Commentary

Identifying drug trends in Europe

Identifying drug trends in Europe

Piecing together the European picture

This section provides an overview of the main developments and trends in the European drug situation. This is arrived at by piecing together information derived from different sources and by taking into account both the strengths and weaknesses of the currently available evidence base. This year’s commentary includes an assessment of how the new data available in 2005 contribute to our understanding of the medium- to long-term trends in the European drug situation.

Polydrug use problems complicate both our understanding of and response to drug use problems

Throughout much of this report, the analytical approach adopted is to focus on each of the main substances used. This substance-specific approach is conceptually easy to understand and has the additional advantage that most indicators of drug use are based on substance-specific behavioural measures. The disadvantage of this approach is that it does not reflect the fact that polydrug use is a major factor in drug problems in Europe. Analysis of the public health impact of drug use needs to take into account the complex picture of the interrelated consumption of psychoactive substances, which include both alcohol and tobacco. For example, in Europe cannabis is often smoked with tobacco, and this has implications both for the harms likely to be associated with this behaviour and for informing drug prevention activities. Toxicological analyses of drug deaths often reveal the presence of a number of substances, and the concurrent consumption of alcohol is known to increase the risks associated with both heroin and cocaine use. Furthermore, focusing on trends in one substance can be misleading if the interrelationship between different drug types is ignored; for example, in this report there is some evidence that the availability of synthetic opiates is increasing, an important consideration in any analysis of trends in heroin use. Similarly, it may be wise to consider the possible overlap in trends in the use of different stimulant drugs, and consider in any analysis the extent to which observed changes might be due to shifts in consumption patterns.

As most of those who present to treatment centres in Europe for a drug problem will have used multiple substances, there is a need to develop better methods of reporting this key aspect of drug use and to understand how polydrug use will impact on the effectiveness of interventions.

Young people and drug use – increasing use of cannabis, but different patterns emerging

Drug use in Europe remains largely a phenomenon of the young, and of young men in particular. Data from population and school surveys provide a useful insight into the way in which patterns of drug use in Europe have been developing since the mid-1990s. Available for inclusion in this year’s annual report are data from the latest round of the European school survey project on alcohol and other drugs (ESPAD) study, which provides a valuable source of data for monitoring drug use in the school populations and for detecting trends over time.

Taking all the available data together, it is clear that the use of cannabis differs considerably between countries. Although the predominant European trend since the mid-1990s has been upward, some countries exhibit a more stable pattern. For example, although rates of cannabis use in the United Kingdom since the 1990s have been particularly high, they have remained stable over this period. In addition, there has been little change in the levels of cannabis use in several low-prevalence countries, including Finland and Sweden in the north of Europe and Greece and Malta in the south. Most of the increases in cannabis use recorded in ESPAD since 1999 have occurred in the new EU Member States. Analysis of schools data and general population survey evidence suggests that, on most measures, the Czech Republic, Spain and France have now joined the United Kingdom to form a group of high-prevalence countries.

There is growing concern in Europe about the negative impact of cannabis use, although information on the extent to which the use of this drug is resulting in public health problems is scarce. Data available on drug treatment demands in Europe place cannabis second only to opiates, although cannabis still accounts for only 12 % of all treatment demands and the overall picture is greatly influenced by the situation in relatively few countries. Data on the regular and intensive use of cannabis are essential for developing an understanding of the likely connection between cannabis use and public health, but currently this information is limited. Although the available data suggest that as many as three million people, mostly young males, may be using cannabis on a daily basis in Europe, the extent to which this group might be experiencing problems because of their use of the drug is not known.

What is happening to problem drug use – is recruitment into heroin use and drug injecting in decline?

Among the most methodologically challenging areas in monitoring drug use is the task of estimating the numbers of people using drugs in a chronic and particularly damaging fashion. The EMCCDA problem drug use indicator has been developed to estimate this type of drug use, and in the majority of EU countries, problem drug use indicators principally reflect the use of opiates and injecting use. Current estimates suggest there are probably between 1.2 and 2.1 million problem drug users in the EU, of whom 850,000 to 1.3 million are likely to be recent injectors. Problem drug use prevalence estimates over time are patchy, making it difficult to identify long-term trends. However, in the EU-15 Member States, indicators broadly suggest that the rapid recruitment into heroin use that most countries had been experiencing peaked at some time in the early 1990s and was followed by a more stable situation thereafter. Although several countries have continued to report increases since 1999, there are recent signs that this situation is not uniform, with prevalence estimates showing no consistent picture at EU level. In particular, the new Member States deserve special mention, as they appear to have experienced heroin problems later and to have a more fluid situation.

Additional sources of information for assessing problem drug use are the numbers of drug-related deaths and treatment demands. Analysis of drug-related deaths (most commonly due to opiate overdose) suggests that the victims constitute an ageing population, with recorded deaths among drug users younger than 25 having fallen since 1996. An important qualification is that data from the newer EU countries, although limited, show until recently an upwards trend in the proportion of deaths among those under 25, although a degree of stabilisation now appears to have occurred. Overall, although the number of drug-related deaths in the EU remains at a historically high level, it seems likely to have peaked.

In most countries, heroin remains the principal drug for which clients seek treatment. In some countries, trends in heroin use among new treatment clients can be tracked historically and show a small decrease in absolute numbers since 1996. Similarly, in some countries a trend suggesting an ageing population of opiate users is reported, although again this observation does not apply to all countries, and in some of the new Member States – again based on limited data – opiate users entering treatment for the first time appear to be relatively young. In some European countries, notably the EU-15 Member States, injecting among new opiate users requesting treatment has been in decline for some time, and across Europe less than half of new clients requesting treatment for opiate use now report injecting. Again, this trend generally does not hold among the new Member States, where injecting remains the predominant mode of administration among heroin users accessing services.

In summary, there is no simple answer to the question of whether heroin use or injecting across Europe is now in decline. In many respects, today’s picture – in terms of recruitment into heroin use and injecting – looks more positive than it did in the early 1990s in the EU-15 Member States. There is evidence that the situation in many countries is now relatively stable, with signs even of an ageing population, perhaps reflecting reduced incidence. However, in some of the new Member States, where escalating heroin problems are a more recent occurrence, injecting continues to be the predominant mode of opiate administration, and from the data available current trends in heroin use are difficult to interpret.

The use of cocaine and other stimulants – no room for complacency

Europe remains a major market for stimulant drugs, and indicators suggest that for Europe as whole the trend in amphetamine, ecstasy and cocaine use continues to be upwards. Ecstasy has, on many measures, overtaken amphetamines as Europe’s second most used drug after cannabis. However, in the United Kingdom, which since the 1990s has on most measures had the highest prevalence rates of ecstasy and amphetamine use, both general and school population recent survey data suggest that rates of use of both drugs may be falling, quite dramatically for amphetamine and to a more limited extent for ecstasy. Nevertheless, prevalence rates in the United Kingdom remain relatively high in comparison with other countries, although the difference is now less marked, as a number of countries now report similar rates of use, resembling the picture described above for cannabis.

Prevalence of cocaine use varies considerably in Europe, but again the trend generally appears upwards. Survey data suggest that, in Spain and the UK in particular, cocaine use increased substantially during the late 1990s, and recently there have been further, albeit small, increases. In both of these countries, estimates for the recent use of cocaine among young adults now exceed those for ecstasy and amphetamine.

The public health impact of stimulant use in Europe is difficult to quantify, although the evidence suggests that we should not be complacent about current consumption patterns. Cocaine-related treatment demands are increasing. Although there is considerable variation between countries, cocaine accounts for about 10 % of all treatment demands across Europe. The use of crack cocaine, a form of the drug particularly associated with health and other problems, remains limited in Europe. Reports of crack cocaine use are generally restricted to a few major cities, but within the communities where this drug is used the resulting harm can be considerable. A number of practical and methodological issues make the assessment of the number of stimulant-related deaths in Europe difficult. Though small in comparison with reported opiate-related deaths, the number of stimulant-related deaths may be increasing and is probably under-reported. Although data are currently very limited, a number of countries indicate that cocaine plays a determining role in around 10 % of all drug-related deaths. Ecstasy-related deaths remain rare in most EU countries, although reporting procedures could be improved.

Drug use in Europe is still lower than in the USA – but prevalence estimates are now similar in some areas


Figure 23 Recent (last year) use of cannabis among young adults (15–34 years old) in Europe and the USA

Notes:

In the USA, the survey was conducted in 2003, and the age range is 16‑34 years (recalculated from original data).

In the European countries, most surveys (17 out of 19) were conducted between 2001 and 2004, and the standard age range is 15‑34 (in some countries the lower end may be 16 or 18 years).

The European average prevalence rate was calculated as the average of the national prevalence rates weighted by national population of 15‑34 year olds (2001, taken from Eurostat).

Sources:

USA: SAMHSA, Office of Applied Studies, National Survey on Drug use and Health, 2003 (www.samhsa.gov) and (http://oas.samhsa.gov/nhsda.htm#NHSDAinfo).

Europe: Table GPS-11 in the 2005 EMCDDA statistical bulletin. Based on Reitox national reports (2004).

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Levels of drug use in the USA have historically been considerably higher than those in European countries. To a large extent, this remains true today, but comparison of data on recent use (last year prevalence) suggests that in a few European countries levels of cannabis, ecstasy and cocaine use among young adults are now similar to those in the USA. And in the case of the recent use of ecstasy by young adults, US estimates are below those in several European countries, possibly reflecting the strong European link in the historical development of the use of this drug. However, overall, the European population average remains lower than the US average on all measures. In many European countries, widespread drug use occurred later than in the USA, and this may be reflected in the higher US lifetime prevalence estimates (see Figures 1, 2 and 3 in the 2005 statistical bulletin), which to some extent can be thought of as cumulative indicators of use levels over time.


Figure 24: Recent (last year) use of ecstasy among young adults (15–34 years old) in Europe and the USA

Figure 25: Recent (last year) use of cocaine among young adults (15–34 years old) in Europe and the USA


Bucking the global trend: no sign of significant methamphetamine problems in Europe

Methamphetamine is a drug known to be particularly associated with health and social problems. Globally, there is considerable concern about growing methamphetamine problems, and rates of use appear to be high or increasing in the USA, Australia, parts of Africa and much of South-East Asia. To date, the use of methamphetamine in Europe has largely been restricted to the Czech Republic, which has a long-established problem with this drug. Elsewhere in Europe, there are only sporadic reports that methamphetamine is available, with some reports of seizures and occasional mentions of importation from the Czech Republic to neighbouring countries. However, given that many European countries have strong links with parts of the world where methamphetamine problems exist, and considering the growing nature of the European market for stimulants, the potential for the spread of methamphetamine use cannot be ignored and thus this remains an important area for vigilance.

Expanding and developing services for those with drug problems

Services for those with drug problems can make a positive difference both to individual drug users and to the communities in which they live. This fact is recognised within many national drug policies, and a commitment to expanding services for those with drug problems is found within both the old and the new EU Action Plan on Drugs. Although it is difficult to map comprehensively the scale of provision for those with drug problems in Europe, several indicators strongly suggest that both treatment services and some forms of harm reduction services have increased considerably. That said, the nature and scale of different types of services varies considerably between countries. One area of service provision that has clearly expanded during the last decade is that of opioid drug substitution treatment, especially in those countries with relatively high levels of injecting heroin use. Methadone accounts for just under 80 % of substitution treatment in Europe, and more than 90 % of substitution treatment in specialist services, but buprenorphine is becoming an increasingly popular pharmacological option and probably accounts for about 20 % of substitution treatment in Europe. (For more information on the use of this drug see ‘Buprenorphine: treatment, misuse and prescription practices’ in the selected issues section that accompanies this report.) It is currently estimated that the number of people in drug substitution treatment in Europe is in excess of 500,000, which would suggest that between one quarter and one half of those with opiate problems may be enrolled in substitution treatment.

Substitution treatment is not the only option for those with opiate problems, but there are insufficient data on other therapeutic approaches to make reliable estimates of the provision of these services at EU level. Considerable progress has been made in developing models of care for those with opiate problems, and the evidence base for judging effectiveness in this area is relatively robust. This is not the case users of other types of drug, who are presenting in increasing numbers at European treatment services. The consensus is far weaker on the most appropriate therapeutic options for those seeking help for stimulant or cannabis problems, for example, and developing effective treatment options for these sorts of clients is likely to become an increasingly important challenge.

Drug use, HIV infection and AIDS – interventions are increasingly available and may be influencing overall trends

The expansion of treatment services is not the only area in which services for problem drug users have improved. Needle and syringe exchange programmes, which provide drug injectors with sterile equipment, are now found in virtually all EU Member States, and in most countries the medium-term trend has been for an increase in both the scale of activities and the geographical coverage. In some Member States, pharmacies also play an important role in extending the coverage of these kinds of programmes. Specialist programmes are often integrated into broader services for those with drug problems, especially low-threshold agencies, and as such are often regarded as a way of making contact with active drug users and perhaps of providing a conduit to treatment and other services.

Overall, the incidence of AIDS due to drug injecting has been in decline for some time. Heterosexual contact has now overtaken injecting drug use as the highest risk factor for the development of AIDS in Europe. This may be attributable to the increasing availability of highly active antiretroviral therapy (HAART) since 1996, the increase in treatment and harm reduction services and declining numbers of drug injectors in most affected countries. Estimates from WHO suggest that in most European countries over 75 % of those needing HAART have access to it. However, coverage is estimated to be poor in a number of Baltic countries, and this may be reflected in an increase in new AIDS cases among drug injectors in at least some countries in this area. At one time rates of new HIV infections were also increasing dramatically in some Baltic countries, but recent rates have declined equally dramatically, probably due to the saturation of the populations most at risk; moreover, arguably, an increase in service provision may be having an effect in some areas.

Among most of the other new EU Member States, HIV prevalence rates remain low, as they do in many of the EU-15 Member States. Of those EU countries where HIV prevalence rates were historically high among drug injectors, most have seen a significant decrease and then stabilisation. This is not to say that these problems have disappeared: despite methodological difficulties that make trends difficult to interpret at the national level, some recent studies report new transmissions among certain subpopulations of drug injectors, emphasising the need for continuing vigilance.

Overall reports of legal sanctions for the possession or use of drugs

Comparable data at the European level on most aspects of the relationship between drugs and crime are largely lacking. The main exception is drug law offences, which are recorded crimes against drug control legislation. Although comparisons between countries must be made with caution, it seems that between the late 1990s and 2003 drug law offences increased in many EU countries. Increases were particularly marked in some of the new Member States. In most countries, the majority of reports are for the possession or use of drugs. In most Member States, the majority of offences involve cannabis, and since 1998 in most countries the proportion of cannabis offences has either increased or remained stable. In contrast, the proportion of offences that are heroin related has fallen in many countries.

In many European countries, there is a growing concern about the wider impact of drug use on the communities in which it occurs. Issues around public safety and the exposure of young people to drugs are among the more commonly cited concerns that can be grouped under the title of ‘Drug-related public nuisance’ – this issue is explored in detail in the selected issues section accompanying the annual report and, continuing the criminal justice theme is a selected issue devoted to a review of strategies to divert those with drug problems away from custodial sentences and towards treatment (‘Alternatives to imprisonment: targeting offending problem drug users in the EU’).

Developments in drug policies – some common elements are apparent, but within the context of respecting national differences

As a reading of this report will clearly demonstrate, across Europe there are considerable differences between Member States in terms of both the drug problems they face and the policies and the scale and nature of interventions. Despite this, there are some common elements in the drug situation facing most countries. At a policy level, Member States express a general political commitment to develop a balanced and evidence-based response, in line with international commitments and, while acknowledging that drug policies remain a national responsibility, also look to the benefits that can accrue from improved cooperation at the European level. These aspirations are expressed in the EU drug strategy and action plans. The EU drug strategy and action plan 2000–2004, while it has not achieved all of the ambitious targets set, is evidence of an important development in the way Member States, EU institutions and specialist agencies can work together to coordinate and measure progress in the drugs field. The new EU Drug Strategy 2005–12 seeks to take forward this process. A fuller discussion on both the evaluation of the 2000–2004 action plan and the some of the elements of the first action plan of the new EU drug strategy can be found within the body of this report, as can a discussion on what common elements are now apparent within the drug policies of Member States and also on what areas still appear divergent.