Heroin use continues to account for the largest share of drug-related diseases and deaths in the EU. The EU drugs agency (EMCDDA) estimates that there are over 1.3 million regular opioid users in the EU and Norway. And around half (51 %) of the drug users entering specialised treatment in Europe report opioids as their main problem drug (1).
Latest data published today show levels of regular opioid use to be relatively stable in Europe (see Chapter 6). But despite these indications, ‘the characteristics of Europe’s opioid problem are changing’, says the agency. Clients in treatment for opioid problems are older (2), fewer of them inject and there are reports of the use of opioids other than heroin in some parts of Europe. Also highlighted are developments in the heroin market and new concerns over the potential for HIV outbreaks among injectors, particularly in marginalised communities. The comments come today as the EMCDDA launches its Annual report 2011: the state of the drugs problem in Europe in Lisbon.
The average prevalence of problem opioid use in the EU and Norway (between 3.6 and 4.4 cases per 1 000 adults aged 15–64) is slightly lower than in Australia (6.3), the USA (5.8) and Canada (5.0), and considerably lower than in Russia (16) and Ukraine (10–13).
Injecting drug use on the decline
People who inject drugs are among those at the highest risk of experiencing health problems related to their drug use, such as blood-borne infections (e.g. HIV/AIDS, hepatitis B, C) and overdoses. In most European countries, injection is mainly associated with opioid use although, in a few, it is associated with the use of amphetamines.
Levels of injecting among opioid users entering treatment vary considerably between countries, from under 10 % in the Netherlands to over 90 % in Latvia and Lithuania (Chapter 6, Figure 13). However, data from treatment clients indicate an overall decrease in opioid injection (particularly heroin injection) in Europe (Figure TDI-7). A five-year analysis of trends in heroin users entering treatment shows that the proportion of those reporting injecting is declining in most European countries. And in the most recent data, under half (40 %) of all those entering treatment for opioid problems are regular injectors (Table TDI-17, part ii).
Rising concern over synthetic opioids
Increasing misuse of opioids other than heroin is reported in Australia, Canada and the USA. Most of these substances are used in medical practice, as pain relievers (e.g. morphine, fentanyl, codeine) or as substitution drugs in the treatment of heroin dependence (methadone, buprenorphine). The report underlines the lack of information, and need for increased monitoring, on the misuse of these products in Europe and expresses concern around reports of the use of synthetic opioids produced illicitly.
Some countries in Europe report that synthetic opioids have displaced heroin from the marketplace. In Estonia, three-quarters of those entering treatment now report fentanyl as their main drug. Fentanyl use is also reported in a number of other countries, particularly in eastern Member States. This drug, a synthetic opioid considerably more potent than heroin and particularly associated with overdoses, is likely to be manufactured illicitly, with the most important production sites thought to be located in countries bordering the EU (3). In Finland, buprenorphine is the most frequently reported primary drug among those entering treatment. Currently in Europe, around 5 % of those entering treatment for drug problems report opioids other than heroin as their primary drug, amounting to around 20 000 patients (see box, Chapter 6).
Disruption in supply of heroin to Europe — new analysis
Explored today is the availability of heroin on the streets of Europe and reasons for a recent instability in the market (see boxes, Chapter 6). ‘It is likely that a combination of factors may have played a role in disrupting the supply of heroin to parts of Europe, causing mainly short-term but severe shortages in some markets’, states the report. The availability of heroin is reported to have dropped sharply in a number of countries at the end of 2010 and early 2011, with the ‘drought’ being particularly evident in Ireland and the UK. Elsewhere — Italy, Slovenia, Russia and Switzerland — shortages may also have been felt, although the extent is less clear. However, heroin supply in other countries remains unaffected.
Among the possible explanations proposed for the apparent heroin shortage in Europe are: the diversion of the drug to markets in Asia; a fall in opium production in Afghanistan in 2009; and an opium poppy blight affecting major Afghan poppy-growing provinces in 2010. However, a recent review of the evidence suggests that successful cooperation between Turkish and EU police forces is likely to have played an important role (4). The agency notes the difficulties in tracking drug availability in Europe and the need to better understand how opium production influences consumer markets. This is especially important given the latest UNODC 2011 Afghanistan Opium Survey (October 2011) which reports increased Afghan production.
Overdose deaths — just the tip of the iceberg?
Over 7 600 fatal overdoses were reported in the EU and Norway in 2009, with opioids associated with the majority of these. According to the agency, many of these deaths could have been prevented.
But studies suggest that overdose deaths may be just the tip of the iceberg. In a special review on drug-related mortality published alongside today’s report (5), the EMCDDA estimates, for the first time, that there may be around 10 000 to 20 000 problem opioid users dying each year in Europe, mainly from overdose, but also from other causes (e.g. diseases, suicide, trauma, etc.). Most victims are male and, on average, in their mid-30s. The review looks at the ‘excess mortality’ in regular opioid users (risk of death compared with the general population) and finds that their risk of dying is 10 to 20 times higher than for their non-drug-using peers. The report underlines the role that services, particularly opioid substitution treatment, can play in saving lives and reducing the human costs of long-term drug problems.
‘Reducing the mortality and morbidity related to drug use is central to European drug policies’, states the Annual report. Under evaluation in some countries are programmes targeting periods known to be risky for opioid users (e.g. leaving prison, dropping out of treatment). Innovative interventions in this area, such as overdose training and take-home doses of naloxone (which blocks the effects of opioids) are now becoming more common in the EU.
Risk of HIV outbreaks among drug injectors
Over the last decade, gains have been made within the EU in addressing HIV infection among injecting drug users — these include a greater availability of prevention, treatment and harm-reduction measures (6). Latest European data show that the average rate of newly reported HIV cases continues to fall in Europe, reaching a new low of 2.85 new cases per million population (in total around 1 300 cases). Here the overall EU situation compares positively, both in a global and a wider European context. Nevertheless this year’s report reveals worrying new developments.
HIV epidemics among drug injectors continue to pose a major public health problem for many countries bordering the EU (see Chapter 7, Figure 15). And with budgets for drug services across Europe becoming overstretched in the economic downturn (7), a danger also exists that countries may be less able to provide adequate responses to those most at risk of infection.
‘Over the last 10 years a proactive, pragmatic and evidence-led approach has delivered real gains in reducing drug-related HIV infection across the EU’, says EMCDDA Director Wolfgang Götz today. ‘We cannot forget, however, that injecting drug use still accounts for over 2 000 HIV/AIDS-related deaths in the EU every year’.
Given the problems facing many EU countries, Götz underlines the need for vigilance in this area: ‘Policymakers must not take their eyes off the ball when it comes to this primary public health objective, especially as conditions for future drug-related outbreaks may now again exist in some Member States. The historical evidence is clear that without effective interventions, HIV infection can, and does, spread quickly among people who inject drugs’.
In July 2011, Greece — historically a low HIV-prevalence country — reported a large outbreak of new HIV infections among drug injectors (170 cases at the time of writing) (8). Recent increases in newly-reported infections have also been noted in Bulgaria, Estonia and Lithuania indicating continued potential for HIV outbreaks among injecting drug users in some countries (see Chapter 7, Figure 16). A recent EMCDDA expert meeting (October 2011) also identified further HIV increases among drug users in Romania and worrying changes in risk factors in Hungary.
The rate of reported new HIV diagnoses (per million population) in 2009 related to injecting drug use remained relatively high in Estonia (63.4), Lithuania (34.9), Latvia (32.7) Portugal (13.4) and Bulgaria (9.7).
Some 700 000 in substitution treatment in Europe
Around 1.1 million Europeans are estimated to have received treatment for illicit drug problems in the EU, Croatia, Turkey and Norway in 2009. For opioid users, both drug-free and substitution treatment are available in all of these countries. Five EU countries (Denmark, Germany, Spain, the Netherlands and the UK) offer heroin-assisted treatment for a small number of chronic heroin users who have failed in other treatment approaches (see box, Chapter 6).
Some 700 000 opioid users received substitution treatment in Europe in 2009, compared with 650 000 in 2007. ’While levels of treatment provision for opioid users are impressive in some countries, coverage still varies greatly and is very low in other countries’, says João Goulão, Chairman of the EMCDDA Management Board. Around 95 % of these treatments are provided in the 15 pre-2004 EU Member States (see Chapter 6, Figure 14).
The EMCDDA estimates that about half of Europe’s 1.3 million problem opioid users have access to substitution treatment, a level that is comparable to those reported for Australia and the United States and higher than that reported for Canada. China reports much lower levels, while Russia, despite having the highest estimated number of problem opioid users, has not introduced this type of treatment (see Chapter 6, Table 11; Chapter 1).
Treatment costs and quality assurance through guidelines
Ensuring the highest treatment quality and best treatment outcome for the lowest possible cost are priorities in the current financial climate. A special EMCDDA review out today (9) states that treatment is cost-beneficial from the societal perspective. The review maps the main funding sources for drug treatment in a number of European countries and summarises the available data on this issue.
Also published today is a review of guidelines for the treatment of drug dependence. It shows how almost all European countries now have drug addiction treatment guidelines, illustrating a growing commitment to developing evidence-based practice in this area. Over 140 sets of guidelines were identified from across Europe in 23 European languages. These focus largely on opioid substitution treatment and aim to help practitioners make informed choices (10).
Commenting today, EMCDDA Director Wolfgang Götz says: ‘Our report clearly shows the value of European cooperation and coordination in the drugs field. We see this in many areas: information sharing and joint actions are increasingly impacting on the cocaine and heroin markets; developments in public health responses are allowing more drug users than ever before to access services. This progress is real and has been underpinned by a strong EU strategy which has allowed Member States to identify priorities, share knowledge and act collectively. Such an outlook is essential if Europe is to continue to respond to the new challenges that the evolving European drug problem now presents’ (11).