An overview of the data
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, a combination buprenorphine/naloxone, diamorphine (heroin-assisted treatment) and slow-release morphine. They further provide information on the legal frameworks of substitution treatment initiation, continuation and dispensing in each country. Finally, information on the estimated number of clients receiving methadone and other opioid substitution treatment from 1993 to 2009 is provided for each country as well as the share of clients in methadone and buprenorphine for 2009.
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, and documents the types of settings and number of sites where syringes were provided in 2009. Part ii of this table gives information about the availability of NSP sites in Europe-wide standardised geographical units (NUTS-2 and NUTS-3) in 2009.
Table HSR-5 on syringe provision gives information on the overall number of syringes provided in the period 2003–09 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. For a subset of 16 countries, part ii of this table provides information on the number of clients and contacts at specialist NSP agencies for the years 2007 and 2009.
Table HSR-6 provides information on Hepatitis B vaccination in Europe. It provides information on both universal immunisation schemes as well as campaigns targeting high-risk groups in the community, as well as programmes in prisons.
Table HSR-7 provides expert ratings (2008 EMCDDA survey) on the level of provision (part i) and availability (part ii) of a number of selected interventions aimed at preventing infectious diseases and reducing overdose risks among prisoners.
Table HSR-8 provides expert ratings (2008 EMCDDA survey) 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 (part ii).
Table HSR-9 provides information on opioid substitution treatment (OST) in prison in Europe. It provides information on the year this treatment option was first introduced in prisons, whether it can be initiated or only continued when started before imprisonment. It also provides the total number of prisoners receiving opioid substitution treatment on a given day in each country and the resulting prevalence rate for the whole prisoner population.
Table HSR-10 provides the estimation of the total number of clients in treatment in 2009.
Retrospective information updates on programmes for syringe provision and on substitution treatment published in the previous Statistical bulletin were made if new information became available.
Figure HSR-1. The figure provides the percentage of problem opioid users receiving opioid substitution treatment for those 16 countries where recent estimates of the total number of opioid users and clients in substitution treatment were available.
Figure HSR-2. The figure provides the total estimated number of clients in OST from 1993 to 2009. From 2003 onwards, the estimated number is presented separately for countries that were members of the European Union before the enlargement on 1 May 2004 (EU-15) and countries that joined the European Union (EU-12) on that date.
Figure HSR-3. The figure provides the average number of syringes distributed through specialised needle and syringe programmes per injecting drug user per year for those 13 European countries where recent estimates (from the years 2004 to 2009) of the total number of injecting drug users were available.
Figure HSR-4. The figure provides the percentage of all prisoners who are on substitution treatment on a given day for those countries where opioid substitution treatment is available in custodial settings.
Summary points
Access to 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 (Spain), has been introduced more quickly and is now available in most EU countries. Diamorphine (heroin) is available in the UK since the 1920s as an unsupervised treatment option for opioid dependence. However, supervised injectable diamorphine is an established treatment option since 2003 in Germany, 2006 in the Netherlands and since 2008 also in Denmark. Trials have been conducted in 2003 Spain and very recently (2011) also in Belgium. Slow-release morphine is a legal drug used in substitution treatment only in five countries (Bulgaria, Luxembourg, Austria, Slovenia and Slovakia) where it has been introduced during the last five years, apart from Austria, where it was available since the late 1990s. A combination buprenorphine/naloxone has been very recently introduced in half of the countries, including Turkey in 2009.
Table HSR-2. Legal framework of substitution treatment initiation, continuation and dispensing.. The table shows who is legally allowed to initiate, continue and dispense opioid substitution treatment 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 shows who is allowed by law to initiate and/or continue the prescription of opioid substitution medications (methadone, buprenorphine, diamorphine, slow-release morphine and the combination buprenorphine/naloxone). Three service providers are presented, namely office-based medical doctors (MD), 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 MDs 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 allowed by law to dispense opioid substitution medications in each country. In this case, pharmacies and outreach mobile units have been added as potential service providers.
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 from 1993 to 2009.
This table shows the estimated number of clients reported to receive opioid substitution treatment and specifically methadone maintenance treatment from 1993 to 2009 for 27 EU Member States, Croatia and Norway, according to available historical data. 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. This overview reflects the increasing availability of opioid substitution treatment in many EU countries. The total number of clients receiving substitution treatment in the EU, Croatia and Norway in 2009 is estimated to be around 700 000, up from 650 000 in 2007 and 560 000 in 2005.
The third part of table HSR-3 provides additional information on the provision of substitution treatment in 2009 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.
Most substitution clients in Europe receive methadone (70–75 %), but the number of countries where it is the only prescribed substance is decreasing, with buprenorphine now available in all but four EU Member States (Bulgaria, Spain, Hungary, Poland). High-dosage buprenorphine treatment corresponds to 20–25 % of all substitution treatment provided in Europe. In the Czech Republic, Croatia, France, Cyprus, Sweden and Finland, more than 50 % of those on substitution treatment are prescribed buprenorphine.
Table HSR-10. Estimation of the total number of clients in treatment (2009)
This table provides information on the estimation of the total number of clients in treatment in 2009 which was calculated to be at least 1.1 million people. The estimation is based on the number of clients reported by countries through different tools available within the EMCDDA data collection on treatment. For each country three sets of data are presented: the total number of clients in substitution treatment, the number of all clients registered through the TDI – Treatment Demand Indicator, and the estimation of the total number of treatment clients as collected in standard table on access to treatment (ST 24). While more than half of these clients received opioid substitution treatment, a substantial number received other forms of treatment for problems related to opioids, stimulants, cannabis and other illicit drugs. This estimate of drug treatment in the European Union, though still in need of refinement, does suggest a considerable level of provision, at least for opioid users. This is the consequence of a major expansion during the last two decades of specialised outpatient services, with a significant involvement of primary health care, mental health services, outreach- and low-threshold service providers.
Figure HSR-1. Number of opioid maintenance treatment clients as a percentage of the estimated number of problem opioid users, 2008.
This figure presents the percentage of problem opioid users receiving opioid substitution treatment for those 16 countries where recent estimates of the total number of opioid users and clients in substitution treatment were available.
A comparison of the number of clients in substitution treatment with the estimated number of problem opioid users suggests a possible saturation of demand for opioid substitution treatment in western European countries and low coverage levels in other parts of Europe. Eight out of the 16 countries for which reliable estimates of the number of problem opioid users are available, eight report a number of substitution treatments corresponding to 40% or more of the target population. Seven of those countries are pre-2004 EU Member States, and the remaining high-coverage country is Malta. Coverage reaches 37% in the Netherlands and 32% in the Czech Republic and Hungary respectively. Of the five countries with coverage levels below 30%, four are ‘post-2004’ countries. The exception in this group is Greece, with an estimated coverage of 23%. Overall, it is estimated that more than 50 % of problem opioid users in the European Union could be receiving substitution treatment. At the same time, these ‘high coverage countries’ contribute two-thirds towards the total estimated number of problem opioid users (POUs) in the EU-27.
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. Estimated number of clients in opioid substitution treatment in EU-15 and EU-12 from 1993 to 2009.
This figure shows historical trends in the provision of substitution treatment in the EU Member States over 16 years, based on estimates between the years 1993 and 2009. In 2009, the total number of opioid users receiving substitution treatment in the European Union, Croatia and Norway is estimated at 700 000 (690 000 for EU Member States) in 2009, up from 650 000 in 2007, and about half a million in 2003 thus clearly reflecting the ongoing scaling-up process in the region. The vast majority of substitution treatments continue to be provided in the 15 pre-2004 Member States that were already in the EU in 1995 (about 95% of the total), and numbers in these countries show signs of continuous increase between 2003 and 2009. In the 12 countries that joined the EU more recently, the number of substitution clients nearly tripled between 2003 and 2009, from 6 400 to 18 000. Relative to the index year 2003, a steep increase can be noted between 2005-2007 in many EU-12 countries, but from 2007 onwards there has been little further increase.
Prevention of infectious diseases
Table HSR-4. Needle and syringe exchange programmes.
The table provides information on the year in which needle and syringe exchange programmes were introduced in the member states and candidate countries, from when they were publicly funded and which types of needle and syringe programmes as well as the number of sites were available in 2009. An additional table also provides information on the geographical availability (based on the European classification of territorial units for statistics defined in the Regulation (EC) No 1059/2003 of 26 May 2003) of NSPs in each country.
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 2009, five countries had needle and syringe programmes in prison. Information on geographical coverage shows a regional imbalance, with lack of availability at regional level in many countries in central and eastern Europe and Sweden.
Table HSR-5. Syringes exchanged, distributed or sold at specialised syringe provision points between the years 2003 and 2009.
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. Outreach programmes and peer-distribution as well as provision through vending machines are included as well as data on the reporting coverage of NSPs.
Data on syringe show that in 2009 nearly 50 million syringes per year were distributed through needle and syringe programmes in 26 countries providing data. Increases in syringe provision to drug users are reported in Belgium (Flemish Community), the Czech Republic, Greece, Hungary, the United Kingdom (Northern Ireland), Luxembourg Latvia, Austria, Romania, Finland and Croatia, thereby confirming earlier trends. Increases were also reported in Slovakia where numbers had previously declined. A decrease compared to 2008 was reported in Lithuania and Portugal, as well as in Spain, Poland, Netherlands and Sweden, where the downward trend was already observed the year before. Overall 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, as presented in the table, which affect data comparability.
Over the last four reporting years (2005–2009) the total number of syringes given out by syringe programmes has increased 32%. A sub-regional analysis of syringe provision trends shows a flattening of the increase among the pre-2004 EU Member States and a rise in the newer Member States.
Table HSR-6. Hepatitis B immunisation in Europe.
The table provides information on both universal immunisation campaigns as well as high-risk groups programmes.
This table shows the current state of Hepatitis B immunisation in Europe. Hepatitis B is included in the routine universal vaccination programmes in most of the Member States, with Italy and Poland being the first ones to start in 1991. Germany, France, Netherlands, the UK and the Scandinavian countries do not include Hepatitis B in their vaccination campaigns although debates on whether to re-introduce it are currently ongoing in the Netherlands. Recent developments in the diagnosis, prevention and treatment of chronic hepatitis have been reported and more than half of the Member States, as well as Turkey and Norway, are implementing specific vaccination programmes for high-risk groups which typically include drug users. Targeted immunisation interventions in custodial settings are available only in 14 countries in Europe.
Figure HSR-3. Syringes distributed through specialised programmes per estimated IDU in 2009 or a more recent year.
This graph shows the available data on the estimated coverage of needle and syringe programmes in different countries. The bars represent the number of syringes distributed, per estimated injecting drug user, per year. In 2009, it was possible to estimate the average number of syringes distributed in a year per injecting drug user for 13 countries. In seven of these countries, the average number of syringes given out by specialised programmes is equivalent to less than 100 per injector, four countries give out between 100 and 200 syringes, and Luxembourg and Norway report the distribution of more than 200 syringes per injector. For the prevention of HIV, UN agencies judge the annual distribution of less than 100 syringes per injecting drug user as low, and of more than 200 syringes per injector as high (WHO, UNODC and UNAIDS, 2009). The overall European average is of 94 syringes per estimated injecting drug user, which excludes however pharmacy syringe sales. These data strongly depend on quality estimates of the number of IDUs as well on the availability of data on syringe provision, and thus should be interpreted with caution, but they suggest that specialised programmes, even if currently available in almost all Member States, may have important variation in coverage.
Responses in prison settings
Table HSR-7. Health responses in prison.
The table provides information on the availability and level of provision of selected health responses to prisoners, according to expert opinion.
The data show that according to expert opinion, 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. Moreover, the level of service provision to prisoners is estimated to be limited or rare in most countries — except for HCV testing on prison entry. It is encouraging to see that in nearly half of the countries, formal drug-specific health promotion trainings for prison staff exist.
Table HSR-9. Opioid substitution treatment in prison in Europe.
The table includes information on the year of introduction and whether it is possible to initiate and/or continue the treatment while in prison. It also provides the total number of prisoners on a given day in each country and the rate of prisoners on opioid substitution treatment.
Following the scaling up of opioid substitution treatment in the community, many countries report increases in the number of opioid substitution clients entering prison. Continuity of care for substitution treatment is particularly important, given the high rates of overdose death on release and for reducing the risks of crimes carried out to fund illicit drug use. Opioid substitution treatment in prison was introduced for the first time in 1985 in the Netherlands, yet the majority of countries introduced it from the late 1990s onwards. In 2008, the continuation of opioid substitution treatment in prisons became possible in Bulgaria, Estonia and Romania. This treatment option is not available in prisons in Greece, Cyprus, Lithuania, Latvia, Slovakia and Turkey.
Figure HSR-4. Proportion of prison population receiving opioid substitution treatment (OST) on a given day.
The figure provides the percentage of prisoners on substitution treatment on a given day in 2008 for those countries where opioid substitution treatment is available in prisons. In six Member States, it can be estimated that on a given day more than 10 % of all prisoners receive opioid substitution treatment, while in another eight countries the corresponding figure is between 3 % and 10 %. In most countries, detoxification is still the ‘default’ treatment for opioid users entering penal institutions, including those are in substitution treatment in the community.
Responses to drug-related deaths
Table HSR-8. Responses to drug-related deaths in Europe.
The table 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, according to expert opinion collected in 2008, 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 reach only in few countries 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.