International - European Union

Basic Data

(Prevalence) "With an annual prevalence of 5.2 per cent, cannabis remains the most commonly used substance in Europe, followed by cocaine, ATS and opioids (mostly heroin). After North America, Western and Central Europe remains a major illicit market for cocaine, with annual prevalence of cocaine use among the general population at about 1.3 per cent. In most parts of Europe, there are stable or declining trends reported in the use of opioids, cannabis, cocaine and ATS; however, the rapid emergence of new synthetic drugs and the increasing interplay between legal “highs” and illicit drug markets pose a major challenge in the region. For instance, although mephedrone has been under national control in all European Union member States since 2010, it is still being sold both online as a legal “high”, as well as through the same illicit supply networks used for drugs such as “ecstasy” and cocaine. Nevertheless, opioids remain the most problematic drugs, are reported to be the primary substances responsible for demand for treatment for drug use and are a major cause of drug-related deaths in Europe."

(Impact of National Policies on Drug Use Prevalence) "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 restricted 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."

(Cannabis Use Prevalence Estimates) "It is conservatively estimated that cannabis has been used at least once (lifetime prevalence) by about 80.5 million Europeans, that is almost one in four of all 15- to 64-year-olds (see Table 3 for a summary of the data). Considerable differences exist between countries, with national prevalence figures varying from 1.6% to 32.5%. For most countries, the prevalence estimates are in the range of 10–30% of all adults.
"An estimated 23 million Europeans have used cannabis in the last year or, on average, 6.8% of all 15- to 64-year-olds. Estimates of last month prevalence will include those using the drug more regularly, though not necessarily in a daily or intensive way. It is estimated that about 12 million Europeans used the drug in the last month: on average, about 3.6% of all 15- to 64-year-olds."

(Prevalence of Problem Heroin Use) "Most European countries are now able to provide prevalence estimates of problem opioid use. Recent national estimates vary between less than one and seven cases per 1,000 population aged 15–64 (Figure 11). The highest estimates of problem opioid use are reported by Ireland, Latvia, Luxembourg and Malta, and the lowest by Cyprus, Hungary, Poland and Finland. Turkey reports less than one case per 1,000 population aged 15–64.
"The average prevalence of problem opioid use in the European Union and Norway, computed from national studies, is estimated to be 4.2 (between 3.9 and 4.4) cases per 1 000 population aged 15–64. This corresponds to some 1.4 million problem opioid users in the European Union and Norway in 2010⁽⁹¹⁾.
"By comparison, estimates for Europe’s neighbouring countries are high, with Russia at 16.4 problem opioid users per 1,000 population aged 15–64 (UNODC, 2011b), and Ukraine at 10–13 per 1,000 population aged 15–64 (UNODC, 2010). Both Australia and the United States report higher estimates of problem opioid use, 6.3 and 5.8 cases per 1,000 population aged 15–64, while the equivalent figure for Canada is 3.0 cases. Comparisons between countries should be made with caution, as definitions of the target population may vary. For example, if non-medical use of prescription opioids was added, the prevalence figure would rise to 39–44 per 1,000 North Americans aged 15–64 (UNODC, 2011b)."

(Estimated Prevalence of Cocaine) "Over the last 10 years, cocaine has established itself as the most commonly used illicit stimulant drug in Europe, although most users are found in a small number of high-prevalence countries, some of which have large populations. It is estimated that about 15.5 million Europeans have used cocaine at least once in their life; on average, 4.6% of adults aged 15–64 (see Table 8 for a summary of the data). National figures vary from 0.3% to 10.2%, with half of the 24 reporting countries, including most central and eastern European countries, reporting low levels of lifetime prevalence (0.5–2.5%).
"About 4 million Europeans are estimated to have used the drug in the last year (1.2% on average). Recent national surveys report last year prevalence estimates of between 0.1% and 2.7%. The prevalence estimate for last month cocaine use in Europe represents about 0.5% of the adult population or about 1.5 million individuals.
"Levels of last year cocaine use above the European average are reported by Ireland, Spain, Italy and the United Kingdom. In all of these countries, last year prevalence data show that cocaine is the most commonly used illicit stimulant drug."

(International Comparisons of Cocaine Prevalence) "Compared with some other parts of the world for which reliable data exist, the estimated last year prevalence of cocaine use among young adults in Europe (2.1%) is below the levels reported for young adults in Australia (4.8 %) and the United States (4.0% among 16- to 34-year-olds), but close to that reported for Canada (1.8%). Two European countries, Spain (4.4%) and the United Kingdom (4.2%), report figures similar to those of Australia and the United States (Figure 9)."

(Prevalence of Amphetamine Use) "Drug prevalence estimates suggest that about 13 million Europeans have tried amphetamines, and about 2 million have used the drug during the last year (see Table 5 for a summary of the data). Among young adults (15–34), lifetime prevalence of amphetamines use varies considerably between countries, from 0.1% to 12.9%, with a weighted European average of 5.5%. Last year use of amphetamines in this age group ranges from 0% to 2.5%, with most countries reporting prevalence levels of 0.5–2.0%. It is estimated that about 1.5 million (1.2%) young Europeans have used amphetamines during the last year. Levels of last year use of amphetamines are higher in surveys among young people linked with dance-music or nightlife settings, with results from 2010 studies in the Czech Republic, the Netherlands and United Kingdom ranging from 8% to 27%."

(Prevalence of Hallucinogens) "Among young adults (15–34 years), lifetime prevalence estimates of LSD use in Europe range from 0.1% to 5.4%. Much lower prevalence levels are reported for last year use ⁽⁶⁹⁾. In the few countries providing comparable data, most report higher levels of use for hallucinogenic mushrooms than for LSD among both the general population and school students. Lifetime prevalence estimates for hallucinogenic mushrooms among young adults range from 0.3% to 8.1%, and last year prevalence estimates are in the range of 0.0–2.2%. Among 15- to 16-year-old school students, most countries report lifetime prevalence estimates for the use of hallucinogenic mushrooms of between 1% and 4% ⁽⁷⁰⁾."

(Prevalence of MDMA Use) "Drug prevalence estimates suggest that about 11.5 million Europeans have tried ecstasy, and about 2 million have used the drug during the last year (see Table 6 for a summary of the data). Use of the drug in the last year is concentrated among young adults, with males generally reporting higher levels of use than females in all countries. Lifetime prevalence of ecstasy use among the 15–34 age group ranges from under 0.6% to 12.4%, with most countries reporting estimates in the range of 2.1–5.8%⁽⁶⁶⁾."

(Per Capita Alcohol Consumption) "The European Union (EU) is the region with the highest alcohol consumption in the world: in 2009, average adult (aged 15+ years) alcohol consumption in the EU was 12.5 litres of pure alcohol – 27g of pure alcohol or nearly three drinks a day, more than double the world average. Although there are many individual country differences, alcohol consumption in the EU as a whole has continued at a stable level over the past decade."

(Alcohol Consumption Trends in the EU) "Although the European per capita consumption of alcohol has remained nearly constant over the past decade, this apparent steadiness hides two opposing trends. The Nordic countries and eastern Europe have seen an increase in adult per capita consumption, whereas western and southern Europe have experienced a decrease. Beer is the most prominent alcoholic beverage in almost all regions. Only in southern Europe does wine remain the most frequently consumed alcoholic drink, but even in southern Europe, the consumption of wine has been decreasing at a high rate whereas beer consumption is only rising slightly. This decrease in wine intake is mainly responsible for the strong downward trend in total alcohol consumption in southern Europe. The Nordic countries are moving in the opposite direction to the southern countries, although the changes are not as marked: wine consumption has steadily increased in the past decade while beer has lost some of its popularity. Southern and eastern Europe are the two regions that show the largest amount of change in their total alcohol consumption, but these changes tend to cancel each other out and are not reflected in the EU average."

(New Drugs and 'Legal Highs') "Between 2005 and 2011, 164 new psychoactive substances were formally notified through the early warning system. In 2011, for the third consecutive year, a record number of substances (49) were detected for the first time in Europe, up from 41 substances in 2010 and 24 in 2009.
"This marked increase in the number of substances notified is occurring in the context of a continually developing ‘legal high’ phenomenon, and reflects both the number of substances that have been launched on the European drugs market and the improved reporting capacities of national early warning systems. The presence of some of these new drugs on the market has been detected through test purchases of ‘legal high’ products on the Internet and from specialised shops. In most cases, however, they were detected through forensic analysis of seizures.
"No first identifications in biological samples (blood, urine) were reported in 2010 or 2011, whereas a quarter of the substances notified in 2009 were detected in biological samples."

(Drug Law Offenses) "Overall, the upward trend in the number of reported drug law offences has slowed since 2009. An EU index, based on data provided by 22 Member States, representing 93% of the population aged 15–64 in the European Union, shows that reported offences increased by an estimated 15% between 2005 and 2010, with a more stable trend since 2008. If all reporting countries are considered, the data reveal upward trends in 19 countries and an overall decline in seven countries over the period ⁽³¹⁾."

(Trends in Drug Offenses) "There has been no major shift in the balance between drug law offences related to use and those related to supply compared with previous years. In most (22) European countries, offences related to drug use or possession for use continued to comprise the majority of drug law offences in 2010, with Spain, France, Hungary, Austria and Turkey reporting the highest proportions
(85–93%) ⁽³²⁾.
"Between 2005 and 2010, there was an estimated 19 % increase in the number of offences related to drug use in Europe. Some country differences can be seen in this analysis, as the number of offences related to use increased in 18 countries and fell in seven during this period. There has, however, been an overall decrease in drug use offences reported in the most recent data (2009–10) (Figure 3). Offences related to the supply of drugs show an estimated increase during the period 2005–10 of about 17% in the European Union. Over this period, 20 countries report an increase in supply-related offences, while Germany, Estonia, the Netherlands, Austria and Poland report an overall decline ⁽³³⁾."

(Cannabis Offenses) "Cannabis continues to be the illicit drug most often mentioned in reported drug law offences in Europe ⁽³⁴⁾. In the majority of European countries, offences involving cannabis accounted for between 50% and 90% of reported drug law offences in 2010. Offences related to other drugs exceeded those related to cannabis in only four countries: the Czech Republic and Latvia with methamphetamine (54% and 34%); and Lithuania and Malta with heroin (34% and 30%).
"In the period 2005–10, the number of drug law offences involving cannabis increased in 15 reporting countries, resulting in an estimated increase of 20% in the European Union. Downward trends are reported by Germany, Italy, Malta, the Netherlands and Austria ⁽³⁵⁾."

(Cannabis Offenses 1999-2004) "In 1999–2004, the number of 'reports' of drug law offences involving cannabis increased overall in the majority of reporting countries, while decreases were evident in Italy and Slovenia. Over the same period, the proportion of drug offences involving cannabis increased in Germany, Spain, France, Lithuania, Luxembourg, Portugal, the United Kingdom and Bulgaria, while it remained stable overall in Ireland and the Netherlands, and decreased in Belgium, Italy, Austria, Slovenia and Sweden. Although in all reporting countries (except in the Czech Republic and Bulgaria and for a few years in Belgium) cannabis is more predominant in offences for use/possession than in other drug law offences, the proportion of use-related offences involving cannabis has decreased since 1999 in several countries -- namely Italy, Cyprus (2002–04), Austria, Slovenia and Turkey (2002–04) -- and has fallen over the last year (2003–04) in most reporting countries, possibly indicating a reduced targeting of cannabis users by law enforcement agencies in these countries."

(Homicide Rates) "The homicide rate in the Americas is, at 15.6 per 100,000, more than double the world average (figure 1.3), while, at 17.4 per 100,000, Africa has the highest rate among all regions, although it also has the largest uncertainty range due to large discrepancies between criminal justice and public health data.⁴ Asia falls between 2.4 and 4.3 per 100,000, and both Europe and Oceania also fall below the global average at 3.5 per 100,000, respectively.
"Subregional and national averages
"As figure 1.4 clearly shows, Southern Africa and Central America, South America and the Caribbean have considerably higher homicide rates than other subregions, while, at the opposite end of the scale, Western, Northern and Southern Europe, and Eastern Asia have the lowest homicide rates. Data show that homicide rates tend to be higher in developing countries, an initial indication that development has a link with homicide levels."

(European Homicide Rates) "Despite some dramatic fluctuations such as those seen in Albania, which experienced an alarming rises in the homicide rate during the civil unrest following the collapse of a pyramid scheme in 1997, homicide rates have decreased or remained more or less stable in the vast majority of European countries since 1995, following the peaks of 1991-1993. An improvement in socio-economic conditions in many Central and Eastern European countries, as well as an improvement in security measures may have contributed to this.
"Most Western and Northern European countries have long been among those with the lowest homicide rates in the world, yet, paradoxically, violent crimes and drug offences have increased in many European countries since the early 1990s.⁸ This may be partly due to changes in the lifestyles of European youths, including changes in their consumption patterns of drugs and alcohol (heavy episodic or “binge” drinking, for, example) and the emergence of new street gangs based on ethnic minority or immigrant group affiliations.⁹ There are indications that these developments have an impact on increased street violence and hospital admissions.¹⁰
"Such a discrepancy between violent crimes and homicide could be due, in part, to the lack of availability of firearms¹¹ (only 27 per cent of homicides are committed with a firearm in Western Europe as opposed to 65 per cent in Central America) as well as to an improvement in the quality of health services reducing the lethality of violent assaults and homicide attempts.¹² Some researchers have also postulated that decreases in homicide rates in Europe may be explained by greater levels of economic equality and an absence of major social conflicts.¹³"

(Heroin Offenses, Trends 1999-2004) "Over the same five-year period, the number of 'reports' and/or the proportion of drug law offences involving heroin decreased in the majority of reporting countries, except Belgium, Austria, Slovenia and Sweden, which reported upward trends in the number of 'reports' involving heroin and/or the proportion of drug offences that involved heroin.
"The opposite trend can be observed for cocaine-related offences: in terms of both number of 'reports' and the proportion of all drug offences, cocaine-related offences have increased since 1999 in most reporting countries. Bulgaria is the only country to report a downward trend in cocaine offences (both numbers and proportions of drug offences)."

(Cocaine Smuggling Routes and Transshipment Countries) "Increasing amounts of Latin American cocaine are now also being sent to Europe (see Figure 2.2). Most consignments are smuggled in container vessels and dispatched directly to ports in Spain (Barcelona), Portugal (Lisbon), the Netherlands (Rotterdam), and Belgium (Antwerp).⁹ The growing emphasis on Europe reflects higher street prices than those in the United States¹⁰ (see Table 2.4) and shifting consumer demand patterns toward this particular narcotic (and derivates, such as crack).¹¹ Based on prevalence rates in 2008, the United States accounted for roughly 44 percent of global cocaine consumption, Europe 25 percent. In the latter case, the UK constitutes the largest cocaine market on the continent in absolute terms, with usage among the general population standing at 1.2 million in 2009.¹²
"The more-common route, however, runs via hubs in West Africa, especially Sierra Leone, Guinea-Bissau, Guinea, Ghana, Mali, and Senegal (see Figure 2.3). All of these countries have weak judicial institutions, lack the resources for effective (or, indeed, even rudimentary) coastal surveillance, and are beset by endemic corruption—making them ideal transshipment hubs for moving narcotics out of Latin America.¹³ According to U.S. officials, between 25 and 35 percent of all Andean cocaine consumed in Europe arrives from one of these states.¹⁴ A 2008 report by UNODC similarly estimated that at least 50 tons of Colombian drugs pass through West Africa every year, with cocaine seizures doubling annually from 1.32 tons in 2005 to 3.16 tons in 2006 to 6.46 tons in 2007.¹⁵ In the words of Antonio María Costa, the former executive director of UNODC, the illicit trade has become so endemic that it has now effectively turned “the Gold Coast into the Coke Coast.”¹⁶"

(Consequences of Cocaine Transshipping in Guinea-Bissau) "Demand for cocaine in Europe, combined with the stepping up of policing in the Caribbean has simply shifted transit routes to West Africa – the balloon effect. Guinea Bissau, already with weak governance, endemic poverty and negligible police infrastructure, has been particularly affected - with serious consequences for one of the most underdeveloped countries on Earth.
"In 2006, the entire GDP of Guinea-Bissau was only US$304 million, the equivalent of six tons of cocaine sold in Europe at the wholesale level. UNODC estimates approximately 40 tons of the cocaine consumed in Europe passes through West Africa. The disparity in wealth between trafficking organisations and authorities has facilitated infiltration and bribery of the little state infrastructure that exists. Investigations show extensive involvement of police, military , government ministers and the presidential family in the cocaine trade, the arrival of which has also triggered cocaine and crack misuse.⁽¹⁶⁾
"The war on drugs has turned Guinea Bissau from a fragile state into a narco-state in just five years."

(Sources of Heroin) "Two forms of imported heroin have historically been available in Europe: the more common of these is brown heroin (its chemical base form), originating mainly from Afghanistan. Less common is white heroin (a salt form), which traditionally came from south-east Asia. Although white heroin has become rare, some countries have recently reported white crystalline heroin products probably originating from south-west Asia. Some limited production of opioid drugs also still takes place in Europe, principally home-made poppy products (e.g. poppy straw, concentrate from crushed poppy stalks or heads) reported in Estonia, Lithuania and Poland."

(Problem Drug Use) "Drug use is associated, both directly and indirectly with a range of negative health and social consequences. Problems are disproportionately found among long-term users of opioids, some forms of stimulants and among those who inject. The use of opioid drugs in particular is associated with drug overdose deaths, and the scale of this problem is illustrated by the fact that, over the last decade, Europe has experienced about one overdose death every hour. However, it is also important to remember that chronic drug users are also at a far greater risk of dying from other causes, including organic diseases, suicide, accidents and trauma. Regardless of the substance used, drug injecting continues to be an important vector for the transmission of infectious diseases, including HIV and hepatitis C, with new HIV outbreaks recently experienced by some European countries underlining the importance of maintaining effective public health responses in this area."

(Problem Opioid Use, 1995-2004) "Reports from some countries, supported by other indicator data, suggest that problem opioid use continued to increase during the latter half of the 1990s (Figure 9) but appears to have stabilised or declined somewhat in more recent years. Repeated estimates on problem opioid use for the period between 2000 and 2004 are available from seven countries (the Czech Republic, Germany, Greece, Spain, Ireland, Italy, Austria): four countries (the Czech Republic, Germany, Greece, Spain) have recorded a decrease in problem opioid use, while one reported an increase (Austria -- although this is difficult to interpret as the data collection system changed during this period). Evidence from people entering treatment for the first time suggests that the incidence of problem opioid use may in general be slowly declining; therefore in the near future a decline in prevalence is to be expected."

(HIV Related to Injection Drug Use) "Data on reported newly diagnosed cases related to injecting drug use for 2010 suggest that, overall, infection rates are still falling in the European Union, following a peak in 2001–02. Of the five countries reporting the highest rates of newly diagnosed infections among injecting drug users between 2005 and 2010, Spain and Portugal continued their downward trend, while, among the others, only Latvia reported a small increase (Figure 17) (108).
"These data are positive, but they must be viewed in the knowledge that potential for new HIV outbreaks among injectors continues to exist in some countries. Taking a two-year perspective (between 2008 and 2010), increases were observed in Estonia, from 26.8 cases per million to 46.3 per million, and in Lithuania, from 12.5 cases per million to 31.8 per million. Bulgaria, a country with, historically, a very low rate of infection, also saw a peak of 9.7 per million in 2009, before falling back to 7.4 per million in 2010."

(Prevalence of HIV Among IDUs) "Prevalence data from samples of drug injectors are available for 25 European countries over the period 2005–10 (109), and although sampling differences mean this information needs to be carefully interpreted, it does provide a complementary data source. In 17 of these countries, HIV prevalence estimates remained unchanged. In seven (Germany, Spain, Italy, Latvia, Poland, Portugal, Norway), HIV prevalence data showed a decrease. Only one country (Bulgaria) reported increasing HIV prevalence: in the capital city, Sofia, consistent with the increase in cases of newly diagnosed infections. The increases in HIV transmission in Greece and Romania reported in 2011 were not observed in HIV prevalence or case reporting data before 2011. Possible further indications of ongoing HIV transmission were observed among small samples of young injecting drug users (aged under 25) in six countries: prevalence levels above 5 % were recorded in Estonia, France, Latvia, Lithuania and Poland, and increasing prevalence in Bulgaria, over the period 2005–10."

(Prevalence of HIV/AIDS) "In the EU/EEA [European Union/European Economic Area], 28,038 HIV infections were diagnosed in 2011 and reported by 29 EU/EEA countries, a rate of 6.3 per 100,000 population when adjusted for reporting delay [1]. The overall rate for men was 8.7 per 100,000 population and 2.8 per 100,000 population for women. The highest rates (per 100,000 population) were observed in Estonia (27.3), Latvia (13.4), Belgium (10.7) and the United Kingdom (10.0). The lowest rates were reported by the Czech Republic (1.5) and Slovakia (0.9). Some 11% of HIV infections were reported among young people aged 15–24 years and 25% were female. The overall male-to-female ratio was 3.0 and highest in Slovakia (15.3), Hungary (11.1), Czech Republic (10.8) and Slovenia (6.9) (Figure 1)."

(New HIV Diagnoses by Method of Transmission) "Men who have sex with men (MSM) accounted for 39% of new HIV diagnoses (n=10,885) in 2011 in the EU/EEA (38% in 2010 ^[2]; 35% in 2009 ^[3]). MSM accounted for more than 50% of the cases in nine countries and more than 30% in another eight countries. Heterosexual transmission accounted for 36% of the HIV infections (n=10,118): more than a third of those cases originated from sub-Saharan Africa countries with a generalised HIV epidemic. More than half of the heterosexually acquired HIV infections in Belgium, Sweden, United Kingdom, Ireland and Norway were reported in persons originating from sub-Saharan Africa. There were 4,384 HIV cases (16%) reported in persons from sub-Saharan Africa in total: they were over-represented in the following transmission modes, as shown in the Table: heterosexual contacts (37%) and mother-to-child transmission (46%). Only 5% (n=1,516) of HIV diagnoses were reported in injecting drug users (IDU). Injecting drug use as predominant mode of transmission was reported in only two countries: Lithuania and Iceland. IDU accounted for 25% or more of the cases in Bulgaria, Greece, Latvia and Romania. Of the remaining 297 cases with reported transmission mode, 222 (1%) were classified as due to mother-to-child transmission and 75 (0.3%) due to transfusion of blood or its products and nosocomial transmission."

(Prevalence and Trends in IDU-Related Hepatitis C) "Viral hepatitis, in particular infection caused by the hepatitis C virus (HCV), is highly prevalent in injecting drug users across Europe (Figure 18). HCV antibody levels among national samples of injecting drug users in 2009–10 varied from 14% to 70%, with seven of the 11 countries with national data (Greece, Italy, Cyprus, Austria, Portugal, Finland, Norway), reporting prevalence over 40% ⁽¹¹¹⁾, a level that may indicate that injecting risks are sufficient for HIV transmission (Vickerman et al., 2010). HCV antibody prevalence levels of over 40 % were also reported in the most recent national data available for Denmark, Luxembourg and Croatia and in nine other countries providing sub-national data (2005–10). The Czech Republic, Hungary, Slovenia (all national, 2009–10) and Turkey (sub-national, 2008) report HCV prevalence of under 25% (5–24%), although infection rates at this level still constitute a significant public health problem.
"Over 2005–10, declining HCV prevalence in injecting drug users at either national or sub-national level was reported in six countries, while five others observed an increase (Bulgaria, Greece, Cyprus, Austria, Romania). Italy reported a decline at national level between 2005 and 2009 — more recent data are not available — with increases in three of the 21 regions (Abruzzo, Umbria, Valle d’Aosta)."

(Hepatitis C Prevalence Among Young Injectors) "Studies on young injectors (under 25) suggest a decline in prevalence of HCV at sub-national level in Slovakia, which may indicate falling transmission rates. Increases among young injecting drug users were reported in Bulgaria, Greece, Cyprus and Austria, although sample sizes in Greece, Cyprus and Austria were small. Increasing HCV prevalence among new injecting drug users (injecting for less than two years) was reported in Greece (nationally and in one region) ⁽¹¹²⁾. These studies, while difficult to interpret for methodological reasons, do illustrate that many injectors continue to contract the virus early in their injecting career, suggesting that the time window for initiating HCV prevention measures may often be small."

(Drug Users and Homelessness) "Getting homeless problem drug users into stable accommodation is the first step towards stabilisation and rehabilitation. Based on the estimated numbers of problem drug users and the proportion of homeless people among clients in treatment, there are approximately 75,600 to 123,300 homeless problem drug users in Europe. As facilities are currently available in most countries, and as some countries continue to implement new structures, the effect of these measures will depend on ensuring that homeless problem drug users can access these services."

(Homelessness and Drug Use) "Abstaining from or reducing drug use, engaging with and completing education, as well as securing and sustaining employment can all be great challenges if an individual has no access to supportive structures such as stable accommodation. Eight per cent of all outpatient clients in the EU starting a new treatment episode in 2009 were living in unstable accommodation (see Figure 1 on p. 45). This ranged from 2 % in Estonia to 20 % in France, 21 % in the Czech Republic and 33 % in Luxembourg. Within this population of drug users there are those subgroups that may be vulnerable or face additional barriers obtaining appropriate accommodation, such as women and young people, or those with enduring mental health problems (Shaw and McVeigh, 2008). There are many reasons why drug users may develop severe accommodation needs (whether they are defined as homeless or inappropriately accommodated), or why homeless people may start using drugs, and such progressions are rarely due to a single factor alone (Pleace, 2008). Typical reasons for homelessness may include a combination of mental health problems, unemployment, financial difficulties, criminal behaviour, relationship problems, family breakdown and difficulties in progressing into independent living after release from an institution (e.g. prison) (UKDPC, 2008a). Conversely, high-risk behaviours such as injecting drug use are reported to be prevalent among homeless people (EMCDDA, 2003a)."

(Health Impact of Opiate Use) "The first and most direct impact of opiates is on health, including heroin-related deaths. Opiates (including synthetics) account for 35% to almost 100% of all drug-related deaths in the 22 European countries that have provided data, and over 85% in 11 of those countries.⁶⁹ In addition, heroin abuse by injection contributes to high rates of serious diseases such as hepatitis B, hepatitis C and HIV.⁷⁰ The HIV epidemic among injecting drug users continues to develop at varying rates across Europe. In the countries of the European Union, the rates of reported newly diagnosed cases of HIV infection among injecting drug users are mostly at stable and low levels, or in decline. However, in post-soviet European countries such as Ukraine, Belarus and the Republic of Moldova, those rates increased in 2007."

(Initiation of Drug Use While In Prison) "Imprisonment forces some drug users to stop using drugs, and some will see this as an opportunity to improve their lives. For others, however, prison may be a setting for initiation into drug use or for switching from one drug to another, often due to lack of availability of the preferred drug inside prison (Fazel et al., 2006; Stöver and Weilandt, 2007) and other possible reasons (e.g. use of substances for which avoiding control measures is easier). Sometimes, this change leads to more harmful patterns of drug use (Niveau and Ritter, 2008). For example, a Belgian study carried out in 2008 found that more than one-third of drug-using prisoners had started to use an additional drug during detention, one that they were not using before entering prison, with heroin being the drug most frequently mentioned (Todts et al., 2008)."

(Drug Use in Prison) "Studies carried out in 15 European countries since 2000 estimated that between 2% and 56% of prisoners have ever used any type of drug while incarcerated, with nine countries reporting levels in the range 20–40% (3). The drug most frequently used by prisoners is cannabis, followed by cocaine and heroin. Estimates of heroin use while in prison ranged from 1% to 21% of prisoners ⁽⁴⁾. The wide variation in prevalence levels between countries may reflect methodological differences in data collection and reporting. Factors such as price and availability will influence the substances used within prison, but studies suggest a tendency towards the use of depressant-type drugs such as heroin, hypnotics and sedatives or drugs with depressant effects such as cannabis. Stimulant drugs may be less popular, as the effects can be more difficult to manage, for both prisoners and prison staff, within the confined prison setting (Bullock, 2003)."

(Drug Users in Prison) "Cannabis is the illicit drug with the highest reported level of lifetime prevalence among prisoners, with between 12% and 70% having tried it at some time in their lives. This reflects drug use experience in the general population, although the levels there are lower (1.6% to 33% among 15- to 64-year-olds). Levels of use of cocaine, Europe’s second most commonly reported illicit drug, both inside and outside prison, are also much higher among prisoners (lifetime prevalence of 6–53%) than among the general population (0.3–10%). Experience of amphetamines among prisoners ranges from 1% to 45%, whereas among the general population the range is from almost zero to 12%. Data on lifetime misuse of other substances (such as volatile substances, hypnotics and sedatives) are limited, and prevalence levels, among both prisoners and the general population, are usually low (EMCDDA, 2012).
"Prisoners differ greatly from the general population in their reported experience of heroin. Whereas less than 1% of the general population have ever used heroin, lifetime prevalence levels among European prisoners are much higher, with eight of the 13 countries that were able to provide information on heroin use reporting levels between 15% and 39%."

(Spending on Treatment) "In terms of unit costs (per person per day) across treatment modalities, there are clear differences between the treatment types. The highest unit costs are reported for inpatient modalities. The unit cost of inpatient psychosocial treatment is estimated to range from EUR 59 to EUR 404 per patient per day, with Sweden reporting the highest unit cost for this treatment. Detoxification carried out in inpatient settings is reported to cost between EUR 110 and EUR 303, with both the highest and the lowest estimates referring to treatment centres in the United Kingdom. Oral substitution treatment with methadone is reported to cost the least of the other treatment modalities, its unit cost ranging EUR 2 to about EUR 37 per patient per day, with the highest cost estimated in Norway. Although the unit costs of opioid substitution treatment are lower than those of the three other treatment modalities, due to the widespread use of this modality, the overall annual expenditure of reporting countries on opioid substitution treatment is higher than their annual expenditure for other treatment types."

(Availability of Substitution Treatment) "Substitution treatment is the predominant treatment option for opioid users in Europe. It is generally provided in specialist outpatient settings, though in some countries it is also available in inpatient settings, and is increasingly provided in prisons⁽²⁰⁾. In addition, office-based general practitioners, often in shared-care arrangements with specialist centres, increasingly play a role. Opioid substitution is available in all EU Member States and in Croatia, Turkey and Norway⁽²¹⁾. Overall, it is estimated that there were about 710 000 substitution treatments in Europe in 2010. Compared with 2009, the number of clients in substitution treatment increased in most countries, though Spain and Slovakia report small decreases⁽²²⁾."

(Availability of Psychosocial Treatment) "In a 2010 survey, national experts reported outpatient psychosocial treatment in Europe to be available to nearly all who seek it in 14 countries, and to the majority of those who seek it in 11 countries. In three countries (Bulgaria, Estonia, Romania) however, outpatient psychosocial treatment is estimated to be available to fewer than half of those who actively seek it. These ratings may hide considerable variation within countries and differences in the availability of specialised treatment programmes for specific target groups, such as older drug users or ethnic minorities. Some countries report difficulties in providing specialised services at a time of economic recession and budgetary cuts."

(Types of Opiate Substitution Treatment Available) "In Europe, methadone is the most commonly prescribed opioid substitute, received by up to three quarters of substitution clients. Buprenorphine-based substitution medications are prescribed to up to a quarter of European substitution clients, and are the principal substitution medications in the Czech Republic, Greece, France, Cyprus, Finland and Sweden (103). The combination buprenorphine-naloxone is available in 15 countries. Treatments with slow-release morphine (Bulgaria, Austria, Slovenia), codeine (Germany, Cyprus) and diacetylmorphine (Belgium, Denmark, Germany, Spain, Netherlands, United Kingdom) represent a small proportion of all treatments."

(Opioid Substitution Treatment) "Substitution treatment is the predominant treatment option for opioid users in Europe. It is generally provided in specialist outpatient settings, though in some countries it is also available in inpatient settings, and is increasingly provided in prisons ⁽²⁰⁾. In addition, office-based general practitioners, often in shared-care arrangements with specialist centres, increasingly play a role. Opioid substitution is available in all EU Member States and in Croatia, Turkey and Norway ⁽²¹⁾. Overall, it is estimated that there were about 710 000 substitution treatments in Europe in 2010. Compared with 2009, the number of clients in substitution treatment increased in most countries, though Spain and Slovakia report small decreases ⁽²²⁾."

(Increasing Availability of Opioid Substitution Treatment) "The most common type of treatment for opioid dependence in Europe is substitution treatment, typically integrated with psychosocial care and provided at specialist outpatient centres. Sixteen countries report that it is also provided by general practitioners. In some countries, general practitioners provide this treatment in a shared-care arrangement with specialist treatment centres. The total number of opioid users receiving substitution treatment in the European Union, Croatia, Turkey and Norway is estimated at 709,000 (698 000 for EU Member States) in 2010, up from 650,000 in 2008, and about half a million in 2003⁽¹⁰¹⁾. The vast majority of substitution treatments continue to be provided in the 15 pre‐2004 EU Member States (about 95% of the total), and medium-term trends (2003–10) show continuous increases (Figure 14). The greatest increases in provision among these countries were observed in Greece, Austria and Finland, where treatment numbers almost tripled.
"An even higher rate of increase was observed in the 12 countries that have joined the European Union since 2004. In these countries, the number of substitution clients rose from 7,800 in 2003 to 20,400 in 2010, with much of the increase occurring after 2005. Proportionally, the expansion of substitution treatment in these countries over the seven-year period was highest in Estonia (sixteenfold from 60 to over 1,000 clients, though still reaching only 5% of opioid injectors) and Bulgaria (eightfold). The smallest increases were reported in Lithuania, Hungary and Slovakia.
"A comparison of the estimated number of problem opioid users with the number of clients in substitution treatment suggests varying coverage levels in Europe. Of the 18 countries for which reliable estimates of the number of problem opioid users are available, nine report a number of clients in substitution treatment corresponding to about 50% or more of the target population⁽¹⁰²⁾. Six of those countries are pre‐2004 EU Member States, and the remaining countries are the Czech Republic, Malta and Norway."

(Availability of Heroin-Assisted Treatment) "A number of European countries have remained at the forefront of innovation with regards to OST and drug dependence therapies. For those who cannot or do not wish to stop injecting, a small number of European countries prescribe injectable OST medicines (including the Netherlands, Switzerland and the United Kingdom) (Cook and Kanaef, 2008). The prescription of pharmaceutical heroin (diacetylmorphine) remains limited to a few European countries (Fischer et al., 2007; EMCDDA, 2009a, Table HSR-1). Despite positive findings from randomised controlled trials in several countries (indicating that diacetylmorphine is effective, safe, and cost-effective, and can reduce drug-related crime and improve patient health), only Denmark, Germany, the Netherlands, Switzerland and the United Kingdom include this intervention as part of the national response to drugs. Pilot programmes are currently underway in Belgium and Luxembourg (EMCDDA, 2009a, Table HSR-1)."

(Availability of Specialized Treatment Services) "Treatment units or programmes that exclusively service one specified target group are a common phenomenon across the EU. Children and young people under the age of 18 are treated in specialised agencies in 23 countries; the treatment of drug users with psychiatric co-morbidity takes place in specialised agencies in 18 countries; and women-specific services are reported to exist in all countries except Cyprus, Latvia, Lithuania, Bulgaria and Turkey. Services designed to meet the needs of immigrant drug users or of groups with specific language requirements or religious or cultural backgrounds are less common but have been reported from Belgium, Germany, Greece, Spain, Lithuania, the Netherlands, Finland, Sweden and the United Kingdom."

(Cost of Opioid Substitution Treatment) "From published studies, it is possible to extract additional data on unit costs. In England, a research study, based on 401 clients from seven clinics specialising in substitution treatment, estimated the range of costs of ‘treatment as usual’ (Raistrick et al., 2007). The average total cost of treatment per patient per day was EUR 3 (EUR 3, price year 2007), excluding the cost of prescribed drugs, and EUR 6 (EUR 5, price year 2007) including prescribed drugs. The study found that among the key factors influencing treatment costs across agencies were the complexity of the case mix, the amount of drugs prescribed, and the gender mix. In England, methadone maintenance was estimated to cost between EUR 2 (EUR 2, price year 2007) and EUR 24 (EUR 22, price year 2007) per patient per day in the 15 programmes studied (Curtis, 2008), while the DTORS research team, reported specialist prescribing at EUR 18 (EUR 17, price year 2006/07) per patient per day (Davies et al., 2009).
"In Spain, Martinez-Raga et al. (2009) reported estimates of EUR 4 (EUR 4, price year 2004) per patient per day in methadone maintenance treatment and EUR 5 (EUR 5, price year 2004) per patient per day in buprenorphine maintenance treatment. As these estimates exclude medication costs, they are not full unit costs. In Lithuania, (3) Vanagas et al. (2010), based on 102 treatment clients, estimated the cost of methadone maintenance treatment at EUR 4 per patient per day (2004 prices, no CPI identified).
"In Germany, the unit cost of oral methadone maintenance treatment (3) was estimated at EUR 10 (EUR 9, price year 2006) per client per day or EUR 3 490 (EUR 3 314, price year 2006) for the 12 month trial period, of which the cost of methadone accounted for about 12 % (von der Schulenburg and Claes, 2006). An estimate for Norway puts the average cost of methadone substitution treatment in that country at EUR 37 (EUR 32, price year 2001) per patient per day (Melberg et al., 2003).
"The unit cost estimates for opioid substitution treatment with methadone reviewed here range from EUR 2 to EUR 37 per patient per day. This variation may reflect differences in one or more of several possible factors: national and regional drug situations and treatment systems, the case mix of patients, year of data collection, and inclusion of medication cost."

(Availability of Opiate Treatment) "Both drug-free and substitution treatments for opioid users are available in all EU Member States, Croatia, Turkey and Norway. In most countries, treatment is conducted in outpatient settings, which can include specialised centres, general practitioners’ surgeries and low-threshold facilities. In a few countries, residential treatment plays an important role in the treatment of opioid dependence⁽¹⁰⁰⁾. A small number of countries offer heroin-assisted treatment for a selected group of chronic heroin users."

(Effectiveness of Safe Consumption Rooms) "A more controversial approach has been adopted in some cities in Europe, where the concept of safe consumption rooms, usually targeting drug injection, has been extended to drug inhalation. Rooms for supervised inhalation have been opened in several Dutch, German and Swiss cities (EMCDDA, 2004c). Although the supervision of consumption hygiene is a main objective of such services, there is some evidence that they could also act as a conduit to other care options; for example, monitoring of one service in Frankfurt, Germany, reported that, during a six-month evaluation period in 2004, more than 1 400 consumptions were supervised, while 332 contact talks, 40 counselling sessions and 99 referrals to other drugs services were documented."

(Safe Smoking Devices) "Provision of specific harm-reduction programmes for crack cocaine smokers in Europe is limited. Some drug consumption facilities in three countries (Germany, Spain,
Netherlands) provide facilities for inhalation of drugs, including crack cocaine. Hygienic inhalation devices
including clean crack pipes or ‘crack kits’ (glass stem with mouth piece, metal screen, lip balm and hand wipes)
are reported to be sporadically provided to drug users who are smoking crack cocaine by some low-threshold facilities in Belgium, Germany, Spain, France, Luxembourg and the Netherlands. Foil is also made available to heroin or cocaine smokers at some low-threshold facilities in 13 EU Member States. In the United Kingdom, the
Advisory Council on the Misuse of Drugs recently reviewed the use of foil as a harm-reduction intervention, finding evidence that its provision may promote smoking over injecting use (ACMD, 2010)."

(Supervised Injection Facilities) "Highly targeted interventions, such as supervised injecting facilities, reach specific subgroups of highly marginalised drug users and contribute to reducing morbidity and mortality. In Denmark, a mobile injection room, providing a safer injecting environment and medical supervision was established in Copenhagen in 2011 by a private organisation (131). Similar to the supervised drug consumption facilities in Germany, Spain, Luxembourg, the Netherlands and Norway, the new facility in Denmark is equipped to reduce the impact of non-fatal overdoses."

(Availability of Syringe Exchange) "In Europe, the availability and coverage of needle and syringe programmes are increasing: of the 30 countries responding to a survey in 2011, 26 indicate needle and syringe programmes as a priority, compared with 23 countries in 2008. In Sweden, where syringe exchange programmes have been operational since 1986, but limited to Skåne County, a new programme in Stockholm was scheduled to open in 2011. Overall, while experts consider current levels of syringe provision as meeting the needs of the majority of injecting drug users in two thirds of European countries, national experts in five countries indicated that free, sterile syringes and other clean drug injection equipment would be available only to a minority of injecting drug users. Nonetheless, during the period 2008–11, the number of countries reporting full or extensive coverage of needle and syringe programmes increased by a third, from 15 to 20."

(Syringe Availability Through Pharmacies) "The purchase of syringes through pharmacies may be a major source of contact with the health service for some injectors, and the potential to exploit this contact point as a conduit to other services clearly exists. Work to motivate and support pharmacists to develop the services they offer to drug users could form an important part of extending the role of pharmacies, but to date only France, Portugal and the United Kingdom appear to be making significant investments in this direction."

(Syringe Exchange Through Pharmacies) "Formally organised pharmacy syringe exchange or distribution networks exist in nine European countries (Belgium, Denmark, Germany, Spain, France, the Netherlands, Portugal, Slovenia and the United Kingdom), although participation in the schemes varies considerably, from nearly half of pharmacies (45%) in Portugal to less than 1% in Belgium. In Northern Ireland, needle and syringe exchange is currently organised exclusively through pharmacies."

(Pharmacy-Based Syringe Exchange) "Pharmacy-based exchange schemes also help to extend the geographical coverage of the provision and, in addition, the sale of clean syringes in pharmacies may increase their availability. The sale of syringes without prescription is permitted in all EU countries except Sweden, although some pharmacists are unwilling to do so and some will even actively discourage drug users from patronising their premises."

(Naloxone and Overdose Prevention in the EU) "In 2011, two thirds of European countries reported that ambulance personnel are trained in naloxone use; in just over half of these countries, naloxone is reported to be one of the standard medications carried in ambulances. Only Italy, Romania and the United Kingdom report the existence of community-based harm-reduction programmes that provide take-home naloxone to opioid users, their family members and carers. Legal barriers remain in place in other European countries, including Estonia, which has the highest drug-related mortality rate among adults (15–64) in the European Union. However, it was demonstrated in the United Kingdom that, with minimal training, healthcare professionals, including drug workers, can increase their knowledge, skills and confidence for managing an opioid overdose and administering naloxone (Mayet at al., 2011)."

(Drug-Related Public Expenditures in the EU) "Public expenditure on all aspects of the drugs phenomenon in Europe was estimated at EUR 34 billion⁽⁸⁾ in 2005 (EMCDDA, 2008d). This figure includes ‘labelled’ expenditure, which is planned by government for tasks related to drugs and identified as such in the budget. Labelled expenditure is traced in official accountancy documents. The greater part of drug-related public expenditure is, however, ‘unlabelled’ — that is, not identified as such in the national budget. Unlabelled expenditure must be estimated by a cost-modelling approach.
"Data for different years are only available for labelled expenditures. In 2008, 22 EU Member States reported a total labelled expenditure on the drugs problem of EUR 4.2 billion. For the 16 countries that reported in both 2005 and 2008, total labelled public expenditure rose from EUR 2.10 billion to EUR 2.25 billion. As a proportion of gross domestic product, total labelled expenditure decreased in nine countries, increased in six countries and remained unchanged in one country⁽⁸⁾.
"Public expenditure related to drugs can be classified according to the international classification of the functions of government (COFOG) system. Of the total labelled expenditure categorised by seven reporting countries (EUR 1.82 billion), most came within two government functions: health (60 %) and public order and safety (34 %) (that is, police services, law courts, prisons). This imbalance can be explained by the fact that expenditure on public order and safety tends to be embedded in broader and more general programmes of action against crime (unlabelled expenditure) (EMCDDA, 2008d)."

(Drug Control Spending Cuts) "In recent years, decreases in drug-related public expenditure have been identified in six countries. In the United Kingdom, a reduction of 5% in labelled public expenditure in 2010/11 in England (5) compared with the previous year was not offset by small increases in labelled expenditure in Northern Ireland, Scotland and Wales. In 2010, labelled expenditure in Estonia fell by 3% compared with 2009, but by 54 % compared with 2008; in Ireland, labelled expenditure fell by 3 % compared with the previous year. In Hungary, a mid-year revision of the 2010 budget saw the funding for labelled activities reduced by 25%. In Croatia, available data point to a 10% cut in labelled drug-related public expenditure in the 2010 budget compared with 2009. In the Czech Republic, despite better data coverage suggesting increasing expenditure in 2010, detailed analysis shows less funding available for treatment and harm reduction. For another four countries, there are no signs of budgetary cuts in the most recent estimates of drug-related expenditure. In Belgium, total drug-related public expenditure increased by 18.5% between 2004 and 2008 (before the recession). In Sweden, total drug-related public expenditure in 2011 increased substantially compared with 2007. In Luxembourg, in 2010, there was an annual increase of 5.6% in total drug-related expenditure. In Finland, in 2009, total drug-related public expenditure increased by 1.6%.
"Studies carried out up to now suggest the existence of considerable variation between countries in terms of the nature and severity of the impact of the economic crisis on their drug-related budgets and expenditure."

Laws and Policies

"The current EU drugs strategy (2005–12) is the first to be submitted to external evaluation. The evaluators found that the strategy has provided added value to the efforts of the Member States in the drugs field and that the promotion of evidence-based interventions in the EU strategy was commended by stakeholders (Rand Europe, 2012). The report highlighted the area of information, research and evaluation, where the EU approach and infrastructures actively support knowledge transfer within Europe. For the next strategy, which will be drafted during 2012, the evaluators recommended maintaining the balanced approach, adopting integrated policy approaches across licit and illicit substances including new psychoactive substances, building up the evidence base in drug supply reduction and clarifying the roles of EU coordination bodies. Given the current political interest in the topic and its clear European dimension, an important issue for the upcoming strategy will be responses to new psychoactive substances."

(Legal Distinctions Between Drugs and Amounts) "In Belgium, Bulgaria, Czech Republic, Spain, Ireland, Italy, Cyprus, Luxembourg, Malta, the Netherlands, Portugal, Romania and the UK, the penalty for a drugs offence officially varies according to the nature of the substance involved. Thus the law in those 13 countries instructs or requests the judicial authorities to distinguish between drugs when prosecuting. Of these 13 countries, in Malta the penalty is only varied for a charge of drug trafficking, whereas in Belgium, Czech Republic, Ireland and Luxembourg it is only different for the offence of possession of (a small amount of) cannabis for personal use.
"In the remaining 14 EU Member States, Croatia and Norway, the law officially does not recognise differences between drugs, and drugs offences may incur the same penalty regardless of the substances involved. However, there is a discrepancy between the formal legal texts and actual practice; the judicial authorities do consider the nature of the substances (as well as the quantity and other determining factors) when sentencing, either using their discretionary power or by applying circulars or directives.

Note: A list of the "Main laws and lists of substances (with examples) can be found at:
http://eldd.emcdda.europa.eu/html.cfm/index5622EN.html.

(EU Drug Strategy) "The EU Drug Strategy has no main priorities specifically focusing on national strategies, laws and public expenditure, however, the cross-cutting theme of coordination does include an objective to: ‘Ensure that a balanced and integrated approach is reflected in national policies and in the EU approach towards third countries and in international fora’. In addition, included under the Strategy’s cross-cutting theme of evaluation, an expected result is: ‘To give clear indications about the merits and shortcoming of current actions and activities on EU level, evaluation should continue to be an integral part of an EU approach to drugs policy’.
"National Drug Strategies In Place
"Over the 2005-2012 period, EU Member States have continued to develop detailed strategies and action plans in the drugs field. As of mid 2011, two more countries have national drug policy documents than was the case in 2005, and it is reasonable to predict that more than 50 separate drug strategies and action plans will have come into force over the eight-year period of the strategy — an average of almost two per country. In terms of content, changes are difficult to assess and might have been relatively limited as the documents are still comprehensive and cover all or most areas of drug policy. On the whole, countries have not extended drug policies into the broader field of addictions, and/or towards the inclusion of licit drugs such as alcohol."

('Global' Scope) "Five countries have adopted strategies or action plans that have a ‘global’ scope, covering licit and illicit drugs and, in some cases, addictive behaviours. The broad approach is reflected in the policy document titles: Belgium’s ‘Comprehensive and integrated policy on drugs’; France’s ‘Governmental plan to fight drugs and drug addiction’; Germany’s ‘National strategy for drug and addiction policy’; Sweden’s ‘Cohesive strategy for alcohol, narcotic drugs, doping and tobacco (ANDT) policy’; and Norway’s ‘Action plan for the drugs and alcohol field’. With the exception of Norway, which has separate tobacco and gambling strategies, there are no separate national strategies for other licit drugs or addictive behaviours in these countries."

(Harm Reduction Measures) "In 2003, the Council of the European Union recommended a number of policies and interventions to the EU Member States to tackle health-related harm associated with drug dependence (26). In a follow-up report in 2007, the Commission of the European Communities confirmed that the prevention and reduction of drug-related harm is a public health objective in all countries (27). National drug policies have been increasingly covering the harm-reduction objectives defined in the EU drugs strategy, and there is now broad agreement among countries on the importance of reducing the spread of infectious diseases and overdose-related morbidity and mortality and other harms.
"During the past two decades, harm-reduction policies have promoted the adoption of evidence-based approaches and helped to remove barriers to service access. One result has been a significant increase in the number of drug users that are in contact with health services and undergoing treatment in Europe. Harm-reduction interventions for drug users now exist in all EU Member States, and while some are just starting to develop services, most can report high levels of provision and coverage."

(Reducing Loss of Life as Policy Priority) "Reducing the loss of life due to drug use is a key policy priority in the majority of European countries, with 16 reporting that it is a focus in their national or regional drug policy documents, or that it is the subject of a specific action plan. In some other European countries, such as Austria and Norway, increases in drug-related deaths observed in previous years have raised awareness of the need for improved responses."

(Alcohol) "When it comes to alcohol policy, it seems that the 15 'old' EU member states have converged to some extent. While alcohol policy has grown weaker in Finland and Sweden, several other countries -- including Southern European ones -- have reinforced their policies, for instance by lowering legal blood-alcohol levels for drivers and introducing stricter age limits for purchasing alcohol in both shops and restaurants."

(Need for Social Reintegration and Services for Drug Users) "Drug use is an important factor that increases the likelihood of concurrent social exclusion (EMCDDA, 2003a). However, there is no clear causality between drug use and social exclusion, as either may lead to the other, and both may be preceded and caused by (unknown) third factors. Many problem drug users already experienced problems in other spheres of life, including social exclusion, prior to their drug use. In this sense, problem drug users can also belong to other vulnerable groups, such as homeless people or people with mental health problems. Likewise, it is important to note that not all drug users are socially excluded (and vice versa).
However, this report focuses on social reintegration of problem drug users, who are at greater risk of social exclusion than non-problem drug users (EMCDDA, 2003a).
"Thus it becomes evident that problem drug users are not a distinct and exclusive population. As a consequence, overlaps exist between social reintegration activities targeted specifically at problem drug users and social reintegration activities for other vulnerable groups. This is reflected in the fact that many social reintegration programmes in the EU target not only problem drug users but a wider population at risk of social exclusion, including, for example, former prisoners and homeless people.
"Finally, European countries have set up a wide range of generic policies and structures that allow their citizens to maintain a minimum standard of life, to strengthen their abilities to be self-dependent and to protect them from the risk of social exclusion. Such generic structures or policies are generally referred to as welfare states. They are expected to provide social security, education and healthcare. European welfare policies generally include a commitment to full employment, social protection for all citizens and social inclusion (see Europe 2020 (1))."

(Homeless and Housing Assistance) "Four countries (16 %; n = 25) reported that the accommodation needs of problem drug users were specifically addressed by actions set out in national social protection and inclusion plans. In Austria the National Action Plan on Social Inclusion (Nationaler Aktionsplan Soziale Eingliederung) states that socially assisted housing should be increasingly provided to drug-dependent people in the future. In the Netherlands, the national government and the municipalities of the four largest cities signed and funded the Strategy Plan for Social Relief (Plan van Aanpak Maatschappelijke Opvang) for those groups with the most complex and persistent needs. In a second phase of the plan, starting in 2010, the remaining 39 municipalities began implementation. In Portugal, the accommodation needs of drug users are addressed through explicit mention of the population in the National Strategy for the Integration of Homeless People.
"Of the 21 (84 %, n = 25) countries reporting that accommodation needs are not specifically addressed, 10 (48 %) stated that drug-using groups are included in plans as part of other targeted populations, most often socially excluded or vulnerable populations. For instance, Denmark, Ireland, Poland, Romania and Sweden address these needs through homelessness strategies. In Germany the Social Service Code guarantees basic social care for all people needing social support including accommodation.
"Six countries (25 %; n = 24) reported that accommodation needs of drug users are explicitly addressed in separate plans that support national employment strategies. These include policies on offender rehabilitation, mental health needs or other disadvantages."

(Prevention Strategies) "Environmental prevention strategies are designed to change the cultural, social, physical and economic environments in which people make their choices about drug use. These strategies typically include measures such as alcohol pricing, and bans on tobacco advertising and smoking where there is good evidence of effectiveness. Other environmental strategies focus on developing protective school environments. Among the examples reported by European countries are: promotion of a positive and supportive learning climate (Poland, Finland); provision of education in citizenship norms and values (France); and making schools safer through the presence of police in the neighbourhood (Portugal).
"It has been argued that a range of social problems, including substance use, teenage pregnancy and violence, are more prevalent in countries with high levels of social and health inequality (Wilkinson and Pickett, 2010). Many Scandinavian countries, such as Finland, invest heavily in broader environmental policies that are geared towards increasing social inclusion at family, school, community and society level and which contribute to, and help maintain, lower levels of drug use. Prevention programmes and interventions targeting specific problems or drugs are less used in these countries."

(Universal Prevention Strategies) "Universal prevention addresses entire populations, predominantly in school and community settings. It aims to reduce substance-related risk behaviour by providing young people with the necessary competences to avoid or delay initiation into substance use. A recent evaluation of the ‘Unplugged’ prevention programme in the Czech Republic found that participating students reported significantly reduced rates of smoking, as well as less frequent smoking, drunkenness, cannabis use, and use of any drug (Gabrhelik et al., 2012). However, there have been recent reports of reductions in the provision of universal prevention in Greece and Spain, and in prevention staffing levels in Latvia, which supports earlier suggestions that prevention is an area affected by budgetary cuts in this period of economic downturn
(EMCDDA, 2011a)."

(Selective Prevention Strategies) "Selective prevention intervenes in specific groups, families or communities who, due to their reduced social ties and resources, may be more likely to develop drug use or progress into dependency. Denmark, Germany, Spain, Austria and Portugal have implemented targeted prevention interventions for pupils in vocational schools, a group of young people identified as being at elevated risk of developing drug use problems. Ireland has taken a broader approach in terms of prevention work with at-risk youth, by working to improve literacy and numeracy among disadvantaged students. Community-level interventions targeting high-risk groups of young people, such as reported by Italy and municipalities in the north of Europe, combine individual and environmental strategies through outreach, youth work, and formal cooperation between local authorities and non-governmental organisations. Such approaches aim to target high-risk youth without recruiting them into specific programmes."

(Integrated Approach to Licit and Illicit Drugs) "The trend towards an integrated approach to substance use appears to exist primarily among the pre-2004 EU Member States. It is these countries that have adopted a global strategy, or that are in the process of integrating their illicit drug and alcohol strategies or that have included many licit drug objectives in their illicit drug strategy. In central and eastern Europe, the picture is mainly one of separate strategies or just illicit drug strategies, with limited mention of licit drugs."

(Definitions) "According to our convention ‘decriminalisation’ comprises removal of a conduct or activity from the sphere of criminal law. Prohibition remains the rule, but sanctions for use (and its preparatory acts) no longer fall within the framework of the criminal law (elimination of the notion of a criminal offence). This may be reflected either by the imposition of sanctions of a different kind (administrative sanctions without the establishment of a police record – even if certain administrative measures are included in the police record in some countries, such as France), or the abolition of all sanctions. Other (non-criminal) laws can then regulate the conduct or activity that has been decriminalised.
"According to our convention ‘depenalisation’ means relaxation of the penal sanction provided for by law. In the case of drugs, and cannabis in particular, depenalisation generally signifies the elimination of custodial penalties. Prohibition remains the rule, but imprisonment is no longer provided for, even if other penal sanctions may be retained (fines, establishment of a police record, or other penal sanctions)."