The need to avoid paying a high price for cost-cutting measures
As Europe enters a period of economic austerity, with rising levels of youth unemployment, there are fears that this may be accompanied by an increase in problematic forms of drug use. Depressed and marginalised communities have always been at elevated risk of experiencing drug problems and the collateral damage of crime and unsafe communities. Europe now faces the double jeopardy that at a time when the need for effective responses may be growing, austerity measures could lead to cuts in provision. Over the last decade, important, if uneven, gains have been made in addressing drug problems. Treatment numbers have grown dramatically and considerable progress has been made in addressing some of the most harmful health consequences of drug use, such as HIV infection. Moreover, studies have demonstrated that interventions can be cost-effective, reducing expenditure on related health, social and crime problems. The risk exists that today’s economic situation may provoke policy decisions that result in Europe accruing long-term costs that far outweigh any short-term savings.
In the spotlight: guidelines, frameworks and improving the evidence base for assessing supply reduction
The Lisbon Treaty, which came into force on 1 December 2009, gives new emphasis to the European Union’s role in establishing guidelines, indicators and supporting the exchange of best practice in the drugs field. In times of economic austerity, it is particularly important to ensure that expenditure is directed towards interventions of proven effectiveness. The European approach to drugs can be characterised as one in which evidence takes priority over ideology. However, there are still many areas where investments are directed towards approaches that lack robust evidence for effectiveness or have been poorly evaluated, while approaches of proven value are not always implemented. This is an ongoing problem in the prevention field, but not limited to this area. Good programme models exist in many areas of demand reduction, and there is a growing understanding of what is likely to constitute effective action. The challenge is to build the consensus necessary to codify this knowledge into a set of guidelines and frameworks that are sufficiently prescriptive to support service improvement, while still being sensitive to the different contexts found across the European Union.
The public health field is long used to the discipline of having to justify the impact of its interventions. The need to extend this approach to supply reduction activities has become an increasingly common theme in the EU policy debate. Expenditure on supply reduction is often difficult to identify in national budgets, but studies suggest that it is considerable and generally exceeds expenditure on public health responses. Recent Council deliberations concluded that evaluation of supply reduction activities is handicapped by the lack of standard indicators and measures. Establishing key indicators for supply reduction is an objective in the current EU drugs action plan. In 2009, the European Commission and the EMCDDA launched a joint initiative to address this problem, and the identification of key supply indicators and a mechanism for their implementation can be expected in 2011.
Policy perspectives: challenges for the European drug policy model
Virtually all EU Member States have adopted a common approach based on a national drug strategy, usually supported by an action plan, which has concrete targets and is time based. This policy model is a rational one as it allows a regular audit of progress and the opportunity to redirect policy where it is found to be lacking. It is also a demanding approach, as new drug strategies have to be developed, agreed and adopted, often while the old strategy is being evaluated. These difficulties are highlighted in this year’s report, where for the first time we report a decrease in the number of countries having a valid national drug strategy in place. This is largely because of the practical challenges of evaluating and renewing national strategy documents that expired in 2008 or 2009. The EMCDDA is working with Member States to develop policy evaluation tools to allow an ongoing review of drug policy developments. There are no simple solutions to the problem of evaluating drug policies, but it would be a shame if failings in processes and planning undermined an important achievement of the European response to drug problems.
As noted in last year’s report, the link between alcohol and drug problems is a strong one. Despite this, no common approach is observable in terms of uniting drug and alcohol policies across the EU Member States. Some countries maintain separate drug and alcohol policies, others link them, and some have not yet developed an alcohol strategy. Strong arguments exist for the need to seek synergies between drug and alcohol policies, not least of which is the fact that they will often be targeting the same populations and settings. Current policy models are also challenged by the growth of the ‘legal highs’ market, as well as the misuse of pharmaceutical products, as discussed below. From a public health perspective, this highlights the need for a more comprehensive approach, encompassing both illicit and licit substances, and possibly other behavioural addictions. The challenge is two-fold: to consider to what extent this overarching vision is justified, and how this perspective might be translated into an appropriate regulatory and control framework.
New developments in national drug laws reveal commonalities and differences
An example of the differences that exist between EU Member States in policy implementation, even where a general consensus prevails, can be found in the area of penalties for drug offences. In most EU countries, the legal systems take into account the type and ‘harmfulness’ of the drug in question and whether the offence relates to involvement in the drug market or to personal use or possession for personal use. These distinctions vary greatly between countries. They may also be codified in law or result from processes operating within the criminal justice system. It is unclear what benefits the different approaches bring or what constitutes good practice, suggesting the value of a comparative analysis in this area. Currently, comparisons between countries should be made with caution, as differences between offences may be as much determined by the legal practice of the country in question as the nature of the offence itself. A second question is the extent to which the policy distinction made between those profiting from the sale and transport of drugs and those who are using them is translated into practice. The most recent data show a slightly downward trend in supply-related offences, while the number of use-related offences continues to rise.
Drug treatment: more available than ever, but inequalities evident
Effectively treating those who have problems with their substance use is a central pillar of Europe’s response to drugs. It is an area in which both the quality and quantity of care available continues to grow. The EMCDDA estimates that more than a million people annually receive some form of treatment for drug problems in the European Union. Treatment expansion has been led by a growth in specialist outpatient care, supported by low-threshold services and outreach. Importantly, in some countries, drug services combine specialist care with the involvement of primary health care services and general practitioners. Some types of drug problems, in particular the more intractable cases, are likely to be best handled by specialist teams. However, an appropriate mix of specialist and generic care can be an important element in increasing the overall availability of care, especially when referral and support channels are well established.
Although treatment provision has increased, inequalities are evident in treatment access across Europe. In most eastern European and some southern European countries, treatment availability is relatively limited, as reflected in long waiting lists. Levels of treatment availability can only be meaningfully assessed in relation to the relative coverage of the population in need of care. It is still difficult to comment with certainty on the extent to which available care meets needs, although some progress has been made in respect to opioid substitution therapy. Overall, the EMCDDA estimates that about 670 000 Europeans now receive opioid substitution treatment, representing about half of the estimated number of problem opioid users. This figure varies greatly between countries, with national estimates ranging from less than 10% to more than 50% of problem opioid users receiving care. Differences in the availability of care are further illustrated by the observation that only around 2% of substitution treatments occur in the 12 Member States who joined the European Union since 2004.
Substitution treatment is also considered a harm-reduction measure. Together with needle and syringe exchange, it has been widely promoted as an important component in a comprehensive HIV prevention strategy for injecting drug users. With overall stable or declining trends in injecting levels and drug-related HIV infection, the European Union’s situation in respect to drug-related HIV transmission looks positive in comparison with many parts of the world. The EMCDDA published a scientific monograph on harm reduction in 2010, which charted the mainstreaming of the concept of harm reduction, with both substitution treatment and syringe exchange now accepted components of European drug policies. The monograph also highlighted the need to improve the evidence base for other harm-reduction interventions and the scarcity of well developed harm-reduction models for problems with stimulant and polydrug use, patterns of use that are becoming increasingly important in Europe. It also noted that responses in Europe are still failing to impact significantly on hepatitis C virus infection among injectors and drug overdose deaths, and that harm-reduction approaches could have an important role to play here.
Developing models of care and response for Europe’s evolving drug problem
Current patterns of drug use are challenging services to develop more complex and differentiated needs-based responses, with better linkage to generic health and social care resources. In respect to substitution treatment, this can be seen in an ageing and more chronic group requiring care, a topic addressed in a Selected issue accompanying this report. The need for treatment and other responses for non-opioid related problems is also growing, with increased numbers of cannabis and stimulant users coming into contact with services. Complex patterns of polydrug consumption, which commonly include alcohol-related problems, represent another challenge. Models of care are improving in these areas, although considerable room for improvement still exists for developing and sharing best practice. While purely pharmacological therapy options for stimulant users still appear unlikely, increased research interest in this area has yielded encouraging findings, including a better understanding of the contribution of psycho-social approaches.
Cannabis: regional variations important
Cannabis remains the most popular illicit drug in Europe, but with large differences in prevalence of use observable between countries, illustrated by the fact that the highest estimates reported are more than 30 times greater than the lowest. Overall, trends in consumption show stable or declining levels of use. Within this general long-term picture, however, divergent patterns can be identified. Of particular note are some countries in eastern Europe where consumption levels still appear to be increasing and, in some cases, now rival or exceed prevalence levels found in western Europe.
There is a growing understanding of the public health implications of cannabis use, which mostly focuses on those users reporting daily and chronic patterns of consumption. Recent reviews examining the adverse health consequences of the drug identify a number of effects, including anxiety, panic reaction and psychotic symptoms. These acute effects account for a substantial number of drug-related hospital emergencies in the few countries that monitor them.
In the most recent data, the overall number of new treatment clients with cannabis as the main drug is decreasing in most countries. The factors behind this change are unclear but merit investigation, as it could indicate either a reduced service capacity to accept new clients or a decrease in the number of people being referred to cannabis-related treatment.
Europe’s considerable appetite for cannabis is reflected in annual seizures of about 1 000 tonnes of the drug. Overall, the data suggest that cannabis, in its various forms, may be becoming more rather than less available on the European market. Despite indications that domestically produced herbal cannabis has become more common, the quantities of herbal cannabis seized in the European Union have remained stable, while resin seizures have increased. In volume terms, the discrepancy between seizures of cannabis resin and herbal cannabis is in the order of ten to one. Any conclusion on the availability of the different types of cannabis in Europe needs to be made with considerable caution as herbal cannabis is produced closer to its intended market and is therefore less likely to be interdicted. There have also been increasing reports of the involvement of organised crime in domestic cannabis production, prompting new action by both national and European law enforcement bodies.
Understanding Europe’s complex market for stimulant drugs
Cocaine remains the second most commonly used illicit drug in Europe, although prevalence levels and trends differ considerably between countries. High and still-increasing levels of cocaine use are observed only in a small number of mostly western European countries, while elsewhere the use of this drug remains limited. Whether this situation will continue or cocaine use will diffuse to other parts of Europe, notably eastern Europe, remains an open question. Worries have been prompted by some evidence that the drug is being increasingly trafficked through the region, as well as by sporadic reports of cocaine use in some settings.
New routes through eastern Europe are not the only issue of concern in relation to cocaine trafficking. The drug continues to enter Europe mainly through the Iberian Peninsula and the Low Countries. However, a relatively new development is the interdiction of secondary extraction facilities that recover cocaine hydrochloride or cocaine base from carrier materials such as beeswax, fertiliser, clothing, herbs, plastics and liquids. Thirty such facilities were reported to Europol by Spain in 2008. This development is indicative of high levels of innovation and technological sophistication among those importing cocaine into the European Union. Because of its high value, cocaine may also be cut or mixed with other substances. The use of levamisole (l-tetramisole) as a cocaine adulterant has been increasingly reported in the United States and Europe, leading to the European early-warning system issuing a warning in 2009. This drug may pose additional health risks to cocaine consumers.
Although drug treatment services in Europe are still dominated by clients with opioid problems, cocaine users now represent about a quarter of new treatment entrants. The majority of these are reported from a small group of countries, principally Spain, Italy and the United Kingdom, and include two distinct groups: socially integrated males who sniff the drug; and marginalised drug users who inject cocaine or use crack cocaine alongside other substances. An additional concern is the increasing mortality associated with cocaine use. About 1 000 cocaine-related deaths are now reported annually, with notable increases in Spain and the United Kingdom, two countries where the use of the drug is long established and at high levels. Although other drugs are generally also found to be present, this rise is worrying, especially given the ongoing concerns about under-reporting of cocaine’s role in deaths of users with pre-existing cardiovascular problems.
Use of amphetamines remains overall lower than cocaine use in Europe, but in many countries amphetamine or methamphetamine remains the most commonly used stimulant drug. Problem amphetamine use is mainly reported by countries in the north of Europe, while problem methamphetamine use remains largely restricted to the Czech Republic and Slovakia. This may be slowly changing, however, as methamphetamine production is now also reported in Lithuania and Poland, with production mainly servicing the Scandinavian markets. Here it may be sold as a replacement for amphetamine. Problem amphetamine and methamphetamine use is the topic of a Selected issue that accompanies this annual report.
Opioids and drug injecting
Heroin use, particularly injecting the drug, still accounts for the greatest share of morbidity and mortality related to drug use in the European Union. The number of problem opioid users in Europe is cautiously estimated at 1.35 million, and most treatment entrants still report opioids as their primary drug. Data from a range of sources point to an overall stable to increasing opioid problem in the European Union since 2003/04. Heroin seizures have increased in number, but not in quantity; although this has to be seen in the context of increasing seizures of the drug in Turkey. Trend data from prevalence estimates appear stable, new treatment demand has been slowly increasing in several countries, drug-induced deaths have increased, as have drug law offences for the last two years. To some extent, this may reflect the long-term nature of opioid problems where, once addicted, users tend to remain dependent for long periods of time. Thus, even a relatively small number of new recruits are sufficient to maintain the overall population. The number of injecting drug users in Europe is estimated to be between 750 000 and 1 million, with large differences in prevalence between countries. Data quality issues mean that this estimate must be treated with considerable caution. Tends in injecting use are particularly difficult to gauge, but data from treatment monitoring suggest that the medium-term trend is downwards and injectors are now in the minority among new opioid users entering treatment services in Europe.
Injecting remains, however, the most common route of administration for opioid users in many eastern European countries. This adds to considerable concern about the public health consequences of drug use in some of the countries neighbouring the European Union. At the eastern border of the European Union, both Russia and Ukraine appear to have levels of problem opioid use two to four times higher than the EU average. The problems associated with opioid use in this region include high rates of HIV infection and drug-induced deaths.
Overdose represents the biggest cause of avoidable mortality associated with illicit drug use in Europe, and toxicological analysis shows the presence of heroin in most drug-induced deaths. This underlines again the importance of opioids for understanding the public health impact of drug use in Europe. Since 2003, the number of drug-induced deaths has been increasing in most European countries, as has the age of those dying, suggesting an ageing population of chronic users. Provisional data suggest a modest increase of reported drug-induced deaths in 2008: with estimates of 7 371 cases in 2008 in EU Member States and Norway, as compared to 7 021 in 2007. These estimates are likely to be conservative. It can also be estimated that for each fatal overdose there are 20–25 non-fatal overdoses, or around 150 000 annually in the European Union. Moreover, it is now recognised that non-fatal overdoses may result in significant health damage as well as indicating increased risks of future overdoses. From a public health perspective, one of the most important challenges for drug services in Europe is to develop effective measures for reducing both fatal and non-fatal overdoses. Currently, this challenge is not being met.
‘Legal highs’: an ongoing challenge for drug monitoring and response
Attempts to identify and respond appropriately to new psychoactive substances struggle to keep pace with a sophisticated, innovative and fast-moving market, which is actively seeking new products and marketing strategies. With 24 new synthetic drugs identified for the first time in Europe, 2009 was a record year for the European early-warning system. This pattern has continued unabated in 2010, with 15 new substances detected by mid-July, including synthetic cathinones, synthetic cannabinoids, as well as new cocaine and amphetamine-like synthetic derivatives.
In July 2010, the scientific committee of the EMCDDA carried out a formal risk assessment of the synthetic cathinone mephedrone. This was prompted by a growing concern that this drug was being marketed as a legal alternative to stimulants like cocaine and ecstasy. The risk assessment was conducted as part of Europe’s fast-track mechanism for controlling new psychoactive substances. However, the pace of development in this area is such that not only had some Member States already introduced legislation banning mephedrone, but some websites selling it had already closed down, sometimes to be quickly replaced by sites offering replacement substances.
There is a need to remain vigilant and to be able to respond rapidly to new developments, such as new chemical groups of psychoactive substances identified in ‘legal-high’ products. This is illustrated by the examples of aminoindanes (methylenedioxyaminoindane, MDAI) and synthetic cocaine derivatives (such as fluorotropacocaine). While still rare, after action was taken against mephedrone in 2010, such substances began to be more frequently detected, and the first reports of users experiencing problems were received by the early-warning system. The EMCDDA is monitoring the availability and possible health impact of these substances.
The example of mephedrone highlights how EU Member States can come under considerable media and public pressure to respond quickly to a potential new threat. The EMCDDA, in close cooperation with Europol and the European Medicines Agency, has been working to provide timely information that is reliable and considered. In this rapidly developing area, there is a growing need to improve Europe’s capacity to monitor developments proactively and, in particular, to test and identify the chemical constituents of the product mixtures available and assess their potential impact on public health. Lack of standard reference material is a problem here. In terms of control strategies, the way these products are produced and marketed makes a strong argument that effective measures will require action at the European level to support national initiatives.
Organised crime recognises the potential of new synthetic substances
Legislating for these new substances is complicated by many factors. Some Member States have introduced generic legislation that covers substances from the same chemical group. This legal option is only available in some countries, and can be difficult to put into practice. Further difficulties arise from the fact that some of these substances may have legitimate non-medical uses, be sold for supposedly legitimate purposes, or be used for research and development purposes by the pharmaceutical industry. That said, even well conceived control measures may not solve all the problems in this area, and the danger exists that they may even increase the momentum for an undesirable transition from a mostly online ‘legal-highs’ market to one that involves organised crime. Cathinone drugs, such as mephedrone, methylone and MDPV, have all appeared on the illicit market, where they are sold as replacements for cocaine, ecstasy and amphetamine, or as the drugs themselves. Europol has noted the interdiction of a number of large illicit ecstasy production sites that were found to be tabletting mephedrone, and more than 20 European countries reported finding this drug in seizures. It is difficult to predict the extent to which new synthetic drugs will become a major part of Europe’s future illicit drug market. Criminal organisations, however, are likely to be quick to recognise the potential of substances that can be bought cheaply in large quantities, can in the future be synthesised relatively easily and are attractive alternatives to controlled drugs.
To ‘design’ a drug to replace a controlled substance is not a new concept. In the past, though, designer drugs were illicitly produced and marketed directly on the illicit market. An important difference today is that we are seeing a new interaction between the illicit and non-illicit markets, whereby chemicals are legally sourced but then sold as replacements for illicit psychoactive substances.
Things to come: medicinal products, counterfeit drugs and new designer medicines
The United States has a long-established drug problem, and developments in this market have sometimes had implications for Europe. Currently, the misuse of prescription drugs, especially opioids such as OxyContin, is a major concern for US drug policy. In Europe, misuse of prescription drugs, with the exception of opioid substitution drugs, has not been regarded as a major problem. This is partly due to the regulatory framework and prescribing practices, which differ from those of the United States. The potential for misuse is also an issue considered within the European pharmacovigilance system, which operates under the responsibility of the European Medicines Agency, with the collaboration of the EMCDDA on drug misuse issues. The spread of counterfeit medicines, manufactured and sold in place of legitimate products, is a growing problem. In 2009, the early-warning system received reports of substances that were based on slight modifications of the chemical structures of medicines with known abuse potential. The rise of new designer medicines would be an unwelcome addition to the task of ensuring that prescribed medicines are not diverted and misused. It is also another example of how innovation in the illicit market requires a robust and joined-up response from pharmaceutical and drug control regulatory frameworks. This issue is more of a potential threat than an immediate problem, but given the speed at which new developments occur in this area, it is important to anticipate future challenges. The suggestion that in the future we will see increasing numbers of new drugs based on existing pharmaceutical products but intended for non-therapeutic use would be particularly worrying.