Overview
The links below give access to the tables in the bulletin and the associated graphics in the section dealing with availability of a number of health and social responses to drug use, including substitution treatment, needle and syringe programmes and other interventions that aim to reduce the negative social and health consequences of drug use in community and prison settings, as well as to a description of the methods and definitions used in compiling these data. A brief overview is provided below. See also the side navigation bar for links to all chapters.
Tables HSR-1, HSR-2 and HSR-3 provide data on the year of introduction of the main opioid substitution treatment drugs, namely methadone buprenorphine, diamorphine (heroin-assisted treatment), slow-release morphine and a combination buprenorphine/naloxone. They further provide information on the legal frameworks and practices of substitution treatment initiation and continuation in each country and, finally, information on the estimated number of clients receiving methadone and other opioid substitution treatment in years 2003, 2005 and 2007
Tables HSR-4 and HSR-5 provide information on needle and syringe programmes (NSPs). Table HSR-4 shows the year of introduction of NSPs in the countries, the settings in which those are implemented and indicate which outreach syringe provision models are in use in 2007.
Table HSR-5 on syringe provision gives information on the overall number of syringes provided in 2003, 2005 and 2007 through fixed and mobile NSP points in the community and in prisons: at specialist drugs or medical agencies, including through outreach work and peer-distribution, through vending machines and pharmacy-based NSP points.
Table HSR-5 part (ii) of the table provides information on the number of syringes provided through specialist drugs or medical agencies with NSPs in the community, as well as the number of individual clients and client contacts at these agencies. Data from prison NSPs, pharmacy-based programmes and vending machines not included.
Tables HSR-6, HSR-7 and HSR-8 are based on information collected through a Structured Questionnaire on 'prevention and reduction of health-related harm associated with drug use' (SQ23/29), submitted by NFPs in 2008.
Table HSR-6 provides information about priority responses to prevent infectious diseases among drug users, according to national policies, based on the selection of three priorities from a multiple choice list with 8 closed and 3 open answer categories.
Table HSR-7 provides expert ratings on the availability and level of provision of a number of selected interventions aimed at preventing infectious diseases and reducing overdose risks among prisoners.
Table HSR-8 provides expert ratings on the level of provision to problem drug users of a number of interventions aiming at the reduction of drug related deaths (part i) and indicates for which target groups specific information material on drug-related deaths and emergencies have been elaborated.
Retrospective information updates on programmes for syringe provision and on methadone substitution published in the previous Statistical bulletin were made if new information became available.
Figure HSR-1. Number of opioid maintenance treatment clients as a percentage of the estimated number of problem opioid users, 2007. The figure provides the percentage of problem opioid users receiving opioid substitution treatment for those ten countries where recent estimates of the total number of opioid users and clients in substitution treatment were available.
Figure HSR-2. Provision of substitution/maintenance treatment in the community and availability in the prison system in 2007. The figure provides a graphic visualisation of EU expert ratings on the existence of opioid substitution treatment in detention centres and the provision to drug users in the community.
Summary points
Access to substitution treatment
- Table HSR-1. Year of introduction of substitution treatment with methadone maintenance treatment (MMT), high-dosage buprenorphine treatment (HDBT), heroin-assisted treatment, slow-release morphine and a combination buprenorphine/naloxone provides information on the year in which opioid substitution treatments were introduced in the EU Member States, Croatia and Norway.
Methadone was pioneered in Europe by Sweden, the Netherlands, the UK and Denmark in the late 1960s and the beginning of the 1970s, but only in the mid-1980s, an acceleration of the rate at which it became an official treatment modality in other European countries, could be noted. High-dosage buprenorphine treatment, which became available in the first European country in 1996, has been introduced more quickly and is now available in most EU countries. Diamorphine as an option in the treatment of opioid dependence is available in the UK since the 1920s, since 2007 in the Netherlands and since 2008 also in Denmark and Germany. Trials have been conducted in Spain and Belgium. Slow-release morphine is a legal drug used in substitution treatment only in 8 countries (Bulgaria, France, Italy, Luxembourg, Netherlands, Slovenia, Slovakia and the UK) where it has been introduced during the last five years, apart Austria where it was available since the late 1990s. A combination buprenorphine/naloxone has been very recently introduced in the majority of the EU Member States.
- Table HSR-2. Legal framework and practice of substitution treatment initiation and continuation in 2007. The table shows who is legally allowed to initiate and continue opioid substitution treatment and by whom such treatment is predominantly provided in each country, with a particular attention to the involvement of medical doctors, an increasingly important player in the provision of substitution treatment in Europe.
This table is based on data collected through Structured Questionnaire on 'treatment programmes’ (SQ27P1), Standard Table (ST) 24 on access to treatment as well as through legal correspondents. It shows who is allowed to initiate and/or continue the prescription of opioid substitution drugs (methadone and buprenorphine) and on the basis of which law or guideline. Three service providers are presented, namely office-based medical doctors, specialised office-based medical doctors, and doctors working at treatment centres — the latter being allowed to start and continue methadone treatment of opioid users in all European countries, Croatia and Norway. It should be noted that a distinction between specialised office-based medical doctors and office-based MDs was made, since some countries require medical doctors to be specialised in substance misuse or to undergo a special training in substitution treatment delivery in order to be allowed to initiate this type of treatment. Finally, Table HSR-2 also presents which service provider is the main player with regard to substitution treatment initiation and continuation in each country.
- Table HSR-3. Estimated number of clients in methadone treatment and of clients receiving any opioid substitution in the EU-27, Croatia, Turkey and Norway, 2003, 2005 and 2007.
This table shows the estimated number of clients reported to receive opioid substitution treatment and specifically methadone maintenance treatment in the years 2003, 2005 and 2007 for 27 EU Member States, Croatia and Norway. As far as possible, treatment in prison and detoxification treatment is not included. It specifies the total number of substitution clients and the number of those receiving methadone treatment in each year. The total number of clients receiving substitution treatment in the EU, Croatia and Norway in 2007 is estimated to be around 600 000, up from 570 000 in 2005 and 500 000 in 2003.
The available data on the number of clients in substitution treatment suggest an increase in all countries, except for Spain, where a decline that had started already in 2002 has continued, and for the Netherlands, Luxembourg, Hungary and France where the situation remained nearly stable. The most rapid scale-ups of such treatments were seen in Estonia, where numbers in substitution treatment increased from 60 to more than 1 000 clients within five years, and in Bulgaria where in 2007 nearly 3 000 treatment places are available, compared to just 380 in 2003. The number of clients in substitution treatment has more than doubled over this period in Latvia, in the Czech Republic, Norway, and Finland. Increases in excess of 40 % were reported by Poland, Greece, Romania, Sweden and Portugal.
The third part of table HSR-3 provides additional information on the provision of substitution treatment in 2007 in 27 EU Member States, Croatia and Norway, namely the estimates and share of clients in methadone and high-dosage buprenorphine treatment, according to the revised and updated versions of the treatment data collection tools which were introduced in 2008.
- Figure HSR-1. Number of opioid maintenance treatment clients as a percentage of the estimated number of problem opioid users, 2007.
This figure presents the percentage of problem opioid users receiving opioid substitution treatment for those ten countries where recent estimates of the total number of opioid users and clients in substitution treatment were available.
Data indicate that the proportion of problem opioid users receiving substitution treatment in 2007 vary considerably between countries, with one out of 20 opioid users in the Slovak Republic, Cyprus and Poland receiving such treatment, about one in five in Greece, one in three in Finland, while more than every second problem opioid user in Italy, Czech Republic and Germany are under substitution treatment, Malta and Austria lie in between this range with estimated rates of 42 % and 45 % of problem opioid users, respectively. Overall, it is estimated that one in three problem opioid users in the European Union is receiving substitution treatment.
It should, however, be borne in mind that wide confidence intervals in the estimates of problem opioid use mean that comparisons between countries can only be made with caution.
- Figure HSR-2. Provision of substitution/maintenance treatment in the community and availability in the prison system in 2007 displays the results of two separate expert ratings: Firstly, a rating about the level of provision of substitution/maintenance treatment to problem opioid users in the community in relation to need, and secondly a rating about the extent to which substitution treatment programmes exists in the national prison systems. Both ratings were made in 2008 by experts from NFPs, using the Structured Questionnaire on 'treatment programmes’ (SQ27/P1) and refer to the situation in 2007.
It shows that in 17 countries, according to expert opinion, a majority or nearly all POUs in community settings, who are in need of substitution/maintenance treatment, would obtain it. The perceived coverage of need is limited in nine countries, and in one country treatment provision is limited to only a few POUs in need.
This rating is displayed in combination with an expert rating on the level to which substitution/maintenance treatment programmes exists in the national prison systems. It should be noted that the rating scales used are not equivalent. This is due to the fact that a reliable rating of ‘provision according to need’ in prison settings was not considered to be feasible because data on the prevalence of POU among prisoners is not systematically collected in most countries. The expert rating on the existence of substitution/maintenance treatment programmes in the prison system shows that in sixteen countries the option to use this type of treatment exists only in less than half of all prisons.
Prevention of infectious diseases
- Table HSR-4. Year of introduction of needle and syringe programmes and types of programmes available in 2007, provides information on the year in which needle and syringe exchange programmes were introduced in the Member States, from when on they were publicly funded, and which types of needle and syringe programmes were available in 2007.
It shows that while needle and syringe distribution at drugs agencies, as well as through outreach workers or mobile units is common, comparatively fewer countries base such programmes at pharmacies or make use of machines to distribute syringes. In 2007, five countries had needle and syringe programmes in prison.
- Table HSR-5. Syringe provision, provides the total number of syringes exchanged, distributed or sold at specialised syringe provision points in the years 2003, 2005 and 2007. The table includes data on syringes given out by fixed and mobile needle and syringe programme points in prisons and in the community, including through specialist drug and medical agencies and publicly funded pharmacy-based syringe exchange programmes. Syringes given out by outreach workers and in peer-distribution as well as through vending machines are included. However, no data on syringe sales outside of publicly subsidised pharmacy-based programmes are included.
The data show that there are continuous increases over the past years in most countries, but a decrease of syringe demand seems to take place in some. Availability and quality of data on syringe exchange has improved, but differences are still apparent in the reporting coverage of needle and syringe programmes among Member States, which affect data comparability.
The second part of HSR-5 gives additional information on the level and intensity of use of specialist drugs and medical agencies with NSPs in the community, providing the number of individual clients and client contacts in the reporting year. Seventeen countries provide data or estimates on client numbers or client contacts, or both. In 11 countries, all specialist agencies with NSPs are able to provide data on clients and contacts. While case definitions are not harmonised between countries, client numbers reflect individual users of specialist drug or medical agencies with NSPs, but not only those who use the syringe exchange. In some countries, the number of syringe exchange clients is known, due to obligation to register for it and/or specific monitoring systems. Few countries use national unique identifiers to avoid double-counting between agencies; in most countries, such controls are merely in place at agency level.
- Table HSR-6. shows countries’ three priority responses to prevent infectious diseases among drug users, according to national policies. Needles and syringe exchange programmes are the intervention regarded as priority in most of the countries (22) followed by infectious diseases counselling and testing (17 countries), information materials dissemination (15 countries) and hepatitis vaccination programmes (11 countries). According to these expert ratings, most countries employ a combination of infectious diseases testing and counselling (VCT) or information material dissemination (IEC) with needle and syringe programming (NSPs).
Responses in prison settings
- Table HSR-7. provides information on the availability and level of provision of selected health responses to prisoners, according to expert opinion. The data show that some activities targeting the prevention of infectious diseases — for example, infectious diseases counselling, HCV testing on prison entry, and HBV vaccination programmes, are more commonly available than other measures such as safer use training, HCV testing on release or prison needle and syringe exchange. Overdose prevention counselling is uncommon in most countries and specific overdose information materials for prison settings exist only in seven countries.
Provision of services to prisoners is limited or rare in most countries — except for HCV testing on prison entry. In nearly half of the countries, formal drug-specific health promotion trainings for prison staff exist.
Responses to drug related deaths
- Table HSR-8. provides expert ratings about the provision of a number of interventions aiming at reducing the risk of overdose deaths, selected from the literature. The data show that the dissemination of specific overdose information materials is a commonly provided service, but that trainings in overdose management and risk education or the assessment of individual risk profiles have only in few countries reached a majority of the target group. In those countries where overdose prevention interventions are more commonly implemented, a diversification of information materials for different target groups can also be noted.