Injecting drug use is strongly associated with severe health problems in drug users, including both blood-borne infections (e.g. HIV/AIDS, hepatitis) and overdose. But the latest analysis of this practice is encouraging, says the EU drugs agency (EMCDDA). In a new report released today ahead of International day against drug abuse and illicit trafficking (26 June), the agency describes how injecting drug use is now stable or declining in most European countries (1).
‘Injecting drug use has a long history in Europe, but came to the fore in the early 1980s in the context of a growing heroin problem and the diffusion of HIV. Since then it has been associated with over 100 000 deaths’, explains Chairman of the EMCDDA Management Board, João Goulão. ‘Some 30 years on, we are encouraged that drug injecting now appears to be waning. But we cannot forget that it is still at the heart of Europe’s drug problem’, he adds.
In this latest report, Trends in injecting drug use in Europe, the EMCDDA estimates that there may be between 750 000 and one million active injecting drug users currently in the EU. And, in several countries, there are still signs of recent recruitment into drug injecting.
The report analyses data from a variety of sources to describe Europe’s current drug injection problem and to plot its trends in recent years (2). Also reviewed are responses to drug injecting and measures to reduce the harm it causes.
Data collected on drug users entering treatment provide a comprehensive picture of drug injecting in Europe. One-third (33 %) of all those entering treatment for drug problems in 26 countries (25 EU + Croatia) report ‘usually injecting’ their main drug of choice. The proportion varies greatly between countries, with ‘usual injectors’ representing under 2 % of all those entering treatment in the Netherlands and 93 % in Lithuania (3).
According to today’s report, of the clients entering treatment for the first time for opioid, cocaine or amphetamine problems, the proportion reporting injecting has decreased in most countries.
Injecting drug use in Europe is mostly linked to opioid use, but now less than half (45 %) of those entering treatment for primary opioid use report ‘usually injecting’ their drug (see Figure 4, p.12). Between 2002 and 2007, among heroin users entering treatment for the first time, the decline in the proportion of injectors was statistically significant in 10 countries. Only two countries, Bulgaria and Slovakia, bucked the trend with statistically significant increases. Over the same five-year period, data on those entering treatment for the first time suggest a declining trend in injecting among primary cocaine users and a stable trend among primary amphetamine users (4).
Among primary opioid users entering treatment, the lowest proportion of current injectors is reported by Denmark (2 %), with Belgium, Spain, France and the Netherlands also reporting levels below 25 %. The highest levels of injecting among this group are reported from countries that entered the EU in 2004 or later: 97 % in Lithuania and over 90 % in Latvia and Romania. Studies of drug users in non-treatment settings (e.g. cohort studies) largely confirm the overall decline in injecting among opioid users in Europe.
The proportion of new (less than two years) and young (under 25) drug users within samples of injecting drug users is used as an indicator of recent initiation to injecting. The report finds that new injectors make up less than 10 % of injectors sampled in 10 EU Member States in the context of infectious disease surveillance. Although in two EU Member States (Czech Republic, Lithuania) and Turkey their proportions are higher (above 20 %), suggesting ongoing new recruitment to injecting here in recent years (see Figure 5, p.14).
Injectors under the age of 25 account for less than 20 % of injectors sampled in 11 countries (10 EU + Turkey), but for over 40 % of injectors sampled in the Czech Republic, Estonia, Latvia, Lithuania, Austria, Romania and Slovakia. Most of the countries reporting higher proportions of young injectors experienced the introduction of heroin use later than elsewhere in Europe. This underlines a need for continued vigilance in these countries to reduce the potential for any future epidemic spread of HIV in these groups of injectors.
HIV infection is one of the most serious health consequences of injecting drug use and one that poses a threat, not only to the drug users themselves, but also to their sexual partners and the general population. According to today’s report, in the EU Member States, the rates of newly diagnosed cases of HIV infection among injecting drug users are mostly at stable and low levels, or in decline (5), consistent with the general trend in injecting drug use. In comparison, among countries neighbouring the EU, increasing rates of reported HIV cases attributed to injecting drug use suggest high levels of drug injecting and ongoing HIV transmission.
European countries target injecting drug use and its consequences through a variety of interventions, mainly in the fields of drug treatment and harm reduction. The most prominent of these is opioid substitution treatment (OST), which is now available in all 27 EU Member States, Croatia and Norway.
According to latest estimates, there are around 650 000 clients in substitution treatment in the EU, representing more than a three-fold increase since 1995. The level of provision, however, is not uniform across countries, with available estimates showing considerable variation. Data from 10 countries show variations in the proportion of problem opioid users with access to OST: from 5 % in Cyprus to over 50 % in Germany.
Providing drug users with access to sterile injecting equipment is an important measure to reduce the harms associated with drug injecting, such as the spread of infectious diseases. Needle and syringe exchange programmes now exist in all 27 EU Member States, Croatia and Norway. Specialised syringe provision outlets — not including pharmacy sales — are estimated to distribute on average about 50 syringes a year per injecting drug user across the EU. In prisons, drug injecting is associated with high levels of syringe sharing, but only five EU countries have implemented syringe exchange programmes in this setting.
‘Injecting drug use was one of the major problems in Europe that motivated policymakers to create the EMCDDA in the early 1990s’, recalls EMCDDA Director Wolfgang Götz. ‘The data we publish today show that injecting drug use is declining in many countries, as are rates of new HIV infections among drug users. These developments can been linked to sound investments made in effective prevention, treatment and harm-reduction measures which now reach many more of those in need. Nonetheless we cannot ignore the fact that many drug users still inject their drugs and that this form of behaviour can be particularly damaging. Targeting drug injection and the harms it causes therefore remains a high priority for European drug policy’.