University Mental Health Research Institute Director: Professor C.N

University Mental Health Research Institute Director: Professor C.N. Stefanis

GREEK REITOX FOCAL POINT

ANNUAL REPORT on the DRUG SITUATION Submitted to the E.M.C.D.D.A. 2001

Plagianakou, S., M.Sc. – Terzidou, M., M.Phil – Yotsidi, V., M.A.

Compilation of data and drawing up of report: Fotiou, A., M.A. Grimani, I., M.Sc. Kontogeorgiou, K., M.Sc. Koumaki, E., M.Sc. Plagianakou, S., M.Sc. Richardson, C., D.Phil. Siamou, I., B.A. Spyropoulou, M., M.Sc. Terzidou, M., M.Phil. Vasiou P., B.A. Yotsidi, V., M.A.

Cover Design: Lada Ioanna DeskTop Publishing: Angelopoulou Katerina Graphics & Design: Foundoukas Marcos

Contact: Greek REITOX Focal Point University Mental Health Research Institute P.O. Box 66 517 15 601 Athens Greece

tel: 0030 1 65 36 902 fax: 0030 1 65 37 273 e-mail: [email protected]

I N D E X

A E AIDS/HIV 40, 44, 45, 52, 55, 56, 73, 74, 103, Ecstasy 19, 22, 27, 46, 67, 68, 70, 72, 73, 108, 110, 124, 132, 138, 174, 180, 186 144, 145, 148, 152, 153 Alcohol and drugs 106, 131, 146 ESPAD study 21, 22, 30, 69, 70, 72, 73, 136 Arrests 61-64, 122, 152, 165, 177 Evaluation 3, 4, 83-86, 88-92, 96-99, 102, Attitudes 10, 11, 19, 20, 21, 24, 27, 29, 60, 104, 105, 109, 113, 114, 116-119, 122, 86, 94, 102, 115, 138 124-126, 129-131, 133-136, 138, 139, Availability of drugs 20, 28, 30, 60, 64, 65, 154, 157, 159, 163, 164, 166, 167, 94, 146, 154, 176, 185 170, 171, 183 Evaluation tools 88, 138, 153, 163, 166 B Budget 11-14, 178 F Family programmes 87, 124, 125 C Funding/funds 11-14, 74, 75, 113, 115, 116, Cannabis 8-11, 19-24, 26-28, 30-35, 38-41, 130-135, 162, 163, 167, 171, 178 46, 47, 58, 60, 65-70, 72, 73, 85, 94, 105, 106, 132, 144, 145, 147-153, G 155, 156 General population 11, 19, 21, 28, 31, 32, 69, Children of drug users 124, 176 71, 84, 128, 132, 146, 154 Cocaine 9, 19, 20, 24-29, 41, 46, 51, 57, Gender specific issues 123 65-68, 71, 72, 100, 106, 128, 144, 145, Geographical departments 184 147-153, 155, 156 Geographical differences 14, 150 Crack 71, 72 Community programmes 81, 89, 101-103 H Community reaction 60 Hallucinogens 46, 72 Comorbidity 56, 124, 160, 162, 183 Harm reduction 19, 48, 72, 74, 79, 82, 84, Convictions 62, 63, 152, 165 106, 107, 109, 110, 112, 121, 124, Crime, drug related 7, 61, 63, 177 133, 154, 160, 162 Criminal justice system 79, 80, 112, 122, Health care 39, 110, 113, 135 165 Health promotion programmes 93, 137 Culture, youth 19, 73, 145, 155 Help lines 103, 104, 110 Hepatitis B 52, 53, 55, 56, 108, 151, 174, 175 D Hepatitis C 40, 52-56, 108, 151, 174 Dealing, drug 9, 79, 122, 137 Heroin 9, 11, 19, 20, 26, 31, 34-36, 38, 40, Deaths related to drugs 10, 48, 49, 106, 151 43, 46-48, 51, 57, 59, 60, 65, 66, 68, Drug scenes; markets 8, 65, 71, 107, 109, 71, 72, 108, 111, 117, 132, 144, 145, 152, 153, 155 147, 149, 151-153, 156, 164, 165 Drug-free programmes 10, 42, 44, 74, 83, High school students; secondary 158, 159, 168 education 22, 23, 40, 49, 93, 94, 97, 134, Drug law offences 62, 63 136, 137, 150 Drug treatment demand 39 Housing 121, 172, 177

XIII

I N Imprisonment/s 6, 7, 10, 62, 87, 132, 152, National Action Plan 3-5, 13, 74, 79 172 National strategy 3, 5, 154 Infancy 87 New trends; emerging trends 19 Infectious diseases, drug related 31, 44, 45, Non-residential programmes 113, 116, 158, 52, 56, 73, 74, 110-113 159, 167-169 Internet 75, 105-106 O J Opiates 27, 28, 40, 46, 58, 67, 71, 106, 147, Justice 38, 79, 80, 112, 122, 165 149 Juvenile delinquents 14, 123, 131, 132 Offender/s 6, 7, 9, 10, 62, 172 Offences, drug related 7, 34, 61, 62, 123, L 172, 176, 185 Law/s 3-10, 12, 14, 38, 62, 93, 128, 132, 152, Outreach work 48, 107 156, 177, 180, 183 Law enforcement 12, 48, 61, 64, 67, 68, 106 P Legislation 5, 8-10 Parents 32, 37, 40, 43, 46, 47, 60, 85, 87-92, Low threshold 39, 41-45, 109, 112, 113 95, 101, 104, 106, 112, 116, 118, 124, 128, 133 M Penalty/-ies 7, 9, 10, 128 Maintenance programmes, see Substitution Policy 3-5, 9, 12, 19, 74, 79, 84-87, 92, and maintenance programmes 116-118, 121, 127, 129, 130, 136, 138, Media 4, 10, 73, 84, 105, 125, 138, 177 154, 158, 163, 170, 171, 177, 183 Media presentation, of drug use 11 demand reduction policy 12, 79, 123, 162, Ministerial decree 5-9, 14, 15, 181 180 Ministry of supply reduction policy 79 Culture 3, 5 Press 11, 84, 87, 105 Defense 3, 5 Prevention 4, 5, 12-14, 23, 30, 55, 56, 74, 79, Education 3, 4, 14, 93 80-82, 84-92, 94-96, 99-102, 105, 106, Finance 3, 5, 12, 67 109, 112, 122, 123, 125, 128-130, 134, Health 3-6, 9, 14, 61, 80, 82, 86, 127, 129 136-138, 160, 162, 178 Justice 3, 9, 14, 15, 62, 172-174, 183 primary prevention 4, 14, 79, 80, 86, 87, Interior 3, 4, 13, 80 89, 93, 126, 129, 131 Labour and Social Affair 5, 83, 119, 120 secondary prevention; see Merchant Marine 3, 5 also Therapy/treatment 12, 80-82, 93, Public Order 3, 5, 48, 66, 80, 122, 123 109, 131, 134 Minorities 59, 74, 126, 127, 137, 172 tertiary prevention, see also Mobile Unit 107, 109-111, 126 rehabilitation/reintegration 82, 86 Mortality, drug related 48 Polydrug use 43, 72, 143-156 Morbidity, drug related 56 Political debate/s 10 Multiple use, see Polydrug use Price, drugs 47, 68

XIV

Prison/s 28, 47, 55, 60, 62, 80, 123, 128, 132 Successful treatment 118, 156, 157, 159, drug use in prison 57 162, 163, 170 Prisoners 119-121, 128 Synthetic drugs/substances 19, 20, 66, released/former prisoners 14, 60, 69-71, 73, 100, 148, 152, 153, 155, 119-121, 181, 182 156 Problem drug use 31, 74 Syringes exchange; needle Prosecution 5, 7-10, 12, 38, 61, 128 exchange 56, 74, 108, 110-112, 180 prosecution policy 9 Public attitudes 10, 11 T Public expenditure 12 Telephone help lines, see help lines Therapeutic/treatment programmes 5-7, 10, Q 12, 14, 20, 33, 47, 53, 56, 80, 83, 104, Quality assurance 79, 128, 129, 136 105, 107, 109, 112-116, 118, 119, 121-125, 127, 130-134, 137, 145, 153, R 154, 157-165, 167, 168, 170, 171, 173, Rehabilitation/reintegration 5, 7, 8, 13, 14, 178, 181, 182 59, 60, 83, 84, 105, 114, 115, 117-122, Therapy/treatment 4, 5, 8, 13, 14, 26, 34, 37, 126, 138, 158, 159, 161, 162, 164, 39-41, 43, 46, 47, 56, 57, 71, 73, 74, 165, 178, 181, 182 79, 80, 83-85, 105-107, 109, 110, Research 11, 12, 19, 21, 22, 30, 59, 74, 75, 112-117, 119-121, 124, 126, 128, 130, 80, 84-86, 94, 101, 108, 117, 122, 123, 135, 137, 138, 150, 153, 154, 156-158, 126, 127, 129-131, 133-135, 138, 148, 160-172, 180-182 150, 154, 155, 161, 167, 171, 172, 185 Trafficking, drugs 5, 60, 121, 122, 177 Residential programmes 113, 114, 116, 159, Training 6, 118, 119, 122, 123, 125, 126, 167-169 128, 129, 131, 134, 136-139, 167, 171, Risk behaviour/s 31, 36, 44, 47, 132, 151, 177, 178 156, 174, 186 Treatment Demand Indicator 39, 40, 47, 52, 55, 69-72, 138, 143, 146, 149, 154, S 156, 167 School programmes 92, 94-97 School/student population 30, 39, 70-72, 146, U 154 University students 23-25, 29, 94, 131 Seizures 66, 67, 106 Self-help groups 79, 127, 128, 181 W Shared syringes/needles 44, 45, 47, 151 Women, dependent/addicted 47, 114, 123, Smuggling 65 124, 150, 160, 164, 173 Social exclusion 59, 84, 122, 126 Workplace 125 Social problems 11, 59, 99, 106, 109, 152, 156 Y Street work 107, 124, 153 Youth programmes 99 Substitution and maintenance programmes 10, 116, 119, 159, 160, 162

L I S T O F A B B R E V I A T I O N S

Abbreviation Definition AA Alcoholics Anonymous ABS Acción por el Bienestar y la Salud (Association for Health and Welfare) DEA Drug Enforcement Agency EEDE Companies’ Association of Advertisement and Communication ESPAD European School Survey Project on Alcohol and Other Drugs EuropASI European Addiction Severity Index ICRC International Certification and Reciprocity Consortium/Alcohol and Other Drugs IREFREA European Research Institute of Risk Factors of Adolescents and Young People KEEL Hellenic Centre for Infectious Diseases Control KETEK Centre of Technological Training KETHEA Therapy Centre for Dependent Individuals NA Narcotics Anonymous NSPH National School of Public Health OAED Employment Organisation of Labour Force OKANA Organisation Against Drugs SDOE Greek Financial and Economic Crimes Office SODN-EMP Central Anti-drug Coordinating Unit TACADE The Advisory Council on Alcohol and Drug Education TREAT (2000) Treatment Systems Research on European Addiction Treatment TUF Treatment Unit Form VPRC V-Project Research Consulting WAPR World Association for Psychosocial Rehabilitation

SUMMARY

MAIN TRENDS AND DEVELOPMENTS

The most important development in Greece, at policy level, is the commitment of the government to give top priority to the problem of drugs on its political agenda, which is displayed in the relevant decisions of the Council of Ministers. The Government has committed itself to introducing a five-year Action Plan (2001-2005) to Parliament until the end of 2001. The Organisation against Drugs (OKANA) will act as the central co-ordinating body in the future. The Ministerial Council has also decided to increase the budget for demand reduction.

Major political concern and debate was raised by the proposal for changes in the legal framework of drugs, which was put forward by 5 Members of Parliament; the proposal refers mainly to the legal distinction between cannabis and other drugs as well as the State-controlled administration of drugs to dependent users.

Although the judiciary system is being updated to meet new needs, the situation in Greek prisons is not very good: insufficient budget, overcrowded prisons, poor global planning, and relative scarcity of medical and health care staff and resources (in particular, scarcity of trained addiction counsellors) are just a few of the problems prisons face. Nevertheless, the Ministry of Justice is making provisions for an increase in the number of prisons and the establishment of treatment units for drug dependent offenders.

The prospective National Action Plan, together with central co-ordination arrangements, has become an imperative in Greece, as the dimensions of the drug problem are steadily increasing.

In 2000, the situation in Greece has not changed dramatically in terms of drug use since last year. The biggest problem remains the increasing rate of drug- related deaths, most of which are caused by the synergic activity of substances.

Polydrug use is a frequent practice both by occasional and dependent users. The phenomenon seems to be increasing but information or reliable data on its epidemiology is still lacking in Greece.

Concerning drug-related health problems, AIDS cases recorded a sudden rise this year. However, rates are still lower in Greece than in most European countries. The high prevalence of Hepatitis C among intravenous drug users seems to have stabilised in 2000, probably as a result of the recently observed trend towards safer administration and the outreach work.

The increasing number of dependent users who seek therapy is not necessarily indicative of an increase in drug dependence; it is rather related to the increased awareness of the users and their motivation to undergo therapy, achieved by the treatment centres themselves and the low-threshold services.

The importance of outreach work is obvious, as obvious as the lack of sufficient low-threshold services; the two existing ones, both situated in Athens, are not enough.

XIX

In 2000, the State responded to the drug problem in a more organised way, in an effort to deal with the situation and to harmonise its interventions with the European Union Action Plan.

More specifically, new programmes have been established in the fields of prevention and treatment.

The Substitution Programme has expanded. New units have been inaugurated and others are being planned, specifically for users who cannot achieve abstinence even after having undergone methadone treatment; the new methadone maintenance unit, created for this purpose, is expected to free places occupied in the methadone units, aiming at total abstinence within a maximum of three years in treatment. This will allow the recruitment of new clients from the long waiting list and will contribute to harm reduction needs.

Current policy on treatment and harm reduction is expected to be greatly enhanced by the new law, which legalises the administration of opiate antagonists by hospitals and doctors.

Adolescent users are becoming the focus of attention, with new specialised programmes being established in many cities, apart from Athens and Thessaloniki.

This intensified effort towards the promotion of treatment facilities has brought evaluation into focus. The identification, though, of successful treatment requires, first of all, its operational definition. Field experts in Greece agree that, in determining success, one should take into account both the procedural and the outcome-related criteria of a programme, while treatment evaluation should be further systematised and promoted with the co-operation of policy- makers and drug professionals. At present, evaluation in Greece is mainly based on internal procedures.

In the field of supply reduction, quantities of seized drugs have increased. The recently ratified agreements between Greece and its neighbouring Balkan countries may have contributed to it.

PART I

NATIONAL AND LOCAL POLICIES AND LEGAL FRAMEWORKS

1. DEVELOPMENTS IN DRUG POLICY AND RESPONSES

1.1 Political framework in the drug field

The adoption of the European Union Action Plan (2000-2004) at European level as well as the proposals of the former All-Party Parliamentary Committee (Greek Parliament, 2000) seem to have had a large impact on the framework of Greek policy in the field of drugs during 2001. Both of the above developments as well as the efforts that have been made by the Greek Organisation Against Drugs (OKANA), the Ministry of Health and the Prime Minister’s Office to improve central coordination of initiatives have led to the governmental commitment to give top priority to the drug problem on the political agenda.

More particularly, in June 2001 the Ministerial Council came up with a number of decisions directed towards a holistic, unified, co-ordinated policy on drugs. A major event that preceded this political commitment and played a crucial role in subsequent changes was the European Congress “National Planning of Drug Policy” that was organised by OKANA and the Ministry of Health in Athens, in March 2001 (see also 8.2 Approaches and new developments).

The core idea of these political decisions is that addicted users are patients whereas drug traffickers are criminals. The document can be considered to fulfil the necessary preconditions for the first official National Strategy on drugs since the enactment of 1729/1987 Law. According to these decisions, the Government commits itself to introduce to Parliament a five-year National Action Plan (2001-2005) with specific targets to be met, activities to be developed and measures to be taken by the end of 2001. The Prime Minister, who is co-ordinating the whole procedure, has assigned the elaboration of the National Action Plan to an Inter-ministerial Committee consisting of representatives from 10 relevant Ministries (Interior, Defence, Finance, Education & Religion, Labour & Social Affairs, Health, Justice, Culture, Public Order and Merchant Marine).

The proposed guidelines, according to the Ministerial Council’s decisions, refer to all fields of activities, on the basis of initiatives that have been taken so far by each Ministry, and to the principal target, which is the co-ordination of activities proposed by different agencies. A short description of measures to be taken in every field of activities is presented below.

1.1.1 Institutional framework

Co-ordination, monitoring and evaluation of overall policy implementation will be assigned to OKANA, which has already assumed this role in part by co- ordinating policy in the drug demand reduction field. Overall drug policy co- ordination requires flexibility and autonomy. Some legislative measures have already been taken in this direction, such as the recent law voted by Parliament and issued in November 2001 (2955/2001). According to this law, the OKANA Management Board will in the future consist of 7 members instead of 15. Moreover, this law provides for the establishment of an Inter-ministerial

3 Committee, presided over by a higher official of OKANA. Furthermore, in order to meet the requirements of its new responsibilities, OKANA will function according to a by-law, which is expected to be finalised by the end of this year. These two major developments in combination with changes in the broader ministerial sector should provide OKANA with the necessary flexibility and autonomy to co-ordinate, monitor and evaluate action in the drug field; finally, OKANA shall be accountable, as has been provided by the Ministerial Council’s decisions, directly to the Prime Minister.

Complementary to changes in the legal status of OKANA, developments in the broader ministerial sector are also planned according to the Ministerial Council’s decisions. More particularly, by the end of 2002 a directorate or office exclusively responsible for the implementation of the National Action Plan shall be created in every relevant Ministry. Moreover, a separate Pay Office for financing drug activities administered by OKANA, will also be set up in 2002 (see also 1.4.2 Developments in funding arrangements).

To assist OKANA in its role of policy making and monitoring policy implementation, an Institute specialised in substance addiction will be set up by the end of the current year, under the auspices of the Ministry of Health. The Institute is expected to be fully operational in the next three years and to provide prevalence rates of drug use, guidelines for treatment and education and evaluation of activities. Its reports shall be submitted to OKANA, the central co- ordination body, which shall be responsible for further action.

1.1.2 Demand reduction

According to the Ministerial Council’s decisions, primary prevention is considered as the principal domain for the development of effective activities to deal with the drug problem.

Along with this central idea, a social media campaign on prevention will be launched by OKANA before the end of this year (see also 9.1.6 Mass media campaigns).

Moreover, active participation and co-ordinated action of relevant Ministries are provided for, within the same scope, in the recent Ministerial Council’s decisions aiming at the fulfilment of several governmental pledges. OKANA –which is still under the supervision of the M i n i s t r y o f H e a l t h – and the M i n i s t r y o f E d u c a t i o n are developing preventive activities at schools through OKANA’s Prevention Centres and through Health Education Programmes respectively. An institutional framework for securing further fruitful co-operation and complementary action are considered necessary, together with the proliferation of local Prevention Centres and the expansion of the National Network of Health Education to primary education level as well (see also 9.1.2 School Programmes). Furthermore, financial support of local governments so that they may be able to subsidy Prevention Centres is also provided for. The M i n i s t r y o f t h e I n t e r i o r has already taken the respective initiatives (see also 1.4.2 Developments in funding arrangements). The Ministry of Defence

4 also plays an important role, according to the recent decisions, since it deals with a significant portion of male young adults, a group in high risk of drug use, as it has been indicated by national prevalence surveys. This is why the national action plan also includes the systematisation of prevention activities in the army; this task shall be assigned to an appropriate, professionally trained staff. Meanwhile, the M i n i s t r y o f C u l t u r e –more specifically, the General Secretariat for Sport– is drawing up a plan for the sensitisation of coaches and other sport professionals on drug use risks.

Treatment and rehabilitation of addicted drug users have also caught the attention of the Ministerial Council. Therefore, the National Strategy includes the proliferation of therapeutic programmes and units, the inauguration of new services, such as the Reception, Information, Assessment and Referral Services, and provisions for the expansion of substitution treatment in the National Health System. To meet the above objectives, the government has already railroaded proposals for financial support of treatment agencies (see also 1.4.2 Developments in funding arrangements), whereas further co- operation between the M i n i s t r y o f H e a l t h and the M i n i s t r y o f Labour and Social Affairs is also planned aiming to expand social security to users after treatment.

1.1.3 Supply reduction

The geographical position of Greece, as well as economic developments in the neighbouring Balkan countries that have resulted in increased illegal immigration, constitute two major contributory factors to border and domestic drug trafficking. However, considering that the existing repressive measures are more or less exhaustive, the Ministerial Council has decided that emphasis should be placed on further enhancement of current initiatives. The continuation and the enhancement of existing activities are based on an upgraded co- ordination that is currently exercised by the Central Anti-drug Co-ordination Unit. In particular, all four prosecution bodies, namely the Police, the Coast Guard, the Customs and the Financial and Economic Crimes Office, which are accountable to three different Ministries (M i n i s t r y o f P u b l i c O r d e r , Ministry of Merchant Marine and Mi n i s t r y o f F i nance) should elaborate a joint action plan. The principle idea consists in the signing of one or more memorandums of agreement among the relevant bodies that will replace the current, unsophisticated co-ordination plan and will establish fruitful co- operation. Thus, the role of the Central Anti-drug Co-ordination Unit would be upgraded by co-ordinating overall prosecution according to a specific plan instead of simply mediating to facilitate information exchange among law- enforcement bodies.

1.2 Policy implementation, legal framework and prosecution

1.2.1 Developments in legislation

A short description of recently enacted laws and ministerial decrees is presented below.

5 Law 2955/2001

• This law includes provisions on the prescription and administration of antagonist substances by public and private agencies as well as physicians. The Ministry of Health, after an opinion by OKANA, shall decide on the specific substances that can be administered and on the conditions of administration. Previous status: Provisions on administration of antagonists by special public units and OKANA after the Ministry of Health had granted the relevant permission. No specific requirements concerning their administration were laid down by a Ministerial Decree. • Decrease in the number of members in the Board of Directors of OKANA. The new Management Board shall consist of 7 members: the President, the Vice President and the Head of the Central Anti-drug Co-ordination Unit; the President of the Central Union of Local Governments; a health professional; a social scientist and a jurist. Previous situation: The OKANA Board of Directors consisted of 15 members and included representatives from relevant Ministries in the drug field, the church, therapeutic programmes and local governments. • Set up of the Inter-ministerial Co-ordination Committee. The Committee shall consist of high-level officials from 10 Ministries and shall be presided over by the director of OKANA. The Committee shall meet at least once a month. Previous status: The Board of Directors of OKANA consisted of representatives from relevant Ministries and exercised inter-ministerial co- ordination.

Law 2943/2001

This law provides that measures against drug traffickers must be stricter as far as both serving of sentence and execution of the right of conditional release are concerned. In particular, “favourable addition of working days” is a special form of custodial sentences that can also apply to convicted drug traffickers but on different terms. Normally, convicted offenders who are remanded in custody for more than six months may work for free while in custody or participate in vocational training programmes, in which case, each day of work is considered as two days of custody. This used to apply to all convicted offenders. The new law stipulates that, in the case of convicted drug dealers, “favourable addition of working days” can apply only if they have already served at least 2/3 of their custodial sentence or at least 20 years in the case of a sentence to life imprisonment. Moreover, conditional release shall apply to convicted drug traffickers only if they have served at least 4/5 of their custodial sentence or at least 25 years in the case of a sentence to life imprisonment. The previous law provided for conditional release after having served 3/5 of custodial sentence or 20 years in the case of a sentence to life imprisonment.

Law 2928/2001

This law refers to amendments to provisions of the Penitentiary Code with regard to criminal organisations as well as to preliminary investigation in drug- related cases:

6 • For the first time in Greece, a definition of “criminal organisation” is provided by law (a structured team with continuous action, composed of 3 or more persons that intends to commit a variety of crimes). The committed crimes, including drug-related ones, are also specifically defined. The penalty imposed on persons who set up or participate in a criminal organisation is up to 10 years of imprisonment. Previous status: The provisions of the Penitentiary Code that were replaced referred to complicity of at least 2 persons in order to commit one or more crimes, which were not, however, specifically defined. The penalty was at least 6 months of imprisonment. In drug-related cases, persons who committed a drug-related offence were considered as offenders. No special reference was made with regard to persons who participated in the perpetration of a drug-related offence. • The preliminary investigation that is conducted by the Public Security Directorate of the Hellenic Police and, in particular, by both sub-directorates in Athens and in Thessaloniki, is under the supervision and guidance of the District Attorney’s Office in Athens and Thessaloniki respectively. The District Attorney’s Office can order or conduct the preliminary investigation. Previous status: Preliminary investigation was conducted throughout the country by officials from all law-enforcement agencies, with regard to possible drug-law offences that fell within their competence, who notified, at the same time, the local prosecution authority about the process. The District Attorney was responsible for further action once a case file had been opened.

Ministerial Decree 30370/20-3-2001

This Decree, issued by the Ministry of Labour, provides for three-year subsidies to employers who employ former drug addicts, between 18-65 years of age, for four years. Former drug addicts must offer proof that they have successfully completed a therapeutic programme authorised by the State. A day’s subsidised wage, for every former drug addict employee, amounts to approximately €22 for full-time occupation and €14.7 for part-time. An additional sum of €293.5 is paid to every employer as bonus, if the three-month probationary period, provided for by the decree, is successfully completed. Persons participating in the OKANA substitution maintenance units also have access to these job opportunities as well as the ones who are at the last stage of social rehabilitation of an authorised treatment programme. Moreover, this decree includes provisions for subsidisation of new enterprises for 100 individuals if they fall into the category of former drug addicts. Those who are at the last stage of social rehabilitation as well as those who participate in the OKANA substitution-maintenance treatment are given the same opportunity. The subsidy amounts to €15,554 and it is granted to new free-lancers gradually during 4 years.

New substances subject to control in the year 2000

- PMMA or 4-MMA (4-methoxymethamphetamine) was classified under Table A of Law 1729/1987 according to the 5322/6-11-2000 Ministerial Decree.

7 - GHB (gamma-hydroxybutyric acid) was classified under Table A of Law 1729/1987 according to the 1067/9-5-2001 Ministerial Decree. - 2 C-B (4 – bromo – 2.5 – dimethoxyphenylethylamine) was classified under Table A of Law 1729/1987 according to the 1067/9-5-2001 Ministerial Decree. - 2 C-T-2 (2.5 – dimethoxy – 4 – ethylthiophenethylamine) was classified under Table A of Law 1729/1987 according to the 1067/9-5-2001 Ministerial Decree. - ZOLPIDEM (N,N,6 – trimethyl – 2 – (4-methylphenyl) imidazo [1,2-a] pyridine – 3 – acetamide) was classified under Table D of Law 1729/1987 according to the 1067/9-5-2001 Ministerial Decree. - KETAMINE (2 – (2-chlorophenyl) – 2 – (methylamino) –cyclohexanone) was re-classified under Table C of Law 1729/1987 according to the 1067/9-5- 2001 Ministerial Decree instead of Table D of the same Law as it was until the recent Decree. - ZOPICLONE 6-(5-chloropyrid-2-yl)-5-(4-methylpiperazine-1- yl) carbonyloxy- 7-oxo-6, 7-dihydro-5H-pyrrolo- [3,4-b] pyrazine was classified under Table D of Law 1729/1987 according to the 3784/18-7-2001 Ministerial Decree. - ZALEPLON N- [3-(3-cyanopyrazolo [1,5-a] pyrimidin-7-yl) phenyl]–N- ethylacetamide was classified under Table D of Law 1729/1987 according to the 3784/18-7-2001 Ministerial Decree.

The law proposal by 5 Members of Parliament

In April 2001, 5 Members of Parliament from three different parliamentary parties submitted to parliament a law proposal entitled “Amendment to the existing legislative framework on drugs and classification of overall law provisions regarding illegal trafficking, treatment and social rehabilitation of addicted drug users”. This proposal encompasses 5 major initiatives:

• Unification of all existing legislation on drugs. (The former All-Party Parliamentary Committee had pointed out this need and steps have already been taken by other authorities in this direction, see also 1.2.2 Guidelines for future developments). • Distinction between cannabis and other drugs with regard to judiciary prosecution of users and traffickers. Cannabis use and trafficking are more leniently treated compared to other drugs, with the aim of eliminating the “bridge” that connects the market of “soft” drugs with the market of “hard” drugs and thus protecting cannabis users from being induced to use “harder” drugs. • State-controlled administration of drugs or substitutions to addicted users at specialised medical centres, by specialised medical staff. The underlying objective is to punish use only if it leads to and promotes trafficking.

8 • Distinction between addicted drug traffickers and “peddlers” with regard to their penal prosecution. “Peddlers” are considered as being obliged to deal small quantities of drugs in order to secure their daily dose. • Definition of “small quantity” of drugs. Current legislation provides that Courts may treat possession or exchange of small quantities of drugs differently than larger quantities on the grounds that small quantities are destined for personal use. However the term “small quantity” remains vague and it is up to the Court to decide with regard to each specific case. This bill determines “small quantities” of cannabis, heroin and cocaine at 10 grams for cannabis, and at 5 grams for heroin and cocaine.

The proposal by the 5 Members of Parliament has already been brought before the All-Party Parliamentary Committee for Drugs, but it has not been brought to Parliament. Experts in the drug field consider that some changes are necessary in the legal framework of drug policy (see also 1.3.1 Political debates).

1.2.2 Guidelines for future developments

The aforementioned decisions of the Ministerial Council also refer to specific steps that should be taken in order to improve both the judicial process and legal policy implementation. In particular, following the remark by the former All- Party Parliamentary Committee on the need for integrated legislation on drugs, the Ministerial Council has included the unification of relevant Greek laws in the future national planning. OKANA has already collected the respective legislation (laws, ministerial and presidential decrees) and has forwarded it to the Ministry of Health. Meanwhile, ΟΚΑΝΑ has set up a Standing Committee in August 2001 to work in this direction.

Moreover, a joint Ministerial Decree (Ministries of Health and Justice) shall be issued in 2002, specifying the quantities of seized drugs, depending on which, offenders will be characterised as users or as traffickers. Dealing of small quantities of drugs or possession of certain substances will be prosecuted according to current legislation. Parliament shall decide on possible changes in the prosecution procedure after the opinion of the All-Party Parliamentary Committee.

1.2.3 Prosecution policy

The priorities and objectives of the prosecution policy of the M i n i s t r y o f J u s t i c e have remained unchanged during the last few years. Courts treat users differently than traffickers whereas addiction plays an equally crucial role in decisions concerning penalties. As a rule, addicted users caught for possession for personal use go unpunished since detoxification units, which the offender is obliged by law (1729/1987) to attend, have not yet been established. Non-addicted users who are arrested for the first time also go unpunished but, according to law, they are obliged to join a counselling programme.

9 Different penalties are also imposed on users who are involved in trafficking depending on whether they are addicted or not. Addicted users face up to 8 years of imprisonment, whereas non-addicted users face life imprisonment. In cases of exchange of small quantities of drugs between users, proven to be exclusively for personal use, the imposed penalty is up to 6 months of imprisonment that can be either commuted to a fine or suspended (Law 2721/1999).

Current legislation also provides for the cases of dependent users who have committed petty crime to secure their dose (Laws 2331/1995, 2721/1999). According to these provisions, prosecution or sentencing can be suspended in case the offender has voluntarily entered and successfully completed an authorised treatment programme. However, Courts quite often do not exercise the above discretional power in the case of offenders participating in the methadone substitution – maintenance programme, since a necessary pre- condition for the above benefits is the successful completion of the programme. The OKANA Standing Committee is working towards the elaboration of a proposal that shall include the relevant provisions in the existing legal framework.

1.3 Developments in public attitudes and debates

1.3.1 Political debates

Great political and social concern was raised when the annual report of the Central Anti-Drug Co-ordinating Body was publicized and data on drug-related deaths were released to the public. Due to the significant increase in deaths compared to previous years, social debate focused on the limited number of treatment facilities, which are thought to be insufficient to cover the existing needs. Blame was put on the State and on competent authorities. At the same time, the media seemed to have forgotten the trouble that was quite often caused by the public in order to discourage the inauguration of new therapeutic units in several parts of Greece.

Another issue that prevailed during the social dialogue was the aforementioned proposal of law by 5 Members of Parliament and, in particular, the provisions referring to the articles on State-controlled administration of drugs to addicted users, as well as to the distinction between cannabis and other illegal drugs. The main counter-argument was that the message that such provisions would pass would be that the State is too soft on the drug problem. Moreover, with regard to the distinction between cannabis and the rest of the drugs, the proposed article does not take into account that, although such a distinction could be medically legitimate, there is also a psychological dimension that cannot be underestimated. Nevertheless, it is also worth mentioning that representatives from 3 out of 4 parliamentary parties are supporting the above law proposal. The Communist Party of Greece does not support the proposed law and it is in favour of mainly drug-free programmes, on the grounds that substitution treatment signifies acceptance by the State and not opposition to drug use.

10 1.3.2 Public attitudes

Research data on public attitudes towards drugs are already three years old and have been presented in detail in previous Greek National Reports. According to the UMHRI survey, conducted in 1998, the majority of the general population aged between 12-64 years old is against the legalisation of both cannabis and heroin. However, as it has already been discussed in previous reports, there was a quite significant increase in people with a more lenient attitude towards legalisation from 1984 to 1998.

In addition to the aforementioned findings, a private research company (V – Project Research Consulting (VPRC)) conducted a national survey in 1999, on a sample of 1185 individuals, exploring public attitudes towards major social problems. With regard to their opinion on who should undertake and decide the overall handling of the drug problem, 52.5% believed that the Greek Government was the competent authority, whereas 42.9% believed that such decisions should be left to the European Union.

However, the need for updating data on public attitudes is considered as urgent, especially with regard to attitudes towards the establishment of local treatment facilities. As it has been noted, public reaction constitutes, in some cases, a major obstacle to the implementation of therapeutic initiatives. Relevant national and local campaigns should also be launched aiming to change attitudes towards wider acceptance of treatment efforts.

1.3.3 Media presentation

In 2000, the Psychiatric Hospital of Attica, in co-operation with the World Association for Psychosocial Rehabilitation (WAPR), conducted a study, using both qualitative and quantitative tools, in order to record the way that the press presents addiction and addicted users. A total number of 1422 press articles on mental health and drugs published in 1999 were collected and analysed.

It was observed that the media present the problem of drug addiction without any special focus on scientific evidence mainly because they are addressed to the lay public. Even expert opinions are reported by journalists and are partially presented. Moreover, there is confusion over the concepts of “use”, “abuse” and “addiction”. Statistical data and research findings are also presented in such a way that false generalisations seem inevitable. In most cases, politicians adopt a stance on the issue through the press, mainly focusing on the legal and political dimensions of the problem. Finally, the lack of press publications focusing on the extent to which drug use is involved in car accidents, advertising, sex and social status, was also observed (Papadi et al., 2000).

1.4 Budgets and funding arrangements

1.4.1 Budgets for demand reduction in the year 2000

As it has already been repeatedly ascertained in previous years, there are difficulties in isolating budgets on drugs from the overall funds for law

11 enforcement agents and State Psychiatric Hospitals. Given the fact that the manpower of prosecution authorities –on which data are available- has remained more or less the same and that the lack of other relevant financial data cannot be easily overcome, the Greek Focal Point has confined itself this year to presenting available data in the 2000 State budget on agencies that operate in the demand reduction field (Ministry of Finance, 2000). Moreover, the allocation of OKANA funds for the year 2000 is also presented in Table 1.

State Budget for demand reduction authorities for the year 2000

- OKANA: €11,738,811 - KETHEA: €6,749,816 - Mental Health Centre: total budget €5,860,129. For the therapeutic programme IASON approximately €586,940.

Allocation of OKANA funds for the year 2000

According to law 2161/1993, OKANA is the central co-ordination, inter- ministerial body in the field of drug demand reduction. At the same time, it is also responsible for studying the phenomenon of drugs on a national scale and for implementing drug demand reduction policy at all levels of prevention. Thus, the allocation of funds on specific activities could be considered as indicative of the way public expenditure on drug demand reduction is allocated.

Table 1. Allocation of OKANA funds for the year 20001

ACTIVITIES EXPENSES (€) Prevention 2,957,282 Prevention Centres 1,915,290 Central Services for the co-ordination of the Prevention Centres network 152,529 Education 618,075 Research (Cooperation with other agencies) 271,388 Treatment (Secondary Prevention) 6,317,181 Substitution – detoxification (5 Units) 4,498,1512 Substitution – maintenance (1 Unit) 348,654 3 Drug-free therapeutic programme 387,507 Help Centre 976,876 Subsidy to therapeutic programme “ATHENA” 105,993

Continued on next page Ê

12 Continued from previous page È

ACTIVITIES EXPENSES (€) Rehabilitation 604,758 Social Rehabilitation Unit 84,697 Vocational Training Centre 520,061 Central Administration 1,891,784 TOTAL 11,771,005

1 According to the OKANA annual financial report 2 This sum includes the housing expenses for a new Unit in Piraeus that shall be inaugurated in 2001 3 The Unit was inaugurated during the second half of the year 2000

1.4.2 Developments in funding arrangements

The recent decisions of the Ministerial Council on drugs have attached great importance not only to the amount of funds directed towards drug demand reduction but also to the funding arrangements that should be made in order to facilitate the implementation of the oncoming National Action Plan.

The Ministerial Council announced its intention to triple the OKANA annual funds, which shall now amount to €44,020,543. An additional sum of €14,673,514 will be appropriated for suitable buildings to cover the existing needs. However, apart from the financial support provided to OKANA to assist its institutional upgrade, a significant increase in funds has also been announced for other agencies operating in the field of demand reduction. For example, KETHEA has received an additional sum of €2,934,703 for the year 2001, whereas its 2002 budget will amount to €8,804,109. A similar increase in funds has been provided for the Mental Health Centre (IASON) reaching the sum of €2,934,703 for 2001 and €5,869,406 for 2002. Financial support of €17,608,217 for State Psychiatric Hospitals has also been included in the state budget for 2002.

A different plan for funding arrangements is also included in the decisions of the Ministerial Council. In particular, a Pay Office for the Treatment of Addictive Substances’ Problems will be established in 2002. The appropriated funds will be covered both by the State Budget and by the confiscation of drug dealers’ properties, aiming to cover the overall financial needs of the National Action Plan. The allocation of funds will be assigned to the Inter-ministerial Committee, which will be gradually replaced by OKANA.

Different funding arrangements have also been provided for the local governments that have contracted to finance Prevention Centres by 50%. According to the decisions of the Ministerial Council, up to 60% of their financial contribution will be covered by the State Budget and 40% by local resources. In 2000, a total sum of €5,459,428 have been allocated by the Ministry of the Interior to 49 local governments for the financial support of Prevention Centres.

13 1.4.3 Geographical differences

The allocation of funds could be considered as geographically balanced, as far as primary prevention is concerned. The estimated annual budget for each Prevention Centre amounts to approximately €146,735, of which half is covered by OKANA and half by local governments. For the time being, at least two Prevention Centres are located in every health district in Greece (overall number: 13). In the future, at least one Prevention Centre will be established in every prefecture in Greece (total number: 54). The National Network of Health Education of the Ministry of Education, which also implements prevention activities, is also covering every Greek health district.

Things are different as far as treatment and rehabilitation are concerned. Treatment services are located in only 5 health districts, whereas their highest concentration is observed in Athens and the wider prefecture of Attica, followed by Thessaloniki (18 and 6 therapeutic programmes respectively). The above prefectures concentrate almost half of the Greek population1. Only three urban areas in the rest of Greece (in three different health districts respectively) are covered by one treatment service each. Nevertheless, future plans are being drawn up in order to satisfy various therapeutic needs in every health district, through the inauguration of respective programmes and/or through the National Health System in public general hospitals.

NEW INFORMATION ON PUBLICATION Law 2955/2001: Supply of hospitals and other health units of the District Health System and other provisions; date of adoption and entry into force: 2/11/2001 Law 2943/2001: Serving of sentence by drug traffickers and other provisions within the competence of the Ministry of Justice; date of adoption and entry into force: 12/9/2001 Law 2928/2001: Amendment to provisions included in the Penitentiary Code and in the Code of Criminal Procedure and other stipulations for the protection of citizens from crimes committed by criminal organisations; date of adoption and entry into force: 27/6/2001 Ministerial Decree 30370/20-3-2001 issued by the Minister of Labour: Subsidisation programmes for new job opportunities and new free-lancers intended for individuals with special needs, former drug addicts, former prisoners, young delinquents or young individuals in social danger; date of adoption: 20/3/2001; entry into force: 2/4/2001 Ministerial Decree 5322/6-11-2000 issued by the Ministers of Health and Justice: Substances subject to the provisions of the law against drugs; date of adoption: 6/11/2000; entry into force: 28/11/2000

1 According to the 1991 population census data

Ministerial Decree 1067/9-5-2001 issued by the Ministers of Health and Justice: Substances subject to the provisions of the law against drugs; date of adoption: 9/5/2001 Ministerial Decree 3784/18-7-2001 issued by the Ministers of Health and Justice: Substances subject to the provisions of the law against drugs; date of adoption: 18/7/2001

PART II

EPIDEMIOLOGY

2. PREVALENCE, PATTERNS AND DEVELOPMENTS IN DRUG USE

2.1 Main developments and emerging trends

2.1.1 Overview of the most important characteristics and developments of the drug situation

Prevalence rates for drug use in Greece are already 4 years old, since the last general population study was conducted in 1998. Since then, indirect evidence points in the direction of considerable increase, mainly concerning occasional and recreational use among young people.

The use of Ecstasy and the use of other synthetic substances seem to become more and more integrated into the youth entertainment culture with increasing force. Almost all young users who frequent nightclubs use cannabis, while ecstasy and cocaine use is highly prevalent among them, as discussed in the following sections of this chapter. There is evidence-based suspicion that a number of these recreational users move on to heroin use and dependence, as indicated by the 2000 data supplied by the STROFI programme addressed to adolescents, also discussed later in the chapter. The size of the risk of dependence that is involved in occasional or recreational use and which are the characteristics of people at risk should become the subject of investigation.

New substances appearing in Europe come to Greece at a slower rate; a few cases of MBDB, GHB and ketamine have been detected among users, while no cases of 4-MTA have as yet been reported. Nevertheless, all the aforementioned substances were prohibited in 2000 and 2001, which is an indication of the usefulness of the Early Warning System .

In general, enhanced mobilisation and new initiatives to promote solutions to the drug problem are being taken by the co-ordinating body, OKANA, covering various aspects of the phenomenon -policy, research and intervention.

2.1.2 Emerging trends

There appears to be a shift from injecting to safer modes of use of heroin, such as sniffing and smoking. This evidence is discussed in the following sections. This shift could probably be attributed to harm reduction interventions.

Harm is, nevertheless, increased by the new combinations of substances, with which users are experimenting and which seem to account for the majority of drug related deaths.

2.1.3 Attitudes

Recent data on attitudes, expressed mainly by young people, derive from studies conducted in 2000. The main results and the methodology of these studies are discussed in different sections of this chapter.

Attitudes of young club-goers (see ch. 2.2.3)

Table 2: Reasons reported by young club-goers as most important for refraining from drug use

Users Non-users (Guessing for (Replying about non-users) themselves) % % They are not interested in the effects of drugs 54.4 73 The cost of drugs is high 39.8 26 They do not know where to get drugs 30.1 18.2 They have not tried drugs so they don’t 46.6 13 know what they are missing Drug users don’t know what they want 8.7 51 out of life They prefer a world without drugs 39.2 61.6

SOURCE: UMHRI, 2001

Young club-goers who use drugs have a somewhat distorted understanding of the protective factors reported by their non-users counterparts. The only case on which users and non-users agreed is the primary reason offered for abstinence, which is that the effects of drugs are not "tempting" to the user; otherwise they disagreed. The next most preferred argument of non-users is that they "want a world without drugs" (Table 2).

Attitudes of university students (see ch. 2.2.2)

Students' attitudes are reflected in the "Away from Home" survey. Almost 40% of the students consider cannabis use harmless or slightly harmful, while the equivalent percentage for synthetic drugs is around 17%. Few students consider cocaine or heroin use harmless or slightly harmful (3% and 0.6% respectively). The perceived availability of all types of drugs is high for the majotity of students of all ages (more than 60%).

Attitudes of air-force conscripts (see ch. 2.2.3)

According to the study findings, 60.5% of young conscripts consider drug users "people with many psychological problems", while for the vast majority (90.9%) cannabis use is considered harmless. Most, 57.2% believed that dependent users should seek assistance from the therapeutic programmes for their problem rather than trying to solve it themselves (Voulalas et al., 2000).

There is a generally observed leniency in Greek young people’s attitudes towards drug use. The percentage of young people who consider cannabis and synthetics use harmless has increased since 1998 (see UMHRI surveys in 1999 Greek National Report). Nevertheless, the perceived danger is largely differentiated between cannabis and synthetics, which indicates that people have already decided on the distinction between "soft" and "hard" drugs.

Contrary to young people, the general public seems concerned about the problem of drugs, as indicated in a survey, conducted in 1999, by the private market research company V-Project Research Consulting, on a nationwide sample of 1,193 individuals. Asked about their main concerns about the future, 13.2% reported drug use increase, which was the second most important fear, preceeded by "increase in criminality" and "increase in the number of immigrants", reported by around 21%.

Another srtudy conducted, in 2000, by the same company on a nationawide sample of 1,432 individuals, revealed that the majority of the repondents (61.4%) opposed the decriminalisation of "soft" drugs.

Nevertheless, it should be stressed that comparisons between annual results as well as between the various studies presented above should be made with caution, as there are differences in methodolgy.

2.2 Drug use surveys

2.2.1 General population

Although evidence from indirect indicators shows that illicit drug use is constantly increasing, no epidemiological surveys investigating the extent of use in the general population have been conducted since 1998.

The last three Greek National Reports have presented detailed results from the 1998 nationwide epidemiological survey that was conducted by the University Mental Health Research Institute.

In summary, the 1998 nationwide survey on a probability sample of 3,752 respondents, aged 12 to 64 years, revealed a sharp increase in illicit drug use prevalence, compared to the previous nationwide survey, in 1984. Overall illicit drug use prevalence tripled in these 15 years -from 4% to 12.2%. (Kokkevi et al. 2000a).

2.2.2 School and youth population

The ESPAD Study on high-school students

The University Mental Health Research Institute (UMHRI) conducted the ESPAD study in Greece in autumn 1999, on a nationwide probability sample

that consisted of 2,205 high-school students, aged 16 years. The Greek version of the ESPAD questionnaire was administered in class by research assistants.

According to the main findings, 9.7% of students reported having experimented and/or used drugs, with cannabis at a percentage of 8.6%. The second most popular illicit drug was ecstasy (2.1%). 14.2% of the students reported use of inhalants. The mean starting age for illicit drug use was 15 years, and it is one year earlier for the use of inhalants.

The use of different substances by Greek students compared to students from the other participating countries to the ESPAD study is presented in Figure 1.

Figure 1: Substances used by Greek high school students in comparison to the other countries in the ESPAD 99 study

SOURCE: The ESPAD Report, 1999

As seen on the figure:

• Cannabis prevalence in Greece (9%) is lower than the average prevalence of the rest of the countries (16%).

• The same applies to other illicit drugs, as well as for tranquillisers and simultaneous use of alcohol and pills.

• Contrary to illicit drug use, inhalants use was reported by a much higher percentage of Greek students (14%) as compared to use reported by their counterparts from other countries (9%) (Hibbel et al., 2000).

The UMHRI high-school students survey

Trends in illicit drug use by high-school students are available from the nationwide surveys of the University Mental Health Research Institute in 1984, 1993 and 1998. The methodology and the main findings of these surveys have been discussed in details in previous Greek National Reports.

The surveys, which used the same methodology, were conducted on nationwide probability samples of approximately 10,000 high-school students, aged 13-18 years; data were collected through questionnaires handed out in class. Trends showed that there was relative stability in the prevalence of drug use between 1984 and 1993, which was followed by a sharp increase in 1998; the overall prevalence of illicit drug use doubled from 6% in 1993 to 13.7% in 1998 (Kokkevi et al. 2000b).

The University of Ioannina school survey

In 1997, the Medical School of the University of Ioannina conducted in 1997 an epidemiological survey on drug use prevalence among high school students in three Greek cities, Athens, Patras and Ioannina. The survey was based on a probability sample of 2,109 students, aged 16-17 years, who filled in a questionnaire handed out in class.

Their main findings are very similar to those of the aforementioned equivalent studies, conducted around the same period: 8.2% of the students reported use of psychotropic substances(including unprescribed use of tranquillisers); the most popular illicit drug was cannabis. (Dimitriou 2000, unpublished dissertation).

The "Away from home" project for university students

The European project “Away from Home”, was a prevention programme for University students, in which 4 European countries participated – the United Kingdom, Spain, Germany and Greece. In Greece the project was carried out by OKANA.

Within the framework of this project, a survey was conducted on a sample of students from the University of Piraeus, the port near Athens.

Objectives: Ø to investigate drug use prevalence, attitudes and related psychosocial factors among University students. Sample: Ø 1,778 students, attending classes in February and March 2000. Data collection: Ø Self-completed questionnaire handed out in the auditoria of all faculties and years of study.

Main findings

After cannabis (9.6%) the second most popular drug was the synthetics (4.1%).

Illicit drug use and its frequency varied significantly according to year of study:

Lifetime frequency increased according to the year of study for cannabis only; The frequency of use increased accordingly to the year of study. As seen in Figure 2, more second-year students (12.4%) reported using cannabis up to 20 times than those who reported using cannabis use 20 times or more (5.4%), while more 5th-year or postgraduate students reported use of cannabis 20 times or more (19.6%) than those who reported lower frequency use (11.8%)

Figure 2: Lifetime frequency of drug use by university students living in Piraeus

SOURCE: OKANA, 2001.

For the rest of the drugs the frequency was lower. Lower frequency use (up to 20 times) by the 5th year and postgraduate students recorded the highest percentages (Figure 3):

• 10.5% of the 5th year and postgraduate students reported tranquillisers use up to 20 times and 5.3% 20 times or more, as compared to around 3% and 0.3% respectively of the students in earlier years.

• Cocaine use was reported by 7.4% of the students in the 5th year and postgraduate students up to 20 times and by 5.3% more than 20 times. The respective percentages for students in the earlier years were around 2% and 0.5% respectively.

Figure 3: Lifetime frequency of tranquillisers and cocaine by university students living in Piraeus

Tranquillisers

Cocaine

SOURCE: OKANA, 2001.

2.2.3 Specific groups

The study in the Greek air forces men

The study was conducted in 2000 by the General Hospital of the Air Forces (Hadjitaschos et al., 2000, p. 13).

Objectives: Ø to investigate the prevalence of drug use among air- force conscripts, their attitudes and related factors Sample: Ø 1,139 conscripts (71.1% of the total number of conscripts in two out of six recruitment periods in 2000) aged 25-30 years Main findings: Ø The percentage of the air force men who admitted using drugs prior to and during their recruitment was 28% for cannabis use, 3.7% for pills and 6% for other substances (heroin, cocaine and LSD). Ø A large percentage of those using pills (48%) began the use at the age of 16-18, while the majority of those using cannabis (60.1%) and those using heroin, cocaine and LSD (67,1%) reported having started at a later age. Ø 94.5% of the users reported having used drugs with their group of friends, while 0.1% reported having been offered the substance inside the camp. Ø The main reasons reported for the initiation of drug use were: curiosity, enjoyment, “fun”, increase of sexual performance and satisfaction, psychological problems, environmental pressure. Ø Involvement in sports could be considered a protective factor considering that 42.9% of non-drug users do sports systematically -a percentage that drops to half in the case of cannabis users.

Similar findings were reported in a study conducted in 1999 in the Greek Navy, and presented in last year’s Greek national Report: 30% of Navy conscripts reported experience of illicit drugs (Menoutis, et al., 1999).

There are direct and indirect indicators showing that there is an increase in the problem of illicit drug use in the Armed Forces. In fact, a considerable percentage of people, who demand treatment, report having been introduced to the use of drugs in the army (In Greece, conscription to the Army is compulsory for all adult men).

The study in the young “Club-goers”

Patterns of recreational use were investigated in the 2001 European IREFREA study, in which the UMHRI participated. The study was entitled: “Alternative

Cultures to Drug Abuse” and it is briefly described below. Findings from this study referring to attitudes are presented in Chapter 2.1

Objectives: Ø to investigate attitudes of drug users and non-users towards the patterns of nightlife and of drug use taking place in nightlife recreational settings. Sample: Ø 204 club/party goers, recruited in Athens, and sampled according to the gender, age group and the involvement or not in the drug use. Age range: 15-30 Data collection: Ø Personal interview, based on a structured questionnaire Main findings: Ø Among those who reported drug use, almost all (95.1%) reported cannabis use, ecstasy and cocaine was reported at equal percentages (22.3%), LSD and amphetamines (speed) 12.6% and 5% respectively.

Drug use in the workplace

Work place drug testing has never been practised widely in Greece, but in the last few years it seems that there is increasing demand for drug testing from various work settings, for specific, mainly, legal reasons.

The Department of Forensic Medicine and Toxicology of the University of Thessaloniki conducted a study, which presented the results of requests for drug testing, collected between 1998 -2000 (Tsoukali & Raikos, 2000).

Objectives: Ø to analyse routinely compiled data from individuals tested for drugs, according to requests from employing agencies Sample: Ø 324 employees consisting of a) professional drivers whose license was revoked for drug use by the Ministry of Transportation, b) individuals who had applied for jobs in security services, and c) foreign basketball players before signing a contract with a Greek team. Data collection: Ø Urine samples taken under supervision and analysed for cannabinoids, opiates, cocaine, amphetamines and benzodiazepines. Period: 1998-2000 (September) Main findings: Ø The number of positive results increased in the last 3 years from 2.9% in 1998 to 12.9% in 2000 Ø Cannabis was the most frequently detected drug -88,5% of all cases (Table 3)

Table 3: Workplace drug testing results in Northern Greece

Cannabis Opiates Amphetamines Benzodiazepines % % % % Total 88.5 11.5 3.8 3.8 Drivers 50.0 - - 3.8 Security services 23.1 11.5 3.8 - Basketball players 11.5 - - -

SOURCE: Tsoukali & Raikos, 2000

Data from prison are presented in the Key issues section

2.2.4 Geographical distribution of use

Major urban cities always present the highest prevalence of illicit drug use. This is both because drugs are more available there and because users from other areas tend to move to larger cities not only for the availability but also for the anonymity they offer.

In Greece, the two larger cities, Athens and Thessaloniki, present the highest percentages. Nevertheless, use in non-metropolitan urban and rural areas appears to be increasing.

The geographical distribution of trends is shown in the school and general population surveys of the UMHRI, (see chapters 2.2.1 and 2.2.2 ) presented in last year’s Greek National Report; it seems that the overall increasing trend in drug use in Greece has indeed affected more Athens and Thessaloniki, but an increasing trend in other urban and rural areas is also prevalent.

Geographical distribution according to the “Away from Home" project

Data from the “Away from Home” project, which was discussed above, indicate that university students who were studying in Piraeus but came from families living in other urban areas of Greece presented lower percentages of illicit drug use than their Piraeus/Athenian fellow-students (Athens and Piraeus may very well be considered as one city) only in the low frequency of lifetime use (up to 20 times); non-Athenian students, though, presented equal with or even higher percentages than the Athenian students in the high frequency of use of tranquillisers and synthetics; cocaine use remained at low percentages for the non-Athenian students (Figure 4).

Figure 4: Lifetime frequency of drug use by 5th year university students and postgraduate students, according to their place of origin

Tranquillisers

Cocaine

SOURCE: OKANA, 2001.

This picture may suggest that students who come to Athens to study may be gradually introduced into the drug culture although still far behind their Athenian counterparts.

Geographical distribution of use by high-school students in 26 prefectures

In 2000, OKANA assigned the University Mental Health Research Institute to conduct epidemiological research on the school population of the 26 Greek prefectures where Prevention Centres of the OKANA function.

Objectives: Ø To investigate drug use prevalence among students in the prefectures where the Prevention Centres of OKANA function. Sample: Ø School sample representative at prefecture level. Overall, 5,000 students, from 97 schools. Age range: 16-17 years. Data collection: Ø The Greek version of the ESPAD protocol was distributed to the students in classroom Main findings: Ø The overall lifetime prevalence of illicit drug use was generally higher in the major urban areas (Athens, Thessaloniki) and lower in the rest of Greece. Ø The higher percentage of high-school students who reported experimentation with illicit drugs was recorded in Thessaloniki, followed by that of Athens, while the lowest was recorded in parts of Crete and parts of northeastern Greece. Ø Thesalloniki presented the highest prevalence of use of any illicit drug for more than twice in a lifetime. Ø Approximately 1 out of 10 school-aged children reported that they had tried cannabis at least once in their lifetime. Ø Sheer experimentation with cannabis is not the case for most students; in most cases the reported frequency was more than 3 times in their lifetime. Ø Boys outnumbered girls in all geographical areas examined. Ø Regarding use in the last 30 days, certain areas in northern and northwestern Greece, in insular and Central Greece scored the highest percentages of students who reported use of cannabis in this reference period. Ø The highest availability of cannabis was reported by students in the large metropolitan areas (Athens and Thessaloniki). High availability was also reported in northern Greece, areas closer to the Balkan route of trafficking.

2.3 Problem drug use

Problem drug use, as drawn by indirect indicators, can be investigated as a phenomenon in two ways manifested: first, by patterns of use and the risk behaviours of existing intravenous users, and second by its incidence, i.e. the rate of new “recruits” to problematic use.

Concerning existing users, evidence from various sources draw a somewhat optimistic picture: data from the Treatment Demand Indicator, show that the percentage of heroin users who inject is decreasing; independent studies show that needle sharing has dropped in the last few years and that users are generally more conscious of the health hazards of use and take greater care, for example by sterilising their equipment properly (Kornarou et al., 1999). The prevalence of infectious diseases among IVDUs presented a relative stability in 2000, as seen from the data of the reference centres presented in the following chapter.

On the other hand, data from adolescent and young adult users show that the number of heroin users has increased in this age group, which might be an indication that the incidence of problematic use rises.

Nevertheless, these are only minor indications of the problem, and since the extent of the problematic prevalence in Greece has not been fully estimated one can only report and interpret data with caution.

2.3.1 Prevalence of problematic use of cannabis

The prevalence of the problematic use of drugs can be estimated in various ways - see the EMCDDA project on Obtaining Comparable National Estimates of Problem Drug Use Prevalence for all EU Member States. One way which is not generally regarded as useful and valid is to ask questions in a general population survey, basically because problematic drug use is a rather rare behaviour so very few respondents will indulge in it (or will admit it), apart from the fact that problematic drug users probably tend to be missed by the usual sampling procedures. The exception to this is cannabis. In the first place, the prevalence of cannabis use is relatively high so it is not a numerically rare behaviour. Secondly, society tends to regard cannabis use as more acceptable than heroin use or use of most other illicit drugs, and this may make respondents more willing to report its use on a questionnaire honestly. Thus, some of the objections to estimating prevalence of use of the drug from general population survey data are partially, although probably not completely, removed. Consequently, the above mentioned EMCDDA project asked for estimates of the prevalence of problematic use of cannabis from general population surveys, as well as by other means.

A number of questions in the Greek general population survey touch on problematic use, by asking about problems arising from the use of cannabis and also by asking about circumstances of use (such as using alone). At the same time, it should be borne in mind that problematic use to the extent of seeking

treatment is at a low level, amounting to only about 50 people per year in the centres covered by the Treatment Demand Indicator.

The following tables, which use data from the 1984 and 1998 nationwide General Population Surveys, present firstly the prevalence of any self-reported lifetime and last year use of cannabis (marijuana, hashish, etc.). They then go on to the responses to questions that may be relevant to problematic use. These are as follows:

• Alone: Ever used cannabis when alone (lifetime) • Problems: Use of cannabis ever caused problems with parents/family/ spouse/friends/teachers/colleagues/employer (lifetime). (Combination of separate questions.) • Interference: Use of cannabis interfered with studies or work, or reduced interest in usual activities (lifetime). (Combination of separate questions.) • Every day: Used cannabis almost every day for a period of at least a fortnight (in the last year) • Dependence: Felt need to use cannabis or depended on it (in the last year)

The last two questions were asked in 1998 but not in 1984.

As can be seen in Table 4, quite a high percentage of cannabis users in 1998 reported “problematic” use (as represented by responses to the above questions), especially in the youngest age group. Overall, almost 18% of lifetime users had used cannabis when they were alone and nearly 10% answered the other items positively, except for “dependence” which was at a much lower level. Since the prevalence of cannabis use had reached quite a high level by 1998, the percentage of the total population who report “problematic” use is not negligible. This indicates that, at least in the younger age groups (below 35) and especially for males, the general population survey provides enough “cases” to offer the prospect of being able to analyse and follow “problematic” use of cannabis. In the total population aged 15-64, use of cannabis when alone was reported by 2.3%, the other items by about 1%.

Table 4: Prevalence of self-reported use and problem use of cannabis, 1998

Age group 15-24 25-34 35-64 Total N=1373* N=642 N=1384 N=3399 Lifetime 16.4 22.6 8.1 12.8 Last year 10.1 7.4 1.0 4.2

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All Users All Users All Users All Users ** Alone 4.5 27.3 3.8 16.8 1.0 12.4 2.3 17.9 Problems 2.9 17.5 1.5 6.8 0.4 4.7 1.1 8.8 Interference 2.7 16.7 1.7 7.5 0.4 5.3 1.2 9.1 Every day 2.7 16.7 1.7 7.5 0.9 5.3 1.4 9.1 Dependence 1.2 6.7 1.0 4.3 0.7 2.9 0.9 4.4

* Unweighted total. Percentages are weighted to reflect the age distribution of the Greek population ** Lifetime users of cannabis

SOURCE: UMHRI, 1998.

Prevalence of any use of cannabis was much lower back in 1984 and many of the percentages in the tables for that year are based on too few cases to be reliable However, it is noticeable that the prevalence of having used cannabis when alone among users in 1984 was quite similar to the 1998 figure. On the other hand, relatively fewer users in 1984 reported problems with other people and interference with their activities compared to the situation in 1998 (Table 5).

Table 5: Prevalence of self-reported use and problem use of cannabis, 1984

Age group 15-24 25-34 35-64 Total N=1859 N=576 N=1262 N=3697 Lifetime 5.0 6.8 2.6 4.1 Last year 2.6 1.7 0.2 1.0 All Users All Users All Users All Users Alone 1.1 20.0 1.4 20.0 0.5 16.7 0.8 18.8 Problems 0.2 4.8 0.2 2.5 0.0 0.0 0.1 2.1 Interference 0.1 1.6 0.0 0.0 0.0 0.0 0.0 0.4

SOURCE: UMHRI, 1984.

2.3.2 Adolescent and young adult drug users

"STROFI" is a therapeutic programme for Adolescent Drug Users and their families, established by the therapeutic centre KETHEA. The programme offers

counselling to adolescent and young adult occasional or dependent drug users and/or arrested for drug related offences.

A brief profile of these young users is given in Figure 5, which includes data from “STROFI” for 1999 and 2000. As shown, the mean age of adolescents who join the programme is slightly dropping, while the percentage of school leavers is increasing. Fewer people are unemployed, but most of those who work have occasional part-time jobs.

Figure 5: Characteristics of adolescent and young adult drug users requesting treatment at "STROFI" in 1999 - 2000

SOURCE: STROFI, 2000, 2001.

Regarding their main substance of abuse (Figure 6) there is a clear shift from cannabis and tranquillisers to heroin use; Cannabis users have decreased from 49% to 35.3%, tranquillisers users have decreased by more than half (from 11.6% to 4.5%), while heroin users have increased from 35.3% to 58.4%. The increase is more obvious in boys than in girls.

Figure 6: Main substance of abuse

Cannabis

Heroin

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Tranquillisers

SOURCE: STROFI and PLEFSI, 2000-2001.

Although adolescents start heroin use at an early age, they seem to be injecting and sharing needles at lower percentages in 2000 compared to the previous year (Figure 7).

Figure 7: Risk behaviours among adolescent and young adult drug users

Needle sharing

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Injecting

SOURCE: STROFI and PLEFSI, 2000-2001.

2.3.3 Children of dependent parents

This specific aspect of problem use constituted the subject of a research project conducted by the University of Thessaloniki, based on a sample of parents drug users under treatment (Georgakas, 2000, unpublished dissertation).

Objectives: Ø To investigate the socio-psychological characteristics of dependent people who have children and the impact of their dependence on the emotional development of their children. Sample: Ø Thirty eight parents, recruited from a) the methadone substitution unit of Thessaloniki, b) the detoxification unit of the psychiatric Hospital of Thessaloniki, and c) the therapeutic community of the Kartera region of Thessaloniki. Data collection: Ø Parents' data: self-reports based on questionnaires and standardised tests. Ø Children's data: replies to standardised tests and other indicators, such as school performance, BMI, etc. Ø 1997-2000 Main findings: Ø The majority of the parents (68.4%) were living together and they had a job (over 60%)

Ø Almost half of the fathers (47.3%) and 26.3% of the mothers had problems with the law Ø Nearly all reported heroin as their main substance of abuse. Ø The majority of the mothers (73.6%) reported drug use during pregnancy Ø 18% of the children in the sample presented withdrawal symptoms immediately after birth Ø Most of the children had behavioural and emotional problems as a result of the problematic relationships in the family

2.3.4 Forensic services data routinely collected between 1990 and 1999

The Laboratory of Forensic Medicine and Toxicology of the University of Thessaloniki, analysed data from cases of drug users who had been referred to them for drug-related indictments during the 90’s.

Objectives: Ø Data logging and assistance for the Justice system, expert knowledge about drug addiction, longitudinal data Sample: Ø 4,088 drug users, referrals from the prosecution authorities Data collection: Ø Records of history of use, medical examination, toxicological analysis

Main findings: Ø The vast majority (93%) were male Ø The mean age of the sample was 28.3 years Ø The mean age for first drug use was 19.9 years Ø 51.3% reported cannabis as the main substance of abuse, while 28.4% used heroin Ø Based on medical examination, 1 out of 4 had used drugs intravenously at least once in their lifetime. Ø 1 out of 4 presented withdrawal symptoms Ø 10% of the males reported having started drug use in the army Ø 12% did not serve in the army due to their dependence Ø Compared to 1990, the mean age of the sample of drug users in 1999 recorded a 5-year decline (from 30.5 in 1990 to 25.5 in 1999).

3. HEALTH CONSEQUENCES

3.1 Drug Treatment Demand

In Greece, the implementation of the treatment demand indicator involves monthly delivery of individual clients’ data by the participating agents. An anonymous identification code is used in order to avoid double counting between treatment centres.

In addition to the drug free and methadone substitution facilities already participating in the national network, in 2000 the Help Centre of OKANA, which is a low threshold program started to provide data based on the Pompidou Group-EMCDDA Treatment Demand Protocol. The Help Centre provides data for the users contacted through the streetwork programme and users using the Centre’s primary health care facilities.

Overall, twelve therapeutic centres (7 drug free centres, 4 substitution units and 1 low threshold service) provided individual data for 2000. It should be mentioned that the methadone substitution programmes provide data for admissions and not for treatment demands.

3.1.1 General picture of clients

During 2000, 1938 individuals (83% male and 17% female) sought treatment for their drug use from the agents participating in this indicator. Almost 46% of users who requested treatment had already been treated on previous occasions while for 54% it was the first time.

Table 6: Number, mean age and gender distribution of users demanding treatment, according to the Treatment Demand Indicator

1994 1995 1996 1997 1998 1999 2000 Number of all treatment demands 846 1130 546 570 1151 1096 1938 Mean age 28 30 30 29 32 28 31 Male(%) / female(%) 84/16 85/15 89/11 86/14 84/16 84/16 83/17 Number of first treatment demands 483 588 360 343 588 608 1049 Mean age 27 29 29 28 30 27 29 Male(%) / female(%) 84/16 85/15 89/11 87/13 84/16 83/17 85/15

SOURCE: Greek Reitox Focal Point, 1994-2001.

The fluctuation in the number of all treatment demands between 1994 and 2000, observed in Table 6, is due to the number of clients admitted to the methadone substitution programme, which admitted clients in 1995 for the first time and in 1998 for the second time, in its two new units. The increase

observed in 2000 is due to the addition of the Help Centre to the TDI reporting system. The increase in mean age observed in 1995 and 1998, compared to the previous years is again due to the large number of admissions in the substitution programme, where older applicants are preferred.

The number of users demanding treatment for the first time has increased steadily since 1994, while the ratio between males and females has remained stable.

The majority of all clients (63%) in 2000, reported living with their parents and having permanent accommodation (90.3%). 9% of them were homeless or had a temporary accommodation. Most of them (62%) were unemployed, while more than half (66.5%) had completed secondary education.

Significantly more new clients reported that they lived with their parental family (67.2% vs 57.3% "all treatments"), while less reported to be unemployed (59% new clients vs 65% "all treatments"). No differences were found regarding the educational level.

Concerning HIV and hepatitis, more than half of those who had been tested and know the result (53.6%) were found positive for hepatitis, mainly C, while 1.5% of those who had been tested for HIV and know the result were found to be positive. The relevant percentages in the new client subgroup are 39.7% and 1.6% respectively. A higher percentage of new clients demanding treatment have never been tested for hepatitis (38.7% vs 7.5%) and HIV (42% vs 9%) compared with those who have been previously treated.

As in previous years, opiate users constituted the largest group (94%) among those seeking help for drug problems. Heroin accounted for most cases (heroin: 89.6%, other opiates: 4.3%). This was also the case for new clients, 90.4% of whom used opiates as the main substance (heroin: 87.3%, other opiates: 3.1%). Even though injection remains the most common route of administration for heroin and other opiates a shift towards safer routes of administration was observed in the last three years. This could be due either to a development of a safer trend in drug taking or to the fact that chronic intravenous users have their veins damaged (Table 7).

Table 7: Route of administration (%) of opiate users

ALL TREATMENT FIRST TREATMENT DEMANDS DEMANDS Route of administration of opiates 1998 1999 2000 1998 1999 2000 Injection 84.3 78 66.2 77.7 72 62.9 Smoking/inhalation 5.5 9.2 11.4 8.3 11 14.4

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Eat/drink 0.7 1 4.5 0.6 0.6 3.5 Sniff 9.5 11.8 17.9 13.4 16.6 19.2

* During 2000 drug users can report more than one route of administration. This is the reason why percentages in the relevant column exceed 100%.

SOURCE: Greek Reitox Focal Point, 2001.

More than half of the opiate users used 3 or more substances at the same time (59.6%); in the new clients subgroup the relevant percentage was 56%. The most popular secondary substance among opiate users was cannabis (all clients: 67.8%, new clients: 70.3%) and benzodiazepines (all clients: 63.1%, new clients: 60.8%) followed by cocaine (all clients: 33.3%, new clients: 29.4%).

3.1.2 Comments on different client profiles in different types of treatment

During 2000, treatment demand data derived from three main sources: a) drug- free treatment facilities, b) methadone substitution programmes and c) OKANA Help Centre, which is a low threshold programme.

Table 8: Number of individuals seeking treatment in different types of treatment services during 2000

Type of treatment services N % Drug-free 861 44.4 Substitution 229 11.8 OKANA Help Centre (low threshold service) 848 43.8 Total 1938 100

SOURCE: Greek Reitox Focal Point, 2001.

As the methadone substitution programme send to the Focal Point data for admissions and not for treatment demands, the above categorization can also be regarded as demands (drug-free), and admissions (substitution), while the Help Centre clients have not demanded treatment -they are contacted through streetwork.

Sociodemographic characteristics

Most of the treatment demanders were males in all types of treatment. Drug- free facilities seemed to be more popular among younger addicts (Figure 8). This is somehow expected since one of the criteria for admission to the methadone programme is age (older than 22) and generally older applicants (aged 35 and over) have priority. Another criterion in this programme is that clients must have at least one failed attempt in a drug-free programme in order to be admitted; therefore, young applicants are mostly found in drug-free units.

Figure 8: Age distribution by type of treatment service

SOURCE: Greek Reitox Focal Point, 2001.

As it has already been mentioned, the majority of drug addicts were unemployed. The highest percentage was observed among clients of the low threshold programme (Figure 9). On the other hand, more clients had a full time job in the drug-free programmes than their counterparts both in the substitution programme and in the low threshold service (drug free services: 25.6%, substitution programmes: 16.6%, low threshold services: 17%).

Figure 9: Labour status by type of treatment service

SOURCE: Greek Reitox Focal Point, 2001.

Most of the clients from drug-free therapy reported living with their parents (drug free services: 78.6%, substitution programmes: 45.4%, low threshold services: 51.2%). The highest percentage of drug addicts who were homeless or had an unstable accommodation was observed in the low threshold service (Figure 10).

Figure 10: Living status by type of treatment service

SOURCE: Greek Reitox Focal Point, 2001

Most of the users, in each treatment facility, were self-referred (drug free services: 49%, substitution programmes: 58%, low threshold services: 51%). Family played an important role as a source of referral only for clients in drug free services.

Finally, the proportion of new clients in drug free services was significantly higher than in the other two treatment facilities (drug free services: 65.4%, substitution programmes: 29.3%, low threshold services: 49.6%). As it was expected, the lowest percentage was observed in methadone programmes, since they admit new clients only to fill the gaps created by the dropouts.

Patterns of use

Intravenous heroin use on a daily basis is another criterion to enter the substitution treatment. Therefore all clients from substitution programmes were heroin users and most of them (73%) were current injectors. Heroin was the main substance involved in the two other types of treatment as well (drug free: 89.2%, low threshold: 87.4%) while current injecting behaviour was less common (drug free: 63.3%, low threshold: 51%).

As it has already been mentioned, polydrug use was very frequent among treatment demanders since more than half of them reported using three or more

substances. The relevant percentage was higher among drug addicts in the low threshold programme.

Figure 11: Number of substances used by type of treatment service

SOURCE: Greek Reitox Focal Point, 2001.

Risk behaviour

Sharing syringes with fellow drug users was found to be common among current injectors. The relevant percentage was considerably higher among current injectors in drug free treatment (drug free: 42.3%, substitution: 19.8%, low threshold: 27.8%).

Table 9: Number (%) of current injectors who share needles and infectious diseases test (based on self-reports)

DRUG FREE METHADONE LOW PROGRAMMES SUBSTITUTION THRESHOLD PROGRAMME Tested for HIV Yes 122 30 88 (59.9%) (90.9%) (73.3%) No 85 3 32 (41.1%) (9.1%) (26.7%) Tested for hepatitis Yes 132 30 89 (63.5%) (90.9%) (74.2%) No 76 3 31 (36.5%) (9.1%) (25.8%)

SOURCE: Greek Reitox Focal Point, 2001.

As seen in the Table above the number of current injectors who shared needles and who had never been tested for any infectious disease was considerably high in drug free facilities. The relevant percentages were lower, although still alarming, for the low-threshold programme although still alarming. The picture was different in methadone substitution where the test for HIV and hepatitis is a prerequisite for entrance.

Self reported prevalence of infectious diseases

Among those who had been tested for hepatitis and knew the test result, the highest percentage of infection was observed among drug addicts in methadone substitution (drug free: 36.6%, substitution: 65.8%, low threshold: 62.8%).

The same applies to HIV infection since 5.9% of drug addicts in substitution were infected, while the relevant percentage was much lower for the two other types of treatment (drug free: 0.8%, low threshold: 0.8%). This can be attributed to the priority that substitution units give to HIV positive drug addicts.

Finally it must be mentioned that the high prevalence (Figure 12) of hepatitis, among drug addicts should make regular tests a requirement of all agents.

Figure 12: Trends in self reported hepatitis (1994-2000)

SOURCE: Greek Reitox Focal Point, 2001.

3.1.3 Comments on treatment demand for different drugs

Most of the users seeking treatment reported problems caused by heroin use. The proportion of people asking treatment for heroin use did not vary considerably. Injection remains the most common route of administration for heroin but a trend towards safer modes of administration (smoking/inhalation) was observed, especially during the last two years.

Demand for treatment associated with cocaine use has always been very low in Greece (between 0.4%-1.4%).

A trend has also been observed in the decreasing number of treatment demands related to hypnotics and sedatives use (from 5.6% in 1994 to 1.2% in 2000). The same applies to cannabis (11.6% in 1997 to 3.9% in 2000).

Finally, it is worth mentioning that demand for treatment related to ecstasy use has always been rare in Greece (0.1%-0.2%). The same applies to stimulants in general (0.1%-0.3%) and to hallucinogens (0.1%).

3.1.4 Characteristics of users seeking treatment in KETHEA

As it has already been discussed in the previous Greek National Reports, two major drug-free treatment services (KETHEA and 18 ANO) have stopped providing data due to reasons of 'confidentiality'. However KETHEA provides the Focal Point with data in aggregated form. The characteristics of KETHEA clients are presented briefly below.

Sociodemographic characteristics

• During 2000, 1899 individuals (85% male and 15% female) sought treatment for drug use. • The mean age of users was 24 years • Almost 75% of users who requested treatment had never been treated before. • The majority of them (80%) lived with their parents • Almost 12% of them lived with other dependents • The majority of them (63%) were unemployed, while 18% of them had a full time job

Patterns of use

• Heroin and other opiates (82%) were the primary substance of use • The main route of administration was injection (52.5%) while the percentage of those who smoked was 28.5%

• The majority (74%) had started their drug use with cannabis

High-risk behaviour

• Half of the users injected currently (last month), while 21% of them shared needles.

3.1.5 Qualitative data

The analysis of Treatment Demand Data during 2000 demonstrated that some characteristics of drug addicts remain stable over the years. In order to further investigate these characteristics interviews were conducted with experts in the field of drugs, working for some of the participating agents in the TDI network. Below we summarise their main points of view based on their experience in the field of addiction.

• A persistent finding is that significantly more male than female users approach the therapeutic units. Can this just be attributed to the numerical superiority of male drug users to female users or does it reveal a weakness of the therapeutic units to meet the needs of female addicts?

According to the experts’ reports, although drug use is generally more wide- spread among males than females, female users undergoing treatment are probably under-represented. This can be partly explained by the fact that female users find it harder to approach therapeutic units -especially low threshold programmes-and it is more difficult for them to enter a therapeutic programme. It is also observed that women addicts drop out of treatment more frequently than men.

• The majority of drug addicts live with their families

Experts attribute this finding to the strong bonds still existing in the Greek family. In most cases family provides not only emotional but also financial support. It is reported that dependent youngsters usually “drain” their parents financially, and several families even have to sell property to provide their children with their daily dose. Most parents believe that without their help their child is going to die or end up in prison.

It is also reported that the living standard in Greece is generally improving, while the drug prices are dropping. Very few families disavow their children because of their addiction, basically being afraid of social criticism. Another factor for “keeping” the user in the family is the difficulty of entering the job market, although most therapeutic services have intensified their efforts in this direction.

• The high percentages of heroin users among those seeking treatment poses the question whether heroin is the par excellence problematic substance, which leads them to therapy or whether this reflects the lack of specialized therapeutic services for other substances.

With the exception of methadone substitution units all the other therapeutic services are intended to all drug addicts. However, the overwhelming number of heroin users in treatment services discourages several non-heroin users. Furthermore, therapeutic services inevitably adjust their services to the needs of heroin users as they constitute the majority of their clients.

• Alternative routes of heroin administration are increasing. Needle sharing has also slightly decreased.

Alternative routes of heroin administration (smoke/inhale, eat/drink, sniff) are mainly adopted when the veins and the muscular system of the user have been damaged. Only a small percentage of heroin addicts come to change their usual way of administration as a result of public awareness campaigns and relevant information.

During 2000 the percentage of those sharing needles has decreased compared to the relevant percentage in 1999. Experts reported that this decrease could be attributed to the emphasis given to harm reduction programmes (special seminars, outreach work). Nevertheless, needle sharing still remains prevalent among intravenous drug users. It forms part of the users’ sub-culture, as a behaviour through which they prove their trust to each other and ascertain their belonging to the group.

3.2 Drug related mortality

The Greek Focal Point collects data on deaths caused by acute intoxication (overdose or synergistic activity of different drugs) on a yearly basis. The Third Section of Drugs of the Public Security Directorate in the Ministry of Public Order is responsible for the collection of data on drug related deaths, which are published in the Annual Report of the Central Anti-drug Co-ordinating Unit (SODN-EMP). These data are based on the death certificates issued by the forensic laboratories in cases of sudden deaths or after a request by the law enforcement authorities for forensic investigation when involvement of drugs is validly suspected in a death case. According to the Third Section of Drugs maintains that the national coverage of these data is 97%.

Drug-related deaths recorded between 1985-2001(until June) are presented in Figure 13.

Deaths increase at the same high rate over the last few years; in 2000 the increase was 14%, which was the highest in 3 years and almost double than the increase observed last year (between 1998-1999). In the first 6 months of 2001 the rate appears equally high.

Figure 13: Drug related deaths (1985-2000)

SOURCE: Central Anti-drug Co-ordinating Unit, 2001.

The basic demographic characteristics of drug users who died of acute intoxication are presented in Table 10. The profile of the average dead drug- user is: Greek male, aged between 20 and 30 years, resident of Attica (the Athens prefecture), secondary education graduate.

In Greece, as well as in other European countries, drug users are an aging population; in 2000 the percentage of deaths concerning people over 30 years old was 41%, compared to 32.2% in 1999 and 17.8% in 1985.

Although heroin appears to account for the majority of deaths, reports from the toxicological laboratories and the Police, show that in almost all cases the cause of death was the combination of heroin with some other substance.

Table 10: Characteristics of drug related death cases in 1990-2001*

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001* Reported deaths 76 94 86 83 164 190 241 241 255 277 312 165** Confirmed drug related deaths 66 79 79 78 146 176 222 232 245 265 304 149* 1. Age < 20 years 2 2 1 4 8 7 14 24 33 47 51 24 21-30 years 34 44 47 49 71 90 98 102 112 122 130 65 > 31 years 30 33 31 25 67 79 110 106 100 96 123 60 2. Sex Male 59 74 70 70 135 162 202 209 216 245 285 137 Female 7 5 9 8 11 14 20 23 29 20 19 12 3. Nationality Greek 63 76 76 74 141 168 212 227 240 251 292 142 Foreigners 3 3 3 4 5 8 10 5 5 14 12 7 4. Area Attica 52 61 61 69 105 136 166 166 170 186 200 106 Thessaloniki 9 12 9 4 21 18 25 38 39 30 49 20 The rest of the 5 6 9 5 20 22 31 28 36 49 55 23 country 5. Marital Status Single 58 67 75 74 129 157 184 96 227 245 289 140 Married 7 11 2 3 13 15 32 8 16 16 12 5 Divorced 1 1 2 1 4 4 6 1 2 4 3 2 6. Education Elementary school 29 33 27 28 31 73 78 36 87 65 111 56 High school 12 39 27 38 23 30 106 66 143 169 178 80

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University 1 3 6 2 1 6 4 2 3 3 4 … Unknown 23 4 19 10 91 66 34 1 12 28 11 13 Illiterate 1 1 … 7. Profession Unemployed 29 51 47 50 81 99 144 73 175 197 232 124 Workers 19 9 15 9 24 29 21 15 31 18 28 4 Private employees 11 10 10 5 16 20 9 6 14 11 15 7 Musicians 2 3 2 … … Sailors 2 4 4 1 1 4 7 1 1 2 … Others 1 2 1 10 19 16 35 8 21 31 6 1 Prostitutes 2 3 1 4 1 1 1 1 … Civil servants 2 2 3 1 … … Journalists 2 … … Scholars 3 1 4 6 20 13 8. Drug Substances Heroin 60 74 73 77 134 157 213 222 243 263 300 148 Morphine 6 3 3 8 3 1 … … Psychotropic 2 2 1 4 13 7 6 1 1 3 1 substances Cocaine 1 1 3 1 1 1 … Hashish-alcohol 2 1 1 …

* From 1-1-2001 until 30-6-2001 ** 30 cases which were reported until 30-6-2001, are still under investigation

SOURCE: Central Anti-drug Co-ordinating Unit, 1990-2001.

3.3 Drug related infectious diseases

3.3.1 HIV and AIDS

According to data from the Center for the Control of AIDS and STDs (KEEL) in 2000, the overall number of new AIDS cases was 522, out of which 16 involved intravenous drug users (Figure 14).

Figure 14: Number of AIDS cases among IVDUs (1985-2000)

SOURCE: KEEL 2001.

The number of AIDS cases in 2000 is 4 times as high as that of 1999! This sharp increase observed was almost anticipated, since the very low prevalence of HIV in Greece for such a long time had made professionals suspicious of a coming increase as discussed in previous Greek National Reports.

3.3.2 Hepatitis B and C

In 2000, various sources provided data on hepatitis in aggregated form. In 2001, data from a small-scale survey will be available, for the first time, by a network of agents similar to the one operating for the treatment demand indicator (see Annex I).

Test results in 2000

Public Laboratories in Athens

The Laboratory of Syngros General Hospital and the Laboratory of the National School of Public Health (NSPH) are the two major Reference Centres for hepatitis B and C testing. Most therapeutic units in Athens send their clients to these centres for medical tests. Users tested are mostly injectors, but in 2000 it was not possible to separate injectors from the overall number of users.

At the Syngros Laboratory, out of the 278 drug users tested for hepatitis B, 11 (4%) were found infected. The majority of them were between 25 and 34 years old. In the case of hepatitis C, out of the 281 drug users, 130 (46.3%) tested positive. The majority of infected users were over 34 years old.

At the laboratory of the NSPH, out of the 650 drug users tested 19 (3%) were infected with hepatitis B and 278 (43%) with hepatitis C.

Therapeutic Programmes

Test results from the methadone substitution programme implemented by OKANA, derive from the two units which function in Thessaloniki. Among the 41 IVDUs tested 2 (4.9%) tested positive for hepatitis B virus. The relevant percentage for hepatitis C was 87.8% (tested: 41, positive test result: 36).

Data from the Centre of Therapy for Dependent Individuals (KETHEA), which is a major drug-free therapeutic agency, indicated that 14 (3.8%) out of the 367 IVDUs tested had hepatitis B. In the case of hepatitis C, 176 (40%) out of the 439 IVDUs tested were infected.

The Psychiatric Hospital of Attica runs a special unit, 18 ANO, for dependent individuals. Out of the 131 IVDUs tested during 2000, 7 (5.3%) tested positive for hepatitis B virus and 68 (52%) were infected with hepatitis C.

The above-mentioned data are compared to the ones of the previous year in Figure 15.

As shown below, the results of the reference centre of “Andreas Syngros” and KETHEA show a decrease in the level of hepatitis C infection in 2000. On the contrary, an increase was observed in the level of hepatitis C infection in OKANA substitution units. Positive test results from NSPH remained relatively stable.

Figure 15: Hepatitis C infection among IVDUs (according to test results)

SOURCES: Andreas Syngros Hospital, NSPH, OKANA, KETHEA, 18 ANO, 2001

Most of the infected IVDUs were males. The majority belonged to the 25-34 age group (Figure 16), with the exception of clients from the substitution programme, almost 54% of whom are over 34 years old.

Figure 16: Age distribution of hepatitis C among IVDUs according to test results

SOURCES: Andreas Syngros Hospital, NSPH, OKANA substitution units of Thessaloniki, KETHEA, 18 ANO, 2001.

Self-reports during 2000

According to 2000 Treatment Demand Indicator data, among those who have been tested and know the test result, self-reported hepatitis C prevalence rate was 51% (known test result: 1356; positive test result: 692) while the respective rate for hepatitis B is 11% (known test result: 1356; positive test result: 148).

Another source of information that uses the TDI protocol is the Psychiatric Hospital of the Korydallos Athens prison. Data from this source indicated that out of the 45 inmates who have been tested and know the test result, 6.7% tested positive for hepatitis B while 40% for hepatitis C.

According to KETHEA treatment demand data among those who have been tested and know the test result, self-reported hepatitis C prevalence rate was 31.3% (known test result: 1132; positive test result: 354) while the respective rate for hepatitis B was 3.7% (known test result: 1124; positive test result: 42).

3.3.3 The Euro Boule de Neige programme

The Euro Boule de Neige is a programme for the prevention of AIDS, hepatitis and similar health risks among drug dependent individuals. The main objective of the programme is to sensitise drug users to the risks related to their drug using practices and inform them of ways to reduce these risks.

The first phase of the programme took place in 1998, in Athens and Thessaloniki. The main objective of this phase was the investigation of the levels of HIV, hepatitis and tuberculosis infection among drug addicts. For this purpose, streetworkers employed an appropriately designed questionnaire.

Overall, 421 drug addicts participated in the first phase. The vast majority (91%) have made intravenous use of substances at least once in their lifetime. Most of them (70.5%) have been tested for HIV and hepatitis. 1.4% of those who have been tested for HIV were seropositive. The majority (83.8%) of drug addicts have been infected with hepatitis C virus, while the relevant percentage for hepatitis B is 41.6%.

Additionally, 37.6% of the drug users, reported that they had been tested for tuberculosis. Among them 4.9% of them were infected.

The Table below presents the basic demographic characteristics of those who have been infected by hepatitis, HIV and tuberculosis.

Table 11: Euro Boule de Neige programme: Demographic characteristics of drug addicts who have been infected with HIV or hepatitis viruses

HEPATITIS B HEPATITIS C AIDS TB (N=77) (N=157) (N=4) (N=20) Gender Male 78.9% 77.3% 75% 4.9% Female 21.1 % 22.7% 25% 5.1% Age group - 25 3.9% 10.9% 33.3% 4.5% 25-34 53.2% 56.4% 0% 3.5% 35 + 42.9% 32.7% 66.7% 7.9% Lifetime injecting 96% 98.7% 100% 4.7%

SOURCE: OKANA, 2000.

Finally, it is worth mentioning that due to the alarming spread of infectious diseases among drug users, various agencies have become actively involved in the field of STDs prevention. Their activities range from education on safe drug use and safe sex to syringe exchange, testing and treatment (Annual Report on the Drug Situation Submitted to the E.M.C.D.D.A, 2000).

3.4 Other drug related morbidity

3.4.1 Non-fatal drug emergencies

No data are currently available on non-fatal drug emergencies in Greece.

3.4.2 Psychiatric co-morbidity

Several studies on psychiatric co-morbidity have been conducted in the last 5-6 years in Greece. They mainly investigated the existence of personality disorders and suicide ideation in drug dependent individuals. The results of these studies are presented in detail in last's year Greek National Report. A brief summary of the main findings is given below.

Personality disorders among users in treatment

At least one personality disorder (PD) was diagnosed in 60% of 226 drug dependent clients in 3 therapeutic programmes. The most prevalent disorder was antisocial PD. Personality disorders were found to be associated with a high level of psychopathology as well as with dropping out of treatment (Kokkevi, et al. 1998).

Personality disorders among users in treatment and in prison

In a sample of 176 users in treatment and in prison antisocial personality disorder (PD) was found in 69.3% of the cases. This type of PD preceded drug dependence. Additionally anxiety PD was diagnosed in 31.8% of the users, while affective PD was diagnosed in 25% of them (Kokkevi and Stefanis, 1995).

Social phobia and depressive symptomatology

Depressive symptomatology was present in 37 out of 48 drug users requesting treatment. Moreover 12.5% of them presented symptoms of social phobia (Liappas et al. 1998).

Suicide attempts among drug dependants

In a sample of 25 drug dependent individuals who had attempted suicide, more than half (56%) were diagnosed as having antisocial personality disorder. Problems in interpersonal relationships were the main self-reported reason for the attempt (Pertessi et al. 1998).

Self-destructive behaviour, suicide attempts and cocaine use

According to the results of a study conducted on 231 treated drug users, cocaine misuse was found to be associated with higher levels of depression compared to other drugs as well as with a higher risk of suicide attempts (Liappas et al. 1996).

Suicidal behaviour and chronic heroin use

In a sample of 458 chronic heroin users the majority (52%) presented suicidal ideation, while 28.6% reported that they had attempted suicide at least once in their lifetime (Tsaklakidou et al. 1996)

3.4.3 Other important health consequences

Drugs and driving

A study conducted in 1999 by the Laboratory of Forensic Medicine and Toxicology in a sample of 856 drivers and 89 pedestrians, victims of traffic accidents, revealed that 41% of the drivers and 19% of the pedestrians had blood-alcohol-concentrations over the limit. In 6% of the cases a psychoactive substance had been consumed before the accident (Athanaselis et al. 1999).

The Laboratory of Forensic Medicine and Toxicology of the University of Thessaloniki carried out another similar study during 1999-2000 in Northern Greece.

Objective: Ø To investigate any involvement of alcohol or other pharmaceutical substances in fatal traffic accidents Sample: Ø 161 blood samples were examined for the identification of any alcohol involvement Ø 101 biological samples were examined for the identification of any narcotic or other pharmaceutical substances Data collection: Ø toxicological analysis following autopsy Main findings: Ø In 49.7% of the blood samples alcohol concentration was above the limit (0.5 g/l). Moreover in 19.3% of them the concentration was above the limit of 1.5 g/l. Ø 11.9% of the biological samples tested positive for one or more narcotic substances. More specifically cannabis was detected in 7.9% of the total number of biological samples, alkaloid opiates in 5% , amphetamines in 1% and benzodiazepines in 1% of the total number of samples Reference: Tsoukali et al. 2000

Another study conducted by the same research team during 1997-2000 is presented below.

Objective: Ø To investigate the involvement of amphetamine consumption in fatal incidents in Northern Greece Sample: Ø Post-mortem biological material of seven drug users Data collection: Ø Post-mortem and toxicological analysis Ø For the detection of amphetamines the liquid-phase extraction and solid-phase extraction (SPE) methods were used Main findings: Ø Amphetamines were found to have a direct contribution in one case, an indirect contribution in three cases while for the remaining three no amphetamine contribution was observed Reference: Raikos et al. 2000

4. SOCIAL AND LEGAL CORRELATES AND CONSEQUENCES

4.1 Social problems

4.1.1 Social exclusion

Although most treatment facilities in Greece implement social reintegration and rehabilitation programmes, users remain socially excluded to a large extent. As it has been discussed in previous chapters, drug use starts at an early age. As a result, the number of school leavers and, therefore, unskilled individuals, who have minimal chances of entering the labour market, increases. The State subsidises the salaries of socially excluded people, including users who have completed their treatment, in an effort to encourage private enterprises to employ them. The high rates of unemployment, though, make the situation more difficult.

The phenomenon of social exclusion of drug users has not been investigated in Greece. Research activity is just starting in this area, with a few studies, which began in 2001 and have not produced results as yet.

Data from a sample of 344 drug users recruited in the streets of Athens showed that most of them are not aware of the social benefits they are entitled to and/or do not know where to turn to for information and social assistance. Only 15% had contacted social services, while 32% had contacted drug related services (European Commission, 1998).

4.1.2 Minorities

The number of immigrants coming to Greece mainly from the ex-soviet countries, Albania and Turkey is increasing. Yet, no special studies on use among these populations have been conducted. A very small number of these people contact drug-related services (Douzenis, 1997).

A very typical case of an adolescent drug user immigrant is described below.

The case of Sonia: an immigrant 15 year old heroin user

(Kefalas, 1997)

Sonia is one of the hundreds of thousands of the Greek minority members who had lived in Albania since the war and were repatriated in the early 90's.

The girl came to Greece with her two elder brothers at the age of 14. Her mother came several months later, while her father followed them at an even later stage. Sonia was working and attending evening school. Shortly after her arrival, her mother left; this time she went to America with her son, where she stayed for four months. These continuous separations probably affected Sonia who had never before lived away from her family.

She was soon introduced to cannabis, pills and later on to heroin. Her parents realised it when she was found in a coma and taken to hospital by the police. Being illegal immigrants, her parents had to face a double problem. She was already 19 years old.

Soon after her discharge, Sonia contacted the Adolescent Unit of the Detoxification Programme of the Psychiatric Hospital of Attica. Her initiative created tension in the family, which soon subsided though, and her parents joined the parents’ groups.

Sonia's family speak of their dream to come to Greece, to their homeland, of which they had an idealised impression, particularly when they compared it to Albania. However, the fact that their daughter was introduced to drugs created ambivalent feelings for Greece. They refuse to accept the role of family relationships and the psychological condition of their daughter; being convinced that "this would never have happened in Albania", they attributed the problem to the high availability of drugs, the huge and impersonal city of Athens which is "full of drug dealers and drug trafficking places".

Repatriated families very often face problems with their "double identity": in Albania they were the Greek minority, in Greece they are illegal immigrants. For an adolescent, who strives to build an identity, this situation can be impossible to handle.

4.1.3 Community reaction

Treatment services in Greece are expanding. Major treatment centres are in a constant search of premises to house new programmes or expand existing ones. This has led to the surfacing of negative attitudes of the public towards drug users and to an increase in the community’s reaction.

The most severe case of strong public reaction was recorded in 2001 when the Therapy Centre for Dependent Individuals (KETHEA) decided to inaugurate a programme for the rehabilitation of detoxified users released from prison. The programme would be housed in a building, owned by KETHEA, located in a central area in Thessaloniki. Local agents, shop-owners, hotel owners started a co-ordinated reaction to stop the programme or have it housed outside the city limits. The local authorities of the city, yielding to public pressure, decided to forbid the establishment of the programme, claiming that it would socially and economically degrade the area, and would have an adverse effect on the interests of all parties involved (public and users). KETHEA publicised the matter, which became a subject on the media for several weeks. Then, a counter-reaction started from people, mainly intellectuals, who became indignant at this decision. Finally, the “Citizen’s Solicitor”, a state organisation, whose duty is to protect citizens from the violation of their rights by the State, intervened and decided that the decision of the local authorities is against the Greek Constitution, according to which any attempt to discriminate against and socially exclude any resident in this country is strictly forbidden. Following this, KETHEA is proceeding with the implementation of the programme.

Another case was that of 18 ANO, the special unit for drug dependent individuals of the Psychiatric Hospital of Attica. They had been renting an apartment to house one of their programmes for several years. The apartment block was owned by “Evangelismos”, a big general hospital in Athens, whose administration suddenly decided, in 2001, to annul their contract with 18 ANO, because they were allegedly pressured by the other tenants of the building, who are professionals in private practice (mainly lawyers) and whose clientele was annoyed by the large number of addicts frequenting the place and the neighbourhood. 18 ANO reacted vehemently and requested the assistance of the Ministry of Health. With the intervention of the Central Health Council, a ministerial body, a temporary solution was given, which allowed 18 ANO to keep the place until a public building is found.

4.2 Drug offences and drug-related crime

4.2.1 Arrests and charges

The Focal Point collects data annually on arrests and charges by the Central Anti-drug Co-ordinating Unit, an inter-ministerial body, in an aggregated form. According to the law enforcement authorities these data have 100% coverage, since every individual who is arrested or charged is recorded without exception.

An individual is arrested when caught by the police as suspect of a specific offence. An individual is charged when there is a specific accusation against him, possibly without having been apprehended. Prosecution of an individual implies being arrested, charged and brought to court.

Figure 17: Arrests and charges by the Hellenic Police and charges by the law enforcement authorities

SOURCE: Hellenic Police and Central Anti-drug Co-ordinating Unit, 2001.

Trends over the seven-year period between 1994 and 2000 show an increase in the number of charges, from 3762 in 1994 to 12543 in 2000. The number of charges reported by the law enforcement authorities during 2000 represents a 15% increase compared to 1999.

The number of arrests reported by the Hellenic Police steadily correspond to around 95% of total arrests; for 2000 the Police did not report data for arrests. The latest trend observed was a 67% increase comparing the number of arrests over the two year period between 1997 and 1999 (in 1998 the Police did not also report data on arrests).

4.2.2 Convictions and imprisonments

The Statistical Service of the Ministry of Justice collects data from all the Greek judicial authorities and prisons on every case of final court conviction or imprisonment of a drug law offender. The Focal Point receives these data in an aggregated form.

The latest data available for convictions and imprisonments refer to 1997.

In 1997 the number of convicted individuals of drug law offences increased compared to 1996 (1484 in 1996, and 1906 in 1997). However, this number represents only a small percentage (2%) of the total number of convictions in the country. The majority of the convicted individuals were men (96%).

Figure 18: Individuals convicted of drug law offences (1985-1997)

SOURCE: Statistical Service of the Ministry of Justice, 2001.

Most of the convicted individuals in 1997 were convicted of drug use (67.7%); these convictions are usually suspended or commuted to fines. The relevant percentages for trafficking and cultivation were respectively 26.5% and 5.8%.

The number of individuals imprisoned for drug law offences remained practically unchanged in 1997 (2069) compared to 1996 (2014).

Figure 19: Individuals imprisoned for drug law offences (1985-1997)

SOURCE: Statistical Service of the Ministry of Justice, 2001.

Most of the imprisoned individuals in 1997 (79.6%) were convicted of trafficking, 12% of them were convicted of cultivation, while a small percentage (8.4%) of them were imprisoned for use only.

This picture is in accordance with the latest law amendments, which are more lenient to users, especially dependent users, and stricter to dealers and traffickers.

4.2.3 Drug related crime

Drug related crime in adolescents and young adults

According to data from the “STROFI” therapeutic unit, the percentage of adolescents and young adults who have been arrested at least once in their lifetime increased in 2000 compared to 1999 (Table 10). The percentage of those who reported six arrests or more has also increased (1999: 11.2%, 2000: 15.8%). In 2000 more individuals were arrested at the age of 15 or younger than in 1999 (1999: 31.6%, 2000: 32.4%). The percentage of those who

reported having an income from illegal sources remained stable in 2000 (1999: 56.8%, 2000: 56.3%).

Table 12: Number of arrests of adolescents and young adults requesting treatment in the 'STROFI' therapeutic unit (1999-2000)

1999 2000 Arrested at least once during their lifetime Yes 266 241 (59.1%) (63.1%) No 184 141 (40.9%) (36.9) Number of arrests 1 – 5 236 203 (88.7%) (84.2%) 6 – 10 19 27 (7.1%) (11.2%) 11 + 11 11 (4.1%) (4.6%) Age of first arrest ≤ 15 84 78 (31.6%) (32.4%) 16-19 177 154 (66.5%) (63.9%) 20 + 5 9 (1.9%) (3.7%)

SOURCE: STOFI and PLEFSI, 2000-2001.

Pharmacy burglaries

Figure 20 shows the trend in the pharmacy burglaries reported in the last 10 years.

The decrease in the number of pharmacies having been burgled in Greece since 1991 could be attributed to various factors; for example, low prices and the increased availability of drugs, as well as the intensification of law enforcement measures (Central Anti-drug Co-ordinating Unit 2001).

Figure 20: Pharmacy burglaries in Greece (1991-2000)

SOURCE: Central Anti-Drug Co-ordinating Unit, 2001.

4.3 Social and economic costs of drug consumption

NO INFORMATION AVAILABLE

5. DRUG MARKETS

5.1 Availability and supply

Due to its geographical position, Greece plays an important role in the illegal drug market not only as the destination country but also in many cases as a gateway for traffickers smuggling cannabis and heroin from the Middle East and Southwest Asia to the West.

Most of the quantities of illegal drugs imported in the country, during 2000, came from Albania and Turkey, through the Balkan routes. More specifically, according to the annual report of the Central Anti-drug Co-ordinating Unit: • In 2000, 82.4% of the heroin brought into Greece came from Turkey, 6% from Albania, 2.3% from Pakistan, while for 9.4% of the overall seized heroin quantity the country of origin was not known. • Latin-America (Venezuela and Colombia) is the main source of cocaine smuggled into Greece. In the majority of cases (86.8%) the most common way of trafficking is by sea.

• In 2000, a large amount of seized cannabis (43%) came from Albania. Turkey is another source of cannabis import (8.8% of the overall seized cannabis quantity) while for 48.2% of the overall seized cannabis quantity the country of origin is not known (Central Anti-drug Co-ordinating Unit 2001).

There are also cases of drug production in Greece. In 2000 the police tracked down, for the first time in Greece, a clandestine laboratory where illegal synthetic drugs were produced.

5.2 Drug seizures

Data on seizures are collected by the Central Anti-drug Co-ordinating Unit and sent to the Focal Point in aggregated form.

In 2000, one big seizure (524.6 kg of heroin) made by the police, caused a considerable increase in the quantity of seized heroin (Figure 21).

Figure 21: Seizures of heroin, cocaine and herbal cannabis (1991-2000)

SOURCE: Central Anti-drug Co-ordinating Unit, 2001.

According to official reports, the observed increase in the quantities seized in 2000 compared to 1999 can be attributed to the increased suppressive measures adopted by the Ministry of Public Order during 2000, as well as to the joint and specialized action of the border outposts.

Table 13: Drug seizures in 2000 made by each of the law enforcement authorities

Police Ministry of Finance Coast Total Customs FECO * Guard Cases 7,995 18 10 151 8,174 Cannabis a. Cannabis resin (kg) 47.371 0.001 1.261 8.057 56.690 b. Cannabis herb (kg) 10,243.526 1,581.596 0.912 3,082.257 14,908.29 c. Cannabis oil (kg) 1.205 - - - 1.205 d. Plants (pieces) 49,840 - - - 49,840 Opiates 643.81 1.53 0.01 15.926 661.27 Stimulants a. Cocaine (kg) 19.214 9.449 126.743 0.008 155.414 b. Amphetamines (kg) 2.008 - - - 2.008 (pills) 30,109 - - - 30,109 c. Ecstasy 53,548 - - 9 53.557 Other psychotropics a. L.S.D. (doses) 111 - - - 111 b. Tranquillisers (kg) 3.7 - - - 3.7 (pills) 29,104 - 6,990 493 36,587 c. Barbiturates (pills) 9 - - - 9

* Financial and Economic Crimes Office

SOURCE: Central Anti-drug Co-ordinating Unit, 2001

In spring 2000, the police seized a large amount of precursor substances and amphetamines (26,159 pills) produced in a clandestine laboratory of a local pharmaceutical industry located in central Greece. This resulted in a sharp increase in amphetamine seizures (30,109 pills) compared to zero seizures in 1999 and the very small amount of seizures (5 pills) in 1998.

It is worth mentioning that the customs authorities sent additional information on the pharmaceutical substance 'clenbuterol'. According to this information, 4,950 pills were seized by customs officials in a border area of the country. The country of origin was Bulgaria.

According to information sent by the General Chemical Laboratory, 8.5 tablets of ketamine and 0.31 gr of ketamine powder were seized during 2000.

Finally, 5,119 ephedrine capsules were seized (4,769 capsules were seized by the Financial and Economic Crimes Office and 350 capsules by the police).

At this point it is worth mentioning that according to the U.S. Department of State and the Bureau for International Narcotics and law enforcement affairs, local U.S. authorities report an excellent working relationship with Greek law enforcement agencies. In August 2000, after a nine-month multinational investigation, the U.S. Drug Enforcement Agency (DEA), working with the Hellenic National Police (HNP), the Greek Financial and Economic Crimes office (SDOE) and Hellenic Coast Guard (HCG), seized 9.5 tons of cocaine off the coast of Venezuela as well as several cargo vessels, and arrested 50 suspects, several of whom were extradited to the United States.

Moreover, SDOE has participated in a number of international narcotics interception operations since it was activated in 1987.

5.3 Price and purity

Information on drug price and purity is given by the Hellenic Police. Samples of the quantities of each seized drug are sent to the National Chemical Laboratory for analysis and police information is based on these analyses.

In 2000, the purity ranged between 23%-77% for cocaine and 65%-81% for heroin.

The retail and trafficking prices of various drugs are presented in the table below.

Table 14: Retail and trafficking drug prices in 2000 (in Euros)

Retail Trafficking Cannabis resin 2.93 - 5.87 /gr 1,467 - 2,348 / kg Cannabis leaves 1.47 - 2.93 /gr 293.5 - 587 / kg Heroin 52.8 - 58.7 /gr 14,674 - 29,347 / kg Amphetamines 3.52 - 4.40 /pill 2.35 - 2.93 /pill Cocaine 58.7 - 88 /gr 29,347 - 58,694 / kg LSD 5.87 – 8.8 /pill 2.93 - 4.4 /pill Ecstasy 11.7 – 23.50 /pill 5.87 - 8.8 /pill

SOURCE: Hellenic Police, 2001

As in previous years, cocaine is by far the most expensive drug, followed by heroin.

6. TRENDS PER DRUG

Information on different drugs derives from the surveys conducted in previous years that have already been discussed in previous sections, as well as from the Early Warning System and the Treatment Demand Indicator. Some of the survey data have been presented in past Greek National reports; an overview of the main findings are presented below.

More specifically, information on trends per drug is based on the following sources: a) General population survey, 1998, b) School population survey, 1998, c) Nightlife and Synthetic Drugs survey, 1998, d) Euro Boule de Neige survey, 1998, e) ESPAD study, 1999, f) Treatment Demand Indicator, 2000, g) Early Warning System 2000-2001, and h) Club-goers survey, 2001.

6.1 Cannabis

In 1998, cannabis prevalence was 5.5% in the youngest age group (12-18) of the general population (see Table 15). Prevalence was much higher in males than females (ratio of 3 to 1). The highest prevalence (around 22.0%) was presented among young adults, aged 19-35 years old.

In 1998, cannabis prevalence was 12.5% among students aged 13-18 of the school population (see Table 15). Prevalence was higher in boys than girls: 16.2% and 9.1%, respectively (ratio of almost 2 to 1). 17-year-old or older students presented the highest prevalence: 21.2%.

In both surveys the prevalence of cannabis tripled in the 5 year-period between 1993 and 1998.

In the 1999 ESPAD study cannabis prevalence was 8.5% (16 year-old students) (see Table 15). Prevalence was higher in boys than girls: 11.1% and 6.6%, respectively (ratio of almost 2 to 1). Cannabis was the most common illicit substance. Two thirds (67.7%) of the students, who reported having taken drugs, had begun with cannabis, (71.2% for boys and 63.7% for girls).

Table 15: Cannabis prevalence

General population School population ESPAD study 1998 1998 1999 Aged 12-18 Aged 13-18 Aged 16 Lifetime 5.5% 12.5% 8.5% Last year 4.3% 10.2% 7.0% Last month 1.7% 6.0% 4.3%

SOURCE: UMHRI, 1998-1999.

In the 1998 Nightlife and Synthetic Drugs survey, cannabis prevalence for young people (aged 14-35) frequenting clubs was 46.4% (13.9% ex-users and 32.5% current users). Male current users outnumbered female current users (41.2% and 17.8%, respectively).

The preference for specific music scenes seemed to be differently associated with drug use. Young people reporting preference in the trance music scene presented the highest percentage (52.8%) of current cannabis users, while those who preferred the rock scene presented the highest percentage (29.9%) of cannabis ex-users (see Table 16).

Table 16: Cannabis use among club/party goers from different music scenes

Trance House Local Rock Ex-users 6.9% 9.3% 8.5% 29.9% Current users 52.8% 34.7% 9.9% 32.5% Prevalence 59.7% 44.0% 18.3% 62.3%

SOURCE: UMHRI, 1998.

In the 2001 club-goers survey, cannabis prevalence was 96.1% among 15-30 – year-old-users.

In the 1998 Euro Boule de Neige survey, the past six months cannabis prevalence was 65.1% for “street” users aged 14-59 years old.

According to the treatment demand indicator, 3.9% of users requesting treatment in 2000 report cannabis as their main substance of abuse. Moreover, 66.7% reported cannabis as their secondary substance.

6.2 Synthetic Drugs

LSD use prevalence increased in the 1998 epidemiological surveys, especially in the school population, from 1.3% in 1993 to 3% in 1998, while amphetamines use remained stable.

The use of synthetics seemed to be quite common among club/party goers, in the 1998 Nightlife and Synthetic Drugs survey, in which adolescents and young adults, 14-35 years old, reported amphetamines use at 6.8%, ecstasy use at 11.8% and LSD use at 11%. Three years later, in the 2001 club-goers survey, among young people aged 15-30 years old that reported drug use, amphetamines prevalence was 10.7%, ecstasy 34% and LSD 21.4%.

In the Euro Boule de Neige survey that was conducted in 1998, 22.3% of “street” users reported having used amphetamines in the past six months, 23.8% reported ecstasy use during the same reference period and 26.6% LSD use.

According to the treatment demand indicator data in 2000, which mainly refer to intravenous heroin users, synthetics use as a secondary substance is low in 2000.

According to data from the Early Warning System in 2000-2001, the use of new synthetic drugs, such as ketamine, akyl nitrates (“poppers”) and GHB mainly involves recreational drug users. These substances, even if they are known for their medicinal use, are regarded as new, because they have recently been distributed recently in the illicit market and have been consumed in the nightlife settings.

Ketamine is regarded as the most popular new drug among certain groups of users. Furthermore, ketamine is mainly sniffed, while an average dose of the substance may contain further substances, such as meth-amphetamine, caffeine and procaine.

6.3 Cocaine/Crack

Epidemiological surveys reveal an increase in cocaine use from 1993 to 1998, especially in the school population where it was doubled, from 1% to 2%.

In the 1998 Nightlife and Synthetic Drugs survey, among young people frequenting clubs the prevalence of cocaine was 12.2%, while in the 2001 club- goers survey, young users reported cocaine use at 35.9%.

Among “street” users recruited by the Euro Boule de Neige survey, cocaine and crack was reported by 72.2% and 4.5%, respectively.

According to data from the treatment demand indicator, 0.8% of users requesting treatment in 2000 reported cocaine as their main substance of abuse. Moreover, 33.3% of them reported cocaine as their secondary substance.

6.4 Heroin/Opiates

Heroin prevalence is usually very low in epidemiological studies as they are not designed to identify problematic or dependent users. In 1998, the prevalence of heroin was very low (0.4%) in the general population, aged 12-18, while it was 1.1.% among students of the same age.

In the Nightlife and Synthetic Drugs survey, in 1998, the prevalence of heroin was 5.4%.

Table 17 shows the prevalence of drugs from several sources.

Table 17: Substance use from different surveys

General School ESPAD NSD1 CLG2 BDN3 TDI4 1998 1998 1999 1998 2001 1998 2000 12-18 13-18 16 14-35 15-30 14-59 14-60 % % % % % % % Substances (1) (2) (3) (4) Cannabis 5.5 12.5 8.5 46.4 96.1 12.0 65.1 3.9 66.7 Amphetamines 0.1 3.9 1.0 6.8 10.7 1.0 22.3 - - Ecstasy 0.2 2.1 2.1 11.8 34.0 2.1 23.8 - 1.6 LSD 0.4 3.0 1.8 11.1 21.4 3.0 26.6 - 3.8 Heroin 0.3 1.1 2.0 5.4 - - 97.1 89.6 7.9 Cocaine 0.3 2.0 1.5 12.2 35.9 3.0 72.2 0.8 33.3 Crack - 1.0 0.7 - - - 4.5 - -

1 NSD: Nightlife and Synthetic Drugs survey 2 CLG: Club-goers survey 3 BDN: Euro Boule de Neige survey 4 TDI: Treatment Demand Indicator. (1): consumers, (2): non-consumers, (3) and (4): main and secondary substance.

SOURCE: UMHRI, 1998-1999, Greek Reitox Focal Point, 2001, OKANA, 2001.

6.5 Multiple use

In the school population, aged 13-18, the prevalence of ecstasy was 2.1%. More than half (58.0%) of those that have at least tried ecstasy have taken ecstasy with cannabis at least once, while 25.3% of them take ecstasy with cannabis most or all of the times. Also, almost half (49.1%) of them have taken ecstasy with alcohol at least once, while 12.0% of them take ecstasy with alcohol most or all of the times (see Table 18).

Table 18: Parallel use of ecstasy with other substances

At least once Most or all of the times Alcohol 49.1% 12.0% Cannabis 58.0% 25.3% Heroin 15.4% 6.8% Cocaine 24.1% 8.1% Hallucinogens 30.2% 8.6% Amphetamines 17.4% 5.6% Other drug 27.2% 11.1%

SOURCE: UMHRI, 1998.

In the ESPAD study, the prevalence of parallel use of alcohol with pills was 3.5% for 16-year-old students, while the prevalence of parallel use of alcohol with cannabis was 5.7% (8.4% for boys and 3.8% for girls).

In the 1998 Nightlife and Synthetic Drugs survey, in 1998, among young people frequenting clubs 16.3% reported taking more than one drug during the same night; 11.8% combined alcohol and 16.1% combined cannabis with something else. The most popular combination was alcohol with cannabis, reported by 8.5% of club/party goers.

According to data from the treatment demand indicator, 29.1% of users requesting treatment in 2000, reported two substances of abuse (a main and a secondary one), while, 58.3% of them reported using at least three substances of abuse (a main and two at least secondary ones).

According to the Early Warning System data for 2000-2001, ecstasy users combine ecstasy with pharmaceutical substances (e.g. “madrax”), while heroin users also use steroids at the same time (“decaduraboline”, “testovirone”).

7. CONCLUSIONS

7.1 Consistency between indicators

The increase in drug use prevalence, although not directly calculated for some years, is illustrated by many indirect indicators.

Most young users consume illicit drugs, mainly cannabis and synthetics, occasionally or recreationally, as part of their entertainment culture. A number of these people, though, might move on to problem use as it is indicated by the increased number of adolescent heroin users who approach the STROFI special unit. Risk factors and risk groups of this shift should be investigated as part of preventive efforts. Could the quite lenient attitude of young people towards drugs be one risk factor for further increase of use recreational or problematic?

There is a sharp increase in AIDS cases among intravenous users, although they are still at lower rates than in other European countries. The same applies to drug-related deaths, which are increasing.

The trend towards safer routes of heroin administration (sniffing, smoking) is one of the first few positive signs. Together with the stabilisation or even decrease in hepatitis prevalence according to the reference centres’ data, it seems that the harm reduction measures are starting to produce results. Nevertheless, attention should be paid to the high percentage of new treatment demanders who have not been tested for infectious diseases.

The Media’s coverage of the drug problem as well as the picture that professionals working in the drug field paint of the current situation give the

impression that public opinion urges the State to enhance its efforts against drugs. However, this attitude is in conflict with the increased public reaction to the enlargement of therapeutic facilities discussed above. It is imperative to boost the process of solving the drug problem once and for all!

7.2 Implications on policy and interventions

In the last few years, the biggest problem arising from the data analysis in Greece has been the increasing number of drug-related deaths. Moreover, HIV/AIDS infection is another major problem that has taken alarming dimensions this year. Harm-reduction measures must be strengthened, especially since their positive contribution is starting to show, as discussed above. Two low-threshold services and a single needle exchange programme are evidently not enough to deal with the problem effectively.

Harm reduction measures are also valuable in tackling the second most serious problem, namely the prevalence of infectious diseases among drug users. It is essential to develop a co-ordinated plan consisting of prevention, vaccination and regular tests. The Focal Point is collaborating with the National Committee on hepatitis and will assist to this end.

The increasing number of users who seek treatment at the substitution programme brings to light many aspects of problem drug use: the ageing population who have tried drug-free programmes and failed; the need for drug- free services to adapt to users' needs and to deal with the possible tendency of users to turn to an "easy solution" to a difficult problem. The State is funding new substitution units to deal with the long waiting lists. The need for methadone maintenance has already been recognised. These are regarded as positive steps, as long as policy makers are cautious to avoid creating a methadone or bouprenorphine using group in the place of the existing heroin using group.

The State's efforts to meet various needs in the field of drug use have been intensified in the last years. They should also be co-ordinated in order to attack the problem globally.

The next step of policy-makers is apparently a National Action Plan, which will have been launched by the end of this year. The Plan is expected to have clearly defined priorities, as well as long and short term goals and to be harmonised with the EU Action Plan.

7.3 Methodological limitations and data quality

Research activity in Greece is steadily increasing in the last few years. However, it is still fragmented and satisfies only some of the existing research needs. A compilation of existing studies in the drug field only shows part of the picture of the drug situation in Greece and therecfore not the whole and

accurate one. For example, special populations, such as arrestees or minorities, are still "untouched"; not studied.

Many studies, some of which are presented in this chapter, do not have a sound methodology to allow for valid interpretations. Even repetitions of previous investigations into the same subject present methodological differences so that trends are difficult to be monitored.

Through its electronic database on research projects on drugs, the Focal Point collects information on the difficulties and needs of drug research in Greece. The current difficulties and needs, as presented by professionals and researchers themselves, are: lack of funds, problems in approaching hidden populations of users, lack of cooperation between drug-related agents, lack of specially trained researchers and/or specialised equipment, and inadequate use of the internet for access to bibliography.

The coordinating body, OKANA, has recently created a "research committee" of key-experts in the field, with the participation of the Focal Point, which is assigned to set priorities in the drug research field and methodological, ethical or other standards for research projects receiving funding. Finally, it is hoped that the prospective Action Plan on drugs will provide for the area of research, by ensuring central coordination and adequate funding.

PART III

DEMAND REDUCTION INTERVENTIONS

8. STRATEGIES IN DEMAND REDUCTION AT NATIONAL LEVEL

8.1 Major strategies and activities

On the grounds of the necessity to achieve an effective, concerted and extensive action among the different agencies in the field of drugs, in 2001 emphasis was placed on the organization and the implementation of a comprehensive policy against drugs (see also Chapter 1.1. Political framework in the drug field). Embracing various domains and scopes of action, this policy pays special attention to the coordination of activities in the demand reduction field. In the same vein, the focus of this first organized attempt at a unified national policy appears to be, to a large extent, in accord with the major strategies presented in the 2000 Annual Report that was submitted to the EMCDDA (pp. 77).

Along these lines, the demand reduction policy for the year 2001 has been directed at the following:

• The Inter-ministerial Committee for Drugs – which is temporarily replacing OKANA in its duty – is bound to submit to the Greek Parliament a 5-year National Action Plan Against Drugs by the end of 2001. In the meantime, the Council has determined specific measures to be taken until the implementation of the Action Plan.

• The inauguration of Primary Prevention Centres across the country remains a major priority, while training of prevention agents has been tailored on a more organized and comprehensive basis.

• Adolescent drug users have become a main target-group in the field of treatment, due to the proliferation of their needs and the parallel lack of specialized services for this age group of drug users.

• The role of the criminal justice system has been acknowledged as highly important for the purposes both of drug demand reduction and suppression.

In particular, the National Action Plan Against Drugs is to concentrate on the following four different levels of intervention: a) central and unified coordination, b) primary prevention, c) treatment and harm reduction, and d) supply reduction. With regard to the measures that will be taken prior to the Action Plan, emphasis is placed not only on organizational and institutional issues (i.e. changes to the statutory framework of OKANA, development of district Directorates on Drugs at each involved Ministry, establishment of a Pay Office for dealing with drug-related problems, developments in the legal framework), but also on the reinforcement of demand reduction interventions.

The step has been to further support the self-help groups of Narcotics and Alcoholics Anonymous. Another development of great importance in terms of quality assurance in the demand reduction field is the establishment of an Institute of Substances and Drug Addiction by the end of 2001. The main role of this Institute will be to develop guidelines, to approve drug-free and substitution

79 programmes as well as training programmes, to supervise the epidemiological research studies and to assess the needs on drug and alcohol issues at a regional level.

Twenty-seven Prevention Centres are to be inaugurated by the end of 2002, the ultimate goal being the establishment of at least one Primary Prevention Centre at each Prefecture. Fifteen prevention centres have already been established in 2000-2001; thus the overall number of prevention centres has risen to fifty-four (Annex II – Table IV). The role of the Local Authorities in primary prevention is to be further enhanced, since the Ministry of Interior shall support them financially in order to subsidy Prevention Centres. Also, a significant development in 2001 has been the fact that prevention programmes may be integrated in the curriculum, although they are not mandatory at school at this point.

At the secondary prevention / treatment level, special emphasis has been placed on the expansion of methadone substitution programmes, the pilot prescription of bubrenorphine within the existing substitution programmes and the permission given, by law, to general hospitals and private doctors to prescribe antagonists (i.e. Naltrexone and Naloxone). Along these lines, the Ministry of Health is considering the possibility of prescribing methadone to drug addicts by public general hospitals as well.

Interventions in adolescent drug users were initiated in 2000 but have become more intense since then. As a result, apart from some existing regional therapeutic programmes which have expanded their services to include adolescent drug users, OKANA has already hired professionals in order to staff specialized treatment units that will be established within the next months.

Regarding the criminal justice system, the first pilot treatment programme within the prison setting was initiated in 2000 by the Multiple Intervention Centre of KETHEA at the Women’s Prison of Koridallos (Athens). Another pilot programme was initiated by the Ministry of Public Order with the assignment of psychologists to some Police Stations in the country in order to offer counselling services to arrested drug users and to their families. The role of the criminal justice system is going to be further upgraded with the expansion of Anti-Drug Units across the country, the continuous training of police officers and the reinforcement of patrols.

8.2 Approaches and New Developments

Primary Prevention Interventions

In 2000-2001, OKANA in co-operation with Local Authorities continued the establishment of new prevention centres with the inauguration of 15 Primary Prevention Centres in total (9 centres in 2000 and 6 in 2001). Overall, this process, which started in 1996 (Figure 22), has resulted in 54 centres, taking into consideration that three Centres called “ODYSSEUS” in the District of

80 Attica were closed down in 2000 due to insuperable difficulties mainly at organizational level. The existing 54 centres cover the needs of 41 out of the 52 Prefectures in the country.

Figure 22: Prevention Centres established by OKANA per year of inauguration

SOURCE: OKANA, 2001

According to data collected by the EDDRA (regarding programmes with at least one year of implementation) and the New Prevention Programmes’ Questionnaire (regarding programmes with less than a year of implementation) in 2000, the majority of the programmes were implemented at the school setting (84 programmes, in total). Fifty programmes were intended for special target- groups such as youth outside school, people in the army, and professionals (i.e. health agents, police officers, journalists, lawyers), while some of them were intended for drug users and their families at a secondary prevention level. Also, forty family prevention programmes and twenty community programmes were implemented in 2000 (Figure 23: For more details on each separate programme see Annex II – Tables II, III).

Figure 23: Number of prevention programmes in 2000 per type of programme

SOURCE: Prevention Centres' network of the Greek Focal Point, 2001

Secondary Prevention Interventions

The main trend in the therapeutic field in 2000-2001 was the emphasis placed on the expansion of substitution treatment and on the provision for new services that satisfy the particular needs of specific drug users groups.

In 2000, OKANA established the first methadone maintenance unit in Athens for those who cannot refrain from drugs even if they have participated in the methadone detoxification programme. Thus, harm reduction from drug use is ensured both at personal and social level, while addicts have the possibility to receive psychosocial services without abstinence being a prerequisite.

Several other changes in the context of substitution treatment took place in 2001. A new substitution-detoxification unit started to operate in Piraeus, as planned by OKANA in its 3-year Action Plan (OKANA, 2000). Thus, the capacity of the substitution units in Athens has increased, which is expected to alleviate to a certain extent, the current problem with the waiting lists for this specific type of programmes. Apart from methadone, both this new unit and the pre-existing ones in Athens (i.e. 1st and 2nd Methadone Detoxification Units) started in 2001 to prescribe bubrenorphine as well, so as to enhance the therapeutic outcome.

Another development in the field of substitution is the proposal, put forward by the Ministry of Health, to allow the general public hospitals to prescribe methadone to drug addicts. This proposal is currently under elaboration and it is

82 expected that it will be realized in the near future. However, hospitals and private doctors are currently waiting for specifications to prescribe antagonists (i.e. Naltrexone and Naloxone) to drug addicted people, so as to assist them in the process of detoxification. Apart from these developments, substitution treatment is to be further expanded at local level with the inauguration of new substitution units in Athens, Thessaloniki, Larisa (Central Greece) and Chania (Crete).

With the aim of providing sufficient information and evaluation services (i.e. diagnostic services) to drug addicts who seek treatment as well as securing referrals to therapeutic programmes adjusted to drug users’ personal needs, OKANA established in 2001 an Admission, Information and Evaluation Service in Athens. This service, which is temporarily lodged in the Help Centre, is currently intended only for those who wish to enroll at a methadone detoxification unit in Athens. At the moment, it is receiving the drug users’ requests for methadone treatment and it is administering the Treatment Demand Protocol to them, while further diagnostic procedures and referrals to several programmes are provided for in the future.

Taking into consideration that there are limited programmes for adolescent drug users in the country, the therapeutic programme “ITHAKI” of KETHEA in Thessaloniki developed a specialized Counselling Centre for this target-group and its families in 2000. The Centre is currently the only one of this type in Northern Greece and it is expected that it will be developed into a comprehensive, multi-phase therapeutic programme in the near future. In this context, OKANA has scheduled the immediate inauguration of five treatment programmes for adolescent drug users in Athens (2 programmes), Thessaloniki, Larisa and Rethimnon (Crete), so as to cover the significant lack of such services at local and regional level. Moreover, new drug-free programmes for addicted adults are to be established across the country both by OKANA and KETHEA within the next two years.

Tertiary Prevention Interventions

Greek professionals in the drug field see after-care and re-integration interventions as an integral part of drug addiction treatment. Within this framework, rehabilitation services are provided in most cases in parallel with therapeutic interventions and/or during the last phase of the treatment process. As far as the second case is concerned, nowadays there are thirteen (13) social rehabilitation units in the country, offering their services to drug users who complete treatment.

In 2001, although no new social rehabilitation programmes were developed, the existing ones enriched their activities with further vocational training activities and developed their co-operation with employers, companies and organizations.

In addition to the treatment agencies, the Ministry of Labour and Social Welfare continued to provide ex-addicts with opportunities for rehabilitation in the job

83 market, through subsidized vacancies, subsidies for private businesses and vocational counselling and training services.

However, drug professionals and policy makers stress the need to intensify reintegration interventions both in terms of training provision and employment rehabilitation of ex-addicts in order to prevent relapse and decrease social exclusion. In this direction, several public organizations and NGO’s – among which is OKANA – submitted their proposals for social rehabilitation programmes, within the framework of the European Community Initiative “EQUAL”.

Socio-cultural developments and developments in the public opinion

In 2000-2001, drug use and possible prerequisites and/or measures to combat it became a quite popular issue among policy makers, health professionals, the mass media and the lay public.

In many cases, local communities proceeded with several initiatives with the aim of putting pressure on policy makers to develop drug services in their region, an action that shows the high degree of sensitisation to drug issues. However, there were a few cases where local agents protested against the establishment of drug programmes in their neighbourhood, due to negative stereotypes of drug addicts. Thus, although the lay public appears to have become more actively involved in drug-related issues and activities compared to previous years, it seems that there is still a need for sensitisation and increased awareness among the general population (see also Chapter 4.1.3: Community Reaction).

In this context, the mass media and especially the local Press continued to play an important role in informing and sensitising the lay public to recent developments in the demand reduction field as well as to the several activities or programmes of the prevention and therapeutic centres.

The emphasis placed by policy makers on substitution treatment and on the harm reduction approach rather than the abstinence-oriented one has aroused great controversy among drug professionals. Although the latter appeared to recognize the need to promote alternative models of therapy in order to satisfy the different needs of drug addicts, they argued that abstinence from drugs should remain the main trend in drug treatment and the ultimate goal of most programmes. Controversy was also aroused among professionals working in general public hospitals, who claimed that methadone should only be prescribed to drug addicts through specialized programmes.

New research findings

In 2000-2001 research studies in the demand reduction field appeared to focus on prevention at different contexts of implementation (i.e. school, community, army) as well as on evaluation issues. Recent work regarding school prevention

84 programmes stresses the importance of an interpersonal and interactive type of drug prevention policy at schools (Aggelou, 2000; Katsama and Roussos, 2000; Roussos, 2000). This model, which goes beyond the traditional ways of teaching students about drug issues, is based on a systemic and a rather dialectic approach to education and, thereby, to prevention. This approach presupposes the active involvement of all participating parties, namely students, teachers, parents, and professionals. This model also invests heavily on the idea that by educating a cluster of students about drug-related risks, these students will then pass their knowledge to their peers through everyday interaction.

The importance of the institution of school in drug prevention is further emphasized in the findings of research conducted in primary schools in Piraeus (Kyritsi and Tsiotra, 2000) and in the Prefecture of Achaia (Passas et. al. 2000). These studies highlight the need for the institutionalisation of an integrated prevention and health promotion policy that shall involve all parties concerned. The various programmes of health education should secure the active and experience-sharing participation of the subjects to education, the latter being in the epicentre of a reflexive process of learning about drugs and drug use (Chourdaki, 2000).

In a similar vein, other studies highlight the valuable role of community involvement in drug prevention. A study on the development of a voluntary drug prevention network in the Prefecture of Achaia points to a number of issues: first, it is important that local community agents become the forerunners and the primary volunteers for all local initiatives against drugs. Secondly, volunteer groups should reflect the social texture of the community in which prevention activities take place. Thirdly, a closer link should be established between theory and practice in the education of prevention. Finally, follow-up training of volunteers should be secured in order for prevention policy to adjust to the changing conditions of the community (Alexopoulou and Athanasopoulou, 2000).

Some other studies conducted in 2000 examine the relationship between drug use and decision processes of drug users. In contrast to data that show a clear- cut relation between drug use and delinquent behaviour (Rigos, 2000), a study on a sample of the student population reveals that the experimental use of cannabis is only minimally related to deviant behaviour of the user (Apostolaki, 2000). Other studies look into the effect that addiction to illicit drugs has on those discharged from the army and the contribution that military service itselft may have to drug prevention (Zlatanos et al., 2000). It is shown that the age of firs-time drug use and the type of the illicit drug used affect military service (i.e. exemption from or interruption of the service). The implications of this study are encapsulated in an alternative proposal that views prevention, treatment and rehabilitation of addicted army recruits as a parallel and integral part of the military service.

In the area of evaluation research, a recently completed study assesses the effectiveness of the first methadone unit in Thessaloniki, eighteen months after it started to operate in 1996. The effectiveness of the programme is reflected in

85 the reduction of use of illegal substances, the decrease in criminality rates and the improvement of both mental and physical condition of the participants in the programme. Based on these findings, it is argued that therapeutic effort cannot be identified solely with the target of abstinence from drugs because this way the majority of drug addicts would be excluded from participating in a therapeutic process (Gazgalidis, 2000). Also, in 2000 special emphasis was placed on the methodological and practical implications of the evaluation studies on therapeutic services, especially the ones that relate to therapeutic communities (Agrafiotis, 2000; Poulopoulos, 2000). Finally, in 2000, OKANA conducted an evaluation study on the 40 Drug Prevention Centres run by OKANA and local authorities. The aim of the study was to objectively document the needs and operational problems of all Drug Prevention Centres, so that future support may be is directed towards satisfying these needs and reducing the existing problems (Paralaimou, 2000).

Meetings and conferences in 2000-2001

Within the framework of exchanging information and experience at national and international level, demand reduction and research agencies organized several meetings and conferences on drug-related issues. Most of them are listed below:

1. Meeting on "Prevention of dependent substances use in the tertiary education for the implementation of the European Programme «Away From Home» in Greece", Athens, 13 November 2000, organized by OKANA.

2. International Seminar on "Drug Addiction Treatment and Care: Services responding to clients' needs or clients adapting to organization of services?", Athens, 24-25 November 2000, organized by ITACA under the auspices of the Greek Ministry of Health.

3. Meeting on "Drug Addiction and Criminality", Athens, 29 January 2001, organized by KETHEA in cooperation with the Department of Psychiatry of the University of California.

4. Congress on “National Planning of Drug Policy”, Athens, 15 March 2001, organized by OKANA.

5. 1st Pan-Hellenic Scientific Conference on "Primary Prevention", Athens, 27- 29 April 2001, organized by the National Council Against Drugs.

6. Meeting on the "Attitudes of Undergraduate Students of the University of Piraeus on Drug Use: Necessity of Implementation of Prevention in tertiary education", Piraeus, 26 May 2001, organized by the Counselling Centre of the University of Piraeus in cooperation with OKANA, within the framework of the European Programme «Away From Home».

7. Meeting on "Licit Dependencies: Alcoholism, Smoking, Gambling etc.", Athens, 28 May 2001, organized by KETHEA in cooperation with the Department of Psychiatry of the University of California.

8. Press Conference organized by the University Mental Health Research Institute in Athens on 12 July 2001, on the occasion of the presentation of the Greek Annual Report for Drugs and Drug Addiction in Greece.

9. Meeting on "Family, Adolescence, and Drug Dependence", Athens, 17 September 2001, organized by KETHEA in cooperation with the Department of Psychiatry of the University of California.

10. Meeting on "Current Approaches to the Problem of Drug Dependence", Chalkidiki, 29-30 September 2001, organized by the Prevention Centre of the Prefecture of Chalkidiki in cooperation with OKANA.

11. Meeting on "Human Rights During the Penal Imprisonment of Young Law- breakers", Athens, 23 October 2001, organized by the Social Youth Support Organization.

9. INTERVENTION AREAS

9.1 Primary Prevention

9.1.1 Infancy and family

Even though interventions for pre-school children are still limited in Greece, due to the fact that prevention policy is focused on primary and secondary school children, family programmes are continuously expanding. The further promotion of interventions for parents appears to arise not only from the establishment of new prevention centres, but mainly – according to prevention agents – from the following factors: a) parents are considered as the main educators/pedagogues of children, b) rapid social and cultural changes affect significantly the couple’s role in shaping the personality of their child, c) parents of adolescents express their concern and trouble in dealing with the multiple demands of their role, d) the increasing need of the family to collaborate with the school community, and e) the intense concern of the parents about the increase of substance use and their lack of information on drug-related issues.

As indicated in Table 19, the main objectives of the prevention programmes intended for parents are communication and improvement of relationships within the family, which are considered to be the main protective factors against dependent substance use. Moreover, more than half of the parents’ programmes aim at reinforcement of the parental role through the acknowledgement, elaboration and expression of emotions. Information on substance use in terms of the role of the family in prevention as well as on children and family psychology also constitute the programmes’ objectives (47.5% and 45%, respectively).

Table 19: Main objectives of parents’ programmes

Objectives of parents’ programmes N=40 %* Improvement of communication/family relationships 27 67.5 Reinforcement of the parental role (acknowledgement, elaboration and expression of emotions) 22 55.0 Information on substance use and on the role of the family in prevention 19 47.5 Information on issues of developmental psychology and/or family psychology 18 45.0 Problem / family conflict management 8 20.0 Acknowledgement of parents’ and children’s needs 6 15.0 Family involvement in preventive actions 5 12.5

* The total of the percentages exceeds 100% because of multiple answers

SOURCE: Prevention Centres’ Network of Greek Focal Point

The achievement of the objectives is, to a large extent, based on applying group techniques, active participatory learning and active experiential approaches (68,2%). Apart from the adoption of these strategies, parents’ programmes also employ the systemic model (40,9%), cognitive model (40,9%), the learning model of personal and social skills (27,3%), and the psychosocial approach (18,2%).

Interventions are also targeted at future parents. More particularly, the Greek Red Cross has been run since 1995 the “Parents School Project”- A Training Programme for Parents and Future Parents. The programme is intended for parents of children/youth up to 18 years old as well as prospective parents and it is aimed at providing information, counselling and support. The ultimate goal of the training programme is to contribute to the full development of the youth’s personality so as to prevent substance dependence, which is mainly achieved by strengthening family relationships. In 2000, forty parents (40) attended the programme. Evaluation results are not available yet.

According to the findings in 2000, half of the parents’ programmes (50%) with a duration of more than a year have been evaluated, 36.4% of the programmes indicate that evaluation is ongoing, while only 13.6% report that they will be evaluated. In terms of the respective programmes with duration of less than a year, 88.8% of the programmes indicate that evaluation is provided for.

Regarding evaluation tools, 81.8% of the programmes report that evaluation is conducted by means of questionnaires that are distributed to the participants. Comments and observations made by the parents as well as observations made by the personnel of the prevention centres and follow-up procedures taking place in some programmes are also taken into account.

88 Below, reference is made to prevention agents that presented specific outcome evaluation results of their programmes.

“Parents’ School”: primary family prevention programme (Prevention Centre of Substance Dependence and Health Promotion “PYXIDA”)

The “Parents’ School”, which has been run since 1995 as an initiative of the Local Government, has been implemented by the Prevention Centre “PYXIDA” since May 1998. During 2000, 180 parents of school-age children and adolescents participated in the programme. Apart from the parents’ groups, the programme also included workshops intended exclusively for the parents of adolescents. The programme was evaluated by means of questionnaires that were distributed ot the participants at the end of the programme. The parents’ replies were as follows (Table 20):

Table 20: Outcome evaluation based on the parents’ replies at the end of the programme

Parents’ replies at the Groups of parents of: Workshops of end of the programme parents of: School age Adolescents Adolescents children % % % Knowledge acquisition on child psychology 54.5 41.4 – Information acquisition on drugs and prevention – – 29.0 Feeling more secure with their children’s upbringing/ education 54.5 64.7 48.3 Expression of emotions and concerns 50.0 47.0 58.7

SOURCE: Prevention Centre of Substance Dependence and Health Promotion “PYXIDA”.

An unexpected result of the specific programme was the fact that those parents who had participated repeatedly in parents groups set up two groups of volunteers and took part in the community programme “Collective action for prevention”.

Prevention programme for parents of elementary school students (Prevention Centre of the Prefecture of Ileia “PAREMVASEIS”)

The specific programme has been run since November 1999 and it mainly refers to experiential workshops for parents. By the end of the year 2000, thirty-

89 five (35) parents had joined the specific intervention. The programme was evaluated by means of questionnaires distributed to the participants, prior to and after its implementation as well as through observations and comments made by the parents and the personnel of the prevention centre. The most significant quantitative evaluation outcome, which is in accordance with the specific objectives of the programme, is the following (Table 21):

Table 21: Evaluation results of the “Prevention programme for parents of elementary school students” with regard to its objectives

PROGRAMMES OBJECTIVES INDICATIVE RESULTS Motivation of the parents, whose • 60% of the parents participating in children already participate in the introductory meetings of the prevention programmes programme declared their participation (in the programme) • 85% of the parents mentioned above joined the programme • 90% of them completed the programme Information on the causes of Prior to the programme’s substance use and the protective implementation: factors against it • 90% declared that prevention depends on information • 75% reported that the State has an essential role in prevention

After the programme’s implementation: • 10% declared that the State has an essential role in prevention • 85% stated that family has the most significant role in prevention, which consists in strengthening the children’s personality • 95% reported that school plays an equally important role in prevention

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Reinforcement of personal and social • 70% reduced negative attributes skills towards their children and partner • 60% further encouraged their children to assume responsibilities Involvement of parents in preventive • 90% expressed their wish for the actions within and outside the school programme to be continued setting • 70% declared that they will put pressure on the teachers for prevention programmes in the school setting to be implemented on a regular basis • 20% asked to participate in the volunteers groups of the Prevention Centre

SOURCE: Prevention Centre of the Prefecture of Ileia “PAREMVASEIS”.

Moreover, the most significant qualitative evaluation results of the programme are the following;

• The experiential workshop, which was run in the school setting, helped the parents familiarise with the setting and facilitated their communication with the teachers. • Many parents reported that it would be useful not only to them but also to the students to have psychologists at school offering their counselling services at any time. • Most of the parents acknowledged the significance of non-verbal communication and the fact that they often convey double messages to their children. • The participants of the workshop were mothers, who thought that the programme would have been more effective if their partners had participated as well.

Mixed training groups of parents with infants and kindergarten teachers (Centre of Communication and Prevention Against Psychoactive Substances of the Prefecture of Pieria)

The programme is intended for parents with infants and kindergarten teachers and aims at the following: a) acquisition of communication skills, b) increase in knowledge on issues of infant psychosocial development, and c) acknowledgment of the significance of the collaboration between parents and

91 kindergarten teachers. In 2000, the total number of the participants was 63. The evaluation of the programme was conducted by means of: a) distribution of a questionnaire at the end of the programme, b) reports by the group- coordinators, and c) comments made by the participants.

The main quantitative and qualitative evaluation results were as follows:

• 69% of the participants declared that they employ the communication skills they acquired from the group-work. 85% of them reported that they apply these skills “very often”. • 85% of the participants indicated that their queries concerning issues of psychosocial development were answered in group-work. • The participants of one of the three mixed groups (i.e., parents-kindergarten teachers) collaborated to the extent that they drew up together a questionnaire that would be completed by the parents. The specific questionnaire will provide useful information for kindergarten teachers so that they may be able to assist adequately the infant’s adjustment to the kindergarten setting. • As the number of application forms for participation in group-work has exceeded the number of available positions of the prevention centre, the programme is expected to continue.

In conclusion, it seems that the parents’ programmes implemented across the country have achieved their objectives to a considerable degree. However, in order to ensure a more permanent, long-term change in the parents’ attitude and behaviour, continuous and systematic preventive interventions in the family are required.

Specific training in family prevention programmes is provided by the “Educational Centre for the Promotion of Health and the Prevention of Drug Abuse” (UMHRI/OKANA) and the “Centre of Therapy for Dependent Individuals” (KETHEA) (see also Chapter 10.4 Training for Professionals).

9.1.2 School programmes

Even though both drug-specific and drug non-specific prevention programmes are still not mandatory at school, interventions in the student population remain the first priority of prevention policy nationwide. This is evident in the increasing number of interventions implemented in the school context and in the expansion of prevention programmes, in both secondary (from 26 programmes in 1998 to 57 in 2000) and primary (from 9 programmes in 1998 to 25 in 2000) education (Figure 24).

Figure 24: Number of prevention programmes in Primary and Secondary Education during 1998-2000

SOURCE: Prevention Centres Network of the Greek Focal Point, 2001.

School prevention programmes in primary and secondary education involve teachers, parents, and the community as agents of change. The Ministry of Education has created a National Network of Health Education in order to plan, promote and support the implementation of health promotion programmes in the school setting. The network consists of the following; a) the Health Promotion Bureau of the Directorate of Secondary Education Curriculum, b) the Responsible for Health Promotion in each Directorate of Secondary Education, c) teachers implementing health promotion programmes, d) Youth Counselling Centres, and e) the Pedagogical Institute. As provided by Law 1817/2000 (Article 7) of the Ministry of Education, the number of Health Promotion programmes organised - nationwide with national resources - by Health Promotion Bureaus of the local Directorates of Primary and Secondary Education has increased. During 1997-2000, 2,100 health promotion programmes were implemented in primary and secondary education, out of which 400 were programmes on combating dependent substance use. In the academic year 2000-2001, 900 relevant programmes have been implemented. So far, health promotion programmes have neither been officially included in the school curriculum nor in the detailed programme of the Ministry of Education, as the organisation of a National Network of Health Education in primary education as well as the completion of the establishment of Counselling Centres throughout Greece are still pending (i.e., 16 centres have been established, so far). Finally, during 1998-2000, 4,000 secondary school teachers were trained on health promotion programmes.

Prevention programmes are developed and implemented in tertiary education as well. According to relevant findings in 2000, primary prevention in university education consists mainly of brief interventions, lasting two to six months. The main aim of these interventions is to inform and heighten awareness of the students on prevention issues related to substance use. Within this framework, OKANA in collaboration with other European organisations (i.e., the TACADE, ABS and IFT-Nord) has had an active participation since 1999 in the implementation of the programme “Away from Home-Drug Prevention Among University Students”, by carrying out a pilot project on the assessment of needs among the student population in the University of Piraeus (see also Chapter 10.3 Research).

The selection of school programmes as the main type of intervention by the prevention centres is based on various factors. The most important ones, as stated by professionals in the field of prevention, are as follows; • Pre-adolescence and adolescence is a crucial age for making personal choices and shaping attitudes and behaviours • Research findings in Greece yield an increase in substance use in the student population, a decrease in the age onset of substance use, and the belief that regular use of cannabis is either slightly harmful or harmless • School constitutes a fundamental institution in the Greek society and a main agent of socialization of young people • Teachers are considered both models of behaviour and “significant others”, who affect the students’ self-esteem and self-concept • The teachers’ need for valid and reliable information on substance use and reinforcement of their role as educators, • The existence of further social and cultural factors (i.e., refugees from the ex- USSR countries, immigrants, unemployment, increased availability of substances) is reflected and influences the school community.

The coexistence of all the factors mentioned above in the school community creates a necessity for a long-term, multidimensional and comprehensive intervention in the school setting with the active participation of students, teachers and parents. In this context, the objectives of the school programmes in primary and secondary education are closely related with the particular socio- psychological needs of students at this age, the difficulties encountered in contemporary schools, and the broader social and cultural demands.

According to data collected in 2000, school programmes aim more at strengthening the personality and the interpersonal relationships of the students rather than informing them on the issue of substance use per se (Table 22). This is indicative of the shift that has occurred in the last few years in the philosophy of prevention, according to which prevention of substance use is mainly achieved by reinforcing and promoting responsible attitudes and behaviours concerning the physical and mental health of the individual.

94 Table 22 also illustrates that emphasis is placed on approaching the teachers, particularly by reinforcing their role and improving their pedagogical relationship with the students. The implementation of prevention programmes by the teachers themselves, the adoption of new pedagogical methods (e.g. active learning, experiential methods, emotional experience) and the development of collaboration among the members of the school community (teachers, students, parents) add to a positive atmosphere in the school setting and have a protective function against dependent substance use.

Table 22: Main objectives of prevention programmes

Objectives of school programmes Ν=84 %* Students Social skills development** 26 30.9 Personal skills development*** 25 29.8 Information/raising awareness of substance use and dependence 14 16.6 Resistance to peer pressure 11 13.1 Creation of nuclei of prevention in the school setting 4 4.8 Teachers Reinforcement of their pedagogical role and relationships with students 34 40.5 Training and/or involvement in prevention programmes 21 25.0 Adoption of alternative methods of teaching 10 11.9 Development of collaboration between teachers and parents 6 7.1 Handling of “difficult cases” of students 4 4.8

* Added percentages exceed 100% because of multiple answers ** Social skills mainly refer to the following: collaboration, teamwork, communication, expression of emotions, opinions and needs, active listening and active participation *** Personal skills mainly refer to the following: self-knowledge, self-esteem, self-confidence, determination, autonomy, stress and emotion’s management, decision making

SOURCE: Prevention Centres’ Network of the Greek Focal Point

For the majority of school programmes (41.2%) the above objectives are achieved by integrating different theoretical models. More particularly, in order to deal with the multi-factorial phenomenon of substance use more effectively, most school programmes implement the integration of the psychosocial, the cognitive and the affective model. In addition, 23.5% of the school programmes employ the psychosocial model alone, while 17.6% and 14.7% adopt the cognitive model and the affective model, respectively. Other theoretical models used in the implementation of prevention school programmes are systems theory (20.6%), the client-centred (8.8%) and the behaviouristic model (8.8%).

95 Out of the thirty four prevention school programmes with duration of more than a year, almost half (47.2%) of them indicate that they have been evaluated, 41.6% that evaluation is ongoing, and 11.1% that evaluation is foreseen. In all school programmes, evaluation is conducted takes place by the personnel, who are implementing the prevention programmes (Figure 25).

Figure 25: Evaluation status of school programmes in 2000

SOURCE: Prevention Centre's Network of the Greek Focal Point, 2001.

The above data show that evaluation has acquired great significance in the prevention field, as 88.9% of the programmes - with duration of more than a year - are either being evaluated or have been evaluated, while in 1998 the respective percentage was 64.2%. This is also confirmed by the findings gathered from school programmes with duration of less than a year. In the year 2000, all programmes (100%) reported that evaluation is foreseen; in 1998 the respective percentage was 76.4%. the following tools and methods were used for the evaluation of school programmes: • Questionnaires distributed to the participants prior to and/or after the implementation of the programme (85.3%) • Diaries, accounts, and internal reports from the personnel of the prevention centres (41.2%) • Estimations from participatory observations of the programmes (made by the personnel) (35.3%) • Personal reports from the programmes’ participants (29.4%) • Focus groups (14.7%)

96 • Record-keeping (11.7%) • Individual interviews with the programmes’ participants (5.8%)

Below, an indicative reference is made to school programmes that presented quantitative evaluation results that are in accordance with their specific objectives.

Health promotion programme for prevention of psychotropic substance use in high school students (Counselling Centre of the Prefecture of Ioannina)

This particular programme, which has been run since March 1999, is aimed at the following: a) developing the personal and social skills of the students, b) acquiring resistance strategies to peer pressure, and c) demystifying substance use. A self-drawn up questionnaire was distributed to 500 students participating in the programme, for their evaluation. The evaluation results are as follows (Table 23).

Table 23: Outcome evaluation of the school programme of the Counselling Centre in Ioannina based on the students’ replies

Evaluation results based on the students’ replies % More effective communication 96.4% Better expression of emotions 94.2% Better management of difficult circumstances 94.2% Coping better with stress 93.4% Acquiring self-knowledge 93.4% Shaping a personal attitude towards substance use 93.4% Acquisition of knowledge on dependent substances 92.7% Dealing with peer pressure 89.1%

SOURCE: Counselling Centre of the Prefecture of Ioannina

Prevention of dependent substance use, promotion of interpersonal relationships and Management of school anxiety (Movement “PROTASI”)

In 1998, the Movement “PROTASI” in collaboration with the Health Promotion Department of Secondary Education, the Prevention Centre of Dependent Substances and the Counselling Centre of the Prefecture of Achaia initiated the implementation of a specific programme, which was intended for junior high- school students. The evaluation of the programme was based on a self-drawn up questionnaire that was distributed to 193 participants (i.e., students) at the

97 end of the second year of the programme’s implementation. The evaluation results deriving from the students’ replies, were the following (Table 24):

Table 24: Outcome evaluation of the school programme of “PROTASI” based on the students’ replies

Evaluation results based on the students’ replies % Greater freedom of expression in the classroom 82.2% Better acquaintance with the teachers 79.3% Better acquaintance with the fellow-students 77.2% Greater efficiency/productivity of the lesson 77.0% Understanding and reduction of stress 70.2% Better management of difficult situations at school 65.1% Acquiring self-knowledge 61.4%

SOURCE: Movement “PROTASI”

Moreover, in terms of the programme’s evaluation process, 75.2% of the students considered that the programme had improved in the second year of its implementation due to a more productive communication and acquaintance between the students and the teachers. In addition, 83.6% reported that experiential teaching contributed to the collaboration and communication among the students.

Prevention programme of dependent substance use “Standing on my own feet” (Municipal Prevention Centre of Corfu “NIKOS MOROS”)

One of the main objectives of this particular programme, which has been run since September 1999, was the adoption of a specific attitude by the teachers in order to attract the students’ attention, motivate them to actively participate in the learning process and promote the communication between teachers and students. Overall, seventeen junior high-school teachers were trained and implemented the programme in seven schools (total number of students: 300).

The evaluation of the programme was based on diaries, supervision material, and questionnaires distributed to both the teachers implementing the programme and the students-participants, prior to and after the implementation of the programme. The evaluation results, as these have derived from the students’ replies in the questionnaires, are illustrated in Table 25.

98 Table 25: Changes reported by the participants in the school programme of the Municipal Centre of Prevention “NIKOS MOROS”

Students’ replies Before After % % Active participation in the lesson 65.8 74.1 Need to change the way the lesson is conducted 47.6 21.2 Need to change their relationship with the teacher 9.8 7.8

SOURCE: Municipal Prevention Centre of Corfu “NIKOS MOROS”

According to qualitative results of the programme, the implementation of new pedagogical techniques (i.e., methods of active learning) by only a few teachers gives rise to problems among the teachers, while in the meantime, it conveys contradictory messages to the students. This is why the implementation of alternative educational methods should be an integral part of the main pedagogical practice in the school setting. The above is reinforced by relevant evaluation results, which suggest that the use of methods of active learning facilitates the collaboration among the students, their communication with the teachers and it enhances their productivity at a cognitive level.

In conclusion, indicative findings of the internal evaluation of the selected programmes presented above as well as the overall evaluation of the school prevention programmes show that the majority of the programmes have achieved their objectives to a considerable degree. The depiction, however, of these positive findings in the epidemiological indicators – particularly the one concerning the prevalence reduction of substance use by youngsters – requires a lot of time, since the elaboration and assimilation of prevention messages and behavioural change constitute a long-term process, presupposing continuous and systematic efforts. Furthermore, it is imperative to promote external evaluation from qualified scientific institutions in order to ensure greater validity and reliability of the evaluation results of the prevention programme.

9.1.3 Youth programmes outside schools

In 2000, nine new youth prevention programmes outside schools were developed including interventions in camps, orphanages, cultural associations and athletic clubs, parish centres, and reception settings of repatriates and refugees. The specific objectives were as follows: a) development of personal and social skills, b) increase in peer pressure resistance and self-esteem, c) development of alternative recreational activities, d) reinforcement of group- work and collaboration among young people, and e) heightening awareness of social problems and prevention of dependent substances use. The main approaches used were the group-centred model, active and experiential learning and peer education.

In July and August 2001, the Prevention Centre for Combating Drugs of the Prefecture of Kavala, in collaboration with the Municipal Service of Children’s Libraries, organised a four-day training programme on personal development

99 for children aged 8-11 who frequent libraries. The topics were adjusted to the specific needs and potential of the children and it focused mainly on boosting up their self-esteem, developing collaboration and accepting the uniqueness of each individual.

In the same context, the Prevention Centre of Drug Dependence and Health Promotion “PYXIDA” continued for the third consecutive year the implementation of the prevention programme entitled “Imagination, knowledge and the will for life as a compass”. The programme is intended for young people aged 15-29, and it is based on life-skills, the cognitive and the social learning models, while the methods applied include experiential approaches and peer education. More particularly, qualitative results indicated that the presence of trained youth in various settings, such as the cultural, social, and athletic ones, renders them agents of prevention in the local community. This is important given the fact that some risk factors (i.e., unemployment and immigrants) seem to have increased in the boroughs, for which the Prevention Centre is responsible.

Youth interventions outside schools include international collaborations. More particularly, in 2001, the Prevention Centre of the Municipality of Heraklion “KESAN” in cooperation with the District of Crete, participated in the European prevention programme “Youth for Europe” within the framework of the “Youth- Exchange Action”. The general aim was to prevent substance use among young people aged 15-26, through the exchange - between Greece (Crete) and Italy (Florence) - of groups of youngsters participating in prevention programmes. The first phase of the programme was completed with the arrival of the Italian group on Crete. In return, the Greek group visited the respective Prevention Centre in Florence.

In the same context, in 2000-2001 the Greek Focal Point and OKANA became both involved in a European collaboration, entitled “Principles and strategies development for prompt intervention in the field of secondary prevention of substance use” (www.drug-prevention.de) with the general aim to create a network that will provide aid on drug-related issues to youngsters outside school.

More particularly, the Greek Focal Point approached a target group consisting of 200 adolescents and young people aged up to 25, from the electronic music and dance scene. The purpose of the project was to develop secondary prevention interventions against illicit substances (e.g. synthetic drugs) in the dance and electronic music scene. The project focused mainly on approaching the target population and describing its profile. The distribution of information- material on the safe use of synthetic drugs and cocaine was appraised by the target-group that considered it to be quite useful. However, a further need arose for a more sufficient description of the risks associated with other illicit substances use as well as for developing new approaching strategies for the target group.

OKANA approached the target group of young people aged 17-29, who spend most of their time in the streets (i.e., “street kids”). The main aim was to identify

100 their psychosocial needs, to assess the availability of psychosocial services and to prevent them from “falling through the cracks” of the system. Data analysis demonstrated that “street kids” are not aware of the availability of psychosocial services. The methods used included semi-structured interviews with 61 “street kids”. Further research remains to be conducted to assess outreach methods, examine the possible reasons why the target group has access to so few services and develop a stronger network among the relevant agencies.

In 2000, the “Educational Centre for the Promotion of Health and the Prevention of Drug Abuse” (UMHRI/OKANA) provided specific training in youth interventions outside school.

9.1.4 Community Programmes

In 2000, community programmes seem to have expanded; in addition, there has been a significant effort by the Prevention Centres to develop networks of volunteers (e.g. mental health professionals, parents, teachers, students, the Church) in the local community.

The Prevention Centres inaugurated by OKANA and co-financed by Local Authorities implement community programmes depending on local needs. Hence, community programmes take place both in cities and in rural areas. as the prevention centres try to approach and cover as many areas as possible of the Prefecture or the Municipality in which they are established.

According to Table 26, the majority of the community programmes aim to provide information and heighten awareness of the local community on issues concerning dependent substances and their prevention. Emphasis is also laid on the creation of nuclei of prevention in the community, with the participation of different agents and groups in preventive interventions, organised either by them or by the prevention centres themselves. The provision of psychosocial help (i.e., counselling, vocational guidance, training) to high-risk groups is the aim of 20% of the community programmes.

Table 26: Main aims of community programmes

Aims of Community Programmes N=20 %* Heighten awareness of prevention and health issues 13 65.0 Information on substance use and prevention 12 60.0 Development of volunteers’ network /nuclei of prevention and involvement in preventive actions 11 55.0 Inspiration of reliance and collaboration in the community 5 23.0 Provision of psychosocial help to high risk groups 4 20.0 Training in the organisation of preventive actions 3 15.0 Networking of local services 2 10.0

* Added percentages exceeds 100% because of multiple answers

SOURCE: Prevention Centres’ Network of the Greek Focal Point

101 The main theoretical models used by the community prevention programmes are systems theory, the community health model, the model of community development, and the social learning theory.

Of the total number of the community programmes with duration of more than a year, the majority (88.9%) report that the evaluation is ongoing, while 11.1% report that the programmes have been evaluated. In terms of the respective programmes with duration of less than a year, 90.9% of them report that evaluation is foreseen.

The main evaluation indicators for the community programmes are as follows:

• Percentage of participation of the target-population in meetings, lectures, events and prevention groups; • Response rate of the social agents for the development of prevention actions and the their frequency; • Response rate of individuals and number of requests for voluntary work; • Number of requests for organisation of events; • Degree of acceptance of the programme by the participants; • Degree of comprehension of the causes of drug use and the philosophy of prevention; • Degree of adoption of new attitudes and degree of behavioural change of the target groups;

The above derive from the keeping of records, the distribution of questionnaires to the participants and observations made by the participants and the personnel of the prevention centres.

Of the prevention agents that evaluated the programmes, indicative reference is made to the Prevention Centre of the Prefecture of Ileia “PAREMVASEIS”. Apart from the number of participants and organised preventive actions, the above Centre also presented quantitative findings on the participants’ degree of comprehension of the philosophy of prevention. The evaluation of the programme, which started in September 1998 as a training and motivation programme for volunteers on the principles and actions of prevention, was realised with the distribution of a self-drawn up questionnaire prior to and after the implementation of the programme. Outcome evaluation showed the following:

• 98% of those who participated in the training workshops completed the programme, while 80% of the participants who were not members of the existing volunteer group entitled “Centre of Social Intervention” joined it after the completion of the programme. • Prior to the implementation of the programme, 50% of the participants indicated that prevention is related with information. Upon completion of the programme, 85% indicated that prevention is related with the cultivation of healthy attitudes and responsible choices.

102 • 70% of the participants indicated at the end of the programme that the role of volunteers is to inform the community on the Prevention Centre’s actions, to take part in and/or to organize them, as well as to promote them according to their social and professional status. • Upon completion of the programme at the end of 2000 the trained volunteers organised twelve prevention actions, for five of which they collaborated with the Prevention Centre.

In the year 2001, the Prevention Centre of the Prefecture of Karditsa continued for the fourth year in a row the implementation of an innovative local community intervention by organising a “Local Prevention Week”. The main aims of the intervention were: a) to inform and heighten the awareness of the wider public of prevention issues and of the prevention programmes organised by the Centre, and b) to develop a wide network of collaboration among the Prevention Centre and the local agents and services. At the same time, a “Local Prevention Week” was also held in the Municipality of Palama (Karditsa), organised by the Palama Municipal Board of Prevention in collaboration with the Prevention Centre of Karditsa. The Palama Municipal Board of Prevention was established after the implementation of the prevention programme “Training of network members in the community” which was organised by the Prevention Centre of Karditsa. The 35-hour training of a group of 15 citizens of the Municipality of Palama concerned the prevention of substance use.

In the last two years, the Holly Archdiocese inaugurated the Foundation of Psychosocial Promotion and Support “DIAKONIA”. This foundation aims to deal with the issue of substance use and AIDS. Approximately forty new priests have been trained and allocated across the thirteen districts of the archdiocese. In addition, the Foundation “DIAKONIA” cooperates with OKANA, KETHEA and local authorities with the aim of promoting primary prevention interventions. The ultimate goal is to develop a comprehensive programme including Primary Prevention, a Counselling Centre, and a Therapeutic Community. In the meantime, a network of volunteers with special knowledge and experience on issues of dependent substances is being developed to support the priests’ mission.

In the year 2000, specific training in community programmes was provided by KETHEA (see also Chapter 10.4 Training for Professionals).

9.1.5 Telephone help-lines

Since 2000, four telephone help-lines have been operating in Greece, three of which are specialized in drug related issues (Table 27). All of them are being funded by the state and/or by local authorities.

103 Table 27: Telephone Help Lines

Telephone Help Lines Contact Number Open Line (Drug Dependence Unit ”18 ANO”) 01-3617089 “SOS Line” (Help Centre-OKANA) 1031 Telephone Help Line of Psychological Support 031-636373 (“ITHAKI” - KETHEA) Solidarity Line 1037 (Ministry of Macedonia & 1037 Thrace)

SOURCE: Therapeutic Programmes’ Network of the Greek Focal Point

The “Open Line” of the Drug Dependence Unit “18 ANO” constitutes the first specialized help-line that has national coverage. It was founded in 1992 and it is an active member of FESAT, which provides systematic training to the personnel of the “Open Line”. According to the findings in the year 2000, there was a stable increase in telephone calls, with a total of 3.500 calls. As far as the callers were concerned: 45% of them were mothers, 10% were fathers, 11.7% relatives, 4.3% spouses, 3.4% friends, 1.8% drug users, and 22.8% professionals. The relevant percentages in relation to the type of requests were the following: 29.2% asked for help, 27% asked for information and made inquires, 14.2% asked for referrals, 1.8% collaboration, while the request of 27.8% of the phone calls was unknown or of some other type.

The “SOS Line” of OKANA, which has been fully operational since September 2000, reported that by the end of the same year the total number of phone calls was 295. 85.4% of the phone calls were made by individuals who were calling for the first time, while 14.6% concerned callers who had also called in the past. Persons contacting the specific help line in 2000 were as follows: 51.9% were parents, 20% relatives, 12.9% drug users and 15.3% others (e.g. professionals).

In November 2000, the Help-Line of Psychological Support of the Therapeutic Programme “ITHAKI” of KETHEA started to operate by providing information on drug-related issues and on drug services throughout Greece as well as support to drug users’ relatives and friends. Evaluation results are not available yet. The ADFAM national help line of England trained the personnel of the “ITHAKI” help-line and it has also undertaken its supervision. It should be noted that the telephone help line of the “ITHAKI” therapeutic programme has regional coverage.

Finally, the telephone help-line of the Prefecture of Aetolocarnania presented in last year’s Annual Report, has ceased to operating as an independent help-line, while information on the “Solidarity Line 1037” is consistent with the one reported in 2000 (see 2000 Annual Report).

104 9.1.6 Mass media campaigns

The issue of drugs was a major mass media topic in 2000-2001. TV spots, radios broadcasts and press articles approached the various dimensions of the drug phenomenon in Greece. In addition, radio stations seem to have become particularly sensitive to the social reintegration of treated drug users.

In the beginning of July 2001, OKANA initiated the process for the creation of a social mass media campaign on prevention with the contribution of the Companies’ Association of Advertisement and Communication (EEDE) in order to carry out the implementation of illicit substances experimentation and use. The target-population of the campaign consists of youngsters (age-group: 12-18). The specific objectives of the intervention are; a) to change the belief that cannabis use is harmless, and b) to alter the perception among youngsters of the recreational use of substances. One advertisement company out of five was selected to run this prevention campaign, and offered to provide its services free-of-charge. The offer includes development of messages, TV spots, radio messages, as well as press and magazine-clips. The presentation of the campaign is expected to begin before the end of 2001.

Within the co-operational framework between demand reduction agencies and the mass media, the Municipal Radio Station of Larisa in collaboration with the Therapeutic Programme “EXODOS” (KETHEA) have scheduled to start broadcasting a radio programme with the title “Clear on FM ”. This particular programme will be run by the Social Rehabilitation Centre “EXODOS”, broadcasting every Saturday, for one hour.

“ATHINA 9.84” - broadcasting on satellite level - constitutes another radio station that is also involved in interventions against substance use. More particularly, “ATHINA 9.84” (www.984Fm.gr) is taking part in the subsidized vocational programmes of the “Employment Organisation of Labour Force” (OAED), thus facilitating the social reintegration of former drug users who have completed therapy.

Training on drug prevention issues is not systematically provided to journalists. However, in the year 2000, two Prevention Centres-the “Prevention Centre of Dependent Drug Use “ORPHEAS” of the Prefecture of Rodopi and the Prevention Centre for Combating Dependence “STATHMOS” of the Municipalities of Kallithea-Moshato-Tayros (Athens) implemented a new prevention programme each, intended for journalists. The two main objectives were: a) to inform and increase awareness of drug-related issues as well as of the main principles of prevention in terms of the journalists’ role, and b) to establish collaboration with the Prevention Centres. Evaluation of mass media campaign interventions has not yet been developed.

9.1.7 Internet

During 2000-2001, the use of the Internet as a means of informing the public on drug issues and promoting drug prevention gradually expanded. The majority of

105 the websites are about both licit (i.e., alcohol, tobacco) and illicit substances, while their target groups mainly include the wider public, families of drug users, and professionals in the drug field. A presentation of the main existing Greek websites is made below: a) www.fora.gr/gr/info/drugs It provides the public with information concerning the following: 1) non- governmental and governmental services on alcohol and drugs, 2) a pilot programme of self-help promotion for coping with drugs and alcohol addiction, 3) first-aid, 4) law enforcement on drugs, 5) the role of a parent as a preventive agent against drugs and alcohol, 6) strategies on how parents can detect substance use by their child, 7) specific drug and alcohol related information on effects, consequences, chronic use, dependence, and harm reduction techniques. b) www.mednet.gr/agogi/narkotik.htm www.mednet.gr/agogi/alkool.htm www.mednet.gr/agogi/kapnisma.htm The Institute of Social and Preventive Medicine releases health promotion information in this website. The first web address offers brief contact information (i.e., addresses and phone numbers) on governmental and non-governmental treatment services for licit and illicit substances. The second and third web addresses provide information on alcohol (e.g. health risks, safe use) and tobacco use (e.g. guidelines for quitting smoking), respectively. c) www.ydt.gr/drug.htm The Greek Police Force has created the aforementioned website, which provides information on public safety concerning drugs, among other issues. The website informs the public on the following:

• drug seizures from 1993 onwards (i.e., cannabis, opiates, amphetamines, cocaine, LSD, MDMA, barbiturates), • drug related deaths from 1988 onwards (i.e., age, sex, nationality, family status, education, occupation, types of substances), and • provides advice on drug use prevention (i.e., information and awareness of substance use, existing training seminars for parents, and techniques of detecting drug use by their child and strategies for coping with substance use). d) www.cosmos.gr/egoke This is site of the “Parents’ and Guardians’ Association”, a social agent that claims to investigate social problems, focusing mostly on drugs and alcohol. The website presents opinions and views on drug issues rather than information.

The use of the Internet is progressively expanding in the therapeutic field. Apart from KETHEA’s website (www.kethea.gr), which offers detailed information on its different programmes that are implemented nationwide, OKANA also has

106 developed a website (www.okana.gr) providing information on its objectives, national and international collaborations, as well as on its prevention activities in the primary, secondary and tertiary level. In addition, in 2000 the Department for Adolescents and Young Adults of the Drug Dependence Unit “18 ANO” also created its website (www.hellasnet.gr/tendetox), in which it offers a brief description of the structural and functional characteristics of its services.

In the year 2001, the Greek Focal Point acquired its own web address (www.ektepn.gr) as well. Also, the Focal Point developed a pivotal electronic database in the demand reduction field (see Annex I), which will be in operation by the middle of November 2001.

9.2 Reduction of drug-related harm

9.2.1 Outreach work

Even greater emphasis was placed on outreach work during 2000-2001 compared to 1999. This is manifested by the expansion of outreach initiatives not only of the ones taken by the existing services but also of the initiatives taken by new ones (i.e., Outreach Station of the Therapeutic Programme “NOSTOS”, streetwork programmes by the “Medecins du Monde-Greek Delegation” and by the Prevention Centres “Athina Health”).

The streetwork programmes of KETHEA and OKANA are held in drug scenes in the area of Athens. In 2000, the Streetwork Programme of the Multiple Intervention Centre employing the “catching client” and the public health models, carried out 176 missions and came into contact with 1,407 users. Moreover, in May 2000, the Multiple Intervention Centre organised a five-day seminar entitled “Development of a training instrument for European street workers” in Athens, for street workers from France, Italy, Spain and Greece within the framework of the European Union project LEONARDO,. The programme was completed at the end of 2000 with the creation of a web page (www.streetworker.fr), offering information and know-how to professionals, who are in charge of planning and implementing street work programmes.

Based on a harm reduction approach for drug users not undergoing treatment, the Streetwork Programme of the OKANA Help Centre, came into contact with 1,324 drug users in 2000. The Help Centre also provides ambulance services in emergency cases with its Mobile Unit of Pre-hospital Medicine (see also Chapter 9.2.2 Low-threshold services).

A streetwork programme, entitled “Streets of Athens”, is also offered by the non-governmental organisation “Medecins du Monde-Greek Delegation” (see framed text).

107

MEDECINS DU MONDE-Greek Delegation

Medecins Du Monde is an independent, non-governmental, international, humanitarian organisation, which was founded in France in 1980. It has expanded in various countries, including Greece, where it was established in March 1990. The Greek Delegation of the Medecins du Monde (www.mdmgreece.gr) consists of a network of services that include the Open Clinic, the Reception Centre of Refugees “PENTELI”, the programme “SOS ROM” for gypsies, the Mobile Medical Unit, and the Shelter Home “NAYSIKA” for the homeless and asylum seekers. It is also involved in various missions abroad, which are carried out by volunteers.

The specific services intended for drug users in Greece are presented below:

Streetwork programme “Streets of Athens”: it has been operating since spring 1998, with a mobile medical unit that is stationed at the centre of Athens (i.e., Omonoia), three times a week from 21:30pm to 00:30am. It mainly provides: a) primary medical care, b) psychological support, c) blood tests for HIV and Hepatitis (in collaboration with the laboratory of the hospital “Andreas Syggros”), d) information on health issues by a G.P. and a psychiatrist, e) social support and counselling, and f) syringe exchange.

From June 2000 to August 2001, the mobile medical unit handled 2.660 cases: 71.2% concerned needle exchange, 24.9% medical issues (e.g., abscesses, overdose symptoms, other dermatological diseases, such as scabies, dermatitis etc) 1.3% psychological support and 1.7% information. So far, blood tests show that 72% of the tested users are infected with Hepatitis C, 0.5% with hepatitis B, and 0.025% with HIV.

Demographic data for the same period of time showed that: • 80% of the new contacts were males. • The mean age was 27, ranging from 14 to 62 years old. • 17% reported that they had a steady job • 95.5% used heroin as main substance.

Open Clinic of Athens: it has operated in the centre of Athens since 1996 and it is intended for drug users, the homeless, immigrants, refugees, gypsies and children running away from home. The Open Clinic consists of three fully equipped surgeries, two dental clinics and other operational settings, which are staffed on a daily basis with more than 50 volunteers. The provided services are as follows: a) medical care, b) psychological support, c) social welfare, and d) epidemiological research.

A streetwork programme is also run within the framework of the Prevention Centre “Athina Health”. This programme was inaugurated in the Municipality of Athens by OKANA. More particularly, a group of staff members of the Prevention Centre take streetwork initiatives at the centre of Athens twice a week, which mainly involve the distribution of leaflets on drug-related issues to drug users.

108 Apart from the streetwork programmes mentioned above, outreach interventions are continued by the KETHEA Mobile Unit of Information “Pegassus” on invitation by local authorities and other local agents. In 2000, “Pegassus” approached 1,435 individuals in total (see Annex II, Table III) by carrying out 15 missions in 14 cities across Greece. The main aim of the interventions was to promote primary prevention by means of motivating the community and to provide secondary prevention interventions to drug users and to their families. The principal strategies of these missions were the community approach, the youth work approach and the model of public health.

Even though the evaluation of streetwork programmes encounters many difficulties due to the nature of the particular work, it has been observed that a significant number of drug users seeking treatment result from the interventions mentioned above.

Along these lines, in 2000 the Therapeutic Programme “NOSTOS” (KETHEA) established an innovative Outreach Station in Piraeus. The Station is located at a central square of Piraeus and it is housed in an old converted railway wagon. This initiative aims to offer crisis intervention to psychotropic substance users. In addition, it is expected to organise prevention actions, mainly intended for high-risk populations.

The main difficulties encountered by outreach programmes and streetwork interventions in particular are the lack of personnel and technical infrastructure as well as the approach of drug users who have not contacted any treatment programmes. A suggested solution to the latter problem is for the personnel of outreach services to attend special seminars on exploring and discovering more efficient ways of approaching drug users of this group. Qualitative findings deriving from semi-structured, individual interviews with personnel from streetwork programmes reveal further difficulties that these people encounter, such as the following: • The lack of a statutory framework for the implementation of streetwork programmes leads to bringing streetwork professionals to the local police departments for identity check. • The reactions of local citizens and shopkeepers to outreach professionals, who are believed to maintain the open drug scene. • The different approach that outreach professionals adopt in contrast to the one adopted by the policemen; the police have a repressive role while streetwork programmes aim at harm reduction from substance use.

9.2.2 Low threshold services

OKANA and KETHEA, which are both non-governmental organisations, remain the two low-threshold services offering programmes to drug users who do not wish to undergo treatment while suffering from serious health and social problems. Harm reduction at health, psychological and social level is still the primary objective of the OKANA Help Centre. The specific services and total number of clients served in 2000 are presented in detail in the framed text below.

109

SERVICES AND PROGRAMMES OF THE HELP CENTRE (OKANA)

The Help Centre was established by OKANA in 1997. In order to achieve its main objective concerning harm reduction on issues of physical and psychosocial health of drug users, a well-organized network of services was developed.

The specific programmes of the Help Centre and the number of the clients served in the year 2000 are presented below:

• General Health Clinic: In the year 2000, there were a total of 2,165 contacts, which corresponded to 1,462 clients. 71.1% of the clients were old cases (i.e., approaching the Centre for the second or third time) and 28.9% were new cases. The most common complaints involved injection complications (e.g. abscess, inflammation), respiratory infection, acute hepatitis, mild heart problems, overdose and withdrawal symptoms. • Microbiological laboratory: It has been run since June 2000 and the following tests are carried out: a) blood tests, b) biochemical tests, c) urine tests, d) virus check (e.g., HBs Ag, Anti-HBs, Anti-HCV, HIV I & II etc), e) pregnancy tests. By the end of the year 2000, the total number of patients amounted to 334, while 6,770 tests had been carried out. • D e n t a l c l i n i c : 441 patients were served (69.6% were old cases and 30.4% new ones). The total number of contacts was 1,719. • N u r s e s e r v i c e : This service is in collaboration with all the other services of the Help Centre. In addition, it is in charge of: a) taking down the medical history/data of the Centre’s clients, and b) implementing the streetwork programme. In this programme, the drug user may exchange a used syringe for a sterilized one. • S o c i a l c a r e s e r v i c e : Through individual meetings, this particular service provides psychological support, treatment motivation, information on the Help Centre’s services as well as information on health care and treatment services offered by other agencies. In addition, it organises seminars on safe use, prevention of infectious diseases and general health issues. In 2000, the total number of drug users, who attended the individual meetings was 244, while 96 users joined the seminars. • L e g a l s e r v i c e : It offers legal advice and support to drug users in cooperation with the Lawyer’s Association of Athens. • Telephone help line: It started to operate in September 2000. An average of 250 individuals use it on a monthly basis. • Mobile Unit of Pre-hospital Medicine (KIM): It constitutes a pioneering unit since it is the only one operating in the European Union. Its main objectives are the instant handling of overdose cases and the offer of paramedics to transfer users who require immediate care to hospitals. During 2000, the Mobile Unit of Pre-hospital Medicine received through its wireless phone, 1,022 phone calls from users of psychotropic substances, mainly heroin and benzodiazepines. 17.6% of the phone calls involved users who had fallen into a coma due to overdose.

110 • “Streetwork” Programme: 106 missions were carried out and 1,324 drug users were contacted. 59.7% of the users were new cases whilst the rest (40.3%) were old ones.

It should be noted that the health and legal services of the Help Centre are not only available to those visiting the Centre on their own initiative but also to those attending the Substitution Programme of OKANA or other specialized Treatment Centres.

Comparative Findings 1998-2000

According to findings in 2000 that are compared to data from the previous two years, the number of new clients approaching the Help Centre has increased as well as the number of those approaching the Centre for the second and third time (Figure 26).

Figure 26: Number of new and old cases approaching OKANA's Help Centre during 1998-2000

SOURCE: Help Centre, 2001.

There was a decrease however, in the programme of syringe-exchange; in 2000, 25,821 syringe-exchanges took place, while in 1999 and 1998 , 86,819 and 46,660, respectively. A slight drop was also noted in the number of phone calls received by the Mobile Unit of Pre-hospital Medicine. In particular, in 2000 there were 1,022 calls, while in 1999 and 1998 there were 1,401 and 1,055 calls respectively. This might be attributed to various reasons, such as the decrease in personnel of certain services and a personnel strike, which lasted for several months.

111 The Multiple Intervention Centre of KETHEA runs various programmes. In 2000, 332 drug users visited the Counselling Centre while the average daily participation in the drop-in centre “Off Club” amounted to 36 drug users (1,817 drug users in total). During the same year, the daily schedule of the “Off Club” activities was further enriched by actions aiming to promote the responsibility and creative expression of the drug users. In addition, the Multiple Intervention Centre of KETHEA organised two programmes for imprisoned population (see also Chapter 9.5 Interventions in the Criminal Justice System).

In 2000, specific training on harm reduction issues and infectious diseases was provided by the non-governmental organization, “Medecins sans Frontiers” in collaboration with the Multiple Intervention Centre of KETHEA (see Chapter 9.2.3 Prevention of infectious diseases).

Finally, OKANA plans to establish a Help Centre in the city of Thessaloniki in order to satisfy the increasing needs for low threshold services. In addition, a drop-in centre is going to be established at the existing Help Centre in Athens.

9.2.3 Prevention of infectious diseases

Prevention interventions concerning infectious diseases and promotion of harm reduction from drugs range from education on safe drug use and safe sex to syringes exchange, testing and treatment.

Therapeutic programmes and low-threshold services organise seminars concerning safe drug use, prevention of infectious diseases and hygiene issues on a regular basis. More particularly, in 2000, “Medecins sans Frontieres” in collaboration with the Multiple Intervention Centre, the Information Centre of the Day and Evening Programme “DIAVASSI”, and the Centre of Family Support of “DIAVASSI” provided specific training on heath issues. The main aim of the seminars was to promote the health conditions of the drug users and their immediate environment (i.e. family, friends). The target groups consisted of: a) drug users who do not wish to abstain from substance use but need information on health issues affecting their daily quality of life, b) former users as well as individuals admitted to residential or non-residential therapeutic communities, and c) family members (parents, spouses, siblings) of the drug users mentioned above.

The specific objectives of these seminars were as follows:

• To provide information provision on health issues and the consequences of substance use on health. • Motivation for physical and psychological detoxification. • Motivation to undergo medical lab tests. • To provide information to the (former) drug user’s immediate family and social environment on the consequences of drug use and/or abstinence on the relationship dynamics. • To provide information to the staff members concerning the effects of substance use and protective strategies against infectious diseases.

112 In addition, treatment and low threshold services provide clients with the opportunity to be tested for infectious diseases or have other medical tests, in collaboration with general regional hospitals and local health services (see also Annual Report 2000). Furthermore, the OKANA Help Centre also offers testing possibilities at its fully equipped health clinic and microbiological laboratory (see also Chapter 9.2.2 Low-threshold services).

In 2000, streetwork programmes on preventing infectious diseases remain a major priority. Moreover, treatment and psychological support to infected individuals are provided by the hospital “Andreas Syngros” in Athens and by general regional hospitals, while the Hellenic Centre for Infectious Diseases Control (KEEL) - which was established in 1992 - has developed a well- organised network of prevention, treatment and social services.

Evaluation concerning prevention of infectious diseases and care of infected individuals is still not available mainly due to the lack of specific indicators that would be included in the evaluation studies of the drug-specific treatment programme.

9.3 Treatment

9.3.1 Treatment and health care at National level

There are currently 26 therapeutic units in Greece run under the auspices of governmental and non-governmental organizations. These consist of 8 drug- free residential programmes, 11 drug-free non-residential programmes (8 for adults and 3 for young people), one-day care clinic, 5 substitution-detoxification units, and 1 substitution-maintenance unit. The total capacity of these programmes is approximately 1700 individuals. Moreover, there are two threshold programmes in the country, both of which are located in Athens (Annex II – Table I).

Information regarding staffing issues, funding sources and training on treatment programmes in the country remains the same with that provided in the 2000 Annual Report submitted to the EMCDDA.

A concise description of the main goals, the services provided, the therapeutic approaches, the evaluation status and the possible problems of the therapeutic programmes currently in operation in Greece is presented below (for more detailed information on comparative data regarding admissions, waiting lists and completion rates see Chapter 12.2 Evaluation of treatments).

Drug-free Residential Treatment

The main therapeutic goals of the 8 drug-free residential units that currently exist in Greece are the following: a. physical and psychological detoxification, b. development of personal skills and abilities for everyday life, c. improvement in

113 physical health, d. improvement in family relations, e. education, and f. expression and management of emotions.

Depending on the philosophy and the theoretical framework of each therapeutic programme, particular models have been adopted in order to achieve the aforementioned objectives. According to information provided by the programmes in 2000, the main theoretical models are the systems approach, the psychoanalytic, the model of therapeutic communities and the model of social learning. In addition, some programmes apply the behavioural model, the model of relapse prevention and the model of social skills.

The therapeutic process includes a wide range of counselling and/or therapy interventions. The main therapeutic approaches are individual counselling and support, individual psychotherapy, group and family therapy.

Along with the purely therapeutic services, the treatment units also provide additional services in order to satisfy the multiple needs of drug users more adequately. According to data supplied by the Treatment Unit Form (TUF) of the year 2000 from seven out of the eight residential treatment units, 51.7% provide vocational guidance, 42.9% accommodation, 42.9% psychiatric assistance and 14.3 % vocational training. In the same context, some therapeutic units provide services tailored to satisfy the needs of special groups of drug addicts, such as the Programme for Dependent Women and the Programme for Individuals with Dual Diagnosis of “18 ANO”, the Specialized Programme for Addicted Mothers of “ITHAKI”, and the programmes for adolescent drug users run by “18 ANO” and KETHEA.

In the year 2000, those participating in the residential treatment programmes did so either on their own initiative or via referrals made by a wide range of sources. In particular, 75% of those who were admitted to the treatment units did so on their own initiative, while other units of the same therapeutic programme (i.e., Counselling Centres) referred 28.6% of drug users. To a lesser extent, drug-users are also referred to by other sources, such as their family, hospitals and other medical units, courts or other drug dependence therapeutic units.

With regard to the evaluation results of the drug-free residential programmes, the Therapeutic Community “NOSTOS” reported that, in 2000, 58% of drug users completed the programme and entered the unit of social rehabilitation. In addition, significant improvement was reported in the employment status of drug users and changes occurred with regard to the patterns of personal time management through their involvement in creative activities. The Therapeutic Community “EXODOS” reported that 30% from those who were admitted to the programme, completed it successfully and were referred to the social rehabilitation phase.

Moreover, according to statistical data provided in 2000, the number of treated people at the Counselling Centre of the Drug and Alcohol Dependence Unit “18 ANO” rose by to 31.8% in 2000 in comparison to 1999 (6.060 and 4.598 individuals, respectively). An increase of 9.5% was also observed between

114 2000 and 1999 in relation to those addicts who sought therapy at the respective unit for the first time (1.205 and 1.100 addicts, respectively).

The main difficulties reported by the drug-free residential treatment programmes in 2000 include the lack of funding, human resources and facilities, as well as the difficulty to provide drug users who participate in programmes with respective certificates which they will be able to use in order to cover their needs for medical care.

Drug-free Non-residential Treatment

The main reason for the development of drug-free non-residential therapeutic units arises from the need to provide adequate treatment services to those drug users who wish to undergo treatment without, however, being separated from their family and social environment. This group of drug users consists of people who maintain a stable job or educational activity and have a relatively well- structured and supportive family and social context. Provision of therapy on a non-residential basis to these addicts is deemed to be a contributory factor to both the therapeutic result and their social rehabilitation given that their interaction with the broader social environment in which they belong and operate is not being interrupted.

The general therapeutic objectives of these programmes concern the physical and psychological recovery of participants, the change in their attitudes and their behaviour towards drug use and the acquisition of coping skills. The specific aims of these programmes are as follows:

• Abstinence from drug use and deviant behaviour • Development of self-knowledge and self-esteem, expression and management of emotions, formation of steady and realistic goals for the future and strengthening of incentives • Development of social, adaptation and problem solving skills • Improvement of physical health • Acquisition of education / training and improvement of vocational skills in order to achieve occupational and social inclusion / stability • Improvement of family, social and peer relations • Relapse prevention

The objectives of non-residential treatment programmes are achieved by means of the following therapeutic approaches: a. individual support/counselling, b. individual psychotherapy based on the cognitive/behavioural or the psychodynamic model, c. group therapy (i.e. confrontation, experiential, and drama therapy groups, as well as group therapy based on the systemic approach), and d. family therapy based on the systemic or the psychodynamic theory. In addition to the aforementioned theoretical models, some therapeutic units also employ the theory of social learning, the model of therapeutic communities and the model of social skills. Special attention is paid on the

115 provision of vocational guidance and counselling, the development of creative groups and the organization of sporting events. Two out of three adolescent treatment programmes provide drug users with grants for educational purposes.

With regard to the main referral sources, all therapeutic programmes intended for young drug users report that the main source of referral is family, while for the programmes intended for adults, only 11.1% of the participants were referred by their family. Instead, 66.7% of the adult drug users who participated in non-residential programmes in 2000 approached the therapeutic units on their own initiative, while 22% were referred by the counselling centres of treatment programmes which are anyway compulsory stages of the therapeutic process in the context of the multi-phase programmes.

There is no clear picture regarding the evaluation status of the non-residential programmes, given the fact that out of 12 programmes in total that are currently in operation, 4 have completed their evaluation, 4 have reported that the evaluation is under way and the rest are expected to be evaluated in the future. These differences demonstrate the existing lack of a single policy in the field of drug treatment, which results in a variable pace of the evaluation development of the therapeutic programmes in the country.

According to statistical results for the year 2000, the number of individuals admitted to the Therapeutic Unit for Adolescent and Young Adults of “18 ANO” also increased in 2000 (332 individuals) in comparison to 1999 (244 individuals). Also, results from the OKANA Therapeutic Programme “GEFIRA” in Patras (Central Greece) show that from June 1998 to August 2000, the programme has provided treatment services to 716 individuals. 213 participants were drug addicts, 291 were parents of drug users, 127 were siblings, 33 were spouses or sexual partners and 52 were other important people to the drug users (i.e., other relatives).

All in all, with regard to the basic needs of the non-residential programmes there is a great need for funding raising and for increase in staff, as well as for training provision. Spatial problems also cry out for their solution due to the increase in the demand for treatment in recent years.

9.3.2 Substitution and maintenance programmes

On the grounds of the emphasis placed by policy makers in 2000-2001 on the implementation of a concise treatment policy and on the consequent further promotion of substitution treatment, several developments occurred regarding substitution programmes in the country. Thus, along with the existing four substitution units in Athens and Thessaloniki (total capacity 650), a new unit was established in Piraeus in 2001 with a capacity of 200 individuals. Moreover, the first maintenance substitution unit was established in Athens in July 2000 (capacity: 200) in order to satisfy the needs of those drug users who have not achieved abstinence although they have participated in the substitution- detoxification programmes.

116 Along with these developments, several other functional changes took place at the substitution-detoxification programmes, as follows:

• Apart from methadone, the pilot prescription of bubrenorphine started in 2001 on the basis of positive evaluation results associated with the respective substitution drug in other countries abroad. • The staff-to-client ratio has started to change with the ultimate goal for one therapist to correspond to forty drug addicts. • Although the admission criteria for all substitution programmes have remained the same (i.e. being an IV heroin addict older than 22, having at least a two-year drug use and having unsuccessfully tried other treatment), the policy regarding premature discharge from the programme has started to become more lenient. This means that drug users who relapse for the second or third time are no longer discharged from the programme, as the case used to be until recently. • In accordance with the above point, despite the fact that detoxification from all drugs including methadone is still the ultimate goal of substitution programmes in the country, a shift to maintenance has emerged. Thus, new maintenance units are expected to be inaugurated in the near future, while drug users participating in the existing substitution programmes are not discharged in case abstinence is not achieved within a certain period of time.

The main impetus for the aforementioned changes appears to be the need to confront the major problem of the waiting lists for substitution treatment, which comprised a total of 2,474 drug addicts in 2000.

Along with the prescription of substitution drugs and antagonists (i.e. Naltrexone, Naloxone), emphasis has also been placed on the provision of psychosocial and medical services. Within the premises of substitution units, drug addicts receive individual and group psychotherapy / counselling, psychiatric help and vocational guidance, while further medical support and assistance is provided for their social reintegration by other agencies or programmes co-operating with the substitution units (i.e. OKANA’s Help Centre and Vocational Training Centre). In this context, a Social Rehabilitation Unit was established in Athens in 2000, for those who completed their treatment in the substitution programmes (see also Chapter 9.4: After-care and reintegration).

Evaluation results, arising mainly from EuropASI, OTI, and urine and blood tests, show that 60%-79% of the patients achieve the objective of harm reduction, whereas only 8.5% to 12% of them have achieved total abstinence from all drugs including methadone (OKANA, 2000). Similar results have been provided by the research study on the effectiveness of the 1st Methadone Substitution Unit in Thessaloniki, eighteen months after its operation. Although only 10% of the participants in the programme achieved abstinence from all drugs including methadone, the reduction of heroin use reached 85%, the reduction of criminality rose to 90%, whereas family and social relations as well as occupational status improved significantly (Gasgalidis, 2000). Further statistical data on admissions and completion rates of substitution programmes in 2000 are presented in Chapter 12.2: Evaluation of the treatments.

117 9.4 After-care and re-integration

9.4.1 Education and training

All of the thirteen specialised Social Rehabilitation Centres existing so far in the country put special emphasis on the training of former drug users, due to their serious educational and occupational problems (i.e. low educational status, unemployment, exclusion from the labour market, etc.). These problems – in addition to the negative social stereotypes of drug users – are considered to hamper ex-drug addicts’ social re-integration, to increase the possibility of relapses and to abate any prior therapeutic achievements. Within this framework, the provision of adequate education and training as a prerequisite for successful treatment and rehabilitation of drug users is perceived to be of the outmost importance.

Regarding drug users’ education, Social Rehabilitation Centres encourage ex- drug addicts to continue and complete their basic education, while many of them offer scholarships to those who wish to have further academic training. In this context, the KETHEA therapeutic programme “EXODOS” initiated a pilot School for Adults for its members in 2000, so that they may be able to participate in the exams of the secondary and tertiary education, and thus to fill their educational gaps. Fifteen students, aged 19-35 years old, attended the School in 2000, while 8 professionals work there on a permanent basis (KETHEA, 2001).

Adolescent drug users who have dropped out of school and have been admitted to the Therapeutic Programme “STROFI” also have the possibility to continue their education at the Transitional School of “STROFI”. Specialised teachers teach all the grades of secondary and tertiary education, while the school also provides computer classes, vocational counselling and training to adolescents, and counselling on academic issues to their parents. Special emphasis is put on handling learning difficulties, while transitional classes for drug users who have dropped out of school a long time ago have been run for the first time in 2000. Peer-education methods and the use of computers are regularly employed to enhance the teaching outcome. According to the evaluation results for the year 2000, 25 pupils successfully participated in the final exams and 4 graduates of the school succeeded in entering Higher Education Institutes. In total, the Transitional School provided its services to 37 adolescents during the academic year 1999-2000 (KETHEA, 2001).

As far as training is concerned, treatment agencies and policy-makers intensified their efforts in 2000-2001, to provide several vocational training programmes to drug users. These programmes are implemented within the following contexts:

• The Social Rehabilitation Centres of the treatment agencies, which have integrated vocational training into their activities. In 2000, these Centres offered training courses on computer literacy, graphics, photography, typography, carpentry and ceramics. Some of these courses were run within the framework of EU programmes.

118 • Specialised Vocational Training Centres, which are run by KETHEA and OKANA. More particularly, KETHEA has set up three such centres in the areas of Athens, Thessaly (Central Greece) and Macedonia (Northern Greece) since 1998. These centres are intended for drug users who participate in KETHEA’s treatment programmes and those who have completed them. OKANA’s Vocational Training Centre started to operate in Athens in April 2000. The centre, which offers various training courses (i.e. stained-glass window technique, computers, administration, floriculture- horticulture, silk-screen printing, bookbinding, sewing), is co-funded by the European Union and the Ministry of Labour. In 2000, ninety participants attended each training course and received a subsidy of 5 Euros per hour.

• Accompanying Supportive Services, which are interrelated with the vocational training programmes offered to drug users under treatment or to former drug users. These services, which are funded by the Ministry of Labour, aim at vocational guidance and training, counselling on employment issues, development of social skills, co-operation with employers and agencies, and follow-up of the trainees during their training and their inclusion in the labour market.

Apart from these efforts, a new Social Rehabilitation Unit was developed in September 2000 by OKANA for former drug users who complete methadone substitution treatment and for those who attend the methadone maintenance programme in Athens. This programme offers career guidance and vocational training as well as psychological therapy.

The Counselling Centre of the Drug Dependency Unit “18 ANO” (Athens) and the KETHEA Support Centre for prisoners and released prisoners (Thessaloniki) provides after-care services to released prisoners. The latter centre also runs vocational training programmes for imprisoned drug users (see 2000 Annual Report submitted to the EMCDDA, pp. 105). Since 2000, KETHEA has run an innovative pilot programme at the Women’s Prison of Koridallos in Athens, providing training courses to the imprisoned population there.

Regarding the evaluation of after-care and re-integration services, results are available only by the social rehabilitation centres of KETHEA. According to these results, in 2000, 338 former drug users participated in these centres. This number exceeded their capacity (147% full) for the fifth consecutive year. During their stay in the KETHEA social rehabilitation centres, 100% of the participants stayed abstinent from all illicit drugs and did not exhibit deviant behaviour, 95% found a full-time occupation or continued their education, and all of them ameliorated their family and social relations. 4/5 of all clients attending the social rehabilitation centres successfully completed the treatment.

9.4.2 Employment

In 2000, the Ministry of Labour in collaboration with the “Employment Organization of Labour Force” (OAED) continued to implement programmes in

119 order to assist the re-integration of socially excluded groups into the job market. The interventions were intended for former drug users who had completed therapy and released prisoners and they included 490 subsidized vacancies in the private sector (300 for ex-addicts and 190 for released prisoners) and 250 subsidies for new businesses (120 for ex-addicts and 130 for released prisoners).

According to statistical data from OAED, the number of participants in these programmes has been constantly increasing, with the largest number of participants recorded in 2000 (Figure 27).

Figure 27: Number of former drug users and released prisoners per year of participation in OAED programmes

SOURCE: Employment Organisation of Labour Force (OAED), 2001.

Based on these data and due to the imperative need for the provision of employment opportunities, the Ministry of Labour has decided to continue its initiative to promote the re-integration of socially excluded groups into the job market for the period 2001-2003. More particularly, this initiative includes the following interventions:

• It provides 300 subsidized full-time posts in the private sector (200 for ex- addicts having completed treatment or participating in the social rehabilitation centres or long-term substitution clients and 100 for released prisoners). The subsidy will amount to 22 Euros per working day for a period of 36 months, on the condition that the person remains employed for a year after the end of the subsidy.

120 • It provides 250 subsidies for new enterprises (100 for ex-addicts and 150 for released prisoners). The subsidy will be 15,554 Euros for 4 years. • In the context of the European Operational Programme “Combating Exclusion from the Labour Market”, it provides subsidised posts and subsidies for new businesses to 150 ex-addicts and 100 released prisoners who have participated in training interventions of the aforementioned Operational Programme.

Despite these efforts by policy-makers, the occupational needs of former drug users remain immense. In addition to that, it has been observed that private companies employ ex-addicts and released prisoners in order to cash in on the subsidies only to dismiss the person they hired as soon as the subsidy has ended. Due to these phenomena, efforts are made by treatment agencies to promote cooperation with various private services and agencies and to develop networks of employers.

In this context, the Work Club of the Therapeutic Programme “DIAVASSI” managed to find a job to almost 100% of the Club members, due to its constant efforts to ensure co-operation with agencies of the public and private sector (for more information about the Work Club, see Annual Report 2000, pp. 104).

9.4.3 Housing

Housing opportunities are provided to drug users either by the treatment agencies or by independent associations. Thus, the Social Rehabilitation Centres of KETHEA offer the possibility to those who have completed the therapeutic programme and have entered the re-integration phase to stay in hostels until they find a regular job and have their own house. Also, some treatment programmes, such as the Therapeutic Programme for Adolescents “STROFI” (Athens) and the Therapeutic Programme “GEFIRA” (Patras), have Guest Houses for drug users who have to travel from their place of residence in order to enroll in their treatment programmes.

The association “Philemon”, which is directed by the First Evangelical Church of Athens, offers structured housing to drug addicts for a period of 9 months. In parallel with housing, “Philemon” provides support and referrals to specialised treatment units, in accordance with Christian principles. Also, the Association for Helping Drug Dependent Individuals ”Metamorphosis”, in close co-operation with the Counselling Centres of treatment programmes in Athens, offers the possibility to stay in hotels for a two-month period to drug addicts who enrol for treatment until they are admitted to the therapeutic community.

However, with the exception of the aforementioned initiatives, the lack of housing services for drug addicts in Greece is so serious that it constitutes one of the major problems in the treatment field. Although professionals in the drug field acknowledge the potential problem of control with regard to drug trafficking and use within the premises of hostels, they also stress the need for the provision of further housing services to drug addicts, in order to promote harm

121 reduction and relapse prevention and to facilitate drug users’ social reintegration.

Specific training in aftercare and reintegration

Due to the increased interest in the social rehabilitation of former drug users, several activities took place in 2000 with the aim of training and sensitising professionals in the field. Some major examples of these activities are presented below:

• KETHEA contributed to the final report of the European network “Friends at Work” which aims at the exchange of information and know-how regarding the inclusion of ex-drug addicts in the labour market (KETHEA, 2001). • A 50-hour experiential workshop on motivational interview and relapse prevention was organised by KETHEA in co-operation with the Addiction Research Institute of Amsterdam. • The Psychiatric Hospital of Attica and the Municipality of Peristeri in Athens organised a meeting on “The Promotion of Mental Health and the Combat against Social Exclusion”, with special emphasis on the former drug users’ problems regarding their social reintegration.

9.5 Interventions in the Criminal Justice System

Police Prevention Activities

Police officers receive special training on prevention issues by the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse (UMHRI/OKANA) as well as by several local Prevention Centres. In 2001, the Educational Centre trained 23 police officers in a two-week training programme. The main aims were to heighten the awareness of the participants of the factors that lead to drug use and to sensitise them to their preventive role as well as to alternative ways of dealing with drug use/users (i.e. co-operation with Prevention Centres, referrals to therapeutic programmes).

Also, in 2000-2001 police officers in some regions (i.e. Thessaloniki) started to patrol outside schools in order to prevent drug trafficking at the school community.

Arrests and referrals to drug services

In 2000-2001, the role of police in drug prevention appears to be advanced. The Ministry of Public Order has launched a pilot programme that consists in the assignment of specialised psychologists to several police stations across the country. The tasks of the psychologists will be to provide counselling services to arrested drug users and to their families, to support police officers in their role and to keep records of the various cases. Preliminary evaluation results from the Security Police of Patras are considered to be positive, since 20 young drug

122 users asked for help from May to July 2001, most of whom were referred to therapeutic agencies. On the basis of the outcome of this pilot phase, the programme is to be expanded to all police stations in the country.

The Counselling Centre for adolescents at the Probation Services Office in Athens is currently the only specialised service that is intended for adolescents who commit offences related to drug use. The Centre operates under the auspices of the Therapeutic Programme “STROFI” (KETHEA) and it provides early interventions to juvenile drug users as well as counselling and treatment services to them and to their families. In 2000, 60 adolescents and 100 parents used the services of the Centre, while 10 of them were admitted to the Therapeutic Communities “STROFI” and “PLEFSI” after having completed the counselling programme at the Centre. Also, a vocational training programme was implemented for twenty adolescent drug users (aged 16-19 years old) who had dropped out of school; their training included classes in computers, Modern Greek literature, drama, painting and sports as well as vocational guidance.

The pilot programme of the Ministry of Public Order and the Counselling Centre for adolescents at the Probation Services Office in Athens appear to be covering an existing need. This is the conclusion drawn from the findings of the Leonardo Da Vinci three-year research project on the needs of juvenile delinquents (Aristotle University of Thessaloniki, 2000). Some major results and conclusions of this study were that only a limited number (4%) of young delinquents have been offered some kind of social services and that drug- dependent juvenile offenders should be referred to specialised programmes.

The Outreach Pilot Programme for Prevention and Early Intervention in Juvenile Delinquents, which has been implemented by OKANA since 1998, was terminated due to its impending replacement with the new therapeutic units for adolescent drug users that OKANA plans to establish in the near future.

Imprisoned population

See Chapter 13.5: Demand reduction policy in prison

9.6 Specific targets and settings

9.6.1 Gender specific issues

The Drug Dependence Unit “18 ANO” (Psychiatric Hospital of Attica) and KETHEA constitute the two therapeutic agencies that provide specialised programmes to women drug addicts.

The Treatment Programme for Dependent Women (“18 ANO”), established in 1997 was developed in an effort to meet the specific needs of women drug users. Findings concerning the programme showed that, in the year 2000, 1/3 of the women who joined the programme were homeless, while 95% were unemployed. In addition, approximately 50% of the specific population

123 prostituted themselves whilst the respective percentage for men amounts only to 6%. HIV infection in women drug users was 14-18% higher than in men. Co- morbidity issues were also reported as well as a history of child abuse in and outside the family. Findings also indicated that women drug users often were victims of sexual abuse and were rejected by their family environment to a greater extent than men. Finally, approximately 50% of their children grow up with no support while women drug users also run the risk of loosing the guardianship of their children upon entering treatment.

Evaluation results demonstrate that a total of 35 women drug users were admitted to the Treatment Programme for Dependent Women (“18 ANO”) in 2000. Thirteen (13) out of 35 of these women completed the programme successfully, while 16 of them interrupted their participation due to the following reasons: 11 dropped out of the programme, while 5 were prematurely discharged due to alcohol use inside the unit. Two out of the latter five were re- admitted to the programme during 2000.

The Treatment Programme for Dependent Women of “18 ANO” is considering developing a treatment programme that will be intended for drug-dependent mothers in the near future.

In February 2000, the residential Therapeutic Community “ITHAKI” (KETHEA) inaugurated the establishment of the Special Unit for Addicted Mothers. It is an innovative nationwide programme, which gives the opportunity to addicted mothers to begin long-term drug treatment while, at the same time, their children are being looked after at a nursery provided by the programme. The specific objectives of the programme are to reinforce the mother-child relationship and to support mothers in their parental role. The Special Unit for Addicted Mothers can admit up to ten women and ten children. Evaluation results are not yet available.

Except for these two treatment services, the street work programmes of OKANA and KETHEA in Athens continue to provide special services (e.g. supply of condoms, information leaflets on harm reduction, referrals to public hospitals, etc) to drug-addicted prostitutes who do not approach therapeutic programmes.

9.6.2 Children of drug users

The nursery for children of drug dependent mothers established in 1998 by the Therapeutic Programme “ITHAKI” (KETHEA) is still the only programme for children of drug users in Greece. Evaluation results are not yet available (see also Annual Report 2000).

9.6.3 Parents of drug users

Family programmes in Greece are well integrated in the treatment process of drug users and their duration is in accordance with the drug user’s course of treatment.

124 In 2000, KETHEA ran 9 Family Programmes in various Greek cities aiming the following: a) to provide information on substance use, dependence and the therapeutic programmes of KETHEA, b) to help families make a positive contribution to the outcome of the drug user’s treatment, c) to create and maintain a therapeutic alliance with the families of the addicts, and d) to bring about changes in the dysfunctional relationships of the family system.

In 2000, the Family Programmes of KETHEA provided introductory training seminars to 4,118 individuals; 3,448 of them participated in treatment interventions by attending either the Parallel Programmes of Family Therapy or the Independent Programmes of Family Therapy (KETHEA, 2001).

9.6.4 Drug use at the workplace

Local and regional prevention centres as well as other organisations (i.e., OKANA, KETHEA and the Hellenic Institute for Hygiene and Safety at the Workplace) implement prevention programmes at the workplace on a regular basis. The main target populations are professionals from: the mass media, the health field, the private sector (i.e. pharmacists, lawyers) and the public sector (i.e., Greek Police Force and Military Force).

These interventions focus mainly on achieving the following objectives: to heighten the awareness and inform employees and employers on health issues and licit and illicit substances, to enhance collaboration with the Prevention Centres, and to create nuclei of prevention. Along these lines, local programmes aim at the motivation and involvement of professionals in community prevention programmes, so that a local prevention network may be established.

In 2001, OKANA joined the European Project “EURIDICE” (www.coopmarcella.it) which is developing a plan of action against drug addiction at the workplace and aims to set up one of the first integrated programmes, explicitly designed for the workplace. The project is partly funded by the European Commission as well as by social bodies, such as enterprises and trade-union organizations.

Within this framework, two meetings took place in 2001 with the participation of the other Member States (i.e., Spain, France, Germany, Belgium, Portugal, The Netherlands, Austria, U.K. and Italy). Moreover, OKANA in collaboration with the Hellenic Institute for Hygiene and Safety at the Workplace has planned to organise a two-day seminar on “Prevention Interventions at the Workplace- Presentation of the European Project EURIDICE”, which will take place at the end of November 2001 in Athens. The seminar is intended for personnel from the Prevention Centres and trade-union members and will be implemented by the co-ordinating body of the programme “Cooperativa Marcella”.

Evaluation of prevention initiatives at the workplace is still quite limited. In addition, no specific training is yet provided for this type of intervention.

125 9.6.5 Ethnic minorities

While the lack of the development of specialized treatment programmes for ethnic minorities is still evident in Greece, there is an increasing number of prevention programmes, which are intended for minorities and socially excluded people. In addition, there are many awareness activities that are being initiated by treatment programmes and volunteer associations.

The Hellenic Centre for Intercultural Psychiatry and Care is continuing its programme “Combating social exclusion in the context of substance abuse”, which has been implemented since 1996. The programme’s objectives include: a) information and increased awareness of the local and, more importantly, the school community on drug dependence, b) social rehabilitation and vocational guidance for adolescents belonging mainly to socially excluded groups, and c) research on mobile populations and on socially and culturally differentiated groups. Evaluation results in 2000 remained the same with the ones presented in the 2000 Annual Report.

In January 2000, the Information and Prevention Centre Against Drugs of the Municipality of Xanthi – a region with a large Muslim population – initiated the implementation of a primary prevention programme in the school community entitled “Health Promotion programme for Secondary School Students”. The main objective of the programme was to help students assume responsibility of their lives and health by developing skills that will help them make conscious and responsible decisions on substance use. The specific programme was one of the first programmes in the prevention field intended for ethnic minorities. Mixing Muslim students with the indigenous ones (i.e. Greek Orthodox) seems to promote the collaboration and communication between the two groups through cross-cultural approach. Outcome evaluation of the programme is not yet available.

In addition, the four Drug Prevention Centres of Attica offer their services to minority groups living in the wider area of Athens, aiming to reduce factors that lead to social marginalisation and exclusion.

In 2000, the Mobile Unit of Information “Pegassus” (KETHEA) laid particular emphasis on initiatives concerning the planning and implementation of prevention interventions for social groups with special cultural characteristics (i.e., gypsies, Muslims of Thrace, immigrants, and refugees). The main goal of this initiative was not only to provide primary and secondary interventions, but also to bring the specific groups closer to the local services, which can address issues concerning their needs.

In 2000-2001, the Hellenic Centre for Intercultural Psychiatry and Care provided specific training in prevention interventions intended for ethnic minorities (see also Chapter 10.4 Training for Professionals). Moreover, training is also offered by the postgraduate course of the Panteion University of Athens (www.panteion.gr) on “Social Exclusion and Minorities”.

126 The rapidly increasing number of minorities and immigrants in Greece, as well as their particular needs, has imposed the development of specialised therapeutic programmes or specialised services in the existing therapeutic programmes. However, the low admission rate of culturally different clients in the current therapeutic programmes could be attributed to the lack of specialised services for this population (Douzenis 1997, STROFI 2000).

In this context, KETHEA is expected to start the implementation of a specialised therapeutic programme entitled “Transitional Integration Centre for Special Social Groups” in 2002 in order to satisfy the needs of the minorities more adequately (see also Annual Report 2000).

9.6.6 Self-help groups

Self-help initiatives seem to have expanded in 2000-2001. The Ministry of Health is planning to take major policy measures that consist in the reinforcement and support of the two non-governmental organizations – Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) –in the near future.

In February 2001, Narcotics Anonymous (NA) organised an open meeting that was intended for the public, professionals in the drug field, priests and teachers in order to provide information on its objectives and to heighten awareness of the substance use phenomenon. The meeting consisted of the presentation of the personal stories of former drug users, a discussion with the participants, the distribution of information material (i.e., leaflets on the NA Association and its twelve-step approach, contact cards, address-lists of settings and time of meetings across Greece), and book displays mainly on the American NA Association.

A pioneering pilot programme, entitled “Programme of Self-Help Promotion”, has recently started its operation in Thessaloniki, under the supervision of the Psychology Department of the School of Social and Clinical Psychology of the Aristotelian University of Thessaloniki. The Programme of Self Help Promotion is funded by OKANA and its main objectives are as follows:

• To promote self-help in combating psychosocial problems with special emphasis on dependence of psychotropic substances and alcohol • To reverse the traditional role of health professionals and to train them in new roles • To conduct research on self-help efficacy on combating psychosocial problems

The main courses of action that are followed in order to achieve the objectives mentioned above are:

• To create a data bank on self-help groups; a group of students- volunteers from the Psychology Department of the Aristotelian University of Thessaloniki has been formed in order to conduct literature research on self- help issues, to gather information, to classify the collected information in an

127 electronic database and to translate selected articles or texts. The material will be available to anyone interested. At the same time, a training group is run, which discusses the latest data and findings on self-help groups for combating psychosocial problems. • To create a web page (www.auth.gr/selfhelp); this web page shall provide the public and health professionals with information on the history of self help groups, the objectives of the particular programme, indicative references for further reading. Moreover, an electronic chat room for online communication among experts, drug users or the wide public is provided. The web page is also offering links with self-help groups (i.e., cocaine anonymous, narcotics anonymous, parents anonymous etc) and institutions or organisations on health issues across the world. • To form self help groups for parents and drug users; this course of action consists in motivating citizens to deal with their problems themselves. First, groups of parents will be formed and then a second phase will follow, during which groups of drug users will also be formed. Both groups will be holding open discussions aiming to facilitate interaction between members and the creation of a network (of support) among each other. • To support members of self-help groups (NA & AA); this intervention refers to members of self-help groups in Thessaloniki. It involves the implementation of actions that will support the target population in legal, educational and professional issues as well as the creation of a drop-in centre. • To develop a social network; the aim is to initiate social actions based on the principles of self-help in order to create nuclei of self-help promotion. • To promote self-help groups in the general population; this action constitutes the ultimate objective of the programme.

9.6.7 Alternatives to prison and prosecution

Pecuniary penalties and confinement in specialized treatment prison units with the offender’s acquiescence constitute alternatives to prison for drug law offenders. The first two specialised detoxification units for drug dependence prisoners will be inaugurated in Thebes (Central Greece) and Cassandra, Chalkidikis (Northern Greece) in the near future (see also 2000 Annual Report).

10. QUALITY ASSURANCE

10.1 Quality assurance procedures

The official criteria and requirements for quality assurance in the drug prevention and treatment fields remain the same with those presented in the 2000 Greek National Report.

Along with these criteria, in 2000-2001 OKANA paid special attention to the promotion of quality regarding training programmes in the primary prevention

128 field. In this context, OKANA, in cooperation with the Greek Focal Point, developed specific evaluation methodology and tools, which were finalised in April 2001. OKANA assigned the training of prevention agents in various types of interventions and educational material to three specific educational agencies and has started to conduct the evaluation of their training services on a systematic basis that includes planning, process and outcome evaluation.

The evaluation plan of training agencies comprises different components, methodologies and sources of information, so as to provide as much a holistic and scientifically sound evaluation as possible. More particularly, the various tools and instruments used are as follows:

• Work plans prior to the implementation of each specific training programme • Summary and final reports at the end of the semester and at the end of the year of implementation, respectively • Self-drawn up evaluation questionnaires on the work of the training agencies filled out by the participants in the training programmes and by the Prevention Centres • Participatory observations in the training seminars by members of the OKANA staff who are responsible for the respective evaluation.

There have been no specific results since this pivotal evaluation plan started to be implemented in 2001. However, it has been reported that the collected data will be analysed and presented within the scope of the strengths and weaknesses of the implemented training programmes, with the aim of making future recommendations regarding the planning and elaboration of training and support provision to prevention agents.

Another development in 2000-2001, regarding quality assurance procedures, was the Scientific Committee for the Certification of Drug Addiction Counsellors in Greece, Cyprus and Malta, which was established by KETHEA in the context of its cooperation with the ICRC (International Certification and Reciprocity Consortium for Alcohol and Other Drugs). This Committee is authorised by the ICRC to issue certificates to professionals from the aforementioned countries according to international standards (KETHEA, 2001).

With the aim of further promoting quality in the drug field, the Ministry of Health has scheduled the inauguration of an Institute of Substances and Drug Addiction by the end of 2001, which will set guidelines and priorities in the field of research, education, prevention, treatment and evaluation.

10.2 Treatment and prevention evaluation

As it has already been mentioned in the previous chapter, a clear and concrete evaluation policy is currently displayed by OKANA only with regard to the training programmes organised in the primary prevention field. Except for this, external evaluation of the municipal prevention centres is currently limited to the monitoring of their several interventions and activities from the year of their

129 establishment to this day, which however does not provide sufficient data on the effectiveness of the prevention programmes implemented in the country.

However, the results of the evaluation study that was carried out by OKANA and the Focal Point in 1999-2000 (see 2000 Annual Report submitted to the EMCDDA), impose the need for the development of a single evaluation policy regarding the effects of prevention programmes. This would enable prevention agents to improve their services and to adjust their programmes to the needs of their population. Moreover, since prevention centres in the country share many functional and structural characteristics (i.e., funding, target-groups, educational material used), it would be useful to have comparable results regarding their outcome at local communities.

The same situation appears to exist in the field of treatment as well, where a respective evaluation policy was planned in 1999 but it has not been implemented yet (see 2000 Annual Report submitted to the EMCDDA). This may be attributed to several factors, such as the various differences of treatment programmes in the country, the existing lack of adequate global co- ordination of all treatment agencies and the prohibition of some professionals in the field to have external evaluation of their programmes. However, OKANA is expected to take action in this direction in the near future, acknowledging the need for a single evaluation policy to be implemented in the treatment field.

An evaluation research project that is expected to contribute a lot to the comparison of the outcome of different treatment facilities to the needs of drug users as well as to the cost-effectiveness of treatment programmes, is the European longitudinal field-study entitled “Treatment systems Research on European Addiction Treatment” (TREAT 2000). This three-year study is conducted by the UMHRI in collaboration with five other European research institutes and, as far as Greece is concerned, it is implemented in seven therapeutic programmes in Athens that implement different types of drug addiction treatment, namely drug-free, substitution and low-threshold programmes (see also Chapter 10.3: Research).

More detailed information about requirements for evaluation, the use of evaluation results and the criteria for the development of a single evaluation policy in the field of drug treatment is given in the Chapter 12.2: Evaluation of the treatments.

10.3 Research

In 2000, research in the demand reduction field continued to expand and particular emphasis was placed on conducting research projects in secondary prevention and evaluation. In addition, more research projects were carried out in the treatment field than in the primary prevention field. This may be attributed to the that fact that prevention centres have been only recently established (i.e., in the last five years) and priority was given to the implementation of the prevention programmes rather than to research.

130 However, there is a fast-growing interest in evaluation projects in both prevention and treatment programmes.

The objectives, structure, organisation and other relevant information of the research projects during 2000-2001 are presented in the following distinct categories; primary prevention, secondary prevention, and evaluation.

Research projects in Primary prevention

1. Title: “Away from home: Drug Prevention in the university student population” (1999-2001) Research Agency: OKANA in collaboration with the University of Piraeus, The Advisory Council on Alcohol and Drug Education – U.K. (TACADE), Acción por el Bienestar y la Salud – Spain (ABS), Institut für Therapieforschung – Germany (IFT-Nord) Source of Funding: OKANA in collaboration with the EU Objectives: • To create - in the existing Counselling Centres of the Universities - specialised services providing drug-related information and counselling. • To provide specialised training to the personnel of the Counselling Centres in the provision of services related to substance use. • To develop and publish information material on the issue of drugs for university students Sample: 1,778 students from 9 departments of the University of Piraeus. Method: questionnaire Results: research is in the process of data-analysis.

Research projects in Secondary Prevention

1. Title: “Needs’ and methods’ assessment of vocational training in juvenile delinquents and juveniles at risk” - A pilot programme LEONARDO DA VINCI “ORESTIS” (1997-2000) Research Agency: Aristotelian University of Thessaloniki in collaboration with the Bremen Universitat and Leiden Universitat Source of funding: EU, Directorate-General XXII, Education, Training and Youth LEONARDO DA VINCI Objectives: • To explore the relationship between the living conditions of juvenile delinquents and delinquent behaviour. • To record the levels of education and vocational training as well as the needs of juvenile delinquents • To formulate proposals in order to adopt a more effective correctional/reformatory policy on juveniles

131 Sample: 200 juveniles, age group: 14-24 (100 detainees in correctional institutions and 100 from the wider group of juvenile delinquents and juveniles at risk, e.g. juveniles in contact with courts) Method: questionnaire Results: • The vast majority of juvenile delinquents come from families with low socio-educational level. • The percentages of juvenile delinquents, who do not have Greek nationality or citizenship are higher than the ones of foreigners in the general population. • 64,5% declared that they had started working at the age of 15 or earlier; according to Greek Law, professional occupation is prohibited at such an early age. This fact suggests that the specific group is subject to exploitation. • Only 4% of the detainees in correctional institutions have received some sort of support from social services, which shows the serious lack of any kind of support provided by official services. • The majority of juveniles declared that they use cannabis with peers. Cannabis is followed by heroin and pills. • There is a significant differentiation between the percentages of juveniles in prison and those outside prison. Only 45% of those outside prison declared that dependent substance use (licit and illicit) takes place in peer groups, compared to 72% of imprisoned juveniles. This could be partly attributed to the different mean age of the two groups. • In terms of substance use, 27% of those outside prison declared that they have used dependent substances, compared to 76% of imprisoned juveniles, who had used dependent substances prior to their imprisonment (AUT, 2000).

2. Title: “Occupational Burnout syndrome” (1999-2000) Research Agency: Alternative Therapeutic Programme “ARGO”, Psychiatric Hospital of Thessaloniki Source of funding: Psychiatric Hospital of Thessaloniki Objectives: Assessment of the needs of personnel Sample: The staff of the following services of the Psychiatric Hospital of Thessaloniki; a. the Physical Detoxification Unit, b. Therapeutic Community of Karteros, and c. Alternative Therapeutic Programme “ARGO” Method: questionnaires Results: the study is in the process of data analysis

3. Title: “Euro-Outcasts: A research project on high-risk behaviours, the life- style of the socially excluded drug users who run the risk of HIV infection and information on HIV/AIDS” (1999-2001).

132 Research Agency: KETHEA in collaboration with Escuella Andaluza de Salud Publica (Granada/Spain), Institute of Social and Health Psychology – ISG (Vienna/Austria), Association Modus Vivendi Y Centre Alpha (Brussels/Belgium), The Merchants Quay Project Ltd (Dublin/Ireland), Asociacion Colectivo “La Calle” (Seville/Spain) and Drogenhilfekolne (Kolne/Germany) Source of funding: the European Union Objectives: Risk assessment and development of a European map of socially excluded drug users Sample: 200 individuals from each participating city and country (Athens, Granada, Vienna, Brussels, Dublin, Seville, and Kolne) Method: individual interviews based on a structured questionnaire. Interviews were based on the peer-group methodology Results: the project is in the process of data collection

4. Title: “Principles and development of strategies for prompt intervention in the field of secondary prevention of substance use” (2000-2001) Research Agency: OKANA “streetwork” services in collaboration with the Greek Focal Point and the Senate Administration for School, Youth and Sport – Drugs Department (Germany), Verein Wiener Sozialprojekte (Austria), Radgivningscenter Amager (Denmark), Merchant’s Quay project (Ireland), The City of Edinburgh Council of Social Work (U.K.) Source of funding: General Directorate 5 (DGV) of the EU Objectives: • To develop principles and strategies for prompt intervention in the field of secondary prevention (target-group: adolescents and youngsters using substances) in order to achieve demand and harm reduction. • To organise a network that will provide aid to young substance-users by making use of the existing structures. • To develop information material for the target-group, the teachers and the parents • To record the procedure that is followed in the six countries. Sample: Two target-groups; a) 200 adolescent and young substance-users from the electronic music and dance scene (e.g. techno-party scene) of four clubs, b) 61 street kids, age group; 14-29. Method: focus-group interviews and questionnaires Results: the project is in the process of data collection (see also Chapter 9.1.3 youth programmes outside schools)

Evaluation Studies

1. Title: “Groups of parents using substances” (1999-2000) Research Agency: Alternative Treatment Programme “ARGO” of the Psychiatric Hospital of Thessaloniki

133 Source of funding: Psychiatric Hospital of Thessaloniki Objectives: Outcome evaluation of the treatment programme Sample: Members (i.e. parents using substances) of the Alternative Treatment Programme “ARGO” Method: application of the WHO-evaluation training Results: The research is in the process of data-analysis

2. Title: “Systemic therapy in drug treatment programmes” (1999-2000) Research Agency: Alternative Treatment Programme “ARGO” of the Psychiatric Hospital of Thessaloniki Source of funding: Psychiatric Hospital of Thessaloniki Objectives: Outcome evaluation of the treatment programme Sample: Members of the Alternative Treatment Programme “ARGO” Method: application of the WHO- evaluation training Results: The research is in the process of data-analysis

3. Title: “Evaluation of the prevention programme at KETEK Renti – Prevention in secondary education” (2000) Research Agency: KETHEA Objectives: To formulate a proposal based on the results of the specific study in order to implement relevant programmes Sample: 12 teachers Method: • Questionnaire answered prior to and after the completion of the programme • Participatory observation Results: The teachers redefined their role through their participation in the programme and acknowledged the value of prevention in the school setting. The group acquired coherence and formed a common code/sense of communication.

4. Title: “Research on the outcome effectiveness of the therapeutic communities of KETHEA” (2000-2001) Research Agency: Department of Sociology of the Hellenic National School of Public Health Source of funding: KETHEA Objectives: outcome effectiveness of the therapeutic communities of KETHEA through the assessment of the condition of their clients, five years after his/her contact with one of KETHEA’s treatment communities Sample: 551 individuals – including even those admitted for one day in one of the six therapeutic communities of KETHEA in 1994-1995 Method: combination of quantitative and qualitative methods

134 • Data Collection concerning the clients through their records in the treatment programmes • Individual interviews Results: the research is in the process of data collection

European Research Project “TREAT 2000”

UMHRI in collaboration with five European research centres, is taking part in a three-year research project (2000-2003) of the European Commission, entitled “TREAT 2000” (Treatment Systems Research on European Addiction Treatment), which is conducted within the framework of the broader developmental programme “Quality of Life and Management of Living Resources”’.

The specific research project aims at the collection of information on the provided health care and treatment system to opiate addicts living in large urban regions. The participating cities are Athens (Greece), Essen (Germany), London (Great Britain), Padova (Italy), Stockholm (Sweden), and Zurich (Switzerland). This collaborative, multiple “centre” study constitutes a prospective longitudinal field-study with repeated assessments (i.e. follow-ups) through the distribution of specific questionnaires/instruments (e.g. adopted version of EuropASI, WHO-DAS, CIDI-short form etc) to 100 opiate users in each participating city as well as to specialised treatment units.

The specific objectives of the project are the following:

• The description and monitoring of the provided care system to opiate addicts in the participating cities • The description and comparison of the course followed by the opiate addict in the treatment and health care system of each city • Evaluation of the effectiveness and approximate cost-effectiveness of treatment systems

One hundred baseline interviews have been completed and UMHRI is now at the stage of collecting the first follow-up data. The collected information and outcome results of the particular research are expected to contribute to the further development and improvement of the treatment systems for substance users and thus satisfy their needs more adequately and effectively.

The relationship between research and drug services remains very strong. In many cases, research projects are carried out by drug services in collaboration with national or international research institutions in order to ensure the use of a scientifically sound methodology in the study.

As far as funding is concerned, it is worth mentioning that many projects are funded either by the drug services themselves (i.e. KETHEA, OKANA) or in collaboration with the EU. The amount spent on research by OKANA in 2000 was 271,388 Euros. However, an overall estimation of the amount spent on

135 research by different sources nationwide is not available yet. The Greek Focal point has recently developed a relevant electronic database in order to fill the gap in information and to promote exchange of experience in the research field.

Training in demand reduction research involves the following: a) seminars organised by national or international research institutions for professionals in the drug field, and b) in-service training according to the needs of the drug agency.

For the first time in Greece, a pioneering workshop, entitled “Workshop on Elaborating and Exploiting Results in Prevention”, was organised in 2000 by the Greek Focal Point; it was intended for representatives of the OKANA Prevention Centres that participated in the 1999 ESPAD-project (total number of Prevention Centres: 26). The interactive approach was employed for the duration of the workshop.

Three groups were formed, each consisting of 9 participants. SPSS data - collected by the Prevention Centres for the ESPAD project - was used as sample material for practicing on various research topics. The workshop was appraised by the participants, who claimed that they had gained important knowledge and practice on research issues (see also Chapter 10.4 Training for professionals).

In conclusion, it is imperative to develop a policy regarding the promotion of training in demand reduction research on a regular basis, in order to ensure the further development of research in the demand reduction field.

10.4 Training for professionals

As a result of the emphasis placed by OKANA on the promotion of training as a means of quality assurance both at the prevention and treatment fields, training activities increased and became more structured in 2000-2001, so as to cover the respective needs of professionals.

Along the same lines, OKANA has enhanced the three-month introductory training in prevention issues that is provided to professionals working at the municipal prevention centres by the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse (OKANA/UMHRI). In addition to this elementary training, OKANA has assigned the continuous training and supervision of prevention agents to specific institutions, so that they may implement particular types of intervention in the primary prevention field. The training programmes of these institutions operate under the supervision and evaluation of OKANA. The main structures and types of training in the prevention field are as follows:

• The Educational Centre for the Promotion of Health and the Prevention of Drug Abuse is responsible for providing training in the implementation of specific educational material produced by the Centre and intended for students of secondary education, families, and youth outside school.

136 Moreover, it offers training in dealing with drug users who seek some kind of assistance and/or treatment. • KETHEA has undertaken the training of prevention agents in the implementation of the specific educational package called “Skills for primary school children” for students of primary education, while it is also responsible for providing training in networking interventions in local and regional services dealing with drug use problems. • The Hellenic Centre for Intercultural Psychiatry and Treatment has been assigned the training of prevention agents in the implementation of interventions in the army as well as at ethnic minorities and culturally different people.

In 2000, the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse provided basic training in prevention to 38 professionals working at prevention centres, while it trained 36 professionals in the educational package “Children’s games” and 13 professionals in the material “Stand on my own feet”. Moreover, in 2000 the Centre published a large number of new information and educational material, for secondary school teachers who implement health promotion programmes, children aged 7-9 years old, adolescents outside schools, and parents (see 2000 Annual Report submitted to the EMCDDA).

In 2000, KETHEA provided an eight-day training in “Skills for primary school children” to 35 professionals working at 13 prevention centres of OKANA and local authorities as well as to 15 professionals of mental health services and educational agents. It also organised supervision groups for 24 prevention agents, who plan or implement the respective prevention programme after having being previously trained. An eight-day training programme on developing networking activities among primary, secondary and tertiary prevention agents at local and regional level was provided to 30 professionals who work in the health districts of Central Greece and Crete. Moreover, in 2000 KETHEA organised a training seminar for prevention agents, entitled “Training agents in prevention”, in collaboration with the English organization TACADE.

A training initiative of great importance was the three-day “Workshop on Elaborating and Exploiting Research Results in Prevention” organised by the UMHRI, in December 2000. The workshop was intended for professionals working at the 26 municipal prevention centres that had participated in the UHMRI’s research on the use of addictive substances among high school students that was carried out in 1999-2000 (see Chapter 2.2.4: Geographical distribution of use). The initiative arose from the expressed need of the staff of prevention centres for assistance, mainly with issues of data processing and drawing up of reports on their research findings. The workshop included training in the main methods of statistical analysis, ways of interpreting and presenting research results, and possible implications of the results in prevention interventions at local communities.

Regarding the treatment field, along with the in-service training that is the main type of training for professionals working at therapeutic programmes, KETHEA has been organising a two-year vocational training programme on “Addiction

137 Counselling Competence: Knowledge, Skills and Attitudes of Professional Practice” since 1998. This programme, which has been organised in collaboration with the University of California, lasts for 2 years (total duration: 200 hours) and it is based upon respective educational material. 102 individuals had participated until September 2001, while the programme is to be continued until 2003. The evaluation of the programme is conducted by means of a questionnaire, drawn up by KETHEA, which is filled in by the participants at the end of the programme.

Some other training programmes organised by KETHEA in 2000 are as following: a) “Social Planning and social policy”, in collaboration with the Department of Social Policy of Boston College, b) “Relapse Prevention”, in collaboration with the Addiction Research Institute of Amsterdam University, c) “Introduction to the psycho-sociology of groups”, in collaboration with the Department of Communication and Mass Media of the Athens University, and d) “Prevention of the dissemination of HIV”, in collaboration with the Hellenic National School of Public Health and the Netherlands Institute for Health Promotion and Disease Prevention. In 2000, the total number of participants in the long-term training programmes of KETHEA was 180 professionals from various specialised services in Greece and Cyprus (KETHEA, 2001).

The Greek Focal Point organises systematic training programmes on the administration of specific treatment evaluation tools. More particularly, in 2000- 2001 the Focal Point provided training in the implementation of the “First Treatment Demand Indicator” and on the “European Addiction Severity Index” (EuropASI). In the last two years, the latter two-day training programme has been attended by 44 professionals from therapeutic units of OKANA and the Drug Dependency Unit “18 ANO”.

Despite the fact that the only available university education on drug-related issues is the two-year postgraduate course offered by the Psychology Department of the University of Thessaloniki, both OKANA and KETHEA offer grants to members of their staff who wish to have further training regarding drug addiction. Scientific knowledge and expertise among professionals working for these two agents is, thus, enhanced by their participation in further vocational training programmes or in respective university studies in Greece or abroad.

A major initiative in the field of training in drug addiction treatment was the one taken by OKANA in 2001, which involved a visit of a group of five Greek experts to several prevention, therapeutic and technology-transfer centres in the United States of America. This visit aimed at the development -in the long term- of specialised educational material for training doctors who work for the National Health System, so that they may be able to deal with drug-related problems more effectively in the future. The exchange of experience and know- how between different treatment and research services (i.e., Centre for Substance Abuse Treatment, Shenandoah Valley Behavioural Health Services, Partners in Drug Abuse Rehabilitation and Counselling) and the dissemination of analogous educational material developed by several specialised agencies in the U.S.A. (i.e., the DANYA International Centre, the University of

138 Pennsylvania, the VA Hospital) are expected to contribute to the development of adequate training programmes and packages for Greek doctors. This is crucial to the expansion of the prescription of substitution drugs and antagonists by the National Health System, which is expected to take place in the near future.

Evaluation of training programmes in the country is still limited to the collection of impact data (i.e., number of participants) and to qualitative information on organisational and procedural issues. However, in 2001 OKANA started to systematically evaluate training programmes in the field of prevention, and therefore, the respective evaluation results are expected to be available in the near future (see Chapter 10.1: Quality assurance procedures).

139

PART IV

KEY ISSUES

11. POLYDRUG USE

Information on this issue derives from qualitative and quantitative sources. Qualitative data derived from a discussion on polydrug use that was held in two sessions among a group of experts consisting of nine scientists and professionals in the drug field, while the quantitative data came from epidemiological surveys and surveys on specific groups, as well as from the Treatment Demand Indicator (TDI).

Definition

According to the World Health Organisation (WHO), polydrug use is defined as:

The consumption of more than one substances or types of substances by a single individual- consumed simultaneously or successively - usually with the intention of enhancing or reducing the effects of the dominant substance. The term is also used in a broader sense that includes the consumption of two or more substances at any time by the same person. Even though the term alludes to the use of illicit substances, alcohol, nicotine and caffeine, in combination with others, are the most frequently used substances in the context of industrial societies. In ICD-10, the disorder caused by multiple substances use (F19), is considered to be “one of the psychological and behavioural disorders attributed to the use of psycho-active substances”. Even though the diagnosis is possible only if the substances taken are known, it is impossible to assess which one contributes more to the disorder. This category should include cases where the “identity” of some or all of the substances used is unclear or unknown, given that many multiple drug users are not aware of the substances they are taking (OKANA, 1999).

According to the group of experts, the definition is broad, as it allows for both occasional use and dependence and it does not impose limitations on the frequency or patterns of use.

Indeed, the phenomenon of polydrug use is equally spread to recreational users as well as to dependent ones.

The group of experts discussed the issue of definition with the aim of further narrowing it and making it more functional. Several parameters were readily agreed upon, while others aroused controversy.

More specifically, it was agreed that:

• Polydrug use can involve both simultaneous use of substances, or parallel use (including also temporarily an alternative use of different substances).

• Both licit and illicit substances involved should be included. The criterion for the inclusion of licit substances is the risk involved, i.e. non-prescribed pharmaceutical substances and excessive use of alcohol.

143 Several questions were raised and it is hoped that the investigation of this issue in this chapter will offer some possible answers or at least throw some light on them.

One major question is whether polydrug use should be defined independently of its frequency and its severity, namely whether both occasional and frequent use and both recreational and addictive use should be included in its definition.

In attempting to settle this issue, one should take into account that regular recreational drug use may lead to dependence and that the exact parameters associated with this shift have not been specified.

In the case of dependence, substances are used either alternatively, when the preferred substance is not available, or whenever the user wishes to enhance the effects of the primary substance or to reduce the side effects from this substance.

It is also reported that the use of adulterated drugs could be regarded as polydrug use, since the unsuspecting user runs the risk of taking increasing dosages of these drugs, which may result in severe health problems, such as overdose symptoms.

Another important question is related to the reliable measurement of polydrug use, since data deriving from self-reports are considered doubtful; a user may report the primary substance and not the others, which he/she may be using only for a certain period of time.

11.1 Patterns and user groups

11.1.1 Combinations and sought effects

Use of a range of drugs

The term “combination” is used here to embrace the parallel and the simultaneous use of substances.

Data from low-threshold services based on “street” users indicate that the most frequent combinations of substances made by these users are the following:

• Heroin combinations: heroin with cannabis or with cannabis and benzodiazepines. Heroin with ecstasy or benzodiazepines, as well as with both substances (ecstasy + benzodiazepines). • Cocaine combinations: cocaine with ketamine or with alcohol. • “Speedball” with benzodiazepines. • Cannabis combinations: cannabis with amphetamine-type substances including ecstasy or with cocaine & methadone, as well as with alcohol. • Ecstasy combinations: ecstasy with other amphetamines or with strychnine and benzodiazepines.

144 Information on new combinations came from the Early Warning System by drug users approaching treatment services:

• Heroin and steroids (decaduraboline, testovirone) • Ecstasy and “madrax” or ecstasy and antiparkinsonian drugs • LSD containing strychnine and cannabis. • LSD and amphetamine

To the users’ knowledge, almost all combinations, except for heroin ones, are habitual among recreational drug users.

According to the group of experts, a great variety of illicit drugs and pharmaceutical substances are used in a parallel way. It has also been observed that the type of substances varies with different categories of users. Particularly, young users mainly experiment with cannabis, pharmaceutical substances (benzodiazepines) or amphetamine-type substances. Several of them pass to dependence, in which case, they use a primary substance, which is mainly heroin and secondary substances, either to decrease the effects of heroin (benzodiazepines or other pharmaceutical substances), or to increase them (“speedball”-heroin+cocaine, alcohol). The above information has also been confirmed by the data from the samples of seized quantities of drugs and of analyses on body fluids.

Reasons for multiple use

The multiple use of substances can be attributed to social and personal reasons. On the one hand, multiple use is related to the socialisation of young users in certain youth sub-cultures to which drug use is regarded as one of their characteristics (e.g. the subculture of the “ravers”). In this case, young users take the drug that prevails in the youth sub-culture to which they belong, as their primary or secondary substance. Experimental use of different drugs among very young users is also associated with adolescence. On the other hand, older drug addicts take more than a single substance to deal with their health problems (self-medication) or for financial reasons, i.e. if the price of the primary substance is too high for them, they substitute it with a much cheaper one. It is possible for drug addicts to cut their primary substance of abuse temporarily and use instead a different one for a certain period of time. The latter has been confirmed by the findings of a Swedish survey on polydrug users attending treatment programmes (Byqvist, 1999).

11.1.2 Historical perspectives and new patterns

Historical perspective

Prevalence

The following data derived from two epidemiological surveys conducted in 1998:

145

1. For the purpose of this study, polydrug users were considered to be those individuals from the general population who drunk alcohol excessively (5 glasses in one occasion and over three times during the last month) and –in a parallel way- used illicit drugs or non-prescribed pharmaceutical substances in the year prior to the survey. Taking into account the above variable, polydrug users represented 1.2% of the general population in 1998, while the respective percentage in 1984 was lower (0.9%). 2. A similar variable was employed for the student population. According to the 1998 data, 6.7% of students aged 13-18 years old reported that they used alcohol and drugs or pharmaceutical substances in a parallel way, while parallel use of illicit drugs or pharmaceutical substances was slightly higher (7.3%). The respective percentages in the 1993 school population survey were lower, especially for multiple use of illicit drugs or pharmaceutical substances (5% and 3.8% respectively).

Treatment Demand Indicator

According to data from the TDI, the majority of users were opiate users (96.1%) and almost all of them used more than one substance (87.4%). Considering the above, the variable was set to represent polydrug users who took more than three substances.

In the last 7 years (1994-2000), polydrug use recorded a tendency to increase after 1996, which seems to be related to the increase of drug availability (Figure 28).

Figure 28: Trends in polydrug use over the years (1994-2000)

SOURCE: Treatment Demand Indicator, 2001.

146

The vast majority of polydrug users were opiate users, since most of them used heroin & other opiates as the main substance over the years.

With regard to secondary substances taken in the last 7 years (1994-2000) among those polydrug users, the most popular substances were: hypnotics & sedatives, cannabis, heroin & other opiates and cocaine (Table 28).

Table 28: Use of secondary substances among polydrug users

YEARS 1994 1995 1996 1997 1998 1999 2000* % % % % % % % Hypnotic & sedatives 79.1 82.8 49.4 63.8 71.7 72.4 83.2 Cannabis 50.7 54.1 77.1 77.2 75.6 77.6 76.9 Heroin & other opiates 31.4 20.5 20 16 8.2 10.0 19.9 Cocaine 17.9 24.6 25.3 18.3 26.7 23.8 45.2**

* Please note that in 2000 drug users reported more than two secondary substances ** The sum of percentages exceed 100% because of multiple answers.

SOURCE: TDI, 2001.

More specifically, the popularity of cannabis, as secondary substance, increased from 1996 onwards, compared to the two previous years (1994- 1995), while the rates of heroin & other opiates gradually decreased over the years.

Groups of users

1. Recreational drug users: the following data came from a small-scale study conducted in 1998 in nightlife settings (clubs, bars, parties) of four youth music scenes (trance, house, rock, local). The variable of polydrug use concerned club/party goers taking one or more drugs and/or pharmaceutical substances, with a frequency ranging from some times a year to every day, as well as excessive alcohol drinking (from a few times a week to every day).

According to the data, 26.2% of club/party goers were polydrug users. More specifically, 14.4% of them used a single drug or pill and drank alcohol excessively (first category), while the respective percentage for those taking more than one illicit or pharmaceutical substance and drinking alcohol excessively (second category) was 11.8%.

147

The majority of polydrug users were men (78.8%), while most of them belonged to the 14-22 years age group (72.5%).

Concerning their favourable music scenes, 71.3% came from the dance scene (trance scene 42.5% and house scene 28.8%).

Almost all of them (93.7%) reported that they took cannabis, while the corresponding percentages of other illicit drugs were also high, especially the percentages of ecstasy (30.8%) and cocaine (28.6%) (Table 29).

Table 29: Substance use among multiple recreational users

% Cannabis 93.7 Ecstasy 30.8 Cocaine 28.6 LSD 24.4 Amphetamines 13.2 Alcohol 73.5

SOURCE: IREFREA, 1998.

Regarding the simultaneous use of drugs and alcohol, almost half of the polydrug users (45.2%) reported that they took two or more substances simultaneously in one occasion.

2. “Street” users: the data derived from a research project (“Boule de Neige”) conducted in 1998 on street users approaching a low-threshold service and a psychiatric hospital. Considering that this group of users were heavy drug users, the variable included polydrug users having used 3 or more substances within the last 6 months.

The majority of “street” users (79.3%) declared that they had used 3 or more substances during the past six months. Polydrug users used a wider variety of substances compared to the users taking one or two substances (“other users”), since they reported that they also use synthetic drugs (LSD, ecstasy), morphine and different types of pharmaceutical substances (hypnotics, anti-depressives and antiparkinsonian drugs). The percentages of certain illicit drugs (cocaine, cannabis and amphetamines), methadone, benzodiazepines and alcohol were significantly higher in the case of polydrug users compared to the respective percentages of “other users” (Table 30).

148 Table 30: Substance use among multiple “street” users and “other users” (within last 6 months)

Polydrug users “Other users” % % Cocaine 84 27.6 Cannabis 75 31 Amphetamines 27.8 1.1 Methadone 49.7 4.6 Benzodiazepines 84 34.5 Alcohol 68.9 28.7

SOURCE: Boule de Neige, 1998.

Furthermore, the most popular drugs among polydrug users were: heroin (99%), benzodiazepines (84%), cocaine (84%), cannabis (77%), alcohol (69%) and methadone (50%), while the most popular drug among “other users” was the heroin (91%).

3. Users approaching treatment services (TDI): as it has already been mentioned, this population included mainly opiate users who had used at least two substances. This is why polydrug users were defined as users who took three or more substances.

Comparisons between polydrug users and users taking one or two substances

According to the 2000 data, more polydrug users reported using opiates as dominant substance (96.1%) than those taking one or two substances (90.7%). This can be partly attributed to the fact that 7.2% of the latter were reported to use cannabis as their dominant substance.

No significant differences appeared among polydrug users and users taking one or two substances with regard to certain socio-demographic characteristics (sex, age, educational level and living conditions), However, the percentage of polydrug users sharing lodgings with other users (18.9%) is higher than the percentage of users taking one or two substances (13.4%).

As regards the employment status, fewer polydrug users reported having a permanent job (17.6%) compared to those taking one or two substances (“other users”) (25.2%). However, the percentage of unemployment of polydrug users was slightly higher than the percentage of “other users” (64% and 58.9% respectively).

149 Profile of Polydrug users

According to the 2000 data, more than half of the users approaching the treatment services declared that they had used 3 or more substances (58.3%). Almost all of them (97.1%) were aged 19 and over, the majority being over 30 years old. Regarding the sex, more men were reported as polydrug users (82.3%) than women (17.7%). The majority of polydrug users (62.7%) lived with their families, while 14.2% lived by themselves. 35.6% of them had graduated from secondary school or had abandoned their studies at the university. Furthermore, a large percentage (29.3%) of polydrug users reported having finished their compulsory studies or having dropped out from the secondary school.

Concerning certain patterns of their drug use, most of them (69%) reported that their initial drug was cannabis, while they had first started using drugs at the age of 16.

Route of administration

1. According to the data from the “Boule de neige” research project, the majority of “street” users from both categories (polydrug users and “other users”) reported injecting heroin (82.9%). However, the respective percentages of the polydrug users were higher than the ones of the “other users” (85.6% and 72.4% respectively). Almost half of the polydrug users declared that they injected cocaine (53.6%), while the respective percentage of the “other users” was significantly lower (13.8%).

2. 77.7% of polydrug users seeking treatment injected their primary substance, while the rest reported that they mostly sniffed or smoked/ inhaled it (18% & 10.6% respectively).

Geographical differences

1. Among the “street” users, more polydrug users came from Thessaloniki (86.6%) than Athens (76.5%).

2. Among the polydrug users approaching treatment services, more than half (63.6%) lived in Athens, while 21.6% lived in Thessaloniki and 8.4% in other urban areas.

11.2 Health consequences

11.2.1 Health consequences and negative effects

1. According to the data from the “Boule de Neige” research project, among the “street” users, 38.2% of polydrug users reported having done a screening test for tuberculosis and 5.6% were infected by the disease. With regard to

150 hepatitis infection, a high percentage (62%) had been infected by different types of the disease (hepatitis A, B, C) and mostly by hepatitis C (38.6%). The respective rates of “other users” were lower but the difference was not significant.

More polydrug users seemed to have adopted risk behaviours compared to “other users”. More specifically, 55.2% reported that they had shared syringes even just once during the past six months, while the respective percentage for “other users” was 35.3%. Furthermore, a significantly larger number of polydrug users (69.7%) reported that they had shared injection material at least once within the same period of time compared to the “other users” (50.6%).

2. Most of the polydrug users approaching treatment services had had a hepatitis test (79%). Among those who knew the test result (74.9%), the majority were infected with hepatitis C (96.7%), while 21.2% of them mentioned that they were infected with hepatitis B. The respective percentages of those taking one or two substances were 92.6% and 18.8%.

More polydrug users reported that they had injected a substance at least once in their life (91.1%) or shared syringes (65.2%) compared to the users taking one or two substances (81.7% & 56.4% respectively).

The group of experts observed that health problems (i.e. dental, heart, kidney or vascular problems), as well as psychological problems, are intensified during the period of multiple use. Furthermore, an expert claimed that the health risks from multiple use, especially in the case of drug addicts, are mostly unpredictable.

It was also mentioned that certain combinations of drugs lead to specific health problems (overdose symptoms, alcoholism) or death. In actual fact, it was mentioned that the simultaneous use of repressive substances, such as heroin + benzodiazepines+ cannabis + alcohol, is highly probable to cause overdose symptoms. Moreover, many addicts who combine cocaine with alcohol become alcoholics, adverse. Finally, a fatal combination of substances (i.e. heroin + benzodiazepines + cannabis + alcohol + cocaine) has been detected in older drug addicts.

However, according to some experts, health problems from multiple use are similar to the ones caused by the abuse of a single substance.

11.2.2 Specific social consequences

A small-scale survey in nightlife settings revealed that polydrug users seemed to be more involved in antisocial activities than the “other users”, i.e. those who reported taking a single illicit substance a few times a year / every day or drinking alcohol excessively. To be more precise, the antisocial behaviour scale derived from relevant questions concerning: 1) driving a car without license, 2) deliberate damage of property, 3) shoplifting and 4) involvement in a physical

151 fight. The mean of this scale appeared to be significantly higher among polydrug users (0.5) compared to “other users” (0.3).

The group of experts reported that multiple drug users usually exhibit a wide range of maladaptive behaviour compared to other users. For example, the adolescent multiple users may also behave in a further antisocial way (i.e. dropping out of school, frequent involvement in physical fights, shop-lifting etc).

Regarding multiple drug addicts, they were reported as more deviant than other users. More specifically, it was observed that there was an increase in car accidents and delinquent activities (i.e. violence towards others or among users and impulse to steal) among this population. In terms of stealing, it was also reported that the use of certain pharmaceutical substances (i.e. benzodiazepines) renders users impassive, who subsequently engage more in such illegal activities. Moreover, according to one expert, there is an increase in law offences (i.e. arrests, convictions and imprisonment) among multiple drug users.

However, some of them believe that all drug addicts (i.e. multiple users or users of a single substance) share similar social problems, such as dropping out of school, dysfunctional family relationships, unemployment, delinquency, etc. Consequently, the categorisation of drug users should not be based on the number of drugs taken. Likewise, each group of drug users is not characterised by distinct social problems. In particular, in the opinion of one expert, the difficulty of a user in being integrated in the existing social context is mainly influenced by the degree of his/her drug addiction.

11.3 Risk assessment and local market

The range of drugs distributed in the illicit market varies from one period to another. This influences the consumption patterns of multiple users, who are in the habit of adding to their repertoire of drugs the substance that prevails in the illicit market for a certain period of time. For example, a heroin user also takes cocaine or ketamine, which are being distributed during that period in the market.

In particular, during the last 10 years, synthetic drugs, such as ecstasy, LSD and speed, as well as increasing amounts of pharmaceutical substances (i.e. benzodiazepines), have been added to the “existing” illicit substances.

Regarding cannabis, increasing amounts of natural cannabis that were imported from Albania, have been distributed to the local market, while the distribution of cannabis resin was very limited. Furthermore, the purity of cannabis from Albania is lower compared to cannabis imported from other parts of the world, such as Middle East.

Experts believe that, nowadays, heroin and cocaine are the most adulterated substances. The purity of heroin is significantly lower compared to the past, which explains why heroin is so frequently adulterated with active or inactive

152 substances. It also explains why some samples of heroin have been tested negative, since they contain substances other than heroin, such as paracetamol or caffeine. Regarding cocaine, it is adulterated with local anaesthetic substances, such as xilocaine and procaine. Moreover, it was reported that some “ecstasy” type substances contain additional substances other than MDMA such as amphetamine or caffeine.

Further information on heroin has revealed that the weight of an average dose of the substance is lower than it was in the past. Consequently, its street price is extremely low (2.93-5.86 Euros) compared to the past. As a result, nowadays heroin is more available to the users.

Regarding the characteristics of drug scenes, the experts believe that drug scenes could be divided into two categories, those that distribute certain drugs, e.g. synthetic drugs and cannabis at rave parties and those called “super markets”, where any kind of drug is available.

11.4 Specific approaches to the interventions

11.4.1 Approaches to polydrug use

According to the group of experts, the philosophy of treatment focuses on the behavioural patterns related to drug use and considers polydrug as one of its parameters. The absence of bibliographical references concerning therapeutic models on multiple use might be a confirmation of that.

This being the case, the development of a specific approach focused on multiple use may run the risk of insufficient treatment. Furthermore, classifying users according to the number of substances that they take could possibly stigmatise them among other users in the field of treatment.

On the other hand, it was reported that therapists should take into account the needs of each user, such as multiple use, in order to employ the proper treatment in each particular case.

Within this framework, therapeutic programmes have made an effort to be as “flexible” as possible, since the treatment that adjusts to each specific case contributes significantly to the treatment outcome of the user and especially of the multiple drug user.

Since evaluation tools provide a detailed assessment of drug use, including its severity and the number of the substances used, new support techniques or services may be developed in each therapeutic programme.

Concerning special services in the context of a street work programme, multiple use was one of the topics of a course on safe drug use, intended for drug users. Another expert made a similar reference, mentioning that one of the aims of an outreach and a streetwork programme is to provide drug users with knowledge on the risks of multiple use.

153 Finally, according to the same group of experts, it is not imperative to develop a national strategy on polydrug use per se, if one takes into account the treatment philosophy prevailing in most therapeutic programmes. Whichever the case, national policy against drug use should be more explicit.

11.4.2 Evaluation results

The treatment outcome in the case of polydrug users in one therapeutic programme was considered to be “poor”, since many of them had dropped out from the treatment programme or had used drugs during their treatment.

On the other hand, in another therapeutic programme, the findings showed that almost half (48%) of the polydrug users, regardless of the length of attendance, had refrained from substance use 5 years after the completion of the programme (KETHEA and NSPH 2001).

The substitution programme claimed that treatment interventions in this type of programme contribute largely to harm reduction in the case of participants who used to be multiple drug addicts prior to their admission to the programme.

Finally, according to data from the recent study on treatment-effectiveness among multiple drug users attending any type of therapeutic community of KETHEA, 3 out of 4 users, who had prematurely dropped out from a certain therapeutic community, approached either different treatment services of KETHEA or other treatment services available in Greece (KETHEA and NSPH 2001).

11.5 Methodological issues

11.5.1 Limitations on data availability

Data sources

1. Epidemiological surveys on general population, University Mental Health Research Institute (UMHRI) 1984, 1998. 2. Epidemiological surveys on high school population, UMHRI 1993, 1998. 3. Small-scale survey on Athenian nightlife settings (clubs, parties, bars and coffee shops) of four youth music scenes (trance, house, rock and Greek popular music), UMHRI 1998. This survey was part of a European Research Programme called “Sonar Project” and organised by IREFREA. 4. Small-scale survey on “street” drug users from Athens and Thessaloniki, Organisation Against Drugs (OKANA) 1998. This survey was part of a European Research Programme called “Boule de neige” and organised by Modus Vivendi asbl -a non-profit organisation- and supported by the French Community of Belgium & Communal Committee of France. 5. Treatment Demand Indicator, 2001. 6. Early Warning System Network.

154 7. Discussion on polydrug use with a group of experts in the drug field (treatment services, Forensic Laboratory of the Medical School of the University of Athens, General Chemical State Laboratory), Greek REITOX Focal Point 2001.

Data gaps

- Most statistical data do not provide us with detailed information on the patterns of polydrug use (e.g. successive or simultaneous use of substances), so the data concerning this issue is limited. - Absence of police data on combinations of substances in the local market. - No specific survey has been conducted on polydrug use. Data presented in this chapter derives from surveys, which do not focus on this issue, so ad- hoc created variables give only a vague picture of the phenomenon.

11.5.2 Future needs

Specific questions on multiple use should be added to the questionnaires distributed to certain groups of users (“street” users, users approaching treatment services or recreational drug users), in which this pattern of drug use is prevalent. This extra information on polydrug use would help scientists, researchers, group of experts and politicians to define the dimensions of this phenomenon.

Conclusions

• According to the group of experts, polydrug use is a multidimensional phenomenon, so its definition should include all the relevant dimensions.

• The main patterns of multiple use concern two categories of drug users. The “new” users who experiment with different substances, using cannabis as their primary substance, whose multiple use is connected with their involvement in certain subcultures, as well as the “old” users who use a primary substance and also take one or more substances for self-medication.

• Multiple use seems to be a frequent pattern of drug use among drug addicts -such as those approaching treatment services and “street” users- or among recreational drug users. The fact that users approaching treatment services in our country usually take more than a single substance is in accordance with other research findings (Gossop et. all, 2000).

• The prevalent pattern of multiple use among recreational drug users is that of the cannabis user who also takes synthetic drugs and/or cocaine and drinks alcohol excessively. This can be confirmed by data from a research conducted on a Scottish dance scene, where most interviewees reported taking at least another psychoactive drug with MDMA (Foryth, 1996).

155 • According to data deriving from the Treatment Demand Indicator and bibliographical references, multiple use among drug addicts seems to be a growing phenomenon in Greece and other European countries, since the respective percentages have recently increased (Bygvist, 1999).

• The most popular substances used by drug addicts are heroin, cannabis, hypnotics and sedatives, cocaine and methadone.

• The majority of polydrug addicts reported intravenous drug use for their primary substance, which was mainly heroin. In particular, most young drug addicts appeared to smoke heroin.

• The health and psychological problems of users intensify during the period of their multiple use. This can be further confirmed by the fact that a large number of multiple users adopt risk behaviour, such as making dangerous combinations of drugs (Darke, 2000) or sharing syringes and other injection material, compared to other users. Similar opinions were expressed concerning the social problems of multiple users, since an increase in unemployment, as well as in illegal activities and law offences, was reported (Kokkevi et all, 1992). However, some individuals from the same group of experts argued that all drug addicts share similar health and social problems, irrespective of the number of substances used, since the degree of drug addiction contributes substantially to the appearance of these problems.

• Experts claimed that the development of specific approaches in the treatment field, which focus on multiple substance use per se, might not be necessary, since the treatment model has become more “flexible”, allowing therapists to adjust treatment interventions to each individual case.

• The new phenomena, which have recently appeared in the local market, include the increase in the amounts of pharmaceutical substances and synthetic drugs distributed in the market, as well as the circulation of adulterated drugs, such as heroin and cocaine. These phenomena contribute to polydrug use (Byqvist, 1999).

• Polydrug use does not seem to be adequately investigated in Greece. The lack of precise data is also reported by European literature (Parrott et al., 2000; Topp et al, 1999; Zador & Sunjic, 2000).

12. SUCCESSFUL TREATMENT: THE EFFECTIVENESS OF THE INTERVENTIONS

Taking into consideration the importance attached by the EU to the definition of the term “successful treatment” of drug addiction, the Greek Focal Point organised two meetings of professionals who are in charge of several therapeutic agencies in the country. These meetings were held with the aim of discussing and elaborating, as a group, on various issues relating to successful

156 treatment. The participants in these meetings represented different treatment settings, intervention approaches and types of treatment (see Annex IV).

The theoretical - scientific framework and the “criteria of success” of the different therapeutic programmes, the methodological dimensions of their evaluation, the practical difficulties encountered and the necessary political prerequisites for achieving “successful treatment” were some of the topics discussed in the meetings. The information presented in the following chapters includes inputs and comments from these two meetings, with the exception of cases where it is indicated that other sources of information were used.

12.1 Approaches to treatments and related concepts of success

12.1.1 The concept of “success” in drug addiction treatment

In the context of clarifying “successful treatment”, it is extremely important to specify the term “treatment”, the way Greek professionals perceive it, before defining “success”. This need arises from the fact that the term treatment constitutes a broad concept, embracing many different interventions, approaches and modalities, which often result in a respective difference of opinion among Greek professionals that inevitably influence the definition of “success”.

Thus, the main relevant conclusions, which were drawn from the aforementioned meetings with the representatives of Greek therapeutic agencies, are as follows:

• The terms “treatment” and “treated addicts” must not be confused with the terms “cure” and “cured or healed addicts” respectively. The latter two concepts rather denote the expected result of treatment, whereas “treatment” mainly refers to the therapeutic process itself, which, in many cases, consists of various interventions, each with different objectives. • As a result,, although physical and psychosocial recovery from drugs could (and should) be the ultimate goal of drug addiction treatments, “success” in treatment should not be equated with “abstinence”, since many therapeutic programmes do not include abstinence in their objectives. In a similar vein, “relapse” should not be equated with “failure” of a therapeutic programme. • In addition to the above, recovery from drug addiction should not be reduced to abstinence from drugs, since drug addiction is a multidimensional problem that affects various domains of one’s life. In this context, it is quite often for drug users to substitute drug use with the use of a legal substance (i.e. alcohol) or with another type of dependent behaviour (i.e. gambling), which should be taken into account when evaluating a treatment programme. • “Treatment” should be perceived both as a multi-phase / multi-intervention procedure and as a continuum within the same therapeutic agent, but also within the national therapeutic system. In this context, “success” is defined - by different criteria in each separate phase or intervention, and the programme’s effectiveness depends on the effectiveness of each different

157 phase. At the same time, however, these different phases or programmes should be seen as links in a chain of activities that aim at the ultimate desired outcome, namely the “success of the agent” or the “success of the whole therapeutic system”. • The definition of “success” and the definition of “drug dependence” appear to be interrelated. It has been observed that therapeutic agencies and policy makers adopt different definitions of drug dependence, which influences their therapeutic or policy planning and the established set of success criteria in each case.

12.1.2 Criteria of success in drug addiction treatment

Based on the above points, the criteria of success are more or less different between the various therapeutic programmes in the country, as each of the latter has different objectives. However, there are several criteria common to all programmes, which could be characterised as more procedural than outcome- related ones (i.e. mean duration of treatment, retention and relapse rates, etc.). Even in this case, though, there are certain limitations on how these common criteria could be applied to different programmes.

The different criteria of success regarding intervention approaches and treatment settings as well as target-groups are presented below.

Drug-free therapeutic programmes

The vast majority of drug-free programmes in Greece are multi-phase ones, consisting of a counselling centre, a detoxification unit in some cases, a therapeutic community (residential or non-residential) and a social rehabilitation centre. As it has already been mentioned, multi-phase therapeutic programmes perceive treatment as a continuum with different objectives at each stage of therapy.

Thus, the main criteria of success for a counselling centre are the following: a) decrease in drug use, b) decrease in deviant behaviour, c) increase in the drug user’s motivation to enrol at the therapeutic community, and d) the drug user’s efforts to take care, and thus to improve, his/her physical health. Different criteria apply in the phases of the therapeutic community and social rehabilitation. In this case, the programme is considered successful when drug users stay abstinent from all illegal drugs and from alcohol, they do not exhibit deviant behaviour, they find a job and make other functional changes in their life (i.e. find their own house away from family, make friends, become involved in social and cultural events, etc.).

Another highly important criterion of success for all programmes of this type is the degree of involvement of the drug user’s family in the therapeutic process. This could be considered as a criterion drawn from the specific social context in Greece, which is quite family-oriented, along with the fact that drug addiction is somehow connected with the family environment and affects it. This factor has

158 several implications for the evaluation process, since the improvement in family relations constitutes an important evaluation indicator of Greek programmes. Also, it should be taken into account that there are cases where the family members of a drug user may participate in a therapeutic programme, even if the drug user himself does not participate.

Although the aforementioned criteria are considered as a common basis for drug-free programmes, attention should be paid to co-existing differences. A major difference lies between residential and non-residential therapeutic programmes. In most cases, the latter are intended for drug users who have already started working or studying and have a more or less supportive family and social environment. The same applies to programmes without different therapeutic phases. In these cases, the criterion of occupational rehabilitation or improvement in educational status does not weigh that much. Differences exist among drug-free residential programmes as well; for example, in their mean duration of treatment. These parameters should be cautiously taken into account when it comes to evaluating a therapeutic programme or making comparisons between similar programmes.

Hence, “successful treatment” in the Greek multi-phase, abstinence-oriented therapeutic programmes is seen as a multi-level change in the drug user’s life and way of living, which is not, however, solely attributed to abstinence from drugs. It is the result of a process comprising different stages of change in each therapeutic phase, which should be taken into account when evaluating such a programme. Recovery from drugs, in its broader sense (both physical and psychosocial), also constitutes a success criterion for the therapeutic programmes that have only one phase.

In relation to the above points, an exception is considered to be a multi-phase drug-free therapeutic agency that is mainly based on the biological definition of drug dependence, and therefore, although it includes psychosocial changes of drug users in its success criteria, it focuses more on the criterion of abstinence. This is also attributed, however, to practical difficulties that the specific agency is facing, which limit the therapeutic possibilities provided to drug users.

Substitution therapeutic programmes

There are several differences in the success criteria of treatment among the existing substitution programmes in the country. First, although the main success criterion for the three substitution-detoxification units in Athens is abstinence from all drugs, including methadone, the respective criterion for the two substitution units in Thessaloniki is decrease in illegal drug use. Thus, the substitution units in Thessaloniki are not abstinence-oriented, at least not to the extent the respective units in Athens are. Second, the units in Athens include abstinence from alcohol in their criteria, which is not the case for the units in Thessaloniki.

Another difference is the one between the substitution-detoxification units and the substitution-maintenance unit in Athens. The substitution-detoxification units

159 attempt to achieve abstinence from all drugs (including methadone) within a specific time limit (approximately 18 months), whereas the maintenance unit has no time limits and it mainly aims at harm reduction from drugs rather than abstinence.

Despite these differences, the common criteria of success shared by all substitution units in the country are as follows:

• The degree of the programme’s “attractiveness” to drug users and the retention rates. These criteria could not be applied, however, to the maintenance programme due to its nature. • The decrease in the drug user’s deviant behaviour. • The degree of improvement in the drug user’s health at all levels, namely the drug user’s physical, psychological and social health.

It should be noted that there is an emerging trend for all substitution programmes in the country to focus more on harm reduction rather than on total abstinence from drugs in the next few years. This is expected to provoke several changes in the respective success criteria of this type of treatment in the future.

Therapeutic programmes intended for specific target groups and drugs used

The main types of programmes for specific target groups in the country are those intended for adolescent and young drug users, for addicts with dual diagnosis and for drug dependent women and/or mothers. All of these treatment programmes are drug-free, and therefore, one of their main success criteria is total abstinence from drugs, taking into consideration that for drug-free therapeutic programmes, in general, abstinence is interrelated with broader changes in one’s life, as it has already been mentioned.

Moreover, the success criteria of such treatment programmes are in tune with the special needs of their target group. Thus, treatment programmes for adolescent and young drug users consider as their primary success criterion the prevention of the transition from drug use to drug addiction. Also, they pay special attention to the improvement in the educational status of the drug user, while the involvement of family in the therapeutic process is of crucial importance. The programmes for addicted women consider as important success criteria the resolution of sex-related problems (i.e. prostitution and sexual abuse) as well as the improvement in the mother-child relationship. The most prominent success criteria of the treatment programme that is intended for drug users with co-morbidity are the physical and psychosocial recovery from drug addiction in parallel with the effective treatment of the existing psychiatric problems.

Regarding the success criteria of therapeutic programmes in relation to the drugs used, there are no specialised programmes for specific substances in the

160 country, apart from a few intended for alcohol users, which share the same criteria with the drug-free treatment programmes.

As it has already been mentioned, some criteria of success could be considered as common to various therapeutic programmes, although attention should be paid to certain limitations as well as to specific social and cultural factors that influence their application. These “common” criteria are presented below.

“Common” criteria of success among different therapeutic programmes

According to the representatives of the existing treatment agencies in Greece, the success of a therapeutic programme could be defined on the basis of the following criteria:

• Admissions to a programme. They are important because even if a drug user stays in a programme only one day, it is considered to be to his/her advantage. In this context, in the case of a multi-phase treatment programme, it is important to take into consideration not only the admissions to the therapeutic community, but also the admissions to the counselling centres. • The programme’s attractiveness. This depends on several factors, such as the degree of easy access to the treatment services, the adequate information of the drug user about the framework and the objectives of the programme, and the quality of the programme’s structure. The waiting lists are not considered as an indicator of the attractiveness of the programme, since they appear to be mainly determined by political decisions. However, the waiting lists of the Greek substitution programmes are considered to have certain implications for their “success”. For example, 20-25% of the drug users on the waiting list pass away before being admitted to the programme, while drug users who participate in the programme are discharged after their second or third relapse in order for other drug users on the waiting lists to be admitted. The latter influences the retention rates of the particular type of programmes in Greece. • Retention rates as well as dropouts. Specific research results (KETHEA & NSPH, 2001) have shown that the longer one stays in a therapeutic programme the fewer relapses he/she has, while the positive influence of the time spent in treatment is evident in other indicators, too (i.e. decrease in deviant behaviour, occupational rehabilitation). Considering the mean duration of treatment as a criterion of success appears to be quite important, since positive therapeutic results are interrelated with adequate time provided for treatment. Regarding dropouts, apart from their number, another indicator of the programme’s quality is the effective way of dealing with them, namely the ability of the programme to bring the drug user back to it. • The flexibility of the programme. A programme of quality should be flexible, in terms of dealing effectively with each different person, according to his or her particular needs. This is of the utmost importance when the programme

161 has to deal with addicts having co-morbidity problems, which is a major issue among Greek therapeutic agencies. • Relapse rates as well as relapse prevention. Relapse appears to be associated with the adoption of a behaviour related to drug addiction rather than with the sole use of drugs after having been abstinent for a certain period of time (i.e. lapse). This means that a relapse may occur prior to drug use. Hence, a criterion that assesses the quality of treatment is the prevention of relapses, in terms of establishing and maintaining the healthy changes in a drug user’s life. This is interrelated with the provision of after- care services, which constitute another criterion of a programme’s quality. Along with the social rehabilitation services, which are considered as an integral part of therapy in Greece, the programme should develop a network of several co-operating agencies and organisations that will assist former drug users in their re-integration process. • The cost-effectiveness of a programme is considered of crucial importance, though attention should be paid in order not to identify the “effective programme” with the “low-cost programme”.

Along with the aforementioned criteria of success, there are some additional parameters that are considered necessary to ensure the quality of a programme (i.e. adequacy of personnel, sufficient funding, establishment of a supportive network in the field of treatment, referrals, etc.). These parameters, however, appear to depend largely on political decisions and, in many cases, this results in inconsistency between the political strategy and the professional choices.

12.1.3 Political and professional choices and principles behind the approaches

Both professionals and policy makers in the drug demand reduction field appear to acknowledge the imperative need for the development of different types of interventions, programmes and approaches in the country, in order to satisfy the particular and different needs of drug users. However, there are certain points regarding “successful treatment” that result in some inconsistency between political and professional choices.

First, the emphasis placed lately by policy makers on harm reduction policy appears to induce opposition from most of the professionals in the drug field. Although the latter accept the value of harm reduction, they argue that abstinence-oriented therapeutic programmes should constitute the core of treatment in the country, instead of substitution programmes, aiming at maintenance to a large or small extent.

Another important issue is the existing lack of a well-co-ordinated and unified network among the different therapeutic services as well as between them and other agencies that could contribute to the treatment and the social rehabilitation of former drug users. Greek professionals argue that the existing therapeutic agencies are quite isolated from each other as well as from other social and health services in the country, and that co-operation among the different agencies in the demand reduction field is limited. This lack impedes the

162 therapeutic outcome, and thus, the “successful treatment”. Along these lines, OKANA has recently taken the initiative and has invited all therapeutic agents in the country in order for a complimentary and coordinated action in the treatment field to be taken at a national level.

Along with the lack of sufficient networking and co-operation in the field of treatment, other factors that impose restraints on the quality and success of treatment services are the lack of funding and adequate personnel – especially with regard to those programmes that operate under the auspices of public hospitals – as well as the lack of treatment services at local and regional level. These problems influence the aforementioned success criterion of “attractiveness” of a programme, result in various organisational difficulties, and reduce the therapeutic results.

A significant issue, regarding the inconsistency between political and professional choices, concerns the evaluation of the therapeutic programmes. It has been argued that, in some cases, the evaluation has been imposed by the state so that administrative measures can be taken rather than improving the provided services. This is probably not to the programmes’ advantage, and it has resulted in respective reservation on the part of professionals, with regard to requests by policy makers to evaluate their programmes. It seems that the lack of active participation of professionals in the policy planning process regarding drug addiction treatment and evaluation is contributing to this inconsistency between them and policy makers. However, the prohibition of professionals to have their treatment programmes evaluated by state agencies may also be attributed to the existing lack of a clear-cut evaluation plan with concise and specific targets.

The principle behind political choices appears to be the biological definition of drug addiction, according to which drug addiction is an illness. This principle is shared by a limited number of therapeutic agents, whereas the majority of them agree that drug addiction is a physical and psychosocial dysfunction that goes beyond the definition of illness and that it involves not only the person but also the family and the wider social context. On the basis of this difference of opinion, it has been argued that the social integration of drug users is impeded by the “double messages” they are receiving from the therapeutic and the socio- political context. This is considered to have inevitable implications for the “success” of treatment programmes.

12.2 Evaluation of the treatments

The evaluation of the treatment programmes in Greece is currently neither in a uniform state of progress nor performed with similar methodology and/or instruments. Therefore, many differences exist in treatment evaluation in the country, in terms of the degree of evaluation development, the type of the evaluation procedure (i.e. ongoing, internal-external, quantitative-qualitative), the evaluation tools used and the analysis and publication of the evaluation results.

163 Follow-up evaluation studies

KETHEA took the initiative to evaluate the effectiveness of its therapeutic communities from mid 1999 to June 2001, with a follow-up study after five years of drug users’ admission, in co-operation with the Department of Sociology of the National School of Public Health (NSPH). The sample of this study included 551 individuals (445 men and 116 women) from the total population of 766 drug users who had been admitted, even for one day, to the six therapeutic communities operating from 1.1.1994 to 31.12.1995 (i.e. ITHAKI, STROFI, EXODOS, PAREMVASI, DIAVASI, NOSTOS). The total number of interviews that were held involved 388 individuals (70.4%) from the sample. The study was based on both quantitative and qualitative methodology. Thus, the EuropASI questionnaire was used in an adapted version for a 5-year follow-up, so as to get standardised information on the different domains of the life of the participants. Also, researchers held an in-depth interview focused on important life events and the management of crisis in the five years following admission as well as on the perceptions of the participants regarding therapy and their satisfaction from the services they received.

Some preliminary results of the study (KETHEA & NSPH, 2001) showed that the therapeutic community model is highly effective in terms of treating and socially rehabilitating drug addicts. Also, the effectiveness of a therapeutic programme depends on the time spent in treatment. A year of intensive treatment on the therapeutic community model appears to result in the decrease in drug use and deviant behaviour and to contribute to the drug user’s occupational rehabilitation.

Figure 29: Heroin use: Changes in relation to the time spent in treatment

Duration of stay in treatment (in days)

* Statistical significant differences up to 99% (a=0.01)

SOURCE: KETHEA & NSPH, 2001.

164 However, it is worth mentioning that, at the moment, there are no data regarding the path followed by drug users in the period following their release or discharge from the therapeutic communities of KETHEA (e.g. whether they approached another treatment programme), which is of the utmost importance in order to offer valid interpretation of the respective evaluation findings.

In Figure 29, heroin, as the main substance used before being admitted to a therapeutic community, decreased by 11% for those who were in treatment for up to 3 months, by 31% for those who stayed for 3 to 9 months, by 47% for those who were in treatment for 9 months to 1 year, and by 76% for those who stayed for one year or more in the therapeutic programme.

There are similar positive results in relation to the drug users’ deviant behaviour (i.e. arrests, convictions, confinements, etc.), since the longer a drug user stayed in the therapeutic programme, the less he/she engaged in criminal activities (Figure 30). This results in a subsequent reduction in personal and social harm from such drug-related problems.

In relation to the occupational rehabilitation of drug users participating in a therapeutic community, respective findings showed that employment rates have increased substantially depending on the time spent in treatment. Thus, employment increased by 157% for the drug users who had stayed for up to 3 months in the therapeutic community, by 286% for those who had stayed for 3 to 9 months, and by 83% and 227% for those who had been in treatment for 9 months to 1 year and for those who had stayed for one year or more in the therapeutic programme, respectively (Figure 31).

Figure 30: Problems with the criminal justice system (arrests, convictions, confinements): Changes in relation to the time spent in treatment

Duration of stay in treatment (in days)

* Statistical significant differences up to 99% (a=0.01)

SOURCE: KETHEA & NSPH, 2001.

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Figure 31: Employment: Changes in relation to the time spent in treatment1

Duration of stay in treatment (in days)

1 It includes full time (>= 20 hours per week) or part time employment (<20 hours per week) on a regular and/or on occasional basis * Statistical significant differences up to 99% (a=0.01)

SOURCE: KETHEA & NSPH, 2001

In contrast to KETHEA, the other treatment agencies in the country either have not provided for a follow-up evaluation or they have faced particular practical problems that impeded the scientifically sound and methodical implementation of such an evaluation. For example, the Drug and Alcohol Dependency Unit “18 ANO” had planned to hold follow-up meetings twice a year with those who complete their therapeutic programme. Due to the lack of personnel, this plan was reduced to the organisation of follow-up meetings once a year with those who had completed treatment five to six years ago. These meetings are expected to take place every three months with the participation of all drug users who complete treatment in the current year and with those who have completed treatment five to six years ago. The data collected from these meetings are mainly qualitative, regarding the changes that former drug users achieved and/or maintained in their lives. However, quantitative data on the basis of self-drawn up questionnaires are going to be used in the near future. Follow-up studies are expected to be conducted by the substitution programmes of OKANA as well.

Evaluation methodology and tools

The most systematic and comprehensive evaluation is conducted by KETHEA, which evaluates its services both internally and externally with the parallel use

166 of quantitative and qualitative methodology (see 2000 Annual Report submitted to the EMCDDA, pp. 119-120). The evaluation of the other treatment services is mainly conducted internally, with the use of self-drawn up or standardised questionnaires and the collection of qualitative data from clinical interviews and, in some cases, from follow-up meetings. Also, urine testing is applied for the assessment of the use of illegal drugs as well as alcohol in some programmes.

The most common instruments used by the Greek treatment programmes are the Treatment Demand Indicator (TDI) and the European Addiction Severity Index (EuropASI), which, however, is not applied to all programmes. Also, some agencies have used the Treatment Discharge Form in its pilot implementation. The self-drawn up questionnaires, as well as the collected qualitative data, are in accordance with the objectives and the philosophy of each separate programme; as a result, there are only limited results from the various therapeutic agencies to be compared.

Comparative data between treatments

The vast majority of the evaluation results, provided by the treatment services in the country, concern process indicators rather than outcome ones. This is due to several factors, including the lack of specific training in evaluation methodology as well as the lack of funding, personnel and adequate infrastructure for the purposes of evaluation. Thus, the evaluation of the Greek treatment services is rather fragmented and “immature” at the moment, despite the willingness of professionals to secure the necessary prerequisites, so that outcome evaluation research may be conducted on their programmes.

Due to the aforementioned difficulties and methodological differences in the evaluation of the therapeutic programmes in the country, comparative analysis of the outcome evaluation data between treatment programmes would result in misleading conclusions at this point. It appears that the current lack of objective and reliable evaluation research studies of the various treatment programmes in Greece prevent the gathering of any analytical and comparable evaluation data concerning the effectiveness of treatment programmes. Thus, before making any comparisons, it is of the utmost importance to plan, to develop, and to conduct scientifically sound, outcome evaluation studies on all treatment programmes.

However, an attempt was made to compare some existing results of process indicators between the main types of treatment in Greece (i.e. drug-free residential programmes, drug-free non-residential programmes for both adults and adolescents, and substitution programmes) based on the data gathered by means of the TUF questionnaire in 2000. It should be taken into account, though, that such a comparative review has certain inherent limitations, due to the structural and functional differences of the various treatment programmes.

These data relate exclusively to the programmes/units of the main phase of treatment (i.e. therapeutic communities) and include the following: a. the number of drug users who were admitted to the therapeutic programmes during

167 2000, b. the number of drug users on waiting lists, and c. the number of drug users who completed their treatment, as well as those who either were prematurely discharged or dropped out from treatment programmes. Also, they include the main reasons for premature discharge.

As far as the a d m i s s i o n of drug users to treatment units is concerned, the total number of admissions exceeded the capacity of the units (170% full) in 2000. In addition, 75,8% of all admissions were new cases (Table 31). These data stress the rising need for treatment of the drug users, and, by implication, the necessity for the establishment of new therapeutic units, which will cover the number of users seeking therapy.

Table 31: Admissions to treatment units and waiting lists for the year 2000

TOTAL NEW WAITING NUMBER OF ADMISSIONS LIST ADMISSIONS N % N % N % Drug-free residential programmes (N=8) 832 32.6 714 37.0 86 3.2 Drug-free non-residential programmes for adults (N=9) 862 33.8 637 33.0 57 2.1 Drug-free non-residential programmes for adolescents 532 20.9 393 20.3 50 1.9 (N=3) Substitution programmes 323 12.7 188 9.7 2474 92.8 (N=4) TOTAL 2549 100.0 1932 100.0 2667 100.0

SOURCE: Therapeutic Programmes’ Network of the Greek Focal Point.

According to Table 31, the largest percentage of new admissions occurred in the drug-free residential programmes for adults (37%), followed by the drug-free non-residential programmes for the same age group (33%), and the respective programmes for adolescents (20.3%). The new admissions to the substitution programmes for the year 2000 amounted only to 9.7% of all therapeutic programmes. This fact is attributed to the lengthy duration of substitution therapy (3 years) until recently, and the subsequent lack of vacancies for the admission of new clients.

In 2000, the great majority (92.8%) of those on w a i t i n g l i s t s applied for the substitution programmes (Table 31), although this percentage was lower than that of 1998, according to which, 98.5% of the total number of drug users on waiting lists concerned the substitution programmes. This decrease is due to the reduced number of individuals on waiting lists for substitution treatment (2,667 in 2000 compared to 4,076 in 1998), given the fact that two new substitution units were inaugurated in 1998. At this point, it is worth mentioning, however, that the percentages of those on waiting lists for drug-free

168 programmes do not give the true picture of the situation, since the waiting lists concern more the counselling centres of these programmes – which constitute the first phase of treatment – rather than the programmes of main therapy.

With regard to the c o m p l e t i o n o f t h e r a p y , out of 24 treatment units recorded on the list, 7 units (2 residential and 5 non-residential therapeutic units/ 4 for adults and 1 for adolescents) did not provide data. Consequently, the data presented in Table 32 refer to 70.8% of the therapeutic units in the country.

Table 32: Drug Users who completed or were discharged from treatment per type of treatment unit

Drug-free Drug-free Drug-free non- Substitution TOTAL* residential non- residential programmes programmes residential programmes for programmes adolescents for adults Completed treatment 40.1 14.9 31.0 15.2 25.9 Premature discharge 8.6 4.2 16.9 48.9 15.8 Drop-outs 38.5 43.3 4.9 10.8 31.7

* The remaining percentage refers to drug-users who were still in treatment

SOURCE: Therapeutic Programmes’ Network of the Greek Focal Point.

According to Table 32, the total percentage of individuals who completed treatment in 2000 was 25.9%, 31.7% of individuals dropped-out, while 15.8% of individuals were prematurely discharged from the treatment unit.

More specifically, the majority of the participants in the drug-free residential programmes (40.1%) completed treatment successfully, 38.5% dropped out, while an early release ticket was issued for 8.6% of the participants. In the non- residential programmes for adults, the percentage of individuals who completed therapy amounted to 14.9%, while 43.3% of them discontinued treatment and 4.2% were prematurely discharged. Finally, with regard to the programmes for adolescents, the majority (31%) completed treatment, 4.9% dropped out, while an early release ticket was issued to 16.9%.

With regard to the substitution programmes, in the year 2000, approximately half of the participants (48.9%) were prematurely discharged. It should be noted, however, that premature discharges from substitution programmes mainly take place so that other drug users on the waiting lists can be admitted. 15.2% of the participants completed therapy, while 10.8% decided to drop out.

169 Table 33: Reasons for premature discharge

REASONS % Use of illicit drugs on the premises 2.7 Use of illicit drugs outside the premises 52.9 Involvement in illegal activities other than using illicit drugs 3.1 Missing therapy or counselling sessions 2.7 Violent behaviour on site 11.8 Violation of unit’s/programme’s rules or regulations 11.4 Other reasons 15.3 TOTAL 100.0

SOURCE: Therapeutic Programmes’ Network of the Greek Focal Point.

According to Table 33, the main reason for premature discharge was the use of illicit drugs outside the unit’s premises (52.9%), followed by other reasons (15.3%) that include aggressive behaviour outside the premises, involvement in sexual relationships with other participants in the programme, issue of writs for arrest, and death.

Aggressive behaviour on the premises and violation of internal regulations amounts to 11.8% and 11.4% respectively of all reasons for premature discharge. Finally, the involvement in other illegal activities (excluding the use of illicit drugs) was the reason for the early release from the unit of 3.1% of the participants. The percentage of those using illicit drugs inside the unit equals the one of those with poor attendance at counselling and/or therapy sessions.

12.3 Methodological issues

As it has already been mentioned, the information regarding the definition of “successful treatment” in the country and the evaluation results of the existing therapeutic programmes arose from two meetings with professionals in the field as well as from data provided by the EDDRA and the TUF questionnaires and relevant evaluation reports.

The two aforementioned questionnaires are distributed to all therapeutic programmes on an annual basis, so as to acquire updated information on the developments and the new evaluation results in the field of treatment. However, in many cases, treatment programmes provide limited information on evaluation results, which may be explained either by the lack of data per se or by some kind of mistrust of how these data will be used (i.e. whether they will be used to the programmes’ advantage or not) given the fact that there is a general scepticism on the part of professionals regarding the use of evaluation – both as a practice and as an outcome – by policy makers.

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The further enhancement of a trustworthy relationship between the Greek Focal Point and treatment agents as well as between treatment agents and policy makers is expected to contribute to the provision of evaluation data and its dissemination. To ensure this, drug professionals should have a more active role and participation in treatment and evaluation policy and practice. In this context, the aforementioned meetings that were organised by the Focal Point aimed, among other things, to strengthen the co-operation between professionals and to help forward their needs and proposals to policy makers. This appeared to be extremely appreciated by the treatment agents and further steps in the same direction are to be taken in the near future.

With the aim of eliminating data gaps, especially in relation to outcome evaluation results, it is important to meet the necessary prerequisites for ensuring evaluation progress in the treatment field. According to Greek professionals, the main prerequisites of such an endeavour are the following:

• To ensure separate funding for evaluation studies, since the existing funds are considered limited even for the therapeutic activities. This inevitably results in the current prioritisation of treatment interventions over research, evaluation and training activities.

• To promote both internal and external evaluation. The latter should be appointed to independent and reliable agents with expertise in evaluation studies and with adequate information on the particular aspects of treatment programmes. Moreover, external evaluation should be conducted with the approval and the voluntary co-operation of the programme’s personnel. Regarding internal evaluation, this is feasible and effective only if special training on evaluation issues is ensured.

• Evaluation should be first and foremost perceived as a research study and not as an administrative measure for imposing changes to the treatment programmes or for reducing their cost. This presupposes the elaboration of specific research plans with the active involvement of the programme’s staff. In this context, a methodological problem may consist in the possible ways of ensuring the reliability and validity of the suggested research plans and methods, as well as the adaptation of specific instruments to the particular context of a therapeutic programme.

• In relation to the previous point, it is necessary to elaborate evaluation plans of both quantitative and qualitative methodology that will be in accordance with the specific functional and structural characteristics of the therapeutic programme under evaluation. An undifferentiated evaluation pattern of the various types of treatment programmes, although easier to develop, would, in the long run, lead to dubious comparable results.

With regard to the aforementioned points, it is necessary to further promote treatment evaluation studies in the country with the establishment of on-going evaluation at each therapeutic programme, the organisation of systematic follow-ups and the introduction of comparative research in the treatment field.

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Special emphasis should also be placed on the development of qualitative methods, on the quantification of qualitative indicators (i.e. improvement in family and social relations, psychological improvement) and on the implementation of cost-effectiveness studies. The monitoring of the course of the drug users within the regional and/or the national therapeutic system as well as their satisfaction from the provided services and their own perceptions regarding treatment appear to be research fields of great interest. Moreover, research on the hidden population of drug users and on the needs of special groups (i.e. minorities, imprisoned drug addicts) is quite limited at the moment.

Finally, the establishment of central management information systems at each therapeutic agent comprising several therapeutic programmes would improve data analysis. The centralised analysis of data from each programme would provide standardised and comparable information between the different units/programmes of each treatment agency and between the various treatment agencies in the country.

13. DRUG USERS IN PRISON

Greece currently has a total of approximately 8350 prisoners, who are housed in 28 prisons nationwide. The total housing capacity of these prisons is, however, 5284 beds (data on 01/10/01). More than one third of the total prison population (N=3402) are being held for drug-related offences. Based on expert evidence, one third of the drug-related offenders have been incarcerated for drug-dealing offences, whereas the remaining two thirds are drug-users.

Table 34: General statistics 2001

Variable N % Housing capacity 5284 Prisoners 8493 100 Held In custody 2409 28.3 Non-Greek 3711 43.6 Female 425 5.0 Juveniles 590 6.9 Drug-related offenders 3402 40.0

SOURCE: Ministry of Justice, 2001

172 Table 35: Prisoners with drug-related offences

Year 1994 1995 1996 1997 1998 1999 2001 N 2501 1890 2171 1998 2280 2648 3402 % 36.3 33.2 36.8 37.6 37.0 36.3 40

SOURCE: Ministry of Justice, 2001

Detainees for drug-related offences are distributed to almost all of the 28 prisons, although the majority can be found mainly in the three largest prisons (Korydallos, Patra, Larissa).

Table 36: Distribution of prisoners for drug-related offences

PRISONS IN CUSTODY CONVICTED Aghia 11 Alikarnassos 8 63 Avlona 33 50 Chalkida 3 31 Chania 30 8 Chios 27 20 Ioannina 70 39 Kasavetia 4 23 Kassandra 15 KAYF Kerkyra 5 48 KKF Women 82 96 Komotini 40 40 Korydallos 350 572 Korinthos 13 8 Kos 5 16 Larissa 10 228 Malandrino 82 Mental Hospital 30 22 Nafplio 73 117 Neapoli 29 3 Patra 24 539

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PRISONS IN CUSTODY CONVICTED Prebantorio 50 49 Thessaloniki 257 63 Tiryntha 4 Trikala 5 53 Tripoli 2 Volos 23 29 1186 2216 3402

SOURCE: Ministry of Justice, 2001

13.1 Epidemiological situation

It is generally difficult to determine the overall number of HIV-positive inmates, much less the number of inmates who may have contracted the disease from dirty needles. At the Korydallos Prison, no systematic data are collected regarding medical cases or results from medical examinations. However, in 2001, 6 prisoners were carrying the HIV-virus and were held in a special unit in the Prisoners’ Hospital for special treatment.

A recent study that was carried out on HIV risk behaviour correlations among injecting drug users in Greek prisons offers valuable information on the epidemiological situation of drug use in prisons (Koulierakis et. al., 1999; 2000). The study, which was carried out in ten prisons nationwide between October 1995 and June 1996, involved a sample of 1000 male prisoners. Data analysis was conducted on 861 questionnaires that were completed and returned. The findings showed high rates of sharing practices in the prisons. Almost 60% of the drug users in the sample admitted having injected drugs at some time while in prison and the vast majority (more than 80%) of those injecting in prison shared equipment during the injecting procedure (Koulierakis et. al., 1999; 2000).

Although data collected through various research projects are not directly comparable, due to differences in methodology, they do give a clear picture of an escalation of drug use among prisoners in at least some major Greek prisons. Reports by doctors, nurses and penitentiary staff in the health centre of the Korydallos Prison indicate that most of the medical problems recorded relate directly or indirectly to injecting drug use (withdrawal syndrome, intra- muscular abscesses, poor stomatic hygiene) and to poor quality of life and health conditions. Similarly, and despite the lack of valid data, there are suspicions that there is a steep increase in blood-transmitted diseases among drug-users in prison (i.e. Hepatitis B and C). This is due to an increase in the use of injected drugs and, owing to strict regulations and inspections as well as

174 the lack of a “clean needle” scheme, the sharing of the same injecting equipment by a large number of inmates (most of the time, one needle per prison wing) (DWB, 2001).

The extent of the problem would easily prove to be greater if tests could cover all inmates. The vast majority (97.1%) of the inmates, who filled in the questionnaire distributed by the Doctors Without Borders-Greece in the Korydallos Prison, reported that they had not been given medical tests upon their incarceration by the prison –or medical authorities. According to the Correctional Code of 1989, all prisoners should be given all the necessary medical examinations on the day of their incarceration or the following day at the latest. In practice, the situation with the check-ups for transmitted diseases comes short of the Code’s provisions. The percentage of inmates tested for transmitted diseases was only 31%. Most importantly, the majority of the inmates (75.6%) were tested on their own initiative (DWB, 2001). Moreover, the percentage of those who claimed that they had been vaccinated was very low, while 52.2% either had no knowledge of the type of the tests taken or could not remember. Only 15.1% were vaccinated for hepatitis B. Again, more than half of those who were vaccinated (54.2%) had done so on their own initiative. Medical examinations and necessary vaccinations do not take place for the following reasons: (a) many prisons do not have a permanent physician on staff, (b) many inmates refuse to be examined and (c) some local hospitals, which are assigned to carry out blood tests, are lacking the essential equipment.

More interesting findings concern drug users held in the Korydallos Prison. Almost half of those who filled in the questionnaire (47.7%) claimed that they had used substances (alcohol, tranquillisers and illicit drugs) in the past. Life in prison did not improve their situation. Only 1.6% of drug-users have abstained from drug use while in prison. Drug use in prison refers primarily to illicit substances (80%), followed by tranquillisers (52.3%) and alcohol (46.7%). In most cases, drug users make a combination of the above substances (DWB, 2001).

Table 37: Use of addictive substances in Korydallos prison

Substance use prior to incarceration (N=136) N % No 71 52.3 Yes 65 47.7

Continued on next page Ê

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Continued from previous page È

Abstinence from drug use in prison (N=65) N % Yes 1 1.6 No 62 95.3 Missing 2 3.1

Type of substance Alcohol 29 46.7 Tranquillisers 34 52.3 Drugs 52 80.0

SOURCE: DWB, 2001

The findings of this study support the hypothesis that in one Greek prison at least, it is highly probable that individuals with a history of drug use will continue substance use while imprisoned. The same study, however, did not consider the extent and nature of drug use in prison.

13.2 Availability and supply1

From the moment they are incarcerated, the overwhelming majority of inmates come very close to, if not enter, a sub-system inside the prison environment that uses and/or traffics drugs.

The drug paths to the Greek prisons are multiple and ever changing. It is estimated that more than half of the drug quantities are brought into prisons through visitation, transfers, and the mail. Prison staff all over the country have sometimes found drugs on children, in babies' prams and hidden in babies' clothing. Some visitors admitted having been forced by third parties to carry drugs. Visitors hide drugs inside every conceivable piece of clothing, from the soles of their shoes to their underwear and in body cavities. Some try putting drugs inside food. In prisons located in or close to urban centres, prisoners’ accomplices slip drugs inside balls and throw them over the prison fence. Prison officials routinely open packages and mail received by inmates and watch visiting areas where drugs might be smuggled.

Prisoners themselves smuggle drugs into prisons. This may happen either after their return to prison, following a short leave granted by the authorities or during their transportation to court to stand trial for various past offences. Guards

1 Information in this section was made available primarily through interviews held with experts and through media reports

176 smuggle drugs into prison too, sometimes offering drugs in exchange for money from the inmates. Prisoners are usually reluctant to report such behaviour.

Some of the consequences of drug trade inside prisons can be far more distressing than outside prisons. Media reports indicate that, in some cases, drug trafficking leads to intimidation, bullying and criminality inside the prison. Many inmates are reluctant to talk publicly about the drug underground for fear of angering the gangs that control the traffic. Drug addicts, who depend on the easy circulation of substances to beguile the cruel reality of prison life, avoid saying anything that might curtail supply.

Media reports explain that the structural characteristics of prisons and the allocation policy for prisoners contribute to the expansion of the problem. The Korydallos prison, for example, is housing nearly 2200 inmates, almost half of whom are held for drug crimes and thefts related to their addictions. This burgeoning population are put in the same sections in the prison and sometimes in cells of 4 inmates. In this respect, prisons provide an environment that sustains substance abuse among users and even fosters drug use in non- users.

13.3 Contextual information

General spatial and structural organisation

It is widely acknowledged that there is still much to be done in Greek prisons to improve living conditions for inmates, especially with regard to the infrastructure/structural characteristics of the buildings and the problem of overcrowding.

The biggest correctional centre in Greece, the Korydallos Prison, has the infrastructure capacity to house up to 900 people. In recent years, due to an increase in the overall relative number of arrests and, subsequently, the large number of individuals that have remanded in custody, this number has been regularly ignored with the average number of prisoners reaching 2200. Both governmental (MoE, 2001) and non-governmental organisations (DWB, 2001) have explicitly stated that overcrowding and the concentration of many inmates in limited space have negative implications for the drug situation in prisons and that this situation is threatening to undermine the objectives of any drug policy in prisons.

The division of prisoners in different sections has also given particular concern. Inmates who have been sentenced for violation of the law on drugs are located in the same prison section with other inmates (DWB, 2001). The private space available to prisoners is usually minimal and as many as 4 individuals may live in one small cell. Sanitary facilities and cleanliness are rather rudimentary. The same applies to spaces intended for recreation, interaction and individual consultation. The implementation of the first educational programmes in prisons albeit still poorly equipped has been a step in the right direction. The workshops of vocational training are scarce and even when they are run their operation is

177 irregular, given the fact that it depends on uncontrollable factors, such as funding from the European Cohesion Fund and other EU programmes (DWB, 2001).

In addition, there is a lack of sufficiently qualified personnel to guard the workshops and, as a result, permanent custodian staff has to work overtime to meet the needs. Social services too are under-staffed. In Avlonas, there are currently 2 social workers for 300 young prisoners, while in the management body of the Korydallos prison, which consists of 49 people, only 9 people operate in the area of social welfare for prisoners (i.e. 7 social workers, 1 criminologist, 1 sociologist) (DWB, 2001).

Despite the genuine efforts made by both governmental and non-governmental organisations, there is still no comprehensive and integrated service to provide treatment and advice on issues of drug addiction. As it is mentioned below, open community treatment programmes have not been developed yet in many Greek prisons. Medical support is rudimentary, while information and documentation on prevention relies purely on the commitment of the staff of non-governmental organisations. The latter, in co-operation with volunteers from the lawyers’ association, are the sole providers of legal advice and support to prisoners. Programmes of occupational rehabilitation for the prisoners are still rudimentary and they depend on external co-operative agencies.

Risk from medical care and related measures

Medical care in prisons needs more support. Expert reviews (BWB, 2001) stress the need to resolve a number of issues: staff for key medical posts, medical expertise and staff permanence. The system that is usually adopted is the “per visit” rotation system whereby specialist doctors visit the prison only on specific days of the week and for only a limited period of time (usually 2 hours). This system is of little help to doctors who are dealing with all kinds of medical problems emerging on a daily basis. In addition, members of the penitentiary personnel fill the positions, which should, in principle, be filled by well-trained nursing staff, although they have not received any special training on first aid or nursing. Their experience is based primarily on practical knowledge, personal interest and basic education at the school for penitentiary staff. Also, there are problems with regard to prison equipment (e.g. lack of basic equipment, old and poorly-serviced tools) (DWB, 2001).

The insufficient budget has negative implications for the available medicines at the pharmacy. The increase in the number of drug users and drug addicted inmates over the last few years, and the lack of long-term integrated programmes for their mental and medical support outside prison, have resulted in a growing demand for psychotropic drugs at the expense of medicines needed for other medical cases (DWB, 2001).

178 Relationships in prison

There is a difference in the way in which penitentiary personnel and inmates perceive their relationship. The majority of the staff considers their relationship with prisoners to be good (43.8%) and/or neutral (40.4%), while some (15.8%) claim that there is a very good rapport between the two parties. No one of the staff thinks of the relationship as being problematic. The latter is in contrast with what seems to be the dominant perception among prisoners, who consider their relationship with the members of the prison staff to be disturbing. Almost 1 prisoner out of 3 of those who filled in the questionnaires (29.6%) think that their relationship with the prison staff is unfavourable. However, an equally important percentage of prisoners (35.5%) find their coexistence with the staff to be either good (20.7%) or very good (14.8%) (DWB, 2001).

Table 38: Perceptions of the quality of relationships between staff and prisoners

Perceptions of staff Perceptions of (N=57) prisoners (N=140) Number % Number % Very good 9 15.8 20 14.8 Good 25 43.8 28 20.7 Neutral 23 40.4 47 34.8 Bad 0 0 41 29.6

SOURCE: DWB, 2001

As for the factors that mostly determine the quality of the relationship between prisoners and the staff, they, too, vary substantially, according to those who filled in the questionnaires. According to the prisoners, the idiosyncrasy and the character of the members of the prison staff account for a good relationship between the prisoners and the prison staff (58.9%). Another important factor seems to be the code of practice, which characterises everyday life in prison (39.5%). Strict norms and regulations in the prison, combined with repulsive behaviour by the staff members, make life in prison unbearable for the majority of inmates. Surprisingly enough, staff members also agree that the current codes of practice are not the appropriate for life in prison, adding that their behaviour towards prisoners is affected by their working conditions to a large extent (DWB, 2001).

179 Table 39: Perceptions of the factors affecting the relationships between prisoners and staff

Perceptions of Perceptions of staff (N=57) prisoners (N=140) Agree % Agree % The code of practice in the prison 29 52.7 51 39.5 Working conditions 27 49.1 The position of the member of staff 24 18.6 Prisoner’s character 21 38.2 The character of the member of staff 76 58.9 Own character 15 27.3 34 26.3

SOURCE: DWB, 2001

Overall, it is clear that there is room for improvement in the relationship between prison staff and prisoners and that the special needs of drug-users and drug addicted inmates must be taken into consideration.

13.4 Demand reduction policy in prison

Laws 1729/87 and 1868/89 acknowledge that drug users constitute a distinctive population in prisons. These laws provide for a special approach to this issue, giving prisoners the opportunity to participate in programmes for mental and physical treatment against drugs while serving their sentence.

Organisation of the drug services in prisons

To this day, there has been no integrated programme for drug use treatment in prisons nationwide. Treatment is primarily provided by the medical staff at each prison. Doctors treat cases of detoxification and mental health problems by prescribing painkillers and tranquillisers for as long as they think it is necessary. Needle-exchange programmes are not implemented in Greek prisons. Bleach is provided in almost every prison and brochures about AIDS in prison are distributed to all inmates (OKANA, 2000). There are no substitution programmes offered in prison. However, Law 2331/1995- Art. 21 (Official gazette, no1, 24/08/1995, p.5243), provides that those who have participated and have completed such programmes may be given the option, subject to a Magistrate’s Court decision, to suspend their sentence and enter a therapeutic community. The time spent in the therapeutic community counts as time served. Prisoners who successfully complete these programmes and have no other pending sentences can benefit from a suspension of their sentence from 3 to 6 years (KETHEA, 2001).

180 In prisons, a wide range of programmes is run by non-governmental organisations that are activated in the wider area of drugs.

The Drug Dependency Unit ”18 ANO” (Psychiatric Hospital of Attica) has implemented self-help groups for drug dependent prisoners since 1995 within a rather limited scope. In 2000, 300 individuals participated in these programmes. Moreover, the Counselling Centre of the Drug Dependency Unit “18 ANO” organises special groups for released prisoners who had previously attended the self-help groups in prison, with the aim of supporting them in their social rehabilitation and preventing relapses. According to data in 2000, 50 released prisoners participated in these special groups.

KETHEA has been conducting programmes for the support of drug users held in various penitentiary institutions in Greece since 1985. These programmes are aimed primarily at informing imprisoned drug users of the risks involved in drug use and advising them on the options open to them of pursuing abstinence from use. Most importantly, the KETHEA programmes for prisoners pave the way for all those drug users who wish to participate in therapeutic programmes.

However, there are serious structural difficulties that surround these programmes and impair their operation. Repeated and ill prepared, organisational and managerial restructuring, which is often the case with correctional institutions, have often affected severely the durability of therapeutic programmes in prisons. The suspension of the KETHEA programme for Juvenile Drug addicted Inmates at the Korydalos Prison in Athens, when that unit was transferred to Avlona (outside Athens), is a typical example of this problem (KETHEA, 2001). Another example is the Drug- Dependency Treatment Unit for Drug Addicted Prisoners in Eleonas, Thebes (central Greece). The Centre would enable juvenile and adult prisoners to participate in treatment programmes. According to the description of the programme, stated in the joint Ministerial Decree no 149020/99, admission to the Drug-Dependency Unit should be voluntary while treatment would be provided in the context of any of three types of treatment programmes: (a) “drug-free”: for prisoners over 21 years old; (b) “drug-free” for juveniles aged up to 21 and (c) “substitution programme” based on the provision of methadone aiming at the treatment (detoxification) of adult prisoners. Although the establishment of the Unit has been planned already since 1999 and the personnel has been appointed and trained, the Unit has not commenced its operation yet.

Despite the problems, KETHEA carries through its support programmes. In the year 2000, drug users/addicted inmates received support in the context of 6 programmes distributed in many correctional institutions: the Korydallos Correctional Institution (Athens- since 1987); the Psychiatric Correctional Institution (Athens- 1987); the Korydallos Correctional Institution for Female prisoners (Athens- since 1988); the Diavata Correctional Institution (Thessaloniki- since 1988); the Kasavetia Correctional Unit for Juvenile prisoners (Volos- since 1998); Military Prisons (Thesaloniki- since 2000).

181 In addition to services offered inside prisons, KETHEA has organised support programmes for prisoners in any area where integrated programmes for drug treatment already exist. The ultimate goal of these programmes is the establishment of a link between services provided inside prisons and those offered outside. In 1999, KETHEA (through its therapeutic programme ITHAKI) founded the Centre for Prisoners and Released Prisoners, in a joint action with the Law School of the Aristotle University of Thessaloniki. Along with the services provided to prisoners (e.g. medical, psychological, vocational, educational and legal support), the scope of the operations of the Centre includes issues of social re-integration for released prisoners (through relapse periods and occupational rehabilitation) and mental and psychological preparation of the family members of released prisoners (through counselling).

In 2000, the Multiple Intervention Centre of KETHEA embarked upon an innovative pilot programme at the Korydallos Correctional Institution for Female prisoners. The programme applies to all inmates who are facing the problem of drug use and drug addiction. Women prisoners participate in therapeutic, educational and vocational activities while they also contribute to small everyday tasks in the therapeutic centre (e.g. cleaning, cooking etc.). The innovative part of the programme consists in that released women, who have successfully completed the programme during their sentence, will be able to receive support, aiming at their smooth re-integration into society through a Reception Centre. At present, the programme is run from 9 a.m. to 5 p.m. but efforts are currently being made to expand its operation on a 24-hour base (KETHEA, 2001).

Figure 32: Participants in support programmes for drug addicted inmates

SOURCE: KETHEA, 2001.

182 In the year 2000, the co-operation with the Ministry of Justice resulted in a substantial improvement in the conditions under which KETHEA programmes are run. The number of participants in these programmes in the year 2000 amounted to 530 prisoners, a number that is expected to rise further in the future.

13.5 Evaluation of drug user treatments in prison

No evaluation of drug user treatment has been conducted in the Greek prisons. However, there are some reports, which have raised issues and which offer an assessment and evaluation of the services provided in prisons for drug users. These reports have been contributory factors to a change in policy with regard to the penitentiary units that house drugs users (see for example the DWB, 2001 report). In October 2001, the Ministry of Environment worked on a draft bill on a “Special Framework for the Planning of Correctional Institutions and their Sustainable Development” (MoE, 2001). The proposed framework, after having reviewed all the structural and operational problems currently characterising correctional institutions in Greece, identified a number of areas where action should be taken mostly aiming at a more efficient and needs-oriented re- organisation and re-installation of correctional institutions around the country.

With regard to drug-users, it is acknowledged that the number of prisoners associated with violation of the law on drugs has increased considerably in recent years. The proportion of drug users in the prison population is also very high. As a result, it is necessary to clearly distinguish between the various types of correctional centres and – with regard to drug issue – between General Hospitals, Treatment Centres for prisoners with co-morbidity problems and Treatment Centres for drug addicted prisoners.

Existing treatment centre for drug addicts detainees Proposed treatment centre for drug addicts detainees ? Possible location of proposed treatment centre for drug addicts detainees

Priority was given to the establishment of three designated correctional institutions: 1 in the greater Thessaloniki (the second largest city in Greece), 1

183 on Crete (due to its relative geographical isolation) and 1 in one of the geographical departments of Thessaly, western Greece, and the Peloponnese. Taking into account the equally important need for the establishment of links with educational institutes, one of the main criteria for the location of the therapeutic correctional institutions should be the existence of educational institutions in the nearby areas.

Finally, KETHEA has conducted some small-scale self-evaluation of its own services, offered in the context of the Multiple Intervention Centre at the Korydallos Correctional Institution for Female prisoners. 12 participants in a Preliminary Community of female prisoners of this innovative pilot programme were asked to assess its quality and effectiveness. Responses converge in the conclusion that interventions of this kind have been extremely helpful to prisoners wishing to abstain from drug use.

Table 40: KETHEA – Multiple Intervention Centre at the Korydallos Correctional Institution for Female Prisoners: Client Satisfaction (N=12)

How helpful was the presence of penitentiary staff to the progress of the programme? Extremely helpful 30% Very helpful 30% Quite helpful 20% Not helpful at all 20%

How satisfied are you with the meeting place of your group? Extremely satisfied 16,7% Very satisfied 25% Fairly satisfied 50% Not satisfied at all 8.3%

How supportive are the therapists? Extremely supportive 83.3% Very supportive 16.7% Not supportive at all 0%

How well do your therapists understand your needs? Very well 50% Well 41.7% Not sufficiently 8.3%

184 Did you reduce the use of drugs while participating in the programme? Very much 83.3% Quite a lot 8.4% Fairly 8.3%

How satisfied are you with the individual sessions? Extremely satisfied 33.3% Very satisfied 50% Fairly satisfied 16.7% Not satisfied at all 0%

SOURCE: Adopted from Tentis, 2001.

More specifically, as Table 40 shows, participants expressed their satisfaction with the result that individual sessions had on their problem (83.3%) as well as with the understanding (91.7%) and support (83.3%) of therapists. The majority (91.7%) also asserted that the programmes led to a reduction in drug use. The only concern expressed by the participants regarded the overall performance of the penitentiary staff (20% thought they were not helpful at all) and the place in which the group meetings and the individual sessions took place (58,3% were not entirely satisfied).

13.6 Methodological issues

Limitations on data availability

Research on drug use among prisoners continues to be very limited in Greece, despite the fact that the number of prisoners held for dug related offences has increased swiftly in recent years and that drug use is becoming the number one problem in the prison system.

Findings are available only in the case of research that has been carried out almost exclusively in one particular, Athens-based prison, namely the Korydallos Prison. On this basis, data cannot be considered to be representative of Greek prisons in general. Given the fact that this prison is the main remand centre in Athens, there is an over-concentration of drug users among this population.

Future needs

Better collaboration is required between ministerial departments, correctional authorities, medical and social welfare services in prisons, and the academic and research community nationwide for the development of a uniform and valid

185 methodological model for measuring and assessing all aspects of the problem of drug use in Greek prisons on an annual basis.

Epidemiological studies on HIV risk behaviours in the prison population are much needed with special focus on (a) the injecting and sharing behaviour of prisoners and (b) the correlations of risk practices with the use of advanced statistical methods.

186

ANNEX I

DRUG MONITORING SYSTEMS AND SOURCES OF INFORMATION

1. THE ACTIVITIES OF THE GREEK FOCAL POINT FOR THE REPORTING YEAR

1.1 Epidemiology

• Treatment Demand Indicator

In 2000, the Focal Point completed and distributed the Greek version of the revised Guide for the collection of data concerning the characteristics of dependent persons requesting treatment. This revision has been based on the new TDI protocol. The results that are presented in this report are based on data gathered by implementing the revised Guide.

In the same year, a new service, the Help Centre of OKANA (Low-threshold programme), was added to the recording system, enriching the profile of the services that participate in the indicator. The Help Centre approaches users, who do not participate in therapeutic or other programmes, through street work and Syringe Exchange Programmes (SEP) and its primary health care clinics.

In addition, the Focal Point has trained the staff of the OKANA Therapeutic Services Network of Patra in the TDI protocol. The Network participated in the indicator in 2001 for the first time.

• Drug-related Deaths and Mortality Indicator a. Drug-related Deaths Indicator

This indicator presents data, which the Focal Point collects regularly and which refer to deaths of acute intoxication recorded in the Special Register of the Hellenic Police.

The Focal Point is currently expecting the Member States to finalise procedures for the implementation of ICD-10 by the end of 2002.

b. Mortality Indicator

The implementation of the Mortality Indicator began in 2000 at the Substitution Programme of OKANA.

• Prevalence of Problem Use Indicator

The implementation of this indicator has been practically and methodologically problematic in Greece.

A viable solution will be possible in 2001, if the Member State expresses its interest in these problems.

197 • General Population Surveys Indicator

Epidemiological surveys in Greece have been undertaken by UMHRI, the mother institute of the Focal Point, and are based on a 75% compatible questionnaire and on absolutely compatible with the suggestions of the European Centre methodology. The next epidemiological survey of general population substance use has been planned by UMHRI for 2002. UMHRI participates in the National Prevalence Surveys Databank (NPSD-EU) and has already sent data files of the 1993 and 1998 general population surveys.

• Prevalence of Infectious Diseases Indicator

During 2000, the Focal Point collected aggregated data from 15 agencies throughout the country, which referred to the results of medical tests for infectious diseases of their clients. Consequently, a National Infectious Diseases Network was established in 2001, with the participation of therapeutic centres, reference centres, and the low-threshold services, which send individual data to the Focal Point, to enable the accurate estimation of the prevalence and incidence of infectious diseases among drug users. First data for this indicator will be available in 2001.

1.2 Demand Reduction

During 2000, the activities of the Demand Reduction Section have been developed in the domains discussed below.

A. Collection of reliable and comparable data on demand reduction programmes in Greece

• The systematic recording of the characteristics of therapeutic and low- threshold units, based on the Treatment Unit Form (TUF, version 1997), as well as the description of interventions in the context of demand reduction (prevention, therapy, rehabilitation, harm reduction, education), based on EDDRA continued during 2000. In addition, data were collected by means of a questionnaire, which was drawn up by the Focal Point with regard to the description of prevention programmes that last less than a year (short-term interventions or recent programmes), and future programmes. • In addition, the Focal Point participates actively in the collection of complementary data at European level (e.g. Data on academic educational programmes on demand reduction, data on prevention interventions at work settings).

B. Promotion and exchange of information at national and European level.

• EDDRA European Electronic Database. Data concerning prevention and therapeutic programmes have been presented on the database since 1997.

198 From the beginning of 2000 until March 2001, thirteen programmes were added, in the context of the annual update of the list. Overall, 31 Greek programmes have been listed on the database since 1997. • Inventory of Drug Prevention and Treatment Services in Greece. This inventory, which was first published in 1996, was updated by the Focal Point in 2000. It includes information on the functional and structural characteristics of the existing demand reduction programmes in Greece until the end of June 2000. An electronic database of the Inventory will be available by the end of 2001. • EDDRA National Electronic Database. This database, which is under construction at the moment, will enable all demand reduction programmes, which operate in Greece and are annually included in the EDDRA questionnaire, to be listed and thus make their activities known. Its integration will enhance communication and exchange of experience among professionals in the field. With the same aim, the creation of an electronic discussion group is also planned.

C. Promotion of the evaluation of research

• It carried out two educational programmes on EuropASI for therapists. • It contributed to the enrichment of the EMCDDA Evaluation Instrument Bank with valid Greek questionnaires, used for the evaluation of prevention, therapeutic and educational programmes. Also, it will undertake the translation and adjustment to Greek standards of all the questionnaires that are listed on this database. • In the period between December 1999 and February 2000, the Focal Point in collaboration with OKANA, evaluated the difficulties and needs of the OKANA Prevention Centres and Local Authorities.

Finally, the development of methodology and instruments to assess both the work of support and educational agencies in the domain of prevention, and the work of Prevention Centres during their three-year contract with OKANA has been scheduled for 2001, again in collaboration with OKANA.

1.3 National Policy and Legislation

The Focal Point is collaborating with OKANA as well as with the Ministries of Justice and Health in an effort to systematically present the national policy and legislation on drugs. OKANA, the co-ordinating body of demand reduction, provides data concerning the philosophy and the policy on dealing with the drug problem.

As far as recent legislative regulations are concerned, the Focal Point is in constant collaboration with the Ministries of Justice and Health. In parallel with this, the Focal Point has subscribed to an Electronic Bank of legal information, for information on current legal developments.

199 1.4 Early Warning System (EWS)

In Greece, the Early Warning System functions on a national information network, which consists of health services, prosecution authorities and toxicological laboratories. The Focal Point co-ordinates the information network in order to collect information on new substances and new ways of using known substances.

The data collected are sent to the EMCDDA after being evaluated by the national EWS Evaluating Committee. This scientific committee consists of representatives of all agencies participating in the information network.

At the same time, the Focal Point provides the agencies that participate in the EWS network with information on new data, collected in Europe and Greece.

Apart from the standard activities of EWS, the following tasks have been accomplished in 2000:

• The Focal Point sent information on the structure and function of EWS to the ADAT programme. These data will be presented in the report of ADAT in parallel with the presentation of the Dutch Antenna programme in Amsterdam, as a model programme for the detection of new trends in substance use.

• EWS Electronic Database (see section 4. Electronic Databases of the Focal Point)

1.5 Qualitative Research

With regard to qualitative research, the activities of the Focal Point are the following:

• Qualitative European Drug Research Network (QED)

The Focal Point continued its collaboration with the QED in 2000, by co- ordinating the collection of data on researchers who are involved both in qualitative research and in publications in scientific or other periodicals that refer to the drug issue. This information is presented in the QED web site.

• Small-scale qualitative studies

The Focal Point considers qualitative research to be important to the enrichment of quantitative data. During 2000, the Focal Point continued its activities on qualitative research by collecting data on open drug scenes through personal semi-structured interviews with professionals from street work programmes.

200 • SONAR programme

The UMHRI has been collaborating with IREFREA on the research programme ‘Sonar Project’ since 1998. This programme is based on small-scale studies in nightclubs, with the aim of collecting and analysing qualitative and quantitative data on recreational use of licit and illicit substances.

The first research project entitled ‘Nightlife recreational settings and drug use among young club goers’ was carried out between 1998 and 1999. A part of the results of this research is included in the publication of IREFREA ‘Nightlife in Europe and Recreational Drug Use’ and in the 1998 and 1999 Annual Reports of the Focal Point on the Drug Situation in Greece.

The second research project entitled “Alternative recreational models as an answer to the established ones (legal and illegal substance use): Prevention interventions in nightlife recreational settings. Individual, collective and social strategies” was planned in 2000 and will be completed in 2001.

• EU project on the development of ideas for Secondary Prevention of drug use

Since 2000, the Focal Point, in collaboration with the Street work programme of the OKANA Help-Centre, has been participating in a European programme with the following objectives:

• The development of concepts and strategies for early intervention in secondary prevention for demand and harm reduction, in relation to two target groups: a) adolescents and young people who are involved in drug use and spend many hours of the day in the streets and b) adolescents and young people who are mostly involved in synthetic and cocaine use in recreational nightlife places • The organisation of a network that will include the agencies that provide services to young people and new users in an attempt to improve and render more effective the provision of services to the previous target groups • The development of informative material for target groups, educators and parents.

In the context of this programme, the Focal Point intends to initiate the following activities in 2001:

• Localisation of the second target group, i.e. adolescents and young people who are involved in recreational drug use • Production of informative material on the dangers of synthetic drug (‘ecstasy’, LSD, ice & speed) and cocaine use, and its distribution to the target group.

201 • Emerging Trends Project

This pilot project, which refers to the investigation of emerging trends in drug use in the European Union, will be implemented in 2001.

1.6 Documentation

• Bibliography on drugs

The documentation section of the Focal Point collected the drug-related scientific material that was published in 2000, in order to compile the Greek Bibliography on drugs, which is updated annually. The Electronic Bibliographic Database is already available (see Section 4).

In 2000, the Focal Point continued the systematic collection of newspaper clips on drugs.

• Drug Research in Greece

The Focal Point has been systematically collecting information on drug-related research projects in Greece since 1998. This attempt was enhanced in 2000 by means of questionnaires that were sent to agencies and persons who conduct researches as well as to funding agencies. The electronic database that includes all relevant information is already available (See section 4).

• Publications and dissemination

In 2000, the Focal Point published the Greek Bibliography on Drugs for 1999. This annual publication contains anything that was published or presented in conferences in 1999 or in previous years but had not been included in earlier publications of the bibliography.

In addition, the Focal Point keeps on distributing its publications, as well as those of EMCDDA and of other international organisations and research groups with which it collaborates. Also, in parallel with the distribution of new editions, the National Centre continues the distribution of older editions. In particular, the following editions have been distributed in 2000:

FOCAL POINT – UMHRI publications

• Annual report of the Focal Point on the drug situation in Greece 1999, Athens 2000 (532 copies, Greek version) • The Greek bibliography on drugs for 1999, Athens 2000 (556 copies, Greek version)

202 • Greek high-school students: health, school, and family. International Survey on Health Behaviour of school aged children, Athens 2000 (534 copies, Greek version) • Inventory of Prevention and Treatment Services for Drugs in Greece. Republished 2000, Athens 2000 (534 copies, Greek version) • Annual report on the drug situation submitted to the EMCDDA 1999, Greek REITOX Focal Point, Athens 1999 (23 copies)

EMCDDA publications

• Drug net (184 copies, bi-monthly) • EMCDDA: Annual report on the state of the drugs problem in the European Union 1999, Lisbon 1999 (755 copies, Greek version) • EMCDDA: Annual report on the state of the drugs problem in the European Union 2000, Lisbon 2000 (870 copies, Greek version) • EMCDDA: Understanding and responding to drug use: the role of qualitative research, Lisbon 2000 (34 copies) • EMCDDA: European Union legal text on drugs (CD), Lisbon 1999 (15 copies) • EMCDDA: General report of activities 1999, Lisbon 2000 (35 copies) • Extensive Greek Press release on the annual report on the drug situation in the European Union 2000 (50 copies, Greek version) • Informative material for the Press conference on the drug situation in the European Union 2000 (450 copies, Greek version)

WHO publications

• Informative note, International Press Release, Greek Press Release on global research on school population health (154 copies, Greek version) • Health and health behaviour of young people, Copenhagen 2000 (35 copies)

European Council publications

• Treated drug users in 23 European cities: data 1997, trends 1996-1997, Council of Europe 1999 (14 copies)

IREFREA publications

• Characteristics and social representation of ecstasy in Europe, Majorca 1998 (15 copies)

203 • Nightlife in Europe and recreational drug use. SONAR 98, Majorca 1998 (33 copies) • Family relationships and prevention of drug use in early adolescence, Majorca 1999 (40 copies)

204 2. THE NATIONAL NETWORK OF THE FOCAL POINT IN 2000

The General National Network of the Focal Point, which is illustrated in Chart 1, comprises four sub-networks:

2.1 Treatment Demand Indicator Network

This network has been operating since 1994 and collecting data on the characteristics of users who contact the agencies. The latter are either specialised therapeutic programmes or general health services that offer medical and psychological support to people who face problems with regard to drug use.

2.2 National Network of the Infectious Diseases Indicator

The network was set up in 2001 and includes reference centres, hospitals, therapeutic centres and agencies that are able to provide data on the results of laboratory tests on infectious diseases of injecting drug users. Some prisons will be able to provide individual data by the end of 2002.

2.3 Early Warning System (EWS) Network

In the context of the Early Warning System (EWS), a National Network of key- Informants has been created to provide information on new synthetic drugs and on new ways of using already known substances. The agencies that collaborate with the Greek EWS are the following: Health Services, 14 Prevention Centres, Law Enforcement Authorities, the General Chemical State Laboratory and the Forensic laboratories of the Universities of Athens, Thessaloniki and Patra.

2.4 National EDDRA Network

Within the framework of the implementation of the EDDRA in Greece, the Focal Point collaborates with a considerable number of prevention, therapeutic, educational, rehabilitation and harm reduction programmes.

205 3. THE ELECTRONIC DATABASES OF THE FOCAL POINT

The Focal Point has designed a number of electronic databases, four of which can be accessed by the public through the Focal Point website www.ektepn.gr., which will be available in English by the end of 2001.

3.1 Bibliography Database

This database has been designed, first, to provide information to professionals in the drug field and second, to enable them to provide the Focal Point with their publications or presentations.

Until now, the base consists of 1,250 listings, which refer to the period 1975- 2000 and will be regularly updated in Greek and English.

3.2 Early Warning System

This electronic database of the EWS has been designed in order to enable and promote the collaboration and communication between the EWS network and the Focal Point, in an effort to exchange valid information on new drugs and new ways of using already known substances at national level.

At European level, the EWS database gives the EMCDDA and the National REITOX Focal Points the opportunity to be informed on new trends in drug use in Greece. The use of this database is restricted to the national and REITOX networks. It is available in Greek and English.

3.3 Research on Drugs in Greece

This database, which is available only in Greek, provides information to professionals on the research projects currently implemented in Greece and enables researchers to collect information on the new projects that they implement.

At present, the database consists of 80 research programmes, which were implemented in Greece from 1993 to 2000.

3.4 Inventory of Drug Prevention and Treatment Services in Greece

Since the published version of the Inventory was in great demand and its annual re-publication as well as update would be time and money consuming, the Focal Point created an electronic version, to facilitate updating and access by the public.

The creation of the database has been based on the division of Greek territory into 13 health districts, so that the reader can search directly the area of interest to him/her. In addition, services have been categorised according to their type (i.e. prevention, therapeutic, consulting etc.). At the moment, the database is in the final phase of its creation and will be available in Greek by the end of November 2001.

206 Chart 1. National Network of Partners of the Focal Point and the data they provide

Ministry of Health OKANA Ministry of Public Order Treatment services

Hellenic Police

(Drug-related deaths)

Institutes/Educational Organisations Ministries of Public Order, Finance and Merchant Marine Greek REITOX Focal Point Central Anti-Drug coordinating Unit Municipalities / Local (Seizures, drug-related convictions) Communities

Ministry of Justice University and Research (Convictions-imprisonments for Institutes drug-related offences)

The Three Infectious Ministry of Education – Toxicological and National Diseases Reference Directorate of Secondary Chemical Laboratories of Centres Education Greece

207

ANNEX II

Table I. Treatment units, geographical location & coverage (Total number: 28 Treatment Units)

UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION & COVERAGE Residential Treatment «PAREMVASI» Alternative Therapeutic Community KETHEA Rafina (Prefecture of Attica) «NOSTOS» Therapeutic Community KETHEA Piraeus (Aegean Islands, Crete & Southern Greece in general)

«ITHAKI» Therapeutic Community KETHEA Sindos, Thessaloniki (Northern Greece) «EXODOS» Therapeutic Community KETHEA Larissa (Central Greece) Residential Therapeutic Programme - Drug & Attica State Psychiatric Haidari (Prefecture of Attica) Alcohol Dependence Unit «18 ΑΝΟ» Hospital Drug Dependence Treatment Unit Thessaloniki State Thessaloniki (Northern Greece) Psychiatric Hospital Programme for Dependent Women – Drug & Alcohol Attica State Psychiatric Filothei (Prefecture of Attica) Dependence Unit «18 ΑΝΟ» Hospital Specialised Programme for Addicted Mothers KETHEA Sindos, Thessaloniki (Northern Greece)

Non-Residential Treatment Adults «DIAVASSI» Open Therapeutic Community KETHEA Athens «DIAVASSI» Evening Therapeutic Programme KETHEA Athens «IASON» Mental Health Centre Athens Programme for Individuals with Dual Diagnosis – Attica State Psychiatric Athens Drug & Alcohol Dependence Unit «18 ΑΝΟ» Hospital Therapeutic Programme «ΑΤΗΕΝΑ» Dept. of Psychiatry, Athens Medical School, University of Athens / OKANA Drug-Free Therapeutic Programme «GEFIRA» OKANA Patras (the Peloponnese) Programme of Family Therapy & Counselling – Attica State Psychiatric Athens Drug & Alcohol Dependence Unit «18 ΑΝΟ» Hospital Alternative Therapeutic Programme «ARGO» Thessaloniki State Thessaloniki (Northern Greece) Psychiatric Hospital Open Therapeutic Programme «ARIADNE» KETHEA Heraklion (Crete) Adolescents Department for Adolescents and Young Adults – Attica State Psychiatric Athens Drug & Alcohol Dependence Unit «18 ΑΝΟ» Hospital «STROFI» Open Therapeutic Community KETHEA Athens «PLEFSI» Early Intervention Community KETHEA Athens

(Continued on next page Ê)

211 (Continued from previous page È)

UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION & COVERAGE Substitution Programmes Substitution Detoxification Programme, 1st Unit OKANA Athens Substitution Detoxification Programme, 2nd Unit OKANA Athens Methadone Substitution Programme, 1st Unit OKANA Thessaloniki Methadone Substitution Programme, 2nd Unit OKANA Thessaloniki Methadone Maintenance Programme OKANA Athens Substitution Methadone Detoxification OKANA Piraeus Programme of Piraeus Low-Threshold Programmes Multiple Intervention Centre KETHEA Athens Help Centre OKANA Athens

212 Τable II: New Prevention Programmes1

Α. SCHOOL PROGRAMMES (Total: 48 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION2 IMPLEMENTATION PERIOD3

«PAREMVASEIS» Drug Prevention Centre (the • Preventive Interventions in secondary school students • Secondary school students 1/1999-ongoing Peloponnese) • Training programme for secondary school teachers • Secondary school teachers • Primary prevention programme for adolescents • Secondary school students of the • Short-term preventive intervention in the school Municipality of Amaliada community • Students, teachers, parents

Prevention Centre Against Drugs (Hios) • Short-term interventions related to smoking and other • Secondary school students 9/1999-5/2000 addictive substances in secondary education • Primary school teachers • Implementation of the programme «Children’s games» • Students, teachers and administrative • Intervention in the School of Merchant Marine Officers personnel

«ELPIDA» Information & Prevention Centre Against Volunteering – First Aid – Security Students 1/2000-5/2000 Drugs (Thessaloniki)

«ORFEUS» Prevention Centre Against Dependent • Short-term preventive intervention in students of KETEK • Students and teachers of KETEK 1/2000-3/2001 Substances (Rodopi) • Training seminars for teachers in the implementation of • School community agencies preventive programmes for primary school students in the • Adolescents of the Muslim secondary Prefecture of Rodopi school of the Municipality of Komotini • Short-term intercultural action at the Muslim secondary school in the Municipality of Komotini

Information & Prevention Centre Against Drugs • Health promotion programme for secondary school • Secondary school teachers 1/2000-4/2000 (Xanthi) teachers • Students of the Nurse School • Short-term intervention programme for Nursery School • Students from the third grade of the students High School • Short-term intervention for the evening secondary school students of Xanthi

1 The order of presentation of the new prevention programmes listed above is according to their inauguration date. 2 This column presents the target-groups of the programmes and not the coverage of individuals approached. 3 The implementation period corresponds to more than one programme. The starting and end dates refer to the total number of the programmes. 213

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

«PNOI» Drug Prevention Centre (Lesvos) Groups of Teachers Secondary school teachers of Mytilini 3/2000-5/2000

«ORIZONTES» Drug Prevention Centre (Grevena) • Training programme for primary school teachers • Primary school teachers of Grevena 7/2000-4/2001 • Training programme «Stand on my own feet» for • Secondary school teachers of Teachers Grevena • Training seminar for teachers • Secondary school teachers

«DIMIOURGIA» Prevention Centre of the • Short-term intervention through experiential workshops • Secondary school teachers 9/2000-5/2001 Prefecture of the Dodecanese • Sensitisation of primary school teachers • Primary school teachers • Sensitisation of secondary school teachers • Secondary school teachers and • Sensitisation seminar for secondary school teachers agencies from the Municipalities of the southern Dodecanese • Secondary school teachers

«ORFEUS» Prevention Centre Against Dependent • Training teachers in the implementation of the programme • Primary school teachers 10/2000-6/2001 Substances (Larissa) «Children’s games» – Supervisions • Secondary school teachers • Training teachers in the programme «Stand on my own • Secondary school students feet» • Primary school students • Implementation of the programme «Stand on my own feet» • «Children’s games»

Information & Prevention Centre Against • Experiential group of teachers - Circle time in the • Primary school teachers of the 10/2000-3/2001 Psychoactive Substances (the Peloponnese) classroom Prefecture of Messinia • Students - teachers experiential group • Secondary school students and • Workshop on «Recreational games» teachers of the Prefecture of Messinia • Primary school teachers

Prevention Centre of the Prefecture of Kavala • Sensitisation seminar for primary school teachers • Primary school teachers 11/2000-5/2001 • Sensitisation seminar for secondary school teachers • Secondary school teachers • Conversation with adolescent • Adolescents, secondary school students

214

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

«FAROS» Drug Prevention Centre (Samos) Two groups of secondary school teachers Secondary school teachers 11/2000-1/2001

Information & Prevention Centre Against Drugs • Short-term preventive intervention in primary school • Primary school students «DIEXODOS» (Kastoria) • «The role of the teacher in the field of prevention» • Primary school teachers 12/2000-1/2001

«DIOLKOS» Drug Prevention Centre of the Sensitisation in primary prevention Primary school teachers 12/2000-2/2001 Prefecture of Corinth

Drug Prevention Centre of the Prefecture of Achaia «Touching the circle» Primary school students and parents 1/2001-6/2001

«NIKOS MOROS» Municipal Drug & AIDS «Skills for primary school students» Primary school teachers 1/2001-6/2002 Prevention Unit (Corfu)

Prevention & Information Centre of the Municipality Preventive actions against substance use and for health Students, teachers, parents 2/2001-9/2001 of Peristeri promotion in the school community

Prevention Centre Against Substance Use Short-term intervention in secondary school teachers Secondary school teachers of the 3/2001-5/2001 (Lefkada) Prefecture of Lefkada

«PROTASI ZOIS» Drug Prevention Centre of the «Skills for primary school students» Primary school teachers 3/2001-5/2002 Prefecture of Magnisia

Prevention Centre Against Drugs (Preveza) • Short-term intervention to heighten awareness in • Secondary school teachers 3/2001-5/2001 communication in the context of prevention in secondary • Primary school teachers education • Short-term intervention to heighten awareness in communication in the context of prevention in primary education

Counselling Centre for Combating Drugs (Ioannina) • Short-term preventive interventions in secondary school students • Secondary school students • Short-term preventive interventions in primary school • Primary school students Not reported students • Teachers • Interventions in groups of teachers • Secondary school students • Health promotion programme for the prevention of the use • High school students of psychotropic substances • Health promotion programme

215 B. PROGRAMMES FOR PARENTS (Total: 18 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

Information, Prevention & Sensitisation Centre • Three introductory meetings for parents Against Psychoactive Substances of the Prefecture • Seminars for parents Parents of students from the Prefecture of 2/2000-11/2000 of Messinia • Cycle of seminars for parents entitled «Adolescence» Messinia • Experiential group of Parents

«ORFEUS» Prevention Centre Against Substance • Introductory meetings for Parents • Parents with infants 3/2000-4/2001 Use (Rodopi) • Short-term preventive intervention in parents for the • Parents from various areas of the implementation of the school material «Communication in Municipality of Rodopi the family» which took place at the Centre of Family Care • Parents with adolescents (National Welfare Organisation) • Awareness interventions in the Parents & Guardians’ Association of the Junior High Schools of the Prefecture of Rodopi

Information & Prevention Centre Against Drugs «Communication in the family» Secondary school parents 3/2000-9/2001 (Lamia) • Single mothers from the Municipality of «ORFEUS» Prevention Centre Against Substance «Communication in the family» Parents’ group Larissa, mothers with adolescents 5/2000-6/2001 Use (Larissa) from the Municipality of Aghia, parents with junior high school students from the Prefecture of Larissa

«PNOI» Prevention Centre Against Drugs (Lesvos) Parents’ groups Parents from various Municipalities 6/2000-12/2000

«ORIZONTES» Prevention Centre Against Drugs Seminar for parents «Communication in the family» Parents of secondary school students 10/2000-4/2001 (Grevena)

«DIMIOURGIA» Prevention Centre (Dodecanese) Sensitisation programme for secondary school parents Parents and Guardians’ Associations from 10/2000-5/2001 the Junior High School of Rhodes

«DIEXODOS» Information & Prevention Centre «Prevention» a new way for combating drugs Parents from the Municipality of Aspoklesia 2/2001 Against Drugs (Kastoria)

«DIOLKOS» Prevention Centre (the Peloponnese) Sensitisation in primary prevention Parents with adolescents 2/2001-3/2001

Centre for Preventing and Combating Drugs Discussions with parents Parents with secondary school children 3/2001-5/2001 (Kavala)

216

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

Prevention Centre Against Substance Use Short-term intervention in parents Parents with secondary school children 5/2001 (Lefkada)

Counselling Centre for Combating Drugs (Ioannina) • Parents’ group • Intervention in the Parents’ and Guardians’ Associations Parents Not reported

C. COMMUNITY PROGRAMMES (Total: 11 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

«INTERVENTIONS» Drug Prevention Centre (the Short-term preventive interventions – Lectures intended for the Wider community 1/2000-on going Peloponnese) wider community

Information & Prevention Centre Against Informative meetings aiming at prevention Wider community 1/2000-11/2001 Psychoactive Substances (the Peloponnese)

«DIEXODOS» Information & Prevention Centre «Prevention», a new way for combating drugs General population, youth boards 4/2000-5/2000 Against Drugs (Kastoria)

«ORIZONTES» Drug Prevention Centre (Grevena) Sensitisation of the community Wider community 5/2000

Municipal Enterprise of Development of the Prevention Programme for the promotion of health Residents of the Municipality of Zografou, 7/2000-7/2003 Municipality of Zografou (Athens) parents, teachers, adolescents

«DIMIOURGIA» Prevention Centre (the Information – Sensitisation of the Local Authorities People who work in the Southern Local 9/2000-6/2001 Dodecanese) Authorities of the Prefecture of the Dodecanese

«ORFEUS» Prevention Centre Against Substance Meetings with the mayor and members from the municipal The Mayor and members of the municipal 2/2001 Use (Rodopi) council council

«STATHMOS» Prevention Centre (4 Municipalities Three-year primary prevention programme for the promotion of General population 3/2001-3/2004 of Athens) health in the Municipality of Kallithea, Moschato, Tauros (Athens)

217

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

Counselling Centre for Combating Drugs (Ioannina) • Cultural events for the general population • General population Not reported • Motivating key-persons working in the local community • People who are responsible for social • Interventions in the local community through Mass Media policy planning, for local authorities campaigns and for local units or associations • General population

D. OTHER PROGRAMMES (Total: 36 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

«PAREMVASEIS» Drug Prevention Centre (the • Dealing with the requests for help of drug users and their • Drug users and their families 6/1998-ongoing Peloponnese) families • Wider community • Organisation and implementation of short-term alternative activities against substance use

Information & Prevention Centre Against • Competition «The creative game» • Secondary school students 2/2000-3/2001 Psychoactive Substances (the Peloponnese) • «The thread of Ariadne»: Experiential workshops • Young people between 13-16 years • Experiential group of non-commissioned officers old • Experiential workshop «Emotions and colours» • Military units • Young people from the Municipality of Kalamata

Prevention Centre Against Drugs (Hios) • Alternative action «Help to refugees» • Refugees 2/2000-10/2000 • Intervention in primary education • Professionals in the prevention field • Intervention in boarding school • Boarders (adolescent) • Intervention in the Women’s Association of the • Women’s Association Municipality of Hios

«PNOI» Drug Prevention Centre (Lesvos) • Training of members of the Association of Women • Women-members from the 3/2000-12/2000 Volunteers Association of Women Volunteers • Groups of members of cultural associations • Members of cultural associations • Groups of health professionals • Health professionals of Lesvos

218

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

«ORPHEUS» Prevention Centre Against Drugs • Short-term preventive interventions in adolescent campers • Male and female adolescent campers (Rodopi) in the Prefecture of Rodopi • Short-term intercultural action in the young repatriates’ • Young repatriates of 13-25 years old association • Members of the cultural association of • Information to cultural associations about the drug the Municipality of Ageirou problem • Social workers of the Prefecture • Informative meetings for the Sensitisation of the social workers in the Prefecture of Rodopi • Chief constable of the Prefecture • Meetings for the Sensitisation of the chief constable of the 3/2000-3/2001 Prefecture of Rodopi in order to co-ordinate the exhibition against drugs «Thrace 2000» • Pharmacists and doctors • Sensitisation meetings with pharmacists and doctors • Mass Media of Thrace • Co-operation with Mass Media personnel in the Prefecture of Thrace

«ELPIDA» Information & Prevention Centre Against Communication and prevention in the army Officers and social scientists of the army 7/2000 Drugs (Thessaloniki)

«DIEXODOS» Information and Prevention Centre Young people – Adolescents acting as prevention agents Boy-scouts and girl-scouts of the Holy 7/2000 Against Drugs (Kastoria) Archbishopric

Information & Prevention Centre Against Drugs • Short-term intervention in young campers • Secondary school children and 7/2000-10/2000 (Xanthi) • Short-term intervention programme in the army adolescents • Officers, soldiers, doctors and social workers of the army

«DIMIOURGIA» Prevention Centre of Dodecanese Sensitisation seminar for the inter – professional group of the Inter- professional group of the pre-school 11/2000-5/2001 Pre-school Centre for Children and Families Centre

Prevention Centre Against Addiction (Athens) «A ship’s diary – Armenistis 1900» Secondary school students 12/2000-3/2001

Social Intervention Centre – Alimos, Argiroupoli, Prevention Programme Against Addictive Substances Adolescents 1/2001 Elliniko and Glyfada – Jointly Owned Municipal Enterprises

Information & Prevention Centre (Drama) • Programme for the creation and operation of Information • Young people from areas near the 1/2001 – 12/2001 Centres for young people borders, with special needs, aged 18- • Programme for the creation and operation of an «info- 30 years old Centre» for young people • Young people from areas near the borders, with special needs, aged 18- 30 years old

219

ORGANISING AGENT TITLE OF THE PROGRAMME POPULATION IMPLEMENTATION PERIOD

Greek Red Cross (Athens) Educational seminars for the prevention of drug addiction Health professionals 2/2001-6/2001

«ORIZONTES» Drug Prevention Centre (Grevena) Short-term programme at the School for Police Officers School for Police Officers 3/2001-4/2001

Prevention & Information Centre Against Drugs Substance use prevention and promotion of mental health Personnel of the psychosocial care service 3/2001-5/2001 (Evros) of the army

Prevention Centre Against Substance Use Short term interventions in students and young people who are Students, young people outside school, 3/2001-8/2001 (Lefkada) members of the parish Centre of the Archbishopric (through church)

Social Intervention Centre – Alimos, Argiroupoli, «A ship’s diary – Armenistis 1900» Adolescents outside school 5/2001-11/2001 Elliniko and Glyfada – Jointly Owned Municipal Enterprises (Athens)

Counselling Centre for Combating Drugs (Ioannina) • Short-term interventions in young people • Young people Not reported • Counselling to students • Students

220

Table III: Prevention Programmes with at least one year of implementation1

Α. SCHOOL PROGRAMMES (Total: 36 programmes)

CAPACITY

ORGANISING AGENT TITLE OF THE PROGRAMME STRATEGIC DIRECT IMPLEMENTATION TARGET TARGET PERIOD GROUP GROUP (Tot: 2.874) (Tot: 9.124)

«PEGASUS» Mobile & Information Unit - KETHEA • Groups of Teachers in Primary and Secondary education – 137 5/1989 – up to date (Athens) • Preventive intervention in secondary school students and training 11 189 6/1999-4/2000 of teachers

«ARGO» Alternative Therapeutic Programme of the Prevention programme in secondary education 50 1100 10/1997 – up to date Psychiatric Hospital of Thessaloniki

Drug Prevention Centre (Arta) • Groups of students aged 14-16 – 112 1/1998 – up to date • Sensitisation – Training in primary education – 25 2/2000 – 12/2000

«ELPIDA» Prevention Centre for Combating • Intervention in students: «School, an alternative way» 800 60 2/1998 – up to date Addictive Substances (Thessaloniki) • «Come to play»: Skills for primary school students 700 180 2/1999 – up to date

• Primary school programme against substance use «Stand on my – 15 9/1998 – up to date «NIKOS MOROS» Municipal Drug & AIDS own feet» Prevention Unit (Corfu) • Prevention programme against substance use in order to – 17 9/1999-6/2000 enhance communication «Stand on my own feet»

Centre for Preventing and Combating Drugs Training programme for the promotion of health «Stand on my own 29 223 9/1998 – up to date (Kavala) feet»

Drug Prevention Centre (Crete) Information – Sensitisation – Training of secondary school teachers – 140 10/1998 – up to date

«PROTASI»Drug Prevention Centre (Peloponnese) Prevention against substance use, promotion of personal relations 27 193 11/1998 – up to date and confrontation of school anxiety

1 The order of the prevention programmes presented above is according to their inauguration date. 221

CAPACITY

ORGANISING AGENT TITLE OF THE PROGRAMME STRATEGIC FINAL IMPLEMENTATION TARGET TARGET PERIOD GROUP GROUP (Tot: 2.874) Tot: 9.124)

Information & Prevention Centre Against Drugs Health promotion programme «Stand on my own feet» 135 300 12/1998 – up to date (Evros)

Counselling Centre for Combating Drugs (Ioannina) Health promotion programme for the prevention of substance use in 500 1000 3/1999 – up to date secondary school students

Drug Prevention Centre (Voiotia) Intervention in secondary school students – – 05/1999 – up to date

Prevention Centre Against Drugs (Rethimno) Training for Secondary school teachers on the material «Stand on – 17 5/1999 – up to date my own feet»

«THISSEAS» Drug Prevention Centre (Cyclades) Prevention Programme Against Substance Use in the Prefecture of – 1.030 9/1999 – up to date Cyclades

«KETHEA» Prevention Unit (Athens) • Teachers’ group acting as a nucleus of prevention in the school 12 – 9/1999–10/2000 community – 22 9/1999–12/2000 • Students’ group acting as a nucleus of prevention in the school – 84 1/2000–12/2000 community of KETEK 102 – 3/2000–11/2000 • Skills for primary school students • Workshops for teachers of the schools of OAED

«PYXIDA» Drug Dependence Prevention & Health • Prevention programme for the promotion of health in primary 63 250 9/1999 – up to date Promotion Centre (Thessaloniki) education «With a compass at the school desks» • Preventive action in schools: Primary prevention programme for 45 662 11/1998 – up to date the promotion of health

Communication & Prevention Centre Against Intervention in secondary school teachers who are going to – 60 10/1999 – up to date Psychoactive Substances (Pieria) implement health promotion programmes

222

CAPACITY

ORGANISING AGENT TITLE OF THE PROGRAMME STRATEGIC DIRECT IMPLEMENTATION TARGET TARGET PERIOD GROUP GROUP (Tot: 2.874) (Tot: 9.124)

«ORIZONTES» Prevention Centre Against «Stand on my own feet» 7 110 11/1999 – up to date Substance Use (Kozani)

«PAREMVASEIS» Drug Prevention Centre • Training for primary school teachers – 43 11/1999 – up to date (Peloponnese) • Prevention programme for primary school students – 74 10/1999 – up to date

Drug Prevention Centre of the Prefecture of Florina Pilot health promotion programme «Skills for primary school 8 100 11/1999-12/2000 students»

«DIEXODOS» Information & Prevention Centre Intervention in secondary education 113 130 1/2000 – up to date Against Drugs (Kastoria)

Information & Prevention Centre Against Drugs Health promotion programme for secondary school students 7 87 1/2000 – up to date (Xanthi)

«ORFEUS» Drug Prevention Centre (Rodopi) Intervention in students and teachers 22 115 1/2000 – up to date

«SEIRIOS» Information & Prevention Centre Short-term preventive interventions against substance use in – 700 2/2000 – up to date Against Substance Use (Thessaloniki) secondary education

Social Intervention Centre – Alimos, Argiroupoli, Sensitisation programme for teachers 60 15 3/2000 – up to date Elliniko and Glyfada – Jointly Owned Municipal Enterprises (Athens)

Counselling and Health Promotion Centre of the Creation of nuclei of prevention groups within the school community 297 1500 10/2000 – up to date Municipality of Heraklion

«STORGI» Drug Prevention Centre (Zakinthos) • Health promotion programme in primary education «Children’s – 120 11/2000 – up to date games» – 200 • Programme for the promotion of health in secondary education

223

Β. PROGRAMMES FOR PARENTS (Total: 22 programmes)

CAPACITY

ORGANISING AGENT TITLE OF THE PROGRAMME STRATEGIC DIRECT IMPLEMENTATION TARGET TARGET PERIOD GROUP GROUP (Tot: 6.562) (Tot 2.429)

«PEGASUS» Mobile Information Unit (Athens) Parents’ group – 128 5/1989 – up to date

Hellenic Red Cross – Directorate of the prevention «Parents’ group – Parents’ training»: Training programme for 40 80 7/1995 – up to date of drug addiction and AIDS (Athens) parents and future parents

Prevention Centre Against Addiction (Athens) «Communication in the family» 115 26 9/1996 – up to date

«PYXIDA» Drug Dependence Prevention & Health «Parents’ school»: Primary prevention programme for families – 180 5/1998 – up to date Promotion Centre (Thessaloniki)

Social Intervention Centre (Elliniko) – Jointly Owned Sensitisation and supporting family programme in the field of 2.500 800 9/1998 – up to date Municipal Enterprises (Athens) prevention against substance use

Centre for Preventing and Combating Drugs Seminar for parents «Communication in the family» – 40 11/1998 – up to date (Kavala)

«ORIZONTES» Drug Prevention Centre Against «Communication in the family» – 100 2/1999 – up to date Substance Use (Kozani)

«PAREMVASEIS» Drug Prevention Centre (the • Cycles of open discussions with parents (Parents’ schools) – 350 4/1999 – up to date Peloponnese) • Prevention programme for parents of primary school students – 35 11/1999 – up to date

Prevention Centre Against Drugs (Rethimno) • Parents’ training (Parents’ school) 75 84 5/1999-12/2000 • Sensitisation of parents – 75 5/1999-12/2000 • Social Intervention Centre (Glyfada) – Jointly Primary prevention & Sensitisation programme for parents 800 80 11/1999 – up to date Owned Municipal Enterprises (Athens)

«DIEXODOS» Information & Prevention Centre Intervention in parents of secondary school students 32 40 11/1999 – up to date Against Drugs (Kastoria)

Prevention Unit of KETHEA (Athens) Teachers’ and educators’ training – 38 11/1999-12/2000

224

CAPACITY

ORGANISING AGENT TITLE OF THE PROGRAMME IMPLEMENTATION STRATEGIC DIRECT PERIOD TARGET TARGET GROUP GROUP (Tot: 6.562) (Tot 2.429)

Information & Prevention Centre Against Drugs Seminars for parents «Communication in the family» – 60 1/2000 – up to date (Xanthi)

Information & Prevention Centre Against Drugs • Intervention in parents with infants and in kindergarten teachers – 63 1/2000 – up to date (Pieria) (mixed groups) • Educational seminar for parents with adolescents – 70 2/2000 – up to date

Prevention Centre Against Drugs (Florina) Workshop on family behaviour – 70 1/2000-12/2000

Prevention Centre Against Drugs (Hios) Intervention in families of young people and adolescents – 30 1/2000 – up to date

Social Intervention Centre (Alimos) – Jointly Owned Sensitisation programme for parents with secondary school children 500 80 2/2000 – up to date Municipal Enterprises (Athens)

Information & Prevention Centre (Drama) «Parents’ school» 2.500 – 3/2000 – up to date

Information & Prevention Centre Against Drugs «Communication in the family»: Intervention in parents of secondary – – 3/2001 – up to date (Lamia) school children

225

C. COMMUNITY PROGRAMMES (Total: 9 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME CAPACITY* IMPLEMENTATION (TOTAL: 5.980) PERIOD

Hellenic Centre of Intercultural Psychiatry and Combating social exclusion in the field of drug addiction in downgraded areas of 600 8/1996 – up to date Treatment (Athens) Athens

«ODOIPORIKO» Information & Prevention Centre Information and Sensitisation programme of drug prevention in the Municipality of 1.500 10/1997 – up to date (Athens) Peristeri

«PYXIDA» Drug Dependence Prevention & Health «Joint action for prevention»: Primary prevention programme in the local 1800 5/1998 – up to date Promotion Centre (Thessaloniki) community

«ALEA ATHENA» Drug Prevention and Health Primary prevention programme against psychoactive substances, including health 400 6/1998 – up to date Promotion Centre promotion programmes as well as counselling for individuals and families

«PALAS ATHENA» Drug Prevention and Health Primary prevention programme against psychoactive substances, including health 500 6/1998 – up to date Promotion Centre promotion programmes as well as counselling for individuals and families

«PROMACHOS ATHENA» Drug Prevention and Primary prevention programme against psychoactive substances, including health 400 6/1998 – up to date Health Promotion Centre promotion programmes as well as counselling for individuals and families

«PRONAIA ATHENA» Drug Prevention and Health Primary prevention programme against psychoactive substances, including health 700 6/1998 – up to date Promotion Centre promotion programmes as well as counselling for individuals and families

«PAREMVASEIS» Drug Prevention Centre of the Training and motivation programme for volunteers in the field of prevention 50 9/1998 – up to date Prefecture of Ilias

Prevention Unit of KETHEA (Athens) Training programmes against exclusion from the labour market / Programmes of 30 5/2000-12/2000 technology transfer

* The capacity of the community programmes refers only to the direct target-group. 226

D. OTHER PROGRAMMES (Total: 14 programmes)

ORGANISING AGENT TITLE OF THE PROGRAMME CAPACITY1 IMPLEMENTATION (Tot: 5.129) PERIOD

«PEGASUS» Mobile Information Unit of KETHEA • Group of soldiers 98 5/1989 – up to date (Athens) • Group of students, adolescents and young people outside school 785 • Drug addicts 118 • Health professionals 220 • Individual meetings with parents and other relatives of drug users 88

«PYXIDA» Drug Dependence Prevention & Health • Primary prevention programme against substance use for young people: “Our 1.500 5/1998 – up to date Promotion Centre (Thessaloniki) compass is imagination, knowledge and will to live” • Information and referral programme for drug users and their families 78 5/1998 – up to date • Pilot prevention programme in army 1.200 9/1999 – up to date

Drug Prevention Centre (Voiotia) Intervention to officers of Thebes 12 11/1998 – up to date

Communication and Prevention Centre Against «Throw your cap in the circle»: Intervention to secondary school students 15 1/1999 – up to date Drugs (Pieria)

Hellenic Red Cross (Athens) Mental health educational seminar aiming at prevention 120 2/1999 – up to date

Prevention Centre Against Drugs (Rethimno) Sensitisation of recruit officers 840 5/1999 - 12/2000

Social Intervention Centre (Trikala) Group of adolescents 20 1/2000 – up to date

Prevention Centre Against Drugs (Hios) Intervention at the military units of Prefecture of Hios 35 1/2000 – up to date

1 The capacity of the “other programmes” refers only to the direct target – group. 227 Table IV. Prevention Centres established by OKANA (1997-2001) (Total Number: 54 Prevention Centres)

Geographical TITLE Town/City Inauguration Region Year THRACE 1) Information & Prevention Centre Against Drugs Xanthi 1997 2) Information & Prevention Centre Against Drugs Alexandroupoli 1998 «ELPIDA» 3) Prevention Centre Against Substance Use «ORPHEUS» Komotini 1999 MACEDONIA 1) Communication & Prevention Centre Against Katerini 1997 Psychoactive Substances «KEP PIERIAS» 2) Prevention Centre for Combating Drugs Kavala 1998 3) Drug Dependence Prevention & Health Promotion Centre Thessaloniki 1998 «PYXIDA» 4) Prevention Centre for Combating Substances «ELPIDA» Thessaloniki 1998 5) Prevention Centre Against Drugs Florina 1998 6) Prevention Centre Against Substances «ORIZONTES» Kozani 1998 7) Information & Prevention Centre Against Drugs Kastoria 1999 «DIEXODOS» 8) Prevention Centre Against Substance Use «PNOI» Halkidiki 1999 9-10) Information and Prevention Centres «SIRIOS» (2 Thessaloniki 2000 Centres) 11) Prevention Centre Against Substances «ORIZONTES» Grevena 2000 12) Information and Prevention Centre of the Western Sector Thessaloniki 2001 of Thessaloniki «Diktio ALFA» EPIRUS 1) Counselling Centre for Combating Drugs Ioannina 1996 2) Prevention Centre «KPN ARTAS» Arta 1997 3) Prevention Centre Against Substance Use «ARIADNE» Igoumenitsa 1999 4) Prevention Centre Against Drugs and Other Substances Preveza 2000 «KE.PRO.NA.P.» THESSALY/ 1) Social Intervention Centre Trikala 1997 SPORADES 2) Prevention Centre Against Dependence Karditsa 1997 3) Drug Prevention Centre «PROTASI ZOIS» Volos 1998 4) Prevention Centre Against Substances «ORPHEUS» Larissa 1999 CENTRAL 1) Drug Prevention Centre Halkida 1997 GREECE 2) «Protasi Zois - Drug Use Prevention» Livadia 1998 3) Prevention & Information Centre Against Drugs Lamia 1998 WESTERN 1) Municipal Prevention Unit «ODYSSEUS» Agrinio 1998 GREECE 2) Drug Prevention Centre Patra 1998 THE 1) Prevention Centre Against Substance Use Amaliada 1998 PELOPONNESE «INTERVENTIONS» 3) Information - Prevention & Sensitisation Centre Against Kalamata 1999 Psychoactive Substances «KEPEPSO» 4) Prevention Centre Against Substance Use «DIOLKOS» Corinth 2000 5) Prevention Centre for Combating Drugs «KPNNA» Tripoli 2001

(Continued on next page Ê)

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Geographical T I T L E Town/City Inauguration Region Year ATTICA 1-4) Drug Prevention & Health Promotion Centre «ATHENA Athens 1998 HEALTH» (4 Centres) 5) Prevention & Information Centre Peristeri 1998 6) Social Intervention Centre –– Joint Municipal Enterprise Athens 1998 of Alimos, Argiroupoli, Elliniko & Glyfada 7) Centre for the Prevention of Substance Use & the Zografou 2000 Promotion of Health 8) Dependence Prevention & Mental Health Promotion Holargos/Aghia 2001 Centre «ARGO» Paraskevi 9) Prevention Centre Against Dependence «STATHMOS» Kallithea/Tauros/ 2001 Moshato IONIAN 1) Municipal Drug & AIDS Prevention Unit «NIKOS Corfu 1997 ISLANDS MOROS» 2) Drug Prevention Centre Against Substances «STORGI» Zakinthos 1998 3) Prevention Centre Against Substance Use Lefkada 2001 4) Prevention Centre Against Substances «KEPRONAKI» Kefalonia (& Ithaca) 2001 NORTH- 1) Prevention Centre Against Substance Use Hios 1998 EASTERN AEGEAN 2) Prevention Centre Against Substance Use «PNOI» Lesvos 2000 3) Drug Prevention and Health Promotion Centre «FAROS» Samos 2000 CYCLADES 1) Prevention Centre Against Substances Paros 1998 2) Prevention Centre Against Substances Siros 1998 THE 1) Drug Prevention Centre «HIPPOCRATES» Kos 1999 DODECANESE 2) Centre for the Prevention of Substance Use and for Rhodes 2000 Health Promotion «DIMIOURGIA» CRETE 1) Prevention Centre Against Drugs Rethimnon 1997 2) Prevention Centre Against Substances Hania 1998

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INTERNET ADDRESSES

www.984Fm.gr (see chapter 9.1.6 Mass media campaigns) www.auth.gr/selfhelp (see chapter 9.6.6 Self help groups) www.coopmarcella.it (see chapter 9.6.4 Patterns of drug users) www.cosmos.gr/egoke (see chapter 9.1.7 Internet) www.drug-prevention.de (see chapter 9.1.3 Youth programmes outside schools) www.ektepn.gr (see chapter 9.1.7 Internet) www.fora.gr/gr/info/drugs (see chapter 9.1.7 Internet) www.hellasnet.gr/tendedox (see chapter 9.1.7 Internet) www.kethea.gr (see chapter 9.1.7 Internet) www.mdmgreece.gr (see chapter 9.2.1 Outreach work) www.mednet.gr/agogi/alkool.htm (see chapter 9.1.7 Internet) www.mednet.gr/agogi/kapnisma.htm (see chapter 9.1.7 Internet) www.mednet.gr/agogi/narkotik.htm (see chapter 9.1.7 Internet) www.okana.gr (see chapter 9.1.7 Internet) www.panteion.gr (see chapter 9.6.5 Ethnic minorities) www.streetworker.fr (see chapter 9.2.1 Outreach work) www.ydt.gr/drug.htm (see chapter 9.1.7 Internet)

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