How to respond to the problems of older heroin users? How to tackle deaths from highly potent fentanils? How to prevent harms from drug and alcohol use in festivals and clubs? These are among the questions explored by a new European guide released today by the EU drugs agency (EMCDDA)(1). Drawing on insights from 30 countries, Health and social responses to drug problems: a European guide presents the agency’s first overview of actions and interventions currently available to address the consequences of illicit drug use. It is designed to benefit those approaching drug problems from a public health planning perspective as well as frontline workers and practitioners.
Drug use today presents us with a complex and ever-shifting set of problems, and a wide diversity of programmes exists to address differing needs and objectives. The new guide provides practical guidance on how responses in the drugs area can be better conceived, targeted and delivered, furnishing the building blocks for developing, and successfully implementing, interventions.
EMCDDA Director Alexis Goosdeel says: ‘The EMCDDA is committed to assisting policymakers and practitioners in planning and delivering policies and programmes that contribute to a healthier and more secure Europe. This innovative new guide surveys some of the main public health challenges in the drugs field today and provides a map with which to navigate the various stages of designing, targeting and implementing effective responses. To remain relevant, those involved in responding to drug problems must be prepared to adapt, innovate and develop new partnerships. This practical guide equips them with the tools to respond to the drug problems of today, but also to prepare for those of tomorrow’.
The guide views health and social responses to drug problems from the three perspectives of responding to:
Designed as an initial reference point, the publication includes summaries and user-friendly signposting to highlight key information, best practice examples and implications for policy and practice. It also acts as a gateway to a wide range of online resources, providing links to evidence and tools.
Evidence-based responses gaining ground in Europe
‘Evidence-based responses appear to be steadily gaining ground in Europe, and within the current financial climate, there appears to be greater interest than ever in ensuring that scarce health resources are well spent’, says the guide. It underlines the importance of understanding what evidence exists to support a specific intervention, and how to use it. Here it provides ‘evidence ratings’ for the different actions explored (Spotlight p. 23), but stresses that what works in one group or setting may fail in a different context. A key message emerging from the guide is that using evidence is an ‘ongoing process’ and that it is essential to develop the knowledge base through collaboration in research, monitoring and the sharing of best practice. The guide links to the EMCDDA Best practice portal, which contains a wide range of resources, including the ‘Xchange’ registry of evidence-based programmes, and standards to boost the quality of responses (Spotlight, p. 164)(2).
The benefits of reaching out and forming new partnerships
Drug problems often interact or co-exist with other health and social problems. The guide therefore underscores the value of drug services forming partnerships with other areas (e.g. sexual and mental health care, housing services) to improve effectiveness and efficiency (Spotlight, p. 31, p. 72). Some groups have a particular need for integrated services, such as ageing opioid users who are vulnerable to health problems, or drug users with mental health issues. ‘Effective cooperation between services is essential to meeting the complex health and social needs of many of those with drug problems’, states the guide.
The guide provides examples of a range of collaborative approaches in Europe, including partnerships between prison and community healthcare providers, which facilitate treatment delivery in prison as well as continuity of care upon release. Also, club owners, the police, health and emergency services and municipalities are teaming up with drug services to prevent and reduce the harms associated with drug and alcohol use in nightlife settings (Chapter 4.2)(3). The value of engaging with local communities and drug users to improve the delivery of services is also explored. Examples include collaboration around drug consumption rooms, which can reduce harms to the community and drug user (Spotlight p. 156), and user-led interventions for recovery and reintegration (Spotlight p. 167).
Harnessing the potential of new technologies
The internet, social networking apps, new payment technologies and encryption software are changing the way in which drugs can be bought and sold. These changes not only affect drug markets and consumption patterns but also offer new opportunities for health and social responses. ‘To remain relevant, those involved in responding to drug problems will need to … harness the potential of new technologies to support the better delivery of prevention, treatment and harm reduction initiatives’, affirms the guide.
A spotlight is placed on e-health interventions, which can use digital technologies to provide harm-reduction advice, train treatment professionals and reach out to vulnerable young people who may be reluctant to engage with formal services (Spotlight p. 119).
Reducing drug-related harms: opportunities and gaps
The guide reviews progress to date in preventing and reducing drug-related harms (e.g. the expansion of opioid substitution treatment) but highlights areas where opportunities exist for further improvement. Hepatitis C infections account for a considerable share of drug-related health costs in Europe)(4). The publication states: ‘Currently, a window of opportunity exists with the emergence of new treatments, and the eradication of this disease now appears a realistic possibility’. Here it highlights the benefits of better coordination between drug and specialist liver services to guarantee adequate treatment coverage and protect those at risk from future reinfection (Spotlight, p. 62). ‘Without effective action, the future costs associated with a hepatitis C infection, in particular, are likely to grow exponentially’, concludes the guide.
Figure 2.5 Hepatitis C treatment before and after the advent of direct-acting antiviral agents
Risk factors associated with fatal overdoses are now well known and there have been some notable advances in life-saving interventions, such as the provision of the opioid-overdose-reversal drug, naloxone. However, the increasing number of overdose deaths in Europe suggests a need to expand the provision of these, and other, interventions which reduce the risk of opioid-related deaths.
Figure 2.3 Interventions to reduce the risk of opioid-related deaths
Figure 2.4 Interventions in place in European countries that can reduce opioid-related deaths
New policy perspectives and modern drug problems call for flexible responses
New policy perspectives and changing drug problems bring fresh challenges for European drug responses. As highlighted, flexibility is needed: ‘…modern drug problems can change quickly and have the potential to overwhelm existing drug policies and response models’. Recent challenges include the rapid emergence of new psychoactive substances, such as highly potent opioids (e.g. fentanils — Spotlight, p. 52) and synthetic cannabinoids (Spotlight, p. 81). As more new substances enter the drugs market, toxicological and forensic capacity must also be improved as part of the frontline response.
Against the contemporary backdrop of socio-demographic and economic change, the guide explores the potential vulnerability of migrants and asylum seekers to drug problems and the need for services which recognise diversity and build trust (Table 3.1). Recent changes in the regulatory framework for cannabis occurring in parts of the Americas are also generating interest among policymakers and the public in Europe (Spotlight, p. 40)(5). And there is a growing interest, in both regions, in exploiting the therapeutic potential of cannabis-based medicines. Developments in the cannabis policy area may have knock-on effects for prevention, treatment and harm reduction responses to this drug, and valuable lessons may be learnt from innovations outside Europe.
3.3 Availability of selective prevention interventions for ethnic minority groups in the European Union, 2015/16
The EU Drugs Strategy 2013–20 aims to reduce drug demand, dependence and drug-related health and social harms and to reduce the supply of drugs. This guide supports the strategy in the area of reducing drug demand and the health and social consequences of drug use.
Alexis Goosdeel concludes: ‘We believe that the EMCDDA can best contribute to the health and security of European citizens by providing an analysis of the drug problems we face, combined with a critical review of potential responses and of the practical tools to support policy decisions and practice. This guide is our first, and most ambitious, attempt yet to assemble information on available health and social responses to drug use in Europe in one easily accessible resource. By highlighting gaps in knowledge and practice alongside opportunities for improvement and development, it provides the basis for a refreshed programme of work in this field for the years to come’.