CHAPTER I Used Drug

WORLD DRUG REPORT

ILLICIT DRUG MARKETS: SITUATION AND TRENDS

A. EXTENT OF DRUG USE and Central Europe, cannabis use has increased. In the absence of recent survey data on drug use in Africa, experts Overall drug use remains stable in the region also perceive an increase in cannabis use. globally Moreover, the global trend in cocaine use, which was stable It is estimated that 1 in 20 adults, or a quarter of a billion after 2010, has shown a recent trend, mainly as a result of people aged 15-64 years, used at least one drug in 2014. an increase in cocaine use in South America. The global Although trends in drug use vary across regions, as does trend in the use of amphetamines is stable, although this updated reporting on data, the extent of drug use among may underplay the situation in regions where recent infor- the world population has remained stable over the past mation on the extent of drug use is unavailable. This is four years. Almost 12 per cent of the total number of particularly the case in Asia, where expert perceptions of people who use drugs, or over 29 million people, are esti- trends and treatment admission reports suggest an increase mated to suffer from drug use disorders. in the use of amphetamines in the region, specifically in East and South-East Asia (see map 1). Cannabis remains the world’s most widely used drug, with an estimated 183 million people having used the drug in The global picture of drug use is compounded by the fact that many people who use drugs, both occasionally and 2014, and amphetamines remain the second most widely CHAPTER I used drug. With an estimated 33 million users, the use of regularly, tend to be polydrug users,1, 2 meaning that they opiates and prescription opioids may not be as widespread use more than one substance concurrently or sequentially, as the use of cannabis, but opioids remain major drugs of usually with the intention of enhancing, potentiating or potential harm and health consequences. Where updated counteracting the effects of another drug.3 The non-med- data are available, as an overall trend, global use of cannabis ical use of prescription drugs, synthetic stimulants and has remained stable over the past three years, although in new psychoactive substances (NPS) in lieu of, or in com- some subregions, particularly North America and Western bination with, conventional drugs gives a picture that blurs

Fig. 1 Global trends in the estimated prevalence Fig. 2 Global trends in the estimated number of of drug use, 2006-2014 people who use drugs, 2006-2014

8 350

7 300

6 250 240 243 246 247 5.2% 5.2% 5.2% 5.2% 226 4.9% 4.9% 5.0% 5 4.6% 4.8% 208 211 203 210 200 4 150

(percentage) 3 Annual Annual prevalence 100 2 (millions) Annual drug users

50 1 0.6%

0 - 26 28 27.3 27.1 27.1 27.3 27.4 27.4 29.5 2006 2007 2008 2009 2010 2011 2012 2013 2014 2006 2007 2008 2009 2010 2011 2012 2013 2014

Prevalence of people who use drugs Number of people who use drugs (percentage) Number of people with drug use problems Prevalence of people with drug use problems (percentage) Source: Responses to the annual report questionnaire. Source: Responses to the annual report questionnaire. Note: Estimates are for adults (ages 15-64), based on past-year use. Note: Estimated percentage of adults (ages 15-64) who used drugs in the past year. 2 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), “Polydrug use: patterns and response” (Lisbon, 1 Wouter Vanderplasschen and others, Poly Substance Use and Mental November 2009). Health Among Individuals Presenting for Substance Abuse Treatment, 3 World Health Organization (WHO), Lexicon of Alcohol and Drug Science and Society Series (Gent, Belgium, Academia Press, 2012). Terms (Geneva, 1994).

WORLD DRUG REPORT 2016 2

Tolerance, cross-tolerance and substitution: Estimates of the extent of drug use managing the effects of drugs and problem drug use reflect the best information available in 2014 The interplay of individual, biological, cultural, social and environmental factors increases or attenuates the vulner- As in previous years, global estimates of the extent of drug use ability of a person to use or to continue using drugs. Con- and problem drug use reflect the best available information in 2014, and changes compared with previous years largely tinuing to use a drug is considered a conditioned response reflect information updated by 20 countries, mostly in North to the positive reinforcement that the person receives as a America, South America and Western and Central Europe, for result of using the drug.8 However, in later stages a person which new data on the extent of drug use or problem drug continues to use drugs merely to maintain drug depend- use were made available in 2014. The concept of problem ence, which is characterized by, among other things, the drug use has been used in prior editions of the World Drug Report as a proxy for estimating the number of people with desire and compulsion to use drugs despite evidence of drug use disorders. In 2014, the estimated number of problem harmful consequences, the development of tolerance — drug users increased by 2 million over the previous year, which by increasing the quantity of the drug or drugs to achieve reflects an increase in the estimated number of opiate users the same effects and a state of withdrawal — and the nega- in North America and Western and Central Europe, as well tive consequences experienced when the person stops using as in the total number of users of cocaine, amphetamines 9 and “ecstasy”. the drug or drugs. Drugs taken together can have a cumulative or synergistic effect, which increases the overall psychoactive experience; the distinction between users of a particular drug, present- that is one way in which drug users may address the devel- ing an interlinked or cyclical epidemic of drug use and opment of tolerance.10 A related phenomenon is “cross- related health consequences in recent years. Additionally, tolerance” — the pharmacological ability of one drug to such a pattern of drug use presents challenges to health have generally the same effect on the nervous system as professionals responding to emergencies related to drug another drug. The phenomenon of cross-tolerance explains use, as well as to those treating people with disorders in part the frequent substitution of drugs that have a similar related to the use of multiple drugs. effect. Examples of such patterns of drug use include the Recent trends in polydrug use and use of alcohol with benzodiazepines, cannabis or cocaine; substitution between drugs concurrent use of heroin, benzodiazepines and antihista- mines; the use of alcohol or other opioids (methadone, Polydrug use encompasses wide variations in patterns of fentanyl etc.); and the use of cocaine and other stimu- 11, 12, 13, 14 drug use, ranging from occasional alcohol and cannabis lants. use to the daily use of a combination of heroin, cocaine, In other situations, people who use drugs may offset the 4, 5 alcohol and benzodiazepines. negative effects of the drugs by concurrently or sequen- Within polydrug use, the concomitant use of opiates and tially using additional drugs with opposite effects. One stimulants such as cocaine and amphetamines is fairly such pattern is “speedballing” — when cocaine is injected common and has been widely reported.6, 7 In the past with heroin or other opioids or when heroin is used with decade, the use of amphetamine and methamphetamine methamphetamine or amphetamine.15 has become quite widespread in different regions, while Market dynamics: substitution and the number of NPS that are stimulants seems to be con- complementarity of drugs stantly increasing. Data on polydrug use are seldom sys- tematically collected, but amphetamines and NPS seem Market dynamics, reflected by changes in availability, to be reported increasingly in polydrug use patterns in purity or price, can affect the choice of drugs. In such cir- different regions. cumstances, people who use drugs can turn to substituting

8 WHO, Neuroscience of Psychoactive Substance Use and Dependence (Geneva, 2004). 9 WHO, The ICD 10, Classification of Mental and Behavioural Disor- 4 EMCDDA (see footnote 2). ders: Clinical Descriptions and Diagnostic Guidelines (Geneva, 1992). 5 Danielle Horyniak and others, “How do drug market changes affect 10 Neuroscience of Psychoactive Substance Use (see footnote 8). characteristic of injecting initiation and subsequent patterns of drug 11 Mim J. Landry (see footnote 7). use? Findings from a cohort of regular heroin and methamphetamine injectors in Melbourne, Australia”, International Journal of 12 Charles P. O’Brien, “Benzodiazepine use, abuse and dependence”, Drug Policy, vol. 26, No. 1 (2015), pp. 43-50. Journal of Clinical Psychiatry, vol. 66, Suppl. 2 (2005), pp. 28-33. 6 Nancy M. Petry and Warren K. Bicket, “Poly drug use in heroin 13 Vanderplasschen and others, “Poly substance use and mental health” addicts: a behavioral economic analysis”, Addiction, vol. 93, No. 3 (see footnote 1). (1998), pp. 321-335. 14 “Polydrug use” (see footnote 2). 7 Mim J. Landry, Understanding Drugs of Abuse: The Processes of 15 Francesco Leri, Jule Bruneau and Jane Stewart, “Understanding Addiction, Treatment and Recovery (Arlington, Virginia, American polydrug use: review of heroin and cocaine co-use” Addiction, vol. Psychiatric Publishing, 1994). 98, No. 1 (2003), pp. 7-22. CHAPTER I 3 Extent of drug use

Map 1 Expert perceptions of changes in trends in the use of

amphetamines,* 2014 or latest year available since 2010

Ç Ç Ç

Ç Ç

Ç ÇÇ Ç ÇÇ

Trend Large increase Some increase Stable Some decrease Large decrease Not known No data available or no ARQ received Data older than 2014

Source: Responses to the annual report questionnaire. Note: The information presented in the map is for 2014 or the latest year since 2010 for which the information is available. The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. The final boundary between the Sudan and South Sudan has not yet been determined. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). * Includes both amphetamine and methamphetamine.

with different drugs; transitioning to alternative routes of opioids and, to a lesser extent, benzodiazepines and meth- drug administration; decreasing their consumption of the amphetamine.21 The same study showed that there was drug; or deciding to enter treatment.16, 17 Common exam- limited substitution with other drugs as the price of meth- ples are heroin being substituted by oxycodone, desomor- amphetamine increased. phine or other opioids and vice versa, as reported in Recent trends in the use of heroin and the various regions.18 non-medical use of prescription opioids in the Economic factors and cross-price elasticity may also affect United States polydrug use.19 An increase in the price of one drug may In the United States of America, over the past decade the result in the use of another (substitution) or it may decrease non-medical use of prescription opioids and the use of the use of another, even though its price remains the same heroin have continued to interplay in the market. Since (complementarity). For example, a study showed that an the high prevalence and associated morbidity and mortal- increase in the price of heroin resulted in an increase in ity of the non-medical use of prescription opioids have benzodiazepine and cocaine purchases.20 In another study, become a major public health issue,22 a recent increase in cross-price elasticity analysis showed that in the case of heroin use has triggered a sharp increase in heroin-related heroin there was significant substitution with prescription overdose deaths.23, 24 Several aspects have driven this

16 Jenny Chalmers, Deborah Bradford and Craig Jones, “The effect of 21 Chalmers and others, “The effect of methamphetamine and heroin methamphetamine and heroin price on polydrug use: a behavioural price on poly drug use” (see footnote 16). economics analysis in Sydney, Australia”, International Journal of Drug Policy, vol. 21, No. 5 (2010), pp. 381-389. 22 Wilson M. Compton, Christopher M. Jones and Grant T. Bald- win, “Relationship between nonmedical prescription-opioid use 17 Horyniak and others, “How do drug market changes affect charac- and heroin use”, New England Journal of Medicine, vol. 374, No. 2 teristics of injecting initiation and subsequent patterns of drug use?” (2016), pp. 154-163. (see footnote 5). 23 United States, Center for Behavioral Health Statistics and Quality, 18 World Drug Report 2014 (United Nations publication, Sales No. Behavioral Health Trends in the United States: Results from the 2014 E.14.X1.7). National Survey on Drug Use and Health, HHS Publication No. 19 Jonathan P. Caulkins and Peter H. Reuter, “The meaning and SMA 15-4927, NSDUH Series H-50 (Rockville, Maryland, 2015). utility of drug prices”, Addiction, vol. 91, No. 9 (1996), pp. 1261- 24 Christopher M. Jones, “Heroin use and heroin use risk behaviors 1264. among nonmedical users of prescription opioid pain relievers: 20 Petry and Bicket, “Poly drug use in heroin addicts: a behavioral United States, 2002-2004 and 2008-2010”, Drug and Alcohol economic analysis”, (see footnote 6). Dependence, vol. 132, Nos. 1 and 2 (2013), pp. 95-100.

WORLD DRUG REPORT 2016 4

Fig. 3 Trends in the use of heroin and Fig. 4 Age-adjusted rates of death related to prescription opioids in the United States, prescription opioids and heroin in the 2002-2014 United States, 2000-2014 14 2 7 1.8 12 6 1.6 10 1.4 5 1.2 8 4 1 6 0.8 3 4 0.6 2 0.4 2 population 100,000 0.2 1 in the past year(millions)

0 0 Number of overdose deaths per 0 Number of people who used heroin 2002 2004 2006 2008 2010 2012 2014 medical purposes in the past year(millions) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 - Prescription opioids Prescription opioids Number of people who used prescription opioids

for non Heroin Heroin

Source: Wilson M. Compton, Christopher M. Jones and Grant T. Source: 100Wilson M. Compton, Christopher M. Jones and Grant T. Baldwin, “Relationship between nonmedical prescription-opioid Baldwin, “Relationship between nonmedical prescription-opioid use and heroin use”, New England Journal of Medicine, vol. 374, use and100 heroin90 use”, New England Journal of Medicine, vol. 374, No. 2 (2016), pp. 154-163. No. 2 (2016),1009080 pp. 154-163. change: law enforcement and regulatory actions to address Fig. 5 809070 Trends in polydrug use among heroin the irrational prescribing and reformulation of prescrip- 708060 users in the United States, 2002-2013 607050 tion opioids with abuse-deterrent technologies; implemen- 100 5060 tation of programmes for monitoring prescription drugs 9040 and education of health-care professionals and the public 80405030 25 about their appropriate use; and increased accessibility, 70304020 reduced prices and high purity of heroin in the United 60203010 26

States. usersof Rate per population 1,000 5010200 In 2014, an estimated 914,000 people aged 12 years or usersof Rate per population 1,000 40100 older had used heroin in the past year — a 145 per cent usersof Rate per population 1,000 30 0 increase since 2007 — while mortality related to heroin 20 2002-2004 2005-2007 2008-2010 2011-2013 use has increased fivefold since 2000.27, 28, 29, 30 10 2002-2004 2005-2007 2008-2010 2011-2013

Rate per 1,000 population usersof Rate per population 1,000 0 From the period 2002-2004 to the period 2011-2013, 2002-2004 2005-2007 2008-2010 2011-2013 Cannabis use in the past year there was an increase in heroin use, particularly among 2002 2005 2008 2011 people who also reported the use of other substances. The Cannabis-2004 use in the-2007 past year-2010 -2013

highest rate of past-year heroin use was among cocaine CannabisCocaine2002-2004 use use in in the2005-2007 the past past year year2008-2010 2011-2013 users (91.5 per 1,000 users),31 followed by those who Cocaine use in the past year reported non-medical use of prescription opioids. Nine CocaineNon-medical use in use the of past opioid year painkillers in out of 10 people who used heroin self-reported co-use of CannabisNon-medicalthe past use year in usethe ofpast opioid year painkillers in heroin with at least one other drug, and most used heroin Non-medicalthe past year use of opioidother prescription painkillers in CocaineNon-medicalthedrugs past usein theyear in pastthe use past yearof other year prescription Non-medicaldrugs in the past use yearof other prescription 25 Ibid. Source: Christopher M. Jones and others, “Vital signs: demo- 26 Compton and others, “Relationship between nonmedical prescrip- graphic and substanceNon-medicaldrugs inuse the trends use past of among yearopioid heroin painkillers users –in United tion” (see footnote 22). States, 2002-2013”,the past Morbidity year and Mortality Weekly Report, vol. 27 It is recognized that households surveys do not capture the full 64, No. 26 (2015).Non-medical use of other prescription extent of heroin use and are an underestimation. Nevertheless, in drugs in the past year the absence of other trend data, this is used to inform the trends in 32 heroin use. with at least three other drugs. Moreover, the proportion 28 Jones, “Heroin use and heroin use risk behaviors” (see footnote 24). of heroin users diagnosed with disorders related to non- 29 World Drug Report 2014 (see footnote 18). medical use of prescription opioids more than doubled, 30 Many of the heroin-related deaths in the United States have also been attributed to the presence of fentanyl in certain parts of 32 Christopher M. Jones and others, “Vital signs: demographic and the country (United States, Drug Enforcement Administration, substance use trends among heroin users – United States, 2002- National Drug Threat Assessment Summary (October 2015). 2013”, Morbidity and Mortality Weekly Report, vol. 64, No. 26 31 Ibid. (2015). CHAPTER I 5 Extent of drug use

Fig. 6 Likelihood of past-year heroin use of initiation and treatment interventions for people with and other indicators depending on opioid use disorder.34 the frequency of non-medical use of prescription opioids in the past year Shift between injecting heroin, amphetamines and new psychoactive substances in Europe 14 12 In some European countries (Austria, Belgium, Czech

a Republic, France, Germany, Ireland, Poland, Spain and 10 the United Kingdom), small, localized groups of high-risk 8 drug users who are in contact with low-threshold services, psychiatric facilities and treatment centres for drug users 6 and who used to inject heroin and amphetamines have

Adjusted ratio odd 4 switched to injecting NPS such as synthetic cathinones.

Adjusted odd ratio Adjusted Reports to the European Monitoring Centre for Drugs 2 and Drug Addiction (EMCDDA) suggest that drug users 0 who inject synthetic cathinones are primarily those who 1-29 days 30-90 days 100-365 days have been injecting heroin and amphetamines and have now either started injecting synthetic cathinones or Frequency of non-medical use of prescription included it in their drug use repertoire.35 People who inject opioids in the past year synthetic cathinones include those who are on opioid substitution treatment, as well as young people beginning Past-year heroin use their drug-injecting use. Ever injected heroin Ever injected opioid pain relievers In Hungary, in the period 2009-2012 a shortage of heroin and an increase in local availability of synthetic cathinones Source: Christopher M. Jones and others, “Vital signs: demo- contributed to high-risk drug users switching to injecting graphic and substance use trends among heroin users – United NPS, primarily synthetic cathinones. A corresponding States, 2002-2013”, Morbidity and Mortality Weekly Report, vol. 64, No. 26 (2015). change in the patterns of injecting was reported both a Odds ratio adjusted for the influence of (confounders) other variables. among clients of needle and syringe programmes (NSP) and those entering treatment. In 2009, the majority of from 20.7 per cent in the period 2002-2004 to 45.2 per cent in the period 2011-2013. Fig. 7 Trends in injecting drugs among clients of needle and syringe programmes in The increase in heroin use in the United States has been Hungary, 2009-2012 more pronounced among a subgroup of people aged 18-25 120 who report a higher frequency of non-medical use of prescription opioids.33 Among this group, the likelihood of 100 using heroin in the past year, ever injecting prescription opioids or becoming dependent on heroin increased with 80 the frequency of non-medical use of prescription opioids 60 in the previous year. Those reporting non-medical use of prescription opioids for over 100 days in the past year were 40 nearly eight times more likely to report dependence on heroin than those who reported less frequent non-medical 20 use of prescription opioids. 0 It appears that the increase in heroin use in the United Percentageof people who inject drugs 2009 2010 2011 2012 States had already begun around 2006 and had preceded Others (synthetic cathinones) the changes introduced in policies and practices related to Cocaine prescription opioids. Nevertheless, given the large number Amphetamine of non-medical users of prescription opioids, even a small Heroin proportion who switch to heroin use has translated into a Source: Anna Péterfi and others, “Changes in patterns of injecting much higher number of people using heroin. drug use in Hungary: a shift to synthetic cathinones”, Drug Test and Analysis, vol. 6, Nos. 7 and 8 (2014), pp. 825-831. Analysis suggests that the problem of opioid use is not substance-specific and requires holistic approaches to 34 Compton and others, “Relationship between nonmedical address the interconnected epidemic through prevention prescription opioids use” (see footnote 22). 35 EMCDDA, “Perspectives on drugs: injection of synthetic 33 Jones, “Heroin use and heroin use risk behaviors” (see footnote 24). cathinones”, 28 May 2015.

WORLD DRUG REPORT 2016 6

people who inject drugs (PWID) were injecting heroin or Fig. 8 Trends in the initiation of injecting amphetamine, whereas by 2012 about 43 per cent of drug use, by substance, in Melbourne, PWID were primarily injecting synthetic cathinones and Australia, 2001, 2001-2004 and since another 40 per cent were injecting amphetamine.36 This 2004 trend was self-reported, as well as confirmed through sam- 80 67 68 ples obtained from injecting equipment. Of the main syn- 70 thetic cathinones injected by PWID, the predominant 55 substance was pentedrone; the other substances reported 60 were 3,4-methylenedioxypyrovalerone (MDPV), mephe- 50 40 drone and 4-methylethcathinone (4-MEC), all of which 40 are stimulants. 30 30 22 There is evidence of similar trends in treatment settings, 20 where the proportion of heroin users dropped consider- 10 ably and the proportion of clients entering treatment for 10 3 5 injecting amphetamine and other stimulants increased Percentage of injectors initiating 0 substantially in 2012. 2001 2001-2004 Post-2004 In Hungary, the reduced availability of heroin did not (high heroin (low heroin period change injecting practices but made users switch to other availability) availability) (contemporary period) injecting substances (such as NPS and amphetamine) that Heroin were more affordable and readily available and also gave Methamphetamine 37 intense effects. Other drugs Drug market changes and patterns of injecting Source: Danielle Horyniak and others, “How do drug market drug use in Australia changes affect characteristics of injecting initiation and subsequent patterns of drug use? Findings from a cohort of regular In Australia, the heroin market changed considerably after heroin and methamphetamine injectors in Melbourne, Australia”, 2000; heroin went from being highly accessible (cheap, International Journal of Drug Policy, vol. 26, No. 1 (2015), pp. high in purity and available) and the most commonly 43-50. injected drug in Australia to being less accessible as a result A cohort study of PWID in Melbourne, who were recruited of a heroin shortage.38 The change resulted in a decrease between November 2008 and March 2010, examined the in the prevalence and frequency of injecting heroin, as well impact that the changing market dynamics might have had as a decline in adverse health consequences related to on drug use patterns.42 Among the participants in the study, heroin use.39 initiation with injecting heroin remained the most common The subsequent years (2001-2004) saw a sustained decrease practice in all three of the periods examined, although it in the availability and use of heroin in Australia. During the declined in the period when heroin availability was low. In same period, methamphetamine emerged on the market at that period, the proportion of PWID who initiated injecting a relatively low price per gram of pure methamphetamine, methamphetamine increased. In the later period (from 2004 which was readily available, and that led to an increase in onwards), the proportion of PWID initiating injecting with methamphetamine use.40 In the years from 2004 onwards, methamphetamine decreased, counterbalancing an increase the illicit markets for both heroin and methamphetamine in initiating injecting with heroin and other drugs, primarily continued to be very dynamic, with the price and purity of prescription opioids. both drugs fluctuating. In the same period, the increased practice of prescribing opioids and their non-medical use In 2013, most of the participants in the study were polydrug (among PWID) was also observed.41 users (44 per cent) or users primarily injecting heroin (41 per cent). Among current PWID, the practice of primarily injecting methamphetamine was not common, but the participants 36 Anna Péterfi and others, “Changes in patterns of injecting drug use in Hungary: a shift to synthetic cathinones”, Drug Test and Analysis, who initiated injecting during the period when heroin avail- vol. 6, Nos. 7 and 8 (2014), pp. 825-831. ability was low were almost twice as likely to be current poly- 37 Ibid. drug injectors. Also, a combination of heroin and 38 Horyniak and others, “How do drug market changes affect charac- methamphetamine was more commonly used by current teristics of injecting initiation and subsequent patterns of drug use?” PWID, and drugs such as heroin were often used to counter (see footnote 5). the “comedown effects” of methamphetamine.43 39 Louisa Dagenhardt and others, “Effects of a sustained heroin shortage in three Australian States”, Addiction, vol. 100, No. 7 (2005), pp. 908-920. teristics of injecting initiation and subsequent patterns of drug use?” 40 Louisa Dagehhardt and others, “The epidemiology of methamphet- (see footnote 5). amine use and harm in Australia”, Drug and Alcohol Review, vol. 27, 42 Ibid. No. 3 (2008), pp. 243-252. 43 Brendan Quinn and others, “Methamphetamine use in Mel- 41 Horyniak and others, “How do drug market changes affect charac- bourne, Australia: baseline characteristics of a prospective meth- CHAPTER I 7 Extent of drug use

The findings of the study suggest that the first drug mine.48, 49 Methamphetamine use has reportedly had a injected reflects the characteristics of the drug market at negative influence on opioid-dependent patients in treat- the time, while later patterns of drug use, including poly- ment who wrongly believed that methamphetamine use drug use, appear to be the result of compensation or sub- could help control their opiate dependence and associated stitution mechanisms brought on by market dynamics. problems such as depression and poor sexual performance These patterns may reflect the cyclical nature of drug epi- and increase their physical energy, attention and concen- demics and may continue to change as drug markets tration and improve social relationships.50 Methampheta- evolve. mine use among heroin users has also been reported in other parts of Asia.51 Methamphetamine smoking among heroin users and polydrug users in Greece Problem drug use as reflected in demand for treatment for drug use In recent years in Greece, both low-threshold services and treatment agencies have reported the smoking of crystal- Information about people in treatment for drug use dis- line methamphetamine on a regular basis among injecting orders can be taken as a proxy for understanding the opioid users. This practice has been reported particularly nature, as well as a latent indicator, of trends in drug use among marginalized migrant subpopulations of persons resulting in severe health consequences. who inject opioids in Athens.44 According to global estimates, nearly one in six people Polydrug use in Greece is common among drug users in with drug use disorders access treatment services each year. treatment. In 2013, almost 71 per cent of clients in treat- Opioids stand out as a major drug of concern in North ment reported having used more than one substance, with America, Europe (particularly Eastern and South-Eastern polydrug use being more common among cocaine (80 per Europe) and Asia. In Eastern and South-Eastern Europe, cent) and opioid users (77 per cent). Misuse of prescrip- nearly three out of every four people in treatment for drug tion drugs and use of cannabis and cocaine were most use disorders are treated for opioid use. The number of frequently reported among users of opioids, while primary people in treatment for cocaine use disorders remains quite cocaine users more frequently reported use of cannabis high in Latin America and the Caribbean, where nearly 45 and opioids. half of people in treatment for drug use disorders are Emerging methamphetamine use among opiate treated for cocaine use. Treatment related to cannabis use users in the Islamic Republic of Iran disorders is more prominent in Africa and Oceania than in other regions. This may be related to the limited treat- In the Islamic Republic of Iran, where opiates remain the ment options for users of other drugs in Africa, where main drug consumed by problem drug users, metham- nearly half of all admissions to treatment for drug use dis- phetamine use has emerged as another drug of concern in orders are for the use of non-specified substances, which recent years. Methamphetamine use has also been masks the true extent of the use of drugs of concern other described as a new form of polydrug use among opiate than cannabis. Amphetamines remain a problem primar- users.46 Many local studies of opiate users in methadone ily in East and South-East Asia and to some extent in treatment have reported the use of methamphetamine North America; while the number of people in treatment among the clients of treatment centres. For example, a for disorders related to the use of amphetamines has been study at an opioid substitution treatment clinic in Zahedan increasing in Asia, half of the people in treatment for drug Province showed that methamphetamine use among use in the region are treated for opioid use disorders. opioid users in treatment increased from 6 per cent in 2009 to almost 20 per cent in 2011.47 Another study of The number and characteristics of people seeking treat- 378 people seeking treatment at a therapeutic community ment for the first time are indirect indicators of trends in centre found that the urine samples of nearly 7 per cent health consequences caused by the use of different sub- of those people had tested positive for methampheta- stances in a region. At the global level, the proportion of

48 Zahra Alam-Mehrjerdi, Azarakhsh Mokri and Kate Dolan, “Methamphetamine use and treatment in Iran: a systematic review amphetamine-using cohort and correlates of methamphetamine from the most populated Persian Gulf country”, Asian Journal of dependence”, Journal of Substance Use, vol. 18, No. 5 (2013), pp. Psychiatry, vol. 16, 2015, pp. 17-25. 349-362. 49 Nasrindokht Sadir and others, “Outcome evaluation of therapeutic 44 EMCDDA, “Perspectives on drugs: health and social responses for community model in Iran”, International Journal of Health Policy methamphetamine users In Europe”, 27 May 2014. and Management, vol. 1, No. 2 (2013), pp. 131-135. 45 EMCDDA, 2014 National Report to the EMCDDA (2013 Data) by 50 Schwann Shariatirad, Masoomeh Maarefvand and Hamed Ekhiari, the Reitox Greek National Focal Point: Greece − New Developments, “Methamphetamine use and methadone maintenance treatment: Trends (Athens, 2014). an emerging problem in the drug addiction treatment network in 46 Zahra A. Mehrjerdi, Alasdair M. Barr and Alireza Noroozi, “Meth- Iran”, International Journal of Drug Policy, vol. 24, No. 6 (2013), amphetamine-associated psychosis: a new health challenge in Iran”, pp. e115 and e116. DARU Journal of Pharmaceutical Sciences (2013). 51 Darshan Singh and others, “Substance abuse and HIV situation in 47 Zahra A. Mehrjerdi, “Crystal in Iran: methamphetamine or heroin Malaysia”, Journal of Food and Drug Analysis, vol. 21, Suppl. No. 4 kerack”, DARU Journal of Pharmaceutical Sciences, 2013. (2013), pp. S46–S51.

WORLD DRUG REPORT 2016 8

Fig. 9 Total number of people in treatment for drug use, including people in treatment for the first time, by drug type and region, 2014

LatinWestern America and and Central the Caribbean Europe WesternNorth and Central America Europe (11(25 countries)countries) (25(3 countries) 250,00025,000 250,000700,000 600,000 200,00020,000 200,000 500,000 150,00015,000 150,000400,000 300,000 100,00010,000 100,000 200,000 5,000 50,000 100,00050,000 Number of people in treatment in people of Number

0 treatment in people of Number 0 Number of people in treatment in people of Number 0 treatment in people of Number 0 ATS ATS ATS ATS s s Opioids Opioids Cocaine Cocaine

Opioids Eastern and South-Eastern Europe Opioids

Western and CentralCocaine Europe Western and Central Europe Cocaine Cannabis Cannabis Western and Central Europe Cannabis (25(25 countries) countries) Cannabis (25(6 countries)countries) Tranquillizer Tranquillizer Tranquillizers 250,000250,000 FirstFirst time time in treatmentin treatment Tranquillizers 250,000100,000 First Firsttime time in treatment in treatment 90,000 200,000200,000 200,00080,000 70,000 150,000150,000 150,00060,000 50,000 100,000100,000 100,00040,000 30,000 50,00050,000 50,00020,000 10,000 Number of people in treatment in people of Number Number of people in treatment in people of Number Number of people in treatment in people of Number 00 treatment in people of Number 0 ATS ATS ATS ATS s s s Opioids Opioids Cocaine Opioids Cocaine Opioids Cocaine Asia AfricaCocaine Cannabis Cannabis

Cannabis Western and Central Europe Cannabis Western and Central Europe (22 countries) (6 countries)

(25 countries) Tranquillizer Tranquillizer FirstFirst time time in in treatment treatment (25 countries) Tranquillizer FirstFirst time time in treatmentin treatment Tranquillizers 700,000250,000 250,00020,000 18,000 600,000 200,000 200,00016,000 500,000 North America 14,000 400,000150,000 (3 countries) 150,00012,000 10,000 700,000 North AmericaNorth America 300,000100,000 8,000 600,000 (3 countries)(3 countries)100,000 200,000 700,000 700,000 6,000 500,00050,000 4,000 100,000 600,000 50,000 600,000 2,000 400,000 North AmericaNorth America Africa Number of people in treatment in people of Number Number of people in treatment in people of Number

500,000 treatment in people of Number 00 500,000 treatment in people of Number 0 300,000 (3 countries)(3 countries) (6 countries) 700,000 700,000 ATS 400,000 ATS 20,000 400,000 ATS 200,000 s 600,000 Others

18,000 s Opioids

600,000 Opioids Opioids Cocaine Cocaine

300,000Cocaine Opioids

300,000 Cocaine Cannabis Cannabis Cannabis 100,000 First time in treatment 16,000 Cannabis 500,000 500,000 200,000 First time in treatment

200,000 Tranquillizer

First time in treatment 14,000 Tranquillizer 0 Tranquillizers First time in treatment Number of people in treatment in people of Number

400,000 Amphetamines First400,000 timeCannabis in100,000 treatment100,000 Opioids Cocaine12,000 ATS Tranquillizers Others 300,000 300,000 0 ATS 10,000

Number of people in treatment 0 in people of Number Number of people in treatment in people of Number Opioids

Cocaine 8,000

200,000 200,000Cannabis ATS

Source: Responses to the annual report questionnaire. ATS6,000 Note: The figures are based on data for 2014 or the latest year since 2010 for which data are available. For each region, the number of people in 100,000 Tranquillizers 100,000 Opioids 4,000 Cocaine Opioids treatment forFirst the time use of in different treatment drugs in the region is weightedCocaine by the total number of people treated in a country. Member States in Oceania (in Cannabis Cannabis 2,000 particular,0 Australia and0 New Zealand) do not provide information on the proportion of people in treatment for the first time, and therefore informa- Number of people in treatment in people of Number tion for Oceania treatment in people of Number is not reflected in the figures. Number of people in treatment in people of Number

0 Tranquillizers First timeFirst in treatment time in treatment Tranquillizers ATS ATS ATS Opioids Cocaine Opioids Cocaine Others Cannabis Cannabis Opioids Cocaine Cannabis Tranquillizers First time inFirst treatment time in treatment FirstTranquillizers time in treatment 100% 90% CHAPTER I 9 Extent of drug use 80% Fig. 10 Primary70% drug used among people in drug treatment, by region, 2003, 2009 and 2014 60% 100%100%50%

90%(percentage) 90%40% 80%80%30% 70%70%20% Proportion treatmentof Proportion demand 60%60%10% 50%50% 0% (percentage) (percentage) 40%40% (percentage) 30%30% 20%20% Proportion treatmentof Proportion demand Proportion treatmentof Proportion demand 10%10%

Proportion of people in drug treatment Proportion 0%0% 2003 2009 2014 2003 2009 2014 2003 2009 2014 2003 2009 2014 2003 2009 2014 2003 2009 2014 2003 2009 2014 Africa North Latin America Asia Eastern and Western and Oceania America and the South-Eastern Central Europe Caribbean Europe Cannabis Opioids Cocaine Amphetamine-type stimulants Other drugs

Source: Responses to the annual report questionnaire. Note: Data used for each point in time are based on reporting from countries in each region for the year cited or the latest year for which data are available. people seeking treatment for cannabis use disorders for different regions and subregions. While demand for treat- the first time remainsCannabisCannabis high — nearlyOpioidsOpioids 50 perCocaine cent.Cocaine In Asia,Amphetamine-typeAmphetamine-type ment for cannabis stimulants stimulants use disordersOtherOther has drugs increaseddrugs in all regions among those being treated for disorders related to the use since 2003, it has done so to a much greater extent in the of amphetamines, nearly 60 per cent are reported to be in Americas, Western and Central Europe and Oceania. At treatment for the first time; in Europe and Latin America, the same time, in the Americas, the proportion of people nearly 40 per cent of those being treated for cocaine use in treatment for cocaine use has decreased over the past disorders are reported to be in treatment for the first time. decade. In Asia, there has been a substantial increase in People seeking treatment for disorders related to the use treatment for the use of amphetamine-type stimulants of cannabis and amphetamines are younger (on average, (ATS) and a decrease in treatment for disorders related to 24 and 25 years of age, respectively) than people seeking opioid use. In Eastern and South-Eastern Europe, treat- treatment for disorders related to the use of other drugs, ment for opioid use disorders has been a matter of concern including those seeking such treatment for the first time. over the past decade. This reflects increasing trends in the use of cannabis and The increase in treatment demand related to cannabis use amphetamines and the resulting increase in people seeking 53 treatment for disorders related to the use of those drugs. in some regions warrants special attention. There is great Fewer people are in treatment for the first time for opioid variability in the definition and practice of what consti- or cocaine use disorders; however, they are typically in tutes treatment of cannabis use disorders. Treatment at their thirties and, in many subregions, reflect an ageing present consists of behavioural or psychosocial interven- cohort of users in treatment52 and show an overall decrease tions that may vary from a one-time online contact, or a in the proportion of treatment demand. brief intervention in an outpatient setting, to a more comprehensive treatment plan including treatment of other Moreover, based on data reported by Member States, it is co-morbidities in an outpatient or inpatient setting.54 estimated that between 40 and 80 per cent of people in treatment for drug use are diagnosed with polydrug use, 53 Wayne Hall, Maria Renström and Vladimir Poznyak, eds., which reflects the complexity of drug use patterns and the The Health and Social Effects of Nonmedical Cannabis Use challenges of treating people with drug use disorders (Geneva, WHO, 2016). effectively. 54 Jan Copeland, Amie Frewen and Kathryn Elkins, Management of Cannabis Use Disorder and Related Issues: A Clinician’s Guide Trends in treatment demand over the past decade also cor- (Sydney, National Cannabis Prevention and Information Centre, roborate the changing patterns of drug use observed in University of New South Wales, 2009); Divya Ramesh and Mar- garet Haney, “Treatment of cannabis use disorders”, in Textbook of Addiction Treatment: International Perspectives, N. El-Guebaly, G. 52 Joseph Gfroerer and others, “Substance abuse treatment need Carrà and M. Galanter, eds. (Milan, Italy, Springer, 2015); and among older adults in 2020: the impact of the aging baby-boom Alan J. Budney and others, “Marijuana dependence and its treat- cohort”, Drug and Alcohol Dependence, vol. 69, No. 2 (2003), pp. ment”, Addiction Science and Clinical Practice, vol. 4, No. 1 (2004), 127-135. pp. 4-16.

WORLD DRUG REPORT 2016 10

What are the potential driving forces ever used cannabis,64 and the proportion increases signifi- behind changes in the number of people in cantly to one out of every six persons (17 per cent) who treatment for cannabis use? started using cannabis in their teens65 and to 25-50 per cent of daily cannabis users.66, 67 The nature and extent of the potential health risks and harms associated with cannabis use are continually under Factors that may influence the number of people in treat- debate.55 Cannabis use can be perceived to be relatively ment when cannabis is the primary drug of concern68 harmless56, 57 when compared with the use of other con- include: changes in the number of people who actually trolled psychoactive substances and also in relation to the need treatment; changes in referrals to treatment; changes use of tobacco or alcohol. However, lower risk does not in awareness of potential problems associated with can- mean no risk: there are harmful health effects associated nabis use; and changes in the availability of treatment for with a higher frequency of cannabis use and initiation at cannabis. Unfortunately, detailed information on trends a very young age, especially among adolescents during the in the number of people in treatment and on potential time of their cognitive and emotional development.58 driving forces is sparse, and consequently the analysis pre- Adverse health effects of cannabis use associated with cog- sented below is limited to the situation in the United States nitive impairments or psychiatric symptoms are well docu- and in European countries. mented in the scientific literature.59, 60, 61 Hence, cannabis Are changing patterns of treatment for use disorders require clinically significant treatment inter- cannabis use a result of more harmful ventions. The transition from drug use to drug dependence consumption patterns? occurs for a much smaller proportion of cannabis users than for opioid, amphetamine or cocaine users.62 How- The risk of adverse health effects increases with harmful ever, because so many people use cannabis, this translates patterns of cannabis use that include high-frequency (daily into a large number who experience cannabis use disorders; or near-daily) use, an earlier age of initiation and con- for example, in the United States, of the 22.2 million cur- sumption of higher-potency cannabis. rent cannabis users in 2014, 4.2 million people aged 12 In the United States, the number of daily (or near-daily) or older had a cannabis use disorder diagnosed in the pre- cannabis users, measured by the number using cannabis 63 vious year. on 20 or more days in the past month and the number Cannabis use disorders are estimated to occur in approxi- using cannabis on 300 or more days in the past year, rose mately 1 out of every 11 persons (9 per cent) who have significantly after 2006, by 58 and 74 per cent, respectively. However, this increase in daily (or near-daily) cannabis use has not translated into an increased number of people 55 Nora D. Volkow and others, “Adverse health effects of marijuana seeking treatment, even when those in treatment referred use”, New England Journal of Medicine, vol. 370, No. 23 (2014), by the criminal justice system are excluded. pp. 2219-2227. 56 David Nutt and others, “Development of a rational scale to assess In Europe, where treatment for cannabis use disorders has the harm of drugs of potential misuse”, The Lancet, vol. 369, No. 9566 (2007), pp. 1047-1053. been on the increase, approximately 1 per cent of the pop- 57 Dirk W. Lachenmeier and Jürgen Rehm, “Comparative risk assess- ulation aged 15-64 are daily (or near-daily) cannabis users; ment of alcohol, tobacco, cannabis and other illicit drugs using the although data on daily use are sparse, there is little evidence margin of exposure approach”, Scientific Reports, vol. 5, No. 8126 (2015). 58 Wayne Hall, “The adverse health effects of cannabis use: what are 64 C. Lopez-Quintero and others, “Probability and predictors of tran- they, and what are their implications for policy?”, International sition from first use to dependence on nicotine, alcohol, cannabis, Journal of Drug Policy, vol. 20, No. 6 (2009), pp. 458-466; Robin and cocaine: results of the National Epidemiologic Survey on Alco- Room and others, Cannabis Policy: Moving Beyond Stalemate hol and Related Conditions (NESARC)”, Drug and Alcohol Depen- (Oxford, Oxford University Press, 2010); and Dan I. Lubman, Ali dence, vol. 115, Nos. 1 and 2 (2011), pp. 120-130. Cheetham and Murat Yücel, “Cannabis and adolescent brain development”, Pharmacology and Therapeutics, vol. 148 (2015), pp. 1-16. 65 James C. Anthony, “The epidemiology of cannabis dependence”, in Cannabis Dependence: Its Nature, Consequences and Treatment, Roger 59 Wayne Hall, “What has research over the past two decades revealed A. Roffman and Robert S. Stephens, eds. (Cambridge, Cambridge about the adverse health effects of recreational cannabis use?”, University Press, 2006), pp. 58-105. Addiction, vol. 114, No. 1 (2015), pp. 19-35; and Wayne Hall and Louisa Degenhardt, “Adverse health effects of non-medical cannabis 66 Wayne Hall and Rosalie L. Pacula, Cannabis Use and Dependence: use”, The Lancet, vol. 374, No. 9698 (October 2009),pp. 1383- Public Health and Public Policy (Cambridge, Cambridge University 1391. Press, 2003). 60 World Drug Report 2014, footnotes 180 and 181, p. 44. 67 EMCDDA, Prevalence of Daily Cannabis Use in the European Union and Norway (Luxembourg: Publications Office of the European 61 Wayne Hall and others, The Health and Social Effects of Nonmedical Union, 2012). Cannabis Use (see footnote 53). 68 In the context of this section of the present report, cannabis treat- 62 James C. Anthony, Lynn A. Warner and Ronald C. Kessler, “Com- ment refers to the situation where cannabis was the primary drug parative epidemiology of dependence on tobacco, alcohol, con- of concern. People in treatment when other drugs were the primary trolled substances, and inhalants: basic findings from the National drug of concern might be treated for their cannabis use at the same Comorbidity Survey”, Experimental and Clinical Psychopharmacol- time. Therefore, the total number of people receiving who use ogy, vol. 2, No. 3 (1994), pp. 244-268. cannabis is actually far greater than the number presented here, 63 Behavioral Health Trends in the United States: Results from the 2014 especially since the use of cannabis is frequent among users of other National Survey on Drug Use and Health (see footnote 23). drugs. CHAPTER I 11 Extent of drug use

Fig. 11 Number of daily (or near-daily) users over time in the United States and has followed no clear of cannabis and number of people in trend in Europe; therefore, it has probably not been an treatment for cannabis use in the United important factor influencing the trends observed in the States, 2002-2012 number of persons in treatment.70, 71 400000 8.0 Increases in the potency of cannabis products (the del- 350000 7.0 ta-9-tetrahydrocannabinol or tetrahydrocannabinol (THC) content), including in the ratio of THC to can- 300000 6.0 nabidiol (a cannabinoid with anti-psychotic properties 250000 5.0 that may partially counterbalance the harm caused by THC), have received considerable attention in relation to 200000 4.0 possible increases in adverse health effects. There is evi- 150000 3.0 dence in some countries that there is now a large variety Numberin treatment of cannabis products on the market and that high-potency 100000 2.0 72, 73

cannabis users(millions) preparations have become more widely available. Nev-

50000 1.0 Number of daily (ornear-daily) ertheless, the interplay between high-potency cannabis products and dosage and how it translates into harm for 0 0.0 users is not well understood. Users may adjust (titrate) the amounts of cannabis they consume to achieve the desired 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 psychoactive effect, although this has been shown to be Total number of people in treatment for whom more difficult for inexperienced users74 and users of cannabis was the primary drug of concern high-potency cannabis.75 Number of people in treatment for whom Are changing patterns of treatment for cannabis was the primary drug of concern referred by themselves or health-care or community cannabis use a result of changes in referrals services or school/employer from the criminal justice system? Number who used cannabis on 20 or more days Several countries have adopted alternative measures to in the past month (millions) incarceration in minor cases involving possession of can- Number who used cannabis on 300 or more days nabis for personal consumption without aggravating cir- in the past year (millions) cumstances (for example, fines, warnings, probation, counselling or even exemption from punishment). In the Sources: United States, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration United States and the majority of countries in Europe, (SAMHSA), Results from the 2013 National Survey on Drug Use there is the option of referral or diversion away from crimi- and Health: Summary of National Findings, NSDUH Series H-48, nal sanctions and into treatment. Thus, the criminal justice HHS Publication No. (SMA) 14-4863 (Rockville, Maryland, SAMHSA, 2014); United States, Department of Health and Human response to cases involving possession of cannabis for per- Services, SAMHSA, Center for Behavioral Health Statistics and sonal use can have an impact on the number of persons Quality, Treatment Episode Data Set: Admissions (TEDS-A) – in treatment for cannabis use. Concatenated, 1992 to 2012, ICPSR25221 (Ann Arbor, Michigan, Inter-university Consortium for Political and Social Research, 2015). In the United States, persons referred to treatment from Note: The data presented in the figure are for people aged 12 years and older; persons in treatment are those for whom cannabis was the the criminal justice system constitute a significant propor- primary drug of concern. tion (47-58 per cent in the period 1992-2012) of those in

70 United States, Department of Health and Human Services, that this rate has changed over the past decade.69 In several Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality, countries in Europe with some of the highest numbers of Treatment Episode Data Set: Admissions (TEDS-A) Concatenated, people in treatment for cannabis use (Germany, Spain and 1992 to 2012, ICPSR 25221 (Ann Arbor, Michigan, Inter-univer- the United Kingdom of Great Britain and Northern Ire- sity Consortium for Political and Social Research, 2015). land), the prevalence of past-month cannabis use has been 71 EMCDDA, Statistical Bulletin, various years. stable or declining in the past decade, although the number 72 For more details, see World Drug Report 2015 ((United Nations of persons in treatment for cannabis use has risen publication, Sales No. E.15.XI.6), pp. 62-64). 73 James R. Burgdorf, Beau Kilmer and Rosalie L. Pacula, “Heteroge- continually. neity in the composition of marijuana seized in California”, Drug and Alcohol Dependence, vol. 117, No. 1 (2011), pp. 59-61. One factor that could explain increased negative health 74 Tom P. Freeman and others, “Just say ‘know’: how do cannabi- effects of cannabis use could be decreasing age of initia- noid concentrations influence users’ estimates of cannabis potency tion, but there is little evidence that cannabis users are and the amount they roll in joints?”, Addiction, vol. 109, No. 10 now starting at an earlier age. The age of initiation of can- (2014), pp. 1686-1694. nabis use reported by those in treatment has changed little 75 Peggy van der Pol and others, “Cross-sectional and prospective relation of cannabis potency, dosing and smoking behaviour with cannabis dependence: an ecological study”, Addiction, vol. 109, No. 69 Prevalence of Daily Cannabis Use (see footnote 67). 7 (2014), pp. 1101-1109.

WORLD DRUG REPORT 2016 12

Fig. 12 Number of people in treatment for canna- Fig. 13 Number of people in treatment for bis use and the prevalence of past-month cannabis use and number of arrests for cannabis use in Germany, Spain and the possession of cannabis in the United United Kingdom, 2006-2013 States, 1992-2012 900,000 36,000 10.0 900,000900,000 32,000 Germany 9.0 800,000 800,000800,000 28,000 8.0 700,000 7.0 700,000 24,000 700,000600,000 6.0 20,000 600,000600,000 5.0 500,000

16,000 500,000Number 4.0 Number 500,000400,000 Number 12,000 3.0 400,000Number 400,000 Number in in treatmentNumber 8,000 300,000 2.0 300,000300,000 4,000 1.0 200,000 200,000 0 0.0 200,000100,000 100,000100,000

Prevalence of cannabis use (percentage) 0 2006 2007 2008 2009 2010 2011 2012 2013 0 0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 18,000 20.0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 16,000 Spain 18.0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Total number of people in treatment for 14,000 16.0 Total number of people in treatment for All clients Totalcannabis number use of people in treatment for 12,000 14.0 Total number of people in treatment for cannabis New clients 12.0 use cannabis use 10,000 Prevalence of use among persons aged 18-6410.0 Number of people in treatment for 8,000 Prevalence of use among persons aged 18-248.0 Numbercannabis of use people who werein treatment referred for by the 6,000 Number of people in treatment for cannabis use 6.0 who werecannabiscriminal referred justice use who by system the were criminal referred justice by the system Number in in treatmentNumber 4,000 4.0 criminal justice system Number of arrests for cannabis possession 2,000 2.0 Number of arrests for cannabis possession 0 0.0 Number of arrests for cannabis possession Sources: United States, Department of Health and Human Services,

Prevalence of cannabis use (percentage) SAMHSA, Center for Behavioral Health Statistics and Quality, Number in treatment for cannabis use cannabis for Number in treatment 30,000 2006 2007 2008 30,0002009 2010 2011 2012 2013 16.0 Treatment Episode16.0 Data Set: Admissions (TEDS-A) – Concatenated, United Kingdom 1992 to 2012, ICPSR25221 (Ann Arbor, Michigan, Inter-university 30,00030,000 United Kingdom 16.016.0 14.0 United25,000 Kingdom 14.0 Consortium for Political and Social Research, 2015); United States, 30,00025,000United Kingdom 14.016.0 25,000 14.0 Executive Office12.0 of the President, National Drug Control Strategy: 25,000 United Kingdom 12.0 Data Supplement 2014 (Washington, D.C., 2014). 20,000All clients 20,000 12.014.0 25,000 12.010.0 Note: The data10.0 on treatment presented in the figure are for people aged 20,00020,000New clients 10.010.012.0 12 years and older for whom cannabis was the primary drug of concern. 20,00015,000 15,000 8.0 8.0 Prevalence of use among persons aged 15-64 10.0 15,00015,000 8.0 8.0 6.0 Prevalence of use10,000 among persons aged 15-24 6.0 treatment for cannabis use.76 However, over the same 15,00010,000 6.0 6.08.0 10,000 20-year period,4.0 40 per cent of those referred from the 10,000 in Number treatment 4.0 Number in in Number treatment

Number in in treatmentNumber 5,000 4.0 4.06.0 Number in in Number treatment 10,0005,000 criminal justice system reported that they had not used 5,000 2.0 2.0 5,000 2.0 4.0 cannabis in the month prior to entering treatment, and Number in in Number treatment 2.0 5,0000 0 0.0 only 22 per0.0 cent reported daily use of cannabis. The 0 0 0.0 0.02.0 number of arrests for cannabis possession follows a pattern Prevalence of cannabis use (percentage) 0 0.0 (percentage) use cannabis of Prevalence Prevalence of cannabis use (percentage) use cannabis of Prevalence that is for the most part similar to the number of people 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Prevalence of cannabis use (percentage) use cannabis of Prevalence 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 in treatment for cannabis, suggesting that changes in treat- 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 All clients All clients (percentage) use cannabis of Prevalence ment for cannabis use in the United States are possibly a

AllNewAllAll clients clients clients2005/06 2006/07 2007/08 New2008/09 clientsclients2009/10 2010/11 2011/12 2012/13 reflection of changes in arrests for cannabis possession. NewAllPrevalenceNewPre clientsvalenceclients clients of of use use amongPrevalence among persons persons of aged use aged among 16-59 persons aged 16-59 In Europe, referrals from the criminal justice system (from PrevalenceNewPrevalence18-64 clients (Germany), of ofuse use among 15-64Prevalence among persons (Spain) persons andofaged use 16-59aged among 16-2416-59 persons aged 16-24 the police, the courts and probation services) also make PrevalencePrevalence16-59 (United of ofuse Kingdom) use among among persons persons aged 16-24aged 16-5916-24 PrevalencePrevalence of of use use among among persons persons aged aged 16-24 an important contribution to the number of persons in 18-24 (Germany), 15-24 (Spain) and treatment as a result of their cannabis use. Typically, one 16-24 (United Kingdom) in five persons who are in treatment and for whom can- Source: Responses to the annual report questionnaire; and nabis was the primary drug of concern were referred from EMCDDA, Statistical Bulletin, 2015. the criminal justice system,77 with the proportion ranging Note: The data presented in the figures are for persons in treatment for whom cannabis was the primary drug of concern; for the United King- 76 Treatment Episode Data Set: Admissions (TEDS-A) – Concatenated, dom, the treatment data refer to the second year in the range given and 1992 to 2012 are for the whole country, but the prevalence rates refer to England and (see footnote 70). Wales only; for Spain, the prevalence rate given for 2007 refers to the 77 Median of 21 per cent from 26 reporting countries using data for years 2007/08. 2013 or the most recent year available. CHAPTER I 13 Extent of drug use from 3.9 per cent in the Netherlands to 80.6 per cent in At the health-care policy level and in international research, Hungary.78 Unfortunately, information is not available treatment for cannabis use has been receiving a relatively with regard to changes over time. high level of visibility and public funding in Europe.86 Since 2008, the number of persons in treatment for can- Have barriers and facilitators of access to treatment influenced the trend in treatment nabis use has been increasing in Europe, which in part is for cannabis use? a reflection of the expansion in the provision of treatment.87 In many countries in Europe, important strides Given that persons who are dependent on cannabis are have been made in the provision of treatment with pro- often reluctant to seek treatment,79 an awareness and grammes that have been implemented, expanded or modi- understanding, particularly among youth, of the potential fied to address the needs of cannabis users, some having harm associated with cannabis use may encourage users adolescents and young adults as their target groups.88, 89 to seek help. In the United States there has been a con- tinuous decline in the perception among youth that can- Gender and drug use nabis use is harmful. The proportion of secondary school students who see a “great risk” from regular cannabis use Men are considered to be three times more likely than has declined since the early 1990s and there has been a women to use cannabis, cocaine or amphetamines, whereas particularly rapid decline since the mid-2000s. In 2014, women are more likely than men to engage in the non- less than 40 per cent of twelfth-grade students (ages 17-18) medical use of prescription opioids and tranquillizers. perceived a “great risk” from regular cannabis use, down Gender disparities in drug use are more attributable to from nearly 80 per cent in the early 1990s.80 In Europe, opportunities to use drugs in a social environment than to either gender being more or less susceptible or vulner- the perception of harm from cannabis use is higher among 90 youth than in the United States and has not shown a able to the use of drugs. Men are considered to have decline. According to European surveys conducted in more opportunities than women to use drugs, but both genders are equally likely to use drugs once an opportunity 2003, 2007 and 2011, the percentage of students perceiv- 91, 92 ing “great risk” of harm from regular cannabis use has been to do so occurs. maintained at 70-72 per cent.81 The greater perception of Gender divide in drug use is narrowing among risk from cannabis use observed in Europe may have been the younger generation a factor in the increasing numbers in treatment. In most surveys, the prevalence of drug use is reportedly There could be considerable unmet demand for treatment higher among young people than among adults and the for cannabis use in Europe. It is estimated that there are gender divide in drug use is narrower among young people 3 million daily (or near-daily) cannabis users (persons who than among adults.93 In Europe, for every two girls who used cannabis 20 or more days in the previous month) in use cannabis there are three boys, whereas the prevalence the region.82 Based on a number of studies, cannabis of cannabis use among adults is nearly twice as high among dependence has been estimated to occur in 25-50 per cent men than among women.94 In the United States, the use of daily users.83, 84 In Europe, a total number of approximately 206,000 persons received treatment in 2010 for 86 Sharon R. Sznitman, “Cannabis treatment in Europe: a survey of which cannabis was either the primary or secondary reason services”, in A Cannabis Reader: Global Issues and Local Experiences 85 − Perspectives on Cannabis Controversies, Treatment and Regulation for entering treatment, suggesting that 10-30 per cent in Europe, vol. 2, S. R. Sznitman, B. Olsson and R. Room, eds., of all daily dependent cannabis users were receiving EMCDDA Monograph Series No. 8, (EMCDDA, Lisbon, 2008). treatment. 87 J. Schettino and others, Treatment of Cannabis-related Disorders in Europe, EMCDDA Insights Series (Lisbon, EMCDDA, 2015). 88 Eva Hoch and others, “CANDIS treatment program for cannabis 78 EMCDDA, Data and statistics, Statistical Bulletin 2015, table use disorders: findings from a randomized multi-site translational TDI-0291. Available at www.emcdda.europa.eu/. trial”, Drug and Alcohol Dependence, vol. 134 (2014), pp. 185-193. 79 Peter Gates and others, “Barriers and facilitators to cannabis treat- 89 Treatment of Cannabis-related Disorders in Europe (see footnote 87). ment”, Drug and Alcohol Review, vol. 31, No. 3 (2012), pp. 311- 319. 90 See World Drug Report 2015. 80 Richard A. Miech and others, Monitoring the Future National Survey 91 Michelle L. van Etten and James C. Anthony, “Male-female differ- Results on Drug Use: 1975-2014, vol. 1, Secondary school students ences in transitions from first drug opportunity to first use: search- (Ann Arbor, Michigan, University of Michigan Institute for Social ing for subgroup variation by age, race, region, and urban status”, Research, 2015), chap. 2. Journal of Women’s Health and Gender-based Medicine, vol. 10, No. 8 (2001). 81 Bjorn Hibell and others, The 2011 ESPAD Report: Substance Use among Students in 36 European Countries; The 2007 ESPAD Report: 92 Michelle L. van Etten, Yehuda D. Neumark and James C. Anthony, Substance Use Among Students in 35 European Countries; and The “Male-female differences in the earliest stages of drug involvement”, 2003 ESPAD Report: Alcohol and other Drug Use among Students in Addiction, vol. 94, No. 9 (1999), pp. 1413-1419. 35 European Countries (Stockholm, Swedish Council for Informa- 93 Jessica H. Cotto and others, “Gender effects on drug use, abuse, tion on Alcohol and Other Drugs, 2012, 2009 and 2004). and dependence: a special analysis of results from the National 82 Prevalence of Daily Cannabis Use (see footnote 67). Survey on Drug Use and Health”, Gender Medicine, vol. 7, No. 5 (2010), pp. 402-413. 83 Hall and Pacula, “Cannabis use and dependence” (see footnote 66). 94 The 2011 ESPAD Report; and the unweighted average of the prev- 84 Prevalence of Daily Cannabis Use (see footnote 67). alence of past-year drug use for European Union member States 85 Ibid. reported by EMCDDA.

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Fig. 14 Ratio of males to females among young for both men and women, the decline in cannabis use was people (ages 12-17) who use cocaine, greater among women (-40 per cent) than among men prescription opioids and cannabis in the (-20 per cent).96 United States, 2002-2013 1.6 B. HEALTH IMPACT OF DRUG USE 1.4 Almost 12 million people inject drugs worldwide 1.2 The joint UNODC/WHO/UNAIDS/World Bank esti- 1 mate for the number of people who inject drugs (PWID) for 2014 is 11.7 million (range: from 8.4 to 19.0 million), 0.8 or 0.25 per cent (range: 0.18-0.40 per cent) of the popu-

Ratio females to males of Ratio lation aged 15-64. PWID experience some of the most 0.6 severe health-related harms associated with unsafe drug use, overall poor health outcomes, including a high risk 0.4 for non-fatal and fatal overdoses, and a greater chance of premature death.97 This is exacerbated by poor access to 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 evidence-informed services for the prevention and treat- Cocaine ment of infections, particularly HIV, hepatitis C and Prescription opioids tuberculosis.98 Cannabis Eastern and South-Eastern Europe is the subregion with by far the highest prevalence of injecting drug use: 1.27 Source: United States, SAMHSA, Center for Behavioral Health Sta- tistics and Quality, Results from the 2013 National Survey on Drug per cent of the population aged 15-64. The subregion Use and Health: Mental Health Detailed Tables (Rockville, Mary- accounts for almost one in four (24 per cent) of the total land, 2014). number of PWID worldwide; almost all PWID in the subregion reside in the Russian Federation and Ukraine. of cannabis, cocaine and prescription opioids among In Central Asia and Transcaucasia and in North America, young people (ages 12-17) was fluctuating over the past the prevalence of injecting drug use is also high: 0.72 per decade but overall the gender gap has remained similar. cent of the population aged 15-64 in Central Asia and Transcaucasia; and 0.65 per cent in North America. Those Gender divide in drug use is changing three subregions combined account for 46 per cent of the In recent years, in countries with established drug use, the total number of PWID worldwide. Although the preva- gender divide in drug use has also been changing in the lence of injecting drug use in East and South-East Asia is adult population, partly reflecting increasing opportuni- at a level below the global average, a large number of ties to use a particular substance. In the United States, PWID (27 per cent of the total number of PWID in the among the population aged 12 and older, heroin use world) reside in the subregion, given that it is the most remains higher among men than among women. However, populated subregion. Three countries (China, Russian over the past decade more women than men have started Federation and United States) together account for nearly using heroin: the prevalence of past-year heroin use among half of the total number of PWID worldwide. women was 0.8 per cent in the period 2002-2004 and twice that figure (1.6 per cent) in the period 2011-2013, Drug use is a major risk factor for the whereas the prevalence of past-year heroin use among men transmission of infectious diseases increased by half in the same period. The increase in heroin Among people who inject drugs, one in seven use was significantly higher among men and women who is living with HIV and one in two is living with were younger (18-25 years old) and more frequent users hepatitis C of prescription opioids.95 PWID represent a key at-risk population for HIV and In the United Kingdom, overall drug use in the adult hepatitis infections, with almost a third of new HIV infec- population declined between 1996 and the period 2013- tions outside sub-Saharan Africa occurring among 2014. However, this decline was more marked among women (-30 per cent) than men (-13 per cent). While the 96 United Kingdom, Home Office, Drug Misuse: Findings for the prevalence of amphetamine use declined by 75 per cent 2013/14 Crime Survey for England and Wales (July 2014). 97 Mathers M. Bradley and others, “Mortality among people who 95 Christopher M. Jones and others, “Vital signs: demographic and inject drugs: a systematic review and meta-analysis”, Bulletin of the substance use trends among heroin users − United States, 2002- World Health Organization, vol. 91, No. 2 (2013), pp. 102-123. 2013, Morbidity and Mortality Weekly Report, vol. 64, No. 26 98 Joint United Nations Programme on HIV/AIDS (UNAIDS), The (2015), pp. 719-725. GAP Report 2014 (Geneva, 2014). CHAPTER I 15 Health impact of drug use

Fig. 15 Estimated number and prevalence of Fig. 16 Estimated number of people who inject people who inject drugs among the drugs living with HIV and prevalence of general population, by region, 2014 HIV among people who inject drugs, by region, 2014 5.0 1.4 0.8 30 4.5 0.7 1.2 25 4.0 0.6 1.0 3.5 20 3.0 0.5 0.8 2.5 0.4 15 0.6 2.0 0.3 10 1.5 0.4 Number(millions) Number (millions) 0.2 1.0 Prevalence (percentage) 5 0.2 0.1 0.5 HI prevalence (percentage) 0.0 0.0 0.0 0 Total Total Total Total Total Total Total Total Total Total South Asia South Asia d Middled East d Middled East North America North America d Transcaucasiad d Transcaucasiad South-West Asia South-West Asia d South-Eastd Asia d South-Eastd Asia Near an Near an d South-Easternd Europe d South-Easternd Europe East an East an Wester andCentraln Europe WesterandCentral n Europe Central an Asia Central an Asia Latin America and the Carribean Latin America and the Carribean Eastern an Eastern an Africa America Asia Europe Oceania Africa America Asia Europe Oceania

Number of people who inject drugs Number of people who inject drugs and are Prevalence of people who inject drugs among living with HI the population aged 15-64 (percentage) HI Prevalence among people who inject drugs (percentage) Sources: Responses to the annual report questionnaire; progress Sources: Responses to the annual report questionnaire; progress reports of the Joint United Nations Programme on HIV/AIDS reports of UNAIDS on the global AIDS response (various years); (UNAIDS) on the global AIDS response (various years); the former the former Reference Group to the United Nations on HIV and Reference Group to the United Nations on HIV and Injecting Drug Injecting Drug Use; and government reports. Use; and government reports. Note: The prevalence of HIV among PWID in Western and Central Note: The 2014 estimate of the total number of PWID worldwide (11.7 Europe has been updated from 7.6 per cent (World Drug Report 2015) million) is slightly lower than the estimate published in the World Drug to 11.2 per cent. This is the result of updated information supplied by Report 2015 (12.2 million), although the prevalence of injecting drug Italy, where nationally representative information became available to use among the population aged 15-64 remains stable. In particular, esti- replace previously reported subnational data. mates are now included for five countries in Africa (including for highly populated countries such as Nigeria) for which no data were previously available. This has led to an increase in the coverage of PWID estimates HIV prevalence is particularly high among PWID in among the population aged 15-64 for Africa, from 29 to 50 per cent, South-West Asia and in Eastern and South-Eastern Europe, and an improved overall estimate for PWID in Africa, with a corresponding reduction in the level of uncertainty of the regional estimate. where 28.2 and 22.9 per cent of PWID, respectively, are living with HIV. The two subregions combined account for 53 per cent of the total number of PWID living with PWID.99 Compared with non-injecting drug users, PWID HIV worldwide. Although both the prevalence of inject- are approximately three times more likely to acquire ing drug use and the prevalence of HIV among PWID in HIV,100 as the sharing of contaminated needles and East and South-East Asia are below the global averages, a syringes is a major risk for the transmission of HIV and large number of PWID living with HIV (330,000, or 21 viral hepatitis. According to joint UNODC/WHO/ per cent of the world total) reside in the subregion. Four UNAIDS/World Bank estimates for 2014, 14.0 per cent countries combined (China, Pakistan, Russian Federation (or 1.6 million) of PWID are living with HIV, 52 per cent and United States) account for 64 per cent of the total (or 6.0 million) of PWID are infected with hepatitis C number of PWID living with HIV. and 9.0 per cent (or 1.1 million) are infected with hepatitis B. Risk behaviour and HIV among users of stimulants remain high 99 Ibid. Studies have found that people who inject stimulants 100 Isabel Tavitian-Exley and others, “Influence of different drugs on HIV risk in people who inject: systematic review and meta-analy- engage in higher-risk sexual behaviours and have higher sis”, Addiction, vol. 110, No. 4, pp. 572-584. HIV prevalence than people who inject opiates. People

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Fig. 17 HIV prevalence among people who inject stimulants and among people who use stimulants but do not inject them

HI prevalence (percentage) 0 5 10 15 20 25 30 35 40 45 50 55 Brazil (Zocratto 2006) United States (McCoy 2004) Brazil (on Diemen 2010) Brazil (Caiaﬀa 2006) United States (Brewer 2007) Brazil (De Azevedo 2007) Canada (Shannon 2008) United States (Kral 2005) Estonia (Talu 2010) United States (Buchanan 2006) United States (Rees 2006) Brazil (Malta 2010) Brazil (Pechansky 2004) Brazil (Pechansky 2006) United States (McCoy 2004) Trinidad and Tobago (Reid 2006) Canada (Shannon 2008) South Africa (Wechsberg 2014) United States (Des arlais 2014) United States (Robertson 2004) United States (Tortu 2004) United States (Weiser 2006) Canada (Marshall 2011) United States (Truong 2011) United States (Lorvick 2012) Argentina and Uruguay (Zocratto 2010) Saint Lucia (Day 2007) Canada (Wylie 2006) Brazil (De Azevedo 2007) Brazil (Bertoni 2014) Brazil (De Carvalho 2009) Uruguay (Ministerio de Salud Pblica 2013) Argentina (Rossi 2008) Argentina and Uruguay (Caiaﬀa 2011) Brazil (Bastos 2014) China (Bao 2012) Thailand (Srirak 2005) United States (Zule 2007) Mexico (Deiss 2011) Thailand (Beyrer 2004) United States (Kral 2011) Colombia (Berbesi 2014) Brazil (Nunes 2007) Thailand (Celentano 2008) Canada (Uhlmann 2014) Brazil (Santos Cruz 2013) Spain (Brugal 2009)

HI prevalence among people who inject stimulants HI prevalence among people who use stimulants but do not inject them

Note: Based on a comprehensive review of studies commissioned by UNODC. (For details on the studies, see the relevant table in the online Statistical Annex to the World Drug Report.) Where available, the upper and lower bounds of 95 per cent confidence intervals are shown. CHAPTER I 17 Health impact of drug use

Sustainable Development Goals related to the prevention and treatment of drug use and HIV The General Assembly at its seventieth care, treatment and rehabilitation of drug Partnership for Sustainable Development session adopted the outcome document use disorders. In this context, UNODC has (Goal 17). The UNAIDS Strategy 2016-2021 of the United Nations summit for the developed the International Standards on mirrors these Sustainable Development adoption of the post-2015 development Drug Use Prevention and the International Goals, setting the following targets for agenda, containing the 2030 Agenda for Standards on the Treatment of Drug Use HIV and AIDS treatment and prevention:b Sustainable Development and the Sustain- Disorders that have already been recog- 1. The 90-90-90 treatment targets (and by a able Development Goals. The 17 Goals nised by Member States as useful guides 2030, the 95-95-95 treatment targets): address the different dimensions of sustain- to improving their services in numerous by 2020: able development. Many of the Sustainable Resolutions, as well as in the Outcome doc- (i) 90 per cent of people (children, ado- Development Goals and their targets are ument of the special session of the General lescents and adults) living with HIV related to the intersection between drugs, Assembly. Measuring access to treatment know their status; peace and justice, but only those related to for substance use requires, at the national (ii) 90 per cent of people living with HIV health and well-being are mentioned here. level, reliable estimates of the number of who know their status are receiving For a broader discussion on the Sustainable people in need of treatment for, or those treatment; Development Goals and the world drug suffering from, drug use disorders and a (iii) 90 per cent of people in treatment problem see chapter II of the present report. reliable estimate of the number of people have suppressed viral loads; provided with treatment interventions for Under Goal 3 (“Ensure healthy lives and 2. The prevention target is to reduce the the use of different drugs. promote well-being for all at all ages”), number of new HIV infections to fewer global leaders have, for the first time, The second main target under Goal 3, than 500,000 per year by 2020 (and to addressed issues related to the prevention namely target 3.3, is to end, by 2030, the fewer than 200,000 per year by 2030); and treatment of substance use. Target epidemics of AIDS, tuberculosis, malaria 3. Zero discrimination (overcoming human 3.5 is to strengthen the prevention and and neglected tropical diseases and combat rights, gender-related and legal barriers treatment of substance abuse, including hepatitis, water-borne diseases and other to HIV services). narcotic drug abuse and harmful use of communicable diseases. Other Goals alcohol. Achieving that target requires, related to addressing HIV and AIDS include inter alia, expanding the coverage and those on achieving gender equality (Goal quality of a range of evidence-based and 5); reducing inequality (Goal 10); promoting a General Assembly resolution 70/1. gender-responsive interventions for the inclusive societies and providing access to b UNAIDS, UNAIDS 2016–2021 Strategy: prevention of drug use, as well as for the justice (Goal 16); and revitalizing the Global On the Fast-Track to End AIDS (2015). who inject stimulants (cocaine and amphetamines) have or drugs), as well as a higher frequency of sexual activity been found to have more sexual partners and more fre- and an increased number of sexual partners.104, 105, 106 quent intercourse with casual partners and regular partners than PWID who inject other drugs. Moreover, a systematic As many stimulants (particularly NPS that are stimulants) review found that the risk of acquiring HIV was 3.6 times have a shorter duration of action, compared with users of greater among people who injected cocaine than among opiates, users of stimulants report a high frequency of non-injecting users of cocaine, and 3.0 times greater injecting, with compulsive re-injecting and a greater likelihood to report the sharing and reuse of needles and among people who injected ATS than among non-inject- 107, 108 ing users of ATS.101 syringes that might be contaminated. The use of stimulants (particularly methamphetamine and amphetamine) to enhance and prolong sexual activity is 104 Francisco I. Bastos and Neilane Bertoni, Pesquisa Nacional sobre o well documented, particularly among men who have sex uso de crack: quem são os usuários de crack e/ou similares do Brasil? with men (MSM).102 There is strong evidence of higher- Quantos são nas capitais brasileiras? (Rio de Janeiro, ICICT/ risk sexual behaviours and higher HIV prevalence among FIOCRUZ, 2014). MSM who use methamphetamine or amphetamine than 105 Tavitian-Exley and others, “Influence of different drugs on HIV risk in people who inject” (see footnote 100). among those who use other drugs.103 These high-risk 106 John S. Atkinson and others, “Multiple sexual partnerships in a sexual behaviours include unprotected sex (or inconsistent sample of African-American crack smokers”, AIDS and Behavior, condom use) and the selling of sex (in exchange for money vol. 14, No. 1 (2010), pp. 48-58; and J. A. Inciardi and others, “The effect of serostatus on HIV risk behaviour change among women sex workers in Miami, Florida”, AIDS Care: Psychological 101 Ibid. and Socio-Medical Aspects of AIDS/HIV, vol. 17, Suppl. No. 1 102 Lydia N. Drumright and others, “Unprotected anal intercourse and (2005), pp. S88-S101. substance use among men who have sex with men with recent HIV 107 Marie C. Van Hout and Tim Bingham, “A costly turn on”: patterns infection”, Journal of Acquired Immune Deficiency Syndromes, vol. of use and perceived consequences of mephedrone based head shop 43, No. 3 (2006), pp. 344-350. products amongst Irish injectors”, International Journal of Drug 103 Nga Thi Thu Vu, Lisa Maher, and Iryna Zablotska, “Amphet- Policy, vol. 23, No. 3 (2012), pp. 188-197. amine-type stimulants and HIV infection among men who have 108 United Kingdom, Public Health England, Health Protection Scot- sex with men: implications on HIV research and prevention from land, Public Health Wales, and Public Health Agency Northern a systematic review and meta-analysis”, Journal of the International Ireland, “Shooting up: infections among people who inject drugs in AIDS Society, vol. 18, No. 1 (2015). the United Kingdom” (London, November 2015).

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It is difficult to quantify the contribution of stimulant use Fig. 18 Drug-related mortality rate and number in increasing HIV infection rates but, compared with use of drug-related deaths, by region, 2014 of other drugs, the preponderance of evidence points Drug-related towards a positive association between stimulant use, mortality rate per Estimated number higher-risk sexual and injecting behaviours and HIV infec- million population of drug-related deaths tions.109, 110 aged 15-64 Outbreaks of HIV among people who use drugs, especially PWID, are a particular concern because HIV can spread Africa 61.9 39,200 very rapidly among PWID when appropriate harm reduc- North tion services are not available, discontinued or scaled 164.5 52,500 down.111 In 2011, such outbreaks occurred among PWID America in Greece (Athens) and Romania, where a significant Latin America increase in the number of new HIV cases among PWID and the Caribbean 15.6 5,200 was reported to be attributable, in part, to the increased use of stimulants (NPS in Romania and mostly cocaine Asia 85,900 in Greece, as a replacement for opioids in both cases), 29.6 which was associated with a higher frequency of injecting Western and and an increase in the sharing of needles and syringes Central Europe 28.9 9,200 among new and young PWID.112, 113 Drug-related deaths remain Eastern and South- Eastern Europe 55.9 12,00 unacceptably high

Number of drug-related deaths worldwide Oceania 101.5 2,500 remains stable Sources: responses to the annual report questionnaire; Inter-Amer- In 2014, there were an estimated 207,400 (range: 113,700- ican Drug Abuse Control Commission; and Louisa Degenhardt 250,100) drug-related deaths114 worldwide, corresponding and others, “Illicit drug use”, in Comparative Quantification of to 43.5 (range: 23.8-52.5) deaths per million people aged Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, vol. 1, Majid Ezzati and others, eds. 15-64. Overdose deaths account for between approxi- (Geneva, World Health Organization (WHO), 2004), p. 1,109. mately one third and one half of all drug-related deaths

worldwide, and in most cases those overdose deaths since 2004; the country experienced a record number of 115, 116 involved opioids. fatal drug overdoses in 2014, 61 per cent of which were 117 The highest drug-related mortality rate continues to be in associated with prescription opioids and heroin. North America, which accounts for approximately one in Fentanyl-related overdose deaths reported in four (25 per cent of) drug-related deaths worldwide. The many countries high mortality rate in North America is attributable in 118 part to better monitoring and reporting of drug-related Fentanyl, a synthetic opioid, has recently been impli- deaths and to the comparatively higher rates of opioid use cated in a significant and increasing number of deaths in in that subregion. In the United States, nearly half a mil- a number of countries. Recent concerns have been raised lion people are estimated to have died from drug overdoses in a number of European countries, especially in Estonia, which has one of the highest drug-related mortality rates 109 Louisa Degenhardt and others, “Meth/amphetamine use and asso- in Europe (127 drug-related deaths per million people ciated HIV: implications for global policy and public health”, Inter- aged 15-64 in 2013), and where overdoses are mostly asso- national Journal of Drug Policy, vol. 21, No. 5 (2010), pp. 347-358. ciated with the use of fentanyl.119, 120 In Canada, during 110 Tavitian-Exley and others, “Influence of different drugs on HIV the six-year period 2009-2014 there were at least 655 risk in people who inject” (see footnote 100). 111 For the purpose of the present report, harm reduction is understood to refer to the set of the measures defined by WHO, UNODC and deaths due to HIV acquired through injecting drug use; suicide; UNAIDS to prevent HIV and other blood-borne infections among and unintentional deaths and trauma due to drug use. people who inject drugs (also referred to in the Commission for 115 Louisa Degenhardt and others, “Illicit drug use”, in Comparative Narcotic Drugs resolution 56/6) for the provision of comprehensive Quantification of Health Risks: Global and Regional Burden of Disease HIV prevention, treatment and care services among people who Attributable to Selected Major Risk Factors, vol. 1, M. Ezzati and inject drugs’. See also the discussion in WHO “Community man- others, eds. (Geneva, WHO, 2004). agement of opioid overdose” 2014. 116 EMCDDA, Mortality related to Drug Use in Europe: Public Health 112 EMCDDA, “HIV outbreak among injecting drug users in Greece” Implications (Luxembourg, Publications Office of the European (Lisbon, November 2012). Union, 2011). 113 Andrei Botescu and others, “HIV/AIDS among injecting drug users 117 Rose A. Rudd and others, “Increases in drug and opioid overdose in Romania: report of a recent outbreak and initial response poli- deaths: United States, 2000-2014”, Morbidity and Mortality Weekly cies” (Lisbon, EMCDDA, 2012). Report, vol. 64, No. 50 (2016), pp. 1378-1382. 114 The definition of drug-related deaths varies between Member States 118 EMCDDA, “Fentanyl drug profile”. Available at www.emcdda. but includes some or all of the following: fatal drug overdoses; europa.eu/publications/drug-profiles/fentanyl. CHAPTER I 19 Health impact of drug use

Are we underestimating the number of drug-related deaths?

Accurate estimates of the extent and pat- is suspected of playing a part or in the practices and information available to the terns of drug-related deaths are vital for absence of information surrounding the responsible physician. Thus, drug-related monitoring the most extreme form of harm circumstances of the death or the envi- deaths are likely to be underreported. that can result from drug use and for evalu- ronment in which the death occurred. The Very few studies have attempted to estimate ating the effectiveness of interventions put process for determining the cause of death the level of underreporting of drug-related in place to reduce drug-related mortality. may vary from country to country and even deaths. In France, for example, significant within the same country. Depending on differences were apparent in official num- The definition of drug-related deaths the discretion of the certifying physician bers from three different institutions with varies from country to country, but could and the available information about the a very low rate of overlapping cases; there include all, or at least some, of the follow- deceased person’s prior medical history and/ was underreporting of approximately a ing: fatal drug overdoses; deaths due to or circumstances of death, more compre- third of the total drug-related deaths.a In a AIDS acquired through injecting drug use; hensive, investigative procedures, including study conducted in Italy, using an approach intentional self-poisoning by exposure to post-mortem toxicological investigations, that examined multiple causes of death (the psychotropic substances (suicide); and unin- may or may not be initiated. Although analysis of all conditions reported on the tentional deaths and trauma (motor vehicle procedures may be well established for death certificate), it was estimated that accidents and other forms of accidental identifying overdose deaths resulting from there were 60 per cent more drug-related death) due to drug use. However, many the use of drugs such as heroin, the process deaths than determined from traditional countries only report overdose deaths. This may become complex if multiple drugs are reporting on a single underlying cause of definition is framed from a health perspec- involved, as in many fatal overdose cases. death.b tive, considering drug-related deaths in the Also, the role of NPS in fatal overdose cases context of the burden of disease. However, may be more difficult to determine, given a broader perspective could also include the unknown toxicology of many NPS, a Eric Janssen, “Drug-related deaths in France deaths resulting from the functioning of particularly when they are used in combi- in 2007: estimates and implications”, Sub- illicit drug markets and could include, for nation with other drugs (including alcohol), stance Use and Misuse, vol. 46, No. 12 example, deaths as a result of violence in which case the risk of overdose can be (2011), pp. 1495-1501. higher. Mortality registers often contain a associated with the illicit supply of and b Francesco Grippo and others, “Drug significant number of deaths classified as trafficking in drugs. induced mortality: a multiple cause unknown or ill-defined or cases in which approach on Italian causes of death Regis- Ascertaining the cause of death can be the true underlying cause of death may ter”, Epidemiology Biostatistics and Public complicated in cases where drug use be miscoded, depending on the coding Health, vol. 12, No. 1 (2015). deaths in which fentanyl was determined to be the cause reported by many prisons and other closed settings.124 or a contributing cause of death, the number of deaths According to the limited data made available to UNODC, increasing markedly in the four largest provinces.121 In recent use of drugs (drug use in the previous 12 months) the United States, there were more than 700 deaths related is reported to be around 23 per cent among the prison to fentanyl use between late 2013 and late 2014. One population, with cannabis use at around 19 per cent and matter of concern is that heroin is often laced with fenta- heroin or amphetamine use among approximately 5 per nyl before being sold, and so heroin users have no know cent. Similarly, a large number of studies in countries ledge of having consumed fentanyl. That situation could throughout the world have found high levels of injecting be exacerbated by the recent increase in heroin use in the drug use among both male and female prisoners.125 United States.122

Prisons are a high-risk environment for Collaborative Group (WHO/PSA/94.4); Chris Beyrer and others, infectious diseases “Drug use, increasing incarceration rates, and prison-associated HIV risks in Thailand”, AIDS and Behavior, vol. 7, No. 2 (2003), pp. 153-161; and Sheila M. Gore and others, “Drug injection and Among vulnerable people who use drugs, particularly HIV prevalence in inmates of Glenochil prison”, British Medical PWID, imprisonment is a common outcome. According Journal, vol. 310, No. 6975 (1995), pp. 293-296. to studies conducted in a large number of countries, 124 Rhidian Hughes and Meg Huby, “Life in prison: perspectives of between 56 and 90 per cent of PWID have been impris- drug injectors”, Deviant Behavior, vol. 21, No. 5 (2000), pp. 451- 123 479; and S. Chu and K. Peddle, Under the Skin: A People’s Case for oned at some stage. Initiation and use of drugs are also Prison Needle and Syringe Programs (Toronto, Canadian HIV/AIDS Legal Network, 2010). 125 Anne Marie DiCenso, Giselle Dias and Jacqueline Gahagan, 119 EMCDDA, European Drug Report 2014: Trends and Developments Unlocking Our Futures: A National Study on Women, Prisons HIV, (Luxembourg, Publications Office of the European Union, 2014). and Hepatitis C (Toronto, Prisoners’HIV/AIDS Support Action 120 Jane Mounteney and others, “Fentanyls: are we missing the signs? Network (PASAN), 2003); Ruth E. Martin and others, “Drug use Highly potent and on the rise in Europe”, International Journal on and risk of bloodborne infections: a survey of female prisoners Drug Policy, vol. 26, No. 7 (2015), pp. 626-631. in British Columbia”, Canadian Journal of Public Health, vol. 96, 121 Canadian Centre on Substance Abuse, “Canadian Community No. 2 (2005), pp. 97-101; and Kate Dolan and others, “People Epidemiology Network on Drug Use (CCENDU) Bulletin: deaths who inject drugs in prison: HIV prevalence, transmission and pre- involving fentanyl in Canada, 2009-2014” (August 2015). vention”, International Journal of Drug Policy, vol. 26, Suppl. No. 1 (2015), pp. S12-S15; Chloé Carpentier and others, “Ten Years 122 2015 National Drug Threat Assessment Summary. of Monitoring Illicit Drug Use in Prison Populations in Europe: 123 WHO, Multi-city study on drug injecting and risk of HIV infec- Issues and Challenges”, The Howard Journal of Criminal Justice, tion: a report prepared on behalf of the WHO International 51: 37–66. doi: 10.1111/j.1468-2311.2011.00677.x (2012).

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Table 1 Ratio of drug-related mortality rates among ex-prisoners to all-cause mortality rates among the general population Country or area Time since release from prison 1 week 2 weeks 45 days 1 year 3 years 4-5 years 7-8 years 15 years United Kingdoma 37.1 12.4 United States 129 Denmark 61.9 Switzerland 50 Taiwan Province of China 29.3 United Statesb 10.3 United States 3.5 United Kingdoma Males 28.9 15.8 Females 68.9 56.3 Australiac Males 14.5 Females 50.3 France Males aged 15-34 124.1 Males aged 35-54 274.2 Source: WHO, Preventing Overdose Deaths in the Criminal Justice System (Copenhagen, 2014). Note: The numbers presented are standardized mortality ratios. They express the ratio of deaths from drug-related causes observed among ex-prisoners compared to the number of deaths from all causes that would be expected among people of comparable age and gender in the general population. a First and second weeks calculated separately. b Not time-limited (median = 4.4 years). c Not time-limited (median = 7.7 years). The risk of HIV, hepatitis and tuberculosis infection in to introducing or expanding those services in prisons. In prisons continues to be a matter of significant concern. In 2014, opioid substitution therapy was available in prisons some settings, the burden of HIV among prisoners may in only 43 countries, whereas 80 countries reported the be up to 50 times higher than among the general availability of such therapy in the community. The avail- population,126 the incidence of tuberculosis is, on average, ability of needle and syringe programmes in prisons was 23 times higher than among the general population127 and reported in only 8 countries, whereas 90 countries reported an estimated two out of every three prisoners with a his- the availability of such programmes in the community. tory of injecting drug use are living with hepatitis C.128 Most of the above-mentioned 8 countries are in Europe and Central Asia, and such interventions are not available Despite the high-risk environment and the scientific evi- in all prison settings.132 dence of the effectiveness of interventions for the treatment of drug use disorders, and the prevention and Substantially higher risk of drug-related death treatment of HIV, hepatitis C and tuberculosis,129 there soon after release from prison are significant gaps in the provision of these services in The period shortly after release from prison is associated most prisons throughout the world. Prisons and other with a substantially increased risk of drug-related death closed settings often lack adequate health services, confi- (primarily fatal overdose), with a mortality rate much dentiality and privacy; furthermore, mandatory (non-vol- higher than from all causes of death among the general untary) HIV testing remains a common practice.130 population.133 The first two weeks after release from prison Available evidence indicates that drug dependence treat- is a period of particular vulnerability, with a risk of drug- ment and harm reduction interventions can be effectively related death 3-8 times higher than in the subsequent 10 implemented within prisons without compromising secu- weeks.134 Moreover, the drug-related mortality rate after rity or increasing drug use.131 In a number of countries, release from prison has been found to be 50-100 times however, there are political, legal and regulatory barriers higher than the mortality rate of the general population. According to the very limited data available, female ex- 126 The Gap Report, 2014 (see footnote 98). prisoners appear to experience poorer outcomes than male 127 Iacopo Baussano and others, “Tuberculosis incidence in prisons: a ex-prisoners, and older ex-prisoners experience poorer out- systematic review”, PLoS Medicine, vol. 7, No. 12 (2010). comes than younger ex-prisoners. This may reflect differ- 128 Sarah Larney and others, “Incidence and prevalence of hepatitis C ent histories and patterns of drug use depending on the in prisons and other closed settings: results of a systematic review and meta-analysis”, Hepatology, vol. 58, No. 4 (2013), pp. 1215- gender and age of ex-prisoners. 1224. 129 UNODC/ILO/UNDP/WHO/UNAIDS policy brief entitled “HIV prevention, treatment and care in prisons and other closed settings: 132 Harm Reduction International, The Global State of Harm Reduction a comprehensive package of interventions” (2013). 2014, Katie Stone, ed. (London, 2014). 130 UNAIDS, UNAIDS 2016–2021 Strategy: On the Fast-Track to End 133 WHO, Preventing Overdose Deaths in the Criminal Justice System AIDS (2015). (Copenhagen, 2014). 131 Thomas Kerr and others, “Harm reduction in prisons: a ‘rights 134 Elizabeth L. C. Merrall and others, “Meta-analysis of drug-related based analysis’”, Critical Public Health, vol. 14, No. 4 (2004), pp. deaths soon after release from prison”, Addiction, vol. 105, No. 9 4-16. (2010), pp. 1545-1554. CHAPTER I 21 Extent of drug supply

The increased risk of drug-related death after release from Fig. 19 Estimated total area under opium poppy prison is principally attributable to two causes: first, and coca bush cultivation, 1998-2015 decreased tolerance to drugs, especially heroin, after a period of relative abstinence that occurs in prison, where 350,000 drug use may be more infrequent and the purity of drugs 300,000 lower than outside of prison; and second, the use of multiple drugs after release from prison, particularly the com- 250,000 bination of depressants (such as benzodiazepines and alcohol) with heroin, which can considerably increase the 200,000 risk of fatal overdose.135 150,000

C. EXTENT OF DRUG SUPPLY Total area (hectares) 100,000

Over the period 2009-2014, the cultivation of cannabis 50,000 plants was reported to UNODC by 129 countries, far 0 more than the 49 countries (mostly in Asia and the Ameri- cas) that reported opium poppy cultivation and the 7 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 countries (in the Americas) that reported coca bush culti- Opium poppy cultivation vation.136 According to the latest UNODC estimates, in Coca bush cultivation terms of area, cannabis is also the most extensively grown drug crop,137 particularly if wild growth is included.138 Sources: UNODC coca and opium surveys in various countries; responses to the annual report questionnaire; and United States, The extent of, and trends in, cannabis cultivation and Department of State, International Narcotics Control Strategy production are, however, difficult to assess, given that sys- Report, various years. tematic measurements do not exist. Despite diverging trends in opium poppy “Old” versus “new” conversion and coca bush cultivation, the production ratios for estimating cocaine of opium and cocaine has returned to the production levels of the late 1990s The last step in calculating cocaine production requires each producing country to estimate factors for converting coca leaf Information relating to the area under illicit cultivation is to cocaine hydrochloride. In the present report, two conversion more reliable in the case of coca bush and opium poppy factors are used for global estimates: (i) an “old” conversion cultivation than in the case of cannabis plant cultivation, ratio, as estimated by the United States Drug Enforcement as it is largely based on scientifically validated surveys. Administration (DEA), for the Plurinational State of Bolivia Although fluctuating, the total area under opium poppy and Peru in the 1990s, and a study by the Government of Colombia and UNODC, for Colombia; (ii) a “new” conver- cultivation in 2015 was higher than in 1998 (18 per cent), sion ratio, based on studies undertaken by DEA in Peru in the year in which the General Assembly held its previous 2005, and in the Plurinational State of Bolivia in 2007-2008. special session dedicated to the world drug problem; and However, these ratios have not been reconfirmed in national the total area under opium poppy cultivation has increased studies. The “new” ratio also considers the conversion factor sharply (by 51 per cent) since 2009 (the year of adoption for Colombia established in 2004. (For more details, see World Drug Report 2010 (United Nations publication, Sales No. E.10. of the Political Declaration and Plan of Action on Inter- XI.13, pp. 251 and 252) and the online methodology section national Cooperation towards an Integrated and Balanced of the present report). Strategy to Counter the World Drug Problem) largely as a result of increased cultivation in Afghanistan. In contrast, the total area under coca bush cultivation has followed a Global estimates show that illicit opium production downward trend, falling by 31 per cent since 1998 and by declined sharply in 2015 (by 38 per cent) to 4,770 tons, 19 per cent since 2009. the level of the late 1990s. Of that amount, the part estimated to have been transformed into heroin would result in an output of 327 tons of heroin of export purity, largely from heroin manufacture in Afghanistan. Cocaine 135 Preventing Overdose Deaths (see footnote 133). production, estimated at 746 tons (based on the “old” 136 Based on reports from countries on the cultivation, eradication and conversion ratio) or 943 tons (based on the “new” seizure of cannabis, opium poppy and coca plants, the main source of the seizures being domestic drug production. conversion ratio) of pure cocaine hydrochloride in 2014, 137 World Drug Report 2009 (United Nations publication Sales No. also declined in the period 2007-2014, returning to its E.09.XI.12). 1998 level. Thus, despite a significant decline in coca bush 138 United Nations International Drug Control Programme, Research cultivation, cocaine production has not fallen in relation Section, “Cannabis as an illicit narcotic crop: a review of the global to its 1998 level, mainly because of increases in the situation of cannabis consumption, trafficking and production”, Bulletin on Narcotics, vol. XLIX, Nos. 1 and 2 (1997), and vol. L, efficiency of cocaine-processing laboratories in the Andean Nos. 1 and 2 (1998) (United Nations publication), pp. 45-83. subregion.

WORLD DRUG REPORT 2016 22

14,000 1,400 Fig14,000. 20 Global production of opium and cocaine,1,400 Fig. 21 Breakdown of drug seizure cases reported 12,000 1998-2015 1,200 worldwide, by type of drug, 2014 14,000 1,400 12,00010,000 1,2001,000 14,000 1,400 12,000 1,200 10,0008,000 1,000800 12,000 1,200 10,0008,000 8001,000 10,0006,000 1,000600 Opium (tons) 8,000 800 Cocaine (tons) 6,0004,000 600400

Opium (tons) 8,000 800 Cocaine (tons) 4,0006,000 400600

Opium (tons) 2,000 200 6,000 600 Cocaine (tons) Opium (tons) 2,0004,000 200400 4,0000 4000 Cocaine (tons) 2,000 200 2,0000 2000 1998 2000 2002 2004 2006 2008 2010 2012 2014 0 0

0 1998 2000 2002 2004 2006 2008 2010 2012 2014 0 Opium 1998 2000 2002 2004 2006 2008 2010 2012 2014 Opium1998 2000 2002 2004 2006 2008 2010 2012 2014 OpiumCocaineOpium (based on 'old conversion ratios) Opium CocaineCocaine (based(based onon 'old"old" conversion conversion ratios) ratios) CocaineCocaine (based(based onon 'old'preliminary"new" conversion conversion new ratios) conversion ratios) Cannabis herb, 39% Cocaine (based on 'old conversion ratios) Cocaineratios') (based on 'preliminary new conversion Cannabis resin, 11% Sources: UNODC coca and opium surveys in various countries; Other forms of cannabis, 4% Cocaineratios') (based on 'preliminary new conversion responses toCocaine the annual (based report on questionnaire; 'preliminary andnew United conversion States, ratios') Methamphetamine, 11% Department ratios')of State, International Narcotics Control Strategy Report, various years. Amphetamine, 3% Ecstasy, 2% Strong increase in trafficking in synthetic Other Amphetamine-type stimulants (ATS), 1% drugs at the global level Cocaine salts, 6% Cocaine base and paste, 5% Although there were 234 substances under international Other coca-related substances, 1% control in 2014 (244 in January 2016), seizure data indi- Heroin, 10% cate that the bulk of the trafficking involved a far smaller Other opioids, 2% number of substances. Cannabis in its various forms con- New psychoactive substances (NPS), 3% tinued to be the most widely trafficked drug in 2014 (as Sedatives and tranquillizers, 1% cannabis was seized in 95 per cent of the reporting coun- Others, 1% tries in 2014 and cannabis seizure cases accounted for over half of the 2.2 million drug seizure cases reported to Source: Responses to the annual report questionnaire. UNODC that year); it was followed by ATS (16 per cent), Note: Information presented in the figure is based on 2.2 million seizure opioids and coca-related substances (accounting for 12 cases reported to UNODC by 63 countries. per cent each). Global quantities of cannabis, cocaine, heroin and mor- seizures. Improvements in precursor control brought the phine seized almost doubled over the period 1998-2008 quantities of intercepted “ecstasy” down from the 2008 but have remained largely stable since then. In contrast, level to a low in 2011, but recent innovations in the manu- ATS seizures have risen more than seven-fold since 1998, facture of “ecstasy” (in particular, the use of pre-precursor suggesting that growth in drug trafficking has been more chemicals not under international control) can already be in synthetic stimulants than in the usual plant-based drugs. seen on the market, as suggested by a doubling of the Growth has been particularly strong in the case of meth- amounts seized between 2011 and 2014. amphetamine seizures and, to a lesser extent, amphetamine Increases in trafficking have been even greater in the group of NPS in recent years. Accounting for 3 per cent of all drug seizure cases in 2014, seizures of NPS are still com- Interpreting drug seizures paratively small (up from 1 per cent in 2009 and 0.1 per A direct indicator of drug law enforcement activity, drug sei- cent in 1998). In terms of the quantity seized, seizures of zures are the result of those successful operations that end in NPS (excluding plant-based NPS such as khat (Catha drug interceptions and are thus influenced by law enforcement edulis) and kratom (Mitragyna speciosa)) rose 15-fold capacity and priorities. At the same time, drug seizures are between 1998 and 2014. Ketamine and synthetic can- one of the key elements in understanding illicit drug market nabinoids have been seized the most; the total quantity of dynamics, drug availability and drug trafficking patterns and trends, particularly if broad geographical entities are considered ketamine seized worldwide increased from an annual aver- and long periods are analysed. age of 3 tons in the period 1998-2008 to 10 tons in the period 2009-2014. CHAPTER I 23 Extent of drug supply

Fig. 22 Quantities of drugs seized worldwide, by Fig. 24 Proportion of women brought into formal type of drug, 2014 contact with the criminal justice system for drug trafficking, by type of drug, 6000 1,200 2010-2014

5000 1,000 20%20% 4000 800

3000 600 15%15%

2000 400

1000 200 10%10% Cannabis seized (tons) Other drugs seized (tons) Other 0 0

Khat 5%5% Opium Heroin Kratom Coca leaf Ecstasy Ketamine Morphine Proportion of women (percentage) Proportion of women (percentage) Other NPS Other Cannabis oil Cannabis Hallucinogens Amphetamine Cannabis herb Cannabis Cannabis resin Cannabis

Coca pastebase 0%0% Synthetic opioids Synthetic Methamphetamine Synthetic cathinones Synthetic Cocaine hydrochloride Cocaine Synthetic cannabinoids Synthetic Sedatives/tranquillizers Other forms of cocaine* Other Opioids All drugs Cannabis Sedatives and tranquillizers Cannabis

Coca-related substances Hallucinogens tranquillizers Sedatives and and Sedatives Hallucinogens

Opioids Plant-based new psychoactive (ATS) stimulants Forms of cocaine Forms substances (NPS) substances substances (NPS) psychoactive New

Amphetamine-type Amphetamine-type stimulants ATS)( NPS (excluding plant-based NPS) * Including crack. Source: Responses to the annual report questionnaire.

Source: Responses 800 to the annual report questionnaire. 800 reported to have been arrested for drug-related offences Note: Based 800700 on information from 120 countries. 700 increased in absolute terms (as did the number of countries 700600 providing to UNODC a breakdown of arrests by gender), Fig. 23 600 Trends in the quantities of drugs seized 800600500worldwide, 1998-2014 whereas the proportion of women in drug-related cases, 500 while fluctuating, followed a downward trend, particularly 800 500400 for offences related to drug trafficking. 600400 700 400300 600 300 According to information from 100 countries, during the 300200 period 2010-2014, women accounted for around 10 per 500Index (base: 100 in 1998) 400200

Index (base: 100 in 1998) 100 cent of all cases in which people were brought into formal 400 200 Index (base: 100 in 1998) 100 contact with the criminal justice system for drug-related 300 100 - 200 - offences. The proportion was slightly lower for the pos- Index (1998=100) (1998=100) Index 200 Index (base: 100 in 1998) - session of drugs for personal use (9 per cent) and slightly 1998 2000 2002 2004 2006 2008 2010 2012 2014

Index 1998) Index 100 in (base: 100 - 1998 2000 2002 2004 2006 2008 2010 2012 2014 higher for drug trafficking (11 per cent); however, those 0 1998 2000 2002 2004 2006 2008 2010 2012 2014 proportions are substantially lower than the proportion of women who use drugs (about a third of the total number 1998 2000 2002 2004 2006 2008 2010 2012 2014 Cannabis1998 2000 herb2002 and2004 resin2006 2008 2010 2012 2014 Cannabis herb and resin of people who use drugs). Cannabis herb herb and and resin resin CocaineCannabis hydrochloride, herb and resin "crack"-cocaine and The proportion of women brought into formal contact CocaineCocaine hydrochloride,hydrochloride, "crack" "crack" cocaine cocaine and and cocaineCocaine basehydrochloride, and paste "crack"-cocaine and with the criminal justice system in drug trafficking cases cocaineCocainecocaine base basehydrochloride, and and paste paste "crack"-cocaine and cocaineHeroinCocaine and base hydrochloride, morphine and paste "crack" cocaine and is clearly above the global average (12 per cent) in Oceania HeroincocaineHeroincocaine andand base base morphine morphine and and paste paste Amphetamine-typeHeroinHeroin and and morphine morphine stimulants stimulants (ATS) (ATS) (19 per cent) and in the Americas (15 per cent) and below average in Africa (2 per cent). Data for Asia show a pro- Amphetamine-type stimulants (ATS) Source: ResponsesAmphetamine-typeAmphetamine-type to the annual report stimulantsstimulants questionnaire. (ATS) (ATS) portion above the global average in East and South-East Asia (13 per cent), while in other Asian subregions the Drug offences, cultivation and gender proportion is below the global average (less than 1 per cent in the Near and Middle East and in South Asia). Data for Men are more involved than women in drug-related crime Europe show a below-average proportion of women brought into formal contact with the criminal justice In all countries, more men than women are brought into system (10 per cent), with the proportion being above formal contact with the criminal justice system for pos- average in Eastern Europe (12 per cent) and below average session of drugs for personal use and for trafficking in in Western and Central Europe (9 per cent) and in South- drugs. In the period 1998-2014, the number of women Eastern Europe (6 per cent).

WORLD DRUG REPORT 2016 24

Women in opium poppy cultivation: attitudes, holds, but it was also a mainstay in rural areas, as poppy perceptions and practices seeds were used to extract oil for cooking and poppy straw was used for fuel in the kitchen, as well as for preparing While women play only a limited role in drug trafficking soap and making poppy tea. in countries in the Near and Middle East (less than 1 per cent), they are involved in the illicit cultivation of drug Drug purchases via the “dark net” crops, particularly opium poppy in Afghanistan. As part are gaining in importance of the annual opium survey conducted by UNODC and the Government of Afghanistan, in 2015 focus group dis- The purchasing of drugs via the Internet, particularly the cussions were held for the first time with women in four “dark net”, may have increased in recent years. This trend northern provinces in order to learn more about their atti- raises concerns in terms of the potential of the “dark net” tudes and participation in opium poppy cultivation and to attract new populations of users by facilitating access to drugs in a setting that, although illegal, allows users to production. avoid direct contact with criminals and law enforcement The discussions revealed that women in Afghanistan took authorities. As the “dark net” cannot be accessed through part in many of the labour-intensive processes in opium traditional web searches, buyers and sellers access it poppy production, such as weeding and clearing fields, as through the “Onion Router” (TOR) to ensure that their well as lancing and later (indoors) breaking opium poppy identities remain concealed. Products are typically paid capsules, removing and cleaning seeds, preparing opium for in bitcoins or in other crypto-currencies and are most gum for sale and processing by-products such as oil and often delivered via postal services. soap. Men were mainly involved in ploughing fields, cul- A number of successful law enforcement operations world- tivating and, at times, lancing capsules. wide have taken place in recent years to shut down trading In most rural communities in Afghanistan, women were platforms on the “dark net”, such as “Silk Road” in Octo- less empowered than men and had only a limited role in ber 2013 or “Silk Road 2.0” in November 2014, as part decision-making. Decisions about opium poppy cultiva- of Operation Onymous, coordinated by the European tion were thus primarily taken by men, although it Police Office (Europol), which also led to the closure of appeared that women were increasingly being consulted, other sites on the “dark net”, including 33 high-profile including about the decision to cultivate opium poppy. marketplaces. Law enforcement pressure also prompted some “voluntary” temporary shutdowns, such as “Agora” In the absence of access to adequate health-care facilities in August 2015. However, as one marketplace closes, the in rural areas, opium had been used for generations by next most credible marketplace tends to absorb the bulk women in northern Afghanistan as a remedy for the most of the displaced business.139 common ailments among children, such as coughs, colic, A global survey140 of more than 100,000 Internet users aches and pains, restlessness and diarrhoea. Self-medica- (three quarters of whom had taken illegal drugs) in 50 tion with opium continued to be a common practice for countries in late 2014 suggested that the proportion of the treatment of ailments among adults, such as aches and drug users purchasing drugs via the Internet had increased pains, sleeplessness and chest pains, which were probably from 1.2 per cent in 2000 to 4.9 per cent in 2009, 16.4 due to respiratory illnesses. Older women may have been per cent in 2013 and 25.3 per cent in 2014. The propor- more regular or dependent users of opium, but younger tion of Internet users making use of the “dark net” for women were becoming increasingly aware that regular drug purchases had also increased, reaching 6.4 per cent opium use could cause dependence and thus tended to (lifetime) in 2014, including 4.5 per cent (70 per cent of rely more on “modern medicines”, when available, for the 6.4 per cent) who had purchased drugs over the “dark net” treatment of common illnesses. in the previous 12 months (ranging from less than 1 per The discussions also revealed that women in Afghanistan cent to 18 per cent). were generally aware that opium could produce depen- Among “recent” drug users, the proportion rose by more dence and that its use for non-medicinal purposes was than 25 per cent from 2013 to 2014 (from 4.6 to 5.8 per forbidden by their religion. They were also concerned that cent). In the period 2012-2014, the proportion doubled the next generation could become dependent on opium, in Australia (from 4.3 to 10.4 per cent) and in the United although resolving their economic problems continued to Kingdom (from 8.0 to 15.1 per cent), and in the period be their main concern. In the absence of economic oppor- 2013-2014, the proportion also increased among “recent” tunities or alternatives, women considered that income users in the United States (from 7.7 per cent in 2013 to generated from opium poppy production could be used 9.6 per cent in 2014). to pay household expenses, enabling them to buy essentials such as food, as well as furniture, clothes and jewellery, 139 Based on the findings of an international conference on joint investigations to combat drug trafficking via the virtual market (“dark and it enabled families to repay their debts and to pay for net”) in the European Union, Bad Erlach, Austria, 10-12 November their children’s education and marriages. The production 2015. of opium poppy not only brought cash income to house 140 Global Drug Survey 2015 findings (www.globaldrugsurvey.com). CHAPTER I 25 Extent of drug supply

Fig. 25 25 Proportion of survey respondents who had purchased drugs on the “dark net”, by country and region, 2014 25 25 20 20 20 15 15 15 10 25 10 25 Proportion (percentage) 25 10 5 Proportion (percentage) 20 Proportion (percentage) 5 20 20 5 0

15 0 All 15 Italy Spain 15 Brazil 0 All France Ireland Austria Greece a a a a b b b b Canada Italy Belgium Poland* Hungary Portugal Scotland Spain Brazil Australia All All Norway* Sweden* Germany Europe** France Ireland Denmark* Austria Greece Oceania** Italy Italy Canada Belgium Poland* Switzerland Hungary Brazil Portugal Spain Spain Brazil Scotland Australia

10 Netherlands Norway* Sweden* Germany Europe** New Zealand France France Ireland Austria Greece Ireland United States Austria 10 Greece Denmark* Canada Canada Oceania** 10 Poland Belgium Europe Belgium Poland* Portugal Hungary Hungary Portugal Norway Switzerland Australia Scotland Sweden Australia Oceania Germany Norway* Sweden* Netherlands Germany Europe** New Zealand Proportion (percentage) Denmark United States Denmark* Oceania** South America** North America** Proportion (percentage) Switzerland Switzerland Proportion (percentage) Proportion (percentage) Netherlands Netherlands England and Wales New Zealand New New Zealand United States United United States South America** 5 North America** (Scotland only) (Scotland South America North America

5 England and Wales 5 Kingdom United Kingdom United South America** North America**

Yes, not withinEngland and Wales the last 12 months Yes, in the last 12 months 0 0 * based on less than 600 respondents ** Regional results: countryYes,results not weighted within the by population last 12 months Yes, in the last 12 months

0 only) (England and Wales

Yes, not within the last 12 months Yes, in the last 12All months

* based on less than 600 All respondents ** Regional results: country results weighted by population Italy All Source: Global Drug Survey 2015 (www.globaldrugsurvey.com). All Spain Brazil Italy Italy Italy France Spain Brazil

* based on less thanIreland 600 respondents ** Regional results: country results weighted by population Austria Greece Spain Spain Brazil Brazil Note: The figure shows the proportionCanada of people participating in the Global Drug Survey who bought drugs via the “dark net” between November France Belgium Poland* Ireland Hungary Portugal Austria Greece Scotland France France Canada Australia Ireland Ireland Norway* Austria Austria Greece Greece Sweden* a Germany b Canada Canada Belgium Poland* Europe** Hungary Portugal

and DecemberScotland 2014. Based on the replies of fewer than 600 respondents. Regional results show the national (and subnational) results weighted Belgium Belgium Poland* Poland* Australia Hungary Hungary Norway* Portugal Denmark* Portugal Sweden* Germany Scotland Oceania** Scotland Australia Australia Norway* Norway* Europe** Sweden* Sweden* Germany Germany Europe** Europe** Switzerland Denmark* by population. Oceania** Denmark* Netherlands Denmark* Oceania** Oceania** Switzerland New Zealand United States Switzerland Switzerland Netherlands Netherlands Netherlands New Zealand United States New Zealand New Zealand United States United States South America** Survey respondents reported a number of advantages to Fig. 26 Drugs purchasedNorth America** on the “dark net”, South America** North America** England and Wales South America** South America** North America** North America** England and Wales England and Wales England and Wales purchasing drugs on the “dark net”. Some of those advan- by type of drug, 2014 40 tages were related to the drug products themselves, which 40 Yes, not within the last 12 months Yes, in the last 12 months 40 Yes, not withinYes, the not lastwere within 12 reportedmonths the last to12 monthsbe generallyYes, in of the better lastYes, 12 quality inmonths the lastand 12 more months * based on less than 600 respondents ** Regional results: country results weighted by population * based on less thanreadily 600 respondents available. ** Other Regional advantages results: country includedresults weighted the fact by that population 30 * based on less than 600 respondents ** Regional results: country results weighted by population 30 the purchaser’s interactions were virtual, thus decreasing 30

the risk to personal safety during transactions, including nd ents (percentage)

nd ents (percentage) 20

through the absence of exposure to physical violence; in nd ents (percentage) 20 20 addition, there was a perceived decrease in the risk of being apprehended by law enforcement authorities.141 This may 10 on on respoof 10 ti on on respoof 10

help explain why, in general, drug users seem ready to pay ti on on respoof

142 ti a premium for drugs purchased via the “dark net” and 0 why people who have never previously used drugs may be Propor 0 Propor 0 Propor

tempted to purchase them online: the survey showed that LSD 2C-E 2C-B around 4 per cent of “dark net” drug users had not used DMT Cocaine Ketamine

any drugs prior to accessing them through the “dark Cannabis* 25I-NBOMe 25C-NBOMe net”.143 At the same time, 30 per cent of people who pur- Mephedrone Amphetamine Cannabis herb MDMA tablets Cannabis resin MDMA powder Methoxetamine chased drugs via the “dark net” reported having consumed Benzodiazepines Magic mushrooms Amphetamine base Amphetamine a wider range of drugs than they did before they began "Ecstasy"-type substances purchasing drugs via the “dark net”. "Ecstasy"-type substances with cannabis Tobacco Hallucinogens"Ecstasy"-typeHallucinogens substances CaHallucinogensCannnnabis CocaineCaCocainennabis NewCocaineNew psychoactive substances asas ofof 20142014 SubstancesNewSubstances psychoac placedtive sunderubstances control as of inin 201420162016 AmphetaminesSubstancesAmphetamines placed under control in 2016 SedaAmphetaminesSedatives Sedatives 141 Ibid. * Hydroponically grown cannabis. 142 International conference on joint investigations to combat drug Source: Global Drug Survey 2015 (www.globaldrugsurvey.com). trafficking via the virtual market (“dark net”) in the European Note: Proportion of survey respondents who bought each drug on the Union, Bad Erlach, Austria, 10-12 November 2015. “dark net” among participants in the Global Drug Survey between 143 Global Drug Survey 2015 (see footnote 140). November and December 2014.

WORLD DRUG REPORT 2016