Europe’s drug market remains resilient, says the EU drugs agency (EMCDDA) today as it launches in Lisbon its European Drug Report 2016: Trends and Developments (1). In its annual review, the agency highlights: the health risks of high-potency products; the continued emergence of new substances; and changing patterns of drug use. It also expresses concern over rises in overdose deaths in some countries and the threats posed by internet drug markets. ‘This new analysis highlights the need for Europe’s drug policy agenda to embrace a broader and more complicated set of policy issues than in the past’, states the report.
Dimitris Avramopoulos, European Commissioner for Migration, Home Affairs and Citizenship, says: ‘Europe faces a growing problem with drugs. New psychoactive substances, stimulants, heroin and other opioids continue to be in high demand and supply, with major impacts on public health. That is why the 2016 European Drug Report is an important addition to our evidence base on the drugs problem and a helpful tool for European policymakers to shape policies and actions to address it. With this knowledge in hand, we will continue to call on EU Member State authorities, third countries, internet companies and civil society to redouble cooperation in fighting this global challenge’.
The return of MDMA: rising use and high-dose products
Today’s report confirms the return of MDMA (often sold as ‘ecstasy’) as a stimulant drug of choice for young people in Europe, citing ‘indications that MDMA is becoming more popular, both with established stimulant consumers and with a new generation of young users’ (2).
Around 2.1 million young adults (15–34 years) report having used MDMA in the last year (1.7 % of this age group). While, until recently, MDMA use had been in decline — following peak levels in the early to mid-2000s — latest survey data point to increased use in Europe (Figure 2.4). Nine out of 12 reporting countries presented higher estimates of use among young adults in new surveys than in the previous comparable survey. There are also signs that MDMA is no longer a niche or sub-cultural drug used in dance clubs, but is now being used by a wider range of young people in more mainstream nightlife settings, such as bars and parties.
Complementing survey data, a 2015 multi-city study found residues of MDMA in municipal wastewater to be higher in 2015 than in 2011, with sharp increases in some cities (Figure 2.5)(3). This may be related to higher purity of MDMA and/or increased availability and use of the drug.
The MDMA revival is associated with ‘innovation in sourcing MDMA precursors, new production techniques and online supply’, explains the EMCDDA. It also reports signs of resurging production, after a decline in the last decade. Large-scale MDMA production facilities, for example, have been dismantled in Belgium (2013) and in the Netherlands (2014).
The availability of products with a high MDMA content prompted the EMCDDA and Europol to issue public health alerts in 2014. Powders, crystals and tablets containing high doses of MDMA are now more commonly available, with tablets sometimes promoted through sophisticated and targeted marketing techniques. This is thought to be a deliberate strategy by producers to boost the reputation of MDMA, after a period in which poor-quality products and adulteration resulted in a decline in use.
EMCDDA Director Alexis Goosdeel says: ‘The revival of MDMA brings with it the need to rethink existing prevention and harm-reduction responses to target and support a new population of users who may be using high-dose products, without fully understanding the risks involved. Intoxications and even deaths associated with this drug are highlighted in our new report. This is particularly worrying since MDMA is moving into more mainstream social settings and is increasingly available via online markets.’
The report highlights that ‘the potential for expansion of online drug supply appears considerable’, although most illicit drug transactions are still played out offline (4). Here the EMCDDA underlines that responding to this ‘growing dark cloud on the horizon’, represents a question of critical importance for the future European policy agenda.
New drugs: new harms and health alerts
Harms related to new drugs in Europe are monitored via the EU Early Warning System (EWS) on new psychoactive substances (NPS). These harms vary in nature but can be serious, including acute poisonings and even deaths. The EMCDDA has issued 34 public health alerts to the Member States relating to the use of NPS since 2014 alone.
The number, type and availability of NPS on the European market continue to grow, with over 560 NPS now monitored by the agency (Figure 1.10). In 2015, 98 new substances were reported for the first time (101 in 2014). Once again, the list of new substances reported was dominated by synthetic cannabinoids and synthetic cathinones (24 and 26 reported respectively). Together, these two groups accounted for almost 80% of the 50 000 NPS seizures in 2014 and over 60% of the 4 tonnes seized (Figure 1.11; 1.12).
Responding effectively and rapidly to the sale of NPS, some of which are found to be highly toxic, is a major challenge. ‘Young consumers may unwittingly be acting as human guinea pigs for substances for which the potential health risks are largely unknown’, states the report.
Synthetic cannabinoids, sold as ‘legal’ replacements for cannabis, can be highly toxic, and mass poisonings have been reported (e.g. in Poland). In February 2016, the EMCDDA issued a warning concerning MDMB-CHMICA, a synthetic cannabinoid associated with 13 deaths and 23 non-fatal intoxications in Europe since 2014. Synthetic cathinones are sold as ‘legal’ replacements for stimulants, such as amphetamine, MDMA and cocaine. The synthetic cathinone alpha-PVP (5), a potent stimulant, has been linked to almost 200 acute intoxications and over 100 deaths since 2011.
The report describes how NPS producers may now be targeting more chronic and problematic drug users. Here concerns are growing over the number of new synthetic opioids detected. (A total of 19 new synthetic opioids, including 11 fentanyls, have been detected since 2009). Many fentanyls are highly potent and may be sold as heroin to unsuspecting users, posing a risk of overdose. In 2015, 32 deaths in Europe were linked to the synthetic opioid acetylfentanyl, leading to an EMCDDA–Europol analysis (6).
Rises in overdose deaths: spotlight on heroin and other opioids
At least 6 800 overdose deaths, mainly related to heroin and other opioids, are estimated to have occurred in the EU in 2014, slightly up on the previous year’s figure (see Chapter 3 and Statistical Bulletin). Worrying rises in these deaths are reported in some countries, with long-established opioid problems (e.g. Ireland, Lithuania, Sweden, UK)(see graphic, Chapter 3 and Figure 3.12).
The reasons behind these rises in fatal overdoses are unclear, but a number of factors may be involved, including: increased heroin availability, higher purity, ageing users and changing consumption patterns, including the use of synthetic opioids and medicines. Overdoses are most commonly reported among older opioid users (35–50), but increases in overdose deaths are also seen among the under-25s in some countries (e.g. Sweden), warranting closer scrutiny. A number of countries now provide the overdose-reversal drug naloxone to opioid users via community schemes (7).
While heroin remains the most commonly used opioid, synthetic opioids are increasingly misused and there has been a rise in the number of countries reporting synthetic opioids as the primary drug used by those entering treatment (Figure 2.9). Synthetic opioids used in substitution treatment (e.g. methadone, buprenorphine) are also regularly found in toxicology reports and these substances are associated with a substantial share of drug-related deaths in some countries (e.g. Ireland, France, Finland, UK). Strategies to prevent the diversion of opioid substitution treatment medications come under the spotlight today in a new EMCDDA analysis (Perspective on Drugs/PODs)(8).
Today’s report is enriched by new city-level data from a selection of hospital emergency rooms across Europe (Figure 3.11). While heroin is the illicit drug most commonly reported in emergencies, cocaine, other stimulants and cannabis feature prominently in some areas. Further developing the monitoring of hospital emergency data will enhance understanding of drug use patterns, acute intoxications and emerging problems (9).
An estimated 1.2 million people received treatment for illicit drug use in the European Union in 2014 (1.5 million including Norway and Turkey). Some 644 000 opioid users received substitution treatment in the EU in 2014 (680 000 including Norway and Turkey). The co-occurrence of substance use and mental health disorders (comorbidity)(10) continues to challenge treatment providers and is explored today in a new EMCDDA analysis (see POD).
Stimulant-related problems ‘becoming more visible’
Recent findings from wastewater analysis and seizure and survey data highlight regional differences in stimulant patterns of use across Europe (Figures 1.5, 2.2, 2.3, 2.6, 2.7). Cocaine use is higher in western and southern European countries — reflecting ports of entry and trafficking routes — while use of amphetamines (amphetamine and methamphetamine) is more prominent in northern and eastern Europe.
The report describes how ‘stimulant-related problems are now becoming more visible’. In some countries, there are concerns over the rising number of new demands for treatment for problems relating to amphetamines, despite relatively stable levels of use (Figure 2.10). Overall, in the last decade, Europe has seen a 50% rise in the number of clients entering treatment for the first time, with amphetamines as their primary drug (see graphic, Chapter 2). This has largely been driven by increases relating to amphetamines in Germany, and, to a lesser extent, to methamphetamine in the Czech Republic.
Despite drug injecting having declined in Europe overall, stimulant injecting is now a concern. Nearly half (47%) of new clients entering treatment in 2014 with amphetamines as their primary drug reported injecting as their main route of administration. A number of countries also report the injection of methamphetamine and cathinones with other drugs (e.g. GHB) among small groups of men who have sex with men. These so-called ‘slamming’ practices are associated with high levels of sexual risk-taking behaviours, pointing to the need for increased cooperation and a joined-up response from drug treatment and sexual health services.
The long-term decline in the number of new HIV diagnoses among people who inject drugs (PWID) in the EU continues. In 2014, newly reported HIV diagnoses among injectors totalled 1 236, the lowest number for over a decade. Nevertheless, in 2015, localised outbreaks of HIV were reported in some marginalised populations in Ireland, Luxembourg and the UK (Scotland). Changes in drug use patterns, particularly increased stimulant injecting, were contributing factors in a number of these outbreaks. ‘Identifying and responding to localised patterns of stimulant use and related harms needs to be given greater priority’, states the report.
Hepatitis C is highly prevalent among PWID in Europe, with national samples in the period 2013–14 showing HCV antibody prevalence of between 15% and 84% (Figure 3.9). While new medicines for treating hepatitis C are increasingly available, providing access to diagnosis and treatment remains a key challenge for professionals working with PWID.
Cocaine remains the most commonly used illicit stimulant drug in Europe, with around 2.4 million young adults (15–34 years) reporting to have used it in the last year. Cocaine was cited as the primary drug by 60 000 clients entering specialised drug treatment in 2014 and by 27 000 clients entering treatment for the first time. Cocaine trafficking to Europe is the subject of a new EMCDDA analysis released today (see POD).
Cannabis: concerns over rises in use, potency and demand for treatment
An estimated 16.6 million young Europeans (15–34 years) have used cannabis in the last 12 months. While levels of use differ between countries (Figure 2.1), overall in Europe they do not appear to be falling and there are signs of some rises. Eight of the 13 countries with recent survey estimates (since 2013), report increases in last-year cannabis use in this age group.
The health and social costs of cannabis use are most pronounced among frequent or long-term users (around 1% of European adults are estimated to be daily or almost-daily cannabis users). Potency levels of herbal cannabis and resin are high by historical standards (see graphic, Chapter 1), which may increase the risks of use.
Data on those entering treatment for cannabis problems can improve understanding of the nature and scale of high-risk use in Europe. The number of those entering treatment for the first time for cannabis problems increased from 45 000 in 2006 to 69 000 in 2014. This rise in demand for treatment has been linked to a number of factors, including changing levels of use and intensive use, availability of more harmful products, different referral practices and greater availability of treatment services.
Cannabis is the most commonly seized drug in Europe, accounting for more than three-quarters of seizures (78%)(Figure 1.1). The number of seizures of herbal cannabis overtook that of cannabis resin in Europe in 2009, and the gap has continued to widen (Figure 1.3). The quantity of cannabis resin seized in the EU, however, is still much higher than that of herbal cannabis (574 tonnes versus 139 tonnes) and the most recent data show that the quantity of resin seized has risen. Changes in Europe’s cannabis resin market are examined today in a new analysis accompanying the report (see POD).
Chair of the EMCDDA Management Board Laura d’Arrigo concludes: ‘Just a few weeks after the United Nations General Assembly Special Session on drugs, this report demonstrates the longstanding commitment of the European Union to an evidence-based approach to drug policy. It provides a comprehensive analysis of the latest tendencies across the 28 EU Member States, Turkey and Norway. It reminds us that, while some of the problems of the past remain firmly with us, new threats continue to emerge, in particular the development of the synthetic drugs market. I am convinced that such a report is a way to share the knowledge on the drug situation in Europe and to build together new responses to these challenges’.