Record levels of treatment provision for Europe’s drug users are among the positive changes seen in the current European drug landscape, according to the European Drug Report 2013: Trends and developments published today by the EU drugs agency (EMCDDA) in Lisbon. Yet, the agency warns that considerable challenges remain for treatment services. Although the number of heroin users entering treatment for the first time continues to fall, the long-term nature of heroin problems means that many of these users will remain in need of help for years to come. And the agency underlines that, with a large number of drug users now in contact with services, there is a growing need to focus on continuity of care, social reintegration and building consensus on what constitute realistic, long-term outcomes for recovery. Among the issues highlighted today is the need to invest in new interventions, such as those developed to treat hepatitis C and prevent overdose. A strong message from the report is that drug treatment is likely to be a cost-effective policy option, even at a time of economic austerity.
The EMCDDA estimates that at least 1.2 million Europeans received treatment for illicit drug use in 2011. Opioid users represent the largest group undergoing treatment, followed by cannabis and cocaine users (Figure 3.5). Substitution treatment remains the ‘first choice’ for treating opioid dependence, says the agency. Some 730 000 Europeans now receive this type of treatment — up from 650 000 in 2008 — representing around half of the estimated 1.4 million problem opioid users in Europe today (see Chapter 3). Psychosocial interventions and detoxification are the other main forms of drug treatment provided.
‘With Europe still facing negative economic growth, increasing unemployment rates and reductions in government spending, available budgets for health, public order and safety measures run the risk of being affected’, says Chairman of the EMCDDA Management Board João Goulão. ‘We are already receiving reports from a number of European countries of cuts in drug-related services. We need to reinforce the message that drug treatment remains the most cost-effective policy option, even in difficult economic times’.
Four areas requiring increased attention are highlighted in the report:
Transmitted through the sharing of needles, syringes and other injecting equipment, hepatitis C is the most common infectious disease among injecting drug users (IDUs) in Europe today, with national samples of IDUs showing between 18% and 80% infected with the virus (HCV)(Figure 2.11). Often known as the ‘hidden epidemic’, hepatitis C infection can go for long periods undiagnosed, with many of those infected showing either mild or no symptoms for 20 years or more. Unlike hepatitis B, hepatitis C has no vaccine, yet the disease is preventable, says the EMCDDA.
In a special focus on treating hepatitis C, published alongside today’s report (see POD), the agency warns that, ‘a large burden of advanced liver disease can be expected over the next decade’ among infected IDUs. This is due to the fact that hepatitis C infection may progress to liver cirrhosis and cancer, requiring costly treatment.
The EMCDDA explores some of the positive advances in treating the disease today, including a new generation of medicines which act in a shorter period of time and carry reduced side-effects (e.g. direct-acting antivirals; interferon-free treatment). But, it says: ‘In spite of the burden of disease and recent improved treatment outcomes for hepatitis C patients, available data show treatment uptake to be very low among IDUs’. Also, in some European countries, initiatives directed at testing and counselling injecting drug users about hepatitis C are ‘still limited and poorly funded’. Studies suggest that encouraging infected drug users into hepatitis C antiviral treatment, not only reduces transmission of the virus, but can also prevent new infections.
‘We now know that drug users can benefit from HCV treatment and that new therapies are becoming available that offer even greater opportunities to intervene effectively’, says EMCDDA Director Wolfgang Götz. ‘We also know that far too few drug users are benefiting from these developments. We must act to promote early intervention, encourage service uptake and remove barriers to care. The long-term costs of inaction in this area, for both those infected and the public purse, will be considerable’.
Drug use is one of the major causes of mortality among young people in Europe, both directly through overdose (drug-induced deaths) and indirectly through drug-related diseases and accidents, violence and suicide. Most studies of cohorts of problem drug users show mortality rates in the range of 1–2% per year, representing an ‘excess mortality’ (risk of death compared with the general population) in this group of 10 to 20 times higher than in their non-drug-using peers (Chapter 2).
Overall, around 6 500 overdose deaths, mainly related to opioids, were reported in 2011. While this is down on the 7 000 cases in 2010 and 7 700 in 2009, reducing drug-related deaths remains a ‘major challenge for public health policy in Europe’, says the report.
Addressing this challenge is brought into focus today in a special EMCDDA review on new responses to drug-related deaths (see POD). The agency highlights, among others, how to improve bystander responses by training peers and families of drug users in recognising and responding to overdoses, so that fatal outcomes can be avoided. This includes the reversal of opioid effects with an effective and inexpensive antidote (naloxone). Five countries — Denmark, Germany, Italy, Romania, UK — report pilot projects or programmes providing take-home naloxone to opioid users, their families and carers (Figure 3.4).
Treatment for drug problems plays a significant role in helping drug users end, or at least manage, their substance use. But there are concerns that measures to encourage their ultimate inclusion in society are often overlooked, potentially undermining their chances of long-term recovery. According to the EMCDDA, all countries today report the existence of social reintegration services of some kind which can help improve social skills, promote education and employability and help meet housing needs (Figure 3.12). But, it adds, that levels of provision are generally ‘insufficient in relation to needs’.
Among clients who entered specialised drug treatment in 2011, about half were unemployed (47%) and almost one in 10 lacked stable accommodation (9%). Low educational attainment is also common among this group, with 36% having completed only primary education (Chapter 3). The success of social reintegration measures often relies on collaboration between different support services. On a positive note, a recent EMCDDA survey showed that 17 out of 28 countries reported the existence of some form of partnership between drug treatment agencies and services offering support in areas such as housing and employment.
Recent studies report that between 5% and 31% of prisoners have ever injected drugs (Chapter 3). While some prisoners stop or reduce their drug use when incarcerated, others may initiate drug use or engage in more harmful practices (e.g. sharing injecting equipment).
Prisoners with drug problems often have complex health needs requiring multidisciplinary responses, making needs assessment upon prison entry an important intervention. Most countries now report partnerships between prison health services and community health providers, but, overall, the provision of drug services in prisons still lags behind provision in the wider community. The EMCDDA emphasises the need to ensure continuity of care for prisoners on their release, when the risk of overdose death is elevated due to reduced opioid tolerance.