Drug use and drug-related problems
The prevalence of cannabis use is about five times that of other substances
In a top-level analysis of patterns and trends in drug use and their related harms, it is helpful to differentiate between three broad groups of substances: cannabis products, various stimulants and opioid drugs. The prevalence of cannabis use is about five times that of other substances, and the number of users entering treatment for cannabis problems has increased in recent years. While the use of heroin and other opioids remains relatively rare, these continue to be the drugs associated with most of the morbidity, mortality and cost of treatment related to drug use in Europe.
Monitoring drug use and drug-related problems
The EMCDDA’s five key epidemiological indicators are used as a basis for monitoring drug use and problems in Europe. These indicators incorporate data sets that cover estimates of recreational use (based mainly on surveys), estimates of high-risk use, drug-related deaths, infectious diseases and drug treatment entry. Taken together they provide the pillars supporting the European analysis of trends and developments in drug use and related harms. Technical information on the indicators can be found online in the Key indicators gateway and in the online Statistical Bulletin. In this chapter, data from the key indicators are complemented by additional data provided by Reitox focal points and other sources.
Drug use is also characterised by different patterns of consumption, ranging from single experimental use to habitual and dependent use. Use of all drugs is generally higher among males, and this difference is often accentuated for more intensive or regular patterns of use. Different consumption patterns are also associated with different levels and types of harm; and more frequent use, high doses, concurrent use of several substances and injection are all linked to elevated health risks.
Almost one in four Europeans have tried illicit drugs
Over 80 million adults, or almost a quarter of the adult population in the European Union, are estimated to have tried illicit drugs at some point in their lives. The most commonly used drug is cannabis (78.9 million), with lower estimates reported for the lifetime use of cocaine (15.6 million), amphetamines (12.0 million) and MDMA (12.3 million). Levels of lifetime use differ considerably between countries, ranging from around one-third of adults in Denmark, France and the United Kingdom, to 8 % or less than one in 10 in Bulgaria, Romania and Turkey.
Cannabis use: rising in Nordic countries
Cannabis is the illicit drug most likely to be used by all age groups. The drug is generally smoked and, in Europe, is commonly mixed with tobacco. Patterns of cannabis use can range from the occasional to the regular and dependent.
An estimated 14.6 million young Europeans (aged 15–34), or 11.7 % of this age group, used cannabis in the last year, with 8.8 million of these aged 15–24 (15.2 % of this age group).
A number of countries have sufficient survey data to allow a statistical analysis of long-term time trends in last year cannabis use among young adults (15–34). Population surveys for Germany, Spain and the United Kingdom report decreasing or stable cannabis prevalence over the past decade. In contrast, increasing prevalence can be observed for Bulgaria, France and three of the Nordic countries, (Denmark, Finland, Sweden). In addition, Norway reported an increase to a new high of 12 % in its most recent survey, although the current time series is insufficient for a statistical analysis of trends.
Taken as a whole, the most recent survey results continue to show divergent patterns in last year cannabis use (Figure 2.1). Of the countries that have produced surveys since 2012, four reported lower estimates, two were stable and eight reported higher estimates than in the previous comparable survey. Few national surveys currently report on the use of synthetic cannabinoids; for those that do, last year prevalence levels are generally low.
FIGURE 2.1 Last year prevalence of cannabis use among young adults (15–34)
Most recent data
Countries with statistically significant trends: Germany, Spain and the United Kingdom
Countries with statistically significant trends: Bulgaria, Denmark, Finland, France and Sweden
Cannabis use among school students
Monitoring substance use among students provides an important window on current youth risk behaviours. In Europe, the European School Survey Project on Alcohol and Other Drugs (ESPAD) study allows some insight into trends over time in substance use among 15- to 16-yearold school students. In the last round of data collection (2011), cannabis accounted for the majority of illicit drug use in this group, with about 24 % reporting having ever used the drug, ranging from 5 % in Norway to 42 % in the Czech Republic. The prevalence of use of illicit drugs other than cannabis was far lower.
In the seven countries that have reported national school surveys undertaken after the ESPAD study (2011), trends in prevalence of cannabis use among students show considerable variation.
Concern about cannabis users
A minority of cannabis users consume the substance intensively. Daily or almost daily cannabis use is defined as use on 20 days or more in the last month. Based on surveys of the general population, it is estimated that almost 1 % of European adults are daily or almost daily cannabis users. Around three-quarters of these are aged between 15 and 34 years, and over three-quarters are male.
While daily cannabis use is rare in the general population, among the nearly 3 % of adults (15–64) who used cannabis in the last month, around one-quarter used the substance daily or almost daily. This proportion varies substantially by country (see Figure 2.2). For the countries with a sufficient number of surveys to identify trends, the proportion of daily or almost daily users among all adults has remained stable over the last decade.
Cannabis is the drug most frequently reported as the principal reason for entering drug treatment by first-time clients in Europe, although what constitutes a treatment response for cannabis users varies considerably. The overall number of reported first-time treatment entrants rose from 45 000 to 61 000 between 2006 and 2013. Taking into account repeat entrants, cannabis was the second most frequently reported drug among all entrants to treatment in 2013 (123 000, 29 %). Considerable national variation exists, however, with reports of primary cannabis use ranging from 3 % of all treatment entrants in Lithuania to over 60 % in Denmark and Hungary. Various factors may contribute to this heterogeneity. For example, around one-quarter of those entering treatment in Europe for primary cannabis use are referred by the criminal justice system (23 000); this ranges from less than 5 % of primary cannabis clients in Bulgaria, Estonia, Latvia and the Netherlands to over 80 % in Hungary.
FIGURE 2.2 Proportion of last month cannabis users (15–64) who used the substance daily or almost daily
Cannabis is the drug most frequently reported as the principal reason for entering drug treatment by first-time clients in Europe
Hospital emergencies associated with cannabis
Although rare, acute emergencies can occur after consuming cannabis, especially at high doses. In countries with higher prevalence levels, cannabis accounts for a sizeable share of drug-related emergencies. A recent study identified an increase in the numbers of cannabis-related emergencies between 2008 and 2012 in 11 of the 13 European countries analysed. In Spain, for example, the number of emergencies related to cannabis increased from 1 589 (25 % of all drug-related emergencies) in 2008 to 1 980 (33 %) in 2011.
The European Drug Emergencies Network (Euro-DEN), which monitors drug-related emergency presentations in 16 sites in 10 European countries, reported that between 10 % and 48 % (16 % on average) of all drug-related presentations involved cannabis, although other substances were present in 90 % of these cases. Most commonly, cannabis was found alongside alcohol, benzodiazepines and stimulants. The most frequently reported problems were neuro-behavioural (agitation, aggression, psychosis and anxiety) and vomiting. In most cases, patients were discharged without the need for inpatient admission.
CANNABIS USERS ENTERING TREATMENT
Cocaine: Europe’s most commonly used stimulant
Cocaine powder is primarily sniffed or snorted, but is also sometimes injected, while crack cocaine is usually smoked. Among regular users, a broad distinction can be made between more socially integrated consumers, who often sniff powder cocaine in a recreational context, and marginalised users, who inject cocaine or smoke crack often alongside the use of opioids. Regular cocaine use has been associated with dependence, cardiovascular, neurological and mental health problems, and with an elevated risk of accidents. Cocaine injection and use of crack cocaine are associated with the greatest health risks, including the transmission of infectious diseases.
Cocaine is the most commonly used illicit stimulant drug in Europe, although most users are found in a restricted number of countries. This is illustrated by survey data which show cocaine use to be more prevalent in the south and west of Europe.
It is estimated that about 2.3 million young adults aged 15 to 34 (1.9 % of this age group) used cocaine in the last year. Many cocaine users consume the drug recreationally, with use highest during weekends and holidays. Data from wastewater analysis carried out in a 2014 European multi-city study confirm daily differences in use. Higher concentrations of benzoylecgonine — the main metabolite of cocaine — were found in samples collected during the weekend (Figure 2.3).
FIGURE 2.3 Cocaine residues in wastewater
In selected European cities
NB: Mean daily amounts of cocaine in milligrams per 1 000 population, from sampling over a one-week period in 2014.
Source: Sewage Analysis Core Group Europe (SCORE).
Only a few countries report last year prevalence of cocaine use among young adults of more than 3 % (Figure 2.4). Among these countries, Spain and the United Kingdom observed statistically significant increasing trends in prevalence until 2008, after which the trend changed to become stable or declining. Below 3 % prevalence, Ireland and Denmark report falls in the most recent data, but as yet this is not statistically discernible, while French surveys up until 2014 show an increasing trend in use.
FIGURE 2.4 Last year prevalence of cocaine use among young adults (15–34)
Most recent data
Decreases in cocaine use are observable in the most recent data; of the countries that have produced surveys since 2012, eight reported lower estimates and three reported higher estimates than in the previous comparable survey.
Continued decline in cocaine treatment demand
The prevalence of problematic forms of cocaine use in Europe is difficult to gauge as only four countries have recent estimates and, for methodological reasons, these are not easy to compare. In 2012, Germany estimated ‘cocaine-dependency’ among the adult population at 0.20 %. In 2013, Italy produced an estimate of 0.23 % for those ‘in need of treatment for cocaine use’, and Spain estimated ‘high-risk cocaine use’ at 0.29 %. For 2011/12, the United Kingdom estimated crack cocaine use among the adult population in England at 0.48 %, and the majority of these were also opioid users.
Cocaine was cited as the primary drug for 13 % of all reported clients entering specialised drug treatment in 2013 (55 000), and 16 % of those entering treatment for the first time (25 000). Differences exist between countries, with more than 70 % of all cocaine clients being reported by only three countries (Spain, Italy, United Kingdom). In the most recent data, the number of cocaine clients entering treatment for the first time has stabilised at around 24 000; this number has declined from a peak of 38 000 in 2008. In 2013, 6 000 clients entering treatment in Europe reported primary crack cocaine use, with the United Kingdom accounting for more than half of these (3 500), and Spain, France and the Netherlands most of the remainder (2 200).
Interpreting the available data on cocaine associated mortality is challenging, in part because this drug may be a factor in some deaths that are attributed to cardiovascular problems. Nonetheless, over 800 deaths associated with cocaine use were reported in 2013 (data from 27 countries). Most of these were attributed to drug overdose, with other substances also being detected in many cases, primarily opioids. At the European level, data quality issues mean that it is not possible to comment on trends. Some countries, however, do have limited information available. For example, between 2012 and 2013, the number of deaths in which the presence of cocaine was recorded increased from 174 to 215 in the United Kingdom and from 19 to 29 in Turkey.
Over 800 deaths associated with cocaine use were reported in 2013
COCAINE USERS ENTERING TREATMENT
Amphetamines: use stable in many countries
Amphetamine and methamphetamine, two closely related stimulants, are both consumed in Europe, although amphetamine is by far the more commonly used. Methamphetamine consumption has historically been restricted to the Czech Republic and, more recently, Slovakia, although there are now signs of growing use in other countries. In some data sets, it is not possible to distinguish between these two substances; in these cases, the generic term amphetamines is used.
Both drugs can be taken orally or nasally; in addition, injection is common among high-risk users in some countries. Methamphetamine can also be smoked, but this route of administration is not commonly reported in Europe.
Adverse health effects linked with amphetamines use include cardiovascular, pulmonary, neurological and mental health problems, while as with other drugs, injection is a risk factor for infectious diseases. As with other stimulants, deaths related to amphetamines can be difficult to identify. However, small numbers are reported annually.
FIGURE 2.5 Last year prevalence of amphetamines use among young adults (15–34)
Most recent data
An estimated 1.3 million (1.0 %) young adults (15–34) used amphetamines during the last year. The most recent national prevalence estimates range from 0.1 % to 1.8 % (Figure 2.5). The data available suggest that from around 2000, most European countries have experienced a relatively stable situation in respect to trends in use. Exceptions here are Spain and the United Kingdom, where a statistically significant decrease in prevalence can be observed since 2000.
New patterns in problem amphetamines use
In respect to long-term, chronic and injecting amphetamine use, historically, problems have mostly been observed in northern European countries. In contrast, long-term methamphetamine problems have been most apparent in the Czech Republic and Slovakia. These countries report estimates of problem use among adults (15–64) at around 0.48 % for the Czech Republic (2013) and 0.21 % in Slovakia (2007). In the Czech Republic, a marked increase in problem or high-risk methamphetamine use, mainly injection, has been observed between 2007 and 2013 (from around 20 000 to over 34 000). There are recent indications that methamphetamine use is diffusing to other countries and new populations, with the use of the drug being reported in countries bordering the Czech Republic (Germany, Austria) in parts of southern Europe (Greece, Cyprus, Turkey) and in northern European countries (Latvia, Norway). A new pattern of methamphetamine use continues to be reported in a number of European countries, where the drug is injected, often alongside other stimulants, among small groups of men who have sex with men. These so-called slamming parties are a concern because of the combination of risk-taking in both drug-use and sexual behaviours.
Around 7 % of clients entering specialised drug treatment in Europe in 2013 report amphetamines (amphetamine and methamphetamine) as their primary drug. This amounts to approximately 29 000 clients, of whom 12 000 entered treatment for the first time in their life. Primary amphetamine users account for a sizeable proportion of reported first-time treatment entries in only Germany, Latvia and Poland. Treatment entrants reporting primary methamphetamine use are concentrated in the Czech Republic and Slovakia, which together account for 95 % of the 8 000 methamphetamine clients in Europe. Increases in first-time entrants for amphetamines are accounted for primarily by Germany, the Czech Republic and Slovakia.
AMPHETAMINES USERS ENTERING TREATMENT
FIGURE 2.6 Last year prevalence of ecstasy use among young adults (15–34)
Most recent data
MDMA (3,4-methylenedioxy-methamphetamine) is commonly used in the form of ecstasy tablets, but is now also increasingly available as crystals and powders; tablets are usually swallowed, but in powder form the drug is also snorted (nasal insufflation). Problems associated with use of this drug include acute hyperthermia, increased heart rate and multi-organ failure, and long-term use has been linked with liver and heart problems. Deaths associated with this drug remain relatively rare, and are sometimes caused by other substances sold as MDMA. There have been recent concerns about acute problems linked with high-dose MDMA tablets and powders. In addition, warnings have been issued in 2014 about ecstasy tablets that contained high concentrations of PMMA — a drug with a worrying safety profile.
Most European surveys have historically collected data on ecstasy rather than MDMA use. It is estimated that 1.8 million young adults (15–34) used ecstasy in the last year (1.4 % of this age group), with national estimates ranging from under 0.1 % to 3.1 %. Among those countries with sufficient data to explore trends statistically, decreasing prevalence can be observed since 2000 in Germany, Spain and the United Kingdom. Denmark has a similar pattern of decreasing prevalence, but at a lower level of statistical certainty (Figure 2.6). In contrast, a pattern of increasing prevalence estimates continues in Bulgaria. Among the countries that have produced new surveys since 2012 results diverge: six reported lower prevalence estimates and seven reported higher estimates than in the previous comparable survey. Ecstasy use is rarely reported as a reason for entering drug treatment, with the drug being responsible for less than 1 % (around 600 cases) of reported first-time treatment entrants in 2013.
Most European surveys have historically collected data on ecstasy rather than MDMA use
GHB, ketamine and hallucinogens: still causing concern in some countries
A number of other psychoactive substances with hallucinogenic, anaesthetic and depressant properties are used in Europe: these include LSD (lysergic acid diethylamide), ketamine, GHB (gamma-hydroxybutyrate) and hallucinogenic mushrooms.
The recreational use of ketamine and GHB (including its precursor GBL, gamma-butyrolactone) has been reported among subgroups of drug users in Europe for the last two decades. There is growing recognition of the health problems related to these substances, for example, damage to the bladder associated with long-term ketamine use. Loss of consciousness, withdrawal syndrome and dependence are risks linked to use of GHB. Treatment requests related to GHB are reported in Belgium, the Netherlands and the United Kingdom.
Where they exist, national estimates of the prevalence of GHB and ketamine use in both adult and school populations remain low. In their most recent surveys, Norway reported last year prevalence of GHB use at 0.1 % for adults (15–64), while Denmark and Spain reported last year prevalence of ketamine use at 0.3 % among young adults (15–34), and the United Kingdom reported last year ketamine use at 1.8 % among 16- to 24-year-olds, a stable trend since 2008.
The overall prevalence levels of hallucinogenic mushrooms and LSD use in Europe have been generally low and stable for a number of years. Among young adults (15–34), national surveys report last year prevalence estimates of under 1 % for both substances.
Higher levels of drug use among nightclub goers
It is well known that some social settings are particularly associated with elevated levels of drug and alcohol consumption. Typically, surveys of young people who regularly attend nightlife events indicate higher levels of drug use compared with the general population. This can been seen in information from the Internet-based Global Drug Survey, where the EMCDDA has commissioned a special analysis of drug use among young adults who self-identified as regular nightclub goers (defined as attending at least every three months). Analysis was performed on a sample of 25 790 young people aged 15–34, from 10 European countries. It should be noted that this is a non-representative, self-selected sample who responded to an online drug survey, and therefore the results must be interpreted with caution. Among this sample, depending on the substance, last year prevalence was between 4 and nearly 25 times higher than that found among the same age group in the general population of the European Union. Grouping together the available countries for each drug and comparing with the weighted average from general population surveys (GPS), around 55 % of the regular club-goers reported last year use of cannabis (GPS weighted country average 12.9 %), with high figures for other drugs: cocaine 22 % (GPS 2.4 %); amphetamines 19 % (GPS 1.2 %); ecstasy 37 % (GPS 1.5 %) (Figure 2.7). Last year prevalence levels among the club-goers were also reported for other drugs, including ketamine (11 %), mephedrone (3 %), synthetic cannabinoids (3 %) and GHB (2 %).
Last year prevalence among young adults (15–34): general population and club-goers (10 countries)
Sources: Global Drug Survey 2014 and the most recent general population surveys for the following countries: Belgium, Germany, Ireland, Spain, France, Hungary, Netherlands, Austria, Portugal, United Kingdom. Amphetamines: minus Belgium and Netherlands. Ecstasy: minus Netherlands.
A small number of club-goers reported experiencing problems with their drug use, with cannabis and ecstasy the drugs most commonly associated with acute emergency presentations among this group.
Use of ‘legal highs’ among young people
The prevalence of use of new psychoactive substances in Europe is hard to ascertain. Where these substances are incorporated in national surveys, the lack of a common methodology means that the data are rarely comparable between countries, and definitional problems complicate things further, especially as the legal status of substances can change rapidly. Nevertheless, some insights into use of these substances is provided by the 2014 Flash Eurobarometer on young people and drugs, a telephone survey of 13 128 young adults aged 15–24 in the 28 EU Member States. In response to a question on perceived availability, over two-thirds of respondents thought it would be difficult or impossible to obtain ‘legal highs’ — defined as new substances that imitate the effects of illicit drugs. Although primarily an attitudinal survey, the Eurobarometer included a question on the use of ‘legal highs’. Currently, these data represent the only EU-wide information source on this topic, although for methodological reasons caution is required in interpreting the results. Overall, 8 % of respondents reported lifetime use of ‘legal highs’, with 3 % reporting use in the last year (Figure 2.8). This represents an increase from the 5 % reporting lifetime use in a similar survey in 2011. The highest levels of use in the last year were reported by young people from Ireland (9 %), while use of ‘legal highs’ in the last year was not reported in the samples from Cyprus and Malta. Of those reporting use in the last year, 68 % had obtained the substance from a friend.
Availability and use of 'legal highs', defined as new substances that imitate the effects of illicit drugs
How easy or dificult would it be for you to get them within 24 hours
Have you ever used them?
Thinking about your use of these substances in the last 12 months, where did you get them?
Multiple answers possible
Source: Flash Europbarometer Survey 401
It is of interest to consider the Eurobarometer results alongside those from other surveys, while noting that different methods and questions are being employed. Nine European countries have reported national estimates of the use of new psychoactive substances or ‘legal highs’ (not including ketamine and GHB), since 2011. Last year prevalence of use of these substances among young adults (aged 15–24) ranges from 9.7 % in Ireland to 0.2 % in Portugal. It should be noted that in both of these countries, measures have been introduced to restrict the direct availability of ‘legal highs’ by closing shops where these products were being sold. Survey data for the United Kingdom (England and Wales) are available on the use of mephedrone. In the most recent survey (2013/14), last year use of this drug among young people aged 16 to 24 was estimated at 1.9 %; this figure was stable compared with the previous year, but down from 4.4 % in 2010/11, before control measures were introduced.
The injection of synthetic cathinones, although not a widespread phenomenon, continues to be reported in some specific populations, including opioid injectors, drug treatment clients in some countries and small populations of men who have sex with men. An increase in treatment demand associated with synthetic cathinone use problems has been reported in Hungary, Romania and the United Kingdom. In the United Kingdom (England), the number of first-time treatment entrants reporting any use of mephedrone increased from 900 to 1 630 between 2011/12 and 2012/13, with numbers stabilising in 2013/14 at 1 641.
Opioids: 1.3 million problem users
The illicit use of opioids remains responsible for a disproportionately large share of the morbidity and mortality resulting from drug use in Europe. The main opioid used in Europe is heroin, which may be smoked, snorted or injected. A range of other synthetic opioids, such as buprenorphine, methadone and fentanyl, are also misused.
The average annual prevalence of high-risk opioid use among adults (15–64) is estimated at around 0.4 % (4 per 1 000 population), the equivalent of 1.3 million problem opioid users in Europe in 2013. Prevalence estimates of high-risk opioid use vary between countries from less than one to around eight cases per 1 000 population aged 15–64. Ten countries have repeated estimates of high-risk opioid use between 2006 and 2013 and these show relatively stable trends (Figure 2.9).
Clients using opioids, mainly heroin, as their primary drug represent 41 % of all drug users who entered specialised treatment in 2013 in Europe (175 000 clients), and 20 % of those entering treatment for the first time (31 000 clients). The number of new heroin clients has more than halved from a peak of 59 000 in 2007 to 23 000 in 2013. Overall, it appears likely that recruitment into heroin use has decreased and that this is now impacting on treatment demand.
FIGURE 2.9 National estimates of last year prevalence of high-risk opioid use
Most recent data
Opioids other than heroin: of increasing concern
The main opioid used in Europe is heroin
In just over a third (11) of European countries, more than 10 % of all opioid clients entering specialised services in 2013 were treated for problems primarily related to opioids other than heroin (Figure 2.10). These substances include methadone, buprenorphine and fentanyl. Overall, misused methadone is the most commonly reported opioid other than heroin, followed by buprenorphine; respectively, these drugs account for 60 % and 30 % of all treatment demands from clients whose primary drug problem relates to opioids other than heroin. In some countries, other opioids now represent the most common form of problem opioid use. In Estonia, for example, the majority of treatment entrants reporting an opioid as their primary drug were using illicit fentanyl, while in Finland most opioid clients are reported to be primary misusers of buprenorphine.
FIGURE 2.10 Treatment entrants citing opioids as primary drug
By type of opioid
Percentage reporting opioids other than heroin
High-risk opioid users: an ageing population
Two trends are evident among opioid users entering treatment: their numbers are declining and the average age is increasing (Figure 2.11). Between 2006 and 2013, the median age of clients entering treatment for problems related to opioid use increased by 5 years. During the same period, the average age of drug-induced deaths (which are mainly related to opioids) increased from 33 to 37 years. A significant number of problem opioid users in Europe with long-term polydrug use histories are now aged in their 40s and 50s. A history of poor health, bad living conditions, tobacco and alcohol use, and age-related deterioration of the immune system make these users susceptible to a range of chronic health problems. Among these are cardiovascular and lung problems resulting from chronic tobacco use and injecting drug use. Long-term heroin users are also reporting chronic pain conditions, while infection with hepatitis virus can place them at increased risk of cirrhosis and other liver problems. The cumulative effects of polydrug use, overdose and infections over many years accelerate physical ageing among these users, with growing implications for treatment and social support services.
FIGURE 2.11 Trends in age structure of clients entering treatment by primary drug
Injecting drug use: long-term decline
Injecting drug users are among those at highest risk of experiencing harms from their drug use, including bloodborne infections or drug overdoses. Injection is most commonly associated with opioid use, although in a few countries, amphetamines injection is a major problem. Recent estimates of the prevalence of injecting drug use are available for 14 countries, where they range from less than one to more than nine cases per 1 000 population aged 15–64.
Among those entering specialised treatment for the first time with amphetamines as their primary drug, 46 % report injecting as their main route of administration, with a stable overall trend (Figure 2.12). Each year, over 70 % of these are reported by the Czech Republic, where the trend has been increasing. For the remaining European countries, injecting as the main route of administration for new amphetamine clients is in decline. Among first-time clients reporting heroin as their primary drug, 33 % reported injecting as their main route of administration, down from 43 % in 2006. Levels of injecting among heroin clients vary between countries, from 8 % in the Netherlands to 100 % in Lithuania. Taking the main three injected drugs together, among first-time entrants to treatment in Europe, injecting as the main route of administration has declined from 28 % in 2006 to 20 % in 2013.
First-time treatment entrants reporting injecting as the main route of administration of their primary drug
HEROIN USERS ENTERING TREATMENT
New HIV cases among injectors fall as Greece curbs outbreak
Drug injection continues to play a central role in the transmission of blood-borne infections such as the hepatitis C virus (HCV) and, in some countries, the human immunodeficiency virus (HIV). Among all HIV cases notified in Europe where the route of transmission is known, the percentage attributable to injecting drug use has remained low and stable (under 8 % for the last decade).
The latest figures show that the increase in the number of new HIV diagnoses in Europe, which resulted from outbreaks in Greece and Romania, has halted and the EU total has dropped to pre-outbreak levels (Figure 2.13). Provisional figures for 2013 show 1 458 newly reported cases, compared with 1 974 in 2012, reversing the upward trend observed since 2010. This drop is largely explained by decreases in Greece, where the number of new cases more than halved from 2012 to 2013, and to a lesser extent, Romania. Although the outbreaks seem to have peaked in these two countries, the number of new diagnoses in 2013 remains at least 10 times higher than the pre-outbreak level in 2010.
In 2013, the average rate of newly reported HIV diagnoses attributed to injecting drug use was 2.5 per million population, with the three Baltic States showing rates 8 to 22 times higher than the EU average. In other countries that have experienced periods with high rates of infection in the past, such as Spain and Portugal, rates of newly reported diagnoses continue to decline.
FIGURE 2.13 Newly diagnosed HIV cases related to injecting drug use
Trends in number of cases
Most recent data (cases per million population)
Data for 2013 (source: ECDC).
Early diagnosis and prompt appropriate treatment are important in preventing progression from HIV infection to AIDS. In 2013, there were 769 notifications of new AIDS cases in Europe attributable to injecting drug use. The relatively high numbers of new diagnoses coming from Bulgaria, Latvia, Greece and Romania suggests that AIDS prevention and HIV treatment responses in these countries require strengthening.
HIV-related mortality is one of the best documented indirect causes of death among drug users. The most recent estimate suggests that about 1 700 people died of HIV/AIDS attributable to injecting drug use in Europe in 2010, and the trend is downward.
Hepatitis and other infections associated with drug use
Viral hepatitis, particularly infection caused by the hepatitis C virus (HCV), is highly prevalent among injecting drug users across Europe. This may have important long-term consequences, as HCV infection, often worsened by heavy alcohol use, is likely to account for increasing numbers of cases of cirrhosis, liver cancer and death among injecting drug users.
HCV antibody levels among national samples of injecting drug users in 2012–13 varied from 14 % to 84 %, with 5 of the 10 countries with national data reporting a prevalence rate in excess of 50 % (Figure 2.14). Among countries with national trend data for the period 2006–13, declining HCV prevalence in injecting drug users was only reported in Norway, while six other countries observed an increase.
Drug use may be a risk factor for other infectious diseases including hepatitis A and B, sexually transmitted diseases, tuberculosis, tetanus and botulism. Sporadic cases of wound botulism among injecting drug users have been reported in Europe. In Norway, six confirmed cases were reported between September and November 2013. Two clusters of wound botulism cases — in Norway and Scotland — were identified in December 2014, and these were under investigation into 2015.
HCV antibody prevalence among injecting drug users, 2012/2013
Drug use is one of the major causes of avoidable mortality among young people in Europe, both directly through overdose (drug-induced deaths) and indirectly through drug-related diseases, accidents, violence and suicide. Most studies on cohorts of problem drug users show mortality rates in the range of 1–2 % per year, and it has been estimated that between 10 000 and 20 000 opioid users die each year in Europe. Overall, opioid users are at least 10 times more likely to die than their peers of the same age and gender. A recent EMCDDA multisite study with data from nine European countries found that most deaths among problem drug users are premature and preventable. The study recorded 2 886 deaths among a sample of over 31 000 participants, with an overall annual mortality rate of 14.2 per 1 000. Cause of death was identified for 71 % of the cases, and half of these deaths were accounted for by external causes, mostly overdose and to a lesser extent suicide, and the other half were attributed to somatic causes including HIV/AIDS, and circulatory and respiratory diseases.
Overdose deaths: recent increases in some countries
Overall, drug overdose continues to be the main cause of death among problem drug users, and over three-quarters of overdose victims are male (78 %). While it is often the deaths among the very young that generate concern, only 8 % of the overdose deaths reported in Europe in 2013 were aged under 25 years. Between 2006 and 2013, a pattern can be observed of decreasing numbers of overdose deaths among younger drug users and increasing numbers among older users (Figure 2.15). This reflects the ageing nature of Europe’s opioid-using population, who are at greatest risk of drug overdose death.
Most countries reported an increasing trend in overdose deaths from 2003 until around 2008/09, when overall levels first stabilised and then began to decline. Caution is required when interpreting overdose data, and especially the EU cumulative total, for a number of reasons, which include systematic under-reporting in some countries and registration processes that result in reporting delays, both for cases and national totals. Because of these delays, the EU total for the current year is a provisional value which is subject to revision as new data become available. The EU estimate for 2013 is a minimum of 6 100 deaths. This is a slight increase from the revised 2012 figure. It is of particular concern that increases are evident in the most recent data from a number of countries with relatively robust reporting systems, including Germany, Sweden and the United Kingdom. Turkey is also showing increases, but this may partly reflect improved reporting.
Number of drug-induced deaths by age group in 2006 and in 2013
Heroin or its metabolites are present in the majority of fatal overdoses reported in Europe, often in combination with other substances. In the United Kingdom (England) and Turkey, increases in reported deaths are driven to a large extent by deaths where heroin is implicated. In addition to heroin, other opioids including methadone, buprenorphine, fentanyls and tramadol are regularly found in toxicological reports, and these substances are now associated with a substantial share of overdose deaths in some countries.
For 2013, the average mortality rate due to overdoses in Europe is estimated at 16 deaths per million population aged 15–64. National mortality rates vary considerably and are influenced by factors such as prevalence and patterns of drug use, particularly injecting and opioid use, the characteristics of drug-using populations, the availability and purity of the drugs, reporting practices and provision of services. Rates of over 40 deaths per million were reported in seven countries, with the highest rates reported in Estonia (127 per million), Norway (70 per million) and Sweden (70 per million) (Figure 2.16). Although national differences in coding and reporting practices, as well as possible under-reporting, make it difficult to compare countries, analysing trends over time within individual countries is valuable. Recent improvements have been observed in the mortality rate due to overdose in Estonia, although the rates still remain eight times higher than the EU average. Overdose deaths there are mostly related to the injection of fentanyls — highly potent opioids.
Heroin or its metabolites are present in the majority of fatal overdoses reported in Europe
FIGURE 2.16 Drug-induced mortality rates among adults (15–64)
Most recent data (cases per million population)
NB: Trends in the ten countries reporting the highest values in 2013.
New drugs: increasingly linked with drug-related harms and deaths
Overall, there is increasing evidence of the role that new psychoactive substances play in hospital emergencies and some drug-induced deaths in Europe. In 2014, the EU Early Warning System issued 16 alerts in relation to new substances being monitored by the mechanism, with many concerning serious adverse events such as deaths. A recent analysis by the European Drug Emergencies Network, which monitors emergency presentations in sites in 10 European countries, found that 9 % of all drugrelated emergencies involved new psychoactive substances, primarily cathinones. In addition, 12 % of all presentations were for GHB or GBL and 2 % were for etamine.
Recent reports of acute adverse health consequences associated with synthetic cannabinoids indicate that use of these substances may in some circumstances result in serious health consequences, including mortality. A 2015 review reported the most common adverse health effects associated with synthetic cannabinoids to be tachycardia, extreme agitation and hallucinations.
Evaluating the toxicological significance of any substance in a death is often complicated, especially given that in most drug-induced deaths multiple substances will have been consumed. These problems are accentuated for new drugs, which may be difficult to detect and not be included in commonly used screening tools. Despite these limitations, some data are available. In Hungary, for example, new psychoactive substances were detected in around half of the reported drug-induced deaths in 2013 (14 out of 31 cases), all in the presence of other substances. Case reports are also collected by the Early Warning System as part of the risk assessment of new drugs. These data indicate the role some new psychoactive substances can play in drug-related morbidity and mortality: for example, the synthetic cathinone MDPV, which was first detected in 2008, had been found in 99 deaths at the time of its risk assessment in 2014.