Changing dynamics in the heroin market, the latest implications of cannabis use and new features and dimensions of the stimulant and ‘new drugs’ scene, are among the issues highlighted by the EU drugs agency (EMCDDA) today as it launches its European Drug Report 2015: Trends and Developments in Lisbon (1). In its annual review, the agency reflects on 20 years of monitoring and examines the global influences and local ramifications of Europe’s ever-changing drugs problem.
Dimitris Avramopoulos, European Commissioner for Migration, Home Affairs and Citizenship, says: ‘The report shows that we are confronted with a rapidly changing, globalised drug market and, therefore, we need to be united, swift and determined in our response to the drugs threat. I am particularly concerned that the Internet is increasingly becoming a new source of supply, for both controlled and uncontrolled psychoactive substances’.
Commissioner Avramopoulos continues: ‘Europe plays a leading role in tackling the “new drugs” phenomenon and we will continue to do so for the wellbeing and safety of our citizens. 101 new uncontrolled psychoactive substances were reported in 2014, challenging our existing control mechanisms. I look forward to the forthcoming EU legislation in this area, which is currently under negotiation. This will further strengthen our responses and equip us with better instruments to deal with these substances more rapidly and more effectively’.
Heroin in decline, but market changes call for close monitoring
Problems relating to heroin still account for a large share of the drug-related health and social costs in Europe, but recent trends in this area have been ‘relatively positive’, says the EMCDDA, noting an ‘overall stagnation in demand for this drug’. Fewer people are now entering specialised drug treatment for the first time for heroin problems: 23 000 in 2013 compared to 59 000 in 2007. And it is estimated that over half (700 000) of Europe’s 1.3 million problem opioid users (i.e. long-duration, dependent users) are now in opioid substitution treatment (Figure 3.6).
Reported seizures data, which help understand trends in heroin supply, also show declines. The quantity of heroin seized in the EU in 2013 (5.6 tonnes) was among the lowest reported in the last 10 years — half the amount seized in 2002 (10 tonnes). The number of heroin seizures also fell from around 45 000 in 2002 to 32 000 in 2013 (Figure 1.6). But against this positive backdrop, the EMCDDA flags up a number of market changes which call for close monitoring.
Latest UN estimates (2), for example, suggest a substantial increase in opium production in Afghanistan in 2013 and 2014, the country supplying most of the heroin used in Europe. A potential knock-on effect of this could be greater availability of heroin on the European market. Also highlighted are signs of market innovation, including the detection inside Europe of heroin processing laboratories, the first time since the 1970s. Two laboratories, converting morphine into heroin, were discovered in Spain in 2013 and 2014.
Changes in heroin trafficking into Europe are also noted. While the traditional ‘Balkan route’ remains prominent, there are signs that the ‘Southern route’ is gaining ground. (This originates in Iran and Pakistan and reaches Europe directly or indirectly via countries in the Arabian Peninsula and east, southern and west Africa). A new analysis released today on opioid trafficking from Asia to Europe points to a diversification in the products traded (e.g. morphine base and opium, in addition to heroin) and in the means of transport and routes used (see ‘Perspectives on Drugs’/POD).
Commenting today, EMCDDA Director Wolfgang Götz says: ‘Changes in law enforcement activity, instability and armed conflict, and the multiple and rapid connections brought by globalisation, are among a variety of factors that can alter trafficking routes. Today, we see marked increases in opium production in Afghanistan and a diversification both in products traded and in trafficking methods and routes used. This is compounded by the fact that crucial stages of the heroin manufacturing process are now being carried out inside Europe. Any potential for a resurgence of heroin problems is worrying and close monitoring of the situation is critical’.
In addition to heroin, other opioids seized by law enforcement agencies in European countries in 2013 included: opium; crude opium preparations (e.g. ‘Kompot’); medicinal products (morphine, methadone, buprenorphine, fentanyl and tramadol); as well as novel synthetic opioids.
Older opioid users in need of tailored services
Opioid dependence is often a chronic condition, and providing appropriate treatment and care to long-term opioid users is a growing challenge for drug treatment and social services today. The report shows how the average age of those entering treatment for opioid problems is increasing, with the median age rising by five years between 2006 and 2013 (Figure 2.11). A significant number of opioid users in Europe with long-term polydrug use histories are now in their 40s and 50s. A history of poor physical and mental health, bad living conditions, infections and the misuse of multiple substances (including alcohol and tobacco), makes this group susceptible to a range of chronic health problems (e.g. cardiovascular, pulmonary, hepatic).
‘Clinical guidelines that take account of the demographic shift in Europe’s problem opioid users are needed’, says the report. These would support effective clinical practice and cover issues such as: drug interactions; take-home dosages of substitution treatment medications (e.g. methadone, buprenorphine); managing pain and treating infections. Few countries report the availability of targeted programmes for older drug users. This group is generally integrated within existing drug treatment services (Figure 3.10). The Netherlands is one of a few countries where retirement homes have been set up to cater for the needs of older drug users.
Hepatitis C treatments improve and new HIV diagnoses stall
Transmitted through the sharing of needles, syringes and other injecting equipment, hepatitis C is the most common infectious disease among people who inject drugs (PWID) in Europe, with national samples of PWIDs showing between 14 % and 84 % infected with the hepatitis C virus in the period 2012–13 (Figure 2.14). Hepatitis C infection is often asymptomatic and can go for decades undiagnosed. Many of those infected go on to develop chronic hepatitis and are at risk of developing liver disease (e.g. cirrhosis, cancer).
A growing number of countries have adopted, or are preparing, specific hepatitis C strategies, which aim in particular to ensure access to hepatitis C testing. While new antiviral medications are available — which stop the disease progressing or allow full recovery — lack of diagnosis, together with high medication costs, are limiting the reach of these new treatments.
Latest data show that rises in the number of new HIV diagnoses attributed to injecting in Europe, resulting from outbreaks in Greece and Romania in 2011/12, have now stalled and that the overall EU total has dropped to pre-outbreak levels (Figure 2.13). Provisional figures for 2013 show 1 458 newly reported HIV infections, compared with 1 974 in 2012, reversing the upward trend since 2010. Despite progress in this area, the EMCDDA underlines the need for continued vigilance and adequate service provision.
Tackling drug overdoses — a challenge for public health policy
Reducing fatal drug overdoses and other drug-related deaths (e.g. drug-related diseases, accidents and suicide) remains an important challenge for public health policy today. It is estimated that at least 6 100 overdose deaths occurred in the EU in 2013, mainly related to heroin and other opioids.
A new analysis accompanying today’s report places the spotlight on benzodiazepine misuse among high-risk opioid users, who may take these medicines to self-medicate or to enhance the effects of opioids (see POD). The analysis shows how the combined use of opioids with benzodiazepines and other central nervous system depressants (e.g. alcohol) contributes to an increased risk of overdose deaths. Prescrib-ing and clinical practice guidelines could play a key role in the management of this complex issue.
Interventions aimed at preventing overdoses encompass targeted strategies, risk education and overdose response training, including the distribution of take-home naloxone (3). Some countries also have a long-established practice of providing ‘drug consumption rooms’ (DCRs). Six EMCDDA reporting countries currently provide these services, totalling around 70 facilities (Denmark, Germany, Spain, Luxembourg, Netherlands, Norway), while France recently approved the experimental trial of DCRs. A review of services delivered in these settings accompanies this year’s analysis (see POD) and shows how DCRs provide a ‘local response’ to ‘local problems’. Among others, DCRs can play a role in reducing drug-related harms (including overdose deaths) and serve as useful spaces to connect hard-to-reach drug users with health services.
Growing importance of cannabis within drug treatment systems in Europe
Cannabis remains the most widely consumed illicit drug in Europe, with an estimated 19.3 million adults (15–64 years) reporting to have used it in the last year, of these 14.6 million being young adults (15–34 years). It is estimated that around 1 % of all adults are daily or almost daily users.
Population surveys for three countries (Germany, Spain and the UK), report decreasing or stable cannabis prevalence over the past decade. In contrast, rising use is observed in Bulgaria, France and four Nordic countries (Denmark, Finland, Sweden, Norway). Taken as a whole, the most recent survey results show divergent trends in last-year cannabis use among young adults (Figure 2.1).
The drug’s high prevalence is reflected in the numbers entering specialised drug treatment, with the largest group of first-time treatment entrants now citing cannabis as their main problem drug. The overall number of those entering treatment for the first time for cannabis problems in Europe rose from 45 000 in 2006 to 61 000 in 2013. While cannabis clients entering treatment are most likely to self-refer (34 %), the analysis notes that around one-quarter of all those entering treatment for primary cannabis use (23 000) were referrals from the criminal justice system. Evidence supports the use of psychosocial interventions in treating drug use problems and these are widely used in treating problems relating to cannabis. These approaches are explored today in an analysis accompanying the report (see POD) and in a recent EMCDDA Insights publication (4).
Acute cannabis-related emergencies, although rare, can occur after consuming the substance, especially at high doses (see purity section below). A recent study, conducted in emergency settings, showed an increase in the numbers of cannabis-related emergencies reported between 2008 and 2012 in 11 of the 13 European countries analysed.
Today’s report highlights the major role played by cannabis in drug-related crime statistics with the drug accounting for 80 % of the number of seizures, and with cannabis use or possession for personal use accounting for over 60 % of all reported drug law offences in Europe (see Figure 1).
The number of seizures of herbal cannabis overtook that of cannabis resin in Europe in 2009, and the gap has continued to widen (Figure 1.3). In 2013, of the 671 000 cannabis seizures reported in the EU, 431 000 were of herbal cannabis (marijuana) and 240 000 of cannabis resin (hashish). This trend is driven, to a large extent, by the increased availability of domestically produced herbal cannabis inside Europe and is mirrored in increasing seizures of cannabis plants. The quantity of cannabis resin seized in the EU is still much higher than that of herbal cannabis (460 tonnes versus 130 tonnes).
Over 130 synthetic cannabinoids, sold as legal replacements for cannabis, have been detected to date by the EU Early Warning System (EWS), adding a new dimension to the cannabis market. The use of these substances can result in adverse health consequences (e.g. kidney damage, pulmonary and cardiovascular effects, convulsions). Recent deaths and acute intoxications in Europe, and internationally, linked to these substances have prompted the EMCDDA to issue public health-related alerts.
Competition in a crowded stimulant market
Europe is confronted with a crowded stimulant market, with cocaine, amphetamines, ecstasy and a growing number of synthetic drugs targeting similar consumer groups. Cocaine remains the most commonly used illicit stimulant drug in Europe, although most users are found in a small number of western EU countries. Around 3.4 million adults (15–64 years) have used cocaine in the last year, of these 2.3 million being young adults (15–34 years). Only a few countries report last-year prevalence of cocaine use among young adults of more than 3 % (Figure 2.4). Decreases in cocaine use are observable in the most recent data. Of the countries that have produced surveys since 2012, eight reported lower estimates and three reported higher estimates than in the previous comparable survey.
Use of amphetamines (encompassing amphetamine and methamphetamine) remains overall lower than that of cocaine in Europe, with around 1.6 million adults reporting last-year use; of these 1.3 million being young adults (15–34 years) (Figure 2.5). New patterns in methamphetamine use are highlighted in today’s report. In the Czech Republic, for example, a marked increase in high-risk methamphetamine use (mainly injection) has been observed, with estimates of the number of users increasing from some 21 000 to over 34 000 between 2007 and 2013. Also reported in a number of European countries is the injection of methamphetamine with other stimulants (e.g. synthetic cathinones) among small groups of men who have sex with men. These so-called ‘slamming’ practices raise concern due to risk-taking in both drug-use and sexual behaviour.
An estimated 2.1 million adults (15–64 years) have used ecstasy in the last year; 1.8 million being young adults (15–34 years) (Figure 2.6). After a period in which tablets sold as ecstasy had a reputation among consumers for poor quality and product adulteration, high-purity MDMA powder and tablets are now more commonly available (see purity section below).
Synthetic cathinones (e.g. mephedrone, pentedrone and MDPV) are now a fixture on the illicit stimulant market in some European countries and are often used interchangeably with amphetamine and ecstasy. Injection of synthetic cathinones, although not widespread in Europe, is a worrying localised problem in groups of high-risk drug users in some countries. Rising treatment demand linked to use of these substances is reported in Hungary, Romania and the UK.
Increases in drug potency and purity fuel concern
A key finding in this year’s report is the marked rise in the potency and purity of Europe’s most commonly used illicit drugs, fuelling concerns for the health of users who, wittingly or unwittingly, may be consuming stronger products (Chapter 1). Overall trends for the period 2006–13 show the potency of cannabis (THC content), the purity of cocaine and the MDMA-content in ecstasy tablets to have risen in countries consistently reporting data; heroin purity also rose in 2013. Technical innovation and market competition are two of the likely factors driving the trend.
Highlighted are concerns over ecstasy tablets with high levels of MDMA, often sold with distinctive shapes and logos. Over the last year, the EMCDDA and Europol have issued public health alerts on the risks of consuming such products. Alerts have also been issued regarding tablets sold as ecstasy but containing other harmful substances, such as PMMA, following a series of deaths.
‘New drugs’ detected at the rate of two per week
New psychoactive substances (NPS or ‘new drugs’, often sold as ‘legal highs’) were detected in the EU last year at the rate of around two per week. A total of 101 new substances were reported to the EWS in 2014 (up from 81 substances in 2013), continuing an upward trend in substances notified in a single year (Figure 1.12). This brings the total number of substances being monitored by the agency to over 450, with more than half of that figure being identified in the last three years alone.
In 2014, the list of substances reported was again dominated by two groups: synthetic cathinones (31 substances) and synthetic cannabinoids (30 substances) — often sold respectively as legal replacements for stimulants and cannabis. These represent the two largest groups monitored by the EWS and, together, make up almost two-thirds of the new drugs notified in 2014. New data on seizures show that around 35 000 seizures of NPS were reported in the EU in 2013 (although this should be seen as a minimum estimate due to lack of routine reporting in this area). Of these, the most commonly seized were synthetic cannabinoids and synthetic cathinones (Figure 1.2).
New studies and surveys are beginning to shed light on the use of NPS, with nine countries now incorporating NPS prevalence in their national drug surveys. In most EU countries, the prevalence of use of these substances appears to be low. However, even limited use of these substances can be a concern, due to the severe toxicity of some NPS. Health and social responses to NPS are gaining momentum and mirror the full range of responses to the more established drugs (e.g. drug education; Internet-based interventions; and needle and syringe exchange programmes).
The Internet and apps: emerging virtual drug markets
The Internet plays a growing role in supplying and marketing drugs to Europeans, with NPS and established drugs both offered for sale online. Use of the ‘surface web’ (accessible via common search engines) for the sale of NPS has received greater attention over the last decade, with EMCDDA monitoring identifying around 650 websites selling ‘legal highs’ to Europeans. A challenging development in the online market is the sale of illicit drugs on ‘cryptomarkets’ or ‘deep web’ online marketplaces (accessible via encryption software). These allow goods and services to be exchanged between parties anonymously, often using ‘crypto currencies’ (e.g. Bitcoin) to facilitate hidden transactions. So-called ‘grey marketplaces’ are also emerging, where sites operate on both the surface and deep web. The report highlights how social media and apps also play an active role in drug markets, whether used directly for buying and selling drugs or indirectly for marketing, opinion-forming or experience-sharing.
‘The growth of online and virtual drug markets pose major challenges to law enforcement and drug control policies’, says the report. ‘Existing regulatory models will need to be adapted to perform in a global and virtual context’.
Chairman of the EMCDDA Management Board Joao Goulão concludes: ‘This 20th analysis of the European drug phenomenon demonstrates how much has changed since the EMCDDA’s first report in 1996, and how much the agency has enhanced understanding of this issue. The complexity of the drugs problem is now far greater, with many of the substances featured today virtually unknown to users two decades ago. The boundaries between old and new drugs are also becoming harder to define, as novel substances increasingly mimic controlled drugs. This annual window on Europe’s drugs problem provides a valuable basis for informing discussions on drug policy today. It also offers important insight for the policies we will need tomorrow’.