Europe’s drugs problem is becoming increasingly complex with new challenges emerging that raise concerns for public health. This is according to the European Drug Report 2014: Trends and developments released today by the EU drugs agency (EMCDDA) in Lisbon (1). In its annual review of the drugs problem, the agency again describes an overall stable situation, with some positive signs in relation to the more established drugs. But this is counter-balanced by new threats posed by synthetic drugs, including stimulants, new psychoactive substances and medicinal products, all of which are becoming more prominent in a changing European drug market.
European Commissioner for Home Affairs Cecilia Malmström says: ‘I am deeply concerned that the drugs consumed in Europe today may be even more damaging to users' health than in the past. There are signs that the ecstasy and cannabis sold on the street are getting stronger. I also note that the EU Early Warning System, our first line of defence against emerging drugs, is coming under growing pressure as the number and diversity of substances continue to rise sharply. The system has already reviewed this year four new substances linked to acute intoxications and deaths in the Member States’.
Commissioner Malmström adds: ‘Europe’s law-enforcement bodies are increasingly faced with the fact that small, easily transported packages of seemingly innocuous powders can contain many thousands of individual doses. This annual analysis from the EMCDDA provides us with a critically important window on Europe’s evolving drugs problem. But this information must now feed into law-enforcement, prevention and treatment. It is essential that we use these data to ensure that the response by European authorities keeps pace with the evolving challenges we face’.
EMCDDA Director Wolfgang Götz says: ‘Looking at the big picture, we see that progress has been made in Europe on some of the major health policy objectives of the past. But the European perspective can obscure some important national differences. Our latest data show how encouraging overall EU trends on overdose deaths and drug-related HIV infections, for example, sit in sharp contrast to worrying developments in a few Member States’.
Recognising this complexity, the report provides a top-level overview of the long-term drug-related trends and developments at European level, while also homing in on emerging problems in some countries.
Heroin in decline, but replacement substances cause concern
Although global heroin production remains high and quantities seized in Turkey are rising (Figures 1.4; 1.5), latest data on the demand for treatment and on seizures in Europe point to a downward trend in the use and availability of this drug. The number of reported first-time entrants to specialist drug treatment for heroin problems fell from a peak of 59 000 in 2007 to 31 000 in 2012. Data on drug supply show that the quantity of heroin seized in 2012 (5 tonnes) was the lowest reported in the last decade, half the amount seized in 2002 (10 tonnes). The number of heroin seizures also fell from some 50 000 in 2010 to 32 000 in 2012.
There are an estimated 1.3 million problem opioid users in Europe, mostly heroin users. The report raises concerns over heroin being replaced by other substances, such as synthetic opioids. Illicitly produced or diverted from medical sources, these include highly potent fentanyls and substances used in opioid substitution treatment (OST) (e.g. methadone, buprenorphine). In 2012, 17 countries reported that over 10% of first-time opioid clients entering specialist treatment were misusing opioids other than heroin (Figure 2.9).
Drug-related deaths: overall reduction, but rises in some countries
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, accidents, violence and suicide. Overall, around 6 100 overdose deaths, mainly related to opioids, were reported in Europe in 2012. This compares to 6 500 reported in 2011 and 7 100 cases in 2009. Progress made in this area may be partly attributed to the scaling up of treatment and harm reduction (e.g. OST). Nevertheless, in contrast to an overall encouraging European trend, overdose deaths remain high, or are increasing, in some countries.
The average mortality rate due to overdoses in Europe is estimated at 17 deaths per million population (15–64 years), but with wide national variations. Rates of over 50 deaths per million were reported in five countries, with the highest rates reported in Estonia (191 per million) and Norway (76 per million), followed by Ireland (70 per million), Sweden (63 per million) and Finland (58 per million) (Figure 2.13) (2).
While heroin is still involved in many fatal overdoses, deaths relating to this drug are generally falling and those linked to synthetic opioids are on the rise in some countries. Overdose deaths rose sharply (by 38%) in Estonia in 2012, with fentanyl and its derivatives present in most cases. Non-controlled fentanyl derivatives and a range of other potent synthetic opioids (e.g. AH-7921) have been increasingly reported on the illicit market through the EU Early Warning System (EU–EWS).
HIV: outbreaks in some countries impact negatively on EU trend
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 findings show, however, that developments in some countries, are impacting negatively on the long-term decline in the number of new HIV diagnoses in Europe. ‘Outbreaks of HIV among drug users in Greece and Romania, together with ongoing problems in some Baltic countries, have stalled Europe’s progress in reducing the number of new drug-related HIV infections’, states the report.
The average rate of newly reported HIV diagnoses attributed to injecting drug use was 3.1 per million population in 2012. In Estonia, the rate of new diagnoses remains high (53.7 cases per million in 2012), while in Latvia, annual rates have been rising since 2009 (up from 34.5 cases per million in 2009 to 46.0 in 2012). There were 1 788 newly reported HIV cases in 2012, slightly more than in 2011 (1 732), continuing the upward trend observed since 2010 (Figure 2.11). Whereas in 2010, Greece and Romania contributed just over 2% of the total number of newly reported diagnoses among those infected through injecting drug use in the EU, by 2012 this figure had increased to around 37% (with Greece reporting a rate of 42.9 cases per million population and Romania 8.0 cases).
Despite Europe’s success in fighting HIV transmission among drug users, the virus retains the potential to spread rapidly in certain groups. A 2013 EMCDDA–ECDC risk-assessment exercise to examine countries vulnerable to new HIV outbreaks revealed that one or more risk indicators were present in around one-third of the 30 countries examined (3). This suggests a need for continued vigilance and better coverage of HIV prevention measures (Figure 3.5).
Stimulants: cocaine stable or declining, but concerns around methamphetamine and MDMA
Cocaine remains the most commonly used illicit stimulant drug in Europe, although most users are found in a small number of western EU countries. An estimated 14.1 million European adults (15–64 years) have ever used the drug; 3.1 million in the last year (see ‘At a glance’ table). Recent data suggest declining use of cocaine, with 11 out of 12 countries running surveys between 2011 and 2013 reporting falls in prevalence among young adults (15–34 years). Looking at long-term trends in cocaine use, decreases were seen in Denmark, Spain and the UK (all reporting relatively high prevalence rates), following a peak in 2008 (Figure 2.5). Most other countries show stable or declining trends.
Use of amphetamines (encompassing amphetamine and methamphetamine) remains overall lower than that of cocaine in Europe, with around 11.4 million adults reporting lifetime use and 1.5 million last-year use. Of the two drugs, amphetamine is more commonly used, but there are growing concerns around the availability and use of methamphetamine in Europe. Today’s report describes how methamphetamine seizures, while still small in number and quantity, have increased over the last decade, suggesting increased availability of the drug (Figure 1.10). In 2012, 7 000 seizures amounting to 343 kg were reported in the EU. A further 4 000 seizures, amounting to 637 kg, were reported by Turkey and Norway (almost twice the amount seized in the entire EU).
Methamphetamine use, historically low in Europe and mainly limited to the Czech Republic and Slovakia, now appears to be spreading (e.g. in Germany). Worrying reports are emerging from south-east Europe (Greece, Cyprus, Turkey) that crystal methamphetamine smoking is a limited, but emerging, problem, with the possibility of a spread among vulnerable populations. And methamphetamine injecting has been reported as a new trend among small groups of men who have sex with men in some large European cities (4).
Also highlighted today are concerns over the re-emergence of high-quality ecstasy (MDMA) powders and pills. Seizures and reports of adverse health events have prompted Europol and the EMCDDA to release a joint warning on the availability of high-potency products containing MDMA (5). Europol reports the dismantling in Belgium in 2013 of the two largest drug production sites ever found in the EU, capable of rapidly producing large volumes of MDMA.
New psychoactive substances: EU Early Warning System ‘under increasing pressure’
The rise in the number, type and availability of new psychoactive substances (NPS or ‘new drugs’) in Europe shows no signs of abating, says the EMCDDA. In 2013, 81 new drugs were notified for the first time to the EU Early Warning System (EU–EWS) (6). This brings the number of new substances monitored by the agency to over 350. According to today’s report, the system is ‘coming under increasing pressure from the volume and variety of new drugs appearing on the market’. Almost 250 substances were detected in the last four years.
New psychoactive substances, not controlled under international law, are often sold on the market as ‘legal highs’ and produced with the intention of mimicking the effects of controlled drugs. Twenty-nine of the drugs detected last year were synthetic cannabinoids, the largest group currently monitored by the EU–EWS. The speed at which recently controlled drugs have been replaced by new substances has prompted a variety of innovative legal responses across Europe (Chapter 4).
New drugs may be produced in clandestine laboratories inside Europe. More commonly, however, they are sourced legally as powders mostly from China and India, and imported into Europe where they are processed, packaged and sold as ‘legal high’ products or ‘research chemicals’, as well as sold directly on the illicit drug market. The Internet continues to play a key role in shaping the NPS market. In 2013, the EMCDDA identified some 650 websites selling these substances to Europeans. In addition, purchasing new and ‘old’ drugs via ‘darknets’ — underground, online networks permitting anonymous communication — represents a new challenge for law enforcement.
Highlighted today are signs that, in some countries, these substances are now targeting the main segments of the drug market. In April 2014, the EMCDDA Scientific Committee risk-assessed four potent and harmful new substances: 25I-NBOMe, AH-7921, MDPV and methoxetamine. These are being sold as replacements for, and could even be more harmful than, the drugs they aim to mimic, respectively: LSD (hallucinogen), morphine (opiate), cocaine (stimulant) and ketamine (a medicine with analgesic and anaesthetic properties). Risk-assessment reports on the four substances have been submitted to the European Commission and the Council of the EU, on the basis of which decisions for EU-wide control measures may be taken.
The emergence of highly potent synthetic substances is a concern flagged by notifications to the EU–EWS. This has implications for both users and law enforcement — such substances can be toxic at very low doses and even small quantities of these drugs can be used to make many individual doses.
Cannabis: controversies, contrasts, contradictions
Attitudinal surveys from the EU (7) suggest that cannabis is still the drug that polarises public opinion the most. This contributes to a lively public debate, which has recently been fuelled by international developments in how cannabis availability and use are controlled (e.g. regulatory changes in some states of the US and in parts of Latin America). European discussions on cannabis control have tended to focus on targeting drug supply and trafficking rather than on personal use. However, the overall number of possession and use offences related to cannabis has been rising steadily for nearly a decade (Figure 4.1).
Around 73.6 million Europeans have tried cannabis in their lifetime, 18.1 million in the last year. An estimated 14.6 million young Europeans (15–34 years), report last-year use. Cannabis use in Europe appears overall to be stable or declining, especially in young age groups. National trends appear more divergent, however, as shown by the fact that of the countries reporting new surveys since 2011, eight reported decreases and five reported increases in last year prevalence (15–34 years) (Figure 2.1).
Public health concerns are greatest for Europeans who use the drug on a daily, or almost daily, basis (around 1% of European adults, 15–64 years). In 2012, cannabis was the drug most frequently reported as the main reason for entering drug treatment by first-time clients. ‘The lack of systematic monitoring in the area of drug-related health emergencies represents a blind spot in Europe’s surveillance of emerging health threats’, says the EMCDDA. From the limited data available, cannabis-related medical emergencies appear to be a growing problem in some high-prevalence countries.
EMCDDA Director Wolfgang Götz concludes: ‘I am proud of the insights provided by this report into both established problems and emerging threats. Sound information is at the heart of Europe’s response to drug problems and our interventions are all the more effective because of this. Over 15 years ago, great vision was shown by the EU institutions and Member States in investing in an EU Early Warning System on new psychoactive substances that is now globally respected. I believe that the system — which has repeatedly demonstrated its value for sharing information and rapidly responding to threats — can be strengthened further. I am deeply concerned, however, that this mechanism is under increasing strain and may be at risk if inadequately resourced’.