European situation on drugs and perspectives for next 10-15 years

Nasjonal Fagkonferanse for lavterskeltiltak i rusfeltet

OSLO 29-11-2017

Julian Vicente (EMCDDA)

Approach used

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Look at the situation in 2017 (16-15) such as it was presented in EDR

Project drug by drug (some drugs/groups of drugs) foreseeable situation in 10-15 years and general drivers

If there are not major unexpected changes, the projection can be correct and we can consider this as the central scenario

But unexcepted changes are common on drugs situation; some included

Finally speculation on substantial changes (but still plausible)

Method to project central scenarios in 10-15 years

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Developments in some EU countries and other regions (e.g. USA, opioids), Trendpotter results and models of past emerging trends (e.g. ecstasy)

Developments often progressive from local trends, but could be quick (e.g. NPS if positive experience and not very toxis)

Developments accelerated by rapid diffusion channels (internet) and rapid market developments (globalization)

Classical monitoring tools should be adapted to new scenario

Diversification of European regions more complex picture

Some relevant trends in last 10-15 years

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Cannabis treatments greatly increased Cannabis local cultivation and high potency products Heroin and injecting declined OST increase Opioid diversified (heroin, substitution medicines, fentanyls…) Aging drug users Stimulants markets and use very diversified Decline in HIV and Hep C in the spotlight Increase in overdose deaths in last years New online markets and cryptomarkers for supply NPS emerged; cathinones, cannabinoids, synthetic opioids

Big country variations

Some drivers for next years; already started

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• Policy and politics; cannabis in the Americas with different models

• New technologies (production, distribution and marketing)

• Increases in cultivation (poppies, coca, marihuana)

• Globalization of the markets (e.g. NPS from China, darknet…)

• Supply reduction strategies (e.g. MDMA, heroin drought)

• Social and cultural/fashion trends

• Demographics – aging users – new groups of users

• Polydrug use

• Improvement in responses (OST, NSP, Low threshold, THN)

More diverse and complex markets (products, users, technology)

Opioids

High-risk opioid users: heroin still dominates

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1.3 million high-risk opioid users

An ageing cohort

Overdose deaths: rise for third year

8 440 deaths in 2015 Heroin and other opioids a

concern Increases among almost all age groups

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630 000 receive opioid substitution treatment methadone most common OST medication national OST trends and coverage varies

1.4 million people in treatment (delete)

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Opioids: possible developments in 10-15 years

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New populations at risk of use Medical users of opioids heroin (USA) –unlikely such extension New marginalised populations (long-term unemployment, social young

subcultures, some immigrants groups vulnerable)

Supply side Increased supply of cheap heroin. Increased supply of synthetic opioids (real threat: e.g. fentanyls-)

Possible positive factors Success/increase in OST Continue general high perception of risk Decrease in supply (enforcement or geo-political factors)

Opioids: possible developments in 10-15 years

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Risk behaviour leading to harms Injecting decreasing, but polydrug use and aging an issue

Overdose deaths Decreases with low injection and broad access to OST New approaches increasing (THN, Safe Consu. Facilities) But in some countries increases continue (polydrug use, leaking of

OST, new potent opioids

Infectious diseases HIV decreasing in almost all EU countries –local outbreaks? HCV high in most countries – combination of harm reduction and new

treatments (very expensive) can decrease prevalence

Figura 8. Proporción de tratados por primera vez en la vida por abuso o dependencia de heroína, cuya vía principal de administración era parenteral. España (%), 1991-2002.

FUENTE: DGPNSD. Observatorio Español sobre Drogas (OED). Indicador Tratamiento.

1993

1995

1991

1997

<20% 20-39% 40-60% >60%

1999

2002

Stimulants

Cocaine: increases in wastewater analysis

Cocaine residues in 22/33 cities between 2015–2016

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MDMA market: recovery continues

High-strength products available Large-scale production facilities

dismantled (BE and NL) seizures increasing

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Amphetamines market

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Amphetamine — overall stability

Methamphetamine — seizures are 1/6 of all amphetamines seizures, but overall increasing trends 2002-2015

Amphetamines: use and problems

17 More used in the North

… rising treatment demand

Stimulants: Possible developments in 10-15 years

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Cocaine: Increasing again (supply and use) Powder cocaine: big extension to all Europe? Not very lkely Crack concentrated in UK; why does not spread to other countries? Possible substitution treatment??

Amphetamines/Methamphetamines Often hard to distinguish by users. Popular in central and northern Europe. Big increase in methamphetamine supply indicators + increase in

treatment demand for Amph/Methamp (mainly Germany). Indications of methamphetamine spread / potential switch to smoking? Possible substitution treatment??

Stimulants: Possible developments in 10

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Ecstasy Big decrease in availability 2008-2010 but recovering Use high in nightlife settings. Not high in general population Increase in availability, may spread use into general population? High potency presentations NL, increased risk – spread?

New synthetic stimulants In recent years; many new synthetic stimulants. Often following decreases in availability of classicals. But methedrone… Initially in recreational users, but now also in high-risk users and injection Probable further expansion of both recreational and high-risk users

Cannabis

Americas – some regulatory changes Europe – diverse

approaches to cannabis regulation and use No government currently

supporting legalisation Need to monitor and

evaluate health implications

Global cannabis policy developments

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Cannabis: Europe’s most commonly used drug

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88 million (>25%) adults 15–64 years have tried cannabis Almost 1% of adults

daily users National diversity in

prevalence and trends

Increasing new treatment demand — 45% of new entrants

Treatment demand for cannabis problems

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Cannabis market

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Over one million seizures Cannabis >70% of EU seizures Around ¾ of drug possession offences

Cannabis: Possible developments in 10-15 years

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A major issue would be changes in regulations/laws – likely in some EU countries

Prevalence of use (young males) moderate increasing trend in many countries

Local production (herb), diversified ways of using, and emergence of synthetic analogues suggest increases in use in next years.

Continuous increase of cannabis treatment; likely to continue Services will need to increasing; treatment entries suggest that

regular/intensive users starting some years ago need to seek treatment

A certain share of present daily users (+/- 3M) will need treatment in next years - 1 M at risk – 650.000 arrested - 60.000 treatments

Cannabis: Possible developments in 10-15 year

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Possibly CUD and social/health problems will increase, often related to polydrug use (e.g. alcohol)

Individually cannabis problems are far less intense that opioids or cocaine, but the big numbers may imply a not negligible social/health burden

Selective prevention and short interventions would need to increase

Will need regulations (driving limits…) and arresting users do not seem the way

New drugs

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66 new substances detected in 2016 Decline from 2014 peak Impact of regulation in EU and

China? 620+ substances monitored

by EWS Deaths and acute

intoxications still a problem

NPS: drop in new detections but availability still high

Increase in seizures of synthetic cannabinoids and cathinones

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80 000 seizures in 2015 60% of seizures are synthetic cathinones and cannabinoids

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25 new synthetic opioids detected between 2009 and 2016

Highly potent, also found in other products

Intoxication risk to users and accidentally exposed

New synthetic opioids — a growing health threat

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Low use in general population but problems for some groups

cathinone injection by opioid

users, MSM synthetic cannabinoids among

homeless use in prison a growing concern New report published: High-risk drug use and new psychoactive substances

NPS: high-risk use in marginalised populations

New drugs: possible developments in 10-15 years

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Developments in chemistry, markets and communication facilitate creation/diffusion of new substances, taking advantage of legal gaps

An big number of NPS have entered market in last years. This trend kely to continue in next years, although developments of individual substances is difficult to foreseen

At present the overall public health impact seems limited, mainly due to low prevalence or decrease availability following legal control

But they are/will be potential threats to be followed closely. The epidemiological monitoring is limited; should be improved

These substances may spread using new market technologies (e.g. internet)

New drugs: possible developments in 10-15 years

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Spread among users of other drugs – some manage to reach non using people (e.g. methedrone, synthetic cannabinoids)

Spread in population of heavy users, adding risks

NPS similar to legal medicines (e.g. benzos, pharma opioids) sold in internet may diffuse mainstream public and markets

Some NPS have more toxicity that original (e.g. synthetic cannabinoids)

Some NPS are extremely toxic (new fentanyls) and their spread could be quick and difficult to predict (EWS aim to help) USA

Possible developments in future (not a clear timeframe but plausible)

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• Catastrophic development

• Changes in paradigms

• Change in research orientation and priorities

Catastrophic development

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• Already happening in USA; declared a national

emergency due to opioid crisis

• Currently 50.000 – 60.000 overdose deaths per year, mainly opioids (heroin and fentanyls)

• For total population the rate is 4 times the EU (it will mean to pass for 8.000 to 36.000 deaths in 2-4 years

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Changes in paradigms (qualitative

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• Drug users as full citizens – participation on policy developments and decision making (e,g, Aids history)

• “Not to send the wrong message” - wrong... for who?

• Changes in legal situation on cannabis in many EU countries • It will create different needs, problems and benefits - closer to alcohol • It will be necessary ad-hoc monitoring, prevention, short interventions,

treatment • Change in many regulations and services –law enforcement- (650K

Ca)

• “high-risk drug use” will not disappear; “Normalization” as a chronic condition, without moral judgements

Changes in paradigm (quantitative)

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• integrated low threshold centers with social service + user’s room + OST + THN + drug testing (recreational drugs and opioids)

• Broad expansion of improved treatment (OST) and quality

• Broad THN including police and pharmacies (EU negotiation of prices)

• Testing places for users and small dealers to know what they are selling

• On line resources for users

• Negotiation of prices and scalation HCV treatment

• Focus on mental health and social vulnerability since school – indicated prevention. Coordination of services (soc-edu-health-police)

• Among high-risk users; diagnosis and treatment mental health problems and social exclusion. With community services (soc-edu-health-police).

Change in research orientation and priorities

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• Research on treatments (e.g. an synthetic opioid that gives a high but not respiratory depression). Synthetic endorphins ?? Others? Genetics?

• Promote research on properties of illegal drugs (research has been almost impossible for decades and still now is extremely difficult)

• Medical uses of individual molecules in cannabis (results promising) • Ketamine as antidepressant (in advance stage) and for alcohol dependence

(and maybe drugs) • Hallucinogens (LSD and psilocybin) for psychotherapy, depression,

dependence, death and dying • Microdosis LSD • Mindfulness • :Research in 60s/70s nothing from the 80s worldwide until recently (with probl) • Many promising substances in 60s/70s schedule I

Change in research orientation and priorities

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• Research on treatments (e.g. an synthetic opioid that gives a high but not respiratory depression). Synthetic endorphins ?? Other sesearch

• Promote research on properties of illegal drugs (research has been almost impossible for decades and still now is extremely difficult)

• Medical uses of individual molecules in cannabis (results promising) • Ketamine as antidepressant (in advance stage) and for alcohol dependence

(and maybe drugs) • Hallucinogens (LSD and psilocybin) for psychotherapy, depression,

dependence, death and dying • Microdosis LSD • Mindfulness • :Research in 60s/70s nothing from the 80s worldwide until recently (with probl) • Many promising substances in 60s/70s schedule I

Conclusions

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• Forecast in drug use, problems and treatment is very difficult

• Classical drugs will remain, with possible increases in amount and potency

• NPS will be continue to be a problem, depending on potency, risk, acceptability of users, regulations. Fentanyls (old or new) very risky.

• New methods of production, trafficking and marketing. Globalization • ,

• Responses will need scalation (OST and others, NSP, THN, HCV..)

• Possibly legal and regulatorily changes will take place – a basic issue will be recognizing users as full citizens with rights and obligations

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Julian Vicente julian.vicente@emcdda.Europa,eu

Acknowledgement: Jane Mounteney

Thank you!