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E 2008 Legalnotice

This publicationofthe European MonitoringCentrefor Drugsand Drug Addiction(EMCDDA)isprotected by copyright.The EMCDDA acceptsnoresponsibility or liability forany consequences arisingfromthe useofthe data contained in this document. The contentofthis publicationdoesnot necessarilyreflect theofficial opinions of theEMCDDA’spartners, theEUMemberStatesorany institution or agencyofthe European UnionorEuropeanCommunities. Agreat deal of additionalinformation on theEuropeanUnion is availableonthe Internet. It canbe accessedthrough theEuropaserver(http://europa.eu).

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This report is availableinBulgarian,Spanish, Czech, Danish, German, Estonian,Greek,English,French, Italian, Latvian, Lithuanian,Hungarian, Dutch, Polish,Portuguese,Romanian,Slovak, Slovenian,Finnish, Swedish, Turkishand Norwegian. Alltranslations were made by theTranslationCentrefor theBodiesofthe European Union. Cataloguingdata canbefound at theend of this publication. Luxembourg:Office forOfficial Publications of theEuropeanCommunities,2008 ISBN 978-92-9168-324-6 ©EuropeanMonitoringCentrefor Drugsand Drug Addiction, 2008 Reproductionisauthorisedprovidedthe sourceisacknowledged. PrintedinLuxembourg

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RuadaCruzdeSanta Apolónia,23–25,1149-045Lisbon, Portugal Tel. (351)218 11 30 00 • Fax(351) 218131711 [email protected] • http://www.emcdda.europa.eu Contents

Foreword 5

Acknowledgements 7

Introductorynote 9

Commentary:The drug situationinEurope— newperspectivesand some old realities 11

Chapter1:Policies andlaws

Internationaland EU policy developments •Nationalstrategies• Public expenditure•Nationallegislation•Crime •Nationalresearch 18

Chapter2:Respondingtodrug problemsinEurope—anoverview

Prevention •Treatment•Harmreduction•Socialreintegration • Health andsocialresponses in prison 28

Chapter3:Cannabis

Supplyand availability •Prevalenceand patterns of use•Treatment 36

Chapter4:Amphetamines,ecstasy andLSD

Supplyand availability •Prevalenceand patterns of use•Recreationalsettings• Treatmentprovision 47

Chapter5:Cocaine andcrack cocaine

Supplyand availability •Prevalenceand patterns of use• Treatmentand harm reduction 58

Chapter6:Opioid useand drug injection

Heroin supplyand availability •Prevalenceand patterns of use• Injectingdrug use•Treatment of problem opioid use 68

Chapter7:Drug-relatedinfectiousdiseasesand drug-relateddeaths

Infectiousdiseases •Preventinginfectiousdiseases •Deathsand mortality• Reducing deaths 78

Chapter8:Newdrugsand emergingtrends

EU actiononnew psychoactivesubstances •Internetshops •GHB andGBL 90

References 95

3

Foreword

We areproud to present this,the thirteenth,annual report developmentand politicalstability of producer and of theEuropeanMonitoringCentrefor Drugsand Drug transitcountries? Onehas only to considerthe worrying Addiction. This report is only possible throughthe hard developments resultingfromthe transiting of cocaine work anddedicationofour partners in theReitoxnetwork throughWestAfricatoberemindedofthe collateral of nationalfocal points andthe expertsthroughout damage that this problem cancause. Europe whohavecontributed to theanalysis. We also On apositivenote, drug useinEuropeappears to be areindebted to thoseEUagenciesand international stabilising,and progress canbenoted in theway in which organisations workinginthe drugsfield.Our report is a EU Member States areaddressingthis issue. Formost collective endeavourand we thank all thosewho have formsofdrug use, ouroverall assessmentisthatweare contributed to it.The rationale behind this work is that a not seeing increases,and in someareas thetrendsappear cool-headedanalysisofwhatweknowabout thedrug to be downward.Interms of responses,wehaveseen situationisaconditionfor an informed, productiveand virtuallyall Member States adoptastrategic approach, reasoneddebate. It ensuresthatopinionsare enlightened andgreater cohesion is visible at theEuropeanlevel. by facts, andthatthose making difficultpolicychoices can Treatmentavailability continues to grow,and in some have aclear understandingofthe costsand benefitsofthe countriesithas reachedthe pointwhere themajorityof optionsavailable. heroin users, onceconsideredahiddenpopulation, are This year hasbeenanexceptionallybusytimefor drug nowincontactwithservices of one sort or another. Not many yearsago,HIV infection amongdrug injectors was policy,and theEMCDDAhas been honoured to have acentral concern in thedrug policy debate.Since then, supported both thefinalevaluationofthe currentEU apragmatic mixtureofprevention, treatmentand harm- actionplanondrugsand thereviewofthe 1998 United reductionmeasureshas become thenorminEurope, and NationsGeneralAssemblySpecialSessiononthe drug ratesofnew infection attributed to drug usehavefallen problem.Itisgratifyingtonotethat, by international andcontinuetodoso. standards, Europe stands outasone of theparts of the worldwhere monitoringcapacitiesare most developed. Good news makespoorheadlines andcan be overlooked. Nonetheless,weare awareofthe limitationsofour current However, it is importanttorecogniseprogress where information resources,and areconstantlyworkingwithour it hasbeenmade. Increasingly, in Europe,wehave partners to improvethe qualityand relevanceofthe data an understandingofwhatmeasurescan be effective available. in addressingdrug problems. An acceptance that our activities can, anddo, make adifferenceisaprerequisite An underlying theme of thepolicydebateondrugsis to securing investmentand policy support. This is not to say thecosts, both hidden andmorevisible,ofEurope’sdrug that ourreportdoesnot highlightmanyareas of concern problem.This issueisaddressedinvarious partsofthis forthe European Union. Examplesinclude thecontinuing report.The EMCDDA hasbeenworkingtodevelopan increases in cocaineuse andthe considerabledifferences understandingofthe public expenditures associated with that still existbetween countriesinthe availability and tacklingdrug useinEUMemberStates. This work is in qualityofservices forthose with problems. We must itsinfancy,and estimatesderived areindicativerather thereforeconcludethat, even if progress hasbeenmade, than precise. Nonetheless,theypoint to considerable thejourneyremainsfar from finished. However, today sums beingspent,withpreliminary figuresofbetween in Europe,morethanatany time in thepast,wehavea EUR28billion andEUR 40 billion. Less easy to express stronger agreementonthe direction we should take. in economic termsisthe harm caused by drug use. MarcelReimen What costsdowecount in lookingatthe tragic loss Chairman, EMCDDA ManagementBoard of lifecausedbydrugsinEurope, thenegativeimpact on communities wheredrugsare producedorsold,or WolfgangGötz in theway that drug trafficking undermines thesocial Director, EMCDDA

5

Acknowledgements

The EMCDDA wouldliketothank thefollowing fortheir help in producingthis report:

• theheads of theReitoxnationalfocal points andtheir staff;

• theservices within each Member Statethatcollectedthe rawdatafor this report;

• themembers of theManagementBoard andthe Scientific Committeeofthe EMCDDA;

• theEuropeanParliament, theCouncil of theEuropeanUnion —inparticularits Horizontal WorkingParty on Drugs— andthe European Commission;

• theEuropeanCentrefor DiseasePreventionand Control(ECDC), theEuropeanMedicinesAgency (EMEA)and Europol;

• thePompidou Groupofthe CouncilofEurope, theUnited NationsOffice on Drugsand Crime, theWHO Regional Officefor Europe,Interpol,the WorldCustoms Organisation, theESPAD project andthe SwedishCouncil forInformation on Alcoholand otherDrugs(CAN),and theEuropeanCentrefor theEpidemiologicalMonitoringofAIDS(EuroHIV);

• theTranslationCentrefor theBodiesofthe European Unionand theOffice forOfficial Publications of theEuropean Communities.

Reitox nationalfocal points

Reitox is theEuropeaninformation network on drugsand drug addiction.The network is comprised of nationalfocal points in theEUMemberStates, Norway,the candidatecountriesand at theEuropeanCommission.Under theresponsibility of their governments, thefocal points arethe nationalauthorities providing drug information to theEMCDDA.

The contactdetailsofthe nationalfocal points maybefound at:

http://www.emcdda.europa.eu/about/partners/reitox-network

7

Introductory note

This annual report is basedoninformation provided to theEMCDDAbythe EU Member States andcandidatecountries andNorway(participating in thework of theEMCDDAsince 2001)inthe form of anationalreport. The statisticaldata reported here relatetothe year 2006 (orthe last year available).Graphicsand tables in this report mayreflectasubset of EU countries: theselection is made on thebasis of thosecountriesfromwhich dataare availablefor theperiodof interest.

Retail prices of drugsreported to theEMCDDAreflectthe pricetothe user.Reports on purity or potency, from most countries, arebased on asample of alldrugsseized, anditisgenerally not possible to relatethe reported datatoa specific levelofthe drug market.For purity or potencyand retail prices,all analyses arebased on typical(modal) values or,intheir absence, mean (ormedian) values.

Reportsofthe prevalenceofdrug usebased on general populationsurveysmostly refertothe nationalpopulationaged 15– 64 years. Countriesusing different upperorlower agelimitsinclude:Bulgaria (18–60), theCzech Republic (18), Denmark(16), Germany (18),Hungary(18–59), Malta(18), Sweden (16) andthe United Kingdom (16–59).

In reportsontreatmentdemand,‘newclients’referstothose whohaveentered treatmentfor thefirsttimeintheir livesand ‘all clients’ refers to allthose entering treatment. Clientsincontinuoustreatmentatthe startofthe year in question are notincludedinthe data. Wherethe proportion of treatmentdemandsfor aprimary drug is given, thedenominatoristhe number of casesfor whichthe primarydrug is known.

Analysis of trends is basedonlyonthose countriesproviding sufficient datatodescribechangesoverthe time period in question.Figures for2005may substitutefor missing 2006 values in trendanalysisofdrug market data; forthe analysis of othertrends, missing data maybeinterpolated.Trendsinpriceare adjusted forinflationatnationallevel.

The term ‘reports’for drug law offences maydescribedifferent conceptsindifferent countries.

Furtherinformation on thedataand analytical methodsisavailable in the2008statisticalbulletin.

The annual report is availablefor downloadingin23languages (http://www.emcdda.europa.eu/publications/annual- report/2008).

The 2008 statisticalbulletin(http://www.emcdda.europa.eu/stats08) presentsthe full set of sourcetablesonwhich the statisticalanalysisinthe annual report is based. It also provides furtherdetail on themethodology used andabout 100 additionalstatisticalgraphs.

Countryoverviews (http://www.emcdda.europa.eu/publications/country-overviews)provide asummaryofkey aspectsof thedrug situationfor each country.

The nationalreports of theReitoxfocal points give adetailed description andanalysisofthe drugsproblem in each countryand areavailable on theEMCDDAwebsite (http://www.emcdda.europa.eu/publications/national-reports).

9

Commentary Thedrug situationinEurope—new perspectives andsomeold realities

Astrong voicefromEuropeinanimportant year for theuser is oftendifficult, andMemberStatesvarygreatly reflectionand policyformation in howtheyhavedrawn thelinebetween these two categories. In Europe,2008has seen theevaluationofthe 2005–08 drug actionplan, togetherwithwork to prepareanew The idea that European countriesare nowmakingless plantotakeforward theEUdrug strategy duringits useofcriminalsanctions fordrug useisnot borne outby second period (2009–12). At thesametime, 13 Member theavailable data. During thepast fiveyears,the number States areredraftingorreviewing theirnationaldrug of reported drug law offences hasincreased in Europe. strategies or actionplans.Internationally, this year Most of thereported drug law offences arerelated to use also marksthe 10-yearreviewpoint of thedeclarations andpossessionfor useratherthansupply, andwhereas andactionplans adopted at the20thUNGeneral offences related to supplyhaveincreased by 12 %, those AssemblySpecialSession(Ungass). This makes2008an related to possessionhaveincreased by over50%. unprecedented year forEuropeanand global reflections Cannabis continues to be thedrug most oftenassociated on howdrug policieshaveperformedtodate, andwhat with drug law offences. directionsshouldbepursued in thefuture. The reasonsfor theincreaseinthe number of drug law Agrowing European consensus canbeseeninthe way offences related to drug useare unclear,and couldeven Member States have adopted nationaldrug strategies and be related to thepossibility that,insomecountries, it may in theircontributiontothe global debate on drugs. All have become administrativelysimpler to issueaconviction butone of theEUMemberStatesnow have nationaldrug forpossession. However, theviewheld by somethat, for policy documents, andaroundhalfofthem nowstructure drug usersand particularly cannabis users, thelikelihood theirnationalpolicydocuments alonglines similartothose of beingcharged with drug offences hasdecreased in foundinthe EU actionplan—anindicationofagrowing recent yearsisnot supported by thedata. Furthermore, policy convergenceinEuropeonhow thedrug problem theextenttowhich sanctionsappliedfor drug possession should be addressed. EU Member States,supported by the have changedisnot clear,and theEMCDDAwillexplore Commission,haveput forwardanincreasinglyunited EU this question in aselected issuenextyear. position in theongoing discussionsthathaveaccompanied theUngassreview. In theEuropeancontributions to the Newsurvey exploresyoung people’s attitudestodrug use debates, emphasis hasbeenplaced on theneed for ArecentEurobarometersurvey exploredyoung comprehensive,balancedand evidence-basedpoliciesand people’sattitudesand perceptionsondrugsand found actions,and on thevalueofimprovedmonitoringofthe considerableconsensus amongcountries. Overall, global drug problem in thepost-Ungassperiod. therisks associated with usingdrugssuchasheroin, cocaineand ecstasywererated as high by between Drug useand theapplicationofcriminal sanctions:a 81 %and 96 %ofthose surveyed. The vast majority of mixedpicture respondents (95%)feltthatthese drugsshouldcontinue In recent years, theEMCDDAhas reported atendency to be controlledinEurope. Viewsoncannabis, however, amongEuropeancountriestomakeastronger distinction were more divided, with 40 %feeling that thedrug in theirdrug lawsbetween thosewho aretraffickingor posedahigh risk,while aboutthe same number (43%) selling drugsand thoseusing them.This distinction has consideredthatcannabisuse represented a‘medium been reflected in areductionofpenalties fordrug use health risk’, broadlysimilar to therisks associated in some countries, though others have rejected moves with smokingtobacco. The perceptionsofhealthrisks to reduce penaltiesorhaveevenincreased them.In associated with cannabis usewerereflected in thelower practice, making adistinction betweenthe supplierand levelofsupport forcontinuingthe banoncannabis

11 Annual report 2008:the stateofthe drugsproblem in Europe

(67%)and theviewheld by asubstantialminority(31 %) up employmentisone of thekey elements of achieving that cannabis should be regulated in asimilar wayto reintegrationintosociety,and it hasbeenshown to be of alcoholand tobaccoproducts. high prognosticvalue. However, re-entry into thelabour market is oftendifficulttoachieve giventhe poor skills and Drug useprevention: evidence base growsbut practiceis loweducationalstatusthatcharacterise many of those slow to change foundamonganoverall ageing populationofchronic drug usersinlong-term treatmentinEurope. Arriving Despitethe almost universalsupport fordrug use at aconsensus on what constitutessuccessfuloutcomes prevention,formalevaluations in this area are forthose with long-termdrug problemsand as to what methodologicallychallengingand,historically,the extent members of this populationcan be successfully evidenceavailable fordemonstrating theeffectiveness of reintegrated back into society arebecomingincreasingly interventionsinthis area hasbeenlimited.This situation importantquestionsfor European drug treatmentservices. is changingasthe scientific basisfor drug prevention continues to grow andmorerigorousstudies arecarried Although Europe continues to seeanexpansion of drug out. Although inferencemuststill oftenbedrawn from the treatmentprovision,considerablevariation still exists resultsofUSstudies,whose relevancetothe European betweencountriesinthe availability of care or the context maybequestionable, thereisnow agrowing extent to whichservices address different typesofdrug bodyofEuropeanwork.Together, theinformation now problems.Moreover, widespread recognitionofthe value availableallowsfor agreater understandingofwhat of providingdrug treatmentoptions to usersinprison typesofactivities arelikelytoprove effective andhow to hasyet to be matchedbyinvestments in services in this target thosemost at risk.Nevertheless,new datasuggests area,which in most countriesremain poorly developed. that in many countries, thepredominant approaches An importantchallengefor drug treatmentservices in areoften still thosethatlackastrongevidencebase Europe is theneed to develop models of care tailored to and, in somecases,include activities that mayevenbe theneedsofamoreheterogeneous populationofdrug counterproductive. The challenge forpolicymakersmay be users. Against thegeneral background whereevidence that thoseprogrammesthatare knowntodeliver benefits does not pointtoasinglebestapproach,someEuropean oftenrequire both agreater investmentofresources and countriesare developinginteresting newmethods to more attentiontotrainingand qualitycontrol. treatcannabisorcocaine users. The complex problems caused by different patterns of polydrug use, including To supportknowledge transfer andbestpracticeinthe alcohol, constitute achallengefor service development. drugsfield,in2008the EMCDDA launched an internet It is thereforelikelythatEuropeandrug treatmentservices portal on best practice. The portal,which includes a will have to develop an increasingly differentiated set of prevention module, provides an overview of thelatest responses in thefutureiftheyare to matchthe increasingly evidenceonprogramme efficacyand effectiveness as well differentiated needsoftheir clients. as toolsand standardsaimed at improvingthe quality of interventions. Examplesofevaluated practices across Stronger signalsthatthe popularity of cannabis Europe arealsoprovided. usemay be declining

Drug treatment: moreemphasisonoutcomes Recent datafromschooland adultpopulationsurveys andclientneeds suggest that overallcannabisuse hasstabilisedoris declininginsomecountries. Differentnationaltrends The number of drug usersreceivingtreatmentfor their arestill apparent andmarkeddifferences existbetween dependencyhas grownconsiderablyinrecentyears,and countries. This is reflected in themedium-term trends,which many countriesnow have asignificantproportionoftheir have seen increases reported oftenbylower prevalence problem opioid usersinlong-term substitutiontreatment. countries, astablesituationfor many others anddeclines This trendhas ledtoawideningofthe available noted amongsomehigher prevalencecountries. pharmaceutical optionsand hasresulted in an increased focusontreatmentquality andoutcome,asopposed Declines in prevalenceare most apparent amongyounger to treatmentuptake, as aprimary policy concern.In agegroups. Newschoolsurvey datafromthe latestHBSC particular,the debate hasmoved on to discussionsabout (Healthbehaviour in school-agedchildren) studyreveala what constitutesrealisticlong-term goalsfor substitution stable or decreasing trendindrug useamong 15-year-old treatmentand to what extent clientsmay be socially students in most countriesduringthe 2001–2006 period reintegrated andreturntoanormallifestyle.Taking andpreliminary reportssuggestthatthis picturemay be

12 Commentary:the drug situationinEurope

nowvisible,and is most evidentinthe 16 –24 agegroup. At aglance—estimates of drug useinEurope The reasonswhy cannabis usemightbebecomingless popularamong youngpeopleare not well-documented, The estimatespresented here relatetothe adultpopulation (15–64 yearsold)and arebased on themost recent data though they mayberelated to possible changesinthe available.For thecompleteset of data andinformation on perceptionsofthe risksassociated with theuse of this themethodology seethe accompanyingstatisticalbulletin. drug.Some commentatorshavesuggested that declines Cannabis in thepopularity of cannabis usemay be associated Lifetime prevalence: at least 71 million with changingattitudes to cigarette smoking. Cannabis (22 %ofEuropeanadults) in Europe is oftensmokedincombination with tobacco, Last year use: about23million European adults or anddrug prevention programmes increasingly address one-third of lifetimeusers togetherthe health implications of usingbothillegal and Last month use: over 12 millionEuropeans legalsubstances. Country variationinlast year use: Despiterecenttrends, levels of cannabis useinEurope overallrange 0.8% to 11.2 % remain high by historical standards, andconsiderable Cocaine numbersofregular andintensive users, mostly young Lifetime prevalence: at least 12 million males, existinmanycountries. Trends in thenumbers (3.6 %ofEuropeanadults) of regularand intensiveusersofcannabismay move Last year use: 4million European adults or one-third of independentlyofthe prevalenceofuse of thedrug among lifetimeusers thegeneralpopulation, andmorefocus on these patterns Last month use: around 2million of useand associated problemsisrequired. Country variationinlast year use: overallrange 0.1% to 3.0% Domestic cannabis production: thebig unknown Ecstasy Lifetime prevalence: about9.5 million Cannabis resinhas historically been thedominantproduct (2.8 %ofEuropeanadults) in many EU Member States,and westernEuroperemains Last year use: over 2.6million or one-third of lifetimeusers overallthe majorglobal consumerofthis form of thedrug. Last month use: more than 1million However, andtoalarge extent undetected,domestic Country variationinlast year use: productionofherbal cannabis hasbeenincreasingin overallrange 0.2% to 3.5% Europe.Most countriesnow report localproduction, whichcan range from afew plantsgrown forpersonal Amphetamines consumption to large-scaleplantations grownfor Lifetime prevalence: almost 11 million (3.3 %ofEuropeanadults) commercialpurposes. Last year use: around 2million or one-fifthoflifetimeusers The extent andrelativemarketshare of domestically Last month use: less than 1million producedherbal cannabis remainsunknown,and in Country variationinlast year use: response to this theEMCDDAiscarryingout astudy on overallrange 0.0% to 1.3% mappingthe cannabis market in Europe.There is also a Opioids growingdebateabout theimplications of theevolving Problem opioid use: betweenone andsix casesper 1000 cannabis market.Concerns beingvoicedinclude the adultpopulation negative impact of cannabis productionsites on local In 2005–06,drug-induceddeathsaccounted for3.5 % communities throughincreased levels of criminality, and of alldeathsofEuropeans 15–39 yearsold,withopioids that domesticallyproducedcannabisistypically of high beingfound in around 70 %ofthem potency. Localproductionalsoposes achallengefor law Principaldrug in around 50 %ofall drug treatmentrequests enforcementbodies, as productionsites arelocated close More than 600000 opioid usersreceived substitution to theconsumer, relativelyeasy to conceal anddonot treatmentin2006 necessitate thetransportationofdrugsacrossnational borders. confirmedbythe latestround of ESPAD(European school project on alcoholand otherdrugs),which is duetobe Cocaineuse stillgrowing in asegmented publishedatthe end of 2008.Inthe United Kingdom, European market forstimulant drugs acountry that used to standout in termsofits high Stimulant drugsplayanimportant role not only in patterns prevalenceofcannabisuse,asteady downward trendis of drug usefound amongthe chronicand marginalised

13 Annual report 2008:the stateofthe drugsproblem in Europe

populationofproblem drug usersinEurope, butalso wastes resultingfromsynthetic drug productioncan be amongthe better socially integrated groups of young considerable. peoplewho usedrugsonamorerecreationalbasis. However, patterns of stimulant usedifferacrossEurope: Cocainetrafficking throughwestAfrica: cocaineisnow themost commonly used stimulant in an area of concernand action many countriesinthe southand west of Europe,and As cocaineuse continues to rise in Europe,increased itsuse continues to grow.Incontrast,the indicatorsfor effortsare beingfocused on cocaineinterdiction. Both amphetamine andecstasy usesuggestanoverall stable or thevolumeand number of cocaineseizurescontinue decliningpicture.Nonetheless,amphetaminesremain the to increase,withannual seizures nowinexcessof120 most used stimulantsinmost countriesincentral,northern tonnes,ofwhich more than threequartersare accounted andeasternEurope, whereinsomecases they represent forbySpain andPortugal. Effortstocounter the an importantpartofthe drug problem.Methamphetamine trafficking in cocaineintoEuropehavebeenbolstered useremainsrareoutside theCzech Republic andSlovakia, by theestablishment, in Lisbon,ofthe Maritime Analysis although theavailability or useofthe drug is sporadically andOperationsCentre–Narcotics(MAOC-N), which reported by othercountries. is playing an importantroleinthe coordination of interdiction activities andthe sharingofintelligence As similarities existinboththe settingsinwhich different amongparticipating Member States. stimulant drugsare used andinthe rationalesoffered fortheir use, to someextentthese substances canbe Although cocaineentersEuropebyanumber of routes, regardedascompeting productsonthe European drug trafficking throughwestAfrican countrieshas dramatically market.This wouldimply that,aswellastargeting increasedand nowrepresentsamajor routefor cocaine individual substances,interventions need to consider destinedtothe European market.This situationhas the stimulant drugsasagroup rather than only as individual potentialtodestabilise andundermine developmentefforts problems. This pointisimportant,asmeasurestoimpact in aregionalready facing many social,healthand political on theavailability of one of these substances maybe challenges. In particular,the income generated by cocaine undermined if they simply result in consumers switchingto trafficking hasconsiderablepotential to underminecriminal alternative products. justice systemsand encourage corruption. The European Unionand itsMemberStatesare workingtogetherwith west African countriestodeveloparange of measures to Developments in syntheticdrug productioninEurope address this growingthreat. increases concerns aboutenvironmentalcosts

European countriesremain majorproducersof Heroin problemsnot diminishing alongside reportsof amphetamines andMDMA, although therelative increased useofsynthetic opioids importance of Europe mayhavedeclinedasproduction The most recent estimatesshowthat, at an estimated hasincreased elsewhere. Typically, between70and 733tonnes, potentialglobal heroin productionhas 90 productionunits aredetected eachyear, mainly continued to increase.However,the impact of this concentrated in afew countriesinwestern andeastern increase on theavailability anduse of this drug in Europe.Law enforcementdatasuggestthatthe production Europe is difficulttogauge.The availabledatamake of syntheticdrugs, includingmethamphetamine,may drawingconclusions in this area difficult. Forexample, be becomingmoresophisticated,withproductionruns thequantityofheroinseizedinthe European Unionhas increasing in scalethrough theuse of larger reaction declined slightly, butthis hasbeencounterbalancedby vessels, industrial andcustom-madeequipmentand mobile considerableincreases in Turkey. units. No strong evidenceexiststosuggest an epidemic growth The increase in thesizeoftypical productionruns in heroin problemssimilar to theone many partsofEurope maybeexacerbatingthe problem of wastedumping. experienced in 1990s; overall, thedatapoint to astable Typically, theproductionofone kilogram of amphetamine butnolonger adiminishingproblem.Assuch, heroin use or MDMA resultsinaround15–20 kilogramsofwaste in Europe remainsaserious public health issueand still material,including toxicand inflammable chemicals accountsfor alarge proportion of theoverall health and whichconstitute an environmentalhazard. The costsin social costsassociated with drug use. Data suggest that termsofenvironmentaldamageand clearingupofsites opioid use, mostly heroin,accountsfor around 60%ofthose that have been used forthe illegaldisposalofchemical in drug treatmentinEurope. Amongthose newtotreatment,

14 Commentary:the drug situationinEurope

therelativeproportionofopioid users—but nottheir actual observed, these have been small. However, thereremain numbers—had been falling, butthis trendnow appears importantdifferences betweencountries. Although data to have levelled out. And, although thereisevidencethat pointtoanimproving situationinEstonia,Latviaand Europe’s opioid-using populationisslowlyageing, thedata Portugal,these countriesstill report disproportionately suggest that newrecruitmentisstill occurringataratethat high ratesofnew infection andaccount forasignificant will ensure that theextentofthe problem will not significantly proportion of allnew HIVcases in Europe attributed to declineinthe foreseeablefuture. drug use. Data from regionalorlocal studiesalsosuggest that transmission of HIVinfection remainsanissue in Perhaps counter-intuitively, giventhe situationin Spainand Italy, although theabsenceofnationalcase Afghanistan, problemswithbothdiverted andillicitly reportingdatamakes trackingtrendsinthese countries producedsynthetic opioidsappeartobeincreasingly difficult. Elsewhere, risk behaviourcontinues andthe common in somecountries. In Latvia,Lithuania and potentialfor newepidemicsremains, strongly suggesting Estonia, forexample,there areindications of agrowing theneed to remain vigilant: forexample,Bulgaria problem caused by theavailability of 3-methylfentanyl reported 34 newcases in 2006,but wasreporting that is illicitlymanufactured outsidethe EU.Due to its virtuallynoinfectionsinthe years2000–03. strength (fentanylisconsiderablymorepotentthanheroin), usingthis drug canbeextremely dangerous, as reflected Drug-relateddeaths: amajorburdenonpublic health in over 70 fentanyl-related fatalpoisonings reported in Estoniain2006. Othercountriesnoteagrowing number The EMCDDA monitorsfatal poisonings directlyattributable of individualsseeking help with problemsrelated to the to drug use(drug-induceddeaths).There are, on average, useofopioidsthatappeartohavebeendiverted from around 7000–8000 drug-induceddeathsreported in therapeuticpurposes,and this contributes to thegrowing Europe each year,and duetoknown underreporting this polydrug useproblem that nowcharacterises chronicdrug figure representsaminimum estimate.Opioids, principally useinparts of Europe. heroin,are thedrugsmost oftenassociated with overdose, although otherdrugsand alcoholare commonly present. Drug injectingand HIV: overall picture positivebut Afterfalling forsomeyears in theearly part of this decade, important nationaldifferences thetrend in drug-induceddeathshas nowlevelledout.The reasonsfor this areunclear,indicatinganeed formore Over 40 %ofall heroin usersenteringoutpatienttreatment research on both thefactorsassociated with overdose and report injecting, underliningthatthis particularly harmful on theeffectiveness of prevention measures.Drug users routeofadministrationremainsanimportant health issue leavingprison maybeatparticularrisk, with arecentstudy in Europe.Injecting is associated with arange of problems reportingmortality rateseighttoten timeshigher than including, butnot limited to,the spread of blood-borne expected.Overall,overdosepreventionremainsanarea infectionsincluding HIVand hepatitisC.Changesinthe requiringincreased investment. proportion of injectors amongthose entering treatment suggest that,inmanycountries, theoverall trendhas been Studieshavealsoshown that overallmortality,when away from injecting, although distinctregionaland national diseases,accidents andviolenceare also takeninto differences canbeseeninthe data. In some countries, consideration,among drug usersisuptofiftytimes higher particularly in easternEurope, drug injectionremainsthe than that foundamongthe general population. Therefore, principalroute of heroin administrationand is reported by investmentinwell-designed cohort studiesisneeded to over80% of heroin usersenteringtreatment. Relativelyhigh provideabetterunderstanding of thecauses andextentof levels of initiation also appear to be still occurringinsome overalldrug-related mortalityand to examinedifferential Member States,asindicated by studiesamong injecting riskssuchasthose experienced by prisoners on release drug usersthatshowarelativelyhigh proportion of young andtreatmentdrop-outs. andnew injectors. Internet andmarketinnovation pose challenges Overall, therateofnewly acquired HIVinfectionsin to drug policy Europe hasbeenfalling sincealocalised epidemic in somecountriescausedapeakatthe beginning of ArecentEMCDDAsurvey hasshown that more than this decade.Declinesininjecting togetherwiththe 200natural,semi-syntheticand syntheticpsychoactive increasing availability of treatmentand harm-reduction productsare soldbyonlineshops in Europe.Many services appear to have resulted in agenerally improving of thesubstances arecategorised as ‘legal highs’ or situation; andwhere someincreases in newinfection are ‘herbal highs’ andadvertisedasalternatives to controlled

15 Annual report 2008:the stateofthe drugsproblem in Europe

substances,althoughtheir actuallegal status mayvary frontlineexperiences arefed into theprocessleading to considerablyacrossEurope. Reportssuggestthatthe thenew EU drug strategy andinformthe evaluationofthe number of online retailersofthese productsisgrowing EU actionplanondrugs. The importance of consultingwith andthattheyadapt rapidly to attempts to control the representatives of non-governmental organisations and market,for example throughthe launch of newproducts. localcommunities hasalsobeenrecognised in theEUdrug In addition, online pharmaciesand online retailers strategy andechoedinareportadopted by theEuropean selling psychoactivesubstances forostensibly legitimate ParliamentinMarch 2008 acknowledgingthe fundamental purposes also potentiallyprovide newavenues forillicit role of civilsociety in thedevelopment, implementation, drug supply. Takentogether, Internetsales nowrepresent evaluationand monitoringofdrug policies. aconsiderablechallengetobothinternationaland nationaldrug policiesand controlmechanisms.Given European drug research andthe need thespeed at whichnew productscan appear andbe fortransnationalcooperation distributed,the monitoringofonlineactivities is becoming Over thelast decade,drug-related research andthe an importantareafor development. infrastructure that supports it (research centres, scientific journals,funding mechanisms)has developed greatly Growingrecognitionofthe importance in Europe,asshown in aselected issueonresearch of dialogue with civilsociety publishedbythe EMCDDA in 2008.Less positively,this Drug problemsare intertwinedwitharange of othersocial progress hasnot been accompanied by acomparable andhealthissues.Consequently, successfulinterventions increase in thecooperation andcoordinationofdrug- in this area requirethe involvementofabroad alliance related research effortsamong EU Member States. of participantsand canbenefit from thesupport of Increasingattention is beingpaidtothis issue, andthe thecommunities in whichtheyare implemented.This European Commission hascommissionedanew studyto understandingisreflected in agrowing recognitionthat provideaninventoryofresearch activity togetherwitha thepolicydebateneedstobeinformedbyadialogue comparative analysis of infrastructuresavailable in Europe with civilsociety.Withthis aiminmind, severalactions andinother regionsofthe world. The report will include have recently been takenwithinthe European discourse recommendations on howtoimprove cooperationatEU on drugs. Amongthe most notable of these is the leveland contribute to adiscussiononhow to improvethe establishmentbythe European Commission of acivil linksbetween European research fundingopportunities society forum, whichprovidesanopportunity to ensure that andneedsofresearch andpolicy.

16

Chapter1 Policies andlaws

Introduction themselvestoachieving measurable resultsinreducingthe supplyand demand forillicitdrugsby2008. Drug policy is set to be an importantissue in 2008.Inthis year,boththe United Nationsand theEuropeanUnion This year’s session of theUnited NationsCommission assessthe resultsoftheir drug policiesonthe useof, and on Narcotic Drugs(CND) haslaunchedthe 10-year review of theprogress made in reaching thegoals harmscausedby, illicitdrugs. The United Nationsreviews andtargetsset duringthe 1998 Ungass.Areport theprogress made in implementing themeasuresand presented by theUnited NationsOffice on Drugsand reaching thegoals decidedduringthe 1998 UN General Crime(UNODC)arguedthatsignificantprogress has AssemblySpecialSession(Ungass)onthe worlddrug been achieved in thelast 10 years, though,insome problem.InEurope, 2008 sees thefinalevaluationof areasand regions,UNMemberStateshavenot fully thecurrent EU actionplanondrugs(2005–08)and the attained the goalsand targetsmentionedinthe political drafting of theactionplanfor 2009–12.Furthermore,an declaration(3). This assessmentistobefollowedbya unprecedented number of EU Member States also review one-yearreflection period,duringwhich discussionswill theirnationaldrug strategies andactionplans anddraft first be held amongintergovernmental expert working newdrug-policydocuments (1)duringthis year. groups andthen in intersessionalmeetings. This will The EMCDDA will discussthe findingsand developments allowpreparationstobemadefor adedicated two- made during2008inits next annual report.This year, day, high-level,segmentatthe 2009 CND, whichwill Chapter1focuses on recent changesindrug policy, decide upon apossible future politicaldeclaration and measures. presentsnew dataondrug-related public expenditure, exploresthree specific dimensionsofdrug laws — The European Unionisplaying an activeroleinthe possessionfor personaluse,alternatives to punishment, Ungass review.Resolutions prepared by theEUwere andthe focusonprotectingthe public —and highlights adopted at the2006(49/1), 2007 (50/12)and 2008 thelatesttrendsindrug-related offences.The chapter (51/4)sessionsofthe CND, allofwhich call fora ends with an overview of drug-related research in EU scientific andtransparent review process.The EMCDDA Member States. hasalsobeeninvolved in expert consultations funded by theEuropeanCommission andheld by theUNODC,and in this context hasprovidedanoverviewofdrug strategies Internationaland EU policy developments andresponses in Europe since1998.

Ungass 10-yearreview Evaluationofthe EU actionplanondrugs In June 1998,the 20th UN GeneralAssemblySpecial In December 2007,the European Commission presented Session(Ungass)convenedinNew York to debate the itssecond progress review on theimplementation of the worlddrug problem.This ‘drug summit’set anew agenda EU actionplanondrugs(2005–08). The report,which forthe internationalcommunity throughthe adoption includes datafromthe EU Member States,the EMCDDA, of threekey documents(2): apolitical declaration; a Europoland theEuropeanCommission,assesses theextent declarationonthe guidingprinciplesofdrug demand to whichthe measures plannedfor 2007 were carriedout. reduction; andafive-partresolutionwithmeasuresto Oneofthe main conclusions of thereviewwas that there enhanceinternationalcooperation.Inadoptingthe aresignsofconvergencebetween Member States’drug politicaldeclaration,UNMemberStatescommitted policies. It also highlighted difficulties in collecting data

(1)The term ‘nationaldrug-policydocument’ meansany officialdocumentapproved by agovernmentthatdefinesgeneral principles andspecific interventionsorobjectives in thefield of drugs, whereofficially represented as adrug strategy,actionplan, programmeorother policy document. (2)http://www.un.org/ga/20special/ (3)http://www.unodc.org/unodc/en/commissions/CND/session/51.html 18 Chapter1:Policiesand laws

on supply-reductionactivities andinlinking some of the Nationaldrug strategies planned actions with theindicator chosen to assesstheir implementation. Newdevelopments Newdrug actionplans or programmes were adopted The final evaluationofthe currentEUactionplanon by four EU Member States (Czech Republic,Estonia, drugstookplace in 2008,withinput from theEUMember Hungary, Finland),Turkeyand Norway in thesecond States,Europol andthe EMCDDA.The evaluationreport half of 2007.All of these documentscover atimespanof is duetobepublished by theCommission in autumn threetofouryears and, with theexception of theTurkish 2008,and itsfindings will contributetothe shapingof actionplan, they have been preceded by previous plans thesecond actionplan(2009–12)under thecurrent EU or programmes.Inthe same year,Spain also adopted strategy on drugs(2005–12). acomplementary nationalactionprogramme against cocaine(2007–10). Other EU developments In early2008, threemoreMemberStatesadopted new In September2007, theCouncil andthe European policy documents. Italy’sfirstdrug actionplanhas atime Parliamentadopted the ’Drug prevention and frameofone year,and is to be followed by afour-year information’programme (4)under thefinancial actionplan(2009–12), whichwillbesynchronised with the framework 2007–13 andthe general programme newEUactionplanondrugs. Malta’sfirstevernational forciviljustice andfundamentalrights. The general drug-policydocument, whilenot definingthe time frame, objectives of theprogramme are: thepreventionand includes almost 50 actions to be implemented in thecoming reductionofdrug use, dependenceand drug-related years. Finally, theUnited Kingdom’s new10-year drug harm;tocontributetothe improvementofinformation strategy (2008–18)is, forthe first time,complemented by a on drug use; andtosupport actions takenunder the three-year actionplan(2008–11), whichdefineskey actions EU drug strategy (2005–12). Under theprogramme, to be implemented in thenearfuture. EUR21.35 millionwillbeavailable forCommission The majority of nationaldrug-policydocuments adopted studies, operationalcostsofEuropeannon-governmental in late2007and early2008focus mainly on illicitdrugs, organisations in thedrugsfield,and transnational with somealsoaddressingother substances such as projects.Joint actions mayalsobeundertakenwith alcohol, tobacco, medicinesand performance-enhancing otherCommunity programmes,for example thesecond drugs. This reflectsatendencyamong European countries, programmeofCommunity actioninthe field of health wherebythe existenceoflinks andsimilaritiesbetween (2008–13)(5), which, in thepartrelated to health theuse of illicitand licitsubstances is acknowledged, but promotiondealing with different health determinants, drug-policydocuments rarely comprehensively address includesactions on illicitdrugsinspecific settings, such substances otherthanillicitdrugs(6). Norway continues to as schoolsand workplaces. be one of theexceptionstothis pattern, with illicitdrugs In June 2006,the European Commission issued aGreen andalcoholfully integrated in itsrecentlyadopted action Paperonthe role of civilsociety in drug policy,ascalled plan. The numerous nationaldrug strategies andaction forinthe currentdrug actionplan. This wasfollowed plans to be developed for2009, togetherwiththose in 2007 by theselection process foranew civilsociety recently adopted,willallow theEMCDDAtoexamine forumondrugs. The purposeofthe forumistoserve whetherthe trendtowards increasing integrationoflicit as aplatformfor theinformalexchange of views and andillicitdrugsinnationaldrug policies, identified in the information betweenthe Commission andcivilsociety 2006 selected issue, hascontinued. organisations in theEU, candidatecountriesand,as appropriate,Europeanneighbourhood policy countries. Generalsituation The forumincludes26organisations representingawide Austria is nowthe only EU Member Statethathas not spectrumofviews.Itmet forthe first time in December adopted anationaldrug strategy or actionplan, though 2007 andagain in May2008todiscuss theevaluation each of itsprovinces hasaregionaldrug or addiction of thecurrent EU actionplanondrugsand thenew strategy or actionplan. In theother 26 Member States, actionplan. as well as in Croatia,Turkeyand Norway,drug policy is

(4)DecisionNo1150/2007/ECofthe European Parliamentand of theCouncil of 25 September2007establishingfor theperiod2007–13 thespecific programme‘drug preventionand information’aspartofthe general programme‘Fundamentalrightsand justice’(OJ L257,3.10.2007,p.23). (5)DecisionNo1350/2007/ EC of theEuropeanParliamentand of theCouncil of 23 October 2007 establishingasecond programmeofCommunity actioninthe field of health (2008–13)(OJ L301,20.11.2007, p. 3). (6)See the2006selected issue European drug policies: extendedbeyondillicit drugs? 19 Annual report 2008:the stateofthe drugsproblem in Europe

Figure1:Trendinthe number of countrieswithnationaldrug- as in theirpolitical,socialand economic contexts, the policy documentsamongthe 27 EU Member States,Croatia, diversitythatexistsamong nationaldrug policies, though Turkey andNorway diminishing, is likelytoremain to somedegreeinthe future.Some examplesofthis diversityare highlighted in Chapter2. 30

Evaluation

25 In 2008,13EUMemberStateshavealready redrafted or aredue to review andredraft theirnationaldrug- policy documents, making this ayearofunprecedented 20 activity in policymaking at nationallevel.Following Italy, Maltaand theUnited Kingdom,Ireland will renewits

countries 15 drug strategy in 2008;France, Portugal andRomania of will renewtheir drug actionplans;Bulgaria,Spain, Cyprus, Lithuaniaand Slovakiawillrenewboththeir drug Number 10 strategies andtheir actionplans.Finally,the Netherlands, whichhas theoldestnationaldrug-policydocumentin Europe,intends to compose anew one during2008. 5 There is agrowing recognitioninEuropeofthe need to includemonitoringand evaluationasanessential 0 componentinnationaldrug strategies andaction plans.Almostall of thecountriesmentionedabove have 2004 2006 2000 2003 2005 2007 2008 2001 2002 1997 1998 1999 1995 1996 producedorplantoproduce aprogress review of the

No national drug-policy document implementation of theirdrug strategies or actionplans, andsomeofthem,for example Ireland,Cyprusand Single national drug-policy document Portugal,could produce more in-depth evaluations in Twocomplementarynational drug-policy documents 2008. Sources: Reitox nationalfocal points. EU Member States differ, however, in theirmethods and set outinnationaldrug-policydocuments.Asapoint of approaches forevaluatingnationaldrug strategies and comparison,in1995, only 10 of these 30 countrieshad actionplans;and thereisaneed to identify best practices developed such an instrument(Figure 1). in this field.This washighlighted at aconferenceon evaluationorganised by thePortuguese Presidencyof Convergencecan also be seen in theformatofdrug theEUinSeptember 2007.Torespond to this challenge, strategies andactionplans.Fourteencountriesnow theEMCDDA, in collaborationwithMemberStates, structuretheir nationaldrug-policydocuments along is exploring thepossibility of developingEuropean linessimilar to thoseofthe currentEUdrug strategy and guidelines in this field. actionplan. Moreover,the same number of countries noworganisetheir nationaldrug policiesusing two complementary instruments:astrategic framework and Drug-relatedpublicexpenditure an actionplan(Figure 1).In2000,when theEuropean For2006, four EU Member States (Czech Republic, Unionusedthis approach forthe first time,onlytwo Ireland,Poland,Portugal) provided detailed information Member States hadtwo complementary drug-policy on public expenditureassociated with tacklingdrugs documents. (summarisedinTable 1).Information on thedivision of The content of nationaldrug-policydocuments is another drug-related expenditurebetween centralgovernmentand area in whichthere aresignsofconvergenceamong regionalorlocal government wasprovidedbytwo of the theEUMemberStates, Croatia,Turkeyand Norway, four countries, allowing acomparison of theroleplayed with graduallymoreevidenceofcommon objectives and by thedifferent sectors of government.Inthe countries common interventionsinthe nationaldrug strategies and forwhich dataare available, thebulk of reported drug- actionplans adopted by different countries. However, as related public expenditureisallocated to activities that are European countriesdifferintheir drug problem as well funded by centralgovernment.

20 Chapter1:Policiesand laws

Eleven Member States gave detailsofexpenditure by the countrieshighlights theneed to adopt acommon approach Stateoncertain activities undertaken in response to the towardsmonitoringthe social cost of drug useinEurope. drug problem.Afurther twocountriesprovidedrough In Italy, thesocialcost of illicitdrug usewas estimated estimatesofoverall public expenditurerelated to thedrug at EUR6473 million, with law enforcementactivities problem (Spain,Malta), though with no information on the accountingfor thelargest shareofthe total(43 %),and activities on whichthe moneywas spent. theremainderdividedbetween healthcare andsocial In 2005,the totaldrug-related public expenditureby services(27 %) andlossofproductivity of drug users European countrieswas calculated to liesomewhere andpeopleindirectlyaffected by drug use(30 %). betweenEUR 13 billionand EUR36billion (EMCDDA, In addition, it wasestimated that drug usersspent EUR3980 millionfor thepurchaseofillicitdrugs. On 2007a).This figurewas estimated by extrapolatingthe thebasis of these data,the cost of drug useinItaly totaldrug-related expenditures of sixcountries(Belgium, is estimated to represent 0.7% of thenationalgross Hungary, Netherlands, Finland, Sweden,United Kingdom) domesticproduct.Indatareported forAustria,in2004, to theother States.Arevised estimate,which includes thedivision betweendirectand indirectcostswas the datafromadditionalcountries(CzechRepublic,France, oppositeofthatreported forItaly:ofthe estimated Luxembourg,Poland,Slovakia),has recently been social cost of drug useofEUR 1444 million, 72 %was proposed (EMCDDA,2008d). The newestimate of drug- accounted forbyindirectcosts. related public expenditureinEuropeisEUR 34 billion (95% confidenceinterval, EUR28–40 billion),which The United Kingdom reported that,in2003/04,the 7 is equivalent to 0.3% of thecombinedgross domestic economic andsocialcostsofClass A()drug usein product of allEUMemberStates. This suggeststhatState Englandand Waleswas EUR22.26 billion, representing an annual cost of EUR63940 foreachproblem drug expenditureonthe drug problem coststhe averageEU user.Itwas suggested that problem drug useaccounted citizenEUR 60 ayear. These figures must,however,still be for99% of thetotal costs. Costsdue to drug-related crime, takenasindicativebecause of thelimited dataonwhich includinglaw enforcementand coststothe victims of drug- they arebased. related crimes,accounted forthe largestproportionofthe overallcost (90%,orEUR 20.1 billion). Reportsonthe social cost of drug use Data on thesocialcost of drug use(directand indirect costscausedbydrug use) were reported by four Member Developmentofnationallegislation States.While these reportsmay provideusefulinsights into Examiningthe changesindrug legislationthathavebeen theimpact of drug useinthe country in whichtheywere made sincethe 1998 Ungass on drugsisofparticular conducted,differences in methodsand in theway results interest in this year of international, European andnational arereported mean that it is not possible to compare the reviews andevaluations of drug-policydocuments. countries. The lack of comparability in thedatafromdifferent Observing thechangesinthree keyareas,this section

Table 1: Drug-labelled public expenditure (1)byselected EU Member States

CountryLabelled expenditures reported by government sector (EUR) Total as a proportion of total public Central Regional Local Total expenditure (2)(%)

Czech Republic 12 821 000 3349 000 1699 000 17 869 000 0.04

Ireland (3) 214 687 000 ––214 687 000 0.39

Poland 68 476 000 644 000 13 253 000 82 373 000 0.08

Portugal 75 195 175 ––75 195 175 0.11

(1)Public expenditures explicitly ‘labelled’ as drug-related in official accountancy documents. (2)Total general government expenditure in the year. (3)InIreland, government departmentsand State agencies are invited to reporttheir annualdrug-related expendituretothe coordinating Department of Community,Rural and Gaeltacht Affairs. These expenditures are not necessarily labelled as drug-related in official accountancy documents. Sources: Reitox national focal points and Eurostat (http://epp.eurostat.ec.europa.eu/).

(7)Class Adrugsare defined as thoseconsideredtobethe most harmful. 21 Annual report 2008:the stateofthe drugsproblem in Europe

anymorethanthis wasraisedtoaclear minimum of four Towardsabetter understanding of drug-related yearsinprison,asfor atraffickingoffence. public expenditure in Europe —EMCDDA2008 Drug usewithinsmall groups presentsanotherchallenge selected issue to attempts to distinguish betweenusersand suppliers.In In response to theEUdrugsactionplan2005–08,the Belgium, thespecific criminal offenceofuse in agroup was EMCDDA hasdevelopedaproject aimedatidentifying, repealed in 2003;inthe same year,anamendmenttothe developingand testing methods forquantifying drug-related Hungariancriminalcodepermitted diversion to treatment public expenditures.Aselected issueonthis topic gives an overview on theoverall figures on drug-related public forthe supplierofasmall quantity to be consumed‘jointly’ expenditurein2005inthe EU Member States andNorway. (since appealed as beinglegally unclear). In 2006,Malta Most of theexpendituresidentified were originally ‘labelled’ foundthatthe minimum six-monthsentencefor suppliers as drug related,and were generally tracedback by wasnot always appropriate in situations of sharing, and exhaustively reviewingofficial accountancy documents, thus changedthe law to permit exceptions. possibly reflectingthe voluntary engagementofthe States in thefield of drugs. When feasible,hiddenor‘unlabelled’ Regarding punishment, maximumorprobablepenalties expenditures embedded in programmes with broadergoals foruse or possessionfor personaluse,inthe absenceof were estimated throughmodelling techniques.This new twofold approach provides standardised estimatesthat aggravatingcircumstances,havebeenreducedinvarious maximisethe validity andcross-country comparability of European countriessince 2001 —eitherfor alldrugs public disbursements in tacklingdrugsand drug addiction. (Estonia,Greece, Hungary, Portugal,Finland)orlimited This selected issueisavailableinprint andonthe Internetin to cannabis (Belgium,Luxembourg, United Kingdom) Englishonly(http://www.emcdda.europa.eu/publications/selected- or drugsoflesserrisk(Romania).However,duringthis issues). period,not allcountrieshavebeenreducingpenalties: France andPoland decidednot to change theirlawsafter consultations;and Denmarkraisedthe ‘normal’ penalties asks thequestion:Dothe changesinlegal definitions and from cautions to fines (which were then increased).A responses to drug usersindicateanew,wider trendin newlaw in Italysaw drug consumption reinstated as an howcountriesviewusersofdrugs? administrativeoffence, andcannabisreclassifiedtobe eligible forthe same penaltiesasother illicitsubstances, Possessionfor personaluse such as heroin andcocaine.Inthe United Kingdom,it During thepast 10 years, most European countrieshave hasbeenannounced that cannabis is to be reclassified movedtowards an approach that distinguishes between upwards. thedrug trafficker, whoisviewedasacriminal, andthe drug user,who is seen more as asickperson in need of Alternatives to punishment treatment. However, Member States differconsiderably The changesindrug users’ access to treatmentvia the in howtheyhavechosentodefine these categoriesinthe criminal justice system typicallyshare twocommon newlawsthattheyhaveadopted in recent years. features. First, they allwiden thescope fordirecting Oneofthe issues on whichMemberStateshaveshown drug usersintotreatment. However, somedifferences thegreatestdegreeofdivergence is whetherornot to set existbetween countriesregarding thestageatwhich the threshold quantities forpersonal possession. In theperiod offeroftreatmentismade, with most countriesoffering 2004–06,Bulgaria removedthe conceptofpersonal treatmentatthe court stage, rather than at theearlier possession, Italyre-enacteditafter 12 yearswithout,and stages of contactwiththe police or prosecutors. Secondly, theUnited Kingdom enactedthe conceptbut then chose they areconditional; breach of thetreatmentorder will not to applyit. Belgiumand Cyprusintroduceddefined restartthe procedureofcriminalcharge, prosecutionor limitquantitiesin2003, forall drugsand forcannabis punishment. respectively;while in Germany,the Länder areworkingto Countrieshaveintroducedorwidenedoptions or systems implementmoreconsistentlyaconstitutionalcourt ruling foroffenders to be referred to treatmentorcounselling, whosereferenceto‘insignificantquantities’ wasundefined, as an alternative to punishmentorimprisonment,inline resultingininterpretationsofbetween 3and 30 grams. with Ungass andEUactionplanobjectives.InIreland and In 2005,inSlovakia, thelegal definitions of personal Malta, followingarrest, drug userscan nowbereferred usewerewidenedfromamaximum of one dose to a to treatment; this is also thecaseinthe United Kingdom, maximumofthree and, foralarger amount,10doses.At wheredrug testing on arrest is authorised in certain thesametime, however, thesentencefor possessionof circumstances.Specialdrug courts have been established

22 Chapter1:Policiesand laws

in Ireland,the United Kingdom (England andScotland) controlledbynew laws: trains andships in Ireland;boats andNorway, andare underdiscussioninMalta;Portugal in Latvia;aviationinFinland.The last fewyears have also set up asystemof‘commissionsfor thedissuasionofdrug seen:lawsand strategies to preventorpunishdrug-related use’ composedofalawyer, adoctorand asocialworker. public nuisance (see the2005selected issue);new powers Newlawsinother countrieshaveintroducedsomeform to closebarsorother premises or excludepeoplefrom of treatmentasanalternative to punishment: in France, them (Belgium,Ireland,Netherlands); andpowerstoclose non-dependentdrug law offendersmay take,and pay privatedwellings wherecommercialdrug distribution or for, awareness courses;inSpain,Hungaryand Latvia, systematic drug usetakes place (respectively,Netherlands, custodialsentences maybesuspended fordrug users United Kingdom). In parallel,new lawstoprotect non- undertakingtreatment; andinBulgaria,Hungary, Romania usersfromthe useoftobaccohavealsobeenintroduced andTurkey, probationmay be combinedwithtreatment. across Europe duringthis time:since 2004,24European The Netherlandsaimstoincreasethe useoftreatmentas Member States (all except Greece, Hungaryand Poland) aconditionofearly releasefromprison.When deemed have prohibited or severely restricted smokinginenclosed appropriate,inFinland,sentenced offenderscan now public places,often with sizeable fines fortransgressors. be directed towardsanopenprison if they stay drug- To summarisethe legalchangesreviewedhere: it free;inGreece, they maybesenttoaspecialtreatment appearsthatcriminalsanctions have oftenbeenreduced unit.Eligibility fordrug-treatmentprogrammeshas been for theindividual user whoavoidsany aggravating extended to thoseconvicted of more serious offences in circumstances,but,almostasacounterbalance,increased Italy(if theoffenceispunishablebyuptosix yearsin forthose whoseactions mayaffectother members of prison,raisedfromfouryears)and Spain(raised from society.The latterreflects an increasedfocus on using threetofive years).InBelgium,atall levels of thecriminal criminal law to protectthe public. justice process,alternatives existtodivertdrug-using offendersintotreatment. Drug-relatedcrime Furtherdescriptionsofthe varioustreatmentalternatives to punishmentand theextentoftheir usecan be foundinthe Drug-related crimeisabroad concept whichmay includeall ELDD’s ‘Topic overview’and ‘Legal reports’ sections (8). crimes committed that are, in someway,linkedtodrugs(9). In practice, routinedataare only availableinEuropeon Focusonprotectingthe public initialreports of drug law offences,mainlyfromthe police. In thepast decade,criminallaw hasincreasinglybeen Though these data areusually takenasindirectindicatorsof used to protectthe public from thedrug user and, in drug useordrug trafficking,itisimportant to notethatthey parallel with thedistinction made betweenthe ‘sick’ user reflect differences in nationallegislationand thedifferent andthe ‘criminal’ trafficker, thecategoryof‘user’isalso ways in whichthe lawsare appliedand enforced.The beinglegally subdividedintothose whodoand those dataalsoreflectdifferences in priorities setand resources whodonot troubleorharmother members of society.The allocated by criminal justice agenciestospecific offences.In measures that reduce criminal penaltiesfor personaluse or addition, thereare variations betweennationalinformation offeralternatives to punishment, described above, arepart systemsondrug law offences,speciallyinrelation to of this development. These treatmentoptions or reduced reportingand recordingpractices.Because these differences penaltiesare,for example,granted on condition that the make comparisonsbetween countriesdifficult, it is more user does not causesomeformofpublicdisturbance. appropriate to compare trends rather than absolutenumbers.

Criteria have also been widenedand penaltiesincreased Overall, thenumber of reported drug law offences in EU forthose offenderswho risk harming othermembers of Member States increasedbyanaverage of 36 %between society.Most legislativeactivity hasconcentrated on those 2001 and2006(Figure 2).The datarevealincreasing taking drugsand then driving (Belgium,Czech Republic, trends in allreporting countriesexceptBulgaria,Greece, Denmark, Spain, France,Latvia, Lithuania, Portugal, Latvia andSlovenia, whichreported an overalldecline 10 Finland).New lawsregulatingtesting fordrugsinthe over thefive-yearperiod( ). workplace in Ireland,Finland andNorwayemphasise that testing is permitted mainly in situations where Use- andsupply-relatedoffences considerabledangerorriskwould arisefrombeing under The balancebetween drug law offences related to useand theinfluence. Drug taking in variousforms of transportis thoserelated to supply(dealing, trafficking,production) is

(8)http://eldd.emcdda.europa.eu (9)For adiscussionofthe relationships betweendrugsand crimesee EMCDDA (2007b). (10)See TableDLO-1 in the2008statisticalbulletin. 23 Annual report 2008:the stateofthe drugsproblem in Europe

similartothatreported in previous years. Most European Figure2:Indexedtrendsinreports fordrug law offences in EU countriesreported that themajorityofthe offences were Member States,2001–06 related to drug useorpossessionfor use, with figuresin 2006 rangingupto93% in Spain(11). However, in the CzechRepublic,the Netherlands, Turkey andNorway, 175 supply-related offences were predominant, with these accountingfor between52% (Turkey) and88% (Czech Republic)ofall drug law offences reported in 2006. 150

The number of drug law offences related to useincreased by an averageof51% between2001and 2006 in the 125 European Union, with twothirdsofthe reportingcountries 00) =1 showinganupward trend, andonlySloveniaand Norway

showingadownwardtrend over thefive-yearperiod(12). In (2001 100

addition, it is worthnotingthat, as aproportionofall drug Index law offences,use-related offences increasedoverthe same period in half of thereporting countries. 75 Offences related to thesupplyofdrugsalsoincreased duringthe period 2001– 06,but at amuchlower pace,

with an averageincreaseof12%in theEuropeanUnion. 50 Over this period,the number of supply-related offences 2001 2002 2003 2004 2005 2006 increasedinmorethanhalfofthe reportingcountries, anddecreased in four countries(Germany,Cyprus, —— Cocaine —— All reports —— Ecstasy Netherlands, Slovenia) (13). —— Amphetamine —— Cannabis —— Heroin

Trends by drug NB:The trendsrepresent theavailableinformation on nationalnumber In most European countries, in 2006,cannabiscontinued of reportsfor drug law offences (criminal andnon-criminal) reported by alllaw enforcementagenciesinthe EU Member to be theillicitdrug most ofteninvolved in reported drug States;all seriesare indexedtoabaseof100 in 2001 and law offences (14). In countrieswhere this is thecase, weighted by country populationsizes to formanoverall EU trend; thetotal number of offences reported in 2006 in countriesincluded cannabis-related offences accounted for36–86 %ofall in thetrends(before weighting)were: amphetamine, 41 069; cannabis,550 878;cocaine,100117; ecstasy, 17 598; heroin, drug law offences.Inafew countries, drugsother than 77 242; allreports,936 866. Countriesmissing datafor twoor cannabis were predominantindrug offences:inthe more consecutiveyears arenot included in thetrend calculations: theoverall trend is basedonall EU countriesexceptthe United CzechRepublic,methamphetamine accounted for60% Kingdom;the trend forcannabisisbased on 18 countries, heroin on 18,cocaine on 17,amphetamineon12and ecstasyon13. of alldrug law offences;inMalta,the figure forheroin Foradditionalinformation on themethodology,see Figure DLO-3 was41%.InLuxembourg, drug law offences were almost in the2008statisticalbulletin. Sources: Reitox nationalfocal points and, forpopulationdata,Eurostat equallydistributed betweencannabis, heroin andcocaine. (http://epp.eurostat.ec.europa.eu/).

In thefive-yearperiod2001–06,the number of drug law Over theperiod2001–06,drug law offences related offences involvingcannabisincreased or remained stable to heroin show adifferent picturetothose related to in most reportingcountries, resultinginanoverall average cannabis or cocaine, droppingbyanaverage of 14 %in increase of 34 %inthe European Union(Figure 2). theEuropeanUnion,mainlybetween 2001 and2003. Downward trends were,however,reported by Bulgaria, However, nationaltrendsinheroinoffences have been theCzech Republic (2002–06), Italyand Slovenia(15). divergingoverthe period,withathird of thecountries reportingupward trends (16). Cocaine-related offences increasedoverthe period 2001– 06 in allEuropeancountriesexceptBulgaria, The EU averagetrendsinoffences forbothamphetamine Germany andSlovakia. The EU averageincreased by andecstasy peaked in 2004.While thetrend for 61 %overthe same period. amphetamine-related offences remained upward (average

(11)See TableDLO-2 in the2008statisticalbulletin. (12)See Figure DLO-2and TableDLO-4 in the2008statisticalbulletin. (13)See TableDLO-5 in the2008statisticalbulletin. (14)See TableDLO-3 in the2008statisticalbulletin. (15)See TableDLO-6 in the2008statisticalbulletin. Foracomplementary analysis of cannabis-related offences,see Chapter3. (16)See TableDLO-7 in the2008statisticalbulletin. 24 Chapter1:Policiesand laws

increase of 41 %over2001–06), theEUaverage for specificallydesignated fordrug-related research canbe offences related to ecstasyfluctuated over theperiodwith availablethrough nationaldrug coordination bodies(Czech no overallchange between2001and 2006. Republic,Spain,France, Luxembourg,Hungary, Poland, Portugal,Norway).Bothtypes of fundingprogrammesoften coupleresearch on illicitdrugswithother areaswithinthe Nationaldrug-relatedresearch addiction field,suchasalcohol, tobaccoand gambling. Research into thedrugsproblem is carriedout in all The fundsare mostly availablethrough contracts for European countries, whereitprovidesthe information commissionedresearch or throughframework programmes essential to describingand understandingthe impact of to whichresearchersapply. Othertypes of fundingsources illicitdrugsonanationalscale.Based on reportsfrom25 reported includefoundations,scientific academies, private Member States,Croatia andNorway, it is possible to give institutions, specialfunds forthe fight againstdrugs, the an overview of theorganisationofdrug-related research European Commission andthe United Nations. in European countries. At atimewhen theimportanceof evidence-basedinterventions is increasingly acknowledged, Structures andprojects it is notable that 21 countriesreported that research results Themajorityofcountriesreported that research takes inform drug policy,atleast to somedegree. placemostly in universities andinspecialisedcentres, someofthem hosting nationalfocal points,followedby Coordinatingand funding public andprivate research centres. Nationalresearch Drug-related research is mentionedinthe nationaldrug networkswerereported by somecountries(Germany, strategy or actionplanof20ofthe 27 reportingcountries, Spain, Portugal). These canplayanimportant role in either as aspecific topic or referred to as an essential theorganisationand fundingofresearch,and mayalso componentofevidence-basedpolicy. In 15 of the27 promotemoredirectlinks betweenresearch andpractice. reportingcountries, structurestocoordinatedrug-related Amongthe majorstudies carriedout since2000 research existatnationallevel.Onlyfive countriesreport reported by theMemberStates, more than half were in that drug-related research is not mentionedintheir epidemiology andabout onethird in appliedresearch nationalstrategiesorthattheydonot have anational (mainlyevaluations of interventionsinpreventionand coordination structure in this field. treatment).Alsocited were studiesindeterminants, risk andprotectivefactorsfor drug use, consequences of drug The Stateisthe main sourceoffunding fordrug-related use, anddrug mechanisms andaffects. research reported by theMemberStates, either through programmes forgeneral research or throughresearch Constraintstodrug-related research were reported by programmes in thedrugsfield.Healthand social sciences severalcountries. Amongthe problemsidentified were: aretwo of themainareas of general research in which organisationalaspects,suchasalackofcoordination fundingmay be foundfor drug-related research.Funding andscatteredresources (Germany,France, Austria); the

More to come on drug-relatedresearch The European Commission hascommissionedanin-depth comparative analysis of research into illicitdrugsinthe Detailed information on research in thedrugsfield carriedout in European Union. The studyshouldprovide an overview European countrieshas been collectedbythe EMCDDA through of thefunding available fordrug-related research from itsnetwork of Reitox nationalfocal points.The information theEuropeanUnion andMemberStates, buildingonthe provided by theMemberStatesincludesadescription of resultsofthe selected issueonresearch,and widening nationalresearch organisations andfunding arrangements. thescope to includeresearch in thefield of drug supply Member States have also provided listsofmainstudies carried reductionand security.The studywillreviewthe existing outsince 2000 andidentified scientific papers,scientific research infrastructure within Member States andat journals andwebsitesthrough whichthe findingsofdrug-related European level, andmakeacomparison with otherregions, research carriedout in theircountry have been disseminated. such as NorthAmericaand Australia.Itwillconclude The EMCDDA is making this andmoreinformation available with recommendations forpolicyoptions to address the throughdifferent disseminationproductsand channels (see knowledgegapsand improvecooperation at European http://www.emcdda.europa.eu/themes/research). level. It will also assessexistingEuropeannetworks, Foramorein-depthreviewofthis topic,see the2008 includingthose of theEMCDDAand itsReitoxnational selected issueondrug-related research (http://www.emcdda. focalpoints. Resultsfromthis studywillbeavailablein europa.eu/publications/selected-issues). early2009.

25 Annual report 2008:the stateofthe drugsproblem in Europe

lack of qualified research staff(Latvia,Hungary);and abstracts andwelcome internationalcontributions.In methodologicalaspects (dataprotectionissues,problems additiontopublications specialising in illicitdrugsand in reaching hidden populations,lackofcontinuityin addiction,articles on illicitdrug useare also publishedin research projects).Several countriesidentified thelimited peer-reviewedjournals from awidearray of disciplines fundingavailable fordrug-related research as amajor andinprofessionalmagazines.In2006, research constraint(Belgium, Greece, Poland,Romania, Finland). findingsinthe drugsfield were publishedinmorethan 100suchEuropeanjournals.Other typesofpublication, Dissemination includingthose by nationalfocal points,alsoplayan importantroleindissemination. Atotal of 25 European peer-reviewedjournals specialising in thedrugsfield andpublishingin11 Reitox nationalfocal points also playanimportant role in languages otherthanEnglish were identified.The disseminating research resultsinall thereporting countries, majority of these nationaljournals publishEnglish mainly by meansoftheir nationalreports.

26

Chapter2 Respondingtodrug problemsinEurope—anoverview

Introduction Improvingthe monitoring of drug supply This chapterpresentsanoverviewofthe responses to reduction drug problemsinEurope, wherepossible highlighting trends,developments andquality issues.The set of Drug supplyreductioncan be defined as encompassing allactivities aimedatpreventingillicitdrugsfromreaching measures reviewedhereincludesprevention, treatment, users. These mayinclude instruments such as international harm reductionand social reintegration, whichtaken conventions,and EU andnationallegislationand policies, togetherformacomprehensive demand-reductionsystem. as well as actions addressingthe variousprocesses The chapteralsoincludesareviewofthe availabledata andactorsinvolved in theproductionand trafficking on theneedsofdrug usersinprisonsand theexisting of illicitdrugsbut also involved in thediversion or illicit responses in this particular setting.Inaddition, future manufactureoflicitsubstances (medicines, precursor chemicals)for illicitendsand in thelaunderingofdrug monitoringchallenges in anotherfield of drug policy,drug money.Law enforcementactivities,alternativedevelopment supplyreduction, arebriefly discussed. initiativesand projectsaimed at preventing drug-related crimeall contributetoreducingthe supplyofillicitdrugs. Monitoringand analysis constitute,asisthe case with drug Prevention demand reduction, an importantsupport forthese activities andtheir evaluation. Drug prevention canbedividedintodifferent levels or strategies,fromenvironmentaltoindicated prevention, Recent data collection exercises in theframework of the annual progress reviews of theEUactionplanondrugs whichideally do not compete butcomplementeach andthe Ungass review (see Chapter1)haverevealeda other. The followingdescription of thecurrent situation mixedpicture regarding theavailability of response datain andtrendsinEuropeisbased on qualitativedataonthe thesupplyreductionfield.Activitiesrelated to international provisionofuniversal andselective prevention reported projectsare usuallywelldocumented,while data on to theEMCDDAin2007(17)and on aliteraturereviewon activities at nationallevel areoften difficult to access and compare.The European Commission,Eurostat,Europol and indicated prevention (EMCDDA,2008f). theEMCDDAare workingtoimprove this situationinthe framework of thenextEUactionplanondrugs(2009–12). Universalprevention Existing conceptualframeworksand information systems, as well as potentialinformation sources formonitoring The objectives of universalschool-based drug prevention andanalysing supplyreductionactivities in theMember in Europe appear to have shifted in recent years. In 2007, States,are to be reviewed. There is also aneed to developinglifeskills wasthe most frequently reported better understand drug markets, in particular supplyand objectiveofpreventionactivities (12out of 28 reporting distribution arrangements,bothintheir economic and countries),whereas in 2004,halfofthe countries(13/26) social dimensions. Twostudies funded by theEuropean Commission will explore both theinformation systemsand reported raisingawareness andproviding information sources on drug supplyreductionand theinternational as theirmainobjective. Creating protective school drug markets. environments,aformofstructuralintervention, was also more oftenmentionedasamainobjectivein2007 (six countries) than it wasin2004(four countries).The agents at schools) areamong thetypes of school-based changesinreported objectives mayreflectthe adoption intervention reported by thelargest number of countries of amorerationaland evidence-basedapproach,but the (Figure3). The effectiveness of these interventionsis extent to whichthis change in objectives reflectsactual unclear.Incontrast,someofthe more strongly evidence- provisionisunclear. basedinterventions arereported in only afew countries. Events forparents andstrategiessolelyproviding These includestandardisedprogrammes, peer approaches information (information days,visitsofexperts or of police or interventionsspecificallyfor boys;all of whichaim

(17)Datawereprovidedbynationalexperts in theMemberStates. 28 Chapter2:Respondingtodrug problemsinEurope—anoverview

Figure3:Most frequent intervention typesinuniversal school-based prevention

Drug testing in schools

Peer-to-peer approaches

Mustap programmes

Visit of police officers to schools

Other drug prevention topics integrated in curricula

Other external lectures

Creative extracurricular activities

Information only on drugs

Information days about drugs

Personal and social skills training outside standardised programmes

Events for parents

0 5 10 15 20

Number of countries

Full provision Extensive provision

NB:Mustap=multisession,standardisedprogrammeswithprinted material. Sources: Reitox nationalfocal points. to improvecommunicationskills,increaseabilities in Family-based prevention is anotherwidelyutilised handling conflicts,stress andfrustration,orcorrect prevention approach.Elevencountriesreported full or normative misperceptionsabout drug use. The overall extensiveprovision of family meetings andevenings. In predominance of interventionsthatlackorhaveonlya commonwithschool-based prevention,family-based weak evidencebasemightbedue to thefact that they prevention seemstobemainlyfocused on providing information.Intensive coaching andtrainingfor families, requirefewerresources andless stafftraining. an approach that hasshown consistentefficacy across In additiontoactivities targetingdrug usespecifically, studies(Petrie et al., 2007), is offeredonalimited basis, structuralinterventions also existinschools.Byaiming with only sevencountriesreporting thehighestprovision to create protective andnormative social environments, levels. structuralinterventions seek to influenceyoung people’s choices aboutdrug use(Toumbourouetal.,2007). Selectiveprevention This approach matchesoverall prevention policiesthat Selectivepreventionisguidedbysocialand demographic increasingly embrace stricterregulations on tobaccoand indicators, such as unemployment, delinquencyortruancy alcoholinschools.Assuch, 20 countriesreporttotal rates. It interveneswithspecific groups,families or entire smokingbansinall schools, and18countriesreportfull communities,where people, duetotheir scarce social ties or extensiveprovision (18)ofdrug policiesinschools.In andresources,may be more likelytodevelopdrug useor centraland westernEuropeinparticular, Member States progress into dependency. report having implemented structuralinterventions aimed Thirteen countriesreportthatmost of theirfamily-based to reduce tobaccoand alcoholuse in schools. These prevention is selective.However,important risk conditions prevention measures mayalsobecomplemented by other of families arerarelyaddressedinEurope. Across 30 structuralmeasures, such as improvingthe design of reportingcountries, only sevenreportfullorextensive school buildingsand school life. provisionofinterventions forsubstance useinfamilies,

(18)Extensive provision: theinterventionisprovidedinamajorityoflocations wherethe size of thetarget populationissufficient forits implementation. Full provision: theinterventionisavailableinalmostall locations wherethe size of thetarget populationissufficient forits implementation. 29 Annual report 2008:the stateofthe drugsproblem in Europe

andfive report providinginterventions forfamilyconflict andneglect.Inaddition, thefollowing categoriesof Drugsand vulnerable groups of youngpeople — interventionswereeachreported by four countries: EMCDDA2008selected issue

addressingsocialdisadvantage(e.g. unemployment), Youngpeoplefromcertain groups areatriskofbecoming helpingwithcriminaljustice problems, or assisting socially excluded,and this maybeassociated with an marginalised families from ethnic minorities.Furthermore, increasedlikelihoodofusing drugsand of developing only threecountriesaddress theneedsoffamilies coping drug useproblems. By focusing interventionsdesigned to reduce drug useand drug-related harm on specific groups, with mentalhealthproblems. thechanceofmeeting theneedsofthese groups canbe Risk conditions of youngvulnerablegroups, forexample, increased, as canthe likelihoodofthe intervention being successful. youngoffenders,homeless,truant,disadvantaged andminorityyouth,are also rarely addresseddespite This selected issueprovidesin-depthinformation on the increasing politicalimportance. Since2004, an increasing risk factors andvulnerability profilesofspecific groups andexploresdrug useand drug-related problemsamong number of drug policieshaveindicated them as primary them.Italsoinvestigatesthe consequences of vulnerability targetsfor prevention interventions, butthe reported level resultingfromtruancy, academic failure, social of intervention provisionhas not increasedduringthis disadvantage, family problemsand delinquency. Also period.Moredetailed dataare presented in the2008 discussedare specific responses to drug useand drug selected issueonvulnerablegroupsofyoung people. problemsamongvulnerablegroups, includinglegislation, prevention andtreatment.

Indicated prevention This selected issueisavailableinprint andonthe Internet in Englishonly(http://emcdda.europa.eu/publications/ Indicated prevention aims to identify individualswith selected-issues). behaviouralorpsychologicalproblemsthatmay be predictive fordeveloping problemsubstance uselater outcomesonsmoking andcannabisuse comparedto in life, andtotarget them individually with special treatmentasusual (Zonnevylle-Benderetal.,2007). interventions. Such individualsinclude school dropouts, andthose with psychiatric disorders,antisocialbehaviour Efficacyand risksofinterventions or earlysignsofdrug use. Areportrecentlypublished by theEMCDDA(2008f) presentslongitudinalstudies Drug useamong children andinfamilies remainsthe definingproblem trajectories, neurobehavioural studies main focusoftargeted prevention in Europe.Alarge andthe increasing knowledgeabout brainplasticity and number of studiesonthe socialand neurobehavioural theroleofneurotransmitters,and highlights findingsfrom predictorsfor progressionintosubstance useshow interventionsreported by Member States. that non-drug-focused prevention effortsmay also have an effectondrug use. Both selective and Children with behaviouraldisorders,suchascoexisting indicated prevention maymoderatethe effectofan attentiondeficit(hyperactivity)disorderand conduct earlydevelopmentaldisadvantage, itstranslationinto disorder, areathigh risk of developingsubstance use social marginalisationand subsequent progressioninto problems. Interveningearly with children with behavioural substanceabuse.Several research studieshaveshown disorders requires close cooperationbetween medical, that interventionsdelivered duringthe earlyschoolyears, social andyouth services.The German‘multi-module aimedtoimprove educationalenvironments andreduce treatmentconcept’, forexample,offersacombination of social exclusion, also have amoderatingeffectonlater counselling forparents andcarers; concurrentmedical, substanceuse (Toumbourouetal.,2007). psychotherapeutic andpsychosocialsupport;and educationalsupport in thekindergartenorschool. The The overalleffectiveness of school-based prevention has Irishapproach of targeted educationand psychological been questioned(Coggans, 2006;Gormanetal.,2007). counselling foryoung people, especiallyfor preventing Recent literature reviews (19), however, show that certain developmentalproblemsinschools,educationfacilities components of school-based prevention,suchasthe focus andthe family,yielded overallpositiveevaluationresults. on normative beliefsand lifeskills,seemtobeeffective. In theNetherlands,astudy on thelong-term preventive Forexample,the EU-Dap study, aEuropeanrandomised effects of treating disruptivebehavioursinyoung people controlledtrial,co-funded by theEuropeanCommission, in middle childhood(aged 8–13)found that manualised to develop andevaluateaschool-based prevention behaviouraltherapy showed significantlybetterfollow-up programme, reported positive outcomes(20). Afollow-up

(19)See the‘Best practice’ portal (http://www.emcdda.europa.eu/themes/best-practice). (20)http://www.eudap.net 30 Chapter2:Respondingtodrug problemsinEurope—anoverview

content of prevention projects. The number of Member TheEMCDDA‘Best practice’ portal States reportingstandards forproject design and evaluationhas increasedfromthree in 2004 to nine The EMCDDA hasthis year launched thefirstmodule of itsInternetportalonbestpracticefor drug-related in 2007.Several Member States report that they are interventions(prevention,treatment, harm reductionand developingcertificationprocessestoguarantee the social reintegration).The portal provides an overview qualityofprogrammesand theefficient useofresources on thelatestevidenceonthe efficacyand effectiveness from public budgets(CzechRepublic,Hungary, Poland, of different interventions, presentingtools andstandards Portugal). In theCzech Republic,for instance,certification aimedatimproving thequality of interventions, as well as highlighting examplesofevaluated practicefromacross of preventive activities is aconditionfor receiving Europe.Itisaimed at practitioners,policymakersand subsidiesfromthe Statebudget. researchersinthe drugsfield andhas astrongEurope- wide focus. Treatment The first moduleofthe portal focuses on universal prevention,inparticularonevidenceofefficacy which This sectionaimstoprovide an overview of drug treatment is basedonseveral reviews publishedsince 2000.For in Europe,describingthe organisationand provisionof detailsofthe findings, seethe portal (http://www.emcdda.europa.eu/themes/best-practice). services.

The portal provides information on theefficacy of various interventions, butitshouldbenoted that theevidence Organisation base remainssometimes limited andthatmaking In general, drug-treatmentservices aremainlyprovided choices betweendifferent interventionsrequirescaution. throughthe public sectorinEUMemberStates, though Furthermore, as controlledtrialsmeasure theefficacy of programmes,how certaininterventions will performin non-governmental organisations (NGOs) mayplayan different settingsremainssubject to question.The new equalrole(sevenMemberStates),orevenbethe main editionofthe EDDRAdatabank,availableonthe portal, provider of treatmentservices (five Member States). featuresexamplesofevaluated interventionsindifferent Generalpractitioners also playanimportant role,and in countriesand settings, andmay provideadditional somecountriesare keyproviders of substitution treatment. guidance. The privatesectorcan also be involved in somecountries, mainly in residentialcare. Nevertheless,funding fordrug studyfound that 15 months afterthe intervention,the treatmentismostly provided by thepublicpurse or is effectofthe programmeremained stable,withreduced linked to social or health insurances. frequenciesofdrunkenness andofcannabisuse observed amongparticipants. The ‘Unplugged’ programmeused Provision in thetrial challengednorms aboutthe acceptance and Drug treatmenttakes place in avariety of settings, beliefsabout theprevalenceofsubstance useamong includingoutpatientand inpatienttreatmentcentres, youth. general practice, low-threshold agenciesand prison. Prevention should not only be effective butmustalsobe Outpatient settings, includinggeneralpractice, account safe —unwanted effects must be kept to aminimum. formost of thetreatmentfor drug useinEurope, mainly Thus,the risksofnegativeeffects should be considered becausesubstitution treatmentisusually delivered carefullywhen designingand evaluatinginterventions. in these settings.Drug usersenteringtreatmentin This is particularly importantfor universalschool-based outpatient settingsare,according tothe latestfigures prevention,which is deliveredtoalarge anddiverse from thetreatmentdemand indicator,onaverage around target population. Forinstance, providinginformation 30 yearsold andpredominantly male (22). Around one aboutdrug effects alone,awidespreadapproach in thirdrefer themselvestotreatment, 22 %are referred to Europe,isnot only ineffective butmay carryrisks of treatmentbythe criminal justice system,withthis figure unwanted effects (Werch andOwen, 2002). The same growinginrecentyears,and theremainingare referred appliestomass-mediacampaigns, whichcan carryrisks throughsocialand health servicesorthrough informal of increasing thepropensityfor substance use(21). networks(23).

Oneway to ensure that prevention programmes are Half of theclients entering treatmentinoutpatientsettings evidencebased andthatrisks of unwanted effects are reported primaryopioid use, while21% cited cannabis reducedistodevelopstandards forthe delivery and and16% cocaineastheir primarydrug.Increases in the

(21)See Chapter3inthis report andthe 2007 annual report. (22)See Tables TDI-10 (partiii)and TDI-21 (partii) in the2008statisticalbulletin. (23)See TableTDI-16inthe 2008 statisticalbulletin. 31 Annual report 2008:the stateofthe drugsproblem in Europe

proportion of clients, andespeciallynew clients, referred substitution treatmentand needle andsyringe exchange to treatmentfor problems with non-opioid drugsmay programmes (NSPs), whichtarget overdose deaths and reflect improvements in treatmentavailability forusersof thespreadofinfectiousdiseases.These measures are cannabis andcocaine in severalMemberStatesaswellas reported to be availableinall countriesexceptTurkey an increase in thenumbersofusersseeking treatmentfor (see also Chapters 6and 8) and, whileconsiderable these drugs(seeChapters3and 5).However,the overall differences existinthe range andlevelsofservice availability of services specificallytargeted to theneedsof provision, thegeneral European trendisone of growth non-opioid drug usersremainslimited. andconsolidationofharm-reductionmeasures.

Treatmentininpatient settingstakes place mostly in In addition, most countriesprovide arange of healthcare therapeuticcommunities,psychiatric hospitalsand andsocialservices at low-threshold agencies. However, specialiseddepartments in general hospitals. The somecountriesreportthatthe implementation of harm- servicesprovidedrange from short-termdetoxificationto reductionmeasureshas been delayeddue to thelackof prolongedpsychiatric andabstinence-based treatment politicalsupport.InGreece, expansionoflow-threshold programmes.Residential servicescan be particularly services andsubstitutiontreatmenthas been stalled; suited fordrug userswithcomplex treatmentneeds, needle andsyringe programmes in Romaniaand Poland duetoco-morbid physical andmentalhealthproblems. were scaled down in 2006,after externalfunding ceased; Inpatientclients are, on average, similartooutpatient Cyprus’sonlyneedle andsyringe exchange programme clients: around 30 yearsold,mainlymales andentering is not officiallyendorsed. In Hungary, whereNSPsand drug treatmentfor primaryopioid use(24). The proportion outreach work have been increasing,astudy amongthe of drug clients with no employmentand unstable out-of-treatmentpopulationsuggests that provisionisstill accommodationis, however, higher amonginpatient insufficient andaccess barriers arehigh. clientsthanamong outpatient clients, in most countries Duetothe specific profile of theBalticStatesand Romania wherecomparisonispossible (25). with regardtoHIV/AIDS, internationaldonorscontinueto Historically,drug-treatmentservices have been organised playanimportant role in these countries. Financialsupport around theneedsofopioid users, whostill represent the forharm-reductionactivities is provided by theGlobalFund main groupofusersintreatment. In themajorityofMember ‘Programme to fight againstAIDS, malariaand tuberculosis’, States,substitutiontreatmentcombinedwithpsychosocial whileinEstonia,Lithuania andLatvia, UNODC hasrecently care hasbecome thepredominant option foropioid users. launched theproject ‘HIV/AIDSpreventionand care among With theintroductionofhigh-dosagebuprenorphine injectingdrug usersand in prison settings’. treatmentinCyprusin2007, substitutiontreatmentis Finally, someMemberStateshaverecentlylookedat nowavailable in allMemberStatesand in Croatia and theconsequences of theintroductionofharm-reduction Norway (26). In Turkey,substitutiontreatmenthas yettobe interventions. In France,the observeddecreaseinmortality introduced, though it is permitted undera2004regulation ratesamong drug userscoincided with theintroduction on treatmentcentres.After methadone,buprenorphine is of triple antiviraltherapies,the developmentofaharm- thesecond most commonly prescribed opioid substitute, reductionpolicyand theavailability of opioid substitution andits useinthe treatmentofopioid dependencehas treatments;inSpain,the decreasing number of injectors increasedinrecentyears (see Chapter6). It is now combinedwitheasy access to methadone maintenance availableasatreatmentoptioninall Member States except treatmentwas associated with adecline of infectious Bulgaria,Hungaryand Poland.In2006, it is estimated diseases anddrug-related deathsamong drug users(De la that 600000 opioid usersreceived substitution treatment Fuente et al., 2006); andinPortugal, availabledatashow in Europe,withanincreasesince thepreviousyearbeing alevelling offofinfectiousdiseases,which probably can reported in 16 of the22countriesproviding data. be attributed,inpart, to an increase in theavailability of harm-reductionand treatmentresponses. Harm reduction Social reintegration The prevention andreductionofdrug-related harm is a public health objectiveinall Member States andinthe Drug usersintreatmentoften report high levels of EU drug strategy andactionplan(European Commission, unemploymentand homelessness.Suchdisadvantage 2007a).The main interventionsinthis field areopioid tendsalsotobemorewidespreadamong specific groups

(24)See Tables TDI-10 (partvii)and TDI-21 (partiv) in the2008statisticalbulletin. (25)See Tables TDI-13 andTDI-15inthe 2008 statisticalbulletin. (26)See Tables HSR-1 andHSR-2 in the2008statisticalbulletin. 32 Chapter2:Respondingtodrug problemsinEurope—anoverview

of users, particularly women,heroinand crack users, those provisionofservices to imprisoneddrug usersand new whobelong to ethnic minorities andthose with co-morbid lawsondrug treatmentinprison. psychiatric problems. Drug use Social reintegrationisrecognised as an essential componentofcomprehensive drug strategies,and it can Data availablefromavariety of studiescontinuetopoint be implemented at anystageofdrug useand in different to an over-representationofdrug usersinEuropean settings. The aims of social reintegrationinterventions prisons, comparedtothe general population. Surveys maybeachievedthrough capacity building,improvement carriedout between2001and 2006 show that the of social abilities,measurestofacilitate andpromote proportion of prisoners (29)who report having ever used employmentand to obtain or improvehousing.Inpractice, an illicitdrug variesgreatly betweenprison populations, reintegrationservices mayoffer vocationalcounselling, detentioncentres andcountries, from athird or less work placements andhousing support, whileprison-based (Bulgaria,Hungary, Romania) to above50% in most interventionsmay link inmatestocommunity-based housing studies, andupto84% in awomen’s prison in England andsocialsupport services in preparationfor theirrelease. andWales.Cannabisremains theillicitdrug most Homelessness,togetherwithliving in unstable frequently reported by prisoners,withlifetimeprevalence accommodation, is one of themost serious formsofsocial levels of up to 78 %. Althoughestimatesoflifetimeuse of exclusionfacingdrug users, affecting about10% of drug othersubstances canbeverylow in someprisons(down to 1%), somestudies report lifetimeprevalencelevelsof usersenteringtreatmentin2006(27). Whilehousing supportisprovidedtodrug treatmentclients in many 50–60 %for heroin,amphetaminesorcocaine among 30 countries, shortages have also been documented,and two prisoners ( ). The most damagingforms of drug usemay countriesreportthatitisdifficultfor drug userstogain also be concentrated amongprisoners, with somestudies access to thegeneral services forthe homeless that are reportingthatmorethanathird of thosesurveyedhave 31 traditionallyusedbyproblem alcoholusers(Ireland,Italy). ever injected drugs( ). Newmeasuresthatcan help meet theaccommodation The fact that drugsfind theirway into most prisons, despite needsofdrug usersare beingundertakeninthree allmeasuresbeing takentoreduce thesupplyofdrugs, countries(Belgium, Denmark, Netherlands),which report is recognised by both prison expertsand policymakers. that facilities forhomeless long-termaddicts arebeing Studiescarriedout between2001and 2006 in Europe centralisedand specialisedcarehomesare beingopened show that between1%and 56 %ofinmates report having fordrug userswithproblem behaviourorco-morbidity. used drugswithinprison,and up to athird of inmates 32 Helpingdrug treatmentclients findemploymentisakey have injected drugswhile in custody( ). This raises elementinsocialreintegration,asone in everytwo clients concernsaroundthe potentialspreadofinfectiousdiseases, entering treatmentisunemployed(28). Newapproaches especiallyinrelation to thesharing of injectionequipment. to helpingclients to findand hold down employmentare The prison populationinthe European Unionisover reported to have shownsuccess,these include: ‘mentoring 607000 (33), with an estimated annual turnover of schemes’,subsidisedworkplaces(since2006alsopossible more than 860000 prisoners.Inmost countries, the in Lithuania),and specialcoachingofemployers and proportion of prisoners sentenced fordrug law offences employees,ascarriedout underthe ‘Ready forwork’ is in therange of 10–30 %. From thedataavailable, project in Ireland,orvarious ‘work andsocialagencies’ in it canbeestimated that more than 400000 people theCzech Republic. with past or currentexperienceofillicitdrug usepass throughEUprisonsevery year.And amongthese,there will be aconsiderablenumber of problem drug users. Healthand social responsesinprison The healthcare needsofthis largepopulationofformer Prisonsrepresent an importantsetting forthe delivery or currentdrug usersinEuropeanprisonswill, to some of health andsocialinterventions to drug users. In this extent,bedeterminedbyhealthproblemsrelated to drug section, dataondrug useand drug usersinEuropean use, notably infectiousdiseases such as hepatitisBand C prisonsisreviewedalong with recent information on the viruses andHIV/AIDS(seeChapter 7).

(27)See TableTDI-15inthe 2008 statisticalbulletin. (28)See TableTDI-20 in the2008statisticalbulletin. (29)The term ‘prisoners’ is used in abroad sensehere, andincludesbothon-remand andconvicted incarcerated persons. (30)See TableDUP-1 in the2008statisticalbulletin. (31)See TableDUP-2 in the2008statisticalbulletin. (32)See Tables DUP-3and DUP-4inthe 2008 statisticalbulletin. (33)Council of Europe Annual PenalStatistics (SPACE), basedonaprison populationsurvey with referenceto1September 2006. 33 Annual report 2008:the stateofthe drugsproblem in Europe

Healthcare areas: drug-related information andprevention; screening forinfectiousdiseases andvaccinations;and drug The responsibility forhealthcareinprison lies,inmost dependencetreatment, includingsubstitutiontreatment. In countries, with theMinistryofJustice.However,this addition, these interventionshavebecome more widely is changing, andinagrowing number of European availablewithincountries. Prison-based substitution countries, theresponsibility hasbeentransferred to the treatmentisofficially availableinall countriesexcept health system (France, Italy, Englandand Walesinthe Bulgaria,Estonia,Latvia, Lithuania, Cyprus, Slovakiaand United Kingdom,Norway).InSpain,comprehensive Turkey,though, in many countries, theoverall accessibility services fordrug usersare developed in allprisons of this treatmentoptionislimited.Spain is currentlythe according to theactionplanofthe nationalstrategyon only European countrythatprovidesawiderange of drugs(2000–08)and basedonacooperation protocol harm-reductionmeasuresinprisons. betweenthe MinistryofHealthand theMinistryofthe In 2006,onlyfourMemberStatesreported socio- Interior,signed in 2005.Inother countries, in orderto demographicdataand information on drug usepatternsof meet theneedsofincreasingnumbersofincarcerated prisoners in drug treatmentthrough theirnationaltreatment drug users, prisonshaveestablished cooperationwith monitoringsystems.InFrance, Cyprusand Slovakia, public health services andspecialist non-governmental an opioid,usually heroin,ismost oftenreported as the drugsagenciesinthe community. primarydrug by thoseenteringdrug treatment; whilein Interventionstargetingdrug-using prisoners have Sweden,primary amphetamine useisthe main reason for expanded in theEuropeanUnion.Comparedtofive years entering treatmentinprison, reflectingbroadly thepatterns ago, more countriesnow report activities in thefollowing of problem drug usewithinthese countries.

Recent legislationondrug treatmentinprison In Romania, anew legalbasis forestablishingsubstitution treatmentinprisonswas created in May2006bythe In 2006 andearly 2007,six countriesrevised theirlegal Common Orderofthe Ministriesfor Justice,PublicHealth, and frameworksand guidelines affecting prisoners’rightstodrug Administrationand InternalAffairsregarding thecontinuation treatment. of integrated medical, psychologicaland social assistance In Belgium, a2006directive from theMinistryfor Justice programmes forinmates. states that inmateshavethe right to thesamerange of In Norway,acircularin2006fromthe MinistryofJustice treatmentoptions as areavailableoutside prison.Meanwhile, andthe MinistryofHealthand Social Affairs strengthened in Ireland newPrison Serviceguidelinesemphasise the cooperationbetween thetwo sectorsand aimedat healthcare standard fortreatmentservices,which should be providing better follow-upduringand afterthe serving comparabletothose available in thecommunity,while being of sentences.Morespecifically,inSlovakia, a2006 appropriate to theprison setting. law permitted theprovision of psychologicalservices to In Denmark, achange in thelaw from January2007entitles drug usersonremand whoare sufferingfromwithdrawal imprisoneddrug userstofreetreatment fortheir drug use. The symptoms.The aimofthis law is to providedrug userswith law stipulates that thetreatmentshouldnormallystart within such services at thetimewhen they aremost needed,at 14 days of theprisoner requesting it from theDanishPrison thetimeofenforcedwithdrawalimmediately upon entering andProbation Service. However, thereisnosuchentitlementif custody. It also created alegislativeframework to support theoffenderisexpected to be released within threemonthsor theexistingspecialtreatmentunits forconvicted drug is consideredunfitornot motivated fortreatment. users.

34

Chapter3 Cannabis

Introduction Drug supplyand availability —dataand sources The European pictureinrespecttocannabishas evolved considerablyoverthe last decade,ashas thedebate Systematic androutine information to describeillicitdrug marketsand trafficking is still limited.Productionestimatesof on howtorespond appropriately to thewidespreaduse heroin,cocaine andcannabisare obtained from cultivation of this drug.Inthe earlyand mid-1990safew countries estimatesbased on fieldwork(sampling on theground) stoodout as having ahigh prevalence, whereasthe andaerialorsatellite surveys. These estimateshavesome European norm waslevelsofuse which, by today’s importantlimitationslinked, forinstance, with variations in standards, were low. In almost all countries, cannabis use yield figures or with thedifficulty of monitoringcrops which increasedduringthe 1990sand early2000s, andthis has arenot growninrestricted geographical areas, likecannabis. resulted todayinafar less variedEuropeanpicture,even Drug seizures areoften considered as an indirectindicator if differences betweencountriesstill exist. Moreover,the of thesupply, trafficking routes andavailability of drugs; however, they also reflect lawenforcementpriorities, last fewyears have seen agrowing understandingofthe resources andstrategies, thevulnerability of traffickers and public health implications of thelong-term andwidespread reportingpractices.Dataonpurityorpotencyand retail useofthis drug,and rising reported levels of treatment prices of illicitdrugsmay also be analysed in orderto demand forcannabis-related problems. Europe may understand retail drug markets. However, theavailability of nowbemovingintoanew phase, as dataare pointing this type of data maybelimited andthere maybequestions to astabilising or even decreasing situation. Levels of of reliability andcomparability.Intelligence information from law enforcementagenciesmay help completethe picture. useremain high by historical standards, however; what constitutesaneffective response to cannabis useremainsa The EMCDDA collects nationaldata on drug seizures, keyquestion in theEuropeandebateondrugs. purity andretail prices in Europe.Other data on drug supplycomeslargely from UNODC’s information systems andanalyses,complemented by additionalinformation from Europol. Information on drug precursorsisobtained Supply andavailability from theINCB, whichisinvolved in internationalinitiatives to preventthe diversionofprecursor chemicals used in the Productionand trafficking manufactureofillicitdrugs.

Cannabis canbecultivated in awiderange of As many partsofthe worldlacksophisticated information environments andgrows wild in many partsofthe world, systemsrelated to drug supply, someofthe estimates anditiscurrently believed that theplant is cultivated in andother data reported,thoughrepresenting thebest 172countriesand territories(UNODC,2008) (34). These approximations available,mustbeinterpreted with caution. factstaken togethermeanthatproducing estimatesofthe worldwideproductionofcannabiswithany precisionis (Reitoxnationalreports). Herbal cannabis in Europe is also likelytobeverydifficult. The latestUNODC figurefor the reported to come from otherparts of theworld,including: global productionofherbal cannabis stands at 41 600 west andsouthernAfrica(Nigeria,Angola), south-east Asia tonnes (2006),ofwhich more than half is accounted for (Thailand),south-westAsia(Pakistan)and theAmericas by theAmericas (North Americaand SouthAmerica) and (Colombia,Jamaica)(CND, 2008;Europol,2008). closetoaquarter by Africa(UNODC,2008). Globalproductionofcannabisresin wasestimated at The widespread cultivationofcannabisalsomeans that asignificantproportionoftraffickingislikelytobeintra- 6000 tonnes in 2006,downfrom7500 tonnes in 2004 regional. This is thecasefor some herbal cannabis in (UNODC,2007a), with Moroccoremainingthe main Europe,where in additiontohome production(35), Albania internationalproducer.The area undercannabisresin andthe Netherlandshavebeennoted as sourcecountries productiondeclinedfrom134 000 hectares in 2003 to

(34)For information on thesources of data fordrug supplyand availability,see thebox on this page. (35)See ‘CannabisproductioninEurope’,p.37. 36 Chapter3:Cannabis

76 400hectaresproducing 1066 tonnes in 2005 (UNODC andGovernmentofMorocco,2007).Resin Cannabis production in Europe productionisalsoreported in Afghanistan, whereitis The issueofdomesticproductionofcannabishas become rising rapidly,Pakistan, India, Nepal, andCentral Asian moreimportant in recent yearsacrossEurope, reflecting andother CIScountries(UNODC,2008).Cannabisresin thefact that amajorityofEuropeancountriesnow producedinMorocco is typicallysmuggledintoEurope report localcultivation of cannabis andsomesubstantial viathe Iberianpeninsula (Europol,2008),withsomeofit seizures of cannabis plants. Cannabis growninEuropeis reported to come from both indoor facilities,where it is beingfurther distributed from theNetherlands. oftencultivated intensively, andfromoutdoor plantations. The size of plantations varieswidely, dependingonthe Seizures motivation andresources of thegrower, from afew plants forpersonaluse to severalthousandinlarge sitesintended In 2006,5230 tonnes of herbal cannabis and1025 forcommercialpurposes. tonnes of cannabis resinwereseizedworldwide,down Available information is patchy anddoesnot allowan from peak levels in 2004.North Americacontinued to accurateassessmentofthe extent of cannabis cultivationin account forthe bulk of herbal cannabis seized (58%), Europe.Nevertheless,reports from anumber of countries whilequantitiesofresin seized remained concentrated in suggest that it maynolonger be viewedasmarginal. For westernand centralEurope(62 %) (UNODC,2008). example,Frenchpopulationsurveysin2005estimated that about200 000 peoplehad growncannabisatleast once In Europe,anestimated 177000 seizures of herbal in theirlifetime. In theUnited Kingdom,morethan cannabis,amounting to 86 tonnes,weremadein 1500 ‘cannabisfarms’, with 400plantsper site on 2006 (36). The United Kingdom is theEUMemberState average, were reportedly closed down by police in London in 2005–06 (Daly, 2007)and most herbal cannabis now reportingthe most seizures of herbal cannabis,though available is thoughttobeproducedeitherlocallyorin data arenot yetavailable for2006. Turkey reported otherEuropeancountries. In theNetherlands,cannabis seizures of record amountsofherbal cannabis in 2006. cultivationiswidespreadinsomeparts of thecountry,with The number of herbal cannabis seizures in Europe has an estimated totalof6000 cultivationsites dismantled in increasedsteadily since2001, whilethere hasbeenan 2005 and2006. overalldecreaseinthe quantity seized,until 2005,with Cannabis productionseems to have experienced asharp an increase noted in themost recent data. increase from theearly to mid-1990sinsomewestern European countries, partly as aresponseofcannabis Seizures of cannabis resininEuropeexceed herbal seizures consumers to theperceived poorquality andhigh price both in termsofnumber andquantity: with twiceasmany of imported resin, then themost widely used cannabis seizures (325 000)and theamountintercepted (713 tonnes) product.Insome countries, it seemsthatamajorityofusers eight timeshigher.Most seizures of resincontinuetobe arenow consuminglocallyproducedherbal cannabis. This partialsubstitutionofdomesticallyproducedherbal reported by Spain(whichaccounted forabout half of all cannabis forimported resinwas made possible by seizures andfor abouttwo thirds of thequantityseizedin advances in horticulturalknowledge andtechnology (to 2006), followed,atadistance, by France andthe United maximiseyieldsand avoiddetection), whichthen spread Kingdom.After aperiodofstabilisationin2001–03,the throughthe Internet(Houghetal.,2003; Jansen,2002; number of cannabis resinseizuresisincreasinginEurope, Szendrei,1997/98). Cannabis that is producedlocally also hasthe advantagefor theproducer that it does not whilethe quantities intercepted increaseduntil 2003–04, need to be transported acrossnationalborders. butthereafterhavebeendeclining.

In 2006,anestimated 10 500seizuresinEuroperesulted Europe andreported in kilogramsshows asteady increase, in therecoveryofabout 2.3million cannabis plants(37) accelerating in 2006 duetorecordseizuresinLithuania. and22tonnesofcannabisplants(64 %accounted by Spain).Following asteady increase since2001, Potencyand price thenumber of seizures of cannabis plantsstabilisedin 2006 (38). Afterasharp declinein2002fromarecord The potencyofcannabisproductsisdeterminedbytheir amount seized in 2001,the number of plantsseizedin content of delta-9-tetrahydrocannabinol (THC), theprimary Europe hasbeenonthe increase,althoughitlevelledoff in activeconstituent. Cannabis potencyvarieswidelybetween 2006 at half thenumber reported in 2001.Overthe same andwithincountries, andbetween different cannabis five-year period,the amount of cannabis plantsseizedin samplesand products. Foranumber of methodological

(36)The data on European drug seizures mentionedinthis chaptercan be foundinTablesSZR-1,SZR-2,SZR-3,SZR-4,SZR-5 andSZR-6 in the2008 statisticalbulletin. (37)Since Turkey reported having seized no cannabis plantsin2005and 2006,after reportinghigh levels of seizures of this material over 2001– 04,it wasexcludedfromthe European analysis. (38) This pictureispreliminaryasdata forthe United Kingdom,the country reportingthe most cannabis plantsseizedin2005, arenot yetavailablefor 2006. 37 Annual report 2008:the stateofthe drugsproblem in Europe

reasons, dataare difficulttointerpretinthis area andthe extent to whichseizuresanalysedreflects theoverall market Population surveys:animportant tool for questionable. Research suggeststhatingeneral cannabis understandingpatternsand trends of produceddomesticallyunder intensiveconditions tendstobe drug useinEurope of higher potency. In 2006,the reported THCcontent of resin Drug useinthe general or school populationcan be samplesrangedfrom2.3 %to18.4%,while that of herbal measured throughrepresentative surveys, whichprovide cannabis rangedfromunder 1% to 13 %. Over theperiod estimatesofthe proportion of individualsthatreporthaving 2001– 06,the potencyofresin andherbal cannabis remained used specific drugsoverdefinedperiods of time.Surveys stable or decreasedinmanyofthe 16 European countries also provideusefulcontextualinformation on patterns of use, sociodemographic characteristics of usersand perceptionsof providingsufficient data; however, upward trends were noted risksand availability (1). forimported cannabis resininthe Netherlandsand forherbal cannabis in sevenother countries. Estimatesofthe potencyof The EMCDDA,inclose collaborationwithnationalexperts, hasdevelopedaset of common core itemsfor useinadult locallyproducedherbal cannabis over anumber of yearsare surveys(the‘European ModelQuestionnaire’,EMQ). This availableonlyfor theNetherlands,which reported adecline protocol hasnow been implemented in most EU Member to 16.0 %in2006, from apeakof20.3% in 2004 (39). States (2). However, thereare still differences between countriesinthe methodology used andyearofdata Typicalretailprices of both herbal cannabis andcannabis collection,and this meansthatsmall differences,inparticular resinvariedfromEUR 2toEUR 14 pergram, with a betweencountries, should be interpreted with caution(3). majority of European countriesreporting prices in therange As surveysare expensivetoconduct,few European countries EUR4–10 forbothproducts. During theperiod2001–06, collectinformation each year,althoughmanycollect it with theexception of Belgiumand Germany,retailprices at intervalsoftwo to four years. In this report,data are of cannabis resin(corrected forinflation) were reported to presented basedonthe most recent survey available in each have decreased. The availabledatafrommost countries country,which in most casesisbetween 2004 and2007. pointtoamorestablesituationfor herbal cannabis prices Of thethree standard time frames used forreporting survey duringthis period,withthe exceptionofGermany and data,lifetimeprevalenceisthe broadest.This measuredoes Austria,where signsofincreasingprices were noted. not reflect thecurrent drug usesituationamongadults,but is useful forreporting on school students andtoprovide insight into patterns of useand incidence. Foradults,the focusison last year andlast month use(4). Identifyingthose whoare using Prevalence andpatternsofuse regularlyorhavingproblems with theiruse of drugsisimportant, andprogress is beingmadeinthis respectwiththe development Among thegeneral population of shortscalestoassess more intensiveforms of useinthe It is conservatively estimated that cannabis hasbeenused generalpopulation, adults andschoolstudents(seethe boxon developingpsychometric scales in the2007annual report). at least once(lifetimeprevalence) by more than 70 million Europeans, that is over one in fiveofall 15-to64-year- (1)Moreinformation on survey methodology is available in the olds(seeTable 2for asummaryofthe data).Although 2008 statisticalbulletin (http://www.emcdda.europa.eu/stats08/gps/methods). considerabledifferences existbetween countries, with (2)Availableathttp://www.emcdda.europa.eu/themes/monitoring/ nationalfiguresvarying from 2% to 37 %, half of the general-population (3)For more information on nationalsurveys, seeTable GPS-121in countriesreportestimatesinthe range 11– 22 %. the2008statisticalbulletin. (4)The EMCDDA standard ageranges are: alladults (15–64 years) Many countriesreportcomparatively high prevalencelevels andyoung adults (15–34 years).This report uses theterms ‘lifetime useorprevalence’,‘last year prevalence’ and‘last monthprevalence’ of last year andlast monthuse of cannabis. It is estimated and, sometimes,the morecolloquialterms ‘lifetimeexperience’, that around 23 millionEuropeans have used cannabis in the ‘recentuse’and ‘current use’,respectively. last year,oronaverage,about 7% of all15- to 64-year-olds. Estimatesoflast monthprevalencewillinclude thoseusing the generallybeing reported amongthe 15-to24-year-olds. drug more regularly, though not necessarily in an intensive This is thecaseinalmostall European countries, the way(seebelow).Itisestimated that about12.5million exceptions beingBelgium,Cyprusand Portugal (40). Europeansusedthe drug in thepreviousmonth,onaverage about4%ofall 15-to64-year-olds. Populationsurvey datasuggestthat, on average, 31 % of youngEuropeanadults (15–34 years) have ever used Cannabis useamong youngadults cannabis,while 13 %haveusedthe drug in thelast year Cannabis useislargely concentrated amongyoung and7%haveuseditinthe last month. It is estimated that people(15–34 years),withthe highestlevelsofuse even higher proportionsofEuropeans in the15–24 age

(39)See Tables PPP-1 andPPP-5 in the2008statisticalbulletinfor potencyand pricedata. (40)See Figure GPS-1inthe 2008 statisticalbulletin. 38 Chapter3:Cannabis

grouphaveusedcannabisinthe last year (17%)orlast between21% and31% (Currie et al., 2008)(41). In this month(9%), though on averageslightlyfeweramong this agegroup,boysusually report ahigher prevalenceof agegroup have triedthe drug (30%). Nationalprevalence cannabis usethangirls,but thedifferenceinreported estimatesofcannabisuse vary widely betweencountries prevalencebetween thesexesissmall or even absent in allmeasuresofprevalence, with countriesatthe upper in someofthe countrieswiththe highestprevalence endofthe scalereporting values up to 10 timesthose of estimates. thelowest-prevalencecountries. As with lifetimeexperience, thereisawidevariation Cannabis useishigher amongmales than amongfemales betweencountriesinestimatesofuse in thelast 30 days (see the2006selected issueongender),althoughmarked amongschoolstudents. In some countriesitisvirtually differences betweencountriesare observed. Forexample, unreported,whereas in others around 15 %ofthose theratio of malestofemalesamong thosereporting useof questionedreportuse duringthe last 30 days,with cannabis in thelast year rangedfrom6.4 malesfor each sometimes even higher figuresfound amongmales.On female in Portugal to 1.3inItaly. thebasis of datacollectedinearlier ESPADsurveys, it is estimated that in 2003 around 3.5million (22.1 %) 15-to Cannabis useamong school students 16 -year-old school students hadusedcannabisatleast onceintheir lifetimeinthe EU Member States together Aftertobaccoand alcohol, cannabis also continues to be thepsychoactivesubstance most commonly used by school with Croatia andTurkey, and, around 1.7million (11%) students. hadusedthe drug in themonth priortothe survey.

Ever in lifetimeuse of cannabis by 15-to16-year-old Internationalcomparisons school students maybetaken to reflect recent or current useasfirstexperimenting with this substanceoften European figures canbecomparedwiththose from other occurs at or around this age. Data from the2005/06 partsofthe world. Forinstance, in theUnited States,the HBSC survey of 15-year-oldsshowedlarge variationin nationalsurvey on drug useand health (Samhsa, 2005) lifetimeprevalenceofcannabisuse across27countries. estimated alifetimeprevalenceofcannabisuse of 49 % Prevalenceestimatesofunder 10 %for ever in lifetimeuse amongyoung adults (15–34 years, recalculated by the of cannabis were reported by fivecountries; 11 countries EMCDDA)and alast year prevalenceof21%.For the reported values between10% and20% and11countries same agegroup,lifetimeprevalenceofcannabisuse was 58 %and last year prevalence28% in Canada (2004), whileinAustralia (2004) thefigureswere48% and20%. Recent school surveys Allthese figuresare abovethe correspondingEuropean The ‘Healthbehaviour in school-agedchildren’ (HBSC) averages,which arerespectively 31 %and 13 %. survey is aWHO collaborativestudy whichinvestigates children’s health andhealthbehaviour andhas included Patterns of cannabis use questionsabout cannabis useamong15-year-old students since2001. The second roundofthis survey with questions Availabledatapoint to avariety of patterns of cannabis aboutcannabisuse wasconducted betweenOctober use. Of thoseaged15–64 whohaveeverusedcannabis, 2005 andMay 2006,withthe participation of 26 EU only 30 %havedone so duringthe last year (42). But, Member States andCroatia. amongthose whohaveusedthe drug in thelast year,on The fourth roundofthe ‘Europeanschoolsurvey project average56% have done so in thelast month. on alcoholand otherdrugs’ (ESPAD)was conducted in 2007 with theparticipation of 25 EU Member States, Estimating intensiveand long-termpatternsofuse is an Croatia andNorway. This survey specificallyinvestigates importantpublichealthissue.Daily or almost dailyuse substanceuse amongschoolstudentswho turn 16 during (use on 20 days or more in thelast 30 days)may be an thecalendaryear. Resultsfromthe latestsurveyswillbe publishedinDecember2008. indicator of intensiveuse.Dataonthis form of cannabis useinEuropewas collected in 2007/08aspartofa Participation in both of these internationalschoolsurveys, ‘field trial’ coordinated by theEMCDDAincollaboration each conducted everyfouryears,has grownineachround andnow includes most European countries. with nationalexperts andthe Reitox focalpointsof13 countries. On thebasis of this data, albeitlimited,itis Spain, Italy, Portugal,Slovakia, Sweden andthe United Kingdom also reported data on cannabis usefromtheir estimated that over 1% of allEuropeanadults,about ownnationalschoolsurveysin2006. 4million,are usingcannabisdaily or almost daily. Most of these cannabis users, about3million,are aged 15–34,

(41)See Figure EYE-5inthe 2008 statisticalbulletin. (42)See Figure GPS-2inthe 2008 statisticalbulletin. 39 Annual report 2008:the stateofthe drugsproblem in Europe

Table 2: Prevalence of cannabis use in the general population —summaryofthe data

Age group Time frame of use

Lifetime Last year Last month

15–64 years

Estimated number of users 71.5 million 23 million 12.5 million in Europe European average 21.8%6.8%3.8%

Range 1.7–36.5%0.8–11.2%0.5–8.7%

Lowest-prevalence countries Romania (1.7%) Malta (0.8%) Malta (0.5%) Malta (3.5%) Bulgaria (1.5%) Sweden (0.6%) Bulgaria (4.4%) Greece (1.7%) Lithuania (0.7%) Cyprus (6.6%) Sweden (2.0%) Bulgaria (0.8%) Highest-prevalence countries Denmark (36.5%) Italy,Spain (11.2%) Spain (8.7%) France (30.6%) Czech Republic (9.3%) Italy (5.8%) United Kingdom (30.1%) France (8.6%) United Kingdom Italy (29.3%) France, Czech Republic (4.8%) 15–34 years

Estimated number of users 42 million 17.5 million 10 million in Europe European average 31.2%13% 7.3%

Range 2.9–49.5%1.9–20.3%1.5–15.5%

Lowest-prevalence countries Romania (2.9%) Malta (1.9%) Greece, Lithuania, Malta (4.8%) Greece (3.2%) Sweden (1.5%) Bulgaria (8.7%) Cyprus (3.4%) Bulgaria (1.7%) Cyprus (9.9%) Bulgaria (3.5%) Highest-prevalence countries Denmark (49.5%) Spain (20.3%) Spain (15.5%) France (43.6%) Czech Republic (19.3%) France, Czech Republic (9.8%) United Kingdom (41.4%) France (16.7%) United Kingdom (9.2%) Spain (38.6%) Italy (16.5%) 15–24 years

Estimated number of users 20 million 11 million 6million in Europe European average 30.7%16.7%9.1%

Range 2.7–44.2%3.6–28.2%1.2–18.6%

Lowest-prevalence countries Romania (2.7%) Greece, Cyprus (3.6%) Greece (1.2%) Malta (4.9%) Sweden (6.0%) Sweden (1.6%) Cyprus (6.9%) Bulgaria, Portugal (6.6%) Cyprus, Lithuania (2.0%) Greece (9.0%) Highest-prevalence countries Denmark (44.2%) Czech Republic (28.2%) Spain (18.6%) Czech Republic (43.9%) Spain (24.3%) Czech Republic (15.4%) France (42.0%) France (21.7%) France (12.7%) United Kingdom (39.5%) United Kingdom (20.9%) United Kingdom (12.0%)

Information based on the last survey available for each country. The study year ranges from 2001 to 2007. The average prevalence for Europe was computed by aweighted average according to the population of the relevant age group in each country. In countries for which no information was available, the average EU prevalence was imputed. Populations used as basis: 15–64 (328 million), 15–34 (134 million) and 15–24 (64 million). The data summarised here are available under ‘General population surveys’ in the 2008 statistical bulletin.

40 Chapter3:Cannabis

representingapproximately2–2.5% of allEuropeans in States in assessing theimplications of more problematic this agegroup (43). formsofcannabisuse on public health andinplanning appropriate interventions(45). Trends in intensivecannabisuse in Europe aredifficultto assess, butamong thecountriesparticipating in both field Patterns of cannabis useamong school students trials in 2004 and2007(Ireland,Greece, Spain, France, Italy, Netherlands, Portugal), theaverage increase was HBSC datashowthatfrequentcannabisuse remainsrare about20%,althoughthis estimation is largelyinfluenced among15-year-old schoolchildren.Onlysix countries by thefiguresofSpain,Franceand Italy. report aprevalenceoffrequentcannabisuse (definedhere as 40 timesormoreduringthe previous 12 months)above Repeated useofcannabiscan be fairly stable over long 2%.However,frequentuse is generallymoreprevalent periodsoftime, even amongyounger users. Arecently amongmales,withestimatesupto5%inseven countries. publishedGermanstudy,which followed up for10years Reportsindicatethatcorrelations existbetween themore acohort of 14-to24-year-olds, showed that amongthose problematic patterns of cannabis useand belongingto whohad used cannabis repeatedly (five timesormore avulnerablegroup (e.g.young offenders, truants, low in theirlife) at thebeginning of thestudy period,alarge educationalachievers), suggesting that specific strategies proportion continued to usethe drug,with56% reporting areneeded to provideasafetynet forthese particularly useafter four yearsand 46 %still usingthe drug after vulnerable youngpeople. This issueishighlighted in the 10 years. Conversely, occasionaluse of thedrug at the 2008 selected issueonvulnerablegroups. beginning of theperiod(one to four times) didnot appear to be associated with subsequent developmentoflong-term An investigation of polydrug usehas been made in andmoreproblematic formsofuse (Perkonigg, 2008). cooperationwithESPAD by comparing school students aged 15–16 yearsin2003who have used cannabis Cannabis dependencehas been increasingly recognised duringthe previous 30 days with theother students. as apossible consequenceofregular useofthe drug, The comparison showsthat, on average, students who even if theseverityand consequences mayappear have used cannabis aremorelikelytohaveusedother less serious than thosecommonly foundwithsome substances.Althoughamong cannabis usersthe last otherpsychoactivesubstances.Nevertheless,due to monthprevalenceofother drug useremained low(below therelativelylarger proportion of thepopulationusing 10 %),levelsofcigarette smokingand binge drinking cannabis regularly, theoverall impact of intensiveforms of amongcannabisuserswas aboutdoublethat(80 %) cannabis useonpublichealthmay be significant. Analysis foundamongthe generalstudent population. These of nationalpopulationsurvey datafor theUnited States comparisonsindicatethatcannabisuse is associated with revealsthataround20–30 %ofdaily usersscoredpositive considerablyhigher than averagerates of both licitand fordependencebetween 2000 and2006(44). In an illicitdrug use(46). Australianstudy,92% of long-termcannabisuserswere classifiedashavingbeendependent at some pointintheir Trends in cannabis use life, with more than half of them judged to be dependent at thetimeofthe study. Afollow-up studycarriedout Only Sweden andNorwayreportaseriesofsurveysof oneyearlater suggested that,among long-termusers, youngpeopleorconscripts datingback to the1970s.A measures of cannabis useand dependencemay be stable first wave of usewas observedinthe 1970s, followed by forthis length of time (Swift et al., 2000). adecline in the1980s andanew substantial increase duringthe 1990s. Analysis of year of initiation in recent The EMCDDA is developing, in collaborationwithseveral surveysalsoidentified substantialcannabisuse expansion countries, methodsfor monitoringthe more intensiveand in Spain(mid-1970s) andGermany (early 1990s) (see the significantlong-term formsofcannabisuse,including 2004 and2007annual reports). dependence. Psychometric scales arebeing tested in severalEUcountriesand theavailable evidencewillbe Nationalsurvey datareported to theEMCDDAshow analysed this year.This information mayassistEUMember that in almost all EU countriescannabisuse increased

(43)The European averages presented arearoughestimation basedonaweighted average(forthe population) forcountrieswithinformation.The averageresultisimputed forcountrieswithout information.The figuresobtainedare 1.2% forall adults (15–64 years) and2.3 %for youngadults (15–34 years).See TableGPS-7 in the2008statisticalbulletin. (44)NSDUH online analysis facility (http://webapp.icpsr.umich.edu/cocoon/SAMHDA/SERIES/00064.xml), accessedon25February 2008 and analysed usingvariables MJDAY30A andDEPNDMRJ. (45)Interventions,e.g.forms of treatment, arepresented in ‘Treatment provision’,p.44. (46)The analysis is basedondata from thedatabase producedwithinthe European school survey project on alcohol andother drugs(ESPAD),and is in line with therules forthe useofthe ESPADdatabase.The nationalprincipal investigatorsproviding datafor each of thecountriesincludedcan be foundonthe project’s website(www.espad.org). 41 Annual report 2008:the stateofthe drugsproblem in Europe

markedly duringthe 1990s, in particular amongyoung school students.AcomparisonofHBSCdataof people(Figure 4) andschoolstudents. Around theyear 2001/02and 2005/06shows astableordecreasing 2000,lifetimeprevalenceofcannabisuse amongthe trendinbothlifetimeand othermorefrequentcannabis 15–34 agegroup increasedtolevelsinexcessof30% useamong 15-year-old school students in most EU in nine countriesand around 40 %intwo cases, while countries(49). Otherrecentnationalschoolsurveys last year prevalencereached 15–20 %inseven countries conducted in Spain, Portugal,Slovakia, Sweden andthe andlast monthprevalence8–15 %insix countries. Of United Kingdom also report stable or decreasing trends. particular interest is thetrend in cannabis useinthe United Kingdom (England andWales), thecountry that As cannabis availability in Europe as awhole does reported thehighestprevalenceestimatesinEuropeinthe not seem to have changedand prices seem to be earlyand mid-1990s, butwhere more recently asteady decreasing in most countriesproviding information,an downward trendhas been observed, particularly among explanation forthe currentstabilisationordecreasehas the16–24 agegroup (47). to be foundelsewhere.The 2005 Frenchpopulation Information from recent nationalsurveyssuggests that survey Baromètresante noted thatamong thosewho had cannabis useisstabilising in many countries. Of the16 stopped usingcannabis, 80 %cited alack of interest countriesfor whichitispossible to analysethe trendfrom as thereasonfor quitting.Partofthe explanation may 2001 and2006, last year prevalenceamong youngadults also be foundinthe observedreductionintobacco increasedby15% or more in sixcountries, decreasedin smoking, whichsharesthe same routeofadministration 48 threebyasimilar amount andwas stable in seven( ). as cannabis andthe behaviourmay,therefore,be Stable or decreasing trends arealsoevident from the associated at some level(Reitox nationalreports and most recently publisheddataoncannabisuse among Currie et al., 2008).

Figure4:Trends in last year prevalenceofcannabisuse amongyoung adults (aged15–34)

% 25

Spain

20 France

Italy

United 15 Kingdom (¹)

Slovakia

Denmark 10 Germany

Netherlands

5 Finland

Sweden

Greece 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

(1)England andWales. NB:See Figure GPS-4inthe 2008 statisticalbulletinfor furtherinformation. Sources: Reitox nationalreports (2007),taken from populationsurveys, reportsorscientific articles.

(47)See Figure GPS-10 in the2008statisticalbulletin. (48)Where information on theexact yearswas not available,information from thepreviousorfollowing year wasused; wherethis information was unavailable,analysiswas not conducted. (49)See FiguresEYE-4and EYE-5inthe 2008 statisticalbulletin. 42 Chapter3:Cannabis

Decreases in experimentaloroccasionaluse of cannabis Those seekingtreatmentinoutpatientsettingsfor arenot necessarily directlyrelated to trends in theregular primarycannabisuse also report usingother drugs: useofthe drug.This canbeseenindatafromtwo 21 %reportusing alcoholasasecondarysubstance, consecutivesurveysamong adolescentsinGermany,which 12 %amphetaminesand ecstasy, and10%cocaine. have showndecreases in lifetimeand last year prevalence, Amongthose receiving treatmentfor otherprimary drugs, while‘regularuse’ofcannabis(more than 10 timesinthe cannabis is reported as thesecond most frequently cited last year)remained unchanged(2.3%)(BZgA,2004and secondarysubstance (21%)after alcohol(32 %) (54). BZgA,2007, cited in theGermannationalreport). Trends in newdemandsfor drug treatment Amongthe approximately160 000 newdemandsfor Cannabis treatment drug treatment(dataavailable from 24 countries) reported Treatmentdemand patterns in 2006,cannabisclients represent thesecond largest group(28 %),after heroin clients(34 %).Comparedtothe In 2006,among 390000 reported treatmentdemands proportion of allclients reportingcannabisastheir primary (dataavailable from 24 countries),cannabiswas the drug,the proportion amongnew clientsishigher.Half primaryreason forenteringtreatmentinabout 21 %ofall of thecountriesreportthatthe proportion of newclients cases, making it thesecond most reported drug after requesting treatmentfor cannabis as theirprimary drug heroin (50). However, inter-countrydifferences were is increasing.The absolutenumber of newdemandsfor considerable, with cannabis cited as theprimary reason for cannabis treatmentincreased over theperiod2002–06, entering treatmentbyless than 5% of allclients in Bulgaria, whilethe proportion of newclients entering treatmentfor Lithuania, Luxembourg andRomania, whereasitisreported primarycannabisuse increasedbetween 2002 and2005 as theprincipal drug by more than 30 %oftreatmentclients andremained at thesamelevel in 2006 (55).

51 in France,Hungaryand theNetherlands ( ). The increasing trendobservedincannabistreatment There arealsoconsiderablevariationsregarding new demandsmay be linked to anumber of factors: treatmentdemands, with cannabis beingcited as increases in cannabis useorintensive andlong-term theprimary drug by less than 10 %ofnew clientsin use; improvements in datacoverage; recent expansion Bulgaria,Lithuania andRomaniaand by more than 50 % anddiversificationofthe treatmentsystem, whichwas in Denmark, Germany,Franceand Hungary(52). Those previously focusedonheroinusersbut is nowtargeting variations maybeexplained by differences in prevalence usersofother drugs; andchangesinlegislationand policies, sometimes resultinginanincreaseofcannabis of intensivecannabisuse,drug treatmentorganisationor treatmentreferralsbythe criminal justice system referral practices.For instance,insomecountrieswithhigh (EMCDDA,2008a). The recent stabilisationofnew proportionsofcannabispatients(e.g. Germany,Hungary, treatmentdemandslinkedtocannabisuse couldalsobe Austria,Sweden),drug treatmentisoffered as an explained by more recent trends regarding cannabis use, alternative to punishmentand it is sometimes compulsory changesinthe treatmentsystemormodifications of the in theevent of arrest;inFrance, whichreports thehighest routes of referral to treatment. proportion of cannabis clientsinEurope, specialised centresfor cannabis usershaverecentlybeencreated and Clientprofiles this will have adirectimpact on reporting. Cannabis usersenteringtreatmentinoutpatientsettings Cannabis usersare mainly treated in outpatient centres, arepredominantly youngmales,withagenderratio of butinsomecountries(Ireland,Slovakia, Finland, Sweden) 5.2males forevery female andameanage of 24 years. around onethird arereported to seek treatmentin Cannabis is themost frequently reported primarydrug inpatientsettings(53). Most cannabis clientsare reported amongthe youngerage groups.Among thoseentering to be self-referred,but this referral routeisless common treatmentfor thefirsttime, primaryuse of cannabis is amongcannabisclients than amongthose seekinghelp reported by 67 %ofthose aged 15–19 yearsand 80 %of forproblemswithother drugs. thoseyounger than 15 years(56).

(50)See Figure TDI-2(part ii)inthe 2008 statisticalbulletin. (51)See TableTDI-5 (partii) in the2008statisticalbulletin. (52)See TableTDI-4 (partii) in the2008statisticalbulletin. (53)See TableTDI-24inthe 2008 statisticalbulletin. (54)See Tables TDI-22 andTDI-23(part i) and(part iv)inthe 2008 statisticalbulletin. (55)See FiguresTDI-1 andTDI-2 andTablesTDI-3 (partiv) andTDI-5 (partii) in the2008statisticalbulletin. (56)See Tables TDI-10 andTDI-21(part ii)inthe 2008 statisticalbulletin. 43 Annual report 2008:the stateofthe drugsproblem in Europe

Most cannabis clientsappeartoberelativelywellsocially Germanrandomised controlledtrial examiningatreatment integrated in comparison to thoseseeking help for programmefor adolescentswithcannabisdisorder problemswithsomeother typesofdrug.Manyare still ‘Candis’ started in 2004.The programmeisbased on in educationand living in stable accommodation, often motivationalenhancement, cognitivebehavioural therapy with theirparents;however,recentresearch also reports andpsychosocialproblem solving. Initialresults show that asocialprofileofcannabispatientsdiffering from the half of thepatientshad stopped usingcannabisbythe end generalpopulationofthe same agegroup andreporting of thetreatment. Another30% reducedtheir cannabis use. amoredisadvantaged background (EMCDDA, 2008a). Furthermore, anoticeabledecreaseinassociated mentaland Overall, primarycannabisusersenteringtreatmentcan social problemswas reported.Afollow-up studyisplanned. be dividedintothree groups,interms of frequencyof Initiativestoprovide treatmentfor youngcannabisusers use: thosewho useitoccasionally(30 %),those usingit have been reported by severalcountries. In France,about oncetoseveraltimes aweek(30 %) andthose usingit 250cannabisconsultationcentres,providing counselling 57 daily(40 %) ( ). However, considerabledifferences are andsupport to usersand theirfamilies,havebeenset up observedbetween countries, particularly in theproportion throughout thecountry since2005. In Denmark, special of regularcannabisusersenteringtreatment. In those fundshaverecentlybeenallocated forthe development countrieswhere cannabis clientsare more numerous,the of targeted programmes foryoung cannabis users. In proportion of dailyusersvariesfromover70% in the addition, Belgium, Germany,France, theNetherlands and Netherlandsand Denmark, to 40–60 %inSpain,France Switzerlandare collaboratinginaninternationalstudy andItaly,and 20–30 %inGermany andHungary. of theeffectiveness of acomprehensive family-based treatmentfor problematic cannabis use(Incant) (58). Treatmentprovision In Germany,there areattemptstotransferthe Internet- Asurvey commissionedbythe EMCDDA on theprovision of basedcannabiscessationprogramme ‘Quitthe shit’(59), cannabis treatmentinasample of drug treatmentservices whichprovidesinteractivecounselling in collaboration in 19 Member States foundthathalfofthe surveyed with outpatient treatmentfacilities,tomunicipalstructures services didnot have programmes specificallydedicated of youthwelfare anddrug care or facilities of drug to cannabis problems(EMCDDA,2008a). This finding dependenceprevention. suggeststhatmanycannabisusersare treated within thesamesettingsasthe usersofother drugs, whichmay The useofinformation andcommunications technology in present difficulties,bothtotreatmentstaff andtoclients. drug demand reductioninterventions continues to grow in Europe.In2006/07,the availability of counselling Of thespecialist services surveyed, most offeredshort andadviceondrug usewas mentionedbynineMember courses of treatmentfor cannabis useofusually less States,witheight reportingthe useofthe Internet(Czech than 20 sessions. Treatmentgenerally took theform Republic,Germany,Estonia,Netherlands,Portugal, of individual counselling andtherapy or counselling Austria,Slovakia, United Kingdom), whileDenmark aboutthe possible implications of cannabis use. Some reported theuse of SMS. These Internet-basedservices are agenciesreported cannabis detoxification, family therapy, therapeuticcommunity andmutualhelpgroupsaspossible targeted at youngpeopleand focusonproblemsrelated components of treatment. Useofresidential care for to alcoholand cannabis. cannabis treatmentwhen provided wasgenerally in the context of socio-behaviouralproblemsrespite. Cannabis usersincontact with thecriminal justicesystem

The scientific literature in this area suggeststhatanumber Cannabis is theillicitdrug most oftenmentionedinpolice of psychotherapies have been showntobeeffective reportsfor drug law offences (60)inEurope, andoffences forcannabistreatment, includingmotivationaltherapy related to this drug in theEuropeanUnion have increased andcognitive-behavioural therapy, butnoformof by an averageof34% between2001and 2006 (Figure2). psychotherapy hasbeenfound to be more effective than The availabledatashowthatthe majority of reported anyother (Nordstromand Levin, 2007). Although most cannabis offences arerelated to useand possessionfor studiesonthe efficacyofcannabistreatmenthavebeen useratherthantotraffickingand supply; with use-related carriedout in theUnited States andAustralia,European offences in themajorityofreporting countriesaccountingfor studiesare nowbeginning to be launched or reported.A 62–95 %ofall reported cannabis offences.

(57)See TableTDI-18inthe 2008 statisticalbulletin. (58)http://www.incant.eu (59)http://www.drugcom.de (60)See TableDLO-6 in the2008statisticalbulletin. 44 Chapter3:Cannabis

With many drug law offendersbeing youngcannabis furtherdevelopmentofdrug useand re-offending,and users, whomightotherwise not come into contactwith mayinclude family,schoolorpsychologicalcounselling. drug services,there have been reportsofincreasing Afollow-up evaluationofthe GermanFReDprogrammes cooperationbetween judicial authoritiesand prevention foryoung offenders(100respondents)found that 44% andcounselling services in schoolsand youthwelfare facilities.Germany,Spain (Catalonia), Luxembourg and of theex-participantsreducedtheir useofalcoholand Austria have implemented protocolsand programmes tobacco, 79 %reducedorstoppedthe consumption of foryoung peoplebreakingdrug lawsorwho have illicitdrugsand 69 %reported no re-offending since been convicted forthe useorpossessionofdrugs, concluding thecourse. An evaluationofthe similaryouth mostly cannabis. The offender maybegiven thechoice offendingteams (YOT)inthe United Kingdom foundthat of completingacourse, insteadofpayingafine.The this approach hadconsiderablepotential benefits(Matrix programmes offeredinthe variouscountriesaim to prevent Research,2007).

Smokingbansand cannabis regulatorytobaccopoliciescould favourably influence perceived norms, whichare predictorsfor both tobaccoand The possible linksbetween tobaccopoliciesand cannabis cannabis use. smokingisanissue meriting attention. Smokingbansare There is also someevidencethatcannabisisaneconomic becomingmorewidespreadinEurope, andnineMember complement(i.e. respondinginthe same direction to price States nowhavefullsmoking bans (publicand workplaces andavailability)tocigarettes(Cameron andWilliams, 2001). includingrestaurants andbars) in place, andBelgium, Isolated studiesfound that higher cigarette taxes appear Denmark, Germany,the Netherlandsand Portugal have to decrease theintensity of marijuanause andmay have a recently introducedatleast partialsmoking bans. modest negative effectonthe probability of useamongmales The link betweentobaccouse andlater illicitdrug usetends (Farrellyetal.,2001). to fall away when adjusting forunderlyingriskfactors, as has Finally, it is worthnotingthatthe Dutchban on smoking been shownbyareviewofprospective studies(Mathersetal., tobaccoinrestaurants andbarsappliesalsotocoffee shops, 2006). However, in Europe,cannabisuse is more prevalent andthatthe city of Amsterdamhas decidedtoban cannabis amongtobaccosmokers than amongnon-smokers andstrong smokinginpublic.

45

Chapter4 Amphetamines,ecstasy andLSD

Introduction Amphetamine andmethamphetamine arecentral nervoussystemstimulants. Of the twodrugs, Globally, aftercannabis, amphetamines(ageneric term amphetamine is by farthe more commonly available that includes both amphetamine andmethamphetamine) in Europe,whereas significantmethamphetamine use andecstasy areamong themost commonly consumed appearstoberestricted to theCzech Republic and illicitdrugs. In Europe today, in termsofthe absolute Slovakia. numbers, cocaineuse maybehigher,but thegeographic concentration of cocaineinafew countriesmeans that for Ecstasyreferstosynthetic substances that arechemically most of theEuropeanUnion,someformofsynthetically related to amphetamines, butwhich differtosomeextent produceddrug remainsthe second most commonly used in theireffects.The best-known memberofthe ecstasy illicitsubstance.Moreover, in partsofEurope, useof groupofdrugsis3,4-methylenedioxy-methamphetamine amphetamines constitutesanimportant part of thedrug (MDMA),but otheranalogues arealsosometimes problem,accountingfor asubstantial proportion of those foundinecstasy tablets(MDA, MDEA). Ecstasyuse was in need of treatment. virtuallyunknown in Europe before thelate1980s,but increaseddramaticallyduringthe 1990s. Itspopularity hashistorically been linked with thedance-music scene Amphetamineand methamphetamine: and, in general, syntheticdrug useathigh prevalenceis differencesand similarities associated with particular cultural sub-groupsorsocial On theillicitdrugsmarket, themainrepresentatives settings. of theamphetamines groupare amphetamineand Consumption estimatesoflysergicaciddiethylamide(LSD), methamphetamine(andtheir salts) —two closelyrelated syntheticsubstances,members of thephenethylamine by farthe most widely knownhallucinogenic drug,have family.Bothsubstances arecentral nervoussystem been lowand somewhatstablefor aconsiderabletimein stimulants, sharingthe same mechanismofaction, and Europe.However,there appearstobeagrowing interest having similarbehavioural effects,tolerance,withdrawal amongyoung peopleinnaturally occurringhallucinogenic andprolonged (chronic)use effects.Amphetamineis substances. less potent than methamphetamine, butinuncontrolled situations theeffects arealmostindistinguishable. Amphetamineand methamphetamineproductsmostly Supply andavailability consist of powders, but‘ice’,the pure crystalline hydrochloridesaltofmethamphetamineisalso Amphetamine used.Tablets containingeitheramphetamineor methamphetaminemay carrylogos similartothose seen on Globalamphetamine production, estimated at 126 MDMA andother ecstasytablets. tonnes in 2006,remainsconcentrated in Europe,which Given thephysicalforms in whichtheyare available, accounted for79% of allamphetamine laboratories amphetamineand methamphetaminemay be ingested, reported in 2006 (UNODC,2008),thoughitisspreading snorted,inhaled and, less commonly,injected.Unlike to otherparts of theworld,notably NorthAmerica thesulphate salt of amphetamine, methamphetamine andsouth-east Asia (61). Globally, over 19 tonnes of hydrochloride, particularly thecrystallineform(‘ice’),is sufficiently volatiletobesmoked. amphetamines wasseizedin2006, most of whichwas intercepted in theNearand Middle East (67%), linked to Source: EMCDDA drug profiles (http://www.emcdda.europa.eu/ ‘Captagon’tablets (62)producedinsouth-easternEurope, publications/drug-profiles/methamphetamine). followed by amphetamine seizures made in westernand centralEurope(27 %),reflecting Europe’s role as both a

(61)For information on thesources of data fordrug supplyand availability,see p.36. (62)Captagon is one of theregisteredtrade namesfor fenetylline, asynthetic centralnervous system stimulant,althoughtablets soldwiththis logo on the illicitmarketare commonly foundtocontain amphetaminemixed with caffeine. 47 Annual report 2008:the stateofthe drugsproblem in Europe

majorproducer andconsumerofthis drug (CND,2008; Methamphetamine UNODC,2008). Productionofmethamphetamine is concentrated in North Most amphetamine seized in Europe is produced, in order Americaand east andsouth-east Asia.In2006, global of importance,inthe Netherlands, Poland andBelgium, productionofmethamphetamine wasestimated at 266tonnes, andtoalesserextentinEstonia andLithuania.In2006, exceedingthatofany of otherillicitsynthetic drug.About 40 sitesinvolved in theproduction, packagingorstorage 15.8 tonnes of methamphetamine wasrecovered worldwidein of amphetamines were discovered in theEuropeanUnion 2006,most of whichwas seized in east andsouth-east Asia, (Europol,2007a); andthe UNODC (2008) reportsthat followed by NorthAmerica, andless than 1% of seizures 123laboratoriesweredismantledinEuropeancountries. originatingfromEurope(UNODC,2007a,2008). Turkey reported seizures of about20million amphetamine tabletswiththe logo ‘Captagon’. Internationalactionagainst themanufacture Productionofamphetamineinthis form is reported in anddiversion of syntheticdrug precursors both Bulgaria andTurkey, andisthought to be largely intended forexportation to consumercountriesinthe Lawenforcementefforts increasingly target theprecursor Near andMiddleEast. chemicals necessary forillicitdrug productionasan additionalcounter-measure,and this area is one in In Europe,anestimated 38 000 seizures amountingto whichinternationalcooperation is particularly valuable. 6.2tonnesofamphetaminepowderweremadein2006. Project Prismisaninternationalinitiativeset up to prevent Whilethe provisionalfiguresfor 2006 suggest adecline thediversion of precursor chemicals used in theillicit from thehigher levels reported in 2004 and2005, both manufactureofsynthetic drugs, throughasystemofpre- export notifications forlicittrade andthe reportingof seizures andthe amount of amphetamines intercepted shipments stopped andseizuresmadewhen suspicious 63 have increasedoverthe five-year period 2001– 06 ( ). transactions occur. Information on activities in this area However, this conclusionisprovisionalasthe most recent arereported to theInternationalNarcotics ControlBoard datafromthe United Kingdom,the country in Europe (INCB, 2008b).

whichtypically reportsthe most seizures,are not yet Globally, reportssuggest that over 11 tonnes of available. Seizures of amphetaminetablets,asopposed ephedrineand pseudo-ephedrine, keyprecursorsof to powder,are increasingly beingreported by afew methamphetamine, were seized in 2006.China accounted countries, with atotal of 390000 tabletsseizedinthe foraroundhalfofthis totalfollowedbyCanada and European Union(mostly in Spain) in 2006. Myanmar.EUMemberStates(mainly Belgiumand Hungary) together with theRussian Federation andUkraine The purity of amphetaminesamplesintercepted in accounted foronly0.3 tonnes,althoughEuropol (2008) Europe in 2006 variedconsiderablyand to such an reportsarecentincreaseinthe exportation, transhipment extent that anycomment on typicalvalues must be made anddiversion of these chemicalsinthe European Union. with caution. Nevertheless,countriesreporting data for Globalseizuresof1-phenyl-2-propanone (P-2-P), whichcan 2006 canbedividedintotwo groups,with10countries be used forthe illicitmanufacture of both amphetamine andmethamphetamine, declined in 2006.Anexception reportingvalues of between2%and 10 %and theothers to this trendwas theEUMemberStates(mainly Denmark, reportinghigher purity levels (25–47 %).This lattergroup Netherlands, Poland)along with Turkey andthe Russian typicallyincludedthose countriesknown forhaving Federation,which together accounted formost of the greaterinvolvementwiththe production, trafficking or global seizures of 2600 litres of P-2-P. This precursor is consumption of amphetamine(Netherlands, Poland,Baltic predominantlyusedfor amphetamineproductioninEurope andNordiccountries).Overthe past fiveyears,the purity with manufacturerstypically sourcingP-2-P from Asian countries(China),althoughsince 2004 it hasalsoreported of amphetaminehas been stable or fallinginmost of those to have been sourcedand traffickedfromthe Russian 19 countrieswhere sufficient dataare availabletoallow Federation (Europol,2007a). an analysis. Globalseizuresof3,4-methylenedioxyphenyl-2-propanone In 2006,the typicalretailpriceofamphetaminevaried (3,4-MDP-2-P), used to manufactureMDMA, decreasedin betweenEUR 10 andEUR 15 agraminhalfofthe 2006 to 7500 litres,ofwhich Canada accounted forall reportingcountries. Over theperiod2001–06,withthe except 105litresseizedbythe Netherlands. Seizures of safrole,which mayreplace3,4-MDP-2-P in thesynthesis of exceptionofthe CzechRepublic,Spain andRomania, MDMA,remained marginal in 2006,with62litresseized theretailpriceofamphetaminewas reported to have worldwide, mostly in Australia;inEurope, only France fallen in all16countriesreporting sufficient datafor reported aseizure of safrole (7 litres). analysis.

(63)The data on European drug seizures mentionedinthis chaptercan be foundinTablesSZR-11toSZR-18inthe 2008 statisticalbulletin. Note that wheredata for2006are absent,the correspondingdata for2005are used to estimate European totals. 48 Chapter4:Amphetamines,ecstasy andLSD

Illicitproductionofmethamphetamine does occurin marketed as ecstasyfrequentlyfound amphetamine or Europe,thoughitislargely limited to theCzech Republic, methamphetamine to be present,often in combination with whereover400 small-scale‘kitchenlaboratories’ were MDMA or one of itsanalogues.InLatviaand Malta, most detected in 2006.The drug is also reported to be tabletsanalyseddid not contain anycontrolledsubstance. producedinSlovakiaand,toalesserextent, Lithuania Most countriesreported that thetypical MDMA content of (INCB, 2008a). ecstasytablets wassomewhere between25and 65 mg — About3000 seizures of methamphetamine amounting although therewas considerablevariation in thesamples to 154kgofthe drug were reported in 17 European analysed (9–90 mg). In addition, high-doseecstasy tablets countriesin2006. Norway accountsfor most seizures containingover130 mg of MDMA were reported by andamounts recovered, followed by Sweden,the Czech somecountries(Belgium, Denmark, Germany,France, Republic andSlovakia. In thelattertwo countries, Netherlands, Norway)and high-quality MDMA powder seizures tended to be small, usuallyofafew gramsor hasnow become availableinsomemarkets.Noclear less.Between 2001 and2006, both thenumber andthe medium-termtrend is observableinthe MDMA content quantity of methamphetamine seized in Europe have been of ecstasytablets.Itisclear,however,thatincomparison increasing;thoughstill remaininglow in comparison to to when thedrug first becamewidelyavailable in Europe otherdrugs. In 2006,the limited dataavailable suggest in theearly 1990s, ecstasyhas become considerably that thetypical purity of methamphetamine fell somewhere cheaper. Although thereare somereports of tabletsbeing between20% and55%. sold foraslittleasEUR 1, most countriesnow report typicalretailprices in therange of EUR3–9per tablet, Ecstasy andthe dataavailable for2001–06 suggest that theretail price(adjusted forinflation) hascontinued to fall. Globalecstasy productionisreported by theUNODC (2007a)tohavefallentoaround102 tonnes in 2006. Productionappears to have become more geographically LSD diffuse,withmanufacturefor localconsumption now LSDuse andtraffickingisstill consideredmarginal, more common in NorthAmericaand east andsouth-east although seizures in Europe arepossibly suggestive of a Asia.Despitethis,Europeremainsthe main locationfor revival in interest in thedrug in thelast fewyears.After ecstasyproduction, with manufactureconcentrated in along-term downward trenddatingback to the1990s, theNetherlands (where,after afew yearsofdecline, both thenumber andthe quantity of seizures have been productionmay have increasedagain in 2006), Belgium increasing since2003. The currentsituationisunclear, and, to alesserextent, Poland andthe United Kingdom. as although thedataprovisionallyavailable indicates a The relativeimportanceofEuropeasbothaconsumerand slightdecline in both measures,the United Kingdom,the producer of ecstasycan be seen from thedataondrug country that usuallyreports thegreatestquantitiesofLSD seizures.Europereported over 20 000 seizures resulting seized,has not yetreported.LSD retail prices (adjusted in theinterceptionofnearly14million ecstasytablets forinflation) have been slightlydeclining since2001, and in 2006.The Netherlandsaccounted forthe largest rangedin2006between EUR5and EUR11per unit in quantity of ecstasyseized(4.1million tablets),followed most European countries. by theUnited Kingdom,Turkey, France andGermany. Overall, thenumber of ecstasyseizureshas decreased Prevalence andpatternsofuse over theperiod2001–06,and thequantityseizedhas also declined,after apeakyearin2002(64). Of the4.5 AmongEUMemberStates, useofamphetamines or tonnes of ecstasyseizedworldwide in 2006,western ecstasyisrelativelyhigh in:the CzechRepublic,Estonia andcentral Europe accounted for43%;asapoint of andthe United Kingdom;and relativelyhigh,inrespect comparison,North Americaaccounted for34% (UNODC, to theoverall nationaldrug situation, in somecentral 2008). andnorthernEuropeancountries. In contrast,overall, consumption levels of synthetichallucinogenic drugssuch In Europe,most ecstasytablets analysed in 2006 contained as lysergicaciddiethylamide(LSD)are lowerand have MDMA or anotherecstasy-likesubstance (MDEA,MDA) been largelystablefor aconsiderableperiod. as theonlypsychoactivesubstance present,with17 countriesreporting that this wasthe case in over 70 %of Higherprevalencelevelsinsomecountriesneed to be thetotal number of tabletsanalysed. Spainand Poland understood in thecontext of,insimpleterms at least, were exceptions,reporting that theanalysisoftablets twodistinctconsumption patterns.Inalimited number of

(64)This pictureispreliminaryasdata forthe United Kingdom,the country reportingthe most seizures in 2005,are not yetavailablefor 2006. 49 Annual report 2008:the stateofthe drugsproblem in Europe

TheEuropeanstimulant market:‘cocainecountries’ and‘amphetamines countries’?

Asynthesis of information from avariety of sources suggests data from generalpopulationsurveysand reportsofseizures that different stimulant drugsmay playasimilar role in different suggeststhatnorthernand centralEuropeancountriesgenerally countriesand,therefore,itmay be wise when developing tend to belong to an ‘amphetamines group’,while in the policy in this area to considernot only theindividual countriesinthe west andsouth of Europe,cocaine uselargely substances butalsothe stimulant market as awhole.Insome predominates. countries, cocaineappears to be thedominantstimulant drug, The relativeimportanceofstimulantsinthe overalldrug whileinothers, amphetamineormethamphetamineappear problem also variesgreatly betweencountries. This can more commonly used.The picturethatemerges from combining be seen in treatmentdata where, forarestricted groupof

Stimulant marketsinEurope: therelativeprevalenceofcocaine or amphetamines in seizures andpopulationsurveys, andthe proportion of drug usersintreatmentreporting these substances as primarydrugs

'4.1$!) 1!, 1"3%)-1"$!)/ )2+1##& 30)/)!- '4.1$!) 30)(1$#/ *"3%)-1"$!)/ 30)(1$# '4.1$!) -0)1-")!- *"3%)-1"$!)/ -0)1-")!-

50 Chapter4:Amphetamines,ecstasy andLSD

countries, theuse,often by injection, of amphetamineor methamphetamine accountsfor asubstantial proportion of theoverall number of problem drug usersand those countries, stimulant drugsare responsible forarelatively seekinghelpfor drug problems. In contrast to these high proportion of alldemandsfor drug treatment chronicpopulations,amoregeneral associationexists (methamphetamineinthe CzechRepublic andSlovakia; betweensynthetic drugs, ecstasyinparticular, and amphetamineinLatvia, Sweden andFinland;and cocaine in Spain, Italyand theNetherlands); whileelsewhere, nightclubs, dancemusic andsomesub-cultures; this results theproportionoftreatmentclients reportingany of these in significantlyhigher levels of usebeing reported among substances as theirmainreason forseeking help is very low, youngpeople, comparedwiththe general population, andsometimes even negligible. andexceedinglyhigh levels of usebeing foundinsome Data from treatmentclients also suggeststhatthose being settings or specific sub-populations. treated forproblemscausedbystimulant drugstendtobe experiencingproblemswithonlyone classofstimulants. Amphetamines Forexample,amongthose receiving treatmentfor cocainein outpatientsettings(alldemands),onlyaround8%reported Recent populationsurveysindicatethatlifetimeprevalence amphetamines as theirsecondarydrug;while among of theuse of amphetamines (65)inEuropevariesbetween amphetamineclients,less than 9% reported cocaineas countries, from 0.1% to 11.9 %ofall adults (15–64 years). asecondaryproblem drug.Moreover, reportsfromsome countriessuggest that one stimulant cansometimes displace On average, 3.3% of allEuropeanadults report having anotheronthe drugsmarket. Forexample,data exists to used amphetaminesatleast once. Useofthe drug in the suggest that:cocaine maybereplacingamphetamines and last year is much lower, with aEuropeanaverage of 0.6% ecstasyamongsomedrug-using populations;and,inthe (range 0.0–1.3%). The estimatessuggestthataround Netherlands, amphetamines maybeusedasacheaper 11 millionEuropeans have triedamphetamines, andabout substitute forcocaine outside of urbanareas. 2million have used thedrug in thelast year (see Table3 Whilestimulant drugsmay differ in theireffects and forasummaryofthe data). consequences,inrespecttodrug treatmentthe options, rates of retentionand outcomesare broadlysimilar (Rawson et Amongyoung adults (15–34 years),lifetimeprevalenceof al., 2000;Copeland andSorensen, 2001). amphetamineuse variesconsiderablybetween countries, To someextent, similarities canalsobeseeninpatterns from 0.2% to 16.5 %, with aEuropeanaverage of about by whichthese drugsare used andinthe overalltypology of users. Forexample,recreationaland less intensive 5%.Last year useofamphetamines in this agegroup anddamagingpatternsofuse amongsociallywell- rangesfrom0.1 %to2.9 %, with themajorityofcountries integrated userscan coexistwithintensive useamong reportingprevalenceestimatesofbetween 0.7% and more marginalised groups,withgreater association 1.9%.Itisestimated that,onaverage,1.3 %ofyoung with dependenceproblemsand more riskymodes of Europeanshaveusedamphetaminesinthe last year. administration,suchasinjection andsmoking.

Problem amphetamineuse TheEMCDDAindicator on problem drug use(PDU) canbeusedinarestricted sensefor amphetamines, whereitdefinesassuchthe injectingorlongduration/ regularuse of thesubstance.Onlyone Member State (Finland)has provided arecentnationalestimate of problem amphetamine use, whichin2005was estimated to amount to between12000 and22000 problem NB:The background colourindicates therelative dominance of amphetamine users(4.3to7.9 casesper 1000,aged cocaineoramphetamines according to generalpopulation surveys(prevalenceofuse in thelast year amongthe 15–54 years),about four timesthe estimated number of populationaged15–34)and data on seizures;pie charts problem opioid usersinthe country. represent theproportionsofall drug treatmentrequests accounted forbythese twodrugs—onlysegments representingcocaine andamphetamines aredisplayed. For The number of reported treatmentdemandsrelating Italy, theNetherlands andPoland,where data on seizures to theuse of amphetamineisrelativelysmall in most were unavailable,onlydata from populationsurveys were used.For Croatia, only seizures datawereused. For European countries. Treatmentfor theuse of amphetamine Norway andBelgiumtreatmentdata were unavailable.The data available forRomaniadid not permit inferences to be accountsfor asizeableproportionofthe overallreported made forthe country as awhole.Inthe CzechRepublic andSlovakia, methamphetamineisthe amphetaminemost commonly used. (65)Survey data on ‘amphetamineuse’often do not distinguish between amphetamineand methamphetamine, though, typicallythis will be related to theuse of amphetamine(sulphate or dexamphetamine),as useofmethamphetamineisuncommon in Europe,withless than 1% of world methamphetamineseizuresreported from this continent. 51 Annual report 2008:the stateofthe drugsproblem in Europe

treatmentdemand in Latvia,Swedenand Finland, where been reported by Latvia andDenmark,while in Sweden between25% and35% of drug clientsenteringtreatment andFinland thepercentageofnew amphetamine clients reported amphetamine as theirprimary drug problem. declined,possibly suggesting an ageing population(67). Otherthaninthese countries, treatmentfor amphetamine Amphetamineusersenteringtreatmentare,onaverage, accountsfor more than 5% of reported drug treatment around 29 yearsold andmale. Although themaleto only in Denmark, Germany,the Netherlandsand Poland, female ratioisaround2:1,the overallproportionof wherebetween 6% and9%ofusersintreatmentreport femalesamong amphetamine clientsishigher than that 66 amphetamine as theirprimary drug ( ). foundfor otherdrugs(68). In most countries, though not in Sweden andFinland,the proportion of newclients entering treatmentfor primary Problem methamphetamineuse amphetamine useisgreater than theproportionofall In contrast to otherparts of theworld,where theuse clientsreceivingtreatmentfor this drug.From2002to of methamphetamine hasincreased in recent years, 2006,the proportion of newclients entering treatmentfor levels of itsuse in Europe appear limited (Griffithsetal., primaryamphetamine usehas been relativelystablein 2008). Historically,use of this drug in Europe hasbeen Europe as awhole,thoughoverthis period an increase has concentrated in theCzech Republic and, to someextent,

Table 3: Prevalence of amphetamines use in the general population —summaryofthe data

Age group Time frame of use

Lifetime Last year

15–64 years

Estimated number of users in Europe 11 million 2million

European average 3.3%0.6%

Range 0.1–11.9%0.0–1.3%

Lowest-prevalence countries Greece (0.1%) Greece, Malta (0.0%) Romania (0.2%) France (0.1%) Malta (0.4%) Portugal (0.2%) Cyprus (0.8%) Highest-prevalence countries United Kingdom (11.9%) United Kingdom, Estonia (1.3%) Denmark (6.9%) Norway,Latvia (1.1%) Norway (3.6%) Ireland (3.5%) 15–34 years

Estimated number of users in Europe 7million 2million

European average 5.1%1.3%

Range 0.2–16.5%0.1–2.9%

Lowest-prevalence countries Greece (0.2%) Greece (0.1%) Romania (0.5%) France (0.2%) Malta (0.7%) Cyprus (0.3%) Cyprus (0.8%) Portugal (0.4%) Highest-prevalence countries United Kingdom (16.5%) Estonia (2.9%) Denmark (12.7%) United Kingdom (2.7%) Norway (5.9%) Latvia (2.4%) Spain, Latvia (5.3%) Denmark (2.2%)

Information based on the last survey available for each country. The study year ranges from 2001 to 2007. The average prevalence for Europe was computed by aweighted average according to the population of the relevant age group in each country. In countries for which no information was available, the average EU prevalence was imputed. Populations used as basis: 15–64 (328 million), 15–34 (134 million) and 15–24 (64 million). The data summarised here are available under ‘General population surveys’ in the 2008 statistical bulletin.

(66)See TableTDI-5 (partii) in the2008statisticalbulletin. (67)See Figure TDI-1and Tables TDI-4(part ii), TDI-5(part ii)and TDI-36 in the2008statisticalbulletin. (68)See TableTDI-37inthe 2008 statisticalbulletin. 52 Chapter4:Amphetamines,ecstasy andLSD

Slovakia. Only these twocountriesreportrecentestimates estimate at 0.3% andthe highestat12%,reflecting the of problem use. In 2006,inthe CzechRepublic there different experiences of someMemberStates. were estimated to be approximately17500–22 500 Amongschoolstudents, largeincreases in prevalence methamphetamine users(2.4to3.1 casesper 1000 levels mayoccur with smallincreases in age, forexample aged 15– 64 years),almosttwice theestimated number dataavailable from 16 countriesshowthat, compared of problem opioid users; andinSlovakia, approximately to younger students,lifetimeprevalenceofecstasy use 6200–15 500methamphetamine users(1.6to4.0 cases among17- to 18-year-old school students is generally per1000 aged 15– 64 years),around20% fewerthan considerablyhigher,suggesting that first useofthe drug theestimated number of problem opioid users. commonly takesplaceafter theage of 16 ( 71). In thelast fiveyears,the reported demand fortreatment Despitethe number of ecstasyusersinEuropebeing related to methamphetamine usehas been increasing similartothatofamphetamine, very feware seen by in both countries. Methamphetamine hasbecome the treatmentservices. In 2006,inmost countries, less than primarydrug most oftenreported by thoserequesting 1% of drug usersenteringtreatmentmentionedecstasy treatmentfor thefirsttimeinSlovakia, whereitaccounts as theirprimary problem drug andinmost countriesonly for25% of alldrug treatmentrequests.Inthe Czech atrivial number of clientsare beingtreated forecstasy- Republic,59% of alldrug treatmentclients report related problems. Only fivecountriesreporthavingmore methamphetamine as theirprimary drug (69). Clients than 100ecstasy clientsenteringtreatment(France, in treatmentfor methamphetamine report high ratesof Italy, Hungary, United Kingdom,Turkey),representing injectingdrug use: around 50 %inSlovakiaand 80 %in between0.5 %and 4% of alldrug clientsinthese theCzech Republic. countries. With an averageage of 24–25 years, users of ecstasyare amongthe youngest groups entering drug Ecstasy treatmentand regularlyreportthe concomitantuse of It is estimated that about9.5 millionEuropeanadults have othersubstances, includingcannabis, cocaine, alcohol triedecstasy (3 %onaverage)and that about3million andamphetamines(72). (0.8 %) have used it in thelast year (see Table4for asummaryofthe data).Considerablevariation exists LSD betweencountries, with recent surveyssuggesting that Lifetime prevalenceofLSD useamong theadultpopulation between0.3 %and 7. 3% of alladults (15–64 years) have (15–64 years) rangesfromalmostzeroto5.4%. Among ever triedthe drug,and with most countriesreporting youngadults (15–34 years),lifetimeprevalenceestimates lifetimeprevalenceestimatesinthe range 1.3–3.1%. arealittlehigher (0.3 %to7.1 %),althoughlower prevalence Useofthe drug in thelast year variedacrossEurope, from levels arereported amongthe 15-to24-year-olds. In contrast, 0.2% to 3.5%.Onall measures,and as with most other in thefew countriesproviding comparabledata, theuse of illicitdrugs, reported usewas farhigher amongmales LSDisoften exceeded by that of hallucinogenic mushrooms, than amongfemales. wherelifetimeprevalenceestimatesfor youngadults range Ecstasyconsumption wasmorecommon amongyoung from 1% to 9%,and last year prevalenceestimatesbetween adults (15–34 years),where lifetimeprevalenceestimates 0.3% and3%(EMCDDA,2006). rangedatnationallevel from 0.5% to 14.6 %, with between0.4 %and 7. 7% of this agegroup reporting Trends in theuse of amphetamines andecstasy usingthe drug in thelast year.Itisestimated that 7. 5 Reportsofstabilising or even decreasing trends in millionyoung Europeans(5.6%)haveevertriedecstasy, amphetamine andecstasy consumption in Europe are with around 2.5million (1.8 %) reportinguse in thelast supported by themost recent data. Aftergeneral increases year.Estimatesofprevalenceare higher still if attentionis in the1990s, populationsurveysnow pointtoanoverall restricted to ayoungerage band:among the15–24 age stabilisation, or even moderate decrease,inthe popularity of group, lifetimeprevalencerangesfrom0.4 %to18.7%, both drugs, although this patternisnot seen in allcountries. though most countriesreported estimatesinthe 2.5–8% range (70). Although most countriesreported estimatesof Amphetamineuse (last 12 months)among youngadults (15– 1.3–4.6% foruse in thelast year by this agegroup,there 34)inthe United Kingdom declined substantiallybetween wasaconsiderabledifferencebetween thelowestnational 1996 (6.5 %) and2002(3.1%), with thefiguresremaining

(69)See TableTDI-5 (partii) in the2008statisticalbulletin. (70)See TableGPS-17inthe 2008 statisticalbulletin. (71)See Tables EYE-1and EYE-2inthe 2008 statisticalbulletin. (72)See Tables TDI-5and TDI-37 (parti), (partii) and(part iii)inthe 2008 statisticalbulletin. 53 Annual report 2008:the stateofthe drugsproblem in Europe

Table 4: Prevalence of ecstasy use in the general population —summaryofthe data

Age group Time frame of use

Lifetime Last year

15–64 years Estimated number of users 9.5 million 2.6 million in Europe European average 2.8%0.8%

Range 0.3–7.3%0.2–3.5%

Lowest-prevalence countries Romania (0.3%) Greece, Malta (0.2%) Greece (0.4%) Denmark, Poland (0.3%) Malta (0.7%) Lithuania (1.0%) Highest-prevalence countries United Kingdom (7.3%) Czech Republic (3.5%) Czech Republic (7.1%) United Kingdom (1.8%) Ireland (5.4%) Estonia (1.7%) Spain (4.4%) Slovakia (1.6%) 15–34 years Estimated number of users 7.5 million 2.5 million in Europe European average 5.6%1.8%

Range 0.5–14.6%0.4–7.7%

Lowest-prevalence countries Romania (0.5%) Greece (0.4%) Greece (0.6%) Italy,Poland (0.7%) Malta (1.4%) Denmark, Lithuania, Portugal (0.9%) Lithuania, Poland (2.1%) Highest-prevalence countries Czech Republic (14.6%) Czech Republic (7.7%) United Kingdom (13.0%) United Kingdom (3.9%) Ireland (9.0%) Estonia (3.7%) Slovakia (8.4%) Netherlands, Slovakia (2.7%)

Information based on the last survey available for each country. The study year ranges from 2001 to 2007. The average prevalence for Europe was computed by aweighted average according to the population of the relevant age group in each country. In countries for which no information was available, the average EU prevalence was imputed. Populations used as basis: 15–64 (328 million), 15–34 (134 million) and 15–24 (64 million). The data summarised here are available under ‘General population surveys’ in the 2008 statistical bulletin.

stable thereafter.Amarkedincreaseinamphetamine use males(75)and in studiesofsomespecific recreational is reported in Denmarkbetween 1994 and2000,but the settings. Aftergeneral increases in useinsomeEuropean resultsofthe 2005 survey indicateadecreaseinthe use countriesinthe late1980s andearly 1990s, leadingto of this substancesince thebeginning of this decade (73). similarlevelsofecstasy useinGermany,Spain andthe Amongthe othercountriesreporting repeated surveysover United Kingdom in themid-1990s, last year prevalence asimilar time span (Germany,Greece, Spain, France, of usehas remained consistentlyhigher in theUnited Netherlands, Slovakia, Finland),the trends arelargely Kingdom comparedtothe othercountries(76). Over stable (74). During thefive-yearperiod2001–06,ofthe 14 thefive-yearperiod, 2001– 06,last year prevalenceof countrieswithsufficient dataonlast year prevalenceof ecstasyuse amongyoung adults decreasedinthree of amphetamineuse amongthe 15–34 agegroup,three report the14countriesproviding sufficient information,while it adecreaseof15% or more,fourreportstabilisationand remained stable in fivecountriesand increasedinsix. sevenreportanincreaseof15% or more. Data from afew countriessuggestthatcocaine could Forecstasy useamong youngadults (15–34), thepicture be replacing amphetaminesand ecstasyamong some is more mixed, with levels of usestill high amongyoung sectors of thedrug-using population. This maybethe

(73)InDenmark in 1994 theinformation refers to ‘harddrugs’,which wasconsideredmainlyamphetamines. (74)See Figure GPS-8inthe 2008 statisticalbulletin. (75)See Figure GPS-9(part ii)inthe 2008 statisticalbulletin. (76)See Figure GPS-21 in the2008statisticalbulletin. 54 Chapter4:Amphetamines,ecstasy andLSD

case in theUnited Kingdom andDenmark,and to reported by malesthanfemales: 42 %and 27 %, some extent in Spain. Both theUnited Kingdom and respectively (EuropeanCommission,2007b). Denmarkreportrelativelyhigh lifetimeprevalence AFrenchsurvey carriedout in 2004 and2005atfive estimatesfor theuse of amphetamines at 11.9 %and electronic musicvenues reported last monthprevalence 6.9% respectively,but levels of reported useinthe last of 32 %for ecstasyand 13 %for amphetamine among year andlast monthare more in line with thosefound asample of 1496 respondents.However,itshouldbe in othercountries. Increases in cocaineconsumption noted that prevalencewas higher amongspecific sub- in these countrieshavebeenmatchedtosomeextent populations that were characterisedbytheir counter- by adecreaseinthe useofamphetamines,raising the cultural elements andlabelledas‘alternative’.Among possibility that one stimulant drug is replacing another these sub-populations,prevalenceestimatesfor ecstasy 77 in these markets( ). Possible changesinthe patterns andamphetamine were 54 %and 29 %respectively. of drug useinother countries(Germany,France, Italy, Netherlands) areless clear. Overall, theinterplay Interventionsinrecreationalsettings betweendifferent drugsthatmay have similarappealto usersremainspoorlyunderstood. An increasingly common trendreported in Europe is for authoritiestoaddress aspects of licitand illicitdrugs An analysis of datafromthose nationalschoolsurveys collectively when considering localpublicorder or newlyavailable in 2007 (Czech Republic,Spain, health issues.This approach is particularly relevant to Portugal,Slovakia, Sweden,United Kingdom)supports interventionstargetingsettingswhere both syntheticand thesuggestion of an overallstabilisationinthe situation stimulant drugsand alcoholare consumed, such as night with no change or even some decrease noted in reported bars andclubs.One of theproblemsinthis area is that lifetimeuse of both amphetamine andecstasy. therelativeroles of illicitand licitsubstances maybe difficulttodistinguish.The useofalcoholamong young Recreationalsettings peopleisagrowing area of concern in Europe,and in 2006 theEuropeanCommission adopted an EU alcohol Useofamphetamines andecstasy in recreationalsettings strategy to supportMemberStatesinreducingalcohol- related harm amongyoung people. Indeed,harmful useof Studiesofdrug useinselected recreationalsettingswhere alcoholisassociated with one in everyfourdeathsamong youngpeoplecongregateand whichare knowntobe youngmen (aged15–29)and onein10among young sometimes associated with drug use, such as danceevents women (79). or musicfestivals,can provideausefulwindowonthe behaviourofthose usingamphetaminesand ecstasyona Concerns aboutthe combineduse of drugsand alcohol regularand intensivebasis. Estimatesofdrug useinthese by youngpeopleinpublicsettingshaveled to the settings aretypically high,but arenot generalisable to the developmentofstrategiesthataim to alterthe social, widerpopulation. economic andphysicalenvironments associated with alcoholand drug consumption,withthe goalsof: Astudy of youngpeopleaged15–30,who regularly modifying consumption behaviours andnorms;creating go outinnightlifesettings, carriedout in 2006 in nine conditions less favourable to intoxication; andreducing European cities (Athens, Berlin,Brno, Lisbon,Liverpool, opportunitiesfor alcoholand drug-related problemsto Ljubljana, Palma, Venice,Vienna) reported lifetime occur(80). Anumber of measures arereported by Member prevalenceestimatesof27% forecstasy useand 17 % States to take placein, or around,nightlifesettingswith foramphetamine.Frequentuse of these drugswas much thespecific aimofreducingharmorpositivelymodifying lower, with only 1.4% of therespondents reportingthat thesocialenvironment. These include: training forbar and they used ecstasyonceaweekormoreoften andless security staff; increasedenforcementofexistinglegislation; than 1% that this wasthe case foramphetamine.The raisingawareness of substance-related harms; provisionof mean ageatfirstuse forbothdrugsamong thestudy late-nighttransport services;and improvements intended groupwas 18 years(78). Concomitant alcoholuse was to provideasafer nightlifeenvironment. Measures in this common,with34% of thoseinterviewedreporting having area arediverse,including such things as:improvements been ‘drunk’morethantwice duringthe four weeksbefore to street lighting;the availability of drinking water; proper interview. This levelofdrunkenness wasmorecommonly ventilation; or even measures to providearapid response

(77)See ‘The European stimulant market: “cocainecountries” and “amphetaminecountries”?’,p.50. (78)See TableEYE-2inthe 2008 statisticalbulletin. (79)http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_factsheet_en.pdf (80)http://www.emcdda.europa.eu/themes/prevention/environmental-strategies 55 Annual report 2008:the stateofthe drugsproblem in Europe

to medicalemergencies. Often, acommon feature of this improvingpublicsafety, with benefitsthatcan extend approach is that it is baseduponadialoguebetween beyond thoseusing drugsand into thewider community. different stakeholders, such as thepolice, licensing However, todayinEurope, such approaches tend to be authorities, club owners andhealthcareproviders,who limited to particular knownproblem areas, ofteninmajor arerequiredtowork togetherinpartnership to identify city centres, andare rarely comprehensively implemented, both localneedsand possible solutions. strongly suggesting that thereisconsiderablepotential forfurther investmentand developmentinthis area.More An example of work in this area canbefound in Denmark generally, thefocus of work in this area hastendedtobe where, in cooperationwithmunicipalauthorities and restricted to interventionstargetingspecific problematic thepolice, restaurantownersand peopleworkingin behaviours,oraspects of theenvironment, rather than thenightlifeenvironmentare offeredcourses to promote thebroader task of addressingthe normative beliefsand shared attitudesonlimitingthe useand sale of drugsand attitudesthatyoung peoplehavetowards theuse of drugs alcohol. Some approaches in this area developed by andalcoholinspecific settings. individual Member States arealsobeginning to attract widerattention,asillustrated by thefact that thesafe-dance guidelines developed in theUnited Kingdom have now Treatmentprovision been implemented in clubsinbothParis andBrussels.Club In most Member States,limited demand is reflected in owners,withthe participation of outreach workersand thelimited availability of treatmentservices specifically localauthorities,helppromotemoderatedrinking,raising targetingusersofamphetamine, methamphetamine awareness of theharms of drugsand alcohol, whileraising or ecstasy. This situationissomewhatdifferent in a thesafetycharacteristics of settings(e.g. providingfree fewMemberStateswithlong-establishedchronic water, stafftrained in first aid, chill-outareas). amphetamine-ormethamphetamine-using populations. The relationshipbetween driving anddrug andalcohol In these countries(principallythe CzechRepublic, consumption hasbeenanissue included in some Slovakia, Finland, Sweden), usersofamphetamineor environmentalstrategies. Exampleshereinclude the methamphetamine aretreated within specialist services. provisionofalternativetransportationfor intoxicated Treatmentoptions appear to consist of detoxification, drivers, whichisavailable in someParisiannightclubs, followed by individual therapyinanoutpatientsetting or andthe promotionofpublictransport optionsbyclubs in grouptherapy in either outpatient or residentialsettings. Brussels.InSpain,preventioncampaignsthatfocus on Therapeutic optionswithrobust evidenceofeffectiveness ‘designated drivers’ andonraising awareness of therisks aregenerallylacking to guidethe treatmentof of driving underthe influenceofpsychoactivesubstances dependenceonpsychostimulants,suchasamphetamines have been conducted,particularlyduringweekends. These andcocaine.Asnoted in Chapter5,nopharmacological campaignsmay have contributed to the16% decrease agents arecurrently availabletohelpuserstomanage observedinSpain in thenumber of traffic accidents abstinenceorreduce thecravingsassociated with involvingyoung peopleaged18–20,in2006(81). psychostimulantdependence. Furthermore, theliterature Strategies that address theenvironmentinwhich young wouldsuggestthatnoparticularpsychosocialintervention peopleconsume both drugsand alcoholappeartohave hasshown strong evidenceofeffectiveness in helping considerablepotential forsafeguardingpublichealthand psychostimulantuserstomaintainabstinence.

(81)For more information on preventioncampaignsacrossEurope, seethe 2007 selected issueondrugsand driving. 56

Chapter5 Cocaineand crack cocaine

Introduction 994tonnesofpurecocaine hydrochloridefor theyear 2007,ofwhich Colombia accounted for61%,Peru 29 % The most recent datacontinues to pointtoanoverall andBolivia10%.Analysisofthe number of laboratories increase in theuse of cocaineinEurope. Population dismantled suggeststhatmost productionremainslocated surveyscarriedout in anumber of countrieshave in these threecountries, although it mayalsooccur in recorded amarkedincreaseinuse amongyoung people otherSouth American countries, before exportationtothe sincethe mid-1990s. These findingsare supported by main consumermarkets in NorthAmericaand Europe. theresults of targeted studies, whichhaveobservedvery Information on illicittraffickinginpotassium permanganate high levels of cocaineuse in somerecreationalsettings (a chemical reagentusedinthe synthesisofcocaine (nightlifeand dance-musicvenues). In parallel,indicators hydrochloride) supports this finding,withColombia of cocaineavailability in Europe,including thenumber reporting99ofthe 101tonnesofpermanganate of seizures of thedrug andthe amount seized,have potassiumseizedglobally in 2006 (INCB, 2008b). increaseddramatically. Cocaineproducedinthe Andean region is then smuggled In some EU Member States,the demand fortreatmentfor to Europe from SouthAmerican countries(viaBrazil, cocaineuse hasincreased substantiallyinrecentyears, Ecuador,Venezuela). Whilethe Caribbeancontinues to be andnow even exceedsthatfor opioid treatmentinsome an importanttransit zone forcocaine headingtoEurope, countries, cities andregions.Moreover, asubstantial transhipmentvia countriesinwestAfrica, in particular proportion of opioid usersintreatmentreportcocaine in theGulfofGuineaand offthe coastsofCapeVerde, as theirsecondarydrug,which maybecontributingto Guinea andGuinea-Bissau,has been increasing markedly theirproblemsand cancomplicatetheir care.Inmany duringthe past fewyears (CND, 2008;INCB, 2008a)(83). countries, cocaineisalsoreported in thetoxicological Spainand Portugal remain themajor entrypointsof analysis of ahigh proportion of drug-related deaths, cocaineintoEurope, thelatter’srolehavingsubstantially generallyincombination with opioidsand other increasedsince 2005.Cocaine continues,however,also substances. to enterEuropemoredirectlyeitherbyshipmentacross The existenceofconsiderabledifferences between theAtlantic or by air;inparticulartothe Netherlands, countries, with many countriesstill reportingverylow Belgium, Italy, France,the United Kingdom andGermany. levels of use, is an importantcaveattothe observation Both theNetherlands andFranceare reported to be major that,overall,cocaine useisincreasinginEurope. National transitcountriesfor furthercocaine distribution in Europe experiences of cocaineproblemsare also very mixed; (Europol,2007b). Recent reportsofcocaine importation with,for example,arelativelysmall number of countries viaeast European countries(Bulgaria,Estonia,Latvia, accountingfor themajorityofall cocainetreatment Lithuania, Romania, Russia)may pointtothe development demandsreported in Europe. of newtraffickingroutesinthis part of Europe.

Seizures Supply andavailability Cocaineisthe most traffickeddrug in theworld after herbal cannabis andcannabisresin.In2006, global Productionand trafficking seizures of cocainedecreased slightlyto706 tonnes. Cultivationofcocabush, thesourceofcocaine,continues SouthAmericacontinued to report thelargest amount to be concentrated in afew countriesinthe Andean seized,accountingfor 45%ofthe global figure,followed region (82). The United NationsOffice on Drugsand by NorthAmericawith24%,and west andcentral Europe Crime(2008)estimated potentialcocaine productionat with 17 %(UNODC,2008).

(82)For information on thesources of data fordrug supplyand availability,see p. 36. (83)See also ‘WestAfrica: nowaregionaltransit hubfor trafficking to Europe’, p. 59. 58 Chapter5:Cocaine andcrack cocaine

amount seized in Portugal since2005, accountingfor 28 % West Africa:now aregionaltransithub for of theEuropeantotal in 2006,pointstothe growinguse trafficking to Europe of theIberian peninsulabycocaine traffickers as an entry

In thelast fiveyears,westAfricahas emerged as an pointtothe European market. importantregionincocaine trafficking to Europe (1), actingasasiteoftransit,storageand repackaging(Europol, Purity andprice 2007b; UNODC 2007b; USDS,2008).Itisestimated that almost aquarter of thecocaine traffickedtoEuropein2007 The typicalpurityofcocaine in Europe rangedbetween wastransited viathis region (UNODC,2008).Against a 1% and90% in 2006,althoughmost countriesreported background of increasing cocaineuse in Europe,the growth values between25% and55% (85). Of the23countries in trafficking viathe west African routeisthought to have providingsufficient data, most reported adeclining contributed to thedeclineinthe priceofthe drug,while reinforcingthe role of theIberian peninsulaasanentry trendinthe purity of cocaineoverthe period 2001– 06; pointfor cocainedistributioninEurope(Europol, 2007b). increases were noted,however,inGreeceand France

Cocaineistrafficked from west AfricatoEuropemainlyby over theperiod2003–06. sea, with largeshipments transported by fishing vesselsto In 2006,the typicalretailpriceofcocaine variedbetween unloadingsites mainly on thecoast of northern Portugal EUR50and EUR75per gram in most European countries, andGaliciainSpain.Smaller shipments of cocaineare traffickedbyair or overland,increasinglyassociated with although Cyprus, Romania, Sweden andTurkeyreported smugglingcannabisresin from northAfrica. much higher values.Overthe period 2001– 06,cocaine

The growth of thewestAfrican cocainetraffickingroute sold on thestreets hasbecome cheaperinthe 18 countries hasbeenattributed to severalfactors. These include reportingsufficient data, with theexception of Romania, more effective controlsonalternativetraffickingroutes whereanincreaseinprice(adjusted forinflation) wasnoted. (Europol,2007b); thegeographicalpositionofwest Africa; andthe economic vulnerabilities of countries in this area,often resultinginweakjudicial andlaw Prevalence andpatternsofuse enforcementsystems.

The internationalcommunity haslaunchedseveral Diversityisnot only foundinthe overalllevelsofcocaine initiativestoaddress theproblem.Amongother initiatives usereported by Member States,itisalsoreflected in the takenbythe European Union, theCouncil,through the characteristics of cocaineusersthemselves,who fall across horizontal workingparty on drugs, hasplaced west Africa abroad social continuum rangingfromsomeofthe most at thetop of theagenda andpresented aresolutiononthe privilegedtothe most marginalised members of society. strengtheningofinternationalsupport to west Africatothe 2008 UN Commission on Narcotic Drugs. Furthermore, Patterns of cocaineuse canbecorrespondinglydiverse, sevenMemberStates, with EU support, have acted rangingfromthe occasionaland recreationaltothe highly together to establishthe Maritime Analysis andOperations compulsiveand dependent. The form that cocaineisused Centre–Narcotics(MAOC-N), alaw enforcementcentre, in (cocaine hydrochlorideorcrack cocaine),and the located in Lisbon,withmilitary support, that aims to routeofadministrationbywhich it is used,are additional suppress cocainetrafficking, with specialfocus on the easternpartofthe Atlantic. complicatingfactors. This diversityisanimportant consideration,bothfor understandingthe range of problems (1)UNODC (2007b)reports that Senegal, Ghana, Mauritania, that arelikelytobeassociated with different patterns of Guinea-Bissau, Cape Verde, Nigeria,Benin andSierraLeone registered thelargest seizures in 2006/07. cocaineuse,and also forinforming thetargetingand developmentofservices foradisparate groupofdrug users.

The number of cocaineseizureshas been on theincreasefor Among thegeneral population thelast 20 yearsinEurope, andcontinued to rise duringthe period 2001– 06,withthe exceptionofadecreasein2003. Overall, cocaineremainsthe second most used illicitdrug The quantity of cocaineseizedhas also been increasing in Europe,after cannabis,althoughuse variesgreatly over thelast decade,but with regularfluctuations.In2006, betweencountries. It is estimated that around 12 million cocaineseizuresinEuropeincreased to 72 700cases and Europeanshaveuseditatleast onceintheir lifetime; thequantityrecovered to 121tonnes(84). Spaincontinued to on average3.6 %ofadults aged 15– 64 years(see be thecountry reportingthe highestseizures, accounting Table5for asummaryofthe data).Nationalfiguresvary for58% of allseizuresand 41 %ofthe quantity from 0.4% to 7. 7%,with12countries, mostly Member intercepted in Europe that year.The huge increase in the States that have joinedthe European Unionsince 2004,

(84)The data on European cocaineseizuresmentionedinthis chaptercan be foundinTablesSZR-9 andSZR-10inthe 2008 statisticalbulletin. Note that acrossthe chapter,where nationaldata for2006are absent,the correspondingdata for2005are used to estimate European totals. (85)See Tables PPP-3 andPPP-7 in the2008statisticalbulletinfor purity andpricedata. 59 Annual report 2008:the stateofthe drugsproblem in Europe

reportingverylow levels of lifetimeprevalenceamong all adults (0.4–1.2%). Estimating cocaineuse by analysing communal wastewater It is estimated that around 4million Europeanshaveused thedrug in thelast year (1.2 %onaverage), although The applicationofrecentdevelopments in analytical againnationalvariation betweencountriesisconsiderable. chemistrytothe detectionofcocaine in wastewater has introducedanew approach to themonitoringofillicitdrug This canbeseeninresults from recent nationalsurveys, useinthe community,known as ‘sewageepidemiology’. whichreportlast year prevalenceestimatesofbetween The method involves measuringthe levels of breakdown 0.1% and3%; though only in four countriesdolevelsof productsofillicitdrugsexcreted in theurine of consumers. useexceed 1%.At2million,the prevalenceestimate for The levels of breakdownproductsmeasuredinwastewater arethen scaled up to calculateconsumption of illicitdrugs last monthuse is around half that forlast year prevalence, amongthe population. In thecaseofcocaine,the main andrepresentsabout 0.5% of theadultpopulation. These metaboliteexcreted in theurine is benzoylecgonine. As estimatesare likelytobeconservative. breakdowninthe humanbodyofcocaine is theonlylikely sourceofbenzoylecgonineinwastewater systems, with Overall, cocaineuse appearstobeconcentrated in a certainassumptions, it is possible to back-calculatefrom fewcountries, notably Spainand theUnited Kingdom, theamount of themetaboliteinthe wastewater to the andtoalesserextentItaly,Denmark andIreland,while amount of cocaineconsumedinthe community (although useofthe drug is relativelylow in most otherEuropean not to thenumber of consumers). countries. In countrieswhere amphetaminesdominatethe Sewage epidemiology is still in an earlystageof market in illicitstimulant drugs, estimatesofuse of cocaine developmentand,aswellasimportant technicaland ethical arelow in almost all cases; conversely, in most countries questions, theinformation it offers must be integrated into currentresearch thinking.These issues areaddressedin wherecocaine is themainillicitstimulant,low levels of thenew EMCDDA publicationonwastewater analysis 86 amphetamineuse arereported ( ). (EMCDDA,2008b). Bringingtogether expertsfromawide range of disciplines, thereportconcludes that,although Cocaineuse among youngadults furtherdevelopments arerequired, sewage epidemiology haspotential fordrug surveillance at thecommunity Cocaineuse is mainly concentrated amongyoung adults level. The approach couldalsohavepotential as adrug (15–34 years).For instance,ofthe 4million Europeans surveillance tool to assist public health andlaw enforcement that have used thedrug in thelast year,aroundseven out officials in identifyingpatternsofdrug useacross municipalities of varyingsizes.And,because wastewater of eight arelikelytobeyoung adults. sampling andanalysiscan be conducted on adaily, weekly In Europe,itisestimated that 7. 5million youngadults or monthly basis, thedata couldpotentiallybeusedto give amorereal-time measurethatprovidescommunities (15–34 years),oranaverage of 5.4%,haveusedcocaine with more possibilities formonitoringthe impact and at least onceintheir life. Nationalfiguresvaryfrom effectiveness of prevention andinterventionactivities. 0.7% to 12.7 %. The European averagefor last year use of cocaineamong this agegroup is estimated at 2.3% translates into 2million 15-to24-year-oldsusing thedrug (3.5 million) andfor last monthuse at 1% (1.5 million). in thelast year. Useisparticularlyhigh amongyoung males(15–34 Cocaineuse is also associated with certainlifestyles. An years),withlast year prevalenceofcocaine usebetween analysis of datafromthe BritishCrime Survey 2003/04 4% and7%inSpain,Denmark,Ireland,Italy andthe estimated that around 13 %of16- to 29-year-oldswho United Kingdom (87). The female to male prevalenceratio frequently visitpubsorwinebarsreportlast year use forlast year userangedbetween 1:1and 1:13 foryoung of cocaine, comparedwith3.7 %among less frequent adults in different countries. Weighted averages forthe visitors. Among30- to 59-year-olds, thefigureswere3.1 % European Unionasawhole suggest that,among cocaine and1%respectively.Reported useofcrack cocainein usersaged15–34,the male to female ratiowas nearly thesamesurvey wasverylow,evenamong thegroup 4:1(3.8males foreachfemale). reportingthe highestcocaine prevalencelevels. This Measures of more recent cocaineuse (last year andlast supports thefindings of more focusedstudies,which month) arehighestamong the15–24 agegroup,although report adifferent profile forthe user of powder cocaine this phenomenon is less marked than in thecaseof comparedtothatfound forcrack cocaine. It is likelythat cannabis or ecstasy(88). Last year prevalenceofcocaine in othercountriescocaine useisalsoassociated with usefor this agegroup is estimated at 2.6%,which similarlifestyle factors.

(86)See ‘The European stimulant market: “cocainecountries” and “amphetamines countries”?’,p.50. (87)See Figure GPS-13 in the2008statisticalbulletin. (88)See Figure GPS-15 andTablesGPS-14toGSP-16for allyears andTablesGPS-17toGPS-19for latestdata in the2008statisticalbulletin. 60 Chapter5:Cocaine andcrack cocaine

Table 5: Prevalence of cocaine use in the general population —summaryofthe data

Age group Time frame of use

Lifetime Last year Last month

15–64 years

Estimated number of users 12 million 4million 2million in Europe European average 3.6%1.2%0.5%

Range 0.4–7.7%0.1–3.0%0–1.6%

Lowest-prevalence countries Romania, Malta Greece (0.1%) Greece, Estonia, Lithuania (0.4%) Poland, Latvia Czech Republic (0.0%) Greece (0.7%) Czech Republic (0.2%) Malta, Lithuania, Poland, Finland, Latvia (0.1%) Highest-prevalence countries United Kingdom (7.7%) Spain (3.0%) Spain (1.6%) Spain (7.0%) United Kingdom (2.6%) United Kingdom (1.3%) Italy (6.6%) Italy (2.2%) Italy (0.8%) Ireland (5.3%) Ireland (1.7%) Ireland (0.5%) 15–34 years

Estimated number of users 7.5 million 3.5 million 1.5 million in Europe European average 5.4%2.3%1%

Range 0.7–12.7%0.2–5.4%0.0–2.8%

Lowest-prevalence countries Romania, Lithuania (0.7%) Greece (0.2%) Estonia (0.0%) Malta (0.9%) Poland (0.3%) Greece, Poland, Latvia, Greece (1.0%) Latvia, Czech Republic (0.4%) Czech Republic (0.1%)

Highest-prevalence countries United Kingdom (12.7%) United Kingdom (5.4%) Spain (2.8%) Spain (9.6%) Spain (5.2%) United Kingdom (2.7%) Denmark (9.1%) Italy (3.2%) Italy (1.2%) Ireland (8.2%) Ireland (3.1%) Denmark, Ireland (1.0%) 15–24 years

Estimated number of users 3million 2million 800 000 in Europe European average 4.5%2.6%1.2%

Range 0.4–11.2%0.2–6.1%0.0–3.2%

Lowest-prevalence countries Romania (0.4%) Greece (0.2%) Estonia (0.0%) Greece (0.6%) Poland (0.3%) Greece Latvia (0.1%) Lithuania (0.7%) Czech Republic (0.4%) Czech Republic, Poland, Malta, Poland (1.1%) Latvia (0.6%) Portugal (0.2%) Highest-prevalence countries United Kingdom (11.2%) United Kingdom (6.1%) United Kingdom (3.2%) Spain (8.7%) Spain (5.8%) Spain (3.1%) Denmark (8.0%) Ireland (3.8%) Italy (1.3%) Ireland (7.0%) Denmark, Italy (3.3%) Bulgaria, Ireland (1.1%)

Information based on the last survey available for each country. The study year ranges from 2001 to 2007. The average prevalence for Europe was computed by aweighted average according to the population of the relevant age group in each country. In countries for which no information was available, the average EU prevalence was imputed. Populations used as basis: 15–64 (328 million), 15–34 (134 million) and 15–24 (64 million). The data summarised here are available under ‘General population surveys’ in the 2008 statistical bulletin.

61 Annual report 2008:the stateofthe drugsproblem in Europe

Studiesconducted in recreationalsettingsoften report that thereported frequencyofuse wasonaverage lower ahigh prevalenceofcocaine use. Forexample,a2006 amongintegrated users(sevendaysamonth)thanamong studyinnineEuropeancities(Athens, Berlin,Brno, Palma, socially excluded users(11 days)oramong opioid usersin Lisbon,Liverpool, Ljubljana, Venice,Vienna),with1383 treatment(14 days). youngpeopleaged15–30 whoregularly ‘goout in nightlifesettings’,found that 29 %reported usingthe drug Problem cocaineuse andtreatmentdemand at least onceand nearly 4% that they used cocaineonce Nationalestimatesofproblem cocaineuse (injection or aweekormoreatsome point(European Commission, long duration/regularuse)are availableonlyfor Spain 2007b).Higherprevalencelevelswerealsoreported in a andItaly,and regionalestimatesare availablefor the 2004–05 Frenchsurvey of 1496 individualsinterviewed United Kingdom.According to themost recent datafor in fivedifferent electronic musicsettings. Nearly 35 % Spain, in 2002 therewerebetween 4.5and 6problem of thesample hadusedcocaine and6%crack or free- cocaineusersper 1000 adultpopulation(15– 64 years). base cocaineduringthe last month. The studyalso Similarly, in Italy, in 2006,there were estimated to be reported differences betweensub-populations:last month between3.7 and4.5 problem cocaineusersper 1000 prevalencewas 50 %for cocaineuse and13% forcrack adults.Information forthe United Kingdom is not directly useamong thoselabelled‘alternative’,while around a comparabletothatofSpain andItaly,asitisbased on quarterofthe more mainstream sub-populations hadused cocaineand 2% crack duringthe last month. crack cocaineuse.In2004–05,one studyestimated the number of problem crack cocaineusersinEngland at 5.7 to 6.4per 1000 adultpopulation. Cocaineuse among school students Amongschoolstudents, overallprevalencelevelsfor Cocaine, mainly powder cocaine, wascited as cocaineuse aremuchlower than thosefor cannabis use. theprincipal reason forenteringdrug treatmentin Ever in lifetimeprevalenceofcocaine useamong 15-to Europe in 2006 by about16% of alltreatmentclients, 16 -year-old school students is 2% or lowerinmost countries, correspondingtoaround61000 reported casesin24 rising to 4% in Spainand 5% in theUnited Kingdom (89). countries(91). Cocainewas also reported as asecondary In countriesthathavereported recent datafromnational drug by around 18 %ofall drug outpatient clients(92). school surveys(Spain, Portugal,Slovakia, Sweden,United There is awidevariation betweencountries, with cocaine Kingdom), prevalenceofcocaine useisstableordecreasing usersmakingupahigh proportion of treatmentclients slightly, although changesinprevalencelevelsare usually only in Spain(47 %) andthe Netherlands(35 %);though, toosmall to be statisticallysignificant. In Spain, recent thedrug nowaccountsfor 25 %oftreatmentdemandsin survey datahaveshown asignificantdecreaseamong 17-to Italy. ElsewhereinEurope, cocaineaccountsfor between 18-year-old school students. 5% and10% of alltreatmentdemands(10 countries) or less than 5% (12countries) (93).

Patterns of cocaineuse The proportion of cocaineusersishigher amongthose Data from general populationsurveyssuggesthigh entering drug treatmentfor thefirsttime. Across Europe,in discontinuationrates amongcocaine users: in those 2006,cocaine wasreported as theprimary drug by 23 % countrieswhere last year prevalenceisabove 2%, of newclients (around37000 individuals) (94). In Spain, between80% and90% of adults whohaveusedcocaine according to thelatestdata, in 2005,cocaine wasthe at least onceintheir lifehavenot used it duringthe last primarydrug most oftencited by thoseenteringtreatment, month(90). andnew cocaineclients represented 63 %ofall new Spanishdrug clients. Only limited information is availableonthe frequencyof cocaineuse in Europe.Ananalysisofthe BritishCrime Trends in cocaineuse Survey foundthatabout 20 %ofthose youngpeople (16–24 years) whohad used cocaineinthe previous Usinglast year prevalenceamong youngadults (15–34 year consumedthe drug more oftenthanonceamonth. years) as an indicator of trends in levels of recent use(as Amulti-cityEuropeanstudy with targeted samplesof cocaineuse concentratesinthis agegroup)shows that cocaineusersinninecities(Prinzleveetal.,2004) found cocaineuse increasedconsiderablyduringthe second half

(89)See TableEYE-1inthe 2008 statisticalbulletin. (90)See Figure GPS-16 in the2008statisticalbulletin. (91)See TableTDI-115 andFigure TDI-2inthe 2008 statisticalbulletin. (92)See TableTDI-22(part i) in the2008statisticalbulletin. (93)See TableTDI-5 (partii) in the2008statisticalbulletin; forSpain data referto2005. (94)See Figure TDI-2inthe 2008 statisticalbulletin. 62 Chapter5:Cocaine andcrack cocaine

Figure5:Trends in last year prevalenceofcocaine useamongyoung adults (aged15–34)

% United Kingdom (¹) 6 Spain

Italy

5 Ireland

Denmark

Norway 4 Germany

Slovakia 3 France

Portugal

2 Estonia

Netherlands

Finland 1 Hungary

Poland

0 Greece 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

(1)England andWales. NB:InDenmark,the valuefor 1994 correspondsto‘hard drugs’.See Figure GPS-14 in the2008statisticalbulletinfor furtherinformation. Sources: Reitox nationalreports (2007),taken from populationsurveys, reportsorscientific articles. of the1990sinSpain,Denmark andthe United Kingdom. drug type areobviously influenced by changesindemand Newdata(2005–07 surveys) confirm therisingtrend fortreatmentbythe usersofother substances. reported already last year in France,Ireland,Spain,the United Kingdom,Italy,Denmark andPortugal; in Germany, Internationalcomparisons theNetherlands,Slovakiaand Finland, astableprevalenceis Overallthe estimated lifetimeprevalenceofcocaine observed; andinPoland,adecline wasreported (Figure5). useislower amongyoung adults in theEuropeanUnion The increasing trendindemand forcocaine treatmentnoted than amongtheir counterparts in Australia,Canada in previous yearsalsoappears to be continuing, even if it is andthe USA. However, at thenationallevel Denmark, disproportionately influenced by afew countries. Between Ireland,Spain,Italy andthe United Kingdom (England 2002 and2006, theproportionofnew clientsdemanding andWales)reporthigher figures than Australia.Onlythe treatmentfor primarycocaine usegrewfrom13% to 25 %, United Kingdom (England andWales)reports alifetime andthe number of reported casesrosefromaround13000 prevalenceestimate that is similartothatofthe USA(96). to almost 30 000.Anincreasewas also observed in the In some respect, this measurecan be seen as reflectingthe number andproportionofall cocaineclients entering historical developmentofcocaine problemsand theearlier drug treatment: from 22 000 clients(13 %ofall treatment experienceofthe USAand,inthe European context,the demands) in 2002 to 50 000 (19%)in2006. The largest United Kingdom,withwidespreadcocaine use. increases were reported by Italyand Spain(95).

The increasing trendincocaine usersenteringdrug Treatmentand harm reduction treatmentmay be related to increases in theprevalence Profile of treatmentclients of cocaineuse andrelated problems, butalsotoother factors (e.g.increaseoftreatmentreferralsorinterventions Outpatient centresaccount fornearlyall (94%)reported specificallytargeted to cocaineusers);and proportionsby cocainetreatmentdemandsinEurope(97). However, it

(95)See FiguresTDI-1 andTDI-3 andTable TDI-3(part ii)inthe 2008 statisticalbulletin. (96)See Figure GPS-20 in the2008statisticalbulletin. (97)See TableTDI-24inthe 2008 statisticalbulletin. 63 Annual report 2008:the stateofthe drugsproblem in Europe

should be noted that cocainetreatmentalsosometimes takesplaceinprivate clinics, sometimes on aresidential Healthproblemsrelatedtococaineuse basis, andthis form of care is not well represented in the Awareness of thelinks betweencocaine useand illness currentmonitoringsystem. is oftenlimited,evenamongmedical professionals. As aresult, somecocaine-related problemswillgo Cocaineclients entering outpatient treatmenthavethe unidentified,and thosesuffering them maynot receive highestmaletofemale ratioamong drug treatment appropriate care.Underreporting of cocaineproblems clients(fivemen forevery woman).Their mean ageis31 will impede theunderstanding of theimpact of thedrug years(98), whichmakes it thethird oldestdrug client group, on public health. afteropioid usersand usersofhypnoticsand sedatives. The risksassociated with certainproblematic modes Most cocaineclients report having started usingthe drug of cocaineuse arewellknown andmostly affect betweenthe ages of 15 and24years (99). recognised groups of users(formerorcurrent opioid users, marginalised groups). Forexample,injecting There is considerableinter-country variationreported in cocaineuse is associated with theriskofinfection and respecttothe routeofadministrationfor cocaineclients. an elevated risk of overdose,while useincombination Overall, around half (55%)ofthe cocaineclients are with opioidsappears to be linked to ahigher risk of reported as snorting thedrug,withnearlyathird (32%) opioid overdose. smokingit, andamuchsmaller proportion (9 %) injecting Health problemsassociated with powder cocaine, thedrug (100). Broadly, twomaingroupsofcocaine however, aremorelikelytogounrecognised andmay affectuserswho mightnot normallyconsiderthemselves userscan be identified amongthose in treatment. The at risk.Chronic useofcocaine cancause significant first of these aretypically more socially integrated, health problems, most of whichare cardiovascular reportingstablehousing andemploymentstatus, and (atherosclerosis,cardiomyopathy, arrhythmias, generallyreportsnortingthe drug.The second is a myocardialischemia) andneurological(cerebrovascular more marginalised groupofclients whoare typically accidents andseizures).These problemscan be aggravated by existing conditions (e.g.vascular smokingorinjecting cocaine(seeEMCDDA, 2006), malformations) andriskfactorssuchassmoking or andmoreoften report usingeithercrack cocaineorthe alcoholuse.Manyofthe deaths attributed to cocaine combination of cocaineand heroin.Crack clients, in areproducedthrough these pathologies. particular,commonly live in largecities, belong to ethnic Useofcocaine in combination with alcoholincreases minority groups,and report high levels of unemployment blood levels of cocainebyasmuchas30%.Froma andpoorliving conditions (101). This problem is small behaviouralperspective,cocaine usemay facilitate in European termsand is geographically limited,with excessive alcoholuse by enabling userstodrink longer, significantcrack cocaineproblemslimited to arelatively whichinturnmay increase theamount of cocaine consumed(Gossopetal.,2006).The formation of smallnumber of cities.In2006, around 8000 crack cocaethylene in theliver mayalsobelinkedtofurther cocaineclients (about 2% of alldrug clients) were possible health risksassociated with thecombineduse reported to have entereddrug treatmentin20European of cocaineand alcohol. countries, although most of them were reported by the There have been fewstudies to assessthe overallpublic 102 United Kingdom ( ). health impact of cocaineuse.Alarge-scale population Treating theproblemsassociated with theconcurrentuse studyinthe USA(1988–94)found that aquarter of non-fatalacutemyocardialinfarctions amongthose of both cocaineand heroin is becominganincreasingly aged 18–45 yearswereattributed to ‘frequentlifetime importantissue in somecountries. Usersintreatment cocaineuse’. Frequent usershad aseven timeshigher maybecurrent or formerheroinusers, sometimes in risk of non-fatalmyocardialinfarctions than non-users substitution treatment. In some countries, they represent (Qureshi et al., 2001). However, it is not possible to thelargest groupofcocaine treatmentclients.Some generalisedirectly from this studytoEurope. Currently, ourunderstanding of thepossible health impact of studieshavesuggested thatconcomitantuse of cocaine increasing cocaineuse in Europe remainspoorly andheroincan be associated with thepresenceof developed andanimportant area forfuturepublic dual diagnosis, or aggravateunderlyingpsychological health inquiry. problemssuchasbipolardisorder. Also,concomitant Forfurther readingonhealthproblemsrelated to cocaineuse duringmethadone maintenancetreatment cocaineuse,see the2007selected issueoncocaine. hasbeenshown to contributetopersistentheroinuse

(98)See Tables TDI-10 andTDI-21inthe 2008 statisticalbulletin. (99)See TableTDI-11(part iii)inthe 2008 statisticalbulletin. (100)See Tables TDI-17 (partii) and(part vi)and TDI-111 (partvii)and (partviii)inthe 2008 statisticalbulletin. (101)See the2007selected issueoncocaine andcrack cocaine. (102)See TableTDI-115 in the2008statisticalbulletin. 64 Chapter5:Cocaine andcrack cocaine

in treating cocainedependence, nordoeffective or re-initiation—arisk forHIV andother blood-borne pharmacologicaltreatmentapproaches exist. Arecent infectionsand serious medical, social andcriminal Cochrane review on psychosocialcocaine andother problems. psychostimulantinterventions concluded that theonly consistent, positive behaviouralresults (retention in Cocainetreatment treatment, reductionindrug consumption)wereobserved Followingthe increase of cocaineuse andassociated in psychosocialinterventions that included contingency problemsinseveral Member States,specialiseddrug managementasacomponent(103). treatmentfacilities face thedifficulttaskofadapting Unlikeopioid dependence, no effective pharmacological theirtraditionally opioid-oriented services to thevaried treatmentoptions arecurrently availabletohelpcocaine cocaineand crack-using populations.However,withthe usersmaintainabstinenceorreduce use(seethe 2007 exceptionofSpain,in2006, Member States assessedthe selected issueoncocaine). Experimentaltherapeutic availability andaccessibility of cocaine-specific treatment drugstoreduce cocaineconsumption andcravings programmes as low. have shownpotential in clinical trials (e.g.baclofen, Of theMemberStatesthatreporthigh prevalencelevelsof tiagabine, topiramate).Modafinil, acentral nervous cocaineorcrack cocaine, severalhavebeenparticularly system stimulant,has shownparticularlypromisingresults active in respondingtothis problem.In2007, Spain as apsychostimulantsubstitutiondrug with theadvantage introducedaspecific nationalactionplanoncocaine,while that,comparedtoother potentialsubstitutedrugs(e.g. Ireland implemented andevaluated anumber of specific d-amphetamine), itsabuse liability is low(Myricketal., programmes aimedatdifferent groups of cocaineusers. 2004). Furthermore, buprenorphine,topiramateand These programmes target problematicintranasalcocaine tiagabinehaveshown promisingresults in reducing users, polydrug userswithcocaine problems, as well as cocaineuse in opioid usersundergoingsubstitution women andsex workersusing cocaine. In Italy, alarge- treatmentwithconcomitantcocaine use. scaleclinicaltrial will be carriedout in 2008 to investigate theeffectiveness of twopharmaceuticals(aripiprazole and Contingency management ropinirole)for thetreatmentofcocaine dependence.

Information on thenatureofthe servicesprovidedto By rewardingabstinence, contingency management(CM) aims to reduce thereinforcing effects of drugs. Typically, problem cocaineusersinEuropeisscarce. Nonetheless, CM is introducedatthe beginning of acourseoftreatment, nationalclinicalpublications or surveysamong with psychosocialsupport,and theincentivesare professionals provideagoodinsightintocurrent contingentonthe productionofdrug-freeurine samples. practices.According to arecentUnited Kingdom Forexample,the incentivecould be vouchers of small report (NICE, 2007), cocaine-related problemsin monetaryvalue, whichincreasewitheachsuccessive period of abstinence. In this scenario, failuretostaydrug- Britishspecialisedtreatmentcentres appear to be only free resultsinthe loss of theaccumulated gains. addressedwhen theprimary drug problem is related to opioids. Also,arecentItalian survey amongexperts This techniquerepeatedly reinforces thedrug-free behaviourofthe client andprovidesaregular goal to involved in thetreatmentofcocaine usersindicated be achieved.The strongest evidencefor theeffectiveness difficulties in applying some of theelements considered of CM in maintainingabstinencefromdrugscomesfrom by them as crucialfactorsfor achievingsuccessful studiesoncocaine andherointreatment, though there treatmentoutcomes, such as providingappropriate is someevidencefor theapproach in cannabis and services (e.g.short-termresidential care,structured methamphetaminetreatment. psychosocialinterventions), or clinically differentiating Although most research on CM hasbeenconducted outside thedifferent typesofcocaine users. These difficulties Europe,feasibility studiesofCMhaverecentlyreported were reported to be duetoorganisationalproblems, positive resultsinSpain forcocaine users(Secades-Villa et al., 2008)and in addressingcocaine useamongopioid lackofresources andlack of effective cocaine-specific substitution treatmentclients in theNetherlands (DeFuentes- treatmentinterventions.Itislikelythatprofessionals in Merillas andDeJong, 2008), wherethe averageincentive otherMemberStatesface similarproblems. Adequate at theend of thetrial wasgoods to thevalueofEUR 150. investment, appropriate treatmentprotocols and An economic analysis by theNationalInstitute forClinical specialisedtrainingneedsare,therefore,likelytobekey Excellence(NICE,2007) in theUnited Kingdom suggested issues forservice developmentinthis area. that CM is acost-effective option in thecontext of cocaine treatment, especiallywhen considering thewider economic Recent literature reviews indicatethatcurrent psychosocial costsofcocaine use. interventionsdonot show strong evidenceofeffectiveness

(103)See ‘Contingency management’. 65 Annual report 2008:the stateofthe drugsproblem in Europe

Immunotherapy forcocaine dependencethrough a be referred to residentialrehabilitation programmes and cocainevaccine(TA-CD) is also underinvestigation. therapeuticcommunities.These programmes not only aimto Onceadministered, thevaccineinduces theproduction achieveabstinence, butoffer respiteand intensivecareand of antibodiesthatbindtococaine moleculesinthe supportinorder to help theuserstochange theirchaotic bloodstream and, thereby, allownaturally occurring andhigh-risklifestyles. enzymestoconvert them into inactivemolecules.The Aqualitative studyinsix Spanishcitiesshowedthatthe resultsofthe initialclinicaltrialsare encouraging,though main substances used amongsex workerswerealcohol furtherstudies arerequiredtotestthe viability of the andcocaine.Drug usewas reported as occasionaland vaccineasapharmacotherapy forcocaine dependence. instrumentalinhelping to reduce psychologicalbarriers The cocainevaccineisprimarily intended to be used or inhibition,and increase tolerance to long hoursof in relapseprevention, butthe term ‘vaccine’ also raises sexwork with different clients. Amongthe consequences expectationsabout itspotential usetoprevent cocaine of drug useinprostitutes were unprotected sexand a dependencewhen used as aprophylactictreatment(e.g. higher risk of violencebyclients.Severecrack cocaine in drug-naive children or adolescents).The effectiveness of consumption patterns arealsooften observedinthis such an approach is uncertainand raises ethicalconcerns, group. whichare discussedindepth in theforthcoming EMCDDA Sexworkerswithcocaine andcrack cocaineproblems publication Addictionneurobiology: ethicaland social aretargeted by outreach andharm-reductionservices. implications. Forexample,inthe Netherlands, municipalhealth services have implemented specialhealthprogrammes Harm reduction targetingcrack cocaine-usingsex workers; in France, theassociation Espoir Goutte d’Or,which focuses on Problem cocaineuse is frequently associated with severe risk prevention andharmreductionfor crack cocaine physical andmentalhealthconsequences.For example, usersand sexworkers, organises voluntary counselling an Irishtwo-yearfollow-up survey on cocaineinlocal on aweeklybasis andrapid testing forHIV and communities revealed adeterioration of thegeneral health hepatitis. of cocaine-dependentclients,especiallyamonginjectors. Severalprojectsalsoreported ariseinthe number of Recreationaluse of cocaineincombination with clientsexperiencingabscesses andwoundsdue to poor excessivealcoholconsumption frequently occurs in injectinghabits; otherproblemsreported amongclients nightlifesettingsand canbeassociated with serious usingcocaine includeweight loss,sexuallytransmitted acutephysicalproblems. As reported in Chapter4, infections, heartconditions,amputations andrisktaking. Member States areincreasinglyadoptinganintegrated approach towardsreducingharmrelated to theuse of Member States usuallyprovide cocaine-injectinguserswith alcoholand illicitdrugsinrecreationalsettings. The thesameservices andfacilities as thoseprovidedtoopioid programmes offeradviceand information to young users, such as recommendations forsafeuse,training peopleonthe risksassociated with alcoholand drug forsafeinjecting andneedle exchange programmes. useingeneral,usually includingmaterialonthe risks Low-threshold drug services playasignificantroleinthis associated with acuteand chroniccocaine consumption. respectastheyprovide basiccare, as well as counselling Themembers of theEuropeanFoundationofDrug andmedical help.Userswithseverecocaine andcrack- Helplinesare also very activeinraising awareness and related problems, such as co-morbid physical andmental providingsupport to drug usersbyofferingadviceand health problemsorsocialproblems, such as housing, can information on therisks of drugs.

66

Chapter6 Opioiduse anddrug injection

Heroin supply andavailability viasouth Asia (Bangladesh) (INCB, 2008a). Within the European Union, theNetherlands and, to alesserextent, Twoforms of imported heroin have historically been Belgiumplayanimportant role as secondarydistribution offeredonthe illicitdrugsmarketinEurope: thecommonly hubs (Europol,2008). availablebrown heroin (its chemical base form), which comesmainlyfromAfghanistan; andwhite heroin (a salt Seizures form), whichtypically originates from south-east Asia, though this form is considerablyless common (104). In Worldwidereported seizures of opioidsincreased in 2006 addition, someopioid drugsare producedwithinEurope, to 384tonnesfor opiumand to 104tonnesfor heroin and principallyhomemadepoppyproducts(e.g. poppystraw, morphine. WhileIranaccounted formost of theopium poppyconcentrate from crushed poppystalksorheads)in (81%)seizedworldwide,heroinand morphinewere someeast European countries(e.g. Latvia,Lithuania). intercepted mainly in Pakistan (34%), followed by Iran (20%), Turkey (10%)and China(6%)(UNODC,2008).

Productionand trafficking In Europe,anestimated 48 200seizuresresulted in the Heroin consumedinEuropeoriginates predominantly interception of 19.4 tonnes of heroin in 2006.The United in Afghanistan, whichremainsthe worldleaderinillicit Kingdom continued to report thehighestnumber of opiumsupply, followed by Myanmar andMexico. Global seizures,while Turkey againreported thegreatestamount 105 opiumproductionincreased againsubstantially(34 %) in seized,with10.3tonnesrecovered in 2006 ( ). The 2007 to an estimated 8870 tonnes,mainlyasaresultof amount of heroin intercepted in an averageseizure varied an increase in Afghan production, whichwas estimated greatlybetween these twocountries, with thesizeofthe at 8200 tonnes.Globalpotential productionofheroin averageseizure in Turkey being100 timesthatreported hasconsequentlyreached arecordlevel in 2007,withan forthe United Kingdom,reflecting different positionsin estimated 733tonnes(UNODC,2008).The rising number thesupplychain (Figure6). Over thelast 10 years, heroin of laboratoriesdismantledinAfghanistanoverthe last few seizures have been fluctuatingdownwards in Europe,with yearssuggests that opiumisincreasinglybeing transformed arelativepeakin2001and arecordlow in 2003.The into morphineorheroininthe country itself. However, large quantity of heroin intercepted in theEuropeanUnion has shownanoverall declinebetween 2001 and2006. In seizures of morphineinneighbouring countries(Pakistan, contrast,the amount seized in Turkey hasincreased almost Iran)indicatethatsignificantprocessing is also taking place three-fold duringthis period. outsideAfghanistan(CND, 2008;UNODC,2007a). Globalseizuresofaceticanhydride (usedinthe illicit Heroin enters Europe mainly by twomajor trafficking routes: manufactureofheroin) increasedto26400 litres in thehistorically importantBalkan routeand itsseveral 2006,most of it recoveredinthe RussianFederation branches,following transitthrough Pakistan,Iranand Turkey; (9 900litres) andColombia (8 800litres),followedby andthe increasingly used ‘northernroute’via centralAsia Turkey (3 800litres) (INCB, 2008b).The trafficking routes andthe RussianFederation(Figure 6).Secondarytrafficking betweenAfghanistanand Europe arealsobeing used to routes were reported forheroinfromsouth-westAsia, for smuggleprecursor chemicals (mainlyaceticanhydride via example directlyfromPakistantoEurope(United Kingdom), the‘northern route’)and syntheticdrugs(mainly ecstasy) butalsovia Pakistan andcountriesinthe Middle East and eastwards(Europol, 2008). Africatoillicitmarkets in Europe andNorth America(INCB, 2008a;Europol,2008; UNODC,2007a;WCO,2007). Seizures of 3-methylfentanyl reported in 2006 in Latvia Heroin from south-west Asia is also smuggled to Europe andLithuania andreports of increasedinjecting of

(104)For information on thesources of data fordrug supplyand availability,see p. 36. (105)See Tables SZR-7 andSZR-8 in the2008statisticalbulletin. Note that,for estimating purposes,2006missing dataonEuropeanseizureswere replaced by 2005 data.This analysis is preliminaryasdata forthe United Kingdom arenot yetavailablefor 2006. 68 Chapter6:Opioid useand drug injection

Figure6:Main heroin trafficking flows from AfghanistantoEurope

To Baltic and Nordic countries

To rest of Asia and Europe

To Arabian Peninsula, and Europe

To eastern, southern and west Africa, and Europe

NB:Traffickingflowsrepresented on themap synthesise theanalyses of avariety of internationaland nationalorganisations (Reitoxnationalfocal points,Europol,INCB, UNODC,WCO). Such analyses arebased on information related to drug seizures along thetraffickingroutes, andalso intelligenceinformation from law enforcementagenciesintransit anddestination countries, andsometimes on reportsfromcomplementary sources.The main trafficking routes represented on themap shouldbeconsideredasindicativeofthe main flows,asthere maybedeviationsto othercountriesalong theroutes, andthere arenumeroussecondarysub-regionalroutesnot represented here whichmay change rapidly.

69 Annual report 2008:the stateofthe drugsproblem in Europe

illegallyproducedfentanylinEstonia,pointstothe need Figure7:Estimatesofthe annual prevalenceofproblem opioid to monitor more closelythe availability of synthetic use(casesper 1000 populationaged15–64) opioidssuchasfentanyl(whichisconsiderablymore potent than heroin). 8 Purity andprice

In 2006,the typicalpurityofbrown heroin ranged

between15% and25% in most reportingcountries, 6 although values under10% were reported in Greece, France andAustria,and higher onesinMalta (31%),

Turkey (36%)and theUnited Kingdom (43%). The typical 00 10 purity of whiteheroinwas generally higher (45–70 %) in 4 per thefew European countriesreporting data (106). Cases The retail priceofbrown heroin variedin2006from EUR14.5per gram in Turkey to EUR110 pergramin 2 Sweden,withmost European countriesreporting typical prices of EUR30–45 pergram. The priceofwhite heroin is reported only by afew European countries andrangedbetween EUR27and EUR110 pergram. Over theperiod2001–06,the retail priceofbrown 0 heroin fell in amajorityofthe 13 European countries TM reportingtimetrends, although signsofincreases have CM OT (2006) CR CR TP been noted in Poland. CR CR TM MM MI (2006) (2006) (2005) (2006) (2006) (2004) Republic (2006) (2002) (2002) (2006) Prevalence estimatesofproblemopioiduse many Ger Malta Cyprus Finland Czech Italy Slovakia Spain Greece Austria Latvia Data in this sectionare derivedfromthe EMCDDA problem drug use(PDU) indicator,which includes mainly NB:The symbol indicates apoint estimate;abar indicates an estimation uncertaintyinterval: a95% confidenceinterval, or one injectingdrug useand theuse of opioids, although in basedonsensitivity analysis. Target groups mayvaryslightly, owingtodifferent estimation methodsand data sources;therefore, afew countriesusersofamphetamines or cocaineare comparisonsshouldbemadewithcaution.Non-standardage also an importantcomponent. Estimatesofthe number of ranges were used in thestudies from Finland(15–54)and Malta (12–64). ForGermany,the interval representsthe lowest boundof problem opioid usersare generally uncertain, giventhe allexistingestimatesand thehighestbound of them,and thepoint estimate asimpleaverage of themidpoints.Methods of estimation relativelylow prevalenceand hidden nature of this type areabbreviated:CR=capture–recapture; TM =treatmentmultiplier; of drug use, andstatisticalextrapolations arerequired MI=multivariateindicator;TP=truncated Poisson;MM=mortality multiplier;CM=combinedmethods;OT=other methods.See Figure to obtain prevalenceestimatesfromthe availabledata PDU-1(part ii)inthe 2008 statisticalbulletinfor furtherdetails. sources.Moreover, as most studiesare basedona Sources: Reitox nationalfocal points. localisedgeographicalarea, such as acityordistrict, overallprevalenceofproblem drug useisestimated to range extrapolationtothe nationallevel is oftendifficult. betweenone and10cases per1000.The lowest well- Patterns of problem drug useinEuropeappeartobe documented estimatesofproblem opioid useavailable are becomingmorediverse.For example,insomecountries from Cyprus, Latvia,the CzechRepublic andFinland (though whereproblem opioid usehas historically predominated, both theCzech Republic andFinland have largenumbersof recent reportssuggestthatother drugsincluding cocaine problem usersofamphetamines), whilethe highestestimates aregrowing in importance.The need foreffective arefromMalta,Austria andItaly (Figure7). monitoringofarange of problem drug usepatternshas From therelativelylimited dataavailable,anestimated prompted theEMCDDAtoreportonproblem drug usesub- averageprevalenceofproblem opioid useofbetween four populations defined by drug andwhich mayoverlap (107). andfive casesper 1000 of thepopulationaged15–64 Estimatesofthe prevalenceofproblem opioid useatnational canbederived.Assumingthis reflectsthe EU as awhole, levelduringthe period 2002–06 range roughlybetween it impliessome1.5 million(1.3million to 1.7million) one andsix casesper 1000 populationaged15–64; problem opioid usersinthe EU andNorwayin2006.

(106)See Tables PPP-2 andPPP-6 in the2008statisticalbulletinfor purity andpricedata. (107)For an overview of available estimatesofthe componentparts of problem drug use, seethe 2008 statisticalbulletin. 70 Chapter6:Opioid useand drug injection

Trends andincidence of problem opioiduse Opioidindicatorsare no longerdecreasing Time trends in theprevalenceofproblem opioid useare difficulttoestimate because of thelimited number of repeated In contrast to trends described in previous annual reports, estimatesand theuncertainty around individual estimates. recent data show someincreases in drug-induceddeaths, heroin seizures andnew treatmentdemandsfor heroin in Data from nine countrieswithrepeated estimatesduringthe theEuropeanUnion. period 2001– 06 suggest diversedevelopments.Prevalence seemsrelativelystableinthe CzechRepublic,Germany, In 2003,the downward trendinthe number of drug- induceddeathsreported in Europe,mostly related to the Greece, Italy, Malta, Slovakiaand Finland, whereasan useofopioids, ceased andbetween 2003 and2005 increase wasobservedinAustria (most recent data2004) most Member States have been reportinganupward andsignsofapossible decrease in Cyprus(108). trend. Numbersofseizuresofheroinincreased by over 10 %in16out of 24 reportingcountriesbetween 2003 Incidenceofproblem opioid use(thenumber of new and2006. Afterfalling forseveral years, newdemands casesoccurring in agiven year)isamoresensitive fortreatmentwithheroinasthe primarydrug have measurefor changesovertime, andmay providean increasedinabout half of thecountriesreporting data earlyviewonfuturedevelopments in prevalenceand in between2005and 2006.This mayreflectachange in incidenceofheroinuse beginning afew yearsearlier, treatmentdemand.The estimation models used,though, because of thenatural time lagbetween initiation of use make severalassumptions.Furthermore,these models andfirsttreatment. canprovide only apartial estimate of incidence, as they These recent trends occuralongside increasedopium arebased on only thosecases that come into contact productioninAfghanistan, raisingaconcern that these with treatment. Only twocountriesreportrecentdata, events mightbelinkedthrough increasedavailability of showingdifferent trends.InItaly,incidenceisestimated heroin on theEuropeanmarket. This is an importantissue to have declined from around 32 500new casesin forfurther investigation as available data do not allowa clear picturetobedrawn.Moreover, importantconfounding 1990 to about22000 newcases in 1997,after whichit factors exist. Forexample,the useofpharmaceutical hasrisen againtoaround30000 newcases in 2006. opioidsfor non-medical purposes is reported to have In Spain, to thecontrary, theincidenceofproblem continued at high levels or increasedinseveral countries opioid useisestimated to have continuouslydeclined (Czech Republic,Estonia,France, Austria,Finland)and may sinceits peak around 1980,althoughinrecentyears represent an importantfactor in explainingtrendsindrug- induceddeaths. (2002–04)itseems to have stabilisedatarelativelylow level(around 3000 newcases peryear).The EMCDDA, in collaborationwithagroup of nationalexperts, treatmentfound that primaryopioid usersaccounted hasrecentlydevelopednew guidelines forincidence overallfor 59 %ofclients butonlyfor 40 %ofclients estimation,inorder to encourage furtherwork in this entering treatmentfor thefirsttimeintheir lives(110 ). area (ScaliaTomba et al., 2008). Most drug clients entering outpatient treatmentfor primaryopioid usealsouse otherdrugs, including Opioidusers in treatment cocaine(25 %),other opioids(23 %) andcannabis Opioids, mainly heroin,remain theprincipal drugsfor (18%). In addition, of thoseintreatmentfor the whichclients seek treatmentinmost reportingcountries. primaryuse of otherdrugs, 13 %ofclients in outpatient Of the 387000 treatmentrequests reported in 2006 treatmentand 11 %ininpatient treatmentreportopioids (dataavailable from 24 countries),heroinwas recorded as asecondarydrug (111). as theprincipal drug in 47 %ofcases forwhich the primarydrug is known. In most countries, between50% Some countriesreportasignificantproportionof and80% of alltreatmentdemandsare reported to be treatmentdemandsrelatingtoopioidsother than heroin. related to opioid use; in theremainingcountriesthe Buprenorphine misuseisreported as themainreason for proportion variesbetween 15 %and 40 %(109). Opioids entering treatmentby40% of allclients in Finlandand arenot only themost frequently reported primarydrug 8% of clientsinFrance. In Latvia andSweden, between amongthose entering treatmentbut even more so among 5% and8%ofdrug clientsreportprimary useofopioids thosewho arealready in treatment. Arecentproject otherthanheroinormethadone:mainlybuprenorphine, involvingninecountriesand focusing on allclients in painkillersand otheropioids(112). Severalcountriesreport

(108)See Tables PDU-6(part ii)and PDU-102inthe 2008 statisticalbulletinfor full information includingconfidenceintervals. (109)See TableTDI-5 in the2007statisticalbulletin. (110 )See TableTDI-39inthe 2008 statisticalbulletin. (111)See Tables TDI-22 andTDI-23inthe 2008 statisticalbulletin. (112)See TableTDI-113 in the2008statisticalbulletin. 71 Annual report 2008:the stateofthe drugsproblem in Europe

an increase in theproportionofpolydrug usersamong Figure8:Estimatesofthe prevalenceofinjecting drug use(cases heroin clientsand ariseinthe number of clientsusing per1000 populationaged15–64) opioidsother than heroin.

The absolutenumber of heroin treatmentdemandsreported 16 throughthe treatmentdemand indicator increasedbyover 30 000 casesfrom108 100to138 500between 2002 and2006. Similarly, amongclients entering treatment forthe first time in theirlife, therewas an increase in the 12 number of primaryheroinusersfromaround33000 in 2002 to over 41 000 in 2006.Factorsthatmightexplain this trendinclude an increase in thenumbersofproblem 00 10 8 heroin users, an expansionintreatmentprovision or per improved reportingcoverage. Cases

Injectingdrug use 4

Prevalence of injectingdrug use

Injectingdrug usersare amongthose at highestriskof

experiencinghealthproblemsfromtheir drug use, such as 0 blood-borne infections(e.g. HIV/AIDS,hepatitis)ordrug- OT induceddeaths. Only 11 countrieswereabletoprovide OT

recent estimatesofthe levels of injectingdrug use, despite MM CR OT (2005) CM (2006) MM CR CM CR theirimportancefor public health (Figure8). Improvingthe TP 2005) (2005) (2006) (2005) (2006) (2006) (2002) (2004) (2006)

levelofinformation availableonthis specialpopulationis, y( Kingdom Republic way therefore, an importantchallengefor thedevelopmentof many Ger Nor Hungar Cyprus Greece Estonia United Slovakia Finland Czech health monitoringsystems in Europe. Croatia

The availableestimatessuggestlarge differences between NB:The symbol indicates apoint estimate;abar indicates an estimation uncertaintyinterval: a95% confidenceinterval, or countriesinthe prevalenceofinjecting drug use. Estimates one basedonsensitivity analysis. ForEstonia,the upperlimit range betweenone andfive casesper 1000 population of theuncertainty interval is off-scale(37.9 per1000). Target groups mayvaryslightly, owingtodifferent estimation methods aged 15– 64 for most of thecountries, with an exceptionally anddata sources;therefore,comparisonsshouldbemadewith high levelof15cases per1000 reported in Estonia. caution. Methodsofestimation areabbreviated:CR=capture– recapture; TM =treatment multiplier;MI=multivariateindicator; TP=truncated Poisson;MM=mortality multiplier;CM=combined The lackofdatamakes drawingconclusions on time methods;OT=other methods.See Figure PDU-2inthe 2008 trends in theprevalenceofinjecting difficult, although the statisticalbulletinfor furtherdetails. Sources: Reitox nationalfocal points. availabledatasuggestadecline in Norway (2001–05), andastablesituationinthe CzechRepublic,Greece, entering treatment, with thelowestproportions of injectors Cyprusand theUnited Kingdom (113). reported in Spain, France andthe Netherlands(under 25 %) andthe highest(over 80 %) in Bulgaria,the Czech Injectingamong opioidusers entering treatment Republic,Romania, Slovakiaand Finland(114).

Overall, 43 %ofall opioid usersenteringdrug outpatient Amongopioid usersenteringoutpatienttreatmentfor treatmentin2006reported injectingthe drug.Changes thefirsttimein2006, aslightlylower proportion report in theproportionofinjectors amongheroinusersentering injectingthe drug (around40%). Lookingattimetrends, treatmentmay indicatetrendsinthe widergroup of theproportionofinjectors amongnew opioid clients problem opioid users. Declines in this proportion between decreasedfrom43% in 2003 to 35 %2006inthe 13 2002 and2006havebeenobservedbyninecountries countrieswhere sufficient dataare available(115). (Denmark,Germany,Ireland,Greece, France,Italy, Sweden,United Kingdom,Turkey),whereas twocountries An analysis of thetreatmentdemand datafor nine report an increase (Romania, Slovakia).Countriesdiffer countriestakingpartinapilot studyrevealedthataround considerablyinthe levels of injectingamong heroin users 63 %ofall opioid clients(thosealready in treatment

(113)See TablePDU-6 (partiii)inthe 2008 statisticalbulletin. (114)See Tables PDU-104, TDI-4, TDI-5and TDI-17 (partv)inthe 2008 statisticalbulletin. (115)See Figure TDI-7and TableTDI-17(part i) in the2008statisticalbulletin. 72 Chapter6:Opioid useand drug injection

andthose entering treatmentinthe last year)reported Lithuania, Austria andRomania, whereasless than 20 % injectingthe drug at entrytotreatment(116). This suggests of theinjectors sampledare under25innineother that amongclients already in treatmentthe proportion of countries. injectors at treatmententrancewas relativelyhigh. In general, alarge proportion of newinjectors hasto Studiesamong injectingdrug usersmay provideanother give causefor alarm, especially if reinforced by alarge window on nationaldifferences andchangesovertimein proportion of younginjectors.While ahigher proportion injectingdrug usewithinEurope. Many countriesconduct of newinjectors canindicateanew upsurgeofinjecting, regularlyrepeated studiesongroupsofinjectors,usually otherfactorscould also relatetothis (e.g.shorter in thecontext of infectiousdisease testing,thatare often injectingcareers,bettertreatmentavailability,higher recruited from avariety of settingsinorder to maximise deathrates amongthe older population). generalisability.Comparisonsbetween countriesshould Countrieswithlong-establishedproblem opioid user be made with cautiondue to potentialbiases in selective populations generallyhavelow proportionsofboth recruitmenttothese studies(117 ). youngand newinjectors.Inthe remaining, oftennewer, Some countriesshowlarge proportions(above20%) Member States data show higher levels of young of newinjecting drug users(injectingfor less than two injectors.The varyinglevelsofnew injectors in these years) in these studies, whereasinseveral countriesthis countries, whereinformation is available, mayreflect proportion is under10% (Figure9). Younginjecting differences in theaverage ageofinitiationaswellas drug users(underage 25)account formorethan40% increasing injectingincidenceamong theyoungerorthe of theinjectors sampledinthe CzechRepublic,Estonia, older populations.

Figure9:Proportion of youngand newinjectors in samplesofinjecting drug users

% 100

80

60

40

20

0 y Kingdom Republic tugal Spain Por Belgium Sweden United Hungar France Luxembourg* Greece Poland Slovenia Malta* Bulgaria* Romania* Austria* Estonia Lithuania Czech Finland*

Young injectors New injectors

NB:Samples areofinjectors tested forinfectiousdiseases (HIV andHCV). The latestavailablesample foreachcountry duringthe period 2002–06 hasbeenused, subjecttothere beingatleast 100injectors. An asteriskindicates that no data areavailablefor newinjectors. Forfurther information,see Figure PDU-3inthe 2008 statisticalbulletin. Sources: Reitox nationalfocal points.

(116)See Tables TDI-17 (partv)and TDI-40 in the2008statisticalbulletin. (117 ) It mightbeexpected that theproportionofyoung or newinjecting drug usersislower in samples recruited from drug treatmentthaninmore‘open’ settingssuchaslow-threshold services,asonaverage clientsenteringtreatmentdosoonlyafter some yearsofusing drugs. However, statisticalanalysis of theassociationbetween recruitmentsetting andproportions of youngornew injecting drug usersshows no statisticalsignificance,suggesting that recruitmentsetting (coded as ‘onlydrug treatment’,‘no drug treatment’ and‘mixedsettings’)may not have astrong effectonthese proportions. 73 Annual report 2008:the stateofthe drugsproblem in Europe

Treatmentofproblemopioiduse on thenumber of clientsinsubstitution treatmentsuggest an overallincreaseinthe last year,exceptfor France, Profile of opioidclients entering treatment theNetherlands,Malta andLuxembourg, wherethe Clientsenteringtreatmentfor primaryopioid usetend situationwas stable.The biggest proportionalincrease to be older (meanage 32 years) than thoseentering wasreported by theCzech Republic (42%), although treatmentfor cocaine, otherstimulantsand cannabis increases in excess of 10 %werealsoreported by Poland (meanage 31,27and 24 yearsrespectively),with (26%), Finland(25 %),Estonia (20%), Sweden (19%), female clientsgenerallybeing one or twoyears younger Norway (15%), Hungaryand Austria (11%). than theirmalecounterparts.Opioid clientsare generally Asimplecomparison of theestimatesofthe number youngerinthose countriesthathavejoinedthe European of problem opioid usersand thereported number Unionsince 2004 andinIreland,Greece, Austria and of treatments deliveredsuggests that more than one Finland(118). in threecould be receiving substitution treatment. It On average, men outnumber women opioid clientsby should,however,beborne in mind that thereisstill threetoone,withhigher proportionsofmen found, in lackofprecision in both datasetswhich impliesthis particular,insouth European countries(Bulgaria,Greece, calculationshouldbeviewedwithcaution. Furthermore, Spain, France,Italy,Cyprus, Malta, Portugal)(119). wide confidenceintervals in theestimatesofproblem Opioid usersreporthigher ratesofunemployment opioid usemeanthatcomparisons betweencountries andlower levels of educationalattainmentthanother aredifficult.Nevertheless,the availabledataindicate clients(seeChapter 2),and in some countriesahigher that theproportionofproblem opioid usersreceiving frequencyofco-morbid psychiatric disorders is noted. substitution treatmentdiffers considerablybetween

Abouthalfofopioid usersseeking treatmentreport initiation before theage of 20 andaroundone third Wideningpharmaceuticaloptions

betweenthe ageof20and 24 years; first useofopioids Newpharmaceutical optionsfor thetreatmentofopioid afterthe ageof25isuncommon (120). An average dependencyhavebeendevelopedand made available in time lagofbetween sevenand nine yearsisreported Europe.The aims of these newprescribing optionsinclude betweenfirstuse of opioidsand first contactwithdrug improvingthe effectiveness of treatment, respondingtothe treatment, with male clientsreporting alonger time lag needsofdifferent groups of opioid usersand reducing the possibilities forthe misuseofsubstitutiondrugs. than females(121). Abuprenorphine/naloxone combination waslaunchedon theEUmarketin2006asanalternativetobuprenorphine Treatmentprovision andcoverage alone,withthe aimofreducingthe potentialand Treatmentfor opioid usersismostly conducted in attractiveness forinjecting use. Anumber of Member States arecurrently assessing thevalueofthis substanceas outpatient settings, whichcan includespecialistcentres, atreatmentoptionfor opioid dependence(1). generalpractitioners andlow-threshold facilities.Ina fewcountries, inpatientcentres also playamajor role, Prescription of medicalheroin(diamorphine),asa treatmentoptionfor chronictreatment-resistantopioid notably Bulgaria,Greece, Finlandand Sweden (122). users, is available to alimited extent in theNetherlands Drug-freeand substitution treatments foropioid use (815 clientsin2006),the United Kingdom (400 clients) areavailable in allEUMemberStates, Croatia and andGermany,where theparticipantsofthe heroin trial continuetoreceivediamorphineaccording to aspecial Norway.InTurkey, thefutureuse of substitution treatment regulation. Additionally, arandomised trialofinjectable is currentlyunder study. In most countriessubstitution opioids(RIOTT) is currentlyunderwayinthe United treatmentisthe most widely available option,thoughin Kingdom whichwillassess theeffectiveness of injectable 2005,Hungary, Poland andSwedenreported that drug- diamorphine, injectable methadone andoralmethadone. free approaches were predominant. In February 2008,itwas also decidedtointroduce a diamorphineprescriptionscheme in Denmark. Substitution treatment, generallyintegrated with psychosocialcare, is typicallyprovidedatspecialised (1)Technical information on thesubstance is available on the EMEA website(http://www.emea.europa.eu/humandocs/ outpatient centresand in shared-care arrangementswith Humans/EPAR/suboxone/suboxone.htm). office-basedgeneralpractitioners.The availabledata

(118)See Tables TDI-10,TDI-32and TDI-103inthe 2008 statisticalbulletin. (119)See Tables TDI-5and TDI-21 in the2008statisticalbulletin. (120)See Tables TDI-11,TDI-107 andTDI-109 in the2008statisticalbulletin. (121)See TableTDI-33inthe 2008 statisticalbulletin. (122)See TableTDI-24inthe 2008 statisticalbulletin. 74 Chapter6:Opioid useand drug injection

countries, with estimated ratesofaround5%in theblack market.The United Kingdom guidelines on Slovakia, 20–30 %inFinland,Greeceand Norway, clinical managementofdrug dependencehavealso 35–45 %inthe CzechRepublic,Malta andItaly,and been updated,and theNationalInstitute forClinical over 50 %inthe United Kingdom (England), Germany Excellencehas issued specific guidance on methadone andCroatia (123). andbuprenorphine prescribing, treatmentwith naltrexone,detoxificationand on psychosocialtreatment. Whileoralmethadone remainsthe main drug used Portugal hasalsodrawn up newguidancetoensure forsubstitution treatmentinEurope, theuse of timelyaccess to treatment. buprenorphine is becomingincreasinglycommon. Onereasonfor this is that it maybeassociated with Treatmentinprisons lowerrates of mortalitywhen misused (Connock et al., 2007). The DanishNationalBoard of Health,after a There is wide recognitionamong EU policymakers for review of substitution guidelines,has nowurged general theneed to harmonisepracticeand qualityofservices practitioners to prescribebuprenorphine insteadof betweencommunity andprisons.However,areport methadone. issued by theEuropeanCommission (2007a)highlighted thelack of servicesfor drug usersavailable in prisons Treatmenteffectiveness,quality andstandards anddrewattention to theimportanceofintervening in this setting.Examplesofthe limitationsinthe provision Reviews of randomised controlledtrialsand observational of drugsservicesinprison include: lackofcapacityand studiesconcludethatmethadone maintenancetreatment expertise(Latvia,Poland,Malta), fragmented assistance (MMT)and buprenorphine maintenancetreatment(BMT) (Latvia), lackofinterventions forspecific groups such as canbothbeeffective forthe managementofopioid youngdrug-using inmates(Austria), andabsenceofa dependence. ArecentCochranereviewconcluded, public-healthbased prevention strategy (Greece). however, that buprenorphine is less effective than methadone deliveredatadequatedoses (Mattick et More positively,prison drug programmes have become al., 2008). Anumber of studieshavealsofound that more widespread,and newinitiatives arereported by diamorphine maintenancecan be effective forpeople many countries. Forexample,inPortugal, thelegal failing torespond to MMT(Schulteetal.,inpress). framework forasyringe exchange programmeinprisons Overall, substitution treatmenthas been linked to a hasbeenestablished;inLithuania,adecreeobliging number of positive outcomesincluding:retention in prisonstoprovide pre-releasecounselling waspassed; in treatment, reductions in illicitopioid useand injecting, Denmark, sinceJanuary 2007,all inmateswithsentences reductions of mortalityand criminal behaviour, and longer than threemonthscan benefit from a‘treatment stabilisationand improvementofhealthand social guarantee’;inthe CzechRepublic,substitutiontreatment conditions of chronicheroinusers. hasbeenexpandedto10prisons;and in Ireland, treatmentservicesinprison arecurrently beingassessed Psychosocial andpsychotherapeutic interventions with theaim of achievingequivalencewiththose in the combinedwithpharmocotherapy have also shownto community. be effective in treatmentoutcome studies, forexample NTORSinthe United Kingdom (Gossop et al., 2002) The levelofdrug treatmentprovision in prison remains andDATOS in theUnited States (Hubbard et al., low, comparedtothe community,althoughthe 2003). These approaches maynot only increase prevalenceofdrug useisgenerally higher.Inmany treatmentmotivation, preventrelapseand reduce harm, countries, detoxificationisthe preferred andsometimes butalsoprovide advice andpractical supporttoclients theonlytreatmentoptionavailable.Substitution treatment whohavetoaddress theirhousing,employmentand is offeredintheoryinmost countries, butdataindicate family-related problemsinparalleltotreatingtheir that fewdrug usersreceiveitinpractice. Exceptions are opioid dependence. The availableevidence, however, Spain, where14% of allsentenced prisoners (19600) doesnot supportthe useofpsychosocialtreatments received substitution treatmentin2006, andthe United alone (Mayet et al., 2004). Kingdom (England andWales), whereitisexpected that thenumbersreceivingmethadone will increase Anumber of countrieshaverecentlyreported making from 6000 to 12 000 followingthe introductionofnew improvements to theirtreatmentguidelines. In Croatia, guidance in April2007. Denmarkand Scotland,substitutionprogrammeshave been reviewedand guidelines have been revisedto Practical guidance forsubstitution treatmentincustodial increase treatmentquality andprevent diversion into settings, endorsedbythe WHOand UNODC,has

(123)See Figure HSR-1 in the2008statisticalbulletin. 75 Annual report 2008:the stateofthe drugsproblem in Europe

recently been published(Kastelic et al., 2008), andsome sufficient dosage andtreatmentlastingfor thedurationof research points to opioid substitution therapyinprison imprisonment(Stallwitzand Stöver,2007).Furthermore, showingpositiveeffects on risk behaviourand mortality carefuldischarge planningand linkagetocommunity (Dolanetal.,2003).Arecentreviewofresearch studies care areother keyelements of servicesinthis area on prison-based substitution programmes concluded needed to ensure that gainsinhealthstatusmadeduring thatpositiveeffects depended on theprovision of time spentincustody arenot subsequently lost (124).

(124)See ‘Elevated risk of drug-induceddeath on completionofprison sentences or treatment’,p.88. 76

Chapter7 Drug-relatedinfectiousdiseasesand drug-relateddeaths

Drug-relatedinfectiousdiseases newlydiagnosed infectionsamong IDUs in the25EU Member States forwhich nationaldataare available Infectiousdiseases such as HIVand hepatitisBand Care was5.0 casesper millionpopulation, down from 5.6in amongthe most serious health consequences of drug use. 2005 (127). Of thethree countriesreporting thehighest Even in countrieswhere HIVprevalenceininjecting drug ratesofnewly diagnosedinfections(Estonia, Latvia, users(IDUs)islow,other infectiousdiseases including Portugal), Portugal continued to report adownward hepatitisA,Band C, sexually transmitted diseases, trendin2005/06,while in Estoniaand Latvia thetrends tuberculosis,tetanus,botulismand humanT-lymphotropic levelled offat142.0 and47.1newly diagnosedcases virusmay disproportionately affectdrug users. The EMCDDA permillion population, respectively.Between 2001 and is systematically monitoringHIV andhepatitis Band C 2006,nostrongincreases have been observedinany amonginjecting drug users(prevalenceofantibodies, countryinthe populationrateofHIV infection.Where or otherspecific markersinthe case of hepatitisB). The someslightincreaseisobserved(e.g. Bulgaria,Ireland), datahavetobeinterpreted with caution, givenseveral this remained belowone additionalcaseper million methodologicallimitations in thedifferent datasystems (125). populationper year.

Lookingatabsolutenumbersreveals whichcountries HIVand AIDS contributemorestronglytothe overallEUtotal.The By theend of 2006,the incidenceofdiagnosed HIV largestnumbersofnewly diagnosedinfectionsamong infection amonginjecting drug users(IDUs)appears to have IDUs were reported in 2006 by countrieswiththe highest been lowinmost countriesofthe European Union, andthe infection rates(Portugal,703 newdiagnoses;Estonia, overallEUsituationappears relativelypositiveinaglobal 191; Latvia,108)(128)and thosewithlarge populations context.This may, at least partly,followfromthe increased (United Kingdom,187;Germany,168;France, 167; availability of prevention,treatmentand harm-reduction Poland,112)(Figure 10). Against thegeneral background measures,including substitutiontreatmentand needle and of decliningtrends, thelargest increases in absolute syringe programmes.Other factors,suchasthe declinein numberssince 2001 areobservedinthe United Kingdom, injectingdrug usethathas been reported in somecountries, with about13additionalcases peryear, andinGermany, mayalsohaveplayedanimportant role.Nonetheless,in with about10additionalcases,althoughthese arenot someparts of Europe,datasuggestthatHIV transmission evenly distributed over theyears.InBulgaria,the lowrate related to injectingdrug usestill continued at relativelyhigh of increase hasaccelerated recently,with0,2,0,7,13 ratesin2006, underliningthe need to ensure thecoverage and34new casesper year between2001and 2006, andeffectiveness of localpreventionpractice. suggesting thepotential foranoutbreak.

TrenddatafromHIV prevalencemonitoringinsamples Trends in HIVinfection of IDUs areanimportant complementtodatafromHIV- Data on newlydiagnosed casesrelated to injecting case reporting, as they provideinformation also on drug usefor 2006 suggest that infection ratesare still non-diagnosedinfection.Prevalencedataare available fallingoverall in theEuropeanUnion,following thepeak from 25 countriesoverthe period 2002–06 (129). In 15 in 2001– 02,which wasdue to outbreaksinEstonia, countries, HIVprevalenceremained unchangedduring Latvia andLithuania (126). In 2006,the overallrateof theperiod. In fivecountries(Bulgaria,Germany,Spain,

(125)For detailsonmethods anddefinitions, seethe 2008 statisticalbulletin. (126)See TableINF-104 in the2008statisticalbulletin. (127)Nationaldata arenot available from Spainand Italy. Adjusting forthose twocountries, theratewould be 5.9cases permillion population, down from 6.4in2005. (128)InPortugal, 703cases were reported by EuroHIVfor 2006,while 432werereported by thePortuguese EpidemiologicalSurveillance Centre of Transmissible Disease(CVEDT); thediscrepancy is duetoclassificationbyreporting year (EuroHIV) versus by year of diagnosis (CVEDT). (129)See TableINF-108 in the2008statisticalbulletin. 78 Chapter7:Drug-related infectiousdiseases anddrug-related deaths

Figure10: Absolutenumber of newlydiagnosed HIVinfectionsamonginjecting drug usersbyyearofreport: countrieswithpeaklevel greaterthan300 (left) andbetween 100and 300(right)

1600 300

1200

200

800

100

400

0 0 1996 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Portugal Estonia Poland Latvia Lithuania United Kingdom Germany France Austria

NB:Nonationaldata areavailablefor Spainand Italy, data areshown forregions whereavailable. Forbothcountriespartial numberstotalledover 100new casesin2005and showed adecliningtrend.For furtherinformation,see TableINF-104 in the2008statisticalbulletin. Source: EuroHIV.

Italy, Latvia)prevalenceshowedstatisticallysignificant The high annual rate of newHIV diagnoses related decreases,all basedonnationalsamples. Although in to injectingdrug useinEstonia,Latviaand Portugal twoofthese,regionalincreases were also reported:in suggeststhattransmission is still occurringinthese Bulgaria,one city,Sofia; andinItaly,eight outof21 countriesathigh levels.For Estonia, this is supported by 2005 prevalencedata, whichsuggestthataround regionsand onecity. Finally, in fivecountries, national athird of newIDUs(thoseinjecting forless than two trends areeithernot reported or appear stable,while years) were HIVpositive. Furtherindications of ongoing therewas at least one sub-nationalsample indicatingan HIVtransmission aregiven by reportsofhigh prevalence increasing trend, even if prevalencelevelsremain mostly levels (over5%) amongyoung IDUs (samplesof50or at lowlevels(Belgium, CzechRepublic,Lithuania,United more IDUs underage 25)inseveral countries: Spain Kingdom,and possibly Slovenia). (nationaldata, 2005), Portugal (nationaldata, 2006), Estonia(tworegions,2005),Latvia(nationaland in two The comparison of trends in newlydiagnosed infections cities,2002/03), Lithuania(one city,2006) andPoland related to injectingdrug usewithtrendsinHIV prevalence (one city,2005) (130). amongIDUssuggeststhatthe incidenceofHIV infection related to injectingdrug useisdeclining in most countries AIDS incidence andaccess to HAART at nationallevel.Interpretation is more difficultwhere Information on theincidenceofAIDSisimportant for these data sources partiallyconflict, as is thecasein, for showingthe newoccurrenceofsymptomaticdisease, example,Bulgaria,Germany andthe United Kingdom; though it is not agoodindicator of HIVtransmission. although in these countries, both theincidenceofnew AIDS incidencedatamay also provideinformation on the diagnoses andits rate of increase (exceptfor Bulgaria in coverage andeffectiveness of highly active antiretroviral 2004–06)are low. treatment(HAART).Highincidencerates of AIDS in some

(130)See Tables INF-109and INF-110inthe 2008 statisticalbulletin. 79 Annual report 2008:the stateofthe drugsproblem in Europe

HepatitisBand C ‘Hot spots’ of HIV/AIDS Whilehigh prevalencelevelsofHIV infection arefound The most recent data indicatethatthe incidenceofHIV only in someEUMemberStates, viralhepatitis and, in infection amongIDUsisgenerally lowinthe European particular,infection caused by hepatitisCvirus (HCV), Union. However, vigilanceisneeded as someMember is more highly prevalentinIDUsacrossEurope. HCV States continuetoshowhigh ratesofnew HIVinfections linked to injectingdrug use, andthe situationisevenmore antibodylevelsamong nationalsamplesofIDUsin worrying in someneighbouring countries. 2005–06 vary from around 15 %to90%,withmost countriestypically reportinglevelsinexcessof40%. AfterarecentHIV epidemic in Estoniaand Latvia,rates of newlydiagnosed infectionsinIDUsdecreased from 2001 Only afew countries(Bulgaria,Czech Republic,Finland) buthavenow stabilisedatstill high levels (142.0 and47.1 report aprevalenceofunder 25 %innationalsamplesof newcases permillion population, respectively,in2006), IDUs;thoughinfection ratesatthis levelstill constitute a suggesting that transmission ratesremain high.Portugalstill significantpublichealthproblem (132). hasthe largestnumber of newlydiagnosed infectionsin theEuropeanUnion (see p. 78)and,althoughthe trendis Within countries, HCVprevalencelevelscan vary down,the annual rate of newlyreported diagnoses is still considerably, reflectingbothregionaldifferences and high at 66.5 newcases permillion populationin2006. thecharacteristics of thesampledpopulation. For In neighbouringcountriestothe east of theEuropean example,inthe United Kingdom,local studiesreport Union, thesituationisofparticularconcern.Inthe two levels between29% and59%,while in Italydifferent largestcountries, Russia andUkraine,the number of regionalestimatesrange from around 40 %to96%.While newlydiagnosed casesishigh andstill increasing.In 2006,newly diagnosed infectionsrelated to injecting estimatesgenerated from non-probability samplesmust drug usewereestimated at over 11 000 in Russia and always be takenwithcaution,the variations in prevalence 7000 in Ukraine(78.6 and152.9 newcases permillion, levels foundare likelytohaveimportant implications for respectively). thetargetingand delivery of prevention andtreatment Highrates of ongoingtransmission amongIDUsindicate programmes.Furthermore,understanding thefactors theneed to review both theavailability,level andrange responsible fordifferentiallevelsofinfection is likelyto of existing serviceprovision,including specific measures inform thedevelopmentofbetterinterventionstrategies. aimedatreducingthe spread of infectiousdiseases,such as needle exchange andsubstitutiontreatment. In addition, Studiesamong young(underage 25)and new(injecting targeted studiesamongIDUsare needed to investigate forless than twoyears)IDUssuggest that thetimewindow whysomepopulations appear particularly vulnerable,the to preventHCV infection is quiteshort,asmanycontract factors associated with risk behaviourand barriers for self-protection,and to identify promisingapproaches to thevirus earlyintheir injectingcareers.Recentstudies preventnew outbreaks. (2005–06)typically report prevalencelevelsofbetween 20 %and 50 %, although with considerablevariation betweensamples. European countriesmay indicatethatmanyIDUsinfected with HIVdonot receiveHAART at asufficiently early The prevalenceofantibodiestohepatitis Bvirus stageintheir infection to obtain maximumbenefit from the (HBV)variestoanevengreater extent than that of treatment. HCVantibodies, possibly partly duetodifferences in vaccinationlevels, although otherfactorsmay playa Portugal remainsthe country with thehighestincidence role.The most completedataset availableisthatfor the of AIDS related to injectingdrug use, with an estimated antibodytothe hepatitisBcoreantigen (anti-HBc), which 22.4 newcases permillion populationin2006, although indicates ahistoryofinfection.In2005–06,six of the thetrend is nowclearly downward,from29.9cases per 11 countriesproviding data on IDUs reported anti-HBc millionin2005. Relativelyhigh levels of AIDS incidence prevalencelevelsofover40% (133). arealsoreported forEstonia,Spain andLatvia, at 17.1, 15.1 and13.5new casesper million, respectively.Among Trends over time in notifiedcases of hepatitisBand C these threecountries, thetrend is downward in Spain show different pictures.The proportion of IDUs amongall andLatvia, butnot in Estonia, wherethe most recent data notifiedcases of hepatitisBmay have declined slightlyin indicateanincreasefrom11.9new casesper millionin somecountries, possibly reflectingthe increasing impact 2005 to 17.1 permillion in 2006.Anincreasehas also of vaccinationprogrammestargeted at IDUs.Inthe case been recorded in Lithuania, from 2.0 newcases per of hepatitisC,the proportion of IDUs amongnotified millionin2005to5.0 casesper millionin2006(131). caseshas declined in fivecountries, buthas increasedin

(131)See Figure INF-1inthe 2008 statisticalbulletin. (132)See Tables INF-111 to INF-113inthe 2008 statisticalbulletin. (133)See TableINF-115 in the2008statisticalbulletin. 80 Chapter7:Drug-related infectiousdiseases anddrug-related deaths

provisioninEuropehaveincreased considerablyover Access to HIVtesting andtreatment thepast decade.Insome countries, however, these interventionsremain limited and, overall, needsstill AmongpeoplewithHIV infection in Europe,asmanyas one in everythree maybeunaware of beinginfected exceed provisioninthese areas. (ECDC, 2007), andreports from someEUMemberStates Arecentcohort studyinAmsterdam pointed to the suggest that levels of awareness mayevenbelower among infected IDUs. benefitsofthe combinedavailability of methadone maintenanceand needle exchange,asthe involvement As aresultmanyofthose whobecome infected with the with both services, comparedtothe involvementwith viruswillnot have theadvantageofearly treatmentand care.Theymay also contributetothe spread of HIVby only one,was associated with alower incidenceofHCV unknowingly exposing others to theriskofinfection.In andHIV infectionsamong injectingdrug users(Vanden addition, thequality of thedata collected by theHIV Berg et al., 2007). surveillance systemsisdiminished. Assessingthe coverage of needle andsyringe Preliminarydata suggest that access to antiretroviral programmesisdifficult, andonlysomecountriesprovide treatmentand care by IDUs is disproportionately low (Donoghoeetal.,2007).Effective antiviral treatment relevant figures. Forinstance, theCzech Republic reports approaches need to take account of thespecific situation anetwork of 90 low-threshold facilities,which reaches andneedsofIDUs. These caninclude coexisting health about25000 drug usersper year,70% of whom are andsocialproblems(e.g. homelessness andlackof injectors,and provides on average210 syringesper IDU. insurance),but also stigmaand discriminationinhealthcare settingsorrepeated arrestsand incarceration. Increases in thenumbersofsyringesgiven out by needle andsyringe programmesare reported from some To improvethe access to HIVtesting andtreatment, the EMCDDA hasdevelopedspecific guidelines foroffering countries: in Estonia, theestimated number of syringes annual voluntary medicalexaminationtoIDUs, including givenout perIDU hasdoubled between2005and testing forHIV andviral hepatitis(1). 2006,reaching112;inthe same period,Hungary’s syringe exchange programmes increasedtheir turnover of (1)http://www.emcdda.europa.eu/publications/methods/ syringesby56% andtheir clientsby84%;and Finland pdu/2008/medical-examination continues to report ariseinthe number of clientsseen andsyringesdistributed at health counselling centres. fiveother countries(CzechRepublic,Luxembourg, Malta, Notall countriesreported increases,however:inMalta Sweden,United Kingdom)(134). Forbothhepatitis Band andSlovakia, syringe provision remained stable in 2006; hepatitisC,the proportion of IDUs amongthe notifiedcases Poland reported adecreaseinthe number of agencies continued to differmarkedlybetween countriesin2006, operatingand areductionof15% in thenumber of suggesting geographic differences in theepidemiology of syringesexchanged; Romaniareported a70% decline these infections, although bias duetodifferent testing and in thenumber of syringesexchangedinBucharest,with reportingpractices cannot be ruledout. financial problemsbeing reported as themaincause.

In anumber of countries, stabilisationordecreases in Preventing infectiousdiseases syringe exchange mayreflectchangesinoverall patterns of drug injectingand in theavailability of treatment: in EU Member States employacombination of some Luxembourg,the number of syringesdistributed by low- of thefollowing measures to reduce thespreadand threshold agencies, afterincreasingfor severalyears, consequences of infectiousdiseases amongdrug stabilisedin2005and decreasedin2006; recent users: drug treatment, includingsubstitution treatment declines in syringe provision have also been reported in (see Chapter6), health information andcounselling, Portugal andBelgium (the Flemishcommunity), andatthe distribution of sterileinjection materials, andeducation locallevel in Germany andthe Netherlands. towardssafer sexand saferuse.The availability and Needle exchange andlow-threshold servicesmay also coverage of these measures variessignificantlybetween provideaconduittocarefor thosewithpooraccess countries. to generic services. This includesprimary healthcare Needle andsyringe programmesand opioid substitution delivery as well as measures to promotesexualhealth, treatmentare availableinall EU Member States,Croatia such as thedistributionofcondomsand lubricants and andNorway, although with considerablediversityin theprovision of safersex education. The delivery of both delivery settingsand targeted population. Levels of infectiousdisease prevention servicesthrough outreach both substitution treatmentand harm-reductionservice teams or at low-threshold facilities is also establishedin

(134)See Tables INF-105and INF-106inthe 2008 statisticalbulletin. 81 Annual report 2008:the stateofthe drugsproblem in Europe

Prevention of viralhepatitis HepatitisBvaccination among drug users In 2006,initiatives to preventthe spread of viralhepatitis Transmission of hepatitisBvirus (HBV)continues among were reported by severalcountries. Forexample,in IDUs in Europe,amongwhomrates of activeHBV infection Luxembourg,following theresults of an action-research (prevalenceofHBsAg)remain high in most countries, project,the provisionofsafer-use counselling foryoung comparedtothe general population(1). Vaccinationis consideredthe most effective measuretoprevent hepatitisB andnew drug userswas strengthenedand free access virus(HBV) infection andits consequences.Inlinewiththe to injectionparaphernalia forIDUswas improved.In 1991 WHOrecommendation, most,but not allEUMember Denmark, free hepatitisAand Bvaccinations have been States have adopted universalvaccinationagainst this availablesince 2006 fordrug usersand theirpartners, virus. Infant vaccinationpolicies, however, will mostly affect andmunicipalities must nowprovide acomprehensive future generations of drug users. To reduce thespreadof theinfection sooner, over half theEUMemberStateshave range of services forinfectiousdiseases to thosewho adopted vaccinationprogrammesspecificallytargeting inject drugs. Finally, in Ireland,aworkinggroup on HCV injectingdrug usersand/orprisoners. Nevertheless, wastaskedin2007withthe developmentofanational coverage of these programmes variesbetween countries, strategy forsurveillance, educationand treatment. andathird of EU Member States still report no vaccination programmespecificallyfor drug users. Prisonsare importantsettingsfor interventionstargeting

Vaccinationprogrammestargetingdrug usersoften face infectiousdiseases related to drug useand forproviding theproblem of lowcomplianceresulting in non-completion healthcare to apopulationthatisotherwise hard to of vaccinationcourses.Given theavailability of asafe reach(seeChapter 2).Recentresearch indicates that it andeffective vaccine, strategies to achieve higher levels is importanttoprovide viraltesting to allthose whohave of immunisationamongthose at risk mayinvolveaflexible ever engagedinillicitdrug useand showed that the approach,targetingdrug usersearly in theircareerand reaching outtothose communities with ahigher prevalence detectionofchronic hepatitisCinfection on receptioninto of drug use. Repeated offers of vaccinationand extradoses prison wasacost-effective measure(Suttonetal.,2006). for thosewithdecreased immune response mayalsohelp In additiontothose with infectionsreceivingthe necessary to achievehigher immunisationresults.This mayrequire treatmentand care,drug usersinprison couldbenefit from EU Member States to review andpossibly fine-tune their arange of interventionssuchashealtheducationand policiesinorder to decrease theoccurrenceofchronic HBV 135 infection andits consequences. hepatitisBimmunisation( ).

1 ( )See Tables INF-106and INF-114inthe 2008 statisticalbulletin. Drug-relateddeathsand mortality

Drug useisone of themajor causes of health problems amajorityofcountries, although servicesinthis area anddeathamong youngpeopleinEurope. The arestill beingdeveloped. Forexample,atransnational considerablemortality resultingfromopioid use, low-threshold prevention network,which will usecommon in particular,isillustrated by an internationalstudy service standardsand epidemiologicalmonitoring supported by theEMCDDA, whichfound that in seven protocols, is currentlybeing establishedinEstonia,Latvia European urbanareas,10% to 23 %ofmortality among andLithuania. 15-to49-year-oldscould be attributed to opioid use Medicalservicesare provided at low-threshold clinics (Bargagli et al., 2005). andbymobileservices, or viareferral schemes. For The EMCDDA’s keyindicator ‘Drug-related deathsand example,the Czechlow-threshold network worksclosely mortalityamong drug users’ principallymonitorsdeaths with regionalpublichealthcareservicestofacilitate directly caused by drug use(drug-induceddeaths)and,to access to counselling,testing andtreatmentfor somatic amorelimited extent,overall mortalityamong drug users, co-morbidity, in particular,viral hepatitis. In Bulgaria,a whichalsoincludesdeathsassociated with variousother mobile surgeryinBourgas,onthe Black Sea, provided health andsocialproblems. 750consultations in 2006.Some Danishmunicipalities received government fundsfor healthcare programmes Drug-induceddeaths targeted at themost vulnerable drug users. In addition, the‘health room’project in Copenhagen,which The EMCDDA definitionofdrug-induceddeaths (136) combineshealthcareand social counselling measures refers to thosedeaths that aredirectlycaused(poisonings with alow-threshold approach,isathree-year pilot or overdoses)bythe consumption of one or more drugs, scheme establishedin2008. whereatleast one of thesubstancespresent is an illicit

(135)See theDUP tables in the2008statisticalbulletin. (136)The term ‘drug-induceddeaths’ hasnow been adopted,asitreflects more accuratelythe case definitionused. 82 Chapter7:Drug-related infectiousdiseases anddrug-related deaths

EMCDDA (137). Nevertheless,differences in thequality Drug-relatedmortality:acomplexconcept of reportingbetween countriesmeanthatany direct

Both thescientific andthe policy debatesondrug-related comparisonsshouldbemadewithcaution. mortalityare hampered by therange of conceptsand During theperiod1990–2005,between 6500 and8500 definitions that have been used in this area.Ifverybroad drug-induceddeathswerereported eachyearbyEU andinclusive conceptsare used,the data maybeoflittle valuefor understandingthe underlying factors associated Member States,addinguptoabout 130000 deaths.These with drug-related mortality. Forexample,ifall deaths with figuresshouldbeconsideredasaminimum estimate (138). apositivetoxicologicalexaminationare groupedtogether, this will includecases wheredrugshaveplayedadirect Populationmortality duetodrug-induceddeath varies causal role,anindirectroleornoroleatall. widely betweencountries, rangingfromthree to fiveto over 70 deaths permillion inhabitantsaged15–64 years Anotherimportant issueisthe substances considered, whichcan be limited to illicitdrugsorextendedtoother (onaverage,21deathsper million).Rates of over 20 psychoactivesubstances andmedicines. In thelatter deaths permillion arefound in 16 European countries case,itmay be difficulttodistinguish deaths that maybe andover40per millioninfive countries. Amongmales primarilyrelated to mentalhealthissues (e.g.suicide in the aged 15–39 years, themortality ratesare,onaverage context of depression) from thoseattributabletosubstance use. Moreover,manydrug-induceddeathsare,infact, andinmost countries, twiceashigh (averaging 44 deaths polydrug deaths,and understandingthe respective role of permillion in Europe). In 2005–06,drug-induceddeaths different drugscan be difficult. accounted for3.5 %ofall deaths amongEuropeans aged 139 Conceptually,drug-related mortalityincludestwo broad 15–39 years, andfor more than 7% in eight countries( ) components.The first,and best documented,referstothose (Figure11). deaths directly caused by theactionofone or more drugs. These deaths aretypically called ‘overdoses’, ‘poisonings’ There is still limited research on themorbidityand or ‘drug-induceddeaths’.The second componentisbroader otherconsequences of non-fataloverdoses andlimited andcoversdeathswhich cannot be directlyattributable investmentinpreventionefforts,despiteevidencethatthe to thepharmacologicalactionofthe drugs, butare numbersmay be considerable. Studieshaveestimated that nevertheless linked with theiruse:long-term consequences therecould be between20and 25 non-fataloverdoses of infectiousdiseases,interactions with mentalhealthissues (e.g.suicide)orwithother circumstances (e.g.roadtraffic foreachfatal one.Althoughitisdifficulttoknowifthese accidents). There arealsodeathsrelated to drugs, butdue estimationscan be appliedtothe European Unionasa to circumstantial reasons(e.g. violencerelated to thedrug whole, it wouldproduce arough estimation of about trade). 120000 to 175000 non-fataloverdoses peryear. The EMCDDA’s currentapproach to reportingonoverall drug-related mortalityisbased on estimating mortality Deaths relatedtoopioids ratesamongcohorts of problem drug users. However, otherapproaches arebeing exploredwhereby data from Heroin varioussources canbecombinedtoestimate thetotal burden of mortalityattributabletodrugsinacommunity Opioid overdose is one of theleading causes of death (see ‘Overall drug-related mortality’,p.86). amongyoung peopleinEurope, particularly among malesinurban areas(140). Opioids, mainly heroin or its metabolites, arepresent in themajorityofdrug-induced drug.The number of drug users, theirpatternsofuse deaths reported in theEuropeanUnion,accountingfor (injection,polydrug use) andthe availability of treatment 55 %toalmost100%ofall cases, with over half of the andemergencyservicesare allfactorsthatcan influence countriesreporting proportionsofover80% (141). In the theoverall number of such deaths in acommunity.In toxicology reportsondeathsattributed to heroin,other general, drug-induceddeaths occurshortly afterthe substances areoften foundthatmay have playeda consumption of thesubstance(s). role.The most frequently reported of these arealcohol, benzodiazepines, otheropioidsand,insomecountries, Improvements in thequality andreliability of European cocaine. Recent work by theEMCDDA, in whichnine datainrecentyears have allowedbetterdescriptions countriesparticipated,found that more than one drug was of overalland nationaltrends, andmost countrieshave mentionedinthe toxicologicalresults of 60 %to90% of nowadopted acasedefinition in line with that of the opioid-induceddeaths. This suggeststhatasubstantial

(137)See detailed methodologicalinformation on drug-related deaths in the2008statisticalbulletin. (138)See TableDRD-2 (parti)inthe 2008 statisticalbulletin. (139)See TableDRD-5 andFigure DRD-7(part ii)inthe 2008 statisticalbulletin. (140)Asmost casesreported to theEMCDDAare opioid overdoses,general characteristics of drug-induceddeathsare used fordescription of opioid cases. (141)See Figure DRD-1inthe 2008 statisticalbulletin. 83 Annual report 2008:the stateofthe drugsproblem in Europe

Figure11: Mortalityrates amongall adults (15–64 years) duetodrug-induceddeaths

80

70

60

50

million 40 per Rate 30

20

10

0 y Kingdom Republic way many tugal Hungar Slovakia Bulgaria Czech France Poland Netherlands Latvia Italy Romania Belgium Cyprus Spain Sweden Greece Ger Malta Lithuania Slovenia Por Austria Finland Ireland United Nor Denmark Luxembourg Estonia

NB:For theCzech Republic,EMCDDASelection Dwas used insteadofthe nationaldefinition;for theUnited Kingdom,the drug strategy definition wasused; forRomania, data referonlytoBucharestand severalcountiesinthe competenceareaofthe Toxicology LaboratoryofBucharest. The calculations of populationmortality ratesare basedonnationalpopulations for2005asreported by Eurostat.Comparisonsofpopulation ratesshouldbemadewithcaution,asthere aresomedifferences in case definitions andquality of reporting. Forconfidenceintervals andmore information on thedata seeFigure DRD-7(part i) in the2008statisticalbulletin. Sources: Reitox nationalreports 2007,taken from nationalmortality registriesorspecialregistries(forensic or police)and Eurostat.

proportion of alldrug-inducedfatalitiesmay be related to associated with opioid substitution medicinesare reported, polydrug use. mostly duetomisuseor, in asmall number of cases, to problemsoccurring duringtreatment(144). The majority of opioid overdose deaths (60–95 %) are male,mostly between20and 40 yearsofage,witha The presenceofmethadone in asubstantial proportion mean ageinmost countriesinthe mid-thirties (142). In many of drug-induceddeathsisreported by severalcountries, countries, themeanage of thosedying from overdose is although,inthe absenceofcommon reportingstandards, increasing,suggesting apossible stabilisationordecrease theroleplayedbythe substance is oftenunclear.Countries in thenumber of youngheroinusers. However, elsewhere reportinganon-trivial number of deaths with thepresence of methadone includeDenmark,Germany,the United (Bulgaria,Estonia,Romania, Austria)arelativelyhigh Kingdom andNorway; othercountriesdid not report cases, proportion of overdose deaths areamong thoseunder 25 or only alimited number (145). In theUnited States,amarked years, whichmay indicateayounger populationusing increase hasbeenreported in deaths related to methadone heroin or injectingdrugsinthese countries(143). since1999.Most of these deaths areattributabletothe misuseofmethadone diverted from hospitals, pharmacies, Methadone and buprenorphine practitioners andpainmanagementphysicians, whileonly Research showsthatsubstitution treatmentreduces therisk alimited number of them areattributed to methadone of fataloverdose. Each year,however,anumber of deaths obtained from substitution programmes (146).

(142)See TableDRD-1 (parti)inthe 2008 statisticalbulletin. (143)See FiguresDRD-2,DRD-3 andDRD-4 in the2008statisticalbulletin. (144)See ‘Deathsrelated to substitution treatment’,p.85. (145)See TableDRD-108 in the2008statisticalbulletin. (146)NationalDrug IntelligenceCenter, ‘Methadone diversion, abuseand misuse: deaths increasing at alarmingrate’,November2007, document 2007- Q0317- 001(http://www.usdoj.gov/ndic/pubs25/25930/index.htm#Key). 84 Chapter7:Drug-related infectiousdiseases anddrug-related deaths

Fentanyl Deaths relatedtosubstitutiontreatment Aworrying epidemic of fatal3-methylfentanylpoisonings in Research hasdemonstrated that theriskofoverdose Estoniahas been recently reported basedonpost-mortem decreases substantiallywhile heroin usersare in forensic toxicology findings, with 46 fatalpoisonings methadone substitution treatment. Forexample,arecent in 2005 and71in2006(Ojanperäetal.,inpress). cohort study, involvingmorethan5000 heroin users, reported that theriskofoverdosedeath wasreducedby Furthermore, preliminaryfindings from Estoniaindicatethat afactor of 9while userswereinsubstitutiontreatment 85 deaths in 2004 were related to thesamesubstance. compared with time outside,including anyother type of There have also been sporadic reportsoffentanyldeaths treatmentornotreatment(Brugal et al., 2005). from otherEuropeancountriesand recent,generally short- Methadone,however,isidentified in thetoxicological lived, epidemicsofdeathshavebeenreported in theUnited reportsofsomedeaths. This does not implythe existence, States;for example,350 deaths were attributed to fentanyl in allcases,ofadirect causal link,asother drugsor in Chicagobetween 2005 and2007(Denton et al., factors maybepresent.Nonetheless,overdosedeath can occur, andamongthe factors that maybeinvolved are: 2008). The very high potencyofthis substancemay elevate changesintolerance,excessive dosage,inappropriate theriskofdrug overdose,while it maybeoverlookedin usebythe client,and thedrug beingusedfor non- toxicologicalscreening.Increased illicitproductionand therapeuticpurposes. useoffentanylistherefore likelytochallengebothexisting Measures to preventdiversion of methadone into the monitoringsystems andpublichealthresponses. illicitmarkethavebeenlinkedtoreductions in thenumber of reported methadone deaths in theUnited Kingdom Deaths relatedtoother drugs (148) (Zador et al., 2006)and,overall,goodpracticein substitution treatmentmay be an importantcomponent Cocaine-induceddeaths aremoredifficulttodefine and in reducing theriskofmethadone-related deaths. Both identify than thoserelated to opioids(seethe 2007 patientand community health is,therefore,likelytobe selected issueoncocaine). Deaths directlycausedby safeguarded by improving: qualitystandards of treatment, includingprescriptionpractices;clientmonitoringduring pharmacologicaloverdoseseemtobeuncommon,and thefirstphases of treatment; monitoringfor possible these areusually linked with very largecocaine doses. cardiactoxicities;information on risksofuse of other Otherwise, most cocainedeaths seem to be theresultof medicinesorpsychoactivesubstances;and dispensing thechronic toxicity of thedrug leadingtocardiovascular practices to decrease theriskofdiversion. andneurologicalcomplications.The role of cocainein The dramatic expansionofmethadone treatmentin these deaths maynot always be identified,and they Europe hasnot been reflected in aparallelriseof methadone-related deaths. Astudy carriedout in the maynot be reported as cocaine-related.Interpreting United Kingdom foundthat, between1993and 2004, thedataondeaths attributable to cocaineisfurther thetotal quantity of oral methadone prescribed increased complicated by thepresenceofother substances in by afactor of 3.6, whilethe number of deaths involving many cases,makingthe drawingofcausalassociations methadone decreasedfrom226 to 194(Morgan et al., difficult. 2006). This representsadecreaseinthe methadone- related deathratefrom13per 1000 patientyears in In 2006,morethan450 deaths related to cocainewere 1993 to 3.1per 1000 patientyears in 2004.While reported in 14 Member States —thoughitislikelythatthe similarstudies in othercountrieswould be very useful, theavailableevidencesuggeststhatmethadone-related number of cocaine-induceddeathsinthe European Union deathsare more likelytobelinkedtodeficienciesin is under-reported. prescribingpractices than to overalllevelsofsubstitution treatment. Deaths in whichecstasy is present continuetobeinfrequently reported.Most deaths with ‘presenceofecstasy’are reported in theUnited Kingdom,but in many casesthe drug Deaths duetobuprenorphine poisoningappeartobe hasnot been identified as thedirectcause of death. infrequent,despitethe increasing useofthis substance in substitution treatmentinmanyEuropeancountries. Whileamphetamine deaths arealsoinfrequentlyreported In France,veryfew deaths arereported,althoughthe in Europe,inthe CzechRepublic asubstantial number number of drug usersreceivingbuprenorphinetreatment of drug-induceddeathshavebeenattributed to pervitin is considerable(76 000–90 000). In Finland, however, (methamphetamine). In Finland, 64 deaths were reported buprenorphine is present in most drug-induceddeaths, in whichamphetamineswereidentified toxicologically, usuallyincombination with sedativemedicinesoralcohol although this does not necessarily implythatthe drug was or takenbyinjection (147). thedirectcause of death.

(147)See TableDRD-108 in the2008statisticalbulletinand the2007annual report forfurther information. (148)See TableDRD-108 in the2008statisticalbulletin. 85 Annual report 2008:the stateofthe drugsproblem in Europe

Trends in drug-induceddeaths Europe hadaveryhigh mortalityratecomparedtopeers Drug-induceddeaths increasedsharplyinEurope of thesameage (see EMCDDA,2006).Other cohort duringthe 1980sand early1990s, possibly paralleling studieshavefound mortalityrates betweensix and54 theincreaseinheroinuse anddrug injection, and timeshigher amongdrug usersthanamong thegeneral thereafter remained at high levels (149). However, population. These differences aremainlydue to drug datafromcountrieswithlongtimeseriessuggest overdose,althoughother factors arealsoimportant,and differentiated trends:insome(e.g. Germany,Spain, in some countriesAIDSdeaths playasignificantrole. France,Italy), deaths peaked in theearly to mid- Darkeetal. (2007) formulatefourbroad categories 1990s, with alater decrease;inother countries(e.g. of deaths in drug users: overdoses (including alcohol Ireland,Greece, Portugal,Finland,Sweden, Norway), intoxication),disease,suicide andtrauma. Among thenumber of deaths peaked around theyear2000, diseases,conditions related to blood-borne viruses (HIV, before decreasing;and in some others (e.g.Denmark, HCVand HBV, seeabove),neoplasms, liverdiseases Netherlands, Austria,United Kingdom), an upward trend anddiseases of thecirculatory andrespiratorysystems wasobserved, butwithout aclear peak (150). canbeassociated with drug use. Trauma involves mostly accidents homicidesand otherviolence. Trends in drug-induceddeaths over theperiod2001to 2005/06are more difficulttodescribe. In thefirstyears ArecentNorwegian studyofacohort of drug users of thedecade(2000–03), many EU countriesreported admitted to drug treatmentfound that among189 decreases and, overall, drug-induceddeaths fell by 3% recorded deaths,overdoses,accounted forhalfofall deaths,where thecauses were known. Diseases,mainly in 2001,14% in 2002 and7%in2003(151). In 2004 and2005, however, most European countriesreported AIDS andliver diseases,accounted foralmostafurther smallincreases.Anumber of factors couldbeassociated quarter, whilesuicide andtraumaeachaccounted for with this,including:increases in polydrug use, apossible aboutone tenth, andalcoholpoisonings forabout 2% growth in theavailability of heroin or an ageing (Figure12).Itshouldbenoted thatthe proportion of AIDS deaths canbeconsiderablyhigher in countrieswith populationofchronic drug users(152). ahigh HIVprevalenceamong drug users. In theabsenceofdatafromsome of thelargercountries, Cohort studiesare avaluable tool forestimating and overallestimatesofthe number of drug-induceddeaths understandingthe overallmortality related to drug for2006remain provisional. However, theavailable use, butother approaches canhelpimprove the datafrom18countriesare suggestive of asmall understandingofthe issueand provideanoverview decrease comparedto2005. at nationallevel.Several newmethods in this area The number of drug-induceddeaths in thoseyounger arecurrently beingexploredbythe EMCDDA,in than 25 yearsofage hasseenamoderateoverall closecollaboration with Member States,withthe aim decrease in Europe,whereas in thoseMemberStates of implementing them at EU level. In one of these joining theEuropeanUnion after2004, until recently approaches,mortality ratesare extrapolated from therehas been an increase in thenumber of deaths cohortstudies to local(Bargagli et al., 2005)or amongthis agegroup (153). However, an increase in the nationalestimatesofproblem drug users(Crutsetal., proportion of youngercases hasbeenobservedinrecent 2008). In anotherapproach,drug-attributablefractions, yearsinGreece, Luxembourg andAustria,and to a derivedfromvarious studies, areappliedtothe causes lesser extent in Bulgaria,Latviaand theNetherlands (154). of deaththatare most frequently related to drug use This observation requires furtherinvestigation,asitcould (e.g.AIDS, accidents,suicidesand poisonings)and pointtoincreases in thenumbersofyoung peopleusing whichare recorded in thegeneralpopulationmortality opioidsinthese countries. registers.

Overall drug-relatedmortality Deaths indirectly relatedtodrug use Arecentstudy foundthatopioid usersrecruited in AIDS deaths attributed to injectingdrug useisanother treatmentineightsites (seven cities andone country)in importantcause of death. BasedondatafromEurostat

(149)See Figure DRD-8inthe 2008 statisticalbulletin. Forhistorical reasons, this trend refers to theEU-15 andNorway. (150)See Figure DRD-11 in the2008statisticalbulletin. (151)Figuresreported here differfromthose reported in previous yearsbecause of changesincasedefinition or coverage in Denmark, Spain, France and theUnited Kingdom,and updates in severalcountries. (152)See ‘Opioid indicatorsare no longer decreasing’, p. 71,and TableDRD-2 (parti)and Figure DRD-12 in the2008statisticalbulletin. (153)See Figure DRD-13 (parti)inthe 2008 statisticalbulletin. (154)See Figure DRD-9inthe 2008 statisticalbulletin. 86 Chapter7:Drug-related infectiousdiseases anddrug-related deaths

Figure12: Knowncauses of deathamongacohortofdrug users Reducing drug-relateddeaths in Norway The reductionofdrug-related deathsisagoalof most nationaldrug strategies,but fewcountrieshave adopted actionplans or provided systematic guidance on measures to be taken. However, in 2007,the United Kingdom’s DepartmentofHealthissuednew guidelines on clinical managementofdrug misuseand dependence, setting outspecific actions forthe prevention of drug- related deaths.

The contributionthattreatment, includingsubstitution alongwithpsychosocialcareand psychotherapy,can make to reduce mortalityamong drug userswas shown in aprospective long-termstudy in Italy(Davoli et al., 2007). The studywas conducted amongacohort of 10 454heroinusersenteringpublictreatment services from 1998 to 2001,and evaluated retention Drug overdose Disease Suicide in treatmentand overdose mortality. The risk of death Trauma Alcohol poisoning amongthe cohortwas,onaverage,increased by afactor of 10 comparedtothe generalpopulation; NB:The data arefromastudy basedonasample of 501drug users though,among drug usersundergoingtreatment, admitted fortreatmentfor drug addiction duringthe period 1981–91.Atotal of 189deathswererecordedupto2003, of theriskofdeathwas four times that of thegeneral whichthe causeofdeath could not be identified in 14 cases. population, andthose whohad stopped treatmentwere Source: Ødegard, E.,Amundsen,E.J.and Kielland,K.B.(2007), ‘Fatal overdoses anddeathsbyother causes in acohortofNorwegian 20 timesmorelikelytodie. drug abusers: acompeting risk approach’, Drug andAlcohol Dependence 89,pp. 176 –82. The targeted dissemination of information on overdose risksand managementvia leaflets, brochuresand andEuroHIV (End-yearreportfor 2005,2006),itcan postersiscommon practiceinmost countries. be estimated that,in2003, over 2600 peoplediedof Furthermore, training workshopstoincreaseknowledge AIDS attributable to drug use(155). Most of these deaths andskills in overdose managementcompetenceare were reported in afew countries, with over 90 %ofthem nowreported from half of allMemberStates. This occurringinSpain,France, Italyand Portugal.AIDS training canaddress drug usersand relatives,aswell mortalitypeakedinthe mid-1990sand hasdecreased as staff, andtypically includes: information on specific substantiallyfollowing theintroductionand increased risks, includingdecreased tolerance afterperiods of coverage of HAART. abstinence;the effects of polydrug use, in particular concomitantalcoholuse,and of usingdrugswhen no With theexception of Spain, Italyand,inparticular, otherpersonispresent;and skills in first aid. In Italy, a Portugal,populationmortality ratesdue to AIDS combination of overdose response training with take- attributable to drug injectionare low. And, in many home dispensing of naloxone is reported to be used countries, overdose mortalityisconsiderablyhigher in half of theaddiction care departments underpublic than AIDS-related mortalityamong drug users(156). The health service coordination. number of deaths from othercauses (e.g.consequences The proactivemonitoringofthe psychosocialwellbeing of otherinfectiousdiseases,violence, accidents)is of drug users, includingofthose in substitution more difficulttoassessatpresent andthere is aneed to treatment, mayhavevalueasdrug overdoses arein improvedatacollectionand estimation in this area (see many cases triggeredbyprevioushealthorsocial precedingsection). events, andrates of intentionaloverdosemightbehigh Suicide appearstobeafrequentcause of deathamong (Oliveretal.,2007). drug users. Aliteraturereview(Darkeand Ross,2002) Afurther challenge,inmanycountries, is that health and foundthatthe suicide rate amongheroinuserswas 14 social services aredealing with an ageing population timeshigher than that foundinthe general population. of long-termdrug users, whomay be more vulnerable

(155)The year 2003 wastaken as themost recent year forwhich information from almost all Member States regarding causes of deathisavailable throughEurostat.For detailed information on sources,numbersand computationssee TableDRD-5 in the2008statisticalbulletin. (156)See Figure DRD-7(part ii)inthe 2008 statisticalbulletin. 87 Annual report 2008:the stateofthe drugsproblem in Europe

to both drug overdose andarange of negative health high levels of somatic disease, notably chronicinfectionsof consequences.Drug injectors,inparticular, maysufferfrom theliver,which furtherincreasetheir vulnerability.

Elevated risk of drug-induceddeath on completion attributed to drug overdoses or,moregenerally,tosubstance of prison sentences or treatment usedisorders.Coroners’records cited theinvolvementof opioidsin95% of thedrug-induceddeaths, benzodiazepines The risk of drug-induceddeath in theimmediate period in 20 %, cocainein14% andtricyclicantidepressantsin10% afterrelease from prison or on relapseafter treatmentis of cases. substantiallyelevated,according to studiescarriedout in The VEdeTTEstudy in Italy(Davolietal.,2007) observeda Europe andelsewhere. deathratefromoverdoseofone per1000 amongheroin Arecentstudy carriedout in theUnited Kingdom (England usersintreatmentand 23 per1000 in thefirstmonth after andWales)comparedthe recordsofalmost49000 prisoners treatment, correspondingtoariskofoverdosedeath 27 times released during1998–2000 with alldeathsrecordedupto higher in thefirstmonth outoftreatment, afteradjustmentfor November 2003 (Farrell andMarsden,2008).Ofthe 442 possible confounders. deaths that occurred amongthe sample duringthis period, Despitethe observedconnectionbetween drug-induced themajority(59 %) were drug-related.Inthe year following deaths andprison releaseortreatmenttermination, few release, thedrug-inducedmortality rate was5.2 per1000 countriesare systematically investing in educatingprisoners men and5.9 per1000 women.Inthe period immediately or thoseintreatmentonthe risk of overdose.Continuityof afterrelease,expected rateswereexceeded by more than care andrehabilitation of drug usersthatare released from 10 timesfor women andmorethaneight timesfor men.All prison arealsoundevelopedinmanycountries. Improvements female and95% of male deaths that occurred duringthe in these twoareas couldrepresentvaluable opportunities to first fortnightoutside prison were drug-related,and couldbe preventdrug-related deaths.

88

Chapter8 Newdrugsand emergingtrends

Introduction therewas aneed to control BZP, butthe control measures should be appropriate to therelativelylow risk posedby The useofnew psychoactivesubstances canhave thesubstance.InMarch 2008,the Counciladopted a importantpublichealthand policy implications,but decision definingBZP as anew psychoactivesubstance monitoringemergingtrendsisaconsiderablechallenge. whichistobemadesubject to control measures and Newpatternsofdrug useare difficulttodetect criminal provisions.MemberStateshaveone year to take because,typically,theyfirstemergeatlow levels,and thenecessary measures,inaccordancewiththeir national in specific localities or amongrestricted sub-groupsof law,tosubmitBZP to control measures,proportionate thepopulation. Fewcountrieshavemonitoringsystems to therisks of thesubstance,and criminal penalties, as that aresensitive to this kind of behaviourand the provided forunder theirlegislationcomplying with their methodologicaldifficulties presented by monitoringthis obligations underthe 1971 United NationsConventionon kind of drug useare considerable. Nonetheless,the PsychotropicSubstances. importance of identifyingpotential newthreats is widely In March2007, theEMCDDAand Europolreported to the recognised,and it is in directresponsetothis that the Commission on theactivemonitoringof1-(3-chlorophenyl) European Union, throughthe Councildecisiononnew piperazine (mCPP) (159). This report wasproducedfor psychoactivesubstances,developedanearly-warning information purposes only andconcluded that ‘mCPPwas system that provides aquick-responsemechanismto unlikelytobecome establishedasarecreationaldrug in theemergenceofnew psychoactivesubstances on the itsown right’due to itsindistinctpsychoactiveproperties European drug scene.Activities in supportofthe early- andsomeadverse effects.Since it appearsthatmCPPhas warningsystemformanimportant part of thework of the no particular appeal to users, it is likelythatits market in EMCDDA andfitwithinabroader perspective of usinga theEuropeanUnion is driven by supplypushratherthan wide variety of datasources to improvethe timeliness and demand pull. sensitivity of theEuropeandrug monitoringsystem. During 2007,atotal of 15 newpsychoactivesubstances were notifiedfor thefirsttimethrough theearly-warning EU actiononnew psychoactivesubstances system to theEMCDDAand Europol. The groupofnewly The Councildecisiononnew psychoactivesubstances (157) notifiedsubstances is diverseand,besides newsynthetic establishesamechanismfor therapid exchange of drugs, includes medicinalproductsand naturallyoccurring information on newpsychoactivesubstances that maypose substances.Nineofthe newlyreported compounds were public health andsocialthreats.Italsoprovidesfor an syntheticdrugssimilar to thoselisted in Schedules Iand II assessmentofthe risksassociated with these newsubstances of the1971United NationsConventiononPsychotropic in orderthatmeasuresapplicable in theMemberStates Substances.Theyincludedsubstances from known forthe control of narcotic andpsychotropicsubstances chemical groups such as phenethylamines, tryptamines andpiperazines,aswellassubstances with aless canalsobeappliedtonew substances.InMay 2007, common chemical make-up. The groupisequally divided ariskassessmentofanew psychoactivesubstance BZP betweensubstances that have pronounced hallucinogenic (1-benzylpiperazine) wascarriedout by theextended effects andthose that exhibitpredominantly stimulant Scientific Committeeofthe EMCDDA,and areportwas properties. submitted to theCouncil andthe European Commission (158). The risk assessmentconcluded that duetoits stimulant Forthe first time,in2007, threenaturally occurring properties,risktohealthand lack of medicalbenefits, substances have been reported throughthe information

(157)Council Decision 2005/387/JHA of 10 May2005onthe information exchange,riskassessmentand control of newpsychoactivesubstances (OJL127,20.5.2005,p.32). (158)http://www.emcdda.europa.eu/publications/risk-assessments/bzp (159)http://www.emcdda.europa.eu/html.cfm/index16775EN.html 90 Chapter8:New drugsand emerging trends

example on theworkingmethods of online shops; the Newsubstancesunder control waythattheyrespond to users’ demands, andnew trends

SinceJanuary 2006,12countrieshavereported additions amongyoung people. To identify currentdevelopments in or changestotheir listsofcontrolledsubstances.mCPP theonlinedrug market,the EMCDDA conducted asnapshot (1-(3-chlorophenyl)piperazine) hasbeenadded to the studyinearly 2008,which surveyed25onlineshops.The list of controlledsubstances in sixcountries(Belgium, resultsofthatstudy arepresented here. Germany,Lithuania,Hungary, Malta, Slovakia) andBZP (1-benzylpiperazine) hasbeenadded in four countries (Estonia,Italy,Lithuania,Malta). Of these substances, Onlineshops mCPP hadbeenactivelymonitored by theEMCDDA There arereports of an increasing number of online andEuropol,and BZPhad been thesubject of arisk assessmentin2007. Othersubstances beingbrought shopsselling psychoactivealternatives to controlled undercontrol in theperiodinclude thehallucinogensDOC drugssuchasLSD,ecstasy,cannabisand opioids. While (4-chloro-2,5-dimethoxyamphetamine),DOI (4-iodo-2,5- thesubstances offeredfor sale by theonlineshops are dimethoxyamphetamine) andbromo-dragonfly(bromo- oftenreferred to as ‘legal highs’ or ‘herbal highs’,in benzodifuranyl-isopropylamine) in Denmarkand Sweden, someEuropeancountriesthese drugsare coveredbythe andketamineinEstonia. same lawsascontrolleddrugs, andmay incurthe same Variousplantswithpsychoactivepropertiesare also penalties. beingcontrolled. To this end, Belgiumhas restructuredits legislationonpsychotropicsubstances to includeanew Within theEuropeanUnion,the majority of online shops categorythatlists plantsorparts of plantsunder control, identified in thesnapshot studyare basedinthe United rather than just theirpsychoactiveingredients as before. Kingdom andthe Netherlandsand,toalesserextent, Amongthe plantsplaced on thelistare khat (qat, Catha edulis)and Salvia divinorum.Khatisnow controlled Germany andAustria.Onlineshops oftenspecialise by 11 countriesinEurope(a2005riskassessmentin in certaintypes of drug-related products, forexample theUnited Kingdom recommended againstcontrol). In somemainlyselldrug paraphernalia,somespecialise in 2006,Swedenadded salvinorine-A, themainactive hallucinogenic mushroomsor‘partypills’, whileothers principleofSalvia divinorum,toits list;the plant has also been putunder control in Germany in 2008.Inthe market awiderange of herbal,semi-syntheticand same period, Tabernanthe iboga hasbeenadded to the syntheticsubstances. list of controlledsubstances in France,following legal Online shopsbased in Europe advertiseover200 controlofthe activeingredient, ibogaine,inBelgium, Denmarkand Sweden.Finally,inresponsetodeaths psychoactiveproducts. The most commonly encountered associated with hallucinogenic mushrooms, Ireland andthe ‘legal highs’ are Salvia divinorum, kratom (Mitragyna Netherlandshavebothmoved to close earlierloopholes speciosa), Hawaiianbabywoodrose(Argyreia nervosa), that hadallowed sale andpossessionoffresh mushrooms hallucinogenic mushrooms(EMCDDA,2006),and a containingpsilocin;inIreland thelaw came into force variety of ‘party pills’. in January2006, whileinthe Netherlandsitisinthe parliamentary process at thetimeofwriting. Forfurther information,alistofsubstances controlled Internet studymethodology acrossthe EU andNorwayispresented in the‘Substances andclassifications table’ in theEuropeanLegal Database To obtain asnapshot, Internetsearcheswereconducted in on Drugs(http://www.emcdda.europa.eu/publications/ January2008using multilingual keywords andthe search legal-reports). engineGoogle(http://www.google.com). Atotal of 68 EU-based online shopswereidentified selling varioustypes of ‘legal highs’.Theywerestratified according to their exchange mechanism; amongthem, Salvia divinorum,a country of origin.EUcountry code domains(e.g. ES,FR, DE)orother indications of beingEU-based(e.g. contact plant with potent psychoactiveproperties(160). address)wereusedfor theidentificationofthe country of origin.Morethanhalfofthe shops(52 %) were located in theUnited Kingdom,37% in theNetherlands,6%in Internet —amarketplace forpsychoactive Germany,4%inAustria and1%inother countries(e.g. substances Ireland,Poland). Arandomsample of 25 online shopswas selected fordetailed analysis. Sampling fractions in each The Internetoffersawindowonthe worldofthe drug user stratum(country of origin)wereproportionaltothose of throughonlineforums andchatrooms as well as thesites of thetotal sample of online shops. Online shopsthatsold online shopsselling psychoactivealternatives to controlled exclusivelytothe trade, rather than to theconsumer, were excluded as were thosethatsold only hallucinogenic substances.Information availablecan give insights into mushrooms. different aspects of theonlinemarketplaceindrugs, for

(160)See ‘New substances undercontrol’. 91 Annual report 2008:the stateofthe drugsproblem in Europe

The substances offeredfor sale areadvertisedtohave in thebody, andthere is currentlynoreadily available effects similartothose of controlleddrugs. Both Salvia toxicologicaltesttodetermine whichofthe twosubstances divinorum andHawaiianbabywoodrose, alongwiththe hasbeenconsumed. less frequently offeredmorningglory(Ipomoeaviolacea) GHBcan be readilymanufactured from GBLand aredescribed as producinghallucinogenic effects similar 1,4-butanediol (1,4-BD),which arecommonly andlegally to thoseofLSD.Kratom is oftenmarketed as asubstitute for used in many branches of industry (e.g.chemicals, opioids, variouspreparationsare offeredasalternatives plastics,pharmaceuticals) andare thus availablefrom to cannabis,and ‘party pills’ aresoldasalternatives commercialsuppliers.The commercialavailability of to MDMA.The ‘party pills’ on offermay contain plant GBLhas thepotential to make this substanceavailable to material or semi-synthetic or syntheticsubstances. drug traffickers andconsumers at levels of priceand risk The main ingredient of synthetic‘partypills’isoften much lowerthanthose normallyencountered in illicitdrug benzylpiperazine (BZP), though theonlineshops appear to marketsinthe European Union. Forexample,the average have replacementsubstances readyfor when BZPbecomes priceofa1gramdoseofGBL purchasedinbulk on the subjecttocontrol measures in theEUMemberStates. The InternetvariesfromEUR 0.09 to EUR2. advertised prices of substances on offervaryfromEUR 1 to EUR11for theequivalentofone dose. Healthrisks

Both GHBand GBLhaveasteep dose–response curve, GHBand itsprecursorGBL:follow-up with rapid onset of symptoms,which greatlyincreases In Europe,gamma-hydroxybutyric acid (GHB)has been therisks associated with illicituse.Nausea, vomiting undersurveillancesince 2000,when ariskassessmentof andvarious degreesofimpaired consciousness arethe thesubstance wasconducted underthe termsofthe 1997 main adverseaffects in most reported casesofGHB joint actiononnew syntheticdrugs(EMCDDA,2002). intoxication. However, thefrequentpresenceofother The additionofGHB to ScheduleIVofthe 1971 UN drugsmay complicatethe clinical presentation. ADutch Convention on PsychotropicSubstances,inMarch 2001, studyof72GHB usersreported that themajorityhad obliged allEUMemberStatestocontrol thedrug under passedout at least oncewhile on GHBand somehad theirlegislationaddressingpsychotropicsubstances,and done so frequently (Korfetal.,2002).Inasurvey of GHB newcontrolsrapidly curtailedthe previously open sale of andGBL usersinthe United Kingdom,adverse reactions GHB. were reported to be more common in club settingsthan in privatehomes(Sumnalletal.,2008).InLondonand GHBoccursnaturally in thehuman body, butisalsoused Barcelona,the patientprofilefor GHBintoxications has as amedicine andasarecreationaldrug.Non-medical been described as mainly youngand male,withthe useofGHB surfacedonthe recreationalnightlifescene majority presentingatweekends, usuallywithconcomitant in someparts of Europe,the USAand Australia during consumption of alcoholorillicitdrugs(Miro et al., 2002; the1990s, specificallyinnightclubswhere many other Wood et al., 2008). drugswerebeing commonly used.Concerns quicklyarose aboutthe health risksassociated with itsuse.Inparticular, Intoxications andemergenciesassociated with GHB anxietiesarose aboutthe potentialfor surreptitiously have been reported in thescientific literature andtothe addingGHB to drinks (commonlyreferred to as ‘drink EMCDDA sincethe late1990s, albeitnot systematically,in spiking’)tofacilitate sexual assault. However, thereisa Belgium, Denmark, Spain, Luxembourg,the Netherlands, lack of forensic evidencefor this,and establishingitis Finland, Sweden,the United Kingdom andNorway. difficultdue to thenarrowtimewindowfor detectingGHB Although GHBisassociated with only averysmall in bodyfluids.However,the associationofGHB with proportion of alldrug intoxicationemergenciesrequiring drug-facilitated sexual assaultmay have contributed to a hospital or ambulance emergencyservices,numbers relatively‘negative image’ of thesubstance (EMCDDA, appear to have increasedsince 2000.InAmsterdam,in 2008c). 2005,the proportion of requests foremergencyassistance that required transportation to hospital washigher forcases GBL related to GHB/GBLthantothose involvingother drugs.

Concerns arenow arisingabout reportsofconsumption In theUnited Kingdom,one London hospital emergency of gamma-butyrolactone (GBL), aprecursor of GHB, department—withacatchmentareathatincludeslocal whichisnot ascheduled substanceinany of theUNdrug club venues whichtypically,but notexclusively,cater for control conventions.GBL is rapidly converted into GHB thegay club scene —recordedatotal of 158GHB and

92 Chapter8:New drugsand emerging trends

GBLpresentations in 2006.While most of these patients 1,4-BD)under drug control or equivalent legislation reported consumption of GHB, chemical analysis of anddiscussions aboutpossible furthercontrolsare in samplescollected from nightclubsinthe same catchment progress in theUnited Kingdom.Inaccordancewith area duringthe same time period foundthatoverhalf Community legislationoncontrol of precursors, GBL of thesamplescontained GBLratherthanGHB.This and1,4-BDare included in thelistofnon-controlled suggeststhatGBL usemay be more common than was substances forwhich voluntary monitoringmeasuresto previously thought(Wood et al., 2008). preventtheir diversionfromlicitindustrialuses arein Duetoits rapid eliminationfromthe body, it is difficultto place in allMemberStates. establishGHB/GBL as acause of intoxicationordeath. Interventionsfor prevention andharmreductionin Furthermore, thereisanabsenceofanaccurateand response to theuse of GHB/GBLare commonly provided comparable system forrecording thenumber of deaths by nationaland community drugsprojectsthattarget andnon-fatal emergenciesrelated to theuse of GHBand nightlifesettings. These interventionsusually consist itsprecursors. of training club staffand disseminating information aboutthe risksofusing GHBand otherdrugs. Such Responses interventionsoften take place in conjunction with other Some Member States (Italy,Latvia, Sweden)have interventionsrelated to ‘clubdrugs’ anduse of alcohol chosen to control GBL(or GBLand theother precursor anddrug combinations(EMCDDA,2008e).

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98 European MonitoringCentrefor Drugsand Drug Addiction

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The European MonitoringCentrefor Drugsand Drug Addiction(EMCDDA) N- C is one of theEuropeanUnion’s decentralisedagencies. Establishedin1993 andbased in Lisbon,itisthe centralsourceofcomprehensive information on drugsand drug addiction in Europe.

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