Since the 1970s, heroin has held centre stage in Europe’s drugs scene and is still responsible for the largest share of drug-related diseases and deaths in the EU. But while heroin-related problems continue, they do so at lower levels, says the EU drugs agency (EMCDDA). According to its Annual report 2012: the state of the drugs problem in Europe, launched in Lisbon today: ‘We may now be moving into a new era in which heroin will play a less central role in Europe’s drugs problem’ (1).
‘Increasingly, it has been noted that, in parts of Europe today, new recruitment into heroin use has fallen, the availability of the drug has declined and, recently, some countries have experienced acute shortages’, states the report. Developments in the illicit drug markets will need to be followed closely to establish whether recent shortages will result in a long-term reduction in heroin availability and in other substances taking its place.
Recent declines in heroin use have occurred against a backdrop of rising treatment provision (Figure HSR-2). Over half of the estimated 1.4 million regular opioid users in the EU and Norway (mostly heroin users) have access to opioid substitution treatment today.
Around half (48 %) of those entering specialist drug treatment report opioids, mainly heroin, as their main problem drug (Table TDI-5, part ii). The long-term and chronic nature of heroin problems means that many of these users will remain in need of help for years to come. But, on a positive note, the report describes how the drug is now claiming fewer new recruits (Figure TDI-1, part ii). Across Europe, the number of those entering specialist drug treatment for the first time for heroin problems fell from 51 000 in 2005 to 46 000 in 2010, having peaked at 61 000 in 2007 (Figure TDI-1, part ii). Among other countries, the decline was noticeable in those with long experience of heroin epidemics such as Italy, Portugal and the UK (Table TDI-3, part i). Opioids, mainly heroin, are present in the majority of reported drug-induced deaths in Europe. New data show a small decrease in these deaths in the EU Member States and Norway from around 7 600 in 2009 to 7 000 in 2010.
Market indicators suggest that heroin is becoming less available on the streets of Europe. The decline in the number of heroin-related offences observed in 2009 continued in 2010 (Chapter 2, Figure 3). Latest figures for seizures also point to an overall decrease in heroin supply. Around 51 000 seizures resulted in the interception of 6 tonnes of heroin in 2010 in the EU and Norway, compared with 56 000 and 8 tonnes in 2009 (Chapter 6, Table 9; Table SZR-7; Table SZR-8). Shortages were felt in some countries in late 2010 and early 2011, particularly in Ireland and the UK where law-enforcement successes may have played a role (2).
Cecilia Malmström, European Commissioner with responsibility for the EMCDDA, says: ‘The decline in heroin use in the EU is the result of long-term efforts to reduce both supply and demand. Vigorous policing along heroin trafficking routes has played an important role in stemming supply. Equally important has been the expansion of substitution treatment, which has removed a significant part of the demand from the market. Together these factors may help create the conditions for a continuing decline in Europe’s heroin market in future. Europe may now represent, in some respects, a more difficult marketplace for this substance’.
Changes in heroin availability in Europe may be linked to a ‘shift in drug use patterns’, says the EMCDDA. Some countries in Europe report that opioids other than heroin are now cited as the main problem drug by a high proportion of those entering treatment (Table TDI-113). In Estonia and Finland, for example, the heroin market collapsed almost a decade ago and never fully recovered. Over three-quarters of those entering treatment in Estonia report the synthetic opioid fentanyl as their main problem drug. A 2012 EMCDDA ‘trendspotter’ meeting examined the latest developments for fentanyl, which is considerably more potent than heroin and particularly associated with overdose and drug-induced deaths (3). Buprenorphine, a synthetic opioid commonly used in substitution treatment, is the most frequently reported misused primary opioid among those entering treatment in Finland.
Other opioids are reported by a high proportion of clients entering treatment in Denmark, Latvia and Austria. Meanwhile, some countries are witnessing problem drug users taking substances other than opioids in times of heroin shortage. Reports include increased injecting of cathinones (Hungary) and of amphetamines (Hungary, Latvia) as well as increased use of benzodiazepines and other medicines (Ireland, Slovenia).
Data from treatment clients continue to show an overall decrease in opioid injection (particularly heroin injection) in Europe. A 10-year analysis of trends (2000–09) in heroin users entering treatment, for example, shows that the proportion of those reporting injecting has declined in most European countries. This trend is particularly clear in western EU Member States and among those entering treatment for the first time (Chapter 6). The EMCDDA estimates that among first-time treatment entrants, the proportion of heroin injectors fell to around a third (38 %) in 2009 from over half (58 %) a decade earlier (4).
While the move away from heroin injecting is encouraging, injectors remain among those at the highest risk of experiencing health problems related to drug use, such as blood-borne infections (e.g. HIV/AIDS, hepatitis B, C), overdoses and drug-induced deaths. Over the last decade, large gains have been made within the EU in addressing HIV infection among people who inject drugs — these include a greater coverage of prevention, treatment and harm-reduction measures. Latest European data show that the average rate of newly reported HIV cases in this group continues to fall and has reached a new low of 2.54 new cases per million population per year (an estimated 1 192 new cases in 2010). The overall EU situation compares positively with some countries bordering the EU, where the average rates are much higher (104.3 in Russia; 151.5 in Ukraine — Chapter 7, Figure 16).
Despite Europe’s success in fighting HIV transmission among drug users, the virus retains the potential to spread rapidly in certain groups. Today’s report provides an update on worrying outbreaks of HIV infection among injectors reported by Greece and Romania in 2011 (see box, Chapter 7) (see also this news update on the topic published today). In Greece, the number of newly diagnosed drug injectors infected with HIV was estimated at around 9–19 per year up to 2010 but then jumped to 241 new cases in 2011, due to a local, but large, epidemic among injectors in Athens. The number increased from 1–6 cases to 114 new cases in Romania in the same period. Responding to the outbreak, Greece substantially increased syringe provision in Athens and its drug treatment capacity (opening 22 new opioid substitution units in 2011). In Romania, access to substitution treatment remains limited, but there are signs that syringe provision is slightly improving following a substantial drop in 2010–11 due to lack of funding.
A recent risk-assessment meeting (October 2012) of the EMCDDA and the European Centre for Disease Prevention and Control (ECDC) examined further reports of increases in HIV risk among injectors in several countries, stressing the need for caution (5).
Chairman of the EMCDDA Management Board João Goulão said: ‘We must remain vigilant to the potential risks of future HIV outbreaks. Countries seeing increases would benefit from critically reviewing their national prevention and control programmes and assessing the quality and coverage of key HIV prevention measures, such as opioid substitution treatment, needle and syringe exchange programmes and antiviral treatment. There is a continuous need to keep public health and sufficient preventive services on the agenda in these challenging economic times’.
Bacterial infections are another potentially serious consequence of injecting drug use and can be life-threatening. Covered in today’s report is a recent anthrax outbreak among heroin users (mainly injectors). Since June 2012, around a dozen new anthrax cases have been reported in four EU countries — Denmark, Germany, France and the UK — possibly related to a common source of contaminated heroin and perhaps linked to the same source incriminated in an earlier anthrax outbreak in Scotland in 2009–10. The 2012 outbreak prompted a joint EMCDDA–ECDC rapid risk assessment on the issue (6). This assessment, which includes recommended measures to respond to the infections, concludes that the risk of exposure to the bacterium is ‘still present’ for heroin users. The agencies’ early-warning networks are currently on alert for new cases and surveillance has been stepped up.
It is estimated that around 635 000 people are held in penal institutions in the European Union. Studies show that drug problems are far more common in prisoners than in the general population. For example, whereas less than 1 % of the general population has ever tried heroin, lifetime prevalence levels among prisoners in 8 of the 13 countries were between 15 % and 39 %. While some prisoners stop or reduce their drug use when incarcerated, others may initiate drug use or begin to engage in more harmful practices (e.g. sharing injecting equipment). Overcrowding, poor hygiene and a lack of healthcare provision affect many prisons and contribute to the overall poor health status found in inmates.
In a new review published today alongside the Annual report, the EMCDDA provides insight into drug use in the prison population and the efforts made at European and national level to improve prisoners’ rights and health (7). The report examines the provision of drug-related services in Europe, from prison entry to prison release, addressing counselling, treatment of dependence and the prevention of infectious diseases.
According to the report, many countries have scaled up the provision of interventions within prisons, particularly opioid substitution treatment. However, rarely do prisons offer a standard of care equivalent or comparable to that provided to the wider community. The report presents progress being made in several European countries towards promoting ‘equivalence of care’ and closing this ‘treatment gap’ between community and prison. This includes integrating prison health services with those in the community and, in some cases, transferring the responsibility of prisoners’ healthcare from justice to health ministries. ‘Prison healthcare has, in the past decade, increasingly been recognised as part of public healthcare’, says the report. Also noted is the need to improve continuity of care for prisoners on their release, when the risk of overdose death is extremely high, due to reduced opioid tolerance. Pre-release counselling and overdose response training are highlighted in this regard.
Europe, a major cannabis consumer, is now an important producer of this, its most popular illicit drug. The Annual report describes a marked shift in the European cannabis market, with an overall trend towards ‘import substitution’ (imported cannabis products being replaced by those grown inside Europe’s borders) (8). Twenty-nine of the 30 EMCDDA reporting countries document some cultivation of herbal cannabis (‘marijuana’). In two-thirds of these countries, cannabis consumption is now dominated by herbal products and, in the other third, by imported resin (‘hashish’) (Chapter 3, Figure 4).
The report shows that the number of herbal cannabis seizures made in Europe has increased steadily since 2005, and, with an estimated 382 000 seizures in 2010, has surpassed that of cannabis resin for the first time (358 000 seizures) (Chapter 3, Table 2). But the quantities of cannabis resin continue to greatly exceed those of herbal cannabis: 106 tonnes of herbal cannabis were seized in 2010 and 563 tonnes of resin.
Some 80.5 million Europeans (15–64 years) have tried cannabis in their lifetime, around 23 million of them having used it in the last year (Chapter 3, Table 3). The latest European data confirm the general stabilising or downward trend in last-year cannabis use among young adults (15–34 years) cited in previous EMCDDA Annual reports (Figure GPS-4, part ii). Among school students (15–16 years), the latest (2011) European school survey project on alcohol and other drugs (ESPAD) found that, in half of the 26 EMCDDA countries participating, a stable trend in lifetime cannabis use was noted since the 2007 survey (9). In the remaining half, there are diverging trends. Nine countries showed a significant increase, the most pronounced reported by France, Latvia, Hungary and Poland. Decreases were observed in four countries (Denmark, Malta, Slovakia, UK) (see Chapter 3, Figure 6).
Concerns remain around the 3 million Europeans (15–64 years) who still use the drug on a daily basis (around 1 % of the European adult population) (10). Taken as a whole, any optimism around steady levels of use needs to be tempered by the fact that this drug remains an important public health issue. Around 25 % of clients entering drug treatment report cannabis as their main problem drug.
EMCDDA Director Wolfgang Götz concludes: ‘The difficult financial situation in Europe, which forms the backdrop of our reporting, means that resources for addressing health and social problems are in short supply. Ensuring the highest treatment quality and best treatment outcome for the lowest possible cost are therefore priorities in the current climate. It is essential to ensure that the available funds are invested in well-targeted activities of proven effectiveness. By working together and sharing experiences and best practice, EU Member States can help achieve this’.
In this regard Götz referred to the recent positive evaluation of the current EU Drug Strategy (2005–2012) and the importance of the upcoming new EU Drug Strategy 2013–2020.