Offering effective treatment to those with substance use problems is a central pillar of Europe’s response to drugs. According to the EU drugs agency (EMCDDA), both the quality and quantity of care available to drug users has improved considerably since the 1990s when better access to drug treatment became a drug policy priority. The EMCDDA estimates that at least 1 million people in the European Union receive some form of treatment for drug problems every year. Yet considerable challenges remain for treatment services. Heroin-related problems maintain a firm hold, both inside the EU and at its borders, and budgetary constraints become a reality in the economic downturn. These issues are explored in the Annual report 2010: the state of the drugs problem in Europe, launched today in Lisbon.
‘Over the last decade, important, if uneven, gains have been made in responding to drug problems’, says EMCDDA Director Wolfgang Götz. ‘Treatment provision has grown dramatically and considerable progress has been made in addressing some of the most harmful health consequences of drug use, such as HIV infection. But at a time when effective responses need to be sustained, austerity measures could lead to reductions in treatment services. Current pressure on the public purse may well provoke policy decisions that result in Europe incurring long-term costs that far outweigh any short-term savings’.
The report explains how the expansion of treatment has been largely due to the substantial growth in outpatient care, such as psychosocial interventions (e.g. counselling) and substitution treatment (e.g. methadone maintenance). But while underlining the ‘considerable level of treatment provision’ in Europe today, it describes the inequalities that still exist in access to care. Among the barriers to treatment are stringent admission criteria, costs for patients and a lack of human and financial resources.
According to today’s report, most progress has been made in the area of substitution treatment, the most common option for treating opioid use in Europe. Some 670 000 Europeans now receive this type of treatment, up from half a million in 2003 and a 10-fold increase since 1993. Several countries have scaled up their provision in the last decade by involving additional service providers, such as general practitioners.
Today substitution treatment is available in all 27 EU countries, as well as Croatia and Norway. And it is thought to be reaching around half of Europe’s problem opioid users. The extent to which this treatment is meeting users’ needs varies greatly between countries. In some Member States, under 10 % of problem opioid users receive this type of treatment while, in others, over half of them do so. Only 2 % of substitution treatments delivered in Europe occur in the 12 Member States which joined the EU in 2004 and 2007. The estimated waiting time for substitution treatment can be over a year in some countries (e.g. Bulgaria, Poland and Greece), depending on the programme and location.
The diverse patterns of drug use in Europe today call for treatment services to respond to a more complex set of needs than a decade ago. With more cannabis, stimulant and polydrug users now in contact with services, there is a growing call for interventions to address problems other than opioid use. The report explores the progress made in responding to new needs. Responses to cannabis problems in Europe include counselling, structured psychosocial interventions and treatment in outpatient and residential settings. Among the innovative approaches developed in some countries (Germany, the Netherlands and the UK) are Internet-based treatments for cannabis problems to reach those reluctant to seek help within the drug treatment system.
Treatment specifically for cocaine users has been developed in several countries. With drug treatment facilities in Europe still mostly tailored to opioid users, socially integrated powder cocaine users may be reluctant to enter treatment due to perceived stigma. Targeting this population, Denmark, Ireland, Italy and Austria now offer treatment outside regular opening hours to accommodate work commitments and provide discretion. Over 50 medical drugs have been evaluated for treating cocaine dependence but, as yet, none have been proven effective. However, more than 100 ongoing randomised controlled trials with new substances are now registered.
Problems and responses related to amphetamines (amphetamine and methamphetamine) are explored today in a special review published alongside the Annual report (see Selected issue). In general, treatment services are more attuned to the needs of users of these substances in countries where their problematic use is long established (e.g. treatments for methamphetamine use in the Czech Republic and Slovakia).
The importance of effective treatment is highlighted today as data reaffirm that Europe’s heroin problem is no longer diminishing. After a decline in heroin-related problems from the mid-1990s to early 2000s, indicators of opioid trends — new treatment demands, deaths, drug-law offences and seizures — point to an ‘overall stable to increasing opioid problem in Europe’.
The EMCDDA estimates that there are around 1.35 million problem opioid users in the EU and Norway most of these heroin users. New data suggest that recruitment to heroin use is still occurring. Based on data from 19 reporting countries, the overall number of those entering treatment, with heroin as the primary drug, increased from 126 720 in 2003 to 144 128 in 2008 (Figure TDI-3, part ii). And between 2007 and 2008, 11 countries reported more users entering treatment for primary heroin use.
Between 6 400 and 8 500 drug-induced deaths were reported annually in Europe in the period 1995–2007, most of these associated with opioid use (typically over 85 %). Since 2003, the number of drug-related deaths has been increasing steadily in most European countries. Data published today suggest a modest increase in reported drug-induced deaths in 2008: with estimates of 7 371 cases that year in EU Member States and Norway, up from 7 021 in 2007 (Table DRD-2, part i). The age of those dying has also been increasing, suggesting an ageing population of chronic opioid users (see news release No 13 and Selected issue). For each fatal overdose in the EU, it is estimated that there are 20–25 non-fatal overdoses or around 150 000 per year. These episodes not only result in significant health damage but are linked to the risk of future fatal overdose.
The upward trend in heroin-related offences reported in last year’s report is confirmed today in the latest European data: the EU average for such offences increased by 39 % in the period 2003–08. The number of heroin-related offences also increased in 16 reporting countries.
Data from 26 reporting countries show that the number of heroin seizures reported in Europe increased from 41 000 to 56 600 in the period 2003–08, the largest number being in the UK (Table SZR-7). While the number of seizures increased, the overall quantity of heroin seized in the EU and Norway fell from around 9 tonnes in 2003 to 8 tonnes in 2008. Yet Turkey, an important transit country for heroin entering the EU, showed a different trend, reporting a record 15.5 tonnes recovered in 2008, a threefold increase since 2003 (4.7 tonnes) (Chapter 6, Table 9, Figure 9; Table SZR-8).
Injecting drug use is strongly associated with severe health problems in drug users, including blood-borne infections (e.g. HIV/AIDS, hepatitis) and overdose. According to the EMCDDA, the latest data from treatment monitoring are encouraging, showing a stable to downward trend in drug injecting. Among heroin users entering treatment, a decline in the proportion of injectors was reported in 13 countries between 2002 and 2007. Latest data show that under half (42 %) of those entering treatment for primary opioid use in Europe report ‘usually injecting’ their drug, while the proportion for those entering for the first time is lower (38 %) (Table TDI-17, parts i and ii).
But while drug injecting may be stable or declining, it remains central to Europe’s drugs problem. And injecting is still the most common route of administration for opioid users in many eastern European countries: the highest proportions of injectors among opioid users entering treatment in 2008 were reported by Romania (95 %), Estonia (91 %) and Slovakia (86 %).
The public health consequences of drug use in some of the EU’s neighbouring countries are also examined in today’s report. At the eastern border of the EU, UNODC estimates that Russia and Ukraine both have levels of problem opioid use that are two to four times higher than the EU average (EU average: around 4 cases per 1000 population aged 15–64). The problems associated with opioid use in this region include high rates of HIV infection and drug-induced deaths (see box, Chapter 6).
Around 1.68 million problem opioid users (mostly injectors) are reported in Russia and between 323 000 and 423 000 in Ukraine (UNODC, 2010). And studies estimate that in both countries around 40 % of them are reported to be HIV positive. The rate of newly reported HIV cases among injecting drug users is much higher in Russia and Ukraine than in other countries and regions of the world, such as Australia, Canada, the USA and the EU.
According to the report: ‘The rate of reported new HIV diagnoses among injecting drug users has remained low in most countries of the European Union, and the overall EU situation compares positively in a global context’.
Data on newly diagnosed cases of HIV infection related to injecting drug use in the EU suggest that infection rates are still generally falling, following a peak in 2001–02.
Of the four countries reporting the highest rates of newly diagnosed infections (Estonia, Latvia, Lithuania, Portugal) all continued their downward trend, with a marked decline in Estonia and Latvia (Chapter 7, Figure 12). Yet, despite declining trends, the rate of new HIV diagnoses was still at relatively high levels in these Member States in 2008, underlining the need to ensure coverage and effectiveness of local prevention practice.
‘The prevention of infectious diseases is an important public health goal of the European Union and a component of most Member States’ drug policies’, says EMCDDA Chairman João Goulão. ‘Europe has made impressive progress in preventing new drug-related infections, but continued effort is essential. The growing and severe drug-related problems now faced by many of our neighbouring countries are not just public health disasters for the countries concerned, they also represent a sizeable threat for the European Union’.