Commentary – the drugs problem in Europe

A new European framework for coordination and cooperation

Although defining national drug policies remains the prerogative of individual European Member States, there is now strong agreement on the benefits that can accrue from working together at the European level. This can be seen in a number of recent developments that support coordination and cooperation activities. Among these developments are the coming into force in 2005 of two new EC regulations on precursors and a Council decision on new drugs. In addition, measures against drug trafficking are strengthened by new legal instruments to address money laundering and confiscation of assets. However, the development that is most central to shaping European collaboration and future actions on the drugs issue is the new EU drugs strategy for 2005–2012 and its two accompanying action plans. In the first of these, around 100 planned specific actions are detailed by EU Member States to be implemented by 2008. A continuous programme of evaluation is envisaged for the strategy, with annual progress reviews and impact assessments at the end of each of the two action plan periods.

The strategy can be seen as representing a European consensus on how the drugs problem should be addressed. There is an explicit commitment to a balanced approach combining both supply- and demand-side measures, matched by an acceptance of the need to base actions on the evidence of effectiveness and, furthermore, to systematically evaluate progress. Important policy differences between European Member States still exist, often reflecting differences in the national drug situations and in the configuration of responses. Nonetheless, the new drugs strategy suggests that the European policy debate on drugs is increasingly characterised by agreement on a common framework for activities. For example, virtually all demand reduction strategies include prevention, treatment and harm reduction elements, although the emphasis on each varies between Member States. Some policy options continue to generate considerable debate – but in general this is against a background of broad agreement on the fundamentals that underpin the European response to the drugs problem.

Drug use and drug supply: a distinction increasingly made

A continuing trend, again evident in the new information reported this year, is for changes to national drug laws to emphasise more strongly a distinction between offences of drug possession for personal use and those involving trafficking and supply. Generally, there is a shift towards increased penalties for the latter and a reduced emphasis on custodial sentences for the former. This development is in line with a greater emphasis overall across Europe on widening the opportunities for drug treatment and on giving more attention to interventions that divert those with drug problems away from the criminal justice system towards treatment and rehabilitation options. For those countries that have made a legal distinction with respect to the possession of drugs for use rather than supply, the question arises whether there is an explicit need to legislate on what quantities of drugs constitute a threshold for personal use. Here no consensus currently prevails and different approaches have been adopted across Europe, ranging from the issuing of general operational guidelines through to specification of legal limits.

Heroin use: an important part of a bigger picture

Data presented in this report show that across Europe as a whole the historical focus on heroin use and injecting as the central elements of the drug problem needs to be widened because of the increasing importance of polydrug use and stimulant use and the growing public health implications of widespread cannabis use. Nevertheless, in many countries opioids (largely heroin) remain the principal drugs for which clients seek treatment, accounting for about 60 % of all recorded treatment requests in 2004 – and among these clients just over half (53 %) reported injecting the drug.

Nearly 25 % of opioid treatment demands are made by individuals aged 35 years or more, with only 7 % of clients seeking treatment for the first time being aged under 20. It should be noted that treatment demand data reflect the number of clients requesting treatment during the reported year and do not include people continuing in treatment; consequently the total number of clients in treatment is considerably higher. Across Europe as a whole, the substantial growth in drug substitution treatment that has occurred in recent years means that the treatment system includes an increasing, and ageing, population of people with heroin problems, who are likely to require care and remain major consumers of resources for many years to come.

Heroin consumed in Europe is manufactured predominantly in Afghanistan. Europe continues to account for the greatest quantities of heroin seized worldwide, and, as a result of an increase in seizures in South-Eastern European countries (particularly Turkey), this region has surpassed Western and Central Europe in terms of volume intercepted. This rising trend in heroin seizures not only underlines the value of coordinated action against trafficking at the wider European level but also raises important questions about the impact of increased heroin production on the European market. No clear trends are visible with respect to average purity; however, the 5-year price trend (1999–2004) corrected for inflation is downwards in most countries. Nevertheless, although heroin is more readily available and cheaper in Europe, there is no evidence yet that this is influencing overall levels of consumption. Overall indicators would suggest that the incidence of new heroin use is still declining in Europe within what is probably a stable situation – with a significant proportion of those with opioid problems now receiving substitution treatment, at least in some countries. Among those new to treatment, the numbers with a significant opioid problem have been decreasing in most countries. Nonetheless, this is an area where waves of epidemic use have been seen in the past, and therefore complacency must be avoided.

In this year’s report, there are worrying indicators that the number of drug-related deaths, which has generally declined since 2000, increased slightly in a majority of countries in 2004. It is too early to judge whether these small changes herald a long-term shift, but it must be remembered that drug-related deaths represent one of the major public health consequences of illicit drug use. Even though the proportion of drug-related deaths occurring in young people has been falling, supporting suggestions that new heroin injecting is declining, available city-based estimates of drug-related mortality (overdose and other causes) suggest that currently 10–23 % of overall mortality among adults aged 15–49 can be attributed to opioid use.

Injecting and injecting-related health problems: a constant companion


At a glance — estimates of drug use in Europe

(Note that these estimates relate to the adult population and are the most recent estimates available. For complete data and full methodological notes see the accompanying statistical bulletin.)

Cannabis

Lifetime prevalence: at least 65 million, or 1 in 5 European adults

Last year use: 22.5 million European adults or one-third of lifetime users

Use in the past 30 days: 12 million Europeans

Country variation in last year use

Overall range 0.8 % to 11.3 %

Typical range 2.8 % to 7.5 % (15 countries)

Cocaine

Lifetime prevalence: at least 10 million, or over 3 % of European adults

Last year use: 3.5 million European adults or one-third of lifetime users

Use in the past 30 days: over 1.5 million

Country variation in last year use

Overall range 0.1 % to 2.7 %

Typical range 0.3 % to 1.2 % (18 countries)

Ecstasy

Lifetime prevalence: about 8.5 million European adults

Last year use: 3 million or one-third of lifetime users

Use in the past 30 days: more than 1 million

Country variation in last year use

Overall range 0.0 % to 3.5 %

Typical range 0.3 % to 1.5 % (15 countries)

Amphetamines

Lifetime prevalence: almost 10 million or around 3 % of European adults

Last year use: 2 million, one-fifth of lifetime users

Use in the past 30 days: less than 1 million

Country variation in last year use

Overall range 0.0 % to 1.4 %

Typical range 0.2 % to 1.1 % (16 countries)

Opioids

Problem opioids use: between 1 and 8 cases per 1 000 adult population (aged 15–64)

Almost 7000 acute drug deaths, with opioids being found in around 70 % of them (2003 data)

Principal drug in about 60 % of all drug treatment requests

More than half a million opioid users received substitution treatment in 2003


In many countries, drug injecting is almost synonymous with heroin use, but there are exceptions, with a few EU countries reporting significant levels of stimulant injecting, mostly among heavy users of amphetamines. Mirroring, to some extent, the picture for heroin, overall the information available suggests a general decrease in drug injection over the longer term. However, in many of the new Member States injecting rates remain high. An important caveat here is that the availability of national or subnational estimates of drug injecting is poor. Moreover, studies of injecting in some regions have even reported slight increases recently. The most comprehensive picture of this behaviour comes from monitoring heroin users in treatment, among whom the proportion of injectors has declined dramatically in some countries, but not in others. Notably, among the old Member States, Denmark, Greece, Spain, France, Italy and the United Kingdom all report declining rates of injecting among heroin users in treatment.

The relationship between drug injecting and health problems is well known, and drug injectors have a high risk of overdose and serious infection as well as other health problems such as septicaemia and thrombosis. HIV infection is the health risk that has galvanised the European public health response to this form of drug use, and almost all countries now have interventions aimed at preventing new infections. For example, needle and syringe provision, once regarded as a controversial intervention is available to some degree in virtually all Member States, although the coverage varies considerably between countries. Most countries report low rates of newly diagnosed HIV infection attributable to drug injecting, and HIV infection rates among injectors are estimated to be below 5 %. However, again important caveats should be borne in mind: first, two of the largest countries most affected by AIDS among drug injectors, Spain and Italy, currently do not provide national HIV case reporting data; and, second, it is reported that HIV transmission is continuing to occur in specific injecting groups across Europe, and there are even signs of increases in some of the population groups studied.

A far more negative picture presents itself for rates of infection with the hepatitis C virus (HCV), which remain almost universally high among drug injectors. Treating the HCV-related health problems among drug injectors and ex-injectors is likely to remain a major health cost for many years to come. In drawing the conclusion that drug injecting may be slowly declining and that Europe has responded well to the challenge posed by the epidemic spread of HIV in the 1990s, there is a real danger that this may lead to complacency about the health threats still posed by this behaviour. High levels of endemic HCV infection, continued transmission among drug injectors, with increased incidence observed in some groups, and a large high-risk group of injectors in some of the new Member States all speak of the need to continue to regard drug injection, and its associated health problems, as a major public health issue in Europe and a critical area for drug policy and research vigilance.

Cocaine: signs of stability for Europe’s second most common illicit drug


Drug use in Europe cheaper than ever before

In this report, for the first time, a 5-year analysis of the street prices of illicit drug is included, corrected for inflation to allow a more accurate assessment of changes in the street price of illicit drugs over time. Data on street prices are difficult both to collect and to interpret. The purity, quantity and variety of the substance bought all influence price, as do geographical factors such as living in a big city or on a regular drug transit route. Drug prices also vary considerably between countries and are subject to fluctuations over time that reflect disruptions in supply. Despite these distortions in the data, across most drug types the available data suggest that in Europe as a whole the cost of buying drugs has fallen. For most countries, the predominant 5-year trend has been a decline in street price for cannabis, heroin, amphetamine, ecstasy and cocaine (see graphic below). Although historical data on street prices are largely lacking and difficult to interpret when available, worryingly this recent trend accords with the suggestion that prices may have been declining over the longer term. For example, information available from some of the high-prevalence countries suggests that cocaine and ecstasy were considerably more expensive in the late 1980s and early 1990s than they are today.

NB:

The trends represent the available information on national street-level prices for each drug in the EU Member States and Norway, weighted by country population sizes to form an overall European trend. Prices have been adjusted for national inflation rates (base year 1999) and all series indexed to a base of 100 in 1999.

Many countries cannot supply these data, which are difficult to obtain and often unreliable and incomplete. Countries missing drug price information for two or more consecutive years are not included in the trend calculations for the drug: the trend for heroin brown is based on 9 countries, amphetamine on 9, cocaine on 13, ecstasy on 13, herbal cannabis on 13, and cannabis resin on 14.

Additionally, where 2004 data are missing (11 cases) 2003 prices are used; for missing 1999 data (1 case) 2000 prices are used; data missing for other years (12 cases) have been interpolated from adjacent years.

For further details on 2004 prices, see Tables PPP-1, PPP-2, PPP-3 and PPP-4 in the statistical bulletin.

Sources:

Price data: Reitox national focal points.

Inflation and population data: http://epp.eurostat.ec.europa.eu/


Estimates of cocaine use (last year prevalence) now place the drug slightly ahead of amphetamine and ecstasy as Europe’s second most used illicit drug. However, the general picture is one of stabilisation in levels of use after a period in which users of the drug increased considerably in number. The large increases in cocaine prevalence experienced by Spain and the United Kingdom from the mid to late 1990s seem to have stabilised since 2000 or 2001. Elsewhere, while some moderate increases in levels of cocaine use have been noted in a few countries; dramatic increases are not being reported. Overall, the cocaine situation remains very heterogeneous in Europe and significant cocaine use is restricted to a few, mainly Western European, countries.

It would be wrong to conclude that the signs of stabilisation in use of cocaine will necessarily result in a stabilisation in the extent of problems attributed to use of this drug. In Europe, cocaine use is at historically high levels, and studies suggest that it is a common pattern for increases in problems relating to a drug to lag some years behind increases in prevalence. This is because it takes time for intensive and regular patterns of drug use to develop and for problems to become visible. This may be beginning to happen in those Europe countries where cocaine use is now well established. In both the Netherlands and Spain, at least one in four treatment demands is now reported to be cocaine related, and overall in Europe new treatment demands for cocaine roughly doubled between 1999 and 2004. Although the use of crack cocaine remains very limited in Europe, reports of problems from some cities suggest that the situation may be deteriorating.

Cocaine is often found in the toxicological analysis of deaths attributed to opioid drugs, and in a number of countries concurrent cocaine use has become a recognised problem for those treating heroin problems. Although data are limited, in the 2005 national reports over 400 deaths were identified as being causally related to cocaine use, and cocaine-related deaths appeared to be increasing in all high-prevalence countries. This figure is almost certainly an underestimate and the impact of cocaine use as a contributor to deaths due to cardiovascular problems remains unknown. The message is clear: if Europe is to avoid experiencing an increase in the public health costs associated with the use of this drug, any stabilisation in overall use of cocaine should not mask the need for both a better identification and understanding of cocaine-related problems and the need for investment in the development of effective responses.

Responding to a more complex European drug problem

A common theme running through this report is the increasing need to develop responses that are sensitive to the complex and multifaceted nature of today’s drug problem. When prevention, treatment or harm reduction activities are considered, there is a need to better understand what constitutes good practice and evidence-based action. Among the total of approximately 380 000 treatment demands reported in 2004, cannabis was the primary reason for referral to treatment in about 15 % of all cases, making it the next most commonly reported drug after heroin. Treatment services are also dealing with more stimulant and polydrug problems, including a considerable overlap of illicit drug and alcohol problems. However, at the population level we do not know enough about the public health implications of regular and persistent use of these types of drugs, nor about the likely intervention needs of those who use them. The evidence base in Europe for determining the response to drug problems is strongest for responding to the problem of illicit opioid use, where a considerable body of evidence supports the development and targeting of services. The growing consensus that exists to guide policy on what is likely to constitute appropriate intervention for problem heroin use is matched by a growing need to develop the same clarity on how we respond to a more heterogeneous European drug problem.

The need better to define and understand polydrug use

A key issue is the need to respond to problems caused by the use of multiple psychoactive substances. Polydrug use is becoming increasingly recognised as a key area for service development. However, definition of the concept remains elusive, and in some respects nearly all those who use drugs can be considered polydrug users. Polydrug use also poses considerable challenges to drug monitoring systems, which tend to be based on behavioural measures of the use of an individual index drug. There is therefore a critical need to develop a better conceptual framework for describing different types of polydrug use as a first step to understanding the implications of this behaviour. This year's report devotes space to presenting the analytical issues that must be addressed if Europe is to meet the challenge of better understanding the needs of the increasing number of individuals whose problems stem from the use of a range of drugs rather than a dependency on a single substance.

Back to the future: anticipating threats and challenges

In this year’s report, as always, an attempt is made to identify emerging trends to anticipate future problems. Such analysis is by definition speculative and must be made with caution. A drug clearly associated with severe public health problems is methamphetamine. While globally methamphetamine problems continue to grow, within Europe the drug remains restricted to a few countries with long-established problems. Although the available information does not permit us to draw any firm conclusion on trends, more countries are reporting seizures or use of the drug, clearly emphasising the need for more intensive monitoring of those population groups most at risk.

In 2006, the EMCDDA published a technical paper on hallucinogenic mushrooms, and this issue is again summarised in our annual reporting. The availability and use of hallucinogenic mushrooms appears to have been increasing since the late 1990s but to large extent has passed unnoticed. For the most part, use of this type of drug appears to be experimental and reports of problems remain rare. However, a growing awareness among policy makers of the availability of hallucinogenic mushrooms has led to the introduction of some actions to increase control measures.

Psilocybin and psilocin, two of the psychoactive substances found in hallucinogenic mushrooms, are controlled by an international convention. However, the fact that mushrooms grow naturally in many countries poses a more complex issue for legislation, and they are treated differently across Europe. More generally, vigilance on emerging substances that may pose a threat to public health and therefore require control is supported by a new Council decision (2005/387/jha) on information exchange, risk assessment and control of new psychoactive substances. An example of the need for early warning information in this area has been the rapid spread of mCPP (1-3-chlorophenyl piperazine) in 2005. The emergence of mCPP illustrates the fact that those involved in the production of illicit drugs are constantly looking for innovation in the form of new chemicals that can be introduced to the market – in this case probably to potentiate or modify the effects of MDMA (ecstasy). Such innovation requires a response as the potential for these substances to cause severe health problems is unknown. The early warning system put in place by the Council decision therefore represents an important mechanism to intervene in a process in which the heath of young Europeans is put at risk by those who pursue profit by avoiding existing drug control mechanisms.