (HBV) and C (HCV) among people who injected drugs, open drug scenes, injecting drug use in public spaces, low-level street crime, and the visible destitution of certain areas within these cities.

Neither traditional responses, such as abstinence-oriented drug treatment, nor incarceration or other forms of repression delivered the desired results. In response, people who use drugs began to organise themselves [3]. The Medisch-sociale Dienst Heroïne Gebruikers (MDHG) [4] in Amsterdam and the Junkiebond [5] in Rotterdam were formed, alongside similar groups in various Dutch cities, all becoming central figures in the drug policy debate. These ‘Drug Users Unions’ challenged repressive and counterproductive policies, demanding access to life-saving services and a health-centred approach to drug policy. They mobilised people, organised demonstrations, published critical literature on methadone programmes, initiated needle and syringe programmes, and pressured local authorities to support the implementation of harm reduction services [6].

In 1974, the MDHG opened the first informal safe space for drug use in Amsterdam, supported by the local government [7]. Here, people could consume their drugs in a safe environment and buy drugs from an in-house dealer. Additional services included medical care, social and housing support, legal assistance, and other essential services, including meals and showers. The organisation provided an alternative to the ‘official’ facilities, where people who use drugs felt safe, understood and respected, instead of being controlled or patronised.

Services provided by the Drug Users Unions were grounded in the principle of peer support. They played a crucial role in scaling up opioid agonist treatment [8], alerted each other about adulterated batches of drugs, provided information and guidance on responding to overdoses, as well as essential information and training on HIV prevention.

A policy shift from repression towards person-centred care and harm reduction

Community-based organisations cooperated closely with Drug User Unions to provide low-threshold services, including outreach work, day and night shelters, and other essential support. On June 8, 1979, the Municipal Health Service in Amsterdam began to operate a methadone bus, one year after Rotterdam and The Hague had already done so. The project proved highly successful, with 352 individuals enrolled by October 1979, a number that surged to more than 1200 by 1981 [9]. In that same year, the ‘drug user movement’ launched the first underground needle and syringe programme, which continued until 1987. It was subsequently absorbed by local authorities who opted to implement needle and syringe programs on a large scale [10]. By the late 1980s, these programmes were operational in 60 Dutch cities.

These initiatives reflected a broader transformation in Dutch drug policy, which sought to balance care with ‘law and order’ through a pragmatic harm reduction approach. Instead of focusing solely on control and punishment, the Netherlands started to experiment and collaborate closely with the drug user movement. Local policymakers and law enforcement officials came on board and gradually adopted the concept of ‘harm reduction’¹ as an important public health strategy and a pillar of Dutch drug policy. Importantly, local police and law enforcement agencies supported and tolerated various harm reduction measures, such as supervised consumption sites and drug checking, focusing their efforts on combating the drug trade rather than targeting individual users [11]. Drug consumption and the possession of quantities of drugs for personal use were de facto decriminalised in the Netherlands, meaning they remained a criminal offence in legislation, but not actively enforced in practice.²

Resisting external pressures

The Netherlands publicly distanced itself from more repressive drug policies enacted by other countries, where people who use drugs were often forced to abstain from drugs and faced punitive measures for possession or use. Giel van Brussel, a medical doctor at the Municipal Health Service in Amsterdam, openly criticised the drug policies of Germany and Sweden, where drug services remained firmly rooted in the law enforcement paradigm. He stated that in these countries, the issue was approached in a totalitarian, almost fascistic way [12].

Conversely, Dutch policies were met with international resistance from the outset, with several countries labelling the Netherlands as a ‘drugs paradise’ [13]. The Dutch were blamed for the increased availability of drugs in other European countries, prompting various EU nations to call for a more restrictive and prohibitionist drug policy, to ‘send the right message’ to drug criminals and young people experimenting with illegal substances [14]. Thanks to several courageous politicians, the Dutch response was protected and the Netherlands became an international advocate for the harm reduction approach.

The new ‘normal’—integration and institutionalisation (1990–2010)

Since the 1990s, harm reduction had become an integrated part of the local health and social care system in the Netherlands. Services were available, accessible, and acceptable to most people who use drugs, and were generally of good quality. Harm reduction interventions delivered on their promises, positively impacting both the individual health and well-being of people who use drugs, as well as public order in cities. Full participation in harm reduction programmes, including needle and syringe programmes, opioid or heroin-assisted treatment,³ and the now officially sanctioned drug consumption rooms was found to significantly reduce the incidence of HIV and HCV infections among people who use drugs [15]. Most people who used heroin were connected to social and health care services, and as a result, homelessness, public drug use, petty crime, and overdoses declined. The success of harm reduction services in the Netherlands has been highlighted by some commentators as one of the country’s greatest public health achievements [16].

Dutch drug policy: an evaluation

In 1995, an extensive evaluation of the Dutch drug policy was published, analysing the previous 20 years of policy implementation [17]. The report highlighted the successes of the health-based approach, including the low and declining use of heroin and cocaine/high-risk drug use among minors, decreased HIV infection rates among people who inject drugs, and stable, low mortality rates [18]. However, it also acknowledged some ongoing societal challenges, including drug-related public nuisance and social disruption, and the rising involvement of criminal organisations in drug trafficking. To address these issues, the evaluation recommended amendments to the Dutch approach, including an increased focus on reducing public nuisance and crime, and to adapt to the evolving drug landscape, such as the increased use of synthetic drugs such as ecstasy [19].

Institutionalisation and re-criminalisation

By the early 2000’s, most street-based people who used drugs lived in sheltered or supported housing. They received social welfare, medical care and tailored drug treatment, and drugs could be consumed safely in on-site drug consumption rooms [20]. This led to significant improvements in many individual lives, as well as in public health and safety. However, a small minority did not fit into these existing structures, and tolerance towards those who continued to engage in public drug use and (petty) crime began to decline [21]. The 1995 evaluation of Dutch drug policy recommended a ‘tougher’ approach towards those causing public nuisance, leading to various criminal justice measures, including compulsory treatment and other forensic psychiatric interventions [22].

Over time, funding aimed at reducing the perceived nuisance resulting from drug use was increased, involving care providers, the police, judicial authorities, and the probation service. Policy recommendations included expanding police and prison capacities to combat drug trafficking, eventually paving the way for a more security-based drug policy approach. In the international arena, the Netherlands shifted to a more conciliatory stance, emphasising drug control and crime prevention to bolster its image as a crime-fighting entity [21]. Consequently, during this period, the Netherlands stopped actively promoting itself as a leader in drug policy innovation and harm reduction.

Increased focus on security and crime prevention (2010–2024)

Over the past two decades, the economic and political landscape in the Netherlands has shifted drastically, mirroring wider trends across Europe. Decades of neo-liberal policies have widened the societal gap between ‘the haves and the have-nots’, exacerbating issues like poverty, homelessness, and societal distrust. Right-wing and populist parties have gained increasing support, hardening societal attitudes toward marginalised populations, who, as in many nations, have been scapegoated to distract from the harms of neoliberal policies [23, 24].

In line with these developments, Dutch politicians have shifted their attention to the challenges associated with drug production and trafficking. The Netherlands, with its long tradition as a hub for drug smuggling and production [25], is a key producer of ecstasy, methamphetamines, and cannabis, and serves as a major transit point for cocaine and heroin. Furthermore, individuals in the Netherlands have become increasingly involved in criminal activities on the darknet [26]. In 2020, Dutch policy advisors argued that the country’s tolerant stance on drug use were exacerbating many of these issues [27].

As this decade progressed, the Dutch government intensified its focus on security and crime prevention, enhancing law enforcement capabilities and increasing the mandate of the police and judiciary. This shift has involved implementing stricter measures to combat drug-related crimes and allocating substantial resources to prevent the Netherlands from becoming a 'narco-state'—a term coined by conservative politicians in the public debate and popular media [28]. However, to date, these efforts have not led to a reduction in production, trafficking, or consumption of drugs. The Dutch drug market remains diverse and accessible, with prices for drugs like cocaine remaining stable over time [29]. Concerningly, the focus on drug control has diverted attention and resources away from other criminal offences. An estimated 60–80% of all police capacity is currently allocated to handling drug-related crime, a situation that has overwhelmed the justice system with non-violent drug cases [30, 31].

Harm reduction budget cuts

In parallel with the heavy investments in the justice system, harm reduction services in the Netherlands have suffered from significant budget cuts. These cuts have gone largely unnoticed due to the decentralised nature of government budgets and the restructuring of funding streams. Due to the successes of harm reduction in the past years, drug use became less visible and was no longer considered a major societal problem. Consequently, harm reduction programmes became an easy target for austerity measures, leading to long waiting lists and severe staff shortages [32].

In recent years, harm reduction organisations like Mainline have observed significant changes in the support and care system for people who use drugs. The institutionalisation of harm reduction has led to the imposition of strict ‘house rules’ and rigid perceptions of what constitutes ‘good conduct’ inside services. Furthermore, low-threshold services, including drug consumption rooms, are dealing with an increasing number of clients presenting complex and multi-layered issues, including drug and alcohol use, health problems, homelessness, (untreated) mental health conditions, and feelings of hopelessness. Minoritised groups, and in particular, migrant communities, often lack access to the Dutch harm reduction services altogether [33]. Moreover, insufficient funding puts excessive pressure on staff, who often lack the necessary resources to adequately meet the needs of these target groups [34]. In an increasingly inaccessible system, harm reduction professionals are struggling to adapt to shifting demographics among clients and rapidly emerging drug trends. Consequently, the Dutch harm reduction infrastructure appears far from future-proof.

The need to reframe harm reduction (2024 and onwards)

In 2024, we stand at the brink of a new tipping point in drug policy. The international system of drug control has failed to deliver meaningful results, leading to a growing demand for change [35]. At the 67th Commission on Narcotic Drugs (CND), Colombia delivered a statement on behalf of 62 countries, calling for a review and reassessment of the international drug control system, and emphasising the need for a framework grounded in health and human rights [36]. Additionally, in a historic move, the UN High Commissioner for Human Rights (OHCHR) issued a strong, rights-affirming statement in 2024 calling for the responsible regulation of psychoactive substances [37], marking the first time a UN body has publicly supported such a position.

However, in the Netherlands, national politicians remain hesitant to adopt more progressive positions. In contrast, at the local level, where policymakers witness firsthand the many counterproductive outcomes of prohibition, there is a growing urgency to address these issues. In recent years, organised crime linked to the drugs trade has seen a troubling surge, including frequent bombings and assassinations [38]. Many Dutch cities have also witnessed the return of open drug scenes [39, 40].

Regulation as a cornerstone of harm reduction

Leading the charge against the current prohibitionist paradigm is Amsterdam Mayor Femke Halsema, who, in January 2024, hosted a groundbreaking international conference dedicated to the legal regulation of drugs [41]. In recent years, countries like the U.S. and Canada have faced devastating drug poisoning crises due to increasingly toxic drug supplies, resulting in a nearly fourfold increase in U.S. drug overdose deaths from 2002 to 2022 [42]. In response, in 2020, Canada introduced a ‘safer supply’ pilot project, offering prescribed medications like opioids, stimulants, and benzodiazepines as safer alternatives to the increasingly potent illegal drug supply [43]. This initiative has led to improved health and quality of life of people who use drugs, reduced overdose risk, and decreased dependency on street drugs [44]. Although Europe has been less affected by the drug poisoning crisis, it now faces the growing threat of nitazenes, highly potent synthetic opioids linked to at least 54 deaths in the UK since 2023, with additional fatalities reported in the Baltic states [45, 46].

The Amsterdam conference brought together policymakers, academics, people who use drugs, and civil society representatives to address the failures and human rights violations resulting from over fifty years of drug prohibition. The event focused on how legal regulation could replace prohibition, rather than debating whether it should, receiving support from several current and former city mayors worldwide [47]. Central to the discussions was the role of harm reduction in a post-prohibition framework. Given the rising threat of highly potent synthetic opioids like nitazenes in Europe, policymakers in the Netherlands must urgently shift from prohibitionist policies and seriously consider legal regulation to improve public health and prevent further avoidable overdose deaths.

Serious debates around responsible regulation are gaining momentum, generating a narrative to reframe harm reduction as a cornerstone in post-prohibitionist policies. Rethinking harm reduction also offers an opportunity to return to its fundamental principles: communities of people who use drugs need to reclaim a leading role in shaping future approaches. Enhancing the alignment between services and the diverse needs of communities is essential. A thorough assessment of existing service provisions alongside community needs serves as an initial step. This evaluation should prioritise the voices of affected individuals, serving as a catalyst to revitalise a robust and resilient movement within communities of people who use drugs.

Conclusion: acknowledging harm reduction as a rights-affirming movement

Harm reduction is an evidence-based, public health approach that has yielded enormous results, including reducing the spread of infectious diseases, decreasing overdose deaths, and improving the overall health and well-being of people who use drugs [48, 49]. The World Health Organization (WHO) [50] and the European Union Drugs Agency (EUDA) [51], formerly known as the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), continue to endorse harm reduction as a vital component of comprehensive drug policies, emphasising the importance of maintaining and expanding these services even amid heightened security measures. Their recommendations stress that effective harm reduction strategies can complement crime prevention efforts, reducing the overall harm associated with drug use and drug laws and mitigating the public health impact.

At the 67th session of the Commission on Narcotic Drugs (CND), member states made a historic decision to include the term "harm reduction" in the official language—a move welcomed and endorsed by The Joint United Nations Programme on HIV and AIDS (UNAIDS) [52]. This milestone signals a growing momentum for policy change, highlighting the need for drastic drug policy reform. As this movement gains traction, it is crucial to promote harm reduction within a system of responsible regulation—moving beyond outdated systems of drug control and repression and toward policies rooted in principles of public health and human rights.

Since its inception, and particularly in the Dutch context, harm reduction is in its essence, a rights-affirming movement. It holds immense potential to empower individuals to assert their entitlements. Harm reduction services provide essential care, encompassing a wide array of strategies to improve individuals' health, socio-economic, and legal circumstances. This should include open discussions and dialogues about drug reform, including regulation of the drug supply. Similar to the momentum seen in the 1970s and 1980s, there is now a renewed push for change. Starting at the grassroots, local level, the time has come to drive systemic transformation and ensure substantial reinvestment in the harm reduction infrastructure.