From margin to mainstream: The evolution of harm reduction responses to problem drug use in Europe

Abstract

Since the 1960s, illicit drug use in Europe has been marked by the serious health consequences of drug injecting, in particular of heroin. The present article discusses the development of two major harm reduction interventions conducted in Europe to reduce heroin injection and its detrimental consequences, namely opioid substitution treatment and needle exchange programmes. Data collected by the EMCDDA, the specialized EU drug monitoring agency, show that these interventions have progressively become part of the common response in Europe for reducing problems related to drug injecting. The data illustrate the emergence in the mid-1980s of these measures as ‘new’ public health responses to injecting drugs and HIV/AIDS, a process that was preceded by intensive discussions between stakeholders at national and local level. Data also indicate that the scaling up of the measures was not immediate, but happened only about a decade later, during the 1990s—and predominantly in the Western part of the European region. While current social, cultural and legal responses to drug use in EU Member States remain diverse, a recent assessment of national priorities and approaches in preventing infectious diseases and drug-related deaths showed a considerable trend towards a convergence of policies across the whole region. This is discussed in relation to strategic guidance and target-oriented action plans that emerged at the level of the European Union since the late 1990s, concluding that European policy consensus was mediated by EU guidance, while not originating from it.

Notes

Notes

[1] The fifteen ‘older’ EU Member States are: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and the United Kingdom. The ten countries that became Member States of the EU on 1 May 2004 are: Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, the Slovak Republic and Slovenia. Bulgaria and Romania joined the EU in 2007. See also http://europa.eu/abc/european_countries/eu_members/index_en.htm

[2] The first formal intergovernmental co-operation initiative in Europe was the establishment of the Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group) at the Council of Europe, following a proposal made by Mr Georges Pompidou, President of the French Republic to his colleagues in the European Community and the Head of State of the United Kingdom in 1971 (http://www.coe.int/t/dg3/pompidou/Default_en.asp).

[3] Treaty Establishing a Constitution for Europe; Part III, Chapter V, Article III-278, Section on Public Health.

[4] As the EU Ombudsman spelled out in a speech about drugs policy in a united Europe: ‘The aim of the European Union drugs policy is thus to add value to national strategies while respecting the principle of subsidiarity set out in the Treaty. The main instruments … are EU action plans, which fall under the responsibility of the Commission. The Commission plays an important role in helping the Member States reach common positions and carried out the policies jointly agreed by and with the Member States. … The main technical and policy forum to facilitate joint efforts of Member States and the Commission is the so-called EU Council's Horizontal Drugs Group which meets monthly and brings together representatives from Member States and the Commission with a view to analysing, taking measures on, and seeking to co-ordinate all drug-fighting activities of the EU’ (Diamandouros, 2005).

[5] See the EU Drugs Strategy (2005–2012). Available online at: http://register.consilium.europa.eu/pdf/en/04/st15/st15074.en04.pdf; and the EU Drugs Action Plan (2005–2008) at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:52005XG0708(01):EN:NOT

[6] The Recommendation is available online at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2003:165:0031:0033:EN:PDF

[7] The EMCDDA is one of the European Union's decentralized agencies. Further information is available online at: www.emcdda.europa.eu

[8] Norway is also an official member country of the EMCDDA, and the agency furthermore co-operates with Turkey and with Croatia, where National Focal Points were established in 2002 and 2007, respectively. The latter countries are preparing to become members of the EMCDDA.

[9] The EMCDDA co-ordinates a network of National focal points (NFPs) set up in the 27 EU Member States, Norway, the European Commission and in the candidate countries. Together, these information collection and exchange points form Reitox (Réseau Européen d’Information sur les Drogues et la Toxicomanie), the European Information Network on Drugs and Drug Addiction. National Focal Points act as an interface between Member State and EMCDDA, co-ordinating and stimulating the data collection from different institutions and experts to the EMCDDA. They are the national authority providing drug information to the EMCDDA, as well as ambassador of the EMCDDA at national level.

[10] The two instruments used in the expert surveys, Structured Questionnaire 23 (2004) and Structured Questionnaire 29 (2005), can be downloaded at: www.emcdda.europa.eu/?nnodeid=5777 and www.emcdda.europa.eu/?nnodeid1333, respectively.

[11] In the UK, heroin prescription has been available since the beginning of the last century. However, this paper considers only the use of substitute drugs as a means to increase heroin users’ treatment adherence, first developed by Dole and Nyswander (1965).

[12] Compiled data from INCB Technical reports (http://www.incb.org) can be found in Table HSR-9. Consumption of methadone (kg) in 29 European countries, in the Unites States of America and total consumption worldwide, 1992 to 2005 of the EMCDDA Statistical Bulletin 2007, online at: www.emcdda.europa.eu/stats07/main

[13] See further methodological notes and links to background data at: http://www.emcdda.europa.eu/html.cfm/index39436EN.html

[14] See also Note 10. Based on a review of policies to prevent infectious diseases among drug users through a questionnaire survey among National Focal Points in 2004 (Structured Questionnaire 23, 2005). Fifteen countries followed the EMCDDA's recommendation to involve a group of national experts in responding to the questionnaire. Experts selected up to 3 out of 11 pre-selected responses to prevent infectious diseases among drug users as priority responses according to the policy in their county. Results are presented in percent of valid replies. Only five countries made use of the option to add further strategies, however, as these were very heterogeneous, they are not presented here. Priority ratings for the pre-selected responses were provided by experts from 24 EU countries. Countries not supplying these ratings were Ireland, Cyprus, Lithuania and the Netherlands.

[15] For an additional rating of the ‘extent of use’ of the different strategies in the countries see: http://ar2006.emcdda.europa.eu/en/elements/fig11-en.html

[16] See also Note 10. Based on a review of policies and interventions to reduce acute drug-related deaths through a questionnaire survey among National Focal Points in 2005 (Structured Questionnaire 29, 2005). Twenty-one countries followed the EMCDDA's recommendation to involve a group of national experts in responding to the questionnaire. As part of the survey, expert opinion was requested about the extent to which five selected response strategies aiming at the reduction of drug-related deaths were in use in their country (question 5). Additional strategies could be added. Answer options were: ‘not in use’; ‘rarely, uncommon’; ‘common but not predominant’; and ‘predominant’ approach. The figure presents the results of the expert ratings as the number of countries in the different rating categories. Valid replies were available from all EU countries except the Slovak Republic and Cyprus.

[17] See the topic overviews on the legal status of substitution treatment in the European Legal Database (ELDD) at: http://eldd.emcdda.europa.eu/html.cfm/index41823EN.html, and the topic overview on the legal framework of needle and syringe programmes in the EU countries at: http://eldd.emcdda.europa.eu/index.cfm?fuseaction=public.Content&nNodeID=13212&sLanguageISO=EN

[18] For example, according to replies to the survey from national policy makers in Slovenia and Estonia, Cyprus, the Slovak Republic and Lithuania, between six and all of the thirteen recommended policies regarding the establishment of risk-reduction services and facilities are based on the Council Recommendation.