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Problem drug use, HIV and injecting:
an overview of the European experience
Paul Griffiths, EMCDDA
Drug Control in the Baltic Region, Vilnius, 27 September 2005
Outline of this presentation
• The EMCDDA
• structure
• working methods
• Overview of available European data on
• problem drug use,
• on responses to problem drug use
• making special reference to injecting and HIV
• A few thoughts on:
• future face of problem drug use in Europe
• what are some key information needs and deficits
European Monitoring Centre for Drugs and
Drug Addiction (EMCDDA)
• The Central reference point for drug information in the EU
• Established in 1993, based in Lisbon, Portugal
• A decentralised agency of the European Union
• a response to the need to cope with new tasks of a technical and/or
scientific nature
• agencies of particular relevance to public health;
•
•
•
EMCDDA – European Monitoring Center for Drugs and Drug Addiction, Lisbon (Portugal)
EMEA – European Medicines Agency, London (United Kingdom)
ECDC – European Centre for Disease Prevention and Control, Solna (Sweden)
Overview of our data collection approach
• Network of national focal points in MS (REITOX )
• Annual reporting
•
•
•
National overview
Standard tables
Structured questionnaires
• Expert groups per indicator area that meet annually
• Liaison with other specialist information providers
• Emphasis on encouraging adoption of common methods & in
providing European level added value
EMCDDA – membership
• Membership pre-2004 – the 15 EU Member States
• Norway started providing data in 2001 (15+1)
• May 2004, enlargement – 10 new members
•
•
Cyprus, Czech Republic, Estonia, Latvia, Lithuania, Hungary, Malta,
Poland, Slovenia, Slovakia.
Candidate countries – Bulgaria, Romania and Turkey
• Important to note that in some areas the new countries
change…
•
•
analysis of the European situation
analysis of data availability
HIV and the European picture
• HIV has to a large extent been one of the major
issues to shape modern European drug policy
• Inextricably linked with epidemic of injecting heroin
use that Europe experienced over the 1990s
• Stimulated investment in new methods to assess problem drug use
and risk behaviours
• Profoundly altered the way services were structured and
orientated…. more proactive, broader set outcome objectives
The European picture is a heterogeneous one
but with some common elements
• Diversity exists in respect to HIV among IDUs
•
•
•
Estimates of between 850,000 and 1.3 million IDUs in EU 25
Some countries have had only small outbreaks of HIV infection and have
managed to maintain very low prevalence rates
Some countries have had major epidemics ….but the overall picture now
appears stable or falling in most countries
• Diversity of responses
•
•
•
Balance of prevention, treatment and harm reduction interventions
Scale of responses & timing of responses
No simple relationship between policy and the situation
• Common elements
•
•
Although major differences remain in emphasis EU members states appear
now to operate within a broad policy consensus
Cautious optimism about stable or an improving situation in respect to drug
injecting, HIV infections among IDUs and heroin consumption in many MS
Overview of the data available on the situation
Data sources on HIV-AIDS in IDU
• Reporting from routine surveillance and HIV/AIDS case
reporting (EuroHIV)
• Data from EMCDDA drug related infectious disease
indicator (IFD)
• routine testing at drug treatment centres
• studies of IDU (in and out of treatment)
• Neither source provides comprehensive coverage or easily
allows the monitoring of trends over time
• Data set is improving
Data sources on HIV-AIDS in IDU
• Routine surveillance suggests IDU no longer
the main route of transmission for AIDS …but
how do we interpret this?
• Data weaker from routine disease
surveillance for HIV prevalence in IDUs
• IFD indicator suggests large differences in
HIV prevalence between countries and large
differences between different populations
within countries
AIDS cases by transmission group* and year of diagnosis (1987-2003) adjusted for
reporting delays, European Union, data reported by 31 December 2003
10000
8000
Injecting
6000
4000
2000
0
1987
1989
1991
1993
1995
1997
1999
2001
2003
Year of diagnosis
HBM
IDU
HC
Transmission group
not reported
NOTE
Excluding France, Netherlands (data not available for the w hole period) and Cyprus (no data available)
source EuroHIV
HIV infections newly diagnosed in injecting drug users in selected EU
countries, Russia and Ukraine, by year of report, cases per million population
(EUROHIV)
1000
900
Cases per million population
800
700
600
500
400
300
200
100
0
1994
1995
1996
1997
1998
Estonia
Latvia
Lithuania
Portugal
Russia
Ukraine
1999
2000
2001
2002
2003
Note: no data available from tw o EU countries w ith
highest AIDS incidence among IDUs (Spain, Italy)
Norway
Turkey
Romenia
Bulgaria
UK
Sweden
Finland
Slovakia
Slovenia
Portugal
Poland
Austria
Netherlands
Malta
Hungary
Luxembourg
Lithuania
Latvia
Cyprus
Italy
Ireland
France
Spain
Greece
Estonia
Germany
Denmark
Czech Republic
Belgium
HIV prevalence among injecting drug users - studies with national and subnational coverage
2002-2003
40%
35%
30%
25%
20%
15%
10%
5%
%
HIV prevalence among IDUs in the EU
EMCDDA 2004
Notes:
Colour indicates midpoints
Local data shown in ()
HIV seroprevalence and diagnostic testing
studies of IDUs (treatment & non treatment)
40%
30%
20%
10%
%
1991
1992
1993
Belgium Flemish Community (DT)
Spain (DT)
Lithuania (DT)
Portugal (DT, DT, DT)*
Greece (DT)
1994
1995
1996
1997
Belgium French Community (SR)
France (SR)
Luxembourg (SR)
Uk England and Wales (SP - UAT)
1998
1999
Germany (SR)
Italy (DT)
Austria (DT)
UK Scotland (DT)
2000
2001
2002
2003
Spain (DT)
Latvia (DT, DT)*
Poland (DT)
Estonia (DT)
HIV in IDUs in Europe
• Marked difference between countries and within
some countries
• High prevalence countries (old MS) Italy, Spain, Portugal, followed
by France
• Some high prevalence estimates from new MS (Latvia, Estonia),
and worries about others (Poland)
• Low prevalence countries in both old and new MS including
countries with high prevalence IDU
• Cautious assessment is the long term trend appears to be stable or
downwards
• Some small increases in recent data in some countries or in
specific subpopulations
• Data quality problems so analysis must be made with caution
A note on HCV prevalence in IDUs
• Prevalence estimates higher and more
convergent than for HIV
• Clear need to finding effective prevention
strategies
• Routine disease surveillance sources of
limited value
• Drug injecting principle route of transmission
for HCV in Europe
What is happening to heroin use and injecting
heroin use ?
• Data from…
• Problem drug use indicator
• Treatment demand indicator (TDI)
• Drug related deaths indicator…
• major cause death among young males in Europe
• and among IDUs the major cause mortality
• e.g. 2001 EU15 reported…
8,347 DRD as compared to 1,633 AIDS deaths among IDUs
Prevalence of problem drug use (indicator)
•
Operational definition PDU: “injecting, long-term or regular use of opiates,
cocaine and/or amphetamines
•
Estimates 1.2 and 2.1 million PDUs in EU 25
•
Historically mainly reflected heroin use and injecting
• Amphetamines in some countries (mainly Nordic countries)
• Growing heroin smoking population (from late 1980s)
•
Prevalence estimates produced from different sources and methods, both
national and local studies (CRC, multipliers, synthetic estimation techniques)
•
Recently some limited work on incidence modelling mostly based on statistical
inference from treatment populations
•
Estimates more often local. Getting national coverage more difficult
•
IDU estimates are particularly lacking
UK 2001 CM
Sweden 2001 CR
Finland 2002 CR
Slovenia 2001 CR
Portugal 2000 PM
Portugal 2000 TM
Poland 2002 CM
Austria 2002 CR
The Netherlands 2001 MI
The Netherlands 2001 TM
Luxembourg 2000 TP
Luxembourg 2000 CR
Italy 2003 CR
Italy 2003 MI
Italy 2003 TM
Ireland 2001 CR
France 1999 MI
France 1999 PM
France 1999 TM
Spain 2000 TM
Greece 2003 CR
Germany 2003 MM
Germany 2003 PM
Germany 2003 TM
Denmark 2001 CR
Czech Republic 2003 TM
Rate per 1 000
Estimated rate of problem drug use (1999-2003 rate per 1 000 aged 15-64)
14
12
10
8
6
4
2
0
0
Norway 2002 MM
UK 2001 CM
Portugal 2000 HM
Portugal 2000 MM
Austria 2000 MM
Luxembourg 2000
HM
France 1999 HM
Greece 2003 CR
Germany 2000 HM
Germany 2000 MM
Rate per 1 000
Estimated rate of IDU
(2000-2003 rate per 1000 aged 15-64)
7
6
5
4
3
2
1
Trend in new treatment demands (%) by drug type
Data from 11 EU countries + Bulgaria from 1996 to 2003
Heroin
80
Cocaine
70
Cannabis
Other Stimulants
60
%
50
40
30
20
10
0
1996
(n.52890)
1997
(n.50844)
1998
(n.54374)
1999
(n.56407)
2000
(n.54428)
2001
(n.58007)
2002
(n.62342)
2003
(n.65336)
Proportion of new outpatient clients injecting
opiates (2003)
100
90
80
70
60
50
40
30
20
10
0
Long term trend in acute drug-related deaths (1985-2003)
300
Index % (1985=100%)
250
200
150
100
50
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003*
INDEX 100,0 104,5 118,7 136,9 153,7 181,0 216,4 223,5 201,8 212,2 225,4 252,4 230,1 235,6 241,1 255,4 240,1 205,8 194,9
EU 15, 1985 to 2003 index year 1985=100
Trend in mean age of drug related deaths 1990-2003
45,0
Austria
Germany
Ireland
Age (Years)
Italy
Luxembourg
The
Netherlands
Portugal
30,0
Spain
Sweden
UK - ONS
UK - DSD
15,0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
General observations PDU
• Mixed picture in terms PDU estimates
• But indicators suggest a peak of PDU in early 1990s
in most countries with a stabilisation thereafter.
• Injecting appears a less popular mode administration
in many countries and most new heroin users to
treatment are non injectors
• DRD most countries getting old and trending down
• Suggesting new recruitment into drug injecting and
heroin use may be down
• The picture looks different for some of the NMS
Overview of Responses
Overview Responses
• Data collection is less well developed in this area
• Treatment data is limited
• substitution treatment
• specialist centres
• underestimate
• Increase in treatment especially substitution
treatment in most EU MS
• Also an Increase in some harm/risk reduction
interventions, particularly NSE
Introduction of MMT & NSP, 1967 to 2001
(EU, Norway and Bulgaria)
30
EE
NO
Cumulative number of countries
25
BE
HU
LV
FR, LT, HU, BU
EL
20
BG
LV, LT,FI
SI
PL
EL, IE,CZ
SK
15
DE
SI
LU
MT
10
ES
FR
LU, PT
DE
CZ
AT, IT
AT
IE, PL
PT
IT
NO
FI
5
BE,
EE
DK
MT, UK
NL, UK
DK, NL, SE
SE
ES
0
1967
1969
1971
1973
1975
1977
1979
1981
Year first publicly funded NSP
1983
1985
1987
1989
1991
1993
Methadone treatment first available
1995
1997
1999
2001
Estimated number of drug users in substitution treatment in 29
European countries (2003) per 100.000 population aged 15-64
450
400
350
300
250
200
150
100
50
0
LU UK ES IE MT FR PT IT SI DK EU DE NL NO SE EL BE CZ LT
+4
FI HU BG LV PL RO
10-year trend in the number of substitution treatment clients
in Europe (EU-15)
600,000
537,000
500,000
400,000
351,000
265,000
300,000
207,000
200,000
100,000
73,400
0
1993
1995
1997
2000
2003
Substitution treatment in the EU
Proportion of substitution drugs used in
medically assisted treatment in Europe, 2003
Buprenorphine
20%
Other
1%
Methadone
79%
Provision of Needle/Syringe Programmes
(number of NSPs per 1000 estimated IDUs)
20
10
0
Spain
UK
Denmark
low
14.8
12.4
7.3
high
14.8
15.8
10.8
Luxembour
France
Ireland
Finland
Belgium
Norway
Austria
Greece
Sweden
5.8
4.2
2.5
1.7
1.8
1.4
0.9
0.2
0.1
5.8
4.2
4.3
2.2
2.2
1.9
1.7
0.2
0.2
g
Conclusions
• Data in this area are often heterogeneous and should be
interpreted with caution
• nonetheless data availability and quality have improved
considerably
• It is possible to provide some better understanding of drug use
and HIV in Europe and to identify trends
• Large differences between countries: PDU/IDU, HIV/HCV, and
in the services available
• The face of problem drug use in Europe may be changing
•
•
more poly drug use, stimulants, cocaine,…
older population heroin injectors with increased service access but likely to
remain major consumers of public health resources
Responses
• Dramatic increase in services
• Substitution treatment and NSE generally now seen
as part of a comprehensive drug demand reduction
strategy (with other elements)
• Although marked differences still exist between
countries in terms of approach and the relative
balance of services available
• Nonetheless estimates now suggest somewhere
between a quarter and one half of those with opiate
problems now receiving substitution treatment
Policy context
• Data has influenced MS and stimulated resource investment
• More policy consensus on the need for comprehensive package
of responses including risk reduction interventions,
• EU recommendation on the prevention and reduction of healthrelated harm associated with drug dependence (2003/488/EC)
• Measures in the new European Strategy & Drug Action Plan
•
•
•
Better understand effective prevention HIV and HCV
Look at protective factors in low prevalence countries
General support for better monitoring across the board
• Increasingly a policy culture of monitoring an assessment and
thus more pressure to provide robust data
Data needs for European level monitoring
• Improved monitoring of HIV in IDU populations especially
targeting high risk populations
• More MS providing problem drug use estimates and better
strategies to get national estimates or to better understand the
available local data
• More estimates of IDU in particular
• More work on incidence estimation
• Better and more comprehensive data on capacity of the
treatment system
• HCV prevention?
• Studies of HIV risk behaviour among NON injecting drug users
likely become increasingly important
Thanks…
Lucas Wiessing & Dagmar Hedrich
www.emcdda.eu.int