Problem drug use, HIV and injecting: an overview of the European experience Paul Griffiths, EMCDDA Drug Control in the Baltic Region, Vilnius, 27 September.

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

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

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 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)

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

Substitution treatment in the EU

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

Thanks…

Lucas Wiessing & Dagmar Hedrich

www.emcdda.eu.int