Country Profile - Netherlands

For the past fifteen years there has been a consistently high level of alcohol related problems in the Netherlands. This has become evident from the number of admissions to general and psychiatric hospitals and in the provisions made for addiction care. These hospitalisations consist of "admissions due to toxic effect of alcohol", "admissions due to alcohol misuse without addiction", "admissions in relation to Korsakoff's syndrome", "admissions due to alcoholic liver diseases" and "admissions due to alcoholic psychosis". Taking into account the correction for under-reporting, the number of alcohol related hospitalisations will be considerably higher still. In 1997 over 21,000 people with alcohol problems were registered by out-patient addiction care, while there were approximately 2,700 hospitalisations in addiction clinics.

Among young people there is a considerable rise in "binge drinking" (often combined with the use of stimulants such as cocaine), particularly in connection with weekends, holidays, and going out.

In spite of the intensification of alcohol prevention, such as the permanent alcohol instruction campaign in the mass media, which was launched in 1986, there has not been a decrease in alcohol consumption. In the autumn of 1998, the Dutch parliament is to discuss a new bill on alcohol, restaurants and cafés, which is meant prevent the selling and serving of alcohol to youngsters under 18.

Medical education and training in a nutshell

What has happened over the past fifteen years in the field of training education for physicians and specialist doctors in the Netherlands? In 1983 a new education project was launched in the department of medical education of Amsterdam University. On the basis of a study of American experiences, a wide, inter-disciplinary educational programme was developed for second and third-year medical students. Medical specialisms relevant to alcohol dependence, such as pharmacology, psychiatry, medical science for General Practitioners (GPs), neurology and internal medicine, co-operated in this programme. Besides a body of knowledge on substance abuse (supported by manuals, video materials and laboratory sessions), this programme paid a lot of attention to attitude since research had shown that, in the course of their professional education, students of medicine developed an increasingly negative attitude towards the treatment of people with alcohol problems. It was emphasised, therefore, that early detection and timely intervention would benefit the prognosis considerably.

This Amsterdam initiative was later taken up, in an adapted version, by the Medical Faculty of Utrecht University, resulting in the existence of two undergraduate medical training programmes focusing explicitly on alcohol problems and other addictions.

In 1998 the Medical Faculty of Leiden State University developed a special training programme for GPs on alcohol problems. This programme is particularly aimed at early detection and was extended to all GP education in the Netherlands from early 1990. Currently the impact of these programmes has declined.

ln the early nineties, the Medical Faculty of Amsterdam University conducted research in all medical faculties in the Netherlands into their educational programmes on alcohol addiction. The major findings were:

• alcohol problems receive most attention in psychiatry
• the emphasis lies mainly on the transfer of knowledge
• on average, five to ten hours (modal value: six) are spent on alcohol problems
• there is little co-operation between the medical specialisms
• psychiatry dominates the field, often partly resulting from the fact that professors and teachers also work in the field of addiction care.

The adoption of new standards or protocols by professional associations also affects the development of attitudes to alcohol problems. Too little use has been made of new forms of training and education, such as distance training, the use of specific websites on alcohol addiction, and the like.

In fact, substance abuse has never been a popular theme in the medical training field. There is wide therapeutic pessimism around the treatment of substance abuse.

In addition to these programmes in medical education, two large-scale medical conferences on alcohol addiction have been organised since 1984. These came about largely on the initiative of the so-called Bereave Committee for postgraduate training. On a smaller scale, in different regions of the Netherlands various associations of GPs have organised seminars about alcohol addiction.

Interest in alcohol problems has been highly variable in the past fifteen years. When in the early nineties the Dutch professional association for GPs (NAG) adopted an alcohol standard, the interest of GPs for alcohol problems picked up again.

So far, few results have come from a recent new initiative on the part of some large institutions in the Dutch world of addiction care (1996, Jellinek, Trimbos Institute) to promote the expertise of GPs especially by means of introducing the flowchart of the Plinius Maior Society.

The substance abuse department of the Dutch Association for Psychiatry pays attention to alcohol problems during its annual national conference. People working in the field of addiction care also organise regular training sessions for local GPs, which sometimes grow into longer projects.

Conclusion

Over the last fifteen years a small group of experts has invested heavily in structural innovations in medical professional education. The national reach, however, is too small. There is too much diffuse effort alongside little coherence and co-ordination. The development of new medical curricula (such as in 1983 at the Medical Faculty in Amsterdam) seems to make a positive contribution to a growing interest in substance abuse in medical undergraduate training.

Dr W. Buisman