Chapter 2
Responding to drug problems in Europe – an overview

Prevention

Experiences in some Member States suggest that drug prevention interventions at the individual level may be more effective if also supported by regulatory policies on legal drugs that can limit the access of young people to these substances and reduce their social acceptability. As a result, environmental prevention strategies that address the normative and cultural framework of substance use are gaining ground in parts of Europe, supported by the first steps taken at EU level: the tobacco advertisement directive and the WHO framework convention on tobacco control (see the section on environmental strategies in the selected issue on developments in drug use within recreational settings).

The role of mass media campaigns is increasingly being seen as one of raising awareness (to underpin, support and explain to the population at large the rationale underlying environmental strategies) rather than one of changing behaviour. In this regard, a recent German review of the international literature (Bühler and Kröger, 2005, cited in the German national report) recommends that media campaigns be used as a supporting measure and not as the only measure to achieve behavioural changes.

Public health prevention

While health promotion – as a framework condition for prevention – strives to encourage people to adopt healthy lifestyles and to create healthy living conditions for all, the new term ‘public health prevention’ is increasingly mentioned by some Member States (Italy, Netherlands, Slovakia) and Norway. Public health prevention entails a range of prevention measures aimed at improving the health of vulnerable sections of society, among which drug prevention is one element. These measures are particularly suited to the needs of young people, whose problem behaviours, including drug use, are strongly conditioned by vulnerability (social and personal) and by living conditions. Hence, as selective and indicated prevention strategies target social and personal risk conditions, they are naturally linked to other youth-relevant public health policies (adolescent mental health strategies regarding conduct disorders, attention deficit disorder, etc.), social policies (the provision of leisure spaces and support for vulnerable youth or deprived families), education policies (reducing school drop-out), etc. Thus, public health prevention targets the full set of vulnerability factors which are relevant for tackling drug problems by involving services and sectors that would not by default have a drugs focus.

Universal school-based prevention

Programme-based prevention approaches are gaining ground within school-based prevention. Programme-based prevention implies standardised delivery in a defined number of sessions, each with exactly defined contents, and detailed teacher and pupil material. This facilitates monitoring and evaluation and increases the accuracy, fidelity and consistency of interventions, leading to high-quality delivery. As a result, more Member States than before are monitoring school-based prevention interventions (the Czech Republic, Greece, Spain, Ireland, Italy, Cyprus, Hungary, the Netherlands and the United Kingdom). The first ever European Drug Abuse Prevention Trial (www.eudap.net) has shown promising results. Funded by the European Commission, the project was implemented and cross-evaluated in seven countries, nine regional centres and 143 schools and involved 7 000 students (3 500 in a trial group and 3 500 in a control group). EU-Dap reports that, compared with the control group, students in the trial group had a 26 % lower probability of smoking daily, a 35 % lower probability of being frequently drunk and a 23 % lower probability of using cannabis. A comparable programme-based research approach is Blueprint in the United Kingdom (30). Additionally, more attention is now given to stricter technical guidance and to better coverage in the implementation of school-based prevention (e.g. in France and Ireland).

Police in schools

The role of the police in school-based prevention is a controversial issue. In Belgium, the French Community recommends that health promotion and prevention policy should be implemented by school authorities and that the police force should not be involved in prevention programmes. Also, in the United Kingdom, a policy paper (ACPO Drugs Committee, 2002) recommended that the police service acts only within its areas of expertise (security, offences, order) and does not get involved in specific drug education. Following this line of action, Portugal continues to run a proximity policing programme, Escola Segura (safe school). During the 2004/05 school year a total of 320 police officers were specifically allocated to the school setting, with the aim of implementing proximity policing and offence dissuasion, both during the day and at night. In France, experts trained by the law enforcement services to liaise with youth or grown-up populations visit schools or other services on request. However, despite recommendations that drug education should not be delivered by police officers in uniform, as it could in some cases be counterproductive, activities carried out by police services within schools are still common in several Member States.

Selective prevention

With the recognition and development of the selective prevention approach by most Member States, vulnerable groups are increasingly being targeted. For example, Germany, Greece, Luxembourg, Austria, Finland and the United Kingdom report programmes targeting young offenders.

Several countries (e.g. Poland and Slovakia) have begun to put emphasis on vulnerable groups. In Sweden, the most obvious increase in activities compared with previous years has been in programmes for pre-school children at risk and school children with externalising behaviours. The number of municipalities implementing these programmes has approximately doubled. In addition, Norway is developing a national strategy for early intervention against problem drug and alcohol use in which prevention efforts will specifically target risk groups. Approaches not based on abstinence are effective in reducing not only consumption but also initiation among those groups in which incipient drug use is already occurring. Thus, Poland has a nationwide programme to change the drug-related behaviour of vulnerable children or children who are in the early stages of drug use. The specific objective of the Polish programme is to support the family in solving drug problems. In this regard, it is helpful that the concept of selective prevention does not focus on drug use and does not stigmatise drug use; rather, its focus is on vulnerability in a broader sense.

Member States increasingly report targeting of specific ethnic groups in their selective prevention policies, with four countries (Belgium, Germany, Italy and Luxembourg) reporting on new projects in this area. In Italy, the priority of many projects is now to protect children, mothers and immigrant families or those belonging to ethnic minorities. Luxembourg reports that special attention is given to young people and to the biggest immigrant community, focusing on linguistic and sociocultural specificities.

Selective prevention in schools

Young people at risk of dropping out of school and/or with behavioural problems are increasingly being addressed by selective drug prevention, for instance in Italy, where some 15 % of prevention interventions in schools are aimed at vulnerable subgroups of students (selective and indicated prevention). The main subgroups at which selective prevention in schools is aimed are students with social behavioural problems, school problems or family problems, immigrant students and those belonging to ethnic minorities. In fact, academic performance and school attendance are good predictors for drug problems, and monitoring these enables early and accurate intervention.

School drop-out is the focus of drug prevention programmes in several Member States. The HUP project in Storstrom County, Denmark, aims to increase the average rate of school completion from 75 % towards the national target of 95 % by focusing on vulnerable students. Similar projects are reported in Ireland, Portugal (47 projects), Romania (one project) and Norway (brochures for teachers). Reducing early school leaving is an official aim of Ireland’s national strategy, with the target of a 10 % reduction compared with 2005/06 rates in LDTF (local drug task force) areas. Students most at risk are targeted by selective prevention programmes in Malta, while in France and Slovakia counselling services are provided in schools on the basis of (self-)referral.

Family-based prevention

With growing numbers of younger children initiating drug use, the improvement and intensification of family-based prevention are of increasing importance. In pre-teenagers, family influence prevails over peer influence. The role of the family in establishing norms and support for children is more relevant to prevention than imparting information on substances.

Family-based prevention in the EU is becoming more targeted and more firmly needs based. Several Member States (Germany, Spain, Ireland, Italy and the United Kingdom) have acknowledged that it can be difficult for institutions to contact problem families. As a result, in the United Kingdom the FRANK campaign has developed an action pack for drug and alcohol action teams and prevention practitioners on how to reach the family, and in several other Member States selective prevention programmes targeted at families at risk are now being implemented. These programmes employ several techniques to attract at-risk families (e.g. providing food, financial incentives, babysitting) mostly based on Kumpfer’s Strengthening Families Program (Kumpfer et al., 1996).

The Strengthening Families Program (SFP) is being implemented in Spain (Palma de Mallorca and Barcelona), the Netherlands (two cities, evaluation study) and Sweden (two cities). Training in Ireland and Italy is under way and it is envisaged in the latter that coverage will extend to several cities. Norway is evaluating the similar MST programme in a randomised controlled trial. These selective family-based programmes have similar features in all Member States where they have been implemented.

Programmes for neglected children and young people from dysfunctional families are being run in Poland and in some provinces in Austria. These programmes are implemented in local community-based venues such as socio-therapeutic common rooms, upbringing facilities, youth clubs and prevention centres.

Some countries are focusing increasingly on the children of alcoholics (Belgium, Germany, Austria). The remaining countries still focus solely on the children of drug users.

Community-located prevention

Most selective prevention programmes are operated at the level of the community. Partly, this is because the various social services involved are usually coordinated at this level. However, in countries where communities have the power and will to enforce local norms, the community is a natural unit for environmental strategies. Community-based selective prevention is common in the Nordic countries and in Belgium, the Netherlands, Poland and the United Kingdom, and is increasing in countries that have made less use of this approach in the past (France, Italy, Hungary, Portugal).

By establishing community norms on the availability and methods of consumption of legal drugs, and by optimising local services, local environmental prevention strategies are a good starting point for effective drug prevention programmes.

Quality control in prevention

Quality control in prevention is of increasing importance, especially as many Member States have devolved the competences and responsibilities for prevention to the local level (Denmark, Italy, the Netherlands, Poland, Portugal and Slovenia) and/or delegated responsibility for drug prevention to non-governmental organisations (NGOs) or semi-independent associations (Belgium, Germany, France, Hungary and Finland). Accordingly, some Member States report on strategies to provide common quality criteria, standards and technical advisory services at the local level, supporting schools or communities in developing school policies (Belgium, Denmark, the Netherlands and the United Kingdom), implementing adequate prevention programmes and assuring minimum quality criteria (Denmark, France, Lithuania, Hungary, Slovakia, the United Kingdom, Romania and Norway).

Greece and Austria are leading the way in defining specifications for the accreditation of prevention agencies or prevention professionals.

Treatment and harm reduction responses

The context for EMCDDA data collection on harm reduction and treatment responses to the drugs problem is provided by two main EU instruments:

  1. The EU drugs strategy 2005–12 and its first action plan 2005–08, which present a framework for national policies as well as detailed recommendations for actions in the Member States aiming at the prevention of drug use and at increasing the coverage and quality of treatment and harm reduction services;

  2. The Council Recommendation of 18 June 2003 (31), which gives further specific recommendations on measures that Member States should consider implementing, in order to prevent and reduce health-related harm associated with drug dependence and to provide for a high level of health protection. This recommendation has been reinforced by its inclusion in the EU action plan as objective 14.

In order to evaluate the level of implementation of the strategy, it is important to determine levels of service provision and the extent to which the services are being used. Ultimately, however, sound estimates of the coverage – the extent to which the intended target group is reached by treatment and harm reduction measures – will be needed to evaluate the action plan objectives and for creating a basis for assessing the impact of the strategy.

Throughout the 8-year implementation period of the strategy, the EMCDDA supports the Commission in the evaluation process by providing data from the EU system of epidemiological indicators and by developing and implementing a number of specific data collection tools to determine service provision and utilisation of treatment and harm reduction services. Compared with the good overview of the epidemiological situation that has been achieved by the EMCDDA-driven development and implementation of indicator-based monitoring, standardised reporting on responses is limited.

Opioid substitution treatment

Methadone maintenance treatment for heroin users was pioneered in Europe by Sweden (in 1967), the Netherlands and the United Kingdom (1968) as well as by Denmark (1970), but its use remained limited for many years.

Following the discovery of the extent to which the HIV epidemic had spread among drug users in Western European countries, therapeutic goals and approaches began to shift in many countries from abstinence as the primary goal to the adoption of interventions more oriented towards the reduction of the harms associated with drug use. The need for repeated treatment interventions was accepted and the benefits of drug maintenance treatment for the stabilisation and improvement of opioid users’ health and social situation as well as for society as a whole was recognised.

After the late 1980s, the rate at which methadone maintenance was introduced as a treatment modality accelerated. By 2001, 24 EU countries as well as Bulgaria, Romania and Norway had introduced it (Figure 1). However, scale and coverage differ considerably between countries (see Chapter 6).


Figure 1 Introduction of methadone maintenance and high-dose buprenorphine treatment in EU Member States, candidate countries and Norway

Sources:

National focal points.

print


In 1996, the legal basis for the use of medication containing buprenorphine in the treatment of heroin users was first established in an EU Member State (see the selected issue on buprenorphine in the 2005 annual report). It is now available and used in the majority of Member States. As buprenorphine is controlled under a less stringent schedule of UN drug conventions, countries are given greater possibilities for its prescription. In some countries, this treatment option has led to rapid increases in the number of clients treated. New pharmacotherapy treatment modalities beyond agonist substitution are being explored, and research attention is now turning towards developing treatment responses for cocaine and crack users, many of whom also use heroin or have used it in the past (see also Chapter 5).

It is estimated that in the EU more than half a million opioid users received substitution treatment in 2003, which represents one-third of the currently estimated 1.5 million problem opioid users (EMCDDA, 2005a). The new Member States and candidate countries account for only a small fraction of the clients in substitution treatment in the European region, which can partly be explained by lower levels of opioid use in these countries. Although the overall provision of substitution treatment remains low in these countries, there are some indications of increases in Estonia, Lithuania and Bulgaria.

The information provided shows that in some countries there have been further increases in methadone treatment provision, but that in eight countries the numbers of people receiving such treatment stabilised or decreased (32). Four of these countries, Denmark, Spain, Malta and the Netherlands, have a profile of long-standing heroin use and highly accessible methadone substitution programmes. The other four countries, Latvia, Hungary, Poland and Romania, are characterised by low geographical coverage of methadone substitution, and in some places there is a waiting list for treatment.

It is difficult to determine if decreasing numbers of clients receiving methadone treatment mean that such clients are switching to buprenorphine treatment when available. The extent to which drug dependence treatment is delivered by GPs is often not known at national level.

Provision and type of drug dependence treatment


Box 3: Actions and interventions concerning drug users in prisons in the new Member States

The present data are based on a joint EMCDDA–WHO/Europe data collection project that was conducted in 2005 (1).

Drug testing in prisons is reported in the majority of new Member States. However, countries vary in terms of their drug testing schemes. Inmates are tested upon admission only in the Czech Republic, Malta and Slovenia. Malta and Slovenia are also the only countries to test prisoners before they go on leave. Random drug testing is carried out in all prisons in the Czech Republic, Malta, Slovenia and Slovakia and in less than 50 % of prisons in Hungary.

Drug-free treatment approaches dominate the interventions in prisons in the new Member States, but the coverage of such interventions is limited. Drug-free treatment with psychological support is reported to be available in less than 50 % of prisons in the Czech Republic, Estonia, Lithuania, Hungary, Poland and Slovakia. Drug-free units exist in most countries, but only the Czech Republic and Slovenia report such facilities in more than 50 % of prisons. Brief detoxification with medication is more widely available (all prisons in Latvia, Hungary, Malta, Slovenia and Slovakia).

The number of prisoners in new Member States having access to treatment with antagonists and substitution treatment is generally low. Except in emergency cases, treatment with antagonists does not appear to exist, and few countries report the availability of opioid substitution treatment for acute detoxification in prison (Hungary, Malta, Poland and Slovenia). Drug-related prerelease interventions mainly take the form of counselling and information provision (Czech Republic, Latvia, Lithuania, Hungary, Poland, Slovenia and Slovakia). Substitution treatment as a prerelease intervention is available in all prisons in Slovenia and in less than 50 % of prisons in Poland.

Few prisons in the new Member States report harm reduction measures for injecting drug users. Needle and syringe exchange programmes are not implemented in prisons in any of the new Member States, and only Estonia, Lithuania and Slovenia report the provision of disinfectants for cleaning syringes. Nevertheless, drug-related infectious diseases are being tackled in prisons. Vaccinations against hepatitis B are available in all prisons in six new Member States (Czech Republic, Estonia, Hungary, Malta, Slovenia and Slovakia), and five countries report the availability of antiviral treatment for hepatitis C-positive prisoners in all prisons (Czech Republic, Lithuania, Poland, Slovenia and Slovakia). Antiretroviral treatment for HIV-positive prisoners is reported by all new Member States (2).

(1) Data were provided by the Czech Republic, Estonia, Latvia, Lithuania, Hungary, Malta, Poland, Slovenia and Slovakia. For further references see EMCDDA (2005c).

(2) No data are available for Cyprus.


A survey conducted among national focal points (NFPs) in 2005 assessed the general characteristics of treatment provision in Europe. National experts were asked whether the majority of opioid users were treated in drug-free or medically assisted programmes or whether both modalities were equally prevalent.

The results show a ratio largely in favour of medically assisted treatment, with the main substance used being methadone (except in the Czech Republic and France; for more details see Chapter 6). The results further show that drug-related treatment in most countries is predominantly provided in outpatient settings – only Latvia and Turkey provide most treatment in inpatient settings. Traditional psychotherapeutic treatment modalities (psychodynamic, cognitive-behavioural, systemic/family therapy or Gestalt therapy) are the most frequently used modalities in outpatient treatment in Ireland, Latvia, the United Kingdom, Bulgaria and Turkey. Nine countries report the provision of predominantly ‘supportive’ methods (which can include counselling, socio-educative and environmental therapy, motivational interviewing or relaxation techniques and acupuncture), and 10 countries combine the different methods in their outpatient work.

Concerning inpatient care, the 12-step Minnesota model is a frequently used model in residential care in Ireland, Lithuania, Hungary and Turkey, while six countries predominantly apply psychotherapeutic treatment modalities, five countries ‘supportive’ methods and 10 countries a combination of such approaches.

Over the last decade, but even more so in the last 5 years, many European countries have ‘opened the doors’ of treatment by expanding their provision of substitution treatment and reducing access limitations. Never before have such large numbers of drug users been reached by the system of care. Many but not all require assistance beyond the treatment of their dependency, and many seem to need low-threshold care as well as substantial support for their reintegration.

Harm reduction responses

At the same time as reaching clients and maintaining contact became an objective in itself, outreach and low-threshold service provision gained recognition and support and have now become essential parts of a comprehensive response in many Member States. Common response profiles are visible in Europe with regard to the prevention of infectious diseases among drug users and the reduction of drug-related deaths (see also Chapter 7).

The reduction of drug-related deaths was defined for the first time as a European drug policy objective 6 years ago, and it is an objective of the current EU action plan (33). The number of countries which include a direct reference to the target of reducing drug-related deaths in their national policies has continued to increase in recent years, with eight countries adopting such strategies during 2004 and 2005 (bringing the total number to 15). Besides national policies, complementary approaches at city level are common: several capital cities (including Athens, Berlin, Brussels, Lisbon and Tallinn) but also wider semi-urban regions (e.g. the eastern region of Ireland, around Dublin) have their own strategies for reducing drug-related deaths. In the Czech Republic, Italy, the Netherlands and the United Kingdom, local or regional policies are reported to exist, and in Bulgaria strategies have been drawn up at local level in nine cities.


Box 4: Low-threshold agencies as an important data source

Low-threshold agencies play a crucial role in increasing drug users’ access to care. For populations of drug users that are ‘hidden’ or more difficult to reach or have lost contact with the care system, these agencies can provide a point of contact and a setting for delivering medical and social services.

Although all low-threshold agencies have in place some system for documenting their service delivery, and monitoring and reporting can be extensive, these activities are primarily orientated towards accountability to funding bodies and less towards internal quality management or service planning and evaluation. All too often, valuable information that is collected remains at the level of the agency. Despite its potential importance for monitoring drug use patterns and trends as well as service access, the low-threshold setting appears to be largely underused. One main obstacle is lack of standardisation and comparability of the collected information.

It is important for improving the quality of data available on the provision and utilisation of harm reduction services that a data collection tool exists that is appropriate for agencies and at the same time produces relevant results for national and European monitoring purposes. An initiative in this direction is the joint EMCDDA–Correlation project, supported by experts from the national focal points of France, Ireland, Hungary and Norway. The Correlation network (European Network for Social Inclusion and Health, www.correlation-net.org) represents governmental and non-governmental organisations from 27 European countries and is funded under the public health programme of the European Commission (DG SANCO).


As in the previous European Union drug strategy and action plan, prevention of the spread of infectious diseases remains an important goal in the current strategy and is specified as objective 16 in the action plan for 2005–08. This emphasises the continued importance that European governments and the Commission place on the health-related consequences of drug use (34).

A large majority of EU countries and Norway have clearly spelled out their approach to the prevention of infectious diseases among drug users and have included concrete objectives or tasks in their national drug strategy documents or have adopted a separate policy text that specifies how infectious disease prevention among drug users shall be tackled (Spain, Latvia, Luxembourg, Sweden), or have done both (Estonia, France, the United Kingdom). Malta and Austria are planning to draw up specific policies for their approach in this area.

In Germany and Greece, concrete measures aimed at the prevention of infectious diseases form part of the national drug strategy, while infectious disease prevention is not explicitly identified as an objective.

These infectious disease prevention strategies are in most cases quite recent, and the timing of their adoption coincides in a number of countries with the previous EU drugs strategy (2000–04), in which a reduction in the incidence of infectious diseases among drug users became a European target for the first time.

According to the reports by NFPs (35), objectives and target groups in national strategies also show a high level of synergy at the European level. Besides drug injectors, target groups include prostitutes and prisoners. In the new Central European Member States in particular, but also in Norway, young people and non-injectors are clearly addressed as further important target groups for action to prevent infectious disease. Danish and Estonian policies widen the target groups even more and include groups in close contact with drug users.

In many EU countries, strategies aimed at reducing infectious disease are clearly geared towards HIV/AIDS, particularly Estonia, Spain, Cyprus, Latvia and Lithuania. However, in 10 countries (37 %), infectious disease strategies explicitly mention the prevention of hepatitis C infection among drug users (36). Ireland launched a consultation process in 2004, preparing such a strategy, and in Germany recommendations on prevention and treatment were issued. Professional and public discussion in Austria was boosted by an international conference on the topic held in Vienna in 2005.

Harm reduction strategies form an important part of the European response to drug use today, and improving access to services for the prevention and reduction of health-related harm is a main priority of the EU drugs strategy 2005–12. The common strategic platform on the reduction of health-related harm that the EU drugs strategy provides is mirrored in many national policies across the EU and has supported a mainstreaming of evidence-based responses in this area.

In 2004, an improvement in the monitoring of syringe availability at European level was documented. However, information on the provision, utilisation and coverage of the wide range of further important services delivered by low-threshold agencies is barely recorded at national level in most countries. A European picture cannot easily be drawn. A project to improve the data situation is described in the box ‘Low-threshold agencies as an important data source’.

Targeted treatment and quality management

The current EU action plan also calls for high-quality treatment and harm reduction services.

The use of quality management tools at the level of the treatment and harm reduction planning has resulted in services being more target group specific, e.g. respecting the different needs of gender groups (see also the selected issue on gender).

Treatment units or programmes that exclusively service one specified target group are a common phenomenon across the EU. Children and young people under the age of 18 are treated in specialised agencies in 23 countries; the treatment of drug users with psychiatric co-morbidity takes place in specialised agencies in 18 countries; and women-specific services are reported to exist in all countries except Cyprus, Latvia, Lithuania, Bulgaria and Turkey. Services designed to meet the needs of immigrant drug users or of groups with specific language requirements or religious or cultural backgrounds are less common but have been reported from Belgium, Germany, Greece, Spain, Lithuania, the Netherlands, Finland, Sweden and the United Kingdom.

Units that specialise in treating cannabis or cocaine users have been reported from 13 countries, and specific treatment programmes for these groups in drugs agencies exist in eight countries. However, the availability and accessibility of such services are rated to be low in most of these countries. A similar specialised programme for amphetamine users is reported from Spain, Slovakia and the United Kingdom.

Further concrete steps towards enhancement of quality in treatment and care are individual case management, mediation of the provision of specialist services (i.e. treatment of co-morbidities) and pretreatment client assessments to better match client profiles with the treatment on offer with the aim of achieving longer retention and increased treatment effectiveness.

Despite the overall expansion of treatment options, engaging with some groups of drug users, particularly those with long-term and chronic problems, remains a challenge for drug services. Outreach and low-threshold interventions are common approaches to attempting to make contact and engage with these hard-to-reach populations. A more controversial approach is the development in some countries of supervised drug consumption rooms mostly targeting drug injectors but now sometimes also extending provision to crack cocaine or heroin smoking (see EMCDDA, 2004c). Another, controversial area of service development and experimentation is the use of heroin by a few countries as an agent for drug substitution treatment. Although, overall, activities in this area remain very limited compared to other treatment options, some studies have suggested that heroin prescribing may have potential benefits for clients where methadone maintenance treatment has failed. For example, a recent German randomised controlled trial of heroin-assisted treatment (Naber and Haasen, 2006) reported positive outcomes in terms of both health and reductions in use of illicit drugs. Nonetheless, no clear consensus currently exists across Europe on the cost and benefits of this approach and it remains an area where there is considerable political and scientific debate.

With the increasing availability and quality of treatment, emphasis in some European cities has also shifted towards reducing the impact of drug use on the community. Assertive outreach work and an attractive range of low-threshold services have shown promise in some local contexts (see ‘Harm reduction approaches’ in Chapter 5) and might be valuable and effective models to be used more broadly to re-establish communication with marginalised groups and eventually channel them into treatment.

The development of ‘safer’ substitution products (i.e. substances less likely to be diverted into the black market) makes it likely that drug dependency treatment will move even further towards the GP’s surgery. This is also a process of normalisation, which allows drug dependency to be treated like a chronic disease such as diabetes.

Some countries report that the large groups of heroin users in substitution treatment create a corresponding demand for social reintegration support, especially for paid work. Under the current economic circumstances, many countries may find it difficult to meet the vocational reintegration needs of older heroin users, even if they are stabilised in drug maintenance treatment. This situation is aggravated by the high levels of morbidity among this group.

Social reintegration

All the available literature and facts and figures from Member states converge towards the same truth: the life situations of drug users are far more problematic and precarious than those of the general population. Thus, in the last two EU drugs action plans, social reintegration has been one of the ultimate aims in order to improve the health and social status of drug users.

The 2005–08 action plan calls on Member States to ‘improve access to and coverage of rehabilitation and social reintegration programmes’. Although social measures are still a less well-established response to problem drug use than treatment, interventions combining treatment, health and social actions are recognised by professionals as the best response to achieve drug user rehabilitation.


Box 5: A gender perspective on drug use and responding to drug problems, in EMCDDA 2006 annual report: selected issues

Generally, among drug users males far outnumber. In the EU Member States, not only is the use of illicit drugs more common in males, but men are much more likely to develop problems, seek treatment and die from drug use.

This selected issue looks at drug use and related problems from a gender perspective. Among the important questions addressed are: What differences exist between the use of drugs by men and women and is the gender gap narrowing? How have Member States developed gender-specific approaches to drug prevention, treatment, social rehabilitation and harm reduction? Are gender-specific responses equally important for males and females?

This selected issue is available in print and on the Internet in English only (http://issues06.emcdda.europa.eu).


Data on social reintegration (37) are scarce in Europe, mostly because of the obstacles to collecting quantitative information in this field. Hence, most of the information related below is based on a qualitative assessment focusing on policy, implementations and quality assurance within the Member States (38).

In 2004/05, in response to the EU action plan, 20 of the 28 reporting countries (39) had a strategy for drug-related social reintegration. A further four countries, although they do not address this issue explicitly in their national drug strategy or other drug policy document, have regional or local strategies in place; three have neither.

The main provider of funds is to be found at state/national level in 11 countries, whereas funding is predominantly at regional/local level in eight countries. In another eight countries, the funding comes from both levels, with no apparent predominant provider, or through health insurance schemes.

In the EU Member States, problem drug users can access social measures through facilities either exclusively dedicated to drug users or targeting socially deprived groups. Among these measures, housing is one of the key pillars. The service most commonly offered to homeless problem drug users is access to ‘generic housing services’ (in 21 countries), while 18 countries offer housing facilities solely for problem drug users and 13 countries combine the two systems. However, there are doubts about the effective access of homeless problem drug users to these facilities. Low availability, local resistance to providing drug users with new facilities, restricted criteria for access and difficulties for homeless problem drug users in sticking to the rules are among the problems reported.

Getting homeless problem drug users into stable accommodation is the first step towards stabilisation and rehabilitation. Based on the estimated numbers of problem drug users and the proportion of homeless people among clients in treatment, there are approximately 75 600 to 123 300 homeless problem drug users in Europe. As facilities are currently available in most countries, and as some countries continue to implement new structures, the effect of these measures will depend on ensuring that homeless problem drug users can access these services.


(30http://www.drugs.gov.uk/young-people/blueprint/

(31) Council Recommendation 2003/488/EC.

(32) See Table NSP-7 in the 2006 statistical bulletin.

(33) Objective 17 of the EU action plan 2005–08 calls for the reduction of drug-related deaths to be included as a specific target at all levels, with interventions specifically designed for this purpose.

(34) In particular, objective 16 of the action plan 2005–08 refers to infectious disease prevention. Objective 14 calls for the implementation of a Council Recommendation on prevention and reduction of health-related harm associated with drug dependence, adopted in 2003 (Council Recommendation 2003/488/EC). A report by the Commission on the implementation of this Recommendation, including information collected from policy makers and Reitox national focal points, is foreseen in 2007 as a contribution to the evaluation of the EU drugs strategy.

(35)  This analysis is largely based on national reporting with a structured questionnaire (SQ 23), updated with information provided by national focal points in their national reports.

(36)  Including France and England, both of which have established full-blown hepatitis C prevention strategies: Plan National Hepatites Virales C et B (2002–2005) (http://www.sante.gouv.fr/htm/actu/hepatites/situation.htm) and Hepatitis C: Action Plan for England, 2004 (http://www.dh.gov.uk/) respectively.

(37) Social reintegration is defined as ‘any social intervention with the aim of integrating former or current problem drug users into the community’. The three ‘pillars’ of social reintegration are (1) housing; (2) education; and (3) employment (including vocational training). Other measures, such as counselling and leisure activities, may also be used.

(38) For more information see http://www.emcdda.europa.eu/?nnodeid=1573.

(39) Member States plus Bulgaria, Romania, Turkey and Norway, but no information available for Estonia.