In Europe, two forms of imported heroin are found: the commonly available brown heroin (its chemical base form) and the less common and usually more expensive white heroin (a salt form), which typically originates from South-east Asia. In addition, some opioid drugs are produced within the EU, but manufacture is mainly confined to small-scale production of home-made poppy products (e.g. poppy straw, poppy concentrate from crushed poppy stalks or heads) in a number of eastern EU countries, for example Lithuania, where the market for poppy stalks and concentrate seems to have stabilised, and Poland, where production of ‘Polish heroin’ might be decreasing (CND, 2006).
Heroin consumed in Europe is predominantly manufactured in Afghanistan, which remains the world leader in illicit opium supply and in 2005 accounted for 89 % of global illicit opium production, followed by Myanmar (7 %). Global production of illicit opium remained relatively stable between 1999 and 2004, except in 2001, when a ban on opium poppy cultivation enforced by the Taliban regime in Afghanistan resulted in a dramatic but short-lived decline; it is estimated that about 4 670 tonnes was produced in 2005, a 4 % decline compared with 2004 (CND, 2006). Global potential production of heroin was estimated at 472 tonnes in 2005 (495 in 2004) (UNODC, 2006).
Heroin enters Europe by two major trafficking routes. The historically important Balkan route continues to play a crucial role in heroin smuggling. Following transit through Pakistan, Iran and Turkey, the route then diverges into a southern branch through Greece, the Former Yugoslav Republic of Macedonia (FYROM), Albania, Italy, Serbia, Montenegro and Bosnia-Herzegovina and a northern branch through Bulgaria, Romania, Hungary, Austria, Germany and the Netherlands, the latter operating as a secondary distribution centre to other Western European countries. Heroin seizures in 2004 suggest that the southern branch has now gained the same importance as the northern branch in terms of volume smuggled (WCO, 2005; INCB, 2006a). Since the mid-1990s, heroin has been increasingly (but to a lesser extent than through the Balkan routes) smuggled to Europe through the ‘silk route’ via central Asia (in particular Turkmenistan, Tajikistan, Kyrgyzstan and Uzbekistan), the Caspian Sea and the Russian Federation, Belarus or Ukraine, to Estonia, Latvia, some of the Nordic countries and Germany (Reitox national reports, 2005; CND, 2006; INCB, 2006a). Although these routes are the most important, countries in the Arabian Peninsula (Oman, United Arab Emirates) have become transit sites for heroin consignments from South and South-West Asia destined for Europe (INCB, 2006a). In addition, heroin destined for Europe (and North America) was seized in 2004 in East and West Africa, the Caribbean, and Central and South America (CND, 2006).
In 2004, 210 tonnes of opium (or 21 tonnes of heroin equivalent), 39.3 tonnes of morphine and 59.2 tonnes of heroin were seized worldwide. Asia (50 %) and Europe (40 %) continued to account for the greatest quantities of heroin seized worldwide. Europe’s share is increasing, largely as a result of increased seizures in South-East European countries (Turkey), which for the first time surpassed the volume intercepted in Western and central Europe (CND, 2006).
In 2004, an estimated 46 000 seizures resulted in the recovery of about 19 tonnes of heroin in the reporting countries. The United Kingdom continued to account for the highest number of seizures, followed by Germany and Italy, while Turkey seized the largest quantities (followed by Italy and the United Kingdom), accounting for nearly half of the total amount intercepted in 2004 (160). Over the period 1999–2004, seizures of heroin fluctuated, and based on data from reporting countries it seems that the decrease observed in 2002–03 was followed by an increase in 2004 (161). Over the 5-year period 1999–2004, total quantities seized steadily increased, reaching a record level in 2004, largely because the quantity of heroin seized in Turkey nearly doubled in 2004 compared with the previous year (162).
In 2004, the average retail price of brown heroin varied widely across Europe, from 12 euros per gram in Turkey to 141 euros per gram in Sweden, while that of white heroin varied between 31 euros per gram in Belgium and 202 euros per gram in Sweden, and the price of heroin of type undistinguished ranged from 35 euros per gram in Slovenia to 82 euros per gram in the United Kingdom (163). Data available for 1999–2004 show a decrease in the average price of heroin, corrected for inflation (164), in most reporting countries (165).
The average purity of brown heroin at user level varied in 2004 from 10 % in Bulgaria to 48 % in Turkey, while that of white heroin varied between 20 % in Germany and 63 % in Denmark, and that of heroin of type undistinguished ranged from 16 % in Hungary to 42–50 % (166) in the Netherlands (167). The average purity of heroin products has been fluctuating in most reporting countries (168) since 1999, making it difficult to identify any overall trend.
Acetic anhydride (169) is an important precursor used in the illicit manufacture of heroin. Operation Topaz is an international initiative to monitor licit trade in acetic anhydride and to investigate methods and routes of diversion (INCB, 2006b). There is considerable licit trade in acetic anhydride, making it difficult to control. This is illustrated by the fact that, since 2001, 22 exporting countries/territories have provided 7 684 pre-export notifications to the INCB involving over 1 350 000 tonnes of acetic anhydride. Seizures in Turkey (1 600 litres in 2004) have significantly declined in recent years, perhaps indicating that traffickers have developed new routes and methods of diversion. In 2004, for the first time, seizures in Europe (Bulgaria) were identified as having come from South-west Asia (INCB, 2006b).
Although aspects of Operation Topaz related to monitoring international trade have proved to be successful, little progress has been made in identifying and dismantling routes used for smuggling acetic anhydride within Afghanistan and in its neighbouring countries (INCB, 2006b).
Project Mustard, run by Europol, aims at identifying and targeting Turkish and associated criminal groups operating towards and within the EU and engaged in the trafficking of drugs, primarily heroin. It provides operational support to live investigations in participating states and enhances the strategic intelligence picture by providing insight into the activities of Turkish organised crime and associated groups (Europol, 2006).
Data in this section are derived from the EMCDDA problem drug use (PDU) indicator, which covers ‘injecting drug use or long duration/regular use of heroin, cocaine and/or amphetamines’. Historically, problem drug use estimates have principally reflected heroin use, although in a few countries, as discussed elsewhere in the report, amphetamine users are an important component.
Red squares indicate stimulant use, other estimates are opioid use.CR, capture–recapture; TM, treatment multiplier; PM, police multiplier; MI, multivariate indicator; MM, mortality multiplier; TP, truncated Poisson; CM, combined methods. For more information see Tables PDU-1, PDU-2 and PDU-3 in the 2006 statistical bulletin. The symbol indicates a point estimate, a bar indicates an uncertainty interval, which can be either a 95 % confidence interval or an interval based on sensitivity analysis. Target groups may vary slightly owing to different methods and data sources, therefore comparisons should be made with caution.
National focal points.
When interpreting the estimates of problem opioid use it should be kept in mind that patterns of use are becoming more diverse. For example, polydrug use problems have become progressively more important in most countries, whereas some countries where opioid problems have historically predominated now report changes towards other drugs. Most heroin users are now believed to use stimulants and other drugs besides opioids, but reliable data on polydrug use are very hard to obtain at the EU level (see Chapter 8).
Information on drug use among prisoners is patchy. Many of the data available in Europe come from ad hoc studies, sometimes carried out at local level in establishments not representative of the national prison system, and using samples of prisoners that vary considerably in size. As a result, differences in terms of the characteristics of the populations studied limit comparisons of data between surveys – within and between countries – as well as extrapolation of results and trend analysis.
Data on drug use among the prison population in the last 5 years (1999–2004) were provided by most European countries (1). They show that, compared with the general population, drug users are overrepresented in prison. The proportion of detainees who report ever having used an illicit drug varies among prisons and detention centres, but average rates range from one-third or fewer in Hungary and Bulgaria to two-thirds or more in the Netherlands, the United Kingdom and Norway, with most countries reporting lifetime prevalence rates of around 50 % (Belgium, Greece, Latvia, Portugal, Finland). Cannabis remains the most frequently used illicit drug, with lifetime prevalence rates among prisoners ranging between 4 % and 86 %, compared with lifetime prevalence rates of 3–57 % for cocaine, 2–59 % for amphetamines and 4–60 % for heroin (2).
Regular drug use or dependence prior to imprisonment is reported by 8–73 % of inmates, while the lifetime prevalence of drug injection among the prison population is 7–38 % (3).
Although the majority of drug users reduce or stop their drug use after incarceration, some detainees continue and others start using drugs (and/or injecting drugs) while in prison. According to available studies, 8–51 % of inmates have used drugs within prison, 10–42 % report regular drug use and 1–15 % have injected drugs while in prison (4). This raises issues around the potential spread of infectious diseases, in particular in relation to access to sterile injection equipment and sharing practices among the prison population.
Repeated surveys carried out in the Czech Republic (1996–2002), Denmark (1995–2002), Lithuania (2003/2004), Hungary (1997/2004), Slovenia (2003/2004) and Sweden (1997–2004) show an increase in the prevalence of various types of drug use among detainees, whereas France (1997/2003) reports a significant decrease in the proportion of injectors among the prison population (5).
(1) Countries reporting studies carried out in the last 5 years (1999–2004) and providing data on drug use patterns in prison populations were Belgium, the Czech Republic, Denmark, Germany, Greece, France, Ireland, Italy, Latvia, Lithuania, Hungary, Malta, the Netherlands, Austria, Portugal, Slovenia, Slovakia, Finland, Sweden, the United Kingdom, Bulgaria and Norway.
(5) See Table DUP-5 in the 2006 statistical bulletin.
Despite the general trend towards diversification of the phenomenon, in many countries estimates of problem drug use are exclusively based on problem use of heroin or other opioids as the primary substance. This can be seen in the estimated rates of problem opioid use (see Figure 8), which for the most part are very similar to those of PDU (170). It is not clear whether in the other countries the prevalence of non-opioid problem use is almost negligible or, possibly, significant but too difficult to estimate.
Estimating the number of problem opioid users is difficult, and analyses of a sophisticated nature are required to obtain prevalence figures from the available data sources. Moreover, estimates are often localised geographically, and extrapolation to form national estimates are not necessarily reliable.
Estimates of the prevalence of problem opioid use at national level over the period 2000–04 range between 1 and 8 cases per 1 000 population aged 15–64 (based on midpoints of estimates). Estimated prevalence rates of problem opioid use differ greatly between countries, although when different methods have been used within one country the results are largely consistent. Higher estimates of problem opioid use are reported by Ireland, Italy, Luxembourg, Malta and Austria (5–8 cases per 1 000 inhabitants aged 15–64 years), and lower rates are reported by the Czech Republic, Germany, Greece, Cyprus, Latvia and the Netherlands (fewer than four cases per 1 000 inhabitants aged 15–64 years) (Figure 8). Some of the lowest well-documented estimates now available are from the new countries of the EU, but in Malta a higher prevalence has been reported (5.4–6.2 cases per 1 000 aged 15–64). One can derive from the limited data a general EU prevalence of problem opioid use of between two and eight cases per 1 000 of the population aged 15–64. However, these estimates are still far from robust and will need to be refined as more data become available.
Local and regional estimates specifically of problem opioid use are not available; however, the available data regarding problem drug use (including use of stimulants and other drugs) suggest that there is a large variation in prevalence among cities and regions. The highest local prevalence estimates in the period 2000–04 are reported from Ireland, Portugal, Slovakia and the United Kingdom, reaching rates of between 15 and 25 per 1 000 (171). Geographic variability is, as might be expected, also marked at the local level; for example, the prevalence in different parts of London varies between 6 and 25 cases per 1 000. The wide variation in local prevalence rates makes generalisation difficult.
A lack of reliable and consistent historical data complicates the assessment of trends over time in problem opioid use. The evidence that has been collected suggests that the prevalence of problematic opioid use differs widely between countries, and that trends are not consistent across the EU. Reports from some countries, supported by other indicator data, suggest that problem opioid use continued to increase during the mid to late 1990s (Figure 9) but appears to have stabilised or declined somewhat in more recent years. Repeated estimates on problem opioid use for the period between 2000 and 2004 are available from seven countries (the Czech Republic, Germany, Greece, Spain, Ireland, Italy, Austria): four countries (the Czech Republic, Germany, Greece, Spain) have recorded a decrease in problem opioid use, while one reported an increase (Austria – although this is difficult to interpret as the data collection system changed during this period). Evidence from people entering treatment for the first time suggests that incidence of problem opioid use may in general be slowly declining, therefore in the near future a decline in prevalence is to be expected.
Injecting drug users (IDUs) are at very high risk of experiencing adverse consequences such as serious infectious diseases or overdoses. It is therefore important to consider drug injection separately.
Despite their importance for public health, few countries provide estimates of injecting drug use at national or subnational level (172). In this section, IDU estimates are not categorised by primary drug, given the scarcity of data, although the trends in the proportion of IDUs among treated heroin users (see below) are of course specific for heroin injecting.
Most available estimates of injecting drug use are derived from either fatal overdose rates or data on infectious diseases (such as HIV). Available estimates vary considerably between countries: since 2000, estimates at national level have mostly ranged between one and six cases per 1 000 population aged 15–64, with some higher estimates existing prior to 2000. Since 2000, the highest national prevalence rates of injecting drug use, among the countries where estimates are available, have been reported by Luxembourg and Austria, with a rate of about six cases per 1 000 population aged 15–64. The lowest estimates are from Cyprus and Greece, at just over one case per 1 000.
Where time trends are available they do not show a general pattern, suggesting declines in some countries and regions (for example in Scotland, United Kingdom) and increases in others. However, the lack of data in this area means that it is not possible to draw a clear picture.
Monitoring the proportion of current injectors among heroin users entering treatment forms an important complement to monitoring the prevalence of injecting drug use in the general population. However, it is important to remember that the observed proportions do not necessarily reflect trends in the prevalence of all injecting drug use. For example, in countries with a high proportion of stimulant users (the Czech Republic, Slovakia, Finland, Sweden), the rates of injecting among heroin users might not be representative of the overall situation.
The proportion of IDUs among primary heroin users entering drug treatment again suggests marked differences in levels of injecting drug use between countries as well as varying trends over time (173). In some countries (Spain, the Netherlands and Portugal), a relatively small proportion of treated heroin users inject, whereas in other countries injection appears to be still the main form of heroin use. In some EU-15 Member States from which data are available (Denmark, Greece, Spain, France, Italy and the United Kingdom), rates of injecting among heroin users in treatment have declined. However, in most of the new Member States, at least where data exist, a large proportion of heroin users entering treatment are injectors.
In many countries, opioids (largely heroin) remain the principal drug for which clients seek treatment. Of the total treatment requests reported for 2004 under the treatment demand indicator, opioids were recorded as the principal drug in about 60 % of cases – and just over half (53 %) of these clients reported injecting the drug (175). It should be noted that the treatment demand indicator does not cover all people in opioid treatment, which is a considerably greater number, only clients requesting treatment during the reported year.
The proportion of clients seeking treatment for heroin use varies between countries. Based on the most recent data available, countries can be classified into three groups according to the proportion of drug users seeking treatment who report problem use of heroin, as follows:
below 50 % – the Czech Republic, Denmark, Hungary, the Netherlands, Poland, Slovakia, Finland, Sweden;
50–70 % – Germany, Spain, France, Ireland, Cyprus, Latvia, Portugal, United Kingdom, Romania;
over 70 % – Greece, Italy, Lithuania, Luxembourg, Malta, Slovenia, Bulgaria (176).
Countries where a sizable proportion of opioid clients are using substances other than heroin include Hungary, where the use of home-made opium poppy products is widespread, and Finland, where most opioid clients are misusing buprenorphine (177).
Most opioid users, as for users of other drugs, seek treatment in an outpatient setting; however, in comparison with cocaine and cannabis clients, a higher proportion of opioid clients are treated in inpatient centres.
Most countries with significant numbers of new heroin clients each year (except Germany, where the reporting base has been extended) report that there has been a decrease in the last 4–5 years, although not among clients who have previously been in treatment. The numbers of repeat requests has generally not declined, and in most countries the total number of treatment demands for heroin has remained roughly stable. Notable exceptions are Germany and the United Kingdom, where total reported requests have increased. Overall, however, the percentage of treatment demands accounted for by heroin (all and new requests) has fallen; in the case of new demands it has declined from about two-thirds to around 40% between 1999 and 2004 in the face of increases in demands for cannabis and cocaine treatment (178).
It has been previously reported that the population of clients requesting treatment for opioid use is an ageing one, and this trend continued in 2004. Nearly all opioid users seeking treatment are over 20 years old, and almost half of them are over 30. Data available at European level show that only a small group of opioid users (less than 7 %) are younger than 20 when they first seek help (179). There are occasional reports of very young people (aged less than 15) seeking treatment for heroin use (180), for example children aged 11–12 in Sofia, Bulgaria, but, in general, demand for treatment for heroin appears to be rare among the young.
Opioid clients are reported to be marginalised in society, with low levels of education, high unemployment rates and often unstable accommodation; Spain reports that 17–18 % of opioid clients are homeless.
Most opioid clients report having used these drugs for the first time between the age of 15 and 24 years, with around 50 % of clients first using the drug before the age of 20 (181). Since the time lag between first use and first demand for treatment is generally between 5 and 10 years and the time between initiation and regular drug use is estimated to be 1.5–2.5 years (Finnish national report), it can be concluded that opioid clients typically experience 3–7 years of regular drug use before first seeking specialised treatment.
Across Europe, among new opioid clients seeking treatment in outpatient centres and for whom the route of administration is known, just over half are injecting the drug. In general, levels of injecting are higher among opioid users seeking treatment in the new Member States (above 60 %) than in the EU-15 Member States (below 60 %), with the exception of Italy and Finland, where the proportion of opioid injectors among clients is 74 % and 79.3 % respectively. The proportion of injectors among opioid clients is lowest in the Netherlands (13 %) and highest in Latvia (86 %) (182).
The EU drug strategy 2005–12 places a high priority on improving the availability of and access to treatment and it calls on Member States to provide a comprehensive range of effective treatments. Historically, residential treatment represented an important setting for the treatment of problem opioid users. However, the increasing diversity of treatment options and, in particular, the considerable expansion of substitution treatment has meant that the relative importance of residential care has declined.
Data on the relative availability of different types of treatment for opioid problems in Europe are currently limited. In response to an EMCDDA questionnaire, experts in most (16) Member States indicated that substitution treatment is the principal form of treatment available. However, in four countries (the Czech Republic, Hungary, Poland and Slovakia), drug-free treatment is reported to be more common, and in two countries, Spain and Sweden, a balance between medically assisted treatment and drug-free treatment options is reported.
Substitution therapy for opioid dependence (mainly treatment with methadone or buprenorphine) is in place in all EU Member States (183) as well as Bulgaria, Romania and Norway, and there is now a substantial European consensus that it is a beneficial approach to the treatment of problem opioid users, although in some countries it remains a sensitive topic (see Chapter 2). The role of substitution treatment is becoming less controversial internationally; the UN system came to a joint position on substitution maintenance therapy in 2004 (WHO/UNODC/UNAIDS, 2004), and in June 2006 WHO included both methadone and buprenorphine in its model list of essential medicines.
There is now a robust evidence base for the value of substitution programmes using drugs such as methadone or buprenorphine. Studies have shown that substitution therapy is associated with decreased use of illicit drugs, reduced rates of injecting, a reduction in behaviours associated with a high risk of spread of HIV or other infectious diseases, such as sharing of equipment, and improvements in both social functioning and general health. Research has also suggested that levels of criminal activity may be reduced and that sufficient provision of substitution treatment may have an impact on the number of drug-related deaths. Optimum outcomes depend on timely entry into the programme, sufficient duration and continuity of substitution treatment, and adequate doses of medication.
While methadone continues to be the most commonly prescribed substitution treatment in Europe, treatment options are still expanding, and buprenorphine is now available in 19 EU countries, Bulgaria and Norway, although it is not clear whether it is officially approved for maintenance treatment in all countries where it is reported to be used. Considering that high-dosage buprenorphine treatment was introduced in Europe only 10 years ago, the drug’s popularity as a therapeutic option has developed remarkably quickly (see Figure 1) (184).
Long-term drug substitution is not the only purpose of opioid pharmacotherapy. Methadone and buprenorphine are also used to treat opioid withdrawal, when the therapeutic goal is to help the individual achieve abstinence by giving a reducing dose over a fixed period to help minimise the distress of withdrawal. The opioid antagonist naltrexone, an aversive pharmacotherapy option for opioid dependence, is also sometimes used as an aid to prevent relapse, as it blocks the effects of heroin, although the evidence base for the use of this drug is still inconclusive.
Some countries (Germany, Spain, the Netherlands and the United Kingdom) also have heroin prescription programmes, although the number of patients receiving this kind of treatment is very small compared with other forms of drug substitution (probably constituting less than 1 % of the total). This form of treatment remains controversial and is generally provided on a scientific trial basis for long-term users in whom other therapeutic options have failed.
A recent review of the effectiveness of drug dependence treatment in preventing HIV transmission found that behavioural interventions can enhance the positive effects of substitution treatment on HIV prevention, whereas the effectiveness of psychological therapy alone is variable. Abstinence-based treatment showed good outcomes with regard to HIV prevention for those who remain in treatment for 3 months or more (Farrell et al., 2005).
Methadone is a controlled drug according to Schedule I of the 1961 Single Convention on Narcotic Drugs, and levels of domestic consumption are monitored annually by the INCB.
According to the EMCDDA, as a minimum estimate from the EU Member States, Bulgaria, Romania and Norway, more than 500 000 clients received substitution treatment during the year (see Table 4 in the 2005 annual report). Excluding the Czech Republic and France, where high-dose buprenorphine treatment (HDBT) is reported to be the most common option, more than 90 % of treatments in all other countries were with methadone.
The EU and the USA together account for 85 % of the world’s methadone consumption, and methadone consumption in these countries has shown a steady increase over the last decade. Amounts consumed stabilised in both regions between 1997 and 2000, but there has been a sharp increase in the United States since then. Currently, levels of methadone consumption in the EU are about half those of the USA (185).
As a rule, noticeable increases in consumption figures follow the introduction of this treatment option at national level. For example, in France, the widespread implementation of methadone substitution treatment in 1995 resulted in a rapid increase in consumption, from 31 kg in 1995 to 446 kg in 2004.
Recently, signs of a stabilisation in levels of methadone consumption can be observed in the statistics for Denmark, Spain, Malta, the Netherlands, and possibly Germany. This matches reported trends in the number of clients in treatment (see Chapter 2).
(160) This should be checked against missing 2004 data when available. Data on both number of heroin seizures and quantities of heroin seized in 2004 were not available for Ireland and the United Kingdom; data on number of heroin seizures were not available for the Netherlands in 2004. For estimating purposes, 2004 missing data were replaced by 2003 data. Data on quantities seized in 2004 provided by the Netherlands were only estimates, which could not be included in the analysis of trends to 2004.
(164) Taking 1999 as the base year for the value of money in all countries.
(165) In the period 1999–2004, data on heroin prices were available for at least 3 consecutive years: for brown heroin in Belgium, the Czech Republic, Spain, France, Ireland, Luxembourg, Poland, Portugal, Slovenia, Sweden, United Kingdom, Bulgaria, Romania, Turkey and Norway; for white heroin in the Czech Republic, Germany, France, Latvia and Sweden; and for heroin of type undistinguished in Lithuania and the United Kingdom.
(166) These two figures correspond to data from two different monitoring systems (see Table PPP-6 (part iii) in the 2006 statistical bulletin); caution is required as the figure 50 % is based on one sample only.
(168) In the period 1999–2004, data on heroin purity were available for at least 3 consecutive years: for brown heroin in the Czech Republic, Denmark, Spain, Ireland, Italy, Luxembourg, Austria, Portugal, Slovakia, the United Kingdom, Turkey and Norway; for white heroin in Denmark, Germany, Estonia, Finland and Norway; and for heroin of type undistinguished in Belgium, Lithuania, Hungary and the Netherlands.
(169) Scheduled under Table I of the 1988 Convention.
(174) See footnote (70).
(183) In Cyprus, the use of methadone in detoxification treatment is reported since 2004 and the beginning of a methadone maintenance treatment pilot project has been announced, but no cases in treatment have been reported. In Turkey, methadone is officially registered for the treatment of opioid dependency, but no treatment cases have been reported.