Health and social responses to drug problems
In this chapter, policies and interventions designed to prevent, treat and reduce harms related to drug use are reviewed
In this chapter, policies and interventions designed to prevent, treat and reduce harms related to drug use are reviewed. The focus is on the extent to which countries have adopted common approaches, which of these are informed by evidence, and whether service provision matches estimated need. The key policy areas monitored at European level include national drug strategies and action plans, drugrelated budgets and public expenditure estimates.
Monitoring health and social responses
Data used here are provided by Reitox focal points and expert working groups, complemented by reports on treatment demands, opioid substitution treatment and needle and syringe provision. Expert ratings provide supplementary information on the availability of services, where more formalised datasets are unavailable. The chapter is also informed by reviews of the scientific evidence on the effectiveness of public health interventions.
National and city level drug strategies
The European Drugs strategy 2013–20 and accompanying action plans provide a framework for coordinated responses to drug problems in Europe. At the country level, this is mirrored in national drug strategies, budgetary frameworks and plans. These time-limited documents usually contain a set of general principles, objectives and priorities, specifying actions and the parties responsible for their implementation. All countries have now a national drug policy and, in all but two countries, this can be found in a national drug strategy document. The exceptions are Austria, where drug strategy is included in regional plans, and Denmark, where the issue is addressed in a number of policy documents and actions. National strategies and action plans that cover both licit and illicit drugs have been adopted by eight countries (Figure 3.1). Evaluation of drug strategies and action plans has been conducted in many countries. The aim of evaluation is generally to assess the changes in the overall drug situation as well as the level of implementation achieved.
National drug strategies and action plans: availability and scope
NB: While the United Kingdom has an illicit drug strategy, both Wales and Northern Ireland have combined strategies which include alcohol.
City authorities in Europe are often responsible for coordinating local drug policy, in some instances with dedicated budgets. In many countries, strategic planning documents also exist to support policy implementation. A recent EMCDDA study reported on 10 capital cities with a dedicated drugs strategy, and in some cases an accompanying action plan. Some of these had broad coverage, while others focused on a specific issue such as overdose deaths, use of GHB or problems linked to open drug scenes. In some cities without a specific drug strategy, drug policy objectives were incorporated into wider local health or crime reduction strategies. In others, drug issues were covered by broader regional or national policy documents.
Austerity impacts on funding for health interventions
The information available on drug-related public expenditure in Europe, at both local and national level, remains sparse and heterogeneous. For the 18 countries that have produced estimates in the past 10 years, drug-related public expenditure is estimated at between 0.01 % and 0.5 % of gross domestic product, with health interventions representing between 24 % and 73 % of total drug-related expenditure. Differences in the scope and quality of the estimates make it difficult to compare drug-related public expenditure between countries.
In the wake of the 2008 economic recession, many European governments imposed fiscal consolidation measures, often referred to as austerity measures. The size of the economic downturn, its impact and the timing and the scale of fiscal measures varied markedly between countries. In many countries, austerity measures led to reductions in public spending in those categories of government activity that encompass the bulk of drugrelated initiatives. Analysis carried out by the EMCDDA suggests that overall, bigger cuts were more often registered in the health sector than in other areas such as public order and safety or social protection. Data for the period 2009–12 show a decline in public spending on health in most countries, compared with the pre-recession period 2005–07, with reductions of more than 10 percentage points in many European countries, at constant prices (Figure 3.2). As drug-related health expenditure represents a small proportion of total public health spending (often less than 1 %), trends in drugrelated funding cannot be directly inferred from this data. Nevertheless, reductions in health funding are likely to have a negative impact on drug-related initiatives and EMCDDA reporting suggests that funding of drug-related research and prevention activities may have been particularly affected.
National drug strategies and action plans: availability and scope
The prevention of drug use and drug-related problems among young people is a key policy objective
Prevention of drug use among young people
The prevention of drug use and drug-related problems among young people is a key policy objective and is one of the pillars of the European Drugs Strategy 2013–20. Drug prevention encompasses a wide range of approaches. Environmental and universal strategies target entire populations, selective prevention targets vulnerable groups who may be at greater risk of developing drug use problems, and indicated prevention focuses on at-risk individuals. Over the last decade, the availability of quality standards, which can support intervention delivery and best practice, has grown. The European Drug Prevention Quality Standards Project provides toolkits to support the implementation of standards in this area.
A relatively robust evidence base exists for some prevention approaches that may be implemented in school settings. While countries report extensive implementation of smoking bans in schools and school drug policies, approaches for which an evidence base exists, prevention approaches solely based on the provision of information are also reported to be quite widely available (Figure 3.3). Providing health-related information may be important in educational terms, however, there is little evidence available to suggest that this form of prevention impacts on future drug-taking behaviour.
Early detection and intervention approaches are used in some schools, often based on the provision of counselling to young substance users. A Canadian programme (Preventure) that targets young sensation-seeking drinkers has been positively evaluated; it has been adapted for use in the Czech Republic, the Netherlands and the United Kingdom.
With regard to the provision of prevention interventions to specific vulnerable groups, the approaches with the highest availability are reported to be those targeting families with substance misuse problems, the provision of interventions for pupils with social and academic problems and interventions for young offenders. One programme of note targeting young offenders is FreD, a set of manualbased interventions, which has been implemented in 15 EU Member States. Evaluations of this programme have shown a fall in repeat-offending rates.
School-based interventions to prevent substance use: provision and evidence of effectiveness (European averages based on expert ratings, 2013)
NB: Evidence statements are based on the EMCDDA Best practice portal and UNODC evidence standards.
New drugs and new challenges
In European countries, initial responses to the emergence of new psychoactive substances have been predominantly regulatory in nature, focused on tackling their supply using legislative tools. Increasingly, however, more attention is being paid to the development of targeted education and prevention activities, as well as training and awarenessraising activities for professionals. In addition, services working in nightlife and recreational settings have tended to integrate their response to new substances within established approaches. The Internet is also increasingly important as a platform for the provision of information and counselling. One development has been the use of ‘online-outreach’ interventions to reach the new target groups. Examples include drug user-led initiatives, such as forums and blogs, which provide consumer protection information and advice. In a few cases, these interventions have been linked with drug testing and pill-checking services, with results and harm reduction messages disseminated online.
Currently, in Europe, new psychoactive substances are not associated with a significant demand for specialist treatment, although service developments are now seen in some countries. The emergence of new drugs has manifested itself in different ways in individual countries, and national responses reflect these differences. In Hungary and Romania, where the injecting of cathinones has been reported, needle and syringe exchange services play an important role. In the United Kingdom, where significant use of mephedrone has been recorded, specialist ‘club-drug clinics’ are engaging with this client group and treatment guidelines are being developed.
The Internet is also increasingly important as a platform for the provision of information and counselling
Most drug treatment provided in outpatient settings
FIGURE 3.4 Numbers receiving drug treatment in Europe in 2013, by setting
Most drug treatment in Europe is provided in outpatient settings, with specialised outpatient centres representing the largest provider in terms of drug users reached, followed by general healthcare centres (Figure 3.4). These include general practitioners’ surgeries, reflecting their role as prescribers of opioid substitution treatment in some large countries, such as Germany and France. A sizeable proportion of drug treatment in Europe is also provided in inpatient settings, such as hospital-based residential centres (e.g. psychiatric hospitals), therapeutic communities and specialised residential treatment centres. The relative importance of outpatient and inpatient provision within national treatment systems varies greatly between countries. In addition, many countries have low-threshold services, and although many of these do not provide structured treatment, in some countries, like France and the Czech Republic, these agencies are considered as an integral part of the national treatment system.
Trends in percentage of clients entering specialised drug treatment services, by primary drug
An estimated 1.6 million people received treatment for illicit drug use in Europe (1.4 million in the European Union) during 2013. This number is 0.3 million above the 2012 estimate. The increase is in part due to improved reporting methods and new data, in particular the inclusion of 200 000 outpatient clients from Turkey.
Data from monitoring treatment entries show that after opioids, cannabis and cocaine users are the second and third largest groups entering specialised drug treatment services (Figure 3.5). Psychosocial interventions are the main treatment modality used with these clients.
Most drug treatment in Europe is provided in outpatient settings
Opioid substitution treatment: the most common modality, but numbers decreasing
Opioid users represent the largest group undergoing specialised treatment in Europe and consume the greatest share of available treatment resources. Substitution treatment, typically combined with psychosocial interventions, is the most common treatment for opioid dependence. This approach is supported by the available evidence, with positive outcomes found in respect to treatment retention, reduced illicit opioid use, reported risk behaviour, and reductions in drug-related harms and mortality.
Methadone is the most commonly prescribed opioid substitution medication, received by over two-thirds (69 %) of substitution clients. A further 28 % of clients are treated with buprenorphine, which is the principal substitution medication used in six countries. Other substances, such as slow-release morphine or diacetylmorphine (heroin), are only prescribed occasionally in Europe, and are estimated to be received by around 3 % of those receiving substitution treatment.
An estimated 700 000 opioid users received substitution treatment in the European Union in 2013, and a slight downtrend has been observed in these data since 2011 (Figure 3.6). Between 2010 and 2013, the largest relative decreases were observed the Czech Republic (41 %, based on estimates), Cyprus (39 %) and Romania (36 %). The highest relative increases over the same period were observed in Poland (80 %), from a low base, and Greece (59 %). When data from Turkey and Norway are included, the 2013 estimate for those receiving substitution treatment increases to 737 000.
Opioid users represent the largest group undergoing specialised treatment in Europe
Trends in number of clients in opioid substitution treatment
Over half of opioid users are in substitution treatment
Coverage of opioid substitution treatment — the proportion of those in need receiving the intervention — is estimated at more than 50 % of Europe’s problem opioid users. This estimate needs to be treated with caution for methodological reasons, but in many countries a majority of opioid users are, or have been, in contact with treatment services. At national level, however, large differences still exist in coverage rates, with the lowest estimates reported by Latvia, Poland and Lithuania (around 10 % or less) (Figure 3.7).
Although less common, alternative treatment options for opioid users are available in all European countries. In the 10 countries providing sufficient data, the coverage of treatment approaches not involving substitution medication is generally within the range of 4 % to 71 % of all problem opioid users in treatment.
Percentage of problem opioid users receiving substitution treatment (estimate)
Responding to diverse needs though targeted interventions
Targeted interventions can facilitate access to treatment and ensure that the needs of different groups are met. The available information suggests that this kind of approach is currently most commonly available to young drug users, those referred from the criminal justice system and pregnant women (Figure 3.8). Targeted programmes for homeless drug users, older drug users and lesbian, gay, bisexual and transgender drug users were less frequently available, despite many countries reporting that there was a need for this kind of provision.
Availability of drug treatment programmes for target groups in Europe (expert ratings, 2013)
Cannabis-specific treatment available in half of countries
The provision of cannabis-specific treatment is increasing in Europe, with half of the countries now reporting its availability. Elsewhere, cannabis treatment is provided within general substance use programmes (Figure 3.9). Services for cannabis users can be diverse, ranging from brief interventions delivered online, to long-term therapeutic engagement in specialist centres. Although most treatment for this group takes place in community or outpatient settings this is not always the case, with around one in five of those entering specialist inpatient drug treatment services now being reported to have a primary cannabis-related problem.
Existence of specialised treatment programmes for cannabis users in European countries
Treatment for cannabis problems utilises psychosocial approaches; family based interventions are often used for adolescents and cognitive-behavioural interventions for adults. The available evidence supports the use of a combination of cognitive-behavioural therapy, motivational interviewing and contingency management approaches. In addition, there is some evidence to support the use of multidimensional family therapy for young cannabis users.
Internet-based interventions have extended the reach and geographical coverage of cannabis programmes. These interventions offer a new way to engage with people experiencing drug problems and have the potential to access some user groups that are not currently in contact with specialist drug services.
Tailoring treatment for ageing drug users
Demographic trends among Europe’s problem drug-using population raise important questions about the appropriateness of drug treatment interventions for ageing clients. Those above the age of 40 will soon comprise the majority of problem opioid users in treatment. In addition to drug-related health problems, opioid users are also increasingly facing health problems related to ageing, often exacerbated by lifestyle factors. Clinical guidelines that take account of the demographic shift in Europe’s problem opioid users are needed. This will support effective clinical practice, as issues around drug interactions, modes of administration, take-home dosages and pain treatment become more complex and important.
Few countries report the availability of targeted programmes for older drug users. This client group is generally integrated within existing drug treatment services (see Figure 3.10). However, both Germany and the Netherlands have set up retirement homes catering for the needs of older drug users. In the future, drug treatment and care programmes will have to be modified and developed if this ageing cohort is to receive an appropriate level of care. This is likely to require staff training and changes in care provision. As this is a client group with relatively poor engagement with the general health system and poor adherence to treatment for drug-related infections, the importance of a multi-disciplinary approach that continues after drug treatment is clear.
Few countries report the availability of targeted programmes for older drug users
Availability of targeted programmes for older drug users (expert ratings, 2013)
Preventing the spread of infectious diseases
Drug users, and particularly those who inject drugs, are at risk of contracting infectious diseases through the sharing of drug use material and through unprotected sex. Preventing the transmission of HIV, viral hepatitis and other infections is therefore an important objective for European drug policies. For injecting opioid users, substitution treatment reduces reported risk behaviour, with some studies suggesting that the protective effect increases when combined with needle and syringe programmes.
Between 2007 and 2013, the reported number of syringes distributed through specialised programmes increased from 43 million to 49 million in 24 countries representing 48 % of the EU population. A divergent picture is evident at country level, with around half reporting an increase in syringe distribution and half a decrease. Among the 12 countries with recent estimates of injection prevalence, the reported number of syringes distributed through specialised programmes in 2013 ranged from less than one in Cyprus to more than 300 per injecting drug users in Estonia and Norway (Figure 3.11).
Number of syringes provided through specialised programmes per injecting drug user (estimate)
Summary indicators for potential elevated risk for HIV infections among injecting drug users
While overall in Europe, the coverage of HIV prevention measures has been increasing, significant populations of injecting drug users continue to have limited access to services. An overview of some top-level indicators of potential risk is provided in Figure 3.12. Based on this simple analysis, around one-third of the countries display some elevated risk, suggesting a need for continued vigilance and for increasing the scaling up of HIV prevention measures.
Hepatitis C treatment improves
Prevention measures targeting the transmission of hepatitis C virus are similar to those for HIV. At the policy level, an increasing number of countries have adopted or are preparing specific hepatitis C strategies. Initiatives directed at testing and counselling injecting drug users have been increasing in the past years, but still remain limited. New diagnostic tools (such as the Fibroscan) have been introduced, and new medications have reduced treatment duration and negative side-effects, facilitating compliance. However, despite growing evidence of the effectiveness of hepatitis C antiviral treatment for infected injecting drug users, reported levels of availability remain limited in a number of countries (see Figure 3.13). This may in part be due to the high costs of the new medications.
Availability of hepatitis C virus testing and treatment (expert ratings, 2013)
Preventing overdoses and drug-related deaths
Reducing fatal drug overdoses and other drug-related deaths remains a major challenge for public health policy in Europe. Targeted responses in this area focus either on preventing the occurrence of overdoses, or on improving the likelihood of surviving an overdose. Drug treatment, particularly opioid substitution treatment, prevents overdoses and reduces the mortality risk of drug users.
Among a selection of interventions targeting drug-related deaths, the provision of information and materials on overdose prevention is reported to be most widely available (Figure 3.14). Training in responding to overdoses, including the distribution of the opioid antagonist drug naloxone, can save lives in overdose situations. However, this form of response is less commonly available. New WHO guidelines strongly recommend that people who are likely to witness an overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of suspected opioid overdose. Naloxone schemes currently exist in seven countries, with schemes established in recent years in Denmark, Estonia and Norway, countries where overdose rates are high. A recent study from Scotland (UK) showed that increased provision of naloxone kits to ‘at risk’ prisoners on liberation coincided with a significant reduction in opioid-related deaths occurring in the first four weeks after prison release.
One of the aims of supervised drug consumption facilities is to reduce the occurrence of overdose and to increase the chance of survival should one occur. Six countries currently provide such facilities — around 70 in total. In recent years, a number of facilities have been closed due to falling demand.
Availability of responses to drug-induced deaths (expert ratings, 2013)
Prison health: a comprehensive response required
Prisoners report higher lifetime rates of drug use than the general population and more harmful patterns of use, illustrated by recent studies showing that between 6 % and 31 % of prisoners have ever injected drugs. On admission to prison, most users reduce or cease consumption of drugs. Illicit drugs do, however, find their way into many prisons, and some prisoners continue or even initiate use during incarceration. High rates of hepatitis C and other infectious diseases have also been observed among prisoner populations. The high incidence of drug problems among prisoners means that health assessment upon prison entry is an important intervention. The WHO have recently recommended that a package of prevention responses, including free and voluntary testing for infectious diseases, distribution of condoms and sterile injecting equipment, infectious diseases treatment and treatment of drug dependence is made available.
Drug treatment, particularly opioid substitution treatment, prevents overdoses and reduces the mortality risk of drug users
Many countries have established interagency partnerships between prison health services and providers in the community. Such partnerships deliver health education and treatment interventions in prison and ensure continuity of care upon prison entry and release. Generally, prison health services remain the responsibility of ministries of justice or interior. In some countries, however, the ministry of health now has responsibility for the delivery of prison health service, potentially facilitating greater integration with general health service provision in the community.
The availability of opioid substitution treatment in prisons is reported by 26 of the 30 countries monitored by the EMCDDA, although no activities were reported in three of these countries in 2013. Overall, it appears that the level of coverage of prisoner populations is increasing, reflecting the widespread availability of this intervention in the community. Restrictions on eligibility may exist however, for example in the Czech Republic and Latvia, treatment in prison is limited to those already having a prescription prior to incarceration. The provision of clean injecting equipment is less common, with only four countries reporting its availability in prisons.
The high incidence of drug problems among prisoners means that health assessment upon prison entry is an important intervention