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In the Netherlands, it is against the law to possess, sell or produce drugs. Soft drugs are less damaging to health than hard drugs. Therefore, in the Netherlands, coffee shops are permitted to sell cannabis under certain strict conditions. A coffee shop is an establishment where cannabis is sold but no alcoholic drinks are sold or consumed. This is part of the Dutch policy of toleration. However, the Netherlands has a policy of toleration regarding soft drugs. This means that the sale of small quantities of soft drugs in coffee shops is a criminal offence but the Public Prosecution Service does not prosecute coffee shops for this offence. Neither does the Public Prosecution Service prosecute members of the public for possession of small quantities of soft drugs. These quantities are defined as follows:. Coffee shops:. Municipalities determine whether to allow coffee shops to operate within their boundaries, and if so, how many. They can also impose additional rules. The objective is to combat the nuisance and crime associated with coffee shops. Coffee shops must become smaller and focus on the local market. This policy will make Dutch coffee shops less attractive to drug users from abroad. To combat drug-related crime and nuisance, the Dutch government introduced a new toleration rule on 1 January only 'residents of the Netherlands' are permitted to visit coffee shops and purchase cannabis there. A resident of the Netherlands is someone who lives in a Dutch municipality and is registered there. Whether this rule is actively enforced differs from municipality to municipality. Coffee shop owners are required to check whether all those admitted to the shop, and allowed to purchase cannabis there, are residents of the Netherlands aged 18 years or older. They should check these facts, for instance, by asking the person to produce a valid identity document or residence permit, in combination with an extract from the municipal population register. It is against the law to grow marijuana and cannabis plants. In cases where no more than 5 plants are grown for personal consumption, the police will generally only seize the plants. If more than 5 plants are found, the Public Prosecution Service will prosecute. In combating cannabis growing, the police collaborate with organisations including housing associations, the Tax and Customs Administration, and energy companies. Tenants found to be growing cannabis may be evicted. The energy company will impose an additional retrospective assessment on those who illegally tap electricity. Toleration policy regarding soft drugs and coffee shops In the Netherlands, it is against the law to possess, sell or produce drugs.

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Official websites use. Share sensitive information only on official, secure websites. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Over the past decade opioid use has risen globally. The causes and consequences of this increase, especially in Europe, are poorly understood. We conducted a population-based cohort study using national statistics on analgesics prescriptions, opioid poisoning hospital admissions and deaths in the Netherlands from to Pain prevalence and severity was determined by using results of — Health Interview Surveys. Between and the proportion of residents receiving opioid prescription rose from 4. Self-reported pain prevalence and severity remained constant, as Over the observation period, the incidence of opioid poisoning hospitalization and death increased from 8. The incidence of severe outcomes related to opioid use increased, as 3. We demonstrated that NSAIDs prescription decreased and opioid prescription increased in the Netherlands since , without an increase in pain prevalence and severity. Consequently, the incidence of severe outcomes related to opioids increased. Opioid prescription and associated medical complications have increased over the recent years, particularly in the United States but also in Europe 1 , 2. Around , individuals in the Netherlands received an opioid prescription in , which increased to over one million individuals 6. Hospital admissions for opioid poisoning increased from 9. Causes for the increased frequency of opioid prescription have not been studied in Europe, although different explanations have been proposed 2. The first cause could be an increased demand for analgesic prescription due to increasing pain prevalence in the population, possibly due to ageing and concomitantly increased morbidity 3 , 4. Nationwide data from the United States have indeed shown that people after the mids gradually reported increased frequency of pain 5. A second reason could be a shift from nonsteroidal anti-inflammatory drugs NSAIDs to opioids prescription. Recently an increasing number of scientific publications have raised awareness that NSAIDs users are at increased risk for adverse events and interactions with other pharmaceutical agents 6 , 7. Simultaneously, the Dutch pain guidelines reintroduced oxycodone in analgesic clinical practice 8. Indeed, preliminary data from the Netherlands showed a peak of NSAIDs use in —, followed by a decrease, while concurrently an increase in oxycodone use has been noted 9. However, it is unknown whether the increase in opioid prescription is paralleled by a similar decrease in NSAIDs prescriptions, which could offer an explanation of the opioid crisis. Together with the increased opioid prescription, an increase in opioid related fatalities, hospitalization and death due to opioid poisoning, was observed. However, information whether hospitalization and death associated with opioid use were also boosted by an increase in illicit opioid use is currently unknown for the Netherlands. Studies from the United States have shown that wide-spread use of prescription opioids in the community preceded illegal opioid trade 10 , The latter introduces an additional risk for severe outcomes, such as overdose, as users of illicit opioids are not monitored Therefore we assessed, among those who were hospitalized or died due to opioid poisoning, how many had not been reimbursed for an opioid prescription, which indicates either in-hospital administration or illicit use. Furthermore, we examined different outcomes of opioid poisoning, i. We aimed to explore two possible causes for increased opioid prescription in the Netherlands: increased pain prevalence and severity, and decreased NSAIDs prescription. Furthermore, we estimated consequences of increased opioid prescription such as hospital admission and death due to opioid poisoning on a population level. The causes and consequences of increased opioid prescription warrant knowledge on precautions needed to be made to prevent further increase in opioid-related fatalities. We conducted a population-based cohort study in the Netherlands. Detailed method descriptions have previously been reported 2. In brief, we performed analyses into prescription reimbursement data, hospitalization, and mortality data using several anonymized databases from Statistics Netherlands CBS covering the total population of the Netherlands between and 13 — Datasets were linked on an individual level, based on the unique anonymized identifiers. Information on pain perception was included in the GE surveys from to The GE is an annual national survey that covers health-related lifestyle choices of Dutch residents Over the four-year period around 38, individuals participated in the survey. To explore the prevalence and severity of pain in the population, we investigated pain-impeded activities of daily living ADL. Pain-impeded ADL was defined as the level of performance of daily activities including outdoor and household chores hindered by pain in the past four weeks Prescription reimbursement data were collected for all Dutch residents entitled to pharmaceutical care, i. Analgesics dispensed from outpatient, community pharmacies, and in residential homes for elderly are collected in the national reimbursement database, whereas medicines dispensed in hospitals and nursing homes are not Individuals were considered exposed to prescription drugs when they filled at least one prescription per studied calendar year. The Dutch Hospital Database contains information about all-cause hospital admissions and the Register of Causes of Death records all-causes of death. Each hospital admission record contains the date of hospital inpatient and outpatient encounters, the discharge date, and the discharge diagnoses 15 , Hospital admissions and deaths registered as due to opioid-related disorders, adverse events of opioid use and opioid overdose were defined as opioid poisoning see Supplement online Opioid poisoning cases were selected based on first hospital admission or death, whichever occurred first, per studied calendar year. We present descriptive statistics for all Dutch residents between and on opioid prescriptions, hospital admissions and mortality. Individuals, who received opioid or NSAIDs prescriptions are presented as counts and as a proportion of the total population per calendar year. Similar analyses were performed on the — GE cohorts where the selected reference group was the GE cohort, whence the weights for standardization analysis were selected. To investigate whether GE surveys were a valid representation of the total population, we linked GEs data with the prescription datafiles of the same calendar year, and performed frequency analysis into opioid and NSAIDs prescription among respondents of the GEs. In , 8 0. In , 31 2. After , there were no missing data. There were no missing data for the total population characteristics and no individuals were lost in the linkage process. To study the impact of increased opioid prescription we performed several analyses. First, we estimated opioid poisoning per calendar year either leading to hospitalization or death. Then we stratified opioid poisoning cases in two categories: whether individuals received opioid prescription or none in the same calendar year. This provides insight in severe outcomes—defined as death, or consequent transfer to another health facility after being hospitalized for opioid poisoning—related to prescription opioid use versus in-hospital or illicit opioid use. Second, we explored residence status prior to hospitalization. Those who were transferred from another health facility to a hospital for an opioid poisoning were considered poisoned whilst being hospitalized, which provides information about in-hospital opioid use. Third, we assessed the severity of opioid poisoning per calendar year by following-up patients after their hospitalization. We classified three main outcomes of opioid poisoning: returning home, prolonged institutionalization, or death. Those who were able to return to their own living environment were considered to have experienced a milder form of poisoning. Those who were transferred to another health facility were considered prolongedly institutionalized due to a more severe poisoning. Individuals who were transferred to a psychiatric hospital were considered having an opioid addiction. Patients who died after being hospitalized for opioid poisoning were considered having experienced an opioid overdose. For the evaluation of analgesic prescription practice and consequences of changes thereof we studied 2 populations: the total Dutch population between and , and the GE survey participants between and For the total Dutch population, among the 16,, mean age, In , 8,, In , 9, GE respondents were included mean \[SD\] age, Stratified analysis showed that natural opioids contributed most to that increase since their use more than doubled 1. Opioid overall and stratified by natural and synthetic , and NSAIDs prescription cases in the Netherlands, from to The number of individuals with neither of these analgesic prescriptions remained stable from to aRR, 1. Opioid and NSAIDs prescription cases stratified by concomitant and single prescription and those with neither of these analgesic prescriptions in the Netherlands, from to Prescription cases are presented as incidence rates per , inhabitants per observed calendar year. Primary axis presents incidence of analgesics prescription, and the secondary axis shows the incidence of those with neither of analgesics prescription. The frequency of opioid poisoning related to opioid prescriptions, nearly doubled after 3. The number of individuals who were hospitalized or died because of opioid poisoning, but had not filled a prescription at a pharmacy also increased, indicative of increase in illicit use 5. Patients with opioid poisoning without an opioid prescription were younger and more often male mean \[SD\] age, Hospitalization and death of opioid poisoning, stratified by receiving opioid prescription in the Netherlands, from to Opioid poisoning cases were derived from hospitalization and death dataset for the year in concern, and duplicate cases were filtered out. That proportion decreased to Residence before and destination after hospitalization for opioid poisoning in the Netherlands, from to Opioid poisoning cases were identified in the hospitalization dataset by the ICDCM codes reported in the Supplement online. We previously reported an increase in opioid prescription and related fatalities in the Netherlands from to 2. In the present study, based on national statistics, and annual population-wide national surveys we further elaborated on causes and consequences of the increase in opioid use. We found a shift from NSAID prescription to opioid prescription, without an overall increase in need for pain treatment. The increase in opioid prescriptions was mainly due to a large increase in the use of natural opioids. The severity of opioid poisoning also increased, since there were more opioid-related deaths among those admitted with opioid poisoning, and the number of those who were consequently transferred to the other care facilities had risen. The increase in opioid prescriptions was mainly due to an increase in natural opioid prescriptions N02AA , namely, morphine, hydromorphone, and especially oxycodone, and not in synthetic opioid prescriptions N02AZ. At the same time a decrease in NSAIDs prescription rate has been observed, although still a large proportion of residents We demonstrated, that a recent increase in opioid prescription cannot be sufficiently explained by increase in prevalence and severity of pain, but that changed analgesic prescription practice, defined as a shift from NSAIDs to opioids prescription, is the most probable reason for opioid epidemic in the Netherlands. The change in analgesic prescription practice subsequently stemmed from a concurrent introduction of oxycodone by revised Dutch pain treatment guidelines 8 , and restriction of NSAIDs use due to their common adverse events by the scientific community 29 , We considered suspicion bias in the observed increase of opioid-related fatalities When suspicion bias would have been the explanation for the increased rate of opioid-related fatalities, an increase in hospital admission and death due to opioid poisoning would have been restricted to those receiving an opioid prescription in the same calendar year. However, the increase also included individuals who had not received opioid prescriptions. These individuals most probably had acquired the drugs illegally, since we found a few in-hospital poisoning 3. These observations render suspicion bias as an explanation for the observed increased rate of opioid poisoning unlikely. Furthermore, this finding is consistent with reports on the opioid epidemic from the United States that showed that widespread opioid use leads to widespread opioid addiction either prescription or illegal use , with gradual increase in severity of consequences fatal or non-fatal opioid poisoning Opioid use and opioid overdose deaths are increasing in most countries in the European union 33 — However, the situation of pharmacologic pain relief in the Netherlands is somewhat different compared with other European countries. For instance, Danish and British pain guidelines advocate NSAIDs as first line treatment, and are far more stringent in opioid prescription compared to the Dutch pain guideline 38 , Furthermore, a decrease in prescription opioid use has been noted since in the United Kingdom Specifically, in the United Kingdom and in Denmark, tramadol is the most frequently prescribed opioid, and not natural opioids, such as oxycodone the opioid that is advocated by Dutch pain guidelines in favour of NSAIDs 41 , This reinforces our finding that a changed analgesic prescription practice, which was preceded by pain guidelines, is indeed responsible for the recent opioid epidemic in the Netherlands. In addition, we showed that, over time, more patients in the Netherlands suffered from prescription opioid poisoning than from illegal opioid poisoning, while in the United Kingdom the far majority of patients have opioid poisoning related with heroin use, i. This research has some methodological issues that warrant commenting. First, to estimate pain prevalence and severity we used results of national health surveys. All other outcomes were identified in the Dutch national statistics. As we consider it unlikely that the missingness was at random, while at the same time the amount of missingness was large, we decided not to impute missing values. However, we consider it unlikely that the reason for missingness changed over the observation period and the level of missingness did not change between and Although, this is an acceptable response rate of questionnaires in social sciences 43 , it may have affected our results. However, population characteristics of survey participants were similar to the total Dutch population from to see the Supplementary Table S1 online , as well as participants were randomly sampled. Therefore, it is unlikely that the results of the national survey are not representative of the whole population. Nevertheless, the missing data may render the absolute numbers of individuals reporting pain inaccurate, where an overestimate seems most likely. Fourth, we did not have the detailed prescription information to enable us to identify individual active substances, dosing, and pharmaceutical dosage forms. Fifth, we only performed research into opioid and NSAIDs prescriptions, but not into other analgesic agents, such as antidepressants and antiepileptic agents, as those are mostly used for neuropathic pain Sixth, NSAIDs are also available as an over the counter medication, and the information about the proportion of the population exposed to them is unknown. In conclusion, the opioid prescription rate is increasing in the Netherlands, without an increase in pain prevalence and severity. This increase is mainly related to natural opioid use, while at the same time NSAIDs prescription is decreasing. This shift in analgesic prescription practice was accompanied by the increase and the worsening of opioid toxicity, which was related to prescription opioids and increased illicit use of opioids. The authors thank Statistics Netherlands for making their data available. The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. Data obtained in all analyses cannot be shared with third parties as Statistics Netherlands does not permit this. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Sci Rep. Find articles by Ajda Bedene. Find articles by Eveline L A van Dorp. Find articles by Tariq Faquih. Find articles by Suzanna C Cannegieter. Find articles by Dennis O Mook-Kanamori. Find articles by Marieke Niesters. Find articles by Monique van Velzen. Find articles by Maaike G J Gademan. Find articles by Frits R Rosendaal. Find articles by Marcel L Bouvy. Find articles by Albert Dahan. Find articles by Willem M Lijfering. Received Mar 20; Accepted Aug 18; Collection date Pain-impeded activities of daily living among the respondents of GE surveys, from to Open in a new tab. Supplementary information. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Leiden buying Heroin