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ENTrends and Developments2016ISSN 2314-9086EuropeanDrugReport

EuropeanDrugReportTrends and Developments2016

I Legal noticeThis publication of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is protected bycopyright. The EMCDDA accepts no responsibility or liability for any consequences arising from the use of the datacontained in this document. The contents of this publication do not necessarily reflect the official opinions of theEMCDDA’s partners, any EU Member State or any agency or institution of the European Union.Europe Direct is a service to help you find answers to your questions about the European Union.Freephone number (*): 00 800 6 7 8 9 10 11(*) The information given is free, as are most calls (though some operators, phone boxes or hotels may charge you).More information on the European Union is available on the internet (http://europa.eu).This report is available in Bulgarian, Spanish, Czech, Danish, German, Estonian, Greek, English, French, Croatian,Italian, Latvian, Lithuanian, Hungarian, Dutch, Polish, Portuguese, Romanian, Slovak, Slovenian, Finnish, Swedish,Turkish and Norwegian. All translations were made by the Translation Centre for the Bodies of the European Union.Luxembourg: Publications Office of the European Union, 2016ISBN: 978-92-9168-890-6doi:10.2810/04312 European Monitoring Centre for Drugs and Drug Addiction, 2016Reproduction is authorised provided the source is acknowledged.Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2016), European Drug Report2016: Trends and Developments, Publications Office of the European Union, Luxembourg.Printed in SpainPrinted on elemental chlorine-free bleached paper (ECF)Praça Europa 1, Cais do Sodré, 1249-289 Lisbon, PortugalTel. 351 211210200info@emcdda.europa.eu I www.emcdda.europa.eutwitter.com/emcdda I facebook.com/emcdda

I Contents5 Preface9 Introductory note and acknowledgementsIIIII11 SUMMARYContinued signs of resilience in the European drug market17 CHAPTER 1Drug supply and the market37 CHAPTER 2Drug use prevalence and trends53 CHAPTER 3Drug-related harms and responses71 ANNEXNational data tables

I PrefaceIt is our great pleasure to present the EMCDDA’s 21st annual analysis of Europe’s drugsituation, our first as newly elected Director of the EMCDDA and as Chair of the agency’sManagement Board. As in previous years, the European Drug Report 2016 offers a timelyreview of the latest trends and developments in the European drug situation, in the form ofan integrated multimedia package. This report is unique in bringing together an up-to-dateand top-level overview of drug use, drug problems and drug markets, and integrating thissituational analysis with information on drug policies and practice.This year’s analysis once more highlights how Europe increasingly faces a more complexdrug problem, in which stimulants, new psychoactive substances, misused medicines andproblematic cannabis use all play a greater part. The report also reminds us that some ofthe problems of the past remain with us — even if the challenges they are now presentingfor both policy and practice are changing. Europe’s opioids problem remains a centralissue in the 2016 analysis, reflecting the significant impact these drugs still have onmortality and morbidity. We see now an increasingly complex relationship between use ofheroin and synthetic opioids, accompanied by a worrying increase in overall estimates ofopioid-related deaths. Treatment services in Europe are also now having to respond to themore complex health needs presented by an ageing cohort of heroin users, andpolicymakers wrestle with the difficult question of what constitutes the most appropriatelong-term therapeutic goals for this group. At the same time, new heroin epidemicsreported in other parts of the world remind us this is an area in which vigilance is requiredand ongoing surveillance remains essential.Our report is very much a collective endeavour, and we must thank here all those whosecontributions made this report possible. As ever, the input from Reitox national focal pointsand national experts forms the basis for the analysis presented here. In addition, we haveto acknowledge the input we have received from our institutional partners at Europeanlevel; in particular the European Commission, Europol, the European Centre for DiseasePrevention and Control and the European Medicines Agency. We are also pleased to notethe inclusion in this year’s report of additional city-level information from Europeanresearch networks, which complements national data in the areas of wastewater analysisand drug-related hospital emergencies and enriches our understanding of both drugconsumption patterns and harms across Europe.5

European Drug Report 2016: Trends and DevelopmentsFinally, we note this report is released at an important time for drug policy development,both in Europe and internationally. Within Europe, the achievements of the current drugaction plan will be evaluated, and deliberations begun on the actions necessary to takeforward the European drug strategy in the coming years. European countries have alsobeen active in the international debates surrounding the UN General Assembly SpecialSession held in New York in April this year. The European position emphasised the value ofa balanced and evidence-based approach grounded in a strong commitment for humanrights. In our view, one of the reasons that Europe can speak with authority in this debate isthe fact that there is a commitment to understanding the changing nature of the problemswe face and to critically assessing what works. We are proud that this report and the workof the EMCDDA and its national partners continues to contribute to this understanding,and remain convinced that sound information is a prerequisite for sound policies andactions in this area.Laura d’ArrigoChair, EMCDDA Management BoardAlexis GoosdeelDirector, EMCDDA6

I Introductory note and acknowledgementsThis report is based on information provided to the EMCDDA by the EU Member States, thecandidate country Turkey, and Norway in the form of a national reporting package.The purpose of the current report is to provide an overview and summary of the Europeandrug situation and responses to it. The statistical data reported here relate to 2014 (or thelast year available). Analysis of trends is based only on those countries providing sufficientdata to describe changes over the period specified. Statistical significance is tested at the0.05 level, unless otherwise stated. The reader should also be aware that monitoringpatterns and trends in a hidden and stigmatised behaviour like drug use is both practicallyand methodologically challenging. For this reason, multiple sources of data are used forthe purposes of analysis in this report. Although considerable improvements can be noted,both nationally and in respect to what is possible to achieve in a European level analysis,the methodological difficulties in this area must be acknowledged. Caution is thereforerequired in interpretation, in particular when countries are compared on any singlemeasure. Caveats and qualifications relating to the data are to be found in the onlineversion of this report and in the Statistical Bulletin, where detailed information onmethodology, qualifications on analysis and comments on the limitations in theinformation set available can be found. Information is also available on the methods anddata used for European level estimates, where interpolation may be used.The EMCDDA would like to thank the following for their help in producing this report: the heads of the Reitox national focal points and their staff; the services and experts within each Member State that collected the raw data for thisreport; the members of the Management Board and the Scientific Committee of the EMCDDA; the European Parliament, the Council of the European Union — in particular itsHorizontal Working Party on Drugs — and the European Commission; the European Centre for Disease Prevention and Control (ECDC), the EuropeanMedicines Agency (EMA) and Europol; the Pompidou Group of the Council of Europe, the United Nations Office on Drugs andCrime, the WHO Regional Office for Europe, Interpol, the World Customs Organisation,the European School Survey Project on Alcohol and Other Drugs (ESPAD), the SewageAnalysis Core Group Europe (SCORE), the European Drug Emergencies Network (EuroDEN) and the Swedish Council for Information on Alcohol and Other Drugs (CAN); the Translation Centre for the Bodies of the European Union, Missing Element Designers,Nigel Hawtin and Composiciones Rali.Reitox national focal pointsReitox is the European information network on drugs and drug addiction. Thenetwork is comprised of national focal points in the EU Member States, thecandidate country Turkey, Norway and at the European Commission. Under theresponsibility of their governments, the focal points are the national authoritiesproviding drug information to the EMCDDA. The contact details of the national focalpoints may be found on the EMCDDA website.9

SummaryEurope’s drug policyagenda needs to embracea broader and morecomplicated set of policy issues

SummaryContinued signs of resiliencein the European drug marketThe analysis presented here describes aEuropean drug market that remainsresilient, with some indicators forcannabis and stimulant drugs, inparticular, now trending upwards.Overall, supply data suggest that thepurity or potency of most illicitsubstances is high or increasing. Themajority of recent survey data onprevalence also show modest increasesin the estimated use of the morecommonly consumed drugs. The drugmarketplace is also more complex, withnew substances available to consumersalongside more established drugs,signals that medicines are becomingmore important, and with polydrug usepatterns the norm among thoseexperiencing drug problems.Interdiction efforts are challenged bythe fact that production of cannabis,synthetic drugs and even some opioidsand new psychoactive substances nowtakes place within Europe, near toconsumer markets. Taken together thisnew analysis highlights the need forEurope’s drug policy agenda toembrace a broader and morecomplicated set of policy issues thanhas historically been the case.IResurgence of MDMAThe return of MDMA as a common stimulant of choice foryoung people is illustrative of some of the new challengesposed by the contemporary drug market. Innovation insourcing precursors, new production techniques andonline supply all appear to be driving a revival in a marketnow characterised by a diversity of products. High-dosepowders, crystals and tablets with a range of logos, coloursand shapes are available, with evidence of production toorder and the use of sophisticated and targeted marketing.This may be a deliberate strategy by producers to improveperception of the drug after a lengthy period in which poordrug quality and adulteration had resulted in a decline inuse. There are signals that this may be achieving somesuccess, with indications that MDMA is becoming morepopular, both with established stimulant consumers andwith a new generation of young users. This points to theneed for prevention and harm reduction responses totarget a new population of users who may be usinghigh-dose products but lack an understanding of theassociated risks.11

European Drug Report 2016: Trends and DevelopmentsI ew data highlight regional patterns in stimulantNuse and harmsThis report suggests that identifying and responding tolocalised patterns of stimulant use and related harmsneeds to be given greater priority. Recent findings fromwastewater analysis parallel seizure and survey data, allhighlighting regional differences in stimulant consumptionpatterns across Europe. Cocaine use appears higher inwestern and southern European countries, whileamphetamines are more prominent in northern andeastern Europe. Both cocaine and amphetamine haveseen a medium-term increase in purity, with pricesremaining largely stable. Stimulant-related problems arealso becoming more visible. Concerns exist about anincreased number of new amphetamines-relatedtreatment demands in some countries, with nearly half ofthese new entrants reporting injecting. Injecting stimulantuse has also been associated with recent outbreaks of HIVin some marginalised populations. Stimulant injectingassociated with high levels of sexual risk-taking behavioursis also a growing concern. This has been reported amongsmall groups of men who have sex with men in someEuropean cities, pointing to a need for increasedcooperation and a joined-up response from drug treatmentand sexual health services.I esponding to cannabis remains a key challengeRfor European drug policiesInternationally, and in Europe, there is currentlyconsiderable public and political debate on the costs andbenefits of different cannabis policy options. Datapresented in this report inform this discussion byillustrating some of the complex issues that need to betaken into consideration. This topic is important, as levelsof cannabis use overall do not appear to be falling and mayeven be starting to rise in some populations. Notably, ofthose countries that have produced a recent surveyestimate (since 2013), a majority have reported increaseduse of this drug.New estimates show that cannabis accounts for thelargest share in value of Europe’s illicit drug market.Cannabis production has become a major incomegenerator for organised crime. Importation of cannabisfrom multiple source countries and increasing domesticproduction in Europe present a considerable challenge forlaw enforcement, with a resulting strain on alreadystretched police and customs resources. Cannabisoffences, the bulk of which are for use or possession forpersonal use, also account for close to three-quarters of alldrug-related offences.12There is also a growing understanding of the health andsocial costs that can accrue from cannabis use. These aremost pronounced among the more frequent and longerterm users, with around 1 % of European adults estimatedto be daily or near-daily cannabis users. For both resin andherbal cannabis, potency levels are high by historicalstandards and this is worrying, as it may increase the risksof users experiencing both acute and chronic healthproblems. The drug is also now responsible for the majorityof new drug treatment entrants, although treatment entrydata must be understood in the context of referralpathways and a wide definition of what constitutes care forthis population. Policy responses in this area must also bemindful that in Europe, unlike in some parts of the world,cannabis is typically smoked with tobacco, making synergybetween cannabis control and tobacco control policiesimportant.I ynthetic cannabinoids dominate seizures of newSpsychoactive substancesAn equally challenging issue for international andEuropean drug policies is how to respond effectively to thedynamic and constantly changing market for new drugs.Very limited information is available on the use of newpsychoactive substances, but the 50 000 reported seizuresof these drugs in 2014 provide some insight into theirrelative availability. Synthetic cannabinoids account forover 60 % of these, and this drug class also featuresprominently in the 98 new substances detected for thefirst time in 2015 and reported to the EU Early WarningSystem for new psychoactive substances. Twenty-four ofthese were synthetic cannabinoids — drugs that act on thesame brain receptors as THC, one of the main activecompounds found in natural cannabis. From a healthperspective, however, many synthetic cannabinoids areconsiderably more toxic, with mass poisonings and evendeaths reported. The threat posed by these substances ishighlighted by a warning issued by the EMCDDA inFebruary 2016 about the synthetic cannabinoid MDMBCHMICA — a drug that had been associated with 13deaths and 23 non-fatal intoxications. This chemical wasidentified in more than 20 different smoking mixtures, anddeaths or poisoning were identified in eight countries, andmay have occurred in others. Consumers of these productswould usually be ignorant of the chemicals they contain.Cannabis accounts for thelargest share in value ofEurope’s illicit drug market

Summary I Continued signs of resilience in the European drug marketAT A GLANCE — ESTIMATES OF DRUG USE IN THE EUROPEAN UNIONCannabisCocaineLifetime22.1 million83.2 million6.6 %24.8 %Last year0Adults(15 64)Adults(15 64)1.1 %5.1 %Last year16.6 million2.4 millionLowest3.2 %13.3 %Lifetime3.6 million 17.1 millionHighest23.9 %Last yearYoung adults(15 34)Used:0Used:Last yearNational estimatesof use in last yearMDMAYoung adults(15 34)Lowest0.2 %1.9 %Highest4.2 %National estimatesof use in last yearAmphetaminesUsed:Adults(15 64)LifetimeLast yearLifetime2.5 million13.0 million1.6 million12.0 million0.5 %3.6 %0.8 %Young adults(15 34)Used:Last year3.9 %Adults(15 64)Last yearLast year2.1 million1.3 million1.7 %Lowest0.3 %Highest5.5 %Young adults(15 34)1.0 %Lowest0.1 %Highest2.9 %National estimatesof use in last yearNational estimatesof use in last yearNew psychoactive substancesOpioidsHigh-risk opioid usersFatal overdosesUsed:1.3 million82 %Opioids are found in82 % of fatal overdosesDrug treatment requestsPrincipal drug in about40 % of all drugtreatment requestsin the European UnionYounger adults(15 24)40 %Last yearLifetime3.0 %8.0 %644 000Opioid usersreceived substitutiontreatment in 2014Source: 2014 Flash Eurobarometer on young people and drugsNB: For the complete set of data and information on the methodology see the accompanying online Statistical Bulletin.13

European Drug Report 2016: Trends and DevelopmentsAdverse events are also associated with both uncontrolledstimulants and opioids reported to the Early WarningSystem. Responding effectively and rapidly to the sale ofobscure chemicals, some of which subsequently are foundto be highly toxic, poses one of the major policy challengesin this area. Young consumers may unwittingly be actingas human guinea pigs for substances for which thepotential health risks are largely unknown. An examplehere is the synthetic cathinone alpha-PVP, which wasrisk-assessed in November 2015. This potentpsychostimulant has been associated with almost 200acute intoxications and over 100 deaths in Europe.Afghanistan, increases in the size of heroin seizures andhigher purity levels, all point to a possible increase inavailability. There is currently, however, no strong evidenceof increases in new heroin uptake, treatment entrance forheroin is declining or stable, and overdoses remainprimarily a problem among older opioid users.Nonetheless, small increases have been observed inoverdose deaths among younger groups in some countries,and this warrants closer attention.Producers of new psychoactive substances increasinglyappear to be targeting the more chronic and problematicsectors of the drug market. Non-controlled syntheticopioids, such as members of the fentanyl family, areavailable, for example. These drugs can be particularlyharmful. An example of note here is acetylfentanyl, whichwas subject to an EMCDDA–Europol joint report in 2015.New psychoactive substances have also been found inproducts marketed as replacements for medicines likebenzodiazepines — medicines that when misused play arole in the drug problem in some countries.The role of synthetic opioids and medicinal drugs alsoappears to be important in drug deaths in parts of Europe.Concerns exist about misused benzodiazepines and othermedicines, diverted from therapeutic providers or obtainedfrom unlicensed sources, but the role these drugs play inoverdose deaths in Europe remains poorly understood.More data are available on synthetic opioids. Syntheticopioid products, mostly but not exclusively drugs used forsubstitution treatment, are more prominent in data ondrug-related deaths in some countries, and there has alsobeen an increase in treatment demand related to thesesubstances. Given the severe public health problemsexperienced in North America and elsewhere with themisuse of opioid medicines, improved surveillance todetect any growing problems in this area at a Europeanlevel is merited. In addition, and noted in the body of thisreport, regulatory frameworks and clinical guidelines canplay a positive role in reducing the risk of diversion ofmedicines from appropriate therapeutic uses.I ises in overdose deaths: heroin backRin the spotlightThis year’s analysis also highlights new concerns aboutrises in overdoses associated with heroin and otheropioids. Heroin features prominently in data on fataloverdoses and is also the most common illicit drugreported in new European city-level data on hospitalemergency presentations. The substances responsible fordrug emergencies vary considerably between cities, withcannabis, cocaine and other stimulants also featuringprominently in some locations. Currently, data on acutedrug problems are not collected systematically at aEuropean level. The pilot city-level study suggests thatroutine monitoring in this area would be valuable to helpbetter understand and track the impact of emerging drugproblems.A number of countries, mostly in the north of Europe, withlong-established opioid problems report recent rises inopioid-related deaths. Understanding the drivers behindtrends in this area, however, is complicated. Possibleexplanations include an increase in heroin availability,increasing purity, an ageing and more vulnerable usercohort and changing drug consumption patterns (includingthe use of synthetic opioids and medicines). Changes inreporting practice may also be important. Supply side data,including increased estimates of heroin production in14IIUse of synthetic opioids: cause of concern ew pharmacological options forNreducing drug harmsThe coming years are likely to see the release of a range ofnew pharmacological options that could lead to increasedopportunities for reducing some of the problems related todrug use. This report highlights two areas where newtherapies and innovative delivery methods are beingintroduced. A number of EU countries provide theoverdose-reversal drug naloxone to opioid users throughcommunity schemes or to drug users leaving prison withthe aim of reducing overdose deaths. The widerimplementation of take-home naloxone in Europe may bein prospect, with the development of nasally administerednaloxone preparations, such as one recently given approvalfor pharmacy sale in the United States. New medicines arealso becoming available that provide greater opportunitiesfor treating hepatitis C virus infections among active druginjectors, including those in drug treatment settings. Newtherapies have a significant potential to provide health

Summary I Continued signs of resilience in the European drug marketgain in the drugs area, but the challenge is to reducebarriers to their uptake and ensure sufficient resources areavailable to meet treatment needs.I ew threats and opportunities provided byNinternet drug marketsAn important new challenge for drug policy is how torespond to the internet’s role as both a communicationmedium and an emerging source of drug supply. Attentionhas focused primarily on the threat posed by darknet drugmarkets. It is also necessary to understand the growingrole of surface websites, especially in respect to supply ofcounterfeit medicines and new psychoactive substances,and social media applications for peer-to-peer exchanges.Online platforms also provide possibilities for prevention,treatment and harm reduction activities, though these areoften overlooked.The supply of drugs through online sources appears to begrowing, albeit from a low base, and the potential forexpansion of online drug supply appears considerable.Moreover, the rapid rate of change in this area, driven byincreasing use of the internet, the deployment of newpayment technologies, innovations in encryption and newoptions for the creation of distributed online marketplaces,makes it difficult for societal responses to keep pace. Howbest to respond to this growing dark cloud on the horizonand how best to exploit the opportunities that this mediumoffers for reducing drug problems are likely to representquestions of critical importance for the future Europeanpolicy agenda.15

1In the global context, Europe is animportant market for drugs

Chapter 1Drug supply and the marketIn the global context, Europe is animportant market for drugs, supportedby both domestic production and drugstrafficked from other world regions.South America, West Asia and NorthAfrica are important source areas forillicit drugs entering Europe, while Chinaand India are source countries for newpsychoactive substances. In addition,some drugs and precursors aretransited through Europe en route toother continents. Europe is also aproducing region for cannabis andsynthetic drugs, with cannabis mostlyproduced for local consumption, whilesome of the synthetic drugs aremanufactured for export to other partsof the world.Monitoring drug markets, supply and lawsThe analysis presented in this chapter draws onreported data on drug seizures, drug precursorseizures and stopped shipments, dismantled drugproduction facilities, drug law offences, retail drugprices, purity and potency. In some cases, theabsence of seizure data from key countries makesthe analysis of trends difficult. It should be noted thattrends can be influenced by a range of factors, whichinclude user habits and preferences, changes inproduction and trafficking, law enforcement activitylevels and the effectiveness of interdiction measures.Full data sets and methodological notes can befound in the online Statistical Bulletin.Also presented here are data on notifications andseizures of new psychoactive substances reported tothe EU Early Warning System by the nationalpartners of the EMCDDA and Europol. As thisinformation is drawn from case reports rather thanroutine monitoring systems, seizure estimatesrepresent a minimum. Data will be influenced byfactors such as increasing awareness of thesesubstances, their changing legal status and thereporting practices of law enforcement agencies. Afull description of the EU Early Warning System canbe found on the EMCDDA website under Action onnew drugs.Supporting information on European drug laws andpolicies is available on the EMCDDA website.17

European Drug Report 2016: Trends and DevelopmentsSizeable markets for cannabis, heroin and amphetamineshave existed in many European countries since the 1970sand 1980s. Over time, other substances also establishedthemselves — including MDMA in the 1990s and cocainein the 2000s. The European market continues to evolve,with the last decade witnessing the emergence of a widerange of new psychoactive substances. Recent changes inthe illicit drug market, largely linked to globalisation andnew technology, include innovation in drug production andtrafficking methods and the establishment of newtrafficking routes.Measures aimed at preventing the supply of drugs involveactions by government and law enforcement agencies andoften depend on international cooperation. At EU level,efforts are coordinated through the EU drugs strategy andaction plans and the EU policy cycle for organised andserious crime. The approach that countries take is reflectedin their national drug strategies and laws. Data on arrestsand seizures are currently the best-documented indicatorsof drug supply disruption efforts.IDrug markets: estimating financial valueIllicit drug markets are complex systems of production anddistribution that generate large sums of money at differentlevels. A conservative estimate values the retail market forillicit drugs in the European Union at EUR 24.3 billion in2013 (likely range EUR 21 billion to EUR 31 billion). Withan estimated retail value of EUR 9.3 billion (likely rangeEUR 8.4–12.9 billion), and responsible for about 38 % ofthe total, cannabis products account for the largest shareof the illicit drug market in Europe. This is followed byheroin, estimated at EUR 6.8 billion (EUR 6.0–7.8 billion)(28 %), and cocaine at EUR 5.7 billion (EUR 4.5–7.0 billion)(24 %). Amphetamines occupy a smaller market share,estimated at EUR 1.8 billion (EUR 1.2–2.5 billion) (8 %),ahead of MDMA, at almost EUR 0.7 billion (EUR 0.61–0.72billion) (3 %). These estimates are based on very limiteddata, which has necessitated some broad assumptions,and hence must be viewed as initial minimum estimatesthat need revision in the future, as the informationunderpinning them is improved.INew supply methods: online drug marketsWhile historically, illicit drug markets have been situated inphysical locations, the last decade has seen theemergence of new internet technologies that havefacilitated the development of online marketplaces. Drugmarkets can operate on the surface web, typically retailingnon-controlled precursor chemicals, new psychoactive18substances or falsified and counterfeit medicines. Theycan also operate on the deep web, through darknetmarkets or cryptomarkets, like AlphaBay or the defunct SilkRoad. Cannabis products and MDMA are reported to bethe illicit drugs most frequently offered for sale on darknetmarkets, alongside a range of medicines.A darknet market is an online sales platform ormarketplace, supported by technologies that protectprivacy, which brings together vendors, listing mostly illicitgoods and services for sale. These markets have manysimilar characteristics to marketplaces such as eBay andAmazon, and customers can search and compare productsand vendors. A range of strategies is used to conceal bothtransactions and the physical locations of servers. Theseinclude anonymisation services, such as Tor (the OnionRouter), that hide a computer’s internet protocol (IP)address; decentralised and relatively untraceablecryptocurrencies, such as bitcoin and liteco

the European Parliament, the Council of the European Union — in particular its Horizontal Working Party on Drugs — and the European Commission; the European Centre for Disease Prevention and Control (ECDC), the European Medicines Agency (EMA) and Europol; the Pompidou Group of the Council of Europe, the United Nations Office on Drugs and

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