• Drug use among the general population and young people
• Prevention
• Problem drug use
• Treatment demand
• Drug-related infectious diseases
• Drug-related deaths
• Treatment responses
• Harm reduction responses
• Drug markets and drug-law offences
• National drug laws
• National drug strategy
• Coordination mechanism in the field of drugs
• Public expenditure
• Drug-related research

Drug use among the general population and young people

In 2008 the fourth National Health Interview Survey, carried out among the general population aged 15 and over, included questions on cannabis, cocaine, amphetamines, ecstasy and opiate use. Lifetime prevalence of cannabis use was reported by 14.3 % of respondents aged 15–64, compared with 13 % in 2004 and 10.8 % in 2001. Last year prevalence of cannabis use was reported by 5.1 % of all respondents, by 11.9 % of those aged 15–24 and by 11.2 % of those aged 15–34.

The Health Behaviour in School-aged Children (HBSC) study was carried out in the Flemish and French communities in 2009–10 among a representative sample of students aged 12–18. In both communities cannabis was the drug most frequently reported by students aged 15–16, with 21 % in the Flemish community and 20 % in the French community reporting that they had used cannabis at least once in their lives. In both communities an increase in the lifetime prevalence of cannabis was noted by age: among respondents aged 18 some 39 % in the Flemish community and 44 % in the French community had used cannabis at least once. In 2009–10 there were signs of a reduction in lifetime prevalence of cannabis use among students in both communities, compared to 2006 data.<

In 2011 the European School Survey Project on Alcohol and Other Drugs (ESPAD) survey was repeated among students aged 15–16 in the Flemish community. Lifetime prevalence of cannabis use was 24 %, and was higher among males (28 %) than females (21 %). Regarding other drugs, lifetime prevalence was 7 % for inhalants, 5 % for amphetamines, and 4 % for ecstasy and for cocaine. Last year prevalence of cannabis was 20 % and last month prevalence was 11 %.

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Prevention

The organisation, implementation and monitoring of prevention activities is the responsibility of Belgium’s community and regional governments, and for this reason strategies for drug prevention differ significantly across the three language communities. For example, in Flemish communities substance use prevention is oriented towards actors in the education and health sectors, and environmental measures are mainly implemented in school settings, while in the French speaking community the approach is one of global health promotion, with a focus on social integration, and access to decent housing and health services. There are also commonalities in the implementation of drug prevention, such as a focus on strengthening the network of field workers available to young people, innovative programmes for children and families, and strong efforts in environmental strategies for recreational settings.

The differences between the communities are particularly accentuated in the case of universal school-based prevention programmes. The French community follows a model in which specialised associations or internal services provide training or counselling in schools. Addiction Support Points, created in 2007, are interfaces between schools and other structures involved in prevention activities, such as police, municipal organisations and associations. In the Flemish community programme-based comprehensive interventions have been adopted, and in the German community priority is given to prevention projects tackling alcohol and tobacco use.

In addition to school-based universal prevention interventions, the French and the Flemish communities also develop and implement activities focusing on parenting skills, and both communities also provide telephone and email helplines and other online early intervention services that are easily accessible. In April 2011 the Flemish community initiated the development of integrated alcohol and drug policies in its communities and cities.

In 2009 the collective Convention No 100 was adopted at the federal level by social partners in the private sector, increasing the priority given to comprehensive workplace-based drug prevention policies, to be implemented at the enterprise’s level.

In the Flemish community selective prevention activities are mainly oriented towards migrants, in particular those from Turkish and Moroccan communities. In 2011 special guidance was issued on how to organise drug use prevention with mentally handicapped young people, while in Limburg province a programme for youngsters with special educational needs has been implemented. Several programmes for children of parents with drug-use problems are also available. In the French community most selective prevention activities target families where parents have drug-use problems and focus on strengthening their parenting capacities.

In recreational settings selective prevention is mostly limited to the dissemination of information through information stands, peer prevention and websites targeted at party-goers, or through mobile teams whose aim is to intervene at locations (generally at large festivals) where there is significant (synthetic) drug use. The Quality Nights charter in Brussels, and Partywise in the Flemish community (replaced in 2012 by Quality Nights), are health promotion labels (like Safe Clubbing guidelines) in recreational settings. They aim to improve the health and safety of people attending festivals, parties, etc. by involving the events organisers and the operators to give them a sense of responsibility about health issues.

Indicated prevention activities are increasingly available in Belgium, especially for children of addicted parents in the French community. Indicated prevention activities in the Flemish community includes promoting screening and early interventions at the primary healthcare level using the ASSIST instrument, which was made available in the Dutch language in 2010. In 2011 a new project was initiated that focuses on brief interventions and referrals to treatment for young people admitted to emergency departments with substance use problems. Some early intervention and motivational interviewing programmes are available in the German-speaking community.

View ‘Prevention profile’ for additional information.

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Problem drug use

No population size estimate of problem drug users is available for Belgium. A national estimate of the number of injecting drug users (IDUs) is derived annually using the HIV multiplier method. The 2011 study indicated no significant changes in the size of the IDU population over the past 10 years and estimated that there were between 18 286 and 36 896 IDUs in Belgium, with a prevalence rate of 3.4 per 1 000 residents aged 15–64 (95 % CI: 2.5–4.8).

Up to 2012 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defined problem drug use as injecting drug use (IDU) or long duration/regular drug use of opiates, cocaine and/or amphetamines. Ecstasy and cannabis were not included in this category.

View 'Problem drug use' topic website for details.

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Treatment demand

The treatment demand indicator (TDI) registration was officially approved by the Inter-ministerial Conference on Public Health in 2006. In 2008 the first treatment demand data were reported. In 2010 a new TDI registration protocol (based on TDI 2.0) was adopted and has been operational since 2011.

Treatment demand data for Belgium for 2011 was based on 122 units. In 2011 there were 5 946 treatment clients, of which 2 246 were new treatment clients.

In 2011 some 29 % of all clients entering treatment were under the age of 25. Among new treatment clients, 44 % were under 25. With regard to gender, 78.4 % of all treatment clients were male and 21.6 % were female. A similar gender distribution was reported for new treatment clients, with 79.6 % male and 20.4 % female.

The majority of all treatment demands were related to opioids, at 36.8 %, followed by cannabis at 31.0 % and cocaine at 12.9 %. Almost half of new treatment demands were related to cannabis (48.2 %), followed by opioids at 18 %, cocaine at 13.6 % and amphetamines at 11.2 %.

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Drug-related infectious diseases

In Belgium, cases of HIV and AIDS are registered at the Scientific Institute of Public Health in Brussels. In 2011 a total of 11 people who were diagnosed with HIV reported injecting drug use as the probable mode of transmission (1.3 % of the total).

Data on the infection rates of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) among users who have injected at least once are available in Belgium from three different sources. For the Walloon region, the data on HIV are self-reported and are collected through a network of organisations. In the Flemish community, data are based on biological tests for a selected sample of IDUs who were in contact with a medical doctor, and these are made available through De Sleutel, an institution composed of several ambulatory and residential treatment centres. Another data source is the outpatient clinic Free Clinic, located in Antwerp, whose data are based on voluntary blood screening offered to patients on a regular basis.

In terms of prevalence rates and trends, there has been a decline in HIV infection rates reported by the French part of the country since 1994, and by the Flemish institution De Sleutel since 1998, while in the last six years the prevalence rates seems to be fluctuating and no clear trends are visible. No self-reported HIV infection among IDUs asking for treatment in the Walloon Region was recorded in 2011, but this is not considered representative and comparable with the data from previous years due to changes in the registration and a small sample size. Diagnostic testing among samples of IDUs in Flemish drug treatment and low-threshold centres indicate HIV prevalence between 4.6 % and 8.3 %, depending on the data source.

The HBV infection rate among IDUs, measured by positive aHBc, was 55.1 % in 2011, compared with 56.3 % in 2010 (Free Clinic), while among de Sleutel clients it was 16.7 %. In 2011 HCV infection rates among IDUs ranged from 42.3 % (data from de Sleutel) to 81.5 % (data from the Free Clinic).

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Drug-related deaths

In Belgium, drug-related deaths are recorded by the General Mortality Register located at the National Institute of Statistics. The national focal point extracts data on drug-related deaths, based on the EMCDDA’s drug-related deaths standard, a standard protocol for extracting these data from registers in the Member States of the European Union (which includes acute deaths directly related to drug consumption or overdoses). The latest available data at the national level are for the period 1999–08. In 2008 some 146 drug-related death cases were registered, of which 87 % were male and the average age at death was 38.3 years. All deaths were toxicologically confirmed. The proportion of drug-related death cases with mixed and unspecified substances was up to 60.3 %, which makes it difficult to identify the main substances involved. Just 32.2 % of the cases reported the involvement of opiates.

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Treatment responses

The national drug strategy document, the Federal Drug Policy Note of 2001, specifies that the treatment offer should be based on a multidisciplinary approach adapted to the complex bio-psychosocial problem of addiction. This approach was further emphasised in the 2010 Communal Declaration and elaborated in the Joint Statement of the Inter-ministerial Conference on Drugs held in 2010. In Belgium different levels of decision-making provide funding for treatment, including the regional and federal governments. For example, at the federal level the Federal Public Service for Public Health, Food Chain Safety and Environment provides the financing for a number of therapeutic communities, crisis centres and day centres that were set up in the 1970s and have expanded their capacities in recent years. Mental health centres are financed by the Walloon Region or by the Flemish community.

A range of services for drug use treatment and/or healthcare is available in a large part of the country, except in the German community where there are no specialist treatment centres for drug users. Overall, treatment offerings encompass specialist inpatient treatment centres, outpatient centres, low-threshold services, units in psychiatric hospitals or psychiatric units in general hospitals, general welfare centres in general health services and self-help groups. Inpatient treatment consisting of detoxification, stabilisation and motivation, and social reintegration is offered at crisis intervention centres, which provide the care based on case-management principles, at specialist hospital units or in therapeutic communities. Specialist outpatient care is provided by nine medical and social care centres and a number of day-care centres. In general, these centres ensure low-threshold help, including a wide range of psychosocial, psychological and healthcare services, as well as opioid substitution treatment for problem drug users. There are also specialist outpatient units at every mental health centre in the Flemish community. Most aftercare and re-integration programmes are delivered in outpatient and inpatient structures. For example, there are halfway houses in therapeutic communities, day treatment in drug centres and employment rehabilitation programmes. In recent year action has been taken to improve treatment for clients with a dual diagnosis or polydrug use and for children and young people, while a pilot project exploring a community reinforcement approach combined with a voucher treatment method has shown promising results for the treatment of cocaine users.

Although methadone substitution treatment was introduced in 1994 and buprenorphine in 2003, a Royal Decree on substitution treatment that mentions methadone and buprenorphine as substitution substances was only adopted in 2006. In the Flemish region, most methadone maintenance programmes are provided by low-threshold, ambulatory and outpatient drug services. However, in smaller towns and rural areas methadone may also be prescribed by general practitioners (GPs) under the supervision of drug services. In the French community a broad range of agencies such as low-threshold facilities, GPs, outpatient specialised units and mental health facilities offer access both to methadone and buprenorphine, though GPs still play the most important role. According to the latest available estimates (2011), a total of 17 701 clients were on substitution treatment, 15 510 of which were on methadone and 2 191 on buprenorphine. In 2007 a pilot heroin-assisted treatment project was implemented in Liege with 200 problem heroin users, and the delivery of treatment started in 2011.

View ‘Treatment profile’ for additional information.

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Harm reduction responses

In 1995 the Belgian federal government formulated an action plan for illegal drugs, with a focus on health and a philosophy of harm reduction. In 1998 a law was adopted allowing for needle exchange programmes. Programmes (stationary, mobile or in pharmacies) are now available across the country, except in the German community. In general, harm reduction projects are set up by NGOs, and some are managed by cities and funded by the Federal Public Service Home Affairs.

In the French community, needle exchange programmes have existed since 1994. Following reorganisation in 2008 a total of 17 official fixed-site and mobile services are now operating, and an additional 10 services distribute injection equipment. In 2000 the Flemish community made the necessary legislative adaptations and in 2001 needle exchange programmes were officially implemented. Similar programmes to those in the French community have been implemented (one in each province). In 2011 approximately 630 000 syringes were distributed through needle exchange programmes in the French community, while in the Flemish community approximately 309 000 syringes were distributed. The exchange rate was above 84.7 % in the French community, and 97.4 % in the Flemish community. In the French community a substantial number of syringes are also distributed through pharmacies via Sterifix (48 470 in 2011), while the number of syringes that are sold is unknown. Annual evaluations of the needle and syringe programmes in the Flemish region indicate that pharmacies play an important role in the provision of injecting material, as almost three-quarters of needle and syringe programme clients obtained additional injecting material from the pharmacies. In Belgium there is no access to safe injection equipment in prisons. In recent years, special emphasis has been given to counselling and testing for HCV.

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Drug markets and drug-law offences

The data from the federal police indicates 35 765 cases of drug-law offences in Belgium in 2011, the lowest number recorded since 2007. Cannabis remains the drug most commonly involved, at 72.8 % of all drug-law offences, and the proportion of cannabis-related offences among all drug-law offences is growing.

More than 110 000 cannabis plants have been seized annually in Belgium since 2006, and in 2011 the number of cannabis plants seized from 1 070 plantations was 337 955. Herbal cannabis, produced domestically and sent from the Netherlands, still dominates in the national drug scene with 5 095 kg of the substance obtained in 21 784 seizures. It is notable that some of the cannabis products cultivated in Belgium are intended for export to the Netherlands. Following few large seizures in 2007 and 2009, the total amounts of seized cannabis resin, primarily of Moroccan origin, dropped to 3 153 kg in 2010, while in 2011 more than 5 000 kg of resin was seized. Heroin seized in Belgium often comes from Turkey and is destined for other European countries. In 2011 the number of heroin seizures declined when compared to previous years, and the quantity seized fell to 140 kg. The cocaine smuggled into Belgium comes predominantly via air or sea from South America (mainly Colombia and the Dominican Republic). In 2011 some 3 263 cocaine seizures were reported. The quantity seized was 7 999 kg, which is the largest since 2005 (9 228 kg). In 2011 the quantity of ecstasy seized doubled compared to 2009–10 but remains below the amount seized in 2008. The amount of amphetamine and methamphetamine seized decreased when compared to the previous year.

The port of Antwerp is one of the largest container ports in the world, and is pivotal in international drug trafficking, as is Brussels airport. Synthetic drugs are illegally produced in Belgium, with export to countries including the United States, Canada, the United Kingdom and, recently, Australia. A peculiarity of the Belgian synthetic drug market is a strong link with the Dutch synthetic drug production market, and often the same people are involved in the synthetic drug market in both countries. In 2011 four illicit synthetic facilities were dismantled in Belgium — one each for ecstasy, amphetamine and methamphetamine, and one for the large-scale production and packaging of synthetic cannabinoids.

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National drug laws

In the first half of 2003 a change in the law and a new prosecution directive were enacted. Cannabis was differentiated from other illicit substances, and the two concepts of problem drug use and public nuisance were introduced. The new status of cannabis allowed the public prosecutor not to prosecute if there was no evidence of problematic drug use or of public nuisance. After the Constitutional Court found that these concepts were insufficiently defined, a new directive issued in February 2005 called for full prosecution only in cases involving disturbance of public order or other aggravating circumstances. This includes possession of cannabis in or near places where schoolchildren might gather and also ‘blatant’ possession in a public place or building.

For drugs other than cannabis, Belgian law punishes possession, production, import, export, or sale with between three months and five years of imprisonment and/or a fine. There is no separate offence of ‘trafficking’, but the term of imprisonment may be increased to 15 or even 20 years in the event of specific aggravating circumstances.

View ‘Legal profile’ for additional information.

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National drug strategy

The federal drug policy of Belgium is expressed in two key policy documents, the Federal Drug Policy Note of 2001 and the Communal Declaration of 2010.

Although it did not have a defined timeframe, the 2001 Federal Drug Policy Note was adopted as a long-term document designed to provide a comprehensive approach through its focus on illicit and licit substances, including alcohol, tobacco and medicines. The Policy Note’s main goal is the prevention and limitation of risks for drug users, their environment and society as a whole. Three pillars are used to articulate the comprehensive approach taken, covering the areas of: (i) prevention of drug consumption; (ii) harm reduction, assistance and re-integration; and (iii) enforcement. In addition, provision was made for the establishment of a system of coordination units at the federal level, integrating representatives of the federal state, the regions and the communities. The five main principles of Belgian drug policy are stated in the Policy Note: (i) a global and integrated approach; (ii) evaluation, epidemiology and scientific research; (iii) prevention for non-(problematic) users; (iv) treatment, risk reduction and reintegration for problematic users; and (v) repression for producers and traffickers.

The 2010 Communal Declaration provided a further statement and confirmation of the approach set out in the 2001 Policy Note. As a result, the Communal Declaration can be considered a more up-to-date elaboration of Belgian policy, rather than a replacement of the earlier document. In this sense, the action points stated in the Policy Note were assessed in terms of the extent to which they had been achieved, with additional steps to be taken, in the Communal Declaration. There are three overarching measures in the Communal Declaration: (i) a global and integrated approach; (ii) scientific research; and (iii) international coherence. Three pillars are used to structure action: (i) prevention, early detection and early intervention; (ii) treatment, harm reduction; (iii) repression (as a last resort). Priorities are focused on different groups within the three pillars, with prevention targeting non-(problematic) users; treatment, risk-reduction and reintegration aimed at problematic users; and repressive measures directed at producers and traffickers. Overall, the Declaration interprets the drugs problem as a public health issue.

View ‘National drug strategies’ for additional information.

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Coordination mechanism in the field of drugs

The General Drugs Policy Cell is responsible for both policy development and overall coordination in Belgium. As such, it operates at the inter-ministerial level as well as the day-to-day operational level. Following the ratification of a cooperation agreement between the state and the different federal levels in September 2002, the General Drugs Policy Cell has been fully operational since 2009. As well as being responsible for the coordination of a global and integrated drug policy in Belgium, the General Drugs Policy Cell is tasked with supporting and advising the different Belgian Governments. It is coordinated by the national drug coordinator and supported by the Federal Public Service of Health, Food Chain Safety and Environment. The composition of the General Drugs Policy Cell includes 17 federal government representatives and 18 regional government representatives; it is composed of members from all relevant authorities. Three different cells support the work of the General Drugs Policy Cell: (i) the Drugs Health Policy Cell, established in 2001; (ii) the Research and Scientific Information Cell, operational since 2011; and (iii) the Drugs Cell, located at the Federal Public Service of Health, Food Chain Safety and Environment.

Functioning as an inter-governmental coordination and decision-making body, the Inter-ministerial Conference on Drugs became operational in 2008 as a result of the 2002 cooperation agreement. The Conference’s members include all relevant ministers. While the General Drugs Policy Cell undertakes policy and coordination work, the Conference executes the proposals that are put forward by the Cell. The main activities of the Conference include:

1. Acquiring a global insight on all aspects of the drugs problem, taking into account personal, national, cultural and other characteristics.
2. Drugs prevention and harm reduction.
3. Improving and diversifying treatment opportunities.
4. Reducing illegal drug production and trafficking.
5. Preparation of documents for the coordination of drugs policy.
6. Preparation of documents for the Belgian representatives in European and international fora.

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Public expenditure

The Belgian Drug Policy Note of 2001 had no associated comprehensive budgets. (¹) Authorities funded three successive studies of drug-related public expenditure for the years 2001, 2004 and 2008. Estimates were based on a well-defined methodology and the last two studies are comparable. In 2012 authorities decided to coordinate the analysis of drug-related public expenditure on a yearly basis.

The latest study, from 2008, estimated that the total drug-related public expenditure (²) at the national level represented 0.11 % of gross domestic product (GDP). The total expenditure was divided into five areas: law enforcement (62.0 %), treatment (34.1 %), prevention (2.9 %), harm reduction (0.6 %) and others (0.4 %). (³)

Trend analysis shows that between 2004 and 2008 drug-related public expenditure remained stable at 0.11 % of GDP but increased in nominal terms by 18.5 %. Law enforcement and, at a smaller scale, treatment were the areas for which expenditure increased most. Expenditure on prevention fell.

(¹) Some of the regions have budgets accompanying their policy notes.

(²) Some of the funds allocated by governments for expenditure on tasks related to drugs are identified as such in the budget (‘labelled’). Often, however, the bulk of drug-related expenditure is not identified (‘unlabelled’) and must be estimated by modelling approaches. The total budget is the sum of labelled and unlabelled drug-related expenditure.

(³) In order to make comparison possible between 2004 and 2008, the figures represented in the text were calculated based on the methodology developed in the 2004 study (De Ruyver et al., 2007). Besides this methodology, a new and refined methodology was developed in 2008. This means that in the study by Vander Laenen et al. (2011) two methodologies were used to calculate drug-related public expenditure in Belgium. Using the new methodology the figures show the following picture: the total drug-related public expenditure at national level represented 0.09 % of GDP. Treatment represented 49.1 % of the total, law enforcement 45.1 %, prevention 3.9 %, harm reduction 0.8 % and others 1.1 %.

View ‘Public expenditure profile’ for additional information.

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Drug-related research

The federal drug strategy provides a budget for scientific research in the drugs field, which is managed by the Federal Science Policy Office through a research programme to support federal policy. Most studies funded through this programme are executed by networks of researchers, and the emphasis is mainly placed on drug treatment and on drug-related crime and nuisance. The national focal point collects information on ongoing and completed studies through its network of partners, and disseminates information on drug-related research findings to audiences through a variety of channels. Recent studies mentioned in the 2012 Belgium National report mainly focused on aspects related to the evaluation of interventions, policies and public expenditures, drug markets, prevalence and patterns of drug use in different settings (including the armed forces, prisons and nightlife) and the health and social consequences of drug use.

View ‘Drug-related research’ for additional information.

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