EMCDDA Conference: 'Identifying Europe's information needs for effective drug policy'
Problem drug use, HIV and injecting: an overview of the European experience Paul Griffiths, EMCDDA...
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Transcript of Problem drug use, HIV and injecting: an overview of the European experience Paul Griffiths, EMCDDA...
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
• 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
Outline of this presentation
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 onebut 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
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
0
2000
4000
6000
8000
10000
1987 1989 1991 1993 1995 1997 1999 2001 2003Year 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
Injecting
HIV infections newly diagnosed in injecting drug users in selected EU countries, Russia and Ukraine, by year of report, cases per million population
(EUROHIV)
0
100
200
300
400
500
600
700
800
900
1000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Ca
ses
pe
r m
illio
n p
op
ula
tion
Estonia Latvia Lithuania
Portugal Russia Ukraine
Note: no data available from tw o EU countries w ith highest AIDS incidence among IDUs (Spain, Italy)
HIV prevalence among injecting drug users - studies with national and subnational coverage 2002-2003
%
5%
10%
15%
20%
25%
30%
35%
40%
Bel
gium
Cze
ch R
epub
lic
Den
mar
k
Ger
man
y
Est
onia
Gre
ece
Spa
in
Fra
nce
Irel
and
Italy
Cyp
rus
Latv
ia
Lith
uani
a
Luxe
mbo
urg
Hun
gary
Mal
ta
Net
herla
nds
Aus
tria
Pol
and
Por
tuga
l
Slo
veni
a
Slo
vaki
a
Fin
land
Sw
eden UK
Bul
garia
Rom
enia
Tur
key
Nor
way
HIV prevalence among IDUs in the EU
EMCDDA 2004Notes: Colour indicates midpointsLocal data shown in ()
HIV seroprevalence and diagnostic testing studies of IDUs (treatment & non treatment)
%
10%
20%
30%
40%
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Belgium Flemish Community (DT) Belgium French Community (SR) Germany (SR) Spain (DT)Spain (DT) France (SR) Italy (DT) Latvia (DT, DT)*Lithuania (DT) Luxembourg (SR) Austria (DT) Poland (DT)Portugal (DT, DT, DT)* Uk England and Wales (SP - UAT) UK Scotland (DT) Estonia (DT)Greece (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
Estimated rate of problem drug use (1999-2003 rate per 1 000 aged 15-
64)
0
2
4
6
8
10
12
14
Cze
ch R
ep
ub
lic 2
00
3 T
M
De
nm
ark
20
01
CR
Ge
rma
ny
20
03
TM
Ge
rma
ny
20
03
PM
Ge
rma
ny
20
03
MM
Gre
ece
20
03
CR
Sp
ain
20
00
TM
Fra
nce
19
99
TM
Fra
nce
19
99
PM
Fra
nce
19
99
MI
Ire
lan
d 2
00
1 C
R
Italy
20
03
TM
Italy
20
03
MI
Italy
20
03
CR
Lu
xem
bo
urg
2
00
0 C
R
Lu
xem
bo
urg
2
00
0 T
P
Th
e N
eth
erl
an
ds
20
01
TM
Th
e N
eth
erl
an
ds
20
01
MI
Au
stri
a 2
00
2 C
R
Po
lan
d 2
00
2 C
M
Po
rtu
ga
l 2
00
0 T
M
Po
rtu
ga
l 2
00
0 P
M
Slo
ven
ia 2
00
1 C
R
Fin
lan
d 2
00
2 C
R
Sw
ed
en
20
01
CR
UK
20
01
CM
Ra
te p
er
1 0
00
Estimated rate of IDU (2000-2003 rate per 1000 aged 15-64)
0
1
2
3
4
5
6
7G
erm
an
y 2
00
0 M
M
Ge
rma
ny
20
00
HM
Gre
ece
20
03
CR
Fra
nce
19
99
HM
Lu
xem
bo
urg
20
00
HM
Au
stri
a 2
00
0 M
M
Po
rtu
ga
l 2
00
0 M
M
Po
rtu
ga
l 2
00
0 H
M
UK
20
01
CM
No
rwa
y 2
00
2 M
M
Ra
te p
er
1 0
00
Trend in new treatment demands (%) by drug typeData from 11 EU countries + Bulgaria from 1996 to 2003
0
10
20
30
40
50
60
70
80
1996(n.52890)
1997(n.50844)
1998(n.54374)
1999(n.56407)
2000(n.54428)
2001(n.58007)
2002(n.62342)
2003(n.65336)
%
Heroin
Cocaine
Cannabis
Other Stimulants
0
10
20
30
40
50
60
70
80
90
100
Nethe
rland
s
Sweden
Denm
ark
United
King
dom
Germ
any
Greec
e
Bulgar
ia
Sloven
ia
Malt
a
Czech
Rep
ublic
Slovak
ia
Finlan
d
Cypru
s
Latvi
a
Total
Proportion of new outpatient clients injecting opiates (2003)
50
100
150
200
250
300
Inde
x %
(19
85=
100%
)
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
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003*
Long term trend in acute drug-related deaths (1985-2003)
EU 15, 1985 to 2003 index year 1985=100
15,0
30,0
45,0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Ag
e (Y
ear
s)
Austria
Germany
Ireland
Italy
Luxembourg
TheNetherlandsPortugal
Spain
Sweden
UK - ONS
UK - DSD
Trend in mean age of drug related deaths 1990-2003
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 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)
ES
DK, NL, SE
MT, UK
NO
IE, PL
AT, ITCZ
DELU, PT
SK FR
SI
LV, LT,FI
ELBG
HU
BE, EE
SE
NL, UKDK
DE
FIIT
ESPT
MTAT
LUSI
EL, IE,CZ
PL
FR, LT, HU, BU
LVBE
NOEE
0
5
10
15
20
25
30
1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
Cu
mu
lati
ve n
um
ber
of
cou
ntr
ies
Year first publicly funded NSP Methadone treatment first available
Estimated number of drug users in substitution treatment in 29
European countries (2003) per 100.000 population aged 15-64
0
50
100
150
200
250
300
350
400
450
LU UK ES IE MT FR PT IT SI DK EU
+ 4
DE NL NO SE EL BE CZ LT FI HU BG LV PL RO
10-year trend in the number of substitution treatment clients in Europe (EU-15)
73,400
207,000
265,000
351,000
537,000
0
100,000
200,000
300,000
400,000
500,000
600,000
1993 1995 1997 2000 2003
Proportion of substitution drugs used in medically assisted treatment in Europe, 2003
Methadone79%
Other1%
Buprenorphine20%
0
10
20
low 14.8 12.4 7.3 5.8 4.2 2.5 1.7 1.8 1.4 0.9 0.2 0.1
high 14.8 15.8 10.8 5.8 4.2 4.3 2.2 2.2 1.9 1.7 0.2 0.2
Spain UK DenmarkLuxembour
gFrance Ireland Finland Belgium Norway Austria Greece Sweden
Provision of Needle/Syringe Programmes (number of NSPs per 1000 estimated IDUs)
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 health-
related 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