Injecting drug users in Europe
Towards an educational approach
Lucas Wiessing
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon
lucas.wiessing@ emcdda.org www.emcdda.org

It has been estimated that there are now 800,000 active drug injecters living in the European Union. Drug injecting, which causes AIDS, is commonly practised among the drug abusers in this part of the world, where it quickly triggered a full-scale endemic of AIDS, HBV and HCV The various member-countries have responded in different ways. But the rates of infection are still alarmingly high everywhere: they are often above 50%, and in some groups, 90% of the drug abusers have been contaminated with the hepatitis C virus.

THE HEROIN EPIDEMIC. The epidemic of problem drug use in Europe has mainly been a heroin epidemic. It began in the late sixties among small groups of youth or "hippies" and began to increase sharply about ten years later. In the northern Scandinavian countries, however, the drug abusers are mostly amphetamine injectors, and these practices were originally associated with criminal circles.

According to the latest estimates, problem drug users now number about 1 to 1.5 million: 1 million of them would meet the standard criteria for dependence. Although it is difficult to compare the figures between individual countries, some significant differences seem to exist. At the lower end of the scale, Belgium, Finland, the Netherlands, Austria, Germany and Sweden have only 2 to 3 drug injectors per 1000 inhabitants in the 15-54 age-group. At the upper end, the United Kingdom (6.6 drug injecters per 1000 inhabitants), Italy (7.7 per 1000) and Luxembourg (8.4 per 1000) have particularly high drug abuse rates.

INTRAVENOUS INJECTING DRUG USE. During the initial wave of heroin abuse, injection was practically the only mode used. In some countries, other routes of administration emerged during ', the late 1970s and the 1980s, such as smoking or'chasing the dragon' (inhaling the vapour of heated heroin), which was introduced into The Netherlands by immigrants from Surinam. During the 1990s, injecting practices declined strongly in The Netherlands and Spain but much less in other countries. The reasons for the declines have not been clearly established, but may include changes in the availability, purity, type and price of heroin as well as fear of AIDS, although the latter factor was probably less ` decisive than the others (De la Fuente et al. 1997). The data available on the injection rates among opiate users undergoing treatment seem to indicate that these lower injection rates have stabilised.

HARM REDUCTION in EU member states, as described by Focal {Points, 1999

DRUG-RELATED INFECTIOUS DISEASES. The great heroin epidemic that struck Europe coincided with the advent of HIV. There existed at that time a large population of susceptible young heroin users who were just starting to inject. It has been established that young, newly starting injectors run higher risks (Fennema et al. 1997).

This, combined with the fact that nothing at all was known at that time about HIV transmission, may partly explain the high infection rates which occurred among    the IDUs in many countries. The countries most seriously affected at first were those in south-western Europe, especially Spain, Italy, and France. Portugal, where the epidemic began later on, now has the highest incidence of AIDS, and is the only country in which the numbers are still on the uprise. In 1990, the IDUs became the largest risk group for AIDS, surpassing homosexual men.
AIDS has declined considerably since about 1996 due to the latest highly active anti-retroviral treatments, and retrospective studies have suggested that the peak in the infection of drug injectors occurred in most countries between 1985 and 1989. However, the youngest age groups continue to be contaminated, despite the overall decrease in the incidence which occurred during the 1990s. Seroprevalence* data on HIV among IDUs in 1996-1998 show the existence of large differences between the infection rates recorded in various countries (EMCDDA 1999a). Although comparisons have to be treated with caution due to the methodological differences, these data suggest that the HIV prevalence may range from 1 % in the UK to more than 10% in The Nether-lands and Portugal, more than 15% in France and Italy, and possibly more than 30% in Spain.

IN SOME COUNTRIES, THE RATES OF CONTAMINATION ARE STILL ON THE INCREASE. A very high local prevalence (48%) was recorded in Lisbon, Portugal, in 1998/1999 (Valle et al. 1999), and the HIV notifications in Finland show that the figures have risen sharply among the IDUs since mid 1998. The situation is even worse as far as hepatitis C infection (HCV) among the drug users is concerned. Although the data sources are not as reliable for HCV as for HIV, most of them give infection rates well over 50%, peaking at a 92% infection rate in a sample of IDUs in Sweden (Krook et al. 1997).

A BRIEF REVIEW OF PREVENTIVE MEASURES. By the late nineties, Harm reduction had become standard practice throughout the European Union (EU). Syringe exchange programmes were implemented in all the member countries, syringes became available at chemists' shops without a prescription in most of these countries except Finland, Ireland and Sweden, although syringe exchange programmes were only more recently implemented in Finland. In Spain, Portugal, France and Italy, where the IDUs were most seriously affected by HIV, preventive measures were actively implemented during the 1990s. The UK and The Netherlands took appropriate steps back in the 1980s. In the case of the UK, this was done in time to prevent a really large-scale epidemic from occurring (Stimson 1996).

In 1999, all 15 member states of the EU reported having set up syringe exchange programs, 12 reported that needles could be readily obtained at chemists' shops, 14 reported that condoms were being distributed and that HIV counselling and testing were available, 12 reported that HIV treatment was available, 11 reported that free HBV vaccination was available to IDUs, 11 reported the existence of specific HCV actions, 15 reported that substitution therapy was available to opiate users (mainly to reduce injecting practices), and 14 reported that prevention measures had been set up in prisons.

In France, the number of opiate users undergoing substitution treatment has greatly increased during the last few years. As methadone was long illegal, the first substance to be widely used for this purpose was buprenorphine (Subutex®*). In the early 1990s, it was estimated that only 50 opiate users were being given methadone as a substitute. Approximately 60,000 opiate users are currently on buprenorphine and another 5,000 are now on methadone (FMCDDA 1999b).

Another useful preventive tool is the 'Stéribox', a kit containing sterile injecting equipment, which is available at chemists' shops. Recently the 'Stéricup' has been added to the range of preventive equipment: this is a sterile heroin cooker designed to prevent the spread of hepatitis C and B (OFDT 1999).

Within a period of only a few years, all the Member States of the European Union had adopted preventive measures to minimise the harmful effects of drug injection.

PRISONS: A RISK FACTOR CONTRIBUTING TO THE SPREAD OF AIDS. Prisons have been called "the motor of the HIV epidemic", but there is a growing awareness of the need for internal prevention programmes. A European expert network reported that HIV tests are available for prisoners on admission in all the EU countries, and participation is mostly on a voluntary basis. However, large differences were observed between the rates of participation, depending on how the tests were presented. Drug testing is being performed in all the European countries, either as a disciplinary measure or in a therapeutic setting.

Prison policies on drug treatment versus substitution programs vary greatly between the EU countries. Pilot studies on needle replacement in prisons are being carried out in Germany and Spain. Bleach and sterilization tablets are available in Denmark, Finland, France, Germany, Greece, Italy and Scotland. Condoms and lubricants are not always available, or only on prescription (England and Wales), which may be a great obstacle for prison inmates.

SELF-PREVENTION FOR PRISON INMATES. Although most European prison inmates undergo HIV screening (from 73% in France to 96% in Spain), the rates of HBV vaccination recorded on the basis of the drug injectors' declarations ranged from 6% in Sweden to 36% in Spain, while the percentage who declared that they had previously undergone a HCV test ranged from 50% in Belgium to 89% in Spain and Sweden (ENHPP 1998). One particularly innovative preventive' activity involves training active IDUs to recognize signs of readiness to be initiated among non-IDUs and to dissuade these candidates from becoming injectors (Hunt et al. 1998). Other preventive options include 'transition periods' via other routes of administration than IDU, such as "chasing the dragon" and anal administration. The experts have concluded that by enlisting the help of drug injectors in this way, it may be possible to reduce the number of people who begin injecting.

CONCLUSION. Some noteworthy changes have certainly taken place in Europe during the 90s. Within a period of only a few years, all the EU Member States have introduced preventive measures to minimise the consequences of injecting' drug use. However, little is still known about either the quantity or the quality of existing services (their supply, the use made of these services, the coverage, etc.). The least that can be said is that the HIV and hepatitis B and C infection rates among the IDUs Europe are still unacceptably high in Europe.

REFERENCES

FMCDDA (2000) Annual Report on the State of the Drugs Problem in the European Union.: FMCDDA, Lisbon.

Fennema, J.S., Van Amcijden, E.J., Van Den Hock, A., Coulinho, R.A. Young and recent-onset injecting drug users are at higher risk for HIV. Addiction 92: 1457-1465,1997.

European Centre for the Epidemiological Monitoring of AIDS (ECEMA). HIV/AIDS Surveillance in Europe, 1994-1996.

Downs AM, Hcistcrkam SH Rava L. Houwchng H. Jager JC. Hamers FF. Back -calculation by hirth cohort incorporatong age- specific disease progression, pre-AIDS mortality and change in European AIDS case definition European Union Concerted Action on Multinational AIDS Scenarios.; AIDS Scenarios. AIDS 2000 : 14 : 2179-89.

Source: PEDDRO december 2001