Problem drug use
In general, prevalence rates
of problem drug use seem to be highest in Italy, Luxembourg,
Portugal and the United Kingdom, with between five and
eight problem drug users per 1 000 inhabitants aged
15 to 64 (this is taking the midpoints of the range
within a country). Rates seem lowest in Belgium (but
this data refers only to IDUs and thus is an underestimate),
Germany and the Netherlands, with two to three problem
drug users per 1 000 inhabitants aged 15 to 64. Intermediate
rates range from between three and five problem drug
users per 1 000 inhabitants aged 15 to 64 in Austria,
Denmark, Finland, France, Ireland, Spain and Norway.
Some countries report slightly different figures than
in 2000 due to improved data and estimates. Denmark
and especially Finland, however, have much higher figures
owing to having suppressed less reliable (and in both
cases lower) estimates.
Besides estimates of prevalence, data
on patterns of use are important. However, there are
little data on patterns of drug use among problem drug
users who are not in treatment, although this is important
information for guiding policy decisions on future treatment
demand. In northern countries, notably Finland and Sweden,
primary amphetamine users form the majority of problem
drug users (an estimated 70 to 80 % in Finland in 1997).
This is contrary to other countries where problem drug
users are mostly primary opiate users (but often polydrug
and methods used to estimate problem drug use
drug use' is defined here as 'injecting drug use
or long-duration/regular use of opiates, cocaine
and/or amphetamines'. This definition excludes
ecstasy and cannabis users and those who never
- or irregularly - use opiates, cocaine or amphetamines.
Opiates include prescribed opiates such as methadone.
national estimates of problem drug use reported
here for the EU and Norway (which also participated
in the EMCDDA project on prevalence estimation)
are for 1996 to 1998. Austria (1995) and Belgium
(1995) could not provide estimates for this time
period, due to lack of more recent data on which
to base the calculations (see Figure 3), while
Luxembourg, Portugal and Italy provided more recent
methods used to produce these estimates are mainly
based on statistical models incorporating drug-related
indicators and include:
multivariate indicator method;
multiplier methods based on police data, treatment
data and mortality rates; and
method using back-calculated numbers of intravenous
drug users (IDUs) with HIV/AIDS, in combination
with HIV/AIDS rates among IDUs.
given in Figure 3 are often derived from a multiple
method approach; therefore the lowest and highest
figures may have been obtained by different methods,
both within and between countries. These methods
do not always refer to the same target group -
for example, HIV/AIDS back calculation and overdose
mortality multipliers target IDUs, while multipliers
from treatment data could only be used for the
wider group of problem opiate users.
countries applied multiple estimation methods
- two (Spain, Luxembourg and the Netherlands),
three (Germany, France, Ireland, Finland and the
United Kingdom) or even four (Italy and Portugal).
Other countries (Belgium, Denmark, Austria, Sweden
and Norway) could only apply one method, while
Greece was still unable to provide an estimate.
Using multiple independent estimates may cross-validate
the single figures and lead to a more reliable
overall estimate for a country. Therefore, a multiple
method approach, if possible on a year-by-year
basis, may ideally be applied.
for policy evaluation, it is still not possible to calculate
trends in the prevalence of problem drug use with the
current methods, data quality and data availability.
Incidence of problem drug use may be an additional and
important way of measuring trends. Incidence is the
number of newly occurring cases in a year, while prevalence
is the total of all existing cases, new and old. Therefore
trends in incidence are much more sensitive to epidemiological
changes and to interventions that prevent new cases
An EMCDDA project produced new incidence
estimates of heroin use for Belgium, Lisbon, Budapest,
London and Amsterdam suggesting that the timing of heroin
epidemics in those regions may have been very different
(see Figure 4, London and Amsterdam not shown).
Figure 5 shows how, even within one
country, in this case Italy, heroin epidemics may occur
in different regions at different moments. The results
also suggest that there might be an initial (epidemic)
period of rapid spread followed by saturation effects
(that is most susceptible persons have become heroin
users) and lower but constant further spread (endemic
situation) a mechanism which is similar to the
spread of infectious diseases. This may have important
implications for decision-makers as regards the optimal
balance between policy measures such as primary prevention,
which needs to be timely to prevent high prevalence,
and secondary prevention (drugs treatment and harm-reduction
measures), which becomes more important once high prevalence
has been established.
In Figure 5, it is notable that the
heroin epidemic in Puglia seems to have started earlier
than in Sicilia and Campania. Puglia, the 'heel' of
Italy, is situated on an important heroin trade route
from the Balkan region into Europe, which may have led
to earlier spread of heroin use. This confirms earlier
results based on geographical analysis of treatment
annual report, EMCDDA).
Differences in the prevalence of drug
use are influenced by a variety of factors in each country.
As countries with more liberal drug policies (such as
the Netherlands) and Those with a more restrictive approach
(such as Sweden) have not very different prevalence
rates, the impact of national drug policies (more liberal
versus more restrictive approaches) on the prevalence
of drug use and especially problem drug use remains
unclear. However, comprehensive national drug policies
are of high importance in reducing adverse consequences
of problem drug use such as HIV infections, hepatitis
B and C and overdose deaths. Other factors that may
affect prevalence of problem drug use are the availability
and price of drugs, unemployment and poverty or other
societal problems (war), the age structure of a country
and the proportion of urban and rural areas. Furthermore,
drug use seems to behave in an epidemic manner (see
for example Figures 4 and 5). It may thus follow long-term
epidemic cycles that for a large part depend on the
demographic replenishment of new generations of 'susceptible'
young people, who have never experienced the problems
associated with heavier patterns of use. At present,
therefore, a final causal interpretation of varying
prevalence rates within EU Member States cannot be made.
Additional qualitative or local information
on trends in problem drug use is available for some
countries or cities.
In Austria, problem drug use prevalence
seems currently stable in most regions, although in
Vienna street workers have registered a decline in the
number of young newcomers on the scene. In France, heroin
consumption is in general declining although it is not
clear what this means in terms of numbers of heroin
users and there are some indications of new, local increases.
In Finland, prevalence estimates for the greater Helsinki
area for 1995-97 suggest that the use of hard drugs
has increased in this area by a minimum of 40 % in two
years. This increase was most pronounced in males, those
over 26 years old and in amphetamine users.
In Germany, heroin use is primarily
found in metropolitan areas, prevalence rates and seizures
in rural areas being much lower. In the new LŠnder,
heroin use is still scarce. Surveys suggest that heroin
use is only slightly increasing or stagnating since
1992; however, cocaine shows stable and uniform growth.
In Greece, data from indirect indicators (treatment,
deaths, low-threshold services) suggest that problem
drug use is increasing. In Ireland, drug users are young
reflecting the general demographic situation. Until
about 1996, the trend in heroin use was towards increased
smoking; however, more recently, injecting is again
increasing. In Italy, drug use levels seem higher in
northern regions but problem drug use may be more evenly
distributed between northern, central and southern regions
even if the level of 'at risk' population is different
between geographical areas. (The total population of
1554-year olds is around 32 million - 44 % live
in the northern regions, 19 % in the central regions
and 37 % in the southern regions.) In addition, northern
regions may have relatively more use of 'recreational
In Luxembourg, the national registration
system showed a marked increase of 42 % of new registrations
between 1998 and 1999, however this is mainly due to
drug law offenders and may reflect policing activity.
There is a large proportion of non-natives from Luxembourg
(48 %) among problem users. The estimated prevalence
shows an upward trend; while injecting drug use has
decreased from over 90 % to about 66 %. In Amsterdam,
the Netherlands, the number of heroin users has moderately
decreased over the years, while the proportion of injectors
among them has strongly decreased. In Portugal, drug
use problems are more significant in the districts of
Lisbon, Porto, Setubal and Faro. In Spain, heroin use,
especially injected, is becoming less relevant and cocaine
problems are becoming more important among drug problems.
In Sweden, there has been an increase in the number
of severe drug users during the 1990s and heroin use
is becoming more common in younger groups of problem
users. In the United Kingdom, a report published in
1998 suggested an increase of new heroin outbreaks among
young people in most regions of England since about
1996, while a recent study in London suggested a two-fold
increase in incidence of non-injected heroin use between
1991 and 1997.