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Please note that the information on this page is based on the EMCDDA Annual report 2010: the state of the drugs problem in Europe. Most statistical data relate to the year 2008 (or the last year available).

 
 

Annual report 2010: the state of the drugs problem in Europe
Responding to drug problems — an overview

Published: 10 November 2010

Treatment

In Europe, the main modalities used for the treatment of drug problems are psychosocial interventions, opioid substitution and detoxification. The relative importance of the different treatment modalities in each country is influenced by several factors, including the organisation of the national health care system.

There is no data set allowing a description of the full population of drug users currently undergoing drug treatment in Europe. Information on an important subgroup of this population is, however, gathered by the EMCDDA’s treatment demand indicator, which collects data on those entering specialised drug treatment services (1). In 2008, the indicator registered about 440 000 treatment entrants, 40 % of whom were entering drug treatment for the first time in their life.

Based on a range of different sources, including the treatment demand indicator, a conservative estimate is that one million people received treatment for illicit drug use in the European Union during 2007. Of these, more than half received opioid substitution treatment. Germany, Spain, France, Italy and the United Kingdom accounted for nearly 80 % of the drug users in contact with treatment.

This estimate of drug treatment in the European Union, though in need of refinement, suggests a considerable level of treatment provision. It also highlights the great increases that have taken place in treatment provision since the mid-1990s, when greater availability and better access to drug treatment became priorities of drug policy. The past two decades have witnessed the expansion of specialist outpatient services and the development of outreach- and low-threshold approaches. Several countries scaled-up their substitution treatment by involving additional service providers, such as general practitioners. As a result, the number receiving substitution treatment in Europe has grown almost ten-fold since 1993 (2). Changes in treatment provision were also prompted by new client groups, such as cannabis and stimulant users, which have accessed treatment in growing numbers during the last 15 years.

While it has become more available in many countries, there are still barriers impeding or discouraging drug users from accessing either drug treatment or some of its modalities. These barriers include regulations such as stringent admission criteria and legal frameworks, treatment costs for patients, lack of trained staff or low geographical density of treatment providers. Other obstacles faced by drug users in need of treatment include inadequate opening hours, requirement of daily attendance and lack of childcare support (e.g. during inpatient treatment), which conflict with their personal and professional situation. Personal beliefs and preconceptions, among both professionals and drug users, regarding the appropriateness, effects and results of specific treatment approaches can also impede treatment access.

Extended waiting times for drug treatment can be one of the consequences of barriers to treatment access. According to information provided by national experts in 2008, limited availability of treatment and lack of resources, as well as delays due to procedural reasons, are the main causes for the existing waiting times, which differ between treatment modalities (see below).

Outpatient treatment

Information is available on about 383 000 drug users entering outpatient treatment in Europe during 2008. Most of these drug users entered treatment in specialised drug treatment services, and only a few countries reported on those entering treatment with a general practitioner or in low-threshold services. More than half of the treatment entrants (53 %) report opioids, mainly heroin, as their primary drug, while 22 % report cannabis and 18 % cocaine (3). The most common route to treatment is self-referral (36 %), followed by referral by the criminal justice system (20 %). The remaining clients are referred through social and health services or informal networks, including family and friends (4).

Clients entering outpatient treatment are predominantly young men, with an average age of 31 years and males four times as numerous as females. Clients entering treatment for the first time and female clients are on average slightly younger. Younger average ages are also reported for cannabis clients (25) and those using stimulants other than cocaine (29), while older mean ages are reported for primary users of cocaine (32) and opioids (34). On average, the youngest drug clients are reported by the Czech Republic (26) and the oldest by Spain (33) (5). Male to female ratios are highest among cannabis (5:1) and cocaine (4.8:1) clients and lowest for those using stimulants other than cocaine (2.2:1). Regardless of the primary drug, gender ratios are highest in countries in the south of Europe and lowest in countries in the north (6).

The two main modalities of outpatient treatment in Europe are psychosocial interventions and opioid substitution treatment. For opioid users, they are often provided in combination. Psychosocial interventions offer support to users as they attempt to manage and overcome their drug problems. These interventions include counselling, motivational enhancement, cognitive-behavioural therapy, case management, group and family therapy and relapse prevention. They are mostly provided, depending on the country, by public institutions or by non-governmental organisations. In 2008, experts from nine of the 27 reporting countries estimated that there is no waiting time for this type of treatment. In ten other countries national experts estimated that average waiting times are no longer than one month. In Norway, the average waiting time is estimated to be ten weeks, while Denmark requires by law that treatment takes place within 14 days. Experts from seven countries could not provide an estimate.

Substitution treatment is the predominant treatment option for opioid users in Europe. It is generally provided in outpatient settings, though in some countries it is also available in inpatient settings and is increasingly provided in prisons (7). Opioid substitution is available in all EU Member States, as well as Croatia and Norway (8). In Turkey, substitution treatment has yet to be introduced, though it is permitted under a 2004 regulation on treatment centres. In most countries, specialised public outpatient services are the main providers of substitution treatment. However, office-based general practitioners, often in shared-care arrangements with specialised centres, play an increasing role in the provision of this type of treatment. These providers are, at different levels, involved in 13 countries.

In 2008, about 670 000 opioid users are estimated to have received substitution treatment in Europe (9). Experts from ten of the 26 reporting countries estimated that there is no waiting time for this type of treatment. In four countries (Czech Republic, Denmark, Italy, Portugal), the average waiting time was estimated to be less than one month. In the Czech Republic, waiting times only apply to methadone, since high-dosage buprenorphine can be prescribed by office-based general practitioners — although the client has to cover the costs of the medication. In another four countries (Hungary, Romania, Finland, Norway), the estimated waiting time ranges between one and six months, while in a further three countries (Bulgaria, Greece, Poland) it is over one year. Among these, Greece reports an average waiting time of 38 months, with data showing 5 261 problem opioid users registered as waiting for admission to substitution programmes in 2008. National average waiting times may, however, mask considerable regional variation. For example, in Ireland the average waiting time for substitution treatment varies from less than 3.5 months in Dublin to 18 months in the Southeast (Comptroller and Auditor General, 2009). Experts from four countries could not provide an estimate of waiting times.

Inpatient treatment

Data are available for about 42 000 drug users who have entered drug treatment in inpatient settings in Europe during 2008. More than half of them report opioids as their principal drug (57 %), with most of the other clients identifying their principal drug as either cannabis (13 %), stimulants other than cocaine (13 %) or cocaine (7 %). Inpatient clients are mainly young men; with a mean age of 30 years and a male to female ratio of 3.5:1 (10).

Inpatient or residential treatment requires clients to stay overnight for a duration of several weeks to several months. In many cases, these programmes aim to enable clients to abstain from drug use, and do not allow substitution treatment. Drug detoxification, a short-term, medically supervised intervention aimed at resolving the withdrawal symptoms associated with chronic drug use, is sometimes a prerequisite to initiate long-term, abstinence-based inpatient treatment. Detoxification is usually provided as an inpatient intervention in hospitals, specialist treatment centres or residential facilities with medical or psychiatric wards.

In inpatient settings, clients receive accommodation and individually structured psychosocial treatments, and take part in activities geared towards rehabilitating them into society. A therapeutic community approach is often used in this context. Inpatient drug treatment is also provided by psychiatric hospitals, notably for clients with co-morbid psychiatric disorders.

Access to inpatient psychosocial treatment is rated as immediate by national experts from Greece, Hungary and Turkey. Experts estimate the average waiting time to be less than one month in 12 countries and 25 weeks in Norway. In Austria, the waiting time is reported to be up to several months, depending on region and treatment facility. Experts from ten countries did not provide an estimate of the waiting time for this type of treatment.

Detoxification is considered to have no waiting time by experts from Hungary, Slovenia, Slovakia, Turkey and the Flemish Community in Belgium. In 11 countries, the estimated average waiting time is less than two weeks. An average waiting time of two weeks to one month is estimated in Cyprus, the Czech Republic and Greece, while in Ireland, Austria and Norway it is estimated at between one and three months. Experts from five countries did not provide an estimate.

Quality assurance

Actions addressing the quality of drug treatment are currently being undertaken by most European countries. These actions include the development and implementation of guidelines, the adoption of national drug action plans which address treatment quality issues, quality certification and accreditation processes, and studies investigating quality differences between treatment centres or benchmarking them.

Recent developments include the implementation of guidelines for treatment quality in six countries, while Cyprus, Turkey and Norway have recently published such guidelines. Ten countries adopted new strategic documents, in some cases entailing accreditation systems. Poland and Slovakia also introduced accreditation criteria for treatment centres; with Slovakia introducing ISO 9001 certification. Four countries, Estonia, Latvia, the Netherlands and Romania, are investigating heterogeneity in the quality of service across their treatment system.

The United Kingdom has a long history of assessing the health system and one of the widest sets of instruments to monitor and improve treatment quality. This now includes a document on clinical governance in drug treatment (NTA, 2009) that addresses lines of responsibility and accountability, quality improvement, risk management policies, and procedures to identify and remedy poor performance.

A study commissioned by the EMCDDA identified 60 national treatment guidelines in 17 out of 22 reporting countries in Europe. The modalities most frequently covered by the guidelines are psychosocial treatment (29), opioid substitution treatment (28), and detoxification (22). Countries with high numbers of patients in opioid substitution treatment appear to be more likely to have developed treatment guidelines for each modality.

Seventeen countries report guidelines specifically for the treatment of opioid users. Five countries have guidelines targeting the use of different substances, while Hungary and Germany have guidelines for amphetamines and cannabis use disorders. Ten countries address long-term problem drug users and nine have developed guidelines for young drug users. Eight countries also address drug users with co-occurring disorders.

Almost all guidelines target treatment professionals (58) and service providers (52), and close to half of them target health care planners (25). Portugal is the only country reporting guidelines targeting clients, while Denmark reports targeting policymakers. Treatment professionals were involved in developing the guidelines in 17 countries, and other professionals in four countries. Researchers also participated in nine countries, policymakers in three and clients in one. More information regarding national treatment guidelines is provided on the EMCDDA’s Best practice portal.

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Footnotes

(1) The treatment demand indicator received data from 29 countries for speciaflised drug centres, with a coverage of more than 60 % of units in most countries (see Table TDI-7 in the 2010 statistical bulletin).

(2) See Table HSR-2 in the 2010 statistical bulletin.

(3) See Table TDI-19 in the 2010 statistical bulletin.

(4) See Table TDI-16 in the 2010 statistical bulletin.

(5) See Tables TDI-10 and TDI-103 in the 2010 statistical bulletin.

(6) See Table TDI-21 in the 2010 statistical bulletin.

(7) See ‘Assistance to drug users in prison’.

(8) See Tables HSR-1 and HSR-2 in the 2010 statistical bulletin.

(9) See Table HSR-3 in the 2010 statistical bulletin.

(10) See Tables TDI-7, TDI-10, TDI-19 and TDI-21 in the 2010 statistical bulletin.

Bibliographic references

Comptroller and Auditor General (2009), Drug addiction treatment and rehabilitation, Comptroller and Auditor General Special Report.

NTA (2009), Clinical governance in drug treatment: a good practice guide for providers and commissioners, NTA, London (available online).

 

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The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU’s decentralised agencies. Read more >>

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Page last updated: Friday, 05 November 2010