The drug situation in perspective
In many respects, this year's report is one of contrasts. On the one hand, drug use appears to be relatively stable in Europe. Prevalence levels overall remain high by historical standards, but they are not rising. And in some important areas, such as cannabis use by young people, there are positive signs. On the other hand, there are worrying indications of developments in the synthetic drugs market and, more generally, in the way drug consumers now use a wider set of substances. Polydrug use, including the combination of illicit drugs with alcohol, and sometimes, medicines and non-controlled substances, has become the dominant pattern of drug use in Europe. This reality presents a challenge to both European drug policies and responses. A comprehensive policy framework for addressing psychoactive substance use is still lacking in most Member States, and treatment services are having to adapt their practice to meet the needs of clients whose problems span multiple substances. Similarly, targeting and assessing the impact of measures to reduce drug supply requires consideration to be given to the overall market for psychoactive substances. Without this wider perspective, gains made in relation to one drug may result in a displacement of use to other products. This report contains many examples of how the European illicit drug market is dynamic, innovative and quick to adapt to both opportunities and control measures.
The European model under review
Europe has, by global standards, a well-developed, mature and arguably relatively effective approach to responding to illicit drug use. At EU level, this is articulated through the current EU drug strategy and its action plan, which represents a unique example of long-term cooperation and knowledge exchange at transnational level. The achievements of the latest EU drug strategy are currently under review. Most Member States now have relatively consistent and well-developed drug strategies that, to a large extent, reflect a common model. Despite these positive developments and an overall increase in service provision for those with drug problems, pronounced differences still exist between countries, particularly in respect to investments made in demand reduction interventions. Addressing these discrepancies will be an important challenge for future EU policies in this area.
The European model can be characterised as pragmatically balancing drug supply reduction and demand reduction objectives, as well as acknowledging the importance of both human rights and community safety. This approach permits both concerted action and cooperation in law enforcement and border control efforts to limit drug supply, as illustrated by current programmes targeting heroin importation routes from Afghanistan, cocaine trafficking via the Atlantic and West Africa and synthetic drug production. It also permits innovative developments in the area of treatment and harm reduction, one example of which is heroin-assisted treatment, which is of growing interest to a number of European countries and is the subject of a new EMCDDA review.
Risk of localised HIV epidemics among drug injectors may be growing
Following reductions in the overall spread of HIV in the European Union, the focus on HIV prevention as a primary public health objective for drug policy has become less evident. However, this year's analysis raises the worrying prospect that the potential risk for new localised HIV epidemics may be growing. The economic downturn affecting many European countries may be increasing the vulnerability of communities while, at the same time, limiting the ability of Member States to provide adequate responses. The historical evidence is clear: if the conditions exist, drug-related HIV infections can spread rapidly within vulnerable communities. Furthermore, the gains made in the European Union in reducing the drug-related spread of HIV have not been seen in many of our neighbouring countries, where transmission of the virus, related to both injecting drug use and unsafe sex, continues to be a major public health problem. Recently, political and economic developments have increased migration from these affected regions towards EU Member States, which can put further pressure on already stretched services.
A particular concern, therefore, is that the conditions now exist in a number of EU Member States, including those that have not previously experienced significant drug-related HIV epidemics, which now make them potentially vulnerable to future problems. Greece, historically a low-prevalence country, reported a local HIV outbreak among injectors in 2011, and the situation in a number of eastern Member States is also worrying, as illustrated by rising rates of infection in Bulgaria. The picture is also looking less positive in some countries that had made progress in addressing drug-related HIV/AIDS epidemics, with gains made in recent years in tackling new infections in Estonia and Lithuania, for example, now looking increasingly fragile, as both these countries report recent increases in infections.
Opioids trends: the need to understand market dynamics
Internationally, and particularly in North America, there has been increasing concern about the availability and misuse of prescription opioids, mainly painkillers. The extent of this phenomenon in Europe is difficult to access from the data currently available. Moreover, direct comparisons between the European Union and other parts of the world are difficult to make, due in large part to the considerable differences that exist in prescribing patterns and regulations. Currently, illicit synthetic opioid use in Europe appears mainly to involve the consumption of substitution drugs diverted from drug treatment. In addition, some countries in northern and central Europe are now reporting the use of fentanyl, which is likely manufactured illicitly outside the European Union. The appearance of this drug is of particular concern and, overall, given the situation elsewhere, a good argument exists for improving our capacity to monitor trends in the misuse of psychoactive products intended to be used only for therapeutic purposes.
As synthetic opioids are used illicitly mainly in place of heroin, information on their use can provide insights into the overall heroin market. Currently, an important question in this area is the extent to which supply reduction measures are now impacting on the availability of heroin on the streets of Europe. The possibility that supply reduction measures are reducing the heroin availability in Europe is supported by indications that some, but not all, EU countries experienced a heroin drought in late 2010, and that this may also have effected some non-EU countries, such as Russia and Switzerland. An alternative explanation put forward to explain this apparent shortage referred to a recent outbreak of poppy blight in some parts of Afghanistan. However, on closer inspection, this association is probably tenuous, although other events in Afghanistan and some significant successes resulting from cooperation between Turkish and EU police forces may have played a role. Any short-term supply problems, however, have to be viewed in the context of the long-term, relatively stable heroin market in Europe.
Despite the importance of information on heroin availability to understanding the dynamics of the illicit drug market Europe, it is worth noting how difficult it is currently to comment on this issue with authority. More sophisticated attempts are now being made to better achieve this based on analysis of both production and use data. However, for a number of technical reasons, considerable caution is still merited when drawing conclusions on this sensitive topic. Good indicators of market availability in Europe are largely lacking, for example. Estimates of opium production in Afghanistan are frequently taken at face value, despite the fact that such calculations are in many ways methodologically challenging. And, suggestions of opium production in other countries in Asia are rarely considered. Moreover, models of heroin flows often include the existence of 'stocks' of stored opium or heroin - although there is limited empirical evidence to support this assumption. Elucidating the relationship between opium production and heroin availability is further complicated by the existence of different trafficking routes into, and sub-markets within, the European Union, and by the significant time lag that is believed to exist between the harvest of opium in Afghanistan and its appearance as heroin on the streets of Europe.
Are overdose deaths just the tip of the iceberg?
The typical fatal overdose victim in Europe is a man in his mid to late thirties, with a long history of opioid problems. Attendance in drug treatment, particularly substitution treatment, is known to reduce the risk of overdose. However, despite a dramatic increase in treatment availability over the years, the number of users dying of drug overdose in Europe has remained stable. Reducing overdose fatalities therefore represents a major challenge for drug services across Europe. Some innovative programmes are currently under evaluation and development in this area, often targeting those events that are known to be particularly risky for opioid users, such as leaving prison or dropping out of treatment. While this work is important, it will only address part of the problem. Studies suggest that overdose deaths may represent somewhere between a third and two-thirds of the overall mortality among problem drug users. Other major causes of death among drug users include AIDS, suicide and trauma. The implications of this finding are discussed in detail in a publication accompanying this report, and strongly point to the high level of excess mortality in this population and the role that services can play in reducing the human costs of long-term drug problems.
Has the cocaine bubble burst?
Over the last decade, cocaine has established itself as the most commonly used stimulant drug in Europe, even though high levels of use are only found in a restricted set of countries. Commentators have noted that part of the appeal of this substance is its image; with cocaine use often portrayed as being part of an affluent and fashionable lifestyle. The reality of regular cocaine use is different, however. The positive image may be increasingly challenged by the growing recognition of cocaine-related problems, which are manifest in increased hospital emergencies, deaths and treatment demands related to this drug. The financial cost associated with regular cocaine consumption may make it a less attractive option in countries in which austerity is now the order of the day. New data raise the question as to whether the popularity of this drug has now peaked. Recent surveys show some decline in use in the countries with the highest prevalence levels, although the picture elsewhere is less clear. Supply data is also equivocal. The amount of cocaine seized has fallen considerably since 2006, and overall both the price and the purity of the drug have also decreased. However, in contrast to volume, the number of seizures has continued to rise, and there is evidence that traffickers are continuing to adapt their practices in response to interdiction efforts; and as they do so, there is the risk of a diffusion in use into new areas.
MDMA on the rebound
In recent years, the European ecstasy market went through a period in which the availability of tablets containing MDMA became increasingly rare. Commonly, 'ecstasy' tablets sold on the illicit market contained other drugs, often a piperazine, with the result that some of those buying what they believed to be an illicit drug were in fact buying a non-controlled substance. The scarcity of MDMA in ecstasy tablets appears to have been related to a shortage of the main precursor PMK, possibly reflecting the success of interdiction efforts. However, the most recent data point to increasing MDMA availability, with some reports noting the existence of very high dosage tablets and high purity powders.
Current MDMA production methods now appear to be based on either safrole or, increasingly, on imported chemicals, such as PMK-glycidate and alpha-phenylacetoacetonitrile, that are structurally similar, though not identical, to the controlled precursors hitherto used. A parallel exists here with developments in the 'legal highs' area, where non-controlled products replace controlled ones. These chemicals are selected with two aims in mind: the new substance should not be subject to current controls, and it should be easily converted into a precursor necessary for MDMA synthesis. This illustrates again the considerable adaptability shown by synthetic drug producers. A related phenomenon has been observed in the amphetamine market, where precursors have been chemically 'masked' to avoid existing border and sales control mechanisms. As producers become more technically sophisticated and seek out new ways to circumvent interdiction efforts and regulations, the possibility to modify and reconvert substances represents another challenge to current drug control approaches.
New psychoactive substances: getting our response right
The rapid emergence of many new non-controlled psychoactive substances represents a growing challenge for current models of drug control.
In 2010, a record 41 new substances were reported to the European early-warning mechanism, and preliminarily data for 2011 show no sign of decline. This reflects both the continuing introduction of new substances and products into the marketplace, as well as the increasing use of proactive measures to identify new substances. The Internet is one of the main marketplaces for these substances, and preliminary results from the latest EMCDDA online survey (July 2011) show that the number of online shops selling psychoactive products continues to increase. Sales practices in this area also appear to have become more sophisticated, with more evidence of measures taken to restrict access and protect the identity of buyers and sellers. Moreover, reports have come to light of illicit drug sales being conducted using restricted websites. It is unclear to what extent this kind of development will represent a significant future threat, but given the speed at which changes have occurred in this area, there is a need to remain vigilant.
Improving our capacity for detecting new drugs
The legal mechanism that supports the European early warning-system is currently under review. The European Commission has conducted an assessment noting both the strengths of the existing system and the need to increase Europe's capacity to respond to the pace of developments in this area. Although Europe has been at the forefront of detecting new psychoactive substances, the global dimensions of this problem were made clear in discussions at a technical symposium hosted by the EMCDDA in 2011. International experts confirmed that products containing new psychoactive substances are now available in many parts of the world, including the Americas, the Middle East, Oceania, and parts of Asia, and that identifying an ever-increasing range of substances in a rapidly changing market is a common problem. The expert consensus emerging from this meeting was that the challenges presented by new drugs will require more proactive monitoring of the market and sharing of forensic information as well as improved identification of the health problems arising from the use of these substances.
Predicting the future: new products and interplay between markets
Most new psychoactive substances reported to the early-warning system have been either stimulants or synthetic cannabinoids, largely reflecting the market for illicit drugs in Europe. It is likely that new substances of these types will continue to enter the market. In addition, producers appear to be exploring other substances with a psychoactive action that may be attractive to consumers. A large and accessible research literature exists that can be exploited for this purpose, and there is concern that the results of pharmaceutical research may be harnessed to provide more of the new psychoactive substances appearing in the future.
Much of the policy focus in this area has been on the legal status of new substances; however, it is also important to see them in the context of the overall drug market. As an example, users report that as well as Internet sales, mephedrone (see Chapter 8) was also sold through the same illicit supply networks as used for drugs such as ecstasy and cocaine. In addition, and as mentioned earlier, non-controlled psychoactive substances may be tableted as ecstasy and sold on the illicit market. Conversely, the controlled drug PMMA has recently been identified in some products advertised as 'legal highs'. Taken as a whole, developments in this area are worrying as they are suggestive of a growing interplay between the 'legal highs' and illicit drug markets.
Cannabis: policy dilemmas
Cannabis remains Europe's most popular illicit drug, but it is also the one on which public attitudes are most divergent. This is reflected in the recent Eurobarometer study of youth attitudes to drug use, which found that views on cannabis prohibition were more mixed than for other drugs. Globally, no clear direction in the development of cannabis policies is evident. Interesting examples of policy development here include the USA and the Netherlands. In the USA, there has been a move towards liberalising the availability of herbal cannabis for medical purposes in some states. In the Netherlands, policymakers now appear to be taking an increasingly robust stance against domestic cannabis production and to the operational rules applied to 'coffee-shop' sales.
The extent to which policy changes influence cannabis use is a much debated question. In data presented in this report, no direct association can be seen between measures of the recent use of this drug and changes made to either increase or decrease penalties for use, suggesting that more complex processes are at work. A general observation may be made that, over the last decade, European cannabis policies have tended to direct law enforcement efforts towards offences connected with trafficking and supply rather than the use of the drug. One reason for this is to avoid the possible negative consequences of bringing large numbers of young people into contact with the criminal justice system, especially if their cannabis use is experimental. However, figures show that the number of offences related to cannabis use in Europe continues to rise, against a background of stable or even declining prevalence. This highlights a possible disconnect between policy objectives and practice. Explaining this observation is difficult, but one possibility is that the data reflect a net-widening effect, in which the adoption of more administrative sanctions for use results in an increased likelihood that they will be applied in practice.
Domestic cannabis production: a growing problem
Europe remains the biggest global market for cannabis resin. Historically, Morocco has been the main producer country of resin consumed in Europe. Recent reports, however, suggest that cannabis resin is increasingly imported from other countries, including Afghanistan and Lebanon. This is supported by recent UNODC field surveys, which reported large-scale cannabis resin production in Afghanistan. Herbal cannabis imported into the European Union comes mainly from neighbouring countries in the Balkan region, and to a lesser extent from some African and Asian countries. Most EU Member States now report domestic cultivation of cannabis, a phenomenon that appears to be increasing. This is mirrored in the existence of 'grow shops', which specialise in equipment for cannabis cultivation. Domestic cultivation can be small-scale, but it may also consist of major production sites run by organised crime gangs. A knock-on effect of this is that some countries are now reporting increases in violence and other crimes associated with large production sites. Developments in the European cannabis market are reviewed in detail in a forthcoming EMCDDA 'Insight'.
Guidelines, standards and the sharing of effective practices
Given the complex and fast-moving nature of contemporary drug problems, it is important to ensure that research findings and the knowledge gained from successful service development are shared as widely as possible. To this end, a number of European initiatives have been launched to identify and help promote the sharing of good practice. In 2011, in collaboration with the EMCDDA, the European Commission held a conference on identifying minimum quality standards and benchmarks for demand reduction programmes. The EMCDDA has also been expanding its web-based resources for disseminating evidence-based practices. It should be noted though, that the availability of evidence does not automatically ensure that it will be translated into practice. An example of this can be found in the area of drug prevention, where despite an increasingly robust evidence base for their effectiveness, selected and environmental strategies are often among the least commonly found interventions. However, a starting point for the adoption of good practices must be an understanding of what approaches have been shown to deliver benefit. And, as information to guide policy choices accumulates and becomes more readily available, investing in approaches not supported by good evidence will become harder to justify.